scholarly journals A Proactive Risk Assessment Framework to Enhance Patient Safety: Analysis of Unintended Retained Foreign Objects in Operating Rooms

2020 ◽  
Vol 9 (1) ◽  
pp. 300-304
Author(s):  
Maryam Tabibzadeh ◽  
Zarna Patel
Keyword(s):  
Risk Assessment ◽  
Patient Safety ◽  
Safety Culture ◽  
Nuclear Regulatory Commission ◽  
Operating Rooms ◽  
Assessment Framework ◽  
Foreign Objects ◽  
Enhance Patient Safety ◽  
Sentinel Event ◽  
Regulatory Commission

According to a study by Johns Hopkins, in average 251,454 Americans die annually from preventable medical errors. Medical error is the third leading cause of death in the U.S. after heart disease and cancer. Among different adverse events in healthcare settings, unintended retained foreign objects (URFOs) has been identified as the most common sentinel event by The Joint Commission. This paper proposes a proactive risk assessment framework to enhance patient safety in operating rooms by addressing the URFOs issue. The risk assessment framework is developed by integrating the 10 traits of a positive safety culture, initially introduced by the Nuclear Regulatory Commission, with an accident investigation framework called AcciMap, originally developed by Rasmussen. The AcciMap is a hierarchical framework, which comprises six layers: government and regulatory bodies, company, management, staff and work. In this study, it has been utilized to capture and analyze socio-technical contributing causes of URFOs across its layers in order to assess the activities of key players in each layer as well as the interactions between those layers. Moreover, we have been able to identify the most influential traits of a positive safety culture affecting the URFOs issue.

Reducing unintended retained foreign objects in operating rooms: a proactive risk assessment framework to improve patient safety

2021 ◽  
pp. 251604352110446
Author(s):  
Maryam Tabibzadeh ◽  
Zarna Patel
Keyword(s):  
Risk Assessment ◽  
Patient Safety ◽  
Safety Culture ◽  
Improve Patient Safety ◽  
Organizational Factors ◽  
Operating Rooms ◽  
Nuclear Industry ◽  
Assessment Framework ◽  
Foreign Objects ◽  
Sentinel Event

According to a study by Johns Hopkins, an average of 251,454 Americans die annually from medical errors. Medical error is the third leading cause of death in the U.S. after heart disease and cancer. Unintended retained foreign objects (URFOs) has been identified as the most common sentinel event by The Joint Commission. This paper proposes a proactive risk assessment framework to enhance patient safety in operating rooms by addressing the URFOs issue. This framework is developed by integrating the 10 traits of a positive safety culture, initially introduced by the nuclear industry and later adopted by other industries, with an accident investigation methodology called AcciMap, originally developed by Rasmussen. The AcciMap is a hierarchical framework consisting of several layers: government and regulatory bodies, company (hospital), (surgery division) management, (operating room) staff, and work. Thirty main categories of socio-technical contributing causes of URFOs were captured across the AcciMap layers. Organizational factors were identified as the root cause of questionable decisions made by staff and management. Financial and budget constraints, inadequate training infrastructure, absence of a risk management infrastructure, and leadership failure are the most influential organizational factors contributed to URFOs. Our mapping of the aforementioned positive safety culture traits on the AcciMap depicted that the four traits of Work Processes, Leadership Safety Values and Actions, Effective Communication, and Continuous Learning had the most influence on the URFOs issue. Associated recommendations to these findings are provided to contribute to reducing risks of URFOs instances.

Combining RAVEN, RELAP5-3D, and PHISICS for Fuel Cycle and Core Design Analysis for New Cladding Criteria

2017 ◽  
Vol 3 (2) ◽  
Author(s):  
Andrea Alfonsi ◽  
George L. Mesina ◽  
Angelo Zoino ◽  
Nolan Anderson ◽  
Cristian Rabiti
Keyword(s):  
Risk Assessment ◽  
National Laboratory ◽  
Nuclear Regulatory Commission ◽  
Probabilistic Risk Assessment ◽  
Reactor Physics ◽  
Idaho National Laboratory ◽  
Accident Scenario ◽  
Regulatory Commission ◽  
Fuel Reload ◽  
Probabilistic Risk

The Nuclear Regulatory Commission (NRC) has considered revision of 10-CFR-50.46C rule (Borchard and Johnson, 2013, “10 CFR 50.46c Rulemaking: Request to Defer Draft Guidance and Extension Request for Final Rule and Final Guidance,” U.S. Nuclear Regulatory Commission, Washington, DC.) to account for burn-up rate effects in future analysis of reactor accident scenarios so that safety margins may evolve as dynamic limits with reactor operation and reloading. To find these limiting conditions, both cladding oxidation and maximum temperature must be cast as functions of fuel exposure. To run a plant model through a long operational transient to fuel reload is computationally intensive, and this must be repeated for each reload until the time of the accident scenario. Moreover for probabilistic risk assessment (PRA), this must be done for many different fuel reload patterns. To perform such new analyses in a reasonable amount of computational time with good accuracy, Idaho National Laboratory (INL) has developed new multiphysics tools by combining existing codes and adding new capabilities. The parallel highly innovative simulation INL code system (PHISICS) toolkit (Rabiti et al., 2016, “New Simulation Schemes and Capabilities for the PHISICS/RELAP5-3D Coupled Suite,” Nucl. Sci. Eng., 182(1), pp. 104–118; Alfonsi et al., 2012, “PHISICS Toolkit: Multi-Reactor Transmutation Analysis Utility—MRTAU,” PHYSOR 2012 Advances in Reactor Physics Linking Research, Industry, and Education, Knoxville, TN, Apr. 15–20.) for neutronic and reactor physics is coupled with the reactor excursion and leak analysis program—three-dimensional (RELAP5-3D) (The RELAP5-3D© Code Development Team, 2014, “RELAP5-3D© Code Manual Volume I: Code Structure, System Models, and Solution Methods,” Rev. 4.2, Idaho National Laboratory, Idaho Falls, ID, Technical Report No. INEEL-EXT-98-00834.) for the loss of coolant accident (LOCA) analysis and reactor analysis and virtual-control environment (RAVEN) (Alfonsi et al., 2013, “RAVEN as a Tool for Dynamic Probabilistic Risk Assessment: Software Overview,” 2013 International Conference on Mathematics and Computational Methods Applied to Nuclear Science and Engineering, Sun Valley, ID, May 5–9, pp. 1247–1261.) for the probabilistic risk assessment (PRA) and margin characterization analysis. For RELAP5-3D to process a single sequence of cores in a continuous run required a sequence of restarting input decks, each with different neutronics or thermal-hydraulic (TH) flow region and culminating in an accident scenario. A new multideck input processing capability was developed and verified for this analysis. The combined RAVEN/PHISICS/RELAP5-3D tool is used to analyze a typical pressurized water reactor (PWR).

Use of patient safety culture instruments in operating rooms: A systematic literature review

2017 ◽  
Vol 10 (2) ◽  
pp. 145-151 ◽  
Author(s):  
Pujng Zhao ◽  
Yaqin Li ◽  
Zhi Li ◽  
Pengli Jia ◽  
Longhao Zhang ◽  
...  
Keyword(s):  
Patient Safety ◽  
Literature Review ◽  
Systematic Literature Review ◽  
Safety Culture ◽  
Patient Safety Culture ◽  
Operating Rooms

A Proactive Risk Assessment Methodology to Enhance Patient Safety: Reducing Wrong Site Surgery as a Preventable Medical Error

2020 ◽  
Vol 64 (1) ◽  
pp. 664-668
Author(s):  
Maryam Tabibzadeh ◽  
Gelareh Jahangiri
Keyword(s):  
Risk Assessment ◽  
Patient Safety ◽  
Integrated System ◽  
Wrong Site Surgery ◽  
Healthcare Settings ◽  
Enhance Patient Safety ◽  
Sentinel Events ◽  
Area Of Concern ◽  
Risk Assessment Methodology ◽  
Wrong Site

Patient safety has been a major area of concern over the last decades in the healthcare industry. The number of preventable medical errors in hospitals has been noticeably high. These errors are more likely to occur in intensive care units including Operating Rooms (ORs). Wrong site surgery is one of the critical sentinel events that occur in healthcare settings. This paper fills an important gap by proposing an integrated, system-oriented methodology for proactive risk assessment of operations in ORs, to specifically analyze the wrong site surgery issue, through the identification and monitoring of appropriate Leading Safety Indicators (LSIs) to evaluate the safety of those operations and generate warning/predicting signals for potential failures. These LSIs are identified across the layers of an introduced framework, which is built on the foundation of the Human-Organization-Technology (HOT) model originally developed by Meshkati (1992). This multi-layered framework captures the contributing causes of wrong site surgery.

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