Incident Investigation

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Mark Fletcher - One of the best experts on this subject based on the ideXlab platform.

  • identification of pesticide poisoning in wildlife
    Journal of Chromatography A, 1996
    Co-Authors: Peter M. Brown, Andrew J. A. Charlton, Mary Cuthbert, Libby Barnett, Leigh Ross, Margaret Green, Liz Gillies, Kathryn Shaw, Mark Fletcher
    Abstract:

    The Wildlife Incident Investigation Scheme investigates Incidents of suspected poisoning of wildlife (also honey bees and companion animals) by pesticides in the United Kingdom. The approach to these Investigations has evolved over the past 30 years. Field Investigations, post-mortem examinations, toxicological data and experience of previous poisoning Incidents assist in the selection and interpretation of appropriate chemical analyses. Several 'multi-residue' and several 'individual compound' analytical methods for pesticides in wildlife are currently in use; these are described.

Peter M. Brown - One of the best experts on this subject based on the ideXlab platform.

  • Analytical methods used in the United Kingdom Wildlife Incident Investigation Scheme for the detection of animal poisoning by pesticides.
    Journal of AOAC International, 2005
    Co-Authors: Peter M. Brown, Gordon Turnbull, Sheonaidh Charman, Andrew J. A. Charlton, Ainsley Jones
    Abstract:

    The United Kingdom Wildlife Incident Investigation Scheme (WIIS) investigates cases of suspected poisoning of wildlife, honey bees, and companion animals by pesticides. Together with field inquiries and veterinary post-mortem examinations, the analytical procedures presented here provide a comprehensive approach to the Investigation of these cases. The paper covers selection of animal tissues for analysis and methods suitable for the analysis of honey bees and for various types of bait. Seven multiresidue methods cover around 130 pesticides, and methods are also described for a further 8 compounds. These methods are currently used on samples submitted to the Scheme in England and Wales.

  • identification of pesticide poisoning in wildlife
    Journal of Chromatography A, 1996
    Co-Authors: Peter M. Brown, Andrew J. A. Charlton, Mary Cuthbert, Libby Barnett, Leigh Ross, Margaret Green, Liz Gillies, Kathryn Shaw, Mark Fletcher
    Abstract:

    The Wildlife Incident Investigation Scheme investigates Incidents of suspected poisoning of wildlife (also honey bees and companion animals) by pesticides in the United Kingdom. The approach to these Investigations has evolved over the past 30 years. Field Investigations, post-mortem examinations, toxicological data and experience of previous poisoning Incidents assist in the selection and interpretation of appropriate chemical analyses. Several 'multi-residue' and several 'individual compound' analytical methods for pesticides in wildlife are currently in use; these are described.

Suzanne Khalid - One of the best experts on this subject based on the ideXlab platform.

  • Integrating systemic accident analysis into patient safety Incident Investigation practices.
    Applied Ergonomics, 2018
    Co-Authors: Aneurin Canham, Gyuchan Thomas Jun, Patrick Waterson, Suzanne Khalid
    Abstract:

    Abstract There is growing awareness of the limitations of current practice regarding the Investigation of patient safety Incidents, including a reliance on Root Cause Analysis (RCA) and a lack of safety expertise. Human Factors and Ergonomics (HFE) can offer safety expertise and systemic approaches to Incident analysis. However, HFE is underutilised in healthcare. This study aims to explore the integration of HFE systemic accident analysis into current practice. The study compares the processes and outputs of a current practice RCA-based Incident analysis and a Systems Theoretic Accident Modelling and Processes (STAMP) analysis on the same medication error Incident. The STAMP analysis was undertaken by two HFE researchers with the participation of twenty-one healthcare stakeholders. The STAMP-based approach guided healthcare stakeholders towards consideration of system design issues and remedial actions, going beyond the individual–based remedial actions proposed by the RCA. The study offers insights into how HFE can be integrated into current practice.

Andrew J. A. Charlton - One of the best experts on this subject based on the ideXlab platform.

  • Analytical methods used in the United Kingdom Wildlife Incident Investigation Scheme for the detection of animal poisoning by pesticides.
    Journal of AOAC International, 2005
    Co-Authors: Peter M. Brown, Gordon Turnbull, Sheonaidh Charman, Andrew J. A. Charlton, Ainsley Jones
    Abstract:

    The United Kingdom Wildlife Incident Investigation Scheme (WIIS) investigates cases of suspected poisoning of wildlife, honey bees, and companion animals by pesticides. Together with field inquiries and veterinary post-mortem examinations, the analytical procedures presented here provide a comprehensive approach to the Investigation of these cases. The paper covers selection of animal tissues for analysis and methods suitable for the analysis of honey bees and for various types of bait. Seven multiresidue methods cover around 130 pesticides, and methods are also described for a further 8 compounds. These methods are currently used on samples submitted to the Scheme in England and Wales.

  • identification of pesticide poisoning in wildlife
    Journal of Chromatography A, 1996
    Co-Authors: Peter M. Brown, Andrew J. A. Charlton, Mary Cuthbert, Libby Barnett, Leigh Ross, Margaret Green, Liz Gillies, Kathryn Shaw, Mark Fletcher
    Abstract:

    The Wildlife Incident Investigation Scheme investigates Incidents of suspected poisoning of wildlife (also honey bees and companion animals) by pesticides in the United Kingdom. The approach to these Investigations has evolved over the past 30 years. Field Investigations, post-mortem examinations, toxicological data and experience of previous poisoning Incidents assist in the selection and interpretation of appropriate chemical analyses. Several 'multi-residue' and several 'individual compound' analytical methods for pesticides in wildlife are currently in use; these are described.

Tony Muschara - One of the best experts on this subject based on the ideXlab platform.

  • A case study combining Incident Investigation approaches to identify system-related root causes.
    2012
    Co-Authors: Bruce K. Vaughen, Tony Muschara
    Abstract:

    This case study demonstrates an effective Incident Investigation approach to identify system-related root causes. The premise is simple: What people do makes sense to them at the time. The approach combines human error concepts and human factors analyses. The combined approach helps define and eliminate hindsight bias (the investigator's bias that exists because of the known bad consequence). The case study's human error mistake was simple and straightforward; however, it failed to capture the role that previous decisions played in the Incident. The team's original recommendation was to be more careful next time. However, a deeper process safety management system-related issue was uncovered by continuing the probe using the human error root cause as the starting point of the Investigation. This is the point where the real systemic issues are found. This case study showed how poor communications between the different people involved with engineering design, contractor fabrication, equipment inspection, and subsequent site installation caused the Incident. The final recommendation of the team was to link the separate management of change (MOC), prestartup safety review (PSSR), and mechanical integrity quality assurance-related efforts together, ensuring an inspection step for replacement-in-kind. In conclusion, the combined approach helps the team better understand the timing and conditions of the event, better understand why people make the decisions they make at the time the event unfolds, and ensures that systemic root causes are discovered so that more appropriate, system-related preventive measures are chosen and implemented.

  • a case study combining Incident Investigation approaches to identify system related root causes
    Process Safety Progress, 2011
    Co-Authors: Bruce K. Vaughen, Tony Muschara
    Abstract:

    This case study demonstrates an effective Incident Investigation approach to identify system-related root causes. The premise is simple: “What people do makes sense to them at the time.” The approach combines human error concepts and human factors analyses. The combined approach helps define and eliminate “hindsight bias” (the investigator's bias that exists because of the known bad consequence). The case study's human error mistake was simple and straightforward; however, it failed to capture the role that previous decisions played in the Incident. The team's original recommendation was to “be more careful next time.” However, a deeper process safety management system-related issue was uncovered by continuing the probe using the human error “root cause” as the starting point of the Investigation. This is the point where the real systemic issues are found. This case study showed how poor communications between the different people involved with engineering design, contractor fabrication, equipment inspection, and subsequent site installation caused the Incident. The final recommendation of the team was to link the separate management of change (MOC), prestartup safety review (PSSR), and mechanical integrity quality assurance-related efforts together, ensuring an inspection step for “replacement-in-kind.” In conclusion, the combined approach helps the team better understand the timing and conditions of the event, better understand why people make the decisions they make at the time the event unfolds, and ensures that systemic root causes are discovered so that more appropriate, system-related preventive measures are chosen and implemented. © 2011 American Institute of Chemical Engineers Process Saf Prog, 2011

  • A case study—combining Incident Investigation approaches to identify system-related root causes
    Process Safety Progress, 2011
    Co-Authors: Bruce K. Vaughen, Tony Muschara
    Abstract:

    This case study demonstrates an effective Incident Investigation approach to identify system-related root causes. The premise is simple: “What people do makes sense to them at the time.” The approach combines human error concepts and human factors analyses. The combined approach helps define and eliminate “hindsight bias” (the investigator's bias that exists because of the known bad consequence). The case study's human error mistake was simple and straightforward; however, it failed to capture the role that previous decisions played in the Incident. The team's original recommendation was to “be more careful next time.” However, a deeper process safety management system-related issue was uncovered by continuing the probe using the human error “root cause” as the starting point of the Investigation. This is the point where the real systemic issues are found. This case study showed how poor communications between the different people involved with engineering design, contractor fabrication, equipment inspection, and subsequent site installation caused the Incident. The final recommendation of the team was to link the separate management of change (MOC), prestartup safety review (PSSR), and mechanical integrity quality assurance-related efforts together, ensuring an inspection step for “replacement-in-kind.” In conclusion, the combined approach helps the team better understand the timing and conditions of the event, better understand why people make the decisions they make at the time the event unfolds, and ensures that systemic root causes are discovered so that more appropriate, system-related preventive measures are chosen and implemented. © 2011 American Institute of Chemical Engineers Process Saf Prog, 2011