Chemical incidents can be prevented or mitigated by improving safety performance and implementing the lessons learned from past incidents. Despite some limitations in the range of information they provide, chemical incident databases can be utilized as sources of lessons learned from incidents by evaluating patterns and relationships that exist between the data variables. Much of the previous research focused on studying the causal factors of incidents; hence, this research analyzes the chemical incidents from both the causal and consequence elements of the incidents. A subset of incidents data reported to the Hazardous Substance Emergency Events Surveillance (HSEES) chemical incident database from 2002-2006 was analyzed using data mining and text mining methodologies. Both methodologies were performed with the aid of STATISTICA software. The analysis studied 12,737 chemical process related incidents and extracted descriptions of incidents in free-text data format from 3,316 incident reports. The structured data was analyzed using data mining tools such as classification and regression trees, association rules, and cluster analysis. The unstructured data (textual data) was transformed into structured data using text mining, and subsequently analyzed further using data mining tools such as, feature selections and cluster analysis. The data mining analysis demonstrated that this technique can be used in estimating the incident severity based on input variables of release quantity and distance between victims and source of release. Using the subset data of ammonia release, the classification and regression tree produced 23 final nodes. Each of the final nodes corresponded to a range of release quantity and, of distance between victims and source of release. For each node, the severity of injury was estimated from the observed severity scores' average. The association rule identified the conditional probability for incidents involving piping, chlorine, ammonia, and benzene in the value of 0.19, 0.04, 0.12, and 0.04 respectively. The text mining was utilized successfully to generate elements of incidents that can be used in developing incident scenarios. Also, the research has identified information gaps in the HSEES database that can be improved to enhance future data analysis. The findings from data mining and text mining should then be used to modify or revise design, operation, emergency response planning or other management strategies.

The study conducted was an archival review of school detailed incident discipline records and description of the school-wide proactive discipline plan developed at an elementary school. The study examined the effects of sequential changes in a proactive school-wide discipline plan. Initially, the baseline data consisted of a full year of school without a proactive school-wide discipline plan. This allowed an assessment of the variation in referrals that occurred across a school year. Subsequent years were assessed in relation to this baseline, and the effects from year to year compared to other years. After the baseline year, substantial changes were made by implementing a school-wide proactive program. In later years, variations were made in the school-wide proactive plan that improved its delivery efficiency. The changes were not major changes but were variations of the original intervention program. Thus, this was a program evaluation on a school-wide basis, incorporating multiple nonconcurrent time series essentially forming an A -- B design with maintenance of improvements under conditions which varied slightly from year to year. The data revealed a higher rate of incidents among ESE and Pre ESE students (students who were later staffed into an ESE program) students then their basic education peers in the primary grades. The data revealed that while the support decreased over time the school-wide mean of incidents increased. The data did not show any decreases in behaviors which would be described of low impact, and there was not a decrease in incidents which would be described as high impact over the course of the evaluation. This study showed that continued behavioral support for teachers may be needed for decreases in incidents over time as well as a possible need to increase attention to students who are at risk behaviorally in order to intervene prior to an ESE placement.

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

In this thesis, I present analysis of security incident reports in IDEA format from Mentat and their aggregation and correlation methods design and implementation. In data analysis, I show huge security reports diversity. Next, I show design of simple framework and system of templates. This framework and system of templates simplify aggregation and correlation methods design and implementation. Finally, I evaluate designed methods using Mentat database dumps. The results showed that designed methods can reduce the number of security reports up to 90% without loss of any significant information.

Communication errors are frequent during the perioperative period and cause clinical incidents and adverse events. The overall aim of the thesis was to study communication – the transfer of information, especially the postoperative handover – between healthcare personnel in an anaesthetic clinic and the effects of using the communication tool SBAR (Situation-Background-Assessment-Recommendation) from a patient safety perspective. The thesis is based on studies using a correlational (Paper I), quasi-experimental (Paper II and III) and descriptive (Paper IV) design. Data were collected using digitally recorded and structured observations of handovers, anaesthetic records, questionnaires, incident reports and focus group interviews. The results from baseline data showed that lack of structure and long duration of the verbal postoperative handover decreased how much the receiver of postoperative handover remembered; the item most likely not to be remembered by the receiver was anaesthetic drugs. The variation in remembered information showed that there were room for improvement (Paper I). Implementing the communication tool SBAR increased memorized information among receivers following postoperative handover. Interruptions were frequent during postoperative handover, which negatively affected memorized information (Paper III). Furthermore, after implementation of SBAR, the personnel’s perception of communication between professionals and the safety climate improved, and the proportion of incident reports related to communication errors decreased in the intervention group (Paper II). The results of the focus group interviews revealed that the nurse anaesthetists, anaesthesiologists and post-anaesthesia care unit nurses had somewhat different focuses and views of the postoperative handover, but all professional groups were uncertain about having all information needed to secure the quality of postoperative care (Paper IV). The findings indicate that using a predictable structure during postoperative handover may improve the information memorized by the receiver, perception of communication between professionals and perception of safety climate. Incidents related to communication errors may also decrease. Long duration of the handover and interruptions may negatively affect the information memorized by receiver. To ensure high quality and safe care, there is a need to achieve a shared understanding across professionals of their work in its entirety.

Text in English / The purpose of this study was to establish the vulnerabilities of the security control measures that are being used at Impala Platinum mines and refinery to prevent the theft of Platinum Group Metals (PGMs). It is important to ensure that the security control measures in place are effective and efficient in preventing the occurrence of such theft. The research examined the security risk management approach to the prevention of theft of PGMs and the causes of theft of PGMs by organised crime syndicates operating in South Africa and abroad. The study found that Impala Platinum employees, in collusion with contractors and members of mine security services, are involved in the theft of PGMs. To achieve the goals and objective of the research study, effective security control measures were identified that will help Impala Platinum mines and refinery to overcome the risks and challenges related to the theft of PGMs. / Security Risk Management / M. Tech. (Security Management)