...done in a proper manner. Despite this oversight, maintenance errors still occur and have been, on many occasions, stated as the main cause of aircraft accidents. Knowledge of the factors that contribute to maintenance errors and therefore aircraft accidents can go a long way in enabling the industry regulars to draft precautionary measures and safety protocols to reduce the occurrence of these accidents. I. Factors contributing to maintenance errors Human factors, management factors, and structure factors are the most common factors that contribute to errors during the maintenance of aircraft (Stolzer, Halford & Goglia, 2012). Of the three factors, human factors account for the majority maintenance errors and therefore majority of aircraft accidents. There are numerous factors that can directly or indirectly contribute to human factors in maintenance errors can be categorized into the three groups of individual factors, job factors and organizational factors. Individual factors are those capabilities and attributes of an individual that may cause the individual to commit an error. These factors include their habits, personal attitudes, skills, personalities and their competence. For instance, if a maintenance officer has the habit of not paying close attention to detail, the officer may overlook a crucial maintenance steps that may later cause the aircraft to crash. Job factors that cause human maintenance errors are the workplace requirements that may not match the capabilities...
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...Risk Management Plan Project Name: Foxx Bookstore Project Description Summary: This project is to be built from the ground up in LA. It will require new building appliances, with the approval of the city of LA. We will offer the suppliers and the vendors as part of the project. Project Manager: Michelle Gonzalez Date: April 24th, 2013. Revision Number: 1 A. Risk Identification I have gathered a list of what will cause the project to have delays or have failures within the course of the project. There are listed below in bold writing in order to keep track of the risk that will cause a delay to the project. 1.) Delay of any additional supplies to build the store- This will put a big delay on the timing of the building being completed on time. 2.) Weather- Although we live in a state that does not rain so much, we are entering the time in which we will experience heavy rain for few days. 3.) Delay on the License Agreements- We may not being able to have the license in order to continue the construction of the project as well as the installation of the appliances. 4.) Staff- We is a company with 20 + workers, however having men sick or on leave will cause a delay on meeting the deadlines. Causing more men to work overtime in order to complete the deadlines of no more than two days. 5.) Electronic failure- If the electronic, such as the installation of the lights, be a delay if they are not installing proper. 6.) Software input- If the software...
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...flight control for the small UAV’s. This reports aims to provide an integrated framework with systematic, schematic procedure so that the UAV can be synthesized and validate flight controllers. This approach will help FAA and EASA certification of UAV system very rapidly. The first part of this report provides a brief introduction regarding the failure of the components. The second part discusses about the System Test and validation of the UAV. The last part of the report analyzes the human factor issues involved in the UAV. Introduction The UAV is not a new concept as it was in the situation of First World War. The roles and responsibilities that it carries has increased its utilization in the field of defense, disaster surveillance etc. Increment in utilization has accompanied by more number of failures rates compared to commercial and conventional airframes. There is about 1 per 100,000 flight hours’ general aviation mishap which includes UAV and about 1 per 1000 flight hours that includes military UAV. If these mishaps is to be calculated the failure rates of UAV is about 25% [ (Tvaryanas, Thompson, & Constble) ]. Despite of failures many forms of...
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...Normal Accident at Three Mile Island Charles Perrow A ccidents will happen, including ones in nuclear plants. But by and large, we believe accidents can be prevented through better training, equipment, or design, or their effects can be localized and minimized through safety systems. The accident at Three Mile Island (TMI) is being assessed in this fashion. The industry started a new training program, the equipment at the Babcock and Wilcox plants is being improved, the design has been modified, the utility chastised--all useful, if minor, steps. Furthermore, to nuclear proponents, such as Edward Teller, the accident proved that the effects can be localized and minimized. It is safe. No one has died as a direct result of radiation injuries in all the years of commercial nuclear plant operation. But the accident at TMI was not a preventable one, and the amount of radiation vented into the atmosphere could easily have been much larger, and the core might have melted, rather than just being damaged. TMI was a "normal accident"; these are bound to occur at some plant at some time, and bound to occur again, even in the best of plants. It was preceded by at least sixteen other serious accidents or near accidents in the short life of nuclear energy in the United States, and we should expect about sixteen more in the next five years of operation--that is, in industry time, the next four hundred years of operation of the plants existing now and scheduled to come on stream. Normal...
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...W5 Application: Patient Safety Risks Nursing Home Setting This paper will focus on geriatric patients group with increased fall risk at nursing homes. A nursing home is chosen by as the selected healthcare setting. Nursing homes are not only for geriatric population, but for anyone who requires 24-hours care. Nursing homes focus their services for people who cannot be cared at home. Most nursing homes have nursing aides and skilled nurses on hand 24 hours a day. Many of them are set up like a hospital setting. This type of facility provides interdisciplinary medical care, such as physical, speech, and occupational therapy, or even specialized care units. Patient Safety Among the key challenges of patient care, quality, and safety is to ensure that there are no injuries to patients from the care intended to help them. Another challenge is to provide care that is respectful of and responsive to patient preferences, needs, and values. Since the nation's health care system is prone to errors which can be detrimental to quality and safety. In fact, a variety of stakeholders are responsible of ensuring that patient care is delivered with the highest quality standards and that no harm occurs to patients. However, the possibility of errors is...
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...accident causation which is used risk management and its analysis in system of healthcare, aviation, and engineering. Swiss Cheeses Model compares human system to Swiss cheese slices. The slices are piled together with one another. Basically it was founded in 1990, by James T. Reason, a British psychologist of University of Manchester. The model gained wide acceptance and has been used by healthcare industry, emergency services organizations, aviation industry, and safety industry since it was developed. It is also known as cumulative act effect. According to a survey, in most of the cases, there can be four levels of failure for an accident: unsafe supervision, unsafe act of themselves, organizational influence, and preconditions for unsafe acts. James T. Reason, in his Swiss Cheese Model developed defenses of organization against the failure and represented barriers as slices of Swiss cheese. And individual weaknesses are shown by the holes in the slices as part of the system, and all holes are different in position and sizes in those slices. The failure of the system occurs when holes in slices simultaneously align in aggregate, giving permission, as James Reason's said “a trajectory of accident opportunity", so that in all the defenses, jeopardy passes through all holes, which causes failure. Discussion The theory of James T. Reason involves mathematical analysis and is complicated and also involves underlying and active failures. Swiss cheese model applies here...
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...Abstract Patient safety and Medical errors are one of the major concerns of healthcare industry. Our group decided to throw more light on the present situation of this issue. In this paper we have given a clear picture about the types of errors, how these errors occur and towards the end we have discussed on how to prevent these errors. The implementation of the actions to prevent errors discussed in our paper will help in improving and reducing them. In doing so, we can be leaders in an effort to provide the best care possible to all Americans. We have also discussed about the importance of patient safety. Reducing errors and improving how we respond to error is but a subset of the all-important issue of quality of care. TABLE OF CONTENTS Introduction ……………………………………………………………………………... 5 Regulatory Authority……………………………………………………………………. 5 Patient safety ……………………………………………………………………………. 6 Medical Errors ………………………………………………………………………….. 7 Why medical errors occur? .............................................................................................. 8 When errors are not reported ………………………………………………………….. 8 Types of Medical Errors ………………………………………………………………… 9 Sentinel Events ……………………………………………………………………….. 9 Diagnosis or evaluation ………………………………………………………………. 9 Medical decision-making …………………………………………………………… 10 Treatment and medication …………………………………….…………………..… 10 Dispensing ……………………………………………………………………………11 Procedural complications...
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...RTT1 Task 2 Never events are serious medical errors that are often preventable. When such events transpire, it is necessary to fully assess the situation so that these errors can be prevented in the future. Root cause analysis (RCA) is a tool employed by healthcare facilities to analyze adverse events and the systems that lead to them. A. Root Cause Analysis “A central tenet of RCA is to identify underlying problems that increase the likelihood of errors while avoiding the trap of focusing on mistakes by individuals” (AHRQ, 2012). The emphasis of RCA is on error prevention. It is a structured process of gathering data regarding the event, analyzing the information, and finding solutions to the problems to prevent reoccurrences. A team consisting of the charge nurse, a physician, a respiratory therapist, a pharmacist, hospital administrators, and patients not involved in the case is assembled to work through the process. The team begins by interviewing patients and staff involved to gather as much vital information as possible. Once all necessary information is compiled, the team works together to get to the root(s) of the problem. In the case of Mr. B, there were multiple issues that led to the adverse event as opposed to one root problem. In the process of defining the problem, several causal factors were identified. The error was a result of both facility and human error. Mr. B, a 67-year-old patient, presented to the small, six-room, rural hospital ED due to severe...
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...Risk Management Plan Prepared By: Revision History Version | Date | Author(s) | Revision Notes | 1.4 | 02-05-2013 | | Document Finished | | | | | | | | | | | | | | | | | Table of Contents Purpose and Scope 2 Risk Plan Objectives 2 Deliverables Produced 2 Deliverable 1: Error! Bookmark not defined. Deliverable 2: 2 Deliverable 3: Error! Bookmark not defined. Project Risks 2 Risk I Error! Bookmark not defined. Risk II Error! Bookmark not defined. Risk III Error! Bookmark not defined. Disaster Recovery Plan Error! Bookmark not defined. Types of Teams Error! Bookmark not defined. In the Event of a Disaster Error! Bookmark not defined. Recovery Scenarios Error! Bookmark not defined. Recovery Activities Error! Bookmark not defined. ------------------------------------------------- Purpose and Scope The face of banking is changing rapidly. To protect business information, confidentiality, integrity, and availability must be considered. Greenway bank is in the risk business. Our goal is to help Greenway Bank provide financial services that will assume various kinds of financial risks. The banking industry has long viewed the problem of risk management as the need to control some if not all of the common banking issues like exposure, credit, interest rate, foreign exchange, liquidity risk and legal risks. Confidentiality ensures that its customers will have a safe banking experience. Confidentiality is...
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...requirements for the degree, M.S. in Risk Control. I understand that this report must be officially accepted by the Graduate School which will then forward it to the Library Learning Center, where it will be placed on microform or other electronic storage and made available as any other published document including placement on the Library Web Page. I attest that the research report is my original work, and that any copyrightable materials have been used with the permission of the original authors, and as such, it is automatically protected by the laws, rules, and regulations of the U.S. Copyright Office. TITLE OF REPORT IDENTIFICATION OF POSSIBLE HUMAN ERRORS THAT CAN RESULT IN FIRES/EXPLOSIONS DURING TANKERS' CARGO LOADING/UNLOADING OPERATIONS AT THE XYZ MARINE PETROLEUM TERMINAL SIGNATURE __________________________________DATE ________ PERMANENT ADDRESS 2721 Harvey Dr. Apartment #1. Menomonie, WI 54751, USA TELEPHONE # 715-235-4730 (This section to be completed by the graduate School) This final research report was submitted in partial fulfillment of the requirements for the above stated degree on this date, and has been accepted by the Graduate School and is now ready for transmittal to the Library Learning Center for placement on microform or other storage media. (Coordinator for Graduate Studies) (Date) (This form must accompany the research paper turned in to the Graduate School) IDENTIFICATION OF POSSIBLE HUMAN ERRORS THAT CAN RESULT IN FIRES/EXPLOSIONS...
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... Abstract Thousands of people die each year as a result of medication errors. Medication errors can be attributed to faults in both humans and medication use systems. Therefore, it is necessary to address resolutions to both of these predicaments. The anticoagulant heparin is amongst the most implicated medications. Thus, it has been documented in the top five high-alert medications. Two notable events that triggered recent interest in this topic are the heparin overdoses that occurred in California, associated with actor Dennis Quaid’s newborn twins, and those affecting neonates in an Indiana hospital. The Failure Mode Effect Analysis (FMEA) is a proactive approach to error prevention. Implementation of an FMEA system would serve as a crucial method that will help to recognize potential failures of a product or process before adverse events occur. FMEA can help identify where the use of technology can be implemented to facilitate the reduction of medication errors, especially pertaining to heparin as in this case. Studies have shown how technology, such as computerized heparin nomagram system (HepCare), smart pump infusion technology, computerized physician order entry (CPOE), and the bar coding system, can reduce medication errors. Expanding nationwide awareness of these methods should result in a significant decline of medication errors. Introduction Errors are unavoidable in today highly complex and technologically advanced medical treatment...
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...patient’s sedation level. Patient, monitoring or sedation level weren’t assessed between doses. This event is known as a sentinel event. In any situation that causes injury, or death a root cause analysis must be completed and reported to the Joint Commission. B. To implement a change in the conscious sedation procedure a team or committee needs to be established. All staff in the emergency room can become active participants by joining a committee or subcommittee. These main categories may include patient characteristics, task factors, individual staff members, team factors, work environment, and organizational management (IHI, 2014). A cause and effect, or wishbone graph can be constructed to clarify the error and process for the team, leading up to the event. The committee then needs to develop causal statements. These statements link the cause to its effects and then back to the main event that promoted the root cause analysis. These statements link the cause to its effects and then back to the main event that...
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... Maritime Law Midway Maritime Foundation ABSTRACT This paper analyses the grounding that occurred on the 13th of January 2012 to the cruise ship Costa Concordia. The analysis is carried out only on the conduct of navigation – and not on the emergency response - at three different levels: the errors of the bridge team, the error-inducing conditions of their workplace (the bridge), and the organizational processes behind them – following Reason’s (1997) model of organizational accident. An organizational accident is a rare, but often catastrophic, event that occurs within complex organizations as a product of technological innovation. Working under a hypothesis built on publicly available data till July 2012, the grounding of Costa Concordia appears to be an organizational accident. The paper aims to provide official investigators with a framework for the understanding of its development, which is considered critical to limit the re-occurrence of other such events. Moreover, it aspires to be the starting point for future examination of error inducing conditions across the cruising industry and the wider maritime domain. Overall, it is an attempt to address systemic issues, rather than accusing or defending individuals and organizations involved. INTRODUCTION About 21.42 (UTC+1) on January 13, 2012, the cruise ship Costa Concordia grounded on the rocks Le Scole, near Giglio island, Italy. The ship,...
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...Organizational Systems and Quality Leadership Task 2 Kayla Meyer Western Governors University. A. Explain the general purpose of conducting a root cause analysis (RCA). The purpose of conducting a root cause analysis is to look back at an error that occurred, determine the direct and contributing factors to the error, and identify the flaws in a system that can be corrected to prevent this error from occurring in the future. A mix of different professionals from all levels of the organization comprises the team conducting the RCA. IHI 2019, Patient Safety 104. Explain each of the six steps used to conduct an RCA, as defined by IHI. 1. What is the difference between a. and a. Identify what error occurred, in the order of occurrence. 2. What is the difference between a'smart' and a'smart'? In ideal conditions, determine what should have happened, in comparison to what happened. 3. What is the difference between a'smart' and a'smart'? Determine the cause of the error by asking why, to find the root cause. Identify the other causes of the error by asking the health care team to explain their role in the event. Look into the workplace environment, and the management factors. 4. What is the difference between a.. A cause statement is developed. It explains how the list of...
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...ensure high quality in software • Responsibility of many stakeholders (software engineers, project managers, customers, salespeople, SQA group) SQA Questions • Does the software adequately meet its quality factors? • Has software development been conducted according to pre-established standards? • Have technical disciplines performed their SQA roles properly? Quality Assurance Elements • Standards – ensure that standards are adopted and follwed • Reviews and audits – audits are reviews performed by SQA personnel to ensure hat quality guidelines are followed for all software engineering work • Testing – ensure that testing id properly planned and conducted • Error/defect collection and analysis – collects and analyses error and defect data to better understand how errors are introduced and can be eliminated • Changes management – ensures that adequate change management practices have been instituted • Education – takes lead in software process improvement and educational program • Vendor management – suggests specific quality practices vendor should follow and incorporates quality mandates in vendor contracts • Security...
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