O presente trabalho tem o objetivo de identificar fatores intervenientes na adoção de energias limpas nos principais setores industriais do Estado de São Paulo. Para tanto, apresenta a fundamentação teórica sobre os diversos temas pertinentes a pesquisa, tais como: o atual cenário energético brasileiro e o desenvolvimento sustentável, bem como o estudo dos métodos aplicados. A análise dos dados realizada teve caráter qualitativo e quantitativo, por meio, respectivamente, da Técnica do Incidente Crítico e da Análise Conjunta. A aplicação da Técnica do Incidente Crítico forneceu os atributos que as empresas consideram importantes no processo de escolha. Já a Análise Conjunta, técnica estatística multivariada de análise de dados, foi utilizada para determinar a utilidade e importância relativa dos atributos relevantes na escolha das empresas. Com os resultados da pesquisa acredita-se que as empresas usuárias e não usuárias de energias limpas poderão ter conhecimentos sobre a opinião de seus pares com relação às vantagens e desvantagens do uso destes energéticos nos processos produtivos, assim como ao governo estabelecer estratégias adequadas para orientar e estimular a adoção de energias que promovem baixo impacto ao meio ambiente. / The scope of the present work is to identify intervening factors in the adoption of clean energy resources in the main industrial sectors of the São Paulo state. In order to perform such evaluation, a theoretical reasoning on the various relevant issues related to the research shall be displayed, such as: the current brazilian energy context and sustainable development, as well as the study of applied methods. The data analysis was realized guided on a qualitative and quantitative basis, by means, respectively, of the Critical Incident Technique and the Conjoint Analysis. The application of the Critical Incident Technique has imputed capabilities that companies regard as pivotal in the selection process. The Conjoint Analysis, on its hand, multivariate statistics technique on data analysis, was used in order to determine the utility and relative importance of the capabilities relevant to the companies\' selection. Based on the results inferred from the research it may be conjectured that companies that adopt and do not adopt clean energy resources may acquire acknowledge about the opinion of its couples in what it concerns the advantages and disadvantages of the use of these energetic in these productive processes, as well the government may set to establish adequate strategies in order to instruct and encourage the adoption of energy resources that promote a lesser impact to the environment.

Devido aos altos índices de acidentes do trabalho nas atividades de distribuição de energia elétrica, é imprescindível o empenho em aprimorar seus sistemas de gestão de segurança e saúde do trabalho. Nesse setor, bem como em outros, o desempenho em segurança é normalmente medido reativamente através de índices de acidentes, abordagem que vem sendo questionada pelos pesquisadores da área, que propõem que seja enfocada a variabilidade do trabalho real. Assim, emerge a premissa de que a gestão de segurança e saúde do trabalho deve estar imersa em uma cultura de informação, onde o sistema de relatos de incidentes se apresenta como ferramenta. É nesse contexto que é apresentado esse estudo realizado em uma concessionária de distribuição de energia elétrica no Rio Grande do Sul. A pesquisa tem por objetivo principal contribuir com a prevenção de acidentes sob uma perspectiva pró-ativa, através da proposição de diretrizes para o projeto, implantação e avaliação de um sistema de relatos de incidentes. A estratégia adotada para condução do estudo foi a pesquisa-ação, o que possibilitou aferir o processo envolvido na implementação do sistema. Durante a fase de projeto, que ocorreu de agosto a setembro de 2009, os pesquisadores em conjunto com membros da empresa determinaram as diretrizes fundamentais de operação do sistema, assim como adaptaram o formulário de relatos de acordo com a realidade da empresa estudada. Na última semana de setembro de 2009 teve início a etapa de implantação do sistema de relatos de incidentes, através de um estudo piloto com duas das sete equipes de eletricistas envolvidas no estudo, precedido por uma capacitação para o uso do sistema. Em meados de dezembro, o sistema de relatos foi estendido para todo o departamento envolvido no estudo e foi conduzido pela equipe de pesquisa até maio de 2010. A etapa de avaliação do sistema ocorreu através de entrevistas, em agosto de 2010 e março de 2011, com membros da empresa envolvidos no estudo, assim como por observações em campo durante toda a pesquisa. Durante a implantação do sistema de relatos de incidentes e a análise dos dados gerados, foi possível aprofundar a compreensão acerca da variabilidade do cenário em que os eletricistas desempenham suas tarefas, assim como identificar ações corretivas prioritárias. Como principais resultados podem ser citadas a prevalência de estruturas fora de padrão como agentes causadores dos incidentes e a influência do ambiente externo na atividade dos eletricistas. Por fim, foi analisado como um sistema de relatos de incidentes pode favorecer os princípios da engenharia de resiliência. / Due to high rates of occupational accidents in the electricity distribution´s activities, an effort is necessary to improve their safety and occupational health management. In this sector, as well as in others, the safety performance is normally measured by reactively accident rates, an approach that has been questioned by researchers, which propose to focus on the variability of the real work. Thus emerges the premise that the safety and occupational health management should be immersed in an information culture, where the incident reporting system is presented as a tool. This is the context of this study, realized in a company of electric energy distribution at Rio Grande do Sul. The research aims at contributing to the prevention of accidents with a proactive approach, by proposing guidelines for design, implementation and evaluation of an incident reports system. The strategy adopted for conducting the study was action research, enabling to assess the process involved in implementing the system. During the project, which occurred from August to September 2009, researchers and members of the company determined the basic orientation of the system operation, as well as adapted the reports form in accordance to the reality of the company. In the last week of September 2009 began the implantation phase of the incident report system, through a pilot study with two of the seven teams of electricians involved in the study, preceded by training. In December, the reporting system was extended to the entire department involved in the study and was lead by the research team until May 2010. The evaluation phase of the system occurred through interviews, in August 2010 and March 2011, with members of the company involved in the study, as well as field observations throughout the research. During the system´s implantation and analysis of data generated, it was possible to deepen the understanding of the variability of the scenario in which the electricians perform their tasks, as well as to identify priorities for corrective actions. Prevalence of non-standard structures as causative agents of the incidents and the influence of external environment on the activity of the electricians were the main results. Finally, it was analyzed how an incident reports system may favor the principles of resilience engineering.

A parada cardiorrespiratória (PCR) é uma intercorrência inesperada em diversos momentos, constituindo grave ameaça à vida das pessoas, principalmente das que sofrem um colapso não-presenciado e dos pacientes/clientes hospitalizados em estado crítico. Neste estudo, sob a luz da pesquisa qualitativa, fazendo uso da técnica do incidente crítico (TIC), foram entrevistados 30 enfermeiros de unidades de internação clínicas de um hospital universitário do interior do Estado de São Paulo, a fim de se estabelecer as exigências críticas no atendimento à PCR em unidades de internação neste hospital, através da vivência de enfermeiros durante as manobras de ressuscitação cardiopulmonar (RCP), identificando os incidentes críticos positivos e/ou negativos durante esse atendimento, além das ocorrências iatrogênicas durante as manobras de RCP. Os dados coletados foram categorizados segundo as situações secundárias, uma vez que determinamos que a situação principal era a ocorrência da PCR, os comportamentos e as conseqüências decorrentes das diversas situações. Nas situações secundárias encontramos as seguintes categorias: estado e/ou condições clínicas do paciente/cliente; habilidades técnicas inerentes à profissão; conhecimento ou não acerca da PCR; identificação e reconhecimento (ou desconhecimento) do local de trabalho; condições dos materiais e equipamentos; capacitação e treinamento; e circunstâncias adversas. Relacionado aos comportamentos positivos, destacamos as seguintes categorias: vivendo a sistematização no atendimento à PCR; a questão dos materiais; e estabelecendo funções durante o atendimento à PCR. Já, quanto aos comportamentos negativos, podemos destacar as seguintes categorias: vivenciando a falta (ou ausência) da sistematização no atendimento à PCR; convivendo com as dificuldades técnicas; o ambiente situacional; materiais: é difícil conhecer a sua importância?; vivendo as ocorrências adversas; e estabelecer funções: lidando com prioridades. Uma vez selecionadas as situações secundárias, os comportamentos positivos e os comportamentos negativos, pudemos categorizar as conseqüências imediatas ao paciente/cliente; na categoria que traz as conseqüências positivas temos: restabelecimento das funções vitais; como categorias com conseqüências negativas ao paciente/cliente temos: até que ponto a RCP ajuda o paciente/cliente e sua família? e óbito. Avaliando as conseqüências positivas para a equipe de enfermagem temos a categoria: salvar vidas: o que isso proporciona ao profissional de enfermagem? E como categoria abrangendo as conseqüências negativas para esses profissionais temos: fazer parte da equipe de enfermagem é saber lidar com o sofrimento. A partir dos incidentes críticos identificados, pode-se estabelecer as exigências críticas no atendimento à PCR no local de estudo e, ressaltar que para um bom desempenho no atendimento à PCR é necessário rapidez, eficiência, conhecimento técnico-científico e habilidade técnica por parte de toda a equipe que realiza esse atendimento. Além disso, identifica-se a necessidade de infra-estrutura adequada, trabalho harmônico e sincronizado entre todos os profissionais, visando o restabelecimento da vida, a limitação do sofrimento, a recuperação do paciente/cliente e a ocorrência mínima de seqüelas. A partir do momento em que esses requisitos não são atendidos, os riscos tornam-se evidentes, as ocorrências iatrogênicas freqüentes e a segurança do paciente/cliente, seriamente comprometida. / The cardiac arrest is an unexpected alternative in several moments, comprising a serious threaten to people’s lives, mostly of those who suffer an unwitnessed collapse and those hospitalized patients in critical state. In this study, under the light of quality research, making use of critical incident technique, 30 nurses of medical admission units of a university hospital in the state of São Paulo were interviewed, in order to establish the critical requirements in taking care of cardiac arrest in admission units in this hospital, through the nurse experience during the maneuvers of cardiac pulmonary resuscitation, identifying the positive and/or negative critical incidents during such care, and also the iatrogenic occurrences during the maneuvers of cardiac pulmonary resuscitation. The recorded data were classified according to secondary situations, once we determinated that the main situation was the occurrence of cardiac arrest, the behaviors, and the alternative consequences of the several situations. On secondary situations, we found the following categories: the patient/client clinical state and conditions; ability of techniques of profession; knowledge or ignorance around the CRA; identification and recognition (or ignorance) of workplace; conditions of material and appliances; capability and training; and adverse circumstances. In relation to the positive behaviors, we highlight the following categories: experiencing the systemization in taking care of cardiac arrest; in relation to the materials; and determining the functions during the medical care to cardiac arrest. As for the negative behaviors, we can highlight the following categories: experiencing the lack (or absence) of systemization in medical care to cardiac arrest; living with adverse occurrences; and to establish functions: dealing with priorities. Once the secondary situation, the positive and negative behaviors were selected, we could classify the immediate consequences to the patient/client, and as category the gruping of positive consequences we have: recovery of vital functions; as categories of negative consequences to the patient/client we have: to what extent the does the cardiac pulmonary resuscitation help the patient/client and his/her family? and death. Evaluating the positive consequences for the nursing team we have the category: saving lives: what does it promote to the professional? And as category comprising the negative consequences for these professional we have: to be part of the team is to know how to deal with pain. From the identified critical incidents we can accentuate that for a good performance in taking care of CRA it is necessary rapidity, efficiency, scientific-technical knowledge and the ability of all the team who perform the medical care. Besides that we identify the need of the adequate infra-structure, harmonious work between all of the professionals, aiming the recovery of life, the limitations of pain, the recovery of the patient/client and the minimal ocurrence of sequelae. From the moment those requirements are fulfilled risks become evident, the iatrogenic occurrences frequent and the patient/client safety seriously committed.

Date: 2008-10-06 Level: Bachelor thesis within Information Technology and business economics, 15p, EIK021 Authors: Anna Karlsson, akn05009@student.mdh.se Lena-Maria Lindström, llm05002@student.mdh.se Magnus Wretlund, mvd05001@student.se Tutor: Marie Mörndal   Title: Managing IT-incidents, a case study at ICAs IT department                            Operations Keywords: IT-incident management, IT-incident management process, IT-incident, ITIL, CCTA   Problem: An organization can benefit by having an established management process of handling IT-incidents. But how can this be achieved? Are there step-by-step procedures? What´s included in the management process of IT-incidents? Is the size of the organization relevant to which model is to be chosen? Can the work of the writers of this essay result in a recommendation of a specific model for IT-incident management? These questions lead to the following essay question; How are IT-incidents managed? Purpose: The purpose of this thesis is to describe and discuss how IT incidents can be managed. Method: The writers of this essay have performed a case study at ICA, a Swedish food retail company. Eleven interviews with nine different persons have been carried out. The interviews are analyzed in the chapter called Resultat och analys. Conclusion: Our conclusion is that there are both similarities and differences in Dept. Operations´ management process for handling IT-incidents compared to what is stated in the CCTA-model. Another conclusion is that it is of highest importance for a business to implement a standard procedure for handling IT-incidents. The lack of such a model could result in e.g. financial losses.

Background: Preventable medical error accounts for approximately 98,000 deaths in the hospital setting each year. A proposed solution to decreasing medical error encompasses the development of a culture of safety. Safety culture has been defined as a common set of values and beliefs that are shared by individuals within an organization that influence their actions and behaviors. In 2015, the safety culture of Registered Nurses (RN) and Patient Care Technicians (PCT) who regularly worked in the Intensive Care Unit (ICU) and Cardiovascular Intensive Care Unit (CVICU) at Flagstaff Medical Center (FMC) was assessed using the Hospital Survey on Patient Safety Culture. This survey functioned as a needs assessment and demonstrated that ICU/CVICU staff had negative reactions to safety culture and error reporting on eight of twelve composites tested. Based off these results, the Incident Decision Tree (IDT) was selected as an intervention to help improve the areas identified in the needs assessment. Purpose: The aims of this quality improvement project included: 1) Development of a protocol for IDT use by ICU/CVICU managers; 2) Implementing the IDT; and 3) Administering a post IDT implementation survey. Methods: The IDT was implemented during a 4-week period in the ICU/CVICU at FMC. During this time, managers used the IDT when processing reported error. Post implementation, an online survey was administered over the course of two weeks to ICU/CVICU managers and unit based RNs and PCTs to reassess their perceptions on the IDT, error reporting, and safety culture. Results: During the implementation period, 23 errors were reported in the ICU/CVICU at FMC with management utilizing the IDT a total of 12 times. Analysis of the reportable data demonstrated that of the 12 incidents, seven were attributed to system failures. The remaining five incidents were processed using the “foresight test.” Conclusions: Results from the post implementation survey demonstrated that ICU/CVICU staff felt the IDT contributed to a non-punitive environment. Staff also reported the IDT helped to increase communication after an error occurred. Lastly, the majority of staff felt the IDT increased transparency in the error reporting process.

Jet flames are commonly used as flame effects in pyrotechnical shows, and are also a possible risk in industries that uses pressurised flammable gas. For these users it is important to  make fire safety engineering calculations to minimise the risks. This project focus on jet flames that are used in pyrotechnic shows where, e.g. it is important to determine the safety distance to the audience. Up to now most studies made concerning jet flames regards jet flames in subsonic regiments, whilst there is a lack of studies concerning sonic jet flames and mathematical formulations for radiation from these cases are limited. This makes pre-determination of temperatures, safety distances, flame heights etc. a challenge. Based on information found, and assumptions when needed, calculations of the safety distance were made.

This dissertation for a bachelor project in computer science at Karlstad University will describe how to conquer a challenge suggested by Tieto: How to create a secure Incident Reporting System with a high level of confidentiality and security for the contents. The system should be easy to use and encourage incident reporting, open for changes and statistics gathering, for those with the relevant authority. The result will be a requirement specification and a prototype incident management system that matches those requirements. Any employee of Tieto will be able to submit an incident report and the system will notify a security administrator at Tieto who will solve the problem. The system will be able to gather information and statistics regarding incidents which can be used as decision support.

Incident response plans are faced with new challenges as organisations expands to the cloud, this thesis aims to highlight these challenges and their potential solutions. Our work has focused on managing the incident response in contrast to earlier work that has been focusing on preventing them.As with any development, security is seldom prioritized. Instead the focus are often aimed towards usability and functionality, which means incident response plans are written, implemented, forgotten and finally becomes obsolete. This could result in an organization losing their ability to produce acceptable forensic images, avoid severe downtime, or prevent similar incidents in the future, which are all important parts of incident response.Traditional incident response plans does not address incidents in the cloud. Thus, an absence of guidelines for managing incidents in the cloud becomes apparent. By compiling literature and performing practical experiments, this thesis exposes weaknesses in traditional incident response plans and demonstrates a need for cloud-specific incident response plans.Based on the conducted experiments, we can conclude that with our cloud-specific incident response plan as a basis, a forensic recovery from a cloud instance can be done in such a way that privacy and confidentiality is maintained. The experiments have also provided a forensically sound method for connecting tools to a cloud instance, we call this approach "Virtual Incident Response Disk" (VIRD). / Incidenthanteringsplaner ställs inför nya utmaningar vid en expandering till molnmiljö, detta arbete ämnar att belysa de problem som uppstår vid hantering av incidenter i molnmiljö samt potentiella lösningar. Incidenthantering i denna nya miljö har inte behandlats i någon större utsträckning i tidigare arbeten då forskningens fokus har legat på att förhindra incidenter istället för att hantera dessa.Som med all utveckling är det lätt att säkerhetsarbetet hamnar på efterkälken till förmån för användarvänlighet och funktion. Detta visar sig ofta inom incidenthantering där planer för incidenthantering skrivs och implementeras för att sedan glömmas bort och sedermera bli förlegade. Detta kan medföra att en organisation förlorar förmågan att producera forensiskt godtagbara avbilder vilket är en viktig del av incidenthantering.Då incidenthanteringsplaner ämnade för traditionell servermiljö inte behandlar hanteringen av incidenter i molnmiljö fungerar det inte att applicera dessa på ny teknik såsom molnmiljö. Genom att sammanställa litteratur och utföra praktiska experiment har vi i detta arbete exponerat svagheter i traditionell incidenthantering och påvisat behovet av en molnspecifik incidenthanteringsplan.Utifrån våra utförda experiment kan vi konstatera att med vår molnspecifika incidenthanteringsplan som grund kan en forensisk utvinning från en molninstans ske på så sätt att bevisets integritet och konfidentialitet bibehålls. Baserat på erfarenheter utifrån våra experiment har även en forensiskt godtagbar metod för att ansluta verktyg till en molninstans arbetats fram, vi kallar detta tillvägagångssätt “Virtual Incident Response Disk” (VIRD).

Bakgrund: Intensivvårdsavdelningen är en högteknologisk miljö där kritiskt sjuka patienter vårdas. Intensivvårdssjuksköterskor möts ständigt av situationer där de utsetts för stress. Det kan vara situationer, anhöriga eller identifiering med patienten som ger emotionell stress. Stress som inte hanteras kan ge följdsjukdomar, kvarvarande emotionell påverkan och leda till utbrändhet. Syfte: Att beskriva intensivvårdssjuksköterskors upplevelser av emotionell stress och copingstrategier efter kritiska incidenter. Metod: Intervjustudie med åtta informanter genomfördes. En kvalitativ innehållsanalys genomfördes av de transkriberade intervjuerna. Resultat: Anhörigas reaktioner uppfattades som en stor del av den emotionella stressen, även brister i vård och rutiner lämnar minnen kvar efter kritiska incidenter. Kollegialt samtal var det som upplevdes ha bäst copingstrategi mot den emotionella stressen. Avkoppling, distraktion och sociala miljöer var också ett stöd mot emotionella upplevelsen. En önskan om mer utrymme för kollegiala samtal framkom under intervjuerna. Slutsats: Att kunna få och ta utrymmet för att genomföra samtal mellan kollegor skulle vara stöd mot emotionell stressen framkom i föreliggande intervjustudie. Ledningen bör skapa utrymme för att kollegiala samtal kan genomföras då det har uppvisat vara bästa copingstrategin hos intensivvårdssjuksköterskor. Det uppdagades att vissa brister fanns i att ledningen inte fick information under obekväm arbetstid och rutiner samt informationskällor behöver förtydligas. Fortsatt forskning: Coping av emotionell stress ger styrkor hos personal att kunna hantera svåra situationer, och gå vidare i arbetet utan kvarvarande påverkan av stressen. Intresse skulle finnas att ta reda på hur andra yrkesgrupper resonerar om coping av emotionell stress i samverkan med intensivvårdssjuksköterskor. / Background: The intensive care unit is a high technology environment were critical ill is treated. Intensive care nurses comes in contact of situation where they may encounter stress. It can be situation, relatives or own identifications that gives emotional stress. Stress that is not cooped with can lead to sickness, persistent emotional effects and lead to burnout. Aim: To describe intensive care nurses experiences of emotional stress and coping strategies after a critical incident. Method: Interview study with eight informants was done. A qualitative content analysis was performed of the transcribed interviews. Results: Relatives reaction is a large part of the emotional stress that was experienced, even flaws in care and routines left memories after critical incidents. Peer to peer talks was the support that had best coping strategies against emotional stress. Relaxation, distraction and social context were also support against the emotional distress. Space, time and place, for peer to peer conversation is a desire among informants. Conclusion: To have and to take the time to perform peer to peer talks is a relief against emotional stress. Management should make it a possibility to conclude these talks as it is the preferred coping strategy. Some indication of flaws in information to management during unsocial hours and a need for routines of information need to be looked over and clarified. Further research: Coping of emotional stress gives resilience with the staff to handle difficult situation and to move forward without any lasting effect of the stress. An interest could be in the future to find out how other professionals reasoning about coping of emotional stress in cooperation with intensive care nurses.

This thesis focuses on the topics of Business Continuity Management and Disaster Recov-ery Management in the context of small and medium sized businesses which offer or use IT services in the cloud. The aim of this thesis is to carry out a theoretical research of BCM and DRM in the aforementioned context and to analyze situation in a specific company based on the results of the research. This includes analysis of specific incidents that hap-pened in the company, analysis of how the company reacts to the incidents and how are the incidents logged and reported. The analysis identifies weak spots in the company and their potentials of improvement. The most serious weak spot discovered is that BCM and DRM are not implemented in the company. In the last part this thesis suggests measures to im-prove the situation in the specific company. That includes both specifying general goals and procedures and also defining specific policies, plans and reaction schemes. Specifically those are politics handling the incidents categorization, warning and communication, inci-dent reporting and performing maintenance.