Why Do We Still Not Know How to Prevent Firefighter Entrapments?—Thoughts and Observations from a Few Perplexed Fire Practitioners

Wildland firefighters continue to die in the line of duty. Flammable landscapes intersect with bold but good-intentioned doers and trigger entrapment—a situation where personnel is unexpectedly caught in fire behaviour-related, life-threatening positions where planned escape routes or safety zones are absent, inadequate, or compromised. We often document, share and discuss these stories, but many are missed, especially when the situation is a near miss. Entrapment continues to be a significant cause of wildland firefighter deaths. Why do we still not know how to prevent them? We review a selection of entrapment reports courtesy of the Wildland Fire Lessons Learned Centre (WFLLC) and focus on human factors involved in entrapment rather than the specifics of fire behaviour and the environment. We found that in order for operational supervisors to make more informed strategic and tactical decisions, a more holistic and complete trend analysis is necessary of the existing database of entrapment incidents. Analysis of the entrapment data would allow training to include a more fulsome understanding of when suppression resources are applying strategies and tactics that might expose them to a higher likelihood of entrapment. Operational supervisors would make more informed decisions as to where and when to deploy resources in critical situations in order to reduce the exposure to unnecessary risk of entrapment.

Death-stricken survivor mother: the lived experience of near miss mothers

Background A Near Miss Mother (NMM) who survives life-threatening conditions, experiences intense physical, emotional, and psychological consequences following the maternal near-miss (MNM) events. The aim of this study was therefore to explore indepth understanding meaning of NMM everyday lived experiences on the social and cultural background of Iran. Methods This qualitative study utilized a hermeneutic phenomenology procedure. The study was conducted in hospitals affiliated with the Educational, Research and Treatment Centerwhich usually handle the NMMs. The sampling was purposeful with a maximum variation of eleven NMMs. Datawere collected using unstructured face-to-face interviews, and thetranscribed data were analyzed using Diekelmann, Allen, and Tanner’s seven-stage thematic analysis approach. Results "Death-stricken survivor mother" was the central emerged theme, and three extracted sub-themes included: "Distorted psyche on a journey to death", "physical destruction due to an ominous event ", and the "vicissitudinous life after reviving ". These sub-themes, in turn, involved 12 sub-themes that emerged from 38 common meanings and 1200 codes. Conclusions Findings demonstrate that the living conditions of NMMs are mixed in all aspects of the MNM event. They need a supportive program that includes additional follow-up visits, psychological support from the time of hospitalization until long-time after discharge, alleviation of social, sexual, and financial worries to return them to the normal life, as well as psychosocial rehabilitation to increase their life quality. Furthermore, post-discharge care in NMMs should be done actively and directly at their homes.

Morbidade neonatal near miss em um serviço de perinatologia

OBJETIVO: identificar os casos de morbidade neonatal near miss em um serviço de Perinatologia do estado do Maranhão. MÉTODO: pesquisa descritiva e transversal de abordagem quantitativa, realizada a partir da análise dos dados de recém-nascidos internados na Unidade Neonatal de um Serviço de Perinatologia no período de 2017 a 2018. As análises estatísticas foram processadas no programa estatístico STATA versão 14.0. RESULTADOS: o peso ao nascer <1500g foi a variável que mais classificou casos de near miss neonatal, seguido pela variável de idade gestacional <34 semanas. Os resultados obtidos demonstraram associação entre hipertensão gestacional e peso ao nascer; hipertensão gestacional e idade gestacional ao nascer; parto cesáreo e Apgar no 5º minuto ≥ 7; parto cesáreo e sexo masculino. CONCLUSÃO: observou-se a importância da abordagem near miss neonatal para a compreensão ampliada da morbimortalidade neonatal e fatores associados.

Association Mining of Near Misses in Hydropower Engineering Construction Based on Convolutional Neural Network Text Classification

Accidents of various types in the construction of hydropower engineering projects occur frequently, which leads to significant numbers of casualties and economic losses. Identifying and eliminating near misses are a significant means of preventing accidents. Mining near-miss data can provide valuable information on how to mitigate and control hazards. However, most of the data generated in the construction of hydropower engineering projects are semi-structured text data without unified standard expression, so data association analysis is time-consuming and labor-intensive. Thus, an artificial intelligence (AI) automatic classification method based on a convolutional neural network (CNN) is adopted to obtain structured data on near-miss locations and near-miss types from safety records. The apriori algorithm is used to further mine the associations between “locations” and “types” by scanning structured data. The association results are visualized using a network diagram. A Sankey diagram is used to reveal the information flow of near-miss specific objects using the “location ⟶ type” strong association rule. The proposed method combines text classification, association rules, and the Sankey diagrams and provides a novel approach for mining semi-structured text. Moreover, the method is proven to be useful and efficient for exploring near-miss distribution laws in hydropower engineering construction to reduce the possibility of accidents and efficiently improve the safety level of hydropower engineering construction sites.

Systemic Approach to Failure Analysis: A Study of Sociotechnical Organization

The paper is an attempt to explore systemic approach to accidents analysis within sociotechnical organization. Unsafe behaviors can result in systemic failures and accidents. The research data came from within an industrial radiography organization where radiation source is used to detect cracks or hidden flaws within machinery and welding joints. The radioactive source can cause severe detrimental effects, even death, if not used safely. This paper is on two isolated events happen in the same company, Industrial Services Private Limited (not real name). The company top management was dealing with the financial crisis and to maintain quality of its services and the safety of staff. The leadership of the company made several business and operational decisions to manage the financial crisis. During that time, several near miss incidents took place, but the first major incident took place when the radiography gamma projector, along with the radioactive source, fallen out of the vehicle because of improper back door closure of the vehicle. In the second incident, the radioactive source remained unshielded after a radiography job, this caused overexposure to radiography workers. The paper provides an opportunity to understand how an organization’s leadership can create conditions for errors and mistakes that result in poor safety culture and ultimately the accident which resulted the system failure and operation shutdown. The paper also tries to propose a conceptual framework to improve safety culture within the sociotechnical systems for the future research in this area.

Effects of Human Factors in Process Safety

Accidents and near-miss accidents in chemical industries are widespread. Most of the incidents occurred due to combinations of organizational and human factors. To identify the causes for an incident of an accident analysis is needed, because it reveals the possible causes behind the accidents. Accident analysis shows the human and organizational factors that support learning from the events. Literature review shows that human error plays an important role of accidents in process industries. The chapter discusses some case studies which are received very little media publicity and also no proper assessment. At first reports on the incidents were collected from newspapers and then the place was visited to conduct an interview with local people and present and past workers with the help of the PESO (M/S Petroleum and Explosive Safety Organization, Eastern Region, Govt. of India).

Case series of maternal mortality and maternal near miss due to severe acute respiratory syndrome coronavirus 2

The severe acute respiratory syndrome coronavirus 2 (SARS-COV-2) that causes the COVID-19 pandemic has affected every household of the remotest part of North East India, Mizoram. The pregnant women do not have a higher chance of getting infected, yet the infection seems to be more severe. We are reporting five cases of maternal death and two cases of maternal near miss in ZMC of Mizoram. Case 1 to 5 were maternal death due to COVID-19. All of them were multigravida within the age group of 27–41 years with a period of gestation 24–37 weeks. The presenting complaints were fever and cough more than 3 days with an investigation report revealing raised C-reactive protein (CRP) and severe pneumonia. Case 6 (Near miss) was 20 years, primigravida at term pregnancy in labor with a history of fever for 2 days with an investigation report revealing raised CRP and severe pneumonia, the baby was delivered asphyxiated and died. Case 7 (Near miss) was 17 years old primigravida at term pregnancy admitted as asymptomatic COVID-19 positive, elective caesarean section was done for Obstetrics indication, the patient later developed fever and moderate pneumonia on 5 days of hospitalization, she also developed eclampsia on 7th hospital day, she survived after intensive care in the intensive care unit.

Fatores associados à morbidade materna grave em Ribeirão Preto, São Paulo, Brasil: estudo de corte transversal

Este estudo investigou os fatores associados à morbidade materna grave entre mulheres atendidas em maternidades públicas do Município de Ribeirão Preto, São Paulo, Brasil. Trata-se de um estudo quantitativo, analítico, transversal. Participaram 1.098 puérperas com parto em uma das quatro maternidades públicas do município. A coleta de dados ocorreu entre 3 de agosto de 2015 e 2 de fevereiro de 2016, a partir de entrevistas face a face, obtenção de informações dos prontuários e dos cartões da gestante. Para a análise de dados, considerou-se como variável dependente a ocorrência de morbidade materna grave, ou seja, quando a mulher era classificada como near miss materno ou condição potencialmente ameaçadora à vida a partir dos critérios de elegibilidade da Organização Mundial de Saúde. Calculou-se a razão do near miss materno, odds ratio (OR), intervalo de 95% de confiança (IC95%) e regressão logística múltipla. A razão do near miss materno foi de 3,6 casos por mil nascidos vivos. As complicações ocorreram principalmente na gravidez (53,8%) e os distúrbios hipertensivos foram os mais frequentes (49,4%). A análise de regressão múltipla mostrou associação entre morbidade materna grave e gestação de risco (OR = 4,5; IC95%: 2,7-7,7) e com trabalho de parto induzido (OR = 2,1; IC95%: 1,2-3,9). A ocorrência de morbidade materna grave, principalmente na gestação, com destaque para as síndromes hipertensivas, aponta para a necessidade de melhor rastreamento e manejo da elevação dos níveis pressóricos no pré-natal. A associação entre morbidade materna grave e gestação de risco também remonta ao pré-natal, para a demanda de uma maior atenção às mulheres classificadas como risco gestacional. A qualidade da assistência é ponto chave para o enfretamento da morbimortalidade materna no país.

Feto-maternal outcomes in near miss events in obstetrics

Background: Maternal near miss is defined by world health organization as a woman, who being close to death survives a complication occurring during pregnancy, delivery or upto 42 days after her end of pregnancy.It is a retrospective diagnosis. Evaluation of near miss maternal morbidity and mortality is a surveillance method to assess the quality of obstetric care and determinants of poor maternal outcome. It is an indicator of quality of obstetrical care. Aims and objectives for current study was to evaluate the cause of near miss maternal morbidity in our hospital which occurred either in admitted patients or were referred from elsewhere and to study the maternal and fetal outcomes in all near miss cases.Methods: A retrospective review of obstetrical records as well as prospective analysis was done at Christian medical college and hospital, a tertiary care teaching institute in North India and referral centre. The study was done for a period of one year from November 2018 to October 2019 retrospectively and for 6 months from November 2019 to April 2020 prospectively. The maternal near miss cases were taken as per WHO criteria.Results: The age ranged from 19 years to 49 years with maximum belonging to age group of 20-24 years. Maximum number of cases was primigravida and was in third trimester. The primary obstetric complication evaluated were hypertensive disorders followed by hematological diseases, viral hepatitis, haemorrhage, and obstructed labour or ruptured uterus.Conclusions: All the causes of MNM observed in this study are preventable causes, which can be identified timely and treated early to prevent maternal mortality, thereby, improving obstetrical and neonatal outcome.