Lee T. Ostrom

Lessons learned from investigations of therapy misadministration events

PURPOSEnInvestigation teams composed of Idaho National Engineering Laboratory (INEL), United States Nuclear Regulatory Commission (NRC), and subcontractor personnel performed detailed investigations and analyses of seven misadministration events that were specifically selected on the basis of particular characteristics. These events were analyzed to identify the direct causes, contributing factors, actions to mitigate the event, and the consequences of these events. The INEL also sought to determine the role played by the recent Quality Management Rule.nnnMETHODS AND MATERIALSnThe investigation teams were multidisciplinary and, depending on the nature of the event, included three or more team members with appropriate expertise in the areas of radiation oncology, medical physics, nuclear medicine technology, risk analysis, and human factors. The investigations focused on the general areas of causes of the event, mitigating actions, and corrective actions. Seven misadministration events were investigated by the teams during 1991 and 1992.nnnRESULTSnResults from the events investigated indicated that (a) the institutional traditions of some licensees contributed to the potential for misadministrations, (b) many misadministrations occurred primarily due to lack of procedures or procedures that were not clearly written, (c) some licensees in this study had not effectively implemented their Quality Management programs, and (d) limited involvement on the part of the Radiation Safety Officer and Authorized Users and changes in routine and unique conditions contribute to the potential for misadministrations.nnnCONCLUSIONSnThe project shows that licensees that have experienced misadministration events appear to lack comprehensive safety cultures, where all aspects of daily operations are shaped with patient and staff safety being the primary objective of all activities.

Developing Risk Models for Aviation Maintenance and Inspection

This article summarizes 2 related research projects sponsored by the National Aeronautics and Space Administration (NASA) Aviation Safety and Security Program. As NASA, the Federal Aviation Administration, and the airline industry have sought to understand causal factors of accidents and incidents, one emerging concern has been aircraft maintenance and subsequent inspection. Risk assessment methodologies are powerful tools for use in understanding the vulnerabilities of complex systems. This article discusses how these techniques are being used to predict the probability of inspectors detecting structural cracks in aluminum aircraft and dents in composite aircraft.

Firing of a Cannon: Psychophysical Evaluation of Ergonomic Hazards

Musculoskeletal-related occupational illnesses and injuries comprise a majority of military medical encounters resulting in decreased combat readiness and degraded human performance. An artillery company performing a live fire exercise was observed for two days along with the collection of perceived exertion, fatigue and pain data. Twenty-five U.S. Marines were involved in the study. Sixteen (64 %) reported becoming injured after returning from combat during a “Call for Fire” exercise and four (16 %) were on limited duty at the time of the study. Their perceptions of exertion, fatigue, and pain increased over the course of both days. In addition, human error also increased over the course of the day and moral decreased as well. The study uncovered that the exposure profile during the support of the “Call for Fire” exercise is leading to degradations in physical performance and increased exposure to physical work place risk factors resulting in various soft tissue injuries.

What Difference Can the Data Make

The anthropometric data which is readily available to the ergonomic practitioner contains gaps in the statures of individuals covered. This study fills in those gaps by analyzing the data sources available to interpolate the dimensions for those statures not represented. The interpolation method used was linear regression relating a specific dimension to the standing stature of the individual. Additionally, this paper compares several sources of data to demonstrate significant differences. Both these pieces of information are important to the practitioner. By filling in the gaps, the practitioner is provided with initial quantitative reference points for individuals when properly arranging a workstation. Currently, only qualitative information is provided concerning optimum workstation design for individuals not represented in the data sources. By demonstrating the lack of a significant difference between data sources, the practitioner may use whichever source is readily available. The results show a significant relationship between the individuals stature and eight different workstation measurements. Finally, there is no significant difference between the data sources examined.

Remote aircraft composite inspection using 3D imaging

The problem stated is there is no reliable in-service inspection method that quickly and easily detects the composite material damage. The aerospace industry needs to make efficient use of the inspections to turn the aircraft around in an efficient timeframe. This paper discusses the methodology for semi-automatic visualization of the process of inspecting composite materials for damage. The research is focused on the application of inspection of composite damage in aircrafts using Light Detection and Ranging (LIDAR). Two configurations using the LIDAR is discussed in determining damage to an aircraft. The configurations are derived from several studies using smaller aircraft parts and a small autonomous RMax helicopter. This study helps provide a solution for a quick turnaround and an efficient scan of the possible composite damage in aircraft. The four primary objectives are: Objective 1: Determine whether semi-automated three-dimensional visualization composite inspection techniques are as effective as experienced human inspectors in locating potential composite damage. Objective 2: Determine whether data from several Light Detection and Ranging (LIDAR) cameras can be combined for use in conducting semi-automated three-dimensional visualization composite inspections. Objective 3: Determine whether LIDAR camera scans can be performed on a moving aircraft for use with semi-automated three-dimensional visualization composite inspections. Objective 4: Assess the important human factors contributors associated with interpreting the LIDAR camera scan data.

Multi-use high-technology testbed

The efficient use of energy is one method of potentially reducing the amount of fossil fuels that are used world-wide to generate electricity. Nuclear energy presents a promising sustainable energy source for the future that generates few to no greenhouse gases. While it creates energy that can be used for electricity it also has many byproducts that are treated as waste or not utilized to their full potential. Waste heat is a major product of nuclear energy that should be harnessed and applied to other processes. These include water desalination/water purification hydrogen production, use in industrial chemical operations, or electricity production. Nuclear energy is most often base load following power and very inflexible. One way to address this is to use Hybrid Energy Systems (HES). By doing this the system can be load following and hence more efficient and sustainable. Therefore, the goal of this project is to create a system that mimics the waste heat from a reactor, demonstrate how to utilize that heat, and show that when energy demand is low the reactor does not need to reduce power; the energy can be directed elsewhere to create goods. This paper presents the details of the Energy Conversion Loop (ECL) that was developed to act as a test bed for experimentation of the aforementioned processes and test the possibility of nuclear HES. Further, the paper presents a proposed intelligent control system that can adapt to the system requirements for the ECL. In addition, the system has great potential for education on critical infrastructure protection and testing of future control logic systems and mechanical systems.

Technology education requirements for physicians

This paper discusses the need for technology education for physicians. A discussion of a series of technology related medical accidents is presented first, followed by a discussion of the types of technologies a physician uses on a daily basis. A set of technology education competencies is presented in a hierarchical format.

Developing risk models for complex systems

Disasters are more likely to occur when systems are not thoroughly analyzed. Several recent disastrous events have elucidated the consequences of not performing rigorous risk assessments and/or not eliminating or mitigating the vulnerabilities found. This paper discusses two risk assessment techniques that can aid in identifying complex system vulnerabilities. The topics discussed are development of a risk framework, Failure Mode and Effect Analysis and Event Tree Analysis. Examples of each of these topics are presented.

Developing Risk Models for Aviation Inspection and Maintenance Tasks

Risk assessment has been used to analyze a wide range of industries to determine vulnerabilities with the ultimate purpose of eliminating the sources of risk or reducing them to a reasonable level. The purpose of this chapter is to show how risk assessment tools can be used to develop risk models of aviation maintenance tasks. Two tools will be discussed in this chapter, though many other methods exist. The tools discussed in this chapter are: uf0b7 Failure Mode and Effect Analysis (FMEA) uf0b7 Event and Fault Tree Analysis Ostrom and Wilhelmsen (2011) discuss a wide range of risk assessment tools and this book provides many examples of how these tools are used to analyze various industries.