Sample records for calculated human error

  1. Do calculation errors by nurses cause medication errors in clinical practice? A literature review.

    PubMed

    Wright, Kerri

    2010-01-01

    This review aims to examine the literature available to ascertain whether medication errors in clinical practice are the result of nurses' miscalculating drug dosages. The research studies highlighting poor calculation skills of nurses and student nurses have been tested using written drug calculation tests in formal classroom settings [Kapborg, I., 1994. Calculation and administration of drug dosage by Swedish nurses, student nurses and physicians. International Journal for Quality in Health Care 6(4): 389 -395; Hutton, M., 1998. Nursing Mathematics: the importance of application Nursing Standard 13(11): 35-38; Weeks, K., Lynne, P., Torrance, C., 2000. Written drug dosage errors made by students: the threat to clinical effectiveness and the need for a new approach. Clinical Effectiveness in Nursing 4, 20-29]; Wright, K., 2004. Investigation to find strategies to improve student nurses' maths skills. British Journal Nursing 13(21) 1280-1287; Wright, K., 2005. An exploration into the most effective way to teach drug calculation skills to nursing students. Nurse Education Today 25, 430-436], but there have been no reviews of the literature on medication errors in practice that specifically look to see whether the medication errors are caused by nurses' poor calculation skills. The databases Medline, CINAHL, British Nursing Index (BNI), Journal of American Medical Association (JAMA) and Archives and Cochrane reviews were searched for research studies or systematic reviews which reported on the incidence or causes of drug errors in clinical practice. In total 33 articles met the criteria for this review. There were no studies that examined nurses' drug calculation errors in practice. As a result studies and systematic reviews that investigated the types and causes of drug errors were examined to establish whether miscalculations by nurses were the causes of errors. The review found insufficient evidence to suggest that medication errors are caused by nurses' poor

  2. Human Error: A Concept Analysis

    NASA Technical Reports Server (NTRS)

    Hansen, Frederick D.

    2007-01-01

    Human error is the subject of research in almost every industry and profession of our times. This term is part of our daily language and intuitively understood by most people however, it would be premature to assume that everyone's understanding of human error s the same. For example, human error is used to describe the outcome or consequence of human action, the causal factor of an accident, deliberate violations,a nd the actual action taken by a human being. As a result, researchers rarely agree on the either a specific definition or how to prevent human error. The purpose of this article is to explore the specific concept of human error using Concept Analysis as described by Walker and Avant (1995). The concept of human error is examined as currently used in the literature of a variety of industries and professions. Defining attributes and examples of model, borderline, and contrary cases are described. The antecedents and consequences of human error are also discussed and a definition of human error is offered.

  3. Human Error In Complex Systems

    NASA Technical Reports Server (NTRS)

    Morris, Nancy M.; Rouse, William B.

    1991-01-01

    Report presents results of research aimed at understanding causes of human error in such complex systems as aircraft, nuclear powerplants, and chemical processing plants. Research considered both slips (errors of action) and mistakes (errors of intention), and influence of workload on them. Results indicated that: humans respond to conditions in which errors expected by attempting to reduce incidence of errors; and adaptation to conditions potent influence on human behavior in discretionary situations.

  4. A theory of human error

    NASA Technical Reports Server (NTRS)

    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.

  5. Human error in airway facilities.

    DOT National Transportation Integrated Search

    2001-01-01

    This report examines human errors in Airway Facilities (AF) with the intent of preventing these errors from being : passed on to the new Operations Control Centers. To effectively manage errors, they first have to be identified. : Human factors engin...

  6. On the Calculation of Uncertainty Statistics with Error Bounds for CFD Calculations Containing Random Parameters and Fields

    NASA Technical Reports Server (NTRS)

    Barth, Timothy J.

    2016-01-01

    This chapter discusses the ongoing development of combined uncertainty and error bound estimates for computational fluid dynamics (CFD) calculations subject to imposed random parameters and random fields. An objective of this work is the construction of computable error bound formulas for output uncertainty statistics that guide CFD practitioners in systematically determining how accurately CFD realizations should be approximated and how accurately uncertainty statistics should be approximated for output quantities of interest. Formal error bounds formulas for moment statistics that properly account for the presence of numerical errors in CFD calculations and numerical quadrature errors in the calculation of moment statistics have been previously presented in [8]. In this past work, hierarchical node-nested dense and sparse tensor product quadratures are used to calculate moment statistics integrals. In the present work, a framework has been developed that exploits the hierarchical structure of these quadratures in order to simplify the calculation of an estimate of the quadrature error needed in error bound formulas. When signed estimates of realization error are available, this signed error may also be used to estimate output quantity of interest probability densities as a means to assess the impact of realization error on these density estimates. Numerical results are presented for CFD problems with uncertainty to demonstrate the capabilities of this framework.

  7. A theory of human error

    NASA Technical Reports Server (NTRS)

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

    1980-01-01

    Human error, a significant contributing factor in a very high proportion of civil transport, general aviation, and rotorcraft accidents is investigated. Correction of the sources of human error requires that one attempt to reconstruct underlying and contributing causes of error from the circumstantial causes cited in official investigative reports. 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 operations is presented. 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. Stochastic Models of Human Errors

    NASA Technical Reports Server (NTRS)

    Elshamy, Maged; Elliott, Dawn M. (Technical Monitor)

    2002-01-01

    Humans play an important role in the overall reliability of engineering systems. More often accidents and systems failure are traced to human errors. Therefore, in order to have meaningful system risk analysis, the reliability of the human element must be taken into consideration. Describing the human error process by mathematical models is a key to analyzing contributing factors. Therefore, the objective of this research effort is to establish stochastic models substantiated by sound theoretic foundation to address the occurrence of human errors in the processing of the space shuttle.

  9. Understanding human management of automation errors.

    PubMed

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

    2014-01-01

    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.

  10. Human error and human factors engineering in health care.

    PubMed

    Welch, D L

    1997-01-01

    Human error is inevitable. It happens in health care systems as it does in all other complex systems, and no measure of attention, training, dedication, or punishment is going to stop it. The discipline of human factors engineering (HFE) has been dealing with the causes and effects of human error since the 1940's. Originally applied to the design of increasingly complex military aircraft cockpits, HFE has since been effectively applied to the problem of human error in such diverse systems as nuclear power plants, NASA spacecraft, the process control industry, and computer software. Today the health care industry is becoming aware of the costs of human error and is turning to HFE for answers. Just as early experimental psychologists went beyond the label of "pilot error" to explain how the design of cockpits led to air crashes, today's HFE specialists are assisting the health care industry in identifying the causes of significant human errors in medicine and developing ways to eliminate or ameliorate them. This series of articles will explore the nature of human error and how HFE can be applied to reduce the likelihood of errors and mitigate their effects.

  11. Understanding human management of automation errors

    PubMed Central

    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

  12. A Method of Calculating Motion Error in a Linear Motion Bearing Stage

    PubMed Central

    Khim, Gyungho; Park, Chun Hong; Oh, Jeong Seok

    2015-01-01

    We report a method of calculating the motion error of a linear motion bearing stage. The transfer function method, which exploits reaction forces of individual bearings, is effective for estimating motion errors; however, it requires the rail-form errors. This is not suitable for a linear motion bearing stage because obtaining the rail-form errors is not straightforward. In the method described here, we use the straightness errors of a bearing block to calculate the reaction forces on the bearing block. The reaction forces were compared with those of the transfer function method. Parallelism errors between two rails were considered, and the motion errors of the linear motion bearing stage were measured and compared with the results of the calculations, revealing good agreement. PMID:25705715

  13. Error estimates for ice discharge calculated using the flux gate approach

    NASA Astrophysics Data System (ADS)

    Navarro, F. J.; Sánchez Gámez, P.

    2017-12-01

    Ice discharge to the ocean is usually estimated using the flux gate approach, in which ice flux is calculated through predefined flux gates close to the marine glacier front. However, published results usually lack a proper error estimate. In the flux calculation, both errors in cross-sectional area and errors in velocity are relevant. While for estimating the errors in velocity there are well-established procedures, the calculation of the error in the cross-sectional area requires the availability of ground penetrating radar (GPR) profiles transverse to the ice-flow direction. In this contribution, we use IceBridge operation GPR profiles collected in Ellesmere and Devon Islands, Nunavut, Canada, to compare the cross-sectional areas estimated using various approaches with the cross-sections estimated from GPR ice-thickness data. These error estimates are combined with those for ice-velocities calculated from Sentinel-1 SAR data, to get the error in ice discharge. Our preliminary results suggest, regarding area, that the parabolic cross-section approaches perform better than the quartic ones, which tend to overestimate the cross-sectional area for flight lines close to the central flowline. Furthermore, the results show that regional ice-discharge estimates made using parabolic approaches provide reasonable results, but estimates for individual glaciers can have large errors, up to 20% in cross-sectional area.

  14. Human errors and measurement uncertainty

    NASA Astrophysics Data System (ADS)

    Kuselman, Ilya; Pennecchi, Francesca

    2015-04-01

    Evaluating the residual risk of human errors in a measurement and testing laboratory, remaining after the error reduction by the laboratory quality system, and quantifying the consequences of this risk for the quality of the measurement/test results are discussed based on expert judgments and Monte Carlo simulations. A procedure for evaluation of the contribution of the residual risk to the measurement uncertainty budget is proposed. Examples are provided using earlier published sets of expert judgments on human errors in pH measurement of groundwater, elemental analysis of geological samples by inductively coupled plasma mass spectrometry, and multi-residue analysis of pesticides in fruits and vegetables. The human error contribution to the measurement uncertainty budget in the examples was not negligible, yet also not dominant. This was assessed as a good risk management result.

  15. Approaches to reducing photon dose calculation errors near metal implants

    DOE Office of Scientific and Technical Information (OSTI.GOV)

    Huang, Jessie Y.; Followill, David S.; Howell, Reb

    Purpose: Dose calculation errors near metal implants are caused by limitations of the dose calculation algorithm in modeling tissue/metal interface effects as well as density assignment errors caused by imaging artifacts. The purpose of this study was to investigate two strategies for reducing dose calculation errors near metal implants: implementation of metal-based energy deposition kernels in the convolution/superposition (C/S) dose calculation method and use of metal artifact reduction methods for computed tomography (CT) imaging. Methods: Both error reduction strategies were investigated using a simple geometric slab phantom with a rectangular metal insert (composed of titanium or Cerrobend), as well asmore » two anthropomorphic phantoms (one with spinal hardware and one with dental fillings), designed to mimic relevant clinical scenarios. To assess the dosimetric impact of metal kernels, the authors implemented titanium and silver kernels in a commercial collapsed cone C/S algorithm. To assess the impact of CT metal artifact reduction methods, the authors performed dose calculations using baseline imaging techniques (uncorrected 120 kVp imaging) and three commercial metal artifact reduction methods: Philips Healthcare’s O-MAR, GE Healthcare’s monochromatic gemstone spectral imaging (GSI) using dual-energy CT, and GSI with metal artifact reduction software (MARS) applied. For the simple geometric phantom, radiochromic film was used to measure dose upstream and downstream of metal inserts. For the anthropomorphic phantoms, ion chambers and radiochromic film were used to quantify the benefit of the error reduction strategies. Results: Metal kernels did not universally improve accuracy but rather resulted in better accuracy upstream of metal implants and decreased accuracy directly downstream. For the clinical cases (spinal hardware and dental fillings), metal kernels had very little impact on the dose calculation accuracy (<1.0%). Of the commercial CT

  16. Forecasting Error Calculation with Mean Absolute Deviation and Mean Absolute Percentage Error

    NASA Astrophysics Data System (ADS)

    Khair, Ummul; Fahmi, Hasanul; Hakim, Sarudin Al; Rahim, Robbi

    2017-12-01

    Prediction using a forecasting method is one of the most important things for an organization, the selection of appropriate forecasting methods is also important but the percentage error of a method is more important in order for decision makers to adopt the right culture, the use of the Mean Absolute Deviation and Mean Absolute Percentage Error to calculate the percentage of mistakes in the least square method resulted in a percentage of 9.77% and it was decided that the least square method be worked for time series and trend data.

  17. Analyzing human errors in flight mission operations

    NASA Technical Reports Server (NTRS)

    Bruno, Kristin J.; Welz, Linda L.; Barnes, G. Michael; Sherif, Josef

    1993-01-01

    A long-term program is in progress at JPL to reduce cost and risk of flight mission operations through a defect prevention/error management program. The main thrust of this program is to create an environment in which the performance of the total system, both the human operator and the computer system, is optimized. To this end, 1580 Incident Surprise Anomaly reports (ISA's) from 1977-1991 were analyzed from the Voyager and Magellan projects. A Pareto analysis revealed that 38 percent of the errors were classified as human errors. A preliminary cluster analysis based on the Magellan human errors (204 ISA's) is presented here. The resulting clusters described the underlying relationships among the ISA's. Initial models of human error in flight mission operations are presented. Next, the Voyager ISA's will be scored and included in the analysis. Eventually, these relationships will be used to derive a theoretically motivated and empirically validated model of human error in flight mission operations. Ultimately, this analysis will be used to make continuous process improvements continuous process improvements to end-user applications and training requirements. This Total Quality Management approach will enable the management and prevention of errors in the future.

  18. Paediatric electronic infusion calculator: An intervention to eliminate infusion errors in paediatric critical care.

    PubMed

    Venkataraman, Aishwarya; Siu, Emily; Sadasivam, Kalaimaran

    2016-11-01

    Medication errors, including infusion prescription errors are a major public health concern, especially in paediatric patients. There is some evidence that electronic or web-based calculators could minimise these errors. To evaluate the impact of an electronic infusion calculator on the frequency of infusion errors in the Paediatric Critical Care Unit of The Royal London Hospital, London, United Kingdom. We devised an electronic infusion calculator that calculates the appropriate concentration, rate and dose for the selected medication based on the recorded weight and age of the child and then prints into a valid prescription chart. Electronic infusion calculator was implemented from April 2015 in Paediatric Critical Care Unit. A prospective study, five months before and five months after implementation of electronic infusion calculator, was conducted. Data on the following variables were collected onto a proforma: medication dose, infusion rate, volume, concentration, diluent, legibility, and missing or incorrect patient details. A total of 132 handwritten prescriptions were reviewed prior to electronic infusion calculator implementation and 119 electronic infusion calculator prescriptions were reviewed after electronic infusion calculator implementation. Handwritten prescriptions had higher error rate (32.6%) as compared to electronic infusion calculator prescriptions (<1%) with a p  < 0.001. Electronic infusion calculator prescriptions had no errors on dose, volume and rate calculation as compared to handwritten prescriptions, hence warranting very few pharmacy interventions. Use of electronic infusion calculator for infusion prescription significantly reduced the total number of infusion prescribing errors in Paediatric Critical Care Unit and has enabled more efficient use of medical and pharmacy time resources.

  19. Human Error: The Stakes Are Raised.

    ERIC Educational Resources Information Center

    Greenberg, Joel

    1980-01-01

    Mistakes related to the operation of nuclear power plants and other technologically complex systems are discussed. Recommendations are given for decreasing the chance of human error in the operation of nuclear plants. The causes of the Three Mile Island incident are presented in terms of the human error element. (SA)

  20. Information systems and human error in the lab.

    PubMed

    Bissell, Michael G

    2004-01-01

    Health system costs in clinical laboratories are incurred daily due to human error. Indeed, a major impetus for automating clinical laboratories has always been the opportunity it presents to simultaneously reduce cost and improve quality of operations by decreasing human error. But merely automating these processes is not enough. To the extent that introduction of these systems results in operators having less practice in dealing with unexpected events or becoming deskilled in problemsolving, however new kinds of error will likely appear. Clinical laboratories could potentially benefit by integrating findings on human error from modern behavioral science into their operations. Fully understanding human error requires a deep understanding of human information processing and cognition. Predicting and preventing negative consequences requires application of this understanding to laboratory operations. Although the occurrence of a particular error at a particular instant cannot be absolutely prevented, human error rates can be reduced. The following principles are key: an understanding of the process of learning in relation to error; understanding the origin of errors since this knowledge can be used to reduce their occurrence; optimal systems should be forgiving to the operator by absorbing errors, at least for a time; although much is known by industrial psychologists about how to write operating procedures and instructions in ways that reduce the probability of error, this expertise is hardly ever put to use in the laboratory; and a feedback mechanism must be designed into the system that enables the operator to recognize in real time that an error has occurred.

  1. Intervention strategies for the management of human error

    NASA Technical Reports Server (NTRS)

    Wiener, Earl L.

    1993-01-01

    This report examines the management of human error in the cockpit. The principles probably apply as well to other applications in the aviation realm (e.g. air traffic control, dispatch, weather, etc.) as well as other high-risk systems outside of aviation (e.g. shipping, high-technology medical procedures, military operations, nuclear power production). Management of human error is distinguished from error prevention. It is a more encompassing term, which includes not only the prevention of error, but also a means of disallowing an error, once made, from adversely affecting system output. Such techniques include: traditional human factors engineering, improvement of feedback and feedforward of information from system to crew, 'error-evident' displays which make erroneous input more obvious to the crew, trapping of errors within a system, goal-sharing between humans and machines (also called 'intent-driven' systems), paperwork management, and behaviorally based approaches, including procedures, standardization, checklist design, training, cockpit resource management, etc. Fifteen guidelines for the design and implementation of intervention strategies are included.

  2. Managing human error in aviation.

    PubMed

    Helmreich, R L

    1997-05-01

    Crew resource management (CRM) programs were developed to address team and leadership aspects of piloting modern airplanes. The goal is to reduce errors through team work. Human factors research and social, cognitive, and organizational psychology are used to develop programs tailored for individual airlines. Flight crews study accident case histories, group dynamics, and human error. Simulators provide pilots with the opportunity to solve complex flight problems. CRM in the simulator is called line-oriented flight training (LOFT). In automated cockpits CRM promotes the idea of automation as a crew member. Cultural aspects of aviation include professional, business, and national culture. The aviation CRM model has been adapted for training surgeons and operating room staff in human factors.

  3. Head repositioning accuracy to neutral: a comparative study of error calculation.

    PubMed

    Hill, Robert; Jensen, Pål; Baardsen, Tor; Kulvik, Kristian; Jull, Gwendolen; Treleaven, Julia

    2009-02-01

    Deficits in cervical proprioception have been identified in subjects with neck pain through the measure of head repositioning accuracy (HRA). Nevertheless there appears to be no general consensus regarding the construct of measurement of error used for calculating HRA. This study investigated four different mathematical methods of measurement of error to determine if there were any differences in their ability to discriminate between a control group and subjects with a whiplash associated disorder. The four methods for measuring cervical joint position error were calculated using a previous data set consisting of 50 subjects with whiplash complaining of dizziness (WAD D), 50 subjects with whiplash not complaining of dizziness (WAD ND) and 50 control subjects. The results indicated that no one measure of HRA uniquely detected or defined the differences between the whiplash and control groups. Constant error (CE) was significantly different between the whiplash and control groups from extension (p<0.05). Absolute errors (AEs) and root mean square errors (RMSEs) demonstrated differences between the two WAD groups in rotation trials (p<0.05). No differences were seen with variable error (VE). The results suggest that a combination of AE (or RMSE) and CE are probably the most suitable measures for analysis of HRA.

  4. The contributions of human factors on human error in Malaysia aviation maintenance industries

    NASA Astrophysics Data System (ADS)

    Padil, H.; Said, M. N.; Azizan, A.

    2018-05-01

    Aviation maintenance is a multitasking activity in which individuals perform varied tasks under constant pressure to meet deadlines as well as challenging work conditions. These situational characteristics combined with human factors can lead to various types of human related errors. The primary objective of this research is to develop a structural relationship model that incorporates human factors, organizational factors, and their impact on human errors in aviation maintenance. Towards that end, a questionnaire was developed which was administered to Malaysian aviation maintenance professionals. Structural Equation Modelling (SEM) approach was used in this study utilizing AMOS software. Results showed that there were a significant relationship of human factors on human errors and were tested in the model. Human factors had a partial effect on organizational factors while organizational factors had a direct and positive impact on human errors. It was also revealed that organizational factors contributed to human errors when coupled with human factors construct. This study has contributed to the advancement of knowledge on human factors effecting safety and has provided guidelines for improving human factors performance relating to aviation maintenance activities and could be used as a reference for improving safety performance in the Malaysian aviation maintenance companies.

  5. Human Error Assessment and Reduction Technique (HEART) and Human Factor Analysis and Classification System (HFACS)

    NASA Technical Reports Server (NTRS)

    Alexander, Tiffaney Miller

    2017-01-01

    Research results have shown that more than half of aviation, aerospace and aeronautics mishaps incidents are attributed to human error. As a part of Safety within space exploration ground processing operations, the identification and/or classification of underlying contributors and causes of human error must be identified, in order to manage human error. This research provides a framework and methodology using the Human Error Assessment and Reduction Technique (HEART) and Human Factor Analysis and Classification System (HFACS), as an analysis tool to identify contributing factors, their impact on human error events, and predict the Human Error probabilities (HEPs) of future occurrences. This research methodology was applied (retrospectively) to six (6) NASA ground processing operations scenarios and thirty (30) years of Launch Vehicle related mishap data. This modifiable framework can be used and followed by other space and similar complex operations.

  6. Human Error Assessment and Reduction Technique (HEART) and Human Factor Analysis and Classification System (HFACS)

    NASA Technical Reports Server (NTRS)

    Alexander, Tiffaney Miller

    2017-01-01

    Research results have shown that more than half of aviation, aerospace and aeronautics mishaps/incidents are attributed to human error. As a part of Safety within space exploration ground processing operations, the identification and/or classification of underlying contributors and causes of human error must be identified, in order to manage human error. This research provides a framework and methodology using the Human Error Assessment and Reduction Technique (HEART) and Human Factor Analysis and Classification System (HFACS), as an analysis tool to identify contributing factors, their impact on human error events, and predict the Human Error probabilities (HEPs) of future occurrences. This research methodology was applied (retrospectively) to six (6) NASA ground processing operations scenarios and thirty (30) years of Launch Vehicle related mishap data. This modifiable framework can be used and followed by other space and similar complex operations.

  7. Human Error Assessment and Reduction Technique (HEART) and Human Factor Analysis and Classification System (HFACS)

    NASA Technical Reports Server (NTRS)

    Alexander, Tiffaney Miller

    2017-01-01

    Research results have shown that more than half of aviation, aerospace and aeronautics mishaps incidents are attributed to human error. As a part of Quality within space exploration ground processing operations, the identification and or classification of underlying contributors and causes of human error must be identified, in order to manage human error.This presentation will provide a framework and methodology using the Human Error Assessment and Reduction Technique (HEART) and Human Factor Analysis and Classification System (HFACS), as an analysis tool to identify contributing factors, their impact on human error events, and predict the Human Error probabilities (HEPs) of future occurrences. This research methodology was applied (retrospectively) to six (6) NASA ground processing operations scenarios and thirty (30) years of Launch Vehicle related mishap data. This modifiable framework can be used and followed by other space and similar complex operations.

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

    DOE Office of Scientific and Technical Information (OSTI.GOV)

    Nelson, W.R.

    1998-09-01

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

  9. Technical approaches for measurement of human errors

    NASA Technical Reports Server (NTRS)

    Clement, W. F.; Heffley, R. K.; Jewell, W. F.; Mcruer, D. T.

    1980-01-01

    Human error is a significant contributing factor in a very high proportion of civil transport, general aviation, and rotorcraft accidents. The technical details of a variety of proven approaches for the measurement of human errors in the context of the national airspace system are presented. Unobtrusive measurements suitable for cockpit operations and procedures in part of full mission simulation are emphasized. Procedure, system performance, and human operator centered measurements are discussed as they apply to the manual control, communication, supervisory, and monitoring tasks which are relevant to aviation operations.

  10. Reflections on human error - Matters of life and death

    NASA Technical Reports Server (NTRS)

    Wiener, Earl L.

    1989-01-01

    The last two decades have witnessed a rapid growth in the introduction of automatic devices into aircraft cockpits, and eleswhere in human-machine systems. This was motivated in part by the assumption that when human functioning is replaced by machine functioning, human error is eliminated. Experience to date shows that this is far from true, and that automation does not replace humans, but changes their role in the system, as well as the types and severity of the errors they make. This altered role may lead to fewer, but more critical errors. Intervention strategies to prevent these errors, or ameliorate their consequences include basic human factors engineering of the interface, enhanced warning and alerting systems, and more intelligent interfaces that understand the strategic intent of the crew and can detect and trap inconsistent or erroneous input before it affects the system.

  11. Combined Uncertainty and A-Posteriori Error Bound Estimates for General CFD Calculations: Theory and Software Implementation

    NASA Technical Reports Server (NTRS)

    Barth, Timothy J.

    2014-01-01

    This workshop presentation discusses the design and implementation of numerical methods for the quantification of statistical uncertainty, including a-posteriori error bounds, for output quantities computed using CFD methods. Hydrodynamic realizations often contain numerical error arising from finite-dimensional approximation (e.g. numerical methods using grids, basis functions, particles) and statistical uncertainty arising from incomplete information and/or statistical characterization of model parameters and random fields. The first task at hand is to derive formal error bounds for statistics given realizations containing finite-dimensional numerical error [1]. The error in computed output statistics contains contributions from both realization error and the error resulting from the calculation of statistics integrals using a numerical method. A second task is to devise computable a-posteriori error bounds by numerically approximating all terms arising in the error bound estimates. For the same reason that CFD calculations including error bounds but omitting uncertainty modeling are only of limited value, CFD calculations including uncertainty modeling but omitting error bounds are only of limited value. To gain maximum value from CFD calculations, a general software package for uncertainty quantification with quantified error bounds has been developed at NASA. The package provides implementations for a suite of numerical methods used in uncertainty quantification: Dense tensorization basis methods [3] and a subscale recovery variant [1] for non-smooth data, Sparse tensorization methods[2] utilizing node-nested hierarchies, Sampling methods[4] for high-dimensional random variable spaces.

  12. Errors induced by the neglect of polarization in radiance calculations for Rayleigh-scattering atmospheres

    NASA Technical Reports Server (NTRS)

    Mishchenko, M. I.; Lacis, A. A.; Travis, L. D.

    1994-01-01

    Although neglecting polarization and replacing the rigorous vector radiative transfer equation by its approximate scalar counterpart has no physical background, it is a widely used simplification when the incident light is unpolarized and only the intensity of the reflected light is to be computed. We employ accurate vector and scalar multiple-scattering calculations to perform a systematic study of the errors induced by the neglect of polarization in radiance calculations for a homogeneous, plane-parallel Rayleigh-scattering atmosphere (with and without depolarization) above a Lambertian surface. Specifically, we calculate percent errors in the reflected intensity for various directions of light incidence and reflection, optical thicknesses of the atmosphere, single-scattering albedos, depolarization factors, and surface albedos. The numerical data displayed can be used to decide whether or not the scalar approximation may be employed depending on the parameters of the problem. We show that the errors decrease with increasing depolarization factor and/or increasing surface albedo. For conservative or nearly conservative scattering and small surface albedos, the errors are maximum at optical thicknesses of about 1. The calculated errors may be too large for some practical applications, and, therefore, rigorous vector calculations should be employed whenever possible. However, if approximate scalar calculations are used, we recommend to avoid geometries involving phase angles equal or close to 0 deg and 90 deg, where the errors are especially significant. We propose a theoretical explanation of the large vector/scalar differences in the case of Rayleigh scattering. According to this explanation, the differences are caused by the particular structure of the Rayleigh scattering matrix and come from lower-order (except first-order) light scattering paths involving right scattering angles and right-angle rotations of the scattering plane.

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

    DOE Office of Scientific and Technical Information (OSTI.GOV)

    Nelson, W.R.

    1999-01-01

    A major component of reliability, safety, and mission success for space missions is ensuring that the humans involved (flight crew, ground crew, mission control, etc.) perform their tasks and functions as required. This includes compliance with training and procedures during normal conditions, and successful compensation when malfunctions or unexpected conditions occur. A very significant issue that affects human performance in space flight is human error. Human errors can invalidate carefully designed equipment and procedures. If certain errors combine with equipment failures or design flaws, mission failure or loss of life can occur. The control of human error during operation ofmore » the International Space Station (ISS) will be critical to the overall success of the program. As experience from Mir operations has shown, human performance plays a vital role in the success or failure of long duration space missions. The Department of Energy{close_quote}s Idaho National Engineering and Environmental Laboratory (INEEL) is developing a systematic approach to enhance human performance and reduce human errors for ISS operations. This approach is based on the systematic identification and evaluation of lessons learned from past space missions such as Mir to enhance the design and operation of ISS. This paper will describe previous INEEL research on human error sponsored by NASA and how it can be applied to enhance human reliability for ISS. {copyright} {ital 1999 American Institute of Physics.}« less

  14. Modeling human response errors in synthetic flight simulator domain

    NASA Technical Reports Server (NTRS)

    Ntuen, Celestine A.

    1992-01-01

    This paper presents a control theoretic approach to modeling human response errors (HRE) in the flight simulation domain. The human pilot is modeled as a supervisor of a highly automated system. The synthesis uses the theory of optimal control pilot modeling for integrating the pilot's observation error and the error due to the simulation model (experimental error). Methods for solving the HRE problem are suggested. Experimental verification of the models will be tested in a flight quality handling simulation.

  15. Avoiding Human Error in Mission Operations: Cassini Flight Experience

    NASA Technical Reports Server (NTRS)

    Burk, Thomas A.

    2012-01-01

    Operating spacecraft is a never-ending challenge and the risk of human error is ever- present. Many missions have been significantly affected by human error on the part of ground controllers. The Cassini mission at Saturn has not been immune to human error, but Cassini operations engineers use tools and follow processes that find and correct most human errors before they reach the spacecraft. What is needed are skilled engineers with good technical knowledge, good interpersonal communications, quality ground software, regular peer reviews, up-to-date procedures, as well as careful attention to detail and the discipline to test and verify all commands that will be sent to the spacecraft. Two areas of special concern are changes to flight software and response to in-flight anomalies. The Cassini team has a lot of practical experience in all these areas and they have found that well-trained engineers with good tools who follow clear procedures can catch most errors before they get into command sequences to be sent to the spacecraft. Finally, having a robust and fault-tolerant spacecraft that allows ground controllers excellent visibility of its condition is the most important way to ensure human error does not compromise the mission.

  16. Human operator response to error-likely situations in complex engineering systems

    NASA Technical Reports Server (NTRS)

    Morris, Nancy M.; Rouse, William B.

    1988-01-01

    The causes of human error in complex systems are examined. First, a conceptual framework is provided in which two broad categories of error are discussed: errors of action, or slips, and errors of intention, or mistakes. Conditions in which slips and mistakes might be expected to occur are identified, based on existing theories of human error. Regarding the role of workload, it is hypothesized that workload may act as a catalyst for error. Two experiments are presented in which humans' response to error-likely situations were examined. Subjects controlled PLANT under a variety of conditions and periodically provided subjective ratings of mental effort. A complex pattern of results was obtained, which was not consistent with predictions. Generally, the results of this research indicate that: (1) humans respond to conditions in which errors might be expected by attempting to reduce the possibility of error, and (2) adaptation to conditions is a potent influence on human behavior in discretionary situations. Subjects' explanations for changes in effort ratings are also explored.

  17. An optimized method to calculate error correction capability of tool influence function in frequency domain

    NASA Astrophysics Data System (ADS)

    Wang, Jia; Hou, Xi; Wan, Yongjian; Shi, Chunyan

    2017-10-01

    An optimized method to calculate error correction capability of tool influence function (TIF) in certain polishing conditions will be proposed based on smoothing spectral function. The basic mathematical model for this method will be established in theory. A set of polishing experimental data with rigid conformal tool is used to validate the optimized method. The calculated results can quantitatively indicate error correction capability of TIF for different spatial frequency errors in certain polishing conditions. The comparative analysis with previous method shows that the optimized method is simpler in form and can get the same accuracy results with less calculating time in contrast to previous method.

  18. Systematic sparse matrix error control for linear scaling electronic structure calculations.

    PubMed

    Rubensson, Emanuel H; Sałek, Paweł

    2005-11-30

    Efficient truncation criteria used in multiatom blocked sparse matrix operations for ab initio calculations are proposed. As system size increases, so does the need to stay on top of errors and still achieve high performance. A variant of a blocked sparse matrix algebra to achieve strict error control with good performance is proposed. The presented idea is that the condition to drop a certain submatrix should depend not only on the magnitude of that particular submatrix, but also on which other submatrices that are dropped. The decision to remove a certain submatrix is based on the contribution the removal would cause to the error in the chosen norm. We study the effect of an accumulated truncation error in iterative algorithms like trace correcting density matrix purification. One way to reduce the initial exponential growth of this error is presented. The presented error control for a sparse blocked matrix toolbox allows for achieving optimal performance by performing only necessary operations needed to maintain the requested level of accuracy. Copyright 2005 Wiley Periodicals, Inc.

  19. Human error and the search for blame

    NASA Technical Reports Server (NTRS)

    Denning, Peter J.

    1989-01-01

    Human error is a frequent topic in discussions about risks in using computer systems. A rational analysis of human error leads through the consideration of mistakes to standards that designers use to avoid mistakes that lead to known breakdowns. The irrational side, however, is more interesting. It conditions people to think that breakdowns are inherently wrong and that there is ultimately someone who is responsible. This leads to a search for someone to blame which diverts attention from: learning from the mistakes; seeing the limitations of current engineering methodology; and improving the discourse of design.

  20. Defining the Relationship Between Human Error Classes and Technology Intervention Strategies

    NASA Technical Reports Server (NTRS)

    Wiegmann, Douglas A.; Rantanen, Eas M.

    2003-01-01

    The modus operandi in addressing human error in aviation systems is predominantly that of technological interventions or fixes. Such interventions exhibit considerable variability both in terms of sophistication and application. Some technological interventions address human error directly while others do so only indirectly. Some attempt to eliminate the occurrence of errors altogether whereas others look to reduce the negative consequences of these errors. In any case, technological interventions add to the complexity of the systems and may interact with other system components in unforeseeable ways and often create opportunities for novel human errors. Consequently, there is a need to develop standards for evaluating the potential safety benefit of each of these intervention products so that resources can be effectively invested to produce the biggest benefit to flight safety as well as to mitigate any adverse ramifications. The purpose of this project was to help define the relationship between human error and technological interventions, with the ultimate goal of developing a set of standards for evaluating or measuring the potential benefits of new human error fixes.

  1. Error rate of automated calculation for wound surface area using a digital photography.

    PubMed

    Yang, S; Park, J; Lee, H; Lee, J B; Lee, B U; Oh, B H

    2018-02-01

    Although measuring would size using digital photography is a quick and simple method to evaluate the skin wound, the possible compatibility of it has not been fully validated. To investigate the error rate of our newly developed wound surface area calculation using digital photography. Using a smartphone and a digital single lens reflex (DSLR) camera, four photographs of various sized wounds (diameter: 0.5-3.5 cm) were taken from the facial skin model in company with color patches. The quantitative values of wound areas were automatically calculated. The relative error (RE) of this method with regard to wound sizes and types of camera was analyzed. RE of individual calculated area was from 0.0329% (DSLR, diameter 1.0 cm) to 23.7166% (smartphone, diameter 2.0 cm). In spite of the correction of lens curvature, smartphone has significantly higher error rate than DSLR camera (3.9431±2.9772 vs 8.1303±4.8236). However, in cases of wound diameter below than 3 cm, REs of average values of four photographs were below than 5%. In addition, there was no difference in the average value of wound area taken by smartphone and DSLR camera in those cases. For the follow-up of small skin defect (diameter: <3 cm), our newly developed automated wound area calculation method is able to be applied to the plenty of photographs, and the average values of them are a relatively useful index of wound healing with acceptable error rate. © 2017 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.

  2. Inborn Errors of Human JAKs and STATs

    PubMed Central

    Casanova, Jean-Laurent; Holland, Steven M.; Notarangelo, Luigi D.

    2012-01-01

    Inborn errors of the genes encoding two of the four human JAKs (JAK3 and TYK2) and three of the six human STATs (STAT1, STAT3, and STAT5B) have been described. We review the disorders arising from mutations in these five genes, highlighting the way in which the molecular and cellular pathogenesis of these conditions has been clarified by the discovery of inborn errors of cytokines, hormones, and their receptors, including those interacting with JAKs and STATs. The phenotypic similarities between mice and humans lacking individual JAK-STAT components suggest that the functions of JAKs and STATs are largely conserved in mammals. However, a wide array of phenotypic differences has emerged between mice and humans carrying bi-allelic null alleles of JAK3, TYK2, STAT1, or STAT5B. Moreover, the high level of allelic heterogeneity at the human JAK3, STAT1, and STAT3 loci has revealed highly diverse immunological and clinical phenotypes, which had not been anticipated. PMID:22520845

  3. Inborn errors of human JAKs and STATs.

    PubMed

    Casanova, Jean-Laurent; Holland, Steven M; Notarangelo, Luigi D

    2012-04-20

    Inborn errors of the genes encoding two of the four human JAKs (JAK3 and TYK2) and three of the six human STATs (STAT1, STAT3, and STAT5B) have been described. We review the disorders arising from mutations in these five genes, highlighting the way in which the molecular and cellular pathogenesis of these conditions has been clarified by the discovery of inborn errors of cytokines, hormones, and their receptors, including those interacting with JAKs and STATs. The phenotypic similarities between mice and humans lacking individual JAK-STAT components suggest that the functions of JAKs and STATs are largely conserved in mammals. However, a wide array of phenotypic differences has emerged between mice and humans carrying biallelic null alleles of JAK3, TYK2, STAT1, or STAT5B. Moreover, the high degree of allelic heterogeneity at the human JAK3, TYK2, STAT1, and STAT3 loci has revealed highly diverse immunological and clinical phenotypes, which had not been anticipated. Copyright © 2012 Elsevier Inc. All rights reserved.

  4. Normal accidents: human error and medical equipment design.

    PubMed

    Dain, Steven

    2002-01-01

    High-risk systems, which are typical of our technologically complex era, include not just nuclear power plants but also hospitals, anesthesia systems, and the practice of medicine and perfusion. In high-risk systems, no matter how effective safety devices are, some types of accidents are inevitable because the system's complexity leads to multiple and unexpected interactions. It is important for healthcare providers to apply a risk assessment and management process to decisions involving new equipment and procedures or staffing matters in order to minimize the residual risks of latent errors, which are amenable to correction because of the large window of opportunity for their detection. This article provides an introduction to basic risk management and error theory principles and examines ways in which they can be applied to reduce and mitigate the inevitable human errors that accompany high-risk systems. The article also discusses "human factor engineering" (HFE), the process which is used to design equipment/ human interfaces in order to mitigate design errors. The HFE process involves interaction between designers and endusers to produce a series of continuous refinements that are incorporated into the final product. The article also examines common design problems encountered in the operating room that may predispose operators to commit errors resulting in harm to the patient. While recognizing that errors and accidents are unavoidable, organizations that function within a high-risk system must adopt a "safety culture" that anticipates problems and acts aggressively through an anonymous, "blameless" reporting mechanism to resolve them. We must continuously examine and improve the design of equipment and procedures, personnel, supplies and materials, and the environment in which we work to reduce error and minimize its effects. Healthcare providers must take a leading role in the day-to-day management of the "Perioperative System" and be a role model in

  5. Defining the Relationship Between Human Error Classes and Technology Intervention Strategies

    NASA Technical Reports Server (NTRS)

    Wiegmann, Douglas A.; Rantanen, Esa; Crisp, Vicki K. (Technical Monitor)

    2002-01-01

    One of the main factors in all aviation accidents is human error. The NASA Aviation Safety Program (AvSP), therefore, has identified several human-factors safety technologies to address this issue. Some technologies directly address human error either by attempting to reduce the occurrence of errors or by mitigating the negative consequences of errors. However, new technologies and system changes may also introduce new error opportunities or even induce different types of errors. Consequently, a thorough understanding of the relationship between error classes and technology "fixes" is crucial for the evaluation of intervention strategies outlined in the AvSP, so that resources can be effectively directed to maximize the benefit to flight safety. The purpose of the present project, therefore, was to examine the repositories of human factors data to identify the possible relationship between different error class and technology intervention strategies. The first phase of the project, which is summarized here, involved the development of prototype data structures or matrices that map errors onto "fixes" (and vice versa), with the hope of facilitating the development of standards for evaluating safety products. Possible follow-on phases of this project are also discussed. These additional efforts include a thorough and detailed review of the literature to fill in the data matrix and the construction of a complete database and standards checklists.

  6. Structured methods for identifying and correcting potential human errors in aviation operations

    DOE Office of Scientific and Technical Information (OSTI.GOV)

    Nelson, W.R.

    1997-10-01

    Human errors have been identified as the source of approximately 60% of the incidents and accidents that occur in commercial aviation. It can be assumed that a very large number of human errors occur in aviation operations, even though in most cases the redundancies and diversities built into the design of aircraft systems prevent the errors from leading to serious consequences. In addition, when it is acknowledged that many system failures have their roots in human errors that occur in the design phase, it becomes apparent that the identification and elimination of potential human errors could significantly decrease the risksmore » of aviation operations. This will become even more critical during the design of advanced automation-based aircraft systems as well as next-generation systems for air traffic management. Structured methods to identify and correct potential human errors in aviation operations have been developed and are currently undergoing testing at the Idaho National Engineering and Environmental Laboratory (INEEL).« less

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

    PubMed

    Eichele, Tom; Debener, Stefan; Calhoun, Vince D; Specht, Karsten; Engel, Andreas K; Hugdahl, Kenneth; von Cramon, D Yves; Ullsperger, Markus

    2008-04-22

    Humans engaged in monotonous tasks are susceptible to occasional errors that may lead to serious consequences, but little is known about brain activity patterns preceding errors. Using functional MRI and applying independent component analysis followed by deconvolution of hemodynamic responses, we studied error preceding brain activity on a trial-by-trial basis. We found a set of brain regions in which the temporal evolution of activation predicted performance errors. These maladaptive brain activity changes started to evolve approximately 30 sec before the error. In particular, a coincident decrease of deactivation in default mode regions of the brain, together with a decline of activation in regions associated with maintaining task effort, raised the probability of future errors. Our findings provide insights into the brain network dynamics preceding human performance errors and suggest that monitoring of the identified precursor states may help in avoiding human errors in critical real-world situations.

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

    PubMed Central

    Eichele, Tom; Debener, Stefan; Calhoun, Vince D.; Specht, Karsten; Engel, Andreas K.; Hugdahl, Kenneth; von Cramon, D. Yves; Ullsperger, Markus

    2008-01-01

    Humans engaged in monotonous tasks are susceptible to occasional errors that may lead to serious consequences, but little is known about brain activity patterns preceding errors. Using functional MRI and applying independent component analysis followed by deconvolution of hemodynamic responses, we studied error preceding brain activity on a trial-by-trial basis. We found a set of brain regions in which the temporal evolution of activation predicted performance errors. These maladaptive brain activity changes started to evolve ≈30 sec before the error. In particular, a coincident decrease of deactivation in default mode regions of the brain, together with a decline of activation in regions associated with maintaining task effort, raised the probability of future errors. Our findings provide insights into the brain network dynamics preceding human performance errors and suggest that monitoring of the identified precursor states may help in avoiding human errors in critical real-world situations. PMID:18427123

  9. Applications of integrated human error identification techniques on the chemical cylinder change task.

    PubMed

    Cheng, Ching-Min; Hwang, Sheue-Ling

    2015-03-01

    This paper outlines the human error identification (HEI) techniques that currently exist to assess latent human errors. Many formal error identification techniques have existed for years, but few have been validated to cover latent human error analysis in different domains. This study considers many possible error modes and influential factors, including external error modes, internal error modes, psychological error mechanisms, and performance shaping factors, and integrates several execution procedures and frameworks of HEI techniques. The case study in this research was the operational process of changing chemical cylinders in a factory. In addition, the integrated HEI method was used to assess the operational processes and the system's reliability. It was concluded that the integrated method is a valuable aid to develop much safer operational processes and can be used to predict human error rates on critical tasks in the plant. Copyright © 2014 Elsevier Ltd and The Ergonomics Society. All rights reserved.

  10. Monte Carlo simulation of expert judgments on human errors in chemical analysis--a case study of ICP-MS.

    PubMed

    Kuselman, Ilya; Pennecchi, Francesca; Epstein, Malka; Fajgelj, Ales; Ellison, Stephen L R

    2014-12-01

    Monte Carlo simulation of expert judgments on human errors in a chemical analysis was used for determination of distributions of the error quantification scores (scores of likelihood and severity, and scores of effectiveness of a laboratory quality system in prevention of the errors). The simulation was based on modeling of an expert behavior: confident, reasonably doubting and irresolute expert judgments were taken into account by means of different probability mass functions (pmfs). As a case study, 36 scenarios of human errors which may occur in elemental analysis of geological samples by ICP-MS were examined. Characteristics of the score distributions for three pmfs of an expert behavior were compared. Variability of the scores, as standard deviation of the simulated score values from the distribution mean, was used for assessment of the score robustness. A range of the score values, calculated directly from elicited data and simulated by a Monte Carlo method for different pmfs, was also discussed from the robustness point of view. It was shown that robustness of the scores, obtained in the case study, can be assessed as satisfactory for the quality risk management and improvement of a laboratory quality system against human errors. Copyright © 2014 Elsevier B.V. All rights reserved.

  11. Human error in aviation operations

    NASA Technical Reports Server (NTRS)

    Billings, C. E.; Lanber, J. K.; Cooper, G. E.

    1974-01-01

    This report is a brief description of research being undertaken by the National Aeronautics and Space Administration. The project is designed to seek out factors in the aviation system which contribute to human error, and to search for ways of minimizing the potential threat posed by these factors. The philosophy and assumptions underlying the study are discussed, together with an outline of the research plan.

  12. A stochastic dynamic model for human error analysis in nuclear power plants

    NASA Astrophysics Data System (ADS)

    Delgado-Loperena, Dharma

    Nuclear disasters like Three Mile Island and Chernobyl indicate that human performance is a critical safety issue, sending a clear message about the need to include environmental press and competence aspects in research. This investigation was undertaken to serve as a roadmap for studying human behavior through the formulation of a general solution equation. The theoretical model integrates models from two heretofore-disassociated disciplines (behavior specialists and technical specialists), that historically have independently studied the nature of error and human behavior; including concepts derived from fractal and chaos theory; and suggests re-evaluation of base theory regarding human error. The results of this research were based on comprehensive analysis of patterns of error, with the omnipresent underlying structure of chaotic systems. The study of patterns lead to a dynamic formulation, serving for any other formula used to study human error consequences. The search for literature regarding error yielded insight for the need to include concepts rooted in chaos theory and strange attractors---heretofore unconsidered by mainstream researchers who investigated human error in nuclear power plants or those who employed the ecological model in their work. The study of patterns obtained from the rupture of a steam generator tube (SGTR) event simulation, provided a direct application to aspects of control room operations in nuclear power plant operations. In doing so, the conceptual foundation based in the understanding of the patterns of human error analysis can be gleaned, resulting in reduced and prevent undesirable events.

  13. TH-E-BRE-07: Development of Dose Calculation Error Predictors for a Widely Implemented Clinical Algorithm

    DOE Office of Scientific and Technical Information (OSTI.GOV)

    Egan, A; Laub, W

    2014-06-15

    Purpose: Several shortcomings of the current implementation of the analytic anisotropic algorithm (AAA) may lead to dose calculation errors in highly modulated treatments delivered to highly heterogeneous geometries. Here we introduce a set of dosimetric error predictors that can be applied to a clinical treatment plan and patient geometry in order to identify high risk plans. Once a problematic plan is identified, the treatment can be recalculated with more accurate algorithm in order to better assess its viability. Methods: Here we focus on three distinct sources dosimetric error in the AAA algorithm. First, due to a combination of discrepancies inmore » smallfield beam modeling as well as volume averaging effects, dose calculated through small MLC apertures can be underestimated, while that behind small MLC blocks can overestimated. Second, due the rectilinear scaling of the Monte Carlo generated pencil beam kernel, energy is not properly transported through heterogeneities near, but not impeding, the central axis of the beamlet. And third, AAA overestimates dose in regions very low density (< 0.2 g/cm{sup 3}). We have developed an algorithm to detect the location and magnitude of each scenario within the patient geometry, namely the field-size index (FSI), the heterogeneous scatter index (HSI), and the lowdensity index (LDI) respectively. Results: Error indices successfully identify deviations between AAA and Monte Carlo dose distributions in simple phantom geometries. Algorithms are currently implemented in the MATLAB computing environment and are able to run on a typical RapidArc head and neck geometry in less than an hour. Conclusion: Because these error indices successfully identify each type of error in contrived cases, with sufficient benchmarking, this method can be developed into a clinical tool that may be able to help estimate AAA dose calculation errors and when it might be advisable to use Monte Carlo calculations.« less

  14. Stopping power and range calculations in human tissues by using the Hartree-Fock-Roothaan wave functions

    NASA Astrophysics Data System (ADS)

    Usta, Metin; Tufan, Mustafa Çağatay

    2017-11-01

    The object of this work is to present the consequences for the stopping power and range values of some human tissues at energies ranging from 1 MeV to 1 GeV and 1-500 MeV, respectively. The considered human tissues are lung, intestine, skin, larynx, breast, bladder, prostate and ovary. In this work, the stopping power is calculated by considering the number of velocity-dependent effective charge and effective mean excitation energies of the target material. We used the Hartree-Fock-Roothaan (HFR) atomic wave function to determine the charge density and the continuous slowing down approximation (CSDA) method for the calculation of the proton range. Electronic stopping power values of tissues results have been compared with the ICRU 44, 46 reports, SRIM, Janni and CasP data over the percent error rate. Range values relate to tissues have compared the range results with the SRIM, FLUKA and Geant4 data. For electronic stopping power results, ICRU, SRIM and Janni's data indicated the best fit with our values at 1-50, 50-250 MeV and 250 MeV-1 GeV, respectively. For range results, the best accordance with the calculated values have been found the SRIM data and the error level is less than 10% in proton therapy. However, greater 30% errors were observed in the 250 MeV and over energies.

  15. Error Patterns in Portuguese Students' Addition and Subtraction Calculation Tasks: Implications for Teaching

    ERIC Educational Resources Information Center

    Watson, Silvana Maria R.; Lopes, João; Oliveira, Célia; Judge, Sharon

    2018-01-01

    Purpose: The purpose of this descriptive study is to investigate why some elementary children have difficulties mastering addition and subtraction calculation tasks. Design/methodology/approach: The researchers have examined error types in addition and subtraction calculation made by 697 Portuguese students in elementary grades. Each student…

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

    PubMed

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

    2017-07-01

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

  17. Human Error and the International Space Station: Challenges and Triumphs in Science Operations

    NASA Technical Reports Server (NTRS)

    Harris, Samantha S.; Simpson, Beau C.

    2016-01-01

    Any system with a human component is inherently risky. Studies in human factors and psychology have repeatedly shown that human operators will inevitably make errors, regardless of how well they are trained. Onboard the International Space Station (ISS) where crew time is arguably the most valuable resource, errors by the crew or ground operators can be costly to critical science objectives. Operations experts at the ISS Payload Operations Integration Center (POIC), located at NASA's Marshall Space Flight Center in Huntsville, Alabama, have learned that from payload concept development through execution, there are countless opportunities to introduce errors that can potentially result in costly losses of crew time and science. To effectively address this challenge, we must approach the design, testing, and operation processes with two specific goals in mind. First, a systematic approach to error and human centered design methodology should be implemented to minimize opportunities for user error. Second, we must assume that human errors will be made and enable rapid identification and recoverability when they occur. While a systematic approach and human centered development process can go a long way toward eliminating error, the complete exclusion of operator error is not a reasonable expectation. The ISS environment in particular poses challenging conditions, especially for flight controllers and astronauts. Operating a scientific laboratory 250 miles above the Earth is a complicated and dangerous task with high stakes and a steep learning curve. While human error is a reality that may never be fully eliminated, smart implementation of carefully chosen tools and techniques can go a long way toward minimizing risk and increasing the efficiency of NASA's space science operations.

  18. Injection Molding Parameters Calculations by Using Visual Basic (VB) Programming

    NASA Astrophysics Data System (ADS)

    Tony, B. Jain A. R.; Karthikeyen, S.; Alex, B. Jeslin A. R.; Hasan, Z. Jahid Ali

    2018-03-01

    Now a day’s manufacturing industry plays a vital role in production sectors. To fabricate a component lot of design calculation has to be done. There is a chance of human errors occurs during design calculations. The aim of this project is to create a special module using visual basic (VB) programming to calculate injection molding parameters to avoid human errors. To create an injection mold for a spur gear component the following parameters have to be calculated such as Cooling Capacity, Cooling Channel Diameter, and Cooling Channel Length, Runner Length and Runner Diameter, Gate Diameter and Gate Pressure. To calculate the above injection molding parameters a separate module has been created using Visual Basic (VB) Programming to reduce the human errors. The outcome of the module dimensions is the injection molding components such as mold cavity and core design, ejector plate design.

  19. Behind Human Error: Cognitive Systems, Computers and Hindsight

    DTIC Science & Technology

    1994-12-01

    evaluations • Organize and/or conduct workshops and conferences CSERIAC is a Department of Defense Information Analysis Cen- ter sponsored by the Defense...Process 185 Neutral Observer Criteria 191 Error Analysis as Causal Judgment 193 Error as Information 195 A Fundamental Surprise 195 What is Human...Kahnemann, 1974), and in risk analysis (Dougherty and Fragola, 1990). The discussions have continued in a wide variety of forums, includ- ing the

  20. Analysis of measured data of human body based on error correcting frequency

    NASA Astrophysics Data System (ADS)

    Jin, Aiyan; Peipei, Gao; Shang, Xiaomei

    2014-04-01

    Anthropometry is to measure all parts of human body surface, and the measured data is the basis of analysis and study of the human body, establishment and modification of garment size and formulation and implementation of online clothing store. In this paper, several groups of the measured data are gained, and analysis of data error is gotten by analyzing the error frequency and using analysis of variance method in mathematical statistics method. Determination of the measured data accuracy and the difficulty of measured parts of human body, further studies of the causes of data errors, and summarization of the key points to minimize errors possibly are also mentioned in the paper. This paper analyses the measured data based on error frequency, and in a way , it provides certain reference elements to promote the garment industry development.

  1. A Quality Improvement Project to Decrease Human Milk Errors in the NICU.

    PubMed

    Oza-Frank, Reena; Kachoria, Rashmi; Dail, James; Green, Jasmine; Walls, Krista; McClead, Richard E

    2017-02-01

    Ensuring safe human milk in the NICU is a complex process with many potential points for error, of which one of the most serious is administration of the wrong milk to the wrong infant. Our objective was to describe a quality improvement initiative that was associated with a reduction in human milk administration errors identified over a 6-year period in a typical, large NICU setting. We employed a quasi-experimental time series quality improvement initiative by using tools from the model for improvement, Six Sigma methodology, and evidence-based interventions. Scanned errors were identified from the human milk barcode medication administration system. Scanned errors of interest were wrong-milk-to-wrong-infant, expired-milk, or preparation errors. The scanned error rate and the impact of additional improvement interventions from 2009 to 2015 were monitored by using statistical process control charts. From 2009 to 2015, the total number of errors scanned declined from 97.1 per 1000 bottles to 10.8. Specifically, the number of expired milk error scans declined from 84.0 per 1000 bottles to 8.9. The number of preparation errors (4.8 per 1000 bottles to 2.2) and wrong-milk-to-wrong-infant errors scanned (8.3 per 1000 bottles to 2.0) also declined. By reducing the number of errors scanned, the number of opportunities for errors also decreased. Interventions that likely had the greatest impact on reducing the number of scanned errors included installation of bedside (versus centralized) scanners and dedicated staff to handle milk. Copyright © 2017 by the American Academy of Pediatrics.

  2. Human error mitigation initiative (HEMI) : summary report.

    DOE Office of Scientific and Technical Information (OSTI.GOV)

    Stevens, Susan M.; Ramos, M. Victoria; Wenner, Caren A.

    2004-11-01

    Despite continuing efforts to apply existing hazard analysis methods and comply with requirements, human errors persist across the nuclear weapons complex. Due to a number of factors, current retroactive and proactive methods to understand and minimize human error are highly subjective, inconsistent in numerous dimensions, and are cumbersome to characterize as thorough. An alternative and proposed method begins with leveraging historical data to understand what the systemic issues are and where resources need to be brought to bear proactively to minimize the risk of future occurrences. An illustrative analysis was performed using existing incident databases specific to Pantex weapons operationsmore » indicating systemic issues associated with operating procedures that undergo notably less development rigor relative to other task elements such as tooling and process flow. Future recommended steps to improve the objectivity, consistency, and thoroughness of hazard analysis and mitigation were delineated.« less

  3. Error Propagation Dynamics of PIV-based Pressure Field Calculations: How well does the pressure Poisson solver perform inherently?

    PubMed

    Pan, Zhao; Whitehead, Jared; Thomson, Scott; Truscott, Tadd

    2016-08-01

    Obtaining pressure field data from particle image velocimetry (PIV) is an attractive technique in fluid dynamics due to its noninvasive nature. The application of this technique generally involves integrating the pressure gradient or solving the pressure Poisson equation using a velocity field measured with PIV. However, very little research has been done to investigate the dynamics of error propagation from PIV-based velocity measurements to the pressure field calculation. Rather than measure the error through experiment, we investigate the dynamics of the error propagation by examining the Poisson equation directly. We analytically quantify the error bound in the pressure field, and are able to illustrate the mathematical roots of why and how the Poisson equation based pressure calculation propagates error from the PIV data. The results show that the error depends on the shape and type of boundary conditions, the dimensions of the flow domain, and the flow type.

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

    DOE Office of Scientific and Technical Information (OSTI.GOV)

    Herberger, Sarah M.; Boring, Ronald L.

    Abstract Objectives: Human reliability analysis (HRA) methods typically analyze human failure events (HFEs) at the overall task level. For dynamic HRA, it is important to model human activities at the subtask level. There exists a disconnect between dynamic subtask level and static task level that presents issues when modeling dynamic scenarios. For example, the SPAR-H method is typically used to calculate the human error probability (HEP) at the task level. As demonstrated in this paper, quantification in SPAR-H does not translate to the subtask level. Methods: Two different discrete distributions were generated for each SPAR-H Performance Shaping Factor (PSF) tomore » define the frequency of PSF levels. The first distribution was a uniform, or uninformed distribution that assumed the frequency of each PSF level was equally likely. The second non-continuous distribution took the frequency of PSF level as identified from an assessment of the HERA database. These two different approaches were created to identify the resulting distribution of the HEP. The resulting HEP that appears closer to the known distribution, a log-normal centered on 1E-3, is the more desirable. Each approach then has median, average and maximum HFE calculations applied. To calculate these three values, three events, A, B and C are generated from the PSF level frequencies comprised of subtasks. The median HFE selects the median PSF level from each PSF and calculates HEP. The average HFE takes the mean PSF level, and the maximum takes the maximum PSF level. The same data set of subtask HEPs yields starkly different HEPs when aggregated to the HFE level in SPAR-H. Results: Assuming that each PSF level in each HFE is equally likely creates an unrealistic distribution of the HEP that is centered at 1. Next the observed frequency of PSF levels was applied with the resulting HEP behaving log-normally with a majority of the values under 2.5% HEP. The median, average and maximum HFE calculations did

  5. Latent human error analysis and efficient improvement strategies by fuzzy TOPSIS in aviation maintenance tasks.

    PubMed

    Chiu, Ming-Chuan; Hsieh, Min-Chih

    2016-05-01

    The purposes of this study were to develop a latent human error analysis process, to explore the factors of latent human error in aviation maintenance tasks, and to provide an efficient improvement strategy for addressing those errors. First, we used HFACS and RCA to define the error factors related to aviation maintenance tasks. Fuzzy TOPSIS with four criteria was applied to evaluate the error factors. Results show that 1) adverse physiological states, 2) physical/mental limitations, and 3) coordination, communication, and planning are the factors related to airline maintenance tasks that could be addressed easily and efficiently. This research establishes a new analytic process for investigating latent human error and provides a strategy for analyzing human error using fuzzy TOPSIS. Our analysis process complements shortages in existing methodologies by incorporating improvement efficiency, and it enhances the depth and broadness of human error analysis methodology. Copyright © 2015 Elsevier Ltd and The Ergonomics Society. All rights reserved.

  6. Using APEX to Model Anticipated Human Error: Analysis of a GPS Navigational Aid

    NASA Technical Reports Server (NTRS)

    VanSelst, Mark; Freed, Michael; Shefto, Michael (Technical Monitor)

    1997-01-01

    The interface development process can be dramatically improved by predicting design facilitated human error at an early stage in the design process. The approach we advocate is to SIMULATE the behavior of a human agent carrying out tasks with a well-specified user interface, ANALYZE the simulation for instances of human error, and then REFINE the interface or protocol to minimize predicted error. This approach, incorporated into the APEX modeling architecture, differs from past approaches to human simulation in Its emphasis on error rather than e.g. learning rate or speed of response. The APEX model consists of two major components: (1) a powerful action selection component capable of simulating behavior in complex, multiple-task environments; and (2) a resource architecture which constrains cognitive, perceptual, and motor capabilities to within empirically demonstrated limits. The model mimics human errors arising from interactions between limited human resources and elements of the computer interface whose design falls to anticipate those limits. We analyze the design of a hand-held Global Positioning System (GPS) device used for radical and navigational decisions in small yacht recalls. The analysis demonstrates how human system modeling can be an effective design aid, helping to accelerate the process of refining a product (or procedure).

  7. Prevalence of refractive errors in the Slovak population calculated using the Gullstrand schematic eye model.

    PubMed

    Popov, I; Valašková, J; Štefaničková, J; Krásnik, V

    2017-01-01

    A substantial part of the population suffers from some kind of refractive errors. It is envisaged that their prevalence may change with the development of society. The aim of this study is to determine the prevalence of refractive errors using calculations based on the Gullstrand schematic eye model. We used the Gullstrand schematic eye model to calculate refraction retrospectively. Refraction was presented as the need for glasses correction at a vertex distance of 12 mm. The necessary data was obtained using the optical biometer Lenstar LS900. Data which could not be obtained due to the limitations of the device was substituted by theoretical data from the Gullstrand schematic eye model. Only analyses from the right eyes were presented. The data was interpreted using descriptive statistics, Pearson correlation and t-test. The statistical tests were conducted at a level of significance of 5%. Our sample included 1663 patients (665 male, 998 female) within the age range of 19 to 96 years. Average age was 70.8 ± 9.53 years. Average refraction of the eye was 2.73 ± 2.13D (males 2.49 ± 2.34, females 2.90 ± 2.76). The mean absolute error from emmetropia was 3.01 ± 1.58 (males 2.83 ± 2.95, females 3.25 ± 3.35). 89.06% of the sample was hyperopic, 6.61% was myopic and 4.33% emmetropic. We did not find any correlation between refraction and age. Females were more hyperopic than males. We did not find any statistically significant hypermetopic shift of refraction with age. According to our estimation, the calculations of refractive errors using the Gullstrand schematic eye model showed a significant hypermetropic shift of more than +2D. Our results could be used in future for comparing the prevalence of refractive errors using same methods we used.Key words: refractive errors, refraction, Gullstrand schematic eye model, population, emmetropia.

  8. Human error analysis of commercial aviation accidents: application of the Human Factors Analysis and Classification system (HFACS).

    PubMed

    Wiegmann, D A; Shappell, S A

    2001-11-01

    The Human Factors Analysis and Classification System (HFACS) is a general human error framework originally developed and tested within the U.S. military as a tool for investigating and analyzing the human causes of aviation accidents. Based on Reason's (1990) model of latent and active failures, HFACS addresses human error at all levels of the system, including the condition of aircrew and organizational factors. The purpose of the present study was to assess the utility of the HFACS framework as an error analysis and classification tool outside the military. The HFACS framework was used to analyze human error data associated with aircrew-related commercial aviation accidents that occurred between January 1990 and December 1996 using database records maintained by the NTSB and the FAA. Investigators were able to reliably accommodate all the human causal factors associated with the commercial aviation accidents examined in this study using the HFACS system. In addition, the classification of data using HFACS highlighted several critical safety issues in need of intervention research. These results demonstrate that the HFACS framework can be a viable tool for use within the civil aviation arena. However, additional research is needed to examine its applicability to areas outside the flight deck, such as aircraft maintenance and air traffic control domains.

  9. Application of human reliability analysis to nursing errors in hospitals.

    PubMed

    Inoue, Kayoko; Koizumi, Akio

    2004-12-01

    Adverse events in hospitals, such as in surgery, anesthesia, radiology, intensive care, internal medicine, and pharmacy, are of worldwide concern and it is important, therefore, to learn from such incidents. There are currently no appropriate tools based on state-of-the art models available for the analysis of large bodies of medical incident reports. In this study, a new model was developed to facilitate medical error analysis in combination with quantitative risk assessment. This model enables detection of the organizational factors that underlie medical errors, and the expedition of decision making in terms of necessary action. Furthermore, it determines medical tasks as module practices and uses a unique coding system to describe incidents. This coding system has seven vectors for error classification: patient category, working shift, module practice, linkage chain (error type, direct threat, and indirect threat), medication, severity, and potential hazard. Such mathematical formulation permitted us to derive two parameters: error rates for module practices and weights for the aforementioned seven elements. The error rate of each module practice was calculated by dividing the annual number of incident reports of each module practice by the annual number of the corresponding module practice. The weight of a given element was calculated by the summation of incident report error rates for an element of interest. This model was applied specifically to nursing practices in six hospitals over a year; 5,339 incident reports with a total of 63,294,144 module practices conducted were analyzed. Quality assurance (QA) of our model was introduced by checking the records of quantities of practices and reproducibility of analysis of medical incident reports. For both items, QA guaranteed legitimacy of our model. Error rates for all module practices were approximately of the order 10(-4) in all hospitals. Three major organizational factors were found to underlie medical

  10. Prediction error induced motor contagions in human behaviors.

    PubMed

    Ikegami, Tsuyoshi; Ganesh, Gowrishankar; Takeuchi, Tatsuya; Nakamoto, Hiroki

    2018-05-29

    Motor contagions refer to implicit effects on one's actions induced by observed actions. Motor contagions are believed to be induced simply by action observation and cause an observer's action to become similar to the action observed. In contrast, here we report a new motor contagion that is induced only when the observation is accompanied by prediction errors - differences between actions one observes and those he/she predicts or expects. In two experiments, one on whole-body baseball pitching and another on simple arm reaching, we show that the observation of the same action induces distinct motor contagions, depending on whether prediction errors are present or not. In the absence of prediction errors, as in previous reports, participants' actions changed to become similar to the observed action, while in the presence of prediction errors, their actions changed to diverge away from it, suggesting distinct effects of action observation and action prediction on human actions. © 2018, Ikegami et al.

  11. Error Patterns with Fraction Calculations at Fourth Grade as a Function of Students' Mathematics Achievement Status

    ERIC Educational Resources Information Center

    Schumacher, Robin F.; Malone, Amelia S.

    2017-01-01

    The goal of this study was to describe fraction-calculation errors among fourth-grade students and to determine whether error patterns differed as a function of problem type (addition vs. subtraction; like vs. unlike denominators), orientation (horizontal vs. vertical), or mathematics-achievement status (low-, average-, or high-achieving). We…

  12. Errors in the Calculation of 27Al Nuclear Magnetic Resonance Chemical Shifts

    PubMed Central

    Wang, Xianlong; Wang, Chengfei; Zhao, Hui

    2012-01-01

    Computational chemistry is an important tool for signal assignment of 27Al nuclear magnetic resonance spectra in order to elucidate the species of aluminum(III) in aqueous solutions. The accuracy of the popular theoretical models for computing the 27Al chemical shifts was evaluated by comparing the calculated and experimental chemical shifts in more than one hundred aluminum(III) complexes. In order to differentiate the error due to the chemical shielding tensor calculation from that due to the inadequacy of the molecular geometry prediction, single-crystal X-ray diffraction determined structures were used to build the isolated molecule models for calculating the chemical shifts. The results were compared with those obtained using the calculated geometries at the B3LYP/6-31G(d) level. The isotropic chemical shielding constants computed at different levels have strong linear correlations even though the absolute values differ in tens of ppm. The root-mean-square difference between the experimental chemical shifts and the calculated values is approximately 5 ppm for the calculations based on the X-ray structures, but more than 10 ppm for the calculations based on the computed geometries. The result indicates that the popular theoretical models are adequate in calculating the chemical shifts while an accurate molecular geometry is more critical. PMID:23203134

  13. Human error in hospitals and industrial accidents: current concepts.

    PubMed

    Spencer, F C

    2000-10-01

    Most data concerning errors and accidents are from industrial accidents and airline injuries. General Electric, Alcoa, and Motorola, among others, all have reported complex programs that resulted in a marked reduction in frequency of worker injuries. In the field of medicine, however, with the outstanding exception of anesthesiology, there is a paucity of information, most reports referring to the 1984 Harvard-New York State Study, more than 16 years ago. This scarcity of information indicates the complexity of the problem. It seems very unlikely that simple exhortation or additional regulations will help because the problem lies principally in the multiple human-machine interfaces that constitute modern medical care. The absence of success stories also indicates that the best methods have to be learned by experience. A liaison with industry should be helpful, although the varieties of human illness are far different from a standardized manufacturing process. Concurrent with the studies of industrial and nuclear accidents, cognitive psychologists have intensively studied how the brain stores and retrieves information. Several concepts have emerged. First, errors are not character defects to be treated by the classic approach of discipline and education, but are byproducts of normal thinking that occur frequently. Second, major accidents are rarely causedby a single error; instead, they are often a combination of chronic system errors, termed latent errors. Identifying and correcting these latent errors should be the principal focus for corrective planning rather than searching for an individual culprit. This nonpunitive concept of errors is a key basis for an effective reporting system, brilliantly demonstrated in aviation with the ASRS system developed more than 25 years ago. The ASRS currently receives more than 30,000 reports annually and is credited with the remarkable increase in safety of airplane travel. Adverse drug events constitute about 25% of hospital

  14. Error Patterns with Fraction Calculations at Fourth Grade as a Function of Students' Mathematics Achievement Status

    ERIC Educational Resources Information Center

    Schumacher, Robin F.; Malone, Amelia S.

    2017-01-01

    The goal of the present study was to describe fraction-calculation errors among 4th-grade students and determine whether error patterns differed as a function of problem type (addition vs. subtraction; like vs. unlike denominators), orientation (horizontal vs. vertical), or mathematics-achievement status (low- vs. average- vs. high-achieving). We…

  15. Human error analysis of commercial aviation accidents using the human factors analysis and classification system (HFACS)

    DOT National Transportation Integrated Search

    2001-02-01

    The Human Factors Analysis and Classification System (HFACS) is a general human error framework : originally developed and tested within the U.S. military as a tool for investigating and analyzing the human : causes of aviation accidents. Based upon ...

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

    PubMed

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

    2013-08-01

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

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

    NASA Technical Reports Server (NTRS)

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

    1998-01-01

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

  18. Modeling human tracking error in several different anti-tank systems

    NASA Technical Reports Server (NTRS)

    Kleinman, D. L.

    1981-01-01

    An optimal control model for generating time histories of human tracking errors in antitank systems is outlined. Monte Carlo simulations of human operator responses for three Army antitank systems are compared. System/manipulator dependent data comparisons reflecting human operator limitations in perceiving displayed quantities and executing intended control motions are presented. Motor noise parameters are also discussed.

  19. Computer Program for Point Location And Calculation of ERror (PLACER)

    USGS Publications Warehouse

    Granato, Gregory E.

    1999-01-01

    A program designed for point location and calculation of error (PLACER) was developed as part of the Quality Assurance Program of the Federal Highway Administration/U.S. Geological Survey (USGS) National Data and Methodology Synthesis (NDAMS) review process. The program provides a standard method to derive study-site locations from site maps in highwayrunoff, urban-runoff, and other research reports. This report provides a guide for using PLACER, documents methods used to estimate study-site locations, documents the NDAMS Study-Site Locator Form, and documents the FORTRAN code used to implement the method. PLACER is a simple program that calculates the latitude and longitude coordinates of one or more study sites plotted on a published map and estimates the uncertainty of these calculated coordinates. PLACER calculates the latitude and longitude of each study site by interpolating between the coordinates of known features and the locations of study sites using any consistent, linear, user-defined coordinate system. This program will read data entered from the computer keyboard and(or) from a formatted text file, and will write the results to the computer screen and to a text file. PLACER is readily transferable to different computers and operating systems with few (if any) modifications because it is written in standard FORTRAN. PLACER can be used to calculate study site locations in latitude and longitude, using known map coordinates or features that are identifiable in geographic information data bases such as USGS Geographic Names Information System, which is available on the World Wide Web.

  20. Human Error Analysis in a Permit to Work System: A Case Study in a Chemical Plant

    PubMed Central

    Jahangiri, Mehdi; Hoboubi, Naser; Rostamabadi, Akbar; Keshavarzi, Sareh; Hosseini, Ali Akbar

    2015-01-01

    Background A permit to work (PTW) is a formal written system to control certain types of work which are identified as potentially hazardous. However, human error in PTW processes can lead to an accident. Methods This cross-sectional, descriptive study was conducted to estimate the probability of human errors in PTW processes in a chemical plant in Iran. In the first stage, through interviewing the personnel and studying the procedure in the plant, the PTW process was analyzed using the hierarchical task analysis technique. In doing so, PTW was considered as a goal and detailed tasks to achieve the goal were analyzed. In the next step, the standardized plant analysis risk-human (SPAR-H) reliability analysis method was applied for estimation of human error probability. Results The mean probability of human error in the PTW system was estimated to be 0.11. The highest probability of human error in the PTW process was related to flammable gas testing (50.7%). Conclusion The SPAR-H method applied in this study could analyze and quantify the potential human errors and extract the required measures for reducing the error probabilities in PTW system. Some suggestions to reduce the likelihood of errors, especially in the field of modifying the performance shaping factors and dependencies among tasks are provided. PMID:27014485

  1. Maths anxiety and medication dosage calculation errors: A scoping review.

    PubMed

    Williams, Brett; Davis, Samantha

    2016-09-01

    A student's accuracy on drug calculation tests may be influenced by maths anxiety, which can impede one's ability to understand and complete mathematic problems. It is important for healthcare students to overcome this barrier when calculating drug dosages in order to avoid administering the incorrect dose to a patient when in the clinical setting. The aim of this study was to examine the effects of maths anxiety on healthcare students' ability to accurately calculate drug dosages by performing a scoping review of the existing literature. This review utilised a six-stage methodology using the following databases; CINAHL, Embase, Medline, Scopus, PsycINFO, Google Scholar, Trip database (http://www.tripdatabase.com/) and Grey Literature report (http://www.greylit.org/). After an initial title/abstract review of relevant papers, and then full text review of the remaining papers, six articles were selected for inclusion in this study. Of the six articles included, there were three experimental studies, two quantitative studies and one mixed method study. All studies addressed nursing students and the presence of maths anxiety. No relevant studies from other disciplines were identified in the existing literature. Three studies took place in the U.S, the remainder in Canada, Australia and United Kingdom. Upon analysis of these studies, four factors including maths anxiety were identified as having an influence on a student's drug dosage calculation abilities. Ultimately, the results from this review suggest more research is required in nursing and other relevant healthcare disciplines regarding the effects of maths anxiety on drug dosage calculations. This additional knowledge will be important to further inform development of strategies to decrease the potentially serious effects of errors in drug dosage calculation to patient safety. Copyright © 2016 Elsevier Ltd. All rights reserved.

  2. The MiAge Calculator: a DNA methylation-based mitotic age calculator of human tissue types.

    PubMed

    Youn, Ahrim; Wang, Shuang

    2018-01-01

    Cell division is important in human aging and cancer. The estimation of the number of cell divisions (mitotic age) of a given tissue type in individuals is of great interest as it allows not only the study of biological aging (using a new molecular aging target) but also the stratification of prospective cancer risk. Here, we introduce the MiAge Calculator, a mitotic age calculator based on a novel statistical framework, the MiAge model. MiAge is designed to quantitatively estimate mitotic age (total number of lifetime cell divisions) of a tissue using the stochastic replication errors accumulated in the epigenetic inheritance process during cell divisions. With the MiAge model, the MiAge Calculator was built using the training data of DNA methylation measures of 4,020 tumor and adjacent normal tissue samples from eight TCGA cancer types and was tested using the testing data of DNA methylation measures of 2,221 tumor and adjacent normal tissue samples of five other TCGA cancer types. We showed that within each of the thirteen cancer types studied, the estimated mitotic age is universally accelerated in tumor tissues compared to adjacent normal tissues. Across the thirteen cancer types, we showed that worse cancer survivals are associated with more accelerated mitotic age in tumor tissues. Importantly, we demonstrated the utility of mitotic age by showing that the integration of mitotic age and clinical information leads to improved survival prediction in six out of the thirteen cancer types studied. The MiAge Calculator is available at http://www.columbia.edu/∼sw2206/softwares.htm .

  3. Use of modeling to identify vulnerabilities to human error in laparoscopy.

    PubMed

    Funk, Kenneth H; Bauer, James D; Doolen, Toni L; Telasha, David; Nicolalde, R Javier; Reeber, Miriam; Yodpijit, Nantakrit; Long, Myra

    2010-01-01

    This article describes an exercise to investigate the utility of modeling and human factors analysis in understanding surgical processes and their vulnerabilities to medical error. A formal method to identify error vulnerabilities was developed and applied to a test case of Veress needle insertion during closed laparoscopy. A team of 2 surgeons, a medical assistant, and 3 engineers used hierarchical task analysis and Integrated DEFinition language 0 (IDEF0) modeling to create rich models of the processes used in initial port creation. Using terminology from a standardized human performance database, detailed task descriptions were written for 4 tasks executed in the process of inserting the Veress needle. Key terms from the descriptions were used to extract from the database generic errors that could occur. Task descriptions with potential errors were translated back into surgical terminology. Referring to the process models and task descriptions, the team used a modified failure modes and effects analysis (FMEA) to consider each potential error for its probability of occurrence, its consequences if it should occur and be undetected, and its probability of detection. The resulting likely and consequential errors were prioritized for intervention. A literature-based validation study confirmed the significance of the top error vulnerabilities identified using the method. Ongoing work includes design and evaluation of procedures to correct the identified vulnerabilities and improvements to the modeling and vulnerability identification methods. Copyright 2010 AAGL. Published by Elsevier Inc. All rights reserved.

  4. THERP and HEART integrated methodology for human error assessment

    NASA Astrophysics Data System (ADS)

    Castiglia, Francesco; Giardina, Mariarosa; Tomarchio, Elio

    2015-11-01

    THERP and HEART integrated methodology is proposed to investigate accident scenarios that involve operator errors during high-dose-rate (HDR) treatments. The new approach has been modified on the basis of fuzzy set concept with the aim of prioritizing an exhaustive list of erroneous tasks that can lead to patient radiological overexposures. The results allow for the identification of human errors that are necessary to achieve a better understanding of health hazards in the radiotherapy treatment process, so that it can be properly monitored and appropriately managed.

  5. Human error identification for laparoscopic surgery: Development of a motion economy perspective.

    PubMed

    Al-Hakim, Latif; Sevdalis, Nick; Maiping, Tanaphon; Watanachote, Damrongpan; Sengupta, Shomik; Dissaranan, Charuspong

    2015-09-01

    This study postulates that traditional human error identification techniques fail to consider motion economy principles and, accordingly, their applicability in operating theatres may be limited. This study addresses this gap in the literature with a dual aim. First, it identifies the principles of motion economy that suit the operative environment and second, it develops a new error mode taxonomy for human error identification techniques which recognises motion economy deficiencies affecting the performance of surgeons and predisposing them to errors. A total of 30 principles of motion economy were developed and categorised into five areas. A hierarchical task analysis was used to break down main tasks of a urological laparoscopic surgery (hand-assisted laparoscopic nephrectomy) to their elements and the new taxonomy was used to identify errors and their root causes resulting from violation of motion economy principles. The approach was prospectively tested in 12 observed laparoscopic surgeries performed by 5 experienced surgeons. A total of 86 errors were identified and linked to the motion economy deficiencies. Results indicate the developed methodology is promising. Our methodology allows error prevention in surgery and the developed set of motion economy principles could be useful for training surgeons on motion economy principles. Copyright © 2015 Elsevier Ltd and The Ergonomics Society. All rights reserved.

  6. Accuracy and Landmark Error Calculation Using Cone-Beam Computed Tomography–Generated Cephalograms

    PubMed Central

    Grauer, Dan; Cevidanes, Lucia S. H.; Styner, Martin A.; Heulfe, Inam; Harmon, Eric T.; Zhu, Hongtu; Proffit, William R.

    2010-01-01

    Objective To evaluate systematic differences in landmark position between cone-beam computed tomography (CBCT)–generated cephalograms and conventional digital cephalograms and to estimate how much variability should be taken into account when both modalities are used within the same longitudinal study. Materials and Methods Landmarks on homologous cone-beam computed tomographic–generated cephalograms and conventional digital cephalograms of 46 patients were digitized, registered, and compared via the Hotelling T2 test. Results There were no systematic differences between modalities in the position of most landmarks. Three landmarks showed statistically significant differences but did not reach clinical significance. A method for error calculation while combining both modalities in the same individual is presented. Conclusion In a longitudinal follow-up for assessment of treatment outcomes and growth of one individual, the error due to the combination of the two modalities might be larger than previously estimated. PMID:19905853

  7. Human errors and violations in computer and information security: the viewpoint of network administrators and security specialists.

    PubMed

    Kraemer, Sara; Carayon, Pascale

    2007-03-01

    This paper describes human errors and violations of end users and network administration in computer and information security. This information is summarized in a conceptual framework for examining the human and organizational factors contributing to computer and information security. This framework includes human error taxonomies to describe the work conditions that contribute adversely to computer and information security, i.e. to security vulnerabilities and breaches. The issue of human error and violation in computer and information security was explored through a series of 16 interviews with network administrators and security specialists. The interviews were audio taped, transcribed, and analyzed by coding specific themes in a node structure. The result is an expanded framework that classifies types of human error and identifies specific human and organizational factors that contribute to computer and information security. Network administrators tended to view errors created by end users as more intentional than unintentional, while errors created by network administrators as more unintentional than intentional. Organizational factors, such as communication, security culture, policy, and organizational structure, were the most frequently cited factors associated with computer and information security.

  8. Human Error as an Emergent Property of Action Selection and Task Place-Holding.

    PubMed

    Tamborello, Franklin P; Trafton, J Gregory

    2017-05-01

    A computational process model could explain how the dynamic interaction of human cognitive mechanisms produces each of multiple error types. With increasing capability and complexity of technological systems, the potential severity of consequences of human error is magnified. Interruption greatly increases people's error rates, as does the presence of other information to maintain in an active state. The model executed as a software-instantiated Monte Carlo simulation. It drew on theoretical constructs such as associative spreading activation for prospective memory, explicit rehearsal strategies as a deliberate cognitive operation to aid retrospective memory, and decay. The model replicated the 30% effect of interruptions on postcompletion error in Ratwani and Trafton's Stock Trader task, the 45% interaction effect on postcompletion error of working memory capacity and working memory load from Byrne and Bovair's Phaser Task, as well as the 5% perseveration and 3% omission effects of interruption from the UNRAVEL Task. Error classes including perseveration, omission, and postcompletion error fall naturally out of the theory. The model explains post-interruption error in terms of task state representation and priming for recall of subsequent steps. Its performance suggests that task environments providing more cues to current task state will mitigate error caused by interruption. For example, interfaces could provide labeled progress indicators or facilities for operators to quickly write notes about their task states when interrupted.

  9. Error analysis regarding the calculation of nonlinear force-free field

    NASA Astrophysics Data System (ADS)

    Liu, S.; Zhang, H. Q.; Su, J. T.

    2012-02-01

    Magnetic field extrapolation is an alternative method to study chromospheric and coronal magnetic fields. In this paper, two semi-analytical solutions of force-free fields (Low and Lou in Astrophys. J. 352:343, 1990) have been used to study the errors of nonlinear force-free (NLFF) fields based on force-free factor α. Three NLFF fields are extrapolated by approximate vertical integration (AVI) Song et al. (Astrophys. J. 649:1084, 2006), boundary integral equation (BIE) Yan and Sakurai (Sol. Phys. 195:89, 2000) and optimization (Opt.) Wiegelmann (Sol. Phys. 219:87, 2004) methods. Compared with the first semi-analytical field, it is found that the mean values of absolute relative standard deviations (RSD) of α along field lines are about 0.96-1.19, 0.63-1.07 and 0.43-0.72 for AVI, BIE and Opt. fields, respectively. While for the second semi-analytical field, they are about 0.80-1.02, 0.67-1.34 and 0.33-0.55 for AVI, BIE and Opt. fields, respectively. As for the analytical field, the calculation error of <| RSD|> is about 0.1˜0.2. It is also found that RSD does not apparently depend on the length of field line. These provide the basic estimation on the deviation of extrapolated field obtained by proposed methods from the real force-free field.

  10. A dose error evaluation study for 4D dose calculations

    NASA Astrophysics Data System (ADS)

    Milz, Stefan; Wilkens, Jan J.; Ullrich, Wolfgang

    2014-10-01

    Previous studies have shown that respiration induced motion is not negligible for Stereotactic Body Radiation Therapy. The intrafractional breathing induced motion influences the delivered dose distribution on the underlying patient geometry such as the lung or the abdomen. If a static geometry is used, a planning process for these indications does not represent the entire dynamic process. The quality of a full 4D dose calculation approach depends on the dose coordinate transformation process between deformable geometries. This article provides an evaluation study that introduces an advanced method to verify the quality of numerical dose transformation generated by four different algorithms. The used transformation metric value is based on the deviation of the dose mass histogram (DMH) and the mean dose throughout dose transformation. The study compares the results of four algorithms. In general, two elementary approaches are used: dose mapping and energy transformation. Dose interpolation (DIM) and an advanced concept, so called divergent dose mapping model (dDMM), are used for dose mapping. The algorithms are compared to the basic energy transformation model (bETM) and the energy mass congruent mapping (EMCM). For evaluation 900 small sample regions of interest (ROI) are generated inside an exemplary lung geometry (4DCT). A homogeneous fluence distribution is assumed for dose calculation inside the ROIs. The dose transformations are performed with the four different algorithms. The study investigates the DMH-metric and the mean dose metric for different scenarios (voxel sizes: 8 mm, 4 mm, 2 mm, 1 mm 9 different breathing phases). dDMM achieves the best transformation accuracy in all measured test cases with 3-5% lower errors than the other models. The results of dDMM are reasonable and most efficient in this study, although the model is simple and easy to implement. The EMCM model also achieved suitable results, but the approach requires a more complex

  11. A dose error evaluation study for 4D dose calculations.

    PubMed

    Milz, Stefan; Wilkens, Jan J; Ullrich, Wolfgang

    2014-11-07

    Previous studies have shown that respiration induced motion is not negligible for Stereotactic Body Radiation Therapy. The intrafractional breathing induced motion influences the delivered dose distribution on the underlying patient geometry such as the lung or the abdomen. If a static geometry is used, a planning process for these indications does not represent the entire dynamic process. The quality of a full 4D dose calculation approach depends on the dose coordinate transformation process between deformable geometries. This article provides an evaluation study that introduces an advanced method to verify the quality of numerical dose transformation generated by four different algorithms.The used transformation metric value is based on the deviation of the dose mass histogram (DMH) and the mean dose throughout dose transformation. The study compares the results of four algorithms. In general, two elementary approaches are used: dose mapping and energy transformation. Dose interpolation (DIM) and an advanced concept, so called divergent dose mapping model (dDMM), are used for dose mapping. The algorithms are compared to the basic energy transformation model (bETM) and the energy mass congruent mapping (EMCM). For evaluation 900 small sample regions of interest (ROI) are generated inside an exemplary lung geometry (4DCT). A homogeneous fluence distribution is assumed for dose calculation inside the ROIs. The dose transformations are performed with the four different algorithms.The study investigates the DMH-metric and the mean dose metric for different scenarios (voxel sizes: 8 mm, 4 mm, 2 mm, 1 mm; 9 different breathing phases). dDMM achieves the best transformation accuracy in all measured test cases with 3-5% lower errors than the other models. The results of dDMM are reasonable and most efficient in this study, although the model is simple and easy to implement. The EMCM model also achieved suitable results, but the approach requires a more complex programming

  12. Safety coaches in radiology: decreasing human error and minimizing patient harm.

    PubMed

    Dickerson, Julie M; Koch, Bernadette L; Adams, Janet M; Goodfriend, Martha A; Donnelly, Lane F

    2010-09-01

    Successful programs to improve patient safety require a component aimed at improving safety culture and environment, resulting in a reduced number of human errors that could lead to patient harm. Safety coaching provides peer accountability. It involves observing for safety behaviors and use of error prevention techniques and provides immediate feedback. For more than a decade, behavior-based safety coaching has been a successful strategy for reducing error within the context of occupational safety in industry. We describe the use of safety coaches in radiology. Safety coaches are an important component of our comprehensive patient safety program.

  13. Approximate error conjugation gradient minimization methods

    DOEpatents

    Kallman, Jeffrey S

    2013-05-21

    In one embodiment, a method includes selecting a subset of rays from a set of all rays to use in an error calculation for a constrained conjugate gradient minimization problem, calculating an approximate error using the subset of rays, and calculating a minimum in a conjugate gradient direction based on the approximate error. In another embodiment, a system includes a processor for executing logic, logic for selecting a subset of rays from a set of all rays to use in an error calculation for a constrained conjugate gradient minimization problem, logic for calculating an approximate error using the subset of rays, and logic for calculating a minimum in a conjugate gradient direction based on the approximate error. In other embodiments, computer program products, methods, and systems are described capable of using approximate error in constrained conjugate gradient minimization problems.

  14. Accurate Bit Error Rate Calculation for Asynchronous Chaos-Based DS-CDMA over Multipath Channel

    NASA Astrophysics Data System (ADS)

    Kaddoum, Georges; Roviras, Daniel; Chargé, Pascal; Fournier-Prunaret, Daniele

    2009-12-01

    An accurate approach to compute the bit error rate expression for multiuser chaosbased DS-CDMA system is presented in this paper. For more realistic communication system a slow fading multipath channel is considered. A simple RAKE receiver structure is considered. Based on the bit energy distribution, this approach compared to others computation methods existing in literature gives accurate results with low computation charge. Perfect estimation of the channel coefficients with the associated delays and chaos synchronization is assumed. The bit error rate is derived in terms of the bit energy distribution, the number of paths, the noise variance, and the number of users. Results are illustrated by theoretical calculations and numerical simulations which point out the accuracy of our approach.

  15. Quantification of residual dose estimation error on log file-based patient dose calculation.

    PubMed

    Katsuta, Yoshiyuki; Kadoya, Noriyuki; Fujita, Yukio; Shimizu, Eiji; Matsunaga, Kenichi; Matsushita, Haruo; Majima, Kazuhiro; Jingu, Keiichi

    2016-05-01

    The log file-based patient dose estimation includes a residual dose estimation error caused by leaf miscalibration, which cannot be reflected on the estimated dose. The purpose of this study is to determine this residual dose estimation error. Modified log files for seven head-and-neck and prostate volumetric modulated arc therapy (VMAT) plans simulating leaf miscalibration were generated by shifting both leaf banks (systematic leaf gap errors: ±2.0, ±1.0, and ±0.5mm in opposite directions and systematic leaf shifts: ±1.0mm in the same direction) using MATLAB-based (MathWorks, Natick, MA) in-house software. The generated modified and non-modified log files were imported back into the treatment planning system and recalculated. Subsequently, the generalized equivalent uniform dose (gEUD) was quantified for the definition of the planning target volume (PTV) and organs at risks. For MLC leaves calibrated within ±0.5mm, the quantified residual dose estimation errors that obtained from the slope of the linear regression of gEUD changes between non- and modified log file doses per leaf gap are in head-and-neck plans 1.32±0.27% and 0.82±0.17Gy for PTV and spinal cord, respectively, and in prostate plans 1.22±0.36%, 0.95±0.14Gy, and 0.45±0.08Gy for PTV, rectum, and bladder, respectively. In this work, we determine the residual dose estimation errors for VMAT delivery using the log file-based patient dose calculation according to the MLC calibration accuracy. Copyright © 2016 Associazione Italiana di Fisica Medica. Published by Elsevier Ltd. All rights reserved.

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

    PubMed

    Helo, Sevann; Moulton, Carol-Anne E

    2017-08-01

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

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

    PubMed Central

    Moulton, Carol-Anne E.

    2017-01-01

    Errors are inherent in medicine due to the imperfectness of human nature. Health care providers may have a difficult time accepting their fallibility, acknowledging mistakes, and disclosing errors. Fear of litigation, shame, blame, and concern about reputation are just some of the barriers preventing physicians from being more candid with their patients, despite the supporting body of evidence that patients cite poor communication and lack of transparency as primary drivers to file a lawsuit in the wake of a medical complication. Proper error disclosure includes a timely explanation of what happened, who was involved, why the error occurred, and how it will be prevented in the future. Medical mistakes afford the opportunity for individuals and institutions to be candid about their weaknesses while improving patient care processes. When a physician takes the Hippocratic Oath they take on a tremendous sense of responsibility for the care of their patients, and often bear the burden of their mistakes in isolation. Physicians may struggle with guilt, shame, and a crisis of confidence, which may thwart efforts to identify areas for improvement that can lead to meaningful change. Coping strategies for providers include discussing the event with others, seeking professional counseling, and implementing quality improvement projects. Physicians and health care organizations need to find adaptive ways to deal with complications that will benefit patients, providers, and their institutions. PMID:28904910

  18. Calculating Interaction Energies Using First Principle Theories: Consideration of Basis Set Superposition Error and Fragment Relaxation

    ERIC Educational Resources Information Center

    Bowen, J. Philip; Sorensen, Jennifer B.; Kirschner, Karl N.

    2007-01-01

    The analysis explains the basis set superposition error (BSSE) and fragment relaxation involved in calculating the interaction energies using various first principle theories. Interacting the correlated fragment and increasing the size of the basis set can help in decreasing the BSSE to a great extent.

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

    DOT National Transportation Integrated Search

    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...

  20. Quantification of errors in ordinal outcome scales using shannon entropy: effect on sample size calculations.

    PubMed

    Mandava, Pitchaiah; Krumpelman, Chase S; Shah, Jharna N; White, Donna L; Kent, Thomas A

    2013-01-01

    Clinical trial outcomes often involve an ordinal scale of subjective functional assessments but the optimal way to quantify results is not clear. In stroke, the most commonly used scale, the modified Rankin Score (mRS), a range of scores ("Shift") is proposed as superior to dichotomization because of greater information transfer. The influence of known uncertainties in mRS assessment has not been quantified. We hypothesized that errors caused by uncertainties could be quantified by applying information theory. Using Shannon's model, we quantified errors of the "Shift" compared to dichotomized outcomes using published distributions of mRS uncertainties and applied this model to clinical trials. We identified 35 randomized stroke trials that met inclusion criteria. Each trial's mRS distribution was multiplied with the noise distribution from published mRS inter-rater variability to generate an error percentage for "shift" and dichotomized cut-points. For the SAINT I neuroprotectant trial, considered positive by "shift" mRS while the larger follow-up SAINT II trial was negative, we recalculated sample size required if classification uncertainty was taken into account. Considering the full mRS range, error rate was 26.1%±5.31 (Mean±SD). Error rates were lower for all dichotomizations tested using cut-points (e.g. mRS 1; 6.8%±2.89; overall p<0.001). Taking errors into account, SAINT I would have required 24% more subjects than were randomized. We show when uncertainty in assessments is considered, the lowest error rates are with dichotomization. While using the full range of mRS is conceptually appealing, a gain of information is counter-balanced by a decrease in reliability. The resultant errors need to be considered since sample size may otherwise be underestimated. In principle, we have outlined an approach to error estimation for any condition in which there are uncertainties in outcome assessment. We provide the user with programs to calculate and incorporate

  1. Horizon sensor errors calculated by computer models compared with errors measured in orbit

    NASA Technical Reports Server (NTRS)

    Ward, K. A.; Hogan, R.; Andary, J.

    1982-01-01

    Using a computer program to model the earth's horizon and to duplicate the signal processing procedure employed by the ESA (Earth Sensor Assembly), errors due to radiance variation have been computed for a particular time of the year. Errors actually occurring in flight at the same time of year are inferred from integrated rate gyro data for a satellite of the TIROS series of NASA weather satellites (NOAA-A). The predicted performance is compared with actual flight history.

  2. Spatial durbin error model for human development index in Province of Central Java.

    NASA Astrophysics Data System (ADS)

    Septiawan, A. R.; Handajani, S. S.; Martini, T. S.

    2018-05-01

    The Human Development Index (HDI) is an indicator used to measure success in building the quality of human life, explaining how people access development outcomes when earning income, health and education. Every year HDI in Central Java has improved to a better direction. In 2016, HDI in Central Java was 69.98 %, an increase of 0.49 % over the previous year. The objective of this study was to apply the spatial Durbin error model using angle weights queen contiguity to measure HDI in Central Java Province. Spatial Durbin error model is used because the model overcomes the spatial effect of errors and the effects of spatial depedency on the independent variable. Factors there use is life expectancy, mean years of schooling, expected years of schooling, and purchasing power parity. Based on the result of research, we get spatial Durbin error model for HDI in Central Java with influencing factors are life expectancy, mean years of schooling, expected years of schooling, and purchasing power parity.

  3. Model-based influences on humans' choices and striatal prediction errors.

    PubMed

    Daw, Nathaniel D; Gershman, Samuel J; Seymour, Ben; Dayan, Peter; Dolan, Raymond J

    2011-03-24

    The mesostriatal dopamine system is prominently implicated in model-free reinforcement learning, with fMRI BOLD signals in ventral striatum notably covarying with model-free prediction errors. However, latent learning and devaluation studies show that behavior also shows hallmarks of model-based planning, and the interaction between model-based and model-free values, prediction errors, and preferences is underexplored. We designed a multistep decision task in which model-based and model-free influences on human choice behavior could be distinguished. By showing that choices reflected both influences we could then test the purity of the ventral striatal BOLD signal as a model-free report. Contrary to expectations, the signal reflected both model-free and model-based predictions in proportions matching those that best explained choice behavior. These results challenge the notion of a separate model-free learner and suggest a more integrated computational architecture for high-level human decision-making. Copyright © 2011 Elsevier Inc. All rights reserved.

  4. Sleep quality, posttraumatic stress, depression, and human errors in train drivers: a population-based nationwide study in South Korea.

    PubMed

    Jeon, Hong Jin; Kim, Ji-Hae; Kim, Bin-Na; Park, Seung Jin; Fava, Maurizio; Mischoulon, David; Kang, Eun-Ho; Roh, Sungwon; Lee, Dongsoo

    2014-12-01

    Human error is defined as an unintended error that is attributable to humans rather than machines, and that is important to avoid to prevent accidents. We aimed to investigate the association between sleep quality and human errors among train drivers. Cross-sectional. Population-based. A sample of 5,480 subjects who were actively working as train drivers were recruited in South Korea. The participants were 4,634 drivers who completed all questionnaires (response rate 84.6%). None. The Pittsburgh Sleep Quality Index (PSQI), the Center for Epidemiologic Studies Depression Scale (CES-D), the Impact of Event Scale-Revised (IES-R), the State-Trait Anxiety Inventory (STAI), and the Korean Occupational Stress Scale (KOSS). Of 4,634 train drivers, 349 (7.5%) showed more than one human error per 5 y. Human errors were associated with poor sleep quality, higher PSQI total scores, short sleep duration at night, and longer sleep latency. Among train drivers with poor sleep quality, those who experienced severe posttraumatic stress showed a significantly higher number of human errors than those without. Multiple logistic regression analysis showed that human errors were significantly associated with poor sleep quality and posttraumatic stress, whereas there were no significant associations with depression, trait and state anxiety, and work stress after adjusting for age, sex, education years, marital status, and career duration. Poor sleep quality was found to be associated with more human errors in train drivers, especially in those who experienced severe posttraumatic stress. © 2014 Associated Professional Sleep Societies, LLC.

  5. Calculation and error analysis of a digital elevation model of Hofsjokull, Iceland, from SAR interferometry

    USGS Publications Warehouse

    Barton, Jonathan S.; Hall, Dorothy K.; Sigurðsson, Oddur; Williams, Richard S.; Smith, Laurence C.; Garvin, James B.; Taylor, Susan; Hardy, Janet

    1999-01-01

    Two ascending European Space Agency (ESA) Earth Resources Satellites (ERS)-1/-2 tandem-mode, synthetic aperture radar (SAR) pairs are used to calculate the surface elevation of Hofsjokull, an ice cap in central Iceland. The motion component of the interferometric phase is calculated using the 30 arc-second resolution USGS GTOPO30 global digital elevation product and one of the ERS tandem pairs. The topography is then derived by subtracting the motion component from the other tandem pair. In order to assess the accuracy of the resultant digital elevation model (DEM), a geodetic airborne laser-altimetry swath is compared with the elevations derived from the interferometry. The DEM is also compared with elevations derived from a digitized topographic map of the ice cap from the University of Iceland Science Institute. Results show that low temporal correlation is a significant problem for the application of interferometry to small, low-elevation ice caps, even over a one-day repeat interval, and especially at the higher elevations. Results also show that an uncompensated error in the phase, ramping from northwest to southeast, present after tying the DEM to ground-control points, has resulted in a systematic error across the DEM.

  6. Calculation and Error Analysis of a Digital Elevation Model of Hofsjokull, Iceland from SAR Interferometry

    NASA Technical Reports Server (NTRS)

    Barton, Jonathan S.; Hall, Dorothy K.; Sigurosson, Oddur; Williams, Richard S., Jr.; Smith, Laurence C.; Garvin, James B.

    1999-01-01

    Two ascending European Space Agency (ESA) Earth Resources Satellites (ERS)-1/-2 tandem-mode, synthetic aperture radar (SAR) pairs are used to calculate the surface elevation of Hofsjokull, an ice cap in central Iceland. The motion component of the interferometric phase is calculated using the 30 arc-second resolution USGS GTOPO30 global digital elevation product and one of the ERS tandem pairs. The topography is then derived by subtracting the motion component from the other tandem pair. In order to assess the accuracy of the resultant digital elevation model (DEM), a geodetic airborne laser-altimetry swath is compared with the elevations derived from the interferometry. The DEM is also compared with elevations derived from a digitized topographic map of the ice cap from the University of Iceland Science Institute. Results show that low temporal correlation is a significant problem for the application of interferometry to small, low-elevation ice caps, even over a one-day repeat interval, and especially at the higher elevations. Results also show that an uncompensated error in the phase, ramping from northwest to southeast, present after tying the DEM to ground-control points, has resulted in a systematic error across the DEM.

  7. Good people who try their best can have problems: recognition of human factors and how to minimise error.

    PubMed

    Brennan, Peter A; Mitchell, David A; Holmes, Simon; Plint, Simon; Parry, David

    2016-01-01

    Human error is as old as humanity itself and is an appreciable cause of mistakes by both organisations and people. Much of the work related to human factors in causing error has originated from aviation where mistakes can be catastrophic not only for those who contribute to the error, but for passengers as well. The role of human error in medical and surgical incidents, which are often multifactorial, is becoming better understood, and includes both organisational issues (by the employer) and potential human factors (at a personal level). Mistakes as a result of individual human factors and surgical teams should be better recognised and emphasised. Attitudes and acceptance of preoperative briefing has improved since the introduction of the World Health Organization (WHO) surgical checklist. However, this does not address limitations or other safety concerns that are related to performance, such as stress and fatigue, emotional state, hunger, awareness of what is going on situational awareness, and other factors that could potentially lead to error. Here we attempt to raise awareness of these human factors, and highlight how they can lead to error, and how they can be minimised in our day-to-day practice. Can hospitals move from being "high risk industries" to "high reliability organisations"? Copyright © 2015 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.

  8. Human factors evaluation of remote afterloading brachytherapy: Human error and critical tasks in remote afterloading brachytherapy and approaches for improved system performance. Volume 1

    DOE Office of Scientific and Technical Information (OSTI.GOV)

    Callan, J.R.; Kelly, R.T.; Quinn, M.L.

    1995-05-01

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

  9. SU-E-T-769: T-Test Based Prior Error Estimate and Stopping Criterion for Monte Carlo Dose Calculation in Proton Therapy

    DOE Office of Scientific and Technical Information (OSTI.GOV)

    Hong, X; Gao, H; Schuemann, J

    2015-06-15

    Purpose: The Monte Carlo (MC) method is a gold standard for dose calculation in radiotherapy. However, it is not a priori clear how many particles need to be simulated to achieve a given dose accuracy. Prior error estimate and stopping criterion are not well established for MC. This work aims to fill this gap. Methods: Due to the statistical nature of MC, our approach is based on one-sample t-test. We design the prior error estimate method based on the t-test, and then use this t-test based error estimate for developing a simulation stopping criterion. The three major components are asmore » follows.First, the source particles are randomized in energy, space and angle, so that the dose deposition from a particle to the voxel is independent and identically distributed (i.i.d.).Second, a sample under consideration in the t-test is the mean value of dose deposition to the voxel by sufficiently large number of source particles. Then according to central limit theorem, the sample as the mean value of i.i.d. variables is normally distributed with the expectation equal to the true deposited dose.Third, the t-test is performed with the null hypothesis that the difference between sample expectation (the same as true deposited dose) and on-the-fly calculated mean sample dose from MC is larger than a given error threshold, in addition to which users have the freedom to specify confidence probability and region of interest in the t-test based stopping criterion. Results: The method is validated for proton dose calculation. The difference between the MC Result based on the t-test prior error estimate and the statistical Result by repeating numerous MC simulations is within 1%. Conclusion: The t-test based prior error estimate and stopping criterion are developed for MC and validated for proton dose calculation. Xiang Hong and Hao Gao were partially supported by the NSFC (#11405105), the 973 Program (#2015CB856000) and the Shanghai Pujiang Talent Program (#14PJ1404500)« less

  10. Accounting for measurement error in human life history trade-offs using structural equation modeling.

    PubMed

    Helle, Samuli

    2018-03-01

    Revealing causal effects from correlative data is very challenging and a contemporary problem in human life history research owing to the lack of experimental approach. Problems with causal inference arising from measurement error in independent variables, whether related either to inaccurate measurement technique or validity of measurements, seem not well-known in this field. The aim of this study is to show how structural equation modeling (SEM) with latent variables can be applied to account for measurement error in independent variables when the researcher has recorded several indicators of a hypothesized latent construct. As a simple example of this approach, measurement error in lifetime allocation of resources to reproduction in Finnish preindustrial women is modelled in the context of the survival cost of reproduction. In humans, lifetime energetic resources allocated in reproduction are almost impossible to quantify with precision and, thus, typically used measures of lifetime reproductive effort (e.g., lifetime reproductive success and parity) are likely to be plagued by measurement error. These results are contrasted with those obtained from a traditional regression approach where the single best proxy of lifetime reproductive effort available in the data is used for inference. As expected, the inability to account for measurement error in women's lifetime reproductive effort resulted in the underestimation of its underlying effect size on post-reproductive survival. This article emphasizes the advantages that the SEM framework can provide in handling measurement error via multiple-indicator latent variables in human life history studies. © 2017 Wiley Periodicals, Inc.

  11. Space-Time Error Representation and Estimation in Navier-Stokes Calculations

    NASA Technical Reports Server (NTRS)

    Barth, Timothy J.

    2006-01-01

    The mathematical framework for a-posteriori error estimation of functionals elucidated by Eriksson et al. [7] and Becker and Rannacher [3] is revisited in a space-time context. Using these theories, a hierarchy of exact and approximate error representation formulas are presented for use in error estimation and mesh adaptivity. Numerical space-time results for simple model problems as well as compressible Navier-Stokes flow at Re = 300 over a 2D circular cylinder are then presented to demonstrate elements of the error representation theory for time-dependent problems.

  12. The current approach to human error and blame in the NHS.

    PubMed

    Ottewill, Melanie

    There is a large body of research to suggest that serious errors are widespread throughout medicine. The traditional response to these adverse events has been to adopt a 'person approach' - blaming the individual seen as 'responsible'. The culture of medicine is highly complicit in this response. Such an approach results in enormous personal costs to the individuals concerned and does little to address the root causes of errors and thus prevent their recurrence. Other industries, such as aviation, where safety is a paramount concern and which have similar structures to the medical profession, have, over the past decade or so, adopted a 'systems' approach to error, recognizing that human error is ubiquitous and inevitable and that systems need to be developed with this in mind. This approach has been highly successful, but has necessitated, first and foremost, a cultural shift. It is in the best interests of patients, and medical professionals alike, that such a shift is embraced in the NHS.

  13. Calculation of stochastic broadening due to noise and field errors in the simple map in action-angle coordinates

    NASA Astrophysics Data System (ADS)

    Hinton, Courtney; Punjabi, Alkesh; Ali, Halima

    2008-11-01

    The simple map is the simplest map that has topology of divertor tokamaks [1]. Recently, the action-angle coordinates for simple map are analytically calculated, and simple map is constructed in action-angle coordinates [2]. Action-angle coordinates for simple map can not be inverted to real space coordinates (R,Z). Because there is logarithmic singularity on the ideal separatrix, trajectories can not cross separatrix [2]. Simple map in action-angle coordinates is applied to calculate stochastic broadening due to magnetic noise and field errors. Mode numbers for noise + field errors from the DIII-D tokamak are used. Mode numbers are (m,n)=(3,1), (4,1), (6,2), (7,2), (8,2), (9,3), (10,3), (11,3), (12,3) [3]. The common amplitude δ is varied from 0.8X10-5 to 2.0X10-5. For this noise and field errors, the width of stochastic layer in simple map is calculated. This work is supported by US Department of Energy grants DE-FG02-07ER54937, DE-FG02-01ER54624 and DE-FG02-04ER54793 1. A. Punjabi, H. Ali, T. Evans, and A. Boozer, Phys. Let. A 364, 140--145 (2007). 2. O. Kerwin, A. Punjabi, and H. Ali, to appear in Physics of Plasmas. 3. A. Punjabi and H. Ali, P1.012, 35^th EPS Conference on Plasma Physics, June 9-13, 2008, Hersonissos, Crete, Greece.

  14. Towards a systematic assessment of errors in diffusion Monte Carlo calculations of semiconductors: Case study of zinc selenide and zinc oxide

    DOE Office of Scientific and Technical Information (OSTI.GOV)

    Yu, Jaehyung; Wagner, Lucas K.; Ertekin, Elif, E-mail: ertekin@illinois.edu

    2015-12-14

    The fixed node diffusion Monte Carlo (DMC) method has attracted interest in recent years as a way to calculate properties of solid materials with high accuracy. However, the framework for the calculation of properties such as total energies, atomization energies, and excited state energies is not yet fully established. Several outstanding questions remain as to the effect of pseudopotentials, the magnitude of the fixed node error, and the size of supercell finite size effects. Here, we consider in detail the semiconductors ZnSe and ZnO and carry out systematic studies to assess the magnitude of the energy differences arising from controlledmore » and uncontrolled approximations in DMC. The former include time step errors and supercell finite size effects for ground and optically excited states, and the latter include pseudopotentials, the pseudopotential localization approximation, and the fixed node approximation. We find that for these compounds, the errors can be controlled to good precision using modern computational resources and that quantum Monte Carlo calculations using Dirac-Fock pseudopotentials can offer good estimates of both cohesive energy and the gap of these systems. We do however observe differences in calculated optical gaps that arise when different pseudopotentials are used.« less

  15. Evaluation of lens distortion errors using an underwater camera system for video-based motion analysis

    NASA Technical Reports Server (NTRS)

    Poliner, Jeffrey; Fletcher, Lauren; Klute, Glenn K.

    1994-01-01

    Video-based motion analysis systems are widely employed to study human movement, using computers to capture, store, process, and analyze video data. This data can be collected in any environment where cameras can be located. One of the NASA facilities where human performance research is conducted is the Weightless Environment Training Facility (WETF), a pool of water which simulates zero-gravity with neutral buoyance. Underwater video collection in the WETF poses some unique problems. This project evaluates the error caused by the lens distortion of the WETF cameras. A grid of points of known dimensions was constructed and videotaped using a video vault underwater system. Recorded images were played back on a VCR and a personal computer grabbed and stored the images on disk. These images were then digitized to give calculated coordinates for the grid points. Errors were calculated as the distance from the known coordinates of the points to the calculated coordinates. It was demonstrated that errors from lens distortion could be as high as 8 percent. By avoiding the outermost regions of a wide-angle lens, the error can be kept smaller.

  16. Hirarchical emotion calculation model for virtual human modellin - biomed 2010.

    PubMed

    Zhao, Yue; Wright, David

    2010-01-01

    This paper introduces a new emotion generation method for virtual human modelling. The method includes a novel hierarchical emotion structure, a group of emotion calculation equations and a simple heuristics decision making mechanism, which enables virtual humans to perform emotionally in real-time according to their internal and external factors. Emotion calculation equations used in this research were derived from psychologic emotion measurements. Virtual humans can utilise the information in virtual memory and emotion calculation equations to generate their own numerical emotion states within the hierarchical emotion structure. Those emotion states are important internal references for virtual humans to adopt appropriate behaviours and also key cues for their decision making. A simple heuristics theory is introduced and integrated into decision making process in order to make the virtual humans decision making more like a real human. A data interface which connects the emotion calculation and the decision making structure together has also been designed and simulated to test the method in Virtools environment.

  17. How we learn to make decisions: rapid propagation of reinforcement learning prediction errors in humans.

    PubMed

    Krigolson, Olav E; Hassall, Cameron D; Handy, Todd C

    2014-03-01

    Our ability to make decisions is predicated upon our knowledge of the outcomes of the actions available to us. Reinforcement learning theory posits that actions followed by a reward or punishment acquire value through the computation of prediction errors-discrepancies between the predicted and the actual reward. A multitude of neuroimaging studies have demonstrated that rewards and punishments evoke neural responses that appear to reflect reinforcement learning prediction errors [e.g., Krigolson, O. E., Pierce, L. J., Holroyd, C. B., & Tanaka, J. W. Learning to become an expert: Reinforcement learning and the acquisition of perceptual expertise. Journal of Cognitive Neuroscience, 21, 1833-1840, 2009; Bayer, H. M., & Glimcher, P. W. Midbrain dopamine neurons encode a quantitative reward prediction error signal. Neuron, 47, 129-141, 2005; O'Doherty, J. P. Reward representations and reward-related learning in the human brain: Insights from neuroimaging. Current Opinion in Neurobiology, 14, 769-776, 2004; Holroyd, C. B., & Coles, M. G. H. The neural basis of human error processing: Reinforcement learning, dopamine, and the error-related negativity. Psychological Review, 109, 679-709, 2002]. Here, we used the brain ERP technique to demonstrate that not only do rewards elicit a neural response akin to a prediction error but also that this signal rapidly diminished and propagated to the time of choice presentation with learning. Specifically, in a simple, learnable gambling task, we show that novel rewards elicited a feedback error-related negativity that rapidly decreased in amplitude with learning. Furthermore, we demonstrate the existence of a reward positivity at choice presentation, a previously unreported ERP component that has a similar timing and topography as the feedback error-related negativity that increased in amplitude with learning. The pattern of results we observed mirrored the output of a computational model that we implemented to compute reward

  18. The missing calculation: the human cost.

    PubMed

    Green, Betty L

    2007-01-01

    The incursion of a foreign animal disease into any country produces devastating impacts on the country and on its producing industry. Although the associated financial losses to the country and its industry inevitably are calculated, the result in compensation to producers is often inadequate. Above and beyond the financial accounting calculations, however, there is a tremendously destructive and overwhelming impact that has been essentially ignored. That is the profound social impact and the real human cost to individual producers in the livestock industry and their families. Any decision to employ mass animal destruction as an animal disease control strategy must take this fundamental human element into full consideration. The author describes the consequences and depth of personal impact that the stamping-out approach has produced on affected individual livestock producers.

  19. Impact of human error on lumber yield in rough mills

    Treesearch

    Urs Buehlmann; R. Edward Thomas; R. Edward Thomas

    2002-01-01

    Rough sawn, kiln-dried lumber contains characteristics such as knots and bark pockets that are considered by most people to be defects. When using boards to produce furniture components, these defects are removed to produce clear, defect-free parts. Currently, human operators identify and locate the unusable board areas containing defects. Errors in determining a...

  20. Human-simulation-based learning to prevent medication error: A systematic review.

    PubMed

    Sarfati, Laura; Ranchon, Florence; Vantard, Nicolas; Schwiertz, Vérane; Larbre, Virginie; Parat, Stéphanie; Faudel, Amélie; Rioufol, Catherine

    2018-01-31

    In the past 2 decades, there has been an increasing interest in simulation-based learning programs to prevent medication error (ME). To improve knowledge, skills, and attitudes in prescribers, nurses, and pharmaceutical staff, these methods enable training without directly involving patients. However, best practices for simulation for healthcare providers are as yet undefined. By analysing the current state of experience in the field, the present review aims to assess whether human simulation in healthcare helps to reduce ME. A systematic review was conducted on Medline from 2000 to June 2015, associating the terms "Patient Simulation," "Medication Errors," and "Simulation Healthcare." Reports of technology-based simulation were excluded, to focus exclusively on human simulation in nontechnical skills learning. Twenty-one studies assessing simulation-based learning programs were selected, focusing on pharmacy, medicine or nursing students, or concerning programs aimed at reducing administration or preparation errors, managing crises, or learning communication skills for healthcare professionals. The studies varied in design, methodology, and assessment criteria. Few demonstrated that simulation was more effective than didactic learning in reducing ME. This review highlights a lack of long-term assessment and real-life extrapolation, with limited scenarios and participant samples. These various experiences, however, help in identifying the key elements required for an effective human simulation-based learning program for ME prevention: ie, scenario design, debriefing, and perception assessment. The performance of these programs depends on their ability to reflect reality and on professional guidance. Properly regulated simulation is a good way to train staff in events that happen only exceptionally, as well as in standard daily activities. By integrating human factors, simulation seems to be effective in preventing iatrogenic risk related to ME, if the program is

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

    PubMed

    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.

  2. Calculation of lens alignment errors using the ray transfer matrices for the lens assembly system with an autocollimator and a rotation stage

    NASA Astrophysics Data System (ADS)

    Chu, Jiyoung; Cho, Sungwhi; Joo, Won Don; Jang, Sangdon

    2017-08-01

    One of the most popular methods for high precision lens assembly of an optical system is using an autocollimator and a rotation stage. Some companies provide software for calculating the state of the lens along with their lens assembly systems, but the calculation algorithms used by the software are unknown. In this paper, we suggest a calculation method for lens alignment errors using ray transfer matrices. Alignment errors resulting from tilting and decentering of a lens element can be calculated from the tilts of the front and back surfaces of the lens. The tilt of each surface can be obtained from the position of the reticle image on the CCD camera of the autocollimator. Rays from a reticle of the autocollimator are reflected from the target surface of the lens, which rotates with the rotation stage, and are imaged on the CCD camera. To obtain a clear image, the distance between the autocollimator and the first lens surface should be adjusted according to the focusing lens of the autocollimator and the lens surfaces from the first to the target surface. Ray propagations for the autocollimator and the tilted lens surfaces can be expressed effectively by using ray transfer matrices and lens alignment errors can be derived from them. This method was compared with Zemax simulation for various lenses with spherical or flat surfaces and the error was less than a few percent.

  3. Operational Interventions to Maintenance Error

    NASA Technical Reports Server (NTRS)

    Kanki, Barbara G.; Walter, Diane; Dulchinos, VIcki

    1997-01-01

    A significant proportion of aviation accidents and incidents are known to be tied to human error. However, research of flight operational errors has shown that so-called pilot error often involves a variety of human factors issues and not a simple lack of individual technical skills. In aircraft maintenance operations, there is similar concern that maintenance errors which may lead to incidents and accidents are related to a large variety of human factors issues. Although maintenance error data and research are limited, industry initiatives involving human factors training in maintenance have become increasingly accepted as one type of maintenance error intervention. Conscientious efforts have been made in re-inventing the team7 concept for maintenance operations and in tailoring programs to fit the needs of technical opeRAtions. Nevertheless, there remains a dual challenge: 1) to develop human factors interventions which are directly supported by reliable human error data, and 2) to integrate human factors concepts into the procedures and practices of everyday technical tasks. In this paper, we describe several varieties of human factors interventions and focus on two specific alternatives which target problems related to procedures and practices; namely, 1) structured on-the-job training and 2) procedure re-design. We hope to demonstrate that the key to leveraging the impact of these solutions comes from focused interventions; that is, interventions which are derived from a clear understanding of specific maintenance errors, their operational context and human factors components.

  4. Hierarchical learning induces two simultaneous, but separable, prediction errors in human basal ganglia.

    PubMed

    Diuk, Carlos; Tsai, Karin; Wallis, Jonathan; Botvinick, Matthew; Niv, Yael

    2013-03-27

    Studies suggest that dopaminergic neurons report a unitary, global reward prediction error signal. However, learning in complex real-life tasks, in particular tasks that show hierarchical structure, requires multiple prediction errors that may coincide in time. We used functional neuroimaging to measure prediction error signals in humans performing such a hierarchical task involving simultaneous, uncorrelated prediction errors. Analysis of signals in a priori anatomical regions of interest in the ventral striatum and the ventral tegmental area indeed evidenced two simultaneous, but separable, prediction error signals corresponding to the two levels of hierarchy in the task. This result suggests that suitably designed tasks may reveal a more intricate pattern of firing in dopaminergic neurons. Moreover, the need for downstream separation of these signals implies possible limitations on the number of different task levels that we can learn about simultaneously.

  5. Hierarchical Learning Induces Two Simultaneous, But Separable, Prediction Errors in Human Basal Ganglia

    PubMed Central

    Tsai, Karin; Wallis, Jonathan; Botvinick, Matthew

    2013-01-01

    Studies suggest that dopaminergic neurons report a unitary, global reward prediction error signal. However, learning in complex real-life tasks, in particular tasks that show hierarchical structure, requires multiple prediction errors that may coincide in time. We used functional neuroimaging to measure prediction error signals in humans performing such a hierarchical task involving simultaneous, uncorrelated prediction errors. Analysis of signals in a priori anatomical regions of interest in the ventral striatum and the ventral tegmental area indeed evidenced two simultaneous, but separable, prediction error signals corresponding to the two levels of hierarchy in the task. This result suggests that suitably designed tasks may reveal a more intricate pattern of firing in dopaminergic neurons. Moreover, the need for downstream separation of these signals implies possible limitations on the number of different task levels that we can learn about simultaneously. PMID:23536092

  6. Human errors and occupational injuries of older female workers in the residential healthcare facilities for the elderly.

    PubMed

    Kim, Jun Sik; Jeong, Byung Yong

    2018-05-03

    The study aimed to describe the characteristics of occupational injuries of female workers in the residential healthcare facilities for the elderly, and analyze human errors as causes of accidents. From the national industrial accident compensation data, 506 female injuries were analyzed by age and occupation. The results showed that medical service worker was the most prevalent (54.1%), followed by social welfare worker (20.4%). Among injuries, 55.7% were <1 year of work experience, and 37.9% were ≥60 years old. Slips/falls were the most common type of accident (42.7%), and proportion of injured by slips/falls increases with age. Among human errors, action errors were the primary reasons, followed by perception errors, and cognition errors. Besides, the ratios of injuries by perception errors and action errors increase with age, respectively. The findings of this study suggest that there is a need to design workplaces that accommodate the characteristics of older female workers.

  7. Sensitivity to prediction error in reach adaptation

    PubMed Central

    Haith, Adrian M.; Harran, Michelle D.; Shadmehr, Reza

    2012-01-01

    It has been proposed that the brain predicts the sensory consequences of a movement and compares it to the actual sensory feedback. When the two differ, an error signal is formed, driving adaptation. How does an error in one trial alter performance in the subsequent trial? Here we show that the sensitivity to error is not constant but declines as a function of error magnitude. That is, one learns relatively less from large errors compared with small errors. We performed an experiment in which humans made reaching movements and randomly experienced an error in both their visual and proprioceptive feedback. Proprioceptive errors were created with force fields, and visual errors were formed by perturbing the cursor trajectory to create a visual error that was smaller, the same size, or larger than the proprioceptive error. We measured single-trial adaptation and calculated sensitivity to error, i.e., the ratio of the trial-to-trial change in motor commands to error size. We found that for both sensory modalities sensitivity decreased with increasing error size. A reanalysis of a number of previously published psychophysical results also exhibited this feature. Finally, we asked how the brain might encode sensitivity to error. We reanalyzed previously published probabilities of cerebellar complex spikes (CSs) and found that this probability declined with increasing error size. From this we posit that a CS may be representative of the sensitivity to error, and not error itself, a hypothesis that may explain conflicting reports about CSs and their relationship to error. PMID:22773782

  8. Evaluating a medical error taxonomy.

    PubMed

    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 standard language for reporting medication errors. This project maps the NCC MERP taxonomy of medication error to MedWatch medical errors involving infusion pumps. Of particular interest are human factors associated with medical device errors. The NCC MERP taxonomy of medication errors is limited in mapping information from MEDWATCH because of the focus on the medical device and the format of reporting.

  9. Error Patterns with Fraction Calculations at Fourth Grade as a Function of Students' Mathematics Achievement Status.

    PubMed

    Schumacher, Robin F; Malone, Amelia S

    2017-09-01

    The goal of the present study was to describe fraction-calculation errors among 4 th -grade students and determine whether error patterns differed as a function of problem type (addition vs. subtraction; like vs. unlike denominators), orientation (horizontal vs. vertical), or mathematics-achievement status (low- vs. average- vs. high-achieving). We specifically addressed whether mathematics-achievement status was related to students' tendency to operate with whole number bias. We extended this focus by comparing low-performing students' errors in two instructional settings that focused on two different types of fraction understandings: core instruction that focused on part-whole understanding vs. small-group tutoring that focused on magnitude understanding. Results showed students across the sample were more likely to operate with whole number bias on problems with unlike denominators. Students with low or average achievement (who only participated in core instruction) were more likely to operate with whole number bias than students with low achievement who participated in small-group tutoring. We suggest instruction should emphasize magnitude understanding to sufficiently increase fraction understanding for all students in the upper elementary grades.

  10. Previous Estimates of Mitochondrial DNA Mutation Level Variance Did Not Account for Sampling Error: Comparing the mtDNA Genetic Bottleneck in Mice and Humans

    PubMed Central

    Wonnapinij, Passorn; Chinnery, Patrick F.; Samuels, David C.

    2010-01-01

    In cases of inherited pathogenic mitochondrial DNA (mtDNA) mutations, a mother and her offspring generally have large and seemingly random differences in the amount of mutated mtDNA that they carry. Comparisons of measured mtDNA mutation level variance values have become an important issue in determining the mechanisms that cause these large random shifts in mutation level. These variance measurements have been made with samples of quite modest size, which should be a source of concern because higher-order statistics, such as variance, are poorly estimated from small sample sizes. We have developed an analysis of the standard error of variance from a sample of size n, and we have defined error bars for variance measurements based on this standard error. We calculate variance error bars for several published sets of measurements of mtDNA mutation level variance and show how the addition of the error bars alters the interpretation of these experimental results. We compare variance measurements from human clinical data and from mouse models and show that the mutation level variance is clearly higher in the human data than it is in the mouse models at both the primary oocyte and offspring stages of inheritance. We discuss how the standard error of variance can be used in the design of experiments measuring mtDNA mutation level variance. Our results show that variance measurements based on fewer than 20 measurements are generally unreliable and ideally more than 50 measurements are required to reliably compare variances with less than a 2-fold difference. PMID:20362273

  11. User Performance Evaluation of Four Blood Glucose Monitoring Systems Applying ISO 15197:2013 Accuracy Criteria and Calculation of Insulin Dosing Errors.

    PubMed

    Freckmann, Guido; Jendrike, Nina; Baumstark, Annette; Pleus, Stefan; Liebing, Christina; Haug, Cornelia

    2018-04-01

    The international standard ISO 15197:2013 requires a user performance evaluation to assess if intended users are able to obtain accurate blood glucose measurement results with a self-monitoring of blood glucose (SMBG) system. In this study, user performance was evaluated for four SMBG systems on the basis of ISO 15197:2013, and possibly related insulin dosing errors were calculated. Additionally, accuracy was assessed in the hands of study personnel. Accu-Chek ® Performa Connect (A), Contour ® plus ONE (B), FreeStyle Optium Neo (C), and OneTouch Select ® Plus (D) were evaluated with one test strip lot. After familiarization with the systems, subjects collected a capillary blood sample and performed an SMBG measurement. Study personnel observed the subjects' measurement technique. Then, study personnel performed SMBG measurements and comparison measurements. Number and percentage of SMBG measurements within ± 15 mg/dl and ± 15% of the comparison measurements at glucose concentrations < 100 and ≥ 100 mg/dl, respectively, were calculated. In addition, insulin dosing errors were modelled. In the hands of lay-users three systems fulfilled ISO 15197:2013 accuracy criteria with the investigated test strip lot showing 96% (A), 100% (B), and 98% (C) of results within the defined limits. All systems fulfilled minimum accuracy criteria in the hands of study personnel [99% (A), 100% (B), 99.5% (C), 96% (D)]. Measurements with all four systems were within zones of the consensus error grid and surveillance error grid associated with no or minimal risk. Regarding calculated insulin dosing errors, all 99% ranges were between dosing errors of - 2.7 and + 1.4 units for measurements in the hands of lay-users and between - 2.5 and + 1.4 units for study personnel. Frequent lay-user errors were not checking the test strips' expiry date and applying blood incorrectly. Data obtained in this study show that not all available SMBG systems complied with ISO 15197

  12. The Error in Total Error Reduction

    PubMed Central

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

    2013-01-01

    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 modelling 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. PMID:23891930

  13. The error in total error reduction.

    PubMed

    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.

  14. Medication errors in anesthesia: unacceptable or unavoidable?

    PubMed

    Dhawan, Ira; Tewari, Anurag; Sehgal, Sankalp; Sinha, Ashish Chandra

    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. Copyright © 2016. Published by Elsevier Editora Ltda.

  15. Detection of Error Related Neuronal Responses Recorded by Electrocorticography in Humans during Continuous Movements

    PubMed Central

    Milekovic, Tomislav; Ball, Tonio; Schulze-Bonhage, Andreas; Aertsen, Ad; Mehring, Carsten

    2013-01-01

    Background Brain-machine interfaces (BMIs) can translate the neuronal activity underlying a user’s movement intention into movements of an artificial effector. In spite of continuous improvements, errors in movement decoding are still a major problem of current BMI systems. If the difference between the decoded and intended movements becomes noticeable, it may lead to an execution error. Outcome errors, where subjects fail to reach a certain movement goal, are also present during online BMI operation. Detecting such errors can be beneficial for BMI operation: (i) errors can be corrected online after being detected and (ii) adaptive BMI decoding algorithm can be updated to make fewer errors in the future. Methodology/Principal Findings Here, we show that error events can be detected from human electrocorticography (ECoG) during a continuous task with high precision, given a temporal tolerance of 300–400 milliseconds. We quantified the error detection accuracy and showed that, using only a small subset of 2×2 ECoG electrodes, 82% of detection information for outcome error and 74% of detection information for execution error available from all ECoG electrodes could be retained. Conclusions/Significance The error detection method presented here could be used to correct errors made during BMI operation or to adapt a BMI algorithm to make fewer errors in the future. Furthermore, our results indicate that smaller ECoG implant could be used for error detection. Reducing the size of an ECoG electrode implant used for BMI decoding and error detection could significantly reduce the medical risk of implantation. PMID:23383315

  16. Temporal uncertainty analysis of human errors based on interrelationships among multiple factors: a case of Minuteman III missile accident.

    PubMed

    Rong, Hao; Tian, Jin; Zhao, Tingdi

    2016-01-01

    In traditional approaches of human reliability assessment (HRA), the definition of the error producing conditions (EPCs) and the supporting guidance are such that some of the conditions (especially organizational or managerial conditions) can hardly be included, and thus the analysis is burdened with incomprehensiveness without reflecting the temporal trend of human reliability. A method based on system dynamics (SD), which highlights interrelationships among technical and organizational aspects that may contribute to human errors, is presented to facilitate quantitatively estimating the human error probability (HEP) and its related variables changing over time in a long period. Taking the Minuteman III missile accident in 2008 as a case, the proposed HRA method is applied to assess HEP during missile operations over 50 years by analyzing the interactions among the variables involved in human-related risks; also the critical factors are determined in terms of impact that the variables have on risks in different time periods. It is indicated that both technical and organizational aspects should be focused on to minimize human errors in a long run. Copyright © 2015 Elsevier Ltd and The Ergonomics Society. All rights reserved.

  17. Systematic analysis of video data from different human-robot interaction studies: a categorization of social signals during error situations.

    PubMed

    Giuliani, Manuel; Mirnig, Nicole; Stollnberger, Gerald; Stadler, Susanne; Buchner, Roland; Tscheligi, Manfred

    2015-01-01

    Human-robot interactions are often affected by error situations that are caused by either the robot or the human. Therefore, robots would profit from the ability to recognize when error situations occur. We investigated the verbal and non-verbal social signals that humans show when error situations occur in human-robot interaction experiments. For that, we analyzed 201 videos of five human-robot interaction user studies with varying tasks from four independent projects. The analysis shows that there are two types of error situations: social norm violations and technical failures. Social norm violations are situations in which the robot does not adhere to the underlying social script of the interaction. Technical failures are caused by technical shortcomings of the robot. The results of the video analysis show that the study participants use many head movements and very few gestures, but they often smile, when in an error situation with the robot. Another result is that the participants sometimes stop moving at the beginning of error situations. We also found that the participants talked more in the case of social norm violations and less during technical failures. Finally, the participants use fewer non-verbal social signals (for example smiling, nodding, and head shaking), when they are interacting with the robot alone and no experimenter or other human is present. The results suggest that participants do not see the robot as a social interaction partner with comparable communication skills. Our findings have implications for builders and evaluators of human-robot interaction systems. The builders need to consider including modules for recognition and classification of head movements to the robot input channels. The evaluators need to make sure that the presence of an experimenter does not skew the results of their user studies.

  18. Combining wrist age and third molars in forensic age estimation: how to calculate the joint age estimate and its error rate in age diagnostics.

    PubMed

    Gelbrich, Bianca; Frerking, Carolin; Weiss, Sandra; Schwerdt, Sebastian; Stellzig-Eisenhauer, Angelika; Tausche, Eve; Gelbrich, Götz

    2015-01-01

    Forensic age estimation in living adolescents is based on several methods, e.g. the assessment of skeletal and dental maturation. Combination of several methods is mandatory, since age estimates from a single method are too imprecise due to biological variability. The correlation of the errors of the methods being combined must be known to calculate the precision of combined age estimates. To examine the correlation of the errors of the hand and the third molar method and to demonstrate how to calculate the combined age estimate. Clinical routine radiographs of the hand and dental panoramic images of 383 patients (aged 7.8-19.1 years, 56% female) were assessed. Lack of correlation (r = -0.024, 95% CI = -0.124 to + 0.076, p = 0.64) allows calculating the combined age estimate as the weighted average of the estimates from hand bones and third molars. Combination improved the standard deviations of errors (hand = 0.97, teeth = 1.35 years) to 0.79 years. Uncorrelated errors of the age estimates obtained from both methods allow straightforward determination of the common estimate and its variance. This is also possible when reference data for the hand and the third molar method are established independently from each other, using different samples.

  19. Reduction of Maintenance Error Through Focused Interventions

    NASA Technical Reports Server (NTRS)

    Kanki, Barbara G.; Walter, Diane; Rosekind, Mark R. (Technical Monitor)

    1997-01-01

    It is well known that a significant proportion of aviation accidents and incidents are tied to human error. In flight operations, research of operational errors has shown that so-called "pilot error" often involves a variety of human factors issues and not a simple lack of individual technical skills. In aircraft maintenance operations, there is similar concern that maintenance errors which may lead to incidents and accidents are related to a large variety of human factors issues. Although maintenance error data and research are limited, industry initiatives involving human factors training in maintenance have become increasingly accepted as one type of maintenance error intervention. Conscientious efforts have been made in re-inventing the "team" concept for maintenance operations and in tailoring programs to fit the needs of technical operations. Nevertheless, there remains a dual challenge: to develop human factors interventions which are directly supported by reliable human error data, and to integrate human factors concepts into the procedures and practices of everyday technical tasks. In this paper, we describe several varieties of human factors interventions and focus on two specific alternatives which target problems related to procedures and practices; namely, 1) structured on-the-job training and 2) procedure re-design. We hope to demonstrate that the key to leveraging the impact of these solutions comes from focused interventions; that is, interventions which are derived from a clear understanding of specific maintenance errors, their operational context and human factors components.

  20. An error analysis perspective for patient alignment systems.

    PubMed

    Figl, Michael; Kaar, Marcus; Hoffman, Rainer; Kratochwil, Alfred; Hummel, Johann

    2013-09-01

    This paper analyses the effects of error sources which can be found in patient alignment systems. As an example, an ultrasound (US) repositioning system and its transformation chain are assessed. The findings of this concept can also be applied to any navigation system. In a first step, all error sources were identified and where applicable, corresponding target registration errors were computed. By applying error propagation calculations on these commonly used registration/calibration and tracking errors, we were able to analyse the components of the overall error. Furthermore, we defined a special situation where the whole registration chain reduces to the error caused by the tracking system. Additionally, we used a phantom to evaluate the errors arising from the image-to-image registration procedure, depending on the image metric used. We have also discussed how this analysis can be applied to other positioning systems such as Cone Beam CT-based systems or Brainlab's ExacTrac. The estimates found by our error propagation analysis are in good agreement with the numbers found in the phantom study but significantly smaller than results from patient evaluations. We probably underestimated human influences such as the US scan head positioning by the operator and tissue deformation. Rotational errors of the tracking system can multiply these errors, depending on the relative position of tracker and probe. We were able to analyse the components of the overall error of a typical patient positioning system. We consider this to be a contribution to the optimization of the positioning accuracy for computer guidance systems.

  1. Uncorrected refractive errors.

    PubMed

    Naidoo, Kovin S; Jaggernath, Jyoti

    2012-01-01

    Global estimates indicate that more than 2.3 billion people in the world suffer from poor vision due to refractive error; of which 670 million people are considered visually impaired because they do not have access to corrective treatment. Refractive errors, if uncorrected, results in an impaired quality of life for millions of people worldwide, irrespective of their age, sex and ethnicity. Over the past decade, a series of studies using a survey methodology, referred to as Refractive Error Study in Children (RESC), were performed in populations with different ethnic origins and cultural settings. These studies confirmed that the prevalence of uncorrected refractive errors is considerably high for children in low-and-middle-income countries. Furthermore, uncorrected refractive error has been noted to have extensive social and economic impacts, such as limiting educational and employment opportunities of economically active persons, healthy individuals and communities. The key public health challenges presented by uncorrected refractive errors, the leading cause of vision impairment across the world, require urgent attention. To address these issues, it is critical to focus on the development of human resources and sustainable methods of service delivery. This paper discusses three core pillars to addressing the challenges posed by uncorrected refractive errors: Human Resource (HR) Development, Service Development and Social Entrepreneurship.

  2. Uncorrected refractive errors

    PubMed Central

    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. PMID:22944755

  3. The dynamics of error processing in the human brain as reflected by high-gamma activity in noninvasive and intracranial EEG.

    PubMed

    Völker, Martin; Fiederer, Lukas D J; Berberich, Sofie; Hammer, Jiří; Behncke, Joos; Kršek, Pavel; Tomášek, Martin; Marusič, Petr; Reinacher, Peter C; Coenen, Volker A; Helias, Moritz; Schulze-Bonhage, Andreas; Burgard, Wolfram; Ball, Tonio

    2018-06-01

    Error detection in motor behavior is a fundamental cognitive function heavily relying on local cortical information processing. Neural activity in the high-gamma frequency band (HGB) closely reflects such local cortical processing, but little is known about its role in error processing, particularly in the healthy human brain. Here we characterize the error-related response of the human brain based on data obtained with noninvasive EEG optimized for HGB mapping in 31 healthy subjects (15 females, 16 males), and additional intracranial EEG data from 9 epilepsy patients (4 females, 5 males). Our findings reveal a multiscale picture of the global and local dynamics of error-related HGB activity in the human brain. On the global level as reflected in the noninvasive EEG, the error-related response started with an early component dominated by anterior brain regions, followed by a shift to parietal regions, and a subsequent phase characterized by sustained parietal HGB activity. This phase lasted for more than 1 s after the error onset. On the local level reflected in the intracranial EEG, a cascade of both transient and sustained error-related responses involved an even more extended network, spanning beyond frontal and parietal regions to the insula and the hippocampus. HGB mapping appeared especially well suited to investigate late, sustained components of the error response, possibly linked to downstream functional stages such as error-related learning and behavioral adaptation. Our findings establish the basic spatio-temporal properties of HGB activity as a neural correlate of error processing, complementing traditional error-related potential studies. Copyright © 2018 The Authors. Published by Elsevier Inc. All rights reserved.

  4. Design, performance, and calculated error of a Faraday cup for absolute beam current measurements of 600-MeV protons

    NASA Technical Reports Server (NTRS)

    Beck, S. M.

    1975-01-01

    A mobile self-contained Faraday cup system for beam current measurments of nominal 600 MeV protons was designed, constructed, and used at the NASA Space Radiation Effects Laboratory. The cup is of reentrant design with a length of 106.7 cm and an outside diameter of 20.32 cm. The inner diameter is 15.24 cm and the base thickness is 30.48 cm. The primary absorber is commercially available lead hermetically sealed in a 0.32-cm-thick copper jacket. Several possible systematic errors in using the cup are evaluated. The largest source of error arises from high-energy electrons which are ejected from the entrance window and enter the cup. A total systematic error of -0.83 percent is calculated to be the decrease from the true current value. From data obtained in calibrating helium-filled ion chambers with the Faraday cup, the mean energy required to produce one ion pair in helium is found to be 30.76 + or - 0.95 eV for nominal 600 MeV protons. This value agrees well, within experimental error, with reported values of 29.9 eV and 30.2 eV.

  5. Does the A-not-B error in adult pet dogs indicate sensitivity to human communication?

    PubMed

    Kis, Anna; Topál, József; Gácsi, Márta; Range, Friederike; Huber, Ludwig; Miklósi, Adám; Virányi, Zsófia

    2012-07-01

    Recent dog-infant comparisons have indicated that the experimenter's communicative signals in object hide-and-search tasks increase the probability of perseverative (A-not-B) errors in both species (Topál et al. 2009). These behaviourally similar results, however, might reflect different mechanisms in dogs and in children. Similar errors may occur if the motor response of retrieving the object during the A trials cannot be inhibited in the B trials or if the experimenter's movements and signals toward the A hiding place in the B trials ('sham-baiting') distract the dogs' attention. In order to test these hypotheses, we tested dogs similarly to Topál et al. (2009) but eliminated the motor search in the A trials and 'sham-baiting' in the B trials. We found that neither an inability to inhibit previously rewarded motor response nor insufficiencies in their working memory and/or attention skills can explain dogs' erroneous choices. Further, we replicated the finding that dogs have a strong tendency to commit the A-not-B error after ostensive-communicative hiding and demonstrated the crucial effect of socio-communicative cues as the A-not-B error diminishes when location B is ostensively enhanced. These findings further support the hypothesis that the dogs' A-not-B error may reflect a special sensitivity to human communicative cues. Such object-hiding and search tasks provide a typical case for how susceptibility to human social signals could (mis)lead domestic dogs.

  6. Application of the epidemiological model in studying human error in aviation

    NASA Technical Reports Server (NTRS)

    Cheaney, E. S.; Billings, C. E.

    1981-01-01

    An epidemiological model is described in conjunction with the analytical process through which aviation occurrence reports are composed into the events and factors pertinent to it. The model represents a process in which disease, emanating from environmental conditions, manifests itself in symptoms that may lead to fatal illness, recoverable illness, or no illness depending on individual circumstances of patient vulnerability, preventive actions, and intervention. In the aviation system the analogy of the disease process is the predilection for error of human participants. This arises from factors in the operating or physical environment and results in errors of commission or omission that, again depending on the individual circumstances, may lead to accidents, system perturbations, or harmless corrections. A discussion of the previous investigations, each of which manifests the application of the epidemiological method, exemplifies its use and effectiveness.

  7. New paradigm for understanding in-flight decision making errors: a neurophysiological model leveraging human factors.

    PubMed

    Souvestre, P A; Landrock, C K; Blaber, A P

    2008-08-01

    Human factors centered aviation accident analyses report that skill based errors are known to be cause of 80% of all accidents, decision making related errors 30% and perceptual errors 6%1. In-flight decision making error is a long time recognized major avenue leading to incidents and accidents. Through the past three decades, tremendous and costly efforts have been developed to attempt to clarify causation, roles and responsibility as well as to elaborate various preventative and curative countermeasures blending state of the art biomedical, technological advances and psychophysiological training strategies. In-flight related statistics have not been shown significantly changed and a significant number of issues remain not yet resolved. Fine Postural System and its corollary, Postural Deficiency Syndrome (PDS), both defined in the 1980's, are respectively neurophysiological and medical diagnostic models that reflect central neural sensory-motor and cognitive controls regulatory status. They are successfully used in complex neurotraumatology and related rehabilitation for over two decades. Analysis of clinical data taken over a ten-year period from acute and chronic post-traumatic PDS patients shows a strong correlation between symptoms commonly exhibited before, along side, or even after error, and sensory-motor or PDS related symptoms. Examples are given on how PDS related central sensory-motor control dysfunction can be correctly identified and monitored via a neurophysiological ocular-vestibular-postural monitoring system. The data presented provides strong evidence that a specific biomedical assessment methodology can lead to a better understanding of in-flight adaptive neurophysiological, cognitive and perceptual dysfunctional status that could induce in flight-errors. How relevant human factors can be identified and leveraged to maintain optimal performance will be addressed.

  8. Error-associated behaviors and error rates for robotic geology

    NASA Technical Reports Server (NTRS)

    Anderson, Robert C.; Thomas, Geb; Wagner, Jacob; Glasgow, Justin

    2004-01-01

    This study explores human error as a function of the decision-making process. One of many models for human decision-making is Rasmussen's decision ladder [9]. The decision ladder identifies the multiple tasks and states of knowledge involved in decision-making. The tasks and states of knowledge can be classified by the level of cognitive effort required to make the decision, leading to the skill, rule, and knowledge taxonomy (Rasmussen, 1987). Skill based decisions require the least cognitive effort and knowledge based decisions require the greatest cognitive effort. Errors can occur at any of the cognitive levels.

  9. Applying human factors principles to alert design increases efficiency and reduces prescribing errors in a scenario-based simulation

    PubMed Central

    Russ, Alissa L; Zillich, Alan J; Melton, Brittany L; Russell, Scott A; Chen, Siying; Spina, Jeffrey R; Weiner, Michael; Johnson, Elizabette G; Daggy, Joanne K; McManus, M Sue; Hawsey, Jason M; Puleo, Anthony G; Doebbeling, Bradley N; Saleem, Jason J

    2014-01-01

    Objective To apply human factors engineering principles to improve alert interface design. We hypothesized that incorporating human factors principles into alerts would improve usability, reduce workload for prescribers, and reduce prescribing errors. Materials and methods We performed a scenario-based simulation study using a counterbalanced, crossover design with 20 Veterans Affairs prescribers to compare original versus redesigned alerts. We redesigned drug–allergy, drug–drug interaction, and drug–disease alerts based upon human factors principles. We assessed usability (learnability of redesign, efficiency, satisfaction, and usability errors), perceived workload, and prescribing errors. Results Although prescribers received no training on the design changes, prescribers were able to resolve redesigned alerts more efficiently (median (IQR): 56 (47) s) compared to the original alerts (85 (71) s; p=0.015). In addition, prescribers rated redesigned alerts significantly higher than original alerts across several dimensions of satisfaction. Redesigned alerts led to a modest but significant reduction in workload (p=0.042) and significantly reduced the number of prescribing errors per prescriber (median (range): 2 (1–5) compared to original alerts: 4 (1–7); p=0.024). Discussion Aspects of the redesigned alerts that likely contributed to better prescribing include design modifications that reduced usability-related errors, providing clinical data closer to the point of decision, and displaying alert text in a tabular format. Displaying alert text in a tabular format may help prescribers extract information quickly and thereby increase responsiveness to alerts. Conclusions This simulation study provides evidence that applying human factors design principles to medication alerts can improve usability and prescribing outcomes. PMID:24668841

  10. Density Functional Calculations of Native Defects in CH 3 NH 3 PbI 3 : Effects of Spin–Orbit Coupling and Self-Interaction Error

    DOE PAGES

    Du, Mao-Hua

    2015-04-02

    We know that native point defects play an important role in carrier transport properties of CH3NH3PbI3. However, the nature of many important defects remains controversial due partly to the conflicting results reported by recent density functional theory (DFT) calculations. In this Letter, we show that self-interaction error and the neglect of spin–orbit coupling (SOC) in many previous DFT calculations resulted in incorrect positions of valence and conduction band edges, although their difference, which is the band gap, is in good agreement with the experimental value. Moreover, this problem has led to incorrect predictions of defect-level positions. Hybrid density functional calculations,more » which partially correct the self-interaction error and include the SOC, show that, among native point defects (including vacancies, interstitials, and antisites), only the iodine vacancy and its complexes induce deep electron and hole trapping levels inside of the band gap, acting as nonradiative recombination centers.« less

  11. Investigating mode errors on automated flight decks: illustrating the problem-driven, cumulative, and interdisciplinary nature of human factors research.

    PubMed

    Sarter, Nadine

    2008-06-01

    The goal of this article is to illustrate the problem-driven, cumulative, and highly interdisciplinary nature of human factors research by providing a brief overview of the work on mode errors on modern flight decks over the past two decades. Mode errors on modem flight decks were first reported in the late 1980s. Poor feedback, inadequate mental models of the automation, and the high degree of coupling and complexity of flight deck systems were identified as main contributors to these breakdowns in human-automation interaction. Various improvements of design, training, and procedures were proposed to address these issues. The author describes when and why the problem of mode errors surfaced, summarizes complementary research activities that helped identify and understand the contributing factors to mode errors, and describes some countermeasures that have been developed in recent years. This brief review illustrates how one particular human factors problem in the aviation domain enabled various disciplines and methodological approaches to contribute to a better understanding of, as well as provide better support for, effective human-automation coordination. Converging operations and interdisciplinary collaboration over an extended period of time are hallmarks of successful human factors research. The reported body of research can serve as a model for future research and as a teaching tool for students in this field of work.

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

    DOE Office of Scientific and Technical Information (OSTI.GOV)

    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 errormore » 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.« less

  13. Dopamine Modulates Adaptive Prediction Error Coding in the Human Midbrain and Striatum.

    PubMed

    Diederen, Kelly M J; Ziauddeen, Hisham; Vestergaard, Martin D; Spencer, Tom; Schultz, Wolfram; Fletcher, Paul C

    2017-02-15

    Learning to optimally predict rewards requires agents to account for fluctuations in reward value. Recent work suggests that individuals can efficiently learn about variable rewards through adaptation of the learning rate, and coding of prediction errors relative to reward variability. Such adaptive coding has been linked to midbrain dopamine neurons in nonhuman primates, and evidence in support for a similar role of the dopaminergic system in humans is emerging from fMRI data. Here, we sought to investigate the effect of dopaminergic perturbations on adaptive prediction error coding in humans, using a between-subject, placebo-controlled pharmacological fMRI study with a dopaminergic agonist (bromocriptine) and antagonist (sulpiride). Participants performed a previously validated task in which they predicted the magnitude of upcoming rewards drawn from distributions with varying SDs. After each prediction, participants received a reward, yielding trial-by-trial prediction errors. Under placebo, we replicated previous observations of adaptive coding in the midbrain and ventral striatum. Treatment with sulpiride attenuated adaptive coding in both midbrain and ventral striatum, and was associated with a decrease in performance, whereas bromocriptine did not have a significant impact. Although we observed no differential effect of SD on performance between the groups, computational modeling suggested decreased behavioral adaptation in the sulpiride group. These results suggest that normal dopaminergic function is critical for adaptive prediction error coding, a key property of the brain thought to facilitate efficient learning in variable environments. Crucially, these results also offer potential insights for understanding the impact of disrupted dopamine function in mental illness. SIGNIFICANCE STATEMENT To choose optimally, we have to learn what to expect. Humans dampen learning when there is a great deal of variability in reward outcome, and two brain regions that

  14. Effect of volume-scattering function on the errors induced when polarization is neglected in radiance calculations in an atmosphere-ocean system.

    PubMed

    Adams, C N; Kattawar, G W

    1993-08-20

    We have developed a Monte Carlo program that is capable of calculating both the scalar and the Stokes vector radiances in an atmosphere-ocean system in a single computer run. The correlated sampling technique is used to compute radiance distributions for both the scalar and the Stokes vector formulations simultaneously, thus permitting a direct comparison of the errors induced. We show the effect of the volume-scattering phase function on the errors in radiance calculations when one neglects polarization effects. The model used in this study assumes a conservative Rayleigh-scattering atmosphere above a flat ocean. Within the ocean, the volume-scattering function (the first element in the Mueller matrix) is varied according to both a Henyey-Greenstein phase function, with asymmetry factors G = 0.0, 0.5, and 0.9, and also to a Rayleigh-scattering phase function. The remainder of the reduced Mueller matrix for the ocean is taken to be that for Rayleigh scattering, which is consistent with ocean water measurement.

  15. An accurate symplectic calculation of the inboard magnetic footprint from statistical topological noise and field errors in the DIII-D

    DOE Office of Scientific and Technical Information (OSTI.GOV)

    Punjabi, Alkesh; Ali, Halima

    2011-02-15

    Any canonical transformation of Hamiltonian equations is symplectic, and any area-preserving transformation in 2D is a symplectomorphism. Based on these, a discrete symplectic map and its continuous symplectic analog are derived for forward magnetic field line trajectories in natural canonical coordinates. The unperturbed axisymmetric Hamiltonian for magnetic field lines is constructed from the experimental data in the DIII-D [J. L. Luxon and L. E. Davis, Fusion Technol. 8, 441 (1985)]. The equilibrium Hamiltonian is a highly accurate, analytic, and realistic representation of the magnetic geometry of the DIII-D. These symplectic mathematical maps are used to calculate the magnetic footprint onmore » the inboard collector plate in the DIII-D. Internal statistical topological noise and field errors are irreducible and ubiquitous in magnetic confinement schemes for fusion. It is important to know the stochasticity and magnetic footprint from noise and error fields. The estimates of the spectrum and mode amplitudes of the spatial topological noise and magnetic errors in the DIII-D are used as magnetic perturbation. The discrete and continuous symplectic maps are used to calculate the magnetic footprint on the inboard collector plate of the DIII-D by inverting the natural coordinates to physical coordinates. The combination of highly accurate equilibrium generating function, natural canonical coordinates, symplecticity, and small step-size together gives a very accurate calculation of magnetic footprint. Radial variation of magnetic perturbation and the response of plasma to perturbation are not included. The inboard footprint from noise and errors are dominated by m=3, n=1 mode. The footprint is in the form of a toroidally winding helical strip. The width of stochastic layer scales as (1/2) power of amplitude. The area of footprint scales as first power of amplitude. The physical parameters such as toroidal angle, length, and poloidal angle covered before striking

  16. Human Reliability and the Cost of Doing Business

    NASA Technical Reports Server (NTRS)

    DeMott, Diana

    2014-01-01

    Most businesses recognize that people will make mistakes and assume errors are just part of the cost of doing business, but does it need to be? Companies with high risk, or major consequences, should consider the effect of human error. In a variety of industries, Human Errors have caused costly failures and workplace injuries. These have included: airline mishaps, medical malpractice, administration of medication and major oil spills have all been blamed on human error. A technique to mitigate or even eliminate some of these costly human errors is the use of Human Reliability Analysis (HRA). Various methodologies are available to perform Human Reliability Assessments that range from identifying the most likely areas for concern to detailed assessments with human error failure probabilities calculated. Which methodology to use would be based on a variety of factors that would include: 1) how people react and act in different industries, and differing expectations based on industries standards, 2) factors that influence how the human errors could occur such as tasks, tools, environment, workplace, support, training and procedure, 3) type and availability of data and 4) how the industry views risk & reliability influences ( types of emergencies, contingencies and routine tasks versus cost based concerns). The Human Reliability Assessments should be the first step to reduce, mitigate or eliminate the costly mistakes or catastrophic failures. Using Human Reliability techniques to identify and classify human error risks allows a company more opportunities to mitigate or eliminate these risks and prevent costly failures.

  17. A Systematic Error Correction Method for TOVS Radiances

    NASA Technical Reports Server (NTRS)

    Joiner, Joanna; Rokke, Laurie; Einaudi, Franco (Technical Monitor)

    2000-01-01

    Treatment of systematic errors is crucial for the successful use of satellite data in a data assimilation system. Systematic errors in TOVS radiance measurements and radiative transfer calculations can be as large or larger than random instrument errors. The usual assumption in data assimilation is that observational errors are unbiased. If biases are not effectively removed prior to assimilation, the impact of satellite data will be lessened and can even be detrimental. Treatment of systematic errors is important for short-term forecast skill as well as the creation of climate data sets. A systematic error correction algorithm has been developed as part of a 1D radiance assimilation. This scheme corrects for spectroscopic errors, errors in the instrument response function, and other biases in the forward radiance calculation for TOVS. Such algorithms are often referred to as tuning of the radiances. The scheme is able to account for the complex, air-mass dependent biases that are seen in the differences between TOVS radiance observations and forward model calculations. We will show results of systematic error correction applied to the NOAA 15 Advanced TOVS as well as its predecessors. We will also discuss the ramifications of inter-instrument bias with a focus on stratospheric measurements.

  18. Applying human factors principles to alert design increases efficiency and reduces prescribing errors in a scenario-based simulation.

    PubMed

    Russ, Alissa L; Zillich, Alan J; Melton, Brittany L; Russell, Scott A; Chen, Siying; Spina, Jeffrey R; Weiner, Michael; Johnson, Elizabette G; Daggy, Joanne K; McManus, M Sue; Hawsey, Jason M; Puleo, Anthony G; Doebbeling, Bradley N; Saleem, Jason J

    2014-10-01

    To apply human factors engineering principles to improve alert interface design. We hypothesized that incorporating human factors principles into alerts would improve usability, reduce workload for prescribers, and reduce prescribing errors. We performed a scenario-based simulation study using a counterbalanced, crossover design with 20 Veterans Affairs prescribers to compare original versus redesigned alerts. We redesigned drug-allergy, drug-drug interaction, and drug-disease alerts based upon human factors principles. We assessed usability (learnability of redesign, efficiency, satisfaction, and usability errors), perceived workload, and prescribing errors. Although prescribers received no training on the design changes, prescribers were able to resolve redesigned alerts more efficiently (median (IQR): 56 (47) s) compared to the original alerts (85 (71) s; p=0.015). In addition, prescribers rated redesigned alerts significantly higher than original alerts across several dimensions of satisfaction. Redesigned alerts led to a modest but significant reduction in workload (p=0.042) and significantly reduced the number of prescribing errors per prescriber (median (range): 2 (1-5) compared to original alerts: 4 (1-7); p=0.024). Aspects of the redesigned alerts that likely contributed to better prescribing include design modifications that reduced usability-related errors, providing clinical data closer to the point of decision, and displaying alert text in a tabular format. Displaying alert text in a tabular format may help prescribers extract information quickly and thereby increase responsiveness to alerts. This simulation study provides evidence that applying human factors design principles to medication alerts can improve usability and prescribing outcomes. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.

  19. Subsecond dopamine fluctuations in human striatum encode superposed error signals about actual and counterfactual reward

    PubMed Central

    Kishida, Kenneth T.; Saez, Ignacio; Lohrenz, Terry; Witcher, Mark R.; Laxton, Adrian W.; Tatter, Stephen B.; White, Jason P.; Ellis, Thomas L.; Phillips, Paul E. M.; Montague, P. Read

    2016-01-01

    In the mammalian brain, dopamine is a critical neuromodulator whose actions underlie learning, decision-making, and behavioral control. Degeneration of dopamine neurons causes Parkinson’s disease, whereas dysregulation of dopamine signaling is believed to contribute to psychiatric conditions such as schizophrenia, addiction, and depression. Experiments in animal models suggest the hypothesis that dopamine release in human striatum encodes reward prediction errors (RPEs) (the difference between actual and expected outcomes) during ongoing decision-making. Blood oxygen level-dependent (BOLD) imaging experiments in humans support the idea that RPEs are tracked in the striatum; however, BOLD measurements cannot be used to infer the action of any one specific neurotransmitter. We monitored dopamine levels with subsecond temporal resolution in humans (n = 17) with Parkinson’s disease while they executed a sequential decision-making task. Participants placed bets and experienced monetary gains or losses. Dopamine fluctuations in the striatum fail to encode RPEs, as anticipated by a large body of work in model organisms. Instead, subsecond dopamine fluctuations encode an integration of RPEs with counterfactual prediction errors, the latter defined by how much better or worse the experienced outcome could have been. How dopamine fluctuations combine the actual and counterfactual is unknown. One possibility is that this process is the normal behavior of reward processing dopamine neurons, which previously had not been tested by experiments in animal models. Alternatively, this superposition of error terms may result from an additional yet-to-be-identified subclass of dopamine neurons. PMID:26598677

  20. Subsecond dopamine fluctuations in human striatum encode superposed error signals about actual and counterfactual reward.

    PubMed

    Kishida, Kenneth T; Saez, Ignacio; Lohrenz, Terry; Witcher, Mark R; Laxton, Adrian W; Tatter, Stephen B; White, Jason P; Ellis, Thomas L; Phillips, Paul E M; Montague, P Read

    2016-01-05

    In the mammalian brain, dopamine is a critical neuromodulator whose actions underlie learning, decision-making, and behavioral control. Degeneration of dopamine neurons causes Parkinson's disease, whereas dysregulation of dopamine signaling is believed to contribute to psychiatric conditions such as schizophrenia, addiction, and depression. Experiments in animal models suggest the hypothesis that dopamine release in human striatum encodes reward prediction errors (RPEs) (the difference between actual and expected outcomes) during ongoing decision-making. Blood oxygen level-dependent (BOLD) imaging experiments in humans support the idea that RPEs are tracked in the striatum; however, BOLD measurements cannot be used to infer the action of any one specific neurotransmitter. We monitored dopamine levels with subsecond temporal resolution in humans (n = 17) with Parkinson's disease while they executed a sequential decision-making task. Participants placed bets and experienced monetary gains or losses. Dopamine fluctuations in the striatum fail to encode RPEs, as anticipated by a large body of work in model organisms. Instead, subsecond dopamine fluctuations encode an integration of RPEs with counterfactual prediction errors, the latter defined by how much better or worse the experienced outcome could have been. How dopamine fluctuations combine the actual and counterfactual is unknown. One possibility is that this process is the normal behavior of reward processing dopamine neurons, which previously had not been tested by experiments in animal models. Alternatively, this superposition of error terms may result from an additional yet-to-be-identified subclass of dopamine neurons.

  1. A system dynamic simulation model for managing the human error in power tools industries

    NASA Astrophysics Data System (ADS)

    Jamil, Jastini Mohd; Shaharanee, Izwan Nizal Mohd

    2017-10-01

    In the era of modern and competitive life of today, every organization will face the situations in which the work does not proceed as planned when there is problems occur in which it had to be delay. However, human error is often cited as the culprit. The error that made by the employees would cause them have to spend additional time to identify and check for the error which in turn could affect the normal operations of the company as well as the company's reputation. Employee is a key element of the organization in running all of the activities of organization. Hence, work performance of the employees is a crucial factor in organizational success. The purpose of this study is to identify the factors that cause the increasing errors make by employees in the organization by using system dynamics approach. The broadly defined targets in this study are employees in the Regional Material Field team from purchasing department in power tools industries. Questionnaires were distributed to the respondents to obtain their perceptions on the root cause of errors make by employees in the company. The system dynamics model was developed to simulate the factor of the increasing errors make by employees and its impact. The findings of this study showed that the increasing of error make by employees was generally caused by the factors of workload, work capacity, job stress, motivation and performance of employees. However, this problem could be solve by increased the number of employees in the organization.

  2. Performance Data Errors in Air Carrier Operations: Causes and Countermeasures

    NASA Technical Reports Server (NTRS)

    Berman, Benjamin A.; Dismukes, R Key; Jobe, Kimberly K.

    2012-01-01

    Several airline accidents have occurred in recent years as the result of erroneous weight or performance data used to calculate V-speeds, flap/trim settings, required runway lengths, and/or required climb gradients. In this report we consider 4 recent studies of performance data error, report our own study of ASRS-reported incidents, and provide countermeasures that can reduce vulnerability to accidents caused by performance data errors. Performance data are generated through a lengthy process involving several employee groups and computer and/or paper-based systems. Although much of the airline indUStry 's concern has focused on errors pilots make in entering FMS data, we determined that errors occur at every stage of the process and that errors by ground personnel are probably at least as frequent and certainly as consequential as errors by pilots. Most of the errors we examined could in principle have been trapped by effective use of existing procedures or technology; however, the fact that they were not trapped anywhere indicates the need for better countermeasures. Existing procedures are often inadequately designed to mesh with the ways humans process information. Because procedures often do not take into account the ways in which information flows in actual flight ops and time pressures and interruptions experienced by pilots and ground personnel, vulnerability to error is greater. Some aspects of NextGen operations may exacerbate this vulnerability. We identify measures to reduce the number of errors and to help catch the errors that occur.

  3. Error-free replicative bypass of (6–4) photoproducts by DNA polymerase ζ in mouse and human cells

    PubMed Central

    Yoon, Jung-Hoon; Prakash, Louise; Prakash, Satya

    2010-01-01

    The ultraviolet (UV)-induced (6–4) pyrimidine–pyrimidone photoproduct [(6–4) PP] confers a large structural distortion in DNA. Here we examine in human cells the roles of translesion synthesis (TLS) DNA polymerases (Pols) in promoting replication through a (6–4) TT photoproduct carried on a duplex plasmid where bidirectional replication initiates from an origin of replication. We show that TLS contributes to a large fraction of lesion bypass and that it is mostly error-free. We find that, whereas Pol η and Pol ι provide alternate pathways for mutagenic TLS, surprisingly, Pol ζ functions independently of these Pols and in a predominantly error-free manner. We verify and extend these observations in mouse cells and conclude that, in human cells, TLS during replication can be markedly error-free even opposite a highly distorting DNA lesion. PMID:20080950

  4. Minimizing human error in radiopharmaceutical preparation and administration via a bar code-enhanced nuclear pharmacy management system.

    PubMed

    Hakala, John L; Hung, Joseph C; Mosman, Elton A

    2012-09-01

    The objective of this project was to ensure correct radiopharmaceutical administration through the use of a bar code system that links patient and drug profiles with on-site information management systems. This new combined system would minimize the amount of manual human manipulation, which has proven to be a primary source of error. The most common reason for dosing errors is improper patient identification when a dose is obtained from the nuclear pharmacy or when a dose is administered. A standardized electronic transfer of information from radiopharmaceutical preparation to injection will further reduce the risk of misadministration. Value stream maps showing the flow of the patient dose information, as well as potential points of human error, were developed. Next, a future-state map was created that included proposed corrections for the most common critical sites of error. Transitioning the current process to the future state will require solutions that address these sites. To optimize the future-state process, a bar code system that links the on-site radiology management system with the nuclear pharmacy management system was proposed. A bar-coded wristband connects the patient directly to the electronic information systems. The bar code-enhanced process linking the patient dose with the electronic information reduces the number of crucial points for human error and provides a framework to ensure that the prepared dose reaches the correct patient. Although the proposed flowchart is designed for a site with an in-house central nuclear pharmacy, much of the framework could be applied by nuclear medicine facilities using unit doses. An electronic connection between information management systems to allow the tracking of a radiopharmaceutical from preparation to administration can be a useful tool in preventing the mistakes that are an unfortunate reality for any facility.

  5. Human error and commercial aviation accidents: an analysis using the human factors analysis and classification system.

    PubMed

    Shappell, Scott; Detwiler, Cristy; Holcomb, Kali; Hackworth, Carla; Boquet, Albert; Wiegmann, Douglas A

    2007-04-01

    The aim of this study was to extend previous examinations of aviation accidents to include specific aircrew, environmental, supervisory, and organizational factors associated with two types of commercial aviation (air carrier and commuter/ on-demand) accidents using the Human Factors Analysis and Classification System (HFACS). HFACS is a theoretically based tool for investigating and analyzing human error associated with accidents and incidents. Previous research has shown that HFACS can be reliably used to identify human factors trends associated with military and general aviation accidents. Using data obtained from both the National Transportation Safety Board and the Federal Aviation Administration, 6 pilot-raters classified aircrew, supervisory, organizational, and environmental causal factors associated with 1020 commercial aviation accidents that occurred over a 13-year period. The majority of accident causal factors were attributed to aircrew and the environment, with decidedly fewer associated with supervisory and organizational causes. Comparisons were made between HFACS causal categories and traditional situational variables such as visual conditions, injury severity, and regional differences. These data will provide support for the continuation, modification, and/or development of interventions aimed at commercial aviation safety. HFACS provides a tool for assessing human factors associated with accidents and incidents.

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

    PubMed

    Anderson, B J; Ellis, J F

    1999-01-01

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

  7. Procedural error monitoring and smart checklists

    NASA Technical Reports Server (NTRS)

    Palmer, Everett

    1990-01-01

    Human beings make and usually detect errors routinely. The same mental processes that allow humans to cope with novel problems can also lead to error. Bill Rouse has argued that errors are not inherently bad but their consequences may be. He proposes the development of error-tolerant systems that detect errors and take steps to prevent the consequences of the error from occurring. Research should be done on self and automatic detection of random and unanticipated errors. For self detection, displays should be developed that make the consequences of errors immediately apparent. For example, electronic map displays graphically show the consequences of horizontal flight plan entry errors. Vertical profile displays should be developed to make apparent vertical flight planning errors. Other concepts such as energy circles could also help the crew detect gross flight planning errors. For automatic detection, systems should be developed that can track pilot activity, infer pilot intent and inform the crew of potential errors before their consequences are realized. Systems that perform a reasonableness check on flight plan modifications by checking route length and magnitude of course changes are simple examples. Another example would be a system that checked the aircraft's planned altitude against a data base of world terrain elevations. Information is given in viewgraph form.

  8. Systemic errors calibration in dynamic stitching interferometry

    NASA Astrophysics Data System (ADS)

    Wu, Xin; Qi, Te; Yu, Yingjie; Zhang, Linna

    2016-05-01

    The systemic error is the main error sauce in sub-aperture stitching calculation. In this paper, a systemic error calibration method is proposed based on pseudo shearing. This method is suitable in dynamic stitching interferometry for large optical plane. The feasibility is vibrated by some simulations and experiments.

  9. Results of a nuclear power plant application of A New Technique for Human Error Analysis (ATHEANA)

    DOE Office of Scientific and Technical Information (OSTI.GOV)

    Whitehead, D.W.; Forester, J.A.; Bley, D.C.

    1998-03-01

    A new method to analyze human errors has been demonstrated at a pressurized water reactor (PWR) nuclear power plant. This was the first application of the new method referred to as A Technique for Human Error Analysis (ATHEANA). The main goals of the demonstration were to test the ATHEANA process as described in the frame-of-reference manual and the implementation guideline, test a training package developed for the method, test the hypothesis that plant operators and trainers have significant insight into the error-forcing-contexts (EFCs) that can make unsafe actions (UAs) more likely, and to identify ways to improve the method andmore » its documentation. A set of criteria to evaluate the success of the ATHEANA method as used in the demonstration was identified. A human reliability analysis (HRA) team was formed that consisted of an expert in probabilistic risk assessment (PRA) with some background in HRA (not ATHEANA) and four personnel from the nuclear power plant. Personnel from the plant included two individuals from their PRA staff and two individuals from their training staff. Both individuals from training are currently licensed operators and one of them was a senior reactor operator on shift until a few months before the demonstration. The demonstration was conducted over a 5-month period and was observed by members of the Nuclear Regulatory Commission`s ATHEANA development team, who also served as consultants to the HRA team when necessary. Example results of the demonstration to date, including identified human failure events (HFEs), UAs, and EFCs are discussed. Also addressed is how simulator exercises are used in the ATHEANA demonstration project.« less

  10. Computer calculated dose in paediatric prescribing.

    PubMed

    Kirk, Richard C; Li-Meng Goh, Denise; Packia, Jeya; Min Kam, Huey; Ong, Benjamin K C

    2005-01-01

    Medication errors are an important cause of hospital-based morbidity and mortality. However, only a few medication error studies have been conducted in children. These have mainly quantified errors in the inpatient setting; there is very little data available on paediatric outpatient and emergency department medication errors and none on discharge medication. This deficiency is of concern because medication errors are more common in children and it has been suggested that the risk of an adverse drug event as a consequence of a medication error is higher in children than in adults. The aims of this study were to assess the rate of medication errors in predominantly ambulatory paediatric patients and the effect of computer calculated doses on medication error rates of two commonly prescribed drugs. This was a prospective cohort study performed in a paediatric unit in a university teaching hospital between March 2003 and August 2003. The hospital's existing computer clinical decision support system was modified so that doctors could choose the traditional prescription method or the enhanced method of computer calculated dose when prescribing paracetamol (acetaminophen) or promethazine. All prescriptions issued to children (<16 years of age) at the outpatient clinic, emergency department and at discharge from the inpatient service were analysed. A medication error was defined as to have occurred if there was an underdose (below the agreed value), an overdose (above the agreed value), no frequency of administration specified, no dose given or excessive total daily dose. The medication error rates and the factors influencing medication error rates were determined using SPSS version 12. From March to August 2003, 4281 prescriptions were issued. Seven prescriptions (0.16%) were excluded, hence 4274 prescriptions were analysed. Most prescriptions were issued by paediatricians (including neonatologists and paediatric surgeons) and/or junior doctors. The error rate in the

  11. Quantifying errors without random sampling.

    PubMed

    Phillips, Carl V; LaPole, Luwanna M

    2003-06-12

    All quantifications of mortality, morbidity, and other health measures involve numerous sources of error. The routine quantification of random sampling error makes it easy to forget that other sources of error can and should be quantified. When a quantification does not involve sampling, error is almost never quantified and results are often reported in ways that dramatically overstate their precision. We argue that the precision implicit in typical reporting is problematic and sketch methods for quantifying the various sources of error, building up from simple examples that can be solved analytically to more complex cases. There are straightforward ways to partially quantify the uncertainty surrounding a parameter that is not characterized by random sampling, such as limiting reported significant figures. We present simple methods for doing such quantifications, and for incorporating them into calculations. More complicated methods become necessary when multiple sources of uncertainty must be combined. We demonstrate that Monte Carlo simulation, using available software, can estimate the uncertainty resulting from complicated calculations with many sources of uncertainty. We apply the method to the current estimate of the annual incidence of foodborne illness in the United States. Quantifying uncertainty from systematic errors is practical. Reporting this uncertainty would more honestly represent study results, help show the probability that estimated values fall within some critical range, and facilitate better targeting of further research.

  12. Relative-Error-Covariance Algorithms

    NASA Technical Reports Server (NTRS)

    Bierman, Gerald J.; Wolff, Peter J.

    1991-01-01

    Two algorithms compute error covariance of difference between optimal estimates, based on data acquired during overlapping or disjoint intervals, of state of discrete linear system. Provides quantitative measure of mutual consistency or inconsistency of estimates of states. Relative-error-covariance concept applied, to determine degree of correlation between trajectories calculated from two overlapping sets of measurements and construct real-time test of consistency of state estimates based upon recently acquired data.

  13. Interruption Practice Reduces Errors

    DTIC Science & Technology

    2014-01-01

    dangers of errors at the PCS. Electronic health record systems are used to reduce certain errors related to poor- handwriting and dosage...10.16, MSE =.31, p< .05, η2 = .18 A significant interaction between the number of interruptions and interrupted trials suggests that trials...the variance when calculating whether a memory has a higher signal than interference. If something in addition to activation contributes to goal

  14. A cognitive taxonomy of medical errors.

    PubMed

    Zhang, Jiajie; Patel, Vimla L; Johnson, Todd R; Shortliffe, Edward H

    2004-06-01

    Propose a cognitive taxonomy of medical errors at the level of individuals and their interactions with technology. Use cognitive theories of human error and human action to develop the theoretical foundations of the taxonomy, develop the structure of the taxonomy, populate the taxonomy with examples of medical error cases, identify cognitive mechanisms for each category of medical error under the taxonomy, and apply the taxonomy to practical problems. Four criteria were used to evaluate the cognitive taxonomy. The taxonomy should be able (1) to categorize major types of errors at the individual level along cognitive dimensions, (2) to associate each type of error with a specific underlying cognitive mechanism, (3) to describe how and explain why a specific error occurs, and (4) to generate intervention strategies for each type of error. The proposed cognitive taxonomy largely satisfies the four criteria at a theoretical and conceptual level. Theoretically, the proposed cognitive taxonomy provides a method to systematically categorize medical errors at the individual level along cognitive dimensions, leads to a better understanding of the underlying cognitive mechanisms of medical errors, and provides a framework that can guide future studies on medical errors. Practically, it provides guidelines for the development of cognitive interventions to decrease medical errors and foundation for the development of medical error reporting system that not only categorizes errors but also identifies problems and helps to generate solutions. To validate this model empirically, we will next be performing systematic experimental studies.

  15. Simulation of rare events in quantum error correction

    NASA Astrophysics Data System (ADS)

    Bravyi, Sergey; Vargo, Alexander

    2013-12-01

    We consider the problem of calculating the logical error probability for a stabilizer quantum code subject to random Pauli errors. To access the regime of large code distances where logical errors are extremely unlikely we adopt the splitting method widely used in Monte Carlo simulations of rare events and Bennett's acceptance ratio method for estimating the free energy difference between two canonical ensembles. To illustrate the power of these methods in the context of error correction, we calculate the logical error probability PL for the two-dimensional surface code on a square lattice with a pair of holes for all code distances d≤20 and all error rates p below the fault-tolerance threshold. Our numerical results confirm the expected exponential decay PL˜exp[-α(p)d] and provide a simple fitting formula for the decay rate α(p). Both noiseless and noisy syndrome readout circuits are considered.

  16. Undergraduate paramedic students cannot do drug calculations

    PubMed Central

    Eastwood, Kathryn; Boyle, Malcolm J; Williams, Brett

    2012-01-01

    BACKGROUND: Previous investigation of drug calculation skills of qualified paramedics has highlighted poor mathematical ability with no published studies having been undertaken on undergraduate paramedics. There are three major error classifications. Conceptual errors involve an inability to formulate an equation from information given, arithmetical errors involve an inability to operate a given equation, and finally computation errors are simple errors of addition, subtraction, division and multiplication. The objective of this study was to determine if undergraduate paramedics at a large Australia university could accurately perform common drug calculations and basic mathematical equations normally required in the workplace. METHODS: A cross-sectional study methodology using a paper-based questionnaire was administered to undergraduate paramedic students to collect demographical data, student attitudes regarding their drug calculation performance, and answers to a series of basic mathematical and drug calculation questions. Ethics approval was granted. RESULTS: The mean score of correct answers was 39.5% with one student scoring 100%, 3.3% of students (n=3) scoring greater than 90%, and 63% (n=58) scoring 50% or less, despite 62% (n=57) of the students stating they ‘did not have any drug calculations issues’. On average those who completed a minimum of year 12 Specialist Maths achieved scores over 50%. Conceptual errors made up 48.5%, arithmetical 31.1% and computational 17.4%. CONCLUSIONS: This study suggests undergraduate paramedics have deficiencies in performing accurate calculations, with conceptual errors indicating a fundamental lack of mathematical understanding. The results suggest an unacceptable level of mathematical competence to practice safely in the unpredictable prehospital environment. PMID:25215067

  17. Undergraduate paramedic students cannot do drug calculations.

    PubMed

    Eastwood, Kathryn; Boyle, Malcolm J; Williams, Brett

    2012-01-01

    Previous investigation of drug calculation skills of qualified paramedics has highlighted poor mathematical ability with no published studies having been undertaken on undergraduate paramedics. There are three major error classifications. Conceptual errors involve an inability to formulate an equation from information given, arithmetical errors involve an inability to operate a given equation, and finally computation errors are simple errors of addition, subtraction, division and multiplication. The objective of this study was to determine if undergraduate paramedics at a large Australia university could accurately perform common drug calculations and basic mathematical equations normally required in the workplace. A cross-sectional study methodology using a paper-based questionnaire was administered to undergraduate paramedic students to collect demographical data, student attitudes regarding their drug calculation performance, and answers to a series of basic mathematical and drug calculation questions. Ethics approval was granted. The mean score of correct answers was 39.5% with one student scoring 100%, 3.3% of students (n=3) scoring greater than 90%, and 63% (n=58) scoring 50% or less, despite 62% (n=57) of the students stating they 'did not have any drug calculations issues'. On average those who completed a minimum of year 12 Specialist Maths achieved scores over 50%. Conceptual errors made up 48.5%, arithmetical 31.1% and computational 17.4%. This study suggests undergraduate paramedics have deficiencies in performing accurate calculations, with conceptual errors indicating a fundamental lack of mathematical understanding. The results suggest an unacceptable level of mathematical competence to practice safely in the unpredictable prehospital environment.

  18. Quantum mechanical calculation of electric fields and vibrational Stark shifts at active site of human aldose reductase

    DOE Office of Scientific and Technical Information (OSTI.GOV)

    Wang, Xianwei; State Key Laboratory of Precision Spectroscopy, Institute of Theoretical and Computational Science, East China Normal University, Shanghai 200062; Zhang, John Z. H.

    2015-11-14

    Recent advance in biophysics has made it possible to directly measure site-specific electric field at internal sites of proteins using molecular probes with C = O or C≡N groups in the context of vibrational Stark effect. These measurements directly probe changes of electric field at specific protein sites due to, e.g., mutation and are very useful in protein design. Computational simulation of the Stark effect based on force fields such as AMBER and OPLS, while providing good insight, shows large errors in comparison to experimental measurement due to inherent difficulties associated with point charge based representation of force fields. Inmore » this study, quantum mechanical calculation of protein’s internal electrostatic properties and vibrational Stark shifts was carried out by using electrostatically embedded generalized molecular fractionation with conjugate caps method. Quantum calculated change of mutation-induced electric field and vibrational Stark shift is reported at the internal probing site of enzyme human aldose reductase. The quantum result is in much better agreement with experimental data than those predicted by force fields, underscoring the deficiency of traditional point charge models describing intra-protein electrostatic properties.« less

  19. Medication calculation and administration workshop and hurdle assessment increases student awareness towards the importance of safe practices to decrease medication errors in the future.

    PubMed

    Wallace, Darlene; Woolley, Torres; Martin, David; Rasalam, Roy; Bellei, Maria

    2016-01-01

    Medication errors are the second most frequently reported hospital incident in Australia and are a global concern. A "Medication Calculation and Administration" workshop followed by a "hurdle" assessment (compulsory task mandating a minimum level of performance as a condition of passing the course) was introduced into Year 2 of the James Cook University medical curriculum to decrease dosage calculation and administration errors among graduates. This study evaluates the effectiveness of this educational activity as a long-term strategy to teach medical students' essential skills in calculating and administering medications. This longitudinal study used a pre- and post-test design to determine whether medical students retained their calculation and administration skills over a period of 4 years. The ability to apply basic mathematical skills to medication dose calculation, principles of safe administration (Part 1), and ability to access reference materials to check indications, contraindications, and writing the medication order with correct abbreviations (Part 2) were compared between Year 2 and 6 assessments. Scores for Parts 1, 2 and total scores were nearly identical from Year 2 to Year 6 (P = 0.663, 0.408, and 0.472, respectively), indicating minimal loss of knowledge by students in this period. Most Year 6 students (86%) were able to recall at least 5 of the "6 Rights of Medication Administration" while 84% reported accessing reference material and 91% reported checking their medical calculations. The "Medication Calculation and Administration" workshop with a combined formative and summative assessment - a "hurdle" - promotes long-term retention of essential clinical skills for medical students. These skills and an awareness of the problem are strategies to assist medical graduates in preventing future medication-related adverse events.

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

    PubMed

    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.

  1. To Err Is Human; To Structurally Prime from Errors Is Also Human

    ERIC Educational Resources Information Center

    Slevc, L. Robert; Ferreira, Victor S.

    2013-01-01

    Natural language contains disfluencies and errors. Do listeners simply discard information that was clearly produced in error, or can erroneous material persist to affect subsequent processing? Two experiments explored this question using a structural priming paradigm. Speakers described dative-eliciting pictures after hearing prime sentences that…

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

    DTIC Science & Technology

    2018-03-20

    USAARL Report No. 2018-08 Review of U.S. Army Unmanned Aerial Systems Accident Reports: Analysis of Human Error Contributions By Kathryn A...3 Statistical Analysis Approach ..............................................................................................3 Results...1 Introduction The success of unmanned aerial systems (UAS) operations relies upon a variety of factors, including, but not limited to

  3. Spacecraft and propulsion technician error

    NASA Astrophysics Data System (ADS)

    Schultz, Daniel Clyde

    Commercial aviation and commercial space similarly launch, fly, and land passenger vehicles. Unlike aviation, the U.S. government has not established maintenance policies for commercial space. This study conducted a mixed methods review of 610 U.S. space launches from 1984 through 2011, which included 31 failures. An analysis of the failure causal factors showed that human error accounted for 76% of those failures, which included workmanship error accounting for 29% of the failures. With the imminent future of commercial space travel, the increased potential for the loss of human life demands that changes be made to the standardized procedures, training, and certification to reduce human error and failure rates. Several recommendations were made by this study to the FAA's Office of Commercial Space Transportation, space launch vehicle operators, and maintenance technician schools in an effort to increase the safety of the space transportation passengers.

  4. Local-search based prediction of medical image registration error

    NASA Astrophysics Data System (ADS)

    Saygili, Görkem

    2018-03-01

    Medical image registration is a crucial task in many different medical imaging applications. Hence, considerable amount of work has been published recently that aim to predict the error in a registration without any human effort. If provided, these error predictions can be used as a feedback to the registration algorithm to further improve its performance. Recent methods generally start with extracting image-based and deformation-based features, then apply feature pooling and finally train a Random Forest (RF) regressor to predict the real registration error. Image-based features can be calculated after applying a single registration but provide limited accuracy whereas deformation-based features such as variation of deformation vector field may require up to 20 registrations which is a considerably high time-consuming task. This paper proposes to use extracted features from a local search algorithm as image-based features to estimate the error of a registration. The proposed method comprises a local search algorithm to find corresponding voxels between registered image pairs and based on the amount of shifts and stereo confidence measures, it predicts the amount of registration error in millimetres densely using a RF regressor. Compared to other algorithms in the literature, the proposed algorithm does not require multiple registrations, can be efficiently implemented on a Graphical Processing Unit (GPU) and can still provide highly accurate error predictions in existence of large registration error. Experimental results with real registrations on a public dataset indicate a substantially high accuracy achieved by using features from the local search algorithm.

  5. APLP2 Regulates Refractive Error and Myopia Development in Mice and Humans

    PubMed Central

    Verhoeven, Virginie J. M.; Hysi, Pirro G.; Wojciechowski, Robert; Singh, Pawan Kumar; Kumar, Ashok; Thinakaran, Gopal; Williams, Cathy

    2015-01-01

    Myopia is the most common vision disorder and the leading cause of visual impairment worldwide. However, gene variants identified to date explain less than 10% of the variance in refractive error, leaving the majority of heritability unexplained (“missing heritability”). Previously, we reported that expression of APLP2 was strongly associated with myopia in a primate model. Here, we found that low-frequency variants near the 5’-end of APLP2 were associated with refractive error in a prospective UK birth cohort (n = 3,819 children; top SNP rs188663068, p = 5.0 × 10−4) and a CREAM consortium panel (n = 45,756 adults; top SNP rs7127037, p = 6.6 × 10−3). These variants showed evidence of differential effect on childhood longitudinal refractive error trajectories depending on time spent reading (gene x time spent reading x age interaction, p = 4.0 × 10−3). Furthermore, Aplp2 knockout mice developed high degrees of hyperopia (+11.5 ± 2.2 D, p < 1.0 × 10−4) compared to both heterozygous (-0.8 ± 2.0 D, p < 1.0 × 10−4) and wild-type (+0.3 ± 2.2 D, p < 1.0 × 10−4) littermates and exhibited a dose-dependent reduction in susceptibility to environmentally induced myopia (F(2, 33) = 191.0, p < 1.0 × 10−4). This phenotype was associated with reduced contrast sensitivity (F(12, 120) = 3.6, p = 1.5 × 10−4) and changes in the electrophysiological properties of retinal amacrine cells, which expressed Aplp2. This work identifies APLP2 as one of the “missing” myopia genes, demonstrating the importance of a low-frequency gene variant in the development of human myopia. It also demonstrates an important role for APLP2 in refractive development in mice and humans, suggesting a high level of evolutionary conservation of the signaling pathways underlying refractive eye development. PMID:26313004

  6. 42 CFR 1005.23 - Harmless error.

    Code of Federal Regulations, 2012 CFR

    2012-10-01

    ... 42 Public Health 5 2012-10-01 2012-10-01 false Harmless error. 1005.23 Section 1005.23 Public Health OFFICE OF INSPECTOR GENERAL-HEALTH CARE, DEPARTMENT OF HEALTH AND HUMAN SERVICES OIG AUTHORITIES APPEALS OF EXCLUSIONS, CIVIL MONEY PENALTIES AND ASSESSMENTS § 1005.23 Harmless error. No error in either...

  7. 42 CFR 1005.23 - Harmless error.

    Code of Federal Regulations, 2014 CFR

    2014-10-01

    ... 42 Public Health 5 2014-10-01 2014-10-01 false Harmless error. 1005.23 Section 1005.23 Public Health OFFICE OF INSPECTOR GENERAL-HEALTH CARE, DEPARTMENT OF HEALTH AND HUMAN SERVICES OIG AUTHORITIES APPEALS OF EXCLUSIONS, CIVIL MONEY PENALTIES AND ASSESSMENTS § 1005.23 Harmless error. No error in either...

  8. 42 CFR 1005.23 - Harmless error.

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ... 42 Public Health 5 2010-10-01 2010-10-01 false Harmless error. 1005.23 Section 1005.23 Public Health OFFICE OF INSPECTOR GENERAL-HEALTH CARE, DEPARTMENT OF HEALTH AND HUMAN SERVICES OIG AUTHORITIES APPEALS OF EXCLUSIONS, CIVIL MONEY PENALTIES AND ASSESSMENTS § 1005.23 Harmless error. No error in either...

  9. 42 CFR 1005.23 - Harmless error.

    Code of Federal Regulations, 2013 CFR

    2013-10-01

    ... 42 Public Health 5 2013-10-01 2013-10-01 false Harmless error. 1005.23 Section 1005.23 Public Health OFFICE OF INSPECTOR GENERAL-HEALTH CARE, DEPARTMENT OF HEALTH AND HUMAN SERVICES OIG AUTHORITIES APPEALS OF EXCLUSIONS, CIVIL MONEY PENALTIES AND ASSESSMENTS § 1005.23 Harmless error. No error in either...

  10. 42 CFR 1005.23 - Harmless error.

    Code of Federal Regulations, 2011 CFR

    2011-10-01

    ... 42 Public Health 5 2011-10-01 2011-10-01 false Harmless error. 1005.23 Section 1005.23 Public Health OFFICE OF INSPECTOR GENERAL-HEALTH CARE, DEPARTMENT OF HEALTH AND HUMAN SERVICES OIG AUTHORITIES APPEALS OF EXCLUSIONS, CIVIL MONEY PENALTIES AND ASSESSMENTS § 1005.23 Harmless error. No error in either...

  11. 42 CFR 3.552 - Harmless error.

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ... 42 Public Health 1 2010-10-01 2010-10-01 false Harmless error. 3.552 Section 3.552 Public Health PUBLIC HEALTH SERVICE, DEPARTMENT OF HEALTH AND HUMAN SERVICES GENERAL PROVISIONS PATIENT SAFETY ORGANIZATIONS AND PATIENT SAFETY WORK PRODUCT Enforcement Program § 3.552 Harmless error. No error in either the...

  12. Development of an errorable car-following driver model

    NASA Astrophysics Data System (ADS)

    Yang, H.-H.; Peng, H.

    2010-06-01

    An errorable car-following driver model is presented in this paper. An errorable driver model is one that emulates human driver's functions and can generate both nominal (error-free), as well as devious (with error) behaviours. This model was developed for evaluation and design of active safety systems. The car-following data used for developing and validating the model were obtained from a large-scale naturalistic driving database. The stochastic car-following behaviour was first analysed and modelled as a random process. Three error-inducing behaviours were then introduced. First, human perceptual limitation was studied and implemented. Distraction due to non-driving tasks was then identified based on the statistical analysis of the driving data. Finally, time delay of human drivers was estimated through a recursive least-square identification process. By including these three error-inducing behaviours, rear-end collisions with the lead vehicle could occur. The simulated crash rate was found to be similar but somewhat higher than that reported in traffic statistics.

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

    PubMed

    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.

  14. Calculating radiotherapy margins based on Bayesian modelling of patient specific random errors

    NASA Astrophysics Data System (ADS)

    Herschtal, A.; te Marvelde, L.; Mengersen, K.; Hosseinifard, Z.; Foroudi, F.; Devereux, T.; Pham, D.; Ball, D.; Greer, P. B.; Pichler, P.; Eade, T.; Kneebone, A.; Bell, L.; Caine, H.; Hindson, B.; Kron, T.

    2015-02-01

    Collected real-life clinical target volume (CTV) displacement data show that some patients undergoing external beam radiotherapy (EBRT) demonstrate significantly more fraction-to-fraction variability in their displacement (‘random error’) than others. This contrasts with the common assumption made by historical recipes for margin estimation for EBRT, that the random error is constant across patients. In this work we present statistical models of CTV displacements in which random errors are characterised by an inverse gamma (IG) distribution in order to assess the impact of random error variability on CTV-to-PTV margin widths, for eight real world patient cohorts from four institutions, and for different sites of malignancy. We considered a variety of clinical treatment requirements and penumbral widths. The eight cohorts consisted of a total of 874 patients and 27 391 treatment sessions. Compared to a traditional margin recipe that assumes constant random errors across patients, for a typical 4 mm penumbral width, the IG based margin model mandates that in order to satisfy the common clinical requirement that 90% of patients receive at least 95% of prescribed RT dose to the entire CTV, margins be increased by a median of 10% (range over the eight cohorts -19% to +35%). This substantially reduces the proportion of patients for whom margins are too small to satisfy clinical requirements.

  15. Moments of inclination error distribution computer program

    NASA Technical Reports Server (NTRS)

    Myler, T. R.

    1981-01-01

    A FORTRAN coded computer program is described which calculates orbital inclination error statistics using a closed-form solution. This solution uses a data base of trajectory errors from actual flights to predict the orbital inclination error statistics. The Scott flight history data base consists of orbit insertion errors in the trajectory parameters - altitude, velocity, flight path angle, flight azimuth, latitude and longitude. The methods used to generate the error statistics are of general interest since they have other applications. Program theory, user instructions, output definitions, subroutine descriptions and detailed FORTRAN coding information are included.

  16. Error protection capability of space shuttle data bus designs

    NASA Technical Reports Server (NTRS)

    Proch, G. E.

    1974-01-01

    Error protection assurance in the reliability of digital data communications is discussed. The need for error protection on the space shuttle data bus system has been recognized and specified as a hardware requirement. The error protection techniques of particular concern are those designed into the Shuttle Main Engine Interface (MEI) and the Orbiter Multiplex Interface Adapter (MIA). The techniques and circuit design details proposed for these hardware are analyzed in this report to determine their error protection capability. The capability is calculated in terms of the probability of an undetected word error. Calculated results are reported for a noise environment that ranges from the nominal noise level stated in the hardware specifications to burst levels which may occur in extreme or anomalous conditions.

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

    NASA Astrophysics Data System (ADS)

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

    2018-03-01

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

  18. 37 CFR 1.775 - Calculation of patent term extension for a human drug, antibiotic drug or human biological product.

    Code of Federal Regulations, 2013 CFR

    2013-07-01

    ... extension for a human drug, antibiotic drug or human biological product. 1.775 Section 1.775 Patents... Review § 1.775 Calculation of patent term extension for a human drug, antibiotic drug or human biological product. (a) If a determination is made pursuant to § 1.750 that a patent for a human drug, antibiotic...

  19. 37 CFR 1.775 - Calculation of patent term extension for a human drug, antibiotic drug or human biological product.

    Code of Federal Regulations, 2012 CFR

    2012-07-01

    ... extension for a human drug, antibiotic drug or human biological product. 1.775 Section 1.775 Patents... Review § 1.775 Calculation of patent term extension for a human drug, antibiotic drug or human biological product. (a) If a determination is made pursuant to § 1.750 that a patent for a human drug, antibiotic...

  20. 37 CFR 1.775 - Calculation of patent term extension for a human drug, antibiotic drug or human biological product.

    Code of Federal Regulations, 2014 CFR

    2014-07-01

    ... extension for a human drug, antibiotic drug or human biological product. 1.775 Section 1.775 Patents... Review § 1.775 Calculation of patent term extension for a human drug, antibiotic drug or human biological product. (a) If a determination is made pursuant to § 1.750 that a patent for a human drug, antibiotic...

  1. 37 CFR 1.775 - Calculation of patent term extension for a human drug, antibiotic drug or human biological product.

    Code of Federal Regulations, 2011 CFR

    2011-07-01

    ... extension for a human drug, antibiotic drug or human biological product. 1.775 Section 1.775 Patents... Review § 1.775 Calculation of patent term extension for a human drug, antibiotic drug or human biological product. (a) If a determination is made pursuant to § 1.750 that a patent for a human drug, antibiotic...

  2. 37 CFR 1.775 - Calculation of patent term extension for a human drug, antibiotic drug or human biological product.

    Code of Federal Regulations, 2010 CFR

    2010-07-01

    ... extension for a human drug, antibiotic drug or human biological product. 1.775 Section 1.775 Patents... Review § 1.775 Calculation of patent term extension for a human drug, antibiotic drug or human biological product. (a) If a determination is made pursuant to § 1.750 that a patent for a human drug, antibiotic...

  3. Evaluating the Performance Diagnostic Checklist-Human Services to Assess Incorrect Error-Correction Procedures by Preschool Paraprofessionals

    ERIC Educational Resources Information Center

    Bowe, Melissa; Sellers, Tyra P.

    2018-01-01

    The Performance Diagnostic Checklist-Human Services (PDC-HS) has been used to assess variables contributing to undesirable staff performance. In this study, three preschool teachers completed the PDC-HS to identify the factors contributing to four paraprofessionals' inaccurate implementation of error-correction procedures during discrete trial…

  4. Error Consistency Analysis Scheme for Infrared Ultraspectral Sounding Retrieval Error Budget Estimation

    NASA Technical Reports Server (NTRS)

    Zhou, Daniel K.; Larar, Allen M.; Liu, Xu; Smith, William L.; Strow, Larry, L.

    2013-01-01

    Great effort has been devoted towards validating geophysical parameters retrieved from ultraspectral infrared radiances obtained from satellite remote sensors. An error consistency analysis scheme (ECAS), utilizing fast radiative transfer model (RTM) forward and inverse calculations, has been developed to estimate the error budget in terms of mean difference and standard deviation of error in both spectral radiance and retrieval domains. The retrieval error is assessed through ECAS without relying on other independent measurements such as radiosonde data. ECAS establishes a link between the accuracies of radiances and retrieved geophysical parameters. ECAS can be applied to measurements from any ultraspectral instrument and any retrieval scheme with its associated RTM. In this manuscript, ECAS is described and demonstrated with measurements from the MetOp-A satellite Infrared Atmospheric Sounding Interferometer (IASI). This scheme can be used together with other validation methodologies to give a more definitive characterization of the error and/or uncertainty of geophysical parameters retrieved from ultraspectral radiances observed from current and future satellite remote sensors such as IASI, the Atmospheric Infrared Sounder (AIRS), and the Cross-track Infrared Sounder (CrIS).

  5. Systematic Error Modeling and Bias Estimation

    PubMed Central

    Zhang, Feihu; Knoll, Alois

    2016-01-01

    This paper analyzes the statistic properties of the systematic error in terms of range and bearing during the transformation process. Furthermore, we rely on a weighted nonlinear least square method to calculate the biases based on the proposed models. The results show the high performance of the proposed approach for error modeling and bias estimation. PMID:27213386

  6. On Space Exploration and Human Error: A Paper on Reliability and Safety

    NASA Technical Reports Server (NTRS)

    Bell, David G.; Maluf, David A.; Gawdiak, Yuri

    2005-01-01

    NASA space exploration should largely address a problem class in reliability and risk management stemming primarily from human error, system risk and multi-objective trade-off analysis, by conducting research into system complexity, risk characterization and modeling, and system reasoning. In general, in every mission we can distinguish risk in three possible ways: a) known-known, b) known-unknown, and c) unknown-unknown. It is probably almost certain that space exploration will partially experience similar known or unknown risks embedded in the Apollo missions, Shuttle or Station unless something alters how NASA will perceive and manage safety and reliability

  7. The Effect of Age, Accommodation and Refractive Error on the Adult Human Eye

    PubMed Central

    Richdale, Kathryn; Bullimore, Mark A.; Sinnott, Loraine T.; Zadnik, Karla

    2015-01-01

    Purpose To quantify changes in ocular dimensions associated with age, refractive error, and accommodative response, in vivo, in 30- to 50-year-old human subjects. Methods The right eyes of 91 adults were examined using ultrasonography, phakometry, keratometry, pachymetry, interferometry, anterior segment optical coherence tomography, and high resolution magnetic resonance imaging. Accommodation was measured subjectively with a push-up test and objectively using open-field autorefraction. Regression analyses were used to assess differences in ocular parameters with age, refractive error and accommodation. Results With age, crystalline lens thickness increased (0.03 mm/yr), anterior lens curvature steepened (0.11 mm/yr), anterior chamber depth decreased (0.02 mm/y) and lens equivalent refractive index decreased (0.001 /y) (all p < 0.01). With increasing myopia, there were significant increases in axial length (0.37 mm/D), vitreous chamber depth (0.34 mm/D), vitreous chamber height (0.09 mm/D) and ciliary muscle ring diameter (0.10 mm/D) (all p < 0.05). Increasing myopia was also associated with steepening of both the cornea (0.16 mm/D) and anterior lens surface (0.011 mm/D) (both p < 0.04). With accommodation, the ciliary muscle ring diameter decreased (0.08 mm/D), and the muscle thinned posteriorly (0.008 mm/D), allowing the lens to shorten equatorially (0.07 mm/D) and thicken axially (0.06 mm/D) (all p < 0.03). Conclusions Refractive error is significantly correlated with not only the axial dimensions, but the anterior equatorial dimension of the adult eye. Further testing and development of accommodating intraocular lenses should account for differences in patients’ preoperative refractive error. PMID:26703933

  8. Delocalization error and "functional tuning" in Kohn-Sham calculations of molecular properties.

    PubMed

    Autschbach, Jochen; Srebro, Monika

    2014-08-19

    Kohn-Sham theory (KST) is the "workhorse" of numerical quantum chemistry. This is particularly true for first-principles calculations of ground- and excited-state properties for larger systems, including electronic spectra, electronic dynamic and static linear and higher order response properties (including nonlinear optical (NLO) properties), conformational or dynamic averaging of spectra and response properties, or properties that are affected by the coupling of electron and nuclear motion. This Account explores the sometimes dramatic impact of the delocalization error (DE) and possible benefits from the use of long-range corrections (LC) and "tuning" of functionals in KST calculations of molecular ground-state and response properties. Tuning refers to a nonempirical molecule-specific determination of adjustable parameters in functionals to satisfy known exact conditions, for instance, that the energy of the highest occupied molecular orbital (HOMO) should be equal to the negative vertical ionization potential (IP) or that the energy as a function of fractional electron numbers should afford straight-line segments. The presentation is given from the viewpoint of a chemist interested in computations of a variety of molecular optical and spectroscopic properties and of a theoretician developing methods for computing such properties with KST. In recent years, the use of LC functionals, functional tuning, and quantifying the DE explicitly have provided valuable insight regarding the performance of KST for molecular properties. We discuss a number of different molecular properties, with examples from recent studies from our laboratory and related literature. The selected properties probe different aspects of molecular electronic structure. Electric field gradients and hyperfine coupling constants can be exquisitely sensitive to the DE because it affects the ground-state electron density and spin density distributions. For π-conjugated molecules, it is shown how the

  9. Estimating IMU heading error from SAR images.

    DOE Office of Scientific and Technical Information (OSTI.GOV)

    Doerry, Armin Walter

    Angular orientation errors of the real antenna for Synthetic Aperture Radar (SAR) will manifest as undesired illumination gradients in SAR images. These gradients can be measured, and the pointing error can be calculated. This can be done for single images, but done more robustly using multi-image methods. Several methods are provided in this report. The pointing error can then be fed back to the navigation Kalman filter to correct for problematic heading (yaw) error drift. This can mitigate the need for uncomfortable and undesired IMU alignment maneuvers such as S-turns.

  10. 45 CFR 98.100 - Error Rate Report.

    Code of Federal Regulations, 2013 CFR

    2013-10-01

    ... 45 Public Welfare 1 2013-10-01 2013-10-01 false Error Rate Report. 98.100 Section 98.100 Public Welfare DEPARTMENT OF HEALTH AND HUMAN SERVICES GENERAL ADMINISTRATION CHILD CARE AND DEVELOPMENT FUND Error Rate Reporting § 98.100 Error Rate Report. (a) Applicability—The requirements of this subpart...

  11. 45 CFR 98.100 - Error Rate Report.

    Code of Federal Regulations, 2014 CFR

    2014-10-01

    ... 45 Public Welfare 1 2014-10-01 2014-10-01 false Error Rate Report. 98.100 Section 98.100 Public Welfare Department of Health and Human Services GENERAL ADMINISTRATION CHILD CARE AND DEVELOPMENT FUND Error Rate Reporting § 98.100 Error Rate Report. (a) Applicability—The requirements of this subpart...

  12. 45 CFR 98.100 - Error Rate Report.

    Code of Federal Regulations, 2012 CFR

    2012-10-01

    ... 45 Public Welfare 1 2012-10-01 2012-10-01 false Error Rate Report. 98.100 Section 98.100 Public Welfare DEPARTMENT OF HEALTH AND HUMAN SERVICES GENERAL ADMINISTRATION CHILD CARE AND DEVELOPMENT FUND Error Rate Reporting § 98.100 Error Rate Report. (a) Applicability—The requirements of this subpart...

  13. 45 CFR 98.100 - Error Rate Report.

    Code of Federal Regulations, 2011 CFR

    2011-10-01

    ... 45 Public Welfare 1 2011-10-01 2011-10-01 false Error Rate Report. 98.100 Section 98.100 Public Welfare DEPARTMENT OF HEALTH AND HUMAN SERVICES GENERAL ADMINISTRATION CHILD CARE AND DEVELOPMENT FUND Error Rate Reporting § 98.100 Error Rate Report. (a) Applicability—The requirements of this subpart...

  14. The calculation of average error probability in a digital fibre optical communication system

    NASA Astrophysics Data System (ADS)

    Rugemalira, R. A. M.

    1980-03-01

    This paper deals with the problem of determining the average error probability in a digital fibre optical communication system, in the presence of message dependent inhomogeneous non-stationary shot noise, additive Gaussian noise and intersymbol interference. A zero-forcing equalization receiver filter is considered. Three techniques for error rate evaluation are compared. The Chernoff bound and the Gram-Charlier series expansion methods are compared to the characteristic function technique. The latter predicts a higher receiver sensitivity

  15. Radiative flux and forcing parameterization error in aerosol-free clear skies

    DOE PAGES

    Pincus, Robert; Mlawer, Eli J.; Oreopoulos, Lazaros; ...

    2015-07-03

    This article reports on the accuracy in aerosol- and cloud-free conditions of the radiation parameterizations used in climate models. Accuracy is assessed relative to observationally validated reference models for fluxes under present-day conditions and forcing (flux changes) from quadrupled concentrations of carbon dioxide. Agreement among reference models is typically within 1 W/m 2, while parameterized calculations are roughly half as accurate in the longwave and even less accurate, and more variable, in the shortwave. Absorption of shortwave radiation is underestimated by most parameterizations in the present day and has relatively large errors in forcing. Error in present-day conditions is essentiallymore » unrelated to error in forcing calculations. Recent revisions to parameterizations have reduced error in most cases. As a result, a dependence on atmospheric conditions, including integrated water vapor, means that global estimates of parameterization error relevant for the radiative forcing of climate change will require much more ambitious calculations.« less

  16. Scout trajectory error propagation computer program

    NASA Technical Reports Server (NTRS)

    Myler, T. R.

    1982-01-01

    Since 1969, flight experience has been used as the basis for predicting Scout orbital accuracy. The data used for calculating the accuracy consists of errors in the trajectory parameters (altitude, velocity, etc.) at stage burnout as observed on Scout flights. Approximately 50 sets of errors are used in Monte Carlo analysis to generate error statistics in the trajectory parameters. A covariance matrix is formed which may be propagated in time. The mechanization of this process resulted in computer program Scout Trajectory Error Propagation (STEP) and is described herein. Computer program STEP may be used in conjunction with the Statistical Orbital Analysis Routine to generate accuracy in the orbit parameters (apogee, perigee, inclination, etc.) based upon flight experience.

  17. Model Error Estimation for the CPTEC Eta Model

    NASA Technical Reports Server (NTRS)

    Tippett, Michael K.; daSilva, Arlindo

    1999-01-01

    Statistical data assimilation systems require the specification of forecast and observation error statistics. Forecast error is due to model imperfections and differences between the initial condition and the actual state of the atmosphere. Practical four-dimensional variational (4D-Var) methods try to fit the forecast state to the observations and assume that the model error is negligible. Here with a number of simplifying assumption, a framework is developed for isolating the model error given the forecast error at two lead-times. Two definitions are proposed for the Talagrand ratio tau, the fraction of the forecast error due to model error rather than initial condition error. Data from the CPTEC Eta Model running operationally over South America are used to calculate forecast error statistics and lower bounds for tau.

  18. Dopamine reward prediction error coding.

    PubMed

    Schultz, Wolfram

    2016-03-01

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

  19. Dopamine reward prediction error coding

    PubMed Central

    Schultz, Wolfram

    2016-01-01

    Reward prediction errors consist of the differences between received and predicted rewards. They are crucial for basic forms of learning about rewards and make us strive for more rewards—an evolutionary beneficial trait. Most dopamine neurons in the midbrain of humans, monkeys, and rodents signal a reward prediction error; they are activated by more reward than predicted (positive prediction error), remain at baseline activity for fully predicted rewards, and show depressed activity with less reward than predicted (negative prediction error). The dopamine signal increases nonlinearly with reward value and codes formal economic utility. Drugs of addiction generate, hijack, and amplify the dopamine reward signal and induce exaggerated, uncontrolled dopamine effects on neuronal plasticity. The striatum, amygdala, and frontal cortex also show reward prediction error coding, but only in subpopulations of neurons. Thus, the important concept of reward prediction errors is implemented in neuronal hardware. PMID:27069377

  20. Understanding Human Error in Naval Aviation Mishaps.

    PubMed

    Miranda, Andrew T

    2018-04-01

    To better understand the external factors that influence the performance and decisions of aviators involved in Naval aviation mishaps. Mishaps in complex activities, ranging from aviation to nuclear power operations, are often the result of interactions between multiple components within an organization. The Naval aviation mishap database contains relevant information, both in quantitative statistics and qualitative reports, that permits analysis of such interactions to identify how the working atmosphere influences aviator performance and judgment. Results from 95 severe Naval aviation mishaps that occurred from 2011 through 2016 were analyzed using Bayes' theorem probability formula. Then a content analysis was performed on a subset of relevant mishap reports. Out of the 14 latent factors analyzed, the Bayes' application identified 6 that impacted specific aspects of aviator behavior during mishaps. Technological environment, misperceptions, and mental awareness impacted basic aviation skills. The remaining 3 factors were used to inform a content analysis of the contextual information within mishap reports. Teamwork failures were the result of plan continuation aggravated by diffused responsibility. Resource limitations and risk management deficiencies impacted judgments made by squadron commanders. The application of Bayes' theorem to historical mishap data revealed the role of latent factors within Naval aviation mishaps. Teamwork failures were seen to be considerably damaging to both aviator skill and judgment. Both the methods and findings have direct application for organizations interested in understanding the relationships between external factors and human error. It presents real-world evidence to promote effective safety decisions.

  1. Emitter location errors in electronic recognition system

    NASA Astrophysics Data System (ADS)

    Matuszewski, Jan; Dikta, Anna

    2017-04-01

    The paper describes some of the problems associated with emitter location calculations. This aspect is the most important part of the series of tasks in the electronic recognition systems. The basic tasks include: detection of emission of electromagnetic signals, tracking (determining the direction of emitter sources), signal analysis in order to classify different emitter types and the identification of the sources of emission of the same type. The paper presents a brief description of the main methods of emitter localization and the basic mathematical formulae for calculating their location. The errors' estimation has been made to determine the emitter location for three different methods and different scenarios of emitters and direction finding (DF) sensors deployment in the electromagnetic environment. The emitter has been established using a special computer program. On the basis of extensive numerical calculations, the evaluation of precise emitter location in the recognition systems for different configuration alignment of bearing devices and emitter was conducted. The calculations which have been made based on the simulated data for different methods of location are presented in the figures and respective tables. The obtained results demonstrate that calculation of the precise emitter location depends on: the number of DF sensors, the distances between emitter and DF sensors, their mutual location in the reconnaissance area and bearing errors. The precise emitter location varies depending on the number of obtained bearings. The higher the number of bearings, the better the accuracy of calculated emitter location in spite of relatively high bearing errors for each DF sensor.

  2. The decline and fall of Type II error rates

    Treesearch

    Steve Verrill; Mark Durst

    2005-01-01

    For general linear models with normally distributed random errors, the probability of a Type II error decreases exponentially as a function of sample size. This potentially rapid decline reemphasizes the importance of performing power calculations.

  3. Intrinsic interactive reinforcement learning - Using error-related potentials for real world human-robot interaction.

    PubMed

    Kim, Su Kyoung; Kirchner, Elsa Andrea; Stefes, Arne; Kirchner, Frank

    2017-12-14

    Reinforcement learning (RL) enables robots to learn its optimal behavioral strategy in dynamic environments based on feedback. Explicit human feedback during robot RL is advantageous, since an explicit reward function can be easily adapted. However, it is very demanding and tiresome for a human to continuously and explicitly generate feedback. Therefore, the development of implicit approaches is of high relevance. In this paper, we used an error-related potential (ErrP), an event-related activity in the human electroencephalogram (EEG), as an intrinsically generated implicit feedback (rewards) for RL. Initially we validated our approach with seven subjects in a simulated robot learning scenario. ErrPs were detected online in single trial with a balanced accuracy (bACC) of 91%, which was sufficient to learn to recognize gestures and the correct mapping between human gestures and robot actions in parallel. Finally, we validated our approach in a real robot scenario, in which seven subjects freely chose gestures and the real robot correctly learned the mapping between gestures and actions (ErrP detection (90% bACC)). In this paper, we demonstrated that intrinsically generated EEG-based human feedback in RL can successfully be used to implicitly improve gesture-based robot control during human-robot interaction. We call our approach intrinsic interactive RL.

  4. The application of SHERPA (Systematic Human Error Reduction and Prediction Approach) in the development of compensatory cognitive rehabilitation strategies for stroke patients with left and right brain damage.

    PubMed

    Hughes, Charmayne M L; Baber, Chris; Bienkiewicz, Marta; Worthington, Andrew; Hazell, Alexa; Hermsdörfer, Joachim

    2015-01-01

    Approximately 33% of stroke patients have difficulty performing activities of daily living, often committing errors during the planning and execution of such activities. The objective of this study was to evaluate the ability of the human error identification (HEI) technique SHERPA (Systematic Human Error Reduction and Prediction Approach) to predict errors during the performance of daily activities in stroke patients with left and right hemisphere lesions. Using SHERPA we successfully predicted 36 of the 38 observed errors, with analysis indicating that the proportion of predicted and observed errors was similar for all sub-tasks and severity levels. HEI results were used to develop compensatory cognitive strategies that clinicians could employ to reduce or prevent errors from occurring. This study provides evidence for the reliability and validity of SHERPA in the design of cognitive rehabilitation strategies in stroke populations.

  5. Estimation of genetic connectedness diagnostics based on prediction errors without the prediction error variance-covariance matrix.

    PubMed

    Holmes, John B; Dodds, Ken G; Lee, Michael A

    2017-03-02

    An important issue in genetic evaluation is the comparability of random effects (breeding values), particularly between pairs of animals in different contemporary groups. This is usually referred to as genetic connectedness. While various measures of connectedness have been proposed in the literature, there is general agreement that the most appropriate measure is some function of the prediction error variance-covariance matrix. However, obtaining the prediction error variance-covariance matrix is computationally demanding for large-scale genetic evaluations. Many alternative statistics have been proposed that avoid the computational cost of obtaining the prediction error variance-covariance matrix, such as counts of genetic links between contemporary groups, gene flow matrices, and functions of the variance-covariance matrix of estimated contemporary group fixed effects. In this paper, we show that a correction to the variance-covariance matrix of estimated contemporary group fixed effects will produce the exact prediction error variance-covariance matrix averaged by contemporary group for univariate models in the presence of single or multiple fixed effects and one random effect. We demonstrate the correction for a series of models and show that approximations to the prediction error matrix based solely on the variance-covariance matrix of estimated contemporary group fixed effects are inappropriate in certain circumstances. Our method allows for the calculation of a connectedness measure based on the prediction error variance-covariance matrix by calculating only the variance-covariance matrix of estimated fixed effects. Since the number of fixed effects in genetic evaluation is usually orders of magnitudes smaller than the number of random effect levels, the computational requirements for our method should be reduced.

  6. Hospital-based transfusion error tracking from 2005 to 2010: identifying the key errors threatening patient transfusion safety.

    PubMed

    Maskens, Carolyn; Downie, Helen; Wendt, Alison; Lima, Ana; Merkley, Lisa; Lin, Yulia; Callum, Jeannie

    2014-01-01

    This report provides a comprehensive analysis of transfusion errors occurring at a large teaching hospital and aims to determine key errors that are threatening transfusion safety, despite implementation of safety measures. Errors were prospectively identified from 2005 to 2010. Error data were coded on a secure online database called the Transfusion Error Surveillance System. Errors were defined as any deviation from established standard operating procedures. Errors were identified by clinical and laboratory staff. Denominator data for volume of activity were used to calculate rates. A total of 15,134 errors were reported with a median number of 215 errors per month (range, 85-334). Overall, 9083 (60%) errors occurred on the transfusion service and 6051 (40%) on the clinical services. In total, 23 errors resulted in patient harm: 21 of these errors occurred on the clinical services and two in the transfusion service. Of the 23 harm events, 21 involved inappropriate use of blood. Errors with no harm were 657 times more common than events that caused harm. The most common high-severity clinical errors were sample labeling (37.5%) and inappropriate ordering of blood (28.8%). The most common high-severity error in the transfusion service was sample accepted despite not meeting acceptance criteria (18.3%). The cost of product and component loss due to errors was $593,337. Errors occurred at every point in the transfusion process, with the greatest potential risk of patient harm resulting from inappropriate ordering of blood products and errors in sample labeling. © 2013 American Association of Blood Banks (CME).

  7. Distribution of standing-wave errors in real-ear sound-level measurements.

    PubMed

    Richmond, Susan A; Kopun, Judy G; Neely, Stephen T; Tan, Hongyang; Gorga, Michael P

    2011-05-01

    Standing waves can cause measurement errors when sound-pressure level (SPL) measurements are performed in a closed ear canal, e.g., during probe-microphone system calibration for distortion-product otoacoustic emission (DPOAE) testing. Alternative calibration methods, such as forward-pressure level (FPL), minimize the influence of standing waves by calculating the forward-going sound waves separate from the reflections that cause errors. Previous research compared test performance (Burke et al., 2010) and threshold prediction (Rogers et al., 2010) using SPL and multiple FPL calibration conditions, and surprisingly found no significant improvements when using FPL relative to SPL, except at 8 kHz. The present study examined the calibration data collected by Burke et al. and Rogers et al. from 155 human subjects in order to describe the frequency location and magnitude of standing-wave pressure minima to see if these errors might explain trends in test performance. Results indicate that while individual results varied widely, pressure variability was larger around 4 kHz and smaller at 8 kHz, consistent with the dimensions of the adult ear canal. The present data suggest that standing-wave errors are not responsible for the historically poor (8 kHz) or good (4 kHz) performance of DPOAE measures at specific test frequencies.

  8. Target Uncertainty Mediates Sensorimotor Error Correction.

    PubMed

    Acerbi, Luigi; Vijayakumar, Sethu; Wolpert, Daniel M

    2017-01-01

    Human movements are prone to errors that arise from inaccuracies in both our perceptual processing and execution of motor commands. We can reduce such errors by both improving our estimates of the state of the world and through online error correction of the ongoing action. Two prominent frameworks that explain how humans solve these problems are Bayesian estimation and stochastic optimal feedback control. Here we examine the interaction between estimation and control by asking if uncertainty in estimates affects how subjects correct for errors that may arise during the movement. Unbeknownst to participants, we randomly shifted the visual feedback of their finger position as they reached to indicate the center of mass of an object. Even though participants were given ample time to compensate for this perturbation, they only fully corrected for the induced error on trials with low uncertainty about center of mass, with correction only partial in trials involving more uncertainty. The analysis of subjects' scores revealed that participants corrected for errors just enough to avoid significant decrease in their overall scores, in agreement with the minimal intervention principle of optimal feedback control. We explain this behavior with a term in the loss function that accounts for the additional effort of adjusting one's response. By suggesting that subjects' decision uncertainty, as reflected in their posterior distribution, is a major factor in determining how their sensorimotor system responds to error, our findings support theoretical models in which the decision making and control processes are fully integrated.

  9. Recognizing and managing errors of cognitive underspecification.

    PubMed

    Duthie, Elizabeth A

    2014-03-01

    James Reason describes cognitive underspecification as incomplete communication that creates a knowledge gap. Errors occur when an information mismatch occurs in bridging that gap with a resulting lack of shared mental models during the communication process. There is a paucity of studies in health care examining this cognitive error and the role it plays in patient harm. The goal of the following case analyses is to facilitate accurate recognition, identify how it contributes to patient harm, and suggest appropriate management strategies. Reason's human error theory is applied in case analyses of errors of cognitive underspecification. Sidney Dekker's theory of human incident investigation is applied to event investigation to facilitate identification of this little recognized error. Contributory factors leading to errors of cognitive underspecification include workload demands, interruptions, inexperienced practitioners, and lack of a shared mental model. Detecting errors of cognitive underspecification relies on blame-free listening and timely incident investigation. Strategies for interception include two-way interactive communication, standardization of communication processes, and technological support to ensure timely access to documented clinical information. Although errors of cognitive underspecification arise at the sharp end with the care provider, effective management is dependent upon system redesign that mitigates the latent contributory factors. Cognitive underspecification is ubiquitous whenever communication occurs. Accurate identification is essential if effective system redesign is to occur.

  10. Joint Estimation of Contamination, Error and Demography for Nuclear DNA from Ancient Humans

    PubMed Central

    Slatkin, Montgomery

    2016-01-01

    When sequencing an ancient DNA sample from a hominin fossil, DNA from present-day humans involved in excavation and extraction will be sequenced along with the endogenous material. This type of contamination is problematic for downstream analyses as it will introduce a bias towards the population of the contaminating individual(s). Quantifying the extent of contamination is a crucial step as it allows researchers to account for possible biases that may arise in downstream genetic analyses. Here, we present an MCMC algorithm to co-estimate the contamination rate, sequencing error rate and demographic parameters—including drift times and admixture rates—for an ancient nuclear genome obtained from human remains, when the putative contaminating DNA comes from present-day humans. We assume we have a large panel representing the putative contaminant population (e.g. European, East Asian or African). The method is implemented in a C++ program called ‘Demographic Inference with Contamination and Error’ (DICE). We applied it to simulations and genome data from ancient Neanderthals and modern humans. With reasonable levels of genome sequence coverage (>3X), we find we can recover accurate estimates of all these parameters, even when the contamination rate is as high as 50%. PMID:27049965

  11. Linear error analysis of slope-area discharge determinations

    USGS Publications Warehouse

    Kirby, W.H.

    1987-01-01

    The slope-area method can be used to calculate peak flood discharges when current-meter measurements are not possible. This calculation depends on several quantities, such as water-surface fall, that are subject to large measurement errors. Other critical quantities, such as Manning's n, are not even amenable to direct measurement but can only be estimated. Finally, scour and fill may cause gross discrepancies between the observed condition of the channel and the hydraulic conditions during the flood peak. The effects of these potential errors on the accuracy of the computed discharge have been estimated by statistical error analysis using a Taylor-series approximation of the discharge formula and the well-known formula for the variance of a sum of correlated random variates. The resultant error variance of the computed discharge is a weighted sum of covariances of the various observational errors. The weights depend on the hydraulic and geometric configuration of the channel. The mathematical analysis confirms the rule of thumb that relative errors in computed discharge increase rapidly when velocity heads exceed the water-surface fall, when the flow field is expanding and when lateral velocity variation (alpha) is large. It also confirms the extreme importance of accurately assessing the presence of scour or fill. ?? 1987.

  12. #2 - An Empirical Assessment of Exposure Measurement Error ...

    EPA Pesticide Factsheets

    Background• Differing degrees of exposure error acrosspollutants• Previous focus on quantifying and accounting forexposure error in single-pollutant models• Examine exposure errors for multiple pollutantsand provide insights on the potential for bias andattenuation of effect estimates in single and bipollutantepidemiological models The National Exposure Research Laboratory (NERL) Human Exposure and Atmospheric Sciences Division (HEASD) conducts research in support of EPA mission to protect human health and the environment. HEASD research program supports Goal 1 (Clean Air) and Goal 4 (Healthy People) of EPA strategic plan. More specifically, our division conducts research to characterize the movement of pollutants from the source to contact with humans. Our multidisciplinary research program produces Methods, Measurements, and Models to identify relationships between and characterize processes that link source emissions, environmental concentrations, human exposures, and target-tissue dose. The impact of these tools is improved regulatory programs and policies for EPA.

  13. [Effect of Mn(II) on the error-prone DNA polymerase iota activity in extracts from human normal and tumor cells].

    PubMed

    Lakhin, A V; Efremova, A S; Makarova, I V; Grishina, E E; Shram, S I; Tarantul, V Z; Gening, L V

    2013-01-01

    The DNA polymerase iota (Pol iota), which has some peculiar features and is characterized by an extremely error-prone DNA synthesis, belongs to the group of enzymes preferentially activated by Mn2+ instead of Mg2+. In this work, the effect of Mn2+ on DNA synthesis in cell extracts from a) normal human and murine tissues, b) human tumor (uveal melanoma), and c) cultured human tumor cell lines SKOV-3 and HL-60 was tested. Each group displayed characteristic features of Mn-dependent DNA synthesis. The changes in the Mn-dependent DNA synthesis caused by malignant transformation of normal tissues are described. It was also shown that the error-prone DNA synthesis catalyzed by Pol iota in extracts of all cell types was efficiently suppressed by an RNA aptamer (IKL5) against Pol iota obtained in our work earlier. The obtained results suggest that IKL5 might be used to suppress the enhanced activity of Pol iota in tumor cells.

  14. Designing to Control Flight Crew Errors

    NASA Technical Reports Server (NTRS)

    Schutte, Paul C.; Willshire, Kelli F.

    1997-01-01

    It is widely accepted that human error is a major contributing factor in aircraft accidents. There has been a significant amount of research in why these errors occurred, and many reports state that the design of flight deck can actually dispose humans to err. This research has led to the call for changes in design according to human factors and human-centered principles. The National Aeronautics and Space Administration's (NASA) Langley Research Center has initiated an effort to design a human-centered flight deck from a clean slate (i.e., without constraints of existing designs.) The effort will be based on recent research in human-centered design philosophy and mission management categories. This design will match the human's model of the mission and function of the aircraft to reduce unnatural or non-intuitive interfaces. The product of this effort will be a flight deck design description, including training and procedures, and a cross reference or paper trail back to design hypotheses, and an evaluation of the design. The present paper will discuss the philosophy, process, and status of this design effort.

  15. Information-Gathering Patterns Associated with Higher Rates of Diagnostic Error

    ERIC Educational Resources Information Center

    Delzell, John E., Jr.; Chumley, Heidi; Webb, Russell; Chakrabarti, Swapan; Relan, Anju

    2009-01-01

    Diagnostic errors are an important source of medical errors. Problematic information-gathering is a common cause of diagnostic errors among physicians and medical students. The objectives of this study were to (1) determine if medical students' information-gathering patterns formed clusters of similar strategies, and if so (2) to calculate the…

  16. Global optimization method based on ray tracing to achieve optimum figure error compensation

    NASA Astrophysics Data System (ADS)

    Liu, Xiaolin; Guo, Xuejia; Tang, Tianjin

    2017-02-01

    Figure error would degrade the performance of optical system. When predicting the performance and performing system assembly, compensation by clocking of optical components around the optical axis is a conventional but user-dependent method. Commercial optical software cannot optimize this clocking. Meanwhile existing automatic figure-error balancing methods can introduce approximate calculation error and the build process of optimization model is complex and time-consuming. To overcome these limitations, an accurate and automatic global optimization method of figure error balancing is proposed. This method is based on precise ray tracing to calculate the wavefront error, not approximate calculation, under a given elements' rotation angles combination. The composite wavefront error root-mean-square (RMS) acts as the cost function. Simulated annealing algorithm is used to seek the optimal combination of rotation angles of each optical element. This method can be applied to all rotational symmetric optics. Optimization results show that this method is 49% better than previous approximate analytical method.

  17. Position Error Covariance Matrix Validation and Correction

    NASA Technical Reports Server (NTRS)

    Frisbee, Joe, Jr.

    2016-01-01

    In order to calculate operationally accurate collision probabilities, the position error covariance matrices predicted at times of closest approach must be sufficiently accurate representations of the position uncertainties. This presentation will discuss why the Gaussian distribution is a reasonable expectation for the position uncertainty and how this assumed distribution type is used in the validation and correction of position error covariance matrices.

  18. Human Health Risk Assessment Calculator. In: SMARTe20ll, EPA/600/C-10/007

    EPA Science Inventory

    This calculator is aimed at supporting a human health risk assessment. Risk scenarios can be built by combining various health effects, exposure pathways, exposure parameters, and analytes. Scenario risk are calculated for each exposure pathway and analyte combination. The out...

  19. Error measuring system of rotary Inductosyn

    NASA Astrophysics Data System (ADS)

    Liu, Chengjun; Zou, Jibin; Fu, Xinghe

    2008-10-01

    The inductosyn is a kind of high-precision angle-position sensor. It has important applications in servo table, precision machine tool and other products. The precision of inductosyn is calibrated by its error. It's an important problem about the error measurement in the process of production and application of the inductosyn. At present, it mainly depends on the method of artificial measurement to obtain the error of inductosyn. Therefore, the disadvantages can't be ignored such as the high labour intensity of the operator, the occurrent error which is easy occurred and the poor repeatability, and so on. In order to solve these problems, a new automatic measurement method is put forward in this paper which based on a high precision optical dividing head. Error signal can be obtained by processing the output signal of inductosyn and optical dividing head precisely. When inductosyn rotating continuously, its zero position error can be measured dynamically, and zero error curves can be output automatically. The measuring and calculating errors caused by man-made factor can be overcome by this method, and it makes measuring process more quickly, exactly and reliably. Experiment proves that the accuracy of error measuring system is 1.1 arc-second (peak - peak value).

  20. Identification of factors associated with diagnostic error in primary care.

    PubMed

    Minué, Sergio; Bermúdez-Tamayo, Clara; Fernández, Alberto; Martín-Martín, José Jesús; Benítez, Vivian; Melguizo, Miguel; Caro, Araceli; Orgaz, María José; Prados, Miguel Angel; Díaz, José Enrique; Montoro, Rafael

    2014-05-12

    Missed, delayed or incorrect diagnoses are considered to be diagnostic errors. The aim of this paper is to describe the methodology of a study to analyse cognitive aspects of the process by which primary care (PC) physicians diagnose dyspnoea. It examines the possible links between the use of heuristics, suboptimal cognitive acts and diagnostic errors, using Reason's taxonomy of human error (slips, lapses, mistakes and violations). The influence of situational factors (professional experience, perceived overwork and fatigue) is also analysed. Cohort study of new episodes of dyspnoea in patients receiving care from family physicians and residents at PC centres in Granada (Spain). With an initial expected diagnostic error rate of 20%, and a sampling error of 3%, 384 episodes of dyspnoea are calculated to be required. In addition to filling out the electronic medical record of the patients attended, each physician fills out 2 specially designed questionnaires about the diagnostic process performed in each case of dyspnoea. The first questionnaire includes questions on the physician's initial diagnostic impression, the 3 most likely diagnoses (in order of likelihood), and the diagnosis reached after the initial medical history and physical examination. It also includes items on the physicians' perceived overwork and fatigue during patient care. The second questionnaire records the confirmed diagnosis once it is reached. The complete diagnostic process is peer-reviewed to identify and classify the diagnostic errors. The possible use of heuristics of representativeness, availability, and anchoring and adjustment in each diagnostic process is also analysed. Each audit is reviewed with the physician responsible for the diagnostic process. Finally, logistic regression models are used to determine if there are differences in the diagnostic error variables based on the heuristics identified. This work sets out a new approach to studying the diagnostic decision-making process

  1. Classification and reduction of pilot error

    NASA Technical Reports Server (NTRS)

    Rogers, W. H.; Logan, A. L.; Boley, G. D.

    1989-01-01

    Human error is a primary or contributing factor in about two-thirds of commercial aviation accidents worldwide. With the ultimate goal of reducing pilot error accidents, this contract effort is aimed at understanding the factors underlying error events and reducing the probability of certain types of errors by modifying underlying factors such as flight deck design and procedures. A review of the literature relevant to error classification was conducted. Classification includes categorizing types of errors, the information processing mechanisms and factors underlying them, and identifying factor-mechanism-error relationships. The classification scheme developed by Jens Rasmussen was adopted because it provided a comprehensive yet basic error classification shell or structure that could easily accommodate addition of details on domain-specific factors. For these purposes, factors specific to the aviation environment were incorporated. Hypotheses concerning the relationship of a small number of underlying factors, information processing mechanisms, and error types types identified in the classification scheme were formulated. ASRS data were reviewed and a simulation experiment was performed to evaluate and quantify the hypotheses.

  2. Empirical State Error Covariance Matrix for Batch Estimation

    NASA Technical Reports Server (NTRS)

    Frisbee, Joe

    2015-01-01

    State estimation techniques effectively provide mean state estimates. However, the theoretical state error covariance matrices provided as part of these techniques often suffer from a lack of confidence in their ability to describe the uncertainty in the estimated states. By a reinterpretation of the equations involved in the weighted batch least squares algorithm, it is possible to directly arrive at an empirical state error covariance matrix. The proposed empirical state error covariance matrix will contain the effect of all error sources, known or not. This empirical error covariance matrix may be calculated as a side computation for each unique batch solution. Results based on the proposed technique will be presented for a simple, two observer and measurement error only problem.

  3. Validation of Metrics as Error Predictors

    NASA Astrophysics Data System (ADS)

    Mendling, Jan

    In this chapter, we test the validity of metrics that were defined in the previous chapter for predicting errors in EPC business process models. In Section 5.1, we provide an overview of how the analysis data is generated. Section 5.2 describes the sample of EPCs from practice that we use for the analysis. Here we discuss a disaggregation by the EPC model group and by error as well as a correlation analysis between metrics and error. Based on this sample, we calculate a logistic regression model for predicting error probability with the metrics as input variables in Section 5.3. In Section 5.4, we then test the regression function for an independent sample of EPC models from textbooks as a cross-validation. Section 5.5 summarizes the findings.

  4. Target Uncertainty Mediates Sensorimotor Error Correction

    PubMed Central

    Vijayakumar, Sethu; Wolpert, Daniel M.

    2017-01-01

    Human movements are prone to errors that arise from inaccuracies in both our perceptual processing and execution of motor commands. We can reduce such errors by both improving our estimates of the state of the world and through online error correction of the ongoing action. Two prominent frameworks that explain how humans solve these problems are Bayesian estimation and stochastic optimal feedback control. Here we examine the interaction between estimation and control by asking if uncertainty in estimates affects how subjects correct for errors that may arise during the movement. Unbeknownst to participants, we randomly shifted the visual feedback of their finger position as they reached to indicate the center of mass of an object. Even though participants were given ample time to compensate for this perturbation, they only fully corrected for the induced error on trials with low uncertainty about center of mass, with correction only partial in trials involving more uncertainty. The analysis of subjects’ scores revealed that participants corrected for errors just enough to avoid significant decrease in their overall scores, in agreement with the minimal intervention principle of optimal feedback control. We explain this behavior with a term in the loss function that accounts for the additional effort of adjusting one’s response. By suggesting that subjects’ decision uncertainty, as reflected in their posterior distribution, is a major factor in determining how their sensorimotor system responds to error, our findings support theoretical models in which the decision making and control processes are fully integrated. PMID:28129323

  5. Simultaneous Control of Error Rates in fMRI Data Analysis

    PubMed Central

    Kang, Hakmook; Blume, Jeffrey; Ombao, Hernando; Badre, David

    2015-01-01

    The key idea of statistical hypothesis testing is to fix, and thereby control, the Type I error (false positive) rate across samples of any size. Multiple comparisons inflate the global (family-wise) Type I error rate and the traditional solution to maintaining control of the error rate is to increase the local (comparison-wise) Type II error (false negative) rates. However, in the analysis of human brain imaging data, the number of comparisons is so large that this solution breaks down: the local Type II error rate ends up being so large that scientifically meaningful analysis is precluded. Here we propose a novel solution to this problem: allow the Type I error rate to converge to zero along with the Type II error rate. It works because when the Type I error rate per comparison is very small, the accumulation (or global) Type I error rate is also small. This solution is achieved by employing the Likelihood paradigm, which uses likelihood ratios to measure the strength of evidence on a voxel-by-voxel basis. In this paper, we provide theoretical and empirical justification for a likelihood approach to the analysis of human brain imaging data. In addition, we present extensive simulations that show the likelihood approach is viable, leading to ‘cleaner’ looking brain maps and operationally superiority (lower average error rate). Finally, we include a case study on cognitive control related activation in the prefrontal cortex of the human brain. PMID:26272730

  6. Preventing medical errors by designing benign failures.

    PubMed

    Grout, John R

    2003-07-01

    One way to successfully reduce medical errors is to design health care systems that are more resistant to the tendencies of human beings to err. One interdisciplinary approach entails creating design changes, mitigating human errors, and making human error irrelevant to outcomes. This approach is intended to facilitate the creation of benign failures, which have been called mistake-proofing devices and forcing functions elsewhere. USING FAULT TREES TO DESIGN FORCING FUNCTIONS: A fault tree is a graphical tool used to understand the relationships that either directly cause or contribute to the cause of a particular failure. A careful analysis of a fault tree enables the analyst to anticipate how the process will behave after the change. EXAMPLE OF AN APPLICATION: A scenario in which a patient is scalded while bathing can serve as an example of how multiple fault trees can be used to design forcing functions. The first fault tree shows the undesirable event--patient scalded while bathing. The second fault tree has a benign event--no water. Adding a scald valve changes the outcome from the undesirable event ("patient scalded while bathing") to the benign event ("no water") Analysis of fault trees does not ensure or guarantee that changes necessary to eliminate error actually occur. Most mistake-proofing is used to prevent simple errors and to create well-defended processes, but complex errors can also result. The utilization of mistake-proofing or forcing functions can be thought of as changing the logic of a process. Errors that formerly caused undesirable failures can be converted into the causes of benign failures. The use of fault trees can provide a variety of insights into the design of forcing functions that will improve patient safety.

  7. Complete Systematic Error Model of SSR for Sensor Registration in ATC Surveillance Networks

    PubMed Central

    Besada, Juan A.

    2017-01-01

    In this paper, a complete and rigorous mathematical model for secondary surveillance radar systematic errors (biases) is developed. The model takes into account the physical effects systematically affecting the measurement processes. The azimuth biases are calculated from the physical error of the antenna calibration and the errors of the angle determination dispositive. Distance bias is calculated from the delay of the signal produced by the refractivity index of the atmosphere, and from clock errors, while the altitude bias is calculated taking into account the atmosphere conditions (pressure and temperature). It will be shown, using simulated and real data, that adapting a classical bias estimation process to use the complete parametrized model results in improved accuracy in the bias estimation. PMID:28934157

  8. Optimizer convergence and local minima errors and their clinical importance

    NASA Astrophysics Data System (ADS)

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

    2003-09-01

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

  9. Optimizer convergence and local minima errors and their clinical importance.

    PubMed

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

    2003-09-07

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

  10. Error image aware content restoration

    NASA Astrophysics Data System (ADS)

    Choi, Sungwoo; Lee, Moonsik; Jung, Byunghee

    2015-12-01

    As the resolution of TV significantly increased, content consumers have become increasingly sensitive to the subtlest defect in TV contents. This rising standard in quality demanded by consumers has posed a new challenge in today's context where the tape-based process has transitioned to the file-based process: the transition necessitated digitalizing old archives, a process which inevitably produces errors such as disordered pixel blocks, scattered white noise, or totally missing pixels. Unsurprisingly, detecting and fixing such errors require a substantial amount of time and human labor to meet the standard demanded by today's consumers. In this paper, we introduce a novel, automated error restoration algorithm which can be applied to different types of classic errors by utilizing adjacent images while preserving the undamaged parts of an error image as much as possible. We tested our method to error images detected from our quality check system in KBS(Korean Broadcasting System) video archive. We are also implementing the algorithm as a plugin of well-known NLE(Non-linear editing system), which is a familiar tool for quality control agent.

  11. Simplification of the kinematic model of human movement

    NASA Astrophysics Data System (ADS)

    Dusza, Jacek J.; Wawrzyniak, Zbigniew M.; del Prado Martinez, David

    2013-10-01

    The paper presents a methods of simplification of the human gait model. The experimental data were obtained in the laboratory of the group SATI in the Electronics Engineering Department of the University of Valencia. As a result of the Mean Double Step (MDS) procedure, the human motion were described by a matrix containing the Cartesian coordinates of 26 markers placed on the human body recorded in the 100 time points. With these data it has been possible to develop an software application which performs a wide diversity of tasks like array simplification, mask calculation for the simplification, error calculation as well as tools for signals comparison and movement animation of the markers. Simplifications were made by the spectral analysis of signals and calculating the standard deviation of the differences between the signal and its approximation. Using this method the signals of displacement could be written as the time series limited to a small number of harmonic signals. This approach allows us for a high degree of data compression. The model presented in this work can be applied into the context of medical diagnostics or rehabilitation because for a given approximation error and a large number of harmonics may demonstrate some abnormalities (of orthopaedic symptoms) in the gait cycle analysis.

  12. Associations between errors and contributing factors in aircraft maintenance

    NASA Technical Reports Server (NTRS)

    Hobbs, Alan; Williamson, Ann

    2003-01-01

    In recent years cognitive error models have provided insights into the unsafe acts that lead to many accidents in safety-critical environments. Most models of accident causation are based on the notion that human errors occur in the context of contributing factors. However, there is a lack of published information on possible links between specific errors and contributing factors. A total of 619 safety occurrences involving aircraft maintenance were reported using a self-completed questionnaire. Of these occurrences, 96% were related to the actions of maintenance personnel. The types of errors that were involved, and the contributing factors associated with those actions, were determined. Each type of error was associated with a particular set of contributing factors and with specific occurrence outcomes. Among the associations were links between memory lapses and fatigue and between rule violations and time pressure. Potential applications of this research include assisting with the design of accident prevention strategies, the estimation of human error probabilities, and the monitoring of organizational safety performance.

  13. Assessing the Impact of Analytical Error on Perceived Disease Severity.

    PubMed

    Kroll, Martin H; Garber, Carl C; Bi, Caixia; Suffin, Stephen C

    2015-10-01

    The perception of the severity of disease from laboratory results assumes that the results are free of analytical error; however, analytical error creates a spread of results into a band and thus a range of perceived disease severity. To assess the impact of analytical errors by calculating the change in perceived disease severity, represented by the hazard ratio, using non-high-density lipoprotein (nonHDL) cholesterol as an example. We transformed nonHDL values into ranges using the assumed total allowable errors for total cholesterol (9%) and high-density lipoprotein cholesterol (13%). Using a previously determined relationship between the hazard ratio and nonHDL, we calculated a range of hazard ratios for specified nonHDL concentrations affected by analytical error. Analytical error, within allowable limits, created a band of values of nonHDL, with a width spanning 30 to 70 mg/dL (0.78-1.81 mmol/L), depending on the cholesterol and high-density lipoprotein cholesterol concentrations. Hazard ratios ranged from 1.0 to 2.9, a 16% to 50% error. Increased bias widens this range and decreased bias narrows it. Error-transformed results produce a spread of values that straddle the various cutoffs for nonHDL. The range of the hazard ratio obscures the meaning of results, because the spread of ratios at different cutoffs overlap. The magnitude of the perceived hazard ratio error exceeds that for the allowable analytical error, and significantly impacts the perceived cardiovascular disease risk. Evaluating the error in the perceived severity (eg, hazard ratio) provides a new way to assess the impact of analytical error.

  14. Error reduction in three-dimensional metrology combining optical and touch probe data

    NASA Astrophysics Data System (ADS)

    Gerde, Janice R.; Christens-Barry, William A.

    2010-08-01

    Analysis of footwear under the Harmonized Tariff Schedule of the United States (HTSUS) is partly based on identifying the boundary ("parting line") between the "external surface area upper" (ESAU) and the sample's sole. Often, that boundary is obscured. We establish the parting line as the curved intersection between the sample outer surface and its insole surface. The outer surface is determined by discrete point cloud coordinates obtained using a laser scanner. The insole surface is defined by point cloud data, obtained using a touch probe device-a coordinate measuring machine (CMM). Because these point cloud data sets do not overlap spatially, a polynomial surface is fitted to the insole data and extended to intersect a mesh fitted to the outer surface point cloud. This line of intersection defines the ESAU boundary, permitting further fractional area calculations to proceed. The defined parting line location is sensitive to the polynomial used to fit experimental data. Extrapolation to the intersection with the ESAU can heighten this sensitivity. We discuss a methodology for transforming these data into a common reference frame. Three scenarios are considered: measurement error in point cloud coordinates, from fitting a polynomial surface to a point cloud then extrapolating beyond the data set, and error from reference frame transformation. These error sources can influence calculated surface areas. We describe experiments to assess error magnitude, the sensitivity of calculated results on these errors, and minimizing error impact on calculated quantities. Ultimately, we must ensure that statistical error from these procedures is minimized and within acceptance criteria.

  15. The error of L5/S1 joint moment calculation in a body-centered non-inertial reference frame when the fictitious force is ignored.

    PubMed

    Xu, Xu; Faber, Gert S; Kingma, Idsart; Chang, Chien-Chi; Hsiang, Simon M

    2013-07-26

    In ergonomics studies, linked segment models are commonly used for estimating dynamic L5/S1 joint moments during lifting tasks. The kinematics data input to these models are with respect to an arbitrary stationary reference frame. However, a body-centered reference frame, which is defined using the position and the orientation of human body segments, is sometimes used to conveniently identify the location of the load relative to the body. When a body-centered reference frame is moving with the body, it is a non-inertial reference frame and fictitious force exists. Directly applying a linked segment model to the kinematics data with respect to a body-centered non-inertial reference frame will ignore the effect of this fictitious force and introduce errors during L5/S1 moment estimation. In the current study, various lifting tasks were performed in the laboratory environment. The L5/S1 joint moments during the lifting tasks were calculated by a linked segment model with respect to a stationary reference frame and to a body-centered non-inertial reference frame. The results indicate that applying a linked segment model with respect to a body-centered non-inertial reference frame will result in overestimating the peak L5/S1 joint moments of the coronal plane, sagittal plane, and transverse plane during lifting tasks by 78%, 2%, and 59% on average, respectively. The instant when the peak moment occurred was delayed by 0.13, 0.03, and 0.09s on average, correspondingly for the three planes. The root-mean-square errors of the L5/S1 joint moment for the three planes are 21Nm, 19Nm, and 9Nm, correspondingly. Copyright © 2013 Elsevier Ltd. All rights reserved.

  16. Comparing errors in ED computer-assisted vs conventional pediatric drug dosing and administration.

    PubMed

    Yamamoto, Loren; Kanemori, Joan

    2010-06-01

    Compared to fixed-dose single-vial drug administration in adults, pediatric drug dosing and administration requires a series of calculations, all of which are potentially error prone. The purpose of this study is to compare error rates and task completion times for common pediatric medication scenarios using computer program assistance vs conventional methods. Two versions of a 4-part paper-based test were developed. Each part consisted of a set of medication administration and/or dosing tasks. Emergency department and pediatric intensive care unit nurse volunteers completed these tasks using both methods (sequence assigned to start with a conventional or a computer-assisted approach). Completion times, errors, and the reason for the error were recorded. Thirty-eight nurses completed the study. Summing the completion of all 4 parts, the mean conventional total time was 1243 seconds vs the mean computer program total time of 879 seconds (P < .001). The conventional manual method had a mean of 1.8 errors vs the computer program with a mean of 0.7 errors (P < .001). Of the 97 total errors, 36 were due to misreading the drug concentration on the label, 34 were due to calculation errors, and 8 were due to misplaced decimals. Of the 36 label interpretation errors, 18 (50%) occurred with digoxin or insulin. Computerized assistance reduced errors and the time required for drug administration calculations. A pattern of errors emerged, noting that reading/interpreting certain drug labels were more error prone. Optimizing the layout of drug labels could reduce the error rate for error-prone labels. Copyright (c) 2010 Elsevier Inc. All rights reserved.

  17. The Mathematics of Computer Error.

    ERIC Educational Resources Information Center

    Wood, Eric

    1988-01-01

    Why a computer error occurred is considered by analyzing the binary system and decimal fractions. How the computer stores numbers is then described. Knowledge of the mathematics behind computer operation is important if one wishes to understand and have confidence in the results of computer calculations. (MNS)

  18. Empirical Analysis of Systematic Communication Errors.

    DTIC Science & Technology

    1981-09-01

    human o~ . .... 8 components in communication systems. (Systematic errors were defined to be those that occur regularly in human communication links...phase of the human communication process and focuses on the linkage between a specific piece of information (and the receiver) and the transmission...communication flow. (2) Exchange. Exchange is the next phase in human communication and entails a concerted effort on the part of the sender and receiver to share

  19. Competition between learned reward and error outcome predictions in anterior cingulate cortex.

    PubMed

    Alexander, William H; Brown, Joshua W

    2010-02-15

    The anterior cingulate cortex (ACC) is implicated in performance monitoring and cognitive control. Non-human primate studies of ACC show prominent reward signals, but these are elusive in human studies, which instead show mainly conflict and error effects. Here we demonstrate distinct appetitive and aversive activity in human ACC. The error likelihood hypothesis suggests that ACC activity increases in proportion to the likelihood of an error, and ACC is also sensitive to the consequence magnitude of the predicted error. Previous work further showed that error likelihood effects reach a ceiling as the potential consequences of an error increase, possibly due to reductions in the average reward. We explored this issue by independently manipulating reward magnitude of task responses and error likelihood while controlling for potential error consequences in an Incentive Change Signal Task. The fMRI results ruled out a modulatory effect of expected reward on error likelihood effects in favor of a competition effect between expected reward and error likelihood. Dynamic causal modeling showed that error likelihood and expected reward signals are intrinsic to the ACC rather than received from elsewhere. These findings agree with interpretations of ACC activity as signaling both perceptions of risk and predicted reward. Copyright 2009 Elsevier Inc. All rights reserved.

  20. Exploring Reactions to Pilot Reliability Certification and Changing Attitudes on the Reduction of Errors

    ERIC Educational Resources Information Center

    Boedigheimer, Dan

    2010-01-01

    Approximately 70% of aviation accidents are attributable to human error. The greatest opportunity for further improving aviation safety is found in reducing human errors in the cockpit. The purpose of this quasi-experimental, mixed-method research was to evaluate whether there was a difference in pilot attitudes toward reducing human error in the…

  1. Quantization error of CCD cameras and their influence on phase calculation in fringe pattern analysis.

    PubMed

    Skydan, Oleksandr A; Lilley, Francis; Lalor, Michael J; Burton, David R

    2003-09-10

    We present an investigation into the phase errors that occur in fringe pattern analysis that are caused by quantization effects. When acquisition devices with a limited value of camera bit depth are used, there are a limited number of quantization levels available to record the signal. This may adversely affect the recorded signal and adds a potential source of instrumental error to the measurement system. Quantization effects also determine the accuracy that may be achieved by acquisition devices in a measurement system. We used the Fourier fringe analysis measurement technique. However, the principles can be applied equally well for other phase measuring techniques to yield a phase error distribution that is caused by the camera bit depth.

  2. Cross Section Sensitivity and Propagated Errors in HZE Exposures

    NASA Technical Reports Server (NTRS)

    Heinbockel, John H.; Wilson, John W.; Blatnig, Steve R.; Qualls, Garry D.; Badavi, Francis F.; Cucinotta, Francis A.

    2005-01-01

    It has long been recognized that galactic cosmic rays are of such high energy that they tend to pass through available shielding materials resulting in exposure of astronauts and equipment within space vehicles and habitats. Any protection provided by shielding materials result not so much from stopping such particles but by changing their physical character in interaction with shielding material nuclei forming, hopefully, less dangerous species. Clearly, the fidelity of the nuclear cross-sections is essential to correct specification of shield design and sensitivity to cross-section error is important in guiding experimental validation of cross-section models and database. We examine the Boltzmann transport equation which is used to calculate dose equivalent during solar minimum, with units (cSv/yr), associated with various depths of shielding materials. The dose equivalent is a weighted sum of contributions from neutrons, protons, light ions, medium ions and heavy ions. We investigate the sensitivity of dose equivalent calculations due to errors in nuclear fragmentation cross-sections. We do this error analysis for all possible projectile-fragment combinations (14,365 such combinations) to estimate the sensitivity of the shielding calculations to errors in the nuclear fragmentation cross-sections. Numerical differentiation with respect to the cross-sections will be evaluated in a broad class of materials including polyethylene, aluminum and copper. We will identify the most important cross-sections for further experimental study and evaluate their impact on propagated errors in shielding estimates.

  3. 45 CFR 98.100 - Error Rate Report.

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ... Welfare DEPARTMENT OF HEALTH AND HUMAN SERVICES GENERAL ADMINISTRATION CHILD CARE AND DEVELOPMENT FUND... rates, which is defined as the percentage of cases with an error (expressed as the total number of cases with an error compared to the total number of cases); the percentage of cases with an improper payment...

  4. Experiential Teaching Increases Medication Calculation Accuracy Among Baccalaureate Nursing Students.

    PubMed

    Hurley, Teresa V

    Safe medication administration is an international goal. Calculation errors cause patient harm despite education. The research purpose was to evaluate the effectiveness of an experiential teaching strategy to reduce errors in a sample of 78 baccalaureate nursing students at a Northeastern college. A pretest-posttest design with random assignment into equal-sized groups was used. The experiential strategy was more effective than the traditional method (t = -0.312, df = 37, p = .004, 95% CI) with a reduction in calculation errors. Evaluations of error type and teaching strategies are indicated to facilitate course and program changes.

  5. Investigating the Causes of Medication Errors and Strategies to Prevention of Them from Nurses and Nursing Student Viewpoint

    PubMed Central

    Gorgich, Enam Alhagh Charkhat; Barfroshan, Sanam; Ghoreishi, Gholamreza; Yaghoobi, Maryam

    2016-01-01

    Introduction and Aim: Medication errors as a serious problem in world and one of the most common medical errors that threaten patient safety and may lead to even death of them. The purpose of this study was to investigate the causes of medication errors and strategies to prevention of them from nurses and nursing student viewpoint. Materials & Methods: This cross-sectional descriptive study was conducted on 327 nursing staff of khatam-al-anbia hospital and 62 intern nursing students in nursing and midwifery school of Zahedan, Iran, enrolled through the availability sampling in 2015. The data were collected by the valid and reliable questionnaire. To analyze the data, descriptive statistics, T-test and ANOVA were applied by use of SPSS16 software. Findings: The results showed that the most common causes of medications errors in nursing were tiredness due increased workload (97.8%), and in nursing students were drug calculation, (77.4%). The most important way for prevention in nurses and nursing student opinion, was reducing the work pressure by increasing the personnel, proportional to the number and condition of patients and also creating a unit as medication calculation. Also there was a significant relationship between the type of ward and the mean of medication errors in two groups. Conclusion: Based on the results it is recommended that nurse-managers resolve the human resources problem, provide workshops and in-service education about preparing medications, side-effects of drugs and pharmacological knowledge. Using electronic medications cards is a measure which reduces medications errors. PMID:27045413

  6. Statistics of the residual refraction errors in laser ranging data

    NASA Technical Reports Server (NTRS)

    Gardner, C. S.

    1977-01-01

    A theoretical model for the range error covariance was derived by assuming that the residual refraction errors are due entirely to errors in the meteorological data which are used to calculate the atmospheric correction. The properties of the covariance function are illustrated by evaluating the theoretical model for the special case of a dense network of weather stations uniformly distributed within a circle.

  7. Wind power error estimation in resource assessments.

    PubMed

    Rodríguez, Osvaldo; Del Río, Jesús A; Jaramillo, Oscar A; Martínez, Manuel

    2015-01-01

    Estimating the power output is one of the elements that determine the techno-economic feasibility of a renewable project. At present, there is a need to develop reliable methods that achieve this goal, thereby contributing to wind power penetration. In this study, we propose a method for wind power error estimation based on the wind speed measurement error, probability density function, and wind turbine power curves. This method uses the actual wind speed data without prior statistical treatment based on 28 wind turbine power curves, which were fitted by Lagrange's method, to calculate the estimate wind power output and the corresponding error propagation. We found that wind speed percentage errors of 10% were propagated into the power output estimates, thereby yielding an error of 5%. The proposed error propagation complements the traditional power resource assessments. The wind power estimation error also allows us to estimate intervals for the power production leveled cost or the investment time return. The implementation of this method increases the reliability of techno-economic resource assessment studies.

  8. Wind Power Error Estimation in Resource Assessments

    PubMed Central

    Rodríguez, Osvaldo; del Río, Jesús A.; Jaramillo, Oscar A.; Martínez, Manuel

    2015-01-01

    Estimating the power output is one of the elements that determine the techno-economic feasibility of a renewable project. At present, there is a need to develop reliable methods that achieve this goal, thereby contributing to wind power penetration. In this study, we propose a method for wind power error estimation based on the wind speed measurement error, probability density function, and wind turbine power curves. This method uses the actual wind speed data without prior statistical treatment based on 28 wind turbine power curves, which were fitted by Lagrange's method, to calculate the estimate wind power output and the corresponding error propagation. We found that wind speed percentage errors of 10% were propagated into the power output estimates, thereby yielding an error of 5%. The proposed error propagation complements the traditional power resource assessments. The wind power estimation error also allows us to estimate intervals for the power production leveled cost or the investment time return. The implementation of this method increases the reliability of techno-economic resource assessment studies. PMID:26000444

  9. Moment expansion for ionospheric range error

    NASA Technical Reports Server (NTRS)

    Mallinckrodt, A.; Reich, R.; Parker, H.; Berbert, J.

    1972-01-01

    On a plane earth, the ionospheric or tropospheric range error depends only on the total refractivity content or zeroth moment of the refracting layer and the elevation angle. On a spherical earth, however, the dependence is more complex; so for more accurate results it has been necessary to resort to complex ray-tracing calculations. A simple, high-accuracy alternative to the ray-tracing calculation is presented. By appropriate expansion of the angular dependence in the ray-tracing integral in a power series in height, an expression is obtained for the range error in terms of a simple function of elevation angle, E, at the expansion height and of the mth moment of the refractivity, N, distribution about the expansion height. The rapidity of convergence is heavily dependent on the choice of expansion height. For expansion heights in the neighborhood of the centroid of the layer (300-490 km), the expansion to N = 2 (three terms) gives results accurate to about 0.4% at E = 10 deg. As an analytic tool, the expansion affords some insight on the influence of layer shape on range errors in special problems.

  10. 'Systemic Failures' and 'Human Error' in Canadian TSB Aviation Reports Between 1996 and 2002

    NASA Technical Reports Server (NTRS)

    Holloway, C. M.; Johnson, C. W.

    2004-01-01

    This paper describes the results of an independent analysis of the primary and contributory causes of aviation accidents in Canada between 1996 and 2003. The purpose of the study was to assess the comparative frequency of a range of causal factors in the reporting of these adverse events. Our results suggest that the majority of these high consequence accidents were attributed to human error. A large number of reports also mentioned wider systemic issues, including the managerial and regulatory context of aviation operations. These issues are more likely to appear as contributory rather than primary causes in this set of accident reports.

  11. Human Factors Risk Analyses of a Doffing Protocol for Ebola-Level Personal Protective Equipment: Mapping Errors to Contamination.

    PubMed

    Mumma, Joel M; Durso, Francis T; Ferguson, Ashley N; Gipson, Christina L; Casanova, Lisa; Erukunuakpor, Kimberly; Kraft, Colleen S; Walsh, Victoria L; Zimring, Craig; DuBose, Jennifer; Jacob, Jesse T

    2018-03-05

    Doffing protocols for personal protective equipment (PPE) are critical for keeping healthcare workers (HCWs) safe during care of patients with Ebola virus disease. We assessed the relationship between errors and self-contamination during doffing. Eleven HCWs experienced with doffing Ebola-level PPE participated in simulations in which HCWs donned PPE marked with surrogate viruses (ɸ6 and MS2), completed a clinical task, and were assessed for contamination after doffing. Simulations were video recorded, and a failure modes and effects analysis and fault tree analyses were performed to identify errors during doffing, quantify their risk (risk index), and predict contamination data. Fifty-one types of errors were identified, many having the potential to spread contamination. Hand hygiene and removing the powered air purifying respirator (PAPR) hood had the highest total risk indexes (111 and 70, respectively) and number of types of errors (9 and 13, respectively). ɸ6 was detected on 10% of scrubs and the fault tree predicted a 10.4% contamination rate, likely occurring when the PAPR hood inadvertently contacted scrubs during removal. MS2 was detected on 10% of hands, 20% of scrubs, and 70% of inner gloves and the predicted rates were 7.3%, 19.4%, 73.4%, respectively. Fault trees for MS2 and ɸ6 contamination suggested similar pathways. Ebola-level PPE can both protect and put HCWs at risk for self-contamination throughout the doffing process, even among experienced HCWs doffing with a trained observer. Human factors methodologies can identify error-prone steps, delineate the relationship between errors and self-contamination, and suggest remediation strategies.

  12. Use of Neuroimaging to Clarify How Human Brains Perform Mental Calculations

    ERIC Educational Resources Information Center

    Ortiz, Enrique

    2010-01-01

    The purpose of this study was to analyze participants' levels of hemoglobin as they performed arithmetic mental calculations using Optical Topography (OT, helmet type brain-scanning system, also known as Functional Near-Infrared Spectroscopy or fNIRS). A central issue in cognitive neuroscience involves the study of how the human brain encodes and…

  13. Visual Prediction Error Spreads Across Object Features in Human Visual Cortex

    PubMed Central

    Summerfield, Christopher; Egner, Tobias

    2016-01-01

    Visual cognition is thought to rely heavily on contextual expectations. Accordingly, previous studies have revealed distinct neural signatures for expected versus unexpected stimuli in visual cortex. However, it is presently unknown how the brain combines multiple concurrent stimulus expectations such as those we have for different features of a familiar object. To understand how an unexpected object feature affects the simultaneous processing of other expected feature(s), we combined human fMRI with a task that independently manipulated expectations for color and motion features of moving-dot stimuli. Behavioral data and neural signals from visual cortex were then interrogated to adjudicate between three possible ways in which prediction error (surprise) in the processing of one feature might affect the concurrent processing of another, expected feature: (1) feature processing may be independent; (2) surprise might “spread” from the unexpected to the expected feature, rendering the entire object unexpected; or (3) pairing a surprising feature with an expected feature might promote the inference that the two features are not in fact part of the same object. To formalize these rival hypotheses, we implemented them in a simple computational model of multifeature expectations. Across a range of analyses, behavior and visual neural signals consistently supported a model that assumes a mixing of prediction error signals across features: surprise in one object feature spreads to its other feature(s), thus rendering the entire object unexpected. These results reveal neurocomputational principles of multifeature expectations and indicate that objects are the unit of selection for predictive vision. SIGNIFICANCE STATEMENT We address a key question in predictive visual cognition: how does the brain combine multiple concurrent expectations for different features of a single object such as its color and motion trajectory? By combining a behavioral protocol that

  14. [Medical errors: inevitable but preventable].

    PubMed

    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. Effect of correlated observation error on parameters, predictions, and uncertainty

    USGS Publications Warehouse

    Tiedeman, Claire; Green, Christopher T.

    2013-01-01

    Correlations among observation errors are typically omitted when calculating observation weights for model calibration by inverse methods. We explore the effects of omitting these correlations on estimates of parameters, predictions, and uncertainties. First, we develop a new analytical expression for the difference in parameter variance estimated with and without error correlations for a simple one-parameter two-observation inverse model. Results indicate that omitting error correlations from both the weight matrix and the variance calculation can either increase or decrease the parameter variance, depending on the values of error correlation (ρ) and the ratio of dimensionless scaled sensitivities (rdss). For small ρ, the difference in variance is always small, but for large ρ, the difference varies widely depending on the sign and magnitude of rdss. Next, we consider a groundwater reactive transport model of denitrification with four parameters and correlated geochemical observation errors that are computed by an error-propagation approach that is new for hydrogeologic studies. We compare parameter estimates, predictions, and uncertainties obtained with and without the error correlations. Omitting the correlations modestly to substantially changes parameter estimates, and causes both increases and decreases of parameter variances, consistent with the analytical expression. Differences in predictions for the models calibrated with and without error correlations can be greater than parameter differences when both are considered relative to their respective confidence intervals. These results indicate that including observation error correlations in weighting for nonlinear regression can have important effects on parameter estimates, predictions, and their respective uncertainties.

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

    PubMed

    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.

  17. Analysis on optical heterodyne frequency error of full-field heterodyne interferometer

    NASA Astrophysics Data System (ADS)

    Li, Yang; Zhang, Wenxi; Wu, Zhou; Lv, Xiaoyu; Kong, Xinxin; Guo, Xiaoli

    2017-06-01

    The full-field heterodyne interferometric measurement technology is beginning better applied by employing low frequency heterodyne acousto-optical modulators instead of complex electro-mechanical scanning devices. The optical element surface could be directly acquired by synchronously detecting the received signal phases of each pixel, because standard matrix detector as CCD and CMOS cameras could be used in heterodyne interferometer. Instead of the traditional four-step phase shifting phase calculating, Fourier spectral analysis method is used for phase extracting which brings lower sensitivity to sources of uncertainty and higher measurement accuracy. In this paper, two types of full-field heterodyne interferometer are described whose advantages and disadvantages are also specified. Heterodyne interferometer has to combine two different frequency beams to produce interference, which brings a variety of optical heterodyne frequency errors. Frequency mixing error and beat frequency error are two different kinds of inescapable heterodyne frequency errors. In this paper, the effects of frequency mixing error to surface measurement are derived. The relationship between the phase extraction accuracy and the errors are calculated. :: The tolerance of the extinction ratio of polarization splitting prism and the signal-to-noise ratio of stray light is given. The error of phase extraction by Fourier analysis that caused by beat frequency shifting is derived and calculated. We also propose an improved phase extraction method based on spectrum correction. An amplitude ratio spectrum correction algorithm with using Hanning window is used to correct the heterodyne signal phase extraction. The simulation results show that this method can effectively suppress the degradation of phase extracting caused by beat frequency error and reduce the measurement uncertainty of full-field heterodyne interferometer.

  18. Preventable Medical Errors Driven Modeling of Medical Best Practice Guidance Systems.

    PubMed

    Ou, Andrew Y-Z; Jiang, Yu; Wu, Po-Liang; Sha, Lui; Berlin, Richard B

    2017-01-01

    In a medical environment such as Intensive Care Unit, there are many possible reasons to cause errors, and one important reason is the effect of human intellectual tasks. When designing an interactive healthcare system such as medical Cyber-Physical-Human Systems (CPHSystems), it is important to consider whether the system design can mitigate the errors caused by these tasks or not. In this paper, we first introduce five categories of generic intellectual tasks of humans, where tasks among each category may lead to potential medical errors. Then, we present an integrated modeling framework to model a medical CPHSystem and use UPPAAL as the foundation to integrate and verify the whole medical CPHSystem design models. With a verified and comprehensive model capturing the human intellectual tasks effects, we can design a more accurate and acceptable system. We use a cardiac arrest resuscitation guidance and navigation system (CAR-GNSystem) for such medical CPHSystem modeling. Experimental results show that the CPHSystem models help determine system design flaws and can mitigate the potential medical errors caused by the human intellectual tasks.

  19. A circadian rhythm in skill-based errors in aviation maintenance.

    PubMed

    Hobbs, Alan; Williamson, Ann; Van Dongen, Hans P A

    2010-07-01

    In workplaces where activity continues around the clock, human error has been observed to exhibit a circadian rhythm, with a characteristic peak in the early hours of the morning. Errors are commonly distinguished by the nature of the underlying cognitive failure, particularly the level of intentionality involved in the erroneous action. The Skill-Rule-Knowledge (SRK) framework of Rasmussen is used widely in the study of industrial errors and accidents. The SRK framework describes three fundamental types of error, according to whether behavior is under the control of practiced sensori-motor skill routines with minimal conscious awareness; is guided by implicit or explicit rules or expertise; or where the planning of actions requires the conscious application of domain knowledge. Up to now, examinations of circadian patterns of industrial errors have not distinguished between different types of error. Consequently, it is not clear whether all types of error exhibit the same circadian rhythm. A survey was distributed to aircraft maintenance personnel in Australia. Personnel were invited to anonymously report a safety incident and were prompted to describe, in detail, the human involvement (if any) that contributed to it. A total of 402 airline maintenance personnel reported an incident, providing 369 descriptions of human error in which the time of the incident was reported and sufficient detail was available to analyze the error. Errors were categorized using a modified version of the SRK framework, in which errors are categorized as skill-based, rule-based, or knowledge-based, or as procedure violations. An independent check confirmed that the SRK framework had been applied with sufficient consistency and reliability. Skill-based errors were the most common form of error, followed by procedure violations, rule-based errors, and knowledge-based errors. The frequency of errors was adjusted for the estimated proportion of workers present at work/each hour of the day

  20. A new open-loop fiber optic gyro error compensation method based on angular velocity error modeling.

    PubMed

    Zhang, Yanshun; Guo, Yajing; Li, Chunyu; Wang, Yixin; Wang, Zhanqing

    2015-02-27

    With the open-loop fiber optic gyro (OFOG) model, output voltage and angular velocity can effectively compensate OFOG errors. However, the model cannot reflect the characteristics of OFOG errors well when it comes to pretty large dynamic angular velocities. This paper puts forward a modeling scheme with OFOG output voltage u and temperature T as the input variables and angular velocity error Δω as the output variable. Firstly, the angular velocity error Δω is extracted from OFOG output signals, and then the output voltage u, temperature T and angular velocity error Δω are used as the learning samples to train a Radial-Basis-Function (RBF) neural network model. Then the nonlinear mapping model over T, u and Δω is established and thus Δω can be calculated automatically to compensate OFOG errors according to T and u. The results of the experiments show that the established model can be used to compensate the nonlinear OFOG errors. The maximum, the minimum and the mean square error of OFOG angular velocity are decreased by 97.0%, 97.1% and 96.5% relative to their initial values, respectively. Compared with the direct modeling of gyro angular velocity, which we researched before, the experimental results of the compensating method proposed in this paper are further reduced by 1.6%, 1.4% and 1.42%, respectively, so the performance of this method is better than that of the direct modeling for gyro angular velocity.

  1. A New Open-Loop Fiber Optic Gyro Error Compensation Method Based on Angular Velocity Error Modeling

    PubMed Central

    Zhang, Yanshun; Guo, Yajing; Li, Chunyu; Wang, Yixin; Wang, Zhanqing

    2015-01-01

    With the open-loop fiber optic gyro (OFOG) model, output voltage and angular velocity can effectively compensate OFOG errors. However, the model cannot reflect the characteristics of OFOG errors well when it comes to pretty large dynamic angular velocities. This paper puts forward a modeling scheme with OFOG output voltage u and temperature T as the input variables and angular velocity error Δω as the output variable. Firstly, the angular velocity error Δω is extracted from OFOG output signals, and then the output voltage u, temperature T and angular velocity error Δω are used as the learning samples to train a Radial-Basis-Function (RBF) neural network model. Then the nonlinear mapping model over T, u and Δω is established and thus Δω can be calculated automatically to compensate OFOG errors according to T and u. The results of the experiments show that the established model can be used to compensate the nonlinear OFOG errors. The maximum, the minimum and the mean square error of OFOG angular velocity are decreased by 97.0%, 97.1% and 96.5% relative to their initial values, respectively. Compared with the direct modeling of gyro angular velocity, which we researched before, the experimental results of the compensating method proposed in this paper are further reduced by 1.6%, 1.4% and 1.2%, respectively, so the performance of this method is better than that of the direct modeling for gyro angular velocity. PMID:25734642

  2. IMRT QA: Selecting gamma criteria based on error detection sensitivity

    DOE Office of Scientific and Technical Information (OSTI.GOV)

    Steers, Jennifer M.; Fraass, Benedick A., E-mail: benedick.fraass@cshs.org

    Purpose: The gamma comparison is widely used to evaluate the agreement between measurements and treatment planning system calculations in patient-specific intensity modulated radiation therapy (IMRT) quality assurance (QA). However, recent publications have raised concerns about the lack of sensitivity when employing commonly used gamma criteria. Understanding the actual sensitivity of a wide range of different gamma criteria may allow the definition of more meaningful gamma criteria and tolerance limits in IMRT QA. We present a method that allows the quantitative determination of gamma criteria sensitivity to induced errors which can be applied to any unique combination of device, delivery technique,more » and software utilized in a specific clinic. Methods: A total of 21 DMLC IMRT QA measurements (ArcCHECK®, Sun Nuclear) were compared to QA plan calculations with induced errors. Three scenarios were studied: MU errors, multi-leaf collimator (MLC) errors, and the sensitivity of the gamma comparison to changes in penumbra width. Gamma comparisons were performed between measurements and error-induced calculations using a wide range of gamma criteria, resulting in a total of over 20 000 gamma comparisons. Gamma passing rates for each error class and case were graphed against error magnitude to create error curves in order to represent the range of missed errors in routine IMRT QA using 36 different gamma criteria. Results: This study demonstrates that systematic errors and case-specific errors can be detected by the error curve analysis. Depending on the location of the error curve peak (e.g., not centered about zero), 3%/3 mm threshold = 10% at 90% pixels passing may miss errors as large as 15% MU errors and ±1 cm random MLC errors for some cases. As the dose threshold parameter was increased for a given %Diff/distance-to-agreement (DTA) setting, error sensitivity was increased by up to a factor of two for select cases. This increased sensitivity with increasing

  3. IMRT QA: Selecting gamma criteria based on error detection sensitivity.

    PubMed

    Steers, Jennifer M; Fraass, Benedick A

    2016-04-01

    The gamma comparison is widely used to evaluate the agreement between measurements and treatment planning system calculations in patient-specific intensity modulated radiation therapy (IMRT) quality assurance (QA). However, recent publications have raised concerns about the lack of sensitivity when employing commonly used gamma criteria. Understanding the actual sensitivity of a wide range of different gamma criteria may allow the definition of more meaningful gamma criteria and tolerance limits in IMRT QA. We present a method that allows the quantitative determination of gamma criteria sensitivity to induced errors which can be applied to any unique combination of device, delivery technique, and software utilized in a specific clinic. A total of 21 DMLC IMRT QA measurements (ArcCHECK®, Sun Nuclear) were compared to QA plan calculations with induced errors. Three scenarios were studied: MU errors, multi-leaf collimator (MLC) errors, and the sensitivity of the gamma comparison to changes in penumbra width. Gamma comparisons were performed between measurements and error-induced calculations using a wide range of gamma criteria, resulting in a total of over 20 000 gamma comparisons. Gamma passing rates for each error class and case were graphed against error magnitude to create error curves in order to represent the range of missed errors in routine IMRT QA using 36 different gamma criteria. This study demonstrates that systematic errors and case-specific errors can be detected by the error curve analysis. Depending on the location of the error curve peak (e.g., not centered about zero), 3%/3 mm threshold = 10% at 90% pixels passing may miss errors as large as 15% MU errors and ±1 cm random MLC errors for some cases. As the dose threshold parameter was increased for a given %Diff/distance-to-agreement (DTA) setting, error sensitivity was increased by up to a factor of two for select cases. This increased sensitivity with increasing dose threshold was consistent

  4. Image defects from surface and alignment errors in grazing incidence telescopes

    NASA Technical Reports Server (NTRS)

    Saha, Timo T.

    1989-01-01

    The rigid body motions and low frequency surface errors of grazing incidence Wolter telescopes are studied. The analysis is based on surface error descriptors proposed by Paul Glenn. In his analysis, the alignment and surface errors are expressed in terms of Legendre-Fourier polynomials. Individual terms in the expression correspond to rigid body motions (decenter and tilt) and low spatial frequency surface errors of mirrors. With the help of the Legendre-Fourier polynomials and the geometry of grazing incidence telescopes, exact and approximated first order equations are derived in this paper for the components of the ray intercepts at the image plane. These equations are then used to calculate the sensitivities of Wolter type I and II telescopes for the rigid body motions and surface deformations. The rms spot diameters calculated from this theory and OSAC ray tracing code agree very well. This theory also provides a tool to predict how rigid body motions and surface errors of the mirrors compensate each other.

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

    PubMed

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

    2016-10-01

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

  6. Coherent errors in quantum error correction

    NASA Astrophysics Data System (ADS)

    Greenbaum, Daniel; Dutton, Zachary

    Analysis of quantum error correcting (QEC) 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. We present analytic results for the logical error as a function of concatenation level and code distance for coherent errors under the repetition code. For data-only coherent errors, we find that the logical error is partially coherent and therefore non-Pauli. However, the coherent part of the error is negligible after two or more concatenation levels or at fewer than ɛ - (d - 1) error correction cycles. Here ɛ << 1 is the rotation angle error per cycle for a single physical qubit and d is the code distance. These results support the validity of modeling coherent errors using a Pauli channel under some minimum requirements for code distance and/or concatenation. We discuss extensions to imperfect syndrome extraction and implications for general QEC.

  7. Effect of Transducer Orientation on Errors in Ultrasound Image-Based Measurements of Human Medial Gastrocnemius Muscle Fascicle Length and Pennation

    PubMed Central

    Gandevia, Simon C.; Herbert, Robert D.

    2016-01-01

    Ultrasound imaging is often used to measure muscle fascicle lengths and pennation angles in human muscles in vivo. Theoretically the most accurate measurements are made when the transducer is oriented so that the image plane aligns with muscle fascicles and, for measurements of pennation, when the image plane also intersects the aponeuroses perpendicularly. However this orientation is difficult to achieve and usually there is some degree of misalignment. Here, we used simulated ultrasound images based on three-dimensional models of the human medial gastrocnemius, derived from magnetic resonance and diffusion tensor images, to describe the relationship between transducer orientation and measurement errors. With the transducer oriented perpendicular to the surface of the leg, the error in measurement of fascicle lengths was about 0.4 mm per degree of misalignment of the ultrasound image with the muscle fascicles. If the transducer is then tipped by 20°, the error increases to 1.1 mm per degree of misalignment. For a given degree of misalignment of muscle fascicles with the image plane, the smallest absolute error in fascicle length measurements occurs when the transducer is held perpendicular to the surface of the leg. Misalignment of the transducer with the fascicles may cause fascicle length measurements to be underestimated or overestimated. Contrary to widely held beliefs, it is shown that pennation angles are always overestimated if the image is not perpendicular to the aponeurosis, even when the image is perfectly aligned with the fascicles. An analytical explanation is provided for this finding. PMID:27294280

  8. Effect of Transducer Orientation on Errors in Ultrasound Image-Based Measurements of Human Medial Gastrocnemius Muscle Fascicle Length and Pennation.

    PubMed

    Bolsterlee, Bart; Gandevia, Simon C; Herbert, Robert D

    2016-01-01

    Ultrasound imaging is often used to measure muscle fascicle lengths and pennation angles in human muscles in vivo. Theoretically the most accurate measurements are made when the transducer is oriented so that the image plane aligns with muscle fascicles and, for measurements of pennation, when the image plane also intersects the aponeuroses perpendicularly. However this orientation is difficult to achieve and usually there is some degree of misalignment. Here, we used simulated ultrasound images based on three-dimensional models of the human medial gastrocnemius, derived from magnetic resonance and diffusion tensor images, to describe the relationship between transducer orientation and measurement errors. With the transducer oriented perpendicular to the surface of the leg, the error in measurement of fascicle lengths was about 0.4 mm per degree of misalignment of the ultrasound image with the muscle fascicles. If the transducer is then tipped by 20°, the error increases to 1.1 mm per degree of misalignment. For a given degree of misalignment of muscle fascicles with the image plane, the smallest absolute error in fascicle length measurements occurs when the transducer is held perpendicular to the surface of the leg. Misalignment of the transducer with the fascicles may cause fascicle length measurements to be underestimated or overestimated. Contrary to widely held beliefs, it is shown that pennation angles are always overestimated if the image is not perpendicular to the aponeurosis, even when the image is perfectly aligned with the fascicles. An analytical explanation is provided for this finding.

  9. Aniseikonia quantification: error rate of rule of thumb estimation.

    PubMed

    Lubkin, V; Shippman, S; Bennett, G; Meininger, D; Kramer, P; Poppinga, P

    1999-01-01

    To find the error rate in quantifying aniseikonia by using "Rule of Thumb" estimation in comparison with proven space eikonometry. Study 1: 24 adult pseudophakic individuals were measured for anisometropia, and astigmatic interocular difference. Rule of Thumb quantification for prescription was calculated and compared with aniseikonia measurement by the classical Essilor Projection Space Eikonometer. Study 2: parallel analysis was performed on 62 consecutive phakic patients from our strabismus clinic group. Frequency of error: For Group 1 (24 cases): 5 ( or 21 %) were equal (i.e., 1% or less difference); 16 (or 67% ) were greater (more than 1% different); and 3 (13%) were less by Rule of Thumb calculation in comparison to aniseikonia determined on the Essilor eikonometer. For Group 2 (62 cases): 45 (or 73%) were equal (1% or less); 10 (or 16%) were greater; and 7 (or 11%) were lower in the Rule of Thumb calculations in comparison to Essilor eikonometry. Magnitude of error: In Group 1, in 10/24 (29%) aniseikonia by Rule of Thumb estimation was 100% or more greater than by space eikonometry, and in 6 of those ten by 200% or more. In Group 2, in 4/62 (6%) aniseikonia by Rule of Thumb estimation was 200% or more greater than by space eikonometry. The frequency and magnitude of apparent clinical errors of Rule of Thumb estimation is disturbingly large. This problem is greatly magnified by the time and effort and cost of prescribing and executing an aniseikonic correction for a patient. The higher the refractive error, the greater the anisometropia, and the worse the errors in Rule of Thumb estimation of aniseikonia. Accurate eikonometric methods and devices should be employed in all cases where such measurements can be made. Rule of thumb estimations should be limited to cases where such subjective testing and measurement cannot be performed, as in infants after unilateral cataract surgery.

  10. Identification of factors associated with diagnostic error in primary care

    PubMed Central

    2014-01-01

    Background Missed, delayed or incorrect diagnoses are considered to be diagnostic errors. The aim of this paper is to describe the methodology of a study to analyse cognitive aspects of the process by which primary care (PC) physicians diagnose dyspnoea. It examines the possible links between the use of heuristics, suboptimal cognitive acts and diagnostic errors, using Reason’s taxonomy of human error (slips, lapses, mistakes and violations). The influence of situational factors (professional experience, perceived overwork and fatigue) is also analysed. Methods Cohort study of new episodes of dyspnoea in patients receiving care from family physicians and residents at PC centres in Granada (Spain). With an initial expected diagnostic error rate of 20%, and a sampling error of 3%, 384 episodes of dyspnoea are calculated to be required. In addition to filling out the electronic medical record of the patients attended, each physician fills out 2 specially designed questionnaires about the diagnostic process performed in each case of dyspnoea. The first questionnaire includes questions on the physician’s initial diagnostic impression, the 3 most likely diagnoses (in order of likelihood), and the diagnosis reached after the initial medical history and physical examination. It also includes items on the physicians’ perceived overwork and fatigue during patient care. The second questionnaire records the confirmed diagnosis once it is reached. The complete diagnostic process is peer-reviewed to identify and classify the diagnostic errors. The possible use of heuristics of representativeness, availability, and anchoring and adjustment in each diagnostic process is also analysed. Each audit is reviewed with the physician responsible for the diagnostic process. Finally, logistic regression models are used to determine if there are differences in the diagnostic error variables based on the heuristics identified. Discussion This work sets out a new approach to studying the

  11. The District Nursing Clinical Error Reduction Programme.

    PubMed

    McGraw, Caroline; Topping, Claire

    2011-01-01

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

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

    NASA Technical Reports Server (NTRS)

    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.

  13. Evaluation of lens distortion errors in video-based motion analysis

    NASA Technical Reports Server (NTRS)

    Poliner, Jeffrey; Wilmington, Robert; Klute, Glenn K.; Micocci, Angelo

    1993-01-01

    In an effort to study lens distortion errors, a grid of points of known dimensions was constructed and videotaped using a standard and a wide-angle lens. Recorded images were played back on a VCR and stored on a personal computer. Using these stored images, two experiments were conducted. Errors were calculated as the difference in distance from the known coordinates of the points to the calculated coordinates. The purposes of this project were as follows: (1) to develop the methodology to evaluate errors introduced by lens distortion; (2) to quantify and compare errors introduced by use of both a 'standard' and a wide-angle lens; (3) to investigate techniques to minimize lens-induced errors; and (4) to determine the most effective use of calibration points when using a wide-angle lens with a significant amount of distortion. It was seen that when using a wide-angle lens, errors from lens distortion could be as high as 10 percent of the size of the entire field of view. Even with a standard lens, there was a small amount of lens distortion. It was also found that the choice of calibration points influenced the lens distortion error. By properly selecting the calibration points and avoidance of the outermost regions of a wide-angle lens, the error from lens distortion can be kept below approximately 0.5 percent with a standard lens and 1.5 percent with a wide-angle lens.

  14. b matrix errors in echo planar diffusion tensor imaging

    PubMed Central

    Boujraf, Saïd; Luypaert, Robert; Osteaux, Michel

    2001-01-01

    Diffusion‐weighted magnetic resonance imaging (DW‐MRI) is a recognized tool for early detection of infarction of the human brain. DW‐MRI uses the signal loss associated with the random thermal motion of water molecules in the presence of magnetic field gradients to derive parameters that reflect the translational mobility of the water molecules in tissues. If diffusion‐weighted images with different values of b matrix are acquired during one individual investigation, it is possible to calculate apparent diffusion coefficient maps that are the elements of the diffusion tensor. The diffusion tensor elements represent the apparent diffusion coefficient of protons of water molecules in each pixel in the corresponding sample. The relation between signal intensity in the diffusion‐weighted images, diffusion tensor, and b matrix is derived from the Bloch equations. Our goal is to establish the magnitude of the error made in the calculation of the elements of the diffusion tensor when the imaging gradients are ignored. PACS number(s): 87.57. –s, 87.61.–c PMID:11602015

  15. Understanding reliance on automation: effects of error type, error distribution, age and experience.

    PubMed

    Sanchez, Julian; Rogers, Wendy A; Fisk, Arthur D; Rovira, Ericka

    2014-03-01

    An obstacle detection task supported by "imperfect" automation was used with the goal of understanding the effects of automation error types and age on automation reliance. Sixty younger and sixty older adults interacted with a multi-task simulation of an agricultural vehicle (i.e. a virtual harvesting combine). The simulator included an obstacle detection task and a fully manual tracking task. A micro-level analysis provided insight into the way reliance patterns change over time. The results indicated that there are distinct patterns of reliance that develop as a function of error type. A prevalence of automation false alarms led participants to under-rely on the automation during alarm states while over relying on it during non-alarms states. Conversely, a prevalence of automation misses led participants to over-rely on automated alarms and under-rely on the automation during non-alarm states. Older adults adjusted their behavior according to the characteristics of the automation similarly to younger adults, although it took them longer to do so. The results of this study suggest the relationship between automation reliability and reliance depends on the prevalence of specific errors and on the state of the system. Understanding the effects of automation detection criterion settings on human-automation interaction can help designers of automated systems make predictions about human behavior and system performance as a function of the characteristics of the automation.

  16. Neurochemical enhancement of conscious error awareness.

    PubMed

    Hester, Robert; Nandam, L Sanjay; O'Connell, Redmond G; Wagner, Joe; Strudwick, Mark; Nathan, Pradeep J; Mattingley, Jason B; Bellgrove, Mark A

    2012-02-22

    How the brain monitors ongoing behavior for performance errors is a central question of cognitive neuroscience. Diminished awareness of performance errors limits the extent to which humans engage in corrective behavior and has been linked to loss of insight in a number of psychiatric syndromes (e.g., attention deficit hyperactivity disorder, drug addiction). These conditions share alterations in monoamine signaling that may influence the neural mechanisms underlying error processing, but our understanding of the neurochemical drivers of these processes is limited. We conducted a randomized, double-blind, placebo-controlled, cross-over design of the influence of methylphenidate, atomoxetine, and citalopram on error awareness in 27 healthy participants. The error awareness task, a go/no-go response inhibition paradigm, was administered to assess the influence of monoaminergic agents on performance errors during fMRI data acquisition. A single dose of methylphenidate, but not atomoxetine or citalopram, significantly improved the ability of healthy volunteers to consciously detect performance errors. Furthermore, this behavioral effect was associated with a strengthening of activation differences in the dorsal anterior cingulate cortex and inferior parietal lobe during the methylphenidate condition for errors made with versus without awareness. Our results have implications for the understanding of the neurochemical underpinnings of performance monitoring and for the pharmacological treatment of a range of disparate clinical conditions that are marked by poor awareness of errors.

  17. Risk assessment of component failure modes and human errors using a new FMECA approach: application in the safety analysis of HDR brachytherapy.

    PubMed

    Giardina, M; Castiglia, F; Tomarchio, E

    2014-12-01

    Failure mode, effects and criticality analysis (FMECA) is a safety technique extensively used in many different industrial fields to identify and prevent potential failures. In the application of traditional FMECA, the risk priority number (RPN) is determined to rank the failure modes; however, the method has been criticised for having several weaknesses. Moreover, it is unable to adequately deal with human errors or negligence. In this paper, a new versatile fuzzy rule-based assessment model is proposed to evaluate the RPN index to rank both component failure and human error. The proposed methodology is applied to potential radiological over-exposure of patients during high-dose-rate brachytherapy treatments. The critical analysis of the results can provide recommendations and suggestions regarding safety provisions for the equipment and procedures required to reduce the occurrence of accidental events.

  18. MISSE 2 PEACE Polymers Experiment Atomic Oxygen Erosion Yield Error Analysis

    NASA Technical Reports Server (NTRS)

    McCarthy, Catherine E.; Banks, Bruce A.; deGroh, Kim, K.

    2010-01-01

    Atomic oxygen erosion of polymers in low Earth orbit (LEO) poses a serious threat to spacecraft performance and durability. To address this, 40 different polymer samples and a sample of pyrolytic graphite, collectively called the PEACE (Polymer Erosion and Contamination Experiment) Polymers, were exposed to the LEO space environment on the exterior of the International Space Station (ISS) for nearly 4 years as part of the Materials International Space Station Experiment 1 & 2 (MISSE 1 & 2). The purpose of the PEACE Polymers experiment was to obtain accurate mass loss measurements in space to combine with ground measurements in order to accurately calculate the atomic oxygen erosion yields of a wide variety of polymeric materials exposed to the LEO space environment for a long period of time. Error calculations were performed in order to determine the accuracy of the mass measurements and therefore of the erosion yield values. The standard deviation, or error, of each factor was incorporated into the fractional uncertainty of the erosion yield for each of three different situations, depending on the post-flight weighing procedure. The resulting error calculations showed the erosion yield values to be very accurate, with an average error of 3.30 percent.

  19. Mistake proofing: changing designs to reduce error

    PubMed Central

    Grout, J R

    2006-01-01

    Mistake proofing uses changes in the physical design of processes to reduce human error. It can be used to change designs in ways that prevent errors from occurring, to detect errors after they occur but before harm occurs, to allow processes to fail safely, or to alter the work environment to reduce the chance of errors. Effective mistake proofing design changes should initially be effective in reducing harm, be inexpensive, and easily implemented. Over time these design changes should make life easier and speed up the process. Ideally, the design changes should increase patients' and visitors' understanding of the process. These designs should themselves be mistake proofed and follow the good design practices of other disciplines. PMID:17142609

  20. Grinding Method and Error Analysis of Eccentric Shaft Parts

    NASA Astrophysics Data System (ADS)

    Wang, Zhiming; Han, Qiushi; Li, Qiguang; Peng, Baoying; Li, Weihua

    2017-12-01

    RV reducer and various mechanical transmission parts are widely used in eccentric shaft parts, The demand of precision grinding technology for eccentric shaft parts now, In this paper, the model of X-C linkage relation of eccentric shaft grinding is studied; By inversion method, the contour curve of the wheel envelope is deduced, and the distance from the center of eccentric circle is constant. The simulation software of eccentric shaft grinding is developed, the correctness of the model is proved, the influence of the X-axis feed error, the C-axis feed error and the wheel radius error on the grinding process is analyzed, and the corresponding error calculation model is proposed. The simulation analysis is carried out to provide the basis for the contour error compensation.

  1. Dipole estimation errors due to not incorporating anisotropic conductivities in realistic head models for EEG source analysis

    NASA Astrophysics Data System (ADS)

    Hallez, Hans; Staelens, Steven; Lemahieu, Ignace

    2009-10-01

    EEG source analysis is a valuable tool for brain functionality research and for diagnosing neurological disorders, such as epilepsy. It requires a geometrical representation of the human head or a head model, which is often modeled as an isotropic conductor. However, it is known that some brain tissues, such as the skull or white matter, have an anisotropic conductivity. Many studies reported that the anisotropic conductivities have an influence on the calculated electrode potentials. However, few studies have assessed the influence of anisotropic conductivities on the dipole estimations. In this study, we want to determine the dipole estimation errors due to not taking into account the anisotropic conductivities of the skull and/or brain tissues. Therefore, head models are constructed with the same geometry, but with an anisotropically conducting skull and/or brain tissue compartment. These head models are used in simulation studies where the dipole location and orientation error is calculated due to neglecting anisotropic conductivities of the skull and brain tissue. Results show that not taking into account the anisotropic conductivities of the skull yields a dipole location error between 2 and 25 mm, with an average of 10 mm. When the anisotropic conductivities of the brain tissues are neglected, the dipole location error ranges between 0 and 5 mm. In this case, the average dipole location error was 2.3 mm. In all simulations, the dipole orientation error was smaller than 10°. We can conclude that the anisotropic conductivities of the skull have to be incorporated to improve the accuracy of EEG source analysis. The results of the simulation, as presented here, also suggest that incorporation of the anisotropic conductivities of brain tissues is not necessary. However, more studies are needed to confirm these suggestions.

  2. Radiation doses and neutron irridation effects on human cells based on calculations

    NASA Astrophysics Data System (ADS)

    Radojevic, B. B.; Cukavac, M.; Jovanovic, D.

    In general, main aim of our paper is to follow influence of neutron's radiation on materials, but one of possible applications of fast neutrons in therapeutical reasons i.e. their influence on carcinom cells of difficuilt geometries in human bodies too. Interactions between neutrons and human cells of tissue are analysed here. We know that the light nuclei of hydrogen, nitrogen, carbon, and oxygen are main constituents of human cells, and that different nuclear models are usually used to present interactions of nuclear particles with mentioned elements. Some of most widely used pre-equilibrium nuclear models are: intranuclear cascade model (ICN), Harp-Miller-Berne (HMB), geometry-dependent hybrid (GDH) and exciton models (EM). In this paper is studied and calculated the primary energetic spectra of the secundary particles (neutrons, protons, and gamas) emitted from this interactions, and followed by corresponding integral cross sections, based on exciton model (EM). The total emission cross-section is the sum of emissions in all stages of energies. Obtained spectra for interactions type of (n, n'), (n, p), and (n, ?), for various incident neutron energies in the interval from 3 MeV up to 30 MeV are analysed too. Some results of calculations are presented here.

  3. An Introduction to Error Analysis for Quantitative Chemistry

    ERIC Educational Resources Information Center

    Neman, R. L.

    1972-01-01

    Describes two formulas for calculating errors due to instrument limitations which are usually found in gravimetric volumetric analysis and indicates their possible applications to other fields of science. (CC)

  4. Error Budgeting

    DOE Office of Scientific and Technical Information (OSTI.GOV)

    Vinyard, Natalia Sergeevna; Perry, Theodore Sonne; Usov, Igor Olegovich

    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 =more » $$\\partial k$$\\ $$\\partial T$$ 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 B 0 is unattenuated backlighter signal. Then ΔT/T=Δln(T)=ΔB/B+ΔB 0/B 0, and consequently Δk/k = 1/T (ΔB/B + ΔB$$_0$$/B$$_0$$ + Δ(pL)/(pL). Transmission is measured in the range of 0.2« less

  5. Air and smear sample calculational tool for Fluor Hanford Radiological control

    DOE Office of Scientific and Technical Information (OSTI.GOV)

    BAUMANN, B.L.

    2003-07-11

    A spreadsheet calculation tool was developed to automate the calculations performed for determining the concentration of airborne radioactivity and smear counting as outlined in HNF-13536, Section 5.2.7, ''Analyzing Air and Smear Samples''. This document reports on the design and testing of the calculation tool. Radiological Control Technicians (RCTs) will save time and reduce hand written and calculation errors by using an electronic form for documenting and calculating work place air samples. Current expectations are RCTs will perform an air sample and collect the filter or perform a smear for surface contamination. RCTs will then survey the filter for gross alphamore » and beta/gamma radioactivity and with the gross counts utilize either hand calculation method or a calculator to determine activity on the filter. The electronic form will allow the RCT with a few key strokes to document the individual's name, payroll, gross counts, instrument identifiers; produce an error free record. This productivity gain is realized by the enhanced ability to perform mathematical calculations electronically (reducing errors) and at the same time, documenting the air sample.« less

  6. Individual Differences in Mathematical Competence Modulate Brain Responses to Arithmetic Errors: An fMRI Study

    ERIC Educational Resources Information Center

    Ansari, Daniel; Grabner, Roland H.; Koschutnig, Karl; Reishofer, Gernot; Ebner, Franz

    2011-01-01

    Data from both neuropsychological and neuroimaging studies have implicated the left inferior parietal cortex in calculation. Comparatively less attention has been paid to the neural responses associated with the commission of calculation errors and how the processing of arithmetic errors is modulated by individual differences in mathematical…

  7. An evaluation of the underlying mechanisms of bloodstain pattern analysis error.

    PubMed

    Behrooz, Nima; Hulse-Smith, Lee; Chandra, Sanjeev

    2011-09-01

    An experiment was designed to explore the underlying mechanisms of blood disintegration and its subsequent effect on area of origin (AO) calculations. Blood spatter patterns were created through the controlled application of pressurized air (20-80 kPa) for 0.1 msec onto suspended blood droplets (2.7-3.2 mm diameter). The resulting disintegration process was captured using high-speed photography. Straight-line triangulation resulted in a 50% height overestimation, whereas using the lowest calculated height for each spatter pattern reduced this error to 8%. Incorporation of projectile motion resulted in a 28% height underestimation. The AO xy-coordinate was found to be very accurate with a maximum offset of only 4 mm, while AO size calculations were found to be two- to fivefold greater than expected. Subsequently, reverse triangulation analysis revealed the rotational offset for 26% of stains could not be attributed to measurement error, suggesting that some portion of error is inherent in the disintegration process. © 2011 American Academy of Forensic Sciences.

  8. Error reduction in EMG signal decomposition

    PubMed Central

    Kline, Joshua C.

    2014-01-01

    Decomposition of the electromyographic (EMG) signal into constituent action potentials and the identification of individual firing instances of each motor unit in the presence of ambient noise are inherently probabilistic processes, whether performed manually or with automated algorithms. Consequently, they are subject to errors. We set out to classify and reduce these errors by analyzing 1,061 motor-unit action-potential trains (MUAPTs), obtained by decomposing surface EMG (sEMG) signals recorded during human voluntary contractions. Decomposition errors were classified into two general categories: location errors representing variability in the temporal localization of each motor-unit firing instance and identification errors consisting of falsely detected or missed firing instances. To mitigate these errors, we developed an error-reduction algorithm that combines multiple decomposition estimates to determine a more probable estimate of motor-unit firing instances with fewer errors. The performance of the algorithm is governed by a trade-off between the yield of MUAPTs obtained above a given accuracy level and the time required to perform the decomposition. When applied to a set of sEMG signals synthesized from real MUAPTs, the identification error was reduced by an average of 1.78%, improving the accuracy to 97.0%, and the location error was reduced by an average of 1.66 ms. The error-reduction algorithm in this study is not limited to any specific decomposition strategy. Rather, we propose it be used for other decomposition methods, especially when analyzing precise motor-unit firing instances, as occurs when measuring synchronization. PMID:25210159

  9. Comprehensive analysis of a medication dosing error related to CPOE.

    PubMed

    Horsky, Jan; Kuperman, Gilad J; Patel, Vimla L

    2005-01-01

    This case study of a serious medication error demonstrates the necessity of a comprehensive methodology for the analysis of failures in interaction between humans and information systems. The authors used a novel approach to analyze a dosing error related to computer-based ordering of potassium chloride (KCl). The method included a chronological reconstruction of events and their interdependencies from provider order entry usage logs, semistructured interviews with involved clinicians, and interface usability inspection of the ordering system. Information collected from all sources was compared and evaluated to understand how the error evolved and propagated through the system. In this case, the error was the product of faults in interaction among human and system agents that methods limited in scope to their distinct analytical domains would not identify. The authors characterized errors in several converging aspects of the drug ordering process: confusing on-screen laboratory results review, system usability difficulties, user training problems, and suboptimal clinical system safeguards that all contributed to a serious dosing error. The results of the authors' analysis were used to formulate specific recommendations for interface layout and functionality modifications, suggest new user alerts, propose changes to user training, and address error-prone steps of the KCl ordering process to reduce the risk of future medication dosing errors.

  10. Dependence of the compensation error on the error of a sensor and corrector in an adaptive optics phase-conjugating system

    DOE Office of Scientific and Technical Information (OSTI.GOV)

    Kiyko, V V; Kislov, V I; Ofitserov, E N

    2015-08-31

    In the framework of a statistical model of an adaptive optics system (AOS) of phase conjugation, three algorithms based on an integrated mathematical approach are considered, each of them intended for minimisation of one of the following characteristics: the sensor error (in the case of an ideal corrector), the corrector error (in the case of ideal measurements) and the compensation error (with regard to discreteness and measurement noises and to incompleteness of a system of response functions of the corrector actuators). Functional and statistical relationships between the algorithms are studied and a relation is derived to ensure calculation of themore » mean-square compensation error as a function of the errors of the sensor and corrector with an accuracy better than 10%. Because in adjusting the AOS parameters, it is reasonable to proceed from the equality of the sensor and corrector errors, in the case the Hartmann sensor is used as a wavefront sensor, the required number of actuators in the absence of the noise component in the sensor error turns out 1.5 – 2.5 times less than the number of counts, and that difference grows with increasing measurement noise. (adaptive optics)« less

  11. Power Measurement Errors on a Utility Aircraft

    NASA Technical Reports Server (NTRS)

    Bousman, William G.

    2002-01-01

    Extensive flight test data obtained from two recent performance tests of a UH 60A aircraft are reviewed. A power difference is calculated from the power balance equation and is used to examine power measurement errors. It is shown that the baseline measurement errors are highly non-Gaussian in their frequency distribution and are therefore influenced by additional, unquantified variables. Linear regression is used to examine the influence of other variables and it is shown that a substantial portion of the variance depends upon measurements of atmospheric parameters. Correcting for temperature dependence, although reducing the variance in the measurement errors, still leaves unquantified effects. Examination of the power difference over individual test runs indicates significant errors from drift, although it is unclear how these may be corrected. In an idealized case, where the drift is correctable, it is shown that the power measurement errors are significantly reduced and the error distribution is Gaussian. A new flight test program is recommended that will quantify the thermal environment for all torque measurements on the UH 60. Subsequently, the torque measurement systems will be recalibrated based on the measured thermal environment and a new power measurement assessment performed.

  12. Distinct prediction errors in mesostriatal circuits of the human brain mediate learning about the values of both states and actions: evidence from high-resolution fMRI.

    PubMed

    Colas, Jaron T; Pauli, Wolfgang M; Larsen, Tobias; Tyszka, J Michael; O'Doherty, John P

    2017-10-01

    Prediction-error signals consistent with formal models of "reinforcement learning" (RL) have repeatedly been found within dopaminergic nuclei of the midbrain and dopaminoceptive areas of the striatum. However, the precise form of the RL algorithms implemented in the human brain is not yet well determined. Here, we created a novel paradigm optimized to dissociate the subtypes of reward-prediction errors that function as the key computational signatures of two distinct classes of RL models-namely, "actor/critic" models and action-value-learning models (e.g., the Q-learning model). The state-value-prediction error (SVPE), which is independent of actions, is a hallmark of the actor/critic architecture, whereas the action-value-prediction error (AVPE) is the distinguishing feature of action-value-learning algorithms. To test for the presence of these prediction-error signals in the brain, we scanned human participants with a high-resolution functional magnetic-resonance imaging (fMRI) protocol optimized to enable measurement of neural activity in the dopaminergic midbrain as well as the striatal areas to which it projects. In keeping with the actor/critic model, the SVPE signal was detected in the substantia nigra. The SVPE was also clearly present in both the ventral striatum and the dorsal striatum. However, alongside these purely state-value-based computations we also found evidence for AVPE signals throughout the striatum. These high-resolution fMRI findings suggest that model-free aspects of reward learning in humans can be explained algorithmically with RL in terms of an actor/critic mechanism operating in parallel with a system for more direct action-value learning.

  13. Minimizing treatment planning errors in proton therapy using failure mode and effects analysis.

    PubMed

    Zheng, Yuanshui; Johnson, Randall; Larson, Gary

    2016-06-01

    Failure mode and effects analysis (FMEA) is a widely used tool to evaluate safety or reliability in conventional photon radiation therapy. However, reports about FMEA application in proton therapy are scarce. The purpose of this study is to apply FMEA in safety improvement of proton treatment planning at their center. The authors performed an FMEA analysis of their proton therapy treatment planning process using uniform scanning proton beams. The authors identified possible failure modes in various planning processes, including image fusion, contouring, beam arrangement, dose calculation, plan export, documents, billing, and so on. For each error, the authors estimated the frequency of occurrence, the likelihood of being undetected, and the severity of the error if it went undetected and calculated the risk priority number (RPN). The FMEA results were used to design their quality management program. In addition, the authors created a database to track the identified dosimetric errors. Periodically, the authors reevaluated the risk of errors by reviewing the internal error database and improved their quality assurance program as needed. In total, the authors identified over 36 possible treatment planning related failure modes and estimated the associated occurrence, detectability, and severity to calculate the overall risk priority number. Based on the FMEA, the authors implemented various safety improvement procedures into their practice, such as education, peer review, and automatic check tools. The ongoing error tracking database provided realistic data on the frequency of occurrence with which to reevaluate the RPNs for various failure modes. The FMEA technique provides a systematic method for identifying and evaluating potential errors in proton treatment planning before they result in an error in patient dose delivery. The application of FMEA framework and the implementation of an ongoing error tracking system at their clinic have proven to be useful in error

  14. Physician's error: medical or legal concept?

    PubMed

    Mujovic-Zornic, Hajrija M

    2010-06-01

    This article deals with the common term of different physician's errors that often happen in daily practice of health care. Author begins with the term of medical malpractice, defined broadly as practice of unjustified acts or failures to act upon the part of a physician or other health care professionals, which results in harm to the patient. It is a common term that includes many types of medical errors, especially physician's errors. The author also discusses the concept of physician's error in particular, which is understood no more in traditional way only as classic error in acting something manually wrong without necessary skills (medical concept), but as an error which violates patient's basic rights and which has its final legal consequence (legal concept). In every case the essential element of liability is to establish this error as a breach of the physician's duty. The first point to note is that the standard of procedure and the standard of due care against which the physician will be judged is not going to be that of the ordinary reasonable man who enjoys no medical expertise. The court's decision should give finale answer and legal qualification in each concrete case. The author's conclusion is that higher protection of human rights in the area of health equaly demands broader concept of physician's error with the accent to its legal subject matter.

  15. Managing Errors to Reduce Accidents in High Consequence Networked Information Systems

    DOE Office of Scientific and Technical Information (OSTI.GOV)

    Ganter, J.H.

    1999-02-01

    Computers have always helped to amplify and propagate errors made by people. The emergence of Networked Information Systems (NISs), which allow people and systems to quickly interact worldwide, has made understanding and minimizing human error more critical. This paper applies concepts from system safety to analyze how hazards (from hackers to power disruptions) penetrate NIS defenses (e.g., firewalls and operating systems) to cause accidents. Such events usually result from both active, easily identified failures and more subtle latent conditions that have resided in the system for long periods. Both active failures and latent conditions result from human errors. We classifymore » these into several types (slips, lapses, mistakes, etc.) and provide NIS examples of how they occur. Next we examine error minimization throughout the NIS lifecycle, from design through operation to reengineering. At each stage, steps can be taken to minimize the occurrence and effects of human errors. These include defensive design philosophies, architectural patterns to guide developers, and collaborative design that incorporates operational experiences and surprises into design efforts. We conclude by looking at three aspects of NISs that will cause continuing challenges in error and accident management: immaturity of the industry, limited risk perception, and resource tradeoffs.« less

  16. Probabilistic model of nonlinear penalties due to collision-induced timing jitter for calculation of the bit error ratio in wavelength-division-multiplexed return-to-zero systems

    NASA Astrophysics Data System (ADS)

    Sinkin, Oleg V.; Grigoryan, Vladimir S.; Menyuk, Curtis R.

    2006-12-01

    We introduce a fully deterministic, computationally efficient method for characterizing the effect of nonlinearity in optical fiber transmission systems that utilize wavelength-division multiplexing and return-to-zero modulation. The method accurately accounts for bit-pattern-dependent nonlinear distortion due to collision-induced timing jitter and for amplifier noise. We apply this method to calculate the error probability as a function of channel spacing in a prototypical multichannel return-to-zero undersea system.

  17. Monte Carlo dose calculation in dental amalgam phantom

    PubMed Central

    Aziz, Mohd. Zahri Abdul; Yusoff, A. L.; Osman, N. D.; Abdullah, R.; Rabaie, N. A.; Salikin, M. S.

    2015-01-01

    It has become a great challenge in the modern radiation treatment to ensure the accuracy of treatment delivery in electron beam therapy. Tissue inhomogeneity has become one of the factors for accurate dose calculation, and this requires complex algorithm calculation like Monte Carlo (MC). On the other hand, computed tomography (CT) images used in treatment planning system need to be trustful as they are the input in radiotherapy treatment. However, with the presence of metal amalgam in treatment volume, the CT images input showed prominent streak artefact, thus, contributed sources of error. Hence, metal amalgam phantom often creates streak artifacts, which cause an error in the dose calculation. Thus, a streak artifact reduction technique was applied to correct the images, and as a result, better images were observed in terms of structure delineation and density assigning. Furthermore, the amalgam density data were corrected to provide amalgam voxel with accurate density value. As for the errors of dose uncertainties due to metal amalgam, they were reduced from 46% to as low as 2% at d80 (depth of the 80% dose beyond Zmax) using the presented strategies. Considering the number of vital and radiosensitive organs in the head and the neck regions, this correction strategy is suggested in reducing calculation uncertainties through MC calculation. PMID:26500401

  18. Modeling coherent errors in quantum error correction

    NASA Astrophysics Data System (ADS)

    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.

  19. Stitching-error reduction in gratings by shot-shifted electron-beam lithography

    NASA Technical Reports Server (NTRS)

    Dougherty, D. J.; Muller, R. E.; Maker, P. D.; Forouhar, S.

    2001-01-01

    Calculations of the grating spatial-frequency spectrum and the filtering properties of multiple-pass electron-beam writing demonstrate a tradeoff between stitching-error suppression and minimum pitch separation. High-resolution measurements of optical-diffraction patterns show a 25-dB reduction in stitching-error side modes.

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

    PubMed

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

    2016-11-01

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

  1. Understanding reliance on automation: effects of error type, error distribution, age and experience

    PubMed Central

    Sanchez, Julian; Rogers, Wendy A.; Fisk, Arthur D.; Rovira, Ericka

    2015-01-01

    An obstacle detection task supported by “imperfect” automation was used with the goal of understanding the effects of automation error types and age on automation reliance. Sixty younger and sixty older adults interacted with a multi-task simulation of an agricultural vehicle (i.e. a virtual harvesting combine). The simulator included an obstacle detection task and a fully manual tracking task. A micro-level analysis provided insight into the way reliance patterns change over time. The results indicated that there are distinct patterns of reliance that develop as a function of error type. A prevalence of automation false alarms led participants to under-rely on the automation during alarm states while over relying on it during non-alarms states. Conversely, a prevalence of automation misses led participants to over-rely on automated alarms and under-rely on the automation during non-alarm states. Older adults adjusted their behavior according to the characteristics of the automation similarly to younger adults, although it took them longer to do so. The results of this study suggest the relationship between automation reliability and reliance depends on the prevalence of specific errors and on the state of the system. Understanding the effects of automation detection criterion settings on human-automation interaction can help designers of automated systems make predictions about human behavior and system performance as a function of the characteristics of the automation. PMID:25642142

  2. Frontal Theta Links Prediction Errors to Behavioral Adaptation in Reinforcement Learning

    PubMed Central

    Cavanagh, James F.; Frank, Michael J.; Klein, Theresa J.; Allen, John J.B.

    2009-01-01

    Investigations into action monitoring have consistently detailed a fronto-central voltage deflection in the Event-Related Potential (ERP) following the presentation of negatively valenced feedback, sometimes termed the Feedback Related Negativity (FRN). The FRN has been proposed to reflect a neural response to prediction errors during reinforcement learning, yet the single trial relationship between neural activity and the quanta of expectation violation remains untested. Although ERP methods are not well suited to single trial analyses, the FRN has been associated with theta band oscillatory perturbations in the medial prefrontal cortex. Medio-frontal theta oscillations have been previously associated with expectation violation and behavioral adaptation and are well suited to single trial analysis. Here, we recorded EEG activity during a probabilistic reinforcement learning task and fit the performance data to an abstract computational model (Q-learning) for calculation of single-trial reward prediction errors. Single-trial theta oscillatory activities following feedback were investigated within the context of expectation (prediction error) and adaptation (subsequent reaction time change). Results indicate that interactive medial and lateral frontal theta activities reflect the degree of negative and positive reward prediction error in the service of behavioral adaptation. These different brain areas use prediction error calculations for different behavioral adaptations: with medial frontal theta reflecting the utilization of prediction errors for reaction time slowing (specifically following errors), but lateral frontal theta reflecting prediction errors leading to working memory-related reaction time speeding for the correct choice. PMID:19969093

  3. Errors from approximation of ODE systems with reduced order models

    DOE Office of Scientific and Technical Information (OSTI.GOV)

    Vassilevska, Tanya

    2016-12-30

    This is a code to calculate the error from approximation of systems of ordinary differential equations (ODEs) by using Proper Orthogonal Decomposition (POD) Reduced Order Models (ROM) methods and to compare and analyze the errors for two POD ROM variants. The first variant is the standard POD ROM, the second variant is a modification of the method using the values of the time derivatives (a.k.a. time-derivative snapshots). The code compares the errors from the two variants under different conditions.

  4. Validation of Calculations in a Digital Thermometer Firmware

    NASA Astrophysics Data System (ADS)

    Batagelj, V.; Miklavec, A.; Bojkovski, J.

    2014-04-01

    State-of-the-art digital thermometers are arguably remarkable measurement instruments, measuring outputs from resistance thermometers and/or thermocouples. Not only that they can readily achieve measuring accuracies in the parts-per-million range, but they also incorporate sophisticated algorithms for the transformation calculation of the measured resistance or voltage to temperature. These algorithms often include high-order polynomials, exponentials and logarithms, and must be performed using both standard coefficients and particular calibration coefficients. The numerical accuracy of these calculations and the associated uncertainty component must be much better than the accuracy of the raw measurement in order to be negligible in the total measurement uncertainty. In order for the end-user to gain confidence in these calculations as well as to conform to formal requirements of ISO/IEC 17025 and other standards, a way of validation of these numerical procedures performed in the firmware of the instrument is required. A software architecture which allows a simple validation of internal measuring instrument calculations is suggested. The digital thermometer should be able to expose all its internal calculation functions to the communication interface, so the end-user can compare the results of the internal measuring instrument calculation with reference results. The method can be regarded as a variation of the black-box software validation. Validation results on a thermometer prototype with implemented validation ability show that the calculation error of basic arithmetic operations is within the expected rounding error. For conversion functions, the calculation error is at least ten times smaller than the thermometer effective resolution for the particular probe type.

  5. Inborn errors of metabolism and the human interactome: a systems medicine approach.

    PubMed

    Woidy, Mathias; Muntau, Ania C; Gersting, Søren W

    2018-02-05

    The group of inborn errors of metabolism (IEM) displays a marked heterogeneity and IEM can affect virtually all functions and organs of the human organism; however, IEM share that their associated proteins function in metabolism. Most proteins carry out cellular functions by interacting with other proteins, and thus are organized in biological networks. Therefore, diseases are rarely the consequence of single gene mutations but of the perturbations caused in the related cellular network. Systematic approaches that integrate multi-omics and database information into biological networks have successfully expanded our knowledge of complex disorders but network-based strategies have been rarely applied to study IEM. We analyzed IEM on a proteome scale and found that IEM-associated proteins are organized as a network of linked modules within the human interactome of protein interactions, the IEM interactome. Certain IEM disease groups formed self-contained disease modules, which were highly interlinked. On the other hand, we observed disease modules consisting of proteins from many different disease groups in the IEM interactome. Moreover, we explored the overlap between IEM and non-IEM disease genes and applied network medicine approaches to investigate shared biological pathways, clinical signs and symptoms, and links to drug targets. The provided resources may help to elucidate the molecular mechanisms underlying new IEM, to uncover the significance of disease-associated mutations, to identify new biomarkers, and to develop novel therapeutic strategies.

  6. Using meta-differential evolution to enhance a calculation of a continuous blood glucose level.

    PubMed

    Koutny, Tomas

    2016-09-01

    We developed a new model of glucose dynamics. The model calculates blood glucose level as a function of transcapillary glucose transport. In previous studies, we validated the model with animal experiments. We used analytical method to determine model parameters. In this study, we validate the model with subjects with type 1 diabetes. In addition, we combine the analytic method with meta-differential evolution. To validate the model with human patients, we obtained a data set of type 1 diabetes study that was coordinated by Jaeb Center for Health Research. We calculated a continuous blood glucose level from continuously measured interstitial fluid glucose level. We used 6 different scenarios to ensure robust validation of the calculation. Over 96% of calculated blood glucose levels fit A+B zones of the Clarke Error Grid. No data set required any correction of model parameters during the time course of measuring. We successfully verified the possibility of calculating a continuous blood glucose level of subjects with type 1 diabetes. This study signals a successful transition of our research from an animal experiment to a human patient. Researchers can test our model with their data on-line at https://diabetes.zcu.cz. Copyright © 2016 The Author. Published by Elsevier Ireland Ltd.. All rights reserved.

  7. Improved accuracy of intraocular lens power calculation with the Zeiss IOLMaster.

    PubMed

    Olsen, Thomas

    2007-02-01

    This study aimed to demonstrate how the level of accuracy in intraocular lens (IOL) power calculation can be improved with optical biometry using partial optical coherence interferometry (PCI) (Zeiss IOLMaster) and current anterior chamber depth (ACD) prediction algorithms. Intraocular lens power in 461 consecutive cataract operations was calculated using both PCI and ultrasound and the accuracy of the results of each technique were compared. To illustrate the importance of ACD prediction per se, predictions were calculated using both a recently published 5-variable method and the Haigis 2-variable method and the results compared. All calculations were optimized in retrospect to account for systematic errors, including IOL constants and other off-set errors. The average absolute IOL prediction error (observed minus expected refraction) was 0.65 dioptres with ultrasound and 0.43 D with PCI using the 5-variable ACD prediction method (p < 0.00001). The number of predictions within +/- 0.5 D, +/- 1.0 D and +/- 2.0 D of the expected outcome was 62.5%, 92.4% and 99.9% with PCI, compared with 45.5%, 77.3% and 98.4% with ultrasound, respectively (p < 0.00001). The 2-variable ACD method resulted in an average error in PCI predictions of 0.46 D, which was significantly higher than the error in the 5-variable method (p < 0.001). The accuracy of IOL power calculation can be significantly improved using calibrated axial length readings obtained with PCI and modern IOL power calculation formulas incorporating the latest generation ACD prediction algorithms.

  8. 45 CFR 98.102 - Content of Error Rate Reports.

    Code of Federal Regulations, 2013 CFR

    2013-10-01

    ....102 Public Welfare DEPARTMENT OF HEALTH AND HUMAN SERVICES GENERAL ADMINISTRATION CHILD CARE AND DEVELOPMENT FUND Error Rate Reporting § 98.102 Content of Error Rate Reports. (a) Baseline Submission Report... payments by the total dollar amount of child care payments that the State, the District of Columbia or...

  9. 45 CFR 98.102 - Content of Error Rate Reports.

    Code of Federal Regulations, 2014 CFR

    2014-10-01

    ....102 Public Welfare Department of Health and Human Services GENERAL ADMINISTRATION CHILD CARE AND DEVELOPMENT FUND Error Rate Reporting § 98.102 Content of Error Rate Reports. (a) Baseline Submission Report... payments by the total dollar amount of child care payments that the State, the District of Columbia or...

  10. 45 CFR 98.102 - Content of Error Rate Reports.

    Code of Federal Regulations, 2012 CFR

    2012-10-01

    ....102 Public Welfare DEPARTMENT OF HEALTH AND HUMAN SERVICES GENERAL ADMINISTRATION CHILD CARE AND DEVELOPMENT FUND Error Rate Reporting § 98.102 Content of Error Rate Reports. (a) Baseline Submission Report... payments by the total dollar amount of child care payments that the State, the District of Columbia or...

  11. 45 CFR 98.102 - Content of Error Rate Reports.

    Code of Federal Regulations, 2011 CFR

    2011-10-01

    ....102 Public Welfare DEPARTMENT OF HEALTH AND HUMAN SERVICES GENERAL ADMINISTRATION CHILD CARE AND DEVELOPMENT FUND Error Rate Reporting § 98.102 Content of Error Rate Reports. (a) Baseline Submission Report... payments by the total dollar amount of child care payments that the State, the District of Columbia or...

  12. Introduction to Forward-Error-Correcting Coding

    NASA Technical Reports Server (NTRS)

    Freeman, Jon C.

    1996-01-01

    This reference publication introduces forward error correcting (FEC) and stresses definitions and basic calculations for use by engineers. The seven chapters include 41 example problems, worked in detail to illustrate points. A glossary of terms is included, as well as an appendix on the Q function. Block and convolutional codes are covered.

  13. Overview of medical errors and adverse events

    PubMed Central

    2012-01-01

    Safety is a global concept that encompasses efficiency, security of care, reactivity of caregivers, and satisfaction of patients and relatives. Patient safety has emerged as a major target for healthcare improvement. Quality assurance is a complex task, and patients in the intensive care unit (ICU) are more likely than other hospitalized patients to experience medical errors, due to the complexity of their conditions, need for urgent interventions, and considerable workload fluctuation. Medication errors are the most common medical errors and can induce adverse events. Two approaches are available for evaluating and improving quality-of-care: the room-for-improvement model, in which problems are identified, plans are made to resolve them, and the results of the plans are measured; and the monitoring model, in which quality indicators are defined as relevant to potential problems and then monitored periodically. Indicators that reflect structures, processes, or outcomes have been developed by medical societies. Surveillance of these indicators is organized at the hospital or national level. Using a combination of methods improves the results. Errors are caused by combinations of human factors and system factors, and information must be obtained on how people make errors in the ICU environment. Preventive strategies are more likely to be effective if they rely on a system-based approach, in which organizational flaws are remedied, rather than a human-based approach of encouraging people not to make errors. The development of a safety culture in the ICU is crucial to effective prevention and should occur before the evaluation of safety programs, which are more likely to be effective when they involve bundles of measures. PMID:22339769

  14. Exponential error reduction in pretransfusion testing with automation.

    PubMed

    South, Susan F; Casina, Tony S; Li, Lily

    2012-08-01

    Protecting the safety of blood transfusion is the top priority of transfusion service laboratories. Pretransfusion testing is a critical element of the entire transfusion process to enhance vein-to-vein safety. Human error associated with manual pretransfusion testing is a cause of transfusion-related mortality and morbidity and most human errors can be eliminated by automated systems. However, the uptake of automation in transfusion services has been slow and many transfusion service laboratories around the world still use manual blood group and antibody screen (G&S) methods. The goal of this study was to compare error potentials of commonly used manual (e.g., tiles and tubes) versus automated (e.g., ID-GelStation and AutoVue Innova) G&S methods. Routine G&S processes in seven transfusion service laboratories (four with manual and three with automated G&S methods) were analyzed using failure modes and effects analysis to evaluate the corresponding error potentials of each method. Manual methods contained a higher number of process steps ranging from 22 to 39, while automated G&S methods only contained six to eight steps. Corresponding to the number of the process steps that required human interactions, the risk priority number (RPN) of the manual methods ranged from 5304 to 10,976. In contrast, the RPN of the automated methods was between 129 and 436 and also demonstrated a 90% to 98% reduction of the defect opportunities in routine G&S testing. This study provided quantitative evidence on how automation could transform pretransfusion testing processes by dramatically reducing error potentials and thus would improve the safety of blood transfusion. © 2012 American Association of Blood Banks.

  15. Analysis of frequency mixing error on heterodyne interferometric ellipsometry

    NASA Astrophysics Data System (ADS)

    Deng, Yuan-long; Li, Xue-jin; Wu, Yu-bin; Hu, Ju-guang; Yao, Jian-quan

    2007-11-01

    A heterodyne interferometric ellipsometer, with no moving parts and a transverse Zeeman laser, is demonstrated. The modified Mach-Zehnder interferometer characterized as a separate frequency and common-path configuration is designed and theoretically analyzed. The experimental data show a fluctuation mainly resulting from the frequency mixing error which is caused by the imperfection of polarizing beam splitters (PBS), the elliptical polarization and non-orthogonality of light beams. The producing mechanism of the frequency mixing error and its influence on measurement are analyzed with the Jones matrix method; the calculation indicates that it results in an error up to several nanometres in the thickness measurement of thin films. The non-orthogonality has no contribution to the phase difference error when it is relatively small; the elliptical polarization and the imperfection of PBS have a major effect on the error.

  16. Distinct prediction errors in mesostriatal circuits of the human brain mediate learning about the values of both states and actions: evidence from high-resolution fMRI

    PubMed Central

    Pauli, Wolfgang M.; Larsen, Tobias; Tyszka, J. Michael; O’Doherty, John P.

    2017-01-01

    Prediction-error signals consistent with formal models of “reinforcement learning” (RL) have repeatedly been found within dopaminergic nuclei of the midbrain and dopaminoceptive areas of the striatum. However, the precise form of the RL algorithms implemented in the human brain is not yet well determined. Here, we created a novel paradigm optimized to dissociate the subtypes of reward-prediction errors that function as the key computational signatures of two distinct classes of RL models—namely, “actor/critic” models and action-value-learning models (e.g., the Q-learning model). The state-value-prediction error (SVPE), which is independent of actions, is a hallmark of the actor/critic architecture, whereas the action-value-prediction error (AVPE) is the distinguishing feature of action-value-learning algorithms. To test for the presence of these prediction-error signals in the brain, we scanned human participants with a high-resolution functional magnetic-resonance imaging (fMRI) protocol optimized to enable measurement of neural activity in the dopaminergic midbrain as well as the striatal areas to which it projects. In keeping with the actor/critic model, the SVPE signal was detected in the substantia nigra. The SVPE was also clearly present in both the ventral striatum and the dorsal striatum. However, alongside these purely state-value-based computations we also found evidence for AVPE signals throughout the striatum. These high-resolution fMRI findings suggest that model-free aspects of reward learning in humans can be explained algorithmically with RL in terms of an actor/critic mechanism operating in parallel with a system for more direct action-value learning. PMID:29049406

  17. Modifying Spearman's Attenuation Equation to Yield Partial Corrections for Measurement Error--With Application to Sample Size Calculations

    ERIC Educational Resources Information Center

    Nicewander, W. Alan

    2018-01-01

    Spearman's correction for attenuation (measurement error) corrects a correlation coefficient for measurement errors in either-or-both of two variables, and follows from the assumptions of classical test theory. Spearman's equation removes all measurement error from a correlation coefficient which translates into "increasing the reliability of…

  18. Increased instrument intelligence--can it reduce laboratory error?

    PubMed

    Jekelis, Albert W

    2005-01-01

    Recent literature has focused on the reduction of laboratory errors and the potential impact on patient management. This study assessed the intelligent, automated preanalytical process-control abilities in newer generation analyzers as compared with older analyzers and the impact on error reduction. Three generations of immuno-chemistry analyzers were challenged with pooled human serum samples for a 3-week period. One of the three analyzers had an intelligent process of fluidics checks, including bubble detection. Bubbles can cause erroneous results due to incomplete sample aspiration. This variable was chosen because it is the most easily controlled sample defect that can be introduced. Traditionally, lab technicians have had to visually inspect each sample for the presence of bubbles. This is time consuming and introduces the possibility of human error. Instruments with bubble detection may be able to eliminate the human factor and reduce errors associated with the presence of bubbles. Specific samples were vortexed daily to introduce a visible quantity of bubbles, then immediately placed in the daily run. Errors were defined as a reported result greater than three standard deviations below the mean and associated with incomplete sample aspiration of the analyte of the individual analyzer Three standard deviations represented the target limits of proficiency testing. The results of the assays were examined for accuracy and precision. Efficiency, measured as process throughput, was also measured to associate a cost factor and potential impact of the error detection on the overall process. The analyzer performance stratified according to their level of internal process control The older analyzers without bubble detection reported 23 erred results. The newest analyzer with bubble detection reported one specimen incorrectly. The precision and accuracy of the nonvortexed specimens were excellent and acceptable for all three analyzers. No errors were found in the

  19. Minimizing the IOL power error induced by keratometric power.

    PubMed

    Camps, Vicente J; Piñero, David P; de Fez, Dolores; Mateo, Verónica

    2013-07-01

    To evaluate theoretically in normal eyes the influence on IOL power (PIOL) calculation of the use of a keratometric index (nk) and to analyze and validate preliminarily the use of an adjusted keratometric index (nkadj) in the IOL power calculation (PIOLadj). A model of variable keratometric index (nkadj) for corneal power calculation (Pc) was used for IOL power calculation (named PIOLadj). Theoretical differences (ΔPIOL) between the new proposed formula (PIOLadj) and which is obtained through Gaussian optics ((Equation is included in full-text article.)) were determined using Gullstrand and Le Grand eye models. The proposed new formula for IOL power calculation (PIOLadj) was prevalidated clinically in 81 eyes of 81 candidates for corneal refractive surgery and compared with Haigis, HofferQ, Holladay, and SRK/T formulas. A theoretical PIOL underestimation greater than 0.5 diopters was present in most of the cases when nk = 1.3375 was used. If nkadj was used for Pc calculation, a maximal calculated error in ΔPIOL of ±0.5 diopters at corneal vertex in most cases was observed independently from the eye model, r1c, and the desired postoperative refraction. The use of nkadj in IOL power calculation (PIOLadj) could be valid with effective lens position optimization nondependent of the corneal power. The use of a single value of nk for Pc calculation can lead to significant errors in PIOL calculation that may explain some IOL power overestimations with conventional formulas. These inaccuracies can be minimized by using the new PIOLadj based on the algorithm of nkadj.

  20. Adjoint-Based, Three-Dimensional Error Prediction and Grid Adaptation

    NASA Technical Reports Server (NTRS)

    Park, Michael A.

    2002-01-01

    Engineering computational fluid dynamics (CFD) analysis and design applications focus on output functions (e.g., lift, drag). Errors in these output functions are generally unknown and conservatively accurate solutions may be computed. Computable error estimates can offer the possibility to minimize computational work for a prescribed error tolerance. Such an estimate can be computed by solving the flow equations and the linear adjoint problem for the functional of interest. The computational mesh can be modified to minimize the uncertainty of a computed error estimate. This robust mesh-adaptation procedure automatically terminates when the simulation is within a user specified error tolerance. This procedure for estimating and adapting to error in a functional is demonstrated for three-dimensional Euler problems. An adaptive mesh procedure that links to a Computer Aided Design (CAD) surface representation is demonstrated for wing, wing-body, and extruded high lift airfoil configurations. The error estimation and adaptation procedure yielded corrected functions that are as accurate as functions calculated on uniformly refined grids with ten times as many grid points.

  1. Error Analysis of Wind Measurements for the University of Illinois Sodium Doppler Temperature System

    NASA Technical Reports Server (NTRS)

    Pfenninger, W. Matthew; Papen, George C.

    1992-01-01

    Four-frequency lidar measurements of temperature and wind velocity require accurate frequency tuning to an absolute reference and long term frequency stability. We quantify frequency tuning errors for the Illinois sodium system, to measure absolute frequencies and a reference interferometer to measure relative frequencies. To determine laser tuning errors, we monitor the vapor cell and interferometer during lidar data acquisition and analyze the two signals for variations as functions of time. Both sodium cell and interferometer are the same as those used to frequency tune the laser. By quantifying the frequency variations of the laser during data acquisition, an error analysis of temperature and wind measurements can be calculated. These error bounds determine the confidence in the calculated temperatures and wind velocities.

  2. Human Error and Commercial Aviation Accidents: A Comprehensive, Fine-Grained Analysis Using HFACS

    DTIC Science & Technology

    2006-07-01

    Factors Figure 2. The HFACS framework. 3 practiced and seemingly automatic behaviors is that they are particularly susceptible to attention and/or memory...been included in most error frameworks, the third and final error form, perceptual errors, has received comparatively less attention . No less...operate safely. After all, just as not everyone can play linebacker for their favorite professional football team or be a concert pianist , not

  3. Inborn Errors in Immunity

    PubMed Central

    Lionakis, M.S.; Hajishengallis, G.

    2015-01-01

    In recent years, the study of genetic defects arising from inborn errors in immunity has resulted in the discovery of new genes involved in the function of the immune system and in the elucidation of the roles of known genes whose importance was previously unappreciated. With the recent explosion in the field of genomics and the increasing number of genetic defects identified, the study of naturally occurring mutations has become a powerful tool for gaining mechanistic insight into the functions of the human immune system. In this concise perspective, we discuss emerging evidence that inborn errors in immunity constitute real-life models that are indispensable both for the in-depth understanding of human biology and for obtaining critical insights into common diseases, such as those affecting oral health. In the field of oral mucosal immunity, through the study of patients with select gene disruptions, the interleukin-17 (IL-17) pathway has emerged as a critical element in oral immune surveillance and susceptibility to inflammatory disease, with disruptions in the IL-17 axis now strongly linked to mucosal fungal susceptibility, whereas overactivation of the same pathways is linked to inflammatory periodontitis. PMID:25900229

  4. Estimating Climatological Bias Errors for the Global Precipitation Climatology Project (GPCP)

    NASA Technical Reports Server (NTRS)

    Adler, Robert; Gu, Guojun; Huffman, George

    2012-01-01

    A procedure is described to estimate bias errors for mean precipitation by using multiple estimates from different algorithms, satellite sources, and merged products. The Global Precipitation Climatology Project (GPCP) monthly product is used as a base precipitation estimate, with other input products included when they are within +/- 50% of the GPCP estimates on a zonal-mean basis (ocean and land separately). The standard deviation s of the included products is then taken to be the estimated systematic, or bias, error. The results allow one to examine monthly climatologies and the annual climatology, producing maps of estimated bias errors, zonal-mean errors, and estimated errors over large areas such as ocean and land for both the tropics and the globe. For ocean areas, where there is the largest question as to absolute magnitude of precipitation, the analysis shows spatial variations in the estimated bias errors, indicating areas where one should have more or less confidence in the mean precipitation estimates. In the tropics, relative bias error estimates (s/m, where m is the mean precipitation) over the eastern Pacific Ocean are as large as 20%, as compared with 10%-15% in the western Pacific part of the ITCZ. An examination of latitudinal differences over ocean clearly shows an increase in estimated bias error at higher latitudes, reaching up to 50%. Over land, the error estimates also locate regions of potential problems in the tropics and larger cold-season errors at high latitudes that are due to snow. An empirical technique to area average the gridded errors (s) is described that allows one to make error estimates for arbitrary areas and for the tropics and the globe (land and ocean separately, and combined). Over the tropics this calculation leads to a relative error estimate for tropical land and ocean combined of 7%, which is considered to be an upper bound because of the lack of sign-of-the-error canceling when integrating over different areas with a

  5. Non-invasive mapping of calculation function by repetitive navigated transcranial magnetic stimulation.

    PubMed

    Maurer, Stefanie; Tanigawa, Noriko; Sollmann, Nico; Hauck, Theresa; Ille, Sebastian; Boeckh-Behrens, Tobias; Meyer, Bernhard; Krieg, Sandro M

    2016-11-01

    Concerning calculation function, studies have already reported on localizing computational function in patients and volunteers by functional magnetic resonance imaging and transcranial magnetic stimulation. However, the development of accurate repetitive navigated TMS (rTMS) with a considerably higher spatial resolution opens a new field in cognitive neuroscience. This study was therefore designed to evaluate the feasibility of rTMS for locating cortical calculation function in healthy volunteers, and to establish this technique for future scientific applications as well as preoperative mapping in brain tumor patients. Twenty healthy subjects underwent rTMS calculation mapping using 5 Hz/10 pulses. Fifty-two previously determined cortical spots of the whole hemispheres were stimulated on both sides. The subjects were instructed to perform the calculation task composed of 80 simple arithmetic operations while rTMS pulses were applied. The highest error rate (80 %) for all errors of all subjects was observed in the right ventral precentral gyrus. Concerning division task, a 45 % error rate was achieved in the left middle frontal gyrus. The subtraction task showed its highest error rate (40 %) in the right angular gyrus (anG). In the addition task a 35 % error rate was observed in the left anterior superior temporal gyrus. Lastly, the multiplication task induced a maximum error rate of 30 % in the left anG. rTMS seems feasible as a way to locate cortical calculation function. Besides language function, the cortical localizations are well in accordance with the current literature for other modalities or lesion studies.

  6. Cognitive errors: thinking clearly when it could be child maltreatment.

    PubMed

    Laskey, Antoinette L

    2014-10-01

    Cognitive errors have been studied in a broad array of fields, including medicine. The more that is understood about how the human mind processes complex information, the more it becomes clear that certain situations are particularly susceptible to less than optimal outcomes because of these errors. This article explores how some of the known cognitive errors may influence the diagnosis of child abuse, resulting in both false-negative and false-positive diagnoses. Suggested remedies for these errors are offered. Copyright © 2014 Elsevier Inc. All rights reserved.

  7. The Surveillance Error Grid

    PubMed Central

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

    2014-01-01

    Introduction: 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. Methods: 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. Results: 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

  8. The surveillance error grid.

    PubMed

    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

  9. XCO2 Retrieval Errors from a PCA-based Approach to Fast Radiative Transfer

    NASA Astrophysics Data System (ADS)

    Somkuti, Peter; Boesch, Hartmut; Natraj, Vijay; Kopparla, Pushkar

    2017-04-01

    Multiple-scattering radiative transfer (RT) calculations are an integral part of forward models used to infer greenhouse gas concentrations in the shortwave-infrared spectral range from satellite missions such as GOSAT or OCO-2. Such calculations are, however, computationally expensive and, combined with the recent growth in data volume, necessitate the use of acceleration methods in order to make retrievals feasible on an operational level. The principle component analysis (PCA)-based approach to fast radiative transfer introduced by Natraj et al. 2005 is a spectral binning method, in which the many line-by-line monochromatic calculations are replaced by a small set of representative ones. From the PCA performed on the optical layer properties for a scene-dependent atmosphere, the results of the representative calculations are mapped onto all spectral points in the given band. Since this RT scheme is an approximation, the computed top-of-atmosphere radiances exhibit errors compared to the "full" line-by-line calculation. These errors ultimately propagate into the final retrieved greenhouse gas concentrations, and their magnitude depends on scene-dependent parameters such as aerosol loadings or viewing geometry. An advantage of this method is the ability to choose the degree of accuracy by increasing or decreasing the number of empirical orthogonal functions used for the reconstruction of the radiances. We have performed a large set of global simulations based on real GOSAT scenes and assess the retrieval errors induced by the fast RT approximation through linear error analysis. We find that across a wide range of geophysical parameters, the errors are for the most part smaller than ± 0.2 ppm and ± 0.06 ppm (out of roughly 400 ppm) for ocean and land scenes respectively. A fast RT scheme that produces low errors is important, since regional biases in XCO2 even in the low sub-ppm range can cause significant changes in carbon fluxes obtained from inversions

  10. Quantitative evaluation for accumulative calibration error and video-CT registration errors in electromagnetic-tracked endoscopy.

    PubMed

    Liu, Sheena Xin; Gutiérrez, Luis F; Stanton, Doug

    2011-05-01

    calibration method and a virtual navigation evaluation system for quantifying the overall errors of the intra-operative data integration. We believe this phantom not only offers us good insights to understand the systematic errors encountered in all phases of an EM-tracked endoscopy procedure but also can provide quality control of laboratory experiments for endoscopic procedures before the experiments are transferred from the laboratory to human subjects.

  11. Nature of the Refractive Errors in Rhesus Monkeys (Macaca mulatta) with Experimentally Induced Ametropias

    PubMed Central

    Qiao-Grider, Ying; Hung, Li-Fang; Kee, Chea-su; Ramamirtham, Ramkumar; Smith, Earl L.

    2010-01-01

    We analyzed the contribution of individual ocular components to vision-induced ametropias in 210 rhesus monkeys. The primary contribution to refractive-error development came from vitreous chamber depth; a minor contribution from corneal power was also detected. However, there was no systematic relationship between refractive error and anterior chamber depth or between refractive error and any crystalline lens parameter. Our results are in good agreement with previous studies in humans, suggesting that the refractive errors commonly observed in humans are created by vision-dependent mechanisms that are similar to those operating in monkeys. This concordance emphasizes the applicability of rhesus monkeys in refractive-error studies. PMID:20600237

  12. Evaluation of drug administration errors in a teaching hospital

    PubMed Central

    2012-01-01

    Background Medication errors can occur at any of the three steps of the medication use process: prescribing, dispensing and administration. We aimed to determine the incidence, type and clinical importance of drug administration errors and to identify risk factors. Methods Prospective study based on disguised observation technique in four wards in a teaching hospital in Paris, France (800 beds). A pharmacist accompanied nurses and witnessed the preparation and administration of drugs to all patients during the three drug rounds on each of six days per ward. Main outcomes were number, type and clinical importance of errors and associated risk factors. Drug administration error rate was calculated with and without wrong time errors. Relationship between the occurrence of errors and potential risk factors were investigated using logistic regression models with random effects. Results Twenty-eight nurses caring for 108 patients were observed. Among 1501 opportunities for error, 415 administrations (430 errors) with one or more errors were detected (27.6%). There were 312 wrong time errors, ten simultaneously with another type of error, resulting in an error rate without wrong time error of 7.5% (113/1501). The most frequently administered drugs were the cardiovascular drugs (425/1501, 28.3%). The highest risks of error in a drug administration were for dermatological drugs. No potentially life-threatening errors were witnessed and 6% of errors were classified as having a serious or significant impact on patients (mainly omission). In multivariate analysis, the occurrence of errors was associated with drug administration route, drug classification (ATC) and the number of patient under the nurse's care. Conclusion Medication administration errors are frequent. The identification of its determinants helps to undertake designed interventions. PMID:22409837

  13. Evaluation of drug administration errors in a teaching hospital.

    PubMed

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

    2012-03-12

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

  14. A nucleotide-analogue-induced gain of function corrects the error-prone nature of human DNA polymerase iota.

    PubMed

    Ketkar, Amit; Zafar, Maroof K; Banerjee, Surajit; Marquez, Victor E; Egli, Martin; Eoff, Robert L

    2012-06-27

    Y-family DNA polymerases participate in replication stress and DNA damage tolerance mechanisms. The properties that allow these enzymes to copy past bulky adducts or distorted template DNA can result in a greater propensity for them to make mistakes. Of the four human Y-family members, human DNA polymerase iota (hpol ι) is the most error-prone. In the current study, we elucidate the molecular basis for improving the fidelity of hpol ι through use of the fixed-conformation nucleotide North-methanocarba-2'-deoxyadenosine triphosphate (N-MC-dATP). Three crystal structures were solved of hpol ι in complex with DNA containing a template 2'-deoxythymidine (dT) paired with an incoming dNTP or modified nucleotide triphosphate. The ternary complex of hpol ι inserting N-MC-dATP opposite dT reveals that the adenine ring is stabilized in the anti orientation about the pseudo-glycosyl torsion angle, which mimics precisely the mutagenic arrangement of dGTP:dT normally preferred by hpol ι. The stabilized anti conformation occurs without notable contacts from the protein but likely results from constraints imposed by the bicyclo[3.1.0]hexane scaffold of the modified nucleotide. Unmodified dATP and South-MC-dATP each adopt syn glycosyl orientations to form Hoogsteen base pairs with dT. The Hoogsteen orientation exhibits weaker base-stacking interactions and is less catalytically favorable than anti N-MC-dATP. Thus, N-MC-dATP corrects the error-prone nature of hpol ι by preventing the Hoogsteen base-pairing mode normally observed for hpol ι-catalyzed insertion of dATP opposite dT. These results provide a previously unrecognized means of altering the efficiency and the fidelity of a human translesion DNA polymerase.

  15. A nucleotide analogue induced gain of function corrects the error-prone nature of human DNA polymerase iota

    PubMed Central

    Ketkar, Amit; Zafar, Maroof K.; Banerjee, Surajit; Marquez, Victor E.; Egli, Martin; Eoff, Robert L

    2012-01-01

    Y-family DNA polymerases participate in replication stress and DNA damage tolerance mechanisms. The properties that allow these enzymes to copy past bulky adducts or distorted template DNA can result in a greater propensity for them to make mistakes. Of the four human Y-family members, human DNA polymerase iota (hpol ι) is the most error-prone. In the current study, we elucidate the molecular basis for improving the fidelity of hpol ι through use of the fixed-conformation nucleotide North-methanocarba-2′-deoxyadenosine triphosphate (N-MC-dATP). Three crystal structures were solved of hpol ι in complex with DNA containing a template 2′-deoxythymidine (dT) paired with an incoming dNTP or modified nucleotide triphosphate. The ternary complex of hpol ι inserting N-MC-dATP opposite dT reveals that the adenine ring is stabilized in the anti orientation about the pseudo-glycosyl torsion angle (χ), which mimics precisely the mutagenic arrangement of dGTP:dT normally preferred by hpol ι. The stabilized anti conformation occurs without notable contacts from the protein but likely results from constraints imposed by the bicyclo[3.1.0]hexane scaffold of the modified nucleotide. Unmodified dATP and South-MC-dATP each adopt syn glycosyl orientations to form Hoogsteen base pairs with dT. The Hoogsteen orientation exhibits weaker base stacking interactions and is less catalytically favorable than anti N-MC-dATP. Thus, N-MC-dATP corrects the error-prone nature of hpol ι by preventing the Hoogsteen base-pairing mode normally observed for hpol ι-catalyzed insertion of dATP opposite dT. These results provide a previously unrecognized means of altering the efficiency and the fidelity of a human translesion DNA polymerase. PMID:22632140

  16. Assessment of the pseudo-tracking approach for the calculation of material acceleration and pressure fields from time-resolved PIV: part I. Error propagation

    NASA Astrophysics Data System (ADS)

    van Gent, P. L.; Schrijer, F. F. J.; van Oudheusden, B. W.

    2018-04-01

    Pseudo-tracking refers to the construction of imaginary particle paths from PIV velocity fields and the subsequent estimation of the particle (material) acceleration. In view of the variety of existing and possible alternative ways to perform the pseudo-tracking method, it is not straightforward to select a suitable combination of numerical procedures for its implementation. To address this situation, this paper extends the theoretical framework for the approach. The developed theory is verified by applying various implementations of pseudo-tracking to a simulated PIV experiment. The findings of the investigations allow us to formulate the following insights and practical recommendations: (1) the velocity errors along the imaginary particle track are primarily a function of velocity measurement errors and spatial velocity gradients; (2) the particle path may best be calculated with second-order accurate numerical procedures while ensuring that the CFL condition is met; (3) least-square fitting of a first-order polynomial is a suitable method to estimate the material acceleration from the track; and (4) a suitable track length may be selected on the basis of the variation in material acceleration with track length.

  17. Quantum Error Correction with Biased Noise

    NASA Astrophysics Data System (ADS)

    Brooks, Peter

    Quantum computing offers powerful new techniques for speeding up the calculation of many classically intractable problems. Quantum algorithms can allow for the efficient simulation of physical systems, with applications to basic research, chemical modeling, and drug discovery; other algorithms have important implications for cryptography and internet security. At the same time, building a quantum computer is a daunting task, requiring the coherent manipulation of systems with many quantum degrees of freedom while preventing environmental noise from interacting too strongly with the system. Fortunately, we know that, under reasonable assumptions, we can use the techniques of quantum error correction and fault tolerance to achieve an arbitrary reduction in the noise level. In this thesis, we look at how additional information about the structure of noise, or "noise bias," can improve or alter the performance of techniques in quantum error correction and fault tolerance. In Chapter 2, we explore the possibility of designing certain quantum gates to be extremely robust with respect to errors in their operation. This naturally leads to structured noise where certain gates can be implemented in a protected manner, allowing the user to focus their protection on the noisier unprotected operations. In Chapter 3, we examine how to tailor error-correcting codes and fault-tolerant quantum circuits in the presence of dephasing biased noise, where dephasing errors are far more common than bit-flip errors. By using an appropriately asymmetric code, we demonstrate the ability to improve the amount of error reduction and decrease the physical resources required for error correction. In Chapter 4, we analyze a variety of protocols for distilling magic states, which enable universal quantum computation, in the presence of faulty Clifford operations. Here again there is a hierarchy of noise levels, with a fixed error rate for faulty gates, and a second rate for errors in the distilled

  18. Error begat error: design error analysis and prevention in social infrastructure projects.

    PubMed

    Love, Peter E D; Lopez, Robert; Edwards, David J; Goh, Yang M

    2012-09-01

    Design errors contribute significantly to cost and schedule growth in social infrastructure projects and to engineering failures, which can result in accidents and loss of life. Despite considerable research that has addressed their error causation in construction projects they still remain prevalent. This paper identifies the underlying conditions that contribute to design errors in social infrastructure projects (e.g. hospitals, education, law and order type buildings). A systemic model of error causation is propagated and subsequently used to develop a learning framework for design error prevention. The research suggests that a multitude of strategies should be adopted in congruence to prevent design errors from occurring and so ensure that safety and project performance are ameliorated. Copyright © 2011. Published by Elsevier Ltd.

  19. Effectiveness of Variable-Gain Kalman Filter Based on Angle Error Calculated from Acceleration Signals in Lower Limb Angle Measurement with Inertial Sensors

    PubMed Central

    Watanabe, Takashi

    2013-01-01

    The wearable sensor system developed by our group, which measured lower limb angles using Kalman-filtering-based method, was suggested to be useful in evaluation of gait function for rehabilitation support. However, it was expected to reduce variations of measurement errors. In this paper, a variable-Kalman-gain method based on angle error that was calculated from acceleration signals was proposed to improve measurement accuracy. The proposed method was tested comparing to fixed-gain Kalman filter and a variable-Kalman-gain method that was based on acceleration magnitude used in previous studies. First, in angle measurement in treadmill walking, the proposed method measured lower limb angles with the highest measurement accuracy and improved significantly foot inclination angle measurement, while it improved slightly shank and thigh inclination angles. The variable-gain method based on acceleration magnitude was not effective for our Kalman filter system. Then, in angle measurement of a rigid body model, it was shown that the proposed method had measurement accuracy similar to or higher than results seen in other studies that used markers of camera-based motion measurement system fixing on a rigid plate together with a sensor or on the sensor directly. The proposed method was found to be effective in angle measurement with inertial sensors. PMID:24282442

  20. Why do adult dogs (Canis familiaris) commit the A-not-B search error?

    PubMed

    Sümegi, Zsófia; Kis, Anna; Miklósi, Ádám; Topál, József

    2014-02-01

    It has been recently reported that adult domestic dogs, like human infants, tend to commit perseverative search errors; that is, they select the previously rewarded empty location in Piagetian A-not-B search task because of the experimenter's ostensive communicative cues. There is, however, an ongoing debate over whether these findings reveal that dogs can use the human ostensive referential communication as a source of information or the phenomenon can be accounted for by "more simple" explanations like insufficient attention and learning based on local enhancement. In 2 experiments the authors systematically manipulated the type of human cueing (communicative or noncommunicative) adjacent to the A hiding place during both the A and B trials. Results highlight 3 important aspects of the dogs' A-not-B error: (a) search errors are influenced to a certain extent by dogs' motivation to retrieve the toy object; (b) human communicative and noncommunicative signals have different error-inducing effects; and (3) communicative signals presented at the A hiding place during the B trials but not during the A trials play a crucial role in inducing the A-not-B error and it can be induced even without demonstrating repeated hiding events at location A. These findings further confirm the notion that perseverative search error, at least partially, reflects a "ready-to-obey" attitude in the dog rather than insufficient attention and/or working memory.

  1. Minimizing treatment planning errors in proton therapy using failure mode and effects analysis

    DOE Office of Scientific and Technical Information (OSTI.GOV)

    Zheng, Yuanshui, E-mail: yuanshui.zheng@okc.procure.com; Johnson, Randall; Larson, Gary

    Purpose: Failure mode and effects analysis (FMEA) is a widely used tool to evaluate safety or reliability in conventional photon radiation therapy. However, reports about FMEA application in proton therapy are scarce. The purpose of this study is to apply FMEA in safety improvement of proton treatment planning at their center. Methods: The authors performed an FMEA analysis of their proton therapy treatment planning process using uniform scanning proton beams. The authors identified possible failure modes in various planning processes, including image fusion, contouring, beam arrangement, dose calculation, plan export, documents, billing, and so on. For each error, the authorsmore » estimated the frequency of occurrence, the likelihood of being undetected, and the severity of the error if it went undetected and calculated the risk priority number (RPN). The FMEA results were used to design their quality management program. In addition, the authors created a database to track the identified dosimetric errors. Periodically, the authors reevaluated the risk of errors by reviewing the internal error database and improved their quality assurance program as needed. Results: In total, the authors identified over 36 possible treatment planning related failure modes and estimated the associated occurrence, detectability, and severity to calculate the overall risk priority number. Based on the FMEA, the authors implemented various safety improvement procedures into their practice, such as education, peer review, and automatic check tools. The ongoing error tracking database provided realistic data on the frequency of occurrence with which to reevaluate the RPNs for various failure modes. Conclusions: The FMEA technique provides a systematic method for identifying and evaluating potential errors in proton treatment planning before they result in an error in patient dose delivery. The application of FMEA framework and the implementation of an ongoing error tracking system at

  2. Evaluate error correction ability of magnetorheological finishing by smoothing spectral function

    NASA Astrophysics Data System (ADS)

    Wang, Jia; Fan, Bin; Wan, Yongjian; Shi, Chunyan; Zhuo, Bin

    2014-08-01

    Power Spectral Density (PSD) has been entrenched in optics design and manufacturing as a characterization of mid-high spatial frequency (MHSF) errors. Smoothing Spectral Function (SSF) is a newly proposed parameter that based on PSD to evaluate error correction ability of computer controlled optical surfacing (CCOS) technologies. As a typical deterministic and sub-aperture finishing technology based on CCOS, magnetorheological finishing (MRF) leads to MHSF errors inevitably. SSF is employed to research different spatial frequency error correction ability of MRF process. The surface figures and PSD curves of work-piece machined by MRF are presented. By calculating SSF curve, the correction ability of MRF for different spatial frequency errors will be indicated as a normalized numerical value.

  3. Error analysis of the Golay3 optical imaging system.

    PubMed

    Wu, Quanying; Fan, Junliu; Wu, Feng; Zhao, Jun; Qian, Lin

    2013-05-01

    We use aberration theory to derive a generalized pupil function of the Golay3 imaging system when astigmatisms exist in its submirrors. Theoretical analysis and numerical simulation using ZEMAX show that the point spread function (PSF) and the modulation transfer function (MTF) of the Golay3 sparse aperture system have a periodic change when there are piston errors. When the peak-valley value of the wavefront (PV(tilt)) due to the tilt error increases from zero to λ, the PSF and the MTF change significantly, and the change direction is determined by the location of the submirror with the tilt error. When PV(tilt) becomes larger than λ, the PSF and the MTF remain unvaried. We calculate the peaks of the signal-to-noise ratio (PSNR) resulting from the piston and tilt errors according to the Strehl ratio, and show that the PSNR decreases when the errors increase.

  4. Optimal algorithm to improve the calculation accuracy of energy deposition for betavoltaic MEMS batteries design

    NASA Astrophysics Data System (ADS)

    Li, Sui-xian; Chen, Haiyang; Sun, Min; Cheng, Zaijun

    2009-11-01

    Aimed at improving the calculation accuracy when calculating the energy deposition of electrons traveling in solids, a method we call optimal subdivision number searching algorithm is proposed. When treating the energy deposition of electrons traveling in solids, large calculation errors are found, we are conscious of that it is the result of dividing and summing when calculating the integral. Based on the results of former research, we propose a further subdividing and summing method. For β particles with the energy in the entire spectrum span, the energy data is set only to be the integral multiple of keV, and the subdivision number is set to be from 1 to 30, then the energy deposition calculation error collections are obtained. Searching for the minimum error in the collections, we can obtain the corresponding energy and subdivision number pairs, as well as the optimal subdivision number. The method is carried out in four kinds of solid materials, Al, Si, Ni and Au to calculate energy deposition. The result shows that the calculation error is reduced by one order with the improved algorithm.

  5. Common Errors in the Calculation of Aircrew Doses from Cosmic Rays

    NASA Astrophysics Data System (ADS)

    O'Brien, Keran; Felsberger, Ernst; Kindl, Peter

    2010-05-01

    Radiation doses to air crew are calculated using flight codes. Flight codes integrate dose rates over the aircraft flight path, which were calculated by transport codes or obtained by measurements from take off at a specific airport to landing at another. The dose rates are stored in various ways, such as by latitude and longitude, or in terms of the geomagnetic vertical cutoff. The transport codes are generally quite satisfactory, but the treatment of the boundary conditions is frequently incorrect. Both the treatment of solar modulation and of the effect of the geomagnetic field are often defective, leading to the systematic overestimate of the crew doses.

  6. Intravenous Chemotherapy Compounding Errors in a Follow-Up Pan-Canadian Observational Study.

    PubMed

    Gilbert, Rachel E; Kozak, Melissa C; Dobish, Roxanne B; Bourrier, Venetia C; Koke, Paul M; Kukreti, Vishal; Logan, Heather A; Easty, Anthony C; Trbovich, Patricia L

    2018-05-01

    Intravenous (IV) compounding safety has garnered recent attention as a result of high-profile incidents, awareness efforts from the safety community, and increasingly stringent practice standards. New research with more-sensitive error detection techniques continues to reinforce that error rates with manual IV compounding are unacceptably high. In 2014, our team published an observational study that described three types of previously unrecognized and potentially catastrophic latent chemotherapy preparation errors in Canadian oncology pharmacies that would otherwise be undetectable. We expand on this research and explore whether additional potential human failures are yet to be addressed by practice standards. Field observations were conducted in four cancer center pharmacies in four Canadian provinces from January 2013 to February 2015. Human factors specialists observed and interviewed pharmacy managers, oncology pharmacists, pharmacy technicians, and pharmacy assistants as they carried out their work. Emphasis was on latent errors (potential human failures) that could lead to outcomes such as wrong drug, dose, or diluent. Given the relatively short observational period, no active failures or actual errors were observed. However, 11 latent errors in chemotherapy compounding were identified. In terms of severity, all 11 errors create the potential for a patient to receive the wrong drug or dose, which in the context of cancer care, could lead to death or permanent loss of function. Three of the 11 practices were observed in our previous study, but eight were new. Applicable Canadian and international standards and guidelines do not explicitly address many of the potentially error-prone practices observed. We observed a significant degree of risk for error in manual mixing practice. These latent errors may exist in other regions where manual compounding of IV chemotherapy takes place. Continued efforts to advance standards, guidelines, technological innovation, and

  7. Aerodynamic calculations of the Sienna towers buildings complex with respect to human vibrations comfort of their users

    NASA Astrophysics Data System (ADS)

    Krajewski, Piotr; Flaga, Łukasz; Flaga, Andrzej

    2018-01-01

    The paper presents aerodynamic calculations of the Sienna Towers high buildings complex in Warsaw using authors mathematical model of the considered issue. Human vibrations comfort criteria were checked according to ISO/6897. Dynamic coefficients used in the calculations were obtained from wind tunnel tests.

  8. Summation-by-Parts operators with minimal dispersion error for coarse grid flow calculations

    NASA Astrophysics Data System (ADS)

    Linders, Viktor; Kupiainen, Marco; Nordström, Jan

    2017-07-01

    We present a procedure for constructing Summation-by-Parts operators with minimal dispersion error both near and far from numerical interfaces. Examples of such operators are constructed and compared with a higher order non-optimised Summation-by-Parts operator. Experiments show that the optimised operators are superior for wave propagation and turbulent flows involving large wavenumbers, long solution times and large ranges of resolution scales.

  9. DNA double strand break repair in human bladder cancer is error prone and involves microhomology-associated end-joining

    PubMed Central

    Bentley, Johanne; Diggle, Christine P.; Harnden, Patricia; Knowles, Margaret A.; Kiltie, Anne E.

    2004-01-01

    In human cells DNA double strand breaks (DSBs) can be repaired by the non-homologous end-joining (NHEJ) pathway. In a background of NHEJ deficiency, DSBs with mismatched ends can be joined by an error-prone mechanism involving joining between regions of nucleotide microhomology. The majority of joins formed from a DSB with partially incompatible 3′ overhangs by cell-free extracts from human glioblastoma (MO59K) and urothelial (NHU) cell lines were accurate and produced by the overlap/fill-in of mismatched termini by NHEJ. However, repair of DSBs by extracts using tissue from four high-grade bladder carcinomas resulted in no accurate join formation. Junctions were formed by the non-random deletion of terminal nucleotides and showed a preference for annealing at a microhomology of 8 nt buried within the DNA substrate; this process was not dependent on functional Ku70, DNA-PK or XRCC4. Junctions were repaired in the same manner in MO59K extracts in which accurate NHEJ was inactivated by inhibition of Ku70 or DNA-PKcs. These data indicate that bladder tumour extracts are unable to perform accurate NHEJ such that error-prone joining predominates. Therefore, in high-grade tumours mismatched DSBs are repaired by a highly mutagenic, microhomology-mediated, alternative end-joining pathway, a process that may contribute to genomic instability observed in bladder cancer. PMID:15466592

  10. Sensitivity analysis of periodic errors in heterodyne interferometry

    NASA Astrophysics Data System (ADS)

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

    2011-03-01

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

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

    PubMed

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

    2010-02-01

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

  12. Modular error embedding

    DOEpatents

    Sandford, II, Maxwell T.; Handel, Theodore G.; Ettinger, J. Mark

    1999-01-01

    A method of embedding auxiliary information into the digital representation of host data containing noise in the low-order bits. The method applies to digital data representing analog signals, for example digital images. The method reduces the error introduced by other methods that replace the low-order bits with auxiliary information. By a substantially reverse process, the embedded auxiliary data can be retrieved easily by an authorized user through use of a digital key. The modular error embedding method includes a process to permute the order in which the host data values are processed. The method doubles the amount of auxiliary information that can be added to host data values, in comparison with bit-replacement methods for high bit-rate coding. The invention preserves human perception of the meaning and content of the host data, permitting the addition of auxiliary data in the amount of 50% or greater of the original host data.

  13. Nature of the refractive errors in rhesus monkeys (Macaca mulatta) with experimentally induced ametropias.

    PubMed

    Qiao-Grider, Ying; Hung, Li-Fang; Kee, Chea-Su; Ramamirtham, Ramkumar; Smith, Earl L

    2010-08-23

    We analyzed the contribution of individual ocular components to vision-induced ametropias in 210 rhesus monkeys. The primary contribution to refractive-error development came from vitreous chamber depth; a minor contribution from corneal power was also detected. However, there was no systematic relationship between refractive error and anterior chamber depth or between refractive error and any crystalline lens parameter. Our results are in good agreement with previous studies in humans, suggesting that the refractive errors commonly observed in humans are created by vision-dependent mechanisms that are similar to those operating in monkeys. This concordance emphasizes the applicability of rhesus monkeys in refractive-error studies. Copyright 2010 Elsevier Ltd. All rights reserved.

  14. Characterizing the SWOT discharge error budget on the Sacramento River, CA

    NASA Astrophysics Data System (ADS)

    Yoon, Y.; Durand, M. T.; Minear, J. T.; Smith, L.; Merry, C. J.

    2013-12-01

    The Surface Water and Ocean Topography (SWOT) is an upcoming satellite mission (2020 year) that will provide surface-water elevation and surface-water extent globally. One goal of SWOT is the estimation of river discharge directly from SWOT measurements. SWOT discharge uncertainty is due to two sources. First, SWOT cannot measure channel bathymetry and determine roughness coefficient data necessary for discharge calculations directly; these parameters must be estimated from the measurements or from a priori information. Second, SWOT measurement errors directly impact the discharge estimate accuracy. This study focuses on characterizing parameter and measurement uncertainties for SWOT river discharge estimation. A Bayesian Markov Chain Monte Carlo scheme is used to calculate parameter estimates, given the measurements of river height, slope and width, and mass and momentum constraints. The algorithm is evaluated using simulated both SWOT and AirSWOT (the airborne version of SWOT) observations over seven reaches (about 40 km) of the Sacramento River. The SWOT and AirSWOT observations are simulated by corrupting the ';true' HEC-RAS hydraulic modeling results with the instrument error. This experiment answers how unknown bathymetry and roughness coefficients affect the accuracy of the river discharge algorithm. From the experiment, the discharge error budget is almost completely dominated by unknown bathymetry and roughness; 81% of the variance error is explained by uncertainties in bathymetry and roughness. Second, we show how the errors in water surface, slope, and width observations influence the accuracy of discharge estimates. Indeed, there is a significant sensitivity to water surface, slope, and width errors due to the sensitivity of bathymetry and roughness to measurement errors. Increasing water-surface error above 10 cm leads to a corresponding sharper increase of errors in bathymetry and roughness. Increasing slope error above 1.5 cm/km leads to a

  15. A computer program to calculate zeroes, extrema, and interval integrals for the associated Legendre functions. [for estimation of bounds of truncation error in spherical harmonic expansion of geopotential

    NASA Technical Reports Server (NTRS)

    Payne, M. H.

    1973-01-01

    A computer program is described for the calculation of the zeroes of the associated Legendre functions, Pnm, and their derivatives, for the calculation of the extrema of Pnm and also the integral between pairs of successive zeroes. The program has been run for all n,m from (0,0) to (20,20) and selected cases beyond that for n up to 40. Up to (20,20), the program (written in double precision) retains nearly full accuracy, and indications are that up to (40,40) there is still sufficient precision (4-5 decimal digits for a 54-bit mantissa) for estimation of various bounds and errors involved in geopotential modelling, the purpose for which the program was written.

  16. Calculation of the Nucleon Axial Form Factor Using Staggered Lattice QCD

    DOE Office of Scientific and Technical Information (OSTI.GOV)

    Meyer, Aaron S.; Hill, Richard J.; Kronfeld, Andreas S.

    The nucleon axial form factor is a dominant contribution to errors in neutrino oscillation studies. Lattice QCD calculations can help control theory errors by providing first-principles information on nucleon form factors. In these proceedings, we present preliminary results on a blinded calculation ofmore » $$g_A$$ and the axial form factor using HISQ staggered baryons with 2+1+1 flavors of sea quarks. Calculations are done using physical light quark masses and are absolutely normalized. We discuss fitting form factor data with the model-independent $z$ expansion parametrization.« less

  17. Math Error Types and Correlates in Adolescents with and without Attention Deficit Hyperactivity Disorder

    PubMed Central

    Capodieci, Agnese; Martinussen, Rhonda

    2017-01-01

    Objective: The aim of this study was to examine the types of errors made by youth with and without a parent-reported diagnosis of attention deficit and hyperactivity disorder (ADHD) on a math fluency task and investigate the association between error types and youths’ performance on measures of processing speed and working memory. Method: Participants included 30 adolescents with ADHD and 39 typically developing peers between 14 and 17 years old matched in age and IQ. All youth completed standardized measures of math calculation and fluency as well as two tests of working memory and processing speed. Math fluency error patterns were examined. Results: Adolescents with ADHD showed less proficient math fluency despite having similar math calculation scores as their peers. Group differences were also observed in error types with youth with ADHD making more switch errors than their peers. Conclusion: This research has important clinical applications for the assessment and intervention on math ability in students with ADHD. PMID:29075227

  18. Math Error Types and Correlates in Adolescents with and without Attention Deficit Hyperactivity Disorder.

    PubMed

    Capodieci, Agnese; Martinussen, Rhonda

    2017-01-01

    Objective: The aim of this study was to examine the types of errors made by youth with and without a parent-reported diagnosis of attention deficit and hyperactivity disorder (ADHD) on a math fluency task and investigate the association between error types and youths' performance on measures of processing speed and working memory. Method: Participants included 30 adolescents with ADHD and 39 typically developing peers between 14 and 17 years old matched in age and IQ. All youth completed standardized measures of math calculation and fluency as well as two tests of working memory and processing speed. Math fluency error patterns were examined. Results: Adolescents with ADHD showed less proficient math fluency despite having similar math calculation scores as their peers. Group differences were also observed in error types with youth with ADHD making more switch errors than their peers. Conclusion: This research has important clinical applications for the assessment and intervention on math ability in students with ADHD.

  19. A Bayesian method for using simulator data to enhance human error probabilities assigned by existing HRA methods

    DOE PAGES

    Groth, Katrina M.; Smith, Curtis L.; Swiler, Laura P.

    2014-04-05

    In the past several years, several international agencies have begun to collect data on human performance in nuclear power plant simulators [1]. This data provides a valuable opportunity to improve human reliability analysis (HRA), but there improvements will not be realized without implementation of Bayesian methods. Bayesian methods are widely used in to incorporate sparse data into models in many parts of probabilistic risk assessment (PRA), but Bayesian methods have not been adopted by the HRA community. In this article, we provide a Bayesian methodology to formally use simulator data to refine the human error probabilities (HEPs) assigned by existingmore » HRA methods. We demonstrate the methodology with a case study, wherein we use simulator data from the Halden Reactor Project to update the probability assignments from the SPAR-H method. The case study demonstrates the ability to use performance data, even sparse data, to improve existing HRA methods. Furthermore, this paper also serves as a demonstration of the value of Bayesian methods to improve the technical basis of HRA.« less

  20. Errors, error detection, error correction and hippocampal-region damage: data and theories.

    PubMed

    MacKay, Donald G; Johnson, Laura W

    2013-11-01

    This review and perspective article outlines 15 observational constraints on theories of errors, error detection, and error correction, and their relation to hippocampal-region (HR) damage. The core observations come from 10 studies with H.M., an amnesic with cerebellar and HR damage but virtually no neocortical damage. Three studies examined the detection of errors planted in visual scenes (e.g., a bird flying in a fish bowl in a school classroom) and sentences (e.g., I helped themselves to the birthday cake). In all three experiments, H.M. detected reliably fewer errors than carefully matched memory-normal controls. Other studies examined the detection and correction of self-produced errors, with controls for comprehension of the instructions, impaired visual acuity, temporal factors, motoric slowing, forgetting, excessive memory load, lack of motivation, and deficits in visual scanning or attention. In these studies, H.M. corrected reliably fewer errors than memory-normal and cerebellar controls, and his uncorrected errors in speech, object naming, and reading aloud exhibited two consistent features: omission and anomaly. For example, in sentence production tasks, H.M. omitted one or more words in uncorrected encoding errors that rendered his sentences anomalous (incoherent, incomplete, or ungrammatical) reliably more often than controls. Besides explaining these core findings, the theoretical principles discussed here explain H.M.'s retrograde amnesia for once familiar episodic and semantic information; his anterograde amnesia for novel information; his deficits in visual cognition, sentence comprehension, sentence production, sentence reading, and object naming; and effects of aging on his ability to read isolated low frequency words aloud. These theoretical principles also explain a wide range of other data on error detection and correction and generate new predictions for future test. Copyright © 2013 Elsevier Ltd. All rights reserved.

  1. Conditional Entropy and Location Error in Indoor Localization Using Probabilistic Wi-Fi Fingerprinting.

    PubMed

    Berkvens, Rafael; Peremans, Herbert; Weyn, Maarten

    2016-10-02

    Localization systems are increasingly valuable, but their location estimates are only useful when the uncertainty of the estimate is known. This uncertainty is currently calculated as the location error given a ground truth, which is then used as a static measure in sometimes very different environments. In contrast, we propose the use of the conditional entropy of a posterior probability distribution as a complementary measure of uncertainty. This measure has the advantage of being dynamic, i.e., it can be calculated during localization based on individual sensor measurements, does not require a ground truth, and can be applied to discrete localization algorithms. Furthermore, for every consistent location estimation algorithm, both the location error and the conditional entropy measures must be related, i.e., a low entropy should always correspond with a small location error, while a high entropy can correspond with either a small or large location error. We validate this relationship experimentally by calculating both measures of uncertainty in three publicly available datasets using probabilistic Wi-Fi fingerprinting with eight different implementations of the sensor model. We show that the discrepancy between these measures, i.e., many location estimates having a high location error while simultaneously having a low conditional entropy, is largest for the least realistic implementations of the probabilistic sensor model. Based on the results presented in this paper, we conclude that conditional entropy, being dynamic, complementary to location error, and applicable to both continuous and discrete localization, provides an important extra means of characterizing a localization method.

  2. Conditional Entropy and Location Error in Indoor Localization Using Probabilistic Wi-Fi Fingerprinting

    PubMed Central

    Berkvens, Rafael; Peremans, Herbert; Weyn, Maarten

    2016-01-01

    Localization systems are increasingly valuable, but their location estimates are only useful when the uncertainty of the estimate is known. This uncertainty is currently calculated as the location error given a ground truth, which is then used as a static measure in sometimes very different environments. In contrast, we propose the use of the conditional entropy of a posterior probability distribution as a complementary measure of uncertainty. This measure has the advantage of being dynamic, i.e., it can be calculated during localization based on individual sensor measurements, does not require a ground truth, and can be applied to discrete localization algorithms. Furthermore, for every consistent location estimation algorithm, both the location error and the conditional entropy measures must be related, i.e., a low entropy should always correspond with a small location error, while a high entropy can correspond with either a small or large location error. We validate this relationship experimentally by calculating both measures of uncertainty in three publicly available datasets using probabilistic Wi-Fi fingerprinting with eight different implementations of the sensor model. We show that the discrepancy between these measures, i.e., many location estimates having a high location error while simultaneously having a low conditional entropy, is largest for the least realistic implementations of the probabilistic sensor model. Based on the results presented in this paper, we conclude that conditional entropy, being dynamic, complementary to location error, and applicable to both continuous and discrete localization, provides an important extra means of characterizing a localization method. PMID:27706099

  3. An investigation of error correcting techniques for OMV and AXAF

    NASA Technical Reports Server (NTRS)

    Ingels, Frank; Fryer, John

    1991-01-01

    The original objectives of this project were to build a test system for the NASA 255/223 Reed/Solomon encoding/decoding chip set and circuit board. This test system was then to be interfaced with a convolutional system at MSFC to examine the performance of the concantinated codes. After considerable work, it was discovered that the convolutional system could not function as needed. This report documents the design, construction, and testing of the test apparatus for the R/S chip set. The approach taken was to verify the error correcting behavior of the chip set by injecting known error patterns onto data and observing the results. Error sequences were generated using pseudo-random number generator programs, with Poisson time distribution between errors and Gaussian burst lengths. Sample means, variances, and number of un-correctable errors were calculated for each data set before testing.

  4. Evaluation of Flow Biosensor Technology in a Chronically-Instrumented Non-Human Primate Model

    NASA Technical Reports Server (NTRS)

    Koenig, S. C.; Reister, C.; Schaub, J.; Muniz, G.; Ferguson, T.; Fanton, J. W.

    1995-01-01

    The Physiology Research Branch of Brooks AFB conducts both human and non-human primate experiments to determine the effects of microgravity and hypergravity on the cardiovascular system and to indentify the particular mechanisms that invoke these responses. Primary investigative research efforts in a non-human primate model require the calculation of total peripheral resistance (TPR), systemic arterial compliance (SAC), and pressure-volume loop characteristics. These calculations require beat-to-beat measurement of aortic flow. We have evaluated commercially available electromagnetic (EMF) and transit-time flow measurement techniques. In vivo and in vitro experiments demonstrated that the average error of these techniques is less than 25 percent for EMF and less than 10 percent for transit-time.

  5. MEDICAL ERROR: CIVIL AND LEGAL ASPECT.

    PubMed

    Buletsa, S; Drozd, O; Yunin, O; Mohilevskyi, L

    2018-03-01

    The scientific article is focused on the research of the notion of medical error, medical and legal aspects of this notion have been considered. The necessity of the legislative consolidation of the notion of «medical error» and criteria of its legal estimation have been grounded. In the process of writing a scientific article, we used the empirical method, general scientific and comparative legal methods. A comparison of the concept of medical error in civil and legal aspects was made from the point of view of Ukrainian, European and American scientists. It has been marked that the problem of medical errors is known since ancient times and in the whole world, in fact without regard to the level of development of medicine, there is no country, where doctors never make errors. According to the statistics, medical errors in the world are included in the first five reasons of death rate. At the same time the grant of medical services practically concerns all people. As a man and his life, health in Ukraine are acknowledged by a higher social value, medical services must be of high-quality and effective. The grant of not quality medical services causes harm to the health, and sometimes the lives of people; it may result in injury or even death. The right to the health protection is one of the fundamental human rights assured by the Constitution of Ukraine; therefore the issue of medical errors and liability for them is extremely relevant. The authors make conclusions, that the definition of the notion of «medical error» must get the legal consolidation. Besides, the legal estimation of medical errors must be based on the single principles enshrined in the legislation and confirmed by judicial practice.

  6. Textbook Error: Short Circuiting on Electrochemical Cell

    ERIC Educational Resources Information Center

    Bonicamp, Judith M.; Clark, Roy W.

    2007-01-01

    Short circuiting an electrochemical cell is an unreported but persistent error in the electrochemistry textbooks. It is suggested that diagrams depicting a cell delivering usable current to a load be postponed, the theory of open-circuit galvanic cells is explained, the voltages from the tables of standard reduction potentials is calculated and…

  7. Correlation and agreement between eplet mismatches calculated using serological, low-intermediate and high resolution molecular human leukocyte antigen typing methods.

    PubMed

    Fidler, Samantha; D'Orsogna, Lloyd; Irish, Ashley B; Lewis, Joshua R; Wong, Germaine; Lim, Wai H

    2018-03-02

    Structural human leukocyte antigen (HLA) matching at the eplet level can be identified by HLAMatchmaker, which requires the entry of four-digit alleles. The aim of this study was to evaluate the agreement between eplet mismatches calculated by serological and two-digit typing methods compared to high-resolution four-digit typing. In a cohort of 264 donor/recipient pairs, the evaluation of measurement error was assessed using intra-class correlation to confirm the absolute agreement between the number of eplet mismatches at class I (HLA-A, -B, C) and II loci (HLA-DQ and -DR) calculated using serological or two-digit molecular typing compared to four-digit molecular typing methods. The proportion of donor/recipient pairs with a difference of >5 eplet mismatches between the HLA typing methods was also determined. Intra-class correlation coefficients between serological and four-digit molecular typing methods were 0.969 (95% confidence intervals [95% CI] 0.960-0.975) and 0.926 (95% CI 0.899-0.944), respectively; and 0.995 (95% CI 0.994-0.996) and 0.993 (95% CI 0.991-0.995), respectively between two-digit and four-digit molecular typing methods. The proportion of donor/recipient pairs with a difference of >5 eplet mismatches at class I and II loci was 4% and 16% for serological versus four-digit molecular typing methods, and 0% and 2% for two-digit versus four-digit molecular typing methods, respectively. In this small predominantly Caucasian population, compared with serology, there is a high level of agreement in the number of eplet mismatches calculated using two-compared to four-digit molecular HLA-typing methods, suggesting that two-digit typing may be sufficient in determining eplet mismatch load in kidney transplantation.

  8. Correlation and agreement between eplet mismatches calculated using serological, low-intermediate and high resolution molecular human leukocyte antigen typing methods

    PubMed Central

    Fidler, Samantha; D’Orsogna, Lloyd; Irish, Ashley B.; Lewis, Joshua R.; Wong, Germaine; Lim, Wai H.

    2018-01-01

    Structural human leukocyte antigen (HLA) matching at the eplet level can be identified by HLAMatchmaker, which requires the entry of four-digit alleles. The aim of this study was to evaluate the agreement between eplet mismatches calculated by serological and two-digit typing methods compared to high-resolution four-digit typing. In a cohort of 264 donor/recipient pairs, the evaluation of measurement error was assessed using intra-class correlation to confirm the absolute agreement between the number of eplet mismatches at class I (HLA-A, -B, C) and II loci (HLA-DQ and -DR) calculated using serological or two-digit molecular typing compared to four-digit molecular typing methods. The proportion of donor/recipient pairs with a difference of >5 eplet mismatches between the HLA typing methods was also determined. Intra-class correlation coefficients between serological and four-digit molecular typing methods were 0.969 (95% confidence intervals [95% CI] 0.960–0.975) and 0.926 (95% CI 0.899–0.944), respectively; and 0.995 (95% CI 0.994–0.996) and 0.993 (95% CI 0.991–0.995), respectively between two-digit and four-digit molecular typing methods. The proportion of donor/recipient pairs with a difference of >5 eplet mismatches at class I and II loci was 4% and 16% for serological versus four-digit molecular typing methods, and 0% and 2% for two-digit versus four-digit molecular typing methods, respectively. In this small predominantly Caucasian population, compared with serology, there is a high level of agreement in the number of eplet mismatches calculated using two-compared to four-digit molecular HLA-typing methods, suggesting that two-digit typing may be sufficient in determining eplet mismatch load in kidney transplantation. PMID:29568344

  9. Longitudinal changes in young children’s 0–100 to 0–1000 number-line error signatures

    PubMed Central

    Reeve, Robert A.; Paul, Jacob M.; Butterworth, Brian

    2015-01-01

    We use a latent difference score (LDS) model to examine changes in young children’s number-line (NL) error signatures (errors marking numbers on a NL) over 18 months. A LDS model (1) overcomes some of the inference limitations of analytic models used in previous research, and in particular (2) provides a more reliable test of hypotheses about the meaning and significance of changes in NL error signatures over time and task. The NL error signatures of 217 6-year-olds’ (on test occasion one) were assessed three times over 18 months, along with their math ability on two occasions. On the first occasion (T1) children completed a 0–100 NL task; on the second (T2) a 0–100 NL and a 0–1000 NL task; on the third (T3) occasion a 0–1000 NL task. On the third and fourth occasions (T3 and T4), children completed mental calculation tasks. Although NL error signatures changed over time, these were predictable from other NL task error signatures, and predicted calculation accuracy at T3, as well as changes in calculation between T3 and T4. Multiple indirect effects (change parameters) showed that associations between initial NL error signatures (0–100 NL) and later mental calculation ability were mediated by error signatures on the 0–1000 NL task. The pattern of findings from the LDS model highlight the value of identifying direct and indirect effects in characterizing changing relationships in cognitive representations over task and time. Substantively, they support the claim that children’s NL error signatures generalize over task and time and thus can be used to predict math ability. PMID:26029152

  10. Statistical error in simulations of Poisson processes: Example of diffusion in solids

    NASA Astrophysics Data System (ADS)

    Nilsson, Johan O.; Leetmaa, Mikael; Vekilova, Olga Yu.; Simak, Sergei I.; Skorodumova, Natalia V.

    2016-08-01

    Simulations of diffusion in solids often produce poor statistics of diffusion events. We present an analytical expression for the statistical error in ion conductivity obtained in such simulations. The error expression is not restricted to any computational method in particular, but valid in the context of simulation of Poisson processes in general. This analytical error expression is verified numerically for the case of Gd-doped ceria by running a large number of kinetic Monte Carlo calculations.

  11. Inborn Errors of Fructose Metabolism. What Can We Learn from Them?

    PubMed

    Tran, Christel

    2017-04-03

    Fructose is one of the main sweetening agents in the human diet and its ingestion is increasing globally. Dietary sugar has particular effects on those whose capacity to metabolize fructose is limited. If intolerance to carbohydrates is a frequent finding in children, inborn errors of carbohydrate metabolism are rare conditions. Three inborn errors are known in the pathway of fructose metabolism; (1) essential or benign fructosuria due to fructokinase deficiency; (2) hereditary fructose intolerance; and (3) fructose-1,6-bisphosphatase deficiency. In this review the focus is set on the description of the clinical symptoms and biochemical anomalies in the three inborn errors of metabolism. The potential toxic effects of fructose in healthy humans also are discussed. Studies conducted in patients with inborn errors of fructose metabolism helped to understand fructose metabolism and its potential toxicity in healthy human. Influence of fructose on the glycolytic pathway and on purine catabolism is the cause of hypoglycemia, lactic acidosis and hyperuricemia. The discovery that fructose-mediated generation of uric acid may have a causal role in diabetes and obesity provided new understandings into pathogenesis for these frequent diseases.

  12. Inborn Errors of Fructose Metabolism. What Can We Learn from Them?

    PubMed Central

    Tran, Christel

    2017-01-01

    Fructose is one of the main sweetening agents in the human diet and its ingestion is increasing globally. Dietary sugar has particular effects on those whose capacity to metabolize fructose is limited. If intolerance to carbohydrates is a frequent finding in children, inborn errors of carbohydrate metabolism are rare conditions. Three inborn errors are known in the pathway of fructose metabolism; (1) essential or benign fructosuria due to fructokinase deficiency; (2) hereditary fructose intolerance; and (3) fructose-1,6-bisphosphatase deficiency. In this review the focus is set on the description of the clinical symptoms and biochemical anomalies in the three inborn errors of metabolism. The potential toxic effects of fructose in healthy humans also are discussed. Studies conducted in patients with inborn errors of fructose metabolism helped to understand fructose metabolism and its potential toxicity in healthy human. Influence of fructose on the glycolytic pathway and on purine catabolism is the cause of hypoglycemia, lactic acidosis and hyperuricemia. The discovery that fructose-mediated generation of uric acid may have a causal role in diabetes and obesity provided new understandings into pathogenesis for these frequent diseases. PMID:28368361

  13. Toward a human-centered aircraft automation philosophy

    NASA Technical Reports Server (NTRS)

    Billings, Charles E.

    1989-01-01

    The evolution of automation in civil aircraft is examined in order to discern trends in the respective roles and functions of automation technology and the humans who operate these aircraft. The effects of advances in automation technology on crew reaction is considered and it appears that, though automation may well have decreased the frequency of certain types of human errors in flight, it may also have enabled new categories of human errors, some perhaps less obvious and therefore more serious than those it has alleviated. It is suggested that automation could be designed to keep the pilot closer to the control of the vehicle, while providing an array of information management and aiding functions designed to provide the pilot with data regarding flight replanning, degraded system operation, and the operational status and limits of the aircraft, its systems, and the physical and operational environment. The automation would serve as the pilot's assistant, providing and calculating data, watching for the unexpected, and keeping track of resources and their rate of expenditure.

  14. Altitude deviations: Breakdowns of an error-tolerant system

    NASA Technical Reports Server (NTRS)

    Palmer, Everett A.; Hutchins, Edwin L.; Ritter, Richard D.; Vancleemput, Inge

    1993-01-01

    Pilot reports of aviation incidents to the Aviation Safety Reporting System (ASRS) provide a window on the problems occurring in today's airline cockpits. The narratives of 10 pilot reports of errors made in the automation-assisted altitude-change task are used to illustrate some of the issues of pilots interacting with automatic systems. These narratives are then used to construct a description of the cockpit as an information processing system. The analysis concentrates on the error-tolerant properties of the system and on how breakdowns can occasionally occur. An error-tolerant system can detect and correct its internal processing errors. The cockpit system consists of two or three pilots supported by autoflight, flight-management, and alerting systems. These humans and machines have distributed access to clearance information and perform redundant processing of information. Errors can be detected as deviations from either expected behavior or as deviations from expected information. Breakdowns in this system can occur when the checking and cross-checking tasks that give the system its error-tolerant properties are not performed because of distractions or other task demands. Recommendations based on the analysis for improving the error tolerance of the cockpit system are given.

  15. Verification of calculated skin doses in postmastectomy helical tomotherapy.

    PubMed

    Ito, Shima; Parker, Brent C; Levine, Renee; Sanders, Mary Ella; Fontenot, Jonas; Gibbons, John; Hogstrom, Kenneth

    2011-10-01

    To verify the accuracy of calculated skin doses in helical tomotherapy for postmastectomy radiation therapy (PMRT). In vivo thermoluminescent dosimeters (TLDs) were used to measure the skin dose at multiple points in each of 14 patients throughout the course of treatment on a TomoTherapy Hi·Art II system, for a total of 420 TLD measurements. Five patients were evaluated near the location of the mastectomy scar, whereas 9 patients were evaluated throughout the treatment volume. The measured dose at each location was compared with calculations from the treatment planning system. The mean difference and standard error of the mean difference between measurement and calculation for the scar measurements was -1.8% ± 0.2% (standard deviation [SD], 4.3%; range, -11.1% to 10.6%). The mean difference and standard error of the mean difference between measurement and calculation for measurements throughout the treatment volume was -3.0% ± 0.4% (SD, 4.7%; range, -18.4% to 12.6%). The mean difference and standard error of the mean difference between measurement and calculation for all measurements was -2.1% ± 0.2% (standard deviation, 4.5%: range, -18.4% to 12.6%). The mean difference between measured and calculated TLD doses was statistically significant at two standard deviations of the mean, but was not clinically significant (i.e., was <5%). However, 23% of the measured TLD doses differed from the calculated TLD doses by more than 5%. The mean of the measured TLD doses agreed with TomoTherapy calculated TLD doses within our clinical criterion of 5%. Copyright © 2011 Elsevier Inc. All rights reserved.

  16. Explicitly Representing the Solvation Shell in Continuum Solvent Calculations

    PubMed Central

    Svendsen, Hallvard F.; Merz, Kenneth M.

    2009-01-01

    A method is presented to explicitly represent the first solvation shell in continuum solvation calculations. Initial solvation shell geometries were generated with classical molecular dynamics simulations. Clusters consisting of solute and 5 solvent molecules were fully relaxed in quantum mechanical calculations. The free energy of solvation of the solute was calculated from the free energy of formation of the cluster and the solvation free energy of the cluster calculated with continuum solvation models. The method has been implemented with two continuum solvation models, a Poisson-Boltzmann model and the IEF-PCM model. Calculations were carried out for a set of 60 ionic species. Implemented with the Poisson-Boltzmann model the method gave an unsigned average error of 2.1 kcal/mol and a RMSD of 2.6 kcal/mol for anions, for cations the unsigned average error was 2.8 kcal/mol and the RMSD 3.9 kcal/mol. Similar results were obtained with the IEF-PCM model. PMID:19425558

  17. QUANTIFYING UNCERTAINTY DUE TO RANDOM ERRORS FOR MOMENT ANALYSES OF BREAKTHROUGH CURVES

    EPA Science Inventory

    The uncertainty in moments calculated from breakthrough curves (BTCs) is investigated as a function of random measurement errors in the data used to define the BTCs. The method presented assumes moments are calculated by numerical integration using the trapezoidal rule, and is t...

  18. Errors in calculated oncotic pressure of dog plasma.

    PubMed

    Gabel, J C; Scott, R L; Adair, T H; Drake, R E; Traber, D L

    1980-12-01

    Several equations to calculate plasma oncotic pressure (pi) from the total protein concentration (C) have been previously described. These equations were derived empirically from samples with a wide range of C obtained by diluting or concentrating normal plasma samples. To test these equations over a range of naturally occurring C, we measured C and pi of plasma samples from 40 dogs. C ranged from 5.3 to 8.7 g/dl and averaged 6.5 +/- 0.1 (mean +/- SE) and pi averaged 17.9 +/- 0.3 mmHg. The regression equation was pi = 78.14 + 1.67 C (r = 0.74). pi increased with C much less than predicted with the commonly used equations. The albumin-to-globulin concentration ratios (A/G), determined in 27 of the dogs, decreased with increasing C (A/G = 1.56-0.128 C, r = 0.62). The lower A/G at the higher C's could cause the lower than predicted increase in pi with C, because the equations were developed from data in which A/G was constant.

  19. Learning mechanisms to limit medication administration errors.

    PubMed

    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.

  20. Reduced discretization error in HZETRN

    DOE Office of Scientific and Technical Information (OSTI.GOV)

    Slaba, Tony C., E-mail: Tony.C.Slaba@nasa.gov; Blattnig, Steve R., E-mail: Steve.R.Blattnig@nasa.gov; Tweed, John, E-mail: jtweed@odu.edu

    2013-02-01

    The deterministic particle transport code HZETRN is an efficient analysis tool for studying the effects of space radiation on humans, electronics, and shielding materials. In a previous work, numerical methods in the code were reviewed, and new methods were developed that further improved efficiency and reduced overall discretization error. It was also shown that the remaining discretization error could be attributed to low energy light ions (A < 4) with residual ranges smaller than the physical step-size taken by the code. Accurately resolving the spectrum of low energy light particles is important in assessing risk associated with astronaut radiation exposure.more » In this work, modifications to the light particle transport formalism are presented that accurately resolve the spectrum of low energy light ion target fragments. The modified formalism is shown to significantly reduce overall discretization error and allows a physical approximation to be removed. For typical step-sizes and energy grids used in HZETRN, discretization errors for the revised light particle transport algorithms are shown to be less than 4% for aluminum and water shielding thicknesses as large as 100 g/cm{sup 2} exposed to both solar particle event and galactic cosmic ray environments.« less

  1. Comparison of Methodologies Using Estimated or Measured Values of Total Corneal Astigmatism for Toric Intraocular Lens Power Calculation.

    PubMed

    Ferreira, Tiago B; Ribeiro, Paulo; Ribeiro, Filomena J; O'Neill, João G

    2017-12-01

    To compare the prediction error in the calculation of toric intraocular lenses (IOLs) associated with methods that estimate the power of the posterior corneal surface (ie, Barrett toric calculator and Abulafia-Koch formula) with that of methods that consider real measures obtained using Scheimpflug imaging: a software that uses vectorial calculation (Panacea toric calculator: http://www.panaceaiolandtoriccalculator.com) and a ray tracing software (PhacoOptics, Aarhus Nord, Denmark). In 107 eyes of 107 patients undergoing cataract surgery with toric IOL implantation (Acrysof IQ Toric; Alcon Laboratories, Inc., Fort Worth, TX), predicted residual astigmatism by each calculation method was compared with manifest refractive astigmatism. Prediction error in residual astigmatism was calculated using vector analysis. All calculation methods resulted in overcorrection of with-the-rule astigmatism and undercorrection of against-the-rule astigmatism. Both estimation methods resulted in lower mean and centroid astigmatic prediction errors, and a larger number of eyes within 0.50 diopters (D) of absolute prediction error than methods considering real measures (P < .001). Centroid prediction error (CPE) was 0.07 D at 172° for the Barrett toric calculator and 0.13 D at 174° for the Abulafia-Koch formula (combined with Holladay calculator). For methods using real posterior corneal surface measurements, CPE was 0.25 D at 173° for the Panacea calculator and 0.29 D at 171° for the ray tracing software. The Barrett toric calculator and Abulafia-Koch formula yielded the lowest astigmatic prediction errors. Directly evaluating total corneal power for toric IOL calculation was not superior to estimating it. [J Refract Surg. 2017;33(12):794-800.]. Copyright 2017, SLACK Incorporated.

  2. Learning time-dependent noise to reduce logical errors: real time error rate estimation in quantum error correction

    NASA Astrophysics Data System (ADS)

    Huo, Ming-Xia; Li, Ying

    2017-12-01

    Quantum error correction is important to quantum information processing, which allows us to reliably process information encoded in quantum error correction codes. Efficient quantum error correction benefits from the knowledge of error rates. We propose a protocol for monitoring error rates in real time without interrupting the quantum error correction. Any adaptation of the quantum error correction code or its implementation circuit is not required. The protocol can be directly applied to the most advanced quantum error correction techniques, e.g. surface code. A Gaussian processes algorithm is used to estimate and predict error rates based on error correction data in the past. We find that using these estimated error rates, the probability of error correction failures can be significantly reduced by a factor increasing with the code distance.

  3. Quantification of airport community noise impact in terms of noise levels, population density, and human subjective response

    NASA Technical Reports Server (NTRS)

    Deloach, R.

    1981-01-01

    The Fraction Impact Method (FIM), developed by the National Research Council (NRC) for assessing the amount and physiological effect of noise, is described. Here, the number of people exposed to a given level of noise is multiplied by a weighting factor that depends on noise level. It is pointed out that the Aircraft-noise Levels and Annoyance MOdel (ALAMO), recently developed at NASA Langley Research Center, can perform the NRC fractional impact calculations for given modes of operation at any U.S. airport. The sensitivity of these calculations to errors in estimates of population, noise level, and human subjective response is discussed. It is found that a change in source noise causes a substantially smaller change in contour area than would be predicted simply on the basis of inverse square law considerations. Another finding is that the impact calculations are generally less sensitive to source noise errors than to systematic errors in population or subjective response.

  4. Error analysis for relay type satellite-aided search and rescue systems

    NASA Technical Reports Server (NTRS)

    Marini, J. W.

    1977-01-01

    An analysis was made of the errors in the determination of the position of an emergency transmitter in a satellite aided search and rescue system. The satellite was assumed to be at a height of 820 km in a near circular near polar orbit. Short data spans of four minutes or less were used. The error sources considered were measurement noise, transmitter frequency drift, ionospheric effects and error in the assumed height of the transmitter. The errors were calculated for several different transmitter positions, data rates and data spans. The only transmitter frequency used was 406 MHz, but the results can be scaled to different frequencies. In a typical case, in which four Doppler measurements were taken over a span of two minutes, the position error was about 1.2 km.

  5. Probing the cosmic causes of errors in supercomputers

    DOE Office of Scientific and Technical Information (OSTI.GOV)

    None

    Cosmic rays from outer space are causing errors in supercomputers. The neutrons that pass through the CPU may be causing binary data to flip leading to incorrect calculations. Los Alamos National Laboratory has developed detectors to determine how much data is being corrupted by these cosmic particles.

  6. Error and Error Mitigation in Low-Coverage Genome Assemblies

    PubMed Central

    Hubisz, Melissa J.; Lin, Michael F.; Kellis, Manolis; Siepel, Adam

    2011-01-01

    The recent release of twenty-two new genome sequences has dramatically increased the data available for mammalian comparative genomics, but twenty of these new sequences are currently limited to ∼2× coverage. Here we examine the extent of sequencing error in these 2× assemblies, and its potential impact in downstream analyses. By comparing 2× assemblies with high-quality sequences from the ENCODE regions, we estimate the rate of sequencing error to be 1–4 errors per kilobase. While this error rate is fairly modest, sequencing error can still have surprising effects. For example, an apparent lineage-specific insertion in a coding region is more likely to reflect sequencing error than a true biological event, and the length distribution of coding indels is strongly distorted by error. We find that most errors are contributed by a small fraction of bases with low quality scores, in particular, by the ends of reads in regions of single-read coverage in the assembly. We explore several approaches for automatic sequencing error mitigation (SEM), making use of the localized nature of sequencing error, the fact that it is well predicted by quality scores, and information about errors that comes from comparisons across species. Our automatic methods for error mitigation cannot replace the need for additional sequencing, but they do allow substantial fractions of errors to be masked or eliminated at the cost of modest amounts of over-correction, and they can reduce the impact of error in downstream phylogenomic analyses. Our error-mitigated alignments are available for download. PMID:21340033

  7. Latent error detection: A golden two hours for detection.

    PubMed

    Saward, Justin R E; Stanton, Neville A

    2017-03-01

    Undetected error in safety critical contexts generates a latent condition that can contribute to a future safety failure. The detection of latent errors post-task completion is observed in naval air engineers using a diary to record work-related latent error detection (LED) events. A systems view is combined with multi-process theories to explore sociotechnical factors associated with LED. Perception of cues in different environments facilitates successful LED, for which the deliberate review of past tasks within two hours of the error occurring and whilst remaining in the same or similar sociotechnical environment to that which the error occurred appears most effective. Identified ergonomic interventions offer potential mitigation for latent errors; particularly in simple everyday habitual tasks. It is thought safety critical organisations should look to engineer further resilience through the application of LED techniques that engage with system cues across the entire sociotechnical environment, rather than relying on consistent human performance. Crown Copyright © 2016. Published by Elsevier Ltd. All rights reserved.

  8. Impact of Uncertainties and Errors in Converting NWS Radiosonde Hygristor Resistances to Relative Humidity

    NASA Technical Reports Server (NTRS)

    Westphal, Douglas L.; Russell, Philip (Technical Monitor)

    1994-01-01

    A set of 2,600 6-second, National Weather Service soundings from NASA's FIRE-II Cirrus field experiment are used to illustrate previously known errors and new potential errors in the VIZ and SDD brand relative humidity (RH) sensors and the MicroART processing software. The entire spectrum of RH is potentially affected by at least one of these errors. (These errors occur before being converted to dew point temperature.) Corrections to the errors are discussed. Examples are given of the effect that these errors and biases may have on numerical weather prediction and radiative transfer. The figure shows the OLR calculated for the corrected and uncorrected soundings using an 18-band radiative transfer code. The OLR differences are sufficiently large to warrant consideration when validating line-by-line radiation calculations that use radiosonde data to specify the atmospheric state, or when validating satellite retrievals. In addition, a comparison of observations of RE during FIRE-II derived from GOES satellite, raman lidar, MAPS analyses, NCAR CLASS sondes, and the NWS sondes reveals disagreement in the RH distribution and underlines our lack of an understanding of the climatology of water vapor.

  9. Impact of Uncertainties and Errors in Converting NWS Radiosonde Hygristor Resistances to Relative Humidity

    NASA Technical Reports Server (NTRS)

    Westphal, Douglas L.; Russell, Philip B. (Technical Monitor)

    1994-01-01

    A set of 2,600 6-second, National Weather Service soundings from NASA's FIRE-II Cirrus field experiment are used to illustrate previously known errors and new potential errors in the VIZ and SDD ) brand relative humidity (RH) sensors and the MicroART processing software. The entire spectrum of RH is potentially affected by at least one of these errors. (These errors occur before being converted to dew point temperature.) Corrections to the errors are discussed. Examples are given of the effect that these errors and biases may have on numerical weather prediction and radiative transfer. The figure shows the OLR calculated for the corrected and uncorrected soundings using an 18-band radiative transfer code. The OLR differences are sufficiently large to warrant consideration when validating line-by-line radiation calculations that use radiosonde data to specify the atmospheric state, or when validating satellite retrievals. in addition, a comparison of observations of RH during FIRE-II derived from GOES satellite, raman lidar, MAPS analyses, NCAR CLASS sondes, and the NWS sondes reveals disagreement in the RH distribution and underlines our lack of an understanding of the climatology of water vapor.

  10. Validation of a program for supercritical power plant calculations

    NASA Astrophysics Data System (ADS)

    Kotowicz, Janusz; Łukowicz, Henryk; Bartela, Łukasz; Michalski, Sebastian

    2011-12-01

    This article describes the validation of a supercritical steam cycle. The cycle model was created with the commercial program GateCycle and validated using in-house code of the Institute of Power Engineering and Turbomachinery. The Institute's in-house code has been used extensively for industrial power plants calculations with good results. In the first step of the validation process, assumptions were made about the live steam temperature and pressure, net power, characteristic quantities for high- and low-pressure regenerative heat exchangers and pressure losses in heat exchangers. These assumptions were then used to develop a steam cycle model in Gate-Cycle and a model based on the code developed in-house at the Institute of Power Engineering and Turbomachinery. Properties, such as thermodynamic parameters at characteristic points of the steam cycle, net power values and efficiencies, heat provided to the steam cycle and heat taken from the steam cycle, were compared. The last step of the analysis was calculation of relative errors of compared values. The method used for relative error calculations is presented in the paper. The assigned relative errors are very slight, generally not exceeding 0.1%. Based on our analysis, it can be concluded that using the GateCycle software for calculations of supercritical power plants is possible.

  11. Accuracy control in Monte Carlo radiative calculations

    NASA Technical Reports Server (NTRS)

    Almazan, P. Planas

    1993-01-01

    The general accuracy law that rules the Monte Carlo, ray-tracing algorithms used commonly for the calculation of the radiative entities in the thermal analysis of spacecraft are presented. These entities involve transfer of radiative energy either from a single source to a target (e.g., the configuration factors). or from several sources to a target (e.g., the absorbed heat fluxes). In fact, the former is just a particular case of the latter. The accuracy model is later applied to the calculation of some specific radiative entities. Furthermore, some issues related to the implementation of such a model in a software tool are discussed. Although only the relative error is considered through the discussion, similar results can be derived for the absolute error.

  12. Blood transfusion sampling and a greater role for error recovery.

    PubMed

    Oldham, Jane

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

  13. Research on error control and compensation in magnetorheological finishing.

    PubMed

    Dai, Yifan; Hu, Hao; Peng, Xiaoqiang; Wang, Jianmin; Shi, Feng

    2011-07-01

    Although magnetorheological finishing (MRF) is a deterministic finishing technology, the machining results always fall short of simulation precision in the actual process, and it cannot meet the precision requirements just through a single treatment but after several iterations. We investigate the reasons for this problem through simulations and experiments. Through controlling and compensating the chief errors in the manufacturing procedure, such as removal function calculation error, positioning error of the removal function, and dynamic performance limitation of the CNC machine, the residual error convergence ratio (ratio of figure error before and after processing) in a single process is obviously increased, and higher figure precision is achieved. Finally, an improved technical process is presented based on these researches, and the verification experiment is accomplished on the experimental device we developed. The part is a circular plane mirror of fused silica material, and the surface figure error is improved from the initial λ/5 [peak-to-valley (PV) λ=632.8 nm], λ/30 [root-mean-square (rms)] to the final λ/40 (PV), λ/330 (rms) just through one iteration in 4.4 min. Results show that a higher convergence ratio and processing precision can be obtained by adopting error control and compensation techniques in MRF.

  14. [Improving blood safety: errors management in transfusion medicine].

    PubMed

    Bujandrić, Nevenka; Grujić, Jasmina; Krga-Milanović, Mirjana

    2014-01-01

    The concept of blood safety includes the entire transfusion chain starting with the collection of blood from the blood donor, and ending with blood transfusion to the patient. The concept involves quality management system as the systematic monitoring of adverse reactions and incidents regarding the blood donor or patient. Monitoring of near-miss errors show the critical points in the working process and increase transfusion safety. The aim of the study was to present the analysis results of adverse and unexpected events in transfusion practice with a potential risk to the health of blood donors and patients. One-year retrospective study was based on the collection, analysis and interpretation of written reports on medical errors in the Blood Transfusion Institute of Vojvodina. Errors were distributed according to the type, frequency and part of the working process where they occurred. Possible causes and corrective actions were described for each error. The study showed that there were not errors with potential health consequences for the blood donor/patient. Errors with potentially damaging consequences for patients were detected throughout the entire transfusion chain. Most of the errors were identified in the preanalytical phase. The human factor was responsible for the largest number of errors. Error reporting system has an important role in the error management and the reduction of transfusion-related risk of adverse events and incidents. The ongoing analysis reveals the strengths and weaknesses of the entire process and indicates the necessary changes. Errors in transfusion medicine can be avoided in a large percentage and prevention is cost-effective, systematic and applicable.

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

    PubMed

    Graber, Mark; Gordon, Ruthanna; Franklin, Nancy

    2002-10-01

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

  16. CCSDT calculations of molecular equilibrium geometries

    NASA Astrophysics Data System (ADS)

    Halkier, Asger; Jørgensen, Poul; Gauss, Jürgen; Helgaker, Trygve

    1997-08-01

    CCSDT equilibrium geometries of CO, CH 2, F 2, HF, H 2O and N 2 have been calculated using the correlation-consistent cc-pVXZ basis sets. Similar calculations have been performed for SCF, CCSD and CCSD(T). In general, bond lengths decrease when improving the basis set and increase when improving the N-electron treatment. CCSD(T) provides an excellent approximation to CCSDT for bond lengths as the largest difference between CCSDT and CCSD(T) is 0.06 pm. At the CCSDT/cc-pVQZ level, basis set deficiencies, neglect of higher-order excitations, and incomplete treatment of core-correlation all give rise to errors of a few tenths of a pm, but to a large extent, these errors cancel. The CCSDT/cc-pVQZ bond lengths deviate on average only by 0.11 pm from experiment.

  17. CREME96 and Related Error Rate Prediction Methods

    NASA Technical Reports Server (NTRS)

    Adams, James H., Jr.

    2012-01-01

    Predicting the rate of occurrence of single event effects (SEEs) in space requires knowledge of the radiation environment and the response of electronic devices to that environment. Several analytical models have been developed over the past 36 years to predict SEE rates. The first error rate calculations were performed by Binder, Smith and Holman. Bradford and Pickel and Blandford, in their CRIER (Cosmic-Ray-Induced-Error-Rate) analysis code introduced the basic Rectangular ParallelePiped (RPP) method for error rate calculations. For the radiation environment at the part, both made use of the Cosmic Ray LET (Linear Energy Transfer) spectra calculated by Heinrich for various absorber Depths. A more detailed model for the space radiation environment within spacecraft was developed by Adams and co-workers. This model, together with a reformulation of the RPP method published by Pickel and Blandford, was used to create the CR ME (Cosmic Ray Effects on Micro-Electronics) code. About the same time Shapiro wrote the CRUP (Cosmic Ray Upset Program) based on the RPP method published by Bradford. It was the first code to specifically take into account charge collection from outside the depletion region due to deformation of the electric field caused by the incident cosmic ray. Other early rate prediction methods and codes include the Single Event Figure of Merit, NOVICE, the Space Radiation code and the effective flux method of Binder which is the basis of the SEFA (Scott Effective Flux Approximation) model. By the early 1990s it was becoming clear that CREME and the other early models needed Revision. This revision, CREME96, was completed and released as a WWW-based tool, one of the first of its kind. The revisions in CREME96 included improved environmental models and improved models for calculating single event effects. The need for a revision of CREME also stimulated the development of the CHIME (CRRES/SPACERAD Heavy Ion Model of the Environment) and MACREE (Modeling and

  18. Reducing measurement errors during functional capacity tests in elders.

    PubMed

    da Silva, Mariane Eichendorf; Orssatto, Lucas Bet da Rosa; Bezerra, Ewertton de Souza; Silva, Diego Augusto Santos; Moura, Bruno Monteiro de; Diefenthaeler, Fernando; Freitas, Cíntia de la Rocha

    2018-06-01

    Accuracy is essential to the validity of functional capacity measurements. To evaluate the error of measurement of functional capacity tests for elders and suggest the use of the technical error of measurement and credibility coefficient. Twenty elders (65.8 ± 4.5 years) completed six functional capacity tests that were simultaneously filmed and timed by four evaluators by means of a chronometer. A fifth evaluator timed the tests by analyzing the videos (reference data). The means of most evaluators for most tests were different from the reference (p < 0.05), except for two evaluators for two different tests. There were different technical error of measurement between tests and evaluators. The Bland-Altman test showed difference in the concordance of the results between methods. Short duration tests showed higher technical error of measurement than longer tests. In summary, tests timed by a chronometer underestimate the real results of the functional capacity. Difference between evaluators' reaction time and perception to determine the start and the end of the tests would justify the errors of measurement. Calculation of the technical error of measurement or the use of the camera can increase data validity.

  19. Unforced errors and error reduction in tennis

    PubMed Central

    Brody, H

    2006-01-01

    Only at the highest level of tennis is the number of winners comparable to the number of unforced errors. As the average player loses many more points due to unforced errors than due to winners by an opponent, if the rate of unforced errors can be reduced, it should lead to an increase in points won. This article shows how players can improve their game by understanding and applying the laws of physics to reduce the number of unforced errors. PMID:16632568

  20. The Enigmatic Cornea and Intraocular Lens Calculations: The LXXIII Edward Jackson Memorial Lecture.

    PubMed

    Koch, Douglas D

    2016-11-01

    To review the progress and challenges in obtaining accurate corneal power measurements for intraocular lens (IOL) calculations. Personal perspective, review of literature, case presentations, and personal data. Through literature review findings, case presentations, and data from the author's center, the types of corneal measurement errors that can occur in IOL calculation are categorized and described, along with discussion of future options to improve accuracy. Advances in IOL calculation technology and formulas have greatly increased the accuracy of IOL calculations. Recent reports suggest that over 90% of normal eyes implanted with IOLs may achieve accuracy to within 0.5 diopter (D) of the refractive target. Though errors in estimation of corneal power can cause IOL calculation errors in eyes with normal corneas, greater difficulties in measuring corneal power are encountered in eyes with diseased, scarred, and postsurgical corneas. For these corneas, problematic issues are quantifying anterior corneal power and measuring posterior corneal power and astigmatism. Results in these eyes are improving, but 2 examples illustrate current limitations: (1) spherical accuracy within 0.5 D is achieved in only 70% of eyes with post-refractive surgery corneas, and (2) astigmatism accuracy within 0.5 D is achieved in only 80% of eyes implanted with toric IOLs. Corneal power measurements are a major source of error in IOL calculations. New corneal imaging technology and IOL calculation formulas have improved outcomes and hold the promise of ongoing progress. Copyright © 2016 Elsevier Inc. All rights reserved.

  1. "First, know thyself": cognition and error in medicine.

    PubMed

    Elia, Fabrizio; Aprà, Franco; Verhovez, Andrea; Crupi, Vincenzo

    2016-04-01

    Although error is an integral part of the world of medicine, physicians have always been little inclined to take into account their own mistakes and the extraordinary technological progress observed in the last decades does not seem to have resulted in a significant reduction in the percentage of diagnostic errors. The failure in the reduction in diagnostic errors, notwithstanding the considerable investment in human and economic resources, has paved the way to new strategies which were made available by the development of cognitive psychology, the branch of psychology that aims at understanding the mechanisms of human reasoning. This new approach led us to realize that we are not fully rational agents able to take decisions on the basis of logical and probabilistically appropriate evaluations. In us, two different and mostly independent modes of reasoning coexist: a fast or non-analytical reasoning, which tends to be largely automatic and fast-reactive, and a slow or analytical reasoning, which permits to give rationally founded answers. One of the features of the fast mode of reasoning is the employment of standardized rules, termed "heuristics." Heuristics lead physicians to correct choices in a large percentage of cases. Unfortunately, cases exist wherein the heuristic triggered fails to fit the target problem, so that the fast mode of reasoning can lead us to unreflectively perform actions exposing us and others to variable degrees of risk. Cognitive errors arise as a result of these cases. Our review illustrates how cognitive errors can cause diagnostic problems in clinical practice.

  2. What Happened, and Why: Toward an Understanding of Human Error Based on Automated Analyses of Incident Reports. Volume 1

    NASA Technical Reports Server (NTRS)

    Maille, Nicolas P.; Statler, Irving C.; Ferryman, Thomas A.; Rosenthal, Loren; Shafto, Michael G.; Statler, Irving C.

    2006-01-01

    The objective of the Aviation System Monitoring and Modeling (ASMM) project of NASA s Aviation Safety and Security Program was to develop technologies that will enable proactive management of safety risk, which entails identifying the precursor events and conditions that foreshadow most accidents. This presents a particular challenge in the aviation system where people are key components and human error is frequently cited as a major contributing factor or cause of incidents and accidents. In the aviation "world", information about what happened can be extracted from quantitative data sources, but the experiential account of the incident reporter is the best available source of information about why an incident happened. This report describes a conceptual model and an approach to automated analyses of textual data sources for the subjective perspective of the reporter of the incident to aid in understanding why an incident occurred. It explores a first-generation process for routinely searching large databases of textual reports of aviation incident or accidents, and reliably analyzing them for causal factors of human behavior (the why of an incident). We have defined a generic structure of information that is postulated to be a sound basis for defining similarities between aviation incidents. Based on this structure, we have introduced the simplifying structure, which we call the Scenario as a pragmatic guide for identifying similarities of what happened based on the objective parameters that define the Context and the Outcome of a Scenario. We believe that it will be possible to design an automated analysis process guided by the structure of the Scenario that will aid aviation-safety experts to understand the systemic issues that are conducive to human error.

  3. Evaluation of students' knowledge about paediatric dosage calculations.

    PubMed

    Özyazıcıoğlu, Nurcan; Aydın, Ayla İrem; Sürenler, Semra; Çinar, Hava Gökdere; Yılmaz, Dilek; Arkan, Burcu; Tunç, Gülseren Çıtak

    2018-01-01

    Medication errors are common and may jeopardize the patient safety. As paediatric dosages are calculated based on the child's age and weight, risk of error in dosage calculations is increasing. In paediatric patients, overdose drug prescribed regardless of the child's weight, age and clinical picture may lead to excessive toxicity and mortalities while low doses may delay the treatment. This study was carried out to evaluate the knowledge of nursing students about paediatric dosage calculations. This research, which is of retrospective type, covers a population consisting of all the 3rd grade students at the bachelor's degree in May, 2015 (148 students). Drug dose calculation questions in exam papers including 3 open ended questions on dosage calculation problems, addressing 5 variables were distributed to the students and their responses were evaluated by the researchers. In the evaluation of the data, figures and percentage distribution were calculated and Spearman correlation analysis was applied. Exam question on the dosage calculation based on child's age, which is the most common method in paediatrics, and which ensures right dosages and drug dilution was answered correctly by 87.1% of the students while 9.5% answered it wrong and 3.4% left it blank. 69.6% of the students was successful in finding the safe dose range, and 79.1% in finding the right ratio/proportion. 65.5% of the answers with regard to Ml/dzy calculation were correct. Moreover, student's four operation skills were assessed and 68.2% of the students were determined to have found the correct answer. When the relation among the questions on medication was examined, a significant relation (correlation) was determined between them. It is seen that in dosage calculations, the students failed mostly in calculating ml/dzy (decimal). This result means that as dosage calculations are based on decimal values, calculations may be ten times erroneous when the decimal point is placed wrongly. Moreover, it

  4. Intermittently-visual Tracking Experiments Reveal the Roles of Error-correction and Predictive Mechanisms in the Human Visual-motor Control System

    NASA Astrophysics Data System (ADS)

    Hayashi, Yoshikatsu; Tamura, Yurie; Sase, Kazuya; Sugawara, Ken; Sawada, Yasuji

    Prediction mechanism is necessary for human visual motion to compensate a delay of sensory-motor system. In a previous study, “proactive control” was discussed as one example of predictive function of human beings, in which motion of hands preceded the virtual moving target in visual tracking experiments. To study the roles of the positional-error correction mechanism and the prediction mechanism, we carried out an intermittently-visual tracking experiment where a circular orbit is segmented into the target-visible regions and the target-invisible regions. Main results found in this research were following. A rhythmic component appeared in the tracer velocity when the target velocity was relatively high. The period of the rhythm in the brain obtained from environmental stimuli is shortened more than 10%. The shortening of the period of rhythm in the brain accelerates the hand motion as soon as the visual information is cut-off, and causes the precedence of hand motion to the target motion. Although the precedence of the hand in the blind region is reset by the environmental information when the target enters the visible region, the hand motion precedes the target in average when the predictive mechanism dominates the error-corrective mechanism.

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

    PubMed

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

    2016-07-01

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

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

    PubMed Central

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

    2016-01-01

    The theory of sky-polarimetric Viking navigation has been widely accepted for decades without any information about the accuracy of this method. Previously, we have measured the accuracy of the first and second steps of this navigation method in psychophysical laboratory and planetarium experiments. Now, we have tested the accuracy of the third step in a planetarium experiment, assuming that the first and second steps are errorless. Using the fists of their outstretched arms, 10 test persons had to estimate the elevation angles (measured in numbers of fists and fingers) of black dots (representing the position of the occluded Sun) projected onto the planetarium dome. The test persons performed 2400 elevation estimations, 48% of which were more accurate than ±1°. We selected three test persons with the (i) largest and (ii) smallest elevation errors and (iii) highest standard deviation of the elevation error. From the errors of these three persons, we calculated their error function, from which the North errors (the angles with which they deviated from the geographical North) were determined for summer solstice and spring equinox, two specific dates of the Viking sailing period. The range of possible North errors ΔωN was the lowest and highest at low and high solar elevations, respectively. At high elevations, the maximal ΔωN was 35.6° and 73.7° at summer solstice and 23.8° and 43.9° at spring equinox for the best and worst test person (navigator), respectively. Thus, the best navigator was twice as good as the worst one. At solstice and equinox, high elevations occur the most frequently during the day, thus high North errors could occur more frequently than expected before. According to our findings, the ideal periods for sky-polarimetric Viking navigation are immediately after sunrise and before sunset, because the North errors are the lowest at low solar elevations. PMID:27493566

  7. Ultraspectral sounding retrieval error budget and estimation

    NASA Astrophysics Data System (ADS)

    Zhou, Daniel K.; Larar, Allen M.; Liu, Xu; Smith, William L.; Strow, Larrabee L.; Yang, Ping

    2011-11-01

    The ultraspectral infrared radiances obtained from satellite observations provide atmospheric, surface, and/or cloud information. The intent of the measurement of the thermodynamic state is the initialization of weather and climate models. Great effort has been given to retrieving and validating these atmospheric, surface, and/or cloud properties. Error Consistency Analysis Scheme (ECAS), through fast radiative transfer model (RTM) forward and inverse calculations, has been developed to estimate the error budget in terms of absolute and standard deviation of differences in both spectral radiance and retrieved geophysical parameter domains. The retrieval error is assessed through ECAS without assistance of other independent measurements such as radiosonde data. ECAS re-evaluates instrument random noise, and establishes the link between radiometric accuracy and retrieved geophysical parameter accuracy. ECAS can be applied to measurements of any ultraspectral instrument and any retrieval scheme with associated RTM. In this paper, ECAS is described and demonstration is made with the measurements of the METOP-A satellite Infrared Atmospheric Sounding Interferometer (IASI).

  8. Asteroid orbital error analysis: Theory and application

    NASA Technical Reports Server (NTRS)

    Muinonen, K.; Bowell, Edward

    1992-01-01

    We present a rigorous Bayesian theory for asteroid orbital error estimation in which the probability density of the orbital elements is derived from the noise statistics of the observations. For Gaussian noise in a linearized approximation the probability density is also Gaussian, and the errors of the orbital elements at a given epoch are fully described by the covariance matrix. The law of error propagation can then be applied to calculate past and future positional uncertainty ellipsoids (Cappellari et al. 1976, Yeomans et al. 1987, Whipple et al. 1991). To our knowledge, this is the first time a Bayesian approach has been formulated for orbital element estimation. In contrast to the classical Fisherian school of statistics, the Bayesian school allows a priori information to be formally present in the final estimation. However, Bayesian estimation does give the same results as Fisherian estimation when no priori information is assumed (Lehtinen 1988, and reference therein).

  9. Ultraspectral Sounding Retrieval Error Budget and Estimation

    NASA Technical Reports Server (NTRS)

    Zhou, Daniel K.; Larar, Allen M.; Liu, Xu; Smith, William L.; Strow, L. Larrabee; Yang, Ping

    2011-01-01

    The ultraspectral infrared radiances obtained from satellite observations provide atmospheric, surface, and/or cloud information. The intent of the measurement of the thermodynamic state is the initialization of weather and climate models. Great effort has been given to retrieving and validating these atmospheric, surface, and/or cloud properties. Error Consistency Analysis Scheme (ECAS), through fast radiative transfer model (RTM) forward and inverse calculations, has been developed to estimate the error budget in terms of absolute and standard deviation of differences in both spectral radiance and retrieved geophysical parameter domains. The retrieval error is assessed through ECAS without assistance of other independent measurements such as radiosonde data. ECAS re-evaluates instrument random noise, and establishes the link between radiometric accuracy and retrieved geophysical parameter accuracy. ECAS can be applied to measurements of any ultraspectral instrument and any retrieval scheme with associated RTM. In this paper, ECAS is described and demonstration is made with the measurements of the METOP-A satellite Infrared Atmospheric Sounding Interferometer (IASI)..

  10. Mental representation of symbols as revealed by vocabulary errors in two bonobos (Pan paniscus).

    PubMed

    Lyn, Heidi

    2007-10-01

    Error analysis has been used in humans to detect implicit representations and categories in language use. The present study utilizes the same technique to report on mental representations and categories in symbol use from two bonobos (Pan paniscus). These bonobos have been shown in published reports to comprehend English at the level of a two-and-a-half year old child and to use a keyboard with over 200 visuographic symbols (lexigrams). In this study, vocabulary test errors from over 10 years of data revealed auditory, visual, and spatio-temporal generalizations (errors were more likely items that looked like sounded like, or were frequently associated with the sample item in space or in time), as well as hierarchical and conceptual categorizations. These error data, like those of humans, are a result of spontaneous responding rather than specific training and do not solely depend upon the sample mode (e.g. auditory similarity errors are not universally more frequent with an English sample, nor were visual similarity errors universally more frequent with a photograph sample). However, unlike humans, these bonobos do not make errors based on syntactical confusions (e.g. confusing semantically unrelated nouns), suggesting that they may not separate syntactical and semantic information. These data suggest that apes spontaneously create a complex, hierarchical, web of representations when exposed to a symbol system.

  11. Error assessment in molecular dynamics trajectories using computed NMR chemical shifts.

    PubMed

    Koes, David R; Vries, John K

    2017-01-01

    Accurate chemical shifts for the atoms in molecular mechanics (MD) trajectories can be obtained from quantum mechanical (QM) calculations that depend solely on the coordinates of the atoms in the localized regions surrounding atoms of interest. If these coordinates are correct and the sample size is adequate, the ensemble average of these chemical shifts should be equal to the chemical shifts obtained from NMR spectroscopy. If this is not the case, the coordinates must be incorrect. We have utilized this fact to quantify the errors associated with the backbone atoms in MD simulations of proteins. A library of regional conformers containing 169,499 members was constructed from 6 model proteins. The chemical shifts associated with the backbone atoms in each of these conformers was obtained from QM calculations using density functional theory at the B3LYP level with a 6-311+G(2d,p) basis set. Chemical shifts were assigned to each backbone atom in each MD simulation frame using a template matching approach. The ensemble average of these chemical shifts was compared to chemical shifts from NMR spectroscopy. A large systematic error was identified that affected the 1 H atoms of the peptide bonds involved in hydrogen bonding with water molecules or peptide backbone atoms. This error was highly sensitive to changes in electrostatic parameters. Smaller errors affecting the 13 C a and 15 N atoms were also detected. We believe these errors could be useful as metrics for comparing the force-fields and parameter sets used in MD simulation because they are directly tied to errors in atomic coordinates.

  12. The spontaneous replication error and the mismatch discrimination mechanisms of human DNA polymerase β

    PubMed Central

    Koag, Myong-Chul; Nam, Kwangho; Lee, Seongmin

    2014-01-01

    To provide molecular-level insights into the spontaneous replication error and the mismatch discrimination mechanisms of human DNA polymerase β (polβ), we report four crystal structures of polβ complexed with dG•dTTP and dA•dCTP mismatches in the presence of Mg2+ or Mn2+. The Mg2+-bound ground-state structures show that the dA•dCTP-Mg2+ complex adopts an ‘intermediate’ protein conformation while the dG•dTTP-Mg2+ complex adopts an open protein conformation. The Mn2+-bound ‘pre-chemistry-state’ structures show that the dA•dCTP-Mn2+ complex is structurally very similar to the dA•dCTP-Mg2+ complex, whereas the dG•dTTP-Mn2+ complex undergoes a large-scale conformational change to adopt a Watson–Crick-like dG•dTTP base pair and a closed protein conformation. These structural differences, together with our molecular dynamics simulation studies, suggest that polβ increases replication fidelity via a two-stage mismatch discrimination mechanism, where one is in the ground state and the other in the closed conformation state. In the closed conformation state, polβ appears to allow only a Watson–Crick-like conformation for purine•pyrimidine base pairs, thereby discriminating the mismatched base pairs based on their ability to form the Watson–Crick-like conformation. Overall, the present studies provide new insights into the spontaneous replication error and the replication fidelity mechanisms of polβ. PMID:25200079

  13. Error rates in forensic DNA analysis: definition, numbers, impact and communication.

    PubMed

    Kloosterman, Ate; Sjerps, Marjan; Quak, Astrid

    2014-09-01

    Forensic DNA casework is currently regarded as one of the most important types of forensic evidence, and important decisions in intelligence and justice are based on it. However, errors occasionally occur and may have very serious consequences. In other domains, error rates have been defined and published. The forensic domain is lagging behind concerning this transparency for various reasons. In this paper we provide definitions and observed frequencies for different types of errors at the Human Biological Traces Department of the Netherlands Forensic Institute (NFI) over the years 2008-2012. Furthermore, we assess their actual and potential impact and describe how the NFI deals with the communication of these numbers to the legal justice system. We conclude that the observed relative frequency of quality failures is comparable to studies from clinical laboratories and genetic testing centres. Furthermore, this frequency is constant over the five-year study period. The most common causes of failures related to the laboratory process were contamination and human error. Most human errors could be corrected, whereas gross contamination in crime samples often resulted in irreversible consequences. Hence this type of contamination is identified as the most significant source of error. Of the known contamination incidents, most were detected by the NFI quality control system before the report was issued to the authorities, and thus did not lead to flawed decisions like false convictions. However in a very limited number of cases crucial errors were detected after the report was issued, sometimes with severe consequences. Many of these errors were made in the post-analytical phase. The error rates reported in this paper are useful for quality improvement and benchmarking, and contribute to an open research culture that promotes public trust. However, they are irrelevant in the context of a particular case. Here case-specific probabilities of undetected errors are needed

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

    PubMed

    Maier, Martin E; Steinhauser, Marco

    2013-10-02

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

  15. Neural markers of errors as endophenotypes in neuropsychiatric disorders

    PubMed Central

    Manoach, Dara S.; Agam, Yigal

    2013-01-01

    Learning from errors is fundamental to adaptive human behavior. It requires detecting errors, evaluating what went wrong, and adjusting behavior accordingly. These dynamic adjustments are at the heart of behavioral flexibility and accumulating evidence suggests that deficient error processing contributes to maladaptively rigid and repetitive behavior in a range of neuropsychiatric disorders. Neuroimaging and electrophysiological studies reveal highly reliable neural markers of error processing. In this review, we evaluate the evidence that abnormalities in these neural markers can serve as sensitive endophenotypes of neuropsychiatric disorders. We describe the behavioral and neural hallmarks of error processing, their mediation by common genetic polymorphisms, and impairments in schizophrenia, obsessive-compulsive disorder, and autism spectrum disorders. We conclude that neural markers of errors meet several important criteria as endophenotypes including heritability, established neuroanatomical and neurochemical substrates, association with neuropsychiatric disorders, presence in syndromally-unaffected family members, and evidence of genetic mediation. Understanding the mechanisms of error processing deficits in neuropsychiatric disorders may provide novel neural and behavioral targets for treatment and sensitive surrogate markers of treatment response. Treating error processing deficits may improve functional outcome since error signals provide crucial information for flexible adaptation to changing environments. Given the dearth of effective interventions for cognitive deficits in neuropsychiatric disorders, this represents a potentially promising approach. PMID:23882201

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

    PubMed

    Gu, Xiuzhu; Itoh, Kenji; Suzuki, Satoshi

    2014-12-01

    This paper describes the development of a haemodialysis error taxonomy system for analysing incidents and predicting the safety status of a dialysis organisation. The error taxonomy system was developed by adapting an error taxonomy system which assumed no specific specialty to haemodialysis situations. Its application was conducted with 1,909 incident reports collected from two dialysis facilities in Japan. Over 70% of haemodialysis incidents were reported as problems or complications related to dialyser, circuit, medication and setting of dialysis condition. Approximately 70% of errors took place immediately before and after the four hours of haemodialysis therapy. Error types most frequently made in the dialysis unit were omission and qualitative errors. Failures or complications classified to staff human factors, communication, task and organisational factors were found in most dialysis incidents. Device/equipment/materials, medicine and clinical documents were most likely to be involved in errors. Haemodialysis nurses were involved in more incidents related to medicine and documents, whereas dialysis technologists made more errors with device/equipment/materials. This error taxonomy system is able to investigate incidents and adverse events occurring in the dialysis setting but is also able to estimate safety-related status of an organisation, such as reporting culture. © 2014 European Dialysis and Transplant Nurses Association/European Renal Care Association.

  17. Neural markers of errors as endophenotypes in neuropsychiatric disorders.

    PubMed

    Manoach, Dara S; Agam, Yigal

    2013-01-01

    Learning from errors is fundamental to adaptive human behavior. It requires detecting errors, evaluating what went wrong, and adjusting behavior accordingly. These dynamic adjustments are at the heart of behavioral flexibility and accumulating evidence suggests that deficient error processing contributes to maladaptively rigid and repetitive behavior in a range of neuropsychiatric disorders. Neuroimaging and electrophysiological studies reveal highly reliable neural markers of error processing. In this review, we evaluate the evidence that abnormalities in these neural markers can serve as sensitive endophenotypes of neuropsychiatric disorders. We describe the behavioral and neural hallmarks of error processing, their mediation by common genetic polymorphisms, and impairments in schizophrenia, obsessive-compulsive disorder, and autism spectrum disorders. We conclude that neural markers of errors meet several important criteria as endophenotypes including heritability, established neuroanatomical and neurochemical substrates, association with neuropsychiatric disorders, presence in syndromally-unaffected family members, and evidence of genetic mediation. Understanding the mechanisms of error processing deficits in neuropsychiatric disorders may provide novel neural and behavioral targets for treatment and sensitive surrogate markers of treatment response. Treating error processing deficits may improve functional outcome since error signals provide crucial information for flexible adaptation to changing environments. Given the dearth of effective interventions for cognitive deficits in neuropsychiatric disorders, this represents a potentially promising approach.

  18. Analysis of the "naming game" with learning errors in communications.

    PubMed

    Lou, Yang; Chen, Guanrong

    2015-07-16

    Naming game simulates the process of naming an objective by a population of agents organized in a certain communication network. By pair-wise iterative interactions, the population reaches consensus asymptotically. We study naming game with communication errors during pair-wise conversations, with error rates in a uniform probability distribution. First, a model of naming game with learning errors in communications (NGLE) is proposed. Then, a strategy for agents to prevent learning errors is suggested. To that end, three typical topologies of communication networks, namely random-graph, small-world and scale-free networks, are employed to investigate the effects of various learning errors. Simulation results on these models show that 1) learning errors slightly affect the convergence speed but distinctively increase the requirement for memory of each agent during lexicon propagation; 2) the maximum number of different words held by the population increases linearly as the error rate increases; 3) without applying any strategy to eliminate learning errors, there is a threshold of the learning errors which impairs the convergence. The new findings may help to better understand the role of learning errors in naming game as well as in human language development from a network science perspective.

  19. Using Fault Trees to Advance Understanding of Diagnostic Errors.

    PubMed

    Rogith, Deevakar; Iyengar, M Sriram; Singh, Hardeep

    2017-11-01

    Diagnostic errors annually affect at least 5% of adults in the outpatient setting in the United States. Formal analytic techniques are only infrequently used to understand them, in part because of the complexity of diagnostic processes and clinical work flows involved. In this article, diagnostic errors were modeled using fault tree analysis (FTA), a form of root cause analysis that has been successfully used in other high-complexity, high-risk contexts. How factors contributing to diagnostic errors can be systematically modeled by FTA to inform error understanding and error prevention is demonstrated. A team of three experts reviewed 10 published cases of diagnostic error and constructed fault trees. The fault trees were modeled according to currently available conceptual frameworks characterizing diagnostic error. The 10 trees were then synthesized into a single fault tree to identify common contributing factors and pathways leading to diagnostic error. FTA is a visual, structured, deductive approach that depicts the temporal sequence of events and their interactions in a formal logical hierarchy. The visual FTA enables easier understanding of causative processes and cognitive and system factors, as well as rapid identification of common pathways and interactions in a unified fashion. In addition, it enables calculation of empirical estimates for causative pathways. Thus, fault trees might provide a useful framework for both quantitative and qualitative analysis of diagnostic errors. Future directions include establishing validity and reliability by modeling a wider range of error cases, conducting quantitative evaluations, and undertaking deeper exploration of other FTA capabilities. Copyright © 2017 The Joint Commission. Published by Elsevier Inc. All rights reserved.

  20. New algorithm for toric intraocular lens power calculation considering the posterior corneal astigmatism.

    PubMed

    Canovas, Carmen; Alarcon, Aixa; Rosén, Robert; Kasthurirangan, Sanjeev; Ma, Joseph J K; Koch, Douglas D; Piers, Patricia

    2018-02-01

    To assess the accuracy of toric intraocular lens (IOL) power calculations of a new algorithm that incorporates the effect of posterior corneal astigmatism (PCA). Abbott Medical Optics, Inc., Groningen, the Netherlands. Retrospective case report. In eyes implanted with toric IOLs, the exact vergence formula of the Tecnis toric calculator was used to predict refractive astigmatism from preoperative biometry, surgeon-estimated surgically induced astigmatism (SIA), and implanted IOL power, with and without including the new PCA algorithm. For each calculation method, the error in predicted refractive astigmatism was calculated as the vector difference between the prediction and the actual refraction. Calculations were also made using postoperative keratometry (K) values to eliminate the potential effect of incorrect SIA estimates. The study comprised 274 eyes. The PCA algorithm significantly reduced the centroid error in predicted refractive astigmatism (P < .001). With the PCA algorithm, the centroid error reduced from 0.50 @ 1 to 0.19 @ 3 when using preoperative K values and from 0.30 @ 0 to 0.02 @ 84 when using postoperative K values. Patients who had anterior corneal against-the-rule, with-the-rule, and oblique astigmatism had improvement with the PCA algorithm. In addition, the PCA algorithm reduced the median absolute error in all groups (P < .001). The use of the new PCA algorithm decreased the error in the prediction of residual refractive astigmatism in eyes implanted with toric IOLs. Therefore, the new PCA algorithm, in combination with an exact vergence IOL power calculation formula, led to an increased predictability of toric IOL power. Copyright © 2018 ASCRS and ESCRS. Published by Elsevier Inc. All rights reserved.

  1. Bulk locality and quantum error correction in AdS/CFT

    NASA Astrophysics Data System (ADS)

    Almheiri, Ahmed; Dong, Xi; Harlow, Daniel

    2015-04-01

    We point out a connection between the emergence of bulk locality in AdS/CFT and the theory of quantum error correction. Bulk notions such as Bogoliubov transformations, location in the radial direction, and the holographic entropy bound all have natural CFT interpretations in the language of quantum error correction. We also show that the question of whether bulk operator reconstruction works only in the causal wedge or all the way to the extremal surface is related to the question of whether or not the quantum error correcting code realized by AdS/CFT is also a "quantum secret sharing scheme", and suggest a tensor network calculation that may settle the issue. Interestingly, the version of quantum error correction which is best suited to our analysis is the somewhat nonstandard "operator algebra quantum error correction" of Beny, Kempf, and Kribs. Our proposal gives a precise formulation of the idea of "subregion-subregion" duality in AdS/CFT, and clarifies the limits of its validity.

  2. Dopamine neurons share common response function for reward prediction error

    PubMed Central

    Eshel, Neir; Tian, Ju; Bukwich, Michael; Uchida, Naoshige

    2016-01-01

    Dopamine neurons are thought to signal reward prediction error, or the difference between actual and predicted reward. How dopamine neurons jointly encode this information, however, remains unclear. One possibility is that different neurons specialize in different aspects of prediction error; another is that each neuron calculates prediction error in the same way. We recorded from optogenetically-identified dopamine neurons in the lateral ventral tegmental area (VTA) while mice performed classical conditioning tasks. Our tasks allowed us to determine the full prediction error functions of dopamine neurons and compare them to each other. We found striking homogeneity among individual dopamine neurons: their responses to both unexpected and expected rewards followed the same function, just scaled up or down. As a result, we could describe both individual and population responses using just two parameters. Such uniformity ensures robust information coding, allowing each dopamine neuron to contribute fully to the prediction error signal. PMID:26854803

  3. Prevention of medication errors: detection and audit.

    PubMed

    Montesi, Germana; Lechi, Alessandro

    2009-06-01

    1. Medication errors have important implications for patient safety, and their identification is a main target in improving clinical practice errors, in order to prevent adverse events. 2. Error detection is the first crucial step. Approaches to this are likely to be different in research and routine care, and the most suitable must be chosen according to the setting. 3. The major methods for detecting medication errors and associated adverse drug-related events are chart review, computerized monitoring, administrative databases, and claims data, using direct observation, incident reporting, and patient monitoring. All of these methods have both advantages and limitations. 4. Reporting discloses medication errors, can trigger warnings, and encourages the diffusion of a culture of safe practice. Combining and comparing data from various and encourages the diffusion of a culture of safe practice sources increases the reliability of the system. 5. Error prevention can be planned by means of retroactive and proactive tools, such as audit and Failure Mode, Effect, and Criticality Analysis (FMECA). Audit is also an educational activity, which promotes high-quality care; it should be carried out regularly. In an audit cycle we can compare what is actually done against reference standards and put in place corrective actions to improve the performances of individuals and systems. 6. Patient safety must be the first aim in every setting, in order to build safer systems, learning from errors and reducing the human and fiscal costs.

  4. Orbit error characteristic and distribution of TLE using CHAMP orbit data

    NASA Astrophysics Data System (ADS)

    Xu, Xiao-li; Xiong, Yong-qing

    2018-02-01

    Space object orbital covariance data is required for collision risk assessments, but publicly accessible two line element (TLE) data does not provide orbital error information. This paper compared historical TLE data and GPS precision ephemerides of CHAMP to assess TLE orbit accuracy from 2002 to 2008, inclusive. TLE error spatial variations with longitude and latitude were calculated to analyze error characteristics and distribution. The results indicate that TLE orbit data are systematically biased from the limited SGP4 model. The biases can reach the level of kilometers, and the sign and magnitude are correlate significantly with longitude.

  5. Simulation of the Effects of Random Measurement Errors

    ERIC Educational Resources Information Center

    Kinsella, I. A.; Hannaidh, P. B. O.

    1978-01-01

    Describes a simulation method for measurement of errors that requires calculators and tables of random digits. Each student simulates the random behaviour of the component variables in the function and by combining the results of all students, the outline of the sampling distribution of the function can be obtained. (GA)

  6. [From the concept of guilt to the value-free notification of errors in medicine. Risks, errors and patient safety].

    PubMed

    Haller, U; Welti, S; Haenggi, D; Fink, D

    2005-06-01

    The number of liability cases but also the size of individual claims due to alleged treatment errors are increasing steadily. Spectacular sentences, especially in the USA, encourage this trend. Wherever human beings work, errors happen. The health care system is particularly susceptible and shows a high potential for errors. Therefore risk management has to be given top priority in hospitals. Preparing the introduction of critical incident reporting (CIR) as the means to notify errors is time-consuming and calls for a change in attitude because in many places the necessary base of trust has to be created first. CIR is not made to find the guilty and punish them but to uncover the origins of errors in order to eliminate them. The Department of Anesthesiology of the University Hospital of Basel has developed an electronic error notification system, which, in collaboration with the Swiss Medical Association, allows each specialist society to participate electronically in a CIR system (CIRS) in order to create the largest database possible and thereby to allow statements concerning the extent and type of error sources in medicine. After a pilot project in 2000-2004, the Swiss Society of Gynecology and Obstetrics is now progressively introducing the 'CIRS Medical' of the Swiss Medical Association. In our country, such programs are vulnerable to judicial intervention due to the lack of explicit legal guarantees of protection. High-quality data registration and skillful counseling are all the more important. Hospital directors and managers are called upon to examine those incidents which are based on errors inherent in the system.

  7. Obstetric Neuraxial Drug Administration Errors: A Quantitative and Qualitative Analytical Review.

    PubMed

    Patel, Santosh; Loveridge, Robert

    2015-12-01

    Drug administration errors in obstetric neuraxial anesthesia can have devastating consequences. Although fully recognizing that they represent "only the tip of the iceberg," published case reports/series of these errors were reviewed in detail with the aim of estimating the frequency and the nature of these errors. We identified case reports and case series from MEDLINE and performed a quantitative analysis of the involved drugs, error setting, source of error, the observed complications, and any therapeutic interventions. We subsequently performed a qualitative analysis of the human factors involved and proposed modifications to practice. Twenty-nine cases were identified. Various drugs were given in error, but no direct effects on the course of labor, mode of delivery, or neonatal outcome were reported. Four maternal deaths from the accidental intrathecal administration of tranexamic acid were reported, all occurring after delivery of the fetus. A range of hemodynamic and neurologic signs and symptoms were noted, but the most commonly reported complication was the failure of the intended neuraxial anesthetic technique. Several human factors were present; most common factors were drug storage issues and similar drug appearance. Four practice recommendations were identified as being likely to have prevented the errors. The reported errors exposed latent conditions within health care systems. We suggest that the implementation of the following processes may decrease the risk of these types of drug errors: (1) Careful reading of the label on any drug ampule or syringe before the drug is drawn up or injected; (2) labeling all syringes; (3) checking labels with a second person or a device (such as a barcode reader linked to a computer) before the drug is drawn up or administered; and (4) use of non-Luer lock connectors on all epidural/spinal/combined spinal-epidural devices. Further study is required to determine whether routine use of these processes will reduce drug

  8. Large-scale compensation of errors in pairwise-additive empirical force fields: comparison of AMBER intermolecular terms with rigorous DFT-SAPT calculations.

    PubMed

    Zgarbová, Marie; Otyepka, Michal; Sponer, Jirí; Hobza, Pavel; Jurecka, Petr

    2010-09-21

    The intermolecular interaction energy components for several molecular complexes were calculated using force fields available in the AMBER suite of programs and compared with Density Functional Theory-Symmetry Adapted Perturbation Theory (DFT-SAPT) values. The extent to which such comparison is meaningful is discussed. The comparability is shown to depend strongly on the intermolecular distance, which means that comparisons made at one distance only are of limited value. At large distances the coulombic and van der Waals 1/r(6) empirical terms correspond fairly well with the DFT-SAPT electrostatics and dispersion terms, respectively. At the onset of electronic overlap the empirical values deviate from the reference values considerably. However, the errors in the force fields tend to cancel out in a systematic manner at equilibrium distances. Thus, the overall performance of the force fields displays errors an order of magnitude smaller than those of the individual interaction energy components. The repulsive 1/r(12) component of the van der Waals expression seems to be responsible for a significant part of the deviation of the force field results from the reference values. We suggest that further improvement of the force fields for intermolecular interactions would require replacement of the nonphysical 1/r(12) term by an exponential function. Dispersion anisotropy and its effects are discussed. Our analysis is intended to show that although comparing the empirical and non-empirical interaction energy components is in general problematic, it might bring insights useful for the construction of new force fields. Our results are relevant to often performed force-field-based interaction energy decompositions.

  9. Human error and crew resource management failures in Naval aviation mishaps: a review of U.S. Naval Safety Center data, 1990-96.

    PubMed

    Wiegmann, D A; Shappell, S A

    1999-12-01

    The present study examined the role of human error and crew-resource management (CRM) failures in U.S. Naval aviation mishaps. All tactical jet (TACAIR) and rotary wing Class A flight mishaps between fiscal years 1990-1996 were reviewed. Results indicated that over 75% of both TACAIR and rotary wing mishaps were attributable, at least in part, to some form of human error of which 70% were associated with aircrew human factors. Of these aircrew-related mishaps, approximately 56% involved at least one CRM failure. These percentages are very similar to those observed prior to the implementation of aircrew coordination training (ACT) in the fleet, suggesting that the initial benefits of the program have not persisted and that CRM failures continue to plague Naval aviation. Closer examination of these CRM-related mishaps suggest that the type of flight operations (preflight, routine, emergency) do play a role in the etiology of CRM failures. A larger percentage of CRM failures occurred during non-routine or extremis flight situations when TACAIR mishaps were considered. In contrast, a larger percentage of rotary wing CRM mishaps involved failures that occurred during routine flight operations. These findings illustrate the complex etiology of CRM failures within Naval aviation and support the need for ACT programs tailored to the unique problems faced by specific communities in the fleet.

  10. Technical Note: On the calculation of stopping-power ratio for stoichiometric calibration in proton therapy

    DOE Office of Scientific and Technical Information (OSTI.GOV)

    Ödén, Jakob; Zimmerman, Jens; Nowik, Patrik

    2015-09-15

    Purpose: The quantitative effects of assumptions made in the calculation of stopping-power ratios (SPRs) are investigated, for stoichiometric CT calibration in proton therapy. The assumptions investigated include the use of the Bethe formula without correction terms, Bragg additivity, the choice of I-value for water, and the data source for elemental I-values. Methods: The predictions of the Bethe formula for SPR (no correction terms) were validated against more sophisticated calculations using the SRIM software package for 72 human tissues. A stoichiometric calibration was then performed at our hospital. SPR was calculated for the human tissues using either the assumption of simplemore » Bragg additivity or the Seltzer-Berger rule (as used in ICRU Reports 37 and 49). In each case, the calculation was performed twice: First, by assuming the I-value of water was an experimentally based value of 78 eV (value proposed in Errata and Addenda for ICRU Report 73) and second, by recalculating the I-value theoretically. The discrepancy between predictions using ICRU elemental I-values and the commonly used tables of Janni was also investigated. Results: Errors due to neglecting the correction terms to the Bethe formula were calculated at less than 0.1% for biological tissues. Discrepancies greater than 1%, however, were estimated due to departures from simple Bragg additivity when a fixed I-value for water was imposed. When the I-value for water was calculated in a consistent manner to that for tissue, this disagreement was substantially reduced. The difference between SPR predictions when using Janni’s or ICRU tables for I-values was up to 1.6%. Experimental data used for materials of relevance to proton therapy suggest that the ICRU-derived values provide somewhat more accurate results (root-mean-square-error: 0.8% versus 1.6%). Conclusions: The conclusions from this study are that (1) the Bethe formula can be safely used for SPR calculations without correction terms

  11. Encoder fault analysis system based on Moire fringe error signal

    NASA Astrophysics Data System (ADS)

    Gao, Xu; Chen, Wei; Wan, Qiu-hua; Lu, Xin-ran; Xie, Chun-yu

    2018-02-01

    Aiming at the problem of any fault and wrong code in the practical application of photoelectric shaft encoder, a fast and accurate encoder fault analysis system is researched from the aspect of Moire fringe photoelectric signal processing. DSP28335 is selected as the core processor and high speed serial A/D converter acquisition card is used. And temperature measuring circuit using AD7420 is designed. Discrete data of Moire fringe error signal is collected at different temperatures and it is sent to the host computer through wireless transmission. The error signal quality index and fault type is displayed on the host computer based on the error signal identification method. The error signal quality can be used to diagnosis the state of error code through the human-machine interface.

  12. Transfer Error and Correction Approach in Mobile Network

    NASA Astrophysics Data System (ADS)

    Xiao-kai, Wu; Yong-jin, Shi; Da-jin, Chen; Bing-he, Ma; Qi-li, Zhou

    With the development of information technology and social progress, human demand for information has become increasingly diverse, wherever and whenever people want to be able to easily, quickly and flexibly via voice, data, images and video and other means to communicate. Visual information to the people direct and vivid image, image / video transmission also been widespread attention. Although the third generation mobile communication systems and the emergence and rapid development of IP networks, making video communications is becoming the main business of the wireless communications, however, the actual wireless and IP channel will lead to error generation, such as: wireless channel multi- fading channels generated error and blocking IP packet loss and so on. Due to channel bandwidth limitations, the video communication compression coding of data is often beyond the data, and compress data after the error is very sensitive to error conditions caused a serious decline in image quality.

  13. Sensitivity of planetary cruise navigation to earth orientation calibration errors

    NASA Technical Reports Server (NTRS)

    Estefan, J. A.; Folkner, W. M.

    1995-01-01

    A detailed analysis was conducted to determine the sensitivity of spacecraft navigation errors to the accuracy and timeliness of Earth orientation calibrations. Analyses based on simulated X-band (8.4-GHz) Doppler and ranging measurements acquired during the interplanetary cruise segment of the Mars Pathfinder heliocentric trajectory were completed for the nominal trajectory design and for an alternative trajectory with a longer transit time. Several error models were developed to characterize the effect of Earth orientation on navigational accuracy based on current and anticipated Deep Space Network calibration strategies. The navigational sensitivity of Mars Pathfinder to calibration errors in Earth orientation was computed for each candidate calibration strategy with the Earth orientation parameters included as estimated parameters in the navigation solution. In these cases, the calibration errors contributed 23 to 58% of the total navigation error budget, depending on the calibration strategy being assessed. Navigation sensitivity calculations were also performed for cases in which Earth orientation calibration errors were not adjusted in the navigation solution. In these cases, Earth orientation calibration errors contributed from 26 to as much as 227% of the total navigation error budget. The final analysis suggests that, not only is the method used to calibrate Earth orientation vitally important for precision navigation of Mars Pathfinder, but perhaps equally important is the method for inclusion of the calibration errors in the navigation solutions.

  14. Skills, rules and knowledge in aircraft maintenance: errors in context

    NASA Technical Reports Server (NTRS)

    Hobbs, Alan; Williamson, Ann

    2002-01-01

    Automatic or skill-based behaviour is generally considered to be less prone to error than behaviour directed by conscious control. However, researchers who have applied Rasmussen's skill-rule-knowledge human error framework to accidents and incidents have sometimes found that skill-based errors appear in significant numbers. It is proposed that this is largely a reflection of the opportunities for error which workplaces present and does not indicate that skill-based behaviour is intrinsically unreliable. In the current study, 99 errors reported by 72 aircraft mechanics were examined in the light of a task analysis based on observations of the work of 25 aircraft mechanics. The task analysis identified the opportunities for error presented at various stages of maintenance work packages and by the job as a whole. Once the frequency of each error type was normalized in terms of the opportunities for error, it became apparent that skill-based performance is more reliable than rule-based performance, which is in turn more reliable than knowledge-based performance. The results reinforce the belief that industrial safety interventions designed to reduce errors would best be directed at those aspects of jobs that involve rule- and knowledge-based performance.

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

    ERIC Educational Resources Information Center

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

    2011-01-01

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

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

    NASA Astrophysics Data System (ADS)

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

    2013-01-01

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

  17. Understanding diagnostic errors in medicine: a lesson from aviation

    PubMed Central

    Singh, H; Petersen, L A; Thomas, E J

    2006-01-01

    The impact of diagnostic errors on patient safety in medicine is increasingly being recognized. Despite the current progress in patient safety research, the understanding of such errors and how to prevent them is inadequate. Preliminary research suggests that diagnostic errors have both cognitive and systems origins. Situational awareness is a model that is primarily used in aviation human factors research that can encompass both the cognitive and the systems roots of such errors. This conceptual model offers a unique perspective in the study of diagnostic errors. The applicability of this model is illustrated by the analysis of a patient whose diagnosis of spinal cord compression was substantially delayed. We suggest how the application of this framework could lead to potential areas of intervention and outline some areas of future research. It is possible that the use of such a model in medicine could help reduce errors in diagnosis and lead to significant improvements in patient care. Further research is needed, including the measurement of situational awareness and correlation with health outcomes. PMID:16751463

  18. Aliased tidal errors in TOPEX/POSEIDON sea surface height data

    NASA Technical Reports Server (NTRS)

    Schlax, Michael G.; Chelton, Dudley B.

    1994-01-01

    Alias periods and wavelengths for the M(sub 2, S(sub 2), N(sub 2), K(sub 1), O(sub 1), and P(sub 1) tidal constituents are calculated for TOPEX/POSEIDON. Alias wavelenghts calculated in previous studies are shown to be in error, and a correct method is presented. With the exception of the K(sub 1) constituent, all of these tidal aliases for TOPEX/POSEIDON have periods shorter than 90 days and are likely to be confounded with long-period sea surface height signals associated with real ocean processes. In particular, the correspondence between the periods and wavelengths of the M(sub 2) alias and annual baroclinic Rossby waves that plagued Geosat sea surface height data is avoided. The potential for aliasing residual tidal errors in smoothed estimates of sea surface height is calculated for the six tidal constituents. The potential for aliasing the lunar tidal constituents M(sub 2), N(sub 2) and O(sub 1) fluctuates with latitude and is different for estimates made at the crossovers of ascending and descending ground tracks than for estimates at points midway between crossovers. The potential for aliasing the solar tidal constituents S(sub 2), K(sub 1) and P(sub 1) varies smoothly with latitude. S(sub 2) is strongly aliased for latitudes within 50 degress of the equator, while K(sub 1) and P(sub 1) are only weakly aliased in that range. A weighted least squares method for estimating and removing residual tidal errors from TOPEX/POSEIDON sea surface height data is presented. A clear understanding of the nature of aliased tidal error in TOPEX/POSEIDON data aids the unambiguous identification of real propagating sea surface height signals. Unequivocal evidence of annual period, westward propagating waves in the North Atlantic is presented.

  19. WASP (Write a Scientific Paper) using Excel - 6: Standard error and confidence interval.

    PubMed

    Grech, Victor

    2018-03-01

    The calculation of descriptive statistics includes the calculation of standard error and confidence interval, an inevitable component of data analysis in inferential statistics. This paper provides pointers as to how to do this in Microsoft Excel™. Copyright © 2018 Elsevier B.V. All rights reserved.

  20. Decision Aids for Multiple-Decision Disease Management as Affected by Weather Input Errors

    USDA-ARS?s Scientific Manuscript database

    Many disease management decision support systems (DSS) rely, exclusively or in part, on weather inputs to calculate an indicator for disease hazard. Error in the weather inputs, typically due to forecasting, interpolation or estimation from off-site sources, may affect model calculations and manage...

  1. Emmetropisation and the aetiology of refractive errors

    PubMed Central

    Flitcroft, D I

    2014-01-01

    The distribution of human refractive errors displays features that are not commonly seen in other biological variables. Compared with the more typical Gaussian distribution, adult refraction within a population typically has a negative skew and increased kurtosis (ie is leptokurtotic). This distribution arises from two apparently conflicting tendencies, first, the existence of a mechanism to control eye growth during infancy so as to bring refraction towards emmetropia/low hyperopia (ie emmetropisation) and second, the tendency of many human populations to develop myopia during later childhood and into adulthood. The distribution of refraction therefore changes significantly with age. Analysis of the processes involved in shaping refractive development allows for the creation of a life course model of refractive development. Monte Carlo simulations based on such a model can recreate the variation of refractive distributions seen from birth to adulthood and the impact of increasing myopia prevalence on refractive error distributions in Asia. PMID:24406411

  2. Use of units of measurement error in anthropometric comparisons.

    PubMed

    Lucas, Teghan; Henneberg, Maciej

    2017-09-01

    Anthropometrists attempt to minimise measurement errors, however, errors cannot be eliminated entirely. Currently, measurement errors are simply reported. Measurement errors should be included into analyses of anthropometric data. This study proposes a method which incorporates measurement errors into reported values, replacing metric units with 'units of technical error of measurement (TEM)' by applying these to forensics, industrial anthropometry and biological variation. The USA armed forces anthropometric survey (ANSUR) contains 132 anthropometric dimensions of 3982 individuals. Concepts of duplication and Euclidean distance calculations were applied to the forensic-style identification of individuals in this survey. The National Size and Shape Survey of Australia contains 65 anthropometric measurements of 1265 women. This sample was used to show how a woman's body measurements expressed in TEM could be 'matched' to standard clothing sizes. Euclidean distances show that two sets of repeated anthropometric measurements of the same person cannot be matched (> 0) on measurements expressed in millimetres but can in units of TEM (= 0). Only 81 women can fit into any standard clothing size when matched using centimetres, with units of TEM, 1944 women fit. The proposed method can be applied to all fields that use anthropometry. Units of TEM are considered a more reliable unit of measurement for comparisons.

  3. Error Sensitivity to Environmental Noise in Quantum Circuits for Chemical State Preparation.

    PubMed

    Sawaya, Nicolas P D; Smelyanskiy, Mikhail; McClean, Jarrod R; Aspuru-Guzik, Alán

    2016-07-12

    Calculating molecular energies is likely to be one of the first useful applications to achieve quantum supremacy, performing faster on a quantum than a classical computer. However, if future quantum devices are to produce accurate calculations, errors due to environmental noise and algorithmic approximations need to be characterized and reduced. In this study, we use the high performance qHiPSTER software to investigate the effects of environmental noise on the preparation of quantum chemistry states. We simulated 18 16-qubit quantum circuits under environmental noise, each corresponding to a unitary coupled cluster state preparation of a different molecule or molecular configuration. Additionally, we analyze the nature of simple gate errors in noise-free circuits of up to 40 qubits. We find that, in most cases, the Jordan-Wigner (JW) encoding produces smaller errors under a noisy environment as compared to the Bravyi-Kitaev (BK) encoding. For the JW encoding, pure dephasing noise is shown to produce substantially smaller errors than pure relaxation noise of the same magnitude. We report error trends in both molecular energy and electron particle number within a unitary coupled cluster state preparation scheme, against changes in nuclear charge, bond length, number of electrons, noise types, and noise magnitude. These trends may prove to be useful in making algorithmic and hardware-related choices for quantum simulation of molecular energies.

  4. Error Correction using Quantum Quasi-Cyclic Low-Density Parity-Check(LDPC) Codes

    NASA Astrophysics Data System (ADS)

    Jing, Lin; Brun, Todd; Quantum Research Team

    Quasi-cyclic LDPC codes can approach the Shannon capacity and have efficient decoders. Manabu Hagiwara et al., 2007 presented a method to calculate parity check matrices with high girth. Two distinct, orthogonal matrices Hc and Hd are used. Using submatrices obtained from Hc and Hd by deleting rows, we can alter the code rate. The submatrix of Hc is used to correct Pauli X errors, and the submatrix of Hd to correct Pauli Z errors. We simulated this system for depolarizing noise on USC's High Performance Computing Cluster, and obtained the block error rate (BER) as a function of the error weight and code rate. From the rates of uncorrectable errors under different error weights we can extrapolate the BER to any small error probability. Our results show that this code family can perform reasonably well even at high code rates, thus considerably reducing the overhead compared to concatenated and surface codes. This makes these codes promising as storage blocks in fault-tolerant quantum computation. Error Correction using Quantum Quasi-Cyclic Low-Density Parity-Check(LDPC) Codes.

  5. Dependence of calculated postshock thermodynamic variables on vibrational equilibrium and input uncertainty

    DOE Office of Scientific and Technical Information (OSTI.GOV)

    Campbell, Matthew Frederick; Owen, Kyle G.; Davidson, David F.

    The purpose of this article is to explore the dependence of calculated postshock thermodynamic properties in shock tube experiments upon the vibrational state of the test gas and upon the uncertainties inherent to calculation inputs. This paper first offers a comparison between state variables calculated according to a Rankine–Hugoniot–equation-based algorithm, known as FROSH, and those derived from shock tube experiments on vibrationally nonequilibrated gases. It is shown that incorrect vibrational relaxation assumptions could lead to errors in temperature as large as 8% for 25% oxygen/argon mixtures at 3500 K. Following this demonstration, this article employs the algorithm to show themore » importance of correct vibrational equilibration assumptions, noting, for instance, that errors in temperature of up to about 2% at 3500 K may be generated for 10% nitrogen/argon mixtures if vibrational relaxation is not treated properly. Lastly, this article presents an extensive uncertainty analysis, showing that postshock temperatures can be calculated with root-of-sum-of-square errors of better than ±1% given sufficiently accurate experimentally measured input parameters.« less

  6. Dependence of calculated postshock thermodynamic variables on vibrational equilibrium and input uncertainty

    DOE PAGES

    Campbell, Matthew Frederick; Owen, Kyle G.; Davidson, David F.; ...

    2017-01-30

    The purpose of this article is to explore the dependence of calculated postshock thermodynamic properties in shock tube experiments upon the vibrational state of the test gas and upon the uncertainties inherent to calculation inputs. This paper first offers a comparison between state variables calculated according to a Rankine–Hugoniot–equation-based algorithm, known as FROSH, and those derived from shock tube experiments on vibrationally nonequilibrated gases. It is shown that incorrect vibrational relaxation assumptions could lead to errors in temperature as large as 8% for 25% oxygen/argon mixtures at 3500 K. Following this demonstration, this article employs the algorithm to show themore » importance of correct vibrational equilibration assumptions, noting, for instance, that errors in temperature of up to about 2% at 3500 K may be generated for 10% nitrogen/argon mixtures if vibrational relaxation is not treated properly. Lastly, this article presents an extensive uncertainty analysis, showing that postshock temperatures can be calculated with root-of-sum-of-square errors of better than ±1% given sufficiently accurate experimentally measured input parameters.« less

  7. Nature and Nurture: the complex genetics of myopia and refractive error

    PubMed Central

    Wojciechowski, Robert

    2010-01-01

    The refractive errors, myopia and hyperopia, are optical defects of the visual system that can cause blurred vision. Uncorrected refractive errors are the most common causes of visual impairment worldwide. It is estimated that 2.5 billion people will be affected by myopia alone with in the next decade. Experimental, epidemiological and clinical research has shown that refractive development is influenced by both environmental and genetic factors. Animal models have demonstrated that eye growth and refractive maturation during infancy are tightly regulated by visually-guided mechanisms. Observational data in human populations provide compelling evidence that environmental influences and individual behavioral factors play crucial roles in myopia susceptibility. Nevertheless, the majority of the variance of refractive error within populations is thought to be due to hereditary factors. Genetic linkage studies have mapped two dozen loci, while association studies have implicated more than 25 different genes in refractive variation. Many of these genes are involved in common biological pathways known to mediate extracellular matrix composition and regulate connective tissue remodeling. Other associated genomic regions suggest novel mechanisms in the etiology of human myopia, such as mitochondrial-mediated cell death or photoreceptor-mediated visual signal transmission. Taken together, observational and experimental studies have revealed the complex nature of human refractive variation, which likely involves variants in several genes and functional pathways. Multiway interactions between genes and/or environmental factors may also be important in determining individual risks of myopia, and may help explain the complex pattern of refractive error in human populations. PMID:21155761

  8. The effect of errors in the assignment of the transmission functions on the accuracy of the thermal sounding of the atmosphere

    NASA Technical Reports Server (NTRS)

    Timofeyev, Y. M.

    1979-01-01

    In order to test the error of calculation in assumed values of the transmission function for Soviet and American radiometers sounding the atmosphere thermally from orbiting satellites, the assumptions of the transmission calculation is varied with respect to atmospheric CO2 content, transmission frequency, and atmospheric absorption. The error arising from variations of the assumptions from the standard basic model is calculated.

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

    PubMed

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

    2016-10-01

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

  10. Usability: Human Research Program - Space Human Factors and Habitability

    NASA Technical Reports Server (NTRS)

    Sandor, Aniko; Holden, Kritina L.

    2009-01-01

    The Usability project addresses the need for research in the area of metrics and methodologies used in hardware and software usability testing in order to define quantifiable and verifiable usability requirements. A usability test is a human-in-the-loop evaluation where a participant works through a realistic set of representative tasks using the hardware/software under investigation. The purpose of this research is to define metrics and methodologies for measuring and verifying usability in the aerospace domain in accordance with FY09 focus on errors, consistency, and mobility/maneuverability. Usability metrics must be predictive of success with the interfaces, must be easy to obtain and/or calculate, and must meet the intent of current Human Systems Integration Requirements (HSIR). Methodologies must work within the constraints of the aerospace domain, be cost and time efficient, and be able to be applied without extensive specialized training.

  11. Errors in fluid therapy in medical wards.

    PubMed

    Mousavi, Maryam; Khalili, Hossein; Dashti-Khavidaki, Simin

    2012-04-01

    Intravenous fluid therapy remains an essential part of patients' care during hospitalization. There are only few studies that focused on fluid therapy in the hospitalized patients, and there is not any consensus statement about fluid therapy in patients who are hospitalized in medical wards. The aim of the present study was to assess intravenous fluid therapy status and related errors in the patients during the course of hospitalization in the infectious diseases wards of a referral teaching hospital. This study was conducted in the infectious diseases wards of Imam Khomeini Complex Hospital, Tehran, Iran. During a retrospective study, data related to intravenous fluid therapy were collected by two clinical pharmacists of infectious diseases from 2008 to 2010. Intravenous fluid therapy information including indication, type, volume and rate of fluid administration was recorded for each patient. An internal protocol for intravenous fluid therapy was designed based on literature review and available recommendations. The data related to patients' fluid therapy were compared with this protocol. The fluid therapy was considered appropriate if it was compatible with the protocol regarding indication of intravenous fluid therapy, type, electrolyte content and rate of fluid administration. Any mistake in the selection of fluid type, content, volume and rate of administration was considered as intravenous fluid therapy errors. Five hundred and ninety-six of medication errors were detected during the study period in the patients. Overall rate of fluid therapy errors was 1.3 numbers per patient during hospitalization. Errors in the rate of fluid administration (29.8%), incorrect fluid volume calculation (26.5%) and incorrect type of fluid selection (24.6%) were the most common types of errors. The patients' male sex, old age, baseline renal diseases, diabetes co-morbidity, and hospitalization due to endocarditis, HIV infection and sepsis are predisposing factors for the

  12. Aged-related Neural Changes during Memory Conjunction Errors

    PubMed Central

    Giovanello, Kelly S.; Kensinger, Elizabeth A.; Wong, Alana T.; Schacter, Daniel L.

    2013-01-01

    Human behavioral studies demonstrate that healthy aging is often accompanied by increases in memory distortions or errors. Here we used event-related functional MRI to examine the neural basis of age-related memory distortions. We utilized the memory conjunction error paradigm, a laboratory procedure known to elicit high levels of memory errors. For older adults, right parahippocampal gyrus showed significantly greater activity during false than during accurate retrieval. We observed no regions in which activity was greater during false than during accurate retrieval for young adults. Young adults, however, showed significantly greater activity than old adults during accurate retrieval in right hippocampus. By contrast, older adults demonstrated greater activity than young adults during accurate retrieval in right inferior and middle prefrontal cortex. These data are consistent with the notion that age-related memory conjunction errors arise from dysfunction of hippocampal system mechanisms, rather than impairments in frontally-mediated monitoring processes. PMID:19445606

  13. National Aeronautics and Space Administration "threat and error" model applied to pediatric cardiac surgery: error cycles precede ∼85% of patient deaths.

    PubMed

    Hickey, Edward J; Nosikova, Yaroslavna; Pham-Hung, Eric; Gritti, Michael; Schwartz, Steven; Caldarone, Christopher A; Redington, Andrew; Van Arsdell, Glen S

    2015-02-01

    We hypothesized that the National Aeronautics and Space Administration "threat and error" model (which is derived from analyzing >30,000 commercial flights, and explains >90% of crashes) is directly applicable to pediatric cardiac surgery. We implemented a unit-wide performance initiative, whereby every surgical admission constitutes a "flight" and is tracked in real time, with the aim of identifying errors. The first 500 consecutive patients (524 flights) were analyzed, with an emphasis on the relationship between error cycles and permanent harmful outcomes. Among 524 patient flights (risk adjustment for congenital heart surgery category: 1-6; median: 2) 68 (13%) involved residual hemodynamic lesions, 13 (2.5%) permanent end-organ injuries, and 7 deaths (1.3%). Preoperatively, 763 threats were identified in 379 (72%) flights. Only 51% of patient flights (267) were error free. In the remaining 257 flights, 430 errors occurred, most commonly related to proficiency (280; 65%) or judgment (69, 16%). In most flights with errors (173 of 257; 67%), an unintended clinical state resulted, ie, the error was consequential. In 60% of consequential errors (n = 110; 21% of total), subsequent cycles of additional error/unintended states occurred. Cycles, particularly those containing multiple errors, were very significantly associated with permanent harmful end-states, including residual hemodynamic lesions (P < .0001), end-organ injury (P < .0001), and death (P < .0001). Deaths were almost always preceded by cycles (6 of 7; P < .0001). Human error, if not mitigated, often leads to cycles of error and unintended patient states, which are dangerous and precede the majority of harmful outcomes. Efforts to manage threats and error cycles (through crew resource management techniques) are likely to yield large increases in patient safety. Copyright © 2015. Published by Elsevier Inc.

  14. Error reduction, patient safety and institutional ethics committees.

    PubMed

    Meaney, Mark E

    2004-01-01

    Institutional ethics committees remain largely absent from the literature on error reduction and patient safety. In this paper, the author endeavors to fill the gap. As noted in the Hastings Center's recent report, "Promoting Patient Safety," the occurrence of medical error involves complex web of multiple factors. Human misstep is certainly one such factor, but not the only one. This paper builds on the Hastings Center's report in arguing that institutional ethics committees ought to play an integral role in the transformation of a "culture of blame" to a "culture of safety" in healthcare delivery.

  15. Combined Uncertainty and A-Posteriori Error Bound Estimates for CFD Calculations: Theory and Implementation

    NASA Technical Reports Server (NTRS)

    Barth, Timothy J.

    2014-01-01

    Simulation codes often utilize finite-dimensional approximation resulting in numerical error. Some examples include, numerical methods utilizing grids and finite-dimensional basis functions, particle methods using a finite number of particles. These same simulation codes also often contain sources of uncertainty, for example, uncertain parameters and fields associated with the imposition of initial and boundary data,uncertain physical model parameters such as chemical reaction rates, mixture model parameters, material property parameters, etc.

  16. Error analysis of multi-needle Langmuir probe measurement technique.

    PubMed

    Barjatya, Aroh; Merritt, William

    2018-04-01

    Multi-needle Langmuir probe is a fairly new instrument technique that has been flown on several recent sounding rockets and is slated to fly on a subset of QB50 CubeSat constellation. This paper takes a fundamental look into the data analysis procedures used for this instrument to derive absolute electron density. Our calculations suggest that while the technique remains promising, the current data analysis procedures could easily result in errors of 50% or more. We present a simple data analysis adjustment that can reduce errors by at least a factor of five in typical operation.

  17. Error analysis of multi-needle Langmuir probe measurement technique

    NASA Astrophysics Data System (ADS)

    Barjatya, Aroh; Merritt, William

    2018-04-01

    Multi-needle Langmuir probe is a fairly new instrument technique that has been flown on several recent sounding rockets and is slated to fly on a subset of QB50 CubeSat constellation. This paper takes a fundamental look into the data analysis procedures used for this instrument to derive absolute electron density. Our calculations suggest that while the technique remains promising, the current data analysis procedures could easily result in errors of 50% or more. We present a simple data analysis adjustment that can reduce errors by at least a factor of five in typical operation.

  18. Identifying model error in metabolic flux analysis - a generalized least squares approach.

    PubMed

    Sokolenko, Stanislav; Quattrociocchi, Marco; Aucoin, Marc G

    2016-09-13

    The estimation of intracellular flux through traditional metabolic flux analysis (MFA) using an overdetermined system of equations is a well established practice in metabolic engineering. Despite the continued evolution of the methodology since its introduction, there has been little focus on validation and identification of poor model fit outside of identifying "gross measurement error". The growing complexity of metabolic models, which are increasingly generated from genome-level data, has necessitated robust validation that can directly assess model fit. In this work, MFA calculation is framed as a generalized least squares (GLS) problem, highlighting the applicability of the common t-test for model validation. To differentiate between measurement and model error, we simulate ideal flux profiles directly from the model, perturb them with estimated measurement error, and compare their validation to real data. Application of this strategy to an established Chinese Hamster Ovary (CHO) cell model shows how fluxes validated by traditional means may be largely non-significant due to a lack of model fit. With further simulation, we explore how t-test significance relates to calculation error and show that fluxes found to be non-significant have 2-4 fold larger error (if measurement uncertainty is in the 5-10 % range). The proposed validation method goes beyond traditional detection of "gross measurement error" to identify lack of fit between model and data. Although the focus of this work is on t-test validation and traditional MFA, the presented framework is readily applicable to other regression analysis methods and MFA formulations.

  19. Preventing medication errors in cancer chemotherapy.

    PubMed

    Cohen, M R; Anderson, R W; Attilio, R M; Green, L; Muller, R J; Pruemer, J M

    1996-04-01

    Recommendations for preventing medication errors in cancer chemotherapy are made. Before a health care provider is granted privileges to prescribe, dispense, or administer antineoplastic agents, he or she should undergo a tailored educational program and possibly testing or certification. Appropriate reference materials should be developed. Each institution should develop a dose-verification process with as many independent checks as possible. A detailed checklist covering prescribing, transcribing, dispensing, and administration should be used. Oral orders are not acceptable. All doses should be calculated independently by the physician, the pharmacist, and the nurse. Dosage limits should be established and a review process set up for doses that exceed the limits. These limits should be entered into pharmacy computer systems, listed on preprinted order forms, stated on the product packaging, placed in strategic locations in the institution, and communicated to employees. The prescribing vocabulary must be standardized. Acronyms, abbreviations, and brand names must be avoided and steps taken to avoid other sources of confusion in the written orders, such as trailing zeros. Preprinted antineoplastic drug order forms containing checklists can help avoid errors. Manufacturers should be encouraged to avoid or eliminate ambiguities in drug names and dosing information. Patients must be educated about all aspects of their cancer chemotherapy, as patients represent a last line of defense against errors. An interdisciplinary team at each practice site should review every medication error reported. Pharmacists should be involved at all sites where antineoplastic agents are dispensed. Although it may not be possible to eliminate all medication errors in cancer chemotherapy, the risk can be minimized through specific steps. Because of their training and experience, pharmacists should take the lead in this effort.

  20. Crystalline lens power and refractive error.

    PubMed

    Iribarren, Rafael; Morgan, Ian G; Nangia, Vinay; Jonas, Jost B

    2012-02-01

    To study the relationships between the refractive power of the crystalline lens, overall refractive error of the eye, and degree of nuclear cataract. All phakic participants of the population-based Central India Eye and Medical Study with an age of 50+ years were included. Calculation of the refractive lens power was based on distance noncycloplegic refractive error, corneal refractive power, anterior chamber depth, lens thickness, and axial length according to Bennett's formula. The study included 1885 subjects. Mean refractive lens power was 25.5 ± 3.0 D (range, 13.9-36.6). After adjustment for age and sex, the standardized correlation coefficients (β) of the association with the ocular refractive error were highest for crystalline lens power (β = -0.41; P < 0.001) and nuclear lens opacity grade (β = -0.42; P < 0.001), followed by axial length (β = -0.35; P < 0.001). They were lowest for corneal refractive power (β = -0.08; P = 0.001) and anterior chamber depth (β = -0.05; P = 0.04). In multivariate analysis, refractive error was significantly (P < 0.001) associated with shorter axial length (β = -1.26), lower refractive lens power (β = -0.95), lower corneal refractive power (β = -0.76), higher lens thickness (β = 0.30), deeper anterior chamber (β = 0.28), and less marked nuclear lens opacity (β = -0.05). Lens thickness was significantly lower in eyes with greater nuclear opacity. Variations in refractive error in adults aged 50+ years were mostly influenced by variations in axial length and in crystalline lens refractive power, followed by variations in corneal refractive power, and, to a minor degree, by variations in lens thickness and anterior chamber depth.

  1. Managing human fallibility in critical aerospace situations

    NASA Astrophysics Data System (ADS)

    Tew, Larry

    2014-11-01

    Human fallibility is pervasive in the aerospace industry with over 50% of errors attributed to human error. Consider the benefits to any organization if those errors were significantly reduced. Aerospace manufacturing involves high value, high profile systems with significant complexity and often repetitive build, assembly, and test operations. In spite of extensive analysis, planning, training, and detailed procedures, human factors can cause unexpected errors. Handling such errors involves extensive cause and corrective action analysis and invariably schedule slips and cost growth. We will discuss success stories, including those associated with electro-optical systems, where very significant reductions in human fallibility errors were achieved after receiving adapted and specialized training. In the eyes of company and customer leadership, the steps used to achieve these results lead to in a major culture change in both the workforce and the supporting management organization. This approach has proven effective in other industries like medicine, firefighting, law enforcement, and aviation. The roadmap to success and the steps to minimize human error are known. They can be used by any organization willing to accept human fallibility and take a proactive approach to incorporate the steps needed to manage and minimize error.

  2. Target Water Consumption Calculation for Human Water Management based on Water Balance

    NASA Astrophysics Data System (ADS)

    Sang, X.; Zhai, Z.; Ye, Y.; Zhai, J.

    2016-12-01

    Degradation of the regional ecological environment has become increasingly serious due to the rapid increase of water usage. Critical to water consumption management is a good approach to control the growth of water usage. Through the identification and analysis of water consumption for various sectors in the hydrosocial cycle, the method for calculating the regional target water consumption also is derived based on water balance theory. Analysis shows that during 1980 - 2004 in Tianjin City, there were 22 years in which the actual water consumption of Tianjin exceeded its target water consumption, with an average excess of 66 million m3 annually. Moreover, calculations show that the maximum human target water consumption water supply is 1.91 billion m3/a. If water consumption is controlled according to the target, the sustainable development of water resource, economic and social growth, and ecological environment in this region can be expected to be achieved.

  3. New methodology to reconstruct in 2-D the cuspal enamel of modern human lower molars.

    PubMed

    Modesto-Mata, Mario; García-Campos, Cecilia; Martín-Francés, Laura; Martínez de Pinillos, Marina; García-González, Rebeca; Quintino, Yuliet; Canals, Antoni; Lozano, Marina; Dean, M Christopher; Martinón-Torres, María; Bermúdez de Castro, José María

    2017-08-01

    In the last years different methodologies have been developed to reconstruct worn teeth. In this article, we propose a new 2-D methodology to reconstruct the worn enamel of lower molars. Our main goals are to reconstruct molars with a high level of accuracy when measuring relevant histological variables and to validate the methodology calculating the errors associated with the measurements. This methodology is based on polynomial regression equations, and has been validated using two different dental variables: cuspal enamel thickness and crown height of the protoconid. In order to perform the validation process, simulated worn modern human molars were employed. The associated errors of the measurements were also estimated applying methodologies previously proposed by other authors. The mean percentage error estimated in reconstructed molars for these two variables in comparison with their own real values is -2.17% for the cuspal enamel thickness of the protoconid and -3.18% for the crown height of the protoconid. This error significantly improves the results of other methodologies, both in the interobserver error and in the accuracy of the measurements. The new methodology based on polynomial regressions can be confidently applied to the reconstruction of cuspal enamel of lower molars, as it improves the accuracy of the measurements and reduces the interobserver error. The present study shows that it is important to validate all methodologies in order to know the associated errors. This new methodology can be easily exportable to other modern human populations, the human fossil record and forensic sciences. © 2017 Wiley Periodicals, Inc.

  4. Differences among Job Positions Related to Communication Errors at Construction Sites

    NASA Astrophysics Data System (ADS)

    Takahashi, Akiko; Ishida, Toshiro

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

  5. Analysis of the “naming game” with learning errors in communications

    NASA Astrophysics Data System (ADS)

    Lou, Yang; Chen, Guanrong

    2015-07-01

    Naming game simulates the process of naming an objective by a population of agents organized in a certain communication network. By pair-wise iterative interactions, the population reaches consensus asymptotically. We study naming game with communication errors during pair-wise conversations, with error rates in a uniform probability distribution. First, a model of naming game with learning errors in communications (NGLE) is proposed. Then, a strategy for agents to prevent learning errors is suggested. To that end, three typical topologies of communication networks, namely random-graph, small-world and scale-free networks, are employed to investigate the effects of various learning errors. Simulation results on these models show that 1) learning errors slightly affect the convergence speed but distinctively increase the requirement for memory of each agent during lexicon propagation; 2) the maximum number of different words held by the population increases linearly as the error rate increases; 3) without applying any strategy to eliminate learning errors, there is a threshold of the learning errors which impairs the convergence. The new findings may help to better understand the role of learning errors in naming game as well as in human language development from a network science perspective.

  6. More on the decoder error probability for Reed-Solomon codes

    NASA Technical Reports Server (NTRS)

    Cheung, K.-M.

    1987-01-01

    The decoder error probability for Reed-Solomon codes (more generally, linear maximum distance separable codes) is examined. McEliece and Swanson offered an upper bound on P sub E (u), the decoder error probability given that u symbol errors occurs. This upper bound is slightly greater than Q, the probability that a completely random error pattern will cause decoder error. By using a combinatoric technique, the principle of inclusion and exclusion, an exact formula for P sub E (u) is derived. The P sub e (u) for the (255, 223) Reed-Solomon Code used by NASA, and for the (31,15) Reed-Solomon code (JTIDS code), are calculated using the exact formula, and the P sub E (u)'s are observed to approach the Q's of the codes rapidly as u gets larger. An upper bound for the expression is derived, and is shown to decrease nearly exponentially as u increases. This proves analytically that P sub E (u) indeed approaches Q as u becomes large, and some laws of large numbers come into play.

  7. Astigmatism error modification for absolute shape reconstruction using Fourier transform method

    NASA Astrophysics Data System (ADS)

    He, Yuhang; Li, Qiang; Gao, Bo; Liu, Ang; Xu, Kaiyuan; Wei, Xiaohong; Chai, Liqun

    2014-12-01

    A method is proposed to modify astigmatism errors in absolute shape reconstruction of optical plane using Fourier transform method. If a transmission and reflection flat are used in an absolute test, two translation measurements lead to obtain the absolute shapes by making use of the characteristic relationship between the differential and original shapes in spatial frequency domain. However, because the translation device cannot guarantee the test and reference flats rigidly parallel to each other after the translations, a tilt error exists in the obtained differential data, which caused power and astigmatism errors in the reconstructed shapes. In order to modify the astigmatism errors, a rotation measurement is added. Based on the rotation invariability of the form of Zernike polynomial in circular domain, the astigmatism terms are calculated by solving polynomial coefficient equations related to the rotation differential data, and subsequently the astigmatism terms including error are modified. Computer simulation proves the validity of the proposed method.

  8. Hessian matrix approach for determining error field sensitivity to coil deviations

    NASA Astrophysics Data System (ADS)

    Zhu, Caoxiang; Hudson, Stuart R.; Lazerson, Samuel A.; Song, Yuntao; Wan, Yuanxi

    2018-05-01

    The presence of error fields has been shown to degrade plasma confinement and drive instabilities. Error fields can arise from many sources, but are predominantly attributed to deviations in the coil geometry. In this paper, we introduce a Hessian matrix approach for determining error field sensitivity to coil deviations. A primary cost function used for designing stellarator coils, the surface integral of normalized normal field errors, was adopted to evaluate the deviation of the generated magnetic field from the desired magnetic field. The FOCUS code (Zhu et al 2018 Nucl. Fusion 58 016008) is utilized to provide fast and accurate calculations of the Hessian. The sensitivities of error fields to coil displacements are then determined by the eigenvalues of the Hessian matrix. A proof-of-principle example is given on a CNT-like configuration. We anticipate that this new method could provide information to avoid dominant coil misalignments and simplify coil designs for stellarators.

  9. At least some errors are randomly generated (Freud was wrong)

    NASA Technical Reports Server (NTRS)

    Sellen, A. J.; Senders, J. W.

    1986-01-01

    An experiment was carried out to expose something about human error generating mechanisms. In the context of the experiment, an error was made when a subject pressed the wrong key on a computer keyboard or pressed no key at all in the time allotted. These might be considered, respectively, errors of substitution and errors of omission. Each of seven subjects saw a sequence of three digital numbers, made an easily learned binary judgement about each, and was to press the appropriate one of two keys. Each session consisted of 1,000 presentations of randomly permuted, fixed numbers broken into 10 blocks of 100. One of two keys should have been pressed within one second of the onset of each stimulus. These data were subjected to statistical analyses in order to probe the nature of the error generating mechanisms. Goodness of fit tests for a Poisson distribution for the number of errors per 50 trial interval and for an exponential distribution of the length of the intervals between errors were carried out. There is evidence for an endogenous mechanism that may best be described as a random error generator. Furthermore, an item analysis of the number of errors produced per stimulus suggests the existence of a second mechanism operating on task driven factors producing exogenous errors. Some errors, at least, are the result of constant probability generating mechanisms with error rate idiosyncratically determined for each subject.

  10. Social deviance activates the brain's error-monitoring system.

    PubMed

    Kim, Bo-Rin; Liss, Alison; Rao, Monica; Singer, Zachary; Compton, Rebecca J

    2012-03-01

    Social psychologists have long noted the tendency for human behavior to conform to social group norms. This study examined whether feedback indicating that participants had deviated from group norms would elicit a neural signal previously shown to be elicited by errors and monetary losses. While electroencephalograms were recorded, participants (N = 30) rated the attractiveness of 120 faces and received feedback giving the purported average rating made by a group of peers. The feedback was manipulated so that group ratings either were the same as a participant's rating or deviated by 1, 2, or 3 points. Feedback indicating deviance from the group norm elicited a feedback-related negativity, a brainwave signal known to be elicited by objective performance errors and losses. The results imply that the brain treats deviance from social norms as an error.

  11. Prediction of discretization error using the error transport equation

    NASA Astrophysics Data System (ADS)

    Celik, Ismail B.; Parsons, Don Roscoe

    2017-06-01

    This study focuses on an approach to quantify the discretization error associated with numerical solutions of partial differential equations by solving an error transport equation (ETE). The goal is to develop a method that can be used to adequately predict the discretization error using the numerical solution on only one grid/mesh. The primary problem associated with solving the ETE is the formulation of the error source term which is required for accurately predicting the transport of the error. In this study, a novel approach is considered which involves fitting the numerical solution with a series of locally smooth curves and then blending them together with a weighted spline approach. The result is a continuously differentiable analytic expression that can be used to determine the error source term. Once the source term has been developed, the ETE can easily be solved using the same solver that is used to obtain the original numerical solution. The new methodology is applied to the two-dimensional Navier-Stokes equations in the laminar flow regime. A simple unsteady flow case is also considered. The discretization error predictions based on the methodology presented in this study are in good agreement with the 'true error'. While in most cases the error predictions are not quite as accurate as those from Richardson extrapolation, the results are reasonable and only require one numerical grid. The current results indicate that there is much promise going forward with the newly developed error source term evaluation technique and the ETE.

  12. Neural network error correction for solving coupled ordinary differential equations

    NASA Technical Reports Server (NTRS)

    Shelton, R. O.; Darsey, J. A.; Sumpter, B. G.; Noid, D. W.

    1992-01-01

    A neural network is presented to learn errors generated by a numerical algorithm for solving coupled nonlinear differential equations. The method is based on using a neural network to correctly learn the error generated by, for example, Runge-Kutta on a model molecular dynamics (MD) problem. The neural network programs used in this study were developed by NASA. Comparisons are made for training the neural network using backpropagation and a new method which was found to converge with fewer iterations. The neural net programs, the MD model and the calculations are discussed.

  13. Dosage uniformity problems which occur due to technological errors in extemporaneously prepared suppositories in hospitals and pharmacies

    PubMed Central

    Kalmár, Éva; Lasher, Jason Richard; Tarry, Thomas Dean; Myers, Andrea; Szakonyi, Gerda; Dombi, György; Baki, Gabriella; Alexander, Kenneth S.

    2013-01-01

    The availability of suppositories in Hungary, especially in clinical pharmacy practice, is usually provided by extemporaneous preparations. Due to the known advantages of rectal drug administration, its benefits are frequently utilized in pediatrics. However, errors during the extemporaneous manufacturing process can lead to non-homogenous drug distribution within the dosage units. To determine the root cause of these errors and provide corrective actions, we studied suppository samples prepared with exactly known errors using both cerimetric titration and HPLC technique. Our results show that the most frequent technological error occurs when the pharmacist fails to use the correct displacement factor in the calculations which could lead to a 4.6% increase/decrease in the assay in individual dosage units. The second most important source of error can occur when the molding excess is calculated solely for the suppository base. This can further dilute the final suppository drug concentration causing the assay to be as low as 80%. As a conclusion we emphasize that the application of predetermined displacement factors in calculations for the formulation of suppositories is highly important, which enables the pharmacist to produce a final product containing exactly the determined dose of an active substance despite the different densities of the components. PMID:25161378

  14. Dosage uniformity problems which occur due to technological errors in extemporaneously prepared suppositories in hospitals and pharmacies.

    PubMed

    Kalmár, Eva; Lasher, Jason Richard; Tarry, Thomas Dean; Myers, Andrea; Szakonyi, Gerda; Dombi, György; Baki, Gabriella; Alexander, Kenneth S

    2014-09-01

    The availability of suppositories in Hungary, especially in clinical pharmacy practice, is usually provided by extemporaneous preparations. Due to the known advantages of rectal drug administration, its benefits are frequently utilized in pediatrics. However, errors during the extemporaneous manufacturing process can lead to non-homogenous drug distribution within the dosage units. To determine the root cause of these errors and provide corrective actions, we studied suppository samples prepared with exactly known errors using both cerimetric titration and HPLC technique. Our results show that the most frequent technological error occurs when the pharmacist fails to use the correct displacement factor in the calculations which could lead to a 4.6% increase/decrease in the assay in individual dosage units. The second most important source of error can occur when the molding excess is calculated solely for the suppository base. This can further dilute the final suppository drug concentration causing the assay to be as low as 80%. As a conclusion we emphasize that the application of predetermined displacement factors in calculations for the formulation of suppositories is highly important, which enables the pharmacist to produce a final product containing exactly the determined dose of an active substance despite the different densities of the components.

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

    PubMed

    Plebani, Mario

    2006-01-01

    Laboratory testing is a highly complex process and, although laboratory services are relatively safe, they are not as safe as they could or should be. Clinical laboratories have long focused their attention on quality control methods and quality assessment programs dealing with analytical aspects of testing. However, a growing body of evidence accumulated in recent decades demonstrates that quality in clinical laboratories cannot be assured by merely focusing on purely analytical aspects. The more recent surveys on errors in laboratory medicine conclude that in the delivery of laboratory testing, mistakes occur more frequently before (pre-analytical) and after (post-analytical) the test has been performed. Most errors are due to pre-analytical factors (46-68.2% of total errors), while a high error rate (18.5-47% of total errors) has also been found in the post-analytical phase. Errors due to analytical problems have been significantly reduced over time, but there is evidence that, particularly for immunoassays, interference may have a serious impact on patients. A description of the most frequent and risky pre-, intra- and post-analytical errors and advice on practical steps for measuring and reducing the risk of errors is therefore given in the present paper. Many mistakes in the Total Testing Process are called "laboratory errors", although these may be due to poor communication, action taken by others involved in the testing process (e.g., physicians, nurses and phlebotomists), or poorly designed processes, all of which are beyond the laboratory's control. Likewise, there is evidence that laboratory information is only partially utilized. A recent document from the International Organization for Standardization (ISO) recommends a new, broader definition of the term "laboratory error" and a classification of errors according to different criteria. In a modern approach to total quality, centered on patients' needs and satisfaction, the risk of errors and mistakes

  16. Asymmetric generalization in adaptation to target displacement errors in humans and in a neural network model.

    PubMed

    Westendorff, Stephanie; Kuang, Shenbing; Taghizadeh, Bahareh; Donchin, Opher; Gail, Alexander

    2015-04-01

    Different error signals can induce sensorimotor adaptation during visually guided reaching, possibly evoking different neural adaptation mechanisms. Here we investigate reach adaptation induced by visual target errors without perturbing the actual or sensed hand position. We analyzed the spatial generalization of adaptation to target error to compare it with other known generalization patterns and simulated our results with a neural network model trained to minimize target error independent of prediction errors. Subjects reached to different peripheral visual targets and had to adapt to a sudden fixed-amplitude displacement ("jump") consistently occurring for only one of the reach targets. Subjects simultaneously had to perform contralateral unperturbed saccades, which rendered the reach target jump unnoticeable. As a result, subjects adapted by gradually decreasing reach errors and showed negative aftereffects for the perturbed reach target. Reach errors generalized to unperturbed targets according to a translational rather than rotational generalization pattern, but locally, not globally. More importantly, reach errors generalized asymmetrically with a skewed generalization function in the direction of the target jump. Our neural network model reproduced the skewed generalization after adaptation to target jump without having been explicitly trained to produce a specific generalization pattern. Our combined psychophysical and simulation results suggest that target jump adaptation in reaching can be explained by gradual updating of spatial motor goal representations in sensorimotor association networks, independent of learning induced by a prediction-error about the hand position. The simulations make testable predictions about the underlying changes in the tuning of sensorimotor neurons during target jump adaptation. Copyright © 2015 the American Physiological Society.

  17. Asymmetric generalization in adaptation to target displacement errors in humans and in a neural network model

    PubMed Central

    Westendorff, Stephanie; Kuang, Shenbing; Taghizadeh, Bahareh; Donchin, Opher

    2015-01-01

    Different error signals can induce sensorimotor adaptation during visually guided reaching, possibly evoking different neural adaptation mechanisms. Here we investigate reach adaptation induced by visual target errors without perturbing the actual or sensed hand position. We analyzed the spatial generalization of adaptation to target error to compare it with other known generalization patterns and simulated our results with a neural network model trained to minimize target error independent of prediction errors. Subjects reached to different peripheral visual targets and had to adapt to a sudden fixed-amplitude displacement (“jump”) consistently occurring for only one of the reach targets. Subjects simultaneously had to perform contralateral unperturbed saccades, which rendered the reach target jump unnoticeable. As a result, subjects adapted by gradually decreasing reach errors and showed negative aftereffects for the perturbed reach target. Reach errors generalized to unperturbed targets according to a translational rather than rotational generalization pattern, but locally, not globally. More importantly, reach errors generalized asymmetrically with a skewed generalization function in the direction of the target jump. Our neural network model reproduced the skewed generalization after adaptation to target jump without having been explicitly trained to produce a specific generalization pattern. Our combined psychophysical and simulation results suggest that target jump adaptation in reaching can be explained by gradual updating of spatial motor goal representations in sensorimotor association networks, independent of learning induced by a prediction-error about the hand position. The simulations make testable predictions about the underlying changes in the tuning of sensorimotor neurons during target jump adaptation. PMID:25609106

  18. Calculation Of Pneumatic Attenuation In Pressure Sensors

    NASA Technical Reports Server (NTRS)

    Whitmore, Stephen A.

    1991-01-01

    Errors caused by attenuation of air-pressure waves in narrow tubes calculated by method based on fundamental equations of flow. Changes in ambient pressure transmitted along narrow tube to sensor. Attenuation of high-frequency components of pressure wave calculated from wave equation derived from Navier-Stokes equations of viscous flow in tube. Developed to understand and compensate for frictional attenuation in narrow tubes used to connect aircraft pressure sensors with pressure taps on affected surfaces.

  19. Error compensation for hybrid-computer solution of linear differential equations

    NASA Technical Reports Server (NTRS)

    Kemp, N. H.

    1970-01-01

    Z-transform technique compensates for digital transport delay and digital-to-analog hold. Method determines best values for compensation constants in multi-step and Taylor series projections. Technique also provides hybrid-calculation error compared to continuous exact solution, plus system stability properties.

  20. Tutorial on Reed-Solomon error correction coding

    NASA Technical Reports Server (NTRS)

    Geisel, William A.

    1990-01-01

    This tutorial attempts to provide a frank, step-by-step approach to Reed-Solomon (RS) error correction coding. RS encoding and RS decoding both with and without erasing code symbols are emphasized. There is no need to present rigorous proofs and extreme mathematical detail. Rather, the simple concepts of groups and fields, specifically Galois fields, are presented with a minimum of complexity. Before RS codes are presented, other block codes are presented as a technical introduction into coding. A primitive (15, 9) RS coding example is then completely developed from start to finish, demonstrating the encoding and decoding calculations and a derivation of the famous error-locator polynomial. The objective is to present practical information about Reed-Solomon coding in a manner such that it can be easily understood.