Case study: The downside of using a worst-case approach in occupational safety policy as an interpretation of the precautionary principle: Putting the uncertain UXO occupational safety risk into probabilistic perspective.

Unexploded ordnance (UXO) from the World Wars on the North Sea floor pose an uncertain occupational safety risk for dredging and cable installation. At present mitigation strategies are based on an interpretation of the precautionary principle that uses a worst-case approach, that is, assuming that UXO will be encountered, will explode, and will harm people onboard. We propose a probabilistic framework to estimate the UXO risk. Using this probabilistic framework, we conclude that the UXO risk during cable installation meets the prevailing safety standard in the Netherlands. Furthermore, we demonstrate that the UXO risk is lower than the general maritime risk, that is, the occupational health risk caused by the mitigation is higher than the UXO risk itself. We conclude that even for uncertain occupational risks, such as the UXO risk in the North Sea, a probabilistic analysis can be more instrumental in the decision-making process on accepting and mitigating risks than using worst-case scenario thinking.

Decision-making and evacuation planning for flood risk management in the Netherlands.

A traditional view of decision-making for evacuation planning is that, given an uncertain threat, there is a deterministic way of defining the best decision. In other words, there is a linear relation between threat, decision, and execution consequences. Alternatives and the impact of uncertainties are not taken into account. This study considers the 'top strategic decision-making' for mass evacuation owing to flooding in the Netherlands. It reveals that the top strategic decision-making process itself is probabilistic because of the decision-makers involved and their crisis managers (as advisers). The paper concludes that deterministic planning is not sufficient, and it recommends probabilistic planning that considers uncertainties in the decision-making process itself as well as other uncertainties, such as forecasts, citizens responses, and the capacity of infrastructure. This results in less optimistic, but more realistic, strategies and a need to pay attention to alternative strategies.

[Medication verification in hospital: is it proportional?] / Medicatieverificatie in ziekenhuizen: een proportioneel instrument?

In 2008 in the Netherlands the Guideline 'Transmission of medication in the chain' was published. This guideline described that upon admission and discharge in the hospital verification of medication should take place. This caused significant investments in staff by hospitals to meet with this guideline. However, despite these efforts 15 years later this has not led to adequate transmission of medication. In this article it is described that the organization of medication verification in hospitals has features of the Risk Regulation Reflex. A better possible solution of this problem is proposed: making community pharmacies responsible for updating the medication overview. This pharmacist should perform this task together with the patient. This should be done in parallel with improving compliance. In hospitals medication reviews in high risk patients could take place.

[Risk management with regard to QT-prolonging drugs]. / Risicomanagement rond QT-verlengende geneesmiddelen.

Drug-induced QT prolongation increases the risk of Torsade de Pointes (TdP). Drug-induced QT prolongation is a complex and unpredictable system due to many uncertainties. Risk factors such as electrolyte disturbances, heart failure and genetics play an important role in estimating the effect on QT prolongation. Moreover, the degree of QT prolongation is not always directly related to the risk of TdP and the assessment of the QT-interval is variable depending on the type and timing of QT measurement. Therefore, the variation in QT measurement may be larger than the effect of certain drugs on the QT interval. Because of the potentially lethal risk, several measures are undertaken to reduce the risk of QT prolongation and TdP, while their effect and proportionality are unclear. We suggest we should be less stringent in certain settings when risk of TdP is extremely low given the limited availability of our resources.

EvacuAid: a probabilistic model to determine the expected loss of life for different mass evacuation strategies during flood threats.

Evacuation of people in case of a threat is a possible risk management strategy. Evacuation has the potential to save lives, but it can be costly with respect to time, money, and credibility. The consequences of an evacuation strategy depend on a combination of the time available, citizen response, authority response, and capacity of the infrastructure. The literature that discusses evacuations in case of flood risk management focuses, in most cases, only on a best-case strategy as a preventive evacuation and excludes other possible strategies. This article introduces a probabilistic method, EvacuAid, to determine the benefits of different types of evacuation with regards to loss of life. The method is applied for a case study in the Netherlands for preventive and vertical evacuation due to flood risk. The results illustrate the impact of uncertainties in available time and actual conditions (e.g., the responses of citizens and authorities and the use of infrastructure). It is concluded that preparation for evacuation requires adaptive planning that takes preventive and vertical evacuation into account, based on a risk management approach.

Time needed to evacuate the Netherlands in the event of large-scale flooding: strategies and consequences.

On 30 May 2008, the Government of the Netherlands informed the national parliament about the effectiveness of preventive evacuation of coastal and river areas in case of flooding. Analysis of a case study showed that it is impossible to evacuate coastal areas preventively within a 48-hour time span preceding a worst credible scenario flood caused by a storm surge. This fact illustrates the need for alternative evacuation strategies, such as vertical evacuation (evacuating to safe havens, inside the flood zone) or shelter-in-place (hiding), to reduce loss of life and the impact of the evacuation. This paper defines these strategies and demonstrates, by returning to the case study used by the Dutch government, that they require different measures, methods of approach, and crisis management processes. In addition, it addresses the need for flexible and scalable preparation so that after detecting and understanding the threat, authorities and citizens can make decisions about different evacuation strategies.

Building Blocks Towards a Proportionate Chemicals Policy With a Focus on the Netherlands.

In this contribution, we propose that 'sound' government policy should be characterised by a proportionate, integral vision with due consideration to tradeoffs between social costs and benefits. This principle also applies to government policy regarding the protection of workers from exposure to chemicals. It should be taken into account that having a job is a huge health benefit. Less educated people are statistically likely to enjoy ten additional healthy years, if employed. Although there is no debate about the risks of exposure to high doses of chemicals, there is most certainly debate on the magnitude, nature and possible cumulative effects of low-dose exposure to chemicals. These are established by model-based assumptions. The current advisory structure in which the Health Council of the Netherlands restricts its focus to the immediate health benefits for workers on the basis of risk avoidance models, and the Social and Economic Council of the Netherlands which focuses primarily on policy costs for trade and industry, is hardly a sound basis for well-considered decision making. The challenge for the scientific experts is to provide political administrators with an insightful social cost-benefit analysis, including all the concomitant uncertainties.

How prepared is prepared enough?

Decisions about disaster preparedness are rarely informed by cost-benefit analyses. This paper presents an economic model to address the thorny question, 'how prepared is prepared enough?' Difficulties related to the use of cost-benefit analysis in the field of disaster management concern the tension between the large number of high-probability events that can be handled by a single emergency response unit and the small number of low-probability events that must be handled by a large number of them. A further special feature of disaster management concerns the opportunity for cooperation between different emergency response units. To account for these issues, we introduce a portfolio approach. Our analysis shows that it would be useful to define disaster preparedness not in terms of capacities, but in terms of the frequency with which response capacity is expected to fall short.

Organisational resilience: Shifting from planning-driven business continuity management to anticipated improvisation.

As unpredictable major-impact events are on the rise, many organisations have adopted an organisational resilience (OR) approach for dealing with these so-called 'black swan events. What OR comprises is subject to ambiguity and multiple interpretations. This article presents a perspective that makes a distinction between predictable risks and unpredictable major-impact events. The article argues that predictable risks would benefit from an adaptive and efficient business continuity management (BCM) capability. Using several cases, the article demonstrates how the adaptability and efficiency of BCM can be improved in practice. For unpredictable events, this article calls for a strategy of anticipated improvisation. Both strategies necessitate executives and regulators to accept less planning and to put more trust in the expertise of specialists and managers.

[Black particles in plasma and carcinogenic pills]. / Zwarte deeltjes in plasma en kankerverwekkende pillen.

Recently in a national newspaper presumed large hazards in care were described. Visible black particles were seen in blood plasma and a cancerogenic substance was found in paracetamol. Every year 300.000 bags of plasma are produced. The black particles were found in 11 bags of plasma. Possibly one of these was administered. During administration 175 micron filters are used. Presumably remaining particles will be degraded by the mononuclear-phagocytic system. In paracetamol 6 ppm of para-chloroaniline was found. Depending of the limit used by either the ICH or the EFSA this means for patients using lifelong 6 grams of paracetamol a risk off respectively 1: 200.000 or 1:20.000. This risk is neglectable compared of the life time risks of cancer in the population (1:3). Journalists should realize that this exaggerated commentary can lead to real serious risks (taking NSAID's instead of paracetamol) and mistrust in regular care.

Prioritizing care during the acute phase: the prominent role of basic psychosocial life support.

The issue of basic psychosocial life support during and after disasters is important. People who are affected by disasters can experience severe distress and may need psychosocial support. However, there still are many questions about service design and effectiveness of psychosocial support. During the process of the Targeted Agenda Program, "Prioritizing Care during the Acute Phase: The Prominent Role of Basic Psychosocial Life Support", a team of experts reached consensus on some important issues concerning psychosocial first aid, civil participation, and risk communication. The experts come from many different backgrounds, which supports the notion that psychosocial care deserves special attention within disaster relief programs involving all disciplines and all responsibilities.

Integrated modelling of medical emergency response process for improved coordination and decision support.

The medical emergency response comprises a domain with complex processes, encompassing multiple heterogeneous entities, from organisations involved in the response to human actors to key information sources. Due to the heterogeneity of the entities and the complexity of the domain, it is important to fully understand the individual processes in which the components are involved and their inter-operations, before attempting to design any technological tool for coordination and decision support. This work starts with the gluing together and visualisation of the interactions of involved entities into a conceptual model, along the identified five workspaces of emergency response. The modelling visualises the domain processes, in a way that reveals the necessary communication and coordination points, the required data sources and data flows, as well as the required decision support needs. Work continues with the identification and modelling of the event-driven discrete-time-based dynamics of the emergency response processes and their compositions, using Petri nets as the modelling technique. Subsequently, an integrated model of the process is presented, which facilitates the parallelisation of the tasks undertaken in an emergency incident.

Naturalistic decision making in forensic science: toward a better understanding of decision making by forensic team leaders.

This study uses the naturalistic decision-making (NDM) perspective to examine how Dutch forensic team leaders (i.e., the officers in charge of criminal forensic research from the crime scene until the use of laboratory assistance) make decisions in real-life settings and identifies the contextual factors that might influence those decisions. First, a focus group interview was conducted to identify four NDM mechanisms in day-to-day forensic decision making. Second, a serious game was conducted to examine the influence of three of these contextual mechanisms. The results uncovered that forensic team leaders (i) were attracted to obtain further information when more information was initially made available, (ii) were likely to devote more attention to emotionally charged cases, and (iii) used not only forensic evidence in the decision making but also tactical, unverified information of the police inquiry. Interestingly, the measured contextual influences did not deviate significantly from a control group of laypeople.