Online patient feedback as a safety valve: An automated language analysis of unnoticed and unresolved safety incidents

Safety reporting systems are widely used in healthcare to identify risks to patient safety. But, their effectiveness is undermined if staff do not notice or report incidents. Patients, however, might observe and report these overlooked incidents because they experience the consequences, are highly motivated, and independent of the organization. Online patient feedback may be especially valuable because it is a channel of reporting that allows patients to report without fear of consequence (e.g., anonymously). Harnessing this potential is challenging because online feedback is unstructured and lacks demonstrable validity and added value. Accordingly, we developed an automated language analysis method for measuring the likelihood of patient-reported safety incidents in online patient feedback. Feedback from patients and families (n = 146,685, words = 22,191,427, years = 2013–2019) about acute NHS trusts (hospital conglomerates; n = 134) in England were analyzed. The automated measure had good precision (0.69) and excellent recall (0.98) in identifying incidents; was independent of staff-reported incidents (r = −0.04 to 0.19); and was associated with hospital-level mortality rates (z = 3.87; p < 0.001). The identified safety incidents were often reported as unnoticed (89%) or unresolved (21%), suggesting that patients use online platforms to give visibility to safety concerns they believe have been missed or ignored. Online stakeholder feedback is akin to a safety valve; being independent and unconstrained it provides an outlet for reporting safety issues that may have been unnoticed or unresolved within formal channels.     

Examining Factors that Influence the Existence of Heinrich's Safety Triangle Using Site‐Specific H&S Data from More than 25,000 Establishments

In the 1930s, Heinrich established one of the most prominent and enduring accident prevention theories when he concluded that high severity occupational safety and health (OSH) incidents are preceded by numerous lower severity incidents and near misses. Seventy‐five years of theory expansion/interpretation includes two fundamental tenets: (1) the ratio of lower to higher severity incidents exists in the form of a “safety‐triangle” and (2) similar causes underlie both high and low severity events. Although used extensively to inform public policy and establishment‐level health and safety priorities, recent research challenges the validity of the two tenets. This study explored the validity of the first tenet, the existence of the safety triangle. The advantage of the current study is the use of a detailed, establishment‐specific data set that evaluated over 25,000 establishments over a 13‐year time period, allowing three specific questions to be explored: (1) Are an increased number of lower severity incidents at an establishment significantly associated with the probability of a fatal event over time? (2) At the establishment level, do the effects of OSH incidents on the probability of a fatality over time decrease as the degree of severity decreases—thereby taking the form of a triangle? and (3) Do distinct methods for delineating incidents by severity affect the existence of the safety triangle form? The answer to all three questions was yes with the triangle form being dependent upon how severity was delineated. The implications of these findings in regard to Heinrich's theory and OSH policy and management are discussed.     

Consumer Confidence in the Safety of Food and Newspaper Coverage of Food Safety Issues: A Longitudinal Perspective

This study develops a longitudinal perspective on consumer confidence in the safety of food to explore if, how, and why consumer confidence changes over time. In the first study, a theory-based monitoring instrument for consumer confidence in the safety of food was developed and validated. The monitoring instrument assesses consumer confidence together with its determinants. Model and measurement invariance were validated rigorously before developments in consumer confidence in the safety of food and its determinants were investigated over time. The results from the longitudinal analysis show that across four waves of annual data collection (2003–2006), the framework was stable and that the relative importance of the determinants of confidence was, generally, constant over time. Some changes were observed regarding the mean ratings on the latent constructs. The second study explored how newspaper coverage of food safety related issues affects consumer confidence in the safety of food through subjective consumer recall of food safety incidents. The results show that the newspaper coverage on food safety issues is positively associated with consumer recall of food safety incidents, both in terms of intensity and recency of media coverage.     

Behavioral Safety in the Food Services Industry: Challenges and Outcomes

During the course of a 6-year behavioral safety consult at a food and drink industry site, data were collected on the number of Occupational Safety Health Administration (OSHA) recordable incidents, number of lost and restricted days, and number of peer safety observations. Employees were trained to identify safe and unsafe behavior, conduct peer observations, and provide peer feedback. Data collected from observations were utilized to deliver graphic feedback. Managers were encouraged to review graphic feedback with employees weekly, provide prompts for observation, and praise employees for conducting observations. A committee composed of employees and managers met monthly to address safety concerns. Reductions in incidents were observed over the course of the behavioral safety intervention, but a reversal to baseline could not be implemented. A negative correlation was observed between number of peer observations and number of recordable incidents. Results suggest that when employees conduct peer observations more frequently, the number of recordable incidents decreases.     

Reduce rework,improve safety: an empirical inquiry into the precursors to error in construction

A positive association between rework and safety events that arise during the construction process has been identified. In-depth semi-structured interviews with operational and project-related employees from an Australian construction organisation were undertaken to determine the precursors to rework and safety events. The analysis enabled the precursors of error to examined under the auspices of: (1) People, (2) Organisation, and (3) Project. It is revealed that the precursors to error for rework and safety incidents were similar. A conceptual framework to simultaneously reduce rework and safety incidents is proposed. It is acknowledged that there is no panacea that can be used to prevent rework from occurring, but from the findings presented indicate that a shift from a position of ‘preventing’ to ‘managing’ errors is required to enable learning to become an embedded feature of an organisation’s culture. As a consequence, this will contribute to productivity and performance improvements being realised.     

The Implementation and Maintenance of a Behavioral Safety Process in a Petroleum Refinery

A values-centered and team-based behavioral safety process was implemented in a petroleum oil refinery. Employee teams defined the refinery's safety values and related practices, which were used to guide the process design and implementation. The process included (a) a safety assessment; (b) the clarification of safety-related values and related practices; (c) process design and executive overview; (d) safety-observation training; (e) feedback, recognition, and celebration; and (f) process maintenance. Data that span 20 years are presented to show the long-term impact on recordable incidents, lost-time cases, and direct costs of injuries. The implementation was associated with an 81% decrease in recordable incidents, a 79% decrease in lost-time cases, and a 97% savings in annual workers' compensation costs over an eight-year period. An interview with the vice president of the refinery is presented to highlight the process's influence on the refinery's safety culture.     

Assessing and Preventing Serious Incidents with Behavioral Science: Enhancing Heinrich’s Triangle for the 21st Century

ABSTRACT

The rate of occupational injuries has been declining annually, but the rate of decline for fatalities has not kept a similar pace. Behavior-based safety (BBS) contributes to reducing personal injuries, and can be applied to preventing serious incidents. To address serious injuries with greater confidence requires a change in perspective on the causes of fatalities and serious injuries. Heinrich’s safety triangle helps describe the ratio between minor incidents and major incidents, but is not adequate in helping to predict serious incidents. Adding a special subset to the safety triangle can assist safety practitioners in predicting and influencing such events. Extending the triangle to include more foundational root causes, such as leadership shortcomings and system failures, will expand the scope of the behavior analysis, and including greater specificity about the precursors to serious incidents will help the precision of the behavior analysis. The implications of the expanded triangle for amplifying the effectiveness of BBS for reducing serious incidents are discussed.     

Stakeholder Actions and Their Impact on the Organizational Cultures of Two Tobacco Companies

We link the behaviors of executives and lawyers in two tobacco companies, in defending their tobacco products to the actions of stakeholders (e.g., the U.S. Government and Congress, medical researchers, consumers, public‐health organizations, tobacco‐control advocates, and insiders who have spoken out). Included in our analysis, which is based on publicly available documents spanning over a period of almost six decades, are critical incidents in which moral disengagement tactics were applied in the decision‐making process. We infer that the disengagement tactics applied by tobacco decision makers are indicative of what Schein and other organizational scientists describe as organizational culture. We equate the critical incidents to the espoused beliefs and values and underlying assumptions which comprise organizational culture and explain that the cultures of these two tobacco companies are not consistent with the stakeholder theory of management. We conclude that the critical incidents we analyze were immoral and the representatives were indeed accountable for these behaviors. From an organizational change perspective, we discuss how analyzing these critical incidents can serve to assess the extent to which an organizational culture is ethical. Furthermore, these critical incidents can be fed back to organizational decision makers and can then be used to initiate organizational changes.     

Optimizing Risk Analysis Relating to External Safety in The Netherlands

Risk analyses in The Netherlands have been optimized so that they now express risks in a numerical form suitable for comparison to national safety standards. This factor is more important to national government than to local authorities; other factors relevant for local authorities are given less emphasis or even completely omitted from the results of the analysis. From a comparison of 16 risk analyses carried out during the last decade, it became clear that in the last 5 years the methods of risk analyses related to external safety have become unified. Results are now presented in terms of individual risk contours and in terms of F-N curves (accident frequency vs. exceeded number of fatalities). This unification seems to be a result of government policy. First, the implementation of the post-Seveso-directive (501/82/EC) in The Netherlands obliges a number of industries to provide the authorities with a quantitative risk assessment. Second, the government has set standards for the maximum permissible risk in residential areas. A unified type of risk analysis is a tool to achieve both these policies. From interviews with local government authorities, however, it has become clear that they need and use some quantitative risk information that is not provided by the unified analysis. They feel they need figures that provide insight into the effects of incidents and into the way effects may change as a result of safety measures. Ultimately, government policy may mean that local officials receive less information than before.     

Risk Management of Domino Effects Considering Dynamic Consequence Analysis

Domino effects are low‐probability high‐consequence accidents causing severe damage to humans, process plants, and the environment. Because domino effects affect large areas and are difficult to control, preventive safety measures have been given priority over mitigative measures. As a result, safety distances and safety inventories have been used as preventive safety measures to reduce the escalation probability of domino effects. However, these safety measures are usually designed considering static accident scenarios. In this study, we show that compared to a static worst‐case accident analysis, a dynamic consequence analysis provides a more rational approach for risk assessment and management of domino effects. This study also presents the application of Bayesian networks and conflict analysis to risk‐based allocation of chemical inventories to minimize the consequences and thus to reduce the escalation probability. It emphasizes the risk management of chemical inventories as an inherent safety measure, particularly in existing process plants where the applicability of other safety measures such as safety distances is limited.     

Managing Safety‐Related Disruptions: Evidence from the U.S. Nuclear Power Industry

Low‐probability, high‐impact events are difficult to manage. Firms may underinvest in risk assessments for low‐probability, high‐impact events because it is not easy to link the direct and indirect benefits of doing so. Scholarly research on the effectiveness of programs aimed at reducing such events faces the same challenge. In this article, we draw on comprehensive industry‐wide data from the U.S. nuclear power industry to explore the impact of conducting probabilistic risk assessment (PRA) on preventing safety‐related disruptions. We examine this using data from over 25,000 monthly event reports across 101 U.S. nuclear reactors from 1985 to 1998. Using Poisson fixed effects models with time trends, we find that the number of safety‐related disruptions reduced between 8% and 27% per month in periods after operators submitted their PRA in response to the Nuclear Regulatory Commission's Generic Letter 88‐20, which required all operators to conduct a PRA. One possible mechanism for this is that the adoption of PRA may have increased learning rates, lowering the rate of recurring events by 42%. We find that operators that completed their PRA before Generic Letter 88‐20 continued to experience safety improvements during 1990–1995. This suggests that revisiting PRA or conducting it again can be beneficial. Our results suggest that even in a highly safety‐conscious industry as nuclear utilities, a more formal approach to quantifying risk has its benefits.     

Redesigning the Downtown of an Expansive Sunbelt City: The Phoenix Case

ABSTRACT

Non-motorized traffic safety is a major public health concern, especially in the sprawling sunbelt cities of the United States. Phoenix is ranked quite high on the number of pedestrian and cyclist crashes in North American cities. This article analyses non-motorist safety incidents in downtown Phoenix. Non-motorist safety concerns were addressed by examining crash types in order to suggest adequate safety treatments. We also demonstrated the use of a countermeasure framework for higher crash locations denominated hotspots. Our findings indicate that it is important to implement a combination of countermeasures to reduce the high number of non-motorist crashes in city centers.     

Trust‐Level Risk Evaluation and Risk Control Guidance in the NHS East of England

In recent years, the healthcare sector has adopted the use of operational risk assessment tools to help understand the systems issues that lead to patient safety incidents. But although these problem‐focused tools have improved the ability of healthcare organizations to identify hazards, they have not translated into measurable improvements in patient safety. One possible reason for this is a lack of support for the solution‐focused process of risk control. This article describes a content analysis of the risk management strategies, policies, and procedures at all acute (i.e., hospital), mental health, and ambulance trusts (health service organizations) in the East of England area of the British National Health Service. The primary goal was to determine what organizational‐level guidance exists to support risk control practice. A secondary goal was to examine the risk evaluation guidance provided by these trusts. With regard to risk control, we found an almost complete lack of useful guidance to promote good practice. With regard to risk evaluation, the trusts relied exclusively on risk matrices. A number of weaknesses were found in the use of this tool, especially related to the guidance for scoring an event's likelihood. We make a number of recommendations to address these concerns. The guidance assessed provides insufficient support for risk control and risk evaluation. This may present a significant barrier to the success of risk management approaches in improving patient safety.     

Residents’ Reactions to Earthquake Early Warnings in Japan

This article empirically examines the effectiveness of earthquake early warning (EEW) in Japan based on experiences of residents who received warnings before earthquake shaking occurred. In Study 1, a survey (N = 299) was conducted to investigate residents’ experiences of, and reactions to, an EEW issued in Gunma and neighboring regions on June 17, 2018. The main results were as follows. (1) People's primary reactions to the EEW were mental, not physical, and thus motionless. Most residents stayed still, not for safety reasons, but because they were focusing on mentally bracing themselves. (2) Residents perceived the EEW to be effective because it enabled them to mentally prepare, rather than take physical protective actions, before strong shaking arrived. (3) In future, residents anticipate that on receipt of an EEW they would undertake mental preparation as opposed to physical protective actions. In Study 2, a survey (N = 450) was conducted on another EEW issued for an earthquake offshore of Chiba Prefecture on July 7, 2018. Results were in line with those of Study 1, suggesting that the findings described above are robust. Finally, given people's lack of impetus to undertake protective action on receipt of an EEW, this article discusses ways to enhance such actions.     

Situated Food Safety Risk and the Influence of Social Norms

Previous studies of risk behavior observed weak or inconsistent relationships between risk perception and risk-taking. One aspect that has often been neglected in such studies is the situational context in which risk behavior is embedded: Even though a person may perceive a behavior as risky, the social norms governing the situation may work as a counteracting force, overriding the influence of risk perception. Three food context studies are reported. In Study 1 (N = 200), we assess how norm strength varies across different social situations, relate the variation in norm strength to the social characteristics of the situation, and identify situations with consistently low and high levels of pressure to comply with the social norm. In Study 2 (N = 502), we investigate how willingness to accept 15 different foods that vary in terms of objective risk relates to perceived risk in situations with low and high pressure to comply with a social norm. In Study 3 (N = 1,200), we test how risk-taking is jointly influenced by the perceived risk associated with the products and the social norms governing the situations in which the products are served. The results indicate that the effects of risk perception and social norm are additive, influencing risk-taking simultaneously but as counteracting forces. Social norm had a slightly stronger absolute effect, leading to a net effect of increased risk-taking. The relationships were stable over different social situations and food safety risks and did not disappear when detailed risk information was presented.     

A structured procedure for materials planning during production transfer

This paper explores materials planning procedures to ensure the materials’ availability during production transfers. The paper defines a production transfer as the preparation, physical transfer and start-up of relocated production. A structured procedure of materials planning during production transfer is developed based on theory, and then validated and refined based on the analysis of four case studies. The paper shows that there is a need for a structured procedure of materials planning during production transfers. It also explains the importance of activities that create prerequisites for the materials’ availability during production transfer, such as updating and adapting documentation, planning and control systems, and describes the activities that ensure the materials’ availability, such as preventive and corrective actions. A valid estimation of the time needed to reach a steady state and a combination of several preventive actions improves the ability to ensure that materials are available. The cases showed differences across company size, because large companies took more and farther-reaching preventive actions.     

Process Safety Behavioral Systems: Behaviors Interlock in Complex Metacontingencies

ABSTRACT

This paper seeks to identify behavioral components active in process safety. Three types of behavior classes are identified as contributors to process safety: task-specific behaviors, safety-directed behaviors, and behaviors associated with situational awareness. Behavioral systems analysis is used to provide a framework for identifying the cross-functional interlocking behavioral contingencies that can, even over a period of years, contribute to process safety incidents. Leadership behaviors are also identified that can create the context in the form of metacontingencies that maintain these interlocking contingencies.     

An Evaluation of Training Procedures for Animal Shelter Volunteers

This study evaluated the effects of 3 training procedures on the correct implementation of a dog walking and enrichment protocol (DWEP). During the shelter’s typical training, volunteers correctly implemented just over half of all DWEP steps (M = 55.2%). Correct implementation of the DWEP procedure improved when participants completed a video-based self-training package (M = 75.3%) but did not reach the preestablished mastery criterion of 85% fidelity with 0 safety errors. Correct implementation improved during coaching (M = 90.6%), which consisted of modeling and positive and corrective feedback, and was maintained during 1-week and 1-month follow-up probes. Criterion performance was demonstrated by 2 of 3 participants at the conclusion of the study.     

Modeling the Cost Effectiveness of Fire Protection Resource Allocation in the United States: Models and a 1980–2014 Case Study

The estimated cost of fire in the United States is about $329 billion a year, yet there are gaps in the literature to measure the effectiveness of investment and to allocate resources optimally in fire protection. This article fills these gaps by creating data‐driven empirical and theoretical models to study the effectiveness of nationwide fire protection investment in reducing economic and human losses. The regression between investment and loss vulnerability shows high R² values (≈0.93). This article also contributes to the literature by modeling strategic (national‐level or state‐level) resource allocation (RA) for fire protection with equity‐efficiency trade‐off considerations, while existing literature focuses on operational‐level RA. This model and its numerical analyses provide techniques and insights to aid the strategic decision‐making process. The results from this model are used to calculate fire risk scores for various geographic regions, which can be used as an indicator of fire risk. A case study of federal fire grant allocation is used to validate and show the utility of the optimal RA model. The results also identify potential underinvestment and overinvestment in fire protection in certain regions. This article presents scenarios in which the model presented outperforms the existing RA scheme, when compared in terms of the correlation of resources allocated with actual number of fire incidents. This article provides some novel insights to policymakers and analysts in fire protection and safety that would help in mitigating economic costs and saving lives.