Influence of Ephemeris Error on GPS Single Point Positioning Accuracy

Science.gov (United States)

Lihua, Ma; Wang, Meng

2013-09-01

The Global Positioning System (GPS) user makes use of the navigation message transmitted from GPS satellites to achieve its location. Because the receiver uses the satellite's location in position calculations, an ephemeris error, a difference between the expected and actual orbital position of a GPS satellite, reduces user accuracy. The influence extent is decided by the precision of broadcast ephemeris from the control station upload. Simulation analysis with the Yuma almanac show that maximum positioning error exists in the case where the ephemeris error is along the line-of-sight (LOS) direction. Meanwhile, the error is dependent on the relationship between the observer and spatial constellation at some time period.

Medical Error Types and Causes Made by Nurses in Turkey

Directory of Open Access Journals (Sweden)

Dilek Kucuk Alemdar

2013-06-01

Full Text Available AIM: This study was carried out as a descriptive study in order to determine types, causes and prevalence of medical errors made by nurses in Turkey. METHOD: Seventy eight (78 nurses who have worked in a randomly selected hospital from five hospitals in Giresun city centre were enrolled in the study. The data was collected by the researchers using the ‘Information Form for Nurses’ and ‘Medical Error Form’. The Medical Error Form consists of 2 parts and 40 items including types and causes of medical errors. Nurses’ socio-demographic variables, medical error types and causes were evaluated using the percentage distribution and mean. RESULTS: The mean age of the nurses was 25.5 years, with a standard deviation 6.03 years. 50% of the nurses graduated health professional high school in the study. 53.8% of the nurses are single, 63.1% worked between 1-5 years, 71.8% day and night shifts and 42.3% in medical clinics. The common types of medical errors were hospital infection rate of 15.4%, diagnostic errors 12.8%, needle or cutting tool injuries and problems related to drug usage which has side effects 10.3%. In the study 38.5% of the nurses reported that they thought the cause of medical error highly was tiredness, 36.4% increased workload and 34.6% long working hours. CONCLUSION: As a result of the present study, nurses mentioned hospital infection, diagnostic errors, needle or cutting tool injuries as the most common medical errors and fatigue, over work load and long working hours as the most common medical error reasons. [TAF Prev Med Bull 2013; 12(3.000: 307-314

Dependence of fluence errors in dynamic IMRT on leaf-positional errors varying with time and leaf number

International Nuclear Information System (INIS)

Zygmanski, Piotr; Kung, Jong H.; Jiang, Steve B.; Chin, Lee

2003-01-01

In d-MLC based IMRT, leaves move along a trajectory that lies within a user-defined tolerance (TOL) about the ideal trajectory specified in a d-MLC sequence file. The MLC controller measures leaf positions multiple times per second and corrects them if they deviate from ideal positions by a value greater than TOL. The magnitude of leaf-positional errors resulting from finite mechanical precision depends on the performance of the MLC motors executing leaf motions and is generally larger if leaves are forced to move at higher speeds. The maximum value of leaf-positional errors can be limited by decreasing TOL. However, due to the inherent time delay in the MLC controller, this may not happen at all times. Furthermore, decreasing the leaf tolerance results in a larger number of beam hold-offs, which, in turn leads, to a longer delivery time and, paradoxically, to higher chances of leaf-positional errors (≤TOL). On the other end, the magnitude of leaf-positional errors depends on the complexity of the fluence map to be delivered. Recently, it has been shown that it is possible to determine the actual distribution of leaf-positional errors either by the imaging of moving MLC apertures with a digital imager or by analysis of a MLC log file saved by a MLC controller. This leads next to an important question: What is the relation between the distribution of leaf-positional errors and fluence errors. In this work, we introduce an analytical method to determine this relation in dynamic IMRT delivery. We model MLC errors as Random-Leaf Positional (RLP) errors described by a truncated normal distribution defined by two characteristic parameters: a standard deviation σ and a cut-off value Δx 0 (Δx 0 ∼TOL). We quantify fluence errors for two cases: (i) Δx 0 >>σ (unrestricted normal distribution) and (ii) Δx 0 0 --limited normal distribution). We show that an average fluence error of an IMRT field is proportional to (i) σ/ALPO and (ii) Δx 0 /ALPO, respectively, where

The error model and experiment of measuring angular position error based on laser collimation

Science.gov (United States)

Cai, Yangyang; Yang, Jing; Li, Jiakun; Feng, Qibo

2018-01-01

Rotary axis is the reference component of rotation motion. Angular position error is the most critical factor which impair the machining precision among the six degree-of-freedom (DOF) geometric errors of rotary axis. In this paper, the measuring method of angular position error of rotary axis based on laser collimation is thoroughly researched, the error model is established and 360 ° full range measurement is realized by using the high precision servo turntable. The change of space attitude of each moving part is described accurately by the 3×3 transformation matrices and the influences of various factors on the measurement results is analyzed in detail. Experiments results show that the measurement method can achieve high measurement accuracy and large measurement range.

SU-E-T-195: Gantry Angle Dependency of MLC Leaf Position Error

Energy Technology Data Exchange (ETDEWEB)

Ju, S; Hong, C; Kim, M; Chung, K; Kim, J; Han, Y; Ahn, S; Chung, S; Shin, E; Shin, J; Kim, H; Kim, D; Choi, D [Department of Radiation Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul (Korea, Republic of)

2014-06-01

Purpose: The aim of this study was to investigate the gantry angle dependency of the multileaf collimator (MLC) leaf position error. Methods: An automatic MLC quality assurance system (AutoMLCQA) was developed to evaluate the gantry angle dependency of the MLC leaf position error using an electronic portal imaging device (EPID). To eliminate the EPID position error due to gantry rotation, we designed a reference maker (RM) that could be inserted into the wedge mount. After setting up the EPID, a reference image was taken of the RM using an open field. Next, an EPID-based picket-fence test (PFT) was performed without the RM. These procedures were repeated at every 45° intervals of the gantry angle. A total of eight reference images and PFT image sets were analyzed using in-house software. The average MLC leaf position error was calculated at five pickets (-10, -5, 0, 5, and 10 cm) in accordance with general PFT guidelines using in-house software. This test was carried out for four linear accelerators. Results: The average MLC leaf position errors were within the set criterion of <1 mm (actual errors ranged from -0.7 to 0.8 mm) for all gantry angles, but significant gantry angle dependency was observed in all machines. The error was smaller at a gantry angle of 0° but increased toward the positive direction with gantry angle increments in the clockwise direction. The error reached a maximum value at a gantry angle of 90° and then gradually decreased until 180°. In the counter-clockwise rotation of the gantry, the same pattern of error was observed but the error increased in the negative direction. Conclusion: The AutoMLCQA system was useful to evaluate the MLC leaf position error for various gantry angles without the EPID position error. The Gantry angle dependency should be considered during MLC leaf position error analysis.

[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

MDEP Generic Common Position No DICWG-01. Common position on the treatment of common cause failure caused by software within digital safety systems

International Nuclear Information System (INIS)

2013-01-01

Common cause failures (CCF)2 have been a significant safety concern for nuclear power plant systems. The increasing dependence on software-in safety systems for nuclear power plants has increased the safety significance of CCF caused by software, when software in redundant channels or portions of safety systems has some common dependency. For example, the effect of systematic failures can lead to a loss of safety in many ways: unwanted actuations, a safety function is not provided when needed. Therefore, nuclear power plants should be systematically protected from the effects of common cause failures caused by software in DI and C safety systems. Software for nuclear power plant safety systems should be of the high quality necessary to help assure against the loss of safety (i.e. developed with high-quality engineering practices, commensurate quality assurance applied, with continuous improvement through corrective actions based on lessons learned from operating experience). However, demonstrating adequate software quality only through verification and validation activities and controls on the development process has proved to be problematic. Therefore, this common position provides guidance for the assessment of the potential for CCF for software. It is recognized that programmable logic devices do not execute software in the conventional sense; however, the application development process using these devices have many similarities with software development, and the deficiencies that may be introduced during the application development process may induce errors in the programmable logic devices that can result in common cause failures of these devices of a type similar to software common cause failure. Although deficiencies with the potential to give rise to software common cause failures can be introduced at all phases of the software life cycle, this common position will only consider the potential for software common cause failures within digital safety system

Reduction of weighing errors caused by tritium decay heating

International Nuclear Information System (INIS)

Shaw, J.F.

1978-01-01

The deuterium-tritium source gas mixture for laser targets is formulated by weight. Experiments show that the maximum weighing error caused by tritium decay heating is 0.2% for a 104-cm 3 mix vessel. Air cooling the vessel reduces the weighing error by 90%

Common Positioning Errors in Digital Panoramic Radiographies Taken In Mashhad Dental School

Directory of Open Access Journals (Sweden)

Ali Bagherpour

2018-06-01

Full Text Available Introduction: The present study was aimed at evaluating common positioning errors on panoramic radiographs taken in the Radiology Department of Mashhad Dental School. Materials and methods: The study sample included 1,990 digital panoramic radiographs taken in the Radiology Department of Mashhad Dental School by a Planmeca Promax (Planmeca Oy, Helsinki, Finland, during a 2-year period (2010–2012. All radiographs, according to dentition and sex, were evaluated for positioning errors. Results: There were 1,927 (96.8% panoramic radiographs with one or more errors. While the number of errors in each image varied between one and five, most images had one error (48.4%. The most common error was that the tongue was not in contact with the hard palate (94.8%. "Open lips" was an error not seen in any patients. Conclusions:positioning errors are common in panoramic radiographies. The most common error observed in this study was a failure to place the tongue on the palate. This error and the other errors reported in this study can be reduced by training the technicians and spending little more time for patient positioning and more effective communication with the patients.

Operator error and emotions. Operator error and emotions - a major cause of human failure

International Nuclear Information System (INIS)

Patterson, B.K.; Bradley, M.; Artiss, W.G.

2000-01-01

This paper proposes the idea that a large proportion of the incidents attributed to operator and maintenance error in a nuclear or industrial plant are actually founded in our human emotions. Basic psychological theory of emotions is briefly presented and then the authors present situations and instances that can cause emotions to swell and lead to operator and maintenance error. Since emotional information is not recorded in industrial incident reports, the challenge is extended to industry, to review incident source documents for cases of emotional involvement and to develop means to collect emotion related information in future root cause analysis investigations. Training must then be provided to operators and maintainers to enable them to know one's emotions, manage emotions, motivate one's self, recognize emotions in others and handle relationships. Effective training will reduce the instances of human error based in emotions and enable a cooperative, productive environment in which to work. (author)

Operator error and emotions. Operator error and emotions - a major cause of human failure

Energy Technology Data Exchange (ETDEWEB)

Patterson, B.K. [Human Factors Practical Incorporated (Canada); Bradley, M. [Univ. of New Brunswick, Saint John, New Brunswick (Canada); Artiss, W.G. [Human Factors Practical (Canada)

2000-07-01

This paper proposes the idea that a large proportion of the incidents attributed to operator and maintenance error in a nuclear or industrial plant are actually founded in our human emotions. Basic psychological theory of emotions is briefly presented and then the authors present situations and instances that can cause emotions to swell and lead to operator and maintenance error. Since emotional information is not recorded in industrial incident reports, the challenge is extended to industry, to review incident source documents for cases of emotional involvement and to develop means to collect emotion related information in future root cause analysis investigations. Training must then be provided to operators and maintainers to enable them to know one's emotions, manage emotions, motivate one's self, recognize emotions in others and handle relationships. Effective training will reduce the instances of human error based in emotions and enable a cooperative, productive environment in which to work. (author)

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.

SU-E-P-36: Evaluation of MLC Positioning Errors in Dynamic IMRT Treatments by Analyzing Dynalog Files

International Nuclear Information System (INIS)

Olasolo, J; Pellejero, S; Gracia, M; Gallardo, N; Martin, M; Lozares, S; Maneru, F; Bragado, L; Miquelez, S; Rubio, A

2015-01-01

Purpose: To assess the accuracy of MLC positioning in Varian linear accelerator, in dynamic IMRT technique, from the analysis of dynalog files generated by the MLC controller. Methods: In Clinac accelerators (pre-TrueBeam technology), control system has an approximately 50ms delay (one control cycle time). Then, the system compares the measured position to the planned position corresponding to the next control cycle. As it has been confirmed by Varian technical support, this effect causes that measured positions appear in dynalogs one cycle out of phase with respect to the planned positions. Around 9000 dynalogs have been analyzed, coming from the three linear accelerators of our center (one Trilogy and two Clinac 21EX) equipped with a Millennium 120 MLC. In order to compare our results to recent publications, leaf positioning errors (RMS and 95th percentile) are calculated with and without delay effect. Dynalogs have been analyzed using a in-house Matlab software. Results: The RMS errors were 0.341, 0.339 and 0.348mm for each Linac; being the average error 0.343 mm. The 95th percentiles of the error were 0.617, 0.607 and 0.625; with an average of 0.617mm. A recent multi-institution study carried out by Kerns et al. found a mean leaf RMS error of 0.32mm and a 95th percentile error value of 0.64mm.Without delay effect, mean leaf RMS errors obtained were 0.040, 0.042 and 0.038mm for each treatment machine; being the average 0.040mm. The 95th percentile error values obtained were 0.057, 0.058 and 0.054 mm, with an average of 0.056mm. Conclusion: Results obtained for the mean leaf RMS error and the mean 95th percentile were consistent with the multi-institution study. Calculated error statistics with delay effect are significantly larger due to the speed proportional and systematic leaf offset. Consequently it is proposed to correct this effect in dynalogs analysis to determine the MLC performance

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.

Force Reproduction Error Depends on Force Level, whereas the Position Reproduction Error Does Not

NARCIS (Netherlands)

Onneweer, B.; Mugge, W.; Schouten, Alfred Christiaan

2016-01-01

When reproducing a previously perceived force or position humans make systematic errors. This study determined the effect of force level on force and position reproduction, when both target and reproduction force are self-generated with the same hand. Subjects performed force reproduction tasks at

Quantitative analysis of the errors positioning of a multi leaf collimator for volumetric arcoterapia treatments

International Nuclear Information System (INIS)

Gomez Gonzalez, N.; Garcia Repiso, S.; Martin Rincon, C.; Cons Perez, N.; Saez Beltran, M.; Delgado Aparicio, J. M.; Perez alvarez, M. E.; Verde Velasco, J. M.; Ramos Pacho, J. A.; Sena Espinel, E. de

2013-01-01

The precision in the positioning of the multi leaf collimation system of a linear accelerator is critical, especially in treatments of IMRT, where small mistakes can cause relevant dosimetry discrepancies regarding the calculated plan. To assess the accuracy and repeatability of the blades positioning can be used controls, including the one known as fence test whose image pattern allows you to find anomalies in a visual way. The objective of this study is to develop a method which allows to quantify the positioning errors of the multi leaf collimator from this test. (Author)

MATLAB implementation of satellite positioning error overbounding by generalized Pareto distribution

Science.gov (United States)

Ahmad, Khairol Amali; Ahmad, Shahril; Hashim, Fakroul Ridzuan

2018-02-01

In the satellite navigation community, error overbound has been implemented in the process of integrity monitoring. In this work, MATLAB programming is used to implement the overbounding of satellite positioning error CDF. Using a trajectory of reference, the horizontal position errors (HPE) are computed and its non-parametric distribution function is given by the empirical Cumulative Distribution Function (ECDF). According to the results, these errors have a heavy-tailed distribution. Sınce the ECDF of the HPE in urban environment is not Gaussian distributed, the ECDF is overbound with the CDF of the generalized Pareto distribution (GPD).

Common positioning errors in panoramic radiography: A review

Energy Technology Data Exchange (ETDEWEB)

Randon, Rafael Henrique Nunes [Stomathology and Oral Diagnostic Program, School of Dentistry of Sao Paulo, University of Sao Paulo, Sao Paulo (Brazil); Pereira, Yamba Carla Lara [Biology Dental Buco Graduate Program, School of Dentistry of Piracicaba, University of Campinas, Piracicaba (Brazil); Nascimento, Glauce Crivelaro do [Psychobiology Graduate Program, School of Philosophy, Science and Literature of Ribeirao Preto, University of Sao Paulo, Ribeirao Preto (Brazil)

2014-03-15

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.

Determination of global positioning system (GPS) receiver clock errors: impact on positioning accuracy

International Nuclear Information System (INIS)

Yeh, Ta-Kang; Hwang, Cheinway; Xu, Guochang; Wang, Chuan-Sheng; Lee, Chien-Chih

2009-01-01

Enhancing the positioning precision is the primary pursuit of global positioning system (GPS) users. To achieve this goal, most studies have focused on the relationship between GPS receiver clock errors and GPS positioning precision. This study utilizes undifferentiated phase data to calculate GPS clock errors and to compare with the frequency of cesium clock directly, to verify estimated clock errors by the method used in this paper. The frequency stability calculated from this paper (the indirect method) and measured from the National Standard Time and Frequency Laboratory (NSTFL) of Taiwan (the direct method) match to 1.5 × 10 −12 (the value from this study was smaller than that from NSTFL), suggesting that the proposed technique has reached a certain level of quality. The built-in quartz clocks in the GPS receivers yield relative frequency offsets that are 3–4 orders higher than those of rubidium clocks. The frequency stability of the quartz clocks is on average two orders worse than that of the rubidium clock. Using the rubidium clock instead of the quartz clock, the horizontal and vertical positioning accuracies were improved by 26–78% (0.6–3.6 mm) and 20–34% (1.3–3.0 mm), respectively, for a short baseline. These improvements are 7–25% (0.3–1.7 mm) and 11% (1.7 mm) for a long baseline. Our experiments show that the frequency stability of the clock, rather than relative frequency offset, is the governing factor of positioning accuracy

Differences among Job Positions Related to Communication Errors at Construction Sites

Science.gov (United States)

Takahashi, Akiko; Ishida, Toshiro

In a previous study, we classified the communicatio n errors at construction sites as faulty intention and message pattern, inadequate channel pattern, and faulty comprehension pattern. This study seeks to evaluate the degree of risk of communication errors and to investigate differences among people in various job positions in perception of communication error risk . Questionnaires based on the previous study were a dministered to construction workers (n=811; 149 adminis trators, 208 foremen and 454 workers). Administrators evaluated all patterns of communication error risk equally. However, foremen and workers evaluated communication error risk differently in each pattern. The common contributing factors to all patterns wer e inadequate arrangements before work and inadequate confirmation. Some factors were common among patterns but other factors were particular to a specific pattern. To help prevent future accidents at construction sites, administrators should understand how people in various job positions perceive communication errors and propose human factors measures to prevent such errors.

Clinical measuring system for the form and position errors of circular workpieces using optical fiber sensors

Science.gov (United States)

Tan, Jiubin; Qiang, Xifu; Ding, Xuemei

1991-08-01

Optical sensors have two notable advantages in modern precision measurement. One is that they can be used in nondestructive measurement because the sensors need not touch the surfaces of workpieces in measuring. The other one is that they can strongly resist electromagnetic interferences, vibrations, and noises, so they are suitable to be used in machining sites. But the drift of light intensity and the changing of the reflection coefficient at different measuring positions of a workpiece may have great influence on measured results. To solve the problem, a spectroscopic differential characteristic compensating method is put forward. The method can be used effectively not only in compensating the measuring errors resulted from the drift of light intensity but also in eliminating the influence to measured results caused by the changing of the reflection coefficient. Also, the article analyzes the possibility of and the means of separating data errors of a clinical measuring system for form and position errors of circular workpieces.

Errors of isotope conveyor weigher caused by profile variations and shift of material

International Nuclear Information System (INIS)

Machaj, B.

1977-01-01

Results of investigations of isotope conveyor weigher in transmission geometry and with long plastic scintillator as a detector are presented in the paper. The results indicate that errors caused by material shift across the conveyor belt can be decreased by forming probe sensitivity to incident radiation along its axis by means of additional radiation absorbents. The errors caused by material profile variations can effectively be diminished by increase of photon energy. Application of 60 Co instead of 137 Cs ensured more than three times lower errors caused by profile variation. Errors caused by vertical movements of the belt with material, decrease considerably, when single point source situated in the center of the measuring head is replaced at least by two point sources situated out of the center, above the edges of the belt. (author)

Compensation for positioning error of industrial robot for flexible vision measuring system

Science.gov (United States)

Guo, Lei; Liang, Yajun; Song, Jincheng; Sun, Zengyu; Zhu, Jigui

2013-01-01

Positioning error of robot is a main factor of accuracy of flexible coordinate measuring system which consists of universal industrial robot and visual sensor. Present compensation methods for positioning error based on kinematic model of robot have a significant limitation that it isn't effective in the whole measuring space. A new compensation method for positioning error of robot based on vision measuring technique is presented. One approach is setting global control points in measured field and attaching an orientation camera to vision sensor. Then global control points are measured by orientation camera to calculate the transformation relation from the current position of sensor system to global coordinate system and positioning error of robot is compensated. Another approach is setting control points on vision sensor and two large field cameras behind the sensor. Then the three dimensional coordinates of control points are measured and the pose and position of sensor is calculated real-timely. Experiment result shows the RMS of spatial positioning is 3.422mm by single camera and 0.031mm by dual cameras. Conclusion is arithmetic of single camera method needs to be improved for higher accuracy and accuracy of dual cameras method is applicable.

Mitigating Errors in External Respiratory Surrogate-Based Models of Tumor Position

International Nuclear Information System (INIS)

Malinowski, Kathleen T.; McAvoy, Thomas J.; George, Rohini; Dieterich, Sonja; D'Souza, Warren D.

2012-01-01

Purpose: To investigate the effect of tumor site, measurement precision, tumor–surrogate correlation, training data selection, model design, and interpatient and interfraction variations on the accuracy of external marker-based models of tumor position. Methods and Materials: Cyberknife Synchrony system log files comprising synchronously acquired positions of external markers and the tumor from 167 treatment fractions were analyzed. The accuracy of Synchrony, ordinary-least-squares regression, and partial-least-squares regression models for predicting the tumor position from the external markers was evaluated. The quantity and timing of the data used to build the predictive model were varied. The effects of tumor–surrogate correlation and the precision in both the tumor and the external surrogate position measurements were explored by adding noise to the data. Results: The tumor position prediction errors increased during the duration of a fraction. Increasing the training data quantities did not always lead to more accurate models. Adding uncorrelated noise to the external marker-based inputs degraded the tumor–surrogate correlation models by 16% for partial-least-squares and 57% for ordinary-least-squares. External marker and tumor position measurement errors led to tumor position prediction changes 0.3–3.6 times the magnitude of the measurement errors, varying widely with model algorithm. The tumor position prediction errors were significantly associated with the patient index but not with the fraction index or tumor site. Partial-least-squares was as accurate as Synchrony and more accurate than ordinary-least-squares. Conclusions: The accuracy of surrogate-based inferential models of tumor position was affected by all the investigated factors, except for the tumor site and fraction index.

Mitigating Errors in External Respiratory Surrogate-Based Models of Tumor Position

Energy Technology Data Exchange (ETDEWEB)

Malinowski, Kathleen T. [Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, MD (United States); Fischell Department of Bioengineering, University of Maryland, College Park, MD (United States); McAvoy, Thomas J. [Fischell Department of Bioengineering, University of Maryland, College Park, MD (United States); Department of Chemical and Biomolecular Engineering and Institute of Systems Research, University of Maryland, College Park, MD (United States); George, Rohini [Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, MD (United States); Dieterich, Sonja [Department of Radiation Oncology, Stanford University School of Medicine, Stanford, CA (United States); D' Souza, Warren D., E-mail: wdsou001@umaryland.edu [Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, MD (United States); Fischell Department of Bioengineering, University of Maryland, College Park, MD (United States)

2012-04-01

Purpose: To investigate the effect of tumor site, measurement precision, tumor-surrogate correlation, training data selection, model design, and interpatient and interfraction variations on the accuracy of external marker-based models of tumor position. Methods and Materials: Cyberknife Synchrony system log files comprising synchronously acquired positions of external markers and the tumor from 167 treatment fractions were analyzed. The accuracy of Synchrony, ordinary-least-squares regression, and partial-least-squares regression models for predicting the tumor position from the external markers was evaluated. The quantity and timing of the data used to build the predictive model were varied. The effects of tumor-surrogate correlation and the precision in both the tumor and the external surrogate position measurements were explored by adding noise to the data. Results: The tumor position prediction errors increased during the duration of a fraction. Increasing the training data quantities did not always lead to more accurate models. Adding uncorrelated noise to the external marker-based inputs degraded the tumor-surrogate correlation models by 16% for partial-least-squares and 57% for ordinary-least-squares. External marker and tumor position measurement errors led to tumor position prediction changes 0.3-3.6 times the magnitude of the measurement errors, varying widely with model algorithm. The tumor position prediction errors were significantly associated with the patient index but not with the fraction index or tumor site. Partial-least-squares was as accurate as Synchrony and more accurate than ordinary-least-squares. Conclusions: The accuracy of surrogate-based inferential models of tumor position was affected by all the investigated factors, except for the tumor site and fraction index.

The causes of prescribing errors in English general practices: a qualitative study.

Science.gov (United States)

Slight, Sarah P; Howard, Rachel; Ghaleb, Maisoon; Barber, Nick; Franklin, Bryony Dean; Avery, Anthony J

2013-10-01

Few detailed studies exist of the underlying causes of prescribing errors in the UK. To examine the causes of prescribing and monitoring errors in general practice and provide recommendations for how they may be overcome. Qualitative interview and focus group study with purposive sampling of English general practices. General practice staff from 15 general practices across three PCTs in England participated in a combination of semi-structured interviews (n = 34) and six focus groups (n = 46). Thematic analysis informed by Reason's Accident Causation Model was used. Seven categories of high-level error-producing conditions were identified: the prescriber, the patient, the team, the working environment, the task, the computer system, and the primary-secondary care interface. These were broken down to reveal various error-producing conditions: the prescriber's therapeutic training, drug knowledge and experience, knowledge of the patient, perception of risk, and their physical and emotional health; the patient's characteristics and the complexity of the individual clinical case; the importance of feeling comfortable within the practice team was highlighted, as well as the safety implications of GPs signing prescriptions generated by nurses when they had not seen the patient for themselves; the working environment with its extensive workload, time pressures, and interruptions; and computer-related issues associated with mis-selecting drugs from electronic pick-lists and overriding alerts were all highlighted as possible causes of prescribing errors and were often interconnected. Complex underlying causes of prescribing and monitoring errors in general practices were highlighted, several of which are amenable to intervention.

The Causes of Medical Error from the Perspective of Nurses

Directory of Open Access Journals (Sweden)

Oguz Isik

2012-08-01

Full Text Available This study was conducted as a descriptive study in order to determine the medical errors in hospital services and preventive measures that could be taken to reduce these errors, from the perspective of nurses. The population of the study is composed of nurses working in 2 public hospitals in center of the province of Sakarya. We haven’t selected sample and it was aimed to reach as many nurses as possible in the study. A total of 441 questionnaires were send and 324 were returned. A questionnaire as a means of data collection was prepared and used by the authors. Structural Equation Modeling, confirmatory factor analysis, descriptive statistical methods, the significance control test between compared means and ANOVA test were used in statistical analysis. Physicians, nurses, work environment and lack of communication are stated as possible causes of medical error. According to nurses, the major causes of medical errors, in order of their frequency, were inadequate number of health personnel, excessive work stress, high number of patients per nurse, the weariness due to the behavior and attitudes of superiors and the pressure to care so many patients in a very short period of time, and long time of study. Compensation of medical error is very difficult in health care. A great amount of health care is provided in hospitals and medical errors in hospital services must be prevented. In order to prevent these errors which directly affect human life, it is thought that adequate number of staff should be employed in hospitals and the attitude of superiors towards the employees should be motivating. [TAF Prev Med Bull 2012; 11(4.000: 421-430

Diagnostic Error in Correctional Mental Health: Prevalence, Causes, and Consequences.

Science.gov (United States)

Martin, Michael S; Hynes, Katie; Hatcher, Simon; Colman, Ian

2016-04-01

While they have important implications for inmates and resourcing of correctional institutions, diagnostic errors are rarely discussed in correctional mental health research. This review seeks to estimate the prevalence of diagnostic errors in prisons and jails and explores potential causes and consequences. Diagnostic errors are defined as discrepancies in an inmate's diagnostic status depending on who is responsible for conducting the assessment and/or the methods used. It is estimated that at least 10% to 15% of all inmates may be incorrectly classified in terms of the presence or absence of a mental illness. Inmate characteristics, relationships with staff, and cognitive errors stemming from the use of heuristics when faced with time constraints are discussed as possible sources of error. A policy example of screening for mental illness at intake to prison is used to illustrate when the risk of diagnostic error might be increased and to explore strategies to mitigate this risk. © The Author(s) 2016.

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.)

Reduction of digital errors of digital charge division type position-sensitive detectors

International Nuclear Information System (INIS)

Uritani, A.; Yoshimura, K.; Takenaka, Y.; Mori, C.

1994-01-01

It is well known that ''digital errors'', i.e. differential non-linearity, appear in a position profile of radiation interactions when the profile is obtained with a digital charge-division-type position-sensitive detector. Two methods are presented to reduce the digital errors. They are the methods using logarithmic amplifiers and a weighting function. The validities of these two methods have been evaluated mainly by computer simulation. These methods can considerably reduce the digital errors. The best results are obtained when both methods are applied. ((orig.))

Effective training based on the cause analysis of operation errors

International Nuclear Information System (INIS)

Fujita, Eimitsu; Noji, Kunio; Kobayashi, Akira.

1991-01-01

The authors have investigated typical error types through our training experience, and analyzed the causes of them. Error types which are observed in simulator training are: (1) lack of knowledge or lack of its applying ability to actual operation; (2) defective mastery of skillbase operation; (3) rote operation or stereotyped manner; (4) mind-setting or lack of redundant verification; (5) lack of team work; (6) misjudgement for the plant overall conditions by operation chief, who directs a reactor operator and a turbine operator in the training. The paper describes training methods used in Japan for BWR utilities to overcome these error types

Errors in translation made by English major students: A study on types and causes

Directory of Open Access Journals (Sweden)

Pattanapong Wongranu

2017-05-01

Full Text Available Many Thai English major students have problems when they translate Thai texts into English, as numerous errors can be found. Therefore, a study of translation errors is needed to find solutions to these problems. The objectives of this research were: 1 to examine types of translation errors in translation from Thai into English, 2 to determine the types of translation errors that are most common, and 3 to find possible explanations for the causes of errors. The results of this study will be used to improve translation teaching and the course “Translation from Thai into English”. The participants were 26 third-year, English major students at Kasetsart University. The data were collected from the students' exercises and examinations. Interviews and stimulated recall were also used to determine translation problems and causes of errors. The data were analyzed by considering the frequency and percentage, and by content analysis. The results shows that the most frequent translation errors were syntactic errors (65%, followed by semantic errors (26.5% and miscellaneous errors (8.5%, respectively. The causes of errors found in this study included translation procedures, carelessness, low self-confidence, and anxiety. It is recommended that more class time be spent to address the problematic points. In addition, more authentic translation and group work should be implemented to increase self-confidence and decrease anxiety.

Analysis of the effects of Eye-Tracker performance on the pulse positioning errors during refractive surgery☆

Science.gov (United States)

Arba-Mosquera, Samuel; Aslanides, Ioannis M.

2012-01-01

Purpose To analyze the effects of Eye-Tracker performance on the pulse positioning errors during refractive surgery. Methods A comprehensive model, which directly considers eye movements, including saccades, vestibular, optokinetic, vergence, and miniature, as well as, eye-tracker acquisition rate, eye-tracker latency time, scanner positioning time, laser firing rate, and laser trigger delay have been developed. Results Eye-tracker acquisition rates below 100 Hz correspond to pulse positioning errors above 1.5 mm. Eye-tracker latency times to about 15 ms correspond to pulse positioning errors of up to 3.5 mm. Scanner positioning times to about 9 ms correspond to pulse positioning errors of up to 2 mm. Laser firing rates faster than eye-tracker acquisition rates basically duplicate pulse-positioning errors. Laser trigger delays to about 300 μs have minor to no impact on pulse-positioning errors. Conclusions The proposed model can be used for comparison of laser systems used for ablation processes. Due to the pseudo-random nature of eye movements, positioning errors of single pulses are much larger than observed decentrations in the clinical settings. There is no single parameter that ‘alone’ minimizes the positioning error. It is the optimal combination of the several parameters that minimizes the error. The results of this analysis are important to understand the limitations of correcting very irregular ablation patterns.

Cause of depth error of borehole logging and its correction

International Nuclear Information System (INIS)

Iida, Yoshimasa; Ikeda, Koki; Tsuruta, Tadahiko; Ito, Hiroaki; Goto, Junichi.

1996-01-01

Data by borehole logging can be used for detailed analysis of geological structures. Depths measured by portable borehole loggers commonly shift a few meters on the level of 400 to 500 meters deep. Therefore, the cause of depth error has to be recognized to make proper corrections for detailed structural analysis. Correlation between depths of drill core and in-rod radiometric logging has been performed in detail on exploration drill holes in the Athabasca basin, Canada. As a result, a common tendency of logging depth shift has been recognized, and an empirical formula (quadratic equation) for this has been obtained. The physical meaning of the formula and the cause of the depth error has been considered. (author)

Preventing marine accidents caused by technology-induced human error

OpenAIRE

Bielić, Toni; Hasanspahić, Nermin; Čulin, Jelena

2017-01-01

The objective of embedding technology on board ships, to improve safety, is not fully accomplished. The paper studies marine accidents caused by human error resulting from improper human-technology interaction. The aim of the paper is to propose measures to prevent reoccurrence of such accidents. This study analyses the marine accident reports issued by Marine Accidents Investigation Branch covering the period from 2012 to 2014. The factors that caused these accidents are examined and categor...

Evaluation of positioning errors of the patient using cone beam CT megavoltage

International Nuclear Information System (INIS)

Garcia Ruiz-Zorrilla, J.; Fernandez Leton, J. P.; Zucca Aparicio, D.; Perez Moreno, J. M.; Minambres Moro, A.

2013-01-01

Image-guided radiation therapy allows you to assess and fix the positioning of the patient in the treatment unit, thus reducing the uncertainties due to the positioning of the patient. This work assesses errors systematic and errors of randomness from the corrections made to a series of patients of different diseases through a protocol off line of cone beam CT (CBCT) megavoltage. (Author)

Medication error in anaesthesia and critical care: A cause for concern

Directory of Open Access Journals (Sweden)

Dilip Kothari

2010-01-01

Full Text Available Medication error is a major cause of morbidity and mortality in medical profession, and anaesthesia and critical care are no exception to it. Man, medicine, machine and modus operandi are the main contributory factors to it. In this review, incidence, types, risk factors and preventive measures of the medication errors are discussed in detail.

SU-E-T-377: Inaccurate Positioning Might Introduce Significant MapCheck Calibration Error in Flatten Filter Free Beams

International Nuclear Information System (INIS)

Wang, S; Chao, C; Chang, J

2014-01-01

Purpose: This study investigates the calibration error of detector sensitivity for MapCheck due to inaccurate positioning of the device, which is not taken into account by the current commercial iterative calibration algorithm. We hypothesize the calibration is more vulnerable to the positioning error for the flatten filter free (FFF) beams than the conventional flatten filter flattened beams. Methods: MapCheck2 was calibrated with 10MV conventional and FFF beams, with careful alignment and with 1cm positioning error during calibration, respectively. Open fields of 37cmx37cm were delivered to gauge the impact of resultant calibration errors. The local calibration error was modeled as a detector independent multiplication factor, with which propagation error was estimated with positioning error from 1mm to 1cm. The calibrated sensitivities, without positioning error, were compared between the conventional and FFF beams to evaluate the dependence on the beam type. Results: The 1cm positioning error leads to 0.39% and 5.24% local calibration error in the conventional and FFF beams respectively. After propagating to the edges of MapCheck, the calibration errors become 6.5% and 57.7%, respectively. The propagation error increases almost linearly with respect to the positioning error. The difference of sensitivities between the conventional and FFF beams was small (0.11 ± 0.49%). Conclusion: The results demonstrate that the positioning error is not handled by the current commercial calibration algorithm of MapCheck. Particularly, the calibration errors for the FFF beams are ~9 times greater than those for the conventional beams with identical positioning error, and a small 1mm positioning error might lead to up to 8% calibration error. Since the sensitivities are only slightly dependent of the beam type and the conventional beam is less affected by the positioning error, it is advisable to cross-check the sensitivities between the conventional and FFF beams to detect

Reader error during CT colonography: causes and implications for training

International Nuclear Information System (INIS)

Slater, Andrew; Tam, Emily; Gartner, Louise; Scarth, Julia; Peiris, Chand; Gupta, Arun; Marshall, Michele; Burling, David; Taylor, Stuart A.; Halligan, Steve

2006-01-01

This study investigated the variability in baseline computed tomography colonography (CTC) performance using untrained readers by documenting sources of error to guide future training requirements. Twenty CTC endoscopically validated data sets containing 32 polyps were consensus read by three unblinded radiologists experienced in CTC, creating a reference standard. Six readers without prior CTC training [four residents and two board-certified subspecialty gastrointestinal (GI) radiologists] read the 20 cases. Readers drew a region of interest (ROI) around every area they considered a potential colonic lesion, even if subsequently dismissed, before creating a final report. Using this final report, reader ROIs were classified as true positive detections, true negatives correctly dismissed, true detections incorrectly dismissed (i.e., classification error), or perceptual errors. Detection of polyps 1-5 mm, 6-9 mm, and ≥10 mm ranged from 7.1% to 28.6%, 16.7% to 41.7%, and 16.7% to 83.3%, respectively. There was no significant difference between polyp detection or false positives for the GI radiologists compared with residents (p=0.67, p=0.4 respectively). Most missed polyps were due to failure of detection rather than characterization (range 82-95%). Untrained reader performance is variable but generally poor. Most missed polyps are due perceptual error rather than characterization, suggesting basic training should focus heavily on lesion detection. (orig.)

Residual setup errors caused by rotation and non-rigid motion in prone-treated cervical cancer patients after online CBCT image-guidance

International Nuclear Information System (INIS)

Ahmad, Rozilawati; Hoogeman, Mischa S.; Quint, Sandra; Mens, Jan Willem; Osorio, Eliana M. Vásquez; Heijmen, Ben J.M.

2012-01-01

Purpose: To quantify the impact of uncorrected or partially corrected pelvis rotation and spine bending on region-specific residual setup errors in prone-treated cervical cancer patients. Methods and materials: Fifteen patients received an in-room CBCT scan twice a week. CBCT scans were registered to the planning CT-scan using a pelvic clip box and considering both translations and rotations. For daily correction of the detected translational pelvis setup errors by couch shifts, residual setup errors were determined for L5, L4 and seven other points of interest (POIs). The same was done for a procedure with translational corrections and limited rotational correction (±3°) by a 6D positioning device. Results: With translational correction only, residual setup errors were large especially for L5/L4 in AP direction (Σ = 5.1/5.5 mm). For the 7 POIs the residual setup errors ranged from 1.8 to 5.6 mm (AP). Using the 6D positioning device, the errors were substantially smaller (for L5/L4 in AP direction Σ = 2.7/2.2 mm). Using this device, the percentage of fractions with a residual AP displacement for L4 > 5 mm reduced from 47% to 9%. Conclusions: Setup variations caused by pelvis rotations are large and cannot be ignored in prone treatment of cervical cancer patients. Corrections with a 6D positioning device may considerably reduce resulting setup errors, but the residual setup errors should still be accounted for by appropriate CTV-to-PTV margins.

Republished error management: Descriptions of verbal communication errors between staff. An analysis of 84 root cause analysis-reports from Danish hospitals

DEFF Research Database (Denmark)

Rabøl, Louise Isager; Andersen, Mette Lehmann; Østergaard, Doris

2011-01-01

Introduction Poor teamwork and communication between healthcare staff are correlated to patient safety incidents. However, the organisational factors responsible for these issues are unexplored. Root cause analyses (RCA) use human factors thinking to analyse the systems behind severe patient safety...... and characteristics of verbal communication errors such as handover errors and error during teamwork. Results Raters found description of verbal communication errors in 44 reports (52%). These included handover errors (35 (86%)), communication errors between different staff groups (19 (43%)), misunderstandings (13...... (30%)), communication errors between junior and senior staff members (11 (25%)), hesitance in speaking up (10 (23%)) and communication errors during teamwork (8 (18%)). The kappa values were 0.44-0.78. Unproceduralized communication and information exchange via telephone, related to transfer between...

Application of grey incidence analysis to connection between human errors and root cause

International Nuclear Information System (INIS)

Ren Yinxiang; Yu Ren; Zhou Gang; Chen Dengke

2008-01-01

By introducing grey incidence analysis, the relatively important impact of root cause upon human errors was researched in the paper. On the basis of WANO statistic data and grey incidence analysis, lack of alternate examine, bad basic operation, short of theoretical knowledge, relaxation of organization and management and deficiency of regulations are the important influence of root cause on human err ors. Finally, the question to reduce human errors was discussed. (authors)

Source position error influence on industry CT image quality

International Nuclear Information System (INIS)

Cong Peng; Li Zhipeng; Wu Haifeng

2004-01-01

Based on the emulational exercise, the influence of source position error on industry CT (ICT) image quality was studied and the valuable parameters were obtained for the design of ICT. The vivid container CT image was also acquired from the CT testing system. (authors)

Quantitative analysis of the errors positioning of a multi leaf collimator for volumetric arcoterapia treatments; Analisis cuantitativo de los errores de posicionamiento de un colimador multilaminas para tratamientos de arcoterapia volumetrica

Energy Technology Data Exchange (ETDEWEB)

Gomez Gonzalez, N.; Garcia Repiso, S.; Martin Rincon, C.; Cons Perez, N.; Saez Beltran, M.; Delgado Aparicio, J. M.; Perez alvarez, M. E.; Verde Velasco, J. M.; Ramos Pacho, J. A.; Sena Espinel, E. de

2013-07-01

The precision in the positioning of the multi leaf collimation system of a linear accelerator is critical, especially in treatments of IMRT, where small mistakes can cause relevant dosimetry discrepancies regarding the calculated plan. To assess the accuracy and repeatability of the blades positioning can be used controls, including the one known as fence test whose image pattern allows you to find anomalies in a visual way. The objective of this study is to develop a method which allows to quantify the positioning errors of the multi leaf collimator from this test. (Author)

Analysis of positioning errors in radiotherapy; Analyse des erreurs de positionnement en radiotherapie

Energy Technology Data Exchange (ETDEWEB)

Josset-Gaudaire, S.; Lisbona, A.; Llagostera, C.; Delpon, G.; Chiavassa, S.; Brunet, G. [Service de physique medicale, ICO Rene-Gauducheau, Saint Herblain (France); Rousset, S.; Nerriere, E.; Leblanc, M. [Service de radiotherapie, ICO Rene-Gauducheau, Saint Herblain (France)

2011-10-15

Within the frame of a study of control imagery management in radiotherapy, the authors report the study of positioning errors associated with control imagery in order to give an overview of practice and to help the adjustment or definition of action levels for clinical practice. Twenty groups of patients have been defined by considering tumour locations (head, ENT, thorax, breast, abdomen, and pelvis), treatment positions, immobilization systems and imagery systems. Positioning errors have thus been analyzed for 340 patients. Aspects and practice to be improved are identified. Short communication

Causes of medication administration errors in hospitals: a systematic review of quantitative and qualitative evidence.

Science.gov (United States)

Keers, Richard N; Williams, Steven D; Cooke, Jonathan; Ashcroft, Darren M

2013-11-01

Underlying systems factors have been seen to be crucial contributors to the occurrence of medication errors. By understanding the causes of these errors, the most appropriate interventions can be designed and implemented to minimise their occurrence. This study aimed to systematically review and appraise empirical evidence relating to the causes of medication administration errors (MAEs) in hospital settings. Nine electronic databases (MEDLINE, EMBASE, International Pharmaceutical Abstracts, ASSIA, PsycINFO, British Nursing Index, CINAHL, Health Management Information Consortium and Social Science Citations Index) were searched between 1985 and May 2013. Inclusion and exclusion criteria were applied to identify eligible publications through title analysis followed by abstract and then full text examination. English language publications reporting empirical data on causes of MAEs were included. Reference lists of included articles and relevant review papers were hand searched for additional studies. Studies were excluded if they did not report data on specific MAEs, used accounts from individuals not directly involved in the MAE concerned or were presented as conference abstracts with insufficient detail. A total of 54 unique studies were included. Causes of MAEs were categorised according to Reason's model of accident causation. Studies were assessed to determine relevance to the research question and how likely the results were to reflect the potential underlying causes of MAEs based on the method(s) used. Slips and lapses were the most commonly reported unsafe acts, followed by knowledge-based mistakes and deliberate violations. Error-provoking conditions influencing administration errors included inadequate written communication (prescriptions, documentation, transcription), problems with medicines supply and storage (pharmacy dispensing errors and ward stock management), high perceived workload, problems with ward-based equipment (access, functionality

Dose deviations caused by positional inaccuracy of multileaf collimator in intensity modulated radiotherapy

International Nuclear Information System (INIS)

Wang, H.C.; Chui, C.S.; Tsai, H.Y.; Chen, C.H.; Tsai, L.F.

2008-01-01

Introduction: Multileaf collimator (MLC) is currently a widely used system in the delivery of intensity modulated radiotherapy (IMRT). The accuracy of the multileaf position plays an important role in the final outcome of the radiation treatment. According to ICRU recommendation, a dose inaccuracy over than 5% of prescribed dose affects treatment results. In order to quantify the influence of leaf positional errors on dose distribution, we set different MLC positional inaccuracy from 0 to 6 mm for step-and-shoot IMRT in clinical cases. Two-dimensional dose distributions of radiotherapy plans with different leaf displacements generated with a commercial treatment planning system. And verification films were used to measure two-dimensional dose distributions. Then a computerized dose comparison system will be introduced to analyze the dose deviations. Materials/methods: We assumed MLC positional inaccuracy from 0 to 6 mm for step-and-shoot IMRT in clinical cases by simulating the different leaf displacements with a commercial treatment planning system. Then we transferred the treatment plans with different leaf offset that may be happened in clinical situation to linear accelerator. Verification films (Kodat EDR2) were well positioned within solid water phantoms to be irradiated by the simulated plans. The films were scanned to display two-dimensional dose distributions. Finally, we compared with the dose distributions with MLC positional inaccuracy by a two-dimensional dose comparison software to analyze the deviations in Gamma indexes and normalized agreement test (NAT) values. Results: In general, the data show that larger leaf positional error induces larger dose error. More fields used for treatment generate lesser errors. Besides, leaf position relative to a field influences the degree of dose error. A leaf lying close to the border of a field leads to a more significant dose deviation than a leaf in the center. Algorithms for intensity modulation also affect

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

Science.gov (United States)

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

1992-12-01

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

Impact of habitat-specific GPS positional error on detection of movement scales by first-passage time analysis.

Directory of Open Access Journals (Sweden)

David M Williams

Full Text Available Advances in animal tracking technologies have reduced but not eliminated positional error. While aware of such inherent error, scientists often proceed with analyses that assume exact locations. The results of such analyses then represent one realization in a distribution of possible outcomes. Evaluating results within the context of that distribution can strengthen or weaken our confidence in conclusions drawn from the analysis in question. We evaluated the habitat-specific positional error of stationary GPS collars placed under a range of vegetation conditions that produced a gradient of canopy cover. We explored how variation of positional error in different vegetation cover types affects a researcher's ability to discern scales of movement in analyses of first-passage time for white-tailed deer (Odocoileus virginianus. We placed 11 GPS collars in 4 different vegetative canopy cover types classified as the proportion of cover above the collar (0-25%, 26-50%, 51-75%, and 76-100%. We simulated the effect of positional error on individual movement paths using cover-specific error distributions at each location. The different cover classes did not introduce any directional bias in positional observations (1 m≤mean≤6.51 m, 0.24≤p≤0.47, but the standard deviation of positional error of fixes increased significantly with increasing canopy cover class for the 0-25%, 26-50%, 51-75% classes (SD = 2.18 m, 3.07 m, and 4.61 m, respectively and then leveled off in the 76-100% cover class (SD = 4.43 m. We then added cover-specific positional errors to individual deer movement paths and conducted first-passage time analyses on the noisy and original paths. First-passage time analyses were robust to habitat-specific error in a forest-agriculture landscape. For deer in a fragmented forest-agriculture environment, and species that move across similar geographic extents, we suggest that first-passage time analysis is robust with regard to

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

Coordinated joint motion control system with position error correction

Science.gov (United States)

Danko, George L.

2016-04-05

Disclosed are an articulated hydraulic machine supporting, control system and control method for same. The articulated hydraulic machine has an end effector for performing useful work. The control system is capable of controlling the end effector for automated movement along a preselected trajectory. The control system has a position error correction system to correct discrepancies between an actual end effector trajectory and a desired end effector trajectory. The correction system can employ one or more absolute position signals provided by one or more acceleration sensors supported by one or more movable machine elements. Good trajectory positioning and repeatability can be obtained. A two joystick controller system is enabled, which can in some cases facilitate the operator's task and enhance their work quality and productivity.

Nonlinear control of ships minimizing the position tracking errors

Directory of Open Access Journals (Sweden)

Svein P. Berge

1999-07-01

Full Text Available In this paper, a nonlinear tracking controller with integral action for ships is presented. The controller is based on state feedback linearization. Exponential convergence of the vessel-fixed position and velocity errors are proven by using Lyapunov stability theory. Since we only have two control devices, a rudder and a propeller, we choose to control the longship and the sideship position errors to zero while the heading is stabilized indirectly. A Virtual Reference Point (VRP is defined at the bow or ahead of the ship. The VRP is used for tracking control. It is shown that the distance from the center of rotation to the VRP will influence on the stability of the zero dynamics. By selecting the VRP at the bow or even ahead of the bow, the damping in yaw can be increased and the zero dynamics is stabilized. Hence, the heading angle will be less sensitive to wind, currents and waves. The control law is simulated by using a nonlinear model of the Japanese training ship Shiojimaru with excellent results. Wind forces are added to demonstrate the robustness and performance of the integral controller.

Impact of MLC leaf position errors on simple and complex IMRT plans for head and neck cancer

International Nuclear Information System (INIS)

Mu, G; Ludlum, E; Xia, P

2008-01-01

The dosimetric impact of random and systematic multi-leaf collimator (MLC) leaf position errors is relatively unknown for head and neck intensity-modulated radiotherapy (IMRT) patients. In this report we studied 17 head and neck IMRT patients, including 12 treated with simple plans ( 100 segments). Random errors (-2 to +2 mm) and systematic errors (±0.5 mm and ±1 mm) in MLC leaf positions were introduced into the clinical plans and the resultant dose distributions were analyzed based on defined endpoint doses. The dosimetric effect was insignificant for random MLC leaf position errors up to 2 mm for both simple and complex plans. However, for systematic MLC leaf position errors, we found significant dosimetric differences between the simple and complex IMRT plans. For 1 mm systematic error, the average changes in D 95% were 4% in simple plans versus 8% in complex plans. The average changes in D 0.1cc of the spinal cord and brain stem were 4% in simple plans versus 12% in complex plans. The average changes in parotid glands were 9% in simple plans versus 13% for the complex plans. Overall, simple IMRT plans are less sensitive to leaf position errors than complex IMRT plans

Characterization of positional errors and their influence on micro four-point probe measurements on a 100 nm Ru film

DEFF Research Database (Denmark)

Kjær, Daniel; Hansen, Ole; Østerberg, Frederik Westergaard

2015-01-01

Thin-film sheet resistance measurements at high spatial resolution and on small pads are important and can be realized with micrometer-scale four-point probes. As a result of the small scale the measurements are affected by electrode position errors. We have characterized the electrode position...... errors in measurements on Ru thin film using an Au-coated 12-point probe. We show that the standard deviation of the static electrode position error is on the order of 5 nm, which significantly affects the results of single configuration measurements. Position-error-corrected dual......-configuration measurements, however, are shown to eliminate the effect of position errors to a level limited either by electrical measurement noise or dynamic position errors. We show that the probe contact points remain almost static on the surface during the measurements (measured on an atomic scale) with a standard...

Early math and reading achievement are associated with the error positivity

Directory of Open Access Journals (Sweden)

Matthew H. Kim

2016-12-01

Full Text Available Executive functioning (EF and motivation are associated with academic achievement and error-related ERPs. The present study explores whether early academic skills predict variability in the error-related negativity (ERN and error positivity (Pe. Data from 113 three- to seven-year-old children in a Go/No-Go task revealed that stronger early reading and math skills predicted a larger Pe. Closer examination revealed that this relation was quadratic and significant for children performing at or near grade level, but not significant for above-average achievers. Early academics did not predict the ERN. These findings suggest that the Pe – which reflects individual differences in motivational processes as well as attention – may be associated with early academic achievement.

CAUSES: On the Role of Surface Energy Budget Errors to the Warm Surface Air Temperature Error Over the Central United States

Science.gov (United States)

Ma, H.-Y.; Klein, S. A.; Xie, S.; Zhang, C.; Tang, S.; Tang, Q.; Morcrette, C. J.; Van Weverberg, K.; Petch, J.; Ahlgrimm, M.; Berg, L. K.; Cheruy, F.; Cole, J.; Forbes, R.; Gustafson, W. I.; Huang, M.; Liu, Y.; Merryfield, W.; Qian, Y.; Roehrig, R.; Wang, Y.-C.

2018-03-01

Many weather forecast and climate models simulate warm surface air temperature (T2m) biases over midlatitude continents during the summertime, especially over the Great Plains. We present here one of a series of papers from a multimodel intercomparison project (CAUSES: Cloud Above the United States and Errors at the Surface), which aims to evaluate the role of cloud, radiation, and precipitation biases in contributing to the T2m bias using a short-term hindcast approach during the spring and summer of 2011. Observations are mainly from the Atmospheric Radiation Measurement Southern Great Plains sites. The present study examines the contributions of surface energy budget errors. All participating models simulate too much net shortwave and longwave fluxes at the surface but with no consistent mean bias sign in turbulent fluxes over the Central United States and Southern Great Plains. Nevertheless, biases in the net shortwave and downward longwave fluxes as well as surface evaporative fraction (EF) are contributors to T2m bias. Radiation biases are largely affected by cloud simulations, while EF bias is largely affected by soil moisture modulated by seasonal accumulated precipitation and evaporation. An approximate equation based upon the surface energy budget is derived to further quantify the magnitudes of radiation and EF contributions to T2m bias. Our analysis ascribes that a large EF underestimate is the dominant source of error in all models with a large positive temperature bias, whereas an EF overestimate compensates for an excess of absorbed shortwave radiation in nearly all the models with the smallest temperature bias.

Republished error management: Descriptions of verbal communication errors between staff. An analysis of 84 root cause analysis-reports from Danish hospitals

DEFF Research Database (Denmark)

Rabøl, Louise Isager; Andersen, Mette Lehmann; Østergaard, Doris

2011-01-01

Introduction Poor teamwork and communication between healthcare staff are correlated to patient safety incidents. However, the organisational factors responsible for these issues are unexplored. Root cause analyses (RCA) use human factors thinking to analyse the systems behind severe patient safety...... (30%)), communication errors between junior and senior staff members (11 (25%)), hesitance in speaking up (10 (23%)) and communication errors during teamwork (8 (18%)). The kappa values were 0.44-0.78. Unproceduralized communication and information exchange via telephone, related to transfer between...... incidents. The RCARs rich descriptions of the incidents revealed the organisational factors and needs related to these errors....

Sensorless SPMSM Position Estimation Using Position Estimation Error Suppression Control and EKF in Wide Speed Range

Directory of Open Access Journals (Sweden)

Zhanshan Wang

2014-01-01

Full Text Available The control of a high performance alternative current (AC motor drive under sensorless operation needs the accurate estimation of rotor position. In this paper, one method of accurately estimating rotor position by using both motor complex number model based position estimation and position estimation error suppression proportion integral (PI controller is proposed for the sensorless control of the surface permanent magnet synchronous motor (SPMSM. In order to guarantee the accuracy of rotor position estimation in the flux-weakening region, one scheme of identifying the permanent magnet flux of SPMSM by extended Kalman filter (EKF is also proposed, which formed the effective combination method to realize the sensorless control of SPMSM with high accuracy. The simulation results demonstrated the validity and feasibility of the proposed position/speed estimation system.

Testing accelerometer rectification error caused by multidimensional composite inputs with double turntable centrifuge.

Science.gov (United States)

Guan, W; Meng, X F; Dong, X M

2014-12-01

Rectification error is a critical characteristic of inertial accelerometers. Accelerometers working in operational situations are stimulated by composite inputs, including constant acceleration and vibration, from multiple directions. However, traditional methods for evaluating rectification error only use one-dimensional vibration. In this paper, a double turntable centrifuge (DTC) was utilized to produce the constant acceleration and vibration simultaneously and we tested the rectification error due to the composite accelerations. At first, we deduced the expression of the rectification error with the output of the DTC and a static model of the single-axis pendulous accelerometer under test. Theoretical investigation and analysis were carried out in accordance with the rectification error model. Then a detailed experimental procedure and testing results were described. We measured the rectification error with various constant accelerations at different frequencies and amplitudes of the vibration. The experimental results showed the distinguished characteristics of the rectification error caused by the composite accelerations. The linear relation between the constant acceleration and the rectification error was proved. The experimental procedure and results presented in this context can be referenced for the investigation of the characteristics of accelerometer with multiple inputs.

Robust Adaptive Beamforming with Sensor Position Errors Using Weighted Subspace Fitting-Based Covariance Matrix Reconstruction.

Science.gov (United States)

Chen, Peng; Yang, Yixin; Wang, Yong; Ma, Yuanliang

2018-05-08

When sensor position errors exist, the performance of recently proposed interference-plus-noise covariance matrix (INCM)-based adaptive beamformers may be severely degraded. In this paper, we propose a weighted subspace fitting-based INCM reconstruction algorithm to overcome sensor displacement for linear arrays. By estimating the rough signal directions, we construct a novel possible mismatched steering vector (SV) set. We analyze the proximity of the signal subspace from the sample covariance matrix (SCM) and the space spanned by the possible mismatched SV set. After solving an iterative optimization problem, we reconstruct the INCM using the estimated sensor position errors. Then we estimate the SV of the desired signal by solving an optimization problem with the reconstructed INCM. The main advantage of the proposed algorithm is its robustness against SV mismatches dominated by unknown sensor position errors. Numerical examples show that even if the position errors are up to half of the assumed sensor spacing, the output signal-to-interference-plus-noise ratio is only reduced by 4 dB. Beam patterns plotted using experiment data show that the interference suppression capability of the proposed beamformer outperforms other tested beamformers.

Direct focusing error correction with ring-wide TBT beam position data

International Nuclear Information System (INIS)

Yang, M.J.

2011-01-01

Turn-By-Turn (TBT) betatron oscillation data is a very powerful tool in studying machine optics. Hundreds and thousands of turns of free oscillations are taken in just few tens of milliseconds. With beam covering all positions and angles at every location TBT data can be used to diagnose focusing errors almost instantly. This paper describes a new approach that observes focusing error collectively over all available TBT data to find the optimized quadrupole strength, one location at a time. Example will be shown and other issues will be discussed. The procedure presented clearly has helped to reduce overall deviations significantly, with relative ease. Sextupoles, being a permanent feature of the ring, will need to be incorporated into the model. While cumulative effect from all sextupoles around the ring may be negligible on turn-to-turn basis it is not so in this transfer line analysis. It should be noted that this procedure is not limited to looking for quadrupole errors. By modifying the target of minimization it could in principle be used to look for skew quadrupole errors and sextupole errors as well.

Errors in accident data, its types, causes and methods of rectification-analysis of the literature.

Science.gov (United States)

Ahmed, Ashar; Sadullah, Ahmad Farhan Mohd; Yahya, Ahmad Shukri

2017-07-29

Most of the decisions taken to improve road safety are based on accident data, which makes it the back bone of any country's road safety system. Errors in this data will lead to misidentification of black spots and hazardous road segments, projection of false estimates pertinent to accidents and fatality rates, and detection of wrong parameters responsible for accident occurrence, thereby making the entire road safety exercise ineffective. Its extent varies from country to country depending upon various factors. Knowing the type of error in the accident data and the factors causing it enables the application of the correct method for its rectification. Therefore there is a need for a systematic literature review that addresses the topic at a global level. This paper fulfils the above research gap by providing a synthesis of literature for the different types of errors found in the accident data of 46 countries across the six regions of the world. The errors are classified and discussed with respect to each type and analysed with respect to income level; assessment with regard to the magnitude for each type is provided; followed by the different causes that result in their occurrence, and the various methods used to address each type of error. Among high-income countries the extent of error in reporting slight, severe, non-fatal and fatal injury accidents varied between 39-82%, 16-52%, 12-84%, and 0-31% respectively. For middle-income countries the error for the same categories varied between 93-98%, 32.5-96%, 34-99% and 0.5-89.5% respectively. The only four studies available for low-income countries showed that the error in reporting non-fatal and fatal accidents varied between 69-80% and 0-61% respectively. The logistic relation of error in accident data reporting, dichotomised at 50%, indicated that as the income level of a country increases the probability of having less error in accident data also increases. Average error in recording information related to the

Action errors, error management, and learning in organizations.

Science.gov (United States)

Frese, Michael; Keith, Nina

2015-01-03

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

Performance of muon reconstruction including Alignment Position Errors for 2016 Collision Data

CERN Document Server

CMS Collaboration

2016-01-01

From 2016 Run muon reconstruction is using non-zero Alignment Position Errors to account for the residual uncertainties of muon chambers' positions. Significant improvements are obtained in particular for the startup phase after opening/closing the muon detector. Performance results are presented for real data and MC simulations, related to both the offline reconstruction and the High-Level Trigger.

Analysis of the effects of Eye-Tracker performance on the pulse positioning errors during refractive surgery

Directory of Open Access Journals (Sweden)

Samuel Arba-Mosquera

2012-01-01

Conclusions: The proposed model can be used for comparison of laser systems used for ablation processes. Due to the pseudo-random nature of eye movements, positioning errors of single pulses are much larger than observed decentrations in the clinical settings. There is no single parameter that ‘alone’ minimizes the positioning error. It is the optimal combination of the several parameters that minimizes the error. The results of this analysis are important to understand the limitations of correcting very irregular ablation patterns.

Evaluation of positioning errors of the patient using cone beam CT megavoltage; Evaluacion de errores de posicionamiento del paciente mediante Cone Beam CT de megavoltaje

Energy Technology Data Exchange (ETDEWEB)

Garcia Ruiz-Zorrilla, J.; Fernandez Leton, J. P.; Zucca Aparicio, D.; Perez Moreno, J. M.; Minambres Moro, A.

2013-07-01

Image-guided radiation therapy allows you to assess and fix the positioning of the patient in the treatment unit, thus reducing the uncertainties due to the positioning of the patient. This work assesses errors systematic and errors of randomness from the corrections made to a series of patients of different diseases through a protocol off line of cone beam CT (CBCT) megavoltage. (Author)

Positioning errors assessed with kV cone-beam CT for image-guided prostate radiotherapy

International Nuclear Information System (INIS)

Li Jiongyan; Guo Xiaomao; Yao Weiqiang; Wang Yanyang; Ma Jinli; Chen Jiayi; Zhang Zhen; Feng Yan

2010-01-01

Objective: To assess set-up errors measured with kilovoltage cone-beam CT (KV-CBCT), and the impact of online corrections on margins required to account for set-up variability during IMRT for patients with prostate cancer. Methods: Seven patients with prostate cancer undergoing IMRT were enrolled onto the study. The KV-CBCT scans were acquired at least twice weekly. After initial set-up using the skin marks, a CBCT scan was acquired and registered with the planning CT to determine the setup errors using an auto grey-scale registration software. Corrections would be made by moving the table if the setup errors were considered clinically significant (i. e. , > 2 mm). A second CBCT scan was acquired immediately after the corrections to evaluate the residual error. PTV margins were derived to account for the measured set-up errors and residual errors determined for this group of patients. Results: 197 KV-CBCT images in total were acquired. The random and systematic positioning errors and calculated PTV margins without correction in mm were : a) Lateral 3.1, 2.1, 9.3; b) Longitudinal 1.5, 1.8, 5.1;c) Vertical 4.2, 3.7, 13.0. The random and systematic positioning errors and calculated PTV margin with correction in mm were : a) Lateral 1.1, 0.9, 3.4; b) Longitudinal 0.7, 1.1, 2.5; c) Vertical 1.1, 1.3, 3.7. Conclusions: With the guidance of online KV-CBCT, set-up errors could be reduced significantly for patients with prostate cancer receiving IMRT. The margin required after online CBCT correction for the patients enrolled in the study would be appoximatively 3-4 mm. (authors)

Impact of documentation errors on accuracy of cause of death coding in an educational hospital in Southern Iran.

Science.gov (United States)

Haghighi, Mohammad Hosein Hayavi; Dehghani, Mohammad; Teshnizi, Saeid Hoseini; Mahmoodi, Hamid

2014-01-01

Accurate cause of death coding leads to organised and usable death information but there are some factors that influence documentation on death certificates and therefore affect the coding. We reviewed the role of documentation errors on the accuracy of death coding at Shahid Mohammadi Hospital (SMH), Bandar Abbas, Iran. We studied the death certificates of all deceased patients in SMH from October 2010 to March 2011. Researchers determined and coded the underlying cause of death on the death certificates according to the guidelines issued by the World Health Organization in Volume 2 of the International Statistical Classification of Diseases and Health Related Problems-10th revision (ICD-10). Necessary ICD coding rules (such as the General Principle, Rules 1-3, the modification rules and other instructions about death coding) were applied to select the underlying cause of death on each certificate. Demographic details and documentation errors were then extracted. Data were analysed with descriptive statistics and chi square tests. The accuracy rate of causes of death coding was 51.7%, demonstrating a statistically significant relationship (p=.001) with major errors but not such a relationship with minor errors. Factors that result in poor quality of Cause of Death coding in SMH are lack of coder training, documentation errors and the undesirable structure of death certificates.

Attitudes of Mashhad Public Hospital's Nurses and Midwives toward the Causes and Rates of Medical Errors Reporting.

Science.gov (United States)

Mobarakabadi, Sedigheh Sedigh; Ebrahimipour, Hosein; Najar, Ali Vafaie; Janghorban, Roksana; Azarkish, Fatemeh

2017-03-01

Patient's safety is one of the main objective in healthcare services; however medical errors are a prevalent potential occurrence for the patients in treatment systems. Medical errors lead to an increase in mortality rate of the patients and challenges such as prolonging of the inpatient period in the hospitals and increased cost. Controlling the medical errors is very important, because these errors besides being costly, threaten the patient's safety. To evaluate the attitudes of nurses and midwives toward the causes and rates of medical errors reporting. It was a cross-sectional observational study. The study population was 140 midwives and nurses employed in Mashhad Public Hospitals. The data collection was done through Goldstone 2001 revised questionnaire. SPSS 11.5 software was used for data analysis. To analyze data, descriptive and inferential analytic statistics were used. Standard deviation and relative frequency distribution, descriptive statistics were used for calculation of the mean and the results were adjusted as tables and charts. Chi-square test was used for the inferential analysis of the data. Most of midwives and nurses (39.4%) were in age range of 25 to 34 years and the lowest percentage (2.2%) were in age range of 55-59 years. The highest average of medical errors was related to employees with three-four years of work experience, while the lowest average was related to those with one-two years of work experience. The highest average of medical errors was during the evening shift, while the lowest were during the night shift. Three main causes of medical errors were considered: illegibile physician prescription orders, similarity of names in different drugs and nurse fatigueness. The most important causes for medical errors from the viewpoints of nurses and midwives are illegible physician's order, drug name similarity with other drugs, nurse's fatigueness and damaged label or packaging of the drug, respectively. Head nurse feedback, peer

Consonant acquisition: a first approach to the distribution of errors in four positions in the word

Directory of Open Access Journals (Sweden)

Silvia Llach

2012-12-01

Full Text Available The goal of this study is to describe the behavior of errors in two types of onsets (initial and intervocalic and two types of codas (in the middle and end of the word in order to determine if any of these positions are more prone to specific types of errors than the others.We have looked into the errors that are frequently produced in these four contexts during the acquisition of consonant sounds in the Catalan language. The data were taken from a study on the acquisition of consonants in Catalan, carried out on 90 children between the ages of 3 and 5 years from several kindergarten schools. The results do show that there are characteristic errors depending on the position within the word.

Determining The Factors Causing Human Error Deficiencies At A Public Utility Company

Directory of Open Access Journals (Sweden)

F. W. Badenhorst

2004-11-01

Full Text Available According to Neff (1977, as cited by Bergh (1995, the westernised culture considers work important for industrial mental health. Most individuals experience work positively, which creates a positive attitude. Should this positive attitude be inhibited, workers could lose concentration and become bored, potentially resulting in some form of human error. The aim of this research was to determine the factors responsible for human error events, which lead to power supply failures at Eskom power stations. Proposals were made for the reduction of these contributing factors towards improving plant performance. The target population was 700 panel operators in Eskom’s Power Generation Group. The results showed that factors leading to human error can be reduced or even eliminated. Opsomming Neff (1977 soos aangehaal deur Bergh (1995, skryf dat in die westerse kultuur werk belangrik vir bedryfsgeestesgesondheid is. Die meeste persone ervaar werk as positief, wat ’n positiewe gesindheid kweek. Indien hierdie positiewe gesindheid geïnhibeer word, kan dit lei tot ’n gebrek aan konsentrasie by die werkers. Werkers kan verveeld raak en dit kan weer lei tot menslike foute. Die doel van hierdie navorsing is om die faktore vas te stel wat tot menslike foute lei, en wat bydra tot onderbrekings in kragvoorsiening by Eskom kragstasies. Voorstelle is gemaak vir die vermindering van hierdie bydraende faktore ten einde die kragaanleg se prestasie te verbeter. Die teiken-populasie was 700 paneel-operateurs in die Kragopwekkingsgroep by Eskom. Die resultate dui daarop dat die faktore wat aanleiding gee tot menslike foute wel verminder, of geëlimineer kan word.

Investigating the causes of human error-induced incidents in the maintenance operations of petrochemical industry by using HFACS

Directory of Open Access Journals (Sweden)

Mohammadreza Azhdari

2017-03-01

Full Text Available Background & Objectives: Maintenance is an important tool for the petrochemical industries to prevent of accidents and increase operational and process safety success. The purpose of this study was to identify the possible causes of incidents caused by human error in the petrochemical maintenance activities by using Human Factors Analysis and Classification System (HFACS. Methods: This study is a cross-sectional analysis that was conducted in Zagros Petrochemical Company, Asaluyeh-Iran. A checklist of human error-induced incidents was developed based on four HFACS main levels and nineteen sub-groups. Hierarchical task analysis (HTA technique was used to identify maintenance activities and tasks. The main causes of possible incidents were identified by checklist and recorded. Corrective and preventive actions were defined depending on priority.   Results: The content analysis of worksheets of 444 activities showed 37.6% of the causes at the level of unsafe actions, 27.5% at the level of unsafe supervision, 20.9% at the level of preconditions for unsafe acts and 14% of the causes at the level of organizational effects. The HFACS sub-groups showed errors (24.36% inadequate supervision (14.89% and violations (13.26% with the most frequency. Conclusion: In order to prevent and reduce the occurrence of the identified errors, reducing the rate of the detected errors is crucial. Findings of this study showed that appropriate controlling measures such as periodical training of work procedures and supervision improvement decrease the human error-induced incidents in petrochemical industry maintenance.

Implication of spot position error on plan quality and patient safety in pencil-beam-scanning proton therapy

Energy Technology Data Exchange (ETDEWEB)

Yu, Juan; Beltran, Chris J., E-mail: beltran.chris@mayo.edu; Herman, Michael G. [Division of Medical Physics, Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota 55905 (United States)

2014-08-15

Purpose: To quantitatively and systematically assess dosimetric effects induced by spot positioning error as a function of spot spacing (SS) on intensity-modulated proton therapy (IMPT) plan quality and to facilitate evaluation of safety tolerance limits on spot position. Methods: Spot position errors (PE) ranging from 1 to 2 mm were simulated. Simple plans were created on a water phantom, and IMPT plans were calculated on two pediatric patients with a brain tumor of 28 and 3 cc, respectively, using a commercial planning system. For the phantom, a uniform dose was delivered to targets located at different depths from 10 to 20 cm with various field sizes from 2{sup 2} to 15{sup 2} cm{sup 2}. Two nominal spot sizes, 4.0 and 6.6 mm of 1 σ in water at isocenter, were used for treatment planning. The SS ranged from 0.5 σ to 1.5 σ, which is 2–6 mm for the small spot size and 3.3–9.9 mm for the large spot size. Various perturbation scenarios of a single spot error and systematic and random multiple spot errors were studied. To quantify the dosimetric effects, percent dose error (PDE) depth profiles and the value of percent dose error at the maximum dose difference (PDE [ΔDmax]) were used for evaluation. Results: A pair of hot and cold spots was created per spot shift. PDE[ΔDmax] is found to be a complex function of PE, SS, spot size, depth, and global spot distribution that can be well defined in simple models. For volumetric targets, the PDE [ΔDmax] is not noticeably affected by the change of field size or target volume within the studied ranges. In general, reducing SS decreased the dose error. For the facility studied, given a single spot error with a PE of 1.2 mm and for both spot sizes, a SS of 1σ resulted in a 2% maximum dose error; a SS larger than 1.25 σ substantially increased the dose error and its sensitivity to PE. A similar trend was observed in multiple spot errors (both systematic and random errors). Systematic PE can lead to noticeable hot

Effect of MLC leaf position, collimator rotation angle, and gantry rotation angle errors on intensity-modulated radiotherapy plans for nasopharyngeal carcinoma

Energy Technology Data Exchange (ETDEWEB)

Bai, Sen; Li, Guangjun; Wang, Maojie; Jiang, Qinfeng; Zhang, Yingjie [State Key Laboratory of Biotherapy and Cancer Center, West China Hospital, Sichuan University, Chengdu, Sichuan (China); Wei, Yuquan, E-mail: yuquawei@vip.sina.com [State Key Laboratory of Biotherapy and Cancer Center, West China Hospital, Sichuan University, Chengdu, Sichuan (China)

2013-07-01

The purpose of this study was to investigate the effect of multileaf collimator (MLC) leaf position, collimator rotation angle, and accelerator gantry rotation angle errors on intensity-modulated radiotherapy plans for nasopharyngeal carcinoma. To compare dosimetric differences between the simulating plans and the clinical plans with evaluation parameters, 6 patients with nasopharyngeal carcinoma were selected for simulation of systematic and random MLC leaf position errors, collimator rotation angle errors, and accelerator gantry rotation angle errors. There was a high sensitivity to dose distribution for systematic MLC leaf position errors in response to field size. When the systematic MLC position errors were 0.5, 1, and 2 mm, respectively, the maximum values of the mean dose deviation, observed in parotid glands, were 4.63%, 8.69%, and 18.32%, respectively. The dosimetric effect was comparatively small for systematic MLC shift errors. For random MLC errors up to 2 mm and collimator and gantry rotation angle errors up to 0.5°, the dosimetric effect was negligible. We suggest that quality control be regularly conducted for MLC leaves, so as to ensure that systematic MLC leaf position errors are within 0.5 mm. Because the dosimetric effect of 0.5° collimator and gantry rotation angle errors is negligible, it can be concluded that setting a proper threshold for allowed errors of collimator and gantry rotation angle may increase treatment efficacy and reduce treatment time.

WISC-R Examiner Errors: Cause for Concern.

Science.gov (United States)

Slate, John R.; Chick, David

1989-01-01

Clinical psychology graduate students (N=14) administered Wechsler Intelligence Scale for Children-Revised. Found numerous scoring and mechanical errors that influenced full-scale intelligence quotient scores on two-thirds of protocols. Particularly prone to error were Verbal subtests of Vocabulary, Comprehension, and Similarities. Noted specific…

The Effect of Antenna Position Errors on Redundant-Baseline Calibration of HERA

Science.gov (United States)

Orosz, Naomi; Dillon, Joshua; Ewall-Wice, Aaron; Parsons, Aaron; HERA Collaboration

2018-01-01

HERA (the Hydrogen Epoch of Reionization Array) is a large, highly-redundant radio interferometer in South Africa currently being built out to 350 14-m dishes. Its mission is to probe large scale structure during and prior to the epoch of reionization using the 21 cm hyperfine transition of neutral hydrogen. The array is designed to be calibrated using redundant baselines of known lengths. However, the dishes can deviate from ideal positions, with errors on the order of a few centimeters. This potentially increases foreground contamination of the 21 cm power spectrum in the cleanest part of Fourier space. The calibration algorithm treats groups of baselines that should be redundant, but are not due to position errors, as if they actually are. Accurate, precise calibration is critical because the foreground signals are 100,000 times stronger than the reionization signal. We explain the origin of this effect and discuss weighting strategies to mitigate it.

Dose variations caused by setup errors in intracranial stereotactic radiotherapy: A PRESAGE study

International Nuclear Information System (INIS)

Teng, Kieyin; Gagliardi, Frank; Alqathami, Mamdooh; Ackerly, Trevor; Geso, Moshi

2014-01-01

Stereotactic radiotherapy (SRT) requires tight margins around the tumor, thus producing a steep dose gradient between the tumor and the surrounding healthy tissue. Any setup errors might become clinically significant. To date, no study has been performed to evaluate the dosimetric variations caused by setup errors with a 3-dimensional dosimeter, the PRESAGE. This research aimed to evaluate the potential effect that setup errors have on the dose distribution of intracranial SRT. Computed tomography (CT) simulation of a CIRS radiosurgery head phantom was performed with 1.25-mm slice thickness. An ideal treatment plan was generated using Brainlab iPlan. A PRESAGE was made for every treatment with and without errors. A prescan using the optical CT scanner was carried out. Before treatment, the phantom was imaged using Brainlab ExacTrac. Actual radiotherapy treatments with and without errors were carried out with the Novalis treatment machine. Postscan was performed with an optical CT scanner to analyze the dose irradiation. The dose variation between treatments with and without errors was determined using a 3-dimensional gamma analysis. Errors are clinically insignificant when the passing ratio of the gamma analysis is 95% and above. Errors were clinically significant when the setup errors exceeded a 0.7-mm translation and a 0.5° rotation. The results showed that a 3-mm translation shift in the superior-inferior (SI), right-left (RL), and anterior-posterior (AP) directions and 2° couch rotation produced a passing ratio of 53.1%. Translational and rotational errors of 1.5 mm and 1°, respectively, generated a passing ratio of 62.2%. Translation shift of 0.7 mm in the directions of SI, RL, and AP and a 0.5° couch rotation produced a passing ratio of 96.2%. Preventing the occurrences of setup errors in intracranial SRT treatment is extremely important as errors greater than 0.7 mm and 0.5° alter the dose distribution. The geometrical displacements affect dose delivery

SU-F-J-208: Prompt Gamma Imaging-Based Prediction of Bragg Peak Position for Realistic Treatment Error Scenarios

Energy Technology Data Exchange (ETDEWEB)

Xing, Y; Macq, B; Bondar, L [Universite catholique de Louvain, Louvain-la-Neuve (Belgium); Janssens, G [IBA, Louvain-la-Neuve (Belgium)

2016-06-15

Purpose: To quantify the accuracy in predicting the Bragg peak position using simulated in-room measurements of prompt gamma (PG) emissions for realistic treatment error scenarios that combine several sources of errors. Methods: Prompt gamma measurements by a knife-edge slit camera were simulated using an experimentally validated analytical simulation tool. Simulations were performed, for 143 treatment error scenarios, on an anthropomorphic phantom and a pencil beam scanning plan for nasal cavity. Three types of errors were considered: translation along each axis, rotation around each axis, and CT-calibration errors with magnitude ranging respectively, between −3 and 3 mm, −5 and 5 degrees, and between −5 and +5%. We investigated the correlation between the Bragg peak (BP) shift and the horizontal shift of PG profiles. The shifts were calculated between the planned (reference) position and the position by the error scenario. The prediction error for one spot was calculated as the absolute difference between the PG profile shift and the BP shift. Results: The PG shift was significantly and strongly correlated with the BP shift for 92% of the cases (p<0.0001, Pearson correlation coefficient R>0.8). Moderate but significant correlations were obtained for all cases that considered only CT-calibration errors and for 1 case that combined translation and CT-errors (p<0.0001, R ranged between 0.61 and 0.8). The average prediction errors for the simulated scenarios ranged between 0.08±0.07 and 1.67±1.3 mm (grand mean 0.66±0.76 mm). The prediction error was moderately correlated with the value of the BP shift (p=0, R=0.64). For the simulated scenarios the average BP shift ranged between −8±6.5 mm and 3±1.1 mm. Scenarios that considered combinations of the largest treatment errors were associated with large BP shifts. Conclusion: Simulations of in-room measurements demonstrate that prompt gamma profiles provide reliable estimation of the Bragg peak position for

Influence of random setup error on dose distribution

International Nuclear Information System (INIS)

Zhai Zhenyu

2008-01-01

Objective: To investigate the influence of random setup error on dose distribution in radiotherapy and determine the margin from ITV to PTV. Methods: A random sample approach was used to simulate the fields position in target coordinate system. Cumulative effect of random setup error was the sum of dose distributions of all individual treatment fractions. Study of 100 cumulative effects might get shift sizes of 90% dose point position. Margins from ITV to PTV caused by random setup error were chosen by 95% probability. Spearman's correlation was used to analyze the influence of each factor. Results: The average shift sizes of 90% dose point position was 0.62, 1.84, 3.13, 4.78, 6.34 and 8.03 mm if random setup error was 1,2,3,4,5 and 6 mm,respectively. Univariate analysis showed the size of margin was associated only by the size of random setup error. Conclusions: Margin of ITV to PTV is 1.2 times random setup error for head-and-neck cancer and 1.5 times for thoracic and abdominal cancer. Field size, energy and target depth, unlike random setup error, have no relation with the size of the margin. (authors)

SU-E-J-94: Positioning Errors Resulting From Using Bony Anatomy Alignment for Treating SBRT Lung Tumor

International Nuclear Information System (INIS)

Frame, C; Ding, G

2014-01-01

Purpose: To quantify patient setups errors based on bony anatomy registration rather than 3D tumor alignment for SBRT lung treatments. Method: A retrospective study was performed for patients treated with lung SBRT and imaged with kV cone beam computed tomography (kV-CBCT) image-guidance. Daily CBCT images were registered to treatment planning CTs based on bony anatomy alignment and then inter-fraction tumor movement was evaluated by comparing shift in the tumor center in the medial-lateral, anterior-posterior, and superior-inferior directions. The PTV V100% was evaluated for each patient based on the average daily tumor displacement to assess the impact of the positioning error on the target coverage when the registrations were based on bony anatomy. Of the 35 patients studied, 15 were free-breathing treatments, 10 used abdominal compression with a stereotactic body frame, and the remaining 10 were performed with BodyFIX vacuum bags. Results: For free-breathing treatments, the range of tumor displacement error is between 1–6 mm in the medial-lateral, 1–13 mm in the anterior-posterior, and 1–7 mm in the superior-inferior directions. These positioning errors lead to 6–22% underdose coverage for PTV - V100% . Patients treated with abdominal compression immobilization showed positional errors of 0–4mm mediallaterally, 0–3mm anterior-posteriorly, and 0–2 mm inferior-superiorly with PTV - V100% underdose ranging between 6–17%. For patients immobilized with the vacuum bags, the positional errors were found to be 0–1 mm medial-laterally, 0–1mm anterior-posteriorly, and 0–2 mm inferior-superiorly with PTV - V100% under dose ranging between 5–6% only. Conclusion: It is necessary to align the tumor target by using 3D image guidance to ensure adequate tumor coverage before performing SBRT lung treatments. The BodyFIX vacuum bag immobilization method has the least positioning errors among the three methods studied when bony anatomy is used for

Influence of Marker Movement Errors on Measuring 3 Dimentional Scapular Position and Orientation

Directory of Open Access Journals (Sweden)

Afsoun Nodehi-Moghaddam

2003-12-01

Full Text Available Objective: Scapulothoracic muscles weakness or fatique can result in abnormal scapular positioning and compromising scapulo-humeral rhythm and shoulder dysfunction .The scapula moves in a -3 Dimentional fashion so the use of 2-Dimentional Techniques cannot fully capture scapular motion . One of approaches to positioining markers of kinematic systems is to mount each marker directly on the skin generally over a bony anatomical landmarks . Howerer skin movement and Motion of underlying bony structures are not Necessaritly identical and substantial errors may be introduced in the description of bone movement when using skin –mounted markers. evaluation of Influence of marker movement errors on 3-Dimentional scapular position and orientation. Materials & Methods: 10 Healthy subjects with a mean age 30.50 participated in the study . They were tested in three sessions A 3-dimentiional electro mechanical digitizer was used to measure scapular position and orientation measures were obtained while arm placed at the side of the body and elevated 45٫90٫120 and full Rang of motion in the scapular plane . At each test positions six bony landmarks were palpated and skin markers were mounted on them . This procedure repeated in the second test session in third session Removal of markers was not performed through obtaining entire Range of motion after mounting the markers . Results: The intraclass correlation coefficients (ICC for scapulor variables were higher (0.92-0.84 when markers were replaced and re-mounted on bony landmarks with Increasing the angle of elevation. Conclusion: our findings suggested significant markers movement error on measuring the upward Rotation and posterior tilt angle of scapula.

SU-E-T-132: Dosimetric Impact of Positioning Errors in Hypo-Fractionated Cranial Radiation Therapy Using Frameless Stereotactic BrainLAB System

International Nuclear Information System (INIS)

Keeling, V; Jin, H; Ali, I; Ahmad, S

2014-01-01

Purpose: To determine dosimetric impact of positioning errors in the stereotactic hypo-fractionated treatment of intracranial lesions using 3Dtransaltional and 3D-rotational corrections (6D) frameless BrainLAB ExacTrac X-Ray system. Methods: 20 cranial lesions, treated in 3 or 5 fractions, were selected. An infrared (IR) optical positioning system was employed for initial patient setup followed by stereoscopic kV X-ray radiographs for position verification. 6D-translational and rotational shifts were determined to correct patient position. If these shifts were above tolerance (0.7 mm translational and 1° rotational), corrections were applied and another set of X-rays was taken to verify patient position. Dosimetric impact (D95, Dmin, Dmax, and Dmean of planning target volume (PTV) compared to original plans) of positioning errors for initial IR setup (XC: Xray Correction) and post-correction (XV: X-ray Verification) was determined in a treatment planning system using a method proposed by Yue et al. (Med. Phys. 33, 21-31 (2006)) with 3D-translational errors only and 6D-translational and rotational errors. Results: Absolute mean translational errors (±standard deviation) for total 92 fractions (XC/XV) were 0.79±0.88/0.19±0.15 mm (lateral), 1.66±1.71/0.18 ±0.16 mm (longitudinal), 1.95±1.18/0.15±0.14 mm (vertical) and rotational errors were 0.61±0.47/0.17±0.15° (pitch), 0.55±0.49/0.16±0.24° (roll), and 0.68±0.73/0.16±0.15° (yaw). The average changes (loss of coverage) in D95, Dmin, Dmax, and Dmean were 4.5±7.3/0.1±0.2%, 17.8±22.5/1.1±2.5%, 0.4±1.4/0.1±0.3%, and 0.9±1.7/0.0±0.1% using 6Dshifts and 3.1±5.5/0.0±0.1%, 14.2±20.3/0.8±1.7%, 0.0±1.2/0.1±0.3%, and 0.7±1.4/0.0±0.1% using 3D-translational shifts only. The setup corrections (XC-XV) improved the PTV coverage by 4.4±7.3% (D95) and 16.7±23.5% (Dmin) using 6D adjustment. Strong correlations were observed between translation errors and deviations in dose coverage for XC. Conclusion

A new stochastic model considering satellite clock interpolation errors in precise point positioning

Science.gov (United States)

Wang, Shengli; Yang, Fanlin; Gao, Wang; Yan, Lizi; Ge, Yulong

2018-03-01

Precise clock products are typically interpolated based on the sampling interval of the observational data when they are used for in precise point positioning. However, due to the occurrence of white noise in atomic clocks, a residual component of such noise will inevitable reside within the observations when clock errors are interpolated, and such noise will affect the resolution of the positioning results. In this paper, which is based on a twenty-one-week analysis of the atomic clock noise characteristics of numerous satellites, a new stochastic observation model that considers satellite clock interpolation errors is proposed. First, the systematic error of each satellite in the IGR clock product was extracted using a wavelet de-noising method to obtain the empirical characteristics of atomic clock noise within each clock product. Then, based on those empirical characteristics, a stochastic observation model was structured that considered the satellite clock interpolation errors. Subsequently, the IGR and IGS clock products at different time intervals were used for experimental validation. A verification using 179 stations worldwide from the IGS showed that, compared with the conventional model, the convergence times using the stochastic model proposed in this study were respectively shortened by 4.8% and 4.0% when the IGR and IGS 300-s-interval clock products were used and by 19.1% and 19.4% when the 900-s-interval clock products were used. Furthermore, the disturbances during the initial phase of the calculation were also effectively improved.

Measurement Error Estimation for Capacitive Voltage Transformer by Insulation Parameters

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Bin Chen

2017-03-01

Full Text Available Measurement errors of a capacitive voltage transformer (CVT are relevant to its equivalent parameters for which its capacitive divider contributes the most. In daily operation, dielectric aging, moisture, dielectric breakdown, etc., it will exert mixing effects on a capacitive divider’s insulation characteristics, leading to fluctuation in equivalent parameters which result in the measurement error. This paper proposes an equivalent circuit model to represent a CVT which incorporates insulation characteristics of a capacitive divider. After software simulation and laboratory experiments, the relationship between measurement errors and insulation parameters is obtained. It indicates that variation of insulation parameters in a CVT will cause a reasonable measurement error. From field tests and calculation, equivalent capacitance mainly affects magnitude error, while dielectric loss mainly affects phase error. As capacitance changes 0.2%, magnitude error can reach −0.2%. As dielectric loss factor changes 0.2%, phase error can reach 5′. An increase of equivalent capacitance and dielectric loss factor in the high-voltage capacitor will cause a positive real power measurement error. An increase of equivalent capacitance and dielectric loss factor in the low-voltage capacitor will cause a negative real power measurement error.

Effect of cooling on thixotropic position-sense error in human biceps muscle.

Science.gov (United States)

Sekihara, Chikara; Izumizaki, Masahiko; Yasuda, Tomohiro; Nakajima, Takayuki; Atsumi, Takashi; Homma, Ikuo

2007-06-01

Muscle temperature affects muscle thixotropy. However, it is unclear whether changes in muscle temperature affect thixotropic position-sense errors. We studied the effect of cooling on thixotropic position-sense errors induced by short-length muscle contraction (hold-short conditioning) in the biceps of 12 healthy men. After hold-short conditioning of the right biceps muscle in a cooled (5.0 degrees C) or control (36.5 degrees C) environment, subjects perceived greater extension of the conditioned forearm at 5.0 degrees C. The angle differences between the two forearms following hold-short conditioning of the right biceps muscle in normal or cooled conditions were significantly different (-3.335 +/- 1.680 degrees at 36.5 degrees C vs. -5.317 +/- 1.096 degrees at 5.0 degrees C; P=0.043). Induction of a tonic vibration reflex in the biceps muscle elicited involuntary forearm elevation, and the angular velocities of the elevation differed significantly between arms conditioned in normal and cooled environments (1.583 +/- 0.326 degrees /s at 36.5 degrees C vs. 3.100 +/- 0.555 degrees /s at 5.0 degrees C, P=0.0039). Thus, a cooled environment impairs a muscle's ability to provide positional information, potentially leading to poor muscle performance.

Observations of geographically correlated orbit errors for TOPEX/Poseidon using the global positioning system

Science.gov (United States)

Christensen, E. J.; Haines, B. J.; Mccoll, K. C.; Nerem, R. S.

1994-01-01

We have compared Global Positioning System (GPS)-based dynamic and reduced-dynamic TOPEX/Poseidon orbits over three 10-day repeat cycles of the ground-track. The results suggest that the prelaunch joint gravity model (JGM-1) introduces geographically correlated errors (GCEs) which have a strong meridional dependence. The global distribution and magnitude of these GCEs are consistent with a prelaunch covariance analysis, with estimated and predicted global rms error statistics of 2.3 and 2.4 cm rms, respectively. Repeating the analysis with the post-launch joint gravity model (JGM-2) suggests that a portion of the meridional dependence observed in JGM-1 still remains, with global rms error of 1.2 cm.

SU-F-T-381: Fast Calculation of Three-Dimensional Dose Considering MLC Leaf Positional Errors for VMAT Plans

Energy Technology Data Exchange (ETDEWEB)

Katsuta, Y [Takeda General Hospital, Aizuwakamatsu City, Fukushima (Japan); Tohoku University Graduate School of Medicine, Sendal, Miyagi (Japan); Kadoya, N; Jingu, K [Tohoku University Graduate School of Medicine, Sendal, Miyagi (Japan); Shimizu, E; Majima, K [Takeda General Hospital, Aizuwakamatsu City, Fukushima (Japan)

2016-06-15

Purpose: In this study, we developed a system to calculate three dimensional (3D) dose that reflects dosimetric error caused by leaf miscalibration for head and neck and prostate volumetric modulated arc therapy (VMAT) without additional treatment planning system calculation on real time. Methods: An original system called clarkson dose calculation based dosimetric error calculation to calculate dosimetric error caused by leaf miscalibration was developed by MATLAB (Math Works, Natick, MA). Our program, first, calculates point doses at isocenter for baseline and modified VMAT plan, which generated by inducing MLC errors that enlarged aperture size of 1.0 mm with clarkson dose calculation. Second, error incuced 3D dose was generated with transforming TPS baseline 3D dose using calculated point doses. Results: Mean computing time was less than 5 seconds. For seven head and neck and prostate plans, between our method and TPS calculated error incuced 3D dose, the 3D gamma passing rates (0.5%/2 mm, global) are 97.6±0.6% and 98.0±0.4%. The dose percentage change with dose volume histogram parameter of mean dose on target volume were 0.1±0.5% and 0.4±0.3%, and with generalized equivalent uniform dose on target volume were −0.2±0.5% and 0.2±0.3%. Conclusion: The erroneous 3D dose calculated by our method is useful to check dosimetric error caused by leaf miscalibration before pre treatment patient QA dosimetry checks.

Compensation of position errors in passivity based teleoperation over packet switched communication networks

NARCIS (Netherlands)

Secchi, C; Stramigioli, Stefano; Fantuzzi, C.

Because of the use of scattering based communication channels, passivity based telemanipulation systems can be subject to a steady state position error between master and slave robots. In this paper, we consider the case in which the passive master and slave sides communicate through a packet

Descriptions of verbal communication errors between staff. An analysis of 84 root cause analysis-reports from Danish hospitals

DEFF Research Database (Denmark)

Rabøl, Louise Isager; Andersen, Mette Lehmann; Østergaard, Doris

2011-01-01

incidents. The objective of this study is to review RCA reports (RCAR) for characteristics of verbal communication errors between hospital staff in an organisational perspective. Method Two independent raters analysed 84 RCARs, conducted in six Danish hospitals between 2004 and 2006, for descriptions......Introduction Poor teamwork and communication between healthcare staff are correlated to patient safety incidents. However, the organisational factors responsible for these issues are unexplored. Root cause analyses (RCA) use human factors thinking to analyse the systems behind severe patient safety...... and characteristics of verbal communication errors such as handover errors and error during teamwork. Results Raters found description of verbal communication errors in 44 reports (52%). These included handover errors (35 (86%)), communication errors between different staff groups (19 (43%)), misunderstandings (13...

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.

Community Influences on the Material Liability of Magistrates for Prejudices Caused by Material Errors

Directory of Open Access Journals (Sweden)

Adriana Ioana Pîrvu

2010-06-01

Full Text Available The paper`s main issue is the fact that in the last years Romania is on top of the list of the states paying the highest damages further to the convictions in front of ECHR, fact that determines an increasing dissatisfaction of legal experts but also of the population. This controversial situation generated the reconsideration of the material liability of magistrates, for the judicial errors and the prejudices consequently created, established not only before international courts but also before domestic courts. Tacking into consideration that, at present, numerous proposals for settling this issue come from more and more subjects, with or without a legislative initiative right, among which the Ministry of Economy and Finances, the Ministry of Justice or The Superior Council of Magistrature the paper tries to capture a perspective view ofthe material liability of magistrates, for the judicial errors in our legal system but also in other systems of law, which can be seen as a source of inspiration. According to the legislation in force, the only one liable before an injured party that suffered a prejudice through a judicial error is the state, whose right and possibility torecover the counter value granted to the prejudiced person through the filing of recourse action against the judge to whom the judicial error is imputable, are acknowledged. The magistrate may be held liable only when the judicial error is caused by the exercise of the function in bad faith or with serious negligence. The application of such concepts as “bad faith” and “serious negligence” is, however, difficult, due to insufficient criteria for their interpretation, considering all the nuances, and quantification, included by law. Also, please note that, through the creation of the possibility that each individual holds the magistrate liable for alleged prejudices caused by the latter, the magistrate’s liability and the good functioning of justice would be seriously

On minimizing assignment errors and the trade-off between false positives and negatives in parentage analysis

KAUST Repository

Harrison, Hugo B.

2013-11-04

Genetic parentage analyses provide a practical means with which to identify parent-offspring relationships in the wild. In Harrison et al.\\'s study (2013a), we compare three methods of parentage analysis and showed that the number and diversity of microsatellite loci were the most important factors defining the accuracy of assignments. Our simulations revealed that an exclusion-Bayes theorem method was more susceptible to false-positive and false-negative assignments than other methods tested. Here, we analyse and discuss the trade-off between type I and type II errors in parentage analyses. We show that controlling for false-positive assignments, without reporting type II errors, can be misleading. Our findings illustrate the need to estimate and report both the rate of false-positive and false-negative assignments in parentage analyses. © 2013 John Wiley & Sons Ltd.

On minimizing assignment errors and the trade-off between false positives and negatives in parentage analysis

KAUST Repository

Harrison, Hugo B.; Saenz Agudelo, Pablo; Planes, Serge; Jones, Geoffrey P.; Berumen, Michael L.

2013-01-01

Genetic parentage analyses provide a practical means with which to identify parent-offspring relationships in the wild. In Harrison et al.'s study (2013a), we compare three methods of parentage analysis and showed that the number and diversity of microsatellite loci were the most important factors defining the accuracy of assignments. Our simulations revealed that an exclusion-Bayes theorem method was more susceptible to false-positive and false-negative assignments than other methods tested. Here, we analyse and discuss the trade-off between type I and type II errors in parentage analyses. We show that controlling for false-positive assignments, without reporting type II errors, can be misleading. Our findings illustrate the need to estimate and report both the rate of false-positive and false-negative assignments in parentage analyses. © 2013 John Wiley & Sons Ltd.

Threats to repair injury caused by judicial errors and criminal damage

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Muntean Vasilisa

2017-12-01

Full Text Available The grounds for the occurrence of punitive damages are related to the illicit actions of the persons with responsibilities in the courts and the criminal prosecution bodies. In order to provide protection against such unfair situations, there are a number of legal guarantees. The legislator has highlighted both the specific circle of reasons (illegal detention, unlawful criminal prosecution, unlawful sentencing, etc. necessary to ensure that the damage caused to the person can be repaired, as well as the circle of conditions for the right to reparation (the acquittal, the order for termination of the criminal proceedings or for the prosecution, etc.. The reparation of the damage caused by judicial and criminal prosecution errors arises at the time when the act whereby the person was convicted or illegally arrested, ie at the time when the rehabilitation act became irrevocable, was found to be illegal.

Evaluation of alignment error of micropore X-ray optics caused by hot plastic deformation

Science.gov (United States)

Numazawa, Masaki; Ishi, Daiki; Ezoe, Yuichiro; Takeuchi, Kazuma; Terada, Masaru; Fujitani, Maiko; Ishikawa, Kumi; Nakajima, Kazuo; Morishita, Kohei; Ohashi, Takaya; Mitsuda, Kazuhisa; Nakamura, Kasumi; Noda, Yusuke

2018-06-01

We report on the evaluation and characterization of micro-electromechanical system (MEMS) X-ray optics produced by silicon dry etching and hot plastic deformation. Sidewalls of micropores formed by etching through a silicon wafer are used as X-ray reflecting mirrors. The wafer is deformed into a spherical shape to focus parallel incidence X-rays. We quantitatively evaluated a mirror alignment error using an X-ray pencil beam (Al Kα line at 1.49 keV). The deviation angle caused only by the deformation was estimated from angular shifts of the X-ray focusing point before and after the deformation to be 2.7 ± 0.3 arcmin on average within the optics. This gives an angular resolution of 12.9 ± 1.4 arcmin in half-power diameter (HPD). The surface profile of the deformed optics measured using a NH-3Ns surface profiler (Mitaka Kohki) also indicated that the resolution was 11.4 ± 0.9 arcmin in HPD, suggesting that we can simply evaluate the alignment error caused by the hot plastic deformation.

Reduction in specimen labeling errors after implementation of a positive patient identification system in phlebotomy.

Science.gov (United States)

Morrison, Aileen P; Tanasijevic, Milenko J; Goonan, Ellen M; Lobo, Margaret M; Bates, Michael M; Lipsitz, Stuart R; Bates, David W; Melanson, Stacy E F

2010-06-01

Ensuring accurate patient identification is central to preventing medical errors, but it can be challenging. We implemented a bar code-based positive patient identification system for use in inpatient phlebotomy. A before-after design was used to evaluate the impact of the identification system on the frequency of mislabeled and unlabeled samples reported in our laboratory. Labeling errors fell from 5.45 in 10,000 before implementation to 3.2 in 10,000 afterward (P = .0013). An estimated 108 mislabeling events were prevented by the identification system in 1 year. Furthermore, a workflow step requiring manual preprinting of labels, which was accompanied by potential labeling errors in about one quarter of blood "draws," was removed as a result of the new system. After implementation, a higher percentage of patients reported having their wristband checked before phlebotomy. Bar code technology significantly reduced the rate of specimen identification errors.

SU-G-BRB-03: Assessing the Sensitivity and False Positive Rate of the Integrated Quality Monitor (IQM) Large Area Ion Chamber to MLC Positioning Errors

Energy Technology Data Exchange (ETDEWEB)

Boehnke, E McKenzie; DeMarco, J; Steers, J; Fraass, B [Cedars-Sinai Medical Center, Los Angeles, CA (United States)

2016-06-15

Purpose: To examine both the IQM’s sensitivity and false positive rate to varying MLC errors. By balancing these two characteristics, an optimal tolerance value can be derived. Methods: An un-modified SBRT Liver IMRT plan containing 7 fields was randomly selected as a representative clinical case. The active MLC positions for all fields were perturbed randomly from a square distribution of varying width (±1mm to ±5mm). These unmodified and modified plans were measured multiple times each by the IQM (a large area ion chamber mounted to a TrueBeam linac head). Measurements were analyzed relative to the initial, unmodified measurement. IQM readings are analyzed as a function of control points. In order to examine sensitivity to errors along a field’s delivery, each measured field was divided into 5 groups of control points, and the maximum error in each group was recorded. Since the plans have known errors, we compared how well the IQM is able to differentiate between unmodified and error plans. ROC curves and logistic regression were used to analyze this, independent of thresholds. Results: A likelihood-ratio Chi-square test showed that the IQM could significantly predict whether a plan had MLC errors, with the exception of the beginning and ending control points. Upon further examination, we determined there was ramp-up occurring at the beginning of delivery. Once the linac AFC was tuned, the subsequent measurements (relative to a new baseline) showed significant (p <0.005) abilities to predict MLC errors. Using the area under the curve, we show the IQM’s ability to detect errors increases with increasing MLC error (Spearman’s Rho=0.8056, p<0.0001). The optimal IQM count thresholds from the ROC curves are ±3%, ±2%, and ±7% for the beginning, middle 3, and end segments, respectively. Conclusion: The IQM has proven to be able to detect not only MLC errors, but also differences in beam tuning (ramp-up). Partially supported by the Susan Scott Foundation.

The role of positional errors while interpolating soil organic carbon contents using satellite imagery

NARCIS (Netherlands)

Samsonova, V.P.; Meshalkina, J.L.; Blagoveschensky, Y.N.; Yaroslavtsev, A.M.; Stoorvogel, J.J.

2018-01-01

Increasingly, soil surveys make use of a combination of legacy data, ancillary data and new field data. While combining the different sources of information, positional errors can play a large role. For example, the spatial discrepancy between remote sensing images and field data can depend on

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.

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

International Nuclear Information System (INIS)

Miyazaki, Takamasa

2007-01-01

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

Residual position errors of lymph node surrogates in breast cancer adjuvant radiotherapy: Comparison of two arm fixation devices and the effect of arm position correction

International Nuclear Information System (INIS)

Kapanen, Mika; Laaksomaa, Marko; Skyttä, Tanja; Haltamo, Mikko; Pehkonen, Jani; Lehtonen, Turkka; Kellokumpu-Lehtinen, Pirkko-Liisa; Hyödynmaa, Simo

2016-01-01

Residual position errors of the lymph node (LN) surrogates and humeral head (HH) were determined for 2 different arm fixation devices in radiotherapy (RT) of breast cancer: a standard wrist-hold (WH) and a house-made rod-hold (RH). The effect of arm position correction (APC) based on setup images was also investigated. A total of 113 consecutive patients with early-stage breast cancer with LN irradiation were retrospectively analyzed (53 and 60 using the WH and RH, respectively). Residual position errors of the LN surrogates (Th1-2 and clavicle) and the HH were investigated to compare the 2 fixation devices. The position errors and setup margins were determined before and after the APC to investigate the efficacy of the APC in the treatment situation. A threshold of 5 mm was used for the residual errors of the clavicle and Th1-2 to perform the APC, and a threshold of 7 mm was used for the HH. The setup margins were calculated with the van Herk formula. Irradiated volumes of the HH were determined from RT treatment plans. With the WH and the RH, setup margins up to 8.1 and 6.7 mm should be used for the LN surrogates, and margins up to 4.6 and 3.6 mm should be used to spare the HH, respectively, without the APC. After the APC, the margins of the LN surrogates were equal to or less than 7.5/6.0 mm with the WH/RH, but margins up to 4.2/2.9 mm were required for the HH. The APC was needed at least once with both the devices for approximately 60% of the patients. With the RH, irradiated volume of the HH was approximately 2 times more than with the WH, without any dose constraints. Use of the RH together with the APC resulted in minimal residual position errors and setup margins for all the investigated bony landmarks. Based on the obtained results, we prefer the house-made RH. However, more attention should be given to minimize the irradiation of the HH with the RH than with the WH.

Propagation of positional error in 3D GIS

NARCIS (Netherlands)

Biljecki, Filip; Heuvelink, Gerard B.M.; Ledoux, Hugo; Stoter, Jantien

2015-01-01

While error propagation in GIS is a topic that has received a lot of attention, it has not been researched with 3D GIS data. We extend error propagation to 3D city models using a Monte Carlo simulation on a use case of annual solar irradiation estimation of building rooftops for assessing the

Blood specimen labelling errors: Implications for nephrology nursing practice.

Science.gov (United States)

Duteau, Jennifer

2014-01-01

Patient safety is the foundation of high-quality health care, as recognized both nationally and worldwide. Patient blood specimen identification is critical in ensuring the delivery of safe and appropriate care. The practice of nephrology nursing involves frequent patient blood specimen withdrawals to treat and monitor kidney disease. A critical review of the literature reveals that incorrect patient identification is one of the major causes of blood specimen labelling errors. Misidentified samples create a serious risk to patient safety leading to multiple specimen withdrawals, delay in diagnosis, misdiagnosis, incorrect treatment, transfusion reactions, increased length of stay and other negative patient outcomes. Barcode technology has been identified as a preferred method for positive patient identification leading to a definitive decrease in blood specimen labelling errors by as much as 83% (Askeland, et al., 2008). The use of a root cause analysis followed by an action plan is one approach to decreasing the occurrence of blood specimen labelling errors. This article will present a review of the evidence-based literature surrounding blood specimen labelling errors, followed by author recommendations for completing a root cause analysis and action plan. A failure modes and effects analysis (FMEA) will be presented as one method to determine root cause, followed by the Ottawa Model of Research Use (OMRU) as a framework for implementation of strategies to reduce blood specimen labelling errors.

A study of the positioning errors of head and neck in the process of intensity modulation radiated therapy of nasopharyngeal carcinoma

International Nuclear Information System (INIS)

Lin Chengguang; Lin Liuwen; Liu Bingti; Liu Xiaomao; Li Guowen

2011-01-01

Objective: To investigate the positioning errors of head and neck during intensity-modulated radiation therapy of nasopharyngeal carcinoma. Methods: Nineteen patients with middle-advanced nasopharyngeal carcinoma (T 2-4 N 1-3 M 0 ), treated by intensity-modulated radiation therapy, underwent repeated CT during their 6-week treatment course. All the patients were immobilized by head-neck-shoulder thermoplastic mask. We evaluated their anatomic landmark coordinated in a total of 66 repeated CT data sets and respective x, y, z shifts relative to their position in the planning CT. Results: The positioning error of the neck was 2.44 mm ± 2.24 mm, 2.05 mm ± 1.42 mm, 1.83 mm ± 1.53 mm in x, y, z respectively. And that of the head was 1.05 mm ± 0.87 mm, 1.23 mm ± 1.05 mm, 1.17 mm ± 1.55 mm respectively. The positioning error between neck and head have respectively statistical difference (t=-6.58, -5.28, -3.42, P=0.000, 0.000, 0.001). The system error of the neck was 2.33, 1.67 and 1.56 higher than that of the head, respectively in left-right, vertical and head-foot directions; and the random error of neck was 2.57, 1.34 and 0.99 higher than that of head respectively. Conclusions: In the process of the intensity-modulated radiation therapy of nasopharyngeal carcinoma, with the immobilization by head-neck-shoulder thermoplastic mask, the positioning error of neck is higher than that of head. (authors)

Rail-guided robotic end-effector position error due to rail compliance and ship motion

NARCIS (Netherlands)

Borgerink, Dian; Stegenga, J.; Brouwer, Dannis Michel; Woertche, H.J.; Stramigioli, Stefano

2014-01-01

A rail-guided robotic system is currently being designed for the inspection of ballast water tanks in ships. This robotic system will manipulate sensors toward the interior walls of the tank. In this paper, the influence of rail compliance on the end-effector position error due to ship movement is

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)

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.

A machine learning approach to the accurate prediction of multi-leaf collimator positional errors

Science.gov (United States)

Carlson, Joel N. K.; Park, Jong Min; Park, So-Yeon; In Park, Jong; Choi, Yunseok; Ye, Sung-Joon

2016-03-01

Discrepancies between planned and delivered movements of multi-leaf collimators (MLCs) are an important source of errors in dose distributions during radiotherapy. In this work we used machine learning techniques to train models to predict these discrepancies, assessed the accuracy of the model predictions, and examined the impact these errors have on quality assurance (QA) procedures and dosimetry. Predictive leaf motion parameters for the models were calculated from the plan files, such as leaf position and velocity, whether the leaf was moving towards or away from the isocenter of the MLC, and many others. Differences in positions between synchronized DICOM-RT planning files and DynaLog files reported during QA delivery were used as a target response for training of the models. The final model is capable of predicting MLC positions during delivery to a high degree of accuracy. For moving MLC leaves, predicted positions were shown to be significantly closer to delivered positions than were planned positions. By incorporating predicted positions into dose calculations in the TPS, increases were shown in gamma passing rates against measured dose distributions recorded during QA delivery. For instance, head and neck plans with 1%/2 mm gamma criteria had an average increase in passing rate of 4.17% (SD  =  1.54%). This indicates that the inclusion of predictions during dose calculation leads to a more realistic representation of plan delivery. To assess impact on the patient, dose volumetric histograms (DVH) using delivered positions were calculated for comparison with planned and predicted DVHs. In all cases, predicted dose volumetric parameters were in closer agreement to the delivered parameters than were the planned parameters, particularly for organs at risk on the periphery of the treatment area. By incorporating the predicted positions into the TPS, the treatment planner is given a more realistic view of the dose distribution as it will truly be

A theory of human error

Science.gov (United States)

Mcruer, D. T.; Clement, W. F.; Allen, R. W.

1981-01-01

Human errors tend to be treated in terms of clinical and anecdotal descriptions, from which remedial measures are difficult to derive. Correction of the sources of human error requires an attempt to reconstruct underlying and contributing causes of error from the circumstantial causes cited in official investigative reports. A comprehensive analytical theory of the cause-effect relationships governing propagation of human error is indispensable to a reconstruction of the underlying and contributing causes. A validated analytical theory of the input-output behavior of human operators involving manual control, communication, supervisory, and monitoring tasks which are relevant to aviation, maritime, automotive, and process control operations is highlighted. This theory of behavior, both appropriate and inappropriate, provides an insightful basis for investigating, classifying, and quantifying the needed cause-effect relationships governing propagation of human error.

SU-E-P-21: Impact of MLC Position Errors On Simultaneous Integrated Boost Intensity-Modulated Radiotherapy for Nasopharyngeal Carcinoma

Energy Technology Data Exchange (ETDEWEB)

Chengqiang, L; Yin, Y; Chen, L [Shandong Cancer Hospital and Institute, 440 Jiyan Road, Jinan, 250117 (China)

2015-06-15

Purpose: To investigate the impact of MLC position errors on simultaneous integrated boost intensity-modulated radiotherapy (SIB-IMRT) for patients with nasopharyngeal carcinoma. Methods: To compare the dosimetric differences between the simulated plans and the clinical plans, ten patients with locally advanced NPC treated with SIB-IMRT were enrolled in this study. All plans were calculated with an inverse planning system (Pinnacle3, Philips Medical System{sub )}. Random errors −2mm to 2mm{sub )},shift errors{sub (} 2mm,1mm and 0.5mm) and systematic extension/ contraction errors (±2mm, ±1mm and ±0.5mm) of the MLC leaf position were introduced respectively into the original plans to create the simulated plans. Dosimetry factors were compared between the original and the simulated plans. Results: The dosimetric impact of the random and system shift errors of MLC position was insignificant within 2mm, the maximum changes in D95% of PGTV,PTV1,PTV2 were-0.92±0.51%,1.00±0.24% and 0.62±0.17%, the maximum changes in the D0.1cc of spinal cord and brainstem were 1.90±2.80% and −1.78±1.42%, the maximum changes in the Dmean of parotids were1.36±1.23% and −2.25±2.04%.However,the impact of MLC extension or contraction errors was found significant. For 2mm leaf extension errors, the average changes in D95% of PGTV,PTV1,PTV2 were 4.31±0.67%,4.29±0.65% and 4.79±0.82%, the averaged value of the D0.1cc to spinal cord and brainstem were increased by 7.39±5.25% and 6.32±2.28%,the averaged value of the mean dose to left and right parotid were increased by 12.75±2.02%,13.39±2.17% respectively. Conclusion: The dosimetric effect was insignificant for random MLC leaf position errors up to 2mm. There was a high sensitivity to dose distribution for MLC extension or contraction errors.We should pay attention to the anatomic changes in target organs and anatomical structures during the course,individual radiotherapy was recommended to ensure adaptive doses.

Positive phase error from parallel conductance in tetrapolar bio-impedance measurements and its compensation

Directory of Open Access Journals (Sweden)

Ivan M Roitt

2010-01-01

Full Text Available Bioimpedance measurements are of great use and can provide considerable insight into biological processes.  However, there are a number of possible sources of measurement error that must be considered.  The most dominant source of error is found in bipolar measurements where electrode polarisation effects are superimposed on the true impedance of the sample.  Even with the tetrapolar approach that is commonly used to circumvent this issue, other errors can persist. Here we characterise the positive phase and rise in impedance magnitude with frequency that can result from the presence of any parallel conductive pathways in the measurement set-up.  It is shown that fitting experimental data to an equivalent electrical circuit model allows for accurate determination of the true sample impedance as validated through finite element modelling (FEM of the measurement chamber.  Finally, the model is used to extract dispersion information from cell cultures to characterise their growth.

[The approaches to factors which cause medication error--from the analyses of many near-miss cases related to intravenous medication which nurses experienced].

Science.gov (United States)

Kawamura, H

2001-03-01

Given the complexity of the intravenous medication process, systematic thinking is essential to reduce medication errors. Two thousand eight hundred cases of 'Hiyari-Hatto' were analyzed. Eight important factors which cause intravenous medication error were clarified as a result. In the following I summarize the systematic approach for each factor. 1. Failed communication of information: illegible handwritten orders, and inaccurate verbal orders and copying cause medication error. Rules must be established to prevent miscommunication. 2. Error-prone design of the hardware: Look-alike packaging and labeling of drugs and the poor design of infusion pumps cause errors. The human-hardware interface should be improved by error-resistant design by manufacturers. 3. Patient names similar to simultaneously operating surgical procedures and interventions: This factor causes patient misidentification. Automated identification devices should be introduced into health care settings. 4. Interruption in the middle of tasks: The efficient assignment of medical work and business work should be made. 5. Inaccurate mixing procedure and insufficient mixing space: Mixing procedures must be standardized and the layout of the working space must be examined. 6. Time pressure: Mismatch between workload and manpower should be improved by reconsidering the work to be done. 7. Lack of information about high alert medications: The pharmacist should play a greater role in the medication process overall. 8. Poor knowledge and skill of recent graduates: Training methods and tools to prevent medication errors must be developed.

Decisions to shoot in a weapon identification task: The influence of cultural stereotypes and perceived threat on false positive errors.

Science.gov (United States)

Fleming, Kevin K; Bandy, Carole L; Kimble, Matthew O

2010-01-01

The decision to shoot a gun engages executive control processes that can be biased by cultural stereotypes and perceived threat. The neural locus of the decision to shoot is likely to be found in the anterior cingulate cortex (ACC), where cognition and affect converge. Male military cadets at Norwich University (N=37) performed a weapon identification task in which they made rapid decisions to shoot when images of guns appeared briefly on a computer screen. Reaction times, error rates, and electroencephalogram (EEG) activity were recorded. Cadets reacted more quickly and accurately when guns were primed by images of Middle-Eastern males wearing traditional clothing. However, cadets also made more false positive errors when tools were primed by these images. Error-related negativity (ERN) was measured for each response. Deeper ERNs were found in the medial-frontal cortex following false positive responses. Cadets who made fewer errors also produced deeper ERNs, indicating stronger executive control. Pupil size was used to measure autonomic arousal related to perceived threat. Images of Middle-Eastern males in traditional clothing produced larger pupil sizes. An image of Osama bin Laden induced the largest pupil size, as would be predicted for the exemplar of Middle East terrorism. Cadets who showed greater increases in pupil size also made more false positive errors. Regression analyses were performed to evaluate predictions based on current models of perceived threat, stereotype activation, and cognitive control. Measures of pupil size (perceived threat) and ERN (cognitive control) explained significant proportions of the variance in false positive errors to Middle-Eastern males in traditional clothing, while measures of reaction time, signal detection response bias, and stimulus discriminability explained most of the remaining variance.

Sensor Interaction as a Source of the Electromagnetic Field Measurement Error

Directory of Open Access Journals (Sweden)

Hartansky R.

2014-12-01

Full Text Available The article deals with analytical calculation and numerical simulation of interactive influence of electromagnetic sensors. Sensors are components of field probe, whereby their interactive influence causes the measuring error. Electromagnetic field probe contains three mutually perpendicular spaced sensors in order to measure the vector of electrical field. Error of sensors is enumerated with dependence on interactive position of sensors. Based on that, proposed were recommendations for electromagnetic field probe construction to minimize the sensor interaction and measuring error.

Position measuring device

International Nuclear Information System (INIS)

Maeda, Kazuyuki; Takahashi, Shuichi; Maruyama, Mayumi

1998-01-01

The present invention provides a device capable of measuring accurate position and distance easily even at places where operator can not easily access, such as cell facilities for vitrifying radioactive wastes. Referring to a case of the vitrifying cell, an objective equipment settled in the cell is photographed by a photographing device. The image is stored in a position measuring device by way of an image input device. After several years, when the objective equipment is exchanged, a new objective equipment is photographed by a photographing device. The image is also stored in the position measuring device. The position measuring device compares the data of both of the images on the basis of pixel unit. Based on the image of the equipment before the exchange as a reference, extent of the displacement of the installation position of the equipment on the image after the exchange caused by installation error and manufacturing error is determined to decide the position of the equipment after exchange relative to the equipment before exchange. (I.S.)

Dosimetric impact of systematic MLC positional errors on step and shoot IMRT for prostate cancer: a planning study

International Nuclear Information System (INIS)

Ung, N.M.; Harper, C.S.; Wee, L.

2011-01-01

Full text: The positional accuracy of multileaf collimators (MLC) is crucial in ensuring precise delivery of intensity-modulated radiotherapy (IMRT). The aim of this planning study was to investigate the dosimetric impact of systematic MLC positional errors on step and shoot IMRT of prostate cancer. A total of 12 perturbations of MLC leaf banks were introduced to six prostate IMRT treatment plans to simulate MLC systematic positional errors. Dose volume histograms (DVHs) were generated for the extraction of dose endpoint parameters. Plans were evaluated in terms of changes to the defined endpoint dose parameters, conformity index (CI) and healthy tissue avoidance (HTA) to planning target volume (PTV), rectum and bladder. Negative perturbations of MLC had been found to produce greater changes to endpoint dose parameters than positive perturbations of MLC (p 9 5 of -1.2 and 0.9% respectively. Negative and positive synchronised MLC perturbations of I mm in one direction resulted in median changes in D 9 5 of -2.3 and 1.8% respectively. Doses to rectum were generally more sensitive to systematic MLC en-ors compared to bladder (p < 0.01). Negative and positive synchronised MLC perturbations of I mm in one direction resulted in median changes in endpoint dose parameters of rectum and bladder from 1.0 to 2.5%. Maximum reduction of -4.4 and -7.3% were recorded for conformity index (CI) and healthy tissue avoidance (HT A) respectively due to synchronised MLC perturbation of 1 mm. MLC errors resulted in dosimetric changes in IMRT plans for prostate. (author)

Phase Error Caused by Speed Mismatch Analysis in the Line-Scan Defect Detection by Using Fourier Transform Technique

Directory of Open Access Journals (Sweden)

Eryi Hu

2015-01-01

Full Text Available The phase error caused by the speed mismatch issue is researched in the line-scan images capturing 3D profile measurement. The experimental system is constructed by a line-scan CCD camera, an object moving device, a digital fringe pattern projector, and a personal computer. In the experiment procedure, the detected object is moving relative to the image capturing system by using a motorized translation stage in a stable velocity. The digital fringe pattern is projected onto the detected object, and then the deformed patterns are captured and recorded in the computer. The object surface profile can be calculated by the Fourier transform profilometry. However, the moving speed mismatch error will still exist in most of the engineering application occasion even after an image system calibration. When the moving speed of the detected object is faster than the expected value, the captured image will be compressed in the moving direction of the detected object. In order to overcome this kind of measurement error, an image recovering algorithm is proposed to reconstruct the original compressed image. Thus, the phase values can be extracted much more accurately by the reconstructed images. And then, the phase error distribution caused by the speed mismatch is analyzed by the simulation and experimental methods.

The conditions that promote fear learning: prediction error and Pavlovian fear conditioning.

Science.gov (United States)

Li, Susan Shi Yuan; McNally, Gavan P

2014-02-01

A key insight of associative learning theory is that learning depends on the actions of prediction error: a discrepancy between the actual and expected outcomes of a conditioning trial. When positive, such error causes increments in associative strength and, when negative, such error causes decrements in associative strength. Prediction error can act directly on fear learning by determining the effectiveness of the aversive unconditioned stimulus or indirectly by determining the effectiveness, or associability, of the conditioned stimulus. Evidence from a variety of experimental preparations in human and non-human animals suggest that discrete neural circuits code for these actions of prediction error during fear learning. Here we review the circuits and brain regions contributing to the neural coding of prediction error during fear learning and highlight areas of research (safety learning, extinction, and reconsolidation) that may profit from this approach to understanding learning. Crown Copyright © 2013. Published by Elsevier Inc. All rights reserved.

Condom Use Errors and Problems: A Comparative Study of HIV-Positive Versus HIV-Negative Young Black Men Who Have Sex With Men.

Science.gov (United States)

Crosby, Richard; Mena, Leandro; Yarber, William L; Graham, Cynthia A; Sanders, Stephanie A; Milhausen, Robin R

2015-11-01

To describe self-reported frequencies of selected condom use errors and problems among young (age, 15-29 years) black men who have sex with men (YBMSM) and to compare the observed prevalence of these errors/problems by HIV serostatus. Between September 2012 October 2014, electronic interview data were collected from 369 YBMSM attending a federally supported sexually transmitted infection clinic located in the southern United States. Seventeen condom use errors and problems were assessed. χ(2) Tests were used to detect significant differences in the prevalence of these 17 errors and problems between HIV-negative and HIV-positive men. The recall period was the past 90 days. The overall mean (SD) number of errors/problems was 2.98 (2.29). The mean (SD) for HIV-negative men was 2.91 (2.15), and the mean (SD) for HIV-positive men was 3.18 (2.57). These means were not significantly different (t = 1.02, df = 367, P = 0.31). Only 2 significant differences were observed between HIV-negative and HIV-positive men. Breakage (P = 0.002) and slippage (P = 0.005) were about twice as likely among HIV-positive men. Breakage occurred for nearly 30% of the HIV-positive men compared with approximately 15% among HIV-negative men. Slippage occurred for approximately 16% of the HIV-positive men compared with approximately 9% among HIV-negative men. A need exists to help YBMSM acquire the skills needed to avert breakage and slippage issues that could lead to HIV transmission. Beyond these 2 exceptions, condom use errors and problems were ubiquitous in this population regardless of HIV serostatus. Clinic-based intervention is warranted for these young men, including education about correct condom use and provision of free condoms and long-lasting lubricants.

The study of CD side to side error in line/space pattern caused by post-exposure bake effect

Science.gov (United States)

Huang, Jin; Guo, Eric; Ge, Haiming; Lu, Max; Wu, Yijun; Tian, Mingjing; Yan, Shichuan; Wang, Ran

2016-10-01

In semiconductor manufacturing, as the design rule has decreased, the ITRS roadmap requires crucial tighter critical dimension (CD) control. CD uniformity is one of the necessary parameters to assure good performance and reliable functionality of any integrated circuit (IC) [1] [2], and towards the advanced technology nodes, it is a challenge to control CD uniformity well. The study of corresponding CD Uniformity by tuning Post-Exposure bake (PEB) and develop process has some significant progress[3], but CD side to side error happening to some line/space pattern are still found in practical application, and the error has approached to over the uniformity tolerance. After details analysis, even though use several developer types, the CD side to side error has not been found significant relationship to the developing. In addition, it is impossible to correct the CD side to side error by electron beam correction as such error does not appear in all Line/Space pattern masks. In this paper the root cause of CD side to side error is analyzed and the PEB module process are optimized as a main factor for improvement of CD side to side error.

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.

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

Identification of causes of human errors in support of the development of intelligent computer-assisted instruction systems for plant operator training

International Nuclear Information System (INIS)

Furuhama, Yutaka; Furuta, Kazuo; Kondo, Shunsuke

1995-01-01

This paper proposes a methodology to identify causes of human error in the operation of plant systems to support the development of CAI system for operator training. The target task of this methodology is goal-driven and knowledge-based planning behaviour, the cognitive process of which is assumed to be modeled as means-end analysis. The methodology uses four criteria to classify errors in an operation into eight groups, and then asks the trainee several questions to prune the causes. To confirm the usefulness of this methodology, a prototype CAI system is developed for the operation of filling up sodium into the primary coolant system of a liquid-metal-cooled fast reactor. The experimental result indicates that the system has the capability of identifying causes of the trainee's error, and consequently of figuring out the characteristics of his/her defect. As a result of this study, several issues are identified for future research

Positive Beliefs about Errors as an Important Element of Adaptive Individual Dealing with Errors during Academic Learning

Science.gov (United States)

Tulis, Maria; Steuer, Gabriele; Dresel, Markus

2018-01-01

Research on learning from errors gives reason to assume that errors provide a high potential to facilitate deep learning if students are willing and able to take these learning opportunities. The first aim of this study was to analyse whether beliefs about errors as learning opportunities can be theoretically and empirically distinguished from…

Dosimetric implications of inter- and intrafractional prostate positioning errors during tomotherapy : Comparison of gold marker-based registrations with native MVCT.

Science.gov (United States)

Wust, Peter; Joswig, Marc; Graf, Reinhold; Böhmer, Dirk; Beck, Marcus; Barelkowski, Thomasz; Budach, Volker; Ghadjar, Pirus

2017-09-01

For high-dose radiation therapy (RT) of prostate cancer, image-guided (IGRT) and intensity-modulated RT (IMRT) approaches are standard. Less is known regarding comparisons of different IGRT techniques and the resulting residual errors, as well as regarding their influences on dose distributions. A total of 58 patients who received tomotherapy-based RT up to 84 Gy for high-risk prostate cancer underwent IGRT based either on daily megavoltage CT (MVCT) alone (n = 43) or the additional use of gold markers (n = 15) under routine conditions. Planned Adaptive (Accuray Inc., Madison, WI, USA) software was used for elaborated offline analysis to quantify residual interfractional prostate positioning errors, along with systematic and random errors and the resulting safety margins after both IGRT approaches. Dosimetric parameters for clinical target volume (CTV) coverage and exposition of organs at risk (OAR) were also analyzed and compared. Interfractional as well as intrafractional displacements were determined. Particularly in the vertical direction, residual interfractional positioning errors were reduced using the gold marker-based approach, but dosimetric differences were moderate and the clinical relevance relatively small. Intrafractional prostate motion proved to be quite high, with displacements of 1-3 mm; however, these did not result in additional dosimetric impairments. Residual interfractional positioning errors were reduced using gold marker-based IGRT; however, this resulted in only slightly different final dose distributions. Therefore, daily MVCT-based IGRT without markers might be a valid alternative.

Dosimetric impact of systematic MLC positional errors on step and shoot IMRT for prostate cancer: a planning study

International Nuclear Information System (INIS)

Ung, N.M.; Wee, L.; Harper, C.S.

2010-01-01

Full text: The positional accuracy of multi leaf collimators (MLC) is crucial in ensuring precise delivery of intensity-modulated radiotherapy (IMRT). The aim of this planning study was to investigate the dosimetric impact of systematic MLC errors on step and shoot IMRT of prostate cancer. Twelve MLC leaf banks perturbations were introduced to six prostate IMRT treatment plans to simulate MLC systematic errors. Dose volume histograms (OYHs) were generated for the extraction of dose endpoint parameters. Plans were evaluated in terms of changes to the defined endpoint dose parameters, conformity index (CI) and healthy tissue avoidance (HTA) to planning target volume (PTY), rectum and bladder. Negative perturbations of MLC had been found to produce greater changes to endpoint dose parameters than positive perturbations of MLC (p < 0.05). Negative and positive synchronized MLC perturbations of I mm resulted in median changes of -2.32 and 1.78%, respectively to 095% of PTY whereas asynchronized MLC perturbations of the same direction and magnitude resulted in median changes of 1.18 and 0.90%, respectively. Doses to rectum were generally more sensitive to systematic MLC errors compared to bladder. Synchronized MLC perturbations of I mm resulted in median changes of endpoint dose parameters to both rectum and bladder from about I to 3%. Maximum reduction of -4.44 and -7.29% were recorded for CI and HTA, respectively, due to synchronized MLC perturbation of I mm. In summary, MLC errors resulted in measurable amount of dose changes to PTY and surrounding critical structures in prostate LMRT. (author)

Consistent errors in first strand cDNA due to random hexamer mispriming.

Directory of Open Access Journals (Sweden)

Thomas P van Gurp

Full Text Available Priming of random hexamers in cDNA synthesis is known to show sequence bias, but in addition it has been suggested recently that mismatches in random hexamer priming could be a cause of mismatches between the original RNA fragment and observed sequence reads. To explore random hexamer mispriming as a potential source of these errors, we analyzed two independently generated RNA-seq datasets of synthetic ERCC spikes for which the reference is known. First strand cDNA synthesized by random hexamer priming on RNA showed consistent position and nucleotide-specific mismatch errors in the first seven nucleotides. The mismatch errors found in both datasets are consistent in distribution and thermodynamically stable mismatches are more common. This strongly indicates that RNA-DNA mispriming of specific random hexamers causes these errors. Due to their consistency and specificity, mispriming errors can have profound implications for downstream applications if not dealt with properly.

VOLUMETRIC ERROR COMPENSATION IN FIVE-AXIS CNC MACHINING CENTER THROUGH KINEMATICS MODELING OF GEOMETRIC ERROR

Directory of Open Access Journals (Sweden)

Pooyan Vahidi Pashsaki

2016-06-01

Full Text Available Accuracy of a five-axis CNC machine tool is affected by a vast number of error sources. This paper investigates volumetric error modeling and its compensation to the basis for creation of new tool path for improvement of work pieces accuracy. The volumetric error model of a five-axis machine tool with the configuration RTTTR (tilting head B-axis and rotary table in work piece side A΄ was set up taking into consideration rigid body kinematics and homogeneous transformation matrix, in which 43 error components are included. Volumetric error comprises 43 error components that can separately reduce geometrical and dimensional accuracy of work pieces. The machining accuracy of work piece is guaranteed due to the position of the cutting tool center point (TCP relative to the work piece. The cutting tool is deviated from its ideal position relative to the work piece and machining error is experienced. For compensation process detection of the present tool path and analysis of the RTTTR five-axis CNC machine tools geometrical error, translating current position of component to compensated positions using the Kinematics error model, converting newly created component to new tool paths using the compensation algorithms and finally editing old G-codes using G-code generator algorithm have been employed.

Gene therapy for the circumvention of inborn errors of metabolism (IEM) caused by single-nucleotide-polymorphisms (SNPs).

Science.gov (United States)

Wiseman, Alan

2004-01-01

Single nucleotide polymorphisms (SNPs) are the result of point mutations in nuclear (and mitochondrial) DNA. Such localised damage to DNA (and its replicative mechanisms) may not be excised fully by the DNA repair mechanism in the genome: and therefore can become inheritable; subsequently to manifest later as an inborn error of metabolism (IEM). Causes of mutagenic damage to the DNA can include background radiation (such as emitted by radon gas), and by reactive oxygen species (ROS): and also by mutagenic chemicals that occur naturally (inter alia in the diet). Other causes of DNA damage are variable environmental hazards such as solar-derived short wave ultraviolet light A. Gene therapy involves the placement of missing genes into particular tissues by the harnessing of suitable vectors (originally these were animal viruses such as SV40). For example, gene therapy in the rat for diabetes has succeeded by liver-production of insulin (using genes obtained from pancreatic Islets of Langerhans cells). Many inborn errors of metabolism could be treated in this way: examples may include 100 haemoglobinopathies (such as sickle cell anaemia), phenylketonuria; and other diseases caused by lack of tissue-production of a particular enzyme (in its catalytically-active conformation).

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

Tracking errors in a prototype real-time tumour tracking system

International Nuclear Information System (INIS)

Sharp, Gregory C; Jiang, Steve B; Shimizu, Shinichi; Shirato, Hiroki

2004-01-01

In motion-compensated radiation therapy, radio-opaque markers can be implanted in or near a tumour and tracked in real-time using fluoroscopic imaging. Tracking these implanted markers gives highly accurate position information, except when tracking fails due to poor or ambiguous imaging conditions. This study investigates methods for automatic detection of tracking errors, and assesses the frequency and impact of tracking errors on treatments using the prototype real-time tumour tracking system. We investigated four indicators for automatic detection of tracking errors, and found that the distance between corresponding rays was most effective. We also found that tracking errors cause a loss of gating efficiency of between 7.6 and 10.2%. The incidence of treatment beam delivery during tracking errors was estimated at between 0.8% and 1.25%

Variation of haemoglobin extinction coefficients can cause errors in the determination of haemoglobin concentration measured by near-infrared spectroscopy

International Nuclear Information System (INIS)

Kim, J G; Liu, H

2007-01-01

Near-infrared spectroscopy or imaging has been extensively applied to various biomedical applications since it can detect the concentrations of oxyhaemoglobin (HbO 2 ), deoxyhaemoglobin (Hb) and total haemoglobin (Hb total ) from deep tissues. To quantify concentrations of these haemoglobin derivatives, the extinction coefficient values of HbO 2 and Hb have to be employed. However, it was not well recognized among researchers that small differences in extinction coefficients could cause significant errors in quantifying the concentrations of haemoglobin derivatives. In this study, we derived equations to estimate errors of haemoglobin derivatives caused by the variation of haemoglobin extinction coefficients. To prove our error analysis, we performed experiments using liquid-tissue phantoms containing 1% Intralipid in a phosphate-buffered saline solution. The gas intervention of pure oxygen was given in the solution to examine the oxygenation changes in the phantom, and 3 mL of human blood was added twice to show the changes in [Hb total ]. The error calculation has shown that even a small variation (0.01 cm -1 mM -1 ) in extinction coefficients can produce appreciable relative errors in quantification of Δ[HbO 2 ], Δ[Hb] and Δ[Hb total ]. We have also observed that the error of Δ[Hb total ] is not always larger than those of Δ[HbO 2 ] and Δ[Hb]. This study concludes that we need to be aware of any variation in haemoglobin extinction coefficients, which could result from changes in temperature, and to utilize corresponding animal's haemoglobin extinction coefficients for the animal experiments, in order to obtain more accurate values of Δ[HbO 2 ], Δ[Hb] and Δ[Hb total ] from in vivo tissue measurements

Variation of haemoglobin extinction coefficients can cause errors in the determination of haemoglobin concentration measured by near-infrared spectroscopy

Science.gov (United States)

Kim, J. G.; Liu, H.

2007-10-01

Near-infrared spectroscopy or imaging has been extensively applied to various biomedical applications since it can detect the concentrations of oxyhaemoglobin (HbO2), deoxyhaemoglobin (Hb) and total haemoglobin (Hbtotal) from deep tissues. To quantify concentrations of these haemoglobin derivatives, the extinction coefficient values of HbO2 and Hb have to be employed. However, it was not well recognized among researchers that small differences in extinction coefficients could cause significant errors in quantifying the concentrations of haemoglobin derivatives. In this study, we derived equations to estimate errors of haemoglobin derivatives caused by the variation of haemoglobin extinction coefficients. To prove our error analysis, we performed experiments using liquid-tissue phantoms containing 1% Intralipid in a phosphate-buffered saline solution. The gas intervention of pure oxygen was given in the solution to examine the oxygenation changes in the phantom, and 3 mL of human blood was added twice to show the changes in [Hbtotal]. The error calculation has shown that even a small variation (0.01 cm-1 mM-1) in extinction coefficients can produce appreciable relative errors in quantification of Δ[HbO2], Δ[Hb] and Δ[Hbtotal]. We have also observed that the error of Δ[Hbtotal] is not always larger than those of Δ[HbO2] and Δ[Hb]. This study concludes that we need to be aware of any variation in haemoglobin extinction coefficients, which could result from changes in temperature, and to utilize corresponding animal's haemoglobin extinction coefficients for the animal experiments, in order to obtain more accurate values of Δ[HbO2], Δ[Hb] and Δ[Hbtotal] from in vivo tissue measurements.

[Transposition errors during learning to reproduce a sequence by the right- and the left-hand movements: simulation of positional and movement coding].

Science.gov (United States)

Liakhovetskiĭ, V A; Bobrova, E V; Skopin, G N

2012-01-01

Transposition errors during the reproduction of a hand movement sequence make it possible to receive important information on the internal representation of this sequence in the motor working memory. Analysis of such errors showed that learning to reproduce sequences of the left-hand movements improves the system of positional coding (coding ofpositions), while learning of the right-hand movements improves the system of vector coding (coding of movements). Learning of the right-hand movements after the left-hand performance involved the system of positional coding "imposed" by the left hand. Learning of the left-hand movements after the right-hand performance activated the system of vector coding. Transposition errors during learning to reproduce movement sequences can be explained by neural network using either vector coding or both vector and positional coding.

The determination of carbon dioxide concentration using atmospheric pressure ionization mass spectrometry/isotopic dilution and errors in concentration measurements caused by dryers.

Science.gov (United States)

DeLacy, Brendan G; Bandy, Alan R

2008-01-01

An atmospheric pressure ionization mass spectrometry/isotopically labeled standard (APIMS/ILS) method has been developed for the determination of carbon dioxide (CO(2)) concentration. Descriptions of the instrumental components, the ionization chemistry, and the statistics associated with the analytical method are provided. This method represents an alternative to the nondispersive infrared (NDIR) technique, which is currently used in the atmospheric community to determine atmospheric CO(2) concentrations. The APIMS/ILS and NDIR methods exhibit a decreased sensitivity for CO(2) in the presence of water vapor. Therefore, dryers such as a nafion dryer are used to remove water before detection. The APIMS/ILS method measures mixing ratios and demonstrates linearity and range in the presence or absence of a dryer. The NDIR technique, on the other hand, measures molar concentrations. The second half of this paper describes errors in molar concentration measurements that are caused by drying. An equation describing the errors was derived from the ideal gas law, the conservation of mass, and Dalton's Law. The purpose of this derivation was to quantify errors in the NDIR technique that are caused by drying. Laboratory experiments were conducted to verify the errors created solely by the dryer in CO(2) concentration measurements post-dryer. The laboratory experiments verified the theoretically predicted errors in the derived equations. There are numerous references in the literature that describe the use of a dryer in conjunction with the NDIR technique. However, these references do not address the errors that are caused by drying.

Influence of chronic neck pain on cervical joint position error (JPE): Comparison between young and elderly subjects.

Science.gov (United States)

Alahmari, Khalid A; Reddy, Ravi Shankar; Silvian, Paul; Ahmad, Irshad; Nagaraj, Venkat; Mahtab, Mohammad

2017-11-06

Evaluation of cervical joint position sense in subjects with chronic neck pain has gained importance in recent times. Different authors have established increased joint position error (JPE) in subjects with acute neck pain. However, there is a paucity of studies to establish the influence of chronic neck pain on cervical JPE. The objective of the study was to understand the influence of chronic neck pain on cervical JPE, and to examine the differences in cervical JPE between young and elderly subjects with chronic neck pain. Forty-two chronic neck pain patients (mean age 47.4) were compared for cervical JPE with 42 age-matched healthy subjects (mean age 47.8), using a digital inclinometer. The cervical JPE were measured in flexion, extension, and rotation in right and left movement directions. The comparison of JPE showed significantly larger errors in subjects with chronic neck pain when compared to healthy subjects (ppain revealed no significant differences (P> 0.05) in cervical JPE. Cervical joint position sense is impaired in subjects with chronic neck pain.

Causes and consequences of timing errors associated with global positioning system collar accelerometer activity monitors

Science.gov (United States)

Adam J. Gaylord; Dana M. Sanchez

2014-01-01

Direct behavioral observations of multiple free-ranging animals over long periods of time and large geographic areas is prohibitively difficult. However, recent improvements in technology, such as Global Positioning System (GPS) collars equipped with motion-sensitive activity monitors, create the potential to remotely monitor animal behavior. Accelerometer-equipped...

The analysis of human error as causes in the maintenance of machines: a case study in mining companies

Directory of Open Access Journals (Sweden)

Kovacevic, Srdja

2016-12-01

Full Text Available This paper describes the two-step method used to analyse the factors and aspects influencing human error during the maintenance of mining machines. The first step is the cause-effect analysis, supported by brainstorming, where five factors and 21 aspects are identified. During the second step, the group fuzzy analytic hierarchy process is used to rank the identified factors and aspects. A case study is done on mining companies in Serbia. The key aspects are ranked according to an analysis that included experts who assess risks in mining companies (a maintenance engineer, a technologist, an ergonomist, a psychologist, and an organisational scientist. Failure to follow technical maintenance instructions, poor organisation of the training process, inadequate diagnostic equipment, and a lack of understanding of the work process are identified as the most important causes of human error.

Motivational processes from expectancy-value theory are associated with variability in the error positivity in young children.

Science.gov (United States)

Kim, Matthew H; Marulis, Loren M; Grammer, Jennie K; Morrison, Frederick J; Gehring, William J

2017-03-01

Motivational beliefs and values influence how children approach challenging activities. The current study explored motivational processes from an expectancy-value theory framework by studying children's mistakes and their responses to them by focusing on two event-related potential (ERP) components: the error-related negativity (ERN) and the error positivity (Pe). Motivation was assessed using a child-friendly challenge puzzle task and a brief interview measure prior to ERP testing. Data from 50 4- to 6-year-old children revealed that greater perceived competence beliefs were related to a larger Pe, whereas stronger intrinsic task value beliefs were associated with a smaller Pe. Motivation was unrelated to the ERN. Individual differences in early motivational processes may reflect electrophysiological activity related to conscious error awareness. Copyright © 2016 Elsevier Inc. All rights reserved.

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.

Causes and Remedies for Errors in International Forest Products Trade Data: Examples from the Hardwood Trade Statistics

Science.gov (United States)

William G. Luppold; William G. Luppold

1995-01-01

The quality of data concerning international hardwood products trade declined in the 1980s because of several problems associated with the collection and processing of individual export transaction records. This note examines the source, impact, and remedies for data problems caused by data screening procedures, nonreporting, recording errors, and alternative...

A mode of error: Immunoglobulin binding protein (a subset of anti-citrullinated proteins can cause false positive tuberculosis test results in rheumatoid arthritis

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Maria Greenwald

2017-12-01

Full Text Available Citrullinated Immunoglobulin Binding Protein (BiP is a newly described autoimmune target in rheumatoid arthritis (RA, one of many cyclic citrullinated peptides(CCP or ACPA. BiP is over-expressed in RA patients causing T cell expansion and increased interferon levels during incubation for the QuantiFERON-Gold tuberculosis test (QFT-G TB. The QFT-G TB has never been validated where interferon is increased by underlying disease, as for example RA.Of ACPA-positive RA patients (n = 126, we found a 13% false-positive TB test rate by QFT-G TB. Despite subsequent biologic therapy for 3 years of all 126 RA patients, none showed evidence of TB without INH. Most of the false-positive RA patients after treatment with biologic therapy reverted to a negative QFT-G test. False TB tests correlated with ACPA level (p < 0.02.Three healthy women without arthritis or TB exposure had negative QFT-G TB. In vitro, all three tested positive every time for TB correlating to the dose of BiP or anti-BiP added, at 2 ug/ml, 5 ug/ml, 10 ug/ml, and 20 ug/ml.BiP naturally found in the majority of ACPA-positive RA patients can result in a false positive QFT-G TB. Subsequent undertreatment of RA, if biologic therapy is withheld, and overtreatment of presumed latent TB may harm patients. Keywords: Tuberculosis, IGRA, Rheumatoid arthritis, Interferon, Anti-citrullinated peptide antibody (ACPA, Immunoglobulin binding protein (BiP

Variation of haemoglobin extinction coefficients can cause errors in the determination of haemoglobin concentration measured by near-infrared spectroscopy

Energy Technology Data Exchange (ETDEWEB)

Kim, J G; Liu, H [Joint Graduate Program in Biomedical Engineering, University of Texas at Arlington/University of Texas Southwestern Medical Center at Dallas, Arlington, TX 76019 (United States)

2007-10-21

Near-infrared spectroscopy or imaging has been extensively applied to various biomedical applications since it can detect the concentrations of oxyhaemoglobin (HbO{sub 2}), deoxyhaemoglobin (Hb) and total haemoglobin (Hb{sub total}) from deep tissues. To quantify concentrations of these haemoglobin derivatives, the extinction coefficient values of HbO{sub 2} and Hb have to be employed. However, it was not well recognized among researchers that small differences in extinction coefficients could cause significant errors in quantifying the concentrations of haemoglobin derivatives. In this study, we derived equations to estimate errors of haemoglobin derivatives caused by the variation of haemoglobin extinction coefficients. To prove our error analysis, we performed experiments using liquid-tissue phantoms containing 1% Intralipid in a phosphate-buffered saline solution. The gas intervention of pure oxygen was given in the solution to examine the oxygenation changes in the phantom, and 3 mL of human blood was added twice to show the changes in [Hb{sub total}]. The error calculation has shown that even a small variation (0.01 cm{sup -1} mM{sup -1}) in extinction coefficients can produce appreciable relative errors in quantification of {delta}[HbO{sub 2}], {delta}[Hb] and {delta}[Hb{sub total}]. We have also observed that the error of {delta}[Hb{sub total}] is not always larger than those of {delta}[HbO{sub 2}] and {delta}[Hb]. This study concludes that we need to be aware of any variation in haemoglobin extinction coefficients, which could result from changes in temperature, and to utilize corresponding animal's haemoglobin extinction coefficients for the animal experiments, in order to obtain more accurate values of {delta}[HbO{sub 2}], {delta}[Hb] and {delta}[Hb{sub total}] from in vivo tissue measurements.

CAUSE-FIT, POSITIVE ATTITUDES AND BEHAVIORS WITHIN HYBRID COLOMBIAN ORGANIZATIONS

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Juan Pablo Román-Calderón

2015-06-01

Full Text Available Socially oriented ventures have provided livelihoods and social recognition to disadvantaged communities in different corners of the world. In some cases, these ventures are the result of Corporate Social Responsibility (CSR programs. In Latin America, this type of undertaking has responded positively to unmet social needs. The social cause drives these organizations and their human resources and they give high value to organizational cause-fit. This paper presents empirical evidence of the effects of perceived cause-fit on several worker attitudes and behaviors. Psychological contract theory was adopted as theoretical background. Employees working in a hybrid (for-profit/socially oriented Colombian organization created by a CSR program participated in the survey. Data provided by 218 employees were analyzed using PLS structural equation modeling. The results suggest the ideological components of the employee-employer relationship predict positive attitudes and cooperative organizational behaviors towards hybrid organizations.

Precise Positioning Method for Logistics Tracking Systems Using Personal Handy-Phone System Based on Mahalanobis Distance

Science.gov (United States)

Yokoi, Naoaki; Kawahara, Yasuhiro; Hosaka, Hiroshi; Sakata, Kenji

Focusing on the Personal Handy-phone System (PHS) positioning service used in physical distribution logistics, a positioning error offset method for improving positioning accuracy is invented. A disadvantage of PHS positioning is that measurement errors caused by the fluctuation of radio waves due to buildings around the terminal are large, ranging from several tens to several hundreds of meters. In this study, an error offset method is developed, which learns patterns of positioning results (latitude and longitude) containing errors and the highest signal strength at major logistic points in advance, and matches them with new data measured in actual distribution processes according to the Mahalanobis distance. Then the matching resolution is improved to 1/40 that of the conventional error offset method.

A Case of Transfusion Error in a Trauma Patient With Subsequent Root Cause Analysis Leading to Institutional Change.

Science.gov (United States)

Clifford, Sean Patrick; Mick, Paul Brian; Derhake, Brian Matthew

2016-01-01

A 28-year-old man presented emergently to the operating room following a gun-shot injury to his right groin. Our hospital's Massive Transfusion Protocol was initiated as the patient entered the operating room actively hemorrhaging and severely hypotensive. During the aggressive resuscitation efforts, the patient was inadvertently transfused 2 units of packed red blood cells intended for another patient due to a series of errors. Fortunately, the incorrect product was compatible, and the patient recovered from his near-fatal injuries. Root cause analysis was used to review the transfusion error and develop an action plan to help prevent future occurrences.

Positional accommodative intraocular lens power error induced by the estimation of the corneal power and the effective lens position

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David P Piñero

2015-01-01

Full Text Available Purpose: To evaluate the predictability of the refractive correction achieved with a positional accommodating intraocular lenses (IOL and to develop a potential optimization of it by minimizing the error associated with the keratometric estimation of the corneal power and by developing a predictive formula for the effective lens position (ELP. Materials and Methods: Clinical data from 25 eyes of 14 patients (age range, 52-77 years and undergoing cataract surgery with implantation of the accommodating IOL Crystalens HD (Bausch and Lomb were retrospectively reviewed. In all cases, the calculation of an adjusted IOL power (P IOLadj based on Gaussian optics considering the residual refractive error was done using a variable keratometric index value (n kadj for corneal power estimation with and without using an estimation algorithm for ELP obtained by multiple regression analysis (ELP adj . P IOLadj was compared to the real IOL power implanted (P IOLReal , calculated with the SRK-T formula and also to the values estimated by the Haigis, HofferQ, and Holladay I formulas. Results: No statistically significant differences were found between P IOLReal and P IOLadj when ELP adj was used (P = 0.10, with a range of agreement between calculations of 1.23 D. In contrast, P IOLReal was significantly higher when compared to P IOLadj without using ELP adj and also compared to the values estimated by the other formulas. Conclusions: Predictable refractive outcomes can be obtained with the accommodating IOL Crystalens HD using a variable keratometric index for corneal power estimation and by estimating ELP with an algorithm dependent on anatomical factors and age.

The interaction of the flux errors and transport errors in modeled atmospheric carbon dioxide concentrations

Science.gov (United States)

Feng, S.; Lauvaux, T.; Butler, M. P.; Keller, K.; Davis, K. J.; Jacobson, A. R.; Schuh, A. E.; Basu, S.; Liu, J.; Baker, D.; Crowell, S.; Zhou, Y.; Williams, C. A.

2017-12-01

Regional estimates of biogenic carbon fluxes over North America from top-down atmospheric inversions and terrestrial biogeochemical (or bottom-up) models remain inconsistent at annual and sub-annual time scales. While top-down estimates are impacted by limited atmospheric data, uncertain prior flux estimates and errors in the atmospheric transport models, bottom-up fluxes are affected by uncertain driver data, uncertain model parameters and missing mechanisms across ecosystems. This study quantifies both flux errors and transport errors, and their interaction in the CO2 atmospheric simulation. These errors are assessed by an ensemble approach. The WRF-Chem model is set up with 17 biospheric fluxes from the Multiscale Synthesis and Terrestrial Model Intercomparison Project, CarbonTracker-Near Real Time, and the Simple Biosphere model. The spread of the flux ensemble members represents the flux uncertainty in the modeled CO2 concentrations. For the transport errors, WRF-Chem is run using three physical model configurations with three stochastic perturbations to sample the errors from both the physical parameterizations of the model and the initial conditions. Additionally, the uncertainties from boundary conditions are assessed using four CO2 global inversion models which have assimilated tower and satellite CO2 observations. The error structures are assessed in time and space. The flux ensemble members overall overestimate CO2 concentrations. They also show larger temporal variability than the observations. These results suggest that the flux ensemble is overdispersive. In contrast, the transport ensemble is underdispersive. The averaged spatial distribution of modeled CO2 shows strong positive biogenic signal in the southern US and strong negative signals along the eastern coast of Canada. We hypothesize that the former is caused by the 3-hourly downscaling algorithm from which the nighttime respiration dominates the daytime modeled CO2 signals and that the latter

Errors in measuring transverse and energy jitter by beam position monitors

Energy Technology Data Exchange (ETDEWEB)

Balandin, V.; Decking, W.; Golubeva, N.

2010-02-15

The problem of errors, arising due to finite BPMresolution, in the difference orbit parameters, which are found as a least squares fit to the BPM data, is one of the standard and important problems of accelerator physics. Even so for the case of transversely uncoupled motion the covariance matrix of reconstruction errors can be calculated ''by hand'', the direct usage of obtained solution, as a tool for designing of a ''good measurement system'', does not look to be fairly straightforward. It seems that a better understanding of the nature of the problem is still desirable. We make a step in this direction introducing dynamic into this problem, which at the first glance seems to be static. We consider a virtual beam consisting of virtual particles obtained as a result of application of reconstruction procedure to ''all possible values'' of BPM reading errors. This beam propagates along the beam line according to the same rules as any real beam and has all beam dynamical characteristics, such as emittances, energy spread, dispersions, betatron functions and etc. All these values become the properties of the BPM measurement system. One can compare two BPM systems comparing their error emittances and rms error energy spreads, or, for a given measurement system, one can achieve needed balance between coordinate and momentum reconstruction errors by matching the error betatron functions in the point of interest to the desired values. (orig.)

Errors in measuring transverse and energy jitter by beam position monitors

International Nuclear Information System (INIS)

Balandin, V.; Decking, W.; Golubeva, N.

2010-02-01

The problem of errors, arising due to finite BPMresolution, in the difference orbit parameters, which are found as a least squares fit to the BPM data, is one of the standard and important problems of accelerator physics. Even so for the case of transversely uncoupled motion the covariance matrix of reconstruction errors can be calculated ''by hand'', the direct usage of obtained solution, as a tool for designing of a ''good measurement system'', does not look to be fairly straightforward. It seems that a better understanding of the nature of the problem is still desirable. We make a step in this direction introducing dynamic into this problem, which at the first glance seems to be static. We consider a virtual beam consisting of virtual particles obtained as a result of application of reconstruction procedure to ''all possible values'' of BPM reading errors. This beam propagates along the beam line according to the same rules as any real beam and has all beam dynamical characteristics, such as emittances, energy spread, dispersions, betatron functions and etc. All these values become the properties of the BPM measurement system. One can compare two BPM systems comparing their error emittances and rms error energy spreads, or, for a given measurement system, one can achieve needed balance between coordinate and momentum reconstruction errors by matching the error betatron functions in the point of interest to the desired values. (orig.)

Automatic detection of patient identification and positioning errors in radiation therapy treatment using 3-dimensional setup images.

Science.gov (United States)

Jani, Shyam S; Low, Daniel A; Lamb, James M

2015-01-01

To develop an automated system that detects patient identification and positioning errors between 3-dimensional computed tomography (CT) and kilovoltage CT planning images. Planning kilovoltage CT images were collected for head and neck (H&N), pelvis, and spine treatments with corresponding 3-dimensional cone beam CT and megavoltage CT setup images from TrueBeam and TomoTherapy units, respectively. Patient identification errors were simulated by registering setup and planning images from different patients. For positioning errors, setup and planning images were misaligned by 1 to 5 cm in the 6 anatomical directions for H&N and pelvis patients. Spinal misalignments were simulated by misaligning to adjacent vertebral bodies. Image pairs were assessed using commonly used image similarity metrics as well as custom-designed metrics. Linear discriminant analysis classification models were trained and tested on the imaging datasets, and misclassification error (MCE), sensitivity, and specificity parameters were estimated using 10-fold cross-validation. For patient identification, our workflow produced MCE estimates of 0.66%, 1.67%, and 0% for H&N, pelvis, and spine TomoTherapy images, respectively. Sensitivity and specificity ranged from 97.5% to 100%. MCEs of 3.5%, 2.3%, and 2.1% were obtained for TrueBeam images of the above sites, respectively, with sensitivity and specificity estimates between 95.4% and 97.7%. MCEs for 1-cm H&N/pelvis misalignments were 1.3%/5.1% and 9.1%/8.6% for TomoTherapy and TrueBeam images, respectively. Two-centimeter MCE estimates were 0.4%/1.6% and 3.1/3.2%, respectively. MCEs for vertebral body misalignments were 4.8% and 3.6% for TomoTherapy and TrueBeam images, respectively. Patient identification and gross misalignment errors can be robustly and automatically detected using 3-dimensional setup images of different energies across 3 commonly treated anatomical sites. Copyright © 2015 American Society for Radiation Oncology. Published by

Landing errors in the men’s floor exercise are caused by flight characteristics

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M Marinsek

2010-06-01

Full Text Available Landing errors on men’s floor exercises are caused by the flight parameters. Depending of the flight phase is determined the magnitude of the landing mistake. On the sample of all gymnasts (n=97 who were competing in the qualifications of the senior Men’s European Championships 2004 in Ljubljana, we analyzed saltos which were performed by them. Variables according to the theoretical model for the evaluation of salto landings in the floor exercise were used. From the mentioned model we chose only those variables that relate to the flight phase. Axis of rotation, number of turns around longitudinal axis and initial landing height havea significant impact on the magnitude of the landing mistake.

A Case of Transfusion Error in a Trauma Patient With Subsequent Root Cause Analysis Leading to Institutional Change

Directory of Open Access Journals (Sweden)

Sean Patrick Clifford MD

2016-05-01

Full Text Available A 28-year-old man presented emergently to the operating room following a gun-shot injury to his right groin. Our hospital’s Massive Transfusion Protocol was initiated as the patient entered the operating room actively hemorrhaging and severely hypotensive. During the aggressive resuscitation efforts, the patient was inadvertently transfused 2 units of packed red blood cells intended for another patient due to a series of errors. Fortunately, the incorrect product was compatible, and the patient recovered from his near-fatal injuries. Root cause analysis was used to review the transfusion error and develop an action plan to help prevent future occurrences.

Setup accuracy of stereoscopic X-ray positioning with automated correction for rotational errors in patients treated with conformal arc radiotherapy for prostate cancer

International Nuclear Information System (INIS)

Soete, Guy; Verellen, Dirk; Tournel, Koen; Storme, Guy

2006-01-01

We evaluated setup accuracy of NovalisBody stereoscopic X-ray positioning with automated correction for rotational errors with the Robotics Tilt Module in patients treated with conformal arc radiotherapy for prostate cancer. The correction of rotational errors was shown to reduce random and systematic errors in all directions. (NovalisBody TM and Robotics Tilt Module TM are products of BrainLAB A.G., Heimstetten, Germany)

Local systematic differences in 2MASS positions

Science.gov (United States)

Bustos Fierro, I. H.; Calderón, J. H.

2018-01-01

We have found that positions in the 2MASS All-sky Catalog of Point Sources show local systematic differences with characteristic length-scales of ˜ 5 to ˜ 8 arcminutes when compared with several catalogs. We have observed that when 2MASS positions are used in the computation of proper motions, the mentioned systematic differences cause systematic errors in the resulting proper motions. We have developed a method to locally rectify 2MASS with respect to UCAC4 in order to diminish the systematic differences between these catalogs. The rectified 2MASS catalog with the proposed method can be regarded as an extension of UCAC4 for astrometry with accuracy ˜ 90 mas in its positions, with negligible systematic errors. Also we show that the use of these rectified positions removes the observed systematic pattern in proper motions derived from original 2MASS positions.

Decrease in Accuracy of a Rotational SINS Caused by its Rotary Table's Errors

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Pin Lv

2014-05-01

Full Text Available We call a strapdown inertial navigation system (SINS that uses the rotation auto-compensation technique (which is a common method to reduce the effect of the bias errors of inertial components a ‘rotational SINS’. In a rotational SINS, the rotary table is an important component, rotating the inertial sensor assembly back and forth in azimuth to accomplish error modulation. As a consequence of the manufacturing process, errors may exist in rotary tables which decrease the navigation accuracy of rotational SINSs. In this study, the errors of rotary tables are considered in terms of installation error, wobble error and angular error, and the models of these errors are established for the rotational SINS. Next, the propagation characteristics of these errors in the rotational SINS are analysed and their effects on navigation results are discussed. Finally, the theoretical conclusions are tested by numerical simulation. This paper supplies a good reference for the development of low-cost rotational SINSs, which usually have low accuracy rotary tables and which may be used in robots, intelligent vehicles and unmanned aerial vehicles (UAVs.

Human errors in NPP operations

International Nuclear Information System (INIS)

Sheng Jufang

1993-01-01

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

TU-AB-201-05: Automatic Adaptive Per-Operative Re-Planning for HDR Prostate Brachytherapy - a Simulation Study On Errors in Needle Positioning

International Nuclear Information System (INIS)

Borot de Battisti, M; Maenhout, M; Lagendijk, J J W; Van Vulpen, M; Moerland, M A; Senneville, B Denis de; Hautvast, G; Binnekamp, D

2015-01-01

Purpose: To develop adaptive planning with feedback for MRI-guided focal HDR prostate brachytherapy with a single divergent needle robotic implant device. After each needle insertion, the dwell positions for that needle are calculated and the positioning of remaining needles and dosimetry are both updated based on MR imaging. Methods: Errors in needle positioning may occur due to inaccurate needle insertion (caused by e.g. the needle’s bending) and unpredictable changes in patient anatomy. Consequently, the dose plan quality might dramatically decrease compared to the preplan. In this study, a procedure was developed to re-optimize, after each needle insertion, the remaining needle angulations, source positions and dwell times in order to obtain an optimal coverage (D95% PTV>19 Gy) without exceeding the constraints of the organs at risk (OAR) (D10% urethra<21 Gy, D1cc bladder<12 Gy and D1cc rectum<12 Gy). Complete HDR procedures with 6 needle insertions were simulated for a patient MR-image set with PTV, prostate, urethra, bladder and rectum delineated. Random angulation errors, modeled by a Gaussian distribution (standard deviation of 3 mm at the needle’s tip), were generated for each needle insertion. We compared the final dose parameters for the situations (I) without re-optimization and (II) with the automatic feedback. Results: The computation time of replanning was below 100 seconds on a current desk computer. For the patient tested, a clinically acceptable dose plan was achieved while applying the automatic feedback (median(range) in Gy, D95% PTV: 19.9(19.3–20.3), D10% urethra: 13.4(11.9–18.0), D1cc rectum: 11.0(10.7–11.6), D1cc bladder: 4.9(3.6–6.8)). This was not the case without re-optimization (median(range) in Gy, D95% PTV: 19.4(14.9–21.3), D10% urethra: 12.6(11.0–15.7), D1cc rectum: 10.9(8.9–14.1), D1cc bladder: 4.8(4.4–5.2)). Conclusion: An automatic guidance strategy for HDR prostate brachytherapy was developed to compensate

Positivity, discontinuity, finite resources, and nonzero error for arbitrarily varying quantum channels

International Nuclear Information System (INIS)

Boche, H.; Nötzel, J.

2014-01-01

This work is motivated by a quite general question: Under which circumstances are the capacities of information transmission systems continuous? The research is explicitly carried out on finite arbitrarily varying quantum channels (AVQCs). We give an explicit example that answers the recent question whether the transmission of messages over AVQCs can benefit from assistance by distribution of randomness between the legitimate sender and receiver in the affirmative. The specific class of channels introduced in that example is then extended to show that the unassisted capacity does have discontinuity points, while it is known that the randomness-assisted capacity is always continuous in the channel. We characterize the discontinuity points and prove that the unassisted capacity is always continuous around its positivity points. After having established shared randomness as an important resource, we quantify the interplay between the distribution of finite amounts of randomness between the legitimate sender and receiver, the (nonzero) probability of a decoding error with respect to the average error criterion and the number of messages that can be sent over a finite number of channel uses. We relate our results to the entanglement transmission capacities of finite AVQCs, where the role of shared randomness is not yet well understood, and give a new sufficient criterion for the entanglement transmission capacity with randomness assistance to vanish

Positive and negative sudden impulses caused by fast forward and reverse interplanetary shocks

Energy Technology Data Exchange (ETDEWEB)

Andrioli, Vania Fatima; Savian, Jairo Francisco, E-mail: vaniafatima@gmail.com, E-mail: savian@lacesm.ufsm.br [Space Science Laboratory of Santa Maria - LACESM/CT - UFSM, Universidade Federal de Santa Maria - UFSM, Centro Tecnologico, Santa Maria, RS (Brazil); Echer, Ezequiel, E-mail: eecher@dge.inpe.br [National Institute for Space Research - INPE - MCT, Sao Jose dos Campos, SP (Brazil); Schuch, Nelson Jorge, E-mail: njschuch@lacesm.ufsm.br [Southern Regional Space Research Center - CRSPE/INPE - MCT, Universidade Federal de Santa Maria - UFSM, Santa Maria, RS (Brazil)

2007-07-01

Fast forward interplanetary shocks (FFS) are characterized by positive jump in all interplanetary plasma parameters (solar wind speed, temperature and density) and interplanetary magnetic field. However the fast reverse interplanetary shocks (FRS) are characterized by negative jump in all mentioned parameters except solar wind speed. Observations show that FFS cause positive sudden impulses (SI) while FRS cause negative SI in the H-component of the geomagnetic field. In this work we investigate the SI caused by interplanetary shocks. We use the observed plasma parameters, upstream and downstream, to calculate the variation of dynamic pressure. We observe that the SI amplitude is larger for positive SI than for negative ones, as a consequence of the fact that FFS have larger dynamic pressure variations as compared to FRS. (author)

The effect of experimental sleep fragmentation on error monitoring.

Science.gov (United States)

Ko, Cheng-Hung; Fang, Ya-Wen; Tsai, Ling-Ling; Hsieh, Shulan

2015-01-01

Experimental sleep fragmentation (SF) is characterized by frequent brief arousals without reduced total sleep time and causes daytime sleepiness and impaired neurocognitive processes. This study explored the impact of SF on error monitoring. Thirteen adults underwent auditory stimuli-induced high-level (H) and low-level (L) SF nights. Flanker task performance and electroencephalogram data were collected in the morning following SF nights. Compared to LSF, HSF induced more arousals and stage N1 sleep, decreased slow wave sleep and rapid-eye-movement sleep (REMS), decreased subjective sleep quality, increased daytime sleepiness, and decreased amplitudes of P300 and error-related positivity (Pe). SF effects on N1 sleep were negatively correlated with SF effects on the Pe amplitude. Furthermore, as REMS was reduced by SF, post-error accuracy compensations were greatly reduced. In conclusion, attentional processes and error monitoring were impaired following one night of frequent sleep disruptions, even when total sleep time was not reduced. Copyright © 2014 Elsevier B.V. All rights reserved.

Visual impairment attributable to uncorrected refractive error and other causes in the Ghanaian youth: The University of Cape Coast Survey.

Science.gov (United States)

Abokyi, Samuel; Ilechie, Alex; Nsiah, Peter; Darko-Takyi, Charles; Abu, Emmanuel Kwasi; Osei-Akoto, Yaw Jnr; Youfegan-Baanam, Mathurin

2016-01-01

To determine the prevalence of visual impairment attributable to refractive error and other causes in a youthful Ghanaian population. A prospective survey of all consecutive visits by first-year tertiary students to the Optometry clinic between August, 2013 and April, 2014. Of the 4378 first-year students aged 16-39 years enumerated, 3437 (78.5%) underwent the eye examination. The examination protocol included presenting visual acuity (PVA), ocular motility, and slit-lamp examination of the external eye, anterior segment and media, and non-dilated fundus examination. Pinhole acuity and fundus examination were performed when the PVA≤6/12 in one or both eyes to determine the principal cause of the vision loss. The mean age of participants was 21.86 years (95% CI: 21.72-21.99). The prevalence of bilateral visual impairment (BVI; PVA in the better eye ≤6/12) and unilateral visual impairment UVI; PVA in the worse eye ≤6/12) were 3.08% (95% CI: 2.56-3.72) and 0.79% (95% CI: 0.54-1.14), respectively. Among 106 participants with BVI, refractive error (96.2%) and corneal opacity (3.8%) were the causes. Of the 27 participants with UVI, refractive error (44.4%), maculopathy (18.5%) and retinal disease (14.8%) were the major causes. There was unequal distribution of BVI in the different age groups, with those above 20 years having a lesser burden. Eye screening and provision of affordable spectacle correction to the youth could be timely to eliminate visual impairment. Copyright © 2014 Spanish General Council of Optometry. Published by Elsevier Espana. All rights reserved.

Correction of electrode modelling errors in multi-frequency EIT imaging.

Science.gov (United States)

Jehl, Markus; Holder, David

2016-06-01

The differentiation of haemorrhagic from ischaemic stroke using electrical impedance tomography (EIT) requires measurements at multiple frequencies, since the general lack of healthy measurements on the same patient excludes time-difference imaging methods. It has previously been shown that the inaccurate modelling of electrodes constitutes one of the largest sources of image artefacts in non-linear multi-frequency EIT applications. To address this issue, we augmented the conductivity Jacobian matrix with a Jacobian matrix with respect to electrode movement. Using this new algorithm, simulated ischaemic and haemorrhagic strokes in a realistic head model were reconstructed for varying degrees of electrode position errors. The simultaneous recovery of conductivity spectra and electrode positions removed most artefacts caused by inaccurately modelled electrodes. Reconstructions were stable for electrode position errors of up to 1.5 mm standard deviation along both surface dimensions. We conclude that this method can be used for electrode model correction in multi-frequency EIT.

Systematic errors in the readings of track etch neutron dosemeters caused by the energy dependence of response

International Nuclear Information System (INIS)

Tanner, R.J.; Thomas, D.J.; Bartlett, D.T.; Horwood, N.

1999-01-01

A study has been performed to assess the extent to which variations in the energy dependence of response of neutron personal dosemeters can cause systematic errors in readings obtained in workplace fields. This involved a detailed determination of the response functions of personal dosemeters used in the UK. These response functions were folded with workplace spectra to ascertain the under- or over-response in workplace fields

Systematic errors in the readings of track etch neutron dosemeters caused by the energy dependence of response

CERN Document Server

Tanner, R J; Bartlett, D T; Horwood, N

1999-01-01

A study has been performed to assess the extent to which variations in the energy dependence of response of neutron personal dosemeters can cause systematic errors in readings obtained in workplace fields. This involved a detailed determination of the response functions of personal dosemeters used in the UK. These response functions were folded with workplace spectra to ascertain the under- or over-response in workplace fields.

Self-monitoring and feedback : A new attempt to find the main cause of lexical bias in phonological speech errors

NARCIS (Netherlands)

Nooteboom, S.G.; Quené, H.

2008-01-01

This paper reports two experiments designed to investigate whether lexical bias in phonological speech errors is caused by immediate feedback of activation, by self-monitoring of inner speech, or by both. The experiments test a number of predictions derived from a model of self-monitoring of inner

Random error in cardiovascular meta-analyses

DEFF Research Database (Denmark)

Albalawi, Zaina; McAlister, Finlay A; Thorlund, Kristian

2013-01-01

BACKGROUND: Cochrane reviews are viewed as the gold standard in meta-analyses given their efforts to identify and limit systematic error which could cause spurious conclusions. The potential for random error to cause spurious conclusions in meta-analyses is less well appreciated. METHODS: We exam...

SU-F-J-131: Reproducibility of Positioning Error Due to Temporarily Indwelled Urethral Catheter for Urethra-Sparing Prostate IMRT

International Nuclear Information System (INIS)

Hirose, K; Takai, Y; Sato, M; Hatayama, Y; Kawaguchi, H; Aoki, M; Akimoto, H; Komai, F; Souma, M; Obara, H; Suzuki, M

2016-01-01

Purpose: The purpose of this study was to prospectively assess the reproducibility of positioning errors due to temporarily indwelled catheter in urethra-sparing image-guided (IG) IMRT. Methods: Ten patients received urethra-sparing prostate IG-IMRT with implanted fiducials. After the first CT scan was performed in supine position, 6-Fr catheter was indwelled into urethra, and the second CT images were taken for planning. While the PTV received 80 Gy, 5% dose reduction was applied for the urethral PRV along the catheter. Additional CT scans were also performed at 5th and 30th fraction. Positions of interests (POIs) were set on posterior edge of prostate at beam isocenter level (POI1) and cranial and caudal edge of prostatic urethra on the post-indwelled CT images. POIs were copied into the pre-indwelled, 5th and 30th fraction’s CT images after fiducial matching on these CT images. The deviation of each POI between pre- and post-indwelled CT and the reproducibility of prostate displacement due to catheter were evaluated. Results: The deviation of POI1 caused by the indwelled catheter to the directions of RL/AP/SI (mm) was 0.20±0.27/−0.64±2.43/1.02±2.31, respectively, and the absolute distances (mm) were 3.15±1.41. The deviation tends to be larger if closer to the caudal edge of prostate. Compared with the pre-indwelled CT scan, a median displacement of all POIs (mm) were 0.3±0.2/2.2±1.1/2.0±2.6 in the post-indwelled, 0.4±0.4/3.4±2.1/2.3±2.6 in 5th, and 0.5±0.5/1.7±2.2/1.9±3.1 in 30th fraction’s CT scan with a similar data distribution. There were 6 patients with 5-mm-over displacement in AP and/or CC directions. Conclusion: Reproducibility of positioning errors due to temporarily indwelling catheter was observed. Especially in case of patients with unusually large shifts by indwelling catheter at the planning process, treatment planning should be performed by using the pre-indwelled CT images with transferred contour of the urethra identified by

SU-F-J-131: Reproducibility of Positioning Error Due to Temporarily Indwelled Urethral Catheter for Urethra-Sparing Prostate IMRT

Energy Technology Data Exchange (ETDEWEB)

Hirose, K; Takai, Y [Hirosaki University, Hirosaki (Japan); Southern Tohoku BNCT Research Center, Koriyama (Japan); Sato, M; Hatayama, Y; Kawaguchi, H; Aoki, M; Akimoto, H [Hirosaki University, Hirosaki (Japan); Komai, F; Souma, M; Obara, H; Suzuki, M [Hirosaki University Hospital, Hirosaki (Japan)

2016-06-15

Purpose: The purpose of this study was to prospectively assess the reproducibility of positioning errors due to temporarily indwelled catheter in urethra-sparing image-guided (IG) IMRT. Methods: Ten patients received urethra-sparing prostate IG-IMRT with implanted fiducials. After the first CT scan was performed in supine position, 6-Fr catheter was indwelled into urethra, and the second CT images were taken for planning. While the PTV received 80 Gy, 5% dose reduction was applied for the urethral PRV along the catheter. Additional CT scans were also performed at 5th and 30th fraction. Positions of interests (POIs) were set on posterior edge of prostate at beam isocenter level (POI1) and cranial and caudal edge of prostatic urethra on the post-indwelled CT images. POIs were copied into the pre-indwelled, 5th and 30th fraction’s CT images after fiducial matching on these CT images. The deviation of each POI between pre- and post-indwelled CT and the reproducibility of prostate displacement due to catheter were evaluated. Results: The deviation of POI1 caused by the indwelled catheter to the directions of RL/AP/SI (mm) was 0.20±0.27/−0.64±2.43/1.02±2.31, respectively, and the absolute distances (mm) were 3.15±1.41. The deviation tends to be larger if closer to the caudal edge of prostate. Compared with the pre-indwelled CT scan, a median displacement of all POIs (mm) were 0.3±0.2/2.2±1.1/2.0±2.6 in the post-indwelled, 0.4±0.4/3.4±2.1/2.3±2.6 in 5th, and 0.5±0.5/1.7±2.2/1.9±3.1 in 30th fraction’s CT scan with a similar data distribution. There were 6 patients with 5-mm-over displacement in AP and/or CC directions. Conclusion: Reproducibility of positioning errors due to temporarily indwelling catheter was observed. Especially in case of patients with unusually large shifts by indwelling catheter at the planning process, treatment planning should be performed by using the pre-indwelled CT images with transferred contour of the urethra identified by

Controlling errors in unidosis carts

Directory of Open Access Journals (Sweden)

Inmaculada Díaz Fernández

2010-01-01

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

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

Epidemic of medical errors and hospital-acquired infections: systemic and social causes

National Research Council Canada - National Science Library

Charney, William

2012-01-01

...) and pharmaceutical errors combined are the second or third leading killer of Americans annually: approximately 300,000 die from a combination of medical errors, hospital acquired infections (HAIs...

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.

Cognitive aspect of diagnostic errors.

Science.gov (United States)

Phua, Dong Haur; Tan, Nigel C K

2013-01-01

Diagnostic errors can result in tangible harm to patients. Despite our advances in medicine, the mental processes required to make a diagnosis exhibits shortcomings, causing diagnostic errors. Cognitive factors are found to be an important cause of diagnostic errors. With new understanding from psychology and social sciences, clinical medicine is now beginning to appreciate that our clinical reasoning can take the form of analytical reasoning or heuristics. Different factors like cognitive biases and affective influences can also impel unwary clinicians to make diagnostic errors. Various strategies have been proposed to reduce the effect of cognitive biases and affective influences when clinicians make diagnoses; however evidence for the efficacy of these methods is still sparse. This paper aims to introduce the reader to the cognitive aspect of diagnostic errors, in the hope that clinicians can use this knowledge to improve diagnostic accuracy and patient outcomes.

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

Unintentional Pharmaceutical-Related Medication Errors Caused by Laypersons Reported to the Toxicological Information Centre in the Czech Republic.

Science.gov (United States)

Urban, Michal; Leššo, Roman; Pelclová, Daniela

2016-07-01

The purpose of the article was to study unintentional pharmaceutical-related poisonings committed by laypersons that were reported to the Toxicological Information Centre in the Czech Republic. Identifying frequency, sources, reasons and consequences of the medication errors in laypersons could help to reduce the overall rate of medication errors. Records of medication error enquiries from 2013 to 2014 were extracted from the electronic database, and the following variables were reviewed: drug class, dosage form, dose, age of the subject, cause of the error, time interval from ingestion to the call, symptoms, prognosis at the time of the call and first aid recommended. Of the calls, 1354 met the inclusion criteria. Among them, central nervous system-affecting drugs (23.6%), respiratory drugs (18.5%) and alimentary drugs (16.2%) were the most common drug classes involved in the medication errors. The highest proportion of the patients was in the youngest age subgroup 0-5 year-old (46%). The reasons for the medication errors involved the leaflet misinterpretation and mistaken dose (53.6%), mixing up medications (19.2%), attempting to reduce pain with repeated doses (6.4%), erroneous routes of administration (2.2%), psychiatric/elderly patients (2.7%), others (9.0%) or unknown (6.9%). A high proportion of children among the patients may be due to the fact that children's dosages for many drugs vary by their weight, and more medications come in a variety of concentrations. Most overdoses could be prevented by safer labelling, proper cap closure systems for liquid products and medication reconciliation by both physicians and pharmacists. © 2016 Nordic Association for the Publication of BCPT (former Nordic Pharmacological Society).

Impact of error fields on plasma identification in ITER

Energy Technology Data Exchange (ETDEWEB)

Martone, R., E-mail: Raffaele.Martone@unina2.it [Ass. EURATOM/ENEA/CREATE, Seconda Università di Napoli, Via Roma 29, Aversa (CE) (Italy); Appel, L. [EURATOM/CCFE Fusion Association, Culham Science Centre, Abingdon (United Kingdom); Chiariello, A.G.; Formisano, A.; Mattei, M. [Ass. EURATOM/ENEA/CREATE, Seconda Università di Napoli, Via Roma 29, Aversa (CE) (Italy); Pironti, A. [Ass. EURATOM/ENEA/CREATE, Università degli Studi di Napoli “Federico II”, Via Claudio 25, Napoli (Italy)

2013-10-15

Highlights: ► The paper deals with the effect on plasma identification of error fields generated by field coils manufacturing and assembly errors. ► EFIT++ is used to identify plasma gaps when poloidal field coils and central solenoid coils are deformed, and the gaps sensitivity with respect to such errors is analyzed. ► Some examples of reconstruction errors in the presence of deformations are reported. -- Abstract: The active control of plasma discharges in present Tokamak devices must be prompt and accurate to guarantee expected performance. As a consequence, the identification step, calculating plasma parameters from diagnostics, should provide in a very short time reliable estimates of the relevant quantities, such as plasma centroid position, plasma-wall distances at given points called gaps, and other geometrical parameters as elongation and triangularity. To achieve the desired response promptness, a number of simplifying assumptions are usually made in the identification algorithms. Among those clearly affecting the quality of the plasma parameters reconstruction, one of the most relevant is the precise knowledge of the magnetic field produced by active coils. Since uncertainties in their manufacturing and assembly process may cause misalignments between the actual and expected geometry and position of magnets, an analysis on the effect of possible wrong information about magnets on the plasma shape identification is documented in this paper.

How Do Simulated Error Experiences Impact Attitudes Related to Error Prevention?

Science.gov (United States)

Breitkreuz, Karen R; Dougal, Renae L; Wright, Melanie C

2016-10-01

The objective of this project was to determine whether simulated exposure to error situations changes attitudes in a way that may have a positive impact on error prevention behaviors. Using a stratified quasi-randomized experiment design, we compared risk perception attitudes of a control group of nursing students who received standard error education (reviewed medication error content and watched movies about error experiences) to an experimental group of students who reviewed medication error content and participated in simulated error experiences. Dependent measures included perceived memorability of the educational experience, perceived frequency of errors, and perceived caution with respect to preventing errors. Experienced nursing students perceived the simulated error experiences to be more memorable than movies. Less experienced students perceived both simulated error experiences and movies to be highly memorable. After the intervention, compared with movie participants, simulation participants believed errors occurred more frequently. Both types of education increased the participants' intentions to be more cautious and reported caution remained higher than baseline for medication errors 6 months after the intervention. This study provides limited evidence of an advantage of simulation over watching movies describing actual errors with respect to manipulating attitudes related to error prevention. Both interventions resulted in long-term impacts on perceived caution in medication administration. Simulated error experiences made participants more aware of how easily errors can occur, and the movie education made participants more aware of the devastating consequences of errors.

Preventing statistical errors in scientific journals.

NARCIS (Netherlands)

Nuijten, M.B.

2016-01-01

There is evidence for a high prevalence of statistical reporting errors in psychology and other scientific fields. These errors display a systematic preference for statistically significant results, distorting the scientific literature. There are several possible causes for this systematic error

Research on Measurement Accuracy of Laser Tracking System Based on Spherical Mirror with Rotation Errors of Gimbal Mount Axes

Science.gov (United States)

Shi, Zhaoyao; Song, Huixu; Chen, Hongfang; Sun, Yanqiang

2018-02-01

This paper presents a novel experimental approach for confirming that spherical mirror of a laser tracking system can reduce the influences of rotation errors of gimbal mount axes on the measurement accuracy. By simplifying the optical system model of laser tracking system based on spherical mirror, we can easily extract the laser ranging measurement error caused by rotation errors of gimbal mount axes with the positions of spherical mirror, biconvex lens, cat's eye reflector, and measuring beam. The motions of polarization beam splitter and biconvex lens along the optical axis and vertical direction of optical axis are driven by error motions of gimbal mount axes. In order to simplify the experimental process, the motion of biconvex lens is substituted by the motion of spherical mirror according to the principle of relative motion. The laser ranging measurement error caused by the rotation errors of gimbal mount axes could be recorded in the readings of laser interferometer. The experimental results showed that the laser ranging measurement error caused by rotation errors was less than 0.1 μm if radial error motion and axial error motion were within ±10 μm. The experimental method simplified the experimental procedure and the spherical mirror could reduce the influences of rotation errors of gimbal mount axes on the measurement accuracy of the laser tracking system.

Causes and cures for errors in the simulation of ion extraction from plasmas

International Nuclear Information System (INIS)

Becker, R.

2006-01-01

For many years, computer programs have been available to simulate the extraction of positive ions from plasmas. The results of such simulations may not always agree with measurements. There are different reasons for this: the mathematical formulation must match with the simulated physics, the number of meshes must be high enough to correctly take into account the nonlinear space charge in the sheath, and ray tracing must be done in sufficiently small steps, using numerically correct field components and partial derivatives. In addition to these hidden problems the user may create errors by a wrong choice of parameters, which are not matching the assumptions of the mathematical formulation. Examples are the use of a positive ion extraction program for the extraction of negative ones, the choice of a wrong angle between the plasma electrode and the beam boundary in the vicinity of the meniscus, and the use of too few trajectories. The design of extraction electrodes generally has the aim to optimize the optical properties and the current of the ion beam. However, it is also important to take into account the surface fields in order to avoid dark currents and sparking

Translational and rotational intra- and inter-fractional errors in patient and target position during a short course of frameless stereotactic body radiotherapy

International Nuclear Information System (INIS)

Josipovic, Mirjana; Fredberg Persson, Gitte; Logadottir, Aashildur; Smulders, Bob; Westmann, Gunnar; Bangsgaard, Jens Peter

2012-01-01

Background. Implementation of cone beam computed tomography (CBCT) in frameless stereotactic body radiotherapy (SBRT) of lung tumours enables setup correction based on tumour position. The aim of this study was to compare setup accuracy with daily soft tissue matching to bony anatomy matching and evaluate intra- and inter-fractional translational and rotational errors in patient and target positions. Material and methods. Fifteen consecutive SBRT patients were included in the study. Vacuum cushions were used for immobilisation. SBRT plans were based on midventilation phase of four-dimensional (4D)-CT or three-dimensional (3D)-CT from PET/CT. Margins of 5 mm in the transversal plane and 10 mm in the cranio-caudal (CC) direction were applied. SBRT was delivered in three fractions within a week. At each fraction, CBCT was performed before and after the treatment. Setup accuracy comparison between soft tissue matching and bony anatomy matching was evaluated on pretreatment CBCTs. From differences in pre- and post-treatment CBCTs, we evaluated the extent of translational and rotational intra-fractional changes in patient position, tumour position and tumour baseline shift. All image registration was rigid with six degrees of freedom. Results. The median 3D difference between patient position based on bony anatomy matching and soft tissue matching was 3.0 mm (0-8.3 mm). The median 3D intra-fractional change in patient position was 1.4 mm (0-12.2 mm) and 2.2 mm (0-13.2 mm) in tumour position. The median 3D intra-fractional baseline shift was 2.2 mm (0-4.7 mm). With correction of translational errors, the remaining systematic and random errors were approximately 1deg. Conclusion. Soft tissue tumour matching improved precision of treatment delivery in frameless SBRT of lung tumours compared to image guidance using bone matching. The intra-fractional displacement of the target position was affected by both translational and rotational changes in tumour baseline position

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.

Review of errors in the issue of medical certificates of cause of death ...

African Journals Online (AJOL)

... significant errors in MCCD records, with the errors more likely in certificates issued by non-specialist medical officers. All the certificates audited had at least one minor error. Training of doctors on proper completion of MCCDs is strongly advocated. Funding: None of the authors received any financial support for this study.

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

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.

Automatic detection of patient identification and positioning errors in radiotherapy treatment using 3D setup images

OpenAIRE

Jani, Shyam

2015-01-01

The success of modern radiotherapy treatment depends on the correct alignment of the radiation beams with the target region in the patient. In the conventional paradigm of image-guided radiation therapy, 2D or 3D setup images are taken immediately prior to treatment and are used by radiation therapy technologists to localize the patient to the same position as defined from the reference planning CT dataset. However, numerous reports in the literature have described errors during this step, wh...

Error Estimation for Indoor 802.11 Location Fingerprinting

DEFF Research Database (Denmark)

Lemelson, Hendrik; Kjærgaard, Mikkel Baun; Hansen, Rene

2009-01-01

providers could adapt their delivered services based on the estimated position error to achieve a higher service quality. Finally, system operators could use the information to inspect whether a location system provides satisfactory positioning accuracy throughout the covered area. For position error...

Chernobyl - system accident or human error?

International Nuclear Information System (INIS)

Stang, E.

1996-01-01

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

Wrong decisions in radiology. Analysis of causes and strategies for error prevention

International Nuclear Information System (INIS)

Lackner, Klaus-Juergen; Krug, Kathrin Barbara

2009-01-01

The book covers observations on errors concerning radiological decisions within a ten-year period. The compiled information is supposed to prevent similar errors in the future. The case studies cover the following issues: cranium, thorax, mamma, abdomen (liver, pancreas, colon), (gastrointestinal tract, urogenital tract), spinal cord, skeleton and blood vessels.

The method to evaluate the position error in graphic positioning technology

Institute of Scientific and Technical Information of China (English)

Huiqing Lu(卢慧卿); Baoguang Wang(王宝光); Lishuang Liu(刘力双); Yabiao Li(李亚标)

2004-01-01

In the measurement of automobile body-in-white, it has been widely studied to position the two dimensional(2D)visual sensors with high precision. In this paper a graphic positioning method is proposed,a hollow tetrahedron is used for a positioning target to replace all the edges of a standard automobile body.A 2D visual sensor can be positioned through adjusting two triangles to be superposed on a screen of the computer, so it is very important to evaluate the superposition precision of the two triangles. Several methods are discussed and the least square method is adopted at last, it makes the adjustment more easy and intuitive with high precision.

Servo control booster system for minimizing following error

Science.gov (United States)

Wise, W.L.

1979-07-26

A closed-loop feedback-controlled servo system is disclosed which reduces command-to-response error to the system's position feedback resolution least increment, ..delta..S/sub R/, on a continuous real-time basis, for all operational times of consequence and for all operating speeds. The servo system employs a second position feedback control loop on a by exception basis, when the command-to-response error greater than or equal to ..delta..S/sub R/, to produce precise position correction signals. When the command-to-response error is less than ..delta..S/sub R/, control automatically reverts to conventional control means as the second position feedback control loop is disconnected, becoming transparent to conventional servo control means. By operating the second unique position feedback control loop used herein at the appropriate clocking rate, command-to-response error may be reduced to the position feedback resolution least increment. The present system may be utilized in combination with a tachometer loop for increased stability.

Analysis of influence on back-EMF based sensorless control of PMSM due to parameter variations and measurement errors

DEFF Research Database (Denmark)

Wang, Z.; Lu, K.; Ye, Y.

2011-01-01

To achieve better performance of sensorless control of PMSM, a precise and stable estimation of rotor position and speed is required. Several parameter uncertainties and variable measurement errors may lead to estimation error, such as resistance and inductance variations due to temperature...... and flux saturation, current and voltage errors due to measurement uncertainties, and signal delay caused by hardwares. This paper reveals some inherent principles for the performance of the back-EMF based sensorless algorithm embedded in a surface mounted PMSM system adapting vector control strategy...

[Cognitive errors in diagnostic decision making].

Science.gov (United States)

Gäbler, Martin

2017-10-01

Approximately 10-15% of our diagnostic decisions are faulty and may lead to unfavorable and dangerous outcomes, which could be avoided. These diagnostic errors are mainly caused by cognitive biases in the diagnostic reasoning process.Our medical diagnostic decision-making is based on intuitive "System 1" and analytical "System 2" diagnostic decision-making and can be deviated by unconscious cognitive biases.These deviations can be positively influenced on a systemic and an individual level. For the individual, metacognition (internal withdrawal from the decision-making process) and debiasing strategies, such as verification, falsification and rule out worst-case scenarios, can lead to improved diagnostic decisions making.

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.

Forecast errors in IEA-countries' energy consumption

DEFF Research Database (Denmark)

Linderoth, Hans

2002-01-01

Every year Policy of IEA Countries includes a forecast of the energy consumption in the member countries. Forecasts concerning the years 1985,1990 and 1995 can now be compared to actual values. The second oil crisis resulted in big positive forecast errors. The oil price drop in 1986 did not have...... the small value is often the sum of large positive and negative errors. Almost no significant correlation is found between forecast errors in the 3 years. Correspondingly, no significant correlation coefficient is found between forecasts errors in the 3 main energy sectors. Therefore, a relatively small...

Death Certification Errors and the Effect on Mortality Statistics.

Science.gov (United States)

McGivern, Lauri; Shulman, Leanne; Carney, Jan K; Shapiro, Steven; Bundock, Elizabeth

Errors in cause and manner of death on death certificates are common and affect families, mortality statistics, and public health research. The primary objective of this study was to characterize errors in the cause and manner of death on death certificates completed by non-Medical Examiners. A secondary objective was to determine the effects of errors on national mortality statistics. We retrospectively compared 601 death certificates completed between July 1, 2015, and January 31, 2016, from the Vermont Electronic Death Registration System with clinical summaries from medical records. Medical Examiners, blinded to original certificates, reviewed summaries, generated mock certificates, and compared mock certificates with original certificates. They then graded errors using a scale from 1 to 4 (higher numbers indicated increased impact on interpretation of the cause) to determine the prevalence of minor and major errors. They also compared International Classification of Diseases, 10th Revision (ICD-10) codes on original certificates with those on mock certificates. Of 601 original death certificates, 319 (53%) had errors; 305 (51%) had major errors; and 59 (10%) had minor errors. We found no significant differences by certifier type (physician vs nonphysician). We did find significant differences in major errors in place of death ( P statistics. Surveillance and certifier education must expand beyond local and state efforts. Simplifying and standardizing underlying literal text for cause of death may improve accuracy, decrease coding errors, and improve national mortality statistics.

Factors associated with specific causes of death amongst HIV-positive individuals in the D:A:D Study

DEFF Research Database (Denmark)

Smith, Colette; Sabin, Caroline A; Lundgren, Jens D

2010-01-01

To investigate any emerging trends in causes of death amongst HIV-positive individuals in the current cART era, and to investigate the factors associated with each specific cause of death.......To investigate any emerging trends in causes of death amongst HIV-positive individuals in the current cART era, and to investigate the factors associated with each specific cause of death....

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

Science.gov (United States)

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

2015-12-01

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

Average beta-beating from random errors

CERN Document Server

Tomas Garcia, Rogelio; Langner, Andy Sven; Malina, Lukas; Franchi, Andrea; CERN. Geneva. ATS Department

2018-01-01

The impact of random errors on average β-beating is studied via analytical derivations and simulations. A systematic positive β-beating is expected from random errors quadratic with the sources or, equivalently, with the rms β-beating. However, random errors do not have a systematic effect on the tune.

Modeling of Geometric Error in Linear Guide Way to Improved the vertical three-axis CNC Milling machine’s accuracy

Science.gov (United States)

Kwintarini, Widiyanti; Wibowo, Agung; Arthaya, Bagus M.; Yuwana Martawirya, Yatna

2018-03-01

The purpose of this study was to improve the accuracy of three-axis CNC Milling Vertical engines with a general approach by using mathematical modeling methods of machine tool geometric errors. The inaccuracy of CNC machines can be caused by geometric errors that are an important factor during the manufacturing process and during the assembly phase, and are factors for being able to build machines with high-accuracy. To improve the accuracy of the three-axis vertical milling machine, by knowing geometric errors and identifying the error position parameters in the machine tool by arranging the mathematical modeling. The geometric error in the machine tool consists of twenty-one error parameters consisting of nine linear error parameters, nine angle error parameters and three perpendicular error parameters. The mathematical modeling approach of geometric error with the calculated alignment error and angle error in the supporting components of the machine motion is linear guide way and linear motion. The purpose of using this mathematical modeling approach is the identification of geometric errors that can be helpful as reference during the design, assembly and maintenance stages to improve the accuracy of CNC machines. Mathematically modeling geometric errors in CNC machine tools can illustrate the relationship between alignment error, position and angle on a linear guide way of three-axis vertical milling machines.

Calculation and simulation on mid-spatial frequency error in continuous polishing

International Nuclear Information System (INIS)

Xie Lei; Zhang Yunfan; You Yunfeng; Ma Ping; Liu Yibin; Yan Dingyao

2013-01-01

Based on theoretical model of continuous polishing, the influence of processing parameters on the polishing result was discussed. Possible causes of mid-spatial frequency error in the process were analyzed. The simulation results demonstrated that the low spatial frequency error was mainly caused by large rotating ratio. The mid-spatial frequency error would decrease as the low spatial frequency error became lower. The regular groove shape was the primary reason of the mid-spatial frequency error. When irregular and fitful grooves were adopted, the mid-spatial frequency error could be lessened. Moreover, the workpiece swing could make the polishing process more uniform and reduce the mid-spatial frequency error caused by the fix-eccentric plane polishing. (authors)

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.

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.

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

NARCIS (Netherlands)

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

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

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

Autonomous orbit determination and its error analysis for deep space using X-ray pulsar

International Nuclear Information System (INIS)

Feng, Dongzhu; Yuan, Xiaoguang; Guo, Hehe; Wang, Xin

2014-01-01

Autonomous orbit determination (OD) is a complex process using filtering method to integrate observation and orbit dynamic model effectively and estimate the position and velocity of a spacecraft. As a novel technology for autonomous interplanetary OD, X-ray pulsar holds great promise for deep space exploration. The position and velocity of spacecraft should be estimated accurately during the OD process. However, under the same condition, the accuracy of OD can be greatly reduced by the error of the initial orbit value and the orbit mutation. To resolve this problem, we propose a novel OD method, which is based on the X-ray pulsar measurement and Adaptive Unscented Kalman Filter (AUKF). The accuracy of OD can be improved obviously because the AUKF estimates the orbit of spacecraft using measurement residual. During the simulation, the orbit of Phoenix Mars Lander, Deep Impact Probe, and Voyager 1 are selected. Compared with Unscented Kalman Filter (UKF) and Extended Kalman Filter (EKF), the simulation results demonstrate that the proposed OD method based on AUKF can accurately determinate the velocity and position and effectively decrease the orbit estimated errors which is caused by the orbit mutation and orbit initial errors. (authors)

Dopamine reward prediction error coding

OpenAIRE

Schultz, Wolfram

2016-01-01

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

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

Determination of UAV position using high accuracy navigation platform

Directory of Open Access Journals (Sweden)

Ireneusz Kubicki

2016-07-01

Full Text Available The choice of navigation system for mini UAV is very important because of its application and exploitation, particularly when the installed on it a synthetic aperture radar requires highly precise information about an object’s position. The presented exemplary solution of such a system draws attention to the possible problems associated with the use of appropriate technology, sensors, and devices or with a complete navigation system. The position and spatial orientation errors of the measurement platform influence on the obtained SAR imaging. Both, turbulences and maneuvers performed during flight cause the changes in the position of the airborne object resulting in deterioration or lack of images from SAR. Consequently, it is necessary to perform operations for reducing or eliminating the impact of the sensors’ errors on the UAV position accuracy. You need to look for compromise solutions between newer better technologies and in the field of software. Keywords: navigation systems, unmanned aerial vehicles, sensors integration

An Analysis of Medication Errors at the Military Medical Center: Implications for a Systems Approach for Error Reduction

National Research Council Canada - National Science Library

Scheirman, Katherine

2001-01-01

An analysis was accomplished of all inpatient medication errors at a military academic medical center during the year 2000, based on the causes of medication errors as described by current research in the field...

Error framing effects on performance: cognitive, motivational, and affective pathways.

Science.gov (United States)

Steele-Johnson, Debra; Kalinoski, Zachary T

2014-01-01

Our purpose was to examine whether positive error framing, that is, making errors salient and cuing individuals to see errors as useful, can benefit learning when task exploration is constrained. Recent research has demonstrated the benefits of a newer approach to training, that is, error management training, that includes the opportunity to actively explore the task and framing errors as beneficial to learning complex tasks (Keith & Frese, 2008). Other research has highlighted the important role of errors in on-the-job learning in complex domains (Hutchins, 1995). Participants (N = 168) from a large undergraduate university performed a class scheduling task. Results provided support for a hypothesized path model in which error framing influenced cognitive, motivational, and affective factors which in turn differentially affected performance quantity and quality. Within this model, error framing had significant direct effects on metacognition and self-efficacy. Our results suggest that positive error framing can have beneficial effects even when tasks cannot be structured to support extensive exploration. Whereas future research can expand our understanding of error framing effects on outcomes, results from the current study suggest that positive error framing can facilitate learning from errors in real-time performance of tasks.

An overview of intravenous-related medication administration errors as reported to MEDMARX, a national medication error-reporting program.

Science.gov (United States)

Hicks, Rodney W; Becker, Shawn C

2006-01-01

Medication errors can be harmful, especially if they involve the intravenous (IV) route of administration. A mixed-methodology study using a 5-year review of 73,769 IV-related medication errors from a national medication error reporting program indicates that between 3% and 5% of these errors were harmful. The leading type of error was omission, and the leading cause of error involved clinician performance deficit. Using content analysis, three themes-product shortage, calculation errors, and tubing interconnectivity-emerge and appear to predispose patients to harm. Nurses often participate in IV therapy, and these findings have implications for practice and patient safety. Voluntary medication error-reporting programs afford an opportunity to improve patient care and to further understanding about the nature of IV-related medication errors.

Medication errors in anesthesia: unacceptable or unavoidable?

Directory of Open Access Journals (Sweden)

Ira Dhawan

Full Text Available Abstract Medication errors are the common causes of patient morbidity and mortality. It adds financial burden to the institution as well. Though the impact varies from no harm to serious adverse effects including death, it needs attention on priority basis since medication errors' are preventable. In today's world where people are aware and medical claims are on the hike, it is of utmost priority that we curb this issue. Individual effort to decrease medication error alone might not be successful until a change in the existing protocols and system is incorporated. Often drug errors that occur cannot be reversed. The best way to ‘treat' drug errors is to prevent them. Wrong medication (due to syringe swap, overdose (due to misunderstanding or preconception of the dose, pump misuse and dilution error, incorrect administration route, under dosing and omission are common causes of medication error that occur perioperatively. Drug omission and calculation mistakes occur commonly in ICU. Medication errors can occur perioperatively either during preparation, administration or record keeping. Numerous human and system errors can be blamed for occurrence of medication errors. The need of the hour is to stop the blame - game, accept mistakes and develop a safe and ‘just' culture in order to prevent medication errors. The newly devised systems like VEINROM, a fluid delivery system is a novel approach in preventing drug errors due to most commonly used medications in anesthesia. Similar developments along with vigilant doctors, safe workplace culture and organizational support all together can help prevent these errors.

High energy hadron-induced errors in memory chips

Energy Technology Data Exchange (ETDEWEB)

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

2001-09-01

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

High energy hadron-induced errors in memory chips

International Nuclear Information System (INIS)

Peterson, R.J.

2001-01-01

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

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

Directory of Open Access Journals (Sweden)

Macarena Suárez-Pellicioni

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

Weissella confusa: a rare cause of vancomycin-resistant Gram-positive bacteraemia.

Science.gov (United States)

Kumar, Anil; Augustine, Deepthi; Sudhindran, S; Kurian, Anu M; Dinesh, Kavitha R; Karim, Shamsul; Philip, Rosamma

2011-10-01

We describe a case of bacteraemia caused by Weissella confusa in a 48-year-old male who was operated on for adenocarcinoma of the gastro-oesophageal junction and maintained on total parenteral nutrition. Blood cultures were positive for a vancomycin-resistant streptococcus-like organism which was identified as W. confusa by 16S rRNA gene sequencing.

Systematic comparison of position and time dependent macroparticle simulations in beam dynamics studies

Directory of Open Access Journals (Sweden)

Ji Qiang

2002-06-01

Full Text Available Macroparticle simulation plays an important role in modern accelerator design and operation. Most linear rf accelerators have been designed based on macroparticle simulations using longitudinal position as the independent variable. In this paper, we have done a systematic comparison between using longitudinal position as the independent variable and using time as the independent variable in macroparticle simulations. We have found that, for an rms-matched beam, the maximum relative moment difference for second, fourth moments and beam maximum amplitudes between these two types of simulations is 0.25% in a 10 m reference transport system with physical parameters similar to the Spallation Neutron Source linac design. The maximum z-to- t transform error in the space-charge force calculation of the position dependent simulation is about 0.1% in such a system. This might cause a several percent error in a complete simulation of a linac with a length of hundreds of meters. Furthermore, the error may be several times larger in simulations of mismatched beams. However, if such errors are acceptable to the linac designer, then one is justified in using position dependent macroparticle simulations in this type of linac design application.

Dosimetric implications of inter- and intrafractional prostate positioning errors during tomotherapy. Comparison of gold marker-based registrations with native MVCT

Energy Technology Data Exchange (ETDEWEB)

Wust, Peter; Joswig, Marc; Graf, Reinhold; Boehmer, Dirk; Beck, Marcus; Barelkowski, Thomasz; Budach, Volker; Ghadjar, Pirus [Charite Universitaetsmedizin Berlin, Department of Radiation Oncology and Radiotherapy, Berlin (Germany)

2017-09-15

For high-dose radiation therapy (RT) of prostate cancer, image-guided (IGRT) and intensity-modulated RT (IMRT) approaches are standard. Less is known regarding comparisons of different IGRT techniques and the resulting residual errors, as well as regarding their influences on dose distributions. A total of 58 patients who received tomotherapy-based RT up to 84 Gy for high-risk prostate cancer underwent IGRT based either on daily megavoltage CT (MVCT) alone (n = 43) or the additional use of gold markers (n = 15) under routine conditions. Planned Adaptive (Accuray Inc., Madison, WI, USA) software was used for elaborated offline analysis to quantify residual interfractional prostate positioning errors, along with systematic and random errors and the resulting safety margins after both IGRT approaches. Dosimetric parameters for clinical target volume (CTV) coverage and exposition of organs at risk (OAR) were also analyzed and compared. Interfractional as well as intrafractional displacements were determined. Particularly in the vertical direction, residual interfractional positioning errors were reduced using the gold marker-based approach, but dosimetric differences were moderate and the clinical relevance relatively small. Intrafractional prostate motion proved to be quite high, with displacements of 1-3 mm; however, these did not result in additional dosimetric impairments. Residual interfractional positioning errors were reduced using gold marker-based IGRT; however, this resulted in only slightly different final dose distributions. Therefore, daily MVCT-based IGRT without markers might be a valid alternative. (orig.) [German] Bei der hochdosierten Bestrahlung des Prostatakarzinoms sind die bildgesteuerte (IGRT) und die intensitaetsmodulierte Bestrahlung (IMRT) Standard. Offene Fragen gibt es beim Vergleich von IGRT-Techniken im Hinblick auf residuelle Fehler und Beeinflussungen der Dosisverteilung. Bei 58 Patienten, deren Hochrisiko-Prostatakarzinom am

Formulation of uncertainty relation of error and disturbance in quantum measurement by using quantum estimation theory

International Nuclear Information System (INIS)

Yu Watanabe; Masahito Ueda

2012-01-01

Full text: When we try to obtain information about a quantum system, we need to perform measurement on the system. The measurement process causes unavoidable state change. Heisenberg discussed a thought experiment of the position measurement of a particle by using a gamma-ray microscope, and found a trade-off relation between the error of the measured position and the disturbance in the momentum caused by the measurement process. The trade-off relation epitomizes the complementarity in quantum measurements: we cannot perform a measurement of an observable without causing disturbance in its canonically conjugate observable. However, at the time Heisenberg found the complementarity, quantum measurement theory was not established yet, and Kennard and Robertson's inequality erroneously interpreted as a mathematical formulation of the complementarity. Kennard and Robertson's inequality actually implies the indeterminacy of the quantum state: non-commuting observables cannot have definite values simultaneously. However, Kennard and Robertson's inequality reflects the inherent nature of a quantum state alone, and does not concern any trade-off relation between the error and disturbance in the measurement process. In this talk, we report a resolution to the complementarity in quantum measurements. First, we find that it is necessary to involve the estimation process from the outcome of the measurement for quantifying the error and disturbance in the quantum measurement. We clarify the implicitly involved estimation process in Heisenberg's gamma-ray microscope and other measurement schemes, and formulate the error and disturbance for an arbitrary quantum measurement by using quantum estimation theory. The error and disturbance are defined in terms of the Fisher information, which gives the upper bound of the accuracy of the estimation. Second, we obtain uncertainty relations between the measurement errors of two observables [1], and between the error and disturbance in the

The influence of the analog-to-digital conversion error on the JT-60 plasma position/shape feedback control system

International Nuclear Information System (INIS)

Yoshida, Michiharu; Kurihara, Kenichi

1995-12-01

In the plasma feedback control system (PFCS) and the direct digital controller (DDC) for the poloidal field coil power supply in the JT-60 tokamak, it is necessary to observe signals of all the poloidal field coil currents. Each of the signals, originally measured by a single sensor, is distributed to the PFCS and DDC through different cable routes and different analog-to-digital converters from each other. This produces the conversion error to the amount of several bits. Consequently, proper voltage from feedback calculation cannot be applied to the coil, and hence the control performance is possibly supposed to deteriorate to a certain extent. This paper describes how this error makes an influence on the plasma horizontal position control and how to improve the deteriorated control performance. (author)

Errors in imaging patients in the emergency setting.

Science.gov (United States)

Pinto, Antonio; Reginelli, Alfonso; Pinto, Fabio; Lo Re, Giuseppe; Midiri, Federico; Muzj, Carlo; Romano, Luigia; Brunese, Luca

2016-01-01

Emergency and trauma care produces a "perfect storm" for radiological errors: uncooperative patients, inadequate histories, time-critical decisions, concurrent tasks and often junior personnel working after hours in busy emergency departments. The main cause of diagnostic errors in the emergency department is the failure to correctly interpret radiographs, and the majority of diagnoses missed on radiographs are fractures. Missed diagnoses potentially have important consequences for patients, clinicians and radiologists. Radiologists play a pivotal role in the diagnostic assessment of polytrauma patients and of patients with non-traumatic craniothoracoabdominal emergencies, and key elements to reduce errors in the emergency setting are knowledge, experience and the correct application of imaging protocols. This article aims to highlight the definition and classification of errors in radiology, the causes of errors in emergency radiology and the spectrum of diagnostic errors in radiography, ultrasonography and CT in the emergency setting.

Entropy Error Model of Planar Geometry Features in GIS

Institute of Scientific and Technical Information of China (English)

LI Dajun; GUAN Yunlan; GONG Jianya; DU Daosheng

2003-01-01

Positional error of line segments is usually described by using "g-band", however, its band width is in relation to the confidence level choice. In fact, given different confidence levels, a series of concentric bands can be obtained. To overcome the effect of confidence level on the error indicator, by introducing the union entropy theory, we propose an entropy error ellipse index of point, then extend it to line segment and polygon,and establish an entropy error band of line segment and an entropy error donut of polygon. The research shows that the entropy error index can be determined uniquely and is not influenced by confidence level, and that they are suitable for positional uncertainty of planar geometry features.

Analysis of Errors in a Special Perturbations Satellite Orbit Propagator

Energy Technology Data Exchange (ETDEWEB)

Beckerman, M.; Jones, J.P.

1999-02-01

We performed an analysis of error densities for the Special Perturbations orbit propagator using data for 29 satellites in orbits of interest to Space Shuttle and International Space Station collision avoidance. We find that the along-track errors predominate. These errors increase monotonically over each 36-hour prediction interval. The predicted positions in the along-track direction progressively either leap ahead of or lag behind the actual positions. Unlike the along-track errors the radial and cross-track errors oscillate about their nearly zero mean values. As the number of observations per fit interval decline the along-track prediction errors, and amplitudes of the radial and cross-track errors, increase.

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.)

Mobility and Position Error Analysis of a Complex Planar Mechanism with Redundant Constraints

Science.gov (United States)

Sun, Qipeng; Li, Gangyan

2018-03-01

Nowadays mechanisms with redundant constraints have been created and attracted much attention for their merits. The mechanism of the redundant constraints in a mechanical system is analyzed in this paper. A analysis method of Planar Linkage with a repetitive structure is proposed to get the number and type of constraints. According to the difference of applications and constraint characteristics, the redundant constraints are divided into the theoretical planar redundant constraints and the space-planar redundant constraints. And the calculation formula for the number of redundant constraints and type of judging method are carried out. And a complex mechanism with redundant constraints is analyzed of the influence about redundant constraints on mechanical performance. With the combination of theoretical derivation and simulation research, a mechanism analysis method is put forward about the position error of complex mechanism with redundant constraints. It points out the direction on how to eliminate or reduce the influence of redundant constraints.

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…

An RFID Indoor Positioning Algorithm Based on Bayesian Probability and K-Nearest Neighbor.

Science.gov (United States)

Xu, He; Ding, Ye; Li, Peng; Wang, Ruchuan; Li, Yizhu

2017-08-05

The Global Positioning System (GPS) is widely used in outdoor environmental positioning. However, GPS cannot support indoor positioning because there is no signal for positioning in an indoor environment. Nowadays, there are many situations which require indoor positioning, such as searching for a book in a library, looking for luggage in an airport, emergence navigation for fire alarms, robot location, etc. Many technologies, such as ultrasonic, sensors, Bluetooth, WiFi, magnetic field, Radio Frequency Identification (RFID), etc., are used to perform indoor positioning. Compared with other technologies, RFID used in indoor positioning is more cost and energy efficient. The Traditional RFID indoor positioning algorithm LANDMARC utilizes a Received Signal Strength (RSS) indicator to track objects. However, the RSS value is easily affected by environmental noise and other interference. In this paper, our purpose is to reduce the location fluctuation and error caused by multipath and environmental interference in LANDMARC. We propose a novel indoor positioning algorithm based on Bayesian probability and K -Nearest Neighbor (BKNN). The experimental results show that the Gaussian filter can filter some abnormal RSS values. The proposed BKNN algorithm has the smallest location error compared with the Gaussian-based algorithm, LANDMARC and an improved KNN algorithm. The average error in location estimation is about 15 cm using our method.

Consequences of leaf calibration errors on IMRT delivery

International Nuclear Information System (INIS)

Sastre-Padro, M; Welleweerd, J; Malinen, E; Eilertsen, K; Olsen, D R; Heide, U A van der

2007-01-01

IMRT treatments using multi-leaf collimators may involve a large number of segments in order to spare the organs at risk. When a large proportion of these segments are small, leaf positioning errors may become relevant and have therapeutic consequences. The performance of four head and neck IMRT treatments under eight different cases of leaf positioning errors has been studied. Systematic leaf pair offset errors in the range of ±2.0 mm were introduced, thus modifying the segment sizes of the original IMRT plans. Thirty-six films were irradiated with the original and modified segments. The dose difference and the gamma index (with 2%/2 mm criteria) were used for evaluating the discrepancies between the irradiated films. The median dose differences were linearly related to the simulated leaf pair errors. In the worst case, a 2.0 mm error generated a median dose difference of 1.5%. Following the gamma analysis, two out of the 32 modified plans were not acceptable. In conclusion, small systematic leaf bank positioning errors have a measurable impact on the delivered dose and may have consequences for the therapeutic outcome of IMRT

SU-E-T-261: Development of An Automated System to Detect Patient Identification and Positioning Errors Prior to Radiotherapy Treatment

Energy Technology Data Exchange (ETDEWEB)

Jani, S; Low, D; Lamb, J [UCLA, Los Angeles, CA (United States)

2015-06-15

Purpose: To develop a system that can automatically detect patient identification and positioning errors using 3D computed tomography (CT) setup images and kilovoltage CT (kVCT) planning images. Methods: Planning kVCT images were collected for head-and-neck (H&N), pelvis, and spine treatments with corresponding 3D cone-beam CT (CBCT) and megavoltage CT (MVCT) setup images from TrueBeam and TomoTherapy units, respectively. Patient identification errors were simulated by registering setup and planning images from different patients. Positioning errors were simulated by misaligning the setup image by 1cm to 5cm in the six anatomical directions for H&N and pelvis patients. Misalignments for spine treatments were simulated by registering the setup image to adjacent vertebral bodies on the planning kVCT. A body contour of the setup image was used as an initial mask for image comparison. Images were pre-processed by image filtering and air voxel thresholding, and image pairs were assessed using commonly-used image similarity metrics as well as custom -designed metrics. A linear discriminant analysis classifier was trained and tested on the datasets, and misclassification error (MCE), sensitivity, and specificity estimates were generated using 10-fold cross validation. Results: Our workflow produced MCE estimates of 0.7%, 1.7%, and 0% for H&N, pelvis, and spine TomoTherapy images, respectively. Sensitivities and specificities ranged from 98.0% to 100%. MCEs of 3.5%, 2.3%, and 2.1% were obtained for TrueBeam images of the above sites, respectively, with sensitivity and specificity estimates between 96.2% and 98.4%. MCEs for 1cm H&N/pelvis misalignments were 1.3/5.1% and 9.1/8.6% for TomoTherapy and TrueBeam images, respectively. 2cm MCE estimates were 0.4%/1.6% and 3.1/3.2%, respectively. Vertebral misalignment MCEs were 4.8% and 4.9% for TomoTherapy and TrueBeam images, respectively. Conclusion: Patient identification and gross misalignment errors can be robustly and

SU-E-T-261: Development of An Automated System to Detect Patient Identification and Positioning Errors Prior to Radiotherapy Treatment

International Nuclear Information System (INIS)

Jani, S; Low, D; Lamb, J

2015-01-01

Purpose: To develop a system that can automatically detect patient identification and positioning errors using 3D computed tomography (CT) setup images and kilovoltage CT (kVCT) planning images. Methods: Planning kVCT images were collected for head-and-neck (H&N), pelvis, and spine treatments with corresponding 3D cone-beam CT (CBCT) and megavoltage CT (MVCT) setup images from TrueBeam and TomoTherapy units, respectively. Patient identification errors were simulated by registering setup and planning images from different patients. Positioning errors were simulated by misaligning the setup image by 1cm to 5cm in the six anatomical directions for H&N and pelvis patients. Misalignments for spine treatments were simulated by registering the setup image to adjacent vertebral bodies on the planning kVCT. A body contour of the setup image was used as an initial mask for image comparison. Images were pre-processed by image filtering and air voxel thresholding, and image pairs were assessed using commonly-used image similarity metrics as well as custom -designed metrics. A linear discriminant analysis classifier was trained and tested on the datasets, and misclassification error (MCE), sensitivity, and specificity estimates were generated using 10-fold cross validation. Results: Our workflow produced MCE estimates of 0.7%, 1.7%, and 0% for H&N, pelvis, and spine TomoTherapy images, respectively. Sensitivities and specificities ranged from 98.0% to 100%. MCEs of 3.5%, 2.3%, and 2.1% were obtained for TrueBeam images of the above sites, respectively, with sensitivity and specificity estimates between 96.2% and 98.4%. MCEs for 1cm H&N/pelvis misalignments were 1.3/5.1% and 9.1/8.6% for TomoTherapy and TrueBeam images, respectively. 2cm MCE estimates were 0.4%/1.6% and 3.1/3.2%, respectively. Vertebral misalignment MCEs were 4.8% and 4.9% for TomoTherapy and TrueBeam images, respectively. Conclusion: Patient identification and gross misalignment errors can be robustly and

'False-positive' and 'false-negative' test results in clinical urine drug testing.

Science.gov (United States)

Reisfield, Gary M; Goldberger, Bruce A; Bertholf, Roger L

2009-08-01

The terms 'false-positive' and 'false-negative' are widely used in discussions of urine drug test (UDT) results. These terms are inadequate because they are used in different ways by physicians and laboratory professionals and they are too narrow to encompass the larger universe of potentially misleading, inappropriate and unexpected drug test results. This larger universe, while not solely comprised of technically 'true' or 'false' positive or negative test results, presents comparable interpretive challenges with corresponding clinical implications. In this review, we propose the terms 'potentially inappropriate' positive or negative test results in reference to UDT results that are ambiguous or unexpected and subject to misinterpretation. Causes of potentially inappropriate positive UDT results include in vivo metabolic conversions of a drug, exposure to nonillicit sources of a drug and laboratory error. Causes of potentially inappropriate negative UDT results include limited assay specificity, absence of drug in the urine, presence of drug in the urine, but below established assay cutoff, specimen manipulation and laboratory error. Clinical UDT interpretation is a complicated task requiring knowledge of recent prescription, over-the-counter and herbal drug administration, drug metabolism and analytical sensitivities and specificities.

Magnetic Nanoparticle Thermometer: An Investigation of Minimum Error Transmission Path and AC Bias Error

Directory of Open Access Journals (Sweden)

Zhongzhou Du

2015-04-01

Full Text Available The signal transmission module of a magnetic nanoparticle thermometer (MNPT was established in this study to analyze the error sources introduced during the signal flow in the hardware system. The underlying error sources that significantly affected the precision of the MNPT were determined through mathematical modeling and simulation. A transfer module path with the minimum error in the hardware system was then proposed through the analysis of the variations of the system error caused by the significant error sources when the signal flew through the signal transmission module. In addition, a system parameter, named the signal-to-AC bias ratio (i.e., the ratio between the signal and AC bias, was identified as a direct determinant of the precision of the measured temperature. The temperature error was below 0.1 K when the signal-to-AC bias ratio was higher than 80 dB, and other system errors were not considered. The temperature error was below 0.1 K in the experiments with a commercial magnetic fluid (Sample SOR-10, Ocean Nanotechnology, Springdale, AR, USA when the hardware system of the MNPT was designed with the aforementioned method.

Anisotropic depth migration: reducing lateral-position uncertainty of subsurface structures in the Alberta foothills

Energy Technology Data Exchange (ETDEWEB)

Vestrum, R.W.; Lawton, D.C.

1999-01-01

Seismic velocity anisotropy causes lateral-positioning errors on seismic images, and the use of anisotropic depth migration corrects this lateral mispositioning of subsurface targets. The assumption of isotropic seismic velocities implies that traditional depth migration corrects only for positioning errors caused by lateral velocity heterogeneity, and mispositioning due to seismic anisotropy remained uncorrected on depth-migrated sections. Also, isotropic depth migration was only applied in cases in which significant lateral velocity changes occurred, and lateral mispositioning due to seismic anisotropy remained uncorrected on time-migrated sections. If seismic is to accurately image the subsurface, then there is a need for reconsidering the assumptions made in depth imaging as well as a need to reconsider at what point depth migration applies to seismic data. Now that it is possible to correct for seismic anisotropy as well as lateral velocity heterogeneity, anisotropic depth migration potentially can be used to improve seismic imaging and positioning in areas in which traditional depth migration did not apply. 5 refs.

Anisotropic depth migration: reducing lateral-position uncertainty of subsurface structures in the Alberta foothills

Energy Technology Data Exchange (ETDEWEB)

Vestrum, R.W.; Lawton, D.C.

1999-11-01

Seismic velocity anisotropy causes lateral-positioning errors on seismic images, and the use of anisotropic depth migration corrects this lateral mispositioning of subsurface targets. The assumption of isotropic seismic velocities implies that traditional depth migration corrects only for positioning errors caused by lateral velocity heterogeneity, and mispositioning due to seismic anisotropy remained uncorrected on depth-migrated sections. Also, isotropic depth migration was only applied in cases in which significant lateral velocity changes occurred, and lateral mispositioning due to seismic anisotropy remained uncorrected on time-migrated sections. If seismic is to accurately image the subsurface, then there is a need for reconsidering the assumptions made in depth imaging as well as a need to reconsider at what point depth migration applies to seismic data. Now that it is possible to correct for seismic anisotropy as well as lateral velocity heterogeneity, anisotropic depth migration potentially can be used to improve seismic imaging and positioning in areas in which traditional depth migration did not apply. 5 refs.

Identifying afterloading PDR and HDR brachytherapy errors using real-time fiber-coupled Al2O3:C dosimetry and a novel statistical error decision criterion

International Nuclear Information System (INIS)

Kertzscher, Gustavo; Andersen, Claus E.; Siebert, Frank-Andre; Nielsen, Soren Kynde; Lindegaard, Jacob C.; Tanderup, Kari

2011-01-01

Background and purpose: The feasibility of a real-time in vivo dosimeter to detect errors has previously been demonstrated. The purpose of this study was to: (1) quantify the sensitivity of the dosimeter to detect imposed treatment errors under well controlled and clinically relevant experimental conditions, and (2) test a new statistical error decision concept based on full uncertainty analysis. Materials and methods: Phantom studies of two gynecological cancer PDR and one prostate cancer HDR patient treatment plans were performed using tandem ring applicators or interstitial needles. Imposed treatment errors, including interchanged pairs of afterloader guide tubes and 2-20 mm source displacements, were monitored using a real-time fiber-coupled carbon doped aluminum oxide (Al 2 O 3 :C) crystal dosimeter that was positioned in the reconstructed tumor region. The error detection capacity was evaluated at three dose levels: dwell position, source channel, and fraction. The error criterion incorporated the correlated source position uncertainties and other sources of uncertainty, and it was applied both for the specific phantom patient plans and for a general case (source-detector distance 5-90 mm and position uncertainty 1-4 mm). Results: Out of 20 interchanged guide tube errors, time-resolved analysis identified 17 while fraction level analysis identified two. Channel and fraction level comparisons could leave 10 mm dosimeter displacement errors unidentified. Dwell position dose rate comparisons correctly identified displacements ≥5 mm. Conclusion: This phantom study demonstrates that Al 2 O 3 :C real-time dosimetry can identify applicator displacements ≥5 mm and interchanged guide tube errors during PDR and HDR brachytherapy. The study demonstrates the shortcoming of a constant error criterion and the advantage of a statistical error criterion.

Sample positioning effects in x-ray spectrometry

International Nuclear Information System (INIS)

Carpenter, D.

Instrument error due to variation in sample position in a crystal x-ray spectrometer can easily exceed the total instrumental error. Lack of reproducibility in sample position in the x-ray optics is the single largest source of system error. The factors that account for sample positioning error are described, and many of the details of flat crystal x-ray optics are discussed

Human errors related to maintenance and modifications

International Nuclear Information System (INIS)

Laakso, K.; Pyy, P.; Reiman, L.

1998-01-01

The focus in human reliability analysis (HRA) relating to nuclear power plants has traditionally been on human performance in disturbance conditions. On the other hand, some studies and incidents have shown that also maintenance errors, which have taken place earlier in plant history, may have an impact on the severity of a disturbance, e.g. if they disable safety related equipment. Especially common cause and other dependent failures of safety systems may significantly contribute to the core damage risk. The first aim of the study was to identify and give examples of multiple human errors which have penetrated the various error detection and inspection processes of plant safety barriers. Another objective was to generate numerical safety indicators to describe and forecast the effectiveness of maintenance. A more general objective was to identify needs for further development of maintenance quality and planning. In the first phase of this operational experience feedback analysis, human errors recognisable in connection with maintenance were looked for by reviewing about 4400 failure and repair reports and some special reports which cover two nuclear power plant units on the same site during 1992-94. A special effort was made to study dependent human errors since they are generally the most serious ones. An in-depth root cause analysis was made for 14 dependent errors by interviewing plant maintenance foremen and by thoroughly analysing the errors. A more simple treatment was given to maintenance-related single errors. The results were shown as a distribution of errors among operating states i.a. as regards the following matters: in what operational state the errors were committed and detected; in what operational and working condition the errors were detected, and what component and error type they were related to. These results were presented separately for single and dependent maintenance-related errors. As regards dependent errors, observations were also made

Impact of error management culture on knowledge performance in professional service firms

Directory of Open Access Journals (Sweden)

Tabea Scheel

2014-01-01

Full Text Available Knowledge is the most crucial resource of the 21st century. For professional service firms (PSFs, knowledge represents the input as well as the output, and thus the fundamental base for performance. As every organization, PSFs have to deal with errors – and how they do that indicates their error culture. Considering the positive potential of errors (e.g., innovation, error management culture is positively related to organizational performance. This longitudinal quantitative study investigates the impact of error management culture on knowledge performance in four waves. The study was conducted in 131 PSFs, i.e. tax accounting offices. As a standard quality management system (QMS was assumed to moderate the relationship between error management culture and knowledge performance, offices' ISO 9000 certification was assessed. Error management culture correlated positively with knowledge performance at a significant level and predicted knowledge performance one year later. While the ISO 9000 certification correlated positively with knowledge performance, its assumed moderation of the relationship between error management culture and knowledge performance was not consistent. The process-oriented QMS seems to function as facilitator for the more behavior-oriented error management culture. However, the benefit of ISO 9000 certification for tax accounting remains to be proven. Given the impact of error management culture on knowledge performance, PSFs should focus on actively promoting positive attitudes towards errors.

Prevalence of Refractive Error and Visual Impairment among Rural ...

African Journals Online (AJOL)

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prevalence of refractive error was 3.5% (myopia 2.6% and hyperopia 0.9%). Refractive error ... 2Department of Ophthalmology, Addis Ababa University Medical Faculty, Ethiopia. Corresponding ... the main cause of low vision and the second cause of blindness .... the visual loss. All data were entered into computers using.

Making Residents Part of the Safety Culture: Improving Error Reporting and Reducing Harms.

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Fox, Michael D; Bump, Gregory M; Butler, Gabriella A; Chen, Ling-Wan; Buchert, Andrew R

2017-01-30

Reporting medical errors is a focus of the patient safety movement. As frontline physicians, residents are optimally positioned to recognize errors and flaws in systems of care. Previous work highlights the difficulty of engaging residents in identification and/or reduction of medical errors and in integrating these trainees into their institutions' cultures of safety. The authors describe the implementation of a longitudinal, discipline-based, multifaceted curriculum to enhance the reporting of errors by pediatric residents at Children's Hospital of Pittsburgh of University of Pittsburgh Medical Center. The key elements of this curriculum included providing the necessary education to identify medical errors with an emphasis on systems-based causes, modeling of error reporting by faculty, and integrating error reporting and discussion into the residents' daily activities. The authors tracked monthly error reporting rates by residents and other health care professionals, in addition to serious harm event rates at the institution. The interventions resulted in significant increases in error reports filed by residents, from 3.6 to 37.8 per month over 4 years (P error reporting correlated with a decline in serious harm events, from 15.0 to 8.1 per month over 4 years (P = 0.01). Integrating patient safety into the everyday resident responsibilities encourages frequent reporting and discussion of medical errors and leads to improvements in patient care. Multiple simultaneous interventions are essential to making residents part of the safety culture of their training hospitals.

Climbing fibers predict movement kinematics and performance errors.

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

2017-09-01

Requisite for understanding cerebellar function is a complete characterization of the signals provided by complex spike (CS) discharge of Purkinje cells, the output neurons of the cerebellar cortex. Numerous studies have provided insights into CS function, with the most predominant view being that they are evoked by error events. However, several reports suggest that CSs encode other aspects of movements and do not always respond to errors or unexpected perturbations. Here, we evaluated CS firing during a pseudo-random manual tracking task in the monkey ( Macaca mulatta ). This task provides extensive coverage of the work space and relative independence of movement parameters, delivering a robust data set to assess the signals that activate climbing fibers. Using reverse correlation, we determined feedforward and feedback CSs firing probability maps with position, velocity, and acceleration, as well as position error, a measure of tracking performance. The direction and magnitude of the CS modulation were quantified using linear regression analysis. The major findings are that CSs significantly encode all three kinematic parameters and position error, with acceleration modulation particularly common. The modulation is not related to "events," either for position error or kinematics. Instead, CSs are spatially tuned and provide a linear representation of each parameter evaluated. The CS modulation is largely predictive. Similar analyses show that the simple spike firing is modulated by the same parameters as the CSs. Therefore, CSs carry a broader array of signals than previously described and argue for climbing fiber input having a prominent role in online motor control. NEW & NOTEWORTHY This article demonstrates that complex spike (CS) discharge of cerebellar Purkinje cells encodes multiple parameters of movement, including motor errors and kinematics. The CS firing is not driven by error or kinematic events; instead it provides a linear representation of each

Ranking of the Causes of Medication Errors in the Viewpoints of Nurses in Selected Hospitals Affiliated With Yazd University of Medical Sciences, Iran

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Roohollah Askari

2017-09-01

Methods: A cross-sectional study was conducted on 220 nurses working in educational hospitals affiliated to Yazd University of Medical Sciences (Shahid Sadoughi, Shahid Rahnemoon and Afshar Hospitals. Stratified random sampling was used. Required data was gathered by Gladstone questionnaire. Data analysis was done through SPSS 16. Results: The most common causes of medication errors were the failure to match the patients' names with ordered drugs, the ill-considered and unreadable nature of the physicians' orders and the nominal similarity of drugs. Failure to match the patients' names with ordered drugs (3.45 ± 2.85 and the incorrect setting of the infusion device by the nurse (8.81 ± 2.57 had the highest and lowest scores from the viewpoints of nurses. Conclusion: Establishing and implementing electronic drug prescription, in service training for improving nurses' pharmacological knowledge, identifying the main types and causes of drug errors, the teaching of proper prescribing techniques are needed.

Constrained motion estimation-based error resilient coding for HEVC

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Guo, Weihan; Zhang, Yongfei; Li, Bo

2018-04-01

Unreliable communication channels might lead to packet losses and bit errors in the videos transmitted through it, which will cause severe video quality degradation. This is even worse for HEVC since more advanced and powerful motion estimation methods are introduced to further remove the inter-frame dependency and thus improve the coding efficiency. Once a Motion Vector (MV) is lost or corrupted, it will cause distortion in the decoded frame. More importantly, due to motion compensation, the error will propagate along the motion prediction path, accumulate over time, and significantly degrade the overall video presentation quality. To address this problem, we study the problem of encoder-sider error resilient coding for HEVC and propose a constrained motion estimation scheme to mitigate the problem of error propagation to subsequent frames. The approach is achieved by cutting off MV dependencies and limiting the block regions which are predicted by temporal motion vector. The experimental results show that the proposed method can effectively suppress the error propagation caused by bit errors of motion vector and can improve the robustness of the stream in the bit error channels. When the bit error probability is 10-5, an increase of the decoded video quality (PSNR) by up to1.310dB and on average 0.762 dB can be achieved, compared to the reference HEVC.

Sleep Loss in Resident Physicians: The Cause of Medical Errors?

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Milton eKramer

2010-10-01

Full Text Available This review begins with the history of the events starting with the death of Libby Zion that lead to the Bell Commission, that the studied her death and made recommendations for improvement that were codified into law in New York state as the 405 law that the ACGME essentially adopted in putting a cap on work hours and establishing the level of staff supervision that must be available to residents in clinical situations particularly the emergency room and acute care units. A summary is then provided of the findings of the laboratory effects of total sleep deprivation including acute total sleep loss and the consequent widespread physiologic alterations, and of the effects of selective and chronic sleep loss. Generally the sequence of responses to increasing sleep loss goes from mood changes to cognitive effects to performance deficits. In the laboratory situation, deficits resulting from sleep deprivation are clearly and definitively demonstrable. Sleep loss in the clinical situation is usually sleep deprivation superimposed on chronic sleep loss. An examination of questionnaire studies, the literature on reports of sleep loss, studies of the reduction of work hours on performance as well as observational and a few interventional studies have yielded contradictory and often equivocal results. The residents generally find they feel better working fewer hours but improvements in patient care are often not reported or do not occur. A change in the attitude of the resident toward his role and his patient has not been salutary. Decreasing sleep loss should have had a positive effect on patient care in reducing medical error, but this remains to be unequivocally demonstrated.

Prevalence of Refractive Error and Visual Impairment among Rural ...

African Journals Online (AJOL)

Refractive error was the major cause of visual impairment accounting for 54% of all causes in the study group. No child was found wearing ... So, large scale community level screening for refractive error should be conducted and integrated with regular school eye screening programs. Effective strategies need to be devised ...

Dopamine reward prediction error coding.

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Schultz, Wolfram

2016-03-01

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

Random and systematic beam modulator errors in dynamic intensity modulated radiotherapy

International Nuclear Information System (INIS)

Parsai, Homayon; Cho, Paul S; Phillips, Mark H; Giansiracusa, Robert S; Axen, David

2003-01-01

This paper reports on the dosimetric effects of random and systematic modulator errors in delivery of dynamic intensity modulated beams. A sliding-widow type delivery that utilizes a combination of multileaf collimators (MLCs) and backup diaphragms was examined. Gaussian functions with standard deviations ranging from 0.5 to 1.5 mm were used to simulate random positioning errors. A clinical example involving a clival meningioma was chosen with optic chiasm and brain stem as limiting critical structures in the vicinity of the tumour. Dose calculations for different modulator fluctuations were performed, and a quantitative analysis was carried out based on cumulative and differential dose volume histograms for the gross target volume and surrounding critical structures. The study indicated that random modulator errors have a strong tendency to reduce minimum target dose and homogeneity. Furthermore, it was shown that random perturbation of both MLCs and backup diaphragms in the order of σ = 1 mm can lead to 5% errors in prescribed dose. In comparison, when MLCs or backup diaphragms alone was perturbed, the system was more robust and modulator errors of at least σ = 1.5 mm were required to cause dose discrepancies greater than 5%. For systematic perturbation, even errors in the order of ±0.5 mm were shown to result in significant dosimetric deviations

Output Error Analysis of Planar 2-DOF Five-bar Mechanism

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Niu, Kejia; Wang, Jun; Ting, Kwun-Lon; Tao, Fen; Cheng, Qunchao; Wang, Quan; Zhang, Kaiyang

2018-03-01

Aiming at the mechanism error caused by clearance of planar 2-DOF Five-bar motion pair, the method of equivalent joint clearance of kinematic pair to virtual link is applied. The structural error model of revolute joint clearance is established based on the N-bar rotation laws and the concept of joint rotation space, The influence of the clearance of the moving pair is studied on the output error of the mechanis. and the calculation method and basis of the maximum error are given. The error rotation space of the mechanism under the influence of joint clearance is obtained. The results show that this method can accurately calculate the joint space error rotation space, which provides a new way to analyze the planar parallel mechanism error caused by joint space.

Apologies and Medical Error

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2008-01-01

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

[Medication error management climate and perception for system use according to construction of medication error prevention system].

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Kim, Myoung Soo

2012-08-01

The purpose of this cross-sectional study was to examine current status of IT-based medication error prevention system construction and the relationships among system construction, medication error management climate and perception for system use. The participants were 124 patient safety chief managers working for 124 hospitals with over 300 beds in Korea. The characteristics of the participants, construction status and perception of systems (electric pharmacopoeia, electric drug dosage calculation system, computer-based patient safety reporting and bar-code system) and medication error management climate were measured in this study. The data were collected between June and August 2011. Descriptive statistics, partial Pearson correlation and MANCOVA were used for data analysis. Electric pharmacopoeia were constructed in 67.7% of participating hospitals, computer-based patient safety reporting systems were constructed in 50.8%, electric drug dosage calculation systems were in use in 32.3%. Bar-code systems showed up the lowest construction rate at 16.1% of Korean hospitals. Higher rates of construction of IT-based medication error prevention systems resulted in greater safety and a more positive error management climate prevailed. The supportive strategies for improving perception for use of IT-based systems would add to system construction, and positive error management climate would be more easily promoted.

Development of Precise Point Positioning Method Using Global Positioning System Measurements

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Byung-Kyu Choi

2011-09-01

Full Text Available Precise point positioning (PPP is increasingly used in several parts such as monitoring of crustal movement and maintaining an international terrestrial reference frame using global positioning system (GPS measurements. An accuracy of PPP data processing has been increased due to the use of the more precise satellite orbit/clock products. In this study we developed PPP algorithm that utilizes data collected by a GPS receiver. The measurement error modelling including the tropospheric error and the tidal model in data processing was considered to improve the positioning accuracy. The extended Kalman filter has been also employed to estimate the state parameters such as positioning information and float ambiguities. For the verification, we compared our results to other of International GNSS Service analysis center. As a result, the mean errors of the estimated position on the East-West, North-South and Up-Down direction for the five days were 0.9 cm, 0.32 cm, and 1.14 cm in 95% confidence level.

Use of Earth's magnetic field for mitigating gyroscope errors regardless of magnetic perturbation.

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Afzal, Muhammad Haris; Renaudin, Valérie; Lachapelle, Gérard

2011-01-01

Most portable systems like smart-phones are equipped with low cost consumer grade sensors, making them useful as Pedestrian Navigation Systems (PNS). Measurements of these sensors are severely contaminated by errors caused due to instrumentation and environmental issues rendering the unaided navigation solution with these sensors of limited use. The overall navigation error budget associated with pedestrian navigation can be categorized into position/displacement errors and attitude/orientation errors. Most of the research is conducted for tackling and reducing the displacement errors, which either utilize Pedestrian Dead Reckoning (PDR) or special constraints like Zero velocity UPdaTes (ZUPT) and Zero Angular Rate Updates (ZARU). This article targets the orientation/attitude errors encountered in pedestrian navigation and develops a novel sensor fusion technique to utilize the Earth's magnetic field, even perturbed, for attitude and rate gyroscope error estimation in pedestrian navigation environments where it is assumed that Global Navigation Satellite System (GNSS) navigation is denied. As the Earth's magnetic field undergoes severe degradations in pedestrian navigation environments, a novel Quasi-Static magnetic Field (QSF) based attitude and angular rate error estimation technique is developed to effectively use magnetic measurements in highly perturbed environments. The QSF scheme is then used for generating the desired measurements for the proposed Extended Kalman Filter (EKF) based attitude estimator. Results indicate that the QSF measurements are capable of effectively estimating attitude and gyroscope errors, reducing the overall navigation error budget by over 80% in urban canyon environment.

The uncorrected refractive error challenge

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Kovin Naidoo

2016-11-01

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

SPACE-BORNE LASER ALTIMETER GEOLOCATION ERROR ANALYSIS

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Y. Wang

2018-05-01

Full Text Available This paper reviews the development of space-borne laser altimetry technology over the past 40 years. Taking the ICESAT satellite as an example, a rigorous space-borne laser altimeter geolocation model is studied, and an error propagation equation is derived. The influence of the main error sources, such as the platform positioning error, attitude measurement error, pointing angle measurement error and range measurement error, on the geolocation accuracy of the laser spot are analysed by simulated experiments. The reasons for the different influences on geolocation accuracy in different directions are discussed, and to satisfy the accuracy of the laser control point, a design index for each error source is put forward.

Reducing visual deficits caused by refractive errors in school and preschool children: results of a pilot school program in the Andean region of Apurimac, Peru

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Latorre-Arteaga, Sergio; Gil-González, Diana; Enciso, Olga; Phelan, Aoife; García-Muñoz, Ángel; Kohler, Johannes

2014-01-01

Background Refractive error is defined as the inability of the eye to bring parallel rays of light into focus on the retina, resulting in nearsightedness (myopia), farsightedness (Hyperopia) or astigmatism. Uncorrected refractive error in children is associated with increased morbidity and reduced educational opportunities. Vision screening (VS) is a method for identifying children with visual impairment or eye conditions likely to lead to visual impairment. Objective To analyze the utility of vision screening conducted by teachers and to contribute to a better estimation of the prevalence of childhood refractive errors in Apurimac, Peru. Design A pilot vision screening program in preschool (Group I) and elementary school children (Group II) was conducted with the participation of 26 trained teachers. Children whose visual acuity was<6/9 [20/30] (Group I) and≤6/9 (Group II) in one or both eyes, measured with the Snellen Tumbling E chart at 6 m, were referred for a comprehensive eye exam. Specificity and positive predictive value to detect refractive error were calculated against clinical examination. Program assessment with participants was conducted to evaluate outcomes and procedures. Results A total sample of 364 children aged 3–11 were screened; 45 children were examined at Centro Oftalmológico Monseñor Enrique Pelach (COMEP) Eye Hospital. Prevalence of refractive error was 6.2% (Group I) and 6.9% (Group II); specificity of teacher vision screening was 95.8% and 93.0%, while positive predictive value was 59.1% and 47.8% for each group, respectively. Aspects highlighted to improve the program included extending training, increasing parental involvement, and helping referred children to attend the hospital. Conclusion Prevalence of refractive error in children is significant in the region. Vision screening performed by trained teachers is a valid intervention for early detection of refractive error, including screening of preschool children. Program

Static-transmission-error vibratory-excitation contributions from plastically deformed gear teeth caused by tooth bending-fatigue damage

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Mark, W. D.; Reagor, C. P.

2007-02-01

To assess gear health and detect gear-tooth damage, the vibratory response from meshing gear-pair excitations is commonly monitored by accelerometers. In an earlier paper, strong evidence was presented suggesting that, in the case of tooth bending-fatigue damage, the principal source of detectable damage is whole-tooth plastic deformation; i.e. yielding, rather than changes in tooth stiffness caused by tooth-root cracks. Such plastic deformations are geometric deviation contributions to the "static-transmission-error" (STE) vibratory excitation caused by meshing gear pairs. The STE contributions caused by two likely occurring forms of such plastic deformations on a single tooth are derived, and displayed in the time domain as a function of involute "roll distance." Example calculations are provided for transverse contact ratios of Qt=1.4 and 1.8, for spur gears and for helical-gear axial contact ratios ranging from Qa=1.2 to Qa=3.6. Low-pass- and band-pass-filtered versions of these same STE contributions also are computed and displayed in the time domain. Several calculations, consisting of superposition of the computed STE tooth-meshing fundamental harmonic contribution and the band-pass STE contribution caused by a plastically deformed tooth, exhibit the amplitude and frequency or phase modulation character commonly observed in accelerometer-response waveforms caused by damaged teeth. General formulas are provided that enable computation of these STE vibratory-excitation contributions for any form of plastic deformation on any number of teeth for spur and helical gears with any contact ratios.

Ocular Causes of Abnormal Head Position: Strabismus Clinic Data

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Kadriye Erkan Turan

2017-08-01

Full Text Available Objectives: To determine the most common ocular causes and types of abnormal head position (AHP and describe their clinical features. Materials and Methods: Patients with AHP who had been followed in the strabismus unit were retrospectively reviewed. Demographic features and orthoptic characteristics were recorded. Results: A total of 163 patients including 61 women (37.4% and 102 men (62.6%, with a mean age of 19.9±18.3 were recruited. The most common causes of AHP were determined as fourth cranial nerve palsy (33.7%, Duane retraction syndrome (21.5%, sixth cranial nerve palsy (11%, nystagmus blockage syndrome (9.8% and Brown syndrome (6.7%. Other less frequent causes were A-V pattern strabismus, comitant strabismus, thyroid orbitopathy and third cranial nerve palsy. The most common types of AHP were head tilt (45.4% and face turn (36.8%. Out of 142 patients whose visual acuity could be evaluated, 28.2% had amblyopia. The frequency of amblyopia varied depending on the diagnosis (p<0.001, while there was no relation between amblyopia and different types of AHP (p=0.497. Stereopsis and fusion could be tested in 128 patients and 43.8% of them had stereopsis and fusion. The presence of stereopsis and fusion was found to be related with the diagnosis (p=0.001, whereas it was not related with the types of AHP (p=0.580. The presence of amblyopia was not significantly associated with fusion (p=1.000 or stereopsis (p=0.602. Conclusion: There are many ocular pathologies that cause AHP. Patients with similar diagnoses may have different types of AHP. Patients may have amblyopia and impaired binocularity despite AHP. Therefore, all patients with AHP should be examined in detail and these points should be considered in the treatment plan.

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

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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.

Error evaluation method for material accountancy measurement. Evaluation of random and systematic errors based on material accountancy data

International Nuclear Information System (INIS)

Nidaira, Kazuo

2008-01-01

International Target Values (ITV) shows random and systematic measurement uncertainty components as a reference for routinely achievable measurement quality in the accountancy measurement. The measurement uncertainty, called error henceforth, needs to be periodically evaluated and checked against ITV for consistency as the error varies according to measurement methods, instruments, operators, certified reference samples, frequency of calibration, and so on. In the paper an error evaluation method was developed with focuses on (1) Specifying clearly error calculation model, (2) Getting always positive random and systematic error variances, (3) Obtaining probability density distribution of an error variance and (4) Confirming the evaluation method by simulation. In addition the method was demonstrated by applying real data. (author)

Position calibration of a 3-DOF hand-controller with hybrid structure

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Zhu, Chengcheng; Song, Aiguo

2017-09-01

A hand-controller is a human-robot interactive device, which measures the 3-DOF (Degree of Freedom) position of the human hand and sends it as a command to control robot movement. The device also receives 3-DOF force feedback from the robot and applies it to the human hand. Thus, the precision of 3-DOF position measurements is a key performance factor for hand-controllers. However, when using a hybrid type 3-DOF hand controller, various errors occur and are considered originating from machining and assembly variations within the device. This paper presents a calibration method to improve the position tracking accuracy of hybrid type hand-controllers by determining the actual size of the hand-controller parts. By re-measuring and re-calibrating this kind of hand-controller, the actual size of the key parts that cause errors is determined. Modifying the formula parameters with the actual sizes, which are obtained in the calibrating process, improves the end position tracking accuracy of the device.

Analytical sensitivity analysis of geometric errors in a three axis machine tool

International Nuclear Information System (INIS)

Park, Sung Ryung; Yang, Seung Han

2012-01-01

In this paper, an analytical method is used to perform a sensitivity analysis of geometric errors in a three axis machine tool. First, an error synthesis model is constructed for evaluating the position volumetric error due to the geometric errors, and then an output variable is defined, such as the magnitude of the position volumetric error. Next, the global sensitivity analysis is executed using an analytical method. Finally, the sensitivity indices are calculated using the quantitative values of the geometric errors

Correcting AUC for Measurement Error.

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Rosner, Bernard; Tworoger, Shelley; Qiu, Weiliang

2015-12-01

Diagnostic biomarkers are used frequently in epidemiologic and clinical work. The ability of a diagnostic biomarker to discriminate between subjects who develop disease (cases) and subjects who do not (controls) is often measured by the area under the receiver operating characteristic curve (AUC). The diagnostic biomarkers are usually measured with error. Ignoring measurement error can cause biased estimation of AUC, which results in misleading interpretation of the efficacy of a diagnostic biomarker. Several methods have been proposed to correct AUC for measurement error, most of which required the normality assumption for the distributions of diagnostic biomarkers. In this article, we propose a new method to correct AUC for measurement error and derive approximate confidence limits for the corrected AUC. The proposed method does not require the normality assumption. Both real data analyses and simulation studies show good performance of the proposed measurement error correction method.

Errors Analysis of Students in Mathematics Department to Learn Plane Geometry

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Mirna, M.

2018-04-01

This article describes the results of qualitative descriptive research that reveal the locations, types and causes of student error in answering the problem of plane geometry at the problem-solving level. Answers from 59 students on three test items informed that students showed errors ranging from understanding the concepts and principles of geometry itself to the error in applying it to problem solving. Their type of error consists of concept errors, principle errors and operational errors. The results of reflection with four subjects reveal the causes of the error are: 1) student learning motivation is very low, 2) in high school learning experience, geometry has been seen as unimportant, 3) the students' experience using their reasoning in solving the problem is very less, and 4) students' reasoning ability is still very low.

Control rod position detector for nuclear reactor

International Nuclear Information System (INIS)

Kudo, Mitsuru; Fujiwara, Hiroshi.

1981-01-01

Purpose: To improve the reliability of a control rod position detector by detecting a reactive code with a combination of control rod position change signals produced from vertical and horizontal axis decoders, generation an error signal and thus simultaneously detecting the operation of more than two lead switches. Constitution: Horizontal and vertical axis position signals responsive to changes in the control rod position are applied from lead switches connected in a predetermined matrix connection corresponding to the notches of the positions of respective position detecting probes, the reactive output from the decoder is detected by a reactive code detecting circuit, which in turn generates a fault signal, and the control rod position code converted in a notch number generating circuit is converted to a predetermined value indicating invalidity. Accordingly, a fault caused by the simultaneous operation of a plurality of failed lead switches can be effectively detected. (Yoshino, Y.)

Positioning performance analysis of the time sum of arrival algorithm with error features

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Gong, Feng-xun; Ma, Yan-qiu

2018-03-01

The theoretical positioning accuracy of multilateration (MLAT) with the time difference of arrival (TDOA) algorithm is very high. However, there are some problems in practical applications. Here we analyze the location performance of the time sum of arrival (TSOA) algorithm from the root mean square error ( RMSE) and geometric dilution of precision (GDOP) in additive white Gaussian noise (AWGN) environment. The TSOA localization model is constructed. Using it, the distribution of location ambiguity region is presented with 4-base stations. And then, the location performance analysis is started from the 4-base stations with calculating the RMSE and GDOP variation. Subsequently, when the location parameters are changed in number of base stations, base station layout and so on, the performance changing patterns of the TSOA location algorithm are shown. So, the TSOA location characteristics and performance are revealed. From the RMSE and GDOP state changing trend, the anti-noise performance and robustness of the TSOA localization algorithm are proved. The TSOA anti-noise performance will be used for reducing the blind-zone and the false location rate of MLAT systems.

An RFID Indoor Positioning Algorithm Based on Bayesian Probability and K-Nearest Neighbor

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He Xu

2017-08-01

Full Text Available The Global Positioning System (GPS is widely used in outdoor environmental positioning. However, GPS cannot support indoor positioning because there is no signal for positioning in an indoor environment. Nowadays, there are many situations which require indoor positioning, such as searching for a book in a library, looking for luggage in an airport, emergence navigation for fire alarms, robot location, etc. Many technologies, such as ultrasonic, sensors, Bluetooth, WiFi, magnetic field, Radio Frequency Identification (RFID, etc., are used to perform indoor positioning. Compared with other technologies, RFID used in indoor positioning is more cost and energy efficient. The Traditional RFID indoor positioning algorithm LANDMARC utilizes a Received Signal Strength (RSS indicator to track objects. However, the RSS value is easily affected by environmental noise and other interference. In this paper, our purpose is to reduce the location fluctuation and error caused by multipath and environmental interference in LANDMARC. We propose a novel indoor positioning algorithm based on Bayesian probability and K-Nearest Neighbor (BKNN. The experimental results show that the Gaussian filter can filter some abnormal RSS values. The proposed BKNN algorithm has the smallest location error compared with the Gaussian-based algorithm, LANDMARC and an improved KNN algorithm. The average error in location estimation is about 15 cm using our method.

Understanding human management of automation errors

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McBride, Sara E.; Rogers, Wendy A.; Fisk, Arthur D.

2013-01-01

Automation has the potential to aid humans with a diverse set of tasks and support overall system performance. Automated systems are not always reliable, and when automation errs, humans must engage in error management, which is the process of detecting, understanding, and correcting errors. However, this process of error management in the context of human-automation interaction is not well understood. Therefore, we conducted a systematic review of the variables that contribute to error management. We examined relevant research in human-automation interaction and human error to identify critical automation, person, task, and emergent variables. We propose a framework for management of automation errors to incorporate and build upon previous models. Further, our analysis highlights variables that may be addressed through design and training to positively influence error management. Additional efforts to understand the error management process will contribute to automation designed and implemented to support safe and effective system performance. PMID:25383042

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

Hand position-dependent modulation of errors in vibrotactile temporal order judgments

DEFF Research Database (Denmark)

Ritterband-Rosenbaum, Anina; Hermosillo, Robert; Kroliczak, Gregory

2014-01-01

this confounded information is processed in the brain is poorly understood. In the present set of experiments, we addressed this knowledge gap by using singlepulse transcranial magnetic stimulation (TMS) to disrupt processing in the right or left posterior parietal cortex (PPC) during a vibrotactile TOJ task...... with stimuli applied to the right and left index fingers. In the first experiment, participants held their hands in an uncrossed configuration, and we found that when the index finger contralateral to the site of TMS was stimulated first, there was a significant increase in TOJ errors. This increase did...... that these TMS-induced changes in TOJ errors were not due to a reduced ability to detect the timing of the vibrotactile stimuli. Taken together, these results demonstrate that both the right and left PPC contribute to the processing underlying vibrotactile TOJs by integrating vibrotactile information...

Blood transfusion sampling and a greater role for error recovery.

Science.gov (United States)

Oldham, Jane

Patient identification errors in pre-transfusion blood sampling ('wrong blood in tube') are a persistent area of risk. These errors can potentially result in life-threatening complications. Current measures to address root causes of incidents and near misses have not resolved this problem and there is a need to look afresh at this issue. PROJECT PURPOSE: This narrative review of the literature is part of a wider system-improvement project designed to explore and seek a better understanding of the factors that contribute to transfusion sampling error as a prerequisite to examining current and potential approaches to error reduction. A broad search of the literature was undertaken to identify themes relating to this phenomenon. KEY DISCOVERIES: Two key themes emerged from the literature. Firstly, despite multi-faceted causes of error, the consistent element is the ever-present potential for human error. Secondly, current focus on error prevention could potentially be augmented with greater attention to error recovery. Exploring ways in which clinical staff taking samples might learn how to better identify their own errors is proposed to add to current safety initiatives.

MDEP Common Position CP-DICWG-13. Common position on spurious actuation

International Nuclear Information System (INIS)

2017-01-01

Spurious actuations produced by Instrumentation and Control (I and C) systems are a safety concern if such actuations could challenge plant safety. Spurious actuations can lead to unnecessary challenges to safety equipment, challenge the ability of safety systems to provide their intended functions, or place the plant in an un-analysed state. Spurious actuation of plant equipment can be caused by factors including, but not limited to, single failures, common cause failures, human (e.g. operator) action, maintenance errors, design errors, or missing requirements. Modern I and C systems can have inter-connectivities, dependencies and commonalities that can, if the overall I and C architecture and the individual I and C systems are not adequately developed and operated, facilitate fault propagation, leading to potential spurious actuation of one or more trains of plant equipment. Sources and contributors of spurious actuations of multiple trains of plant equipment may include inadequate independence among redundant portions of I and C systems, inappropriate allocation of I and C functions, inadequate qualification or design of supporting systems (e.g. heating, ventilation and air conditioning (HVAC) system), or non-classified systems that could have been erroneously classified. Spurious actuations are a type of hazard. Generic Common Position (GCP) DICWG-10 'Common Position on Hazard Identification and Controls for Digital Instrumentation and Control Systems' provides a set of common positions pertaining to identifying and controlling hazards in an I and C system. This common position was developed to add special considerations when identifying and controlling hazards that include spurious actuations. It is expected that GCP DICWG-10 and the common positions in this document be used together for a complete analysis of hazards and their controls (e.g. prevention of spurious actuations in the design of the system/component). Spurious actuations of concern

Open quantum systems and error correction

Science.gov (United States)

Shabani Barzegar, Alireza

Quantum effects can be harnessed to manipulate information in a desired way. Quantum systems which are designed for this purpose are suffering from harming interaction with their surrounding environment or inaccuracy in control forces. Engineering different methods to combat errors in quantum devices are highly demanding. In this thesis, I focus on realistic formulations of quantum error correction methods. A realistic formulation is the one that incorporates experimental challenges. This thesis is presented in two sections of open quantum system and quantum error correction. Chapters 2 and 3 cover the material on open quantum system theory. It is essential to first study a noise process then to contemplate methods to cancel its effect. In the second chapter, I present the non-completely positive formulation of quantum maps. Most of these results are published in [Shabani and Lidar, 2009b,a], except a subsection on geometric characterization of positivity domain of a quantum map. The real-time formulation of the dynamics is the topic of the third chapter. After introducing the concept of Markovian regime, A new post-Markovian quantum master equation is derived, published in [Shabani and Lidar, 2005a]. The section of quantum error correction is presented in three chapters of 4, 5, 6 and 7. In chapter 4, we introduce a generalized theory of decoherence-free subspaces and subsystems (DFSs), which do not require accurate initialization (published in [Shabani and Lidar, 2005b]). In Chapter 5, we present a semidefinite program optimization approach to quantum error correction that yields codes and recovery procedures that are robust against significant variations in the noise channel. Our approach allows us to optimize the encoding, recovery, or both, and is amenable to approximations that significantly improve computational cost while retaining fidelity (see [Kosut et al., 2008] for a published version). Chapter 6 is devoted to a theory of quantum error correction (QEC

Focusing errors in radiography - how they can be recognized and avoided. 2. rev. ed.

International Nuclear Information System (INIS)

Zimmer, E.A.; Zimmer-Brossy, M.

1979-01-01

The importance of the problem of recognizing and judging focusing errors for the daily practice has caused the authors to give this systematic and abundantly pictured account of the most frequent focusing errors, for as yet no such book has been published either in Germany or abroad. To keep it as concise and handy as possible the authors have restricted themselves to the most important standard pictures and omitted to list errors such as: blurred pictures owing to breathing or movement as well as under and overexposed pictures, which are easy to recognize and avoid. By contrast, they describe in detail those characteristic points and lines of orientation that must be checked to verify the technical quality of an X-ray picture. Knowledge of the typical aspects in a correctly focused X-ray picture is a precondition for understanding incorrectly focused pictures which have some characteristic properties as well. Proper interpretation of an incorrectly focused picture then permits to detect also the cause of the focusing error, be it false centring or false positioning. Thus quick and aimed correction becomes possible. To avoid unnecessary repeat X-rays, which are self-prohibitive for reasons of radiation protection alone, each chapter contains at the end a remark starting in which cases the medical indication requires the repetition of an unserviceable X-ray. (orig./ORU) [de

Evaluation of a miniature electromagnetic position tracker

International Nuclear Information System (INIS)

Hummel, Johann; Figl, Michael; Kollmann, Christian; Bergmann, Helmar; Birkfellner, Wolfgang

2002-01-01

The advent of miniaturized electromagnetic digitizers opens a variety of potential clinical applications for computer aided interventions using flexible instruments; endoscopes or catheters can easily be tracked within the body. With respect to the new applications, the systematic distortions induced by various materials such as closed metallic loops, wire guides, catheters, and ultrasound scan heads were systematically evaluated in this paper for a new commercial tracking system. We employed the electromagnetic tracking system Aurora trade mark sign (Mednetix/CH, NDI/Can); data were acquired using the serial port of a PC running SuSE Linux 7.1 (SuSE, Gmbh, Nuernberg). Objects introduced into the digitizer volume included wire loops of different diameters, wire guides, optical tracking tools, an ultrasonic (US) scan head, an endoscope with radial ultrasound scan head and various other objects used in operating rooms and interventional suites. Beyond this, we determined the influence of a C-arm fluoroscopy unit. To quantify the reliability of the system, the miniaturized sensor was mounted on a nonmetallic measurement rack while the transmitter was fixed at three different distances within the digitizer range. The tracker was shown to be more sensitive to distortions caused by materials close to the emitter (average distortion error 13.6 mm±16.6 mm for wire loops positioned at a distance between 100 mm and 200 mm from the emitter). Distortions caused by materials near the sensor (distances smaller than 100 mm) are small (typical error 2.2 mm±1.9 mm). The C-arm fluoroscopy unit caused considerable distortions and limits the reliability of the tracker (distortion error 18.6 mm±24.9 mm). Distortions resulting from the US scan head are high at distances smaller than about 100 mm from the emitter. The distortions also increase when the scan head is positioned horizontally and close to the sensor (average error 4.1 mm±1.5 mm when the scan head is positioned within a

Mean Bias in Seasonal Forecast Model and ENSO Prediction Error.

Science.gov (United States)

Kim, Seon Tae; Jeong, Hye-In; Jin, Fei-Fei

2017-07-20

This study uses retrospective forecasts made using an APEC Climate Center seasonal forecast model to investigate the cause of errors in predicting the amplitude of El Niño Southern Oscillation (ENSO)-driven sea surface temperature variability. When utilizing Bjerknes coupled stability (BJ) index analysis, enhanced errors in ENSO amplitude with forecast lead times are found to be well represented by those in the growth rate estimated by the BJ index. ENSO amplitude forecast errors are most strongly associated with the errors in both the thermocline slope response and surface wind response to forcing over the tropical Pacific, leading to errors in thermocline feedback. This study concludes that upper ocean temperature bias in the equatorial Pacific, which becomes more intense with increasing lead times, is a possible cause of forecast errors in the thermocline feedback and thus in ENSO amplitude.

Analysis of Employee's Survey for Preventing Human-Errors

International Nuclear Information System (INIS)

Sung, Chanho; Kim, Younggab; Joung, Sanghoun

2013-01-01

Human errors in nuclear power plant can cause large and small events or incidents. These events or incidents are one of main contributors of reactor trip and might threaten the safety of nuclear plants. To prevent human-errors, KHNP(nuclear power plants) introduced 'Human-error prevention techniques' and have applied the techniques to main parts such as plant operation, operation support, and maintenance and engineering. This paper proposes the methods to prevent and reduce human-errors in nuclear power plants through analyzing survey results which includes the utilization of the human-error prevention techniques and the employees' awareness of preventing human-errors. With regard to human-error prevention, this survey analysis presented the status of the human-error prevention techniques and the employees' awareness of preventing human-errors. Employees' understanding and utilization of the techniques was generally high and training level of employee and training effect on actual works were in good condition. Also, employees answered that the root causes of human-error were due to working environment including tight process, manpower shortage, and excessive mission rather than personal negligence or lack of personal knowledge. Consideration of working environment is certainly needed. At the present time, based on analyzing this survey, the best methods of preventing human-error are personal equipment, training/education substantiality, private mental health check before starting work, prohibit of multiple task performing, compliance with procedures, and enhancement of job site review. However, the most important and basic things for preventing human-error are interests of workers and organizational atmosphere such as communication between managers and workers, and communication between employees and bosses

Smoking is a cause of social inequality in health, but is social position is cause of smoking?

DEFF Research Database (Denmark)

Mortensen, Laust Hvas

2011-01-01

(for an elaborate example of these misconceptions, see e.g. Mortensen et al.).3 I think this highlights the need for great caution when we apply prescriptive interpretations to descriptive studies. Smoking is a cause of social inequality in health: If smoking was eliminated social differences would......: 28 year cohort study. BMJ 2011; 342:d3785. (2) Mackenbach JP. What would happen to health inequalities if smoking were eliminated? BMJ 2011; 342:d3460. (3) Mortensen LH, Diderichsen F, Smith GD, Andersen AM. The social gradient in birthweight at term: quantification of the mediating role of maternal......The paper by Hart and colleagues describes occupational class differences in cause specific mortality among women who had never smoked.1 In the accompanying commentary smoking is discussed as if it was a mediator of the relationship between social position and health.2 But the uptake of smoking...

Position as a Cause of Deformity in Children with Cerebral Palsy (1976)

Science.gov (United States)

Scrutton, David

2008-01-01

Deformities in the child with cerebral palsy have been ascribed to muscle imbalance (Sharrard 1961) and increased tone (Pollock 1959) or to the type of cerebral palsy (Bobath and Bobath 1975). As far as we know, the position in which the child is nursed, especially during the first year of life, has not been considered as a cause of deformity. It…

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

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.

Analysis of refractive error in visual impairment among residents aged 40 years and above in Dongguan City

Directory of Open Access Journals (Sweden)

Shu-Hui Chen

2015-06-01

Full Text Available AIM: To investigate the prevalence rate of visual impairment caused by refractive error among residents aged 40 years and above, and the influence factors of vision correction. METHODS: We conducted an epidemiological survey of diabetes and diabetic retinopathy among residents aged 40 and above in Guangdong Province, Hengli Town, Dongguan City from 2011 to 2012. At the same time, according to World Health Organization(WHO, according to the daily life vision, 0.05≤visual ability RESULTS: The prevalence rate of visual impairment was 7.90%(707/8 952. The prevalence rate of visual impairment caused by refractive error was 5.57%(499/8 952, accounted for visual impairment of 70.58%(499/707. The prevalence rate of correction of refractive error among visual impairment was 5.36%(480/8 952, accounting for visual impairment of 67.89%(480/707. The prevalence rate of visual impairment uncorrected was 0.21%(19/8 952, accounting for visual impairment of 2.69%(19/707. By χ2 test, with the increase of age, the rate of visual impairment caused by refractive error was significantly decreased(PPP>0.05. The rate of visual impairment can be corrected decreases with age, from 92.1% to 49.1%, there was a statistically significant difference(PPP>0.05. CONCLUSION: Through the development of refractive error correction of positive, can make the daily life of visual impairment in about 2/3 of patients improve eyesight and improve the quality of life of residents.

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

Errors in veterinary practice: preliminary lessons for building better veterinary teams.

Science.gov (United States)

Kinnison, T; Guile, D; May, S A

2015-11-14

Case studies in two typical UK veterinary practices were undertaken to explore teamwork, including interprofessional working. Each study involved one week of whole team observation based on practice locations (reception, operating theatre), one week of shadowing six focus individuals (veterinary surgeons, veterinary nurses and administrators) and a final week consisting of semistructured interviews regarding teamwork. Errors emerged as a finding of the study. The definition of errors was inclusive, pertaining to inputs or omitted actions with potential adverse outcomes for patients, clients or the practice. The 40 identified instances could be grouped into clinical errors (dosing/drugs, surgical preparation, lack of follow-up), lost item errors, and most frequently, communication errors (records, procedures, missing face-to-face communication, mistakes within face-to-face communication). The qualitative nature of the study allowed the underlying cause of the errors to be explored. In addition to some individual mistakes, system faults were identified as a major cause of errors. Observed examples and interviews demonstrated several challenges to interprofessional teamworking which may cause errors, including: lack of time, part-time staff leading to frequent handovers, branch differences and individual veterinary surgeon work preferences. Lessons are drawn for building better veterinary teams and implications for Disciplinary Proceedings considered. British Veterinary Association.

Characterisation of false-positive observations in botanical surveys

Directory of Open Access Journals (Sweden)

Quentin J. Groom

2017-05-01

Full Text Available Errors in botanical surveying are a common problem. The presence of a species is easily overlooked, leading to false-absences; while misidentifications and other mistakes lead to false-positive observations. While it is common knowledge that these errors occur, there are few data that can be used to quantify and describe these errors. Here we characterise false-positive errors for a controlled set of surveys conducted as part of a field identification test of botanical skill. Surveys were conducted at sites with a verified list of vascular plant species. The candidates were asked to list all the species they could identify in a defined botanically rich area. They were told beforehand that their final score would be the sum of the correct species they listed, but false-positive errors counted against their overall grade. The number of errors varied considerably between people, some people create a high proportion of false-positive errors, but these are scattered across all skill levels. Therefore, a person’s ability to correctly identify a large number of species is not a safeguard against the generation of false-positive errors. There was no phylogenetic pattern to falsely observed species; however, rare species are more likely to be false-positive as are species from species rich genera. Raising the threshold for the acceptance of an observation reduced false-positive observations dramatically, but at the expense of more false negative errors. False-positive errors are higher in field surveying of plants than many people may appreciate. Greater stringency is required before accepting species as present at a site, particularly for rare species. Combining multiple surveys resolves the problem, but requires a considerable increase in effort to achieve the same sensitivity as a single survey. Therefore, other methods should be used to raise the threshold for the acceptance of a species. For example, digital data input systems that can verify

A new approach to the form and position error measurement of the auto frame surface based on laser

Science.gov (United States)

Wang, Hua; Li, Wei

2013-03-01

Auto frame is a very large workpiece, with length up to 12 meters and width up to 2 meters, and it's very easy to know that it's inconvenient and not automatic to measure such a large workpiece by independent manual operation. In this paper we propose a new approach to reconstruct the 3D model of the large workpiece, especially the auto truck frame, based on multiple pulsed lasers, for the purpose of measuring the form and position errors. In a concerned area, it just needs one high-speed camera and two lasers. It is a fast, high-precision and economical approach.

Refractive error, visual acuity and causes of vision loss in children in Shandong, China. The Shandong Children Eye Study.

Directory of Open Access Journals (Sweden)

Jian Feng Wu

Full Text Available PURPOSE: To examine the prevalence of refractive errors and prevalence and causes of vision loss among preschool and school children in East China. METHODS: Using a random cluster sampling in a cross-sectional school-based study design, children with an age of 4-18 years were selected from kindergartens, primary schools, and junior and senior high schools in the rural Guanxian County and the city of Weihai. All children underwent a complete ocular examination including measurement of uncorrected (UCVA and best corrected visual acuity (BCVA and auto-refractometry under cycloplegia. Myopia was defined as refractive error of ≤-0.5 diopters (D, high myopia as ≤ -6.0D, and amblyopia as BCVA ≤ 20/32 without any obvious reason for vision reduction and with strabismus or refractive errors as potential reasons. RESULTS: Out of 6364 eligible children, 6026 (94.7% children participated. Prevalence of myopia (overall: 36.9 ± 0.6%;95% confidence interval (CI:36.0,38.0 increased (P<0.001 from 1.7 ± 1.2% (95%CI:0.0,4.0 in the 4-years olds to 84.6 ± 3.2% (95%CI:78.0,91.0 in 17-years olds. Myopia was associated with older age (OR:1.56;95%CI:1.52,1.60;P<0.001, female gender (OR:1.22;95%CI:1.08,1.39;P = 0.002 and urban region (OR:2.88;95%CI:2.53,3.29;P<0.001. Prevalence of high myopia (2.0 ± 0.2% increased from 0.7 ± 0.3% (95%CI:0.1,1.3 in 10-years olds to 13.9 ± 3.0 (95%CI:7.8,19.9 in 17-years olds. It was associated with older age (OR:1.50;95%CI:1.41,1.60;P<0.001 and urban region (OR:3.11;95%CI:2.08,4.66;P<0.001. Astigmatism (≥ 0.75D (36.3 ± 0.6%;95%CI:35.0,38.0 was associated with older age (P<0.001;OR:1.06;95%CI:1.04,1.09, more myopic refractive error (P<0.001;OR:0.94;95%CI:0.91,0.97 and urban region (P<0.001;OR:1.47;95%CI:1.31,1.64. BCVA was ≤ 20/40 in the better eye in 19 (0.32% children. UCVA ≤ 20/40 in at least one eye was found in 2046 (34.05% children, with undercorrected refractive error as cause in 1975 (32.9% children. Amblyopia

Error Parsing: An alternative method of implementing social judgment theory

OpenAIRE

Crystal C. Hall; Daniel M. Oppenheimer

2015-01-01

We present a novel method of judgment analysis called Error Parsing, based upon an alternative method of implementing Social Judgment Theory (SJT). SJT and Error Parsing both posit the same three components of error in human judgment: error due to noise, error due to cue weighting, and error due to inconsistency. In that sense, the broad theory and framework are the same. However, SJT and Error Parsing were developed to answer different questions, and thus use different m...

Thermodynamics of Error Correction

Directory of Open Access Journals (Sweden)

Pablo Sartori

2015-12-01

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

Error-finding and error-correcting methods for the start-up of the SLC

International Nuclear Information System (INIS)

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

1987-02-01

During the commissioning of an accelerator, storage ring, or beam transfer line, one of the important tasks of an accelertor physicist is to check the first-order optics of the beam line and to look for errors in the system. Conceptually, it is important to distinguish between techniques for finding the machine errors that are the cause of the problem and techniques for correcting the beam errors that are the result of the machine errors. In this paper we will limit our presentation to certain applications of these two methods for finding or correcting beam-focus errors and beam-kick errors that affect the profile and trajectory of the beam respectively. Many of these methods have been used successfully in the commissioning of SLC systems. In order not to waste expensive beam time we have developed and used a beam-line simulator to test the ideas that have not been tested experimentally. To save valuable physicist's time we have further automated the beam-kick error-finding procedures by adopting methods from the field of artificial intelligence to develop a prototype expert system. Our experience with this prototype has demonstrated the usefulness of expert systems in solving accelerator control problems. The expert system is able to find the same solutions as an expert physicist but in a more systematic fashion. The methods used in these procedures and some of the recent applications will be described in this paper

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.

[Medical errors: inevitable but preventable].

Science.gov (United States)

Giard, R W

2001-10-27

Medical errors are increasingly reported in the lay press. Studies have shown dramatic error rates of 10 percent or even higher. From a methodological point of view, studying the frequency and causes of medical errors is far from simple. Clinical decisions on diagnostic or therapeutic interventions are always taken within a clinical context. Reviewing outcomes of interventions without taking into account both the intentions and the arguments for a particular action will limit the conclusions from a study on the rate and preventability of errors. The interpretation of the preventability of medical errors is fraught with difficulties and probably highly subjective. Blaming the doctor personally does not do justice to the actual situation and especially the organisational framework. Attention for and improvement of the organisational aspects of error are far more important then litigating the person. To err is and will remain human and if we want to reduce the incidence of faults we must be able to learn from our mistakes. That requires an open attitude towards medical mistakes, a continuous effort in their detection, a sound analysis and, where feasible, the institution of preventive measures.

Numerical optimization with computational errors

CERN Document Server

Zaslavski, Alexander J

2016-01-01

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

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".

Telemetry location error in a forested habitat

Science.gov (United States)

Chu, D.S.; Hoover, B.A.; Fuller, M.R.; Geissler, P.H.; Amlaner, Charles J.

1989-01-01

The error associated with locations estimated by radio-telemetry triangulation can be large and variable in a hardwood forest. We assessed the magnitude and cause of telemetry location errors in a mature hardwood forest by using a 4-element Yagi antenna and compass bearings toward four transmitters, from 21 receiving sites. The distance error from the azimuth intersection to known transmitter locations ranged from 0 to 9251 meters. Ninety-five percent of the estimated locations were within 16 to 1963 meters, and 50% were within 99 to 416 meters of actual locations. Angles with 20o of parallel had larger distance errors than other angles. While angle appeared most important, greater distances and the amount of vegetation between receivers and transmitters also contributed to distance error.

Digitization errors using digital charge division positionsensitive detectors

International Nuclear Information System (INIS)

Berliner, R.; Mildner, D.F.R.; Pringle, O.A.

1981-01-01

The data acquisition speed and electronic stability of a charge division position-sensitive detector may be improved by using digital signal processing with a table look-up high speed multiply to form the charge division quotient. This digitization process introduces a positional quantization difficulty which reduces the detector position sensitivity. The degree of the digitization error is dependent on the pulse height spectrum of the detector and on the resolution or dynamic range of the system analog-to-digital converters. The effects have been investigated analytically and by computer simulation. The optimum algorithm for position sensing determination using 8-bit digitization and arithmetic has a digitization error of less than 1%. (orig.)

Analysis of error-correction constraints in an optical disk

Science.gov (United States)

Roberts, Jonathan D.; Ryley, Alan; Jones, David M.; Burke, David

1996-07-01

The compact disk read-only memory (CD-ROM) is a mature storage medium with complex error control. It comprises four levels of Reed Solomon codes allied to a sequence of sophisticated interleaving strategies and 8:14 modulation coding. New storage media are being developed and introduced that place still further demands on signal processing for error correction. It is therefore appropriate to explore thoroughly the limit of existing strategies to assess future requirements. We describe a simulation of all stages of the CD-ROM coding, modulation, and decoding. The results of decoding the burst error of a prescribed number of modulation bits are discussed in detail. Measures of residual uncorrected error within a sector are displayed by C1, C2, P, and Q error counts and by the status of the final cyclic redundancy check (CRC). Where each data sector is encoded separately, it is shown that error-correction performance against burst errors depends critically on the position of the burst within a sector. The C1 error measures the burst length, whereas C2 errors reflect the burst position. The performance of Reed Solomon product codes is shown by the P and Q statistics. It is shown that synchronization loss is critical near the limits of error correction. An example is given of miscorrection that is identified by the CRC check.

Joint position sense error in people with neck pain: A systematic review.

Science.gov (United States)

de Vries, J; Ischebeck, B K; Voogt, L P; van der Geest, J N; Janssen, M; Frens, M A; Kleinrensink, G J

2015-12-01

Several studies in recent decades have examined the relationship between proprioceptive deficits and neck pain. However, there is no uniform conclusion on the relationship between the two. Clinically, proprioception is evaluated using the Joint Position Sense Error (JPSE), which reflects a person's ability to accurately return his head to a predefined target after a cervical movement. We focused to differentiate between JPSE in people with neck pain compared to healthy controls. Systematic review according to the PRISMA guidelines. Our data sources were Embase, Medline OvidSP, Web of Science, Cochrane Central, CINAHL and Pubmed Publisher. To be included, studies had to compare JPSE of the neck (O) in people with neck pain (P) with JPSE of the neck in healthy controls (C). Fourteen studies were included. Four studies reported that participants with traumatic neck pain had a significantly higher JPSE than healthy controls. Of the eight studies involving people with non-traumatic neck pain, four reported significant differences between the groups. The JPSE did not vary between neck-pain groups. Current literature shows the JPSE to be a relevant measure when it is used correctly. All studies which calculated the JPSE over at least six trials showed a significantly increased JPSE in the neck pain group. This strongly suggests that 'number of repetitions' is a major element in correctly performing the JPSE test. Copyright © 2015 Elsevier Ltd. All rights reserved.

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.

Game Design Principles based on Human Error

Directory of Open Access Journals (Sweden)

Guilherme Zaffari

2016-03-01

Full Text Available This paper displays the result of the authors’ research regarding to the incorporation of Human Error, through design principles, to video game design. In a general way, designers must consider Human Error factors throughout video game interface development; however, when related to its core design, adaptations are in need, since challenge is an important factor for fun and under the perspective of Human Error, challenge can be considered as a flaw in the system. The research utilized Human Error classifications, data triangulation via predictive human error analysis, and the expanded flow theory to allow the design of a set of principles in order to match the design of playful challenges with the principles of Human Error. From the results, it was possible to conclude that the application of Human Error in game design has a positive effect on player experience, allowing it to interact only with errors associated with the intended aesthetics of the game.

Emphasizing the 'positive' in positive reinforcement: Using non-binary rewarding for training monkeys on cognitive tasks.

Science.gov (United States)

Fischer, Benjamin; Wegener, Detlef

2018-04-04

Non-human primates constitute an indispensable model system for studying higher brain func-tions at the neurophysiological level. Studies involving these animals elucidated the neuronal mechanisms of various cognitive and executive functions, such as visual attention, working memory, and decision-making. Positive Reinforcement Training (PRT) constitutes the gold standard for training animals on the cognitive tasks employed in these studies. In the laboratory, PRT is usually based on applying a liquid reward as the reinforcer to strengthen the desired be-havior, and absence of the reward if the animal's response was wrong. By trial-and-error, the monkey may adopt its behavior and successfully reduces the number of error trials, and eventu-ally learns even very sophisticated tasks. However, progress and success of the training strongly depend on reasonable error rates. If errors get too frequent, they may cause a drop in the ani-mal's motivation to cooperate, or its adaptation to high error rates and poor overall perfor-mance. We here introduce an alternative training regime to minimize errors and base the critical information for learning on graded rewarding. For every new task rule, the feedback to the ani-mal is provided by different amounts of reward to distinguish the desired, optimal behavior from less optimally behavior. We applied this regime in different situations during training of visual attention tasks, and analyzed behavioral performance and reaction times to evaluate its effec-tiveness. For both simple and complex behaviors, graded rewarding was found to constitute a powerful technique allowing for effective training without trade-off in accessible task difficulty or task performance.

Prevalence of refractive error in malay primary school children in suburban area of Kota Bharu, Kelantan, Malaysia.

Science.gov (United States)

Hashim, Syaratul-Emma; Tan, Hui-Ken; Wan-Hazabbah, W H; Ibrahim, Mohtar

2008-11-01

Refractive error remains one of the primary causes of visual impairment in children worldwide, and the prevalence of refractive error varies widely. The objective of this study was to determine the prevalence of refractive error and study the possible associated factors inducing refractive error among primary school children of Malay ethnicity in the suburban area of Kota Bharu, Kelantan, Malaysia. A school-based cross-sectional study was performed from January to July 2006 by random selection on Standard 1 to Standard 6 students of 10 primary schools in the Kota Bharu district. Visual acuity assessment was measured using logMAR ETDRS chart. Positive predictive value of uncorrected visual acuity equal or worse than 20/40, was used as a cut-off point for further evaluation by automated refraction and retinoscopic refraction. A total of 840 students were enumerated but only 705 were examined. The prevalence of uncorrected visual impairment was seen in 54 (7.7%) children. The main cause of the uncorrected visual impairment was refractive error which contributed to 90.7% of the total, and with 7.0% prevalence for the studied population. Myopia is the most common type of refractive error among children aged 6 to 12 years with prevalence of 5.4%, followed by hyperopia at 1.0% and astigmatism at 0.6%. A significant positive correlation was noted between myopia development with increasing age (P <0.005), more hours spent on reading books (P <0.005) and background history of siblings with glasses (P <0.005) and whose parents are of higher educational level (P <0.005). Malays in suburban Kelantan (5.4%) have the lowest prevalence of myopia compared with Malays in the metropolitan cities of Kuala Lumpur (9.2%) and Singapore (22.1%). The ethnicity-specific prevalence rate of myopia was the lowest among Malays in Kota Bharu, followed by Kuala Lumpur, and is the highest among Singaporean Malays. Better socio-economic factors could have contributed to higher myopia rates in the

Analysis of errors in forensic science

Directory of Open Access Journals (Sweden)

Mingxiao Du

2017-01-01

Full Text Available Reliability of expert testimony is one of the foundations of judicial justice. Both expert bias and scientific errors affect the reliability of expert opinion, which in turn affects the trustworthiness of the findings of fact in legal proceedings. Expert bias can be eliminated by replacing experts; however, it may be more difficult to eliminate scientific errors. From the perspective of statistics, errors in operation of forensic science include systematic errors, random errors, and gross errors. In general, process repetition and abiding by the standard ISO/IEC:17025: 2005, general requirements for the competence of testing and calibration laboratories, during operation are common measures used to reduce errors that originate from experts and equipment, respectively. For example, to reduce gross errors, the laboratory can ensure that a test is repeated several times by different experts. In applying for forensic principles and methods, the Federal Rules of Evidence 702 mandate that judges consider factors such as peer review, to ensure the reliability of the expert testimony. As the scientific principles and methods may not undergo professional review by specialists in a certain field, peer review serves as an exclusive standard. This study also examines two types of statistical errors. As false-positive errors involve a higher possibility of an unfair decision-making, they should receive more attention than false-negative errors.

Facial motion parameter estimation and error criteria in model-based image coding

Science.gov (United States)

Liu, Yunhai; Yu, Lu; Yao, Qingdong

2000-04-01

Model-based image coding has been given extensive attention due to its high subject image quality and low bit-rates. But the estimation of object motion parameter is still a difficult problem, and there is not a proper error criteria for the quality assessment that are consistent with visual properties. This paper presents an algorithm of the facial motion parameter estimation based on feature point correspondence and gives the motion parameter error criteria. The facial motion model comprises of three parts. The first part is the global 3-D rigid motion of the head, the second part is non-rigid translation motion in jaw area, and the third part consists of local non-rigid expression motion in eyes and mouth areas. The feature points are automatically selected by a function of edges, brightness and end-node outside the blocks of eyes and mouth. The numbers of feature point are adjusted adaptively. The jaw translation motion is tracked by the changes of the feature point position of jaw. The areas of non-rigid expression motion can be rebuilt by using block-pasting method. The estimation approach of motion parameter error based on the quality of reconstructed image is suggested, and area error function and the error function of contour transition-turn rate are used to be quality criteria. The criteria reflect the image geometric distortion caused by the error of estimated motion parameters properly.

Investigating the Factors Affecting the Occurrence and Reporting of Medication Errors from the Viewpoint of Nurses in Sina Hospital, Tabriz, Iran

Directory of Open Access Journals (Sweden)

Massumeh gholizadeh

2016-09-01

Full Text Available Background and objectives: Medication errors can cause serious problems to patients and health system. Initial results of medication errors increase duration of hospitalization and costs. The aim of this study was to determine the reasons of medication errors and the barriers of errors reporting from nurses’ viewpoints. Material and Methods: A cross-sectional descriptive study was conducted in 2013. The study population included all of the nurses working in Tabriz Sina hospital. Study sample was calculated 124 by census method. The data collection tool was questionnaire and data were analyzed using SPSS software version 20 package. Results: In this study, from the viewpoint of nurses, the most important reasons of medication errors included the wrong infusion speed, illegible medication orders, work-related fatigue, noise of ambient and shortages of staff.  Regarding barriers of error reporting, the most important factors were the emphasis of the directors on the person regardless of other factors involved in medication errors and the lake of a clear definition of medication errors. Conclusion: Given the importance of ensuring patient safety, the following corrections can lead to improvement of hospital safety: establishing an effective system for reporting and recording errors, minimizing barriers to reporting by establishing a positive relationship between managers and staff and positive reaction towards reporting error. To reduce medication errors, establishing training classes in relation to drugs information for nurses and continuing evaluation of personnel in the field of drug information using the results of pharmaceutical information in the ward are recommended.

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.

A Reanalysis of Toomela (2003: Spurious measurement error as cause for common variance between personality factors

Directory of Open Access Journals (Sweden)

MATTHIAS ZIEGLER

2009-03-01

Full Text Available The present article reanalyzed data collected by Toomela (2003. The data contain personality self ratings and cognitive ability test results from n = 912 men with military background. In his original article Toomela showed that in the group with the highest cognitive ability, Big-Five-Neuroticism and -Conscientiousness were substantially correlated and could no longer be clearly separated using exploratory factor analysis. The present reanalysis was based on the hypothesis that a spurious measurement error caused by situational demand was responsible. This means, people distorted their answers. Furthermore it was hypothesized that this situational demand was felt due to a person’s military rank but not due to his intelligence. Using a multigroup structural equation model our hypothesis could be confirmed. Moreover, the results indicate that an uncorrelated trait model might represent personalities better when situational demand is partialized. Practical and theoretical implications are discussed.

Error Floor Analysis of Coded Slotted ALOHA over Packet Erasure Channels

DEFF Research Database (Denmark)

Ivanov, Mikhail; Graell i Amat, Alexandre; Brannstrom, F.

2014-01-01

We present a framework for the analysis of the error floor of coded slotted ALOHA (CSA) for finite frame lengths over the packet erasure channel. The error floor is caused by stopping sets in the corresponding bipartite graph, whose enumeration is, in general, not a trivial problem. We therefore ...... identify the most dominant stopping sets for the distributions of practical interest. The derived analytical expressions allow us to accurately predict the error floor at low to moderate channel loads and characterize the unequal error protection inherent in CSA.......We present a framework for the analysis of the error floor of coded slotted ALOHA (CSA) for finite frame lengths over the packet erasure channel. The error floor is caused by stopping sets in the corresponding bipartite graph, whose enumeration is, in general, not a trivial problem. We therefore...

Hemorrhoids detected at colonoscopy: an infrequent cause of false-positive fecal immunochemical test results.

NARCIS (Netherlands)

Turenhout, S.T. van; Oort, F.A.; Terhaar sive Droste, J.S.; Coupe, V.M.; Hulst, R.W. van der; Loffeld, R.J.; Scholten, P.; Depla, A.C.; Bouman, A.A.; Meijer, G.A.; Mulder, C.J.; Rossum, L.G.M. van

2012-01-01

BACKGROUND: Colorectal cancer screening by fecal immunochemical tests (FITs) is hampered by frequent false-positive (FP) results and thereby the risk of complications and strain on colonoscopy capacity. Hemorrhoids might be a plausible cause of FP results. OBJECTIVE: To determine the contribution of

The wind and panacea of defense positions in the solar trackers; El viento y la panacea de la posiciones de defensa en los seguidores solares

Energy Technology Data Exchange (ETDEWEB)

Cabanillas, J. P.

2010-07-01

Common belief that the support structure and panel board no longer receive wind load when the board is placed in horizontal position is misguided. In horizontal position can also receive wind load and the effect of reaching weights cause very high loads. this error causes serious damage when the structure has sufficient strength and bases its survival on the adoption of the horizontal position as the only defense. (Author)

WORKING MEMORY STRUCTURE REVEALED IN ANALYSIS OF RECALL ERRORS

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Regina V Ershova

2017-12-01

Full Text Available We analyzed working memory errors stemming from 193 Russian college students taking the Tarnow Unchunkable Test utilizing double digit items on a visual display.In three-item trials with at most one error per trial, single incorrect tens and ones digits (“singlets” were overrepresented and made up the majority of errors, indicating a base 10 organization.These errors indicate that there are separate memory maps for each position and that there are pointers that can move primarily within these maps. Several pointers make up a pointer collection. The number of pointer collections possible is the working memory capacity limit. A model for self-organizing maps is constructed in which the organization is created by turning common pointer collections into maps thereby replacing a pointer collection with a single pointer.The factors 5 and 11 were underrepresented in the errors, presumably because base 10 properties beyond positional order were used for error correction, perhaps reflecting the existence of additional maps of integers divisible by 5 and integers divisible by 11.

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

Science.gov (United States)

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

1999-01-01

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

New decoding methods of interleaved burst error-correcting codes

Science.gov (United States)

Nakano, Y.; Kasahara, M.; Namekawa, T.

1983-04-01

A probabilistic method of single burst error correction, using the syndrome correlation of subcodes which constitute the interleaved code, is presented. This method makes it possible to realize a high capability of burst error correction with less decoding delay. By generalizing this method it is possible to obtain probabilistic method of multiple (m-fold) burst error correction. After estimating the burst error positions using syndrome correlation of subcodes which are interleaved m-fold burst error detecting codes, this second method corrects erasure errors in each subcode and m-fold burst errors. The performance of these two methods is analyzed via computer simulation, and their effectiveness is demonstrated.

Understanding and Confronting Our Mistakes: The Epidemiology of Error in Radiology and Strategies for Error Reduction.

Science.gov (United States)

Bruno, Michael A; Walker, Eric A; Abujudeh, Hani H

2015-10-01

Arriving at a medical diagnosis is a highly complex process that is extremely error prone. Missed or delayed diagnoses often lead to patient harm and missed opportunities for treatment. Since medical imaging is a major contributor to the overall diagnostic process, it is also a major potential source of diagnostic error. Although some diagnoses may be missed because of the technical or physical limitations of the imaging modality, including image resolution, intrinsic or extrinsic contrast, and signal-to-noise ratio, most missed radiologic diagnoses are attributable to image interpretation errors by radiologists. Radiologic interpretation cannot be mechanized or automated; it is a human enterprise based on complex psychophysiologic and cognitive processes and is itself subject to a wide variety of error types, including perceptual errors (those in which an important abnormality is simply not seen on the images) and cognitive errors (those in which the abnormality is visually detected but the meaning or importance of the finding is not correctly understood or appreciated). The overall prevalence of radiologists' errors in practice does not appear to have changed since it was first estimated in the 1960s. The authors review the epidemiology of errors in diagnostic radiology, including a recently proposed taxonomy of radiologists' errors, as well as research findings, in an attempt to elucidate possible underlying causes of these errors. The authors also propose strategies for error reduction in radiology. On the basis of current understanding, specific suggestions are offered as to how radiologists can improve their performance in practice. © RSNA, 2015.

Analyzing Software Requirements Errors in Safety-Critical, Embedded Systems

Science.gov (United States)

Lutz, Robyn R.

1993-01-01

This paper analyzes the root causes of safety-related software errors in safety-critical, embedded systems. The results show that software errors identified as potentially hazardous to the system tend to be produced by different error mechanisms than non- safety-related software errors. Safety-related software errors are shown to arise most commonly from (1) discrepancies between the documented requirements specifications and the requirements needed for correct functioning of the system and (2) misunderstandings of the software's interface with the rest of the system. The paper uses these results to identify methods by which requirements errors can be prevented. The goal is to reduce safety-related software errors and to enhance the safety of complex, embedded systems.

Detailed semantic analyses of human error incidents occurring at nuclear power plant in USA (interim report). Characteristics of human error incidents occurring in the period from 1992 to 1996

International Nuclear Information System (INIS)

Hirotsu, Yuko; Tsuge, Tadashi; Sano, Toshiaki; Takano, Kenichi; Gouda, Hidenori

2001-01-01

CRIEPI has been conducting detailed analyses of all human error incidents at domestic nuclear power plants (NPPs) collected from Japanese Licensee Event Reports (LERs) using J-HPES (Japanese version of HPES) as an analysis method. Results obtained by the analyses have been stored in J-HPES database. Since 1999, human error incidents have been selected from U.S. LERs, and they are analyzed using J-HPES. In this report, the results, which classified error action, cause, and preventive measure, are summarized for U.S. human error cases occurring in the period from 1992 to 1996. It was suggested as a result of classification that the categories of error action were almost the same as those of Japanese human error cases. Therefore, problems in the process of error action and checkpoints for preventing errors will be extracted by analyzing both U.S. and domestic human error cases. It was also suggested that the interrelations between error actions, causes, and organizational factors could be identified. While taking these suggestions into consideration, we will continue to analyze U.S. human error cases. (author)

Predicting crystalline lens fall caused by accommodation from changes in wavefront error

Science.gov (United States)

He, Lin; Applegate, Raymond A.

2011-01-01

PURPOSE To illustrate and develop a method for estimating crystalline lens decentration as a function of accommodative response using changes in wavefront error and show the method and limitations using previously published data (2004) from 2 iridectomized monkey eyes so that clinicians understand how spherical aberration can induce coma, in particular in intraocular lens surgery. SETTINGS College of Optometry, University of Houston, Houston, USA. DESIGN Evaluation of diagnostic test or technology. METHODS Lens decentration was estimated by displacing downward the wavefront error of the lens with respect to the limiting aperture (7.0 mm) and ocular first surface wavefront error for each accommodative response (0.00 to 11.00 diopters) until measured values of vertical coma matched previously published experimental data (2007). Lens decentration was also calculated using an approximation formula that only included spherical aberration and vertical coma. RESULTS The change in calculated vertical coma was consistent with downward lens decentration. Calculated downward lens decentration peaked at approximately 0.48 mm of vertical decentration in the right eye and approximately 0.31 mm of decentration in the left eye using all Zernike modes through the 7th radial order. Calculated lens decentration using only coma and spherical aberration formulas was peaked at approximately 0.45 mm in the right eye and approximately 0.23 mm in the left eye. CONCLUSIONS Lens fall as a function of accommodation was quantified noninvasively using changes in vertical coma driven principally by the accommodation-induced changes in spherical aberration. The newly developed method was valid for a large pupil only. PMID:21700108

Analyzing Software Errors in Safety-Critical Embedded Systems

Science.gov (United States)

Lutz, Robyn R.

1994-01-01

This paper analyzes the root causes of safty-related software faults identified as potentially hazardous to the system are distributed somewhat differently over the set of possible error causes than non-safety-related software faults.

Error-Resilient Unequal Error Protection of Fine Granularity Scalable Video Bitstreams

Science.gov (United States)

Cai, Hua; Zeng, Bing; Shen, Guobin; Xiong, Zixiang; Li, Shipeng

2006-12-01

This paper deals with the optimal packet loss protection issue for streaming the fine granularity scalable (FGS) video bitstreams over IP networks. Unlike many other existing protection schemes, we develop an error-resilient unequal error protection (ER-UEP) method that adds redundant information optimally for loss protection and, at the same time, cancels completely the dependency among bitstream after loss recovery. In our ER-UEP method, the FGS enhancement-layer bitstream is first packetized into a group of independent and scalable data packets. Parity packets, which are also scalable, are then generated. Unequal protection is finally achieved by properly shaping the data packets and the parity packets. We present an algorithm that can optimally allocate the rate budget between data packets and parity packets, together with several simplified versions that have lower complexity. Compared with conventional UEP schemes that suffer from bit contamination (caused by the bit dependency within a bitstream), our method guarantees successful decoding of all received bits, thus leading to strong error-resilience (at any fixed channel bandwidth) and high robustness (under varying and/or unclean channel conditions).

Pneumonia caused by Bordetella bronchiseptica in two HIV-positive patients

Directory of Open Access Journals (Sweden)

Roberta Filipini Rampelotto

Full Text Available ABSTRACT: CONTEXT AND OBJECTIVE: Bordetella bronchiseptica (BB is a Gram-negative coccobacillus responsible for respiratory diseases in dogs, cats and rabbits. Reports on its development in humans are rare. However, in immunosuppressed patients, especially in those with the immunodeficiency virus (HIV, BB can cause severe pulmonary infections. We report on two cases of pneumonia caused by BB in HIV-positive male patients in a university hospital. CASE REPORT: The first case comprised a 43-year-old patient who was admitted presenting chronic leg pain and coughing, with suspected pneumonia. BB was isolated from sputum culture and was successfully treated with trimethoprim/sulfamethoxazole in association with levofloxacin. The second case comprised a 49-year-old patient who was admitted presenting fever, nausea, sweating and a dry cough, also with suspected pneumonia. BB was isolated from sputum culture, tracheal secretions and bronchoalveolar lavage. The disease was treated with ciprofloxacin but the patient died. CONCLUSION: BB should be included in the etiology of pneumonia in immunodeficient HIV patients. As far as we know, these two were the first cases of pneumonia due to BB to occur in this university hospital.

Impacts of GNSS position offsets on global frame stability

Science.gov (United States)

Griffiths, Jake; Ray, Jim

2014-05-01

Positional offsets appear in Global Navigation Satellite System (GNSS) time series for a variety of reasons. Antenna or radome changes are the most common cause for these discontinuities. Many others are from earthquakes, receiver changes, and different anthropogenic modifications at or near the stations. Some jumps appear for unknown or undocumented reasons. The accurate determination of station velocities, and therefore geophysical parameters and terrestrial reference frames, requires that positional offsets be correctly found and compensated. Williams (2003) found that undetected offsets introduce a random walk error component in individual station time series. The topic of detecting positional offsets has received considerable attention in recent years (e.g., Detection of Offsets in GPS Experiment; DOGEx), and most research groups using GNSS have adopted a combination of manual and automated methods for finding them. The removal of a positional offset is usually handled by estimating the average station position on both sides of the discontinuity, assuming a constant, continuous velocity. This is sufficient in the absence of time-correlated errors. However, GNSS time series contain systematic and power-law errors (white to random walk noise). In this paper, we aim to evaluate the impact to both individual station results and the overall stability of the global reference frame from adding increasing numbers of positional discontinuities. We use the International GNSS Service (IGS) weekly SINEX files, and iteratively insert positional offset parameters at the midpoint of each data segment. Each iteration includes a restacking of the modified SINEX files using the CATREF software from Institut National de l'Information Géographique et Forestière (IGN) to estimate: regularized station positions, secular velocities, Earth orientation parameters, Helmert frame alignment parameters, and the empirical shifts across all positional discontinuities. A comparison of the

Determination of optimal samples for robot calibration based on error similarity

Directory of Open Access Journals (Sweden)

Tian Wei

2015-06-01

Full Text Available Industrial robots are used for automatic drilling and riveting. The absolute position accuracy of an industrial robot is one of the key performance indexes in aircraft assembly, and can be improved through error compensation to meet aircraft assembly requirements. The achievable accuracy and the difficulty of accuracy compensation implementation are closely related to the choice of sampling points. Therefore, based on the error similarity error compensation method, a method for choosing sampling points on a uniform grid is proposed. A simulation is conducted to analyze the influence of the sample point locations on error compensation. In addition, the grid steps of the sampling points are optimized using a statistical analysis method. The method is used to generate grids and optimize the grid steps of a Kuka KR-210 robot. The experimental results show that the method for planning sampling data can be used to effectively optimize the sampling grid. After error compensation, the position accuracy of the robot meets the position accuracy requirements.

Yersinia enterocolitica: an unlikely cause of positive brucellosis tests in greater yellowstone ecosystem bison (Bison bison).

Science.gov (United States)

See, Wade; Edwards, William H; Dauwalter, Stacey; Almendra, Claudia; Kardos, Martin D; Lowell, Jennifer L; Wallen, Rick; Cain, Steven L; Holben, William E; Luikart, Gordon

2012-07-01

Yersinia enterocolitica serotype O:9 has identical O-antigens to those of Brucella abortus and has apparently caused false-positive reactions in numerous brucellosis serologic tests in elk (Cervus canadensis) from southwest Montana. We investigated whether a similar phenomenon was occurring in brucellosis antibody-positive bison (Bison bison) using Y. enterocolitica culturing techniques and multiplex PCR of four diagnostic loci. Feces from 53 Yellowstone bison culled from the population and 113 free-roaming bison from throughout the Greater Yellowstone Ecosystem (GYE) were tested. Yersinia enterocolitica O:9 was not detected in any of 53 the bison samples collected at slaughter facilities or in any of the 113 fecal samples from free-ranging bison. One other Y. enterocolitica serotype was isolated; however, it is not known to cause cross-reaction on B. abortus serologic assays because it lacks the perosamine synthetase gene and thus the O-antigens. These findings suggest that Y. enterocolitica O:9 cross-reactivity with B. abortus antigens is unlikely to have been a cause of false-positive serology tests in GYE bison and that Y. enterocolitica prevalence was low in bison in the GYE during this study.

Errors in the calculation of new salary positions and performance premiums – 2017 MERIT exercise

CERN Multimedia

Staff Association

2017-01-01

Following the receipt of the letters dated May 12th announcing the qualification of their performance (MERIT 2017), and the notification of their salary slips for the month of May, several colleagues have come to us to enquire about the calculation of salary increases and performance premiums. After verification, the Staff Association has informed the Management, in a meeting of the Standing Concertation Committee on June 1st, about errors owing to rounding in the applied formulas. James Purvis, Head of HR department, has published in the CERN Bulletin dated July 18th an article, under the heading “Better precision (rounding)”, that gives a short explanation of these rounding effects. But we want to further bring you more precise explanations. Advancement On the salary slips for the month of May, the calculations of the advancement and new salary positions were done, by the services of administrative computing in the FAP department, on the basis of the salary, rounded to the nearest franc...

Error analysis of mathematical problems on TIMSS: A case of Indonesian secondary students

Science.gov (United States)

Priyani, H. A.; Ekawati, R.

2018-01-01

Indonesian students’ competence in solving mathematical problems is still considered as weak. It was pointed out by the results of international assessment such as TIMSS. This might be caused by various types of errors made. Hence, this study aimed at identifying students’ errors in solving mathematical problems in TIMSS in the topic of numbers that considered as the fundamental concept in Mathematics. This study applied descriptive qualitative analysis. The subject was three students with most errors in the test indicators who were taken from 34 students of 8th graders. Data was obtained through paper and pencil test and student’s’ interview. The error analysis indicated that in solving Applying level problem, the type of error that students made was operational errors. In addition, for reasoning level problem, there are three types of errors made such as conceptual errors, operational errors and principal errors. Meanwhile, analysis of the causes of students’ errors showed that students did not comprehend the mathematical problems given.

Design and application of location error teaching aids in measuring and visualization

Directory of Open Access Journals (Sweden)

Yu Fengning

2015-01-01

Full Text Available As an abstract concept, ‘location error’ in is considered to be an important element with great difficult to understand and apply. The paper designs and develops an instrument to measure the location error. The location error is affected by different position methods and reference selection. So we choose position element by rotating the disk. The tiny movement transfers by grating ruler and programming by PLC can show the error on text display, which also helps students understand the position principle and related concepts of location error. After comparing measurement results with theoretical calculations and analyzing the measurement accuracy, the paper draws a conclusion that the teaching aid owns reliability and a promotion of high value.

Positional reference system for ultraprecision machining

International Nuclear Information System (INIS)

Arnold, J.B.; Burleson, R.R.; Pardue, R.M.

1982-01-01

A stable positional reference system for use in improving the cutting tool-to-part contour position in numerical controlledmultiaxis metal turning machines is provided. The reference system employs a plurality of interferometers referenced to orthogonally disposed metering bars which are substantially isolated from machine strain induced position errors for monitoring the part and tool positions relative to the metering bars. A microprocessor-based control system is employed in conjunction with the plurality of position interferometers and part contour description data inputs to calculate error components for each axis of movement and output them to corresponding axis drives with appropriate scaling and error compensation. Real-time position control, operating in combination with the reference system, makes possible the positioning of the cutting points of a tool along a part locus with a substantially greater degree of accuracy than has been attained previously in the art by referencing and then monitoring only the tool motion relative to a reference position located on the machine base

Positional reference system for ultraprecision machining

Science.gov (United States)

Arnold, J.B.; Burleson, R.R.; Pardue, R.M.

1980-09-12

A stable positional reference system for use in improving the cutting tool-to-part contour position in numerical controlled-multiaxis metal turning machines is provided. The reference system employs a plurality of interferometers referenced to orthogonally disposed metering bars which are substantially isolated from machine strain induced position errors for monitoring the part and tool positions relative to the metering bars. A microprocessor-based control system is employed in conjunction with the plurality of positions interferometers and part contour description data input to calculate error components for each axis of movement and output them to corresponding axis driven with appropriate scaling and error compensation. Real-time position control, operating in combination with the reference system, makes possible the positioning of the cutting points of a tool along a part locus with a substantially greater degree of accuracy than has been attained previously in the art by referencing and then monitoring only the tool motion relative to a reference position located on the machine base.

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

International Nuclear Information System (INIS)

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

1982-06-01

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

A correction for emittance-measurement errors caused by finite slit and collector widths

International Nuclear Information System (INIS)

Connolly, R.C.

1992-01-01

One method of measuring the transverse phase-space distribution of a particle beam is to intercept the beam with a slit and measure the angular distribution of the beam passing through the slit using a parallel-strip collector. Together the finite widths of the slit and each collector strip form an acceptance window in phase space whose size and orientation are determined by the slit width, the strip width, and the slit-collector distance. If a beam is measured using a detector with a finite-size phase-space window, the measured distribution is different from the true distribution. The calculated emittance is larger than the true emittance, and the error depends both on the dimensions of the detector and on the Courant-Snyder parameters of the beam. Specifically, the error gets larger as the beam drifts farther from a waist. This can be important for measurements made on high-brightness beams, since power density considerations require that the beam be intercepted far from a waist. In this paper we calculate the measurement error and we show how the calculated emittance and Courant-Snyder parameters can be corrected for the effects of finite sizes of slit and collector. (Author) 5 figs., 3 refs

Introduction to CAUSES: Description of Weather and Climate Models and Their Near-Surface Temperature Errors in 5 day Hindcasts Near the Southern Great Plains

Science.gov (United States)

Morcrette, C. J.; Van Weverberg, K.; Ma, H.-Y.; Ahlgrimm, M.; Bazile, E.; Berg, L. K.; Cheng, A.; Cheruy, F.; Cole, J.; Forbes, R.; Gustafson, W. I.; Huang, M.; Lee, W.-S.; Liu, Y.; Mellul, L.; Merryfield, W. J.; Qian, Y.; Roehrig, R.; Wang, Y.-C.; Xie, S.; Xu, K.-M.; Zhang, C.; Klein, S.; Petch, J.

2018-03-01

We introduce the Clouds Above the United States and Errors at the Surface (CAUSES) project with its aim of better understanding the physical processes leading to warm screen temperature biases over the American Midwest in many numerical models. In this first of four companion papers, 11 different models, from nine institutes, perform a series of 5 day hindcasts, each initialized from reanalyses. After describing the common experimental protocol and detailing each model configuration, a gridded temperature data set is derived from observations and used to show that all the models have a warm bias over parts of the Midwest. Additionally, a strong diurnal cycle in the screen temperature bias is found in most models. In some models the bias is largest around midday, while in others it is largest during the night. At the Department of Energy Atmospheric Radiation Measurement Southern Great Plains (SGP) site, the model biases are shown to extend several kilometers into the atmosphere. Finally, to provide context for the companion papers, in which observations from the SGP site are used to evaluate the different processes contributing to errors there, it is shown that there are numerous locations across the Midwest where the diurnal cycle of the error is highly correlated with the diurnal cycle of the error at SGP. This suggests that conclusions drawn from detailed evaluation of models using instruments located at SGP will be representative of errors that are prevalent over a larger spatial scale.

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.)

Error identification and improvement in English first additional ...

African Journals Online (AJOL)

This paper seeks to identify errors committed by learners in EFAL essay writing, focussing on causes behind such errors, and strategies to eliminate them as a way of improving learners' writing skills. Document review was adopted as the research method in this study. 15 Grade 10 essays from Mmapadi Secondary school ...

A prospective three-step intervention study to prevent medication errors in drug handling in paediatric care.

Science.gov (United States)

Niemann, Dorothee; Bertsche, Astrid; Meyrath, David; Koepf, Ellen D; Traiser, Carolin; Seebald, Katja; Schmitt, Claus P; Hoffmann, Georg F; Haefeli, Walter E; Bertsche, Thilo

2015-01-01

To prevent medication errors in drug handling in a paediatric ward. One in five preventable adverse drug events in hospitalised children is caused by medication errors. Errors in drug prescription have been studied frequently, but data regarding drug handling, including drug preparation and administration, are scarce. A three-step intervention study including monitoring procedure was used to detect and prevent medication errors in drug handling. After approval by the ethics committee, pharmacists monitored drug handling by nurses on an 18-bed paediatric ward in a university hospital prior to and following each intervention step. They also conducted a questionnaire survey aimed at identifying knowledge deficits. Each intervention step targeted different causes of errors. The handout mainly addressed knowledge deficits, the training course addressed errors caused by rule violations and slips, and the reference book addressed knowledge-, memory- and rule-based errors. The number of patients who were subjected to at least one medication error in drug handling decreased from 38/43 (88%) to 25/51 (49%) following the third intervention, and the overall frequency of errors decreased from 527 errors in 581 processes (91%) to 116/441 (26%). The issue of the handout reduced medication errors caused by knowledge deficits regarding, for instance, the correct 'volume of solvent for IV drugs' from 49-25%. Paediatric drug handling is prone to errors. A three-step intervention effectively decreased the high frequency of medication errors by addressing the diversity of their causes. Worldwide, nurses are in charge of drug handling, which constitutes an error-prone but often-neglected step in drug therapy. Detection and prevention of errors in daily routine is necessary for a safe and effective drug therapy. Our three-step intervention reduced errors and is suitable to be tested in other wards and settings. © 2014 John Wiley & Sons Ltd.

Subdivision Error Analysis and Compensation for Photoelectric Angle Encoder in a Telescope Control System

Directory of Open Access Journals (Sweden)

Yanrui Su

2015-01-01

Full Text Available As the position sensor, photoelectric angle encoder affects the accuracy and stability of telescope control system (TCS. A TCS-based subdivision error compensation method for encoder is proposed. Six types of subdivision error sources are extracted through mathematical expressions of subdivision signals first. Then the period length relationships between subdivision signals and subdivision errors are deduced. And the error compensation algorithm only utilizing the shaft position of TCS is put forward, along with two control models; Model I is that the algorithm applies only to the speed loop of TCS and Model II is applied to both speed loop and position loop. Combined with actual project, elevation jittering phenomenon of the telescope is discussed to decide the necessity of DC-type subdivision error compensation. Low-speed elevation performance before and after error compensation is compared to help decide that Model II is preferred. In contrast to original performance, the maximum position error of the elevation with DC subdivision error compensation is reduced by approximately 47.9% from 1.42″ to 0.74″. The elevation gets a huge decrease in jitters. This method can compensate the encoder subdivision errors effectively and improve the stability of TCS.

Modeling of the effect of tool wear per discharge estimation error on the depth of machined cavities in micro-EDM milling

DEFF Research Database (Denmark)

Puthumana, Govindan; Bissacco, Giuliano; Hansen, Hans Nørgaard

2017-01-01

In micro-EDM milling, real time electrode wear compensation based on tool wear per discharge (TWD) estimation permits the direct control of the position of the tool electrode frontal surface. However, TWD estimation errors will cause errors on the tool electrode axial depth. A simulation tool...... is developed to determine the effects of errors in the initial estimation of TWD and its propagation effect with respect to the error on the depth of the cavity generated. Simulations were applied to micro-EDM milling of a slot of 5000 μm length and 50 μm depth and validated through slot milling experiments...... performed on a micro-EDM machine. Simulations and experimental results were found to be in good agreement, showing the effect of errror amplification through the cavity depth....

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.

Adherence to the Australian National Inpatient Medication Chart: the efficacy of a uniform national drug chart on improving prescription error.

Science.gov (United States)

Atik, Alp

2013-10-01

In 2006, the National Inpatient Medication Chart (NIMC) was introduced as a uniform medication chart in Australian public hospitals with the aim of reducing prescription error. The rate of regular medication prescription error in the NIMC was assessed. Data was collected using the NIMC Audit Tool and analyzed with respect to causes of error per medication prescription and per medication chart. The following prescription requirements were assessed: date, generic drug name, route of administration, dose, frequency, administration time, indication, signature, name and contact details. A total of 1877 medication prescriptions were reviewed. 1653 prescriptions (88.07%) had no contact number, 1630 (86.84%) did not have an indication, 1230 and 675 (35.96%) used a drug's trade name. Within 261 medication charts, all had at least one entry, which did not include an indication, 258 (98.85%) had at least one entry, which did not have a contact number and 200 (76.63%) had at least one entry, which used a trade name. The introduction of a uniform national medication chart is a positive step, but more needs to be done to address the root causes of prescription error. © 2012 John Wiley & Sons Ltd.

Practical Calculation of Thermal Deformation and Manufacture Error uin Surface Grinding

Institute of Scientific and Technical Information of China (English)

周里群; 李玉平

2002-01-01

The paper submits a method to calculate thermal deformation and manufacture error in surface grinding.The author established a simplified temperature field model.and derived the thermal deformaiton of the ground workpiece,It is found that there exists not only a upwarp thermal deformation,but also a parallel expansion thermal deformation.A upwarp thermal deformation causes a concave shape error on the profile of the workpiece,and a parallel expansion thermal deformation causes a dimension error in height.The calculations of examples are given and compared with presented experiment data.

Accuracy of crystal structure error estimates

International Nuclear Information System (INIS)

Taylor, R.; Kennard, O.

1986-01-01

A statistical analysis of 100 crystal structures retrieved from the Cambridge Structural Database is reported. Each structure has been determined independently by two different research groups. Comparison of the independent results leads to the following conclusions: (a) The e.s.d.'s of non-hydrogen-atom positional parameters are almost invariably too small. Typically, they are underestimated by a factor of 1.4-1.45. (b) The extent to which e.s.d.'s are underestimated varies significantly from structure to structure and from atom to atom within a structure. (c) Errors in the positional parameters of atoms belonging to the same chemical residue tend to be positively correlated. (d) The e.s.d.'s of heavy-atom positions are less reliable than those of light-atom positions. (e) Experimental errors in atomic positional parameters are normally, or approximately normally, distributed. (f) The e.s.d.'s of cell parameters are grossly underestimated, by an average factor of about 5 for cell lengths and 2.5 for cell angles. There is marginal evidence that the accuracy of atomic-coordinate e.s.d.'s also depends on diffractometer geometry, refinement procedure, whether or not the structure has a centre of symmetry, and the degree of precision attained in the structure determination. (orig.)

Classification of radiological errors in chest radiographs, using support vector machine on the spatial frequency features of false- negative and false-positive regions

Science.gov (United States)

Pietrzyk, Mariusz W.; Donovan, Tim; Brennan, Patrick C.; Dix, Alan; Manning, David J.

2011-03-01

Aim: To optimize automated classification of radiological errors during lung nodule detection from chest radiographs (CxR) using a support vector machine (SVM) run on the spatial frequency features extracted from the local background of selected regions. Background: The majority of the unreported pulmonary nodules are visually detected but not recognized; shown by the prolonged dwell time values at false-negative regions. Similarly, overestimated nodule locations are capturing substantial amounts of foveal attention. Spatial frequency properties of selected local backgrounds are correlated with human observer responses either in terms of accuracy in indicating abnormality position or in the precision of visual sampling the medical images. Methods: Seven radiologists participated in the eye tracking experiments conducted under conditions of pulmonary nodule detection from a set of 20 postero-anterior CxR. The most dwelled locations have been identified and subjected to spatial frequency (SF) analysis. The image-based features of selected ROI were extracted with un-decimated Wavelet Packet Transform. An analysis of variance was run to select SF features and a SVM schema was implemented to classify False-Negative and False-Positive from all ROI. Results: A relative high overall accuracy was obtained for each individually developed Wavelet-SVM algorithm, with over 90% average correct ratio for errors recognition from all prolonged dwell locations. Conclusion: The preliminary results show that combined eye-tracking and image-based features can be used for automated detection of radiological error with SVM. The work is still in progress and not all analytical procedures have been completed, which might have an effect on the specificity of the algorithm.

A slicing-based approach for locating type errors

NARCIS (Netherlands)

T.B. Dinesh; F. Tip (Frank)

1998-01-01

htmlabstractThe effectiveness of a type checking tool strongly depends on the accuracy of the positional information that is associated with type errors. We present an approach where the location associated with an error message e is defined as a slice P_e of the program P being type checked. We

A slicing-based approach for locating type errors

NARCIS (Netherlands)

T.B. Dinesh; F. Tip (Frank)

1998-01-01

textabstractThe effectiveness of a type checking tool strongly depends on the accuracy of the positional information that is associated with type errors. We present an approach where the location associated with an error message e is defined as a slice P_e of the program P being type checked. We

Measurement of the magnetic field errors on TCV

International Nuclear Information System (INIS)

Piras, F.; Moret, J.-M.; Rossel, J.X.

2010-01-01

A set of 24 saddle loops is used on the Tokamak a Configuration Variable (TCV) to measure the radial magnetic flux at different toroidal and vertical positions. The new system is calibrated together with the standard magnetic diagnostics on TCV. Based on the results of this calibration, the effective current in the poloidal field coils and their position is computed. These corrections are then used to compute the distribution of the error field inside the vacuum vessel for a typical TCV discharge. Since the saddle loops measure the magnetic flux at different toroidal positions, the non-axisymmetric error field is also estimated and correlated to a shift or a tilt of the poloidal field coils.

Short-read reading-frame predictors are not created equal: sequence error causes loss of signal

Directory of Open Access Journals (Sweden)

Trimble William L

2012-07-01

Full Text Available Abstract Background Gene prediction algorithms (or gene callers are an essential tool for analyzing shotgun nucleic acid sequence data. Gene prediction is a ubiquitous step in sequence analysis pipelines; it reduces the volume of data by identifying the most likely reading frame for a fragment, permitting the out-of-frame translations to be ignored. In this study we evaluate five widely used ab initio gene-calling algorithms—FragGeneScan, MetaGeneAnnotator, MetaGeneMark, Orphelia, and Prodigal—for accuracy on short (75–1000 bp fragments containing sequence error from previously published artificial data and “real” metagenomic datasets. Results While gene prediction tools have similar accuracies predicting genes on error-free fragments, in the presence of sequencing errors considerable differences between tools become evident. For error-containing short reads, FragGeneScan finds more prokaryotic coding regions than does MetaGeneAnnotator, MetaGeneMark, Orphelia, or Prodigal. This improved detection of genes in error-containing fragments, however, comes at the cost of much lower (50% specificity and overprediction of genes in noncoding regions. Conclusions Ab initio gene callers offer a significant reduction in the computational burden of annotating individual nucleic acid reads and are used in many metagenomic annotation systems. For predicting reading frames on raw reads, we find the hidden Markov model approach in FragGeneScan is more sensitive than other gene prediction tools, while Prodigal, MGA, and MGM are better suited for higher-quality sequences such as assembled contigs.

Field testing for cosmic ray soft errors in semiconductor memories

International Nuclear Information System (INIS)

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

1996-01-01

This paper presents a review of experiments performed by IBM to investigate the causes of soft errors in semiconductor memory chips under field test conditions. The effects of alpha-particles and cosmic rays are separated by comparing multiple measurements of the soft-error rate (SER) of samples of memory chips deep underground and at various altitudes above the earth. The results of case studies on four different memory chips show that cosmic rays are an important source of the ionizing radiation that causes soft errors. The results of field testing are used to confirm the accuracy of the modeling and the accelerated testing of chips

Evaluation of Data with Systematic Errors

International Nuclear Information System (INIS)

Froehner, F. H.

2003-01-01

Application-oriented evaluated nuclear data libraries such as ENDF and JEFF contain not only recommended values but also uncertainty information in the form of 'covariance' or 'error files'. These can neither be constructed nor utilized properly without a thorough understanding of uncertainties and correlations. It is shown how incomplete information about errors is described by multivariate probability distributions or, more summarily, by covariance matrices, and how correlations are caused by incompletely known common errors. Parameter estimation for the practically most important case of the Gaussian distribution with common errors is developed in close analogy to the more familiar case without. The formalism shows that, contrary to widespread belief, common ('systematic') and uncorrelated ('random' or 'statistical') errors are to be added in quadrature. It also shows explicitly that repetition of a measurement reduces mainly the statistical uncertainties but not the systematic ones. While statistical uncertainties are readily estimated from the scatter of repeatedly measured data, systematic uncertainties can only be inferred from prior information about common errors and their propagation. The optimal way to handle error-affected auxiliary quantities ('nuisance parameters') in data fitting and parameter estimation is to adjust them on the same footing as the parameters of interest and to integrate (marginalize) them out of the joint posterior distribution afterward

Influence of Daily Set-Up Errors on Dose Distribution During Pelvis Radiotherapy

International Nuclear Information System (INIS)

Kasabasic, M.; Ivkovic, A.; Faj, D.; Rajevac, V.; Sobat, H.; Jurkovic, S.

2011-01-01

An external beam radiotherapy (EBRT) using megavoltage beam of linear accelerator is usually the treatment of choice for the cancer patients. The goal of EBRT is to deliver the prescribed dose to the target volume, with as low as possible dose to the surrounding healthy tissue. A large number of procedures and different professions involved in radiotherapy process, uncertainty of equipment and daily patient set-up errors can cause a difference between the planned and delivered dose. We investigated a part of this difference caused by daily patient set-up errors. Daily set-up errors for 35 patients were measured. These set-up errors were simulated on 5 patients, using 3D treatment planning software XiO (CMS Inc., St. Louis, MO). The differences in dose distributions between the planned and shifted ''geometry'' were investigated. Additionally, an influence of the error on treatment plan selection was checked by analyzing the change in dose volume histograms, planning target volume conformity index (CI P TV) and homogeneity index (HI). Simulations showed that patient daily set-up errors can cause significant differences between the planned and actual dose distributions. Moreover, for some patients those errors could influence the choice of treatment plan since CI P TV fell under 97 %. Surprisingly, HI was not as sensitive as CI P TV on set-up errors. The results showed the need for minimizing daily set-up errors by quality assurance programme. (author)

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

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.

A Vision/Inertia Integrated Positioning Method Using Position and Orientation Matching

Directory of Open Access Journals (Sweden)

Xiaoyue Zhang

2017-01-01

Full Text Available A vision/inertia integrated positioning method using position and orientation matching which can be adopted on intelligent vehicle such as automated guided vehicle (AGV and mobile robot is proposed in this work. The method is introduced firstly. Landmarks are placed into the navigation field and camera and inertial measurement unit (IMU are installed on the vehicle. Vision processor calculates the azimuth and position information from the pictures which include artificial landmarks with the known direction and position. Inertial navigation system (INS calculates the azimuth and position of vehicle in real time and the calculated pixel position of landmark can be computed from the INS output position. Then the needed mathematical models are established and integrated navigation is implemented by Kalman filter with the observation of azimuth and the calculated pixel position of landmark. Navigation errors and IMU errors are estimated and compensated in real time so that high precision navigation results can be got. Finally, simulation and test are performed, respectively. Both simulation and test results prove that this vision/inertia integrated positioning method using position and orientation matching has feasibility and it can achieve centimeter-level autonomic continuous navigation.

Quasi-eccentricity error modeling and compensation in vision metrology

Science.gov (United States)

Shen, Yijun; Zhang, Xu; Cheng, Wei; Zhu, Limin

2018-04-01

Circular targets are commonly used in vision applications for its detection accuracy and robustness. The eccentricity error of the circular target caused by perspective projection is one of the main factors of measurement error which needs to be compensated in high-accuracy measurement. In this study, the impact of the lens distortion on the eccentricity error is comprehensively investigated. The traditional eccentricity error turns to a quasi-eccentricity error in the non-linear camera model. The quasi-eccentricity error model is established by comparing the quasi-center of the distorted ellipse with the true projection of the object circle center. Then, an eccentricity error compensation framework is proposed which compensates the error by iteratively refining the image point to the true projection of the circle center. Both simulation and real experiment confirm the effectiveness of the proposed method in several vision applications.

Interventions for reducing medication errors in children in hospital

NARCIS (Netherlands)

Maaskant, Jolanda M; Vermeulen, Hester; Apampa, Bugewa; Fernando, Bernard; Ghaleb, Maisoon A; Neubert, Antje; Thayyil, Sudhin; Soe, Aung

2015-01-01

BACKGROUND: Many hospitalised patients are affected by medication errors (MEs) that may cause discomfort, harm and even death. Children are at especially high risk of harm as the result of MEs because such errors are potentially more hazardous to them than to adults. Until now, interventions to

Interventions for reducing medication errors in children in hospital

NARCIS (Netherlands)

Maaskant, Jolanda M.; Vermeulen, Hester; Apampa, Bugewa; Fernando, Bernard; Ghaleb, Maisoon A.; Neubert, Antje; Thayyil, Sudhin; Soe, Aung

2015-01-01

Background Many hospitalised patients are affected by medication errors (MEs) that may cause discomfort, harm and even death. Children are at especially high risk of harm as the result of MEs because such errors are potentially more hazardous to them than to adults. Until now, interventions to

Error detection and prevention in Embedded Systems Software

DEFF Research Database (Denmark)

Kamel, Hani Fouad

1996-01-01

Despite many efforts to structure the development and design processes of embedded systems, errors are discovered at the final stages of production and sometimes after the delivery of the products. The cost of such errors can be prohibitive.Different design techniques to detect such errors...... systems, a formal model for such systems is introduced. The main characteristics of embedded systems design and the interaction of these properties are described. A taxonomy for the structure of the software developed for such systems based on the amount of processes and processors involved is presented.......The second part includes methods and techniques to detect software design errors.The third part deals with error prevention. It starts with a presentation of different models of the development processes used in industry and taught at universities. This leads us to deduce the major causes of errors...

Enhanced Pedestrian Navigation Based on Course Angle Error Estimation Using Cascaded Kalman Filters.

Science.gov (United States)

Song, Jin Woo; Park, Chan Gook

2018-04-21

An enhanced pedestrian dead reckoning (PDR) based navigation algorithm, which uses two cascaded Kalman filters (TCKF) for the estimation of course angle and navigation errors, is proposed. The proposed algorithm uses a foot-mounted inertial measurement unit (IMU), waist-mounted magnetic sensors, and a zero velocity update (ZUPT) based inertial navigation technique with TCKF. The first stage filter estimates the course angle error of a human, which is closely related to the heading error of the IMU. In order to obtain the course measurements, the filter uses magnetic sensors and a position-trace based course angle. For preventing magnetic disturbance from contaminating the estimation, the magnetic sensors are attached to the waistband. Because the course angle error is mainly due to the heading error of the IMU, and the characteristic error of the heading angle is highly dependent on that of the course angle, the estimated course angle error is used as a measurement for estimating the heading error in the second stage filter. At the second stage, an inertial navigation system-extended Kalman filter-ZUPT (INS-EKF-ZUPT) method is adopted. As the heading error is estimated directly by using course-angle error measurements, the estimation accuracy for the heading and yaw gyro bias can be enhanced, compared with the ZUPT-only case, which eventually enhances the position accuracy more efficiently. The performance enhancements are verified via experiments, and the way-point position error for the proposed method is compared with those for the ZUPT-only case and with other cases that use ZUPT and various types of magnetic heading measurements. The results show that the position errors are reduced by a maximum of 90% compared with the conventional ZUPT based PDR algorithms.

[Positioning errors of CT common rail technique in intensity-modulated radiotherapy for nasopharyngeal carcinoma].

Science.gov (United States)

Tian, Fei; Xu, Zihai; Mo, Li; Zhu, Chaohua; Chen, Chaomin

2012-11-01

To evaluate the value of CT common rail technique for application in intensity-modulated radiotherapy for nasopharyngeal carcinoma (NPC). Twenty-seven NPC patients underwent Somatom CT scans using the Siemens CTVision system prior to the commencement of the radiotherapy sessions. The acquired CT images were registered with the planning CT images using the matching function of the system to obtain the linear set-up errors of 3 directions, namely X (left to right), Y (superior to inferior), and Z (anterior to posterior). The errors were then corrected online on the moving couch. The 27 NPC patients underwent a total of 110 CT scans and the displacement deviations of the X, Y and Z directions were -0.16∓1.68 mm, 0.25∓1.66 mm, and 0.33∓1.09 mm, respectively. CT common rail technique can accurately and rapidly measure the space error between the posture and the target area to improve the set-up precision of intensity-modulated radiotherapy for NPC.

Agricultural injuries in Korea and errors in systems of safety

Directory of Open Access Journals (Sweden)

Hyocher Kim

2016-07-01

It was found that most agricultural injuries were caused by a complex layer of root causes which were classified as errors in the systems of safety. This result indicates that not only training and personal protective equipment, but also regulation of safety design, mitigation devices, inspection/maintenance of workplaces, and other factors play an important role in preventing agricultural injuries. The identification of errors will help farmers to implement easily an effective prevention programme.