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How clinicians detect and differentiate near misses from adverse events in health care is poorly understood. This study adopted a constructivist grounded theory approach and utilized document analysis and semi-structured interviews with 24 managers (middle and senior) and clinicians to examine the processes and factors associated with recognizing and recovering and learning from near misses in daily clinical practice. While safety science suggests that near misses are sources of learning to guide improvement efforts, the study identified how clinicians and managers cognitively downgrade and accept near misses as a routine part of daily practice. Such downgrading reduces the visibility of near misses and creates a paradoxical effect of promoting collective vigilance and increased safety while also encouraging violations in clinical practice. Three approaches to correcting and/or learning from near misses emerged: “doing a quick fix,” “going into the black hole,” and “closing off the swiss-cheese holes”; however, minimal organizational learning occurs. From these findings, two key paradoxes that undermine organization-level learning require further attention: (a) near misses are pervasive in everyday practice but many remain undetected and are missed learning opportunities, and (b) collective vigilance serves as both safety net and safety threat. Study findings suggest that organizational efforts are required to determine which near misses need to be reported. Organizations need to shift the culture from one of “doing a quick fix” to one that learns from near misses in daily practice; they should reinforce the benefits and reduce the risks of collective vigilance, and further encourage learning at the clinical microsystem level. Future research is required to provide insight into how individual, social, and organizational factors influence the recognition, recovery, and instructional value of near misses and safety threats in health care organizations’ daily practice.

Fault tree analysis, FTA, is one of the most commonly used techniques for safety system assessment. Over the past five years the Binary Decision Diagram (BDD) methodology has been introduced which significantly aids the analysis of the fault tree diagram. The approach has been shown to improve both the efficiency of determining the minimal cut sets of the fault tree, and also the accuracy of the calculation procedure used to quantifY the top event parameters. To utilise the BDD technique the fault tree structure needs to be converted into the BDD format. Converting the fault tree is relatively straightforward but requires the basic events of the tree to be placed in an ordering. The ordering of the basic events is -critical to the resulting size of the BDD, and ultimately affects the performance and benefits of this technique. There are a number of variable ordering heuristics in the literature, however the performance of each depends on the tree structure being analysed. These heuristic approaches do not always yield a minimal BDD structure for all trees, some approaches generate orderings that are better for some trees but worse for others. Within this thesis three pattern recognition approaches, that of machine learning classifier systems, multi-layer perceptron networks and radial basis function neural networks, have been investigated to try and select a variable ordering heuristic for a given fault tree from a set of alternatives. In addition a completely new heuristic based on component structural importance measures has been suggested with significant improvement in producing the smallest BDD over those methods currently in the literature.

Modern composite steel frame structures possess a high degree of redundancy. This allows them to survive extreme fires without collapse as there are many alternative loadpaths which can be used to transfer load away from the fire affected part of the structure as demonstrated in the Broadgate fire. Subsequent tests carried out on the Cardington frame showed that it was not necessary to apply fire protection to all steel beams. It was possible to leave selected secondary beams without fire protection. In the event of a fire this results in large deflections due to thermal expansion and material degradation, however, in a fire where servicability requirements do not need to be met this is acceptable so long as life safety is ensured. The weakening beams and large deflections result in a change in the load transfer mechanism with load being carried through tensile membrane action in the slab. This thesis presents a method for calculating the membrane load capacity of composite floor slabs in fire. Extensive numerical modelling at the University of Edinburgh has shown that the temperature distribution through a structural member greatly effects the deflection and pattern of internal stresses and strains. Theoretical solutions were produced to calculate the structural response of laterally restrained beams and plates subject to thermal loads. The theoretical deflections and internal forces were shown to compare well with those from numerical models. To determine the membrane load capacity of concrete floor slabs in fire a three-stage design method was developed. Initially the temperature distribution through the slab was calculated for the design fire. From this the deflection of the slab and resulting stress and strain distributions in the steel reinforcement due to the thermal loads were calculated for the design fire. From this the deflection of the slab and resulting stress and strain distributions in the steel reinforcement due to thermal loads were calculated using equations from the theory developed previously. Failure of the slab was defined based on a limiting value of mechanical strain in the reinforcement, this strain corresponded to a limiting deflection. The load capacity of the slab at the limiting deflection was calculated using an energy method. When compared against results from numerical models the ultimate load capacity was shown to be accurately predicted. None of the fire test carried out on the Cardington structure reached failure. Although demonstrating the inherent strength of such buildings this was also a major short coming as it was not possible to define the point of failure. the design method developed was used to calculate the membrane laod capacity of four of the six Cardington tests. All four tests were shown to have had a significant reserve capacity with none being close to failure.

Driven by research studies and national targets, sedation practices in Intensive care Units (ICU) are undergoing change. Traditionally, ventilated patients in ICUs were kept deeply sedated and only gradually ‘weaned off’ sedation. However, current evidence supports a more ‘wakeful’ patient with the introduction of ‘sedation holds’ encouraging them to regain consciousness (Kress et al. 2000). There is little research exploring ICU nurses’ assessment and management of sedation. Employing a Heideggerian, hermeneutic phenomenological approach to enquiry, the study sought to provide insights into the world of the critical care nurse, nursing with technology, and specifically their beliefs surrounding sedation practices and how organisational factors, knowledge and personal experiences influence their clinical decisions in the care of the ventilated patient. The setting was the Royal Infirmary of Edinburgh, ICU and the purposive sample consisted of 16 ICU nurses with diverse critical care nursing experience. Bedside interviews, utilising an aide memoir, elicited narratives about the nurses’ experiences of sedation practice and a novel sedation monitor (responsiveness). The phenomenological analysis drew upon a number of existing frameworks to guide enquiry. The researcher engaged with the ‘hermeneutic circle’, acknowledging her pre-understandings and using these as a platform to move between the whole of the research and the parts, the descriptions and narratives offered, to develop new knowledge. Themes emerged that demonstrated patients’ sedation status directly impacted upon the nurses’ ICU lived experiences and left them in a state of disequilibrium regarding the requirement to deliver research based care, the desire to deliver holistic care and the duty to deliver safe care. The nurses perceived sedation holds and ‘wakefulness’ as resulting in patient agitation and distress which affected patient safety and comfort. However, the nurses equally felt a pressure of obligation to the doctors to perform such evidence based sedation holds. They described the struggling to maintain patient safety and manage their own fears and anxieties and organisational constraints, whilst experiencing guilt, blame and failure associated with their behavioural discordance with the prescribed decisions and their own clinical decision making processes and strategies. Team work between the two professions and effective leadership is evidently less than ideal. Consequently the implementation of changes in sedation practice is failing to meet either the national targets or to respond to the nurses’ concerns regarding their patient’s short term wellbeing. On both counts this potentially impairs the pursuit of best practice.

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Master of Science / Department of Kinesiology / Katie M. Heinrich / Firefighting is an inherently dangerous occupation with high rates of injuries and fatalities, with the majority of line of duty fatalities due to cardiovascular events. Additionally, firefighters struggle with poor health and low levels of fitness, including very high (>80%) rates of overweight and obesity likely related to the culture of the fire service. Limited resources exist for fire departments that are sensitive to the culture and work requirements of these “tactical athletes”. Though there has been increasing interest in circuit-type high intensity exercise training programs, key research data are lacking for the firefighter population and few studies have focused on training firefighter recruits. PURPOSE: The purpose of this pilot investigation was to examine a novel physical training program on fire academy recruits’ health, fitness, and performance, in addition to examining the programs’ acceptability, feasibility, and future efficacy. METHODS: Thirteen participants were recruited from an entry level fire academy and were randomly assigned to either the control (CG, n=6) or intervention exercise group (TF20, n=7). Due to attrition within the first two weeks of the study, 10 male fire recruits (23±3 years) completed the study (CG, n=3, TF20, n=7). The CG were asked to continue their current exercise habits. TF20 were provided an online-based training program (The First 20) that included periodized workouts, nutritional information, and mental readiness education. All participants completed baseline and post-intervention assessments and 10-weeks of exercise training. Health assessments included resting and post-exercise heart rate and blood pressure and estimated VO₂[subscript]max. Anthropometric measures included height, weight, % body fat, % lean mass, and BMI. Performance was measured using the Candidate Physical Ability Test (CPAT). Psychosocial measures were assessed by a short questionnaire. A feasibility analysis was also completed for those in TF20 group. Due to the small sample size and group differences at baseline, descriptive statistics were calculated and each participant was reviewed as an individual case study. The Wilcoxon Signed Rank Test was used to test for significance among TF20 group. RESULTS: This pilot investigation provided effect sizes and parameter estimates necessary for the design of a larger randomized controlled trial. Even with a small sample size, TF20 group showed improvement on numerous outcome measures including CPAT performance (40% passing at baseline to 86% passing post-intervention). Of five TF20 participants completing the CPAT at baseline and post-intervention, four improved their passing time. TF20 participants significantly increased estimated VO₂[subscript]max (p=0.028) and significantly improved body composition (decreased fat mass (kg) and % fat mass, p=0.028). TF20 participants also significantly improved grip strength (p=0.018). The CG saw no statistically significant differences from baseline to post-intervention. TF20 group completed approximately 75% of the assigned workouts. Participants reported enjoying the workouts and stated a program like this should be offered for fire academy recruits in the future. CONCLUSION: While TF20 participants showed significant fitness gains, the small sample size limited comparisons to the control group or other covariates. TF20 program was well-received although there may be a better way to implement the intervention to increase participation. Participants mentioned they would like group workouts led by a certified strength and conditioning coach/peer fitness trainer as opposed to self-guided workouts. This investigation provides promising results for the efficacy of high-intensity training programs in firefighter recruits. Additionally, this study provides alternative guidance for exercise prescription designed specifically for the firefighter population.

In the Kingdom of Saudi Arabia, there has not been a systematic effort to evaluate the problems of medical error and patient safety as critical issues in healthcare organizational ethics. This dissertation aims to pursue the impact of the original IOM report on this crucial topic by adopting what have been done in the American healthcare system in order to gain insight for the Saudi Arabian healthcare system. This dissertation examines the functions of continuous quality improvement in the healthcare environment of Saudi Arabia through the lens of the organization’s moral agency. This dissertation identifies several areas in Saudi healthcare organizations that are in need of improvement. As a result, this paper makes several recommendations that systematically address patient safety and medical error so that the system can be free from adverse events and medical errors. This dissertation argues that Saudi healthcare organizations have an ethical responsibility to continuously improve the system of healthcare in order to enhance patients’ safety and to reduce medical errors. This dissertation also recommends that Saudi health organizations foster a culture of safety as part of their ethical responsibility toward the customers they serve. Therefore, Saudi healthcare organizations should have an active, anonymous, and confidential reporting system; an open communication and collaboration between healthcare professionals; and create a non-punitive system. In addition, this dissertation argues in favor of patients’ involvement in the treatment process, and for having an ethics committee in Saudi healthcare organizations. / McAnulty College and Graduate School of Liberal Arts; / Health Care Ethics / PhD; / Dissertation;

Naval Aviation has been known for over half a century as being one of the most fascinating professions. Although aircrew may always play a role in the mishap rate, the Navy has shifted its focus to aviation maintenance safety climate as a possible indicator of a future mishap. The School of Aviation Safety developed and implemented a survey, the Maintenance Climate Assessment Survey (MCAS), to assess the safety climate of Naval Aviation squadrons. Researchers have begun reviewing the possible direct relationship between the maintainer, how they view their squadron's climate and aviation mishaps. This thesis examines the construct of squadron maintenance safety climate survey and its relationship to aviation mishaps. The raw data employed includes MCAS responses from 126,058 maintainers between August 2000 and August 2005. This study finds that the MCAS survey construction needs to be revised. The findings are substantial to verify that most questions are formulated to focus on the same factor. Since the survey requires reconstruction, the question of whether it can determine the likelihood of mishaps was never visited. Revising the survey, based on psychometrics, may produce more significant results and gauge maintenance safety climate based on separate and distinct factors.