Dissertations / Theses on the topic 'Process Safety Management'

With the expected growth in air transportation, one can experience an increase in the number of incidents and accidents, despite constant or even slightly declining accident and incident rates. Therefore, it is necessary to examine how to improve aviation safety even further. Several studies and statistical analyses show that most accidents result from human and organizational factors, encompassing pilot error, training deficiencies, management error, an ineffective organizational structure, and a lack of safety culture. In these regards, Aviation Safety Management Systems are widely acknowledged as a managerial tool whereby risks and hazards can be managed to avoid the occurrence of an accident. A Safety Management System is an integrated set of process, beliefs and procedures for identifying, classifying, monitoring and managing the hazard and risk for the safety of the organization. It must include, at least, a safety policy which express commitment from upper management; an effective safety reporting system; a hazard and risk analysis; procedures to determine actions to reduce or eliminate risks; training process which keeps staff trained, informed and upgraded about safety issues; and an evaluating process to ensure that the safety management system remains effective and relevant to the organization. The objective of this dissertation is to define the basic elements (processes) of a Safety Management System, describing its characteristics and the way it can be implemented, and to propose a Safety Management Process to be implemented at an aeronautical industry. It also can be implemented in any other kind of industry that looks forward to improve safety and reduce the number of accidents and incidents. Nonetheless, the process must be customized to meet the characteristics of this industry.

Thesis (S.M.)--Massachusetts Institute of Technology, System Design & Management Program, February 2002.
"November 2001."
Includes bibliographical references (leaf 85).
by Adnan (Eddie) Khan.
S.M.

Thesis (MBA)--Stellenbosch University, 2013.
ENGLISH ABSTRACT: The process safety culture maturity of Sasol Infrachem; namely, Infragas, the Water and Waste, Ammonia and Steam Stations plants, are assessed using human factors dimensions related to man-machine, employee job roles and organisational culture interfaces. Numerous global process safety incidents resulting in catastrophic consequences originating from human and organisational factors have encouraged the organisation to investigate the underlying human factors concerned, and to identify and manage key risks undermining process safety maturity. The research study construct utilises internationally recognised standards to assess process safety maturity which consists of human factors perception surveys supported by employee interviews, process safety sustainability audits, incident reporting effectiveness and assessing the underlying leadership behaviours. Perception surveys and interviews are used to find similarities or differences found in sustainability progress and incident reporting. Primary leadership drivers that hinder process safety maturity related to unwillingness to accept accountability, employee blame, fear and lack of trust are associated with ineffective process safety incident reporting and lack of organisational learning. Key human factors risks identified and assessed in the study are additional resources required to update operating procedures, the provision of employee competence assurance and ineffective safety communication related to equipment labelling that has caused occurrence of repeat process safety incidents. Three process safety maturity models are used to assess the four plants based on commitment towards continuous improvement; incident reporting effectiveness and examining interdependent team leadership behaviours through process safety balance scorecard metrics. The research results indicate the process safety maturity levels in decreasing order are Infragas, Ammonia, Water and Waste and Steam Stations plants. Suggestions are made to accelerate process safety maturity with the aim of effective interchange of knowledge, experience and behaviours related to man-machine, employee job roles, organisational culture and leadership dimensions.

Thesis (S.M.)--Massachusetts Institute of Technology, System Design & Management Program, 2003.
Includes bibliographical references (leaves 131-132).
The International Space Station has the potential to serve as a unique test platform to enable technologies for a wide array of manned and unmanned NASA missions. In order to live up to its promise, the resources required to develop and fly an experiment on the Station must be commensurate with the scientific return that will be obtained. This thesis applies the set of tools and principles known collectively as Lean Engineering to the Payload Safety Review process, one of the activities that must be satisfied by payloads prior to flying. The goal of this study is to attempt to reduce the required resources needed to fly a payload on the Station. Using the MIT Lean Aerospace Initiative Transformation to Lean roadmap, three separate payload examples of increasing degree of complexity are analyzed. Value streams are derived, and estimates for duration and labor requirements are presented based on past experience and data obtained from various stakeholders. Opportunities for waste (muda) reduction are identified. In addition, a comparative analysis is presented where the Safety Review Process is contrasted to similar issues faced by industry over the last several decades as manufacturing processes were transformed in order to increase quality while simultaneously reducing cost. Insights from these analyses, supported by stakeholder data from payload developers and the NASA Payload Safety Review Panel, are used to suggest a redesign to improve the Safety Review process. Three specific recommendations are proposed: 1) Establishment of a group outside NASA that can provide experienced, design assistance to payload developers as an integral part of their design teams; 2) Empowerment of these integrated teams through elimination of the
(cont.) monuments created by intermediary safety reviews conducted by organizations outside the control of the Payload Safety Review Panel; and 3) Preparation of a Safety Verification and Review Plan at the start of each development effort which would contain the schedule and content for all safety-related review activities and data submittals, and would pull these activities throughout the process only when necessary. The revised process reduces the number of discrete steps from a maximum of 27 to 10. Duration of the process and the amount of labor required to complete it are reduced by up to 60% and 20%, respectively. Cost savings on the order of $10 million/year, depending on the number and complexity of the payloads, are obtained.
by Javier de Luis.
S.M.

Thesis: S.M. in Engineering and Management, Massachusetts Institute of Technology, Engineering Systems Division, 2014.
Cataloged from PDF version of thesis.
Includes bibliographical references (page 211).
The Air Force Test Center (AFTC) faces new challenges as it continues into the 21st century as the world's leader in developmental flight test. New technologies are becoming ever more sophisticated and less transparent, driving an increase in complexity for tests designed to evaluate them. This shift will place more demands on the AFTC Safety Management System to effectively analyze hazards and preempt the conditions that lead to accidents. In order to determine whether the AFTC Safety Management System is prepared to handle new safety challenges, this thesis applied Dr. Nancy Leveson's Systems-Theoretic Process Analysis (STPA) technique. The safety management system was analyzed and potential safety constraint violations due to systemic factors, unsafe component interactions, as well as component failures were investigated. The analysis identified the key features that make the system effective; gaps in the sub-processes, roles, responsibilities, and tools; and opportunities to improve the system. These findings will provide insights on how the AFTC Safety Management System can be improved with the aim of preventing accidents from occurring during flight test operations. Finally, this thesis demonstrated the effectiveness of the STPA technique at hazard analysis on an organizational process.
by Nicholas Chung.
S.M. in Engineering and Management

Appropriate access management techniques can improve the safety and efficiency of arterial roads. In order to determine which roads can most benefit by the implementation of access management techniques, a prioritization process was developed to recommend various access management treatments such as limiting access points, installing raised medians, and ensuring adequate signal spacing along corridors. To serve as the basis for the performance index, a database was created including identifying features, characteristics, and crash history for 175 arterial road segments on Utah state routes. Stepwise linear regression was applied to the data collected to determine which characteristics of the roads were correlated with crash rate, crash severity, and specific collision types. Signal spacing, access density, and median type were all determined to be correlated with crash rates and crash severity. Specifically, signals per mile, access density, and two-way left-turn lanes were all positively correlated with crashes. Other characteristics such as adjacent land use and volume were also analyzed. Finally, recommendations for access management treatments were given in the form of a decision tree. The decision tree may be used to classify existing or future road segments into subcategories based on volume, signal spacing, land use, and other criteria, with recommendations provided for each subcategory.

Within the health care system, patient safety outcomes have been criticized for many years. Medical malpractice, common errors, and nosocomial infections (i.e., hospital-acquired infections) are safety concerns, and represent a public health problem. Since the Institute of Medicine (1999) published To Err is Human: Building a Safer Health System in 1999, changes have been made to improve the use of technology and leverage advancements in research that improve patient safety. Nurse leaders can also help to facilitate process improvements in the patient safety culture. The purpose of this capstone project was to explore the nursing leader role in improving patient safety in a hospital setting. The method utilized for this study was a literature review. Prominent articles identifying the role of nursing leadership were included. Seven drivers of patient safety were identified (Sammer, Lyken, Singh, Mains, & Lackan (2011), and subsequently informed this project. The targeted populations were patients, families, nurses, nurse administrators, and medical personnel. Findings regarding the nurse leader role, patient improvements, and barriers to improvements were reviewed. Nurse leaders were found to be of critical importance to patients, medical personnel, and the health care system. The limitations of this review and implications for policy and practice are discussed.

The relationship between mismanagement of information and its adverse effect on plant safety in the process industry is now widely recognised. Ignorance of essential facts and messages will lead inexorably to a catastrophic outcome. This process has been called an 'information disaster'. Many incidents provide lessons on improving Safety Information Management (SIM). Evaluating SIM performance can provide interventions to prevent disasters and improve plant safety. In order to improve SIM performance for the process industry, this research adopted the Balanced Scorecard (BSC) concept to design a performance measurement framework. The framework includes four 'perspectives' and twenty-eight 'indicators' with their own measures. The framework has been developed from an extensive literature review, a plant investigation and two incremental surveys, one of professional opinion in the process industry in Taiwan and the second a broader verification from experts.

The research described in this thesis provides a comparative study of the impact of Process Safety Management System (PSMS) performance and Human Error rates on off-site risk from two major hazards sites in Malaysia. One of the sites was built and run by a multinational company until a few years ago while the other was built and run by a local company since its inception. The sites handle bulk quantities of ammonia for downstream distribution. The study considers: the assessment of the sites PSMS performance using a structured audit technique the assessment of human error potential from ammonia road-tanker filling operations assessing the impact of site PSMS and human error potential on off-site risk from the sites investigating the possibility of linking the assessment of site PSMS performance with human error potential Results of Quantitative Risk Assessment (QRA) conducted on the two sites showed a significant difference in terms of individual and societal risk when site specific PSMS performance and human error potential are taken into consideration. The use of site specific Management Factor (MF) and site specific Human Error Probabilities (HEPs) produces a significant impact on the results of the off-site risk as compared to estimates of risk based only on generic failure rates. This finding emphasized the need to consider explicitly the contribution of site specific PSMS performance and human error potential in major hazard risk assessment especially in developing countries like Malaysia where there exists significant differences on these factors between locally owned and multinational sites. The approach to link the results of the site specific PSMS performance audit with the assessment of human error potential was found to be inadequate to describe all the influences which will be exerted on the reliability of individual tasks involving human error potential.

Thesis: M.B.A., Massachusetts Institute of Technology, Sloan School of Management, 2019, In conjunction with the Leaders for Global Operations Program at MIT
Thesis: S.M., Massachusetts Institute of Technology, Department of Mechanical Engineering, 2019, In conjunction with the Leaders for Global Operations Program at MIT
Cataloged from PDF version of thesis.
Includes bibliographical references (pages 76-77).
In an ideal production system, supply exactly meets demand. Instantaneous, correct quantities arrive exactly at the right location when needed. However, real-world production systems often have variability- a change in the quantity demanded, a broken part, a shipping delay for a snow storm. The variability can be random, so companies are left with a dilemma: too little inventory buffer and a shortage may occur; too much inventory and capital is unnecessarily tied up in inventory sitting on the shelves. Using research conducted at the Boeing 737 program as a case study, this thesis proposes the application of a multi-step approach to optimize the total cost of the production system, balancing holding cost (inventory) with the disruption cost of a shortage. The initial pilot shows that small increases in inventory can have an order of magnitude of cost avoidance. The methodology includes system observation, qualitative interviews with Boeing employees, quantitative data gathering and analysis, proposed changes, and measured results. First, the historical supply and demand variability of the system is identified. Second, the cost of a shortage is estimated for the system. Next, an analytical approach to set safety stock levels is applied to balance the cost of inventory held with the cost of a shortage. By reducing the variability in the system, inventory levels can be reduced while maintaining the service levels. This process is then repeated at regular intervals to optimize the total cost of the system, balancing inventory holding cost and the disruption cost of a shortage.
by Jacob Philip Pellegrini.
M.B.A.
S.M.
M.B.A. Massachusetts Institute of Technology, Sloan School of Management
S.M. Massachusetts Institute of Technology, Department of Mechanical Engineering

Thesis: S.M. in Engineering and Management, Massachusetts Institute of Technology, School of Engineering, System Design and Management Program, 2017.
Cataloged from PDF version of thesis.
Includes bibliographical references (pages 60-65).
Although the use of anti-neoplastic chemotherapy provides benefit to patients with both malignant and non-malignant diseases, the use of these agents can be at times associated with safety concerns for both patients and the healthcare workers that administer the medication. In order to mitigate the risks or hazards that are identified there are several potential tools to consider. The tool considered for this thesis will be applying a System Theoretic Accident Model and Processes (STAMP). STAMP is used to investigate the safety of complex systems involving humans, organizations, computers, and other equipment. STAMP has the advantage of facilitating the understanding of highly complicated environments where traditional safety techniques become too costly and cumbersome and hence less efficient. "In the traditional causality models, accidents are considered to be caused by chains of failure events, each failure directly causing the next one in the chain" (Leveson, Engineering a Safer World, 2011). This view is rather different from the perspective taken by STAMP. In STAMP, accidents arise from complex processes involving, not just component failures and faults, but also system design errors, unintended component interactions, human errors, management oversight inadequacies, and more (Leveson, 2011). This thesis presents the "control structure" component of STPA as derived from inputs from healthcare workers particular to the Dana-Farber Cancer Institute. The suggested control structure will ultimately lay the groundwork for future work on a detailed Systems-Theoretic Process Analysis (STPA) and generate specific recommendations to help address the identified risks and hazards in addressing patient safety issues.
by Harding J. Hall.
S.M. in Engineering and Management

Thesis (MBA)--Stellenbosch University, 2012.
ENGLISH ABSTRACT: Severe flooding in Queensland, Australia in late 2010 and into February of 2011 resulted in significant losses to infrastructure, equipment and coal production. Xstrata Coal (XC) mines suffered billions of dollars worth of losses, resulting in insurance premiums increasing drastically in subsequent months. These events prompted Xstrata‟s top management to reconsider the way in which they managed risk. Initial revelations were that the focus of Risk Management had largely been on the areas of Health and Safety and that, particularly in South Africa, the outcome of all management‟s efforts to manage risk had been to comply with the relevant legislation. There was clearly an attempt to avoid litigation resulting in potential prosecution. The most stringent of this legislation was that of the Mine Health and Safety Act (No. 24 of 996), as promulgated by the Department of Mineral Resources. The requirements were prescriptive to the extent that mine management was required to utilise the Hazard Identification Risk Assessment process to identify hazards, assess the associated risk and apply mitigation, largely in order to prevent incidents which could affect the health and safety of employees. Little regard was given to the fact that mining houses could endure severe financial losses as a result of catastrophic events, which could stop production for significant periods of time. Whilst Xstrata did recognise Business Continuity Risk (BCR), the risk assessment process which was introduced along with the CURA risk register displayed a distinct division between Health and Safety Risk and BCR. Furthermore, this was not a systematic process. Initial risk categories were prescribed by XC mainly based on experiences in Australia. The floods prompted a rethink and Xstrata‟s prescription to conduct business continuity risk assessments (BCRAs) coincided perfectly with this writer‟s exposure to the Enterprise Risk Management Elective at the University of Stellenbosch‟s Business School. As the General Manager of the iMpunzi Complex that comprises three coalmines, it was the responsibility of the writer to carry out the instruction to review the business continuity process. Consequently, the research is intended to assess the current Risk Management environment within Xstrata Coal South Africa by means of an analysis of current documentation and interviews with select key personnel who largely influence and impact the management of risk in the company. Thereafter, the study will progress to the methodology involved in the Risk Assessments, followed by an assessment of the knowledge, skills and qualifications required for the relevant, accountable managers appointed to manage the risks. The findings of the research were that whilst there was quite a rigid framework, which was aligned with ISO 31000 principles for risk management, there were shortcomings in the methodology of the risk assessment process, as well as the considerations for dealing with latent or residual risk. To this extent, the writer recommended: A risk assessment template which prescribes, but is not limited to, the hazards which may be prevalent on a coal mine, including hazards specific to iMpunzi Complex; A revised template for the Risk Treatment Plan, which takes cognisance of Residual Risk; Other recommendations, which may deal with minor findings of the study.

El texto completo de este trabajo no está disponible en el Repositorio Académico UPC por restricciones de la casa editorial donde ha sido publicado.
The present research seeks to show the importance of applying process management techniques and food safety norms in the operational processes of the supply chain to know the meaning and the need for an integrated hybrid model. The article reviews the sugarcane distillery sector of Peru and its main operational problems. Based on the literature reviewed and discussed with academics who have knowledge of the food supply chain, an integrated hybrid model was developed to help any distillery with lower levels of competitiveness than its competitors in other sectors, such as pisco, applying techniques of process management and food safety to increase the efficiency of liquor distilleries. The findings confirm that distilleries can increase their efficiency, thanks to the higher performance of their operations after their alignment with the integrated model.
Revisión por pares

Process monitoring in the chemical and other process industries has been of great practical importance. Early detection of faults is critical in avoiding product quality deterioration, equipment damage, and personal injury. The goal of this dissertation is to develop process monitoring schemes that can be applied to complex process systems. Neural networks have been a popular tool for modeling and pattern classification for monitoring of process systems. However, due to the prohibitive computational cost caused by high dimensionality and frequently changing operating conditions in batch processes, their applications have been difficult. The first part of this work tackles this problem by employing a polynomial-based data preprocessing step that greatly reduces the dimensionality of the neural network process model. The process measurements and manipulated variables go through a polynomial regression step and the polynomial coefficients, which are usually of far lower dimensionality than the original data, are used to build a neural network model to produce residuals for fault classification. Case studies show a significant reduction in neural model construction time and sometimes better classification results as well. The second part of this research investigates classification trees as a promising approach to fault detection and classification. It is found that the underlying principles of classification trees often result in complicated trees even for rather simple problems, and construction time can excessive for high dimensional problems. Fisher Discriminant Analysis (FDA), which features an optimal linear discrimination between different faults and projects original data on to perpendicular scores, is used as a dimensionality reduction tool. Classification trees use the scores to separate observations into different fault classes. A procedure identifies the order of FDA scores that results in a minimum tree cost as the optimal order. Comparisons to other popular multivariate statistical analysis based methods indicate that the new scheme exhibits better performance on a benchmarking problem.

The thesis deals with the issue of the formulation of new requirements to the development of new product with regard to the development of carbon-free economy and product safety improvement. The first part of the thesis describes the state of art of science and technique in the field of process management and the life cycle of a machine tool with emphasis placed on the machine tool development together with requirements and recommendations of ISO 9001:2016 – Quality Management Systems – Requirements. The second part of the thesis includes a research of legislative requirements concerning machine safety and environmental aspects of the design of the machine to be manufactured. The practical part focuses on an analysis of key processes of the company of TOS KUŘIM – OS, a.s. with emphasis placed on safety and environmental friendly design processes with suggestions concerning improvement of processes with implemented sub-processes necessary for the identification and verification of safety. A sub-process that allows for the manufacture of machines able to meet requirements of environmental friendly design is implemented to the processes. The thesis has practical implications for the introduction of automated sub-process of the identification and verification of safety requirements and implementation of the product development in the framework of future environmental friendly design development requirements to the products of TOS KUŘIM – OS, a.s.

Safety and security have emerged as a major force driving change in the multinational hotel industry. As a problem area not well-developed in the literature but considered a crucial force influencing hotel firms' value by the multinational hotel community, safety and security provide an excellent opportunity for industry professionals and academic researchers to improve the value creation of multinational hotel firms. A research need is more urgent in the upscale sector of the industry, and thus, an upscale brand of multinational hotel firm was selected for this study. This case study investigated how a multinational hotel firm developed a process of valuing its investments in safety and security for its properties under an upscale brand. This European hotel firm operates in twenty countries with a variety of business climates. The differences in the remote environments, namely the political, economic, socio-cultural, technological, and ecological environments, presented a great opportunity to gather different views regarding safety and security investments from hotel managers. The dimensions of hotel safety and security were identified by management teams running the firm's hotels to provide scope for decision-making. With this scope, the management teams continued to develop a framework for assessing the value generated from investments in safety and security by identifying the components of an investment decision-making model. A framework as a result of this exploratory study is suggested for future research where causality can be specified and a descriptive decision-making model can be built.
Ph. D.

The management of health and safety risks in the oil refinery tends to be centred on the collection and simulation of technical data which can then be used to make decisions on the wellbeing of the workforce as well as the refinery installations. While the number crunching in the process is immensely vital, there tends to be a problem of ignoring or, at the very least, side-lining the social-cultural values of the people dealing with health and safety risk assessment processes. The economic driver for the operation of the oil refinery tends to be more important because of the generally huge initial financial outlay, and the eventual high costs of maintenance; hence health and safety risk management should have evidence of ensuring that the installations, as well as the people that work in them, are well catered for. In the Kuwait Gulf Oil Company this problem is more evident in newer installations where lean management processes have been instituted by oil firms so that they can reduce waste in the oil refining process without compromising the occupational health and safety needs of the refinery. Therein lies the initial problem of integrating health and safety risk assessment processes because most approaches concentrate on the technical elements of waste elimination while ignoring the social-cultural factors that impact on the health and safety of the workforce. This is an exploratory piece of research that examines the impact of rational and cognitive decision theories – herein called the psychology of risk – and how they impact on the occupational health and safety systems in the oil and gas refining sector of Kuwait. The research concludes that the application of lean concepts in the oil refining process is noble in itself but it needs to be integrated with the rational and cognitive detection factors that are necessary to incorporate and support the social-cultural tendencies of the workforce. The research recommends a framework for incorporating social-cultural values in the decision making process pertaining to health and safety risk assessment in oil refining process plants. Key Words: occupational health and safety risk assessment; lean management; social-cultural values; rational and cognitive decision making; oil and gas process plants.

Vårdprocessen beskriver patientens väg genom vården där utgångspunkten är patientens behov och slutpunkten är då behovet av vård upphör och patienten är färdigbehandlad. Ett grundläggande kvalitetskrav är att vården är säker och att patienten inte riskerar att skadas i vårdprocessen. Den mycket uppmärksammade rapporten "To err is human", som kom i slutet av 1990-talet, visade att ett stort antal dödsfall och medicinska felbehandlingar orsakades av hälso- och sjukvården. Rapporten blev startskottet i en världsomspännande debatt om patientsäkerhet som påverkat säkerhets- och systemsyn. Idag ses felhandlingar inte längre som ett hinder utan som en möjlighet till lärande och ny kunskap. Begreppet patientsäkerhet har lyfts fram och vikten av att vårdprocesserna leder till goda resultat tydliggörs allt mer. Inom alla verksamheter inträffar oförutsedda händelser som får oönskade effekter, något som avviker från det förväntade. En avvikelse definieras som en händelse som inte följer normal rutin och förväntade vårdförlopp. Några av dessa händelser rapporteras och analyseras avseende bakomliggande orsak och allvarlighetsgrad av det inträffade samt sannolikhet för upprepning bedöms. Det saknas dock en övergripande riskvärdering av avvikelser i vårdprocessen och kunskap om var i de olika processerna som de allvarligaste riskerna förekommer. Syftet med studien var att belysa riskvärderade avvikelser i vårdprocessen. Studien bygger på empirisk retrospektiv analys av insamlad data i form av inkluderade data från elektroniskt avvikelsehanteringsverktyg under en period av tolv månader vid ett sjukhus som bedriver elektiv kirurgisk vård. Varje avvikelse riskvärderades, där grad av allvar (gradering 1-4) multiplicerades med sannolikhet för upprepning (gradering 1-4). Ett riskvärde, större eller lika med åtta, klassificerades som avvikelser med hög risk och mindre än åtta som avvikelser med låg risk. Därefter analyserades rapportörens berättelse av vad som inträffat och händelsen relaterades till var i huvud- eller stödprocess den inträffat. Avvikelser med hög risk i huvudprocessen, 67 procent, förekom vid vårdplanering och inskrivning och 33 procent vid utskrivning. Avvikelser med låg risk förekom vid vårdplanering, operation/behandling/omvårdnad samt vid postoperativ vård på uppvakningsavdelning, 67 procent. Av avvikelser med hög risk i stödprocesserna förekom 67 procent i den fysiska arbetsmiljön och 17 procent inom HR/personal och 17 procent inom sterilprocessen. Avvikelser med låg risk i stödprocesserna förekom företrädesvis i den fysiska arbetsmiljön, 54 procent. En systematisk riskvärdering av avvikelser visar vilka områden i vårdprocessen som kräver förbättringsåtgärder och skulle kunna skapa förutsättningar för en säkrare väg för patienten, samt skulle kunna stärka medarbetarnas riskmedvetenhet. Inledning och avslutning av vårdprocessen är områden som ur patientsäkerhetsperspektiv kan förbättras

Nurses have a key role in keeping patients safe from medical errors because they work at the point of care where most errors occur. Nursing work at the intersection of patients and health care systems requires high levels of cognitive activity to anticipate potential problems and effectively respond to rapidly evolving and potentially harmful situations. The literature describes nursing work at the intersection of patient and health care system as well as barriers to providing safe patient care. However, little is known about the systems knowledge nurses use to negotiate the health care system on their patients’ behalf, or how this systems information is exchanged between nurses. Using the clinical microsystem as the conceptual framework, this qualitative descriptive investigation identified and described: 1) the components of systems knowledge needed by nurses, 2) how systems information is exchanged between nurses, and 3) systems information exchanged between staff nurses and travel nurses. Data were collected from a stratified maximum variation sample of 18 nurse leaders, staff nurses, and travel nurses working within a high-functioning neonatal intensive care nursery within a large academic medical center in New England. Data collection methods included participant observation, document review, individual interviews, and a focus group session. Data were analyzed through constant comparison for emerging themes and patterns. Findings were compared for commonalities and differences within and across groups. Three components of systems knowledge emerged: structural, operational, and relational. Systems information exchange occurred through direct and indirect means. Direct means included formal and informal mechanisms. The formal mechanism of orientation was identified by each participant. Informal mechanisms such as peer teaching, problem solving, and modeling behaviors were identified by participants from each of the three nurse groups. Travel nurses’ descriptions of the common themes focused on individual efficacy. Staff nurses focused on fostering smooth unit functioning. Nurse leaders described common themes from a perspective of unit development. Four overarching domains of systems information were exchanged between staff nurses and travel nurses: practice patterns; staffing patterns and roles; tips, tricks, tidbits, and techniques; and environmental elements. Communication emerged as a common theme across nurse groups and domains of systems information exchanged. These findings have implications for nursing orientation and staff development, continuous improvement at the local level, and curriculum development.

Thesis (MBA)--Stellenbosch University, 2001.
Some digitised pages may appear illegible due to the condition of the original hard copy
ENGLISH ABSTRACT: Successful organisations keep a well-balanced fit between their strategy, structure, processes, reward system and culture. Any significant change in any of the elements requires management to rethink and probably redesign the rest of the elements. Tshikondeni Coal Mine went through various changes the last few years. These changes were brought about by, amongst other things, a re-engineering project, production expansion and the appointment of new management A significant portion of the employees was newly appointed. Some of the older employees were appointed in other positions, or were required to do different work. Tshikondeni had to make sure that employees were equipped with the needed competency to do their job to the required standard and in a safe manner. The process started by ensuring that employees' medical profile fit that required by their jobs. They were also trained in identifying the hazards associated with their jobs and how to minimise exposure to risks. The gap between the competencies required for each job and that possessed by the job incumbent was identified. Training was designed to fill the identified gaps. Iscor management's annual salary increase is performance driven. The process of designing post profiles, competency documents and personal performance contracts is described. The link between the personal performance contract, the annual salary increase and the personal development plan is discussed. There is still no clear link between the annual salary increase of operational employees and their performance. Plans are in place to eventually reward all employees on a performance driven basis. The training section on Tshikondeni Mine was designed to support business objectives. It is also aligned with the trends experienced in modern training. The section, amongst other things, caters (through the use of an interactive multi media system) for the bulk of mining employees who can't read or write. All training information is kept on a central database. Employees must not only be able to do their job, but also willing or motivated to do it. Management created a work and home environment conducive towards motivated employees. A psychosocial study was done to. determine how employees and their families felt towards their environment. The results helped management to focus energy where problems were identified. Problems and pitfalls encountered during the process to ensure competency are discussed. The process followed by the mine is elucidated with modern trends, statements, remarks and suggestions found in literature.
AFRIKAANSE OPSOMMING: Hoë prestasie organisasies se strategië, strukture, prosesse, vergoedingstelsels en kultuur is in balans met dit wat sukses voorskryf. Enige wesenlike verandering in enige van die elemente kan veroorsaak dat die res van die elemente herbesoek en moontlik herontwerp moet word. Tshikondeni Steenkoolmyn het groot veranderinge oor die afgelope aantal jare beleef. Hierdie veranderinge was onder andere veroorsaak deur en proses herontwerp, produksie uitbreiding en die aanstelling van nuwe bestuur. en Beduidende hoeveelheid van wernemers was nuut aangestel. Van die ouer werknemers was aangestel in nuwe poste of was verwag om nuwe take te verrig. Tshikondeni moes verseker dat werknemers toegerus was met die nodige bevoegdheid om die werk te kan doen volgens die verlangde standaard en op en veilige manier. Die proses was begin deur te verseker dat werknemers se persoonlike mediese profiel pas by die profiel benodig deur hulle poste. Hulle was opgelei in die identifisering van gevaar in hulle werksomgewing en hoe om die risiko van blootstelling aan die gevaar te minimeer. Die gaping tussen werknemers se bevoegdhede en dié verlang deur hulle poste was geïdentifiseer. Opleiding was ontwikkel om die gapings aan te spreek. Iscor Bestuur ontvang jaarliks enprestasie gebasseerde salaris verhoging. Die proses wat gevolg is met die ontwerp van pos profiele, bevoegdheidsdokumente en persoonlike prestasiekontrakte word beskryf. me verhouding tussen die persoonlike prestasie kontrak, die jaarlikse salaris aanpassing en die persoonlike ontwikkelingsplan word bespreek. Daar is tans nie en duidelike ooreenkoms tussen die jaarlikse salaris aanpassing wat bedryfspersoneel ontvang en hulle prestasievlakke nie. Iscor het wel planne in plek om uiteindelik aan alle werknemers In prestasie gebasseerde vergoeding te betaal. Die opleidingseksie op Tshikondeni is ontwerp om besigheidsdoelwitte te ondersteun. Dit is ook belyn met moderne neigings met betrekking tot opleiding. Die seksie bedien, onder andere die grootste gedeelte van mynbou werknemers wat nie kan lees en skryf nie (met behulp van In interaktiewe multi media stelsel). Alle opleidings inligting word gestoor op In sentrale databasis. Werknemers moet nie net in staat wees om hul werk te kan doen nie, maar moet ook gemotiveerd wees om die werk te wil doen. Bestuur streef daarna om In werk- en huis omgewing te skep wat werknemers motiveer. In Psigososiale studie is gedoen om te bepaal hoe dat wememers en hulle gesinne voel ten opsigte van hulle omgewing. Die resultate het gehelp om bestuur se aandag en energie te fokus om probleme op te los. Probleme en slaggate ondervind tydens die bevoegdheidsproses word bespreek. Die proses gevolg word toegelig met moderne neigings, stellings, opmerkings en voorstelle soos wat gevind word in die literatuur.

HACCP-based food safety programs have been widely acclaimed, accepted and implemented as an effective means of managing food safety risks. While HACCP training is a cornerstone of managing HACCP programs, there is little information about the effectiveness of HACCP training and the durability of HACCP knowledge. Findings reveal a link between involvement level in HACCP activities and the accuracy of HACCP knowledge over time. Opportunities for peer training in HACCP, irrespective of overall experience in the food industry provide favorable circumstances for maintaining accuracy of HACCP knowledge. The optimal window for engaging employees in HACCP is directly following the completion of training for achieving the minimal depletion level of content knowledge. This study further reveals that refresher training in HACCP is necessary within three years. Furthermore, training standardization organizations likely need a formal process of monitoring and maintaining HACCP trainer and trainee qualifications to ensure uniformity in HACCP programming.

Kommuner har en unik position i säkerhetsarbetet genom att vara nära både medborgarna och de olyckor och skador som drabbar befolkningen. Trots långtgående framsteg inom teknologi och ett etablerat välfärdssamhälle utgör personskador till följd av olyckor ett betydande folkhälsoproblem i Sverige liksom i övriga nordiska länder. De svenska kommunerna har ålagts ett vidsträckt ansvar och förväntas vidta åtgärder inom flera samhällsområden för att värna människornas trygghet och säkerhet. De senaste två decennierna har utvecklingen i allt högre grad inneburit olika former av systematiskt och tvärsektoriellt säkerhetsarbete i kommunerna. I detta arbete används olika verktyg och metoder som hjälpmedel och stöd. Vissa verktyg är obligatoriska att använda enligt lagstiftning medan andra är frivilliga. Denna uppsats syftar till att kartlägga kommunernas användning av några av dessa säkerhetsverktyg, samt att för ett av verktygen – olycksutredning – undersöka i vilken utsträckning några särskilda utredningsmetoder förmår stödja den samlade praktiska hantering som en olycksutredning innebär. Uppsatsen bygger på två delarbeten, varav det ena är publicerat i en internationell vetenskaplig tidskrift och det andra är inskickat för bedömning till en annan tidskrift. Artikel I bygger på en enkätstudie till 1283 tjänstemän i 73 kommuner. En fråga handlade om användningen av 16 olika säkerhetsverktyg. Denna fråga besvarades av 50 % av de tillfrågade personerna. Resultaten tyder på att verktygen skyddsrond, riskanalys och riskinventering hade utbredd användning i samtliga sektorer medan övriga verktyg användes begränsat inom vissa sektorer eller nästan inte alls. Artikel II studerar hur olika olycksutredningsmetoder stödjer den praktiska utredningsprocessen. Analysen grundas i en processmodell särskilt framtagen för utvärdering av metoderna. Slutsatserna stöds av data från 114 tester av sådana metoder i kursen Kvalificerad olycksutredningsmetodik vid Karlstads universitet. Över 170 kursdeltagare från olika branscher har medverkat i testerna, som en del i undervisningen. Resultaten visar att bland de bedömda metoderna så är det endast metoderna Avvikelseutredning och STEP som ger ett bra stöd i hela utredningsprocessen. Övriga metoder stödjer huvudsakligen endast själva analysdelen i en olycksutredning. De sammanfattande slutsatserna visar att kommunerna använder sig av verktyg i sitt säkerhetsarbete, men att endast ett fåtal av verktygen används brett i alla kommunsektorer. Bland de undersökta metoderna för verktyget olycksutredning konstateras att det finns stora skillnader i hur dessa stödjer utredningsprocessen. Flera metoder borde kanske snarare benämnas olycksanalysmetoder, istället för olycksutredningsmetoder, då de främst ger stöd för själva analysdelen i utredningsarbetet.
Municipalities have a unique position in safety work by being close to both the citizens and the accidents and injuries that affect the population. Despite far-reaching advances in technology and an established welfare state, injuries resulting from accidents constitute a significant public health problem in Sweden as well as in other Nordic countries. Swedish municipalities are subjected to wide-ranging responsibilities and are expected to take action in a number of societal areas to safeguard people's safety and security. The last two decades are increasingly characterized by systematic and cross-sectorial safety work of various forms in municipalities. In this endeavor a variety of tools and methods intended to aid and support safety work have been introduced. Some tools are required by law while others are optional. This thesis aims to identify to what extent local authorities utilize a number of these safety tools, and secondly to examine whether a set of particular methods aimed to guide one of the tools – accident investigation – are actually supportive to the entire practical investigative process. The thesis is based on two papers, the first of which has been published in an international scientific journal, and the second has been submitted to another journal. Article I is based on a survey targeting 1283 officials in 73 municipalities. One question was about the use of 16 different safety tools. This question was answered by 50 % of the officials. The results show that safety round, risk analysis and risk inventory were reported to be used frequently in all sectors while other tools were used only in certain sectors or virtually not at all. Article II analyzes how different accident investigation methods support the practical investigative process. The evaluation is based on a process model intended to illustrate this process. The analysis comprises data from 114 tests of nine selected methods taught in a recurrent course entitled Advanced Accident Investigation Methodology at Karlstad University. More than 170 participants representing various industries and sectors were involved in the tests. The results show that among the nine assessed methods, only Deviation Analysis and STEP gives good support throughout the entire investigative process. Other methods provide support primarily during the analysis phase of an accident investigation. In summary, our findings show that local authorities make use of safety tools, but only a few of the tools are broadly used across all municipal sectors. Regarding the assessed methods of the tool accident investigation it can be concluded that there are major differences in their way to support throughout the investigative process. It is suggested that several methods should rather be described as accident analysis methods instead of accident investigation methods since they provide support mainly for the analysis step.

Master's thesis is deals with integrated system. In theoretic part is described quality management system, environmental management system and occupational health and safety management system, main attention paid to quality in supplies. Suggestion of solving consists in proposition of new process purchase - choice of supplier, classification of supplier and index for measuring of process purchase.

Submitted by Nadir Basilio (nadirsb@uninove.br) on 2015-07-20T14:05:34Z No. of bitstreams: 1 Ligia Maria Quiterio.pdf: 3090898 bytes, checksum: f660fb6118707979a5a91e1b08534f0a (MD5)
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The purpose of this study was to investigate patients’ safety incidents that may be associated with management communication failures in Intensive Care Units (ICUs) with the purpose of providing information to develop strategies to increase patient safety and improve the quality of health care. This is an empirical, retrospective study of a descriptive nature, conducted through documental, literature research and action research with a quantitative and qualitative approach to the problem. The study period was from May 25 to August 25, 2009, with a population of 202 admissions of ICU patients from a public hospital, tertiary. We identified 999 patient safety incidents and we analyzed according to the international classification for patient safety (ICPS), with predominance of no harm incidents, with 626 (62.66%), and 248 (24.82%) incidents of harm. Age of patients who have suffered harm incidents was 52.77 years (average, SD = 20.01), with minimum variation of 15 and maximum of 96 years; the average length of stay in the units was 10.09 days (SD = 10.14), ranging from 0 to 70 days. Evaluating the Charlson comorbidity scale incidents by communication failures were more frequent (87.6%) when compared with other incidents (p <0.0005). This finding, can be partially explained, since patients with more comorbidities require intensified nursing care, as well as higher number of medications, more exams requests, so are patients who are more prone to incidents in general, standing out there communication. The incidents with no harm were related to documentation and to verbal communication, generating 62.66% of incidents. Written communication failures were associated to medications, diets and clinical processes and procedures. They accounted for most incidents with harm: 24.82%. In this study, all incidents related to communication failures were of preventable type. We developed a form to be used as a check list to reduce communication incidents that can be employed to improve communication and to increase patient safety in hospitals, especially those related to critical care. The detection of communication incidents were originated at medical prescriptions, nursing controls, medical rounds and nursing care. We identified 152 communication failures, in which 49.67% were related between physicians and the ICU nursing staff. Conclusion: The most observed safety incidents due to communication failure were those related to medications, diets and clinical processes and procedures. All of them were of avoidable type, demonstrating that healthcare manager may have a role in the prevention of patient safety incidents while propose strategies to improve the communication among ICU actors.
O objetivo deste trabalho foi estudar os incidentes de segurança que podem estar associados a falhas gerenciais de comunicação em Unidades de Terapia Intensiva (UTIs), com o propósito de fornecer informações para desenvolver estratégias para aumentar a segurança do paciente e aprimorar a qualidade de assistência à saúde. É um estudo empírico, retrospectivo de natureza descritiva, realizado por meio de pesquisa documental, bibliográfica e pesquisa-ação, com abordagem quantitativa e qualitativa do problema. O período de estudo foi de 25 de maio a 25 de agosto de 2009, com uma população de 202 admissões de pacientes internados em UTIs de um hospital público, terciário, de São Paulo. Foram identificados 999 incidentes de segurança e analisados de acordo com a classificação internacional para a segurança do doente (CISD), tendo predominância os incidentes sem danos, com 626 (62,66). A média de idade dos pacientes que sofreram incidentes com danos foi de 52,77 anos (DP=20,01), com variação mínima de 15 e máxima de 96 anos; o tempo médio de permanência nas unidades foi de 10,09 dias (DP=10,14), variando de 0 a 70 dias. Avaliando as comorbidades pela escala de Charlson, os incidentes por falhas de comunicação foram mais frequentes (87,6%), quando comparados com os outros incidentes (p<0.0005), fato esse que pode ser parcialmente explicado, uma vez que pacientes com maior número de comorbidades necessitam de cuidados de enfermagem intensificados, assim como maior número de medicações, maior número de solicitações de exames complementares, logo são pacientes que estão mais sujeitos a incidente em geral, destacando-se aí os de comunicação. Os incidentes sem danos estão relacionados à documentação e à comunicação verbal, e geraram 62,66% dos incidentes. As falhas de comunicação escrita estão associadas a medicações, dietas e aos processos e procedimentos clínicos, e representaram a maioria dos incidentes com danos: 24,82%. Neste estudo, todos os incidentes relacionados às falhas de comunicação foram do tipo evitáveis. A proposta de um instrumento norteador para redução de incidentes de comunicação poderá ser empregada, com o objetivo de melhorar a comunicação e aumentar a segurança dos pacientes em ambiente hospitalar, notadamente relacionados aos cuidados críticos. Quanto à origem dos incidentes de comunicação, as prescrições médicas, controles de enfermagem, as visitas médicas e de enfermagem foram fontes de identificação dos incidentes de segurança dos pacientes. Foram detectadas 152 falhas de comunicação sendo que 49,67% estão associadas à comunicação entre médico e enfermagem da UTI. Conclusão: Falhas de comunicação em UTI foram frequentes no nosso estudo. As mais comuns foram aquelas relacionadas às medicações, às dietas e aos processos e procedimentos clínicos. Todas foram do tipo evitáveis, demonstrando que o gestor pode ter papel na prevenção de incidentes de segurança do paciente ao elaborar estratégias para aprimoramento da comunicação entre os atores da UTI.

Desde a década de 90 o conceito de design for safety (DFS) vem sendo difundido como meio de reduzir os acidentes do trabalho com causas oriundas nas características do projeto do produto. A utilização do DFS na indústria da construção civil desperta o interesse de vários pesquisadores, mas ainda é pequena e conta com uma lacuna entre o conceito e a aplicação do mesmo. Assim, o objetivo deste trabalho consiste em propor um protocolo para integração de requisitos de segurança no trabalho ao processo de desenvolvimento do produto – PISP, com vistas a auxiliar engenheiros e arquitetos a desenvolver projetos seguros para os usuários temporários das edificações (trabalhadores de construção e manutenção). O método de pesquisa envolveu a realização de três estudos de caso: um empreendimento residencial, um industrial e um hospitalar, executados nas cidades da região central do estado RS, respectivamente, formaram o objeto de análise. A integração de requisitos de saúde e segurança do trabalho (SST) ao processo de desenvolvimento do produto (PDP), foi a unidade de análise deste trabalho. O protocolo inclui quatro etapas: identificação de perigos, avaliação de riscos, identificação de requisitos e avaliação e registro do aprendizado. Sua aplicação no desenvolvimento de projetos favorece o trabalho colaborativo entre os envolvidos no PDP, sendo recomendado sua incorporação ao processo de engenharia simultânea ou ao desenvolvimento integrado de produtos, no entanto, é adaptável a qualquer método de PDP adotado pela empresa construtora ou projetista. O estudo constatou que a integração de requisitos de SST desde as fases iniciais do PDP é viável e mais consistente do que quando realizada na fase de projeto ou reprojeto, como sugere o conceito tradicional de DFS.
Since 1990s, the concept design for safety (DFS) has been diffused as way of to reduce the accidents in construction site with causes derived of the characteristics of design. The utilization of DFS in the construction industry awakes the interest of several researches, but yet is low and has a gap between the concept and the application. So, the target this work is to propose a protocol for integration of health and safety work requirements at product development process (PISP), as way of to help engineers and architects to develop safe designs for temporary users of building (workers of construction and maintenance). The research method involved the realization of three cases: a residential undertaking, an industrial and a clinical, was the analysis object. The integration of health and safety work requirements at product development process was analysis unit this work. The protocol has four stages: identification of hazards, assessment of risks, identification of requirements and assessment and register of learning. The application in the development of designs allow the collaborative work between the participants of product development process (PDP), been recommended for incorporation at concurrent engineering process or at integrated development product, however, is adaptive at some method of development of product adopted by designer . The study verified that the integration of health and safety requirements since the early stages of PDP is viable and more solid that when made in design or redesign stages, as suggest the traditional concept of DFS.

Mestrado em Gestão e Estratégia Industrial
Com os serviços e a inovação a contribuírem para o desenvolvimento da economia portuguesa, criar vantagens competitivas, hoje, numa sociedade do conhecimento, exige ofertas mais ajustadas às exigências dos consumidores. Tal não é exceção no setor da saúde que recorre à inovação para o seu desenvolvimento, sendo a Patient Safety (PS) uma das áreas prioritárias nesta atuação. Neste sentido, o presente estudo analisou a influência da perceção de segurança do paciente na inovação, percebendo como são efetuadas alterações às rotinas e, simultaneamente, como é que a inovação tem em conta a PS, nos serviços de ortopedia do Hospital Distrital da Figueira da Foz, E.P.E. (HDFF) e do Hospital Santo André, E.P.E. - Centro Hospitalar Leiria - Pombal (HSA). Suplementarmente, devido à qualidade da informação recolhida, incluiu-se a entrevista realizada ao chefe de serviço de ortopedia do Centro Hospitalar e Universitário de Coimbra, E.P.E. (CHUC). Para a recolha de informação foram usadas as entrevistas semiestruturadas, realizadas aos chefes de serviço, e a tradução do questionário hospitalar Hospital Survey on Patient Safety, elaborada por Eiras e Escoval (2014), aplicado ao HDFF e ao HSA. Da análise concluiu-se que a origem e a tendência seguida por cada serviço no desenvolvimento de novas práticas e a atitude na promoção da PS no processo de inovação, influenciam a forma como a inovação nos serviços hospitalares integra a preocupação com a PS. Também o uso crescente de abordagens sistémicas para a resolução de eventos adversos é cada vez mais uma opção para a melhoria da PS.
With the services and innovation to contribute to the development of the Portuguese economy, create competitive advantage, today, in knowledge society requires more offers adjusted to the demands of consumers. This is no exception in the health sector that has used innovation to their development, being the Patient Safety (PS) one of the priority areas in this action. In this sense, the present study analyzed the influence of patient safety perception in innovation, realizing how changes are made in routines and simultaneously how innovation takes into account the PS, involving the orthopedic services of Hospital Distrital da Figueira da Foz, E.P.E. (HDFF) and the Hospital Santo André, E.P.E. - Hospital Leiria - Pombal (HSA). Furthermore, due to the quality was included the information collected at the interview conducted to the head of orthopedic service at Centro Hospitalar e Universitário de Coimbra, E.P.E. (CHUC). As elements for the collection of information were used the semi-structured interviews, conducted to heads of service, and the translation of the hospital questionnaire Hospital Survey on Patient Safety, drawn up by Eiras and Escoval (2014)), applied to HDFF and HSA. The analysis concluded that the origin and the trend followed by each service in the development of new practices and the attitude in the promotion of PS in the innovation process influence how innovation in hospital services integrates the concern for PS. Similarly, the increased use of system approaches to the resolution of adverse events is becoming an option for improving the PS.

Submitted by Nadir Basilio (nadirsb@uninove.br) on 2015-07-17T16:11:52Z No. of bitstreams: 1 Edzangela de Vasconcelos Santos.pdf: 2212555 bytes, checksum: 062fb866a8c14cd3a67c1143d081e054 (MD5)
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In literature, incidents arising from healthcare assistance are well defined. Nevertheless, there are incidents related to administrative processes that are rarely studied, specifically in ICU. This study aims to analyze the influence of the management of administrative processes in the safety of ICU patients. We used descriptive exploratory empirical approach to perform this research. Data from medical records were obtained and collected daily. Additional information form medical and nursing visits were also noted in an appropriate form for reporting safety incidents and, compared with the records in the chart. Double-checking the records with the printed data collection was performed. In this study, 9,396 incidents were found in 202 admissions. Of these, 653 (6.94%) in 148 admissions were classified as administrative incidents. Thus, we conclude that the administrative incidents occupy a small but important portion of total incidents (6.94%), occurring in processes that directly affect the care provided, and may cause serious damage and even death. Almost all safety incidents related to administrative failures were preventable type, therefore fitting the development and implementation of measures to prevent such occurrences, and consequently contributing to the improvement of management and care for critical patients.
Na literatura estão bem definidos os incidentes decorrentes de ações assistenciais, porém, há uma parcela de incidentes não classificáveis, relacionados essencialmente a processos administrativos sobretudo em UTI. Nesse sentido, o presente estudo objetivou analisar a influência da gestão de processos administrativos na segurança de pacientes internados em quatro UTIs clínicas. A metodologia utilizada conta com uma abordagem empírica de caráter exploratório-descritivo e estratégia de pesquisa-ação. As informações relacionadas à caracterização da população e a potenciais eventos adversos foram registradas em formulários apropriados, criados pela autora. As visitas médicas e de enfermagem foram acompanhadas com caráter observacional, anotadas em impresso próprio para relatos de eventos adversos e comparadas com a revisão diária dos registros dos prontuários. Foi realizada dupla checagem dos prontuários com os impressos de coleta de dados. Neste estudo, foram encontrados 9.396 incidentes em 202 admissões, sendo 653 (6,94%), em 148 admissões, classificados como incidentes administrativos. Dessa forma, concluímos que os incidentes administrativos ocupam uma pequena, porém, importante parcela do total de incidentes e ocorrem em processos que interferem diretamente na assistência prestada, podendo gerar danos graves ou até a morte. Quase a totalidade dos incidentes de segurança relacionada às falhas administrativas foi do tipo evitável, cabendo então o desenvolvimento e implantação de medidas de prevenção dessas ocorrências e, consequentemente contribuindo para a melhoria da gestão e assistência ao paciente crítico.

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O objetivo da presente dissertação é desenvolver uma análise crítica da contribuição da metodologia LOPA para a gestão de segurança de processo na indústria e perpetuar sua aplicação. Como modelo metodológico, utilizou-se a pesquisa bibliográfica e a pesquisa exploratória, através de um questionário aplicado. Utilizaram-se os resultados do questionário para avaliar o perfil dos respondentes, testou-se a confiabilidade interna das escalas do questionário através da utilização do alfa de Cronbach e executou-se um modelo de triangulação a luz do referencial teórico, dos resultados do questionário e da experiência e dos conhecimentos teóricos do pesquisador. Como resultados, detectou-se a baixa disponibilidade de estudos guiados pela comunidade científica internacional que efetivamente relacionem a utilização da metodologia LOPA com a gestão de segurança de processos, confirmou-se o baixo nível de difusão do conhecimento e de utilização da metodologia LOPA e detectou-se a alta relevância de inclusão da metodologia em um sistema de gestão de segurança de processos. As confiabilidades internas calculadas para os clusters do questionário obtiveram classificação alta e muito alta.
The main goal of this Dissertation is develop a critical analysis of the LOPA methodology contribution to the Process Safety Management in the Industry and to disseminate the LOPA. The Dissertation methodological model included a Bibliographical Research and an Exploratory Research (Through a survey applied, mainly, to the process safety professionals. The Dissertation tested the internal reliability of the survey scales (Through the Cronbach alfa tool), evaluated the survey participants profile and used a triangulation model considering the theoretical framework, the survey results and the experience and theoretical knowledge of the researcher. The Results detected the low availability of studies guided by international scientific community that effectively connect the methodology LOPA with Process Safety Management, the low level of dissemination of knowledge and the low utilization frequency of methodology LOPA and detected the high significance of LOPA inclusion in a Process Safety Management System. The internal reliability values calculated to the survey clusters obtained high and very high classification.

The issue of food scandals originating from unsafe food has in recent years caught the attention of the public. Consequently, the number of food recalls has increased, and food retailers and food producers are getting questioned regarding their ability to provide consumers with safe food products. Thus, because the primary responsibility to deal with this problem is the food business operators who have real control over the products within the Food Supply Chain (FSC). Even though food safety has received more interest from academic researchers and practitioners in the latter years, we could identify that previous literature still lacks research on food recalls. In addition, prior research interprets food recalls as generalizable within the FSC and does not have its various product flows in mind. In order to fill the research gap, this study seeks to gain a deeper understanding of food recalls in the context of the different product flows within the FSC from a retailer perspective. Therefore, the purpose of this study was to investigate how the occurrence and the consequences of food recall differ across various product flows within the FSC by focusing on four elements. The elements include the challenges within the FSC to ensure food quality, the reasons behind food recall, the types of food recall, and the consequences they infer. The current study had finally answered the following research question: “How do the occurrence and the consequences of food recalls differ across various product flows within the FSC?” In order to answer the research question and address the purpose of the thesis, a qualitative study was conducted by focusing on Swedish food retailers and conducting interviews with responsible Purchasers within each of the product flows, and additionally, Quality Assurance Managers. The sample of the semi-structured interviews was selected based on the position and experience of food recalls within the retailers. This to assure that the interviewees possessed sufficient insights regarding the studied field to fulfill the purpose of the study and answer its research question. From the gathered data, several themes were derived through the thematic analysis, and the analysis and discussion regarding the elements led us to a conclusion. The result confirmed that the various product flows, and in some cases, even specific products within the flows, need to be taken into consideration when the occurrence and the consequences of food recalls are addressed within the FSC. This is because the different product flows include different products with different characteristics making them more or less complex to handle along the chain and when carrying out food recalls. Even though previous theories assume a general approach, the findings still confirmed the theories regarding the challenges within the FSC to ensure food quality, the reasons behind recalls, the types of recalls, and the consequences the recalls can infer. However, the main differences found between our study and prior research regarding the FSC were that supply chain-related reasons are more commonly related to food reclaims and that environmental consequences are considered an additional consequence of food recalls.

La presente investigación tiene como objetivo mejorar las condiciones de trabajo seguras y saludables para incrementar la productividad de la Asociación Agrícola de Pequeños Agricultores de Bella Unión (AAPABU) que tiene como actividades más relevantes el proceso de cultivo y comercialización de aceitunas en rama. Se expone la propuesta del diseño de un modelo de seguridad y salud ocupacional basada en gestión por procesos y el cumplimiento de la Ley 29783: Ley de Seguridad y Salud en el Trabajo. En el presente trabajo se realiza una revisión de la literatura poniendo de manifiesto la importancia de las MYPE, sobre todo las relacionadas al subsector agrícola, así como la trascendencia de la gestión de seguridad y salud ocupacional dentro de las organizaciones en la actualidad que les permita ser más productivas y competitivas, mediante la recopilación de información por visitas in situ, recopilación de datos estadísticos y entrevistas a profundidad que permitieron identificar oportunidades de mejora. A partir de ello, se propone el diseño de un modelo de gestión de seguridad y salud ocupacional. Finalmente, se realiza las conclusiones y recomendaciones de la propuesta, enfatizando la importancia de crear una cultura de prevención de riesgos.
The objective of this research is to improve safe and healthy working conditions to increase the productivity of the Agricultural Association of Small Farmers of Bella Unión (AAPABU), whose most important activities are the process of growing and marketing olives on the branch. The proposal for the design of an occupational health and safety model based on process management and compliance with Law 29783: Occupational Health and Safety Law. In this paper, a review of the literature is carried out, highlighting the importance of MYPEs, especially those related to the agricultural subsector, as well as the importance of occupational health and safety management within organizations that currently allow them be more productive and competitive, through the collection of information by on-site visits, collection of statistical data and in-depth interviews that allowed us to identify opportunities for improvement. Based on this, the design of an occupational health and safety management model is proposed. Finally, the conclusions and recommendations of the proposal are made, emphasizing the importance of creating a culture of risk prevention.
Tesis

[ES] A través de la evolución y el desarrollo de la humanidad, la historia del individuo, de su comunidad y de la cultura, ha estado marcada por muchos esfuerzos focalizados en la creación de buenas prácticas, herramientas y tecnologías dirigidas hacia la reducción de la vulnerabilidad ante distintos tipos de riesgos. En el ámbito de la calidad, la seguridad alimentaria, la seguridad y la salud ocupacional, la gestión ambiental y la eficiencia energética, estos esfuerzos se han consolidado e integrado en instrumentos para el aseguramiento, la mejora en el desempeño y la garantía en términos de certificación de Sistemas de Gestión, conocidos internacionalmente como Normas ISO, que en la actualidad tienen un amplio abanico de posibilidades y modelos, donde los de mayor utilización corresponden al acrónimo en inglés QHSE3+: ISO 9001:2015 "Quality management systems Requirements", para la Q de calidad; ISO 45001:2018 ISO 45001, "Occupational health and safety management systems - Requirements", para la HS de seguridad y salud en el trabajo; ISO 14001:2015 Environmental management systems Requirements with guidance for use, para la E de medio ambiente; ISO 50001:2018. Energy Management Systems - Requirements with guidance for use, para la E2 de eficiencia energética. El acrónimo considera al final el signo (+), que corresponde a cualquier otro referencial que pueda ser exigido a la organización en función de la naturaleza de sus operaciones y del mercado, o que tenga relevancia en función de la naturaleza de los riesgos de la organización, como, por ejemplo, las normas ISO 21500:2012. Guidance on Project management, ISO 22000:2018. International Organization for Standardization. Food safety management systems - Requirements for any organization in the food chain, e ISO 27001:2013 Information technology - Security techniques -Information security management systems - Requirements. La presente Investigación Doctoral, desarrolla un Modelo Conceptual para los Sistemas de Gestión que cubren los referenciales "QHSE3+", bajo un enfoque integral de riesgos que incluye la perspectiva energética y otras componentes que se puedan requerir, en función de la naturaleza y particularidades del negocio. El enfoque propuesto se basa en el Diseño Sistémico, y en el desarrollo y la aplicación de herramientas dirigidas a facilitar su aplicación e implementación en las diferentes empresas, bajo aplicaciones sencillas en Excel. La estructura de la presente Tesis Doctoral se resume en seis capítulos: El capítulo 1 contiene la introducción y la presentación de los principios y elementos de la gestión integral, la administración de riesgos y el enfoque asociado al acrónimo "QHSE3+", considerando la gestión integral de riesgos y los planteamientos de ISO 31000:2018. En el capítulo 2 se describe la metodología general empleada para el desarrollo de la investigación, el estudio del estado del arte, los principios y las fuentes que enmarcan la investigación, el modelo conceptual, los requisitos, el diagnóstico, y la metodología para la planificación y el desarrollo del proyecto. El capítulo 3, los resultados del diseño del Modelo Conceptual. En el capítulo 4, la presentación de la secuencia de aplicación del modelo. El capítulo 5 contiene el Balance de Resultados cuali-cuantitativos de la aplicación preliminar del modelo. Finalmente, el capítulo 6 resume las conclusiones obtenidas en cada uno de los anteriores capítulos y presenta las posibles líneas futuras de investigación. En los Anexos, se ha incluido la referencia a las ilustraciones utilizadas en el Informe de Tesis, la referencia a los archivos de soporte, Herramientas y Plantillas Generadas, los Ejemplos de Aplicación, las Guías, y finalmente, la referencia al archivo "Una voz desde el TC 176. Entrevista a Leopoldo Colombo".
[CA] A través de tota l'evolució i el desenrotllament de la humanitat, la història de l'individu, de la seua comunitat i de la cultura ha estat marcada per molts esforços focalitzats en la creació de bones pràctiques, ferramentes i tecnologies dirigides cap a la reducció de la vulnerabilitat davant de distints tipus de riscos. En l'àmbit de la qualitat, la seguretat alimentària, la seguretat i la salut ocupacional, la gestió ambiental i l'eficiència energètica, estos esforços s'han consolidat i integrat en instruments per a l'assegurament, la millora en l'exercici i la garantia en termes de certificació de Sistemes de Gestió, coneguts internacionalment com a Normes ISO, que en l'actualitat tenen un ampli palmito de possibilitats i models, on els de major utilització corresponen a l'acrònim en anglés QHSE3+: ISO 9001:2015 "Quality management systems ¿ Requirements", per a la Q de Qualitat. ISO 45001:2018 ISO 45001, "Occupational health and safety management systems - Requirements", per a la HS de seguretat i salut en el treball. ISO 14001:2015 Environmental management systems ¿ Requirements with guidance for use, per a la E de medi ambient. ISO 50001:2018. Energy Management Systems - Requirements with guidance for use, per a la E2 de eficiència energètica. L'acrònim considera al final el signe (+), que correspon a qualsevol altre referent que pot ser exigit a l'organització en funció de la naturalesa de les seues operacions i del mercat, o la importància que té en la funció de la naturalesa dels riscos de l'Organització, com per exemple, la norma ISO 21500: 2012. Orientació sobre gestió de projectes, la norma ISO 22000: 2018. Sistemes de gestió de la innocuïtat dels aliments: requisits per a qualsevol organització de la cadena alimentària i ISO 27001: 2013 Tecnologia de la informació - Tècniques de seguretat - Sistemes de gestió de la seguretat de la informació - Requisits. La present Investigació Doctoral, desenvolupa un Model Conceptual per als Sistemes de Gestió que cobreixen els referencials "QHSE3+", sota un enfocament integral de riscos que inclou la perspectiva energètica i altres components que es puguen requerir, en funció de la naturalesa i particularitats del negoci. L'enfocament proposat es basa en el Disseny Sistèmic, i en el desenvolupament i l'aplicació d'eines dirigides a facilitar la seua aplicació i implementació en les diferents empreses, sota aplicacions senzilles en Excel. L'estructura de la present Tesi Doctoral es resumeix en sis capítols: El capítol 1 conté la introducció i la presentació dels principis i elements de la gestió integral, l'administració de riscos i l'enfocament associat a l'acrònim "QHSE3+", considerant la gestió integral de riscos i els plantejaments d'ISO 31000:2018. En el capítol 2 es descriu la metodologia general empleada per al desenvolupament de la investigació, l'estudi de l'estat de l'art, els principis i les fonts que emmarquen la investigació, el model conceptual, els requisits, el diagnòstic, i la metodologia per a la planificació i el desenvolupament del projecte. El capítol 3, els resultats del disseny del Model Conceptual. En el capítol 4, la presentació de la seqüència d'aplicació del model. El capítol 5 conté el Balanç de Resultats cuali-quantitatius de l'aplicació preliminar del model. Finalment, el capítol 6 resumeix les conclusions obtingudes en cadascun dels anteriors capítols i presenta les possibles línies futures d'investigació. En els Annexos, s'ha inclòs la referència a les il·lustracions utilitzades en l'Informe de Tesi, la referència als arxius de suport, Eines i Plantilles Generades, els Exemples d'Aplicació, les Guies, i finalment, la referència a l'arxiu "Una veu des del TC 176. Entrevista a Leopoldo Colombo".
[EN] Throughout the evolution and development of humanity, the history of the individual, their community and their culture has been characterized by many efforts focused on the creation of good practices, tools and technologies aimed at reducing vulnerability related to different types of risks. In the field of quality, food safety, occupational safety and health, environmental management and energy efficiency, these efforts have been consolidated and integrated into instruments for insurance, improvement in performance, and guarantee in terms of requirements for the certification of Management Systems. These instruments are known internationally as ISO Standards, and currently have a wide range of possibilities and models, where the most commonly used correspond to the acronym in English QHSE3+: ISO 9001:2015 "Quality management systems ¿ Requirements", for the Q of Quality. ISO 45001:2018 ISO 45001, "Occupational health and safety management systems - Requirements", for the HS of the Health and Safety. ISO 14001:2015 Environmental management systems ¿ Requirements with guidance for use, for the E of Environment. ISO 50001:2018. Energy Management Systems - Requirements with guidance for use, for the E2 of Energy Efficiency. The acronym considers at the end the sign (+), which corresponds to any other referential that may be required from the organization depending on the nature of its operations and the market, or that has relevance according to the nature of the risks of the organization, such as the ISO 21500: 2012 Standards. Guidance on project management, ISO 22000: 2018. International Organization for Standardization. Food safety management systems - Requirements for any organization in the food chain, and ISO 27001: 2013 Information technology - Security techniques - Information security management systems - Requirements. This Doctoral Research develops a Conceptual Model for Management Systems that cover the references "QHSE3+", under a comprehensive risk approach that includes the energy perspective and other components that may be required, depending on the nature and particularities of the business. The proposed approach is based on the Systemic Design, and the development and application of tools aimed at facilitating its application and implementation in different companies, under simple applications in Excel. The structure of this Doctoral Thesis is summarized in six chapters, configured as described below: Chapter 1 contains the introduction and presentation of the principles and elements of comprehensive management, risk management and the approach associated with the acronym "QHSE3 +", considering comprehensive risk management and the approaches of ISO 31000: 2018. Chapter 2 describes the general methodology used for the development of the research, the study of the state of the art, the principles and sources that frame the research, the conceptual model, the requirements, the diagnosis, and the methodology for planning. and the development of the project. Chapter 3, the results of the Conceptual Model design. In Chapter 4, the presentation of the model application sequence. Chapter 5 contains the Qualitative and Quantitative Results Balance of the preliminary application of the model. Finally, Chapter 6 summarizes the conclusions obtained in each of the previous chapters and presents the possible future lines of research. In the Annexes, the reference to the illustrations used in the Thesis Report, the reference to the support files, Generated Tools and Templates, the Application Examples, the Guides, and finally, the reference to the file "A voice from TC 176. Interview with Leopoldo Colombo ".
Poveda Orjuela, PP. (2021). Configuración de un modelo conceptual para los sistemas de gestión "qhse3+", con perspectiva de rendimiento energético y administración integral de riesgos [Tesis doctoral]. Universitat Politècnica de València. https://doi.org/10.4995/Thesis/10251/171277
TESIS

As a part of risk management, barrier management proves to be one of the critical factors in maintaining a safe state for operation in the oil and gas industry. With the introduction of non-traditional school of thought (Safety-I vs. Safety-II) on what safety is and how to achieve it, methods such as Functional Resonance Analysis Method (FRAM) have been developed to map sociotechnical systems from a different perspective. FRAM’s potential to be used explicitly in barrier management has yet to be demonstrated. Thus, this study aims to find out how FRAM, as a Safety-II approach, can add value to the barrier management in offshore drilling. To find the suitability of FRAM in barrier management and its potential, firstly, the concepts of risk management, barrier management and FRAM were reviewed. Then, the FRAM approach has been applied to an offshore well production based on its designed barrier system regarding the kick and blowout risks as one of the common risks in offshore industry. The FRAM model was then compared to a traditional (Safety-I) representation of the system, bowtie approach, and the advantages and disadvantages of both methods were discussed. The conclusion of this study is the application of FRAM in barrier management can be beneficial. Not only it indicates the interdependencies of the system, but also provides the analyst with additional information for decision making. FRAM in this study is not replacing a wildly used bowtie method for barrier management. Still, while acknowledging Safety-I’s advantages, it brings out its limitations and provides the analyst with a more comprehensive decision-making support tool.

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O uso e a aplicação cada vez mais constante da tecnologia nuclear consistente em áreas relacionadas à saúde, energia, industrial, bélica, agrícola, entre outras, faz com que haja a necessidade de uma regulamentação de acordo com os padrões de segurança e proteção radiológica internacionais. Dessa forma, utilizando-se de conceitos provenientes do Direito Constitucional, do Direito Ambiental e do Direito do Trabalho, o enfoque da presente pesquisa foi investigar a difícil questão da competência nuclear e a competência ambiental, a impossibilidade de legislar dos Estados, bem como a falta de regulamentação sobre Rejeitos radioativos. Para tanto, foram atualizados e revisados critérios e métodos de interpretação constitucional para solucionar possíveis antinomias jurídicas advindas de múltipla positivação de normas pelos entes federados que dificultam tanto o asseguramento quanto o aprimoramento da Proteção radiológica do trabalhador e do meio ambiente. Finalmente, a hipótese considerada demonstrou que as mudanças na estrutura legislativa nas três esferas de poderes são necessárias, visando à aplicabilidade de responsabilidade legal na esfera nuclear, principalmente no que se refere às entidades administrativas e estatais.
Dissertação (Mestrado em Tecnologia Nuclear)
IPEN/D
Instituto de Pesquisas Energeticas e Nucleares - IPEN-CNEN/SP

Trata-se de um estudo exploratório, descritivo de abordagem quantitativa, que teve por objetivo avaliar o processo de identificação do neonato admitido na unidade de terapia intensiva neonatal e semi-intensiva de um hospital privado no Município de São Paulo. A casuística compôs-se de 540 oportunidades de análise, selecionadas pela amostragem probabilística aleatória simples. A coleta de dados ocorreu no período de maio a agosto de 2010, por meio de um formulário, contendo as três etapas do processo de identificação: componentes de identificação, condições da pulseira e quantitativo de pulseiras. Os dados foram analisados em função da estatística descritiva, e sendo aplicado o teste estatístico com significância de 5%. No que diz respeito ao desempenho geral do processo, o percentual de conformidade foi de 82,2%. No que tange as três etapas integrantes do processo, o maior índice de conformidade (93%) foi atribuído a segunda etapa e o menor (89,3%) a terceira etapa, com diferença estatística significante (p=0,046). Em relação a primeira etapa, a presença do código de internação obteve (98,5%) de conformidade; na segunda,o melhor percentual (99,8%), foi atribuído à confecção correta da pulseira e na terceira, houve (88,5%) de conformidade para o grupo de neonatos em condições especiais, não apresentando diferença estatística significante p=0,895. Acredita-se que os achados deste estudo subsidiem as reestruturações necessárias no processo de identificação dos recém-nascidos e o estabelecimento de metas assistenciais e gerenciais, para a melhoria contínua da qualidade e da segurança dos pacientes.
This is an exploratory, descriptive study of quantitative approach, aiming to evaluate the identification procedure for newborns admitted to a neonatal intensive and semi-intensive care unit of a private hospital in the city of São Paulo. The sample consisted of 540 opportunities for analysis, selected by the simple random probability sampling. Data collection occurred between May and August 2010, using a form containing the three phases of the identification procedure: identification components, conditions of ID bracelet and quantitative of ID bracelets. Data were analyzed according to descriptive statistics and the statistical test was applied with a significance of 5%. Regarding performance of the general process, the percentage of compliance was 82.2%. Regarding the three phases of the process, the highest compliance rate (93%) was related to the second phase and the lowest (89.3%) to the third phase, with a statistically significant difference (p = 0.046). Regarding the first phase, the presence of a hospitalization code obtained (98.5%) of compliance, in the second, the best percentage (99.8%) was attributed to correct manufacturing of the ID bracelet and third, with (88, 5%) of compliance for the group of newborns under special conditions, showing no statistically significant difference p = 0.895. It is believed that the findings of this study will subsidize the necessary reorganization of newborn identification procedure and establishment of assistance and management of goals for the constant improvement of quality and patient safety.

Master's thesis "Innovation processes personal data for the state organization," deals with the protection of personal data for processing, both in paper, as well as electronic form. The main topic is security policy, the assessment of security risks resulting proposals for the introduction of innovative processes aimed to prevent possible leakage and misuse of personal data.

O processo de administração de medicamentos é considerado um processo complexo, crítico e de alto risco para os pacientes e tem apresentado altas taxas de ocorrência de eventos adversos que poderiam ser evitados. Este estudo teve o objetivo de analisar os riscos potenciais do processo de administração de medicamentos antiinfecciosos por via intravenosa de uma unidade de internação, visando a prevenir e a reduzir eventos adversos com medicamentos. A investigação, de natureza exploratória, foi realizada na unidade de Clínica Médica de um Hospital do Estado de Goiás, utilizando o Método de Análise do Modo e Efeito da Falha. Participaram do estudo, além da pesquisadora, seis profissionais envolvidos na terapêutica medicamentosa: médico, enfermeiro, técnico de enfermagem, farmacêutico e os gerentes de Enfermagem e de risco. Foram realizadas 24 reuniões, no período de 19 de fevereiro a 3 de julho de 2008, totalizando 56 horas. Todas os dados foram transcritos e armazenados em um banco eletrônico no programa Microsoft Excel® e analisados no software XFMEA 4. Os resultados indicaram que o processo de administração de medicamentos possui quatro microprocessos, dez atividades e 22 funções. No processo foram identificados 52 modos potenciais da falha (MPF), sendo que as maiores freqüências estiveram nas atividades de administração de medicamentos (16; 30,8%), preparo de medicamentos (12; 23,1%), aprazamento de medicamentos (5; 9,6%) e transcrição de medicamentos para etiquetas (5; 9,6%). Também foram identificados 79 efeitos potencias da falha (EPF), com as maiores freqüências nas atividades: administração de medicamentos (24; 30,4%), preparo de medicamentos (15; 19%) e transcrição de medicamentos para etiquetas (12; 15,2%). Dos EPF, 36,2% foram considerados de gravidade média; 28,7% de moderada, e 27,5% de alta. Em 80% das atividades, foram identificados efeitos de alta gravidade. A classificação dos efeitos apontou que os tipos mais freqüentes foram os erros de: técnica (21; 26,6%), omissão (20; 25,3%) e horário (15; 19%). Foram identificadas 285 causas potenciais da falha (CPF) com as seguintes freqüências quanto aos índices de ocorrência: 91 (31,9%) média, 78 (27,4%), baixa ou relativamente baixa; 40 (14,0%), alta; e 30 (10,5%), extremamente alta. As CPF foram classificadas dentro de três categorias: gestão dos processos organizacionais (125; 43,9%); recursos humanos (124; 41,4%); estrutura física e material (36; 12,6%). Em relação aos tipos de controles, os resultados mostraram que 211 (92,9%) eram de detecção e 12 (5,3%) de prevenção. O cálculo do número de prioridade de risco (NPR) das CPF identificou que 59 (20,7%) eram de alta prioridade de risco, 156 (54,7%) de média e 70 (24, 6%) de baixa. Foram recomendadas 293 ações de melhorias para as 215 CPF de alta e média prioridade, sendo 240 (81,9%) de curto prazo, 39 (13,3%) de médio prazo e 14 (4,8%) de longo prazo. A simulação do impacto das ações propostas possibilitou identificar uma redução de 79,7% dos MPF de alta prioridade de risco e de 59,6% dos MPF de alta criticidade, assim como uma redução do NPR total das atividades entre 90 e 31,8%, com medidas simples e de rápida aplicação, aumentando a confiabilidade e segurança do processo de administração de medicamentos
Intravenous drug administration is a high-risk process due to its complexity and high rates of adverse events. The aim of this study was to analyse potential risks associated to intravenous anti-infectious drug administration process in a hospital unit. It was an exploratory search at a University Hospital Medical Clinic unit in Goiás, by means of failure modes and effects analysis method. For data collection, it was formed a six members multidisciplinary staff: risk and nurse manager, medical, nurse, and pharmacist, in addition to the searcher. A number of 24 meetings was done, from February 19 and July 3, 2008, in an amount of 56 hours. One has collected data, copied and saved them in a Microsoft Excel® electronic data bank. Afterwards, they were analyzed by means of XFMEA 4 software. Results showed that administration process involves 4 micro process, 10 activities, 22 functions. The search identified 52 failure potential modes (FPM) whose most significant frequencies happened in the following activities: drug administration (16; 30.8%); drug preparation (12; 23.1%); drug delay (5; 9,6%) and drug names transcription to tags (5; 9.6%). The study identified also 79 failure potential effects (FPE), whose higher frequencies were: drug administration (24; 30.4%), drug preparation (15; 19%) and transcription to tags (12; 15.2%). Among FPE, 36.2% were considered as of medium severity ones; 28.7% moderate severity, and 27.5% of high severity ones. High severity effects were identified in 80% of the activities. Effect classification pointed that the most frequent types were the following ones: technical (21; 26.6%), omission (20; 25.3%) and schedule (15; 19%). A number of 285 failure potential causes (FPC) were identified with the following occurrence rates: 91 (31.9%) medium, 78 (27.4%), low or extremely low; 40 (14.0%), high; and 30 (10.5%), extremely high. FPC were classified in three categories: organizational process management (125; 43.9%); human resources (124; 41.4%); physical and material structure (36; 12.6%). Concerning to control types, results showed 211 (92.9%) derived from detection and 12 (5.3%) were prevention ones. FPC Risk priority number (RPN) calculation showed that 59 (20.7%) had high-risk priority; 156 (54.7%) medium and 70 (24.6%) low-risk priority. A number of 293 recommendations were done to high and medium priority FPC: 240 (81.9%) short term, 39 (13.3%) de medium term and 14 (4.8%) de long-term ones. Action impact simulation on failure modes allowed to identify a 79.7% reduction in high priority FPM as well a 59.6% one in high criticality FPM ones by means of simple and quick application measures that can improve reliability and safety in drug administration process

This thesis consists of the evaluation of sensor-based risk management against oil spills using an underwater distributed sensor network. The work starts by highlighting the importance of having a performing leak detection system both from an environmental, safety and economic point of view. The case study is the Goliat FPSO in the Barents Sea which has to meet requirements dictated by Norwegian authorities to prevent oil spills. The modeled network is made of passive acoustic sensors monitoring the subsea manifolds. These sensors send their local 1-bit decision to a Fusion Center which takes a global decision on whether the leakage is occurring. This work evaluates how the choice of adapted Fusion Rules (Counting Rule and Weighted Fusion Rule) can affect the performances of the leak detection system in its current geometry. It will also be discussed how different thresholds, selected for a specific FR or sensor test, can change the system performance. The detection methods are based on statistical signal processing adapted to fit this application within the Oil&Gas field. The work also proposes some new leak localization methods developed so they can be coupled with the proposed leak detection methods, giving a coherent set of operations that the sensors and the FC must perform. Performances of detection techniques are assessed balancing the need for high values of True Positive Rate and Precision and low values of False Positive Rate using indexes based both on the ROC curve (like the Youden's Index) and on the PR curve (the F-scores). Whereas, performances of localization techniques will be assessed on their ability to localize the spill in the shortest time; if this is not possible, parameters like the difference between the estimated and the real leak position will be considered. Finally, some tests are carried out applying the different sets of proposed methods.

The purpose of the final thesis is to elaborate selected parts of a technology building project of the Pension for the elderly. The complex includes eleven building objects and the main one is developed in detail. The final thesis includes a technical report about the technology building project, a building schedule, suggestion for realization of the main stages of its construction, a design of mechanical assembly. The final thesis also includes the project of site equipment, technological regulations , an inspection and test plan, an occupational safety and health plan.

Увод. Годишње најмање 30% особа старијих од 65 година доживи један или више падова. Са повећањем година повећава се и озбиљност компликација услед пада, степен функционалног оштећења и ниво инвалидитета. Одговорност за пад приписује се многим факторима ризика. Због сложености њихове природе, од кључног је значаја да се ревидирају концептуални и методолошки оквири за разумевање и предвиђање пада у популацији старих особа. Циљеви истраживања. Утврдити учесталост падова код особа старијих од 65 година; утврдити најзначајније факторе ризика од пада и проценити њихову интеракцију са функционалним способностима и забринутост због пада. Материјал и методологија. Истраживање је спроведено у од фебруара до јуна 2014. године у виду студије пресека и обухватило је 400 испитаника старијих од 65 година. Испитаници су тестирани у кућним условима приликом посете патронажне службе. Коришћени су следећи инструменти: општи упитник, Elderly Fall Screening Test – ЕFST, Multi-factor Falls Questionnaire – MFQ, Tinetti Balance Assessment, Lawton Instrumental Activities of Daily Living Scale − IADL, Falls Efficacy Scale International FES-I. Стaтистички прорaчуни су вршени прогрaмом SPSS верзијa 20. Резултати истраживања. Резултати студије показују да је пад доживело 55% испитаника. Регресиони модел EFST са варијаблама био је статистички значајан, а као независни предиктори показали су се женски пол (OR = 2,751; < 0,001), године старости (OR = 1,138; p < 0,001), и степен образовања (OR = 0,554; p = 0,027). Слични резултати су добијении и за регресиони модел са Тинетијевим скором где су се као независни предиктори показали пол (Beta = -0,107; p = 0,029) старост (Beta = -0,260; p < 0,001) и степен образовања (Beta = 0,191; p < 0,001). Све корелације између ЕFST, FESI, IADL и скором Тинетијевог теста биле су статистички значајне (p < 0,05). Вредности скора FESI биле су у јакој позитивној корелацији са скором ЕFST и изузетно негативној корелацији са IADL и скором Тинетијевог теста. Скор ЕFST показао је умерену негативну корелацију са скором IADL и јаку негативну са скором Тинетијевог теста, док су скор IADL и скор Тинетијевог теста показали умерену позитивну корелацију. Модел EFST био је статистички значајан и у целини тачно класификује 83,3% случајева. Варијабле које су се показале као независни предиктори били су: Тинети скор (OR = 0,783; p < 0,001), скор (OR = 1,041; p = 0,019) и ортостатска хипотензија (OR = 2,291; p = 0,035). Закључак. У испитиваној популацији падови су веома учестала појава и више од половине особа доживела је пад у последњих годину дана. У повећаном ризику од пада су жене. Такође ризик од пада повећава се са годинама старости. Нижи степен образовања показао се као независни предиктор пада. Предикција ризика од пада утврђеног на основу скрининг тест за пад код старих особа у општој популацији могућа је уз висок степен детерминације на основу скора Тинетијевог теста и, скора FESI и ортостатске хипотензије.
Uvod. Godišnje najmanje 30% osoba starijih od 65 godina doživi jedan ili više padova. Sa povećanjem godina povećava se i ozbiljnost komplikacija usled pada, stepen funkcionalnog oštećenja i nivo invaliditeta. Odgovornost za pad pripisuje se mnogim faktorima rizika. Zbog složenosti njihove prirode, od ključnog je značaja da se revidiraju konceptualni i metodološki okviri za razumevanje i predviđanje pada u populaciji starih osoba. Ciljevi istraživanja. Utvrditi učestalost padova kod osoba starijih od 65 godina; utvrditi najznačajnije faktore rizika od pada i proceniti njihovu interakciju sa funkcionalnim sposobnostima i zabrinutost zbog pada. Materijal i metodologija. Istraživanje je sprovedeno u od februara do juna 2014. godine u vidu studije preseka i obuhvatilo je 400 ispitanika starijih od 65 godina. Ispitanici su testirani u kućnim uslovima prilikom posete patronažne službe. Korišćeni su sledeći instrumenti: opšti upitnik, Elderly Fall Screening Test – EFST, Multi-factor Falls Questionnaire – MFQ, Tinetti Balance Assessment, Lawton Instrumental Activities of Daily Living Scale − IADL, Falls Efficacy Scale International FES-I. Statistički proračuni su vršeni programom SPSS verzija 20. Rezultati istraživanja. Rezultati studije pokazuju da je pad doživelo 55% ispitanika. Regresioni model EFST sa varijablama bio je statistički značajan, a kao nezavisni prediktori pokazali su se ženski pol (OR = 2,751; < 0,001), godine starosti (OR = 1,138; p < 0,001), i stepen obrazovanja (OR = 0,554; p = 0,027). Slični rezultati su dobijenii i za regresioni model sa Tinetijevim skorom gde su se kao nezavisni prediktori pokazali pol (Beta = -0,107; p = 0,029) starost (Beta = -0,260; p < 0,001) i stepen obrazovanja (Beta = 0,191; p < 0,001). Sve korelacije između EFST, FESI, IADL i skorom Tinetijevog testa bile su statistički značajne (p < 0,05). Vrednosti skora FESI bile su u jakoj pozitivnoj korelaciji sa skorom EFST i izuzetno negativnoj korelaciji sa IADL i skorom Tinetijevog testa. Skor EFST pokazao je umerenu negativnu korelaciju sa skorom IADL i jaku negativnu sa skorom Tinetijevog testa, dok su skor IADL i skor Tinetijevog testa pokazali umerenu pozitivnu korelaciju. Model EFST bio je statistički značajan i u celini tačno klasifikuje 83,3% slučajeva. Varijable koje su se pokazale kao nezavisni prediktori bili su: Tineti skor (OR = 0,783; p < 0,001), skor (OR = 1,041; p = 0,019) i ortostatska hipotenzija (OR = 2,291; p = 0,035). Zaključak. U ispitivanoj populaciji padovi su veoma učestala pojava i više od polovine osoba doživela je pad u poslednjih godinu dana. U povećanom riziku od pada su žene. Takođe rizik od pada povećava se sa godinama starosti. Niži stepen obrazovanja pokazao se kao nezavisni prediktor pada. Predikcija rizika od pada utvrđenog na osnovu skrining test za pad kod starih osoba u opštoj populaciji moguća je uz visok stepen determinacije na osnovu skora Tinetijevog testa i, skora FESI i ortostatske hipotenzije.
Introduction. Annually at least 30% of people over 65 experience one or more falls. With the increase in years, the severity of complications due to falls, degree of functional impairment and level of disability also increase. The responsibility for the fall is attributed to many risk factors. Due to the complexity of their nature, it is crucial that the conceptual and methodological frameworks for understanding and predicting the decline in the elderly population are revised. Research goals. Determine the incidence of falls in people over 65 years of age; identify the most important risk factors of the fall and evaluate their interaction with functional abilities and fear for falling. Material and methodology. The survey was conducted from February to June 2014 in the form of a cross sectional study and included 400 respondents over 65 years of age. Respondents were tested at home during a visit of the patronage service. The following instruments were used: general questionnaire, Elderly Fall Screening Test - EFST, Multi-factor Falls Questionnaire - MFQ, Tinetti Balance Assessment, Lawton Instrumental Activities of Daily Living Scale - IADL, Falls Efficacy Scale International FES-I. Statistical calculations were performed by the SPSS version 20 program. Research results. The results of the study show that the fall was experienced by 55% of respondents. The regression model EFST with variables was statistically significant, and as independent predictors the female sex (OR = 2,751; <0,001), age (OR = 1,138; p <0,001), and the level of education (OR = 0,554; p = 0.027) were shown. Similar results were obtained for the regression model with the Tinetti's score, where the gender (Beta = -0.107; p = 0.029) age (Beta = -0.260; p <0.001) and education (Beta = 0.191; p < 0.001) were shown as independent predictors. All correlations between EFST, FESI, IADL and the Tinetti's test score were statistically significant (p <0.05). The FESI score values were in a strong positive correlation with the EFST score and extremely negative correlation with IADL and the Tinetti’s test score. The EFST score showed a moderate negative correlation with the IADL score and a strong negative with the Tinetti’s test score, while the IADL score and the Tinetti test score showed moderate positive correlation. The EFST model was statistically significant and in its entirety accurately classified 83.3% of cases. Variables that proved to be independent predictors were: Tinetti score (OR = 0.783; p <0.001), score (OR = 1.041; p = 0.019) and orthostatic hypotension (OR = 2.291; p = 0.035). Conclusion. In the studied population, falls are a very common occurrence and more than half of the people experienced a fall in the past year. Women are at increased risk of falling. Also, the risk of falling increases with age. A lower level of education has proven to be an independent fall predictor. Prediction of the risk of a fall that has been established on the basis of a screening test for elderly people in the general population is possible with a high degree of determination based on the Tinetti test score and, recent FESI and orthostatic hypotension.

Today, the main research field for the automotive industry is to find solutions for active safety. In order to perceive the surrounding environment, tracking nearby traffic objects plays an important role. Validation of the tracking performance is often done in staged traffic scenarios, where additional sensors, mounted on the vehicles, are used to obtain their true positions and velocities. The difficulty of evaluating the tracking performance complicates its development. An alternative approach studied in this thesis, is to record sequences and use non-causal algorithms, such as smoothing, instead of filtering to estimate the true target states. With this method, validation data for online, causal, target tracking algorithms can be obtained for all traffic scenarios without the need of extra sensors. We investigate how non-causal algorithms affects the target tracking performance using multiple sensors and dynamic models of different complexity. This is done to evaluate real-time methods against estimates obtained from non-causal filtering. Two different measurement units, a monocular camera and a LIDAR sensor, and two dynamic models are evaluated and compared using both causal and non-causal methods. The system is tested in two single object scenarios where ground truth is available and in three multi object scenarios without ground truth. Results from the two single object scenarios shows that tracking using only a monocular camera performs poorly since it is unable to measure the distance to objects. Here, a complementary LIDAR sensor improves the tracking performance significantly. The dynamic models are shown to have a small impact on the tracking performance, while the non-causal application gives a distinct improvement when tracking objects at large distances. Since the sequence can be reversed, the non-causal estimates are propagated from more certain states when the target is closer to the ego vehicle. For multiple object tracking, we find that correct associations between measurements and tracks are crucial for improving the tracking performance with non-causal algorithms.

碩士
國立中央大學
環境工程研究所
97
A vapor cloud explosion at British Petroleum’s Texas City refinery proved, once again, the devastating impact of major accident involving large quantities of chemicals. Reports from the Chemical Safety Board and Hazard Investigation on the accident and BP US Refineries Independent Safety Review Panel recommended closer monitoring of process safety data. Despite the comprehensiveness of Process Safety Management, most of chemical and petrochemical companies are not required to report to competent authorities or to reveal to the general public on incidents causing spills, fires, explosions or injuries. Leading and lagging process safety performance indicators become the focus of trade associations, individual companies, government agencies, and academics since 2007. Development of process safety performance indicators was first proposed by Health and Safety Executive of the UK in late 2006. Both leading and lagging performance indicators are derived from the intended functions or effectiveness of risk control systems. Center for Chemical Process Safety of the American Institute of Chemical Engineers proposed the use of leading and lagging metrics to measure the effectiveness or failure of process safety management. The lagging metrics are defined as process safety incident, other incidents, near miss and unsafe behaviors or insufficient operating discipline. In addition to process safety incident, annual total incident rate and incident severity rate are included as well. CCPS views mechanical integrity, action items follow-up, management of change, and employee training and competency as leading metrics. The European counterpart of American Chemistry Council, the European Chemical Industry Council, has a similar set of leading and lagging indicators. Process safety performance indicators of CCPS, HSE, CEFIC, and OECD guidance for safety performance indicators are analyzed in this study. In-depth analysis reveals the fact that CCPS performance metrics are mostly derived from the fundamental principle of protection layers. These metrics cover the basic functions of safety instrumented systems, relief devices, and physical protection of post-release. By definition, the lines of defense against chemical process incidents also include basic process control systems and critical alarms and operator intervention. In addition, process control and alarm management precede other protection layers. Hence objective of this study is to design a set of lagging process safety performance indicators capable of evaluating the effectiveness of process control systems and alarm management to supplement the ones proposed by CCPS.