Sample records for event upset errors

  1. Single-event upset in advanced commercial power PC microprocessors (United States)

    Irom, F.; Farmanesh, F.; Swift, G. M.; Johnston, A. H.


    Single-event upset from heavy ions in measured for advanced commercial microprocessors, comparing upset sensitivity in registers and d-cache for several generations of devices. Multiple-bit upsets and asymmetry in registers upset cross sections are also discussed.

  2. Single-event upset in advanced PowerPC microprocessors (United States)

    Irom, F.; Swift, G. M.; Farmanesh, F.; Millward, D. G.


    Proton and heavy-ion single-event upset susceptibility has been measured for the MotorolaPowerPC7400. The results show that this advanced device has low upset susceptibility, despite the scaling and design advances.

  3. Measuring Single Event Upsets in the ATLAS Inner Tracker

    CERN Multimedia

    CERN. Geneva


    When the HL-LHC starts collecting data, the electronics inside will be subject to massive amounts of radiation. As a result, single event upsets could pose a threat to the ATLAS readout chain. The ABC130, a prototype front-end ASIC for the ATLAS inner tracker, must be tested for its susceptibility to single event upsets.

  4. Testing Electronic Devices for Single-Event Upset (United States)

    Nichols, D. K.; Price, W. E.; Malone, C. J.


    Report prepared describes equipment and summarizes both pretest and onsite procedures for testing of digital electronic devices for susceptibility to single-event upset. Term "single-event upset" denotes variety of temporary or permanent bit flips or latchup induced by single particles of ionizing radiation. Vacuum chamber houses device under test while exposed to ion beam. Vacuum chamber and associated equipment must be brought to ion-beam facility for test.

  5. System-level analysis of single event upset susceptibility in RRAM architectures (United States)

    Liu, Rui; Barnaby, Hugh J.; Yu, Shimeng


    In this work, the single event upset susceptibility of a resistive random access memory (RRAM) system with 1-transistor-1-resistor (1T1R) and crossbar architectures to heavy ion strikes is investigated from the circuit-level to the system-level. From a circuit-level perspective, the 1T1R is only susceptible to single-bit-upset (SBU) due to the isolation of cells, while in the crossbar, multiple-bit-upsets may occur because ion-induced voltage spikes generated on drivers may propagate along rows or columns. Three factors are considered to evaluate system-level susceptibility: the upset rate, the sensitive area, and the vulnerable time window. Our analysis indicates that the crossbar architecture has a smaller maximum bit-error-rate per day as compared to the 1T1R architecture for a given sub-array size, I/O width and susceptible time window.

  6. Frequency Dependence of Single-Event Upset in Highly Advanced PowerPC Microprocessors (United States)

    Irom, Farokh; Farmanesh, Farhad; White, Mark; Kouba, Coy K.


    Single-event upset effects from heavy ions were measured for Motorola silicon-on-insulator (SOI) microprocessor with 90 nm feature sizes at three frequencies of 500, 1066 and 1600 MHz. Frequency dependence of single-event upsets is discussed. The results of our studies suggest the single-event upset in registers and D-Cache tend to increase with frequency. This might have important implications for the overall single-event upset trend as technology moves toward higher frequencies.

  7. Analyzing System on A Chip Single Event Upset Responses using Single Event Upset Data, Classical Reliability Models, and Space Environment Data (United States)

    Berg, Melanie; LaBel, Kenneth; Campola, Michael; Xapsos, Michael


    We are investigating the application of classical reliability performance metrics combined with standard single event upset (SEU) analysis data. We expect to relate SEU behavior to system performance requirements. Our proposed methodology will provide better prediction of SEU responses in harsh radiation environments with confidence metrics. single event upset (SEU), single event effect (SEE), field programmable gate array devises (FPGAs)

  8. Single Event Upset Studies Using the ATLAS SCT

    CERN Document Server

    Dafinca, A; The ATLAS collaboration; Weidberg, A R


    Single Event Upsets (SEU) are expected to occur during high luminosity running of the ATLAS SemiConductor Tracker (SCT). The SEU cross sections were measured in pion beams with momenta in the range 200 to 465 MeV/c and proton test beams at 24 GeV/c but the extrapolation to LHC conditions is non-trivial because of the range of particle types and momenta. The SEUs studied occur in the p-i-n photodiode and the registers in the ABCD chip. Comparisons between predicted SEU rates and those measured from ATLAS data are presented. The implications for ATLAS operation are discussed

  9. Single Event Upset Studies Using the ATLAS SCT

    CERN Document Server

    Weidberg, A R; The ATLAS collaboration


    Single Event Upsets (SEU) are expected to occur during high luminosity running of the ATLAS SemiConductor Tracker (SCT). The SEU cross sections were measured in pion beams with momenta in the range 200 to 465 MeV/c and proton test beams at 24 GeV/c but the extrapolation to LHC conditions is non-trivial because of the range of particle types and momenta. The SEUs studied occur in the \\emph{p-i-n} photodiode and the registers in the ABCD chip. Comparisons between predicted SEU rates and those measured from ATLAS data are presented. The implications for ATLAS operation are discussed.

  10. Single event upset rate estimates for a 16-K CMOS SRAM (United States)

    Browning, J. S.; Koga, R.; Kolasinski, W. A.


    A radiation-hardened 16-K CMOS SRAM has been developed for satellite and deep space applications. The RAM memory cell was modeled to predict the critical charge, necessary for single-particle upset, as a function of temperature, total dose, and hardening feedback resistance. Laboratory measurements of the single event cross section and effective funnel length were made using the Lawrence Berkeley Laboratory's 88-inch cyclotron to generate high energy krypton ions. The combination of modeled and measured parameters permitted estimation of the upset rate for the ramcell, and the mean-time-to-failure for a 512-K word, 22-bit memory system employing error detection and correction circuits while functioning in the Adam's '90 percent worst case' cosmic ray environment. This paper is presented in the form of a tutorial review, summarizing the results of substantial research efforts within the single event community.

  11. Impact of Temporal Masking of Flip-Flop Upsets on Soft Error Rates of Sequential Circuits (United States)

    Chen, R. M.; Mahatme, N. N.; Diggins, Z. J.; Wang, L.; Zhang, E. X.; Chen, Y. P.; Liu, Y. N.; Narasimham, B.; Witulski, A. F.; Bhuva, B. L.; Fleetwood, D. M.


    Reductions in single-event (SE) upset (SEU) rates for sequential circuits due to temporal masking effects are evaluated. The impacts of supply voltage, combinational-logic delay, flip-flop (FF) SEU performance, and particle linear energy transfer (LET) values are analyzed for SE cross sections of sequential circuits. Alpha particles and heavy ions with different LET values are used to characterize the circuits fabricated at the 40-nm bulk CMOS technology node. Experimental results show that increasing the delay of the logic circuit present between FFs and decreasing the supply voltage are two effective ways of reducing SE error rates for sequential circuits for particles with low LET values due to temporal masking. SEU-hardened FFs benefit less from temporal masking than conventional FFs. Circuit hardening implications for SEU-hardened and unhardened FFs are discussed.

  12. Frequency Dependence of Single-event Upset in Advanced Commerical PowerPC Microprocessors (United States)

    Irom, Frokh; Farmanesh, Farhad F.; Swift, Gary M.; Johnston, Allen H.


    This paper examines single-event upsets in advanced commercial SOI microprocessors in a dynamic mode, studying SEU sensitivity of General Purpose Registers (GPRs) with clock frequency. Results are presented for SOI processors with feature sizes of 0.18 microns and two different core voltages. Single-event upset from heavy ions is measured for advanced commercial microprocessors in a dynamic mode with clock frequency up to 1GHz. Frequency and core voltage dependence of single-event upsets in registers is discussed.

  13. Single Event Upset Energy Dependence In a Buck-Converter Power Supply Design

    CERN Document Server

    Drake, G; The ATLAS collaboration; Gopalakrishnan, A; Mahadik, S; Mellado, B; Proudfoot, J; Reed, R; Senthilkumaran, A; Stanek, R


    We present a study of Single Event Upsets (SEU) performed on a commercial pulse-width modulator controller chip for switching power supplies. We performed tests to study the probability of an SEU occurring as a function of incident particle (hadron) energy. We discuss the performance of the circuit, and present a solution using external circuitry to effectively eliminate the effect.

  14. Single-Event Upset Characterization of Common First- and Second-Order All-Digital Phase-Locked Loops (United States)

    Chen, Y. P.; Massengill, L. W.; Kauppila, J. S.; Bhuva, B. L.; Holman, W. T.; Loveless, T. D.


    The single-event upset (SEU) vulnerability of common first- and second-order all-digital-phase-locked loops (ADPLLs) is investigated through field-programmable gate array-based fault injection experiments. SEUs in the highest order pole of the loop filter and fraction-based phase detectors (PDs) may result in the worst case error response, i.e., limit cycle errors, often requiring system restart. SEUs in integer-based linear PDs may result in loss-of-lock errors, while SEUs in bang-bang PDs only result in temporary-frequency errors. ADPLLs with the same frequency tuning range but fewer bits in the control word exhibit better overall SEU performance.

  15. Single event upset studies under neutron radiation of a high speed digital optical data link

    CERN Document Server

    Andrieux, M L; Evans, G; Gallin-Martel, L; Lundqvist, J M; Pearce, M; Rethore, F; Rydström, S; Stroynowski, R; Ye, J


    The results from a series of neutron irradiation tests of a high speed digital optical data link based on a commercial serialiser, commonly known as 'G-link', and a vertical cavity surface emitting laser are described. The link was developed as a candidate for the front-end readout of the ATLAS electromagnetic calorimeter. The components at the emitting end of the link were unaffected by neutron irradiation levels exceeding those expected during 10 years of LHC running. However, the link suffered from single event upsets (SEU) when irradiated with energetic neutrons. A very general method based on the Burst Generation Rate (BGR) model has been developed and is used to extrapolate the error rate observed during tests to that expected at the LHC. A model independent extrapolation was used to check the BGR approach and the results were consistent. To reduce the SEU rate and the deadtime it implies, a Dual G-link system was built and tested with neutron radiation. 17 Refs.

  16. Single Event Upsets in SRAM FPGA based readout electronics for the Time Projection Chamber in the ALICE experiment

    CERN Document Server

    Røed, K; Helstrup, H; Natås, T


    Single Event Upsets in SRAM FPGA based readout electronics for the Time Projection Chamber in the ALICE experiment irradiation test results have been used to predict the single event upset rate expected during operation in the ALICE experiment. Due to the number of FPGAs utilized in the TPC front-end electronics, single event upsets can be a reliability concern. In order to reduce the probability of system malfunction, a reconfiguration solution was developed that enables the possibility to clear single event upsets in the configuration memory of the FPGA. Irradiation test results show that combined with additional system level mitigation techniques, this reconfiguration solution can be used to finally reduce the functional failure rate of the FPGA. Because irradiation testing can be time consuming, costly and sometimes even technically difficult, a software based fault injection solution has been implemented without any modification to the existing hardware setup. It provides an alternative and possibly syst...

  17. Characterization of System Level Single Event Upset (SEU) Responses using SEU Data, Classical Reliability Models, and Space Environment Data (United States)

    Berg, Melanie; Label, Kenneth; Campola, Michael; Xapsos, Michael


    We propose a method for the application of single event upset (SEU) data towards the analysis of complex systems using transformed reliability models (from the time domain to the particle fluence domain) and space environment data.

  18. Single Event Upset Energy Dependence In a Buck-Converter Power Supply Design

    CERN Document Server

    Drake, G; The ATLAS collaboration; De Lurgio, P; Stanek, R; Mellado, B; Gopalakrishnan, A; Mahadik, S; Reed, R; Senthilkumaran, A


    We present a study of Single Event Upsets performed on a commercial pulse-width modulator controller chip that we are using for a switching power supply design for the Atlas Tile Calorimeter at the LHC. We performed tests to study the probability of an SEU occurring as a function of incident particle (hadron) energy. We compare the results with prediction from theory. We discuss the performance of the circuit, and perform an analysis using Bendel parameters. We also present a solution that we found using external circuitry that eliminates the effect.

  19. Single-event upset in highly scaled commercial silicon-on-insulator PowerPc microprocessors (United States)

    Irom, Farokh; Farmanesh, Farhad H.


    Single event upset effects from heavy ions are measured for Motorola and IBM silicon-on-insulator (SOI) microprocessors with different feature sizes, and core voltages. The results are compared with results for similar devices with build substrates. The cross sections of the SOI processors are lower than their bulk counterparts, but the threshold is about the same, even though the charge collections depth is more than an order of magnitude smaller in the SOI devices. The scaling of the cross section with reduction of feature size and core voltage dependence for SOI microprocessors discussed.

  20. First record of single event upset on the ground, Cray-1 computer memory at Los Alamos in 1976

    Energy Technology Data Exchange (ETDEWEB)

    Michalak, Sarah E [Los Alamos National Laboratory; Quinn, Heather M [Los Alamos National Laboratory; Grider, Gary A [Los Alamos National Laboratory; Iwanchuk, Paul N [Los Alamos National Laboratory; Morrison, John F [Los Alamos National Laboratory; Wender, Stephen A [Los Alamos National Laboratory; Normand, Eugene [EN ASSOCIATES, LLC; Wert, Jerry L [BOEING RESEARCH AND TEC; Johnson, Steve [CRAY, INC.


    Records of bit flips in the Cray-1 computer installed at Los Alamos in 1976 lead to an upset rate in the Cray-1 's bipolar SRAMs that correlates with the SEUs being induced by the atmospheric neutrons. In 1976 the Cray Research Company delivered its first supercomputer, the Cray-1, installing it at Los Alamos National Laboratory. Los Alamos had competed with the Lawrence Livermore National Laboratory for the Cray-1 and won, reaching an agreement with Seymour Cray to install the machine for a period of six months for free, after which they could decide whether to buy, lease or return it. As a result, Los Alamos personnel kept track of the computer reliability and performance and so we know that during those six months of operation, 152 memory parity errors were recorded. The computer memory consisted of approximately 70,000 1Kx1 bipolar ECL static RAMs, the Fairchild 10415. What the Los Alamos engineers didn't know is that those bit flips were the result of single event upsets (SEUs) caused by the atmospheric neutrons. Thus, these 152 bit flips were the first recorded SEUs on the earth, and were observed 2 years before the SEUs in the Intel DRAMs that had been found by May and Woods in 1978. The upsets in the DRAMs were shown to have been caused by alpha particles from the chip packaging material. In this paper we will demonstrate that the Cray-1 bit flips, which were found through the use of parity bits in the Cray-1, were likely due to atmospheric neutrons. This paper will follow the same approach as that of the very first paper to demonstrate single event effects, which occurred in satellite flip-flop circuits in 1975. The main difference is that in the four events that occurred over the course of 17 satellite years of operation were shown to be due to single event effects just a few years after those satellite anomalies were recorded. In the case of the Cray-1 bit flips, there has been a delay of more than 30 years between the occurrence of the bit

  1. Evaluation of single-event upset tolerance on 64Mbit DRAM and 16Mbit DRAM

    Energy Technology Data Exchange (ETDEWEB)

    Nemoto, N.; Shindou, H.; Matsuzaki, K.; Akutsu, T.; Matsuda, S. [National Space Development Agency of Japan, Tokyo (Japan); Hirao, T.; Itoh, H.; Nashiyama, I.


    In recent years, reduction in the mission cost is regarded as one of the most important matters, and thus much effort has been made to reduce the cost of electronic components used in spacecrafts without diminishing their performance. On this policy, there has been a growing interest in space application of commercial devices such as highly integrated memory ICs because of low prices and high performance of such devices. To ensure success in this application, it is indispensable to investigate radiation effects, e.g., single-event and total-dose effects, on commercial devices precisely. In the present study, we have evaluated single-event upset (SEU) tolerance for 1Mbit, 4Mbit SRAM and 16Mbit, 64Mbit DRAM by irradiation of high energy heavy ions such as 175MeV-Ar{sup 8+} and 450MeV-Xe{sup 23+}. We observed these SEU tolerance in space. (author)

  2. The board implementation of AVR microcontroller checking for single event upsets (United States)

    Lho, Young Hwan; Jang, Dae Jin; Seo, Kang Kuk; Jung, Jae Ho; Kim, Ki Yup


    Radiation hardening parts are to be used for satellites and nuclear power plants due to various kinds of radiation particles in space and radiation environment. Here, our focus is to implement a testing board of AVR Microcontroller checking for Single Event Upsets (SEU); the effects of protons on the electronic devices. The SEU results form the level change of stored information due to photon radiation and temperature in the space environment. The impact of SEU on PLD (Programmable Logic Devices) technology is most apparent in SRAM/ROM/DRAM devices wherein the state of storage cell can be upset. In this research, a simple and powerful test technique is suggested, and the results are presented for the analysis and future reference. In our experiment, the proton radiation facility (having the energy of 30 MeV with a beam current of 20 uA in the cyclotron) available at KIRAMS (Korea Institute of Radiological Medical Sciences) has been applied on two kinds of commercially available SRAM and EEPROM.

  3. Single event upset in static random access memories in atmospheric neutron environments

    CERN Document Server

    Arita, Y; Ogawa, I; Kishimoto, T


    Single-event upsets (SEUs) in a 0.4 mu m 4Mbit complementary metal oxide semiconductor (CMOS) static random access memory (SRAM) were investigated in various atmospheric neutron environments at sea level, at an altitude of 2612 m mountain, at an altitude of commercial airplane, and at an underground depth of 476m. Neutron-induced SEUs increase with the increase in altitude. For a device with a borophosphosilicate glass (BPSG) film, SEU rates induced by thermal neutrons increase with the decrease in the cell charge of a memory cell. A thermal neutron-induced SEU is significant in SRAMs with a small cell charge. With the conditions of small cell charge, thermal neutron-induced SEUs account for 60% or more of the total neutron-induced SEUs. The SEU rate induced by atmospheric thermal neutrons can be estimated by an acceleration test using sup 2 sup 5 sup 2 Cf. (author)

  4. A simple analytical model of single-event upsets in bulk CMOS (United States)

    Sogoyan, Armen V.; Chumakov, Alexander I.; Smolin, Anatoly A.; Ulanova, Anastasia V.; Boruzdina, Anna B.


    During the last decade, multiple new methods of single event upset (SEU) rate prediction for aerospace systems have been proposed. Despite different models and approaches being employed in these methods, they all share relatively high usage complexity and require information about a device that is not always available to an end user. This work presents an alternative approach to estimating SEU cross-section as a function of linear energy transfer (LET) that can be further developed into a method of SEU rate prediction. The goal is to propose a simple, yet physics-based, approach with just two parameters that can be used even in situations when only a process node of the device is known. The developed approach is based on geometrical interpretation of SEU cross-section and an analytical solution to the diffusion problem obtained for a simplified IC topology model. A good fit of the model to the experimental data encompassing 7 generations of SRAMs is demonstrated.

  5. Single event upset studies on the CMS tracker APV25 readout chip

    CERN Document Server

    Noah, E; Bisello, D; Faccio, F; Friedl, M; Fulcher, J R; Hall, G; Huhtinen, M; Kaminski, A; Pernicka, Manfred; Raymond, M; Wyss, J


    The microstrip tracker for the CMS experiment at the CERN Large Hadron Collider will be read out using APV25 chips. During high luminosity running the tracker will be exposed to particle fluxes up to 10**7 cm**-**2 s**-**1, which raises concerns that the APV25 could occasionally suffer Single Event Upsets (SEUs). The effect of SEU on the APV25 has been studied to investigate implications for CMS detector operation and from the viewpoint of detailed circuit operation, to improve the understanding of its origin and what factors affect its magnitude. Simulations were performed to reconstruct the effects created by highly ionising particles striking sensitive parts of the circuits, along with consideration of the underlying mechanisms of charge deposition, collection and the consequences. A model to predict the behaviour of the memory circuits in the APV25 has been developed and data collected from dedicated experiments using both heavy ions and hadrons have been shown to support it.

  6. Single Event Upset Detection and Hardening schemes for CNTFET SRAM – A Review

    Directory of Open Access Journals (Sweden)



    Full Text Available Carbon nanotubes (CNT provide a better alternative of silicon, when it comes to nano scales. Thanks to its high stability and high performance of carbon nanotube, CNT based FET (CNTFET devices which are gaining popularity of late. Single Event Upset (SEU in a device is caused due to radiation. Radiation can be through two ways, one due to charge particles present in the atmosphere and other due to alpha particles. In this article we review some of the detection and hardening schemes in CMOS SRAM and make related simulations on CNTFET SRAM. The aim of this paper is to present the challenges the CNTFET SRAM is facing when the radiation effects are introduced. A full experimentation of all the schemes of detection and correction schemes will be beyond the scope, so only certain experiments that can be well carried out with CNTFET SRAM memory is more focussed.

  7. Talys calculations for evaluation of neutron-induced single-event upset cross sections

    Energy Technology Data Exchange (ETDEWEB)

    Bourselier, Jean-Christophe


    The computer code TALYS has been used to calculate interactions between cosmic-ray neutrons and silicon nuclei with the goal to describe single-event upset (SEU) cross sections in microelectronics devices. Calculations for the Si(n,X) reaction extend over an energy range of 2 to 200 MeV. The obtained energy spectra of the resulting residuals and light-ions have been integrated using several different critical charges as SEU threshold. It is found that the SEU cross section seems largely to be dominated by {sup 28}Si recoils from elastic scattering. Furthermore, the shape of the SEU cross section as a function of the energy of the incoming neutron changes drastically with decreasing critical charge. The results presented in this report stress the importance of performing studies at mono-energetic neutron beams to advance the understanding of the underlying mechanisms causing SEUs.

  8. Swift heavy ion induced single event upsets in high density UV-EPROM's

    Energy Technology Data Exchange (ETDEWEB)

    Dahiwale, S.S. [Department of Physics, University of Pune, Pune 7 (India); Shinde, N.S. [Department of Chemical Engineering, Mie University (Japan); Kanjilal, D. [Inter University Accelerator Center, New Delhi (India); Bhoraskar, V.N. [Department of Physics, University of Pune, Pune 7 (India); Dhole, S.D. [Department of Physics, University of Pune, Pune 7 (India)], E-mail:


    A few high density UV-EPROM's (32Kb x 8) were irradiated with 5.41 MeV energy {alpha}-particles with fluences from 10{sup 4} to 10{sup 8} alphas/cm{sup 2} and 100 MeV nickel, iodine and silver ions for low fluences between 5 x 10{sup 7} and 10{sup 8} ions/cm{sup 2}. The energy and ion species was selected on the basis of predicted threshold values of linear energy transfer (LET) in silicon. The program which was stored in the memory found to be changed from 0 to 1 and 1 to 0 state, respectively. On the basis of changed states, the cross-sections ({sigma}) were calculated to investigate the single event effects/upsets. No upset was observed in case of {alpha}-particle since it has very low LET, but the SEU cross-section found to be more in case of Iodine i.e. 2.29 x 10{sup -3} cm{sup 2} than that of nickel, 2.12 x 10{sup -3} cm{sup 2} and silver, 2.26 x 10{sup -3}. This mainly attributes that LET for iodine is more as compared to silver and nickel ions, which deposits large amount of energy near the sensitive node of memory cell in the form of electron-hole pairs required to change the state. These measured SEU cross-section were also compared with theoretically predicted values along with the Weibull distribution fit to the ion induced experimental SEU data. The theoretical predicted SEU cross-section 3.27 x 10{sup -3} cm{sup 2} found to be in good agreement with the measured SEU cross-section.

  9. Analyzing Test-As-You-Fly Single Event Upset (SEU) Responses using SEU Data, Classical Reliability Models, and Space Environment Data (United States)

    Berg, Melanie; Label, Kenneth; Campola, Michael; Xapsos, Michael


    We propose a method for the application of single event upset (SEU) data towards the analysis of complex systems using transformed reliability models (from the time domain to the particle fluence domain) and space environment data.

  10. Method and apparatus for increasing resistance of bipolar buried layer integrated circuit devices to single-event upsets (United States)

    Zoutendyk, John A. (Inventor)


    Bipolar transistors fabricated in separate buried layers of an integrated circuit chip are electrically isolated with a built-in potential barrier established by doping the buried layer with a polarity opposite doping in the chip substrate. To increase the resistance of the bipolar transistors to single-event upsets due to ionized particle radiation, the substrate is biased relative to the buried layer with an external bias voltage selected to offset the built-in potential just enough (typically between about +0.1 to +0.2 volt) to prevent an accumulation of charge in the buried-layer-substrate junction.

  11. Single-Event Upset and Scaling Trends in New Generation of the Commercial SOI PowerPC Microprocessors (United States)

    Irom, Farokh; Farmanesh, Farhad; Kouba, Coy K.


    Single-event upset effects from heavy ions are measured for Motorola silicon-on-insulator (SOI) microprocessor with 90 nm feature sizes. The results are compared with previous results for SOI microprocessors with feature sizes of 130 and 180 nm. The cross section of the 90 nm SOI processors is smaller than results for 130 and 180 nm counterparts, but the threshold is about the same. The scaling of the cross section with reduction of feature size and core voltage for SOI microprocessors is discussed.

  12. Multi-physics modelling contributions to investigate the atmospheric cosmic rays on the single event upset sensitivity along the scaling trend of CMOS technologies. (United States)

    Hubert, G; Regis, D; Cheminet, A; Gatti, M; Lacoste, V


    Particles originating from primary cosmic radiation, which hit the Earth's atmosphere give rise to a complex field of secondary particles. These particles include neutrons, protons, muons, pions, etc. Since the 1980s it has been known that terrestrial cosmic rays can penetrate the natural shielding of buildings, equipment and circuit package and induce soft errors in integrated circuits. Recently, research has shown that commercial static random access memories are now so small and sufficiently sensitive that single event upsets (SEUs) may be induced from the electronic stopping of a proton. With continued advancements in process size, this downward trend in sensitivity is expected to continue. Then, muon soft errors have been predicted for nano-electronics. This paper describes the effects in the specific cases such as neutron-, proton- and muon-induced SEU observed in complementary metal-oxide semiconductor. The results will allow investigating the technology node sensitivity along the scaling trend. © The Author 2014. Published by Oxford University Press. All rights reserved. For Permissions, please email:

  13. A random access memory immune to single event upset using a T-Resistor (United States)

    Ochoa, A. Jr.


    In a random access memory cell, a resistance ''T'' decoupling network in each leg of the cell reduces random errors caused by the interaction of energetic ions with the semiconductor material forming the cell. The cell comprises two parallel legs each containing a series pair of complementary MOS transistors having a common gate connected to the node between the transistors of the opposite leg. The decoupling network in each leg is formed by a series pair of resistors between the transistors together with a third resistor interconnecting the junction between the pair of resistors and the gate of the transistor pair forming the opposite leg of the cell. 4 figs.

  14. Total Ionizing Dose Influence on the Single-Event Upset Sensitivity of 130-nm PD SOI SRAMs (United States)

    Zheng, Qiwen; Cui, Jiangwei; Liu, Mengxin; Zhou, Hang; Liu, Mohan; Wei, Ying; Su, Dandan; Ma, Teng; Lu, Wu; Yu, Xuefeng; Guo, Qi; He, Chengfa


    Effect of total ionizing dose (TID) on single-event upset (SEU) hardness of 130 nm partially depleted (PD) silicon-on-insulator (SOI) static random access memories (SRAMs) is investigated in this paper. The measurable synergistic effect of TID on SEU sensitivity of 130-nm PD SOI SRAM was observed in our experiment, even though that is far less than micrometer and submicrometer devices. Moreover, SEU cross section after TID irradiation has no dependence on the data pattern that was applied during TID exposure: SEU cross sections are characterized by TID data pattern and its complement data pattern are decreased consistently rather than a preferred state and a nonpreferred state as micrometer and sub-micrometer SRAMs. The memory cell test structure allowing direct measurement of static noise margin (SNM) under standby operation was designed using identical memory cell layout of SRAM. Direct measurement of the memory cell SNM shows that both data sides' SNM is decreased by TID, indicating that SEU cross section of 130-nm PD SOI SRAM will be increased by TID. And, the decreased SNM is caused by threshold shift in memory cell transistors induced by “radiation-induced narrow channel effect”.

  15. A comparison of heavy ion induced single event upset susceptibility in unhardened 6T/SRAM and hardened ADE/SRAM (United States)

    Wang, Bin; Zeng, Chuanbin; Geng, Chao; Liu, Tianqi; Khan, Maaz; Yan, Weiwei; Hou, Mingdong; Ye, Bing; Sun, Youmei; Yin, Yanan; Luo, Jie; Ji, Qinggang; Zhao, Fazhan; Liu, Jie


    Single event upset (SEU) susceptibility of unhardened 6T/SRAM and hardened active delay element (ADE)/SRAM, fabricated with 0.35 μm silicon-on-insulator (SOI) CMOS technology, was investigated at heavy ion accelerator. The mechanisms were revealed by the laser irradiation and resistor-capacitor hardened techniques. Compared with conventional 6T/SRAM, the hardened ADE/SRAM exhibited higher tolerance to heavy ion irradiation, with an increase of about 80% in the LET threshold and a decrease of ∼64% in the limiting upset cross-section. Moreover, different probabilities between 0 → 1 and 1 → 0 transitions were observed, which were attributed to the specific architecture of ADE/SRAM memory cell. Consequently, the radiation-hardened technology can be an attractive alternative to the SEU tolerance of the device-level.

  16. The supply voltage scaled dependency of the recovery of single event upset in advanced complementary metal—oxide—semiconductor static random-access memory cells (United States)

    Li, Da-Wei; Qin, Jun-Rui; Chen, Shu-Ming


    Using computer-aided design three-dimensional simulation technology, the supply voltage scaled dependency of the recovery of single event upset and charge collection in static random-access memory cells are investigated. It reveals that the recovery linear energy transfer threshold decreases with the supply voltage reducing, which is quite attractive for dynamic voltage scaling and subthreshold circuit radiation-hardened design. Additionally, the effect of supply voltage on charge collection is also investigated. It is concluded that the supply voltage mainly affects the bipolar gain of the parasitical bipolar junction transistor (BJT) and the existence of the source plays an important role in supply voltage variation.

  17. An exact, closed-form expression of the integral chord-length distribution for the calculation of single-event upsets induced by cosmic rays (United States)

    Luke, Keung L.; Buehler, Martin G.


    This paper presents a derivation of an exact closed-form expression of the integral chord-length distribution for the calculation of single-event upsets (SEUs) in an electronic memory cell, caused by cosmic rays. Results computed for two rectangular parallelepipeds using this exact expression are compared with those computed with Bradford's (1979) semiexact expression of C(x). It is found that the values of C(x) are identical for x equal or smaller than b but are vastly different for x greater than b. Moreover, while C(x) of Bradford gives reasonably accurate values of SEU rate for certain sets of computational parameters, it gives values more than 10 times larger than the correct values for other sets of parameters.

  18. Critical Lengths of Error Events in Convolutional Codes

    DEFF Research Database (Denmark)

    Justesen, Jørn; Andersen, Jakob Dahl


    If the calculation of the critical length is based on the expurgated exponent, the length becomes nonzero for low error probabilitites. This result applies to typical long codes, but it may also be useful for modelling error events in specific codes......If the calculation of the critical length is based on the expurgated exponent, the length becomes nonzero for low error probabilitites. This result applies to typical long codes, but it may also be useful for modelling error events in specific codes...

  19. Critical lengths of error events in convolutional codes

    DEFF Research Database (Denmark)

    Justesen, Jørn


    If the calculation of the critical length is based on the expurgated exponent, the length becomes nonzero for low error probabilities. This result applies to typical long codes, but it may also be useful for modeling error events in specific codes......If the calculation of the critical length is based on the expurgated exponent, the length becomes nonzero for low error probabilities. This result applies to typical long codes, but it may also be useful for modeling error events in specific codes...

  20. Critical Lengths of Error Events in Convolutional Codes

    DEFF Research Database (Denmark)

    Justesen, Jørn; Andersen, Jakob Dahl


    If the calculation of the critical length is based on the expurgated exponent, the length becomes nonzero for low error probabilities. This result applies to typical long codes, but it may also be useful for modeling error events in specific codes......If the calculation of the critical length is based on the expurgated exponent, the length becomes nonzero for low error probabilities. This result applies to typical long codes, but it may also be useful for modeling error events in specific codes...

  1. Development of Single-Event Upset hardened programmable logic devices in deep submicron CMOS; Developpement de circuits logiques programmables resistants aux aleas logiques en technologie CMOS submicrometrique

    Energy Technology Data Exchange (ETDEWEB)

    Bonacini, S


    The electronics associated to the particle detectors of the Large Hadron Collider (LHC), under construction at CERN, will operate in a very harsh radiation environment. Commercial Off-The-Shelf (COTS) components cannot be used in the vicinity of particle collision due to their poor radiation tolerance. This thesis is a contribution to the effort to cover the need for radiation-tolerant SEU-robust (Single Event Upset) programmable components for application in high energy physics experiments. Two components are under development: a Programmable Logic Device (PLD) and a Field-Programmable Gate Array (FPGA). The PLD is a fuse-based, 10-input, 8-I/O general architecture device in 0.25 {mu}m CMOS technology. The FPGA under development is a 32*32 logic block array, equivalent to {approx} 25 k gates, in 0.13 {mu}m CMOS. The irradiation test results obtained in the CMOS 0.25 {mu}m technology demonstrate good robustness of the circuit up to an LET (Linear Energy Transfer) of 79.6 cm{sup 2}*MeV/mg, which make it suitable for the target environment. The CMOS 0.13 {mu}m circuit has showed robustness to an LET of 37.4 cm{sup 2}*MeV/mg in the static test mode and has increased sensitivity in the dynamic test mode. This work focused also on the research for an SEU-robust register in both the mentioned technologies. The SEU-robust register is employed as a user data flip-flop in the FPGA and PLD designs and as a configuration cell as well in the FPGA design.


    Directory of Open Access Journals (Sweden)

    Apriyani Puji Hastuti


    Full Text Available Introductions: Medication error is one of many types of errors that could decrease the quality and safety of healthcare. Increasing number of adverse events (AE reflects the number of medication errors. This study aimed to develop a model of medication error prevention based on knowledge management. This model is expected to improve knowledge and skill of nurses to prevent medication error which is characterized by the decrease of adverse events (AE. Methods: This study consisted of two stages. The first stage of research was an explanative survey using cross-sectional approach involving 15 respondents selected by purposive sampling. The second stage was a pre-test experiment involving 29 respondents selected with cluster sampling. Partial Leas square (PLS was used to examine the factors affecting medication error prevention model while the Wilcoxon Signed Rank Test was used to test the effect of medication error prevention model against adverse events (AE. Results: Individual factors (path coefficient 12:56, t = 4,761 play an important role in nurse behavioral changes about medication error prevention based in knowledge management, organizational factor (path coefficient = 0276, t = 2.504 play an important role in nurse behavioral changes about medication error prevention based on knowledge management. Work characteristic factor (path coefficient = 0309, t = 1.98 play an important role in nurse behavioral changes about medication error prevention based on knowledge management. The medication error prevention model based on knowledge management was also significantly decreased adverse event (p = 0.000, α <0.05. Discussion: Factors of individuals, organizations and work characteristics were important in the development of medication error prevention models based on knowledge management.

  3. Airplane Upset Training Evaluation Report (United States)

    Gawron, Valerie J.; Jones, Patricia M. (Technical Monitor)


    Airplane upset accidents are a leading factor in hull losses and fatalities. This study compared five types of airplane-upset training. Each group was composed of eight, non-military pilots flying in their probationary year for airlines operating in the United States. The first group, 'No aero / no upset,' was made up of pilots without any airplane upset training or aerobatic flight experience; the second group, 'Aero/no upset,' of pilots without any airplane-upset training but with aerobatic experience; the third group, 'No aero/upset,' of pilots who had received airplane-upset training in both ground school and in the simulator; the fourth group, 'Aero/upset,' received the same training as Group Three but in addition had aerobatic flight experience; and the fifth group, 'In-flight' received in-flight airplane upset training using an instrumented in-flight simulator. Recovery performance indicated that clearly training works - specifically, all 40 pilots recovered from the windshear upset. However few pilots were trained or understood the use of bank to change the direction of the lift vector to recover from nose high upsets. Further, very few thought of, or used differential thrust to recover from rudder or aileron induced roll upsets. In addition, recovery from icing-induced stalls was inadequate.

  4. Barriers to adverse event and error reporting in anesthesia. (United States)

    Heard, Gaylene C; Sanderson, Penelope M; Thomas, Rowan D


    Although anesthesiologists are leaders in patient safety, there has been little research on factors affecting their reporting of adverse events and errors. First, we explored the attitudinal/emotional factors influencing reporting of an unspecified adverse event caused by error. Second, we used a between-groups study design to ask whether there are different perceived barriers to reporting a case of anaphylaxis caused by an error compared with anaphylaxis not caused by error. Finally, we examined strategies that anesthesiologists believe would facilitate reporting. Where possible, we contrasted our results with published findings from other physician groups. An anonymous, self-administered, mailed survey was conducted of 629 consultant anesthesiologists and 263 anesthesiology residents on the mailing list of the Australian and New Zealand College of Anaesthetists in Victoria, Australia. Participants were randomized into "Error" versus "No Error" groups for the specified anaphylaxis adverse event section of the survey. Data were analyzed using nonparametric descriptive and inferential tests. There were 433 usable returned surveys, a usable response rate of 49%. First, there was only 1 of 13 statements on attitudinal/emotional factors that influenced reporting of an unspecified adverse event caused by error with which more anesthesiologists agreed/strongly agreed than disagreed/strongly disagreed: "Doctors who make errors are blamed by their colleagues." Second, when an error rather than no error had caused anaphylaxis, participants were more likely to agree/strongly agree that 6 statements about litigation, getting into trouble, disciplinary action, being blamed, unsupportive colleagues, and not wanting the case discussed in meetings, were perceived as reporting barriers. Finally, the most favored assistive strategies for reporting were generalized deidentified feedback about adverse event and error reports, role models such as senior colleagues who openly encourage

  5. Radiation-hardened MRAM-based LUT for non-volatile FPGA soft error mitigation with multi-node upset tolerance (United States)

    Zand, Ramtin; DeMara, Ronald F.


    In this paper, we have developed a radiation-hardened non-volatile lookup table (LUT) circuit utilizing spin Hall effect (SHE)-magnetic random access memory (MRAM) devices. The design is motivated by modeling the effect of radiation particles striking hybrid complementary metal oxide semiconductor/spin based circuits, and the resistive behavior of SHE-MRAM devices via established and precise physics equations. The models developed are leveraged in the SPICE circuit simulator to verify the functionality of the proposed design. The proposed hardening technique is based on using feedback transistors, as well as increasing the radiation capacity of the sensitive nodes. Simulation results show that our proposed LUT circuit can achieve multiple node upset (MNU) tolerance with more than 38% and 60% power-delay product improvement as well as 26% and 50% reduction in device count compared to the previous energy-efficient radiation-hardened LUT designs. Finally, we have performed a process variation analysis showing that the MNU immunity of our proposed circuit is realized at the cost of increased susceptibility to transistor and MRAM variations compared to an unprotected LUT design.

  6. Proton-induced single event upset characterisation of a 1 giga-sample per second analog to digital converter; Caracterisation de la sensibilite aux upsets induits par les protons d'un convertisseur analogique numerique de 1 giga-echantillons par seconde

    Energy Technology Data Exchange (ETDEWEB)

    Reed, R.A. [NASA/GSFC Greenbelt, MD (United States); Marshall, P.W. [NASA/GSFC Greenbelt, Consultant, MD (United States); Carts, M.A. [Naval Research Lab., Washington (United States)


    The SPT7760 is an analog to digital converter that is used in satellite for digital processing. In this paper we describe the characterization and analysis of proton-induced single event upsets (SEU) for the SPT7760 operating at sample rates from 125 Msps (Mega-samples per second) to 1 Gsps. The SEU cross-section has been measured as a function of sample rate for various input levels. The data collected is clearly non-linear for all cases. The data shows that this device has a relative low cross-section for proton-induced SEUs and remains functional at a proton dose of 580 krad (Si). (A.C.)

  7. Airplane upset prevention research needs (United States)


    This paper, which concludes the Upset Recovery Session convened and chaired by Dennis : Crider from the National Transportation Safety Board and the first author at the AIAA : Modeling and Simulation Technologies Conference 2008, provides a broad ove...

  8. Proton Upset Monte Carlo Simulation (United States)

    O'Neill, Patrick M.; Kouba, Coy K.; Foster, Charles C.


    The Proton Upset Monte Carlo Simulation (PROPSET) program calculates the frequency of on-orbit upsets in computer chips (for given orbits such as Low Earth Orbit, Lunar Orbit, and the like) from proton bombardment based on the results of heavy ion testing alone. The software simulates the bombardment of modern microelectronic components (computer chips) with high-energy (.200 MeV) protons. The nuclear interaction of the proton with the silicon of the chip is modeled and nuclear fragments from this interaction are tracked using Monte Carlo techniques to produce statistically accurate predictions.

  9. Single Event Test Methodologies and System Error Rate Analysis for Triple Modular Redundant Field Programmable Gate Arrays (United States)

    Allen, Gregory; Edmonds, Larry D.; Swift, Gary; Carmichael, Carl; Tseng, Chen Wei; Heldt, Kevin; Anderson, Scott Arlo; Coe, Michael


    We present a test methodology for estimating system error rates of Field Programmable Gate Arrays (FPGAs) mitigated with Triple Modular Redundancy (TMR). The test methodology is founded in a mathematical model, which is also presented. Accelerator data from 90 nm Xilins Military/Aerospace grade FPGA are shown to fit the model. Fault injection (FI) results are discussed and related to the test data. Design implementation and the corresponding impact of multiple bit upset (MBU) are also discussed.

  10. Error Analysis in the Joint Event Location/Seismic Calibration Inverse Problem

    National Research Council Canada - National Science Library

    Rodi, William L


    This project is developing new mathematical and computational techniques for analyzing the uncertainty in seismic event locations, as induced by observational errors and errors in travel-time models...

  11. Human Error Assessmentin Minefield Cleaning Operation Using Human Event Analysis

    Directory of Open Access Journals (Sweden)

    Mohammad Hajiakbari


    Full Text Available Background & objective: Human error is one of the main causes of accidents. Due to the unreliability of the human element and the high-risk nature of demining operations, this study aimed to assess and manage human errors likely to occur in such operations. Methods: This study was performed at a demining site in war zones located in the West of Iran. After acquiring an initial familiarity with the operations, methods, and tools of clearing minefields, job task related to clearing landmines were specified. Next, these tasks were studied using HTA and related possible errors were assessed using ATHEANA. Results: de-mining task was composed of four main operations, including primary detection, technical identification, investigation, and neutralization. There were found four main reasons for accidents occurring in such operations; walking on the mines, leaving mines with no action, error in neutralizing operation and environmental explosion. The possibility of human error in mine clearance operations was calculated as 0.010. Conclusion: The main causes of human error in de-mining operations can be attributed to various factors such as poor weather and operating conditions like outdoor work, inappropriate personal protective equipment, personality characteristics, insufficient accuracy in the work, and insufficient time available. To reduce the probability of human error in de-mining operations, the aforementioned factors should be managed properly.

  12. Upset Prediction in Friction Welding Using Radial Basis Function Neural Network

    Directory of Open Access Journals (Sweden)

    Wei Liu


    Full Text Available This paper addresses the upset prediction problem of friction welded joints. Based on finite element simulations of inertia friction welding (IFW, a radial basis function (RBF neural network was developed initially to predict the final upset for a number of welding parameters. The predicted joint upset by the RBF neural network was compared to validated finite element simulations, producing an error of less than 8.16% which is reasonable. Furthermore, the effects of initial rotational speed and axial pressure on the upset were investigated in relation to energy conversion with the RBF neural network. The developed RBF neural network was also applied to linear friction welding (LFW and continuous drive friction welding (CDFW. The correlation coefficients of RBF prediction for LFW and CDFW were 0.963 and 0.998, respectively, which further suggest that an RBF neural network is an effective method for upset prediction of friction welded joints.

  13. Investigation of Single-Bit and Multiple-Bit Upsets in Oxide RRAM-Based 1T1R and Crossbar Memory Arrays (United States)

    Liu, Rui; Mahalanabis, Debayan; Barnaby, Hugh J.; Yu, Shimeng


    In this paper, the susceptibility of oxide-based resistive switching random memory (RRAM) to heavy ion strikes is investigated. A physics-based SPICE model calibrated with HfOx RRAM is employed for circuit and array-level simulations. The RRAM state-flipping is attributed to the transient photocurrents at neighboring transistors. Single-bit-upset (SBU) caused by either single-event upset (SEU) or multiple-event upset (MEU) is modeled and simulated in the one-transistor and one-resistor (1T1R) array, which corroborates with experimental observations. In addition, circuit simulation is performed to investigate the impact of transient-induced soft errors in a 1024 ×1024 crossbar array. The sensitive locations in crossbar arrays are the driver circuits at the edge of the array. The simulations show that the crossbar array with HfOx RRAM is of high radiation tolerance thanks to the V/2 bias scheme. However, multiple-bit upset (MBU) may occur if using other oxide materials with lower operation voltage. Voltage spikes generated at the edge of the array may propagate along rows or columns as there is no isolation between cells in the crossbar array.

  14. Vaccination errors reported to the Vaccine Adverse Event Reporting System, (VAERS) United States, 2000-2013. (United States)

    Hibbs, Beth F; Moro, Pedro L; Lewis, Paige; Miller, Elaine R; Shimabukuro, Tom T


    Vaccination errors are preventable events. Errors can have impacts including inadequate immunological protection, possible injury, cost, inconvenience, and reduced confidence in the healthcare delivery system. To describe vaccination error reports submitted to the Vaccine Adverse Event Reporting System (VAERS) and identify opportunities for prevention. We conducted descriptive analyses using data from VAERS, the U.S. spontaneous surveillance system for adverse events following immunization. The VAERS database was searched from 2000 through 2013 for U.S. reports describing vaccination errors and reports were categorized into 11 error groups. We analyzed numbers and types of vaccination error reports, vaccines involved, reporting trends over time, and descriptions of errors for selected reports. We identified 20,585 vaccination error reports documenting 21,843 errors. Annual reports increased from 10 in 2000 to 4324 in 2013. The most common error group was "Inappropriate Schedule" (5947; 27%); human papillomavirus (quadrivalent) (1516) and rotavirus (880) vaccines were most frequently involved. "Storage and Dispensing" errors (4983; 23%) included mostly expired vaccine administered (2746) and incorrect storage of vaccine (2202). "Wrong Vaccine Administered" errors (3372; 15%) included mix-ups between vaccines with similar antigens such as varicella/herpes zoster (shingles), DTaP/Tdap, and pneumococcal conjugate/polysaccharide. For error reports with an adverse health event (5204; 25% of total), 92% were classified as non-serious. We also identified 936 vaccination error clusters (i.e., same error, multiple patients, in a common setting) involving over 6141 patients. The most common error in clusters was incorrect storage of vaccine (582 clusters and more than 1715 patients). Vaccination error reports to VAERS have increased substantially. Contributing factors might include changes in reporting practices, increasing complexity of the immunization schedule

  15. Error Analysis of Satellite Precipitation-Driven Modeling of Flood Events in Complex Alpine Terrain

    Directory of Open Access Journals (Sweden)

    Yiwen Mei


    Full Text Available The error in satellite precipitation-driven complex terrain flood simulations is characterized in this study for eight different global satellite products and 128 flood events over the Eastern Italian Alps. The flood events are grouped according to two flood types: rain floods and flash floods. The satellite precipitation products and runoff simulations are evaluated based on systematic and random error metrics applied on the matched event pairs and basin-scale event properties (i.e., rainfall and runoff cumulative depth and time series shape. Overall, error characteristics exhibit dependency on the flood type. Generally, timing of the event precipitation mass center and dispersion of the time series derived from satellite precipitation exhibits good agreement with the reference; the cumulative depth is mostly underestimated. The study shows a dampening effect in both systematic and random error components of the satellite-driven hydrograph relative to the satellite-retrieved hyetograph. The systematic error in shape of the time series shows a significant dampening effect. The random error dampening effect is less pronounced for the flash flood events and the rain flood events with a high runoff coefficient. This event-based analysis of the satellite precipitation error propagation in flood modeling sheds light on the application of satellite precipitation in mountain flood hydrology.

  16. Mixed Methods Analysis of Medical Error Event Reports: A Report from the ASIPS Collaborative

    National Research Council Canada - National Science Library

    Harris, Daniel M; Westfall, John M; Fernald, Douglas H; Duclos, Christine W; West, David R; Niebauer, Linda; Marr, Linda; Quintela, Javan; Main, Deborah S


    .... This paper presents a mixed methods approach to analyzing narrative error event reports. Mixed methods studies integrate one or more qualitative and quantitative techniques for data collection and analysis...

  17. Standardizing Medication Error Event Reporting in the U.S. Department of Defense

    National Research Council Canada - National Science Library

    Nosek, Ronald A., Jr; McMeekin, Judy; Rake, Geoffrey W


    ...) began an aggressive examination of medical errors and the strategies for minimizing them. A primary goal was the creation of a standardized medication event reporting system, including a central registry for the compilation of reported data...

  18. Negative cognitive errors and positive illusions for negative divorce events: predictors of children's psychological adjustment. (United States)

    Mazur, E; Wolchik, S A; Sandler, I N


    This study examined the relations among negative cognitive errors regarding hypothetical negative divorce events, positive illusions about those same events, actual divorce events, and psychological adjustment in 38 8- to 12-year-old children whose parents had divorced within the previous 2 years. Children's scores on a scale of negative cognitive errors (catastrophizing, overgeneralizing, and personalizing) correlated significantly with self-reported symptoms of anxiety and self-esteem, and with maternal reports of behavior problems. Children's scores on a scale measuring positive illusions (high self-regard, illusion of personal control, and optimism for the future) correlated significantly with less self-reported aggression. Both appraisal types accounted for variance in some measures of symptomatology beyond that explained by actual events. There was no significant association between children's negative cognitive errors and positive illusions. The implications of these results for theories of negative cognitive errors and of positive illusions, as well as for future research, are discussed.

  19. Adverse Drug Events and Medication Errors in African Hospitals: A Systematic Review. (United States)

    Mekonnen, Alemayehu B; Alhawassi, Tariq M; McLachlan, Andrew J; Brien, Jo-Anne E


    Medication errors and adverse drug events are universal problems contributing to patient harm but the magnitude of these problems in Africa remains unclear. The objective of this study was to systematically investigate the literature on the extent of medication errors and adverse drug events, and the factors contributing to medication errors in African hospitals. We searched PubMed, MEDLINE, EMBASE, Web of Science and Global Health databases from inception to 31 August, 2017 and hand searched the reference lists of included studies. Original research studies of any design published in English that investigated adverse drug events and/or medication errors in any patient population in the hospital setting in Africa were included. Descriptive statistics including median and interquartile range were presented. Fifty-one studies were included; of these, 33 focused on medication errors, 15 on adverse drug events, and three studies focused on medication errors and adverse drug events. These studies were conducted in nine (of the 54) African countries. In any patient population, the median (interquartile range) percentage of patients reported to have experienced any suspected adverse drug event at hospital admission was 8.4% (4.5-20.1%), while adverse drug events causing admission were reported in 2.8% (0.7-6.4%) of patients but it was reported that a median of 43.5% (20.0-47.0%) of the adverse drug events were deemed preventable. Similarly, the median mortality rate attributed to adverse drug events was reported to be 0.1% (interquartile range 0.0-0.3%). The most commonly reported types of medication errors were prescribing errors, occurring in a median of 57.4% (interquartile range 22.8-72.8%) of all prescriptions and a median of 15.5% (interquartile range 7.5-50.6%) of the prescriptions evaluated had dosing problems. Major contributing factors for medication errors reported in these studies were individual practitioner factors (e.g. fatigue and inadequate knowledge

  20. Efficiency of Event-Based Sampling According to Error Energy Criterion

    Directory of Open Access Journals (Sweden)

    Marek Miskowicz


    Full Text Available The paper belongs to the studies that deal with the effectiveness of the particular event-based sampling scheme compared to the conventional periodic sampling as a reference. In the present study, the event-based sampling according to a constant energy of sampling error is analyzed. This criterion is suitable for applications where the energy of sampling error should be bounded (i.e., in building automation, or in greenhouse climate monitoring and control. Compared to the integral sampling criteria, the error energy criterion gives more weight to extreme sampling error values. The proposed sampling principle extends a range of event-based sampling schemes and makes the choice of particular sampling criterion more flexible to application requirements. In the paper, it is proved analytically that the proposed event-based sampling criterion is more effective than the periodic sampling by a factor defined by the ratio of the maximum to the mean of the cubic root of the signal time-derivative square in the analyzed time interval. Furthermore, it is shown that the sampling according to energy criterion is less effective than the send-on-delta scheme but more effective than the sampling according to integral criterion. On the other hand, it is indicated that higher effectiveness in sampling according to the selected event-based criterion is obtained at the cost of increasing the total sampling error defined as the sum of errors for all the samples taken.

  1. Efficiency of event-based sampling according to error energy criterion. (United States)

    Miskowicz, Marek


    The paper belongs to the studies that deal with the effectiveness of the particular event-based sampling scheme compared to the conventional periodic sampling as a reference. In the present study, the event-based sampling according to a constant energy of sampling error is analyzed. This criterion is suitable for applications where the energy of sampling error should be bounded (i.e., in building automation, or in greenhouse climate monitoring and control). Compared to the integral sampling criteria, the error energy criterion gives more weight to extreme sampling error values. The proposed sampling principle extends a range of event-based sampling schemes and makes the choice of particular sampling criterion more flexible to application requirements. In the paper, it is proved analytically that the proposed event-based sampling criterion is more effective than the periodic sampling by a factor defined by the ratio of the maximum to the mean of the cubic root of the signal time-derivative square in the analyzed time interval. Furthermore, it is shown that the sampling according to energy criterion is less effective than the send-on-delta scheme but more effective than the sampling according to integral criterion. On the other hand, it is indicated that higher effectiveness in sampling according to the selected event-based criterion is obtained at the cost of increasing the total sampling error defined as the sum of errors for all the samples taken.

  2. BRAT Diet: Recovering from an Upset Stomach (United States)

    ... or clear soup broths. Don’t start eating dairy products, sugary, or fatty foods right away. These ... upset stomach or diarrhea.As you feel better, return to a normal, healthy diet. The BRAT diet ...

  3. [Event-related EEG potentials associated with error detection in psychiatric disorder: literature review]. (United States)

    Balogh, Lívia; Czobor, Pál


    Error-related bioelectric signals constitute a special subgroup of event-related potentials. Researchers have identified two evoked potential components to be closely related to error processing, namely error-related negativity (ERN) and error-positivity (Pe), and they linked these to specific cognitive functions. In our article first we give a brief description of these components, then based on the available literature, we review differences in error-related evoked potentials observed in patients across psychiatric disorders. The PubMed and Medline search engines were used in order to identify all relevant articles, published between 2000 and 2009. For the purpose of the current paper we reviewed publications summarizing results of clinical trials. Patients suffering from schizophrenia, anorexia nervosa or borderline personality disorder exhibited a decrease in the amplitude of error-negativity when compared with healthy controls, while in cases of depression and anxiety an increase in the amplitude has been observed. Some of the articles suggest specific personality variables, such as impulsivity, perfectionism, negative emotions or sensitivity to punishment to underlie these electrophysiological differences. Research in the field of error-related electric activity has come to the focus of psychiatry research only recently, thus the amount of available data is significantly limited. However, since this is a relatively new field of research, the results available at present are noteworthy and promising for future electrophysiological investigations in psychiatric disorders.

  4. Medication errors and adverse drug events in kidney transplant recipients: incidence, risk factors, and clinical outcomes. (United States)

    Taber, David J; Pilch, Nicole A; Bratton, Charles F; McGillicuddy, John W; Chavin, Kenneth D; Baliga, Prabhakar K


    To determine the incidence, risk factors, and clinical outcomes associated with clinically significant medication errors or adverse drug events in kidney transplant recipients. Retrospective observational study. Transplant center at an academic medical center. A total of 476 adults who received kidney transplants between June 2006 and July 2009. Severe or significant medication errors and adverse drug events (medication-related problems [MRPs]) were identified by medical record review. Only patient-induced medication errors (e.g., took wrong dose or frequency of drug, took drug not prescribed) were captured. Clinical outcomes included patient and graft survival, infections (including cytomegalovirus), readmissions, and acute rejection episodes. Thirty-seven (8%) of the 476 patients developed a clinically significant MRP. Univariate and confirmatory multivariate analyses revealed that female sex, African-American race, pretransplantation diabetes mellitus, delayed graft function, and retransplant recipients were independent risk factors for developing an MRP. Patients with MRPs had significantly higher rates of acute rejection (11% vs 30%, p=0.004), cytomegalovirus infection (15% vs 30%, p=0.033), and 30-day readmissions (5% vs 16%, p=0.018). Graft survival was also significantly lower in patients who had MRPs (pmedication errors and associated adverse drug events were common in kidney transplant recipients. General and transplant-specific risk factors were associated with the development of these MRPs, and MRPs were associated with increased risk of rejection and graft loss. © 2012 Pharmacotherapy Publications, Inc.

  5. Upsetting Others and Provoking Ridicule: Children's Reasoning about the Self-Presentational Consequences of Rule Violation (United States)

    Banerjee, Robin; Bennett, Mark; Luke, Nikki


    This study examined children's understanding of the distinctive "self-presentational" impacts of moral and social-conventional rule violations. A sample of 80 children aged 7-8 and 9-10 years generated examples of interpersonal events that would upset others and events that would elicit social attention to the self. As expected, both age groups…

  6. Single Event Effects (SEE) Testing of Embedded DSP Cores within Microsemi RTAX4000D Field Programmable Gate Array (FPGA) Devices (United States)

    Perez, Christopher E.; Berg, Melanie D.; Friendlich, Mark R.


    Motivation for this work is: (1) Accurately characterize digital signal processor (DSP) core single-event effect (SEE) behavior (2) Test DSP cores across a large frequency range and across various input conditions (3) Isolate SEE analysis to DSP cores alone (4) Interpret SEE analysis in terms of single-event upsets (SEUs) and single-event transients (SETs) (5) Provide flight missions with accurate estimate of DSP core error rates and error signatures.

  7. Impact of extended-duration shifts on medical errors, adverse events, and attentional failures.

    Directory of Open Access Journals (Sweden)

    Laura K Barger


    Full Text Available A recent randomized controlled trial in critical-care units revealed that the elimination of extended-duration work shifts (> or =24 h reduces the rates of significant medical errors and polysomnographically recorded attentional failures. This raised the concern that the extended-duration shifts commonly worked by interns may contribute to the risk of medical errors being made, and perhaps to the risk of adverse events more generally. Our current study assessed whether extended-duration shifts worked by interns are associated with significant medical errors, adverse events, and attentional failures in a diverse population of interns across the United States.We conducted a Web-based survey, across the United States, in which 2,737 residents in their first postgraduate year (interns completed 17,003 monthly reports. The association between the number of extended-duration shifts worked in the month and the reporting of significant medical errors, preventable adverse events, and attentional failures was assessed using a case-crossover analysis in which each intern acted as his/her own control. Compared to months in which no extended-duration shifts were worked, during months in which between one and four extended-duration shifts and five or more extended-duration shifts were worked, the odds ratios of reporting at least one fatigue-related significant medical error were 3.5 (95% confidence interval [CI], 3.3-3.7 and 7.5 (95% CI, 7.2-7.8, respectively. The respective odds ratios for fatigue-related preventable adverse events, 8.7 (95% CI, 3.4-22 and 7.0 (95% CI, 4.3-11, were also increased. Interns working five or more extended-duration shifts per month reported more attentional failures during lectures, rounds, and clinical activities, including surgery and reported 300% more fatigue-related preventable adverse events resulting in a fatality.In our survey, extended-duration work shifts were associated with an increased risk of significant medical

  8. Disclosure of adverse events and errors in surgical care: challenges and strategies for improvement. (United States)

    Lipira, Lauren E; Gallagher, Thomas H


    The disclosure of adverse events to patients, including those caused by medical errors, is a critical part of patient-centered healthcare and a fundamental component of patient safety and quality improvement. Disclosure benefits patients, providers, and healthcare institutions. However, the act of disclosure can be difficult for physicians. Surgeons struggle with disclosure in unique ways compared with other specialties, and disclosure in the surgical setting has specific challenges. The frequency of surgical adverse events along with a dysfunctional tort system, the team structure of surgical staff, and obstacles created inadvertently by existing surgical patient safety initiatives may contribute to an environment not conducive to disclosure. Fortunately, there are multiple strategies to address these barriers. Participation in communication and resolution programs, integration of Just Culture principles, surgical team disclosure planning, refinement of informed consent and morbidity and mortality processes, surgery-specific professional standards, and understanding the complexities of disclosing other clinicians' errors all have the potential to help surgeons provide patients with complete, satisfactory disclosures. Improvement in the regularity and quality of disclosures after surgical adverse events and errors will be key as the field of patient safety continues to advance.

  9. Sideline Performance of the Balance Error Scoring System during a Live Sporting Event. (United States)

    Rahn, Carrie; Munkasy, Barry A; Barry Joyner, A; Buckley, Thomas A


    The purpose was to examine the influence of a live sporting sideline environment on balance error scoring system (BESS) performance. Prospective longitudinal cohort study. The BESS was performed by all participants at 3 locations: (1) quiet laboratory, (2) football stadium sidelines, and (3) basketball arena sidelines. The experimental group had 38 participants (age: 20.1 ± 1.1 years; height: 170.0 ± 7.7 cm; mass: 66.7 ± 9.5 kg) who were female intercollegiate student-athletes (SA). The control group consisted of 38 recreationally active female college students (age: 20.8 ± 1.1 years; height: 162.6 ± 6.0 cm; mass: 63.7 ± 10.6 kg). The 2 groups performed the tests at the same locations, the SA group during live sporting events and the control group when no event was occurring. The dependent variable was the total BESS score. Separate 2 × 3 mixed methods analyses of variance investigated the influence of the environment and practice effect. There was a significant interaction for group by environment (P = 0.004), and the SA group committed more errors at both the football and the basketball settings than the control group. The SA group also committed more errors at football (P = 0.028) than baseline. The control group demonstrated a likely practice effect with fewer errors during each administration. The BESS score deteriorated when performed on the sidelines of a live sporting event potentially challenging the clinical utility of the BESS. Clinicians need to consider the role of the local environment when performing the BESS test and should perform postinjury tests in the same environment as the baseline test. When performing balance testing of patients with suspected concussions, clinicians need to consider the environment in which the test is performed and attempt to match the preseason testing environment.

  10. Technology-Induced Errors and Adverse Event Reporting in an Organizational Learning Perspective. (United States)

    Vinther, Line Dausel; Jensen, Christian Møller; Hjelmager, Ditte Meulengracht; Lyhne, Nicoline; Nøhr, Christian


    This paper addresses the possibilities of evaluating technology-induced errors, through the utilization of experiences of the Danish adverse event reporting system. The learning loop in the adverse event reporting system is identified and analyzed, to examine which elements can be utilized to evaluate technologies. The empirical data was collected through interviews and a workshop with members of the nursing staff at a nursing home in Aalborg, Denmark. It was found that, the establishment of sustainable feedback learning loops depends on shared visions in the organization and how creating shared visions requires involvement and participation. Secondly, care workers must possess fundamental knowledge about the technologies available to them. Thirdly comprehensive classification of adverse events should be established to allow for a systematic and goal directed feed-back process.

  11. Field test results of a new ambulatory care Medication Error and Adverse Drug Event Reporting System--MEADERS. (United States)

    Hickner, John; Zafar, Atif; Kuo, Grace M; Fagnan, Lyle J; Forjuoh, Samuel N; Knox, Lyndee M; Lynch, John T; Stevens, Brian Kelly; Pace, Wilson D; Hamlin, Benjamin N; Scherer, Hilary; Hudson, Brenda L; Oppenheimer, Caitlin Carroll; Tierney, William M


    In this study, we developed and field tested the Medication Error and Adverse Drug Event Reporting System (MEADERS)-an easy-to-use, Web-based reporting system designed for busy office practices. We conducted a 10-week field test of MEADERS in which 220 physicians and office staff from 24 practices reported medication errors and adverse drug events they observed during usual clinical care. The main outcomes were (1) use and acceptability of MEADERS measured with a postreporting survey and interviews with office managers and lead physicians, and (2) distributions of characteristics of the medication event reports. A total of 507 anonymous event reports were submitted. The mean reporting time was 4.3 minutes. Of these reports, 357 (70%) included medication errors only, 138 (27%) involved adverse drug events only, and 12 (2.4%) included both. Medication errors were roughly equally divided among ordering medications, implementing prescription orders, errors by patients receiving the medications, and documentation errors. The most frequent contributors to the medication errors and adverse drug events were communication problems (41%) and knowledge deficits (22%). Eight (1.6%) of the reported events led to hospitalization. Reporting raised staff and physician awareness of the kinds of errors that occur in office medication management; however, 36% agreed or strongly agreed that the event reporting "has increased the fear of repercussion in the practice." Time pressure was the main barrier to reporting. It is feasible for primary care clinicians and office staff to report medication errors and adverse drug events to a Web-based reporting system. Time pressures and a punitive culture are barriers to event reporting that must be overcome. Further testing of MEADERS as a quality improvement tool is warranted.

  12. Field Test Results of a New Ambulatory Care Medication Error and Adverse Drug Event Reporting System—MEADERS (United States)

    Hickner, John; Zafar, Atif; Kuo, Grace M.; Fagnan, Lyle J.; Forjuoh, Samuel N.; Knox, Lyndee M.; Lynch, John T.; Stevens, Brian Kelly; Pace, Wilson D.; Hamlin, Benjamin N.; Scherer, Hilary; Hudson, Brenda L.; Oppenheimer, Caitlin Carroll; Tierney, William M.


    PURPOSE In this study, we developed and field tested the Medication Error and Adverse Drug Event Reporting System (MEADERS)—an easy-to-use, Web-based reporting system designed for busy office practices. METHODS We conducted a 10-week field test of MEADERS in which 220 physicians and office staff from 24 practices reported medication errors and adverse drug events they observed during usual clinical care. The main outcomes were (1) use and acceptability of MEADERS measured with a postreporting survey and interviews with office managers and lead physicians, and (2) distributions of characteristics of the medication event reports. RESULTS A total of 507 anonymous event reports were submitted. The mean reporting time was 4.3 minutes. Of these reports, 357 (70%) included medication errors only, 138 (27%) involved adverse drug events only, and 12 (2.4%) included both. Medication errors were roughly equally divided among ordering medications, implementing prescription orders, errors by patients receiving the medications, and documentation errors. The most frequent contributors to the medication errors and adverse drug events were communication problems (41%) and knowledge deficits (22%). Eight (1.6%) of the reported events led to hospitalization. Reporting raised staff and physician awareness of the kinds of errors that occur in office medication management; however, 36% agreed or strongly agreed that the event reporting “has increased the fear of repercussion in the practice.” Time pressure was the main barrier to reporting. CONCLUSIONS It is feasible for primary care clinicians and office staff to report medication errors and adverse drug events to a Web-based reporting system. Time pressures and a punitive culture are barriers to event reporting that must be overcome. Further testing of MEADERS as a quality improvement tool is warranted. PMID:21060122

  13. Sources of Error and the Statistical Formulation of M S: m b Seismic Event Screening Analysis (United States)

    Anderson, D. N.; Patton, H. J.; Taylor, S. R.; Bonner, J. L.; Selby, N. D.


    The Comprehensive Nuclear-Test-Ban Treaty (CTBT), a global ban on nuclear explosions, is currently in a ratification phase. Under the CTBT, an International Monitoring System (IMS) of seismic, hydroacoustic, infrasonic and radionuclide sensors is operational, and the data from the IMS is analysed by the International Data Centre (IDC). The IDC provides CTBT signatories basic seismic event parameters and a screening analysis indicating whether an event exhibits explosion characteristics (for example, shallow depth). An important component of the screening analysis is a statistical test of the null hypothesis H 0: explosion characteristics using empirical measurements of seismic energy (magnitudes). The established magnitude used for event size is the body-wave magnitude (denoted m b) computed from the initial segment of a seismic waveform. IDC screening analysis is applied to events with m b greater than 3.5. The Rayleigh wave magnitude (denoted M S) is a measure of later arriving surface wave energy. Magnitudes are measurements of seismic energy that include adjustments (physical correction model) for path and distance effects between event and station. Relative to m b, earthquakes generally have a larger M S magnitude than explosions. This article proposes a hypothesis test (screening analysis) using M S and m b that expressly accounts for physical correction model inadequacy in the standard error of the test statistic. With this hypothesis test formulation, the 2009 Democratic Peoples Republic of Korea announced nuclear weapon test fails to reject the null hypothesis H 0: explosion characteristics.

  14. Cognitive Moderators of Children's Adjustment to Stressful Divorce Events: The Role of Negative Cognitive Errors and Positive Illusions. (United States)

    Mazur, Elizabeth; Wolchik, Sharlene A.; Virdin, Lynn; Sandler, Irwin N.; West, Stephen G.


    Examined whether children's cognitive biases moderated impact of stressful divorce-related events on adjustment in 9- to 12-year olds. Found that endorsing negative cognitive errors for hypothetical divorce events moderated relations between stressful divorce events and self- and maternal-reports of internalizing and externalizing symptoms for…

  15. Error processing and response inhibition in excessive computer game players: an event-related potential study. (United States)

    Littel, Marianne; van den Berg, Ivo; Luijten, Maartje; van Rooij, Antonius J; Keemink, Lianne; Franken, Ingmar H A


    Excessive computer gaming has recently been proposed as a possible pathological illness. However, research on this topic is still in its infancy and underlying neurobiological mechanisms have not yet been identified. The determination of underlying mechanisms of excessive gaming might be useful for the identification of those at risk, a better understanding of the behavior and the development of interventions. Excessive gaming has been often compared with pathological gambling and substance use disorder. Both disorders are characterized by high levels of impulsivity, which incorporates deficits in error processing and response inhibition. The present study aimed to investigate error processing and response inhibition in excessive gamers and controls using a Go/NoGo paradigm combined with event-related potential recordings. Results indicated that excessive gamers show reduced error-related negativity amplitudes in response to incorrect trials relative to correct trials, implying poor error processing in this population. Furthermore, excessive gamers display higher levels of self-reported impulsivity as well as more impulsive responding as reflected by less behavioral inhibition on the Go/NoGo task. The present study indicates that excessive gaming partly parallels impulse control and substance use disorders regarding impulsivity measured on the self-reported, behavioral and electrophysiological level. Although the present study does not allow drawing firm conclusions on causality, it might be that trait impulsivity, poor error processing and diminished behavioral response inhibition underlie the excessive gaming patterns observed in certain individuals. They might be less sensitive to negative consequences of gaming and therefore continue their behavior despite adverse consequences. © 2012 The Authors, Addiction Biology © 2012 Society for the Study of Addiction.

  16. Interplay between hippocampal sharp wave ripple events and vicarious trial and error behaviors in decision making (United States)

    Papale, Andrew E.; Zielinski, Mark C.; Frank, Loren; Jadhav, Shantanu P.; Redish, A. David


    Summary Current theories posit that memories encoded during experiences are subsequently consolidated into longer-term storage. Hippocampal sharp-wave ripple (SWR) events have been linked to this consolidation process during sleep, but SWRs also occur during awake immobility, where their role remains unclear. We report that awake SWR rates at the reward site are inversely related to the prevalence of vicarious trial and error (VTE) behaviors, thought to be involved in deliberation processes. SWR rates were diminished immediately after VTE behaviors and an increase in the rate of SWR events at the reward site predicted a decrease in subsequent VTE behaviors at the choice point. Furthermore, SWR disruptions increased VTE behaviors. These results suggest an inverse relationship between SWRs and VTE behaviors, and suggest that awake SWRs and associated planning and memory consolidation mechanisms are engaged specifically in the context of higher levels of behavioral certainty. PMID:27866796

  17. The emotional impact of errors or adverse events on healthcare providers in the NICU: The protective role of coworker support. (United States)

    Winning, Adrien M; Merandi, Jenna M; Lewe, Dorcas; Stepney, Lois M C; Liao, Nancy N; Fortney, Christine A; Gerhardt, Cynthia A


    To examine the impact of errors or adverse events on emotional distress and professional quality of life in healthcare providers in the neonatal intensive care unit, and the moderating role of coworker support. Errors or adverse events can result in negative outcomes for healthcare providers. However, the role of coworker support in improving emotional and professional outcomes has not been examined. A cross-sectional online survey from a quality improvement initiative to train peer supporters in a neonatal intensive care unit. During 2015, 463 healthcare providers in a neonatal intensive care unit completed a survey assessing their experiences with an error or adverse event, anxiety, depression, professional quality of life and coworker support. Compared with those who did not experience an error or adverse event (58%), healthcare providers who observed (23%) or were involved (19%) in an incident reported higher levels of anxiety and secondary traumatic stress. Those who were involved in an event reported higher levels of depression and burnout. Differences between the three groups (no event, observation and involvement) for compassion satisfaction were non-significant. Perceived coworker support moderated the association between experiencing an event and both anxiety and depression. Specifically, experiencing an event was associated with higher levels of anxiety and depression when coworkers were perceived as low in supportiveness, but not when they were viewed as highly supportive. Findings suggest that errors or adverse events can have a harmful impact on healthcare providers and that coworker support may reduce emotional distress. © 2017 John Wiley & Sons Ltd.

  18. Gender differences in the pathway from adverse life events to adolescent emotional and behavioural problems via negative cognitive errors. (United States)

    Flouri, Eirini; Panourgia, Constantina


    The aim of this study was to test for gender differences in how negative cognitive errors (overgeneralizing, catastrophizing, selective abstraction, and personalizing) mediate the association between adverse life events and adolescents' emotional and behavioural problems (measured with the Strengths and Difficulties Questionnaire). The sample consisted of 202 boys and 227 girls (aged 11-15 years) from three state secondary schools in disadvantaged areas in one county in the South East of England. Control variables were age, ethnicity, special educational needs, exclusion history, family structure, family socio-economic disadvantage, and verbal cognitive ability. Adverse life events were measured with Tiet et al.'s (1998) Adverse Life Events Scale. For both genders, we assumed a pathway from adverse life events to emotional and behavioural problems via cognitive errors. We found no gender differences in life adversity, cognitive errors, total difficulties, peer problems, or hyperactivity. In both boys and girls, even after adjustment for controls, cognitive errors were related to total difficulties and emotional symptoms, and life adversity was related to total difficulties and conduct problems. The life adversity/conduct problems association was not explained by negative cognitive errors in either gender. However, we found gender differences in how adversity and cognitive errors produced hyperactivity and internalizing problems. In particular, life adversity was not related, after adjustment for controls, to hyperactivity in girls and to peer problems and emotional symptoms in boys. Cognitive errors fully mediated the effect of life adversity on hyperactivity in boys and on peer and emotional problems in girls.

  19. Post-event human decision errors: operator action tree/time reliability correlation

    Energy Technology Data Exchange (ETDEWEB)

    Hall, R E; Fragola, J; Wreathall, J


    This report documents an interim framework for the quantification of the probability of errors of decision on the part of nuclear power plant operators after the initiation of an accident. The framework can easily be incorporated into an event tree/fault tree analysis. The method presented consists of a structure called the operator action tree and a time reliability correlation which assumes the time available for making a decision to be the dominating factor in situations requiring cognitive human response. This limited approach decreases the magnitude and complexity of the decision modeling task. Specifically, in the past, some human performance models have attempted prediction by trying to emulate sequences of human actions, or by identifying and modeling the information processing approach applicable to the task. The model developed here is directed at describing the statistical performance of a representative group of hypothetical individuals responding to generalized situations.

  20. A comparison of emerging methods for errors of commission based on applications to the Davis-Besse (1985) event

    Energy Technology Data Exchange (ETDEWEB)

    Dang, V.N.; Reer, B.; Hirschberg, S. [Paul Scherrer Inst. (PSI), Villigen (Switzerland); Straeter, O.


    Today, a practical, proven methodology for systematically identifying and analysing potential Errors of Commission (EOCs) is not available and typical PSAs do not treat these comprehensively. Five proposed methods are examined, in a comparison centered on applying each to analyze the Davis-Besse event (1985), an event in which the operator response included several actions that can be categorised as EOCs. (author)

  1. An Approach for the Assessment of System Upset Resilience (United States)

    Torres-Pomales, Wilfredo


    This report describes an approach for the assessment of upset resilience that is applicable to systems in general, including safety-critical, real-time systems. For this work, resilience is defined as the ability to preserve and restore service availability and integrity under stated conditions of configuration, functional inputs and environmental conditions. To enable a quantitative approach, we define novel system service degradation metrics and propose a new mathematical definition of resilience. These behavioral-level metrics are based on the fundamental service classification criteria of correctness, detectability, symmetry and persistence. This approach consists of a Monte-Carlo-based stimulus injection experiment, on a physical implementation or an error-propagation model of a system, to generate a system response set that can be characterized in terms of dimensional error metrics and integrated to form an overall measure of resilience. We expect this approach to be helpful in gaining insight into the error containment and repair capabilities of systems for a wide range of conditions.

  2. Model Based Aircraft Upset Detection and Recovery System Project (United States)

    National Aeronautics and Space Administration — This proposal describes a system for detecting upset conditions and providing the corresponding control recovery actions to maintain flight integrity for general...

  3. Considerations for analysis of time-to-event outcomes measured with error: Bias and correction with SIMEX. (United States)

    Oh, Eric J; Shepherd, Bryan E; Lumley, Thomas; Shaw, Pamela A


    For time-to-event outcomes, a rich literature exists on the bias introduced by covariate measurement error in regression models, such as the Cox model, and methods of analysis to address this bias. By comparison, less attention has been given to understanding the impact or addressing errors in the failure time outcome. For many diseases, the timing of an event of interest (such as progression-free survival or time to AIDS progression) can be difficult to assess or reliant on self-report and therefore prone to measurement error. For linear models, it is well known that random errors in the outcome variable do not bias regression estimates. With nonlinear models, however, even random error or misclassification can introduce bias into estimated parameters. We compare the performance of 2 common regression models, the Cox and Weibull models, in the setting of measurement error in the failure time outcome. We introduce an extension of the SIMEX method to correct for bias in hazard ratio estimates from the Cox model and discuss other analysis options to address measurement error in the response. A formula to estimate the bias induced into the hazard ratio by classical measurement error in the event time for a log-linear survival model is presented. Detailed numerical studies are presented to examine the performance of the proposed SIMEX method under varying levels and parametric forms of the error in the outcome. We further illustrate the method with observational data on HIV outcomes from the Vanderbilt Comprehensive Care Clinic. Copyright © 2017 John Wiley & Sons, Ltd.

  4. Upsetting Butt Edge Increases Weld-Joint Strength (United States)

    Vesco, D.


    Mechanical upsetting /a mode of cold forging/ of butt edges to be welded is accomplished by the use of hydraulic rams and pressure rollers. The mechanical upsetting increases the thickness of the material in the heat-affected zone and compensates for the lower specific strength per unit thickness common to this area.

  5. Antisepsis and genital hygiene in scrotal surgery: liability claims in the event of treatment errors. (United States)

    Brühl, Peter


    Systematic observance of infection control principles in surgery, whether conducted on an inpatient or outpatient basis, is an indispensable precondition for quality management. In Germany, the introduction of the Protection against Infection Act (IfSG) on 1 January 2001 represented a milestone for regulation of the framework conditions in outpatient surgery. Once again, infection control issues were the main focus of attention. Section 36(1) IfSG stipulates that infection control policies specify in-house procedures for infection prophylaxis in agreement with quality assurance measures. On 1 January 2004 this was further reinforced, inter alia, by means of a new tripartite contract based on Section 115b of Book 5 of the German Code of Social Law (SGB V). Since experience shows that incidents are more likely to result in liability claims the smaller the operation and the more unexpected the complications from a lay person's perspective, surgery carried out on patients who spend the night before and after the operation outside the hospital or clinic is becoming a particularly liability-prone area. In the event of a postoperative infection, often involving a protracted hospital stay and in some cases considerable permanent damage, the patient often cites an infection control error. This paper highlights by way of example some liability aspects whose observance as a matter of principle can reduce the liability risk for the physician.

  6. Cascade of neural events leading from error commission to subsequent awareness revealed using EEG source imaging.

    Directory of Open Access Journals (Sweden)

    Monica Dhar

    Full Text Available The goal of the present study was to shed light on the respective contributions of three important action monitoring brain regions (i.e. cingulate cortex, insula, and orbitofrontal cortex during the conscious detection of response errors. To this end, fourteen healthy adults performed a speeded Go/Nogo task comprising Nogo trials of varying levels of difficulty, designed to elicit aware and unaware errors. Error awareness was indicated by participants with a second key press after the target key press. Meanwhile, electromyogram (EMG from the response hand was recorded in addition to high-density scalp electroencephalogram (EEG. In the EMG-locked grand averages, aware errors clearly elicited an error-related negativity (ERN reflecting error detection, and a later error positivity (Pe reflecting conscious error awareness. However, no Pe was recorded after unaware errors or hits. These results are in line with previous studies suggesting that error awareness is associated with generation of the Pe. Source localisation results confirmed that the posterior cingulate motor area was the main generator of the ERN. However, inverse solution results also point to the involvement of the left posterior insula during the time interval of the Pe, and hence error awareness. Moreover, consecutive to this insular activity, the right orbitofrontal cortex (OFC was activated in response to aware and unaware errors but not in response to hits, consistent with the implication of this area in the evaluation of the value of an error. These results reveal a precise sequence of activations in these three non-overlapping brain regions following error commission, enabling a progressive differentiation between aware and unaware errors as a function of time elapsed, thanks to the involvement first of interoceptive or proprioceptive processes (left insula, later leading to the detection of a breach in the prepotent response mode (right OFC.

  7. Single event test methodology for integrated optoelectronics (United States)

    Label, Kenneth A.; Cooley, James A.; Stassinopoulos, E. G.; Marshall, Paul; Crabtree, Christina


    A single event upset (SEU), defined as a transient or glitch on the output of a device, and its applicability to integrated optoelectronics are discussed in the context of spacecraft design and the need for more than a bit error rate viewpoint for testing and analysis. A methodology for testing integrated optoelectronic receivers and transmitters for SEUs is presented, focusing on the actual test requirements and system schemes needed for integrated optoelectronic devices. Two main causes of single event effects in the space environment, including protons and galactic cosmic rays, are considered along with ground test facilities for simulating the space environment.

  8. Single Event Upset Phenomena from High Energy Neutrons. (United States)


    code, ANISN, In uniform air and with Monte Carlo calculations in both uni- form and non-uniform air. Comparisons between calculations made in uniform...dispersed in time. StrakerlO has performed time-dependent Monte- Carlo transport calculations in uniform air for a source 50 ft. above ground. Results are...ATTN: ITE ATTN: Org 7112, A. Chabat ATN: SUL ATTN: Tech Lib 3141 Air University Library Sandia National Labs, Livermore ATTN: AUL-LSE ATTi: Library

  9. Mitigating bit flips or single event upsets in epilepsy neurostimulators

    Directory of Open Access Journals (Sweden)

    Alice X. Dong


    Conclusions: Cosmic radiation can threaten RAM and settings of neurostimulators; neuromodulation teams and device designers need to take this threat into account when designing multifunctional neuromodulation systems.


    Energy Technology Data Exchange (ETDEWEB)

    Herberger, Sarah M.; Boring, Ronald L.


    Abstract Objectives: Human reliability analysis (HRA) methods typically analyze human failure events (HFEs) at the overall task level. For dynamic HRA, it is important to model human activities at the subtask level. There exists a disconnect between dynamic subtask level and static task level that presents issues when modeling dynamic scenarios. For example, the SPAR-H method is typically used to calculate the human error probability (HEP) at the task level. As demonstrated in this paper, quantification in SPAR-H does not translate to the subtask level. Methods: Two different discrete distributions were generated for each SPAR-H Performance Shaping Factor (PSF) to define the frequency of PSF levels. The first distribution was a uniform, or uninformed distribution that assumed the frequency of each PSF level was equally likely. The second non-continuous distribution took the frequency of PSF level as identified from an assessment of the HERA database. These two different approaches were created to identify the resulting distribution of the HEP. The resulting HEP that appears closer to the known distribution, a log-normal centered on 1E-3, is the more desirable. Each approach then has median, average and maximum HFE calculations applied. To calculate these three values, three events, A, B and C are generated from the PSF level frequencies comprised of subtasks. The median HFE selects the median PSF level from each PSF and calculates HEP. The average HFE takes the mean PSF level, and the maximum takes the maximum PSF level. The same data set of subtask HEPs yields starkly different HEPs when aggregated to the HFE level in SPAR-H. Results: Assuming that each PSF level in each HFE is equally likely creates an unrealistic distribution of the HEP that is centered at 1. Next the observed frequency of PSF levels was applied with the resulting HEP behaving log-normally with a majority of the values under 2.5% HEP. The median, average and maximum HFE calculations did yield

  11. Upset Prevention and Recovery for Unimpaired and Impaired Aircraft Project (United States)

    National Aeronautics and Space Administration — The objective of the project is the development of an on-board envelope estimation, protection and upset recovery tool to address loss of control incidents in...

  12. Pushing Ahead - SUPRA Airplane Model for Upset Recovery


    Abramov, Nikolay; Goman, M.; Khrabrov, A. N. (Alexander N.); E. N. Kolesnikov; Fucke, Lars; Soemarwoto, B.; Smaili, H.


    One of the primary objectives of the European Union 7th Framework Program research project SUPRA – “Simulation of Upset Recovery in Aviation” – is the development and validation of the aerodynamic model of a generic large transport airplane aimed for piloted simulation in the post-stall region and upset recovery training. Modeling methods for prediction of post-stall flight dynamics, use of the wind tunnel data from different experimental facilities complemented by CFD analysis, validation cr...

  13. Cognitive moderators of children's adjustment to stressful divorce events: the role of negative cognitive errors and positive illusions. (United States)

    Mazur, E; Wolchik, S A; Virdin, L; Sandler, I N; West, S G


    This study examined whether children's cognitive appraisal biases moderate the impact of stressful divorce-related events on psychological adjustment in 355 children ages 9 to 12, whose families had experienced divorce within the past 2 years. Multiple regression indicated that endorsement of negative cognitive errors for hypothetical divorce events moderates the relations between stressful divorce events and self- and maternal reports of internalizing and externalizing symptoms, but only for older children. Positive illusions buffer the effects of stressful divorce events on child-reported depression and mother-reported externalizing problems. Implications of these results for theories of stress and coping, as well as for interventions for children of divorced families, are discussed.

  14. FPGA-based Bit-Error-Rate Tester for SEU-hardened Optical Links

    CERN Document Server

    Detraz, S; Moreira, P; Papadopoulos, S; Papakonstantinou, I; Seif El Nasr, S; Sigaud, C; Soos, C; Stejskal, P; Troska, J; Versmissen, H


    The next generation of optical links for future High-Energy Physics experiments will require components qualified for use in radiation-hard environments. To cope with radiation induced single-event upsets, the physical layer protocol will include Forward Error Correction (FEC). Bit-Error-Rate (BER) testing is a widely used method to characterize digital transmission systems. In order to measure the BER with and without the proposed FEC, simultaneously on several devices, a multi-channel BER tester has been developed. This paper describes the architecture of the tester, its implementation in a Xilinx Virtex-5 FPGA device and discusses the experimental results.

  15. New mechanism for upset of electronics.

    Energy Technology Data Exchange (ETDEWEB)

    Loubriel, Guillermo Manuel; Molina, Luis Leroy; Salazar, Robert Austin; Patterson, Paull Edward; Bacon, Larry Donald


    For many decades, engineers and scientists have studied the effects of high power microwaves (HPM) on electronics. These studies usually focus on means of delivering energy to upset electronic equipment and ways to protect equipment from HPM. The motivation for these studies is to develop the knowledge necessary either to cause disruption or to protect electronics from disruption. Since electronic circuits must absorb sufficient energy to fail and the source used to deliver this energy is far away from the electronic circuit, the source must emit a large quantity of energy. In free space, for example, as the distance between the source and the target increases, the source energy must increase by the square of distance. The HPM community has dedicated substantial resources to the development of higher energy sources as a result. Recently, members of the HPM community suggested a new disruption mechanism that could potentially cause system disruptions at much lower energy levels. The new mechanism, based on nonlinear dynamics, requires an expanded theory of circuit operation. This report summarizes an investigation of electronic circuit nonlinear behavior as it applies to inductor-resistor-diode circuits (known as the Linsay circuit) and phased-locked-loops. With the improvement in computing power and the need to model circuit behavior with greater precision, the nonlinear effects of circuit has become very important. In addition, every integrated circuit has as part of its design a protective circuit. These protective circuits use some variation of semiconductor junctions that can interact with parasitic components, present in every real system. Hence, the protective circuit can behave as a Linsay circuit. Although the nonlinear behavior is understandable, it is difficult to model accurately. Many researchers have used classical diode models successfully to show nonlinear effects within predicted regions of operation. However, these models do not accurately predict

  16. [Medication errors in a neonatal unit: One of the main adverse events]. (United States)

    Esqué Ruiz, M T; Moretones Suñol, M G; Rodríguez Miguélez, J M; Sánchez Ortiz, E; Izco Urroz, M; de Lamo Camino, M; Figueras Aloy, J


    Neonatal units are one of the hospital areas most exposed to the committing of treatment errors. A medication error (ME) is defined as the avoidable incident secondary to drug misuse that causes or may cause harm to the patient. The aim of this paper is to present the incidence of ME (including feeding) reported in our neonatal unit and its characteristics and possible causal factors. A list of the strategies implemented for prevention is presented. An analysis was performed on the ME declared in a neonatal unit. A total of 511 MEs have been reported over a period of seven years in the neonatal unit. The incidence in the critical care unit was 32.2 per 1000 hospital days or 20 per 100 patients, of which 0.22 per 1000 days had serious repercussions. The ME reported were, 39.5% prescribing errors, 68.1% administration errors, 0.6% were adverse drug reactions. Around two-thirds (65.4%) were produced by drugs, with 17% being intercepted. The large majority (89.4%) had no impact on the patient, but 0.6% caused permanent damage or death. Nurses reported 65.4% of MEs. The most commonly implicated causal factor was distraction (59%). Simple corrective action (alerts), and intermediate (protocols, clinical sessions and courses) and complex actions (causal analysis, monograph) were performed. It is essential to determine the current state of ME, in order to establish preventive measures and, together with teamwork and good practices, promote a climate of safety. Copyright © 2015 Asociación Española de Pediatría. Published by Elsevier España, S.L.U. All rights reserved.

  17. Comparison of the Susceptibility to Soft Errors of SRAM-Based FPGA Error Correction Codes Implementations (United States)

    Liu, S.; Sorrenti, G.; Reviriego, P.; Casini, F.; Maestro, J. A.; Alderighi, M.; Mecha, H.


    Nowadays the reliability issues of SRAM-based Field Programmable Gate Arrays (FPGAs) operating in harsh environments are well understood. One major effect is Single Event Upsets (SEUs), which are able to invert the stored logical value in flip-flops and memory cells. This issue is more serious when the affected memory cells are part of the configuration memory used for programming the circuit functionality. The consequences may be alterations of the circuit functionality causing errors which may only be corrected by reprogramming the device. For a better understanding of the robustness of programmed circuits, this paper compares two decoders for Error Correction Codes (ECCs). A Hamming Decoder and a One-Step Majority Logic Decoder (OS-MLD) for the Difference-Set Cyclic Codes (DSCC) are analyzed yielding surprisingly unexpected results for their SEU susceptibility, which are interesting for application designers.

  18. Negative Cognitive Errors and Positive Illusions: Moderators of Relations between Divorce Events and Children's Psychological Adjustment. (United States)

    Mazur, Elizabeth; Wolchik, Sharlene

    Building on prior literature on adults' and children's appraisals of stressors, this study investigated relations among negative and positive appraisal biases, negative divorce events, and children's post-divorce adjustment. Subjects were 79 custodial nonremarried mothers and their children ages 9 to 13 who had experienced parental divorce within…

  19. An event-related potential study on changes of violation and error responses during morphosyntactic learning. (United States)

    Davidson, Douglas J; Indefrey, Peter


    Based on recent findings showing electrophysiological changes in adult language learners after relatively short periods of training, we hypothesized that adult Dutch learners of German would show responses to German gender and adjective declension violations after brief instruction. Adjective declension in German differs from previously studied morphosyntactic regularities in that the required suffixes depend not only on the syntactic case, gender, and number features to be expressed, but also on whether or not these features are already expressed on linearly preceding elements in the noun phrase. Violation phrases and matched controls were presented over three test phases (pretest and training on the first day, and a posttest one week later). During the pretest, no electrophysiological differences were observed between violation and control conditions, and participants' classification performance was near chance. During the training and posttest phases, classification improved, and there was a P600-like violation response to declension but not gender violations. An error-related response during training was associated with improvement in grammatical discrimination from pretest to posttest. The results show that rapid changes in neuronal responses can be observed in adult learners of a complex morphosyntactic rule, and also that error-related electrophysiological responses may relate to grammar acquisition.

  20. Is your error my concern? An event-related potential study on own and observed error detection in cooperation and competition

    Directory of Open Access Journals (Sweden)

    Ellen R.A. De Bruijn


    Full Text Available For successful goal-directed behavior it is essential for humans to continuously monitor one’s actions and detect errors as fast as possible. EEG studies have identified an error-related ERP component known as the error-related negativity or ERN. Theories on error monitoring propose a direct relation to reward processing. Whenever an error is made, the outcome of an action turns out to be worse than expected, resulting in a loss of reward and hence eliciting the ERN. However, as own errors are always associated with a loss of reward, disentangling whether the ERN is error- or reward-dependent has proven to be an extremely difficult endeavor. Recently, an ERN has also been demonstrated following the observation of other’s errors. An important difference with own errors is that other people’s errors can be associated with loss or gain depending on the cooperative or competitive context in which they are made. We conducted an ERP study to disentangle whether performance monitoring is error- or reward-dependent. Twelve pairs (N=24 of participants performed and observed a speeded-choice reaction task in two contexts. Own errors were always associated with a loss of reward. Observed errors in the cooperative context also yielded a loss of reward, but observed errors in the competitive context resulted in a gain. The results showed that the ERN was present following all types of errors independent of who made the error and the outcome of the action. Consequently, the current study demonstrates that performance monitoring as reflected by the ERN is error-specific and not directly dependent on reward.

  1. Pediatric medication error reports in Korea adverse event reporting system database, 1989-2012: comparing with adult reports. (United States)

    Woo, Yeonju; Kim, Hyung Eun; Chung, Sooyoun; Park, Byung Joo


    Children have dynamic process of maturation and substantial changes in growth and development which eventually make the drug safety profiles different from adults. Medication errors (MEs) in pediatrics are reported to occur three times more likely than adults. The aims of this study were to identify the characteristics of pediatric MEs in Korea at national level and help raise awareness of risks from the MEs in pediatrics. We conducted a descriptive analysis with the pediatric ME reports in Korea Adverse Event Reporting System (KAERS) database from 1989 to 2012 and 208 ME reports in pediatrics were found. Based on KAERS database, the proportion of reported pediatric ME in adverse drug event (ADE) reports was 2.73 times (95% CI, 2.35-3.17) higher than that of adult ME. In 208 ME reports, we found a total of 236 ME-related terms within 19 types of MEs. The most common type of MEs was "accidental overdose" (n=58, 24.6%), followed by "drug maladministration" (n=50, 21.2%) and "medication error" (n=41, 17.4%). After the narratives of ME reports were reviewed, we noticed that most of them did no harm to patients, but some cases were needed for medical treatment. Our data suggest that MEs in pediatrics are not negligible in Korea. We expect that this study would increase the awareness of the problem in pediatric MEs and induce the need for further development of an effective national ME preventing system in Korea.

  2. A comparative evaluation of emerging methods for errors of commission based on applications to the Davis-Besse (1985) event

    Energy Technology Data Exchange (ETDEWEB)

    Reer, B.; Dang, V.N.; Hirschberg, S. [Paul Scherrer Inst., Nuclear Energy and Safety Research Dept., CH-5232 Villigen PSI (Switzerland); Straeter, O. [Gesellschaft fur Anlagen- und Reaktorsicherheit (Germany)


    In considering the human role in accidents, the classical PSA methodology applied today focuses primarily on the omissions of actions required of the operators at specific points in the scenario models. A practical, proven methodology is not available for systematically identifying and analyzing the scenario contexts in which the operators might perform inappropriate actions that aggravate the scenario. As a result, typical PSA's do not comprehensively treat these actions, referred to as errors of commission (EOCs). This report presents the results of a joint project of the Paul Scherrer Institut (PSI, Villigen, Switzerland) and the Gesellschaft fuer Anlagen- und Reaktorsicherheit (GRS, Garching, Germany) that examined some methods recently proposed for addressing the EOC issue. Five methods were investigated: 1 ) ATHEANA, 2) the Borssele screening methodology. 3) CREAM, 4) CAHR, and 5) CODA. In addition to a comparison of their scope, basic assumptions, and analytical approach, the methods were each applied in the analysis of PWR Loss of Feedwater scenarios based on the 1985 Davis-Besse event, in which the operator response included actions that can be categorized as EOCs. The aim was to compare how the methods consider a concrete scenario in which EOCs have in fact been observed. These case applications show how the methods are used in practical terms and constitute a common basis for comparing the methods and the insights that they provide. The identification of the potentially significant EOCs to be analysed in the PSA is currently the central problem for their treatment. The identification or search scheme has to consider an extensive set of potential actions that the operators may take. These actions may take place instead of required actions, for example, because the operators fail to assess the plant state correctly, or they may occur even when no action is required. As a result of this broad search space, most methodologies apply multiple schemes to

  3. Investigation and control of factors influencing resistance upset butt welding.

    NARCIS (Netherlands)

    Kerstens, N.F.H.


    The purpose of this work is to investigate the factors influencing the resistance upset butt welding process to obtain an understanding of the metal behaviour and welding process characteristics, so that new automotive steels can be welded with reduced development time and fewer failures in

  4. Showdown or Slow Down? When Someone Upsets You (United States)

    Sometimes, the people you are closest to might say and do things that hurt, anger, or just rub you the wrong way. If someone upsets you, it can be tricky to figure out when and how to talk to them about it, without making things worse.

  5. Sex differences in the events that elicit jealousy among homosexuals

    NARCIS (Netherlands)

    Dijkstra, Pieternel; Groothof, Hinke A. K.; Poel, Gerda A.; Laverman, Teunis, T. G.; Schrier, Michiel; Buunk, Bram P.


    When individuals are asked which event would upset them more - a partner's emotional infidelity or a partner's sexual infidelity- among heterosexuals more men than women select a partner's sexual infidelity as the most upsetting event, whereas more more women than men select a partner's emotional

  6. Insight and Lessons Learned on Organizational Factors and Safety Culture from the Review of Human Error-related Events of NPPs in Korea

    Energy Technology Data Exchange (ETDEWEB)

    Kim, Ji Tae; Lee, Dhong Hoon; Choi, Young Sung [Korea Institute of Nuclear Safety, Daejeon (Korea, Republic of)


    Event investigation is one of the key means of enhancing nuclear safety deriving effective measures and preventing recurrences. However, it is difficult to analyze organizational factors and safety culture. This paper tries to review human error-related events from perspectives of organizational factors and safety culture, and to derive insights and lessons learned in developing the regulatory infrastructure of plant oversight on safety culture.

  7. Adverse Life Events and Emotional and Behavioral Problems in Adolescence: The Role of Non-Verbal Cognitive Ability and Negative Cognitive Errors (United States)

    Flouri, Eirini; Panourgia, Constantina


    The aim of this study was to test whether negative cognitive errors (overgeneralizing, catastrophizing, selective abstraction, and personalizing) mediate the moderator effect of non-verbal cognitive ability on the association between adverse life events (life stress) and emotional and behavioral problems in adolescence. The sample consisted of 430…

  8. Error Detection and Response Adjustment in Youth With Mild Spastic Cerebral Palsy : An Event-Related Brain Potential Study

    NARCIS (Netherlands)

    Hakkarainen, Elina; Pirila, Silja; Kaartinen, Jukka; van der Meere, Jaap J.

    This study evaluated the brain activation state during error making in youth with mild spastic cerebral palsy and a peer control group while carrying out a stimulus recognition task. The key question was whether patients were detecting their own errors and subsequently improving their performance in

  9. Towards Multimodal Error Management:Experimental Evaluation of User Strategies in Event of Faulty Application Behavior in Automotive Environments

    Directory of Open Access Journals (Sweden)

    Gregor McGlaun


    Full Text Available In this work, we present the results of a study analyzing the reactions of subjects on simulated errors of a dedicated in-car interface for controlling infotainment and communication services. The test persons could operate the system, using different input modalities, such as natural or command speech as well as head and hand gestures, or classical tactile paradigms. In various situational contexts, we scrutinized the interaction patterns the test participants applied to overcome different operation tasks. Moreover, we evaluated individual user behavior concerning modality transitions and individual fallback strategies in case of system errors. Two different error types (Hidden System Errors and Apparent System Errors were provoked. As a result, we found out that initially, i.e. with the system working properly, most users prefer tactile or speech interaction. In case of Hidden System Errors, mostly changes from speech to tactile interaction and vice versa occurred. Concerning Apparent System Errors, 87% of the subjects automatically interrupted or cancelled their input procedure. 73% of all test persons who continued interaction, when the reason for the faulty system behavior was gone, strictly kept the selected modality. Regarding the given input vocabulary, none of the subjects selected head or hand gesture input as the leading fallback modality.

  10. An Examination of Radiation-Induced Bit-Upset Patterns in Semiconductor Memories (United States)


    testeur de memoires MOSAID MS2200 pour caracteriser ce genre d’erreur pour les memoires RAM statiques (SRAM) et dynamiques (DRAM). Un accelerateur...Transient Radiation Upset in a 2k SRAM", IEEE Trans. on Nuclear Science, vol NS-32, No.6, Dec 1985. 4. Bendel W.L. and E.L.Petersen, "Proton Upset in Orbit

  11. Development of self-adjusting hydraulic machine for combination forming of upsetting and extruding

    Institute of Scientific and Technical Information of China (English)


    In the paper a self-adjusting hydraulic machine for combination forming of upsetting and extruding is systematacially presented in terms of mechanical principle, design principle, machine construction, design of the key components and working routine. The machine is designed with the following features: The lower movable beam is adjusted by the ejecting cylinder, the upper upsetting beam is reset by the backstroke slide rods, and the upsetting cylinders communicate with the gas-liquid accumulators. These features make the machine conformation compact, save both the backstroke cylinder of the upper upsetting beam and the upsetting cylinder of the lower movable beam, and simplify the hydraulic system. Furthermore, the machine can resolve such problems as incomplete filling at the addendum position, microcracks at the dedendum position, greater force and lower die life during precision forging of spur gears.

  12. Review of Research On Guidance for Recovery from Pitch Axis Upsets (United States)

    Harrison, Stephanie J.


    A literature review was conducted to identify past efforts in providing control guidance for aircraft upset recovery including stall recovery. Because guidance is integrally linked to the intended function of aircraft attitude awareness and upset recognition, it is difficult, if not impossible, to consider these issues separately. This literature review covered the aspects of instrumentation and display symbologies for attitude awareness, aircraft upset recognition, upset and stall alerting, and control guidance. Many different forms of symbology have been investigated including, but not limited to, pitch scale depictions, attitude indicator icons, horizon symbology, attitude recovery arrows, and pitch trim indicators. Past research on different visual and alerting strategies that provide advisories, cautions, and warnings to pilots before entering an unusual attitude (UA) are also discussed. Finally, potential control guidance for recovery from upset or unusual attitudes, including approach-to-stall and stall conditions, are reviewed. Recommendations for future research are made.

  13. Error-related processing following severe traumatic brain injury: an event-related functional magnetic resonance imaging (fMRI) study. (United States)

    Sozda, Christopher N; Larson, Michael J; Kaufman, David A S; Schmalfuss, Ilona M; Perlstein, William M


    Continuous monitoring of one's performance is invaluable for guiding behavior towards successful goal attainment by identifying deficits and strategically adjusting responses when performance is inadequate. In the present study, we exploited the advantages of event-related functional magnetic resonance imaging (fMRI) to examine brain activity associated with error-related processing after severe traumatic brain injury (sTBI). fMRI and behavioral data were acquired while 10 sTBI participants and 12 neurologically-healthy controls performed a task-switching cued-Stroop task. fMRI data were analyzed using a random-effects whole-brain voxel-wise general linear model and planned linear contrasts. Behaviorally, sTBI patients showed greater error-rate interference than neurologically-normal controls. fMRI data revealed that, compared to controls, sTBI patients showed greater magnitude error-related activation in the anterior cingulate cortex (ACC) and an increase in the overall spatial extent of error-related activation across cortical and subcortical regions. Implications for future research and potential limitations in conducting fMRI research in neurologically-impaired populations are discussed, as well as some potential benefits of employing multimodal imaging (e.g., fMRI and event-related potentials) of cognitive control processes in TBI. Copyright © 2011 Elsevier B.V. All rights reserved.

  14. Analysis of Control Strategies for Aircraft Flight Upset Recovery (United States)

    Crespo, Luis G.; Kenny, Sean P.; Cox, David E.; Muri, Daniel G.


    This paper proposes a framework for studying the ability of a control strategy, consisting of a control law and a command law, to recover an aircraft from ight conditions that may extend beyond the normal ight envelope. This study was carried out (i) by evaluating time responses of particular ight upsets, (ii) by evaluating local stability over an equilibrium manifold that included stall, and (iii) by bounding the set in the state space from where the vehicle can be safely own to wings-level ight. These states comprise what will be called the safely recoverable ight envelope (SRFE), which is a set containing the aircraft states from where a control strategy can safely stabilize the aircraft. By safe recovery it is implied that the tran- sient response stays between prescribed limits before converging to a steady horizontal ight. The calculation of the SRFE bounds yields the worst-case initial state corresponding to each control strategy. This information is used to compare alternative recovery strategies, determine their strengths and limitations, and identify the most e ective strategy. In regard to the control law, the authors developed feedback feedforward laws based on the gain scheduling of multivariable controllers. In regard to the command law, which is the mechanism governing the exogenous signals driving the feed- forward component of the controller, we developed laws with a feedback structure that combines local stability and transient response considera- tions. The upset recovery of the Generic Transport Model, a sub-scale twin-engine jet vehicle developed by NASA Langley Research Center, is used as a case study.

  15. Process optimization of joining by upset bulging with local heating (United States)

    Rusch, Michael; Almohallami, Amer; Sviridov, Alexander; Bonk, Christian; Behrens, Bernd-Arno; Bambach, Markus


    Joining by upset bulging is a mechanical joining method where axial load is applied to a tube to form two revolving bulges, which clamp the parts to be joined and create a force and form fit. It can be used to join tubes with other structures such as sheets, plates, tubes or profiles of the same or different materials. Other processes such as welding are often limited in joining multi-material assemblies or high-strength materials. With joining by upset bulging at room temperature, the main drawback is the possible initiation of damage (cracks) in the inner buckling zone because of high local stresses and strains. In this paper, a method to avoid the formation of cracks is introduced. Before forming the bulge the tube is locally heated by an induction coil. For the construction steel (E235+N) a maximum temperature of 700 °C was used to avoid phase transformation. For the numerical study of the process the mechanical properties of the tube material were examined at different temperatures and strain rates to determine its flow curves. A parametrical FE model was developed to simulate the bulging process with local heating. Experiments with local heating were executed and metallographic studies of the bulging area were conducted. While specimens heated to 500 °C showed small cracks left, damage-free flanges could be created at 600 and 700 °C. Static testing of damage-free bulges showed improvements in tensile strength and torsion strength compared to bulges formed at room-temperature, while bending and compression behavior remained nearly unchanged. In cyclic testing the locally heated specimens underwent about 3.7 times as many cycles before failure as the specimens formed at room temperature.

  16. The impact of different background errors in the assimilation of satellite radiances and in-situ observational data using WRFDA for three rainfall events over Iran (United States)

    Zakeri, Zeinab; Azadi, Majid; Ghader, Sarmad


    Satellite radiances and in-situ observations are assimilated through Weather Research and Forecasting Data Assimilation (WRFDA) system into Advanced Research WRF (ARW) model over Iran and its neighboring area. Domain specific background error based on x and y components of wind speed (UV) control variables is calculated for WRFDA system and some sensitivity experiments are carried out to compare the impact of global background error and the domain specific background errors, both on the precipitation and 2-m temperature forecasts over Iran. Three precipitation events that occurred over the country during January, September and October 2014 are simulated in three different experiments and the results for precipitation and 2-m temperature are verified against the verifying surface observations. Results show that using domain specific background error improves 2-m temperature and 24-h accumulated precipitation forecasts consistently, while global background error may even degrade the forecasts compared to the experiments without data assimilation. The improvement in 2-m temperature is more evident during the first forecast hours and decreases significantly as the forecast length increases.

  17. Combining empirical approaches and error modelling to enhance predictive uncertainty estimation in extrapolation for operational flood forecasting. Tests on flood events on the Loire basin, France. (United States)

    Berthet, Lionel; Marty, Renaud; Bourgin, François; Viatgé, Julie; Piotte, Olivier; Perrin, Charles


    An increasing number of operational flood forecasting centres assess the predictive uncertainty associated with their forecasts and communicate it to the end users. This information can match the end-users needs (i.e. prove to be useful for an efficient crisis management) only if it is reliable: reliability is therefore a key quality for operational flood forecasts. In 2015, the French flood forecasting national and regional services (Vigicrues network; implemented a framework to compute quantitative discharge and water level forecasts and to assess the predictive uncertainty. Among the possible technical options to achieve this goal, a statistical analysis of past forecasting errors of deterministic models has been selected (QUOIQUE method, Bourgin, 2014). It is a data-based and non-parametric approach based on as few assumptions as possible about the forecasting error mathematical structure. In particular, a very simple assumption is made regarding the predictive uncertainty distributions for large events outside the range of the calibration data: the multiplicative error distribution is assumed to be constant, whatever the magnitude of the flood. Indeed, the predictive distributions may not be reliable in extrapolation. However, estimating the predictive uncertainty for these rare events is crucial when major floods are of concern. In order to improve the forecasts reliability for major floods, an attempt at combining the operational strength of the empirical statistical analysis and a simple error modelling is done. Since the heteroscedasticity of forecast errors can considerably weaken the predictive reliability for large floods, this error modelling is based on the log-sinh transformation which proved to reduce significantly the heteroscedasticity of the transformed error in a simulation context, even for flood peaks (Wang et al., 2012). Exploratory tests on some operational forecasts issued during the recent floods experienced in

  18. Selective attention and error processing in an illusory conjunction task - An event-related brain potential study

    NARCIS (Netherlands)

    Wijers, AA; Boksem, MAS


    We recorded event-related potentials in an illusory conjunction task, in which subjects were cued on each trial to search for a particular colored letter in a subsequently presented test array, consisting of three different letters in three different colors. In a proportion of trials the target

  19. Classification of event-related potentials associated with response errors in actors and observers based on autoregressive modeling

    NARCIS (Netherlands)

    Vasios, C.E.; Ventouras, E.M.; Matsopoulos, G.K.; Karanasiou, I.; Asvestas, P.; Uzunoglu, N.K.; Schie, H.T. van; Bruijn, E.R.A. de


    Event-Related Potentials (ERPs) provide non-invasive measurements of the electrical activity on the scalp related to the processing of stimuli and preparation of responses by the brain. In this paper an ERP-signal classification method is proposed for discriminating between ERPs of correct and

  20. Estimating Single-Event Logic Cross Sections in Advanced Technologies (United States)

    Harrington, R. C.; Kauppila, J. S.; Warren, K. M.; Chen, Y. P.; Maharrey, J. A.; Haeffner, T. D.; Loveless, T. D.; Bhuva, B. L.; Bounasser, M.; Lilja, K.; Massengill, L. W.


    Reliable estimation of logic single-event upset (SEU) cross section is becoming increasingly important for predicting the overall soft error rate. As technology scales and single-event transient (SET) pulse widths shrink to widths on the order of the setup-and-hold time of flip-flops, the probability of latching an SET as an SEU must be reevaluated. In this paper, previous assumptions about the relationship of SET pulsewidth to the probability of latching an SET are reconsidered and a model for transient latching probability has been developed for advanced technologies. A method using the improved transient latching probability and SET data is used to predict logic SEU cross section. The presented model has been used to estimate combinational logic SEU cross sections in 32-nm partially depleted silicon-on-insulator (SOI) technology given experimental heavy-ion SET data. Experimental SEU data show good agreement with the model presented in this paper.

  1. Events

    Directory of Open Access Journals (Sweden)

    Igor V. Karyakin


    Full Text Available The 9th ARRCN Symposium 2015 was held during 21st–25th October 2015 at the Novotel Hotel, Chumphon, Thailand, one of the most favored travel destinations in Asia. The 10th ARRCN Symposium 2017 will be held during October 2017 in the Davao, Philippines. International Symposium on the Montagu's Harrier (Circus pygargus «The Montagu's Harrier in Europe. Status. Threats. Protection», organized by the environmental organization «Landesbund für Vogelschutz in Bayern e.V.» (LBV was held on November 20-22, 2015 in Germany. The location of this event was the city of Wurzburg in Bavaria.

  2. Single-Event-Hardened All-Digital Delay Generator for FPGA-Based Implementation of a TDC-based readout electronics (United States)

    Balaji, S.; Ramasamy, S.


    This paper addresses the single-events effects on an all-digital delay generator and also investigates the propagation and impact of soft errors in the all-digital delay generator caused by the single-event transients to the time-to-digital converters. The all-digital delay generator is implemented using an array of all-digital delay-locked loops with error correction circuit for improved single-event transients resilience and uses the time interpolation technique for achieving 5 ps sub-gate delay resolution. The effectiveness of the mitigation of single-event upsets and the robustness of the architecture is demonstrated through the simulations in 90 nm CMOS technology at linear energy transfer up to 100 MeVṡcm2/mg. The portability of the mitigation technique is validated by the results obtained through an FPGA implementation of the all-digital delay generator.

  3. Aerodynamic model of transport airplane in extended envelope for simulation of upset recovery


    Abramov, Nikolay; Goman, M.; Khrabrov, A. N. (Alexander N.); E. N. Kolesnikov; Sidoryuk, M. E. (Maria E.); Soemarwoto, B.; Smaili, H.


    The paper presents the aerodynamic model in extended flight envelope for a generic airliner with under wing engines and conventional tail developed within the EU Framework Programme (FP7) research project Simulation of Upset Recovery in Aviation (SUPRA) ( The SUPRA aerodynamic model is covering angles of attack beyond stall and speeds from take-off to cruise flight. The aerodynamic model in extended flight envelope developed for piloted simulation of upset prevention and recov...

  4. Optimizing tensile strength of low-alloy steel joints in upset welding


    Hamedi, M


    Purpose: Purpose In resistance upset welding, the heat is generated by resistance of the interface of abutting surfaces to the flow of electrical current in heating and post-weld heating stages. Upset welding typically results in solid-state welds with no melting at the joint. In this paper, the effect of process parameters including heating and post-weld heating power and their corresponding duration along with interference, on the tensile strength of the welded joint are experimentally inve...

  5. Study design for non-recurring, time-to-event outcomes in the presence of error-prone diagnostic tests or self-reports. (United States)

    Gu, Xiangdong; Balasubramanian, Raji


    Sequentially administered, laboratory-based diagnostic tests or self-reported questionnaires are often used to determine the occurrence of a silent event. In this paper, we consider issues relevant in design of studies aimed at estimating the association of one or more covariates with a non-recurring, time-to-event outcome that is observed using a repeatedly administered, error-prone diagnostic procedure. The problem is motivated by the Women's Health Initiative, in which diabetes incidence among the approximately 160,000 women is obtained from annually collected self-reported data. For settings of imperfect diagnostic tests or self-reports with known sensitivity and specificity, we evaluate the effects of various factors on resulting power and sample size calculations and compare the relative efficiency of different study designs. The methods illustrated in this paper are readily implemented using our freely available R software package icensmis, which is available at the Comprehensive R Archive Network website. An important special case is that when diagnostic procedures are perfect, they result in interval-censored, time-to-event outcomes. The proposed methods are applicable for the design of studies in which a time-to-event outcome is interval censored. Copyright © 2016 John Wiley & Sons, Ltd. Copyright © 2016 John Wiley & Sons, Ltd.

  6. Upset Over Sexual versus Emotional Infidelity Among Gay, Lesbian, Bisexual, and Heterosexual Adults. (United States)

    Frederick, David A; Fales, Melissa R


    One hypothesis derived from evolutionary perspectives is that men are more upset than women by sexual infidelity and women are more upset than men by emotional infidelity. The proposed explanation is that men, in contrast to women, face the risk of unwittingly investing in genetically unrelated offspring. Most studies, however, have relied on small college or community samples of heterosexual participants. We examined upset over sexual versus emotional jealousy among 63,894 gay, lesbian, bisexual, and heterosexual participants. Participants imagined which would upset them more: their partners having sex with someone else (but not falling in love with them) or their partners falling in love with someone else (but not having sex with them). Consistent with this evolutionary perspective, heterosexual men were more likely than heterosexual women to be upset by sexual infidelity (54 vs. 35 %) and less likely than heterosexual women to be upset by emotional infidelity (46 vs. 65 %). This gender difference emerged across age groups, income levels, history of being cheated on, history of being unfaithful, relationship type, and length. The gender difference, however, was limited to heterosexual participants. Bisexual men and women did not differ significantly from each other in upset over sexual infidelity (30 vs. 27 %), regardless of whether they were currently dating a man (35 vs. 29 %) or woman (28 vs. 20 %). Gay men and lesbian women also did not differ (32 vs. 34 %). The findings present strong evidence that a gender difference exists in a broad sample of U.S. adults, but only among heterosexuals.

  7. The Single Event Effect Characteristics of the 486-DX4 Microprocessor (United States)

    Kouba, Coy; Choi, Gwan


    This research describes the development of an experimental radiation testing environment to investigate the single event effect (SEE) susceptibility of the 486-DX4 microprocessor. SEE effects are caused by radiation particles that disrupt the logic state of an operating semiconductor, and include single event upsets (SEU) and single event latchup (SEL). The relevance of this work can be applied directly to digital devices that are used in spaceflight computer systems. The 486-DX4 is a powerful commercial microprocessor that is currently under consideration for use in several spaceflight systems. As part of its selection process, it must be rigorously tested to determine its overall reliability in the space environment, including its radiation susceptibility. The goal of this research is to experimentally test and characterize the single event effects of the 486-DX4 microprocessor using a cyclotron facility as the fault-injection source. The test philosophy is to focus on the "operational susceptibility," by executing real software and monitoring for errors while the device is under irradiation. This research encompasses both experimental and analytical techniques, and yields a characterization of the 486-DX4's behavior for different operating modes. Additionally, the test methodology can accommodate a wide range of digital devices, such as microprocessors, microcontrollers, ASICS, and memory modules, for future testing. The goals were achieved by testing with three heavy-ion species to provide different linear energy transfer rates, and a total of six microprocessor parts were tested from two different vendors. A consistent set of error modes were identified that indicate the manner in which the errors were detected in the processor. The upset cross-section curves were calculated for each error mode, and the SEU threshold and saturation levels were identified for each processor. Results show a distinct difference in the upset rate for different configurations of

  8. Mental representations of attachment figures facilitate recovery following upsetting autobiographical memory recall. (United States)

    Selcuk, Emre; Zayas, Vivian; Günaydin, Gül; Hazan, Cindy; Kross, Ethan


    A growing literature shows that even the symbolic presence of an attachment figure facilitates the regulation of negative affect triggered by external stressors. Yet, in daily life, pernicious stressors are often internally generated--recalling an upsetting experience reliably increases negative affect, rumination, and susceptibility to physical and psychological health problems. The present research provides the first systematic examination of whether activating the mental representation of an attachment figure enhances the regulation of affect triggered by thinking about upsetting memories. Using 2 different techniques for priming attachment figure representations and 2 types of negative affect measures (explicit and implicit), activating the mental representation of an attachment figure (vs. an acquaintance or stranger) after recalling an upsetting memory enhanced recovery--eliminating the negative effects of the memory recall (Studies 1-3). In contrast, activating the mental representation of an attachment figure before recalling an upsetting memory had no such effect (Studies 1 and 2). Furthermore, activating the mental representation of an attachment figure after thinking about upsetting memories reduced negative thinking in a stream of consciousness task, and the magnitude of the attachment-induced affective recovery effects as assessed with explicit affect measures predicted mental and physical health in daily life (Study 3). Finally, a meta-analysis of the 3 studies (Study 4) showed that the regulatory benefits conferred by the mental representation of an attachment figure were weaker for individuals high on attachment avoidance. The implications of these findings for attachment, emotion regulation, and mental and physical health are discussed.

  9. Chrysler Upset Protrusion Joining Techniques for Joining Dissimilar Metals

    Energy Technology Data Exchange (ETDEWEB)

    Logan, Stephen [FCA US LLC, Auburn Hills, MI (United States)


    The project goal was to develop and demonstrate a robust, cost effective, and versatile joining technique, known as Upset Protrusion Joining (UPJ), for joining challenging dissimilar metal com-binations, especially those where one of the metals is a die cast magnesium (Mg) component. Since two of the key obstacles preventing more widespread use of light metals (especially in high volume automotive applications) are 1) a lack of robust joining techniques and 2) susceptibility to galvanic corrosion, and since the majority of the joint combinations evaluated in this project include die cast Mg (the lightest structural metal) as one of the two materials being joined, and since die casting is the most common and cost effective process for producing Mg components, then successful project completion provides a key enabler to high volume application of lightweight materials, thus potentially leading to reduced costs, and encouraging implementation of lightweight multi-material vehicles for significant reductions in energy consumption and reduced greenhouse gas emissions. Eco-nomic benefits to end-use consumers are achieved primarily via the reduction in fuel consumption. Unlike currently available commercial processes, the UPJ process relies on a very robust mechanical joint rather than intermetallic bonding, so the more cathodic material can be coated prior to joining, thus creating a robust isolation against galvanic attack on the more anodic material. Additionally, since the UPJ protrusion is going through a hole that can be pre-drilled or pre-punched prior to coating, the UPJ process is less likely to damage the coating when the joint is being made. Further-more, since there is no additional cathodic material (such as a steel fastener) used to create the joint, there is no joining induced galvanic activity beyond that of the two parent materials. In accordance with its originally proposed plan, this project has successfully developed process variants of UPJ to enable

  10. To Leave a Praxis to Itself May Be to Upset It in Unintended Ways

    DEFF Research Database (Denmark)

    Olsen, Poul Bitsch; Axel, Erik

    , in particular meetings that involved the contractor. We have also used statements from interviews with participants, users, administrators. Some of these have been audiotaped and transcribed. Others are supported with notes only. Most of them have a character of ongoing dialogue. These materials are organized...... by the researchers on a conception of situated praxis, of conflictual cooperation, and on an interest in morals and the meaning of upsetting practices. The organization of the material may hopefully provoke discussions around praxis as part of its further development. Thus, our presentation is based on a notion......, and sometimes we are upsetting because we try to defend a certain line of development or certain aspects of status quo. Sometimes we are upset because we fail to interfere into relevant practice....

  11. Impact of a reengineered electronic error-reporting system on medication event reporting and care process improvements at an urban medical center. (United States)

    McKaig, Donald; Collins, Christine; Elsaid, Khaled A


    A study was conducted to evaluate the impact of a reengineered approach to electronic error reporting at a 719-bed multidisciplinary urban medical center. The main outcome of interest was the monthly reported medication errors during the preimplementation (20 months) and postimplementation (26 months) phases. An interrupted time series analysis was used to describe baseline errors, immediate change following implementation of the current electronic error-reporting system (e-ERS), and trend of error reporting during postimplementation. Errors were categorized according to severity using the National Coordinating Council for Medication Error Reporting and Prevention (NCC MERP) Medication Error Index classifications. Reported errors were further analyzed by reporter and error site. During preimplementation, the monthly reported errors mean was 40.0 (95% confidence interval [CI]: 36.3-43.7). Immediately following e-ERS implementation, monthly reported errors significantly increased by 19.4 errors (95% CI: 8.4-30.5). The change in slope of reported errors trend was estimated at 0.76 (95% CI: 0.07-1.22). Near misses and no-patient-harm errors accounted for 90% of all errors, while errors that caused increased patient monitoring or temporary harm accounted for 9% and 1%, respectively. Nurses were the most frequent reporters, while physicians were more likely to report high-severity errors. Medical care units accounted for approximately half of all reported errors. Following the intervention, there was a significant increase in reporting of prevented errors and errors that reached the patient with no resultant harm. This improvement in reporting was sustained for 26 months and has contributed to designing and implementing quality improvement initiatives to enhance the safety of the medication use process.

  12. Surface accuracy achieved by upsetting of preforms generated by laser rod end melting

    Directory of Open Access Journals (Sweden)

    Brüning Heiko


    Full Text Available Cold forming generally allows the reproduction of parts with a high production rate and low waste of material. For this reason, many small parts for example of the body of a smartphone undergo at least one forming operation during their fabrication, e.g. screws, brackets or springs. However, when the size of forming products is reduced to the micro range, size effects appear and affect the forming process. One size effect leads to the fact that conventional multi stage upsetting processes cannot be scaled to micro range accordingly. As a consequence, the maximum achievable upset ratio decreases from 2.3 in macro range to values below 2 in micro range. This reduces the efficiency of the upsetting process significantly as more upsetting stages have to be carried out to reach the desired shape of the forming product. A very promising approach to reduce required forming stages is the laser rod end melting process which takes advantage of a size effect. Herein, the lower end of a rod is melted by the energy of a laser beam. The molten part of the rod automatically forms spherical due to surface tension. This droplet-shaped part is called “preform”. After total cooling, the preform is upset within a single stage cold forming operation to achieve the desired shape. In this paper, results of the upsetting operation with regard to surface accuracy of the forming product are presented. It is shown that surface characteristics with dimensions as small as 500 nm can be reasonably reproduced.

  13. Global Aerodynamic Modeling for Stall/Upset Recovery Training Using Efficient Piloted Flight Test Techniques (United States)

    Morelli, Eugene A.; Cunningham, Kevin; Hill, Melissa A.


    Flight test and modeling techniques were developed for efficiently identifying global aerodynamic models that can be used to accurately simulate stall, upset, and recovery on large transport airplanes. The techniques were developed and validated in a high-fidelity fixed-base flight simulator using a wind-tunnel aerodynamic database, realistic sensor characteristics, and a realistic flight deck representative of a large transport aircraft. Results demonstrated that aerodynamic models for stall, upset, and recovery can be identified rapidly and accurately using relatively simple piloted flight test maneuvers. Stall maneuver predictions and comparisons of identified aerodynamic models with data from the underlying simulation aerodynamic database were used to validate the techniques.

  14. Investigation of single event upset subject to protons of intermediate energy range

    Energy Technology Data Exchange (ETDEWEB)

    Takami, Y.; Shiraishi, F. (Rikkyo Univ., Yokosuka, Kanagawa (Japan). Inst. for Atomic Energy); Goka, T.; Shimano, Y. (Tsukuba Space Center, NASDA, 2-1-1, Sengen, Tsukuba, Ibaragi 305 (JP)); Sekiguchi, M.; Shida, K. (Inst. for Nuclear Energy, Univ. of Tokyo, 3-2-1 Midoricho, Tanashi, Tokyo 188 (JP)); Kishida, N.; Kadotani, H. (Century Research Center Corp., Tokyo (Japan)); Kikuchi, T. (NEC Corp., 4035 Ikebecho, Midoriku, Yokohama, Kanagawa 226 (JP)); Hoshino, N. (Toshiba Corp., Kawasaki (Japan)); Murakami, S. (Fujitsu Labs. Ltd., Kawasaki, Kanagawa (Japan)); Anayama, H.; Morio, A. (Reliability Center for Electonic Components of Japan, 3-4-13 Nihonbashi, Chuoku, Tokyo 103 (JP))


    Nuclear reaction models to reproduce p + Si nuclear reactions precisely in the incident proton energy region of below 50 MeV were investigated, and a computer code based on exciton models was developed. Si irradiation experiments in the intermediate energy region were performed to measure energy deposit by p + Si nuclear reactions, with two totally depleted Si detectors in face-to-face arrangement. Coincident signals were analyzed by a two dimensional pulse height analyzer. This method is shown to be effective in discriminating signals of contaminating particles.

  15. Influence of heavy ion flux on single event effect testing in memory devices (United States)

    Luo, Jie; Liu, Jie; Sun, Youmei; Hou, Mingdong; Xi, Kai; Liu, Tianqi; Wang, Bin; Ye, Bing


    The natural space presents a particle flux variable environment and choosing a suitable flux value for ground-based single event experiments is an unresolved problem so far. In this work, various types of memory devices have been tested over the ion flux range from 10 to 105 ions/(cm2·s) using different ions covering LET from 10.1 to 99.8 MeV·cm2/mg. It was found that for most devices the error rates of single event upsets are affected by the applied flux value. And the effect involving flux becomes prominent as it is increased above 103 ions/(cm2·s). Different devices behave differently as the flux is increased and the flux effect depends strongly on the LET of the impinging ions. The results concluded in this experiment are discussed in detail and recommendations for choosing appropriate experimental flux are given.

  16. Final results of the supra project : Improved Simulation of Upset Recovery

    NARCIS (Netherlands)

    Fucke, L.; Groen, E.; Goman, M.; Abramov, N.; Wentink, M.; Nooij, S.; Zaichik, L.E.; Khrabrov, A.


    The objective of the European research project SUPRA (Simulation of Upset Recovery in Aviation) is to develop technologies that eventually contribute to a reduction of risk of Loss of control - in flight (LOC-I) accidents, today's major cause of fatal accidents in commercial aviation. To this end

  17. Ground-based Simulation of Upset Recovery in DESDEMONA: Aspects of Motion Cueing and Motion Perception

    NARCIS (Netherlands)

    Groen, E.L.; Wentink, M.; Trujillo, M.; Huhne, R.


    Unsuccessful recovery from unusual flight attitudes, or “airplane upset”, is considered an important factor in civil aviation accidents. It is generally recognized that there is a clear need for enhanced training of recovery procedures from unusual flight attitudes, i.e. situations where an aircraft

  18. Monte Carlo simulation of particle-induced bit upsets

    Directory of Open Access Journals (Sweden)

    Wrobel Frédéric


    Full Text Available We investigate the issue of radiation-induced failures in electronic devices by developing a Monte Carlo tool called MC-Oracle. It is able to transport the particles in device, to calculate the energy deposited in the sensitive region of the device and to calculate the transient current induced by the primary particle and the secondary particles produced during nuclear reactions. We compare our simulation results with SRAM experiments irradiated with neutrons, protons and ions. The agreement is very good and shows that it is possible to predict the soft error rate (SER for a given device in a given environment.

  19. CREME96 and Related Error Rate Prediction Methods (United States)

    Adams, James H., Jr.


    Predicting the rate of occurrence of single event effects (SEEs) in space requires knowledge of the radiation environment and the response of electronic devices to that environment. Several analytical models have been developed over the past 36 years to predict SEE rates. The first error rate calculations were performed by Binder, Smith and Holman. Bradford and Pickel and Blandford, in their CRIER (Cosmic-Ray-Induced-Error-Rate) analysis code introduced the basic Rectangular ParallelePiped (RPP) method for error rate calculations. For the radiation environment at the part, both made use of the Cosmic Ray LET (Linear Energy Transfer) spectra calculated by Heinrich for various absorber Depths. A more detailed model for the space radiation environment within spacecraft was developed by Adams and co-workers. This model, together with a reformulation of the RPP method published by Pickel and Blandford, was used to create the CR ME (Cosmic Ray Effects on Micro-Electronics) code. About the same time Shapiro wrote the CRUP (Cosmic Ray Upset Program) based on the RPP method published by Bradford. It was the first code to specifically take into account charge collection from outside the depletion region due to deformation of the electric field caused by the incident cosmic ray. Other early rate prediction methods and codes include the Single Event Figure of Merit, NOVICE, the Space Radiation code and the effective flux method of Binder which is the basis of the SEFA (Scott Effective Flux Approximation) model. By the early 1990s it was becoming clear that CREME and the other early models needed Revision. This revision, CREME96, was completed and released as a WWW-based tool, one of the first of its kind. The revisions in CREME96 included improved environmental models and improved models for calculating single event effects. The need for a revision of CREME also stimulated the development of the CHIME (CRRES/SPACERAD Heavy Ion Model of the Environment) and MACREE (Modeling and

  20. Disclosure of medical errors. (United States)

    Matlow, Anne; Stevens, Polly; Harrison, Christine; Laxer, Ronald M


    The 1999 release of the Institute of Medicine's document To Err is Human was akin to removing the lid of Pandora's box. Not only were the magnitude and impact of medical errors now apparent to those working in the health care industry, but consumers or health care were alerted to the occurrence of medical events causing harm. One specific solution advocated was the disclosure to patients and their families of adverse events resulting from medical error. Knowledge of the historical perspective, ethical underpinnings, and medico-legal implications gives us a better appreciation of current recommendations for disclosing adverse events resulting from medical error to those affected.

  1. Read disturb errors in a CMOS static RAM chip. [radiation hardened for spacedraft (United States)

    Wood, Steven H.; Marr, James C., IV; Nguyen, Tien T.; Padgett, Dwayne J.; Tran, Joe C.; Griswold, Thomas W.; Lebowitz, Daniel C.


    Results are reported from an extensive investigation into pattern-sensitive soft errors (read disturb errors) in the TCC244 CMOS static RAM chip. The TCC244, also known as the SA2838, is a radiation-hard single-event-upset-resistant 4 x 256 memory chip. This device is being used by the Jet Propulsion Laboratory in the Galileo and Magellan spacecraft, which will have encounters with Jupiter and Venus, respectively. Two aspects of the part's design are shown to result in the occurrence of read disturb errors: the transparence of the signal path from the address pins to the array of cells, and the large resistance in the Vdd and Vss lines of the cells in the center of the array. Probe measurements taken during a read disturb failure illustrate how address skews and the data pattern in the chip combine to produce a bit flip. A capacitive charge pump formed by the individual cell capacitances and the resistance in the supply lines pumps down both the internal cell voltage and the local supply voltage until a bit flip occurs.

  2. Sex differences in the events that elicit jealousy among homosexuals

    NARCIS (Netherlands)

    Dijkstra, Pieternel; Groothof, H.; Poel, G.A.; Haverman, T.TG; Buunk, Abraham (Bram)

    When individuals ale asked which event would upset them more-a partner's emotional infidelity or a partner's sexual infidelity-among heterosexuals more men than women select a partner's sexual infidelity as the most distressing event, whereas more women than men select a partner's emotional

  3. Injecting Artificial Memory Errors Into a Running Computer Program (United States)

    Bornstein, Benjamin J.; Granat, Robert A.; Wagstaff, Kiri L.


    Single-event upsets (SEUs) or bitflips are computer memory errors caused by radiation. BITFLIPS (Basic Instrumentation Tool for Fault Localized Injection of Probabilistic SEUs) is a computer program that deliberately injects SEUs into another computer program, while the latter is running, for the purpose of evaluating the fault tolerance of that program. BITFLIPS was written as a plug-in extension of the open-source Valgrind debugging and profiling software. BITFLIPS can inject SEUs into any program that can be run on the Linux operating system, without needing to modify the program s source code. Further, if access to the original program source code is available, BITFLIPS offers fine-grained control over exactly when and which areas of memory (as specified via program variables) will be subjected to SEUs. The rate of injection of SEUs is controlled by specifying either a fault probability or a fault rate based on memory size and radiation exposure time, in units of SEUs per byte per second. BITFLIPS can also log each SEU that it injects and, if program source code is available, report the magnitude of effect of the SEU on a floating-point value or other program variable.

  4. Upset in Response to a Sibling’s Partner’s Infidelity

    Directory of Open Access Journals (Sweden)

    Dafni Hellstrand


    Full Text Available Existing evidence suggests that the psychological design of romantic jealousy differs for men and women: Men are more likely than women to report greater upset in response to a partner’s sexual than emotional infidelity, whereas women are more likely than men to report greater upset in response to a partner’s emotional than sexual infidelity. However, the observed sex difference can be explained after the fact by both an evolutionary analysis of past reproductive costs and a social constructionist analysis of social and gender role training. Attempting to disentangle these competing perspectives, researchers have measured participants’ upset in response to a sibling’s or a child’s partner’s infidelities. In contrast to what a socialization perspective would predict, participants’ sex did not seem to affect their responses; the key variable was the sex of the sibling or the child, in line with a heuristic application of the evolutionary perspective. The present study attempted not only to test these competing hypotheses but also to extend previous work by involving participants with a gay or lesbian sibling and examining whether participants’ responses are triggered by their sibling’s or sibling’s partner’s sex. In line with an evolutionary perspective, participants’ sex did not assert an effect on their responses. The key variable seemed to be the sex of the sibling (rather than the sex of the sibling’s partner, with participants reporting greater levels of upset in response to the sexual than emotional infidelity of a gay brother’s partner and to the emotional than sexual infidelity of a lesbian sister’s partner. The ensuing discussion offers suggestions for future work on sex-specific triggers of jealousy.

  5. Why Professor Richard Feynman was upset solving the Laplace equation for spherical waves?


    Khelashvili, Anzor; Nadareishvili, Teimuraz


    We take attention to the singular behavior of the Laplace operator in spherical coordinates, which was established in our earlier work. This singularity has many non-trivial consequences. In this article we consider only the simplest ones, which are connected to the solution of Laplace equation in Feynman classical books and Lectures. Feynman was upset looking in his derived solutions, which have a fictitious singular behavior at the origin. We show how these inconsistencies can be avoided.

  6. Elucidating the Role of Toxin-Induced Microbial Stress Responses in Biological Wastewater Treatment Process Upset


    Bott, Charles Briddell


    The overall hypothesis of this work is that the physiological microbial stress response could serve as a rapid, sensitive, and mechanistically-based indicator of process upset in biological wastewater treatment systems that receive sporadic shock loads of toxic chemicals. The microbial stress response is a set of conserved and unique biochemical mechanisms that an organism activates or induces under adverse conditions, specifically for the protection of cellular components or the repair of d...

  7. Nuclear physics of cosmic ray interaction with semiconductor materials: Particle induced soft errors from a physicist`s perspective

    Energy Technology Data Exchange (ETDEWEB)

    Tang, H.H.K.


    The key issues of cosmic-ray-induced soft-error rates, SER (also referred to as single-event upset, SEU, rates) in microelectronic devices are discussed from the viewpoint of fundamental atomic and nuclear interactions between high-energy particles and semiconductors. From sea level to moderate altitudes, the cosmic ray spectrum is dominated by three particle species: nucleons (protons and neutrons), pions, and muons. The characteristic features of high-energy nuclear reactions of these particles with light elements are reviewed. A major cause of soft errors is identified to be the ionization electron-hole pairs induced by the secondary nuclear fragments produced in certain processes. These processes are the inelastic collisions between the cosmic ray particles and nuclei in the host material. A state-of-the-art nuclear spallation reaction model, NUSPA, is developed to simulate these reactions. This model is tested and validated by a large set of nuclear experiments. It is used to generate the crucial database for the soft-error simulators which are currently used throughout IBM for device and circuit analysis. The relative effectiveness of nucleons, pions, and muons as soft-error-inducing agents is evaluated on the basis of nuclear reaction rate calculations and energy-deposition analysis.

  8. Identification of human-induced initiating events in the low power and shutdown operation using the commission error search and assessment method

    Energy Technology Data Exchange (ETDEWEB)

    Kim, Yong Chan; Kim, Jong Hyun [KEPCO International Nuclear Graduate School (KINGS), Ulsan (Korea, Republic of)


    Human-induced initiating events, also called Category B actions in human reliability analysis, are operator actions that may lead directly to initiating events. Most conventional probabilistic safety analyses typically assume that the frequency of initiating events also includes the probability of human-induced initiating events. However, some regulatory documents require Category B actions to be specifically analyzed and quantified in probabilistic safety analysis. An explicit modeling of Category B actions could also potentially lead to important insights into human performance in terms of safety. However, there is no standard procedure to identify Category B actions. This paper describes a systematic procedure to identify Category B actions for low power and shutdown conditions. The procedure includes several steps to determine operator actions that may lead to initiating events in the low power and shutdown stages. These steps are the selection of initiating events, the selection of systems or components, the screening of unlikely operating actions, and the quantification of initiating events. The procedure also provides the detailed instruction for each step, such as operator's action, information required, screening rules, and the outputs. Finally, the applicability of the suggested approach is also investigated by application to a plant example.

  9. Medication Errors (United States)

    ... for You Agency for Healthcare Research and Quality: Medical Errors and Patient Safety Centers for Disease Control and ... Quality Chasm Series National Coordinating Council for Medication Error Reporting and Prevention ... Devices Radiation-Emitting Products Vaccines, Blood & Biologics Animal & ...

  10. In the Land of Ice and Fire: Stressful Events in the Lives of Icelandic Children. (United States)

    Yamamoto, Kaoru; And Others


    A total of 244 students from 4 locations in Iceland responded to a questionnaire about upsetting life events and their experiences. Children converged in their perceptions of stressful events, and their ideas were in close agreement with those of U.S. children. Findings suggest how many events are stressful to children. (SLD)

  11. Error Patterns

    NARCIS (Netherlands)

    Hoede, C.; Li, Z.


    In coding theory the problem of decoding focuses on error vectors. In the simplest situation code words are $(0,1)$-vectors, as are the received messages and the error vectors. Comparison of a received word with the code words yields a set of error vectors. In deciding on the original code word,

  12. Evolution of microstructure and texture in copper during repetitive extrusion-upsetting and subsequent annealing

    DEFF Research Database (Denmark)

    Chen, Q.; Shu, D. Y.; Lin, J.


    The evolution of the microstructure and texture in copper has been studied during repetitive extrusion-upsetting (REU) to a total von Mises strain of 4.7 and during subsequent annealing at different temperatures. It is found that the texture is significantly altered by each deformation pass...... developing predominantly in high misorientation regions. At 350 ºC the microstructure is fully recrystallized with an average grain size of only 2.3 μm and a very weak crystallographic texture. This REU-processed and subsequently annealed material is considered to be potentially suitable for using...

  13. Ferromagnetic grain boundary signature in die-upset RE-Fe-B magnets

    Energy Technology Data Exchange (ETDEWEB)

    Henderson Lewis, L.; Zhu, Y.; Welch, D.O.


    Previous nanostructural and nanocompositional studies performed on the boundaries of deformed grains in two die-upset rare earth magnets with bulk compositions Nd{sub 13.75}Fe{sub 80.25}B{sub 6}, and Pr{sub 13.75}Fe{sub 80.25}B{sub 6} indicate that the intergranular phase in many grain boundaries is enriched in iron relative to the bulk. Preliminary magnetic data are presented that provide further evidence that this grain boundary phase is indeed iron-rich, and in fact appears to be ferromagnetic. Hysteresis loops were performed at 800 K on die-upset magnets with the above compositions. Each sample showed a clear hysteresis with coercivities between 34 and 40 Oe average remanence 4{pi}M{sub R} of 6.8 G for the Nd-based sample and 10.3 G for the Pr-based sample. The ferromagnetic signals measured at high temperature in these magnets are attributed to the iron-rich grain boundary phase. The implications of this conclusion with respect to coercivity are discussed.

  14. Upsetting Analysis of High-Strength Tubular Specimens with the Taguchi Method

    Directory of Open Access Journals (Sweden)

    Tomaž Pepelnjak


    Full Text Available In order to obtain input data for numerical simulations of tube forming, the material properties of tubes need to be determined. A tube tensile test can only be used to measure yield stress and ultimate tensile stress. For tubes with a large diameter/thickness ratio (D/t, tensile specimens are cut out and processed in a similar way as with sheet metal. However, for thin tubes with a diameter/thickness ratio below 10, the tensile specimens could not be cut out. The flow curve of the analyzed tube with a small diameter and D/t ratio of 7 was determined with a ring-shaped specimen. The experimental force-travel diagram was acquired. A reverse-engineering method was used to determine flow curves by numerical simulations. Using an L25 orthogonal array of the Taguchi method different flow curve parameters and friction coefficient combinations were selected. Tube upsetting with determined parameter combinations was performed with the finite element method. With analysis of variance influential equations among selected input parameters were determined for the force levels at six upsetting states. With the evaluation of known friction coefficients and flow curve parameters, K, n, and ε0 according to the Swift approximation were determined and proved by the final shape of the workpiece.

  15. Flight Tests Related to Jet-Transport Upset and Turbulent-Air Penetration (United States)

    Andrews, William H.; Butchart, Stanley P.; Sisk, Thomas R.; Hughes, Donald L.


    A flight program, utilizing a Convair 880 and a Boeing 720 airplane, was conducted in conjunction with wind-tunnel and simulator programs to study problems related to jet-transport upsets and operation in a turbulent environment. During the handling-qualities portion of the program the basic static stability of the airplanes was considered to be satisfactory and the lateral-directional damping was considered to be marginal without damper augmentation. An evaluation of the longitudinal control system indicated that this system can become marginal in effectiveness in the high Mach number and high dynamic-pressure range of the flight envelope. From the upset and recovery phase of the program it was apparent that retrimming the stabilizer and spoiler deployment were valuable tools in effecting a positive recovery; however, if these devices are to be used safely, it appears that a suitable g-meter should be provided in the cockpit because the high control forces in recovery tend to reduce the pilot's sensitivity to the actual acceleration loads. During the turbulence penetrations the pilot noted that the measured vibrations of 4 to 6 cps in the cockpit considerably disrupted their normal scan pattern and suggested that an improvement should be made in the seat cushion and restraint system. Also it was observed that the indicator needles on the flight instruments were quite stable in the turbulent environment.

  16. Medical error

    African Journals Online (AJOL)


    Studies in the USA have shown that medical error is the 8th most common cause of death.2,3. The most common causes of medical error are:- administration of the wrong medication or wrong dose of the correct medication, using the wrong route of administration, giving a treatment to the wrong patient or at the wrong time.4 ...

  17. Medical error and disclosure. (United States)

    White, Andrew A; Gallagher, Thomas H


    Errors occur commonly in healthcare and can cause significant harm to patients. Most errors arise from a combination of individual, system, and communication failures. Neurologists may be involved in harmful errors in any practice setting and should familiarize themselves with tools to prevent, report, and examine errors. Although physicians, patients, and ethicists endorse candid disclosure of harmful medical errors to patients, many physicians express uncertainty about how to approach these conversations. A growing body of research indicates physicians often fail to meet patient expectations for timely and open disclosure. Patients desire information about the error, an apology, and a plan for preventing recurrence of the error. To meet these expectations, physicians should participate in event investigations and plan thoroughly for each disclosure conversation, preferably with a disclosure coach. Physicians should also anticipate and attend to the ongoing medical and emotional needs of the patient. A cultural change towards greater transparency following medical errors is in motion. Substantial progress is still required, but neurologists can further this movement by promoting policies and environments conducive to open reporting, respectful disclosure to patients, and support for the healthcare workers involved. © 2013 Elsevier B.V. All rights reserved.

  18. Keep calm and carry on: Maintaining self-control when intoxicated, upset, or depleted (United States)

    Simons, Jeffrey S.; Wills, Thomas A.; Emery, Noah N.; Spelman, Philip J.


    This study tested within-person associations between intoxication, negative affect, and self-control demands and two forms of self-control failure, interpersonal conflict, and neglecting responsibilities. Effortful control was hypothesised to act as a buffer, reducing individual susceptibility to these within-person effects. In contrast, reactivity was hypothesised to potentiate the within-person associations. 274 young adults aged 18–27 (56% women, 93% white) completed experience sampling assessments for up to 49 days over the course of 1.3 years. Results indicated independent within-person effects of intoxication, negative affect, and self-control demands on the outcomes. Hypothesised moderating effects of reactivity were not supported. Effortful control did not moderate the effects of self-control demands as expected. However, effortful control exhibited a protective effect when individuals were intoxicated or upset to reduce the likelihood of maladaptive behavioural outcomes. PMID:26264715

  19. Survey of Quantitative Research Metrics to Assess Pilot Performance in Upset Recovery (United States)

    Le Vie, Lisa R.


    Accidents attributable to in-flight loss of control are the primary cause for fatal commercial jet accidents worldwide. The National Aeronautics and Space Administration (NASA) conducted a literature review to determine and identify the quantitative standards for assessing upset recovery performance. This review contains current recovery procedures for both military and commercial aviation and includes the metrics researchers use to assess aircraft recovery performance. Metrics include time to first input, recognition time and recovery time and whether that input was correct or incorrect. Other metrics included are: the state of the autopilot and autothrottle, control wheel/sidestick movement resulting in pitch and roll, and inputs to the throttle and rudder. In addition, airplane state measures, such as roll reversals, altitude loss/gain, maximum vertical speed, maximum/minimum air speed, maximum bank angle and maximum g loading are reviewed as well.

  20. Evaluating the Upset Protrusion Joining (UPJ) Method to Join magnesium Castings to Dissimilar Metals

    Energy Technology Data Exchange (ETDEWEB)

    Logan, Stephen D. [FCA US LLC


    This presentation discusses advantages and best practices for incorporating magnesium in automotive component applications to achieve substantial mass reduction, as well as some of the key challenges with respect to joining, coating, and galvanic corrosion, before providing an introduction and status update of the U.S. Department of Energy and Department of Defense jointly sponsored Upset Protrusion Joining (UPJ) process development and evaluation project. This update includes sharing performance results of a benchmark evaluation of the self-pierce riveting (SPR) process for joining dissimilar magnesium (Mg) to aluminum (Al) materials in four unique coating configurations before introducing the UPJ concept and comparing performance results of the joints made with the UPJ process to those made with the SPR process.

  1. Refractive Errors (United States)

    ... halos around bright lights, squinting, headaches, or eye strain. Glasses or contact lenses can usually correct refractive errors. Laser eye surgery may also be a possibility. NIH: National Eye ...

  2. Students’ Written Production Error Analysis in the EFL Classroom Teaching: A Study of Adult English Learners Errors

    Directory of Open Access Journals (Sweden)

    Ranauli Sihombing


    Full Text Available Errors analysis has become one of the most interesting issues in the study of Second Language Acquisition. It can not be denied that some teachers do not know a lot about error analysis and related theories of how L1, L2 or foreign language acquired. In addition, the students often feel upset since they find a gap between themselves and the teachers for the errors the students make and the teachers’ understanding about the error correction. The present research aims to investigate what errors adult English learners make in written production of English. The significances of the study is to know what errors students make in writing that the teachers can find solution to the errors the students make for a better English language teaching and learning especially in teaching English for adults. The study employed qualitative method. The research was undertaken at an airline education center in Bandung. The result showed that syntax errors are more frequently found than morphology errors, especially in terms of verb phrase errors. It is recommended that it is important for teacher to know the theory of second language acquisition in order to know how the students learn and produce theirlanguage. In addition, it will be advantages for teachers if they know what errors students frequently make in their learning, so that the teachers can give solution to the students for a better English language learning achievement.   DOI:

  3. Causes of intravenous medication errors: an ethnographic study


    Taxis, K; Barber, N


    Background: Intravenous (IV) medication errors are frequent events. They are associated with considerable harm, but little is known about their causes. Human error theory is increasingly used to understand adverse events in medicine, but has not yet been applied to study IV errors. Our aim was to investigate causes of errors in IV drug preparation and administration using a framework of human error theory.


    Directory of Open Access Journals (Sweden)

    Andrej Robida


    the surveyed persons agreed to disclosure of the event to a patient but this was the case in less than half of the occasions.Conclusions. The small number of reports of sentinel events, late or incomplete reporting of conducted analyses of root causes and plans for future prevention of these events and survey data showed the state of culture in the majority of hospitals. Fear of reporting and therefore, hiding of errors or ascribing errors to the »usual« complications of a disease or procedures, the reaction of leadership to quickly find a culprit for the event, disregarding a serious approach to analyze the event and taking measures for their future prevention leads to the culture of silence. Root cause analysis of the events showed that the reason frequently lies in systems and processes and not in individuals. Health care will never be without risks for patients. However, with an open approach without the blaming and shaming of individuals, implementation of reporting the events in hospitals and other health care facilities with clear goals of patient safety, standardization of equipment, materials, and processes and education on patient safety many sentinel events and medical errors could and should be prevented.

  5. Refractive errors. (United States)

    Schiefer, Ulrich; Kraus, Christina; Baumbach, Peter; Ungewiß, Judith; Michels, Ralf


    All over the world, refractive errors are among the most frequently occuring treatable distur - bances of visual function. Ametropias have a prevalence of nearly 70% among adults in Germany and are thus of great epidemiologic and socio-economic relevance. In the light of their own clinical experience, the authors review pertinent articles retrieved by a selective literature search employing the terms "ametropia, "anisometropia," "refraction," "visual acuity," and epidemiology." In 2011, only 31% of persons over age 16 in Germany did not use any kind of visual aid; 63.4% wore eyeglasses and 5.3% wore contact lenses. Refractive errors were the most common reason for consulting an ophthalmologist, accounting for 21.1% of all outpatient visits. A pinhole aperture (stenopeic slit) is a suitable instrument for the basic diagnostic evaluation of impaired visual function due to optical factors. Spherical refractive errors (myopia and hyperopia), cylindrical refractive errors (astigmatism), unequal refractive errors in the two eyes (anisometropia), and the typical optical disturbance of old age (presbyopia) cause specific functional limitations and can be detected by a physician who does not need to be an ophthalmologist. Simple functional tests can be used in everyday clinical practice to determine quickly, easily, and safely whether the patient is suffering from a benign and easily correctable type of visual impairment, or whether there are other, more serious underlying causes.

  6. Upset Simulation and Training Initiatives for U.S. Navy Commercial Derived Aircraft (United States)

    Donaldson, Steven; Priest, James; Cunningham, Kevin; Foster, John V.


    Militarized versions of commercial platforms are growing in popularity due to many logistical benefits in the form of commercial off-the-shelf (COTS) parts, established production methods, and commonality for different certifications. Commercial data and best practices are often leveraged to reduce procurement and engineering development costs. While the developmental and cost reduction benefits are clear, these militarized aircraft are routinely operated in flight at significantly different conditions and in significantly different manners than for routine commercial flight. Therefore they are at a higher risk of flight envelope exceedance. This risk may lead to departure from controlled flight and/or aircraft loss1. Historically, the risk of departure from controlled flight for military aircraft has been mitigated by piloted simulation training and engineering analysis of typical aircraft response. High-agility military aircraft simulation databases are typically developed to include high angles of attack (AoA) and sideslip due to the dynamic nature of their missions and have been developed for many tactical configurations over the previous decades. These aircraft simulations allow for a more thorough understanding of the vehicle flight dynamics characteristics at high AoA and sideslip. In recent years, government sponsored research on transport airplane aerodynamic characteristics at high angles of attack has produced a growing understanding of stall/post-stall behavior. This research along with recent commercial airline training initiatives has resulted in improved understanding of simulator-based training requirements and simulator model fidelity.2-5 In addition, inflight training research over the past decade has produced a database of pilot performance and recurrency metrics6. Innovative solutions to aerodynamically model large commercial aircraft for upset conditions such as high AoA, high sideslip, and ballistic damage, as well as capability to accurately

  7. Inpatients’ medical prescription errors

    Directory of Open Access Journals (Sweden)

    Aline Melo Santos Silva


    Full Text Available Objective: To identify and quantify the most frequent prescription errors in inpatients’ medical prescriptions. Methods: A survey of prescription errors was performed in the inpatients’ medical prescriptions, from July 2008 to May 2009 for eight hours a day. Rresults: At total of 3,931 prescriptions was analyzed and 362 (9.2% prescription errors were found, which involved the healthcare team as a whole. Among the 16 types of errors detected in prescription, the most frequent occurrences were lack of information, such as dose (66 cases, 18.2% and administration route (26 cases, 7.2%; 45 cases (12.4% of wrong transcriptions to the information system; 30 cases (8.3% of duplicate drugs; doses higher than recommended (24 events, 6.6% and 29 cases (8.0% of prescriptions with indication but not specifying allergy. Cconclusion: Medication errors are a reality at hospitals. All healthcare professionals are responsible for the identification and prevention of these errors, each one in his/her own area. The pharmacist is an essential professional in the drug therapy process. All hospital organizations need a pharmacist team responsible for medical prescription analyses before preparation, dispensation and administration of drugs to inpatients. This study showed that the pharmacist improves the inpatient’s safety and success of prescribed therapy.

  8. Stepped-wedge cluster randomised controlled trial to assess the effectiveness of an electronic medication management system to reduce medication errors, adverse drug events and average length of stay at two paediatric hospitals: a study protocol. (United States)

    Westbrook, J I; Li, L; Raban, M Z; Baysari, M T; Mumford, V; Prgomet, M; Georgiou, A; Kim, T; Lake, R; McCullagh, C; Dalla-Pozza, L; Karnon, J; O'Brien, T A; Ambler, G; Day, R; Cowell, C T; Gazarian, M; Worthington, R; Lehmann, C U; White, L; Barbaric, D; Gardo, A; Kelly, M; Kennedy, P


    Medication errors are the most frequent cause of preventable harm in hospitals. Medication management in paediatric patients is particularly complex and consequently potential for harms are greater than in adults. Electronic medication management (eMM) systems are heralded as a highly effective intervention to reduce adverse drug events (ADEs), yet internationally evidence of their effectiveness in paediatric populations is limited. This study will assess the effectiveness of an eMM system to reduce medication errors, ADEs and length of stay (LOS). The study will also investigate system impact on clinical work processes. A stepped-wedge cluster randomised controlled trial (SWCRCT) will measure changes pre-eMM and post-eMM system implementation in prescribing and medication administration error (MAE) rates, potential and actual ADEs, and average LOS. In stage 1, 8 wards within the first paediatric hospital will be randomised to receive the eMM system 1 week apart. In stage 2, the second paediatric hospital will randomise implementation of a modified eMM and outcomes will be assessed. Prescribing errors will be identified through record reviews, and MAEs through direct observation of nurses and record reviews. Actual and potential severity will be assigned. Outcomes will be assessed at the patient-level using mixed models, taking into account correlation of admissions within wards and multiple admissions for the same patient, with adjustment for potential confounders. Interviews and direct observation of clinicians will investigate the effects of the system on workflow. Data from site 1 will be used to develop improvements in the eMM and implemented at site 2, where the SWCRCT design will be repeated (stage 2). The research has been approved by the Human Research Ethics Committee of the Sydney Children's Hospitals Network and Macquarie University. Results will be reported through academic journals and seminar and conference presentations. Australian New Zealand

  9. Analysis of the Radiated Field in an Electromagnetic Reverberation Chamber as an Upset-Inducing Stimulus for Digital Systems (United States)

    Torres-Pomales, Wilfredo


    Preliminary data analysis for a physical fault injection experiment of a digital system exposed to High Intensity Radiated Fields (HIRF) in an electromagnetic reverberation chamber suggests a direct causal relation between the time profile of the field strength amplitude in the chamber and the severity of observed effects at the outputs of the radiated system. This report presents an analysis of the field strength modulation induced by the movement of the field stirrers in the reverberation chamber. The analysis is framed as a characterization of the discrete features of the field strength waveform responsible for the faults experienced by a radiated digital system. The results presented here will serve as a basis to refine the approach for a detailed analysis of HIRF-induced upsets observed during the radiation experiment. This work offers a novel perspective into the use of an electromagnetic reverberation chamber to generate upset-inducing stimuli for the study of fault effects in digital systems.

  10. Numerical modeling of electrical upsetting manufacturing processes based on Forge® environment (United States)

    Alves, J.; Acevedo, S.; Marie, S.; Adams, B.; Mocellin, K.; Bay, F.


    The present work reviews the latest developments done within Forge®, finite element numerical simulation software for all bulk metal forming processes, to deal with electric processing of materials. We present a complete parallel finite-element coupled Electrical-Thermal-Mechanical model for two-dimensional and three-dimensional electro forming applications. The electro-thermal modeling is considered by sequential-coupling in which the Joule heating term computed from the electric resolution is used as a source term for the thermal problem. For the experimental comparison we use an electric upsetting forming case developed at the Osnabrück University of Applied Sciences. The forming process consists in a closed die hot forging case in which an electric current is passed through the billet to heat it up. At the same time, it is deformed by an applied pressure on the billets end surface. We compare the experimental set-up with 2D and 3D numerical simulations.

  11. Spark Plasma Sintering and Upsetting of a Gas-Atomized/Air-Atomized Al Alloy Powder Mixture (United States)

    Tünçay, Mehmet Masum; Muñiz-Lerma, José Alberto; Bishop, Donald Paul; Brochu, Mathieu


    Al-Zn-Mg-Cu alloy powder, Alumix 431D, was modified by replacing the native air-atomized pure Al particles with gas-atomized pure Al. Samples were sintered using spark plasma sintering (SPS), and upset forging was applied to the sintered samples by SPS. Densities over 98 and 99% of theoretical were obtained for the sintered and forged samples, respectively. Microstructural analysis and characterization of all samples were done using energy-dispersive spectroscopy and x-ray diffraction. Mechanical properties were evaluated using microhardness and flexural strength and strain measurements. The microhardness value of the T6 tempered sample was comparable to that of its wrought counterpart AA7075. Particle bonding after sintering was incomplete and reveals that composite oxide layer of Al-Zn-Mg-Cu alloy powder is difficult to disrupt, and it is necessary to apply a secondary process like forging to improve particle bonding. The loss in ductility following T6 tempering is ascribed to void formation due to the dissolution of the secondary phases, remaining undissolved precipitates, and a localized lack of cohesion between particles.

  12. Practical Application of a Subscale Transport Aircraft for Flight Research in Control Upset and Failure Conditions (United States)

    Cunningham, Kevin; Foster, John V.; Morelli, Eugene A.; Murch, Austin M.


    Over the past decade, the goal of reducing the fatal accident rate of large transport aircraft has resulted in research aimed at the problem of aircraft loss-of-control. Starting in 1999, the NASA Aviation Safety Program initiated research that included vehicle dynamics modeling, system health monitoring, and reconfigurable control systems focused on flight regimes beyond the normal flight envelope. In recent years, there has been an increased emphasis on adaptive control technologies for recovery from control upsets or failures including damage scenarios. As part of these efforts, NASA has developed the Airborne Subscale Transport Aircraft Research (AirSTAR) flight facility to allow flight research and validation, and system testing for flight regimes that are considered too risky for full-scale manned transport airplane testing. The AirSTAR facility utilizes dynamically-scaled vehicles that enable the application of subscale flight test results to full scale vehicles. This paper describes the modeling and simulation approach used for AirSTAR vehicles that supports the goals of efficient, low-cost and safe flight research in abnormal flight conditions. Modeling of aerodynamics, controls, and propulsion will be discussed as well as the application of simulation to flight control system development, test planning, risk mitigation, and flight research.

  13. Errors in Neonatology

    Directory of Open Access Journals (Sweden)

    Antonio Boldrini


    Full Text Available Introduction: Danger and errors are inherent in human activities. In medical practice errors can lean to adverse events for patients. Mass media echo the whole scenario. Methods: We reviewed recent published papers in PubMed database to focus on the evidence and management of errors in medical practice in general and in Neonatology in particular. We compared the results of the literature with our specific experience in Nina Simulation Centre (Pisa, Italy. Results: In Neonatology the main error domains are: medication and total parenteral nutrition, resuscitation and respiratory care, invasive procedures, nosocomial infections, patient identification, diagnostics. Risk factors include patients’ size, prematurity, vulnerability and underlying disease conditions but also multidisciplinary teams, working conditions providing fatigue, a large variety of treatment and investigative modalities needed. Discussion and Conclusions: In our opinion, it is hardly possible to change the human beings but it is likely possible to change the conditions under they work. Voluntary errors report systems can help in preventing adverse events. Education and re-training by means of simulation can be an effective strategy too. In Pisa (Italy Nina (ceNtro di FormazIone e SimulazioNe NeonAtale is a simulation center that offers the possibility of a continuous retraining for technical and non-technical skills to optimize neonatological care strategies. Furthermore, we have been working on a novel skill trainer for mechanical ventilation (MEchatronic REspiratory System SImulator for Neonatal Applications, MERESSINA. Finally, in our opinion national health policy indirectly influences risk for errors. Proceedings of the 9th International Workshop on Neonatology · Cagliari (Italy · October 23rd-26th, 2013 · Learned lessons, changing practice and cutting-edge research

  14. Error monitoring in musicians

    Directory of Open Access Journals (Sweden)

    Clemens eMaidhof


    Full Text Available To err is human, and hence even professional musicians make errors occasionally during their performances. This paper summarizes recent work investigating error monitoring in musicians, i.e. the processes and their neural correlates associated with the monitoring of ongoing actions and the detection of deviations from intended sounds. EEG Studies reported an early component of the event-related potential (ERP occurring before the onsets of pitch errors. This component, which can be altered in musicians with focal dystonia, likely reflects processes of error detection and/or error compensation, i.e. attempts to cancel the undesired sensory consequence (a wrong tone a musician is about to perceive. Thus, auditory feedback seems not to be a prerequisite for error detection, consistent with previous behavioral results. In contrast, when auditory feedback is externally manipulated and thus unexpected, motor performance can be severely distorted, although not all feedback alterations result in performance impairments. Recent studies investigating the neural correlates of feedback processing showed that unexpected feedback elicits an ERP component after note onsets, which shows larger amplitudes during music performance than during mere perception of the same musical sequences. Hence, these results stress the role of motor actions for the processing of auditory information. Furthermore, recent methodological advances like the combination of 3D motion capture techniques with EEG will be discussed. Such combinations of different measures can potentially help to disentangle the roles of different feedback types such as proprioceptive and auditory feedback, and in general to derive at a better understanding of the complex interactions between the motor and auditory domain during error monitoring. Finally, outstanding questions and future directions in this context will be discussed.

  15. The Usability-Error Ontology

    DEFF Research Database (Denmark)

    Elkin, Peter L.; Beuscart-zephir, Marie-Catherine; Pelayo, Sylvia


    in patients coming to harm. Often the root cause analysis of these adverse events can be traced back to Usability Errors in the Health Information Technology (HIT) or its interaction with users. Interoperability of the documentation of HIT related Usability Errors in a consistent fashion can improve our...... ability to do systematic reviews and meta-analyses. In an effort to support improved and more interoperable data capture regarding Usability Errors, we have created the Usability Error Ontology (UEO) as a classification method for representing knowledge regarding Usability Errors. We expect the UEO...... will grow over time to support an increasing number of HIT system types. In this manuscript, we present this Ontology of Usability Error Types and specifically address Computerized Physician Order Entry (CPOE), Electronic Health Records (EHR) and Revenue Cycle HIT systems....

  16. Effects Influencing Plutonium-Absorber Interactions and Distributions in Routine and Upset Waste Treatment Plant Operations

    Energy Technology Data Exchange (ETDEWEB)

    Delegard, Calvin H. [Pacific Northwest National Lab. (PNNL), Richland, WA (United States); Sinkov, Sergey I. [Pacific Northwest National Lab. (PNNL), Richland, WA (United States); Fiskum, Sandra K. [Pacific Northwest National Lab. (PNNL), Richland, WA (United States)


    This report is the third in a series of analyses written in support of a plan to revise the Hanford Waste Treatment and Immobilization Plant (WTP) Preliminary Criticality Safety Evaluation Report (CSER) that is being implemented at the request of the U.S. Department of Energy (DOE) Criticality Safety Group. A report on the chemical disposition of plutonium in Hanford tank wastes was prepared as Phase 1 of this plan (Delegard and Jones 2015). Phase 2 is the provision of a chemistry report to describe the potential impacts on criticality safety of waste processing operations within the WTP (Freer 2014). In accordance with the request from the Environmental and Nuclear Safety Department of the WTP (Miles and Losey 2012), the Phase 2 report assessed the potential for WTP process conditions within and outside the range of normal control parameters to change the ratio of fissile material to neutron-absorbing material in the waste as it is processed with an eye towards potential implications for criticality safety. The Phase 2 study also considered the implications should WTP processes take place within the credible range of chemistry upset conditions. In the present Phase 3 report, the 28 phenomena described in the Phase 2 report were considered with respect to the disposition of plutonium and various absorber elements. The phenomena identified in the Phase 2 report are evaluated in light of the Phase 1 report and other resources to determine the impacts these phenomena might have to alter the plutonium/absorber dispositions and ratios. The outcomes of the Phase 3 evaluations then can be used to inform subsequent engineering decisions and provide reasonable paths forward to mitigate or overcome real or potential criticality concern in plant operations.

  17. Measuring the upset of CMOS and TTL due to HPM-signals

    Directory of Open Access Journals (Sweden)

    N. Esser


    Full Text Available To measure the performance of electronic components when stressed by High Power Microwave signals a setup was designed and tested which allows a well-defined voltage signal to enter the component during normal operation, and to discriminate its effect on the component. The microwave signal is fed to the outside conductor of a coaxial cable and couples into the inner signal line connected to the device under test (DUT. The disturbing HF-signal is transferred almost independent from frequency to maintain the pulse shape in the time domain. The configuration designed to perform a TEM-coupling within a 50 Ohm system prevents the secondary system from feeding back to the primary system and, due to the geometrical parameters chosen, the coupling efficiency is as high as 50–90%. Linear dimensions and terminations applied allow for pulses up to a width of 12ns and up to a voltage level of 4–5 kV on the outside conductor. These pulse parameters proved to be sufficient to upset the DUTs tested so far. In more than 400 measurements a rectangular pulse of increasing voltage level was applied to different types of CMOS and TTL until the individual DUT was damaged. As well the pulse width (3, 6 or 12 ns and its polarity were varied in single-shot or repetitive-shot experiments (500 shots per voltage at a repetition rate of 3 Hz. The state of the DUT was continuously monitored by measuring both the current of the DUT circuit and that of the oscillator providing the operating signal for the DUT. The results show a very good reproducibility within a set of identical samples, remarkable differences between manufacturers and lower thresholds for repetitive testing, which indicates a memory effect of the DUT to exist for voltage levels significantly below the single-shot threshold.

  18. Exogenous HIV-1 Nef Upsets the IFN-γ-Induced Impairment of Human Intestinal Epithelial Integrity (United States)

    Quaranta, Maria Giovanna; Vincentini, Olimpia; Felli, Cristina; Spadaro, Francesca; Silano, Marco; Moricoli, Diego; Giordani, Luciana; Viora, Marina


    Background The mucosal tissues play a central role in the transmission of HIV-1 infection as well as in the pathogenesis of AIDS. Despite several clinical studies reported intestinal dysfunction during HIV infection, the mechanisms underlying HIV-induced impairments of mucosal epithelial barrier are still unclear. It has been postulated that HIV-1 alters enterocytic function and HIV-1 proteins have been detected in several cell types of the intestinal mucosa. In the present study, we analyzed the effect of the accessory HIV-1 Nef protein on human epithelial cell line. Methodology/Principal Findings We used unstimulated or IFN-γ-stimulated Caco-2 cells, as a model for homeostatic and inflamed gastrointestinal tracts, respectively. We investigated the effect of exogenous recombinant Nef on monolayer integrity analyzing its uptake, transepithelial electrical resistance, permeability to FITC-dextran and the expression of tight junction proteins. Moreover, we measured the induction of proinflammatory mediators. Exogenous Nef was taken up by Caco-2 cells, increased intestinal epithelial permeability and upset the IFN-γ-induced reduction of transepitelial resistance, interfering with tight junction protein expression. Moreover, Nef inhibited IFN-γ-induced apoptosis and up-regulated TNF-α, IL-6 and MIP-3α production by Caco-2 cells while down-regulated IL-10 production. The simultaneous exposure of Caco-2 cells to Nef and IFN-γ did not affect cytokine secretion respect to untreated cells. Finally, we found that Nef counteracted the IFN-γ induced arachidonic acid cascade. Conclusion/Significance Our findings suggest that exogenous Nef, perturbing the IFN-γ-induced impairment of intestinal epithelial cells, could prolong cell survival, thus allowing for accumulation of viral particles. Our results may improve the understanding of AIDS pathogenesis, supporting the discovery of new therapeutic interventions. PMID:21858117

  19. Exogenous HIV-1 Nef upsets the IFN-γ-induced impairment of human intestinal epithelial integrity.

    Directory of Open Access Journals (Sweden)

    Maria Giovanna Quaranta

    Full Text Available The mucosal tissues play a central role in the transmission of HIV-1 infection as well as in the pathogenesis of AIDS. Despite several clinical studies reported intestinal dysfunction during HIV infection, the mechanisms underlying HIV-induced impairments of mucosal epithelial barrier are still unclear. It has been postulated that HIV-1 alters enterocytic function and HIV-1 proteins have been detected in several cell types of the intestinal mucosa. In the present study, we analyzed the effect of the accessory HIV-1 Nef protein on human epithelial cell line.We used unstimulated or IFN-γ-stimulated Caco-2 cells, as a model for homeostatic and inflamed gastrointestinal tracts, respectively. We investigated the effect of exogenous recombinant Nef on monolayer integrity analyzing its uptake, transepithelial electrical resistance, permeability to FITC-dextran and the expression of tight junction proteins. Moreover, we measured the induction of proinflammatory mediators. Exogenous Nef was taken up by Caco-2 cells, increased intestinal epithelial permeability and upset the IFN-γ-induced reduction of transepithelial resistance, interfering with tight junction protein expression. Moreover, Nef inhibited IFN-γ-induced apoptosis and up-regulated TNF-α, IL-6 and MIP-3α production by Caco-2 cells while down-regulated IL-10 production. The simultaneous exposure of Caco-2 cells to Nef and IFN-γ did not affect cytokine secretion respect to untreated cells. Finally, we found that Nef counteracted the IFN-γ induced arachidonic acid cascade.Our findings suggest that exogenous Nef, perturbing the IFN-γ-induced impairment of intestinal epithelial cells, could prolong cell survival, thus allowing for accumulation of viral particles. Our results may improve the understanding of AIDS pathogenesis, supporting the discovery of new therapeutic interventions.

  20. Single Event Testing on Complex Devices: Test Like You Fly versus Test-Specific Design Structures (United States)

    Berg, Melanie; LaBel, Kenneth A.


    We present a framework for evaluating complex digital systems targeted for harsh radiation environments such as space. Focus is limited to analyzing the single event upset (SEU) susceptibility of designs implemented inside Field Programmable Gate Array (FPGA) devices. Tradeoffs are provided between application-specific versus test-specific test structures.

  1. Soft-error tolerance and energy consumption evaluation of embedded computer with magnetic random access memory in practical systems using computer simulations (United States)

    Nebashi, Ryusuke; Sakimura, Noboru; Sugibayashi, Tadahiko


    We evaluated the soft-error tolerance and energy consumption of an embedded computer with magnetic random access memory (MRAM) using two computer simulators. One is a central processing unit (CPU) simulator of a typical embedded computer system. We simulated the radiation-induced single-event-upset (SEU) probability in a spin-transfer-torque MRAM cell and also the failure rate of a typical embedded computer due to its main memory SEU error. The other is a delay tolerant network (DTN) system simulator. It simulates the power dissipation of wireless sensor network nodes of the system using a revised CPU simulator and a network simulator. We demonstrated that the SEU effect on the embedded computer with 1 Gbit MRAM-based working memory is less than 1 failure in time (FIT). We also demonstrated that the energy consumption of the DTN sensor node with MRAM-based working memory can be reduced to 1/11. These results indicate that MRAM-based working memory enhances the disaster tolerance of embedded computers.

  2. Error Budgeting

    Energy Technology Data Exchange (ETDEWEB)

    Vinyard, Natalia Sergeevna [Los Alamos National Lab. (LANL), Los Alamos, NM (United States); Perry, Theodore Sonne [Los Alamos National Lab. (LANL), Los Alamos, NM (United States); Usov, Igor Olegovich [Los Alamos National Lab. (LANL), Los Alamos, NM (United States)


    We calculate opacity from k (hn)=-ln[T(hv)]/pL, where T(hv) is the transmission for photon energy hv, p is sample density, and L is path length through the sample. The density and path length are measured together by Rutherford backscatter. Δk = $\\partial k$\\ $\\partial T$ ΔT + $\\partial k$\\ $\\partial (pL)$. We can re-write this in terms of fractional error as Δk/k = Δ1n(T)/T + Δ(pL)/(pL). Transmission itself is calculated from T=(U-E)/(V-E)=B/B0, where B is transmitted backlighter (BL) signal and B0 is unattenuated backlighter signal. Then ΔT/T=Δln(T)=ΔB/B+ΔB0/B0, and consequently Δk/k = 1/T (ΔB/B + ΔB$_0$/B$_0$ + Δ(pL)/(pL). Transmission is measured in the range of 0.2

  3. Evaluating the Upset Protrusion Joining (UPJ) Method to Join Magnesium Castings to Dissimilar Metals

    Energy Technology Data Exchange (ETDEWEB)

    Logan, Stephen [FCA US LLC, Auburn Hills, MI (United States)


    This presentation discusses advantages and best practices for incorporating magnesium in automotive component applications to achieve substantial mass reduction, as well as some of the key challenges with respect to joining, coating, and galvanic corrosion, before providing an introduction and status update of the U.S. Department of Energy and Department of Defense jointly sponsored Upset Protrusion Joining (UPJ) process development and evaluation project. This update includes sharing performance results of a benchmark evaluation of the self-pierce riveting (SPR) process for joining dissimilar magnesium (Mg) to aluminum (Al) materials in four unique coating configurations before introducing the UPJ concept and comparing performance results of the joints made with the UPJ process to those made with the SPR process. Key results presented include: The benchmark SPR process can produce good joints in the MgAM60B-Al 6013 joint configuration with minimal cracking in the Mg coupons if the rivet is inserted from the Mg side into the Al side; Numerous bare Mg to bare Al joints made with the SPR process separated after only 6-wks of accelerated corrosion testing due to fracture of the rivet as a result of hydrogen embrittlement; For the same joint configurations, UPJ demonstrated substantially higher pre-corrosion joint strengths and post-corrosion joint strengths, primarily because of the larger diameter protrusion compared to smaller SPR rivet diameter and reduced degradation due to accelerated corrosion exposure; As with the SPR process, numerous bare Mg to bare Al joints made with the UPJ process also separated after 6-wks of accelerated corrosion testing, but unlike the SPR experience, the UPJ joints experienced degradation of the boss and head because of galvanic corrosion of the Mg casting, not hydrogen embrittlement of the steel rivet; In the configuration where both the Mg and Al were pretreated with Alodine 5200 prior to joining and the complete assembly was powder

  4. Influences of lubricant pocket geometry and working conditions upon micro lubrication mechanisms in upsetting and strip drawing

    DEFF Research Database (Denmark)

    Shimizu, Ichiro; Martins, P. A. F.; Bay, Niels


    , during upsetting and strip drawing, by means of a rigid-viscoplastic finite-element formulation. Special emphasis is placed on the effect of pocket geometry on the build-up of hydrostatic pressure, which is responsible for the onset of micro-lubrication mechanisms. A good agreement is found between......Micro-lubricant pockets located in the surface of plastically deforming workpieces are recognised to improve the performance of fluid lubrication in a metal-forming process. This work investigates the joint influence of pocket geometry and process working conditions on micro-lubrication mechanisms...

  5. Discussion of medical errors in morbidity and mortality conferences. (United States)

    Pierluissi, Edgar; Fischer, Melissa A; Campbell, Andre R; Landefeld, C Seth


    Morbidity and mortality conferences in residency programs are intended to discuss adverse events and errors with a goal to improve patient care. Little is known about whether residency training programs are accomplishing this goal. To determine the frequency at which morbidity and mortality conference case presentations include adverse events and errors and whether the errors are discussed and attributed to a particular cause. Prospective survey conducted by trained physician observers from July 2000 through April 2001 on 332 morbidity and mortality conference case presentations and discussions in internal medicine (n = 100) and surgery (n = 232) at 4 US academic hospitals. Frequencies of presentation of adverse events and errors, discussion of errors, and attribution of errors. In internal medicine morbidity and mortality conferences, case presentations and discussions were 3 times longer than in surgery conferences (34.1 minutes vs 11.7 minutes; P =.001), more time was spent listening to invited speakers (43.1% vs 0%; Pinternal medicine case presentations included adverse events (37 [37%] vs 166 surgery case presentations [72%]; Perrors causing an adverse event (18 [18%] vs 98 [42%], respectively; P =.001). When an error caused an adverse event, the error was discussed as an error less often in internal medicine (10 errors [48%] vs 85 errors in surgery [77%]; P =.02). Errors were attributed to a particular cause less often in medicine than in surgery conferences (8 [38%] of 21 medicine errors vs 88 [79%] of 112 surgery errors; Perrors, conference leaders in both internal medicine and surgery infrequently used explicit language to signal that an error was being discussed and infrequently acknowledged having made an error. Our findings call into question whether adverse events and errors are routinely discussed in internal medicine training programs. Although adverse events and errors were discussed frequently in surgery cases, teachers in both surgery and internal

  6. Error tracking in a clinical biochemistry laboratory

    DEFF Research Database (Denmark)

    Szecsi, Pal Bela; Ødum, Lars


    BACKGROUND: We report our results for the systematic recording of all errors in a standard clinical laboratory over a 1-year period. METHODS: Recording was performed using a commercial database program. All individuals in the laboratory were allowed to report errors. The testing processes were...... classified according to function, and errors were classified as pre-analytical, analytical, post-analytical, or service-related, and then further divided into descriptive subgroups. Samples were taken from hospital wards (38.6%), outpatient clinics (25.7%), general practitioners (29.4%), and other hospitals....... RESULTS: A total of 1189 errors were reported in 1151 reports during the first year, corresponding to an error rate of 1 error for every 142 patients, or 1 per 1223 tests. The majority of events were due to human errors (82.6%), and only a few (4.3%) were the result of technical errors. Most of the errors...

  7. Impact of Measurement Error on Synchrophasor Applications

    Energy Technology Data Exchange (ETDEWEB)

    Liu, Yilu [Univ. of Tennessee, Knoxville, TN (United States); Oak Ridge National Lab. (ORNL), Oak Ridge, TN (United States); Gracia, Jose R. [Oak Ridge National Lab. (ORNL), Oak Ridge, TN (United States); Ewing, Paul D. [Oak Ridge National Lab. (ORNL), Oak Ridge, TN (United States); Zhao, Jiecheng [Univ. of Tennessee, Knoxville, TN (United States); Tan, Jin [Univ. of Tennessee, Knoxville, TN (United States); Wu, Ling [Univ. of Tennessee, Knoxville, TN (United States); Zhan, Lingwei [Univ. of Tennessee, Knoxville, TN (United States)


    Phasor measurement units (PMUs), a type of synchrophasor, are powerful diagnostic tools that can help avert catastrophic failures in the power grid. Because of this, PMU measurement errors are particularly worrisome. This report examines the internal and external factors contributing to PMU phase angle and frequency measurement errors and gives a reasonable explanation for them. It also analyzes the impact of those measurement errors on several synchrophasor applications: event location detection, oscillation detection, islanding detection, and dynamic line rating. The primary finding is that dynamic line rating is more likely to be influenced by measurement error. Other findings include the possibility of reporting nonoscillatory activity as an oscillation as the result of error, failing to detect oscillations submerged by error, and the unlikely impact of error on event location and islanding detection.

  8. Modeling coherent errors in quantum error correction (United States)

    Greenbaum, Daniel; Dutton, Zachary


    Analysis of quantum error correcting codes is typically done using a stochastic, Pauli channel error model for describing the noise on physical qubits. However, it was recently found that coherent errors (systematic rotations) on physical data qubits result in both physical and logical error rates that differ significantly from those predicted by a Pauli model. Here we examine the accuracy of the Pauli approximation for noise containing coherent errors (characterized by a rotation angle ɛ) under the repetition code. We derive an analytic expression for the logical error channel as a function of arbitrary code distance d and concatenation level n, in the small error limit. We find that coherent physical errors result in logical errors that are partially coherent and therefore non-Pauli. However, the coherent part of the logical error is negligible at fewer than {ε }-({dn-1)} error correction cycles when the decoder is optimized for independent Pauli errors, thus providing a regime of validity for the Pauli approximation. Above this number of correction cycles, the persistent coherent logical error will cause logical failure more quickly than the Pauli model would predict, and this may need to be combated with coherent suppression methods at the physical level or larger codes.

  9. Soft errors in modern electronic systems

    CERN Document Server

    Nicolaidis, Michael


    This book provides a comprehensive presentation of the most advanced research results and technological developments enabling understanding, qualifying and mitigating the soft errors effect in advanced electronics, including the fundamental physical mechanisms of radiation induced soft errors, the various steps that lead to a system failure, the modelling and simulation of soft error at various levels (including physical, electrical, netlist, event driven, RTL, and system level modelling and simulation), hardware fault injection, accelerated radiation testing and natural environment testing, s

  10. The Influence of Surprise on Upset Recovery Performance in Airline Pilots

    NARCIS (Netherlands)

    Landman, H.M.; Groen, Eric L.; van Paassen, M.M.; Bronkhorst, A; Mulder, M.


    Objective: The aim of this study was to test if performance of airline pilots, in performing an aerodynamic stall recovery procedure, decreases when they are surprised, compared to when they anticipate a stall event.
    Background: New flight-safety regulations for commercial aviation recommend the

  11. Immediate error correction process following sleep deprivation. (United States)

    Hsieh, Shulan; Cheng, I-Chen; Tsai, Ling-Ling


    Previous studies have suggested that one night of sleep deprivation decreases frontal lobe metabolic activity, particularly in the anterior cingulated cortex (ACC), resulting in decreased performance in various executive function tasks. This study thus attempted to address whether sleep deprivation impaired the executive function of error detection and error correction. Sixteen young healthy college students (seven women, nine men, with ages ranging from 18 to 23 years) participated in this study. Participants performed a modified letter flanker task and were instructed to make immediate error corrections on detecting performance errors. Event-related potentials (ERPs) during the flanker task were obtained using a within-subject, repeated-measure design. The error negativity or error-related negativity (Ne/ERN) and the error positivity (Pe) seen immediately after errors were analyzed. The results show that the amplitude of the Ne/ERN was reduced significantly following sleep deprivation. Reduction also occurred for error trials with subsequent correction, indicating that sleep deprivation influenced error correction ability. This study further demonstrated that the impairment in immediate error correction following sleep deprivation was confined to specific stimulus types, with both Ne/ERN and behavioral correction rates being reduced only for trials in which flanker stimuli were incongruent with the target stimulus, while the response to the target was compatible with that of the flanker stimuli following sleep deprivation. The results thus warrant future systematic investigation of the interaction between stimulus type and error correction following sleep deprivation.

  12. Reward positivity: Reward prediction error or salience prediction error? (United States)

    Heydari, Sepideh; Holroyd, Clay B


    The reward positivity is a component of the human ERP elicited by feedback stimuli in trial-and-error learning and guessing tasks. A prominent theory holds that the reward positivity reflects a reward prediction error signal that is sensitive to outcome valence, being larger for unexpected positive events relative to unexpected negative events (Holroyd & Coles, 2002). Although the theory has found substantial empirical support, most of these studies have utilized either monetary or performance feedback to test the hypothesis. However, in apparent contradiction to the theory, a recent study found that unexpected physical punishments also elicit the reward positivity (Talmi, Atkinson, & El-Deredy, 2013). The authors of this report argued that the reward positivity reflects a salience prediction error rather than a reward prediction error. To investigate this finding further, in the present study participants navigated a virtual T maze and received feedback on each trial under two conditions. In a reward condition, the feedback indicated that they would either receive a monetary reward or not and in a punishment condition the feedback indicated that they would receive a small shock or not. We found that the feedback stimuli elicited a typical reward positivity in the reward condition and an apparently delayed reward positivity in the punishment condition. Importantly, this signal was more positive to the stimuli that predicted the omission of a possible punishment relative to stimuli that predicted a forthcoming punishment, which is inconsistent with the salience hypothesis. © 2016 Society for Psychophysiological Research.

  13. Negligence, genuine error, and litigation

    Directory of Open Access Journals (Sweden)

    Sohn DH


    Full Text Available David H SohnDepartment of Orthopedic Surgery, University of Toledo Medical Center, Toledo, OH, USAAbstract: Not all medical injuries are the result of negligence. In fact, most medical injuries are the result either of the inherent risk in the practice of medicine, or due to system errors, which cannot be prevented simply through fear of disciplinary action. This paper will discuss the differences between adverse events, negligence, and system errors; the current medical malpractice tort system in the United States; and review current and future solutions, including medical malpractice reform, alternative dispute resolution, health courts, and no-fault compensation systems. The current political environment favors investigation of non-cap tort reform remedies; investment into more rational oversight systems, such as health courts or no-fault systems may reap both quantitative and qualitative benefits for a less costly and safer health system.Keywords: medical malpractice, tort reform, no fault compensation, alternative dispute resolution, system errors

  14. Medical errors in neurosurgery


    Rolston, John D.; Zygourakis, Corinna C.; Han, Seunggu J.; Lau, Catherine Y.; Berger, Mitchel S.; Parsa, Andrew T


    Background: Medical errors cause nearly 100,000 deaths per year and cost billions of dollars annually. In order to rationally develop and institute programs to mitigate errors, the relative frequency and costs of different errors must be documented. This analysis will permit the judicious allocation of scarce healthcare resources to address the most costly errors as they are identified. Methods: Here, we provide a systematic review of the neurosurgical literature describing medical errors...

  15. Medication errors: prescribing faults and prescription errors. (United States)

    Velo, Giampaolo P; Minuz, Pietro


    1. Medication errors are common in general practice and in hospitals. Both errors in the act of writing (prescription errors) and prescribing faults due to erroneous medical decisions can result in harm to patients. 2. Any step in the prescribing process can generate errors. Slips, lapses, or mistakes are sources of errors, as in unintended omissions in the transcription of drugs. Faults in dose selection, omitted transcription, and poor handwriting are common. 3. Inadequate knowledge or competence and incomplete information about clinical characteristics and previous treatment of individual patients can result in prescribing faults, including the use of potentially inappropriate medications. 4. An unsafe working environment, complex or undefined procedures, and inadequate communication among health-care personnel, particularly between doctors and nurses, have been identified as important underlying factors that contribute to prescription errors and prescribing faults. 5. Active interventions aimed at reducing prescription errors and prescribing faults are strongly recommended. These should be focused on the education and training of prescribers and the use of on-line aids. The complexity of the prescribing procedure should be reduced by introducing automated systems or uniform prescribing charts, in order to avoid transcription and omission errors. Feedback control systems and immediate review of prescriptions, which can be performed with the assistance of a hospital pharmacist, are also helpful. Audits should be performed periodically.

  16. [Serious medication order errors at hospitals]. (United States)

    Andersen, Mette Lehmann; Søndergaard, Jens; Hallas, Jesper; Pedersen, Anette; Hellebek, Annemarie


    Medication order errors are frequent in Denmark. It is necessary to know the reasons why these errors happen to be able to implement initiatives limiting medication order errors. In this study we analyzed 811 medications order errors, which were reported as unintended events. The medication order errors were associated with at total of 98 medicinal product; hence nine medicinal products caused 18 errors with severe or catastrophic harm to patients. 46.0% of the errors were incorrect medicinal product, 47.7% were incorrect dosage and 6.3% of the orders were double ordering. Penicillin and warfarin were the most frequently involved medicinal products. The products that most frequently caused severe or catastrophic patient harm were insulin and warfarin. The most frequent errors were "no medicinal product prescribed" and "incorrect medicinal product". The errors with the most severe consequences for the patients were due to "medication was not discontinued" (sevoflurane and warfarin) and "poor patient compliance" (warfarin and insulin). A common feature concerning the errors' origin was incorrect handling of information. Specific initiatives should be taken to counter the above-mentioned problems and reduce the occurrence of medication order errors. Such measures may comprise control, medication reconciliation and imposition of clinical decision support.

  17. Medical errors in neurosurgery. (United States)

    Rolston, John D; Zygourakis, Corinna C; Han, Seunggu J; Lau, Catherine Y; Berger, Mitchel S; Parsa, Andrew T


    Medical errors cause nearly 100,000 deaths per year and cost billions of dollars annually. In order to rationally develop and institute programs to mitigate errors, the relative frequency and costs of different errors must be documented. This analysis will permit the judicious allocation of scarce healthcare resources to address the most costly errors as they are identified. Here, we provide a systematic review of the neurosurgical literature describing medical errors at the departmental level. Eligible articles were identified from the PubMed database, and restricted to reports of recognizable errors across neurosurgical practices. We limited this analysis to cross-sectional studies of errors in order to better match systems-level concerns, rather than reviewing the literature for individually selected errors like wrong-sided or wrong-level surgery. Only a small number of articles met these criteria, highlighting the paucity of data on this topic. From these studies, errors were documented in anywhere from 12% to 88.7% of cases. These errors had many sources, of which only 23.7-27.8% were technical, related to the execution of the surgery itself, highlighting the importance of systems-level approaches to protecting patients and reducing errors. Overall, the magnitude of medical errors in neurosurgery and the lack of focused research emphasize the need for prospective categorization of morbidity with judicious attribution. Ultimately, we must raise awareness of the impact of medical errors in neurosurgery, reduce the occurrence of medical errors, and mitigate their detrimental effects.

  18. Resistance Upset Welding of ODS Steel Fuel Claddings—Evaluation of a Process Parameter Range Based on Metallurgical Observations

    Directory of Open Access Journals (Sweden)

    Fabien Corpace


    Full Text Available Resistance upset welding is successfully applied to Oxide Dispersion Strengthened (ODS steel fuel cladding. Due to the strong correlation between the mechanical properties and the microstructure of the ODS steel, this study focuses on the consequences of the welding process on the metallurgical state of the PM2000 ODS steel. A range of process parameters is identified to achieve operative welding. Characterizations of the microstructure are correlated to measurements recorded during the welding process. The thinness of the clad is responsible for a thermal unbalance, leading to a higher temperature reached. Its deformation is important and may lead to a lack of joining between the faying surfaces located on the outer part of the join which can be avoided by increasing the dissipated energy or by limiting the clad stick-out. The deformation and the temperature reached trigger a recrystallization phenomenon in the welded area, usually combined with a modification of the yttrium dispersion, i.e., oxide dispersion, which can damage the long-life resistance of the fuel cladding. The process parameters are optimized to limit the deformation of the clad, preventing the compactness defect and the modification of the nanoscale oxide dispersion.

  19. Field error lottery (United States)

    James Elliott, C.; McVey, Brian D.; Quimby, David C.


    The level of field errors in a free electron laser (FEL) is an important determinant of its performance. We have computed 3D performance of a large laser subsystem subjected to field errors of various types. These calculations have been guided by simple models such as SWOOP. The technique of choice is use of the FELEX free electron laser code that now possesses extensive engineering capabilities. Modeling includes the ability to establish tolerances of various types: fast and slow scale field bowing, field error level, beam position monitor error level, gap errors, defocusing errors, energy slew, displacement and pointing errors. Many effects of these errors on relative gain and relative power extraction are displayed and are the essential elements of determining an error budget. The random errors also depend on the particular random number seed used in the calculation. The simultaneous display of the performance versus error level of cases with multiple seeds illustrates the variations attributable to stochasticity of this model. All these errors are evaluated numerically for comprehensive engineering of the system. In particular, gap errors are found to place requirements beyond convenient mechanical tolerances of ± 25 μm, and amelioration of these may occur by a procedure using direct measurement of the magnetic fields at assembly time.

  20. Proton Pump Inhibitors and Kidney Disease—GI Upset for the Nephrologist?

    Directory of Open Access Journals (Sweden)

    Stephanie M. Toth-Manikowski


    Full Text Available Widely regarded as safe and effective, PPIs are among the most commonly used medications in the world today. However, a spate of observational studies suggest an association between PPI use and adverse events, including infection, bone fracture, and dementia. This review details evidence linking the use of PPI therapy to the development of kidney disease, including early case reports of acute interstitial nephritis and subsequent large observational studies of AKI, CKD, and ESRD. The majority of studies showed higher risk of kidney outcomes among persons prescribed PPI medications, with effect sizes that were slightly higher for AKI (∼2- to 3-fold compared with CKD and ESRD (1.2- to 1.8-fold. Although observational pharmacoepidemiology studies are limited by the possibility of residual confounding and confounding by indication, many of the described studies conducted rigorous sensitivity analyses aimed at minimizing these biases, including new-user design, comparison to similar agents (e.g., histamine2 receptor antagonists, and evaluation for a dose response, with robust results. Given the widespread use of PPIs, even a small effect on kidney outcomes could result in large public health burden. Timely cessation of PPI therapy when there is no clear indication for use might reduce the population burden of kidney disease.

  1. Plan to extend Arctic's drilling season with new platforms upsets ecologists

    Energy Technology Data Exchange (ETDEWEB)



    Plans to extend the drilling season in Arctic Alaska beyond the traditional winter months has environmentalists worried about the impact on wildlife and the likelihood that oil and gas production will spread more quickly to remote areas. In the past, drilling was confined to the winter only and the thickness of the ice protected the tundra from damage by the heavy drilling equipment. The recent appearance of lightweight drilling equipment, comprised of components that fit together like Lego pieces, can be transported across the tundra beyond the traditional winter months, with promise of minimal damage, combined with significant savings in time and money. Andarko Petroleum Corporation, the company whose planned extended drilling operations are the cause of ecological concern, also claims increased facility to hunt for energy beyond Prudhoe Bay, Alaska's unofficial hub, in places where ice road construction is difficult. Andarko claims that its patented platform design doubles as a production unit and stands about four metres above the tundra, eliminating the need to build permanent production facilities on top of widely used gravel pads, which can leave long-lasting scars on the land and are expensive to clean up. Besides reducing expenses, the arctic platform is claimed to enable exploratory drilling to occur nearly year around. Environmentalists counter by saying that the Andarko plan will increase noise and air pollution, risks greater damage to the ecosystem in the event of a spill, and represents further intrusion upon plants and animals, including caribou, grizzly bears and migratory birds. They are also concerned that the arctic platform concept will help spread industrial activity on Alaska's North Slope. The first arctic platform is expected to be erected 130 km south of Prudhoe Bay as part of a federally sponsored research project to study the feasibility of extracting gas from ice. Specialists at the Alaska Department of Natural Resources

  2. ATC operational error analysis. (United States)


    The primary causes of operational errors are discussed and the effects of these errors on an ATC system's performance are described. No attempt is made to specify possible error models for the spectrum of blunders that can occur although previous res...

  3. Drug Errors in Anaesthesiology

    Directory of Open Access Journals (Sweden)

    Rajnish Kumar Jain


    Full Text Available Medication errors are a leading cause of morbidity and mortality in hospitalized patients. The incidence of these drug errors during anaesthesia is not certain. They impose a considerable financial burden to health care systems apart from the patient losses. Common causes of these errors and their prevention is discussed.

  4. Error patterns II

    NARCIS (Netherlands)

    Hoede, C.; Li, Z.


    In coding theory the problem of decoding focuses on error vectors. In the simplest situation code words are $(0,1)$-vectors, as are the received messages and the error vectors. Comparison of a received word with the code words yields a set of error vectors. In deciding on the original code word,


    Taifoori, Ladan; Valiee, Sina


    The operating room can be home to many different types of nursing errors due to the invasiveness of OR procedures. The nurses' reactions towards errors can be a key factor in patient safety. This article is based on a study, with the aim of investigating nurses' reactions toward nursing errors and the various contributing and resulting factors, conducted at Kurdistan University of Medical Sciences in Sanandaj, Iran in 2014. The goal of the study was to determine how OR nurses' reacted to nursing errors with the goal of having this information used to improve patient safety. Research was conducted as a cross-sectional descriptive study. The participants were all nurses employed in the operating rooms of the teaching hospitals of Kurdistan University of Medical Sciences, which was selected by a consensus method (170 persons). The information was gathered through questionnaires that focused on demographic information, error definition, reasons for error occurrence, and emotional reactions for error occurrence, and emotional reactions toward the errors. 153 questionnaires were completed and analyzed by SPSS software version 16.0. "Not following sterile technique" (82.4 percent) was the most reported nursing error, "tiredness" (92.8 percent) was the most reported reason for the error occurrence, "being upset at having harmed the patient" (85.6 percent) was the most reported emotional reaction after error occurrence", with "decision making for a better approach to tasks the next time" (97.7 percent) as the most common goal and "paying more attention to details" (98 percent) was the most reported planned strategy for future improved outcomes. While healthcare facilities are focused on planning for the prevention and elimination of errors it was shown that nurses can also benefit from support after error occurrence. Their reactions, and coping strategies, need guidance and, with both individual and organizational support, can be a factor in improving patient safety.

  6. Analyzing temozolomide medication errors: potentially fatal. (United States)

    Letarte, Nathalie; Gabay, Michael P; Bressler, Linda R; Long, Katie E; Stachnik, Joan M; Villano, J Lee


    The EORTC-NCIC regimen for glioblastoma requires different dosing of temozolomide (TMZ) during radiation and maintenance therapy. This complexity is exacerbated by the availability of multiple TMZ capsule strengths. TMZ is an alkylating agent and the major toxicity of this class is dose-related myelosuppression. Inadvertent overdose can be fatal. The websites of the Institute for Safe Medication Practices (ISMP), and the Food and Drug Administration (FDA) MedWatch database were reviewed. We searched the MedWatch database for adverse events associated with TMZ and obtained all reports including hematologic toxicity submitted from 1st November 1997 to 30th May 2012. The ISMP describes errors with TMZ resulting from the positioning of information on the label of the commercial product. The strength and quantity of capsules on the label were in close proximity to each other, and this has been changed by the manufacturer. MedWatch identified 45 medication errors. Patient errors were the most common, accounting for 21 or 47% of errors, followed by dispensing errors, which accounted for 13 or 29%. Seven reports or 16% were errors in the prescribing of TMZ. Reported outcomes ranged from reversible hematological adverse events (13%), to hospitalization for other adverse events (13%) or death (18%). Four error reports lacked detail and could not be categorized. Although the FDA issued a warning in 2003 regarding fatal medication errors and the product label warns of overdosing, errors in TMZ dosing occur for various reasons and involve both healthcare professionals and patients. Overdosing errors can be fatal.

  7. Identifying medication errors in the neonatal intensive care unit and ...

    African Journals Online (AJOL)

    Medication errors in paediatrics are relatively understudied in South. Africa (SA). The National Coordinating Council for Medication. Error Reporting and Prevention (NCC MERP) defines a medication error as 'any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication ...

  8. Interpretive Error in Radiology. (United States)

    Waite, Stephen; Scott, Jinel; Gale, Brian; Fuchs, Travis; Kolla, Srinivas; Reede, Deborah


    Although imaging technology has advanced significantly since the work of Garland in 1949, interpretive error rates remain unchanged. In addition to patient harm, interpretive errors are a major cause of litigation and distress to radiologists. In this article, we discuss the mechanics involved in searching an image, categorize omission errors, and discuss factors influencing diagnostic accuracy. Potential individual- and system-based solutions to mitigate or eliminate errors are also discussed. Radiologists use visual detection, pattern recognition, memory, and cognitive reasoning to synthesize final interpretations of radiologic studies. This synthesis is performed in an environment in which there are numerous extrinsic distractors, increasing workloads and fatigue. Given the ultimately human task of perception, some degree of error is likely inevitable even with experienced observers. However, an understanding of the causes of interpretive errors can help in the development of tools to mitigate errors and improve patient safety.

  9. Effect of water chemistry upsets on the dynamics of corrective reagent dosing systems at thermal power stations (United States)

    Voronov, V. N.; Yegoshina, O. V.; Bolshakova, N. A.; Yarovoi, V. O.; Latt, Aie Min


    Typical disturbances in the dynamics of a corrective reagent dosing system under unsteady-state conditions during the unsatisfactory operation of a chemical control system with some water chemistry upsets at thermal and nuclear power stations are considered. An experimental setup representing a physical model for the water chemistry control system is described. The two disturbances, which are most frequently encountered in water chemistry control practice, such as a breakdown or shutdown of temperature compensation during pH measurement and an increase in the heat-transfer fluid flow rate, have been modeled in the process of study. The study of the effect produced by the response characteristics of chemical control analyzers on the operation of a reagent dosing system under unsteady-state conditions is important for the operative control of a water chemistry regime state. The effect of temperature compensation during pH measurement on the dynamics of an ammonia-dosing system in the manual and automatic cycle chemistry control modes has been studied. It has been demonstrated that the reading settling time of a pH meter in the manual ammonia- dosing mode grows with a breakdown in temperature compensation and a simultaneous increase in the temperature of a heat-transfer fluid sample. To improve the efficiency of water chemistry control, some systems for the quality control of a heat-transfer fluid by a chemical parameter with the obligatory compensation of a disturbance in its flow rate have been proposed for use. Experimental results will possibly differ from industrial data due to a great length of sampling lines. For this reason, corrective reagent dosing systems must be adapted to the conditions of a certain power-generating unit in the process of their implementation.

  10. Soft error rate simulation and initial design considerations of neutron intercepting silicon chip (NISC) (United States)

    Celik, Cihangir

    Advances in microelectronics result in sub-micrometer electronic technologies as predicted by Moore's Law, 1965, which states the number of transistors in a given space would double every two years. The most available memory architectures today have submicrometer transistor dimensions. The International Technology Roadmap for Semiconductors (ITRS), a continuation of Moore's Law, predicts that Dynamic Random Access Memory (DRAM) will have an average half pitch size of 50 nm and Microprocessor Units (MPU) will have an average gate length of 30 nm over the period of 2008-2012. Decreases in the dimensions satisfy the producer and consumer requirements of low power consumption, more data storage for a given space, faster clock speed, and portability of integrated circuits (IC), particularly memories. On the other hand, these properties also lead to a higher susceptibility of IC designs to temperature, magnetic interference, power supply, and environmental noise, and radiation. Radiation can directly or indirectly affect device operation. When a single energetic particle strikes a sensitive node in the micro-electronic device, it can cause a permanent or transient malfunction in the device. This behavior is called a Single Event Effect (SEE). SEEs are mostly transient errors that generate an electric pulse which alters the state of a logic node in the memory device without having a permanent effect on the functionality of the device. This is called a Single Event Upset (SEU) or Soft Error . Contrary to SEU, Single Event Latchup (SEL), Single Event Gate Rapture (SEGR), or Single Event Burnout (SEB) they have permanent effects on the device operation and a system reset or recovery is needed to return to proper operations. The rate at which a device or system encounters soft errors is defined as Soft Error Rate (SER). The semiconductor industry has been struggling with SEEs and is taking necessary measures in order to continue to improve system designs in nano

  11. Intraoral radiographic errors. (United States)

    Patel, J R


    The purpose of this investigation was to investigate intraoral radiography in regards to the frequency of errors, the types of error necessitating retakes, and the relationship of error frequency to the teeth area examined and type x-ray cone used. The present study used 283 complete mouth radiographic surveys made, and 890 radiographs were found to be clinically unacceptable for one or more errors in technique. Thirteen and one-tenth errors per one hundred radiographs were found in this study. The three major radiographic errors occurring in this study were incorrect film placement (49.9 percent), cone-cutting (20.8 percent), and incorrect vertical angulation (12.5 percent).

  12. Error coding simulations (United States)

    Noble, Viveca K.


    There are various elements such as radio frequency interference (RFI) which may induce errors in data being transmitted via a satellite communication link. When a transmission is affected by interference or other error-causing elements, the transmitted data becomes indecipherable. It becomes necessary to implement techniques to recover from these disturbances. The objective of this research is to develop software which simulates error control circuits and evaluate the performance of these modules in various bit error rate environments. The results of the evaluation provide the engineer with information which helps determine the optimal error control scheme. The Consultative Committee for Space Data Systems (CCSDS) recommends the use of Reed-Solomon (RS) and convolutional encoders and Viterbi and RS decoders for error correction. The use of forward error correction techniques greatly reduces the received signal to noise needed for a certain desired bit error rate. The use of concatenated coding, e.g. inner convolutional code and outer RS code, provides even greater coding gain. The 16-bit cyclic redundancy check (CRC) code is recommended by CCSDS for error detection.

  13. Medication Errors: New EU Good Practice Guide on Risk Minimisation and Error Prevention. (United States)

    Goedecke, Thomas; Ord, Kathryn; Newbould, Victoria; Brosch, Sabine; Arlett, Peter


    A medication error is an unintended failure in the drug treatment process that leads to, or has the potential to lead to, harm to the patient. Reducing the risk of medication errors is a shared responsibility between patients, healthcare professionals, regulators and the pharmaceutical industry at all levels of healthcare delivery. In 2015, the EU regulatory network released a two-part good practice guide on medication errors to support both the pharmaceutical industry and regulators in the implementation of the changes introduced with the EU pharmacovigilance legislation. These changes included a modification of the 'adverse reaction' definition to include events associated with medication errors, and the requirement for national competent authorities responsible for pharmacovigilance in EU Member States to collaborate and exchange information on medication errors resulting in harm with national patient safety organisations. To facilitate reporting and learning from medication errors, a clear distinction has been made in the guidance between medication errors resulting in adverse reactions, medication errors without harm, intercepted medication errors and potential errors. This distinction is supported by an enhanced MedDRA(®) terminology that allows for coding all stages of the medication use process where the error occurred in addition to any clinical consequences. To better understand the causes and contributing factors, individual case safety reports involving an error should be followed-up with the primary reporter to gather information relevant for the conduct of root cause analysis where this may be appropriate. Such reports should also be summarised in periodic safety update reports and addressed in risk management plans. Any risk minimisation and prevention strategy for medication errors should consider all stages of a medicinal product's life-cycle, particularly the main sources and types of medication errors during product development. This article

  14. Criticality of Low-Energy Protons in Single-Event Effects Testing of Highly-Scaled Technologies (United States)

    Pellish, Jonathan A.; Marshall, Paul W.; Rodbell, Kenneth P.; Gordon, Michael S.; LaBel, Kenneth A.; Schwank, James R.; Dodds, Nathaniel A.; Castaneda, Carlos M.; Berg, Melanie D.; Kim, Hak S.; hide


    We report low-energy proton and low-energy alpha particle single-event effects (SEE) data on a 32 nm silicon-on-insulator (SOI) complementary metal oxide semiconductor (CMOS) latches and static random access memory (SRAM) that demonstrates the criticality of using low-energy protons for SEE testing of highly-scaled technologies. Low-energy protons produced a significantly higher fraction of multi-bit upsets relative to single-bit upsets when compared to similar alpha particle data. This difference highlights the importance of performing hardness assurance testing with protons that include energy distribution components below 2 megaelectron-volt. The importance of low-energy protons to system-level single-event performance is based on the technology under investigation as well as the target radiation environment.

  15. Action errors, error management, and learning in organizations. (United States)

    Frese, Michael; Keith, Nina


    Every organization is confronted with errors. Most errors are corrected easily, but some may lead to negative consequences. Organizations often focus on error prevention as a single strategy for dealing with errors. Our review suggests that error prevention needs to be supplemented by error management--an approach directed at effectively dealing with errors after they have occurred, with the goal of minimizing negative and maximizing positive error consequences (examples of the latter are learning and innovations). After defining errors and related concepts, we review research on error-related processes affected by error management (error detection, damage control). Empirical evidence on positive effects of error management in individuals and organizations is then discussed, along with emotional, motivational, cognitive, and behavioral pathways of these effects. Learning from errors is central, but like other positive consequences, learning occurs under certain circumstances--one being the development of a mind-set of acceptance of human error.

  16. Correction for quadrature errors

    DEFF Research Database (Denmark)

    Netterstrøm, A.; Christensen, Erik Lintz


    In high bandwidth radar systems it is necessary to use quadrature devices to convert the signal to/from baseband. Practical problems make it difficult to implement a perfect quadrature system. Channel imbalance and quadrature phase errors in the transmitter and the receiver result in error signals...

  17. The Eric Cantor Upset

    DEFF Research Database (Denmark)

    Ashbee, Edward


    US update. The surprise primary defat of Eric Cantor, which shows that the Tea Party is still in business......US update. The surprise primary defat of Eric Cantor, which shows that the Tea Party is still in business...

  18. Proofreading for word errors. (United States)

    Pilotti, Maura; Chodorow, Martin; Agpawa, Ian; Krajniak, Marta; Mahamane, Salif


    Proofreading (i.e., reading text for the purpose of detecting and correcting typographical errors) is viewed as a component of the activity of revising text and thus is a necessary (albeit not sufficient) procedural step for enhancing the quality of a written product. The purpose of the present research was to test competing accounts of word-error detection which predict factors that may influence reading and proofreading differently. Word errors, which change a word into another word (e.g., from --> form), were selected for examination because they are unlikely to be detected by automatic spell-checking functions. Consequently, their detection still rests mostly in the hands of the human proofreader. Findings highlighted the weaknesses of existing accounts of proofreading and identified factors, such as length and frequency of the error in the English language relative to frequency of the correct word, which might play a key role in detection of word errors.

  19. Study of Errors among Nursing Students

    Directory of Open Access Journals (Sweden)

    Ella Koren


    Full Text Available The study of errors in the health system today is a topic of considerable interest aimed at reducing errors through analysis of the phenomenon and the conclusions reached. Errors that occur frequently among health professionals have also been observed among nursing students. True, in most cases they are actually “near errors,” but these could be a future indicator of therapeutic reality and the effect of nurses' work environment on their personal performance. There are two different approaches to such errors: (a The EPP (error prone person approach lays full responsibility at the door of the individual involved in the error, whether a student, nurse, doctor, or pharmacist. According to this approach, handling consists purely in identifying and penalizing the guilty party. (b The EPE (error prone environment approach emphasizes the environment as a primary contributory factor to errors. The environment as an abstract concept includes components and processes of interpersonal communications, work relations, human engineering, workload, pressures, technical apparatus, and new technologies. The objective of the present study was to examine the role played by factors in and components of personal performance as compared to elements and features of the environment. The study was based on both of the aforementioned approaches, which, when combined, enable a comprehensive understanding of the phenomenon of errors among the student population as well as a comparison of factors contributing to human error and to error deriving from the environment. The theoretical basis of the study was a model that combined both approaches: one focusing on the individual and his or her personal performance and the other focusing on the work environment. The findings emphasize the work environment of health professionals as an EPE. However, errors could have been avoided by means of strict adherence to practical procedures. The authors examined error events in the

  20. Human error in anesthetic mishaps. (United States)

    Gaba, D M


    While adverse outcomes linked to anesthesia are uncommon in healthy patients, they do occasionally happen. There is rarely a single cause. Anesthesia and surgery bring the patient into a complex world in which innumerable small failings can converge to produce an eventual catastrophe. And for all the technology involved, the anesthesiologist remains the cornerstone of safe anesthesia care, protecting the patient from harm regardless of its source. Responding to the demands of the operating room environment requires on-the-spot decision making in a complex, uncertain, and risky setting. Only responsible, professional human beings acting in concert can perform this task; no machine that we devise now or in the foreseeable future will suffice. I have outlined the components of a dynamic decision-making process that successfully protects patients in almost all cases. However, being human, anesthesiologists do make errors along the way--errors we are just beginning to understand. Sometimes these errors are due to faulty vigilance or incompetence, but usually they are made by appropriately trained, competent practitioners. Anesthesiologists can err in many ways, and recognizing these ways makes it easier to analyze the events leading to an anesthetic accident. More importantly, it better equips us to eliminate or minimize them in the future--and this is the real challenge.

  1. Uncorrected refractive errors

    Directory of Open Access Journals (Sweden)

    Kovin S Naidoo


    Full Text Available Global estimates indicate that more than 2.3 billion people in the world suffer from poor vision due to refractive error; of which 670 million people are considered visually impaired because they do not have access to corrective treatment. Refractive errors, if uncorrected, results in an impaired quality of life for millions of people worldwide, irrespective of their age, sex and ethnicity. Over the past decade, a series of studies using a survey methodology, referred to as Refractive Error Study in Children (RESC, were performed in populations with different ethnic origins and cultural settings. These studies confirmed that the prevalence of uncorrected refractive errors is considerably high for children in low-and-middle-income countries. Furthermore, uncorrected refractive error has been noted to have extensive social and economic impacts, such as limiting educational and employment opportunities of economically active persons, healthy individuals and communities. The key public health challenges presented by uncorrected refractive errors, the leading cause of vision impairment across the world, require urgent attention. To address these issues, it is critical to focus on the development of human resources and sustainable methods of service delivery. This paper discusses three core pillars to addressing the challenges posed by uncorrected refractive errors: Human Resource (HR Development, Service Development and Social Entrepreneurship.

  2. Uncorrected refractive errors. (United States)

    Naidoo, Kovin S; Jaggernath, Jyoti


    Global estimates indicate that more than 2.3 billion people in the world suffer from poor vision due to refractive error; of which 670 million people are considered visually impaired because they do not have access to corrective treatment. Refractive errors, if uncorrected, results in an impaired quality of life for millions of people worldwide, irrespective of their age, sex and ethnicity. Over the past decade, a series of studies using a survey methodology, referred to as Refractive Error Study in Children (RESC), were performed in populations with different ethnic origins and cultural settings. These studies confirmed that the prevalence of uncorrected refractive errors is considerably high for children in low-and-middle-income countries. Furthermore, uncorrected refractive error has been noted to have extensive social and economic impacts, such as limiting educational and employment opportunities of economically active persons, healthy individuals and communities. The key public health challenges presented by uncorrected refractive errors, the leading cause of vision impairment across the world, require urgent attention. To address these issues, it is critical to focus on the development of human resources and sustainable methods of service delivery. This paper discusses three core pillars to addressing the challenges posed by uncorrected refractive errors: Human Resource (HR) Development, Service Development and Social Entrepreneurship.

  3. Uncorrected refractive errors (United States)

    Naidoo, Kovin S; Jaggernath, Jyoti


    Global estimates indicate that more than 2.3 billion people in the world suffer from poor vision due to refractive error; of which 670 million people are considered visually impaired because they do not have access to corrective treatment. Refractive errors, if uncorrected, results in an impaired quality of life for millions of people worldwide, irrespective of their age, sex and ethnicity. Over the past decade, a series of studies using a survey methodology, referred to as Refractive Error Study in Children (RESC), were performed in populations with different ethnic origins and cultural settings. These studies confirmed that the prevalence of uncorrected refractive errors is considerably high for children in low-and-middle-income countries. Furthermore, uncorrected refractive error has been noted to have extensive social and economic impacts, such as limiting educational and employment opportunities of economically active persons, healthy individuals and communities. The key public health challenges presented by uncorrected refractive errors, the leading cause of vision impairment across the world, require urgent attention. To address these issues, it is critical to focus on the development of human resources and sustainable methods of service delivery. This paper discusses three core pillars to addressing the challenges posed by uncorrected refractive errors: Human Resource (HR) Development, Service Development and Social Entrepreneurship. PMID:22944755


    Energy Technology Data Exchange (ETDEWEB)

    Lori Braase; Jodi Grgich


    Event planning is expensive and resource intensive. Function analysis provides a solid foundation for comprehensive event planning (e.g., workshops, conferences, symposiums, or meetings). It has been used at Idaho National Laboratory (INL) to successfully plan events and capture lessons learned, and played a significant role in the development and implementation of the “INL Guide for Hosting an Event.” Using a guide and a functional approach to planning utilizes resources more efficiently and reduces errors that could be distracting or detrimental to an event. This integrated approach to logistics and program planning – with the primary focus on the participant – gives us the edge.

  5. Soft error mechanisms, modeling and mitigation

    CERN Document Server

    Sayil, Selahattin


    This book introduces readers to various radiation soft-error mechanisms such as soft delays, radiation induced clock jitter and pulses, and single event (SE) coupling induced effects. In addition to discussing various radiation hardening techniques for combinational logic, the author also describes new mitigation strategies targeting commercial designs. Coverage includes novel soft error mitigation techniques such as the Dynamic Threshold Technique and Soft Error Filtering based on Transmission gate with varied gate and body bias. The discussion also includes modeling of SE crosstalk noise, delay and speed-up effects. Various mitigation strategies to eliminate SE coupling effects are also introduced. Coverage also includes the reliability of low power energy-efficient designs and the impact of leakage power consumption optimizations on soft error robustness. The author presents an analysis of various power optimization techniques, enabling readers to make design choices that reduce static power consumption an...

  6. Inborn errors of metabolism (United States)

    ... metabolism. A few of them are: Fructose intolerance Galactosemia Maple sugar urine disease (MSUD) Phenylketonuria (PKU) Newborn ... disorder. Alternative Names Metabolism - inborn errors of Images Galactosemia Phenylketonuria test References Bodamer OA. Approach to inborn ...

  7. Medical Errors Reduction Initiative

    National Research Council Canada - National Science Library

    Mutter, Michael L


    The Valley Hospital of Ridgewood, New Jersey, is proposing to extend a limited but highly successful specimen management and medication administration medical errors reduction initiative on a hospital-wide basis...

  8. Design for Error Tolerance

    DEFF Research Database (Denmark)

    Rasmussen, Jens


    An important aspect of the optimal design of computer-based operator support systems is the sensitivity of such systems to operator errors. The author discusses how a system might allow for human variability with the use of reversibility and observability.......An important aspect of the optimal design of computer-based operator support systems is the sensitivity of such systems to operator errors. The author discusses how a system might allow for human variability with the use of reversibility and observability....

  9. Interruption Practice Reduces Errors (United States)


    dangers of errors at the PCS. Electronic health record systems are used to reduce certain errors related to poor- handwriting and dosage...Arlington VA 22202-4302 Respondents should be aware that notwithstanding any other provision of law, no person shall be subject to a penalty for failing to...RESPONSIBLE PERSON a REPORT unclassified b ABSTRACT unclassified c THIS PAGE unclassified Standard Form 298 (Rev. 8-98) Prescribed by ANSI Std Z39

  10. Single event effects induced by 15.14 MeV/u sup 1 sup 3 sup 6 Xe ions

    CERN Document Server

    Hou Ming Dong; LiuJie; Wang Zhi Guang; Jin Yun Fan; Zhu Zhi Yong; Zhen Hong Lou; Liu Chang Long; Chen Xiao Xi; Wei Xin Guo; Zhang Li; Fan You Cheng; Zhu Zhou Rong; Zhang Yiting


    Single event effects induced by 15.14 MeV/u sup 1 sup 3 sup 6 Xe ions in different batches of 32k x 8 bits static random access memory are studied. The incident angle dependences of the cross sections for single event upset and single event latch up are presented. The SEE cross sections are plotted versus energy loss instead of linear energy transfer value in sensitive region. The depth of sensitive volume and thickness of 'dead' layer above the sensitive volume are estimated

  11. Event Modeling

    DEFF Research Database (Denmark)

    Bækgaard, Lars


    are dynamic and we present a modeling approach that can be used to model such dynamics. We characterize events as both information objects and change agents (Bækgaard 1997). When viewed as information objects events are phenomena that can be observed and described. For example, borrow events in a library can......The purpose of this chapter is to discuss conceptual event modeling within a context of information modeling. Traditionally, information modeling has been concerned with the modeling of a universe of discourse in terms of information structures. However, most interesting universes of discourse...... be characterized by their occurrence times and the participating books and borrowers. When we characterize events as information objects we focus on concepts like information structures. When viewed as change agents events are phenomena that trigger change. For example, when borrow event occurs books are moved...

  12. Learning from Errors

    Directory of Open Access Journals (Sweden)

    MA. Lendita Kryeziu


    Full Text Available “Errare humanum est”, a well known and widespread Latin proverb which states that: to err is human, and that people make mistakes all the time. However, what counts is that people must learn from mistakes. On these grounds Steve Jobs stated: “Sometimes when you innovate, you make mistakes. It is best to admit them quickly, and get on with improving your other innovations.” Similarly, in learning new language, learners make mistakes, thus it is important to accept them, learn from them, discover the reason why they make them, improve and move on. The significance of studying errors is described by Corder as: “There have always been two justifications proposed for the study of learners' errors: the pedagogical justification, namely that a good understanding of the nature of error is necessary before a systematic means of eradicating them could be found, and the theoretical justification, which claims that a study of learners' errors is part of the systematic study of the learners' language which is itself necessary to an understanding of the process of second language acquisition” (Corder, 1982; 1. Thus the importance and the aim of this paper is analyzing errors in the process of second language acquisition and the way we teachers can benefit from mistakes to help students improve themselves while giving the proper feedback.

  13. Improving the quality of drug error reporting. (United States)

    Armitage, Gerry; Newell, Robert; Wright, John


    Drug errors are a common and persistent problem in health care and are also associated with serious adverse events. Reporting has become the cornerstone of learning from errors, but is not without its imperfections. The aim of this study is to improve reporting and learning from drug errors through investigating the contributory factors in drug errors and quality of reporting in an acute hospital. A retrospective, random sample of 991 drug error reports from 1999 to 2003 were subjected to quantitative and qualitative analysis. This was followed by 40 qualitative interviews with a volunteer, multi-disciplinary sample of health professionals. The combined analysis has been used to develop a knowledge base for improved drug error reporting. The quality of reports varied considerably, and 27% of reports lacked any contributory factors. Documentary analysis revealed a focus on individuals, sometimes culminating in blame without obvious justification. Doctors submitted few reports, and there were notable differences in reporting according to clinical location. Communication difficulties commonly featured in causation, and high workload and interruptions were predominant contributory factors in the interview data. Interviewees viewed causation as multifactorial, including cognitive and psychosocial factors. Organizational orientation to error was predominantly perceived by interviewees as individual rather than systems-based. Staff felt obliged to report but rarely received feedback. IMPLICATIONS AND CONCLUSION: Drug errors are multifactorial in causation. Current reporting schemes lack a theoretical basis, and are unlikely to capture the information required to ensure learning about causation. Health professionals have reporting fatigue and some remain concerned that reporting promotes individual blame rather than an examination of systems factors. Reporting can be strengthened by human error theory, redesigned to capture a range of contributory factors, facilitate

  14. [Medication errors in anaesthesia: a review of reports from the French Health Products Agency]. (United States)

    Rivière, A; Piriou, V; Durand, D; Arnoux, A; Castot-Villepelet, A


    The purpose of this study was to assess medication errors and risks of medication errors during anaesthetic practice reported at the French Health Products Agency (Afssaps) from 2005 to 2010. Descriptive study. The data are issued of "Medication errors and risks of medication errors" file which group together all cases received by the Medication Errors Unit at Afssaps since 2005. A total of 263 cases were observed by the Medication Errors Unit at Afssaps. Among them, 159 cases were risks of medication errors, 76 cases were patent medication errors and 28 were near misses. Among the 76 cases of patent medication errors, out of which 47 cases were appreciated with adverse reaction and 35 cases were classified as serious. Adverse events were classified as haemodynamic, respiratory and neurologic events. Most of the errors occurred during administration (65%), followed by dispensing errors (14%), storage errors (15%) or preparation errors (4%). Sixty-nine percent of cases of wrong drug errors were found, followed by 26% of errors of strength, 3% of incorrect route of administration errors and 2% of patient errors. In most of cases, similarity in packaging was underlined (n=83). This study showed that the majority of medication errors and risks of medication errors during anaesthetic practice, underline similarity in packaging. Results highlighted the importance of vial labeling presentation (readability and mention understanding) in anaesthetic practice. Copyright © 2011. Published by Elsevier SAS.

  15. Error Free Software (United States)


    A mathematical theory for development of "higher order" software to catch computer mistakes resulted from a Johnson Space Center contract for Apollo spacecraft navigation. Two women who were involved in the project formed Higher Order Software, Inc. to develop and market the system of error analysis and correction. They designed software which is logically error-free, which, in one instance, was found to increase productivity by 600%. USE.IT defines its objectives using AXES -- a user can write in English and the system converts to computer languages. It is employed by several large corporations.

  16. Acetaminophen attenuates error evaluation in cortex. (United States)

    Randles, Daniel; Kam, Julia W Y; Heine, Steven J; Inzlicht, Michael; Handy, Todd C


    Acetaminophen has recently been recognized as having impacts that extend into the affective domain. In particular, double blind placebo controlled trials have revealed that acetaminophen reduces the magnitude of reactivity to social rejection, frustration, dissonance and to both negatively and positively valenced attitude objects. Given this diversity of consequences, it has been proposed that the psychological effects of acetaminophen may reflect a widespread blunting of evaluative processing. We tested this hypothesis using event-related potentials (ERPs). Sixty-two participants received acetaminophen or a placebo in a double-blind protocol and completed the Go/NoGo task. Participants' ERPs were observed following errors on the Go/NoGo task, in particular the error-related negativity (ERN; measured at FCz) and error-related positivity (Pe; measured at Pz and CPz). Results show that acetaminophen inhibits the Pe, but not the ERN, and the magnitude of an individual's Pe correlates positively with omission errors, partially mediating the effects of acetaminophen on the error rate. These results suggest that recently documented affective blunting caused by acetaminophen may best be described as an inhibition of evaluative processing. They also contribute to the growing work suggesting that the Pe is more strongly associated with conscious awareness of errors relative to the ERN. © The Author (2016). Published by Oxford University Press. For Permissions, please email:

  17. Event Modeling

    DEFF Research Database (Denmark)

    Bækgaard, Lars


    The purpose of this chapter is to discuss conceptual event modeling within a context of information modeling. Traditionally, information modeling has been concerned with the modeling of a universe of discourse in terms of information structures. However, most interesting universes of discourse...... are dynamic and we present a modeling approach that can be used to model such dynamics.We characterize events as both information objects and change agents (Bækgaard 1997). When viewed as information objects events are phenomena that can be observed and described. For example, borrow events in a library can...

  18. Error Correcting Codes

    Indian Academy of Sciences (India)

    Home; Journals; Resonance – Journal of Science Education; Volume 1; Issue 10. Error Correcting Codes How Numbers Protect Themselves. Priti Shankar. Series Article Volume 1 ... Author Affiliations. Priti Shankar1. Department of Computer Science and Automation, Indian Institute of Science, Bangalore 560 012, India ...

  19. Random errors revisited

    DEFF Research Database (Denmark)

    Jacobsen, Finn


    the random errors of estimates of the sound intensity in, say, one-third octave bands from the power and cross power spectra of the signals from an intensity probe determined with a dual channel FFT analyser. This is not very practical, though. In this paper it is demonstrated that one can predict the random...

  20. Error Correcting Codes

    Indian Academy of Sciences (India)

    Home; Journals; Resonance – Journal of Science Education; Volume 2; Issue 3. Error Correcting Codes - Reed Solomon Codes. Priti Shankar. Series Article Volume 2 Issue 3 March 1997 pp 33-47. Fulltext. Click here to view fulltext PDF. Permanent link: ...

  1. Errors in uroradiology

    Energy Technology Data Exchange (ETDEWEB)

    Viamonte, M. Jr. (Miami Univ., Miami Beach, FL (United States). Dept. of Radiology)


    This book covering errors in urologic radiology, takes into account the imaging modalities presently used for examining the urinary tract: excretory urography, ultrasonography, computerized tomography and angiography. The author gives examples of anatomical variations, developmental anomalies, and benign conditions that simulate neoplasias and lead to mistakes. (orig.) With 148 figs.

  2. Error Correcting Codes

    Indian Academy of Sciences (India)

    Home; Journals; Resonance – Journal of Science Education; Volume 2; Issue 1. Error Correcting Codes The Hamming Codes. Priti Shankar. Series Article Volume 2 Issue 1 January ... Author Affiliations. Priti Shankar1. Department of Computer Science and Automation, Indian Institute of Science, Bangalore 560 012, India ...

  3. Orwell's Instructive Errors (United States)

    Julian, Liam


    In this article, the author talks about George Orwell, his instructive errors, and the manner in which Orwell pierced worthless theory, faced facts and defended decency (with fluctuating success), and largely ignored the tradition of accumulated wisdom that has rendered him a timeless teacher--one whose inadvertent lessons, while infrequently…

  4. Error management in audit firms: Error climate, type, and originator

    NARCIS (Netherlands)

    Gold, A.H.; Gronewold, U.; Salterio, S.E.


    This paper examines how the treatment of audit staff who discover errors in audit files by superiors affects their willingness to report these errors. The way staff are treated by superiors is labelled as the audit office error management climate. In a "blame-oriented" climate errors are not

  5. Automatic Error Analysis Using Intervals (United States)

    Rothwell, E. J.; Cloud, M. J.


    A technique for automatic error analysis using interval mathematics is introduced. A comparison to standard error propagation methods shows that in cases involving complicated formulas, the interval approach gives comparable error estimates with much less effort. Several examples are considered, and numerical errors are computed using the INTLAB…

  6. Learning from Galileo's errors

    CERN Document Server

    Bernieri, Enrico


    Four hundred years after its publication, Galileo's masterpiece Sidereus Nuncius is still a mine of useful information for historians of science and astronomy. In his short book Galileo reports a large amount of data that, despite its age, has not yet been fully explored. In this paper Galileo's first observations of Jupiter's satellites are quantitatively re-analysed by using modern planetarium software. All the angular records reported in the Sidereus Nuncius are, for the first time, compared with satellites' elongations carefully reconstructed taking into account software accuracy and the indeterminacy of observation time. This comparison allows us to derive the experimental errors of Galileo's measurements and gives us direct insight into the effective angular resolution of Galileo's observations. Until now, historians of science have mainly obtained these indirectly and they are often not correctly estimated. Furthermore, a statistical analysis of Galileo's experimental errors shows an asymmetrical distr...

  7. Error-Free Software (United States)


    001 is an integrated tool suited for automatically developing ultra reliable models, simulations and software systems. Developed and marketed by Hamilton Technologies, Inc. (HTI), it has been applied in engineering, manufacturing, banking and software tools development. The software provides the ability to simplify the complex. A system developed with 001 can be a prototype or fully developed with production quality code. It is free of interface errors, consistent, logically complete and has no data or control flow errors. Systems can be designed, developed and maintained with maximum productivity. Margaret Hamilton, President of Hamilton Technologies, also directed the research and development of USE.IT, an earlier product which was the first computer aided software engineering product in the industry to concentrate on automatically supporting the development of an ultrareliable system throughout its life cycle. Both products originated in NASA technology developed under a Johnson Space Center contract.

  8. Correction of refractive errors

    Directory of Open Access Journals (Sweden)

    Vladimir Pfeifer


    Full Text Available Background: Spectacles and contact lenses are the most frequently used, the safest and the cheapest way to correct refractive errors. The development of keratorefractive surgery has brought new opportunities for correction of refractive errors in patients who have the need to be less dependent of spectacles or contact lenses. Until recently, RK was the most commonly performed refractive procedure for nearsighted patients.Conclusions: The introduction of excimer laser in refractive surgery has given the new opportunities of remodelling the cornea. The laser energy can be delivered on the stromal surface like in PRK or deeper on the corneal stroma by means of lamellar surgery. In LASIK flap is created with microkeratome in LASEK with ethanol and in epi-LASIK the ultra thin flap is created mechanically.

  9. Reporting Self-Made Errors: The Impact of Organizational Error-Management Climate and Error Type

    NARCIS (Netherlands)

    Gold, A.H.; Gronewold, U.; Salterio, S.E.


    We study how an organization's error-management climate affects organizational members' beliefs about other members' willingness to report errors that they discover when chance of error detection by superiors and others is extremely low. An error-management climate, as a component of the

  10. Experimental studies of single-event effects induced by heavy ions (United States)

    Liu, J.; Hou, M. D.; Li, B. Q.; Liu, C. L.; Wang, Z. G.; Cheng, S.; Sun, Y. M.; Jin, Y. F.; Lin, Y. L.; Cai, J. R.; Wang, S. J.; Ye, Z. H.; Zhu, G. W.; Du, H.; Ren, Q. Y.; Wu, W.; Mao, X. M.; Sun, Y. Q.; Guo, R.


    This paper presents the results of ground-based heavy ion test of single-event effect (SEE) vulnerability on microcircuits used in space. We observed the dependence of upset cross-sections on the incident angle of ions in Intel 8086 CPU. SEU cross-sections of various SRAMs did not depend on the stored pattern, but 0→1 and 1→0 transitions were completely different for different manufacturer products. Some SEE protection methods were verified in conditions of ground simulation experiments.

  11. Systematic approaches to adverse events in obstetrics, Part I: Event identification and classification. (United States)

    Pettker, Christian M


    Despite our best intentions to improve health when a patient presents for care, adverse events are ubiquitous in medical practice today. Known complications related to the course of a patient's illness or condition or to the characteristics of the treatment have been an openly stated part of taking care of patients for centuries. However, it is only in the past decade that preventable adverse events, instances of harm related to error and deviations in accepted practice have become a primary part of these conversations. Human and system errors are an innate part of working in a complex environment like health care and we are now well aware of this burden in medicine. Now, we are building ways to react to adverse events from error in systematic ways. A systematic approach to identifying and classifying events is a critical part of any safety program, let alone an obstetric safety program. This article reviews the various systems that are used to identify adverse events, in particular sentinel events, state reportable events, and the significant local adverse "trigger" events in obstetrics. These events typically become identified through robust reporting systems where staff can report adverse, near-miss events, or precursor safety events. After events are reported, a system for classifying events, including a structured tracking and reporting system with built in accountability, is necessary. The concept of the "serious safety event," and how these differ from known complications or unpreventable events, and how this is classified are also reviewed. Copyright © 2017 Elsevier Inc. All rights reserved.

  12. Los errores cometidos

    Directory of Open Access Journals (Sweden)

    José Martínez Terrero


    Full Text Available Durante el Encuentro sobre Comunicación Alternativa y Popular, José Martínez Terrero, SJ, repasó las principales corrientes de la Comunicación Alternativa y Popular, desde los años 60 hasta el presente, rescatando sus aportes conceptuales y prácticos, así como los errores cometidos. A continuación publicamos un extracto que destaca la reflexión crítica y autocrítica.

  13. Performance, postmodernity and errors

    DEFF Research Database (Denmark)

    Harder, Peter


    with the prestige variety, and conflate non-standard variation with parole/performance and class both as erroneous. Nowadays the anti-structural sentiment of present-day linguistics makes it tempting to confuse the rejection of ideal abstract structure with a rejection of any distinction between grammatical...... as deviant from the perspective of function-based structure and discuss to what extent the recognition of a community langue as a source of adaptive pressure may throw light on different types of deviation, including language handicaps and learner errors....

  14. Decreasing paediatric prescribing errors in a district general hospital. (United States)

    Davey, A L; Britland, A; Naylor, R J


    In paediatric inpatients, medication errors occur as frequently as 1 in 4.2 drug orders, with up to 80% of these being prescribing errors. The children's unit of a district general hospital in West Yorkshire, UK. Prescribing errors and preventable adverse drug events (1) The introduction of a junior doctor prescribing tutorial. (2) The introduction of a bedside prescribing guideline. The introduction of the junior doctor prescribing tutorial decreased the prescribing errors by 46%. The introduction of a bedside prescribing guideline did not decrease prescribing errors but may have been helpful to those doctors unable to attend a prescribing tutorial. By investing time and providing appropriate written resources, we have been able to reduce our paediatric prescribing errors on the children's ward by almost half.

  15. FDA Adverse Event Reporting System (FAERS): Latest Quartely Data Files (United States)

    U.S. Department of Health & Human Services — The FDA Adverse Event Reporting System (FAERS) is a database that contains information on adverse event and medication error reports submitted to FDA. The database...

  16. Skylab water balance error analysis (United States)

    Leonard, J. I.


    Estimates of the precision of the net water balance were obtained for the entire Skylab preflight and inflight phases as well as for the first two weeks of flight. Quantitative estimates of both total sampling errors and instrumentation errors were obtained. It was shown that measurement error is minimal in comparison to biological variability and little can be gained from improvement in analytical accuracy. In addition, a propagation of error analysis demonstrated that total water balance error could be accounted for almost entirely by the errors associated with body mass changes. Errors due to interaction between terms in the water balance equation (covariances) represented less than 10% of the total error. Overall, the analysis provides evidence that daily measurements of body water changes obtained from the indirect balance technique are reasonable, precise, and relaible. The method is not biased toward net retention or loss.

  17. Future Events

    Directory of Open Access Journals (Sweden)

    Adli Tıp Uzmanları Derneği ATUD

    2010-04-01 9. Adli Bilimler Sempozyumu 28 Nisan 2011-30 Nisan 2011 Trabzon, Türkiye http:// 7th ISABS Conference in Forensic, Anthropologic and Medical Genetics June 20, 2011-June 24, 2011 Bol, Island of Braä, Croatia URL: com_frontpage&Itemid= 1 2011 National Conference - American College of Forensic Examiners International October 12, 2011-October 14, 2011 Branson, Missouri, USA URL: 47. Ulusal Psikiyatri Kongresi 26 Ekim 2011-30 Ekim 2011 Antalya, Türkiye URL: http://www.psikiyatri201 19th IAFS World Meeting September 12,2011- September 17, 2011 Madeira, Portugal URL: Forensic Psychiatry Review Course October 24th to 26th, 2011 Boston USA URL: 42nd Annual Meeting of the American Academy of Psychiatry and the Law October 27th to 30th 2011 Boston USA URL: International Forensic Scientific Conference “Modern techniques for person’s identification and methods used during the crime scene investigation” 26 October 2011, 27 October 2011 Bucharest, Romania URL: Biennial meeting of the Handwriting Working Group 26 October 2011, 29 October 2011 Delft, The Netherlands URL: Prevention Of Medical Errors & Domestic Violence Bahamas Cruise November 4th to 7th 2011 Florida USA URL: Become a Legal Nurse Consultant November 6th to 7th 2011 Nevada /Las Vegas USA URL Medical Ethics and Professionalism November 11th to 12th 2011 Georgia /Atlanta USA URL: courses.php Professional Boundaries Course November 11th to 13th 2011 Georgia /USA URL: courses.php 2011 AMBI Clinical Ethics Conference November 18th 2011 New York /USA URL: http

  18. Improving the error backpropagation algorithm with a modified error function. (United States)

    Oh, S H


    This letter proposes a modified error function to improve the error backpropagation (EBP) algorithm of multilayer perceptrons (MLPs) which suffers from slow learning speed. To accelerate the learning speed of the EBP algorithm, the proposed method reduces the probability that output nodes are near the wrong extreme value of sigmoid activation function. This is acquired through a strong error signal for the incorrectly saturated output node and a weak error signal for the correctly saturated output node. The weak error signal for the correctly saturated output node, also, prevents overspecialization of learning for training patterns. The effectiveness of the proposed method is demonstrated in a handwritten digit recognition task.

  19. [The error, source of learning]. (United States)

    Joyeux, Stéphanie; Bohic, Valérie


    The error itself is not recognised as a fault. It is the intentionality which differentiates between an error and a fault. An error is unintentional while a fault is a failure to respect known rules. The risk of error is omnipresent in health institutions. Public authorities have therefore set out a series of measures to reduce this risk. Copyright © 2016 Elsevier Masson SAS. All rights reserved.

  20. Uncertainty quantification and error analysis

    Energy Technology Data Exchange (ETDEWEB)

    Higdon, Dave M [Los Alamos National Laboratory; Anderson, Mark C [Los Alamos National Laboratory; Habib, Salman [Los Alamos National Laboratory; Klein, Richard [Los Alamos National Laboratory; Berliner, Mark [OHIO STATE UNIV.; Covey, Curt [LLNL; Ghattas, Omar [UNIV OF TEXAS; Graziani, Carlo [UNIV OF CHICAGO; Seager, Mark [LLNL; Sefcik, Joseph [LLNL; Stark, Philip [UC/BERKELEY; Stewart, James [SNL


    UQ studies all sources of error and uncertainty, including: systematic and stochastic measurement error; ignorance; limitations of theoretical models; limitations of numerical representations of those models; limitations on the accuracy and reliability of computations, approximations, and algorithms; and human error. A more precise definition for UQ is suggested below.

  1. Topography's event

    DEFF Research Database (Denmark)

    Munck Petersen, Rikke

    measure is not there alone since you measure it in something both visual, physical and shaped by views and ideas of society; something thought and abstract. Such knowledge point out the need for being able to measure other factors that visual and physical. Metrical and proportional view of the world seems...... - to stimulate and elaborate the event of conception and topological thinking....

  2. Topography's event

    DEFF Research Database (Denmark)

    Munck Petersen, Rikke

    The aim of the paper is first to discuss how horizon and scale can be understood, secondly how they differ and what they might have in common? If topography can be seen as a way of working with these relations experiences, creations and latencies? Thirdly if diagrams and diagrammatology can bring...... - to stimulate and elaborate the event of conception and topological thinking....

  3. The magnitude and effects of extreme solar particle events

    Directory of Open Access Journals (Sweden)

    Jiggens Piers


    Full Text Available The solar energetic particle (SEP radiation environment is an important consideration for spacecraft design, spacecraft mission planning and human spaceflight. Herein is presented an investigation into the likely severity of effects of a very large Solar Particle Event (SPE on technology and humans in space. Fluences for SPEs derived using statistical models are compared to historical SPEs to verify their appropriateness for use in the analysis which follows. By combining environment tools with tools to model effects behind varying layers of spacecraft shielding it is possible to predict what impact a large SPE would be likely to have on a spacecraft in Near-Earth interplanetary space or geostationary Earth orbit. Also presented is a comparison of results generated using the traditional method of inputting the environment spectra, determined using a statistical model, into effects tools and a new method developed as part of the ESA SEPEM Project allowing for the creation of an effect time series on which statistics, previously applied to the flux data, can be run directly. The SPE environment spectra is determined and presented as energy integrated proton fluence (cm−2 as a function of particle energy (in MeV. This is input into the SHIELDOSE-2, MULASSIS, NIEL, GRAS and SEU effects tools to provide the output results. In the case of the new method for analysis, the flux time series is fed directly into the MULASSIS and GEMAT tools integrated into the SEPEM system. The output effect quantities include total ionising dose (in rads, non-ionising energy loss (MeV g−1, single event upsets (upsets/bit and the dose in humans compared to established limits for stochastic (or cancer-causing effects and tissue reactions (such as acute radiation sickness in humans given in grey-equivalent and sieverts respectively.

  4. Beyond the medical record: other modes of error acknowledgment. (United States)

    Rosenthal, Marilynn M; Cornett, Patricia L; Sutcliffe, Kathleen M; Lewton, Elizabeth


    Studies before and since the 1999 Institute of Medicine report have noted the limitations of using medical record reporting for reliably quantifying and understanding medical error. Quantitative macro analyses of large datasets should be supplemented by small-scale qualitative studies to provide insight into micro-level daily events in clinical and hospital practice that contribute to errors and adverse events and how they are reported. The study design involved semistructured face-to-face interviews with residents about the medical errors in which they recently had been involved and included questions regarding how those errors were acknowledged. This paper reports the ways in which medical error is or is not reported and residents' responses to a perceived medical error. Twenty-six residents were randomly sampled from a total population of 85 residents working in a 600-bed teaching hospital. Outcome measures were based on analysis of cases residents described. Using Ethnograph and traditional methods of content analysis, cases were categorized as Documented, Discussed, and Uncertain. Of 73 cases, 30 (41.1%) were formally acknowledged and Documented in the medical record; 24 (32.9%) were addressed through Discussions but not documented; 19 cases (26%) cases were classified as Uncertain. Twelve cases involved medication errors, which were acknowledged in different categories. The supervisory discussion, the informal discussion, and near-miss contain important information for improving clinical care. Our study also shows the need to improve residents' education to prepare them to recognize and address medical errors.

  5. Error sensitivity analysis in 10-30-day extended range forecasting by using a nonlinear cross-prediction error model (United States)

    Xia, Zhiye; Xu, Lisheng; Chen, Hongbin; Wang, Yongqian; Liu, Jinbao; Feng, Wenlan


    Extended range forecasting of 10-30 days, which lies between medium-term and climate prediction in terms of timescale, plays a significant role in decision-making processes for the prevention and mitigation of disastrous meteorological events. The sensitivity of initial error, model parameter error, and random error in a nonlinear crossprediction error (NCPE) model, and their stability in the prediction validity period in 10-30-day extended range forecasting, are analyzed quantitatively. The associated sensitivity of precipitable water, temperature, and geopotential height during cases of heavy rain and hurricane is also discussed. The results are summarized as follows. First, the initial error and random error interact. When the ratio of random error to initial error is small (10-6-10-2), minor variation in random error cannot significantly change the dynamic features of a chaotic system, and therefore random error has minimal effect on the prediction. When the ratio is in the range of 10-1-2 (i.e., random error dominates), attention should be paid to the random error instead of only the initial error. When the ratio is around 10-2-10-1, both influences must be considered. Their mutual effects may bring considerable uncertainty to extended range forecasting, and de-noising is therefore necessary. Second, in terms of model parameter error, the embedding dimension m should be determined by the factual nonlinear time series. The dynamic features of a chaotic system cannot be depicted because of the incomplete structure of the attractor when m is small. When m is large, prediction indicators can vanish because of the scarcity of phase points in phase space. A method for overcoming the cut-off effect ( m > 4) is proposed. Third, for heavy rains, precipitable water is more sensitive to the prediction validity period than temperature or geopotential height; however, for hurricanes, geopotential height is most sensitive, followed by precipitable water.

  6. Reduced error monitoring in children with autism spectrum disorder : an ERP study

    NARCIS (Netherlands)

    Vlamings, Petra H. J. M.; Jonkman, Lisa M.; Hoeksma, Marco R.; van Engeland, Herman; Kemner, Chantal

    This study investigated self-monitoring in children with autism spectrum disorder (ASD) with event-related potentials looking at both the error-related negativity (ERN) and error-related positivity (Pe). The ERN is related to early error/conflict detection, and the Pe has been associated with

  7. Post-error action control is neurobehaviorally modulated under conditions of constant speeded response

    Directory of Open Access Journals (Sweden)

    Takahiro eSoshi


    Full Text Available Post-error slowing is an error recovery strategy that contributes to action control, and occurs after errors in order to prevent future behavioral flaws. Error recovery often malfunctions in clinical populations, but the relationship between behavioral traits and recovery from error is unclear in healthy populations. The present study investigated the relationship between impulsivity and error recovery by simulating a speeded response situation using a Go/No-go paradigm that forced the participants to constantly make accelerated responses prior to stimuli disappearance (stimulus duration: 250 ms. Neural correlates of post-error processing were examined using event-related potentials (ERPs. Impulsivity traits were measured with self-report questionnaires (BIS-11, BIS/BAS. Behavioral results demonstrated that the commission error for No-go trials was 15%, but post-error slowing did not take place immediately. Delayed post-error slowing was negatively correlated with error rates and impulsivity traits, showing that response slowing was associated with reduced error rates and changed with impulsivity. Response-locked error ERPs were clearly observed for the error trials. Contrary to previous studies, error ERPs were not significantly related to post-error slowing. Stimulus-locked N2 was negatively correlated with post-error slowing and positively correlated with impulsivity traits at the second post-error Go trial: larger N2 activity was associated with greater post-error slowing and less impulsivity. In summary, under constant speeded conditions, error monitoring was dissociated from post-error action control, and post-error slowing did not occur quickly. Furthermore, post-error slowing and its neural correlate (N2 were modulated by impulsivity traits. These findings suggest that there may be clinical and practical efficacy of maintaining cognitive control of actions during error recovery under common daily environments that frequently evoke

  8. Medication errors reported by US family physicians and their office staff. (United States)

    Kuo, G M; Phillips, R L; Graham, D; Hickner, J M


    Most medication error studies come from inpatient settings. There is limited information about medication errors in primary care settings. To describe medication errors reported by family physicians and their office staff and to estimate their preventability using currently available electronic prescribing and monitoring tools. Design, setting, participants and study instrument: In two error reporting studies conducted by the American Academy of Family Physicians (AAFP) National Research Network (NRN), 1265 medical errors were voluntarily reported by >440 primary care clinicians and staff from 52 physician offices. The 194 error reports related to medications were abstracted and analysed using a medication error coding tool-Medication Error Types, Reasons, and Informatics Preventability (METRIP). Type, severity and preventability of medication errors and associated adverse drug events (ADEs). 126 (70%) of the medication errors were prescribing errors, 17 (10%) were medication administration errors, 17 (10%) documentation errors, 13 (7%) dispensing errors and 5 (3%) were monitoring errors. ADEs resulted from 16% of reported medication errors. The severity of harm from reported errors were: prevented and did not reach patients, (72, 41%), reached patients but did not require monitoring (63, 35%), reached patients and required monitoring (15, 8%), reached patients and required intervention (23, 13%) and reached patients and resulted in hospitalisation (5, 3%). No deaths were reported. Of the errors that were prevented from reaching patients, 29 (40%) were prevented by pharmacists, 14 (19%) by physicians, 12 (17%) by patients and 5 (7%) by nurses. 102 (57%) of the reported errors might have been prevented with enhanced electronic prescribing and monitoring tools. Most medication errors reported from US family physician offices were related to prescribing errors and more than half of the errors reached patients. The errors were prevented by pharmacists, patients and

  9. Rapid mapping of volumetric errors

    Energy Technology Data Exchange (ETDEWEB)

    Krulewich, D.; Hale, L.; Yordy, D.


    This paper describes a relatively inexpensive, fast, and easy to execute approach to mapping the volumetric errors of a machine tool, coordinate measuring machine, or robot. An error map is used to characterize a machine or to improve its accuracy by compensating for the systematic errors. The method consists of three steps: (1) modeling the relationship between the volumetric error and the current state of the machine; (2) acquiring error data based on length measurements throughout the work volume; and (3) optimizing the model to the particular machine.

  10. The Implication of Diagnostic Errors. (United States)

    Govindarajan, Raghav


    Diagnostic errors are mistakes in the diagnostic process that lead to a misdiagnosis, a missed diagnosis, or a delayed diagnosis. While the past decade's impetus to improve patient safety has focused on medication errors, health care-associated infections, and postsurgical complications, diagnostic errors have received comparatively less attention. Diagnostic errors will continue to play a major role in the patient safety and quality improvement movement because of their burden on care and their financial burden. Developing a patient-partnered diagnostic approach with self-reflection and awareness of cognitive biases is the key to minimizing the impact of diagnostic errors.

  11. Controlling errors in unidosis carts

    Directory of Open Access Journals (Sweden)

    Inmaculada Díaz Fernández


    Full Text Available Objective: To identify errors in the unidosis system carts. Method: For two months, the Pharmacy Service controlled medication either returned or missing from the unidosis carts both in the pharmacy and in the wards. Results: Uncorrected unidosis carts show a 0.9% of medication errors (264 versus 0.6% (154 which appeared in unidosis carts previously revised. In carts not revised, the error is 70.83% and mainly caused when setting up unidosis carts. The rest are due to a lack of stock or unavailability (21.6%, errors in the transcription of medical orders (6.81% or that the boxes had not been emptied previously (0.76%. The errors found in the units correspond to errors in the transcription of the treatment (3.46%, non-receipt of the unidosis copy (23.14%, the patient did not take the medication (14.36%or was discharged without medication (12.77%, was not provided by nurses (14.09%, was withdrawn from the stocks of the unit (14.62%, and errors of the pharmacy service (17.56% . Conclusions: It is concluded the need to redress unidosis carts and a computerized prescription system to avoid errors in transcription.Discussion: A high percentage of medication errors is caused by human error. If unidosis carts are overlooked before sent to hospitalization units, the error diminishes to 0.3%.

  12. Improving blood safety: Errors management in transfusion medicine

    Directory of Open Access Journals (Sweden)

    Bujandrić Nevenka


    Full Text Available Introduction. The concept of blood safety includes the entire transfusion chain starting with the collection of blood from the blood donor, and ending with blood transfusion to the patient. The concept involves quality management system as the systematic monitoring of adverse reactions and incidents regarding the blood donor or patient. Monitoring of near-miss errors show the critical points in the working process and increase transfusion safety. Objective. The aim of the study was to present the analysis results of adverse and unexpected events in transfusion practice with a potential risk to the health of blood donors and patients. Methods. One-year retrospective study was based on the collection, analysis and interpretation of written reports on medical errors in the Blood Transfusion Institute of Vojvodina. Results. Errors were distributed according to the type, frequency and part of the working process where they occurred. Possible causes and corrective actions were described for each error. The study showed that there were not errors with potential health consequences for the blood donor/patient. Errors with potentially damaging consequences for patients were detected throughout the entire transfusion chain. Most of the errors were identified in the preanalytical phase. The human factor was responsible for the largest number of errors. Conclusion. Error reporting system has an important role in the error management and the reduction of transfusion-related risk of adverse events and incidents. The ongoing analysis reveals the strengths and weaknesses of the entire process and indicates the necessary changes. Errors in transfusion medicine can be avoided in a large percentage and prevention is costeffective, systematic and applicable.

  13. Input error versus output error model reference adaptive control (United States)

    Bodson, Marc; Sastry, Shankar


    Algorithms for model reference adaptive control were developed in recent years, and their stability and convergence properties have been investigated. Typical algorithms in continuous time involve strictly positive real conditions on the reference model, while similar discrete time algorithms do not require such conditions. It is shown how algorithms differ by the use of an input error versus an output error, and present a continuous time input error adaptive control algorithm which does not involve SPR conditions. The connections with other schemes are discussed. The input error scheme has general stability and ocnvergence properties that are similar to the output error scheme. However, analysis using averaging methods reveals some preferable convergence properties of the input error scheme. Several other advantages are also discussed.

  14. Errors in clinical laboratories or errors in laboratory medicine? (United States)

    Plebani, Mario


    Laboratory testing is a highly complex process and, although laboratory services are relatively safe, they are not as safe as they could or should be. Clinical laboratories have long focused their attention on quality control methods and quality assessment programs dealing with analytical aspects of testing. However, a growing body of evidence accumulated in recent decades demonstrates that quality in clinical laboratories cannot be assured by merely focusing on purely analytical aspects. The more recent surveys on errors in laboratory medicine conclude that in the delivery of laboratory testing, mistakes occur more frequently before (pre-analytical) and after (post-analytical) the test has been performed. Most errors are due to pre-analytical factors (46-68.2% of total errors), while a high error rate (18.5-47% of total errors) has also been found in the post-analytical phase. Errors due to analytical problems have been significantly reduced over time, but there is evidence that, particularly for immunoassays, interference may have a serious impact on patients. A description of the most frequent and risky pre-, intra- and post-analytical errors and advice on practical steps for measuring and reducing the risk of errors is therefore given in the present paper. Many mistakes in the Total Testing Process are called "laboratory errors", although these may be due to poor communication, action taken by others involved in the testing process (e.g., physicians, nurses and phlebotomists), or poorly designed processes, all of which are beyond the laboratory's control. Likewise, there is evidence that laboratory information is only partially utilized. A recent document from the International Organization for Standardization (ISO) recommends a new, broader definition of the term "laboratory error" and a classification of errors according to different criteria. In a modern approach to total quality, centered on patients' needs and satisfaction, the risk of errors and mistakes

  15. Least Squared Simulated Errors

    Directory of Open Access Journals (Sweden)

    Peter J. Veazie


    Full Text Available Estimation by minimizing the sum of squared residuals is a common method for parameters of regression functions; however, regression functions are not always known or of interest. Maximizing the likelihood function is an alternative if a distribution can be properly specified. However, cases can arise in which a regression function is not known, no additional moment conditions are indicated, and we have a distribution for the random quantities, but maximum likelihood estimation is difficult to implement. In this article, we present the least squared simulated errors (LSSE estimator for such cases. The conditions for consistency and asymptotic normality are given. Finite sample properties are investigated via Monte Carlo experiments on two examples. Results suggest LSSE can perform well in finite samples. We discuss the estimator’s limitations and conclude that the estimator is a viable option. We recommend Monte Carlo investigation of any given model to judge bias for a particular finite sample size of interest and discern whether asymptotic approximations or resampling techniques are preferable for the construction of tests or confidence intervals.

  16. Contour Error Map Algorithm (United States)

    Merceret, Francis; Lane, John; Immer, Christopher; Case, Jonathan; Manobianco, John


    The contour error map (CEM) algorithm and the software that implements the algorithm are means of quantifying correlations between sets of time-varying data that are binarized and registered on spatial grids. The present version of the software is intended for use in evaluating numerical weather forecasts against observational sea-breeze data. In cases in which observational data come from off-grid stations, it is necessary to preprocess the observational data to transform them into gridded data. First, the wind direction is gridded and binarized so that D(i,j;n) is the input to CEM based on forecast data and d(i,j;n) is the input to CEM based on gridded observational data. Here, i and j are spatial indices representing 1.25-km intervals along the west-to-east and south-to-north directions, respectively; and n is a time index representing 5-minute intervals. A binary value of D or d = 0 corresponds to an offshore wind, whereas a value of D or d = 1 corresponds to an onshore wind. CEM includes two notable subalgorithms: One identifies and verifies sea-breeze boundaries; the other, which can be invoked optionally, performs an image-erosion function for the purpose of attempting to eliminate river-breeze contributions in the wind fields.

  17. Error analysis in laparoscopic surgery (United States)

    Gantert, Walter A.; Tendick, Frank; Bhoyrul, Sunil; Tyrrell, Dana; Fujino, Yukio; Rangel, Shawn; Patti, Marco G.; Way, Lawrence W.


    Iatrogenic complications in laparoscopic surgery, as in any field, stem from human error. In recent years, cognitive psychologists have developed theories for understanding and analyzing human error, and the application of these principles has decreased error rates in the aviation and nuclear power industries. The purpose of this study was to apply error analysis to laparoscopic surgery and evaluate its potential for preventing complications. Our approach is based on James Reason's framework using a classification of errors according to three performance levels: at the skill- based performance level, slips are caused by attention failures, and lapses result form memory failures. Rule-based mistakes constitute the second level. Knowledge-based mistakes occur at the highest performance level and are caused by shortcomings in conscious processing. These errors committed by the performer 'at the sharp end' occur in typical situations which often times are brought about by already built-in latent system failures. We present a series of case studies in laparoscopic surgery in which errors are classified and the influence of intrinsic failures and extrinsic system flaws are evaluated. Most serious technical errors in lap surgery stem from a rule-based or knowledge- based mistake triggered by cognitive underspecification due to incomplete or illusory visual input information. Error analysis in laparoscopic surgery should be able to improve human performance, and it should detect and help eliminate system flaws. Complication rates in laparoscopic surgery due to technical errors can thus be considerably reduced.

  18. Error-related potentials during continuous feedback: using EEG to detect errors of different type and severity

    Directory of Open Access Journals (Sweden)

    Martin eSpüler


    Full Text Available When a person recognizes an error during a task, an error-related potential (ErrP can be measured as response. It has been shown that ErrPs can be automatically detected in tasks with time-discrete feedback, which is widely applied in the field of Brain-Computer Interfaces (BCIs for error correction or adaptation. However, there are only a few studies that concentrate on ErrPs during continuous feedback.With this study, we wanted to answer three different questions: (i Can ErrPs be measured in electroencephalography (EEG recordings during a task with continuous cursor control? (ii Can ErrPs be classified using machine learning methods and is it possible to discriminate errors of different origins? (iii Can we use EEG to detect the severity of an error? To answer these questions, we recorded EEG data from 10 subjects during a video game task and investigated two different types of error (execution error, due to inaccurate feedback; outcome error, due to not achieving the goal of an action. We analyzed the recorded data to show that during the same task, different kinds of error produce different ErrP waveforms and have a different spectral response. This allows us to detect and discriminate errors of different origin in an event-locked manner. By utilizing the error-related spectral response, we show that also a continuous, asynchronous detection of errors is possible.Although the detection of error severity based on EEG was one goal of this study, we did not find any significant influence of the severity on the EEG.

  19. Sepsis: Medical errors in Poland. (United States)

    Rorat, Marta; Jurek, Tomasz


    Health, safety and medical errors are currently the subject of worldwide discussion. The authors analysed medico-legal opinions trying to determine types of medical errors and their impact on the course of sepsis. The authors carried out a retrospective analysis of 66 medico-legal opinions issued by the Wroclaw Department of Forensic Medicine between 2004 and 2013 (at the request of the prosecutor or court) in cases examined for medical errors. Medical errors were confirmed in 55 of the 66 medico-legal opinions. The age of victims varied from 2 weeks to 68 years; 49 patients died. The analysis revealed medical errors committed by 113 health-care workers: 98 physicians, 8 nurses and 8 emergency medical dispatchers. In 33 cases, an error was made before hospitalisation. Hospital errors occurred in 35 victims. Diagnostic errors were discovered in 50 patients, including 46 cases of sepsis being incorrectly recognised and insufficient diagnoses in 37 cases. Therapeutic errors occurred in 37 victims, organisational errors in 9 and technical errors in 2. In addition to sepsis, 8 patients also had a severe concomitant disease and 8 had a chronic disease. In 45 cases, the authors observed glaring errors, which could incur criminal liability. There is an urgent need to introduce a system for reporting and analysing medical errors in Poland. The development and popularisation of standards for identifying and treating sepsis across basic medical professions is essential to improve patient safety and survival rates. Procedures should be introduced to prevent health-care workers from administering incorrect treatment in cases. © The Author(s) 2015.

  20. An error taxonomy system for analysis of haemodialysis incidents. (United States)

    Gu, Xiuzhu; Itoh, Kenji; Suzuki, Satoshi


    This paper describes the development of a haemodialysis error taxonomy system for analysing incidents and predicting the safety status of a dialysis organisation. The error taxonomy system was developed by adapting an error taxonomy system which assumed no specific specialty to haemodialysis situations. Its application was conducted with 1,909 incident reports collected from two dialysis facilities in Japan. Over 70% of haemodialysis incidents were reported as problems or complications related to dialyser, circuit, medication and setting of dialysis condition. Approximately 70% of errors took place immediately before and after the four hours of haemodialysis therapy. Error types most frequently made in the dialysis unit were omission and qualitative errors. Failures or complications classified to staff human factors, communication, task and organisational factors were found in most dialysis incidents. Device/equipment/materials, medicine and clinical documents were most likely to be involved in errors. Haemodialysis nurses were involved in more incidents related to medicine and documents, whereas dialysis technologists made more errors with device/equipment/materials. This error taxonomy system is able to investigate incidents and adverse events occurring in the dialysis setting but is also able to estimate safety-related status of an organisation, such as reporting culture. © 2014 European Dialysis and Transplant Nurses Association/European Renal Care Association.

  1. Errors affect hypothetical intertemporal food choice in women.

    Directory of Open Access Journals (Sweden)

    Manuela Sellitto

    Full Text Available Growing evidence suggests that the ability to control behavior is enhanced in contexts in which errors are more frequent. Here we investigated whether pairing desirable food with errors could decrease impulsive choice during hypothetical temporal decisions about food. To this end, healthy women performed a Stop-signal task in which one food cue predicted high-error rate, and another food cue predicted low-error rate. Afterwards, we measured participants' intertemporal preferences during decisions between smaller-immediate and larger-delayed amounts of food. We expected reduced sensitivity to smaller-immediate amounts of food associated with high-error rate. Moreover, taking into account that deprivational states affect sensitivity for food, we controlled for participants' hunger. Results showed that pairing food with high-error likelihood decreased temporal discounting. This effect was modulated by hunger, indicating that, the lower the hunger level, the more participants showed reduced impulsive preference for the food previously associated with a high number of errors as compared with the other food. These findings reveal that errors, which are motivationally salient events that recruit cognitive control and drive avoidance learning against error-prone behavior, are effective in reducing impulsive choice for edible outcomes.

  2. Development of single-event-effects analysis system at the IMP microbeam facility (United States)

    Guo, Jinlong; Du, Guanghua; Bi, Jinshun; Liu, Wenjing; Wu, Ruqun; Chen, Hao; Wei, Junze; Li, Yaning; Sheng, Lina; Liu, Xiaojun; Ma, Shuyi


    Single-event-effects (SEEs) in integrated circuits (ICs) caused by galactic single ions are the major cause of anomalies for a spacecraft. The main strategies to decrease radiation failures for spacecraft are using SEEs less-sensitive devices and design radiation hardened ICs. High energy ion microbeam is one of the powerful tools to obtain spatial information of SEEs in ICs and to guide the radiation hardening design. The microbeam facility in the Institute of Modern Physics (IMP), Chinese Academy of Science (CAS) can meet both the liner energy transfer (LET) and ion range requirements for SEEs simulation experiments on ground. In order to study SEEs characteristics of ICs at this microbeam platform, a SEEs analysis system was developed. This system can target and irradiate ICs with single ions in micrometer-scale accuracy, meanwhile it acquires multi-channel SEE signals and maps the SEE sensitive regions online. A 4-Mbit NOR Flash memory was tested with this system using 2.2 GeV Kr ions, the radiation sensitive peripheral circuit regions for SEEs of 1 to 0 and 0 to 1 upset, multi-bit-upset and single event latchup have been obtained.

  3. Methods of Run-Time Error Detection in Distributed Process Control Software

    DEFF Research Database (Denmark)

    Drejer, N.

    In this thesis, methods of run-time error detection in application software for distributed process control is designed. The error detection is based upon a monitoring approach in which application software is monitored by system software during the entire execution. The thesis includes definition...... and constraint evaluation is designed for the modt interesting error types. These include: a) semantical errors in data communicated between application tasks; b) errors in the execution of application tasks; and c) errors in the timing of distributed events emitted by the application software. The design...

  4. Error in Drugs Consumption Among Older Patients. (United States)

    Bar-Dayan, Yosefa; Shotashvily, Thomas; Boaz, Mona; Wainstein, Julio

    The cost effectiveness of generic drugs has promoted their use worldwide. However, the large variety of bioequivalent generic and brand-name drugs found in the marketplace increases the complexity and frequency of mistakes in drug consumption. This clinical study investigated the prevalence of various mistakes in drug consumption by patients using a hospital setting. This prospective clinical trial used a hospital setting to identify errors in drug consumption. Six hundred patients who were hospitalized for a minimum of 48 hours in the Internal Medicine Departments were checked at various time points. The medications prescribed by their physician was determined and compared to the medications each patient carried on their person for de facto consumption. Drug consumption errors were found in 13 cases (2.17%), most of which involved duplicate drugs. In 6 of these (46.1%), patients consumed different drugs from the same therapeutic family. In 5 cases (38.5%), patients used chemically similar medications with different names, and in 2 cases (15.4%), patients consumed different drugs from various therapeutic families to treat the same medical condition. Ten of the thirteen cases (76.9%) had the potential to cause serious adverse drug events. More errors were found in female patients (53.8%), elderly patients, and those consuming a large variety of drugs. Variations in names, colors, shapes, and sizes of various drugs cause confusion and errors in drug consumption among patients. Some of these errors have the potential to cause severe, adverse drug effects and can increase morbidity and mortality worldwide.

  5. Pharyngitis – fatal infectious disease or medical error?

    Directory of Open Access Journals (Sweden)

    Marta Rorat


    Full Text Available Reporting on adverse events is essential to create a culture of safety, which focuses on protecting doctors and patients from medical errors. We present a fatal case of Streptococcus C pharyngitis in a 56-year-old man. The clinical course and the results of additional diagnostics and autopsy showed that sepsis followed by multiple organ failure was the ultimate cause of death. The clinical course appeared fatal due to a chain of adverse events, including errors made by the physicians caring for the patient for 10 days.

  6. Processor register error correction management

    Energy Technology Data Exchange (ETDEWEB)

    Bose, Pradip; Cher, Chen-Yong; Gupta, Meeta S.


    Processor register protection management is disclosed. In embodiments, a method of processor register protection management can include determining a sensitive logical register for executable code generated by a compiler, generating an error-correction table identifying the sensitive logical register, and storing the error-correction table in a memory accessible by a processor. The processor can be configured to generate a duplicate register of the sensitive logical register identified by the error-correction table.

  7. Analyzing the Influence of the Angles of Incidence and Rotation on MBU Events Induced by Low LET Heavy Ions in a 28-nm SRAM-Based FPGA (United States)

    Tonfat, Jorge; Kastensmidt, Fernanda Lima; Artola, Laurent; Hubert, Guillaume; Medina, Nilberto H.; Added, Nemitala; Aguiar, Vitor A. P.; Aguirre, Fernando; Macchione, Eduardo L. A.; Silveira, Marcilei A. G.


    This paper shows the impact of low linear energy transfer heavy ions on the reliability of 28-nm Bulk static random access memory (RAM) cells from Artix-7 field-programmable gate array. Irradiation tests on the ground showed significant differences in the multiple bit upset cross section of configuration RAM and block RAM memory cells under various angles of incidence and rotation of the device. Experimental data are analyzed at transistor level by using the single-event effect prediction tool called multiscale single-event phenomenon prediction platform coupled with SPICE simulations.

  8. Tutorial on monitoring time to next medication error. (United States)

    Hovor, Cynthia; Walsh, Cathy


    Alemi and colleagues in this issue of the journal have proposed that rare events can be monitored by shifting from frequency of the event to the examination of the time to the event. This article examines their claim with data obtained from an acute care hospital in the United States. We examined the data on medication omissions to see whether changes in underlying process can be detected through control charts. Medication errors are rare; the article examines medication errors due to omission, which makes the phenomena rarer. The empirical question was whether changes in process of care could be detected using control charts from data on medication omissions. Two different types of control chart, the XmR and Tukey charts, were used to analyze the data. The control chart with the tightest control limits was chosen for further interpretation. The XmR chart showed that there was sufficient power to detect unusual days in which the time to omission error was higher than historical norm. This article suggests that even rare events can be monitored through judicious use of time to the event. It shows the viability of safety teams using time to sentinel events to monitor progress in reducing frequency of sentinel events.

  9. Strategies to reduce medication errors in pediatric ambulatory settings

    Directory of Open Access Journals (Sweden)

    S Mehndiratta


    Full Text Available Worldwide, a large number of children are prescribed drugs on an outpatient basis. Medication errors are fairly common in these settings. Though this matter has been well recognized as a cause of concern, limited data is available from ambulatory settings. Medication errors can be defined as errors that may occur at any step, starting from ordering a medication, to dispensing, administration of the drug and the subsequent monitoring. The outcomes of such errors are variable and may range between those that are clinically insignificant to a life-threatening event. The reasons for these medication errors are multi-factorial. Children are unable to administer medications to themselves and also require a strict weight-based dosing regimen. The risk factors associated with medication errors include complex regimens with multiple medications. Overdosing and under-dosing (10-fold calculation errors, an increased or a decreased frequency of dosing or an inappropriate duration of administration of the medication, are frequently detected errors. The lack of availability of proper formulations adds to the confusion. The low level of literacy among the caregivers can aggravate this problem. There is a lack of proper reporting and monitoring mechanisms in most ambulatory settings, hence these errors remain unrecognized and often go unreported. This article summarizes the current available literature on medication errors in ambulatory settings and the possible strategies that can be adopted to reduce the burden of these errors in order to improve child care and patient safety. Voluntary, anonymous reporting can be introduced in the healthcare institutions to determine the incidence of these errors.


    Schattner, Ami


    Diagnostic errors remain an important target in improving the quality of care and achieving better health outcomes. With a relatively steady rate estimated at 10-15% in many settings, research aiming to elucidate mechanisms of error is highly important. Results indicate that not only cognitive mistakes but a number of factors acting together often culminate in a diagnostic error. Far from being 'unpreventable', several methods and techniques are suggested that may show promise in minimizing diagnostic errors. These measures should be further investigated and incorporated into all phases of medical education.

  11. Structure Errors in System Identification (United States)

    Bekey, G. A.; Hadaegh, F. Y.


    An approach to system identification is presented which explicitly takes structure errors into account and hence provides a systematic way for answering questions concerning the magnitude of estimated parameter errors resulting from structural errors. It is indicated that, from this point of view, it is possible to define near equivalence between process and model and to obtain meaningful theoretical results on solution error system identification. It remains to apply these results to large realistic problems such as those involving models of complex man machine systems.

  12. Identifying Error in AUV Communication

    National Research Council Canada - National Science Library

    Coleman, Joseph; Merrill, Kaylani; O'Rourke, Michael; Rajala, Andrew G; Edwards, Dean B


    Mine Countermeasures (MCM) involving Autonomous Underwater Vehicles (AUVs) are especially susceptible to error, given the constraints on underwater acoustic communication and the inconstancy of the underwater communication channel...

  13. Heuristic errors in clinical reasoning. (United States)

    Rylander, Melanie; Guerrasio, Jeannette


    Errors in clinical reasoning contribute to patient morbidity and mortality. The purpose of this study was to determine the types of heuristic errors made by third-year medical students and first-year residents. This study surveyed approximately 150 clinical educators inquiring about the types of heuristic errors they observed in third-year medical students and first-year residents. Anchoring and premature closure were the two most common errors observed amongst third-year medical students and first-year residents. There was no difference in the types of errors observed in the two groups. Errors in clinical reasoning contribute to patient morbidity and mortality Clinical educators perceived that both third-year medical students and first-year residents committed similar heuristic errors, implying that additional medical knowledge and clinical experience do not affect the types of heuristic errors made. Further work is needed to help identify methods that can be used to reduce heuristic errors early in a clinician's education. © 2015 John Wiley & Sons Ltd.

  14. Event Index - a LHCb Event Search System

    CERN Document Server

    INSPIRE-00392208; Kazeev, Nikita; Redkin, Artem


    LHC experiments generate up to $10^{12}$ events per year. This paper describes Event Index - an event search system. Event Index's primary function is quickly selecting subsets of events from a combination of conditions, such as the estimated decay channel or stripping lines output. Event Index is essentially Apache Lucene optimized for read-only indexes distributed over independent shards on independent nodes.

  15. Measurement Error and Equating Error in Power Analysis (United States)

    Phillips, Gary W.; Jiang, Tao


    Power analysis is a fundamental prerequisite for conducting scientific research. Without power analysis the researcher has no way of knowing whether the sample size is large enough to detect the effect he or she is looking for. This paper demonstrates how psychometric factors such as measurement error and equating error affect the power of…

  16. A Hybrid Unequal Error Protection / Unequal Error Resilience ...

    African Journals Online (AJOL)

    The quality layers are then assigned an Unequal Error Resilience to synchronization loss by unequally allocating the number of headers available for synchronization to them. Following that Unequal Error Protection against channel noise is provided to the layers by the use of Rate Compatible Punctured Convolutional ...

  17. Error coding simulations in C (United States)

    Noble, Viveca K.


    When data is transmitted through a noisy channel, errors are produced within the data rendering it indecipherable. Through the use of error control coding techniques, the bit error rate can be reduced to any desired level without sacrificing the transmission data rate. The Astrionics Laboratory at Marshall Space Flight Center has decided to use a modular, end-to-end telemetry data simulator to simulate the transmission of data from flight to ground and various methods of error control. The simulator includes modules for random data generation, data compression, Consultative Committee for Space Data Systems (CCSDS) transfer frame formation, error correction/detection, error generation and error statistics. The simulator utilizes a concatenated coding scheme which includes CCSDS standard (255,223) Reed-Solomon (RS) code over GF(2(exp 8)) with interleave depth of 5 as the outermost code, (7, 1/2) convolutional code as an inner code and CCSDS recommended (n, n-16) cyclic redundancy check (CRC) code as the innermost code, where n is the number of information bits plus 16 parity bits. The received signal-to-noise for a desired bit error rate is greatly reduced through the use of forward error correction techniques. Even greater coding gain is provided through the use of a concatenated coding scheme. Interleaving/deinterleaving is necessary to randomize burst errors which may appear at the input of the RS decoder. The burst correction capability length is increased in proportion to the interleave depth. The modular nature of the simulator allows for inclusion or exclusion of modules as needed. This paper describes the development and operation of the simulator, the verification of a C-language Reed-Solomon code, and the possibility of using Comdisco SPW(tm) as a tool for determining optimal error control schemes.

  18. Dual Processing and Diagnostic Errors (United States)

    Norman, Geoff


    In this paper, I review evidence from two theories in psychology relevant to diagnosis and diagnostic errors. "Dual Process" theories of thinking, frequently mentioned with respect to diagnostic error, propose that categorization decisions can be made with either a fast, unconscious, contextual process called System 1 or a slow, analytical,…

  19. Barriers to Medical Error Reporting. (United States)

    Poorolajal, Jalal; Rezaie, Shirin; Aghighi, Negar


    This study was conducted to explore the prevalence of medical error underreporting and associated barriers. This cross-sectional study was performed from September to December 2012. Five hospitals, affiliated with Hamadan University of Medical Sciences, in Hamedan, Iran were investigated. A self-administered questionnaire was used for data collection. Participants consisted of physicians, nurses, midwives, residents, interns, and staffs of radiology and laboratory departments. Overall, 50.26% of subjects had committed but not reported medical errors. The main reasons mentioned for underreporting were lack of effective medical error reporting system (60.0%), lack of proper reporting form (51.8%), lack of peer supporting a person who has committed an error (56.0%), and lack of personal attention to the importance of medical errors (62.9%). The rate of committing medical errors was higher in men (71.4%), age of 50-40 years (67.6%), less-experienced personnel (58.7%), educational level of MSc (87.5%), and staff of radiology department (88.9%). This study outlined the main barriers to reporting medical errors and associated factors that may be helpful for healthcare organizations in improving medical error reporting as an essential component for patient safety enhancement.

  20. Barriers to medical error reporting

    Directory of Open Access Journals (Sweden)

    Jalal Poorolajal


    Full Text Available Background: This study was conducted to explore the prevalence of medical error underreporting and associated barriers. Methods: This cross-sectional study was performed from September to December 2012. Five hospitals, affiliated with Hamadan University of Medical Sciences, in Hamedan,Iran were investigated. A self-administered questionnaire was used for data collection. Participants consisted of physicians, nurses, midwives, residents, interns, and staffs of radiology and laboratory departments. Results: Overall, 50.26% of subjects had committed but not reported medical errors. The main reasons mentioned for underreporting were lack of effective medical error reporting system (60.0%, lack of proper reporting form (51.8%, lack of peer supporting a person who has committed an error (56.0%, and lack of personal attention to the importance of medical errors (62.9%. The rate of committing medical errors was higher in men (71.4%, age of 50-40 years (67.6%, less-experienced personnel (58.7%, educational level of MSc (87.5%, and staff of radiology department (88.9%. Conclusions: This study outlined the main barriers to reporting medical errors and associated factors that may be helpful for healthcare organizations in improving medical error reporting as an essential component for patient safety enhancement.

  1. Explaining Errors in Children's Questions (United States)

    Rowland, Caroline F.


    The ability to explain the occurrence of errors in children's speech is an essential component of successful theories of language acquisition. The present study tested some generativist and constructivist predictions about error on the questions produced by ten English-learning children between 2 and 5 years of age. The analyses demonstrated that,…

  2. Physician assistants and the disclosure of medical error. (United States)

    Brock, Douglas M; Quella, Alicia; Lipira, Lauren; Lu, Dave W; Gallagher, Thomas H


    Evolving state law, professional societies, and national guidelines, including those of the American Medical Association and Joint Commission, recommend that patients receive transparent communication when a medical error occurs. Recommendations for error disclosure typically consist of an explanation that an error has occurred, delivery of an explicit apology, an explanation of the facts around the event, its medical ramifications and how care will be managed, and a description of how similar errors will be prevented in the future. Although error disclosure is widely endorsed in the medical and nursing literature, there is little discussion of the unique role that the physician assistant (PA) might play in these interactions. PAs are trained in the medical model and technically practice under the supervision of a physician. They are also commonly integrated into interprofessional health care teams in surgical and urgent care settings. PA practice is characterized by widely varying degrees of provider autonomy. How PAs should collaborate with physicians in sensitive error disclosure conversations with patients is unclear. With the number of practicing PAs growing rapidly in nearly all domains of medicine, their role in the error disclosure process warrants exploration. The authors call for educational societies and accrediting agencies to support policy to establish guidelines for PA disclosure of error. They encourage medical and PA researchers to explore and report best-practice disclosure roles for PAs. Finally, they recommend that PA educational programs implement trainings in disclosure skills, and hospitals and supervising physicians provide and support training for practicing PAs.

  3. Medical error and systems of signaling: conceptual and linguistic definition. (United States)

    Smorti, Andrea; Cappelli, Francesco; Zarantonello, Roberta; Tani, Franca; Gensini, Gian Franco


    In recent years the issue of patient safety has been the subject of detailed investigations, particularly as a result of the increasing attention from the patients and the public on the problem of medical error. The purpose of this work is firstly to define the classification of medical errors, which are distinguished between two perspectives: those that are personal, and those that are caused by the system. Furthermore we will briefly review some of the main methods used by healthcare organizations to identify and analyze errors. During this discussion it has been determined that, in order to constitute a practical, coordinated and shared action to counteract the error, it is necessary to promote an analysis that considers all elements (human, technological and organizational) that contribute to the occurrence of a critical event. Therefore, it is essential to create a culture of constructive confrontation that encourages an open and non-punitive debate about the causes that led to error. In conclusion we have thus underlined that in health it is essential to affirm a system discussion that considers the error as a learning source, and as a result of the interaction between the individual and the organization. In this way, one should encourage a non-guilt bearing discussion on evident errors and on those which are not immediately identifiable, in order to create the conditions that recognize and corrects the error even before it produces negative consequences.

  4. The probability and the management of human error

    Energy Technology Data Exchange (ETDEWEB)

    Dufey, R.B. [Atomic Energy of Canada Limited, Chalk River Laboratories, Chalk River, ON (Canada); Saull, J.W. [International Federation of Airworthiness, Sussex (United Kingdom)


    Embedded within modern technological systems, human error is the largest, and indeed dominant contributor to accident cause. The consequences dominate the risk profiles for nuclear power and for many other technologies. We need to quantify the probability of human error for the system as an integral contribution within the overall system failure, as it is generally not separable or predictable for actual events. We also need to provide a means to manage and effectively reduce the failure (error) rate. The fact that humans learn from their mistakes allows a new determination of the dynamic probability and human failure (error) rate in technological systems. The result is consistent with and derived from the available world data for modern technological systems. Comparisons are made to actual data from large technological systems and recent catastrophes. Best estimate values and relationships can be derived for both the human error rate, and for the probability. We describe the potential for new approaches to the management of human error and safety indicators, based on the principles of error state exclusion and of the systematic effect of learning. A new equation is given for the probability of human error ({lambda}) that combines the influences of early inexperience, learning from experience ({epsilon}) and stochastic occurrences with having a finite minimum rate, this equation is {lambda} 5.10{sup -5} + ((1/{epsilon}) - 5.10{sup -5}) exp(-3*{epsilon}). The future failure rate is entirely determined by the experience: thus the past defines the future.

  5. Onorbit IMU alignment error budget (United States)

    Corson, R. W.


    The Star Tracker, Crew Optical Alignment Sight (COAS), and Inertial Measurement Unit (IMU) from a complex navigation system with a multitude of error sources were combined. A complete list of the system errors is presented. The errors were combined in a rational way to yield an estimate of the IMU alignment accuracy for STS-1. The expected standard deviation in the IMU alignment error for STS-1 type alignments was determined to be 72 arc seconds per axis for star tracker alignments and 188 arc seconds per axis for COAS alignments. These estimates are based on current knowledge of the star tracker, COAS, IMU, and navigation base error specifications, and were partially verified by preliminary Monte Carlo analysis.

  6. Prioritising interventions against medication errors

    DEFF Research Database (Denmark)

    Lisby, Marianne; Pape-Larsen, Louise; Sørensen, Ann Lykkegaard

    experts appointed by 13 healthcare-, professional- and scientific organisations in Denmark. Test of definition: The definition was applied to historic data from a somatic hospital (2003; 64 patients) [2] and further, prospectively tested in comparable studies of medication errors in a psychiatric hospital...... errors was compared between the somatic hospital (2003), the nursing homes and the psychiatric hospital whereas comparison of prescribing errors included all four clinical settings. Results: Definition: The expert panel reached consensus of the following definition “An error in the stages...... of the medication process - ordering, transcribing, dispensing, administering and monitoring the effect - causing harm or implying a risk of harming the patient”. In addition, consensus for 60 of 76 error types covering all stages in the medication process was achieved. Test of definition: The definition...

  7. Events diary (United States)


    as Imperial College, the Royal Albert Hall, the Royal College of Art, the Natural History and Science Museums and the Royal Geographical Society. Under the heading `Shaping the future together' BA2000 will explore science, engineering and technology in their wider cultural context. Further information about this event on 6 - 12 September may be obtained from Sandra Koura, BA2000 Festival Manager, British Association for the Advancement of Science, 23 Savile Row, London W1X 2NB (tel: 0171 973 3075, e-mail: ). Details of the creating SPARKS events may be obtained from or from the website . Other events 3 - 7 July, Porto Alegre, Brazil VII Interamerican conference on physics education: The preparation of physicists and physics teachers in contemporary society. Info: or 27 August - 1 September, Barcelona, Spain GIREP conference: Physics teacher education beyond 2000. Info:

  8. Single Event Effects Test Facility Options at the Oak Ridge National Laboratory

    Energy Technology Data Exchange (ETDEWEB)

    Riemer, Bernie [ORNL; Gallmeier, Franz X [ORNL; Dominik, Laura J [ORNL


    Increasing use of microelectronics of ever diminishing feature size in avionics systems has led to a growing Single Event Effects (SEE) susceptibility arising from the highly ionizing interactions of cosmic rays and solar particles. Single event effects caused by atmospheric radiation have been recognized in recent years as a design issue for avionics equipment and systems. To ensure a system meets all its safety and reliability requirements, SEE induced upsets and potential system failures need to be considered, including testing of the components and systems in a neutron beam. Testing of integrated circuits (ICs) and systems for use in radiation environments requires the utilization of highly advanced laboratory facilities that can run evaluations on microcircuits for the effects of radiation. This paper provides a background of the atmospheric radiation phenomenon and the resulting single event effects, including single event upset (SEU) and latch up conditions. A study investigating requirements for future single event effect irradiation test facilities and developing options at the Spallation Neutron Source (SNS) is summarized. The relatively new SNS with its 1.0 GeV proton beam, typical operation of 5000 h per year, expertise in spallation neutron sources, user program infrastructure, and decades of useful life ahead is well suited for hosting a world-class SEE test facility in North America. Emphasis was put on testing of large avionics systems while still providing tunable high flux irradiation conditions for component tests. Makers of ground-based systems would also be served well by these facilities. Three options are described; the most capable, flexible, and highest-test-capacity option is a new stand-alone target station using about one kW of proton beam power on a gas-cooled tungsten target, with dual test enclosures. Less expensive options are also described.

  9. Coping with human errors through system design: Implications for ecological interface design

    DEFF Research Database (Denmark)

    Rasmussen, Jens; Vicente, Kim J.


    Research during recent years has revealed that human errors are not stochastic events which can be removed through improved training programs or optimal interface design. Rather, errors tend to reflect either systematic interference between various models, rules, and schemata, or the effects of t...... on both the interferences causing error and on the opportunity for error recovery left to the operator.......Research during recent years has revealed that human errors are not stochastic events which can be removed through improved training programs or optimal interface design. Rather, errors tend to reflect either systematic interference between various models, rules, and schemata, or the effects...... of the adaptive mechanisms involved in learning. In terms of design implications, these findings suggest that reliable human-system interaction will be achieved by designing interfaces which tend to minimize the potential for control interference and support recovery from errors. In other words, the focus should...

  10. A Novel Patient Safety Event Reporting Tool in Otolaryngology. (United States)

    Vila, Peter M; Lewis, Sean; Cunningham, Gene; Brereton, Jean; Espinel, Alexandra G; Roberson, David W; Shah, Rahul K


    Objective To report the results of a preliminary analysis of a quality improvement initiative aimed to identify potential latent systems defects. Methods A pilot study of an anonymous, voluntary, event reporting system made available to all members of the American Academy of Otolaryngology-Head and Neck Surgery was performed. The National Coordinating Council for Medication Error Reporting and Prevention (NCC MERP) index was used to classify error types. Descriptive statistics were used to summarize submissions to the database. Results In the 53 cases reported to the database over 22 months, the majority involved errors that had resulted in harm (n = 34, 64%), followed by errors that occurred and did not result in harm (n = 7, 13%). Errors occurred predominantly in the hospital (n = 23, 44%) and operating room (n = 19, 35%). Most entries were classified as either technical (n = 21, 39%) or related to postoperative care (n = 15, 30%). Discussion This preliminary descriptive analysis of a novel otolaryngology patient safety event reporting tool shows that this platform brings unique value to the identification of errors and adverse events in our specialty. Most reported events were classified as errors resulting in harm. The most common type of reported event was a technical error, most often resulting in a nerve injury. Implications for Practice This reporting tool will likely allow for identification and prioritization of improvement opportunities. This example may serve as a guide for other societies to create similar platforms as we strive for a standardized process for event reporting.

  11. Factors that influence the generation of autobiographical memory conjunction errors. (United States)

    Devitt, Aleea L; Monk-Fromont, Edwin; Schacter, Daniel L; Addis, Donna Rose


    The constructive nature of memory is generally adaptive, allowing us to efficiently store, process and learn from life events, and simulate future scenarios to prepare ourselves for what may come. However, the cost of a flexibly constructive memory system is the occasional conjunction error, whereby the components of an event are authentic, but the combination of those components is false. Using a novel recombination paradigm, it was demonstrated that details from one autobiographical memory (AM) may be incorrectly incorporated into another, forming AM conjunction errors that elude typical reality monitoring checks. The factors that contribute to the creation of these conjunction errors were examined across two experiments. Conjunction errors were more likely to occur when the corresponding details were partially rather than fully recombined, likely due to increased plausibility and ease of simulation of partially recombined scenarios. Brief periods of imagination increased conjunction error rates, in line with the imagination inflation effect. Subjective ratings suggest that this inflation is due to similarity of phenomenological experience between conjunction and authentic memories, consistent with a source monitoring perspective. Moreover, objective scoring of memory content indicates that increased perceptual detail may be particularly important for the formation of AM conjunction errors.

  12. Collaborating on medication errors in nursing. (United States)

    Marvanova, Marketa; Henkel, Paul J


    Nurse educators are faced with changing roles and expanding responsibilities for medication administration and monitoring in pursuit of improved patient safety. The aims of this study were to develop, implement and evaluate clinical simulation experiences that included, along with nursing faculty members, a pharmacist educator for the teaching of preventable medication errors in undergraduate nursing education. Four clinical simulation scenarios using high-fidelity patient simulators were developed focusing on select medication problems in nursing practice. Post-simulation evaluation of perceptions and experiences of undergraduate nursing students (n = 69) were assessed using a questionnaire of Likert-type items, including: (1) an evaluation of the simulation experience; and (2) self-reported perceived benefits for clinical ability and confidence in recognising, managing and reporting medication errors. Four hospital-based simulations on select preventable medication errors were piloted with 72 undergraduate nursing students. The majority of students (60.8-84.1%) evaluated the experience positively with regards to time pressure, type/severity of events, challenges, and benefits for critical thinking and decision making regarding patient safety and medication errors. Four clinical simulation scenarios using high-fidelity patient simulators were developed focusing on select medication problems DISCUSSION: The use of a pharmacy educator as a medication expert and member of the interprofessional health care teaching team in nursing education can be beneficial for training on medication safety, and on adverse effects, in a nursing programme in order to enhance nursing students' education. © 2017 John Wiley & Sons Ltd and The Association for the Study of Medical Education.

  13. ERP correlates of error monitoring in adult ADHD

    NARCIS (Netherlands)

    van der Meere, J. J.; Roeyers, H.; Wiersema, J.R

    The purpose of the current study was to evaluate whether error monitoring difficulties persist in adults with attention deficit hyperactivity disorder (ADHD) using the event-related potential (ERP) methodology. Adults with ADHD and age-matched healthy controls executed a visual Go/No-Go task with

  14. Bringing organizational factors to the fore of human error management

    Energy Technology Data Exchange (ETDEWEB)

    Embrey, D. (Human Reliability Associates Ltd., Parbold (United Kingdom))


    Human performance problems account for more than half of all significant events at nuclear power plants, even when these did not necessarily lead to severe accidents. In dealing with the management of human error, both technical and organizational factors need to be taken into account. Most important, a long-term commitment from senior management is needed. (author).

  15. Linear network error correction coding

    CERN Document Server

    Guang, Xuan


    There are two main approaches in the theory of network error correction coding. In this SpringerBrief, the authors summarize some of the most important contributions following the classic approach, which represents messages by sequences?similar to algebraic coding,?and also briefly discuss the main results following the?other approach,?that uses the theory of rank metric codes for network error correction of representing messages by subspaces. This book starts by establishing the basic linear network error correction (LNEC) model and then characterizes two equivalent descriptions. Distances an

  16. Errors in transfusion medicine: have we learned our lesson? (United States)

    Fastman, Barbara Rabin; Kaplan, Harold S


    The phrase "patient safety" represents freedom from accidental or preventable harm due to events occurring in the healthcare setting. Practitioners aim to reduce, if not prevent, medical errors and adverse outcomes. Yet studies performed from many perspectives show that medical error constitutes a serious worldwide problem. Transfusion medicine, with its interdisciplinary intricacies and the danger of fatal outcomes, serves as an exemplar of lessons learned. Opportunity for error in complex systems is vast, and although errors are traditionally blamed on humans, they are often set up by preexisting factors. Transfusion has inherent hazards such as clinical vulnerabilities (eg, contracting an infectious agent or experiencing a transfusion reaction), but there also exists the possibility of hazards associated with process errors. Sample collection errors, or preanalytic errors, may occur when samples are drawn from donors during blood donation, as well as when drawn from patients prior to transfusion-related testing, and account for approximately one-third of events in transfusion. Errors in the analytic phase of the transfusion chain, slips and errors in the laboratory, comprise close to one-third of patient safety-related transfusion events. As many as 40% of mistransfusions are due to errors in the postanalytic phase: often failures in the final check of the right blood and the right patient at the bedside. Bar-code labels, radiofrequency identification tags, and even palm vein-scanning technology are increasingly being utilized in patient identification. The last phase of transfusion, careful monitoring of the recipient for adverse signs or symptoms, when performed diligently can help prevent or manage a potentially fatal reaction caused by an earlier process error or an unavoidable physiologic condition. Ways in which we can and do deal with potential hazards of transfusion are discussed, including a method of hazard reduction termed inherently safer design

  17. Appraisals of Negative Divorce Events and Children's Psychological Adjustment. (United States)

    Mazur, Elizabeth; And Others

    Adding to prior literature on adults' and children's appraisals of stressors, this study examined relationships among children's negative cognitive errors regarding hypothetical negative divorce events, positive illusions about those same events, the actual divorce events, and children's post-divorce psychological adjustment. Subjects were 38…

  18. Medication reconciliation as a strategy for preventing medication errors

    Directory of Open Access Journals (Sweden)

    Luana de Rezende Spalla

    Full Text Available ABSTRACT One of the current barriers proposed to avoid possible medication errors, and consequently harm to patients, is the medication reconciliation, a process in which drugs used by patients prior to hospitalization can be compared with those prescribed in the hospital. This study describes the results of a pharmacist based reconciliation conducted during six months in clinical units of a university hospital. Fourteen patients (23.33% had some kind of problem related to medicine. The majority (80% of medication errors were due to medication omission. Pharmaceutical interventions acceptance level was 90%. The results suggest that pharmacists based reconciliation can have a relevant role in preventing medication errors and adverse events. Moreover, the detailed interview, conducted by the pharmacist, is able to rescue important information regarding the use of drugs, allowing to avoid medications errors and patient injury.

  19. Nursing error: an integrated review of the literature. (United States)

    Mohsenpour, Mohaddeseh; Hosseini, Mohammadali; Abbaszadeh, Abbas; Shahboulaghi, Farahnaz Mohammadi; Khankeh, Hamidreza


    Nursing errors are complex and take place frequently in the care of patients. However, despite their significance, they have not been properly defined or addressed in the literature. This integrative review of the literature explored the concept of nursing error, explained its definitions and described its attributes and measurements. The databases of Medline, CINAHL, Google Scholar and SID were searched using a number of keywords, including malpractice, adverse events and mistake, with and without the word nurse. The aim was to determine the definition of nursing error, regardless of the contextual aspects, in various scientific systems. After reviewing the relevant literature, content analysis (in MAXQDA) was applied to classify the definitions, attributes and measurements obtained on the basis of their similarities and differences. Ultimately, a definition was established for the concept of nursing error.

  20. Asymmetrical Search Errors in Infancy (United States)

    Butterworth, George


    To establish the spatial generality of perseverative errors in infant manual search, a group of infants aged 8-11 months performed Piaget's Stage IV task with an object hidden at successive locations in the vertical plane. (Author/JMB)

  1. Numerical optimization with computational errors

    CERN Document Server

    Zaslavski, Alexander J


    This book studies the approximate solutions of optimization problems in the presence of computational errors. A number of results are presented on the convergence behavior of algorithms in a Hilbert space; these algorithms are examined taking into account computational errors. The author illustrates that algorithms generate a good approximate solution, if computational errors are bounded from above by a small positive constant. Known computational errors are examined with the aim of determining an approximate solution. Researchers and students interested in the optimization theory and its applications will find this book instructive and informative. This monograph contains 16 chapters; including a chapters devoted to the subgradient projection algorithm, the mirror descent algorithm, gradient projection algorithm, the Weiszfelds method, constrained convex minimization problems, the convergence of a proximal point method in a Hilbert space, the continuous subgradient method, penalty methods and Newton’s meth...

  2. Quantile Regression With Measurement Error

    KAUST Repository

    Wei, Ying


    Regression quantiles can be substantially biased when the covariates are measured with error. In this paper we propose a new method that produces consistent linear quantile estimation in the presence of covariate measurement error. The method corrects the measurement error induced bias by constructing joint estimating equations that simultaneously hold for all the quantile levels. An iterative EM-type estimation algorithm to obtain the solutions to such joint estimation equations is provided. The finite sample performance of the proposed method is investigated in a simulation study, and compared to the standard regression calibration approach. Finally, we apply our methodology to part of the National Collaborative Perinatal Project growth data, a longitudinal study with an unusual measurement error structure. © 2009 American Statistical Association.

  3. The uncorrected refractive error challenge

    Directory of Open Access Journals (Sweden)

    Kovin Naidoo


    Full Text Available Refractive error affects people of all ages, socio-economic status and ethnic groups. The most recent statistics estimate that, worldwide, 32.4 million people are blind and 191 million people have vision impairment. Vision impairment has been defined based on distance visual acuity only, and uncorrected distance refractive error (mainly myopia is the single biggest cause of worldwide vision impairment. However, when we also consider near visual impairment, it is clear that even more people are affected. From research it was estimated that the number of people with vision impairment due to uncorrected distance refractive error was 107.8 million,1 and the number of people affected by uncorrected near refractive error was 517 million, giving a total of 624.8 million people.

  4. Comprehensive Error Rate Testing (CERT) (United States)

    U.S. Department of Health & Human Services — The Centers for Medicare and Medicaid Services (CMS) implemented the Comprehensive Error Rate Testing (CERT) program to measure improper payments in the Medicare...

  5. Heuristic thinking: interdisciplinary perspectives on medical error

    Directory of Open Access Journals (Sweden)

    Annegret F. Hannawa


    Full Text Available Approximately 43 million adverse events occur across the globe each year at a cost of at least 23 million disability-adjusted life years and $132 billion in excess health care spending, ranking this safety burden among the top 10 medical causes of disability in the world.1 These findings are likely to be an understatement of the actual severity of the problem, given that the numbers merely reflect seven types of adverse events and completely neglect ambulatory care, and of course they only cover reported incidents. Furthermore, they do not include statistics on children and incidents from India and China, which host more than a third of the world’s population. Best estimates imply that about two thirds of these incidents are preventable. Thus, from a public health perspective, medical errors are a seri- ous global health burden, in fact ahead of high-profile health problems like AIDS and cancer. Interventions to date have not reduced medical errors to satisfactory rates. Even today, far too often, hand hygiene is not practiced properly (even in developed countries, surgical procedures take place in underequipped operating theaters, and checklists are missing or remain uncompleted. The healthcare system seems to be failing in managing its errors − it is costing too much, and the complexity of care causes severe safety hazards that too often harm rather than help patients. In response to this evolving discussion, the International Society for Quality in Healthcare recently nominated an Innovations Team that is now developing new strategies. One of the emerging themes is that the medical field cannot resolve this problem on its own. Instead, interdisciplinary collaborations are needed to advance effective, evidence-based interventions that will eventually result in competent changes. In March 2013, the Institute of Communication and Health at the University of Lugano organized a conference on Communicating Medical Error (COME 2013 in

  6. Error correcting coding for OTN

    DEFF Research Database (Denmark)

    Justesen, Jørn; Larsen, Knud J.; Pedersen, Lars A.


    Forward error correction codes for 100 Gb/s optical transmission are currently receiving much attention from transport network operators and technology providers. We discuss the performance of hard decision decoding using product type codes that cover a single OTN frame or a small number...... of such frames. In particular we argue that a three-error correcting BCH is the best choice for the component code in such systems....

  7. Eliminating US hospital medical errors. (United States)

    Kumar, Sameer; Steinebach, Marc


    Healthcare costs in the USA have continued to rise steadily since the 1980s. Medical errors are one of the major causes of deaths and injuries of thousands of patients every year, contributing to soaring healthcare costs. The purpose of this study is to examine what has been done to deal with the medical-error problem in the last two decades and present a closed-loop mistake-proof operation system for surgery processes that would likely eliminate preventable medical errors. The design method used is a combination of creating a service blueprint, implementing the six sigma DMAIC cycle, developing cause-and-effect diagrams as well as devising poka-yokes in order to develop a robust surgery operation process for a typical US hospital. In the improve phase of the six sigma DMAIC cycle, a number of poka-yoke techniques are introduced to prevent typical medical errors (identified through cause-and-effect diagrams) that may occur in surgery operation processes in US hospitals. It is the authors' assertion that implementing the new service blueprint along with the poka-yokes, will likely result in the current medical error rate to significantly improve to the six-sigma level. Additionally, designing as many redundancies as possible in the delivery of care will help reduce medical errors. Primary healthcare providers should strongly consider investing in adequate doctor and nurse staffing, and improving their education related to the quality of service delivery to minimize clinical errors. This will lead to an increase in higher fixed costs, especially in the shorter time frame. This paper focuses additional attention needed to make a sound technical and business case for implementing six sigma tools to eliminate medical errors that will enable hospital managers to increase their hospital's profitability in the long run and also ensure patient safety.

  8. Errors in Chemical Sensor Measurements

    Directory of Open Access Journals (Sweden)

    Artur Dybko


    Full Text Available Various types of errors during the measurements of ion-selective electrodes, ionsensitive field effect transistors, and fibre optic chemical sensors are described. The errors were divided according to their nature and place of origin into chemical, instrumental and non-chemical. The influence of interfering ions, leakage of the membrane components, liquid junction potential as well as sensor wiring, ambient light and temperature is presented.

  9. Detecting self-produced speech errors before and after articulation: An ERP investigation

    Directory of Open Access Journals (Sweden)

    Kevin Michael Trewartha


    Full Text Available It has been argued that speech production errors are monitored by the same neural system involved in monitoring other types of action errors. Behavioral evidence has shown that speech errors can be detected and corrected prior to articulation, yet the neural basis for such pre-articulatory speech error monitoring is poorly understood. The current study investigated speech error monitoring using a phoneme-substitution task known to elicit speech errors. Stimulus-locked event-related potential (ERP analyses comparing correct and incorrect utterances were used to assess pre-articulatory error monitoring and response-locked ERP analyses were used to assess post-articulatory monitoring. Our novel finding in the stimulus-locked analysis revealed that words that ultimately led to a speech error were associated with a larger P2 component at midline sites (FCz, Cz, and CPz. This early positivity may reflect the detection of an error in speech formulation, or a predictive mechanism to signal the potential for an upcoming speech error. The data also revealed that general conflict monitoring mechanisms are involved during this task as both correct and incorrect responses elicited an anterior N2 component typically associated with conflict monitoring. The response-locked analyses corroborated previous observations that self-produced speech errors led to a fronto-central ERN. These results demonstrate that speech errors can be detected prior to articulation, and that speech error monitoring relies on a central error monitoring mechanism.

  10. Quantum error correction for beginners (United States)

    Devitt, Simon J.; Munro, William J.; Nemoto, Kae


    Quantum error correction (QEC) and fault-tolerant quantum computation represent one of the most vital theoretical aspects of quantum information processing. It was well known from the early developments of this exciting field that the fragility of coherent quantum systems would be a catastrophic obstacle to the development of large-scale quantum computers. The introduction of quantum error correction in 1995 showed that active techniques could be employed to mitigate this fatal problem. However, quantum error correction and fault-tolerant computation is now a much larger field and many new codes, techniques, and methodologies have been developed to implement error correction for large-scale quantum algorithms. In response, we have attempted to summarize the basic aspects of quantum error correction and fault-tolerance, not as a detailed guide, but rather as a basic introduction. The development in this area has been so pronounced that many in the field of quantum information, specifically researchers who are new to quantum information or people focused on the many other important issues in quantum computation, have found it difficult to keep up with the general formalisms and methodologies employed in this area. Rather than introducing these concepts from a rigorous mathematical and computer science framework, we instead examine error correction and fault-tolerance largely through detailed examples, which are more relevant to experimentalists today and in the near future.

  11. Medical Error and Moral Luck. (United States)

    Hubbeling, Dieneke


    This paper addresses the concept of moral luck. Moral luck is discussed in the context of medical error, especially an error of omission that occurs frequently, but only rarely has adverse consequences. As an example, a failure to compare the label on a syringe with the drug chart results in the wrong medication being administered and the patient dies. However, this error may have previously occurred many times with no tragic consequences. Discussions on moral luck can highlight conflicting intuitions. Should perpetrators receive a harsher punishment because of an adverse outcome, or should they be dealt with in the same way as colleagues who have acted similarly, but with no adverse effects? An additional element to the discussion, specifically with medical errors, is that according to the evidence currently available, punishing individual practitioners does not seem to be effective in preventing future errors. The following discussion, using relevant philosophical and empirical evidence, posits a possible solution for the moral luck conundrum in the context of medical error: namely, making a distinction between the duty to make amends and assigning blame. Blame should be assigned on the basis of actual behavior, while the duty to make amends is dependent on the outcome.

  12. Error image aware content restoration (United States)

    Choi, Sungwoo; Lee, Moonsik; Jung, Byunghee


    As the resolution of TV significantly increased, content consumers have become increasingly sensitive to the subtlest defect in TV contents. This rising standard in quality demanded by consumers has posed a new challenge in today's context where the tape-based process has transitioned to the file-based process: the transition necessitated digitalizing old archives, a process which inevitably produces errors such as disordered pixel blocks, scattered white noise, or totally missing pixels. Unsurprisingly, detecting and fixing such errors require a substantial amount of time and human labor to meet the standard demanded by today's consumers. In this paper, we introduce a novel, automated error restoration algorithm which can be applied to different types of classic errors by utilizing adjacent images while preserving the undamaged parts of an error image as much as possible. We tested our method to error images detected from our quality check system in KBS(Korean Broadcasting System) video archive. We are also implementing the algorithm as a plugin of well-known NLE(Non-linear editing system), which is a familiar tool for quality control agent.

  13. Disentangling timing and amplitude errors in streamflow simulations (United States)

    Seibert, Simon Paul; Ehret, Uwe; Zehe, Erwin


    This article introduces an improvement in the Series Distance (SD) approach for the improved discrimination and visualization of timing and magnitude uncertainties in streamflow simulations. SD emulates visual hydrograph comparison by distinguishing periods of low flow and periods of rise and recession in hydrological events. Within these periods, it determines the distance of two hydrographs not between points of equal time but between points that are hydrologically similar. The improvement comprises an automated procedure to emulate visual pattern matching, i.e. the determination of an optimal level of generalization when comparing two hydrographs, a scaled error model which is better applicable across large discharge ranges than its non-scaled counterpart, and "error dressing", a concept to construct uncertainty ranges around deterministic simulations or forecasts. Error dressing includes an approach to sample empirical error distributions by increasing variance contribution, which can be extended from standard one-dimensional distributions to the two-dimensional distributions of combined time and magnitude errors provided by SD. In a case study we apply both the SD concept and a benchmark model (BM) based on standard magnitude errors to a 6-year time series of observations and simulations from a small alpine catchment. Time-magnitude error characteristics for low flow and rising and falling limbs of events were substantially different. Their separate treatment within SD therefore preserves useful information which can be used for differentiated model diagnostics, and which is not contained in standard criteria like the Nash-Sutcliffe efficiency. Construction of uncertainty ranges based on the magnitude of errors of the BM approach and the combined time and magnitude errors of the SD approach revealed that the BM-derived ranges were visually narrower and statistically superior to the SD ranges. This suggests that the combined use of time and magnitude errors to

  14. Brain State Before Error Making in Young Patients With Mild Spastic Cerebral Palsy. (United States)

    Hakkarainen, Elina; Pirilä, Silja; Kaartinen, Jukka; van der Meere, Jaap J


    In the present experiment, children with mild spastic cerebral palsy and a control group carried out a memory recognition task. The key question was if errors of the patient group are foreshadowed by attention lapses, by weak motor preparation, or by both. Reaction times together with event-related potentials associated with motor preparation (frontal late contingent negative variation), attention (parietal P300), and response evaluation (parietal error-preceding positivity) were investigated in instances where 3 subsequent correct trials preceded an error. The findings indicated that error responses of the patient group are foreshadowed by weak motor preparation in correct trials directly preceding an error. © The Author(s) 2015.

  15. Methods of Run-Time Error Detection in Distributed Process Control Software

    DEFF Research Database (Denmark)

    Drejer, N.

    of generic run-time error types, design of methods of observing application software behaviorduring execution and design of methods of evaluating run time constraints. In the definition of error types it is attempted to cover all relevant aspects of the application softwaree behavior. Methods of observation...... and constraint evaluation is designed for the modt interesting error types. These include: a) semantical errors in data communicated between application tasks; b) errors in the execution of application tasks; and c) errors in the timing of distributed events emitted by the application software. The design......In this thesis, methods of run-time error detection in application software for distributed process control is designed. The error detection is based upon a monitoring approach in which application software is monitored by system software during the entire execution. The thesis includes definition...

  16. Types of medication errors in North Carolina nursing homes: a target for quality improvement. (United States)

    Hansen, Richard A; Greene, Sandra B; Williams, Charlotte E; Blalock, Susan J; Crook, Kathleen D; Akers, Roger; Carey, Timothy S


    Medication errors are an important problem in nursing homes, but little is known about the types of medications involved in errors in this setting. Gaining a better understanding of the types of medications commonly involved in medication errors in nursing homes would be an important step toward quality improvement. This study sought to describe the types of medication errors most frequently reported to a statewide repository by North Carolina nursing homes. We also examined whether nursing homes reporting an error involving a drug on the updated Beers list of medications considered potentially inappropriate for use in the elderly were likely to report a greater number of medication errors or more harmful medication errors compared with nursing homes that did not report such an error. Medication errors were defined as preventable events that had the potential to cause/lead to or actually caused/led to inappropriate medication use or patient harm. We analyzed summary reports of medication errors submitted to the State of North Carolina by licensed nursing homes for the 9-month period from January 1, 2004, to September 30, 2004, using a Web-based reporting system. Drugs commonly involved in medication errors were summarized for all nursing homes in the state. Errors involving medications on the updated Beers list also were identified. Nursing homes were profiled and compared according to the type of medication error and whether the error reached the patient and/or caused harm. Among the 384 licensed nursing homes included in our analysis, 9272 medication errors were reported. The specific medication involved was documented for 5986 of these errors. The medications most commonly involved in an error were lorazepam (457 errors [8%]), warfarin (349 [6%]), insulin (332 [6%]), hydrocodone and hydrocodone combinations (233 [4%]), furosemide (173 [3%]), and the fentanyl patch (150 [3%]). The medication errors disproportionately included central nervous system agents (16

  17. Medication Distribution in Hospital: Errors Observed X Errors Perceived

    Directory of Open Access Journals (Sweden)

    G. N. Silva


    Full Text Available Abstract: The aim of the present study was to compare errors committed in the distribution of medicationsat a hospital pharmacy with those perceived by staff members involved in the distributionprocess. Medications distributed to the medical and surgical wards were analyzed. The drugswere dispensed in individualized doses per patient, separated by administration time in boxes orplastic bags for 24 hours of care and using the carbon copy of the prescription. Nineteen staffmembers involved in the drug-dispensing process were also interviewed. In the observationphase, 1963 drugs dispensed in 259 prescriptions were analyzed, with a total of 61 dispensingerrors (3.2% of the medications. The most frequent errors were omission of the prescribedmedication (23% and distribution of non-prescribed medication (14.8%. In the interviews, themain errors perceived by the staff were medications dispensed at a concentration other thanthat prescribed (22% and the distribution of non-prescribed medication or medication differentfrom that prescribed (20%. Differences were found between the most frequent errors observedand those reported by staff members. Nonetheless, the views of the staff proved coherent withthe literature on this issue.Keywords: medication errors, hospital medication system.

  18. Event dependent sampling of recurrent events

    DEFF Research Database (Denmark)

    Kvist, Tine Kajsa; Andersen, Per Kragh; Angst, Jules


    The effect of event-dependent sampling of processes consisting of recurrent events is investigated when analyzing whether the risk of recurrence increases with event count. We study the situation where processes are selected for study if an event occurs in a certain selection interval. Motivation...

  19. Predictors of Errors of Novice Java Programmers (United States)

    Bringula, Rex P.; Manabat, Geecee Maybelline A.; Tolentino, Miguel Angelo A.; Torres, Edmon L.


    This descriptive study determined which of the sources of errors would predict the errors committed by novice Java programmers. Descriptive statistics revealed that the respondents perceived that they committed the identified eighteen errors infrequently. Thought error was perceived to be the main source of error during the laboratory programming…

  20. Learning time-dependent noise to reduce logical errors: real time error rate estimation in quantum error correction (United States)

    Huo, Ming-Xia; Li, Ying


    Quantum error correction is important to quantum information processing, which allows us to reliably process information encoded in quantum error correction codes. Efficient quantum error correction benefits from the knowledge of error rates. We propose a protocol for monitoring error rates in real time without interrupting the quantum error correction. Any adaptation of the quantum error correction code or its implementation circuit is not required. The protocol can be directly applied to the most advanced quantum error correction techniques, e.g. surface code. A Gaussian processes algorithm is used to estimate and predict error rates based on error correction data in the past. We find that using these estimated error rates, the probability of error correction failures can be significantly reduced by a factor increasing with the code distance.

  1. Error-Related Brain Activity in Young Children: Associations with Parental Anxiety and Child Temperamental Negative Emotionality (United States)

    Torpey, Dana C.; Hajcak, Greg; Kim, Jiyon; Kujawa, Autumn J.; Dyson, Margaret W.; Olino, Thomas M.; Klein, Daniel N.


    Background: There is increasing interest in error-related brain activity in anxiety disorders. The error-related negativity (ERN) is a negative deflection in the event-related potential approximately 50 [milliseconds] after errors compared to correct responses. Recent studies suggest that the ERN may be a biomarker for anxiety, as it is positively…

  2. Event Index - an LHCb Event Search System

    CERN Document Server

    Ustyuzhanin, Andrey


    During LHC Run 1, the LHCb experiment recorded around 1011 collision events. This paper describes Event Index | an event search system. Its primary function is to quickly select subsets of events from a combination of conditions, such as the estimated decay channel or number of hits in a subdetector. Event Index is essentially Apache Lucene [1] optimized for read-only indexes distributed over independent shards on independent nodes.

  3. Vaccine Adverse Events (United States)

    ... Biologics Evaluation & Research Vaccine Adverse Events Vaccine Adverse Events Share Tweet Linkedin Pin it More sharing options ... the primary immunization series in infants Report Adverse Event Report a Vaccine Adverse Event Contact FDA (800) ...

  4. Gastrointestinal events with clopidogrel

    DEFF Research Database (Denmark)

    Grove, Erik Lerkevang; Würtz, Morten; Schwarz, Peter


    Clopidogrel prevents cardiovascular events, but has been linked with adverse gastrointestinal (GI) complications, particularly bleeding events.......Clopidogrel prevents cardiovascular events, but has been linked with adverse gastrointestinal (GI) complications, particularly bleeding events....

  5. Medication Errors in Pediatric Anesthesia: A Report From the Wake Up Safe Quality Improvement Initiative. (United States)

    Lobaugh, Lauren M Y; Martin, Lizabeth D; Schleelein, Laura E; Tyler, Donald C; Litman, Ronald S


    Wake Up Safe is a quality improvement initiative of the Society for Pediatric Anesthesia that contains a deidentified registry of serious adverse events occurring in pediatric anesthesia. The aim of this study was to describe and characterize reported medication errors to find common patterns amenable to preventative strategies. In September 2016, we analyzed approximately 6 years' worth of medication error events reported to Wake Up Safe. Medication errors were classified by: (1) medication category; (2) error type by phase of administration: prescribing, preparation, or administration; (3) bolus or infusion error; (4) provider type and level of training; (5) harm as defined by the National Coordinating Council for Medication Error Reporting and Prevention; and (6) perceived preventability. From 2010 to the time of our data analysis in September 2016, 32 institutions had joined and submitted data on 2087 adverse events during 2,316,635 anesthetics. These reports contained details of 276 medication errors, which comprised the third highest category of events behind cardiac and respiratory related events. Medication errors most commonly involved opioids and sedative/hypnotics. When categorized by phase of handling, 30 events occurred during preparation, 67 during prescribing, and 179 during administration. The most common error type was accidental administration of the wrong dose (N = 84), followed by syringe swap (accidental administration of the wrong syringe, N = 49). Fifty-seven (21%) reported medication errors involved medications prepared as infusions as opposed to 1 time bolus administrations. Medication errors were committed by all types of anesthesia providers, most commonly by attendings. Over 80% of reported medication errors reached the patient and more than half of these events caused patient harm. Fifteen events (5%) required a life sustaining intervention. Nearly all cases (97%) were judged to be either likely or certainly preventable. Our findings

  6. Orbit IMU alignment: Error analysis (United States)

    Corson, R. W.


    A comprehensive accuracy analysis of orbit inertial measurement unit (IMU) alignments using the shuttle star trackers was completed and the results are presented. Monte Carlo techniques were used in a computer simulation of the IMU alignment hardware and software systems to: (1) determine the expected Space Transportation System 1 Flight (STS-1) manual mode IMU alignment accuracy; (2) investigate the accuracy of alignments in later shuttle flights when the automatic mode of star acquisition may be used; and (3) verify that an analytical model previously used for estimating the alignment error is a valid model. The analysis results do not differ significantly from expectations. The standard deviation in the IMU alignment error for STS-1 alignments was determined to the 68 arc seconds per axis. This corresponds to a 99.7% probability that the magnitude of the total alignment error is less than 258 arc seconds.

  7. Medication errors in pediatric inpatients

    DEFF Research Database (Denmark)

    Rishoej, Rikke Mie; Almarsdóttir, Anna Birna; Christesen, Henrik Thybo


    The aim was to describe medication errors (MEs) in hospitalized children reported to the national mandatory reporting and learning system, the Danish Patient Safety Database (DPSD). MEs were extracted from DPSD from the 5-year period of 2010-2014. We included reports from public hospitals...... on patients aged 0-17 years and categorized by reporters as medication-related. Reports from psychiatric wards and outpatient clinics were excluded. A ME was defined as any medication-related error occurring in the medication process whether harmful or not. MEs were categorized as harmful if they resulted...... in actual harm or interventions to prevent harm. MEs were further categorized according to occurrence in the medication process, type of error, and the medicines involved. A total of 2071 MEs including 487 harmful MEs were identified. Most MEs occurred during prescribing (40.8%), followed by dispensing (38...

  8. Creating Special Events (United States)

    deLisle, Lee


    "Creating Special Events" is organized as a systematic approach to festivals and events for students who seek a career in event management. This book looks at the evolution and history of festivals and events and proceeds to the nuts and bolts of event management. The book presents event management as the means of planning, organizing, directing,…

  9. A Hybrid Unequal Error Protection / Unequal Error Resilience ...

    African Journals Online (AJOL)


    Following that Unequal Error Protection against channel noise is provided to the layers by the use of ... of the Peak to Peak Signal to Noise power Ratio (PSNR) and the Mean Structural Similarity. Index (MSSIM) metric. Keywords: ..... compensation. IEEE Trans. on Circuits and Systems for Video Technology. pp. 438–452.

  10. Student Errors in Fractions and Possible Causes of These Errors (United States)

    Aksoy, Nuri Can; Yazlik, Derya Ozlem


    In this study, it was aimed to determine the errors and misunderstandings of 5th and 6th grade middle school students in fractions and operations with fractions. For this purpose, the case study model, which is a qualitative research design, was used in the research. In the study, maximum diversity sampling, which is a purposeful sampling method,…

  11. Medication errors: definitions and classification (United States)

    Aronson, Jeffrey K


    To understand medication errors and to identify preventive strategies, we need to classify them and define the terms that describe them. The four main approaches to defining technical terms consider etymology, usage, previous definitions, and the Ramsey–Lewis method (based on an understanding of theory and practice). A medication error is ‘a failure in the treatment process that leads to, or has the potential to lead to, harm to the patient’. Prescribing faults, a subset of medication errors, should be distinguished from prescription errors. A prescribing fault is ‘a failure in the prescribing [decision-making] process that leads to, or has the potential to lead to, harm to the patient’. The converse of this, ‘balanced prescribing’ is ‘the use of a medicine that is appropriate to the patient's condition and, within the limits created by the uncertainty that attends therapeutic decisions, in a dosage regimen that optimizes the balance of benefit to harm’. This excludes all forms of prescribing faults, such as irrational, inappropriate, and ineffective prescribing, underprescribing and overprescribing. A prescription error is ‘a failure in the prescription writing process that results in a wrong instruction about one or more of the normal features of a prescription’. The ‘normal features’ include the identity of the recipient, the identity of the drug, the formulation, dose, route, timing, frequency, and duration of administration. Medication errors can be classified, invoking psychological theory, as knowledge-based mistakes, rule-based mistakes, action-based slips, and memory-based lapses. This classification informs preventive strategies. PMID:19594526

  12. Analysis of Medication Error Reports

    Energy Technology Data Exchange (ETDEWEB)

    Whitney, Paul D.; Young, Jonathan; Santell, John; Hicks, Rodney; Posse, Christian; Fecht, Barbara A.


    In medicine, as in many areas of research, technological innovation and the shift from paper based information to electronic records has created a climate of ever increasing availability of raw data. There has been, however, a corresponding lag in our abilities to analyze this overwhelming mass of data, and classic forms of statistical analysis may not allow researchers to interact with data in the most productive way. This is true in the emerging area of patient safety improvement. Traditionally, a majority of the analysis of error and incident reports has been carried out based on an approach of data comparison, and starts with a specific question which needs to be answered. Newer data analysis tools have been developed which allow the researcher to not only ask specific questions but also to “mine” data: approach an area of interest without preconceived questions, and explore the information dynamically, allowing questions to be formulated based on patterns brought up by the data itself. Since 1991, United States Pharmacopeia (USP) has been collecting data on medication errors through voluntary reporting programs. USP’s MEDMARXsm reporting program is the largest national medication error database and currently contains well over 600,000 records. Traditionally, USP has conducted an annual quantitative analysis of data derived from “pick-lists” (i.e., items selected from a list of items) without an in-depth analysis of free-text fields. In this paper, the application of text analysis and data analysis tools used by Battelle to analyze the medication error reports already analyzed in the traditional way by USP is described. New insights and findings were revealed including the value of language normalization and the distribution of error incidents by day of the week. The motivation for this effort is to gain additional insight into the nature of medication errors to support improvements in medication safety.


    Directory of Open Access Journals (Sweden)

    Alexey M. Nazarenko


    Full Text Available Simulation experiments performed while solving multidisciplinary engineering and scientific problems require joint usage of multiple software tools. Further, when following a preset plan of experiment or searching for optimum solu- tions, the same sequence of calculations is run multiple times with various simulation parameters, input data, or conditions while overall workflow does not change. Automation of simulations like these requires implementing of a workflow where tool execution and data exchange is usually controlled by a special type of software, an integration environment or plat- form. The result is an integration workflow (a platform-dependent implementation of some computing workflow which, in the context of automation, is a composition of weakly coupled (in terms of communication intensity typical subtasks. These compositions can then be decomposed back into a few workflow patterns (types of subtasks interaction. The pat- terns, in their turn, can be interpreted as higher level subtasks.This paper considers execution control and data exchange rules that should be imposed by the integration envi- ronment in the case of an error encountered by some integrated software tool. An error is defined as any abnormal behavior of a tool that invalidates its result data thus disrupting the data flow within the integration workflow. The main requirementto the error handling mechanism implemented by the integration environment is to prevent abnormal termination of theentire workflow in case of missing intermediate results data. Error handling rules are formulated on the basic pattern level and on the level of a composite task that can combine several basic patterns as next level subtasks. The cases where workflow behavior may be different, depending on user's purposes, when an error takes place, and possible error handling op- tions that can be specified by the user are also noted in the work.

  14. Are Divorce Studies Trustworthy? The Effects of Survey Nonresponse and Response Errors


    Mitchell, Colter


    Researchers rely on relationship data to measure the multifaceted nature of families. This article speaks to relationship data quality by examining the ramifications of different types of error on divorce estimates, models predicting divorce behavior, and models employing divorce as a predictor. Comparing matched survey and divorce certificate information from the 1995 Life Events and Satisfaction Study (N = 1,811) showed that nonresponse error is responsible for the majority of the error in ...

  15. Error or "act of God"? A study of patients' and operating room team members' perceptions of error definition, reporting, and disclosure. (United States)

    Espin, Sherry; Levinson, Wendy; Regehr, Glenn; Baker, G Ross; Lingard, Lorelei


    Calls abound for a culture change in health care to improve patient safety. However, effective change cannot proceed without a clear understanding of perceptions and beliefs about error. In this study, we describe and compare operative team members' and patients' perceptions of error, reporting of error, and disclosure of error. Thirty-nine interviews of team members (9 surgeons, 9 nurses, 10 anesthesiologists) and patients (11) were conducted at 2 teaching hospitals using 4 scenarios as prompts. Transcribed responses to open questions were analyzed by 2 researchers for recurrent themes using the grounded-theory method. Yes/no answers were compared across groups using chi-square analyses. Team members and patients agreed on what constitutes an error. Deviation from standards and negative outcome were emphasized as definitive features. Patients and nurse professionals differed significantly in their perception of whether errors should be reported. Nurses were willing to report only events within their disciplinary scope of practice. Although most patients strongly advocated full disclosure of errors (what happened and how), team members preferred to disclose only what happened. When patients did support partial disclosure, their rationales varied from that of team members. Both operative teams and patients define error in terms of breaking the rules and the concept of "no harm no foul." These concepts pose challenges for treating errors as system failures. A strong culture of individualism pervades nurses' perception of error reporting, suggesting that interventions are needed to foster collective responsibility and a constructive approach to error identification.

  16. Human Error and Organizational Management

    Directory of Open Access Journals (Sweden)

    Alecxandrina DEACONU


    Full Text Available The concern for performance is a topic that raises interest in the businessenvironment but also in other areas that – even if they seem distant from thisworld – are aware of, interested in or conditioned by the economy development.As individual performance is very much influenced by the human resource, wechose to analyze in this paper the mechanisms that generate – consciously or not–human error nowadays.Moreover, the extremely tense Romanian context,where failure is rather a rule than an exception, made us investigate thephenomenon of generating a human error and the ways to diminish its effects.

  17. Sexual Assault Characteristics and Perceptions of Event-Related Distress. (United States)

    Blayney, Jessica A; Read, Jennifer P


    Sexual assault (SA) is a potent psychological stressor, linked to harmful mental health outcomes in both the short- and long-term. Specific assault characteristics can add to the toxicity of SA events. Although research has assessed characteristics of the assault itself (e.g., force, penetration), few studies have examined the larger socioenvironmental context in which SA takes place. This was the purpose of the present study. Young adults (N = 220; 80% female; 54% current students) reported on their most recent SA during college. Cross-sectional associations were tested via structural equation modeling to determine the contributions of socioenvironmental context and assault characteristics in predicting event-related distress. Socioenvironmental context from the most recent assault included assault setting, intoxication at the time of the assault, perpetrator relationship, and prior consensual sexual experiences with the perpetrator. We also examined assault characteristics, including physical force and penetration. Participants reported how upsetting the most recent assault was (a) at the time it occurred and (b) currently. Results revealed differential patterns for socioenvironmental context and assault characteristics based on the timing of distress (past or present). Notably, many of the socioenvironmental factors showed associations with distress above and beyond the powerful effects of physical force and penetration. These findings have important implications for our understanding of the unique factors that contribute to and maintain psychological distress in sexually victimized young adults. © The Author(s) 2015.

  18. The valuation error in the compound values

    Directory of Open Access Journals (Sweden)

    Marina Ciuna


    Full Text Available In appraising the “valore di trasformazione” the valuation error is composed by the error on market value and the error on construction cost.  In appraising the “valore complementare” the valuation error is composed by the error on market value of complex real property and on market value of the residual part. The final error is a function of the partial errors and it can be studied using estimative and market ratios. The application of the compounds values to real estate appraisal misleads unacceptable errors if carried out with the expertise.

  19. Errors in laparoscopic surgery: what surgeons should know. (United States)

    Galleano, R; Franceschi, A; Ciciliot, M; Falchero, F; Cuschieri, A


    Some two decades after its introduction, minimal access surgery (MAS) is still evolving. Undoubtedly, its significant uptake world wide is due to its clinical benefits to patient outcome. These benefits include reduced traumatic insult, reduction of pain, earlier return to bowel function, decrease disability, shorter hospitalization and better cosmetic results. Nonetheless complications due to the laparoscopic approach are not rare as documented by several studies on task specific or procedure related MAS morbidity. In all these instances, error analysis research has demonstrated that an understanding of the underlying causes of these complications requires a comprehensive approach addressing the entire system related to the procedure for identification and characterization of the errors ultimately responsible for the morbidity. The present review covers definition, taxonomy and incidence of errors in medicine with special reference to MAS. In addition, possible root causes of adverse events in laparoscopy are explored and existing methods to study errors are reviewed. Finally specific areas requiring further human factors research to enhance safety of patients undergoing laparoscopic operations are identified. The hope is that awareness of causes and mechanisms of errors may reduce incidence of errors in clinical practice for the final benefit of the patients.

  20. Latent error detection: A golden two hours for detection. (United States)

    Saward, Justin R E; Stanton, Neville A


    Undetected error in safety critical contexts generates a latent condition that can contribute to a future safety failure. The detection of latent errors post-task completion is observed in naval air engineers using a diary to record work-related latent error detection (LED) events. A systems view is combined with multi-process theories to explore sociotechnical factors associated with LED. Perception of cues in different environments facilitates successful LED, for which the deliberate review of past tasks within two hours of the error occurring and whilst remaining in the same or similar sociotechnical environment to that which the error occurred appears most effective. Identified ergonomic interventions offer potential mitigation for latent errors; particularly in simple everyday habitual tasks. It is thought safety critical organisations should look to engineer further resilience through the application of LED techniques that engage with system cues across the entire sociotechnical environment, rather than relying on consistent human performance. Crown Copyright © 2016. Published by Elsevier Ltd. All rights reserved.

  1. Error monitoring is related to processing internal affective states. (United States)

    Maier, Martin E; Scarpazza, Cristina; Starita, Francesca; Filogamo, Roberto; Làdavas, Elisabetta


    Detecting behavioral errors is critical for optimizing performance. Here, we tested whether error monitoring is enhanced in emotional task contexts, and whether this enhancement depends on processing internal affective states. Event-related potentials were recorded in individuals with low and high levels of alexithymia-that is, individuals with difficulties identifying and describing their feelings. We administered a face word Stroop paradigm (Egner, Etkin, Gale, & Hirsch, 2008) in which the task was to classify emotional faces either with respect to their expression (happy or fearful; emotional task set) or with respect to their gender (female or male; neutral task set). The error-related negativity, a marker of rapid error monitoring, was enhanced in individuals with low alexithymia when they adopted the emotional task set. By contrast, individuals with high alexithymia did not show such an enhancement. Moreover, in the high-alexithymia group, the difference in the error-related negativities between the emotional and neutral task sets correlated negatively with difficulties identifying their own feelings, as measured by the Toronto Alexithymia Scale. These results show that error-monitoring activity is stronger in emotional task contexts and that this enhancement depends on processing internal affective states.

  2. Detecting medication errors in the New Zealand pharmacovigilance database: a retrospective analysis. (United States)

    Kunac, Desireé L; Tatley, Michael V


    Despite the traditional focus being adverse drug reactions (ADRs), pharmacovigilance centres have recently been identified as a potentially rich and important source of medication error data. To identify medication errors in the New Zealand Pharmacovigilance database (Centre for Adverse Reactions Monitoring [CARM]), and to describe the frequency and characteristics of these events. A retrospective analysis of the CARM pharmacovigilance database operated by the New Zealand Pharmacovigilance Centre was undertaken for the year 1 January-31 December 2007. All reports, excluding those relating to vaccines, clinical trials and pharmaceutical company reports, underwent a preventability assessment using predetermined criteria. Those events deemed preventable were subsequently classified to identify the degree of patient harm, type of error, stage of medication use process where the error occurred and origin of the error. A total of 1412 reports met the inclusion criteria and were reviewed, of which 4.3% (61/1412) were deemed preventable. Not all errors resulted in patient harm: 29.5% (18/61) were 'no harm' errors but 65.5% (40/61) of errors were deemed to have been associated with some degree of patient harm (preventable adverse drug events [ADEs]). For 5.0% (3/61) of events, the degree of patient harm was unable to be determined as the patient outcome was unknown. The majority of preventable ADEs (62.5% [25/40]) occurred in adults aged 65 years and older. The medication classes most involved in preventable ADEs were antibacterials for systemic use and anti-inflammatory agents, with gastrointestinal and respiratory system disorders the most common adverse events reported. For both preventable ADEs and 'no harm' events, most errors were incorrect dose and drug therapy monitoring problems consisting of failures in detection of significant drug interactions, past allergies or lack of necessary clinical monitoring. Preventable events were mostly related to the prescribing and

  3. A Six Sigma Trial For Reduction of Error Rates in Pathology Laboratory. (United States)

    Tosuner, Zeynep; Gücin, Zühal; Kiran, Tuğçe; Büyükpinarbaşili, Nur; Turna, Seval; Taşkiran, Olcay; Arici, Dilek Sema


    A major target of quality assurance is the minimization of error rates in order to enhance patient safety. Six Sigma is a method targeting zero error (3.4 errors per million events) used in industry. The five main principles of Six Sigma are defining, measuring, analysis, improvement and control. Using this methodology, the causes of errors can be examined and process improvement strategies can be identified. The aim of our study was to evaluate the utility of Six Sigma methodology in error reduction in our pathology laboratory. The errors encountered between April 2014 and April 2015 were recorded by the pathology personnel. Error follow-up forms were examined by the quality control supervisor, administrative supervisor and the head of the department. Using Six Sigma methodology, the rate of errors was measured monthly and the distribution of errors at the preanalytic, analytic and postanalytical phases was analysed. Improvement strategies were reclaimed in the monthly intradepartmental meetings and the control of the units with high error rates was provided. Fifty-six (52.4%) of 107 recorded errors in total were at the pre-analytic phase. Forty-five errors (42%) were recorded as analytical and 6 errors (5.6%) as post-analytical. Two of the 45 errors were major irrevocable errors. The error rate was 6.8 per million in the first half of the year and 1.3 per million in the second half, decreasing by 79.77%. The Six Sigma trial in our pathology laboratory provided the reduction of the error rates mainly in the pre-analytic and analytic phases.

  4. Having Fun with Error Analysis (United States)

    Siegel, Peter


    We present a fun activity that can be used to introduce students to error analysis: the M&M game. Students are told to estimate the number of individual candies plus uncertainty in a bag of M&M's. The winner is the group whose estimate brackets the actual number with the smallest uncertainty. The exercise produces enthusiastic discussions and…

  5. and Correlated Error-Regressor

    African Journals Online (AJOL)

    Nekky Umera

    in queuing theory and econometrics, where the usual assumption of independent error terms may not be plausible in most cases. Also, when using time-series data on a number of micro-economic units, such as households and service oriented channels, where the stochastic disturbance terms in part reflect variables which ...

  6. Typical errors of ESP users (United States)

    Eremina, Svetlana V.; Korneva, Anna A.


    The paper presents analysis of the errors made by ESP (English for specific purposes) users which have been considered as typical. They occur as a result of misuse of resources of English grammar and tend to resist. Their origin and places of occurrence have also been discussed.

  7. Learner Corpora without Error Tagging

    Directory of Open Access Journals (Sweden)

    Rastelli, Stefano


    Full Text Available The article explores the possibility of adopting a form-to-function perspective when annotating learner corpora in order to get deeper insights about systematic features of interlanguage. A split between forms and functions (or categories is desirable in order to avoid the "comparative fallacy" and because – especially in basic varieties – forms may precede functions (e.g., what resembles to a "noun" might have a different function or a function may show up in unexpected forms. In the computer-aided error analysis tradition, all items produced by learners are traced to a grid of error tags which is based on the categories of the target language. Differently, we believe it is possible to record and make retrievable both words and sequence of characters independently from their functional-grammatical label in the target language. For this purpose at the University of Pavia we adapted a probabilistic POS tagger designed for L1 on L2 data. Despite the criticism that this operation can raise, we found that it is better to work with "virtual categories" rather than with errors. The article outlines the theoretical background of the project and shows some examples in which some potential of SLA-oriented (non error-based tagging will be possibly made clearer.

  8. Serial and spatial error correlation

    NARCIS (Netherlands)

    Elhorst, J. Paul

    This paper demonstrates that jointly modeling serial and spatial error correlation results in a trade-off between the serial and spatial autocorrelation coefficients. Ignoring this trade-off causes inefficiency and may lead to nonstationarity. (C) 2008 Elsevier B.V. All rights reserved.

  9. Finding errors in big data

    NARCIS (Netherlands)

    Puts, Marco; Daas, Piet; de Waal, A.G.

    No data source is perfect. Mistakes inevitably creep in. Spotting errors is hard enough when dealing with survey responses from several thousand people, but the difficulty is multiplied hugely when that mysterious beast Big Data comes into play. Statistics Netherlands is about to publish its first

  10. Magnitude control of commutator errors

    NARCIS (Netherlands)

    Geurts, Bernardus J.; Wesseling, P.; Oñate, E.; Périaux, J.


    Non-uniform filtering of the Navier-Stokes equations expresses itself, next to the turbulent stresses, in additional closure terms known as commutator errors. These terms require explicit subgrid modeling if the non-uniformity of the filter is sufficiently pronounced. We derive expressions for the

  11. Theory of Test Translation Error (United States)

    Solano-Flores, Guillermo; Backhoff, Eduardo; Contreras-Nino, Luis Angel


    In this article, we present a theory of test translation whose intent is to provide the conceptual foundation for effective, systematic work in the process of test translation and test translation review. According to the theory, translation error is multidimensional; it is not simply the consequence of defective translation but an inevitable fact…

  12. Error signals driving locomotor adaptation

    DEFF Research Database (Denmark)

    Choi, Julia T; Jensen, Peter; Nielsen, Jens Bo


    anaesthesia (n = 5) instead of repetitive nerve stimulation. Foot anaesthesia reduced ankle adaptation to external force perturbations during walking. Our results suggest that cutaneous input plays a role in force perception, and may contribute to the 'error' signal involved in driving walking adaptation when...

  13. What Is a Reading Error? (United States)

    Labov, William; Baker, Bettina


    Early efforts to apply knowledge of dialect differences to reading stressed the importance of the distinction between differences in pronunciation and mistakes in reading. This study develops a method of estimating the probability that a given oral reading that deviates from the text is a true reading error by observing the semantic impact of the…

  14. Error Detection in Numeric Codes

    Indian Academy of Sciences (India)


    engineering at IIT Patna. His interests include watching and playing cricket, listening to music and playing sitar. His research interests include cryptography and pattern recognition. This article investigates the e±ciency of four com- monly used methods for detecting the most fre- quent types of errors committed by individuals.

  15. Error and its meaning in forensic science. (United States)

    Christensen, Angi M; Crowder, Christian M; Ousley, Stephen D; Houck, Max M


    The discussion of "error" has gained momentum in forensic science in the wake of the Daubert guidelines and has intensified with the National Academy of Sciences' Report. Error has many different meanings, and too often, forensic practitioners themselves as well as the courts misunderstand scientific error and statistical error rates, often confusing them with practitioner error (or mistakes). Here, we present an overview of these concepts as they pertain to forensic science applications, discussing the difference between practitioner error (including mistakes), instrument error, statistical error, and method error. We urge forensic practitioners to ensure that potential sources of error and method limitations are understood and clearly communicated and advocate that the legal community be informed regarding the differences between interobserver errors, uncertainty, variation, and mistakes. © 2013 American Academy of Forensic Sciences.

  16. Search for gamma-ray events in the BATSE data base (United States)

    Lewin, Walter


    We find large location errors and error radii in the locations of channel 1 Cygnus X-1 events. These errors and their associated uncertainties are a result of low signal-to-noise ratios (a few sigma) in the two brightest detectors for each event. The untriggered events suffer from similarly low signal-to-noise ratios, and their location errors are expected to be at least as large as those found for Cygnus X-1 with a given signal-to-noise ratio. The statistical error radii are consistent with those found for Cygnus X-1 and with the published estimates. We therefore expect approximately 20 - 30 deg location errors for the untriggered events. Hence, many of the untriggered events occurring within a few months of the triggered activity from SGR 1900 plus 14 are indeed consistent with the SGR source location, although Cygnus X-1 is also a good candidate.

  17. A technique for human error analysis (ATHEANA)

    Energy Technology Data Exchange (ETDEWEB)

    Cooper, S.E.; Ramey-Smith, A.M.; Wreathall, J.; Parry, G.W. [and others


    Probabilistic risk assessment (PRA) has become an important tool in the nuclear power industry, both for the Nuclear Regulatory Commission (NRC) and the operating utilities. Human reliability analysis (HRA) is a critical element of PRA; however, limitations in the analysis of human actions in PRAs have long been recognized as a constraint when using PRA. A multidisciplinary HRA framework has been developed with the objective of providing a structured approach for analyzing operating experience and understanding nuclear plant safety, human error, and the underlying factors that affect them. The concepts of the framework have matured into a rudimentary working HRA method. A trial application of the method has demonstrated that it is possible to identify potentially significant human failure events from actual operating experience which are not generally included in current PRAs, as well as to identify associated performance shaping factors and plant conditions that have an observable impact on the frequency of core damage. A general process was developed, albeit in preliminary form, that addresses the iterative steps of defining human failure events and estimating their probabilities using search schemes. Additionally, a knowledge- base was developed which describes the links between performance shaping factors and resulting unsafe actions.

  18. How trainees would disclose medical errors: educational implications for training programmes. (United States)

    White, Andrew A; Bell, Sigall K; Krauss, Melissa J; Garbutt, Jane; Dunagan, W Claiborne; Fraser, Victoria J; Levinson, Wendy; Larson, Eric B; Gallagher, Thomas H


    The disclosure of harmful errors to patients is recommended, but appears to be uncommon. Understanding how trainees disclose errors and how their practices evolve during training could help educators design programmes to address this gap. This study was conducted to determine how trainees would disclose medical errors. We surveyed 758 trainees (488 students and 270 residents) in internal medicine at two academic medical centres. Surveys depicted one of two harmful error scenarios that varied by how apparent the error would be to the patient. We measured attitudes and disclosure content using scripted responses. Trainees reported their intent to disclose the error as 'definitely' (43%), 'probably' (47%), 'only if asked by patient' (9%), and 'definitely not' (1%). Trainees were more likely to disclose obvious errors than errors that patients were unlikely to recognise (55% versus 30%; p error rather than only an adverse event had occurred. Regarding apologies, trainees were split between conveying a general expression of regret (52%) and making an explicit apology (46%). Respondents at higher levels of training were less likely to use explicit apologies (trend p errors (odds ratio 1.40, p = 0.03). Trainees may not be prepared to disclose medical errors to patients and worrisome trends in trainee apology practices were observed across levels of training. Medical educators should intensify efforts to enhance trainees' skills in meeting patients' expectations for the open disclosure of harmful medical errors. © Blackwell Publishing Ltd 2011.

  19. The Sources of Error in Spanish Writing. (United States)

    Justicia, Fernando; Defior, Sylvia; Pelegrina, Santiago; Martos, Francisco J.


    Determines the pattern of errors in Spanish spelling. Analyzes and proposes a classification system for the errors made by children in the initial stages of the acquisition of spelling skills. Finds the diverse forms of only 20 Spanish words produces 36% of the spelling errors in Spanish; and substitution is the most frequent type of error. (RS)

  20. Error Analysis of Band Matrix Method


    Taniguchi, Takeo; Soga, Akira


    Numerical error in the solution of the band matrix method based on the elimination method in single precision is investigated theoretically and experimentally, and the behaviour of the truncation error and the roundoff error is clarified. Some important suggestions for the useful application of the band solver are proposed by using the results of above error analysis.

  1. Error Correction in Oral Classroom English Teaching (United States)

    Jing, Huang; Xiaodong, Hao; Yu, Liu


    As is known to all, errors are inevitable in the process of language learning for Chinese students. Should we ignore students' errors in learning English? In common with other questions, different people hold different opinions. All teachers agree that errors students make in written English are not allowed. For the errors students make in oral…

  2. Pathologists' Perspectives on Disclosing Harmful Pathology Error. (United States)

    Dintzis, Suzanne M; Clennon, Emily K; Prouty, Carolyn D; Reich, Lisa M; Elmore, Joann G; Gallagher, Thomas H


    - Medical errors are unfortunately common. The US Institute of Medicine proposed guidelines for mitigating and disclosing errors. Implementing these recommendations in pathology will require a better understanding of how errors occur in pathology, the relationship between pathologists and treating clinicians in reducing error, and pathologists' experiences with and attitudes toward disclosure of medical error. - To understand pathologists' attitudes toward disclosing pathology error to treating clinicians and patients. - We conducted 5 structured focus groups in Washington State and Missouri with 45 pathologists in academic and community practice. Participants were questioned about pathology errors, how clinicians respond to pathology errors, and what roles pathologists should play in error disclosure to patients. - These pathologists believe that neither treating physicians nor patients understand the subtleties and limitations of pathologic diagnoses, which complicates discussions about pathology errors. Pathologists' lack of confidence in communication skills and fear of being misrepresented or misunderstood are major barriers to their participation in disclosure discussions. Pathologists see potential for their future involvement in disclosing error to patients, but at present advocate reliance on treating clinicians to disclose pathology errors to patients. Most group members believed that going forward pathologists should offer to participate more actively in error disclosure to patients. - Pathologists lack confidence in error disclosure communication skills with both treating physicians and patients. Improved communication between pathologists and treating physicians could enhance transparency and promote disclosure of pathology errors. Consensus guidelines for best practices in pathology error disclosure may be useful.

  3. Correction of errors in power measurements

    DEFF Research Database (Denmark)

    Pedersen, Knud Ole Helgesen


    Small errors in voltage and current measuring transformers cause inaccuracies in power measurements.In this report correction factors are derived to compensate for such errors.......Small errors in voltage and current measuring transformers cause inaccuracies in power measurements.In this report correction factors are derived to compensate for such errors....

  4. Error-Related Psychophysiology and Negative Affect (United States)

    Hajcak, G.; McDonald, N.; Simons, R.F.


    The error-related negativity (ERN/Ne) and error positivity (Pe) have been associated with error detection and response monitoring. More recently, heart rate (HR) and skin conductance (SC) have also been shown to be sensitive to the internal detection of errors. An enhanced ERN has consistently been observed in anxious subjects and there is some…

  5. Total Survey Error for Longitudinal Surveys

    NARCIS (Netherlands)

    Lynn, Peter; Lugtig, P.J.


    This article describes the application of the total survey error paradigm to longitudinal surveys. Several aspects of survey error, and of the interactions between different types of error, are distinct in the longitudinal survey context. Furthermore, error trade-off decisions in survey design and

  6. Climbing fibers predict movement kinematics and performance errors. (United States)

    Streng, Martha L; Popa, Laurentiu S; Ebner, Timothy J


    Requisite for understanding cerebellar function is a complete characterization of the signals provided by complex spike (CS) discharge of Purkinje cells, the output neurons of the cerebellar cortex. Numerous studies have provided insights into CS function, with the most predominant view being that they are evoked by error events. However, several reports suggest that CSs encode other aspects of movements and do not always respond to errors or unexpected perturbations. Here, we evaluated CS firing during a pseudo-random manual tracking task in the monkey (Macaca mulatta). This task provides extensive coverage of the work space and relative independence of movement parameters, delivering a robust data set to assess the signals that activate climbing fibers. Using reverse correlation, we determined feedforward and feedback CSs firing probability maps with position, velocity, and acceleration, as well as position error, a measure of tracking performance. The direction and magnitude of the CS modulation were quantified using linear regression analysis. The major findings are that CSs significantly encode all three kinematic parameters and position error, with acceleration modulation particularly common. The modulation is not related to "events," either for position error or kinematics. Instead, CSs are spatially tuned and provide a linear representation of each parameter evaluated. The CS modulation is largely predictive. Similar analyses show that the simple spike firing is modulated by the same parameters as the CSs. Therefore, CSs carry a broader array of signals than previously described and argue for climbing fiber input having a prominent role in online motor control.NEW & NOTEWORTHY This article demonstrates that complex spike (CS) discharge of cerebellar Purkinje cells encodes multiple parameters of movement, including motor errors and kinematics. The CS firing is not driven by error or kinematic events; instead it provides a linear representation of each

  7. Entropic error-disturbance relations (United States)

    Coles, Patrick; Furrer, Fabian


    We derive an entropic error-disturbance relation for a sequential measurement scenario as originally considered by Heisenberg, and we discuss how our relation could be tested using existing experimental setups. Our relation is valid for discrete observables, such as spin, as well as continuous observables, such as position and momentum. The novel aspect of our relation compared to earlier versions is its clear operational interpretation and the quantification of error and disturbance using entropic quantities. This directly relates the measurement uncertainty, a fundamental property of quantum mechanics, to information theoretical limitations and offers potential applications in for instance quantum cryptography. PC is funded by National Research Foundation Singapore and Ministry of Education Tier 3 Grant ``Random numbers from quantum processes'' (MOE2012-T3-1-009). FF is funded by Japan Society for the Promotion of Science, KAKENHI grant No. 24-02793.

  8. Error studies of Halbach Magnets

    Energy Technology Data Exchange (ETDEWEB)

    Brooks, S. [Brookhaven National Lab. (BNL), Upton, NY (United States)


    These error studies were done on the Halbach magnets for the CBETA “First Girder” as described in note [CBETA001]. The CBETA magnets have since changed slightly to the lattice in [CBETA009]. However, this is not a large enough change to significantly affect the results here. The QF and BD arc FFAG magnets are considered. For each assumed set of error distributions and each ideal magnet, 100 random magnets with errors are generated. These are then run through an automated version of the iron wire multipole cancellation algorithm. The maximum wire diameter allowed is 0.063” as in the proof-of-principle magnets. Initially, 32 wires (2 per Halbach wedge) are tried, then if this does not achieve 1e-­4 level accuracy in the simulation, 48 and then 64 wires. By “1e-4 accuracy”, it is meant the FOM defined by √(Σn≥sextupole an 2+bn 2) is less than 1 unit, where the multipoles are taken at the maximum nominal beam radius, R=23mm for these magnets. The algorithm initially uses 20 convergence interations. If 64 wires does not achieve 1e-­4 accuracy, this is increased to 50 iterations to check for slow converging cases. There are also classifications for magnets that do not achieve 1e-4 but do achieve 1e-3 (FOM ≤ 10 units). This is technically within the spec discussed in the Jan 30, 2017 review; however, there will be errors in practical shimming not dealt with in the simulation, so it is preferable to do much better than the spec in the simulation.


    Directory of Open Access Journals (Sweden)

    Anny Victor Purba


    Full Text Available Medication errors according to the National Coordinating Council Medication Error Reporting and Prevention (NCCMERP are: as any preventable events that may cause or lead to inappropriate medication uses or harm to patients while the medications are in the control of health care professionals, patienst, or consumers. In the United States it was estimated 7,000 deaths every year caused by medication errors, and caused the budget for treatments due to medication errors to almost $ 2 Billion. This research aimed to determine types, frequencies, causes of errors in the pharmaceutical cares and the reporting systems. Data were collected using 4.9% patient names, 5.4% not giving information about the other effects of medicines prospectively for 3 (three months with observation. Prescriptions were taken retrospectively 1 (one month before the data collection. The research was conducted at 4 (four big hospitals and 16 pharmacies in 4 (four cities which had similarities in such errors as 86% prescribers who did not write patients' age, and 48.7% for weight. There were errors on 14.4% directions, 7.4% overdoses, 7.4% wrong dosages, and 1.8% drug interactions in the prescriptions. There were 14.9% no prescriber office addresses and 1.9% miscalculated the amount of medicines. In filling the prescription in pharmacies, 3.9% wrong amounts of divided powder were dispensed, 4.9% wrong names, 34% no precaution about side effects of the medicines. The prevention system is generally as follows: prescriptions are checked for the completeness; checked for patients' name, age, and weight; assessed patients' conditions if having any pregnancies, allergies, diseases and contraceptions. Doubted or unclear prescriptions were confirmed to the prescribers, refused to fill and returned to patients if the prescribers could not be reached. Each step of the process was checked double. If medication error occurs the pharmacist should contact the patient and correct the error

  10. National Special Security Events

    National Research Council Canada - National Science Library

    Reese, Shawn


    ...) as National Special Security Events (NSSE) Beginning in September 1998 through February 2007, there have been 27 events designated as NSSEs Some of these events have included presidential inaugurations, presidential nominating conventions...

  11. Automated Testing with Targeted Event Sequence Generation

    DEFF Research Database (Denmark)

    Jensen, Casper Svenning; Prasad, Mukul R.; Møller, Anders


    Automated software testing aims to detect errors by producing test inputs that cover as much of the application source code as possible. Applications for mobile devices are typically event-driven, which raises the challenge of automatically producing event sequences that result in high coverage....... Some existing approaches use random or model-based testing that largely treats the application as a black box. Other approaches use symbolic execution, either starting from the entry points of the applications or on specific event sequences. A common limitation of the existing approaches...... is that they often fail to reach the parts of the application code that require more complex event sequences. We propose a two-phase technique for automatically finding event sequences that reach a given target line in the application code. The first phase performs concolic execution to build summaries...

  12. Strategy for Syntax Error Recovering

    Directory of Open Access Journals (Sweden)

    Henry F Báez


    Full Text Available This paper describes a new strategy for syntax error recovering for a compiler that does not have instruction separators like ";" or opening and closing brackets like "{" and "}". This strategy is based on 4 steps. 1. Find a set of tokens (called ACEPTA set for each non terminal symbol of the grammar. 2. During the syntax analysis of each non terminal symbol, eliminate the tokens that are not in the ACEPTA set. 3. Eliminate repeated tokens that are not accepted by the grammar, and 4. Complete symbols in the syntax analysis with the hope that the token that has not been erased later will match with a terminal symbol expected by the syntax analyser; otherwise the symbol will be eliminated in some particular productions. The strategy for sintax error recovering is a method that can be used in whatever not ambiguos context free grammar includying those that use instruction separators like ";". It is implemented with an algorithm and it is much more easy to implement than other strategies for syntax error recovering like those based on stacks.

  13. Using Classical Reliability Models and Single Event Upset (SEU) Data to Determine Optimum Implementation Schemes for Triple Modular Redundancy (TMR) in SRAM-Based Field Programmable Gate Array (FPGA) Devices (United States)

    Berg, M.; Kim, H.; Phan, A.; Seidleck, C.; LaBel, K.; Pellish, J.; Campola, M.


    Space applications are complex systems that require intricate trade analyses for optimum implementations. We focus on a subset of the trade process, using classical reliability theory and SEU data, to illustrate appropriate TMR scheme selection.

  14. Human Errors - A Taxonomy for Describing Human Malfunction in Industrial Installations

    DEFF Research Database (Denmark)

    Rasmussen, Jens


    as physiological factors are also taken into consideration. The taxonomy for event analysis, including human malfunction, is presented. Possibilities for the prediction of human error are discussed. The need for careful studies in actual work situations is expressed. Such studies could provide a better......This paper describes the definition and the characteristics of human errors. Different types of human behavior are classified, and their relation to different error mechanisms are analyzed. The effect of conditioning factors related to affective, motivating aspects of the work situation as well...... understanding of the complexity of human error situations as well as the data needed to characterize these situations....

  15. Design Margin Elimination Through Robust Timing Error Detection at Ultra-Low Voltage


    Reyserhove, Hans; Dehaene, Wim


    This paper discusses a timing error masking-aware ARM Cortex M0 microcontroller system. Through in-path timing error detection, operation at the point-of-first-failure is possi- ble without corrupting the pipeline state, effectively eliminat- ing traditional timing margins. Error events are flagged and gathered to allow dynamic voltage scaling. The error-aware microcontroller was implemented in a 40nm CMOS process and realizes ultra-low voltage operation down to 0.29V at 5MHz consuming 12.90p...

  16. Root cause analysis of transfusion error: identifying causes to implement changes. (United States)

    Elhence, Priti; Veena, S; Sharma, Raj Kumar; Chaudhary, R K


    As part of ongoing efforts to improve transfusion safety, an error reporting system was implemented in our hospital-based transfusion medicine unit at a tertiary care medical institute. This system is based on Medical Event Reporting System-Transfusion Medicine (MERS-TM) and collects data on all near miss, no harm, and misadventures related to the transfusion process. Root cause analyses of one such innocuous appearing error demonstrate how weaknesses in the system can be identified to make necessary changes to achieve transfusion safety. The reported error was investigated, classified, coded, and analyzed using MERS-TM prototype, modified and adopted for our institute. The consequent error was a "mistransfusion" but a "no-harm event" as the transfused unit was of the same blood group as the patient. It was a high event severity level error (level 1). Multiple errors preceded the final error at various functional locations in the transfusion process. Human, organizational, and patient-related factors were identified as root causes and corrective actions were initiated to prevent future occurrences. This case illustrates the usefulness of having an error reporting system in hospitals to highlight human and system failures associated with transfusion that may otherwise go unnoticed. Areas can be identified where resources need to be targeted to improve patient safety. © 2010 American Association of Blood Banks.


    Directory of Open Access Journals (Sweden)

    Volodymyr Kharchenko


    Full Text Available Purpose: the aim of this study is to research applied models of air traffic controllers’ errors prevention in terminal control areas (TMA under uncertainty conditions. In this work the theoretical framework descripting safety events and errors of air traffic controllers connected with the operations in TMA is proposed. Methods: optimisation of terminal control area formal description based on the Threat and Error management model and the TMA network model of air traffic flows. Results: the human factors variables associated with safety events in work of air traffic controllers under uncertainty conditions were obtained. The Threat and Error management model application principles to air traffic controller operations and the TMA network model of air traffic flows were proposed. Discussion: Information processing context for preventing air traffic controller errors, examples of threats in work of air traffic controllers, which are relevant for TMA operations under uncertainty conditions.

  18. Statistical analysis with measurement error or misclassification strategy, method and application

    CERN Document Server

    Yi, Grace Y


    This monograph on measurement error and misclassification covers a broad range of problems and emphasizes unique features in modeling and analyzing problems arising from medical research and epidemiological studies. Many measurement error and misclassification problems have been addressed in various fields over the years as well as with a wide spectrum of data, including event history data (such as survival data and recurrent event data), correlated data (such as longitudinal data and clustered data), multi-state event data, and data arising from case-control studies. Statistical Analysis with Measurement Error or Misclassification: Strategy, Method and Application brings together assorted methods in a single text and provides an update of recent developments for a variety of settings. Measurement error effects and strategies of handling mismeasurement for different models are closely examined in combination with applications to specific problems. Readers with diverse backgrounds and objectives can utilize th...

  19. High incidence of medication documentation errors in a Swiss university hospital due to the handwritten prescription process

    Directory of Open Access Journals (Sweden)

    Röder Christoph


    Full Text Available Abstract Background Medication errors have been reported to be a leading cause of death in hospitalized patients. In this study we focused on identifying and quantifying errors in the handwritten drug ordering and dispensing documentation processes which could possibly lead to adverse drug events. Methods We studied 1,934 ordered agents (165 consecutive patients retrospectively for medication documentation errors. Errors were categorized into: Prescribing errors, transcription errors and administration documentation errors on the nurses' medication lists. The legibility of prescriptions was analyzed to explore its possible influence on the error rate in the documentation process. Results Documentation errors occurred in 65 of 1,934 prescribed agents (3.5%. The incidence of patient charts showing at least one error was 43%. Prescribing errors were found 39 times (37%, transcription errors 56 times (53%, and administration documentation errors 10 times (10%. The handwriting readability was rated as good in 2%, moderate in 42%, bad in 52%, and unreadable in 4%. Conclusions This study revealed a high incidence of documentation errors in the traditional handwritten prescription process. Most errors occurred when prescriptions were transcribed into the patients' chart. The readability of the handwritten prescriptions was generally bad. Replacing the traditional handwritten documentation process with information technology could potentially improve the safety in the medication process.

  20. Complexity index (COMIX) and not type of treatment predicts undetected errors in radiotherapy planning and delivery. (United States)

    Morganti, Alessio G; Deodato, Francesco; Zizzari, Simone; Cilla, Savino; Digesu', Cinzia; Macchia, Gabriella; Panunzi, Simona; De Gaetano, Andrea; Piermattei, Angelo; Cellini, Numa; Valentini, Vincenzo


    Quality assurance procedures (QA) may reduce the risk of errors in radiotherapy. The aim of this study was to assess a QA program based on independent check (IC) procedures in patients undergoing 3D, intensity modulated (IMRT) and extracranial stereotactic (ESRT) radiotherapy. IC for set-up (IC1) and for radiotherapy treatments (IC2) was tested on 622 patients over a year. Fifteen events/parameters and 17 parameters were verified by IC1 and IC2, respectively. A third evaluation check (IC3) was performed before treatment. Potential errors were classified based on their magnitude. Incidents involving only incorrect or incomplete documentation were segregated. Treatments were classified based on a complexity index (COMIX). With IC1, 75 documentation incidents and 31 potential errors were checked, and with IC2 111 documentation incidents and 6 potential errors were checked. During the study period 10 errors undetected by standard procedures (IC1, IC2) were detected by chance or by IC3. The incidence of errors and serious errors undetected by standard procedures was 1.6% and 0.6%, respectively. There was no higher incidence of errors undetected in patients undergoing IMRT or ESRT, while there was a higher incidence of errors undetected in more complex treatments (p < 0.001). Systematic QA procedures can reduce the risk of errors. The risk of errors undetected by standard procedures is not correlated with the treatment technological level (3D versus IMRT/ESRT).

  1. Righting errors in writing errors: the Wing and Baddeley (1980) spelling error corpus revisited. (United States)

    Wing, Alan M; Baddeley, Alan D


    We present a new analysis of our previously published corpus of handwriting errors (slips) using the proportional allocation algorithm of Machtynger and Shallice (2009). As previously, the proportion of slips is greater in the middle of the word than at the ends, however, in contrast to before, the proportion is greater at the end than at the beginning of the word. The findings are consistent with the hypothesis of memory effects in a graphemic output buffer.

  2. Detection of error related neuronal responses recorded by electrocorticography in humans during continuous movements.

    Directory of Open Access Journals (Sweden)

    Tomislav Milekovic

    Full Text Available BACKGROUND: Brain-machine interfaces (BMIs can translate the neuronal activity underlying a user's movement intention into movements of an artificial effector. In spite of continuous improvements, errors in movement decoding are still a major problem of current BMI systems. If the difference between the decoded and intended movements becomes noticeable, it may lead to an execution error. Outcome errors, where subjects fail to reach a certain movement goal, are also present during online BMI operation. Detecting such errors can be beneficial for BMI operation: (i errors can be corrected online after being detected and (ii adaptive BMI decoding algorithm can be updated to make fewer errors in the future. METHODOLOGY/PRINCIPAL FINDINGS: Here, we show that error events can be detected from human electrocorticography (ECoG during a continuous task with high precision, given a temporal tolerance of 300-400 milliseconds. We quantified the error detection accuracy and showed that, using only a small subset of 2×2 ECoG electrodes, 82% of detection information for outcome error and 74% of detection information for execution error available from all ECoG electrodes could be retained. CONCLUSIONS/SIGNIFICANCE: The error detection method presented here could be used to correct errors made during BMI operation or to adapt a BMI algorithm to make fewer errors in the future. Furthermore, our results indicate that smaller ECoG implant could be used for error detection. Reducing the size of an ECoG electrode implant used for BMI decoding and error detection could significantly reduce the medical risk of implantation.

  3. Strategies implementation to reduce medicine preparation error rate in neonatal intensive care units. (United States)

    Campino, Ainara; Santesteban, Elena; Pascual, Pilar; Sordo, Beatriz; Arranz, Casilda; Unceta, Maria; Lopez-de-Heredia, Ion


    This study assessed the rate of errors in intravenous medicine preparation at bedside in neonatal intensive care units versus preparation error rate in a hospital pharmacy service before and after several strategies were implemented. We performed a prospective observational study during 2013-2015. Ten Spanish neonatal intensive care units and one hospital pharmacy service participated in the study. Two types of preparation errors were considered, calculation errors and accuracy errors. The study was carried out over three consecutive phases: (1) pre-intervention phase, when medicine preparation samples were collected from neonatal intensive care units and hospital pharmacy service according to their normal clinical practice; (2) intervention phase, when protocol standardisation and educational strategy took place; and (3) post-intervention phase, when new medicine samples were collected after strategy implementation. In neonatal intensive care units, 1.35 % of samples registered calculation errors in pre-intervention phase; no calculation errors were registered in hospital pharmacy service samples. In post-intervention phase, no calculation errors were registered in either group. Accuracy error rate decreased both in neonatal intensive care units (54.7 vs 23 %) and hospital pharmacy service (38.3 vs 14.6 %). Calculation errors can disappear with good standardisation protocols. Decrease in accuracy error depends on good preparation technique and environmental factors. • Medication use is associated with a risk of errors and adverse events. Medication errors are more frequent and have more severe consequences in paediatric patients. • Lack of commercial drug formulations adapted to newborn infants makes medicine preparation process more prone to error. What is New: • Calculation errors are minimising using concentration standard protocols. Preparation rules are essential to ensure the accuracy process. • Environmental conditions affect the accuracy process.

  4. An adaptive orienting theory of error processing. (United States)

    Wessel, Jan R


    The ability to detect and correct action errors is paramount to safe and efficient goal-directed behaviors. Existing work on the neural underpinnings of error processing and post-error behavioral adaptations has led to the development of several mechanistic theories of error processing. These theories can be roughly grouped into adaptive and maladaptive theories. While adaptive theories propose that errors trigger a cascade of processes that will result in improved behavior after error commission, maladaptive theories hold that error commission momentarily impairs behavior. Neither group of theories can account for all available data, as different empirical studies find both impaired and improved post-error behavior. This article attempts a synthesis between the predictions made by prominent adaptive and maladaptive theories. Specifically, it is proposed that errors invoke a nonspecific cascade of processing that will rapidly interrupt and inhibit ongoing behavior and cognition, as well as orient attention toward the source of the error. It is proposed that this cascade follows all unexpected action outcomes, not just errors. In the case of errors, this cascade is followed by error-specific, controlled processing, which is specifically aimed at (re)tuning the existing task set. This theory combines existing predictions from maladaptive orienting and bottleneck theories with specific neural mechanisms from the wider field of cognitive control, including from error-specific theories of adaptive post-error processing. The article aims to describe the proposed framework and its implications for post-error slowing and post-error accuracy, propose mechanistic neural circuitry for post-error processing, and derive specific hypotheses for future empirical investigations. © 2017 Society for Psychophysiological Research.

  5. Human Errors and Bridge Management Systems

    DEFF Research Database (Denmark)

    Thoft-Christensen, Palle; Nowak, A. S.

    Human errors are divided in two groups. The first group contains human errors, which effect the reliability directly. The second group contains human errors, which will not directly effect the reliability of the structure. The methodology used to estimate so-called reliability distributions...... on basis of reliability profiles for bridges without human errors are extended to include bridges with human errors. The first rehabilitation distributions for bridges without and with human errors are combined into a joint first rehabilitation distribution. The methodology presented is illustrated...

  6. Human Error Assessment and Reduction Technique (HEART) and Human Factor Analysis and Classification System (HFACS) (United States)

    Alexander, Tiffaney Miller


    Research results have shown that more than half of aviation, aerospace and aeronautics mishaps incidents are attributed to human error. As a part of Safety within space exploration ground processing operations, the identification and/or classification of underlying contributors and causes of human error must be identified, in order to manage human error. This research provides a framework and methodology using the Human Error Assessment and Reduction Technique (HEART) and Human Factor Analysis and Classification System (HFACS), as an analysis tool to identify contributing factors, their impact on human error events, and predict the Human Error probabilities (HEPs) of future occurrences. This research methodology was applied (retrospectively) to six (6) NASA ground processing operations scenarios and thirty (30) years of Launch Vehicle related mishap data. This modifiable framework can be used and followed by other space and similar complex operations.

  7. Human Error Assessment and Reduction Technique (HEART) and Human Factor Analysis and Classification System (HFACS) (United States)

    Alexander, Tiffaney Miller


    Research results have shown that more than half of aviation, aerospace and aeronautics mishaps incidents are attributed to human error. As a part of Quality within space exploration ground processing operations, the identification and or classification of underlying contributors and causes of human error must be identified, in order to manage human error.This presentation will provide a framework and methodology using the Human Error Assessment and Reduction Technique (HEART) and Human Factor Analysis and Classification System (HFACS), as an analysis tool to identify contributing factors, their impact on human error events, and predict the Human Error probabilities (HEPs) of future occurrences. This research methodology was applied (retrospectively) to six (6) NASA ground processing operations scenarios and thirty (30) years of Launch Vehicle related mishap data. This modifiable framework can be used and followed by other space and similar complex operations.

  8. Disclosure of Harmful Medical Error to Patients: A Review With Recommendations for Pathologists. (United States)

    Heher, Yael K; Dintzis, Suzanne M


    Harmful error is an infrequent but serious challenge in the pathology laboratory. Regulatory bodies and advocacy groups have mandated and encouraged disclosure of error to patients. Many pathologists are interested in participating in disclosure of harmful error but are ill-equipped to do so. This review of the literature with recommendations examines the current state of the patient safety movement and error disclosure as it pertains to pathology and provides a practical and explicit guide for pathologists for who, when, and how to disclose harmful pathology error to patients. The authors provide a definition of harmful pathology error, and the rationale and principles behind effective disclosure are discussed. The changing culture of medicine and its effect on pathology is examined including the trend towards increasing transparency and patient engagement. Related topics are addressed including the management of expected adverse events, barriers to disclosure, and additional resources for the implementation of disclosure programs in pathology.


    Directory of Open Access Journals (Sweden)



    Full Text Available The accounting information is reliable when it does not contain significant errors, is not biasedand accurately represents the transactions and events. In the light of the regulations complying with Europeandirectives, the information is significant if its omission or wrong presentation may influence the decisions users makebased on annual financial statements. Given that the professional practice sees errors in registering or interpretinginformation, as well as omissions and wrong calculations, the Romanian accounting regulations stipulate treatmentsfor correcting errors in compliance with international references. Thus, the correction of the errors corresponding tothe current period is accomplished based on the retained earnings in the case of significant errors or on the currentearnings when the errors are insignificant. The different situations in the professional practice triggered by errorsrequire both knowledge of regulations and professional rationale to be addressed.

  10. Human Error Assessment and Reduction Technique (HEART) and Human Factor Analysis and Classification System (HFACS) (United States)

    Alexander, Tiffaney Miller


    Research results have shown that more than half of aviation, aerospace and aeronautics mishaps/incidents are attributed to human error. As a part of Safety within space exploration ground processing operations, the identification and/or classification of underlying contributors and causes of human error must be identified, in order to manage human error. This research provides a framework and methodology using the Human Error Assessment and Reduction Technique (HEART) and Human Factor Analysis and Classification System (HFACS), as an analysis tool to identify contributing factors, their impact on human error events, and predict the Human Error probabilities (HEPs) of future occurrences. This research methodology was applied (retrospectively) to six (6) NASA ground processing operations scenarios and thirty (30) years of Launch Vehicle related mishap data. This modifiable framework can be used and followed by other space and similar complex operations.

  11. Q-circle measurement error (United States)

    Hearn, Chase P.; Bradshaw, Edward S.


    High-Q lumped and distributed networks near resonance are generally modeled as elementary three element RLC circuits. The widely used Q-circle measurement technique is based on this assumption. It is shown that this assumption can lead to errors when measuring the Q-factor of more complex resonators, particularly when heavily loaded by the external source. In the Q-circle technique, the resonator is assumed to behave as a pure series (or parallel) RLC circuit and the intercept frequencies are found experimentally at which the components of impedance satisfy the absolute value of Im(Z) = Re(Z) (unloaded Q) and absolute value of Im(Z) = Ro+Re(Z) (loaded Q). The Q-factor is then determined as the ratio of the resonant frequency to the intercept bandwidth. This relationship is exact for simple series or parallel RLC circuits, regardless of the Q-factor, but not for more complex circuits. This is shown to be due to the fact that the impedance components of the circuit vary with frequency differently from those in a pure series RLC circuit, causing the Q-factor as determined above to be in error.

  12. Flood basalts and extinction events (United States)

    Stothers, Richard B.


    The largest known effusive eruptions during the Cenozoic and Mesozoic Eras, the voluminous flood basalts, have long been suspected as being associated with major extinctions of biotic species. Despite the possible errors attached to the dates in both time series of events, the significance level of the suspected correlation is found here to be 1 percent to 4 percent. Statistically, extinctions lag eruptions by a mean time interval that is indistinguishable from zero, being much less than the average residual derived from the correlation analysis. Oceanic flood basalts, however, must have had a different biological impact, which is still uncertain owing to the small number of known examples and differing physical factors. Although not all continental flood basalts can have produced major extinction events, the noncorrelating eruptions may have led to smaller marine extinction events that terminated at least some of the less catastrophically ending geologic stages. Consequently, the 26 Myr quasi-periodicity seen in major marine extinctions may be only a sampling effect, rather than a manifestation of underlying periodicity.

  13. Analysis of Employee's Survey for Preventing Human-Errors

    Energy Technology Data Exchange (ETDEWEB)

    Sung, Chanho; Kim, Younggab; Joung, Sanghoun [KHNP Central Research Institute, Daejeon (Korea, Republic of)


    Human errors in nuclear power plant can cause large and small events or incidents. These events or incidents are one of main contributors of reactor trip and might threaten the safety of nuclear plants. To prevent human-errors, KHNP(nuclear power plants) introduced 'Human-error prevention techniques' and have applied the techniques to main parts such as plant operation, operation support, and maintenance and engineering. This paper proposes the methods to prevent and reduce human-errors in nuclear power plants through analyzing survey results which includes the utilization of the human-error prevention techniques and the employees' awareness of preventing human-errors. With regard to human-error prevention, this survey analysis presented the status of the human-error prevention techniques and the employees' awareness of preventing human-errors. Employees' understanding and utilization of the techniques was generally high and training level of employee and training effect on actual works were in good condition. Also, employees answered that the root causes of human-error were due to working environment including tight process, manpower shortage, and excessive mission rather than personal negligence or lack of personal knowledge. Consideration of working environment is certainly needed. At the present time, based on analyzing this survey, the best methods of preventing human-error are personal equipment, training/education substantiality, private mental health check before starting work, prohibit of multiple task performing, compliance with procedures, and enhancement of job site review. However, the most important and basic things for preventing human-error are interests of workers and organizational atmosphere such as communication between managers and workers, and communication between employees and bosses.

  14. An Error Analysis on TFL Learners’ Writings

    Directory of Open Access Journals (Sweden)

    Arif ÇERÇİ


    Full Text Available The main purpose of the present study is to identify and represent TFL learners’ writing errors through error analysis. All the learners started learning Turkish as foreign language with A1 (beginner level and completed the process by taking C1 (advanced certificate in TÖMER at Gaziantep University. The data of the present study were collected from 14 students’ writings in proficiency exams for each level. The data were grouped as grammatical, syntactic, spelling, punctuation, and word choice errors. The ratio and categorical distributions of identified errors were analyzed through error analysis. The data were analyzed through statistical procedures in an effort to determine whether error types differ according to the levels of the students. The errors in this study are limited to the linguistic and intralingual developmental errors

  15. A Comparative Study on Error Analysis

    DEFF Research Database (Denmark)

    Wu, Xiaoli; Zhang, Chun


    students (N= 54 students from LU; and N= 33 students from AU) participating in the studies, among them 44 are 2nd-year students (n=28 from LU and n=16 from AU) and 43 3rd-year students (n=26 from LU and n=17 from AU). Students’ writing samples were first collected and the errors on the use of comparative...... of the grammatical errors with using comparative sentences is developed, which include comparative item-related errors, comparative result-related errors and blend errors. The results further indicate that these errors could attribute to negative L1 transfer and overgeneralization of grammatical rule and structures......Title: A Comparative Study on Error Analysis Subtitle: - Belgian (L1) and Danish (L1) learners’ use of Chinese (L2) comparative sentences in written production Xiaoli Wu, Chun Zhang Abstract: Making errors is an inevitable and necessary part of learning. The collection, classification and analysis...

  16. Cognitive Diagnostic Error in Internal Medicine

    NARCIS (Netherlands)

    C.K.A. van den Berge (Kees)


    textabstractThis thesis focuses on the subject of cognitive diagnostic error in internal medicine; mistakes resulting from flaws in physicians’ reasoning processes. More specifically, this thesis addresses errors caused by confirmation and availability bias. Recently, the potential of cognitive

  17. Game Design Principles based on Human Error

    Directory of Open Access Journals (Sweden)

    Guilherme Zaffari


    Full Text Available This paper displays the result of the authors’ research regarding to the incorporation of Human Error, through design principles, to video game design. In a general way, designers must consider Human Error factors throughout video game interface development; however, when related to its core design, adaptations are in need, since challenge is an important factor for fun and under the perspective of Human Error, challenge can be considered as a flaw in the system. The research utilized Human Error classifications, data triangulation via predictive human error analysis, and the expanded flow theory to allow the design of a set of principles in order to match the design of playful challenges with the principles of Human Error. From the results, it was possible to conclude that the application of Human Error in game design has a positive effect on player experience, allowing it to interact only with errors associated with the intended aesthetics of the game.

  18. Understanding human management of automation errors (United States)

    McBride, Sara E.; Rogers, Wendy A.; Fisk, Arthur D.


    Automation has the potential to aid humans with a diverse set of tasks and support overall system performance. Automated systems are not always reliable, and when automation errs, humans must engage in error management, which is the process of detecting, understanding, and correcting errors. However, this process of error management in the context of human-automation interaction is not well understood. Therefore, we conducted a systematic review of the variables that contribute to error management. We examined relevant research in human-automation interaction and human error to identify critical automation, person, task, and emergent variables. We propose a framework for management of automation errors to incorporate and build upon previous models. Further, our analysis highlights variables that may be addressed through design and training to positively influence error management. Additional efforts to understand the error management process will contribute to automation designed and implemented to support safe and effective system performance. PMID:25383042

  19. Stochastic Event Counter for Discrete-Event Systems Under Unreliable Observations

    Energy Technology Data Exchange (ETDEWEB)

    Tae-Sic Yoo; Humberto E. Garcia


    This paper addresses the issues of counting the occurrence of special events in the framework of partiallyobserved discrete-event dynamical systems (DEDS). First, we develop a noble recursive procedure that updates active counter information state sequentially with available observations. In general, the cardinality of active counter information state is unbounded, which makes the exact recursion infeasible computationally. To overcome this difficulty, we develop an approximated recursive procedure that regulates and bounds the size of active counter information state. Using the approximated active counting information state, we give an approximated minimum mean square error (MMSE) counter. The developed algorithms are then applied to count special routing events in a material flow system.

  20. Compendium of Single Event Effects, Total Ionizing Dose, and Displacement Damage for Candidate Spacecraft Electronics for NASA (United States)

    LaBel, Kenneth A.; OBryan, Martha V.; Chen, Dakai; Campola, Michael J.; Casey, Megan C.; Pellish, Jonathan A.; Lauenstein, Jean-Marie; Wilcox, Edward P.; Topper, Alyson D.; Ladbury, Raymond L.; hide


    We present results and analysis investigating the effects of radiation on a variety of candidate spacecraft electronics to proton and heavy ion induced single event effects (SEE), proton-induced displacement damage (DD), and total ionizing dose (TID). Introduction: This paper is a summary of test results.NASA spacecraft are subjected to a harsh space environment that includes exposure to various types of ionizing radiation. The performance of electronic devices in a space radiation environment is often limited by its susceptibility to single event effects (SEE), total ionizing dose (TID), and displacement damage (DD). Ground-based testing is used to evaluate candidate spacecraft electronics to determine risk to spaceflight applications. Interpreting the results of radiation testing of complex devices is quite difficult. Given the rapidly changing nature of technology, radiation test data are most often application-specific and adequate understanding of the test conditions is critical. Studies discussed herein were undertaken to establish the application-specific sensitivities of candidate spacecraft and emerging electronic devices to single-event upset (SEU), single-event latchup (SEL), single-event gate rupture (SEGR), single-event burnout (SEB), single-event transient (SET), TID, enhanced low dose rate sensitivity (ELDRS), and DD effects.

  1. Cultural Issues in Adverse Event Reporting - An ethnographic study. (United States)

    Harter, Christopher D; Nøhr, Christian


    Adverse event reporting is a frequently used mechanism to establish a learning cycle to avoid future errors. However a precondition is that the potential - as well as the occurred adverse events is reported. This study explores two comparable internal medicine departments to find possible explanations on a differing frequency of adverse event reporting. Ethnographic methods - observation and interviews - are applied to collect data. The analysis reveals specific, but common ways of doing task prioritization and rating of adverse event severity. The interpesonal relationships, however, show significant differences in the two departments and can be the most plausible explanation of the difference in adverse event reporting.

  2. Error Propagation in a System Model (United States)

    Schloegel, Kirk (Inventor); Bhatt, Devesh (Inventor); Oglesby, David V. (Inventor); Madl, Gabor (Inventor)


    Embodiments of the present subject matter can enable the analysis of signal value errors for system models. In an example, signal value errors can be propagated through the functional blocks of a system model to analyze possible effects as the signal value errors impact incident functional blocks. This propagation of the errors can be applicable to many models of computation including avionics models, synchronous data flow, and Kahn process networks.

  3. Protecting weak measurements against systematic errors


    Pang, Shengshi; Alonso, Jose Raul Gonzalez; Brun, Todd A.; Jordan, Andrew N.


    In this work, we consider the systematic error of quantum metrology by weak measurements under decoherence. We derive the systematic error of maximum likelihood estimation in general to the first-order approximation of a small deviation in the probability distribution, and study the robustness of standard weak measurement and postselected weak measurements against systematic errors. We show that, with a large weak value, the systematic error of a postselected weak measurement when the probe u...

  4. Nursing Errors in Intensive Care Unit by Human Error Identification in Systems Tool: A Case Study

    National Research Council Canada - National Science Library

    Nezamodini, Zeynab Sadat; Khodamoradi, Fatemeh; Malekzadeh, Maryam; Vaziri, Hossein


    ...’ community that are preventable and require serious attention. Objectives The current study aimed to identify possible nursing errors applying human error identification in systems tool (HEIST...

  5. Episodes, events, and models

    Directory of Open Access Journals (Sweden)

    Sangeet eKhemlani


    Full Text Available We describe a novel computational theory of how individuals segment perceptual information into representations of events. The theory is inspired by recent findings in the cognitive science and cognitive neuroscience of event segmentation. In line with recent theories, it holds that online event segmentation is automatic, and that event segmentation yields mental simulations of events. But it posits two novel principles as well: first, discrete episodic markers track perceptual and conceptual changes, and can be retrieved to construct event models. Second, the process of retrieving and reconstructing those episodic markers is constrained and prioritized. We describe a computational implementation of the theory, as well as a robotic extension of the theory that demonstrates the processes of online event segmentation and event model construction. The theory is the first unified computational account of event segmentation and temporal inference. We conclude by demonstrating now neuroimaging data can constrain and inspire the construction of process-level theories of human reasoning.

  6. Amphetamine increases errors during episodic memory retrieval. (United States)

    Ballard, Michael Edward; Gallo, David A; de Wit, Harriet


    Moderate doses of stimulant drugs are known to enhance memory encoding and consolidation, but their effects on memory retrieval have not been explored in depth. In laboratory animals, stimulants seem to improve retrieval of emotional memories, but comparable studies have not been carried out in humans. In the present study, we examined the effects of dextroamphetamine (AMP) on retrieval of emotional and unemotional stimuli in healthy young adults, using doses that enhanced memory formation when administered before encoding in our previous study. During 3 sessions, healthy volunteers (n = 31) received 2 doses of AMP (10 and 20 mg) and placebo in counterbalanced order under double-blind conditions. During each session, they first viewed emotional and unemotional pictures and words in a drug-free state, and then 2 days later their memory was tested, 1 hour after AMP or placebo administration. Dextroamphetamine did not affect the number of emotional or unemotional stimuli remembered, but both doses increased recall intrusions and false recognition. Dextroamphetamine (20 mg) also increased the number of positively rated picture descriptions and words generated during free recall. These data provide the first evidence that therapeutic range doses of stimulant drugs can increase memory retrieval errors. The ability of AMP to positively bias recollection of prior events could contribute to its potential for abuse.

  7. Error Analysis and the EFL Classroom Teaching (United States)

    Xie, Fang; Jiang, Xue-mei


    This paper makes a study of error analysis and its implementation in the EFL (English as Foreign Language) classroom teaching. It starts by giving a systematic review of the concepts and theories concerning EA (Error Analysis), the various reasons causing errors are comprehensively explored. The author proposes that teachers should employ…

  8. Error Analysis in Mathematics. Technical Report #1012 (United States)

    Lai, Cheng-Fei


    Error analysis is a method commonly used to identify the cause of student errors when they make consistent mistakes. It is a process of reviewing a student's work and then looking for patterns of misunderstanding. Errors in mathematics can be factual, procedural, or conceptual, and may occur for a number of reasons. Reasons why students make…

  9. Acoustic Evidence for Phonologically Mismatched Speech Errors (United States)

    Gormley, Andrea


    Speech errors are generally said to accommodate to their new phonological context. This accommodation has been validated by several transcription studies. The transcription methodology is not the best choice for detecting errors at this level, however, as this type of error can be difficult to perceive. This paper presents an acoustic analysis of…


    African Journals Online (AJOL)


    prevalence of refractive error was 3.5% (myopia 2.6% and hyperopia 0.9%). Refractive error was the major cause of visual impairment accounting for 54% of all causes in the study group. No child was found wearing corrective spectacles during the study period. CONCLUSIONS: Refractive error was the commonest cause ...

  11. Systems approach to reduce errors in surgery

    NARCIS (Netherlands)

    Dankelman, J.; Grimbergen, C. A.


    Reducing the number of medical errors significantly is the challenge for the coming decade. In medicine and in surgery, in particular, errors are traditionally treated as being committed by individuals. To reduce human errors, two approaches can be used: the person approach and the systems approach.

  12. Jonas Olson's Evidence for Moral Error Theory

    NARCIS (Netherlands)

    Evers, Daan


    Jonas Olson defends a moral error theory in (2014). I first argue that Olson is not justified in believing the error theory as opposed to moral nonnaturalism in his own opinion. I then argue that Olson is not justified in believing the error theory as opposed to moral contextualism either (although

  13. Diagnostic errors and reflective practice in medicine

    NARCIS (Netherlands)

    S. Mamede (Silvia); H.G. Schmidt (Henk); R.M.J.P. Rikers (Remy)


    textabstractBackground: Adverse effects of medical errors have received increasing attention. Diagnostic errors account for a substantial fraction of all medical errors, and strategies for their prevention have been explored. A crucial requirement for that is better understanding of origins of

  14. Notions of "Error" and Appropriate Corrective Treatment. (United States)

    Lee, Nancy


    The relationship between the notion of "error" in linguistics and language teaching theory and its potential application to error correction in the second language classroom is examined. Definitions of "error" in psycholinguistics, native speech, and English second language instruction are discussed, and the relationship of interlanguage…

  15. Survey of Radar Refraction Error Corrections (United States)


    ELECTRONIC TRAJECTORY MEASUREMENTS GROUP RCC 266-16 SURVEY OF RADAR REFRACTION ERROR CORRECTIONS DISTRIBUTION A: Approved for...DOCUMENT 266-16 SURVEY OF RADAR REFRACTION ERROR CORRECTIONS November 2016 Prepared by Electronic...This page intentionally left blank. Survey of Radar Refraction Error Corrections, RCC 266-16 iii Table of Contents Preface

  16. A vector model for error propagation

    Energy Technology Data Exchange (ETDEWEB)

    Smith, D.L.; Geraldo, L.P.


    A simple vector model for error propagation, which is entirely equivalent to the conventional statistical approach, is discussed. It offers considerable insight into the nature of error propagation while, at the same time, readily demonstrating the significance of uncertainty correlations. This model is well suited to the analysis of error for sets of neutron-induced reaction cross sections. 7 refs., 1 fig.

  17. Measurement error in a single regressor

    NARCIS (Netherlands)

    Meijer, H.J.; Wansbeek, T.J.


    For the setting of multiple regression with measurement error in a single regressor, we present some very simple formulas to assess the result that one may expect when correcting for measurement error. It is shown where the corrected estimated regression coefficients and the error variance may lie,

  18. 40 CFR 97.256 - Account error. (United States)


    ... 40 Protection of Environment 20 2010-07-01 2010-07-01 false Account error. 97.256 Section 97.256... Account error. The Administrator may, at his or her sole discretion and on his or her own motion, correct any error in any CAIR SO2 Allowance Tracking System account. Within 10 business days of making such...

  19. 40 CFR 96.56 - Account error. (United States)


    ... 40 Protection of Environment 20 2010-07-01 2010-07-01 false Account error. 96.56 Section 96.56... Tracking System § 96.56 Account error. The Administrator may, at his or her sole discretion and on his or her own motion, correct any error in any NOX Allowance Tracking System account. Within 10 business...

  20. 40 CFR 97.56 - Account error. (United States)


    ... 40 Protection of Environment 20 2010-07-01 2010-07-01 false Account error. 97.56 Section 97.56... Account error. The Administrator may, at his or her sole discretion and on his or her own motion, correct any error in any NOX Allowance Tracking System account. Within 10 business days of making such...

  1. 40 CFR 97.156 - Account error. (United States)


    ... 40 Protection of Environment 20 2010-07-01 2010-07-01 false Account error. 97.156 Section 97.156... Account error. The Administrator may, at his or her sole discretion and on his or her own motion, correct any error in any CAIR NOX Allowance Tracking System account. Within 10 business days of making such...

  2. 40 CFR 97.356 - Account error. (United States)


    ... 40 Protection of Environment 20 2010-07-01 2010-07-01 false Account error. 97.356 Section 97.356... System § 97.356 Account error. The Administrator may, at his or her sole discretion and on his or her own motion, correct any error in any CAIR NOX Ozone Season Allowance Tracking System account. Within 10...

  3. 40 CFR 96.156 - Account error. (United States)


    ... 40 Protection of Environment 20 2010-07-01 2010-07-01 false Account error. 96.156 Section 96.156... Tracking System § 96.156 Account error. The Administrator may, at his or her sole discretion and on his or her own motion, correct any error in any CAIR NOX Allowance Tracking System account. Within 10...

  4. 40 CFR 73.37 - Account error. (United States)


    ... 40 Protection of Environment 16 2010-07-01 2010-07-01 false Account error. 73.37 Section 73.37... ALLOWANCE SYSTEM Allowance Tracking System § 73.37 Account error. The Administrator may, at his or her sole discretion and on his or her own motion, correct any error in any Allowance Tracking System account. Within...

  5. 40 CFR 96.256 - Account error. (United States)


    ... 40 Protection of Environment 20 2010-07-01 2010-07-01 false Account error. 96.256 Section 96.256... Tracking System § 96.256 Account error. The Administrator may, at his or her sole discretion and on his or her own motion, correct any error in any CAIR SO2 Allowance Tracking System account. Within 10...

  6. Drivers of coupled model ENSO error dynamics and the spring predictability barrier (United States)

    Larson, Sarah M.; Kirtman, Ben P.


    Despite recent improvements in ENSO simulations, ENSO predictions ultimately remain limited by error growth and model inadequacies. Determining the accompanying dynamical processes that drive the growth of certain types of errors may help the community better recognize which error sources provide an intrinsic limit to predictability. This study applies a dynamical analysis to previously developed CCSM4 error ensemble experiments that have been used to model noise-driven error growth. Analysis reveals that ENSO-independent error growth is instigated via a coupled instability mechanism. Daily error fields indicate that persistent stochastic zonal wind stress perturbations (τx^' } ) near the equatorial dateline activate the coupled instability, first driving local SST and anomalous zonal current changes that then induce upwelling anomalies and a clear thermocline response. In particular, March presents a window of opportunity for stochastic τx^' } to impose a lasting influence on the evolution of eastern Pacific SST through December, suggesting that stochastic τx^' } is an important contributor to the spring predictability barrier. Stochastic winds occurring in other months only temporarily affect eastern Pacific SST for 2-3 months. Comparison of a control simulation with an ENSO cycle and the ENSO-independent error ensemble experiments reveals that once the instability is initiated, the subsequent error growth is modulated via an ENSO-like mechanism, namely the seasonal strength of the Bjerknes feedback. Furthermore, unlike ENSO events that exhibit growth through the fall, the growth of ENSO-independent SST errors terminates once the seasonal strength of the Bjerknes feedback weakens in fall. Results imply that the heat content supplied by the subsurface precursor preceding the onset of an ENSO event is paramount to maintaining the growth of the instability (or event) through fall.

  7. Single Event Effects Testing of the Linfinity SG1525A Pulse Width Modulator Controller (United States)

    Howard, J. W., Jr.; Carts, M. A.; LaBel, K. A.; Forney, J. D.; Irwin, T. L.


    Pulse Width Modulator (PWM) Controllers are the heart of switching power supply systems in development today. The PWMs considered here have the same integration advantages as many other controllers but it also includes the interface drivers for the follow-on power Field Effect Transistors (FET). Previous work on these types of devices looked into the required test methodologies [ 11 and the impact of radiation on the soft start and shutdown circuits of typically incorporated in the technology [2]. Taking advantage of this previous work this study was undertaken to determine the single event destructive and transient susceptibility of the Linfinity SG1525A Pulse Width Modulator Controller. The device was monitored for transient interruptions in the output signals and for destructive events induced by exposing it to a heavy ion beam at the Texas A&M University Cyclotron Single Event Effects Test Facility. After exposing these devices to the beam, a new upset mode has been identified that can lead to catastrophic power supply system failure if this event would occur while drive power FETs off the two device outputs. The devices and the test methods used will be described first. This will be followed by a brief description of the data collected to date (not all data can be presented with the length constraints of the summary) and a summary of the key results.

  8. Estimation of joint position error. (United States)

    Agostini, Valentina; Rosati, Samanta; Balestra, Gabriella; Trucco, Marco; Visconti, Lorenzo; Knaflitz, Marco


    Joint position error (JPE) is frequently used to assess proprioception in rehabilitation and sport science. During position-reposition tests the subject is asked to replicate a specific target angle (e.g. 30° of knee flexion) for a specific number of times. The aim of this study is to find an effective method to estimate JPE from the joint kinematic signal. Forty healthy subjects were tested to assess knee joint position sense. Three different methods of JPE estimation are described and compared using a hierarchical clustering approach. Overall, the 3 methods showed a high degree of similarity, ranging from 88% to 100%. We concluded that it is preferable to use the more user-independent method, in which the operator does not have to manually place "critical" markers.

  9. Bayesian network models for error detection in radiotherapy plans. (United States)

    Kalet, Alan M; Gennari, John H; Ford, Eric C; Phillips, Mark H


    The purpose of this study is to design and develop a probabilistic network for detecting errors in radiotherapy plans for use at the time of initial plan verification. Our group has initiated a multi-pronged approach to reduce these errors. We report on our development of Bayesian models of radiotherapy plans. Bayesian networks consist of joint probability distributions that define the probability of one event, given some set of other known information. Using the networks, we find the probability of obtaining certain radiotherapy parameters, given a set of initial clinical information. A low probability in a propagated network then corresponds to potential errors to be flagged for investigation. To build our networks we first interviewed medical physicists and other domain experts to identify the relevant radiotherapy concepts and their associated interdependencies and to construct a network topology. Next, to populate the network's conditional probability tables, we used the Hugin Expert software to learn parameter distributions from a subset of de-identified data derived from a radiation oncology based clinical information database system. These data represent 4990 unique prescription cases over a 5 year period. Under test case scenarios with approximately 1.5% introduced error rates, network performance produced areas under the ROC curve of 0.88, 0.98, and 0.89 for the lung, brain and female breast cancer error detection networks, respectively. Comparison of the brain network to human experts performance (AUC of 0.90 ± 0.01) shows the Bayes network model performs better than domain experts under the same test conditions. Our results demonstrate the feasibility and effectiveness of comprehensive probabilistic models as part of decision support systems for improved detection of errors in initial radiotherapy plan verification procedures.

  10. Left neglect dyslexia: Perseveration and reading error types. (United States)

    Ronchi, Roberta; Algeri, Lorella; Chiapella, Laura; Gallucci, Marcello; Spada, Maria Simonetta; Vallar, Giuseppe


    Right-brain-damaged patients may show a reading disorder termed neglect dyslexia. Patients with left neglect dyslexia omit letters on the left-hand-side (the beginning, when reading left-to-right) part of the letter string, substitute them with other letters, and add letters to the left of the string. The aim of this study was to investigate the pattern of association, if any, between error types in patients with left neglect dyslexia and recurrent perseveration (a productive visuo-motor deficit characterized by addition of marks) in target cancellation. Specifically, we aimed at assessing whether different productive symptoms (relative to the reading and the visuo-motor domains) could be associated in patients with left spatial neglect. Fifty-four right-brain-damaged patients took part in the study: 50 out of the 54 patients showed left spatial neglect, with 27 of them also exhibiting left neglect dyslexia. Neglect dyslexic patients who showed perseveration produced mainly substitution neglect errors in reading. Conversely, omissions were the prevailing reading error pattern in neglect dyslexic patients without perseveration. Addition reading errors were much infrequent. Different functional pathological mechanisms may underlie omission and substitution reading errors committed by right-brain-damaged patients with left neglect dyslexia. One such mechanism, involving the defective stopping of inappropriate responses, may contribute to both recurrent perseveration in target cancellation, and substitution errors in reading. Productive pathological phenomena, together with deficits of spatial attention to events taking place on the left-hand-side of space, shape the manifestations of neglect dyslexia, and, more generally, of spatial neglect. Copyright © 2016 Elsevier Ltd. All rights reserved.

  11. Bayesian network models for error detection in radiotherapy plans (United States)

    Kalet, Alan M.; Gennari, John H.; Ford, Eric C.; Phillips, Mark H.


    The purpose of this study is to design and develop a probabilistic network for detecting errors in radiotherapy plans for use at the time of initial plan verification. Our group has initiated a multi-pronged approach to reduce these errors. We report on our development of Bayesian models of radiotherapy plans. Bayesian networks consist of joint probability distributions that define the probability of one event, given some set of other known information. Using the networks, we find the probability of obtaining certain radiotherapy parameters, given a set of initial clinical information. A low probability in a propagated network then corresponds to potential errors to be flagged for investigation. To build our networks we first interviewed medical physicists and other domain experts to identify the relevant radiotherapy concepts and their associated interdependencies and to construct a network topology. Next, to populate the network’s conditional probability tables, we used the Hugin Expert software to learn parameter distributions from a subset of de-identified data derived from a radiation oncology based clinical information database system. These data represent 4990 unique prescription cases over a 5 year period. Under test case scenarios with approximately 1.5% introduced error rates, network performance produced areas under the ROC curve of 0.88, 0.98, and 0.89 for the lung, brain and female breast cancer error detection networks, respectively. Comparison of the brain network to human experts performance (AUC of 0.90 ± 0.01) shows the Bayes network model performs better than domain experts under the same test conditions. Our results demonstrate the feasibility and effectiveness of comprehensive probabilistic models as part of decision support systems for improved detection of errors in initial radiotherapy plan verification procedures.

  12. Comparing measurement error correction methods for rate-of-change exposure variables in survival analysis. (United States)

    Veronesi, Giovanni; Ferrario, Marco M; Chambless, Lloyd E


    In this article we focus on comparing measurement error correction methods for rate-of-change exposure variables in survival analysis, when longitudinal data are observed prior to the follow-up time. Motivational examples include the analysis of the association between changes in cardiovascular risk factors and subsequent onset of coronary events. We derive a measurement error model for the rate of change, estimated through subject-specific linear regression, assuming an additive measurement error model for the time-specific measurements. The rate of change is then included as a time-invariant variable in a Cox proportional hazards model, adjusting for the first time-specific measurement (baseline) and an error-free covariate. In a simulation study, we compared bias, standard deviation and mean squared error (MSE) for the regression calibration (RC) and the simulation-extrapolation (SIMEX) estimators. Our findings indicate that when the amount of measurement error is substantial, RC should be the preferred method, since it has smaller MSE for estimating the coefficients of the rate of change and of the variable measured without error. However, when the amount of measurement error is small, the choice of the method should take into account the event rate in the population and the effect size to be estimated. An application to an observational study, as well as examples of published studies where our model could have been applied, are also provided.

  13. Revenue Forecast Errors in the European Union


    Afonso, António; Carvalho, Rui


    In this paper we assess the determinants of revenue forecast errors for the EU-15 between 1999 and 2012, based on the forecasts published bi-annually by the European Commission. Our results show that personal income rate changes increase the revenue forecast errors: for forecasts made in t for t, increases in the corporate tax rate implies a decrease in the revenue forecast errors, in t+1 and t+2. Moreover, an increase in GDP forecast errors decreases revenue errors, whereas an increase in th...

  14. Analysis of errors in forensic science

    Directory of Open Access Journals (Sweden)

    Mingxiao Du


    Full Text Available Reliability of expert testimony is one of the foundations of judicial justice. Both expert bias and scientific errors affect the reliability of expert opinion, which in turn affects the trustworthiness of the findings of fact in legal proceedings. Expert bias can be eliminated by replacing experts; however, it may be more difficult to eliminate scientific errors. From the perspective of statistics, errors in operation of forensic science include systematic errors, random errors, and gross errors. In general, process repetition and abiding by the standard ISO/IEC:17025: 2005, general requirements for the competence of testing and calibration laboratories, during operation are common measures used to reduce errors that originate from experts and equipment, respectively. For example, to reduce gross errors, the laboratory can ensure that a test is repeated several times by different experts. In applying for forensic principles and methods, the Federal Rules of Evidence 702 mandate that judges consider factors such as peer review, to ensure the reliability of the expert testimony. As the scientific principles and methods may not undergo professional review by specialists in a certain field, peer review serves as an exclusive standard. This study also examines two types of statistical errors. As false-positive errors involve a higher possibility of an unfair decision-making, they should receive more attention than false-negative errors.

  15. Model error estimation in ensemble data assimilation

    Directory of Open Access Journals (Sweden)

    S. Gillijns


    Full Text Available A new methodology is proposed to estimate and account for systematic model error in linear filtering as well as in nonlinear ensemble based filtering. Our results extend the work of Dee and Todling (2000 on constant bias errors to time-varying model errors. In contrast to existing methodologies, the new filter can also deal with the case where no dynamical model for the systematic error is available. In the latter case, the applicability is limited by a matrix rank condition which has to be satisfied in order for the filter to exist. The performance of the filter developed in this paper is limited by the availability and the accuracy of observations and by the variance of the stochastic model error component. The effect of these aspects on the estimation accuracy is investigated in several numerical experiments using the Lorenz (1996 model. Experimental results indicate that the availability of a dynamical model for the systematic error significantly reduces the variance of the model error estimates, but has only minor effect on the estimates of the system state. The filter is able to estimate additive model error of any type, provided that the rank condition is satisfied and that the stochastic errors and measurement errors are significantly smaller than the systematic errors. The results of this study are encouraging. However, it remains to be seen how the filter performs in more realistic applications.

  16. Approximate error conjugation gradient minimization methods (United States)

    Kallman, Jeffrey S


    In one embodiment, a method includes selecting a subset of rays from a set of all rays to use in an error calculation for a constrained conjugate gradient minimization problem, calculating an approximate error using the subset of rays, and calculating a minimum in a conjugate gradient direction based on the approximate error. In another embodiment, a system includes a processor for executing logic, logic for selecting a subset of rays from a set of all rays to use in an error calculation for a constrained conjugate gradient minimization problem, logic for calculating an approximate error using the subset of rays, and logic for calculating a minimum in a conjugate gradient direction based on the approximate error. In other embodiments, computer program products, methods, and systems are described capable of using approximate error in constrained conjugate gradient minimization problems.

  17. Advanced hardware design for error correcting codes

    CERN Document Server

    Coussy, Philippe


    This book provides thorough coverage of error correcting techniques. It includes essential basic concepts and the latest advances on key topics in design, implementation, and optimization of hardware/software systems for error correction. The book’s chapters are written by internationally recognized experts in this field. Topics include evolution of error correction techniques, industrial user needs, architectures, and design approaches for the most advanced error correcting codes (Polar Codes, Non-Binary LDPC, Product Codes, etc). This book provides access to recent results, and is suitable for graduate students and researchers of mathematics, computer science, and engineering. • Examines how to optimize the architecture of hardware design for error correcting codes; • Presents error correction codes from theory to optimized architecture for the current and the next generation standards; • Provides coverage of industrial user needs advanced error correcting techniques.

  18. Complications: acknowledging, managing, and coping with human error. (United States)

    Helo, Sevann; Moulton, Carol-Anne E


    Errors are inherent in medicine due to the imperfectness of human nature. Health care providers may have a difficult time accepting their fallibility, acknowledging mistakes, and disclosing errors. Fear of litigation, shame, blame, and concern about reputation are just some of the barriers preventing physicians from being more candid with their patients, despite the supporting body of evidence that patients cite poor communication and lack of transparency as primary drivers to file a lawsuit in the wake of a medical complication. Proper error disclosure includes a timely explanation of what happened, who was involved, why the error occurred, and how it will be prevented in the future. Medical mistakes afford the opportunity for individuals and institutions to be candid about their weaknesses while improving patient care processes. When a physician takes the Hippocratic Oath they take on a tremendous sense of responsibility for the care of their patients, and often bear the burden of their mistakes in isolation. Physicians may struggle with guilt, shame, and a crisis of confidence, which may thwart efforts to identify areas for improvement that can lead to meaningful change. Coping strategies for providers include discussing the event with others, seeking professional counseling, and implementing quality improvement projects. Physicians and health care organizations need to find adaptive ways to deal with complications that will benefit patients, providers, and their institutions.

  19. Differences in medication errors between central and remote site telepharmacies. (United States)

    Scott, David M; Friesner, Daniel L; Rathke, Ann M; Peterson, Charles D; Anderson, Howard C


    To examine differences in dispensing errors within community telepharmacy practices by comparing error rates across central sites (community telepharmacy sites with pharmacists present) and the corresponding remote sites, which are staffed by registered technicians and overseen by the central site pharmacist. Cross-sectional pilot study with a test group (remote sites) and comparison group (central sites). 24 rural community telepharmacies (14 remote sites and 10 central sites). Pharmacy staff. The Pharmacy Quality Commitment (PQC) reporting system was integrated into the North Dakota Telepharmacy Project and used to track dispensing errors over a 45-month period. Both pharmacists and pharmacy technicians were trained on the use of the PQC system. The PQC system focused on two quality-related events (QREs): a "near miss" (i.e., a mistake discovered by the pharmacy staff before a medication reaches the patient) and an "error" (i.e., a mistake discovered after the patient leaves the pharmacy with the medication). The distribution of QREs across central and remote sites. The remote (central) telepharmacy group reported 47,078 (62,480) prescriptions and a QRE rate of 1.34% (1.43%). QREs at the remote sites were more likely than at the central sites to be caught at the final pharmacist check (58.2% vs. 40.8%, P differences between central and remote sites existed based on how QREs arose and how they were caught. Pharmacists must recognize this fact and use diligence when working in a telepharmacy setting.

  20. Error-Induced Blindness: Error Detection Leads to Impaired Sensory Processing and Lower Accuracy at Short Response-Stimulus Intervals. (United States)

    Buzzell, George A; Beatty, Paul J; Paquette, Natalie A; Roberts, Daniel M; McDonald, Craig G


    Empirical evidence indicates that detecting one's own mistakes can serve as a signal to improve task performance. However, little work has focused on how task constraints, such as the response-stimulus interval (RSI), influence post-error adjustments. In the present study, event-related potential (ERP) and behavioral measures were used to investigate the time course of error-related processing while humans performed a difficult visual discrimination task. We found that error commission resulted in a marked reduction in both task performance and sensory processing on the following trial when RSIs were short, but that such impairments were not detectable at longer RSIs. Critically, diminished sensory processing at short RSIs, indexed by the stimulus-evoked P1 component, was predicted by an ERP measure of error processing, the Pe component. A control analysis ruled out a general lapse in attention or mind wandering as being predictive of subsequent reductions in sensory processing; instead, the data suggest that error detection causes an attentional bottleneck, which can diminish sensory processing on subsequent trials that occur in short succession. The findings demonstrate that the neural system dedicated to monitoring and improving behavior can, paradoxically, at times be the source of performance failures. SIGNIFICANCE STATEMENT The performance-monitoring system is a network of brain regions dedicated to monitoring behavior to adjust task performance when necessary. Previous research has demonstrated that activation of the performance monitoring system following incorrect decisions serves to improve future task performance. However, the present study provides evidence that, when perceptual decisions must be made rapidly (within approximately half a second of each other), activation of the performance-monitoring system is predictive of impaired task-related attention on the subsequent trial. The data illustrate that the cognitive demands imposed by error processing

  1. Frecuencia de errores de los pacientes con su medicación Frequency of medication errors by patients

    Directory of Open Access Journals (Sweden)

    José Joaquín Mira


    Full Text Available OBJETIVO: Analizar la frecuencia de errores de medicación que son cometidos e informados por los pacientes. MÉTODOS: Estudio descriptivo basado en encuestas telefónicas a una muestra aleatoria de pacientes adultos del nivel primario de salud del sistema público español. Respondieron un total de 1 247 pacientes (tasa de respuesta, 75%. El 63% eran mujeres y 29% eran mayores de 70 años. RESULTADOS: Mientras 37 pacientes (3%, IC 95%: 2-4 sufrieron complicaciones asociadas a la medicación en el curso del tratamiento, 241 (19,4%, IC 95%: 17-21 informaron haber cometido algún error con la medicación. Un menor tiempo de consulta (P OBJECTIVE: Analyze the frequency of medication errors committed and reported by patients. METHODS: Descriptive study based on a telephone survey of a random sample of adult patients from the primary care level of the Spanish public health care system. A total of 1 247 patients responded (75% response rate; 63% were women and 29% were older than 70 years. RESULTS: While 37 patients (3%, 95% CI: 2-4 experienced complications associated with medication in the course of treatment, 241 (19.4%, 95% CI: 17-21 reported having made some mistake with their medication. A shorter consultation time (P < 0.01 and a worse assessment of the information provided by the physician (P < 0.01 were associated with the fact that during pharmacy dispensing the patient was told that the prescribed treatment was not appropriate. CONCLUSIONS: In addition to the known risks of an adverse event due to a health intervention resulting from a system or practitioner error, there are risks associated with patient errors in the self-administration of medication. Patients who were unsatisfied with the information provided by the physician reported a greater number of errors.

  2. Co-design Events

    DEFF Research Database (Denmark)

    Brandt, Eva; Eriksen, Mette Agger


    One powerful co-design event is worth a thousand hours of individual work! Driving Innovation as a series of co-design events helps mobilize and involve all stakeholders to explore present everyday practices and to sketch new possible futures. But what makes a co-design event powerful? And why...... are series of events better than a sequence of deliverables and milestones in keeping innovation on track?...

  3. Event Modelling in CMS

    CERN Document Server

    Gunnellini, Paolo


    Latest tests of double parton scattering, underlying event tunes, minimum bias, and diffraction made by comparing CMS Run I and Run II data to the state-of-the-art theoretical predictions interfaced with up-to-date parton shower codes are presented. Studies to derive and to test the new CMS event tune obtained through jet kinematics in top quark pair events and global event variables are described.

  4. #JeSuisCharlie: Towards a Multi-Method Study of Hybrid Media Events

    Directory of Open Access Journals (Sweden)

    Johanna Sumiala


    Full Text Available This article suggests a new methodological model for the study of hybrid media events with global appeal. This model, developed in the project on the 2015 Charlie Hebdo attacks in Paris, was created specifically for researching digital media—and in particular, Twitter. The article is structured as follows. Firstly, the methodological scope is discussed against the theoretical context, e.g. the theory of media events. In the theoretical discussion, special emphasis is given to i disruptive, upsetting, or disintegrative media events and hybrid media events and ii the conditions of today’s heterogeneous and globalised media communication landscape. Secondly, the article introduces a multi-method approach developed for the analysis of hybrid media events. In this model, computational social science—namely, automated content analysis (ACA and social network analytics (SNA—are combined with a qualitative approach—specifically, digital ethnography. The article outlines three key phases for research in which the interplay between quantitative and qualitative approaches is played out. In the first phase, preliminary digital ethnography is applied to provide the outline of the event. In the second phase, quantitative social network analytics are applied to construct the digital field for research. In this phase, it is necessary to map a what is circulating on the websites and b where this circulation takes place. The third and final phase applies a qualitative approach and digital ethnography to provide a more nuanced, in-depth interpretation of what (substance/content is circulating and how this material connects with the ‘where’ in the digital landscape, hence constituting links and connections in the hybrid media landscape. In conclusion, the article reflects on how this multi-method approach contributes to understanding the workings of today’s hybrid media events: how they create and maintain symbolic battles over certain imagined

  5. On the Spatial and Temporal Sampling Errors of Remotely Sensed Precipitation Products

    Directory of Open Access Journals (Sweden)

    Ali Behrangi


    Full Text Available Observation with coarse spatial and temporal sampling can cause large errors in quantification of the amount, intensity, and duration of precipitation events. In this study, the errors resulting from temporal and spatial sampling of precipitation events were quantified and examined using the latest version (V4 of the Global Precipitation Measurement (GPM mission integrated multi-satellite retrievals for GPM (IMERG, which is available since spring of 2014. Relative mean square error was calculated at 0.1° × 0.1° every 0.5 h between the degraded (temporally and spatially and original IMERG products. The temporal and spatial degradation was performed by producing three-hour (T3, six-hour (T6, 0.5° × 0.5° (S5, and 1.0° × 1.0° (S10 maps. The results show generally larger errors over land than ocean, especially over mountainous regions. The relative error of T6 is almost 20% larger than T3 over tropical land, but is smaller in higher latitudes. Over land relative error of T6 is larger than S5 across all latitudes, while T6 has larger relative error than S10 poleward of 20°S–20°N. Similarly, the relative error of T3 exceeds S5 poleward of 20°S–20°N, but does not exceed S10, except in very high latitudes. Similar results are also seen over ocean, but the error ratios are generally less sensitive to seasonal changes. The results also show that the spatial and temporal relative errors are not highly correlated. Overall, lower correlations between the spatial and temporal relative errors are observed over ocean than over land. Quantification of such spatiotemporal effects provides additional insights into evaluation studies, especially when different products are cross-compared at a range of spatiotemporal scales.

  6. Prescription errors in UK critical care units. (United States)

    Ridley, S A; Booth, S A; Thompson, C M


    Drug prescription errors are a common cause of adverse incidents and may be largely preventable. The incidence of prescription errors in UK critical care units is unknown. The aim of this study was to collect data about prescription errors and so calculate the incidence and variation of errors nationally. Twenty-four critical care units took part in the study for a 4-week period. The total numbers of new and re-written prescriptions were recorded daily. Errors were classified according to the nature of the error. Over the 4-week period, 21,589 new prescriptions (or 15.3 new prescriptions per patient) were written. Eighty-five per cent (18,448 prescriptions) were error free, but 3141 (15%) prescriptions had one or more errors (2.2 erroneous prescriptions per patient, or 145.5 erroneous prescriptions per 1000 new prescriptions). The five most common incorrect prescriptions were for potassium chloride (10.2% errors), heparin (5.3%), magnesium sulphate (5.2%), paracetamol (3.2%) and propofol (3.1%). Most of the errors were minor or would have had no adverse effects but 618 (19.6%) errors were considered significant, serious or potentially life threatening. Four categories (not writing the order according to the British National Formulary recommendations, an ambiguous medication order, non-standard nomenclature and writing illegibly) accounted for 47.9% of all errors. Although prescription rates (and error rates) in critical care appear higher than elsewhere in hospital, the number of potentially serious errors is similar to other areas of high-risk practice.

  7. Conferences and Events

    International Development Research Centre (IDRC) Digital Library (Canada)

    André Lavoie


    Jun 14, 2016 ... Events include business meetings; corporate, branch or divisional management meetings; employee ... are responsible for demonstrating the highest standard of ethical conduct as outlined in the IDRC ... All other events such as social events, the Government of Canada Workplace Charitable. Campaign ...

  8. Traumatic events and children (United States)

    ... for in your child and how to take care of your child after a traumatic event. Get professional help if your child is not recovering. Kinds of Traumatic Events Your child could experience a one-time traumatic event or a repeated trauma that happens over and over again. Examples of ...

  9. The effect of learner errors on POS tag errors during automatic POS ...

    African Journals Online (AJOL)

    An evaluation of an unedited version of the sample indicated that learner spelling errors contributed substantially to tagging errors. All spelling errors were then corrected and the edited sample was retagged. With the spelling errors removed, the performance of all three taggers improved. This article reports on the influence ...

  10. Foot placement during error and pedal applications in naturalistic driving. (United States)

    Wu, Yuqing; Boyle, Linda Ng; McGehee, Daniel; Roe, Cheryl A; Ebe, Kazutoshi; Foley, James


    Data from a naturalistic driving study was used to examine foot placement during routine foot pedal movements and possible pedal misapplications. The study included four weeks of observations from 30 drivers, where pedal responses were recorded and categorized. The foot movements associated with pedal misapplications and errors were the focus of the analyses. A random forest algorithm was used to predict the pedal application types based the video observations, foot placements, drivers' characteristics, drivers' cognitive function levels and anthropometric measurements. A repeated multinomial logit model was then used to estimate the likelihood of the foot placement given various driver characteristics and driving scenarios. The findings showed that prior foot location, the drivers' seat position, and the drive sequence were all associated with incorrect foot placement during an event. The study showed that there is a potential to develop a driver assistance system that can reduce the likelihood of a pedal error. Copyright © 2016 Elsevier Ltd. All rights reserved.

  11. Medication error report: Intrathecal administration of labetalol during obstetric anesthesia. (United States)

    Laha, Baisakhi; Hazra, Avijit


    Labetalol, a combined alfa and beta-adrenergic receptor antagonist, is used as an antihypertensive drug. We report a case of an acute rise in blood pressure and lower limb pain due to the inadvertent intrathecal administration of labetalol, mistaking it for bupivacaine, during obstetric anesthesia. The situation was rescued by converting to general anesthesia. The cesarean delivery was uneventful, and mother as well as newborn child showed no ill-effect. This particular medication error was attributable to a failure on the part of the doctors administering the injection to read and cross-check medication labels and the practice of keeping multiple injections together. In the absence of an organized medication error reporting system and action on that basis, such events may recur in future.

  12. Le parole che noi usiamo: l’errore in storia

    Directory of Open Access Journals (Sweden)

    Aurelio Musi


    Full Text Available Unlike the hard sciences, historiography lacks a specific nomenclature. The lexicon employed by historians is drawn from the plain language of everyday life. Therefore, the words of history are to be defined within the spatio-temporal framework, and to be construed through processes of contextualization and comparison. My work here stems from these considerations, and attempts to chart the occurrence of errors in historiography. In particular, I take into account the way in which historiographic mistakes arise from the intermingling of words, space, and historical time. Another significant aspect concerns the relationship between history, fiction, and arbitrariness. The latter concept is linked to historical interpretation, which constitutes the last stage of historiographical work, after the analysis and the reconstruction of events. The last part of this paper offers a typology of frequent errors in historiography.

  13. Rational error in internal medicine. (United States)

    Federspil, Giovanni; Vettor, Roberto


    Epistemologists have selected two basic categories: that of errors committed in scientific research, when a researcher devises or accepts an unfounded hypothesis, and that of mistakes committed in the application of scientific knowledge whereby doctors rely on knowledge held to be true at the time in order to understand an individual patient's signs and symptoms. The paper will deal exclusively with the latter, that is to say the mistakes which physicians make while carrying out their day-to-day medical duties. The paper will deal with the mistakes committed in medicine trying also to offer a classification. It will take into account also examples of mistakes in Bayesian reasoning and mistakes of reasoning committed by clinicians regard inductive reasoning. Moreover, many other mistakes are due to fallacies of deductive logic, logic which they use on a day-to-day basis while examining patients in order to envisage the consequences of the various diagnostic or physiopathologic hypotheses. The existence of a different type of mistakes that are part of the psychology of thought will be also pointed out. We conclude that internists often make mistakes because, unknowingly, they fail to reason correctly. These mistakes can occur in two ways: either because he does not observe the laws of formal logic, or because his practical rationality does not match theoretical rationality and so his reasoning becomes influenced by the circumstances in which he finds himself.

  14. On Nautical Observation Errors Evaluation

    Directory of Open Access Journals (Sweden)

    Wlodzimierz Filipowicz


    Full Text Available Mathematical Theory of Evidence (MTE enables upgrading models and solving crucial problems in many disciplines. MTE delivers new unique opportunity once one engages possibilistic concept. Since fuzziness is widely perceived as something that enables encoding knowledge thus models build upon fuzzy platforms accepts ones skill within given field. At the same time evidence combining scheme is a mechanism enabling enrichment initial data informative context. Therefore it can be exploited in many cases where uncertainty and lack of precision prevail. In nautical applications, for example, it can be used in order to handle data feature systematic and random deflections. Theoretical background was discussed and computer application was successfully implemented in order to cope with erroneous and uncertain data. Output of the application resulted in making a fix and a posteriori evaluating its quality. It was also proven that it can be useful for calibrating measurement appliances. Unique feature of the combination scheme proven by the author in his previous paper, enables identifying measurement systematic deflection. Based on the theorem the paper aims at further exploration of practical aspects of the problem. It concentrates on reduction of hypothesis frame reduction and random along with systematic errors identifications.

  15. Event studies in Turkey

    Directory of Open Access Journals (Sweden)

    Ulkem Basdas


    Full Text Available The primary goal of this paper is to review the event studies conducted for Turkey to in order to identify the common components in their designs. This paper contributes to the existing literature by reviewing all event studies for Turkey for the first time, but more importantly; this review leads to the upcoming event studies on Turkey by highlighting main components of a proper design. Based on the review of 75 studies, it is observed that event studies generally choose BIST-100 (formerly, ISE-100 market index and market adjusted returns with the parametric tests. In general, the studies prefer to rely on one type of model to calculate abnormal returns without discussing the selection of the underlying model. Especially for the event studies focusing on the impact of political events or macroeconomic announcements in Turkey, there is a risk of clustering due to the application of same event date for all observations.

  16. Medication errors in anesthesia: unacceptable or unavoidable? (United States)

    Dhawan, Ira; Tewari, Anurag; Sehgal, Sankalp; Sinha, Ashish Chandra

    Medication errors are the common causes of patient morbidity and mortality. It adds financial burden to the institution as well. Though the impact varies from no harm to serious adverse effects including death, it needs attention on priority basis since medication errors' are preventable. In today's world where people are aware and medical claims are on the hike, it is of utmost priority that we curb this issue. Individual effort to decrease medication error alone might not be successful until a change in the existing protocols and system is incorporated. Often drug errors that occur cannot be reversed. The best way to 'treat' drug errors is to prevent them. Wrong medication (due to syringe swap), overdose (due to misunderstanding or preconception of the dose, pump misuse and dilution error), incorrect administration route, under dosing and omission are common causes of medication error that occur perioperatively. Drug omission and calculation mistakes occur commonly in ICU. Medication errors can occur perioperatively either during preparation, administration or record keeping. Numerous human and system errors can be blamed for occurrence of medication errors. The need of the hour is to stop the blame - game, accept mistakes and develop a safe and 'just' culture in order to prevent medication errors. The newly devised systems like VEINROM, a fluid delivery system is a novel approach in preventing drug errors due to most commonly used medications in anesthesia. Similar developments along with vigilant doctors, safe workplace culture and organizational support all together can help prevent these errors. Copyright © 2016. Published by Elsevier Editora Ltda.

  17. Medication errors in anesthesia: unacceptable or unavoidable?

    Directory of Open Access Journals (Sweden)

    Ira Dhawan

    Full Text Available Abstract Medication errors are the common causes of patient morbidity and mortality. It adds financial burden to the institution as well. Though the impact varies from no harm to serious adverse effects including death, it needs attention on priority basis since medication errors' are preventable. In today's world where people are aware and medical claims are on the hike, it is of utmost priority that we curb this issue. Individual effort to decrease medication error alone might not be successful until a change in the existing protocols and system is incorporated. Often drug errors that occur cannot be reversed. The best way to ‘treat' drug errors is to prevent them. Wrong medication (due to syringe swap, overdose (due to misunderstanding or preconception of the dose, pump misuse and dilution error, incorrect administration route, under dosing and omission are common causes of medication error that occur perioperatively. Drug omission and calculation mistakes occur commonly in ICU. Medication errors can occur perioperatively either during preparation, administration or record keeping. Numerous human and system errors can be blamed for occurrence of medication errors. The need of the hour is to stop the blame - game, accept mistakes and develop a safe and ‘just' culture in order to prevent medication errors. The newly devised systems like VEINROM, a fluid delivery system is a novel approach in preventing drug errors due to most commonly used medications in anesthesia. Similar developments along with vigilant doctors, safe workplace culture and organizational support all together can help prevent these errors.

  18. The effectiveness of risk management program on pediatric nurses' medication error. (United States)

    Dehghan-Nayeri, Nahid; Bayat, Fariba; Salehi, Tahmineh; Faghihzadeh, Soghrat


    Medication therapy is one of the most complex and high-risk clinical processes that nurses deal with. Medication error is the most common type of error that brings about damage and death to patients, especially pediatric ones. However, these errors are preventable. Identifying and preventing undesirable events leading to medication errors are the main risk management activities. The aim of this study was to investigate the effectiveness of a risk management program on the pediatric nurses' medication error rate. This study is a quasi-experimental one with a comparison group. In this study, 200 nurses were recruited from two main pediatric hospitals in Tehran. In the experimental hospital, we applied the risk management program for a period of 6 months. Nurses of the control hospital did the hospital routine schedule. A pre- and post-test was performed to measure the frequency of the medication error events. SPSS software, t-test, and regression analysis were used for data analysis. After the intervention, the medication error rate of nurses at the experimental hospital was significantly lower (P < 0.001) and the error-reporting rate was higher (P < 0.007) compared to before the intervention and also in comparison to the nurses of the control hospital. Based on the results of this study and taking into account the high-risk nature of the medical environment, applying the quality-control programs such as risk management can effectively prevent the occurrence of the hospital undesirable events. Nursing mangers can reduce the medication error rate by applying risk management programs. However, this program cannot succeed without nurses' cooperation.

  19. Error-related processing in adult males with elevated psychopathic traits. (United States)

    Steele, Vaughn R; Maurer, J Michael; Bernat, Edward M; Calhoun, Vince D; Kiehl, Kent A


    Psychopathy is a serious personality disorder characterized by dysfunctional affective and behavioral symptoms. In incarcerated populations, elevated psychopathic traits have been linked to increased rates of violent recidivism. Cognitive processes related to error processing have been shown to differentiate individuals with high and low psychopathic traits and may contribute to poor decision making that increases the risk of recidivism. Error processing abnormalities related to psychopathy may be attributable to error-monitoring (error detection) or posterror processing (error evaluation). A recent 'bottleneck' theory predicts deficiencies in posterror processing in individuals with high psychopathic traits. In the current study, incarcerated males (n = 93) performed a Go/NoGo response inhibition task while event-related potentials (ERPs) were recorded. Classic time-domain windowed component and principal component analyses were used to measure error-monitoring (as measured with the error-related negativity [ERN/Ne]) and posterror processing (as measured with the error positivity [Pe]). Psychopathic traits were assessed using Hare's Psychopathy Checklist-Revised (PCL-R). PCL-R Total score, Factor 1 (interpersonal-affective traits), and Facet 3 (lifestyle traits) scores were positively related to posterror processes (i.e., increased Pe amplitude) but unrelated to error-monitoring processes (i.e., ERN/Ne). These results support the attentional bottleneck theory and further describe deficiencies related to elevated psychopathic traits that could be beneficial for new treatment strategies for psychopathy. (c) 2016 APA, all rights reserved).

  20. Admissions and Readmissions Related to Adverse Events, 2007-2014 (United States)


    adverse drug events and surgical errors, placing health care injury among the top 10 causes of death in the United States (US). Medical errors lead to...Newborn and other neonates ( perinatal period) 186 0.4 19 0.1 224 0.4 0 0.0 357 0.8 596 0.5 Pre-MDC 318 0.7 335 1.5 671 1.2 21 1.5 485 1.2 1,306

  1. Database design to ensure anonymous study of medical errors: a report from the ASIPS Collaborative. (United States)

    Pace, Wilson D; Staton, Elizabeth W; Higgins, Gregory S; Main, Deborah S; West, David R; Harris, Daniel M


    Medical error reporting systems are important information sources for designing strategies to improve the safety of health care. Applied Strategies for Improving Patient Safety (ASIPS) is a multi-institutional, practice-based research project that collects and analyzes data on primary care medical errors and develops interventions to reduce error. The voluntary ASIPS Patient Safety Reporting System captures anonymous and confidential reports of medical errors. Confidential reports, which are quickly de-identified, provide better detail than do anonymous reports; however, concerns exist about the confidentiality of those reports should the database be subject to legal discovery or other security breaches. Standard database elements, for example, serial ID numbers, date/time stamps, and backups, could enable an outsider to link an ASIPS report to a specific medical error. The authors present the design and implementation of a database and administrative system that reduce this risk, facilitate research, and maintain near anonymity of the events, practices, and clinicians.

  2. [Surveillance of health care errors. An overview of the published data in Argentina]. (United States)

    Codermatz, Marcela A; Trillo, Carolina; Berenstein, Graciela; Ortiz, Zulma


    In the last decades, public health surveillance extended its scope of study to new fields, such as medical errors, in order to improve patient safety. This study was aimed to review all the evidence produced in Argentina about the surveillance of medical errors. An exhaustive literature search was performed. A total of 4656 abstracts were assessed (150 MEDLINE, 145 LILACS, and 4361 hand searched abstracts). Of them, 52 were analysed and 8 were considered relevant for health care error surveillance. Different approaches were used to study medical errors. Some of them have focused on patient safety and others on medical malpractice. There is still a need to improve the surveillance of this type of event. Mainly, the quality reports of study design and surveillance attributes were unclear. A critical appraisal and synthesis of all relevant studies on health care errors may help to understand not only the state of the art, but also to define research priorities.

  3. Prioritising the prevention of medication handling errors. (United States)

    Bertsche, Thilo; Niemann, Dorothee; Mayer, Yvonne; Ingram, Katrin; Hoppe-Tichy, Torsten; Haefeli, Walter E


    Medication errors are frequent in a hospital setting and often caused by inappropriate drug handling. Systematic strategies for their prevention however are still lacking. We developed and applied a classification model to categorise medication handling errors and defined the urgency of correction on the basis of these findings. Nurses on medical wards (including intensive and intermediate care units) of a 1,680-bed teaching hospital. In a prospective observational study we evaluated the prevalence of 20 predefined medication handling errors on the ward. In a concurrent questionnaire survey, we assessed the knowledge of the nurses on medication handling. The severity of errors observed in individual areas was scored considering prevalence, potential risk of an error, and the involved drug. These scores and the prevalence of corresponding knowledge deficits were used to define the urgency of preventive strategies according to a four-field decision matrix. Prevalence and potential risk of medication handling errors, corresponding knowledge deficits in nurses committing the errors, and priority of quality improvement. In 1,376 observed processes 833 medication handling errors were detected. Errors concerning preparation (mean 0.88 errors per observed process [95% CI: 0.81-0.96], N = 645) were more frequent than administration errors (0.36 [0.32-0.41], N = 701, P errors than enteral drugs (0.32 [0.28-0.36], N = 794, P medication errors 30.9% concerned processes of high risk, 19.0% of moderate risk, and 50.1% of low risk. Of these errors 11.4% were caused by critical dose drugs, 81.6% by uncomplicated drugs, and 6.9% by nutritional supplements or diluents without active ingredient. According to the decision matrix that also considered knowledge deficits two error types concerning enteral drugs (flaws in light protection and prescribing information) were given maximum priority for quality improvement. For parenteral drugs five errors (incompatibilities, flaws in hygiene

  4. Intelligent post processing of seismic events

    Directory of Open Access Journals (Sweden)

    F. Ringdal


    established near Apatity on the Kola peninsula. The third step in the post processing is a relocation of the event, using refined arrivai times and recomputed azimuths from broad band flk analysis. By introducing region specific travel time corrections, a median error of 1.4 km from the reported location has been obtained. This should be compared to the median error of 10.8 km for the automatie IMS processing for these events. This improvement in location accuracy clearly demonstrates the usefulness of the intelligent post processing approach.

  5. Soft error aware physical synthesis (United States)

    Assis, Thiago Rocha de

    With increased public interest in protecting the environment, scientists and engineers aim to improve energy conversion efficiency. Thermoelectrics offer many advantages as thermal management technology. When compared to vapor compression refrigeration, above approximately 200 to 600 watts, cost in dollars per watt as well as COP are not advantageous for thermoelectrics. The goal of this work was to determine if optimized pulse supercooling operation could improve cooling capacity or efficiency of a thermoelectric device. The basis of this research is a thermal-electrical analogy based modeling study using SPICE. Two models were developed. The first model, a standalone thermocouple with no attached mass to be cooled. The second, a system that includes a module attached to a heat generating mass. With the thermocouple study, a new approach of generating response surfaces with characteristic parameters was applied. The current pulse height and pulse on-time was identified for maximizing Net Transient Advantage, a newly defined metric. The corresponding pulse height and pulse on-time was utilized for the system model. Along with the traditional steady state starting current of Imax, Iopt was employed. The pulse shape was an isosceles triangle. For the system model, metrics new to pulse cooling were Qc, power consumption and COP. The effects of optimized current pulses were studied by changing system variables. Further studies explored time spacing between pulses and temperature distribution in the thermoelement. It was found net Q c over an entire pulse event can be improved over Imax steady operation but not over steady I opt operation. Qc can be improved over Iopt operation but only during the early part of the pulse event. COP is reduced in transient pulse operation due to the different time constants of Qc and Pin. In some cases lower performance interface materials allow more Qc and better COP during transient operation than higher performance interface materials

  6. Error propagation in a digital avionic mini processor. M.S. Thesis (United States)

    Lomelino, Dale L.


    A methodology is introduced and demonstrated for the study of error propagation from the gate to the chip level. The importance of understanding error propagation derives from its close tie with system activity. In this system the target system is BDX-930, a digital avionic multiprocessor. The simulator used was developed at NASA-Langley, and is a gate level, event-driven, unit delay, software logic simulator. An approach is highly structured and easily adapted to other systems. The analysis shows the nature and extent of the dependency of error propagation on microinstruction type, assembly level instruction, and fault-free gate activity.

  7. Neurophysiological responses to gun-shooting errors. (United States)

    Xu, Xiaowen; Inzlicht, Michael


    The present study investigated the neural responses to errors in a shooting game - and how these neural responses may relate to behavioral performance - by examining the ERP components related to error detection (error-related negativity; ERN) and error awareness (error-related positivity; Pe). The participants completed a Shooter go/no-go task, which required them to shoot at armed targets using a gaming gun, and avoid shooting innocent non-targets. The amplitude of the ERN and Pe was greater for shooting errors than correct shooting responses. The ERN and Pe amplitudes elicited by incorrect shooting appeared to have good internal reliability. The ERN and Pe amplitudes elicited by shooting behaviors also predicted better behavioral sensitivity towards shoot/don't-shoot stimuli. These results suggest that it is possible to obtain online brain response measures to shooting responses and that neural responses to shooting are predictive of behavioral responses. Copyright © 2014 Elsevier B.V. All rights reserved.

  8. Error handling strategies in multiphase inverse modeling

    Energy Technology Data Exchange (ETDEWEB)

    Finsterle, S.; Zhang, Y.


    Parameter estimation by inverse modeling involves the repeated evaluation of a function of residuals. These residuals represent both errors in the model and errors in the data. In practical applications of inverse modeling of multiphase flow and transport, the error structure of the final residuals often significantly deviates from the statistical assumptions that underlie standard maximum likelihood estimation using the least-squares method. Large random or systematic errors are likely to lead to convergence problems, biased parameter estimates, misleading uncertainty measures, or poor predictive capabilities of the calibrated model. The multiphase inverse modeling code iTOUGH2 supports strategies that identify and mitigate the impact of systematic or non-normal error structures. We discuss these approaches and provide an overview of the error handling features implemented in iTOUGH2.

  9. Association between licence status and medication errors. (United States)

    Conroy, Sharon


    Unlicensed and off label drug use in children is common and leads to well-recognised problems. This study aimed to determine whether a relationship exists between medication errors and licence status. Reports of errors in a UK children's hospital from 2004 to 2006 were analysed in terms of licence status and degree of harm and compared to the incidence of unlicensed and off label drug use in the hospital. 20 of 158 (13%) errors were considered to have caused moderate harm and 12 of these involved unlicensed/off label drugs. 138 (87%) caused no or low harm. None caused severe harm. Unlicensed drug usage was significantly more likely to be associated with errors than licensed use in both children and neonates. Unlicensed drug use appears to be associated with medication errors in neonates and children. Medication errors causing moderate harm were significantly more likely to be associated with both unlicensed and off label than licensed drugs.

  10. Influence of organizational culture on human error

    Energy Technology Data Exchange (ETDEWEB)

    Friedlander, M.A.; Evans, S.A. [Pennsylvania Power and Light Co., Allentown, PA (United States)


    Much has been written in contemporary business literature during the last decade describing the role that corporate culture plays in virtually every aspect of a firm`s success. In 1990 Kotter and Heskett wrote, {open_quotes}We found that firms with cultures that emphasized all of the key managerial constituencies (customers, stockholders, and employees) and leadership from managers at all levels out-performed firms that did not have those cultural traits by a huge margin. Over an eleven year period, the former increased revenues by an average of 682 percent versus 166 percent for the latter, expanded their workforce by 282 percent versus 36 percent, grew their stock prices by 901 percent versus 74 percent, and improved their net incomes by 756 percent versus 1 percent.{close_quotes} Since the mid-1980s, several electric utilities have documented their efforts to undertake strategic culture change. In almost every case, these efforts have yielded dramatic improvements in the {open_quotes}bottom-line{close_quotes} operational and financial results (e.g., Western Resources, Arizona Public Service, San Diego Gas & Electric, and Electricity Trust of South Australia). Given the body of evidence that indicates a relationship between high-performing organizational culture and the financial and business success of a firm, Pennsylvania Power & Light Company undertook a study to identify the relationship between organizational culture and the frequency, severity, and nature of human error at the Susquehanna Steam Electric Station. The underlying proposition for this asssessment is that organizational culture is an independent variable that transforms external events into organizational performance.

  11. Human errors identification using the human factors analysis and classification system technique (HFACS

    Directory of Open Access Journals (Sweden)

    G. A. Shirali


    .Result: In this study, 158 reports of accident in Ahvaz steel industry were analyzed by HFACS technique. This analysis showed that most of the human errors were: in the first level was related to the skill-based errors, in the second to the physical environment, in the third level to the inadequate supervision and in the fourth level to the management of resources. .Conclusion: Studying and analyzing of past events using the HFACS technique can identify the major and root causes of accidents and can be effective on prevent repetitions of such mishaps. Also, it can be used as a basis for developing strategies to prevent future events in steel industries.

  12. Measuring Systematic Error with Curve Fits (United States)

    Rupright, Mark E.


    Systematic errors are often unavoidable in the introductory physics laboratory. As has been demonstrated in many papers in this journal, such errors can present a fundamental problem for data analysis, particularly when comparing the data to a given model.1-3 In this paper I give three examples in which my students use popular curve-fitting software and adjust the theoretical model to account for, and even exploit, the presence of systematic errors in measured data.

  13. A Systematic Approach to Error Free Telemetry (United States)


    diversity) and LDPC is being used to correct errors caused by the transmission channel. Each receive site coupled the telemetry receiver, CH1 and CH2...A SYSTEMATIC APPROACH TO ERROR FREE TELEMETRY 412TW-TIM-17-03 DISTRIBUTION A: Approved for public release. Distribution is...Systematic Approach to Error -Free Telemetry) was submitted by the Commander, 412th Test Wing, Edwards AFB, California 93524. Prepared by

  14. MPC-Relevant Prediction-Error Identification

    DEFF Research Database (Denmark)

    Jørgensen, John Bagterp; Jørgensen, Sten Bay


    A prediction-error-method tailored for model based predictive control is presented. The prediction-error method studied are based on predictions using the Kalman filter and Kalman predictors for a linear discrete-time stochastic state space model. The linear discrete-time stochastic state space m...... is to be applied. The suitability of the proposed prediction error-method for predictive control is demonstrated for dual composition control of a simulated binary distillation column....

  15. Geometric errors measurement for coordinate measuring machines (United States)

    Pan, Fangyu; Nie, Li; Bai, Yuewei; Wang, Xiaogang; Wu, Xiaoyan


    Error compensation is a good choice to improve Coordinate Measuring Machines’ (CMM) accuracy. In order to achieve the above goal, the basic research is done. Firstly, analyzing the error source which finds out 21 geometric errors affecting CMM’s precision seriously; secondly, presenting the measurement method and elaborating the principle. By the experiment, the feasibility is validated. Therefore, it lays a foundation for further compensation which is better for CMM’s accuracy.

  16. Error Propagation Analysis for Quantitative Intracellular Metabolomics


    Jana Tillack; Nicole Paczia; Katharina Nöh; Wolfgang Wiechert; Stephan Noack


    Model-based analyses have become an integral part of modern metabolic engineering and systems biology in order to gain knowledge about complex and not directly observable cellular processes. For quantitative analyses, not only experimental data, but also measurement errors, play a crucial role. The total measurement error of any analytical protocol is the result of an accumulation of single errors introduced by several processing steps. Here, we present a framework for the quantification of i...

  17. Prescribing Errors Involving Medication Dosage Forms (United States)

    Lesar, Timothy S


    CONTEXT Prescribing errors involving medication dose formulations have been reported to occur frequently in hospitals. No systematic evaluations of the characteristics of errors related to medication dosage formulation have been performed. OBJECTIVE To quantify the characteristics, frequency, and potential adverse patient effects of prescribing errors involving medication dosage forms . DESIGN Evaluation of all detected medication prescribing errors involving or related to medication dosage forms in a 631-bed tertiary care teaching hospital. MAIN OUTCOME MEASURES Type, frequency, and potential for adverse effects of prescribing errors involving or related to medication dosage forms. RESULTS A total of 1,115 clinically significant prescribing errors involving medication dosage forms were detected during the 60-month study period. The annual number of detected errors increased throughout the study period. Detailed analysis of the 402 errors detected during the last 16 months of the study demonstrated the most common errors to be: failure to specify controlled release formulation (total of 280 cases; 69.7%) both when prescribing using the brand name (148 cases; 36.8%) and when prescribing using the generic name (132 cases; 32.8%); and prescribing controlled delivery formulations to be administered per tube (48 cases; 11.9%). The potential for adverse patient outcome was rated as potentially “fatal or severe” in 3 cases (0.7%), and “serious” in 49 cases (12.2%). Errors most commonly involved cardiovascular agents (208 cases; 51.7%). CONCLUSIONS Hospitalized patients are at risk for adverse outcomes due to prescribing errors related to inappropriate use of medication dosage forms. This information should be considered in the development of strategies to prevent adverse patient outcomes resulting from such errors. PMID:12213138

  18. How social is error observation? The neural mechanisms underlying the observation of human and machine errors. (United States)

    Desmet, Charlotte; Deschrijver, Eliane; Brass, Marcel


    Recently, it has been shown that the medial prefrontal cortex (MPFC) is involved in error execution as well as error observation. Based on this finding, it has been argued that recognizing each other's mistakes might rely on motor simulation. In the current functional magnetic resonance imaging (fMRI) study, we directly tested this hypothesis by investigating whether medial prefrontal activity in error observation is restricted to situations that enable simulation. To this aim, we compared brain activity related to the observation of errors that can be simulated (human errors) with brain activity related to errors that cannot be simulated (machine errors). We show that medial prefrontal activity is not only restricted to the observation of human errors but also occurs when observing errors of a machine. In addition, our data indicate that the MPFC reflects a domain general mechanism of monitoring violations of expectancies.

  19. Human Error Mechanisms in Complex Work Environments

    DEFF Research Database (Denmark)

    Rasmussen, Jens


    Human error taxonomies have been developed from analysis of industrial incident reports as well as from psychological experiments. In this paper the results of the two approaches are reviewed and compared. It is found, in both cases, that a fairly small number of basic psychological mechanisms...... will account for most of the action errors observed. In addition, error mechanisms appear to be intimately related to the development of high skill and know-how in a complex work context. This relationship between errors and human adaptation is discussed in detail for individuals and organisations...

  20. Errors and erasures decoding for interference channels (United States)

    Stuber, G.; Mark, J.; Blake, I.

    This paper examines the gains to be realized by using an errors-and-erasures decoding strategy on a pulse jammed channel, rather than errors-only, for concatenated Reed-Solomon/orthogonal codes. The work is largely computational and serves to quantify the gains achievable in such a situation. Previous studies have shown that the gains of errors-and-erasures over errors-only on the AWGN channel are minimal. The gains reported here for the pulse jammed channel are more substantial, particularly for the lower duty cycles.