Nature's Greatest Puzzles

Energy Technology Data Exchange (ETDEWEB)

Quigg, Chris; /Fermilab

2005-02-01

It is a pleasure to be part of the SLAC Summer Institute again, not simply because it is one of the great traditions in our field, but because this is a moment of great promise for particle physics. I look forward to exploring many opportunities with you over the course of our two weeks together. My first task in talking about Nature's Greatest Puzzles, the title of this year's Summer Institute, is to deconstruct the premise a little bit.

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.

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)

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

Common patterns in 558 diagnostic radiology errors.

Science.gov (United States)

Donald, Jennifer J; Barnard, Stuart A

2012-04-01

As a Quality Improvement initiative our department has held regular discrepancy meetings since 2003. We performed a retrospective analysis of the cases presented and identified the most common pattern of error. A total of 558 cases were referred for discussion over 92 months, and errors were classified as perceptual or interpretative. The most common patterns of error for each imaging modality were analysed, and the misses were scored by consensus as subtle or non-subtle. Of 558 diagnostic errors, 447 (80%) were perceptual and 111 (20%) were interpretative errors. Plain radiography and computed tomography (CT) scans were the most frequent imaging modalities accounting for 246 (44%) and 241 (43%) of the total number of errors, respectively. In the plain radiography group 120 (49%) of the errors occurred in chest X-ray reports with perceptual miss of a lung nodule occurring in 40% of this subgroup. In the axial and appendicular skeleton missed fractures occurred most frequently, and metastatic bone disease was overlooked in 12 of 50 plain X-rays of the pelvis or spine. The majority of errors within the CT group were in reports of body scans with the commonest perceptual errors identified including 16 missed significant bone lesions, 14 cases of thromboembolic disease and 14 gastrointestinal tumours. Of the 558 errors, 312 (56%) were considered subtle and 246 (44%) non-subtle. Diagnostic errors are not uncommon and are most frequently perceptual in nature. Identification of the most common patterns of error has the potential to improve the quality of reporting by improving the search behaviour of radiologists. © 2012 The Authors. Journal of Medical Imaging and Radiation Oncology © 2012 The Royal Australian and New Zealand College of Radiologists.

Errors and untimely radiodiagnosis of occupational diseases

International Nuclear Information System (INIS)

Sokolik, L.I.; Shkondin, A.N.; Sergienko, N.S.; Doroshenko, A.N.; Shumakov, A.V.

1987-01-01

Most errors in the diagnosis of occupational diseases occur due to hyperdiagnosis (37%), because data of dynamic clinico-roentgenological examination were not considered (23%). Defects in the organization of prophylactic fluorography results in untimely diagnosis of dust-induced occupational diseases. Errors also occurred because working conditions were not always considered atypical development and course were not always analyzed

Medication errors: an overview for clinicians.

Science.gov (United States)

Wittich, Christopher M; Burkle, Christopher M; Lanier, William L

2014-08-01

Medication error is an important cause of patient morbidity and mortality, yet it can be a confusing and underappreciated concept. This article provides a review for practicing physicians that focuses on medication error (1) terminology and definitions, (2) incidence, (3) risk factors, (4) avoidance strategies, and (5) disclosure and legal consequences. A medication error is any error that occurs at any point in the medication use process. It has been estimated by the Institute of Medicine that medication errors cause 1 of 131 outpatient and 1 of 854 inpatient deaths. Medication factors (eg, similar sounding names, low therapeutic index), patient factors (eg, poor renal or hepatic function, impaired cognition, polypharmacy), and health care professional factors (eg, use of abbreviations in prescriptions and other communications, cognitive biases) can precipitate medication errors. Consequences faced by physicians after medication errors can include loss of patient trust, civil actions, criminal charges, and medical board discipline. Methods to prevent medication errors from occurring (eg, use of information technology, better drug labeling, and medication reconciliation) have been used with varying success. When an error is discovered, patients expect disclosure that is timely, given in person, and accompanied with an apology and communication of efforts to prevent future errors. Learning more about medication errors may enhance health care professionals' ability to provide safe care to their patients. Copyright © 2014 Mayo Foundation for Medical Education and Research. Published by Elsevier Inc. All rights reserved.

A model for the statistical description of analytical errors occurring in clinical chemical laboratories with time.

Science.gov (United States)

Hyvärinen, A

1985-01-01

The main purpose of the present study was to describe the statistical behaviour of daily analytical errors in the dimensions of place and time, providing a statistical basis for realistic estimates of the analytical error, and hence allowing the importance of the error and the relative contributions of its different sources to be re-evaluated. The observation material consists of creatinine and glucose results for control sera measured in daily routine quality control in five laboratories for a period of one year. The observation data were processed and computed by means of an automated data processing system. Graphic representations of time series of daily observations, as well as their means and dispersion limits when grouped over various time intervals, were investigated. For partition of the total variation several two-way analyses of variance were done with laboratory and various time classifications as factors. Pooled sets of observations were tested for normality of distribution and for consistency of variances, and the distribution characteristics of error variation in different categories of place and time were compared. Errors were found from the time series to vary typically between days. Due to irregular fluctuations in general and particular seasonal effects in creatinine, stable estimates of means or of dispersions for errors in individual laboratories could not be easily obtained over short periods of time but only from data sets pooled over long intervals (preferably at least one year). Pooled estimates of proportions of intralaboratory variation were relatively low (less than 33%) when the variation was pooled within days. However, when the variation was pooled over longer intervals this proportion increased considerably, even to a maximum of 89-98% (95-98% in each method category) when an outlying laboratory in glucose was omitted, with a concomitant decrease in the interaction component (representing laboratory-dependent variation with time

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.

Greatest Happiness Principle in a Complex System Approach

Directory of Open Access Journals (Sweden)

Katalin Martinás

2012-06-01

Full Text Available The principle of greatest happiness was the basis of ethics in Plato’s and Aristotle’s work, it served as the basis of utility principle in economics, and the happiness research has become a hot topic in social sciences in Western countries in particular in economics recently. Nevertheless there is a considerable scientific pessimism over whether it is even possible to affect sustainable increases in happiness.In this paper we outline an economic theory of decision based on the greatest happiness principle (GHP. Modern equilibrium economics is a simple system simplification of the GHP, the complex approach outlines a non-equilibrium economic theory. The comparison of the approaches reveals the fact that the part of the results – laws of modern economics – follow from the simplifications and they are against the economic nature. The most important consequence is that within the free market economy one cannot be sure that the path found by it leads to a beneficial economic system.

Spent fuel bundle counter sequence error manual - BRUCE NGS

International Nuclear Information System (INIS)

Nicholson, L.E.

1992-01-01

The Spent Fuel Bundle Counter (SFBC) is used to count the number and type of spent fuel transfers that occur into or out of controlled areas at CANDU reactor sites. However if the transfers are executed in a non-standard manner or the SFBC is malfunctioning, the transfers are recorded as sequence errors. Each sequence error message typically contains adequate information to determine the cause of the message. This manual provides a guide to interpret the various sequence error messages that can occur and suggests probable cause or causes of the sequence errors. Each likely sequence error is presented on a 'card' in Appendix A. Note that it would be impractical to generate a sequence error card file with entries for all possible combinations of faults. Therefore the card file contains sequences with only one fault at a time. Some exceptions have been included however where experience has indicated that several faults can occur simultaneously

Spent fuel bundle counter sequence error manual - DARLINGTON NGS

International Nuclear Information System (INIS)

Nicholson, L.E.

1992-01-01

The Spent Fuel Bundle Counter (SFBC) is used to count the number and type of spent fuel transfers that occur into or out of controlled areas at CANDU reactor sites. However if the transfers are executed in a non-standard manner or the SFBC is malfunctioning, the transfers are recorded as sequence errors. Each sequence error message typically contains adequate information to determine the cause of the message. This manual provides a guide to interpret the various sequence error messages that can occur and suggests probable cause or causes of the sequence errors. Each likely sequence error is presented on a 'card' in Appendix A. Note that it would be impractical to generate a sequence error card file with entries for all possible combinations of faults. Therefore the card file contains sequences with only one fault at a time. Some exceptions have been included however where experience has indicated that several faults can occur simultaneously

Characteristics of pediatric chemotherapy medication errors in a national error reporting database.

Science.gov (United States)

Rinke, Michael L; Shore, Andrew D; Morlock, Laura; Hicks, Rodney W; Miller, Marlene R

2007-07-01

Little is known regarding chemotherapy medication errors in pediatrics despite studies suggesting high rates of overall pediatric medication errors. In this study, the authors examined patterns in pediatric chemotherapy errors. The authors queried the United States Pharmacopeia MEDMARX database, a national, voluntary, Internet-accessible error reporting system, for all error reports from 1999 through 2004 that involved chemotherapy medications and patients aged error reports, 85% reached the patient, and 15.6% required additional patient monitoring or therapeutic intervention. Forty-eight percent of errors originated in the administering phase of medication delivery, and 30% originated in the drug-dispensing phase. Of the 387 medications cited, 39.5% were antimetabolites, 14.0% were alkylating agents, 9.3% were anthracyclines, and 9.3% were topoisomerase inhibitors. The most commonly involved chemotherapeutic agents were methotrexate (15.3%), cytarabine (12.1%), and etoposide (8.3%). The most common error types were improper dose/quantity (22.9% of 327 cited error types), wrong time (22.6%), omission error (14.1%), and wrong administration technique/wrong route (12.2%). The most common error causes were performance deficit (41.3% of 547 cited error causes), equipment and medication delivery devices (12.4%), communication (8.8%), knowledge deficit (6.8%), and written order errors (5.5%). Four of the 5 most serious errors occurred at community hospitals. Pediatric chemotherapy errors often reached the patient, potentially were harmful, and differed in quality between outpatient and inpatient areas. This study indicated which chemotherapeutic agents most often were involved in errors and that administering errors were common. Investigation is needed regarding targeted medication administration safeguards for these high-risk medications. Copyright (c) 2007 American Cancer Society.

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

Errors and mistakes in breast ultrasound diagnostics

Directory of Open Access Journals (Sweden)

Wiesław Jakubowski

2012-09-01

Full Text Available Sonomammography is often the first additional examination performed in the diagnostics of breast diseases. The development of ultrasound imaging techniques, particularly the introduction of high frequency transducers, matrix transducers, harmonic imaging and finally, elastography, influenced the improvement of breast disease diagnostics. Neverthe‑ less, as in each imaging method, there are errors and mistakes resulting from the techni‑ cal limitations of the method, breast anatomy (fibrous remodeling, insufficient sensitivity and, in particular, specificity. Errors in breast ultrasound diagnostics can be divided into impossible to be avoided and potentially possible to be reduced. In this article the most frequently made errors in ultrasound have been presented, including the ones caused by the presence of artifacts resulting from volumetric averaging in the near and far field, artifacts in cysts or in dilated lactiferous ducts (reverberations, comet tail artifacts, lateral beam artifacts, improper setting of general enhancement or time gain curve or range. Errors dependent on the examiner, resulting in the wrong BIRADS‑usg classification, are divided into negative and positive errors. The sources of these errors have been listed. The methods of minimization of the number of errors made have been discussed, includ‑ ing the ones related to the appropriate examination technique, taking into account data from case history and the use of the greatest possible number of additional options such as: harmonic imaging, color and power Doppler and elastography. In the article examples of errors resulting from the technical conditions of the method have been presented, and those dependent on the examiner which are related to the great diversity and variation of ultrasound images of pathological breast lesions.

Detailed semantic analyses of human error incidents occurring at domestic nuclear power plants to fiscal year 2000

International Nuclear Information System (INIS)

Tsuge, Tadashi; Hirotsu, Yuko; Takano, Kenichi; Ebisu, Mitsuhiro; Tsumura, Joji

2003-01-01

Analysing and evaluating observed cases of human error incidents with the emphasis on human factors and behavior involved was essential for preventing recurrence of those. CRIEPI has been conducting detailed and structures analyses of all incidents reported during last 35 year based on J-HPES, from the beginning of the first Tokai nuclear power operation till fiscal year of 2000, in which total 212 human error cases are identified. Results obtained by the analyses have been stored into the J-HPES data-base. This summarized the semantic analyses on all case-studies stored in the above data-base to grasp the practical and concrete contents and trend of more frequently observed human errors (as are called trigger actions here), causal factors and preventive measures. These semantic analyses have been executed by classifying all those items into some categories that could be considered as having almost the same meaning using the KJ method. Followings are obtained typical results by above analyses: (1) Trigger action-Those could be classified into categories of operation or categories of maintenance. Operational timing errors' and 'operational quantitative errors' were major actions in trigger actions of operation, those occupied about 20% among all actions. At trigger actions of maintenance, 'maintenance quantitative error' were major actions, those occupied quarter among all actions; (2) Causal factor- 'Human internal status' were major factors, as in concrete factors, those occupied 'improper persistence' and 'lack of knowledge'; (3) Preventive measure-Most frequent measures got were job management changes in procedural software improvements, which was from 70% to 80%. As for preventive measures of operation, software improvements have been implemented on 'organization and work practices' and 'individual consciousness'. Concerning preventive measures of maintenance, improvements have been implemented on 'organization and work practices'. (author)

Common Errors in Ecological Data Sharing

Directory of Open Access Journals (Sweden)

Robert B. Cook

2013-04-01

Full Text Available Objectives: (1 to identify common errors in data organization and metadata completeness that would preclude a “reader” from being able to interpret and re-use the data for a new purpose; and (2 to develop a set of best practices derived from these common errors that would guide researchers in creating more usable data products that could be readily shared, interpreted, and used.Methods: We used directed qualitative content analysis to assess and categorize data and metadata errors identified by peer reviewers of data papers published in the Ecological Society of America’s (ESA Ecological Archives. Descriptive statistics provided the relative frequency of the errors identified during the peer review process.Results: There were seven overarching error categories: Collection & Organization, Assure, Description, Preserve, Discover, Integrate, and Analyze/Visualize. These categories represent errors researchers regularly make at each stage of the Data Life Cycle. Collection & Organization and Description errors were some of the most common errors, both of which occurred in over 90% of the papers.Conclusions: Publishing data for sharing and reuse is error prone, and each stage of the Data Life Cycle presents opportunities for mistakes. The most common errors occurred when the researcher did not provide adequate metadata to enable others to interpret and potentially re-use the data. Fortunately, there are ways to minimize these mistakes through carefully recording all details about study context, data collection, QA/ QC, and analytical procedures from the beginning of a research project and then including this descriptive information in the metadata.

Characteristics of medication errors with parenteral cytotoxic drugs

OpenAIRE

Fyhr, A; Akselsson, R

2012-01-01

Errors involving cytotoxic drugs have the potential of being fatal and should therefore be prevented. The objective of this article is to identify the characteristics of medication errors involving parenteral cytotoxic drugs in Sweden. A total of 60 cases reported to the national error reporting systems from 1996 to 2008 were reviewed. Classification was made to identify cytotoxic drugs involved, type of error, where the error occurred, error detection mechanism, and consequences for the pati...

Error Analysis in Mathematics. Technical Report #1012

Science.gov (United States)

Lai, Cheng-Fei

2012-01-01

Error analysis is a method commonly used to identify the cause of student errors when they make consistent mistakes. It is a process of reviewing a student's work and then looking for patterns of misunderstanding. Errors in mathematics can be factual, procedural, or conceptual, and may occur for a number of reasons. Reasons why students make…

Medication errors with the use of allopurinol and colchicine: a retrospective study of a national, anonymous Internet-accessible error reporting system.

Science.gov (United States)

Mikuls, Ted R; Curtis, Jeffrey R; Allison, Jeroan J; Hicks, Rodney W; Saag, Kenneth G

2006-03-01

To more closely assess medication errors in gout care, we examined data from a national, Internet-accessible error reporting program over a 5-year reporting period. We examined data from the MEDMARX database, covering the period from January 1, 1999 through December 31, 2003. For allopurinol and colchicine, we examined error severity, source, type, contributing factors, and healthcare personnel involved in errors, and we detailed errors resulting in patient harm. Causes of error and the frequency of other error characteristics were compared for gout medications versus other musculoskeletal treatments using the chi-square statistic. Gout medication errors occurred in 39% (n = 273) of facilities participating in the MEDMARX program. Reported errors were predominantly from the inpatient hospital setting and related to the use of allopurinol (n = 524), followed by colchicine (n = 315), probenecid (n = 50), and sulfinpyrazone (n = 2). Compared to errors involving other musculoskeletal treatments, allopurinol and colchicine errors were more often ascribed to problems with physician prescribing (7% for other therapies versus 23-39% for allopurinol and colchicine, p < 0.0001) and less often due to problems with drug administration or nursing error (50% vs 23-27%, p < 0.0001). Our results suggest that inappropriate prescribing practices are characteristic of errors occurring with the use of allopurinol and colchicine. Physician prescribing practices are a potential target for quality improvement interventions in gout care.

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)

Cultural differences in categorical memory errors persist with age.

Science.gov (United States)

Gutchess, Angela; Boduroglu, Aysecan

2018-01-02

This cross-sectional experiment examined the influence of aging on cross-cultural differences in memory errors. Previous research revealed that Americans committed more categorical memory errors than Turks; we tested whether the cognitive constraints associated with aging impacted the pattern of memory errors across cultures. Furthermore, older adults are vulnerable to memory errors for semantically-related information, and we assessed whether this tendency occurs across cultures. Younger and older adults from the US and Turkey studied word pairs, with some pairs sharing a categorical relationship and some unrelated. Participants then completed a cued recall test, generating the word that was paired with the first. These responses were scored for correct responses or different types of errors, including categorical and semantic. The tendency for Americans to commit more categorical memory errors emerged for both younger and older adults. In addition, older adults across cultures committed more memory errors, and these were for semantically-related information (including both categorical and other types of semantic errors). Heightened vulnerability to memory errors with age extends across cultural groups, and Americans' proneness to commit categorical memory errors occurs across ages. The findings indicate some robustness in the ways that age and culture influence memory errors.

Digital Particle Image Velocimetry: Partial Image Error (PIE)

International Nuclear Information System (INIS)

Anandarajah, K; Hargrave, G K; Halliwell, N A

2006-01-01

This paper quantifies the errors due to partial imaging of seeding particles which occur at the edges of interrogation regions in Digital Particle Image Velocimetry (DPIV). Hitherto, in the scientific literature the effect of these partial images has been assumed to be negligible. The results show that the error is significant even at a commonly used interrogation region size of 32 x 32 pixels. If correlation of interrogation region sizes of 16 x 16 pixels and smaller is attempted, the error which occurs can preclude meaningful results being obtained. In order to reduce the error normalisation of the correlation peak values is necessary. The paper introduces Normalisation by Signal Strength (NSS) as the preferred means of normalisation for optimum accuracy. In addition, it is shown that NSS increases the dynamic range of DPIV

Ironic Effects of Drawing Attention to Story Errors

Science.gov (United States)

Eslick, Andrea N.; Fazio, Lisa K.; Marsh, Elizabeth J.

2014-01-01

Readers learn errors embedded in fictional stories and use them to answer later general knowledge questions (Marsh, Meade, & Roediger, 2003). Suggestibility is robust and occurs even when story errors contradict well-known facts. The current study evaluated whether suggestibility is linked to participants’ inability to judge story content as correct versus incorrect. Specifically, participants read stories containing correct and misleading information about the world; some information was familiar (making error discovery possible), while some was more obscure. To improve participants’ monitoring ability, we highlighted (in red font) a subset of story phrases requiring evaluation; readers no longer needed to find factual information. Rather, they simply needed to evaluate its correctness. Readers were more likely to answer questions with story errors if they were highlighted in red font, even if they contradicted well-known facts. Though highlighting to-be-evaluated information freed cognitive resources for monitoring, an ironic effect occurred: Drawing attention to specific errors increased rather than decreased later suggestibility. Failure to monitor for errors, not failure to identify the information requiring evaluation, leads to suggestibility. PMID:21294039

Competition increases binding errors in visual working memory.

Science.gov (United States)

Emrich, Stephen M; Ferber, Susanne

2012-04-20

When faced with maintaining multiple objects in visual working memory, item information must be bound to the correct object in order to be correctly recalled. Sometimes, however, binding errors occur, and participants report the feature (e.g., color) of an unprobed, non-target item. In the present study, we examine whether the configuration of sample stimuli affects the proportion of these binding errors. The results demonstrate that participants mistakenly report the identity of the unprobed item (i.e., they make a non-target response) when sample items are presented close together in space, suggesting that binding errors can increase independent of increases in memory load. Moreover, the proportion of these non-target responses is linearly related to the distance between sample items, suggesting that these errors are spatially specific. Finally, presenting sample items sequentially decreases non-target responses, suggesting that reducing competition between sample stimuli reduces the number of binding errors. Importantly, these effects all occurred without increases in the amount of error in the memory representation. These results suggest that competition during encoding can account for some of the binding errors made during VWM recall.

Spent fuel bundle counter sequence error manual - RAPPS (200 MW) NGS

International Nuclear Information System (INIS)

Nicholson, L.E.

1992-01-01

The Spent Fuel Bundle Counter (SFBC) is used to count the number and type of spent fuel transfers that occur into or out of controlled areas at CANDU reactor sites. However if the transfers are executed in a non-standard manner or the SFBC is malfunctioning, the transfers are recorded as sequence errors. Each sequence error message typically contains adequate information to determine the cause of the message. This manual provides a guide to interpret the various sequence error messages that can occur and suggests probable cause or causes of the sequence errors. Each likely sequence error is presented on a 'card' in Appendix A. Note that it would be impractical to generate a sequence error card file with entries for all possible combinations of faults. Therefore the card file contains sequences with only one fault at a time. Some exceptions have been included however where experience has indicated that several faults can occur simultaneously

Spent fuel bundle counter sequence error manual - KANUPP (125 MW) NGS

International Nuclear Information System (INIS)

Nicholson, L.E.

1992-01-01

The Spent Fuel Bundle Counter (SFBC) is used to count the number and type of spent fuel transfers that occur into or out of controlled areas at CANDU reactor sites. However if the transfers are executed in a non-standard manner or the SFBC is malfunctioning, the transfers are recorded as sequence errors. Each sequence error message may contain adequate information to determine the cause of the message. This manual provides a guide to interpret the various sequence error messages that can occur and suggests probable cause or causes of the sequence errors. Each likely sequence error is presented on a 'card' in Appendix A. Note that it would be impractical to generate a sequence error card file with entries for all possible combinations of faults. Therefore the card file contains sequences with only one fault at a time. Some exceptions have been included however where experience has indicated that several faults can occur simultaneously

Error identification and recovery by student nurses using human patient simulation: opportunity to improve patient safety.

Science.gov (United States)

Henneman, Elizabeth A; Roche, Joan P; Fisher, Donald L; Cunningham, Helene; Reilly, Cheryl A; Nathanson, Brian H; Henneman, Philip L

2010-02-01

This study examined types of errors that occurred or were recovered in a simulated environment by student nurses. Errors occurred in all four rule-based error categories, and all students committed at least one error. The most frequent errors occurred in the verification category. Another common error was related to physician interactions. The least common errors were related to coordinating information with the patient and family. Our finding that 100% of student subjects committed rule-based errors is cause for concern. To decrease errors and improve safe clinical practice, nurse educators must identify effective strategies that students can use to improve patient surveillance. Copyright 2010 Elsevier Inc. All rights reserved.

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

Prescribing Errors in Cardiovascular Diseases in a Tertiary Health ...

African Journals Online (AJOL)

Prescription errors are now known to be contributing to a large number of deaths during the treatment of cardiovascular diseases. However, there is paucity of information about these errors occurring in health facilities in Nigeria. The objective of this study was to investigate the prevalence of prescribing errors in ...

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

Medication errors in anaesthetic practice: a report of two cases and ...

African Journals Online (AJOL)

EB

2013-09-03

Sep 3, 2013 ... Key words: Medication errors, anaesthetic practice, vigilance, safety .... reports in the Australian Incident Monitoring Study. (AIMS). ... contribute to systems failure and prescription errors were most ... being due to equipment error.17 Previous studies have ... errors reported occurred during day shifts and they.

A Simulation-Based Soft Error Estimation Methodology for Computer Systems

OpenAIRE

Sugihara, Makoto; Ishihara, Tohru; Hashimoto, Koji; Muroyama, Masanori

2006-01-01

This paper proposes a simulation-based soft error estimation methodology for computer systems. Accumulating soft error rates (SERs) of all memories in a computer system results in pessimistic soft error estimation. This is because memory cells are used spatially and temporally and not all soft errors in them make the computer system faulty. Our soft-error estimation methodology considers the locations and the timings of soft errors occurring at every level of memory hierarchy and estimates th...

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

Stochastic and sensitivity analysis of shape error of inflatable antenna reflectors

Science.gov (United States)

San, Bingbing; Yang, Qingshan; Yin, Liwei

2017-03-01

Inflatable antennas are promising candidates to realize future satellite communications and space observations since they are lightweight, low-cost and small-packaged-volume. However, due to their high flexibility, inflatable reflectors are difficult to manufacture accurately, which may result in undesirable shape errors, and thus affect their performance negatively. In this paper, the stochastic characteristics of shape errors induced during manufacturing process are investigated using Latin hypercube sampling coupled with manufacture simulations. Four main random error sources are involved, including errors in membrane thickness, errors in elastic modulus of membrane, boundary deviations and pressure variations. Using regression and correlation analysis, a global sensitivity study is conducted to rank the importance of these error sources. This global sensitivity analysis is novel in that it can take into account the random variation and the interaction between error sources. Analyses are parametrically carried out with various focal-length-to-diameter ratios (F/D) and aperture sizes (D) of reflectors to investigate their effects on significance ranking of error sources. The research reveals that RMS (Root Mean Square) of shape error is a random quantity with an exponent probability distribution and features great dispersion; with the increase of F/D and D, both mean value and standard deviation of shape errors are increased; in the proposed range, the significance ranking of error sources is independent of F/D and D; boundary deviation imposes the greatest effect with a much higher weight than the others; pressure variation ranks the second; error in thickness and elastic modulus of membrane ranks the last with very close sensitivities to pressure variation. Finally, suggestions are given for the control of the shape accuracy of reflectors and allowable values of error sources are proposed from the perspective of reliability.

Error threshold ghosts in a simple hypercycle with error prone self-replication

International Nuclear Information System (INIS)

Sardanyes, Josep

2008-01-01

A delayed transition because of mutation processes is shown to happen in a simple hypercycle composed by two indistinguishable molecular species with error prone self-replication. The appearance of a ghost near the hypercycle error threshold causes a delay in the extinction and thus in the loss of information of the mutually catalytic replicators, in a kind of information memory. The extinction time, τ, scales near bifurcation threshold according to the universal square-root scaling law i.e. τ ∼ (Q hc - Q) -1/2 , typical of dynamical systems close to a saddle-node bifurcation. Here, Q hc represents the bifurcation point named hypercycle error threshold, involved in the change among the asymptotic stability phase and the so-called Random Replication State (RRS) of the hypercycle; and the parameter Q is the replication quality factor. The ghost involves a longer transient towards extinction once the saddle-node bifurcation has occurred, being extremely long near the bifurcation threshold. The role of this dynamical effect is expected to be relevant in fluctuating environments. Such a phenomenon should also be found in larger hypercycles when considering the hypercycle species in competition with their error tail. The implications of the ghost in the survival and evolution of error prone self-replicating molecules with hypercyclic organization are discussed

Quantum error-correcting code for ternary logic

Science.gov (United States)

Majumdar, Ritajit; Basu, Saikat; Ghosh, Shibashis; Sur-Kolay, Susmita

2018-05-01

Ternary quantum systems are being studied because they provide more computational state space per unit of information, known as qutrit. A qutrit has three basis states, thus a qubit may be considered as a special case of a qutrit where the coefficient of one of the basis states is zero. Hence both (2 ×2 ) -dimensional and (3 ×3 ) -dimensional Pauli errors can occur on qutrits. In this paper, we (i) explore the possible (2 ×2 ) -dimensional as well as (3 ×3 ) -dimensional Pauli errors in qutrits and show that any pairwise bit swap error can be expressed as a linear combination of shift errors and phase errors, (ii) propose a special type of error called a quantum superposition error and show its equivalence to arbitrary rotation, (iii) formulate a nine-qutrit code which can correct a single error in a qutrit, and (iv) provide its stabilizer and circuit realization.

Normalization of Deviation: Quotation Error in Human Factors.

Science.gov (United States)

Lock, Jordan; Bearman, Chris

2018-05-01

Objective The objective of this paper is to examine quotation error in human factors. Background Science progresses through building on the work of previous research. This requires accurate quotation. Quotation error has a number of adverse consequences: loss of credibility, loss of confidence in the journal, and a flawed basis for academic debate and scientific progress. Quotation error has been observed in a number of domains, including marine biology and medicine, but there has been little or no previous study of this form of error in human factors, a domain that specializes in the causes and management of error. Methods A study was conducted examining quotation accuracy of 187 extracts from 118 published articles that cited a control article (Vaughan's 1996 book: The Challenger Launch Decision: Risky Technology, Culture, and Deviance at NASA). Results Of extracts studied, 12.8% ( n = 24) were classed as inaccurate, with 87.2% ( n = 163) being classed as accurate. A second dimension of agreement was examined with 96.3% ( n = 180) agreeing with the control article and only 3.7% ( n = 7) disagreeing. The categories of accuracy and agreement form a two by two matrix. Conclusion Rather than simply blaming individuals for quotation error, systemic factors should also be considered. Vaughan's theory, normalization of deviance, is one systemic theory that can account for quotation error. Application Quotation error is occurring in human factors and should receive more attention. According to Vaughan's theory, the normal everyday systems that promote scholarship may also allow mistakes, mishaps, and quotation error to occur.

Correlated Errors in the Surface Code

Science.gov (United States)

Lopez, Daniel; Mucciolo, E. R.; Novais, E.

2012-02-01

A milestone step into the development of quantum information technology would be the ability to design and operate a reliable quantum memory. The greatest obstacle to create such a device has been decoherence due to the unavoidable interaction between the quantum system and its environment. Quantum Error Correction is therefore an essential ingredient to any quantum computing information device. A great deal of attention has been given to surface codes, since it has very good scaling properties. In this seminar, we discuss the time evolution of a qubit encoded in the logical basis of a surface code. The system is interacting with a bosonic environment at zero temperature. Our results show how much spatial and time correlations can be detrimental to the efficiency of the code.

[Monitoring medication errors in an internal medicine service].

Science.gov (United States)

Smith, Ann-Loren M; Ruiz, Inés A; Jirón, Marcela A

2014-01-01

Patients admitted to internal medicine services receive multiple drugs and thus are at risk of medication errors. To determine the frequency of medication errors (ME) among patients admitted to an internal medicine service of a high complexity hospital. A prospective observational study conducted in 225 patients admitted to an internal medicine service. Each stage of drug utilization system (prescription, transcription, dispensing, preparation and administration) was directly observed by trained pharmacists not related to hospital staff during three months. ME were described and categorized according to the National Coordinating Council for Medication Error Reporting and Prevention. In each stage of medication use, the frequency of ME and their characteristics were determined. A total of 454 drugs were prescribed to the studied patients. In 138 (30,4%) indications, at least one ME occurred, involving 67 (29,8%) patients. Twenty four percent of detected ME occurred during administration, mainly due to wrong time schedules. Anticoagulants were the therapeutic group with the highest occurrence of ME. At least one ME occurred in approximately one third of patients studied, especially during the administration stage. These errors could affect the medication safety and avoid achieving therapeutic goals. Strategies to improve the quality and safe use of medications can be implemented using this information.

Errors in the administration of intravenous medication in Brazilian hospitals.

Science.gov (United States)

Anselmi, Maria Luiza; Peduzzi, Marina; Dos Santos, Claudia Benedita

2007-10-01

To verify the frequency of errors in the preparation and administration of intravenous medication in three Brazilian hospitals in the State of Bahia. The administration of intravenous medications constitutes a central activity in Brazilian nursing. Errors in performing this activity may result in irreparable damage to patients and may compromise the quality of care. Cross-sectional study, conducted in three hospitals in the State of Bahia, Brazil. Direct observation of the nursing staff (nurse technicians, auxiliary nurses and nurse attendants), preparing and administering intravenous medication. When preparing medication, wrong patient error did not occur in any of the three hospitals, whereas omission dose was the most frequent error in all study sites. When administering medication, the most frequent errors in the three hospitals were wrong dose and omission dose. The rates of error found are considered low compared with similar studies. The most frequent types of errors were wrong dose and omission dose. The hospitals studied showed different results with the smallest rates of errors occurring in hospital 1 that presented the best working conditions. Relevance to clinical practice. Studies such as this one have the potential to improve the quality of care.

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...

Greatest Happiness Principle in a Complex System: Maximisation versus Driving Force

Directory of Open Access Journals (Sweden)

Katalin Martinás

2012-06-01

Full Text Available From philosophical point of view, micro-founded economic theories depart from the principle of the pursuit of the greatest happiness. From mathematical point of view, micro-founded economic theories depart from the utility maximisation program. Though economists are aware of the serious limitations of the equilibrium analysis, they remain in that framework. We show that the maximisation principle, which implies the equilibrium hypothesis, is responsible for this impasse. We formalise the pursuit of the greatest happiness principle by the help of the driving force postulate: the volumes of activities depend on the expected wealth increase. In that case we can get rid of the equilibrium hypothesis and have new insights into economic theory. For example, in what extent standard economic results depend on the equilibrium hypothesis?

Association of medication errors with drug classifications, clinical units, and consequence of errors: Are they related?

Science.gov (United States)

Muroi, Maki; Shen, Jay J; Angosta, Alona

2017-02-01

Registered nurses (RNs) play an important role in safe medication administration and patient safety. This study examined a total of 1276 medication error (ME) incident reports made by RNs in hospital inpatient settings in the southwestern region of the United States. The most common drug class associated with MEs was cardiovascular drugs (24.7%). Among this class, anticoagulants had the most errors (11.3%). The antimicrobials was the second most common drug class associated with errors (19.1%) and vancomycin was the most common antimicrobial that caused errors in this category (6.1%). MEs occurred more frequently in the medical-surgical and intensive care units than any other hospital units. Ten percent of MEs reached the patients with harm and 11% reached the patients with increased monitoring. Understanding the contributing factors related to MEs, addressing and eliminating risk of errors across hospital units, and providing education and resources for nurses may help reduce MEs. Copyright © 2016 Elsevier Inc. All rights reserved.

Learning from your mistakes: The functional value of spontaneous error monitoring in aphasia

Directory of Open Access Journals (Sweden)

Erica L. Middleton

2014-04-01

Ex. 4.\t(T = umbrella “umbelella, umbrella”: Phonological error; DetCorr We used mixed effects logistic regression to assess whether the log odds of changing from error to correct was predicted by monitoring status of the error (DetCorr vs. NoDet; DetNoCorr vs. NoDet; whether the monitoring benefit interacted with direction of change (forward, backward; and whether effects varied by error type. Figure 1 (top shows that the proportion accuracy change was higher for DetCorr, relative to NoDet, consistent with a monitoring benefit. The difference in log odds was significant for semantic errors in both directions (forward: coeff. = -1.73; z= -7.78; p < .001; backward: coeff = -0.92; z= -3.60; p < .001, and for phonological errors in both directions (forward: coeff. = -0.74; z= -2.73; p=.006; backward : coeff. = -.76; z = -2.73; p = .006. The difference between DetNoCorr and NoDet was not significant in any condition. Figure 1 (bottom shows that for Semantic errors, there was a directional asymmetry favoring the Forward condition (interaction: coeff. = .79; z = 2.32; p = .02. Phonological errors, in contrast, produced comparable effects in Forward and Backward direction. The results demonstrated a benefit for errors that were detected and corrected. This monitoring benefit was present in both the forward and backward direction, supporting the Strength hypothesis. Of greatest interest, the monitoring benefit for Semantic errors was greater in the forward than backward direction, indicating a role for learning.

Error Tendencies in Processing Student Feedback for Instructional Decision Making.

Science.gov (United States)

Schermerhorn, John R., Jr.; And Others

1985-01-01

Seeks to assist instructors in recognizing two basic errors that can occur in processing student evaluation data on instructional development efforts; offers a research framework for future investigations of the error tendencies and related issues; and suggests ways in which instructors can confront and manage error tendencies in practice. (MBR)

NDE errors and their propagation in sizing and growth estimates

International Nuclear Information System (INIS)

Horn, D.; Obrutsky, L.; Lakhan, R.

2009-01-01

this work, additional calculations can be performed as needed. Changes in the identification of correlated effects, the magnitude of errors, and the analytical form of voltage response can be made easily. The calculated errors on growth may be used to reduce conservative margins on plugging limits and the sensitivity analysis can be used to identify the technique improvements that would provide the greatest benefits. (author)

Medication administration errors in Eastern Saudi Arabia

International Nuclear Information System (INIS)

Mir Sadat-Ali

2010-01-01

To assess the prevalence and characteristics of medication errors (ME) in patients admitted to King Fahd University Hospital, Alkhobar, Kingdom of Saudi Arabia. Medication errors are documented by the nurses and physicians standard reporting forms (Hospital Based Incident Report). The study was carried out in King Fahd University Hospital, Alkhobar, Kingdom of Saudi Arabia and all the incident reports were collected during the period from January 2008 to December 2009. The incident reports were analyzed for age, gender, nationality, nursing unit, and time where ME was reported. The data were analyzed and the statistical significance differences between groups were determined by Student's t-test, and p-values of <0.05 using confidence interval of 95% were considered significant. There were 38 ME reported for the study period. The youngest patient was 5 days and the oldest 70 years. There were 31 Saudis, and 7 non-Saudi patients involved. The most common error was missed medication, which was seen in 15 (39.5%) patients. Over 15 (39.5%) of errors occurred in 2 units (pediatric medicine, and obstetrics and gynecology). Nineteen (50%) of the errors occurred during the 3-11 pm shift. Our study shows that the prevalence of ME in our institution is low, in comparison with the world literature. This could be due to under reporting of the errors, and we believe that ME reporting should be made less punitive so that ME can be studied and preventive measures implemented (Author).

Stigma and Discrimination in HIV/AIDS; The greatest Challenge to ...

African Journals Online (AJOL)

The greatest challenge to the efforts of the various agencies and governments in the care, support and treatment of people living with HIV/AIDS, appears to be stigma and discrimination. Stigma and discrimination has to be addressed through public education, legislation to protect people living with HIV/AIDS and also by ...

Analysis of the interface tracking errors

International Nuclear Information System (INIS)

Cerne, G.; Tiselj, I.; Petelin, S.

2001-01-01

An important limitation of the interface-tracking algorithm is the grid density, which determines the space scale of the surface tracking. In this paper the analysis of the interface tracking errors, which occur in a dispersed flow, is performed for the VOF interface tracking method. A few simple two-fluid tests are proposed for the investigation of the interface tracking errors and their grid dependence. When the grid density becomes too coarse to follow the interface changes, the errors can be reduced either by using denser nodalization or by switching to the two-fluid model during the simulation. Both solutions are analyzed and compared on a simple vortex-flow test.(author)

Error estimation in plant growth analysis

Directory of Open Access Journals (Sweden)

Andrzej Gregorczyk

2014-01-01

Full Text Available The scheme is presented for calculation of errors of dry matter values which occur during approximation of data with growth curves, determined by the analytical method (logistic function and by the numerical method (Richards function. Further formulae are shown, which describe absolute errors of growth characteristics: Growth rate (GR, Relative growth rate (RGR, Unit leaf rate (ULR and Leaf area ratio (LAR. Calculation examples concerning the growth course of oats and maize plants are given. The critical analysis of the estimation of obtained results has been done. The purposefulness of joint application of statistical methods and error calculus in plant growth analysis has been ascertained.

Audit of medication errors by anesthetists in North Western Nigeria ...

African Journals Online (AJOL)

... errors do occur in the everyday practice of anesthetists in Nigeria as in other countries and can lead to morbidity and mortality in our patients. Routine audit and reporting of critical incidents including errors in drug administration should be encouraged. Reduction of medication errors is an important aspect of patient safety, ...

North error estimation based on solar elevation errors in the third step of sky-polarimetric Viking navigation.

Science.gov (United States)

Száz, Dénes; Farkas, Alexandra; Barta, András; Kretzer, Balázs; Egri, Ádám; Horváth, Gábor

2016-07-01

The theory of sky-polarimetric Viking navigation has been widely accepted for decades without any information about the accuracy of this method. Previously, we have measured the accuracy of the first and second steps of this navigation method in psychophysical laboratory and planetarium experiments. Now, we have tested the accuracy of the third step in a planetarium experiment, assuming that the first and second steps are errorless. Using the fists of their outstretched arms, 10 test persons had to estimate the elevation angles (measured in numbers of fists and fingers) of black dots (representing the position of the occluded Sun) projected onto the planetarium dome. The test persons performed 2400 elevation estimations, 48% of which were more accurate than ±1°. We selected three test persons with the (i) largest and (ii) smallest elevation errors and (iii) highest standard deviation of the elevation error. From the errors of these three persons, we calculated their error function, from which the North errors (the angles with which they deviated from the geographical North) were determined for summer solstice and spring equinox, two specific dates of the Viking sailing period. The range of possible North errors Δ ω N was the lowest and highest at low and high solar elevations, respectively. At high elevations, the maximal Δ ω N was 35.6° and 73.7° at summer solstice and 23.8° and 43.9° at spring equinox for the best and worst test person (navigator), respectively. Thus, the best navigator was twice as good as the worst one. At solstice and equinox, high elevations occur the most frequently during the day, thus high North errors could occur more frequently than expected before. According to our findings, the ideal periods for sky-polarimetric Viking navigation are immediately after sunrise and before sunset, because the North errors are the lowest at low solar elevations.

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.

Human errors, countermeasures for their prevention and evaluation

International Nuclear Information System (INIS)

Kohda, Takehisa; Inoue, Koichi

1992-01-01

The accidents originated in human errors have occurred as ever in recent large accidents such as the TMI accident and the Chernobyl accident. The proportion of the accidents originated in human errors is unexpectedly high, therefore, the reliability and safety of hardware are improved hereafter, but the improvement of human reliability cannot be expected. Human errors arise by the difference between the function required for men and the function actually accomplished by men, and the results exert some adverse effect to systems. Human errors are classified into design error, manufacture error, operation error, maintenance error, checkup error and general handling error. In terms of behavior, human errors are classified into forget to do, fail to do, do that must not be done, mistake in order and do at improper time. The factors in human error occurrence are circumstantial factor, personal factor and stress factor. As the method of analyzing and evaluating human errors, system engineering method such as probabilistic risk assessment is used. The technique for human error rate prediction, the method for human cognitive reliability, confusion matrix and SLIM-MAUD are also used. (K.I.)

Iatrogenic medication errors in a paediatric intensive care unit in ...

African Journals Online (AJOL)

Errors most frequently encountered included failure to calculate rates of infusion and the conversion of mL to mEq or mL to mg for potassium, phenobarbitone and digoxin. Of the 117 children admitted, 111 (94.9%) were exposed to at least one medication error. Two or more medication errors occurred in 34.1% of cases.

Reducing patient identification errors related to glucose point-of-care testing

Directory of Open Access Journals (Sweden)

Gaurav Alreja

2011-01-01

Full Text Available Background: Patient identification (ID errors in point-of-care testing (POCT can cause test results to be transferred to the wrong patient′s chart or prevent results from being transmitted and reported. Despite the implementation of patient barcoding and ongoing operator training at our institution, patient ID errors still occur with glucose POCT. The aim of this study was to develop a solution to reduce identification errors with POCT. Materials and Methods: Glucose POCT was performed by approximately 2,400 clinical operators throughout our health system. Patients are identified by scanning in wristband barcodes or by manual data entry using portable glucose meters. Meters are docked to upload data to a database server which then transmits data to any medical record matching the financial number of the test result. With a new model, meters connect to an interface manager where the patient ID (a nine-digit account number is checked against patient registration data from admission, discharge, and transfer (ADT feeds and only matched results are transferred to the patient′s electronic medical record. With the new process, the patient ID is checked prior to testing, and testing is prevented until ID errors are resolved. Results: When averaged over a period of a month, ID errors were reduced to 3 errors/month (0.015% in comparison with 61.5 errors/month (0.319% before implementing the new meters. Conclusion: Patient ID errors may occur with glucose POCT despite patient barcoding. The verification of patient identification should ideally take place at the bedside before testing occurs so that the errors can be addressed in real time. The introduction of an ADT feed directly to glucose meters reduced patient ID errors in POCT.

New method of classifying human errors at nuclear power plants and the analysis results of applying this method to maintenance errors at domestic plants

International Nuclear Information System (INIS)

Takagawa, Kenichi; Miyazaki, Takamasa; Gofuku, Akio; Iida, Hiroyasu

2007-01-01

Since many of the adverse events that have occurred in nuclear power plants in Japan and abroad have been related to maintenance or operation, it is necessary to plan preventive measures based on detailed analyses of human errors made by maintenance workers or operators. Therefore, before planning preventive measures, we developed a new method of analyzing human errors. Since each human error is an unsafe action caused by some misjudgement made by a person, we decided to classify them into six categories according to the stage in the judgment process in which the error was made. By further classifying each error into either an omission-type or commission-type, we produced 12 categories of errors. Then, we divided them into the two categories of basic error tendencies and individual error tendencies, and categorized background factors into four categories: imperfect planning; imperfect facilities or tools; imperfect environment; and imperfect instructions or communication. We thus defined the factors in each category to make it easy to identify factors that caused the error. Then using this method, we studied the characteristics of human errors that involved maintenance workers and planners since many maintenance errors have occurred. Among the human errors made by workers (worker errors) during the implementation stage, the following three types were prevalent with approximately 80%: commission-type 'projection errors', omission-type comprehension errors' and commission type 'action errors'. The most common among the individual factors of worker errors was 'repetition or habit' (schema), based on the assumption of a typical situation, and the half number of the 'repetition or habit' cases (schema) were not influenced by any background factors. The most common background factor that contributed to the individual factor was 'imperfect work environment', followed by 'insufficient knowledge'. Approximately 80% of the individual factors were 'repetition or habit' or

Wind Power Forecasting Error Distributions: An International Comparison

DEFF Research Database (Denmark)

Hodge, Bri-Mathias; Lew, Debra; Milligan, Michael

2012-01-01

Wind power forecasting is essential for greater penetration of wind power into electricity systems. Because no wind forecasting system is perfect, a thorough understanding of the errors that may occur is a critical factor for system operation functions, such as the setting of operating reserve...... levels. This paper provides an international comparison of the distribution of wind power forecasting errors from operational systems, based on real forecast data. The paper concludes with an assessment of similarities and differences between the errors observed in different locations....

Automated Classification of Phonological Errors in Aphasic Language

Science.gov (United States)

Ahuja, Sanjeev B.; Reggia, James A.; Berndt, Rita S.

1984-01-01

Using heuristically-guided state space search, a prototype program has been developed to simulate and classify phonemic errors occurring in the speech of neurologically-impaired patients. Simulations are based on an interchangeable rule/operator set of elementary errors which represent a theory of phonemic processing faults. This work introduces and evaluates a novel approach to error simulation and classification, it provides a prototype simulation tool for neurolinguistic research, and it forms the initial phase of a larger research effort involving computer modelling of neurolinguistic processes.

Was ocean acidification responsible for history's greatest extinction?

Science.gov (United States)

Schultz, Colin

2011-11-01

Two hundred fifty million years ago, the world suffered the greatest recorded extinction of all time. More than 90% of marine animals and a majority of terrestrial species disappeared, yet the cause of the Permian-Triassic boundary (PTB) dieoff remains unknown. Various theories abound, with most focusing on rampant Siberian volcanism and its potential consequences: global warming, carbon dioxide poisoning, ocean acidification, or the severe drawdown of oceanic dissolved oxygen levels, also known as anoxia. To narrow the range of possible causes, Montenegro et al. ran climate simulations for PTB using the University of Victoria Earth System Climate Model, a carbon cycle-climate coupled general circulation model.

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.

Error in the delivery of radiation therapy: Results of a quality assurance review

International Nuclear Information System (INIS)

Huang, Grace; Medlam, Gaylene; Lee, Justin; Billingsley, Susan; Bissonnette, Jean-Pierre; Ringash, Jolie; Kane, Gabrielle; Hodgson, David C.

2005-01-01

Purpose: To examine error rates in the delivery of radiation therapy (RT), technical factors associated with RT errors, and the influence of a quality improvement intervention on the RT error rate. Methods and materials: We undertook a review of all RT errors that occurred at the Princess Margaret Hospital (Toronto) from January 1, 1997, to December 31, 2002. Errors were identified according to incident report forms that were completed at the time the error occurred. Error rates were calculated per patient, per treated volume (≥1 volume per patient), and per fraction delivered. The association between tumor site and error was analyzed. Logistic regression was used to examine the association between technical factors and the risk of error. Results: Over the study interval, there were 555 errors among 28,136 patient treatments delivered (error rate per patient = 1.97%, 95% confidence interval [CI], 1.81-2.14%) and among 43,302 treated volumes (error rate per volume = 1.28%, 95% CI, 1.18-1.39%). The proportion of fractions with errors from July 1, 2000, to December 31, 2002, was 0.29% (95% CI, 0.27-0.32%). Patients with sarcoma or head-and-neck tumors experienced error rates significantly higher than average (5.54% and 4.58%, respectively); however, when the number of treated volumes was taken into account, the head-and-neck error rate was no longer higher than average (1.43%). The use of accessories was associated with an increased risk of error, and internal wedges were more likely to be associated with an error than external wedges (relative risk = 2.04; 95% CI, 1.11-3.77%). Eighty-seven errors (15.6%) were directly attributed to incorrect programming of the 'record and verify' system. Changes to planning and treatment processes aimed at reducing errors within the head-and-neck site group produced a substantial reduction in the error rate. Conclusions: Errors in the delivery of RT are uncommon and usually of little clinical significance. Patient subgroups and

Coping and acceptance: the greatest challenge for veterans with intestinal stomas.

Science.gov (United States)

Krouse, Robert S; Grant, Marcia; Rawl, Susan M; Mohler, M Jane; Baldwin, Carol M; Coons, Stephen Joel; McCorkle, Ruth; Schmidt, C Max; Ko, Clifford Y

2009-03-01

Intestinal stomas (ostomies) create challenges for veterans. The goal of this qualitative analysis was to understand better patients' perspectives regarding their greatest challenge. Ostomates at three Veterans Affairs locations were surveyed using the modified City of Hope Quality of Life-Ostomy questionnaire that contained an open-ended request for respondents to describe their greatest challenge. The response rate was 51% (239 of 467); 68% (163 of 239) completed the open-ended item. Content analysis was performed by an experienced qualitative research team. Coping and acceptance were the most commonly addressed themes. The most frequently expressed issues and advice were related to a need for positive thinking and insight regarding adjustment over time. Coping strategies included the use of humor, recognition of positive changes resulting from the stoma, and normalization of life with an ostomy. Coping and acceptance are common themes described by veterans with an intestinal stoma. Health-care providers can assist veterans by utilizing ostomate self-management strategies, experience, and advice.

Nursing Errors in Intensive Care Unit by Human Error Identification in Systems Tool: A Case Study

Directory of Open Access Journals (Sweden)

Nezamodini

2016-03-01

Full Text Available Background Although health services are designed and implemented to improve human health, the errors in health services are a very common phenomenon and even sometimes fatal in this field. Medical errors and their cost are global issues with serious consequences for the patients’ community that are preventable and require serious attention. Objectives The current study aimed to identify possible nursing errors applying human error identification in systems tool (HEIST in the intensive care units (ICUs of hospitals. Patients and Methods This descriptive research was conducted in the intensive care unit of a hospital in Khuzestan province in 2013. Data were collected through observation and interview by nine nurses in this section in a period of four months. Human error classification was based on Rose and Rose and Swain and Guttmann models. According to HEIST work sheets the guide questions were answered and error causes were identified after the determination of the type of errors. Results In total 527 errors were detected. The performing operation on the wrong path had the highest frequency which was 150, and the second rate with a frequency of 136 was doing the tasks later than the deadline. Management causes with a frequency of 451 were the first rank among identified errors. Errors mostly occurred in the system observation stage and among the performance shaping factors (PSFs, time was the most influencing factor in occurrence of human errors. Conclusions Finally, in order to prevent the occurrence and reduce the consequences of identified errors the following suggestions were proposed : appropriate training courses, applying work guidelines and monitoring their implementation, increasing the number of work shifts, hiring professional workforce, equipping work space with appropriate facilities and equipment.

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.

Scaffolding--How Can Contingency Lead to Successful Learning When Dealing with Errors?

Science.gov (United States)

Wischgoll, Anke; Pauli, Christine; Reusser, Kurt

2015-01-01

Errors indicate learners' misunderstanding and can provide learning opportunities. Providing learning support which is contingent on learners' needs when errors occur is considered effective for developing learners' understanding. The current investigation examines how tutors and tutees interact productively with errors when working on a…

The greatest hydroelectric power plant in the world. Itaipu Hydroelectric Power Plant

International Nuclear Information System (INIS)

Andonov - Chento, Ilija

2004-01-01

Details to demonstrate the size and engineering achievements of one of the world's greatest hydroelectric power plant are given. Principal technical features of construction and operation of the Itaipu Dam are tabulated and discussed

Managing organizational errors: Three theoretical lenses on a bank collapse

OpenAIRE

Giolito, Vincent

2015-01-01

Errors have been shown to be a major source of organizational disasters, yet scant research has paid attention to the management of errors that is, what managers do once errors have occurred and how actions may determine outcomes. In an early attempt to build a theory of the management of organizational errors, this paper examines how extant theory applies to the collapse of a bank. The financial industry was chosen because of the systemic risks it entails, as demonstrated by the financial cr...

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.

Learning from mistakes. Factors that influence how students and residents learn from medical errors.

Science.gov (United States)

Fischer, Melissa A; Mazor, Kathleen M; Baril, Joann; Alper, Eric; DeMarco, Deborah; Pugnaire, Michele

2006-05-01

Trainees are exposed to medical errors throughout medical school and residency. Little is known about what facilitates and limits learning from these experiences. To identify major factors and areas of tension in trainees' learning from medical errors. Structured telephone interviews with 59 trainees (medical students and residents) from 1 academic medical center. Five authors reviewed transcripts of audiotaped interviews using content analysis. Trainees were aware that medical errors occur from early in medical school. Many had an intense emotional response to the idea of committing errors in patient care. Students and residents noted variation and conflict in institutional recommendations and individual actions. Many expressed role confusion regarding whether and how to initiate discussion after errors occurred. Some noted the conflict between reporting errors to seniors who were responsible for their evaluation. Learners requested more open discussion of actual errors and faculty disclosure. No students or residents felt that they learned better from near misses than from actual errors, and many believed that they learned the most when harm was caused. Trainees are aware of medical errors, but remaining tensions may limit learning. Institutions can immediately address variability in faculty response and local culture by disseminating clear, accessible algorithms to guide behavior when errors occur. Educators should develop longitudinal curricula that integrate actual cases and faculty disclosure. Future multi-institutional work should focus on identified themes such as teaching and learning in emotionally charged situations, learning from errors and near misses and balance between individual and systems responsibility.

The treatment of commission errors in first generation human reliability analysis methods

Energy Technology Data Exchange (ETDEWEB)

Alvarengga, Marco Antonio Bayout; Fonseca, Renato Alves da, E-mail: bayout@cnen.gov.b, E-mail: rfonseca@cnen.gov.b [Comissao Nacional de Energia Nuclear (CNEN) Rio de Janeiro, RJ (Brazil); Melo, Paulo Fernando Frutuoso e, E-mail: frutuoso@nuclear.ufrj.b [Coordenacao dos Programas de Pos-Graduacao de Engenharia (PEN/COPPE/UFRJ), RJ (Brazil). Programa de Engenharia Nuclear

2011-07-01

Human errors in human reliability analysis can be classified generically as errors of omission and commission errors. Omission errors are related to the omission of any human action that should have been performed, but does not occur. Errors of commission are those related to human actions that should not be performed, but which in fact are performed. Both involve specific types of cognitive error mechanisms, however, errors of commission are more difficult to model because they are characterized by non-anticipated actions that are performed instead of others that are omitted (omission errors) or are entered into an operational task without being part of the normal sequence of this task. The identification of actions that are not supposed to occur depends on the operational context that will influence or become easy certain unsafe actions of the operator depending on the operational performance of its parameters and variables. The survey of operational contexts and associated unsafe actions is a characteristic of second-generation models, unlike the first generation models. This paper discusses how first generation models can treat errors of commission in the steps of detection, diagnosis, decision-making and implementation, in the human information processing, particularly with the use of THERP tables of errors quantification. (author)

The two errors of using the within-subject standard deviation (WSD) as the standard error of a reliable change index.

Science.gov (United States)

Maassen, Gerard H

2010-08-01

In this Journal, Lewis and colleagues introduced a new Reliable Change Index (RCI(WSD)), which incorporated the within-subject standard deviation (WSD) of a repeated measurement design as the standard error. In this note, two opposite errors in using WSD this way are demonstrated. First, being the standard error of measurement of only a single assessment makes WSD too small when practice effects are absent. Then, too many individuals will be designated reliably changed. Second, WSD can grow unlimitedly to the extent that differential practice effects occur. This can even make RCI(WSD) unable to detect any reliable change.

Error Distributions on Large Entangled States with Non-Markovian Dynamics

DEFF Research Database (Denmark)

McCutcheon, Dara; Lindner, Netanel H.; Rudolph, Terry

2014-01-01

We investigate the distribution of errors on a computationally useful entangled state generated via the repeated emission from an emitter undergoing strongly non-Markovian evolution. For emitter-environment coupling of pure-dephasing form, we show that the probability that a particular patten...... of errors occurs has a bound of Markovian form, and thus, accuracy threshold theorems based on Markovian models should be just as effective. Beyond the pure-dephasing assumption, though complicated error structures can arise, they can still be qualitatively bounded by a Markovian error model....

The epidemiology and type of medication errors reported to the National Poisons Information Centre of Ireland.

Science.gov (United States)

Cassidy, Nicola; Duggan, Edel; Williams, David J P; Tracey, Joseph A

2011-07-01

Medication errors are widely reported for hospitalised patients, but limited data are available for medication errors that occur in community-based and clinical settings. Epidemiological data from poisons information centres enable characterisation of trends in medication errors occurring across the healthcare spectrum. The objective of this study was to characterise the epidemiology and type of medication errors reported to the National Poisons Information Centre (NPIC) of Ireland. A 3-year prospective study on medication errors reported to the NPIC was conducted from 1 January 2007 to 31 December 2009 inclusive. Data on patient demographics, enquiry source, location, pharmaceutical agent(s), type of medication error, and treatment advice were collated from standardised call report forms. Medication errors were categorised as (i) prescribing error (i.e. physician error), (ii) dispensing error (i.e. pharmacy error), and (iii) administration error involving the wrong medication, the wrong dose, wrong route, or the wrong time. Medication errors were reported for 2348 individuals, representing 9.56% of total enquiries to the NPIC over 3 years. In total, 1220 children and adolescents under 18 years of age and 1128 adults (≥ 18 years old) experienced a medication error. The majority of enquiries were received from healthcare professionals, but members of the public accounted for 31.3% (n = 736) of enquiries. Most medication errors occurred in a domestic setting (n = 2135), but a small number occurred in healthcare facilities: nursing homes (n = 110, 4.68%), hospitals (n = 53, 2.26%), and general practitioner surgeries (n = 32, 1.36%). In children, medication errors with non-prescription pharmaceuticals predominated (n = 722) and anti-pyretics and non-opioid analgesics, anti-bacterials, and cough and cold preparations were the main pharmaceutical classes involved. Medication errors with prescription medication predominated for adults (n = 866) and the major medication

The epidemiology and type of medication errors reported to the National Poisons Information Centre of Ireland.

LENUS (Irish Health Repository)

Cassidy, Nicola

2012-02-01

INTRODUCTION: Medication errors are widely reported for hospitalised patients, but limited data are available for medication errors that occur in community-based and clinical settings. Epidemiological data from poisons information centres enable characterisation of trends in medication errors occurring across the healthcare spectrum. AIM: The objective of this study was to characterise the epidemiology and type of medication errors reported to the National Poisons Information Centre (NPIC) of Ireland. METHODS: A 3-year prospective study on medication errors reported to the NPIC was conducted from 1 January 2007 to 31 December 2009 inclusive. Data on patient demographics, enquiry source, location, pharmaceutical agent(s), type of medication error, and treatment advice were collated from standardised call report forms. Medication errors were categorised as (i) prescribing error (i.e. physician error), (ii) dispensing error (i.e. pharmacy error), and (iii) administration error involving the wrong medication, the wrong dose, wrong route, or the wrong time. RESULTS: Medication errors were reported for 2348 individuals, representing 9.56% of total enquiries to the NPIC over 3 years. In total, 1220 children and adolescents under 18 years of age and 1128 adults (>\\/= 18 years old) experienced a medication error. The majority of enquiries were received from healthcare professionals, but members of the public accounted for 31.3% (n = 736) of enquiries. Most medication errors occurred in a domestic setting (n = 2135), but a small number occurred in healthcare facilities: nursing homes (n = 110, 4.68%), hospitals (n = 53, 2.26%), and general practitioner surgeries (n = 32, 1.36%). In children, medication errors with non-prescription pharmaceuticals predominated (n = 722) and anti-pyretics and non-opioid analgesics, anti-bacterials, and cough and cold preparations were the main pharmaceutical classes involved. Medication errors with prescription medication predominated for

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.

Error Correction for Non-Abelian Topological Quantum Computation

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James R. Wootton

2014-03-01

Full Text Available The possibility of quantum computation using non-Abelian anyons has been considered for over a decade. However, the question of how to obtain and process information about what errors have occurred in order to negate their effects has not yet been considered. This is in stark contrast with quantum computation proposals for Abelian anyons, for which decoding algorithms have been tailor-made for many topological error-correcting codes and error models. Here, we address this issue by considering the properties of non-Abelian error correction, in general. We also choose a specific anyon model and error model to probe the problem in more detail. The anyon model is the charge submodel of D(S_{3}. This shares many properties with important models such as the Fibonacci anyons, making our method more generally applicable. The error model is a straightforward generalization of those used in the case of Abelian anyons for initial benchmarking of error correction methods. It is found that error correction is possible under a threshold value of 7% for the total probability of an error on each physical spin. This is remarkably comparable with the thresholds for Abelian models.

A second study of the prediction of cognitive errors using the 'CREAM' technique

International Nuclear Information System (INIS)

Collier, Steve; Andresen, Gisle

2000-03-01

Some human errors, such as errors of commission and knowledge-based errors, are not adequately modelled in probabilistic safety assessments. Even qualitative methods for handling these sorts of errors are comparatively underdeveloped. The 'Cognitive Reliability and Error Analysis Method' (CREAM) was recently developed for prediction of cognitive error modes. It has not yet been comprehensively established how reliable, valid and generally useful it could be to researchers and practitioners. A previous study of CREAM at Halden was promising, showing a relationship between errors predicted in advance and those that actually occurred in simulated fault scenarios. The present study continues this work. CREAM was used to make predictions of cognitive error modes throughout two rather difficult fault scenarios. Predictions were made of the most likely cognitive error mode, were one to occur at all, at several points throughout the expected scenarios, based upon the scenario design and description. Each scenario was then run 15 times with different operators. Error modes occurring during simulations were later scored using the task description for the scenario, videotapes of operator actions, eye-track recording, operators' verbal protocols and an expert's concurrent commentary. The scoring team had no previous substantive knowledge of the experiment or the techniques used, so as to provide a more stringent test of the data and knowledge needed for scoring. The scored error modes were then compared with the CREAM predictions to assess the degree of agreement. Some cognitive error modes were predicted successfully, but the results were generally not so encouraging as the previous study. Several problems were found with both the CREAM technique and the data needed to complete the analysis. It was felt that further development was needed before this kind of analysis can be reliable and valid, either in a research setting or as a practitioner's tool in a safety assessment

Human Error Assessmentin Minefield Cleaning Operation Using Human Event Analysis

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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.

The Effect of In-Game Errors on Learning Outcomes. CRESST Report 835

Science.gov (United States)

Kerr, Deirdre; Chung, Gregory K. W. K.

2013-01-01

Student mathematical errors are rarely random and often occur because students are applying procedures that they believe to be accurate. Traditional approaches often view such errors as indicators of students' failure to understand the construct in question, but some theorists view errors as opportunities for students to expand their mental model…

A general model of cognitive errors applicable to the behaviour of NPP operators

International Nuclear Information System (INIS)

Senders, J.W.; Moray, N.P.

1986-01-01

Cognitive behaviour is, most generally put, that behaviour which is mental. In the context of Nuclear Power Plant (NPP) operations, cognitive behaviour is that which analyses, judges and transforms information received from the environment; makes use of memory; imposes meaning; predicts, interpolates and extrapolates; decides on and chooses goals, plans and courses of action. Behaviour of these kinds arises in the course of responding to emergencies and it is precisely there that the greatest importance must be attached to errors by operators

Impact of Communication Errors in Radiology on Patient Care, Customer Satisfaction, and Work-Flow Efficiency.

Science.gov (United States)

Siewert, Bettina; Brook, Olga R; Hochman, Mary; Eisenberg, Ronald L

2016-03-01

The purpose of this study is to analyze the impact of communication errors on patient care, customer satisfaction, and work-flow efficiency and to identify opportunities for quality improvement. We performed a search of our quality assurance database for communication errors submitted from August 1, 2004, through December 31, 2014. Cases were analyzed regarding the step in the imaging process at which the error occurred (i.e., ordering, scheduling, performance of examination, study interpretation, or result communication). The impact on patient care was graded on a 5-point scale from none (0) to catastrophic (4). The severity of impact between errors in result communication and those that occurred at all other steps was compared. Error evaluation was performed independently by two board-certified radiologists. Statistical analysis was performed using the chi-square test and kappa statistics. Three hundred eighty of 422 cases were included in the study. One hundred ninety-nine of the 380 communication errors (52.4%) occurred at steps other than result communication, including ordering (13.9%; n = 53), scheduling (4.7%; n = 18), performance of examination (30.0%; n = 114), and study interpretation (3.7%; n = 14). Result communication was the single most common step, accounting for 47.6% (181/380) of errors. There was no statistically significant difference in impact severity between errors that occurred during result communication and those that occurred at other times (p = 0.29). In 37.9% of cases (144/380), there was an impact on patient care, including 21 minor impacts (5.5%; result communication, n = 13; all other steps, n = 8), 34 moderate impacts (8.9%; result communication, n = 12; all other steps, n = 22), and 89 major impacts (23.4%; result communication, n = 45; all other steps, n = 44). In 62.1% (236/380) of cases, no impact was noted, but 52.6% (200/380) of cases had the potential for an impact. Among 380 communication errors in a radiology department, 37

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

Defining near misses : towards a sharpened definition based on empirical data about error handling processes

NARCIS (Netherlands)

Kessels-Habraken, M.M.P.; Schaaf, van der T.W.; Jonge, de J.; Rutte, C.G.

2010-01-01

Medical errors in health care still occur frequently. Unfortunately, errors cannot be completely prevented and 100% safety can never be achieved. Therefore, in addition to error reduction strategies, health care organisations could also implement strategies that promote timely error detection and

A Human Error Analysis Procedure for Identifying Potential Error Modes and Influencing Factors for Test and Maintenance Activities

International Nuclear Information System (INIS)

Kim, Jae Whan; Park, Jin Kyun

2010-01-01

Periodic or non-periodic test and maintenance (T and M) activities in large, complex systems such as nuclear power plants (NPPs) are essential for sustaining stable and safe operation of the systems. On the other hand, it also has been raised that human erroneous actions that might occur during T and M activities has the possibility of incurring unplanned reactor trips (RTs) or power derate, making safety-related systems unavailable, or making the reliability of components degraded. Contribution of human errors during normal and abnormal activities of NPPs to the unplanned RTs is known to be about 20% of the total events. This paper introduces a procedure for predictively analyzing human error potentials when maintenance personnel perform T and M tasks based on a work procedure or their work plan. This procedure helps plant maintenance team prepare for plausible human errors. The procedure to be introduced is focusing on the recurrent error forms (or modes) in execution-based errors such as wrong object, omission, too little, and wrong action

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.

The error performance analysis over cyclic redundancy check codes

Science.gov (United States)

Yoon, Hee B.

1991-06-01

The burst error is generated in digital communication networks by various unpredictable conditions, which occur at high error rates, for short durations, and can impact services. To completely describe a burst error one has to know the bit pattern. This is impossible in practice on working systems. Therefore, under the memoryless binary symmetric channel (MBSC) assumptions, the performance evaluation or estimation schemes for digital signal 1 (DS1) transmission systems carrying live traffic is an interesting and important problem. This study will present some analytical methods, leading to efficient detecting algorithms of burst error using cyclic redundancy check (CRC) code. The definition of burst error is introduced using three different models. Among the three burst error models, the mathematical model is used in this study. The probability density function, function(b) of burst error of length b is proposed. The performance of CRC-n codes is evaluated and analyzed using function(b) through the use of a computer simulation model within CRC block burst error. The simulation result shows that the mean block burst error tends to approach the pattern of the burst error which random bit errors generate.

Medical Errors Management Before and After Implementation of Accreditation in Hospital

Directory of Open Access Journals (Sweden)

Ghassem Abedi

2014-12-01

Full Text Available Background and purpose: This study aimed to manage medical errors before and after the implementation of accreditation in public, private, and social security hospitals of Mazandaran, Iran. Materials and Methods: This descriptive study has been done in 38 hospitals. Data were collected through documents reviewed relating to 2013 and 2014. The paired t-test and Friedman test were used by statistical software SPSS. Results: Results showed that the most and the least percent of reported errors, before accreditation, in sequence, were related to public clinical unit (55.9% and operating rooms (0.6%, and after accreditation in public clinical unit (46.6% and operating rooms (2.3% in teaching centers. The most errors (before accreditation occurred in the morning (62% and the least, in the evening (8.3% in teaching centers. Furthermore, after accreditation, the most errors occurred in the morning (64.8% and the least, in the night (17.3% in therapeutic hospitals. Paired t-test showed that there is no significant difference between medical errors before and after accreditation. Friedman test showed that structural/systemic errors reported were the most important medical errors in teaching centers after accreditation and therapeutic hospitals before accreditation (P < 0.05. Conclusion: There is no significant difference between the rate of reported errors before and after the implementation of accreditation. This illustrates that the role of management in controlling of medical errors has been poor, and stronger management should be applied in providing health care services.

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

Profile of drug administration errors in anesthesia among anesthesiologists from Santa Catarina

Directory of Open Access Journals (Sweden)

Thomas Rolf Erdmann

2016-02-01

Full Text Available INTRODUCTION: Anesthesiology is the only medical specialty that prescribes, dilutes, and administers drugs without conferral by another professional. Adding to the high frequency of drug administration, a propitious scenario to errors is created. OBJECTIVE: Access the prevalence of drug administration errors during anesthesia among anesthesiologists from Santa Catarina, the circumstances in which they occurred, and possible associated factors. MATERIALS AND METHODS: An electronic questionnaire was sent to all anesthesiologists from Sociedade de Anestesiologia do Estado de Santa Catarina, with direct or multiple choice questions on responder demographics and anesthesia practice profile; prevalence of errors, type and consequence of error; and factors that may have contributed to the errors. RESULTS: Of the respondents, 91.8% reported they had committed administration errors, adding the total error of 274 and mean of 4.7 (6.9 errors per respondent. The most common error was replacement (68.4%, followed by dose error (49.1%, and omission (35%. Only 7% of respondents reported neuraxial administration error. Regarding circumstances of errors, they mainly occurred in the morning (32.7%, in anesthesia maintenance (49%, with 47.8% without harm to the patient and 1.75% with the highest morbidity and irreversible damage, and 87.3% of cases with immediate identification. As for possible contributing factors, the most frequent were distraction and fatigue (64.9% and misreading of labels, ampoules, or syringes (54.4%. CONCLUSION: Most respondents committed more than one error in anesthesia administration, mainly justified as a distraction or fatigue, and of low gravity.

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

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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

Double symbol error rates for differential detection of narrow-band FM

Science.gov (United States)

Simon, M. K.

1985-01-01

This paper evaluates the double symbol error rate (average probability of two consecutive symbol errors) in differentially detected narrow-band FM. Numerical results are presented for the special case of MSK with a Gaussian IF receive filter. It is shown that, not unlike similar results previously obtained for the single error probability of such systems, large inaccuracies in predicted performance can occur when intersymbol interference is ignored.

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.

Speech abilities in preschool children with speech sound disorder with and without co-occurring language impairment.

Science.gov (United States)

Macrae, Toby; Tyler, Ann A

2014-10-01

The authors compared preschool children with co-occurring speech sound disorder (SSD) and language impairment (LI) to children with SSD only in their numbers and types of speech sound errors. In this post hoc quasi-experimental study, independent samples t tests were used to compare the groups in the standard score from different tests of articulation/phonology, percent consonants correct, and the number of omission, substitution, distortion, typical, and atypical error patterns used in the production of different wordlists that had similar levels of phonetic and structural complexity. In comparison with children with SSD only, children with SSD and LI used similar numbers but different types of errors, including more omission patterns ( p < .001, d = 1.55) and fewer distortion patterns ( p = .022, d = 1.03). There were no significant differences in substitution, typical, and atypical error pattern use. Frequent omission error pattern use may reflect a more compromised linguistic system characterized by absent phonological representations for target sounds (see Shriberg et al., 2005). Research is required to examine the diagnostic potential of early frequent omission error pattern use in predicting later diagnoses of co-occurring SSD and LI and/or reading problems.

Frequency of medication errors in an emergency department of a large teaching hospital in southern Iran

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Vazin A

2014-12-01

Full Text Available Afsaneh Vazin,1 Zahra Zamani,1 Nahid Hatam2 1Department of Clinical Pharmacy, Faculty of Pharmacy, 2School of Management and Medical Information Sciences, Shiraz University of Medical Sciences, Shiraz, Iran Abstract: This study was conducted with the purpose of determining the frequency of medication errors (MEs occurring in tertiary care emergency department (ED of a large academic hospital in Iran. The incidence of MEs was determined through the disguised direct observation method conducted by a trained observer. A total of 1,031 medication doses administered to 202 patients admitted to the tertiary care ED were observed over a course of 54 6-hour shifts. Following collection of the data and analysis of the errors with the assistance of a clinical pharmacist, frequency of errors in the different stages was reported and analyzed in SPSS-21 software. For the 202 patients and the 1,031 medication doses evaluated in the present study, 707 (68.5% MEs were recorded in total. In other words, 3.5 errors per patient and almost 0.69 errors per medication are reported to have occurred, with the highest frequency of errors pertaining to cardiovascular (27.2% and antimicrobial (23.6% medications. The highest rate of errors occurred during the administration phase of the medication use process with a share of 37.6%, followed by errors of prescription and transcription with a share of 21.1% and 10% of errors, respectively. Omission (7.6% and wrong time error (4.4% were the most frequent administration errors. The less-experienced nurses (P=0.04, higher patient-to-nurse ratio (P=0.017, and the morning shifts (P=0.035 were positively related to administration errors. Administration errors marked the highest share of MEs occurring in the different medication use processes. Increasing the number of nurses and employing the more experienced of them in EDs can help reduce nursing errors. Addressing the shortcomings with further research should result in reduction

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.

Nonresponse Error in Mail Surveys: Top Ten Problems

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Jeanette M. Daly

2011-01-01

Full Text Available Conducting mail surveys can result in nonresponse error, which occurs when the potential participant is unwilling to participate or impossible to contact. Nonresponse can result in a reduction in precision of the study and may bias results. The purpose of this paper is to describe and make readers aware of a top ten list of mailed survey problems affecting the response rate encountered over time with different research projects, while utilizing the Dillman Total Design Method. Ten nonresponse error problems were identified, such as inserter machine gets sequence out of order, capitalization in databases, and mailing discarded by postal service. These ten mishaps can potentiate nonresponse errors, but there are ways to minimize their frequency. Suggestions offered stem from our own experiences during research projects. Our goal is to increase researchers' knowledge of nonresponse error problems and to offer solutions which can decrease nonresponse error in future projects.

Investigating Medication Errors in Educational Health Centers of Kermanshah

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Mohsen Mohammadi

2015-08-01

Full Text Available Background and objectives : Medication errors can be a threat to the safety of patients. Preventing medication errors requires reporting and investigating such errors. The present study was conducted with the purpose of investigating medication errors in educational health centers of Kermanshah. Material and Methods: The present research is an applied, descriptive-analytical study and is done as a survey. Error Report of Ministry of Health and Medical Education was used for data collection. The population of the study included all the personnel (nurses, doctors, paramedics of educational health centers of Kermanshah. Among them, those who reported the committed errors were selected as the sample of the study. The data analysis was done using descriptive statistics and Chi 2 Test using SPSS version 18. Results: The findings of the study showed that most errors were related to not using medication properly, the least number of errors were related to improper dose, and the majority of errors occurred in the morning. The most frequent reason for errors was staff negligence and the least frequent was the lack of knowledge. Conclusion: The health care system should create an environment for detecting and reporting errors by the personnel, recognizing related factors causing errors, training the personnel and create a good working environment and standard workload.

Prevalence and reporting of recruitment, randomisation and treatment errors in clinical trials: A systematic review.

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Yelland, Lisa N; Kahan, Brennan C; Dent, Elsa; Lee, Katherine J; Voysey, Merryn; Forbes, Andrew B; Cook, Jonathan A

2018-06-01

Background/aims In clinical trials, it is not unusual for errors to occur during the process of recruiting, randomising and providing treatment to participants. For example, an ineligible participant may inadvertently be randomised, a participant may be randomised in the incorrect stratum, a participant may be randomised multiple times when only a single randomisation is permitted or the incorrect treatment may inadvertently be issued to a participant at randomisation. Such errors have the potential to introduce bias into treatment effect estimates and affect the validity of the trial, yet there is little motivation for researchers to report these errors and it is unclear how often they occur. The aim of this study is to assess the prevalence of recruitment, randomisation and treatment errors and review current approaches for reporting these errors in trials published in leading medical journals. Methods We conducted a systematic review of individually randomised, phase III, randomised controlled trials published in New England Journal of Medicine, Lancet, Journal of the American Medical Association, Annals of Internal Medicine and British Medical Journal from January to March 2015. The number and type of recruitment, randomisation and treatment errors that were reported and how they were handled were recorded. The corresponding authors were contacted for a random sample of trials included in the review and asked to provide details on unreported errors that occurred during their trial. Results We identified 241 potentially eligible articles, of which 82 met the inclusion criteria and were included in the review. These trials involved a median of 24 centres and 650 participants, and 87% involved two treatment arms. Recruitment, randomisation or treatment errors were reported in 32 in 82 trials (39%) that had a median of eight errors. The most commonly reported error was ineligible participants inadvertently being randomised. No mention of recruitment, randomisation

The Frame Constraint on Experimentally Elicited Speech Errors in Japanese

Science.gov (United States)

Saito, Akie; Inoue, Tomoyoshi

2017-01-01

The so-called syllable position effect in speech errors has been interpreted as reflecting constraints posed by the frame structure of a given language, which is separately operating from linguistic content during speech production. The effect refers to the phenomenon that when a speech error occurs, replaced and replacing sounds tend to be in the…

Eigen's Error Threshold and Mutational Meltdown in a Quasispecies Model

OpenAIRE

Bagnoli, F.; Bezzi, M.

1998-01-01

We introduce a toy model for interacting populations connected by mutations and limited by a shared resource. We study the presence of Eigen's error threshold and mutational meltdown. The phase diagram of the system shows that the extinction of the whole population due to mutational meltdown can occur well before an eventual error threshold transition.

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

Science.gov (United States)

Soshi, Takahiro; Ando, Kumiko; Noda, Takamasa; Nakazawa, Kanako; Tsumura, Hideki; Okada, Takayuki

2014-01-01

Post-error slowing (PES) 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 PES did not take place immediately. Delayed PES 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 PES. Stimulus-locked N2 was negatively correlated with PES and positively correlated with impulsivity traits at the second post-error Go trial: larger N2 activity was associated with greater PES and less impulsivity. In summary, under constant speeded conditions, error monitoring was dissociated from post-error action control, and PES did not occur quickly. Furthermore, PES 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 impulsive behaviors.

Error rates in forensic DNA analysis: Definition, numbers, impact and communication

NARCIS (Netherlands)

Kloosterman, A.; Sjerps, M.; Quak, A.

2014-01-01

Forensic DNA casework is currently regarded as one of the most important types of forensic evidence, and important decisions in intelligence and justice are based on it. However, errors occasionally occur and may have very serious consequences. In other domains, error rates have been defined and

Self-reported medical, medication and laboratory error in eight countries: risk factors for chronically ill adults.

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Scobie, Andrea

2011-04-01

To identify risk factors associated with self-reported medical, medication and laboratory error in eight countries. The Commonwealth Fund's 2008 International Health Policy Survey of chronically ill patients in eight countries. None. A multi-country telephone survey was conducted between 3 March and 30 May 2008 with patients in Australia, Canada, France, Germany, the Netherlands, New Zealand, the UK and the USA who self-reported being chronically ill. A bivariate analysis was performed to determine significant explanatory variables of medical, medication and laboratory error (P error: age 65 and under, education level of some college or less, presence of two or more chronic conditions, high prescription drug use (four+ drugs), four or more doctors seen within 2 years, a care coordination problem, poor doctor-patient communication and use of an emergency department. Risk factors with the greatest ability to predict experiencing an error encompassed issues with coordination of care and provider knowledge of a patient's medical history. The identification of these risk factors could help policymakers and organizations to proactively reduce the likelihood of error through greater examination of system- and organization-level practices.

Mismeasurement and the resonance of strong confounders: correlated errors.

Science.gov (United States)

Marshall, J R; Hastrup, J L; Ross, J S

1999-07-01

Confounding in epidemiology, and the limits of standard methods of control for an imperfectly measured confounder, have been understood for some time. However, most treatments of this problem are based on the assumption that errors of measurement in confounding and confounded variables are independent. This paper considers the situation in which a strong risk factor (confounder) and an inconsequential but suspected risk factor (confounded) are each measured with errors that are correlated; the situation appears especially likely to occur in the field of nutritional epidemiology. Error correlation appears to add little to measurement error as a source of bias in estimating the impact of a strong risk factor: it can add to, diminish, or reverse the bias induced by measurement error in estimating the impact of the inconsequential risk factor. Correlation of measurement errors can add to the difficulty involved in evaluating structures in which confounding and measurement error are present. In its presence, observed correlations among risk factors can be greater than, less than, or even opposite to the true correlations. Interpretation of multivariate epidemiologic structures in which confounding is likely requires evaluation of measurement error structures, including correlations among measurement errors.

Applying Intelligent Algorithms to Automate the Identification of Error Factors.

Science.gov (United States)

Jin, Haizhe; Qu, Qingxing; Munechika, Masahiko; Sano, Masataka; Kajihara, Chisato; Duffy, Vincent G; Chen, Han

2018-05-03

Medical errors are the manifestation of the defects occurring in medical processes. Extracting and identifying defects as medical error factors from these processes are an effective approach to prevent medical errors. However, it is a difficult and time-consuming task and requires an analyst with a professional medical background. The issues of identifying a method to extract medical error factors and reduce the extraction difficulty need to be resolved. In this research, a systematic methodology to extract and identify error factors in the medical administration process was proposed. The design of the error report, extraction of the error factors, and identification of the error factors were analyzed. Based on 624 medical error cases across four medical institutes in both Japan and China, 19 error-related items and their levels were extracted. After which, they were closely related to 12 error factors. The relational model between the error-related items and error factors was established based on a genetic algorithm (GA)-back-propagation neural network (BPNN) model. Additionally, compared to GA-BPNN, BPNN, partial least squares regression and support vector regression, GA-BPNN exhibited a higher overall prediction accuracy, being able to promptly identify the error factors from the error-related items. The combination of "error-related items, their different levels, and the GA-BPNN model" was proposed as an error-factor identification technology, which could automatically identify medical error factors.

Massive the Higgs boson and the greatest hunt in science

CERN Document Server

Sample, Ian

2013-01-01

Now fully updated -- this is the dramatic and gripping account of the greatest scientific discovery of our time. In the early 1960s, three groups of physicists, working independently in different countries, stumbled upon an idea that would change physics and fuel the imagination of scientists for decades. That idea was the Higgs boson -- to find it would be to finally understand the origins of mass -- the last building block of life itself. Now, almost 50 years later, that particle has finally been discovered.

Prescribing error at hospital discharge: a retrospective review of medication information in an Irish hospital.

Science.gov (United States)

Michaelson, M; Walsh, E; Bradley, C P; McCague, P; Owens, R; Sahm, L J

2017-08-01

Prescribing error may result in adverse clinical outcomes leading to increased patient morbidity, mortality and increased economic burden. Many errors occur during transitional care as patients move between different stages and settings of care. To conduct a review of medication information and identify prescribing error among an adult population in an urban hospital. Retrospective review of medication information was conducted. Part 1: an audit of discharge prescriptions which assessed: legibility, compliance with legal requirements, therapeutic errors (strength, dose and frequency) and drug interactions. Part 2: A review of all sources of medication information (namely pre-admission medication list, drug Kardex, discharge prescription, discharge letter) for 15 inpatients to identify unintentional prescription discrepancies, defined as: "undocumented and/or unjustified medication alteration" throughout the hospital stay. Part 1: of the 5910 prescribed items; 53 (0.9%) were deemed illegible. Of the controlled drug prescriptions 11.1% (n = 167) met all the legal requirements. Therapeutic errors occurred in 41% of prescriptions (n = 479) More than 1 in 5 patients (21.9%) received a prescription containing a drug interaction. Part 2: 175 discrepancies were identified across all sources of medication information; of which 78 were deemed unintentional. Of these: 10.2% (n = 8) occurred at the point of admission, whereby 76.9% (n = 60) occurred at the point of discharge. The study identified the time of discharge as a point at which prescribing errors are likely to occur. This has implications for patient safety and provider work load in both primary and secondary care.

Nurses' Behaviors and Visual Scanning Patterns May Reduce Patient Identification Errors

Science.gov (United States)

Marquard, Jenna L.; Henneman, Philip L.; He, Ze; Jo, Junghee; Fisher, Donald L.; Henneman, Elizabeth A.

2011-01-01

Patient identification (ID) errors occurring during the medication administration process can be fatal. The aim of this study is to determine whether differences in nurses' behaviors and visual scanning patterns during the medication administration process influence their capacities to identify patient ID errors. Nurse participants (n = 20)…

Neutron-induced soft errors in CMOS circuits

International Nuclear Information System (INIS)

Hazucha, P.

1999-01-01

The subject of this thesis is a systematic study of soft errors occurring in CMOS integrated circuits when being exposed to radiation. The vast majority of commercial circuits operate in the natural environment ranging from the sea level to aircraft flight altitudes (less than 20 km), where the errors are caused mainly by interaction of atmospheric neutrons with silicon. Initially, the soft error rate (SER) of a static memory was measured for supply voltages from 2V to 5V when irradiated by 14 MeV and 100 MeV neutrons. Increased error rate due to the decreased supply voltage has been identified as a potential hazard for operation of future low-voltage circuits. A novel methodology was proposed for accurate SER characterization of a manufacturing process and it was validated by measurements on a 0.6 μm process and 100 MeV neutrons. The methodology can be applied to the prediction of SER in the natural environment

Medication errors in home care: a qualitative focus group study.

Science.gov (United States)

Berland, Astrid; Bentsen, Signe Berit

2017-11-01

To explore registered nurses' experiences of medication errors and patient safety in home care. The focus of care for older patients has shifted from institutional care towards a model of home care. Medication errors are common in this situation and can result in patient morbidity and mortality. An exploratory qualitative design with focus group interviews was used. Four focus group interviews were conducted with 20 registered nurses in home care. The data were analysed using content analysis. Five categories were identified as follows: lack of information, lack of competence, reporting medication errors, trade name products vs. generic name products, and improving routines. Medication errors occur frequently in home care and can threaten the safety of patients. Insufficient exchange of information and poor communication between the specialist and home-care health services, and between general practitioners and healthcare workers can lead to medication errors. A lack of competence in healthcare workers can also lead to medication errors. To prevent these, it is important that there should be up-to-date information and communication between healthcare workers during the transfer of patients from specialist to home care. Ensuring competence among healthcare workers with regard to medication is also important. In addition, there should be openness and accurate reporting of medication errors, as well as in setting routines for the preparation, alteration and administration of medicines. To prevent medication errors in home care, up-to-date information and communication between healthcare workers is important when patients are transferred from specialist to home care. It is also important to ensure adequate competence with regard to medication, and that there should be openness when medication errors occur, as well as in setting routines for the preparation, alteration and administration of medications. © 2017 John Wiley & Sons Ltd.

Nature and frequency of medication errors in a geriatric ward: an Indonesian experience

Directory of Open Access Journals (Sweden)

Ernawati DK

2014-06-01

Full Text Available Desak Ketut Ernawati,1,2 Ya Ping Lee,2 Jeffery David Hughes21Faculty of Medicine, Udayana University, Denpasar, Bali, Indonesia; 2School of Pharmacy and Curtin Health Innovation and Research Institute, Curtin University, Perth, WA, AustraliaPurpose: To determine the nature and frequency of medication errors during medication delivery processes in a public teaching hospital geriatric ward in Bali, Indonesia.Methods: A 20-week prospective study on medication errors occurring during the medication delivery process was conducted in a geriatric ward in a public teaching hospital in Bali, Indonesia. Participants selected were inpatients aged more than 60 years. Patients were excluded if they had a malignancy, were undergoing surgery, or receiving chemotherapy treatment. The occurrence of medication errors in prescribing, transcribing, dispensing, and administration were detected by the investigator providing in-hospital clinical pharmacy services.Results: Seven hundred and seventy drug orders and 7,662 drug doses were reviewed as part of the study. There were 1,563 medication errors detected among the 7,662 drug doses reviewed, representing an error rate of 20.4%. Administration errors were the most frequent medication errors identified (59%, followed by transcription errors (15%, dispensing errors (14%, and prescribing errors (7%. Errors in documentation were the most common form of administration errors. Of these errors, 2.4% were classified as potentially serious and 10.3% as potentially significant.Conclusion: Medication errors occurred in every stage of the medication delivery process, with administration errors being the most frequent. The majority of errors identified in the administration stage were related to documentation. Provision of in-hospital clinical pharmacy services could potentially play a significant role in detecting and preventing medication errors.Keywords: geriatric, medication errors, inpatients, medication delivery process

Error Analysis of Brailled Instructional Materials Produced by Public School Personnel in Texas

Science.gov (United States)

Herzberg, Tina

2010-01-01

In this study, a detailed error analysis was performed to determine if patterns of errors existed in braille transcriptions. The most frequently occurring errors were the insertion of letters or words that were not contained in the original print material; the incorrect usage of the emphasis indicator; and the incorrect formatting of titles,…

Penicillin: the medicine with the greatest impact on therapeutic outcomes.

Science.gov (United States)

Kardos, Nelson; Demain, Arnold L

2011-11-01

The principal point of this paper is that the discovery of penicillin and the development of the supporting technologies in microbiology and chemical engineering leading to its commercial scale production represent it as the medicine with the greatest impact on therapeutic outcomes. Our nomination of penicillin for the top therapeutic molecule rests on two lines of evidence concerning the impact of this event: (1) the magnitude of the therapeutic outcomes resulting from the clinical application of penicillin and the subsequent widespread use of antibiotics and (2) the technologies developed for production of penicillin, including both microbial strain selection and improvement plus chemical engineering methods responsible for successful submerged fermentation production. These became the basis for production of all subsequent antibiotics in use today. These same technologies became the model for the development and production of new types of bioproducts (i.e., anticancer agents, monoclonal antibodies, and industrial enzymes). The clinical impact of penicillin was large and immediate. By ushering in the widespread clinical use of antibiotics, penicillin was responsible for enabling the control of many infectious diseases that had previously burdened mankind, with subsequent impact on global population demographics. Moreover, the large cumulative public effect of the many new antibiotics and new bioproducts that were developed and commercialized on the basis of the science and technology after penicillin demonstrates that penicillin had the greatest therapeutic impact event of all times. © Springer-Verlag 2011

Updating expected action outcome in the medial frontal cortex involves an evaluation of error type.

Science.gov (United States)

Maier, Martin E; Steinhauser, Marco

2013-10-02

Forming expectations about the outcome of an action is an important prerequisite for action control and reinforcement learning in the human brain. The medial frontal cortex (MFC) has been shown to play an important role in the representation of outcome expectations, particularly when an update of expected outcome becomes necessary because an error is detected. However, error detection alone is not always sufficient to compute expected outcome because errors can occur in various ways and different types of errors may be associated with different outcomes. In the present study, we therefore investigate whether updating expected outcome in the human MFC is based on an evaluation of error type. Our approach was to consider an electrophysiological correlate of MFC activity on errors, the error-related negativity (Ne/ERN), in a task in which two types of errors could occur. Because the two error types were associated with different amounts of monetary loss, updating expected outcomes on error trials required an evaluation of error type. Our data revealed a pattern of Ne/ERN amplitudes that closely mirrored the amount of monetary loss associated with each error type, suggesting that outcome expectations are updated based on an evaluation of error type. We propose that this is achieved by a proactive evaluation process that anticipates error types by continuously monitoring error sources or by dynamically representing possible response-outcome relations.

Computational error and complexity in science and engineering computational error and complexity

CERN Document Server

Lakshmikantham, Vangipuram; Chui, Charles K; Chui, Charles K

2005-01-01

The book "Computational Error and Complexity in Science and Engineering” pervades all the science and engineering disciplines where computation occurs. Scientific and engineering computation happens to be the interface between the mathematical model/problem and the real world application. One needs to obtain good quality numerical values for any real-world implementation. Just mathematical quantities symbols are of no use to engineers/technologists. Computational complexity of the numerical method to solve the mathematical model, also computed along with the solution, on the other hand, will tell us how much computation/computational effort has been spent to achieve that quality of result. Anyone who wants the specified physical problem to be solved has every right to know the quality of the solution as well as the resources spent for the solution. The computed error as well as the complexity provide the scientific convincing answer to these questions. Specifically some of the disciplines in which the book w...

Minimizing driver errors: examining factors leading to failed target tracking and detection.

Science.gov (United States)

2013-06-01

Driving a motor vehicle is a common practice for many individuals. Although driving becomes : repetitive and a very habitual task, errors can occur that lead to accidents. One factor that can be a : cause for such errors is a lapse in attention or a ...

Reducing diagnostic errors in medicine: what's the goal?

Science.gov (United States)

Graber, Mark; Gordon, Ruthanna; Franklin, Nancy

2002-10-01

This review considers the feasibility of reducing or eliminating the three major categories of diagnostic errors in medicine: "No-fault errors" occur when the disease is silent, presents atypically, or mimics something more common. These errors will inevitably decline as medical science advances, new syndromes are identified, and diseases can be detected more accurately or at earlier stages. These errors can never be eradicated, unfortunately, because new diseases emerge, tests are never perfect, patients are sometimes noncompliant, and physicians will inevitably, at times, choose the most likely diagnosis over the correct one, illustrating the concept of necessary fallibility and the probabilistic nature of choosing a diagnosis. "System errors" play a role when diagnosis is delayed or missed because of latent imperfections in the health care system. These errors can be reduced by system improvements, but can never be eliminated because these improvements lag behind and degrade over time, and each new fix creates the opportunity for novel errors. Tradeoffs also guarantee system errors will persist, when resources are just shifted. "Cognitive errors" reflect misdiagnosis from faulty data collection or interpretation, flawed reasoning, or incomplete knowledge. The limitations of human processing and the inherent biases in using heuristics guarantee that these errors will persist. Opportunities exist, however, for improving the cognitive aspect of diagnosis by adopting system-level changes (e.g., second opinions, decision-support systems, enhanced access to specialists) and by training designed to improve cognition or cognitive awareness. Diagnostic error can be substantially reduced, but never eradicated.

Issues with data and analyses: Errors, underlying themes, and potential solutions.

Science.gov (United States)

Brown, Andrew W; Kaiser, Kathryn A; Allison, David B

2018-03-13

Some aspects of science, taken at the broadest level, are universal in empirical research. These include collecting, analyzing, and reporting data. In each of these aspects, errors can and do occur. In this work, we first discuss the importance of focusing on statistical and data errors to continually improve the practice of science. We then describe underlying themes of the types of errors and postulate contributing factors. To do so, we describe a case series of relatively severe data and statistical errors coupled with surveys of some types of errors to better characterize the magnitude, frequency, and trends. Having examined these errors, we then discuss the consequences of specific errors or classes of errors. Finally, given the extracted themes, we discuss methodological, cultural, and system-level approaches to reducing the frequency of commonly observed errors. These approaches will plausibly contribute to the self-critical, self-correcting, ever-evolving practice of science, and ultimately to furthering knowledge.

An Analysis and Quantification Method of Human Errors of Soft Controls in Advanced MCRs

International Nuclear Information System (INIS)

Lee, Seung Jun; Kim, Jae Whan; Jang, Seung Cheol

2011-01-01

In this work, a method was proposed for quantifying human errors that may occur during operation executions using soft control. Soft controls of advanced main control rooms (MCRs) have totally different features from conventional controls, and thus they may have different human error modes and occurrence probabilities. It is important to define the human error modes and to quantify the error probability for evaluating the reliability of the system and preventing errors. This work suggests a modified K-HRA method for quantifying error probability

School Issues Under [Section] 504 and the ADA: The Latest and Greatest.

Science.gov (United States)

Aleman, Steven R.

This paper highlights recent guidance and rulings from the Office of Civil Rights (OCR) of interest to administrators, advocates, and attorneys. It is a companion piece to Student Issues on SectionNB504/ADA: The Latest and Greatest. Compliance with SectionNB504 and the Americans with Disabilities Act (ADA) continues to involve debate and dialog on…

Evaluation of drug administration errors in a teaching hospital

OpenAIRE

Berdot, Sarah; Sabatier, Brigitte; Gillaizeau, Florence; Caruba, Thibaut; Prognon, Patrice; Durieux, Pierre

2012-01-01

Abstract Background Medication errors can occur at any of the three steps of the medication use process: prescribing, dispensing and administration. We aimed to determine the incidence, type and clinical importance of drug administration errors and to identify risk factors. Methods Prospective study based on disguised observation technique in four wards in a teaching hospital in Paris, France (800 beds). A pharmacist accompanied nurses and witnessed the preparation and administration of drugs...

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.

Modeling the probability distribution of positional errors incurred by residential address geocoding

Directory of Open Access Journals (Sweden)

Mazumdar Soumya

2007-01-01

Full Text Available Abstract Background The assignment of a point-level geocode to subjects' residences is an important data assimilation component of many geographic public health studies. Often, these assignments are made by a method known as automated geocoding, which attempts to match each subject's address to an address-ranged street segment georeferenced within a streetline database and then interpolate the position of the address along that segment. Unfortunately, this process results in positional errors. Our study sought to model the probability distribution of positional errors associated with automated geocoding and E911 geocoding. Results Positional errors were determined for 1423 rural addresses in Carroll County, Iowa as the vector difference between each 100%-matched automated geocode and its true location as determined by orthophoto and parcel information. Errors were also determined for 1449 60%-matched geocodes and 2354 E911 geocodes. Huge (> 15 km outliers occurred among the 60%-matched geocoding errors; outliers occurred for the other two types of geocoding errors also but were much smaller. E911 geocoding was more accurate (median error length = 44 m than 100%-matched automated geocoding (median error length = 168 m. The empirical distributions of positional errors associated with 100%-matched automated geocoding and E911 geocoding exhibited a distinctive Greek-cross shape and had many other interesting features that were not capable of being fitted adequately by a single bivariate normal or t distribution. However, mixtures of t distributions with two or three components fit the errors very well. Conclusion Mixtures of bivariate t distributions with few components appear to be flexible enough to fit many positional error datasets associated with geocoding, yet parsimonious enough to be feasible for nascent applications of measurement-error methodology to spatial epidemiology.

Masked and unmasked error-related potentials during continuous control and feedback

Science.gov (United States)

Lopes Dias, Catarina; Sburlea, Andreea I.; Müller-Putz, Gernot R.

2018-06-01

The detection of error-related potentials (ErrPs) in tasks with discrete feedback is well established in the brain–computer interface (BCI) field. However, the decoding of ErrPs in tasks with continuous feedback is still in its early stages. Objective. We developed a task in which subjects have continuous control of a cursor’s position by means of a joystick. The cursor’s position was shown to the participants in two different modalities of continuous feedback: normal and jittered. The jittered feedback was created to mimic the instability that could exist if participants controlled the trajectory directly with brain signals. Approach. This paper studies the electroencephalographic (EEG)—measurable signatures caused by a loss of control over the cursor’s trajectory, causing a target miss. Main results. In both feedback modalities, time-locked potentials revealed the typical frontal-central components of error-related potentials. Errors occurring during the jittered feedback (masked errors) were delayed in comparison to errors occurring during normal feedback (unmasked errors). Masked errors displayed lower peak amplitudes than unmasked errors. Time-locked classification analysis allowed a good distinction between correct and error classes (average Cohen-, average TPR  =  81.8% and average TNR  =  96.4%). Time-locked classification analysis between masked error and unmasked error classes revealed results at chance level (average Cohen-, average TPR  =  60.9% and average TNR  =  58.3%). Afterwards, we performed asynchronous detection of ErrPs, combining both masked and unmasked trials. The asynchronous detection of ErrPs in a simulated online scenario resulted in an average TNR of 84.0% and in an average TPR of 64.9%. Significance. The time-locked classification results suggest that the masked and unmasked errors were indistinguishable in terms of classification. The asynchronous classification results suggest that the

Sensitivity analysis of periodic errors in heterodyne interferometry

International Nuclear Information System (INIS)

Ganguly, Vasishta; Kim, Nam Ho; Kim, Hyo Soo; Schmitz, Tony

2011-01-01

Periodic errors in heterodyne displacement measuring interferometry occur due to frequency mixing in the interferometer. These nonlinearities are typically characterized as first- and second-order periodic errors which cause a cyclical (non-cumulative) variation in the reported displacement about the true value. This study implements an existing analytical periodic error model in order to identify sensitivities of the first- and second-order periodic errors to the input parameters, including rotational misalignments of the polarizing beam splitter and mixing polarizer, non-orthogonality of the two laser frequencies, ellipticity in the polarizations of the two laser beams, and different transmission coefficients in the polarizing beam splitter. A local sensitivity analysis is first conducted to examine the sensitivities of the periodic errors with respect to each input parameter about the nominal input values. Next, a variance-based approach is used to study the global sensitivities of the periodic errors by calculating the Sobol' sensitivity indices using Monte Carlo simulation. The effect of variation in the input uncertainty on the computed sensitivity indices is examined. It is seen that the first-order periodic error is highly sensitive to non-orthogonality of the two linearly polarized laser frequencies, while the second-order error is most sensitive to the rotational misalignment between the laser beams and the polarizing beam splitter. A particle swarm optimization technique is finally used to predict the possible setup imperfections based on experimentally generated values for periodic errors

Sensitivity analysis of periodic errors in heterodyne interferometry

Science.gov (United States)

Ganguly, Vasishta; Kim, Nam Ho; Kim, Hyo Soo; Schmitz, Tony

2011-03-01

Periodic errors in heterodyne displacement measuring interferometry occur due to frequency mixing in the interferometer. These nonlinearities are typically characterized as first- and second-order periodic errors which cause a cyclical (non-cumulative) variation in the reported displacement about the true value. This study implements an existing analytical periodic error model in order to identify sensitivities of the first- and second-order periodic errors to the input parameters, including rotational misalignments of the polarizing beam splitter and mixing polarizer, non-orthogonality of the two laser frequencies, ellipticity in the polarizations of the two laser beams, and different transmission coefficients in the polarizing beam splitter. A local sensitivity analysis is first conducted to examine the sensitivities of the periodic errors with respect to each input parameter about the nominal input values. Next, a variance-based approach is used to study the global sensitivities of the periodic errors by calculating the Sobol' sensitivity indices using Monte Carlo simulation. The effect of variation in the input uncertainty on the computed sensitivity indices is examined. It is seen that the first-order periodic error is highly sensitive to non-orthogonality of the two linearly polarized laser frequencies, while the second-order error is most sensitive to the rotational misalignment between the laser beams and the polarizing beam splitter. A particle swarm optimization technique is finally used to predict the possible setup imperfections based on experimentally generated values for periodic errors.

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.

Evaluation of drug administration errors in a teaching hospital

Directory of Open Access Journals (Sweden)

Berdot Sarah

2012-03-01

Full Text Available Abstract Background Medication errors can occur at any of the three steps of the medication use process: prescribing, dispensing and administration. We aimed to determine the incidence, type and clinical importance of drug administration errors and to identify risk factors. Methods Prospective study based on disguised observation technique in four wards in a teaching hospital in Paris, France (800 beds. A pharmacist accompanied nurses and witnessed the preparation and administration of drugs to all patients during the three drug rounds on each of six days per ward. Main outcomes were number, type and clinical importance of errors and associated risk factors. Drug administration error rate was calculated with and without wrong time errors. Relationship between the occurrence of errors and potential risk factors were investigated using logistic regression models with random effects. Results Twenty-eight nurses caring for 108 patients were observed. Among 1501 opportunities for error, 415 administrations (430 errors with one or more errors were detected (27.6%. There were 312 wrong time errors, ten simultaneously with another type of error, resulting in an error rate without wrong time error of 7.5% (113/1501. The most frequently administered drugs were the cardiovascular drugs (425/1501, 28.3%. The highest risks of error in a drug administration were for dermatological drugs. No potentially life-threatening errors were witnessed and 6% of errors were classified as having a serious or significant impact on patients (mainly omission. In multivariate analysis, the occurrence of errors was associated with drug administration route, drug classification (ATC and the number of patient under the nurse's care. Conclusion Medication administration errors are frequent. The identification of its determinants helps to undertake designed interventions.

Theoretical explanations and practices regarding the distinction between the concepts: judicial error, error of law and fundamental vice in the legislation of the Republic of Moldova

Directory of Open Access Journals (Sweden)

Vasilisa Muntean

2017-10-01

Full Text Available In the research, a doctrinal and legal analysis of the concept of legal error is carried out. The author provides a self-defined definition of the concept addressed and highlights the main causes and conditions for the occurrence of judicial errors. At present, in the specialized legal doctrine of the Republic of Moldova, the problem of defining the judicial error has been little approached. In this respect, this scientific article is a scientific approach aimed at elucidating the theoretical and normative deficiencies and errors that occur in the area of reparation of the prejudice caused by judicial errors. In order to achieve our goal, we aim to create a core of ideas and referral mechanisms that ensure a certain interpretative and decisional homogeneity in the doctrinal and legal characterization of the phrase "judicial error".

FedWeb Greatest Hits: Presenting the New Test Collection for Federated Web Search

NARCIS (Netherlands)

Demeester, Thomas; Trieschnigg, Rudolf Berend; Zhou, Ke; Nguyen, Dong-Phuong; Hiemstra, Djoerd

This paper presents 'FedWeb Greatest Hits', a large new test collection for research in web information retrieval. As a combination and extension of the datasets used in the TREC Federated Web Search Track, this collection opens up new research possibilities on federated web search challenges, as

[Medication errors in Spanish intensive care units].

Science.gov (United States)

Merino, P; Martín, M C; Alonso, A; Gutiérrez, I; Alvarez, J; Becerril, F

2013-01-01

To estimate the incidence of medication errors in Spanish intensive care units. Post hoc study of the SYREC trial. A longitudinal observational study carried out during 24 hours in patients admitted to the ICU. Spanish intensive care units. Patients admitted to the intensive care unit participating in the SYREC during the period of study. Risk, individual risk, and rate of medication errors. The final study sample consisted of 1017 patients from 79 intensive care units; 591 (58%) were affected by one or more incidents. Of these, 253 (43%) had at least one medication-related incident. The total number of incidents reported was 1424, of which 350 (25%) were medication errors. The risk of suffering at least one incident was 22% (IQR: 8-50%) while the individual risk was 21% (IQR: 8-42%). The medication error rate was 1.13 medication errors per 100 patient-days of stay. Most incidents occurred in the prescription (34%) and administration (28%) phases, 16% resulted in patient harm, and 82% were considered "totally avoidable". Medication errors are among the most frequent types of incidents in critically ill patients, and are more common in the prescription and administration stages. Although most such incidents have no clinical consequences, a significant percentage prove harmful for the patient, and a large proportion are avoidable. Copyright © 2012 Elsevier España, S.L. and SEMICYUC. All rights reserved.

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.

Utilizing measure-based feedback in control-mastery theory: A clinical error.

Science.gov (United States)

Snyder, John; Aafjes-van Doorn, Katie

2016-09-01

Clinical errors and ruptures are an inevitable part of clinical practice. Often times, therapists are unaware that a clinical error or rupture has occurred, leaving no space for repair, and potentially leading to patient dropout and/or less effective treatment. One way to overcome our blind spots is by frequently and systematically collecting measure-based feedback from the patient. Patient feedback measures that focus on the process of psychotherapy such as the Patient's Experience of Attunement and Responsiveness scale (PEAR) can be used in conjunction with treatment outcome measures such as the Outcome Questionnaire 45.2 (OQ-45.2) to monitor the patient's therapeutic experience and progress. The regular use of these types of measures can aid clinicians in the identification of clinical errors and the associated patient deterioration that might otherwise go unnoticed and unaddressed. The current case study describes an instance of clinical error that occurred during the 2-year treatment of a highly traumatized young woman. The clinical error was identified using measure-based feedback and subsequently understood and addressed from the theoretical standpoint of the control-mastery theory of psychotherapy. An alternative hypothetical response is also presented and explained using control-mastery theory. (PsycINFO Database Record (c) 2016 APA, all rights reserved).

Medication errors in outpatient care in Colombia, 2005-2013.

Science.gov (United States)

Machado-Alba, Jorge E; Moncada, Juan Carlos; Moreno-Gutiérrez, Paula Andrea

2016-06-03

Medication errors outside the hospital have been poorly studied despite representing an important threat to patient safety. To describe the characteristics of medication errors in outpatient dispensing pharmacists reported in a pharmaco-surveillance system between 2005 and 2013 in Colombia. We conducted a descriptive study by reviewing and categorizing medication error reports from outpatient pharmacy services to a national medication dispensing company between January, 2005 and September, 2013. Variables considered included: process involved (administration, dispensing, prescription and transcription), wrong drug, time delay for the report, error type, cause and severity. The analysis was conducted in the SPSS® software, version 22.0. A total of 14,873 medication errors were reviewed, of which 67.2% in fact occurred, 15.5% reached the patient and 0.7% caused harm. Administration (OR=93.61, CI 95%: 48.510-180.655, perrors (OR=5.64; CI 95%: 3.488-9.142, perror reaching the patient. It is necessary to develop surveillance systems for medication errors in ambulatory care, focusing on the prescription, transcription and dispensation processes. Special strategies are needed for the prevention of medication errors related to anti-infective drugs.

Active Mycobacterium Infection Due to Intramuscular BCG Administration Following Multi-Steps Medication Errors

Directory of Open Access Journals (Sweden)

MohammadReza Rafati

2015-10-01

Full Text Available Bacillus Calmette-Guérin (BCG is indicated for treatment of primary or relapsing flat urothelial cell carcinoma in situ (CIS of the urinary bladder. Disseminated infectious complications occasionally occur due to BCG as a vaccine and intravesical therapy.  Intramuscular (IM or Intravenous (IV administrations of BCG are rare medication errors which are more probable to produce systemic infections. This report presents 13 years old case that several steps medication errors occurred consequently from physician handwriting, pharmacy dispensing, nursing administration and patient family. The physician wrote βHCG instead of HCG in the prescription. βHCG was read as BCG by the pharmacy staff and 6 vials of intravesical BCG were administered IM twice a week for 3 consecutive weeks. The patient experienced fever and chills after each injection, but he was admitted 2 months after first IM administration of BCG with fever and pancytopenia. Unfortunately four month after using drug, during second admission duo to cellulitis at the sites of BCG injection the physicians diagnosed the medication error. Using handwritten prescription and inappropriate abbreviations, spending inadequate time for taking a brief medical history in pharmacy, lack of verifying name, dose and wrote before medication administration and lack of considering medication error as an important differential diagnosis had roles to occur this multi-steps medication error.

16-bit error detection and correction (EDAC) controller design using FPGA for critical memory applications

International Nuclear Information System (INIS)

Misra, M.K.; Sridhar, N.; Krishnakumar, B.; Ilango Sambasivan, S.

2002-01-01

Full text: Complex electronic systems require the utmost reliability, especially when the storage and retrieval of critical data demands faultless operation, the system designer must strive for the highest reliability possible. Extra effort must be expended to achieve this reliability. Fortunately, not all systems must operate with these ultra reliability requirements. The majority of systems operate in an area where system failure is not hazardous. But the applications like nuclear reactors, medical and avionics are the areas where system failure may prove to have harsh consequences. High-density memories generate errors in their stored data due to external disturbances like power supply surges, system noise, natural radiation etc. These errors are called soft errors or transient errors, since they don't cause permanent damage to the memory cell. Hard errors may also occur on system memory boards. These hard errors occur if one RAM component or RAM cell fails and is stuck at either 0 or 1. Although less frequent, hard errors may cause a complete system failure. These are the major problems associated with memories

Medication errors: classification of seriousness, type, and of medications involved in the reports from a university teaching hospital

Directory of Open Access Journals (Sweden)

Gabriella Rejane dos Santos Dalmolin

2013-12-01

Full Text Available Medication errors can be frequent in hospitals; these errors are multidisciplinary and occur at various stages of the drug therapy. The present study evaluated the seriousness, the type and the drugs involved in medication errors reported at the Hospital de Clínicas de Porto Alegre. We analyzed written error reports for 2010-2011. The sample consisted of 165 reports. The errors identified were classified according to seriousness, type and pharmacological class. 114 reports were categorized as actual errors (medication errors and 51 reports were categorized as potential errors. There were more medication error reports in 2011 compared to 2010, but there was no significant change in the seriousness of the reports. The most common type of error was prescribing error (48.25%. Errors that occurred during the process of drug therapy sometimes generated additional medication errors. In 114 reports of medication errors identified, 122 drugs were cited. The reflection on medication errors, the possibility of harm resulting from these errors, and the methods for error identification and evaluation should include a broad perspective of the aspects involved in the occurrence of errors. Patient safety depends on the process of communication involving errors, on the proper recording of information, and on the monitoring itself.

The greatest challenges reported by long-term colorectal cancer survivors with stomas.

Science.gov (United States)

McMullen, Carmit K; Hornbrook, Mark C; Grant, Marcia; Baldwin, Carol M; Wendel, Christopher S; Mohler, M Jane; Altschuler, Andrea; Ramirez, Michelle; Krouse, Robert S

2008-04-01

This paper presents a qualitative analysis of the greatest challenges reported by long-term colorectal cancer survivors with ostomies. Surveys that included an open-ended question about challenges of living with an ostomy were administered at three Kaiser Permanente regions: Northern California, Northwest, and Hawaii. The study was coordinated at the Southern Arizona Veterans Affairs Health Care System in Tucson. The City of Hope Quality of Life Model for Ostomy Patients provided a framework for the study's design, measures, data collection, and data analysis. The study's findings may be generalized broadly to community settings across the United States. Results replicate those of previous research among veterans, California members of the United Ostomy Association, Koreans with ostomies, and colorectal cancer survivors with ostomies residing in the United Kingdom. The greatest challenges reported by 178 colorectal cancer survivors with ostomies confirmed the Institute of Medicine's findings that survivorship is a distinct, chronic phase of cancer care and that cancer's effects are broad and pervasive. The challenges reported by study participants should inform the design, testing and integration of targeted education, early interventions, and ongoing support services for colorectal cancer patients with ostomies.

Radiology errors: are we learning from our mistakes?

International Nuclear Information System (INIS)

Mankad, K.; Hoey, E.T.D.; Jones, J.B.; Tirukonda, P.; Smith, J.T.

2009-01-01

Aim: To question practising radiologists and radiology trainees at a large international meeting in an attempt to survey individuals about error reporting. Materials and methods: Radiologists attending the 2007 Radiological Society of North America (RSNA) annual meeting were approached to fill in a written questionnaire. Participants were questioned as to their grade, country in which they practised, and subspecialty interest. They were asked whether they kept a personal log of their errors (with an error defined as 'a mistake that has management implications for the patient'), how many errors they had made in the preceding 12 months, and the types of errors that had occurred. They were also asked whether their local department held regular discrepancy/errors meetings, how many they had attended in the preceding 12 months, and the perceived atmosphere at these meetings (on a qualitative scale). Results: A total of 301 radiologists with a wide range of specialty interests from 32 countries agreed to take part. One hundred and sixty-six of 301 (55%) of responders were consultant/attending grade. One hundred and thirty-five of 301 (45%) were residents/fellows. Fifty-nine of 301 (20%) of responders kept a personal record of their errors. The number of errors made per person per year ranged from none (2%) to 16 or more (7%). The majority (91%) reported making between one and 15 errors/year. Overcalls (40%), under-calls (25%), and interpretation error (15%) were the predominant error types. One hundred and seventy-eight of 301 (59%) of participants stated that their department held regular errors meeting. One hundred and twenty-seven of 301 (42%) had attended three or more meetings in the preceding year. The majority (55%) who had attended errors meetings described the atmosphere as 'educational.' Only a small minority (2%) described the atmosphere as 'poor' meaning non-educational and/or blameful. Conclusion: Despite the undeniable importance of learning from errors

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.

Human error as the root cause of severe accidents at nuclear reactors

International Nuclear Information System (INIS)

Kovács Zoltán; Rýdzi, Stanislav

2017-01-01

A root cause is a factor inducing an undesirable event. It is feasible for root causes to be eliminated through technological process improvements. Human error was the root cause of all severe accidents at nuclear power plants. The TMI accident was caused by a series of human errors. The Chernobyl disaster occurred after a badly performed test of the turbogenerator at a reactor with design deficiencies, and in addition, the operators ignored the safety principles and disabled the safety systems. At Fukushima the tsunami risk was underestimated and the project failed to consider the specific issues of the site. The paper describes the severe accidents and points out the human errors that caused them. Also, provisions that might have eliminated those severe accidents are suggested. The fact that each severe accident occurred on a different type of reactor is relevant – no severe accident ever occurred twice at the same reactor type. The lessons learnt from the severe accidents and the safety measures implemented on reactor units all over the world seem to be effective. (orig.)

The Impact of Bar Code Medication Administration Technology on Reported Medication Errors

Science.gov (United States)

Holecek, Andrea

2011-01-01

The use of bar-code medication administration technology is on the rise in acute care facilities in the United States. The technology is purported to decrease medication errors that occur at the point of administration. How significantly this technology affects actual rate and severity of error is unknown. This descriptive, longitudinal research…

A simulation study on the variation of virtual NMR signals by winding, bobbin, spacer error of HTS magnet

Energy Technology Data Exchange (ETDEWEB)

Kim, Jun Seong; Lee, Woo Seung; Kim, Jin Sub; Song, Seung Hyun; Nam, Seok Ho; Jeon, Hae Ryong; Beak, Geon Woo; Ko, Tae Kuk [Yonsei University, Seoul (Korea, Republic of)

2016-09-15

Recently, production technique and property of the High-Temperature Superconductor (HTS) tape have been improved. Thus, the study on applying an HTS magnet to the high magnetic field application is rapidly increased. A Nuclear Magnetic Resonance (NMR) spectrometer requires high magnitude and homogeneous of central magnetic field. However, the HTS magnet has fabrication errors because shape of HTS is tape and HTS magnet is manufactured by winding HTS tape to the bobbin. The fabrication errors are winding error, bobbin diameter error, spacer thickness error and so on. The winding error occurs when HTS tape is departed from the arranged position on the bobbin. The bobbin diameter and spacer thickness error occur since the diameter of bobbin and spacer are inaccurate. These errors lead magnitude and homogeneity of central magnetic field to be different from its ideal design. The purpose of this paper is to investigate the effect of winding error, bobbin diameter error and spacer thickness error on the central field and field homogeneity of HTS magnet using the virtual NMR signals in MATLAB simulation.

Remote one-qubit information concentration and decoding of operator quantum error-correction codes

International Nuclear Information System (INIS)

Hsu Liyi

2007-01-01

We propose the general scheme of remote one-qubit information concentration. To achieve the task, the Bell-correlated mixed states are exploited. In addition, the nonremote one-qubit information concentration is equivalent to the decoding of the quantum error-correction code. Here we propose how to decode the stabilizer codes. In particular, the proposed scheme can be used for the operator quantum error-correction codes. The encoded state can be recreated on the errorless qubit, regardless how many bit-flip errors and phase-flip errors have occurred

Numerical study of the systematic error in Monte Carlo schemes for semiconductors

Energy Technology Data Exchange (ETDEWEB)

Muscato, Orazio [Univ. degli Studi di Catania (Italy). Dipt. di Matematica e Informatica; Di Stefano, Vincenza [Univ. degli Studi di Messina (Italy). Dipt. di Matematica; Wagner, Wolfgang [Weierstrass-Institut fuer Angewandte Analysis und Stochastik (WIAS) im Forschungsverbund Berlin e.V. (Germany)

2008-07-01

The paper studies the convergence behavior of Monte Carlo schemes for semiconductors. A detailed analysis of the systematic error with respect to numerical parameters is performed. Different sources of systematic error are pointed out and illustrated in a spatially one-dimensional test case. The error with respect to the number of simulation particles occurs during the calculation of the internal electric field. The time step error, which is related to the splitting of transport and electric field calculations, vanishes sufficiently fast. The error due to the approximation of the trajectories of particles depends on the ODE solver used in the algorithm. It is negligible compared to the other sources of time step error, when a second order Runge-Kutta solver is used. The error related to the approximate scattering mechanism is the most significant source of error with respect to the time step. (orig.)

The impact of participative management perceptions on customer service, medical errors, burnout, and turnover intentions.

Science.gov (United States)

Angermeier, Ingo; Dunford, Benjamin B; Boss, Alan D; Boss, R Wayne

2009-01-01

Numerous challenges confront managers in the healthcare industry, making it increasingly difficult for healthcare organizations to gain and sustain a competitive advantage. Contemporary management challenges in the industry have many different origins (e.g., economic, financial, clinical, and legal), but there is growing recognition that some of management's greatest problems have organizational roots. Thus, healthcare organizations must examine their personnel management strategies to ensure that they are optimized for fostering a highly committed and productive workforce. Drawing on a sample of 2,522 employees spread across 312 departments within a large U.S. healthcare organization, this article examines the impact of a participative management climate on four employee-level outcomes that represent some of the greatest challenges in the healthcare industry: customer service, medical errors, burnout, and turnover intentions. This study provides clear evidence that employee perceptions of the extent to which their work climate is participative rather than authoritarian have important implications for critical work attitudes and behavior. Specifically, employees in highly participative work climates provided 14 percent better customer service, committed 26 percent fewer clinical errors, demonstrated 79 percent lower burnout, and felt 61 percent lower likelihood of leaving the organization than employees in more authoritarian work climates. These findings suggest that participative management initiatives have a significant impact on the commitment and productivity of individual employees, likely improving the patient care and effectiveness of healthcare organizations as a whole.

The influence of selected socio-demographic variables on symptoms occurring during the menopause

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Marta Makara-Studzińska

2015-02-01

Full Text Available Introduction: It is considered that the lifestyle conditioned by socio-demographic or socio-economic factors determines the health condition of people to the greatest extent. The aim of this study is to evaluate the influence of selected socio-demographic factors on the kinds of symptoms occurring during menopause. Material and methods : The study group consisted of 210 women aged 45 to 65, not using hormone replacement therapy, staying at healthcare centers for rehabilitation treatment. The study was carried out in 2013-2014 in the Silesian, Podlaskie and Lesser Poland voivodeships. The set of tools consisted of the authors’ own survey questionnaire and the Menopause Rating Scale (MRS. Results : The most commonly occurring symptom in the group of studied women was a depressive mood, from the group of psychological symptoms, followed by physical and mental fatigue, and discomfort connected with muscle and joint pain. The greatest intensity of symptoms was observed in the group of women with the lowest level of education, reporting an average or bad material situation, and unemployed women. Conclusions : An alarmingly high number of reported psychological symptoms in the group of menopausal women was observed, and in particular among the group of low socio-economic status. Career seems to be a factor reducing the risk of occurrence of psychological symptoms. There is an urgent need for health promotion and prophylaxis in the group of menopausal women, and in many cases for implementation of specialist psychological assistance.

Quantitative estimation of the human error probability during soft control operations

International Nuclear Information System (INIS)

Lee, Seung Jun; Kim, Jaewhan; Jung, Wondea

2013-01-01

Highlights: ► An HRA method to evaluate execution HEP for soft control operations was proposed. ► The soft control tasks were analyzed and design-related influencing factors were identified. ► An application to evaluate the effects of soft controls was performed. - Abstract: In this work, a method was proposed for quantifying human errors that can occur during operation executions using soft controls. Soft controls of advanced main control rooms have totally different features from conventional controls, and thus they may have different human error modes and occurrence probabilities. It is important to identify the human error modes and quantify the error probability for evaluating the reliability of the system and preventing errors. This work suggests an evaluation framework for quantifying the execution error probability using soft controls. In the application result, it was observed that the human error probabilities of soft controls showed both positive and negative results compared to the conventional controls according to the design quality of advanced main control rooms

Barriers to medication error reporting among hospital nurses.

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Rutledge, Dana N; Retrosi, Tina; Ostrowski, Gary

2018-03-01

The study purpose was to report medication error reporting barriers among hospital nurses, and to determine validity and reliability of an existing medication error reporting barriers questionnaire. Hospital medication errors typically occur between ordering of a medication to its receipt by the patient with subsequent staff monitoring. To decrease medication errors, factors surrounding medication errors must be understood; this requires reporting by employees. Under-reporting can compromise patient safety by disabling improvement efforts. This 2017 descriptive study was part of a larger workforce engagement study at a faith-based Magnet ® -accredited community hospital in California (United States). Registered nurses (~1,000) were invited to participate in the online survey via email. Reported here are sample demographics (n = 357) and responses to the 20-item medication error reporting barriers questionnaire. Using factor analysis, four factors that accounted for 67.5% of the variance were extracted. These factors (subscales) were labelled Fear, Cultural Barriers, Lack of Knowledge/Feedback and Practical/Utility Barriers; each demonstrated excellent internal consistency. The medication error reporting barriers questionnaire, originally developed in long-term care, demonstrated good validity and excellent reliability among hospital nurses. Substantial proportions of American hospital nurses (11%-48%) considered specific factors as likely reporting barriers. Average scores on most barrier items were categorised "somewhat unlikely." The highest six included two barriers concerning the time-consuming nature of medication error reporting and four related to nurses' fear of repercussions. Hospitals need to determine the presence of perceived barriers among nurses using questionnaires such as the medication error reporting barriers and work to encourage better reporting. Barriers to medication error reporting make it less likely that nurses will report medication

Medication errors: prescribing faults and prescription errors.

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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.

Identification of Special Patterns of Numerical Typographic Errors Increases the Likelihood of Finding a Misplaced Patient File

OpenAIRE

Sun, Ying-Chou; Tang, Dah-Dian; Zeng, Qing; Greenes, Robert

2002-01-01

When a typographic error of a patient identification number occurs on a patient document such as an envelope for radiology films or the cover of a patient record, it will result in misplacement of the document. Once misplaced, such documents are often extremely difficult to recover. After analyzing 290 numerical typos, we found that errors do not occur randomly. Instead, many of the typos share certain specific patterns. Six major types of non-random numeral typographic error patterns have be...

Recommendations to avoid gross errors of dose in radiotherapeutic treatments

International Nuclear Information System (INIS)

Souza, Cleber Nogueira de; Monti, Carlos Roberto; Sibata, Claudio Hissao

2001-01-01

Human mistakes are an important source of errors in radiotherapy and may occur at every step of the radiotherapy planning and treatment. To reduce this level of uncertainties, several specialized organizations have recommended a comprehensive quality assurance program. In Brazil, the requirement for these programs has been strongly stressed, and most radiotherapy services have pursued this goal regarding radiation units and dosimetry equipment, as well as the verification of the calculations of the patient's dose and the revision of the plan charts. As a contribution to the improvement of quality control, we present some recommendations to avoid failure of treatment due to error in the delivered dose, such as redundant check of the manual or computer calculations, weekly check of the total dose for each patient, and prevention of inadvertent access to any safety system of the equipment by any staff member that is only supposed to operate the machine. Moreover, the use of a computerized treatment record and verification system should be considered in order to eliminate errors due to incorrect selection of the treatment parameters, in a daily basis. We report four radioactive incidents with patient injuries occurred throughout the world and some gross errors of dose. (author)

Forecast Combination under Heavy-Tailed Errors

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Gang Cheng

2015-11-01

Full Text Available Forecast combination has been proven to be a very important technique to obtain accurate predictions for various applications in economics, finance, marketing and many other areas. In many applications, forecast errors exhibit heavy-tailed behaviors for various reasons. Unfortunately, to our knowledge, little has been done to obtain reliable forecast combinations for such situations. The familiar forecast combination methods, such as simple average, least squares regression or those based on the variance-covariance of the forecasts, may perform very poorly due to the fact that outliers tend to occur, and they make these methods have unstable weights, leading to un-robust forecasts. To address this problem, in this paper, we propose two nonparametric forecast combination methods. One is specially proposed for the situations in which the forecast errors are strongly believed to have heavy tails that can be modeled by a scaled Student’s t-distribution; the other is designed for relatively more general situations when there is a lack of strong or consistent evidence on the tail behaviors of the forecast errors due to a shortage of data and/or an evolving data-generating process. Adaptive risk bounds of both methods are developed. They show that the resulting combined forecasts yield near optimal mean forecast errors relative to the candidate forecasts. Simulations and a real example demonstrate their superior performance in that they indeed tend to have significantly smaller prediction errors than the previous combination methods in the presence of forecast outliers.

Fringe order error in multifrequency fringe projection phase unwrapping: reason and correction.

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Zhang, Chunwei; Zhao, Hong; Zhang, Lu

2015-11-10

A multifrequency fringe projection phase unwrapping algorithm (MFPPUA) is important to fringe projection profilometry, especially when a discontinuous object is measured. However, a fringe order error (FOE) may occur when MFPPUA is adopted. An FOE will result in error to the unwrapped phase. Although this kind of phase error does not spread, it brings error to the eventual 3D measurement results. Therefore, an FOE or its adverse influence should be obviated. In this paper, reasons for the occurrence of an FOE are theoretically analyzed and experimentally explored. Methods to correct the phase error caused by an FOE are proposed. Experimental results demonstrate that the proposed methods are valid in eliminating the adverse influence of an FOE.

Medication Errors in Patients with Enteral Feeding Tubes in the Intensive Care Unit.

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Sohrevardi, Seyed Mojtaba; Jarahzadeh, Mohammad Hossein; Mirzaei, Ehsan; Mirjalili, Mahtabalsadat; Tafti, Arefeh Dehghani; Heydari, Behrooz

2017-01-01

Most patients admitted to Intensive Care Units (ICU) have problems in using oral medication or ingesting solid forms of drugs. Selecting the most suitable dosage form in such patients is a challenge. The current study was conducted to assess the frequency and types of errors of oral medication administration in patients with enteral feeding tubes or suffering swallowing problems. A cross-sectional study was performed in the ICU of Shahid Sadoughi Hospital, Yazd, Iran. Patients were assessed for the incidence and types of medication errors occurring in the process of preparation and administration of oral medicines. Ninety-four patients were involved in this study and 10,250 administrations were observed. Totally, 4753 errors occurred among the studied patients. The most commonly used drugs were pantoprazole tablet, piracetam syrup, and losartan tablet. A total of 128 different types of drugs and nine different oral pharmaceutical preparations were prescribed for the patients. Forty-one (35.34%) out of 116 different solid drugs (except effervescent tablets and powders) could be substituted by liquid or injectable forms. The most common error was the wrong time of administration. Errors of wrong dose preparation and administration accounted for 24.04% and 25.31% of all errors, respectively. In this study, at least three-fourth of the patients experienced medication errors. The occurrence of these errors can greatly impair the quality of the patients' pharmacotherapy, and more attention should be paid to this issue.

Persistent and late occurring lesions in irradiated feet of rats: their clinical relevance

International Nuclear Information System (INIS)

Hopewell, J.W.

1982-01-01

Radiation-induced deformity, as characterized by tissue loss, has been investigated in rat feet. The acute epithelial response and the loss of deeper tissues occur concomitantly after irradiation. The greatest loss of tissue (severe deformity) was produced in feet where the healing of the epithelial reaction was greatly delayed. While deformity will clearly continue to ''persist'' after the acute reaction has healed it is misleading to refer to this lesion as ''late'' damage. A late-occurring lesion, not previously described in the literature, can be produced in the rat foot by high doses of radiation delivered in such a way that moist desquamation is avoided, i.e. by extending the total treatment time. Parallels are drawn between reactions in rodents and those in the skin of pig and man. (author)

Operator quantum error-correcting subsystems for self-correcting quantum memories

International Nuclear Information System (INIS)

Bacon, Dave

2006-01-01

The most general method for encoding quantum information is not to encode the information into a subspace of a Hilbert space, but to encode information into a subsystem of a Hilbert space. Recently this notion has led to a more general notion of quantum error correction known as operator quantum error correction. In standard quantum error-correcting codes, one requires the ability to apply a procedure which exactly reverses on the error-correcting subspace any correctable error. In contrast, for operator error-correcting subsystems, the correction procedure need not undo the error which has occurred, but instead one must perform corrections only modulo the subsystem structure. This does not lead to codes which differ from subspace codes, but does lead to recovery routines which explicitly make use of the subsystem structure. Here we present two examples of such operator error-correcting subsystems. These examples are motivated by simple spatially local Hamiltonians on square and cubic lattices. In three dimensions we provide evidence, in the form a simple mean field theory, that our Hamiltonian gives rise to a system which is self-correcting. Such a system will be a natural high-temperature quantum memory, robust to noise without external intervening quantum error-correction procedures

THE SELF-CORRECTION OF ENGLISH SPEECH ERRORS IN SECOND LANGUANGE LEARNING

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Ketut Santi Indriani

2015-05-01

Full Text Available The process of second language (L2 learning is strongly influenced by the factors of error reconstruction that occur when the language is learned. Errors will definitely appear in the learning process. However, errors can be used as a step to accelerate the process of understanding the language. Doing self-correction (with or without giving cues is one of the examples. In the aspect of speaking, self-correction is done immediately after the error appears. This study is aimed at finding (i what speech errors the L2 speakers are able to identify, (ii of the errors identified, what speech errors the L2 speakers are able to self correct and (iii whether the self-correction of speech error are able to immediately improve the L2 learning. Based on the data analysis, it was found that the majority identified errors are related to noun (plurality, subject-verb agreement, grammatical structure and pronunciation.. B2 speakers tend to correct errors properly. Of the 78% identified speech errors, as much as 66% errors could be self-corrected accurately by the L2 speakers. Based on the analysis, it was also found that self-correction is able to improve L2 learning ability directly. This is evidenced by the absence of repetition of the same error after the error had been corrected.

Operating personnel error analysis during operation failures in the Kozloduj NPP

International Nuclear Information System (INIS)

Jonkova, A.

1990-01-01

The failures due to personnel errors are analyzed for 10 years period (1977-1986). Most of the results are presented in absolute values and are considered in dynamics. The indices for relative shares are compared by alternative analysis. One of the most important causes is the fluctuation of manpower. The failures distribution by months within the year and by hours of the day is given. The biggest number of failures occurred in the period April-October (without August - the month of the leaves), when the refueling and repair were taken place, and in January-February, due to heavy meteorological conditions and some fatigue and disconcentration because of multiple holidays. The failures during the day shifts had the greatest relative share - 42%, during the afternoon shifts - 26% and during the night shifts - 32% The most 'dangerous' time periods happened to be 11-12 h and 13-14 h (deteriorated attention after lunch), 20-22 h (physiological drop of the psychological activity), 0-3 h (the lowest level of physiological and psychological activity) and in the first and last hours of every shift. Three groups of causes are pointed out as the most frequent: improper actions connected with orders; improper independent actions; uncoordinated teamwork. The following measures are proposed for reducing the effect of the human factor: setting up the training centre; preliminary evaluation of the professional qualification of the operators; current dynamic control of their neuro-psychological fitness and occupational reliability. 1 fig, 2 tabs, 5 refs

Automation of Commanding at NASA: Reducing Human Error in Space Flight

Science.gov (United States)

Dorn, Sarah J.

2010-01-01

Automation has been implemented in many different industries to improve efficiency and reduce human error. Reducing or eliminating the human interaction in tasks has been proven to increase productivity in manufacturing and lessen the risk of mistakes by humans in the airline industry. Human space flight requires the flight controllers to monitor multiple systems and react quickly when failures occur so NASA is interested in implementing techniques that can assist in these tasks. Using automation to control some of these responsibilities could reduce the number of errors the flight controllers encounter due to standard human error characteristics. This paper will investigate the possibility of reducing human error in the critical area of manned space flight at NASA.

Hospital medication errors in a pharmacovigilance system in Colombia

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Jorge Enrique Machado-Alba

2015-11-01

Full Text Available Objective: this study analyzes the medication errors reported to a pharmacovigilance system by 26 hospitals for patients in the healthcare system of Colombia. Methods: this retrospective study analyzed the medication errors reported to a systematized database between 1 January 2008 and 12 September 2013. The medication is dispensed by the company Audifarma S.A. to hospitals and clinics around Colombia. Data were classified according to the taxonomy of the National Coordinating Council for Medication Error Reporting and Prevention (NCC MERP. The data analysis was performed using SPSS 22.0 for Windows, considering p-values < 0.05 significant. Results: there were 9 062 medication errors in 45 hospital pharmacies. Real errors accounted for 51.9% (n = 4 707, of which 12.0% (n = 567 reached the patient (Categories C to I and caused harm (Categories E to I to 17 subjects (0.36%. The main process involved in errors that occurred (categories B to I was prescription (n = 1 758, 37.3%, followed by dispensation (n = 1 737, 36.9%, transcription (n = 970, 20.6% and administration (n = 242, 5.1%. The errors in the administration process were 45.2 times more likely to reach the patient (CI 95%: 20.2–100.9. Conclusions: medication error reporting systems and prevention strategies should be widespread in hospital settings, prioritizing efforts to address the administration process.

Roles of dopamine neurons in mediating the prediction error in aversive learning in insects.

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Terao, Kanta; Mizunami, Makoto

2017-10-31

In associative learning in mammals, it is widely accepted that the discrepancy, or error, between actual and predicted reward determines whether learning occurs. The prediction error theory has been proposed to account for the finding of a blocking phenomenon, in which pairing of a stimulus X with an unconditioned stimulus (US) could block subsequent association of a second stimulus Y to the US when the two stimuli were paired in compound with the same US. Evidence for this theory, however, has been imperfect since blocking can also be accounted for by competitive theories. We recently reported blocking in classical conditioning of an odor with water reward in crickets. We also reported an "auto-blocking" phenomenon in appetitive learning, which supported the prediction error theory and rejected alternative theories. The presence of auto-blocking also suggested that octopamine neurons mediate reward prediction error signals. Here we show that blocking and auto-blocking occur in aversive learning to associate an odor with salt water (US) in crickets, and our results suggest that dopamine neurons mediate aversive prediction error signals. We conclude that the prediction error theory is applicable to both appetitive learning and aversive learning in insects.

ERROR DETECTION BY ANTICIPATION FOR VISION-BASED CONTROL

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A ZAATRI

2001-06-01

Full Text Available A vision-based control system has been developed.  It enables a human operator to remotely direct a robot, equipped with a camera, towards targets in 3D space by simply pointing on their images with a pointing device. This paper presents an anticipatory system, which has been designed for improving the safety and the effectiveness of the vision-based commands. It simulates these commands in a virtual environment. It attempts to detect hard contacts that may occur between the robot and its environment, which can be caused by machine errors or operator errors as well.

How common are cognitive errors in cases presented at emergency medicine resident morbidity and mortality conferences?

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Chu, David; Xiao, Jane; Shah, Payal; Todd, Brett

2018-06-20

Cognitive errors are a major contributor to medical error. Traditionally, medical errors at teaching hospitals are analyzed in morbidity and mortality (M&M) conferences. We aimed to describe the frequency of cognitive errors in relation to the occurrence of diagnostic and other error types, in cases presented at an emergency medicine (EM) resident M&M conference. We conducted a retrospective study of all cases presented at a suburban US EM residency monthly M&M conference from September 2011 to August 2016. Each case was reviewed using the electronic medical record (EMR) and notes from the M&M case by two EM physicians. Each case was categorized by type of primary medical error that occurred as described by Okafor et al. When a diagnostic error occurred, the case was reviewed for contributing cognitive and non-cognitive factors. Finally, when a cognitive error occurred, the case was classified into faulty knowledge, faulty data gathering or faulty synthesis, as described by Graber et al. Disagreements in error type were mediated by a third EM physician. A total of 87 M&M cases were reviewed; the two reviewers agreed on 73 cases, and 14 cases required mediation by a third reviewer. Forty-eight cases involved diagnostic errors, 47 of which were cognitive errors. Of these 47 cases, 38 involved faulty synthesis, 22 involved faulty data gathering and only 11 involved faulty knowledge. Twenty cases contained more than one type of cognitive error. Twenty-nine cases involved both a resident and an attending physician, while 17 cases involved only an attending physician. Twenty-one percent of the resident cases involved all three cognitive errors, while none of the attending cases involved all three. Forty-one percent of the resident cases and only 6% of the attending cases involved faulty knowledge. One hundred percent of the resident cases and 94% of the attending cases involved faulty synthesis. Our review of 87 EM M&M cases revealed that cognitive errors are commonly

Impact of Stewardship Interventions on Antiretroviral Medication Errors in an Urban Medical Center: A 3-Year, Multiphase Study.

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Zucker, Jason; Mittal, Jaimie; Jen, Shin-Pung; Cheng, Lucy; Cennimo, David

2016-03-01

There is a high prevalence of HIV infection in Newark, New Jersey, with University Hospital admitting approximately 600 HIV-infected patients per year. Medication errors involving antiretroviral therapy (ART) could significantly affect treatment outcomes. The goal of this study was to evaluate the effectiveness of various stewardship interventions in reducing the prevalence of prescribing errors involving ART. This was a retrospective review of all inpatients receiving ART for HIV treatment during three distinct 6-month intervals over a 3-year period. During the first year, the baseline prevalence of medication errors was determined. During the second year, physician and pharmacist education was provided, and a computerized order entry system with drug information resources and prescribing recommendations was implemented. Prospective audit of ART orders with feedback was conducted in the third year. Analyses and comparisons were made across the three phases of this study. Of the 334 patients with HIV admitted in the first year, 45% had at least one antiretroviral medication error and 38% had uncorrected errors at the time of discharge. After education and computerized order entry, significant reductions in medication error rates were observed compared to baseline rates; 36% of 315 admissions had at least one error and 31% had uncorrected errors at discharge. While the prevalence of antiretroviral errors in year 3 was similar to that of year 2 (37% of 276 admissions), there was a significant decrease in the prevalence of uncorrected errors at discharge (12%) with the use of prospective review and intervention. Interventions, such as education and guideline development, can aid in reducing ART medication errors, but a committed stewardship program is necessary to elicit the greatest impact. © 2016 Pharmacotherapy Publications, Inc.

Evaluation of Retro recon for SRS planning correction according to the error of recognize to coordinate

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Moon, Hyeon Seok; Jeong, Deok Yang; Do, Gyeong Min; Lee, Yeong Cheol; KIm, Sun Myung; Kim, Young Bun [Dept. of Radiation Oncology, Korea University Guro Hospital, Seoul (Korea, Republic of)

2016-12-15

The purpose of this study was to evaluate the Retro recon in SRS planning using BranLAB when stereotactic location error occurs by metal artifact. By CT simulator, image were acquired from head phantom(CIRS, PTW, USA). To observe stereotactic location recognizing and beam hardening, CT image were approved by SRS planning system(BrainLAB, Feldkirchen, Germany). In addition, we compared acquisition image(1.25mm slice thickness) and Retro recon image(using for 2.5 mm, 5mm slice thickness). To evaluate these three images quality, the test were performed by AAPM phantom study. In patient, it was verified stereotactic location error. All the location recognizing error did not occur in scanned image of phantom. AAPM phantom scan images all showed the same trend. Contrast resolution and Spatial resolution are under 6.4 mm, 1.0 mm. In case of noise and uniformity, under 11, 5 of HU were measured. In patient, the stereotactic location error was not occurred at reconstructive image. For BrainLAB planning, using Retro recon were corrected stereotactic error at beam hardening. Retro recon may be the preferred modality for radiation treatment planning and approving image quality.

Meniscal tear. Diagnostic errors in MR imaging

International Nuclear Information System (INIS)

Barrera, M. C.; Recondo, J. A.; Gervas, C.; Fernandez, E.; Villanua, J. A.M.; Salvador, E.

2003-01-01

To analyze diagnostic discrepancies found between magnetic resonance (MR) and arthroscopy, and the determine the reasons that they occur. Two-hundred and forty-eight MR knee explorations were retrospectively checked. Forty of these showed diagnostic discrepancies between MR and arthroscopy. Two radiologists independently re-analyzed the images from 29 of the 40 studies without knowing which diagnosis had resulted from which of the two techniques. Their interpretations were correlated with the initial MR diagnosis, MR images and arthroscopic results. Initial errors in MR imaging were classified as either unavoidable, interpretive, or secondary to equivocal findings. Eleven MR examinations could not be checked since their corresponding imaging results could not be located. Of 34 errors found in the original diagnoses, 12 (35.5%)were classified as unavoidable, 14 (41.2%) as interpretative and 8 (23.5%) as secondary to equivocal findings. 41.2% of the errors were avoided in the retrospective study probably due to our department having greater experience in interpreting MR images, 25.5% were unavailable even in the retrospective study. A small percentage of diagnostic errors were due to the presence of subtle equivocal findings. (Author) 15 refs

Error-Transparent Quantum Gates for Small Logical Qubit Architectures

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Kapit, Eliot

2018-02-01

One of the largest obstacles to building a quantum computer is gate error, where the physical evolution of the state of a qubit or group of qubits during a gate operation does not match the intended unitary transformation. Gate error stems from a combination of control errors and random single qubit errors from interaction with the environment. While great strides have been made in mitigating control errors, intrinsic qubit error remains a serious problem that limits gate fidelity in modern qubit architectures. Simultaneously, recent developments of small error-corrected logical qubit devices promise significant increases in logical state lifetime, but translating those improvements into increases in gate fidelity is a complex challenge. In this Letter, we construct protocols for gates on and between small logical qubit devices which inherit the parent device's tolerance to single qubit errors which occur at any time before or during the gate. We consider two such devices, a passive implementation of the three-qubit bit flip code, and the author's own [E. Kapit, Phys. Rev. Lett. 116, 150501 (2016), 10.1103/PhysRevLett.116.150501] very small logical qubit (VSLQ) design, and propose error-tolerant gate sets for both. The effective logical gate error rate in these models displays superlinear error reduction with linear increases in single qubit lifetime, proving that passive error correction is capable of increasing gate fidelity. Using a standard phenomenological noise model for superconducting qubits, we demonstrate a realistic, universal one- and two-qubit gate set for the VSLQ, with error rates an order of magnitude lower than those for same-duration operations on single qubits or pairs of qubits. These developments further suggest that incorporating small logical qubits into a measurement based code could substantially improve code performance.

Characteristics of the Traumatic Forensic Cases Admitted To Emergency Department and Errors in the Forensic Report Writing.

Science.gov (United States)

Aktas, Nurettin; Gulacti, Umut; Lok, Ugur; Aydin, İrfan; Borta, Tayfun; Celik, Murat

2018-01-01

To identify errors in forensic reports and to describe the characteristics of traumatic medico-legal cases presenting to the emergency department (ED) at a tertiary care hospital. This study is a retrospective cross-sectional study. The study includes cases resulting in a forensic report among all traumatic patients presenting to the ED of Adiyaman University Training and Research Hospital, Adiyaman, Turkey during a 1-year period. We recorded the demographic characteristics of all the cases, time of presentation to the ED, traumatic characteristics of medico-legal cases, forms of suicide attempt, suspected poisonous substance exposure, the result of follow-up and the type of forensic report. A total of 4300 traumatic medico-legal cases were included in the study and 72% of these cases were male. Traumatic medico-legal cases occurred at the greatest frequency in July (10.1%) and 28.9% of all cases occurred in summer. The most frequent causes of traumatic medico-legal cases in the ED were traffic accidents (43.4%), violent crime (30.5%), and suicide attempt (7.2%). The most common method of attempted suicide was drug intake (86.4%). 12.3% of traumatic medico-legal cases were hospitalized and 24.2% of those hospitalized were admitted to the orthopedics service. The most common error in forensic reports was the incomplete recording of the patient's "cooperation" status (82.7%). Additionally, external traumatic lesions were not defined in 62.4% of forensic reports. The majority of traumatic medico-legal cases were male age 18-44 years, the most common source of trauma was traffic accidents and in the summer months. When writing a forensic report, emergency physicians made mistakes in noting physical examination findings and identifying external traumatic lesions. Physicians should make sure that the traumatic medico-legal patients they treat have adequate documentation for reference during legal proceedings. The legal duties and responsibilities of physicians should be

Optimizer convergence and local minima errors and their clinical importance

International Nuclear Information System (INIS)

Jeraj, Robert; Wu, Chuan; Mackie, Thomas R

2003-01-01

Two of the errors common in the inverse treatment planning optimization have been investigated. The first error is the optimizer convergence error, which appears because of non-perfect convergence to the global or local solution, usually caused by a non-zero stopping criterion. The second error is the local minima error, which occurs when the objective function is not convex and/or the feasible solution space is not convex. The magnitude of the errors, their relative importance in comparison to other errors as well as their clinical significance in terms of tumour control probability (TCP) and normal tissue complication probability (NTCP) were investigated. Two inherently different optimizers, a stochastic simulated annealing and deterministic gradient method were compared on a clinical example. It was found that for typical optimization the optimizer convergence errors are rather small, especially compared to other convergence errors, e.g., convergence errors due to inaccuracy of the current dose calculation algorithms. This indicates that stopping criteria could often be relaxed leading into optimization speed-ups. The local minima errors were also found to be relatively small and typically in the range of the dose calculation convergence errors. Even for the cases where significantly higher objective function scores were obtained the local minima errors were not significantly higher. Clinical evaluation of the optimizer convergence error showed good correlation between the convergence of the clinical TCP or NTCP measures and convergence of the physical dose distribution. On the other hand, the local minima errors resulted in significantly different TCP or NTCP values (up to a factor of 2) indicating clinical importance of the local minima produced by physical optimization

Bias correction of bounded location errors in presence-only data

Science.gov (United States)

Hefley, Trevor J.; Brost, Brian M.; Hooten, Mevin B.

2017-01-01

Location error occurs when the true location is different than the reported location. Because habitat characteristics at the true location may be different than those at the reported location, ignoring location error may lead to unreliable inference concerning species–habitat relationships.We explain how a transformation known in the spatial statistics literature as a change of support (COS) can be used to correct for location errors when the true locations are points with unknown coordinates contained within arbitrary shaped polygons.We illustrate the flexibility of the COS by modelling the resource selection of Whooping Cranes (Grus americana) using citizen contributed records with locations that were reported with error. We also illustrate the COS with a simulation experiment.In our analysis of Whooping Crane resource selection, we found that location error can result in up to a five-fold change in coefficient estimates. Our simulation study shows that location error can result in coefficient estimates that have the wrong sign, but a COS can efficiently correct for the bias.

Potential Errors and Test Assessment in Software Product Line Engineering

Directory of Open Access Journals (Sweden)

Hartmut Lackner

2015-04-01

Full Text Available Software product lines (SPL are a method for the development of variant-rich software systems. Compared to non-variable systems, testing SPLs is extensive due to an increasingly amount of possible products. Different approaches exist for testing SPLs, but there is less research for assessing the quality of these tests by means of error detection capability. Such test assessment is based on error injection into correct version of the system under test. However to our knowledge, potential errors in SPL engineering have never been systematically identified before. This article presents an overview over existing paradigms for specifying software product lines and the errors that can occur during the respective specification processes. For assessment of test quality, we leverage mutation testing techniques to SPL engineering and implement the identified errors as mutation operators. This allows us to run existing tests against defective products for the purpose of test assessment. From the results, we draw conclusions about the error-proneness of the surveyed SPL design paradigms and how quality of SPL tests can be improved.

Measurement-based analysis of error latency. [in computer operating system

Science.gov (United States)

Chillarege, Ram; Iyer, Ravishankar K.

1987-01-01

This paper demonstrates a practical methodology for the study of error latency under a real workload. The method is illustrated with sampled data on the physical memory activity, gathered by hardware instrumentation on a VAX 11/780 during the normal workload cycle of the installation. These data are used to simulate fault occurrence and to reconstruct the error discovery process in the system. The technique provides a means to study the system under different workloads and for multiple days. An approach to determine the percentage of undiscovered errors is also developed and a verification of the entire methodology is performed. This study finds that the mean error latency, in the memory containing the operating system, varies by a factor of 10 to 1 (in hours) between the low and high workloads. It is found that of all errors occurring within a day, 70 percent are detected in the same day, 82 percent within the following day, and 91 percent within the third day. The increase in failure rate due to latency is not so much a function of remaining errors but is dependent on whether or not there is a latent error.

Critical evidence for the prediction error theory in associative learning.

Science.gov (United States)

Terao, Kanta; Matsumoto, Yukihisa; Mizunami, Makoto

2015-03-10

In associative learning in mammals, it is widely accepted that the discrepancy, or error, between actual and predicted reward determines whether learning occurs. Complete evidence for the prediction error theory, however, has not been obtained in any learning systems: Prediction error theory stems from the finding of a blocking phenomenon, but blocking can also be accounted for by other theories, such as the attentional theory. We demonstrated blocking in classical conditioning in crickets and obtained evidence to reject the attentional theory. To obtain further evidence supporting the prediction error theory and rejecting alternative theories, we constructed a neural model to match the prediction error theory, by modifying our previous model of learning in crickets, and we tested a prediction from the model: the model predicts that pharmacological intervention of octopaminergic transmission during appetitive conditioning impairs learning but not formation of reward prediction itself, and it thus predicts no learning in subsequent training. We observed such an "auto-blocking", which could be accounted for by the prediction error theory but not by other competitive theories to account for blocking. This study unambiguously demonstrates validity of the prediction error theory in associative learning.

Cumulative error models for the tank calibration problem

International Nuclear Information System (INIS)

Goldman, A.; Anderson, L.G.; Weber, J.

1983-01-01

The purpose of a tank calibration equation is to obtain an estimate of the liquid volume that corresponds to a liquid level measurement. Calibration experimental errors occur in both liquid level and liquid volume measurements. If one of the errors is relatively small, the calibration equation can be determined from wellknown regression and calibration methods. If both variables are assumed to be in error, then for linear cases a prototype model should be considered. Many investigators are not familiar with this model or do not have computing facilities capable of obtaining numerical solutions. This paper discusses and compares three linear models that approximate the prototype model and have the advantage of much simpler computations. Comparisons among the four models and recommendations of suitability are made from simulations and from analyses of six sets of experimental data

Identification of Special Patterns of Numerical Typographic Errors to Increases the Likelihood of Finding a Misplaced Patient File

OpenAIRE

Sun, Ying-Chou; Tang, Dah-Dian; Zeng, Qing; Greenes, Robert

2001-01-01

When a typographic error of a patient identification number occurs on a patient document such as an envelope for radiology films or the cover of a patient record, it will result in misplacement of the document. Once misplaced, such documents are often extremely difficult to recover. After analyzing 290 numerical typos, we found that errors do not occur randomly. Instead, many of the typos share certain specific patterns. Six major types of non-random numeral typographic error patterns have be...

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…

Prevalence and cost of hospital medical errors in the general and elderly United States populations.

Science.gov (United States)

Mallow, Peter J; Pandya, Bhavik; Horblyuk, Ruslan; Kaplan, Harold S

2013-12-01

The primary objective of this study was to quantify the differences in the prevalence rate and costs of hospital medical errors between the general population and an elderly population aged ≥65 years. Methods from an actuarial study of medical errors were modified to identify medical errors in the Premier Hospital Database using data from 2009. Visits with more than four medical errors were removed from the population to avoid over-estimation of cost. Prevalence rates were calculated based on the total number of inpatient visits. There were 3,466,596 total inpatient visits in 2009. Of these, 1,230,836 (36%) occurred in people aged ≥ 65. The prevalence rate was 49 medical errors per 1000 inpatient visits in the general cohort and 79 medical errors per 1000 inpatient visits for the elderly cohort. The top 10 medical errors accounted for more than 80% of the total in the general cohort and the 65+ cohort. The most costly medical error for the general population was postoperative infection ($569,287,000). Pressure ulcers were most costly ($347,166,257) in the elderly population. This study was conducted with a hospital administrative database, and assumptions were necessary to identify medical errors in the database. Further, there was no method to identify errors of omission or misdiagnoses within the database. This study indicates that prevalence of hospital medical errors for the elderly is greater than the general population and the associated cost of medical errors in the elderly population is quite substantial. Hospitals which further focus their attention on medical errors in the elderly population may see a significant reduction in costs due to medical errors as a disproportionate percentage of medical errors occur in this age group.

Applying the intention-to-treat principle in practice: Guidance on handling randomisation errors.

Science.gov (United States)

Yelland, Lisa N; Sullivan, Thomas R; Voysey, Merryn; Lee, Katherine J; Cook, Jonathan A; Forbes, Andrew B

2015-08-01

The intention-to-treat principle states that all randomised participants should be analysed in their randomised group. The implications of this principle are widely discussed in relation to the analysis, but have received limited attention in the context of handling errors that occur during the randomisation process. The aims of this article are to (1) demonstrate the potential pitfalls of attempting to correct randomisation errors and (2) provide guidance on handling common randomisation errors when they are discovered that maintains the goals of the intention-to-treat principle. The potential pitfalls of attempting to correct randomisation errors are demonstrated and guidance on handling common errors is provided, using examples from our own experiences. We illustrate the problems that can occur when attempts are made to correct randomisation errors and argue that documenting, rather than correcting these errors, is most consistent with the intention-to-treat principle. When a participant is randomised using incorrect baseline information, we recommend accepting the randomisation but recording the correct baseline data. If ineligible participants are inadvertently randomised, we advocate keeping them in the trial and collecting all relevant data but seeking clinical input to determine their appropriate course of management, unless they can be excluded in an objective and unbiased manner. When multiple randomisations are performed in error for the same participant, we suggest retaining the initial randomisation and either disregarding the second randomisation if only one set of data will be obtained for the participant, or retaining the second randomisation otherwise. When participants are issued the incorrect treatment at the time of randomisation, we propose documenting the treatment received and seeking clinical input regarding the ongoing treatment of the participant. Randomisation errors are almost inevitable and should be reported in trial publications. The

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.)

Post-error expression of speed and force while performing a simple, monotonous task with a haptic pen

NARCIS (Netherlands)

Bruns, M.; Keyson, D.V.; Jabon, M.E.; Hummels, C.C.M.; Hekkert, P.P.M.; Bailenson, J.N.

2013-01-01

Control errors often occur in repetitive and monotonous tasks, such as manual assembly tasks. Much research has been done in the area of human error identification; however, most existing systems focus solely on the prediction of errors, not on increasing worker accuracy. The current study examines

Systematic Analysis of Video Data from Different Human-Robot Interaction Studies: A Categorisation of Social Signals During Error Situations

OpenAIRE

Manuel eGiuliani; Nicole eMirnig; Gerald eStollnberger; Susanne eStadler; Roland eBuchner; Manfred eTscheligi

2015-01-01

Human?robot interactions are often affected by error situations that are caused by either the robot or the human. Therefore, robots would profit from the ability to recognize when error situations occur. We investigated the verbal and non-verbal social signals that humans show when error situations occur in human?robot interaction experiments. For that, we analyzed 201 videos of five human?robot interaction user studies with varying tasks from four independent projects. The analysis shows tha...

Characterization of identification errors and uses in localization of poor modal correlation

Science.gov (United States)

Martin, Guillaume; Balmes, Etienne; Chancelier, Thierry

2017-05-01

While modal identification is a mature subject, very few studies address the characterization of errors associated with components of a mode shape. This is particularly important in test/analysis correlation procedures, where the Modal Assurance Criterion is used to pair modes and to localize at which sensors discrepancies occur. Poor correlation is usually attributed to modeling errors, but clearly identification errors also occur. In particular with 3D Scanning Laser Doppler Vibrometer measurement, many transfer functions are measured. As a result individual validation of each measurement cannot be performed manually in a reasonable time frame and a notable fraction of measurements is expected to be fairly noisy leading to poor identification of the associated mode shape components. The paper first addresses measurements and introduces multiple criteria. The error measures the difference between test and synthesized transfer functions around each resonance and can be used to localize poorly identified modal components. For intermediate error values, diagnostic of the origin of the error is needed. The level evaluates the transfer function amplitude in the vicinity of a given mode and can be used to eliminate sensors with low responses. A Noise Over Signal indicator, product of error and level, is then shown to be relevant to detect poorly excited modes and errors due to modal property shifts between test batches. Finally, a contribution is introduced to evaluate the visibility of a mode in each transfer. Using tests on a drum brake component, these indicators are shown to provide relevant insight into the quality of measurements. In a second part, test/analysis correlation is addressed with a focus on the localization of sources of poor mode shape correlation. The MACCo algorithm, which sorts sensors by the impact of their removal on a MAC computation, is shown to be particularly relevant. Combined with the error it avoids keeping erroneous modal components

Structural damage detection robust against time synchronization errors

International Nuclear Information System (INIS)

Yan, Guirong; Dyke, Shirley J

2010-01-01

Structural damage detection based on wireless sensor networks can be affected significantly by time synchronization errors among sensors. Precise time synchronization of sensor nodes has been viewed as crucial for addressing this issue. However, precise time synchronization over a long period of time is often impractical in large wireless sensor networks due to two inherent challenges. First, time synchronization needs to be performed periodically, requiring frequent wireless communication among sensors at significant energy cost. Second, significant time synchronization errors may result from node failures which are likely to occur during long-term deployment over civil infrastructures. In this paper, a damage detection approach is proposed that is robust against time synchronization errors in wireless sensor networks. The paper first examines the ways in which time synchronization errors distort identified mode shapes, and then proposes a strategy for reducing distortion in the identified mode shapes. Modified values for these identified mode shapes are then used in conjunction with flexibility-based damage detection methods to localize damage. This alternative approach relaxes the need for frequent sensor synchronization and can tolerate significant time synchronization errors caused by node failures. The proposed approach is successfully demonstrated through numerical simulations and experimental tests in a lab

Error quantification of abnormal extreme high waves in Operational Oceanographic System in Korea

Science.gov (United States)

Jeong, Sang-Hun; Kim, Jinah; Heo, Ki-Young; Park, Kwang-Soon

2017-04-01

In winter season, large-height swell-like waves have occurred on the East coast of Korea, causing property damages and loss of human life. It is known that those waves are generated by a local strong wind made by temperate cyclone moving to eastward in the East Sea of Korean peninsula. Because the waves are often occurred in the clear weather, in particular, the damages are to be maximized. Therefore, it is necessary to predict and forecast large-height swell-like waves to prevent and correspond to the coastal damages. In Korea, an operational oceanographic system (KOOS) has been developed by the Korea institute of ocean science and technology (KIOST) and KOOS provides daily basis 72-hours' ocean forecasts such as wind, water elevation, sea currents, water temperature, salinity, and waves which are computed from not only meteorological and hydrodynamic model (WRF, ROMS, MOM, and MOHID) but also wave models (WW-III and SWAN). In order to evaluate the model performance and guarantee a certain level of accuracy of ocean forecasts, a Skill Assessment (SA) system was established as a one of module in KOOS. It has been performed through comparison of model results with in-situ observation data and model errors have been quantified with skill scores. Statistics which are used in skill assessment are including a measure of both errors and correlations such as root-mean-square-error (RMSE), root-mean-square-error percentage (RMSE%), mean bias (MB), correlation coefficient (R), scatter index (SI), circular correlation (CC) and central frequency (CF) that is a frequency with which errors lie within acceptable error criteria. It should be utilized simultaneously not only to quantify an error but also to improve an accuracy of forecasts by providing a feedback interactively. However, in an abnormal phenomena such as high-height swell-like waves in the East coast of Korea, it requires more advanced and optimized error quantification method that allows to predict the abnormal

Frequency of medical errors in hospitalized children in khorramabad Madani hospital during six months in 2008

Directory of Open Access Journals (Sweden)

azam Mohsenzadeh

2010-02-01

Full Text Available Many hospitalized children are suffered from medical errors that may cause serious injuries. The aim of this study was to evaluate medical errors in hospitalized children in khorramabad Madani hospital in the first half of 2008. Materials and Methods: This study was a cross sectional that was performed for all medical errors in hospitalized children in khorramabad Madani hospital from 21/3/2008 to 21/9/2008. The sampling method was census. Studied variables included: age, sex, weight, kinds of errers, education of parents, job of parents. Data was collected by questionnaire and analyzed by SPSS software. Results: In this study out of 2250 records, 151 (6/3% had medical errors. 53%were girls and 47% were boys that there was a significant relation between sex and medical errors. 46/4%were related to age group lower than 2 years old. Most of the errors were occurred in weight group of 6kg. Types of medical errors included drug ordering 46/3% (involved incorrect dosage of drug (37%, frequency 28%, rout 19% and others 16%, transcribing10%, administering32/4%, dispensing11/3%. Most errors related to liquid therapy 76/2% and intravenous rout 85/4%. Most errors were occurred during night 47% and during weekend 56/6%. Conclusion: Medical errors are common in hospitalized patients, and in our study the rate of medical errors was 6/3%. So further efforts are needed to reduce them.

Drug administration errors in an institution for individuals with intellectual disability : an observational study

NARCIS (Netherlands)

van den Bemt, P M L A; Robertz, R; de Jong, A L; van Roon, E N; Leufkens, H G M

BACKGROUND: Medication errors can result in harm, unless barriers to prevent them are present. Drug administration errors are less likely to be prevented, because they occur in the last stage of the drug distribution process. This is especially the case in non-alert patients, as patients often form

Generalizing human error rates: A taxonomic approach

International Nuclear Information System (INIS)

Buffardi, L.; Fleishman, E.; Allen, J.

1989-01-01

It is well established that human error plays a major role in malfunctioning of complex, technological systems and in accidents associated with their operation. Estimates of the rate of human error in the nuclear industry range from 20-65% of all system failures. In response to this, the Nuclear Regulatory Commission has developed a variety of techniques for estimating human error probabilities for nuclear power plant personnel. Most of these techniques require the specification of the range of human error probabilities for various tasks. Unfortunately, very little objective performance data on error probabilities exist for nuclear environments. Thus, when human reliability estimates are required, for example in computer simulation modeling of system reliability, only subjective estimates (usually based on experts' best guesses) can be provided. The objective of the current research is to provide guidelines for the selection of human error probabilities based on actual performance data taken in other complex environments and applying them to nuclear settings. A key feature of this research is the application of a comprehensive taxonomic approach to nuclear and non-nuclear tasks to evaluate their similarities and differences, thus providing a basis for generalizing human error estimates across tasks. In recent years significant developments have occurred in classifying and describing tasks. Initial goals of the current research are to: (1) identify alternative taxonomic schemes that can be applied to tasks, and (2) describe nuclear tasks in terms of these schemes. Three standardized taxonomic schemes (Ability Requirements Approach, Generalized Information-Processing Approach, Task Characteristics Approach) are identified, modified, and evaluated for their suitability in comparing nuclear and non-nuclear power plant tasks. An agenda for future research and its relevance to nuclear power plant safety is also discussed

Common errors of drug administration in infants: causes and avoidance.

Science.gov (United States)

Anderson, B J; Ellis, J F

1999-01-01

Drug administration errors are common in infants. Although the infant population has a high exposure to drugs, there are few data concerning pharmacokinetics or pharmacodynamics, or the influence of paediatric diseases on these processes. Children remain therapeutic orphans. Formulations are often suitable only for adults; in addition, the lack of maturation of drug elimination processes, alteration of body composition and influence of size render the calculation of drug doses complex in infants. The commonest drug administration error in infants is one of dose, and the commonest hospital site for this error is the intensive care unit. Drug errors are a consequence of system error, and preventive strategies are possible through system analysis. The goal of a zero drug error rate should be aggressively sought, with systems in place that aim to eliminate the effects of inevitable human error. This involves review of the entire system from drug manufacture to drug administration. The nuclear industry, telecommunications and air traffic control services all practise error reduction policies with zero error as a clear goal, not by finding fault in the individual, but by identifying faults in the system and building into that system mechanisms for picking up faults before they occur. Such policies could be adapted to medicine using interventions both specific (the production of formulations which are for children only and clearly labelled, regular audit by pharmacists, legible prescriptions, standardised dose tables) and general (paediatric drug trials, education programmes, nonpunitive error reporting) to reduce the number of errors made in giving medication to infants.

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}.

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

Detecting medication errors in the New Zealand pharmacovigilance database: a retrospective analysis.

Science.gov (United States)

Kunac, Desireé L; Tatley, Michael V

2011-01-01

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

Errors in Aviation Decision Making: Bad Decisions or Bad Luck?

Science.gov (United States)

Orasanu, Judith; Martin, Lynne; Davison, Jeannie; Null, Cynthia H. (Technical Monitor)

1998-01-01

Despite efforts to design systems and procedures to support 'correct' and safe operations in aviation, errors in human judgment still occur and contribute to accidents. In this paper we examine how an NDM (naturalistic decision making) approach might help us to understand the role of decision processes in negative outcomes. Our strategy was to examine a collection of identified decision errors through the lens of an aviation decision process model and to search for common patterns. The second, and more difficult, task was to determine what might account for those patterns. The corpus we analyzed consisted of tactical decision errors identified by the NTSB (National Transportation Safety Board) from a set of accidents in which crew behavior contributed to the accident. A common pattern emerged: about three quarters of the errors represented plan-continuation errors, that is, a decision to continue with the original plan despite cues that suggested changing the course of action. Features in the context that might contribute to these errors were identified: (a) ambiguous dynamic conditions and (b) organizational and socially-induced goal conflicts. We hypothesize that 'errors' are mediated by underestimation of risk and failure to analyze the potential consequences of continuing with the initial plan. Stressors may further contribute to these effects. Suggestions for improving performance in these error-inducing contexts are discussed.

Using a Delphi Method to Identify Human Factors Contributing to Nursing Errors.

Science.gov (United States)

Roth, Cheryl; Brewer, Melanie; Wieck, K Lynn

2017-07-01

The purpose of this study was to identify human factors associated with nursing errors. Using a Delphi technique, this study used feedback from a panel of nurse experts (n = 25) on an initial qualitative survey questionnaire followed by summarizing the results with feedback and confirmation. Synthesized factors regarding causes of errors were incorporated into a quantitative Likert-type scale, and the original expert panel participants were queried a second time to validate responses. The list identified 24 items as most common causes of nursing errors, including swamping and errors made by others that nurses are expected to recognize and fix. The responses provided a consensus top 10 errors list based on means with heavy workload and fatigue at the top of the list. The use of the Delphi survey established consensus and developed a platform upon which future study of nursing errors can evolve as a link to future solutions. This list of human factors in nursing errors should serve to stimulate dialogue among nurses about how to prevent errors and improve outcomes. Human and system failures have been the subject of an abundance of research, yet nursing errors continue to occur. © 2016 Wiley Periodicals, Inc.

Detecting and correcting partial errors: Evidence for efficient control without conscious access.

Science.gov (United States)

Rochet, N; Spieser, L; Casini, L; Hasbroucq, T; Burle, B

2014-09-01

Appropriate reactions to erroneous actions are essential to keeping behavior adaptive. Erring, however, is not an all-or-none process: electromyographic (EMG) recordings of the responding muscles have revealed that covert incorrect response activations (termed "partial errors") occur on a proportion of overtly correct trials. The occurrence of such "partial errors" shows that incorrect response activations could be corrected online, before turning into overt errors. In the present study, we showed that, unlike overt errors, such "partial errors" are poorly consciously detected by participants, who could report only one third of their partial errors. Two parameters of the partial errors were found to predict detection: the surface of the incorrect EMG burst (larger for detected) and the correction time (between the incorrect and correct EMG onsets; longer for detected). These two parameters provided independent information. The correct(ive) responses associated with detected partial errors were larger than the "pure-correct" ones, and this increase was likely a consequence, rather than a cause, of the detection. The respective impacts of the two parameters predicting detection (incorrect surface and correction time), along with the underlying physiological processes subtending partial-error detection, are discussed.

Analysis of liquid medication dose errors made by patients and caregivers using alternative measuring devices.

Science.gov (United States)

Ryu, Gyeong Suk; Lee, Yu Jeung

2012-01-01

Patients use several types of devices to measure liquid medication. Using a criterion ranging from a 10% to 40% variation from a target 5 mL for a teaspoon dose, previous studies have found that a considerable proportion of patients or caregivers make errors when dosing liquid medication with measuring devices. To determine the rate and magnitude of liquid medication dose errors that occur with patient/caregiver use of various measuring devices in a community pharmacy. Liquid medication measurements by patients or caregivers were observed in a convenience sample of community pharmacy patrons in Korea during a 2-week period in March 2011. Participants included all patients or caregivers (N = 300) who came to the pharmacy to buy over-the-counter liquid medication or to have a liquid medication prescription filled during the study period. The participants were instructed by an investigator who was also a pharmacist to select their preferred measuring devices from 6 alternatives (etched-calibration dosing cup, printed-calibration dosing cup, dosing spoon, syringe, dispensing bottle, or spoon with a bottle adapter) and measure a 5 mL dose of Coben (chlorpheniramine maleate/phenylephrine HCl, Daewoo Pharm. Co., Ltd) syrup using the device of their choice. The investigator used an ISOLAB graduated cylinder (Germany, blue grad, 10 mL) to measure the amount of syrup dispensed by the study participants. Participant characteristics were recorded including gender, age, education level, and relationship to the person for whom the medication was intended. Of the 300 participants, 257 (85.7%) were female; 286 (95.3%) had at least a high school education; and 282 (94.0%) were caregivers (parent or grandparent) for the patient. The mean (SD) measured dose was 4.949 (0.378) mL for the 300 participants. In analysis of variance of the 6 measuring devices, the greatest difference from the 5 mL target was a mean 5.552 mL for 17 subjects who used the regular (etched) dosing cup and 4

Using snowball sampling method with nurses to understand medication administration errors.

Science.gov (United States)

Sheu, Shuh-Jen; Wei, Ien-Lan; Chen, Ching-Huey; Yu, Shu; Tang, Fu-In

2009-02-01

We aimed to encourage nurses to release information about drug administration errors to increase understanding of error-related circumstances and to identify high-alert situations. Drug administration errors represent the majority of medication errors, but errors are underreported. Effective ways are lacking to encourage nurses to actively report errors. Snowball sampling was conducted to recruit participants. A semi-structured questionnaire was used to record types of error, hospital and nurse backgrounds, patient consequences, error discovery mechanisms and reporting rates. Eighty-five nurses participated, reporting 328 administration errors (259 actual, 69 near misses). Most errors occurred in medical surgical wards of teaching hospitals, during day shifts, committed by nurses working fewer than two years. Leading errors were wrong drugs and doses, each accounting for about one-third of total errors. Among 259 actual errors, 83.8% resulted in no adverse effects; among remaining 16.2%, 6.6% had mild consequences and 9.6% had serious consequences (severe reaction, coma, death). Actual errors and near misses were discovered mainly through double-check procedures by colleagues and nurses responsible for errors; reporting rates were 62.5% (162/259) vs. 50.7% (35/69) and only 3.5% (9/259) vs. 0% (0/69) were disclosed to patients and families. High-alert situations included administration of 15% KCl, insulin and Pitocin; using intravenous pumps; and implementation of cardiopulmonary resuscitation (CPR). Snowball sampling proved to be an effective way to encourage nurses to release details concerning medication errors. Using empirical data, we identified high-alert situations. Strategies for reducing drug administration errors by nurses are suggested. Survey results suggest that nurses should double check medication administration in known high-alert situations. Nursing management can use snowball sampling to gather error details from nurses in a non

Effect of Pharmacist Participation During Physician Rounds and Prescription Error in the Intensive Care Unit

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Marlina A. Turnodihardjo

2016-09-01

Full Text Available Patient’s safety is now a prominent issue in pharmaceutical care because of adverse drug events that is common in hospitalized patients. Majority of error are likely occured during prescribing, which is the first stage of pharmacy process. Prescription errors mostly occured in an Intensive Care Unit (ICU, which is due to the severity of the illness of its patients as well as the large number of medications prescribed. Pharmacist participation actually could reduce prescribing error made by doctors. The main objective of this study was to determine the effect of pharmacist participation during physician rounds on prescription errors in the ICU. This study was a quasi-experimental design with one group pre-post test. A prospective study was conducted from April to May 2015 by screening 110 samples of orders. Screening was done to identify type of prescription errors. Prescription error was defined as error in the prescription writing process – incomplete information and not according to agreement. Mann-Whitney test was used to analyze the differences in prescribing errors. The results showed that there was the differences between prescription errors before and during the pharmacist participation (p<0.05. There was also a significant negative correlation between the frequency of pharmacist recommendation on drug ordering and prescription errors (r= –0.638; p<0.05. It means the pharmacist participation was one of the strategies that can be adopted to prevent in prescribing errors and implementation of collaboration between both doctors and pharmacists. In other words, the supporting hospital management system which would encourage interpersonal communication among health care proffesionals is needed.

[Errors in medicine. Causes, impact and improvement measures to improve patient safety].

Science.gov (United States)

Waeschle, R M; Bauer, M; Schmidt, C E

2015-09-01

The guarantee of quality of care and patient safety is of major importance in hospitals even though increased economic pressure and work intensification are ubiquitously present. Nevertheless, adverse events still occur in 3-4 % of hospital stays and of these 25-50 % are estimated to be avoidable. The identification of possible causes of error and the development of measures for the prevention of medical errors are essential for patient safety. The implementation and continuous development of a constructive culture of error tolerance are fundamental.The origins of errors can be differentiated into systemic latent and individual active causes and components of both categories are typically involved when an error occurs. Systemic causes are, for example out of date structural environments, lack of clinical standards and low personnel density. These causes arise far away from the patient, e.g. management decisions and can remain unrecognized for a long time. Individual causes involve, e.g. confirmation bias, error of fixation and prospective memory failure. These causes have a direct impact on patient care and can result in immediate injury to patients. Stress, unclear information, complex systems and a lack of professional experience can promote individual causes. Awareness of possible causes of error is a fundamental precondition to establishing appropriate countermeasures.Error prevention should include actions directly affecting the causes of error and includes checklists and standard operating procedures (SOP) to avoid fixation and prospective memory failure and team resource management to improve communication and the generation of collective mental models. Critical incident reporting systems (CIRS) provide the opportunity to learn from previous incidents without resulting in injury to patients. Information technology (IT) support systems, such as the computerized physician order entry system, assist in the prevention of medication errors by providing

Water flux in animals: analysis of potential errors in the tritiated water method

International Nuclear Information System (INIS)

Nagy, K.A.; Costa, D.

1979-03-01

Laboratory studies indicate that tritiated water measurements of water flux are accurate to within -7 to +4% in mammals, but errors are larger in some reptiles. However, under conditions that can occur in field studies, errors may be much greater. Influx of environmental water vapor via lungs and skin can cause errors exceeding +-50% in some circumstances. If water flux rates in an animal vary through time, errors approach +-15% in extreme situations, but are near +-3% in more typical circumstances. Errors due to fractional evaporation of tritiated water may approach -9%. This error probably varies between species. Use of an inappropriate equation for calculating water flux from isotope data can cause errors exceeding +-100%. The following sources of error are either negligible or avoidable: use of isotope dilution space as a measure of body water volume, loss of nonaqueous tritium bound to excreta, binding of tritium with nonaqueous substances in the body, radiation toxicity effects, and small analytical errors in isotope measurements. Water flux rates measured with tritiated water should be within +-10% of actual flux rates in most situations

Water flux in animals: analysis of potential errors in the tritiated water method

Energy Technology Data Exchange (ETDEWEB)

Nagy, K.A.; Costa, D.

1979-03-01

Laboratory studies indicate that tritiated water measurements of water flux are accurate to within -7 to +4% in mammals, but errors are larger in some reptiles. However, under conditions that can occur in field studies, errors may be much greater. Influx of environmental water vapor via lungs and skin can cause errors exceeding +-50% in some circumstances. If water flux rates in an animal vary through time, errors approach +-15% in extreme situations, but are near +-3% in more typical circumstances. Errors due to fractional evaporation of tritiated water may approach -9%. This error probably varies between species. Use of an inappropriate equation for calculating water flux from isotope data can cause errors exceeding +-100%. The following sources of error are either negligible or avoidable: use of isotope dilution space as a measure of body water volume, loss of nonaqueous tritium bound to excreta, binding of tritium with nonaqueous substances in the body, radiation toxicity effects, and small analytical errors in isotope measurements. Water flux rates measured with tritiated water should be within +-10% of actual flux rates in most situations.

Asymptotics for the greatest zeros of solutions of a particular O.D.E.

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Silvia Noschese

1994-05-01

Full Text Available This paper deals with the Liouville-Stekeloff method for approximating solutions of homogeneous linear ODE and a general result due to Tricomi which provides estimates for the zeros of functions by means of the knowledge of an asymptotic representation. From the classical tools we deduce information about the asymptotics of the greatest zeros of a class of solutions of a particular ODE, including the classical Hermite polynomials.

ERF/ERFC, Calculation of Error Function, Complementary Error Function, Probability Integrals

International Nuclear Information System (INIS)

Vogel, J.E.

1983-01-01

1 - Description of problem or function: ERF and ERFC are used to compute values of the error function and complementary error function for any real number. They may be used to compute other related functions such as the normal probability integrals. 4. Method of solution: The error function and complementary error function are approximated by rational functions. Three such rational approximations are used depending on whether - x .GE.4.0. In the first region the error function is computed directly and the complementary error function is computed via the identity erfc(x)=1.0-erf(x). In the other two regions the complementary error function is computed directly and the error function is computed from the identity erf(x)=1.0-erfc(x). The error function and complementary error function are real-valued functions of any real argument. The range of the error function is (-1,1). The range of the complementary error function is (0,2). 5. Restrictions on the complexity of the problem: The user is cautioned against using ERF to compute the complementary error function by using the identity erfc(x)=1.0-erf(x). This subtraction may cause partial or total loss of significance for certain values of x

Medication administration errors in an intensive care unit in Ethiopia

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Agalu Asrat

2012-05-01

Full Text Available Abstract Background Medication administration errors in patient care have been shown to be frequent and serious. Such errors are particularly prevalent in highly technical specialties such as the intensive care unit (ICU. In Ethiopia, the prevalence of medication administration errors in the ICU is not studied. Objective To assess medication administration errors in the intensive care unit of Jimma University Specialized Hospital (JUSH, Southwest Ethiopia. Methods Prospective observation based cross-sectional study was conducted in the ICU of JUSH from February 7 to March 24, 2011. All medication interventions administered by the nurses to all patients admitted to the ICU during the study period were included in the study. Data were collected by directly observing drug administration by the nurses supplemented with review of medication charts. Data was edited, coded and entered in to SPSS for windows version 16.0. Descriptive statistics was used to measure the magnitude and type of the problem under study. Results Prevalence of medication administration errors in the ICU of JUSH was 621 (51.8%. Common administration errors were attributed to wrong timing (30.3%, omission due to unavailability (29.0% and missed doses (18.3% among others. Errors associated with antibiotics took the lion's share in medication administration errors (36.7%. Conclusion Medication errors at the administration phase were highly prevalent in the ICU of Jimma University Specialized Hospital. Supervision to the nurses administering medications by more experienced ICU nurses or other relevant professionals in regular intervals is helpful in ensuring that medication errors don’t occur as frequently as observed in this study.

A methodology for translating positional error into measures of attribute error, and combining the two error sources

Science.gov (United States)

Yohay Carmel; Curtis Flather; Denis Dean

2006-01-01

This paper summarizes our efforts to investigate the nature, behavior, and implications of positional error and attribute error in spatiotemporal datasets. Estimating the combined influence of these errors on map analysis has been hindered by the fact that these two error types are traditionally expressed in different units (distance units, and categorical units,...

Slow Learner Errors Analysis in Solving Fractions Problems in Inclusive Junior High School Class

Science.gov (United States)

Novitasari, N.; Lukito, A.; Ekawati, R.

2018-01-01

A slow learner whose IQ is between 71 and 89 will have difficulties in solving mathematics problems that often lead to errors. The errors could be analyzed to where the errors may occur and its type. This research is qualitative descriptive which aims to describe the locations, types, and causes of slow learner errors in the inclusive junior high school class in solving the fraction problem. The subject of this research is one slow learner of seventh-grade student which was selected through direct observation by the researcher and through discussion with mathematics teacher and special tutor which handles the slow learner students. Data collection methods used in this study are written tasks and semistructured interviews. The collected data was analyzed by Newman’s Error Analysis (NEA). Results show that there are four locations of errors, namely comprehension, transformation, process skills, and encoding errors. There are four types of errors, such as concept, principle, algorithm, and counting errors. The results of this error analysis will help teachers to identify the causes of the errors made by the slow learner.

Applying lessons learned to enhance human performance and reduce human error for ISS operations

Energy Technology Data Exchange (ETDEWEB)

Nelson, W.R.

1998-09-01

A major component of reliability, safety, and mission success for space missions is ensuring that the humans involved (flight crew, ground crew, mission control, etc.) perform their tasks and functions as required. This includes compliance with training and procedures during normal conditions, and successful compensation when malfunctions or unexpected conditions occur. A very significant issue that affects human performance in space flight is human error. Human errors can invalidate carefully designed equipment and procedures. If certain errors combine with equipment failures or design flaws, mission failure or loss of life can occur. The control of human error during operation of the International Space Station (ISS) will be critical to the overall success of the program. As experience from Mir operations has shown, human performance plays a vital role in the success or failure of long duration space missions. The Department of Energy`s Idaho National Engineering and Environmental Laboratory (INEEL) is developed a systematic approach to enhance human performance and reduce human errors for ISS operations. This approach is based on the systematic identification and evaluation of lessons learned from past space missions such as Mir to enhance the design and operation of ISS. This paper describes previous INEEL research on human error sponsored by NASA and how it can be applied to enhance human reliability for ISS.

Decodoku: Quantum error rorrection as a simple puzzle game

Science.gov (United States)

Wootton, James

To build quantum computers, we need to detect and manage any noise that occurs. This will be done using quantum error correction. At the hardware level, QEC is a multipartite system that stores information non-locally. Certain measurements are made which do not disturb the stored information, but which do allow signatures of errors to be detected. Then there is a software problem. How to take these measurement outcomes and determine: a) The errors that caused them, and (b) how to remove their effects. For qubit error correction, the algorithms required to do this are well known. For qudits, however, current methods are far from optimal. We consider the error correction problem of qubit surface codes. At the most basic level, this is a problem that can be expressed in terms of a grid of numbers. Using this fact, we take the inherent problem at the heart of quantum error correction, remove it from its quantum context, and presented in terms of simple grid based puzzle games. We have developed three versions of these puzzle games, focussing on different aspects of the required algorithms. These have been presented and iOS and Android apps, allowing the public to try their hand at developing good algorithms to solve the puzzles. For more information, see www.decodoku.com. Funding from the NCCR QSIT.

Double checking medicines: defence against error or contributory factor?

Science.gov (United States)

Armitage, Gerry

2008-08-01

The double checking of medicines in health care is a contestable procedure. It occupies an obvious position in health care practice and is understood to be an effective defence against medication error but the process is variable and the outcomes have not been exposed to testing. This paper presents an appraisal of the process using data from part of a larger study on the contributory factors in medication errors and their reporting. Previous research studies are reviewed; data are analysed from a review of 991 drug error reports and a subsequent series of 40 in-depth interviews with health professionals in an acute hospital in northern England. The incident reports showed that errors occurred despite double checking but that action taken did not appear to investigate the checking process. Most interview participants (34) talked extensively about double checking but believed the process to be inconsistent. Four key categories were apparent: deference to authority, reduction of responsibility, automatic processing and lack of time. Solutions to the problems were also offered, which are discussed with several recommendations. Double checking medicines should be a selective and systematic procedure informed by key principles and encompassing certain behaviours. Psychological research may be instructive in reducing checking errors but the aviation industry may also have a part to play in increasing error wisdom and reducing risk.

Safe and effective error rate monitors for SS7 signaling links

Science.gov (United States)

Schmidt, Douglas C.

1994-04-01

This paper describes SS7 error monitor characteristics, discusses the existing SUERM (Signal Unit Error Rate Monitor), and develops the recently proposed EIM (Error Interval Monitor) for higher speed SS7 links. A SS7 error monitor is considered safe if it ensures acceptable link quality and is considered effective if it is tolerant to short-term phenomena. Formal criteria for safe and effective error monitors are formulated in this paper. This paper develops models of changeover transients, the unstable component of queue length resulting from errors. These models are in the form of recursive digital filters. Time is divided into sequential intervals. The filter's input is the number of errors which have occurred in each interval. The output is the corresponding change in transmit queue length. Engineered EIM's are constructed by comparing an estimated changeover transient with a threshold T using a transient model modified to enforce SS7 standards. When this estimate exceeds T, a changeover will be initiated and the link will be removed from service. EIM's can be differentiated from SUERM by the fact that EIM's monitor errors over an interval while SUERM's count errored messages. EIM's offer several advantages over SUERM's, including the fact that they are safe and effective, impose uniform standards in link quality, are easily implemented, and make minimal use of real-time resources.

A prospective, multicenter study of pharmacist activities resulting in medication error interception in the emergency department.

Science.gov (United States)

Patanwala, Asad E; Sanders, Arthur B; Thomas, Michael C; Acquisto, Nicole M; Weant, Kyle A; Baker, Stephanie N; Merritt, Erica M; Erstad, Brian L

2012-05-01

The primary objective of this study is to determine the activities of pharmacists that lead to medication error interception in the emergency department (ED). This was a prospective, multicenter cohort study conducted in 4 geographically diverse academic and community EDs in the United States. Each site had clinical pharmacy services. Pharmacists at each site recorded their medication error interceptions for 250 hours of cumulative time when present in the ED (1,000 hours total for all 4 sites). Items recorded included the activities of the pharmacist that led to medication error interception, type of orders, phase of medication use process, and type of error. Independent evaluators reviewed all medication errors. Descriptive analyses were performed for all variables. A total of 16,446 patients presented to the EDs during the study, resulting in 364 confirmed medication error interceptions by pharmacists. The pharmacists' activities that led to medication error interception were as follows: involvement in consultative activities (n=187; 51.4%), review of medication orders (n=127; 34.9%), and other (n=50; 13.7%). The types of orders resulting in medication error interceptions were written or computerized orders (n=198; 54.4%), verbal orders (n=119; 32.7%), and other (n=47; 12.9%). Most medication error interceptions occurred during the prescribing phase of the medication use process (n=300; 82.4%) and the most common type of error was wrong dose (n=161; 44.2%). Pharmacists' review of written or computerized medication orders accounts for only a third of medication error interceptions. Most medication error interceptions occur during consultative activities. Copyright © 2011. Published by Mosby, Inc.

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.

At the cross-roads: an on-road examination of driving errors at intersections.

Science.gov (United States)

Young, Kristie L; Salmon, Paul M; Lenné, Michael G

2013-09-01

A significant proportion of road trauma occurs at intersections. Understanding the nature of driving errors at intersections therefore has the potential to lead to significant injury reductions. To further understand how the complexity of modern intersections shapes behaviour of these errors are compared to errors made mid-block, and the role of wider systems failures in intersection error causation is investigated in an on-road study. Twenty-five participants drove a pre-determined urban route incorporating 25 intersections. Two in-vehicle observers recorded the errors made while a range of other data was collected, including driver verbal protocols, video, driver eye glance behaviour and vehicle data (e.g., speed, braking and lane position). Participants also completed a post-trial cognitive task analysis interview. Participants were found to make 39 specific error types, with speeding violations the most common. Participants made significantly more errors at intersections compared to mid-block, with misjudgement, action and perceptual/observation errors more commonly observed at intersections. Traffic signal configuration was found to play a key role in intersection error causation, with drivers making more errors at partially signalised compared to fully signalised intersections. Copyright © 2012 Elsevier Ltd. All rights reserved.

High-Performance Region-of-Interest Image Error Concealment with Hiding Technique

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Shih-Chang Hsia

2010-01-01

Full Text Available Recently region-of-interest (ROI based image coding is a popular topic. Since ROI area contains much more important information for an image, it must be prevented from error decoding while suffering from channel lost or unexpected attack. This paper presents an efficient error concealment method to recover ROI information with a hiding technique. Based on the progressive transformation, the low-frequency components of ROI are encoded to disperse its information into the high-frequency bank of original image. The capability of protection is carried out with extracting the ROI coefficients from the damaged image without increasing extra information. Simulation results show that the proposed method can efficiently reconstruct the ROI image when ROI bit-stream occurs errors, and the measurement of PSNR result outperforms the conventional error concealment techniques by 2 to 5 dB.

The assessment of cognitive errors using an observer-rated method.

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Drapeau, Martin

2014-01-01

Cognitive Errors (CEs) are a key construct in cognitive behavioral therapy (CBT). Integral to CBT is that individuals with depression process information in an overly negative or biased way, and that this bias is reflected in specific depressotypic CEs which are distinct from normal information processing. Despite the importance of this construct in CBT theory, practice, and research, few methods are available to researchers and clinicians to reliably identify CEs as they occur. In this paper, the author presents a rating system, the Cognitive Error Rating Scale, which can be used by trained observers to identify and assess the cognitive errors of patients or research participants in vivo, i.e., as they are used or reported by the patients or participants. The method is described, including some of the more important rating conventions to be considered when using the method. This paper also describes the 15 cognitive errors assessed, and the different summary scores, including valence of the CEs, that can be derived from the method.

A Conceptual Framework for Predicting Error in Complex Human-Machine Environments

Science.gov (United States)

Freed, Michael; Remington, Roger; Null, Cynthia H. (Technical Monitor)

1998-01-01

We present a Goals, Operators, Methods, and Selection Rules-Model Human Processor (GOMS-MHP) style model-based approach to the problem of predicting human habit capture errors. Habit captures occur when the model fails to allocate limited cognitive resources to retrieve task-relevant information from memory. Lacking the unretrieved information, decision mechanisms act in accordance with implicit default assumptions, resulting in error when relied upon assumptions prove incorrect. The model helps interface designers identify situations in which such failures are especially likely.

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.

Analysis of error type and frequency in apraxia of speech among Portuguese speakers

Directory of Open Access Journals (Sweden)

Maysa Luchesi Cera

Full Text Available Abstract Most studies characterizing errors in the speech of patients with apraxia involve English language. Objectives: To analyze the types and frequency of errors produced by patients with apraxia of speech whose mother tongue was Brazilian Portuguese. Methods: 20 adults with apraxia of speech caused by stroke were assessed. The types of error committed by patients were analyzed both quantitatively and qualitatively, and frequencies compared. Results: We observed the presence of substitution, omission, trial-and-error, repetition, self-correction, anticipation, addition, reiteration and metathesis, in descending order of frequency, respectively. Omission type errors were one of the most commonly occurring whereas addition errors were infrequent. These findings differed to those reported in English speaking patients, probably owing to differences in the methodologies used for classifying error types; the inclusion of speakers with apraxia secondary to aphasia; and the difference in the structure of Portuguese language to English in terms of syllable onset complexity and effect on motor control. Conclusions: The frequency of omission and addition errors observed differed to the frequency reported for speakers of English.

Analysis of error type and frequency in apraxia of speech among Portuguese speakers.

Science.gov (United States)

Cera, Maysa Luchesi; Minett, Thaís Soares Cianciarullo; Ortiz, Karin Zazo

2010-01-01

Most studies characterizing errors in the speech of patients with apraxia involve English language. To analyze the types and frequency of errors produced by patients with apraxia of speech whose mother tongue was Brazilian Portuguese. 20 adults with apraxia of speech caused by stroke were assessed. The types of error committed by patients were analyzed both quantitatively and qualitatively, and frequencies compared. We observed the presence of substitution, omission, trial-and-error, repetition, self-correction, anticipation, addition, reiteration and metathesis, in descending order of frequency, respectively. Omission type errors were one of the most commonly occurring whereas addition errors were infrequent. These findings differed to those reported in English speaking patients, probably owing to differences in the methodologies used for classifying error types; the inclusion of speakers with apraxia secondary to aphasia; and the difference in the structure of Portuguese language to English in terms of syllable onset complexity and effect on motor control. The frequency of omission and addition errors observed differed to the frequency reported for speakers of English.

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

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,

Diagnostic Error in Stroke-Reasons and Proposed Solutions.

Science.gov (United States)

Bakradze, Ekaterina; Liberman, Ava L

2018-02-13

We discuss the frequency of stroke misdiagnosis and identify subgroups of stroke at high risk for specific diagnostic errors. In addition, we review common reasons for misdiagnosis and propose solutions to decrease error. According to a recent report by the National Academy of Medicine, most people in the USA are likely to experience a diagnostic error during their lifetimes. Nearly half of such errors result in serious disability and death. Stroke misdiagnosis is a major health care concern, with initial misdiagnosis estimated to occur in 9% of all stroke patients in the emergency setting. Under- or missed diagnosis (false negative) of stroke can result in adverse patient outcomes due to the preclusion of acute treatments and failure to initiate secondary prevention strategies. On the other hand, the overdiagnosis of stroke can result in inappropriate treatment, delayed identification of actual underlying disease, and increased health care costs. Young patients, women, minorities, and patients presenting with non-specific, transient, or posterior circulation stroke symptoms are at increased risk of misdiagnosis. Strategies to decrease diagnostic error in stroke have largely focused on early stroke detection via bedside examination strategies and a clinical decision rules. Targeted interventions to improve the diagnostic accuracy of stroke diagnosis among high-risk groups as well as symptom-specific clinical decision supports are needed. There are a number of open questions in the study of stroke misdiagnosis. To improve patient outcomes, existing strategies to improve stroke diagnostic accuracy should be more broadly adopted and novel interventions devised and tested to reduce diagnostic errors.

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

Chronology of prescribing error during the hospital stay and prediction of pharmacist's alerts overriding: a prospective analysis

Directory of Open Access Journals (Sweden)

Bruni Vanida

2010-01-01

Full Text Available Abstract Background Drug prescribing errors are frequent in the hospital setting and pharmacists play an important role in detection of these errors. The objectives of this study are (1 to describe the drug prescribing errors rate during the patient's stay, (2 to find which characteristics for a prescribing error are the most predictive of their reproduction the next day despite pharmacist's alert (i.e. override the alert. Methods We prospectively collected all medication order lines and prescribing errors during 18 days in 7 medical wards' using computerized physician order entry. We described and modelled the errors rate according to the chronology of hospital stay. We performed a classification and regression tree analysis to find which characteristics of alerts were predictive of their overriding (i.e. prescribing error repeated. Results 12 533 order lines were reviewed, 117 errors (errors rate 0.9% were observed and 51% of these errors occurred on the first day of the hospital stay. The risk of a prescribing error decreased over time. 52% of the alerts were overridden (i.e error uncorrected by prescribers on the following day. Drug omissions were the most frequently taken into account by prescribers. The classification and regression tree analysis showed that overriding pharmacist's alerts is first related to the ward of the prescriber and then to either Anatomical Therapeutic Chemical class of the drug or the type of error. Conclusions Since 51% of prescribing errors occurred on the first day of stay, pharmacist should concentrate his analysis of drug prescriptions on this day. The difference of overriding behavior between wards and according drug Anatomical Therapeutic Chemical class or type of error could also guide the validation tasks and programming of electronic alerts.

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.

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

Spectral Analysis of Forecast Error Investigated with an Observing System Simulation Experiment

Science.gov (United States)

Prive, N. C.; Errico, Ronald M.

2015-01-01

The spectra of analysis and forecast error are examined using the observing system simulation experiment (OSSE) framework developed at the National Aeronautics and Space Administration Global Modeling and Assimilation Office (NASAGMAO). A global numerical weather prediction model, the Global Earth Observing System version 5 (GEOS-5) with Gridpoint Statistical Interpolation (GSI) data assimilation, is cycled for two months with once-daily forecasts to 336 hours to generate a control case. Verification of forecast errors using the Nature Run as truth is compared with verification of forecast errors using self-analysis; significant underestimation of forecast errors is seen using self-analysis verification for up to 48 hours. Likewise, self analysis verification significantly overestimates the error growth rates of the early forecast, as well as mischaracterizing the spatial scales at which the strongest growth occurs. The Nature Run-verified error variances exhibit a complicated progression of growth, particularly for low wave number errors. In a second experiment, cycling of the model and data assimilation over the same period is repeated, but using synthetic observations with different explicitly added observation errors having the same error variances as the control experiment, thus creating a different realization of the control. The forecast errors of the two experiments become more correlated during the early forecast period, with correlations increasing for up to 72 hours before beginning to decrease.

CT for suspected appendicitis in children: an analysis of diagnostic errors

International Nuclear Information System (INIS)

Taylor, George A.; Callahan, Michael J.; Rodriguez, Diana; Smink, Douglas S.

2006-01-01

Mistakes have been made by the use of CT in diagnosing children with suspected appendicitis. Although others have reported the frequency of diagnostic errors, we were unable to find any studies that addressed the specific situations in which diagnostic errors occurred in children with suspected appendicitis. To investigate the frequency and type of diagnostic errors resulting from CT of children with suspected appendicitis when compared to surgical and pathological diagnosis. We reviewed imaging, clinical and pathological data on 1,207 consecutive pediatric patients who underwent CT examination for suspected appendicitis. Imaging findings were categorized as false-positive, false-negative, or indeterminate. Errors were classified as interpretative, technical or unavoidable. Concordance between surgical and pathological findings was also evaluated. The imaging findings of 34 patients (2.8%) were discrepant with the pathological examination or clinical follow-up. The errors in 23 cases were classified as interpretive (68%) and 11 as unavoidable (32%), and no errors were classified as technical. There were 23 false-positive errors (68%), 6 false-negative errors (18%), and 5 indeterminate imaging studies (15%). Isolated CT findings of an enlarged (greater than 6 mm) appendix, fat stranding, thickened bowel or non-visualization of the distal appendix were the most common false-positive CT findings. Of these 34 patients, 22 underwent appendectomy, with 10 (45%) having discordant surgical and pathological findings. (orig.)

Uncoupling nicotine mediated motoneuron axonal pathfinding errors and muscle degeneration in zebrafish

International Nuclear Information System (INIS)

Welsh, Lillian; Tanguay, Robert L.; Svoboda, Kurt R.

2009-01-01

Zebrafish embryos offer a unique opportunity to investigate the mechanisms by which nicotine exposure impacts early vertebrate development. Embryos exposed to nicotine become functionally paralyzed by 42 hpf suggesting that the neuromuscular system is compromised in exposed embryos. We previously demonstrated that secondary spinal motoneurons in nicotine-exposed embryos were delayed in development and that their axons made pathfinding errors (Svoboda, K.R., Vijayaraghaven, S., Tanguay, R.L., 2002. Nicotinic receptors mediate changes in spinal motoneuron development and axonal pathfinding in embryonic zebrafish exposed to nicotine. J. Neurosci. 22, 10731-10741). In that study, we did not consider the potential role that altered skeletal muscle development caused by nicotine exposure could play in contributing to the errors in spinal motoneuron axon pathfinding. In this study, we show that an alteration in skeletal muscle development occurs in tandem with alterations in spinal motoneuron development upon exposure to nicotine. The alteration in the muscle involves the binding of nicotine to the muscle-specific AChRs. The nicotine-induced alteration in muscle development does not occur in the zebrafish mutant (sofa potato, [sop]), which lacks muscle-specific AChRs. Even though muscle development is unaffected by nicotine exposure in sop mutants, motoneuron axonal pathfinding errors still occur in these mutants, indicating a direct effect of nicotine exposure on nervous system development.

ERROR ANALYSIS IN THE TRAVEL WRITING MADE BY THE STUDENTS OF ENGLISH STUDY PROGRAM

Directory of Open Access Journals (Sweden)

Vika Agustina

2015-05-01

Full Text Available This study was conducted to identify the kinds of errors in surface strategy taxonomy and to know the dominant type of errors made by the fifth semester students of English Department of one State University in Malang-Indonesia in producing their travel writing. The type of research of this study is document analysis since it analyses written materials, in this case travel writing texts. The analysis finds that the grammatical errors made by the students based on surface strategy taxonomy theory consist of four types. They are (1 omission, (2 addition, (3 misformation and (4 misordering. The most frequent errors occuring in misformation are in the use of tense form. Secondly, the errors are in omission of noun/verb inflection. The next error, there are many clauses that contain unnecessary phrase added there.

The underreporting of medication errors: A retrospective and comparative root cause analysis in an acute mental health unit over a 3-year period.

Science.gov (United States)

Morrison, Maeve; Cope, Vicki; Murray, Melanie

2018-05-15

Medication errors remain a commonly reported clinical incident in health care as highlighted by the World Health Organization's focus to reduce medication-related harm. This retrospective quantitative analysis examined medication errors reported by staff using an electronic Clinical Incident Management System (CIMS) during a 3-year period from April 2014 to April 2017 at a metropolitan mental health ward in Western Australia. The aim of the project was to identify types of medication errors and the context in which they occur and to consider recourse so that medication errors can be reduced. Data were retrieved from the Clinical Incident Management System database and concerned medication incidents from categorized tiers within the system. Areas requiring improvement were identified, and the quality of the documented data captured in the database was reviewed for themes pertaining to medication errors. Content analysis provided insight into the following issues: (i) frequency of problem, (ii) when the problem was detected, and (iii) characteristics of the error (classification of drug/s, where the error occurred, what time the error occurred, what day of the week it occurred, and patient outcome). Data were compared to the state-wide results published in the Your Safety in Our Hands (2016) report. Results indicated several areas upon which quality improvement activities could be focused. These include the following: structural changes; changes to policy and practice; changes to individual responsibilities; improving workplace culture to counteract underreporting of medication errors; and improvement in safety and quality administration of medications within a mental health setting. © 2018 Australian College of Mental Health Nurses Inc.

Assessing explicit error reporting in the narrative electronic medical record using keyword searching.

Science.gov (United States)

Cao, Hui; Stetson, Peter; Hripcsak, George

2003-01-01

Many types of medical errors occur in and outside of hospitals, some of which have very serious consequences and increase cost. Identifying errors is a critical step for managing and preventing them. In this study, we assessed the explicit reporting of medical errors in the electronic record. We used five search terms "mistake," "error," "incorrect," "inadvertent," and "iatrogenic" to survey several sets of narrative reports including discharge summaries, sign-out notes, and outpatient notes from 1991 to 2000. We manually reviewed all the positive cases and identified them based on the reporting of physicians. We identified 222 explicitly reported medical errors. The positive predictive value varied with different keywords. In general, the positive predictive value for each keyword was low, ranging from 3.4 to 24.4%. Therapeutic-related errors were the most common reported errors and these reported therapeutic-related errors were mainly medication errors. Keyword searches combined with manual review indicated some medical errors that were reported in medical records. It had a low sensitivity and a moderate positive predictive value, which varied by search term. Physicians were most likely to record errors in the Hospital Course and History of Present Illness sections of discharge summaries. The reported errors in medical records covered a broad range and were related to several types of care providers as well as non-health care professionals.

Social Media - DoD’s Greatest Information Sharing Tool or Weakest Security Link?

Science.gov (United States)

2010-04-15

or position of the Department of the Army, Department of Defense, or the U.S. Government. SOCIAL MEDIA – DOD’S GREATEST INFORMATION SHARING TOOL...appropriateness and effectiveness of these policies in securing the information network. 15. SUBJECT TERMS Social media , information...TYPE Civilian Research Paper 3. DATES COVERED (From - To) August 2009-April 2010 4. TITLE AND SUBTITLE 5a. CONTRACT NUMBER Social Media

Wind power forecast error smoothing within a wind farm

International Nuclear Information System (INIS)

Saleck, Nadja; Bremen, Lueder von

2007-01-01

Smoothing of wind power forecast errors is well-known for large areas. Comparable effects within a wind farm are investigated in this paper. A Neural Network was taken to predict the power output of a wind farm in north-western Germany comprising 17 turbines. A comparison was done between an algorithm that fits mean wind and mean power data of the wind farm and a second algorithm that fits wind and power data individually for each turbine. The evaluation of root mean square errors (RMSE) shows that relative small smoothing effects occur. However, it can be shown for this wind farm that individual calculations have the advantage that only a few turbines are needed to give better results than the use of mean data. Furthermore different results occurred if predicted wind speeds are directly fitted to observed wind power or if predicted wind speeds are first fitted to observed wind speeds and then applied to a power curve. The first approach gives slightly better RMSE values, the bias improves considerably

Errors and malpractice lawsuits in radiology: what the radiologist needs to know.

Science.gov (United States)

Busardò, Francesco Paolo; Frati, Paola; Santurro, Alessandro; Zaami, Simona; Fineschi, Vittorio

2015-09-01

All medical specialties dealing with patients include an intrinsic risk in exposing them to issues resulting from human errors. Radiology is not spared from this risk since it includes "decision-making under conditions of uncertainty." In medical imaging, the line between the word "error" and misdiagnosis or discrepancy is very difficult to demarcate, mainly because the diagnostic process is not a binary relation and it is not always possible to establish if a pathological condition is present or not. The error in radiology is strongly related to the diagnostic process; hence, it can be defined as a "diagnostic error" which represents the most common cause of medical malpractice suits against radiologists. In this paper, the authors described the features of errors occurring in radiology, trying to establish their impact and prevalence. Secondly, some data coming from different countries were compared in order to highlight the most frequent causes leading to malpractice lawsuits in radiology and how the phenomenon of malpractice in this field is represented worldwide.

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)

Symmetric and Asymmetric Patterns of Attraction Errors in Producing Subject-Predicate Agreement in Hebrew: An Issue of Morphological Structure

Science.gov (United States)

Deutsch, Avital; Dank, Maya

2011-01-01

A common characteristic of subject-predicate agreement errors (usually termed attraction errors) in complex noun phrases is an asymmetrical pattern of error distribution, depending on the inflectional state of the nouns comprising the complex noun phrase. That is, attraction is most likely to occur when the head noun is the morphologically…

Development of a framework to estimate human error for diagnosis tasks in advanced control room

International Nuclear Information System (INIS)

Kim, Ar Ryum; Jang, In Seok; Seong, Proong Hyun

2014-01-01

In the emergency situation of nuclear power plants (NPPs), a diagnosis of the occurring events is crucial for managing or controlling the plant to a safe and stable condition. If the operators fail to diagnose the occurring events or relevant situations, their responses can eventually inappropriate or inadequate Accordingly, huge researches have been performed to identify the cause of diagnosis error and estimate the probability of diagnosis error. D.I Gertman et al. asserted that 'the cognitive failures stem from erroneous decision-making, poor understanding of rules and procedures, and inadequate problem solving and this failures may be due to quality of data and people's capacity for processing information'. Also many researchers have asserted that human-system interface (HSI), procedure, training and available time are critical factors to cause diagnosis error. In nuclear power plants, a diagnosis of the event is critical for safe condition of the system. As advanced main control room is being adopted in nuclear power plants, the operators may obtain the plant data via computer-based HSI and procedure. Also many researchers have asserted that HSI, procedure, training and available time are critical factors to cause diagnosis error. In this regards, using simulation data, diagnosis errors and its causes were identified. From this study, some useful insights to reduce diagnosis errors of operators in advanced main control room were provided

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

PS-022 Complex automated medication systems reduce medication administration error rates in an acute medical ward

DEFF Research Database (Denmark)

Risør, Bettina Wulff; Lisby, Marianne; Sørensen, Jan

2017-01-01

Background Medication errors have received extensive attention in recent decades and are of significant concern to healthcare organisations globally. Medication errors occur frequently, and adverse events associated with medications are one of the largest causes of harm to hospitalised patients...... cabinet, automated dispensing and barcode medication administration; (2) non-patient specific automated dispensing and barcode medication administration. The occurrence of administration errors was observed in three 3 week periods. The error rates were calculated by dividing the number of doses with one...

Experiences with Lean Six Sigma as improvement strategy to reduce parenteral medication administration errors and associated potential risk of harm.

Science.gov (United States)

van de Plas, Afke; Slikkerveer, Mariëlle; Hoen, Saskia; Schrijnemakers, Rick; Driessen, Johanna; de Vries, Frank; van den Bemt, Patricia

2017-01-01

In this controlled before-after study the effect of improvements, derived from Lean Six Sigma strategy, on parenteral medication administration errors and the potential risk of harm was determined. During baseline measurement, on control versus intervention ward, at least one administration error occurred in 14 (74%) and 6 (46%) administrations with potential risk of harm in 6 (32%) and 1 (8%) administrations. Most administration errors with high potential risk of harm occurred in bolus injections: 8 (57%) versus 2 (67%) bolus injections were injected too fast with a potential risk of harm in 6 (43%) and 1 (33%) bolus injections on control and intervention ward. Implemented improvement strategies, based on major causes of too fast administration of bolus injections, were: Substitution of bolus injections by infusions, education, availability of administration information and drug round tabards. Post intervention, on the control ward in 76 (76%) administrations at least one error was made (RR 1.03; CI95:0.77-1.38), with a potential risk of harm in 14 (14%) administrations (RR 0.45; CI95:0.20-1.02). In 40 (68%) administrations on the intervention ward at least one error occurred (RR 1.47; CI95:0.80-2.71) but no administrations were associated with a potential risk of harm. A shift in wrong duration administration errors from bolus injections to infusions, with a reduction of potential risk of harm, seems to have occurred on the intervention ward. Although data are insufficient to prove an effect, Lean Six Sigma was experienced as a suitable strategy to select tailored improvements. Further studies are required to prove the effect of the strategy on parenteral medication administration errors.

Peak-counts blood flow model-errors and limitations

International Nuclear Information System (INIS)

Mullani, N.A.; Marani, S.K.; Ekas, R.D.; Gould, K.L.

1984-01-01

The peak-counts model has several advantages, but its use may be limited due to the condition that the venous egress may not be negligible at the time of peak-counts. Consequently, blood flow measurements by the peak-counts model will depend on the bolus size, bolus duration, and the minimum transit time of the bolus through the region of interest. The effect of bolus size on the measurement of extraction fraction and blood flow was evaluated by injecting 1 to 30ml of rubidium chloride in the femoral vein of a dog and measuring the myocardial activity with a beta probe over the heart. Regional blood flow measurements were not found to vary with bolus sizes up to 30ml. The effect of bolus duration was studied by injecting a 10cc bolus of tracer at different speeds in the femoral vein of a dog. All intravenous injections undergo a broadening of the bolus duration due to the transit time of the tracer through the lungs and the heart. This transit time was found to range from 4-6 second FWHM and dominates the duration of the bolus to the myocardium for up to 3 second injections. A computer simulation has been carried out in which the different parameters of delay time, extraction fraction, and bolus duration can be changed to assess the errors in the peak-counts model. The results of the simulations show that the error will be greatest for short transit time delays and for low extraction fractions

Antiretroviral medication prescribing errors are common with hospitalization of HIV-infected patients.

Science.gov (United States)

Commers, Tessa; Swindells, Susan; Sayles, Harlan; Gross, Alan E; Devetten, Marcel; Sandkovsky, Uriel

2014-01-01

Errors in prescribing antiretroviral therapy (ART) often occur with the hospitalization of HIV-infected patients. The rapid identification and prevention of errors may reduce patient harm and healthcare-associated costs. A retrospective review of hospitalized HIV-infected patients was carried out between 1 January 2009 and 31 December 2011. Errors were documented as omission, underdose, overdose, duplicate therapy, incorrect scheduling and/or incorrect therapy. The time to error correction was recorded. Relative risks (RRs) were computed to evaluate patient characteristics and error rates. A total of 289 medication errors were identified in 146/416 admissions (35%). The most common was drug omission (69%). At an error rate of 31%, nucleoside reverse transcriptase inhibitors were associated with an increased risk of error when compared with protease inhibitors (RR 1.32; 95% CI 1.04-1.69) and co-formulated drugs (RR 1.59; 95% CI 1.19-2.09). Of the errors, 31% were corrected within the first 24 h, but over half (55%) were never remedied. Admissions with an omission error were 7.4 times more likely to have all errors corrected within 24 h than were admissions without an omission. Drug interactions with ART were detected on 51 occasions. For the study population (n = 177), an increased risk of admission error was observed for black (43%) compared with white (28%) individuals (RR 1.53; 95% CI 1.16-2.03) but no significant differences were observed between white patients and other minorities or between men and women. Errors in inpatient ART were common, and the majority were never detected. The most common errors involved omission of medication, and nucleoside reverse transcriptase inhibitors had the highest rate of prescribing error. Interventions to prevent and correct errors are urgently needed.

Measuring Error Identification and Recovery Skills in Surgical Residents.

Science.gov (United States)

Sternbach, Joel M; Wang, Kevin; El Khoury, Rym; Teitelbaum, Ezra N; Meyerson, Shari L

2017-02-01

Although error identification and recovery skills are essential for the safe practice of surgery, they have not traditionally been taught or evaluated in residency training. This study validates a method for assessing error identification and recovery skills in surgical residents using a thoracoscopic lobectomy simulator. We developed a 5-station, simulator-based examination containing the most commonly encountered cognitive and technical errors occurring during division of the superior pulmonary vein for left upper lobectomy. Successful completion of each station requires identification and correction of these errors. Examinations were video recorded and scored in a blinded fashion using an examination-specific rating instrument evaluating task performance as well as error identification and recovery skills. Evidence of validity was collected in the categories of content, response process, internal structure, and relationship to other variables. Fifteen general surgical residents (9 interns and 6 third-year residents) completed the examination. Interrater reliability was high, with an intraclass correlation coefficient of 0.78 between 4 trained raters. Station scores ranged from 64% to 84% correct. All stations adequately discriminated between high- and low-performing residents, with discrimination ranging from 0.35 to 0.65. The overall examination score was significantly higher for intermediate residents than for interns (mean, 74 versus 64 of 90 possible; p = 0.03). The described simulator-based examination with embedded errors and its accompanying assessment tool can be used to measure error identification and recovery skills in surgical residents. This examination provides a valid method for comparing teaching strategies designed to improve error recognition and recovery to enhance patient safety. Copyright © 2017 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.

Error-related anterior cingulate cortex activity and the prediction of conscious error awareness

Directory of Open Access Journals (Sweden)

Catherine eOrr

2012-06-01

Full Text Available Research examining the neural mechanisms associated with error awareness has consistently identified dorsal anterior cingulate activity (ACC as necessary but not predictive of conscious error detection. Two recent studies (Steinhauser and Yeung, 2010; Wessel et al. 2011 have found a contrary pattern of greater dorsal ACC activity (in the form of the error-related negativity during detected errors, but suggested that the greater activity may instead reflect task influences (e.g., response conflict, error probability and or individual variability (e.g., statistical power. We re-analyzed fMRI BOLD data from 56 healthy participants who had previously been administered the Error Awareness Task, a motor Go/No-go response inhibition task in which subjects make errors of commission of which they are aware (Aware errors, or unaware (Unaware errors. Consistent with previous data, the activity in a number of cortical regions was predictive of error awareness, including bilateral inferior parietal and insula cortices, however in contrast to previous studies, including our own smaller sample studies using the same task, error-related dorsal ACC activity was significantly greater during aware errors when compared to unaware errors. While the significantly faster RT for aware errors (compared to unaware was consistent with the hypothesis of higher response conflict increasing ACC activity, we could find no relationship between dorsal ACC activity and the error RT difference. The data suggests that individual variability in error awareness is associated with error-related dorsal ACC activity, and therefore this region may be important to conscious error detection, but it remains unclear what task and individual factors influence error awareness.

Ultrahigh Error Threshold for Surface Codes with Biased Noise

Science.gov (United States)

Tuckett, David K.; Bartlett, Stephen D.; Flammia, Steven T.

2018-02-01

We show that a simple modification of the surface code can exhibit an enormous gain in the error correction threshold for a noise model in which Pauli Z errors occur more frequently than X or Y errors. Such biased noise, where dephasing dominates, is ubiquitous in many quantum architectures. In the limit of pure dephasing noise we find a threshold of 43.7(1)% using a tensor network decoder proposed by Bravyi, Suchara, and Vargo. The threshold remains surprisingly large in the regime of realistic noise bias ratios, for example 28.2(2)% at a bias of 10. The performance is, in fact, at or near the hashing bound for all values of the bias. The modified surface code still uses only weight-4 stabilizers on a square lattice, but merely requires measuring products of Y instead of Z around the faces, as this doubles the number of useful syndrome bits associated with the dominant Z errors. Our results demonstrate that large efficiency gains can be found by appropriately tailoring codes and decoders to realistic noise models, even under the locality constraints of topological codes.

Error propagation in spatial modeling of public health data: a simulation approach using pediatric blood lead level data for Syracuse, New York.

Science.gov (United States)

Lee, Monghyeon; Chun, Yongwan; Griffith, Daniel A

2018-04-01

Lead poisoning produces serious health problems, which are worse when a victim is younger. The US government and society have tried to prevent lead poisoning, especially since the 1970s; however, lead exposure remains prevalent. Lead poisoning analyses frequently use georeferenced blood lead level data. Like other types of data, these spatial data may contain uncertainties, such as location and attribute measurement errors, which can propagate to analysis results. For this paper, simulation experiments are employed to investigate how selected uncertainties impact regression analyses of blood lead level data in Syracuse, New York. In these simulations, location error and attribute measurement error, as well as a combination of these two errors, are embedded into the original data, and then these data are aggregated into census block group and census tract polygons. These aggregated data are analyzed with regression techniques, and comparisons are reported between the regression coefficients and their standard errors for the error added simulation results and the original results. To account for spatial autocorrelation, the eigenvector spatial filtering method and spatial autoregressive specifications are utilized with linear and generalized linear models. Our findings confirm that location error has more of an impact on the differences than does attribute measurement error, and show that the combined error leads to the greatest deviations. Location error simulation results show that smaller administrative units experience more of a location error impact, and, interestingly, coefficients and standard errors deviate more from their true values for a variable with a low level of spatial autocorrelation. These results imply that uncertainty, especially location error, has a considerable impact on the reliability of spatial analysis results for public health data, and that the level of spatial autocorrelation in a variable also has an impact on modeling results.

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.

Residents' numeric inputting error in computerized physician order entry prescription.

Science.gov (United States)

Wu, Xue; Wu, Changxu; Zhang, Kan; Wei, Dong

2016-04-01

Computerized physician order entry (CPOE) system with embedded clinical decision support (CDS) can significantly reduce certain types of prescription error. However, prescription errors still occur. Various factors such as the numeric inputting methods in human computer interaction (HCI) produce different error rates and types, but has received relatively little attention. This study aimed to examine the effects of numeric inputting methods and urgency levels on numeric inputting errors of prescription, as well as categorize the types of errors. Thirty residents participated in four prescribing tasks in which two factors were manipulated: numeric inputting methods (numeric row in the main keyboard vs. numeric keypad) and urgency levels (urgent situation vs. non-urgent situation). Multiple aspects of participants' prescribing behavior were measured in sober prescribing situations. The results revealed that in urgent situations, participants were prone to make mistakes when using the numeric row in the main keyboard. With control of performance in the sober prescribing situation, the effects of the input methods disappeared, and urgency was found to play a significant role in the generalized linear model. Most errors were either omission or substitution types, but the proportion of transposition and intrusion error types were significantly higher than that of the previous research. Among numbers 3, 8, and 9, which were the less common digits used in prescription, the error rate was higher, which was a great risk to patient safety. Urgency played a more important role in CPOE numeric typing error-making than typing skills and typing habits. It was recommended that inputting with the numeric keypad had lower error rates in urgent situation. An alternative design could consider increasing the sensitivity of the keys with lower frequency of occurrence and decimals. To improve the usability of CPOE, numeric keyboard design and error detection could benefit from spatial

The Impact of Error-Management Climate, Error Type and Error Originator on Auditors’ Reporting Errors Discovered on Audit Work Papers

NARCIS (Netherlands)

A.H. Gold-Nöteberg (Anna); U. Gronewold (Ulfert); S. Salterio (Steve)

2010-01-01

textabstractWe examine factors affecting the auditor’s willingness to report their own or their peers’ self-discovered errors in working papers subsequent to detailed working paper review. Prior research has shown that errors in working papers are detected in the review process; however, such

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.

Medication prescribing errors in a public teaching hospital in India: A prospective study.

Directory of Open Access Journals (Sweden)

Pote S

2007-03-01

Full Text Available Background: To prevent medication errors in prescribing, one needs to know their types and relative occurrence. Such errors are a great cause of concern as they have the potential to cause patient harm. The aim of this study was to determine the nature and types of medication prescribing errors in an Indian setting.Methods: The medication errors were analyzed in a prospective observational study conducted in 3 medical wards of a public teaching hospital in India. The medication errors were analyzed by means of Micromedex Drug-Reax database.Results: Out of 312 patients, only 304 were included in the study. Of the 304 cases, 103 (34% cases had at least one error. The total number of errors found was 157. The drug-drug interactions were the most frequently (68.2% occurring type of error, which was followed by incorrect dosing interval (12% and dosing errors (9.5%. The medication classes involved most were antimicrobial agents (29.4%, cardiovascular agents (15.4%, GI agents (8.6% and CNS agents (8.2%. The moderate errors contributed maximum (61.8% to the total errors when compared to the major (25.5% and minor (12.7% errors. The results showed that the number of errors increases with age and number of medicines prescribed.Conclusion: The results point to the establishment of medication error reporting at each hospital and to share the data with other hospitals. The role of clinical pharmacist in this situation appears to be a strong intervention; and the clinical pharmacist, initially, could confine to identification of the medication errors.

LOWER BOUNDS ON PHOTOMETRIC REDSHIFT ERRORS FROM TYPE Ia SUPERNOVA TEMPLATES

International Nuclear Information System (INIS)

Asztalos, S.; Nikolaev, S.; De Vries, W.; Olivier, S.; Cook, K.; Wang, L.

2010-01-01

Cosmology with Type Ia supernova heretofore has required extensive spectroscopic follow-up to establish an accurate redshift. Though this resource-intensive approach is tolerable at the present discovery rate, the next generation of ground-based all-sky survey instruments will render it unsustainable. Photometry-based redshift determination may be a viable alternative, though the technique introduces non-negligible errors that ultimately degrade the ability to discriminate between competing cosmologies. We present a strictly template-based photometric redshift estimator and compute redshift reconstruction errors in the presence of statistical errors. Under highly degraded photometric conditions corresponding to a statistical error σ of 0.5, the residual redshift error is found to be 0.236 when assuming a nightly observing cadence and a single Large Synoptic Science Telescope (LSST) u-band filter. Utilizing all six LSST bandpass filters reduces the residual redshift error to 9.1 x 10 -3 . Assuming a more optimistic statistical error σ of 0.05, we derive residual redshift errors of 4.2 x 10 -4 , 5.2 x 10 -4 , 9.2 x 10 -4 , and 1.8 x 10 -3 for observations occuring nightly, every 5th, 20th and 45th night, respectively, in each of the six LSST bandpass filters. Adopting an observing cadence in which photometry is acquired with all six filters every 5th night and a realistic supernova distribution, binned redshift errors are combined with photometric errors with a σ of 0.17 and systematic errors with a σ∼ 0.003 to derive joint errors (σ w , σ w ' ) of (0.012, 0.066), respectively, in (w,w') with 68% confidence using Fisher matrix formalism. Though highly idealized in the present context, the methodology is nonetheless quite relevant for the next generation of ground-based all-sky surveys.

Medication Errors in Pediatric Anesthesia: A Report From the Wake Up Safe Quality Improvement Initiative.

Science.gov (United States)

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

2017-09-01

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

Putts that get missed on the right: investigating lateralized attentional biases and the nature of putting errors in golf.

Science.gov (United States)

Roberts, Ross; Turnbull, Oliver H

2010-02-01

Although the effects of lateral biases in visual attention ("pseudoneglect") have been examined in real-world settings, this phenomenon has yet to be considered within the realm of sporting performance. In the present study, we investigated the effects of pseudoneglect on putting errors in golf. Novice golfers (n = 30) performed 90 putting trials followed by a series of pseudoneglect tasks: requiring participants to bisect lines manually and with a biomechanical bisection tool. All pseudoneglect measures were performed with both the left and right hands. Results demonstrated a leftward bias for all the pseudoneglect tasks, and a rightward bias for putting error. Moreover, the results revealed that individuals who bisected lines to the left on the Bisection Tool (the typical class of pseudoneglect error for humans) with the left hand (the hand that typically produces the greatest pseudoneglect bias) displayed significantly smaller rightward putting errors. Moreover, these individuals also holed more putts. No other pseudoneglect tasks were shown to impact on putting performance. Our findings suggest that lateralized attentional biases have a significant effect on sport performance; they appear to influence a wide range of precision-based sports (e.g. shooting, archery). Findings are also discussed in terms of the processes that are likely to be involved in this effect.

Electromagnetic torque on the toroidal plasma and the error-field induced torque

International Nuclear Information System (INIS)

Pustovitov, V. D.

2007-01-01

The electromagnetic torque on the toroidal plasma is calculated assuming a linear plasma response to the applied perturbation, which may be the error field or the field created by the correction coils, or both. The result is compared with recently published expressions for the error field induced torque (Zheng et al 2006 Nucl. Fusion 46 L9, Zheng and Kotschenreuther 2006 Phys. Rev. Lett. 97 165001), and the conclusions of these papers are revised. We resolve the problem of the torque resonance raised there. It is shown that the strong increase in the torque due to the static error field must occur at the resistive wall mode stability limit and not at the no-wall stability limit

Distributed error and alarm processing in the CMS data acquisition system

Energy Technology Data Exchange (ETDEWEB)

Bauer, G.; et al.

2012-01-01

The error and alarm system for the data acquisition of the Compact Muon Solenoid (CMS) at CERN was successfully used for the physics runs at Large Hadron Collider (LHC) during first three years of activities. Error and alarm processing entails the notification, collection, storing and visualization of all exceptional conditions occurring in the highly distributed CMS online system using a uniform scheme. Alerts and reports are shown on-line by web application facilities that map them to graphical models of the system as defined by the user. A persistency service keeps a history of all exceptions occurred, allowing subsequent retrieval of user defined time windows of events for later playback or analysis. This paper describes the architecture and the technologies used and deals with operational aspects during the first years of LHC operation. In particular we focus on performance, stability, and integration with the CMS sub-detectors.

RAMs: the problem of transient errors due to alpha radiation

International Nuclear Information System (INIS)

Goujon, Pierre.

1980-01-01

Errors that remained unexplained for a long time have occurred with dynamic random access memories. It has been known since 1978 that they are due to stray alpha radiation. A good understanding of this phenomenon enables its effects to be neutralized and the reliability of the products to be guarantied [fr

Errors in laboratory medicine: practical lessons to improve patient safety.

Science.gov (United States)

Howanitz, Peter J

2005-10-01

Patient safety is influenced by the frequency and seriousness of errors that occur in the health care system. Error rates in laboratory practices are collected routinely for a variety of performance measures in all clinical pathology laboratories in the United States, but a list of critical performance measures has not yet been recommended. The most extensive databases describing error rates in pathology were developed and are maintained by the College of American Pathologists (CAP). These databases include the CAP's Q-Probes and Q-Tracks programs, which provide information on error rates from more than 130 interlaboratory studies. To define critical performance measures in laboratory medicine, describe error rates of these measures, and provide suggestions to decrease these errors, thereby ultimately improving patient safety. A review of experiences from Q-Probes and Q-Tracks studies supplemented with other studies cited in the literature. Q-Probes studies are carried out as time-limited studies lasting 1 to 4 months and have been conducted since 1989. In contrast, Q-Tracks investigations are ongoing studies performed on a yearly basis and have been conducted only since 1998. Participants from institutions throughout the world simultaneously conducted these studies according to specified scientific designs. The CAP has collected and summarized data for participants about these performance measures, including the significance of errors, the magnitude of error rates, tactics for error reduction, and willingness to implement each of these performance measures. A list of recommended performance measures, the frequency of errors when these performance measures were studied, and suggestions to improve patient safety by reducing these errors. Error rates for preanalytic and postanalytic performance measures were higher than for analytic measures. Eight performance measures were identified, including customer satisfaction, test turnaround times, patient identification

Making related errors facilitates learning, but learners do not know it.

Science.gov (United States)

Huelser, Barbie J; Metcalfe, Janet

2012-05-01

Producing an error, so long as it is followed by corrective feedback, has been shown to result in better retention of the correct answers than does simply studying the correct answers from the outset. The reasons for this surprising finding, however, have not been investigated. Our hypothesis was that the effect might occur only when the errors produced were related to the targeted correct response. In Experiment 1, participants studied either related or unrelated word pairs, manipulated between participants. Participants either were given the cue and target to study for 5 or 10 s or generated an error in response to the cue for the first 5 s before receiving the correct answer for the final 5 s. When the cues and targets were related, error-generation led to the highest correct retention. However, consistent with the hypothesis, no benefit was derived from generating an error when the cue and target were unrelated. Latent semantic analysis revealed that the errors generated in the related condition were related to the target, whereas they were not related to the target in the unrelated condition. Experiment 2 replicated these findings in a within-participants design. We found, additionally, that people did not know that generating an error enhanced memory, even after they had just completed the task that produced substantial benefits.

Nurses' Perceived Skills and Attitudes About Updated Safety Concepts: Impact on Medication Administration Errors and Practices.

Science.gov (United States)

Armstrong, Gail E; Dietrich, Mary; Norman, Linda; Barnsteiner, Jane; Mion, Lorraine

Approximately a quarter of medication errors in the hospital occur at the administration phase, which is solely under the purview of the bedside nurse. The purpose of this study was to assess bedside nurses' perceived skills and attitudes about updated safety concepts and examine their impact on medication administration errors and adherence to safe medication administration practices. Findings support the premise that medication administration errors result from an interplay among system-, unit-, and nurse-level factors.

Error Detection and Error Classification: Failure Awareness in Data Transfer Scheduling

Energy Technology Data Exchange (ETDEWEB)

Louisiana State University; Balman, Mehmet; Kosar, Tevfik

2010-10-27

Data transfer in distributed environment is prone to frequent failures resulting from back-end system level problems, like connectivity failure which is technically untraceable by users. Error messages are not logged efficiently, and sometimes are not relevant/useful from users point-of-view. Our study explores the possibility of an efficient error detection and reporting system for such environments. Prior knowledge about the environment and awareness of the actual reason behind a failure would enable higher level planners to make better and accurate decisions. It is necessary to have well defined error detection and error reporting methods to increase the usability and serviceability of existing data transfer protocols and data management systems. We investigate the applicability of early error detection and error classification techniques and propose an error reporting framework and a failure-aware data transfer life cycle to improve arrangement of data transfer operations and to enhance decision making of data transfer schedulers.

The application of two recently developed human reliability techniques to cognitive error analysis

International Nuclear Information System (INIS)

Gall, W.

1990-01-01

Cognitive error can lead to catastrophic consequences for manned systems, including those whose design renders them immune to the effects of physical slips made by operators. Four such events, pressurized water and boiling water reactor accidents which occurred recently, were analysed. The analysis identifies the factors which contributed to the errors and suggests practical strategies for error recovery or prevention. Two types of analysis were conducted: an unstructured analysis based on the analyst's knowledge of psychological theory, and a structured analysis using two recently-developed human reliability analysis techniques. In general, the structured techniques required less effort to produce results and these were comparable to those of the unstructured analysis. (author)

Study on Network Error Analysis and Locating based on Integrated Information Decision System

Science.gov (United States)

Yang, F.; Dong, Z. H.

2017-10-01

Integrated information decision system (IIDS) integrates multiple sub-system developed by many facilities, including almost hundred kinds of software, which provides with various services, such as email, short messages, drawing and sharing. Because the under-layer protocols are different, user standards are not unified, many errors are occurred during the stages of setup, configuration, and operation, which seriously affect the usage. Because the errors are various, which may be happened in different operation phases, stages, TCP/IP communication protocol layers, sub-system software, it is necessary to design a network error analysis and locating tool for IIDS to solve the above problems. This paper studies on network error analysis and locating based on IIDS, which provides strong theory and technology supports for the running and communicating of IIDS.

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...

Measurement Rounding Errors in an Assessment Model of Project Led Engineering Education

Directory of Open Access Journals (Sweden)

Francisco Moreira

2009-11-01

Full Text Available This paper analyzes the rounding errors that occur in the assessment of an interdisciplinary Project-Led Education (PLE process implemented in the Integrated Master degree on Industrial Management and Engineering (IME at University of Minho. PLE is an innovative educational methodology which makes use of active learning, promoting higher levels of motivation and students’ autonomy. The assessment model is based on multiple evaluation components with different weights. Each component can be evaluated by several teachers involved in different Project Supporting Courses (PSC. This model can be affected by different types of errors, namely: (1 rounding errors, and (2 non-uniform criteria of rounding the grades. A rigorous analysis of the assessment model was made and the rounding errors involved on each project component were characterized and measured. This resulted in a global maximum error of 0.308 on the individual student project grade, in a 0 to 100 scale. This analysis intended to improve not only the reliability of the assessment results, but also teachers’ awareness of this problem. Recommendations are also made in order to improve the assessment model and reduce the rounding errors as much as possible.

Missed opportunities for diagnosis: lessons learned from diagnostic errors in primary care.

Science.gov (United States)

Goyder, Clare R; Jones, Caroline H D; Heneghan, Carl J; Thompson, Matthew J

2015-12-01

Because of the difficulties inherent in diagnosis in primary care, it is inevitable that diagnostic errors will occur. However, despite the important consequences associated with diagnostic errors and their estimated high prevalence, teaching and research on diagnostic error is a neglected area. To ascertain the key learning points from GPs' experiences of diagnostic errors and approaches to clinical decision making associated with these. Secondary analysis of 36 qualitative interviews with GPs in Oxfordshire, UK. Two datasets of semi-structured interviews were combined. Questions focused on GPs' experiences of diagnosis and diagnostic errors (or near misses) in routine primary care and out of hours. Interviews were audiorecorded, transcribed verbatim, and analysed thematically. Learning points include GPs' reliance on 'pattern recognition' and the failure of this strategy to identify atypical presentations; the importance of considering all potentially serious conditions using a 'restricted rule out' approach; and identifying and acting on a sense of unease. Strategies to help manage uncertainty in primary care were also discussed. Learning from previous examples of diagnostic errors is essential if these events are to be reduced in the future and this should be incorporated into GP training. At a practice level, learning points from experiences of diagnostic errors should be discussed more frequently; and more should be done to integrate these lessons nationally to understand and characterise diagnostic errors. © British Journal of General Practice 2015.

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 ...

Complications: acknowledging, managing, and coping with human error.

Science.gov (United States)

Helo, Sevann; Moulton, Carol-Anne E

2017-08-01

Errors are inherent in medicine due to the imperfectness of human nature. Health care providers may have a difficult time accepting their fallibility, acknowledging mistakes, and disclosing errors. Fear of litigation, shame, blame, and concern about reputation are just some of the barriers preventing physicians from being more candid with their patients, despite the supporting body of evidence that patients cite poor communication and lack of transparency as primary drivers to file a lawsuit in the wake of a medical complication. Proper error disclosure includes a timely explanation of what happened, who was involved, why the error occurred, and how it will be prevented in the future. Medical mistakes afford the opportunity for individuals and institutions to be candid about their weaknesses while improving patient care processes. When a physician takes the Hippocratic Oath they take on a tremendous sense of responsibility for the care of their patients, and often bear the burden of their mistakes in isolation. Physicians may struggle with guilt, shame, and a crisis of confidence, which may thwart efforts to identify areas for improvement that can lead to meaningful change. Coping strategies for providers include discussing the event with others, seeking professional counseling, and implementing quality improvement projects. Physicians and health care organizations need to find adaptive ways to deal with complications that will benefit patients, providers, and their institutions.

Local blur analysis and phase error correction method for fringe projection profilometry systems.

Science.gov (United States)

Rao, Li; Da, Feipeng

2018-05-20

We introduce a flexible error correction method for fringe projection profilometry (FPP) systems in the presence of local blur phenomenon. Local blur caused by global light transport such as camera defocus, projector defocus, and subsurface scattering will cause significant systematic errors in FPP systems. Previous methods, which adopt high-frequency patterns to separate the direct and global components, fail when the global light phenomenon occurs locally. In this paper, the influence of local blur on phase quality is thoroughly analyzed, and a concise error correction method is proposed to compensate the phase errors. For defocus phenomenon, this method can be directly applied. With the aid of spatially varying point spread functions and local frontal plane assumption, experiments show that the proposed method can effectively alleviate the system errors and improve the final reconstruction accuracy in various scenes. For a subsurface scattering scenario, if the translucent object is dominated by multiple scattering, the proposed method can also be applied to correct systematic errors once the bidirectional scattering-surface reflectance distribution function of the object material is measured.

A Preliminary Study on the Measures to Assess the Organizational Safety: The Cultural Impact on Human Error Potential

International Nuclear Information System (INIS)

Lee, Yong Hee; Lee, Yong Hee

2011-01-01

The Fukushima I nuclear accident following the Tohoku earthquake and tsunami on 11 March 2011 occurred after twelve years had passed since the JCO accident which was caused as a result of an error made by JCO employees. These accidents, along with the Chernobyl accident, associated with characteristic problems of various organizations caused severe social and economic disruptions and have had significant environmental and health impact. The cultural problems with human errors occur for various reasons, and different actions are needed to prevent different errors. Unfortunately, much of the research on organization and human error has shown widely various or different results which call for different approaches. In other words, we have to find more practical solutions from various researches for nuclear safety and lead a systematic approach to organizational deficiency causing human error. This paper reviews Hofstede's criteria, IAEA safety culture, safety areas of periodic safety review (PSR), teamwork and performance, and an evaluation of HANARO safety culture to verify the measures used to assess the organizational safety

A Preliminary Study on the Measures to Assess the Organizational Safety: The Cultural Impact on Human Error Potential

Energy Technology Data Exchange (ETDEWEB)

Lee, Yong Hee; Lee, Yong Hee [Korea Atomic Energy Research Institute, Daejeon (Korea, Republic of)

2011-10-15

The Fukushima I nuclear accident following the Tohoku earthquake and tsunami on 11 March 2011 occurred after twelve years had passed since the JCO accident which was caused as a result of an error made by JCO employees. These accidents, along with the Chernobyl accident, associated with characteristic problems of various organizations caused severe social and economic disruptions and have had significant environmental and health impact. The cultural problems with human errors occur for various reasons, and different actions are needed to prevent different errors. Unfortunately, much of the research on organization and human error has shown widely various or different results which call for different approaches. In other words, we have to find more practical solutions from various researches for nuclear safety and lead a systematic approach to organizational deficiency causing human error. This paper reviews Hofstede's criteria, IAEA safety culture, safety areas of periodic safety review (PSR), teamwork and performance, and an evaluation of HANARO safety culture to verify the measures used to assess the organizational safety

Paediatric Patient Safety and the Need for Aviation Black Box Thinking to Learn From and Prevent Medication Errors.

Science.gov (United States)

Huynh, Chi; Wong, Ian C K; Correa-West, Jo; Terry, David; McCarthy, Suzanne

2017-04-01

Since the publication of To Err Is Human: Building a Safer Health System in 1999, there has been much research conducted into the epidemiology, nature and causes of medication errors in children, from prescribing and supply to administration. It is reassuring to see growing evidence of improving medication safety in children; however, based on media reports, it can be seen that serious and fatal medication errors still occur. This critical opinion article examines the problem of medication errors in children and provides recommendations for research, training of healthcare professionals and a culture shift towards dealing with medication errors. There are three factors that we need to consider to unravel what is missing and why fatal medication errors still occur. (1) Who is involved and affected by the medication error? (2) What factors hinder staff and organisations from learning from mistakes? Does the fear of litigation and criminal charges deter healthcare professionals from voluntarily reporting medication errors? (3) What are the educational needs required to prevent medication errors? It is important to educate future healthcare professionals about medication errors and human factors to prevent these from happening. Further research is required to apply aviation's 'black box' principles in healthcare to record and learn from near misses and errors to prevent future events. There is an urgent need for the black box investigations to be published and made public for the benefit of other organisations that may have similar potential risks for adverse events. International sharing of investigations and learning is also needed.

How EFL students can use Google to correct their “untreatable” written errors

Directory of Open Access Journals (Sweden)

Luc Geiller

2014-09-01

Full Text Available This paper presents the findings of an experiment in which a group of 17 French post-secondary EFL learners used Google to self-correct several “untreatable” written errors. Whether or not error correction leads to improved writing has been much debated, some researchers dismissing it is as useless and others arguing that error feedback leads to more grammatical accuracy. In her response to Truscott (1996, Ferris (1999 explains that it would be unreasonable to abolish correction given the present state of knowledge, and that further research needed to focus on which types of errors were more amenable to which types of error correction. In her attempt to respond more effectively to her students’ errors, she made the distinction between “treatable” and “untreatable” ones: the former occur in “a patterned, rule-governed way” and include problems with verb tense or form, subject-verb agreement, run-ons, noun endings, articles, pronouns, while the latter include a variety of lexical errors, problems with word order and sentence structure, including missing and unnecessary words. Substantial research on the use of search engines as a tool for L2 learners has been carried out suggesting that the web plays an important role in fostering language awareness and learner autonomy (e.g. Shei 2008a, 2008b; Conroy 2010. According to Bathia and Richie (2009: 547, “the application of Google for language learning has just begun to be tapped.” Within the framework of this study it was assumed that the students, conversant with digital technologies and using Google and the web on a regular basis, could use various search options and the search results to self-correct their errors instead of relying on their teacher to provide direct feedback. After receiving some in-class training on how to formulate Google queries, the students were asked to use a customized Google search engine limiting searches to 28 information websites to correct up to

A Survey of Wireless Fair Queuing Algorithms with Location-Dependent Channel Errors

Directory of Open Access Journals (Sweden)

Anca VARGATU

2011-01-01

Full Text Available The rapid development of wireless networks has brought more and more attention to topics related to fair allocation of resources, creation of suitable algorithms, taking into account the special characteristics of wireless environment and insurance fair access to the transmission channel, with delay bound and throughput guaranteed. Fair allocation of resources in wireless networks requires significant challenges, because of errors that occur only in these networks, such as location-dependent and bursty channel errors. In wireless networks, frequently happens, because interference of radio waves, that a user experiencing bad radio conditions during a period of time, not to receive resources in that period. This paper analyzes some resource allocation algorithms for wireless networks with location dependent errors, specifying the base idea for each algorithm and the way how it works. The analyzed fair queuing algorithms differ by the way they treat the following aspects: how to select the flows which should receive additional services, how to allocate these resources, which is the proportion received by error free flows and how the flows affected by errors are compensated.

An advanced human reliability analysis methodology: analysis of cognitive errors focused on

International Nuclear Information System (INIS)

Kim, J. H.; Jeong, W. D.

2001-01-01

The conventional Human Reliability Analysis (HRA) methods such as THERP/ASEP, HCR and SLIM has been criticised for their deficiency in analysing cognitive errors which occurs during operator's decision making process. In order to supplement the limitation of the conventional methods, an advanced HRA method, what is called the 2 nd generation HRA method, including both qualitative analysis and quantitative assessment of cognitive errors has been being developed based on the state-of-the-art theory of cognitive systems engineering and error psychology. The method was developed on the basis of human decision-making model and the relation between the cognitive function and the performance influencing factors. The application of the proposed method to two emergency operation tasks is presented

Proactive safety management in health care : towards a broader view of risk analysis, error recovery, and safety culture

NARCIS (Netherlands)

Habraken, M.M.P.

2010-01-01

Medical errors occur frequently. The harm and additional costs associated with those errors ask for effective safety management. According to the objective of minimal patient harm, safety management in health care should be proactive; that is, risks should be anticipated and reduced before patients

Random and Systematic Errors Share in Total Error of Probes for CNC Machine Tools

Directory of Open Access Journals (Sweden)

Adam Wozniak

2018-03-01

Full Text Available Probes for CNC machine tools, as every measurement device, have accuracy limited by random errors and by systematic errors. Random errors of these probes are described by a parameter called unidirectional repeatability. Manufacturers of probes for CNC machine tools usually specify only this parameter, while parameters describing systematic errors of the probes, such as pre-travel variation or triggering radius variation, are used rarely. Systematic errors of the probes, linked to the differences in pre-travel values for different measurement directions, can be corrected or compensated, but it is not a widely used procedure. In this paper, the share of systematic errors and random errors in total error of exemplary probes are determined. In the case of simple, kinematic probes, systematic errors are much greater than random errors, so compensation would significantly reduce the probing error. Moreover, it shows that in the case of kinematic probes commonly specified unidirectional repeatability is significantly better than 2D performance. However, in the case of more precise strain-gauge probe systematic errors are of the same order as random errors, which means that errors correction or compensation, in this case, would not yield any significant benefits.

Test-Retest Reliability of the Adaptive Chemistry Assessment Survey for Teachers: Measurement Error and Alternatives to Correlation

Science.gov (United States)

Harshman, Jordan; Yezierski, Ellen

2016-01-01

Determining the error of measurement is a necessity for researchers engaged in bench chemistry, chemistry education research (CER), and a multitude of other fields. Discussions regarding what constructs measurement error entails and how to best measure them have occurred, but the critiques about traditional measures have yielded few alternatives.…

Symbol and Bit Error Rates Analysis of Hybrid PIM-CDMA

Directory of Open Access Journals (Sweden)

Ghassemlooy Z

2005-01-01

Full Text Available A hybrid pulse interval modulation code-division multiple-access (hPIM-CDMA scheme employing the strict optical orthogonal code (SOCC with unity and auto- and cross-correlation constraints for indoor optical wireless communications is proposed. In this paper, we analyse the symbol error rate (SER and bit error rate (BER of hPIM-CDMA. In the analysis, we consider multiple access interference (MAI, self-interference, and the hybrid nature of the hPIM-CDMA signal detection, which is based on the matched filter (MF. It is shown that the BER/SER performance can only be evaluated if the bit resolution conforms to the condition set by the number of consecutive false alarm pulses that might occur and be detected, so that one symbol being divided into two is unlikely to occur. Otherwise, the probability of SER and BER becomes extremely high and indeterminable. We show that for a large number of users, the BER improves when increasing the code weight . The results presented are compared with other modulation schemes.

Learning from mistakes: errors in approaches to melanoma and the urgent need for updated national guidelines.

Science.gov (United States)

Simionescu, Olga; Blum, Andreas; Grigore, Mariana; Costache, Mariana; Avram, Alina; Testori, Alessandro

2016-09-01

The tracking and identification of errors in the detection and follow-up of melanoma are important because there is huge potential to increase awareness about the most vulnerable aspects of diagnosis and treatment, and to improve both from the perspective of healthcare economics. The present study was designed to identify where errors occur and to propose a minimum set of rules for the routine guidance of any specialist in melanoma management. This report describes the evaluation of a unique series of 33 cases in which errors applying to many steps in the diagnosis and treatment of melanoma were detected. Cases were collected at two centers in Romania, one public and one private, as part of a process of obtaining patient-requested second opinions. A total of 166 errors were identified across the 33 patients, most of which were treatment errors. The errors fell into six categories: clinical diagnostic errors (36 errors among 30 patients); primary surgical errors (31 errors among 16 patients); pathology errors (24 errors among 17 patients); sentinel lymph node biopsy errors (13 errors among 13 patients); staging errors (17 errors among 13 patients); and treatment or management errors (45 errors among 33 patients). Based on the present results, we propose that in countries lacking national guidelines, clinicians should adhere to international evidence-based guidelines for the diagnosis and treatment of melanoma. © 2015 The International Society of Dermatology.

Systematic errors of EIT systems determined by easily-scalable resistive phantoms.

Science.gov (United States)

Hahn, G; Just, A; Dittmar, J; Hellige, G

2008-06-01

We present a simple method to determine systematic errors that will occur in the measurements by EIT systems. The approach is based on very simple scalable resistive phantoms for EIT systems using a 16 electrode adjacent drive pattern. The output voltage of the phantoms is constant for all combinations of current injection and voltage measurements and the trans-impedance of each phantom is determined by only one component. It can be chosen independently from the input and output impedance, which can be set in order to simulate measurements on the human thorax. Additional serial adapters allow investigation of the influence of the contact impedance at the electrodes on resulting errors. Since real errors depend on the dynamic properties of an EIT system, the following parameters are accessible: crosstalk, the absolute error of each driving/sensing channel and the signal to noise ratio in each channel. Measurements were performed on a Goe-MF II EIT system under four different simulated operational conditions. We found that systematic measurement errors always exceeded the error level of stochastic noise since the Goe-MF II system had been optimized for a sufficient signal to noise ratio but not for accuracy. In time difference imaging and functional EIT (f-EIT) systematic errors are reduced to a minimum by dividing the raw data by reference data. This is not the case in absolute EIT (a-EIT) where the resistivity of the examined object is determined on an absolute scale. We conclude that a reduction of systematic errors has to be one major goal in future system design.

Systematic errors of EIT systems determined by easily-scalable resistive phantoms

International Nuclear Information System (INIS)

Hahn, G; Just, A; Dittmar, J; Hellige, G

2008-01-01

We present a simple method to determine systematic errors that will occur in the measurements by EIT systems. The approach is based on very simple scalable resistive phantoms for EIT systems using a 16 electrode adjacent drive pattern. The output voltage of the phantoms is constant for all combinations of current injection and voltage measurements and the trans-impedance of each phantom is determined by only one component. It can be chosen independently from the input and output impedance, which can be set in order to simulate measurements on the human thorax. Additional serial adapters allow investigation of the influence of the contact impedance at the electrodes on resulting errors. Since real errors depend on the dynamic properties of an EIT system, the following parameters are accessible: crosstalk, the absolute error of each driving/sensing channel and the signal to noise ratio in each channel. Measurements were performed on a Goe-MF II EIT system under four different simulated operational conditions. We found that systematic measurement errors always exceeded the error level of stochastic noise since the Goe-MF II system had been optimized for a sufficient signal to noise ratio but not for accuracy. In time difference imaging and functional EIT (f-EIT) systematic errors are reduced to a minimum by dividing the raw data by reference data. This is not the case in absolute EIT (a-EIT) where the resistivity of the examined object is determined on an absolute scale. We conclude that a reduction of systematic errors has to be one major goal in future system design

Medication errors: the role of the patient.

Science.gov (United States)

Britten, Nicky

2009-06-01

1. Patients and their carers will usually be the first to notice any observable problems resulting from medication errors. They will probably be unable to distinguish between medication errors, adverse drug reactions, or 'side effects'. 2. Little is known about how patients understand drug related problems or how they make attributions of adverse effects. Some research suggests that patients' cognitive models of adverse drug reactions bear a close relationship to models of illness perception. 3. Attributions of adverse drug reactions are related to people's previous experiences and to their level of education. The evidence suggests that on the whole patients' reports of adverse drug reactions are accurate. However, patients do not report all the problems they perceive and are more likely to report those that they do perceive as severe. Patients may not report problems attributed to their medications if they are fearful of doctors' reactions. Doctors may respond inappropriately to patients' concerns, for example by ignoring them. Some authors have proposed the use of a symptom checklist to elicit patients' reports of suspected adverse drug reactions. 4. Many patients want information about adverse drug effects, and the challenge for the professional is to judge how much information to provide and the best way of doing so. Professionals' inappropriate emphasis on adherence may be dangerous when a medication error has occurred. 5. Recent NICE guidelines recommend that professionals should ask patients if they have any concerns about their medicines, and this approach is likely to yield information conducive to the identification of medication errors.

The alarming reality of medication error: a patient case and review of Pennsylvania and National data.

Science.gov (United States)

da Silva, Brianna A; Krishnamurthy, Mahesh

2016-01-01

A 71-year-old female accidentally received thiothixene (Navane), an antipsychotic, instead of her anti-hypertensive medication amlodipine (Norvasc) for 3 months. She sustained physical and psychological harm including ambulatory dysfunction, tremors, mood swings, and personality changes. Despite the many opportunities for intervention, multiple health care providers overlooked her symptoms. Errors occurred at multiple care levels, including prescribing, initial pharmacy dispensation, hospitalization, and subsequent outpatient follow-up. This exemplifies the Swiss Cheese Model of how errors can occur within a system. Adverse drug events (ADEs) account for more than 3.5 million physician office visits and 1 million emergency department visits each year. It is believed that preventable medication errors impact more than 7 million patients and cost almost $21 billion annually across all care settings. About 30% of hospitalized patients have at least one discrepancy on discharge medication reconciliation. Medication errors and ADEs are an underreported burden that adversely affects patients, providers, and the economy. Medication reconciliation including an 'indication review' for each prescription is an important aspect of patient safety. The decreasing frequency of pill bottle reviews, suboptimal patient education, and poor communication between healthcare providers are factors that threaten patient safety. Medication error and ADEs cost billions of health care dollars and are detrimental to the provider-patient relationship.

Near Misses in Financial Trading: Skills for Capturing and Averting Error.

Science.gov (United States)

Leaver, Meghan; Griffiths, Alex; Reader, Tom

2018-05-01

The aims of this study were (a) to determine whether near-miss incidents in financial trading contain information on the operator skills and systems that detect and prevent near misses and the patterns and trends revealed by these data and (b) to explore if particular operator skills and systems are found as important for avoiding particular types of error on the trading floor. In this study, we examine a cohort of near-miss incidents collected from a financial trading organization using the Financial Incident Analysis System and report on the nontechnical skills and systems that are used to detect and prevent error in this domain. One thousand near-miss incidents are analyzed using distribution, mean, chi-square, and associative analysis to describe the data; reliability is provided. Slips/lapses (52%) and human-computer interface problems (21%) often occur alone and are the main contributors to error causation, whereas the prevention of error is largely a result of teamwork (65%) and situation awareness (46%) skills. No matter the cause of error, situation awareness and teamwork skills are used most often to detect and prevent the error. Situation awareness and teamwork skills appear universally important as a "last line" of defense for capturing error, and data from incident-monitoring systems can be analyzed in a fashion more consistent with a "Safety-II" approach. This research provides data for ameliorating risk within financial trading organizations, with implications for future risk management programs and regulation.

Cross-cultural differences in categorical memory errors.

Science.gov (United States)

Schwartz, Aliza J; Boduroglu, Aysecan; Gutchess, Angela H

2014-06-01

Cultural differences occur in the use of categories to aid accurate recall of information. This study investigated whether culture also contributed to false (erroneous) memories, and extended cross-cultural memory research to Turkish culture, which is shaped by Eastern and Western influences. Americans and Turks viewed word pairs, half of which were categorically related and half unrelated. Participants then attempted to recall the second word from the pair in response to the first word cue. Responses were coded as correct, as blanks, or as different types of errors. Americans committed more categorical errors than did Turks, and Turks mistakenly recalled more non-categorically related list words than did Americans. These results support the idea that Americans use categories either to organize information in memory or to support retrieval strategies to a greater extent than Turks and suggest that culture shapes not only accurate recall but also erroneous distortions of memory. © 2014 Cognitive Science Society, Inc.

Pathways to extinction: beyond the error threshold.

Science.gov (United States)

Manrubia, Susanna C; Domingo, Esteban; Lázaro, Ester

2010-06-27

Since the introduction of the quasispecies and the error catastrophe concepts for molecular evolution by Eigen and their subsequent application to viral populations, increased mutagenesis has become a common strategy to cause the extinction of viral infectivity. Nevertheless, the high complexity of virus populations has shown that viral extinction can occur through several other pathways apart from crossing an error threshold. Increases in the mutation rate enhance the appearance of defective forms and promote the selection of mechanisms that are able to counteract the accelerated appearance of mutations. Current models of viral evolution take into account more realistic scenarios that consider compensatory and lethal mutations, a highly redundant genotype-to-phenotype map, rough fitness landscapes relating phenotype and fitness, and where phenotype is described as a set of interdependent traits. Further, viral populations cannot be understood without specifying the characteristics of the environment where they evolve and adapt. Altogether, it turns out that the pathways through which viral quasispecies go extinct are multiple and diverse.

CO2 production in animals: analysis of potential errors in the doubly labeled water method

International Nuclear Information System (INIS)

Nagy, K.A.

1979-03-01

Laboratory validation studies indicate that doubly labeled water ( 3 HH 18 O and 2 HH 18 O) measurements of CO 2 production are accurate to within +-9% in nine species of mammals and reptiles, a bird, and an insect. However, in field studies, errors can be much larger under certain circumstances. Isotopic fraction of labeled water can cause large errors in animals whose evaporative water loss comprises a major proportion of total water efflux. Input of CO 2 across lungs and skin caused errors exceeding +80% in kangaroo rats exposed to air containing 3.4% unlabeled CO 2 . Analytical errors of +-1% in isotope concentrations can cause calculated rates of CO 2 production to contain errors exceeding +-70% in some circumstances. These occur: 1) when little decline in isotope concentractions has occured during the measurement period; 2) when final isotope concentrations closely approach background levels; and 3) when the rate of water flux in an animal is high relative to its rate of CO 2 production. The following sources of error are probably negligible in most situations: 1) use of an inappropriate equation for calculating CO 2 production, 2) variations in rates of water or CO 2 flux through time, 3) use of H 2 O-18 dilution space as a measure of body water volume, 4) exchange of 0-18 between water and nonaqueous compounds in animals (including excrement), 5) incomplete mixing of isotopes in the animal, and 6) input of unlabeled water via lungs and skin. Errors in field measurements of CO 2 production can be reduced to acceptable levels (< 10%) by appropriate selection of study subjects and recapture intervals

The design and analysis of single flank transmission error testor for loaded gears

Science.gov (United States)

Houser, D. R.; Bassett, D. E.

1985-01-01

Due to geometrical imperfections in gears and finite tooth stiffnesses, the motion transmitted from an input gear shaft to an output gear shaft will not have conjugate action. In order to strengthen the understanding of transmission error and to verify mathematical models of gear transmission error, a test stand that will measure the transmission error of a gear pair at operating loads, but at reduced speeds would be desirable. This document describes the design and development of a loaded transmission error tester. For a gear box with a gear ratio of one, few tooth meshing combinations will occur during a single test. In order to observe the effects of different tooth mesh combinations and to increase the ability to load test gear pairs with higher gear ratios, the system was designed around a gear box with a gear ratio of two.

Statistical reporting errors and collaboration on statistical analyses in psychological science

NARCIS (Netherlands)

Veldkamp, C.L.S.; Nuijten, M.B.; Dominguez Alvarez, L.; van Assen, M.A.L.M.; Wicherts, J.M.

2014-01-01

Statistical analysis is error prone. A best practice for researchers using statistics would therefore be to share data among co-authors, allowing double-checking of executed tasks just as co-pilots do in aviation. To document the extent to which this ‘co-piloting’ currently occurs in psychology, we

Error correcting code with chip kill capability and power saving enhancement

Energy Technology Data Exchange (ETDEWEB)

Gara, Alan G [Mount Kisco, NY; Chen, Dong [Croton On Husdon, NY; Coteus, Paul W [Yorktown Heights, NY; Flynn, William T [Rochester, MN; Marcella, James A [Rochester, MN; Takken, Todd [Brewster, NY; Trager, Barry M [Yorktown Heights, NY; Winograd, Shmuel [Scarsdale, NY

2011-08-30

A method and system are disclosed for detecting memory chip failure in a computer memory system. The method comprises the steps of accessing user data from a set of user data chips, and testing the user data for errors using data from a set of system data chips. This testing is done by generating a sequence of check symbols from the user data, grouping the user data into a sequence of data symbols, and computing a specified sequence of syndromes. If all the syndromes are zero, the user data has no errors. If one of the syndromes is non-zero, then a set of discriminator expressions are computed, and used to determine whether a single or double symbol error has occurred. In the preferred embodiment, less than two full system data chips are used for testing and correcting the user data.

Errors in preparation and administration of parenteral drugs in neonatology: evaluation and corrective actions.

Science.gov (United States)

Hasni, Nesrine; Ben Hamida, Emira; Ben Jeddou, Khouloud; Ben Hamida, Sarra; Ayadi, Imene; Ouahchi, Zeineb; Marrakchi, Zahra

2016-12-01

The medication iatrogenic risk is quite unevaluated in neonatology Objective: Assessment of errors that occurred during the preparation and administration of injectable medicines in a neonatal unit in order to implement corrective actions to reduce the occurrence of these errors. A prospective, observational study was performed in a neonatal unit over a period of one month. The practice of preparing and administering injectable medications were identified through a standardized data collection form. These practices were compared with summaries of the characteristics of each product (RCP) and the bibliography. One hundred preparations were observed of 13 different drugs. 85 errors during preparations and administration steps were detected. These errors were divided into preparation errors in 59% of cases such as changing the dilution protocol (32%), the use of bad solvent (11%) and administration errors in 41% of cases as errors timing of administration (18%) or omission of administration (9%). This study showed a high rate of errors during stages of preparation and administration of injectable drugs. In order to optimize the care of newborns and reduce the risk of medication errors, corrective actions have been implemented through the establishment of a quality assurance system which consisted of the development of injectable drugs preparation procedures, the introduction of a labeling system and staff training.

Online Synthesis for Error Recovery in Digital Microfluidic Biochips with Operation Variability

DEFF Research Database (Denmark)

Alistar, Mirela; Pop, Paul; Madsen, Jan

2012-01-01

. The droplet volumes can vary erroneously due to parametric faults, thus impacting negatively the correctness of the application. Researchers have proposed approaches that synthesize offline predetermined recovery subroutines, which are activated online when errors occur. In this paper, we propose an online...

Prediction and error of baldcypress stem volume from stump diameter

Science.gov (United States)

Bernard R. Parresol

1998-01-01

The need to estimate the volume of removals occurs for many reasons, such as in trespass cases, severance tax reports, and post-harvest assessments. A logarithmic model is presented for prediction of baldcypress total stem cubic foot volume using stump diameter as the independent variable. Because the error of prediction is as important as the volume estimate, the...

Female residents experiencing medical errors in general internal medicine: a qualitative study.

Science.gov (United States)

Mankaka, Cindy Ottiger; Waeber, Gérard; Gachoud, David

2014-07-10

Doctors, especially doctors-in-training such as residents, make errors. They have to face the consequences even though today's approach to errors emphasizes systemic factors. Doctors' individual characteristics play a role in how medical errors are experienced and dealt with. The role of gender has previously been examined in a few quantitative studies that have yielded conflicting results. In the present study, we sought to qualitatively explore the experience of female residents with respect to medical errors. In particular, we explored the coping mechanisms displayed after an error. This study took place in the internal medicine department of a Swiss university hospital. Within a phenomenological framework, semi-structured interviews were conducted with eight female residents in general internal medicine. All interviews were audiotaped, fully transcribed, and thereafter analyzed. Seven main themes emerged from the interviews: (1) A perception that there is an insufficient culture of safety and error; (2) The perceived main causes of errors, which included fatigue, work overload, inadequate level of competences in relation to assigned tasks, and dysfunctional communication; (3) Negative feelings in response to errors, which included different forms of psychological distress; (4) Variable attitudes of the hierarchy toward residents involved in an error; (5) Talking about the error, as the core coping mechanism; (6) Defensive and constructive attitudes toward one's own errors; and (7) Gender-specific experiences in relation to errors. Such experiences consisted in (a) perceptions that male residents were more confident and therefore less affected by errors than their female counterparts and (b) perceptions that sexist attitudes among male supervisors can occur and worsen an already painful experience. This study offers an in-depth account of how female residents specifically experience and cope with medical errors. Our interviews with female residents convey the

[Medication errors in a hospital emergency department: study of the current situation and critical points for improving patient safety].

Science.gov (United States)

Pérez-Díez, Cristina; Real-Campaña, José Manuel; Noya-Castro, María Carmen; Andrés-Paricio, Felicidad; Reyes Abad-Sazatornil, María; Bienvenido Povar-Marco, Javier

2017-01-01

To determine the frequency of medication errors and incident types in a tertiary-care hospital emergency department. To quantify and classify medication errors and identify critical points where measures should be implemented to improve patient safety. Prospective direct-observation study to detect errors made in June and July 2016. The overall error rate was 23.7%. The most common errors were made while medications were administered (10.9%). We detected 1532 incidents: 53.6% on workdays (P=.001), 43.1% during the afternoon/evening shift (P=.004), and 43.1% in observation areas (P=.004). The medication error rate was significant. Most errors and incidents occurred during the afternoon/evening shift and in the observation area. Most errors were related to administration of medications.

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.

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.

Speech error and tip-of-the-tongue diary for mobile devices

Directory of Open Access Journals (Sweden)

Michael S Vitevitch

2015-08-01

Full Text Available Collections of various types of speech errors have increased our understanding of the acquisition, production, and perception of language. Although such collections of naturally occurring language errors are invaluable for a number of reasons, the process of collecting various types of speech errors presents many challenges to the researcher interested in building such a collection, among them a significant investment of time and effort to obtain a sufficient number of examples to enable statistical analysis. Here we describe a freely accessible website (http://spedi.ku.edu that helps users document slips of the tongue, slips of the ear, and tip of the tongue states that they experience firsthand or observe in others. The documented errors are amassed, and made available for other users to analyze, thereby distributing the time and effort involved in collecting errors across a large number of individuals instead of saddling the lone researcher, and facilitating distribution of the collection to other researchers. This approach also addresses some issues related to data curation that hampered previous error collections, and enables the collection to continue to grow over a longer period of time than previous collections. Finally, this web-based tool creates an opportunity for language scientists to engage in outreach efforts to increase the understanding of language disorders and research in the general public.

Coping with medical error: a systematic review of papers to assess the effects of involvement in medical errors on healthcare professionals' psychological well-being.

Science.gov (United States)

Sirriyeh, Reema; Lawton, Rebecca; Gardner, Peter; Armitage, Gerry

2010-12-01

Previous research has established health professionals as secondary victims of medical error, with the identification of a range of emotional and psychological repercussions that may occur as a result of involvement in error.2 3 Due to the vast range of emotional and psychological outcomes, research to date has been inconsistent in the variables measured and tools used. Therefore, differing conclusions have been drawn as to the nature of the impact of error on professionals and the subsequent repercussions for their team, patients and healthcare institution. A systematic review was conducted. Data sources were identified using database searches, with additional reference and hand searching. Eligibility criteria were applied to all studies identified, resulting in a total of 24 included studies. Quality assessment was conducted with the included studies using a tool that was developed as part of this research, but due to the limited number and diverse nature of studies, no exclusions were made on this basis. Review findings suggest that there is consistent evidence for the widespread impact of medical error on health professionals. Psychological repercussions may include negative states such as shame, self-doubt, anxiety and guilt. Despite much attention devoted to the assessment of negative outcomes, the potential for positive outcomes resulting from error also became apparent, with increased assertiveness, confidence and improved colleague relationships reported. It is evident that involvement in a medical error can elicit a significant psychological response from the health professional involved. However, a lack of literature around coping and support, coupled with inconsistencies and weaknesses in methodology, may need be addressed in future work.

The Error Reporting in the ATLAS TDAQ System

Science.gov (United States)

Kolos, Serguei; Kazarov, Andrei; Papaevgeniou, Lykourgos

2015-05-01

The ATLAS Error Reporting provides a service that allows experts and shift crew to track and address errors relating to the data taking components and applications. This service, called the Error Reporting Service (ERS), gives to software applications the opportunity to collect and send comprehensive data about run-time errors, to a place where it can be intercepted in real-time by any other system component. Other ATLAS online control and monitoring tools use the ERS as one of their main inputs to address system problems in a timely manner and to improve the quality of acquired data. The actual destination of the error messages depends solely on the run-time environment, in which the online applications are operating. When an application sends information to ERS, depending on the configuration, it may end up in a local file, a database, distributed middleware which can transport it to an expert system or display it to users. Thanks to the open framework design of ERS, new information destinations can be added at any moment without touching the reporting and receiving applications. The ERS Application Program Interface (API) is provided in three programming languages used in the ATLAS online environment: C++, Java and Python. All APIs use exceptions for error reporting but each of them exploits advanced features of a given language to simplify the end-user program writing. For example, as C++ lacks language support for exceptions, a number of macros have been designed to generate hierarchies of C++ exception classes at compile time. Using this approach a software developer can write a single line of code to generate a boilerplate code for a fully qualified C++ exception class declaration with arbitrary number of parameters and multiple constructors, which encapsulates all relevant static information about the given type of issues. When a corresponding error occurs at run time, the program just need to create an instance of that class passing relevant values to one

Detected-jump-error-correcting quantum codes, quantum error designs, and quantum computation

International Nuclear Information System (INIS)

Alber, G.; Mussinger, M.; Beth, Th.; Charnes, Ch.; Delgado, A.; Grassl, M.

2003-01-01

The recently introduced detected-jump-correcting quantum codes are capable of stabilizing qubit systems against spontaneous decay processes arising from couplings to statistically independent reservoirs. These embedded quantum codes exploit classical information about which qubit has emitted spontaneously and correspond to an active error-correcting code embedded in a passive error-correcting code. The construction of a family of one-detected-jump-error-correcting quantum codes is shown and the optimal redundancy, encoding, and recovery as well as general properties of detected-jump-error-correcting quantum codes are discussed. By the use of design theory, multiple-jump-error-correcting quantum codes can be constructed. The performance of one-jump-error-correcting quantum codes under nonideal conditions is studied numerically by simulating a quantum memory and Grover's algorithm

Patterns of poststroke brain damage that predict speech production errors in apraxia of speech and aphasia dissociate.

Science.gov (United States)

Basilakos, Alexandra; Rorden, Chris; Bonilha, Leonardo; Moser, Dana; Fridriksson, Julius

2015-06-01

Acquired apraxia of speech (AOS) is a motor speech disorder caused by brain damage. AOS often co-occurs with aphasia, a language disorder in which patients may also demonstrate speech production errors. The overlap of speech production deficits in both disorders has raised questions on whether AOS emerges from a unique pattern of brain damage or as a subelement of the aphasic syndrome. The purpose of this study was to determine whether speech production errors in AOS and aphasia are associated with distinctive patterns of brain injury. Forty-three patients with history of a single left-hemisphere stroke underwent comprehensive speech and language testing. The AOS Rating Scale was used to rate speech errors specific to AOS versus speech errors that can also be associated with both AOS and aphasia. Localized brain damage was identified using structural magnetic resonance imaging, and voxel-based lesion-impairment mapping was used to evaluate the relationship between speech errors specific to AOS, those that can occur in AOS or aphasia, and brain damage. The pattern of brain damage associated with AOS was most strongly associated with damage to cortical motor regions, with additional involvement of somatosensory areas. Speech production deficits that could be attributed to AOS or aphasia were associated with damage to the temporal lobe and the inferior precentral frontal regions. AOS likely occurs in conjunction with aphasia because of the proximity of the brain areas supporting speech and language, but the neurobiological substrate for each disorder differs. © 2015 American Heart Association, Inc.

Voluntary Medication Error Reporting by ED Nurses: Examining the Association With Work Environment and Social Capital.

Science.gov (United States)

Farag, Amany; Blegen, Mary; Gedney-Lose, Amalia; Lose, Daniel; Perkhounkova, Yelena

2017-05-01

Medication errors are one of the most frequently occurring errors in health care settings. The complexity of the ED work environment places patients at risk for medication errors. Most hospitals rely on nurses' voluntary medication error reporting, but these errors are under-reported. The purpose of this study was to examine the relationship among work environment (nurse manager leadership style and safety climate), social capital (warmth and belonging relationships and organizational trust), and nurses' willingness to report medication errors. A cross-sectional descriptive design using a questionnaire with a convenience sample of emergency nurses was used. Data were analyzed using descriptive, correlation, Mann-Whitney U, and Kruskal-Wallis statistics. A total of 71 emergency nurses were included in the study. Emergency nurses' willingness to report errors decreased as the nurses' years of experience increased (r = -0.25, P = .03). Their willingness to report errors increased when they received more feedback about errors (r = 0.25, P = .03) and when their managers used a transactional leadership style (r = 0.28, P = .01). ED nurse managers can modify their leadership style to encourage error reporting. Timely feedback after an error report is particularly important. Engaging experienced nurses to understand error root causes could increase voluntary error reporting. Published by Elsevier Inc.

Exploring the initial steps of the testing process: frequency and nature of pre-preanalytic errors.

Science.gov (United States)

Carraro, Paolo; Zago, Tatiana; Plebani, Mario

2012-03-01

Few data are available on the nature of errors in the so-called pre-preanalytic phase, the initial steps of the testing process. We therefore sought to evaluate pre-preanalytic errors using a study design that enabled us to observe the initial procedures performed in the ward, from the physician's test request to the delivery of specimens in the clinical laboratory. After a 1-week direct observational phase designed to identify the operating procedures followed in 3 clinical wards, we recorded all nonconformities and errors occurring over a 6-month period. Overall, the study considered 8547 test requests, for which 15 917 blood sample tubes were collected and 52 982 tests undertaken. No significant differences in error rates were found between the observational phase and the overall study period, but underfilling of coagulation tubes was found to occur more frequently in the direct observational phase (P = 0.043). In the overall study period, the frequency of errors was found to be particularly high regarding order transmission [29 916 parts per million (ppm)] and hemolysed samples (2537 ppm). The frequency of patient misidentification was 352 ppm, and the most frequent nonconformities were test requests recorded in the diary without the patient's name and failure to check the patient's identity at the time of blood draw. The data collected in our study confirm the relative frequency of pre-preanalytic errors and underline the need to consensually prepare and adopt effective standard operating procedures in the initial steps of laboratory testing and to monitor compliance with these procedures over time.

Perceptual learning eases crowding by reducing recognition errors but not position errors.

Science.gov (United States)

Xiong, Ying-Zi; Yu, Cong; Zhang, Jun-Yun

2015-08-01

When an observer reports a letter flanked by additional letters in the visual periphery, the response errors (the crowding effect) may result from failure to recognize the target letter (recognition errors), from mislocating a correctly recognized target letter at a flanker location (target misplacement errors), or from reporting a flanker as the target letter (flanker substitution errors). Crowding can be reduced through perceptual learning. However, it is not known how perceptual learning operates to reduce crowding. In this study we trained observers with a partial-report task (Experiment 1), in which they reported the central target letter of a three-letter string presented in the visual periphery, or a whole-report task (Experiment 2), in which they reported all three letters in order. We then assessed the impact of training on recognition of both unflanked and flanked targets, with particular attention to how perceptual learning affected the types of errors. Our results show that training improved target recognition but not single-letter recognition, indicating that training indeed affected crowding. However, training did not reduce target misplacement errors or flanker substitution errors. This dissociation between target recognition and flanker substitution errors supports the view that flanker substitution may be more likely a by-product (due to response bias), rather than a cause, of crowding. Moreover, the dissociation is not consistent with hypothesized mechanisms of crowding that would predict reduced positional errors.

Error suppression and error correction in adiabatic quantum computation: non-equilibrium dynamics

International Nuclear Information System (INIS)

Sarovar, Mohan; Young, Kevin C

2013-01-01

While adiabatic quantum computing (AQC) has some robustness to noise and decoherence, it is widely believed that encoding, error suppression and error correction will be required to scale AQC to large problem sizes. Previous works have established at least two different techniques for error suppression in AQC. In this paper we derive a model for describing the dynamics of encoded AQC and show that previous constructions for error suppression can be unified with this dynamical model. In addition, the model clarifies the mechanisms of error suppression and allows the identification of its weaknesses. In the second half of the paper, we utilize our description of non-equilibrium dynamics in encoded AQC to construct methods for error correction in AQC by cooling local degrees of freedom (qubits). While this is shown to be possible in principle, we also identify the key challenge to this approach: the requirement of high-weight Hamiltonians. Finally, we use our dynamical model to perform a simplified thermal stability analysis of concatenated-stabilizer-code encoded many-body systems for AQC or quantum memories. This work is a companion paper to ‘Error suppression and error correction in adiabatic quantum computation: techniques and challenges (2013 Phys. Rev. X 3 041013)’, which provides a quantum information perspective on the techniques and limitations of error suppression and correction in AQC. In this paper we couch the same results within a dynamical framework, which allows for a detailed analysis of the non-equilibrium dynamics of error suppression and correction in encoded AQC. (paper)

The conditions for attaining the greatest degree of system stability with strict generator excitation control

Energy Technology Data Exchange (ETDEWEB)

Gruzdev, I.A.; Ekimova, M.M.; Truspekova, G.A.

1982-01-01

Expressions are derived for an idealized model of a complex electric power system; these expressions define the greatest level of stability of an electric power system and the optimum combination of stabilization factors with automatic excitation control in a single power system. The possibility of increasing the level of stability of an electric power system with simultaneous strict automatic excitation control of the synychronous generators in several power systems is analyzed.

VR-based training and assessment in ultrasound-guided regional anesthesia: from error analysis to system design.

LENUS (Irish Health Repository)

2011-01-01

If VR-based medical training and assessment is to improve patient care and safety (i.e. a genuine health gain), it has to be based on clinically relevant measurement of performance. Metrics on errors are particularly useful for capturing and correcting undesired behaviors before they occur in the operating room. However, translating clinically relevant metrics and errors into meaningful system design is a challenging process. This paper discusses how an existing task and error analysis was translated into the system design of a VR-based training and assessment environment for Ultrasound Guided Regional Anesthesia (UGRA).

The Errors of Our Ways: Understanding Error Representations in Cerebellar-Dependent Motor Learning.

Science.gov (United States)

Popa, Laurentiu S; Streng, Martha L; Hewitt, Angela L; Ebner, Timothy J

2016-04-01

The cerebellum is essential for error-driven motor learning and is strongly implicated in detecting and correcting for motor errors. Therefore, elucidating how motor errors are represented in the cerebellum is essential in understanding cerebellar function, in general, and its role in motor learning, in particular. This review examines how motor errors are encoded in the cerebellar cortex in the context of a forward internal model that generates predictions about the upcoming movement and drives learning and adaptation. In this framework, sensory prediction errors, defined as the discrepancy between the predicted consequences of motor commands and the sensory feedback, are crucial for both on-line movement control and motor learning. While many studies support the dominant view that motor errors are encoded in the complex spike discharge of Purkinje cells, others have failed to relate complex spike activity with errors. Given these limitations, we review recent findings in the monkey showing that complex spike modulation is not necessarily required for motor learning or for simple spike adaptation. Also, new results demonstrate that the simple spike discharge provides continuous error signals that both lead and lag the actual movements in time, suggesting errors are encoded as both an internal prediction of motor commands and the actual sensory feedback. These dual error representations have opposing effects on simple spike discharge, consistent with the signals needed to generate sensory prediction errors used to update a forward internal model.

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.

Trends in Health Information Technology Safety: From Technology-Induced Errors to Current Approaches for Ensuring Technology Safety

Science.gov (United States)

2013-01-01

Objectives Health information technology (HIT) research findings suggested that new healthcare technologies could reduce some types of medical errors while at the same time introducing classes of medical errors (i.e., technology-induced errors). Technology-induced errors have their origins in HIT, and/or HIT contribute to their occurrence. The objective of this paper is to review current trends in the published literature on HIT safety. Methods A review and synthesis of the medical and life sciences literature focusing on the area of technology-induced error was conducted. Results There were four main trends in the literature on technology-induced error. The following areas were addressed in the literature: definitions of technology-induced errors; models, frameworks and evidence for understanding how technology-induced errors occur; a discussion of monitoring; and methods for preventing and learning about technology-induced errors. Conclusions The literature focusing on technology-induced errors continues to grow. Research has focused on the defining what an error is, models and frameworks used to understand these new types of errors, monitoring of such errors and methods that can be used to prevent these errors. More research will be needed to better understand and mitigate these types of errors. PMID:23882411

Rotational error in path integration: encoding and execution errors in angle reproduction.

Science.gov (United States)

Chrastil, Elizabeth R; Warren, William H

2017-06-01

Path integration is fundamental to human navigation. When a navigator leaves home on a complex outbound path, they are able to keep track of their approximate position and orientation and return to their starting location on a direct homebound path. However, there are several sources of error during path integration. Previous research has focused almost exclusively on encoding error-the error in registering the outbound path in memory. Here, we also consider execution error-the error in the response, such as turning and walking a homebound trajectory. In two experiments conducted in ambulatory virtual environments, we examined the contribution of execution error to the rotational component of path integration using angle reproduction tasks. In the reproduction tasks, participants rotated once and then rotated again to face the original direction, either reproducing the initial turn or turning through the supplementary angle. One outstanding difficulty in disentangling encoding and execution error during a typical angle reproduction task is that as the encoding angle increases, so does the required response angle. In Experiment 1, we dissociated these two variables by asking participants to report each encoding angle using two different responses: by turning to walk on a path parallel to the initial facing direction in the same (reproduction) or opposite (supplementary angle) direction. In Experiment 2, participants reported the encoding angle by turning both rightward and leftward onto a path parallel to the initial facing direction, over a larger range of angles. The results suggest that execution error, not encoding error, is the predominant source of error in angular path integration. These findings also imply that the path integrator uses an intrinsic (action-scaled) rather than an extrinsic (objective) metric.

ADVANCED MMIS TOWARD SUBSTANTIAL REDUCTION IN HUMAN ERRORS IN NPPS

Directory of Open Access Journals (Sweden)

POONG HYUN SEONG

2013-04-01

Full Text Available This paper aims to give an overview of the methods to inherently prevent human errors and to effectively mitigate the consequences of such errors by securing defense-in-depth during plant management through the advanced man-machine interface system (MMIS. It is needless to stress the significance of human error reduction during an accident in nuclear power plants (NPPs. Unexpected shutdowns caused by human errors not only threaten nuclear safety but also make public acceptance of nuclear power extremely lower. We have to recognize there must be the possibility of human errors occurring since humans are not essentially perfect particularly under stressful conditions. However, we have the opportunity to improve such a situation through advanced information and communication technologies on the basis of lessons learned from our experiences. As important lessons, authors explained key issues associated with automation, man-machine interface, operator support systems, and procedures. Upon this investigation, we outlined the concept and technical factors to develop advanced automation, operation and maintenance support systems, and computer-based procedures using wired/wireless technology. It should be noted that the ultimate responsibility of nuclear safety obviously belongs to humans not to machines. Therefore, safety culture including education and training, which is a kind of organizational factor, should be emphasized as well. In regard to safety culture for human error reduction, several issues that we are facing these days were described. We expect the ideas of the advanced MMIS proposed in this paper to lead in the future direction of related researches and finally supplement the safety of NPPs.

Advanced MMIS Toward Substantial Reduction in Human Errors in NPPs

Energy Technology Data Exchange (ETDEWEB)

Seong, Poong Hyun; Kang, Hyun Gook [Korea Advanced Institute of Science and Technology, Daejeon (Korea, Republic of); Na, Man Gyun [Chosun Univ., Gwangju (Korea, Republic of); Kim, Jong Hyun [KEPCO International Nuclear Graduate School, Ulsan (Korea, Republic of); Heo, Gyunyoung [Kyung Hee Univ., Yongin (Korea, Republic of); Jung, Yoensub [Korea Hydro and Nuclear Power Co., Ltd., Daejeon (Korea, Republic of)

2013-04-15

This paper aims to give an overview of the methods to inherently prevent human errors and to effectively mitigate the consequences of such errors by securing defense-in-depth during plant management through the advanced man-machine interface system (MMIS). It is needless to stress the significance of human error reduction during an accident in nuclear power plants (NPPs). Unexpected shutdowns caused by human errors not only threaten nuclear safety but also make public acceptance of nuclear power extremely lower. We have to recognize there must be the possibility of human errors occurring since humans are not essentially perfect particularly under stressful conditions. However, we have the opportunity to improve such a situation through advanced information and communication technologies on the basis of lessons learned from our experiences. As important lessons, authors explained key issues associated with automation, man-machine interface, operator support systems, and procedures. Upon this investigation, we outlined the concept and technical factors to develop advanced automation, operation and maintenance support systems, and computer-based procedures using wired/wireless technology. It should be noted that the ultimate responsibility of nuclear safety obviously belongs to humans not to machines. Therefore, safety culture including education and training, which is a kind of organizational factor, should be emphasized as well. In regard to safety culture for human error reduction, several issues that we are facing these days were described. We expect the ideas of the advanced MMIS proposed in this paper to lead in the future direction of related researches and finally supplement the safety of NPPs.

Advanced MMIS Toward Substantial Reduction in Human Errors in NPPs

International Nuclear Information System (INIS)

Seong, Poong Hyun; Kang, Hyun Gook; Na, Man Gyun; Kim, Jong Hyun; Heo, Gyunyoung; Jung, Yoensub

2013-01-01

This paper aims to give an overview of the methods to inherently prevent human errors and to effectively mitigate the consequences of such errors by securing defense-in-depth during plant management through the advanced man-machine interface system (MMIS). It is needless to stress the significance of human error reduction during an accident in nuclear power plants (NPPs). Unexpected shutdowns caused by human errors not only threaten nuclear safety but also make public acceptance of nuclear power extremely lower. We have to recognize there must be the possibility of human errors occurring since humans are not essentially perfect particularly under stressful conditions. However, we have the opportunity to improve such a situation through advanced information and communication technologies on the basis of lessons learned from our experiences. As important lessons, authors explained key issues associated with automation, man-machine interface, operator support systems, and procedures. Upon this investigation, we outlined the concept and technical factors to develop advanced automation, operation and maintenance support systems, and computer-based procedures using wired/wireless technology. It should be noted that the ultimate responsibility of nuclear safety obviously belongs to humans not to machines. Therefore, safety culture including education and training, which is a kind of organizational factor, should be emphasized as well. In regard to safety culture for human error reduction, several issues that we are facing these days were described. We expect the ideas of the advanced MMIS proposed in this paper to lead in the future direction of related researches and finally supplement the safety of NPPs

Main visual symptoms associated to refractive errors and spectacle need in a Brazilian population

Directory of Open Access Journals (Sweden)

Silvana Schellini

2016-12-01

Full Text Available AIM: To determine the main visual symptoms in a Brazilian population sample, associated to refractive errors (REs and spectacle need to suggest priorities in preventive programs. METHODS: A cross-sectional study was conducted in nine counties of the southeast region of Brazil, using a systematic sampling of households, between March 2004 and July 2005. The population was defined as individuals aged between 1 and 96y, inhabitants of 3600 residences to be evaluated and 3012 households were included, corresponding to 8010 subjects considered for participation in the survey, of whom 7654 underwent ophthalmic examinations. The individuals were evaluated according their demographic data, eye complaints and eye examination including the RE and the need to prescribe spectacles according to age. Statistical analysis was performed using SPSS software package and descriptive analysis using 95% confidence intervals (P<0.05. RESULTS: The main symptom detected was asthenopia, most frequent in the 2nd and 3rd decades of life, with a significant decline after the 4th decade. Astigmatism was the RE most associated with asthenopia. Reduced near vision sight was more frequent in those ≥40y with a progressive decline thereafter. Spectacles were most frequently required in subjects of ≥40 years of age. CONCLUSION: The main symptom related to the vision was asthenopia and was associated to astigmatism. The greatest need for spectacles prescription occurred after 40’s, mainly to correct near vision. Subjects of ≥40 years old were determined to be at high risk of uncorrected REs. These observations can guide intervention programs for the Brazilian population.

Study of Periodic Fabrication Error of Optical Splitter Device Performance

OpenAIRE

Ab-Rahman, Mohammad Syuhaimi; Ater, Foze Saleh; Jumari, Kasmiran; Mohammad, Rahmah

2012-01-01

In this paper, the effect of fabrication errors (FEs) on the performance of 1×4 optical power splitter is investigated in details. The FE, which is assumed to take regular shape, is considered in each section of the device. Simulation result show that FE has a significant effect on the output power especially when it occurs in coupling regions.

GPS/DR Error Estimation for Autonomous Vehicle Localization.

Science.gov (United States)

Lee, Byung-Hyun; Song, Jong-Hwa; Im, Jun-Hyuck; Im, Sung-Hyuck; Heo, Moon-Beom; Jee, Gyu-In

2015-08-21

Autonomous vehicles require highly reliable navigation capabilities. For example, a lane-following method cannot be applied in an intersection without lanes, and since typical lane detection is performed using a straight-line model, errors can occur when the lateral distance is estimated in curved sections due to a model mismatch. Therefore, this paper proposes a localization method that uses GPS/DR error estimation based on a lane detection method with curved lane models, stop line detection, and curve matching in order to improve the performance during waypoint following procedures. The advantage of using the proposed method is that position information can be provided for autonomous driving through intersections, in sections with sharp curves, and in curved sections following a straight section. The proposed method was applied in autonomous vehicles at an experimental site to evaluate its performance, and the results indicate that the positioning achieved accuracy at the sub-meter level.

Errors in spectroscopic measurements of SO2 due to nonexponential absorption of laser radiation, with application to the remote monitoring of atmospheric pollutants

International Nuclear Information System (INIS)

Brassington, D.J.; Moncrieff, T.M.; Felton, R.C.; Jolliffe, B.W.; Marx, B.R.; Rowley, W.R.C.; Woods, P.T.

1984-01-01

Methods of measuring the concentration of atmospheric pollutants by laser absorption spectroscopy, such as differential absorption lidar (DIAL) and integrated long-path techniques, all rely on the validity of Beer's exponential absorption law. It is shown here that departures from this law occur if the probing laser has a bandwidth larger than the wavelength scale of structure in the absorption spectrum of the pollutant. A comprehensive experimental and theoretical treatment of the errors resulting from these departures is presented for the particular case of SO 2 monitoring at approx.300 nm. It is shown that the largest error occurs where the initial calibration measurement of absorption cross section is made at low pressure, in which case errors in excess of 5% in the cross section could occur for laser bandwidths >0.01 nm. Atmospheric measurements by DIAL or long-path methods are in most cases affected less, because pressure broadening smears the spectral structure, but when measuring high concentrations errors can exceed 5%

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.

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

Prediction-error of Prediction Error (PPE)-based Reversible Data Hiding

OpenAIRE

Wu, Han-Zhou; Wang, Hong-Xia; Shi, Yun-Qing

2016-01-01

This paper presents a novel reversible data hiding (RDH) algorithm for gray-scaled images, in which the prediction-error of prediction error (PPE) of a pixel is used to carry the secret data. In the proposed method, the pixels to be embedded are firstly predicted with their neighboring pixels to obtain the corresponding prediction errors (PEs). Then, by exploiting the PEs of the neighboring pixels, the prediction of the PEs of the pixels can be determined. And, a sorting technique based on th...

The alarming reality of medication error: a patient case and review of Pennsylvania and National data

Directory of Open Access Journals (Sweden)

Brianna A. da Silva

2016-09-01

Full Text Available Case description: A 71-year-old female accidentally received thiothixene (Navane, an antipsychotic, instead of her anti-hypertensive medication amlodipine (Norvasc for 3 months. She sustained physical and psychological harm including ambulatory dysfunction, tremors, mood swings, and personality changes. Despite the many opportunities for intervention, multiple health care providers overlooked her symptoms. Discussion: Errors occurred at multiple care levels, including prescribing, initial pharmacy dispensation, hospitalization, and subsequent outpatient follow-up. This exemplifies the Swiss Cheese Model of how errors can occur within a system. Adverse drug events (ADEs account for more than 3.5 million physician office visits and 1 million emergency department visits each year. It is believed that preventable medication errors impact more than 7 million patients and cost almost $21 billion annually across all care settings. About 30% of hospitalized patients have at least one discrepancy on discharge medication reconciliation. Medication errors and ADEs are an underreported burden that adversely affects patients, providers, and the economy. Conclusion: Medication reconciliation including an ‘indication review’ for each prescription is an important aspect of patient safety. The decreasing frequency of pill bottle reviews, suboptimal patient education, and poor communication between healthcare providers are factors that threaten patient safety. Medication error and ADEs cost billions of health care dollars and are detrimental to the provider–patient relationship.

Tracking errors in tractography of the gastrocnemius muscle. A comparison between the transverse and sagittal planes

International Nuclear Information System (INIS)

Aoki, Takako; Tohdoh, Yukihiro; Tawara, Noriyuki; Okuwaki, Toru; Horiuchi, Akira; Itagaki, Takuma; Niitsu, Mamoru

2010-01-01

In scans taken in conventional direction, tracking errors may occur when using a streamline-based algorithm for the tractography of the gastrocnemius muscle. To solve errors in tracking, we applied tractography to the musculotendinous junction and performed fiber tracking on the gastrocnemius muscle of 10 healthy subjects with their written informed consent. We employed a spin-echo diffusion tensor imaging (SE-DTI) sequence with 6-direction diffusion gradient sensitization and acquired DTI images at 1.5 tesla using a body array coil with parallel imaging. We compared tractography obtained in the transverse and sagittal planes using anatomical reference and found that the gastrocnemius muscle and musculotendinous junction were significantly better visualized on sagittal scans and in 3 regions of interest. We utilized Mann-Whitney U-test to determine significant differences between rates of concordance (P 2 value of skeletal muscle is around 50 ms, and TE should be as short as possible. A streamline-based algorithm is based on the continuity of a vector. It is easy to take running of the muscle fiber in sagittal scan. Therefore, tracking error is hard to occur. In conclusion, sagittal scanning may be one way to eliminate tracking errors in the tractography of the gastrocnemius muscle. Tracking errors were smaller with sagittal scans than transverse scans, and sagittal scans allow better fiber tracking. (author)

Verification of mid-ocean ballast water exchange using naturally occurring coastal tracers

Energy Technology Data Exchange (ETDEWEB)

Murphy, Kathleen; Boehme, Jennifer; Coble, Paula; Cullen, Jay; Field, Paul; Moore, Willard; Perry, Elgin; Sherrell, Robert; Ruiz, Gregory

2004-04-01

We examined methods for verifying whether or not ships have performed mid-ocean ballast water exchange (BWE) on four commercial vessels operating in the Pacific and Atlantic Oceans. During BWE, a ship replaces the coastal water in its ballast tanks with water drawn from the open ocean, which is considered to harbor fewer organisms capable of establishing in coastal environments. We measured concentrations of several naturally occurring chemical tracers (salinity, six trace elements, colored dissolved organic matter fluorescence and radium isotopes) along ocean transects and in ballast tanks subjected to varying degrees of BWE (0-99%). Many coastal tracers showed significant concentration changes due to BWE, and our ability to detect differences between exchanged and unexchanged ballast tanks was greatest under multivariate analysis. An expanded dataset, which includes additional geographic regions, is now needed to test the generality of our results.

Verification of mid-ocean ballast water exchange using naturally occurring coastal tracers

International Nuclear Information System (INIS)

Murphy, Kathleen; Boehme, Jennifer; Coble, Paula; Cullen, Jay; Field, Paul; Moore, Willard; Perry, Elgin; Sherrell, Robert; Ruiz, Gregory

2004-01-01

We examined methods for verifying whether or not ships have performed mid-ocean ballast water exchange (BWE) on four commercial vessels operating in the Pacific and Atlantic Oceans. During BWE, a ship replaces the coastal water in its ballast tanks with water drawn from the open ocean, which is considered to harbor fewer organisms capable of establishing in coastal environments. We measured concentrations of several naturally occurring chemical tracers (salinity, six trace elements, colored dissolved organic matter fluorescence and radium isotopes) along ocean transects and in ballast tanks subjected to varying degrees of BWE (0-99%). Many coastal tracers showed significant concentration changes due to BWE, and our ability to detect differences between exchanged and unexchanged ballast tanks was greatest under multivariate analysis. An expanded dataset, which includes additional geographic regions, is now needed to test the generality of our results

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.)

Objective and intentional errors on modern geographical maps of Serbia and surroundings

Directory of Open Access Journals (Sweden)

Vemić Mirčeta

2009-01-01

Full Text Available The paper analyses the occurrence and the major causes of objective, as well as intentional errors that can be perceived in maps of Serbia and its surroundings over a period of more than one hundred years, when this branch of cartography has manifested visible growth and results. In this respect, the scope and the character of objective, unintentional errors, mostly due to a lack of proper technique and technology for gathering data, gradually decreased over time. These errors were the object of constant professional scrutiny and scientific research, and were not often repeated as a result. On the other hand, intentional errors, which were registered as being of mass proportions at the beginning of the above-mentioned period, mainly occurred as a result of a speculative approach to map making. Such errors, however, did not decrease, but constantly multiplied in terms of their scope and type. Parallel with the above-mentioned errors, in many maps one can perceive intentional errors committed with a view to clouding or distorting the real picture of the mapped phenomena, for the purpose of propaganda, manipulation and various misrepresentations in connection with the turbulent geopolitical events in Serbia and its surroundings over the past thirty years. These errors have rarely been discussed and written about within the scientific community, even though there have been frequent reactions in the press and in other media. This paper lays special emphasis on such intentional errors, which cause a lot of damage to the modern cartography of Serbia, in scientific, social, educational and cultural terms, as well as practical and economic terms, and in terms of use.

Monitoring and reporting of preanalytical errors in laboratory medicine: the UK situation.

Science.gov (United States)

Cornes, Michael P; Atherton, Jennifer; Pourmahram, Ghazaleh; Borthwick, Hazel; Kyle, Betty; West, Jamie; Costelloe, Seán J

2016-03-01

Most errors in the clinical laboratory occur in the preanalytical phase. This study aimed to comprehensively describe the prevalence and nature of preanalytical quality monitoring practices in UK clinical laboratories. A survey was sent on behalf of the Association for Clinical Biochemistry and Laboratory Medicine Preanalytical Working Group (ACB-WG-PA) to all heads of department of clinical laboratories in the UK. The survey captured data on the analytical platform and Laboratory Information Management System in use; which preanalytical errors were recorded and how they were classified and gauged interest in an external quality assurance scheme for preanalytical errors. Of the 157 laboratories asked to participate, responses were received from 104 (66.2%). Laboratory error rates were recorded per number of specimens, rather than per number of requests in 51% of respondents. Aside from serum indices for haemolysis, icterus and lipaemia, which were measured in 80% of laboratories, the most common errors recorded were booking-in errors (70.1%) and sample mislabelling (56.9%) in laboratories who record preanalytical errors. Of the laboratories surveyed, 95.9% expressed an interest in guidance on recording preanalytical error and 91.8% expressed interest in an external quality assurance scheme. This survey observes a wide variation in the definition, repertoire and collection methods for preanalytical errors in the UK. Data indicate there is a lot of interest in improving preanalytical data collection. The ACB-WG-PA aims to produce guidance and support for laboratories to standardize preanalytical data collection and to help establish and validate an external quality assurance scheme for interlaboratory comparison. © The Author(s) 2015.

Patterns of Post-Stroke Brain Damage that Predict Speech Production Errors in Apraxia of Speech and Aphasia Dissociate

Science.gov (United States)

Basilakos, Alexandra; Rorden, Chris; Bonilha, Leonardo; Moser, Dana; Fridriksson, Julius

2015-01-01

Background and Purpose Acquired apraxia of speech (AOS) is a motor speech disorder caused by brain damage. AOS often co-occurs with aphasia, a language disorder in which patients may also demonstrate speech production errors. The overlap of speech production deficits in both disorders has raised questions regarding if AOS emerges from a unique pattern of brain damage or as a sub-element of the aphasic syndrome. The purpose of this study was to determine whether speech production errors in AOS and aphasia are associated with distinctive patterns of brain injury. Methods Forty-three patients with history of a single left-hemisphere stroke underwent comprehensive speech and language testing. The Apraxia of Speech Rating Scale was used to rate speech errors specific to AOS versus speech errors that can also be associated with AOS and/or aphasia. Localized brain damage was identified using structural MRI, and voxel-based lesion-impairment mapping was used to evaluate the relationship between speech errors specific to AOS, those that can occur in AOS and/or aphasia, and brain damage. Results The pattern of brain damage associated with AOS was most strongly associated with damage to cortical motor regions, with additional involvement of somatosensory areas. Speech production deficits that could be attributed to AOS and/or aphasia were associated with damage to the temporal lobe and the inferior pre-central frontal regions. Conclusion AOS likely occurs in conjunction with aphasia due to the proximity of the brain areas supporting speech and language, but the neurobiological substrate for each disorder differs. PMID:25908457

Evaluating the Frequency of Errors in Preparation and Administration of Intravenous Medications in the Intensive Care Unit of Shahid-Sadoughi Hospital in Yazd

Directory of Open Access Journals (Sweden)

SeyedMojtaba Sohrevardi

2015-10-01

Full Text Available Background: In most Iranian hospitals, the nurses in the wards prepare intravenous (IV drugs and unfortunately pharmacists are not involved in this process. The severity of the patients in Intensive Care Unit (ICU heightens the risk of errors. More over the frequency of using IV drugs in this unit is high, so we decided to determine the frequency and types of errors, which occur in the preparation and administration of commonly, used IV medications in an ICU.Method: A prospective cross sectional study was performed from November 2013 to August 2014, in the intensive care unit in Shahid-Sadoughi hospital in Yazd. Medication errors occurred in the process of preparation and administration of IV drugs, were recorded by a pharmacy student and were evaluated by direct observation, according to the method established by Barker and McConnell.Results: A total number of 843 intravenous doses were evaluated. The most common type of error (34.26% was the injection of IV doses faster than the recommended rate followed by preparation (15.69%, administration (9.23% and compatibility with doctor’s order (6.24%. Amikacin was the most common drug involved in errors (41.67%. Most of errors were occurred at afternoon (8 p.m, 28.36%.Conclusion: According to our study the rate of errors in preparation and administration of IV drugs was high in this ICU. Employing more nurses, using developed medical instruments and clinical pharmacists can help to decrease these errors and improve the quality of patient care.

Speech Abilities in Preschool Children with Speech Sound Disorder with and without Co-Occurring Language Impairment

Science.gov (United States)

Macrae, Toby; Tyler, Ann A.

2014-01-01

Purpose: The authors compared preschool children with co-occurring speech sound disorder (SSD) and language impairment (LI) to children with SSD only in their numbers and types of speech sound errors. Method: In this post hoc quasi-experimental study, independent samples t tests were used to compare the groups in the standard score from different…

Human error mode identification for NPP main control room operations using soft controls

International Nuclear Information System (INIS)

Lee, Seung Jun; Kim, Jaewhan; Jang, Seung-Cheol

2011-01-01

The operation environment of main control rooms (MCRs) in modern nuclear power plants (NPPs) has considerably changed over the years. Advanced MCRs, which have been designed by adapting digital and computer technologies, have simpler interfaces using large display panels, computerized displays, soft controls, computerized procedure systems, and so on. The actions for the NPP operations are performed using soft controls in advanced MCRs. Soft controls have different features from conventional controls. Operators need to navigate the screens to find indicators and controls and manipulate controls using a mouse, touch screens, and so on. Due to these different interfaces, different human errors should be considered in the human reliability analysis (HRA) for advanced MCRs. In this work, human errors that could occur during operation executions using soft controls were analyzed. This work classified the human errors in soft controls into six types, and the reasons that affect the occurrence of the human errors were also analyzed. (author)

Evaluation of a Web-based Error Reporting Surveillance System in a Large Iranian Hospital.

Science.gov (United States)

Askarian, Mehrdad; Ghoreishi, Mahboobeh; Akbari Haghighinejad, Hourvash; Palenik, Charles John; Ghodsi, Maryam

2017-08-01

Proper reporting of medical errors helps healthcare providers learn from adverse incidents and improve patient safety. A well-designed and functioning confidential reporting system is an essential component to this process. There are many error reporting methods; however, web-based systems are often preferred because they can provide; comprehensive and more easily analyzed information. This study addresses the use of a web-based error reporting system. This interventional study involved the application of an in-house designed "voluntary web-based medical error reporting system." The system has been used since July 2014 in Nemazee Hospital, Shiraz University of Medical Sciences. The rate and severity of errors reported during the year prior and a year after system launch were compared. The slope of the error report trend line was steep during the first 12 months (B = 105.727, P = 0.00). However, it slowed following launch of the web-based reporting system and was no longer statistically significant (B = 15.27, P = 0.81) by the end of the second year. Most recorded errors were no-harm laboratory types and were due to inattention. Usually, they were reported by nurses and other permanent employees. Most reported errors occurred during morning shifts. Using a standardized web-based error reporting system can be beneficial. This study reports on the performance of an in-house designed reporting system, which appeared to properly detect and analyze medical errors. The system also generated follow-up reports in a timely and accurate manner. Detection of near-miss errors could play a significant role in identifying areas of system defects.

An analysis of error patterns in children's backward digit recall in noise

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Osman, Homira; Sullivan, Jessica R.

2015-01-01

The purpose of the study was to determine whether perceptual masking or cognitive processing accounts for a decline in working memory performance in the presence of competing speech. The types and patterns of errors made on the backward digit span in quiet and multitalker babble at -5 dB signal-to-noise ratio (SNR) were analyzed. The errors were classified into two categories: item (if digits that were not presented in a list were repeated) and order (if correct digits were repeated but in an incorrect order). Fifty five children with normal hearing were included. All the children were aged between 7 years and 10 years. Repeated measures of analysis of variance (RM-ANOVA) revealed the main effects for error type and digit span length. In terms of listening condition interaction it was found that the order errors occurred more frequently than item errors in the degraded listening condition compared to quiet. In addition, children had more difficulty recalling the correct order of intermediate items, supporting strong primacy and recency effects. Decline in children's working memory performance was not primarily related to perceptual difficulties alone. The majority of errors was related to the maintenance of sequential order information, which suggests that reduced performance in competing speech may result from increased cognitive processing demands in noise. PMID:26168949

Diagnostic errors in interpretation of pediatric musculoskeletal radiographs at common injury sites

International Nuclear Information System (INIS)

Bisset, George S.; Crowe, James

2014-01-01

Extremity pain represents one of the most common reasons for obtaining conventional radiographs in childhood. Despite the frequency of these examinations little is known about the incidence of diagnostic errors by interpreting pediatric radiologists. The purpose of this study was to develop a standard error rate of pediatric radiologists by double-reading of extremity radiographs (elbow, wrists, knees and ankles) in children presenting with a history of trauma or pain. During a 6-month period all major extremity radiographs (excluding digits) obtained at a large pediatric referral hospital for evaluation of pain or trauma were reviewed by two senior pediatric radiologists and compared to the official interpretation. All radiographs were interpreted initially by a board-certified pediatric radiologist with a Certificate of Added Qualification (CAQ). We reviewed 3,865 radiographic series in children and young adults 2-20 years of age. We tabulated misses and overcalls. We did not assess the clinical significance of the errors. There were 61 miss errors and 44 overcalls in 1,235 abnormal cases and 2,630 normal cases, for a 1.6% miss rate and a 1.1% overcall rate. Misses and overcalls were most common in the ankle. Interpretive errors by pediatric radiologists reviewing certain musculoskeletal radiographs are relatively infrequent. Diagnostic errors in the form of a miss or overcall occurred in 2.7% of the radiographs. (orig.)

Detecting Role Errors in the Gene Hierarchy of the NCI Thesaurus

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Yehoshua Perl

2008-01-01

Full Text Available Gene terminologies are playing an increasingly important role in the ever-growing field of genomic research. While errors in large, complex terminologies are inevitable, gene terminologies are even more susceptible to them due to the rapid growth of genomic knowledge and the nature of its discovery. It is therefore very important to establish quality- assurance protocols for such genomic-knowledge repositories. Different kinds of terminologies oftentimes require auditing methodologies adapted to their particular structures. In light of this, an auditing methodology tailored to the characteristics of the NCI Thesaurus’s (NCIT’s Gene hierarchy is presented. The Gene hierarchy is of particular interest to the NCIT’s designers due to the primary role of genomics in current cancer research. This multiphase methodology focuses on detecting role-errors, such as missing roles or roles with incorrect or incomplete target structures, occurring within that hierarchy. The methodology is based on two kinds of abstraction networks, called taxonomies, that highlight the role distribution among concepts within the IS-A (subsumption hierarchy. These abstract views tend to highlight portions of the hierarchy having a higher concentration of errors. The errors found during an application of the methodology

Laboratory errors and patient safety.

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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

Specialist Physicians' Attitudes and Practice Patterns Regarding Disclosure of Pre-referral Medical Errors.

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Dossett, Lesly A; Kauffmann, Rondi M; Lee, Jay S; Singh, Harkamal; Lee, M Catherine; Morris, Arden M; Jagsi, Reshma; Quinn, Gwendolyn P; Dimick, Justin B

2018-06-01

Our objective was to determine specialist physicians' attitudes and practices regarding disclosure of pre-referral errors. Physicians are encouraged to disclose their own errors to patients. However, no clear professional norms exist regarding disclosure when physicians discover errors in diagnosis or treatment that occurred at other institutions before referral. We conducted semistructured interviews of cancer specialists from 2 National Cancer Institute-designated Cancer Centers. We purposively sampled specialists by discipline, sex, and experience-level who self-described a >50% reliance on external referrals (n = 30). Thematic analysis of verbatim interview transcripts was performed to determine physician attitudes regarding disclosure of pre-referral medical errors; whether and how physicians disclose these errors; and barriers to providing full disclosure. Participants described their experiences identifying different types of pre-referral errors including errors of diagnosis, staging and treatment resulting in adverse events ranging from decreased quality of life to premature death. The majority of specialists expressed the belief that disclosure provided no benefit to patients, and might unnecessarily add to their anxiety about their diagnoses or prognoses. Specialists had varying practices of disclosure including none, non-verbal, partial, event-dependent, and full disclosure. They identified a number of barriers to disclosure, including medicolegal implications and damage to referral relationships, the profession's reputation, and to patient-physician relationships. Specialist physicians identify pre-referral errors but struggle with whether and how to provide disclosure, even when clinical circumstances force disclosure. Education- or communication-based interventions that overcome barriers to disclosing pre-referral errors warrant development.

Association between Refractive Errors and Ocular Biometry in Iranian Adults

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Hashemi, Hassan; Khabazkhoob, Mehdi; Emamian, Mohammad Hassan; Shariati, Mohammad; Miraftab, Mohammad; Yekta, Abbasali; Ostadimoghaddam, Hadi; Fotouhi, Akbar

2015-01-01

Purpose: To investigate the association between ocular biometrics such as axial length (AL), anterior chamber depth (ACD), lens thickness (LT), vitreous chamber depth (VCD) and corneal power (CP) with different refractive errors. Methods: In a cross-sectional study on the 40 to 64-year-old population of Shahroud, random cluster sampling was performed. Ocular biometrics were measured using the Allegro Biograph (WaveLight AG, Erlangen, Germany) for all participants. Refractive errors were determined using cycloplegic refraction. Results: In the first model, the strongest correlations were found between spherical equivalent with axial length and corneal power. Spherical equivalent was strongly correlated with axial length in high myopic and high hyperopic cases, and with corneal power in high hyperopic cases; 69.5% of variability in spherical equivalent was attributed to changes in these variables. In the second model, the correlations between vitreous chamber depth and corneal power with spherical equivalent were stronger in myopes than hyperopes, while the correlations between lens thickness and anterior chamber depth with spherical equivalent were stronger in hyperopic cases than myopic ones. In the third model, anterior chamber depth + lens thickness correlated with spherical equivalent only in moderate and severe cases of hyperopia, and this index was not correlated with spherical equivalent in moderate to severe myopia. Conclusion: In individuals aged 40-64 years, corneal power and axial length make the greatest contribution to spherical equivalent in high hyperopia and high myopia. Anterior segment biometric components have a more important role in hyperopia than myopia. PMID:26730304

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...

Errors in nonword repetition: bridging short- and long-term memory

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F.H. Santos

2006-03-01

Full Text Available According to the working memory model, the phonological loop is the component of working memory specialized in processing and manipulating limited amounts of speech-based information. The Children's Test of Nonword Repetition (CNRep is a suitable measure of phonological short-term memory for English-speaking children, which was validated by the Brazilian Children's Test of Pseudoword Repetition (BCPR as a Portuguese-language version. The objectives of the present study were: i to investigate developmental aspects of the phonological memory processing by error analysis in the nonword repetition task, and ii to examine phoneme (substitution, omission and addition and order (migration errors made in the BCPR by 180 normal Brazilian children of both sexes aged 4-10, from preschool to 4th grade. The dominant error was substitution [F(3,525 = 180.47; P < 0.0001]. The performance was age-related [F(4,175 = 14.53; P < 0.0001]. The length effect, i.e., more errors in long than in short items, was observed [F(3,519 = 108.36; P < 0.0001]. In 5-syllable pseudowords, errors occurred mainly in the middle of the stimuli, before the syllabic stress [F(4,16 = 6.03; P = 0.003]; substitutions appeared more at the end of the stimuli, after the stress [F(12,48 = 2.27; P = 0.02]. In conclusion, the BCPR error analysis supports the idea that phonological loop capacity is relatively constant during development, although school learning increases the efficiency of this system. Moreover, there are indications that long-term memory contributes to holding memory trace. The findings were discussed in terms of distinctiveness, clustering and redintegration hypotheses.

GPS/DR Error Estimation for Autonomous Vehicle Localization

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Byung-Hyun Lee

2015-08-01

Full Text Available Autonomous vehicles require highly reliable navigation capabilities. For example, a lane-following method cannot be applied in an intersection without lanes, and since typical lane detection is performed using a straight-line model, errors can occur when the lateral distance is estimated in curved sections due to a model mismatch. Therefore, this paper proposes a localization method that uses GPS/DR error estimation based on a lane detection method with curved lane models, stop line detection, and curve matching in order to improve the performance during waypoint following procedures. The advantage of using the proposed method is that position information can be provided for autonomous driving through intersections, in sections with sharp curves, and in curved sections following a straight section. The proposed method was applied in autonomous vehicles at an experimental site to evaluate its performance, and the results indicate that the positioning achieved accuracy at the sub-meter level.

Common positioning errors in panoramic radiography: A review

International Nuclear Information System (INIS)

Randon, Rafael Henrique Nunes; Pereira, Yamba Carla Lara; Nascimento, Glauce Crivelaro do

2014-01-01

Professionals performing radiographic examinations are responsible for maintaining optimal image quality for accurate diagnoses. These professionals must competently execute techniques such as film manipulation and processing to minimize patient exposure to radiation. Improper performance by the professional and/or patient may result in a radiographic image of unsatisfactory quality that can also lead to a misdiagnosis and the development of an inadequate treatment plan. Currently, the most commonly performed extraoral examination is panoramic radiography. The invention of panoramic radiography has resulted in improvements in image quality with decreased exposure to radiation and at a low cost. However, this technique requires careful, accurate positioning of the patient's teeth and surrounding maxillofacial bone structure within the focal trough. Therefore, we reviewed the literature for the most common types of positioning errors in panoramic radiography to suggest the correct techniques. We would also discuss how to determine if the most common positioning errors occurred in panoramic radiography, such as in the positioning of the patient's head, tongue, chin, or body.

Wechsler Adult Intelligence Scale-Revised Block Design broken configuration errors in nonpenetrating traumatic brain injury.

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Wilde, M C; Boake, C; Sherer, M

2000-01-01

Final broken configuration errors on the Wechsler Adult Intelligence Scale-Revised (WAIS-R; Wechsler, 1981) Block Design subtest were examined in 50 moderate and severe nonpenetrating traumatically brain injured adults. Patients were divided into left (n = 15) and right hemisphere (n = 19) groups based on a history of unilateral craniotomy for treatment of an intracranial lesion and were compared to a group with diffuse or negative brain CT scan findings and no history of neurosurgery (n = 16). The percentage of final broken configuration errors was related to injury severity, Benton Visual Form Discrimination Test (VFD; Benton, Hamsher, Varney, & Spreen, 1983) total score and the number of VFD rotation and peripheral errors. The percentage of final broken configuration errors was higher in the patients with right craniotomies than in the left or no craniotomy groups, which did not differ. Broken configuration errors did not occur more frequently on designs without an embedded grid pattern. Right craniotomy patients did not show a greater percentage of broken configuration errors on nongrid designs as compared to grid designs.

Estimating misclassification error: a closer look at cross-validation based methods

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Ounpraseuth Songthip

2012-11-01

Full Text Available Abstract Background To estimate a classifier’s error in predicting future observations, bootstrap methods have been proposed as reduced-variation alternatives to traditional cross-validation (CV methods based on sampling without replacement. Monte Carlo (MC simulation studies aimed at estimating the true misclassification error conditional on the training set are commonly used to compare CV methods. We conducted an MC simulation study to compare a new method of bootstrap CV (BCV to k-fold CV for estimating clasification error. Findings For the low-dimensional conditions simulated, the modest positive bias of k-fold CV contrasted sharply with the substantial negative bias of the new BCV method. This behavior was corroborated using a real-world dataset of prognostic gene-expression profiles in breast cancer patients. Our simulation results demonstrate some extreme characteristics of variance and bias that can occur due to a fault in the design of CV exercises aimed at estimating the true conditional error of a classifier, and that appear not to have been fully appreciated in previous studies. Although CV is a sound practice for estimating a classifier’s generalization error, using CV to estimate the fixed misclassification error of a trained classifier conditional on the training set is problematic. While MC simulation of this estimation exercise can correctly represent the average bias of a classifier, it will overstate the between-run variance of the bias. Conclusions We recommend k-fold CV over the new BCV method for estimating a classifier’s generalization error. The extreme negative bias of BCV is too high a price to pay for its reduced variance.

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

Sleep-Dependent Reductions in Reality-Monitoring Errors Arise from More Conservative Decision Criteria

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Westerberg, Carmen E.; Hawkins, Christopher A.; Rendon, Lauren

2018-01-01

Reality-monitoring errors occur when internally generated thoughts are remembered as external occurrences. We hypothesized that sleep-dependent memory consolidation could reduce them by strengthening connections between items and their contexts during an afternoon nap. Participants viewed words and imagined their referents. Pictures of the…

Patient identification error among prostate needle core biopsy specimens--are we ready for a DNA time-out?

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Suba, Eric J; Pfeifer, John D; Raab, Stephen S

2007-10-01

Patient identification errors in surgical pathology often involve switches of prostate or breast needle core biopsy specimens among patients. We assessed strategies for decreasing the occurrence of these uncommon and yet potentially catastrophic events. Root cause analyses were performed following 3 cases of patient identification error involving prostate needle core biopsy specimens. Patient identification errors in surgical pathology result from slips and lapses of automatic human action that may occur at numerous steps during pre-laboratory, laboratory and post-laboratory work flow processes. Patient identification errors among prostate needle biopsies may be difficult to entirely prevent through the optimization of work flow processes. A DNA time-out, whereby DNA polymorphic microsatellite analysis is used to confirm patient identification before radiation therapy or radical surgery, may eliminate patient identification errors among needle biopsies.

Scaling prediction errors to reward variability benefits error-driven learning in humans.

Science.gov (United States)

Diederen, Kelly M J; Schultz, Wolfram

2015-09-01

Effective error-driven learning requires individuals to adapt learning to environmental reward variability. The adaptive mechanism may involve decays in learning rate across subsequent trials, as shown previously, and rescaling of reward prediction errors. The present study investigated the influence of prediction error scaling and, in particular, the consequences for learning performance. Participants explicitly predicted reward magnitudes that were drawn from different probability distributions with specific standard deviations. By fitting the data with reinforcement learning models, we found scaling of prediction errors, in addition to the learning rate decay shown previously. Importantly, the prediction error scaling was closely related to learning performance, defined as accuracy in predicting the mean of reward distributions, across individual participants. In addition, participants who scaled prediction errors relative to standard deviation also presented with more similar performance for different standard deviations, indicating that increases in standard deviation did not substantially decrease "adapters'" accuracy in predicting the means of reward distributions. However, exaggerated scaling beyond the standard deviation resulted in impaired performance. Thus efficient adaptation makes learning more robust to changing variability. Copyright © 2015 the American Physiological Society.

Frequency of Burnout, Sleepiness and Depression in Emergency Medicine Residents with Medical Errors in the Emergency Department

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Alireza Aala

2014-07-01

Full Text Available Aims: Medical error is a great concern of the patients and physicians. It usually occurs due to physicians’ exhaustion, distress and fatigue. In this study, we aimed to evaluate frequency of distress and fatigue among emergency medicine residents reporting a medical error. Materials and Methods: The study population consisted of emergency medicine residents who completed an emailed questionnaire including self-assessment of medical errors, the Epworth Sleepiness Scale (ESS score, the Maslach Burnout Inventory, and PRIME-MD validated depression screening tool.   Results: In this survey, 100 medical errors were reported including diagnostic errors in 53, therapeutic errors in 24 and following errors in 23 subjects. Most errors were reported by males and third year residents. Residents had no signs of depression, but all had some degrees of sleepiness and burnout. There were significant differences between errors subtypes and age, residency year, depression, sleepiness and burnout scores (p<0.0001.   Conclusion: In conclusion, residents committing a medical error usually experience burnout and have some grades of sleepiness that makes them less motivated increasing the probability of medical errors. However, as none of the residents had depression, it could be concluded that depression has no significant role in medical error occurrence and perhaps it is a possible consequence of medical error.    Keywords: Residents; Medical error; Burnout; Sleepiness; Depression

Errors in dentistry: a call for apology.

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Schwartz, Barry

2005-01-01

Bad outcomes occur in dentistry and sometimes these are the results of dental errors. In both cases, this essay will argue that apologies are very important in maintaining a relationship with the patient that is based on trust and mutual respect. Nevertheless, apologies are often not forthcoming in dentistry for a number of reasons that deserve careful examination. In particular, the dentist's fear that an apology will increase the risk of legal harm will be critiqued. Ethical and psychological reasons for making an apology will be discussed, and strategies to assist clinicians in making an apology will be offered.

Comparing Absolute Error with Squared Error for Evaluating Empirical Models of Continuous Variables: Compositions, Implications, and Consequences

Science.gov (United States)

Gao, J.

2014-12-01

Reducing modeling error is often a major concern of empirical geophysical models. However, modeling errors can be defined in different ways: When the response variable is continuous, the most commonly used metrics are squared (SQ) and absolute (ABS) errors. For most applications, ABS error is the more natural, but SQ error is mathematically more tractable, so is often used as a substitute with little scientific justification. Existing literature has not thoroughly investigated the implications of using SQ error in place of ABS error, especially not geospatially. This study compares the two metrics through the lens of bias-variance decomposition (BVD). BVD breaks down the expected modeling error of each model evaluation point into bias (systematic error), variance (model sensitivity), and noise (observation instability). It offers a way to probe the composition of various error metrics. I analytically derived the BVD of ABS error and compared it with the well-known SQ error BVD, and found that not only the two metrics measure the characteristics of the probability distributions of modeling errors differently, but also the effects of these characteristics on the overall expected error are different. Most notably, under SQ error all bias, variance, and noise increase expected error, while under ABS error certain parts of the error components reduce expected error. Since manipulating these subtractive terms is a legitimate way to reduce expected modeling error, SQ error can never capture the complete story embedded in ABS error. I then empirically compared the two metrics with a supervised remote sensing model for mapping surface imperviousness. Pair-wise spatially-explicit comparison for each error component showed that SQ error overstates all error components in comparison to ABS error, especially variance-related terms. Hence, substituting ABS error with SQ error makes model performance appear worse than it actually is, and the analyst would more likely accept a

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

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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.

Heuristic errors in clinical reasoning.

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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.

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

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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.

A chance to avoid mistakes human error

International Nuclear Information System (INIS)

Amaro, Pablo; Obeso, Eduardo; Gomez, Ruben

2010-01-01

Trying to give an answer to the lack of public information in the industry, in relationship with the different tools that are managed in the nuclear industry for minimizing the human error, a group of workers from different sections of the St. Maria de Garona NPP (Quality Assurance/ Organization and Human Factors) decided to embark on a challenging and exciting project: 'Write a book collecting all the knowledge accumulated during their daily activities, very often during lecture time of external information received from different organizations within the nuclear industry (INPO, WANO...), but also visiting different NPP's, maintaining meetings and participating in training courses related de Human and Organizational Factors'. Main objective of the book is presenting to the industry in general, the different tools that are used and fostered in the nuclear industry, in a practical way. In this way, the assimilation and implementation in others industries could be possible and achievable in and efficient context. One year of work, and our project is a reality. We have presented and abstract during the last Spanish Nuclear Society meeting in Sevilla, last October...and the best, the book is into the market for everybody in web-site: www.bubok.com. The book is structured in the following areas: 'Errare humanum est': Trying to present what is the human error to the reader, its origin and the different barriers. The message is that the reader see the error like something continuously present in our lives... even more frequently than we think. Studying its origin can be established aimed at barriers to avoid or at least minimize it. 'Error's bitter face': Shows the possible consequences of human errors. What better that presenting real experiences that have occurred in the industry. In the book, accidents in the nuclear industry, like Tree Mile Island NPP, Chernobyl NPP, and incidents like Davis Besse NPP in the past, helps to the reader to make a reflection about the

Awareness of technology-induced errors and processes for identifying and preventing such errors.

Science.gov (United States)

Bellwood, Paule; Borycki, Elizabeth M; Kushniruk, Andre W

2015-01-01

There is a need to determine if organizations working with health information technology are aware of technology-induced errors and how they are addressing and preventing them. The purpose of this study was to: a) determine the degree of technology-induced error awareness in various Canadian healthcare organizations, and b) identify those processes and procedures that are currently in place to help address, manage, and prevent technology-induced errors. We identified a lack of technology-induced error awareness among participants. Participants identified there was a lack of well-defined procedures in place for reporting technology-induced errors, addressing them when they arise, and preventing them.

Explaining quantitative variation in the rate of Optional Infinitive errors across languages: a comparison of MOSAIC and the Variational Learning Model.

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Freudenthal, Daniel; Pine, Julian; Gobet, Fernand

2010-06-01

In this study, we use corpus analysis and computational modelling techniques to compare two recent accounts of the OI stage: Legate & Yang's (2007) Variational Learning Model and Freudenthal, Pine & Gobet's (2006) Model of Syntax Acquisition in Children. We first assess the extent to which each of these accounts can explain the level of OI errors across five different languages (English, Dutch, German, French and Spanish). We then differentiate between the two accounts by testing their predictions about the relation between children's OI errors and the distribution of infinitival verb forms in the input language. We conclude that, although both accounts fit the cross-linguistic patterning of OI errors reasonably well, only MOSAIC is able to explain why verbs that occur more frequently as infinitives than as finite verb forms in the input also occur more frequently as OI errors than as correct finite verb forms in the children's output.

Error Analysis Of Students Working About Word Problem Of Linear Program With NEA Procedure

Science.gov (United States)

Santoso, D. A.; Farid, A.; Ulum, B.

2017-06-01

Evaluation and assessment is an important part of learning. In evaluation process of learning, written test is still commonly used. However, the tests usually do not following-up by further evaluation. The process only up to grading stage not to evaluate the process and errors which done by students. Whereas if the student has a pattern error and process error, actions taken can be more focused on the fault and why is that happen. NEA procedure provides a way for educators to evaluate student progress more comprehensively. In this study, students’ mistakes in working on some word problem about linear programming have been analyzed. As a result, mistakes are often made students exist in the modeling phase (transformation) and process skills (process skill) with the overall percentage distribution respectively 20% and 15%. According to the observations, these errors occur most commonly due to lack of precision of students in modeling and in hastiness calculation. Error analysis with students on this matter, it is expected educators can determine or use the right way to solve it in the next lesson.

Incidence and Severity of Prescribing Errors in Parenteral Nutrition for Pediatric Inpatients at a Neonatal and Pediatric Intensive Care Unit

Directory of Open Access Journals (Sweden)

Theresa Hermanspann

2017-06-01

Full Text Available ObjectivesPediatric inpatients are particularly vulnerable to medication errors (MEs, especially in highly individualized preparations like parenteral nutrition (PN. Aside from prescribing via a computerized physician order entry system (CPOE, we evaluated the effect of cross-checking by a clinical pharmacist to prevent harm from PN order errors in a neonatal and pediatric intensive care unit (NICU/PICU.MethodsThe incidence of prescribing errors in PN in a tertiary level NICU/PICU was surveyed prospectively between March 2012 and July 2013 (n = 3,012 orders. A pharmacist cross-checked all PN orders prior to preparation. Errors were assigned to seven different error-type categories. Three independent experts from different academic tertiary level NICUs judged the severity of each error according to the National Coordinating Council for Medication Error Reporting and Prevention (NCC MERP Index (categories A–I.ResultsThe error rate was 3.9% for all 3,012 orders (118 prescribing errors in 111 orders. 77 (6.0%, 1,277 orders errors occurred in the category concentration range, all concerning a relative overdose of calcium gluconate for peripheral infusion. The majority of all events (60% were assigned to categories C and D (without major harmful consequences while 28% could not be assigned due to missing majority decision. Potential harmful consequences requiring interventions (category E could have occurred in 12% of assessments.ConclusionNext to systematic application of clinical guidelines and prescribing via CPOE, order review by a clinical pharmacist is still required to effectively reduce MEs and thus to prevent minor and major adverse drug events with the aim to enhance medication safety.

Assessment of residual error for online cone-beam CT-guided treatment of prostate cancer patients

International Nuclear Information System (INIS)

Letourneau, Daniel; Martinez, Alvaro A.; Lockman, David; Yan Di; Vargas, Carlos; Ivaldi, Giovanni; Wong, John

2005-01-01

±0.9 mm. The average difference between the setup corrections obtained with coil and soft-tissue registration was greatest in the superoinferior direction and was equal to -1.1 ± 2.9 mm. Conclusion: On the basis of the residual setup error measurements, the margin required after online CBCT correction for the patients enrolled in this study would be approximatively 3 mm and is considered to be a lower limit owing to the small intrafraction motion observed. The discrepancy between setup corrections derived from registration using coils or soft tissue can be due in part to the lack of complete three-dimensional information with the coils or to the difficulty in prostate delineation and requires further study

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.)

DOI resolution measurement and error analysis with LYSO and APDs

International Nuclear Information System (INIS)

Lee, Chae-hun; Cho, Gyuseong

2008-01-01

Spatial resolution degradation in PET occurs at the edge of Field Of View (FOV) due to parallax error. To improve spatial resolution at the edge of FOV, Depth-Of-Interaction (DOI) PET has been investigated and several methods for DOI positioning were proposed. In this paper, a DOI-PET detector module using two 8x4 array avalanche photodiodes (APDs) (Hamamatsu, S8550) and a 2 cm long LYSO scintillation crystal was proposed and its DOI characteristics were investigated experimentally. In order to measure DOI positions, signals from two APDs were compared. Energy resolution was obtained from the sum of two APDs' signals and DOI positioning error was calculated. Finally, an optimum DOI step size in a 2 cm long LYSO were suggested to help to design a DOI-PET

Modern Palliative Radiation Treatment: Do Complexity and Workload Contribute to Medical Errors?

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D' Souza, Neil, E-mail: neil.dsouza@sunnybrook.ca [Department of Radiation Oncology, University of Toronto, Toronto, Ontario (Canada); Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario (Canada); Holden, Lori [Department of Radiation Oncology, University of Toronto, Toronto, Ontario (Canada); Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario (Canada); Robson, Sheila [Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario (Canada); Mah, Kathy; Di Prospero, Lisa; Wong, C. Shun; Chow, Edward; Spayne, Jacqueline [Department of Radiation Oncology, University of Toronto, Toronto, Ontario (Canada); Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario (Canada)

2012-09-01

Purpose: To examine whether treatment workload and complexity associated with palliative radiation therapy contribute to medical errors. Methods and Materials: In the setting of a large academic health sciences center, patient scheduling and record and verification systems were used to identify patients starting radiation therapy. All records of radiation treatment courses delivered during a 3-month period were retrieved and divided into radical and palliative intent. 'Same day consultation, planning and treatment' was used as a proxy for workload and 'previous treatment' and 'multiple sites' as surrogates for complexity. In addition, all planning and treatment discrepancies (errors and 'near-misses') recorded during the same time frame were reviewed and analyzed. Results: There were 365 new patients treated with 485 courses of palliative radiation therapy. Of those patients, 128 (35%) were same-day consultation, simulation, and treatment patients; 166 (45%) patients had previous treatment; and 94 (26%) patients had treatment to multiple sites. Four near-misses and 4 errors occurred during the audit period, giving an error per course rate of 0.82%. In comparison, there were 10 near-misses and 5 errors associated with 1100 courses of radical treatment during the audit period. This translated into an error rate of 0.45% per course. An association was found between workload and complexity and increased palliative therapy error rates. Conclusions: Increased complexity and workload may have an impact on palliative radiation treatment discrepancies. This information may help guide the necessary recommendations for process improvement for patients who require palliative radiation therapy.

Controlling errors in unidosis carts

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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%.

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)

Proposal of procedures to prevent errors in radiotherapy based in learned lessons of accidental expositions

International Nuclear Information System (INIS)

Bueno, Giselle Oliveira Vieira

2007-01-01

In order to consider some procedures to prevent errors in radiotherapy based in learned lessons of accidental expositions and in accordance with information contained in international reports elaborated by International Atomic Energy Agency (IAEA) and of the data base availability by the European group Radiation Oncology Safety Information System (ROSIS) on the events, a research of the occurred errors was performed. For the evaluation of the incidents a data base based in the ROSIS and added plus a parameter was created 'type of error'. All the stored data make possible the evaluation of the 839 incidents in terms of frequency of the type of error, the process of detention, the number of reached patients and the degree of severity. Of the 50 types of found errors, the type of error more frequently was 'incorrect treatment coordinate', confirmed with the data of literature and representing 28,96 por cent of the total of the incidents. The results showed 44,44 por cent are discovered at the moment of the treatment and that the process of verification of the fiche or clinical revision of the patient is a verification more occurred insurance and in 43,33 por cent of the searched events. The results indicated that more than 50 por cent of the incidents the severity degree are void and approximately 62 por cent a patient are affected during the accomplishment of the radiotherapy. This work showed that to analyze the data base according to methodology proposal for Klein et al.; for Reason, and Dunscombe et al. is interesting to insert more characteristic detailed in the data base such as: the number of fractions for affected patient, number of fields of treatment for fraction that was affected, shunting line of the prescribed dose and shunting line of the volume prescribed in all the registered in cadastral map events. Some causes exist that can lead the errors when patient they are submitted to the radiotherapy. Some measures can be taken so that these errors do not

First error bounds for the porous media approximation of the Poisson-Nernst-Planck equations

Energy Technology Data Exchange (ETDEWEB)

Schmuck, Markus [Imperial College, London (United Kingdom). Depts. of Chemical Engineering and Mathematics

2012-04-15

We study the well-accepted Poisson-Nernst-Planck equations modeling transport of charged particles. By formal multiscale expansions we rederive the porous media formulation obtained by two-scale convergence in [42, 43]. The main result is the derivation of the error which occurs after replacing a highly heterogeneous solid-electrolyte composite by a homogeneous one. The derived estimates show that the approximation errors for both, the ion densities quantified in L{sup 2}-norm and the electric potential measured in H{sup 1}-norm, are of order O(s{sup 1/2}). (orig.)

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