The purpose of this study is to find out if the Swedish Air Force and the military aviation industry, Saab Aerosystems, use an HTO perspective in incident investigations. The research objectives are to explore existing organizational and accident models, analyze the reporting system using the models, and suggest possible improvements to the existing incident investigation system. Fishman’s (1999) model for pragmatic studies was used to describe the study’s theoretical approach. Triangulation by literary review, case study and interviews were used to ensure validity and reliability. Three models were chosen: Rollenhagen’s HTO model (1997), Leveson’s STAMP (2002), and Shappell and Wiegmann’s HFACS (2000). The models were further tested in the case study, revealing that their usefulness depends on type of incident, and that they leave a lot up to the investigator. Interviews were conducted with key individuals at Saab Aerosystems as well as at the Swedish Armed Forces’ Headquarters. The interviews showed that the incident reporting system in question is a well functioning one, mainly due to the blame-free culture, multidisciplinary investigative teams, good feedback and a generally good knowledge of the HTO concept. Difficulties within the organizations exist due to organizational boundaries between the manufacturer and the operator, and recurring structural reorganizations within the Swedish Armed Forces. Saab acknowledges the emphasis on technical issues. The Flight Safety department at the headquarters is currently working with implementing HFACS into the Flight Safety Database. Our recommendations for Saab Aerosystems and the Air Force include: For Saab Aerosystems: Evaluate and learn from existing HTO work within the organization, and incorporate the results into existing processes and instructions for incident investigations. Make use of the theoretical models, where applicable, in the processes as well. Focus on HFACS in order to synchronize with the Air Force. Consider employing an HTO specialist. For the Air Force: Consider influences from other HTO models, like Rollenhagen’s or Leveson’s models, while still in the development phase of implementing HFACS. Perform risk analyses regarding the effects on flight safety when doing reorganizations. For both Saab Aerosystems and the Air Force we recommend: Use Leveson’s model STAMP for complex and serious incidents, comprising of organizational, human and technical aspects. / Denna studie har som syfte att ta reda på om det svenska Flygvapnet och den militära flygindustrin, Saab Aerosystems, använder ett MTO-perspektiv vid incidentutredningar. Forskningsmålen är att utforska befintliga organisations- och olycksmodeller, att analysera rapporteringssystemet med hjälp av modellerna, samt att föreslå möjliga förbättringar på det existerande incidentrapporterings- och utredningssystemet. Fishmans (1999) modell för pragmatiska studier användes som teoretisk utgångspunkt. För att säkerställa validitet och reliabilitet användes triangulering, bestående av litteraturstudie, fallstudie, samt intervjuer. Tre modeller valdes ut: Rollenhagens MTO-modell (1997), Levesons STAMP (2002) och Shappell och Wiegmanns HFACS (2000). Modellerna användes i fallstudien, med resultatet att modellernas användbarhet bedömdes variera beroende på typ av incident, samt att de lämnar mycket åt utredarens erfarenhet. Intervjuer genomfördes med nyckelpersoner på Saab Aerosystems och på Försvarsmaktens Högkvarter. Intervjuerna visade att rapporteringssystemet i fråga är väl fungerande, främst tack vare rapporteringskulturen, de multidisciplinära utredningsgrupperna, god återkoppling och en generellt sett god kännedom om MTO-konceptet. Organisatoriska svårigheter är dels gränsdragningen mellan tillverkare och användare, dels återkommande omstruktureringar inom Försvarsmakten. Saab medger också att deras fokus ligger främst på det tekniska. Flygsäkerhetsavdelningen på Högkvarteret arbetar med att införa HFACS i flyg­säker­hetsdatabasen. Våra rekommendationer till Saab Aerosystems och till Flygvapnet inkluderar: Till Saab Aerosystems: Utvärdera och drag lärdom av befintligt MTO-arbete inom organisationen, inkludera dessa resultat i befintliga processer och instruktioner för incidentutredningar. Utnyttja fler teoretiska modeller i processen, där så är lämpligt. Fokusera på HFACS för att synkronisera med Flygvapnet. Fundera på att anställa en MTO-specialist. Till Flygvapnet: Fundera på att också införa delar av andra MTO-modeller, som Rollenhagens eller Levesons modeller, under implementeringsfasen av HFACS. Genomför riskanalyser av påverkan på flygsäkerhet vid omorganisationer. Till både Saab Aerosystems och Flygvapnet rekommenderar vi: använd Levesons modell STAMP vid mer komplexa och allvarliga incidenter som innefattar organisatoriska, mänskliga och tekniska aspekter.

Background: Tobacco use increases the odds of suffering and dying prematurely from a host of chronic disease, including heart disease, stroke, cancer, lung diseases, and mental illness. There is limited published data especially from Canada on the prevalence, etiology, consumption patterns and treatment of tobacco use among persons with mental illness. Objectives: First, understand the social epidemiology and describe the characteristics of a typical smoker with mental illness. Second, understand the likelihood of receiving smoking cessation interventions in mental health institutions of Ontario. Methods: Secondary analysis of the data obtained using the Ontario Mental Health Reporting System (OMHRS). Census level data collected from all the individuals admitted to mental health institutions in Ontario during the period of October 2005 and September 2006. Cross tabs were used to analyze the social epidemiology of smokers. Odds ratios were calculated for the likelihood of the psychiatric diagnosis and receiving smoking cessation intervention. Results: Forty-seven percent of the individuals admitted in mental health beds during the study duration were smokers. The mean age of smokers was lower as compared to non-smokers. Individuals with the diagnosis of substance use disorder were the most likely to be smokers as compared to the reference group. Smokers scoring higher on CAGE score or having a diagnosis of substance use disorder and had more than 5 drinks of alcohol in the last 14 days are more likely to receive the intervention as compared to other smokers. Conclusion: The results of this study suggest that significantly huge populations of individuals in mental health institutions are smokers. The smoking prevalence is higher in males and these males are also more likely to have a diagnosis of substance-related disorder. There is a lack of smoking cessation interventions in mental health facilities.

iSmart Taxi är en Android mobilapplikation (app) för taxiförarna på iSmart Taxi AB. Förarna kan med hjälp av denna applikation rapportera deras körningar. Denna applikation har skapats med hjälp av ett REST-API för att interagera med databasen.   Rapporten innehåller beskrivning om hur applikationen skapades och hur återkoppling från testfall som genomfördes av användarna påverkade applikationens design. / iSmart Taxi is a mobile application (app) for taxi drivers at iSmart TaxiAB. The application helps the drivers to register their fares on an Android mobile. A REST-API was build to interact with the database.   The report contains a description of how the application was created and how the feedback from the tests conducted by the users affected application design.

In this research, we detail the development of a novel, easy-to-use system to facilitate electronic patient falls reporting within a long-term residential care facility (LTRCF) using off-the-shelf technology that can be inexpensively implemented in a wide variety of settings. We report the results of four complimentary system evaluation measures that take into consideration varied organizational stakeholders’ perspectives: 1) System-level benefits and costs, 2) System usability, via scenario-based use cases, 3) A holistic assessment of users’ physical, cognitive, and marcoergonomic (work system) challenges in using the system, and 4) User technology acceptance. We report the viability of collecting and analyzing data specific to each evaluation measure and detail the relative merits of each measure in judging whether the system is acceptable to each stakeholder. The electronic falls reporting system was successfully implemented, with 100% electronic submission rate at 3-months post-implementation period. The system-level benefits and costs approach showed that the electronic system required no initial investment costs aside from personnel costs and significant benefits accrued from user time savings. The usability analysis revealed several fixable design flaws and demonstrated the importance of scenario-based user training. The technology acceptance model showed that users perceived the reporting system to be useful and easy to use, even more so after implementation. Finally, the holistic human factors evaluation identified challenges encountered when nurses used the system as a part of their daily work, guiding further system redesign. The four-pronged evaluation framework accounted for varied stakeholder perspectives and goals and is a highly scalable framework that can be easily applied to Health IT (Information Technology) implementations in other LTRCFs.

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.

Yes / Background: The efficacy of medicines depends on their accessibility and availability. Dedicated medicine shortage reporting systems (MSRS) have been set up in different countries, either mandatory or voluntary, following the recommendations of the World Health Organisation to ensure these. Objectives: To explore how the Medicine Shortages Reporting System (MSRS) can tackle medicine shortages through improved access and sustainability. Methods: Personnel directly involved in the reporting mechanisms for medicine shortages in eight (8) countries participated in semi-structured interviews. An interview protocol based on the Dynamic Capabilities View and Organisational Information Processing Theory (OIPT) was developed. It contained questions related to participant's views on the process involved in MSRS and how it was used to tackle shortages. Data were thematically analysed. Results: Three core elements were identified to influence MSRS's ability to tackle shortages and ensure sustainability; (1) the ability to identify what information requirements the reporting system needs, (2) identify information processing capabilities, and (3) the ability to match requirements and information processing capabilities through a dynamic capability decision-making process. The dynamic decision-making process involves reiteratively sensing shortages by understanding and validating information received. Conclusion: Building MSRS to tackle shortages for accessibility and sustainability is a systemic process that entails understanding the various elements and processes of MSRS. It includes defining medicine shortages, reconfiguring resources, defining accessibility and ensuring the system's sustainability. Our study provides insights into MSRS developed for mitigating medicine shortages and provides a framework for a sustainable MSRS. The findings extend the literature on medicine shortage management by identifying the various elements required to set up an MSRS. It also provides practical implications for countries that seek to establish MSRS to mitigate medicine shortages. Further studies could extend the number of participating countries to provide a clearer picture of the MSRS and how it can reduce medicine shortages. / This research is supported by the National Institute for Health and Care Research (NIHR) Yorkshire and Humber Patient Safety Research Collaboration (NIHR Yorkshire and Humber PSRC). Grant number - NIHR204293.

<p>Syftet är att beskriva symtom och biverkningar som kvinnor med avancerad bröstcancer och cytostatikabehandling rapporterat i ett datoriserat rapporteringssystem före läkarbesök. Undersöka tillfredsställelsen med detta system; se om det finns en skillnad mellan äldre och yngre; undersöka kvinnornas uppfattning om vad som kan förbättras i uppföljningen av symtom/biverkningar samt stödet från läkare. Detta är en kvantitativ, deskriptiv tvärsnittsstudie baserat på rapporteringssystemets databas samt enkätundersökning.</p><p> </p><p>Biverkningarna trötthet, smärta och nervpåverkan rapporterades mest frekvent. Tidsåtgången för rapportering ansågs utav de flesta vara kort eller mycket kort och formuläret upplevdes av majoriteten vara ganska lätt till mycket lätt att använda oberoende av datorvana. Läkaren ansågs från hög grad till mycket hög grad vara ett stöd i att hantera symtom och biverkningar av två tredjedelar av respondenterna. Hälften ansåg att rapporterade biverkningar och symtom uppmärksammades av läkaren i hög grad till mycket hög grad.</p><p> </p><p>Undersökningen bekräftar det tidigare forskning visat om datoriserade rapporteringssystem i vården, att de är funktionella oavsett ålder samt att intresse finns för att använda dessa i större utsträckning. På grund av litet urval och relativt stort bortfall i enkätstudien kan dock inga direkta slutsatser dras men undersökningen antyder att behov finns att vidareutveckla rapporteringssystemet.</p> / <p>The aim of the study is to describe symptoms and side effects that women with advanced breast cancer and chemotherapy reported in an adverse drug reporting system before seeing their oncologist; examine the satisfaction with this system; if there are any differences between older and younger women; the women’s opinion of what improvements could be done in the follow-up of the symptoms/side effects and the support from the oncologist. This is a quantitative, descriptive cross-sectional study based on the database of the adverse drug reporting system and the questionnaire survey.</p><p> </p><p>The side effects fatigue, pain and peripheral neuropathy were most frequently reported. The time consumption for reporting was considered short or very short and the majority thought that the questionnaire was fairly easy to very easy to use independent of computer habits. The oncologists where considered from a high extent to a very high extent being a support in handling the symptoms/side effects by two thirds of the respondents. Two fourths felt that the oncologists attended reported symptoms/side effects from a high extent to a very high extent.</p><p>Because of a small sample and a relatively large drop-out no real conclusions can be drawn except the need for further development of the system.</p>

<p>Ett flygsäkerhetsarbete bygger på ett förtroende mellan individen och organisationen. Det finns en brist inom Försvarsmakten rapporteringssystem, där fördelningen av rapporter med avseende på mänskliga misstag, är avvikande från vad som anses som normalt inom flygverksamhet. Varför avviker rapporteringen i FM från normalbilden? Ett perspektiv som kan förklara denna avvikelse är rättvisekulturperspektivet.</p><p>Syftet är att diskutera huruvida den ojämna fördelningen av avvikelserapporter med avseende på mänskliga misstag i FM flygsäkerhetsarbete kan förklaras ur ett just culture perspektiv med fokus på regler och styrdokument .</p><p>Resultatet är att FM inte är att anse som en rättvisekultur. Framförallt är detta på grund av den bristfälliga kulturella grunden, disciplinsystemet och skyddandet av rapporteringssystemet.</p> / <p>Flight safety relies on trust between the person and the organization. There is a deficiency in the Swedish armed forces reporting system whereas the distribution between human factor reports and other reports is deviant from the normal distribution in flying operations. Why is that? A perspective that could help explaining this is the <em>just culture</em> perspective.</p><p>The purpose of this essay is to discus whether the uneven distribution in the reporting system in regards of human error in the Swedish armed forces can be explained by a just culture perspective in regards of rules and documents.</p><p>The result is that the Swedish armed forces are not considered a just culture. Mainly because of the insufficient foundation of the flight safety culture, the existence of a disciplinary system and the failure to protect the reporting system.</p>

Ett flygsäkerhetsarbete bygger på ett förtroende mellan individen och organisationen. Det finns en brist inom Försvarsmakten rapporteringssystem, där fördelningen av rapporter med avseende på mänskliga misstag, är avvikande från vad som anses som normalt inom flygverksamhet. Varför avviker rapporteringen i FM från normalbilden? Ett perspektiv som kan förklara denna avvikelse är rättvisekulturperspektivet. Syftet är att diskutera huruvida den ojämna fördelningen av avvikelserapporter med avseende på mänskliga misstag i FM flygsäkerhetsarbete kan förklaras ur ett just culture perspektiv med fokus på regler och styrdokument . Resultatet är att FM inte är att anse som en rättvisekultur. Framförallt är detta på grund av den bristfälliga kulturella grunden, disciplinsystemet och skyddandet av rapporteringssystemet. / Flight safety relies on trust between the person and the organization. There is a deficiency in the Swedish armed forces reporting system whereas the distribution between human factor reports and other reports is deviant from the normal distribution in flying operations. Why is that? A perspective that could help explaining this is the just culture perspective. The purpose of this essay is to discus whether the uneven distribution in the reporting system in regards of human error in the Swedish armed forces can be explained by a just culture perspective in regards of rules and documents. The result is that the Swedish armed forces are not considered a just culture. Mainly because of the insufficient foundation of the flight safety culture, the existence of a disciplinary system and the failure to protect the reporting system.

Šiame dokumente aprašytas darbas susideda ir trijų pagrindinių dalių. Pirmojoje, inžinerinėje dalyje atlikome vizitų registravimo sistemos (toliau - „PharmaCODE“) analizę ir projektavimą. Čia pateikėme esmines verslo aplinkos, reikalavimų ir konkurentų analizės, o taipogi ir projektavimo detales. Pateikėme pagrindinius architektūrinius sprendimus. Antrojoje darbo dalyje aprašėme sistemos kokybės tyrimus, naudojant statinės išeities kodų analizės įrankius ir metodus. Šioje dalyje aprašėme kokius įrankius naudojome ir pateikėme pagrindinius kodo analizės rezultatus. Trečiojoje darbo dalyje gilinomės į išeities tekstų analizės metodus ir įrankius, sukūrėme patobulintą analizės taisyklę. Mūsų taisyklės pagalba pavyko aptikti daugiau potencialių SQL-įterpinių saugumo spragų nei aptiko jos pirmtakė – Microsoft projektuota kodo analizės taisyklė. / This work consists of three major parts. First – engineering part – is analysis and design of call reporting system (codename – “PharmaCODE”). We will provide main details of business analysis and design decisions. Second part is all about testing and ensuring system quality, mainly by means of static source code analysis tools & methods. We will describe tools being used and provide main results of source code analysis in this part. And finally, in the third part of this we go deeper into static source code analysis and try to improve one of analysis rules. These days, when there is plenty of evolving web-based applications, security is gaining more and more impact. Most of those systems have, and depend on, back-end databases. However, web-based applications are vulnerable to SQL-injection attacks. In this paper we present technique of solving this problem using secure-coding guidelines and .NET Framework’s static code analysis methods for enforcing those guidelines. This approach lets developers discover vulnerabilities in their code early in development process. We provide a research and realization of improved code analysis rule, which can automatically discover SQL-injection vulnerabilities in MSIL code.