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Sample records for support error reporting

  1. 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.

  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

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

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    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.

  5. 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

  6. 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…

  7. The Error Reporting in the ATLAS TDAQ System

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    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

  8. 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.

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

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    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.

  10. Barriers to medication error reporting among hospital nurses.

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

    2018-03-01

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

  11. 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

  12. 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.

  13. 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.

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

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    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.

  15. 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

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

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    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.

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

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    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.

  18. 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.

  19. 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]:…

  20. 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.

  1. 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

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

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    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

  3. Error-information in tutorial documentation: Supporting users' errors to facilitate initial skill learning

    NARCIS (Netherlands)

    Lazonder, Adrianus W.; van der Meij, Hans

    1995-01-01

    Novice users make many errors when they first try to learn how to work with a computer program like a spreadsheet or wordprocessor. No matter how user-friendly the software or the training manual, errors can and will occur. The current view on errors is that they can be helpful or disruptive,

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

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    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.

  5. 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.

  6. 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.

  7. 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...

  8. 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.

  9. 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.

  10. Random synaptic feedback weights support error backpropagation for deep learning

    Science.gov (United States)

    Lillicrap, Timothy P.; Cownden, Daniel; Tweed, Douglas B.; Akerman, Colin J.

    2016-01-01

    The brain processes information through multiple layers of neurons. This deep architecture is representationally powerful, but complicates learning because it is difficult to identify the responsible neurons when a mistake is made. In machine learning, the backpropagation algorithm assigns blame by multiplying error signals with all the synaptic weights on each neuron's axon and further downstream. However, this involves a precise, symmetric backward connectivity pattern, which is thought to be impossible in the brain. Here we demonstrate that this strong architectural constraint is not required for effective error propagation. We present a surprisingly simple mechanism that assigns blame by multiplying errors by even random synaptic weights. This mechanism can transmit teaching signals across multiple layers of neurons and performs as effectively as backpropagation on a variety of tasks. Our results help reopen questions about how the brain could use error signals and dispel long-held assumptions about algorithmic constraints on learning. PMID:27824044

  11. 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...

  12. 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...

  13. 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...

  14. 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

  15. 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 ...

  16. 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

  17. 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.

  18. 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.

  19. 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

  20. 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...

  1. 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)

  2. 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

  3. 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.

  4. 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

  5. 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

  6. Research progress of the static and dynamic characteristics and motion errors of hydrostatic supports

    Directory of Open Access Journals (Sweden)

    Zhiwei WANG

    2016-06-01

    Full Text Available At present, the research on static and dynamic characteristics of hydrostatic supports depend on the form and structure of the restrictor, which are mainly focused on the influences of recess shape, bearing structure, bearing surface roughness, lubricant and elastic deformations of the bearing. There are few studies on the thermal effect of hydrostatic supports and static and dynamic characteristics of hydrostatic guideways. The research on motion errors of hydrostatic supports is primarily based on the static equilibrium of the moving part. The effects of the motion speed of the moving part and structural deformation on the motion errors are not considered. Finally, the research prospects from the standardization, modularization and industrialization of hydrostatic supports, thermal effect of hydrostatic bearing, the static and dynamic characteristics of hydrostatic guideways and motion errors of hydrostatic supports under operating conditions are concluded.

  7. 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.

  8. 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...

  9. 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.

  10. 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.

  11. 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...

  12. 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.

  13. 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.

  14. [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.

  15. 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...

  16. 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.

  17. A Method and Support Tool for the Analysis of Human Error Hazards in Digital Devices

    International Nuclear Information System (INIS)

    Lee, Yong Hee; Kim, Seon Soo; Lee, Yong Hee

    2012-01-01

    In recent years, many nuclear power plants have adopted modern digital I and C technologies since they are expected to significantly improve their performance and safety. Modern digital technologies were expected to significantly improve both the economical efficiency and safety of nuclear power plants. However, the introduction of an advanced main control room (MCR) is accompanied with lots of changes in forms and features and differences through virtue of new digital devices. Many user-friendly displays and new features in digital devices are not enough to prevent human errors in nuclear power plants (NPPs). It may be an urgent to matter find the human errors potentials due to digital devices, and their detailed mechanisms. We can then consider them during the design of digital devices and their interfaces. The characteristics of digital technologies and devices may give many opportunities to the interface management, and can be integrated into a compact single workstation in an advanced MCR, such that workers can operate the plant with minimum burden under any operating condition. However, these devices may introduce new types of human errors, and thus we need a means to evaluate and prevent such errors, especially within digital devices for NPPs. This research suggests a new method named HEA-BIS (Human Error Analysis based on Interaction Segment) to confirm and detect human errors associated with digital devices. This method can be facilitated by support tools when used to ensure the safety when applying digital devices in NPPs

  18. 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

  19. Estimation of the wind turbine yaw error by support vector machines

    DEFF Research Database (Denmark)

    Sheibat-Othman, Nida; Othman, Sami; Tayari, Raoaa

    2015-01-01

    Wind turbine yaw error information is of high importance in controlling wind turbine power and structural load. Normally used wind vanes are imprecise. In this work, the estimation of yaw error in wind turbines is studied using support vector machines for regression (SVR). As the methodology...... is data-based, simulated data from a high fidelity aero-elastic model is used for learning. The model simulates a variable speed horizontal-axis wind turbine composed of three blades and a full converter. Both partial load (blade angles fixed at 0 deg) and full load zones (active pitch actuators...

  20. 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.

  1. 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.

  2. 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

  3. 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

  4. Robust Least-Squares Support Vector Machine With Minimization of Mean and Variance of Modeling Error.

    Science.gov (United States)

    Lu, Xinjiang; Liu, Wenbo; Zhou, Chuang; Huang, Minghui

    2017-06-13

    The least-squares support vector machine (LS-SVM) is a popular data-driven modeling method and has been successfully applied to a wide range of applications. However, it has some disadvantages, including being ineffective at handling non-Gaussian noise as well as being sensitive to outliers. In this paper, a robust LS-SVM method is proposed and is shown to have more reliable performance when modeling a nonlinear system under conditions where Gaussian or non-Gaussian noise is present. The construction of a new objective function allows for a reduction of the mean of the modeling error as well as the minimization of its variance, and it does not constrain the mean of the modeling error to zero. This differs from the traditional LS-SVM, which uses a worst-case scenario approach in order to minimize the modeling error and constrains the mean of the modeling error to zero. In doing so, the proposed method takes the modeling error distribution information into consideration and is thus less conservative and more robust in regards to random noise. A solving method is then developed in order to determine the optimal parameters for the proposed robust LS-SVM. An additional analysis indicates that the proposed LS-SVM gives a smaller weight to a large-error training sample and a larger weight to a small-error training sample, and is thus more robust than the traditional LS-SVM. The effectiveness of the proposed robust LS-SVM is demonstrated using both artificial and real life cases.

  5. 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

  6. 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

  7. 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.

  8. 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.

  9. 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.

  10. 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

  11. 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

  12. 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.

  13. 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

  14. Final Report - BRER Core Support

    International Nuclear Information System (INIS)

    Evan B. Douple

    2007-01-01

    This contract provided core support for activities of the advisory committee of experts comprising the Board on Radiation Effects Research (BRER), in The National Academies Division on Earth and Life Studies. That committee met two times during the funding period. The committee members provided oversight and advice regarding ongoing BRER projects and also assisted in the identification of potential committee members for new studies and the development of proposals for projects in the radiation sciences worthy for future study. In addition, funding provided support for the planning, advertisement, and invited speakers travel-expense reimbursement for the Third and Fourth Gilbert W. Beebe Symposia held at The National Academies on December 1, 2004 and on November 30, 2005, respectively

  15. Novette diagnostic support. Final report

    International Nuclear Information System (INIS)

    Cirigliano, R.; Franco, E.; Koppel, L.; Rodrigues, B.; Smith, J.

    1985-02-01

    The primary research areas were the following: (1) contribute x-ray diagnostic, experimental, and data reduction and analysis support for the Novette DANTE x-ray spectrometer experiments. This effort was expanded to improve the overall quality of the Novette database; (2) experimental and calculational characterization of the x-ray imaging properties of an ellipsoidal x-ray collection optic serving as a sensitivity enhancing component of the Transmission Grating Streak Spectrometer; (3) performance simulation of the x-ray dispersion properties of candidate x-ray laser cavity, normal incidence end-mirror optics; (4) contribute x-ray diagnostic, experimental, and data reduction and analysis support for the Novette Henway crystal spectrometer and the MCPIGS microchannel plate intensified grazing incident spectrometer experiments; and (5) perform a technical performance vs cost evaluation of commercially available hardware required to perform the NOVA neutron time-of-flight experiments

  16. 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.

  17. 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.

  18. 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

  19. 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.

  20. 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...

  1. 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.

  2. 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.

  3. 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.

  4. 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

  5. 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.

  6. Support of protective work of human error in a nuclear power plant

    International Nuclear Information System (INIS)

    Yoshizawa, Yuriko

    1999-01-01

    The nuclear power plant human factor group of the Tokyo Electric Power Co., Ltd. supports various protective work of human error conducted at the nuclear power plant. Its main researching theme are studies on human factor on operation of a nuclear power plant, and on recovery and common basic study on human factor. In addition, on a base of the obtained informations, assistance to protective work of human error conducted at the nuclear power plant as well as development for its actual use was also promoted. Especially, for actions sharing some dangerous informations, various assistances such as a proposal on actual example analytical method to effectively understand a dangerous information not facially but faithfully, construction of a data base to conveniently share such dangerous information, and practice on non-accident business survey for a hint of effective promotion of the protection work, were promoted. Here were introduced on assistance and investigation for effective sharing of the dangerous informations for various actions on protection of human error mainly conducted in nuclear power plant. (G.K.)

  7. 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

  8. 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...

  9. 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.

  10. 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...

  11. USACE AIS Transmit Technical Support Summary Report

    Science.gov (United States)

    2014-09-01

    the TAG block for the correct transmitters, and then send to the USACE AIS network. B. Outbound openings in the USCG firewall for the USCG Message...USACE AIS Transmit Technical Support Summary Report Distribution Statement A: Approved for public release; distribution is unlimited...September 2014 Report No. CD-D-09-15 USACE AIS Transmit Technical Support Summary Report ii UNCLAS//Public | CG-926 RDC | I. Gonin et al. Public

  12. 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

  13. 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

  14. 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,

  15. 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.

  16. 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.

  17. 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.

  18. 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.

  19. 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

  20. 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.

  1. 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

  2. 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.

  3. 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.

  4. Child support and alimony: 1983 (supplemental report).

    Science.gov (United States)

    Sanders, R A

    1986-10-01

    The concern has continued over the financial situation of US women and their children after divorce and separation and over the situation of never-married mothers, in part due to the low average incomes and accompanying high incidence of poverty among families with family householders and no husband present. This report presents information on both the award and actual receipt of child support to women on behalf of their children and on alimony for their own support. Additional data concerning receipt and type of property settlement following divorce is provided for ever-divorced women. As of spring 1984, 8.7 million mothers were living with children under 21 years of age whose fathers were not living in the household; 58% or about 5 million of these women were awarded or had an agreement to receive child support payments for their children as of the survey date. Of the 5 million women awarded child support, 4 million were supposed to receive child support for their children in 1983. Of those due payment, about half received the full amount they were due. The child support award rate reported in 1984 (58%) was not significantly different from that of 1982; however, the proportion of women receiving payments in 1983 (76%) increased slightly over that of the previous survey (72%). The average (mean) amount of child support received in 1983 was $2340. About 43% of the 2.9 million women below the poverty level were awarded child support. Whites and college-educated women were more likely to be awarded child support. Only about 14% of the 17.4 million ever-divorced or currently separated women as of spring 1984 were awarded or had an agreement to receive alimony or maintenance payments In spring 1984, about 37% of the 14.8 million women who had ever been divorced reported receiving some form of property settlement.

  5. 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.

  6. 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.

  7. 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

  8. Child support and alimony: 1985 (supplemental report).

    Science.gov (United States)

    Hanlon, R A

    1989-03-01

    This report on child support and alimony is based on data from the 1987 and 1986 US Current Population Surveys. As of spring 1986, 8.8 million mothers were living with children under 21 years of age whose fathers were not living in the household; 61%, or about 5.4 million, of these women were awarded or had an agreement to receive child support payments for their children as of the survey date. Of the 5.4 million women awarded child support, 4.4 million were supposed to receive child support for their children in 1985. Of those due payment, about half received the full amount they were due. Of the remaining women, there was no evidence of a difference between the proportion receiving partial payment and those receiving no payment at all--about 26% each. Of the 5.4 million women with awards for their children, 45% had health insurance included as part of the award. Of the 3.4 million women without child support awards, about half (48%) wanted but could not obtain awards for their children. The child support award rate reported in 1986 showed a slight increase from that of 1984 (up 2.2% to 58%). The proportion of women awarded child support payments in 1986 was higher for Whites (71%) than for Blacks (36%) or Hispanics (42%). Women with 4 or more years of college were more likely to have been awarded support payments (77%) than women with 4 years of high school (63%). The average (mean) amount of child support received in 1985 was $2200.

  9. 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.

  10. 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.

  11. 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.

  12. 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.

  13. Experiences of and support for nurses as second victims of adverse nursing errors: a qualitative systematic review.

    Science.gov (United States)

    Cabilan, C J; Kynoch, Kathryn

    2017-09-01

    Second victims are clinicians who have made adverse errors and feel traumatized by the experience. The current published literature on second victims is mainly representative of doctors, hence nurses' experiences are not fully depicted. This systematic review was necessary to understand the second victim experience for nurses, explore the support provided, and recommend appropriate support systems for nurses. To synthesize the best available evidence on nurses' experiences as second victims, and explore their experiences of the support they receive and the support they need. Participants were registered nurses who made adverse errors. The review included studies that described nurses' experiences as second victims and/or the support they received after making adverse errors. All studies conducted in any health care settings worldwide. The qualitative studies included were grounded theory, discourse analysis and phenomenology. A structured search strategy was used to locate all unpublished and published qualitative studies, but was limited to the English language, and published between 1980 and February 2017. The references of studies selected for eligibility screening were hand-searched for additional literature. Eligible studies were assessed by two independent reviewers for methodological quality using a standardized critical appraisal instrument from the Joanna Briggs Institute Qualitative Assessment and Review Instrument (JBI QARI). Themes and narrative statements were extracted from papers included in the review using the standardized data extraction tool from JBI QARI. Data synthesis was conducted using the Joanna Briggs Institute meta-aggregation approach. There were nine qualitative studies included in the review. The narratives of 284 nurses generated a total of 43 findings, which formed 15 categories based on similarity of meaning. Four synthesized findings were generated from the categories: (i) The error brings a considerable emotional burden to the

  14. 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

  15. Engineering Technical Support Center Annual Report Fiscal ...

    Science.gov (United States)

    The United States Environmental Protection Agency (EPA or Agency) Office of Research and Development (ORD) created the Engineering Technical Support Center (ETSC) in 1987, one of several technical support centers created as part of the Technical Support Project (TSP). ETSC provides engineering expertise to Agency program and regional offices and remediation teams working at contaminated sites across the country. The ETSC is operated within ORD’s Land Remediation and Pollution Control Division (LRPCD) of the National Risk Management Research Laboratory (NRMRL) in Cincinnati, Ohio. The ETSC’s mission is to provide site-specific scientific and engineering technical support to Remedial Project Managers, On-Scene Coordinators, and other remediation personnel at contaminated sites. This allows local, regional, or national authorities to work more quickly, efficiently, and cost effectively, while also increasing the technical experience of the remediation team. Since its inception, the ETSC has supported countless projects across all EPA Regions in almost all states and territories. This report highlights significant projects the ETSC supported in fiscal year 2015 (FY15). These projects addressed an array of environmental scenarios, such as remote mining contamination, expansive landfill waste, cumulative impacts from multiple contamination sources, and persistent threats from abandoned industrial sites. Constructing and testing new and innovative treatment technol

  16. 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...

  17. 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…

  18. 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…

  19. 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 ...

  20. The introduction of an acute physiological support service for surgical patients is an effective error reduction strategy.

    Science.gov (United States)

    Clarke, D L; Kong, V Y; Naidoo, L C; Furlong, H; Aldous, C

    2013-01-01

    Acute surgical patients are particularly vulnerable to human error. The Acute Physiological Support Team (APST) was created with the twin objectives of identifying high-risk acute surgical patients in the general wards and reducing both the incidence of error and impact of error on these patients. A number of error taxonomies were used to understand the causes of human error and a simple risk stratification system was adopted to identify patients who are particularly at risk of error. During the period November 2012-January 2013 a total of 101 surgical patients were cared for by the APST at Edendale Hospital. The average age was forty years. There were 36 females and 65 males. There were 66 general surgical patients and 35 trauma patients. Fifty-six patients were referred on the day of their admission. The average length of stay in the APST was four days. Eleven patients were haemo-dynamically unstable on presentation and twelve were clinically septic. The reasons for referral were sepsis,(4) respiratory distress,(3) acute kidney injury AKI (38), post-operative monitoring (39), pancreatitis,(3) ICU down-referral,(7) hypoxia,(5) low GCS,(1) coagulopathy.(1) The mortality rate was 13%. A total of thirty-six patients experienced 56 errors. A total of 143 interventions were initiated by the APST. These included institution or adjustment of intravenous fluids (101), blood transfusion,(12) antibiotics,(9) the management of neutropenic sepsis,(1) central line insertion,(3) optimization of oxygen therapy,(7) correction of electrolyte abnormality,(8) correction of coagulopathy.(2) CONCLUSION: Our intervention combined current taxonomies of error with a simple risk stratification system and is a variant of the defence in depth strategy of error reduction. We effectively identified and corrected a significant number of human errors in high-risk acute surgical patients. This audit has helped understand the common sources of error in the general surgical wards and will inform

  1. 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

  2. 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.

  3. 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.

  4. 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.

  5. 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.

  6. 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...

  7. Stope and Gully Support: Final report

    CSIR Research Space (South Africa)

    Roberts, MKC

    1995-12-01

    Full Text Available This project had two objectives namely: Develop a rationale for the design of stope support systems. Determine support resistance criteria for the support of stope gullies for both static and dynamic loading and develop improved support systems...

  8. 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...

  9. ADVANCED RADIATION THEORY SUPPORT ANNUAL REPORT 2002, FINAL REPORT

    International Nuclear Information System (INIS)

    DAVIS, J.; APRUZESE, J.; CHONG, Y.; CLARK, R.; DASGUPTA, A.; GIULIANI, J.; KEPPLE, P.; TERRY, R.; THORNHILL, J.; VELIKOVICH, A.

    2003-01-01

    Z-PINCH PHYSICS RADIATION FROM WIRE ARRAYS. This report describes the theory support of DTRA's Plasma Radiation Source (PRS) program carried out by NRL's Radiation Hydrodynamics Branch (Code 6720) in FY 2002. Included is work called for in DTRA MIPR 02-2045M - ''Plasma Radiation Theory Support'' and in DOE's Interagency Agreement DE-AI03-02SF22562 - ''Spectroscopic and Plasma Theory Support for Sandia National Laboratories High Energy Density Physics Campaign''. Some of this year's work was presented at the Dense Z-Pinches 5th International Conference held June 23-28 in Albuquerque, New Mexico. A common theme of many of these presentations was a demonstration of the importance of correctly treating the radiation physics for simulating Plasma Radiation Source (PRS) load behavior and diagnosing load properties, e.g, stagnation temperatures and densities. These presentations are published in the AIP Conference Proceedings and, for reference, they are included in Section 1 of this report. Rather than describe each of these papers in the Executive Summary, they refer to the abstracts that accompany each paper. As a testament to the level of involvement and expertise that the Branch brings to DTRA as well as the general Z-Pinch community, eight first-authored presentations were contributed at this conference as well as a Plenary and an Invited Talk. The remaining four sections of this report discuss subjects either not presented at the conference or requiring more space than allotted in the Proceedings

  10. 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.

  11. 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.

  12. 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

  13. 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.

  14. 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

  15. 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.

  16. 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

  17. 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...

  18. Support to LANL: Cost estimation. Final report

    International Nuclear Information System (INIS)

    1993-01-01

    This report summarizes the activities and progress by ICF Kaiser Engineers conducted on behalf of Los Alamos National Laboratories (LANL) for the US Department of Energy, Office of Waste Management (EM-33) in the area of improving methods for Cost Estimation. This work was conducted between October 1, 1992 and September 30, 1993. ICF Kaiser Engineers supported LANL in providing the Office of Waste Management with planning and document preparation services for a Cost and Schedule Estimating Guide (Guide). The intent of the Guide was to use Activity-Based Cost (ABC) estimation as a basic method in preparing cost estimates for DOE planning and budgeting documents, including Activity Data Sheets (ADSs), which form the basis for the Five Year Plan document. Prior to the initiation of the present contract with LANL, ICF Kaiser Engineers was tasked to initiate planning efforts directed toward a Guide. This work, accomplished from June to September, 1992, included visits to eight DOE field offices and consultation with DOE Headquarters staff to determine the need for a Guide, the desired contents of a Guide, and the types of ABC estimation methods and documentation requirements that would be compatible with current or potential practices and expertise in existence at DOE field offices and their contractors

  19. 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

  20. SVM-Maj: a majorization approach to linear support vector machines with different hinge errors

    NARCIS (Netherlands)

    P.J.F. Groenen (Patrick); G.I. Nalbantov (Georgi); J.C. Bioch (Cor)

    2007-01-01

    textabstractSupport vector machines (SVM) are becoming increasingly popular for the prediction of a binary dependent variable. SVMs perform very well with respect to competing techniques. Often, the solution of an SVM is obtained by switching to the dual. In this paper, we stick to the primal

  1. 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.

  2. Comparison of the errors in basic life support performance after training using the 2000 and 2005 ERC guidelines.

    Science.gov (United States)

    Owen, Andrew; Kocierz, Laura; Aggarwal, Naresh; Hulme, Jonathan

    2010-06-01

    The importance of immediate cardiopulmonary resuscitation (CPR) and defibrillation after cardiac arrest is established. The 2005 European Resuscitation Council (ERC) guidelines were altered to try to improve survival after cardiac arrest. This observational study compares the errors in basic life support (BLS) performance after training using the 2000 or 2005 guidelines. First-year healthcare students at the University of Birmingham, United Kingdom, were taught adult BLS in a standardised 8-h course: an historical group with previous ERC guidelines (Old), the other with 2005 ERC guidelines (New). 2537 (Old 1773; New 764) students were trained and assessed in BLS. There was no difference in overall error rate between Old and New (5.53% vs. 6.70% (p>0.05)) or adherence to the sequence of the respective BLS algorithm. The New group ("hands in centre of the chest") had significantly more erroneous hand positions compared to the Old group (5.23% vs. 1.64%, pERC guidelines do not significantly improve correct BLS performance. Removal of hand placement measurement results in a significant increase in hand position errors. The clinical benefit of an increased number of compressions impaired by worsened hand positioning is unknown and requires further study. Copyright 2010 Elsevier Ireland Ltd. All rights reserved.

  3. 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.

  4. 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.

  5. 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.)

  6. Maryland Family Support Services Consortium. Final Report.

    Science.gov (United States)

    Gardner, James F.; Markowitz, Ricka Keeney

    The Maryland Family Support Services Consortium is a 3-year demonstration project which developed unique family support models at five sites serving the needs of families with a developmentally disabled child (ages birth to 21). Caseworkers provided direct intensive services to 224 families over the 3-year period, including counseling, liaison and…

  7. 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.

  8. 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

  9. 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.

  10. 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.

  11. 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.

  12. 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…

  13. 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.

  14. Thinking, doing and support. Background report

    International Nuclear Information System (INIS)

    Verhue, D.; Binnema, H.; Mulder, S.

    2007-09-01

    By request of the Netherlands Environmental Assessment Agency, Veldkamp and TNS NIPO conducted research on the societal support for the acceptance of measures for the solution of a number of sustainability issues in February and March 2007. The objective of this study was to determine which characteristics of measures determine societal support and how this coheres with the issue that is solved with the measures. Measures that were examined entailed the sustainability issues biodiversity and climate change. In the case of biodiversity measures were examines that deal with the limitation of space utilization, whereas in climate change measures were examined that focus on energy saving and electricity generation. Moreover, for development cooperation, the type of aid with the greatest support has been identified. [mk] [nl

  15. 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.

  16. 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.

  17. Child Support Enforcement Annual Data Reports Form 157 - YR 2013

    Data.gov (United States)

    U.S. Department of Health & Human Services — The Office of Child Support Enforcement's Annual Data Report from State agencies administering child support enforcement plans under Title IV-D of the Social...

  18. Child Support Enforcement Annual Data Report Form 157

    Data.gov (United States)

    U.S. Department of Health & Human Services — The Office of Child Support Enforcement's Annual Data Report from State agencies administering child support enforcement plans under Title IV-D of the Social...

  19. 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...

  20. NRC ARDC Guidance Support Status Report

    Energy Technology Data Exchange (ETDEWEB)

    Holbrook, Mark R. [Idaho National Lab. (INL), Idaho Falls, ID (United States)

    2017-07-01

    This report provides a summary that reflects the progress and status of proposed regulatory design criteria for advanced non-light water reactor (LWR) designs in accordance with the Level 3 milestone M3AT-17IN2001013 in work package AT-17IN200101. These criteria have been designated as advanced reactor design criteria (ARDC) and they provide guidance to future applicants for addressing the general design criteria (GDC) that are currently applied specifically to LWR designs. This report provides a summary of Phase 2 activities related to the various tasks associated with ARDC development and the subsequent development of ARDC regulatory guidance for sodium fast reactor (SFR) and modular high-temperature gas-cooled reactor (HTGR) designs. Status Report Organization: Section 2 discusses the origin of the GDC and their application to LWRs. Section 3 addresses the objective of this initiative and how it benefits the advanced non-LWR reactor vendors. Section 4 discusses the scope and structure of the initiative. Section 5 provides background on the U.S. Department of Energy (DOE) ARDC team’s original development of the proposed ARDC that were submitted to the NRC for consideration. Section 6 provides a summary of recent ARDC Phase 2 activities. Appendices A through E document the DOE ARDC team’s public comments on various sections of the NRC’s draft regulatory guide DG–1330, “Guidance for Developing Principal Design Criteria for Non-Light Water Reactors.”

  1. NRC ARDC Guidance Support Status Report

    International Nuclear Information System (INIS)

    Holbrook, Mark R.

    2017-01-01

    This report provides a summary that reflects the progress and status of proposed regulatory design criteria for advanced non-light water reactor (LWR) designs in accordance with the Level 3 milestone M3AT-17IN2001013 in work package AT-17IN200101. These criteria have been designated as advanced reactor design criteria (ARDC) and they provide guidance to future applicants for addressing the general design criteria (GDC) that are currently applied specifically to LWR designs. This report provides a summary of Phase 2 activities related to the various tasks associated with ARDC development and the subsequent development of ARDC regulatory guidance for sodium fast reactor (SFR) and modular high-temperature gas-cooled reactor (HTGR) designs. Status Report Organization: Section 2 discusses the origin of the GDC and their application to LWRs. Section 3 addresses the objective of this initiative and how it benefits the advanced non-LWR reactor vendors. Section 4 discusses the scope and structure of the initiative. Section 5 provides background on the U.S. Department of Energy (DOE) ARDC team’s original development of the proposed ARDC that were submitted to the NRC for consideration. Section 6 provides a summary of recent ARDC Phase 2 activities. Appendices A through E document the DOE ARDC team’s public comments on various sections of the NRC’s draft regulatory guide DG–1330, “Guidance for Developing Principal Design Criteria for Non-Light Water Reactors.”

  2. Biomedical Engineering support. Semiannual progress report

    International Nuclear Information System (INIS)

    Kolff, W.J.; Smith, L.M.; Sandquist, G.M.

    1976-01-01

    The basic goal of the ERDA Artificial Heart Program is to develop and construct an artificial heart, powered by a 238 Pu heat source, which can be successfully employed as an emplantable total artificial heart system for animal experiments. Future studies will be directed at developing and evaluating a satisfactory system for total heart replacement in humans. A total of 32 ERDA artificial hearts have been implanted since the initiation of the program. During the reporting period ten total heart replacement experiments were performed in calves using the ERDA blood pump powered by an electric motor implanted in the abdomen. Results of the experiments are given

  3. Draft federal GHG accounting and reporting : technical support document

    Science.gov (United States)

    2010-07-01

    This is a technical support document (TSD) that accompanies the Federal Greenhouse Gas Accounting and Reporting Guidance (or Guidance). This document provides detailed information on the inventory reporting process and accepted calculation methodolog...

  4. 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

  5. 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…

  6. 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)

  7. 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.

  8. Enewetak radiological support project. Final report

    International Nuclear Information System (INIS)

    Friesen, B.

    1982-09-01

    From 1972 through 1980, the Department of Energy acted in an advisory role to the Defense Nuclear Agency during planning for and execution of the cleanup of Enewetak Atoll. The Nevada Operations Office of the Department of Energy was responsible for the radiological characterization of the atoll and for certification of radiological condition of each island upon completion of the project. In-situ measurements of gamma rays emitted by americium-241 were utilized along with wet chemistry separation of plutonium from soil samples to identify and delineate surface areas requiring removal of soil. Military forces removed over 100,000 cubic yards of soil from the surface of five islands and deposited this material in a crater remaining from the nuclear testing period. Subsurface soil was excavated and removed from several locations where measurements indicated the presence of radionuclides above predetermined criteria. The methodologies of data acquisition, analysis and interpretation are described and detailed results are provided in text, figures and microfiche. The final radiological condition of each of 43 islets is reported

  9. 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

  10. 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.

  11. 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.

  12. 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.

  13. 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.

  14. Engineering Technical Support Center Annual Report Fiscal Year 2016

    Science.gov (United States)

    This report highlights significant projects that the ETSC supported in fiscal year 2016. These projects have addressed an array of environmental scenarios, including, but not limited to remote mining contamination, expansive landfill waste, cumulative impacts from multiple contam...

  15. 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

  16. 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.

  17. Statistical Modeling of Radiometric Error Propagation in Support of Hyperspectral Imaging Inversion and Optimized Ground Sensor Network Design

    National Research Council Canada - National Science Library

    Klempner, Scott

    2008-01-01

    .... Error modeling and propagation methodology is developed for each link in the imaging chain, and representative values are determined for the purpose of exercising the model and observing the system...

  18. 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

  19. 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…

  20. 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.

  1. 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)

  2. 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.

  3. 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).

  4. 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....

  5. 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

  6. 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.

  7. 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.

  8. 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

  9. 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

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

    International Nuclear Information System (INIS)

    Furuhama, Yutaka; Furuta, Kazuo; Kondo, Shunsuke

    1995-01-01

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

  11. 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 ...

  12. Behavior-aware decision support systems : LDRD final report.

    Energy Technology Data Exchange (ETDEWEB)

    Hirsch, Gary B.; Homer, Jack (Homer Consulting); Chenoweth, Brooke N.; Backus, George A.; Strip, David R.

    2007-11-01

    As Sandia National Laboratories serves its mission to provide support for the security-related interests of the United States, it is faced with considering the behavioral responses that drive problems, mitigate interventions, or lead to unintended consequences. The effort described here expands earlier works in using healthcare simulation to develop behavior-aware decision support systems. This report focuses on using qualitative choice techniques and enhancing two analysis models developed in a sister project.

  13. 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.

  14. 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).

  15. Consultation system for image diagnosis: Report formation support system

    International Nuclear Information System (INIS)

    Ikeda, M.; Sakuma, S.; Ishigaki, T.; Suzuki, K.; Oikawa, K.

    1987-01-01

    The authors developed a consultation system for image diagnosis, involving artificial intelligence ideas. In this system, the authors proposed a new report formation support system and implemented it in lymphangiography. This support system starts with the input of image interpretation. The input process is made mainly by selecting items. This system encodes the input findings into the semantic network, which is represented as a directed graph, and it reserves them into the knowledge database in the above structure. Finally, the output (report) is made in the near natural language, which corresponds to the input findings

  16. 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.

  17. Finnish support programme to IAEA safeguards. Annual report 1994

    International Nuclear Information System (INIS)

    Tarvainen, M.

    1995-05-01

    Implementation of the Finnish Support Programme to IAEA Safeguards (FINSP) during the calender year in question is summarized. FINSP is carried out trough separate tasks concentrating on verification of nuclear material, training and expert services to the IAEA. In addition to the Finnish summary, the report includes detailed description of each task in English

  18. The Battle Command Sustainment Support System: Initial Analysis Report

    Science.gov (United States)

    2016-09-01

    products including jet fuels, distillate fuels, residual fuels, automotive gasoline , specified bulk lubricating oils, aircraft engine oils, fuel...contained within this report. 15. SUBJECT TERMS Mission command Software Tactical applications (TacApps) Command post ...computing environment (CPCE) Command post client Battle command sustainment support System (BCS3) Logistics

  19. Breast milk donation and social support: reports of women donors.

    Science.gov (United States)

    De Alencar, Lucienne Christine Estevez; Seidl, Eliane Maria Fleury

    2010-01-01

    The study aimed to characterize the behavior of human milk donation and to describe the informal social and formal institutional support, according to reports from women donors. It is an exploratory, cross-sectional, descriptive study using domicile interviews based on structured and semi-structured scripts. The participants were 36 women enrolled in two human milk banks of the public health system of the Federal District. Statistical analysis of quantitative data and categorical content analysis of qualitative data were performed. Categories of reasons that most influenced the frequency of expressing were: food, time availability, negative emotions and fluid intake. The manual expressing technique was reported as predominant. The use of breast shells was cited by almost a third of the donors. Most frequent suggestions for improving institutional support were more attention and support from the milk banks for the donor. The study may serve as a stimulus for the implementation of technical and political strategies to encourage this practice.

  20. 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.

  1. 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...

  2. 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.

  3. 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.

  4. 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.

  5. 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.

  6. Infrastructure support for the Waste Management Institute. Progress report

    International Nuclear Information System (INIS)

    1995-01-01

    North Carolina A ampersand T State University is in the process of developing an infrastructure for an interdisciplinary Waste Management Institute (WMI). The Interdisciplinary Waste Management Institute (WMI) was approved in June 1994 by the General Administration of the University of North Carolina as an academic support unit with research and public service functions. The mission of the WMI is to enhance awareness and understanding of waste management issues and to provide instructional support including research and outreach. The goals of WMI are as follows: increase the number of minority professionals who will work in waste management fields; develop cooperative and exchange programs involving faculty, students, government, and industry; serve as institutional sponsor of public awareness workshops and lecture series; and support interdisciplinary research programs. Accomplishments for this reporting period are presented for WMI enrollment; waste management and certificate program; waste management instructional projects; undergraduate scholarship/stipend and faculty student development projects; research; and community relations

  7. 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.

  8. 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)

  9. 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.

  10. 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.

  11. Hanford radiological protection support services annual report for 1987

    International Nuclear Information System (INIS)

    Lyon, M.; Fix, J.J.; Kenoyer, J.L.; Leonowich, J.A.; Palmer, H.E.; Sula, M.J.

    1988-08-01

    This report documents the performance of certain radiological protection sitewide services during calendar year (CY) 1987 by Pacific Northwest Laboratory in support of the US Department of Energy-Richland Operations Office (DOE-RL) and contractor activities on the Hanford Site. The routine program for each service is discussed along with any significant program changes and tasks, investigations, and studies performed in support of each program. Other related activities such as publications, presentations, and memberships on standards or industry committees are also discussed. The programs covered provide services in the areas of: external dosimetry, internal dosimetry, in vivo measurements, instrument calibration and evaluation, calibration of radiation sources traceable to the National Bureau of Standards, and radiological records. 21 refs., 10 figs., 12 tabs

  12. Implant support for removable partial overdentures: a case report.

    Science.gov (United States)

    Halterman, S M; Rivers, J A; Keith, J D; Nelson, D R

    1999-01-01

    Functional stability and the preservation of remaining alveolar bone are primary, and often elusive, goals when restoring the partially edentulous arch. The incorporation of dental implants for the partial support of removable prostheses offers a practical adjunct in the fulfillment of these objectives. Planning for complex courses of treatment that include dental implants requires close coordination between the surgeon and the restorative dentist. Decisions that deal with type, location, size, number of implant fixtures, and design of the prosthesis are critical. All of these areas must be discussed and established as acceptable to the patient and each clinician before the initiation of treatment. In this report, we present a course of patient treatment in which a removable partial denture is supported by natural remaining teeth in conjunction with osseointegrated implants.

  13. Hanford radiological protection support services annual report for 1988

    International Nuclear Information System (INIS)

    Lyon, M.; Fix, J.J.; Kenoyer, J.L.; Leonowich, J.A.; Palmer, H.E.; Sula, M.J.

    1989-06-01

    The report documents the performance of certain radiological protection sitewide services during calendar year (CY) 1988 by Pacific Northwest Laboratory (PNL) in support of the US Department of Energy-Richland Operations Office (DOE-RL) and contractor activities on the Hanford Site. The routine program for each service is discussed along with any significant program changes and tasks, investigations, and studies performed in support of each program. Other related activities such as publications, presentations, and memberships on standard or industry committees are also listed. The programs covered provide services in the areas of (1) internal dosimetry, (2) in vivo measurements, (3) external dosimetry, (4) instrument calibration and evaluation, (5) calibration of radiation sources traceable to the National Institute of Standards and Technology (NIST) (formerly the National Bureau of Standards), and (6) radiological records. 23 refs., 15 figs., 15 tabs

  14. 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.

  15. 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.

  16. 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.

  17. 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

  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. Student financial support. An inventory in 24 European countries. Background report for the project on portability of student financial support

    OpenAIRE

    Vossensteyn, Johan J.

    2004-01-01

    This report provides a description of the current national systems of student financial support in 24 European countries. It provides information on tuition fees, grants, scholarships, student loans, and indirect student support through students families (family allowances and tax benefits) and support in kind in the form of subsidies for travel, accommodation, student restaurants etc. It forms a background report for the study on the extent to which student financial support can be used for ...

  1. Support patient search on pathology reports with interactive online learning based data extraction.

    Science.gov (United States)

    Zheng, Shuai; Lu, James J; Appin, Christina; Brat, Daniel; Wang, Fusheng

    2015-01-01

    Structural reporting enables semantic understanding and prompt retrieval of clinical findings about patients. While synoptic pathology reporting provides templates for data entries, information in pathology reports remains primarily in narrative free text form. Extracting data of interest from narrative pathology reports could significantly improve the representation of the information and enable complex structured queries. However, manual extraction is tedious and error-prone, and automated tools are often constructed with a fixed training dataset and not easily adaptable. Our goal is to extract data from pathology reports to support advanced patient search with a highly adaptable semi-automated data extraction system, which can adjust and self-improve by learning from a user's interaction with minimal human effort. We have developed an online machine learning based information extraction system called IDEAL-X. With its graphical user interface, the system's data extraction engine automatically annotates values for users to review upon loading each report text. The system analyzes users' corrections regarding these annotations with online machine learning, and incrementally enhances and refines the learning model as reports are processed. The system also takes advantage of customized controlled vocabularies, which can be adaptively refined during the online learning process to further assist the data extraction. As the accuracy of automatic annotation improves overtime, the effort of human annotation is gradually reduced. After all reports are processed, a built-in query engine can be applied to conveniently define queries based on extracted structured data. We have evaluated the system with a dataset of anatomic pathology reports from 50 patients. Extracted data elements include demographical data, diagnosis, genetic marker, and procedure. The system achieves F-1 scores of around 95% for the majority of tests. Extracting data from pathology reports could enable

  2. Support patient search on pathology reports with interactive online learning based data extraction

    Directory of Open Access Journals (Sweden)

    Shuai Zheng

    2015-01-01

    Full Text Available Background: Structural reporting enables semantic understanding and prompt retrieval of clinical findings about patients. While synoptic pathology reporting provides templates for data entries, information in pathology reports remains primarily in narrative free text form. Extracting data of interest from narrative pathology reports could significantly improve the representation of the information and enable complex structured queries. However, manual extraction is tedious and error-prone, and automated tools are often constructed with a fixed training dataset and not easily adaptable. Our goal is to extract data from pathology reports to support advanced patient search with a highly adaptable semi-automated data extraction system, which can adjust and self-improve by learning from a user′s interaction with minimal human effort. Methods : We have developed an online machine learning based information extraction system called IDEAL-X. With its graphical user interface, the system′s data extraction engine automatically annotates values for users to review upon loading each report text. The system analyzes users′ corrections regarding these annotations with online machine learning, and incrementally enhances and refines the learning model as reports are processed. The system also takes advantage of customized controlled vocabularies, which can be adaptively refined during the online learning process to further assist the data extraction. As the accuracy of automatic annotation improves overtime, the effort of human annotation is gradually reduced. After all reports are processed, a built-in query engine can be applied to conveniently define queries based on extracted structured data. Results: We have evaluated the system with a dataset of anatomic pathology reports from 50 patients. Extracted data elements include demographical data, diagnosis, genetic marker, and procedure. The system achieves F-1 scores of around 95% for the majority of

  3. 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

  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

    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

  5. 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

  6. Methodology development to support NPR strategic planning. Final report

    International Nuclear Information System (INIS)

    1996-01-01

    This report covers the work performed in support of the Office of New Production Reactors during the 9 month period from January through September 1990. Because of the rapid pace of program activities during this time period, the emphasis on work performed shifted from the strategic planning emphasis toward supporting initiatives requiring a more immediate consideration and response. Consequently, the work performed has concentrated on researching and helping identify and resolve those issues considered to be of most immediate concern. Even though they are strongly interrelated, they can be separated into two broad categories as follows: The first category encompasses program internal concerns. Included are issues associated with the current demand for accelerating staff growth, satisfying the immediate need for appropriate skill and experience levels, team building efforts necessary to assure the development of an effective operating organization, ability of people and organizations to satisfactorily understand and execute their assigned roles and responsibilities, and the general facilitation of inter/intra organization communications and working relationships. The second category encompasses program execution concerns. These include those efforts required in development of realistic execution plans and implementation of appropriate control mechanisms which provide for effective forecasting, planning, managing, and controlling of on-going (or soon to be) program substantive activities according to the master integrated schedule and budget

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

    Science.gov (United States)

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

    2011-03-01

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

  8. 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.

  9. 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....

  10. 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...

  11. Report on DOE support for GSC13 travel award

    Energy Technology Data Exchange (ETDEWEB)

    Gilbert, Jack Anthony [University of Chicago

    2012-04-18

    Consortium. The 3-day conference was held at the Kingkey Palace Hotel, Shenzhen, China, on March 5-7th, 2012, and was hosted by the Beijing Genomics Institute (BGI). The meeting was entitled ‘From Genomes to Interactions to Communities to Models’ and aimed to be a scientific meeting that highlighted the role of data standards associated with genomic, metagenomic and amplicon sequence data, and the contextual information associated with the sample that data was generated from. To this end the meeting focused on genomic projects for animals, plants, fungi and viruses, metagenomic studies in host-microbe interactions, and community dynamics in microbial communities. In addition the meeting hosted a Genomic Observatories Network session, a GSC biodiversity working group session, and a Microbiology of the Built Environment session sponsored by the Alfred P. Sloan Foundation. The meeting was very well organized by the local hosts at BGI, and all attendees reported that they were very happy with the outcome, service and quality of the science presented. Highlights were keynotes by Rita Colwell, Mitch Sogin and Jim Tiedje. The 5 attendees paid for by the DOE award were Daniel Smith and Jared Wilkening (University of Chicago); Patrick Chain (Los Alamos National Laboratory), Austin Davis-Richardson (University of Florida) and Greg Caporoaso (University of Northern Arizona). Each attendee was able to either present or become involved with the attending scientists, and each reported that they had got something significant out of the meeting. Here are detailed their personal accounts of the GSC13 meeting. We thank DOE for the helping to fund this valuable outreach initiative, and for supporting the attendance of these bright young scientists at this important meeting.

  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. Development of transportation asset management decision support tools : final report.

    Science.gov (United States)

    2017-08-09

    This study developed a web-based prototype decision support platform to demonstrate the benefits of transportation asset management in monitoring asset performance, supporting asset funding decisions, planning budget tradeoffs, and optimizing resourc...

  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. Engineering Technical Support Center Annual Report Fiscal Year 2015

    Science.gov (United States)

    The United States Environmental Protection Agency (EPA or Agency) Office of Research and Development (ORD) created the Engineering Technical Support Center (ETSC) in 1987, one of several technical support centers created as part of the Technical Support Project (TSP). ETSC provid...

  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. 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 ...

  18. 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.)

  19. Model supported sensor information platform for the transversal dynamics and longitudinal dynamics of vehicles. Applications to error diagnostics and error tolerance; Modellgestuetzte Sensorinformationsplattform fuer die Quer- und Laengsdynamik von Kraftfahrzeugen. Anwendungen zur Fehlerdiagnose und Fehlertoleranz

    Energy Technology Data Exchange (ETDEWEB)

    Halbe, Iris

    2008-07-01

    The contribution under consideration contacts engineers and scientists within the range of the motor vehicle dynamics. For the monitoring of the signals measured in series vehicle, a sensor information platform is designed. Thus, this supplies correct sensor information to the monitoring systems and offers estimated parameters and conditions for the regulation. The basis is a comprehensive concept of the transverse dynamics, longitudinal dynamics and staggering dynamics with different physical and experimental models. On the basis of these models, several procedures of error recognition are pointed out (observer, parity equations, parameter estimation), and their suitability in the driving dynamics is examined. Based on the results of error recognition, the defective sensor is diagnosed with Fuzzy in order to replace it with a computed signal. This error tolerance becomes possible by a two-trace model with a Kalman filter. Furthermore, conditions and parameters are estimated with different methods.

  20. Student financial support. An inventory in 24 European countries. Background report for the project on portability of student financial support

    NARCIS (Netherlands)

    Vossensteyn, Johan J.

    2004-01-01

    This report provides a description of the current national systems of student financial support in 24 European countries. It provides information on tuition fees, grants, scholarships, student loans, and indirect student support through students families (family allowances and tax benefits) and

  1. Hanford Radiological Protection Support Services Annual Report for 2000

    Energy Technology Data Exchange (ETDEWEB)

    Lynch, Timothy P.; Bihl, Donald E.; Johnson, Michelle L.; Maclellan, Jay A.; Piper, Roman K.

    2001-05-07

    During calendar year 2000, the Pacific Northwest National Laboratory performed its customary radiological protection support services in support of the U.S. Department of Energy Richland Operations Office and the Hanford contractors. These services included: 1) external dosimetry, 2) internal dosimetry, 3) in vivo monitoring, 4) radiological records, 5) instrument calibration and evaluation, and 6) calibration of radiation sources traceable to the National Institute of Standards and Technology. Each program summary describes the routine operations, program changes and improvements, program assessments, supporting technical studies, and professional activities.

  2. 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.

  3. Child Support Enforcement Annual Data Report Form 34A - 2007

    Data.gov (United States)

    U.S. Department of Health & Human Services — This dataset contains annual data on collections received and distributed by State agencies administering the Child Support Enforcement program under title IV-D of...

  4. Child Support Enforcement Annual Data Report Form 34A - 2006

    Data.gov (United States)

    U.S. Department of Health & Human Services — This dataset contains annual data on collections received and distributed by State agencies administering the Child Support Enforcement program under title IV-D of...

  5. 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.

  6. 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.

  7. 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

  8. Hanford Radiological Protection Support Services Annual Report for 1998

    Energy Technology Data Exchange (ETDEWEB)

    DE Bihl; JA MacLellan; ML Johnson; RK Piper; TP Lynch

    1999-05-14

    During calendar year (CY) 1998, the Pacific Northwest National Laboratory (PNNL) performed its customary radiological protection support services in support of the U.S. Department of Energy (DOE) Richland Operations OffIce (RL) and the Hanford contractors. These services included: 1) external dosimetry, 2) internal dosimetry, 3) in vivo measurements, 4) radiological records, 5) instrument calibra- tion and evaluation, and 6) calibration of radiation sources traceable to the National Institute of Standards and Technology (MST). The services were provided under a number of projects as summarized here.

  9. Student Support for EIPBN 2015 Conference - Final Report

    Energy Technology Data Exchange (ETDEWEB)

    Farrow, Reginald C. [New Jersey Inst. of Technology, Newark, NJ (United States)

    2016-01-19

    The 59th International Conference on Electron, Ion and Photon Beam Technology and Nanofabrication, 2015, held at the Manchester Grand Hyatt in San Diego, CA from May 26 to May 29, 2015 was a great success in large part because financial support allowed robust participation from students. The students gave oral and poster presentations of their research and many will publish peer-reviewed articles in a special conference issue of the Journal of Vacuum Science and Technology B. The Department of Energy Office of Basic Energy Sciences supported 10 students from US universities with a $5,000 grant (DE-SC0013773).

  10. Student Support for EIPBN 2016 Conference - Final Report

    Energy Technology Data Exchange (ETDEWEB)

    Farrow, Reginald C. [New Jersey Inst. of Technology, Newark, NJ (United States)

    2017-01-26

    The 60th International Conference on Electron, Ion, and Photon Beam Technology and Nanofabrication (EIPBN) was held in Pittsburgh, PA, from May 31st to June 3rd, 2016. The conference received technical co-sponsorship from the American Vacuum Society (AVS) in cooperation with the Optical Society of America (OSA), and the American Physical Society (APS). The conference was a great success in large part because financial support allowed robust participation from students. The students gave oral and poster presentations of their research and many published peer-reviewed articles in a special conference issue of the Journal of Vacuum Science and Technology B. The Department of Energy Office of Basic Energy Sciences supported 10 students from US universities with a $5,000 grant (DE-SC0015555).

  11. Logistics analysis in support of DOE fee adequacy report

    International Nuclear Information System (INIS)

    McNair, G.W.; Wood, T.W.; Shay, M.R.; Cashwell, J.W.

    1985-01-01

    In compliance with the Nuclear Waste Policy Act of 1982, the US Department of Energy is required to determine annually the adequacy of the 1-mil per kilowatt-hour fee assessment of nuclear power plants. To support this determination, a series of analyses were performed to detail the anticipated costs that will be incurred to provide transportation equipment and services. The results of these analyses are documented in this presentation

  12. NIF target area design support. Final summary report

    International Nuclear Information System (INIS)

    Tokheim, R.E.; Seaman, L.; Curran, D.R.

    1996-02-01

    SRI International continued support work for the National Ignition Facility, Chamber Dynamics Group at Lawrence Livermore National Laboratory (LLNL). The work entailed computational modeling of shrapnel and debris generation from copper shine shields, hohlraum, and stainless steel cryogenic support tubes for 1.8 MJ and 1.0 MJ no-yield and 20 MJ yield shots. Also, the authors addressed the effects of shrapnel at the first wall. Computations for 1.8 MJ showed an ionized gold hohlraum, but about half solid and half ionized copper shine shields, when material cell phase boundaries were maintained. This debris generation represents a potential threat to the first wall and debris shields. Further work is required to translate these results into particle size distributions based on computed strain rates. The authors used simple algorithms for x-ray loading of frost layers protecting the target support to compute peak stress attenuation. They developed algorithmic formulas for predicting damage in candidate first wall materials and they found damage algorithms for fused-silica debris shield material. They obtained very preliminary computational results at 20 MJ for predicting shrapnel mass and particle density at the first wall in spherical polar coordinate space with the hohlraum axis as the polar direction

  13. Student Support for EIPBN 2014 Conference - Final Report

    Energy Technology Data Exchange (ETDEWEB)

    Farrow, Reginald C.

    2014-09-16

    The 58th International Conference on Electron, Ion and Photon Beam Technology and Nanofabrication (EIPBN), 2014, was held at the Omni Shoreham Hotel in Washington, DC, May 27 to 30, 2014. The EIPBN Conference is recognized as the foremost international meeting dedicated to lithographic science and technology and its application to micro and nanofabrication techniques. The conference brought together 386 engineers and scientists from industries and universities from all over the world to discuss recent progress and future trends. Among the emerging technologies that are within the scope of EIPBN is Nanofabrication for Energy Sources along with nanofabrication for the realization of low power integrated circuits. Every year, EIPBN provides financial support for students to attend the conference. Travel support for 43 students came from a mixture of government agencies and corporate donors. The Department of Energy Office of Basic Energy Sciences provided $5,000 to support student travel from US universities to participate at EIPBN 2014 through grant DE-SC0011789.

  14. 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.

  15. Child Support Enforcement Annual Data Report Form 157 – YR 2014

    Data.gov (United States)

    U.S. Department of Health & Human Services — The Office of Child Support Enforcement's Annual Data Report from State agencies administering child support enforcement plans under Title IV-D of the Social...

  16. 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

  17. 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...

  18. 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.

  19. Fundamental research of decision support systems: Final report

    International Nuclear Information System (INIS)

    Kurstedt, H.A. Jr.

    1986-01-01

    Through an iterative application of Decision Support Systems (DSS) apparatus and evolution of DSS concepts, we redefined DSS from a systems perspective. By focusing on successful DSS and the definition of success for the newly-defined DSS, we generated a paradigm for understanding, applying, and improving DSS. The significance of the research is that we now: (1) understand the various roles management tools play within the new DSS concept; (2) recognize the need for characterizing the domain of responsibility of a manager to obtain a successful DSS; and (3) have learned special characteristics of government agencies like Nuclear Materials (NM) to identify what features of the new DSS concept can be expected to improve performance

  20. Hanford Radiological Protection Support Services annual report for 1992

    International Nuclear Information System (INIS)

    Lyon, M.; Bihl, D.E.; Fix, J.J.; Piper, R.K.; Froelich, T.J.; Lynch, T.P.

    1993-07-01

    Various Hanford Site radiation protection services provided by the Pacific Northwest Laboratory for the US Department of Energy Richland Field Office and Hanford contractors are described in this annual report of calendar year 1992. These activities include internal dosimetry measurements and evaluations, in vivo measurements, external dosimetry measurements and evaluations, instrument calibration and evaluation, radiation source calibration, and radiological record keeping. For each of these activities, the routine program and any program changes or enhancements are described, as well as associated tasks, investigations, and studies. Program-related publications, presentations, and other staff professional activities are also described

  1. Hanford radiological protection support services annual report for 1990

    International Nuclear Information System (INIS)

    Lyon, M.; Bihl, D.E.; Fix, J.J.; Piper, R.K.; Freolich, T.J.; Leonowich, J.A.; Lynch, T.P.

    1991-07-01

    Various Hanford site-wide radiation protection services provided by the Pacific Northwest Laboratory for the US Department of Energy-Richland Operations Office and Hanford contractors are described in this annual report for calendar year 1990. These activities include internal dosimetry measurements and evaluations, in vivo measurements, external dosimetry measurements and evaluations, instrument calibration and evaluation, radiation source calibration, and radiological records keeping. For each of these activities, the routine program, program changes and enhancements, associated tasks, investigations and studies, and related publications, presentations, and other staff professional activities are discussed as applicable. 22 refs., 10 figs., 19 tabs

  2. Hanford Radiological Protection Support Services annual report for 1993

    International Nuclear Information System (INIS)

    Lyon, M.; Bihl, D.E.; Fix, J.J.; Froelich, T.J.; Piper, R.K.; Olsen, P.C.

    1994-07-01

    Various Hanford Site radiation protection services provided by the Pacific Northwest Laboratory for the US Department of Energy Richland Operations Office and Hanford contractors are described in this annual report for calendar year 1993. These activities include internal dosimetry measurements and evaluations, in vivo measurements, external dosimetry measurements and evaluations, instrument calibration and evaluation, radiation source calibration, and radiological record keeping. For each of these activities, the routine program and any program changes or enhancements are described, as well as associated tasks, investigations, and studies. Program-related publications, presentations, and other staff professional activities are also described

  3. Hanford radiological protection support services annual report for 1997

    Energy Technology Data Exchange (ETDEWEB)

    Lyon, M.; Bihl, D.E.; Fix, J.J.; Johnson, M.L.; Lynch, T.P.; Piper, R.K.

    1998-06-01

    Various Hanford Site radiation protection services provided by the Pacific Northwest National Laboratory for the US Department of Energy Richland Operations Office and Hanford contractors are described in this annual report for calendar year 1997. These activities include external dosimetry measurements and evaluations, internal dosimetry measurements and evaluations, in vivo measurements, radiological exposure record keeping, radiation source calibration, and instrument calibration and evaluation. For each of these activities, the routine program and any program changes or enhancements are described as well as associated tasks, investigations, and studies. Program-related publications, presentations, and other staff professional activities are also described.

  4. Hanford radiological protection support services annual report 1996

    International Nuclear Information System (INIS)

    Lyon, M.; Bihl, D.E.; Fix, J.J.; Froelich, T.J.; Piper, R.K.; Schulze, S.A.

    1997-06-01

    Various Hanford Site radiation protection services provided by the Pacific Northwest National Laboratory for the US Department of Energy Richland Operations Office and Hanford contractors are described in this annual report for calendar year 1996. These activities include external dosimetry measurements and evaluations, internal dosimetry measurements and evaluations, in vivo measurements, radiological exposure record keeping, radiation source calibration, and instrument calibration and evaluation. For each of these activities, the routine program and any program changes or enhancements are described, as well as associated tasks, investigations, and studies. Program-related publications, presentations, and other staff professional activities are also described

  5. Hanford radiological protection support services. Annual report for 1995

    International Nuclear Information System (INIS)

    Lyon, M.; Bihl, D.E.; Carbaugh, E.H.

    1996-05-01

    Various Hanford Site radiation protection services provided by the Pacific Northwest National Laboratory for the U.S. Department of Energy Richland Operations Office and Hanford contractors are described in this annual report for calendar year 1995. These activities include external dosimetry measurements and evaluations, internal dosimetry measurements and evaluations, in vivo measurements, radiological record keeping, radiation source calibration, and instrument calibration and evaluation. For each of these activities, the routine program and any program changes or enhancements are described, as well as associated tasks, investigations, and studies. Program-related publications, presentations, and other staff professional activities are also described

  6. Climatology in support of climate risk management : a progress report.

    OpenAIRE

    McGregor, G.R.

    2015-01-01

    Climate risk management has emerged over the last decade as a distinct area of activity within the wider field of climatology. Its focus is on integrating climate and non-climate information in order to enhance the decision-making process in a wide range of climate-sensitive sectors of society, the economy and the environment. Given the burgeoning pure and applied climate science literature that addresses a range of climate risks, the purpose of this progress report is to provide an overview ...

  7. Hanford radiological protection support services annual report for 1991

    International Nuclear Information System (INIS)

    Lyon, M.; Bihl, D.E.; Fix, J.J.; Piper, R.K.; Froelich, T.J.; Leonwich, J.A.; Lynch, T.P.

    1992-07-01

    Various Hanford sitewide radiation protection services provided by the Pacific Northwest Laboratory for the US Department of Energy, Richland Field Office and Hanford contractors are described In this annual report for calendar year 1991. These activities include internal dosimetry measurements and evaluations, in vivo measurements, external dosimetry measurements and evaluations, instrument calibration and evaluation, radiation source calibration, and radiological records keeping. For each of these activities, the routine program, program changes and enhancements, associated tasks, investigations and studies, and related publications, presentations, and other staff professional activities are discussed as applicable

  8. Hanford radiological protection support services annual report for 1997

    International Nuclear Information System (INIS)

    Lyon, M.; Bihl, D.E.; Fix, J.J.; Johnson, M.L.; Lynch, T.P.; Piper, R.K.

    1998-06-01

    Various Hanford Site radiation protection services provided by the Pacific Northwest National Laboratory for the US Department of Energy Richland Operations Office and Hanford contractors are described in this annual report for calendar year 1997. These activities include external dosimetry measurements and evaluations, internal dosimetry measurements and evaluations, in vivo measurements, radiological exposure record keeping, radiation source calibration, and instrument calibration and evaluation. For each of these activities, the routine program and any program changes or enhancements are described as well as associated tasks, investigations, and studies. Program-related publications, presentations, and other staff professional activities are also described

  9. Hanford radiological protection support services annual report for 1996

    Energy Technology Data Exchange (ETDEWEB)

    Lyon, M.; Bihl, D.E.; Fix, J.J.; Froelich, T.J.; Piper, R.K.; Schulze, S.A.

    1997-06-01

    Various Hanford Site radiation protection services provided by the Pacific Northwest National Laboratory for the US Department of Energy Richland Operations Office and Hanford contractors are described in this annual report for calendar year 1996. These activities include external dosimetry measurements and evaluations, internal dosimetry measurements and evaluations, in vivo measurements, radiological exposure record keeping, radiation source calibration, and instrument calibration and evaluation. For each of these activities, the routine program and any program changes or enhancements are described, as well as associated tasks, investigations, and studies. Program-related publications, presentations, and other staff professional activities are also described.

  10. Hanford Radiological Protection Support Services Annual Report for 1999

    International Nuclear Information System (INIS)

    TP Lynch; DE Bihl; ML Johnson; MA MacLellan; RK Piper

    2000-01-01

    During calendar year (CY) 1999, the Pacific Northwest National Laboratory (PNNL) performed its customary radiological protection support services in support of the U.S. Department of Energy (DOE) Richland Operations Office (RL) and the Hanford contractors. These services included: (1) external dosimetry, (2) internal dosimetry, (3) in vivo measurements, (4) radiological records, (5) instrument calibration and evaluation, and (6) calibration of radiation sources traceable to the National Institute of Standards and Technology (NIST). The services were provided under a number of programs as summarized here. Along with providing site-wide nuclear accident and environmental dosimetry capabilities, the Hanford External Dosimetry Program (HEDP) supports Hanford radiation protection programs by providing external radiation monitoring capabilities for all Hanford workers and visitors to help ensure their health and safety. Processing volumes decreased in CY 1999 relative to prior years for all types of dosimeters, with an overall decrease of 19%. During 1999, the HEDP passed the National Voluntary Laboratory Accreditation Program (NVLAP) performance testing criteria in 15 different categories. HEDP computers and processors were tested and upgraded to become Year 2000 (Y2K) compliant. Several changes and improvements were made to enhance the interpretation of dosimeter results. The Hanford Internal Dosimetry Program (HIDP) provides for the assessment and documentation of occupational dose from intakes of radionuclides at the Hanford Site. Performance problems carried over from CY 1998 continued to plague the in vitro bioassay contractor. A new contract was awarded for the in vitro bioassay program. A new computer system was put into routine operation by the in vivo bioassay program. Several changes to HIDP protocols were made that were related to bioassay grace periods, using field data to characterize the amount of alpha activity present and using a new default particle

  11. Hanford Radiological Protection Support Services Annual Report for 1999

    Energy Technology Data Exchange (ETDEWEB)

    TP Lynch; DE Bihl; ML Johnson; MA MacLellan; RK Piper

    2000-05-19

    During calendar year (CY) 1999, the Pacific Northwest National Laboratory (PNNL) performed its customary radiological protection support services in support of the U.S. Department of Energy (DOE) Richland Operations Office (RL) and the Hanford contractors. These services included: (1) external dosimetry, (2) internal dosimetry, (3) in vivo measurements, (4) radiological records, (5) instrument calibration and evaluation, and (6) calibration of radiation sources traceable to the National Institute of Standards and Technology (NIST). The services were provided under a number of programs as summarized here. Along with providing site-wide nuclear accident and environmental dosimetry capabilities, the Hanford External Dosimetry Program (HEDP) supports Hanford radiation protection programs by providing external radiation monitoring capabilities for all Hanford workers and visitors to help ensure their health and safety. Processing volumes decreased in CY 1999 relative to prior years for all types of dosimeters, with an overall decrease of 19%. During 1999, the HEDP passed the National Voluntary Laboratory Accreditation Program (NVLAP) performance testing criteria in 15 different categories. HEDP computers and processors were tested and upgraded to become Year 2000 (Y2K) compliant. Several changes and improvements were made to enhance the interpretation of dosimeter results. The Hanford Internal Dosimetry Program (HIDP) provides for the assessment and documentation of occupational dose from intakes of radionuclides at the Hanford Site. Performance problems carried over from CY 1998 continued to plague the in vitro bioassay contractor. A new contract was awarded for the in vitro bioassay program. A new computer system was put into routine operation by the in vivo bioassay program. Several changes to HIDP protocols were made that were related to bioassay grace periods, using field data to characterize the amount of alpha activity present and using a new default particle

  12. 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.

  13. Logistics analysis in support of DOE fee adequacy report

    International Nuclear Information System (INIS)

    McNair, G.W.; Shay, M.R.; Wood, T.W.; Cashwell, J.W.

    1985-02-01

    The Nuclear Waste Policy Act of 1982 (Public Law 97-485) established a Nuclear Waste Fund to pay for the management and permanent disposal of commercial spent nuclear fuel and high-level radioactive waste in geologic repositories. The revenues for this fund come from a fee on electricity generated by nuclear power plants. The Act also established the Office of Civilian Radioactive Waste Management (OCRWM) within the Department of Energy (DOE) to administer the program for the management of commercial spent fuel and high-level waste. In managing this program, the DOE is required by the Act to determine annually whether the fee generates sufficient revenue to cover all costs. To support this determination, a series of analyses were performed to detail the anticipated cost that will be incurred to provide adequate transportation services within the waste management system. The analyses estimate the cost for providing transportation services between individual reactor sites and a repository. The ''base case'' scenarios investigate a two repository waste management system that is described in the draft DOE mission plan. Various geologic media combinations are investigated to provide a range of transportation costs that may be incurred. The results of the analyses are given as total transport cost (capital, maintenance, and shipping), description of fleet requirements (number and types of casks required), total transportation mileages, and required number of shipments. In addition, information is provided on the amounts of storage that will be required at individual sites and characteristics of the spent fuel that will be received at the various facilities throughout the waste management system

  14. Computational support for ITS, ECTOR, PIXY, and PHERMEX. Annual report

    International Nuclear Information System (INIS)

    Hughes, T.P.; Welch, D.R.; Carlson, R.L.

    1993-04-01

    This report describes calculations carried out in the past year to assist in the design and understanding of experiments on the ITS, ECTOR, PIXY and PHERMEX machines at LANL. The main results are summarized as follows. ITS: Transport calculations were carried out for Milestone 4, modeling the beam all the way from the cathode surface to the target, and gave good agreement with measurements. The LAMDA transport code was upgraded to compute the focusing effect of the accelerating gaps more accurately, and to remove some approximations in the treatment of space-charge. The code is currently being used in the analysis of the Milestone 5 BBU experiments. ECTOR and PIXY: Beam focusing in the gas cell was studied in detail. The focal length was found to progressively shorten during the pulse. As a result, the minimum spot-size was significantly smaller than the time-averaged value. One may be able to exploit this using shaped converters. The beam distribution at the converter was used as input for the MCNP radiation transport code to obtain a radiographic spot-size. The result agrees reasonably well with experimental data from ECTOR. PHERMEX: The new diode using a flat cathode has almost triple the perveance (current/voltage 3/2 ) of the old Pierce diode. The current is somewhat lower than that originally predicted by simulation because the cathode has a small inset from the surrounding electrode. When this effect is included, the calculated current agrees quite well with the experiment

  15. 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)

  16. 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.

  17. Final report for the Light Water Breeder Reactor proof-of-breeding analytical support project

    Energy Technology Data Exchange (ETDEWEB)

    Graczyk, D.G.; Hoh, J.C.; Martino, F.J.; Nelson, R.E.; Osudar, J.; Levitz, N.M.

    1987-05-01

    The technology of breeding /sup 233/U from /sup 232/Th in a light water reactor is being developed and evaluated by the Westinghouse Bettis Atomic Power Laboratory (BAPL) through operation and examination of the Shippingport Light Water Breeder Reactor (LWBR). Bettis is determining the end-of-life (EOL) inventory of fissile uranium in the LWBR core by nondestructive assay of a statistical sample comprising approximately 500 EOL fuel rods. This determination is being made with an irradiated-fuel assay gauge based on neutron interrogation and detection of delayed neutrons from each rod. The EOL fissile inventory will be compared with the beginning-of-life fissile loading of the LWBR to determine the extent of breeding. In support of the BAPL proof-of-breeding (POB) effort, Argonne National Laboratory (ANL) carried out destructive physical, chemical, and radiometric analyses on 17 EOL LWBR fuel rods that were previously assayed with the nondestructive gauge. The ANL work included measurements on the intact rods; shearing of the rods into pre-designated contiguous segments; separate dissolution of each of the more than 150 segments; and analysis of the dissolver solutions to determine each segment's uranium content, uranium isotopic composition, and loading of selected fission products. This report describes the facilities in which this work was carried out, details operations involved in processing each rod, and presents a comprehensive discussion of uncertainties associated with each result of the ANL measurements. Most operations were carried out remotely in shielded cells. Automated equipment and procedures, controlled by a computer system, provided error-free data acquisition and processing, as well as full replication of operations with each rod. Despite difficulties that arose during processing of a few rod segments, the ANL destructive-assay results satisfied the demanding needs of the parent LWBR-POB program.

  18. Final report for the Light Water Breeder Reactor proof-of-breeding analytical support project

    International Nuclear Information System (INIS)

    Graczyk, D.G.; Hoh, J.C.; Martino, F.J.; Nelson, R.E.; Osudar, J.; Levitz, N.M.

    1987-05-01

    The technology of breeding 233 U from 232 Th in a light water reactor is being developed and evaluated by the Westinghouse Bettis Atomic Power Laboratory (BAPL) through operation and examination of the Shippingport Light Water Breeder Reactor (LWBR). Bettis is determining the end-of-life (EOL) inventory of fissile uranium in the LWBR core by nondestructive assay of a statistical sample comprising approximately 500 EOL fuel rods. This determination is being made with an irradiated-fuel assay gauge based on neutron interrogation and detection of delayed neutrons from each rod. The EOL fissile inventory will be compared with the beginning-of-life fissile loading of the LWBR to determine the extent of breeding. In support of the BAPL proof-of-breeding (POB) effort, Argonne National Laboratory (ANL) carried out destructive physical, chemical, and radiometric analyses on 17 EOL LWBR fuel rods that were previously assayed with the nondestructive gauge. The ANL work included measurements on the intact rods; shearing of the rods into pre-designated contiguous segments; separate dissolution of each of the more than 150 segments; and analysis of the dissolver solutions to determine each segment's uranium content, uranium isotopic composition, and loading of selected fission products. This report describes the facilities in which this work was carried out, details operations involved in processing each rod, and presents a comprehensive discussion of uncertainties associated with each result of the ANL measurements. Most operations were carried out remotely in shielded cells. Automated equipment and procedures, controlled by a computer system, provided error-free data acquisition and processing, as well as full replication of operations with each rod. Despite difficulties that arose during processing of a few rod segments, the ANL destructive-assay results satisfied the demanding needs of the parent LWBR-POB program

  19.  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

  20. 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.

  1. 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.

  2. 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.

  3. 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

  4. 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.

  5. Psychometrics of a Child Report Measure of Maternal Support following Disclosure of Sexual Abuse.

    Science.gov (United States)

    Smith, Daniel W; Sawyer, Genelle K; Heck, Nicholas C; Zajac, Kristyn; Solomon, David; Self-Brown, Shannon; Danielson, Carla K; Ralston, M Elizabeth

    2017-04-01

    The study examined a new child report measure of maternal support following child sexual abuse. One hundred and forty-six mother-child dyads presenting for a forensic evaluation completed assessments including standardized measures of adjustment. Child participants also responded to 32 items considered for inclusion in a new measure, the Maternal Support Questionnaire-Child Report (MSQ-CR). Exploratory factor analysis of the Maternal Support Questionnaire-Child Report resulted in a three factor, 20-item solution: Emotional Support (9 items), Skeptical Preoccupation (5 items), and Protection/Retaliation (6 items). Each factor demonstrated adequate internal consistency. Construct and concurrent validity of the new measure were supported in comparison to other trauma-specific measures. The Maternal Support Questionnaire-Child Report demonstrated sound psychometric properties. Future research is needed to determine whether the Maternal Support Questionnaire-Child Report provides a more sensitive approximation of maternal support following disclosure of sexual abuse, relative to measures of global parent-child relations and to contextualize discrepancies between mother and child ratings of maternal support.

  6. 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

  7. 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

  8. Errorful and errorless learning: The impact of cue-target constraint in learning from errors.

    Science.gov (United States)

    Bridger, Emma K; Mecklinger, Axel

    2014-08-01

    The benefits of testing on learning are well described, and attention has recently turned to what happens when errors are elicited during learning: Is testing nonetheless beneficial, or can errors hinder learning? Whilst recent findings have indicated that tests boost learning even if errors are made on every trial, other reports, emphasizing the benefits of errorless learning, have indicated that errors lead to poorer later memory performance. The possibility that this discrepancy is a function of the materials that must be learned-in particular, the relationship between the cues and targets-was addressed here. Cued recall after either a study-only errorless condition or an errorful learning condition was contrasted across cue-target associations, for which the extent to which the target was constrained by the cue was either high or low. Experiment 1 showed that whereas errorful learning led to greater recall for low-constraint stimuli, it led to a significant decrease in recall for high-constraint stimuli. This interaction is thought to reflect the extent to which retrieval is constrained by the cue-target association, as well as by the presence of preexisting semantic associations. The advantage of errorful retrieval for low-constraint stimuli was replicated in Experiment 2, and the interaction with stimulus type was replicated in Experiment 3, even when guesses were randomly designated as being either correct or incorrect. This pattern provides support for inferences derived from reports in which participants made errors on all learning trials, whilst highlighting the impact of material characteristics on the benefits and disadvantages that accrue from errorful learning in episodic memory.

  9. 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-.

  10. 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.

  11. Quantifying the Personal Creative Experience: Evaluation of Digital Creativity Support Tools Using Self-Report and Physiological Responses

    Science.gov (United States)

    Carroll, Erin Ashley

    2013-01-01

    Creativity is understood intuitively, but it is not easily defined and therefore difficult to measure. This makes it challenging to evaluate the ability of a digital tool to support the creative process. When evaluating creativity support tools (CSTs), it is critical to look beyond traditional time, error, and other productivity measurements that…

  12. 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

  13. Objective support for subjective reports of successful inner speech in two people with aphasia.

    Science.gov (United States)

    Hayward, William; Snider, Sarah F; Luta, George; Friedman, Rhonda B; Turkeltaub, Peter E

    2016-01-01

    People with aphasia frequently report being able to say a word correctly in their heads, even if they are unable to say that word aloud. It is difficult to know what is meant by these reports of "successful inner speech". We probe the experience of successful inner speech in two people with aphasia. We show that these reports are associated with correct overt speech and phonologically related nonword errors, that they relate to word characteristics associated with ease of lexical access but not ease of production, and that they predict whether or not individual words are relearned during anomia treatment. These findings suggest that reports of successful inner speech are meaningful and may be useful to study self-monitoring in aphasia, to better understand anomia, and to predict treatment outcomes. Ultimately, the study of inner speech in people with aphasia could provide critical insights that inform our understanding of normal language.

  14. Summary of the Supplemental Model Reports Supporting the Disposal Criticality Analysis Methodology Topical Report

    International Nuclear Information System (INIS)

    Brownson, D. A.

    2002-01-01

    The Department of Energy (DOE) Office of Civilian Radioactive Waste Management (OCRWM) has committed to a series of model reports documenting the methodology to be utilized in the Disposal Criticality Analysis Methodology Topical Report (YMP 2000). These model reports detail and provide validation of the methodology to be utilized for criticality analyses related to: (1) Waste form/waste package degradation; (2) Waste package isotopic inventory; (3) Criticality potential of degraded waste form/waste package configurations (effective neutron multiplication factor); (4) Probability of criticality (for each potential critical configuration as well as total event); and (5) Criticality consequences. This purpose of this summary report is to provide a status of the model reports and a schedule for their completion. This report also provides information relative to the model report content and validation. The model reports and their revisions are being generated as a result of: (1) Commitments made in the Disposal Criticality Analysis Methodology Topical Report (YMP 2000); (2) Open Items from the Safety Evaluation Report (Reamer 2000); (3) Key Technical Issue agreements made during DOE/U.S. Nuclear Regulatory Commission (NRC) Technical Exchange Meeting (Reamer and Williams 2000); and (4) NRC requests for additional information (Schlueter 2002)

  15. Sensing technology for damage assessment of sign supports and cantilever poles : final report, August 31, 2010.

    Science.gov (United States)

    2010-08-31

    This report presents the results of research activities conducted under Contract No. 519691-PIT 008 on Sensing Technology for : Damage Assessment of Sign Supports and Cantilever Poles between the University of Pittsburgh and the Pennsylvania De...

  16. Brief Report: An Online Support Intervention--Perceptions of Adolescents with Physical Disabilities

    Science.gov (United States)

    Stewart, Miriam; Barnfather, Alison; Magill-Evans, Joyce; Ray, Lynne; Letourneau, Nicole

    2011-01-01

    Adolescents with cerebral palsy and spina bifida report restricted interactions with peers and gaps in social support. A pilot online support intervention offered interactions with peers. Five mentors with cerebral palsy or spina bifida and 22 adolescents with the same disabilities met weekly online for 25 group sessions over six months.…

  17. Employer-Supported Training in Australia: Participation, Demand and Supply. NCVER Technical Report

    Science.gov (United States)

    Shah, Chandra

    2017-01-01

    This report provides an analysis of employer-supported training in Australia. Employer-supported training is the largest share of adult education and training in all Organisation for Economic Co-operation and Development (OECD) countries. It has benefits for individuals, firms, and society. Cross-country studies have shown a positive association…

  18. Physician assistants and the disclosure of medical error.

    Science.gov (United States)

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

    2014-06-01

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

  19. The ethics and practical importance of defining, distinguishing and disclosing nursing errors: a discussion paper.

    Science.gov (United States)

    Johnstone, Megan-Jane; Kanitsaki, Olga

    2006-03-01

    Nurses globally are required and expected to report nursing errors. As is clearly demonstrated in the international literature, fulfilling this requirement is not, however, without risks. In this discussion paper, the notion of 'nursing error', the practical and moral importance of defining, distinguishing and disclosing nursing errors and how a distinct definition of 'nursing error' fits with the new 'system approach' to human-error management in health care are critiqued. Drawing on international literature and two key case exemplars from the USA and Australia, arguments are advanced to support the view that although it is 'right' for nurses to report nursing errors, it will be very difficult for them to do so unless a non-punitive approach to nursing-error management is adopted.

  20. Controlling and Autonomy-Supportive Parenting in the United States and China: Beyond Children's Reports

    Science.gov (United States)

    Cheung, Cecilia S.; Pomerantz, Eva M.; Wang, Meifang; Qu, Yang

    2016-01-01

    Research comparing the predictive power of parents' control and autonomy support in the United States and China has relied almost exclusively on children's reports. Such reports may lead to inaccurate conclusions if they do not reflect parents' practices to the same extent in the two countries. A total of 394 American and Chinese children…

  1. Biomass Support for the China Renewable Energy Law: Final Report, December 2005

    Energy Technology Data Exchange (ETDEWEB)

    2006-10-01

    Final subcontractor report giving an overview of the biomass power generation technologies used in China. Report covers resources, technologies, foreign technologies and resources for comparison purposes, biomass potential in China, and finally government policies in China that support/hinder development of the using biomass in China for power generation.

  2. BASINs 4.0 Climate Assessment Tool (CAT): Supporting Documentation and User's Manual (Final Report)

    Science.gov (United States)

    EPA announced the availability of the report, BASINS 4.0 Climate Assessment Tool (CAT): Supporting Documentation and User's Manual. This report was prepared by the EPA's Global Change Research Program (GCRP), an assessment-oriented program, that sits within the Office of R...

  3. 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

  4. 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.

  5. Geopressure industrial forums, newsletter and lease support. Final report, April 7, 1981-December 31, 1983

    Energy Technology Data Exchange (ETDEWEB)

    Knutson, C.F.

    1983-12-01

    In the course of this contract C. K. GeoEnergy: (1) planned, organized, conducted, and reported on six DOE/Industry Forum meetings where the progress of DOE's resource development program was outlined and discussed (these six forum meetings included three meetings of the Drilling and Testing Subgroup and three meetings of the Overview Group), (2) prepared and distributed 15 newsletters, and (3) prepared three reports for DOE lease support. This final report includes summaries of each of the forum meetings as well as the three lease support meetings and the newsletter program.

  6. M3MS-16OR0401086 – Report on NEAMS Workbench Support for MOOSE Applications

    Energy Technology Data Exchange (ETDEWEB)

    Lefebvre, Robert A. [Oak Ridge National Lab. (ORNL), Oak Ridge, TN (United States). Reactor and Nuclear Systems Division; Langley, Brandon R. [Oak Ridge National Lab. (ORNL), Oak Ridge, TN (United States). Reactor and Nuclear Systems Division; Thompson, Adam B. [Oak Ridge National Lab. (ORNL), Oak Ridge, TN (United States). Reactor and Nuclear Systems Division

    2016-09-23

    This report summarizes the status of the Nuclear Energy Advanced Modeling and Simulation (NEAMS) Workbench from Oak Ridge National Laboratory (ORNL) and the integration of the MOOSE framework. This report marks the completion of NEAMS milestone M3MS-16OR0401086. This report documents the developed infrastructure to support the MOOSE framework applications, the applications’ results, visualization status, the collaboration that facilitated this progress, and future considerations.

  7. Material Not Categorized As Waste (MNCAW) data report. Radioactive Waste Technical Support Program

    Energy Technology Data Exchange (ETDEWEB)

    Casey, C.; Heath, B.A.

    1992-11-01

    The Department of Energy (DOE), Headquarters, requested all DOE sites storing valuable materials to complete a questionnaire about each material that, if discarded, could be liable to regulation. The Radioactive Waste Technical Support Program entered completed questionnaires into a database and analyzed them for quantities and type of materials stored. This report discusses the data that TSP gathered. The report also discusses problems revealed by the questionnaires and future uses of the data. Appendices contain selected data about material reported.

  8. 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.

  9. 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.

  10. Error-Free Software

    Science.gov (United States)

    1989-01-01

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

  11. Savannah River Site human error data base development for nonreactor nuclear facilities

    International Nuclear Information System (INIS)

    Benhardt, H.C.; Held, J.E.; Olsen, L.M.; Vail, R.E.; Eide, S.A.

    1994-01-01

    As part of an overall effort to upgrade and streamline methodologies for safety analyses of nonreactor nuclear facilities at the Savannah River Site (SRS), a human error data base has been developed and is presented in this report. The data base fulfills several needs of risk analysts supporting safety analysis report (SAR) development. First, it provides a single source for probabilities or rates for a wide variety of human errors associated with the SRS nonreactor nuclear facilities. Second, it provides a documented basis for human error probabilities or rates. And finally, it provides actual SRS-specific human error data to support many of the error probabilities or rates. Use of a single, documented reference source for human errors, supported by SRS-specific human error data, will improve the consistency and accuracy of human error modeling by SRS risk analysts. It is envisioned that SRS risk analysts will use this report as both a guide to identifying the types of human errors that may need to be included in risk models such as fault and event trees, and as a source for human error probabilities or rates. For each human error in this report, ffime different mean probabilities or rates are presented to cover a wide range of conditions and influencing factors. The ask analysts must decide which mean value is most appropriate for each particular application. If other types of human errors are needed for the risk models, the analyst must use other sources. Finally, if human enors are dominant in the quantified risk models (based on the values obtained fmm this report), then it may be appropriate to perform detailed human reliability analyses (HRAS) for the dominant events. This document does not provide guidance for such refined HRAS; in such cases experienced human reliability analysts should be involved

  12. 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

  13. 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.

  14. 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.

  15. Waste Treatment Plant Support Program: Summaries of Reports Produced During Fiscal Years 1999-2010

    International Nuclear Information System (INIS)

    Beeman, Gordon H.

    2010-01-01

    The Waste Treatment Plant (WTP) being built on the U.S. Department of Energy (DOE) Hanford Site will be the largest chemical processing plant in the United States. Bechtel National Inc. (BNI) is the designer and constructor for the WTP. The Pacific Northwest National Laboratory (PNNL) has provided significant research and testing support to the WTP. This report provides a summary of reports developed initially under PNNL's '1831' use agreement and later PNNL's '1830' prime contract with DOE in support of the WTP. In March 2001, PNNL under its '1831' use agreement entered into a contract with BNI to support their research and testing activities. However, PNNL support to the WTP predates BNI involvement. Prior to March 2001, PNNL supported British Nuclear Fuels Ltd. in its role as overall designer and constructor. In February 2007, execution of PNNL's support to the WTP was moved under its '1830' prime contract with DOE. Documents numbered 'PNWD-XXXX' were issued under PNNL's '1831' use agreement. Documents numbered 'PNNL-XXXX' were issued under PNNL's '1830' prime contract with DOE. The documents are sorted by fiscal year and categorized as follows: (1) Characterization; (2) HLW (High Level Waste); (3) Material Characterization; (4) Pretreatment; (5) Simulant Development; (6) Vitrification; and (7) Waste Form Qualification. This report is intended to provide a compendium of reports issued by PNWD/PNNL in support of the Waste Treatment Plant. Copies of all reports can be obtained by clicking on http://www.pnl.gov/rpp-wtp/ and downloading the .pdf file(s) to your computer.

  16. 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

  17. 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

  18. Going Beyond the Conventional Approach - Liquid Supported Denture: A Case Report

    Directory of Open Access Journals (Sweden)

    Dipti S Shah

    2013-01-01

    Full Text Available Background: The concept of conditioning oral mucosa has gained momentum over the last few years. Different tissue conditioning materials and soft liners have been used for this purpose. But the limitations of these materials has led to the introduction of liquid-supported dentures, which is a newer alternative to conventional complete denture prosthesis in cases with inflamed tissues, atrophic and severely resorbed edentulous ridges. Liquid supported Denture consists of a base which is covered with a preshaped close fitting flexible foil containing a thin film of high viscosity liquid which cushions the underlying tissues. This case report describes fabrication of liquid-supported dentures for patients with compromised tissues.

  19. Reporting of funding sources and conflict of interest in the supportive and palliative oncology literature.

    Science.gov (United States)

    Hui, David; Reddy, Akhila; Parsons, Henrique A; Bruera, Eduardo

    2012-09-01

    The reporting of funding support and conflict of interest has not been examined in the supportive/palliative oncology literature. We examined the frequency of funding and conflict of interest reporting and various study characteristics associated with such reporting. We systematically searched MEDLINE PubMed, PsycInfo, EMBASE, ISI Web of Science, and CINAHL for original studies related to palliative care and cancer in the first six months of 2004 and 2009. For each article, we reviewed the study design, research topic, journal type, and reporting of funding and conflict of interest. Three hundred forty-four (41%) and 504 (59%) of 848 articles were from 2004 and 2009, respectively. Five hundred two of 848 (59%) studies reported no funding sources, whereas 216 (26%), 70 (8%), 34 (4%), and 26 (3%) reported one, two, three, and four or more sources, respectively. Key funding sources included governmental agencies (n=182/848, 21%), philanthropic foundations (n=163/848, 19%), university departments (n=76/848, 9%), and industry (n=27/848, 3%). Conflict of interest was not reported in 436 of 848 (51%) studies, and only 94 of 848 (11%) explicitly stated no conflict of interest. Other than extramural funding, conflict of interest reporting of any kind was extremely rare (mostly less than 1%). Conflict of interest reporting increased between 2004 and 2009 (39% vs. 55%, Pfunding and conflict of interest reporting were associated with prospective studies, larger sample sizes, nontherapeutic studies, North American authors, and publication in palliative care/oncology journals (P≤0.008 for all comparisons). A majority of supportive/palliative oncology studies did not report funding sources and conflict of interest, raising the need for standardization. Copyright © 2012 U.S. Cancer Pain Relief Committee. Published by Elsevier Inc. All rights reserved.

  20. 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

  1. Valuing Errors for Learning: Espouse or Enact?

    Science.gov (United States)

    Grohnert, Therese; Meuwissen, Roger H. G.; Gijselaers, Wim H.

    2017-01-01

    Purpose: This study aims to investigate how organisations can discourage covering up and instead encourage learning from errors through a supportive learning from error climate. In explaining professionals' learning from error behaviour, this study distinguishes between espoused (verbally expressed) and enacted (behaviourally expressed) values…

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

    Science.gov (United States)

    Taifoori, Ladan; Valiee, Sina

    2015-09-01

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

  3. 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.)...

  4. Understanding human management of automation errors

    Science.gov (United States)

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

    2013-01-01

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

  5. Actionable findings and the role of IT support: report of the ACR Actionable Reporting Work Group.

    Science.gov (United States)

    Larson, Paul A; Berland, Lincoln L; Griffith, Brent; Kahn, Charles E; Liebscher, Lawrence A

    2014-06-01

    The ACR formed the Actionable Reporting Work Group to address the potential role of IT in the communication of imaging findings, especially in cases that require nonroutine communication because of the urgency of the findings or their unexpected nature. These findings that require special communication with referring clinicians are classified as "actionable findings." The work group defines 3 categories of actionable findings that require, respectively, communication and clinical decision within minutes (category 1), hours (category 2), or days (category 3). Although the work group does not believe that there can be definitive lists of such findings, it developed lists in each category that would apply in most general hospital settings. For each category, the work group discusses ways in which IT can assist interpreting radiologists in successfully communicating to the relevant clinicians to ensure optimal patient care. IT systems can also help document the communication and facilitate auditing of the documentation. The work group recommends that vendors develop platforms that can be customized on the basis of local preferences and needs. Whatever system is used, it should be highly reliable and fit seamlessly into radiologists' workflow. Copyright © 2014 American College of Radiology. Published by Elsevier Inc. All rights reserved.

  6. 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.

  7. 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.

  8. Reporting Data with "Over-the-Counter" Data Analysis Supports Improves Educators' Data Analyses

    Science.gov (United States)

    Rankin, Jenny Grant

    2014-01-01

    The benefits of making data-informed decisions to improve learning rely on educators correctly interpreting given data. Many educators routinely misinterpret data, even at districts with proactive support for data use. The tool most educators use for data analyses, which is an information technology data system or its reports, typically reports…

  9. Youth report of healthcare transition counseling and autonomy support from their rheumatologist

    Directory of Open Access Journals (Sweden)

    Wells Courtney Kellerman

    2012-11-01

    Full Text Available Abstract Background To increase understanding of the healthcare transition (HCT process for young people living with Juvenile Idopathic Arthritis (JIA by examining: 1 the extent to which youth report discussing HCT topics with their rheumatologist and 2 the association between youth perceptions of autonomy support from their rheumatologist and HCT discussions. Methods Data are from an online survey of youth in the United States with rheumatologic conditions (n= 134. HCT discussion was measured by 4 questions from the National Survey of Children with Special Health Care Needs. Youth perception of autonomy support was measured using a validated 6-item scale. Results One third of the youth (33.7% reported talking to their rheumatologist about transferring to adult medicine. Less than half (40.8% of respondents talked with their rheumatologist about adult healthcare needs, and less than a quarter (22.0% discussed acquiring health insurance as an adult. Nearly two-thirds of respondents (62.7% reported that their rheumatologist usually/always encourages self-care responsibility. Multivariate analyses revealed significant associations between rheumatologist support for youth autonomy and HCT counseling. Conclusion The low frequency of HCT counseling reported indicates a continuing need to increase awareness among rheumatologist in the USA. The strong associations between rheumatologist’s support for youth autonomy and HCT counseling suggest that developmentally “in-tune” providers may deliver the best guidance about transition planning for youth living with arthritis.

  10. 32 CFR 555.9 - Reporting requirements for work in support of DOE.

    Science.gov (United States)

    2010-07-01

    ... 32 National Defense 3 2010-07-01 2010-07-01 true Reporting requirements for work in support of DOE. 555.9 Section 555.9 National Defense Department of Defense (Continued) DEPARTMENT OF THE ARMY MILITARY.... This notification shall include: (1) A brief statement of the problem. (2) Nature of corrective action...

  11. 78 FR 45071 - Annual Report for Mobility Fund Phase I Support and Record Retention

    Science.gov (United States)

    2013-07-26

    ... Record Retention, adopted as part of the Connect America Fund & Intercarrier Compensation Reform Order... Communications Commission released a Report and Order in the Universal Service Fund & Intercarrier Compensation... for Mobility Fund Phase I Support and Record Retention AGENCY: Federal Communications Commission...

  12. Waste Treatment Plant Support Program: Summaries of Reports Produced During Fiscal Years 1999-2010

    Energy Technology Data Exchange (ETDEWEB)

    Beeman, Gordon H. [Pacific Northwest National Lab. (PNNL), Richland, WA (United States)

    2010-08-01

    The Waste Treatment Plant (WTP) being built on the U.S. Department of Energy (DOE) Hanford Site will be the largest chemical processing plant in the United States. Bechtel National Inc. (BNI) is the designer and constructor for the WTP. The Pacific Northwest National Laboratory (PNNL) has provided significant research and testing support to the WTP. This report provides a summary of reports developed initially under PNNL’s “1831” use agreement and later PNNL’s “1830” prime contract with DOE in support of the WTP. In March 2001, PNNL under its “1831” use agreement entered into a contract with BNI to support their research and testing activities. However, PNNL support to the WTP predates BNI involvement. Prior to March 2001, PNNL supported British Nuclear Fuels Ltd. in its role as overall designer and constructor. In February 2007, execution of PNNL’s support to the WTP was moved under its “1830” prime contract with DOE.

  13. STARS - Supportability Trend Analysis and Reporting System for the National Space Transportation System

    Science.gov (United States)

    Graham, Leroy J.; Doempke, Gerald T.

    1990-01-01

    The concept, implementation, and long-range goals of a Supportability Trend Analysis and Reporting System (STARS) for the National Space Transportation System (NSTS) are discussed. The requirement was established as a direct result of the recommendations of the Rogers Commission investigation of the circumstances of the Space Shuttle Challenger accident. STARS outlines the requirements for the supportability-trend data collection, analysis, and reporting requirements that each of the project offices supporting the Space Shuttle are required to provide to the NSTS program office. STARS data give the historic and predictive logistics information necessary for all levels of NSTS management to make safe and cost-effective decisions concerning the smooth flow of Space Shuttle turnaround.

  14. 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...

  15. Quantitative Analysis of Uncertainty in Medical Reporting: Part 3: Customizable Education, Decision Support, and Automated Alerts.

    Science.gov (United States)

    Reiner, Bruce I

    2017-12-18

    In order to better elucidate and understand the causative factors and clinical implications of uncertainty in medical reporting, one must first create a referenceable database which records a number of standardized metrics related to uncertainty language, clinical context, technology, and provider and patient data. The resulting analytics can in turn be used to create context and user-specific reporting guidelines, real-time decision support, educational resources, and quality assurance measures. If this technology can be directly integrated into reporting technology and workflow, the goal is to proactively improve clinical outcomes at the point of care.

  16. Safety research needs for Russian-designed reactors / report by an OECD Support Group

    International Nuclear Information System (INIS)

    1996-01-01

    Seven Task Teams were formed within the OECD Support Group, addressing the following topics: Thermal-Hydraulics/Plant Transients for VVERs, Integrity of Equipment and Structures for VVERs, Severe Accidents for VVERs, Operational Safety Issues, Thermal-Hydraulics/Plant Transients for RBMKs, Integrity of Equipment and Structures for RBMKs, Severe Accidents for RBMKs. Each Task Team prepared and presented its report to the Support Group as a whole for review and approval. Consequently, the report represents a consensus of the Support Group that outlines the arguments for the safely research needs with the focus on the main technical issues that justify the need and urgency. The written text addresses three basic questions: What is the safety concern? What are the open issues? What are the safety research needs? The safety research needs as identified by the seven Task Teams, and approved by the Support Group, are reflected in the structure of the report. The chapter on the Uses of Safety Research provides examples on how Western research has been applied to improve the safety of nuclear power plants. In addition, the chapter emphasises the need for a national safety research policy

  17. 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.

  18. Parenting and Family Support for Families 'at risk' - Implications from Child Abuse Reports

    Directory of Open Access Journals (Sweden)

    Ann Marie Halpenny

    2012-01-01

    Full Text Available The importance of family experiences on children’s development and wellbeing has been widely documented. Yet, recent reports generated by inquiries into child abuse and neglect in the Irish context raise disturbing questions with regard to how the severe maltreatment of children can occur within the family context. It is imperative that the messages generated from these inquiries can effectively inform policy and practice in terms of protecting children from harm and providing support to families at-risk. The present paper draws together key issues for parenting and family support for families ‘at risk’ based on the Roscommon and Monageer inquiries with a view to gaining insight into key issues which need to be addressed in terms of protecting children from harm and providing support for parents experiencing adversity. A number of implications arising from these reports are outlined and discussed. Specifically, the need to amplify the focus on support for parenting in the context of poverty and substance abuse is highlighted with a particular emphasis on developing sensitive screening and assessment for parents who may be difficult to engage with due to chronic mental health issues. The importance of accessing the voice of children within the provision of family support is also underlined in these findings. A key recommendation from these reports is that the needs, wishes and feelings of each child must be considered as well as the totality of the family situation. Moreover, the need for staff in child welfare and protection services to have access to ongoing training and professional development to meet the complex and changing needs of the children and families they are working with is also highlighted. Specifically, ongoing training for frontline staff in understanding the effects of drug and alcohol dependency, and, in particular, the effects on parenting and parent-child relationships is underscored in findings from these reports.

  19. 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.

  20. Operator support systems in nuclear power plants national report from Romania

    International Nuclear Information System (INIS)

    Bengulescu, D.; Jianu, A.

    1996-01-01

    The report gives a short overview of the status of the activities in Romania relevant for the present Co-ordination Research Programme: the development of small size simulators and computerised support systems for the CANDU systems; the development of an expert system for risk monitoring, as a component of the Cernavoda PSA activities for PSA team training and design changes evaluation; the implementation in Romania of a segment of an integrated and comprehensive real-time on-line decision support system for nuclear emergency in Europe. 11 refs

  1. 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

  2. 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

  3. 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.

  4. 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...

  5. Dissociating response conflict and error likelihood in anterior cingulate cortex.

    Science.gov (United States)

    Yeung, Nick; Nieuwenhuis, Sander

    2009-11-18

    Neuroimaging studies consistently report activity in anterior cingulate cortex (ACC) in conditions of high cognitive demand, leading to the view that ACC plays a crucial role in the control of cognitive processes. According to one prominent theory, the sensitivity of ACC to task difficulty reflects its role in monitoring for the occurrence of competition, or "conflict," between responses to signal the need for increased cognitive control. However, a contrasting theory proposes that ACC is the recipient rather than source of monitoring signals, and that ACC activity observed in relation to task demand reflects the role of this region in learning about the likelihood of errors. Response conflict and error likelihood are typically confounded, making the theories difficult to distinguish empirically. The present research therefore used detailed computational simulations to derive contrasting predictions regarding ACC activity and error rate as a function of response speed. The simulations demonstrated a clear dissociation between conflict and error likelihood: fast response trials are associated with low conflict but high error likelihood, whereas slow response trials show the opposite pattern. Using the N2 component as an index of ACC activity, an EEG study demonstrated that when conflict and error likelihood are dissociated in this way, ACC activity tracks conflict and is negatively correlated with error likelihood. These findings support the conflict-monitoring theory and suggest that, in speeded decision tasks, ACC activity reflects current task demands rather than the retrospective coding of past performance.

  6. Report on task 4.1.3. - Survey of anticipated functional requirement for operator support systems

    International Nuclear Information System (INIS)

    Silvani, V.

    1993-01-01

    This is a preliminary report summarizing some topics related to the surveillance activity on anticipated functional requirements of the Operator Support Systems (OSS's) in NPP's. Additional information are expected will be available by analyzing the questionnaire. Functionalities examined are those referring to system functions, user's needs, technology trend, standard status. For practical purposes this document is divided in two main sections: the first section presents a summary of major OSS requirements and related problems as derived from the existing literature; the second section presents a study of OSS to be used to support the operator training presently under development in ENEA. Finally, appendix 2 reports a summary of major functions performed by the OSS's presently in operation or under development in laboratories. Refs, 1 tab

  7. Hungarian national report on activities related to operator support systems for nuclear power plants

    International Nuclear Information System (INIS)

    Adorjan, F.; Lux, I.; Vegh, J.; Vegh, E.

    1993-01-01

    According to the summary report of the Co-ordinated Research Meeting on ''Operator Support Systems in Nuclear Power Plants'', 13-16 October 1992, the national reports shall cover the following topics: General summary of the national activity; description of the results in the framework of the CRP; overview of the OSS related recent national activity. Accordingly, in the first section we give an overview of the operator support systems developed in Hungary. The second section summarizes the data collected in order to comply with the Tasks 4.1.1 and 4.1.2 of the CRP. In the third section we summarize the most recent works pertaining to the development and application of OSS at nuclear power plants

  8. 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.

  9. Invited review: Experimental design, data reporting, and sharing in support of animal systems modeling research.

    Science.gov (United States)

    McNamara, J P; Hanigan, M D; White, R R

    2016-12-01

    The National Animal Nutrition Program "National Research Support Project 9" supports efforts in livestock nutrition, including the National Research Council's committees on the nutrient requirements of animals. Our objective was to review the status of experimentation and data reporting in animal nutrition literature and to provide suggestions for the advancement of animal nutrition research and the ongoing improvement of field-applied nutrient requirement models. Improved data reporting consistency and completeness represent a substantial opportunity to improve nutrition-related mathematical models. We reviewed a body of nutrition research; recorded common phrases used to describe diets, animals, housing, and environmental conditions; and proposed equivalent numerical data that could be reported. With the increasing availability of online supplementary material sections in journals, we developed a comprehensive checklist of data that should be included in publications. To continue to improve our research effectiveness, studies utilizing multiple research methodologies to address complex systems and measure multiple variables will be necessary. From the current body of animal nutrition literature, we identified a series of opportunities to integrate research focuses (nutrition, reproduction and genetics) to advance the development of nutrient requirement models. From our survey of current experimentation and data reporting in animal nutrition, we identified 4 key opportunities to advance animal nutrition knowledge: (1) coordinated experiments should be designed to employ multiple research methodologies; (2) systems-oriented research approaches should be encouraged and supported; (3) publication guidelines should be updated to encourage and support sharing of more complete data sets; and (4) new experiments should be more rapidly integrated into our knowledge bases, research programs and practical applications. Copyright © 2016 American Dairy Science Association

  10. WIPP supplementary roof support system Room 1, Panel 1: Geotechnical field data analysis report

    International Nuclear Information System (INIS)

    1993-03-01

    The design of the Room 1, Panel 1, supplementary roof support system was finalized in September 1991, and the system successfully installed in the test bin area between the bulkheads by December 1991. Simultaneously with the support system installation, existing monitoring system was upgraded to meet the needs of the installed roof support. This included extensometers, closure stations, rockbolt load cells as well as survey measurements of roof sag and floor lift. A Project Control Group (PCG) was established in order to monitor room and support system performance. Weekly meetings of the PCG were held to review all monitored data against criteria set in the initial design, and to modify these where necessary. Records of these meetings have been kept, with copies of all data summaries and action notes. These data records are maintained in the Engineering data files. After more than ten months of monitoring and reviewing experience, several modifications have been made both to the way data has been reported as well as to the load adjustment criteria. The support system has performed as expected in the design, with no signs of instability developing considering the rates of roof deformation, the rock bolt loads and the observed fracture behavior in the roof. This is particularly true of the horizon in which the rockbolt anchors are located, the most critical part of the design. The distribution of load build-up, throughout the 286 rockbolt load cells installed, in the Room 1 has been found satisfactory, and the load increases as evaluated by the PCG on a weekly basis have been within the acceptable range. The minimum life of the installed support system is estimated at 15 years based on the highest roof expansion rate experienced to date. This report provides analysis of geotechnical field data collected up to December 1992

  11. Final report on the evolution of supporting conditions for the feeders of 500 MWe PHWR

    International Nuclear Information System (INIS)

    Mishra, Rajesh; Soni, R.S.; Kushawaha, H.S.; Mahajan, S.C.; Kakodkar, A.; Hariprasad, K.

    1994-01-01

    This report deals with the evolution of generic supporting conditions for the feeders of 500 MWe PHWR based on the analysis and qualification of a few representative feeders. There are 196 different feeder pipe configurations for a total of 748 feeders. The present analysis was aimed at evolving a generalised supporting criteria based on the analysis of some representative feeders. The analysis was carried out for various loadings viz. pressure, temperature, dead weight, operating basis earthquake (OBE), safe shutdown earthquake (SSE) and creep loadings. The analysis for OBE and SSE loadings were carried out using response spectrum method. The effect of spacers between various feeders was modelled using higher damping values than those prescribed in ASME code. Based on the above analyses, generic supporting arrangements for the feeders of various groups have been finalized. This report gives details about the mathematical modelling, the analysis approach, the optimised supporting criteria, finalization of grouping and fixing of boundaries between various groups of feeders. (author). 34 refs., 51 figs., 69 tabs

  12. 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...

  13. Removable Partial Denture Supported by Implants with Prefabricated Telescopic Abutments - A Case Report

    Science.gov (United States)

    Sehgal, Komal

    2014-01-01

    Implants have been designed to rehabilitate edentulous patients with fixed prosthesis or implant supported overdentures. Implant-supported single crowns and fixed partial dentures have become successful treatment alternatives to removable and fixed partial dentures. However, it is common to have clinical situations which make it impossible to use conventional as well as implant supported fixed partial dentures. The implant supported removable partial dentures can be a treatment modality that offers the multitude of benefits of implant-based therapy—biologic, biomechanical, social, and psychological to such patients. The aim of this article is to present a case report describing the fabrication and advantages of removable partial denture supported by teeth and implants for a patient with long edentulous span. The patient was satisfied with his dentures in terms of function and aesthetics. Regular follow-up visits over a period of three years revealed that the periodontal condition of remaining natural dentition and peri-implant conditions were stable. There was no evidence of excessive residual ridge resorption or mobility of the teeth, nor were any visible changes in the bone levels of the natural teeth or implants noted on radiographs. PMID:25121066

  14. Removable partial denture supported by implants with prefabricated telescopic abutments - a case report.

    Science.gov (United States)

    Kumar, Lalit; Sehgal, Komal

    2014-06-01

    Implants have been designed to rehabilitate edentulous patients with fixed prosthesis or implant supported overdentures. Implant-supported single crowns and fixed partial dentures have become successful treatment alternatives to removable and fixed partial dentures. However, it is common to have clinical situations which make it impossible to use conventional as well as implant supported fixed partial dentures. The implant supported removable partial dentures can be a treatment modality that offers the multitude of benefits of implant-based therapy-biologic, biomechanical, social, and psychological to such patients. The aim of this article is to present a case report describing the fabrication and advantages of removable partial denture supported by teeth and implants for a patient with long edentulous span. The patient was satisfied with his dentures in terms of function and aesthetics. Regular follow-up visits over a period of three years revealed that the periodontal condition of remaining natural dentition and peri-implant conditions were stable. There was no evidence of excessive residual ridge resorption or mobility of the teeth, nor were any visible changes in the bone levels of the natural teeth or implants noted on radiographs.

  15. Errors and conflict at the task level and the response level.

    Science.gov (United States)

    Desmet, Charlotte; Fias, Wim; Hartstra, Egbert; Brass, Marcel

    2011-01-26

    In the last decade, research on error and conflict processing has become one of the most influential research areas in the domain of cognitive control. There is now converging evidence that a specific part of the posterior frontomedian cortex (pFMC), the rostral cingulate zone (RCZ), is crucially involved in the processing of errors and conflict. However, error-related research has focused primarily on a specific error type, namely, response errors. The aim of the present study was to investigate whether errors on the task level rely on the same neural and functional mechanisms. Here we report a dissociation of both error types in the pFMC: whereas response errors activate the RCZ, task errors activate the dorsal frontomedian cortex. Although this last region shows an overlap in activation for task and response errors on the group level, a closer inspection of the single-subject data is more in accordance with a functional anatomical dissociation. When investigating brain areas related to conflict on the task and response levels, a clear dissociation was perceived between areas associated with response conflict and with task conflict. Overall, our data support a dissociation between response and task levels of processing in the pFMC. In addition, we provide additional evidence for a dissociation between conflict and errors both at the response level and at the task level.

  16. Self-reported differences in empowerment between lurkers and posters in online patient support groups.

    Science.gov (United States)

    van Uden-Kraan, Cornelia F; Drossaert, Constance H C; Taal, Erik; Seydel, Erwin R; van de Laar, Mart A F J

    2008-06-30

    Patients who visit online support groups benefit in various ways. Results of our earlier study indicated that participation in online support groups had a profound effect on the participants' feelings of "being empowered." However, most studies of online patient support groups have focused on the members of these groups who actively contribute by sending postings (posters). Thus far, little is known about the impact for "lurkers" (ie, those who do not actively participate by sending postings). In the present study, we explored if lurkers in online patient support groups profit to the same extent as posters do. We searched the Internet with the search engine Google to identify all Dutch online support groups for patients with breast cancer, fibromyalgia, and arthritis. Invitations to complete an online survey were sent out by the owners of 19 groups. In the online questionnaire, we asked questions about demographic and health characteristics, use of and satisfaction with the online support group, empowering processes, and empowering outcomes. The online questionnaire was completed by 528 individuals, of which 109 (21%) identified themselves as lurkers. Lurkers (mean age 47 years) were slightly older than active participants (mean age 43 years, P = .002), had a shorter disease history (time since diagnosis 3.7 years vs 5.4 years, P = .001), and reported lower mental well-being (SF 12 subscore 37.7 vs 40.5, P = .004). No significant differences were found in other demographic variables. Posters indicated visiting the online support groups significantly more often for social reasons, such as curiosity about how other members were doing, to enjoy themselves, as a part of their daily routine (all P posters did not differ in their information-related reasons for visiting the online support group. Lurkers were significantly less satisfied with the online support group compared to posters (P posters. However, lurkers did not differ significantly from posters with regard to

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

    Science.gov (United States)

    Kim, Myoung Soo

    2012-08-01

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

  18. [Electronic and structural properties of individual nanometer-size supported metallic clusters]. Final performance report

    Energy Technology Data Exchange (ETDEWEB)

    Reifenberger, R.

    1993-09-01

    This report summarizes the work performed under contract DOE-FCO2-84ER45162. During the past ten years, our study of electron emission from laser-illuminated field emission tips has taken on a broader scope by addressing problems of direct interest to those concerned with the unique physical and chemical properties of nanometer-size clusters. The work performed has demonstrated that much needed data can be obtained on individual nanometer-size clusters supported on a wide-variety of different substrates. The work was performed in collaboration with R.P. Andres in the School of Chemical Engineering at Purdue University. The Multiple Expansion Cluster Source developed by Andres and his students was essential for producing the nanometer-size clusters studied. The following report features a discussion of these results. This report provides a motivation for studying the properties of nanometer-size clusters and summarizes the results obtained.

  19. Quick-Reaction Report on DoD Support for the 1996 Paralympics and Centennial Olympic Games

    National Research Council Canada - National Science Library

    Lane, F

    1996-01-01

    This audit report is the first in a series of reports that will be issued in response to a request from the Director, Office of Special Events regarding DoD support of the 1996 Olympic and Paralympic Games...

  20. Understanding the psychology of seeking support to increase Health Science student engagement in academic support services. A Practice Report

    Directory of Open Access Journals (Sweden)

    Gerard Francis Hoyne

    2013-04-01

    Full Text Available Increasing student engagement within higher education academic support services is a constant challenge. Whilst engagement with support is positively associated with successful retention, and non-engagement connected to attrition, the most vulnerable students are often the least likely to engage. Our data has shown that Health Science students are reluctant to engage with academic support services despite being made aware of their academic deficiencies. The “psychology of seeking support” was used as a lens to identify some of the multifaceted issues around student engagement. The School of Health Sciences made attendance at support courses compulsory for those students who were below the benchmark score in a post entrance literacy test. Since the policy change was implemented, there has been a 50% reduction in the fail rate of “at risk” students in a core literacy unit. These findings are encouraging and will help reduce student attrition in the long term.

  1. 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.

  2. Managing errors in radiology: a working model

    International Nuclear Information System (INIS)

    Melvin, C.; Bodley, R.; Booth, A.; Meagher, T.; Record, C.; Savage, P.

    2004-01-01

    AIM: To develop a practical mechanism for reviewing reporting discrepancies as addressed in the Royal College of Radiologists publication 'To err is human. The case for review of reporting discrepancies'. MATERIALS AND METHODS: A regular meeting was developed, and has evolved, within the department to review discrepancies. Standard forms were devised for submission of cases as well as recording and classification of discrepancies. This has resulted in availability of figures that can be audited annually. RESULTS: Eighty-one cases involving error were reviewed over a 12-month period. Seven further cases flagged as discrepancies were not identified on peer review. Twenty-four reports were amended subsequent to the meeting. Nineteen additional cases were brought to the meeting as illustrative of teaching points or for discussion. CONCLUSION: We have evolved a successful process of reviewing reporting errors, which enjoys the confidence and support of all clinical radiologists, and is perceived as a method of improving patient care through an increasing awareness of lapses in performance

  3. Report of the summative evaluation by the advisory committee on research support and collaborative activities

    International Nuclear Information System (INIS)

    2005-03-01

    The Research Evaluation Committee of the Japan Atomic Energy Research Institute (JAERI) set up an Advisory Committee on Research Support and Collaborative Activities in accordance with the 'Fundamental Guideline for the Evaluation of Research and Development (R and D) at JAERI' and its subsidiary regulations. The Advisory Committee on Research Support and Collaborative Activities evaluated the adequacy of the plans of research support and collaborative activities to be succeeded from JAERI to a new research institute which will be established by integration of JAERI and the Japan Nuclear Cycle Development Institute (JNC). The Advisory Committee consisted of nine specialists from outside the JAERI conducted its activities from June 2004 to August 2004. The evaluation was performed on the basis of the materials submitted in advance and of the oral presentations made at the Advisory Committee meeting which was held on July 21, 2004, in line with the items, viewpoints, and criteria for the evaluation specified by the Research Evaluation Committee. The result of the evaluation by the Advisory Committee was submitted to the Research Evaluation Committee, and was judged to be appropriate at its meeting held on December 1, 2004. This report describes the result of the evaluation by the Advisory Committee on Research Support and Collaborative Activities. (author)

  4. Relating Complexity and Error Rates of Ontology Concepts. More Complex NCIt Concepts Have More Errors.

    Science.gov (United States)

    Min, Hua; Zheng, Ling; Perl, Yehoshua; Halper, Michael; De Coronado, Sherri; Ochs, Christopher

    2017-05-18

    Ontologies are knowledge structures that lend support to many health-information systems. A study is carried out to assess the quality of ontological concepts based on a measure of their complexity. The results show a relation between complexity of concepts and error rates of concepts. A measure of lateral complexity defined as the number of exhibited role types is used to distinguish between more complex and simpler concepts. Using a framework called an area taxonomy, a kind of abstraction network that summarizes the structural organization of an ontology, concepts are divided into two groups along these lines. Various concepts from each group are then subjected to a two-phase QA analysis to uncover and verify errors and inconsistencies in their modeling. A hierarchy of the National Cancer Institute thesaurus (NCIt) is used as our test-bed. A hypothesis pertaining to the expected error rates of the complex and simple concepts is tested. Our study was done on the NCIt's Biological Process hierarchy. Various errors, including missing roles, incorrect role targets, and incorrectly assigned roles, were discovered and verified in the two phases of our QA analysis. The overall findings confirmed our hypothesis by showing a statistically significant difference between the amounts of errors exhibited by more laterally complex concepts vis-à-vis simpler concepts. QA is an essential part of any ontology's maintenance regimen. In this paper, we reported on the results of a QA study targeting two groups of ontology concepts distinguished by their level of complexity, defined in terms of the number of exhibited role types. The study was carried out on a major component of an important ontology, the NCIt. The findings suggest that more complex concepts tend to have a higher error rate than simpler concepts. These findings can be utilized to guide ongoing efforts in ontology QA.

  5. 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.

  6. Summary report on safety and licensing strategy support for the ABR prototype

    International Nuclear Information System (INIS)

    Cahalan, J. E.; Nuclear Engineering Division

    2007-01-01

    Argonne National Laboratory is providing support to the US Department of Energy in the Global Nuclear Energy Partnership (GNEP) in certification of an advanced, sodium-cooled fast reactor. The reactor is to be constructed as a prototype for future commercial power reactors that will produce electricity while consuming actinides recovered from light water reactor spent fuel. This prototype reactor has been called the Advanced Burner Reactor, or ABR, and is now often referred to as the advanced recycle reactor. As part of its activities, Argonne is providing technical services to assist definition of a safety and licensing strategy for the ABR prototype, and to further implementation of the strategy. In FY06, an organizational meeting was held for DOE and its laboratory contractors to discuss licensing alternatives and review previous licensing experience for the Fast Flux Test Facility (FFTF) and the Clinch River Breeder Reactor Plant (CRBRP). Near the end of FY06, a report summarizing the discussions and conclusions was written. One of the top-level conclusions recorded in the report was a recommendation to follow a licensing strategy that included the US Nuclear Regulatory Commission (NRC) as the regulatory review and licensing authority. In FY07, activities ar Argonne to support safety and licensing progress have continued. These activities have focused on further evaluation of licensing alternatives; assessment of design, analysis, and documentation implications of licensing paths; and initial technical interactions with the Nuclear Regulatory Commission. This report summarizes FY07 activities

  7. 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.

  8. Hybrid vehicle turbine engine technology support (HVTE-TS) project. 1995--1996 annual report

    Energy Technology Data Exchange (ETDEWEB)

    NONE

    1996-12-31

    This report presents a summary of technical work accomplished on the Hybrid Vehicle Turbine Engine--Technology Support (HVTE-TS) Project during calendar years 1995 and 1996. Work was performed under an initial National Aeronautics and Space Administration (NASA) contract DEN3-336. As of September 1996 the contract administration was transferred to the US Department of Energy (DoE) Chicago Operations Office, and renumbered as DE-AC02-96EE50553. The purpose of the HVTE-TS program is to develop gas turbine engine technology in support of DoE and automotive industry programs exploring the use of gas turbine generator sets in hybrid-electric automotive propulsion systems. The program focus is directed to the development of four key technologies to be applied to advanced turbogenerators for hybrid vehicles: Structural ceramic materials and processes; Low emissions combustion systems; Regenerators and seals systems; and Insulation systems and processes. 60 figs., 9 tabs.

  9. Final report on evaluation of cyclocraft support of oil and gas operations in wetland areas

    Energy Technology Data Exchange (ETDEWEB)

    Eggington, W.J.; Stevens, P.M.; John, C.J.; Harder, B.J.; Lindstedt, D.M.

    1994-10-01

    The cyclocraft is a proven hybrid aircraft, capable of VTOL, lifting heavy and bulky loads, highly controllable, having high safety characteristics and low operating costs. Mission Research Corporation (MRC), under Department of Energy sponsorship, is evaluating the potential use of cyclocraft in the transport of drill rigs, mud, pipes and other materials and equipment, in a cost effective and environmentally safe manner, to support oil and gas drilling, production, and transportation operations in wetland areas. Based upon the results of an earlier parametric study, a cyclocraft design, having a payload capacity of 45 tons and designated H.1 Cyclocraft, was selected for further study, including the preparation of a preliminary design and a development plan, and the determination of operating costs. This report contains all of the results derived from the program to evaluate the use of cyclocraft in the support of oil and gas drilling and production operations in wetland areas.

  10. 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.

  11. Chemistry and materials science progress report. Weapons-supporting research and laboratory directed research and development: FY 1995

    Energy Technology Data Exchange (ETDEWEB)

    NONE

    1996-04-01

    This report covers different materials and chemistry research projects carried out a Lawrence Livermore National Laboratory during 1995 in support of nuclear weapons programs and other programs. There are 16 papers supporting weapons research and 12 papers supporting laboratory directed research.

  12. Chemistry and materials science progress report. Weapons-supporting research and laboratory directed research and development: FY 1995

    International Nuclear Information System (INIS)

    1996-04-01

    This report covers different materials and chemistry research projects carried out a Lawrence Livermore National Laboratory during 1995 in support of nuclear weapons programs and other programs. There are 16 papers supporting weapons research and 12 papers supporting laboratory directed research

  13. 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.

  14. [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.

  15. Canister storage building (CSB) safety analysis report phase 3: Safety analysis documentation supporting CSB construction

    International Nuclear Information System (INIS)

    Garvin, L.J.

    1997-01-01

    The Canister Storage Building (CSB) will be constructed in the 200 East Area of the U.S. Department of Energy (DOE) Hanford Site. The CSB will be used to stage and store spent nuclear fuel (SNF) removed from the Hanford Site K Basins. The objective of this chapter is to describe the characteristics of the site on which the CSB will be located. This description will support the hazard analysis and accident analyses in Chapter 3.0. The purpose of this report is to provide an evaluation of the CSB design criteria, the design's compliance with the applicable criteria, and the basis for authorization to proceed with construction of the CSB

  16. Final report of the Multiprogram Laboratory Panel Energy Research Advisory Board. Volume II. Support studies

    International Nuclear Information System (INIS)

    Spiewak, I.; Guthrie, M.P.; Nichols, J.P.; Preston, E.L.; West, C.D.; Wilbanks, T.J.; Wilkes, B.Y.; Zerby, A.C.

    1982-09-01

    Volume II - support studies for nine national laboratories include: report of statistical data on the multiprogram laboratories; examples of national laboratory use in foreign countries; domestic models for national laboratory utilization; relationships of laboratories with industry and universities; uses of laboratories for training industrial R and D personnel; legal mandates and constraints on the national laboratories; with appendices on facts about Harwell, CEN-Saclay, TNO, Studsvik, and JAERI-Tokai; the Requirements Boards of the United Kingdom Department of Industry; impact of President's FY 1983 budget; and the PNL experiment

  17. Resource Allocation Support System (RASS): Summary report of the 1992 pilot study

    International Nuclear Information System (INIS)

    Buehring, W.A.; Whitfield, R.G.; Wolsko, T.D.; Kier, P.H.; Absil, M.J.G.; Jusko, M.J.; Sapinski, P.F.

    1993-02-01

    The Resource Allocation Support System (RASS) is a decision-aiding system being developed to assist the US Department of Energy's (DOE's) Office of Waste Management in program and budget decision making. Four pilot studies were conducted at DOE field offices in summer 1992 to evaluate and improve the RASS design. This report summarizes the combined results of the individual field office pilot studies. Results are presented from different perspectives to illustrate the type of information that would be available from RASS. Lessons learned and directions for future RASS developments are also presented

  18. 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

  19. Manager support for work/family issues and its impact on employee-reported pain in the extended care setting

    Science.gov (United States)

    O’Donnell, Emily M.; Berkman, Lisa F.; Subramanian, Sv

    2012-01-01

    Objective Supervisor-level policies and the presence of a manager engaged in an employee’s need to achieve work/family balance, or “supervisory support,” may benefit employee health, including self-reported pain. Methods We conducted a census of employees at four selected extended-care facilities in the Boston metropolitan region (n= 368). Supervisory support was assessed through interviews with managers and pain was employee-reported. Results Our multilevel logistic models indicate that employees with managers who report the lowest levels of support for work/family balance experience twice as much overall pain as employees with managers who report high levels of support. Conclusions Low supervisory support for work/family balance is associated with an increased prevalence of employee-reported pain in extended-care facilities. We recommend that manager-level policies and practices receive additional attention as a potential risk factor for poor health in this setting. PMID:22892547

  20. Manager support for work-family issues and its impact on employee-reported pain in the extended care setting.

    Science.gov (United States)

    O'Donnell, Emily M; Berkman, Lisa F; Subramanian, S V

    2012-09-01

    Supervisor-level policies and the presence of a manager engaged in an employee's need to achieve work-family balance, or "supervisory support," may benefit employee health, including self-reported pain. We conducted a census of employees at four selected extended care facilities in the Boston metropolitan region (n = 368). Supervisory support was assessed through interviews with managers and pain was reported by employees. Our multilevel logistic models indicate that employees with managers who report the lowest levels of support for work-family balance experience twice as much overall pain as employees with managers who report high levels of support. Low supervisory support for work-family balance is associated with an increased prevalence of employee-reported pain in extended care facilities. We recommend that manager-level policies and practices receive additional attention as a potential risk factor for poor health in this setting.

  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. Nature and Prevalence of Mentoring Support Reported by Air Force Nurses

    National Research Council Canada - National Science Library

    Zabokrtsky, Deedra

    2001-01-01

    .... Four types of mentoring support: career mentoring, coaching, collegial social, and collegial task support, were measured using the Mentoring and Communication Support Scale. Participants (N = 467...

  3. Error monitoring and empathy: Explorations within a neurophysiological context.

    Science.gov (United States)

    Amiruddin, Azhani; Fueggle, Simone N; Nguyen, An T; Gignac, Gilles E; Clunies-Ross, Karen L; Fox, Allison M

    2017-06-01

    Past literature has proposed that empathy consists of two components: cognitive and affective empathy. Error monitoring mechanisms indexed by the error-related negativity (ERN) have been associated with empathy. Studies have found that a larger ERN is associated with higher levels of empathy. We aimed to expand upon previous work by investigating how error monitoring relates to the independent theoretical domains of cognitive and affective empathy. Study 1 (N = 24) explored the relationship between error monitoring mechanisms and subcomponents of empathy using the Questionnaire of Cognitive and Affective Empathy and found no relationship. Study 2 (N = 38) explored the relationship between the error monitoring mechanisms and overall empathy. Contrary to past findings, there was no evidence to support a relationship between error monitoring mechanisms and scores on empathy measures. A subsequent meta-analysis (Study 3, N = 125) summarizing the relationship across previously published studies together with the two studies reported in the current paper indicated that overall there was no significant association between ERN and empathy and that there was significant heterogeneity across studies. Future investigations exploring the potential variables that may moderate these relationships are discussed. © 2017 Society for Psychophysiological Research.

  4. 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…

  5. 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.,…

  6. Idaho National Laboratory Transportation Task Report On Achieving Moderator Exclusion And Supporting Standardized Transportation

    International Nuclear Information System (INIS)

    Morton, D.K.; Carlsen, B.W.; Alsaed, H.

    2011-01-01

    Following the defunding of the Yucca Mountain Project, it is reasonable to assume that commercial used fuel will remain in storage for the foreseeable future. This report proposes supplementing the ongoing research and development work related to potential degradation of used fuel, baskets, poisons, and storage canisters during an extended period of storage with a parallel path. This parallel path can assure criticality safety during transportation by implementing a concept that achieves moderator exclusion (no in-leakage of moderator into the used fuel cavity). Using updated risk assessment insights for additional technical justification and relying upon a component inside of the transportation cask that provides a watertight function, a strong argument can be made that moderator intrusion is not credible and should not be a required assumption for criticality evaluations during normal conditions of transportation. A demonstrating testing program supporting a detailed analytical effort as well as updated risk assessment insights can provide the basis for moderator exclusion during hypothetical accident conditions. This report also discusses how this engineered concept can support the goal of standardized transportation.

  7. 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)

  8. Implant-supported titanium prostheses following augmentation procedures: a clinical report.

    Science.gov (United States)

    Knabe, C; Hoffmeister, B

    2003-03-01

    This report describes a novel technique for fabricating retrievable implant-supported titanium (Ti) prostheses in patients requiring a comprehensive treatment plan involving the combined efforts of maxillofacial surgery and implant prosthodontics. Following bone graft reconstructive surgery and implant placement prosthetic treatment was initiated by inserting ITI-Octa abutments. An impression was made, and a framework was fabricated by fusing Ti-cast frameworks to prefabricated titanium copings by laser-welding. This was followed by veneering or fabrication of a removable denture with Ti metal re-enforcement. Favourable clinical results have been achieved using these screw-retained Ti implant-supported restorations for patients treated with reconstructive bone graft-surgery, with clinical observation periods ranging from three to four years. The present observations suggest that these screw-retained implant-supported Ti prostheses may be a meaningful contribution to implant prosthodontics, facilitating retrievable restorations of optimum biocompatibility, good marginal precision and with a good esthetic result. However, controlled clinical studies are needed to establish the long-term serviceability of these Ti restorations.

  9. The prolongation of somatic support in a pregnant woman with brain-death: a case report

    Directory of Open Access Journals (Sweden)

    Amaral Eliana

    2006-04-01

    Full Text Available Abstract Background Medical literature has increasingly reported cases of maternal brain death during pregnancy. This is a rare situation which demands the decision and, depending on the gestational age, the implementation of a set of measures to prolong the homeostasis of the human body after brain death for the purpose of maintaining the foetus alive until its viability. Case presentation A 40 year old woman suffered an intracranial haemorrhage during the 25th week of pregnancy. Despite neurosurgical drainage of a gross intraparenchymatous haematoma, the patient developed brain death. Upon confirmation of this diagnosis, she received full ventilatory and nutritional support, vasoactive drugs, maintenance of normothermia, hormone replacement and other supportive measures required to prolong gestation and improve the survival prognosis of her foetus. All decisions regarding the patient's treatment were taken in consensus with her family. She also received corticosteroids to accelerate foetal lung maturity. During the twenty-five days of somatic support, the woman's condition remained stable; however, during the last seven days the foetus developed oligohydramnios and brain-sparring, which led the medical team to take the decision to perform a Caesarean section at that moment. After delivery, the patient's organs were removed for donation. The male infant was born weighing 815 g, with an Apgar score of 9 and 10 at the first and fifth minutes, respectively. The infant was admitted to the neonatal intensive care unit, but did not require mechanical ventilation and had no major complications. He was discharged at 40 days of life, with no sequelae and weighing 1850 g. Conclusion These results are in accordance with findings from previous studies and case reports suggesting the appropriateness and safety of extended somatic support during pregnancy under certain circumstances. They also suggest the need for prompt diagnosis of brain death before the

  10. Indicators assessing the performance of renewable energy support policies in 27 Member States. D17 Report

    Energy Technology Data Exchange (ETDEWEB)

    Steinhilber, S.; Ragwitz, M. [Fraunhofer Institute for Systems and Innovation Research ISI, Karlsruhe (Germany); Rathmann, M.; Klessmann, C.; Noothout, P. [Ecofys, Utrecht (Netherlands)

    2011-10-15

    The core objective of the RE-Shaping project is to assist Member State governments in preparing for the implementation of Directive 2009/28/EC (on the promotion of the use of energy from renewable sources) and to guide a European policy for RES (renewable energy sources) in the mid- to long term. The past and present success of policies for renewable energies will be evaluated and recommendations derived to improve future RES support schemes. The core content of this collaborative research activity comprises: Developing a comprehensive policy background for RES support instruments; Providing the European Commission and Member States with scientifically based and statistically robust indicators to measure the success of currently implemented RES policies; Proposing innovative financing schemes for lower costs and better capital availability in RES financing; Initiation of National Policy Processes which attempt to stimulate debate and offer key stakeholders a meeting place to set and implement RES targets as well as options to improve the national policies fostering RES market penetration; Assessing options to coordinate or even gradually harmonize national RES policy approaches. It is the objective of this report to assess the performance of Member States in promoting renewable energy technologies (RET) that has been achieved during recent years. The report was originally published in late 2010 and has now been updated using the latest available data. The focus shall be on the following aspects: Monitoring the historic success of RET-support with quantitative indicators; Extension of existing Policy Effectiveness Indicator and economic indicators; New: Deployment Status Indicator and Electricity Market Preparedness indicator; followed by Conclusions and recommendations.

  11. Unaccounted source of systematic errors in measurements of the Newtonian gravitational constant G

    Science.gov (United States)

    DeSalvo, Riccardo

    2015-06-01

    Many precision measurements of G have produced a spread of results incompatible with measurement errors. Clearly an unknown source of systematic errors is at work. It is proposed here that most of the discrepancies derive from subtle deviations from Hooke's law, caused by avalanches of entangled dislocations. The idea is supported by deviations from linearity reported by experimenters measuring G, similarly to what is observed, on a larger scale, in low-frequency spring oscillators. Some mitigating experimental apparatus modifications are suggested.

  12. Reporting and Recording Post 2012 GHG Mitigation Commitments, Actions and Support

    Energy Technology Data Exchange (ETDEWEB)

    NONE

    2009-07-01

    This study assesses the long-term economic and environmental effects of introducing price caps and price floors in hypothetical climate change mitigation architecture, which aims to reduce global energy-related CO2 emissions by 50% by 2050. Based on abatement costs in IPCC and IEA reports, this quantitative analysis confirms what qualitative analyses have already suggested: introducing price caps could significantly reduce economic uncertainty. This uncertainty stems primarily from unpredictable economic growth and energy prices, and ultimately unabated emission trends. In addition, the development of abatement technologies is uncertain. With price caps, the expected costs could be reduced by about 50% and the uncertainty on economic costs could be one order of magnitude lower. Reducing economic uncertainties may spur the adoption of more ambitious policies by helping to alleviate policy makers' concerns of economic risks. Meanwhile, price floors would reduce the level of emissions beyond the objective if the abatement costs ended up lower than forecasted. If caps and floors are commensurate with the ambition of the policy pursued and combined with slightly tightened emission objectives, climatic results could be on average similar to those achieved with 'straight' objectives (i.e. with no cost-containment mechanism). This papers reviews current proposals in the UNFCCC negotiations for future mechanisms to report and record Parties' GHG mitigation actions and commitments, as well as support provided for such actions. It explores the possible purposes, coverage and form of a reporting/recording mechanism post-2012 and highlights the decision points that are needed in order to establish such a mechanism. It examines what information such a mechanism could include in terms of actions, commitments and support, as well as the institutional implications of different design options.

  13. Material report in support to RCC-MRX code 2010 stainless steel parts and products

    International Nuclear Information System (INIS)

    Ancelet, Olivier; Lebarbe, Thierry; Dubiez-Le Goff, Sophie; Bonne, Dominique; Gelineau, Odile

    2012-01-01

    This paper presents the Material Report dedicated to stainless steels parts and products issued by AFCEN (Association Francaise pour les regles de Conception et de Construction des Materiels des Chaudieres Electro-Nucleaires) in support to RCC-MRx 2010 Code. The RCC-MRx Code is the result of the merger of the RCC-MX 2008, developed in the context of the research reactor Jules Horowitz Reactor project, in the RCC-MR 2007, which set up rules applicable to the design of components operating at high temperature and to the Vacuum Vessel of ITER (a presentation of RCC-MRx 2010 Code is the subject of another paper proposed in this Congress; it explains in particular the status of this Code). This Material Report is part of a set of Criteria of RCC-MRx (this set of Criteria is under construction). The Criteria aim at explaining the design and construction rules of the Code. They cover analyses rules as well as part procurement, welding, methods of tests and examination and fabrication rules. The Material Report particularly provides justifications and explanations on requirements and features dealing with parts and products proposed in the Code. The Material Report contains the following information: Introduction of the grade(s): codes and standards and Reference Procurement Specifications covering parts and products, applications and experience gained, - Physical properties, - Mechanical properties used for design calculations (base metal and welds): basic mechanical properties, creep mechanical properties, irradiated mechanical properties, - Fabrication: experience gained, metallurgy, - Welding: weldability, experience gained during welding and repair procedure qualifications, - Non-destructive examination, - In-service behaviour. In the article, examples of data supplied in the Material Report dedicated to stainless steels will be exposed. (authors)

  14. Improving knowledge management through the support of image examination and data annotation using DICOM structured reporting.

    Science.gov (United States)

    Torres, José Salavert; Damian Segrelles Quilis, J; Espert, Ignacio Blanquer; García, Vicente Hernandez

    2012-12-01

    An important effort has been invested on improving the image diagnosis process in different medical areas using information technologies. The field of medical imaging involves two main data types: medical imaging and reports. Developments based on the DICOM standard have demonstrated to be a convenient and widespread solution among the medical community. The main objective of this work is to design a Web application prototype that will be able to improve diagnosis and follow-on of breast cancer patients. It is based on TRENCADIS middleware, which provides a knowledge-oriented storage model composed by federated repositories of DICOM image studies and DICOM-SR medical reports. The full structure and contents of the diagnosis reports are used as metadata for indexing images. The TRENCADIS infrastructure takes full advantage of Grid technologies by deploying multi-resource grid services that enable multiple views (reports schemes) of the knowledge database. The paper presents a real deployment of such Web application prototype in the Dr. Peset Hospital providing radiologists with a tool to create, store and search diagnostic reports based on breast cancer explorations (mammography, magnetic resonance, ultrasound, pre-surgery biopsy and post-surgery biopsy), improving support for diagnostics decisions. A technical details for use cases (outlining enhanced multi-resource grid services communication and processing steps) and interactions between actors and the deployed prototype are described. As a result, information is more structured, the logic is clearer, network messages have been reduced and, in general, the system is more resistant to failures. Copyright © 2012 Elsevier Inc. All rights reserved.

  15. 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)

  16. Status Report on Efforts to Enhance Instrumentation to Support Advanced Test Reactor Irradiations

    Energy Technology Data Exchange (ETDEWEB)

    J. L. Rempe; D. L. Knudson; J. E. Daw

    2011-03-01

    The Department of Energy (DOE) designated the Advanced Test Reactor (ATR) as a National Scientific User Facility (NSUF) in April 2007 to support U.S. leadership in nuclear science and technology. By attracting new research users - universities, laboratories, and industry - the ATR NSUF facilitates basic and applied nuclear research and development, further advancing the nation's energy security needs. A key component of the ATR NSUF effort is to prove new in-pile instrumentation techniques that are capable of providing real-time measurements of key parameters during irradiation. To address this need, an assessment of instrumentation available and under-development at other test reactors was completed. Based on this review, recommendations were made with respect to what instrumentation is needed at the ATR; and a strategy was developed for obtaining these sensors. In 2009, a report was issued documenting this program’s strategy and initial progress toward accomplishing program objectives. In 2009, a report was issued documenting this instrumentation development strategy and initial progress toward accomplishing instrumentation development program objectives. This document reports progress toward implementing this strategy in 2010.

  17. Status Report on Efforts to Enhance Instrumentation to Support Advanced Test Reactor Irradiations

    Energy Technology Data Exchange (ETDEWEB)

    J. Rempe; D. Knudson; J. Daw; T. Unruh; B. Chase; R. Schley; J. Palmer; K. Condie

    2014-01-01

    The Department of Energy (DOE) designated the Advanced Test Reactor (ATR) as a National Scientific User Facility (NSUF) in April 2007 to support the growth of nuclear science and technology in the United States (US). By attracting new research users - universities, laboratories, and industry - the ATR NSUF facilitates basic and applied nuclear research and development, further advancing the nation's energy security needs. A key component of the ATR NSUF effort at the Idaho National Laboratory (INL) is to design, develop, and deploy new in-pile instrumentation techniques that are capable of providing real-time measurements of key parameters during irradiation. To address this need, an assessment of instrumentation available and under-development at other test reactors was completed. Based on this initial review, recommendations were made with respect to what instrumentation is needed at the ATR, and a strategy was developed for obtaining these sensors. In 2009, a report was issued documenting this program’s strategy and initial progress toward accomplishing program objectives. Since 2009, annual reports have been issued to provide updates on the program strategy and the progress made on implementing the strategy. This report provides an update reflecting progress as of January 2014.

  18. Supporting documents for LLL area 27 (410 area) safety analysis reports, Nevada Test Site

    Energy Technology Data Exchange (ETDEWEB)

    Odell, B. N. [comp.

    1977-02-01

    The following appendices are common to the LLL Safety Analysis Reports Nevada Test Site and are included here as supporting documents to those reports: Environmental Monitoring Report for the Nevada Test Site and Other Test Areas Used for Underground Nuclear Detonations, U. S. Environmental Protection Agency, Las Vegas, Rept. EMSL-LV-539-4 (1976); Selected Census Information Around the Nevada Test Site, U. S. Environmental Protection Agency, Las Vegas, Rept. NERC-LV-539-8 (1973); W. J. Hannon and H. L. McKague, An Examination of the Geology and Seismology Associated with Area 410 at the Nevada Test Site, Lawrence Livermore Laboratory, Livermore, Rept. UCRL-51830 (1975); K. R. Peterson, Diffusion Climatology for Hypothetical Accidents in Area 410 of the Nevada Test Site, Lawrence Livermore Laboratory, Livermore, Rept. UCRL-52074 (1976); J. R. McDonald, J. E. Minor, and K. C. Mehta, Development of a Design Basis Tornado and Structural Design Criteria for the Nevada Test Site, Nevada, Lawrence Livermore Laboratory, Livermore, Rept. UCRL-13668 (1975); A. E. Stevenson, Impact Tests of Wind-Borne Wooden Missiles, Sandia Laboratories, Tonopah, Rept. SAND 76-0407 (1976); and Hydrology of the 410 Area (Area 27) at the Nevada Test Site.

  19. Status Report on Efforts to Enhance Instrumentation to Support Advanced Test Reactor Irradiations

    International Nuclear Information System (INIS)

    Rempe, J.L.; Knudson, D.L.; Daw, J.E.

    2011-01-01

    The Department of Energy (DOE) designated the Advanced Test Reactor (ATR) as a National Scientific User Facility (NSUF) in April 2007 to support U.S. leadership in nuclear science and technology. By attracting new research users - universities, laboratories, and industry - the ATR NSUF facilitates basic and applied nuclear research and development, further advancing the nation's energy security needs. A key component of the ATR NSUF effort is to prove new in-pile instrumentation techniques that are capable of providing real-time measurements of key parameters during irradiation. To address this need, an assessment of instrumentation available and under-development at other test reactors was completed. Based on this review, recommendations were made with respect to what instrumentation is needed at the ATR; and a strategy was developed for obtaining these sensors. In 2009, a report was issued documenting this program's strategy and initial progress toward accomplishing program objectives. In 2009, a report was issued documenting this instrumentation development strategy and initial progress toward accomplishing instrumentation development program objectives. This document reports progress toward implementing this strategy in 2010.

  20. 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.

  1. Status of safety-related qualification and design verification and support programs in support of HTGR PSARs. Biannual report for period ending January 31, 1975

    International Nuclear Information System (INIS)

    Tully, G.R. Jr.; Stiehl, G.L. Jr.

    1975-01-01

    Programs reported are core seismic studies, core support posts, primary coolant moisture monitor, moisture monitor compressor, control rod system, orifice and drive mechanism, reserve shutdown system, main loop coolant shutoff valve, auxiliary loop coolant shutoff valve, core auxiliary heat exchanger, auxiliary loop coolant circulator assembly, auxiliary loop coolant circulator motor speed controls, PPS electronic modules and main loop helium circulator. (U.S.)

  2. Engineering Technical Support Center, Innovative Science and Technical Support for Cost-Effective Cleanups: Five Year Summary Report for 2007-2012

    Science.gov (United States)

    This report summarizes a variety of significant projects that ETSC and its colleagues in the Land Remediation and Pollution Control Division (LRPCD) have supported during the last five years. Projects have addressed an array of environmental scenarios, including remote mining co...

  3. 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...

  4. Decreased hospital length of stay associated with presentation of cases at morning report with librarian support

    Science.gov (United States)

    Banks, Daniel E.; Shi, Runhua; Timm, Donna F.; Christopher, Kerri Ann; Duggar, David Charles; Comegys, Marianne; McLarty, Jerry

    2007-01-01

    Objective: The research sought to determine whether case discussion at residents' morning report (MR), accompanied by a computerized literature search and librarian support, affects hospital charges, length of stay (LOS), and thirty-day readmission rate. Methods: This case-control study, conducted from August 2004 to March 2005, compared outcomes for 105 cases presented at MR within 24 hours of admission to 19,210 potential matches, including cases presented at MR and cases not presented at MR. With matching criteria of patient age (± 5 years), identical primary diagnosis, and secondary diagnoses (within 3 additional diagnoses) using International Classification of Diseases (ICD-9) codes, 55 cases were matched to 136 controls. Statistical analyses included Student's t tests, chi-squared tests, and nonparametric methods. Results: LOS differed significantly between matched MR cases and controls (3 days vs. 5 days, P librarians, was an effective means for introducing evidence-based medicine into patient care practices. PMID:17971885

  5. Prosthetic treatment of oligodontia with a tooth-supported overdenture--a case report.

    Science.gov (United States)

    Akeredolu, P A

    2002-01-01

    An unusual case of oligodontia is reported in a 20 year old Nigerian male. It is unusual because of the isolated occurrence of the oligodontia which is unassociated with a family history or any other clinical features suggestive of specific syndromes or severe systemic abnormality. The patient presented with conically or peg shaped anterior and malformed posterior teeth in both the maxilla and mandible. Full mouth periapical radiographs revealed stunted roots, widening of the periodontal space and an unerupted tooth in the right mandibular premolar region. Tooth-supported upper and lower removable partial overdenture were fabricated for him. This modality of treatment is a better choice which helps not only to preserve the alveolar ridge height and improve aesthetics, but also preserves the proprioceptive mechanisms associated with the periodontal membrane of natural teeth.

  6. Brief Report: An Independent Replication and Extension of Psychometric Evidence Supporting the Theory of Mind Inventory.

    Science.gov (United States)

    Greenslade, Kathryn J; Coggins, Truman E

    2016-08-01

    This study presents an independent replication and extension of psychometric evidence supporting the Theory of Mind Inventory (ToMI). Parents of 20 children with ASD (4; 1-6; 7 years; months) and 20 with typical development (3; 1-6; 5), rated their child's theory of mind abilities in everyday situations. Other parent report and child behavioral assessments included the Social Responsiveness Scale-2, Vineland Adaptive Behavior Scales-2, Peabody Picture Vocabulary Test-4, and Clinical Evaluation of Language Fundamentals-Preschool, 2. Results revealed high internal consistency, expected developmental changes in children with typical development, expected group differences between children with and without ASD, and strong correlations with other measures of social and communication abilities. The ToMI demonstrates strong psychometrics, suggesting considerable utility in identifying theory of mind deficits in children with ASD.

  7. Canister storage building (CSB) safety analysis report phase 3: Safety analysis documentation supporting CSB construction

    Energy Technology Data Exchange (ETDEWEB)

    Garvin, L.J.

    1997-04-28

    The Canister Storage Building (CSB) will be constructed in the 200 East Area of the U.S. Department of Energy (DOE) Hanford Site. The CSB will be used to stage and store spent nuclear fuel (SNF) removed from the Hanford Site K Basins. The objective of this chapter is to describe the characteristics of the site on which the CSB will be located. This description will support the hazard analysis and accident analyses in Chapter 3.0. The purpose of this report is to provide an evaluation of the CSB design criteria, the design's compliance with the applicable criteria, and the basis for authorization to proceed with construction of the CSB.

  8. [Peer support programs in mental health in France: Status report and challenges].

    Science.gov (United States)

    Villani, M; Kovess-Masféty, V

    2018-03-23

    Recovery is a process through which people experiencing mental illness learn to live with their disorder and reach social insertion and citizenship. This positive approach focuses on a person's competencies and strengths rather than on the symptoms. Within this philosophy, peer support has been unevenly developing in mental health services worldwide with roots in the South-American social programs for homeless people and in the American recovery circles in the field of addiction. Therapeutic efficiency of peer support has been proven by several studies including a control group, as being at least as good as traditional services and even better in some specific areas such as reduction of need for emergency services and ability to reach "difficult" patients. The integration of former psychiatric services users in mental health services can take several forms, from the participation to scientific research studies to the direct involvement in a professional team at mental health facilities. In this context, our research aims to sum up the situation in France in comparison with other countries. We conducted a worldwide literature review in English and in French on peer support experiences and policies in mental health services, using medical and psychological databases (PsycInfo, PsycArticles, SantéPsy, Cairn, Medline, Wiley Interscience and PubPsych) on a recent period: 2005-2016. In total, 32 relevant scientific papers have been included in our research. In some cases, we have also used official reports, blogs, Internet sites, and mass media articles when they were relevant. Our results show that this movement has been long to develop in France, with controversies having been raised since the beginning on the role that peers should play and confusion with existing social integration programs in the associative sector. Drawing inspiration from the Canadian model, a recent "peer mentor" initiative has been analyzed after 2 years of existence: many benefits for services

  9. 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...

  10. 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.)

  11. Magnet-retained implant-supported overdentures: review and 1-year clinical report.

    Science.gov (United States)

    Ceruti, Paola; Bryant, S Ross; Lee, Jun-Ho; MacEntee, Michael I

    2010-01-01

    Open-field aluminum-nickle-cobalt magnets have been used in prosthodontics for many years, but success has been limited because these magnets are susceptible to corrosion by the saliva and because their retentive force is weak relative to the initial retention offered by mechanical attachments. More recently, magnets have been made from alloys of the rare earth elements samarium and neodymium, which provide stronger magnetic force per unit size. In addition, a new generation of laser-welded containers has improved protection from salivary corrosion. The current resurgence of interest in this type of attachment appears justified because, unlike mechanical attachments, magnets have potential for unlimited durability and might therefore be superior to mechanical ball or bar attachments for the retention of removable prostheses on implants. To date, no long-term prospective trials have been conducted to confirm the clinical durability of this new generation of magnets for retaining dentures on either teeth or implants. The aim of this study was to document initial clinical experiences and levels of satisfaction among edentulous patients treated with mandibular implant-supported overdentures retained using a new generation of rare-earth magnetic attachments. At the outset, all but one of the 17 patients had had several years of experience with implant-supported overdentures. During the first year, the mean overall satisfaction among these 17 patients increased from less than 70 to over 90 out of 100 (standardized visual analogue scale). No unusual difficulties were encountered in rendering the treatment or maintaining the attachments. This report offers preliminary evidence of the excellent potential of these magnets for retaining mandibular implant-supported overdentures.

  12. 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.

  13. Final report for Conference Support Grant "From Computational Biophysics to Systems Biology - CBSB12"

    Energy Technology Data Exchange (ETDEWEB)

    Hansmann, Ulrich H.E.

    2012-07-02

    This report summarizes the outcome of the international workshop From Computational Biophysics to Systems Biology (CBSB12) which was held June 3-5, 2012, at the University of Tennessee Conference Center in Knoxville, TN, and supported by DOE through the Conference Support Grant 120174. The purpose of CBSB12 was to provide a forum for the interaction between a data-mining interested systems biology community and a simulation and first-principle oriented computational biophysics/biochemistry community. CBSB12 was the sixth in a series of workshops of the same name organized in recent years, and the second that has been held in the USA. As in previous years, it gave researchers from physics, biology, and computer science an opportunity to acquaint each other with current trends in computational biophysics and systems biology, to explore venues of cooperation, and to establish together a detailed understanding of cells at a molecular level. The conference grant of $10,000 was used to cover registration fees and provide travel fellowships to selected students and postdoctoral scientists. By educating graduate students and providing a forum for young scientists to perform research into the working of cells at a molecular level, the workshop adds to DOE's mission of paving the way to exploit the abilities of living systems to capture, store and utilize energy.

  14. Temporary septic holding tank at the 100-C remedial action support facility -- Engineering report

    International Nuclear Information System (INIS)

    Jackson, G.J.

    1996-08-01

    The primary mission of the Hanford Site from 1943 to 1990 was to produce nuclear materials for national defense. Waste disposal activities associated with this mission resulted in the creation of more than 1,000 waste sites contaminated with radioactive and chemically hazardous constituents. Investigation and remediation of these waste sites is governed by the Tri-Party Agreement. The agreement grouped the waste sites into 78 operable units, each of which was to be investigated and remediated separately. The 100 C Remedial Action Support Facility will be required near the 105-C Reactor to support the 105-C Interim Storage Project. This project is part of the decommissioning of the eight surplus reactor buildings along the Columbia River in the 100 Area. This facility, will be a temporary, modular building sized to provide office and work space for the supervisors, engineers, and technicians assigned to the project and engaged in the associated field work. This report describes the project location, geology and potential flooding, design criteria, operations, and maintenance

  15. Collection of offshore human error probability data

    International Nuclear Information System (INIS)

    Basra, Gurpreet; Kirwan, Barry

    1998-01-01

    Accidents such as Piper Alpha have increased concern about the effects of human errors in complex systems. Such accidents can in theory be predicted and prevented by risk assessment, and in particular human reliability assessment (HRA), but HRA ideally requires qualitative and quantitative human error data. A research initiative at the University of Birmingham led to the development of CORE-DATA, a Computerised Human Error Data Base. This system currently contains a reasonably large number of human error data points, collected from a variety of mainly nuclear-power related sources. This article outlines a recent offshore data collection study, concerned with collecting lifeboat evacuation data. Data collection methods are outlined and a selection of human error probabilities generated as a result of the study are provided. These data give insights into the type of errors and human failure rates that could be utilised to support offshore risk analyses

  16. Nursing Associated Medication Errors: Are Internationally Educated Nurses Different from U.S. Educated Nurses?

    Directory of Open Access Journals (Sweden)

    Jay J. Shen

    2018-02-01

    Full Text Available Medication errors can be detrimental to patient safety and contribute to additional costs in healthcare. The United States has seen a steady increase in internationally-educated nurses (IENs entering the nursing workforce. The current study builds upon the existing research examining the relationship between IENs and medication errors by controlling for confounding factors and testing whether IENs were more likely to make multiple medication errors compared to USENs. This study was a quasi-case control study. The 2006 and 2010 medication error incident data from hospital risk management departments were used. The final sample was 1,773, representing 788 registered nurse in the case group and 985 registered nurses in the control group. Multivariable analyses were conducted to examine single medication error, multiple errors, and consequence of medication errors, in comparing the IENs to USENs. IENs tended to have multiple errors more often than USENs in 2006 (31.7% for IENs and 20.5% for USENs, p = 0.03, but these differences became marginally significant after combining both years of data and completing the multivariable models adjusting for covariates (Odds ratio = 1.38, p = 0.06. No significant differences in making a single error and medication error consequences were observed between IENs and USENs. Although no significant differences between IENs and USENs in having medication error incidents were observed, IENs might be more likely to have multiple medication error incidents in a year compared to USENs. Policies that encourage targeted orientation addressing implicit belief systems about the nursing role and explains patient safety expectations as well as procedures for medication administration may be beneficial for IENs. Supportive leadership that is culturally competent, ensures ongoing continuing education in pharmacology, and provides culturally appropriate incentives for self-reporting medication errors are important.

  17. Prevalence of Refractive errors among Primary School Pupils in ...

    African Journals Online (AJOL)

    Administrator

    Effective management of blindness due to refractive errors is readily available in developed countries. 1 ... Key words: Refractive errors, Children, Prevalence, Kenya. 165 .... financial support towards the funding of this study. REFERENCES. 1.

  18. Environmental Public Health Indicators Impact Report: Data and methods that support environmental public health decision-making by communities

    Science.gov (United States)

    This report presents the results of twenty competitively funded Science-To-Achieve-Results (STAR) grants in EPA's Environmental Public Health Indicators (EPHI) research program. The grantsdirectly supported health interventions, informed policy and decision-making, and improved t...

  19. 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.

  20. 94-1 Research and development project lead laboratory support. Status report, January 1--March 31, 1997

    Energy Technology Data Exchange (ETDEWEB)

    Rink, N.A. [comp.

    1997-08-01

    This status report is published for Los Alamos National Laboratory 94-1 Research and Development Project Support. The Department of Energy Office of Environmental Management funds these projects in order to support the storage or disposal of legacy plutonium and plutonium-bearing materials that resulted from weapons production throughout the DOE complex. This report summarizes status and technical progress for Los Alamos 94-1 projects during the second quarter of fiscal year 1997.

  1. Observed and Reported Supportive Coparenting as Predictors of Infant-Mother and Infant-Father Attachment Security

    OpenAIRE

    Brown, Geoffrey L.; Schoppe-Sullivan, Sarah J.; Mangelsdorf, Sarah C.; Neff, Cynthia

    2010-01-01

    This study examined associations between supportive coparenting and infant-mother and infant-father attachment security. Observed and parent-reported coparenting, and observed maternal and paternal sensitivity were assessed in a sample of 68 families with 3.5-month-old infants. Infant-mother and infant-father attachment security were assessed in the Strange Situation Procedure (Ainsworth, Blehar, Waters, & Wall, 1978) at 12 and 13 months of age, respectively. Observed and reported supportive ...

  2. 94-1 Research and development project lead laboratory support. Status report, January 1--March 31, 1997

    International Nuclear Information System (INIS)

    Rink, N.A.

    1997-08-01

    This status report is published for Los Alamos National Laboratory 94-1 Research and Development Project Support. The Department of Energy Office of Environmental Management funds these projects in order to support the storage or disposal of legacy plutonium and plutonium-bearing materials that resulted from weapons production throughout the DOE complex. This report summarizes status and technical progress for Los Alamos 94-1 projects during the second quarter of fiscal year 1997

  3. 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…

  4. 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.

  5. 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.

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

    Science.gov (United States)

    Frese, Michael; Keith, Nina

    2015-01-03

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

  7. 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…

  8. Medication errors in anesthesia: unacceptable or unavoidable?

    Directory of Open Access Journals (Sweden)

    Ira Dhawan

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

  9. 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)

  10. 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)

  11. Task Order 22 – Engineering and Technical Support, Deep Borehole Field Test. AREVA Summary Review Report

    Energy Technology Data Exchange (ETDEWEB)

    Denton, Mark A. [AREVA Federal Services, Charlotte, NC (United States)

    2016-01-19

    Under Task Order 22 of the industry Advisory and Assistance Services (A&AS) Contract to the Department of Energy (DOE) DE-NE0000291, AREVA has been tasked with providing assistance with engineering, analysis, cost estimating, and design support of a system for disposal of radioactive wastes in deep boreholes (without the use of radioactive waste). As part of this task order, AREVA was requested, through a letter of technical direction, to evaluate Sandia National Laboratory’s (SNL’s) waste package borehole emplacement system concept recommendation using input from DOE and SNL. This summary review report (SRR) documents this evaluation, with its focus on the primary input document titled: “Deep Borehole Field Test Specifications/M2FT-15SN0817091” Rev. 1 [1], hereafter referred to as the “M2 report.” The M2 report focuses on the conceptual design development for the Deep Borehole Field Test (DBFT), mainly the test waste packages (WPs) and the system for demonstrating emplacement and retrieval of those packages in the Field Test Borehole (FTB). This SRR follows the same outline as the M2 report, which allows for easy correlation between AREVA’s review comments, discussion, potential proposed alternatives, and path forward with information established in the M2 report. AREVA’s assessment focused on three primary elements of the M2 report: the conceptual design of the WPs proposed for deep borehole disposal (DBD), the mode of emplacement of the WP into DBD, and the conceptual design of the DBFT. AREVA concurs with the M2 report’s selection of the wireline emplacement mode specifically over the drill-string emplacement mode and generically over alternative emplacement modes. Table 5-1 of this SRR compares the pros and cons of each emplacement mode considered viable for DBD. The primary positive characteristics of the wireline emplacement mode include: (1) considered a mature technology; (2) operations are relatively simple; (3) probability of a

  12. Online Platform as a Tool to Support Postgraduate Training in General Practice – A Case Report

    Science.gov (United States)

    Dini, Lorena; Galanski, Claire; Döpfmer, Susanne; Gehrke-Beck, Sabine; Bayer, Gudrun; Boeckle, Martin; Micheel, Isabel; Novak, Jasminko; Heintze, Christoph

    2017-01-01

    Objective: Physicians in postgraduate training (PPT) in General Practice (GP) typically have very little interaction with their peers, as there is usually only one resident physician working in their respective department or GP office at a given time. Therefore, the online platform KOLEGEA, presented here, aims to support postgraduate training in general practice (PT in GP) in Germany through virtual interaction. Methodology: In 2012, the interdisciplinary research project KOLEGEA set up an online platform that any physicians in PT in GP can use for free after registration with their unitary continuous education number (Einheitliche Fortbildungsnummer, EFN). It offers problem-based learning and allows to discuss self-published anonymized patient cases with the community that can be classified and discussed with experienced mentors (specialists in general practice - GPs) in small virtual groups. Results: An anonymous online survey carried out as part of the 2014 project evaluation showed a good acceptance of the platform, even though shortage of time was mentioned as a limiting factor for its use. Data analysis showed that KOLEGEA was used by PPT in GP in all federal states. Patterns of passive use were predominant (90%). This report also describes the further development of the platform (in 2015 and 2016) that integrates an activity monitor as part of a gamification concept. Conclusions: Due to a low response rate of the 2014 online survey and the preliminary evaluations of usage patterns we could identify only initial trends regarding the role of KOLEGEA in supporting PPT. The platform was perceived as a helpful supplement to better structure PT in GP. PMID:29226227

  13. 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.

  14. Mental health and psychosocial support in crisis and conflict: report of the Mental Health Working Group.

    Science.gov (United States)

    Allden, K; Jones, L; Weissbecker, I; Wessells, M; Bolton, P; Betancourt, T S; Hijazi, Z; Galappatti, A; Yamout, R; Patel, P; Sumathipala, A

    2009-01-01

    The Working Group on Mental Health and Psychosocial Support was convened as part of the 2009 Harvard Humanitarian Action Summit. The Working Group chose to focus on ethical issues in mental health and psychosocial research and programming in humanitarian settings. The Working Group built on previous work and recommendations, such as the Inter-Agency Standing Committee's Guidelines on Mental Health and Psychosocial Support in Emergency Settings. The objective of this working group was to address one of the factors contributing to the deficiency of research and the need to develop the evidence base on mental health and psychosocial support interventions during complex emergencies by proposing ethical research guidelines. Outcomes research is vital for effective program development in emergency settings, but to date, no comprehensive ethical guidelines exist for guiding such research efforts. Working Group members conducted literature reviews which included peer-reviewed publications, agency reports, and relevant guidelines on the following topics: general ethical principles in research, cross-cultural issues, research in resource-poor countries, and specific populations such as trauma and torture survivors, refugees, minorities, children and youth, and the mentally ill. Working Group members also shared key points regarding ethical issues encountered in their own research and fieldwork. The group adapted a broad definition of the term "research", which encompasses needs assessments and data gathering, as well as monitoring and evaluation. The guidelines are conceptualized as applying to formal and informal processes of assessment and evaluation in which researchers as well as most service providers engage. The group reached consensus that it would be unethical not to conduct research and evaluate outcomes of mental health and psychosocial interventions in emergency settings, given that there currently is very little good evidence base for such interventions

  15. Families, nurses and organisations contributing factors to medication administration error in paediatrics: a literature review

    Directory of Open Access Journals (Sweden)

    Albara Alomari

    2015-05-01

    Full Text Available Background: Medication error is the most common adverse event for hospitalised children and can lead to significant harm. Despite decades of research and implementation of a number of initiatives, the error rates continue to rise, particularly those associated with administration. Objectives: The objective of this literature review is to explore the factors involving nurses, families and healthcare systems that impact on medication administration errors in paediatric patients. Design: A review was undertaken of studies that reported on factors that contribute to a rise or fall in medication administration errors, from family, nurse and organisational perspectives. The following databases were searched: Medline, Embase, CINAHL and the Cochrane library. The title, abstract and full article were reviewed for relevance. Articles were excluded if they were not research studies, they related to medications and not medication administration errors or they referred to medical errors rather than medication errors. Results: A total of 15 studies met the inclusion criteria. The factors contributing to medication administration errors are communication failure between the parents and healthcare professionals, nurse workload, failure to adhere to policy and guidelines, interruptions, inexperience and insufficient nurse education from organisations. Strategies that were reported to reduce errors were doublechecking by two nurses, implementing educational sessions, use of computerised prescribing and barcoding administration systems. Yet despite such interventions, errors persist. The review highlighted families that have a central role in caring for the child and therefore are key to the administration process, but have largely been ignored in research studies relating to medication administration. Conclusions: While there is a consensus about the factors that contribute to errors, sustainable and effective solutions remain elusive. To date, families have not

  16. Supportive or suggestive: Do human figure drawings help 5- to 7-year-old children to report touch?

    Science.gov (United States)

    Brown, Deirdre A; Pipe, Margaret-Ellen; Lewis, Charlie; Lamb, Michael E; Orbach, Yael

    2007-02-01

    The authors examined the accuracy of information elicited from seventy-nine 5- to 7-year-old children about a staged event that included physical contact-touching. Four to six weeks later, children's recall for the event was assessed using an interview protocol analogous to those used in forensic investigations with children. Following the verbal interview, children were asked about touch when provided with human figure drawings (drawings only), following practice using the human figure drawings (drawings with instruction), or without drawings (verbal questions only). In this touch-inquiry phase of the interview, most children provided new information. Children in the drawings conditions reported more incorrect information than those in the verbal questions condition. Forensically relevant errors were infrequent and were rarely elaborated on. Although asking children to talk about innocuous touch may lead them to report unreliable information, especially when human figure drawings are used as aids, errors are reduced when open-ended prompts are used to elicit further information about reported touches. Copyright 2007 APA, all rights reserved.

  17. 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.

  18. 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.

  19. Primary Care Providers' Perspectives on Errors of Omission.

    Science.gov (United States)

    Poghosyan, Lusine; Norful, Allison A; Fleck, Elaine; Bruzzese, Jean-Marie; Talsma, AkkeNeel; Nannini, Angela

    2017-01-01

    Despite recent focus on patient safety in primary care, little attention has been paid to errors of omission, which represent significant gaps in care and threaten patient safety in primary care but are not well studied or categorized. The purpose of this study was to develop a typology of errors of omission from the perspectives of primary care providers (PCPs) and understand what factors within practices lead to or prevent these omissions. A qualitative descriptive design was used to collect data from 26 PCPs, both physicians and nurse practitioners, from the New York State through individual interviews. One researcher conducted all interviews, which were audiotaped, transcribed verbatim, and analyzed in ATLAS.ti, Berlin by 3 researchers using content analysis. They immersed themselves into data, read transcripts independently, and conducted inductive coding. The final codes were linked to each other to develop the typology of errors of omission and the themes. Data saturation was reached at the 26th interview. PCPs reported that omitting patient teaching, patient followup, emotional support, and addressing mental health needs were the main categories of errors of omission. PCPs perceived that time constraints, unplanned patient visits and emergencies, and administrative burden led to these gaps in care. They emphasized that organizational support and infrastructure, effective teamwork and communication, and preparation for the patient encounter were important safeguards to prevent errors of omission within their practices. Errors of omission are common in primary care and could threaten patient safety. Efforts to eliminate them should focus on strengthening organizational attributes of practices, improving teamwork and communication, and assigning manageable workload to PCPs. Practice and policy change is necessary to address gaps in care and prevent them before they result in patient harm. © Copyright 2017 by the American Board of Family Medicine.

  20. 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).

  1. Child Support: States' Implementation of the 1984 Child Support Enforcement Amendments. Briefing Report to the Chairman, Subcommittee on Public Assistance and Unemployment Compensation, Committee on Ways and Means, House of Representatives.

    Science.gov (United States)

    General Accounting Office, Washington, DC. Div. of Human Resources.

    This document reports on the states' implementation of the Child Support Enforcement Amendments of 1984. The Child Support Enforcement Program is a federally administered, state run program in which child support agencies locate absent parents, establish paternity, obtain support orders, and enforce support collections with the purpose of reducing…

  2. Information Characteristics and Errors in Expectations

    DEFF Research Database (Denmark)

    Antoniou, Constantinos; Harrison, Glenn W.; Lau, Morten Igel

    Behavioural finance theories draw on evidence from psychology that suggest that some people respond to information in a biased manner, and construct theories of inefficient markets. However, these biases are not always robust when tested in economic conditions, which casts doubt on their relevance...... to market efficiency. We design an economic experiment to test a psychological hypothesis of errors in expectations widely cited in finance, which states that, in violations of Bayes Rule, some people respond more forcefully to the strength of an information signal. The strength of a signal is how saliently...... it supports a specific hypothesis, as opposed to its weight, which is its predictive validity. We find that the strength-weight bias affects expectations, but that its magnitude is three times lower than originally reported in the psychology literature. This suggests that its impact on financial markets...

  3. Generic data sources for the update of an environmental report in support of license renewal

    International Nuclear Information System (INIS)

    Mauro, John J.

    1991-01-01

    Over the past 2 years, our organization has been providing assistance to the NUMARC PLEX working group in matters pertaining to the environmental impacts of license renewal. Part of this support was the identification of data sets and publications that may be useful to the NRC in the preparation of their Environment Report Supplements (ERSs). The following presents a strategy for preparing an ERS, along with references and data sets pertinent to each ER topic. Each section of the ERS should present the following information: (1) Updated information on plant design and operating experience, along with projections of the plant impacts through the end of its currently licensed period of operation. These impacts are used as a baseline against which to compare the projected impacts for the period of license renewal. In addition, the baseline impacts may be compared to the impacts projected in the plant's original Environmental Report and Environmental Impact Statement. (2) Projections of how the impacts may change during the period of license renewal. The purpose of this information will be to determine the degree to which the projected impacts differ significantly from the impacts presented in the original ER and those that have actually occurred during the period of plant operation. We believe that the ERS will reveal that (1) the actual impacts that have occurred during the period of plant operation are comparable to, or less than, those predicted in the original ER, (2) many impacts have been decreasing with time, such as routine radioactive emissions, and (3) the impacts predicted for the period of license renewal will be comparable to, or less than, the baseline impacts. (author)

  4. 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

  5. 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

  6. Study supporting the phasing out of environmentally harmful subsidies. Annexes to Final Report

    Energy Technology Data Exchange (ETDEWEB)

    Withana, S.; Ten Brink, P.; Franckx, L.; Hirschnitz-Garbers, M.; Mayeres, I.; Oosterhuis, F.; Porsch, L.

    2012-10-15

    The need to reform ineffective or harmful public subsidies has long been recognised and has been a contentious point of discussion for several years. The EU has a long-standing commitment to removing or phasing out environmentally harmful subsidies (EHS). Most recently, the need to phase out EHS is reiterated in the 'Roadmap for a resource efficient Europe' which includes a milestone that 'by 2020 EHS will be phased out, with due regard to the impact on people in need'. Despite several commitments, progress has been slow and subsidies remain an issue in most EU countries. This study focuses specifically on EHS at the level of EU Member States; it identifies key types of EHS and examines cases of existing EHS across a range of environmental sectors and issues, including subsidies from non-action. The study also analyses examples of good practices in the reform of EHS in EU Member States and the lessons that can be learnt from these cases. Finally, based on this analysis, it develops practical recommendations on phasing out and reforming EHS to support the objectives of the Europe 2020 Strategy and the resource efficiency agenda. The study was carried out between January and October 2012 and is based on an analysis of literature and consultation with experts and policy makers. The sectoral cases studied are listed and discussed in this annex report: agriculture, climate and energy, fisheries, food, forestry, materials, transport, waste, and water.

  7. Semi-Annual Report on Work Supporting the International Forum for Reactor Aging Management (IFRAM)

    International Nuclear Information System (INIS)

    Bond, Leonard J.; Brenchley, David L.

    2011-01-01

    During the first six months of this project, Pacific Northwest National Laboratory has provided planning and leadership support for the establishment of the International Forum for Reactor Aging Management (IFRAM). This entailed facilitating the efforts of the Global Steering Committee to prepare the charter, operating guidelines, and other documents for IFRAM. It also included making plans for the Inaugural meeting and facilitating its success. This meeting was held on August 4 5, 2011, in Colorado Springs, Colorado. Representatives from Asia, Europe, and the United States met to share information on reactor aging management and to make plans for the future. Professor Tetsuo Shoji was elected chairperson of the Leadership Council. This kick-off event transformed the dream of an international forum into a reality. On August 4-5, 2011, IFRAM began to achieve its mission. The work completed successfully during this period was built upon important previous efforts. This included the development of a proposal for establishing IFRAM and engaging experts in Asia and Europe. The proposal was presented at Engagement workshops in Seoul, Korea (October 2009) and Petten, The Netherlands (May 2010). Participants in both groups demonstrated strong interest in the establishment of IFRAM. Therefore, the Global Steering Committee was formed to plan and carry out the start-up of IFRAM in 2011. This report builds on the initial activities and documents the results of activities over the last six months.

  8. Data quality objectives summary report in support of Hanford Generating Plant. Revision 1

    International Nuclear Information System (INIS)

    Miller, M.S.; Marske, S.G.

    1996-09-01

    The Hanford Generating Plant (HGP) consists of two 430 MW low-pressure turbine generators and is owned by the Washington Public Power Supply System (WPPSS). Steam from the N Reactor powered the HGP turbines before passing through the turbine condenser, where waste heat was transferred to the cooling water. The DOE-RL requested that Environmental Restoration Contractor (ERC) generate a sampling and analysis plan to assist in the assessment of decontamination and decommissioning (D and D) and remediation of the HGP and 11 associated Solid Waste Management Units (SWMUs). This report summarizes the results of the Data Quality Objectives planning process as applied to HGP. The characterization data will be used to better estimate the cost for D and D and remediation. These costs will be utilized in an agreement between the Department of Energy-Richland Office (DOE-RL) and the WPSS. The agreement will define which organization will perform D and D of the HGP building, external support buildings, and remediation of buildings and soils surrounding the facility. The sampling and analysis design is presented in Section 7 with Tables 7-1 and 7-3 summarizing the design, number, location, analytes, and analytical methods to be used. The purpose of the sampling is to provide the nature and depth of contaminants. In locations where it was difficult to make assumptions related to extent, the design allows for limited characterization related to extent of contamination

  9. Report on FY17 testing in support of integrated EPP-SMT design methods development

    Energy Technology Data Exchange (ETDEWEB)

    Wang, Yanli . [Oak Ridge National Lab. (ORNL), Oak Ridge, TN (United States); Jetter, Robert I. [Oak Ridge National Lab. (ORNL), Oak Ridge, TN (United States); Sham, T. -L. [Oak Ridge National Lab. (ORNL), Oak Ridge, TN (United States)

    2017-08-01

    The goal of the proposed integrated Elastic Perfectly-Plastic (EPP) and Simplified Model Test (SMT) methodology is to incorporate a SMT data-based approach for creep-fatigue damage evaluation into the EPP methodology to avoid the separate evaluation of creep and fatigue damage and eliminate the requirement for stress classification in current methods; thus greatly simplifying evaluation of elevated temperature cyclic service. The purpose of this methodology is to minimize over-conservatism while properly accounting for localized defects and stress risers. To support the implementation of the proposed methodology and to verify the applicability of the code rules, thermomechanical tests continued in FY17. This report presents the recent test results for Type 1 SMT specimens on Alloy 617 with long hold times, pressurization SMT on Alloy 617, and two-bar thermal ratcheting test results on SS316H at the temperature range of 405 °C to 705 °C. Preliminary EPP strain range analysis on the two-bar tests are critically evaluated and compared with the experimental results.

  10. Final Technical Report: Supporting Wind Turbine Research and Testing - Gearbox Durability Study

    Energy Technology Data Exchange (ETDEWEB)

    Matthew Malkin

    2012-04-30

    The combination of premature failure of wind turbine gearboxes and the downtime caused by those failures leads to an increase in the cost of electricity produced by the wind. There is a need for guidance to asset managers regarding how to maximize the longevity of their gearboxes in order to help keep the cost of wind energy as low as possible. A low cost of energy supports the US Department of Energy's goal of achieving 20% of the electricity in the United States produced by wind by the year 2030. DNV KEMA has leveraged our unique position in the industry as an independent third party engineering organization to study the problem of gearbox health management and develop guidance to project operators. This report describes the study. The study was conducted in four tasks. In Task 1, data that may be related to gearbox health and are normally available to wind project operators were collected for analysis. Task 2 took a more in-depth look at a small number of gearboxes to gain insight in to relevant failure modes. Task 3 brought together the previous tasks by evaluating the available data in an effort to identify data that could provide early indications of impending gearbox failure. Last, the observations from the work were collected to develop recommendations regarding gearbox health management.

  11. Therapeutical attitudes in tooth supported overdentures with ball attachements. Case report.

    Science.gov (United States)

    Țâncu, A M; Melescanu Imre, M; Preoteasa, C T; Preoteasa, E

    2014-01-01

    Tooth supported overdenture with ball attachments has a number of advantages in prosthetics, but presents some difficulties as well, which sometimes make impossible the use of these anchoring systems; these difficulties should be well known. In this regard we present a suggestive case. It is the case of a patient, aged 57, who came for treatment, suffering from subtotal maxillary and mandibular edentulism (present 11 and 21, respectively 33 and 43), previously having an overdenture prosthesis on natural teeth, with special systems - ball attachment type, dissatisfied with the treatment (due to repeated fractures and functional intolerance to dentures). Clinical examination revealed an increase of the vertical dimension of occlusion and reduced prosthetic space at a correct, functional DVO value, aspects that were explaining the patient's reported complaints. As a therapeutic approach, having into consideration the balance conditions that were favorable for complete dentures and the large ball attachments volume, which did not allow keeping them at a functional DVO at any of the jaws, and the relatively young age of the patient, it was decided to remove the ball attachments and to keep the teeth for a simple overdenture, both to the maxillar and the mandible, over coronary reduced teeth, enough to allow the denture thickness at a functional DVO. Good end result of prosthetics, with stable, functional dentures, which were well tolerated and offered satisfaction to the patient, have led to an increased quality of life.

  12. Therapeutical attitudes in tooth supported overdentures with ball attachements. Case report

    Science.gov (United States)

    Țâncu, AM; Melescanu Imre, M; Preoteasa, CT; Preoteasa, E

    2014-01-01

    Tooth supported overdenture with ball attachments has a number of advantages in prosthetics, but presents some difficulties as well, which sometimes make impossible the use of these anchoring systems; these difficulties should be well known. In this regard we present a suggestive case. It is the case of a patient, aged 57, who came for treatment, suffering from subtotal maxillary and mandibular edentulism (present 11 and 21, respectively 33 and 43), previously having an overdenture prosthesis on natural teeth, with special systems – ball attachment type, dissatisfied with the treatment (due to repeated fractures and functional intolerance to dentures). Clinical examination revealed an increase of the vertical dimension of occlusion and reduced prosthetic space at a correct, functional DVO value, aspects that were explaining the patient’s reported complaints. As a therapeutic approach, having into consideration the balance conditions that were favorable for complete dentures and the large ball attachments volume, which did not allow keeping them at a functional DVO at any of the jaws, and the relatively young age of the patient, it was decided to remove the ball attachments and to keep the teeth for a simple overdenture, both to the maxillar and the mandible, over coronary reduced teeth, enough to allow the denture thickness at a functional DVO. Good end result of prosthetics, with stable, functional dentures, which were well tolerated and offered satisfaction to the patient, have led to an increased quality of life. PMID:27057258

  13. Semi-Annual Report on Work Supporting the International Forum for Reactor Aging Management (IFRAM)

    Energy Technology Data Exchange (ETDEWEB)

    Bond, Leonard J.; Brenchley, David L.

    2011-11-30

    During the first six months of this project, Pacific Northwest National Laboratory has provided planning and leadership support for the establishment of the International Forum for Reactor Aging Management (IFRAM). This entailed facilitating the efforts of the Global Steering Committee to prepare the charter, operating guidelines, and other documents for IFRAM. It also included making plans for the Inaugural meeting and facilitating its success. This meeting was held on August 4 5, 2011, in Colorado Springs, Colorado. Representatives from Asia, Europe, and the United States met to share information on reactor aging management and to make plans for the future. Professor Tetsuo Shoji was elected chairperson of the Leadership Council. This kick-off event transformed the dream of an international forum into a reality. On August 4-5, 2011, IFRAM began to achieve its mission. The work completed successfully during this period was built upon important previous efforts. This included the development of a proposal for establishing IFRAM and engaging experts in Asia and Europe. The proposal was presented at Engagement workshops in Seoul, Korea (October 2009) and Petten, The Netherlands (May 2010). Participants in both groups demonstrated strong interest in the establishment of IFRAM. Therefore, the Global Steering Committee was formed to plan and carry out the start-up of IFRAM in 2011. This report builds on the initial activities and documents the results of activities over the last six months.

  14. 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.

  15. 94-1 Research and Development Project Lead laboratory support. Status report, October 1--December 31, 1995

    Energy Technology Data Exchange (ETDEWEB)

    Dinehart, M. [comp.

    1996-05-01

    This is a quarterly progress report of the 94-1 Research and Development Lead Laboratory Support Technical Program Plan for the first quarter of FY 1996. The report provides details concerning descriptions, DOE-complex-wide material stabilization technology needs, scientific background and approach, progress, benefits to the DOE complex, and collaborations for selected subprojects. An executive summary and report on end-of-quarter spending is included.

  16. 94-1 Research and Development Project Lead laboratory support. Status report, October 1--December 31, 1995

    International Nuclear Information System (INIS)

    Dinehart, M.

    1996-05-01

    This is a quarterly progress report of the 94-1 Research and Development Lead Laboratory Support Technical Program Plan for the first quarter of FY 1996. The report provides details concerning descriptions, DOE-complex-wide material stabilization technology needs, scientific background and approach, progress, benefits to the DOE complex, and collaborations for selected subprojects. An executive summary and report on end-of-quarter spending is included

  17. Self-reported differences in empowerment between lurkers and posters in online patient support groups.

    NARCIS (Netherlands)

    van Uden-Kraan, Cornelia F.; Drossaert, Constance H C; Taal, Erik; Seydel, Erwin R.; van de Laar, M.A.

    2008-01-01

    BACKGROUND: Patients who visit online support groups benefit in various ways. Results of our earlier study indicated that participation in online support groups had a profound effect on the participants' feelings of "being empowered." However, most studies of online patient support groups have

  18. Self-reported differences in empowerment between lurkers and posters in online patient support groups

    NARCIS (Netherlands)

    Kraan, C.F.; Drossaert, Constance H.C.; Taal, Erik; Seydel, E.R.; van de Laar, Mart A F J

    2008-01-01

    Background: Patients who visit online support groups benefit in various ways. Results of our earlier study indicated that participation in online support groups had a profound effect on the participants’ feelings of “being empowered.” However, most studies of online patient support groups have

  19. Help prevent hospital errors

    Science.gov (United States)

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

  20. 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

  1. 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)

  2. 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

  3. 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...

  4. 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

  5. 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.

  6. Elmo Bumpy Torus proof of principle, Phase II: Title 1 report. Volume IX. Support structure

    International Nuclear Information System (INIS)

    Conlee, J.L.

    1982-01-01

    The EBT-P support structure provides structural support for the 36 mirror coil magnets, magnet protection system, the toroidal vessel, and much of the device ancillary equipment. The structure is comprised of a primary support and a superstructure. The primary support is a reinforced concrete ring located directly inboard of the torus and is supported by nine columns. The toroidal vessel and the mirror coil magnets are cantilevered from the ring with the centerline of the torus located eight feet above the floor. The superstructure is an aluminum truss structure that rests on the concrete ring. The superstructure provides support for the device ancillary equipment. Engineering drawings of the support structure are given

  7. Apologies and Medical Error

    Science.gov (United States)

    2008-01-01

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

  8. Thermodynamics of Error Correction

    Directory of Open Access Journals (Sweden)

    Pablo Sartori

    2015-12-01

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

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

    Science.gov (United States)

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

    2016-04-01

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

  10. 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)

  11. Professional medical writing support and the quality of randomised controlled trial reporting: a cross-sectional study.

    Science.gov (United States)

    Gattrell, William T; Hopewell, Sally; Young, Kate; Farrow, Paul; White, Richard; Wager, Elizabeth; Winchester, Christopher C

    2016-02-21

    Authors may choose to work with professional medical writers when writing up their research for publication. We examined the relationship between medical writing support and the quality and timeliness of reporting of the results of randomised controlled trials (RCTs). Cross-sectional study. Primary reports of RCTs published in BioMed Central journals from 2000 to 16 July 2014, subdivided into those with medical writing support (n=110) and those without medical writing support (n=123). Proportion of items that were completely reported from a predefined subset of the Consolidated Standards of Reporting Trials (CONSORT) checklist (12 items known to be commonly poorly reported), overall acceptance time (from manuscript submission to editorial acceptance) and quality of written English as assessed by peer reviewers. The effect of funding source and publication year was examined. The number of articles that completely reported at least 50% of the CONSORT items assessed was higher for those with declared medical writing support (39.1% (43/110 articles); 95% CI 29.9% to 48.9%) than for those without (21.1% (26/123 articles); 95% CI 14.3% to 29.4%). Articles with declared medical writing support were more likely than articles without such support to have acceptable written English (81.1% (43/53 articles); 95% CI 67.6% to 90.1% vs 47.9% (23/48 articles); 95% CI 33.5% to 62.7%). The median time of overall acceptance was longer for articles with declared medical writing support than for those without (167 days (IQR 114.5-231 days) vs 136 days (IQR 77-193 days)). In this sample of open-access journals, declared professional medical writing support was associated with more complete reporting of clinical trial results and higher quality of written English. Medical writing support may play an important role in raising the quality of clinical trial reporting. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go

  12. Monitoring and Evaluation; Statistical Support for Life-cycle Studies, 2003 Annual Report.

    Energy Technology Data Exchange (ETDEWEB)

    Skalski, John

    2003-12-01

    This report summarizes the statistical analysis and consulting activities performed under Contract No. 00004134, Project No. 199105100 funded by Bonneville Power Administration during 2003. These efforts are focused on providing real-time predictions of outmigration timing, assessment of life-history performance measures, evaluation of status and trends in recovery, and guidance on the design and analysis of Columbia Basin fish and wildlife studies monitoring and evaluation studies. The overall objective of the project is to provide BPA and the rest of the fisheries community with statistical guidance on design, analysis, and interpretation of monitoring data, which will lead to improved monitoring and evaluation of salmonid mitigation programs in the Columbia/Snake River Basin. This overall goal is being accomplished by making fisheries data readily available for public scrutiny, providing statistical guidance on the design and analyses of studies by hands-on support and written documents, and providing real-time analyses of tagging results during the smolt outmigration for review by decision makers. For a decade, this project has been providing in-season projections of smolt outmigration timing to assist in spill management. As many as 50 different fish stocks at 8 different hydroprojects are tracked and real-time to predict the 'percent of run to date' and 'date to specific percentile'. The project also conducts added-value analyses of historical tagging data to understand relationships between fish responses, environmental factors, and anthropogenic effects. The statistical analysis of historical tagging data crosses agency lines in order to assimilate information on salmon population dynamics irrespective of origin. The lessons learned from past studies are used to improve the design and analyses of future monitoring and evaluation efforts. Through these efforts, the project attempts to provide the fisheries community with reliable analyses

  13. [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.

  14. Relationship Between Self-Assessed Fidelity and Self-Reported Employment in the Individual Placement and Support Model of Supported Employment.

    Science.gov (United States)

    Margolies, Paul J; Humensky, Jennifer L; Chiang, I-Chin; Covell, Nancy H; Jewell, Thomas C; Broadway-Wilson, Karen; Gregory, Raymond; Scannevin, Gary; Dixon, Lisa B

    2018-05-01

    A growing body of literature demonstrates that high-fidelity implementation of the individual placement and support (IPS) model of supported employment increases the chances of achieving desired outcomes. This study examined the relationship between IPS fidelity, as self-reported by program sites, and employment outcomes and determined whether this relationship was maintained over time. A total of 78 outpatient programs in New York State provided data on self-reported IPS fidelity and employment outcomes. Pearson correlations were used to determine the relationship between fidelity scores and competitive employment rates. A mixed-effects model examined the relationship between repeated fidelity and employment measures over time. A significant positive relationship was found between better self-reported IPS fidelity and greater employment. The relationship between IPS fidelity and employment was sustained over time (up to one year). Higher-fidelity implementation of the IPS model, as self-assessed by program sites, was associated with higher employment rates, which were sustained over time.

  15. 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.

  16. 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.

  17. Clinical research in implant dentistry: evaluation of implant-supported restorations, aesthetic and patient-reported outcomes.

    Science.gov (United States)

    Lang, Niklaus P; Zitzmann, Nicola U

    2012-02-01

    The articles discussed in working group 3 dealt with specific aspects of clinical research. In this context, the literature reporting on survival and complication rates of implant-supported or implant-tooth supported restorations in longitudinal studies of at least 5 years were discussed. The second aspect dealt with the evaluation of aesthetic outcomes in clinical studies and the related index systems available. Finally, the third aspect discussed dealt with patient-reported outcome measures (PROMs). A detailed appraisal of the available methodology was presented. © 2012 John Wiley & Sons A/S.

  18. 94-1 Research and development project lead laboratory support. Status report, July 1, 1996--September 30, 1996

    Energy Technology Data Exchange (ETDEWEB)

    Rink, N. [comp.

    1997-03-01

    This document reports status and technical progress for Los Alamos 94-1 Research and Development projects. Updated schedule charts are shown in the appendix. This is the fourth status report published for Los Alamos National Laboratory 94-1 Research and Development Project Support. The Department of Energy Office of Environmental Management (DOE/EM) funds these projects in order to support the storage or disposal of legacy plutonium and plutonium-bearing materials resulting from weapons production throughout the DOE complex. This document also serves as an end-for-year review of projects and positions the program for FY97.

  19. GPHS-RTGs in support of the Cassini Mission. Semi annual technical report, 30 September 1996--30 March 1997

    International Nuclear Information System (INIS)

    1997-01-01

    The technical progress achieved during the period 27 January through 30 September 1996 through 30 March 1997 on Contract DE-AC03-91SF18852 Radioisotope Thermoelectric Generators and Ancillary Activities is described. This report is organized by program task structure: spacecraft integration and liaison; engineering support; safety; qualified unicouple production; ETG fabrication, assembly, and test; ground support equipment (GSE); RTG shipping and launch support; designs, reviews, and mission applications; project management, quality assurance, reliability, contract changes, CAGO acquisition (operating funds), and CAGO maintenance and repair; and CAGO acquisition (capital funds)

  20. Social Support and Self-Reported Stress Levels in a Predominantly African American Sample of Women with Systemic Lupus Erythematosus

    Directory of Open Access Journals (Sweden)

    Edith Marie Williams

    2015-01-01

    Full Text Available Lupus patients should avoid stress because physical or emotional stress can affect overall physical health. It has been suggested that social support has a positive influence on health status, but there is a lack of information in the literature on the association between the two among lupus patients. The current study investigated the association between social support and self-reported stress and coping status among African American women with lupus using data collected from two linked cross-sectional surveys. No social support differences in groups of high and low stress/coping were revealed; a duplicate study with a larger sample size is required.

  1. Structural revisions of small molecules reported to cross-link G-quadruplex DNA in vivo reveal a repetitive assignment error in the literature

    Czech Academy of Sciences Publication Activity Database

    Reyes Gutierrez, Paul Eduardo; Kapal, Tomáš; Klepetářová, Blanka; Šaman, David; Pohl, Radek; Zawada, Zbigniew; Kužmová, Erika; Hájek, Miroslav; Teplý, Filip

    2016-01-01

    Roč. 6, Mar 23 (2016), č. článku 23499. ISSN 2045-2322 R&D Projects: GA ČR GA13-19213S; GA MŠk LO1302 Grant - others:AV ČR(CZ) M200551208 Institutional support: RVO:61388963 Keywords : 1,2-disubstituted benzimidazoles * chemical synthesis * promoter region Subject RIV: CC - Organic Chemistry Impact factor: 4.259, year: 2016 http://www.nature.com/articles/srep23499

  2. Beyond Mentoring: Social Support Structures for Young Australian Carpentry Apprentices. Research Report

    Science.gov (United States)

    Buchanan, John; Raffaele, Catherine; Glozier, Nick; Kanagaratnam, Aran

    2016-01-01

    This research focused on how apprenticeships, at their best, provide extensive social support for young people. It draws on, and contributes to, debates about workforce (and especially vocational) development in contemporary Australia. It also contributes to the growing literature on social support and health, especially the role that work could…

  3. Tube-support response to tube-denting evaluation. Volume 1. Final report

    International Nuclear Information System (INIS)

    Anderson, P.L.; Hall, J.F.; Shah, P.K.; Wills, R.L.

    1983-05-01

    The response of the tube supports is one of the important considerations of tube denting in a steam generator. Investigations have indicated that damaged tube supports have the potential to distort and damage tubes. This investigation considers the response to tube denting of the Combustion Engineering type tube supports. Drilled support plates and eggcrate tube supports are tested in a model steam generator in which tube denting is induced. The experimental data is used to verify and refine analytical predictor models developed using finite element techniques. It was found that analytical models underpredicted the deformations of the tube supports and appropriate modifications to enhance the predictive capability are identified. Non-destructive examination methods are evaluated for application to operating steam generators. It was found that the standard eddy current and profilometry techniques are acceptable methods for determining tube deformations, but these techniques are not adequate to assess tube support damage. Radiography is judged to be the best available means of determining the extent and progression of damage in tube supports

  4. Hungarian national report on activities related to operator support systems for nuclear power plants

    International Nuclear Information System (INIS)

    Adorjan, F.; Lux, I.; Vegh, J.; Vegh, E.

    1996-01-01

    Computerized operator support systems and related activities in Hungary are summarized. Systems developed in the past, presently developed and used as well as being in a planning phase are briefly described. Activity of the Hungarian participants in the framework of the co-ordinated project on operator support systems for nuclear power plant is summarized. (author). 55 refs

  5. Project Management Support and Services for the Environmental Restoration and Waste Management. Final report

    International Nuclear Information System (INIS)

    1995-01-01

    The Los Alamos National Laboratory (LANL) Environmental Restoration Technical Support Office (ERTSO) contracted Project Time ampersand Cost, Inc. (PT ampersand C) on 16 November 1992 to provide support services to the US Department of Energy (DOE). ERTSO had traditionally supported the DOE Albuquerque office in the Environmental Restoration and Waste Management Programs and had also supported the Office of Waste Management (EM-30) at DOE Headquarters in Germantown, Maryland. PT ampersand C was requested to provide project management and support services for the DOE as well as liaison and coordination of responses and efforts between various agencies. The primary objective of this work was to continue LANL's technical support role to EM-30 and assist in the development of the COE Cost and Schedule Estimating (CASE) Guide for EM-30. PT ampersand C's objectives, as specified in Section B of the contract, were well met during the duration of the project through the review and comment of various draft documents, trips to DOE sites providing program management support and participating in the training for the EM-30 Cost and Schedule Estimating Guide, drafting memos and scheduling future projects, attending numerous meetings with LANL, DOE and other subcontractors, and providing written observations and recommendations.he results obtained were determined to be satisfactory by both the LANL ERTSO and DOE EM-30 organizations. The objective to further the support from LANL and their associated subcontractor (PT ampersand C) was met. The contract concluded with no outstanding issues

  6. Performance of planning support systems: what is it, and how do we report on it?

    NARCIS (Netherlands)

    te Brömmelstroet, M.C.G.

    2013-01-01

    Planning Support Systems (PSSs) are a family of computer based instruments specifically designed to support actors in their complex tasks in the field of planning. There is a gap between the high expectations that PSS developers have about the usefulness of their instruments and the instruments’

  7. Student Support Funding for Higher Education Institutions, 2001-02. Report.

    Science.gov (United States)

    Higher Education Funding Council for England, Bristol.

    This publication provides information about the allocation of funds for student support to higher education institutions in England in 2001-2002 and requests monitoring information on the use of these funds. Student support funds include a variety of services to students, including fee waivers, help with living costs in some cases, and child care…

  8. Twitter Social Media is an Effective Tool for Breast Cancer Patient Education and Support: Patient-Reported Outcomes by Survey.

    Science.gov (United States)

    Attai, Deanna J; Cowher, Michael S; Al-Hamadani, Mohammed; Schoger, Jody M; Staley, Alicia C; Landercasper, Jeffrey

    2015-07-30

    Despite reported benefits, many women do not attend breast cancer support groups. Abundant online resources for support exist, but information regarding the effectiveness of participation is lacking. We report the results of a Twitter breast cancer support community participant survey. The aim was to determine the effectiveness of social media as a tool for breast cancer patient education and decreasing anxiety. The Breast Cancer Social Media Twitter support community (#BCSM) began in July 2011. Institutional review board approval with a waiver of informed consent was obtained for a deidentified survey that was posted for 2 weeks on Twitter and on the #BCSM blog and Facebook page. There were 206 respondents to the survey. In all, 92.7% (191/206) were female. Respondents reported increased knowledge about breast cancer in the following domains: overall knowledge (80.9%, 153/189), survivorship (85.7%, 162/189), metastatic breast cancer (79.4%, 150/189), cancer types and biology (70.9%, 134/189), clinical trials and research (66.1%, 125/189), treatment options (55.6%, 105/189), breast imaging (56.6%, 107/189), genetic testing and risk assessment (53.9%, 102/189), and radiotherapy (43.4%, 82/189). Participation led 31.2% (59/189) to seek a second opinion or bring additional information to the attention of their treatment team and 71.9% (136/189) reported plans to increase their outreach and advocacy efforts as a result of participation. Levels of reported anxiety before and after participation were analyzed: 29 of 43 (67%) patients who initially reported "high or extreme" anxiety reported "low or no" anxiety after participation (Psocial media support group.

  9. Use of patient-reported outcomes in outpatient settings as a means of patient involvement and self-management support

    DEFF Research Database (Denmark)

    Mejdahl, Caroline; Nielsen, Berit Kjærside; Hjøllund, Niels Henrik Ingvar

    2016-01-01

    Rationale, aims and objectives: Patient-reported outcomes (PROs) are being implemented in clinical practice across different healthcare settings with varying purposes. Involving patients in reporting outcomes may increase their attention to symptoms and thereby support their self-management. The ...... to strengthen patient involvement and securing benefit from PROs.......Rationale, aims and objectives: Patient-reported outcomes (PROs) are being implemented in clinical practice across different healthcare settings with varying purposes. Involving patients in reporting outcomes may increase their attention to symptoms and thereby support their self......-management. The aim of the present study was to describe patients’ experiences with a web-based PRO system where patients complete a PRO questionnaire at home or in the outpatient clinic prior to a consultation. Moreover, the study aimed to explore how PROs influenced the interaction between patients and clinicians...

  10. A Crime Analysis Decision Support System for Crime Report Classification and Visualization

    Science.gov (United States)

    Ku, Chih-Hao

    2012-01-01

    Today's Internet-based crime reporting systems make timely and anonymous crime reporting possible. However, these reports also result in a rapidly growing set of unstructured text files. Complicating the problem is that the information has not been filtered or guided in a detective-led interview resulting in much irrelevant information. To…

  11. Final Report for Subcontract B541028, Pore-Scale Modeling to Support 'Pore Connectivity' Research Work

    International Nuclear Information System (INIS)

    Ewing, R.P.

    2009-01-01

    This report covers modeling aspects of a combined experimental and modeling task in support of the DOE Science and Technology Program (formerly OSTI) within the Office of Civilian Radioactive Waste Management (OCRWM). Research Objectives The research for this project dealt with diffusive retardation: solute moving through a fracture diffuses into and out of the rock matrix. This diffusive exchange retards overall solute movement, and retardation both dilutes waste being released, and allows additional decay. Diffusive retardation involves not only fracture conductivity and matrix diffusion, but also other issues and processes: contaminants may sorb to the rock matrix, fracture flow may be episodic, a given fracture may or may not flow depending on the volume of flow and the fracture's connection to the overall fracture network, the matrix imbibes water during flow episodes and dries between episodes, and so on. The objective of the project was to improve understanding of diffusive retardation of radionuclides due to fracture / matrix interactions. Results from combined experimental/modeling work were to (1) determine whether the current understanding and model representation of matrix diffusion is valid, (2) provide insights into the upscaling of laboratory-scale diffusion experiments, and (3) help in evaluating the impact on diffusive retardation of episodic fracture flow and pore connectivity in Yucca Mountain tuffs. Questions explored included the following: (1) What is the relationship between the diffusion coefficient measured at one scale, to that measured or observed at a different scale? In classical materials this relationship is trivial; in low-connectivity materials it is not. (2) Is the measured diffusivity insensitive to the shape of the sample? Again, in classical materials there should be no sample shape effect. (3) Does sorption affect diffusive exchange in low-connectivity media differently than in classical media? (4) What is the effect of matrix

  12. LIBERTARISMO & ERROR CATEGORIAL

    Directory of Open Access Journals (Sweden)

    Carlos G. Patarroyo G.

    2009-01-01

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

  13. Libertarismo & Error Categorial

    OpenAIRE

    PATARROYO G, CARLOS G

    2009-01-01

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

  14. Error Free Software

    Science.gov (United States)

    1985-01-01

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

  15. Diagnostic Error in Stroke-Reasons and Proposed Solutions.

    Science.gov (United States)

    Bakradze, Ekaterina; Liberman, Ava L

    2018-02-13

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

  16. Bayesian network models for error detection in radiotherapy plans

    International Nuclear Information System (INIS)

    Kalet, Alan M; Ford, Eric C; Phillips, Mark H; Gennari, John H

    2015-01-01

    The purpose of this study is to design and develop a probabilistic network for detecting errors in radiotherapy plans for use at the time of initial plan verification. Our group has initiated a multi-pronged approach to reduce these errors. We report on our development of Bayesian models of radiotherapy plans. Bayesian networks consist of joint probability distributions that define the probability of one event, given some set of other known information. Using the networks, we find the probability of obtaining certain radiotherapy parameters, given a set of initial clinical information. A low probability in a propagated network then corresponds to potential errors to be flagged for investigation. To build our networks we first interviewed medical physicists and other domain experts to identify the relevant radiotherapy concepts and their associated interdependencies and to construct a network topology. Next, to populate the network’s conditional probability tables, we used the Hugin Expert software to learn parameter distributions from a subset of de-identified data derived from a radiation oncology based clinical information database system. These data represent 4990 unique prescription cases over a 5 year period. Under test case scenarios with approximately 1.5% introduced error rates, network performance produced areas under the ROC curve of 0.88, 0.98, and 0.89 for the lung, brain and female breast cancer error detection networks, respectively. Comparison of the brain network to human experts performance (AUC of 0.90 ± 0.01) shows the Bayes network model performs better than domain experts under the same test conditions. Our results demonstrate the feasibility and effectiveness of comprehensive probabilistic models as part of decision support systems for improved detection of errors in initial radiotherapy plan verification procedures. (paper)

  17. Further HTGR core support structure reliability studies. Interim report No. 1

    International Nuclear Information System (INIS)

    Platus, D.L.

    1976-01-01

    Results of a continuing effort to investigate high temperature gas cooled reactor (HTGR) core support structure reliability are described. Graphite material and core support structure component physical, mechanical and strength properties required for the reliability analysis are identified. Also described are experimental and associated analytical techniques for determining the required properties, a procedure for determining number of tests required, properties that might be monitored by special surveillance of the core support structure to improve reliability predictions, and recommendations for further studies. Emphasis in the study is directed towards developing a basic understanding of graphite failure and strength degradation mechanisms; and validating analytical methods for predicting strength and strength degradation from basic material properties

  18. Child Support Enforcement Annual Data Report Form 34A – 2011

    Data.gov (United States)

    U.S. Department of Health & Human Services — This dataset contains annual data on collections received and distributed by State agencies administering the Child Support Enforcement program under title IV-D of...

  19. Report of the psychological support given to victims of the Goiania radiological accident in Brazil

    International Nuclear Information System (INIS)

    Nunes, Lenice Cruvinel; Pereira, Maria Emilia Pontes

    1988-02-01

    The psychological support given to the victims of the Goiania accident are described. The assistance lasted two months on the average and was given while the victims were in the hospital