Bakgrund: Varje år drabbas omkring 100 000 patienter av vårdskador inom somatisk sjukvård i Sverige, förutom det lidande som det innebär för den enskilda individen medför det även ökade kostnader på både individ- och samhällsnivå. Det dominerande sättet att arbeta med patientsäkerhet inom hälso- och sjukvård är genom avvikelserapportering och analysering av negativa händelser. Specialistsjuksköterskan inom anestesisjukvård är precis som all annan hälso- och sjukvårdspersonal skyldig att rapportera när en avvikelse observerats. En strategi som kan användas för att koppla avvikelserapportering till förbättrad patientsäkerhet är att analysera avvikelser och koda händelserna till specifika områden. Genom att identifiera ett specifikt problem kan ett tvärvetenskapligt team därefter skapas för att granska de negativa händelserna kopplat till en specifik kategori, för att utifrån det resultatet utveckla förbättringar.  Syfte: Syftet var att beskriva och kartlägga innehållet i perioperativa avvikelserapporter på operationsavdelningen som berör patientsäkerheten, relaterade till anestesisjuksköterskans profession. Metod: En retrospektiv registerstudie med induktiv ansats. Datamaterialet analyserades med kvalitativ manifest innehållsanalys. Resultat: Fyra kategorier och fjorton underkategorier framkom under analysförfarandet. I kategorin patientomhändertagande identifierades flest avvikelserapporter, följt av kommunikation, teknik och organisation. Slutsats: Studiens resultat visar att de avvikelserapporter på operationsavdelningen, som berört patientsäkerhet relaterade till anestesisjuksköterskans profession, som var vanligast förekommande, var relaterade till patientomhändertagande eller kommunikation. I patientomhändertagande var läkemedelsrelaterade avvikelserapporter en av de vanligast förekommande och i kategorin kommunikation var det kommunikationen mellan vårdpersonal som genererade flest avvikelserapporter. Utifrån resultatet ses att mer forskning och fler förbättringsåtgärder behöver göras för att öka patientsäkerheten. / Background: Every year around 100,000 patients suffer from care injuries in somatic health care in Sweden, in addition to the suffering it entails for the individual, it also entails increased costs at both individual and societal level. The dominant way of working with patient safety in healthcare is through incident reporting and analysis of negative events. The anesthetic care nurse, just like all other personnel is obliged to report when an incident is observed. One strategy that can be used to link incident reporting to improve patient safety is to analyze incidents and code the events to specific areas. By identifying a specific problem, a multidisciplinary team can then be created to review the negative events linked to a specific category, in order to develop improvements based on that result. Aim: The aim was to describe and map out the content of perioperative incident reports in the operating department that affect patient safety, related to the nurse anesthetist´s profession. Method: A retrospective registry study with an inductive approach. The data was analyzed using qualitative manifest content analysis. Results: Four categories and fourteen subcategories emerged during the analysis procedure. Most incident reports were identified in the category patient care, followed by communication, technology and organization. Conclusion: The results of this study show that the incident reports in the operating department, which affected patient safety related to the nurse anesthetist's profession, which were most common, were related to patient care or communication. In patient care, medication-related incident reports were among the most frequently occurring, and in the communication category, it was communication between healthcare staff that generated the most incident reports.

Introduction: Incident reporting systems have been implemented in health care for over a decade and contain reports of critical incidents (CI). These must be analyzed in order to suggest, implement and evaluate solutions for minimizing the risk of future CIs to occur, thereby increasing patient safety. Drug-related CIs (DRCI) are one type of CI which may represent up to 1/3rd of all CIs, therefore this CI-type is characterized in this study. Aim: To categorize and characterize DRCIs reported in the Critical Incident Reporting System North Rhine-Westphalia (CIRS-NRW). Materials & Methods: In this explorative, retrospective, descriptive study, 553 reports from the CIRS-NRW, reported between the 1st of January 2019 and the 15th of September 2021, were analyzed. These were categorized by setting, medication use process stage, ATC-code, patient age and look-alike, sound-alike (LASA), and then analyzed via descriptive statistics. Various subgroup analyses were also conducted. Results: DRCIs occurred mostly in the hospital (48,5%) and pharmacy (40,7%) settings, during the prescribing (33,8%) and administration (33,5%) of drugs and the ATC-codes N02 (9,4%), B01 (6,9%) and N05 (5,4%) were commonly involved. Patient age contained >50% missing data and LASA was involved in 16,5% of DRCIs. Subgroups were often small, likely resulting in low statistical power. Conclusion: By successfully characterizing the DRCIs, some potential areas of improvement for reducing future DRCIs were highlighted, however there are many more variables of relevance for patient safety than those analyzed in this study, underlining the need for further studies characterizing more DRCIs including additional variables.

This research sheds light on the nature of the role of the operational risk controller in the financial services industry. The focus is on understanding how operational risk controllers interact with different layers of the organisation and become influential with the business lines and senior management. Nine semi-structured interviews were conducted with operational risk controllers, and it was found that their work is becoming increasingly focused on managing people with a view to creating mutual understanding. To achieve this, operational risk controllers should work more as independent facilitators in their interactions with the first line and senior management, as engaged toolmakers when adapting and reconfiguring tools, and as non-financial risk controllers when attempting to enable business leaders to understand the magnitude of operational risks.

Bakgrund: Varje dag drabbas patienter av undvikbara vårdskador som orsakar mänskligt lidande och får ekonomiska konsekvenser för samhället. När avvikelser inte rapporteras kan det påverka patientsäkerheten. Tidigare studier visar ett samband mellan låg patientsäkerhet och få rapporterade avvikelser och tillbud. Sjuksköterskan ska bedriva förebyggande patientsäkerhetsarbete och ramverket Fundamentals of Care framhäver vikten av hög omvårdnadskompentens. Trots det visar studier att sjuksköterskor undviker att skriva avvikelserapporter. Syfte: Syftet med litteraturstudien var att belysa orsaker som kunde leda till att sjuksköterskor inte skrev avvikelserapporter gällande patientsäkerhet.Metod: Studien genomfördes som en litteraturstudie. Tretton vetenskapliga artiklar med kvalitativ studiedesign inhämtades från två databaser och analyserades med metoden av Popenoe m.fl. Resultat: Sjuksköterskors avvikelserapportering uteblev när de upplevde oro för negativa konsekvenser eller påverkades av kulturen som rådde på arbetsplatsen. De upplevde även att brister i organisationen och rapporteringssystemet orsakade utebliven avvikelserapportering. Resultatet presenteras i fyra rubriker med tillhörande underrubriker: rädsla, arbetsplatsens kultur, organisationen och rapporteringssystemet. Slutsats: Utebliven avvikelserapportering bland sjuksköterskor är en global problematik och kan förhindra sjuksköterskor från att utförapatientsäkert omvårdnadsarbete. En god säkerhetskultur är av vikt för att säkerställa effektivt omvårdnadsarbete, men det kan vara svårt för en enskild sjuksköterska att våga stå upp för patientsäkerheten mot en stark kultur. Fortsatt forskning krävs för att förstå och åtgärda orsakerna till utebliven rapportering. / Background: Every day patients suffer avoidable health care injuries that cause human suffering and have an economic impact on society. When incident reports are not written, it can affect patient safety. Previous studies show a correlation between low patient safety and few reported incidents. Nurses are meant to carry out preventive patient safety work and the framework Fundamentals of Care emphasizes the importance of high nursing competence. Yet, studies show that nurses avoid writing incident reports. Aim: The aim of the literature review was to highlight reasons why nurses might not write patient safety incident reports.Method: The study was conducted as a literature review. Thirteen scientific articles with a qualitative study design were retrieved from two databases and analyzed using the method of Popenoe et al. Result: Nurses did not report incidents when they were concerned about negative outcomes or were impacted by the workplace culture. Nurses also expressed that organizational and reporting system flaws caused non-reporting. The findings are presented under four headings and subheadings: fear, workplace culture, organization and reporting system. Conclusion: Non-reporting of incidents among nurses is a global problem and can prevent nurses from performing patient-safe nursing work. A good safety culture is important to ensure effective nursing care, but it can be difficult to stand up for patient safety against a strong culture. Further research is needed to understand and address the reasons for non-reporting.

Varje år drabbas tusentals patienter av skador inom vården på grund av felbehandlingar, stress och brister i kommunikation mellan vårdpersonal. Utöver detta dör över tusen patienter varje år till följd av vårdskador. Som en jämförelse kan nämnas att det är fler personer än vad som exempelvis dör i trafikolyckor. Arbetet med patientsäkerhet är därför ett mycket viktigt område. För att identifiera risker och tillbud är rapportering och utredning av avvikelser ett viktigt verktyg och för detta används digitala avvikelsesystem. Då det är tidigare känt att hälso- och sjukvården är en sektor som upplevt utmaningar inom digitala system ses behovet att undersöka vad den generella uppfattningen är kring de avvikelsesystem som används av Sveriges landsting. Specifikt syftar denna studie att undersöka uppfattningar kring användbarheten i dessa system och vart eventuella utmaningar ses. Genom resultatet kan det konstateras att det finns stora skillnader kring de generella uppfattningarna om avvikelsesystemen. Gällande de generella uppfattningarna om användbarheten i avvikelsesystemet ses mindre variationer och hos en tydlig majoritet av landstingen ses en negativ uppfattning. Dock krävs en fördjupad studie för säkerhet i resultatet. Specifika användbarhetsutmaningar har uppmärksammats på den nivå i systemet som hanterar och utreder avvikelser. En ytterligare utmaning tyder på att majoriteten av avvikelsesystemen är för komplexa i förhållande till verksamhetens behov vilket kan innebära en negativ påverkan på användbarheten i avvikelsesystemet. Sammanfattningsvis ger därför denna studie stöd för att vidare forskning kring användbarhetsaspekter inom avvikelsesystem kan vara av värde för hälso- och sjukvårdens avvikelsehanteringsprocesser och lärande. / Every year, thousands of patients suffer from injuries due to medical errors, a stressed working environment and miscommunication between health care professionals. In addition, over a thousand patients die each year due to medical injuries. As a comparison, this number is higher than, for example, deaths caused by traffic accidents. Therefore, the work on patient safety is a very important area. In order to identify risks and incidents, reporting and investigation of incidents is an important tool, and for this digital Incident Reporting Systems are used. Knowing that health care is a sector that has previously experienced challenges within digital systems this motivates a need to investigate general perceptions and challenges in Incident Reporting Systems used by Swedish County Councils. In particular, this study aims to investigate the perceptions of the usability in these systems and where potential challenges are seen. With support from the results, it can be concluded that there are significant differences on the general perceptions of the Incident Reporting Systems. In regards to the general perceptions on the usability in the Incident Reporting Systems less variation is seen, and by a clear majority of the County Councils a negative perception is seen. Although, an additional in-depth study is needed to attain reliability in the results. Specific usability challenges have been recognised at the advanced user level who are handling and investigating the reported incidents. Another challenge suggests that the majority of the Incident Reporting Systems are too complex in relation to the needs of the business which may have a negative impact on the usability of the Incident Reporting System. To summarize, this study supports that further research on the usability aspects of Incident Reporting Systems can be of value to health care’s incident reporting processes and learning.

Workplace accidents and injuries are a growing problem for organizations in Sweden as well as in many other countries. As a consequence, improving workplace safety has become an area of increasing concern for employers and politicians as well as researchers. The aim of this thesis was to contribute to an increased understanding of how leadership and management practices can influence safety in organizations. In Study I, three leadership styles were investigated to determine their relative importance for different safety outcomes. A leadership style specifically emphasizing safety was found to contribute the most to employee safety behaviors; transformational leadership was found to be positive for safety behaviors only when it also involved a safety focus; and a transactional leadership style (management-by-exception active) was shown to be slightly negatively related to workplace safety. Study II examined the role of leader communication approaches for patient safety and the mechanisms involved in this relationship. Support was found for a model showing that one-way communication of safety values and leader feedback communication were both related to increased patient safety through the mediation of different employee safety behaviors (safety compliance and organizational citizen behaviors). Study III explored whether and in what ways the use of staff bonus systems may compromise safety in high-risk organizations. The three investigated systems were all found to provide limited incentives for any behavioral change. However, the results indicate that design characteristics such as clearly defined and communicated bonus goals, which are perceived as closely linked to performance and which aim at improved safety, are imperative for the influence that bonus programs have on safety. Group-directed goals also appeared to be more advantageous than corporate- or individual-level goals. The thesis highlights the importance of actively emphasizing and communicating safety-related issues, both through leadership and in managerial practices, for the achievement of enhanced workplace safety. / <p>At the time of the doctoral defense, the following paper was unpublished and had a status as follows: Paper 1: Manuscript.</p>

The Aviation Safety Action Program (ASAP) is a voluntary, non-jeopardy reporting program supported by commercial airlines. The program provides pilots with a way to report unsafe occurrences, including their own errors, without risk of punitive action on the part of the airlines or the Federal Aviation Administration (FAA). Through a set of on-site visits to airlines with ASAP programs, deficiencies were identified in the way airlines collect ASAP reports from pilots. It was concluded that these deficiencies might be limiting the ability of airlines to identify hazards contributing to reported safety events. The purpose of this research was to determine if the use of an ASAP reporting form based on a human factors model, referred to as the Threat and Error Management (TEM) model, would result in pilots providing a larger quantity and higher quality of information as compared to information provided by pilots using a standard ASAP reporting form. The TEM model provides a framework for a taxonomy that includes factors related to safety events pilots encounter, behaviors and errors they make, and threats associated with the complexities of their operational environment. A comparison of reports collected using the TEM Reporting Form and a standard reporting form demonstrated that narrative descriptions provided by pilots using the TEM Reporting Form included both a larger quantity and higher quality of information. Quantity of information was measured by comparing the average word count of the narrative descriptions. Quality of information was measured by comparing the discriminatory power of the words in the narrative descriptions and the extent to which the narrative descriptions from the two sets of reports contributed to a set of latent concepts. The findings suggest that the TEM Reporting Form can help pilots provide longer descriptions, more relevant information related to safety hazards, and expand on concepts that contribute to reported safety events. The use of the TEM Reporting Form for the collection of ASAP reports should be considered by airlines as a preferred collection method for improving the quantity and quality of information reported by pilots through ASAP programs. / text

Submitted by Cinthia Ferreira Costa (cinthiac.costa@gmail.com) on 2018-09-03T13:17:52Z No. of bitstreams: 1 TA_Cinthia Costa_versão final.pdf: 765367 bytes, checksum: f616f7fa6b7603c5ba1ac56f1db7dfbf (MD5) / Approved for entry into archive by Simone de Andrade Lopes Pires (simone.lopes@fgv.br) on 2018-09-03T19:51:28Z (GMT) No. of bitstreams: 1 TA_Cinthia Costa_versão final.pdf: 765367 bytes, checksum: f616f7fa6b7603c5ba1ac56f1db7dfbf (MD5) / Approved for entry into archive by Suzane Guimarães (suzane.guimaraes@fgv.br) on 2018-09-04T14:41:02Z (GMT) No. of bitstreams: 1 TA_Cinthia Costa_versão final.pdf: 765367 bytes, checksum: f616f7fa6b7603c5ba1ac56f1db7dfbf (MD5) / Made available in DSpace on 2018-09-04T14:41:02Z (GMT). No. of bitstreams: 1 TA_Cinthia Costa_versão final.pdf: 765367 bytes, checksum: f616f7fa6b7603c5ba1ac56f1db7dfbf (MD5) Previous issue date: 2018-07-30 / A segurança do paciente é uma preocupação mundial e de alta prioridade na agenda da Organização Mundial da Saúde (OMS) e seus países membros. Nesse contexto, a gestão de incidentes nos serviços de saúde tem papel essencial para a redução de riscos e danos aos pacientes. Esta pesquisa teve como objetivo conhecer como é realizada a gestão de incidentes nos hospitais paulistanos e qual a visão dos gestores sobre a segurança do paciente como um fator estratégico e de competitividade. Foi realizada pesquisa qualitativa, por meio de entrevistas semiestruturadas com o auxílio de roteiro de entrevista em oito hospitais, sendo cinco privados e três filantrópicos no período de março e abril de 2018. A pesquisa demonstrou um maior número de organizações com sistema de notificação de incidentes informatizado, o crescimento dos serviços de atendimento ao cliente como referência para o contato do paciente ou familiar quando da ocorrência de um incidente e o papel da direção na informação ao paciente e familiar sobre os incidentes ocorridos. Considerando que o movimento pela segurança do paciente é relativamente recente no Brasil, o nível de maturidade da cultura de segurança dos hospitais entrevistados demonstrou ser positiva. O uso de indicadores aponta a valorização do tema dentre as preocupações da gestão e, em alguns casos, da alta direção. Pelas respostas dos entrevistados, é possível afirmar que a segurança do paciente faz parte da estratégia das organizações participantes deste estudo, demonstrando um cuidado corporativo de direcionar os esforços da qualidade e da segurança. / Patient safety is a global concern and hight priority on the schedule of the World Health Organization (WHO) and its member countries. In this context, incident management in health services plays a key role in reducing risks and damaging patients. This research had as objective to know how the management of incidents at the hospitals in São Paulo is and what the managers' view on patient safety as a strategic and competitive factor. A qualitative research of an exploratory nature was carried out, through semi-structured interviews in eight hospitals, five private and three philanthropic in the period of March and April of 2018. The research demonstrated the largest number of organizations with computerized incident reporting system, the growth of customer service as a reference for patient or family contact when an incident occurred, the role of management in patient information and familiarity with the incidents. Considering that the patient safety movement is relatively recent in Brazil, the level of safety culture maturity of the hospitals interviewed demonstrated to be positive. The use of indicators points out the appreciation of the theme among the concerns of management and, in some cases, top management. From the respondents' answers, it is possible to affirm that patient safety is part of the strategy of the organizations participating in this study demonstrating a care corporate effort to direct quality and safety efforts.

Cette thèse décrit les applications du traitement automatique des langues (TAL) à la gestion des risques industriels. Elle se concentre sur le domaine de l'aviation civile, où le retour d'expérience (REX) génère de grandes quantités de données, sous la forme de rapports d'accidents et d'incidents. Nous commençons par faire un panorama des différentes types de données générées dans ce secteur d'activité. Nous analysons les documents, comment ils sont produits, collectés, stockés et organisés ainsi que leurs utilisations. Nous montrons que le paradigme actuel de stockage et d’organisation est mal adapté à l’utilisation réelle de ces documents et identifions des domaines problématiques ou les technologies du langage constituent une partie de la solution. Répondant précisément aux besoins d'experts en sécurité, deux solutions initiales sont implémentées : la catégorisation automatique de documents afin d'aider le codage des rapports dans des taxonomies préexistantes et un outil pour l'exploration de collections de rapports, basé sur la similarité textuelle. En nous basant sur des observations de l'usage de ces outils et sur les retours de leurs utilisateurs, nous proposons différentes méthodes d'analyse des textes issus du REX et discutons des manières dont le TAL peut être appliqué dans le cadre de la gestion de la sécurité dans un secteur à haut risque. En déployant et évaluant certaines solutions, nous montrons que même des aspects subtils liés à la variation et à la multidimensionnalité du langage peuvent être traités en pratique afin de gérer la surabondance de données REX textuelles de manière ascendante / This thesis describes the applications of natural language processing (NLP) to industrial risk management. We focus on the domain of civil aviation, where incident reporting and accident investigations produce vast amounts of information, mostly in the form of textual accounts of abnormal events, and where efficient access to the information contained in the reports is required. We start by drawing a panorama of the different types of data produced in this particular domain. We analyse the documents themselves, how they are stored and organised as well as how they are used within the community. We show that the current storage and organisation paradigms are not well adapted to the data analysis requirements, and we identify the problematic areas, for which NLP technologies are part of the solution. Specifically addressing the needs of aviation safety professionals, two initial solutions are implemented: automatic classification for assisting in the coding of reports within existing taxonomies and a system based on textual similarity for exploring collections of reports. Based on the observation of real-world tool usage and on user feedback, we propose different methods and approaches for processing incident and accident reports and comprehensively discuss how NLP can be applied within the safety information processing framework of a high-risk sector. By deploying and evaluating certain approaches, we show how elusive aspects related to the variability and multidimensionality of language can be addressed in a practical manner and we propose bottom-up methods for managing the overabundance of textual feedback data / Тoзи реферат описва приложението на автоматичната обработка на естествен език (ОЕЕ) в контекста на управлението на риска в гражданското въздухоплаване. В тази област докладването на инциденти и разследването на произшествия генерират голямо количество информация, главно под формата на текстови описания на необичайни събития. На първо време описваме раличните типове (текстови) данни, които секторът произвежда. Анализираме самите документи, методите за съхраняването им, как са организирани, както и техните употреби от екперти по сигурността. Показваме, че съвремените парадигми за съхраняване и организация не са добре приспособени към реалната употреба на този тип данни и установяваме проблемните зони, в които ОЕЕ е част от решението. Две приложения, отговарящи прецизно на нуждите на експерти по авиационна сигурност, са имплементирани: автоматична класификация на доклади за инциденти и система за проучване на на колекции, основаваща се върху текстовото сходство. Въз основа на наблюдения на реалната употреба на приложенията, предлагаме няколко метода за обработка на доклади за инциденти и произшествия и обсъждаме в дълбочина как ОЕЕ може да бъде проложено на различни нива в информационнo-обработващите структури на един високорисков сектор. Оценявайки методите показваме, че трудностите свързани с многоизмерността и изменимостта на човешкия език могат да бъдат ефективно адресирани и предлагаме надеждни възходящи методи за справяне със свръхизобилието на доклади за инциденти в текстови формат

The thesis objective is to analyze existing situation concerning reporting of the aviation accidents or incidents in national level and according the outputs from the analyses to develop recommendations, how database system ECCAIRS can by used for reporting on the national base. The focus of the thesis is investigation and evaluation of the existing national situation / from theoretical point of view and practical point of view/ and develop recommendation. As source of the investigation ware used existing legislation documents and foreign experience. For collection of the foreign experience was designed special type of questioner. The questioners ware distributed to the pre-selected number of authorities represented pre-selected states. During all process of analysis and investigation situation was discussed with local Czech authorities too. International law / ICAO Annex 13 of the Chicago Convention and EU Directive 94/56 / ware considers as one of the basic sources for the information.