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The complexity of the modern systems providing health care presents a unique challenge in delivering care of the required quality in a safe environment. Issues of safety have been thrust into the limelight because of adverse events highly publicized in the general media. In the United States of America, improving the safety and quality in health care has been set forth as a priority for improvements in the 21st century in the report from the Institute of Medicine. Many measures have now been initiated for improving the safety of patients at hospital, regional, and national level, and through initiatives sponsored by governments and private organizations. In this review, we summarize known concepts and current issues on the safety of patients, and their applicability to children with congenital cardiac disease. Prior to examining the issues of medical error and safety, it is important to define the terminology. An error is defined as the failure of a planned action to be completed as intended, also known as an execution error, or the use of a wrong plan to achieve an aim, this representing a planning error. An active error is an error that occurs at the level of the frontline operator, and the effects of which are felt immediately. A latent error is an error in the design, organization, training and maintenance, that leads to operator errors, and the effects of which are typically dormant in the system for lengthy periods of time. Latent errors may cause harm given the right circumstances and environment. An adverse event is defined as an injury resulting from medical intervention. A preventable adverse event is an adverse event that occurs due to medical error. Negligent adverse events are a subset of preventable adverse events where the care provided did not meet the standard of care expected of that practitioner. The study of improving the delivery of safe care for our patients is a rapidly growing field. Important components for development of programmes to improve the safety of patients include the leadership for the programme, the implementation of process design based on human limitations, the promotion of teamwork and function, the anticipation of unexpected events, and the creation of a learning environment. Much is yet to be learned about the risk and incidence of adverse events during hospitalization of children with congenital cardiac disease. Errors due to human factors, such as poor communication, poor coordination, and suboptimal team work, have shown to be important causes of adverse outcomes in children undergoing cardiac surgery, and should be a focus for improvement. Future research on evaluating causes and prevention of medical errors and adverse events in this population at high risk, and consuming high resources, is essential. Issues of inadequate safeguards for patients have been prominent in the media, and have been highlighted in reports from the Institute of Medicine. Our review discusses research on the causes of medical error, and proposes concepts to design successful programmes to improve safety for the patients on a local level.

Background: It is important to ensure a patient-safe environment in the perioperative setting. With this in mind, a "patient-safety first" philosophy was adopted within our operating room service., Methods: During the first phase of the interventional study (2001-2002), we defined and executed the organizational and educational aspects of the intervention. Thereafter, the implementation phase (2003-2005) was performed. According to our zero tolerance policy, in the event that a major error in patient readiness for anesthesia and surgery was found in the operating room holding area, the patient would be returned to the parent department ("failure") and the surgical procedure delayed until the major error was corrected., Results: The data of 15,856 patients were recorded. During the 3-yr implementation period, 112 patients (0.71%) were returned to the department. A statistically significant (P < 0.002) reduction in major errors was recorded when comparing the year 2003 to the years 2004 and 2005 (1.04, 0.59, and 0.49% for the years 2003, 2004, and 2005, respectively). Furthermore, stepwise logistic regression demonstrated a time-dependant significant decrease in the incidence of a major error that resulted from inadequate patient preparation (odds ratio = 1.48, 95% CI: 1.16-1.87). In addition, the mean time between failures was 6.6, 11.2, and 14.7 days for the years 2003, 2004, and 2005, respectively (P < 0.03). Finally, a significant (P < 0.0001) improvement in patient preparation over time, as well as the overall probability that the patient preparation score = 100% (P < 0.001), were demonstrated., Conclusions: Education and increased awareness can decrease perioperative errors. However, even with a carefully designed policy in place, an error-free environment was not achieved. Therefore, monitoring and system analysis should be performed on a continuing basis.

Purpose: The challenges of health care; its safety, effectiveness, and efficiency; the quality of care; and the outcomes patients experience are issues central to nursing practice. This centrality needs to be affirmed as the profession shapes its practice over the next 50 years. The purpose of this article is to initiate a dialogue on the future of nursing practice., Methods: The methods used are observation, reflection, dialogue, and proposed actions., Findings: The results of this process are preliminary. They suggest that the establishment of nursing hospitals is a distinct possibility., Conclusions: This article concludes with a series of arguments for and against this position along with an invitation for your participation in this dialogue., Nursing Implications: The major implications of this article are not "nursing" implications per se but client and patient implications and the future contribution of nursing to improved health and patient care.

Objectives: The aim of this paper was to analyze the impact of economic growth measured by real gross domestic product (GDP) on the incidence of occupational injuries in Austria., Methods: The relationship between GDP and the occupational injury rate of the wage-earning population between 1955 and 2004 was analyzed using an error correction model. The sample size increased from 1.568,371 persons in 1955 to 2.656,952 in 2004. Occupational injuries were divided into fatal and non-fatal injuries., Results: Occupational injuries (fatal and non-fatal) decreased from 8.59% to 4.08%: non-fatal injuries decreased from 8.56% to 4.07%; fatal injuries decreased from 0.03% to 0.01%. Austrian GDP increased from EUR 37.7 billion to EUR 202.8 billion (base year 1995). Statistical analysis clearly shows that a growing economy is associated with declining injury rates (fatal and non-fatal). Two mechanisms are discussed. Firstly, rising GDP is accompanied by greater investment in safer technologies and occupational safety measures. Secondly, booming economies are associated with a reduced risk of unemployment, which is already known to be a risk factor for occupational injuries., Conclusions: Economic development appears to have an impact on the incidence of occupational injuries in Austria. Health policy should emphasize the necessity for safety at work particularly in phases of economic slowdown.

Despite the availability of resources and practices that would reduce work-related morbidity and mortality in the construction industry, their diffusion to workers has been slow, partly because the ties between management and trade workers are weak. In promoting an innovation, it is necessary to target the stakeholders who will be making the decisions related to it. The authors' focus is on ergonomics, but their observations may be applied more broadly to other areas of intervention-effectiveness research.

The European waste sector is undergoing a period of unprecedented change driven by business consolidation, new legislation and heightened public and government scrutiny. One feature is the transition of the sector towards a process industry with increased pre-treatment of wastes prior to the disposal of residues and the co-location of technologies at single sites, often also for resource recovery and residuals management. Waste technologies such as in-vessel composting, the thermal treatment of clinical waste, the stabilisation of hazardous wastes, biomass gasification, sludge combustion and the use of wastes as fuel, present operators and regulators with new challenges as to their safe and environmentally responsible operation. A second feature of recent change is an increased regulatory emphasis on public and ecosystem health and the need for assessments of risk to and from waste installations. Public confidence in waste management, secured in part through enforcement of the planning and permitting regimes and sound operational performance, is central to establishing the infrastructure of new waste technologies. Well-informed risk management plays a critical role. We discuss recent developments in risk analysis within the sector and the future needs of risk analysis that are required to respond to the new waste and resource management agenda.

The quality and safety movement in surgical specialty practice is gaining momentum. On the basis of risk-adjusted outcomes of coronary artery surgery and the improved risk assessment in the Veterans Affairs system, a growing array of surgical specialists has focused on recognition of legitimate risk factors, identification of performance measures that are valid surrogates for better practices, and refinement of risk-adjusted outcomes. Recognition of educational needs, personal practice patterns, and systems deficiencies now permits a broad-based application of long-standing primarily medical issues to elective surgical procedures in an organized and Integrated fashion. Approximately 85,000 patients per day undergo elective operations in the United States. A platform based on physician involvement and leadership has been tested in the Surgical Care Improvement Project, funded by a subcontract from the Centers for Medicare and Medicaid Services. This effort has defined factors worthy of further verification and provides a framework for an ethical and valid pay-for-performance scheme.

Background: Data are scarce that inform the ways consumers of health care and caregivers help improve the care that is delivered. The healthcare system is quite broad. To improve it, we first must understand it, understand its various subsystems, and understand how they shape individual behavior., Discussion: Both consumers and providers can effectively improve health care. An example of an influential consumer is provided, focusing a successful effort to improve care in the intensive care unit. The overall model for improving outcomes assumes providers can be classified into high-quality and low-quality providers. The model then aims to increase the number of people exposed to high-quality caregivers. There are three primary levers for driving this change: using market forces, provider improvements, and policy change. This article touches briefly on the first and focuses on the second and third., Conclusion: A number of grassroots programs highlight ways providers can improve care by approaching patient safety and quality as a science. In addition, the Josie King Act and its legislative progeny provide some hope that a new policy environment can reward and reinforce providers' efforts to drive up safety and quality.

Background: Inevitably, occupational epidemiologists must decide when and how to shift research attention and resources from investigations of old, established health hazards to a focus on newly emerging potential risk factors. As yet unknown occupational health consequences of burgeoning worldwide technologies, such as the microelectronics industry, and increasing recognition of the importance of common, yet non-traditional occupationally-related health effects, such as musculoskeletal disorders in office workers, give strong impetus for embarking in new directions. However, there remains much to be learned from continued investigation of well-established occupational hazards, such as asbestos, benzene, and lead., Objectives: A rational strategy for planning future research will need to consider optimizing resources., Conclusions: The following suggestions are offered. 1) First and foremost, occupational risk factors are most directly, and arguably most validly, identified by studying workers in well-defined cohorts, ideally when exposures are adequately characterized. To this end, industry-based cohort studies should be given priority, at least for older hazards, over population-based case-control and surveillance designs. 2) Defined cohorts with extensive exposure and health outcome data should continue to be followed, as resources permit; 3) Launching cohort studies for potential new hazards should incorporate extensive exposure assessments at the outset, and should preferentially select inception cohorts of newly hired workers. Valid biomarkers of pre-clinical disease will be especially valuable in this regard. 4) Capitalizing on new technological advances in exposure assessment, clinical medicine, molecular genetics should be encouraged

The successful leader and manager have two very important challenges: to scan the horizon and not be thrown into crisis by not seeing predictable surprises, and to recognize the longer, more pervasive trends that are in the distant future. An annual autopsy of the past year and a review of the years ahead will not only fulfill the requirements for an annual report, but will be a learning experience for the team. When we are open to new ideas, lead by inviting dialogue rather than demanding, and openly trust, believe in, and inspire others, the organization will also adopt these values as its operating framework. Our annual plans will then be living documents that create the roadmap for excellence.

Present-day public hospitals are often lacking in humanity, costing more and doing less, and run by executive staff with minimal clinical knowledge.

In this article an overview of the historical development of light water reactor health physics programs is presented. Operational health physics programs have developed and matured as experience in operating and maintaining light water reactors has been gained. Initial programs grew quickly in both size and complexity with the number and size of nuclear units under construction and in operation. Operational health physics programs evolved to face various challenges confronted by the nuclear industry, increasing the effectiveness of radiological safety measures. Industry improvements in radiological safety performance have resulted in significant decreases in annual collective exposures from a high value of 790 person-rem in 1980 to 117 person-rem per reactor in 2002. Though significant gains have been made, the continued viability of the nuclear power industry is confronted with an aging workforce, as well as the challenges posed by deregulation and the need to maintain operational excellence.

In 2005, the Health Physics Society celebrates its 50th anniversary. During its half century of existence, the Society has evolved from a small group of operationally oriented radiation protection scientists into an organization of several thousand with a recognized and respected peer reviewed journal. The bold decision to form an organization devoted to radiation safety in the United States spurred the formation of such societies in other countries and led to the formation of an international confederation of national societies, which has facilitated scientific communication and exchange worldwide. It also led to the formation of a separate body for the certification of health physicists, which in turn has grown into an academy with more than 1,000 members, and was instrumental in providing basic information establishing the need for a registry of radiation protection technologists.

A spatially implemented model designed to assist the identification of optimal countermeasure strategies for radioactively contaminated regions is described. Collective and individual ingestion doses for people within the affected area are estimated together with collective exported ingestion dose. A range of countermeasures are incorporated within the model, and environmental restrictions have been included as appropriate. The model evaluates the effectiveness of a given combination of countermeasures through a cost function which balances the benefit obtained through the reduction in dose with the cost of implementation. The optimal countermeasure strategy is the combination of individual countermeasures (and when and where they are implemented) which gives the lowest value of the cost function. The model outputs should not be considered as definitive solutions, rather as interactive inputs to the decision making process. As a demonstration the model has been applied to a hypothetical scenario in Cumbria (UK). This scenario considered a published nuclear power plant accident scenario with a total deposition of 1.7x10(14), 1.2x10(13), 2.8x10(10) and 5.3x10(9)Bq for Cs-137, Sr-90, Pu-239/240 and Am-241, respectively. The model predicts that if no remediation measures were implemented the resulting collective dose would be approximately 36 000 person-Sv (predominantly from 137Cs) over a 10-year period post-deposition. The optimal countermeasure strategy is predicted to avert approximately 33 000 person-Sv at a cost of approximately 160 million pounds. The optimal strategy comprises a mixture of ploughing, AFCF (ammonium-ferric hexacyano-ferrate) administration, potassium fertiliser application, clean feeding of livestock and food restrictions. The model recommends specific areas within the contaminated area and time periods where these measures should be implemented.

This short paper describes a number of investigations carried out to ensure preparedness for crises involving radioactivity to catering operations and private households in Finland. The specific recommendations for catering kitchens during crises were published in 1994. A study to determine the level of adherence to these recommendations is summarised here, together with its findings and subsequent recommendations. Another study on the pre-planning of crisis menus is described. New challenges for the catering kitchens are touched upon. A crisis food preparation booklet for households is described and based on consumers' attitudes suggestions are made for how this can be improved in the future.

Both the farm-specific and regional costs of clean feeding as a countermeasure to reduce ingestion of contaminated grass when there is insufficient supply of other types of roughage were estimated for dairy farming in Finland in the first year after contamination. The cost estimation considered expenditures and revenues associated with milk production and were calculated using farm models developed for economic planning. A hypothetical contamination scenario was designed using RODOS models for atmospheric dispersion and transfer in terrestrial food chains. Costs for intervention after two similar hypothetical atmospheric dispersion and deposition scenarios in early June and in July were estimated. As a reference, the cost of complete replacement of fodder throughout the area was also calculated. Feed substitution costs were higher in June than in July, due to the availability of some harvested silage in the later scenario. In the first case, the additional costs of clean feeding amounted to one-fifth of the normal production costs. Effective advisory/support services, available to farmers, can substantially improve the implementation of countermeasures. However, high costs and insufficient sources of clean feed would restrict the use of clean feeding as the sole countermeasure after serious contamination during the growing season.

The Chernobyl accident led to a long-term crisis that affected agriculture, food and living conditions in complex ways, and that modified the usual economical, political and social relations between public and private stakeholders at local, national and international level. The EC FARMING project aims to create a European stakeholder network to consider possible rehabilitation strategies for rural areas contaminated after a nuclear accident. The Institute of Patrimonial Strategies of the National Institute on Agronomy had responsibility for setting up the French stakeholder group. The objective was to develop favourable conditions and ways whereby stakeholders could deal with such a complex situation as a nuclear emergency and develop rehabilitation strategies. The results from the 3-year work programme on both strategic and technical aspects, showed an increasing commitment from the stakeholders that led to the building up of a common understanding of what a nuclear accident could be and how it could be dealt with.

In the case of radioactive contamination of the environment with an impact on the food chain, the remediation strategy will not only be based on scientific knowledge and technical experience, but will also be dictated by peculiarities of the country. These characteristics include the agro-industrial structure, the local and international economical contexts and the political configuration including the distribution of responsibilities and competencies. This paper identifies and illustrates the most relevant characteristics of the Belgian agricultural system and political environment; it also describes the past experience with food chain contamination, which is expected to influence the attitude of Belgian stakeholders, who would be involved in the setting up of countermeasure strategies for maintaining agricultural production and food safety. The picture drawn explains why several countermeasures aiming to reduce the contamination in food products, although scientifically sound and technically feasible, are hardly acceptable or even not acceptable at all, to the stakeholders.

An expert group was established in 2001 representing various organisations and authorities responsible for primary production, food processing, the distribution and consumption of foodstuffs, food safety and availability, catering and extension services, nature conservation, research into environmental impacts, and the media. The aim was to strengthen networking and improve the stakeholder response to accidental radioactive contamination of rural areas through participation in the FARMING network project. A hypothetical contamination of a large milk-producing area provided a suitable framework for evaluation of actions ensuring clean feeding of dairy cows during grazing. The following year the group received a compilation of rural countermeasures and waste disposal methods, described by the STRATEGY project. The robust, uncomplicated approach of the evaluation meetings was fruitful and efficient, and the multidisciplinary group was capable of taking shared views on various measures after updating their knowledge together. High priority was given to measurements of radioactivity and the provision of information and advice to a wider audience.

The EC FARMING network (Food and Agriculture Restoration Management Involving Networked Groups) was set up to bring together the many and diverse stakeholders who would be involved in intervention following wide scale radioactive contamination of the food chain, so that acceptable strategies can be developed for maintaining agricultural production and safe food supply. The network comprises stakeholder panels in the UK, Finland, Belgium, France and Greece that have met regularly since 2001 to debate, discuss and exchange opinion on the acceptability, constraints and impact of various countermeasure options and strategies. The objectives of this paper are to consolidate the main achievements of the FARMING project over the period 2000-2004, to highlight the various difficulties that were encountered and to discuss the challenges for engaging stakeholders in off-site emergency management and long-term rehabilitation in the future.

The importance of major stakeholders participating in the formulation of strategies for maintaining food safety and agricultural production following a nuclear accident has been successfully demonstrated by the UK 'Agriculture and Food Countermeasures Working Group' (AFCWG). The organisation, membership and terms of reference of the group are described. Details are given of the achievements of the AFCWG and its sub-groups, which include agreeing management options that would be included in a recovery handbook for decision-makers in the UK and tackling the disposal of large volumes of contaminated milk, potentially resulting from a nuclear accident.

The STRATEGY project (Sustainable Restoration and Long-Term Management of Contaminated Rural, Urban and Industrial Ecosystems) aimed to provide a holistic decision framework for the selection of optimal restoration strategies for the long-term sustainable management of contaminated areas in Western Europe. A critical evaluation was carried out of countermeasures and waste disposal options, from which compendia of state-of-the-art restoration methods were compiled. A decision support system capable of optimising spatially varying restoration strategies, that considered the level of averted dose, costs (including those of waste disposal) and environmental side effects was developed. Appropriate methods of estimating indirect costs associated with side effects and of communicating with stakeholders were identified. The importance of stakeholder consultation at a local level and of ensuring that any response is site and scenario specific were emphasised. A value matrix approach was suggested as a method of addressing social and ethical issues within the decision-making process, and was designed to be compatible with both the countermeasure compendia and the decision support system. The applicability and usefulness of STRATEGY outputs for food production systems in the medium to long term is assessed.

The public's reaction to life threatening situations is determined by a variety of factors. In the case of nuclear accidents, the panic experienced by citizens may be reasonably justified. This paper briefly describes the parameters that cause panic reactions from a consumer's point of view and summarizes citizen's demands concerning nuclear crisis management.

In this article an overview of the historical development of light water reactor health physics programs is presented. Operational health physics programs have developed and matured as experience in operating and maintaining light water reactors has been gained. Initial programs grew quickly in both size and complexity with the number and size of nuclear units under construction and in operation. Operational health physics programs evolved to face various challenges confronted by the nuclear industry, increasing the effectiveness of radiological safety measures. Industry improvements in radiological safety performance have resulted in significant decreases in annual collective exposures from a high value of 790 person-rem in 1980 to 117 person-rem per reactor in 2002. Though significant gains have been made, the continued viability of the nuclear power industry is confronted with an aging workforce, as well as the challenges posed by deregulation and the need to maintain operational excellence.

By the GIS technology, this paper studied the impact of groundwater resource temporal-spatial change in the lake area of Minqin Oasis on the ecological security of irrigation region landscape. The results showed that the depth of groundwater was descending continuously, the velocity of groundwater line change in the center of irrigation region was faster than that in the edge region, and consequently, the area of the descending funnel of groundwater line was enlarged. From 1987 to 2001, the area with a groundwater depth deeper than 3 m was increased from 81.2% to 97.4%. The descending of groundwater line due to soil water reducing was the main reason that resulted in the destruction and deadness of forests. When the depth of groundwater was deeper than 8 m and soil water content was less than 12%, the die-back rate of tree was morn than 90%, and that of shrub was more than 50%. Impacted by the descend of groundwater depth, the area of forest land, shrub land and open-canopy land was decreased by 67%, 54% and 31%, and the number of their patches was decreased by 35, 42 and 50, respectively. The mineralization degree of groundwater in northern irrigation region increased obviously, and changed the safe pattern of crop growth. The benefit of agriculture decreased, and the adjustment of planting construction was restricted seriously, which became the main impact factor on the ecological security of irrigation region. Reasonably distributing water resource between upper and lower river basin, reducing unreasonable land use, decreasing farmland area, and constructing safety landscape pattern could lead to the balance between the exploitation and replenishment of groundwater resource, prevent the descend of groundwater depth and the increase of groundwater mineralization, and improve the ecological security of the irrigation region.

How much progress has the health care field made in its patient safety endeavors in the five years since "To Err Is Human" sparked major headlines and soul-searching?

The occupational safety and health management system(OSHMS)has been introduced into many companies and factories in Japan. However, there are certain factories that are considering the introduction of OSHMS, while other factories are not interested in it. In the factories which have introduced OSHMS, occupational health activities are still insufficient. Passage by which OSHMS was introduced into Japan and a basic way to advance OSHMS is described in this paper. In addition, for OSHMS to spread to many companies in the future, and to achieve good results, the themes and prospects which should be examined are described. The themes shown in this paper are as follows: risk assessment, revision of the law and regulation, system auditing, individual management of safety and health rules, evaluation of the low concentration exposure influence, appropriate job suitability system, training of the expert, the support organization, supporting small and medium-sized scale factories.

The predecessor organizations of the National Council on Radiation Protection and Measurements (NCRP) were established in 1929 (the U.S. Advisory Committee on X-Ray and Radium Protection) and in 1946 (the National Committee on Radiation Protection and Measurements). In 1964, the NCRP was formally chartered by the U.S. Congress as a national resource for scientific guidance on issues related to radiation measurements and health protection. In this paper the history and scientific contributions of NCRP are reviewed, followed by a discussion of its evolving mission and future scientific goals.

For the past ten years, a real improvement in knowledge and methods concerning blood transfusion safety has been made. In this observation, concerning a polytraumatism patient who received massive blood transfusion with no immunologic nor infectious complications occurring one year later, brings evidence of real progress on blood transfusion safety for improvement in short and long term prognosis for polytransfused patients., (Copyright John Libbey Eurotext 2003.)

Possibly two of the greatest challenges of a radiation safety program are to ensure that all regulatory requirements are being met and to involve the users in maintaining compliance. At the Fred Hutchinson Cancer Research Center (FHCRC), the radiation safety office has developed an audit program that accomplishes these two challenges for the FHCRC ionizing radiation safety program, which has resulted in quality improvements in the laboratory environment and culminated in an excellent State inspection.