WorldWideScience

Sample records for reportable personnel errors

  1. A Comprehensive Quality Assurance Program for Personnel and Procedures in Radiation Oncology: Value of Voluntary Error Reporting and Checklists

    International Nuclear Information System (INIS)

    Kalapurakal, John A.; Zafirovski, Aleksandar; Smith, Jeffery; Fisher, Paul; Sathiaseelan, Vythialingam; Barnard, Cynthia; Rademaker, Alfred W.; Rave, Nick; Mittal, Bharat B.

    2013-01-01

    Purpose: This report describes the value of a voluntary error reporting system and the impact of a series of quality assurance (QA) measures including checklists and timeouts on reported error rates in patients receiving radiation therapy. Methods and Materials: A voluntary error reporting system was instituted with the goal of recording errors, analyzing their clinical impact, and guiding the implementation of targeted QA measures. In response to errors committed in relation to treatment of the wrong patient, wrong treatment site, and wrong dose, a novel initiative involving the use of checklists and timeouts for all staff was implemented. The impact of these and other QA initiatives was analyzed. Results: From 2001 to 2011, a total of 256 errors in 139 patients after 284,810 external radiation treatments (0.09% per treatment) were recorded in our voluntary error database. The incidence of errors related to patient/tumor site, treatment planning/data transfer, and patient setup/treatment delivery was 9%, 40.2%, and 50.8%, respectively. The compliance rate for the checklists and timeouts initiative was 97% (P<.001). These and other QA measures resulted in a significant reduction in many categories of errors. The introduction of checklists and timeouts has been successful in eliminating errors related to wrong patient, wrong site, and wrong dose. Conclusions: A comprehensive QA program that regularly monitors staff compliance together with a robust voluntary error reporting system can reduce or eliminate errors that could result in serious patient injury. We recommend the adoption of these relatively simple QA initiatives including the use of checklists and timeouts for all staff to improve the safety of patients undergoing radiation therapy in the modern era

  2. Barriers to medical error reporting

    Directory of Open Access Journals (Sweden)

    Jalal Poorolajal

    2015-01-01

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

  3. Analysis of Medication Error Reports

    Energy Technology Data Exchange (ETDEWEB)

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

    2004-11-15

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

  4. Motorcycle Training for California Driver Licensing Personnel. Final Report.

    Science.gov (United States)

    California State Dept. of Motor Vehicles, Sacramento.

    The development of a 6-hour motorcycle course of instruction for personnel responsible for motorcycle licensing is described in this project report. The primary goals are stated and include (1) training driver licensing personnel in motorcycle safety and principles of operation, and (2) purchasing and installing appropriate motorcycle skill…

  5. Personnel selection and emotional stability certification: establishing a false negative error rate when clinical interviews

    International Nuclear Information System (INIS)

    Berghausen, P.E. Jr.

    1987-01-01

    The security plans of nuclear plants generally require that all personnel who are to have unescorted access to protected areas or vital islands be screened for emotional instability. Screening typically consists of first administering the MMPI and then conducting a clinical interview. Interviews-by-exception protocols provide for only those employees to be interviewed who have some indications of psychopathology in their MMPI results. A problem arises when the indications are not readily apparent: False negatives are likely to occur, resulting in employees being erroneously granted unescorted access. The present paper describes the development of a predictive equation which permits accurate identification, via analysis of MMPI results, of those employees who are most in need of being interviewed. The predictive equation also permits knowing probably maximum false negative error rates when a given percentage of employees is interviewed

  6. Automated personnel data base system specifications, Task V. Final report

    International Nuclear Information System (INIS)

    Bartley, H.J.; Bocast, A.K.; Deppner, F.O.; Harrison, O.J.; Kraas, I.W.

    1978-11-01

    The full title of this study is 'Development of Qualification Requirements, Training Programs, Career Plans, and Methodologies for Effective Management and Training of Inspection and Enforcement Personnel.' Task V required the development of an automated personnel data base system for NRC/IE. This system is identified as the NRC/IE Personnel, Assignment, Qualifications, and Training System (PAQTS). This Task V report provides the documentation for PAQTS including the Functional Requirements Document (FRD), the Data Requirements Document (DRD), the Hardware and Software Capabilities Assessment, and the Detailed Implementation Schedule. Specific recommendations to facilitate implementation of PAQTS are also included

  7. 6th technical report on personnel training

    Energy Technology Data Exchange (ETDEWEB)

    NONE

    1996-09-01

    This issue is the collection of the paper presented at the title meeting. Separate abstracts were presented for 3 of the papers in this report. The remaining 9 were considered outside the subject scope of INIS. (J.P.N.)

  8. Report on the Personnel Dosimetry at AB Atomenergi during 1962

    Energy Technology Data Exchange (ETDEWEB)

    Edvardsson, K A; Hagsgaard, S

    1964-07-15

    This report presents the results of the personnel dosimetry at AB Atomenergi during 1963. No doses exceeding the recommendations of ICRP have been reported. The sum of the reported external total body doses during the year is for AB Atomenergi 64.2 manrem which, distributed over the whole company personnel, corresponds to about 40 mrem per year and person or about 1 % of the maximum permissible dose. 37800 gamma films and 6700 neutron films have been evaluated. The total number of urine analyses is 3603 and of whole body measurements 211.

  9. Report on the Personnel Dosimetry at AB Atomenergi during 1964

    International Nuclear Information System (INIS)

    Edvardsson, K.A.; Hagsgaard, S.

    1966-01-01

    This report presents the results of the personnel dosimetry at AB Atomenergi during 1964. No doses exceeding the recommendations of ICRP were reported. The sum of the reported external total body doses during the year was for AB Atomenergi 51.5 manrem which, distributed over the whole company personnel, corresponds to an average dose of about 35 mrem per year and person or less than 1 % of the maximum permissible dose. 31,400 gamma films and 5,800 neutron films were evaluated. The films were changed every month. Urine analyses numbered 2,731 and whole body measurements 485. A comparison is made between dose distributions at AB Atomenergi and at institutions in other countries. The fraction of all personnel carrying dosimeters and exposed to more than a nominal dose seems generally to have been less than 10-20 %

  10. Report on the Personnel Dosimetry at AB Atomenergi during 1964

    Energy Technology Data Exchange (ETDEWEB)

    Edvardsson, K A; Hagsgaard, S

    1966-01-15

    This report presents the results of the personnel dosimetry at AB Atomenergi during 1964. No doses exceeding the recommendations of ICRP were reported. The sum of the reported external total body doses during the year was for AB Atomenergi 51.5 manrem which, distributed over the whole company personnel, corresponds to an average dose of about 35 mrem per year and person or less than 1 % of the maximum permissible dose. 31,400 gamma films and 5,800 neutron films were evaluated. The films were changed every month. Urine analyses numbered 2,731 and whole body measurements 485. A comparison is made between dose distributions at AB Atomenergi and at institutions in other countries. The fraction of all personnel carrying dosimeters and exposed to more than a nominal dose seems generally to have been less than 10-20 %.

  11. Operating personnel error analysis during operation failures in the Kozloduj NPP

    International Nuclear Information System (INIS)

    Jonkova, A.

    1990-01-01

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

  12. AEC Advisory Committee report emphasizes personnel exchanges

    International Nuclear Information System (INIS)

    Anon.

    1984-01-01

    The Advisory Committee on Cooperation with Developing Countries set up in August 1983 in the AEC has studied for about one year the actual situations of nuclear energy development and utilization in developing countries and their expections toward Japan and also problems in Japan in this connection. The Advisory Committee's report is summarized: significance of nuclear energy cooperation; status of nuclear energy energy utilizations in developing countries; status and problems in Japan's cooperation (technical cooperation through IAEA and technical cooperation by JAERI, JAIF, etc.); future prospects (areas of cooperation including the uses of radioisotopes and radiation and research reactors, nuclear power generation, etc. and tasks of the Government and the private sector in expanding the cooperation). (Mori, K.)

  13. Error review: Can this improve reporting performance?

    International Nuclear Information System (INIS)

    Tudor, Gareth R.; Finlay, David B.

    2001-01-01

    AIM: This study aimed to assess whether error review can improve radiologists' reporting performance. MATERIALS AND METHODS: Ten Consultant Radiologists reported 50 plain radiographs, in which the diagnoses were established. Eighteen of the radiographs were normal, 32 showed an abnormality. The radiologists were shown their errors and then re-reported the series of radiographs after an interval of 4-5 months. The accuracy of the reports to the established diagnoses was assessed. Chi-square test was used to calculate the difference between the viewings. RESULTS: On re-reporting the radiographs, seven radiologists improved their accuracy score, two had a lower score and one radiologist showed no score difference. Mean accuracy pre-education was 82.2%, (range 78-92%) and post-education was 88%, (range 76-96%). Individually, two of the radiologists showed a statistically significant improvement post-education (P < 0.01,P < 0.05). Assessing the group as a whole, there was a trend for improvement post-education but this did not reach statistical significance. Assessing only the radiographs where errors were made on the initial viewing, for the group as a whole there was a 63% improvement post-education. CONCLUSION: We suggest that radiologists benefit from error review, although there was not a statistically significant improvement for the series of radiographs in total. This is partly explained by the fact that some radiologists gave incorrect responses post-education that had initially been correct, thus masking the effect of the educational intervention. Tudor, G.R. and Finlay, D.B. (2001

  14. Report on the Personnel Dosimetry at AB Atomenergi during 1965

    International Nuclear Information System (INIS)

    Edvardsson, K.A.

    1966-10-01

    This report presents the results of the personnel dosimetry at AB Atomenergi during 1965. No doses exceeding the recommendations of ICRP were reported. For AB Atomenergi the average external total body dose during the year was 60 mrem which corresponds to 89.4 manrem. 31200 gamma films and 5850 neutron films were evaluated. 2067 urine analyses and 692 measurements of body activity were made

  15. Report on the Personnel Dosimetry at AB Atomenergi during 1969

    Energy Technology Data Exchange (ETDEWEB)

    Carlsson, J; Wahlberg, T

    1971-05-15

    This report presents the results of personnel dosimetry at AB Atomenergi during 1969. 24,200 gamma films and 3,300 neutron films were evaluated. 770 urine analyses and 1,150 measurements of body activity were made. The external total body gamma dose for all employees (quarterly doses < 100 mrem are not reported) corresponds to 136 manrem. The highest external total body gamma dose during 1969 to one person was 4,800 mrem

  16. Report on the Personnel Dosimetry at AB Atomenergi during 1968

    Energy Technology Data Exchange (ETDEWEB)

    Carlsson, J; Wahlberg, T

    1969-08-15

    This report presents the results of personnel dosimetry at AB Atomenergi during 1968. 25600 gamma films and 3900 neutron films were evaluated. 1737 urine analyses and 1066 measurements of body activity were made. The external total body gamma dose for all employees (quarterly doses {<=} 100 mrem are not reported) corresponds to 136 manrem. The highest external total body gamma dose during 1968 to one person was 4,500 mrem.

  17. Report on the Personnel Dosimetry at AB Atomenergi during 1965

    Energy Technology Data Exchange (ETDEWEB)

    Edvardsson, K A

    1966-10-15

    This report presents the results of the personnel dosimetry at AB Atomenergi during 1965. No doses exceeding the recommendations of ICRP were reported. For AB Atomenergi the average external total body dose during the year was 60 mrem which corresponds to 89.4 manrem. 31200 gamma films and 5850 neutron films were evaluated. 2067 urine analyses and 692 measurements of body activity were made.

  18. Defense Forensic Enterprise: Assessment and Status Report Personnel Accounting Extract

    Science.gov (United States)

    2013-12-01

    pathology , forensic anthropology, forensic toxicology, and DNA analysis to iden- tify human remains. Per DOD Directive 5205.15E, the stakeholders fall...Defense Forensic Enterprise Assessment and Status Report Personnel Accounting Extract Christine A. Hughes • Jeffrey E. Chilton John J. Clifford • C...community-related sections from a CNA report titled, “Defense Forensic Enterprise Assessment and Status Report” [1]. The first sec- tion within this

  19. Report on the Personnel Dosimetry at AB Atomenergi during 1967

    International Nuclear Information System (INIS)

    Carlsson, J.; Wahlberg, T.

    1968-12-01

    This report presents the results of personnel dosimetry at AB Atomenergi during 1967. The external total body gamma dose for all employees (quarterly doses ≤ 100 mrem are not reported) corresponds to 140 manrem. The highest external total body gamma dose during 1967 to one person was 5700 mrem. 24700 gamma films and 3900 neutron films were evaluated. 1988 urine analyses and 989 measurements of body activity were made

  20. Report on the Personnel Dosimetry at AB Atomenergi during 1967

    Energy Technology Data Exchange (ETDEWEB)

    Carlsson, J; Wahlberg, T

    1968-12-15

    This report presents the results of personnel dosimetry at AB Atomenergi during 1967. The external total body gamma dose for all employees (quarterly doses {<=} 100 mrem are not reported) corresponds to 140 manrem. The highest external total body gamma dose during 1967 to one person was 5700 mrem. 24700 gamma films and 3900 neutron films were evaluated. 1988 urine analyses and 989 measurements of body activity were made.

  1. Development of the Human Error Management Criteria and the Job Aptitude Evaluation Criteria for Rail Safety Personnel

    Energy Technology Data Exchange (ETDEWEB)

    Koo, In Soo; Seo, Sang Mun; Park, Geun Ok (and others)

    2008-08-15

    It has been estimated that up to 90% of all workplace accidents have human error as a cause. Human error has been widely recognized as a key factor in almost all the highly publicized accidents, including Daegu subway fire of February 18, 2003 killed 198 people and injured 147. Because most human behavior is 'unintentional', carried out automatically, root causes of human error should be carefully investigated and regulated by a legal authority. The final goal of this study is to set up some regulatory guidance that are supposed to be used by the korean rail organizations related to safety managements and the contents are : - to develop the regulatory guidance for managing human error, - to develop the regulatory guidance for managing qualifications of rail drivers - to develop the regulatory guidance for evaluating the aptitude of the safety-related personnel.

  2. Development of the Human Error Management Criteria and the Job Aptitude Evaluation Criteria for Rail Safety Personnel

    International Nuclear Information System (INIS)

    Koo, In Soo; Seo, Sang Mun; Park, Geun Ok

    2008-08-01

    It has been estimated that up to 90% of all workplace accidents have human error as a cause. Human error has been widely recognized as a key factor in almost all the highly publicized accidents, including Daegu subway fire of February 18, 2003 killed 198 people and injured 147. Because most human behavior is 'unintentional', carried out automatically, root causes of human error should be carefully investigated and regulated by a legal authority. The final goal of this study is to set up some regulatory guidance that are supposed to be used by the korean rail organizations related to safety managements and the contents are : - to develop the regulatory guidance for managing human error, - to develop the regulatory guidance for managing qualifications of rail drivers - to develop the regulatory guidance for evaluating the aptitude of the safety-related personnel

  3. Personnel neutron dose assessment upgrade: Volume 1, Personnel neutron dosimetry assessment: [Final report

    International Nuclear Information System (INIS)

    Hadlock, D.E.; Brackenbush, L.W.; Griffith, R.V.; Hankins, D.E.; Parkhurst, M.A.; Stroud, C.M.; Faust, L.G.; Vallario, E.J.

    1988-07-01

    This report provides guidance on the characteristics, use, and calibration criteria for personnel neutron dosimeters. The report is applicable for neutrons with energies ranging from thermal to less than 20 MeV. Background for general neutron dosimetry requirements is provided, as is relevant federal regulations and other standards. The characteristics of personnel neutron dosimeters are discussed, with particular attention paid to passive neutron dosimetry systems. Two of the systems discussed are used at DOE and DOE-contractor facilities (nuclear track emulsion and thermoluminescent-albedo) and another (the combination TLD/TED) was recently developed. Topics discussed in the field applications of these dosimeters include their theory of operation, their processing, readout, and interpretation, and their advantages and disadvantages for field use. The procedures required for occupational neutron dosimetry are discussed, including radiation monitoring and the wearing of dosimeters, their exchange periods, dose equivalent evaluations, and the documenting of neutron exposures. The coverage of dosimeter testing, maintenance, and calibration includes guidance on the selection of calibration sources, the effects of irradiation geometries, lower limits of detectability, fading, frequency of calibration, spectrometry, and quality control. 49 refs., 6 figs., 8 tabs

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

    Science.gov (United States)

    Herzberg, Tina

    2010-01-01

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

  5. Report on the Personnel Dosimetry at AB Atomenergi during 1962

    International Nuclear Information System (INIS)

    Edvardsson, K.A.; Hagsgaard, S.

    1963-12-01

    This report presents the results of the personnel dosimetry at AB Atomenergi during 1962. No doses exceeding the recommendations of ICRP have been reported. The sum of the reported external total body doses (≥ 100 mrem/quarter) is for the whole of AB Atomenergi during this year 74. 2 manrem corresponding to about 50 mrem/year and person or 1 % of the maximum permissible dose. 32500 gamma films and 6200 neutron films have been evaluated. The total number of urine analyses is 2700 and of whole body measurements 10

  6. Report on the Personnel Dosimetry at AB Atomenergi during 1962

    Energy Technology Data Exchange (ETDEWEB)

    Edvardsson, K A; Hagsgaard, S

    1963-12-15

    This report presents the results of the personnel dosimetry at AB Atomenergi during 1962. No doses exceeding the recommendations of ICRP have been reported. The sum of the reported external total body doses ({>=} 100 mrem/quarter) is for the whole of AB Atomenergi during this year 74. 2 manrem corresponding to about 50 mrem/year and person or 1 % of the maximum permissible dose. 32500 gamma films and 6200 neutron films have been evaluated. The total number of urine analyses is 2700 and of whole body measurements 10.

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

    Science.gov (United States)

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

    2006-03-01

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

  8. 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…

  9. Teamwork and Clinical Error Reporting among Nurses in Korean Hospitals

    Directory of Open Access Journals (Sweden)

    Jee-In Hwang, PhD

    2015-03-01

    Conclusions: Teamwork was rated as moderate and was positively associated with nurses' error reporting performance. Hospital executives and nurse managers should make substantial efforts to enhance teamwork, which will contribute to encouraging the reporting of errors and improving patient safety.

  10. Nuclear power plant personnel errors in decision-making as an object of probabilistic risk assessment

    International Nuclear Information System (INIS)

    Reer, B.

    1993-09-01

    The integration of human error - also called man-machine system analysis (MMSA) - is an essential part of probabilistic risk assessment (PRA). A new method is presented which allows for a systematic and comprehensive PRA inclusions of decision-based errors due to conflicts or similarities. For the error identification procedure, new question techniques are developed. These errors are shown to be identified by looking at retroactions caused by subordinate goals as components of the overall safety relevant goal. New quantification methods for estimating situation-specific probabilities are developed. The factors conflict and similarity are operationalized in a way that allows their quantification based on informations which are usually available in PRA. The quantification procedure uses extrapolations and interpolations based on a poor set of data related to decision-based errors. Moreover, for passive errors in decision-making a completely new approach is presented where errors are quantified via a delay initiating the required action rather than via error probabilities. The practicability of this dynamic approach is demonstrated by a probabilistic analysis of the actions required during the total loss of feedwater event at the Davis-Besse plant 1985. The extensions of the ''classical'' PRA method developed in this work are applied to a MMSA of the decay heat removal (DHR) of the ''HTR-500''. Errors in decision-making - as potential roots of extraneous acts - are taken into account in a comprehensive and systematic manner. Five additional errors are identified. However, the probabilistic quantification results a nonsignificant increase of the DHR failure probability. (orig.) [de

  11. Error identification, disclosure, and reporting: practice patterns of three emergency medicine provider types.

    Science.gov (United States)

    Hobgood, Cherri; Xie, Jipan; Weiner, Bryan; Hooker, James

    2004-02-01

    To gather preliminary data on how the three major types of emergency medicine (EM) providers, physicians, nurses (RNs), and out-of-hospital personnel (EMTs), differ in error identification, disclosure, and reporting. A convenience sample of emergency department (ED) providers completed a brief survey designed to evaluate error frequency, disclosure, and reporting practices as well as error-based discussion and educational activities. One hundred sixteen subjects participated: 41 EMTs (35%), 33 RNs (28%), and 42 physicians (36%). Forty-five percent of EMTs, 56% of RNs, and 21% of physicians identified no clinical errors during the preceding year. When errors were identified, physicians learned of them via dialogue with RNs (58%), patients (13%), pharmacy (35%), and attending physicians (35%). For known errors, all providers were equally unlikely to inform the team caring for the patient. Disclosure to patients was limited and varied by provider type (19% EMTs, 23% RNs, and 74% physicians). Disclosure education was rare, with error to a patient. Error discussions are widespread, with all providers indicating they discussed their own as well as the errors of others. This study suggests that error identification, disclosure, and reporting challenge all members of the ED care delivery team. Provider-specific education and enhanced teamwork training will be required to further the transformation of the ED into a high-reliability organization.

  12. 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.

  13. Barriers to medication error reporting among hospital nurses.

    Science.gov (United States)

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

    2018-03-01

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

  14. Learning from medication errors through a nationwide reporting programme

    NARCIS (Netherlands)

    Cheung, K.C.

    2015-01-01

    One of the strategies to enhance patient safety is the spontaneous reporting and analysis of medication errors. Sharing this information with other healthcare providers will help to prevent the reoccurrence of similar medication errors. In The Netherlands medication errors can be reported to a

  15. Report: Management Alert - EPA Has Not Initiated Required Background Investigations for Information Systems Contractor Personnel

    Science.gov (United States)

    Report #17-P-0409, September 27, 2017. Not vetting contractor personnel before granting them network access exposes the EPA to risks. Contractor personnel with potentially questionable backgrounds who access sensitive agency data could cause harm.

  16. 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.

  17. Organizational safety culture and medical error reporting by Israeli nurses.

    Science.gov (United States)

    Kagan, Ilya; Barnoy, Sivia

    2013-09-01

    To investigate the association between patient safety culture (PSC) and the incidence and reporting rate of medical errors by Israeli nurses. Self-administered structured questionnaires were distributed to a convenience sample of 247 registered nurses enrolled in training programs at Tel Aviv University (response rate = 91%). The questionnaire's three sections examined the incidence of medication mistakes in clinical practice, the reporting rate for these errors, and the participants' views and perceptions of the safety culture in their workplace at three levels (organizational, departmental, and individual performance). Pearson correlation coefficients, t tests, and multiple regression analysis were used to analyze the data. Most nurses encountered medical errors from a daily to a weekly basis. Six percent of the sample never reported their own errors, while half reported their own errors "rarely or sometimes." The level of PSC was positively and significantly correlated with the error reporting rate. PSC, place of birth, error incidence, and not having an academic nursing degree were significant predictors of error reporting, together explaining 28% of variance. This study confirms the influence of an organizational safety climate on readiness to report errors. Senior healthcare executives and managers can make a major impact on safety culture development by creating and promoting a vision and strategy for quality and safety and fostering their employees' motivation to implement improvement programs at the departmental and individual level. A positive, carefully designed organizational safety culture can encourage error reporting by staff and so improve patient safety. © 2013 Sigma Theta Tau International.

  18. THE INFLUENCE OF ACCOUNTANCY ERRORS ON FINANCIAL AND TAX REPORTS

    Directory of Open Access Journals (Sweden)

    Mariana GURĂU

    2016-06-01

    Full Text Available To make mistakes is human. An accountant may do mistakes, too. Accountancy errors are defined and classsified by accounting regulations. These set what is the accountant treatment for correcting accountancy errors. However, even though one of the objectives in accounting normalization is made by the disconnection between accountancy and taxation, the accountancy errors influence especially tax reports. We will further point the impact of accountancy errors on financial and tax reports. We will also approach the accountancy principles that impose the rules described for correcting the errors.

  19. Estimation of Total Error in DWPF Reported Radionuclide Inventories

    International Nuclear Information System (INIS)

    Edwards, T.B.

    1995-01-01

    This report investigates the impact of random errors due to measurement and sampling on the reported concentrations of radionuclides in DWPF's filled canister inventory resulting from each macro-batch. The objective of this investigation is to estimate the variance of the total error in reporting these radionuclide concentrations

  20. Nurses' attitude and intention of medication administration error reporting.

    Science.gov (United States)

    Hung, Chang-Chiao; Chu, Tsui-Ping; Lee, Bih-O; Hsiao, Chia-Chi

    2016-02-01

    The Aims of this study were to explore the effects of nurses' attitudes and intentions regarding medication administration error reporting on actual reporting behaviours. Underreporting of medication errors is still a common occurrence. Whether attitude and intention towards medication administration error reporting connect to actual reporting behaviours remain unclear. This study used a cross-sectional design with self-administered questionnaires, and the theory of planned behaviour was used as the framework for this study. A total of 596 staff nurses who worked in general wards and intensive care units in a hospital were invited to participate in this study. The researchers used the instruments measuring nurses' attitude, nurse managers' and co-workers' attitude, report control, and nurses' intention to predict nurses' actual reporting behaviours. Data were collected from September-November 2013. Path analyses were used to examine the hypothesized model. Of the 596 nurses invited to participate, 548 (92%) completed and returned a valid questionnaire. The findings indicated that nurse managers' and co-workers' attitudes are predictors for nurses' attitudes towards medication administration error reporting. Nurses' attitudes also influenced their intention to report medication administration errors; however, no connection was found between intention and actual reporting behaviour. The findings reflected links among colleague perspectives, nurses' attitudes, and intention to report medication administration errors. The researchers suggest that hospitals should increase nurses' awareness and recognition of error occurrence. Regardless of nurse managers' and co-workers' attitudes towards medication administration error reporting, nurses are likely to report medication administration errors if they detect them. Management of medication administration errors should focus on increasing nurses' awareness and recognition of error occurrence. © 2015 John Wiley & Sons Ltd.

  1. Barriers to Medical Error Reporting for Physicians and Nurses.

    Science.gov (United States)

    Soydemir, Dilek; Seren Intepeler, Seyda; Mert, Hatice

    2017-10-01

    The purpose of the study was to determine what barriers to error reporting exist for physicians and nurses. The study, of descriptive qualitative design, was conducted with physicians and nurses working at a training and research hospital. In-depth interviews were held with eight physicians and 15 nurses, a total of 23 participants. Physicians and nurses do not choose to report medical errors that they experience or witness. When barriers to error reporting were examined, it was seen that there were four main themes involved: fear, the attitude of administration, barriers related to the system, and the employees' perceptions of error. It is important in terms of preventing medical errors to identify the barriers that keep physicians and nurses from reporting errors.

  2. Medication errors reported to the National Medication Error Reporting System in Malaysia: a 4-year retrospective review (2009 to 2012).

    Science.gov (United States)

    Samsiah, A; Othman, Noordin; Jamshed, Shazia; Hassali, Mohamed Azmi; Wan-Mohaina, W M

    2016-12-01

    Reporting and analysing the data on medication errors (MEs) is important and contributes to a better understanding of the error-prone environment. This study aims to examine the characteristics of errors submitted to the National Medication Error Reporting System (MERS) in Malaysia. A retrospective review of reports received from 1 January 2009 to 31 December 2012 was undertaken. Descriptive statistics method was applied. A total of 17,357 MEs reported were reviewed. The majority of errors were from public-funded hospitals. Near misses were classified in 86.3 % of the errors. The majority of errors (98.1 %) had no harmful effects on the patients. Prescribing contributed to more than three-quarters of the overall errors (76.1 %). Pharmacists detected and reported the majority of errors (92.1 %). Cases of erroneous dosage or strength of medicine (30.75 %) were the leading type of error, whilst cardiovascular (25.4 %) was the most common category of drug found. MERS provides rich information on the characteristics of reported MEs. Low contribution to reporting from healthcare facilities other than government hospitals and non-pharmacists requires further investigation. Thus, a feasible approach to promote MERS among healthcare providers in both public and private sectors needs to be formulated and strengthened. Preventive measures to minimise MEs should be directed to improve prescribing competency among the fallible prescribers identified.

  3. Learning from Errors: Critical Incident Reporting in Nursing

    Science.gov (United States)

    Gartmeier, Martin; Ottl, Eva; Bauer, Johannes; Berberat, Pascal Oliver

    2017-01-01

    Purpose: The purpose of this paper is to conceptualize error reporting as a strategy for informal workplace learning and investigate nurses' error reporting cost/benefit evaluations and associated behaviors. Design/methodology/approach: A longitudinal survey study was carried out in a hospital setting with two measurements (time 1 [t1]:…

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

    NARCIS (Netherlands)

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

    2010-01-01

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

  5. Recognition of medical errors' reporting system dimensions in educational hospitals.

    Science.gov (United States)

    Yarmohammadian, Mohammad H; Mohammadinia, Leila; Tavakoli, Nahid; Ghalriz, Parvin; Haghshenas, Abbas

    2014-01-01

    Nowadays medical errors are one of the serious issues in the health-care system and carry to account of the patient's safety threat. The most important step for achieving safety promotion is identifying errors and their causes in order to recognize, correct and omit them. Concerning about repeating medical errors and harms, which were received via theses errors concluded to designing and establishing medical error reporting systems for hospitals and centers that are presenting therapeutic services. The aim of this study is the recognition of medical errors' reporting system dimensions in educational hospitals. This research is a descriptive-analytical and qualities' study, which has been carried out in Shahid Beheshti educational therapeutic center in Isfahan during 2012. In this study, relevant information was collected through 15 face to face interviews. That each of interviews take place in about 1hr and creation of five focused discussion groups through 45 min for each section, they were composed of Metron, educational supervisor, health officer, health education, and all of the head nurses. Concluded data interviews and discussion sessions were coded, then achieved results were extracted in the presence of clear-sighted persons and after their feedback perception, they were categorized. In order to make sure of information correctness, tables were presented to the research's interviewers and final the corrections were confirmed based on their view. The extracted information from interviews and discussion groups have been divided into nine main categories after content analyzing and subject coding and their subsets have been completely expressed. Achieved dimensions are composed of nine domains of medical error concept, error cases according to nurses' prospection, medical error reporting barriers, employees' motivational factors for error reporting, purposes of medical error reporting system, error reporting's challenges and opportunities, a desired system

  6. Burnout, engagement and resident physicians' self-reported errors.

    Science.gov (United States)

    Prins, J T; van der Heijden, F M M A; Hoekstra-Weebers, J E H M; Bakker, A B; van de Wiel, H B M; Jacobs, B; Gazendam-Donofrio, S M

    2009-12-01

    Burnout is a work-related syndrome that may negatively affect more than just the resident physician. On the other hand, engagement has been shown to protect employees; it may also positively affect the patient care that the residents provide. Little is known about the relationship between residents' self-reported errors and burnout and engagement. In our national study that included all residents and physicians in The Netherlands, 2115 questionnaires were returned (response rate 41.1%). The residents reported on burnout (Maslach Burnout Inventory-Health and Social Services), engagement (Utrecht Work Engagement Scale) and self-assessed patient care practices (six items, two factors: errors in action/judgment, errors due to lack of time). Ninety-four percent of the residents reported making one or more mistake without negative consequences for the patient during their training. Seventy-one percent reported performing procedures for which they did not feel properly trained. More than half (56%) of the residents stated they had made a mistake with a negative consequence. Seventy-six percent felt they had fallen short in the quality of care they provided on at least one occasion. Men reported more errors in action/judgment than women. Significant effects of specialty and clinical setting were found on both types of errors. Residents with burnout reported significantly more errors (p engaged residents reported fewer errors (p burnout and to keep residents engaged in their work.

  7. Teamwork and clinical error reporting among nurses in Korean hospitals.

    Science.gov (United States)

    Hwang, Jee-In; Ahn, Jeonghoon

    2015-03-01

    To examine levels of teamwork and its relationships with clinical error reporting among Korean hospital nurses. The study employed a cross-sectional survey design. We distributed a questionnaire to 674 nurses in two teaching hospitals in Korea. The questionnaire included items on teamwork and the reporting of clinical errors. We measured teamwork using the Teamwork Perceptions Questionnaire, which has five subscales including team structure, leadership, situation monitoring, mutual support, and communication. Using logistic regression analysis, we determined the relationships between teamwork and error reporting. The response rate was 85.5%. The mean score of teamwork was 3.5 out of 5. At the subscale level, mutual support was rated highest, while leadership was rated lowest. Of the participating nurses, 522 responded that they had experienced at least one clinical error in the last 6 months. Among those, only 53.0% responded that they always or usually reported clinical errors to their managers and/or the patient safety department. Teamwork was significantly associated with better error reporting. Specifically, nurses with a higher team communication score were more likely to report clinical errors to their managers and the patient safety department (odds ratio = 1.82, 95% confidence intervals [1.05, 3.14]). Teamwork was rated as moderate and was positively associated with nurses' error reporting performance. Hospital executives and nurse managers should make substantial efforts to enhance teamwork, which will contribute to encouraging the reporting of errors and improving patient safety. Copyright © 2015. Published by Elsevier B.V.

  8. Psychological safety and error reporting within Veterans Health Administration hospitals.

    Science.gov (United States)

    Derickson, Ryan; Fishman, Jonathan; Osatuke, Katerine; Teclaw, Robert; Ramsel, Dee

    2015-03-01

    In psychologically safe workplaces, employees feel comfortable taking interpersonal risks, such as pointing out errors. Previous research suggested that psychologically safe climate optimizes organizational outcomes. We evaluated psychological safety levels in Veterans Health Administration (VHA) hospitals and assessed their relationship to employee willingness of reporting medical errors. We conducted an ANOVA on psychological safety scores from a VHA employees census survey (n = 185,879), assessing variability of means across racial and supervisory levels. We examined organizational climate assessment interviews (n = 374) evaluating how many employees asserted willingness to report errors (or not) and their stated reasons. Finally, based on survey data, we identified 2 (psychologically safe versus unsafe) hospitals and compared their number of employees who would be willing/unwilling to report an error. Psychological safety increased with supervisory level (P hospital (71% would report, 13% would not) were less willing to report an error than at the psychologically safe hospital (91% would, 0% would not). A substantial minority would not report an error and were willing to admit so in a private interview setting. Their stated reasons as well as higher psychological safety means for supervisory employees both suggest power as an important determinant. Intentions to report were associated with psychological safety, strongly suggesting this climate aspect as instrumental to improving patient safety and reducing costs.

  9. Pocket book {sup E}xpectations of operating personnel action and card criteria, previous meeting and precursor of error; Libro de bolsillo expectativas de actuacion del personal de operacion y tarjeta criterios reunion previa y precursores de error

    Energy Technology Data Exchange (ETDEWEB)

    Rodrigo Gonzalez, M.

    2012-07-01

    We have developed a pocket manual of performance expectations of operating personnel. Additionally, it has created a card pocket systematizing the application of previous meetings (pre-job) depending on the existence of error precursors and following the commission of an error. This manual serves to communicate expectations and performance expected to the Operation Staff. The results show a positive change in a short period of time working practices, both in training (simulator) and control room.

  10. Teamwork and Clinical Error Reporting among Nurses in Korean Hospitals

    OpenAIRE

    Jee-In Hwang, PhD; Jeonghoon Ahn, PhD

    2015-01-01

    Purpose: To examine levels of teamwork and its relationships with clinical error reporting among Korean hospital nurses. Methods: The study employed a cross-sectional survey design. We distributed a questionnaire to 674 nurses in two teaching hospitals in Korea. The questionnaire included items on teamwork and the reporting of clinical errors. We measured teamwork using the Teamwork Perceptions Questionnaire, which has five subscales including team structure, leadership, situation monitori...

  11. Improving Mental Health Reporting Practices in Between Personnel Security Investigations

    Science.gov (United States)

    2017-06-01

    derogatory information, unfavorable administrative actions, and adverse actions to the appropriate personnel security, human resources , and...national security clearance? What type of clearances do people typically have (e.g., Secret, Top Secret, TS/SCI, SAP , etc.)? (2) Does [the

  12. Electronic error-reporting systems: a case study into the impact on nurse reporting of medical errors.

    Science.gov (United States)

    Lederman, Reeva; Dreyfus, Suelette; Matchan, Jessica; Knott, Jonathan C; Milton, Simon K

    2013-01-01

    Underreporting of errors in hospitals persists despite the claims of technology companies that electronic systems will facilitate reporting. This study builds on previous analyses to examine error reporting by nurses in hospitals using electronic media. This research asks whether the electronic media creates additional barriers to error reporting, and, if so, what practical steps can all hospitals take to reduce these barriers. This is a mixed-method case study nurses' use of an error reporting system, RiskMan, in two hospitals. The case study involved one large private hospital and one large public hospital in Victoria, Australia, both of which use the RiskMan medical error reporting system. Information technology-based error reporting systems have unique access problems and time demands and can encourage nurses to develop alternative reporting mechanisms. This research focuses on nurses and raises important findings for hospitals using such systems or considering installation. This article suggests organizational and technical responses that could reduce some of the identified barriers. Crown Copyright © 2013. Published by Mosby, Inc. All rights reserved.

  13. Operator errors

    International Nuclear Information System (INIS)

    Knuefer; Lindauer

    1980-01-01

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

  14. The Error Reporting in the ATLAS TDAQ system

    CERN Document Server

    Kolos, S; The ATLAS collaboration; Papaevgeniou, L

    2014-01-01

    The ATLAS Error Reporting feature, which is used in the TDAQ environment, provides a service that allows experts and shift crew to track and address errors relating to the data taking components and applications. This service, called the Error Reporting Service(ERS), gives software applications the opportunity to collect and send comprehensive data about errors, happening at run-time, to a place where it can be intercepted in real-time by any other system component. Other ATLAS online control and monitoring tools use the Error Reporting service as one of their main inputs to address system problems in a timely manner and to improve the quality of acquired data. The actual destination of the error messages depends solely on the run-time environment, in which the online applications are operating. When applications send information to ERS, depending on the actual configuration the information may end up in a local file, in a database, in distributed middle-ware, which can transport it to an expert system or dis...

  15. The Error Reporting in the ATLAS TDAQ System

    CERN Document Server

    Kolos, S; The ATLAS collaboration; Papaevgeniou, L

    2015-01-01

    The ATLAS Error Reporting feature, which is used in the TDAQ environment, provides a service that allows experts and shift crew to track and address errors relating to the data taking components and applications. This service, called the Error Reporting Service(ERS), gives software applications the opportunity to collect and send comprehensive data about errors, happening at run-time, to a place where it can be intercepted in real-time by any other system component. Other ATLAS online control and monitoring tools use the Error Reporting service as one of their main inputs to address system problems in a timely manner and to improve the quality of acquired data. The actual destination of the error messages depends solely on the run-time environment, in which the online applications are operating. When applications send information to ERS, depending on the actual configuration the information may end up in a local file, in a database, in distributed middle-ware, which can transport it to an expert system or dis...

  16. 45 CFR 60.6 - Reporting errors, omissions, and revisions.

    Science.gov (United States)

    2010-10-01

    ... 45 Public Welfare 1 2010-10-01 2010-10-01 false Reporting errors, omissions, and revisions. 60.6 Section 60.6 Public Welfare DEPARTMENT OF HEALTH AND HUMAN SERVICES GENERAL ADMINISTRATION NATIONAL PRACTITIONER DATA BANK FOR ADVERSE INFORMATION ON PHYSICIANS AND OTHER HEALTH CARE PRACTITIONERS Reporting of...

  17. Interim status report of the TMI personnel-dosimetry project

    International Nuclear Information System (INIS)

    Rich, B.L.; Alvarez, J.L.; Adams, S.R.

    1981-06-01

    The current 2-chip TLD personnel dosimeter in use at Three Mile Island (TMI) has been shown inadequate for the anticipated high beta/gamma fields during TMI recovery operations in some areas. This project surveyed the available dosimeter systems, set up an Idaho National Engineering Laboratory (INEL) prototype system, and compared this system with those commercial systems that could be made immediately available for comparison. Of the systems tested, the new INEL personnel dosimeter was found to produce the most accurate results for use in recovery operations at TMI-2. The other multiple-chip or multiple-filter systems were found less desirable at present. The most prominent deficiencies in the INEL dosimeter stem from the fact that it lacks a completely automated reader and its x-ray and thermal neutron responses require additional development. A automated prototype reader system may be in operation by the end of CY-1981. Three alternatives for operational dosimetry are discussed. A combination of a modified version of the presently used Harshaw 2-chip dosimeter and the INEL dosimeter is recommended

  18. The Error Reporting in the ATLAS TDAQ System

    Science.gov (United States)

    Kolos, Serguei; Kazarov, Andrei; Papaevgeniou, Lykourgos

    2015-05-01

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

  19. A comparative study of voluntarily reported medication errors among ...

    African Journals Online (AJOL)

    errors among adult patients in intensive care (IC) and non-. IC settings in Riyadh, ... safety “To err is human: Building a safer health care system” .... regression analysis was used to identify factors affecting the .... that work in non-ICU areas are less likely to report such ... ve.org/read), which permit unrestricted use, distribution ...

  20. Human error probability estimation using licensee event reports

    International Nuclear Information System (INIS)

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

    1984-07-01

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

  1. Syntactic and semantic errors in radiology reports associated with speech recognition software.

    Science.gov (United States)

    Ringler, Michael D; Goss, Brian C; Bartholmai, Brian J

    2017-03-01

    Speech recognition software can increase the frequency of errors in radiology reports, which may affect patient care. We retrieved 213,977 speech recognition software-generated reports from 147 different radiologists and proofread them for errors. Errors were classified as "material" if they were believed to alter interpretation of the report. "Immaterial" errors were subclassified as intrusion/omission or spelling errors. The proportion of errors and error type were compared among individual radiologists, imaging subspecialty, and time periods. In all, 20,759 reports (9.7%) contained errors, of which 3992 (1.9%) were material errors. Among immaterial errors, spelling errors were more common than intrusion/omission errors ( p reports, reports reinterpreting results of outside examinations, and procedural studies (all p < .001). Error rate decreased over time ( p < .001), which suggests that a quality control program with regular feedback may reduce errors.

  2. The effect of reporting speed on plain film reporting errors

    International Nuclear Information System (INIS)

    Edwards, A.J.; Ricketts, C.; Dubbins, P.A.; Roobottom, C.A.; Wells, I.P.

    2003-01-01

    AIM: To determine whether reporting plain films at faster rates lead to a deterioration in accuracy. METHODS: Fourteen consultant radiologists were asked to report a total of 90 radiographs in three sets of 30. They reported the first set at the rate they would report normally and the subsequent two sets in two thirds and one half of the original time. The 90 radiographs were the same for each radiologist, however, the order was randomly generated for each. RESULTS: There was no significant difference in overall accuracy for each of the three film sets (p=0.74). Additionally no significant difference in the total number of false-negatives for each film set was detected (p=0.14). However, there was a significant decrease in the number of false-positive reports when the radiologists were asked to report at higher speeds (p=0.003). CONCLUSIONS: When reporting accident and emergency radiographs increasing reporting speed has no overall effect upon accuracy, however, it does lead to less false-positive reports

  3. "Why Don't They Report?" Hospital Personnel Working with Children at Risk

    Science.gov (United States)

    Svärd, Veronica

    2017-01-01

    Hospital personnel have been shown to report child maltreatment to social services less frequently than other professionals. This quantitative study shows that one-half of the respondents within the four largest Swedish children's hospitals had never made a report. However, nurses' and nurse assistants' odds of being low reporters were…

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

    OpenAIRE

    Nazir, Iqbal

    2017-01-01

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

  5. Child Maltreatment Reporting by Educational Personnel: Implications for Racial Disproportionality in the Child Welfare System

    Science.gov (United States)

    Krase, Kathryn Suzanne

    2015-01-01

    African American children are disproportionally overrepresented in the U.S. child protection system. Because educational personnel are a significant source of reports of suspected child maltreatment across the country and in all states, the present study examines the impact of these reports on racial disproportionality and disparity at the…

  6. Bounding quantum gate error rate based on reported average fidelity

    International Nuclear Information System (INIS)

    Sanders, Yuval R; Wallman, Joel J; Sanders, Barry C

    2016-01-01

    Remarkable experimental advances in quantum computing are exemplified by recent announcements of impressive average gate fidelities exceeding 99.9% for single-qubit gates and 99% for two-qubit gates. Although these high numbers engender optimism that fault-tolerant quantum computing is within reach, the connection of average gate fidelity with fault-tolerance requirements is not direct. Here we use reported average gate fidelity to determine an upper bound on the quantum-gate error rate, which is the appropriate metric for assessing progress towards fault-tolerant quantum computation, and we demonstrate that this bound is asymptotically tight for general noise. Although this bound is unlikely to be saturated by experimental noise, we demonstrate using explicit examples that the bound indicates a realistic deviation between the true error rate and the reported average fidelity. We introduce the Pauli distance as a measure of this deviation, and we show that knowledge of the Pauli distance enables tighter estimates of the error rate of quantum gates. (fast track communication)

  7. Improving patient safety in radiotherapy through error reporting and analysis

    International Nuclear Information System (INIS)

    Findlay, Ú.; Best, H.; Ottrey, M.

    2016-01-01

    Aim: To improve patient safety in radiotherapy (RT) through the analysis and publication of radiotherapy errors and near misses (RTE). Materials and methods: RTE are submitted on a voluntary basis by NHS RT departments throughout the UK to the National Reporting and Learning System (NRLS) or directly to Public Health England (PHE). RTE are analysed by PHE staff using frequency trend analysis based on the classification and pathway coding from Towards Safer Radiotherapy (TSRT). PHE in conjunction with the Patient Safety in Radiotherapy Steering Group publish learning from these events, on a triannual and summarised on a biennial basis, so their occurrence might be mitigated. Results: Since the introduction of this initiative in 2010, over 30,000 (RTE) reports have been submitted. The number of RTE reported in each biennial cycle has grown, ranging from 680 (2010) to 12,691 (2016) RTE. The vast majority of the RTE reported are lower level events, thus not affecting the outcome of patient care. Of the level 1 and 2 incidents reported, it is known the majority of them affected only one fraction of a course of treatment. This means that corrective action could be taken over the remaining treatment fractions so the incident did not have a significant impact on the patient or the outcome of their treatment. Analysis of the RTE reports demonstrates that generation of error is not confined to one professional group or to any particular point in the pathway. It also indicates that the pattern of errors is replicated across service providers in the UK. Conclusion: Use of the terminology, classification and coding of TSRT, together with implementation of the national voluntary reporting system described within this report, allows clinical departments to compare their local analysis to the national picture. Further opportunities to improve learning from this dataset must be exploited through development of the analysis and development of proactive risk management strategies

  8. 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.

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

    African Journals Online (AJOL)

    EB

    2013-09-03

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

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

    National Research Council Canada - National Science Library

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

    2005-01-01

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

  11. Quantification of the reliability of personnel actions from the evaluation of actual German operational experience. Final report

    International Nuclear Information System (INIS)

    Preischl, W.; Fassmann, W.

    2013-07-01

    characterizing human reliability from data source ''reportable events'', - Methods to select samples characterizing human reliability from data source ''safety relevant, undoubtedly error free performed personnel actions'', - Mathematical proven methodology to derive probabilistic human performance data based on samples taken from OE, - 85 new probabilistic human performance data based on operational experience in German nuclear power plants, - Approach based on accepted behavioural knowledge to structure the obtained results and to link them to the new ''second generation'' human reliability assessment methodologies. The obtained data are forming the first data base on human reliability completely derived from operational experience of German nuclear power plants. Many subject matter experts from the plants supported the research project and contributed considerably to the research results.

  12. TITLE III EVALUATION REPORT FOR THE MATERIAL AND PERSONNEL HANDLING SYSTEM

    International Nuclear Information System (INIS)

    T. A. Misiak

    1998-01-01

    This Title III Evaluation Report (TER) provides the results of an evaluation that was conducted on the Material and Personnel Handling System. This TER has been written in accordance with the ''Technical Document Preparation Plan for the Mined Geologic Disposal System Title III Evaluation Reports'' (BA0000000-01717-4600-00005 REV 03). The objective of this evaluation is to provide recommendations to ensure consistency between the technical baseline requirements, baseline design, and the as-constructed Material and Personnel Handling System. Recommendations for resolving discrepancies between the as-constructed system, the technical baseline requirements, and the baseline design are included in this report. Cost and Schedule estimates are provided for all recommended modifications

  13. Educational Imperatives for Oral Health Personnel: Change or Decay? Report of a WHO Expert Committee. Technical Report Series 794.

    Science.gov (United States)

    World Health Organization, Geneva (Switzerland).

    This report highlights trends in disease patterns and technological advances that call for sweeping changes in the education of oral health personnel. It first provides a brief history of the development of dental education. The second and most extensive section analyzes global trends for dental caries, periodontal conditions, tooth loss and…

  14. FRamework Assessing Notorious Contributing Influences for Error (FRANCIE): Perspective on Taxonomy Development to Support Error Reporting and Analysis

    Energy Technology Data Exchange (ETDEWEB)

    Lon N. Haney; David I. Gertman

    2003-04-01

    Beginning in the 1980s a primary focus of human reliability analysis was estimation of human error probabilities. However, detailed qualitative modeling with comprehensive representation of contextual variables often was lacking. This was likely due to the lack of comprehensive error and performance shaping factor taxonomies, and the limited data available on observed error rates and their relationship to specific contextual variables. In the mid 90s Boeing, America West Airlines, NASA Ames Research Center and INEEL partnered in a NASA sponsored Advanced Concepts grant to: assess the state of the art in human error analysis, identify future needs for human error analysis, and develop an approach addressing these needs. Identified needs included the need for a method to identify and prioritize task and contextual characteristics affecting human reliability. Other needs identified included developing comprehensive taxonomies to support detailed qualitative modeling and to structure meaningful data collection efforts across domains. A result was the development of the FRamework Assessing Notorious Contributing Influences for Error (FRANCIE) with a taxonomy for airline maintenance tasks. The assignment of performance shaping factors to generic errors by experts proved to be valuable to qualitative modeling. Performance shaping factors and error types from such detailed approaches can be used to structure error reporting schemes. In a recent NASA Advanced Human Support Technology grant FRANCIE was refined, and two new taxonomies for use on space missions were developed. The development, sharing, and use of error taxonomies, and the refinement of approaches for increased fidelity of qualitative modeling is offered as a means to help direct useful data collection strategies.

  15. Prepopulated radiology report templates: a prospective analysis of error rate and turnaround time.

    Science.gov (United States)

    Hawkins, C M; Hall, S; Hardin, J; Salisbury, S; Towbin, A J

    2012-08-01

    Current speech recognition software allows exam-specific standard reports to be prepopulated into the dictation field based on the radiology information system procedure code. While it is thought that prepopulating reports can decrease the time required to dictate a study and the overall number of errors in the final report, this hypothesis has not been studied in a clinical setting. A prospective study was performed. During the first week, radiologists dictated all studies using prepopulated standard reports. During the second week, all studies were dictated after prepopulated reports had been disabled. Final radiology reports were evaluated for 11 different types of errors. Each error within a report was classified individually. The median time required to dictate an exam was compared between the 2 weeks. There were 12,387 reports dictated during the study, of which, 1,173 randomly distributed reports were analyzed for errors. There was no difference in the number of errors per report between the 2 weeks; however, radiologists overwhelmingly preferred using a standard report both weeks. Grammatical errors were by far the most common error type, followed by missense errors and errors of omission. There was no significant difference in the median dictation time when comparing studies performed each week. The use of prepopulated reports does not alone affect the error rate or dictation time of radiology reports. While it is a useful feature for radiologists, it must be coupled with other strategies in order to decrease errors.

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

    OpenAIRE

    Ovidiu Constantin Bunget; Alin Constantin Dumitrescu

    2009-01-01

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

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

    Science.gov (United States)

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

    2017-05-01

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

  18. Defining Reported Errors on Web-based Reporting System Using ICPS From Nine Units in a Korean University Hospital

    Directory of Open Access Journals (Sweden)

    Chul-Hoon Kim, DDS, PhD

    2009-12-01

    Conclusion: The web-based error reporting system using ICPS proved to be an easy, feasible system for hospitals in Korea. This system will be helpful for inducing general agreement upon errors within clinical nursing practice and bring more attention to any errors made or near misses. Also, it will be able to ameliorate the punitive culture for errors and transform error reporting into a habit for healthcare providers.

  19. [The effectiveness of error reporting promoting strategy on nurse's attitude, patient safety culture, intention to report and reporting rate].

    Science.gov (United States)

    Kim, Myoungsoo

    2010-04-01

    The purpose of this study was to examine the impact of strategies to promote reporting of errors on nurses' attitude to reporting errors, organizational culture related to patient safety, intention to report and reporting rate in hospital nurses. A nonequivalent control group non-synchronized design was used for this study. The program was developed and then administered to the experimental group for 12 weeks. Data were analyzed using descriptive analysis, X(2)-test, t-test, and ANCOVA with the SPSS 12.0 program. After the intervention, the experimental group showed significantly higher scores for nurses' attitude to reporting errors (experimental: 20.73 vs control: 20.52, F=5.483, p=.021) and reporting rate (experimental: 3.40 vs control: 1.33, F=1998.083, porganizational culture and intention to report. The study findings indicate that strategies that promote reporting of errors play an important role in producing positive attitudes to reporting errors and improving behavior of reporting. Further advanced strategies for reporting errors that can lead to improved patient safety should be developed and applied in a broad range of hospitals.

  20. 45 CFR 98.100 - Error Rate Report.

    Science.gov (United States)

    2010-10-01

    ... Welfare DEPARTMENT OF HEALTH AND HUMAN SERVICES GENERAL ADMINISTRATION CHILD CARE AND DEVELOPMENT FUND... the total dollar amount of payments made in the sample); the average amount of improper payment; and... not received. (e) Costs of Preparing the Error Rate Report—Provided the error rate calculations and...

  1. 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.

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

    Science.gov (United States)

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

    2010-09-01

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

  3. Strontium-90 Error Discovered in Subcontract Laboratory Spreadsheet. Topical Report

    International Nuclear Information System (INIS)

    Brown, D.D.; Nagel, A.S.

    1999-07-01

    West Valley Demonstration Project health physicists and environment scientists discovered a series of errors in a subcontractor's spreadsheet being used to reduce data as part of their strontium-90 analytical process

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

    Science.gov (United States)

    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.

  5. Factors associated with reporting nursing errors in Iran: a qualitative study

    Directory of Open Access Journals (Sweden)

    Hashemi Fatemeh

    2012-10-01

    Full Text Available Abstract Background Reporting the professional errors for improving patient safety is considered essential not only in hospitals, but also in ambulatory care centers. Unfortunately, a great number of nurses, similar to most clinicians, do not report their errors. Therefore, the present study aimed to clarify the factors associated with reporting the nursing errors through the experiences of clinical nurses and nursing managers. Methods A total of 115 nurses working in the hospitals and specialized clinics affiliated to Tehran and Shiraz Universities of Medical Sciences, Iran participated in this qualitative study. The study data were collected through a semi-structured group discussion conducted in 17 sessions and analyzed by inductive content analysis approach. Results The main categories emerged in this study were: a general approaches of the nurses towards errors, b barriers in reporting the nursing errors, and c motivators in error reporting. Conclusion Error reporting provides extremely valuable information for preventing future errors and improving the patient safety. Overall, regarding motivators and barriers in reporting the nursing errors, it is necessary to enact regulations in which the ways of reporting the error and its constituent elements, such as the notion of the error, are clearly identified.

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

    Science.gov (United States)

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

    2011-07-01

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

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

    LENUS (Irish Health Repository)

    Cassidy, Nicola

    2012-02-01

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

  8. The Impact of a Patient Safety Program on Medical Error Reporting

    Science.gov (United States)

    2005-05-01

    307 The Impact of a Patient Safety Program on Medical Error Reporting Donald R. Woolever Abstract Background: In response to the occurrence of...a sentinel event—a medical error with serious consequences—Eglin U.S. Air Force (USAF) Regional Hospital developed and implemented a patient safety...communication, teamwork, and reporting. Objective: To determine the impact of a patient safety program on patterns of medical error reporting. Methods: This

  9. Review of U.S. Army Unmanned Aerial Systems Accident Reports: Analysis of Human Error Contributions

    Science.gov (United States)

    2018-03-20

    within report documents. The information presented was obtained through a request to use the U.S. Army Combat Readiness Center’s Risk Management ...controlled flight into terrain (13 accidents), fueling errors by improper techniques (7 accidents), and a variety of maintenance errors (10 accidents). The...and 9 of the 10 maintenance accidents. Table 4. Frequencies Based on Source of Human Error Human error source Presence Poor Planning

  10. Neurological Manifestations Among US Government Personnel Reporting Directional Audible and Sensory Phenomena in Havana, Cuba.

    Science.gov (United States)

    Swanson, Randel L; Hampton, Stephen; Green-McKenzie, Judith; Diaz-Arrastia, Ramon; Grady, M Sean; Verma, Ragini; Biester, Rosette; Duda, Diana; Wolf, Ronald L; Smith, Douglas H

    2018-03-20

    From late 2016 through August 2017, US government personnel serving on diplomatic assignment in Havana, Cuba, reported neurological symptoms associated with exposure to auditory and sensory phenomena. To describe the neurological manifestations that followed exposure to an unknown energy source associated with auditory and sensory phenomena. Preliminary results from a retrospective case series of US government personnel in Havana, Cuba. Following reported exposure to auditory and sensory phenomena in their homes or hotel rooms, the individuals reported a similar constellation of neurological symptoms resembling brain injury. These individuals were referred to an academic brain injury center for multidisciplinary evaluation and treatment. Report of experiencing audible and sensory phenomena emanating from a distinct direction (directional phenomena) associated with an undetermined source, while serving on US government assignments in Havana, Cuba, since 2016. Descriptions of the exposures and symptoms were obtained from medical record review of multidisciplinary clinical interviews and examinations. Additional objective assessments included clinical tests of vestibular (dynamic and static balance, vestibulo-ocular reflex testing, caloric testing), oculomotor (measurement of convergence, saccadic, and smooth pursuit eye movements), cognitive (comprehensive neuropsychological battery), and audiometric (pure tone and speech audiometry) functioning. Neuroimaging was also obtained. Of 24 individuals with suspected exposure identified by the US Department of State, 21 completed multidisciplinary evaluation an average of 203 days after exposure. Persistent symptoms (>3 months after exposure) were reported by these individuals including cognitive (n = 17, 81%), balance (n = 15, 71%), visual (n = 18, 86%), and auditory (n = 15, 68%) dysfunction, sleep impairment (n = 18, 86%), and headaches (n = 16, 76%). Objective findings included cognitive (n

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

    Science.gov (United States)

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

    2017-08-01

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

  12. Identifying medication error chains from critical incident reports: a new analytic approach.

    Science.gov (United States)

    Huckels-Baumgart, Saskia; Manser, Tanja

    2014-10-01

    Research into the distribution of medication errors usually focuses on isolated stages within the medication use process. Our study aimed to provide a novel process-oriented approach to medication incident analysis focusing on medication error chains. Our study was conducted across a 900-bed teaching hospital in Switzerland. All reported 1,591 medication errors 2009-2012 were categorized using the Medication Error Index NCC MERP and the WHO Classification for Patient Safety Methodology. In order to identify medication error chains, each reported medication incident was allocated to the relevant stage of the hospital medication use process. Only 25.8% of the reported medication errors were detected before they propagated through the medication use process. The majority of medication errors (74.2%) formed an error chain encompassing two or more stages. The most frequent error chain comprised preparation up to and including medication administration (45.2%). "Non-consideration of documentation/prescribing" during the drug preparation was the most frequent contributor for "wrong dose" during the administration of medication. Medication error chains provide important insights for detecting and stopping medication errors before they reach the patient. Existing and new safety barriers need to be extended to interrupt error chains and to improve patient safety. © 2014, The American College of Clinical Pharmacology.

  13. A description of medication errors reported by pharmacists in a neonatal intensive care unit.

    Science.gov (United States)

    Pawluk, Shane; Jaam, Myriam; Hazi, Fatima; Al Hail, Moza Sulaiman; El Kassem, Wessam; Khalifa, Hanan; Thomas, Binny; Abdul Rouf, Pallivalappila

    2017-02-01

    Background Patients in the Neonatal Intensive Care Unit (NICU) are at an increased risk for medication errors. Objective The objective of this study is to describe the nature and setting of medication errors occurring in patients admitted to an NICU in Qatar based on a standard electronic system reported by pharmacists. Setting Neonatal intensive care unit, Doha, Qatar. Method This was a retrospective cross-sectional study on medication errors reported electronically by pharmacists in the NICU between January 1, 2014 and April 30, 2015. Main outcome measure Data collected included patient information, and incident details including error category, medications involved, and follow-up completed. Results A total of 201 NICU pharmacists-reported medication errors were submitted during the study period. All reported errors did not reach the patient and did not cause harm. Of the errors reported, 98.5% occurred in the prescribing phase of the medication process with 58.7% being due to calculation errors. Overall, 53 different medications were documented in error reports with the anti-infective agents being the most frequently cited. The majority of incidents indicated that the primary prescriber was contacted and the error was resolved before reaching the next phase of the medication process. Conclusion Medication errors reported by pharmacists occur most frequently in the prescribing phase of the medication process. Our data suggest that error reporting systems need to be specific to the population involved. Special attention should be paid to frequently used medications in the NICU as these were responsible for the greatest numbers of medication errors.

  14. Error message recording and reporting in the SLC control system

    International Nuclear Information System (INIS)

    Spencer, N.; Bogart, J.; Phinney, N.; Thompson, K.

    1985-01-01

    Error or information messages that are signaled by control software either in the VAX host computer or the local microprocessor clusters are handled by a dedicated VAX process (PARANOIA). Messages are recorded on disk for further analysis and displayed at the appropriate console. Another VAX process (ERRLOG) can be used to sort, list and histogram various categories of messages. The functions performed by these processes and the algorithms used are discussed

  15. Error message recording and reporting in the SLC control system

    International Nuclear Information System (INIS)

    Spencer, N.; Bogart, J.; Phinney, N.; Thompson, K.

    1985-04-01

    Error or information messages that are signaled by control software either in the VAX host computer or the local microprocessor clusters are handled by a dedicated VAX process (PARANOIA). Messages are recorded on disk for further analysis and displayed at the appropriate console. Another VAX process (ERRLOG) can be used to sort, list and histogram various categories of messages. The functions performed by these processes and the algorithms used are discussed

  16. Safety climate and attitude toward medication error reporting after hospital accreditation in South Korea.

    Science.gov (United States)

    Lee, Eunjoo

    2016-09-01

    This study compared registered nurses' perceptions of safety climate and attitude toward medication error reporting before and after completing a hospital accreditation program. Medication errors are the most prevalent adverse events threatening patient safety; reducing underreporting of medication errors significantly improves patient safety. Safety climate in hospitals may affect medication error reporting. This study employed a longitudinal, descriptive design. Data were collected using questionnaires. A tertiary acute hospital in South Korea undergoing a hospital accreditation program. Nurses, pre- and post-accreditation (217 and 373); response rate: 58% and 87%, respectively. Hospital accreditation program. Perceived safety climate and attitude toward medication error reporting. The level of safety climate and attitude toward medication error reporting increased significantly following accreditation; however, measures of institutional leadership and management did not improve significantly. Participants' perception of safety climate was positively correlated with their attitude toward medication error reporting; this correlation strengthened following completion of the program. Improving hospitals' safety climate increased nurses' medication error reporting; interventions that help hospital administration and managers to provide more supportive leadership may facilitate safety climate improvement. Hospitals and their units should develop more friendly and intimate working environments that remove nurses' fear of penalties. Administration and managers should support nurses who report their own errors. © The Author 2016. Published by Oxford University Press in association with the International Society for Quality in Health Care. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.

  17. Proportion of medication error reporting and associated factors among nurses: a cross sectional study.

    Science.gov (United States)

    Jember, Abebaw; Hailu, Mignote; Messele, Anteneh; Demeke, Tesfaye; Hassen, Mohammed

    2018-01-01

    A medication error (ME) is any preventable event that may cause or lead to inappropriate medication use or patient harm. Voluntary reporting has a principal role in appreciating the extent and impact of medication errors. Thus, exploration of the proportion of medication error reporting and associated factors among nurses is important to inform service providers and program implementers so as to improve the quality of the healthcare services. Institution based quantitative cross-sectional study was conducted among 397 nurses from March 6 to May 10, 2015. Stratified sampling followed by simple random sampling technique was used to select the study participants. The data were collected using structured self-administered questionnaire which was adopted from studies conducted in Australia and Jordan. A pilot study was carried out to validate the questionnaire before data collection for this study. Bivariate and multivariate logistic regression models were fitted to identify factors associated with the proportion of medication error reporting among nurses. An adjusted odds ratio with 95% confidence interval was computed to determine the level of significance. The proportion of medication error reporting among nurses was found to be 57.4%. Regression analysis showed that sex, marital status, having made a medication error and medication error experience were significantly associated with medication error reporting. The proportion of medication error reporting among nurses in this study was found to be higher than other studies.

  18. Estimation of total error in DWPF reported radionuclide inventories. Revision 1

    International Nuclear Information System (INIS)

    Edwards, T.B.

    1995-01-01

    The Defense Waste Processing Facility (DWPF) at the Savannah River Site is required to determine and report the radionuclide inventory of its glass product. For each macro-batch, the DWPF will report both the total amount (in curies) of each reportable radionuclide and the average concentration (in curies/gram of glass) of each reportable radionuclide. The DWPF is to provide the estimated error of these reported values of its radionuclide inventory as well. The objective of this document is to provide a framework for determining the estimated error in DWPF's reporting of these radionuclide inventories. This report investigates the impact of random errors due to measurement and sampling on the total amount of each reportable radionuclide in a given macro-batch. In addition, the impact of these measurement and sampling errors and process variation are evaluated to determine the uncertainty in the reported average concentrations of radionuclides in DWPF's filled canister inventory resulting from each macro-batch

  19. Voice recognition versus transcriptionist: error rates and productivity in MRI reporting.

    Science.gov (United States)

    Strahan, Rodney H; Schneider-Kolsky, Michal E

    2010-10-01

    Despite the frequent introduction of voice recognition (VR) into radiology departments, little evidence still exists about its impact on workflow, error rates and costs. We designed a study to compare typographical errors, turnaround times (TAT) from reported to verified and productivity for VR-generated reports versus transcriptionist-generated reports in MRI. Fifty MRI reports generated by VR and 50 finalized MRI reports generated by the transcriptionist, of two radiologists, were sampled retrospectively. Two hundred reports were scrutinised for typographical errors and the average TAT from dictated to final approval. To assess productivity, the average MRI reports per hour for one of the radiologists was calculated using data from extra weekend reporting sessions. Forty-two % and 30% of the finalized VR reports for each of the radiologists investigated contained errors. Only 6% and 8% of the transcriptionist-generated reports contained errors. The average TAT for VR was 0 h, and for the transcriptionist reports TAT was 89 and 38.9 h. Productivity was calculated at 8.6 MRI reports per hour using VR and 13.3 MRI reports using the transcriptionist, representing a 55% increase in productivity. Our results demonstrate that VR is not an effective method of generating reports for MRI. Ideally, we would have the report error rate and productivity of a transcriptionist and the TAT of VR. © 2010 The Authors. Journal of Medical Imaging and Radiation Oncology © 2010 The Royal Australian and New Zealand College of Radiologists.

  20. Voice recognition versus transcriptionist: error rated and productivity in MRI reporting

    International Nuclear Information System (INIS)

    Strahan, Rodney H.; Schneider-Kolsky, Michal E.

    2010-01-01

    Full text: Purpose: Despite the frequent introduction of voice recognition (VR) into radiology departments, little evidence still exists about its impact on workflow, error rates and costs. We designed a study to compare typographical errors, turnaround times (TAT) from reported to verified and productivity for VR-generated reports versus transcriptionist-generated reports in MRI. Methods: Fifty MRI reports generated by VR and 50 finalised MRI reports generated by the transcriptionist, of two radiologists, were sampled retrospectively. Two hundred reports were scrutinised for typographical errors and the average TAT from dictated to final approval. To assess productivity, the average MRI reports per hour for one of the radiologists was calculated using data from extra weekend reporting sessions. Results: Forty-two % and 30% of the finalised VR reports for each of the radiologists investigated contained errors. Only 6% and 8% of the transcriptionist-generated reports contained errors. The average TAT for VR was 0 h, and for the transcriptionist reports TAT was 89 and 38.9 h. Productivity was calculated at 8.6 MRI reports per hour using VR and 13.3 MRI reports using the transcriptionist, representing a 55% increase in productivity. Conclusion: Our results demonstrate that VR is not an effective method of generating reports for MRI. Ideally, we would have the report error rate and productivity of a transcriptionist and the TAT of VR.

  1. Responsibility for reporting patient death due to hospital error in Japan when an error occurred at a referring institution.

    Science.gov (United States)

    Maeda, Shoichi; Starkey, Jay; Kamishiraki, Etsuko; Ikeda, Noriaki

    2013-12-01

    In Japan, physicians are required to report unexpected health care-associated patient deaths to the police. Patients needing to be transferred to another institution often have complex medical problems. If a medical error occurs, it may be either at the final or the referring institution. Some fear that liability will fall on the final institution regardless of where the error occurred or that the referring facility may oppose such reporting, leading to a failure to report to police or to recommend an autopsy. Little is known about the actual opinions of physicians and risk managers in this regard. The authors sent standardised, self-administered questionnaires to all hospitals in Japan that participate in the national general residency program. Most physicians and risk managers in Japan indicated that they would report a patient's death to the police where the patient has been transferred. Of those who indicated they would not report to the police, the majority still indicated they would recommend an autopsy

  2. Medication errors of nurses and factors in refusal to report medication errors among nurses in a teaching medical center of iran in 2012.

    Science.gov (United States)

    Mostafaei, Davoud; Barati Marnani, Ahmad; Mosavi Esfahani, Haleh; Estebsari, Fatemeh; Shahzaidi, Shiva; Jamshidi, Ensiyeh; Aghamiri, Seyed Samad

    2014-10-01

    About one third of unwanted reported medication consequences are due to medication errors, resulting in one-fifth of hospital injuries. The aim of this study was determined formal and informal medication errors of nurses and the level of importance of factors in refusal to report medication errors among nurses. The cross-sectional study was done on the nursing staff of Shohada Tajrish Hospital, Tehran, Iran in 2012. The data was gathered through a questionnaire, made by the researchers. The questionnaires' face and content validity was confirmed by experts and for measuring its reliability test-retest was used. The data was analyzed by descriptive statistics. We used SPSS for related statistical analyses. The most important factors in refusal to report medication errors respectively were: lack of medication error recording and reporting system in the hospital (3.3%), non-significant error reporting to hospital authorities and lack of appropriate feedback (3.1%), and lack of a clear definition for a medication error (3%). There were both formal and informal reporting of medication errors in this study. Factors pertaining to management in hospitals as well as the fear of the consequences of reporting are two broad fields among the factors that make nurses not report their medication errors. In this regard, providing enough education to nurses, boosting the job security for nurses, management support and revising related processes and definitions are some factors that can help decreasing medication errors and increasing their report in case of occurrence.

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

    Directory of Open Access Journals (Sweden)

    Gabriella Rejane dos Santos Dalmolin

    2013-12-01

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

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

    National Research Council Canada - National Science Library

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

    2005-01-01

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

  5. Effects of Shame and Guilt on Error Reporting Among Obstetric Clinicians.

    Science.gov (United States)

    Zabari, Mara Lynne; Southern, Nancy L

    2018-04-17

    To understand how the experiences of shame and guilt, coupled with organizational factors, affect error reporting by obstetric clinicians. Descriptive cross-sectional. A sample of 84 obstetric clinicians from three maternity units in Washington State. In this quantitative inquiry, a variant of the Test of Self-Conscious Affect was used to measure proneness to guilt and shame. In addition, we developed questions to assess attitudes regarding concerns about damaging one's reputation if an error was reported and the choice to keep an error to oneself. Both assessments were analyzed separately and then correlated to identify relationships between constructs. Interviews were used to identify organizational factors that affect error reporting. As a group, mean scores indicated that obstetric clinicians would not choose to keep errors to themselves. However, bivariate correlations showed that proneness to shame was positively correlated to concerns about one's reputation if an error was reported, and proneness to guilt was negatively correlated with keeping errors to oneself. Interview data analysis showed that Past Experience with Responses to Errors, Management and Leadership Styles, Professional Hierarchy, and Relationships With Colleagues were influential factors in error reporting. Although obstetric clinicians want to report errors, their decisions to report are influenced by their proneness to guilt and shame and perceptions of the degree to which organizational factors facilitate or create barriers to restore their self-images. Findings underscore the influence of the organizational context on clinicians' decisions to report errors. Copyright © 2018 AWHONN, the Association of Women’s Health, Obstetric and Neonatal Nurses. Published by Elsevier Inc. All rights reserved.

  6. Evidence Report: Risk of Performance Errors Due to Training Deficiencies

    Science.gov (United States)

    Barshi, Immanuel; Dempsey, Donna L.

    2016-01-01

    Substantial evidence supports the claim that inadequate training leads to performance errors. Barshi and Loukopoulos (2012) demonstrate that even a task as carefully developed and refined over many years as operating an aircraft can be significantly improved by a systematic analysis, followed by improved procedures and improved training (see also Loukopoulos, Dismukes, & Barshi, 2009a). Unfortunately, such a systematic analysis of training needs rarely occurs during the preliminary design phase, when modifications are most feasible. Training is often seen as a way to compensate for deficiencies in task and system design, which in turn increases the training load. As a result, task performance often suffers, and with it, the operators suffer and so does the mission. On the other hand, effective training can indeed compensate for such design deficiencies, and can even go beyond to compensate for failures of our imagination to anticipate all that might be needed when we send our crew members to go where no one else has gone before. Much of the research literature on training is motivated by current training practices aimed at current training needs. Although there is some experience with operations in extreme environments on Earth, there is no experience with long-duration space missions where crews must practice semi-autonomous operations, where ground support must accommodate significant communication delays, and where so little is known about the environment. Thus, we must develop robust methodologies and tools to prepare our crews for the unknown. The research necessary to support such an endeavor does not currently exist, but existing research does reveal general challenges that are relevant to long-duration, high-autonomy missions. The evidence presented here describes issues related to the risk of performance errors due to training deficiencies. Contributing factors regarding training deficiencies may pertain to organizational process and training programs for

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

    Science.gov (United States)

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

    2018-06-01

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

  8. Medical error identification, disclosure, and reporting: do emergency medicine provider groups differ?

    Science.gov (United States)

    Hobgood, Cherri; Weiner, Bryan; Tamayo-Sarver, Joshua H

    2006-04-01

    To determine if the three types of emergency medicine providers--physicians, nurses, and out-of-hospital providers (emergency medical technicians [EMTs])--differ in their identification, disclosure, and reporting of medical error. A convenience sample of providers in an academic emergency department evaluated ten case vignettes that represented two error types (medication and cognitive) and three severity levels. For each vignette, providers were asked the following: 1) Is this an error? 2) Would you tell the patient? 3) Would you report this to a hospital committee? To assess differences in identification, disclosure, and reporting by provider type, error type, and error severity, the authors constructed three-way tables with the nonparametric Somers' D clustered on participant. To assess the contribution of disclosure instruction and environmental variables, fixed-effects regression stratified by provider type was used. Of the 116 providers who were eligible, 103 (40 physicians, 26 nurses, and 35 EMTs) had complete data. Physicians were more likely to classify an event as an error (78%) than nurses (71%; p = 0.04) or EMTs (68%; p error to the patient (59%) than physicians (71%; p = 0.04). Physicians were the least likely to report the error (54%) compared with nurses (68%; p = 0.02) or EMTs (78%; p error types, identification, disclosure, and reporting increased with increasing severity. Improving patient safety hinges on the ability of health care providers to accurately identify, disclose, and report medical errors. Interventions must account for differences in error identification, disclosure, and reporting by provider type.

  9. Cardiopulmonary resuscitation; use, training and self-confidence in skills. A self-report study among hospital personnel

    Directory of Open Access Journals (Sweden)

    Hopstock Laila A

    2008-12-01

    Full Text Available Abstract Background Immediate start of basic cardiopulmonary resuscitation (CPR and early defibrillation have been highlighted as crucial for survival from cardiac arrest, but despite new knowledge, new technology and massive personnel training the survival rates from in-hospital cardiac arrest are still low. National guidelines recommend regular intervals of CPR training to make all hospital personnel able to perform basic CPR till advanced care is available. This study investigates CPR training, resuscitation experience and self-confidence in skills among hospital personnel outside critical care areas. Methods A cross-sectional study was performed at three Norwegian hospitals. Data on CPR training and CPR use were collected by self-reports from 361 hospital personnel. Results A total of 89% reported training in CPR, but only 11% had updated their skills in accordance with the time interval recommended by national guidelines. Real resuscitation experience was reported by one third of the respondents. Both training intervals and use of skills in resuscitation situations differed among the professions. Self-reported confidence decreased only after more than two years since last CPR training. Conclusion There is a gap between recommendations and reality in CPR training among hospital personnel working outside critical care areas.

  10. A human error taxonomy for analysing healthcare incident reports: assessing reporting culture and its effects on safety perfomance

    DEFF Research Database (Denmark)

    Itoh, Kenji; Omata, N.; Andersen, Henning Boje

    2009-01-01

    The present paper reports on a human error taxonomy system developed for healthcare risk management and on its application to evaluating safety performance and reporting culture. The taxonomy comprises dimensions for classifying errors, for performance-shaping factors, and for the maturity...

  11. Error or "act of God"? A study of patients' and operating room team members' perceptions of error definition, reporting, and disclosure.

    Science.gov (United States)

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

    2006-01-01

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

  12. Perceptions and Attitudes towards Medication Error Reporting in Primary Care Clinics: A Qualitative Study in Malaysia.

    Science.gov (United States)

    Samsiah, A; Othman, Noordin; Jamshed, Shazia; Hassali, Mohamed Azmi

    2016-01-01

    To explore and understand participants' perceptions and attitudes towards the reporting of medication errors (MEs). A qualitative study using in-depth interviews of 31 healthcare practitioners from nine publicly funded, primary care clinics in three states in peninsular Malaysia was conducted for this study. The participants included family medicine specialists, doctors, pharmacists, pharmacist assistants, nurses and assistant medical officers. The interviews were audiotaped and transcribed verbatim. Analysis of the data was guided by the framework approach. Six themes and 28 codes were identified. Despite the availability of a reporting system, most of the participants agreed that MEs were underreported. The nature of the error plays an important role in determining the reporting. The reporting system, organisational factors, provider factors, reporter's burden and benefit of reporting also were identified. Healthcare practitioners in primary care clinics understood the importance of reporting MEs to improve patient safety. Their perceptions and attitudes towards reporting of MEs were influenced by many factors which affect the decision-making process of whether or not to report. Although the process is complex, it primarily is determined by the severity of the outcome of the errors. The participants voluntarily report the errors if they are familiar with the reporting system, what error to report, when to report and what form to use.

  13. 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...

  14. The relationships among work stress, strain and self-reported errors in UK community pharmacy.

    Science.gov (United States)

    Johnson, S J; O'Connor, E M; Jacobs, S; Hassell, K; Ashcroft, D M

    2014-01-01

    Changes in the UK community pharmacy profession including new contractual frameworks, expansion of services, and increasing levels of workload have prompted concerns about rising levels of workplace stress and overload. This has implications for pharmacist health and well-being and the occurrence of errors that pose a risk to patient safety. Despite these concerns being voiced in the profession, few studies have explored work stress in the community pharmacy context. To investigate work-related stress among UK community pharmacists and to explore its relationships with pharmacists' psychological and physical well-being, and the occurrence of self-reported dispensing errors and detection of prescribing errors. A cross-sectional postal survey of a random sample of practicing community pharmacists (n = 903) used ASSET (A Shortened Stress Evaluation Tool) and questions relating to self-reported involvement in errors. Stress data were compared to general working population norms, and regressed on well-being and self-reported errors. Analysis of the data revealed that pharmacists reported significantly higher levels of workplace stressors than the general working population, with concerns about work-life balance, the nature of the job, and work relationships being the most influential on health and well-being. Despite this, pharmacists were not found to report worse health than the general working population. Self-reported error involvement was linked to both high dispensing volume and being troubled by perceived overload (dispensing errors), and resources and communication (detection of prescribing errors). This study contributes to the literature by benchmarking community pharmacists' health and well-being, and investigating sources of stress using a quantitative approach. A further important contribution to the literature is the identification of a quantitative link between high workload and self-reported dispensing errors. Copyright © 2014 Elsevier Inc. All rights

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

    Science.gov (United States)

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

    2017-09-01

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

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

    NARCIS (Netherlands)

    Mikuls, TR; Curtis, [No Value; Allison, JJ; Hicks, RW; Saag, KG

    Objectives. To more closely assess medication errors in gout care, we examined data from a national, Internet-accessible error reporting program over a 5-year reporting period. Methods. We examined data from the MEDMARX (TM) database, covering the period from January 1, 1999 through December 31,

  17. Model Agreements for the granting of Associate Member Status Implementation arrangements concerning eligibility for personnel appointments and industrial participation for Associate Member States Progress report by the Management

    CERN Document Server

    2011-01-01

    Model Agreements for the granting of Associate Member Status Implementation arrangements concerning eligibility for personnel appointments and industrial participation for Associate Member States Progress report by the Management

  18. Using Personnel and Financial Data for Reporting Purposes: What Are the Challenges to Using Such Data Accurately?

    Science.gov (United States)

    Valcik, Nicolas A.; Stigdon, Andrea D.

    2008-01-01

    Although institutional researchers devote a great deal of time mining and using student data to fulfill mandatory federal and state reports and analyze institutional effectiveness, financial and personnel information is also necessary for such endeavors. In this article, the authors discuss the challenges that arise from extracting data from…

  19. Isolating Graphical Failure-Inducing Input for Privacy Protection in Error Reporting Systems

    Directory of Open Access Journals (Sweden)

    Matos João

    2016-04-01

    Full Text Available This work proposes a new privacy-enhancing system that minimizes the disclosure of information in error reports. Error reporting mechanisms are of the utmost importance to correct software bugs but, unfortunately, the transmission of an error report may reveal users’ private information. Some privacy-enhancing systems for error reporting have been presented in the past years, yet they rely on path condition analysis, which we show in this paper to be ineffective when it comes to graphical-based input. Knowing that numerous applications have graphical user interfaces (GUI, it is very important to overcome such limitation. This work describes a new privacy-enhancing error reporting system, based on a new input minimization algorithm called GUIᴍɪɴ that is geared towards GUI, to remove input that is unnecessary to reproduce the observed failure. Before deciding whether to submit the error report, the user is provided with a step-by-step graphical replay of the minimized input, to evaluate whether it still yields sensitive information. We also provide an open source implementation of the proposed system and evaluate it with well-known applications.

  20. Task Force Report, Safety of Personnel in LHC underground areas following the accident of 19th September 2008

    CERN Document Server

    Delille, B; Inigo-Golfin, J; Lindell, G; Roy, G; Tavian, L; Thomas, E; Trant, R; Völlinger, C

    2009-01-01

    In January 2009, the Task Force on Safety of Personnel in the LHC underground areas following the accident in sector 3-4 of 19th September 2008 (Safety Task Force) received from the CERN Director General the mandate to investigate the impact of the accident of 19th September 2008 on the safety of personnel working in the LHC underground areas. This mandate includes the elaboration of preventive and/or corrective measures, if deemed necessary. This report gives the conclusions and recommendations of the Safety Task Force which have been reviewed by an external advisory committee of safety experts.

  1. Transparency When Things Go Wrong: Physician Attitudes About Reporting Medical Errors to Patients, Peers, and Institutions.

    Science.gov (United States)

    Bell, Sigall K; White, Andrew A; Yi, Jean C; Yi-Frazier, Joyce P; Gallagher, Thomas H

    2017-12-01

    Transparent communication after medical error includes disclosing the mistake to the patient, discussing the event with colleagues, and reporting to the institution. Little is known about whether attitudes about these transparency practices are related. Understanding these relationships could inform educational and organizational strategies to promote transparency. We analyzed responses of 3038 US and Canadian physicians to a medical error communication survey. We used bivariate correlations, principal components analysis, and linear regression to determine whether and how physician attitudes about transparent communication with patients, peers, and the institution after error were related. Physician attitudes about disclosing errors to patients, peers, and institutions were correlated (all P's transparent communication with patients and peers/institution included female sex, US (vs Canadian) doctors, academic (vs private) practice, the belief that disclosure decreased likelihood of litigation, and the belief that system changes occur after error reporting. In addition, younger physicians, surgeons, and those with previous experience disclosing a serious error were more likely to agree with disclosure to patients. In comparison, doctors who believed that disclosure would decrease patient trust were less likely to agree with error disclosure to patients. Previous disclosure education was associated with attitudes supporting greater transparency with peers/institution. Physician attitudes about discussing errors with patients, colleagues, and institutions are related. Several predictors of transparency affect all 3 practices and are potentially modifiable by educational and institutional strategies.

  2. Using incident reports to inform the prevention of medication administration errors.

    Science.gov (United States)

    Härkänen, Marja; Saano, Susanna; Vehviläinen-Julkunen, Katri

    2017-11-01

    To describe ways of preventing medication administration errors based on reporters' views expressed in medication administration incident reports. Medication administration errors are very common, and nurses play important roles in committing and in preventing such errors. Thus far, incident reporters' perceptions of how to prevent medication administration errors have rarely been analysed. This is a qualitative, descriptive study using an inductive content analysis of the incident reports related to medication administration errors (n = 1012). These free-text descriptions include reporters' views on preventing the reoccurrence of medication administration errors. The data were collected from two hospitals in Finland and pertain to incidents that were reported between 1 January 2013 and 31 December 2014. Reporters' views on preventing medication administration errors were divided into three main categories related to individuals (health professionals), teams and organisations. The following categories related to individuals in preventing medication administration errors were identified: (1) accuracy and preciseness; (2) verification; and (3) following the guidelines, responsibility and attitude towards work. The team categories were as follows: (1) distribution of work; (2) flow of information and cooperation; and (3) documenting and marking the drug information. The categories related to organisation were as follows: (1) work environment; (2) resources; (3) training; (4) guidelines; and (5) development of the work. Health professionals should administer medication with a high moral awareness and an attempt to concentrate on the task. Nonetheless, the system should support health professionals by providing a reasonable work environment and encouraging collaboration among the providers to facilitate the safe administration of medication. Although there are numerous approaches to supporting medication safety, approaches that support the ability of individual health

  3. Chamber personnel's use of Nitrox 50 during hyperbaric oxygen treatment: a quality study--research report.

    Science.gov (United States)

    Hansen, Marco B; Jansen, Tejs; Sifakis, Michael B; Hyldegaard, Ole; Jansen, Erik C

    2013-01-01

    We aimed to evaluate the feasibility and safety of using Nitrox 50 as breathing gas during attendance in a multiplace hyperbaric chamber. Paper logs between Jan.-Dec. 2011 were reviewed to analyze nitrogen gas-loading, actual bottom time, total bottom time and surface interval time. With the use of the Norwegian Diving Tables nitrogen gas-loading was converted to Repetitive Group Letters. Symptoms of decompression sickness and health problems related to hyperbaric exposures were registered at weekly staff meetings. The chamber personnel breathed chamber air or Nitrox 50. 1,207 hyperbaric exposures were distributed to five chamber attendants and technicians, 14 doctors, and six nurses. Nitrox 50 was inhaled on 978 occasions (81.0%). Median nitrogen gas-loading after first pressurization complied with Repetitive Group Letter A (range A-E), second to C (range A-F), third to D (range A-F), fourth to E (range C-H), fifth to F (range C-H), and sixth to E (range B-G). No symptoms of decompression sickness were reported (95% CI 0.00-0.33%). Breathing Nitrox 50 during repetitive hyperbaric sessions seems to be feasible and safe while meeting high demands in number of treatment sessions and patient flow and with fewer people employed in the hyperbaric unit.

  4. Perofrmance testing of personnel dosimetry services. Final report of a two-year pilot study, October 1977-September 1979

    International Nuclear Information System (INIS)

    Plato, P.; Hudson, G.

    1980-01-01

    A two-year pilot study was conducted of the Health Physics Society Standards Committee (HPSSC) Standard titled, Criteria for Testing Personnel Dosimetry Performance. The objectives of the pilot study were: to give processors an opportunity to correct any problems that are uncovered; to develop operational and administrative prodedures to be used later by a permanent testing laboratory; and to determine whether the proposed HPSSC Standard provides an adequate and practical test of dosimetry performance. Fifty-nine dosimetry processors volunteered to submit dosimeters for test irradiations according to the requirements of the HPSSC Standard. The feasibility of using the HPSSC Standard for a future mandatory testing program for personnel dosimetry processors is discussed. This report shows the results of the pilot study and contains recommendations for revisions in the Standard that will make a mandatory testing program useful to regulatory agencies, dosimetry processors, and radiation workers that use personnel dosimeters

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

    Science.gov (United States)

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

    2014-09-01

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

  6. Variability in Threshold for Medication Error Reporting Between Physicians, Nurses, Pharmacists, and Families.

    Science.gov (United States)

    Keefer, Patricia; Kidwell, Kelley; Lengyel, Candice; Warrier, Kavita; Wagner, Deborah

    2017-01-01

    Voluntary medication error reporting is an imperfect resource used to improve the quality of medication administration. It requires judgment by front-line staff to determine how to report enough to identify opportunities to improve patients' safety but not jeopardize that safety by creating a culture of "report fatigue." This study aims to provide information on interpretability of medication error and the variability between the subgroups of caregivers in the hospital setting. Survey participants included nursing, physician (trainee and graduated), patient/families, pharmacist across a large academic health system, including an attached free-standing pediatric hospital. Demographics and survey questions were collected and analyzed using Fischer's exact testing with SAS v9.3. Statistically significant variability existed between the four groups for a majority of the questions. This included all cases designated as administration errors and many, but not all, cases of prescribing events. Commentary provided in the free-text portion of the survey was sub-analyzed and found to be associated with medication allergy reporting and lack of education surrounding report characteristics. There is significant variability in the threshold to report specific medication errors in the hospital setting. More work needs to be done to further improve the education surrounding error reporting in hospitals for all noted subgroups. Copyright© Bentham Science Publishers; For any queries, please email at epub@benthamscience.org.

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

    Science.gov (United States)

    Meurier, C E

    2000-07-01

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

  8. The frequency of diagnostic errors in radiologic reports depends on the patient's age

    International Nuclear Information System (INIS)

    Diaz, Sandra; Ekberg, Olle

    2010-01-01

    Background: Patients who undergo treatment may suffer preventable medical errors. Some of these errors are due to diagnostic imaging procedures. Purpose: To compare the frequency of diagnostic errors in different age groups in an urban European population. Material and Methods: A total of 19 129 reported radiologic examinations were included. During a 6-month period, the analyzed age groups were: children (aged 0-9 years), adults (40-49 years), and elderly (86-95 years). Results: The frequency of radiologic examinations per year was 0.3 in children, 0.6 in adults, and 1.1 in elderly. Significant errors were significantly more frequent in the elderly (1.7%) and children (1.4%) compared with adults (0.8%). There were 60 false-positive reports and 232 false-negative reports. Most errors were made by staff radiologists after hours when they reported on examinations outside their area of expertise. Conclusion: Diagnostic errors are more frequent in children and the elderly compared with middle-aged adults

  9. Measurement error and timing of predictor values for multivariable risk prediction models are poorly reported.

    Science.gov (United States)

    Whittle, Rebecca; Peat, George; Belcher, John; Collins, Gary S; Riley, Richard D

    2018-05-18

    Measurement error in predictor variables may threaten the validity of clinical prediction models. We sought to evaluate the possible extent of the problem. A secondary objective was to examine whether predictors are measured at the intended moment of model use. A systematic search of Medline was used to identify a sample of articles reporting the development of a clinical prediction model published in 2015. After screening according to a predefined inclusion criteria, information on predictors, strategies to control for measurement error and intended moment of model use were extracted. Susceptibility to measurement error for each predictor was classified into low and high risk. Thirty-three studies were reviewed, including 151 different predictors in the final prediction models. Fifty-one (33.7%) predictors were categorised as high risk of error, however this was not accounted for in the model development. Only 8 (24.2%) studies explicitly stated the intended moment of model use and when the predictors were measured. Reporting of measurement error and intended moment of model use is poor in prediction model studies. There is a need to identify circumstances where ignoring measurement error in prediction models is consequential and whether accounting for the error will improve the predictions. Copyright © 2018. Published by Elsevier Inc.

  10. The Relationship between Reports of Psychological Capital and Reports of Job Satisfaction among Administrative Personnel at a Private Institution of Higher Education

    Science.gov (United States)

    Mello, James A.

    2012-01-01

    The purpose of this single-site case study was to investigate the relationship between administrative personnel's reports of psychological capital (Luthans, Youssef, & Avolio, 2007) and their reports of job satisfaction (Hackman & Oldham, 1980). Specifically, two surveys, the Psychological Capital Questionnaire (Luthans, Youssef, &…

  11. Outlier Removal and the Relation with Reporting Errors and Quality of Psychological Research

    Science.gov (United States)

    Bakker, Marjan; Wicherts, Jelte M.

    2014-01-01

    Background The removal of outliers to acquire a significant result is a questionable research practice that appears to be commonly used in psychology. In this study, we investigated whether the removal of outliers in psychology papers is related to weaker evidence (against the null hypothesis of no effect), a higher prevalence of reporting errors, and smaller sample sizes in these papers compared to papers in the same journals that did not report the exclusion of outliers from the analyses. Methods and Findings We retrieved a total of 2667 statistical results of null hypothesis significance tests from 153 articles in main psychology journals, and compared results from articles in which outliers were removed (N = 92) with results from articles that reported no exclusion of outliers (N = 61). We preregistered our hypotheses and methods and analyzed the data at the level of articles. Results show no significant difference between the two types of articles in median p value, sample sizes, or prevalence of all reporting errors, large reporting errors, and reporting errors that concerned the statistical significance. However, we did find a discrepancy between the reported degrees of freedom of t tests and the reported sample size in 41% of articles that did not report removal of any data values. This suggests common failure to report data exclusions (or missingness) in psychological articles. Conclusions We failed to find that the removal of outliers from the analysis in psychological articles was related to weaker evidence (against the null hypothesis of no effect), sample size, or the prevalence of errors. However, our control sample might be contaminated due to nondisclosure of excluded values in articles that did not report exclusion of outliers. Results therefore highlight the importance of more transparent reporting of statistical analyses. PMID:25072606

  12. The prevalence of statistical reporting errors in psychology (1985–2013)

    NARCIS (Netherlands)

    Nuijten, M.B.; Hartgerink, C.H.J.; van Assen, M.A.L.M.; Epskamp, S.; Wicherts, J.M.

    2016-01-01

    This study documents reporting errors in a sample of over 250,000 p-values reported in eight major psychology journals from 1985 until 2013, using the new R package “statcheck.” statcheck retrieved null-hypothesis significance testing (NHST) results from over half of the articles from this period.

  13. The prevalence of statistical reporting errors in psychology (1985-2013)

    NARCIS (Netherlands)

    Nuijten, M.B.; Hartgerink, C.H.J.; van Assen, M.A.L.M.; Epskamp, S.; Wicherts, J.M.

    2016-01-01

    This study documents reporting errors in a sample of over 250,000 p-values reported in eight major psychology journals from 1985 until 2013, using the new R package “statcheck.” statcheck retrieved null-hypothesis significance testing (NHST) results from over half of the articles from this period.

  14. A Chance to Get Ahead: Proficiency Examinations for Clerical Laboratory Personnel. Final Report.

    Science.gov (United States)

    Linehan, Jean D.

    Four Proficiency Examinations for Clinical Laboratory Personnel were developed in Clinical Chemistry, Microbiology, Hematology, and Blood Banking. Purpose of project was to enable competent military laboratory technicians who lack credentials to demonstrate their job-related skills and knowledge for civilian positions, and also to help civilians…

  15. Industry to Education Technology Transfer Program. Composite Materials--Personnel Development. Final Report.

    Science.gov (United States)

    Tomezsko, Edward S. J.

    A composite materials education program was established to train Boeing Helicopter Company employees in the special processing of new filament-reinforced polymer composite materials. During the personnel development phase of the joint Boeing-Penn State University project, an engineering instructor from Penn State completed a 5-month, full-time…

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

    Energy Technology Data Exchange (ETDEWEB)

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

    2002-03-01

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

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

    International Nuclear Information System (INIS)

    Svenson, Ola; Salo, Ilkka

    2002-03-01

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

  18. Statistical Reporting Errors and Collaboration on Statistical Analyses in Psychological Science.

    Science.gov (United States)

    Veldkamp, Coosje L S; Nuijten, Michèle B; Dominguez-Alvarez, Linda; van Assen, Marcel A L M; Wicherts, Jelte M

    2014-01-01

    Statistical analysis is error prone. A best practice for researchers using statistics would therefore be to share data among co-authors, allowing double-checking of executed tasks just as co-pilots do in aviation. To document the extent to which this 'co-piloting' currently occurs in psychology, we surveyed the authors of 697 articles published in six top psychology journals and asked them whether they had collaborated on four aspects of analyzing data and reporting results, and whether the described data had been shared between the authors. We acquired responses for 49.6% of the articles and found that co-piloting on statistical analysis and reporting results is quite uncommon among psychologists, while data sharing among co-authors seems reasonably but not completely standard. We then used an automated procedure to study the prevalence of statistical reporting errors in the articles in our sample and examined the relationship between reporting errors and co-piloting. Overall, 63% of the articles contained at least one p-value that was inconsistent with the reported test statistic and the accompanying degrees of freedom, and 20% of the articles contained at least one p-value that was inconsistent to such a degree that it may have affected decisions about statistical significance. Overall, the probability that a given p-value was inconsistent was over 10%. Co-piloting was not found to be associated with reporting errors.

  19. Consistency errors in p-values reported in Spanish psychology journals.

    Science.gov (United States)

    Caperos, José Manuel; Pardo, Antonio

    2013-01-01

    Recent reviews have drawn attention to frequent consistency errors when reporting statistical results. We have reviewed the statistical results reported in 186 articles published in four Spanish psychology journals. Of these articles, 102 contained at least one of the statistics selected for our study: Fisher-F , Student-t and Pearson-c 2 . Out of the 1,212 complete statistics reviewed, 12.2% presented a consistency error, meaning that the reported p-value did not correspond to the reported value of the statistic and its degrees of freedom. In 2.3% of the cases, the correct calculation would have led to a different conclusion than the reported one. In terms of articles, 48% included at least one consistency error, and 17.6% would have to change at least one conclusion. In meta-analytical terms, with a focus on effect size, consistency errors can be considered substantial in 9.5% of the cases. These results imply a need to improve the quality and precision with which statistical results are reported in Spanish psychology journals.

  20. Models of cognitive behavior in nuclear power plant personnel. A feasibility study: main report. Volume 2

    International Nuclear Information System (INIS)

    Woods, D.D.; Roth, E.M.; Hanes, L.F.

    1986-07-01

    This report contains the results of a feasibility study to determine if the current state of models human cognitive activities can serve as the basis for improved techniques for predicting human error in nuclear power plants emergency operations. Based on the answer to this questions, two subsequent phases of research are planned. Phase II is to develop a model of cognitive activities, and Phase III is to test the model. The feasibility study included an analysis of the cognitive activities that occur in emergency operations and an assessment of the modeling concepts/tools available to capture these cognitive activities. The results indicated that a symbolic processing (or artificial intelligence) model of cognitive activities in nuclear power plants is both desirable and feasible. This cognitive model can be built upon the computational framework provided by an existing artificial intelligence system for medical problem solving called Caduceus. The resulting cognitive model will increase the capability to capture the human contribution to risk in probabilistic risk assessments studies. Volume I summarizes the major findings and conclusions of the study. Volume II provides a complete description of the methods and results, including a synthesis of the cognitive activities that occur during emergency operations, and a literature review on cognitive modeling relevant to nuclear power plants. 112 refs., 10 figs

  1. Understanding the barriers to physician error reporting and disclosure: a systemic approach to a systemic problem.

    Science.gov (United States)

    Perez, Bianca; Knych, Stephen A; Weaver, Sallie J; Liberman, Aaron; Abel, Eileen M; Oetjen, Dawn; Wan, Thomas T H

    2014-03-01

    The issues of medical errors and medical malpractice have stimulated significant interest in establishing transparency in health care, in other words, ensuring that medical professionals formally report medical errors and disclose related outcomes to patients and families. However, research has amply shown that transparency is not a universal practice among physicians. A review of the literature was carried out using the search terms "transparency," "patient safety," "disclosure," "medical error," "error reporting," "medical malpractice," "doctor-patient relationship," and "physician" to find articles describing physician barriers to transparency. The current literature underscores that a complex Web of factors influence physician reluctance to engage in transparency. Specifically, 4 domains of barriers emerged from this analysis: intrapersonal, interpersonal, institutional, and societal. Transparency initiatives will require vigorous, interdisciplinary efforts to address the systemic and pervasive nature of the problem. Several ethical and social-psychological barriers suggest that medical schools and hospitals should collaborate to establish continuity in education and ensure that knowledge acquired in early education is transferred into long-term learning. At the institutional level, practical and cultural barriers suggest the creation of supportive learning environments and private discussion forums where physicians can seek moral support in the aftermath of an error. To overcome resistance to culture transformation, incremental change should be considered, for example, replacing arcane transparency policies and complex reporting mechanisms with clear, user-friendly guidelines.

  2. Investigating Medication Errors in Educational Health Centers of Kermanshah

    Directory of Open Access Journals (Sweden)

    Mohsen Mohammadi

    2015-08-01

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

  3. Errors in self-reports of health services use: impact on alzheimer disease clinical trial designs.

    Science.gov (United States)

    Callahan, Christopher M; Tu, Wanzhu; Stump, Timothy E; Clark, Daniel O; Unroe, Kathleen T; Hendrie, Hugh C

    2015-01-01

    Most Alzheimer disease clinical trials that compare the use of health services rely on reports of caregivers. The goal of this study was to assess the accuracy of self-reports among older adults with Alzheimer disease and their caregiver proxy respondents. This issue is particularly relevant to Alzheimer disease clinical trials because inaccuracy can lead both to loss of power and increased bias in study outcomes. We compared respondent accuracy in reporting any use and in reporting the frequency of use with actual utilization data as documented in a comprehensive database. We next simulated the impact of underreporting and overreporting on sample size estimates and treatment effect bias for clinical trials comparing utilization between experimental groups. Respondents self-reports have a poor level of accuracy with κ-values often below 0.5. Respondents tend to underreport use even for rare events such as hospitalizations and nursing home stays. In analyses simulating underreporting and overreporting of varying magnitude, we found that errors in self-reports can increase the required sample size by 15% to 30%. In addition, bias in the reported treatment effect ranged from 3% to 18% due to both underreporting and overreporting errors. Use of self-report data in clinical trials of Alzheimer disease treatments may inflate sample size needs. Even when adequate power is achieved by increasing sample size, reporting errors can result in a biased estimate of the true effect size of the intervention.

  4. Personnel monitoring

    International Nuclear Information System (INIS)

    1965-01-01

    This film stresses the need for personnel monitoring in work areas where there is a hazard of exposure to radiation. It illustrates the use of personnel monitoring devices (specially the film dosimeter), the assessment of exposure to radiation and the detailed recording of the results on personnel filing cards

  5. Personnel monitoring

    Energy Technology Data Exchange (ETDEWEB)

    NONE

    1966-12-31

    This film stresses the need for personnel monitoring in work areas where there is a hazard of exposure to radiation. It illustrates the use of personnel monitoring devices (specially the film dosimeter), the assessment of exposure to radiation and the detailed recording of the results on personnel filing cards

  6. 45 CFR 61.6 - Reporting errors, omissions, revisions or whether an action is on appeal.

    Science.gov (United States)

    2010-10-01

    ... 45 Public Welfare 1 2010-10-01 2010-10-01 false Reporting errors, omissions, revisions or whether an action is on appeal. 61.6 Section 61.6 Public Welfare DEPARTMENT OF HEALTH AND HUMAN SERVICES GENERAL ADMINISTRATION HEALTHCARE INTEGRITY AND PROTECTION DATA BANK FOR FINAL ADVERSE INFORMATION ON...

  7. Source Memory Errors Associated with Reports of Posttraumatic Flashbacks: A Proof of Concept Study

    Science.gov (United States)

    Brewin, Chris R.; Huntley, Zoe; Whalley, Matthew G.

    2012-01-01

    Flashbacks are involuntary, emotion-laden images experienced by individuals with posttraumatic stress disorder (PTSD). The qualities of flashbacks could under certain circumstances lead to source memory errors. Participants with PTSD wrote a trauma narrative and reported the experience of flashbacks. They were later presented with stimuli from…

  8. Translating Research Into Practice: Voluntary Reporting of Medication Errors in Critical Access Hospitals

    Science.gov (United States)

    Jones, Katherine J.; Cochran, Gary; Hicks, Rodney W.; Mueller, Keith J.

    2004-01-01

    Context:Low service volume, insufficient information technology, and limited human resources are barriers to learning about and correcting system failures in small rural hospitals. This paper describes the implementation of and initial findings from a voluntary medication error reporting program developed by the Nebraska Center for Rural Health…

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

    African Journals Online (AJOL)

    Background: Mistakes in the identification and administration of drugs may be fatal. This is especially so in the practice of anaesthesia. This is a report of 2 cases of near fatality due to mistakes in drug administration from look-alike medications. Objective: To highlight the significance of medication errors in our practice and ...

  10. Barriers to reporting medication errors and near misses among nurses: A systematic review.

    Science.gov (United States)

    Vrbnjak, Dominika; Denieffe, Suzanne; O'Gorman, Claire; Pajnkihar, Majda

    2016-11-01

    To explore barriers to nurses' reporting of medication errors and near misses in hospital settings. Systematic review. Medline, CINAHL, PubMed and Cochrane Library in addition to Google and Google Scholar and reference lists of relevant studies published in English between January 1981 and April 2015 were searched for relevant qualitative, quantitative or mixed methods empirical studies or unpublished PhD theses. Papers with a primary focus on barriers to reporting medication errors and near misses in nursing were included. The titles and abstracts of the search results were assessed for eligibility and relevance by one of the authors. After retrieval of the full texts, two of the authors independently made decisions concerning the final inclusion and these were validated by the third reviewer. Three authors independently assessed methodological quality of studies. Relevant data were extracted and findings were synthesised using thematic synthesis. From 4038 identified records, 38 studies were included in the synthesis. Findings suggest that organizational barriers such as culture, the reporting system and management behaviour in addition to personal and professional barriers such as fear, accountability and characteristics of nurses are barriers to reporting medication errors. To overcome reported barriers it is necessary to develop a non-blaming, non-punitive and non-fearful learning culture at unit and organizational level. Anonymous, effective, uncomplicated and efficient reporting systems and supportive management behaviour that provides open feedback to nurses is needed. Nurses are accountable for patients' safety, so they need to be educated and skilled in error management. Lack of research into barriers to reporting of near misses' and low awareness of reporting suggests the need for further research and development of educational and management approaches to overcome these barriers. Copyright © 2016 Elsevier Ltd. All rights reserved.

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

    Science.gov (United States)

    Benjamin, David M; Pendrak, Robert F

    2003-07-01

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

  12. Factors affecting nursing students' intention to report medication errors: An application of the theory of planned behavior.

    Science.gov (United States)

    Ben Natan, Merav; Sharon, Ira; Mahajna, Marlen; Mahajna, Sara

    2017-11-01

    Medication errors are common among nursing students. Nonetheless, these errors are often underreported. To examine factors related to nursing students' intention to report medication errors, using the Theory of Planned Behavior, and to examine whether the theory is useful in predicting students' intention to report errors. This study has a descriptive cross-sectional design. Study population was recruited in a university and a large nursing school in central and northern Israel. A convenience sample of 250 nursing students took part in the study. The students completed a self-report questionnaire, based on the Theory of Planned Behavior. The findings indicate that students' intention to report medication errors was high. The Theory of Planned Behavior constructs explained 38% of variance in students' intention to report medication errors. The constructs of behavioral beliefs, subjective norms, and perceived behavioral control were found as affecting this intention, while the most significant factor was behavioral beliefs. The findings also reveal that students' fear of the reaction to disclosure of the error from superiors and colleagues may impede them from reporting the error. Understanding factors related to reporting medication errors is crucial to designing interventions that foster error reporting. Copyright © 2017 Elsevier Ltd. All rights reserved.

  13. Incident reporting: Its role in aviation safety and the acquisition of human error data

    Science.gov (United States)

    Reynard, W. D.

    1983-01-01

    The rationale for aviation incident reporting systems is presented and contrasted to some of the shortcomings of accident investigation procedures. The history of the United State's Aviation Safety Reporting System (ASRS) is outlined and the program's character explained. The planning elements that resulted in the ASRS program's voluntary, confidential, and non-punitive design are discussed. Immunity, from enforcement action and misuse of the volunteered data, is explained and evaluated. Report generation techniques and the ASRS data analysis process are described; in addition, examples of the ASRS program's output and accomplishments are detailed. Finally, the value of incident reporting for the acquisition of safety information, particularly human error data, is explored.

  14. Barriers to the medication error reporting process within the Irish National Ambulance Service, a focus group study.

    Science.gov (United States)

    Byrne, Eamonn; Bury, Gerard

    2018-02-08

    Incident reporting is vital to identifying pre-hospital medication safety issues because literature suggests that the majority of errors pre-hospital are self-identified. In 2016, the National Ambulance Service (NAS) reported 11 medication errors to the national body with responsibility for risk management and insurance cover. The Health Information and Quality Authority in 2014 stated that reporting of clinical incidents, of which medication errors are a subset, was not felt to be representative of the actual events occurring. Even though reporting systems are in place, the levels appear to be well below what might be expected. Little data is available to explain this apparent discrepancy. To identify, investigate and document the barriers to medication error reporting within the NAS. An independent moderator led four focus groups in March of 2016. A convenience sample of 18 frontline Paramedics and Advanced Paramedics from Cork City and County discussed medication errors and the medication error reporting process. The sessions were recorded and anonymised, and the data was analysed using a process of thematic analysis. Practitioners understood the value of reporting errors. Barriers to reporting included fear of consequences and ridicule, procedural ambiguity, lack of feedback and a perceived lack of both consistency and confidentiality. The perceived consequences for making an error included professional, financial, litigious and psychological. Staff appeared willing to admit errors in a psychologically safe environment. Barriers to reporting are in line with international evidence. Time constraints prevented achievement of thematic saturation. Further study is warranted.

  15. Information Management System Development for the Investigation, Reporting, and Analysis of Human Error in Naval Aviation Maintenance

    National Research Council Canada - National Science Library

    Nelson, Douglas

    2001-01-01

    The purpose of this research is to evaluate and refine a safety information management system that will facilitate data collection, organization, query, analysis and reporting of maintenance errors...

  16. What are incident reports telling us? A comparative study at two Australian hospitals of medication errors identified at audit, detected by staff and reported to an incident system.

    Science.gov (United States)

    Westbrook, Johanna I; Li, Ling; Lehnbom, Elin C; Baysari, Melissa T; Braithwaite, Jeffrey; Burke, Rosemary; Conn, Chris; Day, Richard O

    2015-02-01

    To (i) compare medication errors identified at audit and observation with medication incident reports; (ii) identify differences between two hospitals in incident report frequency and medication error rates; (iii) identify prescribing error detection rates by staff. Audit of 3291 patient records at two hospitals to identify prescribing errors and evidence of their detection by staff. Medication administration errors were identified from a direct observational study of 180 nurses administering 7451 medications. Severity of errors was classified. Those likely to lead to patient harm were categorized as 'clinically important'. Two major academic teaching hospitals in Sydney, Australia. Rates of medication errors identified from audit and from direct observation were compared with reported medication incident reports. A total of 12 567 prescribing errors were identified at audit. Of these 1.2/1000 errors (95% CI: 0.6-1.8) had incident reports. Clinically important prescribing errors (n = 539) were detected by staff at a rate of 218.9/1000 (95% CI: 184.0-253.8), but only 13.0/1000 (95% CI: 3.4-22.5) were reported. 78.1% (n = 421) of clinically important prescribing errors were not detected. A total of 2043 drug administrations (27.4%; 95% CI: 26.4-28.4%) contained ≥ 1 errors; none had an incident report. Hospital A had a higher frequency of incident reports than Hospital B, but a lower rate of errors at audit. Prescribing errors with the potential to cause harm frequently go undetected. Reported incidents do not reflect the profile of medication errors which occur in hospitals or the underlying rates. This demonstrates the inaccuracy of using incident frequency to compare patient risk or quality performance within or across hospitals. New approaches including data mining of electronic clinical information systems are required to support more effective medication error detection and mitigation. © The Author 2015. Published by Oxford University Press in association

  17. Report: EPA’s Information Systems and Data Are at Risk Due to Insufficient Training of Personnel With Significant Information Security Responsibilities

    Science.gov (United States)

    Report #14-P-0142, March 21, 2014. The EPA places its information systems and data at risk due to an organizational structure that has not specified required duties and responsibilities to ensure personnel are trained on key information security roles.

  18. 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...

  19. Medication administration error reporting and associated factors among nurses working at the University of Gondar referral hospital, Northwest Ethiopia, 2015.

    Science.gov (United States)

    Bifftu, Berhanu Boru; Dachew, Berihun Assefa; Tiruneh, Bewket Tadesse; Beshah, Debrework Tesgera

    2016-01-01

    Medication administration is the final step/phase of medication process in which its error directly affects the patient health. Due to the central role of nurses in medication administration, whether they are the source of an error, a contributor, or an observer they have the professional, legal and ethical responsibility to recognize and report. The aim of this study was to assess the prevalence of medication administration error reporting and associated factors among nurses working at The University of Gondar Referral Hospital, Northwest Ethiopia. Institution based quantitative cross - sectional study was conducted among 282 Nurses. Data were collected using semi-structured, self-administered questionnaire of the Medication Administration Errors Reporting (MAERs). Binary logistic regression with 95 % confidence interval was used to identify factors associated with medication administration errors reporting. The estimated medication administration error reporting was found to be 29.1 %. The perceived rates of medication administration errors reporting for non-intravenous related medications were ranged from 16.8 to 28.6 % and for intravenous-related from 20.6 to 33.4 %. Education status (AOR =1.38, 95 % CI: 4.009, 11.128), disagreement over time - error definition (AOR = 0.44, 95 % CI: 0.468, 0.990), administrative reason (AOR = 0.35, 95 % CI: 0.168, 0.710) and fear (AOR = 0.39, 95 % CI: 0.257, 0.838) were factors statistically significant for the refusal of reporting medication administration errors at p-value definition, administrative reason and fear were factors statistically significant for the refusal of errors reporting at p-value definition of reportable errors and strengthen the educational status of nurses by the health care organization.

  20. Medication Errors in a Swiss Cardiovascular Surgery Department: A Cross-Sectional Study Based on a Novel Medication Error Report Method

    Directory of Open Access Journals (Sweden)

    Kaspar Küng

    2013-01-01

    Full Text Available The purpose of this study was (1 to determine frequency and type of medication errors (MEs, (2 to assess the number of MEs prevented by registered nurses, (3 to assess the consequences of ME for patients, and (4 to compare the number of MEs reported by a newly developed medication error self-reporting tool to the number reported by the traditional incident reporting system. We conducted a cross-sectional study on ME in the Cardiovascular Surgery Department of Bern University Hospital in Switzerland. Eligible registered nurses ( involving in the medication process were included. Data on ME were collected using an investigator-developed medication error self reporting tool (MESRT that asked about the occurrence and characteristics of ME. Registered nurses were instructed to complete a MESRT at the end of each shift even if there was no ME. All MESRTs were completed anonymously. During the one-month study period, a total of 987 MESRTs were returned. Of the 987 completed MESRTs, 288 (29% indicated that there had been an ME. Registered nurses reported preventing 49 (5% MEs. Overall, eight (2.8% MEs had patient consequences. The high response rate suggests that this new method may be a very effective approach to detect, report, and describe ME in hospitals.

  1. Pilot Error in Air Carrier Mishaps: Longitudinal Trends Among 558 Reports, 1983–2002

    Science.gov (United States)

    Baker, Susan P.; Qiang, Yandong; Rebok, George W.; Li, Guohua

    2009-01-01

    Background Many interventions have been implemented in recent decades to reduce pilot error in flight operations. This study aims to identify longitudinal trends in the prevalence and patterns of pilot error and other factors in U.S. air carrier mishaps. Method National Transportation Safety Board investigation reports were examined for 558 air carrier mishaps during 1983–2002. Pilot errors and circumstances of mishaps were described and categorized. Rates were calculated per 10 million flights. Results The overall mishap rate remained fairly stable, but the proportion of mishaps involving pilot error decreased from 42% in 1983–87 to 25% in 1998–2002, a 40% reduction. The rate of mishaps related to poor decisions declined from 6.2 to 1.8 per 10 million flights, a 71% reduction; much of this decrease was due to a 76% reduction in poor decisions related to weather. Mishandling wind or runway conditions declined by 78%. The rate of mishaps involving poor crew interaction declined by 68%. Mishaps during takeoff declined by 70%, from 5.3 to 1.6 per 10 million flights. The latter reduction was offset by an increase in mishaps while the aircraft was standing, from 2.5 to 6.0 per 10 million flights, and during pushback, which increased from 0 to 3.1 per 10 million flights. Conclusions Reductions in pilot errors involving decision making and crew coordination are important trends that may reflect improvements in training and technological advances that facilitate good decisions. Mishaps while aircraft are standing and during push-back have increased and deserve special attention. PMID:18225771

  2. Computer code for calculating personnel doses due to tritium exposures

    International Nuclear Information System (INIS)

    Graham, C.L.; Parlagreco, J.R.

    1977-01-01

    This report describes a computer code written in LLL modified Fortran IV that can be used on a CDC 7600 for calculating personnel doses due to internal exposures to tritium. The code is capable of handling various exposure situations and is also capable of detecting a large variety of data input errors that would lead to errors in the dose assessment. The critical organ is the body water

  3. The systems approach to error reduction: factors influencing inoculation injury reporting in the operating theatre.

    Science.gov (United States)

    Cutter, Jayne; Jordan, Sue

    2013-11-01

    To examine the frequency of, and factors influencing, reporting of mucocutaneous and percutaneous injuries in operating theatres. Surgeons and peri-operative nurses risk acquiring blood-borne viral infections during surgical procedures. Appropriate first-aid and prophylactic treatment after an injury can significantly reduce the risk of infection. However, studies indicate that injuries often go unreported. The 'systems approach' to error reduction relies on reporting incidents and near misses. Failure to report will compromise safety. A postal survey of all surgeons and peri-operative nurses engaged in exposure prone procedures in nine Welsh hospitals, face-to-face interviews with selected participants and telephone interviews with Infection Control Nurses. The response rate was 51.47% (315/612). Most respondents reported one or more percutaneous (183/315, 58.1%) and/or mucocutaneous injuries (68/315, 21.6%) in the 5 years preceding the study. Only 54.9% (112/204) reported every injury. Surgeons were poorer at reporting: 70/133 (52.6%) reported all or >50% of their injuries compared with 65/71 nurses (91.5%). Injuries are frequently under-reported, possibly compromising safety in operating theatres. A significant number of inoculation injuries are not reported. Factors influencing under-reporting were identified. This knowledge can assist managers in improving reporting and encouraging a robust safety culture within operating departments. © 2012 John Wiley & Sons Ltd.

  4. Technology-related medication errors in a tertiary hospital: a 5-year analysis of reported medication incidents.

    Science.gov (United States)

    Samaranayake, N R; Cheung, S T D; Chui, W C M; Cheung, B M Y

    2012-12-01

    Healthcare technology is meant to reduce medication errors. The objective of this study was to assess unintended errors related to technologies in the medication use process. Medication incidents reported from 2006 to 2010 in a main tertiary care hospital were analysed by a pharmacist and technology-related errors were identified. Technology-related errors were further classified as socio-technical errors and device errors. This analysis was conducted using data from medication incident reports which may represent only a small proportion of medication errors that actually takes place in a hospital. Hence, interpretation of results must be tentative. 1538 medication incidents were reported. 17.1% of all incidents were technology-related, of which only 1.9% were device errors, whereas most were socio-technical errors (98.1%). Of these, 61.2% were linked to computerised prescription order entry, 23.2% to bar-coded patient identification labels, 7.2% to infusion pumps, 6.8% to computer-aided dispensing label generation and 1.5% to other technologies. The immediate causes for technology-related errors included, poor interface between user and computer (68.1%), improper procedures or rule violations (22.1%), poor interface between user and infusion pump (4.9%), technical defects (1.9%) and others (3.0%). In 11.4% of the technology-related incidents, the error was detected after the drug had been administered. A considerable proportion of all incidents were technology-related. Most errors were due to socio-technical issues. Unintended and unanticipated errors may happen when using technologies. Therefore, when using technologies, system improvement, awareness, training and monitoring are needed to minimise medication errors. Copyright © 2012 Elsevier Ireland Ltd. All rights reserved.

  5. Human factors affecting the performance of inspection personnel in nuclear power plants: Final report

    International Nuclear Information System (INIS)

    Karimi, S.S.

    1988-12-01

    This study investigates the problem of poor performance among nuclear power plant inspection personnel both in training and in the field. First, a systems perspective is employed to explore the psychological processes and relevant human factors that may be associated with workers' inadequate performance. Second, two separate yet related approaches are used to clarify the definition of competence: (1) a theory-based (or ''top-down'') approach, in which effective performance is construed as a product of a skillful, motivated person interacting with a responsive environment; and (2) an empirical (or ''bottom-up'') approach, in which key persons and context characteristics are generated based on the opinions of experts in the industry. Using a series of semi-structured interviews, two empirical studies were conducted in the latter approach. Overall, the results of both studies converged with the theoretical analysis emphasizing (1) the reciprocal and dynamic interplay of contextual and motivational factors influencing performance, and (2) the salient role of supervisory practices in terms of support, cooperation, and efficiency in contributing to the outcome of performance. 53 refs., 14 figs., 7 tabs

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

    International Nuclear Information System (INIS)

    Zhang Li; Zou Yanhua; Huang Weigang

    2010-01-01

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

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

    National Research Council Canada - National Science Library

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

    2005-01-01

    The Applied Strategies for Improving Patient Safety (ASIPS) collaborative developed an ambulatory primary care patient safety reporting system through an Agency for Healthcare Research and Quality (AHRQ...

  8. Personnel Preparation.

    Science.gov (United States)

    Fair, George, Ed.; Stodden, Robert, Ed.

    1981-01-01

    Three articles comprise a section on personnel preparation in vocational education. Articles deal with two inservice programs in career/vocational education for the handicapped and a project to train paraprofessionals to assist special educators in vocational education. (CL)

  9. Radiographer and radiologist perception error in reporting double contrast barium enemas: A pilot study

    International Nuclear Information System (INIS)

    Booth, Alison M.; Mannion, Richard A.J.

    2005-01-01

    Purpose: The practice of radiographers performing double contrast barium enemas (DCBE) is now widespread and in many centres the radiographer's opinion is, at least, contributing to a dual reporting system [Bewell J, Chapman AH. Radiographer performed barium enemas - results of a survey to assess progress. Radiography 1996;2:199-205; Leslie A, Virjee JP. Detection of colorectal carcinoma on double contrast barium enema when double reporting is routinely performed: an audit of current practice. Clin Radiol 2001;57:184-7; Culpan DG, Mitchell AJ, Hughes S, Nutman M, Chapman AH. Double contrast barium enema sensitivity: a comparison of studies by radiographers and radiologists. Clin Radiol 2002;57:604-7]. To ensure this change in practice does not lead to an increase in reporting errors, this study aimed to compare the perception abilities of radiographers with those of radiologists. Methods: Three gastro-intestinal (GI) radiographers and three consultant radiologists independently reported on a selection of 50 DCBE examinations, including the level of certainty in their comments for each examination. A blinded comparison of the results with an independent 'standard report' was recorded. Results: The results demonstrate there was no significant difference in perception error for any of the levels of certainty, for single reporting, for double reading by a radiographer/radiologist or by two radiologists. Conclusions: The study shows that radiographers can perceive abnormalities on DCBE at similar sensitivities and specificities as radiologists. While the participants in the study may be typical of a district general hospital, the nature of the study gives it limited external validity. As a pilot, the results demonstrate that, with slight modification, the methodology could be used for a larger study

  10. Associations between communication climate and the frequency of medical error reporting among pharmacists within an inpatient setting.

    Science.gov (United States)

    Patterson, Mark E; Pace, Heather A; Fincham, Jack E

    2013-09-01

    Although error-reporting systems enable hospitals to accurately track safety climate through the identification of adverse events, these systems may be underused within a work climate of poor communication. The objective of this analysis is to identify the extent to which perceived communication climate among hospital pharmacists impacts medical error reporting rates. This cross-sectional study used survey responses from more than 5000 pharmacists responding to the 2010 Hospital Survey on Patient Safety Culture (HSOPSC). Two composite scores were constructed for "communication openness" and "feedback and about error," respectively. Error reporting frequency was defined from the survey question, "In the past 12 months, how many event reports have you filled out and submitted?" Multivariable logistic regressions were used to estimate the likelihood of medical error reporting conditional upon communication openness or feedback levels, controlling for pharmacist years of experience, hospital geographic region, and ownership status. Pharmacists with higher communication openness scores compared with lower scores were 40% more likely to have filed or submitted a medical error report in the past 12 months (OR, 1.4; 95% CI, 1.1-1.7; P = 0.004). In contrast, pharmacists with higher communication feedback scores were not any more likely than those with lower scores to have filed or submitted a medical report in the past 12 months (OR, 1.0; 95% CI, 0.8-1.3; P = 0.97). Hospital work climates that encourage pharmacists to freely communicate about problems related to patient safety is conducive to medical error reporting. The presence of feedback infrastructures about error may not be sufficient to induce error-reporting behavior.

  11. Pre-Departure Clearance (PDC): An Analysis of Aviation Safety Reporting System Reports Concerning PDC Related Errors

    Science.gov (United States)

    Montalyo, Michael L.; Lebacqz, J. Victor (Technical Monitor)

    1994-01-01

    Airlines operating in the United States are required to operate under instrument flight rules (EFR). Typically, a clearance is issued via voice transmission from clearance delivery at the departing airport. In 1990, the Federal Aviation Administration (FAA) began deployment of the Pre-Departure Clearance (PDC) system at 30 U.S. airports. The PDC system utilizes aeronautical datalink and Aircraft Communication and Reporting System (ACARS) to transmit departure clearances directly to the pilot. An objective of the PDC system is to provide an immediate reduction in voice congestion over the clearance delivery frequency. Participating airports report that this objective has been met. However, preliminary analysis of 42 Aviation Safety Reporting System (ASRS) reports has revealed problems in PDC procedures and formatting which have caused errors in the proper execution of the clearance. It must be acknowledged that this technology, along with other advancements on the flightdeck, is adding more responsibility to the crew and increasing the opportunity for error. The present study uses these findings as a basis for further coding and analysis of an additional 82 reports obtained from an ASRS database search. These reports indicate that clearances are often amended or exceptions are added in order to accommodate local ATC facilities. However, the onboard ACARS is limited in its ability to emphasize or highlight these changes which has resulted in altitude and heading deviations along with increases in ATC workload. Furthermore, few participating airports require any type of PDC receipt confirmation. In fact, 35% of all ASRS reports dealing with PDC's include failure to acquire the PDC at all. Consequently, this study examines pilots' suggestions contained in ASRS reports in order to develop recommendations to airlines and ATC facilities to help reduce the amount of incidents that occur.

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

    Science.gov (United States)

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

    2017-01-01

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

  13. Nuclear Test Personnel Review

    Science.gov (United States)

    FOIA Electronic Reading Room Privacy Impact Assessment DTRA No Fear Act Reporting Nuclear Test Personnel Review NTPR Fact Sheets NTPR Radiation Dose Assessment Documents US Atmospheric Nuclear Test History Documents US Underground Nuclear Test History Reports NTPR Radiation Exposure Reports Enewetak

  14. Policies on documentation and disciplinary action in hospital pharmacies after a medication error.

    Science.gov (United States)

    Bauman, A N; Pedersen, C A; Schommer, J C; Griffith, N L

    2001-06-15

    Hospital pharmacies were surveyed about policies on medication error documentation and actions taken against pharmacists involved in an error. The survey was mailed to 500 randomly selected hospital pharmacy directors in the United States. Data were collected on the existence of medication error reporting policies, what types of errors were documented and how, and hospital demographics. The response rate was 28%. Virtually all of the hospitals had policies and procedures for medication error reporting. Most commonly, documentation of oral and written reprimand was placed in the personnel file of a pharmacist involved in an error. One sixth of respondents had no policy on documentation or disciplinary action in the event of an error. Approximately one fourth of respondents reported that suspension or termination had been used as a form of disciplinary action; legal action was rarely used. Many respondents said errors that caused harm (42%) or death (40%) to the patient were documented in the personnel file, but 34% of hospitals did not document errors in the personnel file regardless of error type. Nearly three fourths of respondents differentiated between errors caught and not caught before a medication leaves the pharmacy and between errors caught and not caught before administration to the patient. More emphasis is needed on documentation of medication errors in hospital pharmacies.

  15. Uses of tuberculosis mortality surveillance to identify programme errors and improve database reporting.

    Science.gov (United States)

    Selig, L; Guedes, R; Kritski, A; Spector, N; Lapa E Silva, J R; Braga, J U; Trajman, A

    2009-08-01

    In 2006, 848 persons died from tuberculosis (TB) in Rio de Janeiro, Brazil, corresponding to a mortality rate of 5.4 per 100 000 population. No specific TB death surveillance actions are currently in place in Brazil. Two public general hospitals with large open emergency rooms in Rio de Janeiro City. To evaluate the contribution of TB death surveillance in detecting gaps in TB control. We conducted a survey of TB deaths from September 2005 to August 2006. Records of TB-related deaths and deaths due to undefined causes were investigated. Complementary data were gathered from the mortality and TB notification databases. Seventy-three TB-related deaths were investigated. Transmission hazards were identified among firefighters, health care workers and in-patients. Management errors included failure to isolate suspected cases, to confirm TB, to correct drug doses in underweight patients and to trace contacts. Following the survey, 36 cases that had not previously been notified were included in the national TB notification database and the outcome of 29 notified cases was corrected. TB mortality surveillance can contribute to TB monitoring and evaluation by detecting correctable and specific programme- and hospital-based care errors, and by improving the accuracy of TB database reporting. Specific local and programmatic interventions can be proposed as a result.

  16. Latex glove sensitivity amongst diagnostic imaging healthcare personnel: a self-reporting investigation

    International Nuclear Information System (INIS)

    Healy, Jan; Brennan, Patrick C.; Bowden, Julie Anne

    2003-01-01

    The use of latex gloves has risen dramatically among healthcare workers resulting in an increase in the number of workers experiencing reactions to gloves. Little evidence of reactions among Irish healthcare workers is available. The current, self-reporting study investigated the prevalence to latex gloves amongst four professional groups within three Diagnostic Imaging Departments. Prevalence is similar to that demonstrated elsewhere with 18.3% of individuals expressing latex associated symptoms. Symptoms included itching and redness of hands, dry cracked skin, soreness of eyes and upper respiratory tract complaints. These results indicate that latex hypersensitivity is a real problem amongst Irish healthcare workers. This preliminary work provides the basis of a much larger controlled study currently being planned

  17. Automatic component calibration and error diagnostics for model-based accelerator control. Phase I final report

    International Nuclear Information System (INIS)

    Carl Stern; Martin Lee

    1999-01-01

    Phase I work studied the feasibility of developing software for automatic component calibration and error correction in beamline optics models. A prototype application was developed that corrects quadrupole field strength errors in beamline models

  18. Automatic component calibration and error diagnostics for model-based accelerator control. Phase I final report

    CERN Document Server

    Carl-Stern

    1999-01-01

    Phase I work studied the feasibility of developing software for automatic component calibration and error correction in beamline optics models. A prototype application was developed that corrects quadrupole field strength errors in beamline models.

  19. Personnel dose assignment practices

    International Nuclear Information System (INIS)

    Fix, J.J.

    1993-04-01

    Implementation of DOE N 5480.6 Radiological Control Manual Article 511(3) requirements, to minimize the assignment of personnel dosimeters, should be done only under a broader context ensuring that capabilities are in place to monitor and record personnel exposure both for compliance and for potential litigation. As noted in NCRP Report No. 114, personnel dosimetry programs are conducted to meet four major objectives: radiation safety program control and evaluation; regulatory compliance; epidemiological research; and litigation. A change to Article 511(3) is proposed that would require that minimizing the assignment of personnel dosimeters take place only following full evaluation of overall capabilities (e.g., access control, area dosimetry, etc.) to meet the NCRP objectives

  20. Error in laboratory report data for platelet count assessment in patients suspicious for dengue: a note from observation

    Directory of Open Access Journals (Sweden)

    Somsri Wiwanitkit

    2016-08-01

    Full Text Available Dengue is a common tropical infection that is still a global health threat. An important laboratory parameter for the management of dengue is platelet count. Platelet count is an useful test for diagnosis and following up on dengue. However, errors in laboratory reports can occur. This study is a retrospective analysis on laboratory report data of complete blood count in cases with suspicious dengue in a medical center within 1 month period during the outbreak season on October, 2015. According to the studied period, there were 184 requests for complete blood count for cases suspected for dengue. From those 184 laboratory report records, errors can be seen in 12 reports (6.5%. This study demonstrates that there are considerable high rate of post-analytical errors in laboratory reports. Interestingly, the platelet count in those erroneous reports can be unreliable and ineffective or problematic when it is used for the management of dengue suspicious patients.

  1. Exploring behavioural determinants relating to health professional reporting of medication errors: a qualitative study using the Theoretical Domains Framework.

    Science.gov (United States)

    Alqubaisi, Mai; Tonna, Antonella; Strath, Alison; Stewart, Derek

    2016-07-01

    Effective and efficient medication reporting processes are essential in promoting patient safety. Few qualitative studies have explored reporting of medication errors by health professionals, and none have made reference to behavioural theories. The objective was to describe and understand the behavioural determinants of health professional reporting of medication errors in the United Arab Emirates (UAE). This was a qualitative study comprising face-to-face, semi-structured interviews within three major medical/surgical hospitals of Abu Dhabi, the UAE. Health professionals were sampled purposively in strata of profession and years of experience. The semi-structured interview schedule focused on behavioural determinants around medication error reporting, facilitators, barriers and experiences. The Theoretical Domains Framework (TDF; a framework of theories of behaviour change) was used as a coding framework. Ethical approval was obtained from a UK university and all participating hospital ethics committees. Data saturation was achieved after interviewing ten nurses, ten pharmacists and nine physicians. Whilst it appeared that patient safety and organisational improvement goals and intentions were behavioural determinants which facilitated reporting, there were key determinants which deterred reporting. These included the beliefs of the consequences of reporting (lack of any feedback following reporting and impacting professional reputation, relationships and career progression), emotions (fear and worry) and issues related to the environmental context (time taken to report). These key behavioural determinants which negatively impact error reporting can facilitate the development of an intervention, centring on organisational safety and reporting culture, to enhance reporting effectiveness and efficiency.

  2. Criteria and methods for estimating external effective dose equivalent from personnel monitoring results: EDE implementation guide. Final report

    International Nuclear Information System (INIS)

    Owen, D.

    1998-09-01

    Title 10 Part 20 of the Code of Federal regulations requires that nuclear power plant licensees evaluate worker radiation exposure using a risk-based methodology termed the effective dose equivalent (EDE). EDE is a measure of radiation exposure that represents an individual's risk of stochastic injury from their exposure. EPRI has conducted research into how photons interact with the body. These results have been coupled with information on how the body's organs differ in their susceptibility to radiation injury, to produce a methodology for assessing the effective dose equivalent. The research and the resultant methodology have been described in numerous technical reports, scientific journal articles, and technical meetings. EPRI is working with the Nuclear Energy Institute to have the EPRI effective dose equivalent methodology accepted by the Nuclear Regulatory Commission for use at US nuclear power plants. In order to further familiarize power plant personnel with the methodology, this report summarizes the EDE research and presents some simple guidelines for its implementing the methodology

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

    Science.gov (United States)

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

    2013-01-01

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

  4. Frequency and analysis of non-clinical errors made in radiology reports using the National Integrated Medical Imaging System voice recognition dictation software.

    Science.gov (United States)

    Motyer, R E; Liddy, S; Torreggiani, W C; Buckley, O

    2016-11-01

    Voice recognition (VR) dictation of radiology reports has become the mainstay of reporting in many institutions worldwide. Despite benefit, such software is not without limitations, and transcription errors have been widely reported. Evaluate the frequency and nature of non-clinical transcription error using VR dictation software. Retrospective audit of 378 finalised radiology reports. Errors were counted and categorised by significance, error type and sub-type. Data regarding imaging modality, report length and dictation time was collected. 67 (17.72 %) reports contained ≥1 errors, with 7 (1.85 %) containing 'significant' and 9 (2.38 %) containing 'very significant' errors. A total of 90 errors were identified from the 378 reports analysed, with 74 (82.22 %) classified as 'insignificant', 7 (7.78 %) as 'significant', 9 (10 %) as 'very significant'. 68 (75.56 %) errors were 'spelling and grammar', 20 (22.22 %) 'missense' and 2 (2.22 %) 'nonsense'. 'Punctuation' error was most common sub-type, accounting for 27 errors (30 %). Complex imaging modalities had higher error rates per report and sentence. Computed tomography contained 0.040 errors per sentence compared to plain film with 0.030. Longer reports had a higher error rate, with reports >25 sentences containing an average of 1.23 errors per report compared to 0-5 sentences containing 0.09. These findings highlight the limitations of VR dictation software. While most error was deemed insignificant, there were occurrences of error with potential to alter report interpretation and patient management. Longer reports and reports on more complex imaging had higher error rates and this should be taken into account by the reporting radiologist.

  5. Residents' Ratings of Their Clinical Supervision and Their Self-Reported Medical Errors: Analysis of Data From 2009.

    Science.gov (United States)

    Baldwin, DeWitt C; Daugherty, Steven R; Ryan, Patrick M; Yaghmour, Nicholas A; Philibert, Ingrid

    2018-04-01

    Medical errors and patient safety are major concerns for the medical and medical education communities. Improving clinical supervision for residents is important in avoiding errors, yet little is known about how residents perceive the adequacy of their supervision and how this relates to medical errors and other education outcomes, such as learning and satisfaction. We analyzed data from a 2009 survey of residents in 4 large specialties regarding the adequacy and quality of supervision they receive as well as associations with self-reported data on medical errors and residents' perceptions of their learning environment. Residents' reports of working without adequate supervision were lower than data from a 1999 survey for all 4 specialties, and residents were least likely to rate "lack of supervision" as a problem. While few residents reported that they received inadequate supervision, problems with supervision were negatively correlated with sufficient time for clinical activities, overall ratings of the residency experience, and attending physicians as a source of learning. Problems with supervision were positively correlated with resident reports that they had made a significant medical error, had been belittled or humiliated, or had observed others falsifying medical records. Although working without supervision was not a pervasive problem in 2009, when it happened, it appeared to have negative consequences. The association between inadequate supervision and medical errors is of particular concern.

  6. Recruitment into diabetes prevention programs: what is the impact of errors in self-reported measures of obesity?

    Science.gov (United States)

    Hernan, Andrea; Philpot, Benjamin; Janus, Edward D; Dunbar, James A

    2012-07-08

    Error in self-reported measures of obesity has been frequently described, but the effect of self-reported error on recruitment into diabetes prevention programs is not well established. The aim of this study was to examine the effect of using self-reported obesity data from the Finnish diabetes risk score (FINDRISC) on recruitment into the Greater Green Triangle Diabetes Prevention Project (GGT DPP). The GGT DPP was a structured group-based lifestyle modification program delivered in primary health care settings in South-Eastern Australia. Between 2004-05, 850 FINDRISC forms were collected during recruitment for the GGT DPP. Eligible individuals, at moderate to high risk of developing diabetes, were invited to undertake baseline tests, including anthropometric measurements performed by specially trained nurses. In addition to errors in calculating total risk scores, accuracy of self-reported data (height, weight, waist circumference (WC) and Body Mass Index (BMI)) from FINDRISCs was compared with baseline data, with impact on participation eligibility presented. Overall, calculation errors impacted on eligibility in 18 cases (2.1%). Of n = 279 GGT DPP participants with measured data, errors (total score calculation, BMI or WC) in self-report were found in n = 90 (32.3%). These errors were equally likely to result in under- or over-reported risk. Under-reporting was more common in those reporting lower risk scores (Spearman-rho = -0.226, p-value recruit participants at moderate to high risk of diabetes, accurately categorising levels of overweight and obesity using self-report data. The results could be generalisable to other diabetes prevention programs using screening tools which include self-reported levels of obesity.

  7. Comparison of two self-reported measures of physical work demands in hospital personnel: a cross-sectional study

    DEFF Research Database (Denmark)

    Nabe-Nielsen, Kirsten; Fallentin, Nils; Christensen, Karl B

    2008-01-01

    daily number of patient handling tasks and Hollmann's physical load index). METHODS: A questionnaire was distributed to 535 hospital employees in a psychiatric and an orthopedic ward in a Danish hospital. Of these 411 (77%) filled in and returned the questionnaire. Only the 373 respondents who had non...... the prevalence odds ratio (POR) for LBP was 5.38 (95% CI 2.03-14.29) in the group performing more than 10 patient handling tasks per day and 2.29 (95% CI 0.93-5.66) in the group with the highest score on the physical load index. CONCLUSION: In specialized hospital wards the daily number of patient handling tasks......BACKGROUND: Low back pain (LBP) is a frequent health complaint among health care personnel. Several work tasks and working postures are associated with an increased risk of LBP. The aim of this study was to compare two self-reported measures of physical demands and their association with LBP (the...

  8. The role of financial auditor in detecting and reporting fraud and error

    OpenAIRE

    Bunget, Ovidiu-Constantin

    2009-01-01

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

  9. Comparison of two self-reported measures of physical work demands in hospital personnel: A cross-sectional study

    Directory of Open Access Journals (Sweden)

    Jensen Jette N

    2008-04-01

    Full Text Available Abstract Background Low back pain (LBP is a frequent health complaint among health care personnel. Several work tasks and working postures are associated with an increased risk of LBP. The aim of this study was to compare two self-reported measures of physical demands and their association with LBP (the daily number of patient handling tasks and Hollmann's physical load index. Methods A questionnaire was distributed to 535 hospital employees in a psychiatric and an orthopedic ward in a Danish hospital. Of these 411 (77% filled in and returned the questionnaire. Only the 373 respondents who had non-missing values on both measures of physical demands were included in the analyses. The distribution of physical demands in different job groups and wards are presented, variance analysis models are employed, and logistic regression analysis is used to analyze the association between measures of physical demands and LBP. Results In combination, hospital ward and job category explained 56.6% and 23.3% of the variance in the self-reported physical demands measured as the daily number of patient handling tasks and as the score on the physical load index, respectively. When comparing the 6% with the highest exposure the prevalence odds ratio (POR for LBP was 5.38 (95% CI 2.03–14.29 in the group performing more than 10 patient handling tasks per day and 2.29 (95% CI 0.93–5.66 in the group with the highest score on the physical load index. Conclusion In specialized hospital wards the daily number of patient handling tasks seems to be a more feasible measure of exposure when assessing the risk of LBP compared to more advanced measures of physical load on the lower lumbar spine.

  10. Analysis of error patterns in clinical radiotherapy

    International Nuclear Information System (INIS)

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

    1996-01-01

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

  11. Implementation of an audit with feedback knowledge translation intervention to promote medication error reporting in health care: a protocol.

    Science.gov (United States)

    Hutchinson, Alison M; Sales, Anne E; Brotto, Vanessa; Bucknall, Tracey K

    2015-05-19

    Health professionals strive to deliver high-quality care in an inherently complex and error-prone environment. Underreporting of medical errors challenges attempts to understand causative factors and impedes efforts to implement preventive strategies. Audit with feedback is a knowledge translation strategy that has potential to modify health professionals' medical error reporting behaviour. However, evidence regarding which aspects of this complex, multi-dimensional intervention work best is lacking. The aims of the Safe Medication Audit Reporting Translation (SMART) study are to: 1. Implement and refine a reporting mechanism to feed audit data on medication errors back to nurses 2. Test the feedback reporting mechanism to determine its utility and effect 3. Identify characteristics of organisational context associated with error reporting in response to feedback A quasi-experimental design, incorporating two pairs of matched wards at an acute care hospital, is used. Randomisation occurs at the ward level; one ward from each pair is randomised to receive the intervention. A key stakeholder reference group informs the design and delivery of the feedback intervention. Nurses on the intervention wards receive the feedback intervention (feedback of analysed audit data) on a quarterly basis for 12 months. Data for the feedback intervention come from medication documentation point-prevalence audits and weekly reports on routinely collected medication error data. Weekly reports on these data are obtained for the control wards. A controlled interrupted time series analysis is used to evaluate the effect of the feedback intervention. Self-report data are also collected from nurses on all four wards at baseline and at completion of the intervention to elicit their perceptions of the work context. Additionally, following each feedback cycle, nurses on the intervention wards are invited to complete a survey to evaluate the feedback and to establish their intentions to change

  12. Quantification of the reliability of personnel actions from the evaluation of actual German operational experience. Final report; Quantifizierung der Zuverlaessigkeit von Personalhandlungen durch Auswertung der aktuellen deutschen Betriebserfahrung. Abschlussbericht

    Energy Technology Data Exchange (ETDEWEB)

    Preischl, W.; Fassmann, W.

    2013-07-15

    characterizing human reliability from data source ''reportable events'', - Methods to select samples characterizing human reliability from data source ''safety relevant, undoubtedly error free performed personnel actions'', - Mathematical proven methodology to derive probabilistic human performance data based on samples taken from OE, - 85 new probabilistic human performance data based on operational experience in German nuclear power plants, - Approach based on accepted behavioural knowledge to structure the obtained results and to link them to the new ''second generation'' human reliability assessment methodologies. The obtained data are forming the first data base on human reliability completely derived from operational experience of German nuclear power plants. Many subject matter experts from the plants supported the research project and contributed considerably to the research results.

  13. Civil Service Evaluation. The Evolving Role of the U.S. Office of Personnel Management. A Report concerning Significant Actions of the U.S. Office of Personnel Management

    National Research Council Canada - National Science Library

    Erdreich, Ben

    1998-01-01

    The Government's program to oversee Federal personnel systems has existed in some form since World War II when rapid expansion of the civil service necessitated the delegation of personnel authorities...

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

    Science.gov (United States)

    Holecek, Andrea

    2011-01-01

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

  15. 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)

  16. Warfarin and Rivaroxaban Duplication: A Case Report and Medication Error Analysis.

    Science.gov (United States)

    Fusco, Julie A; Paulus, Eric J; Shubat, Alexandra R; Miah, Sharminara

    2015-12-01

    A 62-year-old African American man received unintentional duplicate anticoagulation therapy with warfarin 5 mg and rivaroxaban 20 mg daily for the treatment of recurrent pulmonary embolism. The patient presented to the anticoagulation clinic 6 days after hospital discharge with an International Normalized Ratio (INR) of 2.3 and he was instructed to continue warfarin 5 mg daily. Seven days later, he returned to the clinic with an INR >8.0 using a point-of-care device. He denied any signs or symptoms of bleeding. During the interview, he reported starting a new medication for neuropathy 5 days earlier. The clinical pharmacist contacted the dispensing pharmacy and determined rivaroxaban 20 mg was the new medication. The patient denied receiving new prescription counseling at the dispensing pharmacy. Because rivaroxaban can falsely elevate INR results, the actual INR value was unknown. To minimize the risk for recurrent venous thromboembolism, vitamin K was not administered and no warfarin doses were held. Rather, the patient was instructed to stop rivaroxaban and reduce the warfarin dose. Five days later, the patient returned with an INR of 4.3. He still had not experienced any signs or symptoms of bleeding. The patient was quickly stabilized on a warfarin maintenance dose of 22.5 mg weekly. The anticoagulation clinic pharmacist notified management at the clinic and at the dispensing pharmacy in an effort to identify process errors and prevent additional incidents.

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

    Science.gov (United States)

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

    2016-03-01

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

  18. 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

  19. Error reporting from the da Vinci surgical system in robotic surgery: A Canadian multispecialty experience at a single academic centre.

    Science.gov (United States)

    Rajih, Emad; Tholomier, Côme; Cormier, Beatrice; Samouëlian, Vanessa; Warkus, Thomas; Liberman, Moishe; Widmer, Hugues; Lattouf, Jean-Baptiste; Alenizi, Abdullah M; Meskawi, Malek; Valdivieso, Roger; Hueber, Pierre-Alain; Karakewicz, Pierre I; El-Hakim, Assaad; Zorn, Kevin C

    2017-05-01

    The goal of the study is to evaluate and report on the third-generation da Vinci surgical (Si) system malfunctions. A total of 1228 robotic surgeries were performed between January 2012 and December 2015 at our academic centre. All cases were performed by using a single, dual console, four-arm, da Vinci Si robot system. The three specialties included urology, gynecology, and thoracic surgery. Studied outcomes included the robotic surgical error types, immediate consequences, and operative side effects. Error rate trend with time was also examined. Overall robotic malfunctions were documented on the da Vinci Si systems event log in 4.97% (61/1228) of the cases. The most common error was related to pressure sensors in the robotic arms indicating out of limit output. This recoverable fault was noted in 2.04% (25/1228) of cases. Other errors included unrecoverable electronic communication-related in 1.06% (13/1228) of cases, failed encoder error in 0.57% (7/1228), illuminator-related in 0.33% (4/1228), faulty switch in 0.24% (3/1228), battery-related failures in 0.24% (3/1228), and software/hardware error in 0.08% (1/1228) of cases. Surgical delay was reported only in one patient. No conversion to either open or laparoscopic occurred secondary to robotic malfunctions. In 2015, the incidence of robotic error rose to 1.71% (21/1228) from 0.81% (10/1228) in 2014. Robotic malfunction is not infrequent in the current era of robotic surgery in various surgical subspecialties, but rarely consequential. Their seldom occurrence does not seem to affect patient safety or surgical outcome.

  20. An Analysis of the Relationship between Select Organizational Climate Factors and Job Satisfaction Factors as Reported by Community College Personnel

    Science.gov (United States)

    San Giacomo, Rose-Marie Carla

    2011-01-01

    The purpose of this study was to investigate the overall satisfaction with organizational climate factors across seven studies of various levels of community college personnel. A secondary purpose was to determine if there was a significant relationship between satisfaction with organizational climate factors and the importance of job satisfaction…

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

    Science.gov (United States)

    Scobie, Andrea

    2011-04-01

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

  2. Human error in remote Afterloading Brachytherapy

    International Nuclear Information System (INIS)

    Quinn, M.L.; Callan, J.; Schoenfeld, I.; Serig, D.

    1994-01-01

    Remote Afterloading Brachytherapy (RAB) is a medical process used in the treatment of cancer. RAB uses a computer-controlled device to remotely insert and remove radioactive sources close to a target (or tumor) in the body. Some RAB problems affecting the radiation dose to the patient have been reported and attributed to human error. To determine the root cause of human error in the RAB system, a human factors team visited 23 RAB treatment sites in the US. The team observed RAB treatment planning and delivery, interviewed RAB personnel, and performed walk-throughs, during which staff demonstrated the procedures and practices used in performing RAB tasks. Factors leading to human error in the RAB system were identified. The impact of those factors on the performance of RAB was then evaluated and prioritized in terms of safety significance. Finally, the project identified and evaluated alternative approaches for resolving the safety significant problems related to human error

  3. Participant characteristics associated with errors in self-reported energy intake from the Women's Health Initiative food-frequency questionnaire.

    Science.gov (United States)

    Horner, Neilann K; Patterson, Ruth E; Neuhouser, Marian L; Lampe, Johanna W; Beresford, Shirley A; Prentice, Ross L

    2002-10-01

    Errors in self-reported dietary intake threaten inferences from studies relying on instruments such as food-frequency questionnaires (FFQs), food records, and food recalls. The objective was to quantify the magnitude, direction, and predictors of errors associated with energy intakes estimated from the Women's Health Initiative FFQ. Postmenopausal women (n = 102) provided data on sociodemographic and psychosocial characteristics that relate to errors in self-reported energy intake. Energy intake was objectively estimated as total energy expenditure, physical activity expenditure, and the thermic effect of food (10% addition to other components of total energy expenditure). Participants underreported energy intake on the FFQ by 20.8%; this error trended upward with younger age (P = 0.07) and social desirability (P = 0.09) but was not associated with body mass index (P = 0.95). The correlation coefficient between reported energy intake and total energy expenditure was 0.24; correlations were higher among women with less education, higher body mass index, and greater fat-free mass, social desirability, and dissatisfaction with perceived body size (all P diet and disease association studies.

  4. A survey of mindset theories of intelligence and medical error self-reporting among pediatric housestaff and faculty.

    Science.gov (United States)

    Jegathesan, Mithila; Vitberg, Yaffa M; Pusic, Martin V

    2016-02-11

    Intelligence theory research has illustrated that people hold either "fixed" (intelligence is immutable) or "growth" (intelligence can be improved) mindsets and that these views may affect how people learn throughout their lifetime. Little is known about the mindsets of physicians, and how mindset may affect their lifetime learning and integration of feedback. Our objective was to determine if pediatric physicians are of the "fixed" or "growth" mindset and whether individual mindset affects perception of medical error reporting.  We sent an anonymous electronic survey to pediatric residents and attending pediatricians at a tertiary care pediatric hospital. Respondents completed the "Theories of Intelligence Inventory" which classifies individuals on a 6-point scale ranging from 1 (Fixed Mindset) to 6 (Growth Mindset). Subsequent questions collected data on respondents' recall of medical errors by self or others. We received 176/349 responses (50 %). Participants were equally distributed between mindsets with 84 (49 %) classified as "fixed" and 86 (51 %) as "growth". Residents, fellows and attendings did not differ in terms of mindset. Mindset did not correlate with the small number of reported medical errors. There is no dominant theory of intelligence (mindset) amongst pediatric physicians. The distribution is similar to that seen in the general population. Mindset did not correlate with error reports.

  5. Self-reported health and sleep complaints among nursing personnel working under 12 h night and day shifts.

    Science.gov (United States)

    Portela, Luciana F; Rotenberg, Lúcia; Waissmann, William

    2004-01-01

    This cross-sectional exploratory study involved health care workers of various skill types and levels. We tested the hypothesis that the prevalence of diseases, sleep complaints, and insufficient time for nonprofessional activities (family, leisure, and rest) are higher among night than day workers. Data collection was carried out in two public hospitals using questionnaires and other forms. Night work was explored as a risk factor, considering a night worker as one who had at least one night job on the occasion of the research. Data were assessed by a univariate analysis. The association between work schedule and the dependent variables--health conditions, sleep complaints, and insufficient time for nonprofessional activities--was evaluated through the estimation of the prevalence ratio, with a confidence interval of 95%. Two hundred and fifty-eight female nursing personnel participated; 41.5% were moonlighters, and only 20 worked a shift of less than 12h in length. Reports of migraine and need of medical care the 2 weeks before the survey were more prevalent among day than night workers (PR=0.71; CI=0.55-0.92 and PR=0.71; CI=0.52-0.95, respectively). Migraine headaches occurred less frequently among night than day workers as confirmed by comparing the reports of the night workers and day workers whose work history was always day shifts (PR = 0.74; CI = 0.57-0.96). Reports of mild emotional disorders (mild depression, tension, anxiety, or insomnia) were less frequent among night (PR=0.76; CI=0.59-0.98) and ex-night workers (PR=0.68; CI=0.50-0.91) than day workers who never had worked a night job. The healthy worker effect does not seem to explain the results of the comparisons between day and night workers. The possible role of exposure by day workers to some risk factors, such as stress, was suggested as an explanation for these results. No significant difference was observed between night and day workers as to sleep complaints, a result that may have been

  6. Report of the Error and Emittance Task Force on the superconducting super collider: Part 1, Resistive machines

    International Nuclear Information System (INIS)

    1993-10-01

    A review of the design and specifications of the resistive accelerators in the SSC complex was conducted during the past year. This review was initiated in response to a request from the SSC Project Manager. The Error and Emittance Task Force was created October 30, 1992, and charged with reviewing issues associated with the specification of errors and tolerances throughout the injector chain and in the Collider, and to optimize the global error budget. Effects which directly impact the emittance budget were of prime importance. The Task Force responded to three charges: Examination of the resistive accelerators and their injection and extraction systems; examination of the connecting beamlines and the overall approach taken in their design; and global filling, timing, and synchronization issues. The High Energy Booster and the Collider were deemed to be sufficiently different from the resistive accelerators that it was decided to treat them as a separate group. They will be the subject of a second part to this report

  7. An emerging network storage management standard: Media error monitoring and reporting information (MEMRI) - to determine optical tape data integrity

    Science.gov (United States)

    Podio, Fernando; Vollrath, William; Williams, Joel; Kobler, Ben; Crouse, Don

    1998-01-01

    Sophisticated network storage management applications are rapidly evolving to satisfy a market demand for highly reliable data storage systems with large data storage capacities and performance requirements. To preserve a high degree of data integrity, these applications must rely on intelligent data storage devices that can provide reliable indicators of data degradation. Error correction activity generally occurs within storage devices without notification to the host. Early indicators of degradation and media error monitoring 333 and reporting (MEMR) techniques implemented in data storage devices allow network storage management applications to notify system administrators of these events and to take appropriate corrective actions before catastrophic errors occur. Although MEMR techniques have been implemented in data storage devices for many years, until 1996 no MEMR standards existed. In 1996 the American National Standards Institute (ANSI) approved the only known (world-wide) industry standard specifying MEMR techniques to verify stored data on optical disks. This industry standard was developed under the auspices of the Association for Information and Image Management (AIIM). A recently formed AIIM Optical Tape Subcommittee initiated the development of another data integrity standard specifying a set of media error monitoring tools and media error monitoring information (MEMRI) to verify stored data on optical tape media. This paper discusses the need for intelligent storage devices that can provide data integrity metadata, the content of the existing data integrity standard for optical disks, and the content of the MEMRI standard being developed by the AIIM Optical Tape Subcommittee.

  8. Personnel supply and demand issues in the nuclear power industry. Final report of the Nuclear Manpower Study Committee

    International Nuclear Information System (INIS)

    1981-01-01

    The anticipated personnel needs of the nuclear power industry have varied widely in recent years, in response to both increasing regulatory requirements and declining orders for new plants. Recent employment patterns in the nuclear energy field, with their fluctuations, resemble those of defense industries more than those traditionally associated with electric utilities. Reactions to the accident at Three Mile Island Unit 2 by industry and regulators have increased the demand for trained and experienced personnel, causing salaries to rise. Industry, for example, has established several advisory organizations like the Institute for Nuclear Power Operations (INPO). At the same time, the US Nuclear Regulatory Commission (NRC) has imposed many new construction and operating requirements in an effort to take advantage of lessons learned from the Three Mile Island incident and to respond to the perceived public interest in better regulation of nuclear power. Thus, at present, utilities, architect-engineer firms, reactor vendors, and organizations in the nuclear development community have heavy workloads

  9. Development and Implementation of a Model Training Program to Assist Special Educators, Parks and Resource Management Personnel and Parents to Cooperatively Plan and Conduct Outdoor/Environmental Education Programs for Handicapped Children and Youth. Final Report.

    Science.gov (United States)

    Vinton, Dennis A.; Zachmeyer, Richard F.

    This final report presents a description of a 3-year project to develop and implement a model training program (for special education personnel, park and resource management personnel, and parents of disabled children) designed to promote outdoor environmental education for disabled children. The project conducted 22 training workshops (2-5 days)…

  10. Statistical reporting errors and collaboration on statistical analyses in psychological science

    NARCIS (Netherlands)

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

    2014-01-01

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

  11. Measurement Error and Bias in Value-Added Models. Research Report. ETS RR-17-25

    Science.gov (United States)

    Kane, Michael T.

    2017-01-01

    By aggregating residual gain scores (the differences between each student's current score and a predicted score based on prior performance) for a school or a teacher, value-added models (VAMs) can be used to generate estimates of school or teacher effects. It is known that random errors in the prior scores will introduce bias into predictions of…

  12. Systematic analysis of dependent human errors from the maintenance history at finnish NPPs - A status report

    Energy Technology Data Exchange (ETDEWEB)

    Laakso, K. [VTT Industrial Systems (Finland)

    2002-12-01

    Operating experience has shown missed detection events, where faults have passed inspections and functional tests to operating periods after the maintenance activities during the outage. The causes of these failures have often been complex event sequences, involving human and organisational factors. Especially common cause and other dependent failures of safety systems may significantly contribute to the reactor core damage risk. The topic has been addressed in the Finnish studies of human common cause failures, where experiences on latent human errors have been searched and analysed in detail from the maintenance history. The review of the bulk of the analysis results of the Olkiluoto and Loviisa plant sites shows that the instrumentation and control and electrical equipment is more prone to human error caused failure events than the other maintenance and that plant modifications and also predetermined preventive maintenance are significant sources of common cause failures. Most errors stem from the refuelling and maintenance outage period at the both sites, and less than half of the dependent errors were identified during the same outage. The dependent human errors originating from modifications could be reduced by a more tailored specification and coverage of their start-up testing programs. Improvements could also be achieved by a more case specific planning of the installation inspection and functional testing of complicated maintenance works or work objects of higher plant safety and availability importance. A better use and analysis of condition monitoring information for maintenance steering could also help. The feedback from discussions of the analysis results with plant experts and professionals is still crucial in developing the final conclusions and recommendations that meet the specific development needs at the plants. (au)

  13. The content of lexical stimuli and self-reported physiological state modulate error-related negativity amplitude.

    Science.gov (United States)

    Benau, Erik M; Moelter, Stephen T

    2016-09-01

    The Error-Related Negativity (ERN) and Correct-Response Negativity (CRN) are brief event-related potential (ERP) components-elicited after the commission of a response-associated with motivation, emotion, and affect. The Error Positivity (Pe) typically appears after the ERN, and corresponds to awareness of having committed an error. Although motivation has long been established as an important factor in the expression and morphology of the ERN, physiological state has rarely been explored as a variable in these investigations. In the present study, we investigated whether self-reported physiological state (SRPS; wakefulness, hunger, or thirst) corresponds with ERN amplitude and type of lexical stimuli. Participants completed a SRPS questionnaire and then completed a speeded Lexical Decision Task with words and pseudowords that were either food-related or neutral. Though similar in frequency and length, food-related stimuli elicited increased accuracy, faster errors, and generated a larger ERN and smaller CRN than neutral words. Self-reported thirst correlated with improved accuracy and smaller ERN and CRN amplitudes. The Pe and Pc (correct positivity) were not impacted by physiological state or by stimulus content. The results indicate that physiological state and manipulations of lexical content may serve as important avenues for future research. Future studies that apply more sensitive measures of physiological and motivational state (e.g., biomarkers for satiety) or direct manipulations of satiety may be a useful technique for future research into response monitoring. Copyright © 2016 Elsevier Inc. All rights reserved.

  14. Medication errors: prescribing faults and prescription errors.

    Science.gov (United States)

    Velo, Giampaolo P; Minuz, Pietro

    2009-06-01

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

  15. The impact of safety organizing, trusted leadership, and care pathways on reported medication errors in hospital nursing units.

    Science.gov (United States)

    Vogus, Timothy J; Sutcliffe, Kathleen M

    2011-01-01

    Prior research has found that safety organizing behaviors of registered nurses (RNs) positively impact patient safety. However, little research exists on the joint benefits of safety organizing and other contextual factors that help foster safety. Although we know that organizational practices often have more powerful effects when combined with other mutually reinforcing practices, little research exists on the joint benefits of safety organizing and other contextual factors believed to foster safety. Specifically, we examined the benefits of bundling safety organizing with leadership (trust in manager) and design (use of care pathways) factors on reported medication errors. A total of 1033 RNs and 78 nurse managers in 78 emergency, internal medicine, intensive care, and surgery nursing units in 10 acute-care hospitals in Indiana, Iowa, Maryland, Michigan, and Ohio who completed questionnaires between December 2003 and June 2004. Cross-sectional analysis of medication errors reported to the hospital incident reporting system for the 6 months after the administration of the survey linked to survey data on safety organizing, trust in manager, use of care pathways, and RN characteristics and staffing. Multilevel Poisson regression analyses indicated that the benefits of safety organizing on reported medication errors were amplified when paired with high levels of trust in manager or the use of care pathways. Safety organizing plays a key role in improving patient safety on hospital nursing units especially when bundled with other organizational components of a safety supportive system.

  16. Systematic Review of Errors in Inhaler Use

    DEFF Research Database (Denmark)

    Sanchis, Joaquin; Gich, Ignasi; Pedersen, Søren

    2016-01-01

    in these outcomes over these 40 years and when partitioned into years 1 to 20 and years 21 to 40. Analyses were conducted in accordance with recommendations from Preferred Reporting Items for Systematic Reviews and Meta-Analyses and Strengthening the Reporting of Observational Studies in Epidemiology. Results Data...... A systematic search for articles reporting direct observation of inhaler technique by trained personnel covered the period from 1975 to 2014. Outcomes were the nature and frequencies of the three most common errors; the percentage of patients demonstrating correct, acceptable, or poor technique; and variations...

  17. 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).

  18. 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....

  19. Inducible error-prone repair in B. subtilis. Progress report, September 1, 1979-February 28, 1981

    International Nuclear Information System (INIS)

    Yasbin, R.E.

    1980-10-01

    The mechanism of activation and the mode of action of the SOS system in Bacillus subtilis are being investigated. Interesting aspects of the SOS system in B. subtilis include: (1) the differences between the SOS functions in this bacterium and in the enteric bacteria; (2) the spontaneous activation of SOS functions in competent cells; and (3) the difficulty in establishing the presence of error-prone repair in this bacterium. In order to characterize the SOS system of B. subtilis, attempts will be made to: (1) isolate bacteria mutated in genes controlling various repair functions; (2) investigate inducible repair; (3) determine the role of endogenous prophages in DNA repair phenomena; and (4) utilize competent B. subtilis as a tester system for the detection of potential carcinogens. Data obtained during the past 18 months demonstrate: (1) the ability of the B. subtilis Comptest to detect potential environmental carcinogens; (2) the importance of DNA polymerase III in W-reactivation in B. subtilis; and (3) the control the bacteriophage SPβ has over the inducible DNA modification system in B. subtilis. Furthermore, the data also suggests the lack of error-prone repair in B. subtilis, and the differences which exist between the Bacilli and the enteric bacteria with regards to SOS phenomena. In order to further characterize inducible repair functions in B. subtilis, results will also be presented on attempts to mobilize error-prone repair systems of other bacterial species

  20. Medication Review and Transitions of Care: A Case Report of a Decade-Old Medication Error.

    Science.gov (United States)

    Comer, Rachel; Lizer, Mitsi

    2017-10-01

    A 69-year-old Caucasian male with a 25-year history of paranoid schizophrenia was brought to the emergency department because of violence toward the staff in his nursing facility. He was diagnosed with a urinary tract infection and was admitted to the behavioral health unit for medication stabilization. History included a five-year state psychiatric hospital admission and nursing facility placement. Because of poor cognitive function, the patient was unable to corroborate medication history, so the pharmacy student on rotation performed an in-depth chart review. The review revealed a transcription error in 2003 deleting amantadine 100 mg twice daily and adding amiodarone 100 mg twice daily. Subsequent hospitalization resulted in another transcription error increasing the amiodarone to 200 mg twice daily. All electrocardiograms conducted were negative for atrial fibrillation. Once detected, the consulted cardiologist discontinued the amiodarone, and the primary care provider was notified via letter and discharge papers. An admission four months later revealed that the nursing facility restarted the amiodarone. Amiodarone was discontinued and the facility was again notified. This case reviews how a 10-year-old medication error went undetected in the electronic medical records through numerous medication reconciliations, but was uncovered when a single comprehensive medication review was conducted.

  1. Learning from incident reports in the Australian medical imaging setting: handover and communication errors.

    Science.gov (United States)

    Hannaford, N; Mandel, C; Crock, C; Buckley, K; Magrabi, F; Ong, M; Allen, S; Schultz, T

    2013-02-01

    To determine the type and nature of incidents occurring within medical imaging settings in Australia and identify strategies that could be engaged to reduce the risk of their re-occurrence. 71 search terms, related to clinical handover and communication, were applied to 3976 incidents in the Radiology Events Register. Detailed classification and thematic analysis of a subset of incidents that involved handover or communication (n=298) were undertaken to identify the most prevalent types of error and to make recommendations about patient safety initiatives in medical imaging. Incidents occurred most frequently during patient preparation (34%), when requesting imaging (27%) and when communicating a diagnosis (23%). Frequent problems within each of these stages of the imaging cycle included: inadequate handover of patients (41%) or unsafe or inappropriate transfer of the patient to or from medical imaging (35%); incorrect information on the request form (52%); and delayed communication of a diagnosis (36%) or communication of a wrong diagnosis (36%). The handover of patients and clinical information to and from medical imaging is fraught with error, often compromising patient safety and resulting in communication of delayed or wrong diagnoses, unnecessary radiation exposure and a waste of limited resources. Corrective strategies to address safety concerns related to new information technologies, patient transfer and inadequate test result notification policies are relevant to all healthcare settings. Handover and communication errors are prevalent in medical imaging. System-wide changes that facilitate effective communication are required.

  2. Inducible error-prone repair in B. subtilis. Progress report, September 1, 1981-April 30, 1983

    International Nuclear Information System (INIS)

    Yasbin, R.E.

    1982-12-01

    Considerable progress has been made on determining the mechanisms of mutagenesis in B. subtilis and on elucidating the interactions between DNA repair systems and mutagenesis in this bacterium. Specifically, the B. subtilis W-reactivation system has been shown to involve a damage-specific (pyrimidine dimer) repair mechanism which may or may not be error-free. On the other hand, error-prone repair (as defined by the ability of cells to be mutated by low doses of uv) has been definitively established in this bacterium. The investigation of the genes controlling the error-prone repair system has revealed that uv mutagenesis is significantly decreased in cells carrying the recG13 mutation. In addition, cells lacking a functional excision repair system are hypermutable to EMS, although these cells are not hypersensitive to the killing activity of EMS. Both EMS and uv generate the same spectrum of mutants (reversions vs suppressors); however, cells lacking a functional excision repair system apparently generate more suppressor mutations when exposed to uv as compared to the other strains tested. A genomic library for B. subtilis has been established. This library will be specifically used to isolate a cloned fragment of DNA which codes for the major subunit of the Bacillus DNA polymerase III. However, this bank can also be used to isolate Bacillus genes which control most of the repair functions. Furthermore, we have begun the process of cloning the E. coli phr + gene in to B. subtilis

  3. Balancing Work Responsibilities and Family Needs: The Federal Civil Service Response. A Report Concerning Significant Actions of the U.S. Office of Personnel Management. A Report to the President and the Congress of the United States.

    Science.gov (United States)

    Merit Systems Protection Board, Washington, DC.

    This report examines actions of the U.S. Office of Personnel Management in providing leadership to several of the government's human resource management programs in the work and family benefits area. It reviews employee benefit programs that help civilian federal workers balance their work responsibilities and personal needs. Programs reviewed are…

  4. Implementation of the Education of the Handicapped Act [Public Law 94-142], 1988. Tenth Annual Report to Congress. Summary of Information on the Supply of and Demand for Personnel. Reporting Data on the 1985-86 School Year.

    Science.gov (United States)

    National Clearinghouse for Professions in Special Education, Reston, VA.

    This paper summarizes information reported by states for the 1985-86 school year on supply of and demand for personnel necessary for implementation of the Education of the Handicapped Act. Following a narrative section which synthesizes the statistics, tables give data for numbers of teachers needed and employed, broken down by handicapping…

  5. Implementation of the Education of the Handicapped Act [Public Law 94-142], 1987. Ninth Annual Report to Congress. Summary of Information on the Supply of and Demand for Personnel. Reporting Data on the 1984-85 School Year.

    Science.gov (United States)

    National Clearinghouse for Professions in Special Education, Reston, VA.

    This paper summarizes information reported by states for the 1984-1985 school year on supply of and demand for personnel necessary for implementation of the Education of the Handicapped Act. Following a narrative section which synthesizes the statistics, tables give data for numbers of teachers needed and employed, broken down by handicapping…

  6. 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

  7. List of Error-Prone Abbreviations, Symbols, and Dose Designations

    Science.gov (United States)

    ... Analysis and Coaching Report an Error Report a Medication Error Report a Vaccine Error Consumer Error Reporting Search ... which have been reported through the ISMP National Medication Errors Reporting Program (ISMP MERP) as being frequently misinterpreted ...

  8. Learning without Borders: A Review of the Implementation of Medical Error Reporting in Médecins Sans Frontières.

    Directory of Open Access Journals (Sweden)

    Leslie Shanks

    Full Text Available To analyse the results from the first 3 years of implementation of a medical error reporting system in Médecins Sans Frontières-Operational Centre Amsterdam (MSF programs.A medical error reporting policy was developed with input from frontline workers and introduced to the organisation in June 2010. The definition of medical error used was "the failure of a planned action to be completed as intended or the use of a wrong plan to achieve an aim." All confirmed error reports were entered into a database without the use of personal identifiers.179 errors were reported from 38 projects in 18 countries over the period of June 2010 to May 2013. The rate of reporting was 31, 42, and 106 incidents/year for reporting year 1, 2 and 3 respectively. The majority of errors were categorized as dispensing errors (62 cases or 34.6%, errors or delays in diagnosis (24 cases or 13.4% and inappropriate treatment (19 cases or 10.6%. The impact of the error was categorized as no harm (58, 32.4%, harm (70, 39.1%, death (42, 23.5% and unknown in 9 (5.0% reports. Disclosure to the patient took place in 34 cases (19.0%, did not take place in 46 (25.7%, was not applicable for 5 (2.8% cases and not reported for 94 (52.5%. Remedial actions introduced at headquarters level included guideline revisions and changes to medical supply procedures. At field level improvements included increased training and supervision, adjustments in staffing levels, and adaptations to the organization of the pharmacy.It was feasible to implement a voluntary reporting system for medical errors despite the complex contexts in which MSF intervenes. The reporting policy led to system changes that improved patient safety and accountability to patients. Challenges remain in achieving widespread acceptance of the policy as evidenced by the low reporting and disclosure rates.

  9. When ab ≠ c - c': published errors in the reports of single-mediator models.

    Science.gov (United States)

    Petrocelli, John V; Clarkson, Joshua J; Whitmire, Melanie B; Moon, Paul E

    2013-06-01

    Accurate reports of mediation analyses are critical to the assessment of inferences related to causality, since these inferences are consequential for both the evaluation of previous research (e.g., meta-analyses) and the progression of future research. However, upon reexamination, approximately 15% of published articles in psychology contain at least one incorrect statistical conclusion (Bakker & Wicherts, Behavior research methods, 43, 666-678 2011), disparities that beget the question of inaccuracy in mediation reports. To quantify this question of inaccuracy, articles reporting standard use of single-mediator models in three high-impact journals in personality and social psychology during 2011 were examined. More than 24% of the 156 models coded failed an equivalence test (i.e., ab = c - c'), suggesting that one or more regression coefficients in mediation analyses are frequently misreported. The authors cite common sources of errors, provide recommendations for enhanced accuracy in reports of single-mediator models, and discuss implications for alternative methods.

  10. The Impact of Measurement Error on Estimates of the Price Reaction to USDA Crop Reports

    OpenAIRE

    Aulerich, Nicole M.; Irwin, Scott H.; Nelson, Carl H.

    2007-01-01

    This paper investigates the impact of USDA crop production reports in corn and soybean futures markets. The analysis is based on all corn and soybean production reports released over 1970-2006. The empirical analysis compares the typical OLS event study approach to the new Identification by Censoring (ITC) technique. Corn and soybean production reports are analyzed both separately and together for impact in corn and soybean futures prices. ITC proves to be the more useful method because it av...

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

    Science.gov (United States)

    Hwang, Jee-In; Park, Hyeoun-Ae

    2017-12-01

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

  12. The Relationships Among Perceived Patients' Safety Culture, Intention to Report Errors, and Leader Coaching Behavior of Nurses in Korea: A Pilot Study.

    Science.gov (United States)

    Ko, YuKyung; Yu, Soyoung

    2017-09-01

    This study was undertaken to explore the correlations among nurses' perceptions of patient safety culture, their intention to report errors, and leader coaching behaviors. The participants (N = 289) were nurses from 5 Korean hospitals with approximately 300 to 500 beds each. Sociodemographic variables, patient safety culture, intention to report errors, and coaching behavior were measured using self-report instruments. Data were analyzed using descriptive statistics, Pearson correlation coefficient, the t test, and the Mann-Whitney U test. Nurses' perceptions of patient safety culture and their intention to report errors showed significant differences between groups of nurses who rated their leaders as high-performing or low-performing coaches. Perceived coaching behavior showed a significant, positive correlation with patient safety culture and intention to report errors, i.e., as nurses' perceptions of coaching behaviors increased, so did their ratings of patient safety culture and error reporting. There is a need in health care settings for coaching by nurse managers to provide quality nursing care and thus improve patient safety. Programs that are systematically developed and implemented to enhance the coaching behaviors of nurse managers are crucial to the improvement of patient safety and nursing care. Moreover, a systematic analysis of the causes of malpractice, as opposed to a focus on the punitive consequences of errors, could increase error reporting and therefore promote a culture in which a higher level of patient safety can thrive.

  13. Research results reported by OEO summer (1981) student employees of LLNL working with Earth Sciences (K) Division personnel

    International Nuclear Information System (INIS)

    Doyle, M.C.; Griffith, P.J.; Kreevoy, E.P.; Turner, H.J. III; Tatman, D.A.

    1982-01-01

    Significant experimental results were achieved in a number of research programs that were carried out during the summer of 1981 by students sponsored by the Office of Equal Opportunity at the Lawrence Livermore National Laboratory. These students were working with Earth Sciences (K) Division personnel. Accomplishments include the following: (1) preparation of post-burn stratigraphic sections for the Hoe Creek III experiment, Underground Coal Gasification project; (2) preparation of miscellaneous stratigraphic sections in the Climax granite near the Spent Fuel Test, Nevada Test Site, for the Waste Isolation Project; (3) confirmation of the applicability of a new theory relating to subsidence (solid matrix movement); (4) experimental confirmation that organic groundwater contaminants produced during an underground coal gasification experiment can be removed by appropriate bacterial treatment; (5) development of data supporting the extension of the Greenville Fault Zone into the Northern Diablo Range (Alameda and Santa Clara Counties, California); (6) completion of a literature review on hazardous waste (current disposal technology, regulations, research needs); (7) preparation of a map showing levels of background seismic noise in the USSR; (8) demonstration of a correlation of explosion size with the P-wave magnitude of the seismic signal produced by the explosion; and (9) reduction of data showing the extent of ground motion resulting from subsidence in the vicinity of the Hoe Creek III experiment, Underground Coal Gasification Project

  14. Research results reported by OEO summer (1981) student employees of LLNL working with Earth Sciences (K) Division personnel

    Energy Technology Data Exchange (ETDEWEB)

    Doyle, M. C.; Griffith, P. J.; Kreevoy, E. P.; Turner, III, H. J.; Tatman, D. A.

    1982-01-01

    Significant experimental results were achieved in a number of research programs that were carried out during the summer of 1981 by students sponsored by the Office of Equal Opportunity at the Lawrence Livermore National Laboratory. These students were working with Earth Sciences (K) Division personnel. Accomplishments include the following: (1) preparation of post-burn stratigraphic sections for the Hoe Creek III experiment, Underground Coal Gasification project; (2) preparation of miscellaneous stratigraphic sections in the Climax granite near the Spent Fuel Test, Nevada Test Site, for the Waste Isolation Project; (3) confirmation of the applicability of a new theory relating to subsidence (solid matrix movement); (4) experimental confirmation that organic groundwater contaminants produced during an underground coal gasification experiment can be removed by appropriate bacterial treatment; (5) development of data supporting the extension of the Greenville Fault Zone into the Northern Diablo Range (Alameda and Santa Clara Counties, California); (6) completion of a literature review on hazardous waste (current disposal technology, regulations, research needs); (7) preparation of a map showing levels of background seismic noise in the USSR; (8) demonstration of a correlation of explosion size with the P-wave magnitude of the seismic signal produced by the explosion; and (9) reduction of data showing the extent of ground motion resulting from subsidence in the vicinity of the Hoe Creek III experiment, Underground Coal Gasification Project.

  15. Use of control room simulators for training of nuclear power plant personnel

    International Nuclear Information System (INIS)

    2004-09-01

    Safety analysis and operational experience consistently indicate that human error is the greatest contributor to the risk of a severe accident in a nuclear power plant. Subsequent to the Three Mile Island accident, major changes were made internationally in reducing the potential for human error through improved procedures, information presentation, and training of operators. The use of full scope simulators in the training of operators is an essential element of these efforts to reduce human error. The operators today spend a large fraction of their time training and retraining on the simulator. As indicated in the IAEA Safety Guide on Recruitment, Qualification and Training of Personnel for Nuclear Power Plants, NS-G-2.8, 2002, representative simulator facilities should be used for training of control room operators and shift supervisors. Simulator training should incorporate normal, abnormal and accident conditions. The ability of the simulator to closely represent the actual conditions and environment that would be experienced in a real situation is critical to the value of the training received. The objective of this report is to provide nuclear power plant (NPP) managers, training centre managers and personnel involved with control room simulator training with practical information they can use to improve the performance of their personnel. While the emphasis in this publication is on simulator training of control room personnel using full scope simulators, information is also provided on how organizations have effectively used control room simulators for training of other NPP personnel, including simulators other than full-scope simulators

  16. Military Personnel: DOD's Predatory Lending Report Addressed Mandated Issues, but Support Is Limited for Some Findings and Recommendations

    National Research Council Canada - National Science Library

    Farrell, Brenda S

    2007-01-01

    ... (see the list of related GAO products at the end of this report). In conducting our review, we limited the scope of our work to the types of loans that DOD identified as being predatory in its mandated 2006 report...

  17. Nurse perceptions of organizational culture and its association with the culture of error reporting: a case of public sector hospitals in Pakistan.

    Science.gov (United States)

    Jafree, Sara Rizvi; Zakar, Rubeena; Zakar, Muhammad Zakria; Fischer, Florian

    2016-01-05

    There is an absence of formal error tracking systems in public sector hospitals of Pakistan and also a lack of literature concerning error reporting culture in the health care sector. Nurse practitioners have front-line knowledge and rich exposure about both the organizational culture and error sharing in hospital settings. The aim of this paper was to investigate the association between organizational culture and the culture of error reporting, as perceived by nurses. The authors used the "Practice Environment Scale-Nurse Work Index Revised" to measure the six dimensions of organizational culture. Seven questions were used from the "Survey to Solicit Information about the Culture of Reporting" to measure error reporting culture in the region. Overall, 309 nurses participated in the survey, including female nurses from all designations such as supervisors, instructors, ward-heads, staff nurses and student nurses. We used SPSS 17.0 to perform a factor analysis. Furthermore, descriptive statistics, mean scores and multivariable logistic regression were used for the analysis. Three areas were ranked unfavorably by nurse respondents, including: (i) the error reporting culture, (ii) staffing and resource adequacy, and (iii) nurse foundations for quality of care. Multivariable regression results revealed that all six categories of organizational culture, including: (1) nurse manager ability, leadership and support, (2) nurse participation in hospital affairs, (3) nurse participation in governance, (4) nurse foundations of quality care, (5) nurse-coworkers relations, and (6) nurse staffing and resource adequacy, were positively associated with higher odds of error reporting culture. In addition, it was found that married nurses and nurses on permanent contract were more likely to report errors at the workplace. Public healthcare services of Pakistan can be improved through the promotion of an error reporting culture, reducing staffing and resource shortages and the

  18. Inducible error-prone repair in B. subtilis. Progress report, September 1, 1981-April 30, 1985

    Energy Technology Data Exchange (ETDEWEB)

    Yasbin, R.E.

    1984-12-01

    The objective was to investigate and elucidate the molecular mechanisms responsible for (i) inducible DNA repair system(s) and for (ii) error-prone repair in the gram positive bacterium Bacillus subtilis. The SOS-like system of Bacillus subtilis consists of several coordinately induced phenomena (e.g., cellular filamentation, prophage induction, and Weigle reactivation of uv-damaged bacteriophage) which are expressed after cellular insult such as DNA damage or inhibition of DNA replication. Mutagenesis of the bacterial chromosome and the development or maintenance of competence also appear to be involved in the SOS-like response in this bacterium. The genetic characterization of the SOS-like system has involved an analysis of (i) the effects of various DNA repair mutations on the expression of inducible phenomena and (ii) the tsi-23 mutation, which renders host strains thermally inducible for each of the SOS-like functions. Bacterial filamentation was unaffected by any of the DNA repair mutations studied. In contrast, the induction of prophage after thermal or uv pretreatment was abolished in strains carrying the recE4, recA1, recB2, or recG13 mutation. Weigle reactivation was also inhibited by the recE4, recA1, recB2, or recG13 mutation, whereas levels of W-reactivation were lower in strains which carried the uvrA42, polA5, or rec-961 mutation than in the DNA repair-proficient strain. Strains which carried the recE4 allele were incapable of chromosomal DNA-mediated transformation, and the frequency of this event was decreased in strains carrying the recA1, recB2, or tsi-23 mutation. Plasmid DNA transformation efficiency was decreased only in strains carrying the tsi-23 mutation in addition to the recE4, recA1, recB2, mutation. The results indicate that the SOS-like or SOB system of B. subtilis is regulated at different levels by two or more gene products.

  19. 75 FR 13287 - Proposed Collection; Comment Request for an Unmodified SF 278 Executive Branch Personnel Public...

    Science.gov (United States)

    2010-03-19

    .... SUPPLEMENTARY INFORMATION: Title: Executive Branch Personnel Public Financial Disclosure Report. Form Number: SF... Executive Branch Personnel Public Financial Disclosure Report AGENCY: Office of Government Ethics (OGE... 278 Executive Branch Personnel Public Financial Disclosure Report to the Office of Management and...

  20. Inducible error-prone repair in B. subtilis. Progress report, May 1, 1983-April 30, 1984

    International Nuclear Information System (INIS)

    Yasbin, R.E.

    1983-12-01

    DNA repair mechanisms in Bacillus subtilis were investigated following mutagenesis via ultraviolet radiation or by chemical mutagens. A bioassay is described whereby the efficiency of repair mechanisms can be measured. DNA cloning studies to transfer the photoreactivation gene from E. coli to B. subtilis are reported. The mutation, which induces the SOS-like system in B. subtilis when grown at 45 0 C, was characterized in order to begin delineation of the genes controlling this system, efforts directed at isolation and cloning of a DNA Polymerase III gene of B. subtilis are related. (DT)

  1. Aged-care nurses in rural Tasmanian clinical settings more likely to think hypothetical medication error would be reported and disclosed compared to hospital and community nurses.

    Science.gov (United States)

    Carnes, Debra; Kilpatrick, Sue; Iedema, Rick

    2015-12-01

    This study aims to determine the likelihood that rural nurses perceive a hypothetical medication error would be reported in their workplace. This employs cross-sectional survey using hypothetical error scenario with varying levels of harm. Clinical settings in rural Tasmania. Participants were 116 eligible surveys received from registered and enrolled nurses. Frequency of responses indicating the likelihood that severe, moderate and near miss (no harm) scenario would 'always' be reported or disclosed. Eighty per cent of nurses viewed a severe error would 'always' be reported, 64.8% a moderate error and 45.7% a near-miss error. In regards to disclosure, 54.7% felt this was 'always' likely to occur for a severe error, 44.8% for a moderate error and 26.4% for a near miss. Across all levels of severity, aged-care nurses were more likely than nurses in other settings to view error to 'always' be reported (ranging from 72-96%, P = 0.010 to 0.042,) and disclosed (68-88%, P = 0.000). Those in a management role were more likely to view error to 'always' be disclosed compared to those in a clinical role (50-77.3%, P = 0.008-0.024). Further research in rural clinical settings is needed to improve the understanding of error management and disclosure. © 2015 The Authors. Australian Journal of Rural Health published by Wiley Publishing Asia Pty Ltd on behalf of National Rural Health Alliance.

  2. Performance estimates for personnel access control systems

    International Nuclear Information System (INIS)

    Bradley, R.G.

    1980-10-01

    Current performance estimates for personnel access control systems use estimates of Type I and Type II verification errors. A system performance equation which addresses normal operation, the insider, and outside adversary attack is developed. Examination of this equation reveals the inadequacy of classical Type I and II error evaluations which require detailed knowledge of the adversary threat scenario for each specific installation. Consequently, new performance measures which are consistent with the performance equation and independent of the threat are developed as an aid in selecting personnel access control systems

  3. Medication Errors in Hospitals: A Study of Factors Affecting Nursing Reporting in a Selected Center Affiliated with Shahid Beheshti University of Medical Sciences

    Directory of Open Access Journals (Sweden)

    HamidReza Mirzaee

    2015-10-01

    Full Text Available Background: Medication errors are mentioned as the most common important challenges threatening healthcare system in all countries worldwide. This study is conducted to investigate the most significant factors in refusal to report medication errors among nursing staff.Methods: The cross-sectional study was conducted on all nursing staff of a selected Education& Treatment Center in 2013. Data was collected through a teacher made questionnaire. The questionnaires’ face and content validity was confirmed by experts and for measuring its reliability test-retest was used. Data was analyzed by descriptive and analytic statistics. 16th  version of SPSS was also used for related statistics.Results: The most important factors in refusal to report medication errors respectively are: lack of reporting system in the hospital(3.3%, non-significance of reporting medication errors to hospital authorities and lack of appropriate feedback(3.1%, and lack of a clear definition for a medication error (3%. there was a significant relationship between the most important factors of refusal to report medication errors and work shift (p:0.002, age(p:0.003, gender(p:0.005, work experience(p<0.001 and employment type of nurses(p:0.002.Conclusion: Factors pertaining to management in hospitals as well as the fear of the consequences of reporting are two broad fields among the factors that make nurses not report their medication errors. In this regard, providing enough education to nurses, boosting the job security for nurses, management support and revising related processes and definitions are some factors that can help decreasing medication errors and increasing their report in case of occurrence.

  4. Nasogastric Tube Placement Errors and Complications in Pediatric Intensive Care Unit: A Case Report

    Directory of Open Access Journals (Sweden)

    Mahin Seyedhejazi

    2011-11-01

    Full Text Available Nasal ala pressure sores are among complications of nasogastric tube in Pediatric Intensive Care Unit (PICU. The severity of the injury is usually minor and easily ignored. However, the complication could be easily avoided. This is a case of nasal ala sore after the place-ment of nasal enteral tube in a pediatric intensive care unit in our center. A 5-month-old female with pulmonary hypertension secondary to bronchiectasis with nasal ala pressure sore were reported. She was hospitalized in pediatric intensive care unit at Tabriz Children Hospital in 2010.After 53 days of PICU hospitalization she had nasal ala sore. Conclusion: We know that nasal ala pressure sores could easily be avoided when preventive procedures were performed during nasogastric tube insertion.

  5. Report of the results of the second phase of Research Coordinated Program of IAEA ''Regional Intercomparison of Personnel Dosimetry''

    International Nuclear Information System (INIS)

    Morales, J.; Diaz, E.; Hernandez, E.; Capote, E.

    1998-01-01

    In this report the results of an intercomparison program within a research coordinated program are presented. This is a second phase of the study that consisted in to evaluate the implementation of the new ICRU quantities for individual monitoring by the dosimetry laboratories. In this report the organization aspects, quality control of the irradiations performed by the reference laboratory (SSDL of the Centro de Proteccion e Higiene de las radiaciones) as well the results of the participant laboratories are included

  6. Understanding nurses' and physicians' fear of repercussions for reporting errors: clinician characteristics, organization demographics, or leadership factors?

    Science.gov (United States)

    Castel, Evan S; Ginsburg, Liane R; Zaheer, Shahram; Tamim, Hala

    2015-08-14

    Identifying and understanding factors influencing fear of repercussions for reporting and discussing medical errors in nurses and physicians remains an important area of inquiry. Work is needed to disentangle the role of clinician characteristics from those of the organization-level and unit-level safety environments in which these clinicians work and learn, as well as probing the differing reporting behaviours of nurses and physicians. This study examines the influence of clinician demographics (age, gender, and tenure), organization demographics (teaching status, location of care, and province) and leadership factors (organization and unit leadership support for safety) on fear of repercussions, and does so for nurses and physicians separately. A cross-sectional analysis of 2319 nurse and 386 physician responders from three Canadian provinces to the Modified Stanford patient safety climate survey (MSI-06). Data were analyzed using exploratory factor analysis, multiple linear regression, and hierarchical linear regression. Age, gender, tenure, teaching status, and province were not significantly associated with fear of repercussions for nurses or physicians. Mental health nurses had poorer fear responses than their peers outside of these areas, as did community physicians. Strong organization and unit leadership support for safety explained the most variance in fear for both nurses and physicians. The absence of associations between several plausible factors including age, tenure and teaching status suggests that fear is a complex construct requiring more study. Substantially differing fear responses across locations of care indicate areas where interventions may be needed. In addition, since factors affecting fear of repercussions appear to be different for nurses and physicians, tailoring patient safety initiatives to each group may, in some instances, be fruitful. Although further investigation is needed to examine these and other factors in detail, supportive

  7. Neutron personnel dosimetry

    International Nuclear Information System (INIS)

    Griffith, R.V.

    1981-01-01

    The current state-of-the-art in neutron personnel dosimetry is reviewed. Topics covered include dosimetry needs and alternatives, current dosimetry approaches, personnel monitoring devices, calibration strategies, and future developments

  8. Comparison of intensive care unit medication errors reported to the United States' MedMarx and the United Kingdom's National Reporting and Learning System: a cross-sectional study.

    Science.gov (United States)

    Wahr, Joyce A; Shore, Andrew D; Harris, Lindsay H; Rogers, Philippa; Panesar, Sukhmeet; Matthew, Linda; Pronovost, Peter J; Cleary, Kevin; Pham, Julius C

    2014-01-01

    The objective was to compare the characteristics of medication errors reported to 2 national error reporting systems by conducting a cross-sectional analysis of errors reported from adult intensive care units to the UK National Reporting and Learning System and the US MedMarx system. Outcome measures were error types, severity of patient harm, stage of medication process, and involved medications. The authors analyzed 2837 UK error reports and 56 368 US reports. Differences were observed between UK and US errors for wrong dose (44% vs 29%), omitted dose (8.6% vs 27%), and stage of medication process (prescribing: 14% vs 49%; administration: 71% vs 42%). Moderate/severe harm or death was reported in 4.9% of UK versus 3.4% of US errors. Gentamicin was cited in 7.4% of the UK versus 0.7% of the US reports (odds ratio = 9.25). There were differences in the types of errors reported and the medications most often involved. These differences warrant further examination.

  9. Bibliography of reports by US Geological Survey personnel pertaining to underground nuclear testing and radioactive waste disposal at the Nevada Test Site, and radioactive waste disposal at the WIPP Site, New Mexico, January 1, 1979-December 31, 1979

    International Nuclear Information System (INIS)

    Glanzman, V.M.

    1980-01-01

    This bibliography presents reports released to the public between January 1, 1979, and December 31, 1979, by personnel of the US Geological Survey. Reports include information on underground nuclear testing and waste management projects at the NTS (Nevada Test Site) and radioactive waste projects at the WIPP (Waste Isolation Pilot Plant) site, New Mexico. Reports on Project Dribble, Tatum Dome, Mississippi, previously prepared as administrative reports and released to the public as 474-series reports during 1979 are also included in this bibliography

  10. Liver Hematoma Presented as Midgut Volvulus Due To Medical Error: A Case Report

    Directory of Open Access Journals (Sweden)

    Karimi

    2016-02-01

    Full Text Available Introduction The use of an umbilical catheterization is a usual practice in neonatal units. The insertion of the catheter has potential complications. Case Presentation Here, we report on our observation of a seven-day-old female newborn admitted for an abdominal distention and vomiting bile. Initially, diagnosis was midgut volvulus, for which an operation was performed. During the surgery, no intestinal malrotation, mesenteric defect or atresia was observed. Postoperative diagnosis was abdominal wall hematoma and rand ligament and ileus, as well as, sub-capsular liver hematoma. The patient had been hospitalized at birth at a neonatal intensive care unit (NICU. With the appearance of icterus on the first day of life, at the NICU tried to insert the umbilical catheter that had been filed. Conclusions The complication found in the patient was the result of an aggressive act (the umbilical catheter insertion. This intervention should not be carried out unless there are clear indications, and if so, it should be done with much care.

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

    Science.gov (United States)

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

    2018-01-01

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

  12. Personnel Monitoring Department - DEMIN

    International Nuclear Information System (INIS)

    1989-01-01

    The activities and purposes of the Personnel Monitoring Dept. of the Institute of Radioprotection and Dosimetry of the Brazilian CNEN are presented. A summary of the personnel monitoring service is given, such as dosemeters supply, laboratorial inspections, and so on. The programs of working, publishing, courses and personnel interchange are also presented. (J.A.M.M.)

  13. A Review of the Labor Market, Manpower Characteristics and Training of Motor Vehicle Repair Personnel. Final Report.

    Science.gov (United States)

    McCutcheon, R. W.; And Others

    To determine whether current automotive mechanic training programs provide adequate exposure to the knowledge and skills needed to properly service and repair motor vehicles, data were gathered on the tasks, service and repair establishments, job market, labor force, and training programs. Primary sources of data are reports prepared by various…

  14. Motor Vehicle Repairs and Inspection Personnel--Manpower Development Program. Final Report, 1 July, 1968-31 December, 1969.

    Science.gov (United States)

    McCutcheon, R. W.; And Others

    A perennial problem facing vocational educators is the need to correlate required on-the-job skills and knowledge with the instruction in the corresponding vocational education program. Using this as an objective, data were gathered on current automotive mechanic training programs by reviewing selected government reports and related literature and…

  15. Personnel training and certification

    International Nuclear Information System (INIS)

    Whittemore, W.L.

    1976-01-01

    In order to make the full benefits of neutron radiography available in the nondestructive test (NDT) field, it has been necessary to formalize its application. A group under the Penetrating Radiation Committee of the American Society for Nondestructive Testing (ASNT) was organized to prepare a recommended practice for neutron radiography. The recommended practices require the establishment of an appropriate certification program. The requirements on the employer to establish and maintain a qualification and certification program are outlined. To conduct a program of nondestructive testing using neutron radiography requires the usual three levels of qualified and certified personnel. The program is administered by a Level III person. Routine exposure, reviews, and reporting of test results are the responsibilities of Level I and Level II personnal. The amount of training and nature of the required practical examination are also specified. The recommended practices document assures users that NDT work in the field of neutron radiography is performed by qualified personnel. Although no training courses are available to provide experience in the depth required by the recommended practices document, SNT-TC-1A, short courses are provided at a number of locations to familarize user's representatives with the interpretation of neutron radiographs and capabilities and limitations of the technique

  16. IAEA activities on NPP personnel training and qualification

    International Nuclear Information System (INIS)

    Kossilov, A.

    1998-01-01

    Activities of IAEA concerning training and qualification of NPP personnel consider the availability of sufficient number of competent personnel which is one of the most critical requirements for safe and reliable NPP operation and maintenance. Competence of personnel is essential for reducing the frequency of events connected to human errors and equipment failures. The IAEA Guidebook on Nuclear Power Plant Personnel Training and its Evaluation incorporates the experience gained worldwide and provides recommendations on the use of SAT being the best practice for attaining and maintaining the qualification and competence of NPP personnel and for quality assurance of training

  17. Personnel preferences in personnel planning and scheduling

    OpenAIRE

    van der Veen, Egbert

    2013-01-01

    Summary The personnel of an organization often has two conflicting goals. Individual employees like to have a good work-life balance, by having personal preferences taken into account, whereas there is also the common goal to work efficiently. By applying techniques and methods from Operations Research, a subfield of applied mathematics, we show that operational efficiency can be achieved while taking personnel preferences into account. In the design of optimization methods, we explicitly con...

  18. Error Patterns

    NARCIS (Netherlands)

    Hoede, C.; Li, Z.

    2001-01-01

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

  19. 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.

  20. Recommendations of the EVA GEC ESTRO Working Group: prescribing, recording, and reporting in endovascular brachytherapy. Quality assurance, equipment, personnel and education

    International Nuclear Information System (INIS)

    Poetter, Richard; Limbergen, Erik van; Dries, Wim; Popowski, Youri; Coen, Veronique; Fellner, Claudia; Georg, Dietmar; Kirisits, Christian; Levendag, Peter; Marijnissen, Hans; Marsiglia, Hugo; Mazeron, Jean-Jaques; Pokrajac, Boris; Scalliet, Pierre; Tamburini, Vittorio

    2001-01-01

    Endovascular brachytherapy is a new, rapidly growing field of interest in radiotherapy for the prevention of neointimal hyperplasia after angioplasty in both coronary and peripheral arteries. Many physics aspects of these treatments have already been addressed in the report of the American Association of Physicists in Medicine task group on 'Intravascular brachytherapy', but up to now there are no generally accepted recommendations for recording and reporting radiation doses and volumes. The terminology to be used by all individuals involved in such treatments (radiation oncologists, physicists, and interventionalists) is not clearly defined. The Endovascular Groupe Europeen de Curietherapie/European Society for Therapeutic Radiology and Oncology Working Group in this document presents recommendations for a common language for general use in endovascular brachytherapy. This proposal addresses general terms and concepts for target and dose specification as well as detailed recommendations for dose prescription, recording and reporting in endovascular brachytherapy for both peripheral and coronary arteries. Additionally, quality assurance and radiation safety aspects are briefly addressed, as are aspects related to equipment, personnel, and training and education related to endovascular brachytherapy

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

    Science.gov (United States)

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

    2017-12-21

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

  2. Self-reported hand hygiene perceptions and barriers among companion animal veterinary clinic personnel in Ontario, Canada

    Science.gov (United States)

    Anderson, Maureen E.C.; Weese, J. Scott

    2016-01-01

    The objective of this study was to describe the perceived importance of and barriers to hand hygiene among companion animal clinic staff. An anonymous, voluntary written questionnaire was completed by 356 of approximately 578 individuals (62%) from 49/51 clinics. On a scale of 1 (not important) to 7 (very important), the percentage of respondents who rated hand hygiene as a 5 or higher was at least 82% in all clinical scenarios queried. The most frequently reported reason for not performing hand hygiene was forgetting to do so (40%, 141/353). Specific discussion of hand hygiene practices at work was recalled by 32% (114/354) of respondents. Although veterinary staff seem to recognize the importance of hand hygiene, it should be emphasized more during staff training. Other barriers including time constraints and skin irritation should also be addressed, possibly through increased access to and use of alcohol-based hand sanitizers. PMID:26933265

  3. Self-Reported and Observed Punitive Parenting Prospectively Predicts Increased Error-Related Brain Activity in Six-Year-Old Children.

    Science.gov (United States)

    Meyer, Alexandria; Proudfit, Greg Hajcak; Bufferd, Sara J; Kujawa, Autumn J; Laptook, Rebecca S; Torpey, Dana C; Klein, Daniel N

    2015-07-01

    The error-related negativity (ERN) is a negative deflection in the event-related potential (ERP) occurring approximately 50 ms after error commission at fronto-central electrode sites and is thought to reflect the activation of a generic error monitoring system. Several studies have reported an increased ERN in clinically anxious children, and suggest that anxious children are more sensitive to error commission--although the mechanisms underlying this association are not clear. We have previously found that punishing errors results in a larger ERN, an effect that persists after punishment ends. It is possible that learning-related experiences that impact sensitivity to errors may lead to an increased ERN. In particular, punitive parenting might sensitize children to errors and increase their ERN. We tested this possibility in the current study by prospectively examining the relationship between parenting style during early childhood and children's ERN approximately 3 years later. Initially, 295 parents and children (approximately 3 years old) participated in a structured observational measure of parenting behavior, and parents completed a self-report measure of parenting style. At a follow-up assessment approximately 3 years later, the ERN was elicited during a Go/No-Go task, and diagnostic interviews were completed with parents to assess child psychopathology. Results suggested that both observational measures of hostile parenting and self-report measures of authoritarian parenting style uniquely predicted a larger ERN in children 3 years later. We previously reported that children in this sample with anxiety disorders were characterized by an increased ERN. A mediation analysis indicated that ERN magnitude mediated the relationship between harsh parenting and child anxiety disorder. Results suggest that parenting may shape children's error processing through environmental conditioning and thereby risk for anxiety, although future work is needed to confirm this

  4. Self-reported and observed punitive parenting prospectively predicts increased error-related brain activity in six-year-old children

    Science.gov (United States)

    Meyer, Alexandria; Proudfit, Greg Hajcak; Bufferd, Sara J.; Kujawa, Autumn J.; Laptook, Rebecca S.; Torpey, Dana C.; Klein, Daniel N.

    2017-01-01

    The error-related negativity (ERN) is a negative deflection in the event-related potential (ERP) occurring approximately 50 ms after error commission at fronto-central electrode sites and is thought to reflect the activation of a generic error monitoring system. Several studies have reported an increased ERN in clinically anxious children, and suggest that anxious children are more sensitive to error commission—although the mechanisms underlying this association are not clear. We have previously found that punishing errors results in a larger ERN, an effect that persists after punishment ends. It is possible that learning-related experiences that impact sensitivity to errors may lead to an increased ERN. In particular, punitive parenting might sensitize children to errors and increase their ERN. We tested this possibility in the current study by prospectively examining the relationship between parenting style during early childhood and children’s ERN approximately three years later. Initially, 295 parents and children (approximately 3 years old) participated in a structured observational measure of parenting behavior, and parents completed a self-report measure of parenting style. At a follow-up assessment approximately three years later, the ERN was elicited during a Go/No-Go task, and diagnostic interviews were completed with parents to assess child psychopathology. Results suggested that both observational measures of hostile parenting and self-report measures of authoritarian parenting style uniquely predicted a larger ERN in children 3 years later. We previously reported that children in this sample with anxiety disorders were characterized by an increased ERN. A mediation analysis indicated that ERN magnitude mediated the relationship between harsh parenting and child anxiety disorder. Results suggest that parenting may shape children’s error processing through environmental conditioning and thereby risk for anxiety, although future work is needed to

  5. Traumatic events, other operational stressors and physical and mental health reported by Australian Defence Force personnel following peacekeeping and war-like deployments

    Directory of Open Access Journals (Sweden)

    Waller Michael

    2012-07-01

    Full Text Available Abstract Background The association between stressful events on warlike deployments and subsequent mental health problems has been established. Less is known about the effects of stressful events on peacekeeping deployments. Methods Two cross sectional studies of the Australian Defence Force were used to contrast the prevalence of exposures reported by a group deployed on a peacekeeping operation (Bougainville, n = 1704 and those reported by a group deployed on operations which included warlike and non-warlike exposures (East Timor, n = 1333. A principal components analysis was used to identify groupings of non-traumatic exposures on deployment. Multiple regression models were used to assess the association between self-reported objective and subjective exposures, stressors on deployment and subsequent physical and mental health outcomes. Results The principal components analysis produced four groups of non-traumatic stressors which were consistent between the peacekeeping and more warlike deployments. These were labelled ‘separation’, ‘different culture’, ‘other people’ and ‘work frustration’. Higher levels of traumatic and non-traumatic exposures were reported by veterans of East Timor compared to Bougainville. Higher levels of subjective traumatic exposures were associated with increased rates of PTSD in East Timor veterans and more physical and psychological health symptoms in both deployed groups. In Bougainville and East Timor veterans some non-traumatic deployment stressors were also associated with worse health outcomes. Conclusion Strategies to best prepare, identify and treat those exposed to traumatic events and other stressors on deployment should be considered for Defence personnel deployed on both warlike and peacekeeping operations.

  6. Peer Feedback, Learning, and Improvement: Answering the Call of the Institute of Medicine Report on Diagnostic Error.

    Science.gov (United States)

    Larson, David B; Donnelly, Lane F; Podberesky, Daniel J; Merrow, Arnold C; Sharpe, Richard E; Kruskal, Jonathan B

    2017-04-01

    In September 2015, the Institute of Medicine (IOM) published a report titled "Improving Diagnosis in Health Care," in which it was recommended that "health care organizations should adopt policies and practices that promote a nonpunitive culture that values open discussion and feedback on diagnostic performance." It may seem counterintuitive that a report addressing a highly technical skill such as medical diagnosis would be focused on organizational culture. The wisdom becomes clearer, however, when examined in the light of recent advances in the understanding of human error and individual and organizational performance. The current dominant model for radiologist performance improvement is scoring-based peer review, which reflects a traditional quality assurance approach, derived from manufacturing in the mid-1900s. Far from achieving the goals of the IOM, which are celebrating success, recognizing mistakes as an opportunity to learn, and fostering openness and trust, we have found that scoring-based peer review tends to drive radiologists inward, against each other, and against practice leaders. Modern approaches to quality improvement focus on using and enhancing interpersonal professional relationships to achieve and maintain high levels of individual and organizational performance. In this article, the authors review the recommendations set forth by the recent IOM report, discuss the science and theory that underlie several of those recommendations, and assess how well they fit with the current dominant approach to radiology peer review. The authors also offer an alternative approach to peer review: peer feedback, learning, and improvement (or more succinctly, "peer learning"), which they believe is better aligned with the principles promoted by the IOM. © RSNA, 2016.

  7. Caffeine Use among Active Duty Navy and Marine Corps Personnel

    Science.gov (United States)

    Knapik, Joseph J.; Trone, Daniel W.; McGraw, Susan; Steelman, Ryan A.; Austin, Krista G.; Lieberman, Harris R.

    2016-01-01

    Data from the National Health and Nutrition Examination Survey (NHANES) indicate 89% of Americans regularly consume caffeine, but these data do not include military personnel. This cross-sectional study examined caffeine use in Navy and Marine Corps personnel, including prevalence, amount of daily consumption, and factors associated with use. A random sample of Navy and Marine Corps personnel was contacted and asked to complete a detailed questionnaire describing their use of caffeine-containing substances, in addition to their demographic, military, and lifestyle characteristics. A total of 1708 service members (SMs) completed the questionnaire. Overall, 87% reported using caffeinated beverages ≥1 time/week, with caffeine users consuming a mean ± standard error of 226 ± 5 mg/day (242 ± 7 mg/day for men, 183 ± 8 mg/day for women). The most commonly consumed caffeinated beverages (% users) were coffee (65%), colas (54%), teas (40%), and energy drinks (28%). Multivariable logistic regression modeling indicated that characteristics independently associated with caffeine use (≥1 time/week) included older age, white race/ethnicity, higher alcohol consumption, and participating in less resistance training. Prevalence of caffeine use in these SMs was similar to that reported in civilian investigations, but daily consumption (mg/day) was higher. PMID:27735834

  8. Caffeine Use among Active Duty Navy and Marine Corps Personnel

    Directory of Open Access Journals (Sweden)

    Joseph J. Knapik

    2016-10-01

    Full Text Available Data from the National Health and Nutrition Examination Survey (NHANES indicate 89% of Americans regularly consume caffeine, but these data do not include military personnel. This cross-sectional study examined caffeine use in Navy and Marine Corps personnel, including prevalence, amount of daily consumption, and factors associated with use. A random sample of Navy and Marine Corps personnel was contacted and asked to complete a detailed questionnaire describing their use of caffeine-containing substances, in addition to their demographic, military, and lifestyle characteristics. A total of 1708 service members (SMs completed the questionnaire. Overall, 87% reported using caffeinated beverages ≥1 time/week, with caffeine users consuming a mean ± standard error of 226 ± 5 mg/day (242 ± 7 mg/day for men, 183 ± 8 mg/day for women. The most commonly consumed caffeinated beverages (% users were coffee (65%, colas (54%, teas (40%, and energy drinks (28%. Multivariable logistic regression modeling indicated that characteristics independently associated with caffeine use (≥1 time/week included older age, white race/ethnicity, higher alcohol consumption, and participating in less resistance training. Prevalence of caffeine use in these SMs was similar to that reported in civilian investigations, but daily consumption (mg/day was higher.

  9. Development of an FAA-EUROCONTROL technique for the analysis of human error in ATM : final report.

    Science.gov (United States)

    2002-07-01

    Human error has been identified as a dominant risk factor in safety-oriented industries such as air traffic control (ATC). However, little is known about the factors leading to human errors in current air traffic management (ATM) systems. The first s...

  10. Patient identification errors: the detective in the laboratory.

    Science.gov (United States)

    Salinas, Maria; López-Garrigós, Maite; Lillo, Rosa; Gutiérrez, Mercedes; Lugo, Javier; Leiva-Salinas, Carlos

    2013-11-01

    The eradication of errors regarding patients' identification is one of the main goals for safety improvement. As clinical laboratory intervenes in 70% of clinical decisions, laboratory safety is crucial in patient safety. We studied the number of Laboratory Information System (LIS) demographic data errors registered in our laboratory during one year. The laboratory attends a variety of inpatients and outpatients. The demographic data of outpatients is registered in the LIS, when they present to the laboratory front desk. The requests from the primary care centers (PCC) are made electronically by the general practitioner. A manual step is always done at the PCC to conciliate the patient identification number in the electronic request with the one in the LIS. Manual registration is done through hospital information system demographic data capture when patient's medical record number is registered in LIS. Laboratory report is always sent out electronically to the patient's electronic medical record. Daily, every demographic data in LIS is manually compared to the request form to detect potential errors. Fewer errors were committed when electronic order was used. There was great error variability between PCC when using the electronic order. LIS demographic data manual registration errors depended on patient origin and test requesting method. Even when using the electronic approach, errors were detected. There was a great variability between PCC even when using this electronic modality; this suggests that the number of errors is still dependent on the personnel in charge of the technology. © 2013.

  11. Military Personnel Procurement Resources Report

    Science.gov (United States)

    1991-05-28

    printed materials and literature (item 7). This category should indicate most costs are attributed to production. 5. Sales Promotion . Display costs of...incentive items for promotional and publicity purposes. Show production and media costs attributed to sales promotion (calendars, pencils and key...This category should indicate most costs are attributed to production. 5. Sales Promotion . Display costs of incentive items for promotional and

  12. Application of a New Statistical Model for Measurement Error to the Evaluation of Dietary Self-report Instruments.

    Science.gov (United States)

    Freedman, Laurence S; Midthune, Douglas; Carroll, Raymond J; Commins, John M; Arab, Lenore; Baer, David J; Moler, James E; Moshfegh, Alanna J; Neuhouser, Marian L; Prentice, Ross L; Rhodes, Donna; Spiegelman, Donna; Subar, Amy F; Tinker, Lesley F; Willett, Walter; Kipnis, Victor

    2015-11-01

    Most statistical methods that adjust analyses for dietary measurement error treat an individual's usual intake as a fixed quantity. However, usual intake, if defined as average intake over a few months, varies over time. We describe a model that accounts for such variation and for the proximity of biomarker measurements to self-reports within the framework of a meta-analysis, and apply it to the analysis of data on energy, protein, potassium, and sodium from a set of five large validation studies of dietary self-report instruments using recovery biomarkers as reference instruments. We show that this time-varying usual intake model fits the data better than the fixed usual intake assumption. Using this model, we estimated attenuation factors and correlations with true longer-term usual intake for single and multiple 24-hour dietary recalls (24HRs) and food frequency questionnaires (FFQs) and compared them with those obtained under the "fixed" method. Compared with the fixed method, the estimates using the time-varying model showed slightly larger values of the attenuation factor and correlation coefficient for FFQs and smaller values for 24HRs. In some cases, the difference between the fixed method estimate and the new estimate for multiple 24HRs was substantial. With the new method, while four 24HRs had higher estimated correlations with truth than a single FFQ for absolute intakes of protein, potassium, and sodium, for densities the correlations were approximately equal. Accounting for the time element in dietary validation is potentially important, and points toward the need for longer-term validation studies.

  13. Personnel preferences in personnel planning and scheduling

    NARCIS (Netherlands)

    van der Veen, Egbert

    2013-01-01

    Summary The personnel of an organization often has two conflicting goals. Individual employees like to have a good work-life balance, by having personal preferences taken into account, whereas there is also the common goal to work efficiently. By applying techniques and methods from Operations

  14. Preventing Errors in Laterality

    OpenAIRE

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

    2014-01-01

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

  15. Personnel Policy and Profit

    DEFF Research Database (Denmark)

    Bingley, Paul; Westergård-Nielsen, Niels Chr.

    2004-01-01

    personnel structure variation. It is found that personnel policy is strongly related to economic performance. At the margin, more hires are associated with lower profit, and more separations with higher profit. For the average firm, one new job, all else equal, is associated with ?2680 (2000 prices) lower...

  16. Web-Based Information Management System for the Investigation, Reporting, and Analysis of Human Error in Naval Aviation Maintenance

    National Research Council Canada - National Science Library

    Boex, Anthony

    2001-01-01

    .... The Human Factors Analysis and Classification System-Maintenance Extension (HFACS-ME) taxonomy, a framework for classifying and analyzing the presence of maintenance errors that lead to mishaps, is the foundation of this tool...

  17. Qualification of nuclear power plant operations personnel

    International Nuclear Information System (INIS)

    1984-01-01

    With the ultimate aim of reducing the possibility of human error in nuclear power plant operations, the Guidebook discusses the organizational aspects, the staffing requirements, the educational systems and qualifications, the competence requirements, the ways to establish, preserve and verify competence, the specific aspects of personnel management and training for nuclear power plant operations, and finally the particular situations and difficulties to be overcome by utilities starting their first nuclear power plant. An important aspect presented in the Guidebook is the experience in training and qualification of nuclear power plant personnel in various countries: Argentina, Belgium, Canada, Czechoslovakia, France, Federal Republic of Germany, Spain, Sweden, United Kingdom and United States of America

  18. Pedal Application Errors

    Science.gov (United States)

    2012-03-01

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

  19. Einstein's error

    International Nuclear Information System (INIS)

    Winterflood, A.H.

    1980-01-01

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

  20. Unique safety manual for experimental personnel

    International Nuclear Information System (INIS)

    Busick, D.D.; Warren, G.J.

    1979-01-01

    Within a few months of the discovery of x-rays the first radiation injuries were reported (ta71). During the past thirty years both the number and complexity of x-ray analytical units have increased markedly. The world-wide number of incidents leading to severe injury has also increased. For analytical x-ray machines the need for engineered and administrative safeguards has long been recognized. At Stanford Synchrotron Radiation Laboratory (SSRL) the personnel protection system has been carefully designed to maximize safety and minimize experimental interference. However, all possible experimental configurations cannot be anticipated and some interference is to be expected. There are means by which safeguards can be substituted as long as these substitutions do not degrade the existing degree of safety. any substitutions must be evaluated by the Radiation Safety Committee, the SSRL staff and Operational Health Physics. Some studies have indicated that between fifty and ninety percent of serious radiation accidents are directly related to human errors, i.e., ignoring administrative proccedures, by-passing engineered safeguards or by inadequate training. Lindell has estimated the annual probability of serious injury to be about 1:100 per macchine. No matter what the real probability of serious injury is the personnel protection system should reduce this risk to a value that approaches zero. It is hoped that this manual will bring into sharper focus some of the more serious results of unnecessary risk taking. We also hope that it will convey the very real necessity for safeguards which may at times appear to be arbitrary and unnecessary impediments to experimental purposes

  1. Training of nonlicensed personnel

    International Nuclear Information System (INIS)

    Hetrick, D.E.

    1975-01-01

    The safety and efficiency with which a station operates is a function of the competence and proficiency of all personnel. This includes the nonlicensed personnel who make up the bulk of the station staff. Thus the training of these members of the station complement is an important function in overall station performance. Standards, regulations, regulatory guides, and codes provide guidance to the training requirements for such personnel. Training needs and objectives must be established, a plan prepared and then all incorporated into a training program. A well planned and operated training program will stimulate effective communications between the different groups within the station and between the station and off site support groups

  2. INTOR critical issue D: maintainability. Tritium containment and personnel access vs remote maintenance, Chapter VI of the US INTOR report for Phase Two A, Part 2

    International Nuclear Information System (INIS)

    Spampinato, P.T.; Finn, P.A.; Gohar, Y.

    1984-01-01

    The purpose of this study is to compare the benefits and costs associated with personnel access mmaintenance procedures compared to those of all-remote maintenance procedures. The INTOR Phase Two A, Part I configuration was used to make this comparison. For both approaches, capital and operating costs were considered to first order, maintenance equipment requirements were investigated, maintenance requirements common to both approaches and unique to each were identified, tritium handling requirements were outlined, and maintenance scenarios and device downtime were developed for both. In addition, estimates of person-rem exposure were made for the personnel access approach

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

    Science.gov (United States)

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

    2017-09-01

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

  4. Civilian Personnel: Career Management

    National Research Council Canada - National Science Library

    2001-01-01

    This revision; (1) Contains changes required by the establishment of a consolidated and realigned management structure for civilian personnel, manpower, and related functions in the Office of the Assistant Secretary of the Army...

  5. Personnel neutron dosimetry

    International Nuclear Information System (INIS)

    Hankins, D.

    1982-04-01

    This edited transcript of a presentation on personnel neutron discusses the accuracy of present dosimetry practices, requirements, calibration, dosemeter types, quality factors, operational problems, and dosimetry for a criticality accident. 32 figs

  6. Personnel radiation dosimetry

    International Nuclear Information System (INIS)

    1987-01-01

    The book contains the 21 technical papers presented at the Technical Committee Meeting to Elaborate Procedures and Data for the Intercomparison of Personnel Dosimeters organizaed by the IAEA on 22-26 April 1985. A separate abstract was prepared for each of these papers. A list of areas in which additional research and development work is needed and recommendations for an IAEA-sponsored intercomparison program on personnel dosimetry is also included

  7. Towards reporting standards for neuropsychological study results: A proposal to minimize communication errors with standardized qualitative descriptors for normalized test scores.

    Science.gov (United States)

    Schoenberg, Mike R; Rum, Ruba S

    2017-11-01

    Rapid, clear and efficient communication of neuropsychological results is essential to benefit patient care. Errors in communication are a lead cause of medical errors; nevertheless, there remains a lack of consistency in how neuropsychological scores are communicated. A major limitation in the communication of neuropsychological results is the inconsistent use of qualitative descriptors for standardized test scores and the use of vague terminology. PubMed search from 1 Jan 2007 to 1 Aug 2016 to identify guidelines or consensus statements for the description and reporting of qualitative terms to communicate neuropsychological test scores was conducted. The review found the use of confusing and overlapping terms to describe various ranges of percentile standardized test scores. In response, we propose a simplified set of qualitative descriptors for normalized test scores (Q-Simple) as a means to reduce errors in communicating test results. The Q-Simple qualitative terms are: 'very superior', 'superior', 'high average', 'average', 'low average', 'borderline' and 'abnormal/impaired'. A case example illustrates the proposed Q-Simple qualitative classification system to communicate neuropsychological results for neurosurgical planning. The Q-Simple qualitative descriptor system is aimed as a means to improve and standardize communication of standardized neuropsychological test scores. Research are needed to further evaluate neuropsychological communication errors. Conveying the clinical implications of neuropsychological results in a manner that minimizes risk for communication errors is a quintessential component of evidence-based practice. Copyright © 2017 Elsevier B.V. All rights reserved.

  8. Wheelchairmanship Project. A Program to Educate Personnel in the Transportation, Hotel and Restaurant, and Entertainment Industries in Improved Techniques for Serving Disabled People. Final Report.

    Science.gov (United States)

    Smith, Anita P.; And Others

    In a project designed to train customer service personnel in improved methods of assisting the physically disabled, audio-visual training materials were developed and presented during 2-week courses involving 1,058 employees at transportation, hotel/restaurant, and entertainment centers in 25 cities. The participants judged the training program…

  9. Final Report of an Expansion of a Model for Development of Proficiency/Equivalency Tests for Clinical Laboratory Personnel, July 1, 1980-June 30, 1981.

    Science.gov (United States)

    New Jersey Coll. of Medicine and Dentistry, Newark. School of Allied Health Professions.

    A project was conducted to expand a previously developed model for developing proficiency/equivalency tests to evaluate previously acquired knowledge and skill competencies in the areas of clinical microbiology and clinical hematology. Designed for a target group consisting of on-the-job trainees, military personnel, and medical laboratory…

  10. The Frequencies of Different Inborn Errors of Metabolism in Adult Metabolic Centres: Report from the SSIEM Adult Metabolic Physicians Group

    NARCIS (Netherlands)

    Sirrs, S.; Hollak, C.; Merkel, M.; Sechi, A.; Glamuzina, E.; Janssen, M.C.H.; Lachmann, R.; Langendonk, J.; Scarpelli, M.; Omran, T. Ben; Mochel, F.; Tchan, M.C.

    2016-01-01

    BACKGROUND: There are few centres which specialise in the care of adults with inborn errors of metabolism (IEM). To anticipate facilities and staffing needed at these centres, it is of interest to know the distribution of the different disorders. METHODS: A survey was distributed through the

  11. Implementation of the Education of the Handicapped Act [Public Law 94-142], 1989. Eleventh Annual Report to Congress. Information on the Supply and Demand for Personnel: Excerpts. Reporting Data on the 1986-87 School Year. Information on Personnel Supply and Demand.

    Science.gov (United States)

    National Clearinghouse for Professions in Special Education, Reston, VA.

    This paper concerns the supply and demand for special education personnel for the 1986-87 school year. Obtaining valid, reliable, and comparable data on all the elements that generated personnel need was not possible. Single indicators were most commonly used to obtain data for planning by states, school districts, universities, and the Federal…

  12. A theory-based approach to understanding condom errors and problems reported by men attending an STI clinic.

    Science.gov (United States)

    Crosby, Richard A; Salazar, Laura F; Yarber, William L; Sanders, Stephanie A; Graham, Cynthia A; Head, Sara; Arno, Janet N

    2008-05-01

    We employed the information-motivation-behavioral skills (IMB) model to guide an investigation of correlates for correct condom use among 278 adult (18-35 years old) male clients attending a sexually transmitted infection (STI) clinic. An anonymous questionnaire aided by a CD-recording of the questions was administered. Linear Structural Relations Program was used to conduct path analyses of the hypothesized IMB model. Parameter estimates showed that while information did not directly affect behavioral skills, it did have a direct (negative) effect on condom use errors. Motivation had a significant direct (positive) effect on behavioral skills and a significant indirect (positive) effect on condom use errors through behavioral skills. Behavioral skills had a direct (negative) effect on condom use errors. Among men attending a public STI clinic, these findings suggest brief, clinic-based, safer sex programs for men who have sex with women should incorporate activities to convey correct condom use information, instill motivation to use condoms correctly, and directly enhance men's behavioral skills for correct use of condoms.

  13. 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

  14. Evaluating a medical error taxonomy.

    OpenAIRE

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

    2002-01-01

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

  15. Training of maintenance personnel

    International Nuclear Information System (INIS)

    Rabouhams, J.

    1986-01-01

    This lecture precises the method and means developed by EDF to ensure the training of maintenance personnel according to their initial educational background and their experience. The following points are treated: General organization of the training for maintenance personnel in PWR and GCR nuclear power stations and in Creys Malville fast breeder reactor; Basic nuclear training and pedagogical aids developed for this purpose; Specific training and training provided by contractors; complementary training taking into account the operation experience and feedback; Improvement of velocity, competence and safety during shut-down operations by adapted training. (orig.)

  16. Guidelines for the calibration of personnel dosimeters

    International Nuclear Information System (INIS)

    Roberson, P.L.; Holbrook, K.L.

    1984-01-01

    This guide describes minimum acceptable performance levels for personnel dosimetry systems used at Department of Energy (DOE) facilities. The goal is to improve both the quality of radiological calibrations and the methods of comparing reported occupational doses between DOE facilities. Reference calibration techniques are defined. A standard for evaluation of personnel dosimetry systems and recommended design parameters for personnel dosimeters are also included. Approximate intervals for the radiation energies for which these guidelines are appropriate are 15 keV to 2 MeV for photons; above 0.3 MeV for beta particles; and 1 keV to 2 MeV for neutrons. An analysis of ANSI N13.11 was completed using performance evaluations of selected personnel dosimetry systems in use at DOE facilities. The results of this analysis are incorporated in the guidelines

  17. Personnel photographic film dosimetry

    International Nuclear Information System (INIS)

    Keirim-Markus, I.B.

    1981-01-01

    Technology of personnel photographic film dosimetry (PPD) based on the photographic effect of ionizing radiation is described briefly. Kinds of roentgen films used in PPD method are enumerated, compositions of a developer and fixing agents for these films are given [ru

  18. Harmonious personnel scheduling

    NARCIS (Netherlands)

    Fijn van Draat, Laurens; Post, Gerhard F.; Veltman, Bart; Winkelhuijzen, Wessel

    2006-01-01

    The area of personnel scheduling is very broad. Here we focus on the ‘shift assignment problem’. Our aim is to discuss how ORTEC HARMONY handles this planning problem. In particular we go into the structure of the optimization engine in ORTEC HARMONY, which uses techniques from genetic algorithms,

  19. Visual disability, visual function, and myopia among rural chinese secondary school children: the Xichang Pediatric Refractive Error Study (X-PRES)--report 1.

    Science.gov (United States)

    Congdon, Nathan; Wang, Yunfei; Song, Yue; Choi, Kai; Zhang, Mingzhi; Zhou, Zhongxia; Xie, Zhenling; Li, Liping; Liu, Xueyu; Sharma, Abhishek; Wu, Bin; Lam, Dennis S C

    2008-07-01

    To evaluate visual acuity, visual function, and prevalence of refractive error among Chinese secondary-school children in a cross-sectional school-based study. Uncorrected, presenting, and best corrected visual acuity, cycloplegic autorefraction with refinement, and self-reported visual function were assessed in a random, cluster sample of rural secondary school students in Xichang, China. Among the 1892 subjects (97.3% of the consenting children, 84.7% of the total sample), mean age was 14.7 +/- 0.8 years, 51.2% were female, and 26.4% were wearing glasses. The proportion of children with uncorrected, presenting, and corrected visual disability (visual disability when tested without correction, 98.7% was due to refractive error, while only 53.8% (414/770) of these children had appropriate correction. The girls had significantly (P visual disability and myopia visual function (ANOVA trend test, P Visual disability in this population was common, highly correctable, and frequently uncorrected. The impact of refractive error on self-reported visual function was significant. Strategies and studies to understand and remove barriers to spectacle wear are needed.

  20. Development and demonstration of surveillance and diagnostics of rotating machinery for reducing radiation exposure to nuclear power plant personnel: Appendices: Final report

    International Nuclear Information System (INIS)

    Allen, J.W.; Bohanick, J.S.

    1988-01-01

    This program was designed to reduce radiation exposure to power plant personnel resulting from inspection, maintenance, and repair of rotating equipment. The new rotating machinery monitoring system for this program was installed at GGNS during August 1983. The following nine appendices are presented: signals monitored at GGNS; definition of characterized spectral values; instructions for alignment and balance programs; machine diagrams; FFT program; software module descriptions; sample radiation survey forms used for exposure study; radiation exposure compared to other plants; and a technical section instruction for the vibration monitoring program at GGNS

  1. Error forecasting schemes of error correction at receiver

    International Nuclear Information System (INIS)

    Bhunia, C.T.

    2007-08-01

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

  2. Alkaptonuria--first inborn error of metabolism known for a century and new treatment option--preliminary report.

    Science.gov (United States)

    Sykut-Cegielska, Jolanta

    2015-01-01

    Alkaptonuria is a rare inborn error of metabolism, identified over a century ago. But its basic pathomechanism (i.e. ochronosis) is still not completely explained. Though clinical onset of osteoarthropathy and complications from other organs (including: heart and blood vessels, skin, eyes, kidneys) occurs at adult age, the symptoms are progressive, cause severe pains and significantly limit everyday life of the patients. Until now no effective therapeutic methods have been known in alkaptonuria. Recently, thanks to an initiative of the international patient organization for alkaptonuria, a hope for a potential treatment availability, appears. So, alkaptonuria is an example of a role of multidysciplinary care, cooperation and ongoing progress in the area of rare diseases.

  3.  Patient safety in orthopedic surgery: prioritizing key areas of iatrogenic harm through an analysis of 48,095 incidents reported to a national database of errors

    Directory of Open Access Journals (Sweden)

    Panesar SS

    2013-03-01

    Full Text Available  Sukhmeet S Panesar,1 Andrew Carson-Stevens,2 Sarah A Salvilla,1 Bhavesh Patel,3 Saqeb B Mirza,4 Bhupinder Mann51Centre for Population Health Sciences, The University of Edinburgh, Edinburgh, UK; 2Institute of Primary Care and Public Health, Cardiff University, Cardiff, UK; 3National Patient Safety Agency, London, UK; 4Department of Trauma and Orthopaedic Surgery, University Hospital Southampton NHS Foundation Trust, Southampton General Hospital, Southampton, Hampshire, UK; 5Buckinghamshire Healthcare NHS Trust, Stoke Mandeville Hospital, Aylesbury, UKBackground: With scientific and technological advances, the practice of orthopedic surgery has transformed the lives of millions worldwide. Such successes however have a downside; not only is the provision of comprehensive orthopedic care becoming a fiscal challenge to policy-makers and funders, concerns are also being raised about the extent of the associated iatrogenic harm. The National Reporting and Learning System (NRLS in England and Wales is an underused resource which collects intelligence from reports about health care error.Methods: Using methods akin to case-control methodology, we have identified a method of prioritizing the areas of a national database of errors that have the greatest propensity for harm. Our findings are presented using odds ratios (ORs and 95% confidence intervals (CIs.Results: The largest proportion of surgical patient safety incidents reported to the NRLS was from the trauma and orthopedics specialty, 48,095/163,595 (29.4%. Of those, 14,482/48,095 (30.1% resulted in iatrogenic harm to the patient and 71/48,095 (0.15% resulted in death. The leading types of errors associated with harm involved the implementation of care and on-going monitoring (OR 5.94, 95% CI 5.53, 6.38; self-harming behavior of patients in hospitals (OR 2.14, 95% CI 1.45, 3.18; and infection control (OR 1.91, 95% CI 1.69, 2.17. We analyze these data to quantify the extent and type of iatrogenic

  4. Occupational stress among police personnel in India

    Directory of Open Access Journals (Sweden)

    G Ragesh

    2017-06-01

    Full Text Available Background: Occupational stress and associated physical and mental health related issues are not addressed in Indian police personnel with adequate importance. Methods: Cross-sectional survey was conducted among police personnel (both male and female in Calicut urban police district, Kerala state, India. Police personnel from all designations (ranks, except from the all India services (Indian Police Service were included in the study. Data were collected using a specifically designed datasheet covering socio-demographic profile, physical and mental health related details which was prepared by researchers. Occupational stress was measured using Operational Police Stress Questionnaire (PSQ-OP and Organisational Police Stress Questionnaire (PSQ-ORG. Result: The study found that both operational and organisational stress was significant among the police officers. Organisational stress was experienced in moderate level by 68% and in high level by 14%. Operational stress scores were in the moderate range in 67% and in high range in 16.5%. The younger age group (21-35 years and lower level rank police personnel had higher stress. Stress was higher among female police personnel compared to males. While 23% of them had been diagnosed with physical illnesses, a significant four per cent of them with mental illness, and 29% of them reported substance abuse. Conclusion: The results point to the high level of stress among Indian police personnel and the need for urgent interventions from the government to address the occupational stress.

  5. 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.

  6. Modernization of personnel training

    International Nuclear Information System (INIS)

    Haferburg, M.; Rehn, H.

    1997-01-01

    Personnel training in German nuclear power plants adheres to high standards complying with government regulations. The development of PC technology allows the introduction of new training methods, e.g. computer based training (CBT), as well as their integration into existing systems. In Germany, the operators of nuclear power plants have developed their own computer based standards with a screen design, a hardware platform and an assessment standard. 25% of the theoretical training of the shift personnel is covered by CBT. The CBT-Programmes offer multimedia features: videos, photographs, sound, graphs and switching diagrams of existing systems, practice oriented simulations and 3-D animations. Interaction is the most important attribute of an efficient self-learning-programme. A typical example of such an appropriate theme is the CBT-Lesson ''Pressure Surges in Pipes and Components of Power Plants''. (author)

  7. Do Military Personnel Patent

    Science.gov (United States)

    2016-12-01

    following questions: In what fields are military personnel most likely to patent, and how do demographics, such as age, race, and gender , along with...technologies, which have transformed how the United States wages war. DARPA continues to develop new technologies and capabilities for the U.S. military today...build the European navies so it instead decided to utilize an innovative ship design to exploit a gap specific to the British Royal Navy. The six

  8. Internal consistency, test-retest reliability and measurement error of the self-report version of the social skills rating system in a sample of Australian adolescents.

    Directory of Open Access Journals (Sweden)

    Sharmila Vaz

    Full Text Available The social skills rating system (SSRS is used to assess social skills and competence in children and adolescents. While its characteristics based on United States samples (US are published, corresponding Australian figures are unavailable. Using a 4-week retest design, we examined the internal consistency, retest reliability and measurement error (ME of the SSRS secondary student form (SSF in a sample of Year 7 students (N = 187, from five randomly selected public schools in Perth, western Australia. Internal consistency (IC of the total scale and most subscale scores (except empathy on the frequency rating scale was adequate to permit independent use. On the importance rating scale, most IC estimates for girls fell below the benchmark. Test-retest estimates of the total scale and subscales were insufficient to permit reliable use. ME of the total scale score (frequency rating for boys was equivalent to the US estimate, while that for girls was lower than the US error. ME of the total scale score (importance rating was larger than the error using the frequency rating scale. The study finding supports the idea of using multiple informants (e.g. teacher and parent reports, not just student as recommended in the manual. Future research needs to substantiate the clinical meaningfulness of the MEs calculated in this study by corroborating them against the respective Minimum Clinically Important Difference (MCID.

  9. Internal consistency, test-retest reliability and measurement error of the self-report version of the social skills rating system in a sample of Australian adolescents.

    Science.gov (United States)

    Vaz, Sharmila; Parsons, Richard; Passmore, Anne Elizabeth; Andreou, Pantelis; Falkmer, Torbjörn

    2013-01-01

    The social skills rating system (SSRS) is used to assess social skills and competence in children and adolescents. While its characteristics based on United States samples (US) are published, corresponding Australian figures are unavailable. Using a 4-week retest design, we examined the internal consistency, retest reliability and measurement error (ME) of the SSRS secondary student form (SSF) in a sample of Year 7 students (N = 187), from five randomly selected public schools in Perth, western Australia. Internal consistency (IC) of the total scale and most subscale scores (except empathy) on the frequency rating scale was adequate to permit independent use. On the importance rating scale, most IC estimates for girls fell below the benchmark. Test-retest estimates of the total scale and subscales were insufficient to permit reliable use. ME of the total scale score (frequency rating) for boys was equivalent to the US estimate, while that for girls was lower than the US error. ME of the total scale score (importance rating) was larger than the error using the frequency rating scale. The study finding supports the idea of using multiple informants (e.g. teacher and parent reports), not just student as recommended in the manual. Future research needs to substantiate the clinical meaningfulness of the MEs calculated in this study by corroborating them against the respective Minimum Clinically Important Difference (MCID).

  10. Employment of security personnel

    International Nuclear Information System (INIS)

    Anon.

    1990-01-01

    If a company or institution hires personnel of a security service company to protect its premises, this kind of employment does not mean the company carries on temporary employment business. Within the purview of section 99, sub-section 1 of the BetrVG (Works Constitution Act), the security service personnel is not 'employed' in the proper sense even if the security tasks fulfilled by them are done at other times by regular employees of the company or institution. The court decision also decided that the Works Council need not give consent to employment of foreign security personnel. The court decision was taken for settlement of court proceedings commenced by Institute of Plasma Physics in Garching. In his comments, W. Hunold accedes to the court's decision and discusses the underlying reasons of this decision and of a previous ruling in the same matter by putting emphasis on the difference between a contract for services and a contract for work, and a contract for temporary employment. The author also discusses the basic features of an employment contract. (orig./HP) [de

  11. Automatic personnel contamination monitor

    International Nuclear Information System (INIS)

    Lattin, Kenneth R.

    1978-01-01

    United Nuclear Industries, Inc. (UNI) has developed an automatic personnel contamination monitor (APCM), which uniquely combines the design features of both portal and hand and shoe monitors. In addition, this prototype system also has a number of new features, including: micro computer control and readout, nineteen large area gas flow detectors, real-time background compensation, self-checking for system failures, and card reader identification and control. UNI's experience in operating the Hanford N Reactor, located in Richland, Washington, has shown the necessity of automatically monitoring plant personnel for contamination after they have passed through the procedurally controlled radiation zones. This final check ensures that each radiation zone worker has been properly checked before leaving company controlled boundaries. Investigation of the commercially available portal and hand and shoe monitors indicated that they did not have the sensitivity or sophistication required for UNI's application, therefore, a development program was initiated, resulting in the subject monitor. Field testing shows good sensitivity to personnel contamination with the majority of alarms showing contaminants on clothing, face and head areas. In general, the APCM has sensitivity comparable to portal survey instrumentation. The inherit stand-in, walk-on feature of the APCM not only makes it easy to use, but makes it difficult to bypass. (author)

  12. Electronic Official Personnel Folder System

    Data.gov (United States)

    US Agency for International Development — The eOPF is a digital recreation of paper personnel folder that stores electronic personnel data spanning an individual's Federal career. eOPF allows employees to...

  13. Critical Newborn Screens in Double Heterozygotes of Inborn Errors of Metabolism—A Clinical Report and Recommendations

    Directory of Open Access Journals (Sweden)

    Katherine G. Langley

    2016-11-01

    Full Text Available The practice of newborn screening has been in place in the USA since the 1960s, with individual states initially screening for different numbers of disorders. In the early 2000s many efforts were made to standardize the various disorders being screened. Currently, there are at least 34 disorders that each state is mandated to include on their screening panel. Of those 34 disorders, the majority are inborn errors of metabolism (IEM which include urea cycle disorders (UCD, citrullinemia (CIT and argininosuccinic aciduria (ASA, as well as a number of fatty acid oxidation disorders. We present here four cases of infants who had critical newborn screens (NBS in the Commonwealth of Virginia and underwent genetic testing because their clinical presentation and follow-up laboratory studies were not consistent with the disorder that was flagged by NBS. These newborns were found to be carriers for two different IEMs (in three cases or compound heterozygotes (in one case. Currently no guidelines exist with respect to the appropriate way to manage these children who may or may not be symptomatic in the newborn period. We propose some general recommendations for management based on our experience with these four probands, and discuss the necessity for further conversation and collaboration between physicians encountering these not-so-infrequent presentations.

  14. The Frequencies of Different Inborn Errors of Metabolism in Adult Metabolic Centres: Report from the SSIEM Adult Metabolic Physicians Group.

    Science.gov (United States)

    Sirrs, S; Hollak, C; Merkel, M; Sechi, A; Glamuzina, E; Janssen, M C; Lachmann, R; Langendonk, J; Scarpelli, M; Ben Omran, T; Mochel, F; Tchan, M C

    2016-01-01

    There are few centres which specialise in the care of adults with inborn errors of metabolism (IEM). To anticipate facilities and staffing needed at these centres, it is of interest to know the distribution of the different disorders. A survey was distributed through the list-serve of the SSIEM Adult Metabolic Physicians group asking clinicians for number of patients with confirmed diagnoses, types of diagnoses and age at diagnosis. Twenty-four adult centres responded to our survey with information on 6,692 patients. Of those 6,692 patients, 510 were excluded for diagnoses not within the IEM spectrum (e.g. bone dysplasias, hemochromatosis) or for age less than 16 years, leaving 6,182 patients for final analysis. The most common diseases followed by the adult centres were phenylketonuria (20.6%), mitochondrial disorders (14%) and lysosomal storage disorders (Fabry disease (8.8%), Gaucher disease (4.2%)). Amongst the disorders that can present with acute metabolic decompensation, the urea cycle disorders, specifically ornithine transcarbamylase deficiency, were most common (2.2%), followed by glycogen storage disease type I (1.5%) and maple syrup urine disease (1.1%). Patients were frequently diagnosed as adults, particularly those with mitochondrial disease and lysosomal storage disorders. A wide spectrum of IEM are followed at adult centres. Specific knowledge of these disorders is needed to provide optimal care including up-to-date knowledge of treatments and ability to manage acute decompensation.

  15. Reporting Errors in Siblings’ Survival Histories and Their Impact on Adult Mortality Estimates: Results From a Record Linkage Study in Senegal

    Science.gov (United States)

    Helleringer, Stéphane; Pison, Gilles; Kanté, Almamy M.; Duthé, Géraldine; Andro, Armelle

    2014-01-01

    Estimates of adult mortality in countries with limited vital registration (e.g., sub-Saharan Africa) are often derived from information about the survival of a respondent’s siblings. We evaluated the completeness and accuracy of such data through a record linkage study conducted in Bandafassi, located in southeastern Senegal. We linked at the individual level retrospective siblings’ survival histories (SSH) reported by female respondents (n = 268) to prospective mortality data and genealogies collected through a health and demographic surveillance system (HDSS). Respondents often reported inaccurate lists of siblings. Additions to these lists were uncommon, but omissions were frequent: respondents omitted 3.8 % of their live sisters, 9.1 % of their deceased sisters, and 16.6 % of their sisters who had migrated out of the DSS area. Respondents underestimated the age at death of the siblings they reported during the interview, particularly among siblings who had died at older ages (≥45 years). Restricting SSH data to person-years and events having occurred during a recent reference period reduced list errors but not age and date errors. Overall, SSH data led to a 20 % underestimate of 45q15 relative to HDSS data. Our study suggests new quality improvement strategies for SSH data and demonstrates the potential use of HDSS data for the validation of “unconventional” demographic techniques. PMID:24493063

  16. Reporting errors in siblings' survival histories and their impact on adult mortality estimates: results from a record linkage study in Senegal.

    Science.gov (United States)

    Helleringer, Stéphane; Pison, Gilles; Kanté, Almamy M; Duthé, Géraldine; Andro, Armelle

    2014-04-01

    Estimates of adult mortality in countries with limited vital registration (e.g., sub-Saharan Africa) are often derived from information about the survival of a respondent's siblings. We evaluated the completeness and accuracy of such data through a record linkage study conducted in Bandafassi, located in southeastern Senegal. We linked at the individual level retrospective siblings' survival histories (SSH) reported by female respondents (n = 268) to prospective mortality data and genealogies collected through a health and demographic surveillance system (HDSS). Respondents often reported inaccurate lists of siblings. Additions to these lists were uncommon, but omissions were frequent: respondents omitted 3.8 % of their live sisters, 9.1 % of their deceased sisters, and 16.6 % of their sisters who had migrated out of the DSS area. Respondents underestimated the age at death of the siblings they reported during the interview, particularly among siblings who had died at older ages (≥45 years). Restricting SSH data to person-years and events having occurred during a recent reference period reduced list errors but not age and date errors. Overall, SSH data led to a 20 % underestimate of 45 q 15 relative to HDSS data. Our study suggests new quality improvement strategies for SSH data and demonstrates the potential use of HDSS data for the validation of "unconventional" demographic techniques.

  17. Simulators for training nuclear power plant personnel

    International Nuclear Information System (INIS)

    1993-01-01

    Simulator training and retraining of operations personnel is essential for their acquiring the necessary knowledge, skills and qualification for operating a nuclear power plant, and for effective feedback of experience including human based operating errors. Simulator training is the most effective way by far of training operations personnel in co-operation and communication in a team, which also involves instilling attitudes and approaches for achieving excellence and individual responsibility and alertness. This technical document provides guidance to Member States on the procurement, setting up and utilization of a simulator training centre; it will also be useful for organizations with previous experience in the use of simulators for training. The document is the result of a series of advisory and consultants meetings held in the framework of the International Working Group on Nuclear Power Plant Control and Instrumentation in 1989-1992. 17 refs, 2 tabs

  18. Development and demonstration of surveillance and diagnostics of rotating machinery for reducing radiation exposure to nuclear power plant personnel: Final report

    International Nuclear Information System (INIS)

    Allen, J.W.; Bohanick, J.S.

    1988-01-01

    This program was designed to reduce radiation exposure to power plant personnel resulting from inspection, maintenance, and repair of rotating equipment. The new rotating machinery monitoring system for this program was installed at GGNS during August 1983. This document provides a functional description of the hardware and software that comprise the system and discusses the application of the monitoring system to achieving overall program goals. The analyses of the monitored rotating machinery during the plant startup phase and after the plant's first fuel cycle are presented in addition to the radiation dose reduction which occurred as a direct and indirect result of the RMSS. The dose reduction program at GGNS is reviewed and recommendations made to incorporate this program with the RMSS. 28 refs., 64 figs., 43 tabs

  19. Qualification of NPP operations personnel

    International Nuclear Information System (INIS)

    Wang Jiao.

    1987-01-01

    Competence of personnel is one of the important problems for safety operation of nuclear power plant. This paper gives a description of some aspects, such as the administration of NPP, posts, competence of personnel, training, assessing the competence and personnel management

  20. 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

  1. Error Budgeting

    Energy Technology Data Exchange (ETDEWEB)

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

    2017-10-04

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

  2. Medical error

    African Journals Online (AJOL)

    QuickSilver

    Department of Psychiatry, University of Melbourne, Australia systems of ... traditional M&M (morbidity and mortality) meetings play a significant role in education .... inaccurate and inflammatory media reports their community accepted the ex-.

  3. Medication errors among nurses in teaching hospitals in the west of Iran: what we need to know about prevalence, types, and barriers to reporting

    Directory of Open Access Journals (Sweden)

    Afshin Fathi

    2017-05-01

    Full Text Available OBJECTIVES This study aimed to examine the prevalence and types of medication errors (MEs, as well as barriers to reporting MEs, among nurses working in 7 teaching hospitals affiliated with Kermanshah University of Medical Sciences in 2016. METHODS A convenience sampling method was used to select the study participants (n=500 nurses. A self-constructed questionnaire was employed to collect information on participants’ socio-demographic characteristics (10 items, their perceptions about the main causes of MEs (31 items, and barriers to reporting MEs to nurse managers (11 items. Data were collected from September 1 to November 30, 2016. Negative binomial regression was used to identify the main predictors of the frequency of MEs among nurses. RESULTS The prevalence of MEs was 17.0% (95% confidence interval, 13.7 to 20.3%. The most common types of MEs were administering medications at the wrong time (24.0%, dosage errors (16.8%, and administering medications to the wrong patient (13.8%. A heavy workload and the type of shift work were considered to be the main causes of MEs by nursing staff. Our findings showed that 45.0% of nurses did not report MEs. A heavy workload due to a high number of patients was the most important reason for not reporting MEs (mean score, 3.57±1.03 among nurses. Being male, having a second unrelated job, and fixed shift work significantly increased MEs among nurses (p=0.001. CONCLUSIONS Our study documented a high prevalence of MEs among nurses in the west of Iran. A heavy workload was considered to be the most important barrier to reporting MEs among nurses. Thus, appropriate strategies (e.g., reducing the nursing staff workload should be developed to address MEs and improve patient safety in hospital settings in Iran.

  4. Increased error rates in preliminary reports issued by radiology residents working more than 10 consecutive hours overnight.

    Science.gov (United States)

    Ruutiainen, Alexander T; Durand, Daniel J; Scanlon, Mary H; Itri, Jason N

    2013-03-01

    To determine if the rate of major discrepancies between resident preliminary reports and faculty final reports increases during the final hours of consecutive 12-hour overnight call shifts. Institutional review board exemption status was obtained for this study. All overnight radiology reports interpreted by residents on-call between January 2010 and June 2010 were reviewed by board-certified faculty and categorized as major discrepancies if they contained a change in interpretation with the potential to impact patient management or outcome. Initial determination of a major discrepancy was at the discretion of individual faculty radiologists based on this general definition. Studies categorized as major discrepancies were secondarily reviewed by the residency program director (M.H.S.) to ensure consistent application of the major discrepancy designation. Multiple variables associated with each report were collected and analyzed, including the time of preliminary interpretation, time into shift study was interpreted, volume of studies interpreted during each shift, day of the week, patient location (inpatient or emergency department), block of shift (2-hour blocks for 12-hour shifts), imaging modality, patient age and gender, resident identification, and faculty identification. Univariate risk factor analysis was performed to determine the optimal data format of each variable (ie, continuous versus categorical). A multivariate logistic regression model was then constructed to account for confounding between variables and identify independent risk factors for major discrepancies. We analyzed 8062 preliminary resident reports with 79 major discrepancies (1.0%). There was a statistically significant increase in major discrepancy rate during the final 2 hours of consecutive 12-hour call shifts. Multivariate analysis confirmed that interpretation during the last 2 hours of 12-hour call shifts (odds ratio (OR) 1.94, 95% confidence interval (CI) 1.18-3.21), cross

  5. Personnel ionizing radiation dosimeter

    International Nuclear Information System (INIS)

    Williams, R.A.

    1975-01-01

    A dosimeter and method for use by personnel working in an area of mixed ionizing radiation fields for measuring and/or determining the effective energy of x- and gamma radiation; beta, x-, and gamma radiation dose equivalent to the surface of the body; beta, x-, and gamma radiation dose equivalent at a depth in the body; the presence of slow neutron, fast neutron dose equivalent; and orientation of the person wearing the dosimeter to the source of radiation is disclosed. Optionally integrated into this device and method are improved means for determining neutron energy spectrum and absorbed dose from fission gamma and neutron radiation resulting from accidental criticality

  6. Personnel policy and management

    International Nuclear Information System (INIS)

    Dangelmaier, P.

    1986-01-01

    In the field of personnel policy and management two main points must be considered and fitted together: the aspects of the applicant and the aspects of the utility. The applicant wishes a position which suits to his abilities, education, training, experience and self-evaluation. The enterprise has beside these qualification criteria to look to some additional points: reliability - not only in the profession of the applicant but also in his daily life. In this examination licensing authorities are involved too; responsibility in a very broad sense and the ability to make correct decisions sometimes under stress situations. (orig.)

  7. The training of the operation personnel

    International Nuclear Information System (INIS)

    Martin, H.D.

    1975-01-01

    A survey about training places and the volume of the training program for reactor personnel in the Federal Republic of Germany is given. Paragraph 7 of the atomic energy act, which imposes on the operators of nuclear energy plants the qualifired training of the personnel, is refered to. Positive experiences with the use of simulation equipment for training have led to the planning of a simulator-centre which is expected to be ready for operation in 1977. The versatile program of this centre is briefly reported. (ORU) [de

  8. Training of personnel

    International Nuclear Information System (INIS)

    1997-01-01

    Selected staffs (in the area of NPPs) are examined by the State Examining Committee established by Nuclear Regulatory Authority of the Slovak Republic (NRA SR's) chairman. The committee consists of representatives of NRA SR , Bohunice NPPs, Mochovce NPP, Research Institute of Nuclear Energy and experts from the Faculty of Electrical Engineering and Information Technology of the Slovak Technical University. The review of selected personnel of NPP V-1, V-2 and Mochovce NPP which passed exams in 1996 is given. NRA SR paid attention to the upgrading training process of individual categories of staff for V-1, V-2 and Mochovce NPPs, simulator training and training with computerized simulation system according to the United criteria of nuclear installation personnel training that started in 1992. During the year, an inspection was performed focused on examination of technical equipment of the simulator of Mochovce NPP, professional eligibility and overall preparation of simulator training including simulator software. Throughout the year launching works continued at the simulator with the deadline of commissioning to trial use operation in the first half of 1997

  9. Quo vadis, personnel monitoring

    International Nuclear Information System (INIS)

    Becker, K.

    1975-01-01

    With the increasing use of nuclear power and radiation sources, the selection of optimum systems for personnel monitoring is becoming a matter of worldwide concern. The present status of personnel dosimetry, sometimes characterized by unstable and inaccurate detectors and oversimplified interpretation of the results, leaves much to be desired. In particular, photographic film, although having certain advantages with regard to economics and information content, undergoes rapid changes in warm and humid climates. Careful sealing reduces, but does not prevent, these problems. The replacement of film by solid-state dosimeters, primarily thermoluminescence dosimeters, is in progress or being considered by an increasing number of institutions and requires a number of decisions concerning the choice of the optimum detector(s), badge design, and evaluation system; organizational matters, such as the desirability of automation and computerized bookkeeping; etc. The change also implies the potential use of such advanced concepts as different detectors and monitoring periods for the large number of low-risk persons and the small number of high-risk radiation workers. (auth)

  10. Severe accident testing of a personnel airlock

    International Nuclear Information System (INIS)

    Clauss, D.B.; Parks, M.B.; Julien, J.T.; Peters, S.W.

    1988-01-01

    Sandia National Laboratories (Sandia) is investigating the leakage potential of mechanical penetrations as part of a research program on containment integrity under severe accident loads for the U.S. Nuclear Regulatory Commission (NRC). Barnes et al. (1984) and Shackelford et al. (1985) identified leakage from personnel airlocks as an important failure mode of containments subject to severe accident loads. However, these studies were based on relatively simple analysis methods. The complex structural interaction between the door, gasket, and bulkhead in personnel airlocks makes analytical evaluation of leakage difficult. In order to provide data to validate methods for evaluating the leakage potential, a full-size personnel airlock was subject to simulated severe accident loads consisting of pressure and temperature up to 300 psig and 800 degrees F. The test was conducted at Chicago Bridge and Iron under contract to Sandia. The authors provide a detailed report on the test program

  11. Personnel Selection Method Based on Personnel-Job Matching

    OpenAIRE

    Li Wang; Xilin Hou; Lili Zhang

    2013-01-01

    The existing personnel selection decisions in practice are based on the evaluation of job seeker's human capital, and it may be difficult to make personnel-job matching and make each party satisfy. Therefore, this paper puts forward a new personnel selection method by consideration of bilateral matching. Starting from the employment thoughts of ¡°satisfy¡±, the satisfaction evaluation indicator system of each party are constructed. The multi-objective optimization model is given according to ...

  12. Quantifying behavioural determinants relating to health professional reporting of medication errors: a cross-sectional survey using the Theoretical Domains Framework.

    Science.gov (United States)

    Alqubaisi, Mai; Tonna, Antonella; Strath, Alison; Stewart, Derek

    2016-11-01

    The aims of this study were to quantify the behavioural determinants of health professional reporting of medication errors in the United Arab Emirates (UAE) and to explore any differences between respondents. A cross-sectional survey of patient-facing doctors, nurses and pharmacists within three major hospitals of Abu Dhabi, the UAE. An online questionnaire was developed based on the Theoretical Domains Framework (TDF, a framework of behaviour change theories). Principal component analysis (PCA) was used to identify components and internal reliability determined. Ethical approval was obtained from a UK university and all hospital ethics committees. Two hundred and ninety-four responses were received. Questionnaire items clustered into six components of knowledge and skills, feedback and support, action and impact, motivation, effort and emotions. Respondents generally gave positive responses for knowledge and skills, feedback and support and action and impact components. Responses were more neutral for the motivation and effort components. In terms of emotions, the component with the most negative scores, there were significant differences in terms of years registered as health professional (those registered longest most positive, p = 0.002) and age (older most positive, p Theoretical Domains Framework to quantify the behavioural determinants of health professional reporting of medication errors. • Questionnaire items relating to emotions surrounding reporting generated the most negative responses with significant differences in terms of years registered as health professional (those registered longest most positive) and age (older most positive) with no differences for gender and health profession. • Interventions based on behaviour change techniques mapped to emotions should be prioritised for development.

  13. Errors in Neonatology

    Directory of Open Access Journals (Sweden)

    Antonio Boldrini

    2013-06-01

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

  14. Use of error-detection and diagnosis methods in existing buildings - Final report; Einsatz von Fehlerdetektions- und Diagnosemethoden in realen Gebaeuden (IEA Annex 34) - Schlussbericht

    Energy Technology Data Exchange (ETDEWEB)

    Gruber, P.

    2000-10-15

    This report for the Swiss Federal Office of Energy (SFOE) discusses the results of tests made with two expert systems used for error-detection and diagnosis in existing buildings. These expert systems were developed within the framework of the International Energy Agency's (IEA) Annex 25 Project entitled 'Real Time Simulation of Heating, Ventilation and Air-conditioning (HVAC) Systems for Building Optimisation, Fault Detection and Diagnosis'. The aim of using these tools was to help detect planning, installation and commissioning errors. These cannot only affect system performance but also can cause increased energy consumption and a reduction of the working life of the system's components. The tests of the tools took place within the framework of the IEA's Annex 34 'Computer-aided Evaluation of HVAC System Performance: the Practical Application of Fault Detection and Diagnosis Techniques in Real Buildings'. Experience gained with the two tools is presented and discussed. The quality of the results and the use of the systems in practice are discussed and commented on. They strongly differ from one tool to the other.

  15. New Employee Orientation, Division of Personnel and Labor Relations,

    Science.gov (United States)

    understanding work rules and procedures, provide you with the resources you need, as well as guide you through Employee Training Exit Survey HR Forms New Employee Orientation For Admin Staff Classification Form Packets Personnel Memoranda Personnel Rules Policies and Procedures Recruitment Services Reports Sections Director's

  16. Training of nuclear power plant personnel in Canada

    International Nuclear Information System (INIS)

    Tennant, D.

    1993-01-01

    All of the utilities, Ontario Hydro, Hydro Quebec and New Brunswick Power, operating Nuclear Power Plants in Canada have Training Centres which provide training for all of their plant personnel whose job activities could affect plant and personnel safety. This report points out the methods used for training, which generally conform to that described by the IAEA as a Systematic Approach to Training (SAT)

  17. Experience from training of personnel abroad

    International Nuclear Information System (INIS)

    Otcenasek, P.

    1983-01-01

    In the first period of the development of nuclear technology specialists received mainly theoretical training in brief study courses and training sessions. These courses did not place high demands on training methods. In the subsequent period long-term, well-conceived and costly systems of training were developed placing emphasis on specialized knowledge and especially on practical training. The third stage has now been launched which is characterized by the departure from classical control rooms to data collection and processing in centralized information systems, selective recording according to situation and choice, etc. This stage is passing on to the system of the minimization of the human factor error. A significant problem of the human factor in nuclear technology is the time aspect. Schools specializing in the education and training of specialists, technical personnel and workers for the nuclear programme have been established. Following such education personnel are selected for specialized training in training centres which have been equipped with costly training equipment including simulators. With regard to the importance of the human factor in nuclear installations, control computers are being introduced to an increasing extent and individuals and groups of workers and personnel are trained in operation. (E.S.)

  18. Error-correction coding

    Science.gov (United States)

    Hinds, Erold W. (Principal Investigator)

    1996-01-01

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

  19. Error and its meaning in forensic science.

    Science.gov (United States)

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

    2014-01-01

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

  20. Randomized clinical trials in dentistry: Risks of bias, risks of random errors, reporting quality, and methodologic quality over the years 1955-2013.

    Directory of Open Access Journals (Sweden)

    Humam Saltaji

    Full Text Available To examine the risks of bias, risks of random errors, reporting quality, and methodological quality of randomized clinical trials of oral health interventions and the development of these aspects over time.We included 540 randomized clinical trials from 64 selected systematic reviews. We extracted, in duplicate, details from each of the selected randomized clinical trials with respect to publication and trial characteristics, reporting and methodologic characteristics, and Cochrane risk of bias domains. We analyzed data using logistic regression and Chi-square statistics.Sequence generation was assessed to be inadequate (at unclear or high risk of bias in 68% (n = 367 of the trials, while allocation concealment was inadequate in the majority of trials (n = 464; 85.9%. Blinding of participants and blinding of the outcome assessment were judged to be inadequate in 28.5% (n = 154 and 40.5% (n = 219 of the trials, respectively. A sample size calculation before the initiation of the study was not performed/reported in 79.1% (n = 427 of the trials, while the sample size was assessed as adequate in only 17.6% (n = 95 of the trials. Two thirds of the trials were not described as double blinded (n = 358; 66.3%, while the method of blinding was appropriate in 53% (n = 286 of the trials. We identified a significant decrease over time (1955-2013 in the proportion of trials assessed as having inadequately addressed methodological quality items (P < 0.05 in 30 out of the 40 quality criteria, or as being inadequate (at high or unclear risk of bias in five domains of the Cochrane risk of bias tool: sequence generation, allocation concealment, incomplete outcome data, other sources of bias, and overall risk of bias.The risks of bias, risks of random errors, reporting quality, and methodological quality of randomized clinical trials of oral health interventions have improved over time; however, further efforts that contribute to the development of more stringent

  1. 76 FR 78658 - Webinar Overview of the National Vaccine Advisory Committee Healthcare Personnel Influenza...

    Science.gov (United States)

    2011-12-19

    ... Committee Healthcare Personnel Influenza Vaccination Subgroup's Draft Report and Draft Recommendations for Achieving the Healthy People 2020 Annual Coverage Goals for Influenza Vaccination in Healthcare Personnel... Influenza Vaccination Subgroup (HCPIVS), will host an informational webinar to introduce the committee's...

  2. 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.

  3. Interpreting the change detection error matrix

    NARCIS (Netherlands)

    Oort, van P.A.J.

    2007-01-01

    Two different matrices are commonly reported in assessment of change detection accuracy: (1) single date error matrices and (2) binary change/no change error matrices. The third, less common form of reporting, is the transition error matrix. This paper discuses the relation between these matrices.

  4. Traumatic events, other operational stressors and physical and mental health reported by Australian Defence Force personnel following peacekeeping and war-like deployments

    OpenAIRE

    Waller, Michael; Treloar, Susan A; Sim, Malcolm R; McFarlane, Alexander C; McGuire, Annabel C L; Bleier, Jonathan; Dobson, Annette J

    2012-01-01

    Abstract Background The association between stressful events on warlike deployments and subsequent mental health problems has been established. Less is known about the effects of stressful events on peacekeeping deployments. Methods Two cross sectional studies of the Australian Defence Force were used to contrast the prevalence of exposures reported by a group deployed on a peacekeeping operation (Bougainville, n = 1704) and those reported by a group deployed on operations which included warl...

  5. Use of a urinary sugars biomarker to assess measurement error in self-reported sugars intake in the Nutrition and Physical Activity Assessment Study (NPAAS)

    Science.gov (United States)

    Tasevska, Natasha; Midthune, Douglas; Tinker, Lesley F.; Potischman, Nancy; Lampe, Johanna W.; Neuhouser, Marian L.; Beasley, Jeannette M.; Van Horn, Linda; Prentice, Ross L.; Kipnis, Victor

    2014-01-01

    Background Measurement error (ME) in self-reported sugars intake may be obscuring the association between sugars and cancer risk in nutritional epidemiologic studies. Methods We used 24-hour urinary sucrose and fructose as a predictive biomarker for total sugars, to assess ME in self-reported sugars intake. The Nutrition and Physical Activity Assessment Study (NPAAS) is a biomarker study within the Women’s Health Initiative (WHI) Observational Study, that includes 450 post-menopausal women aged 60–91. Food Frequency Questionnaires (FFQ), 4-day food records (4DFR) and three 24-h dietary recalls (24HRs) were collected along with sugars and energy dietary biomarkers. Results Using the biomarker, we found self-reported sugars to be substantially and roughly equally misreported across the FFQ, 4DFR and 24HR. All instruments were associated with considerable intake- and person-specific bias. Three 24HRs would provide the least attenuated risk estimate for sugars (attenuation factor, AF=0.57), followed by FFQ (AF=0.48), and 4DFR (AF=0.32), in studies of energy-adjusted sugars and disease risk. In calibration models, self-reports explained little variation in true intake (5–6% for absolute sugars; 7–18% for sugars density). Adding participants’ characteristics somewhat improved the percentage variation explained (16–18% for absolute sugars; 29–40% for sugars density). Conclusions None of the self-report instruments provided a good estimate of sugars intake, although overall 24HRs seemed to perform the best. Impact Assuming the calibrated sugars biomarker is unbiased, this analysis suggests that, measuring the biomarker in a subsample of the study population for calibration purposes may be necessary for obtaining unbiased risk estimates in cancer association studies. PMID:25234237

  6. Laboratory errors and patient safety.

    Science.gov (United States)

    Miligy, Dawlat A

    2015-01-01

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

  7. Site security personnel training manual

    International Nuclear Information System (INIS)

    1978-10-01

    As required by 10 CFR Part 73, this training manual provides guidance to assist licensees in the development of security personnel training and qualifications programs. The information contained in the manual typifies the level and scope of training for personnel assigned to perform security related tasks and job duties associated with the protection of nuclear fuel cycle facilities and nuclear power reactors

  8. Personnel Officers: Judging Their Qualifications.

    Science.gov (United States)

    Webb, Gisela

    1988-01-01

    Discusses the backgrounds and qualifications appropriate for a library personnel administrator, including (1) a master's degree in library science; (2) library work experience; (3) additional training in administration, personnel management, organizational development, and psychology; and (4) personal attributes such as good communication skills,…

  9. Personnel Practices for Small Colleges.

    Science.gov (United States)

    Bouchard, Ronald A.

    Personnel administration in higher education is the focus of this "hands-on, how-to-do-it" guide that provides fundamental materials for developing and maintaining a sound personnel program. Part One (Employment) examines government regulations, employee recruitment and selection, pre-employment inquiries and screening, post-employment process,…

  10. MITS instrumentation error analysis report

    International Nuclear Information System (INIS)

    Nelson, D.W.; Hillon, D.D.

    1980-01-01

    The MITS (Machine Interface Test System) installation consists of three types of process monitoring and control instrumentation: flow, pressure, and temperature. An effort has been made to assess the various instruments used and assign a value to the accuracy that can be expected. Efforts were also made to analyze the calibration and installation procedures to be used and determine how these might effect the system accuracy

  11. Neutron personnel dosimetry

    International Nuclear Information System (INIS)

    Griffith, R.V.

    1982-01-01

    The measurement of neutron exposures to personnel is an issue that has received increased attention in the last few years. It is important to consider key aspects of the whole dosimetry system when developing dose estimates. This begins with selection of proper dosimeters and survey instruments, and extends through the calibration methods. One must match the spectral response and sensitivity of the dosimeter to the spectral characteristics of the neutron fields. Threshold detectors that are insensitive to large fractions of neutrons in the lower energy portion of reactor spectra should be avoided. Use of two or more detectors with responses that complement each other will improve measurement quality. It is important to understand the spectral response of survey instruments, so that spectra which result in significant overresponse do not lead to overestimation of dose. Calibration sources that do not match operational field spectra can contribute to highly erroneous results. In those situations, in-field calibration techniques should be employed. Although some detection developments have been made in recent years, a lot can be done with existing technology until fully satisfactory, long term solutions are obtained

  12. Personnel dosimetry in fluoroscopy

    International Nuclear Information System (INIS)

    Baechler, S.; Gardon, M.; Bochud, F.; Sans-Merce, M.; Verdun, F.R.; Trueb, Ph.

    2006-01-01

    Physicians who frequently perform fluoroscopic examinations are exposed to high intensity radiation fields and should use protective equipment such as lead aprons, thyroid shields and lead glasses. Standard individual dosimeters are worn under the lead apron in order to measure a dose that is representative of effective dose. However, large parts of the body are not protected by the apron (e.g. arms, head). Given a protection factor for the apron of about 100, an important irradiation of a body part not under the apron could go undetected. A study was conducted to analyse this situation by measuring dose using two dosimeters, one over-apron and one under-apron, for radiologists performing frequent fluoroscopic examinations. Measurements made over six-month period show that, indeed, the use of a single under-apron dosimeter is inadequate for personnel monitoring. Large doses to the head and arms are going undetected by this technique. A method for weighting the doses measured by under- and over-apron dosimeters to obtain a value better representative of the effective dose will be proposed. (authors)

  13. Special training of shift personnel

    International Nuclear Information System (INIS)

    Martin, H.D.

    1981-01-01

    The first step of on-the-job training is practical observation phase in an operating Nuclear Plant, where the participants are assigned to shift work. The simulator training for operating personnel, for key personnel and, to some extent, also for maintenance personnel and specialists give the practical feeling for Nuclear Power Plant behaviour during normal and abnormal conditions. During the commissioning phase of the own Nuclear Power Plant, which is the most important practical training, the participants are integrated into the commissioning staff and assisted during their process of practical learning by special instructors. The preparation for the licensing exams is vitally important for shift personnel and special courses are provided after the first non-nuclear trial operation of the plant. Personnel training also includes performance of programmes and material for retraining, training of instructors and assistance in building up special training programmes and material as well as training centers. (orig./RW)

  14. Medication errors in pediatric inpatients

    DEFF Research Database (Denmark)

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

    2017-01-01

    The aim was to describe medication errors (MEs) in hospitalized children reported to the national mandatory reporting and learning system, the Danish Patient Safety Database (DPSD). MEs were extracted from DPSD from the 5-year period of 2010–2014. We included reports from public hospitals on pati...... safety in pediatric inpatients.(Table presented.)...

  15. Medication errors detected in non-traditional databases

    DEFF Research Database (Denmark)

    Perregaard, Helene; Aronson, Jeffrey K; Dalhoff, Kim

    2015-01-01

    AIMS: We have looked for medication errors involving the use of low-dose methotrexate, by extracting information from Danish sources other than traditional pharmacovigilance databases. We used the data to establish the relative frequencies of different types of errors. METHODS: We searched four...... errors, whereas knowledge-based errors more often resulted in near misses. CONCLUSIONS: The medication errors in this survey were most often action-based (50%) and knowledge-based (34%), suggesting that greater attention should be paid to education and surveillance of medical personnel who prescribe...

  16. Self contained compressed air breathing apparatus to facilitate personnel decontamination

    Energy Technology Data Exchange (ETDEWEB)

    McDonald, C W [Radiological and Safety Division, Atomic Energy Establishment, Winfrith, Dorchester, Dorset (United Kingdom)

    1963-11-15

    This report describes the modification of a Self Contained Compressed Air Breathing Apparatus to provide extended respiratory protection to grossly contaminated personnel during a decontamination period which may exceed the duration of the Breathing Apparatus air supply. (author)

  17. Self contained compressed air breathing apparatus to facilitate personnel decontamination

    International Nuclear Information System (INIS)

    McDonald, C.W.

    1963-11-01

    This report describes the modification of a Self Contained Compressed Air Breathing Apparatus to provide extended respiratory protection to grossly contaminated personnel during a decontamination period which may exceed the duration of the Breathing Apparatus air supply. (author)

  18. Report from LHC MDs 1391 and 1483: Tests of new methods for study of nonlinear errors in the LHC experimental insertions

    CERN Document Server

    Maclean, Ewen Hamish; Fuchsberger, Kajetan; Giovannozzi, Massimo; Persson, Tobias Hakan Bjorn; Tomas Garcia, Rogelio; CERN. Geneva. ATS Department

    2017-01-01

    Nonlinear errors in experimental insertions can pose a significant challenge to the operability of low-β∗ colliders. Previously such errors in the LHC have been studied via their feed-down to tune and coupling under the influence of the nominal crossing angle bumps. This method has proved useful in validating various components of the magnetic model. To understand and correct those errors where significant discrepancies exist with the magnetic model however, will require further development of this technique, in addition to the application of novel methods. In 2016 studies were performed to test new methods for the study of the IR-nonlinear errors.

  19. 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.

  20. Survey of international personnel radiation dosimetry programs

    International Nuclear Information System (INIS)

    Swaja, R.E.

    1985-04-01

    In September of 1983, a mail survey was conducted to determine the status of external personnel gamma and neutron radiation dosimetry programs at international agencies. A total of 130 agencies participated in this study including military, regulatory, university, hospital, laboratory, and utility facilities. Information concerning basic dosimeter types, calibration sources, calibration phantoms, corrections to dosimeter responses, evaluating agencies, dose equivalent reporting conventions, ranges of typical or expected dose equivalents, and degree of satisfaction with existing systems was obtained for the gamma and neutron personnel monitoring programs at responding agencies. Results of this survey indicate that to provide the best possible occupational radiation monitoring programs and to improve dosimetry accuracy in performance studies, facility dosimetrists, regulatory and standards agencies, and research laboratories must act within their areas of responsibility to become familiar with their radiation monitoring systems, establish common reporting guidelines and performance standards, and provide opportunities for dosimetry testing and evaluation. 14 references, 10 tables

  1. Learning from prescribing errors

    OpenAIRE

    Dean, B

    2002-01-01

    

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

  2. Personnel dosimetry: specialized industrial services. Jan 1997-Aug 2001

    International Nuclear Information System (INIS)

    Guillen, J.A.

    2001-09-01

    The purpose of this report is to evaluate data from personnel dosimetry of the Servicios Industriales Especializados, that is a licensee with gamma sources for non destructive testing. Data of the period Jan-97 to Aug-01 are evaluated in terms of collective doses. This report was made according to the national regulations that stablish to control that annual limits and reference levels in personnel dosimetry must be controlled

  3. Evaluation of Personnel Dosimetry data in Guatemala

    International Nuclear Information System (INIS)

    Guillen, J.A.

    2002-01-01

    The purpose of this report is to present the evaluated data from external exposures of 1268 radiation workers in Guatemala carried out in the period of 1997-2000. The collective dose in medicine, industry and other applications shown a tendency to increase in the period of study, radiology is the practice that shown a trend to decrease, that could be explained as a result of inspections and personnel training carried out in this practice

  4. Hanford personnel dosimeter supporting studies FY-1981

    International Nuclear Information System (INIS)

    1982-08-01

    This report examined specific functional components of the routine external personnel dosimeter program at Hanford. Components studied included: dosimeter readout; dosimeter calibration; dosimeter field response; dose calibration algorithm; dosimeter design; and TLD chip acceptance procedures. Additional information is also presented regarding the dosimeter response to light- and medium-filtered x-rays, high energy photons and neutrons. This study was conducted to clarify certain data obtained during the FY-1980 studies

  5. Competency assessments for nuclear industry personnel

    International Nuclear Information System (INIS)

    2004-04-01

    In 1996, the IAEA published Technical Reports Series No. 380, Nuclear Power Plant Personnel Training and its Evaluation: A Guidebook. This publication provides guidance for the development, implementation and evaluation of training programmes for all nuclear power plant personnel using the systematic approach to training (SAT) methodology. The SAT methodology has since been adopted and used for the development and implementation of training programmes for all types of nuclear facility and activities in the nuclear industry. The IAEA Technical Working Group on Training and Qualification of Nuclear Power Plant Personnel recommended that an additional publication be prepared to provide further guidance concerning competency assessments used for measuring the knowledge, skills and attitudes of personnel as the result of training. This publication has been prepared in response to that recommendation. A critical component of SAT (as part of the implementation phase) is the assessment of whether personnel have achieved the standards identified in the training objectives. The nuclear industry spends a significant amount of resources conducting competency assessments. Competency assessments are used for employee selection, trainee assessment, qualification, requalification and authorization (in some Member States the terminology may be 'certification' or 'licensing'), and job advancement and promotion. Ineffective testing methods and procedures, or inappropriate interpretation of test results, can have significant effects on both human performance and nuclear safety. Test development requires unique skills and, as with any skill, training and experience are needed to develop and improve them. Test item and examination development, use, interpretation of results and examination refinement, like all other aspects of SAT, should be part of an ongoing, systematic process. This publication is primarily intended for use by personnel responsible for developing and administering

  6. Myopia, spectacle wear, and risk of bicycle accidents among rural Chinese secondary school students: the Xichang Pediatric Refractive Error Study report no. 7.

    Science.gov (United States)

    Zhang, Mingzhi; Congdon, Nathan; Li, Liping; Song, Yue; Choi, Kai; Wang, Yunfei; Zhou, Zhongxia; Liu, Xiaojian; Sharma, Abhishek; Chen, Weihong; Lam, Dennis S C

    2009-06-01

    To study the effect of myopia and spectacle wear on bicycle-related injuries in rural Chinese students. Myopia is common among Chinese students but few studies have examined its effect on daily activities. Data on visual acuity, refractive error, current spectacle wear, and history of bicycle use and accidents during the past 3 years were sought from 1891 students undergoing eye examinations in rural Guangdong province. Refractive and accident data were available for 1539 participants (81.3%), among whom the mean age was 14.6 years, 52.5% were girls, 26.8% wore glasses, and 12.9% had myopia of less than -4 diopters in both eyes. More than 90% relied on bicycles to get to school daily. A total of 2931 accidents were reported by 423 participants, with 68 requiring medical attention. Male sex (odds ratio, 1.55; P accident, but habitual visual acuity and myopia were unassociated with the crash risk, after adjusting for age, sex, time spent riding, and risky riding behaviors. These results may be consistent with data on motor vehicle accidents implicating peripheral vision (potentially compromised by spectacle wear) more strongly than central visual acuity in mediating crash risk.

  7. Some problems of NPP personnel training

    International Nuclear Information System (INIS)

    Vajshnis, P.P.; Kumkov, L.P.; Omel'chuk, V.V.

    1984-01-01

    Shortcomings of NPP personnel training are discussed. Development of full-scale training systems is necessary for qualitative training operative personnel. Primary problems that should be necessarily solved for ensuring effective training NPP personnel are considered

  8. Personnel Investigations and Clearance Tracking (OPI)

    Data.gov (United States)

    Office of Personnel Management — Security file-related information for the U.S. Office of Personnel Management (OPM)'s employee and contractor personnel. The data is OPM-specific, not government-wide.

  9. 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.

  10. Energy Requirements of Military Personnel

    National Research Council Canada - National Science Library

    Tharion, William J; Lieberman, Harris R; Montain, Scott J; Young, Andrew J; Baker-Fulco, Carol J

    2005-01-01

    ...) have been measured while training under various conditions. Group mean total energy expenditures for 424 male military personnel from various units engaged in diverse missions ranged from 13.0 to 29.8 MJ per day...

  11. Individual protection of NPP personnel

    International Nuclear Information System (INIS)

    Koshcheev, V.S.; Gol'dshtejn, D.S.; Chetverikova, Z.S.

    1983-01-01

    Specific features of NPP personnel individual protection are considered, mainly with respect to maintenance and repair works on various type reactors. The major concern is given to the selection and application reglamentations of the individual protection system (IPS), employment of sanitary locks, the organization of individual protection under the conditions of a heating microclimate. The ways are specified to the development and introduction of the most effective IPS and improvement of the entire NPP personnel individual protection system with respect to providing the necessary protection effect for maintaining high working capability of the personnel and minimizing the IPS impact on human organism functional systems. The accumulated experience in the personnel individual protection can be applied during construction and operation of NPP's in CMEA member-countries [ru

  12. Personnel monitoring in geologic fields

    International Nuclear Information System (INIS)

    Romanova, I.N.; Seredin, Yu.V.

    1981-01-01

    State of radiation safety for the personnel of geologic crews carrying out neutron logging of wells using Po-Be sources has been evaluated. Given are results of development of methods for the evaluation of individual radiation loads for personnel when working with Po-Be neutron sources useful for the application in practice by a geologic logging crew as well as a quantitative evaluation of profissional radiation loads during this kind of work. The following methods are recommended for personnel monitoring: 1) calculation of whole-body irradiation doses and hands from averaged values of radiation dose rate; 2) calculational tabulated determination of irradiation doses during recharging of shanks of well instruments. Personnel monitoring by means of instrumental methods is not necessary in the considered case [ru

  13. Transportation security personnel training manual

    International Nuclear Information System (INIS)

    1978-11-01

    Objective of this manual is to train security personnel to protect special nuclear materials and nuclear facilities against theft and sabotage as required by 10 CFR Part 73. This volume contains the introduction and rationale

  14. Office of Personnel Management (OPM)

    Data.gov (United States)

    Social Security Administration — The purpose of this agreement is for SSA to verify SSN information for the Office of Personnel Management. OPM will use the SSN verifications in its investigative...

  15. Personnel external dose monitoring system

    International Nuclear Information System (INIS)

    Zhao Hengyuan

    1989-01-01

    The status and trend of personnel external dose monitoring system are introduced briefly. Their characteristics, functions and TLD bedges of some commercially available automatic TLD system, including UD-710A (Matsushita, Japan), Harshaw-2271, 2276 (Harshaw, USA), Harshaw-8000 (Harshaw/Filtrol), Studsvik-1313 (Sweden) and Pitman-800 (UK) were depicted in detail. Finally, personnel dose management and record keeping system were presented and two examples were given

  16. THEORETICAL BASIS FOR MANAGEMENT OF PERSONNEL RISKS

    OpenAIRE

    Haliashova, Katsiaryna

    2017-01-01

    Necessity of personnel risks management is based on research results. The authors' approaches to the determination of personnel risks and to their management have been explored. The author's definition of the concept of "personnel risks" is proposed. A classification of personnel risks is developed depending on the stage of origin and the tasks of the personnel policy, as well as the methods of management personnel risks in the organization. The article presents a methodical approach to perso...

  17. 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

  18. Part two: Error propagation

    International Nuclear Information System (INIS)

    Picard, R.R.

    1989-01-01

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

  19. Learning from Errors

    OpenAIRE

    Martínez-Legaz, Juan Enrique; Soubeyran, Antoine

    2003-01-01

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

  20. Citizen's Report

    Data.gov (United States)

    Office of Personnel Management — The fiscal year (FY) 2008 Citizen's Report is a summary of performance and financial results for the U.S. Office of Personnel Management (OPM). OPM chose to produce...

  1. Generalized Gaussian Error Calculus

    CERN Document Server

    Grabe, Michael

    2010-01-01

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

  2. New classification of operators' human errors at overseas nuclear power plants and preparation of easy-to-use case sheets

    International Nuclear Information System (INIS)

    Takagawa, Kenichi

    2004-01-01

    At nuclear power plants, plant operators examine other human error cases, including those that occurred at other plants, so that they can learn from such experiences and avoid making similar errors again. Although there is little data available on errors made at domestic plants, nuclear operators in foreign countries are reporting even minor irregularities and signs of faults, and a large amount of data on human errors at overseas plants could be collected and examined. However, these overseas data have not been used effectively because most of them are poorly organized or not properly classified and are often hard to understand. Accordingly, we carried out a study on the cases of human errors at overseas power plants in order to help plant personnel clearly understand overseas experiences and avoid repeating similar errors, The study produced the following results, which were put to use at nuclear power plants and other facilities. (1) ''One-Point-Advice'' refers to a practice where a leader gives pieces of advice to his team of operators in order to prevent human errors before starting work. Based on this practice and those used in the aviation industry, we have developed a new method of classifying human errors that consists of four basic actions and three applied actions. (2) We used this new classification method to classify human errors made by operators at overseas nuclear power plants. The results show that the most frequent errors caused not by operators themselves but due to insufficient team monitoring, for which superiors and/or their colleagues were responsible. We therefore analyzed and classified possible factors contributing to insufficient team monitoring, and demonstrated that the frequent errors have also occurred at domestic power plants. (3) Using the new classification formula, we prepared a human error case sheets that is easy for plant personnel to understand. The sheets are designed to make data more understandable and easier to remember

  3. TRIAGE of Irradiated Personnel

    Science.gov (United States)

    1996-09-25

    DISTRIBUTION/AVAILABILITY STATEMENT APUBLIC RELEASE , 13. SUPPLEMENTARY NOTES 14. ABSTRACT See Report 15. SUBJECT TERMS 16. SECURITY CLASSIFICATION OF...4510). Under draft STANAG 4511, multiple pro- phylactic antiemetic medications and regimens were evaluated prior to adoption of granisetron . Two drugs...exceeded the criteria (shown below), granisetron and ondansetron. The former was adopted due to a better technical profile and the operational

  4. Characteristics of medication errors with parenteral cytotoxic drugs

    OpenAIRE

    Fyhr, A; Akselsson, R

    2012-01-01

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

  5. An Exploratory Analysis of the Navy Personnel Support Delivery Model

    Science.gov (United States)

    2017-09-01

    and accurate information, and seamless customer relationship management (Department of the Navy, 2010). There will be field level support for when...of Management and Budget, Paperwork Reduction Project (0704-0188) Washington, DC 20503. 1. AGENCY USE ONLY (Leave blank) 2. REPORT DATE September...through the Pay and Personnel Management Department (PERS-2). The current pay and personnel service delivery model is manpower heavy and relies on

  6. Cytogenic Investigations in Flight Personnel

    International Nuclear Information System (INIS)

    Wolf, G.; Obe, G.; Bergau, L.

    1999-01-01

    During long-distance flights at high altitudes flight personnel are exposed to cosmic radiation. In order to determine whether there are biological effects of such low dose radiation exposure in aircrew, chromosomal aberrations were investigated in 59 female cabin attendants and a matched control group of 31 members of station personnel. The mean number of dicentric chromosomes amounts to 1.3 (95% CI 1.0-1.6) per 1,000 cells in cabin attendants and 1.4 (95% CI 1.0-1.9) per 1,000 cells in controls. In an additional control group of 56 female clerks from Berlin the mean frequency of dicentric chromosomes was 1.3 (95% CI 1.0-1.6). Neither in dicentric frequency and distribution nor in other aberrations was a significant difference between the groups of flight and station personnel found. The high frequency of multi-aberrant cells was remarkable in flight personnel as well as in station personnel. The reason for this phenomenon is unknown and needs further investigation. (author)

  7. Evaluating Community College Personnel: A Research Report.

    Science.gov (United States)

    Deegan, William L.; And Others

    A statewide survey was conducted of local evaluation policies, procedures, and problems of implementing evaluation programs on the campuses of California community colleges. The following areas were studied: (1) the process of development of the evaluation program; (2) procedures utilized in the first year of implementing Senate Bill 696…

  8. 76 FR 81359 - National Security Personnel System

    Science.gov (United States)

    2011-12-28

    ... Security Personnel System AGENCY: Department of Defense; Office of Personnel Management. ACTION: Final rule... concerning the National Security Personnel System (NSPS). Section 1113 of the National Defense Authorization... National Security Personnel System (NSPS) in regulations jointly prescribed by DOD and OPM (Office of...

  9. 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.

  10. Training of research reactor personnel

    International Nuclear Information System (INIS)

    Cherruau, F.

    1980-01-01

    Research reactor personnel operate the reactor and carry out the experiments. These two types of work entail different activities, and therefore different skills and competence, the number of relevant staff being basically a function of the size, complexity and versatility of the reactor. Training problems are often reactor-specific, but the present paper considers them from three different viewpoints: the training or retraining of new staff or of personnel already employed at an existing facility, and training of personnel responsible for the start-up and operation of a new reactor, according to whether local infrastructure and experience already exist or whether they have to be built up from scratch. On-the-spot experience seems to be an essential basis for sound training, but requires teaching abilities and aids often difficult to bring together, and the availability of instructors that does not always fit in smoothly with current operational and experimental tasks. (author)

  11. Impact of Measurement Error on Synchrophasor Applications

    Energy Technology Data Exchange (ETDEWEB)

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

    2015-07-01

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

  12. Prescription Errors in Psychiatry

    African Journals Online (AJOL)

    Arun Kumar Agnihotri

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

  13. Personnel Management theories and applications

    Institute of Scientific and Technical Information of China (English)

    Yanni Feng

    2010-01-01

    @@ 1.Introduction Many new businesses are opened in the whole world every day.Unfortunately,only a minor part of them has success and continues its activity.There is a variety of reasons which determine the hankruptcy of companies.Most of them are included in running a business,and more and more people come to realize the significance of management,especially personnel management,as personnel represents the relationship between people in the company,which is a key point for the development of enterprise.

  14. Ethnic Minority Personnel Careers: Hindrances and Hopes

    OpenAIRE

    Ross, Catharine

    2004-01-01

    Personnel departments often have particular responsibility for equal opportunities within their organizations. This paper explores equal opportunities within personnel departments themselves, in relation to the careers of ethnic minority personnel practitioners. Through primary research, it identifies a range of criteria which can affect personnel careers, of which ethnic origin is often one. However, although being categorized as of ethnic minority origin often hinders personnel careers, the...

  15. Basis scheme of personnel training system

    International Nuclear Information System (INIS)

    Rerucha, F.; Odehnal, J.

    1998-01-01

    Basic scheme of the training system for NPP personnel of CEZ-EDU personnel training system is described in detail. This includes: specific training both basic and periodic, and professional training meaning specialized and continuous training. The following schemes are shown: licence acquisition and authorisation for PWR-440 Control Room Personnel; upgrade training for job positions of Control Room personnel; maintaining and refresh training; module training for certificate acquisition of servicing shift and operating personnel

  16. Failure to paint the left quarter of a watercolor and no error in a line drawing: a case report of an art teacher with unilateral spatial neglect.

    Science.gov (United States)

    Kondo, Minako; Mori, Toshiko; Makino, Kenichiro; Okazaki, Tetsuya; Hachisuka, Kenji

    2012-06-01

    A 54-year-old art teacher, experienced a right putaminal hemorrhage, and thereafter suffered severe left hemiplegia and unilateral spatial neglect, and was transferred to the rehabilitation department of the University Hospital 1 month after the onset. Although the unilateral spatial neglect was improving, the patient was unable to paint the left quarter of a watercolor, but there was no error in line drawing. The occurrence of errors only in a watercolor suggests that the neural process for painting a watercolor is different from that of line drawing.

  17. Radiation monitoring data representation for duty personnel

    Energy Technology Data Exchange (ETDEWEB)

    Gavrilov, S.L.; Kiselev, V.P.; Krasnoperov, S.N.; Kudeshov, E.V.; Maslov, S.Y.; Semin, N.N.; Sirotinskiy, S.E.; Yakovlev, V.Y. [Nuclear Safety Institute of the Russian Academy of Sciences (NSI RAS), Moscow (Russian Federation)

    2014-07-01

    Currently, Web-GIS technologies are widely used to generate a reliable and intuitive web-based interface to monitor the current radiation situation in various regions of the Russian Federation. The developed 'Server Web-Monitoring' web-application is intended for duty personnel and can operate not only on desktop computers but also on mobile devices. The subsystem of duty personnel notification about any Off-Normal Situation (ONS) (such as: critical threshold exceedances or failures in operation of monitoring systems) is also considered in the paper. Three types of Automated Radiation Monitoring Systems (ARMS) are available for monitoring: - regional ARMS; - facility-level ARMS; - ARMS of nuclear power plant surveillance areas. Google Maps and Google Maps API toolbox are used as the cartographic basis. In the general-monitoring window only general information on each of the local systems is available. Next, the operator can move to monitoring of local ARMS he is interested in. The operator can either view a list of Radiation Situation Monitoring Posts (RSMP) showing the current data in the right frame or hide it and use the map only. Viewing the log of critical threshold exceedances for 24 hours and a report on all RSMPs of a given system over the last 7 days is also possible. The report contains maximum values of measurements for every day and for each RSMP. The developed web-application includes: - monitoring of the radiation situation and its changes on the general map of the Russian Federation and on maps of local ARMS; - displaying 7-day reports for all RSMPs of the selected ARMS; - displaying the log of critical threshold exceedances recorded over the past day. The notification subsystem informs duty personnel on all ONS, namely, on critical threshold exceedances in the incoming data and failures in operation of monitoring systems. The key features of the notification subsystem are: - round-the-clock functioning; - automatic notification in case of

  18. Report from LHC MD 1391: First tests of the variation of amplitude detuning with crossing angle as an observable for high-order errors in low-β∗ colliders

    CERN Document Server

    Maclean, Ewen Hamish; Fuchsberger, Kajetan; Giovannozzi, Massimo; Persson, Tobias Hakan Bjorn; Tomas Garcia, Rogelio; CERN. Geneva. ATS Department

    2017-01-01

    Nonlinear errors in experimental insertions can pose a significant challenge to the operability of low-β∗ colliders. When crossing schemes are applied high-order errors, such as decapole and dodecapole multipole components in triplets and separation dipoles, can feed-down to give a normal octupole perturbation. Such fields may contribute to distortion of the assumed tune footprint, influencing lifetime and the Landau damping of instabilities. Conversely, comparison of amplitude detuning coefficients with and without crossing schemes applied should allow for the beam-based study of such high-order errors. In this note first measurements of amplitude detuning with crossing bumps in the experimental insertions are reported.

  19. [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.

  20. A relational database for personnel radiation exposure management

    International Nuclear Information System (INIS)

    David, W.; Miller, P.D.

    1993-01-01

    In-house utility personnel developed a relational data base for personnel radiation exposure management computer system during a 2 1/2 year period. The (PREM) Personnel Radiation Exposure Management System was designed to meet current Nuclear Regulatory Commission (NRC) requirements related to radiological access control, Radiation Work Permits (RWP) management, automated personnel dosimetry reporting, ALARA planning and repetitive job history dose archiving. The system has been operational for the past 18 months which includes a full refueling outage at Clinton Power Station. The Radiation Protection Department designed PREM to establish a software platform for implementing future revisions to 10CFR20 in 1993. Workers acceptance of the system has been excellent. Regulatory officials have given the system high marks as a radiological tool because of the system's ability to track the entire job from start to finish

  1. Error tracking in a clinical biochemistry laboratory

    DEFF Research Database (Denmark)

    Szecsi, Pal Bela; Ødum, Lars

    2009-01-01

    BACKGROUND: We report our results for the systematic recording of all errors in a standard clinical laboratory over a 1-year period. METHODS: Recording was performed using a commercial database program. All individuals in the laboratory were allowed to report errors. The testing processes were cl...

  2. Study of personnel monitoring programs

    International Nuclear Information System (INIS)

    Guerra, Aline B.; Lorenzini, Fabiane; Carlos, Janaina; Bernasiuk, Maria E.B.; Rizzatti, Mara R.; Fuentefria, Jose L.B.

    1996-01-01

    Surveillance of several health institutions who use ionizing radiation sources, as well as data from the state of Rio Grande do Sul (Brazil) are studied concerning the use of personnel dosimeters. The results show that several institutions do not provide them and those which provide do not know how to use them

  3. Rights & Responsibilities. Personnel Management Module.

    Science.gov (United States)

    Barker, Gale; And Others

    This module on rights and responsibilities is intended to introduce the hospitality manager or supervisor to sound personnel management practices that comply with the law. The material is presented in a self-instructional format in seven sections. At the beginning of each section is a statement of the objectives that will be achieved as a result…

  4. Personnel monitoring for beta rays

    International Nuclear Information System (INIS)

    Piesch, E.; Johns, T.F.

    1983-01-01

    The practical considerations which have to be taken into account in the design of personnel monitors intended to measure doses resulting from exposure to beta rays are discussed. These include the measurement of doses in situations involving either fairly uniform or non-uniform irradiation and of doses to the male gonads. (UK)

  5. Project Management Personnel Competencies Evaluation

    Directory of Open Access Journals (Sweden)

    Paul POCATILU

    2006-01-01

    Full Text Available An important factor for the success management of IT projects is the human resource. People involved in the project management process have to be evaluated. In order to do that, same criteria has to be specified. This paper describes some aspects regarding the personnel evaluation.

  6. Random Measurement Error as a Source of Discrepancies between the Reports of Wives and Husbands Concerning Marital Power and Task Allocation.

    Science.gov (United States)

    Quarm, Daisy

    1981-01-01

    Findings for couples (N=119) show wife's work, money, and spare time low between-spouse correlations are due in part to random measurement error. Suggests that increasing reliability of measures by creating multi-item indices can also increase correlations. Car purchase, vacation, and child discipline were not accounted for by random measurement…

  7. The Impact of Short-Term Science Teacher Professional Development on the Evaluation of Student Understanding and Errors Related to Natural Selection. CRESST Report 822

    Science.gov (United States)

    Buschang, Rebecca E.

    2012-01-01

    This study evaluated the effects of a short-term professional development session. Forty volunteer high school biology teachers were randomly assigned to one of two professional development conditions: (a) developing deep content knowledge (i.e., control condition) or (b) evaluating student errors and understanding in writing samples (i.e.,…

  8. Error management process for power stations

    International Nuclear Information System (INIS)

    Hirotsu, Yuko; Takeda, Daisuke; Fujimoto, Junzo; Nagasaka, Akihiko

    2016-01-01

    The purpose of this study is to establish 'error management process for power stations' for systematizing activities for human error prevention and for festering continuous improvement of these activities. The following are proposed by deriving concepts concerning error management process from existing knowledge and realizing them through application and evaluation of their effectiveness at a power station: an entire picture of error management process that facilitate four functions requisite for maraging human error prevention effectively (1. systematizing human error prevention tools, 2. identifying problems based on incident reports and taking corrective actions, 3. identifying good practices and potential problems for taking proactive measures, 4. prioritizeng human error prevention tools based on identified problems); detail steps for each activity (i.e. developing an annual plan for human error prevention, reporting and analyzing incidents and near misses) based on a model of human error causation; procedures and example of items for identifying gaps between current and desired levels of executions and outputs of each activity; stages for introducing and establishing the above proposed error management process into a power station. By giving shape to above proposals at a power station, systematization and continuous improvement of activities for human error prevention in line with the actual situation of the power station can be expected. (author)

  9. Authorization of nuclear power plant control room personnel: Methods and practices with emphasis on the use of simulators

    International Nuclear Information System (INIS)

    2006-07-01

    In 2002 the IAEA published a revision to Safety Guide NS-G-2.8, Recruitment, Qualification and Training of Personnel for Nuclear Power Plants. This Safety Guide provides recommendations on the authorization of designated personnel who have a direct impact on nuclear safety. The IAEA Technical Working Group on Training and Qualification of Nuclear Power Plant Personnel recommended that an additional report be prepared that provided information on the practices in Member States on the use of simulators in the authorization of control room staff. This publication has been prepared in response to that recommendation. In gathering information for the report, Member States were asked to: respond to a survey on the use of simulators and the involvement of regulatory body in operator authorization; and to complete a questionnaire on their practices in authorizing control room staff. Safety analysis and operating experience consistently indicate that human error is a major contributor to nuclear power plant (NPP) accident risk. With the recent world wide emphasis and implementation of full scope simulators for nuclear power plant personnel training, operators spend a large portion of their training time on simulators. As described in the foreword to IAEA-TECDOC-1411, Use of Control Room Simulators for Training of Nuclear Power Plant Personnel, simulators provide operators an opportunity to learn and practice the abilities that are required in accident and infrequently used plant evolutions. Because of their fidelity, full scope simulators are now used by most Member States in the authorization examinations of control room personnel. This situation is becoming more common as more plants acquire modern full scope plant referenced simulators. This publication provides information and examples based upon experience in a variety of Member States. The body of the report provides general information that represents the practices of the Member States that contributed to the

  10. Human factors evaluation of remote afterloading brachytherapy: Human error and critical tasks in remote afterloading brachytherapy and approaches for improved system performance. Volume 1

    Energy Technology Data Exchange (ETDEWEB)

    Callan, J.R.; Kelly, R.T.; Quinn, M.L. [Pacific Science and Engineering Group, San Diego, CA (United States)] [and others

    1995-05-01

    Remote Afterloading Brachytherapy (RAB) is a medical process used in the treatment of cancer. RAB uses a computer-controlled device to remotely insert and remove radioactive sources close to a target (or tumor) in the body. Some RAB problems affecting the radiation dose to the patient have been reported and attributed to human error. To determine the root cause of human error in the RAB system, a human factors team visited 23 RAB treatment sites in the US The team observed RAB treatment planning and delivery, interviewed RAB personnel, and performed walk-throughs, during which staff demonstrated the procedures and practices used in performing RAB tasks. Factors leading to human error in the RAB system were identified. The impact of those factors on the performance of RAB was then evaluated and prioritized in terms of safety significance. Finally, the project identified and evaluated alternative approaches for resolving the safety significant problems related to human error.

  11. Human factors evaluation of remote afterloading brachytherapy: Human error and critical tasks in remote afterloading brachytherapy and approaches for improved system performance. Volume 1

    International Nuclear Information System (INIS)

    Callan, J.R.; Kelly, R.T.; Quinn, M.L.

    1995-05-01

    Remote Afterloading Brachytherapy (RAB) is a medical process used in the treatment of cancer. RAB uses a computer-controlled device to remotely insert and remove radioactive sources close to a target (or tumor) in the body. Some RAB problems affecting the radiation dose to the patient have been reported and attributed to human error. To determine the root cause of human error in the RAB system, a human factors team visited 23 RAB treatment sites in the US The team observed RAB treatment planning and delivery, interviewed RAB personnel, and performed walk-throughs, during which staff demonstrated the procedures and practices used in performing RAB tasks. Factors leading to human error in the RAB system were identified. The impact of those factors on the performance of RAB was then evaluated and prioritized in terms of safety significance. Finally, the project identified and evaluated alternative approaches for resolving the safety significant problems related to human error

  12. 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

  13. Radiation exposure of non-monitored hospital personnel

    International Nuclear Information System (INIS)

    Renaud, L.; Blanchette, J.; Galand, C.

    1993-02-01

    This addendum to report INFO--0437-1 reports the raw results of phase 2 of the survey of medical personnel exposed to nuclear medicine patients. It also presents floor plans of the three hospitals surveyed. (L.L.) (42 tabs., 36 figs.)

  14. Development of neutron personnel monitoring system based on CR-39 solid state nuclear track detector

    International Nuclear Information System (INIS)

    Massand, O.P.; Kundu, H.K.; Marathe, P.K.; Supe, S.J.

    1990-01-01

    Personnel neutron monitoring aims at providing a method to evaluate the magnitude of the detrimental effects on the personnel exposed to neutrons. Neutron monitoring is done for a small though growing number of personnel working with neutrons in a wide range of situations. Over the years, many solid state nuclear track detectors (SSNTD) have been tried for neutron personnel monitoring. CR-39 SSNTD is a proton sensitive polymer and offers a lot of promise for neutron personnel monitoring due to its high sensitivity and lower energy threshold for neutron detection. This report presents the mechanism of track formation in this polymer, the development of this neutron personnel monitoring system in our laboratory, its various characteristics and its promise as a routine personnel neutron monitor. (author). 1 tab., 7 figs

  15. Higher operational safety of nuclear power plants by evaluating the behaviour of operating personnel

    International Nuclear Information System (INIS)

    Mertins, M.; Glasner, P.

    1990-01-01

    In the GDR power reactors have been operated since 1966. Since that time operational experiences of 73 cumulative reactor years have been collected. The behaviour of operating personnel is an essential factor to guarantee the safety of operation of the nuclear power plant. Therefore a continuous analysis of the behaviour of operating personnel has been introduced at the GDR nuclear power plants. In the paper the overall system of the selection, preparation and control of the behaviour of nuclear power plant operating personnel is presented. The methods concerned are based on recording all errors of operating personnel and on analyzing them in order to find out the reasons. The aim of the analysis of reasons is to reduce the number of errors. By a feedback of experiences the nuclear safety of the nuclear power plant can be increased. All data necessary for the evaluation of errors are recorded and evaluated by a computer program. This method is explained thoroughly in the paper. Selected results of error analysis are presented. It is explained how the activities of the personnel are made safer by means of this analysis. Comparisons with other methods are made. (author). 3 refs, 4 figs

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

    Energy Technology Data Exchange (ETDEWEB)

    Louisiana State University; Balman, Mehmet; Kosar, Tevfik

    2010-10-27

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

  17. The error in total error reduction.

    Science.gov (United States)

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

    2014-02-01

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

  18. Assuring the competence of nuclear power plant contractor personnel

    Energy Technology Data Exchange (ETDEWEB)

    NONE

    2001-07-01

    This report was prepared in response to a recommendation by the IAEA International Working Group on Training and Qualification of NPP Personnel (JWG-T and Q) and supported by a number of IAEA meetings on NPP personnel training. IAEA publications on NPP training are the only international documents available to all Member States with nuclear programmes. This report complements the following IAEA publications on NPP personnel training: Technical Reports Series No. 380, Nuclear Power Plant Personnel Training and its Evaluation, A Guidebook; IAEA-TECDOC-1057, Experience in the Use of Systematic Approach to Training (SAT) for Nuclear Power Plant Personnel and IAEA-TECDOC-1063, IAEA World Survey on Nuclear Power Plant Personnel Training. This TECDOC also supplements the IAEA Safety Guide 50-SG-O1 (Rev. 1), Staffing of Nuclear Power Plants and the Recruitment Training and Authorization of Operating Personnel and Safety Standards Series No. NS-R-2, Safety of Nuclear Power Plants. Operation. Within the context of this report NPP contractors are defined as any personnel working for a nuclear power plant who are not directly employed by the nuclear power plant. Competence is the ability to perform to identified standards; it comprises skills, knowledge and attitudes and may be developed through education, experience and training. Qualification is a formal statement of achievement, resulting from an auditable assessment; if competence is assessed, the qualification becomes a formal statement of competence and may be shown on a certificate, diploma, etc. It is recognized that personnel are used to perform tasks that are of a specialised or temporary nature where it is not feasible to hire or maintain a full-time NPP employee. Accordingly, contractors may be used in a variety of situations to support NPPs. Typical situations include: supplies and services being delivered by the contractors that are subject to different quality standards based on a graded approach to assuring

  19. Assuring the competence of nuclear power plant contractor personnel

    International Nuclear Information System (INIS)

    2001-07-01

    This report was prepared in response to a recommendation by the IAEA International Working Group on Training and Qualification of NPP Personnel (JWG-T and Q) and supported by a number of IAEA meetings on NPP personnel training. IAEA publications on NPP training are the only international documents available to all Member States with nuclear programmes. This report complements the following IAEA publications on NPP personnel training: Technical Reports Series No. 380, Nuclear Power Plant Personnel Training and its Evaluation, A Guidebook; IAEA-TECDOC-1057, Experience in the Use of Systematic Approach to Training (SAT) for Nuclear Power Plant Personnel and IAEA-TECDOC-1063, IAEA World Survey on Nuclear Power Plant Personnel Training. This TECDOC also supplements the IAEA Safety Guide 50-SG-O1 (Rev. 1), Staffing of Nuclear Power Plants and the Recruitment Training and Authorization of Operating Personnel and Safety Standards Series No. NS-R-2, Safety of Nuclear Power Plants. Operation. Within the context of this report NPP contractors are defined as any personnel working for a nuclear power plant who are not directly employed by the nuclear power plant. Competence is the ability to perform to identified standards; it comprises skills, knowledge and attitudes and may be developed through education, experience and training. Qualification is a formal statement of achievement, resulting from an auditable assessment; if competence is assessed, the qualification becomes a formal statement of competence and may be shown on a certificate, diploma, etc. It is recognized that personnel are used to perform tasks that are of a specialised or temporary nature where it is not feasible to hire or maintain a full-time NPP employee. Accordingly, contractors may be used in a variety of situations to support NPPs. Typical situations include: supplies and services being delivered by the contractors that are subject to different quality standards based on a graded approach to assuring

  20. 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.

  1. Errors in Neonatology

    OpenAIRE

    Antonio Boldrini; Rosa T. Scaramuzzo; Armando Cuttano

    2013-01-01

    Introduction: Danger and errors are inherent in human activities. In medical practice errors can lean to adverse events for patients. Mass media echo the whole scenario. Methods: We reviewed recent published papers in PubMed database to focus on the evidence and management of errors in medical practice in general and in Neonatology in particular. We compared the results of the literature with our specific experience in Nina Simulation Centre (Pisa, Italy). Results: In Neonatology the main err...

  2. A Review of Mercury Exposure and Health of Dental Personnel

    Directory of Open Access Journals (Sweden)

    Natasha Nagpal

    2017-03-01

    Full Text Available Considerable effort has been made to address the issue of occupational health and environmental exposure to mercury. This review reports on the current literature of mercury exposure and health impacts on dental personnel. Citations were searched using four comprehensive electronic databases for articles published between 2002 and 2015. All original articles that evaluated an association between the use of dental amalgam and occupational mercury exposure in dental personnel were included. Fifteen publications from nine different countries met the selection criteria. The design and quality of the studies showed significant variation, particularly in the choice of biomarkers as an indicator of mercury exposure. In several countries, dental personnel had higher mercury levels in biological fluids and tissues than in control groups; some work practices increased mercury exposure but the exposure levels remained below recommended guidelines. Dental personnel reported more health conditions, often involving the central nervous system, than the control groups. Clinical symptoms reported by dental professionals may be associated with low-level, long-term exposure to occupational mercury, but may also be due to the effects of aging, occupational overuse, and stress. It is important that dental personnel, researchers, and educators continue to encourage and monitor good work practices by dental professionals.

  3. Systematic Procedural Error

    National Research Council Canada - National Science Library

    Byrne, Michael D

    2006-01-01

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

  4. Human errors and mistakes

    International Nuclear Information System (INIS)

    Wahlstroem, B.

    1993-01-01

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

  5. Essential themes in Personnel economics

    OpenAIRE

    Josheski, Dushko

    2014-01-01

    In this paper are presented essential themes in the subject of personnel economics. In the first part analysis has been conducted on the impact of peer pressure on workplace behaviour. Then again models for compensation structures within firms, and their influence on the utility of work by employees. In the final section of the paper the productivity spillover effect has been analyzed, and the causes of existence of spillovers and their impact on workers’ productivity

  6. Modern methods of personnel dosimetry

    International Nuclear Information System (INIS)

    Kraus, W.; Herrmann, D.; Kiesewetter, W.

    The physical properties of radiation detectors for personnel dosimetry are described and compared. The suitability of different types of dosimeters for operational and central monitoring of normal occupational exposure, for accident and catastrophe dosimetry and for background and space-flight dosimetry is discussed. The difficulties in interpreting the dosimeter reading with respect to the dose in individual body organs are discussed briefly. 430 literature citations (up to Spring 1966) are given

  7. The LHC personnel safety system

    International Nuclear Information System (INIS)

    Ninin, P.; Valentini, F.; Ladzinski, T.

    2011-01-01

    Large particle physics installations such as the CERN Large Hadron Collider require specific Personnel Safety Systems (PSS) to protect the personnel against the radiological and industrial hazards. In order to fulfill the French regulation in matter of nuclear installations, the principles of IEC 61508 and IEC 61513 standard are used as a methodology framework to evaluate the criticality of the installation, to design and to implement the PSS.The LHC PSS deals with the implementation of all physical barriers, access controls and interlock devices around the 27 km of underground tunnel, service zones and experimental caverns of the LHC. The system shall guarantee the absence of personnel in the LHC controlled areas during the machine operations and, on the other hand, ensure the automatic accelerator shutdown in case of any safety condition violation, such as an intrusion during beam circulation. The LHC PSS has been conceived as two separate and independent systems: the LHC Access Control System (LACS) and the LHC Access Safety System (LASS). The LACS, using off the shelf technologies, realizes all physical barriers and regulates all accesses to the underground areas by identifying users and checking their authorizations.The LASS has been designed according to the principles of the IEC 61508 and 61513 standards, starting from a risk analysis conducted on the LHC facility equipped with a standard access control system. It consists in a set of safety functions realized by a dedicated fail-safe and redundant hardware guaranteed to be of SIL3 class. The integration of various technologies combining electronics, sensors, video and operational procedures adopted to establish an efficient personnel safety system for the CERN LHC accelerator is presented in this paper. (authors)

  8. Career path for operations personnel

    International Nuclear Information System (INIS)

    Asher, J.A.

    1985-01-01

    This paper explains how selected personnel can now obtain a Bachelor of Science degree in Physics with a Nuclear Power Operations option. The program went into effect the Fall of 1984. Another program was worked out in 1982 whereby students attending the Nuclear Operators Training Program could obtain an Associates of Science degree in Mechanical Engineering Technology at the end of two years of study. This paper presents tables and charts which describe these programs and outline the career path for operators

  9. Moral distress in nursing personnel

    OpenAIRE

    Barlem,Edison Luiz Devos; Lunardi,Valéria Lerch; Lunardi,Guilherme Lerch; Tomaschewski-Barlem,Jamila Geri; Silveira,Rosemary Silva da; Dalmolin,Graziele de Lima

    2013-01-01

    OBJECTIVE: to analyze the frequency and intensity of moral distress experienced by nursing personnel in southern Brazil, covering elements of their professional practice. METHOD: a survey was undertaken in two hospitals in Rio Grande do Sul, Brazil, with 247 nurses. Data was collected by means of the adapted Moral Distress Scale. RESULTS: the perception of situations that lead to moral distress is enhanced in nurses and in nursing staff working in institutions with greater openness to dialogu...

  10. TLD personnel dosimetry and its relationship with the radiodiagnostic training

    International Nuclear Information System (INIS)

    Gaona, E.; Franco E, J.G.; Gaona C, E.

    2002-01-01

    The personnel dosimetry and the training in radiological protection in radiodiagnostic in Mexico before 1997 were almost nonexistent except few services of public and private radiology, we can to say that the personnel dosimetry and the obligatory training was born in the year 1997, together with the present Mexican Official Standards in radiology. This study has the purpose to make an evaluation of the personnel dosimetry of 110 radiology services distributed in the Mexican Republic for the year 2001 and to estimate the annual and bimonthly mean doses, as well as its trust intervals and its relationships with the personnel training in radiological protection by means of a sampling that was realized in two stages (1997 and 2000) in the metropolitan area of Mexico City. The results show that the received doses by the medical and technical personnel in the participating radiology services are in the 0.03 mSv and 0.94 mSv interval and the mean is 0.25 mSv. The estimated annual personnel dose would be in the 0.18 mSv to 5.64 mSv interval, which are values very lower to the annual dose limit that is 50 mSv and its magnitude is similar to the effective annual dose by natural background radiation. In the first stage in training was found that there is not a significant difference in the response frequencies among the medical and technical personnel with a p < 0.05. The 52% of the occupational exposure personnel of radiology uses dosemeter, but only 17% of them know the dose reports. the 15.8% of personnel considers that dosemeter protects against radiation and only 16.5% knows the annual maximum permissible dose for stochastic effects. The second stage, the results shown that there is a significant difference in the response of frequencies among medical and technical personnel, the same results which are obtained for members and non members of a professional association with a p < 0.05. The 38% has personnel dosimetry, the 19% knows the principles of radiological

  11. Group representations, error bases and quantum codes

    Energy Technology Data Exchange (ETDEWEB)

    Knill, E

    1996-01-01

    This report continues the discussion of unitary error bases and quantum codes. Nice error bases are characterized in terms of the existence of certain characters in a group. A general construction for error bases which are non-abelian over the center is given. The method for obtaining codes due to Calderbank et al. is generalized and expressed purely in representation theoretic terms. The significance of the inertia subgroup both for constructing codes and obtaining the set of transversally implementable operations is demonstrated.

  12. Personnel exposures in industrial radiography

    International Nuclear Information System (INIS)

    Shenoy, K.S.; Patel, P.H.

    1979-01-01

    The manifold increase in production, and ease of availability of radioisotopes in India have been responsible for a tremendous increase in use of radioisotopes in industrial radiography during past fifteen years. Among various applications of radioisotopes the industrial radiography involves a large potential risk of occupational radiation exposures. The dose records of past fifteen years in respect of all radiation workers maintained by the Personnel Monitoring Group of Division of Radiological Protection of the Bhabha Atomic Research Centre, Bombay, have been analysed. Analysis of excessive exposure (exceeding 400 mrem/fortnight) reveals that this figure is increasing at an alarming rate among the radiation workers of this category. In spite of various regulatory controls the dose per person per week has remained higher as compared to the same in other categories. This combined with the increase in number of radiation workers every year would soon contribute significantly to the per capita dose for radiation workers. Use of adequately shielded fool-proof remote control equipment and training of all personnel in safe handling of radiation sources seem to be the only solution to arrest the rate of increase in personnel exposures of this category. (auth.)

  13. Department of the Army - The Fiscal Year 2008 Military Personnel, Army Appropriation and the Antideficiency Act

    Science.gov (United States)

    2010-06-22

    of the Army, U.S. Army Audit Agency, Budgeting for the Military Personnel, Army Appropriation, Report No. A-2010-0028- FFM (Jan. 6, 2010); Department...of the Army, U.S. Army Audit Agency, Military Personnel, Army FY 05 Subsistence Charges, Report No. A-2008-0037- FFM (Feb. 12, 2008); Department of

  14. National Finance Center Personnel/Payroll System

    Data.gov (United States)

    US Agency for International Development — The NFC system is an USDA system used for processing transactions for payroll/personnel systems. Personnel processing is done through EPIC/HCUP, which is web-based....

  15. Nuclear security. DOE actions to improve the personnel clearance program

    International Nuclear Information System (INIS)

    Fultz, Keith O.; Bannerman, Carl J.; Daniel, Beverly A.

    1988-11-01

    The status of the Department of Energy's (DOE) implementation of recommendations in our two reports on DOE's personnel security clearance program was determined. The recommendations were aimed at improving the timeliness, accuracy, and efficiency of personnel security clearance decisions. Specifically, the objective was to determine and report on steps DOE is taking to implement these recommendations. In summary, it was found that DOE has either initiated action or is studying ways to address all the recommendations, but none of the recommendations have been completely implemented. The effectiveness of the DOE actions will depend, in part, on the adequacy of its internal control system for overseeing and evaluating program operations. DOE's personnel security clearance program is intended to provide reasonable assurance that personnel with access to classified information and materials are trustworthy. The Department requests that the Office of Personnel Management or the Federal Bureau of Investigation collect personal data on each person who requires such access to do his or her job. Based on these background investigations, DOE officials authorize individuals whose personal histories indicate that they are trustworthy to have access to classified information, secured facilities, and controlled materials as needed to perform their jobs. DOE has five types of these authorizations or personnel security clearances and must update information on personnel holding each type at 5-year intervals to confirm their continuing reliability. The five types are based on the types of security interests to which the person needs access, e.g., persons needing nuclear weapons-related data must have a Q clearance, and persons with a top secret clearance can have access to national security data classified as top secret

  16. Use of FMEA analysis to reduce risk of errors in prescribing and administering drugs in paediatric wards: a quality improvement report.

    Science.gov (United States)

    Lago, Paola; Bizzarri, Giancarlo; Scalzotto, Francesca; Parpaiola, Antonella; Amigoni, Angela; Putoto, Giovanni; Perilongo, Giorgio

    2012-01-01

    Administering medication to hospitalised infants and children is a complex process at high risk of error. Failure mode and effect analysis (FMEA) is a proactive tool used to analyse risks, identify failures before they happen and prioritise remedial measures. To examine the hazards associated with the process of drug delivery to children, we performed a proactive risk-assessment analysis. Five multidisciplinary teams, representing different divisions of the paediatric department at Padua University Hospital, were trained to analyse the drug-delivery process, to identify possible causes of failures and their potential effects, to calculate a risk priority number (RPN) for each failure and plan changes in practices. To identify higher-priority potential failure modes as defined by RPNs and planning changes in clinical practice to reduce the risk of patients harm and improve safety in the process of medication use in children. In all, 37 higher-priority potential failure modes and 71 associated causes and effects were identified. The highest RPNs related (>48) mainly to errors in calculating drug doses and concentrations. Many of these failure modes were found in all the five units, suggesting the presence of common targets for improvement, particularly in enhancing the safety of prescription and preparation of endovenous drugs. The introductions of new activities in the revised process of administering drugs allowed reducing the high-risk failure modes of 60%. FMEA is an effective proactive risk-assessment tool useful to aid multidisciplinary groups in understanding a process care and identifying errors that may occur, prioritising remedial interventions and possibly enhancing the safety of drug delivery in children.

  17. [Errors in wound management].

    Science.gov (United States)

    Filipović, Marinko; Novinscak, Tomislav

    2014-10-01

    Chronic ulcers have adverse effects on the patient quality of life and productivity, thus posing financial burden upon the healthcare system. Chronic wound healing is a complex process resulting from the interaction of the patient general health status, wound related factors, medical personnel skill and competence, and therapy related products. In clinical practice, considerable improvement has been made in the treatment of chronic wounds, which is evident in the reduced rate of the severe forms of chronic wounds in outpatient clinics. However, in spite of all the modern approaches, efforts invested by medical personnel and agents available for wound care, numerous problems are still encountered in daily practice. Most frequently, the problems arise from inappropriate education, of young personnel in particular, absence of multidisciplinary approach, and inadequate communication among the personnel directly involved in wound treatment. To perceive them more clearly, the potential problems or complications in the management of chronic wounds can be classified into the following groups: problems mostly related to the use of wound coverage and other etiology related specificities of wound treatment; problems related to incompatibility of the agents used in wound treatment; and problems arising from failure to ensure aseptic and antiseptic performance conditions.

  18. 10 CFR 36.55 - Personnel monitoring.

    Science.gov (United States)

    2010-01-01

    ... 10 Energy 1 2010-01-01 2010-01-01 false Personnel monitoring. 36.55 Section 36.55 Energy NUCLEAR REGULATORY COMMISSION LICENSES AND RADIATION SAFETY REQUIREMENTS FOR IRRADIATORS Operation of Irradiators § 36.55 Personnel monitoring. (a) Irradiator operators shall wear a personnel dosimeter that is...

  19. 49 CFR 193.2711 - Personnel health.

    Science.gov (United States)

    2010-10-01

    ... 49 Transportation 3 2010-10-01 2010-10-01 false Personnel health. 193.2711 Section 193.2711 Transportation Other Regulations Relating to Transportation (Continued) PIPELINE AND HAZARDOUS MATERIALS SAFETY...: FEDERAL SAFETY STANDARDS Personnel Qualifications and Training § 193.2711 Personnel health. Each operator...

  20. Personnel Development Practices in Turkish Education System

    Science.gov (United States)

    Ozdemir, Tuncay Yavuz

    2016-01-01

    Nowadays everything develops and changes very quickly and sustainability of organizational goals will be possible only when personnel can keep up with these changes. From administrative aspect it is important to enhance personnel's potential and prompt them to achieve organizational goals. Personnel development is a process which influences and…

  1. Does the Current 20th Century Navy Personnel Management System Meet 21st Century Sailors’ Needs

    Science.gov (United States)

    2003-04-01

    49 Personnel Management and Labor Economics Literature . . . . 56 Technical Reports of Defense Manpower Analysis...4. MANPOWER MODELING AND PERSONNEL CHARACTERISTICS 159 Labor Economics and Requirements Determination . . . . . . 159...assigned in courses. The second grouping concerns the key ideas of other authors on the subjects of personnel management and labor economics . Although the

  2. Learning from Errors

    Science.gov (United States)

    Metcalfe, Janet

    2017-01-01

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

  3. The District Nursing Clinical Error Reduction Programme.

    Science.gov (United States)

    McGraw, Caroline; Topping, Claire

    2011-01-01

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

  4. Common patterns in 558 diagnostic radiology errors.

    Science.gov (United States)

    Donald, Jennifer J; Barnard, Stuart A

    2012-04-01

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

  5. 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.

  6. Occupational injury rates in personnel of emergency medical services

    Directory of Open Access Journals (Sweden)

    Robert Gałązkowski

    2015-12-01

    Full Text Available [i][/i][b]Introduction and objectives. [/b]The system of emergency medical services (EMS in Poland was established in 2006. The risk of occupational injuries to EMS personnel is very high, irrespective of the country where they operate, as they face many hazards in their everyday work. The aim of this study is to describe the type, incidence and consequences of occupational accidents among the personnel of the National Emergency Medical Services in Poland (NEMS – land and air ambulance crews in 2008–2012. [b]Material and methods:[/b] The study reviewed all occupational accidents among the EMS personnel reported to the National Labour Inspectorate in 2008–2012. [b]Results[/b]: In the period reported, the number of accidents decreased from 32 in 2008 to just 6 in 2012. Traffic accidents predominated and most of the victims were male paramedics under 30 years of age. The most common injuries included multiple organ injuries and injuries of the cervical spine, chest and trunk. [b]Conclusions:[/b] The growing professional experience of the EMS personnel has a beneficial effect on occupational injury rates as they tend to decrease with longer employment. Occupational accidents are definitely more common among ambulance crews than in the personnel of other organizational units of the National Emergency Medical Services.

  7. Perceived effect of deployment on families of UK military personnel.

    Science.gov (United States)

    Thandi, G; Greenberg, N; Fear, N T; Jones, N

    2017-10-01

    In the UK, little is known about the perceived effects of deployment, on military families, from military personnel in theatre. To investigate military personnel's perceptions of the impact of deployment on intimate relationships and children. Deployed service personnel who were in a relationship, and who had children, completed a survey while deployed on combat operations. Data were taken from four mental health surveys carried out in Iraq in 2009 and Afghanistan in 2010, 2011 and 2014. Among 4265 participants, after adjusting for military and social-demographic covariates, perceiving that deployment had a negative impact on intimate relationships and children was associated with psychological distress, and traumatic stress symptoms. Military personnel who reported being in danger of being injured or killed during deployment, were more likely to report a perceived negative effect of deployment on their intimate relationships. Reservists were less likely to report a perceived negative impact of deployment on their children compared with regulars. Military personnel who themselves planned to separate from their partner were more likely to report psychological distress, and stressors at home. Perceived insufficient support from the Ministry of Defence was associated with poor mental health, and holding a junior rank. Deployed UK military personnel with symptoms of psychological distress, who experienced stressors at home, were especially likely to perceive that their family were inadequately supported by the military. Those planning to separate from their partner were at increased risk of suffering with mental health problems while deployed. © The Author 2017. Published by Oxford University Press on behalf of the Society of Occupational Medicine. All rights reserved. For Permissions, please email: journals.permissions@oup.com

  8. Error Discounting in Probabilistic Category Learning

    Science.gov (United States)

    Craig, Stewart; Lewandowsky, Stephan; Little, Daniel R.

    2011-01-01

    The assumption in some current theories of probabilistic categorization is that people gradually attenuate their learning in response to unavoidable error. However, existing evidence for this error discounting is sparse and open to alternative interpretations. We report 2 probabilistic-categorization experiments in which we investigated error…

  9. A Global Perspective of Vaccination of Healthcare Personnel against Measles: Systematic Review

    Science.gov (United States)

    Fiebelkorn, Amy Parker; Seward, Jane F.; Orenstein, Walter

    2015-01-01

    Measles transmission has been well documented in healthcare facilities. Healthcare personnel who are unvaccinated and who lack other evidence of measles immunity put themselves and their patients at risk for measles. We conducted a systematic literature review of measles vaccination policies and their implementation in healthcare personnel, measles seroprevalence among healthcare personnel, measles transmission and disease burden in healthcare settings, and impact/costs incurred by healthcare facilities for healthcare-associated measles transmission. Five database searches yielded 135 relevant articles; 47 additional articles were found through cross-referencing. The risk of acquiring measles is estimated to be 2 to 19 times higher for susceptible healthcare personnel than for the general population. Fifty-three articles published worldwide during 1989–2013 reported measles transmission from patients to healthcare personnel; many of the healthcare personnel were unvaccinated or had unknown vaccination status. Eighteen articles published worldwide during 1982–2013 described examples of transmission from healthcare personnel to patients or to other healthcare personnel. Half of European countries have no measles vaccine policies for healthcare personnel. There is no global policy recommendation for the vaccination of healthcare personnel against measles. Even in countries such as the United States or Finland that have national policies, the recommendations are not uniformly implemented in healthcare facilities. Measles serosusceptibility in healthcare personnel varied widely across studies (median 6.5%, range 0%-46%) but was consistently higher among younger healthcare personnel. Deficiencies in documentation of two doses of measles vaccination or other evidence of immunity among healthcare personnel presents challenges in responding to measles exposures in healthcare settings. Evaluating and containing exposures and outbreaks in healthcare settings can be

  10. Human error mechanisms in complex work environments

    International Nuclear Information System (INIS)

    Rasmussen, J.

    1988-01-01

    Human error taxonomies have been developed from analysis of industrial incident reports as well as from psychological experiments. In this paper the results of the two approaches are reviewed and compared. It is found, in both cases, that a fairly small number of basic psychological mechanisms will account for most of the action errors observed. In addition, error mechanisms appear to be intimately related to the development of high skill and know-how in a complex work context. This relationship between errors and human adaptation is discussed in detail for individuals and organisations. The implications for system safety and briefly mentioned, together with the implications for system design. (author)

  11. Human error mechanisms in complex work environments

    International Nuclear Information System (INIS)

    Rasmussen, Jens; Danmarks Tekniske Hoejskole, Copenhagen)

    1988-01-01

    Human error taxonomies have been developed from analysis of industrial incident reports as well as from psychological experiments. In this paper the results of the two approaches are reviewed and compared. It is found, in both cases, that a fairly small number of basic psychological mechanisms will account for most of the action errors observed. In addition, error mechanisms appear to be intimately related to the development of high skill and know-how in a complex work context. This relationship between errors and human adaptation is discussed in detail for individuals and organisations. The implications for system safety are briefly mentioned, together with the implications for system design. (author)

  12. Generalizing human error rates: A taxonomic approach

    International Nuclear Information System (INIS)

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

    1989-01-01

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

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

    Science.gov (United States)

    Heydari, Sepideh; Holroyd, Clay B

    2016-08-01

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

  14. Radiological protection of service and civilian personnel

    International Nuclear Information System (INIS)

    1990-01-01

    Since the United Kingdom's defence nuclear industry was founded in the late 1940s, Service and civilian personnel have been exposed to ionising radiation. During the last forty years, as knowledge about the effects of radiation exposure has grown, concern to ensure adequate protection against exposure has also increased,. As part of our continuing scrutiny of the Ministry of Defence (MoD), we have undertaken a short inquiry to examine MoD's current and future policy and practice on radiological protection. The principal work involving exposure of Service and civilian personnel to significant levels of radiation falls into two discrete areas: the nuclear weapons programme and the nuclear propulsion programme. The nuclear weapons programme involves research, the production of nuclear warheads and their deployment with Her Majesty's Forces. The nuclear propulsion programme involves research, production, operation, refitting and decommissioning of pressurised water reactors as a source of propulsion power in Royal Navy submarines. These two nuclear programmes are not the only sources of ionising radiation within MoD's responsibility: it also arises from research, non-destructive testing and medical applications, most notably conventional radiography. In this Report we have concentrated upon ionising radiation arising from the two defence nuclear programmes. (author)

  15. [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

  16. National synchrotron light source medical personnel protection interlock

    International Nuclear Information System (INIS)

    Buda, S.; Gmur, N.F.; Larson, R.; Thomlinson, W.

    1998-01-01

    This report is founded on reports written in April 1987 by Robert Hettel for angiography operations at the Stanford Synchrotron Research Laboratory (SSRL) and a subsequent report covering angiography operations at the National Synchrotron Light Source (NSLS); BNL Informal Report 47681, June 1992. The latter report has now been rewritten in order to accurately reflect the design and installation of a new medical safety system at the NSLS X17B2 beamline Synchrotron Medical Research Facility (SMERF). Known originally as the Angiography Personnel Protection Interlock (APPI), this system has been modified to incorporate other medical imaging research programs on the same beamline and thus the name has been changed to the more generic Medical Personnel Protection Interlock (MPPI). This report will deal almost exclusively with the human imaging (angiography, bronchography, mammography) aspects of the safety system, but will briefly explain the modular aspects of the system allowing other medical experiments to be incorporated

  17. NATIONAL SYNCHROTRON LIGHT SOURCE MEDICAL PERSONNEL PROTECTION INTERLOCK

    Energy Technology Data Exchange (ETDEWEB)

    BUDA,S.; GMUR,N.F.; LARSON,R.; THOMLINSON,W.

    1998-11-03

    This report is founded on reports written in April 1987 by Robert Hettel for angiography operations at the Stanford Synchrotron Research Laboratory (SSRL) and a subsequent report covering angiography operations at the National Synchrotron Light Source (NSLS); BNL Informal Report 47681, June 1992. The latter report has now been rewritten in order to accurately reflect the design and installation of a new medical safety system at the NSLS X17B2 beamline Synchrotron Medical Research Facility (SMERF). Known originally as the Angiography Personnel Protection Interlock (APPI), this system has been modified to incorporate other medical imaging research programs on the same beamline and thus the name has been changed to the more generic Medical Personnel Protection Interlock (MPPI). This report will deal almost exclusively with the human imaging (angiography, bronchography, mammography) aspects of the safety system, but will briefly explain the modular aspects of the system allowing other medical experiments to be incorporated.

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

    Science.gov (United States)

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

    2015-08-01

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

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

    Science.gov (United States)

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

    2015-01-01

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

  20. WAYS TO INCREASE ACCURACY AND RELIABILITY OF INDIVIDUAL DOSES ASSESSMENTS IN PERSONNEL WITHIN THERMOLUMINESCENCE TECHNIQUE

    Directory of Open Access Journals (Sweden)

    G. N. Kaydanovskiy

    2012-01-01

    Full Text Available The paper analyses the main sources of measurement errors of individual doses in personnel performed within the thermoluminescence technique and gives recommendations to minimize these errors. The reasons that reduce reliability of effective dose assessments derived from measured values of personal dose equivalent are imperfections of guidance documents. Changes to the Guidelines «Organization and implementation of individual dosimetric control. Staff of health institutions» are justified.

  1. 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.

  2. 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.

  3. Medication administration errors in Eastern Saudi Arabia

    International Nuclear Information System (INIS)

    Mir Sadat-Ali

    2010-01-01

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

  4. Applying Intelligent Algorithms to Automate the Identification of Error Factors.

    Science.gov (United States)

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

    2018-05-03

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

  5. Study of the adequacy of personnel for the US nuclear program

    International Nuclear Information System (INIS)

    1981-11-01

    The report will emphasize fission topics relative to fusion because of the relative number of personnel involved. However, the commonality of types of personnel and their required educational background are such that the health of the fission educational infrastructure will affect the future supply of fusion technologists. Alternatively, the attractive aspects of some closely related fusion research in universities can help attract the high quality personnel needed in the fission field. The report's recommendations are therefore based on the needs of both programs. A separate study of the detailed requirements for fusion scientific and engineering personnel has been prepared by the Office of Fusion Energy. In this report, the present status of nuclear power, historic personnel requirements, future requirements, and constraints on future supply are analyzed. The intent of this report is to provide a context for conclusions and recommendation of Government actions leading to an adequate supply of nuclear manpower both for the industrial and Government components of the nuclear enterprise

  6. Errors and violations

    International Nuclear Information System (INIS)

    Reason, J.

    1988-01-01

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

  7. Learning mechanisms to limit medication administration errors.

    Science.gov (United States)

    Drach-Zahavy, Anat; Pud, Dorit

    2010-04-01

    This paper is a report of a study conducted to identify and test the effectiveness of learning mechanisms applied by the nursing staff of hospital wards as a means of limiting medication administration errors. Since the influential report ;To Err Is Human', research has emphasized the role of team learning in reducing medication administration errors. Nevertheless, little is known about the mechanisms underlying team learning. Thirty-two hospital wards were randomly recruited. Data were collected during 2006 in Israel by a multi-method (observations, interviews and administrative data), multi-source (head nurses, bedside nurses) approach. Medication administration error was defined as any deviation from procedures, policies and/or best practices for medication administration, and was identified using semi-structured observations of nurses administering medication. Organizational learning was measured using semi-structured interviews with head nurses, and the previous year's reported medication administration errors were assessed using administrative data. The interview data revealed four learning mechanism patterns employed in an attempt to learn from medication administration errors: integrated, non-integrated, supervisory and patchy learning. Regression analysis results demonstrated that whereas the integrated pattern of learning mechanisms was associated with decreased errors, the non-integrated pattern was associated with increased errors. Supervisory and patchy learning mechanisms were not associated with errors. Superior learning mechanisms are those that represent the whole cycle of team learning, are enacted by nurses who administer medications to patients, and emphasize a system approach to data analysis instead of analysis of individual cases.

  8. 10 CFR 26.125 - Licensee testing facility personnel.

    Science.gov (United States)

    2010-01-01

    ... 10 Energy 1 2010-01-01 2010-01-01 false Licensee testing facility personnel. 26.125 Section 26.125 Energy NUCLEAR REGULATORY COMMISSION FITNESS FOR DUTY PROGRAMS Licensee Testing Facilities § 26.125... reports, if any; results of tests that establish employee competency for the position he or she holds...

  9. Air Force Integrated Personnel and Pay System (AFIPPS)

    Science.gov (United States)

    2016-03-01

    Technical Guidance to include Information Technolgy (IT) Standards identified in the Technical View One (1) (TV-1) and implementation guidance of GIG...Compliant with Global Information Grid (GIG) Technical Guidance to include Information Technolgy (IT) Standards identified in the Technical View One...2016 Major Automated Information System Annual Report Air Force Integrated Personnel and Pay System (AFIPPS) Defense Acquisition Management

  10. Storage of radioactive material - accidents - precipitation - personnel monitoring

    International Nuclear Information System (INIS)

    Matijasic, A.; Gacinovic, O.

    1961-12-01

    This volume covers the reports on four routine tasks concerned with safe handling of radioactive material and influence of nuclear facilities on the environment. The tasks performed were as follows: Storage of solid and liquid radioactive material; actions in case of accidents; radiation monitoring of the fallout, water and ground; personnel dosimetry

  11. Help prevent hospital errors

    Science.gov (United States)

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

  12. Rounding errors in weighing

    International Nuclear Information System (INIS)

    Jeach, J.L.

    1976-01-01

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

  13. Spotting software errors sooner

    International Nuclear Information System (INIS)

    Munro, D.

    1989-01-01

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

  14. Errors in energy bills

    International Nuclear Information System (INIS)

    Kop, L.

    2001-01-01

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

  15. Medical Errors Reduction Initiative

    National Research Council Canada - National Science Library

    Mutter, Michael L

    2005-01-01

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

  16. The surveillance error grid.

    Science.gov (United States)

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

    2014-07-01

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

  17. Design for Error Tolerance

    DEFF Research Database (Denmark)

    Rasmussen, Jens

    1983-01-01

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

  18. Unmasking the health problems faced by the police personnel

    Directory of Open Access Journals (Sweden)

    G.Jahnavi

    2012-11-01

    Full Text Available Aim: To assess the health problems of the police personnel under Vijayawada police commisionerate 2. To make the health check ups regular and 3. To make the physical fitness programme mandatory for them.Study design: cross sectional study Methodology: Health check up was done for 617 police personnel from 12.11.09 to 4.12.09. In the morning hours, a group of junior doctors, paramedical staff and technicians visited the police dispensary to do the general check up, take blood samples and ECG. The following afternoon a group of specialists visited to check the same patients along with their reports to make the final diagnosis. Results: Out of 617 police personnel 259 (42% were overweight/obese, lack of physical activity was found in 397 (64% of them, alcohol consumption was present in 148 (24% and smoking in 136 (22% of the police personnel. Diabetes was diagnosed in 229 (37% and hypertension in 203 (33%. Anemia was detected in 154 (25%, visual abnormalities in 59 (10%, lipid abnormalities in 185 (30%, liver function test abnormalities in 31 (5%, ECG abnormalities in 25 (4%, renal function abnormalities in 6 (1%. Conclusion: A Physical fitness Schedule along with Stress alleviation techniques to be made mandatory for the police personnel to keep them physically and mentally fit, to perform critical job functions, to alleviate stress, and to improve their quality of life. Routine health checkups should be done to detect lurking dangers.

  19. IAEA world survey on nuclear power plant personnel training

    International Nuclear Information System (INIS)

    1999-01-01

    Training of personnel is acknowledged to be essential for safe and reliable operation of nuclear power plants. The preparation of this TECDOC was recommended by the IAEA International Working group on Nuclear Power Plant Personnel Training and Qualification and represents a unique compilation of information including all aspects of NPP personnel training from 23 Member States and 129 training organizations. The basic aims of this survey are: to provide a worldwide overview of all aspects of NPP personnel training; to foster both national and international cooperation between organizations involved in nuclear training; to provide the means of exchange of experiences and practices in systematic approach to training (SAT). The survey provides information for each corresponding country on the: national system and organization of training; job positions for which SAT is used; training programmes for key operations, maintenance, instructor and other jobs; role of management and the regulatory body; training facilities; recommended training practices; availability of training personnel from organizations outside the country; and contact points. The three main parts of the publication are the summary, the analysis of training programmes for each job position and the analysis of training resources, and the country reports

  20. Pulmonary function test in traffic police personnel in Pondicherry.

    Science.gov (United States)

    Pal, Pravati; John, Robert A; Dutta, T K; Pal, G K

    2010-01-01

    Traffic policemen working in the busy traffic signal areas get exposed to the vehicular emissions for years together. The fumes, chemicals and particles present in the emission are reported to be damaging to the lung functions of these individuals. Since there were no data available on the PFT parameters of traffic police personnel of Pondicherry, this study was taken up to assess the effect of traffic air pollution on their pulmonary functions. PFT parameters were recorded in age- and BMI-matched 30 traffic police personnel (study group) and 30 general police personnel (control group) of male gender. As chronic smoking is known to be a critical factor in altering lung function, PFT parameters were compared between the smokers as well as nonsmokers of both the groups. In nonsmokers, there was significant decrease in VC (P traffic police personnel compared to the general police personnel. This may be due to exposure to vehicular pollution for several hours in a day for many years causing decreased functional capacity of the lungs and chronic smoking worsens the condition.

  1. Analyzing temozolomide medication errors: potentially fatal.

    Science.gov (United States)

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

    2014-10-01

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

  2. Apologies and Medical Error

    Science.gov (United States)

    2008-01-01

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

  3. 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.

  4. EPIC: an Error Propagation/Inquiry Code

    International Nuclear Information System (INIS)

    Baker, A.L.

    1985-01-01

    The use of a computer program EPIC (Error Propagation/Inquiry Code) will be discussed. EPIC calculates the variance of a materials balance closed about a materials balance area (MBA) in a processing plant operated under steady-state conditions. It was designed for use in evaluating the significance of inventory differences in the Department of Energy (DOE) nuclear plants. EPIC rapidly estimates the variance of a materials balance using average plant operating data. The intent is to learn as much as possible about problem areas in a process with simple straightforward calculations assuming a process is running in a steady-state mode. EPIC is designed to be used by plant personnel or others with little computer background. However, the user should be knowledgeable about measurement errors in the system being evaluated and have a limited knowledge of how error terms are combined in error propagation analyses. EPIC contains six variance equations; the appropriate equation is used to calculate the variance at each measurement point. After all of these variances are calculated, the total variance for the MBA is calculated using a simple algebraic sum of variances. The EPIC code runs on any computer that accepts a standard form of the BASIC language. 2 refs., 1 fig., 6 tabs

  5. Analysis of personnel monitoring control card data

    International Nuclear Information System (INIS)

    Ande, C.D.; Sneha, C.; Madhumita, B.; Bakshi, A.K.; Datta, D.

    2018-01-01

    In India, personnel monitoring of radiation workers for X-, beta- and gamma- radiation is carried out using a thermoluminescence dosemeter (TLD) system based on CaSO 4 :Dy Teflon TLD disc. A large number of radiation workers get very low occupational doses and their doses are reported as zero since it is not above detectable limits. Therefore, the detection of low levels of occupational dose over and above the natural background assumes great importance. In the present system, the estimation of the background dose is achieved by use of control dosemeters. An analysis of the readings of the control dosimeters sent to various institutions was carried out to arrive at conclusions regarding the validity of the use of control dosimeter

  6. Notes on human error analysis and prediction

    International Nuclear Information System (INIS)

    Rasmussen, J.

    1978-11-01

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

  7. Management and Evaluation System on Human Error, Licence Requirements, and Job-aptitude in Rail and the Other Industries

    Energy Technology Data Exchange (ETDEWEB)

    Koo, In Soo; Suh, S. M.; Park, G. O. (and others)

    2006-07-15

    Rail system is a system that is very closely related to the public life. When an accident happens, the public using this system should be injured or even be killed. The accident that recently took place in Taegu subway system, because of the inappropriate human-side task performance, showed demonstratively how its results could turn out to be tragic one. Many studies have shown that the most cases of the accidents have occurred because of performing his/her tasks in inappropriate way. It is generally recognised that the rail system without human element could never be happened quite long time. So human element in rail system is going to be the major factor to the next tragic accident. This state of the art report studied the cases of the managements and evaluation systems related to human errors, license requirements, and job aptitudes in the areas of rail and the other industries for the purpose of improvement of the task performance of personnel which consists of an element and finally enhancement of rail safety. The human errors, license requirements, and evaluation system of the job aptitude on people engaged in agencies with close relation to rail do much for development and preservation their abilities. But due to various inside and outside factors, to some extent it may have limitations to timely reflect overall trends of society, technology, and a sense of value. Removal and control of the factors of human errors will have epochal roles in safety of the rail system through the case studies of this report. Analytical results on case studies of this report will be used in the project 'Development of Management Criteria on Human Error and Evaluation Criteria on Job-aptitude of Rail Safe-operation Personnel' which has been carried out as a part of 'Integrated R and D Program for Railway Safety'.

  8. Management and Evaluation System on Human Error, Licence Requirements, and Job-aptitude in Rail and the Other Industries

    International Nuclear Information System (INIS)

    Koo, In Soo; Suh, S. M.; Park, G. O.

    2006-07-01

    Rail system is a system that is very closely related to the public life. When an accident happens, the public using this system should be injured or even be killed. The accident that recently took place in Taegu subway system, because of the inappropriate human-side task performance, showed demonstratively how its results could turn out to be tragic one. Many studies have shown that the most cases of the accidents have occurred because of performing his/her tasks in inappropriate way. It is generally recognised that the rail system without human element could never be happened quite long time. So human element in rail system is going to be the major factor to the next tragic accident. This state of the art report studied the cases of the managements and evaluation systems related to human errors, license requirements, and job aptitudes in the areas of rail and the other industries for the purpose of improvement of the task performance of personnel which consists of an element and finally enhancement of rail safety. The human errors, license requirements, and evaluation system of the job aptitude on people engaged in agencies with close relation to rail do much for development and preservation their abilities. But due to various inside and outside factors, to some extent it may have limitations to timely reflect overall trends of society, technology, and a sense of value. Removal and control of the factors of human errors will have epochal roles in safety of the rail system through the case studies of this report. Analytical results on case studies of this report will be used in the project 'Development of Management Criteria on Human Error and Evaluation Criteria on Job-aptitude of Rail Safe-operation Personnel' which has been carried out as a part of 'Integrated R and D Program for Railway Safety'

  9. [Errors in laboratory daily practice].

    Science.gov (United States)

    Larrose, C; Le Carrer, D

    2007-01-01

    Legislation set by GBEA (Guide de bonne exécution des analyses) requires that, before performing analysis, the laboratory directors have to check both the nature of the samples and the patients identity. The data processing of requisition forms, which identifies key errors, was established in 2000 and in 2002 by the specialized biochemistry laboratory, also with the contribution of the reception centre for biological samples. The laboratories follow a strict criteria of defining acceptability as a starting point for the reception to then check requisition forms and biological samples. All errors are logged into the laboratory database and analysis report are sent to the care unit specifying the problems and the consequences they have on the analysis. The data is then assessed by the laboratory directors to produce monthly or annual statistical reports. This indicates the number of errors, which are then indexed to patient files to reveal the specific problem areas, therefore allowing the laboratory directors to teach the nurses and enable corrective action.

  10. Background and Theory Behind the Compensation, Accessions, and Personnel Management (CAPM) Model

    National Research Council Canada - National Science Library

    Ausink, John; Cave, Jonathan; Carrillo, Manuel

    2003-01-01

    .... This report descries the Compensation, Accession, and Personnel Management (CAPM) model, which was developed to be a relatively easy-to-use personal computer-based analytical tool that would enable decisionmakers to study the effects of changes in policy on retention behavior and future inventories of military personnel.

  11. Suicidal or Self-Harming Ideation in Military Personnel Transitioning to Civilian Life

    Science.gov (United States)

    Mansfield, Alyssa J.; Bender, Randall H.; Hourani, Laurel L.; Larson, Gerald E.

    2011-01-01

    Suicides have markedly increased among military personnel in recent years. We used path analysis to examine factors associated with suicidal/self-harming ideation among male Navy and Marine Corps personnel transitioning to civilian life. Roughly 7% of men (Sailors = 5.3%, Marines = 9.0%) reported ideation during the previous 30 days. Results…

  12. Burnout among Danish prison personnel

    DEFF Research Database (Denmark)

    Andersen, Dorte Raaby; Andersen, Lars Peter; Gadegaard, Charlotte Ann

    2017-01-01

    Objectives The objective of this follow-up study was to investigate associations between individual, occupational and work environment factors and burnout among both uniformed and non-uniformed personnel working in the Danish Prison and Probation Service. Methods The participants (N = 4808......) with client contact received a questionnaire in 2010 and again in 2011. In 2010, 2843 participants responded to the questionnaire (59.1%), and in 2011, 1741 responded to the questionnaire, yielding a response rate of 61.2% of the baseline population, and 36.2% of the invited population. Burnout and work...... characteristics were measured with validated scales from the Copenhagen Psychosocial Questionnaire, and data was analysed by logistic regression. Results Risk factors with the highest impact on burnout were work environmental factors: quantitative demands, emotional demands, involvement in and meaning of work...

  13. The Daresbury personnel safety system

    International Nuclear Information System (INIS)

    Poole, D.E.; Ring, T.

    1989-01-01

    The personnel safety system designed for the SRS at Daresbury is a unified system covering the three accelerators of the source itself, the beamlines and the experimental stations. The system has also been applied to the experimental areas of the Nuclear Structure Facility, and is therefore established as a site standard. A dual guardline interlock module forms a building block for a relay based interlock system completely independent of the machine control system, although comprehensive monitoring of the system status via the control system computer is a feature. An outline of the design criteria adopted for the system is presented together with a more detailed description of the philosophy of the guardline logic and the way this is implemented in a standard modular form. The emphasis is on the design features of a modern microprocessor based variant of the original SRS system. Experience with the original system during build-up and operation of the SRS facility is described. 2 refs., 4 figs

  14. Director general presentation to personnel

    CERN Multimedia

    2016-01-01

    Dear Colleagues, Many important discussions are scheduled for the upcoming Council Week (13-17 June) on topics including the Medium-Term Plan, the Pension Fund and other matters of great relevance to us.   I would therefore like to share the main outcome of the week with you and I invite you to join me and the Directors in the Main Auditorium at 10 a.m. on Thursday 23 June. The meeting will last about one hour and a webcast will also be available. Best regards, Fabiola Gianotti DG presentation to personnel Thursday 23 June at 10 am Main Auditorium Retransmission in Council Chamber, IT Auditorium, Kjell Jonhsen Auditorium, Prevessin 864-1-C02 Webcast on cern.ch/webcast More information on the event page.

  15. Training of personnel in the field of radioactive materials transport

    International Nuclear Information System (INIS)

    Fasten, Ch.

    1997-01-01

    Training of personnel in the whole nuclear fuel cycle and also in the other fields of the use of radioactivity is one of the essentials with respect to compliance assurance. The transport of radioactive material is the only activity that takes place outside a facility: on roads, on railways, on the sea or in the air. A high level of safety is therefore an absolute requirement for all transport operations. To ensure this high level the training of the personnel involved in these activities plays an important role. Many studies show that most of the incidents in radioactive materials transport are caused by man-made errors: even so there have been no events with serious radiological consequences anywhere worldwide. There are many requirements in the various national and international regulations for the safe transport of radioactive material with regard to training. An overview is given of the special regulations, e.g. for road transport drivers, for safety advisers in the whole field of the transport of dangerous goods, for specially educated personnel in sea and air transports. In addition, the newest developments in the European Community in this field are discussed. An evaluation of the present regulations and proposals for further rules are also given. (Author)

  16. The aspect of personnel metal attitude in the production safety

    International Nuclear Information System (INIS)

    Joyosukarto, Priyanto M.

    2002-01-01

    The occurrence of an accident could always be traced to component/system failures and/or human error. The two factors are closely related to competency of the personnel's involved, in which mental attitude is a decisive factor. Furthermore mental attitude could be viewed as an element of Safety (S) Culture. Consequently, S. Culture could might created or at lea ts, be enhanced by the introduction of appropriate values, norms, as well as attitudes. The ABC and TBC of safety norm have been discussed briefly. Whereas mental attitude has been defined and discussed in detail and graded into six levels, namely: attending, responding, complying, accepting, preferring, and integrating. To assure highest level of safety, personnel must achieve integrating level of attitude, in the sense that he would merely do an action on the basis of safety values and/or norms prevailing in the system, not due to external pressure. Furthermore, considering the work as a physical and an emotional activity resulting in stress and strain on the body, Karate exercises have been promoted as an alternative for enhancing mental attitude by means of reducing personnel vulnerability to strain and stress. This method is accomplished by exploiting Roux's Low of conditioning effect and by implementation of an in-depth understanding on the spiritual aspect of Karate. It is concluded that in the field of production safety, there is a positive correlation between Karate, mental attitude, competence, performance, quality, and safety

  17. Learning from Errors

    Directory of Open Access Journals (Sweden)

    MA. Lendita Kryeziu

    2015-06-01

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

  18. Compact disk error measurements

    Science.gov (United States)

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

    1993-01-01

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

  19. Technical guidelines for personnel dosimetry calibrations

    International Nuclear Information System (INIS)

    Roberson, P.L.; Fox, R.A.; Hadley, R.T.; Holbrook, K.L.; Hooker, C.D.; McDonald, J.C.

    1983-01-01

    A base of technical information has been acquire and used to evaluate the calibration, design, and performance of selected personnel systems in use at Department of Energy (DOE) facilites. A technical document was prepared to guide DOE and DOE contractors in selecting and evaluating personnel dosimetry systems and calibration. A parallel effort was initiated to intercompare the adiological calibrations standards used to calibrate DOE personnel dosimeters

  20. Optimising the education of responsible shift personnel in nuclear power plants. Volume 2 for Chapter 4: General areas of staff education

    International Nuclear Information System (INIS)

    1985-01-01

    Themes are discussed which have not in fact become learning objectives, but which nevertheless influence the education of shift personnel. This volume contains articles on the following: the influence factors of human error; the demands on a simulator for the education of shift personnel; technical aids for supporting stuff and principles of leadership and motivation. (DG) [de