Friday, December 14, 2012

Kempsey flood defence failure due to waterlogged sensor

BBC Website 14 December 2012

A faulty sensor caused the failure of £1.5m flood defences, leading to 15 homes flooding in a Worcestershire village, a report has found. 

Two pumps designed to start automatically during flooding failed to activate in Kempsey in the early hours of 25 November.

The sensor had become waterlogged during heavy rainfall, the Environment Agency-commissioned report found.

Officially unveiled in July, the flood defence pumps are part of a project that included earth embankments and a series of sluice gates.
They were tested successfully during floods in the summer.

The agency said now it knew what the problem was, it would be working to fix it. 'Dry' future

The pumps, which are working, will be operated manually by EA staff throughout the winter when flooding is possible.

"We will ensure the faults are rectified as soon as possible so the pumping station operates automatically as it is designed to," the EA said.

Anthony Perry, West Midlands flood risk manager for the agency, said: "We are very sorry that the pumping station did not operate as intended in Kempsey, especially as it had operated successfully twice this year.
"Our thoughts go out to the residents affected.

"We will continue to be in Kempsey to switch on the pumps at times of flood until the faults are fixed, and will work with the local community to regain their trust in this scheme."

Friday, November 30, 2012

Press guidelines for reporting science stories post Leveson

The Guardian 29 November 2012 by Fiona Fox

The following guidelines, drawn up in consultation with scientists, science reporters, editors and subeditors, are intended for use by newsrooms to ensure that the reporting of science and health stories is balanced and accurate. They are not intended as a prescriptive checklist and of course shorter articles or NIBs ["news in brief" items] will not be able to cover every point. Above and beyond specific guidelines, familiarity with the technicalities and common pitfalls in science and health reporting is invaluable and every newsroom should aim to employ specialist science and health correspondents. Wherever possible, the advice and skills of these specialists should be sought and respected on major, relevant stories; the guidelines below will be especially useful for editors and general reporters who are less familiar with how science works.

• State the source of the story – eg interview, conference, journal article, a survey from a charity or trade body, etc – ideally with enough information for readers to look it up or a web link.
• Specify the size and nature of the study – eg who/what were the subjects, how long did it last, what was tested or was it an observation? If space, mention the major limitations.
• When reporting a link between two things, indicate whether or not there is evidence that one causes the other.
• Give a sense of the stage of the research – eg cells in a laboratory or trials in humans – and a realistic time frame for any new treatment or technology.
• On health risks, include the absolute risk whenever it is available in the press release or the research paper - ie if "cupcakes double cancer risk" state the outright risk of that cancer, with and without cupcakes.
• Especially on a story with public health implications, try to frame a new finding in the context of other evidence – eg does it reinforce or conflict with previous studies? If it attracts serious scientific concerns, they should not be ignored.
• If space, quote both the researchers themselves and external sources with appropriate expertise. Be wary of scientists and press releases over-claiming for studies.
• Distinguish between findings and interpretation or extrapolation; don't suggest health advice if none has been offered.
• Remember patients: don't call something a "cure" that is not a cure.
• Headlines should not mislead the reader about a story's contents and quotation marks should not be used to dress up overstatement.

Wednesday, November 07, 2012

Multiple learnings following Sandy

It seems a lot of things failed as a result of super-storm Sandy.  Here are a few examples.

New York Times 31 October 2012 
 *  "Power systems failures throughout the Northeast have been the main culprits in the shutdown of more than 20 percent of the cell tower sites in 10 states, causing millions of lost calls on Wednesday". "Slow progress was made in restoring some services."
* Emergency calls (911) were interrupted by the storm.  Although the service was re-established fairly quickly it involved calls being routed to different centres and in some cases the centres did not know where the call was coming from.

Wall Street Journal 31 October 2012
* People have returned to using pay phones for the first time in many years because mobile phone services were unavailable

Infoworld 5 November 2012
*  Many data centres were left without power
* The demand for mobile generators was greater than supply so that many of the centres could not establish back-up power

Prorepublica 1 November 2012
* NYU hospital's backup system undone by key part being located in flooded basement
* Langone Medical Center had spent several million dollars protecting its backup power system from flooding
* Had removed a fuel tank and a set of emergency generators at street level and switched to an “extremely modern, extremely reliable” system of rooftop generators
* One vulnerability remained, and it proved to be the system’s Achilles Heel. A portion of the hospital’s power distribution circuits, which direct the generated electricity out into various areas of the hospital, were located in the hospital’s basement.

One observer has made the following comment "Cell networks are the first to become overloaded, first to fail, and the hardest to restore."

Friday, October 26, 2012

Workplace safety: A cultural change

Financial News and Daily Record by Karen Brune Mathis 28 March 2012

Organizational consultant Hal Resnick contends that workplace safety is a culture and creating it can require major organizational change.

The root causes of major accidents — and most others — lies in the lack of a fundamental safety culture.  In virtually every one the post-disaster analysis revealed a set of underlying conditions that made these disasters both predictable and avoidable.

Resnick says that “Management’s excuse is that excessive attention to safety will hamper productivity and break the bank.  The reality is that creating a safety culture drives the same values and actions that also create increased productivity; enhanced product quality and reliability; increased innovation; continuous improvement; enhanced employee engagement; and an improved bottom line." 

“It’s both the right thing to do and it makes good business sense."

According to Resnick, a safety culture has three dimensions: organizational or structural, group norms, and individual responsibility and accountability.

Structural attributes of a safety culture
• Are roles and responsibilities clearly defined and followed?
• Are employees empowered to act to address safety concerns, or are they expected to follow the chain of command?
• Does the organization recognize and reward employees who raise issues, or is the general response to shoot the messenger?
• Are work processes and procedures clearly defined and followed?
• Is attention to safety everywhere or confined to an employee’s own work area?
• Does the company expect everyone to do work safely or is the message that the organization can’t afford the time to do everything “by the book”?
• Are safety reports reviewed with action and follow-up or do they generate a defensive response?
Group norms and values
• Are employees at all levels across the organization encouraged to speak up to raise concerns without fear of retaliation or reproach?
• Are audits welcomed or seen as an intrusion?
• Is safety perceived as a real commitment or an act of compliance?
• Does peer pressure encourage individuals to speak up or keep their mouth shut?
• Are safety and production intertwined or is safety seen as a cost that interferes with production?
• Are accidents seen as preventable or to some extent unavoidable?
• Are employees encouraged to have a questioning attitude?
• Do employees believe they are treated with trust and respect?
Individual responsibility and accountability
• Do employees at all levels accept personal responsibility and accountability for safety or is it seen primarily as the job of the safety department?
• Are potential safety issues identified and addressed before an incident happens?
• Does senior management lead safety by personal example?
• Do all employees have the authority to stop work or is that authority reserved only for management?

Thursday, October 18, 2012

Google shares suspended after accidental email wipes $22bn off value

The Guardian by Charles Arthur 18 October 2012

Search engine's unfinished financial release inadvertently sent, revealing quarterly results well below Wall Street expectations

It was the printer's error that wiped about $20bn from the value of the world's biggest search engine. Shares in Google were suspended after an accidental email to the US stock market authorities revealed that the company's latest quarterly results were far below Wall Street's demanding expectations.

The inadvertent – and clearly unfinished – financial release began with the words "PENDING LARRY QUOTE" – referring to the company's chief executive, Larry Page, whose job, normally, would be to put the best gloss on the financial figures. But he was likely to be offering different sentiments after the stock tumbled 9% before trading was halted. After trading resumed the shares recovered slightly to close down 8%.

Monday, October 01, 2012

Five Changing Trends in Managing Workplace Ergonomics

Occupational Health and Safety by Walt Rostykus 1 October 2012

Traditionally, safety professionals have driven ergonomic improvements in an effort to reduce injuries, but all along they have been the wrong people to do this.

Occupational ergonomics continues to emerge as one of the priority workplace issues addressed by employers today. This is driven primarily by the need to reduce musculoskeletal disorders (MSDs). In our recent benchmarking study, we found that participants attributed between 24 and 75 percent of injuries to poor ergonomic conditions. This rate has remained relatively consistent over the past several studies. Most companies attribute the high incidence of MSDs to:
  • Reduction of other types of injuries. As a result of programs focused on reducing and eliminating mechanical, electrical, and chemical hazards, MSDs are emerging as a priority issue.
  • Increased work demand on individual employees. This is typically attributed to workforce downsizing, production rate changes, cost constraints, and "doing more with less."
  • Aging workforce. Some companies attribute their MSDs to the capabilities, conditioning, and condition of both older and younger workers.
The five trends are as follows

1. Getting Proactive - using quantitative tools to measure exposure to MSD risk factors and then focus their efforts on changing the job conditions to reduce the level of exposure—before an injury occurs.
2. Integrating the Process - managing ergonomics as a process that is aligned with, or integrated into, existing improvement processes (e.g. Lean Manufacturing, Six Sigma, Continuous Improvement, and Safety Management Systems). This engages people across an organization, ensures that the processes are sustainable as time, leaders, and business needs change, integrates the processes into the business and ensures that they are not dependent upon a few people, and provides a logical system for determining and driving improvement.
3. Engaging Others and Shifting Ownership -Successful organizations expand ownership, involvement, and accountability for ergonomics to people outside the EHS staff.4. Moving Upstream - Consistently addressing ergonomics in the design phase of new processes, equipment, layouts, and products is a common practice of advanced organizations. About 5 percent of all organizations are at this level. The greatest value of good upstream design is the reduced cost of making changes. The cost of changing equipment and layout once it is in place is more than 1,000 times the cost of making the change in the design phase.
5. Addressing the Office - The biggest trend in managing office ergonomics has been the movement toward employee-driven assessments and workplace changes. By providing online training and self-assessments, employers are enabling and empowering individuals to take the first steps in adjusting their workstations to fit them.

In addition to these common trends, we’ve identified two common challenges with managing ergonomics that companies at all levels of program maturity have experienced.
1. Funding for training and engineering solutions
2. Failure to use or meet established ergonomic design standards.

Wednesday, September 19, 2012

Wrong medical procedure a result of 'human error'

Irish Times by Fiona Gartland 19 September 2012

A CONSULTANT paediatrician who incorrectly recorded a procedure to be carried out on a 2½-year-old girl – who was later given the wrong operation – told a Medical Council fitness-to-practise committee yesterday the mistake was “human error”.

Prof Martin Corbally, who was a paediatric surgeon at Our Lady’s Children’s Hospital in Crumlin when the incident happened in 2010, said he was “probably quite tired” when he filled out the letter in question and accepted he made a mistake. But he said he had correctly recorded the procedure on the admissions card as “tongue tie upper frenulum” and administration had not completed the hospital booking system correctly because they omitted the words “upper frenulum”. “That is where the error really lay,” he said.

“I would see 80 to 100 patients a week between my three clinics and I was not really remembering their names,” he said. He also said he had “no way of knowing” the procedure that should have been carried out on Baby X when she attended for surgery weeks after he had seen her in outpatients.

If the procedure had been transcribed properly by administration he would have remembered, he said. He also said on the morning of the surgery he had been very busy and had three patients in intensive care.
He denied his instruction to his junior “to release the tongue tie” amounted to poor professional performance. There had been a series of errors in the case, he said.

“To err is human,” he said. “Everybody can make a mistake.” Prof Corbally said after the incident, procedures at the hospital had been improved. He also said he was “deeply concerned” about risk in surgery and had taken a course in risk management after the case involving the patient who had the wrong kidney removed. He had also carried out a study about parental involvement in medical staff meetings ahead of surgery on children.

In earlier evidence, an expert witness for the Medical Council, UK consultant paediatric surgeon Hugh Grant, from John Radcliffe Hospital, Oxford, said he believed the transcript error made by Prof Corbally amounted to poor professional performance and “started the chain of events” that led to the incident.
Under cross-examination from Eileen Barrington SC, for Prof Corbally, who queried whether a transcript error could be poor professional performance, Mr Grant said if you call a lump on the arm a lump on the leg you are applying your knowledge incorrectly which amounted to poor professional performance.

A Strategy for Human Factors/Ergonomics as a Discipline and Profession

ergoweb 19 September 2012. 

Peter Budnick refers to a paper from the Institute of Ergonomics and Human Factors (IEHF).  "In essence, the topic boils down to a few key questions, at least in my mind:
  • is there such thing as an ergonomics discipline or profession?
  • if so, what and who does it encompass?"
It is suggested their are four main reasons why Human Factors/Ergonomics (HFE) is under-utilized:
  1. many potential beneficiaries are not aware of the value HFE can bring;
  2. sometimes when there is a demand for HFE, there isn't enough "high-quality HFE," or that the available HFE resources are too limited in scope to be recognized as applicable;
  3. the HFE field is small in comparison to established design disciplines such as engineering and psychology, and though HFE principles may be applied within these disciplines, there may be no explicit reference to the HFE discipline.
  4. "... the very strength of HFE, its multi-disciplinary base, is also a potential weakness; a diversity of topics, views and practices exist within the HFE community, resulting in unclear communication to the external world."
 Key characteristics of HFE are identified as
  1. HFE takes a systems approach.
  2. HFE is design driven.
  3. HFE focuses on two related outcomes: performance and well-being.

The value of HFE for stakeholders
The committee recognizes that the demand for HFE is directly related to the perceived value of HFE among stakeholders of system design. They identify those stakeholders as (interested readers are directed to the full paper, cited below, for additional details):
  • System actors (employees in work-systems, and end-users for products and services) who can benefit from HFE through:
    • Improved physical, psychological and social well-being
    • Higher motivation, growth and job satisfaction 
    • Improved performance 
    • Better experience
    • Shorter time of familiarization
    • Better fitting of products/services to individual characteristics/needs
    • Fewer mistakes
    • Greater efficiency
  • System experts (any of a variety of professionals that can be involved in a design effort) who can benefit from HFE through:
    • Better users’ acceptance of designed systems
    • Better performance
    • Better fit with (legal) standards 
    • Improved development process 
  • System decision makers (e.g., managers, purchasers) who can benefit from HFE through:
    • Better productivity
    • Better quality and reliability of production processes and produced goods and services
    • Lower operating costs due to lower levels of health problems, motivational deficits, accidents, absenteeism, and related productivity loss
    • More innovation by increased employee creativity 
    • Better reputation for hiring and retention of talented employees
    • Better decision-making
    • Better market performance 
    • Greater profitability
    • Less re-design
  • System influencers who can benefit from HFE through:
    • Social wealth
    • Economic wealth

Friday, August 31, 2012

Can’t Sleep? It Could Be Your iPad

CBC Phily by Denise Mann 31 August 2012

New research shows that all of those nighttime hours spent with your tablet can wreak havoc on your sleep.
The bright light emitted from these tablets can suppress melatonin. That’s a hormone that helps control sleep and wake cycles, called circadian rhythms. 

“If they are bright and they are big and are close to your eyes, they have more potential to disrupt your melatonin than the TV, which is usually farther way,” says researcher Mariana Figueroa. She is an associate professor at Rensselaer Polytechnic Institute in Troy, N.Y.
iPhones and other small gadgets may not affect circadian rhythms. “Smaller devices emit less light,” she says. But even if these devices aren’t zapping the body’s melatonin supply, they may still be disrupting sleep by delaying your bedtime, she says.

Possible solutions include:

* Invest in a filter
* Dim the lights
* Hold the tablet further from your face
* Don't use late in the evening

Saturday, August 25, 2012

Human Error Leaves Zookeeper, Tiger Dead in Germany Read more: 25 August 2012

After someone apparently did not close a security gate properly, a tiger named Altai was able to escape from its enclosure in the Cologne Zoo in western Germany,

The tiger wandered to an adjacent storage building where he attacked and killed a 43-year-old zookeeper.

The director of a zoo, Theo Pagel, shot the tiger from the roof a nearby building with a rifle, killing the animal.
The tiger was killed before he could enter public areas and armed officers and a helicopter were at the scene. Visitors at the zoo were evacuated and the zoo closed briefly. A special “Summer Night” event, at which people can visit the zoo after-hours, has been cancelled.

Tuesday, August 07, 2012

Too Many Screens: Why Drones Are So Hard To Fly, So Easy To Crash

AOL Defense 7 August 2012 by Sydney J Freedberg Jr

The US military depends on drones. But amidst the justifiable excitement over the rise of the robots, it's easy to overlook that today's unmanned systems are not truly autonomous but rather require a lot of human guidance by remote control -- and bad design often makes the human's job needlessly awkward, to the point of causing crashes. Fixing that is the next big challenge for the unmanned industry.

"Too many screens with too much information, folks" -- that's the bottom line, said Col. John Dougherty, a Predator operations commander with the North Dakota National Guard, speaking at a workshop on the first day of 2012 conference of the Association for Unmanned Unmanned Vehicle Systems International (AUVSI) here in Vegas. "I am tired of all these black panels all over the place," Dougherty went on, urging designers to "de-clutter for sanity." But instead, he lamented, "they keep strapping the stuff on," adding more and more sub-systems each with its own unique and user-unfriendly display.

"Human factors was not integrated into the original design of the Predator," Dougherty said. "They were never given the time," because what was originally a technology demonstration project proved so valuable it was rushed into widespread use. As a result, he said, the percentage of major mishaps caused by "human factors" is, ironically, higher for Predators than for manned aircraft.

It's even harder to design a control system for troops operating unmanned systems in the field, instead of from a relatively pristine command center. Something as simple as having to look down at a handheld display can distract a foot soldier from the threats around him, and the light from the screen can give away his position at night, said Army Staff Sergeant Stanley Sweet, an unmanned ground vehicle trainer at Fort Benning and veteran of two tours in Iraq.

Often, Sweet went on, when engineers develop control systems, "they want to use a touchscreen, which looks neat -- [but] the sand, the dirt, the mud, how is it going to affect the screen?" he asked. "How is it going to hold up? My experience is they don't." Controls meant for foot troops have to be physically rugged and conceptually uncomplicated, more like game controllers than like militarized iPads. Infantrymen have no time to navigate complex menus while wondering, "Oh, by the way am I going to get shot at," said Sweet. "If the technology is slow, it will not be used."


 More autonomy isn't always the solution, however. When operators do have to take more direct control of unmanned systems, they are badly hampered simply by not being in the vehicle. "In a prior life I was in the airplane, I was there, so a whole bunch of information was being fed to me simply because I was in it," like whether the aircraft was accelerating or not, said Col. Dougherty, a former F-16 pilot. When the operator is in a command post on the ground, however, his screens may tell him the vehicle is moving ahead or swiveling its sensor array, but his inner ear and his peripheral vision are both telling him he's standing still.

Some of the solutions on offer at the workshop included stereo images to improve depth perception, audio cues in three dimensions to alert operators to what's happening behind them, and virtual-reality "telepresence" goggles that let the operator turn his head to see to the side, instead of sitting still and watching images slide past on a screen.

What's essential, said Dougherty, is to break down the cultural preconceptions in the Air Force and elsewhere about what a proper control interface looks like. What works for manned aircraft may not translate to unmanned. "I don't need a cockpit to feel good about myself," he said. "What you need is an appropriate interface, [whether] it's a dome that I'm immersed in or it's a series of flat panels or something that comes down over my eyes with gloves." Our thinking about how best to control the new unmanned technology is still catching up to the possibilities.

Wednesday, May 16, 2012

Decreased Productivity due to Presenteeism

Ergoweb 16 May 2012

A study involving Sweedish employees has found that presenteeism (attending work when ill) was associated with the psychosocial risk factors of work demands, work control, social climate, employee commitment to the organization, and role compatibility.  When these issues were addressed, the odds of future presenteeism were reduced for all risk factors except work demands.

Whilst the impacts of absenteeism are quite well understood, this is not the case for presenteeism.  In this study particpants were asked “How many times the past 12 months have you been at work even though you according to your health state should have stayed at home?” At the time of the first evaluation, 45.4% reported as performing presenteeism two or more days over the prior year while at the second evaluation, this changed to 44.8% - not statistically significant.

In presenting background information, the authors note that studies have found:
  1. An average of $2.30 productivity loss occurs for every $1.00 spent on medical and pharmacy costs
  2. Presenteeism costs an estimated $255 per employee per year among US companies
  3. For some specific disorders, financial losses due to presenteeism far exceed those due to absenteeism
  4. Higher levels of presenteeism are related to high stress, lack of emotional fulfillment, physical inactivity, unhealthy body mass index, and poor diet
  5. Higher levels of absenteeism are associated with physical inactivity, high stress, and diabetes/high blood glucose
  6. Employees who perceived their jobs to be more stressful than satisfying had greater levels of presenteeism, poor health, greater levels of depression, and riskier lifestyle behavior.

Monday, May 14, 2012

Risk Focus: Slips, trips and falls

UK P&I Club Loss Prevention Booklet

Slips, trips and falls represent nearly one in three of the large personal injury claims submitted to the Club and which aggregate to a staggering $155 m over the past ten years. They are constant too, with very little variation in numbers of claims from year to year.

It is easy to dismiss these unpleasant accidents as ‘human error’, or even ‘crew negligence’, but to examine
the detail of so many of them is to reveal other contributors to the chain of causation. Training could have been deficient or even completely missing, as there is often an assumption that people ‘can look after themselves’ and must take responsibility for their own actions. The environment, which is mostly a function of design, may well have been a contributor, if there was inadequate lighting, or the dangers were not obvious, or the particular design of the ship required people to put themselves ‘in hazard’ just to get a job done. And the procedures aboard ship may have been devised without proper consideration of the risks of carrying them out.

‘We have always done it this way!’ may be no guarantee that it will be the safest way, and may involve people in taking hazardous short cuts. But because of the huge costs of these claims, and because of the human suffering represented by each of them, the Club strongly believes that a concerted attack must be made on the incidence of slips, trip and falls. These are accidents which occur for a reason, and if we understand the reasons behind the existence of these hazards rather better, then we can put in place controls that will hopefully prevent accidents occurring, but will also mitigate their consequences.

A proactive and precautionary approach can be very useful in reducing the incidents of slips, trips and falls, in first of all identifying hazards which have the potential to hurt people. Very often accidents occur because nobody has considered that what they are doing might be hazardous. Just walking around the ship with a sharp eye and an open mind can help to identify features which might, in an unguarded moment, hurt people.

A Bow Tie has been developed highlighting that 'controls' that reduce the risk of slips trips and falls include:

* Adequate lighting
* Hazards/Obstructions identified/clearly marked
* Non-slip surfaces in place/maintained
* Appropriate footwear used
* Good housekeeping of working areas - oil/rubbish/equipment
* Access control - guardrails/wires etc
* Safety equipment in use - harness/nets etc

And mitigation to reduce the risk of a significant claim include:
* Accident reporting system
* Personal protective equipment
* Adequate first aid
* Evidence collection/retention
* Use of third party assistance

Wednesday, May 09, 2012

DNA Contamination blamed on human error

Channel 4 News 9 May 2012

The error occurred at what is described as the most advanced automated DNA testing system in the UK at LGC forensics labs in Teddington. A used plastic sample holder containing up to eight vials of DNA was mistakenly reloaded into the machine by a laboratory worker, instead of being put into a bin. The system had been installed in March 2011, and the contamination occurred in October.
Every DNA sample in that seven month period has been checked, and LGC said no other instance of contamination had been uncovered. The regulator is now working with the company in monitoring new procedures that have been put in place, to ensure the mistake is not repeated.

The DNA mix up was discovered by Greater Manchester Police detectives, after they had charged a 20 year old suspect in October last year with raping a woman in a park.
At that time LGC had informed the GMP that there was a strong match with DNA extracted from clothing. But detectives found that the suspect could not have been at the scene, because he was in prison 300 miles away, awaiting trial on other unrelated offences.

Greater Manchester Police were informed of the mix-up in March, and the Crown Prosecution Service dropped the case against Adam Scott from Exeter, in Devon.

There was some concern that the blunder could have implications for the convictions in the Stephen Lawrence case, which depended heavily on DNA evidence, and for which some of the tests were carried out at the same laboratory, but further tests to double check results were carried elsewhere.

Friday, May 04, 2012

Your doctor is only human, but patient safety is priority

This is Nottingham 4 May 2012

Numerous studies from around the world have shown that sometimes doctors make mistakes when prescribing, and occasionally patients are harmed as a result.
Along with colleagues from the University of Nottingham, and several other universities, we have recently completed the largest study ever of prescribing errors in general practices.

This week the General Medical Council (GMC) launched our report at a press conference in London and life has been a bit of a whirlwind since with headline news on Wednesday, and me being asked to do numerous radio interviews (including a 5:30am call from Radio 4!).

The likely reason for this level of media interest has been the uncomfortable finding that around one in 20 prescriptions issued by GPs contains an error.

It is important, however, to emphasise that we found the vast majority were safe. Also, many of the errors we found were relatively minor. The study showed the need for improvement in terms of typing clear dosage instructions on prescriptions, getting the dose and timing right, and making sure blood tests are done if these are needed.

We are now looking at ways of helping GPs.

We have published an important study in The Lancet showing how pharmacists can help GPs reduce errors.
And we are developing a "patient safety toolkit" to help general practices with patient safety.

Wednesday, May 02, 2012

Millions of GP prescriptions contain dangerous errors: research

The Telegraph 2 May 2012 by Rebecca Smith

Almost two million GP prescriptions contain potentially life threatening errors with mistakes in those given to one in five patients, research by the General Medical Council has found. 

Errors including wrong dosages, lack of instructions and insufficient monitoring of patients on dangerous drugs were 'common'.

Elderly and young children are twice as likely to be given a prescription with an error because the over 75s are often on several drugs and the correct dose can be difficult to calculate in youngsters because it is usually based on body weight, the study found.
Time pressures during GP consultations are thought to be to blame along with complex computer software that makes it easy to select the wrong drug or incorrect dose from drop-down menus and frequent distractions and interruptions.

Several GPs said practice nurses who are responsible for managing some long-term conditions often asked them to sign prescriptions without seeing the patient and this made them 'uneasy' and also interrupted them during clinic meaning they may make mistakes themselves.

Also repeat prescriptions were often issued without questioning if the patient still needed the medicine, or if superior ones were available and results from separate clinics were often not relayed to the GP meaning drug doses were not adjusted, it was found.

Human error and not a lack of understanding or knowledge was behind most mistakes, the study said.
Extending the average GP consultation from 13 minutes to 15 and better training in safety would help, lead author, Prof Tony Avery, of Nottingham University, said.

Pharmacists and GP receptionists can also help by carrying out medicine reviews and checking monitoring arrangements.

Errors classed as severe included, a 62-year-old woman with a documented allergy to penicillin who was prescribed flucloxacillin, a similar drug, and elderly patients prescribed blood thinner warfarin, who should have been closely monitored but who were not tested for two years.

Moderate errors included a four-year-old girl with a stomach upset who was prescribed a drug that should be used 'with caution' in children.

Minor errors found in the study included a one-year-old girl who was given two prescriptions for antibiotics in the same consultation but with different doses stipulated.

Failing to request that the patient be monitored was the most common serious error followed by prescribing a drug the patient was allergic to.

Almost all of the serious errors related to one drug, warfarin, which has been used as rat poison. It is prescribed to thin the blood in people at risk of blood clots. It must be carefully monitored because it interacts with other drugs and some foods and patients with levels too high can suffer potentially life threatening stomach bleeds.

Repetitive strain? Try repetitive rest

Morgan Hill Times 2 May 2012 by Nancy Lowe

Many computer users stay in a “ready-to-go” position at all times without giving arm, hand, shoulder and neck muscles enough opportunities to rest. There's a simple method to correct this. I call it repetitive rest, but one of my clients called it the “zen” of ergonomics, and once you try it you may agree.

During computer interactions there can be many, many moments when your hands are not actively engaged in keying or mousing. You are reading an email, composing creative thoughts in your mind or waiting for a page or application to open. These instances may last a few seconds or over a minute. Instead of hovering over the keyboard or grasping the mouse to be ready for the next click, this is a wonderful opportunity to give your body a breather by resting your hands and arms in relaxed, neutral positions.

Saturday, April 28, 2012

Air France Flight 447: 'Damn it, we’re going to crash’

The Telegraph 28 April by Nick Ross

With the report into the tragedy of Air France 447 due next month, Airbus’s 'brilliant’ aircraft design may have contributed to one of the world’s worst aviation disasters and the deaths of all 228 onboard.

In the early hours of June 1 2009, Air France Flight 447 from Rio de Janeiro to Paris went missing, along with 216 passengers and 12 crew. The Airbus A330-200 disappeared mid-ocean, beyond radar coverage and in darkness. It took a shocked and bewildered Air France six hours to concede its loss and for several agonising days there was no trace.
The official report by French accident investigators is due in a month and seems likely to echo provisional verdicts suggesting human error. There is no doubt that at least one of AF447’s pilots made a fatal and sustained mistake, and the airline must bear responsibility for the actions of its crew.

But there is another, worrying implication that the errors committed by the pilot doing the flying were not corrected by his more experienced colleagues because they did not know he was behaving in a manner bound to induce a stall. And the reason for that fatal lack of awareness lies partly in the design of the control stick – the “side stick” – used in all Airbus cockpits.
The plane’s pitot (pronounced pea-toe) tubes – small, forward-facing ducts that use airflow to measure airspeed had apparently frozen over, blanking airspeed indicators and causing the autopilot to disengage. From then on the crew failed to maintain sufficient speed, resulting in a stall which, over almost four minutes, sent 228 people plummeting to their deaths.

But why? Normally an A330 can fly itself, overriding unsafe commands. Even if systems fail there is standard procedure to fall back on: if you set engine thrust to 85 per cent and pitch the nose five degrees above the horizontal, the aircraft will more or less fly level. How was it that three pilots trained by a safe and prestigious airline could so disastrously lose control? Either there was something wrong with the plane, or with the crew. Airbus and Air France, both with much to lose, were soon pointing accusing fingers at each other.

In July last year the French air crash investigation organisation, the Bureau d’Enquêtes et d’Analyses (BEA), published its third interim report. For Air France the conclusion was crushing: the crew had ignored repeated stall alerts and kept trying to climb, instead of levelling off or descending to pick up speed. The A330 had become so slow that it simply ceased to fly. Its reputation on the line, Air France came as close as it dared to repudiating the finding. The pilots, said the airline, had “showed unfailing professional attitude, remaining committed to their task to the very end”.

But the airline’s case seemed thin. All indications suggested the aircraft had functioned just as it was designed. The black box recordings showed that the plane was responsive to the point of impact. The case against the pilots looked even worse when a transcript of the voice recorder was leaked. It confirmed that one of the pilots had pulled the stick back and kept it there for almost the entirety of the emergency. With its nose pointed too far upwards, it was little wonder that the Airbus had eventually lost momentum and stalled. But this analysis begs the question: even if one pilot got things badly wrong, why did his two colleagues fail to spot the problem? The transcript of increasingly panicky conversations in the cockpit suggests they did, but too late.

Friday, April 20, 2012

UK firm's 1,300 staff accidentally given marching orders

Reuters 20 April 2012

Workers at investment firm Aviva Investors got a shock on Friday when the company accidentally sent an email with leaving instructions intended for one departing employee to the entire worldwide staff of 1,300 people.
The firm's human resources department realized its mistake and recalled the offending message 25 minutes later and soon afterwards sent out another email apologizing to staff for the error, company spokesman Paul Lockstone said.

"An email which was intended for a member of staff who was leaving today was accidentally sent to all Aviva Investors staff worldwide," Lockstone said.

"People were pretty quickly aware of the fact that this was a mistake ... I don't believe any of our staff would have seen it really as anything other than the mistake that it was."

The email was a standard message sent to people leaving the company, covering things such as handing back company equipment and confidentiality rules, and did not tell recipients they were fired, Lockstone said.

Wednesday, February 29, 2012

Pilots admit they 'nod off' – and their hours are set to soar

The Independent Jonathan Brown 23 February 2012

The lives of air passengers could be put at risk by tired pilots falling asleep or making an error as a result of new European rules increasing their working hours, MPs were warned yesterday.

The pilots' union, Balpa, said that even under the present system, which limits the amount of time they can spend in the air after waking, nearly half of its members admitted nodding off in the cockpit.

Giving evidence to the Transport Select Committee, the union's head of safety, Dr Rob Hunter, said the real figure was likely to be much higher because of under-reporting by pilots who were often unaware they'd been asleep.

Balpa is opposing the harmonisation of rules between Britain and the rest of Europe which it said could lead to some pilots working for up to 22 hours at a stretch. Current safety laws limit this period to 16 and a half hours.

In a survey of 500 pilots Balpa found that 43 per cent had involuntarily fallen asleep while flying. Of these a third said they had woken to find their co-pilot slumbering as well. Even under the present system the union estimated that pilots could be landing when they had a one in five chance of falling asleep – meaning their reactions would be those of a pilot with a blood-alcohol level four times the current legal limit for flying. Balpa said the new rules would make the situation "much worse".
A crash involving a Colgan Air flight in New York three years ago, in which 50 people died, led to a change in US rules to minimise pilot fatigue.

After a sudden loss of cabin pressure pilots have 15 seconds to put on their oxygen masks before they lose consciousness. Even when flying on autopilot they must make routine checks and monitor radio transmissions.

Current0700 Pilot awakes
0800 Arrives at airport to begin shift – take-off and landing; post-flight checks
2400 Finishes shift; starts rest period including 10 hours of hotel availability
1000 Begin new shift

0700 Pilot awakes
0800 Arrives at airport and begins four hours on standby
1200 Flight begins
0400 Discretionary rest period starts
0600 Shift ends – eight-hour sleep period
1400 Begins new shift

Natural Disasters Influence Mental Mistakes

Psych Central By Rick Nauert PhD on February 13, 2012 

A new study in the journal Human Factors finds that survivors of disasters may experience intellectual challenges in addition to stress and anxiety. This mental decline may cause survivors to make serious errors in their daily lives. It was published by New Zealand researchers after the Christchurch earthquake.

Studies have found that more traffic accidents and accident-related fatalities occur following human-made disasters such as the September 11, 2001, terrorist attacks. Experts believe the mishaps are due to increased cognitive impairment that can lead to higher stress levels and an increase in intrusive thoughts. 

This study was looking at human performance and required two sessions with volunteers.  The earthquake occurred between the sessions so the researchers took the opportunity to compare before and after.
Normally, participant performance would improve during the second session, but the authors found an increase in errors of omission following the earthquake.

If the participants reported being anxious following the quake, their response times sped up and they made more errors of commission, whereas those who reported depression logged slower response times.

“People would find themselves zoning out and making more errors than usual after the quake.”
Investigators believe future research is needed to explore this phenomenon further, but the scientists’’ findings may point to potentially serious complications arising from post-disaster performance in daily life and work tasks.

These findings also suggest that police, emergency responders, and others working in the aftermath of the disaster may also experience cognitive disruption, which can interfere with their ability to perform rescue-related tasks.

“Presumably people are under increased cognitive load after a major disaster,” Helton continued.
“Processing a disaster during tasks is perhaps similar to dual-tasking, like driving and having a cell phone conversation at the same time, and this can have consequences.”

Friday, February 10, 2012

Taking a stand at the office

Montreal Gazette Jill Barker, 9 February 2012

Jimmy Rogers got rid of his office furniture while recuperating from a herniated disc, which made sitting painful. First he put his laptop on top of a filing cabinet and stood up to work. Then he went for "something more ergonomic,”

Now he spends a full day working standing up. Part of a growing trend of office workers who work at a at a standing desk

There is growing amount of evidence suggesting that too much time spent in a chair isn’t good for your health.

The American Cancer Society recently released a report stating that women who spent more than six hours a day sitting had a 37-per-cent higher risk of mortality, compared to those who sat fewer than three hours a day, within the study’s 13-year time period. As for men, six hours a day spent in a chair increased the likelihood of death by 18 per cent over men who spent less than half that time seated.

Researchers believe excessive sitting causes the body to go into a type of “sleep mode,” which shuts down muscle activity and has a negative effect on the body’s metabolic functions.

Standing, on the other hand, encourages movement, which boosts muscle activity, calorie burn and, according to some health experts, alertness. Yet despite its seemingly obvious benefits, there’s little research proving that more time standing will negate the health risks associated with too much sitting.

McGill University kinesiology professor Julie Côté, a specialist in ergonomics and biomechanics, is currently gathering data on the physiological responses of incorporating more standing postures in the workplace.
Her study measures blood flow to the legs and muscle activity in the low back during occupational standing and sitting.

Finding just the right desk and adjusting it to just the right height is the easy part of the switch from sitting to standing. Finding the endurance to stand for extended periods of time is the real challenge.

“Start gradually,” Côté said. “And never stand longer than 90 minutes without changing your position. The worst thing you can do is stay static.”

Most people don’t spend the whole day on their feet, rather they alternate between sitting and standing, which is where the adjustable desk helps.

Rogers suggests getting around the expense of an adjustable desk by using a chair the height of a bar stool. This inexpensive option allows you to install a stationary platform to hold your computer, monitor and phone, while still being able to move easily from sitting to standing.

As for suggestions on how to ease the discomfort associated with long periods spent standing, Rogers recommends placing a cushioned mat under your feet, wearing footwear with good support and alternating elevating one foot on a riser.

Côté says finding out what works best for you is all part of the learning curve associated with moving from sitting to standing. And since there is no clear research suggesting that one strategy works better than another, it’s okay to experiment.

Thursday, February 09, 2012

Nudge theory trials 'are working' say officials

BBC Website 8 February 2012

Nudge theory  involves making minor changes in communications such using simpler language in letters, highlighting key messages and stressing "social norms." Trials have been taking place across a number of UK government departments, and it appears that some of these are working by boosting compliance and reducing fraud, error and debt.

Eight trials have shown that "relatively minor changes to processes, forms and language can have a significant positive impact on behaviour". A local authority saved £240,000 on false council tax claims. Letters from Revenue and Customs.that emphasised "social norms" produced a 15% higher response rate than the standard letter. Including images of untaxed vehicles in demands for payment of duties had proved successful.

Examples of the ideas being tried include:

  • Using handwritten fonts to personalise letters
  • Asking people to complete an "honesty code" in letters
  • Sending a "thank you" letter to people who have complied
  • Highlighting key information in bold or "strong" colours
  • Using lotteries or prize draws to encourage people to pay tax returns early
  • Linking tax evasion to the impact on council services
  • Naming and shaming late payers on a website

The report summarising these findings is available at The Cabinet Office"

Tuesday, January 24, 2012

Human Factor Named Biggest Challenge Facing Offshore Oil and Gas [SURVEY]

Article at gCaptain 23 January 2012

Survey of industry professionals released today by Oil & Gas IQ.

Found that 48.6% said that human factors and behavioral safety is the biggest challenge regarding offshore safety.  Also, nearly three-quarters of survey respondents claimed there was more pressure on offshore operators regarding Health and Safety (HSE) than there had been in previous years, no doubt fueled by recent oil spill disasters such as the Deepwater Horizon spill.

The survey noted that 10.8% of respondents named problems with technology and equipment as a worry, with a similar number saying that having the right processes in place and reacting to new legislation were their firm’s biggest challenges. The study was released ahead of the 2012 Offshore Safety Summit, taking place March 19-21 in Aberdeen