Engaging the opioid epidemic head on: Improving proper disposal of unused opioid medications after surgery

2021 ◽  
Vol 17 (3) ◽  
pp. 189-194
Author(s):  
Rachael Haverland, MD, MS ◽  
Todd Luckritz, PharmD, RPh ◽  
Elisabeth Lim, MPH ◽  
Matthew R. Buras, MS ◽  
Johnny Yi, MD
Keyword(s):  
Demographic Data ◽  
The United States ◽  
Opioid Abuse ◽  
Gynecologic Surgery ◽  
Medical Provider ◽  
Written Information ◽  
Laparoscopic Excision ◽  
Medication Disposal ◽  
Opioid Medications ◽  
Proper Disposal

Background: Currently, in the United States, there is an epidemic of opioid abuse. While this problem is well known to the public due to significant media and political attention, patients are poorly educated on the proper handling and disposal of unused opioids. Instead, the onus has fallen on the healthcare provider to minimize the number of opioids prescribed.Study objective: To improve proper opioid disposal rates after gynecologic surgery by providing educational materials along with a disposal bag.Study design: We performed a prospective study evaluating baseline understanding of medication disposal using a questionnaire given to the patients during their preoperative visit. Subsequently, patients were provided written information on proper disposal of their medications and an activated charcoal medication disposal bag. Study patients completed a survey about disposal of their unused opioids at their last post-operative visit. The success of education and proper disposal of opioid medications were evaluated.Results: Thirty-five patients, average age of 45 (range 20-77), were enrolled, and 31 patients successfully completed both surveys. The surgeries performed included hysterectomy 23 percent (n = 7), laparoscopic excision of endometriosis 32 percent (n = 10), laparoscopic ovarian cystectomy 23 percent (n = 7), prolapse repair 3 percent (n = 1), and midurethral sling procedures 19 percent (n = 6). Chronic pelvic pain was identified in 39 percent (n = 12) of our patient population. Prior to education, 52 percent (n = 16) of patients did not dispose of their opioids. Furthermore, 71 percent (n = 22) of patients stated they had never been educated by a medical provider regarding appropriate disposal. Nineteen percent (n = 6) confirmed they have used an opioid medication prescribed to someone else. Demographic data show 65 percent (n = 20) of these patients had completed a college degree or greater. After education and being given a reliable option for medication disposal with the Deterra® bag, 94 percent (n = 29) of patients properly disposed of their opioids after surgery, demonstrating a 45 percent (p 0.001) increase in proper disposal. In our study alone, 491 tablets of 5mg oxycodone were properly disposed. The majority of patients, 77 percent (n = 24) used the drug disposal bag, and when queried, stated they would be willing to pay on average $7.70 (range 0-20) per bag. Without education and a simple option for disposal, 422 tablets prescribed may have been subject to inappropriate diversion.Conclusion: This study clearly shows that patient education, coupled with a reliable option for opioid disposal, is effective. We strongly encourage other surgical institutions to implement similar practices not only for our surgical patients’ safety, but also for the tens of thousands of patients who died of opioid abuse in the last year. 

Understanding Characteristics Of Users With Signs Of Opioid Misuse On Twitter (Preprint)

2020 ◽  
Author(s):  
Haya Jarad ◽  
Junhua Yang ◽  
Abeed Sarker
Keyword(s):  
United States ◽  
Pain Management ◽  
Religious Orientation ◽  
The United States ◽  
Opioid Abuse ◽  
Management Tool ◽  
Opioid Misuse ◽  
Major Health Problem ◽  
Personal Traits ◽  
And Behaviors

BACKGROUND Opioid misuse is a major health problem in the United States, and can lead to addiction and fatal overdose. The United States is in the midst of an opioid epidemic; in 2018, an average of approximately 130 Americans died daily from an opioid overdose and 2.1 million have an opioid use disorder (OUD). In addition to electronic health records (EHRs), social media have also been harnessed for studying and predicting physical and behavioral outcomes of OUD. Specifically, it has been shown that on Twitter the use of certain language patterns and their frequencies in subjects’ tweets are indicative of significant healthcare outcomes such as opioid misuse/use and suicide ideation. We sought to understand personal traits and behaviors of Twitter chatters relative to the motive of opioid misuse; pain or recreational. OBJECTIVE . METHODS We collected tweets using the Twitter public developer application programming interface (API) between April 13, 2018 – and May 21, 2018. A list of opioid-related keywords were searched for such as methadone, codeine, fentanyl, hydrocodone, vicodin, heroin and oxycodone. We manually annotated tweets into three classes: no-opioid misuse, pain-misuse and recreational-misuse, the latter two representing misuse for pain or recreation/addiction. We computed the coding agreement between the two annotators using the Cohen’s Kappa statistic. We applied the Linguistic Inquiry and Word Count (LIWC) tool on historical tweets, with at least 500 words, of users in the dataset to analyze their language use and learn about their personality raits and behaviors. LIWC is a text processing software that analyzes text narratives and produces approximately 90 variables scored based on word use that pertain to phsycological, emotional, behavioral, and linguistic processes. A multiclass logistic regression model with backward selection based on the BIC criterion was used to identify variables associated with pain and recreational opioid misuse compared to the base class; no-opioid misuse.. The goal was to understand whether personal traits or behaviors differ across different classes. We reported the odd ratios of different variables in both pain and recreational related opioid misuse classes with respect to the no-opioid misuse class. RESULTS The manual annotation resulted in a total of 1,164 opioid related tweets. 229 tweets were assigned to the pain-related class, 769 were in the recreational class, and 166 tweets were tagged with no opioid misuse class. The overall inter-annotator agreement (IAA) was 0.79. Running LIWC on the tweets resulted in 55 variables. We selected the best model based on BIC. We examined the variables with the highest odd ratios to determine those associated with both pain and recreational opioid misuse as compared to the base class. Certain traits such as depression, stress, and melancholy are established in the literature as commonplace amongst opiod abuse indiviuals. In our analysis, these same characteristics, amongst others, were identified as significantly positively associated with both the Pain and Recreational groups compared to the no-opioid misuse group. Despite the different motivaions for opiod abuse, both groups present the same core personality traits. Interestingly, individuals who misuse opioids as a pain management tool exhibited higher odds ratios for psychological processees and personal traits based on their tweet language. These include a strong focus on discipline, as demonstrated by the variables “disciplined”, “cautious” and “work_oriented”. Their tweet language is also indicative of cheerfulness, a variable absent in the recreational misuse group. Variables associated with the reacreational misuse group revolve around external factors. They are generous and motivated by reward, while maintaining a religious orientation. Based on their tweet language, this group is also characterized as “active”; we understand that these individuals are more social and community focused . CONCLUSIONS To our best knowledge, this is the first study to investigate motivations of opioid abuse as it relates to tweet language. Previous studies utilizing Twitter data were limited to simply detecting opiod abuse likelihood through tweets. By delving deeper into the classes of opioid abuse and its motivation, we offer greater insight into opioid abuse behavior. This insight extends beyond simple identification, and explores patterns in motivation. We conclude that user language on Twitter is indicative of significant differences in personal traits and behaviors depending on abuse motivation: pain management or recreation.

Operation of a hyperbaric oxygen therapy center in Korea: Report of our experience from a setting in its nascent stages

2019 ◽  
pp. 135-143
Author(s):  
Yoon Seop Kim ◽  
Yoonsuk Lee ◽  
Sun Ju Kim ◽  
Sung Oh Hwang ◽  
Yong Sung Cha ◽  
...  
Keyword(s):  
Critically Ill ◽  
Hyperbaric Oxygen ◽  
Critically Ill Patients ◽  
Demographic Data ◽  
Developed Countries ◽  
The United States ◽  
Medical Society ◽  
Hyperbaric Medicine ◽  
Therapy Center ◽  
Hbo2 Therapy

Purpose: Hyperbaric medicine is nascent in Korea when compared to other developed countries, such as the United States and Japan. Our facility has been managed by physicians with certifications from the Undersea and Hyperbaric Medical Society (UHMS) and National Oceanic and Atmospheric Administration in diving and clinical diseases since October 2016. This study was conducted to share similar issues that are encountered during the establishment of a program in a new area through our experiences in the operation of a hyperbaric oxygen (HBO2) therapy center. Methods: In this retrospective observational study we collected data on HBO2 patients treated at our center between October 2016 and June 2018 after HBO2 was conducted by HBO2-certified physicians. We then compared demographic data of patients with data from January 2011 to September 2015 – before HBO2 operations were conducted by HBO2-certified physicians. Result: A total of 692 patients received 5,130 treatments. Twelve indicated diseases were treated using HBO2 therapy. Fifty-six critically ill patients with intubation received HBO2. Although two patients experienced seizure due to oxygen toxicity during the study period, certified physicians and inside attendant took immediate corrective action. Conclusion: After the establishment of the HBO2 center operated by physicians with certification, more patients, including critically ill patients, received HBO2 safely for various diseases. In order to improve the practice of hyperbaric medicine in Korea, the Korean Academy of Undersea and Hyperbaric Medicine (KAUHM), an advanced and well-organized academic society, should communicate often with HBO2 centers, with the aim to set Korean education programs at UHMS course levels and increase reimbursement for HBO2 therapy.

scholarly journals Examining the Economic and Environmental Impacts of COVID-19 Using Earth Observation Data

2020 ◽  
Vol 13 (1) ◽  
pp. 5
Author(s):  
William Straka ◽  
Shobha Kondragunta ◽  
Zigang Wei ◽  
Hai Zhang ◽  
Steven D. Miller ◽  
...  
Keyword(s):  
Air Quality ◽  
Los Angeles ◽  
Environmental Impacts ◽  
Demographic Data ◽  
The United States ◽  
Earth Observation ◽  
Observation Data ◽  
Washington Dc ◽  
Mobility Data ◽  
Earth Observation Data

The COVID-19 pandemic has infected almost 73 million people and is responsible for over 1.63 million fatalities worldwide since early December 2019, when it was first reported in Wuhan, China. In the early stages of the pandemic, social distancing measures, such as lockdown restrictions, were applied in a non-uniform way across the world to reduce the spread of the virus. While such restrictions contributed to flattening the curve in places like Italy, Germany, and South Korea, it plunged the economy in the United States to a level of recession not seen since WWII, while also improving air quality due to the reduced mobility. Using daily Earth observation data (Day/Night Band (DNB) from the National Oceanic and Atmospheric Administration Suomi-NPP and NO2 measurements from the TROPOspheric Monitoring Instrument TROPOMI) along with monthly averaged cell phone derived mobility data, we examined the economic and environmental impacts of lockdowns in Los Angeles, California; Chicago, Illinois; Washington DC from February to April 2020—encompassing the most profound shutdown measures taken in the U.S. The preliminary analysis revealed that the reduction in mobility involved two major observable impacts: (i) improved air quality (a reduction in NO2 and PM2.5 concentration), but (ii) reduced economic activity (a decrease in energy consumption as measured by the radiance from the DNB data) that impacted on gross domestic product, poverty levels, and the unemployment rate. With the continuing rise of COVID-19 cases and declining economic conditions, such knowledge can be combined with unemployment and demographic data to develop policies and strategies for the safe reopening of the economy while preserving our environment and protecting vulnerable populations susceptible to COVID-19 infection.

Modelling disparities in health services utilisation for older Blacks: a quantile regression framework

2014 ◽  
Vol 35 (8) ◽  
pp. 1657-1683 ◽  
Author(s):  
ANDY SHARMA
Keyword(s):  
Health Services ◽  
Quantile Regression ◽  
Scale Effects ◽  
Ethnic Disparities ◽  
The United States ◽  
Models Of Care ◽  
Medical Intervention ◽  
Medical Provider ◽  
Absolute Deviation ◽  
The Best Approximation

ABSTRACTWith the on-going ageing of the United States population, resolving health disparities continues to be a prominent and worthwhile goal, particularly in the areas of promoting minority health and reducing racial/ethnic disparities. This analysis employs the 2004 and 2005 Household Component records from the Medical Expenditures Panel Survey, which correspond to data files H89 and H97, to examine utilisation by race across the entire distribution function; more specifically, applying the behavioural model of health services utilisation and employing a Quantile Regression (QR) framework. This is a noteworthy contribution because the conditional mean may not be the best approximation for a skewed-location distribution. In contrast, QR is robust to outliers and scale effects since the estimation minimises least absolute deviation. The sample consists of 2,525 older adults at least 65 years of age with 303 corresponding to Black and 2,222 corresponding to White. Results suggest older Blacks continue to utilise health services (i.e. office or clinic visits with a physician or medical provider) at lower levels and this is more pronounced at and below the median quantile (i.e. below the 50th cut-off). Usual source of care (USC) continues to play an important role. Beliefs surrounding the need for insurance and medical intervention are also significant and explain some of the racial disparities. Although utilisation disparities persist for older Blacks, collaborative and flexible models of care can reach this group.

scholarly journals Diagnostic Stewardship Effectively Reduces Healthcare-Onset Clostridioides difficile Infections and Concurrent Laxative Use

2020 ◽  
Vol 41 (S1) ◽  
pp. s189-s191
Author(s):  
Dipesh Solanky ◽  
Ian Drobish ◽  
Derek Juang ◽  
Scott Johns ◽  
Sanjay Mehta ◽  
...  
Keyword(s):  
Enteral Feeding ◽  
Demographic Data ◽  
Healthcare Facility ◽  
The United States ◽  
Nucleic Acid Amplification ◽  
Fiscal Year ◽  
Medication Cost ◽  
Laxative Use ◽  
Clostridioides Difficile ◽  
Test Ordering

Background:Clostridioides difficile infection (CDI) accounts for >500,000 community-, nursing-, and hospital-acquired infections (HAIs), as well as 15,000–30,000 deaths, and =$4.8 billion in the United States annually. C. difficile toxin B gene nucleic acid amplification testing (NAAT) cannot distinguish between active CDI and colonization, particularly in the setting of laxative use or enteral feeding. Lack of judicious testing can result in the incorrect diagnosis of CDI, unnecessary CDI treatment, increased costs, and falsely augmented HAI rates. Like many healthcare facilities, the VA San Diego Healthcare System (VASDHS) solely utilizes C. difficile NAAT for CDI diagnosis. The aim of this study was to implement and evaluate a facility-wide initiative at the VASDHS to reduce healthcare onset, healthcare facility associated CDI (HO-HCFA CDI), including the use of a test ordering algorithm. Methods: From fiscal year (FY) 2015–2018, various measures were implemented including a hand hygiene initiative, reduction in fluoroquinolone usage, prompt isolation of patients with CDI, thorough terminal cleaning of rooms, and, lastly, a test-ordering algorithm starting FY2018. A retrospective study was performed to assess VASDHS HO-HCFA CDI case incidence, risk factors for infection, laxative or enteral feeding use at the time of testing, and CDI treatment. Results: Patient demographic data, medical history, CDI history, laxative use, treatment, and cost of CDI treatment were reviewed. From 2015 to 2018, 127 cases of HO-HCFA CDI were identified. The total number of HO-HCFA CDI cases and medication cost for CDI treatment were dramatically reduced from 2017 to 2018 following implementation of the test-ordering algorithm (Table 1, Fig. 1). This trend corresponded to a significant reduction in median HO-HCFA CDI cases per month (P = .02), medication cost of CDI treatment (P = .02), and proton pump inhibitor (PPI) use at the time of testing (P = .01). The number of positive HO-HCFA CDI cases associated with laxative use or escalation at the time of CDI testing (accounting for those on chronic laxatives) also decreased across the study period—most dramatically from 2015 vs 2016 (20 vs 14) and 2017 vs 2018 (11 vs 4) (Table 1). Conclusions: At the VASDHS, diagnostic stewardship of C. difficile NAAT with the use of a test-ordering algorithm significantly reduced HO-HCFA CDI incidence and treatment cost. This trend also corresponded with significantly less PPI use at the time of testing and reduced detection of colonization among patients with laxative-induced diarrhea. Diagnostic stewardship may serve as an effective tool to correctly diagnose and treat HO-HCFA CDI, while significantly reducing treatment costs.Funding: NoneDisclosures: None

Opioid Therapy for Chronic Noncancer Pain: Safe, Effective, Appropriate?

2016 ◽  
Author(s):  
Joseph V. Pergolizzi Jr ◽  
Robert B. Raffa ◽  
Robert Taylor ◽  
Jo Ann LeQuang
Keyword(s):  
Risk Factors ◽  
Chronic Pain ◽  
Elderly Patients ◽  
The United States ◽  
Opioid Therapy ◽  
Abuse Liability ◽  
Opioid Abuse ◽  
Individual Risk ◽  
Chronic Noncancer Pain ◽  
Routes Of Administration

In determining the appropriate role of opioids, two public health crises must be balanced: the opioid abuse epidemic and the “silent” crisis of unrelieved chronic pain. Opioids can be used safely and effectively in selected patients; however, clinicians must be aware of their abuse liability and individual risk factors for opioid misuse. A number of opioids are approved for use in the United States, and although there are class effects, there can be great variability among patients with regard to opioid response. In addition to the medication, prescribers must also determine the most appropriate dose and route of administration. Considerations must be made for special population, such as the renally impaired, those with hepatic dysfunction, and pediatric and elderly patients. Another factor is abuse-deterrent properties. Of particular interest as an opioid agent is buprenorphine, which is available in various routes of administration and because of its unique pharmacokinetics may be administered to renally compromised and elderly patients without dosing restrictions. Buprenorphine is also associated with a lower abuse liability than other opioids. Patients suffering moderate to severe pain syndromes should not be denied access to effective pain control, which in some cases may appropriately include opioid therapy. Key words: Buprenorphine, Chronic Pain, Opioid, Opioid Abuse, Opioid Prescribing, Risk Factors for Opioid Abuse

Abstract TP383: Ischemic Stroke Patients With Diabetes Looking for Practices in Need of Improvement

Stroke ◽  
2020 ◽  
Vol 51 (Suppl_1) ◽  
Author(s):  
Cynthia Bautista ◽  
Sally Gerard
Keyword(s):  
Ischemic Stroke ◽  
Cause Of Death ◽  
Demographic Data ◽  
Stroke Care ◽  
The United States ◽  
Stroke Patients ◽  
Co Morbidity ◽  
Patients With Diabetes ◽  
Care Outcomes ◽  
Stroke Center

Background/Purpose: Stroke is the fifth leading cause of death and Diabetes is the seventh leading cause of death in the United States. Diabetes is an independent risk factor for stroke. Diabetes is a common co-morbidity in stroke patients and is associated with poor outcomes after stroke. Get with the Guidelines - Stroke (GWTG-S) Registry database provides a rich opportunity to look at disease-specific data and find opportunities for improving care. The purpose of this study was to examine specific elements of acute ischemic stroke care in patients with diabetes using the GWTG-S at Comprehensive and Primary Stroke Centers in Northeast of America. Methods: A retrospective, descriptive study at both a Comprehensive and Primary Stroke Center. The analysis focused on patients with ischemic stroke and diabetes entered in the GWTG-S from January 1, 2015, to December 31, 2017. Data were analyzed looking at measures specific to stroke and the presence of diabetes. General demographic data were examined to compare populations and quality outcome measures. Results: The sample of patients with ischemic stroke and diabetes was over 1,000 patient’s at the two sites (Comprehensive site N = 804, Primary site N = 203) Incidence of ischemic stroke with diabetes at the two sites were 32% and 26%, respectively. Demographic data were similar in most categories including age, race, and gender. Significant differences were found in regard to the type of insurance. Stroke care outcomes indicated thrombolytic administration rates were the same at 8%. Diabetes care outcomes indicated patients discharged on insulin occurred in 18% to 26% of the sample. Conclusion/Implications for Practice: Ischemic stroke patients with diabetes were shown to receive similar care at both a comprehensive and primary care stroke center. There were no differences between centers in thrombolysis treatment for ischemic stroke patients with diabetes. Several opportunities for improvement in diabetes-related care need to be addressed.

scholarly journals Mismanagement of Solid Waste & its Impact on the Environment of Peshawar City

2012 ◽  
Vol 2 (4) ◽  
pp. 182
Author(s):  
Obaid-ur- Rehman ◽  
Syed Jamil Hassan Kazmi ◽  
Anwar Alam
Keyword(s):  
Local Government ◽  
Solid Waste ◽  
Demographic Data ◽  
Solid Wastes ◽  
Phase Iii ◽  
Sample Surveys ◽  
Interview Schedule ◽  
Afghan Refugees ◽  
Demographic Yearbook ◽  
Proper Disposal

The purpose of the study is to investigate reasons, types and workable for the disposal of wastes in Peshawar city with special emphasis on Municipal Corporation, Peshawar Development Authority (PDA) and local govt. The focus of the study is to ensure proper management of solid waste and cleanliness of the targeted areas. The data was collected through pre-designed questionnaire and interview schedule. The major sources of demographic data are census, sample surveys, demographic yearbook, statistical handbook, national and international publications. (Alam: 2006). Board, Karkhano and Hayat Abad Phase III were the targeted area of the study. A sample of size 300 was selected out of 37,839 population in three target areas i.e. Board 96 out of 12,164, Hayat Abad Phase III 121 out of 15,281, and Karkhano 83 out of 10,394 through proportion allocation method of sampling.The results of the study indicated that Local government has no proper planning, for the disposal of solid waste. The  residents  have no awareness for the proper disposal of the solid wastes.  Population is directly proportion to the increase in solid wastes mismanagement, more over Afghan Refugees has accelerated the solid waste mismanagement in the area. 

scholarly journals Optimizing Screening for HIV

2020 ◽  
Author(s):  
Antoine Chaillon ◽  
Martin Hoenigl ◽  
Lorri Freitas ◽  
Haruna Feldman ◽  
Winston Tilghman ◽  
...  
Keyword(s):  
At Risk ◽  
Screening Program ◽  
Demographic Data ◽  
The United States ◽  
Hiv Prevalence ◽  
Screening Tests ◽  
Transmitted Infection ◽  
Sexually Transmitted ◽  
At Risk Populations ◽  
Zip Code

Abstract Background The HIV epidemic is unevenly distributed throughout the United States, even within neighborhoods. This study evaluated how effectively current testing approaches reached persons at risk for HIV infection across San Diego (SD) County, California. Methods HIV case and testing data, sexually transmitted infection (STI) and socio-demographic data for SD County were collected from the SD Health and Human Services Agency and the ‘Early Test’ community-based HIV screening program between 1998 and 2016. Relationships between HIV diagnoses, HIV prevalence, and STI diagnoses with screening at zip code level were evaluated. Results Overall, 379,074 HIV tests were performed. The numbers of HIV tests performed on persons residing in a zip code or region overall strongly correlated with prevalent HIV cases (R2=0.714), new HIV diagnoses (R2=0.798), and STI diagnoses (R2=0.768 [chlamydia],0.836 [gonorrhea], 0.655 [syphilis]) in those regions. Zip codes with the highest HIV prevalence had the highest number of tests per resident and fewest number of tests per diagnosis. Even though most screening tests occurred at fixed venues located in high prevalence areas, screening of residents from lower prevalence areas was mostly proportional to the prevalence of HIV and rates of new HIV and STI diagnoses in those locales. Conclusion This study supported the ability of a small number of standalone testing centers to reach at-risk populations dispersed across SD County. These methods can also be used to highlight geographic areas, or demographic segments that may benefit from more intensive screening.

scholarly journals Estimating the Number of Agricultural Fatal Injuries Prevented by Agricultural Engineering Developments in the United States

Safety ◽  
2019 ◽  
Vol 5 (4) ◽  
pp. 63
Author(s):  
Salah F. Issa ◽  
Kiana Patrick ◽  
Steven Thomson ◽  
Bradley Rein
Keyword(s):  
United States ◽  
Direct Reduction ◽  
Demographic Data ◽  
The United States ◽  
Current Status ◽  
United States Bureau ◽  
Agricultural Engineering ◽  
Agricultural Safety ◽  
The Impact ◽  
Fatal Injuries

Agriculture has been consistently marked as one of the deadliest industries by the United States Bureau of Labor Statistics (BLS). While this statistic is widely used in promoting agricultural safety and health, it does not paint a complete picture on the current status of agricultural safety and the advances that have been made in the last century. For example, even with a stagnant rate of injury, the BLS has reported that fatal incidents decreased from a high of 855 incidents in 1993 to a low of 500 incidents in 2013. The purpose of this study was to analyze the impact that agricultural engineering developments had on reducing fatal injuries. Agricultural engineering developments are defined as any agricultural improvement that results in a direct reduction in the amount of labor needed. This study uses existing federal agricultural statistical, injury and demographic data to calculate the impact that engineering, in contrast to yield improvements and safety enhancements, contributed to a reduction in the number of fatal incidents. The study found that engineering developments could have contributed to the reduction in the number of fatal injuries by about 170 incidents from 1992 to 2015. This represents 63% of the total reduction in the number of fatal injuries. In conclusion, agricultural engineering developments play a substantial role in reducing the number of fatal incidents by removing and reducing labor exposure to hazardous environments.

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