Learning from what went wrong--two case studies
Grotefendt, R.H.; Chastain, J.W.
Journal of Hazardous Materials 115(1-3): 115-118
2004
ISSN/ISBN: 0304-3894 PMID: 15518972 DOI: 10.1016/j.jhazmat.2004.05.005
Accession: 049459367
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Summary
Safer design of process equipment can protect against unexpected events. Two case studies involving the design of a process vessel and the subsequent events will be reviewed. One case study will show how the original design minimized equipment damage from an operational error, and how additional safeguards will prevent recurrence. The second case study will show that over time small process changes can lead to an unexpected chemical reaction that results in a vessel rupture. We will also cover the additional safeguards added to prevent recurrence.
References
Seiden, S.C.; Barach, P. 2006: Wrong-side/wrong-site, wrong-procedure, and wrong-patient adverse events: Are they preventable? Archives of Surgery 141(9): 931-939Angle, J.F.; Nemcek, A.A.; Cohen, A.M.; Miller, D.L.; Grassi, C.J.; D'Agostino, H.R.; Khan, A.Ahmed.; Kundu, S.; Osnis, R.B.; Rajan, D.K.; Schwartzberg, M.S.; Swan, T.L.; Vedantham, S.; Wallace, M.J.; Cardella, J.F.; Balter, S.; Brown, D.B.; Clark, T.W.I.; Connolly, B.L.; Davison, B.D.; Khilnani, N.M.; Malloy, P.C.; McGraw, J.Kevin.; Meyers, P.M.; Millward, S.F.; Owens, C.A.; Postoak, D.; Rajan, D.K.; Roberts, A.C.; Rose, S.C.; Siddiqu, N.H.; Stokes, L.; Thorpe, P.E.; Wagner, L.K.; Wiechmann, B.N.; Zuckerman, D.A.; Bakal, C.W.; Lewis, C.A.; Rholl, K.S.; Sack 2009: Quality improvement guidelines for preventing wrong site, wrong procedure, and wrong person errors: application of the joint commission "universal protocol for preventing wrong site, wrong procedure, wrong person surgery" to the practice of interventional radiology Journal of Vascular and Interventional Radiology: Jvir 20(7 Suppl): S256-S262
Angle, J.F.; Nemcek, A.A.; Cohen, A.M.; Miller, D.L.; Grassi, C.J.; D'Agostino, H.R.; Khan, A.Ahmed.; Kundu, S.; Osnis, R.B.; Rajan, D.K.; Schwartzberg, M.S.; Swan, T.L.; Vedantham, S.; Wallace, M.J.; Cardella, J.F.; Balter, S.; Brown, D.B.; Clark, T.W.I.; Connolly, B.L.; Davison, B.D.; Khilnani, N.M.; Malloy, P.C.; McGraw, J.Kevin.; Meyers, P.M.; Millward, S.F.; Owens, C.A.; Postoak, D.; Rajan, D.K.; Roberts, A.C.; Rose, S.C.; Siddiqu, N.H.; Stokes, L.; Thorpe, P.E.; Wagner, L.K.; Wiechmann, B.N.; Zuckerman, D.A.; Bakal, C.W.; Lewis, C.A.; Rholl, K.S.; Sack 2008: Quality improvement guidelines for preventing wrong site, wrong procedure, and wrong person errors: application of the joint commission "Universal Protocol for Preventing Wrong Site, Wrong Procedure, Wrong Person Surgery" to the practice of interventional radiology Journal of Vascular and Interventional Radiology: Jvir 19(8): 1145-1151
McClelland, D.C. 1943: Studies in serial verbal discrimination learning: Iii. The influence of difficulty on reminiscence in responses to right and wrong words Journal of Experimental Psychology 32(3): 235-246
McClelland, D.C. 1942: Studies in serial verbal discrimination learning. Ii. Retention of responses to right and wrong words in a transfer situation Journal of Experimental Psychology 31(2): 149-162
Karlinsky, A.; Alexander, B.; Hodges, N.J. 2022: "You're wrong, I'll switch, I'm wrong, I'll stay": how task-switching strategies are modulated by a partner in a multi-task learning protocol Acta Psychologica 222: 103475
Ross, E.W.; Marker, P.M. 2005: Social Studies: Wrong, Right, or Left? A Critical Response to the Fordham Institute's Where Did Social Studies Go Wrong? (Part Ii) The Social Studies 96(5): 187-188
Taghavi, K.; Sykes, P.; Innes, C.; Gibbs, D.; Hunter, L.; McBurnie, W.; Simcock, B. 2015: Wrong place at the wrong time: a case of cervical embryonal rhabdomyosarcoma in pregnancy Gynecologic Oncology Reports 12: 77-79
Wyles, S M.; Hakky, S M.; Ahmed, A R. 2011: V-07 The case of being in the wrong place at the wrong time: the consequences of undiagnosed anatomical anomalies Surgery for Obesity and Related Diseases 7(3): 356-357
Wyles, S.M.; Hakky, S.; Ahmed, A.R. 2011: The case of being in the wrong place at the wrong time: the consequences of undiagnosed anatomic anomalies Surgery for Obesity and Related Diseases: Official Journal of the American Society for Bariatric Surgery 7(4): 543-545
Barratt, J.; Eitner, F.; Feehally, J.; Floege, J.ür. 2009: Immune complex formation in IgA nephropathy: a case of the 'right' antibodies in the 'wrong' place at the 'wrong' time? Nephrology Dialysis Transplantation: Official Publication of the European Dialysis and Transplant Association - European Renal Association 24(12): 3620-3623
Patel, P.; Kelschenbach, K. 2022: Air in the Wrong Place at the Wrong Time: a Case of Pneumomediastinum and Pneumopericardium in the Setting of COVID-19 Disease Cureus 14(5): E25075
Ross, E.W.; Marker, P.M. 2005: Social Studies: Wrong, Right, or Left? A Critical Response to the Fordham Institute's Where Did Social Studies Go Wrong? The Social Studies 96(4): 139-142
Judson, I.R. 1991: Phase Ii studies: wrong doses, wrong patients? European Journal of Cancer 27(10): 1198-1200
2006: Best practices for preventing wrong site, wrong person, and wrong procedure errors in perioperative settings AORN Journal 84(Suppl. 1): S13-S29
Pugh, M.J.V.; Fincke, B.G.; Bierman, A.S.; Chang, B.-H.; Rosen, A.K.; Cunningham, F.E.; Amuan, M.E.; Burk, M.L.; Berlowitz, D.R. 2005: Potentially inappropriate prescribing in elderly veterans: are we using the wrong drug, wrong dose, or wrong duration? Journal of the American Geriatrics Society 53(8): 1282-1289
Michaels, R.K.; Makary, M.A.; Dahab, Y.; Frassica, F.J.; Heitmiller, E.; Rowen, L.C.; Crotreau, R.; Brem, H.; Pronovost, P.J. 2007: Achieving the National Quality Forum's "Never Events": prevention of wrong site, wrong procedure, and wrong patient operations Annals of Surgery 245(4): 526-532
Paul J Watson; Vicky Harding; Emma Hollyman; Carol Sweet; Louis Gifford; Sue Mickleburgh; Heather Muncey 1999: Wrong Problem, Wrong Treatment and the Wrong Way to Deal with Pain: Readers respond to an article on inappropriate referral to physiotherapy PhysioTherapy 85(9): 522-524
Saufl, N.M. 2004: Universal protocol for preventing wrong site, wrong procedure, wrong person surgery Journal of Perianesthesia Nursing: Official Journal of the American Society of Perianesthesia Nurses 19(5): 348-351
Patterson, M.C. 2000: Niemann-Pick disease, type C The wrong lipids, in the wrong place at the wrong time Journal of Neurochemistry 74(Suppl ): S3