WorldWideScience

Sample records for event upset errors

  1. Computing in the presence of soft bit errors. [caused by single event upset on spacecraft

    Science.gov (United States)

    Rasmussen, R. D.

    1984-01-01

    It is shown that single-event-upsets (SEUs) due to cosmic rays are a significant source of single bit error in spacecraft computers. The physical mechanism of SEU, electron hole generation by means of Linear Energy Transfer (LET), it discussed with reference made to the results of a study of the environmental effects on computer systems of the Galileo spacecraft. Techniques for making software more tolerant of cosmic ray effects are considered, including: reducing the number of registers used by the software; continuity testing of variables; redundant execution of major procedures for error detection; and encoding state variables to detect single-bit changes. Attention is also given to design modifications which may reduce the cosmic ray exposure of on-board hardware. These modifications include: shielding components operating in LEO; removing low-power Schottky parts; and the use of CMOS diodes. The SEU parameters of different electronic components are listed in a table.

  2. Single event upset test programs

    International Nuclear Information System (INIS)

    Russen, L.C.

    1984-11-01

    It has been shown that the heavy ions in cosmic rays can give rise to single event upsets in VLSI random access memory devices (RAMs). Details are given of the programs written to test 1K, 4K, 16K and 64K memories during their irradiation with heavy charged ions, in order to simulate the effects of cosmic rays in space. The test equipment, which is used to load the memory device to be tested with a known bit pattern, and subsequently interrogate it for upsets, or ''flips'', is fully described. (author)

  3. Calculation of cosmic ray induced single event upsets: Program CRUP (Cosmic Ray Upset Program)

    Science.gov (United States)

    Shapiro, P.

    1983-09-01

    This report documents PROGRAM CRUP, COSMIC RAY UPSET PROGRAM. The computer program calculates cosmic ray induced single-event error rates in microelectronic circuits exposed to several representative cosmic-ray environments.

  4. Single event upsets correlated with environment

    International Nuclear Information System (INIS)

    Vampola, A.L.; Albin, F.; Lauriente, M.; Wilkinson, D.C.; Allen, J.

    1994-01-01

    Single Event Upset rates on satellites in different Earth orbits are correlated with solar protons and geomagnetic activity and also with the NASA AP8 proton model to extract information about satellite anomalies caused by the space environment. An extensive discussion of the SEU data base from the TOMS solid state recorder and an algorithm for correcting spontaneous upsets in it are included as an Appendix. SAMPEX and TOMS, which have the same memory chips, have similar normalized responses in the South Atlantic Anomaly. SEU rates due to solar protons over the polar caps are within expectations. No geomagnetic activity effects can be discerned in the SEU rates

  5. Measuring Single Event Upsets in the ATLAS Inner Tracker

    CERN Multimedia

    CERN. Geneva

    2015-01-01

    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.

  6. Heavy Ion Irradiation Fluence Dependence for Single-Event Upsets in a NAND Flash Memory

    Science.gov (United States)

    Chen, Dakai; Wilcox, Edward; Ladbury, Raymond L.; Kim, Hak; Phan, Anthony; Seidleck, Christina; Label, Kenneth

    2016-01-01

    We investigated the single-event effect (SEE) susceptibility of the Micron 16 nm NAND flash, and found that the single-event upset (SEU) cross section varied inversely with cumulative fluence. We attribute the effect to the variable upset sensitivities of the memory cells. Furthermore, the effect impacts only single cell upsets in general. The rate of multiple-bit upsets remained relatively constant with fluence. The current test standards and procedures assume that SEU follow a Poisson process and do not take into account the variability in the error rate with fluence. Therefore, traditional SEE testing techniques may underestimate the on-orbit event rate for a device with variable upset sensitivity.

  7. Heavy Ion Irradiation Fluence Dependence for Single-Event Upsets of NAND Flash Memory

    Science.gov (United States)

    Chen, Dakai; Wilcox, Edward; Ladbury, Raymond; Kim, Hak; Phan, Anthony; Seidleck, Christina; LaBel, Kenneth

    2016-01-01

    We investigated the single-event effect (SEE) susceptibility of the Micron 16 nm NAND flash, and found the single-event upset (SEU) cross section varied inversely with fluence. The SEU cross section decreased with increasing fluence. We attribute the effect to the variable upset sensitivities of the memory cells. The current test standards and procedures assume that SEU follow a Poisson process and do not take into account the variability in the error rate with fluence. Therefore, heavy ion irradiation of devices with variable upset sensitivity distribution using typical fluence levels may underestimate the cross section and on-orbit event rate.

  8. Heavy ion and proton-induced single event multiple upset

    International Nuclear Information System (INIS)

    Reed, R.A.; Carts, M.A.; Marshall, P.W.

    1997-01-01

    Individual ionizing heavy ion events are shown to cause two or more adjacent memory cells to change logic states in a high density CMOS SRAM. A majority of the upsets produced by normally incident heavy ions are due to single-particle events that causes a single cell to upset. However, for grazing angles a majority of the upsets produced by heavy-ion irradiation are due to single-particle events that cause two or more cells to change logic states. Experimental evidence of a single proton-induced spallation reaction that causes two adjacent memory cells to change logic states is presented. Results from a dual volume Monte-Carlo simulation code for proton-induced single-event multiple upsets are within a factor of three of experimental data for protons at normal incidence and 70 degrees

  9. Single Event Upsets in the ATLAS IBL Front End ASICs

    CERN Document Server

    Rozanov, Alexander; The ATLAS collaboration

    2018-01-01

    During operation at instantaneous luminosities of up to 2.1 10^{34} cm^{-2} s^{-1} the front end chips of the ATLAS innermost pixel layer (IBL) experienced single event upsets affecting its global registers as well as the settings for the individual pixels, causing, among other things loss of occupancy, noisy pixels, and silent pixels. A quantitative analysis of the single event upsets as well as the operational issues and mitigation techniques will be presented.

  10. Single Event Upsets in the ATLAS IBL Front End ASICs

    CERN Document Server

    Rozanov, Alexandre; The ATLAS collaboration

    2018-01-01

    During operation at instantaneous luminosities of up to 2.1 1034 cm2 s−1 frontend chips of the ATLAS innermost pixel layer (IBL) experienced single event upsets affecting its global registers as well as the settings for the individual pixels, causing, amongst other things loss of occupancy, noisy pixels, and silent pixels. A quantitative analysis of the single event upsets as well as the operational issues and mitigation techniques are presented.

  11. The single event upset environment for avionics at high latitude

    International Nuclear Information System (INIS)

    Sims, A.J.; Dyer, C.S.; Peerless, C.L.; Farren, J.

    1994-01-01

    Modern avionic systems for civil and military applications are becoming increasingly reliant upon embedded microprocessors and associated memory devices. The phenomenon of single event upset (SEU) is well known in space systems and designers have generally been careful to use SEU tolerant devices or to implement error detection and correction (EDAC) techniques where appropriate. In the past, avionics designers have had no reason to consider SEU effects but is clear that the more prevalent use of memory devices combined with increasing levels of IC integration will make SEU mitigation an important design consideration for future avionic systems. To this end, it is necessary to work towards producing models of the avionics SEU environment which will permit system designers to choose components and EDAC techniques which are based on predictions of SEU rates correct to much better than an order of magnitude. Measurements of the high latitude SEU environment at avionics altitude have been made on board a commercial airliner. Results are compared with models of primary and secondary cosmic rays and atmospheric neutrons. Ground based SEU tests of static RAMs are used to predict rates in flight

  12. Charge collection and SEU (Single Event Upset) mechanisms

    International Nuclear Information System (INIS)

    Musseau, O.

    1994-01-01

    The purpose of this paper is to review the mechanisms of single event upset in microelectronic devices due to interaction with cosmic ions. Experimental and theoretical results are presented, and actual questions and problems are discussed. A brief introduction recalls the creation of the dense plasma of electron-hole pairs along the ion track. The basic processes for charge collection in a simple np junction (drift and diffusion) are presented. The funneling-field effect is discussed and experimental results are compared to numerical simulations and semi-empirical models. Charge collection in actual microelectronic structures is then presented. Single event upset of memory cells is discussed, based on numerical and experimental data. The main parameters for device characterization are presented. From the physical interpretation of charge collection mechanisms, the intrinsic sensitivity of various microelectronic technologies is determined and compared to experimental data. Scaling laws and future trends are discussed. (author)

  13. Analyzing System on A Chip Single Event Upset Responses using Single Event Upset Data, Classical Reliability Models, and Space Environment Data

    Science.gov (United States)

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

    2017-01-01

    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)

  14. Single Event Upset Studies Using the ATLAS SCT

    CERN Document Server

    Weidberg, A R; The ATLAS collaboration

    2013-01-01

    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.

  15. Single Event Upset Studies Using the ATLAS SCT

    CERN Document Server

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

    2014-01-01

    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

  16. Device simulation of charge collection and single-event upset

    International Nuclear Information System (INIS)

    Dodd, P.E.

    1996-01-01

    In this paper the author reviews the current status of device simulation of ionizing-radiation-induced charge collection and single-event upset (SEU), with an emphasis on significant results of recent years. The author presents an overview of device-modeling techniques applicable to the SEU problem and the unique challenges this task presents to the device modeler. He examines unloaded simulations of radiation-induced charge collection in simple p/n diodes, SEU in dynamic random access memories (DRAM's), and SEU in static random access memories (SRAM's). The author concludes with a few thoughts on future issues likely to confront the SEU device modeler

  17. Single event upset threshold estimation based on local laser irradiation

    International Nuclear Information System (INIS)

    Chumakov, A.I.; Egorov, A.N.; Mavritsky, O.B.; Yanenko, A.V.

    1999-01-01

    An approach for estimation of ion-induced SEU threshold based on local laser irradiation is presented. Comparative experiment and software simulation research were performed at various pulse duration and spot size. Correlation of single event threshold LET to upset threshold laser energy under local irradiation was found. The computer analysis of local laser irradiation of IC structures was developed for SEU threshold LET estimation. The correlation of local laser threshold energy with SEU threshold LET was shown. Two estimation techniques were suggested. The first one is based on the determination of local laser threshold dose taking into account the relation of sensitive area to local irradiated area. The second technique uses the photocurrent peak value instead of this relation. The agreement between the predicted and experimental results demonstrates the applicability of this approach. (authors)

  18. TDRS-1 single event upsets and the effect of the space environment

    International Nuclear Information System (INIS)

    Wilkinson, D.C.; Daughtridge, S.C.; Stone, J.L.; Sauer, H.H.; Darling, P.

    1991-01-01

    The systematic recording of Single Event Upsets on TDRS-1 from 1984 to 1990 allows correlations to be drawn between those upsets and the space environment. In this paper, ground based neutron monitor data are used to illustrate the long-term relationship between galactic cosmic rays and TDRS-1 upsets. The short-term effects of energetic solar particles are illustrated with space environment data from GOES-7

  19. Single event upset susceptibilities of latchup immune CMOS process programmable gate arrays

    Science.gov (United States)

    Koga, R.; Crain, W. R.; Crawford, K. B.; Hansel, S. J.; Lau, D. D.; Tsubota, T. K.

    Single event upsets (SEU) and latchup susceptibilities of complementary metal oxide semiconductor programmable gate arrays (CMOS PPGA's) were measured at the Lawrence Berkeley Laboratory 88-in. cyclotron facility with Xe (603 MeV), Cu (290 MeV), and Ar (180 MeV) ion beams. The PPGA devices tested were those which may be used in space. Most of the SEU measurements were taken with a newly constructed tester called the Bus Access Storage and Comparison System (BASACS) operating via a Macintosh II computer. When BASACS finds that an output does not match a prerecorded pattern, the state of all outputs, position in the test cycle, and other necessary information is transmitted and stored in the Macintosh. The upset rate was kept between 1 and 3 per second. After a sufficient number of errors are stored, the test is stopped and the total fluence of particles and total errors are recorded. The device power supply current was closely monitored to check for occurrence of latchup. Results of the tests are presented, indicating that some of the PPGA's are good candidates for selected space applications.

  20. Position sensitive regions in a generic radiation sensor based on single event upsets in dynamic RAMs

    International Nuclear Information System (INIS)

    Darambara, D.G.; Spyrou, N.M.

    1997-01-01

    Modern integrated circuits are highly complex systems and, as such, are susceptible to occasional failures. Semiconductor memory devices, particularly dynamic random access memories (dRAMs), are subject to random, transient single event upsets (SEUs) created by energetic ionizing radiation. These radiation-induced soft failures in the stored data of silicon based memory chips provide the foundation for a new, highly efficient, low cost generic radiation sensor. The susceptibility and the detection efficiency of a given dRAM device to SEUs is a complicated function of the circuit design and geometry, the operating conditions and the physics of the charge collection mechanisms involved. Typically, soft error rates measure the cumulative response of all sensitive regions of the memory by broad area chip exposure in ionizing radiation environments. However, this study shows that many regions of a dynamic memory are competing charge collection centres having different upset thresholds. The contribution to soft fails from discrete regions or individual circuit elements of the memory device is unambiguously separated. Hence the use of the dRAM as a position sensitive radiation detector, with high spatial resolution, is assessed and demonstrated. (orig.)

  1. Single-event phenomena on recent semiconductor devices. Charge-type multiple-bit upsets in high integrated memories

    International Nuclear Information System (INIS)

    Makihara, Akiko; Shindou, Hiroyuki; Nemoto, Norio; Kuboyama, Satoshi; Matsuda, Sumio; Ohshima, Takeshi; Hirao, Toshio; Itoh, Hisayoshi

    2001-01-01

    High integrated memories are used in solid state data recorder (SSDR) of the satellite for accumulating observation data. Single event upset phenomena which turn over an accumulated data in the memory cells are caused by heavy ion incidence. Studies on single-bit upset and multiple-bit upset phenomena in the high integrated memory cells are in progress recently. 16 Mbit DRAM (Dynamic Random Access Memories) and 64 Mbit DRAM are irradiated by heavy ion species, such as iodine, bromine and nickel, in comparison with the irradiation damage in the cosmic environment. Data written on the memory devices are read out after the irradiation. The memory cells in three kinds of states, all of charged state, all of discharged state, and an alternative state of charge and discharge, are irradiated for sorting out error modes caused by heavy ion incidence. The soft error in a single memory cells is known as a turn over from charged state to discharged state. Electrons in electron-hole pair generated by heavy ion incidence are captured in a diffusion region between capacitor electrodes of semiconductor. The charged states in the capacitor electrodes before the irradiation are neutralized and changed to the discharged states. According to high integration of the memories, many of the cells are affected by a single ion incidence. The multiple-bit upsets, however, are generated in the memory cells of discharged state before the irradiation, also. The charge-type multiple-bit upsets is considered as that error data are written on the DRAM during refresh cycle of a sense-up circuit and a pre-charge circuit which control the DRAM. (M. Suetake)

  2. In-flight and ground testing of single event upset sensitivity in static RAMs

    International Nuclear Information System (INIS)

    Johansson, K.; Dyreklev, P.; Granbom, B.; Calvet, C.; Fourtine, S.; Feuillatre, O.

    1998-01-01

    This paper presents the results from in-flight measurements of single event upsets (SEU) in static random access memories (SRAM) caused by the atmospheric radiation environment at aircraft altitudes. The memory devices were carried on commercial airlines at high altitude and mainly high latitudes. The SEUs were monitored by a Component Upset Test Equipment (CUTE), designed for this experiment. The in flight results are compared to ground based testing with neutrons from three different sources

  3. Single event upset mitigation techniques for FPGAs utilized in nuclear power plant digital instrumentation and control

    International Nuclear Information System (INIS)

    Wang Xin; Holbert, Keith E.; Clark, Lawrence T.

    2011-01-01

    Highlights: → Triple modular redundancy (TMR) implementation is the best solution for digital I and C. → Maximal probability of two simultaneous errors with TMR maximum partition is 4.44%. → Dual modular redundancy minimum logic partitioning design is an additional option. - Abstract: Field programmable gate arrays (FPGAs) are integrated circuits being increasingly used for digital instrumentation and control (I and C) in nuclear power plants (NPPs) because of low cost, re-configurability and low design turn-around time. However, to ensure reliability, proper design techniques must be employed since the memory and logic in FPGAs are susceptible to single event upsets (SEUs). Triple modular redundancy (TMR) has become a common SEU mitigation design technique because of its straightforward implementation and reliable results. Partitioned TMR approaches are introduced in this paper, and formulae derived indicate that the maximum probability of two simultaneous errors [P E ] max is inversely proportional to the number of logic partitions in a TMR design, when each redundant logic block in every logic partition has the same number of sensitive nodes. However, the maximum logic partitioning design cannot completely eliminate the possibility of two simultaneous upsets. For the example test circuit it is found that [P E ] max is reduced dramatically from 66.67% for minimum logic partitioning to 4.44% for maximum logic partitioning. Because TMR introduces significant overhead due to its full hardware redundancy, a dual modular redundancy approach is also examined for application to less demanding situations. By comparative analysis this study reaches the conclusion that the maximum logic partitioning TMR implementation is the best solution for digital I and C applications in NPPs where obtaining robustness is of the highest importance, despite its higher area overhead.

  4. Impact of NBTI Aging on the Single-Event Upset of SRAM Cells

    CERN Document Server

    Bagatin, M; Gerardin, Simone; Paccagnella, Alessandro; Bagatin, Marta

    2010-01-01

    We analyzed the impact of negative bias temperature instability (NBTI) on the single-event upset rate of SRAM cells through experiments and SPICE simulations. We performed critical charge simulations introducing different degradation patterns in the cells, in three technology nodes, from 180 to 90 nm. The simulations results were checked with alpha-particle and heavy-ion irradiations on a 130-nm technology. Both simulations and experimental results show that NBTI degradation does not significantly affect the single-event upset SRAM cell rate as long as the parametric drift induced by aging is within 10\\%.

  5. Causal relationships between solar proton events and single event upsets for communication satellites

    Science.gov (United States)

    Lohmeyer, W. Q.; Cahoy, K.; Liu, Shiyang

    In this work, we analyze a historical archive of single event upsets (SEUs) maintained by Inmarsat, one of the world's leading providers of global mobile satellite communications services. Inmarsat has operated its geostationary communication satellites and collected extensive satellite anomaly and telemetry data since 1990. Over the course of the past twenty years, the satellites have experienced more than 226 single event upsets (SEUs), a catch-all term for anomalies that occur in a satellite's electronics such as bit-flips, trips in power supplies, and memory changes in attitude control systems. While SEUs are seemingly random and difficult to predict, we correlate their occurrences to space weather phenomena, and specifically show correlations between SEUs and solar proton events (SPEs). SPEs are highly energetic protons that originate from solar coronal mass ejections (CMEs). It is thought that when these particles impact geostationary (GEO) satellites they can cause SEUs as well as solar array degradation. We calculate the associated statistical correlations that each SEU occurs within one day, one week, two weeks, and one month of 10 MeV SPEs between 10 - 10,000 particle flux units (pfu). However, we find that SPEs are most prevalent at solar maximum and that the SEUs on Inmarsat's satellites occur out of phase with the solar maximum. Ultimately, this suggests that SPEs are not the primary cause of the Inmarsat SEUs. A better understanding of the causal relationship between SPEs and SEUs will help the satellite communications industry develop component and operational space weather mitigation techniques as well as help the space weather community to refine radiation models.

  6. Relationship between single-event upset immunity and fabrication processes of recent memories

    International Nuclear Information System (INIS)

    Nemoto, N.; Shindou, H.; Kuboyama, S.; Matsuda, S.; Itoh, H.; Okada, S.; Nashiyama, I.

    1999-01-01

    Single-Event upset (SEU) immunity for commercial devices were evaluated by irradiation tests using high-energy heavy ions. We show test results and describe the relationship between observed SEU and structures/fabrication processes. We have evaluated single-even upset (SEU) tolerance of recent commercial memory devices using high energy heavy ions in order to find relationship between SEU rate and their fabrication process. It was revealed that the change of the process parameter gives much effect for the SEU rate of the devices. (authors)

  7. 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

    2012-01-01

    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.

  8. Neutron-induced single event upsets in static RAMS observed at 10 km flight altitude

    International Nuclear Information System (INIS)

    Olsen, J.; Becher, P.E.; Fynbo, P.B.; Raaby, P. Schultz, J.

    1993-01-01

    Neutron induced single event upsets (SEUs) in static memory devices (SRAMs) have so far been seen only in laboratory environments. The authors report observations of 14 neutron induced SEUs at commercial aircraft flight altitudes as well. The observed SEU rate at 10 km flight altitude based on exposure of 160 standard 256 Kbit CMOS SRAMs is 4.8 · 10 -8 upsets/bit/day. In the laboratory 117 SRAMs of two different brands were irradiated with fast neutrons from a Pu-Be source. A total of 176 SEUs have been observed, among these are two SEU pairs. The upset rates from the laboratory tests are compared to those found in the airborne SRAMS

  9. NEPP Update of Independent Single Event Upset Field Programmable Gate Array Testing

    Science.gov (United States)

    Berg, Melanie; Label, Kenneth; Campola, Michael; Pellish, Jonathan

    2017-01-01

    This presentation provides a NASA Electronic Parts and Packaging (NEPP) Program update of independent Single Event Upset (SEU) Field Programmable Gate Array (FPGA) testing including FPGA test guidelines, Microsemi RTG4 heavy-ion results, Xilinx Kintex-UltraScale heavy-ion results, Xilinx UltraScale+ single event effect (SEE) test plans, development of a new methodology for characterizing SEU system response, and NEPP involvement with FPGA security and trust.

  10. Investigation of Single Events Upsets in Silicon and GaAs Structures Using Reaction Calculations

    Science.gov (United States)

    1994-09-01

    Cubed Corporation. The CREME (Cosmic-Ray-Effects on Microelectronics) (73) and the CRUP (Cos- mic Ray Upset Program) (74) are both from the Naval...knowledge, that is impossible to do in advance. The errors per bit day calculated using CREME and CRUP for a device exposed to Adams’ 90% worst-case...emitter junction was measured for alpha particles ion measurements and used in CREME (2) and CRUP from an Americium source in two ways: First, the (3

  11. Microbeam mapping of single event latchups and single event upsets in CMOS SRAMs

    International Nuclear Information System (INIS)

    Barak, J.; Adler, E.; Fischer, B.E.; Schloegl, M.; Metzger, S.

    1998-01-01

    The first simultaneous microbeam mapping of single event upset (SEU) and latchup (SEL) in the CMOS RAM HM65162 is presented. The authors found that the shapes of the sensitive areas depend on V DD , on the ions being used and on the site on the chip being hit by the ion. In particular, they found SEL sensitive sites close to the main power supply lines between the memory-bit-arrays by detecting the accompanying current surge. All these SELs were also accompanied by bit-flips elsewhere in the memory (which they call indirect SEUs in contrast to the well known SEUs induced in the hit memory cell only). When identical SEL sensitive sites were hit farther away from the supply lines only indirect SEL sensitive sites could be detected. They interpret these events as latent latchups in contrast to the classical ones detected by their induced current surge. These latent SELs were probably decoupled from the main supply lines by the high resistivity of the local supply lines

  12. Estimation of the LET threshold of single event upset of microelectronics in experiments with Cf-252

    International Nuclear Information System (INIS)

    Kuznetsov, N.V.; Nymmik, R.A.

    1996-01-01

    A method is proposed for analyzing single event upsets (SEU) in large scale integration circuits of random access memory (RAM) when exposed to Cf-252 fission fragments. The method makes is possible to find the RAM linear energy transfer (LET) threshold to be used for estimations of RAM SEU rates in space. The method is illustrated by analyzing experimental data for the 2 x 8 kbit CMOS/bulk RAM. (author)

  13. Acquisition and classification of static single-event upset cross section for SRAM-based FPGAs

    International Nuclear Information System (INIS)

    Yao Zhibin; Fan Ruyu; Guo Hongxia; Wang Zhongming; He Baoping; Zhang Fengqi; Zhang Keying

    2011-01-01

    In order to evaluate single event upsets (SEUs) in SRAM-based FPGAs and to find the sensitive resource in configuration memory, a heavy ions irradiation experiment was carried out on a Xilinx FPGAs device XCV300PQ240. The experiment was conducted to gain the static SEU cross section and classify the SEUs in configurations memory according to different resource uses. The results demonstrate that the inter-memory of SRAM-based FPGAs is extremely sensitive to heavy-ion-induced SEUs. The LUT and routing resources are the main source of SEUs in the configuration memory, which covers more than 97.46% of the total upsets. The SEU sensitivity of various resources is different. The IOB control bit and LUT elements are more sensitive,and more attention should be paid to the LUT elements in radiation hardening,which account for a quite large proportion of the configuration memory. (authors)

  14. Single event upsets calculated from new ENDF/B-VI proton and neutron data up to 150 MeV

    International Nuclear Information System (INIS)

    Chadwick, M.B.

    1999-01-01

    Single-event upsets (SEU) in microelectronics are calculated from newly-developed silicon nuclear reaction recoil data that extend up to 150 MeV, for incident protons and neutrons. Calculated SEU cross sections are compared with measured data

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

    Science.gov (United States)

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

    2017-01-01

    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.

  16. Single Event Upset Analysis: On-orbit performance of the Alpha Magnetic Spectrometer Digital Signal Processor Memory aboard the International Space Station

    Science.gov (United States)

    Li, Jiaqiang; Choutko, Vitaly; Xiao, Liyi

    2018-03-01

    Based on the collection of error data from the Alpha Magnetic Spectrometer (AMS) Digital Signal Processors (DSP), on-orbit Single Event Upsets (SEUs) of the DSP program memory are analyzed. The daily error distribution and time intervals between errors are calculated to evaluate the reliability of the system. The particle density distribution of International Space Station (ISS) orbit is presented and the effects from the South Atlantic Anomaly (SAA) and the geomagnetic poles are analyzed. The impact of solar events on the DSP program memory is carried out combining data analysis and Monte Carlo simulation (MC). From the analysis and simulation results, it is concluded that the area corresponding to the SAA is the main source of errors on the ISS orbit. Solar events can also cause errors on DSP program memory, but the effect depends on the on-orbit particle density.

  17. Single event upsets in semiconductor devices induced by highly ionising particles.

    Science.gov (United States)

    Sannikov, A V

    2004-01-01

    A new model of single event upsets (SEUs), created in memory cells by heavy ions and high energy hadrons, has been developed. The model takes into account the spatial distribution of charge collection efficiency over the cell area not considered in previous approaches. Three-dimensional calculations made by the HADRON code have shown good agreement with experimental data for the energy dependence of proton SEU cross sections, sensitive depths and other SEU observables. The model is promising for prediction of SEU rates for memory chips exposed in space and in high-energy experiments as well as for the development of a high-energy neutron dosemeter based on the SEU effect.

  18. Calculation of neutron-induced single-event upset cross sections for semiconductor memory devices

    International Nuclear Information System (INIS)

    Ikeuchi, Taketo; Watanabe, Yukinobu; Nakashima, Hideki; Sun, Weili

    2001-01-01

    Neutron-induced single-event upset (SEU) cross sections for semiconductor memory devices are calculated by the Burst Generation Rate (BGR) method using LA150 data and QMD calculation in the neutron energy range between 20 MeV and 10 GeV. The calculated results are compared with the measured SEU cross sections for energies up to 160 MeV, and the validity of the calculation method and the nuclear data used is verified. The kind of reaction products and the neutron energy range that have the most effect on SEU are discussed. (author)

  19. 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

    2012-01-01

    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.

  20. Low-energy neutron-induced single-event upsets in static random access memory

    International Nuclear Information System (INIS)

    Guo Xiaoqiang; Guo Hongxia; Wang Guizhen; Ling Dongsheng; Chen Wei; Bai Xiaoyan; Yang Shanchao; Liu Yan

    2009-01-01

    The visual analysis method of data process was provided for neutron-induced single-event upset(SEU) in static random access memory(SRAM). The SEU effects of six CMOS SRAMs with different feature size(from 0.13 μm to 1.50 μm) were studied. The SEU experiments were performed using the neutron radiation environment at Xi'an pulsed reactor. And the dependence of low-energy neutron-induced SEU cross section on SRAM's feature size was given. The results indicate that the decreased critical charge is the dominant factor for the increase of single event effect sensitivity of SRAM devices with decreased feature size. Small-sized SRAM devices are more sensitive than large-sized ones to single event effect induced by low-energy neutrons. (authors)

  1. Investigation of radial dose effect on single event upset cross-section due to heavy ions using GEANT4

    International Nuclear Information System (INIS)

    Boorboor, S.; Feghhi, S.A.H.; Jafari, H.

    2015-01-01

    The heavy ions are the main cause to produce single event upset (SEU) damage on electronic devices since they are high LET radiations. The dimension of electronic components in new technology, arise a challenge in radiation effect estimations. Accurate investigations require fully considering the ion track in energy deposition as a radial dose distribution. In this work, the distribution of delta rays as well as LET have been calculated to determine ionization structure around ion track by a Monte Carlo code, GEANT4. The radial dose of several heavy ions with different energy in silicon was investigated and compared with the works by other authors in this field. The results showed that heavy ions with identical LET can have different SEU cross-section in silicon transistors. As a demonstrative example, according to our results, the error probability for 4.8 GeV iron was 8 times greater than that for 15 MeV carbon ions, in transistors with new process technology which have small dimension and low critical charges. Our results show that considering radial dose distribution considerably improves the accuracy of the SEU cross-section estimation in electronic devices especially for new technologies. - Highlights: • The single event upset is produced by heavy ions interaction on electronic devices. • The radial dose of several heavy ions in silicon was calculated by GEANT4. • Heavy ions with identical LET had different SEU cross-section in silicon transistors. • Low dimension and critical charge devices were more sensitive to radial dose effect

  2. 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

    1997-11-01

    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)

  3. Influence of edge effects on single event upset susceptibility of SOI SRAMs

    International Nuclear Information System (INIS)

    Gu, Song; Liu, Jie; Zhao, Fazhan; Zhang, Zhangang; Bi, Jinshun; Geng, Chao; Hou, Mingdong; Liu, Gang; Liu, Tianqi; Xi, Kai

    2015-01-01

    An experimental investigation of the single event upset (SEU) susceptibility for heavy ions at tilted incidence was performed. The differences of SEU cross-sections between tilted incidence and normal incidence at equivalent effective linear energy transfer were 21% and 57% for the silicon-on-insulator (SOI) static random access memories (SRAMs) of 0.5 μm and 0.18 μm feature size, respectively. The difference of SEU cross-section raised dramatically with increasing tilt angle for SOI SRAM of deep-submicron technology. The result of CRÈME-MC simulation for tilted irradiation of the sensitive volume indicates that the energy deposition spectrum has a substantial tail extending into the low energy region. The experimental results show that the influence of edge effects on SEU susceptibility cannot be ignored in particular with device scaling down

  4. Single Event Upset in Static Random Access Memories in Atmospheric Neutron Environments

    Science.gov (United States)

    Arita, Yutaka; Takai, Mikio; Ogawa, Izumi; Kishimoto, Tadafumi

    2003-07-01

    Single-event upsets (SEUs) in a 0.4 μm 4 Mbit 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 476 m. 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 252Cf.

  5. A simple analytical model of single-event upsets in bulk CMOS

    Energy Technology Data Exchange (ETDEWEB)

    Sogoyan, Armen V.; Chumakov, Alexander I.; Smolin, Anatoly A., E-mail: aasmol@spels.ru; Ulanova, Anastasia V.; Boruzdina, Anna B.

    2017-06-01

    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.

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

    Energy Technology Data Exchange (ETDEWEB)

    Bourselier, Jean-Christophe

    2005-08-15

    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.

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

    International Nuclear Information System (INIS)

    Noah, E.; Bauer, T.; Bisello, D.; Faccio, F.; Friedl, M.; Fulcher, J.R.; Hall, G.; Huhtinen, M.; Kaminsky, A.; Pernicka, M.; Raymond, M.; Wyss, J.

    2002-01-01

    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

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

    International Nuclear Information System (INIS)

    Bourselier, Jean-Christophe

    2005-08-01

    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 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

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

    CERN Document Server

    Arita, Y; Ogawa, I; Kishimoto, T

    2003-01-01

    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)

  10. Study on relations between heavy ions single event upset cross sections and γ accumulated doses

    International Nuclear Information System (INIS)

    He Chaohui; Geng Bin; Wang Yanping; Peng Honglun; Yang Hailiang; Chen Xiaohua; Li Guozheng

    2002-01-01

    Experiments were done under 252 Cf and 60 Co γ source to study the relation between heavy ion Single Event Upset (SEU) cross sections and γ accumulated doses. There was no obvious rule and little influence of γ accumulated doses on SEU cross sections when Static Random Access Memories were in power off mode and static power on mode. In active measuring mode, the SEU cross section increased as the accumulated doses increasing when same data were written in memory cells. If reverse data, such as '55' and 'AA', were written in memory cells during the experiment, the SEU cross sections decreased to the level when memories were not irradiated under 60 Co γ source, even more small. It implied that the influence of γ accumulated doses on SEU cross sections can be set off by this method

  11. A simple analytical model of single-event upsets in bulk CMOS

    International Nuclear Information System (INIS)

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

    2017-01-01

    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.

  12. Implications of the spatial dependence of the single-event-upset threshold in SRAMs measured with a pulsed laser

    International Nuclear Information System (INIS)

    Buchner, S.; Langworthy, J.B.; Stapor, W.J.; Campbell, A.B.; Rivet, S.

    1994-01-01

    Pulsed laser light was used to measure single event upset (SEU) thresholds for a large number of memory cells in both CMOS and bipolar SRAMs. Results showed that small variations in intercell upset threshold could not explain the gradual rise in the curve of cross section versus linear energy transfer (LET). The memory cells exhibited greater intracell variations implying that the charge collection efficiency within a memory cell varies spatially and contributes substantially to the shape of the curve of cross section versus LET. The results also suggest that the pulsed laser can be used for hardness-assurance measurements on devices with sensitive areas larger than the diameter of the laser beam

  13. 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: sanjay@physics.unipune.ernet.in

    2008-04-15

    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.

  14. Application of RADSAFE to Model Single Event Upset Response of a 0.25 micron CMOS SRAM

    Science.gov (United States)

    Warren, Kevin M.; Weller, Robert A.; Sierawski, Brian; Reed, Robert A.; Mendenhall, Marcus H.; Schrimpf, Ronald D.; Massengill, Lloyd; Porter, Mark; Wilkerson, Jeff; LaBel, Kenneth A.; hide

    2006-01-01

    The RADSAFE simulation framework is described and applied to model Single Event Upsets (SEU) in a 0.25 micron CMOS 4Mbit Static Random Access Memory (SRAM). For this circuit, the RADSAFE approach produces trends similar to those expected from classical models, but more closely represents the physical mechanisms responsible for SEU in the SRAM circuit.

  15. Impact of temperature on single event upset measurement by heavy ions in SRAM devices

    International Nuclear Information System (INIS)

    Liu Tianqi; Geng Chao; Zhang Zhangang; Gu Song; Tong Teng; Xi Kai; Hou Mingdong; Liu Jie; Zhao Fazhan; Liu Gang; Han Zhengsheng

    2014-01-01

    The temperature dependence of single event upset (SEU) measurement both in commercial bulk and silicon on insulator (SOI) static random access memories (SRAMs) has been investigated by experiment in the Heavy Ion Research Facility in Lanzhou (HIRFL). For commercial bulk SRAM, the SEU cross section measured by 12 C ions is very sensitive to the temperature. The temperature test of SEU in SOI SRAM was conducted by 209 Bi and 12 C ions, respectively, and the SEU cross sections display a remarkable growth with the elevated temperature for 12 C ions but keep constant for 209 Bi ions. The impact of temperature on SEU measurement was analyzed by Monte Carlo simulation. It is revealed that the SEU cross section is significantly affected by the temperature around the threshold linear energy transfer of SEU occurrence. As the SEU occurrence approaches saturation, the SEU cross section gradually exhibits less temperature dependency. Based on this result, the experimental data measured in HIRFL was analyzed, and then a reasonable method of predicting the on-orbit SEU rate was proposed. (semiconductor devices)

  16. Single Event Upset Rate Estimates for a 16-K CMOS (Complementary Metal Oxide Semiconductor) SRAM (Static Random Access Memory).

    Science.gov (United States)

    1986-09-30

    4 . ~**..ft.. ft . - - - ft SI TABLES 9 I. SA32~40 Single Event Upset Test, 1140-MeV Krypton, 9/l8/8~4. . .. .. .. .. .. .16 II. CRUP Simulation...cosmic ray interaction analysis described in the remainder of this report were calculated using the CRUP computer code 3 modified for funneling. The... CRUP code requires, as inputs, the size of a depletion region specified as a retangular parallel piped with dimensions a 9 b S c, the effective funnel

  17. Development of Single-Event Upset hardened programmable logic devices in deep submicron CMOS

    International Nuclear Information System (INIS)

    Bonacini, S.

    2007-11-01

    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 μm CMOS technology. The FPGA under development is a 32*32 logic block array, equivalent to ∼ 25 k gates, in 0.13 μm CMOS. The irradiation test results obtained in the CMOS 0.25 μm technology demonstrate good robustness of the circuit up to an LET (Linear Energy Transfer) of 79.6 cm 2 *MeV/mg, which make it suitable for the target environment. The CMOS 0.13 μm circuit has showed robustness to an LET of 37.4 cm 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

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

    Science.gov (United States)

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

    2017-01-01

    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.

  19. Characterization of System on a Chip (SoC) Single Event Upset (SEU) Responses Using SEU Data, Classical Reliability Models, and Space Environment Data

    Science.gov (United States)

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

    2017-01-01

    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.

  20. FinFET memory cell improvements for higher immunity against single event upsets

    Science.gov (United States)

    Sajit, Ahmed Sattar

    The 21st century is witnessing a tremendous demand for transistors. Life amenities have incorporated the transistor in every aspect of daily life, ranging from toys to rocket science. Day by day, scaling down the transistor is becoming an imperious necessity. However, it is not a straightforward process; instead, it faces overwhelming challenges. Due to these scaling changes, new technologies, such as FinFETs for example, have emerged as alternatives to the conventional bulk-CMOS technology. FinFET has more control over the channel, therefore, leakage current is reduced. FinFET could bridge the gap between silicon devices and non-silicon devices. The semiconductor industry is now incorporating FinFETs in systems and subsystems. For example, Intel has been using them in their newest processors, delivering potential saving powers and increased speeds to memory circuits. Memory sub-systems are considered a vital component in the digital era. In memory, few rows are read or written at a time, while the most rows are static; hence, reducing leakage current increases the performance. However, as a transistor shrinks, it becomes more vulnerable to the effects from radioactive particle strikes. If a particle hits a node in a memory cell, the content might flip; consequently, leading to corrupting stored data. Critical fields, such as medical and aerospace, where there are no second chances and cannot even afford to operate at 99.99% accuracy, has induced me to find a rigid circuit in a radiated working environment. This research focuses on a wide spectrum of memories such as 6T SRAM, 8T SRAM, and DICE memory cells using FinFET technology and finding the best platform in terms of Read and Write delay, susceptibility level of SNM, RSNM, leakage current, energy consumption, and Single Event Upsets (SEUs). This research has shown that the SEU tolerance that 6T and 8T FinFET SRAMs provide may not be acceptable in medical and aerospace applications where there is a very high

  1. Comparison of analytical models and experimental results for single-event upset in CMOS SRAMs

    International Nuclear Information System (INIS)

    Mnich, T.M.; Diehl, S.E.; Shafer, B.D.

    1983-01-01

    In an effort to design fully radiation-hardened memories for satellite and deep-space applications, a 16K and a 2K CMOS static RAM were modeled for single-particle upset during the design stage. The modeling resulted in the addition of a hardening feedback resistor in the 16K remained tentatively unaltered. Subsequent experiments, using the Lawrence Berkeley Laboratories' 88-inch cyclotron to accelerate krypton and oxygen ions, established an upset threshold for the 2K and the 16K without resistance added, as well as a hardening threshold for the 16K with feedback resistance added. Results for the 16K showed it to be hardenable to the higher level than previously published data for other unhardened 16K RAMs. The data agreed fairly well with the modeling results; however, a close look suggests that modification of the simulation methodology is required to accurately predict the resistance necessary to harden the RAM cell

  2. Single-Event Upset and Scaling Trends in New Generation of the Commercial SOI PowerPC Microprocessors

    Science.gov (United States)

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

    2006-01-01

    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.

  3. Nuclear data relevant to single event upsets in semiconductor memories induced by cosmic-ray neutrons and protons

    International Nuclear Information System (INIS)

    Watanabe, Yukinobu

    2008-01-01

    The role of nuclear data is examined in the study of single event upset (SEU) phenomena in semiconductor memories caused by cosmic-ray neutrons and protons. Neutron and proton SEU cross sections are calculated with a simplified semi-empirical model using experimental heavy-ion SEU cross-sections and a dedicated database of neutron and proton induced reactions on 28 Si. Some impacts of the nuclear reaction data on SEU simulation are analyzed by investigating relative contribution of secondary ions and neutron elastic scattering to SEU and influence of simultaneous multiple ions emission on SEU. (author)

  4. Synergistic effects of total ionizing dose on single event upset sensitivity in static random access memory under proton irradiation

    International Nuclear Information System (INIS)

    Xiao Yao; Guo Hong-Xia; Zhang Feng-Qi; Zhao Wen; Wang Yan-Ping; Zhang Ke-Ying; Ding Li-Li; Luo Yin-Hong; Wang Yuan-Ming; Fan Xue

    2014-01-01

    Synergistic effects of the total ionizing dose (TID) on the single event upset (SEU) sensitivity in static random access memories (SRAMs) were studied by using protons. The total dose was cumulated with high flux protons during the TID exposure, and the SEU cross section was tested with low flux protons at several cumulated dose steps. Because of the radiation-induced off-state leakage current increase of the CMOS transistors, the noise margin became asymmetric and the memory imprint effect was observed. (interdisciplinary physics and related areas of science and technology)

  5. Simulation of thermal-neutron-induced single-event upset using particle and heavy-ion transport code system

    International Nuclear Information System (INIS)

    Arita, Yutaka; Kihara, Yuji; Mitsuhasi, Junichi; Niita, Koji; Takai, Mikio; Ogawa, Izumi; Kishimoto, Tadafumi; Yoshihara, Tsutomu

    2007-01-01

    The simulation of a thermal-neutron-induced single-event upset (SEU) was performed on a 0.4-μm-design-rule 4 Mbit static random access memory (SRAM) using particle and heavy-ion transport code system (PHITS): The SEU rates obtained by the simulation were in very good agreement with the result of experiments. PHITS is a useful tool for simulating SEUs in semiconductor devices. To further improve the accuracy of the simulation, additional methods for tallying the energy deposition are required for PHITS. (author)

  6. Solar Particle Induced Upsets in the TDRS-1 Attitude Control System RAM During the October 1989 Solar Particle Events

    Science.gov (United States)

    Croley, D. R.; Garrett, H. B.; Murphy, G. B.; Garrard,T. L.

    1995-01-01

    The three large solar particle events, beginning on October 19, 1989 and lasting approximately six days, were characterized by high fluences of solar protons and heavy ions at 1 AU. During these events, an abnormally large number of upsets (243) were observed in the random access memory of the attitude control system (ACS) control processing electronics (CPE) on-board the geosynchronous TDRS-1 (Telemetry and Data Relay Satellite). The RAM unit affected was composed of eight Fairchild 93L422 memory chips. The Galileo spacecraft, launched on October 18, 1989 (one day prior to the solar particle events) observed the fluxes of heavy ions experienced by TDRS-1. Two solid-state detector telescopes on-board Galileo, designed to measure heavy ion species and energy, were turned on during time periods within each of the three separate events. The heavy ion data have been modeled and the time history of the events reconstructed to estimate heavy ion fluences. These fluences were converted to effective LET spectra after transport through the estimated shielding distribution around the TDRS-1 ACS system. The number of single event upsets (SEU) expected was calculated by integrating the measured cross section for the Fairchild 93L422 memory chip with average effective LET spectrum. The expected number of heavy ion induced SEU's calculated was 176. GOES-7 proton data, observed during the solar particle events, were used to estimate the number of proton-induced SEU's by integrating the proton fluence spectrum incident on the memory chips, with the two-parameter Bendel cross section for proton SEU'S. The proton fluence spectrum at the device level was gotten by transporting the protons through the estimated shielding distribution. The number of calculated proton-induced SEU's was 72, yielding a total of 248 predicted SEU'S, very dose to the 243 observed SEU'S. These calculations uniquely demonstrate the roles that solar heavy ions and protons played in the production of SEU

  7. Single event upset and charge collection measurements using high energy protons and neutrons

    International Nuclear Information System (INIS)

    Normand, E.; Oberg, D.L.; Wert, J.L.; Ness, J.D.; Majewski, P.P.; Wender, S.; Gavron, A.

    1994-01-01

    RAMs, microcontrollers and surface barrier detectors were exposed to beams of high energy protons and neutrons to measure the induced number of upsets as well as energy deposition. The WNR facility at Los Alamos provided a neutron spectrum similar to that of the atmospheric neutrons. Its effect on devices was compared to that of protons with energies of 200, 400, 500, and 800 MeV. Measurements indicate that SEU cross sections for 400 MeV protons are similar to those induced by the atmospheric neutron spectrum

  8. Solar particle induced upsets in the TDRS-1 attitude control system RAM during the October 1989 solar particle events

    International Nuclear Information System (INIS)

    Croley, D.R.; Garrett, H.B.; Murphy, G.B.; Garrard, T.L.

    1995-01-01

    The three large solar particle events, beginning on October 19, 1989 and lasting approximately six days, were characterized by high fluences of solar protons and heavy ions at 1 AU. During these events, an abnormally large number of upsets (243) were observed in the random access memory of the attitude control system (ACS) control processing electronics (CPE) on-board the geosynchronous TDRS-1 (Telemetry and Data Relay Satellite). The RAM unit affected was composed of eight Fairchild 93L422 memory chips. The Galileo spacecraft, launched on October 18, 1989 (one day prior to the solar particle events) observed the fluxes of heavy ions experienced by TDRS-1. Two solid-state detector telescopes on-board Galileo, designed to measure heavy ion species and energy, were turned on during time periods within each of the three separate events. The heavy ion data have been modeled and the time history of the events reconstructed to estimate heavy ion fluences. These fluences were converted to effective LET spectra after transport through the estimated shielding distribution around the TDRS-1 ACS system. The number of single event upsets (SEU) expected was calculated by integrating the measured cross section for the Fairchild 93L422 memory chip with average effective LET spectrum. The expected number of heavy ion induced SEU's calculated was 176. GOES-7 proton data, observed during the solar particle events, were used to estimate the number of proton-induced SEU's by integrating the proton fluence spectrum incident on the memory chips, with the two-parameter Bendel cross section for proton SEU's. The proton fluence spectrum at the device level was gotten by transporting the protons through the estimated shielding distribution. The number of calculated proton-induced SEU's was 72, yielding a total of 248 predicted SEU's, very close to the 243 observed SEU's

  9. Feasibility of a neutron detector-dosemeter based on single-event upsets in dynamic random-access memories

    International Nuclear Information System (INIS)

    Phillips, G.W.; August, R.A.; Campbell, A.B.; Nelson, M.E.; Guardala, N.A.; Price, J.L.; Moscovitch, M.

    2002-01-01

    The feasibility was investigated of a solid-state neutron detector/dosemeter based on single-event upset (SEU) effects in dynamic random-access memories (DRAMs), commonly used in computer memories. Such a device, which uses a neutron converter material to produce a charged particle capable of causing an upset, would be light-weight, low-power, and could be read simply by polling the memory for bit flips. It would have significant advantages over standard solid-state neutron dosemeters which require off-line processing for track etching and analysis. Previous efforts at developing an SEU neutron detector/dosemeter have suffered from poor response, which can be greatly enhanced by selecting a modern high-density DRAM chip for SEU sensitivity and by using a thin 10 B film as a converter. Past attempts to use 10 B were not successful because the average alpha particle energy was insufficient to penetrate to the sensitive region of the memory. This can be overcome by removing the surface passivation layer before depositing the 10 B film or by implanting 10B directly into the chip. Previous experimental data show a 10 3 increase in neutron sensitivity by chips containing borosilicate glass, which could be used in an SEU detector. The results are presented of simulations showing that the absolute efficiency of an SEU neutron dosemeter can be increased by at least a factor of 1000 over earlier designs. (author)

  10. Monte Carlo calculation of the cross-section of single event upset induced by 14MeV neutrons

    International Nuclear Information System (INIS)

    Li, H.; Deng, J.Y.; Chang, D.M.

    2005-01-01

    High-density static random access memory may experience single event upsets (SEU) in neutron environments. We present a new method to calculate the SEU cross-section. Our method is based on explicit generation and transport of the secondary reaction products and detailed accounting for energy loss by ionization. Instead of simulating the behavior of the circuit, we use the Monte Carlo method to simulate the process of energy deposition in sensitive volumes. Thus, we do not need to know details about the circuit. We only need a reasonable guess for the size of the sensitive volumes. In the Monte Carlo simulation, the cross-section of SEU induced by 14MeV neutrons is calculated. We can see that the Monte Carlo simulation not only can provide a new method to calculate SEU cross-section, but also can give a detailed description about random process of the SEU

  11. Nuclear data relevant to single-event upsets (SEU) in microelectronics and their application to SEU simulation

    International Nuclear Information System (INIS)

    Watanabe, Yukinobu; Tukamoto, Yasuyuki; Kodama, Akihiro; Nakashima, Hideki

    2004-01-01

    A cross-section database for neutron-induced reactions on 28 Si was developed in the energy range between 2 MeV and 3 GeV in order to analyze single-event upsets (SEUs) phenomena induced by cosmic-ray neutrons in microelectronic devices. A simplified spherical device model was proposed for simulation of the initial process of SEUs. The model was applied to SEU cross-section calculations for semiconductor memory devices. The calculated results were compared with measured SEU cross-sections and the other simulation result. The dependence of SEU cross-sections on incident neutron energy and secondary ions having the most important effects on SEUs are discussed. (author)

  12. Neutron-induced Single Event Upset on the RPC front-end chips for the CMS experiment

    Energy Technology Data Exchange (ETDEWEB)

    Abbrescia, M.; Colaleo, A.; Iaselli, G.; Loddo, F.; Maggi, M.; Marangelli, B.; Natali, S.; Nuzzo, S.; Pugliese, G.; Ranieri, A.; Romano, F.; Altieri, S.; Belli, G.; Bruno, G.; Guida, R.; Merlo, M.; Ratti, S.P.; Riccardi, C.; Torre, P.; Vitulo, P. E-mail: paolo.vitulo@pv.infn.it; De Bari, A.; Manera, S

    2002-05-21

    Neutrons from a reactor and from a cyclotron have been used to characterise the CMS Resistive Plate Chambers (RPCs) front-end chip to neutron-induced damaging events. Single Event Upset (SEU) cross-sections have been measured up to 60 MeV for different chip thresholds. Tests at a reactor were done with an integrated fast (E{sub n}>3 MeV) neutron fluence of 1.7x10{sup 10} cm{sup -2} and a thermal neutron fluence of 9.5x10{sup 11} cm{sup -2}. High-energy neutrons from a cyclotron were used up to a fluence of 10{sup 12} cm{sup -2}. Data indicate the existence of a chip SEU sensitivity already at thermal energy and a saturated SEU cross-section from 3 to 60 MeV. Values of the SEU cross-sections from the thermal run well agree with those obtained by another CMS group that uses the same technology (0.8 {mu}m BiCMOS) though with different architecture. Cross-sections obtained with fast neutrons (from 3 MeV to about 10 MeV) are consistently higher by one order of magnitude compared to the thermal one. The average time between consecutive SEU events in each chip of the CMS barrel RPCs can be estimated to be 1 h.

  13. Notice of Violation of IEEE Publication PrinciplesJoint Redundant Residue Number Systems and Module Isolation for Mitigating Single Event Multiple Bit Upsets in Datapath

    Science.gov (United States)

    Li, Lei; Hu, Jianhao

    2010-12-01

    Notice of Violation of IEEE Publication Principles"Joint Redundant Residue Number Systems and Module Isolation for Mitigating Single Event Multiple Bit Upsets in Datapath"by Lei Li and Jianhao Hu,in the IEEE Transactions on Nuclear Science, vol.57, no.6, Dec. 2010, pp. 3779-3786After careful and considered review of the content and authorship of this paper by a duly constituted expert committee, this paper has been found to be in violation of IEEE's Publication Principles.This paper contains substantial duplication of original text from the paper cited below. The original text was copied without attribution (including appropriate references to the original author(s) and/or paper title) and without permission.Due to the nature of this violation, reasonable effort should be made to remove all past references to this paper, and future references should be made to the following articles:"Multiple Error Detection and Correction Based on Redundant Residue Number Systems"by Vik Tor Goh and M.U. Siddiqi,in the IEEE Transactions on Communications, vol.56, no.3, March 2008, pp.325-330"A Coding Theory Approach to Error Control in Redundant Residue Number Systems. I: Theory and Single Error Correction"by H. Krishna, K-Y. Lin, and J-D. Sun, in the IEEE Transactions on Circuits and Systems II: Analog and Digital Signal Processing, vol.39, no.1, Jan 1992, pp.8-17In this paper, we propose a joint scheme which combines redundant residue number systems (RRNS) with module isolation (MI) for mitigating single event multiple bit upsets (SEMBUs) in datapath. The proposed hardening scheme employs redundant residues to improve the fault tolerance for datapath and module spacings to guarantee that SEMBUs caused by charge sharing do not propagate among the operation channels of different moduli. The features of RRNS, such as independence, parallel and error correction, are exploited to establish the radiation hardening architecture for the datapath in radiation environments. In the proposed

  14. A random access memory immune to single event upset using a T-Resistor

    Science.gov (United States)

    Ochoa, A. Jr.

    1987-10-28

    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.

  15. Random access memory immune to single event upset using a T-resistor

    Science.gov (United States)

    Ochoa, Jr., Agustin

    1989-01-01

    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.

  16. Challenge and Error: Critical Events and Attention-Related Errors

    Science.gov (United States)

    Cheyne, James Allan; Carriere, Jonathan S. A.; Solman, Grayden J. F.; Smilek, Daniel

    2011-01-01

    Attention lapses resulting from reactivity to task challenges and their consequences constitute a pervasive factor affecting everyday performance errors and accidents. A bidirectional model of attention lapses (error [image omitted] attention-lapse: Cheyne, Solman, Carriere, & Smilek, 2009) argues that errors beget errors by generating attention…

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

    International Nuclear Information System (INIS)

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

    2013-01-01

    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. (geophysics, astronomy, and astrophysics)

  18. Preventing Medication Error Based on Knowledge Management Against Adverse Event

    OpenAIRE

    Hastuti, Apriyani Puji; Nursalam, Nursalam; Triharini, Mira

    2017-01-01

    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 sta...

  19. Critical lengths of error events in convolutional codes

    DEFF Research Database (Denmark)

    Justesen, Jørn

    1994-01-01

    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

    1998-01-01

    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 a Nuclear Reaction Database on Silicon for Simulation of Neutron-Induced Single-Event Upsets in Microelectronics and its Application

    International Nuclear Information System (INIS)

    Watanabe, Yukinobu; Kodama, Akihiro; Tukamoto, Yasuyuki; Nakashima, Hideki

    2005-01-01

    We have developed a cross-section database for neutron-induced reactions on 28Si in the energy range between 2 MeV and 3 GeV in order to analyze single-event upsets (SEUs) phenomena induced by cosmic-ray neutrons in microelectronic devices. A simplified spherical device model is proposed for simulation of the initial processes of SEUs. The model is applied to SEU cross-section calculations for semiconductor memory devices. The calculated results are compared with measured SEU cross sections and the other simulation result. The dependence of SEU cross sections on incident neutron energy and secondary ions having the most important effects on SEUs are discussed

  2. Relationship between single-event upset immunity and fabrication processes of recent memories; Relations entre l'immunite au SEU et les procedes de fabrication de memoires recentes

    Energy Technology Data Exchange (ETDEWEB)

    Nemoto, N.; Shindou, H.; Kuboyama, S.; Matsuda, S. [National Space Development Agency of Japan, Ibaraki-ken (Japan); Itoh, H.; Okada, S.; Nashiyama, I. [Japan Atomic Energy Research Inst., Takasaki, Gunma (Japan)

    1999-07-01

    Single-Event upset (SEU) immunity for commercial devices were evaluated by irradiation tests using high-energy heavy ions. We show test results and describe the relationship between observed SEU and structures/fabrication processes. We have evaluated single-even upset (SEU) tolerance of recent commercial memory devices using high energy heavy ions in order to find relationship between SEU rate and their fabrication process. It was revealed that the change of the process parameter gives much effect for the SEU rate of the devices. (authors)

  3. Upsetting the apple cart: a community anticoagulation clinic survey of life event factors that undermine safe therapy.

    Science.gov (United States)

    Edmundson, Sarah; Stuenkel, Diane L; Connolly, Phyllis M

    2005-09-01

    Anticoagulation therapy is a life-enhancing therapy for patients who are at risk for embolic events secondary to atrial fibrillation, valve replacement, and other comorbidities. Clinicians are motivated to decrease the amount of time that patients are either under- or over-anticoagulated, common conditions that decrease patient safety at either extreme. The primary purpose of this descriptive study was to examine the relationship between personal life event factors as measured by Norbeck's Life Events Questionnaire, core demographics such as age and income, and anticoagulation regulation. Although many factors affect anticoagulation therapy, the precise impact of life events, positive or negative, is unknown. The salient findings of this study (n = 202) showed a small, though statistically significant, inverse relationship (r = -0.184, P < .01) between negative life events and decreased time within therapeutic international normalized ratio. Total Life Event scores showed a statistically significant inverse relationship (r = -0.159, P < .05) to international normalized ratio time within therapeutic level. Lower income was inversely associated with higher negative Life Event scores (r = -0.192, P < .01). The findings demonstrate the need for strategies that address the potential impact of life events in conjunction with coexisting screening measures used in anticoagulation clinics. Implications for this study are limited by lack of methodology documenting concurrent social support factors and limitations of the research tool to reflect life event issues specific to outpatient seniors.

  4. Analysis by Monte Carlo simulations of the sensitivity to single event upset of SRAM memories under spatial proton or terrestrial neutron environment

    International Nuclear Information System (INIS)

    Lambert, D.

    2006-07-01

    Electronic systems in space and terrestrial environments are subjected to a flow of particles of natural origin, which can induce dysfunctions. These particles can cause Single Event Upsets (SEU) in SRAM memories. Although non-destructive, the SEU can have consequences on the equipment functioning in applications requiring a great reliability (airplane, satellite, launcher, medical, etc). Thus, an evaluation of the sensitivity of the component technology is necessary to predict the reliability of a system. In atmospheric environment, the SEU sensitivity is mainly caused by the secondary ions resulting from the nuclear reactions between the neutrons and the atoms of the component. In space environment, the protons with strong energies induce the same effects as the atmospheric neutrons. In our work, a new code of prediction of the rate of SEU has been developed (MC-DASIE) in order to quantify the sensitivity for a given environment and to explore the mechanisms of failures according to technology. This code makes it possible to study various technologies of memories SRAM (Bulk and SOI) in neutron and proton environment between 1 MeV and 1 GeV. Thus, MC-DASIE was used with experiment data to study the effect of integration on the sensitivity of the memories in terrestrial environment, a comparison between the neutron and proton irradiations and the influence of the modeling of the target component on the calculation of the rate of SEU. (author)

  5. 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

    2007-11-15

    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.

  6. Adverse Drug Events caused by Serious Medication Administration Errors

    Science.gov (United States)

    Sawarkar, Abhivyakti; Keohane, Carol A.; Maviglia, Saverio; Gandhi, Tejal K; Poon, Eric G

    2013-01-01

    OBJECTIVE To determine how often serious or life-threatening medication administration errors with the potential to cause patient harm (or potential adverse drug events) result in actual patient harm (or adverse drug events (ADEs)) in the hospital setting. DESIGN Retrospective chart review of clinical events that transpired following observed medication administration errors. BACKGROUND Medication errors are common at the medication administration stage for hospitalized patients. While many of these errors are considered capable of causing patient harm, it is not clear how often patients are actually harmed by these errors. METHODS In a previous study where 14,041 medication administrations in an acute-care hospital were directly observed, investigators discovered 1271 medication administration errors, of which 133 had the potential to cause serious or life-threatening harm to patients and were considered serious or life-threatening potential ADEs. In the current study, clinical reviewers conducted detailed chart reviews of cases where a serious or life-threatening potential ADE occurred to determine if an actual ADE developed following the potential ADE. Reviewers further assessed the severity of the ADE and attribution to the administration error. RESULTS Ten (7.5% [95% C.I. 6.98, 8.01]) actual adverse drug events or ADEs resulted from the 133 serious and life-threatening potential ADEs, of which 6 resulted in significant, three in serious, and one life threatening injury. Therefore 4 (3% [95% C.I. 2.12, 3.6]) serious and life threatening potential ADEs led to serious or life threatening ADEs. Half of the ten actual ADEs were caused by dosage or monitoring errors for anti-hypertensives. The life threatening ADE was caused by an error that was both a transcription and a timing error. CONCLUSION Potential ADEs at the medication administration stage can cause serious patient harm. Given previous estimates of serious or life-threatening potential ADE of 1.33 per 100

  7. Interactive analysis of human error factors in NPP operation events

    International Nuclear Information System (INIS)

    Zhang Li; Zou Yanhua; Huang Weigang

    2010-01-01

    Interactive of human error factors in NPP operation events were introduced, and 645 WANO operation event reports from 1999 to 2008 were analyzed, among which 432 were found relative to human errors. After classifying these errors with the Root Causes or Causal Factors, and then applying SPSS for correlation analysis,we concluded: (1) Personnel work practices are restricted by many factors. Forming a good personnel work practices is a systematic work which need supports in many aspects. (2)Verbal communications,personnel work practices, man-machine interface and written procedures and documents play great roles. They are four interaction factors which often come in bundle. If some improvements need to be made on one of them,synchronous measures are also necessary for the others.(3) Management direction and decision process, which are related to management,have a significant interaction with personnel factors. (authors)

  8. Airplane Upset Training Evaluation Report

    Science.gov (United States)

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

    2002-01-01

    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.

  9. The measurement and prediction of proton upset

    Science.gov (United States)

    Shimano, Y.; Goka, T.; Kuboyama, S.; Kawachi, K.; Kanai, T.

    1989-12-01

    The authors evaluate tolerance to proton upset for three kinds of memories and one microprocessor unit for space use by irradiating them with high-energy protons up to nearly 70 MeV. They predict the error rates of these memories using a modified semi-empirical equation of Bendel and Petersen (1983). A two-parameter method was used instead of Bendel's one-parameter method. There is a large difference between these two methods with regard to the fitted parameters. The calculation of upset rates in orbits were carried out using these parameters and NASA AP8MAC, AP8MIC. For the 93419 RAM the result of this calculation was compared with the in-orbit data taken on the MOS-1 spacecraft. A good agreement was found between the two sets of upset-rate data.

  10. Categorizing errors and adverse events for learning: a provider perspective.

    Science.gov (United States)

    Ginsburg, Liane R; Chuang, You-Ta; Richardson, Julia; Norton, Peter G; Berta, Whitney; Tregunno, Deborah; Ng, Peggy

    2009-01-01

    There is little agreement in the literature as to what types of patient safety events (PSEs) should be the focus for learning, change and improvement, and we lack clear and universally accepted definitions of error. In particular, the way front-line providers or managers understand and categorize different types of errors, adverse events and near misses and the kinds of events this audience believes to be valuable for learning are not well understood. Focus groups of front-line providers, managers and patient safety officers were used to explore how people in healthcare organizations understand and categorize different types of PSEs in the context of bringing about learning from such events. A typology of PSEs was developed from the focus group data and then mailed, along with a short questionnaire, to focus group participants for member checking and validation. Four themes emerged from our data: (1) incidence study categories are problematic for those working in organizations; (2) preventable events should be the focus for learning; (3) near misses are an important but complex category, differentiated based on harm potential and proximity to patients; (4) staff disagree on whether events causing severe harm or events with harm potential are most valuable for learning. A typology of PSEs based on these themes and checked by focus group participants indicates that staff and their managers divide events into simple categories of minor and major events, which are differentiated based on harm or harm potential. Confusion surrounding patient safety terminology detracts from the abilities of providers to talk about and reflect on a range of PSEs, and from opportunities to enhance learning, reduce event reoccurrence and improve patient safety at the point of care.

  11. Radiation-hardened MRAM-based LUT for non-volatile FPGA soft error mitigation with multi-node upset tolerance

    Science.gov (United States)

    Zand, Ramtin; DeMara, Ronald F.

    2017-12-01

    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.

  12. Proton induced single event upset cross section prediction for 0.15 μm six-transistor (6T) silicon-on-insulator static random access memories

    International Nuclear Information System (INIS)

    Li Lei; Zhou Wanting; Liu Huihua

    2012-01-01

    In this paper, an efficient physics-based method to estimate the saturated proton upset cross section for six-transistor (6T) silicon-on-insulator (SOI) static random access memory (SRAM) cells using layout and technology parameters is proposed. This method calculates the effects of radiation based on device physics. The simple method handles the problem with ease by SPICE simulations, which can be divided into two stages. At first, it uses a standard SPICE program to predict the cross section for recoiling heavy ions with linear energy transfer (LET) of 14 MeV-cm 2 /mg. Then, the predicted cross section for recoiling heavy ions with LET of 14 MeV-cm 2 /mg is used to estimate the saturated proton upset cross section for 6T SOI SRAM cells with a simple model. The calculated proton induced upset cross section based on this method is in good agreement with the test results of 6T SOI SRAM cells processed using 0.15 μm technology. (author)

  13. Human error probability estimation using licensee event reports

    International Nuclear Information System (INIS)

    Voska, K.J.; O'Brien, J.N.

    1984-07-01

    Objective of this report is to present a method for using field data from nuclear power plants to estimate human error probabilities (HEPs). These HEPs are then used in probabilistic risk activities. This method of estimating HEPs is one of four being pursued in NRC-sponsored research. The other three are structured expert judgment, analysis of training simulator data, and performance modeling. The type of field data analyzed in this report is from Licensee Event reports (LERs) which are analyzed using a method specifically developed for that purpose. However, any type of field data or human errors could be analyzed using this method with minor adjustments. This report assesses the practicality, acceptability, and usefulness of estimating HEPs from LERs and comprehensively presents the method for use

  14. Translational errors as an early event in prion conversion.

    Science.gov (United States)

    Hatin, I; Bidou, L; Cullin, C; Rousset, J P

    2001-01-01

    A prion is an infectious, altered form of a cellular protein which can self-propagate and affect normal phenotype. Prion conversion has been observed for mammalian and yeast proteins but molecular mechanisms that trigger this process remain unclear. Up to now, only post-translational models have been explored. In this work, we tested the hypothesis that co-translational events may be implicated in the conformation changes of the Ure2p protein of Saccharomyces cerevisiae. This protein can adopt a prion conformation leading to an [URE3] phenotype which can be easily assessed and quantified. We analyzed the effect of two antibiotics, known to affect translation, on [URE3] conversion frequency. For cells treated with G418 we observed a parallel increase of translational errors rate and frequency of [URE3] conversion. By contrast, cycloheximide which was not found to affect translational fidelity, has no influence on the induction of [URE3] phenotype. These results raise the possibility that the mechanism of prion conversion might not only involve alternative structures of strictly identical molecules but also aberrant proteins resulting from translational errors.

  15. SUPRA - Enhanced upset recovery simulation

    NARCIS (Netherlands)

    Groen, E.; Ledegang, W.; Field, J.; Smaili, H.; Roza, M.; Fucke, L.; Nooij, S.; Goman, M.; Mayrhofer, M.; Zaichik, L.E.; Grigoryev, M.; Biryukov, V.

    2012-01-01

    The SUPRA research project - Simulation of Upset Recovery in Aviation - has been funded by the European Union 7th Framework Program to enhance the flight simulation envelope for upset recovery simulation. Within the project an extended aerodynamic model, capturing the key aerodynamics during and

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

    National Research Council Canada - National Science Library

    Rodi, William L

    2006-01-01

    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...

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

    Directory of Open Access Journals (Sweden)

    Mohammad Hajiakbari

    2015-12-01

    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.

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

    Directory of Open Access Journals (Sweden)

    Yiwen Mei

    2016-03-01

    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.

  19. Cause analysis and preventives for human error events in Daya Bay NPP

    International Nuclear Information System (INIS)

    Huang Weigang; Zhang Li

    1998-01-01

    Daya Bay Nuclear Power Plant is put into commercial operation in 1994 Until 1996, there are 368 human error events in operating and maintenance area, occupying 39% of total events. These events occurred mainly in the processes of maintenance, test equipment isolation and system on-line, in particular in refuelling and maintenance. The author analyses root causes for human errorievents, which are mainly operator omission or error procedure deficiency; procedure not followed; lack of training; communication failures; work management inadequacy. The protective measures and treatment principle for human error events are also discussed, and several examples applying them are given. Finally, it is put forward that key to prevent human error event lies in the coordination and management, person in charge of work, and good work habits of staffs

  20. Broad Beam and Ion Microprobe Studies of Single-Event Upsets in High Speed 0.18micron Silicon Germanium Heterojunction Bipolar Transistors and Circuits

    Science.gov (United States)

    Reed, Robert A.; Marshall, Paul W.; Pickel, Jim; Carts, Martin A.; Irwin, TIm; Niu, Guofu; Cressler, John; Krithivasan, Ramkumar; Fritz, Karl; Riggs, Pam

    2003-01-01

    SiGe based technology is widely recognized for its tremendous potential to impact the high speed microelectronic industry, and therefore the space industry, by monolithic incorporation of low power complementary logic with extremely high speed SiGe Heterojunction Bipolar Transistor (HBT) logic. A variety of studies have examined the ionizing dose, displacement damage and single event characteristics, and are reported. Accessibility to SiGe through an increasing number of manufacturers adds to the importance of understanding its intrinsic radiation characteristics, and in particular the single event effect (SEE) characteristics of the high bandwidth HBT based circuits. IBM is now manufacturing in its 3rd generation of their commercial SiGe processes, and access is currently available to the first two generations (known as and 6HP) through the MOSIS shared mask services with anticipated future release of the latest (7HP) process. The 5 HP process is described and is characterized by a emitter spacing of 0.5 micron and a cutoff frequency ff of 50 GHz, whereas the fully scaled 7HP HBT employs a 0.18 micron emitter and has an fT of 120 GHz. Previous investigations have the examined SEE response of 5 HP HBT circuits through both circuit testing and modeling. Charge collection modeling studies in the 5 H P process have also been conducted, but to date no measurements have been reported of charge collection in any SiGe HBT structures. Nor have circuit models for charge collection been developed in any version other than the 5 HP HBT structure. Our investigation reports the first indications of both charge collection and circuit response in IBM s 7HP-based SiGe process. We compare broad beam heavy ion SEU test results in a fully function Pseudo-Random Number (PRN) sequence generator up to frequencies of 12 Gbps versus effective LET, and also report proton test results in the same circuit. In addition, we examine the charge collection characteristics of individual 7HP HBT

  1. Investigations on human error hazards in recent unintended trip events of Korean nuclear power plants

    Energy Technology Data Exchange (ETDEWEB)

    Kim, Sa Kil; Jang, Tong Il; Lee, Yong Hee; Shin, Kwang Hyeon [KAERI, Daejeon (Korea, Republic of)

    2012-10-15

    According to the Operational Performance Information System (OPIS) which has been operated to improve the public understanding by the KINS (Korea Institute of Nuclear Safety), unintended trip events by mainly human errors counted up to 38 cases (18.7%) from 2000 to 2011. Although the Nuclear Power Plant (NPP) industry in Korea has been making efforts to reduce the human errors which have largely contributed to trip events, the human error rate might keep increasing. Interestingly, digital based I and C systems is the one of the reduction factors of unintended reactor trips. Human errors, however, have occurred due to the digital based I and C systems because those systems require new or changed behaviors to the NPP operators. Therefore, it is necessary that the investigations of human errors consider a new methodology to find not only tangible behavior but also intangible behavior such as organizational behaviors. In this study we investigated human errors to find latent factors such as decisions and conditions in the all of the unintended reactor trip events during last dozen years. To find them, we applied the HFACS (Human Factors Analysis and Classification System) which is a commonly utilized tool for investigating human contributions to aviation accidents under a widespread evaluation scheme. The objective of this study is to find latent factors behind of human errors in nuclear reactor trip events. Therefore, a method to investigate unintended trip events by human errors and the results will be discussed in more detail.

  2. Investigations on human error hazards in recent unintended trip events of Korean nuclear power plants

    International Nuclear Information System (INIS)

    Kim, Sa Kil; Jang, Tong Il; Lee, Yong Hee; Shin, Kwang Hyeon

    2012-01-01

    According to the Operational Performance Information System (OPIS) which has been operated to improve the public understanding by the KINS (Korea Institute of Nuclear Safety), unintended trip events by mainly human errors counted up to 38 cases (18.7%) from 2000 to 2011. Although the Nuclear Power Plant (NPP) industry in Korea has been making efforts to reduce the human errors which have largely contributed to trip events, the human error rate might keep increasing. Interestingly, digital based I and C systems is the one of the reduction factors of unintended reactor trips. Human errors, however, have occurred due to the digital based I and C systems because those systems require new or changed behaviors to the NPP operators. Therefore, it is necessary that the investigations of human errors consider a new methodology to find not only tangible behavior but also intangible behavior such as organizational behaviors. In this study we investigated human errors to find latent factors such as decisions and conditions in the all of the unintended reactor trip events during last dozen years. To find them, we applied the HFACS (Human Factors Analysis and Classification System) which is a commonly utilized tool for investigating human contributions to aviation accidents under a widespread evaluation scheme. The objective of this study is to find latent factors behind of human errors in nuclear reactor trip events. Therefore, a method to investigate unintended trip events by human errors and the results will be discussed in more detail

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

    Directory of Open Access Journals (Sweden)

    Wei Liu

    2013-01-01

    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.

  4. Negative cognitive errors and positive illusions for negative divorce events: predictors of children's psychological adjustment.

    Science.gov (United States)

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

    1992-12-01

    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.

  5. 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

    2005-01-01

    ...) 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...

  6. 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

    2005-01-01

    .... 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...

  7. Adverse Drug Events and Medication Errors in African Hospitals: A Systematic Review.

    Science.gov (United States)

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

    2018-03-01

    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

  8. Single-word multiple-bit upsets in static random access devices

    International Nuclear Information System (INIS)

    Koga, R.; Pinkerton, S.D.; Lie, T.J.; Crawford, K.B.

    1993-01-01

    Energetic ions and protons can cause single event upsets (SEUs) in static random access memory (SRAM) cells. In some cases multiple bits may be upset as the result of a single event. Space-borne electronics systems incorporating high-density SRAM are vulnerable to single-word multiple-bit upsets (SMUs). The authors review here recent observations of SMU, present the results of a systematic investigation of the physical cell arrangements employed in several currently available SRAM device types, and discuss implications for the occurrence and mitigation of SMU

  9. An assessment of the risk significance of human errors in selected PSAs and operating events

    International Nuclear Information System (INIS)

    Palla, R.L. Jr.; El-Bassioni, A.

    1991-01-01

    Sensitivity studies based on Probabilistic Safety Assessments (PSAs) for a pressurized water reactor and a boiling water reactor are described. In each case human errors modeled in the PSAs were categorized according to such factors as error type, location, timing, and plant personnel involved. Sensitivity studies were then conducted by varying the error rates in each category and evaluating the corresponding change in total core damage frequency and accident sequence frequency. Insights obtained are discussed and reasons for differences in risk sensitivity between plants are explored. A separate investigation into the role of human error in risk-important operating events is also described. This investigation involved the analysis of data from the USNRC Accident Sequence Precursor program to determine the effect of operator-initiated events on accident precursor trends, and to determine whether improved training can be correlated to current trends. The findings of this study are also presented. 5 refs., 15 figs., 1 tab

  10. Analysis of human error and organizational deficiency in events considering risk significance

    International Nuclear Information System (INIS)

    Lee, Yong Suk; Kim, Yoonik; Kim, Say Hyung; Kim, Chansoo; Chung, Chang Hyun; Jung, Won Dea

    2004-01-01

    In this study, we analyzed human and organizational deficiencies in the trip events of Korean nuclear power plants. K-HPES items were used in human error analysis, and the organizational factors by Jacobs and Haber were used for organizational deficiency analysis. We proposed the use of CCDP as a risk measure to consider risk information in prioritizing K-HPES items and organizational factors. Until now, the risk significance of events has not been considered in human error and organizational deficiency analysis. Considering the risk significance of events in the process of analysis is necessary for effective enhancement of nuclear power plant safety by focusing on causes of human error and organizational deficiencies that are associated with significant risk

  11. Proton upset rate prediction: a new sensitive volume concept definition

    International Nuclear Information System (INIS)

    Inguimbert, Christophe

    1999-01-01

    We present a model for predicting proton induced single event upset rate. The approach uses heavy ion cross section experimental data combined with nuclear reaction calculations in order to determine the proton upset cross section. The p+Si nuclear reaction as well as the Si(p, p)Si Coulombic scattering are described. The upset rate calculation depends on the energy deposited available in the charge collection region (sensitive region). This region is treated as a rectangular parallelepiped of thickness d at depth h. The sensitive thickness d is used as an input parameter in our model we have developed an original method to probe the sensitive region to evaluate d with reasonable accuracy d. We use short range ions and we propose a new mathematical analysis of these experimental data to determine h and d. This method consists in de-convoluting the heavy ion upset cross section σ_S_E_U(r) by the LET function of the incident ion LET(r) (r is the range of the incident ion). Our results are in relatively good agreement with other models. The accuracy of the method allows us to discuss the validity of the sensitive volume concept. Furthermore, we extrapolate an internal gain factor α that permit to take into account the charge collection mechanisms. α and d serve for quick and reasonably accurate prediction of proton induced SEU cross section in microelectronic devices. (author) [fr

  12. Cosmic and terrestrial single-event radiation effects in dynamic random access memories

    International Nuclear Information System (INIS)

    Massengill, L.W.

    1996-01-01

    A review of the literature on single-event radiation effects (SEE) on MOS integrated-circuit dynamic random access memories (DRAM's) is presented. The sources of single-event (SE) radiation particles, causes of circuit information loss, experimental observations of SE information upset, technological developments for error mitigation, and relationships of developmental trends to SE vulnerability are discussed

  13. Challenges in disclosure of adverse events and errors in surgery; perspectives from sub-Saharan Africa.

    Science.gov (United States)

    Ibrahim, Abdulrasheed; Garba, Ekundayo Stephen; Asuku, Malachy Eneye

    2012-01-01

    Surgery in sub-Saharan Africa is widely known to be done against a background of poverty and illiteracy, late presentation with complicated pathologies, and a desperate lack of infrastructure. In addition, patient autonomy and self determination are highly flavored by cultural practices and religious beliefs. Any of these factors can influence the pattern and disclosure of adverse events and errors. The impact of these in the relationships between surgeons and patients, and between health institutions and patients must be considered as it may affect disclosure and response to errors. This article identifies the peculiar socioeconomic and cultural challenges that may hinder disclosure and proposes strategies for instituting disclosure of errors and adverse events services in Sub-Saharan Africa.

  14. Understanding the nature of errors in nursing: using a model to analyse critical incident reports of errors which had resulted in an adverse or potentially adverse event.

    Science.gov (United States)

    Meurier, C E

    2000-07-01

    Human errors are common in clinical practice, but they are under-reported. As a result, very little is known of the types, antecedents and consequences of errors in nursing practice. This limits the potential to learn from errors and to make improvement in the quality and safety of nursing care. The aim of this study was to use an Organizational Accident Model to analyse critical incidents of errors in nursing. Twenty registered nurses were invited to produce a critical incident report of an error (which had led to an adverse event or potentially could have led to an adverse event) they had made in their professional practice and to write down their responses to the error using a structured format. Using Reason's Organizational Accident Model, supplemental information was then collected from five of the participants by means of an individual in-depth interview to explore further issues relating to the incidents they had reported. The detailed analysis of one of the incidents is discussed in this paper, demonstrating the effectiveness of this approach in providing insight into the chain of events which may lead to an adverse event. The case study approach using critical incidents of clinical errors was shown to provide relevant information regarding the interaction of organizational factors, local circumstances and active failures (errors) in producing an adverse or potentially adverse event. It is suggested that more use should be made of this approach to understand how errors are made in practice and to take appropriate preventative measures.

  15. Medication errors: an analysis comparing PHICO's closed claims data and PHICO's Event Reporting Trending System (PERTS).

    Science.gov (United States)

    Benjamin, David M; Pendrak, Robert F

    2003-07-01

    Clinical pharmacologists are all dedicated to improving the use of medications and decreasing medication errors and adverse drug reactions. However, quality improvement requires that some significant parameters of quality be categorized, measured, and tracked to provide benchmarks to which future data (performance) can be compared. One of the best ways to accumulate data on medication errors and adverse drug reactions is to look at medical malpractice data compiled by the insurance industry. Using data from PHICO insurance company, PHICO's Closed Claims Data, and PHICO's Event Reporting Trending System (PERTS), this article examines the significance and trends of the claims and events reported between 1996 and 1998. Those who misread history are doomed to repeat the mistakes of the past. From a quality improvement perspective, the categorization of the claims and events is useful for reengineering integrated medication delivery, particularly in a hospital setting, and for redesigning drug administration protocols on low therapeutic index medications and "high-risk" drugs. Demonstrable evidence of quality improvement is being required by state laws and by accreditation agencies. The state of Florida requires that quality improvement data be posted quarterly on the Web sites of the health care facilities. Other states have followed suit. The insurance industry is concerned with costs, and medication errors cost money. Even excluding costs of litigation, an adverse drug reaction may cost up to $2500 in hospital resources, and a preventable medication error may cost almost $4700. To monitor costs and assess risk, insurance companies want to know what errors are made and where the system has broken down, permitting the error to occur. Recording and evaluating reliable data on adverse drug events is the first step in improving the quality of pharmacotherapy and increasing patient safety. Cost savings and quality improvement evolve on parallel paths. The PHICO data

  16. A mediation skills model to manage disclosure of errors and adverse events to patients.

    Science.gov (United States)

    Liebman, Carol B; Hyman, Chris Stern

    2004-01-01

    In 2002 Pennsylvania became the first state to impose on hospitals a statutory duty to notify patients in writing of a serious event. If the disclosure conversations are carefully planned, properly executed, and responsive to patients' needs, this new requirement creates possible benefits for both patient safety and litigation risk management. This paper describes a model for accomplishing these goals that encourages health care providers to communicate more effectively with patients following an adverse event or medical error, learn from mistakes, respond to the concerns of patients and families after an adverse event, and arrive at a fair and cost-effective resolution of valid claims.

  17. Task types and error types involved in the human-related unplanned reactor trip events

    International Nuclear Information System (INIS)

    Kim, Jae Whan; Park, Jin Kyun

    2008-01-01

    In this paper, the contribution of task types and error types involved in the human-related unplanned reactor trip events that have occurred between 1986 and 2006 in Korean nuclear power plants are analysed in order to establish a strategy for reducing the human-related unplanned reactor trips. Classification systems for the task types, error modes, and cognitive functions are developed or adopted from the currently available taxonomies, and the relevant information is extracted from the event reports or judged on the basis of an event description. According to the analyses from this study, the contributions of the task types are as follows: corrective maintenance (25.7%), planned maintenance (22.8%), planned operation (19.8%), periodic preventive maintenance (14.9%), response to a transient (9.9%), and design/manufacturing/installation (6.9%). According to the analysis of the error modes, error modes such as control failure (22.2%), wrong object (18.5%), omission (14.8%), wrong action (11.1%), and inadequate (8.3%) take up about 75% of the total unplanned trip events. The analysis of the cognitive functions involved in the events indicated that the planning function had the highest contribution (46.7%) to the human actions leading to unplanned reactor trips. This analysis concludes that in order to significantly reduce human-induced or human-related unplanned reactor trips, an aide system (in support of maintenance personnel) for evaluating possible (negative) impacts of planned actions or erroneous actions as well as an appropriate human error prediction technique, should be developed

  18. Task types and error types involved in the human-related unplanned reactor trip events

    Energy Technology Data Exchange (ETDEWEB)

    Kim, Jae Whan; Park, Jin Kyun [Korea Atomic Energy Research Institute, Daejeon (Korea, Republic of)

    2008-12-15

    In this paper, the contribution of task types and error types involved in the human-related unplanned reactor trip events that have occurred between 1986 and 2006 in Korean nuclear power plants are analysed in order to establish a strategy for reducing the human-related unplanned reactor trips. Classification systems for the task types, error modes, and cognitive functions are developed or adopted from the currently available taxonomies, and the relevant information is extracted from the event reports or judged on the basis of an event description. According to the analyses from this study, the contributions of the task types are as follows: corrective maintenance (25.7%), planned maintenance (22.8%), planned operation (19.8%), periodic preventive maintenance (14.9%), response to a transient (9.9%), and design/manufacturing/installation (6.9%). According to the analysis of the error modes, error modes such as control failure (22.2%), wrong object (18.5%), omission (14.8%), wrong action (11.1%), and inadequate (8.3%) take up about 75% of the total unplanned trip events. The analysis of the cognitive functions involved in the events indicated that the planning function had the highest contribution (46.7%) to the human actions leading to unplanned reactor trips. This analysis concludes that in order to significantly reduce human-induced or human-related unplanned reactor trips, an aide system (in support of maintenance personnel) for evaluating possible (negative) impacts of planned actions or erroneous actions as well as an appropriate human error prediction technique, should be developed.

  19. [Event-related EEG potentials associated with error detection in psychiatric disorder: literature review].

    Science.gov (United States)

    Balogh, Lívia; Czobor, Pál

    2010-01-01

    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.

  20. Latency and mode of error detection as reflected in Swedish licensee event reports

    Energy Technology Data Exchange (ETDEWEB)

    Svenson, Ola; Salo, Ilkka [Stockholm Univ., (Sweden). Dept. of Psychology

    2002-03-01

    Licensee event reports (LERs) from an industry provide important information feedback about safety to the industry itself, the regulators and to the public. LERs from four nuclear power reactors were analyzed to find out about detection times, mode of detection and qualitative differences in reports from different reactors. The reliability of the coding was satisfactory and measured as the covariance between the ratings from two independent judges. The results showed differences in detection time across the reactors. On the average about ten percent of the errors remained undetected for 100 weeks or more, but the great majority of errors were detected soon after their first appearance in the plant. On the average 40 percent of the errors were detected in regular tests and 40 per cent through alarms. Operators found about 10 per cent of the errors through noticing something abnormal in the plant. The remaining errors were detected in various other ways. There were qualitative differences between the LERs from the different reactors reflecting the different conditions in the plants. The number of reports differed by a magnitude 1:2 between the different plants. However, a greater number of LERs can indicate both higher safety standards (e.g., a greater willingness to report all possible events to be able to learn from them) and lower safety standards (e.g., reporting as few events as possible to make a good impression). It was pointed out that LERs are indispensable in order to maintain safety of an industry and that the differences between plants found in the analyses of this study indicate how error reports can be used to initiate further investigations for improved safety.

  1. Latency and mode of error detection as reflected in Swedish licensee event reports

    International Nuclear Information System (INIS)

    Svenson, Ola; Salo, Ilkka

    2002-03-01

    Licensee event reports (LERs) from an industry provide important information feedback about safety to the industry itself, the regulators and to the public. LERs from four nuclear power reactors were analyzed to find out about detection times, mode of detection and qualitative differences in reports from different reactors. The reliability of the coding was satisfactory and measured as the covariance between the ratings from two independent judges. The results showed differences in detection time across the reactors. On the average about ten percent of the errors remained undetected for 100 weeks or more, but the great majority of errors were detected soon after their first appearance in the plant. On the average 40 percent of the errors were detected in regular tests and 40 per cent through alarms. Operators found about 10 per cent of the errors through noticing something abnormal in the plant. The remaining errors were detected in various other ways. There were qualitative differences between the LERs from the different reactors reflecting the different conditions in the plants. The number of reports differed by a magnitude 1:2 between the different plants. However, a greater number of LERs can indicate both higher safety standards (e.g., a greater willingness to report all possible events to be able to learn from them) and lower safety standards (e.g., reporting as few events as possible to make a good impression). It was pointed out that LERs are indispensable in order to maintain safety of an industry and that the differences between plants found in the analyses of this study indicate how error reports can be used to initiate further investigations for improved safety

  2. Soft error evaluation in SRAM using α sources

    International Nuclear Information System (INIS)

    He Chaohui; Chu Jun; Ren Xueming; Xia Chunmei; Yang Xiupei; Zhang Weiwei; Wang Hongquan; Xiao Jiangbo; Li Xiaolin

    2006-01-01

    Soft errors in memories influence directly the reliability of products. To compare the ability of three different memories against soft errors by experiments of alpha particles irradiation, the numbers of soft errors are measured for three different SRAMs and the cross sections of single event upset (SEU) and failures in time (FIT) are calculated. According to the cross sections of SEU, the ability of A166M against soft errors is the best and then B166M, the last B200M. The average FIT of B166M is smaller than that of B200M, and that of A166M is the biggest among them. (authors)

  3. A trend analysis of human error events for proactive prevention of accidents. Methodology development and effective utilization

    International Nuclear Information System (INIS)

    Hirotsu, Yuko; Ebisu, Mitsuhiro; Aikawa, Takeshi; Matsubara, Katsuyuki

    2006-01-01

    This paper described methods for analyzing human error events that has been accumulated in the individual plant and for utilizing the result to prevent accidents proactively. Firstly, a categorization framework of trigger action and causal factors of human error events were reexamined, and the procedure to analyze human error events was reviewed based on the framework. Secondly, a method for identifying the common characteristics of trigger action data and of causal factor data accumulated by analyzing human error events was clarified. In addition, to utilize the results of trend analysis effectively, methods to develop teaching material for safety education, to develop the checkpoints for the error prevention and to introduce an error management process for strategic error prevention were proposed. (author)

  4. Event-Related Potentials for Post-Error and Post-Conflict Slowing

    Science.gov (United States)

    Chang, Andrew; Chen, Chien-Chung; Li, Hsin-Hung; Li, Chiang-Shan R.

    2014-01-01

    In a reaction time task, people typically slow down following an error or conflict, each called post-error slowing (PES) and post-conflict slowing (PCS). Despite many studies of the cognitive mechanisms, the neural responses of PES and PCS continue to be debated. In this study, we combined high-density array EEG and a stop-signal task to examine event-related potentials of PES and PCS in sixteen young adult participants. The results showed that the amplitude of N2 is greater during PES but not PCS. In contrast, the peak latency of N2 is longer for PCS but not PES. Furthermore, error-positivity (Pe) but not error-related negativity (ERN) was greater in the stop error trials preceding PES than non-PES trials, suggesting that PES is related to participants' awareness of the error. Together, these findings extend earlier work of cognitive control by specifying the neural correlates of PES and PCS in the stop signal task. PMID:24932780

  5. Soft error rate analysis methodology of multi-Pulse-single-event transients

    International Nuclear Information System (INIS)

    Zhou Bin; Huo Mingxue; Xiao Liyi

    2012-01-01

    As transistor feature size scales down, soft errors in combinational logic because of high-energy particle radiation is gaining more and more concerns. In this paper, a combinational logic soft error analysis methodology considering multi-pulse-single-event transients (MPSETs) and re-convergence with multi transient pulses is proposed. In the proposed approach, the voltage pulse produced at the standard cell output is approximated by a triangle waveform, and characterized by three parameters: pulse width, the transition time of the first edge, and the transition time of the second edge. As for the pulse with the amplitude being smaller than the supply voltage, the edge extension technique is proposed. Moreover, an efficient electrical masking model comprehensively considering transition time, delay, width and amplitude is proposed, and an approach using the transition times of two edges and pulse width to compute the amplitude of pulse is proposed. Finally, our proposed firstly-independently-propagating-secondly-mutually-interacting (FIP-SMI) is used to deal with more practical re-convergence gate with multi transient pulses. As for MPSETs, a random generation model of MPSETs is exploratively proposed. Compared to the estimates obtained using circuit level simulations by HSpice, our proposed soft error rate analysis algorithm has 10% errors in SER estimation with speed up of 300 when the single-pulse-single-event transient (SPSET) is considered. We have also demonstrated the runtime and SER decrease with the increment of P0 using designs from the ISCAS-85 benchmarks. (authors)

  6. Working group of experts on rare events in human error analysis and quantification

    International Nuclear Information System (INIS)

    Goodstein, L.P.

    1977-01-01

    In dealing with the reference problem of rare events in nuclear power plants, the group has concerned itself with the man-machine system and, in particular, with human error analysis and quantification. The Group was requested to review methods of human reliability prediction, to evaluate the extent to which such analyses can be formalized and to establish criteria to be met by task conditions and system design which would permit a systematic, formal analysis. Recommendations are given on the Fessenheim safety system

  7. Trend analysis of human error events and assessment of their proactive prevention measure at Rokkasho reprocessing plant

    International Nuclear Information System (INIS)

    Yamazaki, Satoru; Tanaka, Izumi; Wakabayashi, Toshio

    2012-01-01

    A trend analysis of human error events is important for preventing the recurrence of human error events. We propose a new method for identifying the common characteristics from results of trend analysis, such as the latent weakness of organization, and a management process for strategic error prevention. In this paper, we describe a trend analysis method for human error events that have been accumulated in the organization and the utilization of the results of trend analysis to prevent accidents proactively. Although the systematic analysis of human error events, the monitoring of their overall trend, and the utilization of the analyzed results have been examined for the plant operation, such information has never been utilized completely. Sharing information on human error events and analyzing their causes lead to the clarification of problems in the management and human factors. This new method was applied to the human error events that occurred in the Rokkasho reprocessing plant from 2010 October. Results revealed that the output of this method is effective in judging the error prevention plan and that the number of human error events is reduced to about 50% those observed in 2009 and 2010. (author)

  8. Technology-Induced Errors and Adverse Event Reporting in an Organizational Learning Perspective.

    Science.gov (United States)

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

    2017-01-01

    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.

  9. The modulating effect of personality traits on neural error monitoring: evidence from event-related FMRI.

    Science.gov (United States)

    Sosic-Vasic, Zrinka; Ulrich, Martin; Ruchsow, Martin; Vasic, Nenad; Grön, Georg

    2012-01-01

    The present study investigated the association between traits of the Five Factor Model of Personality (Neuroticism, Extraversion, Openness for Experiences, Agreeableness, and Conscientiousness) and neural correlates of error monitoring obtained from a combined Eriksen-Flanker-Go/NoGo task during event-related functional magnetic resonance imaging in 27 healthy subjects. Individual expressions of personality traits were measured using the NEO-PI-R questionnaire. Conscientiousness correlated positively with error signaling in the left inferior frontal gyrus and adjacent anterior insula (IFG/aI). A second strong positive correlation was observed in the anterior cingulate gyrus (ACC). Neuroticism was negatively correlated with error signaling in the inferior frontal cortex possibly reflecting the negative inter-correlation between both scales observed on the behavioral level. Under present statistical thresholds no significant results were obtained for remaining scales. Aligning the personality trait of Conscientiousness with task accomplishment striving behavior the correlation in the left IFG/aI possibly reflects an inter-individually different involvement whenever task-set related memory representations are violated by the occurrence of errors. The strong correlations in the ACC may indicate that more conscientious subjects were stronger affected by these violations of a given task-set expressed by individually different, negatively valenced signals conveyed by the ACC upon occurrence of an error. Present results illustrate that for predicting individual responses to errors underlying personality traits should be taken into account and also lend external validity to the personality trait approach suggesting that personality constructs do reflect more than mere descriptive taxonomies.

  10. The modulating effect of personality traits on neural error monitoring: evidence from event-related FMRI.

    Directory of Open Access Journals (Sweden)

    Zrinka Sosic-Vasic

    Full Text Available The present study investigated the association between traits of the Five Factor Model of Personality (Neuroticism, Extraversion, Openness for Experiences, Agreeableness, and Conscientiousness and neural correlates of error monitoring obtained from a combined Eriksen-Flanker-Go/NoGo task during event-related functional magnetic resonance imaging in 27 healthy subjects. Individual expressions of personality traits were measured using the NEO-PI-R questionnaire. Conscientiousness correlated positively with error signaling in the left inferior frontal gyrus and adjacent anterior insula (IFG/aI. A second strong positive correlation was observed in the anterior cingulate gyrus (ACC. Neuroticism was negatively correlated with error signaling in the inferior frontal cortex possibly reflecting the negative inter-correlation between both scales observed on the behavioral level. Under present statistical thresholds no significant results were obtained for remaining scales. Aligning the personality trait of Conscientiousness with task accomplishment striving behavior the correlation in the left IFG/aI possibly reflects an inter-individually different involvement whenever task-set related memory representations are violated by the occurrence of errors. The strong correlations in the ACC may indicate that more conscientious subjects were stronger affected by these violations of a given task-set expressed by individually different, negatively valenced signals conveyed by the ACC upon occurrence of an error. Present results illustrate that for predicting individual responses to errors underlying personality traits should be taken into account and also lend external validity to the personality trait approach suggesting that personality constructs do reflect more than mere descriptive taxonomies.

  11. Sources of Error and the Statistical Formulation of M S: m b Seismic Event Screening Analysis

    Science.gov (United States)

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

    2014-03-01

    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.

  12. Cognitive Moderators of Children's Adjustment to Stressful Divorce Events: The Role of Negative Cognitive Errors and Positive Illusions.

    Science.gov (United States)

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

    1999-01-01

    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…

  13. Evaluation of the upset risk in CMOS SRAM through full three dimensional simulation

    International Nuclear Information System (INIS)

    Moreau, Y.; Gasiot, J.; Duzellier, S.

    1995-01-01

    Upsets caused by incident heavy ion on CMOS static RAM are studied here. Three dimensional device simulations, based on a description of a full epitaxial CMOS inverter, and experimental results are reported for evaluation of single and multiple bit error risk. The particular influences of hit location and incidence angle are examined

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

    OpenAIRE

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

    2008-01-01

    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 infidelity as the most upsetting event. Because homosexuals' mating psychology is unlike that of heterosexuals, the present study examinend which of these two events is more upsetting in a sample of ...

  15. Event (error and near-miss) reporting and learning system for process improvement in radiation oncology.

    Science.gov (United States)

    Mutic, Sasa; Brame, R Scott; Oddiraju, Swetha; Parikh, Parag; Westfall, Melisa A; Hopkins, Merilee L; Medina, Angel D; Danieley, Jonathan C; Michalski, Jeff M; El Naqa, Issam M; Low, Daniel A; Wu, Bin

    2010-09-01

    The value of near-miss and error reporting processes in many industries is well appreciated and typically can be supported with data that have been collected over time. While it is generally accepted that such processes are important in the radiation therapy (RT) setting, studies analyzing the effects of organized reporting and process improvement systems on operation and patient safety in individual clinics remain scarce. The purpose of this work is to report on the design and long-term use of an electronic reporting system in a RT department and compare it to the paper-based reporting system it replaced. A specifically designed web-based system was designed for reporting of individual events in RT and clinically implemented in 2007. An event was defined as any occurrence that could have, or had, resulted in a deviation in the delivery of patient care. The aim of the system was to support process improvement in patient care and safety. The reporting tool was designed so individual events could be quickly and easily reported without disrupting clinical work. This was very important because the system use was voluntary. The spectrum of reported deviations extended from minor workflow issues (e.g., scheduling) to errors in treatment delivery. Reports were categorized based on functional area, type, and severity of an event. The events were processed and analyzed by a formal process improvement group that used the data and the statistics collected through the web-based tool for guidance in reengineering clinical processes. The reporting trends for the first 24 months with the electronic system were compared to the events that were reported in the same clinic with a paper-based system over a seven-year period. The reporting system and the process improvement structure resulted in increased event reporting, improved event communication, and improved identification of clinical areas which needed process and safety improvements. The reported data were also useful for the

  16. Single Versus Multiple Events Error Potential Detection in a BCI-Controlled Car Game With Continuous and Discrete Feedback.

    Science.gov (United States)

    Kreilinger, Alex; Hiebel, Hannah; Müller-Putz, Gernot R

    2016-03-01

    This work aimed to find and evaluate a new method for detecting errors in continuous brain-computer interface (BCI) applications. Instead of classifying errors on a single-trial basis, the new method was based on multiple events (MEs) analysis to increase the accuracy of error detection. In a BCI-driven car game, based on motor imagery (MI), discrete events were triggered whenever subjects collided with coins and/or barriers. Coins counted as correct events, whereas barriers were errors. This new method, termed ME method, combined and averaged the classification results of single events (SEs) and determined the correctness of MI trials, which consisted of event sequences instead of SEs. The benefit of this method was evaluated in an offline simulation. In an online experiment, the new method was used to detect erroneous MI trials. Such MI trials were discarded and could be repeated by the users. We found that, even with low SE error potential (ErrP) detection rates, feasible accuracies can be achieved when combining MEs to distinguish erroneous from correct MI trials. Online, all subjects reached higher scores with error detection than without, at the cost of longer times needed for completing the game. Findings suggest that ErrP detection may become a reliable tool for monitoring continuous states in BCI applications when combining MEs. This paper demonstrates a novel technique for detecting errors in online continuous BCI applications, which yields promising results even with low single-trial detection rates.

  17. Corrected multiple upsets and bit reversals for improved 1-s resolution measurements

    International Nuclear Information System (INIS)

    Brucker, G.J.; Stassinopoulos, E.G.; Stauffer, C.A.

    1994-01-01

    Previous work has studied the generation of single and multiple errors in control and irradiated static RAM samples (Harris 6504RH) which were exposed to heavy ions for relatively long intervals of time (minute), and read out only after the beam was shut off. The present investigation involved storing 4k x 1 bit maps every second during 1 min ion exposures at low flux rates of 10 3 ions/cm 2 -s in order to reduce the chance of two sequential ions upsetting adjacent bits. The data were analyzed for the presence of adjacent upset bit locations in the physical memory plane, which were previously defined to constitute multiple upsets. Improvement in the time resolution of these measurements has provided more accurate estimates of multiple upsets. The results indicate that the percentage of multiples decreased from a high of 17% in the previous experiment to less than 1% for this new experimental technique. Consecutive double and triple upsets (reversals of bits) were detected. These were caused by sequential ions hitting the same bit, with one or two reversals of state occurring in a 1-min run. In addition to these results, a status review for these same parts covering 3.5 years of imprint damage recovery is also presented

  18. Visual correlation analytics of event-based error reports for advanced manufacturing

    OpenAIRE

    Nazir, Iqbal

    2017-01-01

    With the growing digitalization and automation in the manufacturing domain, an increasing amount of process data and error reports become available. To minimize the number of errors and maximize the efficiency of the production line, it is important to analyze the generated error reports and find solutions that can reduce future errors. However, not all errors have the equal importance, as some errors may be the result of previously occurred errors. Therefore, it is important for domain exper...

  19. UpSet: Visualization of Intersecting Sets

    Science.gov (United States)

    Lex, Alexander; Gehlenborg, Nils; Strobelt, Hendrik; Vuillemot, Romain; Pfister, Hanspeter

    2016-01-01

    Understanding relationships between sets is an important analysis task that has received widespread attention in the visualization community. The major challenge in this context is the combinatorial explosion of the number of set intersections if the number of sets exceeds a trivial threshold. In this paper we introduce UpSet, a novel visualization technique for the quantitative analysis of sets, their intersections, and aggregates of intersections. UpSet is focused on creating task-driven aggregates, communicating the size and properties of aggregates and intersections, and a duality between the visualization of the elements in a dataset and their set membership. UpSet visualizes set intersections in a matrix layout and introduces aggregates based on groupings and queries. The matrix layout enables the effective representation of associated data, such as the number of elements in the aggregates and intersections, as well as additional summary statistics derived from subset or element attributes. Sorting according to various measures enables a task-driven analysis of relevant intersections and aggregates. The elements represented in the sets and their associated attributes are visualized in a separate view. Queries based on containment in specific intersections, aggregates or driven by attribute filters are propagated between both views. We also introduce several advanced visual encodings and interaction methods to overcome the problems of varying scales and to address scalability. UpSet is web-based and open source. We demonstrate its general utility in multiple use cases from various domains. PMID:26356912

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

    Energy Technology Data Exchange (ETDEWEB)

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

    1982-11-01

    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.

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

    International Nuclear Information System (INIS)

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

    1982-11-01

    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

  2. Epidemiology of Adverse Events and Medical Errors in the Care of Cardiology Patients.

    Science.gov (United States)

    Ohta, Yoshinori; Miki, Izumi; Kimura, Takeshi; Abe, Mitsuru; Sakuma, Mio; Koike, Kaoru; Morimoto, Takeshi

    2016-11-02

    There have been epidemiological studies of adverse events (AEs) among general patients but those of patients cared by cardiologist are not well scrutinized. We investigated the occurrence of AEs and medical errors (MEs) among adult patients with cardiology in Japan. We conducted a cross-sectional study of adult outpatients at a Japanese teaching hospital from February through November 2006. We measured AE and ME incidents from patient report, which were verified by medical records, laboratory data, incident reports, and prescription queries. Two independent physicians reviewed the incidents to determine whether they were AEs or MEs and to assess severity and symptoms. We identified 144 AEs and 30 MEs (16.3 and 3.9 per 100 patients, respectively). Of the 144 AEs, 99 were solely adverse drug events (ADEs), 20 were solely non-ADEs, and the remaining 25 were both causes. The most frequent symptoms of ADEs were skin and allergic reactions due to medication. The most frequent symptoms of non-ADEs were bleeding due to therapeutic interventions. Among AEs, 12% was life threatening. Life-threatening AEs were 25% of non-ADEs and 5% of ADEs (P = 0.0003). Among the 30 MEs, 21MEs (70%) were associated with drugs. Adverse events were common among cardiology patients. Adverse drug events were the most frequent AEs, and non-ADEs were more critical than ADEs. Such data should be recognized among practicing physicians to improve the patients' outcomes.This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially.

  3. Gender differences in the pathway from adverse life events to adolescent emotional and behavioural problems via negative cognitive errors.

    Science.gov (United States)

    Flouri, Eirini; Panourgia, Constantina

    2011-06-01

    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.

  4. An investigation on unintended reactor trip events in terms of human error hazards of Korean nuclear power plants

    International Nuclear Information System (INIS)

    Kim, Sa Kil; Lee, Yong Hee; Jang, Tong Il; Oh, Yeon Ju; Shin, Kwang Hyeon

    2014-01-01

    Highlights: • A methodology to identify human error hazards has been established. • The proposed methodology is a preventive approach to identify not only human error causes but also its hazards. • Using the HFACS framework we tried to find out not causations but all of the hazards and relationships among them. • We determined countermeasures against human errors through dealing with latent factors such as organizational influences. - Abstract: A new approach for finding the hazards of human errors, and not just their causes, in the nuclear industry is currently required. This is because finding causes of human errors is really impossible owing to the multiplicity of causes in each case. Thus, this study aims at identifying the relationships among human error hazards and determining the strategies for preventing human error events by means of a reanalysis of the reactor trip events in Korea NPPs. We investigated human errors to find latent factors such as decisions and conditions in all of the unintended reactor trip events during the last dozen years. In this study, we applied the HFACS (Human Factors Analysis and Classification System), which is a commonly utilized tool for investigating human contributions to aviation accidents under a widespread evaluation scheme. Using the HFACS framework, we tried to find out not the causations but all of the hazards and their relationships in terms of organizational factors. Through the trial, we proposed not only meaningful frequencies of each hazards also correlations of them. Also, considering the correlations of each hazards, we suggested useful strategies to prevent human error event. A method to investigate unintended nuclear reactor trips by human errors and the results will be discussed in more detail

  5. Trend analysis of nuclear reactor automatic trip events subjected to operator's human error at United States nuclear power plants

    International Nuclear Information System (INIS)

    Takagawa, Kenichi

    2009-01-01

    Trends in nuclear reactor automatic trip events due to human errors during plant operating mode have been analyzed by extracting 20 events which took place in the United States during the period of seven years from 2002 to 2008, cited in the LERs (Licensee Event Reports) submitted to the US Nuclear Regulatory Commission (NRC). It was shown that the yearly number of events was relatively large before 2005, and thereafter the number decreased. A period of stable operation, in which the yearly number was kept very small, continued for about three years, and then the yearly number turned to increase again. Before 2005, automatic trip events occurred more frequently during periodic inspections or start-up/shut-down operations. The recent trends, however, indicate that trip events became more frequent due to human errors during daily operations. Human errors were mostly caused by the self-conceit and carelessness of operators through the whole period. The before mentioned trends in the yearly number of events might be explained as follows. The decrease in the automatic trip events is attributed to sharing trouble information, leading as a consequence to improvement of the manual and training for the operations which have a higher potential risk of automatic trip. Then, while the period of stable operation continued, some operators came to pay less attention to preventing human errors and not interest in the training, leading to automatic trip events in reality due to miss-operation. From these analyses on trouble experiences in the US, we learnt the followings to prevent the occurrence similar troubles in Japan: Operators should be thoroughly skilled in basic actions to prevent human errors as persons concerned. And it should be further emphasized that they should elaborate by imaging actual plant operations even though the simulator training gives them successful experiences. (author)

  6. Considerations for analysis of time-to-event outcomes measured with error: Bias and correction with SIMEX.

    Science.gov (United States)

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

    2018-04-15

    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.

  7. How to Cope with the Rare Human Error Events Involved with organizational Factors in Nuclear Power Plants

    Energy Technology Data Exchange (ETDEWEB)

    Kim, Sa Kil; Luo, Meiling; Lee, Yong Hee [Korea Atomic Research Institute, Daejeon (Korea, Republic of)

    2014-10-15

    The current human error guidelines (e.g. US DOD handbooks, US NRC Guidelines) are representative tools to prevent human errors. These tools, however, have limits that they do not adapt all operating situations and circumstances such as design base events. In other words, these tools are only adapted foreseeable standardized operating situations and circumstances. In this study, our research team proposed an evidence-based approach such as UK's safety case to coping with the rare human error events such as TMI, Chernobyl, Fukushima accidents. These accidents are representative events involved with rare human errors. Our research team defined the 'rare human errors' as the follow three characterized events; Extremely low frequency Extremely high complicated structure Extremely serious damage of human life and property A safety case is a structured argument, supported by evidence, intended to justify that a system is acceptably safe. The definition by UK defense standard 00-56 issue 4 states that such an evidence-based approach can be contrast with a prescriptive approach to safety certification, which require safety to be justified using a prescribed process. Safety managements and safety regulatory activities based on safety case are effective to control organizational factors in terms of integrated safety management. Especially safety issues relevant with public acceptance are useful to provide practical evidences to the public reasonably. European Union including UK has developed the concept of engineered safety management system to deal with public acceptance using the safety case. In Korea nuclear industry, the Korean Atomic Research Institute has firstly performed a basic research to adapt the safety case in the field of radioactive waste according to the IAEA SSG-23(KAERI/TR-4497, 4531). Excepting the radioactive waste, there is no try to adapt the safety case yet. Most incidents and accidents involved human during operating NPPs have a tendency

  8. How to Cope with the Rare Human Error Events Involved with organizational Factors in Nuclear Power Plants

    International Nuclear Information System (INIS)

    Kim, Sa Kil; Luo, Meiling; Lee, Yong Hee

    2014-01-01

    The current human error guidelines (e.g. US DOD handbooks, US NRC Guidelines) are representative tools to prevent human errors. These tools, however, have limits that they do not adapt all operating situations and circumstances such as design base events. In other words, these tools are only adapted foreseeable standardized operating situations and circumstances. In this study, our research team proposed an evidence-based approach such as UK's safety case to coping with the rare human error events such as TMI, Chernobyl, Fukushima accidents. These accidents are representative events involved with rare human errors. Our research team defined the 'rare human errors' as the follow three characterized events; Extremely low frequency Extremely high complicated structure Extremely serious damage of human life and property A safety case is a structured argument, supported by evidence, intended to justify that a system is acceptably safe. The definition by UK defense standard 00-56 issue 4 states that such an evidence-based approach can be contrast with a prescriptive approach to safety certification, which require safety to be justified using a prescribed process. Safety managements and safety regulatory activities based on safety case are effective to control organizational factors in terms of integrated safety management. Especially safety issues relevant with public acceptance are useful to provide practical evidences to the public reasonably. European Union including UK has developed the concept of engineered safety management system to deal with public acceptance using the safety case. In Korea nuclear industry, the Korean Atomic Research Institute has firstly performed a basic research to adapt the safety case in the field of radioactive waste according to the IAEA SSG-23(KAERI/TR-4497, 4531). Excepting the radioactive waste, there is no try to adapt the safety case yet. Most incidents and accidents involved human during operating NPPs have a tendency

  9. A Recent Revisit Study on the Human Error Events of Nuclear Facilities in Korea

    International Nuclear Information System (INIS)

    Lee, Y.-H.

    2016-01-01

    After Fukushima accident we have launched two new projects in Korea. One is for the development of the countermeasures for human errors in nuclear facilities, and the other is for the safety culture of nuclear power plant itself. There had happened several succeeding events that turned out to be the typical flags of the human and organizational factor issues for the safety of the other socio-technical systems as well as nuclear power plants in Korea. The second safety culture project was an ambitious development to establish an infra system utilising system dynamics, business process modeling and big-data techniques to provide effective and efficient information basis to various interest parties related to the nuclear power plants. However the project has been drastically cancelled last year without any further discussion on the original issues raised before in Korea. It may come not only from the conflicting perspectives among the different approaches to nuclear safety culture but also from the misunderstandings on the human factors for the nuclear safety.

  10. 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.

  11. Communicating natural hazards. The case of marine extreme events and the importance of the forecast's errors.

    Science.gov (United States)

    Marone, Eduardo; Camargo, Ricardo

    2013-04-01

    Scientific knowledge has to fulfill some necessary conditions. Among them, it has to be properly communicated. Usually, scientists (mis)understand that the communication requirement is satisfied by publishing their results on peer reviewed journals. Society claims for information in other formats or languages and other tools and approaches have to be used, otherwise the scientific discoveries will not fulfill its social mean. However, scientists are not so well trained to do so. These facts are particularly relevant when the scientific work has to deal with natural hazards, which do not affect just a lab or a computer experiment, but the life and fate of human beings. We are actually working with marine extreme events related with sea level changes, waves and other coastal hazards. Primary, the work is developed on the classic scientific format, but focusing not only in the stochastic way of predicting such extreme events, but estimating the potential errors the forecasting methodologies intrinsically have. The scientific results are translated to a friendly format required by stakeholders (which are financing part of the work). Finally, we hope to produce a document prepared for the general public. Each of the targets has their own characteristics and we have to use the proper communication tools and languages. Also, when communicating such knowledge, we have to consider that stakeholders and general public have no obligation of understanding the scientific language, but scientists have the responsibility of translating their discoveries and predictions in a proper way. The information on coastal hazards is analyzed in statistical and numerical ways, departing from long term observation of, for instance, sea level. From the analysis it is possible to recognize different natural regimes and to present the return times of extreme events, while from the numerical models, properly tuned to reproduce the same past ocean behavior using hindcast approaches, it is

  12. Exploring human error in military aviation flight safety events using post-incident classification systems.

    Science.gov (United States)

    Hooper, Brionny J; O'Hare, David P A

    2013-08-01

    Human error classification systems theoretically allow researchers to analyze postaccident data in an objective and consistent manner. The Human Factors Analysis and Classification System (HFACS) framework is one such practical analysis tool that has been widely used to classify human error in aviation. The Cognitive Error Taxonomy (CET) is another. It has been postulated that the focus on interrelationships within HFACS can facilitate the identification of the underlying causes of pilot error. The CET provides increased granularity at the level of unsafe acts. The aim was to analyze the influence of factors at higher organizational levels on the unsafe acts of front-line operators and to compare the errors of fixed-wing and rotary-wing operations. This study analyzed 288 aircraft incidents involving human error from an Australasian military organization occurring between 2001 and 2008. Action errors accounted for almost twice (44%) the proportion of rotary wing compared to fixed wing (23%) incidents. Both classificatory systems showed significant relationships between precursor factors such as the physical environment, mental and physiological states, crew resource management, training and personal readiness, and skill-based, but not decision-based, acts. The CET analysis showed different predisposing factors for different aspects of skill-based behaviors. Skill-based errors in military operations are more prevalent in rotary wing incidents and are related to higher level supervisory processes in the organization. The Cognitive Error Taxonomy provides increased granularity to HFACS analyses of unsafe acts.

  13. An Approach for the Assessment of System Upset Resilience

    Science.gov (United States)

    Torres-Pomales, Wilfredo

    2013-01-01

    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.

  14. Trend analysis and comparison of operators' human error events occurred at overseas and domestic nuclear power plants

    International Nuclear Information System (INIS)

    Takagawa, Kenichi

    2006-01-01

    Human errors by operators at overseas and domestic nuclear power plants during the period from 2002 to 2005 were compared and their trends analyzed. The most frequently cited cause of such errors was 'insufficient team monitoring' (inadequate superiors' and other crews' instructions and supervision) both at overseas and domestic plants, followed by 'insufficient self-checking' (lack of cautions by the operator himself). A comparison of the effects of the errors on the operations of plants in Japan and the United Sates showed that the drop in plant output and plant shutdowns at plants in Japan were approximately one-tenth of those in the United States. The ratio of automatic reactor trips to the total number of human errors reported is about 6% for both Japanese and American plants. Looking at changes in the incidence of human errors by years of occurrence, although a distinctive trend cannot be identified for domestic nuclear power plants due to insufficient reported cases, 'inadequate self-checking' as a factor contributing to human errors at overseas nuclear power plants has decreased significantly over the past four years. Regarding changes in the effects of human errors on the operations of plants during the four-year period, events leading to an automatic reactor trip have tended to increase at American plants. Conceivable factors behind this increasing tendency included lack of operating experience by a team (e.g., plant transients and reactor shutdowns and startups) and excessive dependence on training simulators. (author)

  15. Prediction of human errors by maladaptive changes in event-related brain networks

    NARCIS (Netherlands)

    Eichele, T.; Debener, S.; Calhoun, V.D.; Specht, K.; Engel, A.K.; Hugdahl, K.; Cramon, D.Y. von; Ullsperger, M.

    2008-01-01

    Humans engaged in monotonous tasks are susceptible to occasional errors that may lead to serious consequences, but little is known about brain activity patterns preceding errors. Using functional Mill and applying independent component analysis followed by deconvolution of hemodynamic responses, we

  16. SIMULATED HUMAN ERROR PROBABILITY AND ITS APPLICATION TO DYNAMIC HUMAN FAILURE EVENTS

    Energy Technology Data Exchange (ETDEWEB)

    Herberger, Sarah M.; Boring, Ronald L.

    2016-10-01

    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

  17. Single-Event Effect Performance of a Conductive-Bridge Memory EEPROM

    Science.gov (United States)

    Chen, Dakai; Wilcox, Edward; Berg, Melanie; Kim, Hak; Phan, Anthony; Figueiredo, Marco; Seidleck, Christina; LaBel, Kenneth

    2015-01-01

    We investigated the heavy ion single-event effect (SEE) susceptibility of the industry’s first stand-alone memory based on conductive-bridge memory (CBRAM) technology. The device is available as an electrically erasable programmable read-only memory (EEPROM). We found that single-event functional interrupt (SEFI) is the dominant SEE type for each operational mode (standby, dynamic read, and dynamic write/read). SEFIs occurred even while the device is statically biased in standby mode. Worst case SEFIs resulted in errors that filled the entire memory space. Power cycle did not always clear the errors. Thus the corrupted cells had to be reprogrammed in some cases. The device is also vulnerable to bit upsets during dynamic write/read tests, although the frequency of the upsets are relatively low. The linear energy transfer threshold for cell upset is between 10 and 20 megaelectron volts per square centimeter per milligram, with an upper limit cross section of 1.6 times 10(sup -11) square centimeters per bit (95 percent confidence level) at 10 megaelectronvolts per square centimeter per milligram. In standby mode, the CBRAM array appears invulnerable to bit upsets.

  18. Cognitive moderators of children's adjustment to stressful divorce events: the role of negative cognitive errors and positive illusions.

    Science.gov (United States)

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

    1999-01-01

    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.

  19. Specimen Identification Errors in Breast Biopsies: Age Matters. Report of Two Near-Miss Events and Review of the Literature.

    Science.gov (United States)

    Tozbikian, Gary; Gemignani, Mary L; Brogi, Edi

    2017-09-01

    The consequences of patient identification errors due to specimen mislabeling can be deleterious. We describe two near-miss events involving mislabeled breast specimens from two patients who sought treatment at our institution. In both cases, microscopic review of the slides identified inconsistencies between the histologic findings and patient age, unveiling specimen identification errors. By correlating the clinical information with the microscopic findings, we identified mistakes that had occurred at the time of specimen accessioning at the original laboratories. In both cases, thanks to a timely reassignment of the specimens, the patients suffered no harm. These cases highlight the importance of routine clinical and pathologic correlation as a critical component of quality assurance and patient safety. A review of possible specimen identification errors in the anatomic pathology setting is presented. © 2017 Wiley Periodicals, Inc.

  20. An audit strategy for time-to-event outcomes measured with error: application to five randomized controlled trials in oncology.

    Science.gov (United States)

    Dodd, Lori E; Korn, Edward L; Freidlin, Boris; Gu, Wenjuan; Abrams, Jeffrey S; Bushnell, William D; Canetta, Renzo; Doroshow, James H; Gray, Robert J; Sridhara, Rajeshwari

    2013-10-01

    Measurement error in time-to-event end points complicates interpretation of treatment effects in clinical trials. Non-differential measurement error is unlikely to produce large bias [1]. When error depends on treatment arm, bias is of greater concern. Blinded-independent central review (BICR) of all images from a trial is commonly undertaken to mitigate differential measurement-error bias that may be present in hazard ratios (HRs) based on local evaluations. Similar BICR and local evaluation HRs may provide reassurance about the treatment effect, but BICR adds considerable time and expense to trials. We describe a BICR audit strategy [2] and apply it to five randomized controlled trials to evaluate its use and to provide practical guidelines. The strategy requires BICR on a subset of study subjects, rather than a complete-case BICR, and makes use of an auxiliary-variable estimator. When the effect size is relatively large, the method provides a substantial reduction in the size of the BICRs. In a trial with 722 participants and a HR of 0.48, an average audit of 28% of the data was needed and always confirmed the treatment effect as assessed by local evaluations. More moderate effect sizes and/or smaller trial sizes required larger proportions of audited images, ranging from 57% to 100% for HRs ranging from 0.55 to 0.77 and sample sizes between 209 and 737. The method is developed for a simple random sample of study subjects. In studies with low event rates, more efficient estimation may result from sampling individuals with events at a higher rate. The proposed strategy can greatly decrease the costs and time associated with BICR, by reducing the number of images undergoing review. The savings will depend on the underlying treatment effect and trial size, with larger treatment effects and larger trials requiring smaller proportions of audited data.

  1. [Medication errors in a neonatal unit: One of the main adverse events].

    Science.gov (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

    2016-04-01

    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.

  2. 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

    2009-01-01

    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.

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

    Directory of Open Access Journals (Sweden)

    Alice X. Dong

    2016-01-01

    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.

  4. Rates of medical errors and preventable adverse events among hospitalized children following implementation of a resident handoff bundle.

    Science.gov (United States)

    Starmer, Amy J; Sectish, Theodore C; Simon, Dennis W; Keohane, Carol; McSweeney, Maireade E; Chung, Erica Y; Yoon, Catherine S; Lipsitz, Stuart R; Wassner, Ari J; Harper, Marvin B; Landrigan, Christopher P

    2013-12-04

    Handoff miscommunications are a leading cause of medical errors. Studies comprehensively assessing handoff improvement programs are lacking. To determine whether introduction of a multifaceted handoff program was associated with reduced rates of medical errors and preventable adverse events, fewer omissions of key data in written handoffs, improved verbal handoffs, and changes in resident-physician workflow. Prospective intervention study of 1255 patient admissions (642 before and 613 after the intervention) involving 84 resident physicians (42 before and 42 after the intervention) from July-September 2009 and November 2009-January 2010 on 2 inpatient units at Boston Children's Hospital. Resident handoff bundle, consisting of standardized communication and handoff training, a verbal mnemonic, and a new team handoff structure. On one unit, a computerized handoff tool linked to the electronic medical record was introduced. The primary outcomes were the rates of medical errors and preventable adverse events measured by daily systematic surveillance. The secondary outcomes were omissions in the printed handoff document and resident time-motion activity. Medical errors decreased from 33.8 per 100 admissions (95% CI, 27.3-40.3) to 18.3 per 100 admissions (95% CI, 14.7-21.9; P < .001), and preventable adverse events decreased from 3.3 per 100 admissions (95% CI, 1.7-4.8) to 1.5 (95% CI, 0.51-2.4) per 100 admissions (P = .04) following the intervention. There were fewer omissions of key handoff elements on printed handoff documents, especially on the unit that received the computerized handoff tool (significant reductions of omissions in 11 of 14 categories with computerized tool; significant reductions in 2 of 14 categories without computerized tool). Physicians spent a greater percentage of time in a 24-hour period at the patient bedside after the intervention (8.3%; 95% CI 7.1%-9.8%) vs 10.6% (95% CI, 9.2%-12.2%; P = .03). The average duration of verbal

  5. Development of a new cause classification method considering plant ageing and human errors for adverse events which occurred in nuclear power plants and some results of its application

    International Nuclear Information System (INIS)

    Miyazaki, Takamasa

    2007-01-01

    The adverse events which occurred in nuclear power plants are analyzed to prevent similar events, and in the analysis of each event, the cause of the event is classified by a cause classification method. This paper shows a new cause classification method which is improved in several points as follows: (1) the whole causes are systematically classified into three major categories such as machine system, operation system and plant outside causes, (2) the causes of the operation system are classified into several management errors normally performed in a nuclear power plant, (3) the content of ageing is defined in detail for their further analysis, (4) human errors are divided and defined by the error stage, (5) human errors can be related to background factors, and so on. This new method is applied to the adverse events which occurred in domestic and overseas nuclear power plants in 2005. From these results, it is clarified that operation system errors account for about 60% of the whole causes, of which approximately 60% are maintenance errors, about 40% are worker's human errors, and that the prevention of maintenance errors, especially worker's human errors is crucial. (author)

  6. Interplay between Hippocampal Sharp-Wave-Ripple Events and Vicarious Trial and Error Behaviors in Decision Making.

    Science.gov (United States)

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

    2016-12-07

    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. Copyright © 2016 Elsevier Inc. All rights reserved.

  7. Upset in response to a Sibling's partner's infidelities.

    Science.gov (United States)

    Michalski, Richard L; Shackelford, Todd K; Salmon, Catherine A

    2007-03-01

    Using data collected from people with at least one brother and one sister, and consistent with an evolutionary perspective, we find that older men and women (a) are more upset by a brother's partner's sexual infidelity than by her emotional infidelity and (b) are more upset by a sister's partner's emotional infidelity than by his sexual infidelity. There were no effects of participant sex or sex of in-law on upset over a sibling's partner's infidelities, but there was an effect of participant sex on reports of upset over one's own partner's infidelities. The results suggest that the key variable among older participants is the sex of the sibling or, correspondingly, the sex of the sibling's partner, as predicted from an evolutionary analysis of reproductive costs, and not the sex of the participant, as predicted from a socialization perspective. Discussion offers directions for future work on jealousy.

  8. Application of reactors for testing neutron-induced upsets in commercial SRAMs

    International Nuclear Information System (INIS)

    Griffin, P.J.; Luera, T.F.; Sexton, F.W.; Cooper, P.J.; Karr, S.G.; Hash, G.L.; Fuller, E.

    1997-01-01

    Reactor neutron environments can be used to test/screen the sensitivity of unhardened commercial SRAMs to low-LET neutron-induced upset. Tests indicate both thermal/epithermal (< 1 keV) and fast neutrons can cause upsets in unhardened parts. Measured upset rates in reactor environments can be used to model the upset rate for arbitrary neutron spectra

  9. Single-event effect ground test issues

    International Nuclear Information System (INIS)

    Koga, R.

    1996-01-01

    Ground-based single event effect (SEE) testing of microcircuits permits characterization of device susceptibility to various radiation induced disturbances, including: (1) single event upset (SEU) and single event latchup (SEL) in digital microcircuits; (2) single event gate rupture (SEGR), and single event burnout (SEB) in power transistors; and (3) bit errors in photonic devices. These characterizations can then be used to generate predictions of device performance in the space radiation environment. This paper provides a general overview of ground-based SEE testing and examines in critical depth several underlying conceptual constructs relevant to the conduct of such tests and to the proper interpretation of results. These more traditional issues are contrasted with emerging concerns related to the testing of modern, advanced microcircuits

  10. Nurses' systems thinking competency, medical error reporting, and the occurrence of adverse events: a cross-sectional study.

    Science.gov (United States)

    Hwang, Jee-In; Park, Hyeoun-Ae

    2017-12-01

    Healthcare professionals' systems thinking is emphasized for patient safety. To report nurses' systems thinking competency, and its relationship with medical error reporting and the occurrence of adverse events. A cross-sectional survey using a previously validated Systems Thinking Scale (STS), was conducted. Nurses from two teaching hospitals were invited to participate in the survey. There were 407 (60.3%) completed surveys. The mean STS score was 54.5 (SD 7.3) out of 80. Nurses with higher STS scores were more likely to report medical errors (odds ratio (OR) = 1.05; 95% confidence interval (CI) = 1.02-1.08) and were less likely to be involved in the occurrence of adverse events (OR = 0.96; 95% CI = 0.93-0.98). Nurses showed moderate systems thinking competency. Systems thinking was a significant factor associated with patient safety. Impact Statement: The findings of this study highlight the importance of enhancing nurses' systems thinking capacity to promote patient safety.

  11. 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)

    1999-12-01

    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

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

    International Nuclear Information System (INIS)

    Reer, B.; Dang, V.N.; Hirschberg, S.; Straeter, O.

    1999-12-01

    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

  13. Benzodiazepine Use During Hospitalization: Automated Identification of Potential Medication Errors and Systematic Assessment of Preventable Adverse Events.

    Directory of Open Access Journals (Sweden)

    David Franklin Niedrig

    Full Text Available Benzodiazepines and "Z-drug" GABA-receptor modulators (BDZ are among the most frequently used drugs in hospitals. Adverse drug events (ADE associated with BDZ can be the result of preventable medication errors (ME related to dosing, drug interactions and comorbidities. The present study evaluated inpatient use of BDZ and related ME and ADE.We conducted an observational study within a pharmacoepidemiological database derived from the clinical information system of a tertiary care hospital. We developed algorithms that identified dosing errors and interacting comedication for all administered BDZ. Associated ADE and risk factors were validated in medical records.Among 53,081 patients contributing 495,813 patient-days BDZ were administered to 25,626 patients (48.3% on 115,150 patient-days (23.2%. We identified 3,372 patient-days (2.9% with comedication that inhibits BDZ metabolism, and 1,197 (1.0% with lorazepam administration in severe renal impairment. After validation we classified 134, 56, 12, and 3 cases involving lorazepam, zolpidem, midazolam and triazolam, respectively, as clinically relevant ME. Among those there were 23 cases with associated adverse drug events, including severe CNS-depression, falls with subsequent injuries and severe dyspnea. Causality for BDZ was formally assessed as 'possible' or 'probable' in 20 of those cases. Four cases with ME and associated severe ADE required administration of the BDZ antagonist flumazenil.BDZ use was remarkably high in the studied setting, frequently involved potential ME related to dosing, co-medication and comorbidities, and rarely cases with associated ADE. We propose the implementation of automated ME screening and validation for the prevention of BDZ-related ADE.

  14. Using a structured morbidity and mortality meeting to understand the contribution of human error to adverse surgical events in a South African regional hospital.

    Science.gov (United States)

    Clarke, Damian L; Furlong, Heidi; Laing, Grant L; Aldous, Colleen; Thomson, Sandie Rutherford

    2013-10-22

    Several authors have suggested that the traditional surgical morbidity and mortality meeting be developed as a tool to identify surgical errors and turn them into learning opportunities for staff. We report our experience with these meetings. A structured template was developed for each morbidity and mortality meeting. We used a grid to analyse mortality and classify the death as: (i) death expected/death unexpected; and (ii) death unpreventable/death preventable. Individual cases were then analysed using a combination of error taxonomies. During the period June - December 2011, a total of 400 acute admissions (195 trauma and 205 non-trauma) were managed at Edendale Hospital, Pietermaritzburg, South Africa. During this period, 20 morbidity and mortality meetings were held, at which 30 patients were discussed. There were 10 deaths, of which 5 were unexpected and potentially avoidable. A total of 43 errors were recognised, all in the domain of the acute admissions ward. There were 33 assessment failures, 5 logistical failures, 5 resuscitation failures, 16 errors of execution and 27 errors of planning. Seven patients experienced a number of errors, of whom 5 died. Error theory successfully dissected out the contribution of error to adverse events in our institution. Translating this insight into effective strategies to reduce the incidence of error remains a challenge. Using the examples of error identified at the meetings as educational cases may help with initiatives that directly target human error in trauma care.

  15. A software solution to estimate the SEU-induced soft error rate for systems implemented on SRAM-based FPGAs

    International Nuclear Information System (INIS)

    Wang Zhongming; Lu Min; Yao Zhibin; Guo Hongxia

    2011-01-01

    SRAM-based FPGAs are very susceptible to radiation-induced Single-Event Upsets (SEUs) in space applications. The failure mechanism in FPGA's configuration memory differs from those in traditional memory device. As a result, there is a growing demand for methodologies which could quantitatively evaluate the impact of this effect. Fault injection appears to meet such requirement. In this paper, we propose a new methodology to analyze the soft errors in SRAM-based FPGAs. This method is based on in depth understanding of the device architecture and failure mechanisms induced by configuration upsets. The developed programs read in the placed and routed netlist, search for critical logic nodes and paths that may destroy the circuit topological structure, and then query a database storing the decoded relationship of the configurable resources and corresponding control bit to get the sensitive bits. Accelerator irradiation test and fault injection experiments were carried out to validate this approach. (semiconductor integrated circuits)

  16. Inadequacies of Physical Examination as a Cause of Medical Errors and Adverse Events: A Collection of Vignettes.

    Science.gov (United States)

    Verghese, Abraham; Charlton, Blake; Kassirer, Jerome P; Ramsey, Meghan; Ioannidis, John P A

    2015-12-01

    Oversights in the physical examination are a type of medical error not easily studied by chart review. They may be a major contributor to missed or delayed diagnosis, unnecessary exposure to contrast and radiation, incorrect treatment, and other adverse consequences. Our purpose was to collect vignettes of physical examination oversights and to capture the diversity of their characteristics and consequences. A cross-sectional study using an 11-question qualitative survey for physicians was distributed electronically, with data collected from February to June of 2011. The participants were all physicians responding to e-mail or social media invitations to complete the survey. There were no limitations on geography, specialty, or practice setting. Of the 208 reported vignettes that met inclusion criteria, the oversight was caused by a failure to perform the physical examination in 63%; 14% reported that the correct physical examination sign was elicited but misinterpreted, whereas 11% reported that the relevant sign was missed or not sought. Consequence of the physical examination inadequacy included missed or delayed diagnosis in 76% of cases, incorrect diagnosis in 27%, unnecessary treatment in 18%, no or delayed treatment in 42%, unnecessary diagnostic cost in 25%, unnecessary exposure to radiation or contrast in 17%, and complications caused by treatments in 4%. The mode of the number of physicians missing the finding was 2, but many oversights were missed by many physicians. Most oversights took up to 5 days to identify, but 66 took longer. Special attention and skill in examining the skin and its appendages, as well as the abdomen, groin, and genitourinary area could reduce the reported oversights by half. Physical examination inadequacies are a preventable source of medical error, and adverse events are caused mostly by failure to perform the relevant examination. Copyright © 2015 Elsevier Inc. All rights reserved.

  17. 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.

    2008-01-01

    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

  18. A Novel Application of Machine Learning Methods to Model Microcontroller Upset Due to Intentional Electromagnetic Interference

    Science.gov (United States)

    Bilalic, Rusmir

    A novel application of support vector machines (SVMs), artificial neural networks (ANNs), and Gaussian processes (GPs) for machine learning (GPML) to model microcontroller unit (MCU) upset due to intentional electromagnetic interference (IEMI) is presented. In this approach, an MCU performs a counting operation (0-7) while electromagnetic interference in the form of a radio frequency (RF) pulse is direct-injected into the MCU clock line. Injection times with respect to the clock signal are the clock low, clock rising edge, clock high, and the clock falling edge periods in the clock window during which the MCU is performing initialization and executing the counting procedure. The intent is to cause disruption in the counting operation and model the probability of effect (PoE) using machine learning tools. Five experiments were executed as part of this research, each of which contained a set of 38,300 training points and 38,300 test points, for a total of 383,000 total points with the following experiment variables: injection times with respect to the clock signal, injected RF power, injected RF pulse width, and injected RF frequency. For the 191,500 training points, the average training error was 12.47%, while for the 191,500 test points the average test error was 14.85%, meaning that on average, the machine was able to predict MCU upset with an 85.15% accuracy. Leaving out the results for the worst-performing model (SVM with a linear kernel), the test prediction accuracy for the remaining machines is almost 89%. All three machine learning methods (ANNs, SVMs, and GPML) showed excellent and consistent results in their ability to model and predict the PoE on an MCU due to IEMI. The GP approach performed best during training with a 7.43% average training error, while the ANN technique was most accurate during the test with a 10.80% error.

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

    NARCIS (Netherlands)

    Kerstens, N.F.H.

    2010-01-01

    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

  20. 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)

    2014-08-15

    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.

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

    International Nuclear Information System (INIS)

    Kim, Ji Tae; Lee, Dhong Hoon; Choi, Young Sung

    2014-01-01

    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

  2. Analysis of Task Types and Error Types of the Human Actions Involved in the Human-related Unplanned Reactor Trip Events

    International Nuclear Information System (INIS)

    Kim, Jae Whan; Park, Jin Kyun; Jung, Won Dea

    2008-02-01

    This report provides the task types and error types involved in the unplanned reactor trip events that have occurred during 1986 - 2006. The events that were caused by the secondary system of the nuclear power plants amount to 67 %, and the remaining 33 % was by the primary system. The contribution of the activities of the plant personnel was identified as the following order: corrective maintenance (25.7 %), planned maintenance (22.8 %), planned operation (19.8 %), periodic preventive maintenance (14.9 %), response to a transient (9.9 %), and design/manufacturing/installation (9.9%). According to the analysis of error modes, the error modes such as control failure (22.2 %), wrong object (18.5 %), omission (14.8 %), wrong action (11.1 %), and inadequate (8.3 %) take up about 75 % of all the unplanned trip events. The analysis of the cognitive functions involved showed that the planning function makes the highest contribution to the human actions leading to unplanned reactor trips, and it is followed by the observation function (23.4%), the execution function (17.8 %), and the interpretation function (10.3 %). The results of this report are to be used as important bases for development of the error reduction measures or development of the error mode prediction system for the test and maintenance tasks in nuclear power plants

  3. Analysis of Task Types and Error Types of the Human Actions Involved in the Human-related Unplanned Reactor Trip Events

    Energy Technology Data Exchange (ETDEWEB)

    Kim, Jae Whan; Park, Jin Kyun; Jung, Won Dea

    2008-02-15

    This report provides the task types and error types involved in the unplanned reactor trip events that have occurred during 1986 - 2006. The events that were caused by the secondary system of the nuclear power plants amount to 67 %, and the remaining 33 % was by the primary system. The contribution of the activities of the plant personnel was identified as the following order: corrective maintenance (25.7 %), planned maintenance (22.8 %), planned operation (19.8 %), periodic preventive maintenance (14.9 %), response to a transient (9.9 %), and design/manufacturing/installation (9.9%). According to the analysis of error modes, the error modes such as control failure (22.2 %), wrong object (18.5 %), omission (14.8 %), wrong action (11.1 %), and inadequate (8.3 %) take up about 75 % of all the unplanned trip events. The analysis of the cognitive functions involved showed that the planning function makes the highest contribution to the human actions leading to unplanned reactor trips, and it is followed by the observation function (23.4%), the execution function (17.8 %), and the interpretation function (10.3 %). The results of this report are to be used as important bases for development of the error reduction measures or development of the error mode prediction system for the test and maintenance tasks in nuclear power plants.

  4. Patient safety incident reports related to traditional Japanese Kampo medicines: medication errors and adverse drug events in a university hospital for a ten-year period.

    Science.gov (United States)

    Shimada, Yutaka; Fujimoto, Makoto; Nogami, Tatsuya; Watari, Hidetoshi; Kitahara, Hideyuki; Misawa, Hiroki; Kimbara, Yoshiyuki

    2017-12-21

    Kampo medicine is traditional Japanese medicine, which originated in ancient traditional Chinese medicine, but was introduced and developed uniquely in Japan. Today, Kampo medicines are integrated into the Japanese national health care system. Incident reporting systems are currently being widely used to collect information about patient safety incidents that occur in hospitals. However, no investigations have been conducted regarding patient safety incident reports related to Kampo medicines. The aim of this study was to survey and analyse incident reports related to Kampo medicines in a Japanese university hospital to improve future patient safety. We selected incident reports related to Kampo medicines filed in Toyama University Hospital from May 2007 to April 2017, and investigated them in terms of medication errors and adverse drug events. Out of 21,324 total incident reports filed in the 10-year survey period, we discovered 108 Kampo medicine-related incident reports. However, five cases were redundantly reported; thus, the number of actual incidents was 103. Of those, 99 incidents were classified as medication errors (77 administration errors, 15 dispensing errors, and 7 prescribing errors), and four were adverse drug events, namely Kampo medicine-induced interstitial pneumonia. The Kampo medicine (crude drug) that was thought to induce interstitial pneumonia in all four cases was Scutellariae Radix, which is consistent with past reports. According to the incident severity classification system recommended by the National University Hospital Council of Japan, of the 99 medication errors, 10 incidents were classified as level 0 (an error occurred, but the patient was not affected) and 89 incidents were level 1 (an error occurred that affected the patient, but did not cause harm). Of the four adverse drug events, two incidents were classified as level 2 (patient was transiently harmed, but required no treatment), and two incidents were level 3b (patient was

  5. Adverse Life Events and Emotional and Behavioral Problems in Adolescence: The Role of Non-Verbal Cognitive Ability and Negative Cognitive Errors

    Science.gov (United States)

    Flouri, Eirini; Panourgia, Constantina

    2011-01-01

    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…

  6. Error analysis and prevention of cosmic ion-induced soft errors in static CMOS RAMS

    International Nuclear Information System (INIS)

    Diehl, S.E.; Ochoa, A. Jr.; Dressendorfer, P.V.; Koga, R.; Kolasinski, W.A.

    1982-06-01

    Cosmic ray interactions with memory cells are known to cause temporary, random, bit errors in some designs. The sensitivity of polysilicon gate CMOS static RAM designs to logic upset by impinging ions has been studied using computer simulations and experimental heavy ion bombardment. Results of the simulations are confirmed by experimental upset cross-section data. Analytical models have been extended to determine and evaluate design modifications which reduce memory cell sensitivity to cosmic ions. A simple design modification, the addition of decoupling resistance in the feedback path, is shown to produce static RAMs immune to cosmic ray-induced bit errors

  7. Study of run time errors of the ATLAS Pixel Detector in the 2012 data taking period

    CERN Document Server

    AUTHOR|(INSPIRE)INSPIRE-00339072

    2013-05-16

    The high resolution silicon Pixel detector is critical in event vertex reconstruction and in particle track reconstruction in the ATLAS detector. During the pixel data taking operation, some modules (Silicon Pixel sensor +Front End Chip+ Module Control Chip (MCC)) go to an auto-disable state, where the Modules don’t send the data for storage. Modules become operational again after reconfiguration. The source of the problem is not fully understood. One possible source of the problem is traced to the occurrence of single event upset (SEU) in the MCC. Such a module goes to either a Timeout or Busy state. This report is the study of different types and rates of errors occurring in the Pixel data taking operation. Also, the study includes the error rate dependency on Pixel detector geometry.

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

    OpenAIRE

    Kerstens, N.F.H.

    2010-01-01

    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 production. In principle the welding process is rather simple, the materials to be joined are clamped between two electrodes and pressed together. Because there is an interface present with a higher resist...

  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

    2004-10-01

    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. Neutron detection using soft errors in dynamic random access memories

    International Nuclear Information System (INIS)

    Darambara, D.G.; Spyrou, N.M.

    1992-01-01

    The fact that energetic alpha particles have been observed to be capable of inducing single-event upsets in integrated circuit memories has become a topic of considerable interest in the past few years. One recognized difficulty with dynamic random access memory devices (dRAMs) is that the alpha-particle 'contamination' present within the dRAM encapsulating material interact sufficiently as to corrupt stored data. The authors essentially utilized the fact that these corruptions may be induced in dRAMs by the interaction of charged particles with the chip of the dRAM itself as a basis of a hardware system for neutron detection with a view to applications in neutron imaging and elemental analysis. The design incorporates a bank of dRAMs on which the particles are incident. Initially, these particles were alpha particles from an appropriate alpha-emitting source employed to assess system parameters. The sensitivity of the device to logic state upsets by ionizing radiation is a function of design and technology parameters, inducing storage node area, node capacitance, operating voltage, minority carrier lifetime, electric fields pattern in the bulk silicon, and specific device geometry. The soft error rate of the device in a given package depends on the flux of alphas, the energy spectrum, the distribution of incident angles, the target area, the total stored charge, the collection efficiency, the cell geometry, the supply voltage, the cycle and refreshing time, and the noise margin

  11. Operator errors

    International Nuclear Information System (INIS)

    Knuefer; Lindauer

    1980-01-01

    Besides that at spectacular events a combination of component failure and human error is often found. Especially the Rasmussen-Report and the German Risk Assessment Study show for pressurised water reactors that human error must not be underestimated. Although operator errors as a form of human error can never be eliminated entirely, they can be minimized and their effects kept within acceptable limits if a thorough training of personnel is combined with an adequate design of the plant against accidents. Contrary to the investigation of engineering errors, the investigation of human errors has so far been carried out with relatively small budgets. Intensified investigations in this field appear to be a worthwhile effort. (orig.)

  12. 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

    Science.gov (United States)

    Zakeri, Zeinab; Azadi, Majid; Ghader, Sarmad

    2018-01-01

    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.

  13. Dynamic effect in ultrasonic assisted micro-upsetting

    Science.gov (United States)

    Presz, Wojciech

    2018-05-01

    The use of ultrasonic assistance in microforming is becoming more and more popular. Mainly due to the beneficial effect of vibrations on the flow of plastic deformation reported already in the 50s of the last century. The influence is of two types: surface and volume. The surface effect is mainly the reduction of friction forces, and volumetric is the impact on the dislocation movement and even on phase transitions. The work focuses on the dynamic aspect of vibration assisted microforming. The use of ultrasonic vibrations at a frequency of 20 kHz and an amplitude of 16 µm, in the micro-upsetting process of an aluminum sample resulted in a high concentration of strain on both ends of the sample - at 14% of the height on both sides. There was observed (in relation to deformations of the sample without vibrations) 150-250% increase and a 50% decrease in strain in the center of the sample. At the same time, the larger deformations occurred from the impact side of the punch. Analyzing the course of forces of the upsetting process in the loading and unloading phase as well as the process of breaking glass samples, the spring deflections of key system elements and their natural frequencies were determined or calculated. Based on the determined or calculated parameters of the test stand, it was shown that during the micro-upsetting process the punch may detach from the sample surface and this is the main reason for the phenomena occurring. Detach of the punch is also the cause of the observed instability of the measurement of force, which should be considered unbelievable in such a situation.

  14. 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.

    Science.gov (United States)

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

    2017-04-01

    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; www.vigicrues.gouv.fr) 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

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

    NARCIS (Netherlands)

    Wijers, AA; Boksem, MAS

    2005-01-01

    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

  16. Modeling and control of a DC upset resistance butt welding process

    NARCIS (Netherlands)

    Naus, G.J.L.; Meulenberg, R.; Molengraft, van de M.J.G.

    2007-01-01

    This paper presents the analysis and synthesis of modeling and control of the DC upset resistance butt welding process used in rim production lines. A new control strategy is developed, enabling active control of the welding seam temperature and the upset size. As a result, set-up times and energy

  17. Events

    Directory of Open Access Journals (Sweden)

    Igor V. Karyakin

    2016-02-01

    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.

  18. Review of Research On Guidance for Recovery from Pitch Axis Upsets

    Science.gov (United States)

    Harrison, Stephanie J.

    2016-01-01

    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.

  19. The action characterization matrix: A link between HERA (Human Events Reference for ATHEANA) and ATHEANA (a technique for human error analysis)

    International Nuclear Information System (INIS)

    Hahn, H.A.

    1997-01-01

    The Technique for Human Error Analysis (ATHEANA) is a newly developed human reliability analysis (HRA) methodology that aims to facilitate better representation and integration of human performance into probabilistic risk assessment (PRA) modeling and quantification by analyzing risk-significant operating experience in the context of existing behavior science models. The fundamental premise of ATHEANA is that error-forcing contexts (EFCs), which refer to combinations of equipment/material conditions and performance shaping factors (PSFs), set up or create the conditions under which unsafe actions (UAs) can occur. ATHEANA is being developed in the context of nuclear power plant (NPP) PRAs, and much of the language used to describe the method and provide examples of its application are specific to that industry. Because ATHEANA relies heavily on the analysis of operational events that have already occurred as a mechanism for generating creative thinking about possible EFCs, a database, called the Human Events Reference for ATHEANA (HERA), has been developed to support the methodology. Los Alamos National Laboratory's (LANL) Human Factors Group has recently joined the ATHEANA project team; LANL is responsible for further developing the database structure and for analyzing additional exemplar operational events for entry into the database. The Action Characterization Matrix (ACM) is conceived as a bridge between the HERA database structure and ATHEANA. Specifically, the ACM allows each unsafe action or human failure event to be characterized according to its representation along each of six different dimensions: system status, initiator status, unsafe action mechanism, information processing stage, equipment/material conditions, and performance shaping factors. This report describes the development of the ACM and provides details on the structure and content of its dimensions

  20. Analysis of Control Strategies for Aircraft Flight Upset Recovery

    Science.gov (United States)

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

    2012-01-01

    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.

  1. Meiotic errors followed by two parallel postzygotic trisomy rescue events are a frequent cause of constitutional segmental mosaicism

    Directory of Open Access Journals (Sweden)

    Robberecht Caroline

    2012-04-01

    Full Text Available Abstract Structural copy number variation (CNV is a frequent cause of human variation and disease. Evidence is mounting that somatic acquired CNVs are prevalent, with mosaicisms of large segmental CNVs in blood found in up to one percent of both the healthy and patient populations. It is generally accepted that such constitutional mosaicisms are derived from postzygotic somatic mutations. However, few studies have tested this assumption. Here we determined the origin of CNVs which coexist with a normal cell line in nine individuals. We show that in 2/9 the CNV originated during meiosis. The existence of two cell lines with 46 chromosomes thus resulted from two parallel trisomy rescue events during postzygotic mitoses.

  2. Single event effect testing of the Intel 80386 family and the 80486 microprocessor

    International Nuclear Information System (INIS)

    Moran, A.; LaBel, K.; Gates, M.; Seidleck, C.; McGraw, R.; Broida, M.; Firer, J.; Sprehn, S.

    1996-01-01

    The authors present single event effect test results for the Intel 80386 microprocessor, the 80387 coprocessor, the 82380 peripheral device, and on the 80486 microprocessor. Both single event upset and latchup conditions were monitored

  3. On Error Analysis of ORIGEN Decay Data Library Based on ENDF/B-VII.1 via Decay Heat Estimation after a Fission Event

    Energy Technology Data Exchange (ETDEWEB)

    Kim, Do Heon; Gil, Choong-Sup; Lee, Young-Ouk [Korea Atomic Energy Research Institute, Daejeon (Korea, Republic of)

    2015-10-15

    The method is strongly dependent on the available nuclear structure data, i.e., fission product yield data and decay data. Consequently, the improvements in the nuclear structure data could have guaranteed more reliable decay heat estimation for short cooling times after fission. The SCALE-6.1.3 code package includes the ENDF/B-VII.0-based fission product yield data and ENDF/B-VII.1-based decay data libraries for the ORIGEN-S code. The generation and validation of the new ORIGEN-S yield data libraries based on the recently available fission product yield data such as ENDF/B-VII.1, JEFF-3.1.1, JENDL/FPY-2011, and JENDL-4.0 have been presented in the previous study. According to the study, the yield data library in the SCALE-6.1.3 could be regarded as the latest one because it resulted in almost the same outcomes as the ENDF/B-VII.1. A research project on the production of the nuclear structure data for decay heat estimation of nuclear fuel has been carried out in Korea Atomic Energy Research Institute (KAERI). The data errors contained in the ORIGEN-S decay data library of SCALE-6.1.3 have been clearly identified by their changing variables. Also, the impacts of the decay data errors have been analyzed by estimating the decay heats for the fission product nuclides and their daughters after {sup 235}U thermal-neutron fission. Although the impacts of decay data errors are quite small, it reminds us the possible importance of decay data when estimating the decay heat for short cooling times after a fission event.

  4. Phenotyping for patient safety: algorithm development for electronic health record based automated adverse event and medical error detection in neonatal intensive care.

    Science.gov (United States)

    Li, Qi; Melton, Kristin; Lingren, Todd; Kirkendall, Eric S; Hall, Eric; Zhai, Haijun; Ni, Yizhao; Kaiser, Megan; Stoutenborough, Laura; Solti, Imre

    2014-01-01

    Although electronic health records (EHRs) have the potential to provide a foundation for quality and safety algorithms, few studies have measured their impact on automated adverse event (AE) and medical error (ME) detection within the neonatal intensive care unit (NICU) environment. This paper presents two phenotyping AE and ME detection algorithms (ie, IV infiltrations, narcotic medication oversedation and dosing errors) and describes manual annotation of airway management and medication/fluid AEs from NICU EHRs. From 753 NICU patient EHRs from 2011, we developed two automatic AE/ME detection algorithms, and manually annotated 11 classes of AEs in 3263 clinical notes. Performance of the automatic AE/ME detection algorithms was compared to trigger tool and voluntary incident reporting results. AEs in clinical notes were double annotated and consensus achieved under neonatologist supervision. Sensitivity, positive predictive value (PPV), and specificity are reported. Twelve severe IV infiltrates were detected. The algorithm identified one more infiltrate than the trigger tool and eight more than incident reporting. One narcotic oversedation was detected demonstrating 100% agreement with the trigger tool. Additionally, 17 narcotic medication MEs were detected, an increase of 16 cases over voluntary incident reporting. Automated AE/ME detection algorithms provide higher sensitivity and PPV than currently used trigger tools or voluntary incident-reporting systems, including identification of potential dosing and frequency errors that current methods are unequipped to detect. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.

  5. Effects of Cabin Upsets on Adsorption Columns for Air Revitalization

    Science.gov (United States)

    LeVan, Douglas

    1999-01-01

    The National Aeronautics and Space Administration (NASA) utilizes adsorption technology as part of contaminant removal systems designed for long term missions. A variety of trace contaminants can be effectively removed from gas streams by adsorption onto activated carbon. An activated carbon adsorption column meets NASA's requirements of a lightweight and efficient means of controlling trace contaminant levels aboard spacecraft and space stations. The activated carbon bed is part of the Trace Contaminant Control System (TCCS) which is utilized to purify the cabin atmosphere. TCCS designs oversize the adsorption columns to account for irregular fluctuations in cabin atmospheric conditions. Variations in the cabin atmosphere include changes in contaminant concentrations, temperature, and relative humidity. Excessively large deviations from typical conditions can result from unusual crew activity, equipment malfunctions, or even fires. The research carried out under this award focussed in detail on the effects of cabin upsets on the performance of activated carbon adsorption columns. Both experiments and modeling were performed with an emphasis on the roll of a change in relative humidity on adsorption of trace contaminants. A flow through fixed-bed apparatus was constructed at the NASA Ames Research Center, and experiments were performed there. Modeling work was performed at the University of Virginia.

  6. Upset Prevention and Recovery for Unimpaired and Impaired Aircraft, Phase II

    Data.gov (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...

  7. Development and Flight Testing of an Automated Upset Recovery System, Phase I

    Data.gov (United States)

    National Aeronautics and Space Administration — Loss of control (LOC) due to upset is one of the main causes of accidents in manned aircraft and is already emerging as a significant causal factor in unmanned...

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

    OpenAIRE

    Dafni Hellstrand; Elisavet Chrysochoou

    2015-01-01

    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 constructi...

  9. Reactor internals design/analysis for normal, upset, and faulted conditions

    International Nuclear Information System (INIS)

    Burke, F.R.

    1977-06-01

    The analytical procedures used by Babcock and Wilcox to demonstrate the structural integrity of the 205-FA reactor internals are described. Analytical results are presented and compared to ASME Code allowable limits for Normal, Upset, and Faulted conditions. The particular faulted condition considered is a simultaneous loss-of-coolant accident and safe shutdown earthquake. The operating basis earthquake is addressed as an Upset condition

  10. Statistics and methodology of multiple cell upset characterization under heavy ion irradiation

    International Nuclear Information System (INIS)

    Zebrev, G.I.; Gorbunov, M.S.; Useinov, R.G.; Emeliyanov, V.V.; Ozerov, A.I.; Anashin, V.S.; Kozyukov, A.E.; Zemtsov, K.S.

    2015-01-01

    Mean and partial cross-section concepts and their connections to multiplicity and statistics of multiple cell upsets (MCUs) in highly-scaled digital memories are introduced and discussed. The important role of the experimental determination of the upset statistics is emphasized. It was found that MCU may lead to quasi-linear dependence of cross-sections on linear energy transfer (LET). A new form of function for interpolation of mean cross-section dependences on LET has been proposed

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

    Science.gov (United States)

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

    2014-09-01

    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. Upset due to a single particle caused propagated transients in a bulk CMOS microprocessor

    International Nuclear Information System (INIS)

    Leavy, J.F.; Hoffmann, L.F.; Shoran, R.W.; Johnson, M.T.

    1991-01-01

    This paper reports on data pattern advances observed in preset, single event upset (SEU) hardened clocked flip-flops, during static Cf-252 exposures on a bulk CMOS microprocessor, that were attributable to particle caused anomalous clock signals, or propagated transients. SPICE simulations established that particle strikes in the output nodes of a clock control logic flip-flop could produce transients of sufficient amplitude and duration to be accepted as legitimate pulses by clock buffers fed by the flip-flop's output nodes. The buffers would then output false clock pulses, thereby advancing the state of the present flip-flops. Masking the clock logic on one of the test chips made the flip-flop data advance cease, confirming the clock logic as the source of the SEU. By introducing N 2 gas, at reduced pressures, into the SEU test chamber to attenuate Cf-252 particle LET's, a 24-26 MeV-cm 2 /mg LET threshold was deduced. Subsequent tests, at the 88-inch cyclotron at Berkeley, established an LET threshold of 30 MeV-cm 2 /mg (283 MeV Cu at 0 degrees) for the generation of false clocks. Cyclotron SEU tests are considered definitive, while Cf-252 data usually is not. However, in this instance Cf-252 tests proved analytically useful, providing SEU characterization data that was both timely and inexpensive

  13. Modeling of Single Event Transients With Dual Double-Exponential Current Sources: Implications for Logic Cell Characterization

    Science.gov (United States)

    Black, Dolores A.; Robinson, William H.; Wilcox, Ian Z.; Limbrick, Daniel B.; Black, Jeffrey D.

    2015-08-01

    Single event effects (SEE) are a reliability concern for modern microelectronics. Bit corruptions can be caused by single event upsets (SEUs) in the storage cells or by sampling single event transients (SETs) from a logic path. An accurate prediction of soft error susceptibility from SETs requires good models to convert collected charge into compact descriptions of the current injection process. This paper describes a simple, yet effective, method to model the current waveform resulting from a charge collection event for SET circuit simulations. The model uses two double-exponential current sources in parallel, and the results illustrate why a conventional model based on one double-exponential source can be incomplete. A small set of logic cells with varying input conditions, drive strength, and output loading are simulated to extract the parameters for the dual double-exponential current sources. The parameters are based upon both the node capacitance and the restoring current (i.e., drive strength) of the logic cell.

  14. Densification of sintered molybdenum during hot upsetting: experiments and modelling

    International Nuclear Information System (INIS)

    Parteder, E.; Kopp, R.

    1999-01-01

    The densification behaviour of sintered molybdenum is investigated experimentally and by modelling using a pressure dependent plasticity model. Therefore the yield condition of Gurson, extended by Tvergaard is used. The uniaxial compression test is applied to determine the evolution of the density as well as the stress-strain curves for the porous metal. Powder metallurgical molybdenum exhibits closed porosity after consolidation due to sintering with nearly spherical shaped pores. The experimental results show that the densification, especially during the first stage of deformation, is different from that of powder compacts or partially consolidated powder materials with open porosity. During hot upsetting, the pores change their size and shape. This behaviour strongly affects the densification rate. For an accurate prediction of the evolution of the density using Gurson's model, the parameters q 1 and q 2 introduced by Tvergaard, will be defined as internal variables. The use of internal variables is justified by the fact that the pores change their shape during deformation, although the link between the internal variables and the pore shape is not explicitly established in this paper. If the loading is proportional (which means that the ratio of the stress-components does not change with plastic strain), the pore shape can be associated with the applied plastic strain. With this association the parameters q i can be defined as a function from the invariant quantity equivalent plastic strain, which can be used as the internal variable in the finite element simulation. The influence of the porosity on the flow stress at different levels of plastic strain will also be investigated and is used as a second information to fit both parameters q 1 and q 2 . (orig.)

  15. Modeling the cosmic-ray-induced soft-error rate in integrated circuits: An overview

    International Nuclear Information System (INIS)

    Srinivasan, G.R.

    1996-01-01

    This paper is an overview of the concepts and methodologies used to predict soft-error rates (SER) due to cosmic and high-energy particle radiation in integrated circuit chips. The paper emphasizes the need for the SER simulation using the actual chip circuit model which includes device, process, and technology parameters as opposed to using either the discrete device simulation or generic circuit simulation that is commonly employed in SER modeling. Concepts such as funneling, event-by-event simulation, nuclear history files, critical charge, and charge sharing are examined. Also discussed are the relative importance of elastic and inelastic nuclear collisions, rare event statistics, and device vs. circuit simulations. The semi-empirical methodologies used in the aerospace community to arrive at SERs [also referred to as single-event upset (SEU) rates] in integrated circuit chips are reviewed. This paper is one of four in this special issue relating to SER modeling. Together, they provide a comprehensive account of this modeling effort, which has resulted in a unique modeling tool called the Soft-Error Monte Carlo Model, or SEMM

  16. Microstructure and mechanical properties of resistance upset butt welded 304 austenitic stainless steel joints

    International Nuclear Information System (INIS)

    Sharifitabar, M.; Halvaee, A.; Khorshahian, S.

    2011-01-01

    Graphical abstract: Three different microstructural zones formed at different distances from the joint interface in resistance upset butt welding of 304 austenitic stainless steel. Highlights: → Evaluation of microstructure in resistance upset welding of 304 stainless steel. → Evaluation of welding parameters effects on mechanical properties of the joint. → Introducing the optimum welding condition for joining stainless steel bars. -- Abstract: Resistance upset welding (UW) is a widely used process for joining metal parts. In this process, current, time and upset pressure are three parameters that affect the quality of welded products. In the present research, resistance upset butt welding of 304 austenitic stainless steel and effect of welding power and upset pressure on microstructure, tensile strength and fatigue life of the joint were investigated. Microstructure of welds were studied using scanning electron microscopy (SEM). X-ray diffraction (XRD) analysis was used to distinguish the phase(s) that formed at the joint interface and in heat affected zone (HAZ). Energy dispersive spectroscopy (EDS) linked to the SEM was used to determine chemical composition of phases formed at the joint interface. Fatigue tests were performed using a pull-push fatigue test machine and the fatigue properties were analyzed drawing stress-number of cycles to failure (S-N) curves. Also tensile strength tests were performed. Finally tensile and fatigue fracture surfaces were studied by SEM. Results showed that there were three different microstructural zones at different distances from the joint interface and delta ferrite phase has formed in these regions. There was no precipitation of chromium carbide at the joint interface and in the HAZ. Tensile and fatigue strengths of the joint decreased with welding power. Increasing of upset pressure has also considerable influence on tensile strength of the joint. Fractography of fractured samples showed that formation of hot spots at

  17. Upset Over Sexual versus Emotional Infidelity Among Gay, Lesbian, Bisexual, and Heterosexual Adults.

    Science.gov (United States)

    Frederick, David A; Fales, Melissa R

    2016-01-01

    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.

  18. Stability and performance analysis of a jump linear control system subject to digital upsets

    Science.gov (United States)

    Wang, Rui; Sun, Hui; Ma, Zhen-Yang

    2015-04-01

    This paper focuses on the methodology analysis for the stability and the corresponding tracking performance of a closed-loop digital jump linear control system with a stochastic switching signal. The method is applied to a flight control system. A distributed recoverable platform is implemented on the flight control system and subject to independent digital upsets. The upset processes are used to stimulate electromagnetic environments. Specifically, the paper presents the scenarios that the upset process is directly injected into the distributed flight control system, which is modeled by independent Markov upset processes and independent and identically distributed (IID) processes. A theoretical performance analysis and simulation modelling are both presented in detail for a more complete independent digital upset injection. The specific examples are proposed to verify the methodology of tracking performance analysis. The general analyses for different configurations are also proposed. Comparisons among different configurations are conducted to demonstrate the availability and the characteristics of the design. Project supported by the Young Scientists Fund of the National Natural Science Foundation of China (Grant No. 61403395), the Natural Science Foundation of Tianjin, China (Grant No. 13JCYBJC39000), the Scientific Research Foundation for the Returned Overseas Chinese Scholars, State Education Ministry, China, the Tianjin Key Laboratory of Civil Aircraft Airworthiness and Maintenance in Civil Aviation of China (Grant No. 104003020106), and the Fund for Scholars of Civil Aviation University of China (Grant No. 2012QD21x).

  19. Chrysler Upset Protrusion Joining Techniques for Joining Dissimilar Metals

    Energy Technology Data Exchange (ETDEWEB)

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

    2017-09-28

    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

  20. CREME96 and Related Error Rate Prediction Methods

    Science.gov (United States)

    Adams, James H., Jr.

    2012-01-01

    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

  1. Single event upset test structures for digital CMOS application specific integrated circuits

    International Nuclear Information System (INIS)

    Baze, M.P.; Bartholet, W.G.; Braatz, J.C.; Dao, T.A.

    1993-01-01

    An approach has been developed for the design and utilization of SEU test structures for digital CMOS ASICs. This approach minimizes the number of test structures required by categorizing ASIC library cells according to their SEU response and designing a structure to characterize each response for each category. Critical SEU response parameters extracted from these structures are used to evaluate the SEU hardness of ASIC libraries and predict the hardness of ASIC chips

  2. The Single Event Upset (SEU) response to 590 MeV protons

    Science.gov (United States)

    Nichols, D. K.; Price, W. E.; Smith, L. S.; Soli, G. A.

    1984-01-01

    The presence of high-energy protons in cosmic rays, solar flares, and trapped radiation belts around Jupiter poses a threat to the Galileo project. Results of a test of 10 device types (including 1K RAM, 4-bit microP sequencer, 4-bit slice, 9-bit data register, 4-bit shift register, octal flip-flop, and 4-bit counter) exposed to 590 MeV protons at the Swiss Institute of Nuclear Research are presented to clarify the picture of SEU response to the high-energy proton environment of Jupiter. It is concluded that the data obtained should remove the concern that nuclear reaction products generated by protons external to the device can cause significant alteration in the device SEU response. The data also show only modest increases in SEU cross section as proton energies are increased up to the upper limits of energy for both the terrestrial and Jovian trapped proton belts.

  3. Radiation environment measurements and single event upset observations in sun-synchronous orbit

    International Nuclear Information System (INIS)

    Dyer, C.S.; Sims, A.J.; Farren, J.; Stephen, J.; Underwood, C.

    1991-01-01

    This paper reports on analysis of data from the Cosmic Radiation Environment and Dosimetry experiment (CREDO) carried in sun-synchronous polar orbit on UoSat-3 which shows the influence of cosmic rays, trapped protons and solar particles and allows comparison with device behavior

  4. Direct observation of asperity deformation of specimens with random rough surfaces in upsetting and indentation processes

    DEFF Research Database (Denmark)

    Azushima, A.; Kuba, S.; Tani, S.

    2006-01-01

    The trapping behavior of liquid lubricant and contact behavior of asperities at the workpiece-tool interface during upsetting and indentation are observed directly using a compression subpress which consists of a transparent die made of sapphire, a microscope with a CCD camera and a video system....... The experiments are carried out without lubricant and with lubricant. Specimens used are commercially pure A1100 aluminum with a random rough surface. From these observations, the change in the fraction of real contact area is measured by an image processor. The real contact area ratios in upsetting experiments...

  5. Direct Observation of Asperity Deformation of Specimen with Random Rough Surface in Upsetting Process

    DEFF Research Database (Denmark)

    Azushima, A.; Kuba, S.; Tani, S.

    2004-01-01

    The trapping behavior of liquid lubricant and contact behavior of asperities at the workpiece-tool interface during upsetting and indentation are observed directly using a compression subpress which consists of a transparent die made of sapphire, a microscope with a CCD camera and a video system....... The experiments are carried out without lubricant and with lubricant. Specimens used are commercially pure A1100 Aluminum with a random rough surface. From this observation, the change in the fraction of real contact area is measured by an image processor. The real contact area ratios in upsetting experiment...

  6. Test CMOS/SOS RAM for transient radiation upset comparative research and failure analysis

    International Nuclear Information System (INIS)

    Nikiforov, A.Y.; Poljakov, I.V.

    1995-01-01

    The test Complementary Metal-Oxide-Semiconductor/Silicon-on-Sapphire Random Access Memory (CMOS/SOS RAM) with eight types of memory cells was designed and tested at high dose rates with a flash X-ray machine and laser simulator. The memory cell (MC) design with additional transistors and RC-chain was found to be upset free up to 2 x 10 12 rad(Si)/s. An inversion effect was discovered in which almost 100% logic upset was observed in poorly protected memory cell arrays at very high dose rates

  7. A Model for Microcontroller Functionality Upset Induced by External Pulsed Electromagnetic Irradiation

    Science.gov (United States)

    2016-11-21

    AFRL-RD-PS- AFRL-RD-PS- TN-2016-0003 TN-2016-0003 A Model for Microcontroller Functionality Upset Induced by External Pulsed Electromagnetic...TYPE Technical Note 3. DATES COVERED (From - To) 22-11-2015 – 21-11-2016 4. TITLE AND SUBTITLE A Model for Microcontroller Functionality Upset Induced by... microcontroller (µC) subjected to external irradiation by a narrowband electromagnetic (EM) pulse. In our model, the state of a µC is completely specified by

  8. Errors in Neonatology

    OpenAIRE

    Antonio Boldrini; Rosa T. Scaramuzzo; Armando Cuttano

    2013-01-01

    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 err...

  9. Fabrication and properties of Y-Ba-Cu-O high Tc superconductor by upset-forging method

    International Nuclear Information System (INIS)

    Chang, Ho Jung; Kang, Kae Myung; Song, Jin Tae

    1990-01-01

    YBa 2 Cu 3 O 7-x oxide superconductors was fabricated by sintering process and upset-forging method, respectively, and microstructures and conduction properties were compared. There was no difference in crystal structure the (001) x-ray reflection presumably due to preferred crystal orientation of the YBa 2 Cu 3 O 7-x superconductor. Furthermore, the grain size of the 123-phase increased as the reduction ratio became larger during the upset-forging. The critical temperature for zero resistivity of both samples was almost the same, i.e., about 90K. These results have demonstrated the potential of producing YBa 2 Cu 3 O 7-x superconducting wire or tape effectively using a upset-forging method. The critical current density of the upset-forged sample, however, was lower than that of the sintered one, which fact might be ascribed to microcrack formation during fast upset-forging. (Author)

  10. Ductile failure in upsetting of a rapid-solidification-processed aluminium alloy

    NARCIS (Netherlands)

    Habraken, F.A.C.M.; Dautzenberg, J.H.

    1993-01-01

    Cold upset-tests have been performed on a Rapid Solidification Processed (RSP) aluminium-alloy, produced by the ‘melt-spun ribbons’-process out of 70% car-scrap and 30% primary scrap. The ribbons are hot extruded, resulting in 29 mm diameter bar. Its properties regarding plastic flow and fracture

  11. CMOS/SOS RAM transient radiation upset and ''inversion'' effect investigation

    International Nuclear Information System (INIS)

    Nikiforov, A.Y.; Poljakov, I.V.

    1996-01-01

    The Complementary Metal-Oxide-Semiconductor/Silicon-on-Sapphire Random Access Memory (CMOS/SOS RAM) transient upset and inversion effect were investigated with pulsed laser, pulsed voltage generator and low-intensity light simulators. It was found that the inversion of information occurs due to memory cell photocurrents simultaneously with the power supply voltage drop transfer to memory cells outputs

  12. 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.

    2012-01-01

    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

  13. Approaches to proton single-event rate calculations

    International Nuclear Information System (INIS)

    Petersen, E.L.

    1996-01-01

    This article discusses the fundamentals of proton-induced single-event upsets and of the various methods that have been developed to calculate upset rates. Two types of approaches are used based on nuclear-reaction analysis. Several aspects can be analyzed using analytic methods, but a complete description is not available. The paper presents an analytic description for the component due to elastic-scattering recoils. There have been a number of studies made using Monte Carlo methods. These can completely describe the reaction processes, including the effect of nuclear reactions occurring outside the device-sensitive volume. They have not included the elastic-scattering processes. The article describes the semiempirical approaches that are most widely used. The quality of previous upset predictions relative to space observations is discussed and leads to comments about the desired quality of future predictions. Brief sections treat the possible testing limitation due to total ionizing dose effects, the relationship of proton and heavy-ion upsets, upsets due to direct proton ionization, and relative proton and cosmic-ray upset rates

  14. Injecting Artificial Memory Errors Into a Running Computer Program

    Science.gov (United States)

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

    2008-01-01

    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.

  15. Monte Carlo simulation of particle-induced bit upsets

    Science.gov (United States)

    Wrobel, Frédéric; Touboul, Antoine; Vaillé, Jean-Roch; Boch, Jérôme; Saigné, Frédéric

    2017-09-01

    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.

  16. Monte Carlo simulation of particle-induced bit upsets

    Directory of Open Access Journals (Sweden)

    Wrobel Frédéric

    2017-01-01

    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.

  17. Characteristics of patients making serious inhaler errors with a dry powder inhaler and association with asthma-related events in a primary care setting

    Science.gov (United States)

    Westerik, Janine A. M.; Carter, Victoria; Chrystyn, Henry; Burden, Anne; Thompson, Samantha L.; Ryan, Dermot; Gruffydd-Jones, Kevin; Haughney, John; Roche, Nicolas; Lavorini, Federico; Papi, Alberto; Infantino, Antonio; Roman-Rodriguez, Miguel; Bosnic-Anticevich, Sinthia; Lisspers, Karin; Ställberg, Björn; Henrichsen, Svein Høegh; van der Molen, Thys; Hutton, Catherine; Price, David B.

    2016-01-01

    Abstract Objective: Correct inhaler technique is central to effective delivery of asthma therapy. The study aim was to identify factors associated with serious inhaler technique errors and their prevalence among primary care patients with asthma using the Diskus dry powder inhaler (DPI). Methods: This was a historical, multinational, cross-sectional study (2011–2013) using the iHARP database, an international initiative that includes patient- and healthcare provider-reported questionnaires from eight countries. Patients with asthma were observed for serious inhaler errors by trained healthcare providers as predefined by the iHARP steering committee. Multivariable logistic regression, stepwise reduced, was used to identify clinical characteristics and asthma-related outcomes associated with ≥1 serious errors. Results: Of 3681 patients with asthma, 623 (17%) were using a Diskus (mean [SD] age, 51 [14]; 61% women). A total of 341 (55%) patients made ≥1 serious errors. The most common errors were the failure to exhale before inhalation, insufficient breath-hold at the end of inhalation, and inhalation that was not forceful from the start. Factors significantly associated with ≥1 serious errors included asthma-related hospitalization the previous year (odds ratio [OR] 2.07; 95% confidence interval [CI], 1.26–3.40); obesity (OR 1.75; 1.17–2.63); poor asthma control the previous 4 weeks (OR 1.57; 1.04–2.36); female sex (OR 1.51; 1.08–2.10); and no inhaler technique review during the previous year (OR 1.45; 1.04–2.02). Conclusions: Patients with evidence of poor asthma control should be targeted for a review of their inhaler technique even when using a device thought to have a low error rate. PMID:26810934

  18. 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

  19. Single event effects and performance predictions for space applications of RISC processors

    International Nuclear Information System (INIS)

    Kimbrough, J.R.; Colella, N.J.; Denton, S.M.; Shaeffer, D.L.; Shih, D.; Wilburn, J.W.; Coakley, P.G.; Casteneda, C.; Koga, R.; Clark, D.A.; Ullmann, J.L.

    1994-01-01

    Proton and ion Single Event Phenomena (SEP) tests were performed on 32-b processors including R3000A's from all commercial manufacturers along with the Performance PR3400 family, Integrated Device Technology Inc. 79R3081, LSI Logic Corporation LR33000HC, and Intel i80960MX parts. The microprocessors had acceptable upset rates for operation in a low earth orbit or a lunar mission such as CLEMENTINE with a wide range in proton total dose failure. Even though R3000A devices are 60% smaller in physical area than R3000 devices, there was a 340% increase in device Single Event Upset (SEU) cross section. Software tests of varying complexity demonstrate that registers and other functional blocks using register architecture dominate the cross section. The current approach of giving a single upset cross section can lead to erroneous upset rates depending on the application software

  20. Improved ensemble-mean forecast skills of ENSO events by a zero-mean stochastic model-error model of an intermediate coupled model

    Science.gov (United States)

    Zheng, F.; Zhu, J.

    2015-12-01

    To perform an ensemble-based ENSO probabilistic forecast, the crucial issue is to design a reliable ensemble prediction strategy that should include the major uncertainties of a forecast system. In this study, we developed a new general ensemble perturbation technique to improve the ensemble-mean predictive skill of forecasting ENSO using an intermediate coupled model (ICM). The model uncertainties are first estimated and analyzed from EnKF analysis results through assimilating observed SST. Then, based on the pre-analyzed properties of the model errors, a zero-mean stochastic model-error model is developed to mainly represent the model uncertainties induced by some important physical processes missed in the coupled model (i.e., stochastic atmospheric forcing/MJO, extra-tropical cooling and warming, Indian Ocean Dipole mode, etc.). Each member of an ensemble forecast is perturbed by the stochastic model-error model at each step during the 12-month forecast process, and the stochastical perturbations are added into the modeled physical fields to mimic the presence of these high-frequency stochastic noises and model biases and their effect on the predictability of the coupled system. The impacts of stochastic model-error perturbations on ENSO deterministic predictions are examined by performing two sets of 21-yr retrospective forecast experiments. The two forecast schemes are differentiated by whether they considered the model stochastic perturbations, with both initialized by the ensemble-mean analysis states from EnKF. The comparison results suggest that the stochastic model-error perturbations have significant and positive impacts on improving the ensemble-mean prediction skills during the entire 12-month forecast process. Because the nonlinear feature of the coupled model can induce the nonlinear growth of the added stochastic model errors with model integration, especially through the nonlinear heating mechanism with the vertical advection term of the model, the

  1. Team errors: definition and taxonomy

    International Nuclear Information System (INIS)

    Sasou, Kunihide; Reason, James

    1999-01-01

    In error analysis or error management, the focus is usually upon individuals who have made errors. In large complex systems, however, most people work in teams or groups. Considering this working environment, insufficient emphasis has been given to 'team errors'. This paper discusses the definition of team errors and its taxonomy. These notions are also applied to events that have occurred in the nuclear power industry, aviation industry and shipping industry. The paper also discusses the relations between team errors and Performance Shaping Factors (PSFs). As a result, the proposed definition and taxonomy are found to be useful in categorizing team errors. The analysis also reveals that deficiencies in communication, resource/task management, excessive authority gradient, excessive professional courtesy will cause team errors. Handling human errors as team errors provides an opportunity to reduce human errors

  2. 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)

    2015-03-15

    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.

  3. Error Patterns

    NARCIS (Netherlands)

    Hoede, C.; Li, Z.

    2001-01-01

    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,

  4. The educational inclusion of the students with upsets of the oral communication

    Directory of Open Access Journals (Sweden)

    Merling Murguia Moré

    2015-09-01

    Full Text Available The educational inclusion imposes challenges to the National System of Education, to optimize the attention to the students with upsets of the oral communication. Is the objective of the article to share the design of an investigation that assists to the scientific problem how to contribute to the improvement of the educational inclusion of the students with upsets of the oral communication? The employment of the investigation-action-participativa it drives to the execution of the objective related with the construction of a pedagogic model for the improvement of this process. The results of the investigation will constitute a necessary contribution to the educational inclusion in the National System of Education

  5. Effect of Friction on Barreling during cold Upset Forging of Aluminium 6082 Alloy Solid cylinders

    Science.gov (United States)

    Priyadarshini, Amrita; Kiran, C. P.; Suresh, K.

    2018-03-01

    Friction is one of the significant factors in forging operations since it affects metal flow in the die, forming load, strain distribution, tool and die life, surface quality of the product etc. In upset forging, the frictional forces at the die-workpiece interface oppose the outward flow of the material due to which the specimen develops a barrel shape. As a result, the deformation becomes non-uniform or inhomogeneous which is undesirable. Barreling can be reduced by applying effective lubricant on the surface of the platens. The objective of the present work is to study experimentally the effect of various frictional conditions (dry, grease, mineral oil) on barreling during upset forging of aluminum 6082 solid cylinders of different aspect ratio (length/diameter: 0.5, 0.75, 1). The friction coefficients are determined using the ring compression test. Curvature of barrel is determined based on the assumption that the curvature of the barrel follows the geometry of circular arc.

  6. Some aspects of barreling in sintered plain carbon steel powder metallurgy preforms during cold upsetting

    Directory of Open Access Journals (Sweden)

    Sumesh Narayan

    2012-04-01

    Full Text Available The present research establishes a relationship of bulged diameter with densification and hydrostatic stress in forming of sintered iron (Fe powder metallurgy preforms cold upset under two different frictional conditions, namely, nil/no and graphite lubricant condition. Sintered plain carbon steel cylindrical preforms with carbon (C contents of 0, 0.35, 0.75 and 1.1% with constant initial theoretical density of 84% and aspect ratio of 0.4 and 0.6 were prepared using a suitable die-set assembly on a 1 MN capacity hydraulic press and sintered for 90 minutes at 1200 °C. Each sintered preform was cold upset under two different frictional constraints. It is seen that the degree of bulging reduces with reducing frictional constraints at the die contact surface. Further, it is found that the bulging ratio changed as a function of relative density and hydrostatic stress, respectively, according to the power law equations.

  7. Dynamics Modeling and Simulation of Large Transport Airplanes in Upset Conditions

    Science.gov (United States)

    Foster, John V.; Cunningham, Kevin; Fremaux, Charles M.; Shah, Gautam H.; Stewart, Eric C.; Rivers, Robert A.; Wilborn, James E.; Gato, William

    2005-01-01

    As part of NASA's Aviation Safety and Security Program, research has been in progress to develop aerodynamic modeling methods for simulations that accurately predict the flight dynamics characteristics of large transport airplanes in upset conditions. The motivation for this research stems from the recognition that simulation is a vital tool for addressing loss-of-control accidents, including applications to pilot training, accident reconstruction, and advanced control system analysis. The ultimate goal of this effort is to contribute to the reduction of the fatal accident rate due to loss-of-control. Research activities have involved accident analyses, wind tunnel testing, and piloted simulation. Results have shown that significant improvements in simulation fidelity for upset conditions, compared to current training simulations, can be achieved using state-of-the-art wind tunnel testing and aerodynamic modeling methods. This paper provides a summary of research completed to date and includes discussion on key technical results, lessons learned, and future research needs.

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

    Directory of Open Access Journals (Sweden)

    Dafni Hellstrand

    2015-08-01

    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.

  9. Are Sexual and Emotional Infidelity Equally Upsetting to Men and Women? Making Sense of Forced-Choice Responses

    Directory of Open Access Journals (Sweden)

    David A. Lishner

    2008-10-01

    Full Text Available Forced-choice measures that assess reactions to imagined sexual and emotional infidelity are ubiquitous in studies testing the Jealousy as a Specific Innate Module (JSIM model. One potential problem with such measures is that they fail to identify respondents who find both forms of infidelity equally upsetting. To examine this issue, an experiment was conducted in which two groups of participants imagined a romantic infidelity after which participants in the first group used a traditional forced-choice measure to indicate whether they found sexual or emotional infidelity more upsetting. Participants in the second group instead used a modified forced-choice measure that allowed them also to indicate whether they found both forms of infidelity equally upsetting. Consistent with previous research, those given the traditional forced-choice measure tended to respond in a manner that supported the JSIM model. However, the majority of participants given the modified measure indicated that both forms of infidelity were equally upsetting.

  10. Solid-state resistance upset welding: A process with unique advantages for advanced materials

    International Nuclear Information System (INIS)

    Kanne, W.R. Jr.

    1993-01-01

    Solid-state resistance upset welding is suitable for joining many alloys that are difficult to weld using fusion processes. Since no melting takes place, the weld metal retains many of the characteristics of the base metal. Resulting welds have a hot worked structure, and thereby have higher strength than fusion welds in the same mate. Since the material being joined is not melted, compositional gradients are not introduced, second phase materials are minimally disrupted, and minor alloying elements, do not affect weldability. Solid-state upset welding has been adapted for fabrication of structures considered very large compared to typical resistance welding applications. The process has been used for closure of capsules, small vessels, and large containers. Welding emphasis has been on 304L stainless steel, the material for current applications. Other materials have, however, received enough attention to have demonstrated capability for joining alloys that are not readily weldable using fusion welding methods. A variety of other stainless steels (including A-286), superalloys (including TD nickel), refractory metals (including tungsten), and aluminum alloys (including 2024) have been successfully upset welded

  11. Double peak-induced distance error in short-time-Fourier-transform-Brillouin optical time domain reflectometers event detection and the recovery method.

    Science.gov (United States)

    Yu, Yifei; Luo, Linqing; Li, Bo; Guo, Linfeng; Yan, Jize; Soga, Kenichi

    2015-10-01

    The measured distance error caused by double peaks in the BOTDRs (Brillouin optical time domain reflectometers) system is a kind of Brillouin scattering spectrum (BSS) deformation, discussed and simulated for the first time in the paper, to the best of the authors' knowledge. Double peak, as a kind of Brillouin spectrum deformation, is important in the enhancement of spatial resolution, measurement accuracy, and crack detection. Due to the variances of the peak powers of the BSS along the fiber, the measured starting point of a step-shape frequency transition region is shifted and results in distance errors. Zero-padded short-time-Fourier-transform (STFT) can restore the transition-induced double peaks in the asymmetric and deformed BSS, thus offering more accurate and quicker measurements than the conventional Lorentz-fitting method. The recovering method based on the double-peak detection and corresponding BSS deformation can be applied to calculate the real starting point, which can improve the distance accuracy of the STFT-based BOTDR system.

  12. Comparison of maintenance worker's human error events occurred at United States and domestic nuclear power plants. The proposal of the classification method with insufficient knowledge and experience and the classification result of its application

    International Nuclear Information System (INIS)

    Takagawa, Kenichi

    2008-01-01

    Human errors by maintenance workers in U.S. nuclear power plants were compared with those in Japanese nuclear power plants for the same period in order to identify the characteristics of such errors. As for U.S. events, cases which occurred during 2006 were selected from the Nuclear Information Database of the Institute to Nuclear Safety System while Japanese cases that occurred during the same period, were extracted from the Nuclear Information Archives (NUCIA) owned by JANTI. The most common cause of human errors was insufficient knowledge or experience' accounting for about 40% for U.S. cases and 50% or more of cases in Japan. To break down 'insufficient knowledge', we classified the contents of knowledge into five categories; method', 'nature', 'reason', 'scope' and 'goal', and classified the level of knowledge into four categories: 'known', 'comprehended', 'applied' and analytic'. By using this classification, the patterns of combination of each item of the content and the level of knowledge were compared. In the U.S. cases, errors due to 'insufficient knowledge of nature and insufficient knowledge of method' were prevalent while three other items', 'reason', scope' and 'goal' which involve work conditions among the contents of knowledge rarely occurred. In Japan, errors arising from 'nature not being comprehended' were rather prevalent while other cases were distributed evenly for all categories including the work conditions. For addressing insufficient knowledge or experience', we consider that the following approaches are valid: according to the knowledge level which is required for the work, the reflection of knowledge on the procedure or education materials, training and confirmation of understanding level, virtual practice and instruction of experience should be implemented. As for the knowledge on the work conditions, it is necessary to enter the work conditions in the procedure and education materials while conducting training or education. (author)

  13. An advanced SEU tolerant latch based on error detection

    Science.gov (United States)

    Xu, Hui; Zhu, Jianwei; Lu, Xiaoping; Li, Jingzhao

    2018-05-01

    This paper proposes a latch that can mitigate SEUs via an error detection circuit. The error detection circuit is hardened by a C-element and a stacked PMOS. In the hold state, a particle strikes the latch or the error detection circuit may cause a fault logic state of the circuit. The error detection circuit can detect the upset node in the latch and the fault output will be corrected. The upset node in the error detection circuit can be corrected by the C-element. The power dissipation and propagation delay of the proposed latch are analyzed by HSPICE simulations. The proposed latch consumes about 77.5% less energy and 33.1% less propagation delay than the triple modular redundancy (TMR) latch. Simulation results demonstrate that the proposed latch can mitigate SEU effectively. Project supported by the National Natural Science Foundation of China (Nos. 61404001, 61306046), the Anhui Province University Natural Science Research Major Project (No. KJ2014ZD12), the Huainan Science and Technology Program (No. 2013A4011), and the National Natural Science Foundation of China (No. 61371025).

  14. Crying without a cause and being easily upset in two-year-olds: heritability and predictive power of behavioral problems.

    Science.gov (United States)

    Groen-Blokhuis, Maria M; Middeldorp, Christel M; M van Beijsterveldt, Catharina E; Boomsma, Dorret I

    2011-10-01

    In order to estimate the influence of genetic and environmental factors on 'crying without a cause' and 'being easily upset' in 2-year-old children, a large twin study was carried out. Prospective data were available for ~18,000 2-year-old twin pairs from the Netherlands Twin Register. A bivariate genetic analysis was performed using structural equation modeling in the Mx software package. The influence of maternal personality characteristics and demographic and lifestyle factors was tested to identify specific risk factors that may underlie the shared environment of twins. Furthermore, it was tested whether crying without a cause and being easily upset were predictive of later internalizing, externalizing and attention problems. Crying without a cause yielded a heritability estimate of 60% in boys and girls. For easily upset, the heritability was estimated at 43% in boys and 31% in girls. The variance explained by shared environment varied between 35% and 63%. The correlation between crying without a cause and easily upset (r = .36) was explained both by genetic and shared environmental factors. Birth cohort, gestational age, socioeconomic status, parental age, parental smoking behavior and alcohol use during pregnancy did not explain the shared environmental component. Neuroticism of the mother explained a small proportion of the additive genetic, but not of the shared environmental effects for easily upset. Crying without a cause and being easily upset at age 2 were predictive of internalizing, externalizing and attention problems at age 7, with effect sizes of .28-.42. A large influence of shared environmental factors on crying without a cause and easily upset was detected. Although these effects could be specific to these items, we could not explain them by personality characteristics of the mother or by demographic and lifestyle factors, and we recognize that these effects may reflect other maternal characteristics. A substantial influence of genetic factors

  15. Single-event transients (SET) in analog circuits

    International Nuclear Information System (INIS)

    Chen Panxun; Zhou Kaiming

    2006-01-01

    A new phenomenon of single- event upset is introduced. The transient signal is produced in the output of analog circuits after a heavy ion strikes. The transient upset can influence the circuit connected with the output of analog circuits. For example, the output of operational amplifier can be connected with the input of a digital counter, and the pulse of sufficiently high transient output induced by an ion can increase counts of the counter. On the other hand, the transient voltage signal at the output of analog circuits can change the stage of other circuits. (authors)

  16. Error-related brain activity and error awareness in an error classification paradigm.

    Science.gov (United States)

    Di Gregorio, Francesco; Steinhauser, Marco; Maier, Martin E

    2016-10-01

    Error-related brain activity has been linked to error detection enabling adaptive behavioral adjustments. However, it is still unclear which role error awareness plays in this process. Here, we show that the error-related negativity (Ne/ERN), an event-related potential reflecting early error monitoring, is dissociable from the degree of error awareness. Participants responded to a target while ignoring two different incongruent distractors. After responding, they indicated whether they had committed an error, and if so, whether they had responded to one or to the other distractor. This error classification paradigm allowed distinguishing partially aware errors, (i.e., errors that were noticed but misclassified) and fully aware errors (i.e., errors that were correctly classified). The Ne/ERN was larger for partially aware errors than for fully aware errors. Whereas this speaks against the idea that the Ne/ERN foreshadows the degree of error awareness, it confirms the prediction of a computational model, which relates the Ne/ERN to post-response conflict. This model predicts that stronger distractor processing - a prerequisite of error classification in our paradigm - leads to lower post-response conflict and thus a smaller Ne/ERN. This implies that the relationship between Ne/ERN and error awareness depends on how error awareness is related to response conflict in a specific task. Our results further indicate that the Ne/ERN but not the degree of error awareness determines adaptive performance adjustments. Taken together, we conclude that the Ne/ERN is dissociable from error awareness and foreshadows adaptive performance adjustments. Our results suggest that the relationship between the Ne/ERN and error awareness is correlative and mediated by response conflict. Copyright © 2016 Elsevier Inc. All rights reserved.

  17. Einstein's error

    International Nuclear Information System (INIS)

    Winterflood, A.H.

    1980-01-01

    In discussing Einstein's Special Relativity theory it is claimed that it violates the principle of relativity itself and that an anomalous sign in the mathematics is found in the factor which transforms one inertial observer's measurements into those of another inertial observer. The apparent source of this error is discussed. Having corrected the error a new theory, called Observational Kinematics, is introduced to replace Einstein's Special Relativity. (U.K.)

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

    DEFF Research Database (Denmark)

    Olsen, Poul Bitsch; Axel, Erik

    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...... of praxis. Praxis is formed by the reciprocal differentiations of acts. In order to be able to act here, we try to arrange things to be done in specific ways there. In order to build the house here, we arrange a supply of inhabitants here, a conglomerate of producers there etc.. Furthermore, what we achieve...

  19. Three-dimensional simulation of charge collection and multiple-bit upset in Si devices

    International Nuclear Information System (INIS)

    Dodd, P.E.; Sexton, F.W.; Winokur, P.S.

    1994-01-01

    In this paper, three-dimensional numerical simulation is used to explore the basic charge-collection mechanisms in silicon n + /p diodes. For diodes on lightly-doped substrates ( 15 cm -3 ) struck by a 100-MeV Fe ion, the funneling effect is very strong and essentially all collection is by funnel-assisted drift. This drift collection may occur as late as several nanoseconds after the strike, later than is usually associated with drift collection. For moderately-doped substrates (∼1 x 10 16 cm -3 ) and epitaxial structures grown on heavily-doped substrates, the funnel effect is weaker and drift and diffusion are of more equal importance. For 5-MeV He (α-particle) strikes with low-density charge tracks, the charge-collection transient exhibits both drift and diffusion regimes regardless of the substrate doping. Simulations of diodes with passive external loads indicate that while the current response is altered considerably by the load, total collected charge is not greatly affected for the simple resistive loads studied. Three-dimensional mixed-mode simulation is performed to investigate charge-collection behavior and upset mechanisms in complete CMOS SRAM cells. Simulations of double SRAM cell structures indicate that only collection by diffusion from ''between-node'' strikes is capable of producing multiple-bit upsets in the simulated technology. Limitations of the simulations, specifically carrier-carrier scattering models and large concentration gradients, are also discussed

  20. Simulation Study of Flap Effects on a Commercial Transport Airplane in Upset Conditions

    Science.gov (United States)

    Cunningham, Kevin; Foster, John V.; Shah, Gautam H.; Stewart, Eric C.; Ventura, Robin N.; Rivers, Robert A.; Wilborn, James E.; Gato, William

    2005-01-01

    As part of NASA's Aviation Safety and Security Program, a simulation study of a twinjet transport airplane crew training simulation was conducted to address fidelity for upset or loss of control conditions and to study the effect of flap configuration in those regimes. Piloted and desktop simulations were used to compare the baseline crew training simulation model with an enhanced aerodynamic model that was developed for high-angle-of-attack conditions. These studies were conducted with various flap configurations and addressed the approach-to-stall, stall, and post-stall flight regimes. The enhanced simulation model showed that flap configuration had a significant effect on the character of departures that occurred during post-stall flight. Preliminary comparisons with flight test data indicate that the enhanced model is a significant improvement over the baseline. Some of the unrepresentative characteristics that are predicted by the baseline crew training simulation for flight in the post-stall regime have been identified. This paper presents preliminary results of this simulation study and discusses key issues regarding predicted flight dynamics characteristics during extreme upset and loss-of-control flight conditions with different flap configurations.

  1. Prediction of particle orientation in simple upsetting process of NdFeB magnets

    Energy Technology Data Exchange (ETDEWEB)

    Chang, Chao-Cheng; Hsiao, Po-Jen [Department of Mold and Die Engineering, National Kaohsiung University of Applied Sciences, 415 Chien-Kung Road, Sanmin District, Kaohsiung 80778, Taiwan (China); You, Jr-Shiang; Chen, Yen-Ju; Chang, Can-Xun [Metal Forming Technology Section, Metal Processing R and D Department, Metal Industries Research and Development Centre, 1001 Kaonan Highway, Kaohsiung 81160, Taiwan (China)

    2013-12-16

    The magnetic properties of NdFeB magnets are strongly affected by crystallographic texture which is highly associated with particle orientation. This study proposed a method for predicting the particle orientation in the simple upsetting process of NdFeB magnets. The method is based on finite element simulation with flow net analysis. The magnets in a cylindrical form were compressed by two flat dies in a chamber filled with argon at 750°C. Three forming speeds were taken into account in order to obtain flow stress curves used in simulations. The micrographs of the cross sections of the deformed magnets show that the particle deformation significantly increases with the compression. The phenomenon was also predicted by the proposed method. Both simulated and experimental results show that the inhomogeneity of the texture of the NdFeB magnets can be increased by the simple upsetting process. The predicted particle orientations were in a good agreement with those examined in the deformed magnets. The proposed method for predicting particle orientations can also be used in other forming processes of NdFeB magnets.

  2. Prediction of particle orientation in simple upsetting process of NdFeB magnets

    International Nuclear Information System (INIS)

    Chang, Chao-Cheng; Hsiao, Po-Jen; You, Jr-Shiang; Chen, Yen-Ju; Chang, Can-Xun

    2013-01-01

    The magnetic properties of NdFeB magnets are strongly affected by crystallographic texture which is highly associated with particle orientation. This study proposed a method for predicting the particle orientation in the simple upsetting process of NdFeB magnets. The method is based on finite element simulation with flow net analysis. The magnets in a cylindrical form were compressed by two flat dies in a chamber filled with argon at 750°C. Three forming speeds were taken into account in order to obtain flow stress curves used in simulations. The micrographs of the cross sections of the deformed magnets show that the particle deformation significantly increases with the compression. The phenomenon was also predicted by the proposed method. Both simulated and experimental results show that the inhomogeneity of the texture of the NdFeB magnets can be increased by the simple upsetting process. The predicted particle orientations were in a good agreement with those examined in the deformed magnets. The proposed method for predicting particle orientations can also be used in other forming processes of NdFeB magnets

  3. SENTINEL EVENTS

    Directory of Open Access Journals (Sweden)

    Andrej Robida

    2004-09-01

    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.

  4. Approximation errors during variance propagation

    International Nuclear Information System (INIS)

    Dinsmore, Stephen

    1986-01-01

    Risk and reliability analyses are often performed by constructing and quantifying large fault trees. The inputs to these models are component failure events whose probability of occuring are best represented as random variables. This paper examines the errors inherent in two approximation techniques used to calculate the top event's variance from the inputs' variance. Two sample fault trees are evaluated and several three dimensional plots illustrating the magnitude of the error over a wide range of input means and variances are given

  5. 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

    2016-12-01

    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: https://doi.org/10.24071/llt.2015.180205

  6. Errors in causal inference: an organizational schema for systematic error and random error.

    Science.gov (United States)

    Suzuki, Etsuji; Tsuda, Toshihide; Mitsuhashi, Toshiharu; Mansournia, Mohammad Ali; Yamamoto, Eiji

    2016-11-01

    To provide an organizational schema for systematic error and random error in estimating causal measures, aimed at clarifying the concept of errors from the perspective of causal inference. We propose to divide systematic error into structural error and analytic error. With regard to random error, our schema shows its four major sources: nondeterministic counterfactuals, sampling variability, a mechanism that generates exposure events and measurement variability. Structural error is defined from the perspective of counterfactual reasoning and divided into nonexchangeability bias (which comprises confounding bias and selection bias) and measurement bias. Directed acyclic graphs are useful to illustrate this kind of error. Nonexchangeability bias implies a lack of "exchangeability" between the selected exposed and unexposed groups. A lack of exchangeability is not a primary concern of measurement bias, justifying its separation from confounding bias and selection bias. Many forms of analytic errors result from the small-sample properties of the estimator used and vanish asymptotically. Analytic error also results from wrong (misspecified) statistical models and inappropriate statistical methods. Our organizational schema is helpful for understanding the relationship between systematic error and random error from a previously less investigated aspect, enabling us to better understand the relationship between accuracy, validity, and precision. Copyright © 2016 Elsevier Inc. All rights reserved.

  7. Experimental study on heavy-ion single event effect on nanometer DDR SRAM

    International Nuclear Information System (INIS)

    Luo Yinhong; Zhang Fengqi; Guo Hongxia; Zhou Hui; Wang Yanping; Zhang Keying

    2013-01-01

    Single event effect experimental study on 90 nm and 65 nm DDR SRAM were carried out, single event upset (SEU) cross section was discussed as a function of several parameters such as feature size, test pattern, incidence angle, supply voltage. Key influence factors and effect rule were analyzed. Feasibility of the current test method was discussed. Results indicate that, SEU cross section reduces as technologies scale down; the influence of test pattern and power supply on SEU cross section is small; tilt angle increases SEU cross section due to multiple upset increasement. The applicability of cosine tilt test method is correlative to ion species and linear energy transfer (LET) values. (authors)

  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.

    Science.gov (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

    2016-10-21

    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. Errors in Neonatology

    Directory of Open Access Journals (Sweden)

    Antonio Boldrini

    2013-06-01

    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

  10. 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.

    2017-01-01

    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...... strain of 4.7 is measured to be ∼0.3μm. This refined microstructure is unstable at room temperature as is evident from the presence of a small number of recrystallized grains in the deformed matrix. Pronounced recrystallization took place during annealing at 200 °C for 1 h with recrystallized grains...... 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...

  11. Texture evolution in upset-forged P/M and wrought tantalum: Experimentation and modeling

    International Nuclear Information System (INIS)

    Bingert, J.F.; Desch, P.B.; Bingert, S.R.; Maudlin, P.J.; Tome, C.N.

    1997-11-01

    Preferred orientations in polycrystalline materials can significantly affect their physical and mechanical response through the retention of anisotropic properties inherent to the single crystal. In this study the texture evolution in upset-forged PIM and wrought tantalum was measured as a function of initial texture, compressive strain, and relative position in the pressing. A / duplex fiber texture parallel to the compression axis was generally observed, with varying degrees of a radial component evident in the wrought material. The development of deformation textures derives from restricted crystallographic slip conditions that generate lattice rotations, and these grain reorientations can be modeled as a function of the prescribed deformation gradient. Texture development was simulated for equivalent deformations using both a modified Taylor approach and a viscoplastic self-consistent (VPSC) model. A comparison between the predicted evolution and experimental results shows a good correlation with the texture components, but an overly sharp prediction at large strains from both the Taylor and VPSC models

  12. Survey of Quantitative Research Metrics to Assess Pilot Performance in Upset Recovery

    Science.gov (United States)

    Le Vie, Lisa R.

    2016-01-01

    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.

  13. Self-efficacy for controlling upsetting thoughts and emotional eating in family caregivers.

    Science.gov (United States)

    MacDougall, Megan; Steffen, Ann

    2017-10-01

    Self-efficacy for controlling upsetting thoughts was examined as a predictor of emotional eating by family caregivers of physically and cognitively impaired older adults. Adult women (N = 158) providing healthcare assistance for an older family member completed an online survey about caregiving stressors, depressive symptoms, self-efficacy, and emotional eating. A stress process framework was used as a conceptual model to guide selection of variables predicting emotional eating scores. A hierarchical multiple regression was conducted and the overall model was significant (R 2 = .21, F(4,153) = 10.02, p accounting for IADL, role overload, and depression scores. These findings replicate previous research demonstrating the relationship between managing cognitions about caregiving and behavioral responses to stressors, and point to the importance of addressing cognitive processes in efforts to improve caregiver health behaviors.

  14. A capacitively coupled dose-rate-dependent transient upset mechanism in a bipolar memory

    International Nuclear Information System (INIS)

    Turfler, R.M.; Pease, R.L.; Dinger, G.; Armstrong, B.

    1992-01-01

    This paper reports on a pattern sensitivity that was observed in the threshold dose rate response of a bipolar 16K PROM for radiation pulse widths of 20-100 ns. For the worst case pattern, the upset threshold was a factor of three lower than for the commonly used checkerboard pattern. The mechanism for this pattern sensitivity was found to be a capacitively coupled voltage transient on a sensitive node which caused a low-to-high transition at the output. A design fix was implemented to significantly alter the ratio of the two parasitic capacitances in a capacitive divider which reduced the amplitude of the voltage transient at the sensitive node. It was demonstrated that in the redesign, the pattern sensitivity was eliminated

  15. Crying without a cause and being easily upset in two-year-olds: heritability and predictive power of behavioral problems

    NARCIS (Netherlands)

    Groen-Blokhuis, Maria M.; Middeldorp, Christel M.; van Beijsterveldt, Catharina E.; Boomsma, Dorret I.

    2011-01-01

    In order to estimate the influence of genetic and environmental factors on 'crying without a cause' and 'being easily upset' in 2-year-old children, a large twin study was carried out. Prospective data were available for ~18,000 2-year-old twin pairs from the Netherlands Twin Register. A bivariate

  16. Crying Without a Cause and Being Easily Upset in Two-Year-Olds: Heritability and Predictive Power of Behavioral Problems

    NARCIS (Netherlands)

    Groen-Blokhuis, M.M.; Middeldorp, C.M.; van Beijsterveldt, C.E.M.; Boomsma, D.I.

    2011-01-01

    In order to estimate the influence of genetic and environmental factors on 'crying without a cause' and 'being easily upset' in 2-year-old children, a large twin study was carried out. Prospective data were available for ∼18,000 2-year-old twin pairs from the Netherlands Twin Register. A bivariate

  17. Measurements of proton upset induced in Cmos devices synthesis of CEA studies

    International Nuclear Information System (INIS)

    Mijuin, D.; Buisson, J.; Brunet, J.P.; Murat, J.; Chapuis, T.

    1990-01-01

    Within its space activities, the Departement d'Electronique et d'Instrumentation Nucleaire (DEIN) is involved in a research program regarding the behaviour of electronic components submitted to the type of radiations encountered in earth orbits or by planetary probes. Located at Saclay, the SATURNE synchrotron is a tool well suited to simulate the effects of high energy cosmic particles. The DEIN has thus carried out several experimental runs in which CMOS SRAM were irradiated with a proton beam. SATURNE is a synchrotron designed for basic research in the physics of light particles and heavy ions of intermediate energy. The energy supplied to the protons lies between 0.2 and 2.9 GeV with an intensity larger than 10 12 protons cycle -1 . During the experiment and in order to lower the proton energy under 200 MeV, an Al-absorber was used. The flux measurement was obtained by two different methods: measurement by activation and measurement by counting (scintillator coupled with a PM). The increase number of upsets during irradiation was determined, on line, for each cycle, by a testor using a comparative hardware method. The testor was designed by the DEIN. Latch-up was also detected. The results, presented in this paper, were obtained during the run of September 1990. The upset cross-sections per bit of static memories MHS 65162. MHS 65641, MOSTEK 48H64 and HYUNDAI 6116 were measured for 1000, 200, 158.9, 147.5, 122.6, 93.3 and 66.2 MeV. These experimental values were fitted using the Bendel equation with two variable parameters proposed by Stapor and al (3). The results of the run of September 1990 encourage us to pursue our studies. By now, it seems necessary to improve the experimental line (elimination of the parasitic effects generated by the Al-absorber) and to upgrade the methods used for measuring the flux

  18. Medication Errors - A Review

    OpenAIRE

    Vinay BC; Nikhitha MK; Patel Sunil B

    2015-01-01

    In this present review article, regarding medication errors its definition, medication error problem, types of medication errors, common causes of medication errors, monitoring medication errors, consequences of medication errors, prevention of medication error and managing medication errors have been explained neatly and legibly with proper tables which is easy to understand.

  19. Statistical errors in Monte Carlo estimates of systematic errors

    Science.gov (United States)

    Roe, Byron P.

    2007-01-01

    For estimating the effects of a number of systematic errors on a data sample, one can generate Monte Carlo (MC) runs with systematic parameters varied and examine the change in the desired observed result. Two methods are often used. In the unisim method, the systematic parameters are varied one at a time by one standard deviation, each parameter corresponding to a MC run. In the multisim method (see ), each MC run has all of the parameters varied; the amount of variation is chosen from the expected distribution of each systematic parameter, usually assumed to be a normal distribution. The variance of the overall systematic error determination is derived for each of the two methods and comparisons are made between them. If one focuses not on the error in the prediction of an individual systematic error, but on the overall error due to all systematic errors in the error matrix element in data bin m, the number of events needed is strongly reduced because of the averaging effect over all of the errors. For simple models presented here the multisim model was far better if the statistical error in the MC samples was larger than an individual systematic error, while for the reverse case, the unisim model was better. Exact formulas and formulas for the simple toy models are presented so that realistic calculations can be made. The calculations in the present note are valid if the errors are in a linear region. If that region extends sufficiently far, one can have the unisims or multisims correspond to k standard deviations instead of one. This reduces the number of events required by a factor of k2. The specific terms unisim and multisim were coined by Peter Meyers and Steve Brice, respectively, for the MiniBooNE experiment. However, the concepts have been developed over time and have been in general use for some time.

  20. Statistical errors in Monte Carlo estimates of systematic errors

    Energy Technology Data Exchange (ETDEWEB)

    Roe, Byron P. [Department of Physics, University of Michigan, Ann Arbor, MI 48109 (United States)]. E-mail: byronroe@umich.edu

    2007-01-01

    For estimating the effects of a number of systematic errors on a data sample, one can generate Monte Carlo (MC) runs with systematic parameters varied and examine the change in the desired observed result. Two methods are often used. In the unisim method, the systematic parameters are varied one at a time by one standard deviation, each parameter corresponding to a MC run. In the multisim method (see ), each MC run has all of the parameters varied; the amount of variation is chosen from the expected distribution of each systematic parameter, usually assumed to be a normal distribution. The variance of the overall systematic error determination is derived for each of the two methods and comparisons are made between them. If one focuses not on the error in the prediction of an individual systematic error, but on the overall error due to all systematic errors in the error matrix element in data bin m, the number of events needed is strongly reduced because of the averaging effect over all of the errors. For simple models presented here the multisim model was far better if the statistical error in the MC samples was larger than an individual systematic error, while for the reverse case, the unisim model was better. Exact formulas and formulas for the simple toy models are presented so that realistic calculations can be made. The calculations in the present note are valid if the errors are in a linear region. If that region extends sufficiently far, one can have the unisims or multisims correspond to k standard deviations instead of one. This reduces the number of events required by a factor of k{sup 2}.

  1. Statistical errors in Monte Carlo estimates of systematic errors

    International Nuclear Information System (INIS)

    Roe, Byron P.

    2007-01-01

    For estimating the effects of a number of systematic errors on a data sample, one can generate Monte Carlo (MC) runs with systematic parameters varied and examine the change in the desired observed result. Two methods are often used. In the unisim method, the systematic parameters are varied one at a time by one standard deviation, each parameter corresponding to a MC run. In the multisim method (see ), each MC run has all of the parameters varied; the amount of variation is chosen from the expected distribution of each systematic parameter, usually assumed to be a normal distribution. The variance of the overall systematic error determination is derived for each of the two methods and comparisons are made between them. If one focuses not on the error in the prediction of an individual systematic error, but on the overall error due to all systematic errors in the error matrix element in data bin m, the number of events needed is strongly reduced because of the averaging effect over all of the errors. For simple models presented here the multisim model was far better if the statistical error in the MC samples was larger than an individual systematic error, while for the reverse case, the unisim model was better. Exact formulas and formulas for the simple toy models are presented so that realistic calculations can be made. The calculations in the present note are valid if the errors are in a linear region. If that region extends sufficiently far, one can have the unisims or multisims correspond to k standard deviations instead of one. This reduces the number of events required by a factor of k 2

  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)

    2017-10-04

    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. Intelligent error correction method applied on an active pixel sensor based star tracker

    Science.gov (United States)

    Schmidt, Uwe

    2005-10-01

    Star trackers are opto-electronic sensors used on-board of satellites for the autonomous inertial attitude determination. During the last years star trackers became more and more important in the field of the attitude and orbit control system (AOCS) sensors. High performance star trackers are based up today on charge coupled device (CCD) optical camera heads. The active pixel sensor (APS) technology, introduced in the early 90-ties, allows now the beneficial replacement of CCD detectors by APS detectors with respect to performance, reliability, power, mass and cost. The company's heritage in star tracker design started in the early 80-ties with the launch of the worldwide first fully autonomous star tracker system ASTRO1 to the Russian MIR space station. Jena-Optronik recently developed an active pixel sensor based autonomous star tracker "ASTRO APS" as successor of the CCD based star tracker product series ASTRO1, ASTRO5, ASTRO10 and ASTRO15. Key features of the APS detector technology are, a true xy-address random access, the multiple windowing read out and the on-chip signal processing including the analogue to digital conversion. These features can be used for robust star tracking at high slew rates and under worse conditions like stray light and solar flare induced single event upsets. A special algorithm have been developed to manage the typical APS detector error contributors like fixed pattern noise (FPN), dark signal non-uniformity (DSNU) and white spots. The algorithm works fully autonomous and adapts to e.g. increasing DSNU and up-coming white spots automatically without ground maintenance or re-calibration. In contrast to conventional correction methods the described algorithm does not need calibration data memory like full image sized calibration data sets. The application of the presented algorithm managing the typical APS detector error contributors is a key element for the design of star trackers for long term satellite applications like

  4. Negligence, genuine error, and litigation

    OpenAIRE

    Sohn DH

    2013-01-01

    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 syst...

  5. High-energy heavy ion testing of VLSI devices for single event ...

    Indian Academy of Sciences (India)

    Unknown

    per describes the high-energy heavy ion radiation testing of VLSI devices for single event upset (SEU) ... The experimental set up employed to produce low flux of heavy ions viz. silicon ... through which they pass, leaving behind a wake of elec- ... for use in Bus Management Unit (BMU) and bulk CMOS ... was scheduled.

  6. Dealing with unexpected events on the flight deck : A conceptual model of startle and surprise

    NARCIS (Netherlands)

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

    2017-01-01

    Objective: A conceptual model is proposed in order to explain pilot performance in surprising and startling situations. Background: Today’s debate around loss of control following in-flight events and the implementation of upset prevention and recovery training has highlighted the importance of

  7. Human errors in NPP operations

    International Nuclear Information System (INIS)

    Sheng Jufang

    1993-01-01

    Based on the operational experiences of nuclear power plants (NPPs), the importance of studying human performance problems is described. Statistical analysis on the significance or frequency of various root-causes and error-modes from a large number of human-error-related events demonstrate that the defects in operation/maintenance procedures, working place factors, communication and training practices are primary root-causes, while omission, transposition, quantitative mistake are the most frequent among the error-modes. Recommendations about domestic research on human performance problem in NPPs are suggested

  8. Effect of material parameters on stress wave propagation during fast upsetting

    Institute of Scientific and Technical Information of China (English)

    WANG Zhong-jin; CHENG Li-dong

    2008-01-01

    Based'on a dynamic analysis method and an explicit algorithm, a dynamic explicit finite element code was developed for modeling the fast upsetting process of block under drop hammer impact, in which the hammer velocity during the deformation was calculated by energy conservation law according to the operating principle of hammer equipment. The stress wave propagation and its effect on the deformation were analyzed by the stress and strain distributions. Industrial pure lead, oxygen-free high-conductivity (OFHC) copper and 7039 aluminum alloy were chosen to investigate the effect of material parameters on the stress wave propagation. The results show that the stress wave propagates from top to bottom of block, and then reflects back when it reaches the bottom surface. After that, stress wave propagates and reflects repeatedly between the upper surface and bottom surface. The stress wave propagation has a significant effect on the deformation at the initial stage, and then becomes weak at the middle-final stage. When the ratio of elastic modulus or the slope of stress-strain curve to mass density becomes larger, the velocity of stress wave propagation increases, and the influence of stress wave on the deformation becomes small.

  9. The impact of meal timing on performance, sleepiness, gastric upset, and hunger during simulated night shift.

    Science.gov (United States)

    Grant, Crystal Leigh; Dorrian, Jillian; Coates, Alison Maree; Pajcin, Maja; Kennaway, David John; Wittert, Gary Allen; Heilbronn, Leonie Kaye; Vedova, Chris Della; Gupta, Charlotte Cecilia; Banks, Siobhan

    2017-10-07

    This study examined the impact of eating during simulated night shift on performance and subjective complaints. Subjects were randomized to eating at night (n=5; 23.2 ± 5.5 y) or not eating at night (n=5; 26.2 ± 6.4 y). All participants were given one sleep opportunity of 8 h (22:00 h-06:00 h) before transitioning to the night shift protocol. During the four days of simulated night shift participants were awake from 16:00 h-10:00 h with a daytime sleep of 6 h (10:00 h-16:00 h). In the simulated night shift protocol, meals were provided at ≈0700 h, 1900 h and 0130 h (eating at night); or ≈0700 h, 0930 h, 1410 h and 1900 h (not eating at night). Subjects completed sleepiness, hunger and gastric complaint scales, a Digit Symbol Substitution Task and a 10-min Psychomotor Vigilance Task. Increased sleepiness and performance impairment was evident in both conditions at 0400 h (phunger and a small but significant elevation in stomach upset across the night (p<0.026). Eating at night was associated with elevated bloating on night one, which decreased across the protocol. Restricting food intake may limit performance impairments at night. Dietary recommendations to improve night-shift performance must also consider worker comfort.

  10. Texture evolution maps for upset deformation of body-centered cubic metals

    International Nuclear Information System (INIS)

    Lee, Myoung-Gyu; Wang, Jue; Anderson, Peter M.

    2007-01-01

    Texture evolution maps are used as a tool to visualize texture development during upset deformation in body-centered cubic metals. These maps reveal initial grain orientations that tend toward normal direction (ND)|| versus ND|| . To produce these maps, a finite element analysis (FEA) with a rate-dependent crystal plasticity constitutive relation for tantalum is used. A reference case having zero workpiece/die friction shows that ∼64% of randomly oriented grains rotate toward ND|| and ∼36% rotate toward ND|| . The maps show well-established trends that increasing strain rate sensitivity and decreasing latent-to-self hardening ratio reduce both and percentages, leading to more diffuse textures. Reducing operative slip systems from both {1 1 0}/ and {1 1 2}/ to just {1 1 0}/ has a mixed effect: it increases the percentage but decreases the percentage. Reducing the number of slip systems and increasing the number of FEA integration points per grain strengthen - texture bands that are observed experimentally

  11. Soft-error tolerance and energy consumption evaluation of embedded computer with magnetic random access memory in practical systems using computer simulations

    Science.gov (United States)

    Nebashi, Ryusuke; Sakimura, Noboru; Sugibayashi, Tadahiko

    2017-08-01

    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.

  12. Single event effects induced by 15.14 MeV/u 136Xe ions

    International Nuclear Information System (INIS)

    Hou Mingdong; Zhang Qingxiang; Liu Jie; Wang Zhiguang; Jin Yunfan; Zhu Zhiyong; Zhen Honglou; Liu Changlong; Chen Xiaoxi; Wei Xinguo; Zhang Lin; Fan Youcheng; Zhu Zhourong; Zhang Yiting

    2002-01-01

    Single event effects induced by 15.14 MeV/u 136 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

  13. upSET, the Drosophila homologue of SET3, Is Required for Viability and the Proper Balance of Active and Repressive Chromatin Marks

    Directory of Open Access Journals (Sweden)

    Kyle A. McElroy

    2017-02-01

    Full Text Available Chromatin plays a critical role in faithful implementation of gene expression programs. Different post-translational modifications (PTMs of histone proteins reflect the underlying state of gene activity, and many chromatin proteins write, erase, bind, or are repelled by, these histone marks. One such protein is UpSET, the Drosophila homolog of yeast Set3 and mammalian KMT2E (MLL5. Here, we show that UpSET is necessary for the proper balance between active and repressed states. Using CRISPR/Cas-9 editing, we generated S2 cells that are mutant for upSET. We found that loss of UpSET is tolerated in S2 cells, but that heterochromatin is misregulated, as evidenced by a strong decrease in H3K9me2 levels assessed by bulk histone PTM quantification. To test whether this finding was consistent in the whole organism, we deleted the upSET coding sequence using CRISPR/Cas-9, which we found to be lethal in both sexes in flies. We were able to rescue this lethality using a tagged upSET transgene, and found that UpSET protein localizes to transcriptional start sites (TSS of active genes throughout the genome. Misregulated heterochromatin is apparent by suppressed position effect variegation of the wm4 allele in heterozygous upSET-deleted flies. Using nascent-RNA sequencing in the upSET-mutant S2 lines, we show that this result applies to heterochromatin genes generally. Our findings support a critical role for UpSET in maintaining heterochromatin, perhaps by delimiting the active chromatin environment.

  14. Single event effects in pulse width modulation controllers

    International Nuclear Information System (INIS)

    Penzin, S.H.; Crain, W.R.; Crawford, K.B.; Hansel, S.J.; Kirshman, J.F.; Koga, R.

    1996-01-01

    SEE testing was performed on pulse width modulation (PWM) controllers which are commonly used in switching mode power supply systems. The devices are designed using both Set-Reset (SR) flip-flops and Toggle (T) flip-flops which are vulnerable to single event upset (SEU) in a radiation environment. Depending on the implementation of the different devices the effect can be significant in spaceflight hardware

  15. 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)

    2015-07-01

    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.

  16. 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.

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

    Directory of Open Access Journals (Sweden)

    N. Esser

    2004-01-01

    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. 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)

    2015-05-01

    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.

  19. Modeling coherent errors in quantum error correction

    Science.gov (United States)

    Greenbaum, Daniel; Dutton, Zachary

    2018-01-01

    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.

  20. 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

    2010-01-01

    , 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...

  1. Learning from prescribing errors

    OpenAIRE

    Dean, B

    2002-01-01

    

 The importance of learning from medical error has recently received increasing emphasis. This paper focuses on prescribing errors and argues that, while learning from prescribing errors is a laudable goal, there are currently barriers that can prevent this occurring. Learning from errors can take place on an individual level, at a team level, and across an organisation. Barriers to learning from prescribing errors include the non-discovery of many prescribing errors, lack of feedback to th...

  2. Soft errors in modern electronic systems

    CERN Document Server

    Nicolaidis, Michael

    2010-01-01

    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

  3. Reward positivity: Reward prediction error or salience prediction error?

    Science.gov (United States)

    Heydari, Sepideh; Holroyd, Clay B

    2016-08-01

    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.

  4. High electrical resistivity Nd-Fe-B die-upset magnet doped with eutectic DyF3–LiF salt mixture

    Directory of Open Access Journals (Sweden)

    K. M. Kim

    2017-05-01

    Full Text Available Nd-Fe-B-type die-upset magnet with high electrical resistivity was prepared by doping of eutectic DyF3–LiF salt mixture. Mixture of melt-spun Nd-Fe-B flakes (MQU-F: Nd13.6Fe73.6Co6.6Ga0.6B5.6 and eutectic binary (DyF3–LiF salt (25 mol% DyF3 – 75 mol% LiF was hot-pressed and then die-upset. By adding the eutectic salt mixture (> 4 wt%, electrical resistivity of the die-upset magnet was enhanced to over 400 μΩ.cm compared to 190 μΩ.cm of the un-doped magnet. Remarkable enhancement of the electrical resistivity was attributed to homogeneous and continuous coverage of the interface between flakes by the easily melted eutectic salt dielectric mixture. It was revealed that active substitution of the Nd atoms in neighboring flakes by the Dy atoms from the added (DyF3–LiF salt mixture had occurred during such a quick thermal processing of hot-pressing and die-upsetting. This Dy substitution led to coercivity enhancement in the die-upset magnet doped with the eutectic (DyF3–LiF salt mixture. Coercivity and remanence of the die-upset magnet doped with (DyF3–LiF salt mixture was as good as those of the DyF3-doped magnet.

  5. Two-dimensional errors

    International Nuclear Information System (INIS)

    Anon.

    1991-01-01

    This chapter addresses the extension of previous work in one-dimensional (linear) error theory to two-dimensional error analysis. The topics of the chapter include the definition of two-dimensional error, the probability ellipse, the probability circle, elliptical (circular) error evaluation, the application to position accuracy, and the use of control systems (points) in measurements

  6. Part two: Error propagation

    International Nuclear Information System (INIS)

    Picard, R.R.

    1989-01-01

    Topics covered in this chapter include a discussion of exact results as related to nuclear materials management and accounting in nuclear facilities; propagation of error for a single measured value; propagation of error for several measured values; error propagation for materials balances; and an application of error propagation to an example of uranium hexafluoride conversion process

  7. Learning from Errors

    OpenAIRE

    Martínez-Legaz, Juan Enrique; Soubeyran, Antoine

    2003-01-01

    We present a model of learning in which agents learn from errors. If an action turns out to be an error, the agent rejects not only that action but also neighboring actions. We find that, keeping memory of his errors, under mild assumptions an acceptable solution is asymptotically reached. Moreover, one can take advantage of big errors for a faster learning.

  8. Negligence, genuine error, and litigation

    Directory of Open Access Journals (Sweden)

    Sohn DH

    2013-02-01

    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

  9. Sensation seeking and error processing.

    Science.gov (United States)

    Zheng, Ya; Sheng, Wenbin; Xu, Jing; Zhang, Yuanyuan

    2014-09-01

    Sensation seeking is defined by a strong need for varied, novel, complex, and intense stimulation, and a willingness to take risks for such experience. Several theories propose that the insensitivity to negative consequences incurred by risks is one of the hallmarks of sensation-seeking behaviors. In this study, we investigated the time course of error processing in sensation seeking by recording event-related potentials (ERPs) while high and low sensation seekers performed an Eriksen flanker task. Whereas there were no group differences in ERPs to correct trials, sensation seeking was associated with a blunted error-related negativity (ERN), which was female-specific. Further, different subdimensions of sensation seeking were related to ERN amplitude differently. These findings indicate that the relationship between sensation seeking and error processing is sex-specific. Copyright © 2014 Society for Psychophysiological Research.

  10. Generalized Gaussian Error Calculus

    CERN Document Server

    Grabe, Michael

    2010-01-01

    For the first time in 200 years Generalized Gaussian Error Calculus addresses a rigorous, complete and self-consistent revision of the Gaussian error calculus. Since experimentalists realized that measurements in general are burdened by unknown systematic errors, the classical, widespread used evaluation procedures scrutinizing the consequences of random errors alone turned out to be obsolete. As a matter of course, the error calculus to-be, treating random and unknown systematic errors side by side, should ensure the consistency and traceability of physical units, physical constants and physical quantities at large. The generalized Gaussian error calculus considers unknown systematic errors to spawn biased estimators. Beyond, random errors are asked to conform to the idea of what the author calls well-defined measuring conditions. The approach features the properties of a building kit: any overall uncertainty turns out to be the sum of a contribution due to random errors, to be taken from a confidence inter...

  11. Preliminary evaluation of Am/Cm melter feed preparation process upset recovery flowsheets

    International Nuclear Information System (INIS)

    Stone, M.E.

    2000-01-01

    This document summarizes the results from the development of flowsheets to recover from credible processing errors specified in TTR 99-MNSS/SE-006. The proposed flowsheets were developed in laboratory scale equipment and will be utilized with minor modifications for full scale demonstrations in the Am/Cm Pilot Facility

  12. Medication errors: prescribing faults and prescription errors.

    Science.gov (United States)

    Velo, Giampaolo P; Minuz, Pietro

    2009-06-01

    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.

  13. Clinical errors and medical negligence.

    Science.gov (United States)

    Oyebode, Femi

    2013-01-01

    This paper discusses the definition, nature and origins of clinical errors including their prevention. The relationship between clinical errors and medical negligence is examined as are the characteristics of litigants and events that are the source of litigation. The pattern of malpractice claims in different specialties and settings is examined. Among hospitalized patients worldwide, 3-16% suffer injury as a result of medical intervention, the most common being the adverse effects of drugs. The frequency of adverse drug effects appears superficially to be higher in intensive care units and emergency departments but once rates have been corrected for volume of patients, comorbidity of conditions and number of drugs prescribed, the difference is not significant. It is concluded that probably no more than 1 in 7 adverse events in medicine result in a malpractice claim and the factors that predict that a patient will resort to litigation include a prior poor relationship with the clinician and the feeling that the patient is not being kept informed. Methods for preventing clinical errors are still in their infancy. The most promising include new technologies such as electronic prescribing systems, diagnostic and clinical decision-making aids and error-resistant systems. Copyright © 2013 S. Karger AG, Basel.

  14. High energy hadron-induced errors in memory chips

    Energy Technology Data Exchange (ETDEWEB)

    Peterson, R.J. [University of Colorado, Boulder, CO (United States)

    2001-09-01

    We have measured probabilities for proton, neutron and pion beams from accelerators to induce temporary or soft errors in a wide range of modern 16 Mb and 64 Mb dRAM memory chips, typical of those used in aircraft electronics. Relations among the cross sections for these particles are deduced, and failure rates for aircraft avionics due to cosmic rays are evaluated. Measurement of alpha pha particle yields from pions on aluminum, as a surrogate for silicon, indicate that these reaction products are the proximate cause of the charge deposition resulting in errors. Heavy ions can cause damage to solar panels and other components in satellites above the atmosphere, by the heavy ionization trails they leave. However, at the earth's surface or at aircraft altitude it is known that cosmic rays, other than heavy ions, can cause soft errors in memory circuit components. Soft errors are those confusions between ones and zeroes that cause wrong contents to be stored in the memory, but without causing permanent damage to the circuit. As modern aircraft rely increasingly upon computerized and automated systems, these soft errors are important threats to safety. Protons, neutrons and pions resulting from high energy cosmic ray bombardment of the atmosphere pervade our environment. These particles do not induce damage directly by their ionization loss, but rather by reactions in the materials of the microcircuits. We have measured many cross sections for soft error upsets (SEU) in a broad range of commercial 16 Mb and 64 Mb dRAMs with accelerator beams. Here we define {sigma} SEU = induced errors/number of sample bits x particles/cm{sup 2}. We compare {sigma} SEU to find relations among results for these beams, and relations to reaction cross sections in order to systematize effects. We have modelled cosmic ray effects upon the components we have studied. (Author)

  15. High energy hadron-induced errors in memory chips

    International Nuclear Information System (INIS)

    Peterson, R.J.

    2001-01-01

    We have measured probabilities for proton, neutron and pion beams from accelerators to induce temporary or soft errors in a wide range of modern 16 Mb and 64 Mb dRAM memory chips, typical of those used in aircraft electronics. Relations among the cross sections for these particles are deduced, and failure rates for aircraft avionics due to cosmic rays are evaluated. Measurement of alpha pha particle yields from pions on aluminum, as a surrogate for silicon, indicate that these reaction products are the proximate cause of the charge deposition resulting in errors. Heavy ions can cause damage to solar panels and other components in satellites above the atmosphere, by the heavy ionization trails they leave. However, at the earth's surface or at aircraft altitude it is known that cosmic rays, other than heavy ions, can cause soft errors in memory circuit components. Soft errors are those confusions between ones and zeroes that cause wrong contents to be stored in the memory, but without causing permanent damage to the circuit. As modern aircraft rely increasingly upon computerized and automated systems, these soft errors are important threats to safety. Protons, neutrons and pions resulting from high energy cosmic ray bombardment of the atmosphere pervade our environment. These particles do not induce damage directly by their ionization loss, but rather by reactions in the materials of the microcircuits. We have measured many cross sections for soft error upsets (SEU) in a broad range of commercial 16 Mb and 64 Mb dRAMs with accelerator beams. Here we define σ SEU = induced errors/number of sample bits x particles/cm 2 . We compare σ SEU to find relations among results for these beams, and relations to reaction cross sections in order to systematize effects. We have modelled cosmic ray effects upon the components we have studied. (Author)

  16. Field error lottery

    Energy Technology Data Exchange (ETDEWEB)

    Elliott, C.J.; McVey, B. (Los Alamos National Lab., NM (USA)); Quimby, D.C. (Spectra Technology, Inc., Bellevue, WA (USA))

    1990-01-01

    The level of field errors in an 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 utilization 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 mechanical tolerances of {plus minus}25{mu}m, and amelioration of these may occur by a procedure utilizing direct measurement of the magnetic fields at assembly time. 4 refs., 12 figs.

  17. A novel back-up control structure to manage nonroutine steam upsets in industrial methanol distillation columns

    DEFF Research Database (Denmark)

    Udugama, Isuru A.; Zander, Cornina; Mansouri, Seyed Soheil

    2017-01-01

    Industrial methanol production plants have extensive heat integration to achieve energy efficient operations where steam generated from these heat integration operations are used to provide reboiler duty for methanol distillation columns that purify crude methanol produced into industrial AA grade...... supervisory layer to control the column during these non-routine process upsets. These control schemes were tested against realistic reboiler duty disturbances that can occur in an industrial process. The tests revealed that both the MPC and supervisory systems control structures are able to regulate...... the process, even during sudden drops in reboiler duty. However, the cost of implementation and the relative simplicity will likely favour the implementation of the supervisory control structure in an industrial environment....

  18. Prescription Errors in Psychiatry

    African Journals Online (AJOL)

    Arun Kumar Agnihotri

    clinical pharmacists in detecting errors before they have a (sometimes serious) clinical impact should not be underestimated. Research on medication error in mental health care is limited. .... participation in ward rounds and adverse drug.

  19. The single-event effect evaluation technology for nano integrated circuits

    International Nuclear Information System (INIS)

    Zheng Hongchao; Zhao Yuanfu; Yue Suge; Fan Long; Du Shougang; Chen Maoxin; Yu Chunqing

    2015-01-01

    Single-event effects of nano scale integrated circuits are investigated. Evaluation methods for single-event transients, single-event upsets, and single-event functional interrupts in nano circuits are summarized and classified in detail. The difficulties in SEE testing are discussed as well as the development direction of test technology, with emphasis placed on the experimental evaluation of a nano circuit under heavy ion, proton, and laser irradiation. The conclusions in this paper are based on many years of testing at accelerator facilities and our present understanding of the mechanisms for SEEs, which have been well verified experimentally. (paper)

  20. Medication errors : the impact of prescribing and transcribing errors on preventable harm in hospitalised patients

    NARCIS (Netherlands)

    van Doormaal, J.E.; van der Bemt, P.M.L.A.; Mol, P.G.M.; Egberts, A.C.G.; Haaijer-Ruskamp, F.M.; Kosterink, J.G.W.; Zaal, Rianne J.

    Background: Medication errors (MEs) affect patient safety to a significant extent. Because these errors can lead to preventable adverse drug events (pADEs), it is important to know what type of ME is the most prevalent cause of these pADEs. This study determined the impact of the various types of

  1. Analysis of error patterns in clinical radiotherapy

    International Nuclear Information System (INIS)

    Macklis, Roger; Meier, Tim; Barrett, Patricia; Weinhous, Martin

    1996-01-01

    Purpose: Until very recently, prescription errors and adverse treatment events have rarely been studied or reported systematically in oncology. We wished to understand the spectrum and severity of radiotherapy errors that take place on a day-to-day basis in a high-volume academic practice and to understand the resource needs and quality assurance challenges placed on a department by rapid upswings in contract-based clinical volumes requiring additional operating hours, procedures, and personnel. The goal was to define clinical benchmarks for operating safety and to detect error-prone treatment processes that might function as 'early warning' signs. Methods: A multi-tiered prospective and retrospective system for clinical error detection and classification was developed, with formal analysis of the antecedents and consequences of all deviations from prescribed treatment delivery, no matter how trivial. A department-wide record-and-verify system was operational during this period and was used as one method of treatment verification and error detection. Brachytherapy discrepancies were analyzed separately. Results: During the analysis year, over 2000 patients were treated with over 93,000 individual fields. A total of 59 errors affecting a total of 170 individual treated fields were reported or detected during this period. After review, all of these errors were classified as Level 1 (minor discrepancy with essentially no potential for negative clinical implications). This total treatment delivery error rate (170/93, 332 or 0.18%) is significantly better than corresponding error rates reported for other hospital and oncology treatment services, perhaps reflecting the relatively sophisticated error avoidance and detection procedures used in modern clinical radiation oncology. Error rates were independent of linac model and manufacturer, time of day (normal operating hours versus late evening or early morning) or clinical machine volumes. There was some relationship to

  2. Analyzing temozolomide medication errors: potentially fatal.

    Science.gov (United States)

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

    2014-10-01

    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.

  3. Errors in otology.

    Science.gov (United States)

    Kartush, J M

    1996-11-01

    Practicing medicine successfully requires that errors in diagnosis and treatment be minimized. Malpractice laws encourage litigators to ascribe all medical errors to incompetence and negligence. There are, however, many other causes of unintended outcomes. This article describes common causes of errors and suggests ways to minimize mistakes in otologic practice. Widespread dissemination of knowledge about common errors and their precursors can reduce the incidence of their occurrence. Consequently, laws should be passed to allow for a system of non-punitive, confidential reporting of errors and "near misses" that can be shared by physicians nationwide.

  4. Event-by-event jet quenching

    Energy Technology Data Exchange (ETDEWEB)

    Fries, R.J.; Rodriguez, R.; Ramirez, E.

    2010-08-14

    High momentum jets and hadrons can be used as probes for the quark gluon plasma (QGP) formed in nuclear collisions at high energies. We investigate the influence of fluctuations in the fireball on jet quenching observables by comparing propagation of light quarks and gluons through averaged, smooth QGP fireballs with event-by-event jet quenching using realistic inhomogeneous fireballs. We find that the transverse momentum and impact parameter dependence of the nuclear modification factor R{sub AA} can be fit well in an event-by-event quenching scenario within experimental errors. However the transport coefficient {cflx q} extracted from fits to the measured nuclear modification factor R{sub AA} in averaged fireballs underestimates the value from event-by-event calculations by up to 50%. On the other hand, after adjusting {cflx q} to fit R{sub AA} in the event-by-event analysis we find residual deviations in the azimuthal asymmetry v{sub 2} and in two-particle correlations, that provide a possible faint signature for a spatial tomography of the fireball. We discuss a correlation function that is a measure for spatial inhomogeneities in a collision and can be constrained from data.

  5. Event-by-event jet quenching

    Energy Technology Data Exchange (ETDEWEB)

    Rodriguez, R. [Cyclotron Institute and Physics Department, Texas A and M University, College Station, TX 77843 (United States); Fries, R.J., E-mail: rjfries@comp.tamu.ed [Cyclotron Institute and Physics Department, Texas A and M University, College Station, TX 77843 (United States); RIKEN/BNL Research Center, Brookhaven National Laboratory, Upton, NY 11973 (United States); Ramirez, E. [Physics Department, University of Texas El Paso, El Paso, TX 79968 (United States)

    2010-09-27

    High momentum jets and hadrons can be used as probes for the quark gluon plasma (QGP) formed in nuclear collisions at high energies. We investigate the influence of fluctuations in the fireball on jet quenching observables by comparing propagation of light quarks and gluons through averaged, smooth QGP fireballs with event-by-event jet quenching using realistic inhomogeneous fireballs. We find that the transverse momentum and impact parameter dependence of the nuclear modification factor R{sub AA} can be fit well in an event-by-event quenching scenario within experimental errors. However the transport coefficient q extracted from fits to the measured nuclear modification factor R{sub AA} in averaged fireballs underestimates the value from event-by-event calculations by up to 50%. On the other hand, after adjusting q to fit R{sub AA} in the event-by-event analysis we find residual deviations in the azimuthal asymmetry v{sub 2} and in two-particle correlations, that provide a possible faint signature for a spatial tomography of the fireball. We discuss a correlation function that is a measure for spatial inhomogeneities in a collision and can be constrained from data.

  6. Human decision error (HUMDEE) trees

    International Nuclear Information System (INIS)

    Ostrom, L.T.

    1993-01-01

    Graphical presentations of human actions in incident and accident sequences have been used for many years. However, for the most part, human decision making has been underrepresented in these trees. This paper presents a method of incorporating the human decision process into graphical presentations of incident/accident sequences. This presentation is in the form of logic trees. These trees are called Human Decision Error Trees or HUMDEE for short. The primary benefit of HUMDEE trees is that they graphically illustrate what else the individuals involved in the event could have done to prevent either the initiation or continuation of the event. HUMDEE trees also present the alternate paths available at the operator decision points in the incident/accident sequence. This is different from the Technique for Human Error Rate Prediction (THERP) event trees. There are many uses of these trees. They can be used for incident/accident investigations to show what other courses of actions were available and for training operators. The trees also have a consequence component so that not only the decision can be explored, also the consequence of that decision

  7. Negligence, genuine error, and litigation

    Science.gov (United States)

    Sohn, David H

    2013-01-01

    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. PMID:23426783

  8. UNDERSTANDING OR NURSES' REACTIONS TO ERRORS AND USING THIS UNDERSTANDING TO IMPROVE PATIENT SAFETY.

    Science.gov (United States)

    Taifoori, Ladan; Valiee, Sina

    2015-09-01

    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.

  9. Addressing Medical Errors in Hand Surgery

    OpenAIRE

    Johnson, Shepard P.; Adkinson, Joshua M.; Chung, Kevin C.

    2014-01-01

    Influential think-tank such as the Institute of Medicine has raised awareness about the implications of medical errors. In response, organizations, medical societies, and institutions have initiated programs to decrease the incidence and effects of these errors. Surgeons deal with the direct implications of adverse events involving patients. In addition to managing the physical consequences, they are confronted with ethical and social issues when caring for a harmed patient. Although there is...

  10. The error in total error reduction.

    Science.gov (United States)

    Witnauer, James E; Urcelay, Gonzalo P; Miller, Ralph R

    2014-02-01

    Most models of human and animal learning assume that learning is proportional to the discrepancy between a delivered outcome and the outcome predicted by all cues present during that trial (i.e., total error across a stimulus compound). This total error reduction (TER) view has been implemented in connectionist and artificial neural network models to describe the conditions under which weights between units change. Electrophysiological work has revealed that the activity of dopamine neurons is correlated with the total error signal in models of reward learning. Similar neural mechanisms presumably support fear conditioning, human contingency learning, and other types of learning. Using a computational modeling approach, we compared several TER models of associative learning to an alternative model that rejects the TER assumption in favor of local error reduction (LER), which assumes that learning about each cue is proportional to the discrepancy between the delivered outcome and the outcome predicted by that specific cue on that trial. The LER model provided a better fit to the reviewed data than the TER models. Given the superiority of the LER model with the present data sets, acceptance of TER should be tempered. Copyright © 2013 Elsevier Inc. All rights reserved.

  11. The District Nursing Clinical Error Reduction Programme.

    Science.gov (United States)

    McGraw, Caroline; Topping, Claire

    2011-01-01

    The District Nursing Clinical Error Reduction (DANCER) Programme was initiated in NHS Islington following an increase in the number of reported medication errors. The objectives were to reduce the actual degree of harm and the potential risk of harm associated with medication errors and to maintain the existing positive reporting culture, while robustly addressing performance issues. One hundred medication errors reported in 2007/08 were analysed using a framework that specifies the factors that predispose to adverse medication events in domiciliary care. Various contributory factors were identified and interventions were subsequently developed to address poor drug calculation and medication problem-solving skills and incorrectly transcribed medication administration record charts. Follow up data were obtained at 12 months and two years. The evaluation has shown that although medication errors do still occur, the programme has resulted in a marked shift towards a reduction in the associated actual degree of harm and the potential risk of harm.

  12. A qualitative description of human error

    International Nuclear Information System (INIS)

    Li Zhaohuan

    1992-11-01

    The human error has an important contribution to risk of reactor operation. The insight and analytical model are main parts in human reliability analysis. It consists of the concept of human error, the nature, the mechanism of generation, the classification and human performance influence factors. On the operating reactor the human error is defined as the task-human-machine mismatch. The human error event is focused on the erroneous action and the unfavored result. From the time limitation of performing a task, the operation is divided into time-limited and time-opened. The HCR (human cognitive reliability) model is suited for only time-limited. The basic cognitive process consists of the information gathering, cognition/thinking, decision making and action. The human erroneous action may be generated in any stage of this process. The more natural ways to classify human errors are presented. The human performance influence factors including personal, organizational and environmental factors are also listed

  13. A qualitative description of human error

    Energy Technology Data Exchange (ETDEWEB)

    Zhaohuan, Li [Academia Sinica, Beijing, BJ (China). Inst. of Atomic Energy

    1992-11-01

    The human error has an important contribution to risk of reactor operation. The insight and analytical model are main parts in human reliability analysis. It consists of the concept of human error, the nature, the mechanism of generation, the classification and human performance influence factors. On the operating reactor the human error is defined as the task-human-machine mismatch. The human error event is focused on the erroneous action and the unfavored result. From the time limitation of performing a task, the operation is divided into time-limited and time-opened. The HCR (human cognitive reliability) model is suited for only time-limited. The basic cognitive process consists of the information gathering, cognition/thinking, decision making and action. The human erroneous action may be generated in any stage of this process. The more natural ways to classify human errors are presented. The human performance influence factors including personal, organizational and environmental factors are also listed.

  14. Notes on human error analysis and prediction

    International Nuclear Information System (INIS)

    Rasmussen, J.

    1978-11-01

    The notes comprise an introductory discussion of the role of human error analysis and prediction in industrial risk analysis. Following this introduction, different classes of human errors and role in industrial systems are mentioned. Problems related to the prediction of human behaviour in reliability and safety analysis are formulated and ''criteria for analyzability'' which must be met by industrial systems so that a systematic analysis can be performed are suggested. The appendices contain illustrative case stories and a review of human error reports for the task of equipment calibration and testing as found in the US Licensee Event Reports. (author)

  15. Systematic Procedural Error

    National Research Council Canada - National Science Library

    Byrne, Michael D

    2006-01-01

    .... This problem has received surprisingly little attention from cognitive psychologists. The research summarized here examines such errors in some detail both empirically and through computational cognitive modeling...

  16. Human errors and mistakes

    International Nuclear Information System (INIS)

    Wahlstroem, B.

    1993-01-01

    Human errors have a major contribution to the risks for industrial accidents. Accidents have provided important lesson making it possible to build safer systems. In avoiding human errors it is necessary to adapt the systems to their operators. The complexity of modern industrial systems is however increasing the danger of system accidents. Models of the human operator have been proposed, but the models are not able to give accurate predictions of human performance. Human errors can never be eliminated, but their frequency can be decreased by systematic efforts. The paper gives a brief summary of research in human error and it concludes with suggestions for further work. (orig.)

  17. Multi-bits error detection and fast recovery in RISC cores

    International Nuclear Information System (INIS)

    Wang Jing; Yang Xing; Zhang Weigong; Shen Jiao; Qiu Keni; Zhao Yuanfu

    2015-01-01

    The particles-induced soft errors are a major threat to the reliability of microprocessors. Even worse, multi-bits upsets (MBUs) are ever-increased due to the rapidly shrinking feature size of the IC on a chip. Several architecture-level mechanisms have been proposed to protect microprocessors from soft errors, such as dual and triple modular redundancies (DMR and TMR). However, most of them are inefficient to combat the growing multi-bits errors or cannot well balance the critical paths delay, area and power penalty. This paper proposes a novel architecture, self-recovery dual-pipeline (SRDP), to effectively provide soft error detection and recovery with low cost for general RISC structures. We focus on the following three aspects. First, an advanced DMR pipeline is devised to detect soft error, especially MBU. Second, SEU/MBU errors can be located by enhancing self-checking logic into pipelines stage registers. Third, a recovery scheme is proposed with a recovery cost of 1 or 5 clock cycles. Our evaluation of a prototype implementation exhibits that the SRDP can successfully detect particle-induced soft errors up to 100% and recovery is nearly 95%, the other 5% will inter a specific trap. (paper)

  18. Multi-bits error detection and fast recovery in RISC cores

    Science.gov (United States)

    Jing, Wang; Xing, Yang; Yuanfu, Zhao; Weigong, Zhang; Jiao, Shen; Keni, Qiu

    2015-11-01

    The particles-induced soft errors are a major threat to the reliability of microprocessors. Even worse, multi-bits upsets (MBUs) are ever-increased due to the rapidly shrinking feature size of the IC on a chip. Several architecture-level mechanisms have been proposed to protect microprocessors from soft errors, such as dual and triple modular redundancies (DMR and TMR). However, most of them are inefficient to combat the growing multi-bits errors or cannot well balance the critical paths delay, area and power penalty. This paper proposes a novel architecture, self-recovery dual-pipeline (SRDP), to effectively provide soft error detection and recovery with low cost for general RISC structures. We focus on the following three aspects. First, an advanced DMR pipeline is devised to detect soft error, especially MBU. Second, SEU/MBU errors can be located by enhancing self-checking logic into pipelines stage registers. Third, a recovery scheme is proposed with a recovery cost of 1 or 5 clock cycles. Our evaluation of a prototype implementation exhibits that the SRDP can successfully detect particle-induced soft errors up to 100% and recovery is nearly 95%, the other 5% will inter a specific trap.

  19. Medication Errors: New EU Good Practice Guide on Risk Minimisation and Error Prevention.

    Science.gov (United States)

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

    2016-06-01

    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

  20. Research on generation mechanism of single event transient current generated in the semiconductor using ion accelerator

    International Nuclear Information System (INIS)

    Hirao, Toshio

    2007-01-01

    Single-event upset (SEU) is triggered when an amount of electric charges induced by energetic ion incidence exceeds a value known as a critical charge in a very short time period. Therefore, accurate evaluation of electric charge and understanding of basic mechanism of SEU are necessary for the improvement of SEU torrance of electronic devices. In this paper, the collected charges for the single event transient current induced on semiconductor by heavy ion microbeams, and application to use microbeam for single event studies are presented. (author)

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

    Science.gov (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

  2. Learning from Errors

    Science.gov (United States)

    Metcalfe, Janet

    2017-01-01

    Although error avoidance during learning appears to be the rule in American classrooms, laboratory studies suggest that it may be a counterproductive strategy, at least for neurologically typical students. Experimental investigations indicate that errorful learning followed by corrective feedback is beneficial to learning. Interestingly, the…

  3. Future challenges in single event effects for advanced CMOS technologies

    International Nuclear Information System (INIS)

    Guo Hongxia; Wang Wei; Luo Yinhong; Zhao Wen; Guo Xiaoqiang; Zhang Keying

    2010-01-01

    SEE have became a substantial Achilles heel for the reliability of space-based advanced CMOS technologies with features size downscaling. Future space and defense systems require identification and understanding of single event effects to develop hardening approaches for advanced technologies, including changes in device geometry and materials affect energy deposition, charge collection,circuit upset, parametric degradation devices. Topics covered include the impact of technology scaling on radiation response, including single event transients in high speed digital circuits, evidence for single event effects caused by proton direct ionization, and the impact for SEU induced by particle energy effects and indirect ionization. The single event effects in CMOS replacement technologies are introduced briefly. (authors)

  4. Experimental Research and Method for Calculation of 'Upsetting-with-Buckling' Load at the Impression-Free (Dieless Preforming of Workpiece

    Directory of Open Access Journals (Sweden)

    Kukhar Volodymir

    2018-01-01

    Full Text Available This paper presents the results of experimental studies of load characteristic changes during the upsetting of high billets with the upsetting ratio (height to diameter ratio from 3.0 to 6.0, which is followed by buckling. Such pass is an effective way of preforming the workpiece for production of forgings with a bended axis or dual forming, and belongs to impression-free (dieless operation of bulk forming. Based on the experimental data analysis, an engineering method for calculation of workpiece pre-forming load as a maximum buckling force has been developed. The analysis of the obtained data confirmed the possibility of performing of this pre-forming operation on the main forging equipment, since the load of shaping by buckling does not exceed the load of the dieforging.

  5. Experimental Research and Method for Calculation of 'Upsetting-with-Buckling' Load at the Impression-Free (Dieless) Preforming of Workpiece

    Science.gov (United States)

    Kukhar, Volodymir; Artiukh, Victor; Prysiazhnyi, Andrii; Pustovgar, Andrey

    2018-03-01

    This paper presents the results of experimental studies of load characteristic changes during the upsetting of high billets with the upsetting ratio (height to diameter ratio) from 3.0 to 6.0, which is followed by buckling. Such pass is an effective way of preforming the workpiece for production of forgings with a bended axis or dual forming, and belongs to impression-free (dieless) operation of bulk forming. Based on the experimental data analysis, an engineering method for calculation of workpiece pre-forming load as a maximum buckling force has been developed. The analysis of the obtained data confirmed the possibility of performing of this pre-forming operation on the main forging equipment, since the load of shaping by buckling does not exceed the load of the dieforging.

  6. Action errors, error management, and learning in organizations.

    Science.gov (United States)

    Frese, Michael; Keith, Nina

    2015-01-03

    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.

  7. 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

    2017-08-01

    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.

  8. Accelerated testing for cosmic soft-error rate

    International Nuclear Information System (INIS)

    Ziegler, J.F.; Muhlfeld, H.P.; Montrose, C.J.; Curtis, H.W.; O'Gorman, T.J.; Ross, J.M.

    1996-01-01

    This paper describes the experimental techniques which have been developed at IBM to determine the sensitivity of electronic circuits to cosmic rays at sea level. It relates IBM circuit design and modeling, chip manufacture with process variations, and chip testing for SER sensitivity. This vertical integration from design to final test and with feedback to design allows a complete picture of LSI sensitivity to cosmic rays. Since advanced computers are designed with LSI chips long before the chips have been fabricated, and the system architecture is fully formed before the first chips are functional, it is essential to establish the chip reliability as early as possible. This paper establishes techniques to test chips that are only partly functional (e.g., only 1Mb of a 16Mb memory may be working) and can establish chip soft-error upset rates before final chip manufacturing begins. Simple relationships derived from measurement of more than 80 different chips manufactured over 20 years allow total cosmic soft-error rate (SER) to be estimated after only limited testing. Comparisons between these accelerated test results and similar tests determined by ''field testing'' (which may require a year or more of testing after manufacturing begins) show that the experimental techniques are accurate to a factor of 2

  9. Study of Errors among Nursing Students

    Directory of Open Access Journals (Sweden)

    Ella Koren

    2007-09-01

    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

  10. A study of the recovery from 120 events

    International Nuclear Information System (INIS)

    Baumont, Genevieve; Menage, F.; Bigot, F.

    1998-01-01

    The author reports a study which aimed at providing additional information for improving safety by using event analysis. The approach concentrates on the dynamics of error detection and the way errors and shortcomings are managed. The study is based on a systematic analysis of 120 events in nuclear power plants. The authors first outline the differences between the activities described in significant events and that which is assumed to take place during event and accident situations. They describe the methods used to transpose human reliability PSA model to event analysis, report the analysis (event selection, data studied during event analysis, types of errors). Studies concern events during power operation or plant outage. Results are analyzed in terms of number of events, percentage of error type, percentage of activation of engineered safety features before operators recovered the situation. They comment who recovers the error and how it is recovered, and more precisely discuss the case of multiple error situations

  11. Uncorrected refractive errors.

    Science.gov (United States)

    Naidoo, Kovin S; Jaggernath, Jyoti

    2012-01-01

    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.

  12. Uncorrected refractive errors

    Directory of Open Access Journals (Sweden)

    Kovin S Naidoo

    2012-01-01

    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.

  13. High cortisol awakening response is associated with impaired error monitoring and decreased post-error adjustment.

    Science.gov (United States)

    Zhang, Liang; Duan, Hongxia; Qin, Shaozheng; Yuan, Yiran; Buchanan, Tony W; Zhang, Kan; Wu, Jianhui

    2015-01-01

    The cortisol awakening response (CAR), a rapid increase in cortisol levels following morning awakening, is an important aspect of hypothalamic-pituitary-adrenocortical axis activity. Alterations in the CAR have been linked to a variety of mental disorders and cognitive function. However, little is known regarding the relationship between the CAR and error processing, a phenomenon that is vital for cognitive control and behavioral adaptation. Using high-temporal resolution measures of event-related potentials (ERPs) combined with behavioral assessment of error processing, we investigated whether and how the CAR is associated with two key components of error processing: error detection and subsequent behavioral adjustment. Sixty university students performed a Go/No-go task while their ERPs were recorded. Saliva samples were collected at 0, 15, 30 and 60 min after awakening on the two consecutive days following ERP data collection. The results showed that a higher CAR was associated with slowed latency of the error-related negativity (ERN) and a higher post-error miss rate. The CAR was not associated with other behavioral measures such as the false alarm rate and the post-correct miss rate. These findings suggest that high CAR is a biological factor linked to impairments of multiple steps of error processing in healthy populations, specifically, the automatic detection of error and post-error behavioral adjustment. A common underlying neural mechanism of physiological and cognitive control may be crucial for engaging in both CAR and error processing.

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

    Energy Technology Data Exchange (ETDEWEB)

    Anon

    2003-03-01

    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

  15. Preventing Errors in Laterality

    OpenAIRE

    Landau, Elliot; Hirschorn, David; Koutras, Iakovos; Malek, Alexander; Demissie, Seleshie

    2014-01-01

    An error in laterality is the reporting of a finding that is present on the right side as on the left or vice versa. While different medical and surgical specialties have implemented protocols to help prevent such errors, very few studies have been published that describe these errors in radiology reports and ways to prevent them. We devised a system that allows the radiologist to view reports in a separate window, displayed in a simple font and with all terms of laterality highlighted in sep...

  16. Errors and violations

    International Nuclear Information System (INIS)

    Reason, J.

    1988-01-01

    This paper is in three parts. The first part summarizes the human failures responsible for the Chernobyl disaster and argues that, in considering the human contribution to power plant emergencies, it is necessary to distinguish between: errors and violations; and active and latent failures. The second part presents empirical evidence, drawn from driver behavior, which suggest that errors and violations have different psychological origins. The concluding part outlines a resident pathogen view of accident causation, and seeks to identify the various system pathways along which errors and violations may be propagated

  17. Error processing - evidence from intracerebral ERP recordings

    Czech Academy of Sciences Publication Activity Database

    Brázdil, M.; Roman, R.; Falkenstein, M.; Daniel, P.; Jurák, Pavel; Rektor, I.

    2002-01-01

    Roč. 146, č. 4 (2002), s. - ISSN 1432-1106 R&D Projects: GA ČR GA102/95/0467; GA ČR GA102/02/1339 Institutional research plan: CEZ:AV0Z2065902 Keywords : error processing * event-related potentials * intracerebral recordings Subject RIV: FA - Cardiovascular Diseases incl. Cardiotharic Surgery

  18. Assessment of radiation doses in normal operation, upset accident conditions at the Olkiluoto nuclear waste facility

    International Nuclear Information System (INIS)

    Rossi, J.; Raiko, H.; Suolanen, V.

    2009-09-01

    Radiation doses for workers of the facility, for inhabitants in the environment and for terrestrial ecosystem possibly caused by the encapsulation and disposal facility to be built at Olkiluoto during its operation were considered in the study. The study covers both the normal operation of the plant and some hypothetical incidents and accidents. Release through the ventilation stack is assumed to be filtered both in normal operation and in hypothetical abnormal fault and accident cases. Calculation of the offsite doses from normal operation is based on the hypothesis that on average one fuel pin per 100 fuel bundles for all batches of spent fuel transported to the encapsulation facility is leaking. The release magnitude in incidents and accidents is based on the event chains, which lead to loss of fuel pin tightness followed by a discharge of radionuclides into the handling space and to some degree to the atmosphere through the ventilation stack equipped with redundant filters. The critical group is conservatively assumed to live at the distance of 200 meters from the encapsulation and disposal plant and thus it will receive the largest doses in most dispersion conditions. The dose value to a member of the critical group was calculated on the basis of the weather data in such a way that greater dose than obtained here is caused only in 0.5 percent of dispersion conditions. The results obtained indicate that during normal operation the doses to workers remain small and the dose to the member of the critical group is less than 0,001 mSv per year. In the case of hypothetical fault and accident releases the offsite doses do not exceed either the limit values set by the safety authority. The highest dose rates to the reference organisms of the terrestrial ecosystem with conservative assumptions from the largest release were estimated to be of the order of 100 μ Gy/h at the distance of 200 m. As a chronic exposure this dose rate is expected to bring up detrimental

  19. Help prevent hospital errors

    Science.gov (United States)

    ... this page: //medlineplus.gov/ency/patientinstructions/000618.htm Help prevent hospital errors To use the sharing features ... in the hospital. If You Are Having Surgery, Help Keep Yourself Safe Go to a hospital you ...

  20. Pedal Application Errors

    Science.gov (United States)

    2012-03-01

    This project examined the prevalence of pedal application errors and the driver, vehicle, roadway and/or environmental characteristics associated with pedal misapplication crashes based on a literature review, analysis of news media reports, a panel ...

  1. Rounding errors in weighing

    International Nuclear Information System (INIS)

    Jeach, J.L.

    1976-01-01

    When rounding error is large relative to weighing error, it cannot be ignored when estimating scale precision and bias from calibration data. Further, if the data grouping is coarse, rounding error is correlated with weighing error and may also have a mean quite different from zero. These facts are taken into account in a moment estimation method. A copy of the program listing for the MERDA program that provides moment estimates is available from the author. Experience suggests that if the data fall into four or more cells or groups, it is not necessary to apply the moment estimation method. Rather, the estimate given by equation (3) is valid in this instance. 5 tables

  2. Spotting software errors sooner

    International Nuclear Information System (INIS)

    Munro, D.

    1989-01-01

    Static analysis is helping to identify software errors at an earlier stage and more cheaply than conventional methods of testing. RTP Software's MALPAS system also has the ability to check that a code conforms to its original specification. (author)

  3. Errors in energy bills

    International Nuclear Information System (INIS)

    Kop, L.

    2001-01-01

    On request, the Dutch Association for Energy, Environment and Water (VEMW) checks the energy bills for her customers. It appeared that in the year 2000 many small, but also big errors were discovered in the bills of 42 businesses

  4. Medical Errors Reduction Initiative

    National Research Council Canada - National Science Library

    Mutter, Michael L

    2005-01-01

    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...

  5. The surveillance error grid.

    Science.gov (United States)

    Klonoff, David C; Lias, Courtney; Vigersky, Robert; Clarke, William; Parkes, Joan Lee; Sacks, David B; Kirkman, M Sue; Kovatchev, Boris

    2014-07-01

    Currently used error grids for assessing clinical accuracy of blood glucose monitors are based on out-of-date medical practices. Error grids have not been widely embraced by regulatory agencies for clearance of monitors, but this type of tool could be useful for surveillance of the performance of cleared products. Diabetes Technology Society together with representatives from the Food and Drug Administration, the American Diabetes Association, the Endocrine Society, and the Association for the Advancement of Medical Instrumentation, and representatives of academia, industry, and government, have developed a new error grid, called the surveillance error grid (SEG) as a tool to assess the degree of clinical risk from inaccurate blood glucose (BG) monitors. A total of 206 diabetes clinicians were surveyed about the clinical risk of errors of measured BG levels by a monitor. The impact of such errors on 4 patient scenarios was surveyed. Each monitor/reference data pair was scored and color-coded on a graph per its average risk rating. Using modeled data representative of the accuracy of contemporary meters, the relationships between clinical risk and monitor error were calculated for the Clarke error grid (CEG), Parkes error grid (PEG), and SEG. SEG action boundaries were consistent across scenarios, regardless of whether the patient was type 1 or type 2 or using insulin or not. No significant differences were noted between responses of adult/pediatric or 4 types of clinicians. Although small specific differences in risk boundaries between US and non-US clinicians were noted, the panel felt they did not justify separate grids for these 2 types of clinicians. The data points of the SEG were classified in 15 zones according to their assigned level of risk, which allowed for comparisons with the classic CEG and PEG. Modeled glucose monitor data with realistic self-monitoring of blood glucose errors derived from meter testing experiments plotted on the SEG when compared to

  6. Design for Error Tolerance

    DEFF Research Database (Denmark)

    Rasmussen, Jens

    1983-01-01

    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....

  7. Apologies and Medical Error

    Science.gov (United States)

    2008-01-01

    One way in which physicians can respond to a medical error is to apologize. Apologies—statements that acknowledge an error and its consequences, take responsibility, and communicate regret for having caused harm—can decrease blame, decrease anger, increase trust, and improve relationships. Importantly, apologies also have the potential to decrease the risk of a medical malpractice lawsuit and can help settle claims by patients. Patients indicate they want and expect explanations and apologies after medical errors and physicians indicate they want to apologize. However, in practice, physicians tend to provide minimal information to patients after medical errors and infrequently offer complete apologies. Although fears about potential litigation are the most commonly cited barrier to apologizing after medical error, the link between litigation risk and the practice of disclosure and apology is tenuous. Other barriers might include the culture of medicine and the inherent psychological difficulties in facing one’s mistakes and apologizing for them. Despite these barriers, incorporating apology into conversations between physicians and patients can address the needs of both parties and can play a role in the effective resolution of disputes related to medical error. PMID:18972177

  8. Thermodynamics of Error Correction

    Directory of Open Access Journals (Sweden)

    Pablo Sartori

    2015-12-01

    Full Text Available Information processing at the molecular scale is limited by thermal fluctuations. This can cause undesired consequences in copying information since thermal noise can lead to errors that can compromise the functionality of the copy. For example, a high error rate during DNA duplication can lead to cell death. Given the importance of accurate copying at the molecular scale, it is fundamental to understand its thermodynamic features. In this paper, we derive a universal expression for the copy error as a function of entropy production and work dissipated by the system during wrong incorporations. Its derivation is based on the second law of thermodynamics; hence, its validity is independent of the details of the molecular machinery, be it any polymerase or artificial copying device. Using this expression, we find that information can be copied in three different regimes. In two of them, work is dissipated to either increase or decrease the error. In the third regime, the protocol extracts work while correcting errors, reminiscent of a Maxwell demon. As a case study, we apply our framework to study a copy protocol assisted by kinetic proofreading, and show that it can operate in any of these three regimes. We finally show that, for any effective proofreading scheme, error reduction is limited by the chemical driving of the proofreading reaction.

  9. Soft error mechanisms, modeling and mitigation

    CERN Document Server

    Sayil, Selahattin

    2016-01-01

    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...

  10. Chernobyl - system accident or human error?

    International Nuclear Information System (INIS)

    Stang, E.

    1996-01-01

    Did human error cause the Chernobyl disaster? The standard point of view is that operator error was the root cause of the disaster. This was also the view of the Soviet Accident Commission. The paper analyses the operator errors at Chernobyl in a system context. The reactor operators committed errors that depended upon a lot of other failures that made up a complex accident scenario. The analysis is based on Charles Perrow's analysis of technological disasters. Failure possibility is an inherent property of high-risk industrial installations. The Chernobyl accident consisted of a chain of events that were both extremely improbable and difficult to predict. It is not reasonable to put the blame for the disaster on the operators. (author)

  11. EVENT PLANNING USING FUNCTION ANALYSIS

    Energy Technology Data Exchange (ETDEWEB)

    Lori Braase; Jodi Grgich

    2011-06-01

    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.

  12. Learning from Errors

    Directory of Open Access Journals (Sweden)

    MA. Lendita Kryeziu

    2015-06-01

    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. Compact disk error measurements

    Science.gov (United States)

    Howe, D.; Harriman, K.; Tehranchi, B.

    1993-01-01

    The objectives of this project are as follows: provide hardware and software that will perform simple, real-time, high resolution (single-byte) measurement of the error burst and good data gap statistics seen by a photoCD player read channel when recorded CD write-once discs of variable quality (i.e., condition) are being read; extend the above system to enable measurement of the hard decision (i.e., 1-bit error flags) and soft decision (i.e., 2-bit error flags) decoding information that is produced/used by the Cross Interleaved - Reed - Solomon - Code (CIRC) block decoder employed in the photoCD player read channel; construct a model that uses data obtained via the systems described above to produce meaningful estimates of output error rates (due to both uncorrected ECC words and misdecoded ECC words) when a CD disc having specific (measured) error statistics is read (completion date to be determined); and check the hypothesis that current adaptive CIRC block decoders are optimized for pressed (DAD/ROM) CD discs. If warranted, do a conceptual design of an adaptive CIRC decoder that is optimized for write-once CD discs.

  14. Event Investigation

    International Nuclear Information System (INIS)

    Korosec, D.

    2000-01-01

    The events in the nuclear industry are investigated from the license point of view and from the regulatory side too. It is well known the importance of the event investigation. One of the main goals of such investigation is to prevent the circumstances leading to the event and the consequences of the event. The protection of the nuclear workers against nuclear hazard, and the protection of general public against dangerous effects of an event could be achieved by systematic approach to the event investigation. Both, the nuclear safety regulatory body and the licensee shall ensure that operational significant events are investigated in a systematic and technically sound manner to gather information pertaining to the probable causes of the event. One of the results should be appropriate feedback regarding the lessons of the experience to the regulatory body, nuclear industry and general public. In the present paper a general description of systematic approach to the event investigation is presented. The systematic approach to the event investigation works best where cooperation is present among the different divisions of the nuclear facility or regulatory body. By involving management and supervisors the safety office can usually improve their efforts in the whole process. The end result shall be a program which serves to prevent events and reduce the time and efforts solving the root cause which initiated each event. Selection of the proper method for the investigation and an adequate review of the findings and conclusions lead to the higher level of the overall nuclear safety. (author)

  15. Single event phenomena in atmospheric neutron environments

    International Nuclear Information System (INIS)

    Gossett, C.A.; Hughlock, B.W.; Katoozi, M.; LaRue, G.S.; Wender, S.A.

    1993-01-01

    As integrated circuit technology achieves higher density through smaller feature sizes and as the airplane manufacturing industry integrates more sophisticated electronic components into the design of new aircraft, it has become increasingly important to evaluate the contribution of single event effects, primarily Single Event Upset (SEU), to the safety and reliability of commercial aircraft. In contrast to the effects of radiation on electronic systems in space applications for which protons and heavy ions are of major concern, in commercial aircraft applications the interactions of high energy neutrons are the dominant cause of single event effects. These high energy neutrons are produced by the interaction of solar and galactic cosmic rays, principally protons and heavy ions, in the upper atmosphere. This paper will describe direct experimental measurements of neutron-induced Single Event Effect (SEE) rates in commercial high density static random access memories in a neutron environment characteristic of that at commercial airplane altitudes. The first experimental measurements testing current models for neutron-silicon burst generation rates will be presented, as well as measurements of charge collection in silicon test structures as a function of neutron energy. These are the first laboratory SEE and charge collection measurements using a particle beam having a continuum energy spectrum and with a shape nearly identical to that observed during flight

  16. Drought Persistence Errors in Global Climate Models

    Science.gov (United States)

    Moon, H.; Gudmundsson, L.; Seneviratne, S. I.

    2018-04-01

    The persistence of drought events largely determines the severity of socioeconomic and ecological impacts, but the capability of current global climate models (GCMs) to simulate such events is subject to large uncertainties. In this study, the representation of drought persistence in GCMs is assessed by comparing state-of-the-art GCM model simulations to observation-based data sets. For doing so, we consider dry-to-dry transition probabilities at monthly and annual scales as estimates for drought persistence, where a dry status is defined as negative precipitation anomaly. Though there is a substantial spread in the drought persistence bias, most of the simulations show systematic underestimation of drought persistence at global scale. Subsequently, we analyzed to which degree (i) inaccurate observations, (ii) differences among models, (iii) internal climate variability, and (iv) uncertainty of the employed statistical methods contribute to the spread in drought persistence errors using an analysis of variance approach. The results show that at monthly scale, model uncertainty and observational uncertainty dominate, while the contribution from internal variability is small in most cases. At annual scale, the spread of the drought persistence error is dominated by the statistical estimation error of drought persistence, indicating that the partitioning of the error is impaired by the limited number of considered time steps. These findings reveal systematic errors in the representation of drought persistence in current GCMs and suggest directions for further model improvement.

  17. LIBERTARISMO & ERROR CATEGORIAL

    Directory of Open Access Journals (Sweden)

    Carlos G. Patarroyo G.

    2009-01-01

    Full Text Available En este artículo se ofrece una defensa del libertarismo frente a dos acusaciones según las cuales éste comete un error categorial. Para ello, se utiliza la filosofía de Gilbert Ryle como herramienta para explicar las razones que fundamentan estas acusaciones y para mostrar por qué, pese a que ciertas versiones del libertarismo que acuden a la causalidad de agentes o al dualismo cartesiano cometen estos errores, un libertarismo que busque en el indeterminismo fisicalista la base de la posibilidad de la libertad humana no necesariamente puede ser acusado de incurrir en ellos.

  18. Libertarismo & Error Categorial

    OpenAIRE

    PATARROYO G, CARLOS G

    2009-01-01

    En este artículo se ofrece una defensa del libertarismo frente a dos acusaciones según las cuales éste comete un error categorial. Para ello, se utiliza la filosofía de Gilbert Ryle como herramienta para explicar las razones que fundamentan estas acusaciones y para mostrar por qué, pese a que ciertas versiones del libertarismo que acuden a la causalidad de agentes o al dualismo cartesiano cometen estos errores, un libertarismo que busque en el indeterminismo fisicalista la base de la posibili...

  19. Error Free Software

    Science.gov (United States)

    1985-01-01

    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.

  20. Trial application of a technique for human error analysis (ATHEANA)

    International Nuclear Information System (INIS)

    Bley, D.C.; Cooper, S.E.; Parry, G.W.

    1996-01-01

    The new method for HRA, ATHEANA, has been developed based on a study of the operating history of serious accidents and an understanding of the reasons why people make errors. Previous publications associated with the project have dealt with the theoretical framework under which errors occur and the retrospective analysis of operational events. This is the first attempt to use ATHEANA in a prospective way, to select and evaluate human errors within the PSA context

  1. DETECTING AND REPORTING THE FRAUDS AND ERRORS BY THE AUDITOR

    OpenAIRE

    Ovidiu Constantin Bunget; Alin Constantin Dumitrescu

    2009-01-01

    Responsibility for preventing and detecting fraud rest with management entities.Although the auditor is not and cannot be held responsible for preventing fraud and errors, in yourwork, he can have a positive role in preventing fraud and errors by deterring their occurrence. Theauditor should plan and perform the audit with an attitude of professional skepticism, recognizingthat condition or events may be found that indicate that fraud or error may exist.Based on the audit risk assessment, aud...

  2. 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

    2002-01-01

    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

  3. Error Correcting Codes

    Indian Academy of Sciences (India)

    Science and Automation at ... the Reed-Solomon code contained 223 bytes of data, (a byte ... then you have a data storage system with error correction, that ..... practical codes, storing such a table is infeasible, as it is generally too large.

  4. 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 ... Author Affiliations. Priti Shankar1. Department of Computer Science and Automation, Indian Institute of Science, Bangalore 560 012, India ...

  5. Technical errors and complications in orthopaedic trauma surgery

    NARCIS (Netherlands)

    Meeuwis, M.A.; de Jongh, M.A.C.; Roukema, J.A.; van der Heijden, F.H.W.M.; Verhofstad, M. H. J.

    2016-01-01

    Introduction Adverse events and associated morbidity and subsequent costs receive increasing attention in clinical practice and research. As opposed to complications, errors are not described or analysed in literature on fracture surgery. The aim of this study was to provide a description of errors

  6. The Eric Cantor Upset

    DEFF Research Database (Denmark)

    Ashbee, Edward

    2014-01-01

    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...

  7. Representing cognitive activities and errors in HRA trees

    International Nuclear Information System (INIS)

    Gertman, D.I.

    1992-01-01

    A graphic representation method is presented herein for adapting an existing technology--human reliability analysis (HRA) event trees, used to support event sequence logic structures and calculations--to include a representation of the underlying cognitive activity and corresponding errors associated with human performance. The analyst is presented with three potential means of representing human activity: the NUREG/CR-1278 HRA event tree approach; the skill-, rule- and knowledge-based paradigm; and the slips, lapses, and mistakes paradigm. The above approaches for representing human activity are integrated in order to produce an enriched HRA event tree -- the cognitive event tree system (COGENT)-- which, in turn, can be used to increase the analyst's understanding of the basic behavioral mechanisms underlying human error and the representation of that error in probabilistic risk assessment. Issues pertaining to the implementation of COGENT are also discussed

  8. Event Modeling

    DEFF Research Database (Denmark)

    Bækgaard, Lars

    2001-01-01

    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...

  9. Imagery of Errors in Typing

    Science.gov (United States)

    Rieger, Martina; Martinez, Fanny; Wenke, Dorit

    2011-01-01

    Using a typing task we investigated whether insufficient imagination of errors and error corrections is related to duration differences between execution and imagination. In Experiment 1 spontaneous error imagination was investigated, whereas in Experiment 2 participants were specifically instructed to imagine errors. Further, in Experiment 2 we…

  10. Correction of refractive errors

    Directory of Open Access Journals (Sweden)

    Vladimir Pfeifer

    2005-10-01

    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.

  11. Error-Free Software

    Science.gov (United States)

    1989-01-01

    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.

  12. Minimum Tracking Error Volatility

    OpenAIRE

    Luca RICCETTI

    2010-01-01

    Investors assign part of their funds to asset managers that are given the task of beating a benchmark. The risk management department usually imposes a maximum value of the tracking error volatility (TEV) in order to keep the risk of the portfolio near to that of the selected benchmark. However, risk management does not establish a rule on TEV which enables us to understand whether the asset manager is really active or not and, in practice, asset managers sometimes follow passively the corres...

  13. Error-correction coding

    Science.gov (United States)

    Hinds, Erold W. (Principal Investigator)

    1996-01-01

    This report describes the progress made towards the completion of a specific task on error-correcting coding. The proposed research consisted of investigating the use of modulation block codes as the inner code of a concatenated coding system in order to improve the overall space link communications performance. The study proposed to identify and analyze candidate codes that will complement the performance of the overall coding system which uses the interleaved RS (255,223) code as the outer code.

  14. Satellite Photometric Error Determination

    Science.gov (United States)

    2015-10-18

    Satellite Photometric Error Determination Tamara E. Payne, Philip J. Castro, Stephen A. Gregory Applied Optimization 714 East Monument Ave, Suite...advocate the adoption of new techniques based on in-frame photometric calibrations enabled by newly available all-sky star catalogs that contain highly...filter systems will likely be supplanted by the Sloan based filter systems. The Johnson photometric system is a set of filters in the optical

  15. Video Error Correction Using Steganography

    Science.gov (United States)

    Robie, David L.; Mersereau, Russell M.

    2002-12-01

    The transmission of any data is always subject to corruption due to errors, but video transmission, because of its real time nature must deal with these errors without retransmission of the corrupted data. The error can be handled using forward error correction in the encoder or error concealment techniques in the decoder. This MPEG-2 compliant codec uses data hiding to transmit error correction information and several error concealment techniques in the decoder. The decoder resynchronizes more quickly with fewer errors than traditional resynchronization techniques. It also allows for perfect recovery of differentially encoded DCT-DC components and motion vectors. This provides for a much higher quality picture in an error-prone environment while creating an almost imperceptible degradation of the picture in an error-free environment.

  16. Video Error Correction Using Steganography

    Directory of Open Access Journals (Sweden)

    Robie David L

    2002-01-01

    Full Text Available The transmission of any data is always subject to corruption due to errors, but video transmission, because of its real time nature must deal with these errors without retransmission of the corrupted data. The error can be handled using forward error correction in the encoder or error concealment techniques in the decoder. This MPEG-2 compliant codec uses data hiding to transmit error correction information and several error concealment techniques in the decoder. The decoder resynchronizes more quickly with fewer errors than traditional resynchronization techniques. It also allows for perfect recovery of differentially encoded DCT-DC components and motion vectors. This provides for a much higher quality picture in an error-prone environment while creating an almost imperceptible degradation of the picture in an error-free environment.

  17. Threat and error management for anesthesiologists: a predictive risk taxonomy

    Science.gov (United States)

    Ruskin, Keith J.; Stiegler, Marjorie P.; Park, Kellie; Guffey, Patrick; Kurup, Viji; Chidester, Thomas

    2015-01-01

    Purpose of review Patient care in the operating room is a dynamic interaction that requires cooperation among team members and reliance upon sophisticated technology. Most human factors research in medicine has been focused on analyzing errors and implementing system-wide changes to prevent them from recurring. We describe a set of techniques that has been used successfully by the aviation industry to analyze errors and adverse events and explain how these techniques can be applied to patient care. Recent findings Threat and error management (TEM) describes adverse events in terms of risks or challenges that are present in an operational environment (threats) and the actions of specific personnel that potentiate or exacerbate those threats (errors). TEM is a technique widely used in aviation, and can be adapted for the use in a medical setting to predict high-risk situations and prevent errors in the perioperative period. A threat taxonomy is a novel way of classifying and predicting the hazards that can occur in the operating room. TEM can be used to identify error-producing situations, analyze adverse events, and design training scenarios. Summary TEM offers a multifaceted strategy for identifying hazards, reducing errors, and training physicians. A threat taxonomy may improve analysis of critical events with subsequent development of specific interventions, and may also serve as a framework for training programs in risk mitigation. PMID:24113268

  18. Abnormal error monitoring in math-anxious individuals: evidence from error-related brain potentials.

    Directory of Open Access Journals (Sweden)

    Macarena Suárez-Pellicioni

    Full Text Available This study used event-related brain potentials to investigate whether math anxiety is related to abnormal error monitoring processing. Seventeen high math-anxious (HMA and seventeen low math-anxious (LMA individuals were presented with a numerical and a classical Stroop task. Groups did not differ in terms of trait or state anxiety. We found enhanced error-related negativity (ERN in the HMA group when subjects committed an error on the numerical Stroop task, but not on the classical Stroop task. Groups did not differ in terms of the correct-related negativity component (CRN, the error positivity component (Pe, classical behavioral measures or post-error measures. The amplitude of the ERN was negatively related to participants' math anxiety scores, showing a more negative amplitude as the score increased. Moreover, using standardized low resolution electromagnetic tomography (sLORETA we found greater activation of the insula in errors on a numerical task as compared to errors in a non-numerical task only for the HMA group. The results were interpreted according to the motivational significance theory of the ERN.

  19. Interval sampling methods and measurement error: a computer simulation.

    Science.gov (United States)

    Wirth, Oliver; Slaven, James; Taylor, Matthew A

    2014-01-01

    A simulation study was conducted to provide a more thorough account of measurement error associated with interval sampling methods. A computer program simulated the application of momentary time sampling, partial-interval recording, and whole-interval recording methods on target events randomly distributed across an observation period. The simulation yielded measures of error for multiple combinations of observation period, interval duration, event duration, and cumulative event duration. The simulations were conducted up to 100 times to yield measures of error variability. Although the present simulation confirmed some previously reported characteristics of interval sampling methods, it also revealed many new findings that pertain to each method's inherent strengths and weaknesses. The analysis and resulting error tables can help guide the selection of the most appropriate sampling method for observation-based behavioral assessments. © Society for the Experimental Analysis of Behavior.

  20. Diagnostic errors in pediatric radiology

    International Nuclear Information System (INIS)

    Taylor, George A.; Voss, Stephan D.; Melvin, Patrice R.; Graham, Dionne A.

    2011-01-01

    Little information is known about the frequency, types and causes of diagnostic errors in imaging children. Our goals were to describe the patterns and potential etiologies of diagnostic error in our subspecialty. We reviewed 265 cases with clinically significant diagnostic errors identified during a 10-year period. Errors were defined as a diagnosis that was delayed, wrong or missed; they were classified as perceptual, cognitive, system-related or unavoidable; and they were evaluated by imaging modality and level of training of the physician involved. We identified 484 specific errors in the 265 cases reviewed (mean:1.8 errors/case). Most discrepancies involved staff (45.5%). Two hundred fifty-eight individual cognitive errors were identified in 151 cases (mean = 1.7 errors/case). Of these, 83 cases (55%) had additional perceptual or system-related errors. One hundred sixty-five perceptual errors were identified in 165 cases. Of these, 68 cases (41%) also had cognitive or system-related errors. Fifty-four system-related errors were identified in 46 cases (mean = 1.2 errors/case) of which all were multi-factorial. Seven cases were unavoidable. Our study defines a taxonomy of diagnostic errors in a large academic pediatric radiology practice and suggests that most are multi-factorial in etiology. Further study is needed to define effective strategies for improvement. (orig.)

  1. A preliminary taxonomy of medical errors in family practice.

    Science.gov (United States)

    Dovey, S M; Meyers, D S; Phillips, R L; Green, L A; Fryer, G E; Galliher, J M; Kappus, J; Grob, P

    2002-09-01

    To develop a preliminary taxonomy of primary care medical errors. Qualitative analysis to identify categories of error reported during a randomized controlled trial of computer and paper reporting methods. The National Network for Family Practice and Primary Care Research. Family physicians. Medical error category, context, and consequence. Forty two physicians made 344 reports: 284 (82.6%) arose from healthcare systems dysfunction; 46 (13.4%) were errors due to gaps in knowledge or skills; and 14 (4.1%) were reports of adverse events, not errors. The main subcategories were: administrative failure (102; 30.9% of errors), investigation failures (82; 24.8%), treatment delivery lapses (76; 23.0%), miscommunication (19; 5.8%), payment systems problems (4; 1.2%), error in the execution of a clinical task (19; 5.8%), wrong treatment decision (14; 4.2%), and wrong diagnosis (13; 3.9%). Most reports were of errors that were recognized and occurred in reporters' practices. Affected patients ranged in age from 8 months to 100 years, were of both sexes, and represented all major US ethnic groups. Almost half the reports were of events which had adverse consequences. Ten errors resulted in patients being admitted to hospital and one patient died. This medical error taxonomy, developed from self-reports of errors observed by family physicians during their routine clinical practice, emphasizes problems in healthcare processes and acknowledges medical errors arising from shortfalls in clinical knowledge and skills. Patient safety strategies with most effect in primary care settings need to be broader than the current focus on medication errors.

  2. Minimum Error Entropy Classification

    CERN Document Server

    Marques de Sá, Joaquim P; Santos, Jorge M F; Alexandre, Luís A

    2013-01-01

    This book explains the minimum error entropy (MEE) concept applied to data classification machines. Theoretical results on the inner workings of the MEE concept, in its application to solving a variety of classification problems, are presented in the wider realm of risk functionals. Researchers and practitioners also find in the book a detailed presentation of practical data classifiers using MEE. These include multi‐layer perceptrons, recurrent neural networks, complexvalued neural networks, modular neural networks, and decision trees. A clustering algorithm using a MEE‐like concept is also presented. Examples, tests, evaluation experiments and comparison with similar machines using classic approaches, complement the descriptions.

  3. A chance to avoid mistakes human error

    International Nuclear Information System (INIS)

    Amaro, Pablo; Obeso, Eduardo; Gomez, Ruben

    2010-01-01

    human factor contribution to the events 'The explanations of the error': The evolution of the human error concept and which are the causes that are behind him, are presented in this chapter. Several examples try to facilitate understanding. In the appendix II, we present a series of 'Cause Codes' used in the industry, trying to aid to the technicians when they are assessing and researching events. 'The battle against error': Its the main objective of the book. Present one after other, the tools that are managed in the nuclear industry in a practical way. What's, Who have to use it and When to use it, are described with sufficient detail so that anyone can assimilated the tool and, if is applicable, look for the implementation in his organization. (authors)

  4. [Adverse events prevention ability].

    Science.gov (United States)

    Aparo, Ugo Luigi; Aparo, Andrea

    2007-03-01

    The issue of how to address medical errors is the key to improve the health care system performances. Operational evidence collected in the last five years shows that the solution is only partially linked to future technological developments. Cultural and organisational changes are mandatory to help to manage and drastically reduce the adverse events in health care organisations. Classical management, merely based on coordination and control, is inadequate. Proactive, self-organising network based structures must be put in place and managed using adaptive, fast evolving management tools.

  5. Standard Errors for Matrix Correlations.

    Science.gov (United States)

    Ogasawara, Haruhiko

    1999-01-01

    Derives the asymptotic standard errors and intercorrelations for several matrix correlations assuming multivariate normality for manifest variables and derives the asymptotic standard errors of the matrix correlations for two factor-loading matrices. (SLD)

  6. Error forecasting schemes of error correction at receiver

    International Nuclear Information System (INIS)

    Bhunia, C.T.

    2007-08-01

    To combat error in computer communication networks, ARQ (Automatic Repeat Request) techniques are used. Recently Chakraborty has proposed a simple technique called the packet combining scheme in which error is corrected at the receiver from the erroneous copies. Packet Combining (PC) scheme fails: (i) when bit error locations in erroneous copies are the same and (ii) when multiple bit errors occur. Both these have been addressed recently by two schemes known as Packet Reversed Packet Combining (PRPC) Scheme, and Modified Packet Combining (MPC) Scheme respectively. In the letter, two error forecasting correction schemes are reported, which in combination with PRPC offer higher throughput. (author)

  7. Evaluating a medical error taxonomy.

    OpenAIRE

    Brixey, Juliana; Johnson, Todd R.; Zhang, Jiajie

    2002-01-01

    Healthcare has been slow in using human factors principles to reduce medical errors. The Center for Devices and Radiological Health (CDRH) recognizes that a lack of attention to human factors during product development may lead to errors that have the potential for patient injury, or even death. In response to the need for reducing medication errors, the National Coordinating Council for Medication Errors Reporting and Prevention (NCC MERP) released the NCC MERP taxonomy that provides a stand...

  8. Analysis of Employee's Survey for Preventing Human-Errors

    International Nuclear Information System (INIS)

    Sung, Chanho; Kim, Younggab; Joung, Sanghoun

    2013-01-01

    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

  9. 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

    2010-01-01

    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.

  10. Error Patterns in Problem Solving.

    Science.gov (United States)

    Babbitt, Beatrice C.

    Although many common problem-solving errors within the realm of school mathematics have been previously identified, a compilation of such errors is not readily available within learning disabilities textbooks, mathematics education texts, or teacher's manuals for school mathematics texts. Using data on error frequencies drawn from both the Fourth…

  11. Performance, postmodernity and errors

    DEFF Research Database (Denmark)

    Harder, Peter

    2013-01-01

    speaker’s competency (note the –y ending!) reflects adaptation to the community langue, including variations. This reversal of perspective also reverses our understanding of the relationship between structure and deviation. In the heyday of structuralism, it was tempting to confuse the invariant system...... 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....

  12. Analysis of cosmic ray neutron-induced single-event phenomena

    International Nuclear Information System (INIS)

    Tukamoto, Yasuyuki; Watanabe, Yukinobu; Nakashima, Hideki

    2003-01-01

    We have developed a database of cross sections for the n+ 28 Si reaction in the energy range between 2 MeV and 3 GeV in order to analyze single-event upset (SEU) phenomena induced by cosmic-ray neutrons in semiconductor memory devices. The data are applied to calculations of SEU cross sections using the Burst Generation Rate (BGR) model including two parameters, critical charge and effective depth. The calculated results are compared with measured SEU cross-sections for energies up to 160 MeV, and the reaction products that provide important effects on SEU are mainly investigated. (author)

  13. FDA Adverse Event Reporting System (FAERS): Latest Quartely Data Files

    Data.gov (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...

  14. Fusion events

    International Nuclear Information System (INIS)

    Aboufirassi, M; Angelique, J.C.; Bizard, G.; Bougault, R.; Brou, R.; Buta, A.; Colin, J.; Cussol, D.; Durand, D.; Genoux-Lubain, A.; Horn, D.; Kerambrun, A.; Laville, J.L.; Le Brun, C.; Lecolley, J.F.; Lefebvres, F.; Lopez, O.; Louvel, M.; Meslin, C.; Metivier, V.; Nakagawa, T.; Peter, J.; Popescu, R.; Regimbart, R.; Steckmeyer, J.C.; Tamain, B.; Vient, E.; Wieloch, A.; Yuasa-Nakagawa, K.

    1998-01-01

    The fusion reactions between low energy heavy ions have a very high cross section. First measurements at energies around 30-40 MeV/nucleon indicated no residue of either complete or incomplete fusion, thus demonstrating the disappearance of this process. This is explained as being due to the high amount o energies transferred to the nucleus, what leads to its total dislocation in light fragments and particles. Exclusive analyses have permitted to mark clearly the presence of fusion processes in heavy systems at energies above 30-40 MeV/nucleon. Among the complete events of the Kr + Au reaction at 60 MeV/nucleon the majority correspond to binary collisions. Nevertheless, for the most considerable energy losses, a class of events do occur for which the detected fragments appears to be emitted from a unique source. These events correspond to an incomplete projectile-target fusion followed by a multifragmentation. Such events were singled out also in the reaction Xe + Sn at 50 MeV/nucleon. For the events in which the energy dissipation was maximal it was possible to isolate an isotropic group of events showing all the characteristics of fusion nuclei. The fusion is said to be incomplete as pre-equilibrium Z = 1 and Z = 2 particles are emitted. The cross section is of the order of 25 mb. Similar conclusions were drown for the systems 36 Ar + 27 Al and 64 Zn + nat Ti. A cross section value of ∼ 20 mb was determined at 55 MeV/nucleon in the first case, while the measurement of evaporation light residues in the last system gave an upper limit of 20-30 mb for the cross section at 50 MeV/nucleon

  15. Soft error rate estimations of the Kintex-7 FPGA within the ATLAS Liquid Argon (LAr) Calorimeter

    International Nuclear Information System (INIS)

    Wirthlin, M J; Harding, A; Takai, H

    2014-01-01

    This paper summarizes the radiation testing performed on the Xilinx Kintex-7 FPGA in an effort to determine if the Kintex-7 can be used within the ATLAS Liquid Argon (LAr) Calorimeter. The Kintex-7 device was tested with wide-spectrum neutrons, protons, heavy-ions, and mixed high-energy hadron environments. The results of these tests were used to estimate the configuration ram and block ram upset rate within the ATLAS LAr. These estimations suggest that the configuration memory will upset at a rate of 1.1 × 10 −10 upsets/bit/s and the bram memory will upset at a rate of 9.06 × 10 −11 upsets/bit/s. For the Kintex 7K325 device, this translates to 6.85 × 10 −3 upsets/device/s for configuration memory and 1.49 × 10 −3 for block memory

  16. Analysis for Human-related Events during the Overhaul

    Energy Technology Data Exchange (ETDEWEB)

    Kim, Ji Tae; Kim, Min Chull; Choi, Dong Won; Lee, Durk Hun [Korea Institute of Nuclear Safety, Daejeon (Korea, Republic of)

    2011-10-15

    The event frequency due to human error is decreasing among 20 operating Nuclear Power Plants (NPPs) excluding the NPP (Shin-Kori unit-1) in the commissioning stage since 2008. However, the events due to human error during an overhaul (O/H) occur annually (see Table I). An analysis for human-related events during the O/H was performed. Similar problems were identified for each event from the analysis and also, organizational and safety cultural factors were also identified

  17. Multiple cell upset cross-section modeling: A possible interpretation for the role of the ion energy-loss straggling and Auger recombination

    International Nuclear Information System (INIS)

    Zebrev, G.I.; Zemtsov, K.S.

    2016-01-01

    We found that the energy deposition fluctuations in the sensitive volumes may cause the multiple cell upset (MCU) multiplicity scatter in the nanoscale (with feature sizes less than 100 nm) memories. A microdosimetric model of the MCU cross-section dependence on LET is proposed. It was shown that ideally a staircase-shaped cross-section vs LET curve spreads due to the energy-loss straggling impact into a quasi-linear dependence with a slope depending on the memory cell area, the cell critical energy and efficiency of charge collection. This paper also presents a new model of the Auger recombination as a limiting process of the electron–hole charge yield, especially at the high-LET ion impact. A modified form of the MCU cross-section vs LET data interpolation is proposed, discussed and validated.

  18. Multiple cell upset cross-section modeling: A possible interpretation for the role of the ion energy-loss straggling and Auger recombination

    Energy Technology Data Exchange (ETDEWEB)

    Zebrev, G.I., E-mail: gizebrev@mephi.ru; Zemtsov, K.S.

    2016-08-11

    We found that the energy deposition fluctuations in the sensitive volumes may cause the multiple cell upset (MCU) multiplicity scatter in the nanoscale (with feature sizes less than 100 nm) memories. A microdosimetric model of the MCU cross-section dependence on LET is proposed. It was shown that ideally a staircase-shaped cross-section vs LET curve spreads due to the energy-loss straggling impact into a quasi-linear dependence with a slope depending on the memory cell area, the cell critical energy and efficiency of charge collection. This paper also presents a new model of the Auger recombination as a limiting process of the electron–hole charge yield, especially at the high-LET ion impact. A modified form of the MCU cross-section vs LET data interpolation is proposed, discussed and validated.

  19. Controlling errors in unidosis carts

    Directory of Open Access Journals (Sweden)

    Inmaculada Díaz Fernández

    2010-01-01

    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%.

  20. Error sensitivity analysis in 10-30-day extended range forecasting by using a nonlinear cross-prediction error model

    Science.gov (United States)

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

    2017-06-01

    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.

  1. Prioritising interventions against medication errors

    DEFF Research Database (Denmark)

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

    errors are therefore needed. Development of definition: A definition of medication errors including an index of error types for each stage in the medication process was developed from existing terminology and through a modified Delphi-process in 2008. The Delphi panel consisted of 25 interdisciplinary......Abstract Authors: Lisby M, Larsen LP, Soerensen AL, Nielsen LP, Mainz J Title: Prioritising interventions against medication errors – the importance of a definition Objective: To develop and test a restricted definition of medication errors across health care settings in Denmark Methods: Medication...... errors constitute a major quality and safety problem in modern healthcare. However, far from all are clinically important. The prevalence of medication errors ranges from 2-75% indicating a global problem in defining and measuring these [1]. New cut-of levels focusing the clinical impact of medication...

  2. Social aspects of clinical errors.

    Science.gov (United States)

    Richman, Joel; Mason, Tom; Mason-Whitehead, Elizabeth; McIntosh, Annette; Mercer, Dave

    2009-08-01

    Clinical errors, whether committed by doctors, nurses or other professions allied to healthcare, remain a sensitive issue requiring open debate and policy formulation in order to reduce them. The literature suggests that the issues underpinning errors made by healthcare professionals involve concerns about patient safety, professional disclosure, apology, litigation, compensation, processes of recording and policy development to enhance quality service. Anecdotally, we are aware of narratives of minor errors, which may well have been covered up and remain officially undisclosed whilst the major errors resulting in damage and death to patients alarm both professionals and public with resultant litigation and compensation. This paper attempts to unravel some of these issues by highlighting the historical nature of clinical errors and drawing parallels to contemporary times by outlining the 'compensation culture'. We then provide an overview of what constitutes a clinical error and review the healthcare professional strategies for managing such errors.

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

    Directory of Open Access Journals (Sweden)

    Takahiro eSoshi

    2015-01-01

    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

  4. The next organizational challenge: finding and addressing diagnostic error.

    Science.gov (United States)

    Graber, Mark L; Trowbridge, Robert; Myers, Jennifer S; Umscheid, Craig A; Strull, William; Kanter, Michael H

    2014-03-01

    Although health care organizations (HCOs) are intensely focused on improving the safety of health care, efforts to date have almost exclusively targeted treatment-related issues. The literature confirms that the approaches HCOs use to identify adverse medical events are not effective in finding diagnostic errors, so the initial challenge is to identify cases of diagnostic error. WHY HEALTH CARE ORGANIZATIONS NEED TO GET INVOLVED: HCOs are preoccupied with many quality- and safety-related operational and clinical issues, including performance measures. The case for paying attention to diagnostic errors, however, is based on the following four points: (1) diagnostic errors are common and harmful, (2) high-quality health care requires high-quality diagnosis, (3) diagnostic errors are costly, and (4) HCOs are well positioned to lead the way in reducing diagnostic error. FINDING DIAGNOSTIC ERRORS: Current approaches to identifying diagnostic errors, such as occurrence screens, incident reports, autopsy, and peer review, were not designed to detect diagnostic issues (or problems of omission in general) and/or rely on voluntary reporting. The realization that the existing tools are inadequate has spurred efforts to identify novel tools that could be used to discover diagnostic errors or breakdowns in the diagnostic process that are associated with errors. New approaches--Maine Medical Center's case-finding of diagnostic errors by facilitating direct reports from physicians and Kaiser Permanente's electronic health record--based reports that detect process breakdowns in the followup of abnormal findings--are described in case studies. By raising awareness and implementing targeted programs that address diagnostic error, HCOs may begin to play an important role in addressing the problem of diagnostic error.

  5. Errors in clinical laboratories or errors in laboratory medicine?

    Science.gov (United States)

    Plebani, Mario

    2006-01-01

    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

  6. Applicability of LET to single events in microelectronic structures

    Science.gov (United States)

    Xapsos, Michael A.

    1992-12-01

    LET is often used as a single parameter to determine the energy deposited in a microelectronic structure by a single event. The accuracy of this assumption is examined for ranges of ion energies and volumes of silicon appropriate for modern microelectronics. It is shown to be accurate only under very restricted conditions. Significant differences arise because (1) LET is related to energy lost by the ion, not energy deposited in the volume; and (2) LET is an average value and does not account for statistical variations in energy deposition. Criteria are suggested for determining when factors other than LET should be considered, and new analytical approaches are presented to account for them. One implication of these results is that improvements can be made in space upset rate predictions by incorporating the new methods into currently used codes such as CREME and CRUP.

  7. Errors in abdominal computed tomography

    International Nuclear Information System (INIS)

    Stephens, S.; Marting, I.; Dixon, A.K.

    1989-01-01

    Sixty-nine patients are presented in whom a substantial error was made on the initial abdominal computed tomography report. Certain features of these errors have been analysed. In 30 (43.5%) a lesion was simply not recognised (error of observation); in 39 (56.5%) the wrong conclusions were drawn about the nature of normal or abnormal structures (error of interpretation). The 39 errors of interpretation were more complex; in 7 patients an abnormal structure was noted but interpreted as normal, whereas in four a normal structure was thought to represent a lesion. Other interpretive errors included those where the wrong cause for a lesion had been ascribed (24 patients), and those where the abnormality was substantially under-reported (4 patients). Various features of these errors are presented and discussed. Errors were made just as often in relation to small and large lesions. Consultants made as many errors as senior registrar radiologists. It is like that dual reporting is the best method of avoiding such errors and, indeed, this is widely practised in our unit. (Author). 9 refs.; 5 figs.; 1 tab

  8. Error and discrepancy in radiology: inevitable or avoidable?

    OpenAIRE

    Brady, Adrian P.

    2016-01-01

    Abstract Errors and discrepancies in radiology practice are uncomfortably common, with an estimated day-to-day rate of 3?5% of studies reported, and much higher rates reported in many targeted studies. Nonetheless, the meaning of the terms ?error? and ?discrepancy? and the relationship to medical negligence are frequently misunderstood. This review outlines the incidence of such events, the ways they can be categorized to aid understanding, and potential contributing factors, both human- and ...

  9. Automated Testing with Targeted Event Sequence Generation

    DEFF Research Database (Denmark)

    Jensen, Casper Svenning; Prasad, Mukul R.; Møller, Anders

    2013-01-01

    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...

  10. Laboratory errors and patient safety.

    Science.gov (United States)

    Miligy, Dawlat A

    2015-01-01

    Laboratory data are extensively used in medical practice; consequently, laboratory errors have a tremendous impact on patient safety. Therefore, programs designed to identify and reduce laboratory errors, as well as, setting specific strategies are required to minimize these errors and improve patient safety. The purpose of this paper is to identify part of the commonly encountered laboratory errors throughout our practice in laboratory work, their hazards on patient health care and some measures and recommendations to minimize or to eliminate these errors. Recording the encountered laboratory errors during May 2008 and their statistical evaluation (using simple percent distribution) have been done in the department of laboratory of one of the private hospitals in Egypt. Errors have been classified according to the laboratory phases and according to their implication on patient health. Data obtained out of 1,600 testing procedure revealed that the total number of encountered errors is 14 tests (0.87 percent of total testing procedures). Most of the encountered errors lay in the pre- and post-analytic phases of testing cycle (representing 35.7 and 50 percent, respectively, of total errors). While the number of test errors encountered in the analytic phase represented only 14.3 percent of total errors. About 85.7 percent of total errors were of non-significant implication on patients health being detected before test reports have been submitted to the patients. On the other hand, the number of test errors that have been already submitted to patients and reach the physician represented 14.3 percent of total errors. Only 7.1 percent of the errors could have an impact on patient diagnosis. The findings of this study were concomitant with those published from the USA and other countries. This proves that laboratory problems are universal and need general standardization and bench marking measures. Original being the first data published from Arabic countries that

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

    Directory of Open Access Journals (Sweden)

    Martin eSpüler

    2015-03-01

    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.

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

    Science.gov (United States)

    Spüler, Martin; Niethammer, Christian

    2015-01-01

    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. PMID:25859204

  13. The magnitude and effects of extreme solar particle events

    Directory of Open Access Journals (Sweden)

    Jiggens Piers

    2014-06-01

    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.

  14. Risk analysis of brachytherapy events

    International Nuclear Information System (INIS)

    Buricova, P.; Zackova, H.; Hobzova, L.; Novotny, J.; Kindlova, A.

    2005-01-01

    For prevention radiological events it is necessary to identify hazardous situation and to analyse the nature of committed errors. Though the recommendation on the classification and prevention of radiological events: Radiological accidents has been prepared in the framework of Czech Society of Radiation Oncology, Biology and Physics and it was approved by Czech regulatory body (SONS) in 1999, only a few reports have been submitted up to now from brachytherapy practice. At the radiotherapy departments attention has been paid more likely to the problems of dominant teletherapy treatments. But in the two last decades the usage of brachytherapy methods has gradually increased because .nature of this treatment well as the possibilities of operating facility have been completely changed: new radionuclides of high activity are introduced and sophisticate afterloading systems controlled by computers are used. Consequently also the nature of errors, which can occurred in the clinical practice, has been changing. To determine the potentially hazardous parts of procedure the so-called 'process tree', which follows the flow of entire treatment process, has been created for most frequent type of applications. Marking the location of errors on the process tree indicates where failures occurred and accumulation of marks along branches show weak points in the process. Analysed data provide useful information to prevent medical events in brachytherapy .The results strength the requirements given in Recommendations of SONS and revealed the need for its amendment. They call especially for systematic registration of the events. (authors)

  15. Toward Joint Hypothesis-Tests Seismic Event Screening Analysis: Ms|mb and Event Depth

    Energy Technology Data Exchange (ETDEWEB)

    Anderson, Dale [Los Alamos National Laboratory; Selby, Neil [AWE Blacknest

    2012-08-14

    Well established theory can be used to combine single-phenomenology hypothesis tests into a multi-phenomenology event screening hypothesis test (Fisher's and Tippett's tests). Commonly used standard error in Ms:mb event screening hypothesis test is not fully consistent with physical basis. Improved standard error - Better agreement with physical basis, and correctly partitions error to include Model Error as a component of variance, correctly reduces station noise variance through network averaging. For 2009 DPRK test - Commonly used standard error 'rejects' H0 even with better scaling slope ({beta} = 1, Selby et al.), improved standard error 'fails to rejects' H0.

  16. Error and discrepancy in radiology: inevitable or avoidable?

    Science.gov (United States)

    Brady, Adrian P

    2017-02-01

    Errors and discrepancies in radiology practice are uncomfortably common, with an estimated day-to-day rate of 3-5% of studies reported, and much higher rates reported in many targeted studies. Nonetheless, the meaning of the terms "error" and "discrepancy" and the relationship to medical negligence are frequently misunderstood. This review outlines the incidence of such events, the ways they can be categorized to aid understanding, and potential contributing factors, both human- and system-based. Possible strategies to minimise error are considered, along with the means of dealing with perceived underperformance when it is identified. The inevitability of imperfection is explained, while the importance of striving to minimise such imperfection is emphasised. • Discrepancies between radiology reports and subsequent patient outcomes are not inevitably errors. • Radiologist reporting performance cannot be perfect, and some errors are inevitable. • Error or discrepancy in radiology reporting does not equate negligence. • Radiologist errors occur for many reasons, both human- and system-derived. • Strategies exist to minimise error causes and to learn from errors made.

  17. An error taxonomy system for analysis of haemodialysis incidents.

    Science.gov (United States)

    Gu, Xiuzhu; Itoh, Kenji; Suzuki, Satoshi

    2014-12-01

    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.

  18. Dopamine reward prediction error coding.

    Science.gov (United States)

    Schultz, Wolfram

    2016-03-01

    Reward prediction errors consist of the differences between received and predicted rewards. They are crucial for basic forms of learning about rewards and make us strive for more rewards-an evolutionary beneficial trait. Most dopamine neurons in the midbrain of humans, monkeys, and rodents signal a reward prediction error; they are activated by more reward than predicted (positive prediction error), remain at baseline activity for fully predicted rewards, and show depressed activity with less reward than predicted (negative prediction error). The dopamine signal increases nonlinearly with reward value and codes formal economic utility. Drugs of addiction generate, hijack, and amplify the dopamine reward signal and induce exaggerated, uncontrolled dopamine effects on neuronal plasticity. The striatum, amygdala, and frontal cortex also show reward prediction error coding, but only in subpopulations of neurons. Thus, the important concept of reward prediction errors is implemented in neuronal hardware.

  19. Architecture design for soft errors

    CERN Document Server

    Mukherjee, Shubu

    2008-01-01

    This book provides a comprehensive description of the architetural techniques to tackle the soft error problem. It covers the new methodologies for quantitative analysis of soft errors as well as novel, cost-effective architectural techniques to mitigate them. To provide readers with a better grasp of the broader problem deffinition and solution space, this book also delves into the physics of soft errors and reviews current circuit and software mitigation techniques.

  20. Dopamine reward prediction error coding

    OpenAIRE

    Schultz, Wolfram

    2016-01-01

    Reward prediction errors consist of the differences between received and predicted rewards. They are crucial for basic forms of learning about rewards and make us strive for more rewards?an evolutionary beneficial trait. Most dopamine neurons in the midbrain of humans, monkeys, and rodents signal a reward prediction error; they are activated by more reward than predicted (positive prediction error), remain at baseline activity for fully predicted rewards, and show depressed activity with less...

  1. Electrophysiological correlates of error processing in borderline personality disorder.

    Science.gov (United States)

    Ruchsow, Martin; Walter, Henrik; Buchheim, Anna; Martius, Philipp; Spitzer, Manfred; Kächele, Horst; Grön, Georg; Kiefer, Markus

    2006-05-01

    The electrophysiological correlates of error processing were investigated in patients with borderline personality disorder (BPD) using event-related potentials (ERP). Twelve patients with BPD and 12 healthy controls were additionally rated with the Barratt impulsiveness scale (BIS-10). Participants performed a Go/Nogo task while a 64 channel EEG was recorded. Three ERP components were of special interest: error-related negativity (ERN)/error negativity (Ne), early error positivity (early Pe) reflecting automatic error processing, and the late Pe component which is thought to mirror the awareness of erroneous responses. We found smaller amplitudes of the ERN/Ne in patients with BPD compared to controls. Moreover, significant correlations with the BIS-10 non-planning sub-score could be demonstrated for both the entire group and the patient group. No between-group differences were observed for the early and late Pe components. ERP measures appear to be a suitable tool to study clinical time courses in BPD.

  2. 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

    2006-01-01

    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...

  3. Human Errors in Decision Making

    OpenAIRE

    Mohamad, Shahriari; Aliandrina, Dessy; Feng, Yan

    2005-01-01

    The aim of this paper was to identify human errors in decision making process. The study was focused on a research question such as: what could be the human error as a potential of decision failure in evaluation of the alternatives in the process of decision making. Two case studies were selected from the literature and analyzed to find the human errors contribute to decision fail. Then the analysis of human errors was linked with mental models in evaluation of alternative step. The results o...

  4. Finding beam focus errors automatically

    International Nuclear Information System (INIS)

    Lee, M.J.; Clearwater, S.H.; Kleban, S.D.

    1987-01-01

    An automated method for finding beam focus errors using an optimization program called COMFORT-PLUS. The steps involved in finding the correction factors using COMFORT-PLUS has been used to find the beam focus errors for two damping rings at the SLAC Linear Collider. The program is to be used as an off-line program to analyze actual measured data for any SLC system. A limitation on the application of this procedure is found to be that it depends on the magnitude of the machine errors. Another is that the program is not totally automated since the user must decide a priori where to look for errors

  5. Heuristic errors in clinical reasoning.

    Science.gov (United States)

    Rylander, Melanie; Guerrasio, Jeannette

    2016-08-01

    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.

  6. 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 ...

  7. Pharyngitis – fatal infectious disease or medical error?

    Directory of Open Access Journals (Sweden)

    Marta Rorat

    2015-08-01

    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.

  8. Disclosing harmful medical errors to patients: tackling three tough cases.

    Science.gov (United States)

    Gallagher, Thomas H; Bell, Sigall K; Smith, Kelly M; Mello, Michelle M; McDonald, Timothy B

    2009-09-01

    A gap exists between recommendations to disclose errors to patients and current practice. This gap may reflect important, yet unanswered questions about implementing disclosure principles. We explore some of these unanswered questions by presenting three real cases that pose challenging disclosure dilemmas. The first case involves a pancreas transplant that failed due to the pancreas graft being discarded, an error that was not disclosed partly because the family did not ask clarifying questions. Relying on patient or family questions to determine the content of disclosure is problematic. We propose a standard of materiality that can help clinicians to decide what information to disclose. The second case involves a fatal diagnostic error that the patient's widower was unaware had happened. The error was not disclosed out of concern that disclosure would cause the widower more harm than good. This case highlights how institutions can overlook patients' and families' needs following errors and emphasizes that benevolent deception has little role in disclosure. Institutions should consider whether involving neutral third parties could make disclosures more patient centered. The third case presents an intraoperative cardiac arrest due to a large air embolism where uncertainty around the clinical event was high and complicated the disclosure. Uncertainty is common to many medical errors but should not deter open conversations with patients and families about what is and is not known about the event. Continued discussion within the medical profession about applying disclosure principles to real-world cases can help to better meet patients' and families' needs following medical errors.

  9. Error studies for SNS Linac. Part 1: Transverse errors

    International Nuclear Information System (INIS)

    Crandall, K.R.

    1998-01-01

    The SNS linac consist of a radio-frequency quadrupole (RFQ), a drift-tube linac (DTL), a coupled-cavity drift-tube linac (CCDTL) and a coupled-cavity linac (CCL). The RFQ and DTL are operated at 402.5 MHz; the CCDTL and CCL are operated at 805 MHz. Between the RFQ and DTL is a medium-energy beam-transport system (MEBT). This error study is concerned with the DTL, CCDTL and CCL, and each will be analyzed separately. In fact, the CCL is divided into two sections, and each of these will be analyzed separately. The types of errors considered here are those that affect the transverse characteristics of the beam. The errors that cause the beam center to be displaced from the linac axis are quad displacements and quad tilts. The errors that cause mismatches are quad gradient errors and quad rotations (roll)

  10. Error begat error: design error analysis and prevention in social infrastructure projects.

    Science.gov (United States)

    Love, Peter E D; Lopez, Robert; Edwards, David J; Goh, Yang M

    2012-09-01

    Design errors contribute significantly to cost and schedule growth in social infrastructure projects and to engineering failures, which can result in accidents and loss of life. Despite considerable research that has addressed their error causation in construction projects they still remain prevalent. This paper identifies the underlying conditions that contribute to design errors in social infrastructure projects (e.g. hospitals, education, law and order type buildings). A systemic model of error causation is propagated and subsequently used to develop a learning framework for design error prevention. The research suggests that a multitude of strategies should be adopted in congruence to prevent design errors from occurring and so ensure that safety and project performance are ameliorated. Copyright © 2011. Published by Elsevier Ltd.

  11. Representing cognitive activities and errors in HRA trees

    International Nuclear Information System (INIS)

    Gertman, D.I.

    1992-01-01

    This paper discusses development of a means by which to present cognitive information in human reliability assessment (HRA) event trees. The descriptions found in probabilistic risk assessments (PRAs) regarding the demands on, and the resulting performance of, nuclear power plant (NPP) crews often make use of the technique for human error rate prediction (THERP), which provides a mechanism, the HRA event tree, for presenting the analyst's conceptualization of the activities underlying performance and the errors associated with that performance. When using THERP, analysts have often omitted the more complex elements of human cognition from these trees. There has yet to be a concerted effort to take theory, principles, and data from cognitive psychology and wed it to the logic structure of the HRA event tree. This paper attempts to do so. The COGENT modeling scheme (cognitively based HRA event trees) adds two taxonomies to the HRA event tree proposed by Swain and Guttman. The first taxonomy, the one proposed by Norman and Reason, describes the type of error committed and implies something about the underlying cognition as well. The second of these, the Rasmussen taxonomy, provides description regarding the skill-based, rule-based, or knowledge-based behavior underlying the execution of tasks. It is not apparent and must be deduced from the pattern of errors exhibited by personnel

  12. Technique for human-error sequence identification and signification

    International Nuclear Information System (INIS)

    Heslinga, G.

    1988-01-01

    The aim of the present study was to investigate whether the event-tree technique can be used for the analysis of sequences of human errors that could cause initiating events. The scope of the study was limited to a consideration of the performance of procedural actions. The event-tree technique was modified to adapt it for this study and will be referred to as the 'Technique for Human-Error-Sequence Identification and Signification' (THESIS). The event trees used in this manner, i.e. THESIS event trees, appear to present additional problems if they are applied to human performance instead of technical systems. These problems, referred to as the 'Man-Related Features' of THESIS, are: the human capability to choose among several procedures, the ergonomics of the panel layout, human actions of a continuous nature, dependence between human errors, human capability to recover possible errors, the influence of memory during the recovery attempt, variability in human performance and correlations between human;erropr probabilities. The influence of these problems on the applicability of THESIS was assessed by means of mathematical analysis, field studies and laboratory experiments (author). 130 refs.; 51 figs.; 24 tabs

  13. Event Index - a LHCb Event Search System

    CERN Document Server

    INSPIRE-00392208; Kazeev, Nikita; Redkin, Artem

    2015-12-23

    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.

  14. Dual Processing and Diagnostic Errors

    Science.gov (United States)

    Norman, Geoff

    2009-01-01

    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,…

  15. Barriers to medical error reporting

    Directory of Open Access Journals (Sweden)

    Jalal Poorolajal

    2015-01-01

    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.

  16. A theory of human error

    Science.gov (United States)

    Mcruer, D. T.; Clement, W. F.; Allen, R. W.

    1981-01-01

    Human errors tend to be treated in terms of clinical and anecdotal descriptions, from which remedial measures are difficult to derive. Correction of the sources of human error requires an attempt to reconstruct underlying and contributing causes of error from the circumstantial causes cited in official investigative reports. A comprehensive analytical theory of the cause-effect relationships governing propagation of human error is indispensable to a reconstruction of the underlying and contributing causes. A validated analytical theory of the input-output behavior of human operators involving manual control, communication, supervisory, and monitoring tasks which are relevant to aviation, maritime, automotive, and process control operations is highlighted. This theory of behavior, both appropriate and inappropriate, provides an insightful basis for investigating, classifying, and quantifying the needed cause-effect relationships governing propagation of human error.

  17. Correcting AUC for Measurement Error.

    Science.gov (United States)

    Rosner, Bernard; Tworoger, Shelley; Qiu, Weiliang

    2015-12-01

    Diagnostic biomarkers are used frequently in epidemiologic and clinical work. The ability of a diagnostic biomarker to discriminate between subjects who develop disease (cases) and subjects who do not (controls) is often measured by the area under the receiver operating characteristic curve (AUC). The diagnostic biomarkers are usually measured with error. Ignoring measurement error can cause biased estimation of AUC, which results in misleading interpretation of the efficacy of a diagnostic biomarker. Several methods have been proposed to correct AUC for measurement error, most of which required the normality assumption for the distributions of diagnostic biomarkers. In this article, we propose a new method to correct AUC for measurement error and derive approximate confidence limits for the corrected AUC. The proposed method does not require the normality assumption. Both real data analyses and simulation studies show good performance of the proposed measurement error correction method.

  18. Cognitive aspect of diagnostic errors.

    Science.gov (United States)

    Phua, Dong Haur; Tan, Nigel C K

    2013-01-01

    Diagnostic errors can result in tangible harm to patients. Despite our advances in medicine, the mental processes required to make a diagnosis exhibits shortcomings, causing diagnostic errors. Cognitive factors are found to be an important cause of diagnostic errors. With new understanding from psychology and social sciences, clinical medicine is now beginning to appreciate that our clinical reasoning can take the form of analytical reasoning or heuristics. Different factors like cognitive biases and affective influences can also impel unwary clinicians to make diagnostic errors. Various strategies have been proposed to reduce the effect of cognitive biases and affective influences when clinicians make diagnoses; however evidence for the efficacy of these methods is still sparse. This paper aims to introduce the reader to the cognitive aspect of diagnostic errors, in the hope that clinicians can use this knowledge to improve diagnostic accuracy and patient outcomes.

  19. Investigation of human performance events at French power stations

    International Nuclear Information System (INIS)

    Ghertman, F.; Griffon-Fouco, M.

    1985-01-01

    This paper is concerned with the collection of data on human errors that occur at operating power plants. Three collection methods are used, each relating to a difference level of analysis. (1) Simplified statistical analysis of the causes of human errors: Events which have occurred at operating power plants and which are attributable to human errors are selected. The errors thus identified are analysed briefly and are described by a simplified classification, statistical analysis then being applied to find the principal factors underlying these errors. By way of example, an analysis is given of data on emergency shut-downs involving a human error component that occurred at 900 MW(e) PWR plants during 1982, 1983, 1984. (2) In-depth statistical analysis of the causes of certain human errors: The errors selected are analysed and described by means of a detailed classification. By way of example, the collection and evaluation of data on human errors occurring during periodic tests at a 900 MW(e) power plant over a period of six months are described. (3) In-depth analysis of certain events due to human errors: The events selected are analysed by means of a method which reconstitutes the multicausal aspect of the event and of each human error. By way of example, a description is given of an emergency core cooling required at a 900 MW(e) PWR plant. In conclusion, it is explained how these three methods of collection play complementary roles

  20. Simulating events

    Energy Technology Data Exchange (ETDEWEB)

    Ferretti, C; Bruzzone, L [Techint Italimpianti, Milan (Italy)

    2000-06-01

    The Petacalco Marine terminal on the Pacific coast in the harbour of Lazaro Carclenas (Michoacan) in Mexico, provides coal to the thermoelectric power plant at Pdte Plutarco Elias Calles in the port area. The plant is being converted from oil to burn coal to generate 2100 MW of power. The article describes the layout of the terminal and equipment employed in the unloading, coal stacking, coal handling areas and the receiving area at the power plant. The contractor Techint Italimpianti has developed a software system, MHATIS, for marine terminal management which is nearly complete. The discrete event simulator with its graphic interface provides a real-type decision support system for simulating changes to the terminal operations and evaluating impacts. The article describes how MHATIS is used. 7 figs.

  1. Event generators

    International Nuclear Information System (INIS)

    Durand, D.; Gulminelli, F.; Lopez, O.; Vient, E.

    1998-01-01

    The results concerning the heavy ion collision simulations at Fermi energies by means of phenomenological models obtained in the last two years ar presented. The event generators are essentially following the phase of elaboration of analysis methods of data obtained by INDRA or NAUTILUS 4 π multidetectors. To identify and correctly quantify a phenomenon or a physical quantity it is necessary to verify by simulation the feasibility and validity of the analysis and also to estimate the bias introduced by the experimental filter. Many studies have shown this, for instance: the determination of the collision reaction plan for flow studies, determination of kinematical characteristics of the quasi-projectiles, and the excitation energy measurement stored in the hot nuclei. To Eugene, the currently utilised generator, several improvements were added: introduction of space-time correlations between the different products emitted in the decay of excited nuclei by calculating the trajectories of the particles in the final phase of the reaction; taking into account in the decay cascade of the discrete levels of the lighter fragments; the possibility of the schematically description of the explosion of the nucleus by simultaneous emission of multi-fragments. Thus, by comparing the calculations with the data relative to heavy systems studied with the NAUTILUS assembly it was possible to extract the time scales in the nuclear fragmentation. The utilisation of these event generators was extended to the analysis of INDRA data concerning the determination of the vaporization threshold in the collisions Ar + Ni and also the research of the expansion effects in the collisions Xe + Sn at 50 MeV/u

  2. Events | Indian Academy of Sciences

    Indian Academy of Sciences (India)

    Home; Events. 404! error. The page your are looking for can not be found! Please check the link or use the navigation bar at the top. YouTube; Twitter; Facebook; Blog. Academy News. IAS Logo. 29th Mid-year meeting. Posted on 19 January 2018. The 29th Mid-year meeting of the Academy will be held from 29–30 June ...

  3. Analysis of gross error rates in operation of commercial nuclear power stations

    International Nuclear Information System (INIS)

    Joos, D.W.; Sabri, Z.A.; Husseiny, A.A.

    1979-01-01

    Experience in operation of US commercial nuclear power plants is reviewed over a 25-month period. The reports accumulated in that period on events of human error and component failure are examined to evaluate gross operator error rates. The impact of such errors on plant operation and safety is examined through the use of proper taxonomies of error, tasks and failures. Four categories of human errors are considered; namely, operator, maintenance, installation and administrative. The computed error rates are used to examine appropriate operator models for evaluation of operator reliability. Human error rates are found to be significant to a varying degree in both BWR and PWR. This emphasizes the import of considering human factors in safety and reliability analysis of nuclear systems. The results also indicate that human errors, and especially operator errors, do indeed follow the exponential reliability model. (Auth.)

  4. The probability and the management of human error

    International Nuclear Information System (INIS)

    Dufey, R.B.; Saull, J.W.

    2004-01-01

    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 (λ) that combines the influences of early inexperience, learning from experience (ε) and stochastic occurrences with having a finite minimum rate, this equation is λ 5.10 -5 + ((1/ε) - 5.10 -5 ) exp(-3*ε). The future failure rate is entirely determined by the experience: thus the past defines the future

  5. Comprehensive analysis of a medication dosing error related to CPOE.

    Science.gov (United States)

    Horsky, Jan; Kuperman, Gilad J; Patel, Vimla L

    2005-01-01

    This case study of a serious medication error demonstrates the necessity of a comprehensive methodology for the analysis of failures in interaction between humans and information systems. The authors used a novel approach to analyze a dosing error related to computer-based ordering of potassium chloride (KCl). The method included a chronological reconstruction of events and their interdependencies from provider order entry usage logs, semistructured interviews with involved clinicians, and interface usability inspection of the ordering system. Information collected from all sources was compared and evaluated to understand how the error evolved and propagated through the system. In this case, the error was the product of faults in interaction among human and system agents that methods limited in scope to their distinct analytical domains would not identify. The authors characterized errors in several converging aspects of the drug ordering process: confusing on-screen laboratory results review, system usability difficulties, user training problems, and suboptimal clinical system safeguards that all contributed to a serious dosing error. The results of the authors' analysis were used to formulate specific recommendations for interface layout and functionality modifications, suggest new user alerts, propose changes to user training, and address error-prone steps of the KCl ordering process to reduce the risk of future medication dosing errors.

  6. Physician assistants and the disclosure of medical error.

    Science.gov (United States)

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

    2014-06-01

    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.

  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

    Science.gov (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.

    2017-08-01

    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. Events diary

    Science.gov (United States)

    2000-01-01

    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: sandra.koura@britassoc.org.uk ). Details of the creating SPARKS events may be obtained from creating.sparks@britassoc.org.uk or from the website www.britassoc.org.uk . 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: IACPE7@if.ufrgs.br or cabbat1.cnea.gov.ar/iacpe/iacpei.htm 27 August - 1 September, Barcelona, Spain GIREP conference: Physics teacher education beyond 2000. Info: www.blues.uab.es/phyteb/index.html

  9. Errors, error detection, error correction and hippocampal-region damage: data and theories.

    Science.gov (United States)

    MacKay, Donald G; Johnson, Laura W

    2013-11-01

    This review and perspective article outlines 15 observational constraints on theories of errors, error detection, and error correction, and their relation to hippocampal-region (HR) damage. The core observations come from 10 studies with H.M., an amnesic with cerebellar and HR damage but virtually no neocortical damage. Three studies examined the detection of errors planted in visual scenes (e.g., a bird flying in a fish bowl in a school classroom) and sentences (e.g., I helped themselves to the birthday cake). In all three experiments, H.M. detected reliably fewer errors than carefully matched memory-normal controls. Other studies examined the detection and correction of self-produced errors, with controls for comprehension of the instructions, impaired visual acuity, temporal factors, motoric slowing, forgetting, excessive memory load, lack of motivation, and deficits in visual scanning or attention. In these studies, H.M. corrected reliably fewer errors than memory-normal and cerebellar controls, and his uncorrected errors in speech, object naming, and reading aloud exhibited two consistent features: omission and anomaly. For example, in sentence production tasks, H.M. omitted one or more words in uncorrected encoding errors that rendered his sentences anomalous (incoherent, incomplete, or ungrammatical) reliably more often than controls. Besides explaining these core findings, the theoretical principles discussed here explain H.M.'s retrograde amnesia for once familiar episodic and semantic information; his anterograde amnesia for novel information; his deficits in visual cognition, sentence comprehension, sentence production, sentence reading, and object naming; and effects of aging on his ability to read isolated low frequency words aloud. These theoretical principles also explain a wide range of other data on error detection and correction and generate new predictions for future test. Copyright © 2013 Elsevier Ltd. All rights reserved.

  10. Linear network error correction coding

    CERN Document Server

    Guang, Xuan

    2014-01-01

    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

  11. The cost of human error intervention

    International Nuclear Information System (INIS)

    Bennett, C.T.; Banks, W.W.; Jones, E.D.

    1994-03-01

    DOE has directed that cost-benefit analyses be conducted as part of the review process for all new DOE orders. This new policy will have the effect of ensuring that DOE analysts can justify the implementation costs of the orders that they develop. We would like to argue that a cost-benefit analysis is merely one phase of a complete risk management program -- one that would more than likely start with a probabilistic risk assessment. The safety community defines risk as the probability of failure times the severity of consequence. An engineering definition of failure can be considered in terms of physical performance, as in mean-time-between-failure; or, it can be thought of in terms of human performance, as in probability of human error. The severity of consequence of a failure can be measured along any one of a number of dimensions -- economic, political, or social. Clearly, an analysis along one dimension cannot be directly compared to another but, a set of cost-benefit analyses, based on a series of cost-dimensions, can be extremely useful to managers who must prioritize their resources. Over the last two years, DOE has been developing a series of human factors orders, directed a lowering the probability of human error -- or at least changing the distribution of those errors. The following discussion presents a series of cost-benefit analyses using historical events in the nuclear industry. However, we would first like to discuss some of the analytic cautions that must be considered when we deal with human error

  12. Geophysical events

    Science.gov (United States)

    This is a summary of SEAN Bulletin, 13(3), March 31, 1988, a publication of the Smithsonian Institution's Scientific Event Alert Network. The complete bulletin is available in the microfiche edition of Eos as a microfiche supplement or as a paper reprint. For the microfiche, order document E88-002 at $2.50 (U.S.) by writing to AGU Orders, 2000 Florida Avenue, N.W., Washington, DC 20009 or by calling toll free on 800-424-2488. For the paper reprint, order SEAN Bulletin (giving volume and issue numbers and issue date) through the same address; the price is $3.50 for one copy of each issue number for those who do not have a deposit account, $2 for those who do; additional copies of each issue number are $1. Subscriptions to SEAN Bulletin are also available from AGU-Orders; the price is $18 for 12 monthly issues mailed to a U.S. address, $28 if mailed elsewhere, and must be prepaid.

  13. Prescription Errors in Psychiatry | Nair | Internet Journal of Medical ...

    African Journals Online (AJOL)

    Adverse events involving psychotropic drugs are common and some may be due to errors in clinical decision making of a type not detected by the studies reviewed. These are potentially preventable. On the basis of this, it is recommended that medicine management in mental health settings should be a priority for future ...

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

    International Nuclear Information System (INIS)

    Embrey, D.

    1991-01-01

    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. Iatrogenic medication errors in a paediatric intensive care unit in ...

    African Journals Online (AJOL)

    This unit has guided the development of various types of adverse event reporting, ... iatrogenic medi cation errors in children at healthcare facilities in industrialised .... A pharmacist dispenses electronically submitted medication orders but ..... Hand-held devices such as smartphones with medication dosage applications.

  16. Minimalist fault-tolerance techniques for mitigating single-event effects in non-radiation-hardened microcontrollers

    Science.gov (United States)

    Caldwell, Douglas Wyche

    Commercial microcontrollers--monolithic integrated circuits containing microprocessor, memory and various peripheral functions--such as are used in industrial, automotive and military applications, present spacecraft avionics system designers an appealing mix of higher performance and lower power together with faster system-development time and lower unit costs. However, these parts are not radiation-hardened for application in the space environment and Single-Event Effects (SEE) caused by high-energy, ionizing radiation present a significant challenge. Mitigating these effects with techniques which require minimal additional support logic, and thereby preserve the high functional density of these devices, can allow their benefits to be realized. This dissertation uses fault-tolerance to mitigate the transient errors and occasional latchups that non-hardened microcontrollers can experience in the space radiation environment. Space systems requirements and the historical use of fault-tolerant computers in spacecraft provide context. Space radiation and its effects in semiconductors define the fault environment. A reference architecture is presented which uses two or three microcontrollers with a combination of hardware and software voting techniques to mitigate SEE. A prototypical spacecraft function (an inertial measurement unit) is used to illustrate the techniques and to explore how real application requirements impact the fault-tolerance approach. Low-cost approaches which leverage features of existing commercial microcontrollers are analyzed. A high-speed serial bus is used for voting among redundant devices and a novel wire-OR output voting scheme exploits the bidirectional controls of I/O pins. A hardware testbed and prototype software were constructed to evaluate two- and three-processor configurations. Simulated Single-Event Upsets (SEUs) were injected at high rates and the response of the system monitored. The resulting statistics were used to evaluate

  17. Preparation and Properties of Anisotropic Nano-crystalline NdFeB Powders Made by Hydrogen Decrepitation of Die Upsetting Magnets

    Energy Technology Data Exchange (ETDEWEB)

    Yi, P P; Lee, D; Yan, A R, E-mail: ypp@nimte.ac.cn [Ningbo Institute of Material Technology and Engineering, Chinese Academy of Sciences, Ningbo 315201 (China)

    2011-01-01

    Anisotropic nanocrystalline NdFeB powders were prepared by hydrogen decrepitation (HD) of die upsetting magnets. The effects of varying temperatures of HD on the microstructure and magnetic properties of the anisotropic NdFeB particles were studied. It shows that the powders which obtained by HD process at higher temperature were larger than that at lower temperature, and the HD powders show a well anisotropy at 723 K, the remanence (B{sub r}) was more than 12.46 kG, the maximum energy product ((BH){sub max}) was 19.06 MGOe, and the coercivity (H{sub cj}) was 7.2 kOe. The microstructure of the anisotropic powders revealed that with a reasonable HD temperature, the platelet grains were not destroyed. They were nearly 150-300 nm long and 30-50 nm wide. The results indicate that HD process was an effective way to prepare the anisotropic NdFeB powders.

  18. Error field considerations for BPX

    International Nuclear Information System (INIS)

    LaHaye, R.J.

    1992-01-01

    Irregularities in the position of poloidal and/or toroidal field coils in tokamaks produce resonant toroidal asymmetries in the vacuum magnetic fields. Otherwise stable tokamak discharges become non-linearly unstable to disruptive locked modes when subjected to low level error fields. Because of the field errors, magnetic islands are produced which would not otherwise occur in tearing mode table configurations; a concomitant reduction of the total confinement can result. Poloidal and toroidal asymmetries arise in the heat flux to the divertor target. In this paper, the field errors from perturbed BPX coils are used in a field line tracing code of the BPX equilibrium to study these deleterious effects. Limits on coil irregularities for device design and fabrication are computed along with possible correcting coils for reducing such field errors

  19. The uncorrected refractive error challenge

    Directory of Open Access Journals (Sweden)

    Kovin Naidoo

    2016-11-01

    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.

  20. Quantile Regression With Measurement Error

    KAUST Repository

    Wei, Ying

    2009-08-27

    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.

  1. Comprehensive Error Rate Testing (CERT)

    Data.gov (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...

  2. Numerical optimization with computational errors

    CERN Document Server

    Zaslavski, Alexander J

    2016-01-01

    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...

  3. Dual processing and diagnostic errors.

    Science.gov (United States)

    Norman, Geoff

    2009-09-01

    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, conscious, and conceptual process, called System 2. Exemplar theories of categorization propose that many category decisions in everyday life are made by unconscious matching to a particular example in memory, and these remain available and retrievable individually. I then review studies of clinical reasoning based on these theories, and show that the two processes are equally effective; System 1, despite its reliance in idiosyncratic, individual experience, is no more prone to cognitive bias or diagnostic error than System 2. Further, I review evidence that instructions directed at encouraging the clinician to explicitly use both strategies can lead to consistent reduction in error rates.

  4. Changes in medical errors after implementation of a handoff program.

    Science.gov (United States)

    Starmer, Amy J; Spector, Nancy D; Srivastava, Rajendu; West, Daniel C; Rosenbluth, Glenn; Allen, April D; Noble, Elizabeth L; Tse, Lisa L; Dalal, Anuj K; Keohane, Carol A; Lipsitz, Stuart R; Rothschild, Jeffrey M; Wien, Matthew F; Yoon, Catherine S; Zigmont, Katherine R; Wilson, Karen M; O'Toole, Jennifer K; Solan, Lauren G; Aylor, Megan; Bismilla, Zia; Coffey, Maitreya; Mahant, Sanjay; Blankenburg, Rebecca L; Destino, Lauren A; Everhart, Jennifer L; Patel, Shilpa J; Bale, James F; Spackman, Jaime B; Stevenson, Adam T; Calaman, Sharon; Cole, F Sessions; Balmer, Dorene F; Hepps, Jennifer H; Lopreiato, Joseph O; Yu, Clifton E; Sectish, Theodore C; Landrigan, Christopher P

    2014-11-06

    Miscommunications are a leading cause of serious medical errors. Data from multicenter studies assessing programs designed to improve handoff of information about patient care are lacking. We conducted a prospective intervention study of a resident handoff-improvement program in nine hospitals, measuring rates of medical errors, preventable adverse events, and miscommunications, as well as resident workflow. The intervention included a mnemonic to standardize oral and written handoffs, handoff and communication training, a faculty development and observation program, and a sustainability campaign. Error rates were measured through active surveillance. Handoffs were assessed by means of evaluation of printed handoff documents and audio recordings. Workflow was assessed through time-motion observations. The primary outcome had two components: medical errors and preventable adverse events. In 10,740 patient admissions, the medical-error rate decreased by 23% from the preintervention period to the postintervention period (24.5 vs. 18.8 per 100 admissions, P<0.001), and the rate of preventable adverse events decreased by 30% (4.7 vs. 3.3 events per 100 admissions, P<0.001). The rate of nonpreventable adverse events did not change significantly (3.0 and 2.8 events per 100 admissions, P=0.79). Site-level analyses showed significant error reductions at six of nine sites. Across sites, significant increases were observed in the inclusion of all prespecified key elements in written documents and oral communication during handoff (nine written and five oral elements; P<0.001 for all 14 comparisons). There were no significant changes from the preintervention period to the postintervention period in the duration of oral handoffs (2.4 and 2.5 minutes per patient, respectively; P=0.55) or in resident workflow, including patient-family contact and computer time. Implementation of the handoff program was associated with reductions in medical errors and in preventable adverse events

  5. Error correcting coding for OTN

    DEFF Research Database (Denmark)

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

    2010-01-01

    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....

  6. Eliminating US hospital medical errors.

    Science.gov (United States)

    Kumar, Sameer; Steinebach, Marc

    2008-01-01

    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.

  7. Heuristic thinking: interdisciplinary perspectives on medical error

    Directory of Open Access Journals (Sweden)

    Annegret F. Hannawa

    2013-12-01

    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

  8. [Medical errors: inevitable but preventable].

    Science.gov (United States)

    Giard, R W

    2001-10-27

    Medical errors are increasingly reported in the lay press. Studies have shown dramatic error rates of 10 percent or even higher. From a methodological point of view, studying the frequency and causes of medical errors is far from simple. Clinical decisions on diagnostic or therapeutic interventions are always taken within a clinical context. Reviewing outcomes of interventions without taking into account both the intentions and the arguments for a particular action will limit the conclusions from a study on the rate and preventability of errors. The interpretation of the preventability of medical errors is fraught with difficulties and probably highly subjective. Blaming the doctor personally does not do justice to the actual situation and especially the organisational framework. Attention for and improvement of the organisational aspects of error are far more important then litigating the person. To err is and will remain human and if we want to reduce the incidence of faults we must be able to learn from our mistakes. That requires an open attitude towards medical mistakes, a continuous effort in their detection, a sound analysis and, where feasible, the institution of preventive measures.

  9. Quantum error correction for beginners

    International Nuclear Information System (INIS)

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

    2013-01-01

    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. (review article)

  10. Medical Error and Moral Luck.

    Science.gov (United States)

    Hubbeling, Dieneke

    2016-09-01

    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.

  11. Recurring events - Volume 2

    International Nuclear Information System (INIS)

    2003-04-01

    known, thus the actions taken were not effective in preventing recurrence of an event, - The contributing factors or causes of the event were not taken into account in defining the actions to be taken. Several good practices were identified to prevent recurring events. These practices are part of related guides provided by national and international bodies. Some of these are: - NPPs should analyse recurring events in-depth, in order to identify root causes and contributing factors to prevent further recurrence. The specific factors that failed to prevent recurrence should be investigated and identified (that is, why prior operating experience was not effectively applied). - For minor events, trend analyses should be performed to monitor the frequency of component failures (which may be unavoidable) or the frequency of minor human performance problems (which may indicate weaknesses in error prevention processes and programs). - Analysis of external operating experiences from other NPPs should be strengthened to broaden the basis for preventive measures; - Actions taken after events should be assessed regarding their effectiveness in preventing recurrence of similar events. Subsequent to the workshop, a more detailed search of reports of operating experience, including IRS and other reports from national sources, resulted in the determination of a number of recurring categories: - Loss of RHR at mid-loop (in the 1999 report also); - BWR instability (in the 1999 report also); - PWR vessel corrosion due to boric acid effects; - Hydrogen detonation in BWR piping; - Steam Generator Tube Rupture; - Multiple valve failures in ECCS; - Service Water Failure due to Marine Biofouling (in the 1999 report also); - System Level Failures with Human Factors Considerations; - Strainer Clogging (sources of emergency injection or recirculation). Five conclusions were established on the basis of the workshop and the recurring event analysis: Conclusion 1: Recurring events continue to be

  12. 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

    2015-01-01

    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.

  13. Using Fault Trees to Advance Understanding of Diagnostic Errors.

    Science.gov (United States)

    Rogith, Deevakar; Iyengar, M Sriram; Singh, Hardeep

    2017-11-01

    Diagnostic errors annually affect at least 5% of adults in the outpatient setting in the United States. Formal analytic techniques are only infrequently used to understand them, in part because of the complexity of diagnostic processes and clinical work flows involved. In this article, diagnostic errors were modeled using fault tree analysis (FTA), a form of root cause analysis that has been successfully used in other high-complexity, high-risk contexts. How factors contributing to diagnostic errors can be systematically modeled by FTA to inform error understanding and error prevention is demonstrated. A team of three experts reviewed 10 published cases of diagnostic error and constructed fault trees. The fault trees were modeled according to currently available conceptual frameworks characterizing diagnostic error. The 10 trees were then synthesized into a single fault tree to identify common contributing factors and pathways leading to diagnostic error. FTA is a visual, structured, deductive approach that depicts the temporal sequence of events and their interactions in a formal logical hierarchy. The visual FTA enables easier understanding of causative processes and cognitive and system factors, as well as rapid identification of common pathways and interactions in a unified fashion. In addition, it enables calculation of empirical estimates for causative pathways. Thus, fault trees might provide a useful framework for both quantitative and qualitative analysis of diagnostic errors. Future directions include establishing validity and reliability by modeling a wider range of error cases, conducting quantitative evaluations, and undertaking deeper exploration of other FTA capabilities. Copyright © 2017 The Joint Commission. Published by Elsevier Inc. All rights reserved.

  14. ERM model analysis for adaptation to hydrological model errors

    Science.gov (United States)

    Baymani-Nezhad, M.; Han, D.

    2018-05-01

    Hydrological conditions are changed continuously and these phenomenons generate errors on flood forecasting models and will lead to get unrealistic results. Therefore, to overcome these difficulties, a concept called model updating is proposed in hydrological studies. Real-time model updating is one of the challenging processes in hydrological sciences and has not been entirely solved due to lack of knowledge about the future state of the catchment under study. Basically, in terms of flood forecasting process, errors propagated from the rainfall-runoff model are enumerated as the main source of uncertainty in the forecasting model. Hence, to dominate the exciting errors, several methods have been proposed by researchers to update the rainfall-runoff models such as parameter updating, model state updating, and correction on input data. The current study focuses on investigations about the ability of rainfall-runoff model parameters to cope with three types of existing errors, timing, shape and volume as the common errors in hydrological modelling. The new lumped model, the ERM model, has been selected for this study to evaluate its parameters for its use in model updating to cope with the stated errors. Investigation about ten events proves that the ERM model parameters can be updated to cope with the errors without the need to recalibrate the model.

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

    Directory of Open Access Journals (Sweden)

    Kevin Michael Trewartha

    2013-11-01

    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.

  16. Brain State Before Error Making in Young Patients With Mild Spastic Cerebral Palsy.

    Science.gov (United States)

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

    2015-10-01

    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.

  17. Significant events caused by extraneous acts

    International Nuclear Information System (INIS)

    Verlaeken, J.

    1987-01-01

    The operating experience feedback system of VINCOTTE, called ARIANE, consists, among others, of preparing synthesis reports on specific safety concerns. A recent report deals with significant events caused by extranous acts. Events attributable to human error are numerous. Confusion errors have already been analysed in several publications (NES IRS 664 etc.). However, are described here some ten incidents where extranous acts occurred: ZION 2 (September 76), OYSTER CREEK (May 79), PALISADES (January 81), CATAWBA (August 85), etc. The contributing factors for these unfortunate initiatives are explained; several resort to psychological influences. Corrective actions are discussed, and some general lessons are drawn. (author)

  18. 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......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...

  19. Predictors of Errors of Novice Java Programmers

    Science.gov (United States)

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

    2012-01-01

    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

    Science.gov (United States)

    Huo, Ming-Xia; Li, Ying

    2017-12-01

    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.