Medication Errors in Vietnamese Hospitals: Prevalence, Potential Outcome and Associated Factors

PubMed Central

Nguyen, Huong-Thao; Nguyen, Tuan-Dung; van den Heuvel, Edwin R.; Haaijer-Ruskamp, Flora M.; Taxis, Katja

2015-01-01

Background Evidence from developed countries showed that medication errors are common and harmful. Little is known about medication errors in resource-restricted settings, including Vietnam. Objectives To determine the prevalence and potential clinical outcome of medication preparation and administration errors, and to identify factors associated with errors. Methods This was a prospective study conducted on six wards in two urban public hospitals in Vietnam. Data of preparation and administration errors of oral and intravenous medications was collected by direct observation, 12 hours per day on 7 consecutive days, on each ward. Multivariable logistic regression was applied to identify factors contributing to errors. Results In total, 2060 out of 5271 doses had at least one error. The error rate was 39.1% (95% confidence interval 37.8%- 40.4%). Experts judged potential clinical outcomes as minor, moderate, and severe in 72 (1.4%), 1806 (34.2%) and 182 (3.5%) doses. Factors associated with errors were drug characteristics (administration route, complexity of preparation, drug class; all p values < 0.001), and administration time (drug round, p = 0.023; day of the week, p = 0.024). Several interactions between these factors were also significant. Nurse experience was not significant. Higher error rates were observed for intravenous medications involving complex preparation procedures and for anti-infective drugs. Slightly lower medication error rates were observed during afternoon rounds compared to other rounds. Conclusions Potentially clinically relevant errors occurred in more than a third of all medications in this large study conducted in a resource-restricted setting. Educational interventions, focusing on intravenous medications with complex preparation procedure, particularly antibiotics, are likely to improve patient safety. PMID:26383873

Can eye-tracking technology improve situational awareness in paramedic clinical education?

PubMed

Williams, Brett; Quested, Andrew; Cooper, Simon

2013-01-01

Human factors play a significant part in clinical error. Situational awareness (SA) means being aware of one's surroundings, comprehending the present situation, and being able to predict outcomes. It is a key human skill that, when properly applied, is associated with reducing medical error: eye-tracking technology can be used to provide an objective and qualitative measure of the initial perception component of SA. Feedback from eye-tracking technology can be used to improve the understanding and teaching of SA in clinical contexts, and consequently, has potential for reducing clinician error and the concomitant adverse events.

Disclosure of Medical Errors: What Factors Influence How Patients Respond?

PubMed Central

Mazor, Kathleen M; Reed, George W; Yood, Robert A; Fischer, Melissa A; Baril, Joann; Gurwitz, Jerry H

2006-01-01

BACKGROUND Disclosure of medical errors is encouraged, but research on how patients respond to specific practices is limited. OBJECTIVE This study sought to determine whether full disclosure, an existing positive physician-patient relationship, an offer to waive associated costs, and the severity of the clinical outcome influenced patients' responses to medical errors. PARTICIPANTS Four hundred and seven health plan members participated in a randomized experiment in which they viewed video depictions of medical error and disclosure. DESIGN Subjects were randomly assigned to experimental condition. Conditions varied in type of medication error, level of disclosure, reference to a prior positive physician-patient relationship, an offer to waive costs, and clinical outcome. MEASURES Self-reported likelihood of changing physicians and of seeking legal advice; satisfaction, trust, and emotional response. RESULTS Nondisclosure increased the likelihood of changing physicians, and reduced satisfaction and trust in both error conditions. Nondisclosure increased the likelihood of seeking legal advice and was associated with a more negative emotional response in the missed allergy error condition, but did not have a statistically significant impact on seeking legal advice or emotional response in the monitoring error condition. Neither the existence of a positive relationship nor an offer to waive costs had a statistically significant impact. CONCLUSIONS This study provides evidence that full disclosure is likely to have a positive effect or no effect on how patients respond to medical errors. The clinical outcome also influences patients' responses. The impact of an existing positive physician-patient relationship, or of waiving costs associated with the error remains uncertain. PMID:16808770

Emotion perception, non-social cognition and symptoms as predictors of theory of mind in schizophrenia.

PubMed

Vaskinn, Anja; Andersson, Stein; Østefjells, Tiril; Andreassen, Ole A; Sundet, Kjetil

2018-06-05

Theory of mind (ToM) can be divided into cognitive and affective ToM, and a distinction can be made between overmentalizing and undermentalizing errors. Research has shown that ToM in schizophrenia is associated with non-social and social cognition, and with clinical symptoms. In this study, we investigate cognitive and clinical predictors of different ToM processes. Ninety-one individuals with schizophrenia participated. ToM was measured with the Movie for the Assessment of Social Cognition (MASC) yielding six scores (total ToM, cognitive ToM, affective ToM, overmentalizing errors, undermentalizing errors and no mentalizing errors). Neurocognition was indexed by a composite score based on the non-social cognitive tests in the MATRICS Consensus Cognitive Battery (MCCB). Emotion perception was measured with Emotion in Biological Motion (EmoBio), a point-light walker task. Clinical symptoms were assessed with the Positive and Negative Syndrome Scale (PANSS). Seventy-one healthy control (HC) participants completed the MASC. Individuals with schizophrenia showed large impairments compared to HC for all MASC scores, except overmentalizing errors. Hierarchical regression analyses with the six different MASC scores as dependent variables revealed that MCCB was a significant predictor of all MASC scores, explaining 8-18% of the variance. EmoBio increased the explained variance significantly, to 17-28%, except for overmentalizing errors. PANSS excited symptoms increased explained variance for total ToM, affective ToM and no mentalizing errors. Both social and non-social cognition were significant predictors of ToM. Overmentalizing was only predicted by non-social cognition. Excited symptoms contributed to overall and affective ToM, and to no mentalizing errors. Copyright © 2018 Elsevier Inc. All rights reserved.

Validating and calibrating the Nintendo Wii balance board to derive reliable center of pressure measures.

PubMed

Leach, Julia M; Mancini, Martina; Peterka, Robert J; Hayes, Tamara L; Horak, Fay B

2014-09-29

The Nintendo Wii balance board (WBB) has generated significant interest in its application as a postural control measurement device in both the clinical and (basic, clinical, and rehabilitation) research domains. Although the WBB has been proposed as an alternative to the "gold standard" laboratory-grade force plate, additional research is necessary before the WBB can be considered a valid and reliable center of pressure (CoP) measurement device. In this study, we used the WBB and a laboratory-grade AMTI force plate (AFP) to simultaneously measure the CoP displacement of a controlled dynamic load, which has not been done before. A one-dimensional inverted pendulum was displaced at several different displacement angles and load heights to simulate a variety of postural sway amplitudes and frequencies (<1 Hz). Twelve WBBs were tested to address the issue of inter-device variability. There was a significant effect of sway amplitude, frequency, and direction on the WBB's CoP measurement error, with an increase in error as both sway amplitude and frequency increased and a significantly greater error in the mediolateral (ML) (compared to the anteroposterior (AP)) sway direction. There was no difference in error across the 12 WBB's, supporting low inter-device variability. A linear calibration procedure was then implemented to correct the WBB's CoP signals and reduce measurement error. There was a significant effect of calibration on the WBB's CoP signal accuracy, with a significant reduction in CoP measurement error (quantified by root-mean-squared error) from 2-6 mm (before calibration) to 0.5-2 mm (after calibration). WBB-based CoP signal calibration also significantly reduced the percent error in derived (time-domain) CoP sway measures, from -10.5% (before calibration) to -0.05% (after calibration) (percent errors averaged across all sway measures and in both sway directions). In this study, we characterized the WBB's CoP measurement error under controlled, dynamic conditions and implemented a linear calibration procedure for WBB CoP signals that is recommended to reduce CoP measurement error and provide more reliable estimates of time-domain CoP measures. Despite our promising results, additional work is necessary to understand how our findings translate to the clinical and rehabilitation research domains. Once the WBB's CoP measurement error is fully characterized in human postural sway (which differs from our simulated postural sway in both amplitude and frequency content), it may be used to measure CoP displacement in situations where lower accuracy and precision is acceptable.

Validating and Calibrating the Nintendo Wii Balance Board to Derive Reliable Center of Pressure Measures

PubMed Central

Leach, Julia M.; Mancini, Martina; Peterka, Robert J.; Hayes, Tamara L.; Horak, Fay B.

2014-01-01

The Nintendo Wii balance board (WBB) has generated significant interest in its application as a postural control measurement device in both the clinical and (basic, clinical, and rehabilitation) research domains. Although the WBB has been proposed as an alternative to the “gold standard” laboratory-grade force plate, additional research is necessary before the WBB can be considered a valid and reliable center of pressure (CoP) measurement device. In this study, we used the WBB and a laboratory-grade AMTI force plate (AFP) to simultaneously measure the CoP displacement of a controlled dynamic load, which has not been done before. A one-dimensional inverted pendulum was displaced at several different displacement angles and load heights to simulate a variety of postural sway amplitudes and frequencies (<1 Hz). Twelve WBBs were tested to address the issue of inter-device variability. There was a significant effect of sway amplitude, frequency, and direction on the WBB's CoP measurement error, with an increase in error as both sway amplitude and frequency increased and a significantly greater error in the mediolateral (ML) (compared to the anteroposterior (AP)) sway direction. There was no difference in error across the 12 WBB's, supporting low inter-device variability. A linear calibration procedure was then implemented to correct the WBB's CoP signals and reduce measurement error. There was a significant effect of calibration on the WBB's CoP signal accuracy, with a significant reduction in CoP measurement error (quantified by root-mean-squared error) from 2–6 mm (before calibration) to 0.5–2 mm (after calibration). WBB-based CoP signal calibration also significantly reduced the percent error in derived (time-domain) CoP sway measures, from −10.5% (before calibration) to −0.05% (after calibration) (percent errors averaged across all sway measures and in both sway directions). In this study, we characterized the WBB's CoP measurement error under controlled, dynamic conditions and implemented a linear calibration procedure for WBB CoP signals that is recommended to reduce CoP measurement error and provide more reliable estimates of time-domain CoP measures. Despite our promising results, additional work is necessary to understand how our findings translate to the clinical and rehabilitation research domains. Once the WBB's CoP measurement error is fully characterized in human postural sway (which differs from our simulated postural sway in both amplitude and frequency content), it may be used to measure CoP displacement in situations where lower accuracy and precision is acceptable. PMID:25268919

Clinical Outcomes of an Optimized Prolate Ablation Procedure for Correcting Residual Refractive Errors Following Laser Surgery.

PubMed

Chung, Byunghoon; Lee, Hun; Choi, Bong Joon; Seo, Kyung Ryul; Kim, Eung Kwon; Kim, Dae Yune; Kim, Tae-Im

2017-02-01

The purpose of this study was to investigate the clinical efficacy of an optimized prolate ablation procedure for correcting residual refractive errors following laser surgery. We analyzed 24 eyes of 15 patients who underwent an optimized prolate ablation procedure for the correction of residual refractive errors following laser in situ keratomileusis, laser-assisted subepithelial keratectomy, or photorefractive keratectomy surgeries. Preoperative ophthalmic examinations were performed, and uncorrected distance visual acuity, corrected distance visual acuity, manifest refraction values (sphere, cylinder, and spherical equivalent), point spread function, modulation transfer function, corneal asphericity (Q value), ocular aberrations, and corneal haze measurements were obtained postoperatively at 1, 3, and 6 months. Uncorrected distance visual acuity improved and refractive errors decreased significantly at 1, 3, and 6 months postoperatively. Total coma aberration increased at 3 and 6 months postoperatively, while changes in all other aberrations were not statistically significant. Similarly, no significant changes in point spread function were detected, but modulation transfer function increased significantly at the postoperative time points measured. The optimized prolate ablation procedure was effective in terms of improving visual acuity and objective visual performance for the correction of persistent refractive errors following laser surgery.

The Clinical Assessment in the Legal Field: An Empirical Study of Bias and Limitations in Forensic Expertise

PubMed Central

Iudici, Antonio; Salvini, Alessandro; Faccio, Elena; Castelnuovo, Gianluca

2015-01-01

According to the literature, psychological assessment in forensic contexts is one of the most controversial application areas for clinical psychology. This paper presents a review of systematic judgment errors in the forensic field. Forty-six psychological reports written by psychologists, court consultants, have been analyzed with content analysis to identify typical judgment errors related to the following areas: (a) distortions in the attribution of causality, (b) inferential errors, and (c) epistemological inconsistencies. Results indicated that systematic errors of judgment, usually referred also as “the man in the street,” are widely present in the forensic evaluations of specialist consultants. Clinical and practical implications are taken into account. This article could lead to significant benefits for clinical psychologists who want to deal with this sensitive issue and are interested in improving the quality of their contribution to the justice system. PMID:26648892

Computer-assisted bar-coding system significantly reduces clinical laboratory specimen identification errors in a pediatric oncology hospital.

PubMed

Hayden, Randall T; Patterson, Donna J; Jay, Dennis W; Cross, Carl; Dotson, Pamela; Possel, Robert E; Srivastava, Deo Kumar; Mirro, Joseph; Shenep, Jerry L

2008-02-01

To assess the ability of a bar code-based electronic positive patient and specimen identification (EPPID) system to reduce identification errors in a pediatric hospital's clinical laboratory. An EPPID system was implemented at a pediatric oncology hospital to reduce errors in patient and laboratory specimen identification. The EPPID system included bar-code identifiers and handheld personal digital assistants supporting real-time order verification. System efficacy was measured in 3 consecutive 12-month time frames, corresponding to periods before, during, and immediately after full EPPID implementation. A significant reduction in the median percentage of mislabeled specimens was observed in the 3-year study period. A decline from 0.03% to 0.005% (P < .001) was observed in the 12 months after full system implementation. On the basis of the pre-intervention detected error rate, it was estimated that EPPID prevented at least 62 mislabeling events during its first year of operation. EPPID decreased the rate of misidentification of clinical laboratory samples. The diminution of errors observed in this study provides support for the development of national guidelines for the use of bar coding for laboratory specimens, paralleling recent recommendations for medication administration.

SBAR improves communication and safety climate and decreases incident reports due to communication errors in an anaesthetic clinic: a prospective intervention study.

PubMed

Randmaa, Maria; Mårtensson, Gunilla; Leo Swenne, Christine; Engström, Maria

2014-01-21

We aimed to examine staff members' perceptions of communication within and between different professions, safety attitudes and psychological empowerment, prior to and after implementation of the communication tool Situation-Background-Assessment-Recommendation (SBAR) at an anaesthetic clinic. The aim was also to study whether there was any change in the proportion of incident reports caused by communication errors. A prospective intervention study with comparison group using preassessments and postassessments. Questionnaire data were collected from staff in an intervention (n=100) and a comparison group (n=69) at the anaesthetic clinic in two hospitals prior to (2011) and after (2012) implementation of SBAR. The proportion of incident reports due to communication errors was calculated during a 1-year period prior to and after implementation. Anaesthetic clinics at two hospitals in Sweden. All licensed practical nurses, registered nurses and physicians working in the operating theatres, intensive care units and postanaesthesia care units at anaesthetic clinics in two hospitals were invited to participate. Implementation of SBAR in an anaesthetic clinic. The primary outcomes were staff members' perception of communication within and between different professions, as well as their perceptions of safety attitudes. Secondary outcomes were psychological empowerment and incident reports due to error of communication. In the intervention group, there were statistically significant improvements in the factors 'Between-group communication accuracy' (p=0.039) and 'Safety climate' (p=0.011). The proportion of incident reports due to communication errors decreased significantly (p<0.0001) in the intervention group, from 31% to 11%. Implementing the communication tool SBAR in anaesthetic clinics was associated with improvement in staff members' perception of communication between professionals and their perception of the safety climate as well as with a decreased proportion of incident reports related to communication errors. ISRCTN37251313.

The thinking doctor: clinical decision making in contemporary medicine.

PubMed

Trimble, Michael; Hamilton, Paul

2016-08-01

Diagnostic errors are responsible for a significant number of adverse events. Logical reasoning and good decision-making skills are key factors in reducing such errors, but little emphasis has traditionally been placed on how these thought processes occur, and how errors could be minimised. In this article, we explore key cognitive ideas that underpin clinical decision making and suggest that by employing some simple strategies, physicians might be better able to understand how they make decisions and how the process might be optimised. © 2016 Royal College of Physicians.

A new method for the assessment of patient safety competencies during a medical school clerkship using an objective structured clinical examination

PubMed Central

Daud-Gallotti, Renata Mahfuz; Morinaga, Christian Valle; Arlindo-Rodrigues, Marcelo; Velasco, Irineu Tadeu; Arruda Martins, Milton; Tiberio, Iolanda Calvo

2011-01-01

INTRODUCTION: Patient safety is seldom assessed using objective evaluations during undergraduate medical education. OBJECTIVE: To evaluate the performance of fifth-year medical students using an objective structured clinical examination focused on patient safety after implementation of an interactive program based on adverse events recognition and disclosure. METHODS: In 2007, a patient safety program was implemented in the internal medicine clerkship of our hospital. The program focused on human error theory, epidemiology of incidents, adverse events, and disclosure. Upon completion of the program, students completed an objective structured clinical examination with five stations and standardized patients. One station focused on patient safety issues, including medical error recognition/disclosure, the patient-physician relationship and humanism issues. A standardized checklist was completed by each standardized patient to assess the performance of each student. The student's global performance at each station and performance in the domains of medical error, the patient-physician relationship and humanism were determined. The correlations between the student performances in these three domains were calculated. RESULTS: A total of 95 students participated in the objective structured clinical examination. The mean global score at the patient safety station was 87.59±1.24 points. Students' performance in the medical error domain was significantly lower than their performance on patient-physician relationship and humanistic issues. Less than 60% of students (n = 54) offered the simulated patient an apology after a medical error occurred. A significant correlation was found between scores obtained in the medical error domains and scores related to both the patient-physician relationship and humanistic domains. CONCLUSIONS: An objective structured clinical examination is a useful tool to evaluate patient safety competencies during the medical student clerkship. PMID:21876976

Impact of pharmacist interventions in older patients: a prospective study in a tertiary hospital in Germany

PubMed Central

Cortejoso, L; Dietz, RA; Hofmann, G; Gosch, M; Sattler, A

2016-01-01

Background Inappropriate pharmacotherapy among older adults remains a critical issue in our health care systems. Besides polypharmacy and multiple comorbidities, the age-related pharmacokinetic and pharmacodynamic changes may increase the risk of adverse drug reactions and medication errors. Objective The main target of this study was to describe the characteristics of pharmaceutical interventions in two geriatric wards (orthogeriatric ward and geriatric day unit) of a general teaching hospital and to evaluate the clinical significance of the detected medication errors. Materials and methods The study was conducted between August 2014 and October 2015 and was based on a triple approach that included validation of medical orders, medication reconciliation at patients’ admission, and a predischarge planning appointment with the patient. The validation of medical orders was based on analyzing the suitability of the drugs prescribed, the drug dose depending on the patient’s characteristics, the presence of contraindications and interactions between drugs, and the proposal of alternative drugs included in the hospital formulary. Results A total of 2,307 interventions associated to a medication error in 15,282 medical orders for 1,859 older patients were recorded. The greater part of the interventions carried out on the orthogeriatric ward at admission and at discharge were due to omission of a drug in the medical order (20.0%) and clinically significant interactions requiring monitoring (30.4%), respectively. The main factor triggering pharmacist’s recommendations on the geriatric day unit was clinically significant interactions (21.1%). With regard to the clinical severity of the detected errors, 68.1% were considered significant, 24.8% were of minor significance, and 7.2% were clinically serious. Conclusion Our findings show the importance of clinical pharmacist involvement in the optimization of pharmacotherapy in older adults, ensuring that they receive effective, safe, and efficient drug therapy. PMID:27713625

Clinical Errors and Medical Negligence

PubMed Central

Oyebode, Femi

2013-01-01

This paper discusses the definition, nature and origins of clinical errors including their prevention. The relationship between clinical errors and medical negligence is examined as are the characteristics of litigants and events that are the source of litigation. The pattern of malpractice claims in different specialties and settings is examined. Among hospitalized patients worldwide, 3–16s% suffer injury as a result of medical intervention, the most common being the adverse effects of drugs. The frequency of adverse drug effects appears superficially to be higher in intensive care units and emergency departments but once rates have been corrected for volume of patients, comorbidity of conditions and number of drugs prescribed, the difference is not significant. It is concluded that probably no more than 1 in 7 adverse events in medicine result in a malpractice claim and the factors that predict that a patient will resort to litigation include a prior poor relationship with the clinician and the feeling that the patient is not being kept informed. Methods for preventing clinical errors are still in their infancy. The most promising include new technologies such as electronic prescribing systems, diagnostic and clinical decision-making aids and error-resistant systems. PMID:23343656

Clinical errors and medical negligence.

PubMed

Oyebode, Femi

2013-01-01

This paper discusses the definition, nature and origins of clinical errors including their prevention. The relationship between clinical errors and medical negligence is examined as are the characteristics of litigants and events that are the source of litigation. The pattern of malpractice claims in different specialties and settings is examined. Among hospitalized patients worldwide, 3-16% suffer injury as a result of medical intervention, the most common being the adverse effects of drugs. The frequency of adverse drug effects appears superficially to be higher in intensive care units and emergency departments but once rates have been corrected for volume of patients, comorbidity of conditions and number of drugs prescribed, the difference is not significant. It is concluded that probably no more than 1 in 7 adverse events in medicine result in a malpractice claim and the factors that predict that a patient will resort to litigation include a prior poor relationship with the clinician and the feeling that the patient is not being kept informed. Methods for preventing clinical errors are still in their infancy. The most promising include new technologies such as electronic prescribing systems, diagnostic and clinical decision-making aids and error-resistant systems. Copyright © 2013 S. Karger AG, Basel.

Clinical decision-making: heuristics and cognitive biases for the ophthalmologist.

PubMed

Hussain, Ahsen; Oestreicher, James

Diagnostic errors have a significant impact on health care outcomes and patient care. The underlying causes and development of diagnostic error are complex with flaws in health care systems, as well as human error, playing a role. Cognitive biases and a failure of decision-making shortcuts (heuristics) are human factors that can compromise the diagnostic process. We describe these mechanisms, their role with the clinician, and provide clinical scenarios to highlight the various points at which biases may emerge. We discuss strategies to modify the development and influence of these processes and the vulnerability of heuristics to provide insight and improve clinical outcomes. Copyright © 2017 Elsevier Inc. All rights reserved.

Anatomic, clinical, and neuropsychological correlates of spelling errors in primary progressive aphasia.

PubMed

Shim, Hyungsub; Hurley, Robert S; Rogalski, Emily; Mesulam, M-Marsel

2012-07-01

This study evaluates spelling errors in the three subtypes of primary progressive aphasia (PPA): agrammatic (PPA-G), logopenic (PPA-L), and semantic (PPA-S). Forty-one PPA patients and 36 age-matched healthy controls were administered a test of spelling. The total number of errors and types of errors in spelling to dictation of regular words, exception words and nonwords, were recorded. Error types were classified based on phonetic plausibility. In the first analysis, scores were evaluated by clinical diagnosis. Errors in spelling exception words and phonetically plausible errors were seen in PPA-S. Conversely, PPA-G was associated with errors in nonword spelling and phonetically implausible errors. In the next analysis, spelling scores were correlated to other neuropsychological language test scores. Significant correlations were found between exception word spelling and measures of naming and single word comprehension. Nonword spelling correlated with tests of grammar and repetition. Global language measures did not correlate significantly with spelling scores, however. Cortical thickness analysis based on MRI showed that atrophy in several language regions of interest were correlated with spelling errors. Atrophy in the left supramarginal gyrus and inferior frontal gyrus (IFG) pars orbitalis correlated with errors in nonword spelling, while thinning in the left temporal pole and fusiform gyrus correlated with errors in exception word spelling. Additionally, phonetically implausible errors in regular word spelling correlated with thinning in the left IFG pars triangularis and pars opercularis. Together, these findings suggest two independent systems for spelling to dictation, one phonetic (phoneme to grapheme conversion), and one lexical (whole word retrieval). Copyright © 2012 Elsevier Ltd. All rights reserved.

An affordable cuff-less blood pressure estimation solution.

PubMed

Jain, Monika; Kumar, Niranjan; Deb, Sujay

2016-08-01

This paper presents a cuff-less hypertension pre-screening device that non-invasively monitors the Blood Pressure (BP) and Heart Rate (HR) continuously. The proposed device simultaneously records two clinically significant and highly correlated biomedical signals, viz., Electrocardiogram (ECG) and Photoplethysmogram (PPG). The device provides a common data acquisition platform that can interface with PC/laptop, Smart phone/tablet and Raspberry-pi etc. The hardware stores and processes the recorded ECG and PPG in order to extract the real-time BP and HR using kernel regression approach. The BP and HR estimation error is measured in terms of normalized mean square error, Error Standard Deviation (ESD) and Mean Absolute Error (MAE), with respect to a clinically proven digital BP monitor (OMRON HBP1300). The computed error falls under the maximum standard allowable error mentioned by Association for the Advancement of Medical Instrumentation; MAE <; 5 mmHg and ESD <; 8mmHg. The results are validated using two-tailed dependent sample t-test also. The proposed device is a portable low-cost home and clinic bases solution for continuous health monitoring.

A clinic-based study of refractive errors, strabismus, and amblyopia in pediatric age-group.

PubMed

Al-Tamimi, Elham R; Shakeel, Ayisha; Yassin, Sanaa A; Ali, Syed I; Khan, Umar A

2015-01-01

The purpose of this cross-sectional observational study was to determine the distribution and patterns of refractive errors, strabismus, and amblyopia in children seen at a pediatric eye care. The study was conducted in a Private Hospital in Dammam, Kingdom of Saudi Arabia, from March to July 2013. During this period, a total of 1350 children, aged 1-15 years were seen at this Center's Pediatric Ophthalmology Unit. All the children underwent complete ophthalmic examination with cycloplegic refraction. Refractive errors accounted for 44.4% of the cases, the predominant refractive error being hypermetropia which represented 83%. Strabismus and amblyopia were present in 38% and 9.1% of children, respectively. In this clinic-based study, the focus was on the frequency of refractive errors, strabismus, and amblyopia which were considerably high. Hypermetropia was the predominant refractive error in contrast to other studies in which myopia was more common. This could be attributed to the criteria for sample selection since it was clinic-based rather than a population-based study. However, it is important to promote public education on the significance of early detection of refractive errors, and have periodic screening in schools.

Paediatric in-patient prescribing errors in Malaysia: a cross-sectional multicentre study.

PubMed

Khoo, Teik Beng; Tan, Jing Wen; Ng, Hoong Phak; Choo, Chong Ming; Bt Abdul Shukor, Intan Nor Chahaya; Teh, Siao Hean

2017-06-01

Background There is a lack of large comprehensive studies in developing countries on paediatric in-patient prescribing errors in different settings. Objectives To determine the characteristics of in-patient prescribing errors among paediatric patients. Setting General paediatric wards, neonatal intensive care units and paediatric intensive care units in government hospitals in Malaysia. Methods This is a cross-sectional multicentre study involving 17 participating hospitals. Drug charts were reviewed in each ward to identify the prescribing errors. All prescribing errors identified were further assessed for their potential clinical consequences, likely causes and contributing factors. Main outcome measures Incidence, types, potential clinical consequences, causes and contributing factors of the prescribing errors. Results The overall prescribing error rate was 9.2% out of 17,889 prescribed medications. There was no significant difference in the prescribing error rates between different types of hospitals or wards. The use of electronic prescribing had a higher prescribing error rate than manual prescribing (16.9 vs 8.2%, p < 0.05). Twenty eight (1.7%) prescribing errors were deemed to have serious potential clinical consequences and 2 (0.1%) were judged to be potentially fatal. Most of the errors were attributed to human factors, i.e. performance or knowledge deficit. The most common contributing factors were due to lack of supervision or of knowledge. Conclusions Although electronic prescribing may potentially improve safety, it may conversely cause prescribing errors due to suboptimal interfaces and cumbersome work processes. Junior doctors need specific training in paediatric prescribing and close supervision to reduce prescribing errors in paediatric in-patients.

Target motion tracking in MRI-guided transrectal robotic prostate biopsy.

PubMed

Tadayyon, Hadi; Lasso, Andras; Kaushal, Aradhana; Guion, Peter; Fichtinger, Gabor

2011-11-01

MRI-guided prostate needle biopsy requires compensation for organ motion between target planning and needle placement. Two questions are studied and answered in this paper: 1) is rigid registration sufficient in tracking the targets with an error smaller than the clinically significant size of prostate cancer and 2) what is the effect of the number of intraoperative slices on registration accuracy and speed? we propose multislice-to-volume registration algorithms for tracking the biopsy targets within the prostate. Three orthogonal plus additional transverse intraoperative slices are acquired in the approximate center of the prostate and registered with a high-resolution target planning volume. Both rigid and deformable scenarios were implemented. Both simulated and clinical MRI-guided robotic prostate biopsy data were used to assess tracking accuracy. average registration errors in clinical patient data were 2.6 mm for the rigid algorithm and 2.1 mm for the deformable algorithm. rigid tracking appears to be promising. Three tracking slices yield significantly high registration speed with an affordable error.

Assessment of legibility and completeness of handwritten and electronic prescriptions.

PubMed

Albarrak, Ahmed I; Al Rashidi, Eman Abdulrahman; Fatani, Rwaa Kamil; Al Ageel, Shoog Ibrahim; Mohammed, Rafiuddin

2014-12-01

To assess the legibility and completeness of handwritten prescriptions and compare with electronic prescription system for medication errors. Prospective study. King Khalid University Hospital (KKUH), Riyadh, Saudi Arabia. Handwritten prescriptions were received from clinical units of Medicine Outpatient Department (MOPD), Primary Care Clinic (PCC) and Surgery Outpatient Department (SOPD) whereas electronic prescriptions were collected from the pediatric ward. The handwritten prescription was assessed for completeness by the checklist designed according to the hospital prescription and evaluated for legibility by two pharmacists. The comparison between handwritten and electronic prescription errors was evaluated based on the validated checklist adopted from previous studies. Legibility and completeness of prescriptions. 398 prescriptions (199 handwritten and 199 e-prescriptions) were assessed. About 71 (35.7%) of handwritten and 5 (2.5%) of electronic prescription errors were identified. A significant statistical difference (P < 0.001) was observed between handwritten and e-prescriptions in omitted dose and omitted route of administration category of error distribution. The rate of completeness in patient identification in handwritten prescriptions was 80.97% in MOPD, 76.36% in PCC and 85.93% in SOPD clinic units. Assessment of medication prescription completeness was 91.48% in MOPD, 88.48% in PCC, and 89.28% in SOPD. This study revealed a high incidence of prescribing errors in handwritten prescriptions. The use of e-prescription system showed a significant decline in the incidence of errors. The legibility of handwritten prescriptions was relatively good whereas the level of completeness was very low.

Patient safety in the clinical laboratory: a longitudinal analysis of specimen identification errors.

PubMed

Wagar, Elizabeth A; Tamashiro, Lorraine; Yasin, Bushra; Hilborne, Lee; Bruckner, David A

2006-11-01

Patient safety is an increasingly visible and important mission for clinical laboratories. Attention to improving processes related to patient identification and specimen labeling is being paid by accreditation and regulatory organizations because errors in these areas that jeopardize patient safety are common and avoidable through improvement in the total testing process. To assess patient identification and specimen labeling improvement after multiple implementation projects using longitudinal statistical tools. Specimen errors were categorized by a multidisciplinary health care team. Patient identification errors were grouped into 3 categories: (1) specimen/requisition mismatch, (2) unlabeled specimens, and (3) mislabeled specimens. Specimens with these types of identification errors were compared preimplementation and postimplementation for 3 patient safety projects: (1) reorganization of phlebotomy (4 months); (2) introduction of an electronic event reporting system (10 months); and (3) activation of an automated processing system (14 months) for a 24-month period, using trend analysis and Student t test statistics. Of 16,632 total specimen errors, mislabeled specimens, requisition mismatches, and unlabeled specimens represented 1.0%, 6.3%, and 4.6% of errors, respectively. Student t test showed a significant decrease in the most serious error, mislabeled specimens (P < .001) when compared to before implementation of the 3 patient safety projects. Trend analysis demonstrated decreases in all 3 error types for 26 months. Applying performance-improvement strategies that focus longitudinally on specimen labeling errors can significantly reduce errors, therefore improving patient safety. This is an important area in which laboratory professionals, working in interdisciplinary teams, can improve safety and outcomes of care.

Clinical relevance of pharmacist intervention in an emergency department.

PubMed

Pérez-Moreno, Maria Antonia; Rodríguez-Camacho, Juan Manuel; Calderón-Hernanz, Beatriz; Comas-Díaz, Bernardino; Tarradas-Torras, Jordi

2017-08-01

To evaluate the clinical relevance of pharmacist intervention on patient care in emergencies, to determine the severity of detected errors. Second, to analyse the most frequent types of interventions and type of drugs involved and to evaluate the clinical pharmacist's activity. A 6-month observational prospective study of pharmacist intervention in the Emergency Department (ED) at a 400-bed hospital in Spain was performed to record interventions carried out by the clinical pharmacists. We determined whether the intervention occurred in the process of medication reconciliation or another activity, and whether the drug involved belonged to the High-Alert Medications Institute for Safe Medication Practices (ISMP) list. To evaluate the severity of the errors detected and clinical relevance of the pharmacist intervention, a modified assessment scale of Overhage and Lukes was used. Relationship between clinical relevance of pharmacist intervention and the severity of medication errors was assessed using ORs and Spearman's correlation coefficient. During the observation period, pharmacists reviewed the pharmacotherapy history and medication orders of 2984 patients. A total of 991 interventions were recorded in 557 patients; 67.2% of the errors were detected during medication reconciliation. Medication errors were considered severe in 57.2% of cases and 64.9% of pharmacist intervention were considered relevant. About 10.9% of the drugs involved are in the High-Alert Medications ISMP list. The severity of the medication error and the clinical significance of the pharmacist intervention were correlated (Spearman's ρ=0.728/p<0.001). In this single centre study, the clinical pharmacists identified and intervened on a high number of severe medication errors. This suggests that emergency services will benefit from pharmacist-provided drug therapy services. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/.

Transperineal prostate biopsy under magnetic resonance image guidance: a needle placement accuracy study.

PubMed

Blumenfeld, Philip; Hata, Nobuhiko; DiMaio, Simon; Zou, Kelly; Haker, Steven; Fichtinger, Gabor; Tempany, Clare M C

2007-09-01

To quantify needle placement accuracy of magnetic resonance image (MRI)-guided core needle biopsy of the prostate. A total of 10 biopsies were performed with 18-gauge (G) core biopsy needle via a percutaneous transperineal approach. Needle placement error was assessed by comparing the coordinates of preplanned targets with the needle tip measured from the intraprocedural coherent gradient echo images. The source of these errors was subsequently investigated by measuring displacement caused by needle deflection and needle susceptibility artifact shift in controlled phantom studies. Needle placement error due to misalignment of the needle template guide was also evaluated. The mean and standard deviation (SD) of errors in targeted biopsies was 6.5 +/- 3.5 mm. Phantom experiments showed significant placement error due to needle deflection with a needle with an asymmetrically beveled tip (3.2-8.7 mm depending on tissue type) but significantly smaller error with a symmetrical bevel (0.6-1.1 mm). Needle susceptibility artifacts observed a shift of 1.6 +/- 0.4 mm from the true needle axis. Misalignment of the needle template guide contributed an error of 1.5 +/- 0.3 mm. Needle placement error was clinically significant in MRI-guided biopsy for diagnosis of prostate cancer. Needle placement error due to needle deflection was the most significant cause of error, especially for needles with an asymmetrical bevel. (c) 2007 Wiley-Liss, Inc.

Application of objective clinical human reliability analysis (OCHRA) in assessment of technical performance in laparoscopic rectal cancer surgery.

PubMed

Foster, J D; Miskovic, D; Allison, A S; Conti, J A; Ockrim, J; Cooper, E J; Hanna, G B; Francis, N K

2016-06-01

Laparoscopic rectal resection is technically challenging, with outcomes dependent upon technical performance. No robust objective assessment tool exists for laparoscopic rectal resection surgery. This study aimed to investigate the application of the objective clinical human reliability analysis (OCHRA) technique for assessing technical performance of laparoscopic rectal surgery and explore the validity and reliability of this technique. Laparoscopic rectal cancer resection operations were described in the format of a hierarchical task analysis. Potential technical errors were defined. The OCHRA technique was used to identify technical errors enacted in videos of twenty consecutive laparoscopic rectal cancer resection operations from a single site. The procedural task, spatial location, and circumstances of all identified errors were logged. Clinical validity was assessed through correlation with clinical outcomes; reliability was assessed by test-retest. A total of 335 execution errors identified, with a median 15 per operation. More errors were observed during pelvic tasks compared with abdominal tasks (p < 0.001). Within the pelvis, more errors were observed during dissection on the right side than the left (p = 0.03). Test-retest confirmed reliability (r = 0.97, p < 0.001). A significant correlation was observed between error frequency and mesorectal specimen quality (r s = 0.52, p = 0.02) and with blood loss (r s = 0.609, p = 0.004). OCHRA offers a valid and reliable method for evaluating technical performance of laparoscopic rectal surgery.

Decreasing scoring errors on Wechsler Scale Vocabulary, Comprehension, and Similarities subtests: a preliminary study.

PubMed

Linger, Michele L; Ray, Glen E; Zachar, Peter; Underhill, Andrea T; LoBello, Steven G

2007-10-01

Studies of graduate students learning to administer the Wechsler scales have generally shown that training is not associated with the development of scoring proficiency. Many studies report on the reduction of aggregated administration and scoring errors, a strategy that does not highlight the reduction of errors on subtests identified as most prone to error. This study evaluated the development of scoring proficiency specifically on the Wechsler (WISC-IV and WAIS-III) Vocabulary, Comprehension, and Similarities subtests during training by comparing a set of 'early test administrations' to 'later test administrations.' Twelve graduate students enrolled in an intelligence-testing course participated in the study. Scoring errors (e.g., incorrect point assignment) were evaluated on the students' actual practice administration test protocols. Errors on all three subtests declined significantly when scoring errors on 'early' sets of Wechsler scales were compared to those made on 'later' sets. However, correcting these subtest scoring errors did not cause significant changes in subtest scaled scores. Implications for clinical instruction and future research are discussed.

A long-term follow-up evaluation of electronic health record prescribing safety

PubMed Central

Abramson, Erika L; Malhotra, Sameer; Osorio, S Nena; Edwards, Alison; Cheriff, Adam; Cole, Curtis; Kaushal, Rainu

2013-01-01

Objective To be eligible for incentives through the Electronic Health Record (EHR) Incentive Program, many providers using older or locally developed EHRs will be transitioning to new, commercial EHRs. We previously evaluated prescribing errors made by providers in the first year following transition from a locally developed EHR with minimal prescribing clinical decision support (CDS) to a commercial EHR with robust CDS. Following system refinements, we conducted this study to assess the rates and types of errors 2 years after transition and determine the evolution of errors. Materials and methods We conducted a mixed methods cross-sectional case study of 16 physicians at an academic-affiliated ambulatory clinic from April to June 2010. We utilized standardized prescription and chart review to identify errors. Fourteen providers also participated in interviews. Results We analyzed 1905 prescriptions. The overall prescribing error rate was 3.8 per 100 prescriptions (95% CI 2.8 to 5.1). Error rates were significantly lower 2 years after transition (p<0.001 compared to pre-implementation, 12 weeks and 1 year after transition). Rates of near misses remained unchanged. Providers positively appreciated most system refinements, particularly reduced alert firing. Discussion Our study suggests that over time and with system refinements, use of a commercial EHR with advanced CDS can lead to low prescribing error rates, although more serious errors may require targeted interventions to eliminate them. Reducing alert firing frequency appears particularly important. Our results provide support for federal efforts promoting meaningful use of EHRs. Conclusions Ongoing error monitoring can allow CDS to be optimally tailored and help achieve maximal safety benefits. Clinical Trials Registration ClinicalTrials.gov, Identifier: NCT00603070. PMID:23578816

CE: Original Research: Exploring How Nursing Schools Handle Student Errors and Near Misses.

PubMed

Disch, Joanne; Barnsteiner, Jane; Connor, Susan; Brogren, Fabiana

2017-10-01

: Background: Little attention has been paid to how nursing students learn about quality and safety, and to the tools and policies that guide nursing schools in helping students respond to errors and near misses. This study sought to determine whether prelicensure nursing programs have a policy for reporting and following up on student clinical errors and near misses, a tool for such reporting, a tool or process (or both) for identifying trends, strategies for follow-up with students after errors and near misses, and strategies for follow-up with clinical agencies and individual faculty members. A national electronic survey of 1,667 schools of nursing with a prelicensure registered nursing program was conducted. Data from 494 responding schools (30%) were analyzed. Of the responding schools, 245 (50%) reported having no policy for managing students following a clinical error or near miss, and 272 (55%) reported having no tool for reporting student errors or near misses. Significant work is needed if the principles of a fair and just culture are to shape the response to nursing student errors and near misses. For nursing schools, some essential first steps are to understand the tools and policies a school has in place; the school's philosophy regarding errors and near misses; the resources needed to establish a fair and just culture; and how faculty can work together to create learning environments that eliminate or minimize the negative consequences of errors and near misses for patients, students, and faculty.

[Longer working hours of pharmacists in the ward resulted in lower medication-related errors--survey of national university hospitals in Japan].

PubMed

Matsubara, Kazuo; Toyama, Akira; Satoh, Hiroshi; Suzuki, Hiroshi; Awaya, Toshio; Tasaki, Yoshikazu; Yasuoka, Toshiaki; Horiuchi, Ryuya

2011-04-01

It is obvious that pharmacists play a critical role as risk managers in the healthcare system, especially in medication treatment. Hitherto, there is not a single multicenter-survey report describing the effectiveness of clinical pharmacists in preventing medical errors from occurring in the wards in Japan. Thus, we conducted a 1-month survey to elucidate the relationship between the number of errors and working hours of pharmacists in the ward, and verified whether the assignment of clinical pharmacists to the ward would prevent medical errors between October 1-31, 2009. Questionnaire items for the pharmacists at 42 national university hospitals and a medical institute included the total and the respective numbers of medication-related errors, beds and working hours of pharmacist in 2 internal medicine and 2 surgical departments in each hospital. Regardless of severity, errors were consecutively reported to the Medical Security and Safety Management Section in each hospital. The analysis of errors revealed that longer working hours of pharmacists in the ward resulted in less medication-related errors; this was especially significant in the internal medicine ward (where a variety of drugs were used) compared with the surgical ward. However, the nurse assignment mode (nurse/inpatients ratio: 1 : 7-10) did not influence the error frequency. The results of this survey strongly indicate that assignment of clinical pharmacists to the ward is critically essential in promoting medication safety and efficacy.

Correlations between Preoperative Angle Parameters and Postoperative Unpredicted Refractive Errors after Cataract Surgery in Open Angle Glaucoma (AOD 500).

PubMed

Lee, Wonseok; Bae, Hyoung Won; Lee, Si Hyung; Kim, Chan Yun; Seong, Gong Je

2017-03-01

To assess the accuracy of intraocular lens (IOL) power prediction for cataract surgery with open angle glaucoma (OAG) and to identify preoperative angle parameters correlated with postoperative unpredicted refractive errors. This study comprised 45 eyes from 45 OAG subjects and 63 eyes from 63 non-glaucomatous cataract subjects (controls). We investigated differences in preoperative predicted refractive errors and postoperative refractive errors for each group. Preoperative predicted refractive errors were obtained by biometry (IOL-master) and compared to postoperative refractive errors measured by auto-refractometer 2 months postoperatively. Anterior angle parameters were determined using swept source optical coherence tomography. We investigated correlations between preoperative angle parameters [angle open distance (AOD); trabecular iris surface area (TISA); angle recess area (ARA); trabecular iris angle (TIA)] and postoperative unpredicted refractive errors. In patients with OAG, significant differences were noted between preoperative predicted and postoperative real refractive errors, with more myopia than predicted. No significant differences were recorded in controls. Angle parameters (AOD, ARA, TISA, and TIA) at the superior and inferior quadrant were significantly correlated with differences between predicted and postoperative refractive errors in OAG patients (-0.321 to -0.408, p<0.05). Superior quadrant AOD 500 was significantly correlated with postoperative refractive differences in multivariate linear regression analysis (β=-2.925, R²=0.404). Clinically unpredicted refractive errors after cataract surgery were more common in OAG than in controls. Certain preoperative angle parameters, especially AOD 500 at the superior quadrant, were significantly correlated with these unpredicted errors.

Correlations between Preoperative Angle Parameters and Postoperative Unpredicted Refractive Errors after Cataract Surgery in Open Angle Glaucoma (AOD 500)

PubMed Central

Lee, Wonseok; Bae, Hyoung Won; Lee, Si Hyung; Kim, Chan Yun

2017-01-01

Purpose To assess the accuracy of intraocular lens (IOL) power prediction for cataract surgery with open angle glaucoma (OAG) and to identify preoperative angle parameters correlated with postoperative unpredicted refractive errors. Materials and Methods This study comprised 45 eyes from 45 OAG subjects and 63 eyes from 63 non-glaucomatous cataract subjects (controls). We investigated differences in preoperative predicted refractive errors and postoperative refractive errors for each group. Preoperative predicted refractive errors were obtained by biometry (IOL-master) and compared to postoperative refractive errors measured by auto-refractometer 2 months postoperatively. Anterior angle parameters were determined using swept source optical coherence tomography. We investigated correlations between preoperative angle parameters [angle open distance (AOD); trabecular iris surface area (TISA); angle recess area (ARA); trabecular iris angle (TIA)] and postoperative unpredicted refractive errors. Results In patients with OAG, significant differences were noted between preoperative predicted and postoperative real refractive errors, with more myopia than predicted. No significant differences were recorded in controls. Angle parameters (AOD, ARA, TISA, and TIA) at the superior and inferior quadrant were significantly correlated with differences between predicted and postoperative refractive errors in OAG patients (-0.321 to -0.408, p<0.05). Superior quadrant AOD 500 was significantly correlated with postoperative refractive differences in multivariate linear regression analysis (β=-2.925, R2=0.404). Conclusion Clinically unpredicted refractive errors after cataract surgery were more common in OAG than in controls. Certain preoperative angle parameters, especially AOD 500 at the superior quadrant, were significantly correlated with these unpredicted errors. PMID:28120576

Identification of patient information corruption in the intensive care unit: using a scoring tool to direct quality improvements in handover.

PubMed

Pickering, Brian W; Hurley, Killian; Marsh, Brian

2009-11-01

To use a handover assessment tool for identifying patient information corruption and objectively evaluating interventions designed to reduce handover errors and improve medical decision making. The continuous monitoring, intervention, and evaluation of the patient in modern intensive care unit practice generates large quantities of information, the platform on which medical decisions are made. Information corruption, defined as errors of distortion/omission compared with the medical record, may result in medical judgment errors. Identifying these errors may lead to quality improvements in intensive care unit care delivery and safety. Handover assessment instrument development study divided into two phases by the introduction of a handover intervention. Closed, 17-bed, university-affiliated mixed surgical/medical intensive care unit. Senior and junior medical members of the intensive care unit team. Electronic handover page. Study subjects were asked to recall clinical information commonly discussed at handover on individual patients. The handover score measured the percentage of information correctly retained for each individual doctor-patient interaction. The clinical intention score, a subjective measure of medical judgment, was graded (1-5) by three blinded intensive care unit experts. A total of 137 interactions were scored. Median (interquartile range) handover scores for phases 1 and 2 were 79.07% (67.44-84.50) and 83.72% (76.16-88.37), respectively. Score variance was reduced by the handover intervention (p < .05). Increasing median handover scores, 68.60 to 83.72, were associated with increases in clinical intention scores from 1 to 5 (chi-square = 23.59, df = 4, p < .0001). When asked to recall clinical information discussed at handover, medical members of the intensive care unit team provide data that are significantly corrupted compared with the medical record. Low subjective clinical judgment scores are significant associated with low handover scores. The handover/clinical intention scores may, therefore, be useful screening tools for intensive care unit system vulnerability to medical error. Additionally, handover instruments can identify interventions that reduce system vulnerability to error and may be used to guide quality improvements in handover practice.

Assessment of legibility and completeness of handwritten and electronic prescriptions

PubMed Central

Albarrak, Ahmed I; Al Rashidi, Eman Abdulrahman; Fatani, Rwaa Kamil; Al Ageel, Shoog Ibrahim; Mohammed, Rafiuddin

2014-01-01

Objectives To assess the legibility and completeness of handwritten prescriptions and compare with electronic prescription system for medication errors. Design Prospective study. Setting King Khalid University Hospital (KKUH), Riyadh, Saudi Arabia. Subjects and methods Handwritten prescriptions were received from clinical units of Medicine Outpatient Department (MOPD), Primary Care Clinic (PCC) and Surgery Outpatient Department (SOPD) whereas electronic prescriptions were collected from the pediatric ward. The handwritten prescription was assessed for completeness by the checklist designed according to the hospital prescription and evaluated for legibility by two pharmacists. The comparison between handwritten and electronic prescription errors was evaluated based on the validated checklist adopted from previous studies. Main outcome measures Legibility and completeness of prescriptions. Results 398 prescriptions (199 handwritten and 199 e-prescriptions) were assessed. About 71 (35.7%) of handwritten and 5 (2.5%) of electronic prescription errors were identified. A significant statistical difference (P < 0.001) was observed between handwritten and e-prescriptions in omitted dose and omitted route of administration category of error distribution. The rate of completeness in patient identification in handwritten prescriptions was 80.97% in MOPD, 76.36% in PCC and 85.93% in SOPD clinic units. Assessment of medication prescription completeness was 91.48% in MOPD, 88.48% in PCC, and 89.28% in SOPD. Conclusions This study revealed a high incidence of prescribing errors in handwritten prescriptions. The use of e-prescription system showed a significant decline in the incidence of errors. The legibility of handwritten prescriptions was relatively good whereas the level of completeness was very low. PMID:25561864

Refractive errors and strabismus in Down's syndrome in Korea.

PubMed

Han, Dae Heon; Kim, Kyun Hyung; Paik, Hae Jung

2012-12-01

The aims of this study were to examine the distribution of refractive errors and clinical characteristics of strabismus in Korean patients with Down's syndrome. A total of 41 Korean patients with Down's syndrome were screened for strabismus and refractive errors in 2009. A total of 41 patients with an average age of 11.9 years (range, 2 to 36 years) were screened. Eighteen patients (43.9%) had strabismus. Ten (23.4%) of 18 patients exhibited esotropia and the others had intermittent exotropia. The most frequently detected type of esotropia was acquired non-accommodative esotropia, and that of exotropia was the basic type. Fifteen patients (36.6%) had hypermetropia and 20 (48.8%) had myopia. The patients with esotropia had refractive errors of +4.89 diopters (D, ±3.73) and the patients with exotropia had refractive errors of -0.31 D (±1.78). Six of ten patients with esotropia had an accommodation weakness. Twenty one patients (63.4%) had astigmatism. Eleven (28.6%) of 21 patients had anisometropia and six (14.6%) of those had clinically significant anisometropia. In Korean patients with Down's syndrome, esotropia was more common than exotropia and hypermetropia more common than myopia. Especially, Down's syndrome patients with esotropia generally exhibit clinically significant hyperopic errors (>+3.00 D) and evidence of under-accommodation. Thus, hypermetropia and accommodation weakness could be possible factors in esotropia when it occurs in Down's syndrome patients. Based on the results of this study, eye examinations of Down's syndrome patients should routinely include a measure of accommodation at near distances, and bifocals should be considered for those with evidence of under-accommodation.

Visual Performance on the Small Letter Contrast Test: Effects of Aging, Low Luminance and Refractive Error

DTIC Science & Technology

2000-08-01

luminance performance and aviation, many aviators develop ametropias refractive error having comparable effects on during their careers. We were... statistically (0.04 logMAR, the non-aviator group. Separate investigators at p=0.01), but not clinically significant (ə/2 line different research facilities... statistically significant (0.11 ± 0.1 logCS, t=4.0, sensitivity on the SLCT decreased for the aviator pɘ.001), yet there is significant overlap group at a

Task errors by emergency physicians are associated with interruptions, multitasking, fatigue and working memory capacity: a prospective, direct observation study.

PubMed

Westbrook, Johanna I; Raban, Magdalena Z; Walter, Scott R; Douglas, Heather

2018-01-09

Interruptions and multitasking have been demonstrated in experimental studies to reduce individuals' task performance. These behaviours are frequently used by clinicians in high-workload, dynamic clinical environments, yet their effects have rarely been studied. To assess the relative contributions of interruptions and multitasking by emergency physicians to prescribing errors. 36 emergency physicians were shadowed over 120 hours. All tasks, interruptions and instances of multitasking were recorded. Physicians' working memory capacity (WMC) and preference for multitasking were assessed using the Operation Span Task (OSPAN) and Inventory of Polychronic Values. Following observation, physicians were asked about their sleep in the previous 24 hours. Prescribing errors were used as a measure of task performance. We performed multivariate analysis of prescribing error rates to determine associations with interruptions and multitasking, also considering physician seniority, age, psychometric measures, workload and sleep. Physicians experienced 7.9 interruptions/hour. 28 clinicians were observed prescribing 239 medication orders which contained 208 prescribing errors. While prescribing, clinicians were interrupted 9.4 times/hour. Error rates increased significantly if physicians were interrupted (rate ratio (RR) 2.82; 95% CI 1.23 to 6.49) or multitasked (RR 1.86; 95% CI 1.35 to 2.56) while prescribing. Having below-average sleep showed a >15-fold increase in clinical error rate (RR 16.44; 95% CI 4.84 to 55.81). WMC was protective against errors; for every 10-point increase on the 75-point OSPAN, a 19% decrease in prescribing errors was observed. There was no effect of polychronicity, workload, physician gender or above-average sleep on error rates. Interruptions, multitasking and poor sleep were associated with significantly increased rates of prescribing errors among emergency physicians. WMC mitigated the negative influence of these factors to an extent. These results confirm experimental findings in other fields and raise questions about the acceptability of the high rates of multitasking and interruption in clinical environments. © Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.

Route learning in amnesia: a comparison of trial-and-error and errorless learning in patients with the Korsakoff syndrome.

PubMed

Kessels, Roy P C; van Loon, Eke; Wester, Arie J

2007-10-01

To examine the errorless learning approach using a procedural memory task (i.e. learning of actual routes) in patients with amnesia, as compared to trial-and-error learning. Counterbalanced self-controlled cases series. Psychiatric hospital (Korsakoff clinic). A convenience sample of 10 patients with the Korsakoff amnestic syndrome. All patients learned a route in four sessions on separate days using an errorless approach and a different route using trial-and-error. Error rate was scored during route learning and standard neuro-psychological tests were administered (i.e. subtest route recall of the Rivermead Behavioural Memory Test (RBMT) and the Dutch version of the California Verbal Learning Test (VLGT)). A significant learning effect was found in the trial-and-error condition over consecutive sessions (P = 0.006), but no performance difference was found between errorless and trial-and-error learning of the routes. VLGT performance was significantly correlated with a trial-and-error advantage (P < 0.05); no significant correlation was found between the RBMT subtest and the learning conditions. Errorless learning was no more successful than trial-and-error learning of a procedural spatial task in patients with the Korsakoff syndrome (severe amnesia).

Cognitive bias in clinical practice - nurturing healthy skepticism among medical students.

PubMed

Bhatti, Alysha

2018-01-01

Errors in clinical reasoning, known as cognitive biases, are implicated in a significant proportion of diagnostic errors. Despite this knowledge, little emphasis is currently placed on teaching cognitive psychology in the undergraduate medical curriculum. Understanding the origin of these biases and their impact on clinical decision making helps stimulate reflective practice. This article outlines some of the common types of cognitive biases encountered in the clinical setting as well as cognitive debiasing strategies. Medical educators should nurture healthy skepticism among medical students by raising awareness of cognitive biases and equipping them with robust tools to circumvent such biases. This will enable tomorrow's doctors to improve the quality of care delivered, thus optimizing patient outcomes.

Method for Expressing Clinical and Statistical Significance of Ocular and Corneal Wavefront Error Aberrations

PubMed Central

Smolek, Michael K.

2011-01-01

Purpose The significance of ocular or corneal aberrations may be subject to misinterpretation whenever eyes with different pupil sizes or the application of different Zernike expansion orders are compared. A method is shown that uses simple mathematical interpolation techniques based on normal data to rapidly determine the clinical significance of aberrations, without concern for pupil and expansion order. Methods Corneal topography (Tomey, Inc.; Nagoya, Japan) from 30 normal corneas was collected and the corneal wavefront error analyzed by Zernike polynomial decomposition into specific aberration types for pupil diameters of 3, 5, 7, and 10 mm and Zernike expansion orders of 6, 8, 10 and 12. Using this 4×4 matrix of pupil sizes and fitting orders, best-fitting 3-dimensional functions were determined for the mean and standard deviation of the RMS error for specific aberrations. The functions were encoded into software to determine the significance of data acquired from non-normal cases. Results The best-fitting functions for 6 types of aberrations were determined: defocus, astigmatism, prism, coma, spherical aberration, and all higher-order aberrations. A clinical screening method of color-coding the significance of aberrations in normal, postoperative LASIK, and keratoconus cases having different pupil sizes and different expansion orders is demonstrated. Conclusions A method to calibrate wavefront aberrometry devices by using a standard sample of normal cases was devised. This method could be potentially useful in clinical studies involving patients with uncontrolled pupil sizes or in studies that compare data from aberrometers that use different Zernike fitting-order algorithms. PMID:22157570

A Methodology for Validating Safety Heuristics Using Clinical Simulations: Identifying and Preventing Possible Technology-Induced Errors Related to Using Health Information Systems

PubMed Central

Borycki, Elizabeth; Kushniruk, Andre; Carvalho, Christopher

2013-01-01

Internationally, health information systems (HIS) safety has emerged as a significant concern for governments. Recently, research has emerged that has documented the ability of HIS to be implicated in the harm and death of patients. Researchers have attempted to develop methods that can be used to prevent or reduce technology-induced errors. Some researchers are developing methods that can be employed prior to systems release. These methods include the development of safety heuristics and clinical simulations. In this paper, we outline our methodology for developing safety heuristics specific to identifying the features or functions of a HIS user interface design that may lead to technology-induced errors. We follow this with a description of a methodological approach to validate these heuristics using clinical simulations. PMID:23606902

Theory of mind in schizophrenia: error types and associations with symptoms.

PubMed

Fretland, Ragnhild A; Andersson, Stein; Sundet, Kjetil; Andreassen, Ole A; Melle, Ingrid; Vaskinn, Anja

2015-03-01

Social cognition is an important determinant of functioning in schizophrenia. However, how social cognition relates to the clinical symptoms of schizophrenia is still unclear. The aim of this study was to explore the relationship between a social cognition domain, Theory of Mind (ToM), and the clinical symptoms of schizophrenia. Specifically, we investigated the associations between three ToM error types; 1) "overmentalizing" 2) "reduced ToM and 3) "no ToM", and positive, negative and disorganized symptoms. Fifty-two participants with a diagnosis of schizophrenia or schizoaffective disorder were assessed with the Movie for the Assessment of Social Cognition (MASC), a video-based ToM measure. An empirically validated five-factor model of the Positive and Negative Syndrome Scale (PANSS) was used to assess clinical symptoms. There was a significant, small-moderate association between overmentalizing and positive symptoms (rho=.28, p=.04). Disorganized symptoms correlated at a trend level with "reduced ToM" (rho=.27, p=.05). There were no other significant correlations between ToM impairments and symptom levels. Positive/disorganized symptoms did not contribute significantly in explaining total ToM performance, whereas IQ did (B=.37, p=.01). Within the undermentalizing domain, participants performed more "reduced ToM" errors than "no ToM" errors. Overmentalizing was associated with positive symptoms. The undermentalizing error types were unrelated to symptoms, but "reduced ToM" was somewhat associated to disorganization. The higher number of "reduced ToM" responses suggests that schizophrenia is characterized by accuracy problems rather than a fundamental lack of mental state concept. The findings call for the use of more sensitive measures when investigating ToM in schizophrenia to avoid the "right/wrong ToM"-dichotomy. Copyright © 2015 Elsevier B.V. All rights reserved.

Detecting ‘Wrong Blood in Tube’ Errors: Evaluation of a Bayesian Network Approach

PubMed Central

Doctor, Jason N.; Strylewicz, Greg

2010-01-01

Objective In an effort to address the problem of laboratory errors, we develop and evaluate a method to detect mismatched specimens from nationally collected blood laboratory data in two experiments. Methods In Experiment 1 and 2 using blood labs from National Health and Nutrition Examination Survey (NHANES) and values derived from the Diabetes Prevention Program (DPP) respectively, a proportion of glucose and HbA1c specimens were randomly mismatched. A Bayesian network that encoded probabilistic relationships among analytes was used to predict mismatches. In Experiment 1 the performance of the network was compared against existing error detection software. In Experiment 2 the network was compared against 11 human experts recruited from the American Academy of Clinical Chemists. Results were compared via area under the receiver-operating characteristics curves (AUCs) and with agreement statistics. Results In Experiment 1 the network was most predictive of mismatches that produced clinically significant discrepancies between true and mismatched scores ((AUC of 0.87 (±0.04) for HbA1c and 0.83 (±0.02) for glucose), performed well in identifying errors among those self-reporting diabetes (N = 329) (AUC = 0.79 (± 0.02)) and performed significantly better than the established approach it was tested against (in all cases p < .0.05). In Experiment 2 it performed better (and in no case worse) than 7 of the 11 human experts. Average percent agreement was 0.79. and Kappa (κ) was 0.59, between experts and the Bayesian network. Conclusions Bayesian network can accurately identify mismatched specimens. The algorithm is best at identifying mismatches that result in a clinically significant magnitude of error. PMID:20566275

Clinical and Radiographic Evaluation of Procedural Errors during Preparation of Curved Root Canals with Hand and Rotary Instruments: A Randomized Clinical Study.

PubMed

Khanna, Rajesh; Handa, Aashish; Virk, Rupam Kaur; Ghai, Deepika; Handa, Rajni Sharma; Goel, Asim

2017-01-01

The process of cleaning and shaping the canal is not an easy goal to obtain, as canal curvature played a significant role during the instrumentation of the curved canals. The present in vivo study was conducted to evaluate procedural errors during the preparation of curved root canals using hand Nitiflex and rotary K3XF instruments. Procedural errors such as ledge formation, instrument separation, and perforation (apical, furcal, strip) were determined in sixty patients, divided into two groups. In Group I, thirty teeth in thirty patients were prepared using hand Nitiflex system, and in Group II, thirty teeth in thirty patients were prepared using K3XF rotary system. The evaluation was done clinically as well as radiographically. The results recorded from both groups were compiled and put to statistical analysis. Chi-square test was used to compare the procedural errors (instrument separation, ledge formation, and perforation). In the present study, both hand Nitiflex and rotary K3XF showed ledge formation and instrument separation. Although ledge formation and instrument separation by rotary K3XF file system was less as compared to hand Nitiflex. No perforation was seen in both the instrument groups. Canal curvature played a significant role during the instrumentation of the curved canals. Procedural errors such as ledge formation and instrument separation by rotary K3XF file system were less as compared to hand Nitiflex.

Clinical and Radiographic Evaluation of Procedural Errors during Preparation of Curved Root Canals with Hand and Rotary Instruments: A Randomized Clinical Study

PubMed Central

Khanna, Rajesh; Handa, Aashish; Virk, Rupam Kaur; Ghai, Deepika; Handa, Rajni Sharma; Goel, Asim

2017-01-01

Background: The process of cleaning and shaping the canal is not an easy goal to obtain, as canal curvature played a significant role during the instrumentation of the curved canals. Aim: The present in vivo study was conducted to evaluate procedural errors during the preparation of curved root canals using hand Nitiflex and rotary K3XF instruments. Materials and Methods: Procedural errors such as ledge formation, instrument separation, and perforation (apical, furcal, strip) were determined in sixty patients, divided into two groups. In Group I, thirty teeth in thirty patients were prepared using hand Nitiflex system, and in Group II, thirty teeth in thirty patients were prepared using K3XF rotary system. The evaluation was done clinically as well as radiographically. The results recorded from both groups were compiled and put to statistical analysis. Statistical Analysis: Chi-square test was used to compare the procedural errors (instrument separation, ledge formation, and perforation). Results: In the present study, both hand Nitiflex and rotary K3XF showed ledge formation and instrument separation. Although ledge formation and instrument separation by rotary K3XF file system was less as compared to hand Nitiflex. No perforation was seen in both the instrument groups. Conclusion: Canal curvature played a significant role during the instrumentation of the curved canals. Procedural errors such as ledge formation and instrument separation by rotary K3XF file system were less as compared to hand Nitiflex. PMID:29042727

Algorithm for Correcting the Keratometric Error in the Estimation of the Corneal Power in Keratoconus Eyes after Accelerated Corneal Collagen Crosslinking

PubMed Central

Caravaca-Arens, Esteban; de Fez, Dolores; Blanes-Mompó, Francisco J.

2017-01-01

Purpose To analyze the errors associated to corneal power calculation using the keratometric approach in keratoconus eyes after accelerated corneal collagen crosslinking (CXL) surgery and to obtain a model for the estimation of an adjusted corneal refractive index (nkadj) minimizing such errors. Methods Potential differences (ΔPc) among keratometric (Pk) and Gaussian corneal power (PcGauss) were simulated. Three algorithms based on the use of nkadj for the estimation of an adjusted keratometric corneal power (Pkadj) were developed. The agreement between Pk(1.3375) (keratometric power using the keratometric index of 1.3375), PcGauss, and Pkadj was evaluated. The validity of the algorithm developed was investigated in 21 keratoconus eyes undergoing accelerated CXL. Results P k(1.3375) overestimated corneal power between 0.3 and 3.2 D in theoretical simulations and between 0.8 and 2.9 D in the clinical study (ΔPc). Three linear equations were defined for nkadj to be used for different ranges of r1c. In the clinical study, differences between Pkadj and PcGauss did not exceed ±0.8 D nk = 1.3375. No statistically significant differences were found between Pkadj and PcGauss (p > 0.05) and Pk(1.3375) and Pkadj (p < 0.001). Conclusions The use of the keratometric approach in keratoconus eyes after accelerated CXL can lead to significant clinical errors. These errors can be minimized with an adjusted keratometric approach. PMID:29201459

Effects of Head-Mounted Display on the Oculomotor System and Refractive Error in Normal Adolescents.

PubMed

Ha, Suk-Gyu; Na, Kun-Hoo; Kweon, Il-Joo; Suh, Young-Woo; Kim, Seung-Hyun

2016-07-01

To investigate the clinical effects of head-mounted display on the refractive error and oculomotor system in normal adolescents. Sixty volunteers (age: 13 to 18 years) watched a three-dimensional movie and virtual reality application of head-mounted display for 30 minutes. The refractive error (diopters [D]), angle of deviation (prism diopters [PD]) at distance (6 m) and near (33 cm), near point of accommodation, and stereoacuity were measured before, immediately after, and 10 minutes after watching the head-mounted display. The refractive error was presented as spherical equivalent (SE). Refractive error was measured repeatedly after every 10 minutes when a myopic shift greater than 0.15 D was observed after watching the head-mounted display. The mean age of the participants was 14.7 ± 1.3 years and the mean SE before watching head-mounted display was -3.1 ± 2.6 D. One participant in the virtual reality application group was excluded due to motion sickness and nausea. After 30 minutes of watching the head-mounted display, the SE, near point of accommodation, and stereoacuity in both eyes did not change significantly (all P > .05). Immediately after watching the head-mounted display, esophoric shift was observed (0.6 ± 1.5 to 0.2 ± 1.5 PD), although it was not significant (P = .06). Transient myopic shifts of 17.2% to 30% were observed immediately after watching the head-mounted display in both groups, but recovered fully within 40 minutes after watching the head-mounted display. There were no significant clinical effects of watching head-mounted display for 30 minutes on the normal adolescent eye. Transient changes in refractive error and binocular alignment were noted, but were not significant. [J Pediatr Ophthalmol Strabismus. 2016;53(4):238-245.]. Copyright 2016, SLACK Incorporated.

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

PubMed

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

2018-04-01

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

Improving accuracy of clinical coding in surgery: collaboration is key.

PubMed

Heywood, Nick A; Gill, Michael D; Charlwood, Natasha; Brindle, Rachel; Kirwan, Cliona C

2016-08-01

Clinical coding data provide the basis for Hospital Episode Statistics and Healthcare Resource Group codes. High accuracy of this information is required for payment by results, allocation of health and research resources, and public health data and planning. We sought to identify the level of accuracy of clinical coding in general surgical admissions across hospitals in the Northwest of England. Clinical coding departments identified a total of 208 emergency general surgical patients discharged between 1st March and 15th August 2013 from seven hospital trusts (median = 20, range = 16-60). Blinded re-coding was performed by a senior clinical coder and clinician, with results compared with the original coding outcome. Recorded codes were generated from OPCS-4 & ICD-10. Of all cases, 194 of 208 (93.3%) had at least one coding error and 9 of 208 (4.3%) had errors in both primary diagnosis and primary procedure. Errors were found in 64 of 208 (30.8%) of primary diagnoses and 30 of 137 (21.9%) of primary procedure codes. Median tariff using original codes was £1411.50 (range, £409-9138). Re-calculation using updated clinical codes showed a median tariff of £1387.50, P = 0.997 (range, £406-10,102). The most frequent reasons for incorrect coding were "coder error" and a requirement for "clinical interpretation of notes". Errors in clinical coding are multifactorial and have significant impact on primary diagnosis, potentially affecting the accuracy of Hospital Episode Statistics data and in turn the allocation of health care resources and public health planning. As we move toward surgeon specific outcomes, surgeons should increase collaboration with coding departments to ensure the system is robust. Copyright © 2016 Elsevier Inc. All rights reserved.

Do Work Condition Interventions Affect Quality and Errors in Primary Care? Results from the Healthy Work Place Study.

PubMed

Linzer, Mark; Poplau, Sara; Brown, Roger; Grossman, Ellie; Varkey, Anita; Yale, Steven; Williams, Eric S; Hicks, Lanis; Wallock, Jill; Kohnhorst, Diane; Barbouche, Michael

2017-01-01

While primary care work conditions are associated with adverse clinician outcomes, little is known about the effect of work condition interventions on quality or safety. A cluster randomized controlled trial of 34 clinics in the upper Midwest and New York City. Primary care clinicians and their diabetic and hypertensive patients. Quality improvement projects to improve communication between providers, workflow design, and chronic disease management. Intervention clinics received brief summaries of their clinician and patient outcome data at baseline. We measured work conditions and clinician and patient outcomes both at baseline and 6-12 months post-intervention. Multilevel regression analyses assessed the impact of work condition changes on outcomes. Subgroup analyses assessed impact by intervention category. There were no significant differences in error reduction (19 % vs. 11 %, OR of improvement 1.84, 95 % CI 0.70, 4.82, p = 0.21) or quality of care improvement (19 % improved vs. 44 %, OR 0.62, 95 % CI 0.58, 1.21, p = 0.42) between intervention and control clinics. The conceptual model linking work conditions, provider outcomes, and error reduction showed significant relationships between work conditions and provider outcomes (p ≤ 0.001) and a trend toward a reduced error rate in providers with lower burnout (OR 1.44, 95 % CI 0.94, 2.23, p = 0.09). Few quality metrics, short time span, fewer clinicians recruited than anticipated. Work-life interventions improving clinician satisfaction and well-being do not necessarily reduce errors or improve quality. Longer, more focused interventions may be needed to produce meaningful improvements in patient care. ClinicalTrials.gov # NCT02542995.

The "Measuring Outcomes of Clinical Connectivity" (MOCC) trial: investigating data entry errors in the Electronic Primary Care Research Network (ePCRN).

PubMed

Fontaine, Patricia; Mendenhall, Tai J; Peterson, Kevin; Speedie, Stuart M

2007-01-01

The electronic Primary Care Research Network (ePCRN) enrolled PBRN researchers in a feasibility trial to test the functionality of the network's electronic architecture and investigate error rates associated with two data entry strategies used in clinical trials. PBRN physicians and research assistants who registered with the ePCRN were eligible to participate. After online consent and randomization, participants viewed simulated patient records, presented as either abstracted data (short form) or progress notes (long form). Participants transcribed 50 data elements onto electronic case report forms (CRFs) without integrated field restrictions. Data errors were analyzed. Ten geographically dispersed PBRNs enrolled 100 members and completed the study in less than 7 weeks. The estimated overall error rate if field restrictions had been applied was 2.3%. Participants entering data from the short form had a higher rate of correctly entered data fields (94.5% vs 90.8%, P = .004) and significantly more error-free records (P = .003). Feasibility outcomes integral to completion of an Internet-based, multisite study were successfully achieved. Further development of programmable electronic safeguards is indicated. The error analysis conducted in this study will aid design of specific field restrictions for electronic CRFs, an important component of clinical trial management systems.

Effects of Diaphragmatic Breathing Patterns on Balance: A Preliminary Clinical Trial.

PubMed

Stephens, Rylee J; Haas, Mitchell; Moore, William L; Emmil, Jordan R; Sipress, Jayson A; Williams, Alex

The purpose of this study was to determine the feasibility of performing a larger study to determine if training in diaphragmatic breathing influences static and dynamic balance. A group of 13 healthy persons (8 men, 5 women), who were staff, faculty, or students at the University of Western States participated in an 8-week breathing and balance study using an uncontrolled clinical trial design. Participants were given a series of breathing exercises to perform weekly in the clinic and at home. Balance and breathing were assessed at the weekly clinic sessions. Breathing was evaluated with Liebenson's breathing assessment, static balance with the Modified Balance Error Scoring System, and dynamic balance with OptoGait's March in Place protocol. Improvement was noted in mean diaphragmatic breathing scores (1.3 to 2.6, P < .001), number of single-leg stance balance errors (7.1 to 3.8, P = .001), and tandem stance balance errors (3.2 to 0.9, P = .039). A decreasing error rate in single-leg stance was associated with improvement in breathing score within participants over the 8 weeks of the study (-1.4 errors/unit breathing score change, P < .001). Tandem stance performance did not reach statistical significance (-0.5 error/unit change, P = .118). Dynamic balance was insensitive to balance change, being error free for all participants throughout the study. This proof-of-concept study indicated that promotion of a costal-diaphragmatic breathing pattern may be associated with improvement in balance and suggests that a study of this phenomenon using an experimental design is feasible. Copyright © 2017. Published by Elsevier Inc.

Condom Use Errors and Problems: A Comparative Study of HIV-Positive Versus HIV-Negative Young Black MSM

PubMed Central

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

2015-01-01

Objective To describe self-reported frequencies of selected condom use errors and problems among young (ages 15–29) Black MSM (YBMSM) and to compare the observed prevalence of these errors/problems by HIV serostatus. Methods Between September 2012 October 2014, electronic interview data were collected from 369 YBMSM attending a federally supported STI clinic located in the southern U.S. Seventeen condom use errors and problems were assessed. Chi-square tests were used to detect significant differences in the prevalence of these 17 errors and problems between HIV-negative and HIV-positive men. Results The recall period was the past 90 days. The overall mean number of errors/problems was 2.98 (sd=2.29). The mean for HIV-negative men was 2.91 (sd=2.15) and the mean for HIV-positive men was 3.18 (sd=2.57). These means were not significantly different (t=1.02, df=367, P=.31). Only two significant differences were observed between HIV-negative and HIV-positive men. Breakage (P = .002) and slippage (P = .005) were about twice as likely among HIV-positive men. Breakage occurred for nearly 30% of the HIV-positive men compared to about 15% among HIV-negative men. Slippage occurred for about 16% of the HIV-positive men compared to about 9% among HIV-negative men. Conclusion A need exists to help YBMSM acquire the skills needed to avert breakage and slippage issues that could lead to HIV transmission. Beyond these two exceptions, condom use errors and problems were ubiquitous in this population regardless of HIV serostatus. Clinic-based intervention is warranted for these young men, including education about correct condom use and provision of free condoms and long-lasting lubricants. PMID:26462188

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 in pre- and post-examination steps must be minimized to guarantee the total quality of laboratory services.

SU-E-T-789: Validation of 3DVH Accuracy On Quantifying Delivery Errors Based On Clinical Relevant DVH Metrics

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

Ma, T; Kumaraswamy, L

Purpose: Detection of treatment delivery errors is important in radiation therapy. However, accurate quantification of delivery errors is also of great importance. This study aims to evaluate the 3DVH software’s ability to accurately quantify delivery errors. Methods: Three VMAT plans (prostate, H&N and brain) were randomly chosen for this study. First, we evaluated whether delivery errors could be detected by gamma evaluation. Conventional per-beam IMRT QA was performed with the ArcCHECK diode detector for the original plans and for the following modified plans: (1) induced dose difference error up to ±4.0% and (2) control point (CP) deletion (3 to 10more » CPs were deleted) (3) gantry angle shift error (3 degree uniformly shift). 2D and 3D gamma evaluation were performed for all plans through SNC Patient and 3DVH, respectively. Subsequently, we investigated the accuracy of 3DVH analysis for all cases. This part evaluated, using the Eclipse TPS plans as standard, whether 3DVH accurately can model the changes in clinically relevant metrics caused by the delivery errors. Results: 2D evaluation seemed to be more sensitive to delivery errors. The average differences between ECLIPSE predicted and 3DVH results for each pair of specific DVH constraints were within 2% for all three types of error-induced treatment plans, illustrating the fact that 3DVH is fairly accurate in quantifying the delivery errors. Another interesting observation was that even though the gamma pass rates for the error plans are high, the DVHs showed significant differences between original plan and error-induced plans in both Eclipse and 3DVH analysis. Conclusion: The 3DVH software is shown to accurately quantify the error in delivered dose based on clinically relevant DVH metrics, where a conventional gamma based pre-treatment QA might not necessarily detect.« less

Learning clinical reasoning.

PubMed

Pinnock, Ralph; Welch, Paul

2014-04-01

Errors in clinical reasoning continue to account for significant morbidity and mortality, despite evidence-based guidelines and improved technology. Experts in clinical reasoning often use unconscious cognitive processes that they are not aware of unless they explain how they are thinking. Understanding the intuitive and analytical thinking processes provides a guide for instruction. How knowledge is stored is critical to expertise in clinical reasoning. Curricula should be designed so that trainees store knowledge in a way that is clinically relevant. Competence in clinical reasoning is acquired by supervised practice with effective feedback. Clinicians must recognise the common errors in clinical reasoning and how to avoid them. Trainees can learn clinical reasoning effectively in everyday practice if teachers provide guidance on the cognitive processes involved in making diagnostic decisions. © 2013 The Authors. Journal of Paediatrics and Child Health © 2013 Paediatrics and Child Health Division (Royal Australasian College of Physicians).

Assessing Error Awareness as a Mediator of the Relationship between Subjective Concerns and Cognitive Performance in Older Adults

PubMed Central

Buckley, Rachel F.; Laming, Gemma; Chen, Li Peng Evelyn; Crole, Alice; Hester, Robert

2016-01-01

Objectives Subjective concerns of cognitive decline (SCD) often manifest in older adults who exhibit objectively normal cognitive functioning. This subjective-objective discrepancy is counter-intuitive when mounting evidence suggests that subjective concerns relate to future clinical progression to Alzheimer’s disease, and so possess the potential to be a sensitive early behavioural marker of disease. In the current study, we aimed to determine whether individual variability in conscious awareness of errors in daily life might mediate this subjective-objective relationship. Methods 67 cognitively-normal older adults underwent cognitive, SCD and mood tests, and an error awareness task. Results Poorer error awareness was not found to mediate a relationship between SCD and objective performance. Furthermore, non-clinical levels of depressive symptomatology were a primary driving factor of SCD and error awareness, and significantly mediated a relationship between the two. Discussion We were unable to show that poorer error awareness mediates SCD and cognitive performance in older adults. Our study does suggest, however, that underlying depressive symptoms influence both poorer error awareness and greater SCD severity. Error awareness is thus not recommended as a proxy for SCD, as reduced levels of error awareness do not seem to be reflected by greater SCD. PMID:27832173

Effect of surgical guide design and surgeon's experience on the accuracy of implant placement.

PubMed

Hinckfuss, Simon; Conrad, Heather J; Lin, Lianshan; Lunos, Scott; Seong, Wook-Jin

2012-08-01

Implant position is a key determinant of esthetic and functional success. Achieving the goal of ideal implant position may be affected by case selection, prosthodontically driven treatment planning, site preparation, surgeon's experience and use of a surgical guide. The combined effect of surgical guide design, surgeon's experience, and size of the edentulous area on the accuracy of implant placement was evaluated in a simulated clinical setting. Twenty-one volunteers were recruited to participate in the study. They were divided evenly into 3 groups (novice, intermediate, and experienced). Each surgeon placed implants in single and double sites using 4 different surgical guide designs (no guide, tube, channel, and guided) and written instructions describing the ideal implant positions. A definitive typodont was constructed that had 3 implants in prosthetically determined ideal positions of single and double sites. The position and angulation of implants placed by the surgeons in the duplicate typodonts was measured using a computerized coordinate measuring machine and compared to the definitive typodont. The mean absolute positional error for all guides was 0.273, 0.340, 0.197 mm in mesial-distal, buccal-lingual, vertical positions, respectively, with an overall range of 0.00 to 1.81 mm. The mean absolute angle error for all guides was 1.61° and 2.39° in the mesial-distal and buccal-lingual angulations, respectively, with an overall range of 0.01° to 9.7°. Surgical guide design had a statistically significant effect on the accuracy of implant placement regardless of the surgeon's experience level. Experienced surgeons had significantly less error in buccal-lingual angulation. The size of the edentulous sites was found to affect both implant angle and position significantly. The magnitude of error in position and angulation caused by surgical guide design, surgeon's experience, and site size reported in this study are possibly not large enough to be clinically significant; however, it is likely that errors would be magnified in clinical practice. Future research is recommended to evaluate the effect of surgical guide design in vivo on implant angulation and position error.

Medication Administration Errors in an Adult Emergency Department of a Tertiary Health Care Facility in Ghana.

PubMed

Acheampong, Franklin; Tetteh, Ashalley Raymond; Anto, Berko Panyin

2016-12-01

This study determined the incidence, types, clinical significance, and potential causes of medication administration errors (MAEs) at the emergency department (ED) of a tertiary health care facility in Ghana. This study used a cross-sectional nonparticipant observational technique. Study participants (nurses) were observed preparing and administering medication at the ED of a 2000-bed tertiary care hospital in Accra, Ghana. The observations were then compared with patients' medication charts, and identified errors were clarified with staff for possible causes. Of the 1332 observations made, involving 338 patients and 49 nurses, 362 had errors, representing 27.2%. However, the error rate excluding "lack of drug availability" fell to 12.8%. Without wrong time error, the error rate was 22.8%. The 2 most frequent error types were omission (n = 281, 77.6%) and wrong time (n = 58, 16%) errors. Omission error was mainly due to unavailability of medicine, 48.9% (n = 177). Although only one of the errors was potentially fatal, 26.7% were definitely clinically severe. The common themes that dominated the probable causes of MAEs were unavailability, staff factors, patient factors, prescription, and communication problems. This study gives credence to similar studies in different settings that MAEs occur frequently in the ED of hospitals. Most of the errors identified were not potentially fatal; however, preventive strategies need to be used to make life-saving processes such as drug administration in such specialized units error-free.

Clinical vision characteristics of the congenital achromatopsias. I. Visual acuity, refractive error, and binocular status.

PubMed

Haegerstrom-Portnoy, G; Schneck, M E; Verdon, W A; Hewlett, S E

1996-07-01

Visual acuity, refractive error, and binocular status were determined in 43 autosomal recessive (AR) and 15 X-linked (XL) congenital achromats. The achromats were classified by color matching and spectral sensitivity data. Large interindividual variation in refractive error and visual acuity was present within each achromat group (complete AR, incomplete AR, and XL). However, the number of individuals with significant interocular acuity differences is very small. Most XLs are myopic; ARs show a wide range of refractive error from high myopia to high hyperopia. Acuity of the AR and XL groups was very similar. With-the-rule astigmatism of large amount is very common in achromats, particularly ARs. There is a close association between strabismus and interocular acuity differences in the ARs, with the fixating eye having better than average acuity. The large overlap of acuity and refractive error of XL and AR achromats suggests that these measures are less useful for differential diagnosis than generally indicated by the clinical literature.

Interventions to reduce medication errors in neonatal care: a systematic review

PubMed Central

Nguyen, Minh-Nha Rhylie; Mosel, Cassandra

2017-01-01

Background: Medication errors represent a significant but often preventable cause of morbidity and mortality in neonates. The objective of this systematic review was to determine the effectiveness of interventions to reduce neonatal medication errors. Methods: A systematic review was undertaken of all comparative and noncomparative studies published in any language, identified from searches of PubMed and EMBASE and reference-list checking. Eligible studies were those investigating the impact of any medication safety interventions aimed at reducing medication errors in neonates in the hospital setting. Results: A total of 102 studies were identified that met the inclusion criteria, including 86 comparative and 16 noncomparative studies. Medication safety interventions were classified into six themes: technology (n = 38; e.g. electronic prescribing), organizational (n = 16; e.g. guidelines, policies, and procedures), personnel (n = 13; e.g. staff education), pharmacy (n = 9; e.g. clinical pharmacy service), hazard and risk analysis (n = 8; e.g. error detection tools), and multifactorial (n = 18; e.g. any combination of previous interventions). Significant variability was evident across all included studies, with differences in intervention strategies, trial methods, types of medication errors evaluated, and how medication errors were identified and evaluated. Most studies demonstrated an appreciable risk of bias. The vast majority of studies (>90%) demonstrated a reduction in medication errors. A similar median reduction of 50–70% in medication errors was evident across studies included within each of the identified themes, but findings varied considerably from a 16% increase in medication errors to a 100% reduction in medication errors. Conclusion: While neonatal medication errors can be reduced through multiple interventions aimed at improving the medication use process, no single intervention appeared clearly superior. Further research is required to evaluate the relative cost-effectiveness of the various medication safety interventions to facilitate decisions regarding uptake and implementation into clinical practice. PMID:29387337

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

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.

Spinal intra-operative three-dimensional navigation with infra-red tool tracking: correlation between clinical and absolute engineering accuracy

NASA Astrophysics Data System (ADS)

Guha, Daipayan; Jakubovic, Raphael; Gupta, Shaurya; Yang, Victor X. D.

2017-02-01

Computer-assisted navigation (CAN) may guide spinal surgeries, reliably reducing screw breach rates. Definitions of screw breach, if reported, vary widely across studies. Absolute quantitative error is theoretically a more precise and generalizable metric of navigation accuracy, but has been computed variably and reported in fewer than 25% of clinical studies of CAN-guided pedicle screw accuracy. We reviewed a prospectively-collected series of 209 pedicle screws placed with CAN guidance to characterize the correlation between clinical pedicle screw accuracy, based on postoperative imaging, and absolute quantitative navigation accuracy. We found that acceptable screw accuracy was achieved for significantly fewer screws based on 2mm grade vs. Heary grade, particularly in the lumbar spine. Inter-rater agreement was good for the Heary classification and moderate for the 2mm grade, significantly greater among radiologists than surgeon raters. Mean absolute translational/angular accuracies were 1.75mm/3.13° and 1.20mm/3.64° in the axial and sagittal planes, respectively. There was no correlation between clinical and absolute navigation accuracy, in part because surgeons appear to compensate for perceived translational navigation error by adjusting screw medialization angle. Future studies of navigation accuracy should therefore report absolute translational and angular errors. Clinical screw grades based on post-operative imaging, if reported, may be more reliable if performed in multiple by radiologist raters.

P-value interpretation and alpha allocation in clinical trials.

PubMed

Moyé, L A

1998-08-01

Although much value has been placed on type I error event probabilities in clinical trials, interpretive difficulties often arise that are directly related to clinical trial complexity. Deviations of the trial execution from its protocol, the presence of multiple treatment arms, and the inclusion of multiple end points complicate the interpretation of an experiment's reported alpha level. The purpose of this manuscript is to formulate the discussion of P values (and power for studies showing no significant differences) on the basis of the event whose relative frequency they represent. Experimental discordance (discrepancies between the protocol's directives and the experiment's execution) is linked to difficulty in alpha and beta interpretation. Mild experimental discordance leads to an acceptable adjustment for alpha or beta, while severe discordance results in their corruption. Finally, guidelines are provided for allocating type I error among a collection of end points in a prospectively designed, randomized controlled clinical trial. When considering secondary end point inclusion in clinical trials, investigators should increase the sample size to preserve the type I error rates at acceptable levels.

Heuristic errors in clinical reasoning.

PubMed

Rylander, Melanie; Guerrasio, Jeannette

2016-08-01

Errors in clinical reasoning contribute to patient morbidity and mortality. The purpose of this study was to determine the types of heuristic errors made by third-year medical students and first-year residents. This study surveyed approximately 150 clinical educators inquiring about the types of heuristic errors they observed in third-year medical students and first-year residents. Anchoring and premature closure were the two most common errors observed amongst third-year medical students and first-year residents. There was no difference in the types of errors observed in the two groups. Errors in clinical reasoning contribute to patient morbidity and mortality Clinical educators perceived that both third-year medical students and first-year residents committed similar heuristic errors, implying that additional medical knowledge and clinical experience do not affect the types of heuristic errors made. Further work is needed to help identify methods that can be used to reduce heuristic errors early in a clinician's education. © 2015 John Wiley & Sons Ltd.

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.

Iatrogenic disease management: moderating medication errors and risks in a pharmacy benefit management environment.

PubMed

Nair, Vinit; Salmon, J Warren; Kaul, Alan F

2007-12-01

Disease Management (DM) programs have advanced to address costly chronic disease patterns in populations. This is in part due to the programs' significant clinical and economical value, coupled with interest by pharmaceutical manufacturers, managed care organizations, and pharmacy benefit management firms. While cost containment realizations for many such interventions have been less than anticipated, this article explores potentials in marrying Medication Error Risk Reduction into DM programs within managed care environments. Medication errors are an emergent serious problem now gaining attention in US health policy. They represent a failure within population-based health programs because they remain significant cost drivers. Therefore, medication errors should be addressed in an organized fashion, with DM being a worthy candidate for piggybacking such programs to achieve the best synergistic effects.

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

PubMed

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

2014-01-01

Post-error slowing (PES) is an error recovery strategy that contributes to action control, and occurs after errors in order to prevent future behavioral flaws. Error recovery often malfunctions in clinical populations, but the relationship between behavioral traits and recovery from error is unclear in healthy populations. The present study investigated the relationship between impulsivity and error recovery by simulating a speeded response situation using a Go/No-go paradigm that forced the participants to constantly make accelerated responses prior to stimuli disappearance (stimulus duration: 250 ms). Neural correlates of post-error processing were examined using event-related potentials (ERPs). Impulsivity traits were measured with self-report questionnaires (BIS-11, BIS/BAS). Behavioral results demonstrated that the commission error for No-go trials was 15%, but PES did not take place immediately. Delayed PES was negatively correlated with error rates and impulsivity traits, showing that response slowing was associated with reduced error rates and changed with impulsivity. Response-locked error ERPs were clearly observed for the error trials. Contrary to previous studies, error ERPs were not significantly related to PES. Stimulus-locked N2 was negatively correlated with PES and positively correlated with impulsivity traits at the second post-error Go trial: larger N2 activity was associated with greater PES and less impulsivity. In summary, under constant speeded conditions, error monitoring was dissociated from post-error action control, and PES did not occur quickly. Furthermore, PES and its neural correlate (N2) were modulated by impulsivity traits. These findings suggest that there may be clinical and practical efficacy of maintaining cognitive control of actions during error recovery under common daily environments that frequently evoke impulsive behaviors.

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

PubMed Central

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

2015-01-01

Post-error slowing (PES) is an error recovery strategy that contributes to action control, and occurs after errors in order to prevent future behavioral flaws. Error recovery often malfunctions in clinical populations, but the relationship between behavioral traits and recovery from error is unclear in healthy populations. The present study investigated the relationship between impulsivity and error recovery by simulating a speeded response situation using a Go/No-go paradigm that forced the participants to constantly make accelerated responses prior to stimuli disappearance (stimulus duration: 250 ms). Neural correlates of post-error processing were examined using event-related potentials (ERPs). Impulsivity traits were measured with self-report questionnaires (BIS-11, BIS/BAS). Behavioral results demonstrated that the commission error for No-go trials was 15%, but PES did not take place immediately. Delayed PES was negatively correlated with error rates and impulsivity traits, showing that response slowing was associated with reduced error rates and changed with impulsivity. Response-locked error ERPs were clearly observed for the error trials. Contrary to previous studies, error ERPs were not significantly related to PES. Stimulus-locked N2 was negatively correlated with PES and positively correlated with impulsivity traits at the second post-error Go trial: larger N2 activity was associated with greater PES and less impulsivity. In summary, under constant speeded conditions, error monitoring was dissociated from post-error action control, and PES did not occur quickly. Furthermore, PES and its neural correlate (N2) were modulated by impulsivity traits. These findings suggest that there may be clinical and practical efficacy of maintaining cognitive control of actions during error recovery under common daily environments that frequently evoke impulsive behaviors. PMID:25674058

The effect of a clinical pharmacist discharge service on medication discrepancies in patients with heart failure

PubMed Central

Lenderink, Albert W.; Widdershoven, Jos W. M. G.; van den Bemt, Patricia M. L. A.

2010-01-01

Objective Heart failure patients are regularly admitted to hospital and frequently use multiple medication. Besides intentional changes in pharmacotherapy, unintentional changes may occur during hospitalisation. The aim of this study was to investigate the effect of a clinical pharmacist discharge service on medication discrepancies and prescription errors in patients with heart failure. Setting A general teaching hospital in Tilburg, the Netherlands. Method An open randomized intervention study was performed comparing an intervention group, with a control group receiving regular care by doctors and nurses. The clinical pharmacist discharge service consisted of review of discharge medication, communicating prescribing errors with the cardiologist, giving patients information, preparation of a written overview of the discharge medication and communication to both the community pharmacist and the general practitioner about this medication. Within 6 weeks after discharge all patients were routinely scheduled to visit the outpatient clinic and medication discrepancies were measured. Main outcome measure The primary endpoint was the frequency of prescription errors in the discharge medication and medication discrepancies after discharge combined. Results Forty-four patients were included in the control group and 41 in the intervention group. Sixty-eight percent of patients in the control group had at least one discrepancy or prescription error against 39% in the intervention group (RR 0.57 (95% CI 0.37–0.88)). The percentage of medications with a discrepancy or prescription error in the control group was 14.6% and in the intervention group it was 6.1% (RR 0.42 (95% CI 0.27–0.66)). Conclusion This clinical pharmacist discharge service significantly reduces the risk of discrepancies and prescription errors in medication of patients with heart failure in the 1st month after discharge. PMID:20809276

Impact of number of co-existing rotors and inter-electrode distance on accuracy of rotor localization☆,☆☆

PubMed Central

Aronis, Konstantinos N.; Ashikaga, Hiroshi

2018-01-01

Background Conflicting evidence exists on the efficacy of focal impulse and rotor modulation on atrial fibrillation ablation. A potential explanation is inaccurate rotor localization from multiple rotors coexistence and a relatively large (9–11 mm) inter-electrode distance (IED) of the multi-electrode basket catheter. Methods and results We studied a numerical model of cardiac action potential to reproduce one through seven rotors in a two-dimensional lattice. We estimated rotor location using phase singularity, Shannon entropy and dominant frequency. We then spatially downsampled the time series to create IEDs of 2–30 mm. The error of rotor localization was measured with reference to the dynamics of phase singularity at the original spatial resolution (IED = 1 mm). IED has a significant impact on the error using all the methods. When only one rotor is present, the error increases exponentially as a function of IED. At the clinical IED of 10 mm, the error is 3.8 mm (phase singularity), 3.7 mm (dominant frequency), and 11.8 mm (Shannon entropy). When there are more than one rotors, the error of rotor localization increases 10-fold. The error based on the phase singularity method at the clinical IED of 10 mm ranges from 30.0 mm (two rotors) to 96.1 mm (five rotors). Conclusions The magnitude of error of rotor localization using a clinically available basket catheter, in the presence of multiple rotors might be high enough to impact the accuracy of targeting during AF ablation. Improvement of catheter design and development of high-density mapping catheters may improve clinical outcomes of FIRM-guided AF ablation. PMID:28988690

Impact of number of co-existing rotors and inter-electrode distance on accuracy of rotor localization.

PubMed

Aronis, Konstantinos N; Ashikaga, Hiroshi

Conflicting evidence exists on the efficacy of focal impulse and rotor modulation on atrial fibrillation ablation. A potential explanation is inaccurate rotor localization from multiple rotors coexistence and a relatively large (9-11mm) inter-electrode distance (IED) of the multi-electrode basket catheter. We studied a numerical model of cardiac action potential to reproduce one through seven rotors in a two-dimensional lattice. We estimated rotor location using phase singularity, Shannon entropy and dominant frequency. We then spatially downsampled the time series to create IEDs of 2-30mm. The error of rotor localization was measured with reference to the dynamics of phase singularity at the original spatial resolution (IED=1mm). IED has a significant impact on the error using all the methods. When only one rotor is present, the error increases exponentially as a function of IED. At the clinical IED of 10mm, the error is 3.8mm (phase singularity), 3.7mm (dominant frequency), and 11.8mm (Shannon entropy). When there are more than one rotors, the error of rotor localization increases 10-fold. The error based on the phase singularity method at the clinical IED of 10mm ranges from 30.0mm (two rotors) to 96.1mm (five rotors). The magnitude of error of rotor localization using a clinically available basket catheter, in the presence of multiple rotors might be high enough to impact the accuracy of targeting during AF ablation. Improvement of catheter design and development of high-density mapping catheters may improve clinical outcomes of FIRM-guided AF ablation. Copyright © 2017 Elsevier Inc. All rights reserved.

Measuring Data Quality Through a Source Data Verification Audit in a Clinical Research Setting.

PubMed

Houston, Lauren; Probst, Yasmine; Humphries, Allison

2015-01-01

Health data has long been scrutinised in relation to data quality and integrity problems. Currently, no internationally accepted or "gold standard" method exists measuring data quality and error rates within datasets. We conducted a source data verification (SDV) audit on a prospective clinical trial dataset. An audit plan was applied to conduct 100% manual verification checks on a 10% random sample of participant files. A quality assurance rule was developed, whereby if >5% of data variables were incorrect a second 10% random sample would be extracted from the trial data set. Error was coded: correct, incorrect (valid or invalid), not recorded or not entered. Audit-1 had a total error of 33% and audit-2 36%. The physiological section was the only audit section to have <5% error. Data not recorded to case report forms had the greatest impact on error calculations. A significant association (p=0.00) was found between audit-1 and audit-2 and whether or not data was deemed correct or incorrect. Our study developed a straightforward method to perform a SDV audit. An audit rule was identified and error coding was implemented. Findings demonstrate that monitoring data quality by a SDV audit can identify data quality and integrity issues within clinical research settings allowing quality improvement to be made. The authors suggest this approach be implemented for future research.

Young African American Men Having Sex with Multiple Partners Are More Likely to Use Condoms Incorrectly: A Clinic-Based Study

PubMed Central

Crosby, Richard; DiClemente, Ralph J.; Yarber, William L.; Snow, Gregory; Troutman, Adewale

2009-01-01

This study tested the research hypothesis that men’s errors using condoms would be associated with having multiple sex partners. Specifically, men engaging in sex with three or more women were compared to those having sex with two or fewer women. Recruitment (N=271) occurred in a publicly-funded STD clinic located in a metropolitan area of the Southern U.S. All men were clinically diagnosed with a STD. Men completed a self-reported questionnaire (using a three-month recall period). Those reporting sex with men were excluded from the analysis leaving an analytic sample of 264 men. About one-half of the men (48.5%) reporting penetrative sex with three or more women during the recall period. Compared to those men reporting sex with two or fewer women, men having ≥3 women sex partners were significantly more likely to report: 1) not using condoms from start to finish of sex (P=.005); 2) that condoms slipped off during sex or withdrawal (P=.04); and 3) that condoms broke during sex (P=.03). A summary measure of condom use errors indicated that men with ≥3 women partners reported significantly greater numbers of errors than their counterparts reporting sex with ≤ 2 sex partners (Mean difference 1.7; P=.009). Among young African American men, newly diagnosed with an STD, reporting recent (past three months) sex with multiple partners may be emblematic of condom errors. These men may benefit from, clinic-based, targeted counseling and education designed to foster improved quality of condom use. PMID:19477797

Physician attitudes and practices related to voluntary error and near-miss reporting.

PubMed

Smith, Koren S; Harris, Kendra M; Potters, Louis; Sharma, Rajiv; Mutic, Sasa; Gay, Hiram A; Wright, Jean; Samuels, Michael; Ye, Xiaobu; Ford, Eric; Terezakis, Stephanie

2014-09-01

Incident learning systems are important tools to improve patient safety in radiation oncology, but physician participation in these systems is poor. To understand reporting practices and attitudes, a survey was sent to staff members of four large academic radiation oncology centers, all of which have in-house reporting systems. Institutional review board approval was obtained to send a survey to employees including physicians, dosimetrists, nurses, physicists, and radiation therapists. The survey evaluated barriers to reporting, perceptions of errors, and reporting practices. The responses of physicians were compared with those of other professional groups. There were 274 respondents to the survey, with a response rate of 81.3%. Physicians and other staff agreed that errors and near-misses were happening in their clinics (93.8% v 88.7%, respectively) and that they have a responsibility to report (97% overall). Physicians were significantly less likely to report minor near-misses (P = .001) and minor errors (P = .024) than other groups. Physicians were significantly more concerned about getting colleagues in trouble (P = .015), liability (P = .009), effect on departmental reputation (P = .006), and embarrassment (P < .001) than their colleagues. Regression analysis identified embarrassment among physicians as a critical barrier. If not embarrassed, participants were 2.5 and 4.5 times more likely to report minor errors and major near-miss events, respectively. All members of the radiation oncology team observe errors and near-misses. Physicians, however, are significantly less likely to report events than other colleagues. There are important, specific barriers to physician reporting that need to be addressed to encourage reporting and create a fair culture around reporting. Copyright © 2014 by American Society of Clinical Oncology.

Information technology and medication safety: what is the benefit?

PubMed Central

Kaushal, R; Bates, D

2002-01-01



 Medication errors occur frequently and have significant clinical and financial consequences. Several types of information technologies can be used to decrease rates of medication errors. Computerized physician order entry with decision support significantly reduces serious inpatient medication error rates in adults. Other available information technologies that may prove effective for inpatients include computerized medication administration records, robots, automated pharmacy systems, bar coding, "smart" intravenous devices, and computerized discharge prescriptions and instructions. In outpatients, computerization of prescribing and patient oriented approaches such as personalized web pages and delivery of web based information may be important. Public and private mandates for information technology interventions are growing, but further development, application, evaluation, and dissemination are required. PMID:12486992

Automated drug dispensing system reduces medication errors in an intensive care setting.

PubMed

Chapuis, Claire; Roustit, Matthieu; Bal, Gaëlle; Schwebel, Carole; Pansu, Pascal; David-Tchouda, Sandra; Foroni, Luc; Calop, Jean; Timsit, Jean-François; Allenet, Benoît; Bosson, Jean-Luc; Bedouch, Pierrick

2010-12-01

We aimed to assess the impact of an automated dispensing system on the incidence of medication errors related to picking, preparation, and administration of drugs in a medical intensive care unit. We also evaluated the clinical significance of such errors and user satisfaction. Preintervention and postintervention study involving a control and an intervention medical intensive care unit. Two medical intensive care units in the same department of a 2,000-bed university hospital. Adult medical intensive care patients. After a 2-month observation period, we implemented an automated dispensing system in one of the units (study unit) chosen randomly, with the other unit being the control. The overall error rate was expressed as a percentage of total opportunities for error. The severity of errors was classified according to National Coordinating Council for Medication Error Reporting and Prevention categories by an expert committee. User satisfaction was assessed through self-administered questionnaires completed by nurses. A total of 1,476 medications for 115 patients were observed. After automated dispensing system implementation, we observed a reduced percentage of total opportunities for error in the study compared to the control unit (13.5% and 18.6%, respectively; p<.05); however, no significant difference was observed before automated dispensing system implementation (20.4% and 19.3%, respectively; not significant). Before-and-after comparisons in the study unit also showed a significantly reduced percentage of total opportunities for error (20.4% and 13.5%; p<.01). An analysis of detailed opportunities for error showed a significant impact of the automated dispensing system in reducing preparation errors (p<.05). Most errors caused no harm (National Coordinating Council for Medication Error Reporting and Prevention category C). The automated dispensing system did not reduce errors causing harm. Finally, the mean for working conditions improved from 1.0±0.8 to 2.5±0.8 on the four-point Likert scale. The implementation of an automated dispensing system reduced overall medication errors related to picking, preparation, and administration of drugs in the intensive care unit. Furthermore, most nurses favored the new drug dispensation organization.

Medical students' experiences with medical errors: an analysis of medical student essays.

PubMed

Martinez, William; Lo, Bernard

2008-07-01

This study aimed to examine medical students' experiences with medical errors. In 2001 and 2002, 172 fourth-year medical students wrote an anonymous description of a significant medical error they had witnessed or committed during their clinical clerkships. The assignment represented part of a required medical ethics course. We analysed 147 of these essays using thematic content analysis. Many medical students made or observed significant errors. In either situation, some students experienced distress that seemingly went unaddressed. Furthermore, this distress was sometimes severe and persisted after the initial event. Some students also experienced considerable uncertainty as to whether an error had occurred and how to prevent future errors. Many errors may not have been disclosed to patients, and some students who desired to discuss or disclose errors were apparently discouraged from doing so by senior doctors. Some students criticised senior doctors who attempted to hide errors or avoid responsibility. By contrast, students who witnessed senior doctors take responsibility for errors and candidly disclose errors to patients appeared to recognise the importance of honesty and integrity and said they aspired to these standards. There are many missed opportunities to teach students how to respond to and learn from errors. Some faculty members and housestaff may at times respond to errors in ways that appear to contradict professional standards. Medical educators should increase exposure to exemplary responses to errors and help students to learn from and cope with errors.

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 plotted on the SEG when compared to the data plotted on the CEG and PEG produced risk estimates that were more granular and reflective of a continuously increasing risk scale. Discussion: The SEG is a modern metric for clinical risk assessments of BG monitor errors that assigns a unique risk score to each monitor data point when compared to a reference value. The SEG allows the clinical accuracy of a BG monitor to be portrayed in many ways, including as the percentages of data points falling into custom-defined risk zones. For modeled data the SEG, compared with the CEG and PEG, allows greater precision for quantifying risk, especially when the risks are low. This tool will be useful to allow regulators and manufacturers to monitor and evaluate glucose monitor performance in their surveillance programs. PMID:25562886

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 the data plotted on the CEG and PEG produced risk estimates that were more granular and reflective of a continuously increasing risk scale. The SEG is a modern metric for clinical risk assessments of BG monitor errors that assigns a unique risk score to each monitor data point when compared to a reference value. The SEG allows the clinical accuracy of a BG monitor to be portrayed in many ways, including as the percentages of data points falling into custom-defined risk zones. For modeled data the SEG, compared with the CEG and PEG, allows greater precision for quantifying risk, especially when the risks are low. This tool will be useful to allow regulators and manufacturers to monitor and evaluate glucose monitor performance in their surveillance programs. © 2014 Diabetes Technology Society.

CONSENSUS STATEMENT BY THE AMERICAN ASSOCIATION OF CLINICAL ENDOCRINOLOGISTS AND AMERICAN COLLEGE OF ENDOCRINOLOGY ON THE QUALITY OF DXA SCANS AND REPORTS.

PubMed

Licata, Angelo A; Binkley, Neil; Petak, Steven M; Camacho, Pauline M

2018-02-01

High-quality dual-energy X-ray absorptiometry (DXA) scans are necessary for accurate diagnosis of osteoporosis and monitoring of therapy; however, DXA scan reports may contain errors that cause confusion about diagnosis and treatment. This American Association of Clinical Endocrinologists/American College of Endocrinology consensus statement was generated to draw attention to many common technical problems affecting DXA report conclusions and provide guidance on how to address them to ensure that patients receive appropriate osteoporosis care. The DXA Writing Committee developed a consensus based on discussion and evaluation of available literature related to osteoporosis and osteodensitometry. Technical errors may include errors in scan acquisition and/or analysis, leading to incorrect diagnosis and reporting of change over time. Although the International Society for Clinical Densitometry advocates training for technologists and medical interpreters to help eliminate these problems, many lack skill in this technology. Suspicion that reports are wrong arises when clinical history is not compatible with scan interpretation (e.g., dramatic increase/decrease in a short period of time; declines in previously stable bone density after years of treatment), when different scanners are used, or when inconsistent anatomic sites are used for monitoring the response to therapy. Understanding the concept of least significant change will minimize erroneous conclusions about changes in bone density. Clinicians must develop the skills to differentiate technical problems, which confound reports, from real biological changes. We recommend that clinicians review actual scan images and data, instead of relying solely on the impression of the report, to pinpoint errors and accurately interpret DXA scan images. AACE = American Association of Clinical Endocrinologists; BMC = bone mineral content; BMD = bone mineral density; DXA = dual-energy X-ray absorptiometry; ISCD = International Society for Clinical Densitometry; LSC = least significant change; TBS = trabecular bone score; WHO = World Health Organization.

Impact of Frequent Interruption on Nurses' Patient-Controlled Analgesia Programming Performance.

PubMed

Campoe, Kristi R; Giuliano, Karen K

2017-12-01

The purpose was to add to the body of knowledge regarding the impact of interruption on acute care nurses' cognitive workload, total task completion times, nurse frustration, and medication administration error while programming a patient-controlled analgesia (PCA) pump. Data support that the severity of medication administration error increases with the number of interruptions, which is especially critical during the administration of high-risk medications. Bar code technology, interruption-free zones, and medication safety vests have been shown to decrease administration-related errors. However, there are few published data regarding the impact of number of interruptions on nurses' clinical performance during PCA programming. Nine acute care nurses completed three PCA pump programming tasks in a simulation laboratory. Programming tasks were completed under three conditions where the number of interruptions varied between two, four, and six. Outcome measures included cognitive workload (six NASA Task Load Index [NASA-TLX] subscales), total task completion time (seconds), nurse frustration (NASA-TLX Subscale 6), and PCA medication administration error (incorrect final programming). Increases in the number of interruptions were associated with significant increases in total task completion time ( p = .003). We also found increases in nurses' cognitive workload, nurse frustration, and PCA pump programming errors, but these increases were not statistically significant. Complex technology use permeates the acute care nursing practice environment. These results add new knowledge on nurses' clinical performance during PCA pump programming and high-risk medication administration.

Recognizing and Reducing Analytical Errors and Sources of Variation in Clinical Pathology Data in Safety Assessment Studies.

PubMed

Schultze, A E; Irizarry, A R

2017-02-01

Veterinary clinical pathologists are well positioned via education and training to assist in investigations of unexpected results or increased variation in clinical pathology data. Errors in testing and unexpected variability in clinical pathology data are sometimes referred to as "laboratory errors." These alterations may occur in the preanalytical, analytical, or postanalytical phases of studies. Most of the errors or variability in clinical pathology data occur in the preanalytical or postanalytical phases. True analytical errors occur within the laboratory and are usually the result of operator or instrument error. Analytical errors are often ≤10% of all errors in diagnostic testing, and the frequency of these types of errors has decreased in the last decade. Analytical errors and increased data variability may result from instrument malfunctions, inability to follow proper procedures, undetected failures in quality control, sample misidentification, and/or test interference. This article (1) illustrates several different types of analytical errors and situations within laboratories that may result in increased variability in data, (2) provides recommendations regarding prevention of testing errors and techniques to control variation, and (3) provides a list of references that describe and advise how to deal with increased data variability.

Algorithm for Correcting the Keratometric Error in the Estimation of the Corneal Power in Keratoconus Eyes after Accelerated Corneal Collagen Crosslinking.

PubMed

Piñero, David P; Camps, Vicente J; Caravaca-Arens, Esteban; de Fez, Dolores; Blanes-Mompó, Francisco J

2017-01-01

To analyze the errors associated to corneal power calculation using the keratometric approach in keratoconus eyes after accelerated corneal collagen crosslinking (CXL) surgery and to obtain a model for the estimation of an adjusted corneal refractive index ( n k adj ) minimizing such errors. Potential differences (Δ P c ) among keratometric ( P k ) and Gaussian corneal power ( P c Gauss ) were simulated. Three algorithms based on the use of n k adj for the estimation of an adjusted keratometric corneal power ( P k adj ) were developed. The agreement between P k (1.3375) (keratometric power using the keratometric index of 1.3375), P c Gauss , and P k adj was evaluated. The validity of the algorithm developed was investigated in 21 keratoconus eyes undergoing accelerated CXL. P k (1.3375) overestimated corneal power between 0.3 and 3.2 D in theoretical simulations and between 0.8 and 2.9 D in the clinical study (Δ P c ). Three linear equations were defined for n k adj to be used for different ranges of r 1c . In the clinical study, differences between P k adj and P c Gauss did not exceed ±0.8 D n k = 1.3375. No statistically significant differences were found between P k adj and P c Gauss ( p > 0.05) and P k (1.3375) and P k adj ( p < 0.001). The use of the keratometric approach in keratoconus eyes after accelerated CXL can lead to significant clinical errors. These errors can be minimized with an adjusted keratometric approach.

Paediatric Refractive Errors in an Eye Clinic in Osogbo, Nigeria.

PubMed

Michaeline, Isawumi; Sheriff, Agboola; Bimbo, Ayegoro

2016-03-01

Paediatric ophthalmology is an emerging subspecialty in Nigeria and as such there is paucity of data on refractive errors in the country. This study set out to determine the pattern of refractive errors in children attending an eye clinic in South West Nigeria. A descriptive study of 180 consecutive subjects seen over a 2-year period. Presenting complaints, presenting visual acuity (PVA), age and sex were recorded. Clinical examination of the anterior and posterior segments of the eyes, extraocular muscle assessment and refraction were done. The types of refractive errors and their grades were determined. Corrected VA was obtained. Data was analysed using descriptive statistics in proportions, chi square with p value <0.05. The age range of subjects was between 3 and 16 years with mean age = 11.7 and SD = 0.51; with males making up 33.9%.The commonest presenting complaint was blurring of distant vision (40%), presenting visual acuity 6/9 (33.9%), normal vision constituted >75.0%, visual impairment20% and low vision 23.3%. Low grade spherical and cylindrical errors occurred most frequently (35.6% and 59.9% respectively). Regular astigmatism was significantly more common, P <0.001. The commonest diagnosis was simple myopic astigmatism (41.1%). Four cases of strabismus were seen. Simple spherical and cylindrical errors were the commonest types of refractive errors seen. Visual impairment and low vision occurred and could be a cause of absenteeism from school. Low-cost spectacle production or dispensing unit and health education are advocated for the prevention of visual impairment in a hospital set-up.

Type-II generalized family-wise error rate formulas with application to sample size determination.

PubMed

Delorme, Phillipe; de Micheaux, Pierre Lafaye; Liquet, Benoit; Riou, Jérémie

2016-07-20

Multiple endpoints are increasingly used in clinical trials. The significance of some of these clinical trials is established if at least r null hypotheses are rejected among m that are simultaneously tested. The usual approach in multiple hypothesis testing is to control the family-wise error rate, which is defined as the probability that at least one type-I error is made. More recently, the q-generalized family-wise error rate has been introduced to control the probability of making at least q false rejections. For procedures controlling this global type-I error rate, we define a type-II r-generalized family-wise error rate, which is directly related to the r-power defined as the probability of rejecting at least r false null hypotheses. We obtain very general power formulas that can be used to compute the sample size for single-step and step-wise procedures. These are implemented in our R package rPowerSampleSize available on the CRAN, making them directly available to end users. Complexities of the formulas are presented to gain insight into computation time issues. Comparison with Monte Carlo strategy is also presented. We compute sample sizes for two clinical trials involving multiple endpoints: one designed to investigate the effectiveness of a drug against acute heart failure and the other for the immunogenicity of a vaccine strategy against pneumococcus. Copyright © 2016 John Wiley & Sons, Ltd. Copyright © 2016 John Wiley & Sons, Ltd.

Route Learning Impairment in Temporal Lobe Epilepsy

PubMed Central

Bell, Brian D.

2012-01-01

Memory impairment on neuropsychological tests is relatively common in temporal lobe epilepsy (TLE) patients. But memory rarely has been evaluated in more naturalistic settings. This study assessed TLE (n = 19) and control (n = 32) groups on a real-world route learning (RL) test. Compared to the controls, the TLE group committed significantly more total errors across the three RL test trials. RL errors correlated significantly with standardized auditory and visual memory and visual-perceptual test scores in the TLE group. In the TLE subset for whom hippocampal data were available (n = 14), RL errors also correlated significantly with left hippocampal volume. This is one of the first studies to demonstrate real-world memory impairment in TLE patients and its association with both mesial temporal lobe integrity and standardized memory test performance. The results support the ecological validity of clinical neuropsychological assessment. PMID:23041173

Time trend of injection drug errors before and after implementation of bar-code verification system.

PubMed

Sakushima, Ken; Umeki, Reona; Endoh, Akira; Ito, Yoichi M; Nasuhara, Yasuyuki

2015-01-01

Bar-code technology, used for verification of patients and their medication, could prevent medication errors in clinical practice. Retrospective analysis of electronically stored medical error reports was conducted in a university hospital. The number of reported medication errors of injected drugs, including wrong drug administration and administration to the wrong patient, was compared before and after implementation of the bar-code verification system for inpatient care. A total of 2867 error reports associated with injection drugs were extracted. Wrong patient errors decreased significantly after implementation of the bar-code verification system (17.4/year vs. 4.5/year, p< 0.05), although wrong drug errors did not decrease sufficiently (24.2/year vs. 20.3/year). The source of medication errors due to wrong drugs was drug preparation in hospital wards. Bar-code medication administration is effective for prevention of wrong patient errors. However, ordinary bar-code verification systems are limited in their ability to prevent incorrect drug preparation in hospital wards.

SU-G-JeP1-12: Head-To-Head Performance Characterization of Two Multileaf Collimator Tracking Algorithms for Radiotherapy

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

Caillet, V; Colvill, E; Royal North Shore Hospital, St Leonards, Sydney

2016-06-15

Purpose: Multi-leaf collimator (MLC) tracking is being clinically pioneered to continuously compensate for thoracic and abdominal motion during radiotherapy. The purpose of this work is to characterize the performance of two MLC tracking algorithms for cancer radiotherapy, based on a direct optimization and a piecewise leaf fitting approach respectively. Methods: To test the algorithms, both physical and in silico experiments were performed. Previously published high and low modulation VMAT plans for lung and prostate cancer cases were used along with eight patient-measured organ-specific trajectories. For both MLC tracking algorithm, the plans were run with their corresponding patient trajectories. The physicalmore » experiments were performed on a Trilogy Varian linac and a programmable phantom (HexaMotion platform). For each MLC tracking algorithm, plan and patient trajectory, the tracking accuracy was quantified as the difference in aperture area between ideal and fitted MLC. To compare algorithms, the average cumulative tracking error area for each experiment was calculated. The two-sample Kolmogorov-Smirnov (KS) test was used to evaluate the cumulative tracking errors between algorithms. Results: Comparison of tracking errors for the physical and in silico experiments showed minor differences between the two algorithms. The KS D-statistics for the physical experiments were below 0.05 denoting no significant differences between the two distributions pattern and the average error area (direct optimization/piecewise leaf-fitting) were comparable (66.64 cm2/65.65 cm2). For the in silico experiments, the KS D-statistics were below 0.05 and the average errors area were also equivalent (49.38 cm2/48.98 cm2). Conclusion: The comparison between the two leaf fittings algorithms demonstrated no significant differences in tracking errors, neither in a clinically realistic environment nor in silico. The similarities in the two independent algorithms give confidence in the use of either algorithm for clinical implementation.« less

Medication errors in the Middle East countries: a systematic review of the literature.

PubMed

Alsulami, Zayed; Conroy, Sharon; Choonara, Imti

2013-04-01

Medication errors are a significant global concern and can cause serious medical consequences for patients. Little is known about medication errors in Middle Eastern countries. The objectives of this systematic review were to review studies of the incidence and types of medication errors in Middle Eastern countries and to identify the main contributory factors involved. A systematic review of the literature related to medication errors in Middle Eastern countries was conducted in October 2011 using the following databases: Embase, Medline, Pubmed, the British Nursing Index and the Cumulative Index to Nursing & Allied Health Literature. The search strategy included all ages and languages. Inclusion criteria were that the studies assessed or discussed the incidence of medication errors and contributory factors to medication errors during the medication treatment process in adults or in children. Forty-five studies from 10 of the 15 Middle Eastern countries met the inclusion criteria. Nine (20 %) studies focused on medication errors in paediatric patients. Twenty-one focused on prescribing errors, 11 measured administration errors, 12 were interventional studies and one assessed transcribing errors. Dispensing and documentation errors were inadequately evaluated. Error rates varied from 7.1 % to 90.5 % for prescribing and from 9.4 % to 80 % for administration. The most common types of prescribing errors reported were incorrect dose (with an incidence rate from 0.15 % to 34.8 % of prescriptions), wrong frequency and wrong strength. Computerised physician rder entry and clinical pharmacist input were the main interventions evaluated. Poor knowledge of medicines was identified as a contributory factor for errors by both doctors (prescribers) and nurses (when administering drugs). Most studies did not assess the clinical severity of the medication errors. Studies related to medication errors in the Middle Eastern countries were relatively few in number and of poor quality. Educational programmes on drug therapy for doctors and nurses are urgently needed.

Medical error and related factors during internship and residency.

PubMed

Ahmadipour, Habibeh; Nahid, Mortazavi

2015-01-01

It is difficult to determine the real incidence of medical errors due to the lack of a precise definition of errors, as well as the failure to report them under certain circumstances. We carried out a cross- sectional study in Kerman University of Medical Sciences, Iran in 2013. The participants were selected through the census method. The data were collected using a self-administered questionnaire, which consisted of questions on the participants' demographic data and questions on the medical errors committed. The data were analysed by SPSS 19. It was found that 270 participants had committed medical errors. There was no significant difference in the frequency of errors committed by interns and residents. In the case of residents, the most common error was misdiagnosis and in that of interns, errors related to history-taking and physical examination. Considering that medical errors are common in the clinical setting, the education system should train interns and residents to prevent the occurrence of errors. In addition, the system should develop a positive attitude among them so that they can deal better with medical errors.

Preanalytical errors in medical laboratories: a review of the available methodologies of data collection and analysis.

PubMed

West, Jamie; Atherton, Jennifer; Costelloe, Seán J; Pourmahram, Ghazaleh; Stretton, Adam; Cornes, Michael

2017-01-01

Preanalytical errors have previously been shown to contribute a significant proportion of errors in laboratory processes and contribute to a number of patient safety risks. Accreditation against ISO 15189:2012 requires that laboratory Quality Management Systems consider the impact of preanalytical processes in areas such as the identification and control of non-conformances, continual improvement, internal audit and quality indicators. Previous studies have shown that there is a wide variation in the definition, repertoire and collection methods for preanalytical quality indicators. The International Federation of Clinical Chemistry Working Group on Laboratory Errors and Patient Safety has defined a number of quality indicators for the preanalytical stage, and the adoption of harmonized definitions will support interlaboratory comparisons and continual improvement. There are a variety of data collection methods, including audit, manual recording processes, incident reporting mechanisms and laboratory information systems. Quality management processes such as benchmarking, statistical process control, Pareto analysis and failure mode and effect analysis can be used to review data and should be incorporated into clinical governance mechanisms. In this paper, The Association for Clinical Biochemistry and Laboratory Medicine PreAnalytical Specialist Interest Group review the various data collection methods available. Our recommendation is the use of the laboratory information management systems as a recording mechanism for preanalytical errors as this provides the easiest and most standardized mechanism of data capture.

Pilot study on the feasibility of a computerized speech recognition charting system.

PubMed

Feldman, C A; Stevens, D

1990-08-01

The objective of this study was to determine the feasibility of developing and using a voice recognition computerized charting system to record dental clinical examination data. More specifically, the study was designed to analyze the time and error differential between the traditional examiner/recorder method (ASSISTANT) and computerized voice recognition method (VOICE). DMFS examinations were performed twice on 20 patients using the traditional ASSISTANT and the VOICE charting system. A statistically significant difference was found when comparing the mean ASSISTANT time of 2.69 min to the VOICE time of 3.72 min (P less than 0.001). No statistically significant difference was found when comparing the mean ASSISTANT recording errors of 0.1 to VOICE recording errors of 0.6 (P = 0.059). 90% of the patients indicated they felt comfortable with the dentist talking to a computer and only 5% of the sample indicated they opposed VOICE. Results from this pilot study indicate that a charting system utilizing voice recognition technology could be considered a viable alternative to traditional examiner/recorder methods of clinical charting.

Organizational safety culture and medical error reporting by Israeli nurses.

PubMed

Kagan, Ilya; Barnoy, Sivia

2013-09-01

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

Making electronic prescribing alerts more effective: scenario-based experimental study in junior doctors

PubMed Central

Shah, Priya; Wyatt, Jeremy C; Makubate, Boikanyo; Cross, Frank W

2011-01-01

Objective Expert authorities recommend clinical decision support systems to reduce prescribing error rates, yet large numbers of insignificant on-screen alerts presented in modal dialog boxes persistently interrupt clinicians, limiting the effectiveness of these systems. This study compared the impact of modal and non-modal electronic (e-) prescribing alerts on prescribing error rates, to help inform the design of clinical decision support systems. Design A randomized study of 24 junior doctors each performing 30 simulated prescribing tasks in random order with a prototype e-prescribing system. Using a within-participant design, doctors were randomized to be shown one of three types of e-prescribing alert (modal, non-modal, no alert) during each prescribing task. Measurements The main outcome measure was prescribing error rate. Structured interviews were performed to elicit participants' preferences for the prescribing alerts and their views on clinical decision support systems. Results Participants exposed to modal alerts were 11.6 times less likely to make a prescribing error than those not shown an alert (OR 11.56, 95% CI 6.00 to 22.26). Those shown a non-modal alert were 3.2 times less likely to make a prescribing error (OR 3.18, 95% CI 1.91 to 5.30) than those not shown an alert. The error rate with non-modal alerts was 3.6 times higher than with modal alerts (95% CI 1.88 to 7.04). Conclusions Both kinds of e-prescribing alerts significantly reduced prescribing error rates, but modal alerts were over three times more effective than non-modal alerts. This study provides new evidence about the relative effects of modal and non-modal alerts on prescribing outcomes. PMID:21836158

Social aspects of clinical errors.

PubMed

Richman, Joel; Mason, Tom; Mason-Whitehead, Elizabeth; McIntosh, Annette; Mercer, Dave

2009-08-01

Clinical errors, whether committed by doctors, nurses or other professions allied to healthcare, remain a sensitive issue requiring open debate and policy formulation in order to reduce them. The literature suggests that the issues underpinning errors made by healthcare professionals involve concerns about patient safety, professional disclosure, apology, litigation, compensation, processes of recording and policy development to enhance quality service. Anecdotally, we are aware of narratives of minor errors, which may well have been covered up and remain officially undisclosed whilst the major errors resulting in damage and death to patients alarm both professionals and public with resultant litigation and compensation. This paper attempts to unravel some of these issues by highlighting the historical nature of clinical errors and drawing parallels to contemporary times by outlining the 'compensation culture'. We then provide an overview of what constitutes a clinical error and review the healthcare professional strategies for managing such errors.

Medical errors in primary care clinics – a cross sectional study

PubMed Central

2012-01-01

Background Patient safety is vital in patient care. There is a lack of studies on medical errors in primary care settings. The aim of the study is to determine the extent of diagnostic inaccuracies and management errors in public funded primary care clinics. Methods This was a cross-sectional study conducted in twelve public funded primary care clinics in Malaysia. A total of 1753 medical records were randomly selected in 12 primary care clinics in 2007 and were reviewed by trained family physicians for diagnostic, management and documentation errors, potential errors causing serious harm and likelihood of preventability of such errors. Results The majority of patient encounters (81%) were with medical assistants. Diagnostic errors were present in 3.6% (95% CI: 2.2, 5.0) of medical records and management errors in 53.2% (95% CI: 46.3, 60.2). For management errors, medication errors were present in 41.1% (95% CI: 35.8, 46.4) of records, investigation errors in 21.7% (95% CI: 16.5, 26.8) and decision making errors in 14.5% (95% CI: 10.8, 18.2). A total of 39.9% (95% CI: 33.1, 46.7) of these errors had the potential to cause serious harm. Problems of documentation including illegible handwriting were found in 98.0% (95% CI: 97.0, 99.1) of records. Nearly all errors (93.5%) detected were considered preventable. Conclusions The occurrence of medical errors was high in primary care clinics particularly with documentation and medication errors. Nearly all were preventable. Remedial intervention addressing completeness of documentation and prescriptions are likely to yield reduction of errors. PMID:23267547

Cost effectiveness of a pharmacist-led information technology intervention for reducing rates of clinically important errors in medicines management in general practices (PINCER).

PubMed

Elliott, Rachel A; Putman, Koen D; Franklin, Matthew; Annemans, Lieven; Verhaeghe, Nick; Eden, Martin; Hayre, Jasdeep; Rodgers, Sarah; Sheikh, Aziz; Avery, Anthony J

2014-06-01

We recently showed that a pharmacist-led information technology-based intervention (PINCER) was significantly more effective in reducing medication errors in general practices than providing simple feedback on errors, with cost per error avoided at £79 (US$131). We aimed to estimate cost effectiveness of the PINCER intervention by combining effectiveness in error reduction and intervention costs with the effect of the individual errors on patient outcomes and healthcare costs, to estimate the effect on costs and QALYs. We developed Markov models for each of six medication errors targeted by PINCER. Clinical event probability, treatment pathway, resource use and costs were extracted from literature and costing tariffs. A composite probabilistic model combined patient-level error models with practice-level error rates and intervention costs from the trial. Cost per extra QALY and cost-effectiveness acceptability curves were generated from the perspective of NHS England, with a 5-year time horizon. The PINCER intervention generated £2,679 less cost and 0.81 more QALYs per practice [incremental cost-effectiveness ratio (ICER): -£3,037 per QALY] in the deterministic analysis. In the probabilistic analysis, PINCER generated 0.001 extra QALYs per practice compared with simple feedback, at £4.20 less per practice. Despite this extremely small set of differences in costs and outcomes, PINCER dominated simple feedback with a mean ICER of -£3,936 (standard error £2,970). At a ceiling 'willingness-to-pay' of £20,000/QALY, PINCER reaches 59 % probability of being cost effective. PINCER produced marginal health gain at slightly reduced overall cost. Results are uncertain due to the poor quality of data to inform the effect of avoiding errors.

The importance of expert feedback during endovascular simulator training.

PubMed

Boyle, Emily; O'Keeffe, Dara A; Naughton, Peter A; Hill, Arnold D K; McDonnell, Ciaran O; Moneley, Daragh

2011-07-01

Complex endovascular skills are difficult to obtain in the clinical environment. Virtual reality (VR) simulator training is a valuable addition to current training curricula, but is there a benefit in the absence of expert trainers? Eighteen endovascular novices performed a renal artery angioplasty/stenting (RAS) on the Vascular Interventional Surgical Trainer simulator. They were randomized into three groups: Group A (n = 6, control), no performance feedback; Group B (n = 6, nonexpert feedback), feedback after every procedure from a nonexpert facilitator; and Group C (n = 6, expert feedback), feedback after every procedure from a consultant vascular surgeon. Each trainee completed RAS six times. Simulator-measured performance metrics included procedural and fluoroscopy time, contrast volume, accuracy of balloon placement, and handling errors. Clinical errors were also measured by blinded video assessment. Data were analyzed using SPSS version 15. A clear learning curve was observed across the six trials. There were no significant differences between the three groups for the general performance metrics, but Group C made fewer errors than Groups A (P = .009) or B (P = .004). Video-based error assessment showed that Groups B and C performed better than Group A (P = .002 and P = .000, respectively). VR simulator training for novices can significantly improve general performance in the absence of expert trainers. Procedure-specific qualitative metrics are improved with expert feedback, but nonexpert facilitators can also enhance the quality of training and may represent a valuable alternative to expert clinical faculty. Copyright © 2011 Society for Vascular Surgery. Published by Mosby, Inc. All rights reserved.

Ethical Considerations on Disclosure When Medical Error Is Discovered During Medicolegal Death Investigation.

PubMed

Wolf, Dwayne A; Drake, Stacy A; Snow, Francine K

2017-12-01

In the course of fulfilling their statutory role, physicians performing medicolegal investigations may recognize clinical colleagues' medical errors. If the error is found to have led directly to the patient's death (missed diagnosis or incorrect diagnosis, for example), then the forensic pathologist has a professional responsibility to include the information in the autopsy report and make sure that the family is appropriately informed. When the error is significant but did not lead directly to the patient's demise, ethical questions may arise regarding the obligations of the medical examiner to disclose the error to the clinicians or to the family. This case depicts the discovery of medical error likely unrelated to the cause of death and describes one possible ethical approach to disclosure derived from an ethical reasoning model addressing ethical principles of respect for persons/autonomy, beneficence, nonmaleficence, and justice.

Axial length variation impacts on retinal vessel density and foveal avascular zone area measurement using optical coherence tomography angiography

NASA Astrophysics Data System (ADS)

Sampson, Danuta M.; Gong, Peijun; An, Di; Menghini, Moreno; Hansen, Alex; Mackey, David A.; Sampson, David D.; Chen, Fred K.

2017-04-01

We examined the impact of axial length on superficial retinal vessel density (SRVD) and foveal avascular zone area (FAZA) measurement using optical coherence tomography angiography. The SRVD and FAZA were quantified before and after correction for magnification error associated with axial length variation. Although SRVD did not differ before and after correction for magnification error in the parafoveal region, change in foveal SRVD and FAZA were significant. This has implications for clinical trials outcome in diseased eyes where significant capillary dropout may occur in the parafovea.

Assessing the use of cognitive heuristic representativeness in clinical reasoning.

PubMed

Payne, Velma L; Crowley, Rebecca S; Crowley, Rebecca

2008-11-06

We performed a pilot study to investigate use of the cognitive heuristic Representativeness in clinical reasoning. We tested a set of tasks and assessments to determine whether subjects used the heuristics in reasoning, to obtain initial frequencies of heuristic use and related cognitive errors, and to collect cognitive process data using think-aloud techniques. The study investigates two aspects of the Representativeness heuristic - judging by perceived frequency and representativeness as causal beliefs. Results show that subjects apply both aspects of the heuristic during reasoning, and make errors related to misapplication of these heuristics. Subjects in this study rarely used base rates, showed significant variability in their recall of base rates, demonstrated limited ability to use provided base rates, and favored causal data in diagnosis. We conclude that the tasks and assessments we have developed provide a suitable test-bed to study the cognitive processes underlying heuristic errors.

Assessing Use of Cognitive Heuristic Representativeness in Clinical Reasoning

PubMed Central

Payne, Velma L.; Crowley, Rebecca S.

2008-01-01

We performed a pilot study to investigate use of the cognitive heuristic Representativeness in clinical reasoning. We tested a set of tasks and assessments to determine whether subjects used the heuristics in reasoning, to obtain initial frequencies of heuristic use and related cognitive errors, and to collect cognitive process data using think-aloud techniques. The study investigates two aspects of the Representativeness heuristic - judging by perceived frequency and representativeness as causal beliefs. Results show that subjects apply both aspects of the heuristic during reasoning, and make errors related to misapplication of these heuristics. Subjects in this study rarely used base rates, showed significant variability in their recall of base rates, demonstrated limited ability to use provided base rates, and favored causal data in diagnosis. We conclude that the tasks and assessments we have developed provide a suitable test-bed to study the cognitive processes underlying heuristic errors. PMID:18999140

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

PubMed

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

2016-04-01

Computerized physician order entry (CPOE) system with embedded clinical decision support (CDS) can significantly reduce certain types of prescription error. However, prescription errors still occur. Various factors such as the numeric inputting methods in human computer interaction (HCI) produce different error rates and types, but has received relatively little attention. This study aimed to examine the effects of numeric inputting methods and urgency levels on numeric inputting errors of prescription, as well as categorize the types of errors. Thirty residents participated in four prescribing tasks in which two factors were manipulated: numeric inputting methods (numeric row in the main keyboard vs. numeric keypad) and urgency levels (urgent situation vs. non-urgent situation). Multiple aspects of participants' prescribing behavior were measured in sober prescribing situations. The results revealed that in urgent situations, participants were prone to make mistakes when using the numeric row in the main keyboard. With control of performance in the sober prescribing situation, the effects of the input methods disappeared, and urgency was found to play a significant role in the generalized linear model. Most errors were either omission or substitution types, but the proportion of transposition and intrusion error types were significantly higher than that of the previous research. Among numbers 3, 8, and 9, which were the less common digits used in prescription, the error rate was higher, which was a great risk to patient safety. Urgency played a more important role in CPOE numeric typing error-making than typing skills and typing habits. It was recommended that inputting with the numeric keypad had lower error rates in urgent situation. An alternative design could consider increasing the sensitivity of the keys with lower frequency of occurrence and decimals. To improve the usability of CPOE, numeric keyboard design and error detection could benefit from spatial incidence of errors found in this study. Copyright © 2016 Elsevier Ireland Ltd. All rights reserved.

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).

Evaluation of analytical errors in a clinical chemistry laboratory: a 3 year experience.

PubMed

Sakyi, As; Laing, Ef; Ephraim, Rk; Asibey, Of; Sadique, Ok

2015-01-01

Proficient laboratory service is the cornerstone of modern healthcare systems and has an impact on over 70% of medical decisions on admission, discharge, and medications. In recent years, there is an increasing awareness of the importance of errors in laboratory practice and their possible negative impact on patient outcomes. We retrospectively analyzed data spanning a period of 3 years on analytical errors observed in our laboratory. The data covered errors over the whole testing cycle including pre-, intra-, and post-analytical phases and discussed strategies pertinent to our settings to minimize their occurrence. We described the occurrence of pre-analytical, analytical and post-analytical errors observed at the Komfo Anokye Teaching Hospital clinical biochemistry laboratory during a 3-year period from January, 2010 to December, 2012. Data were analyzed with Graph Pad Prism 5(GraphPad Software Inc. CA USA). A total of 589,510 tests was performed on 188,503 outpatients and hospitalized patients. The overall error rate for the 3 years was 4.7% (27,520/58,950). Pre-analytical, analytical and post-analytical errors contributed 3.7% (2210/58,950), 0.1% (108/58,950), and 0.9% (512/58,950), respectively. The number of tests reduced significantly over the 3-year period, but this did not correspond with a reduction in the overall error rate (P = 0.90) along with the years. Analytical errors are embedded within our total process setup especially pre-analytical and post-analytical phases. Strategic measures including quality assessment programs for staff involved in pre-analytical processes should be intensified.

Quantitative Analysis Tools and Digital Phantoms for Deformable Image Registration Quality Assurance.

PubMed

Kim, Haksoo; Park, Samuel B; Monroe, James I; Traughber, Bryan J; Zheng, Yiran; Lo, Simon S; Yao, Min; Mansur, David; Ellis, Rodney; Machtay, Mitchell; Sohn, Jason W

2015-08-01

This article proposes quantitative analysis tools and digital phantoms to quantify intrinsic errors of deformable image registration (DIR) systems and establish quality assurance (QA) procedures for clinical use of DIR systems utilizing local and global error analysis methods with clinically realistic digital image phantoms. Landmark-based image registration verifications are suitable only for images with significant feature points. To address this shortfall, we adapted a deformation vector field (DVF) comparison approach with new analysis techniques to quantify the results. Digital image phantoms are derived from data sets of actual patient images (a reference image set, R, a test image set, T). Image sets from the same patient taken at different times are registered with deformable methods producing a reference DVFref. Applying DVFref to the original reference image deforms T into a new image R'. The data set, R', T, and DVFref, is from a realistic truth set and therefore can be used to analyze any DIR system and expose intrinsic errors by comparing DVFref and DVFtest. For quantitative error analysis, calculating and delineating differences between DVFs, 2 methods were used, (1) a local error analysis tool that displays deformation error magnitudes with color mapping on each image slice and (2) a global error analysis tool that calculates a deformation error histogram, which describes a cumulative probability function of errors for each anatomical structure. Three digital image phantoms were generated from three patients with a head and neck, a lung and a liver cancer. The DIR QA was evaluated using the case with head and neck. © The Author(s) 2014.

Improving the quality of cognitive screening assessments: ACEmobile, an iPad-based version of the Addenbrooke's Cognitive Examination-III.

PubMed

Newman, Craig G J; Bevins, Adam D; Zajicek, John P; Hodges, John R; Vuillermoz, Emil; Dickenson, Jennifer M; Kelly, Denise S; Brown, Simona; Noad, Rupert F

2018-01-01

Ensuring reliable administration and reporting of cognitive screening tests are fundamental in establishing good clinical practice and research. This study captured the rate and type of errors in clinical practice, using the Addenbrooke's Cognitive Examination-III (ACE-III), and then the reduction in error rate using a computerized alternative, the ACEmobile app. In study 1, we evaluated ACE-III assessments completed in National Health Service (NHS) clinics ( n  = 87) for administrator error. In study 2, ACEmobile and ACE-III were then evaluated for their ability to capture accurate measurement. In study 1, 78% of clinically administered ACE-IIIs were either scored incorrectly or had arithmetical errors. In study 2, error rates seen in the ACE-III were reduced by 85%-93% using ACEmobile. Error rates are ubiquitous in routine clinical use of cognitive screening tests and the ACE-III. ACEmobile provides a framework for supporting reduced administration, scoring, and arithmetical error during cognitive screening.

Putting Meaning Back Into the Mean: A Comment on the Misuse of Elementary Statistics in a Sample of Manuscripts Submitted to Clinical Therapeutics.

PubMed

Forrester, Janet E

2015-12-01

Errors in the statistical presentation and analyses of data in the medical literature remain common despite efforts to improve the review process, including the creation of guidelines for authors and the use of statistical reviewers. This article discusses common elementary statistical errors seen in manuscripts recently submitted to Clinical Therapeutics and describes some ways in which authors and reviewers can identify errors and thus correct them before publication. A nonsystematic sample of manuscripts submitted to Clinical Therapeutics over the past year was examined for elementary statistical errors. Clinical Therapeutics has many of the same errors that reportedly exist in other journals. Authors require additional guidance to avoid elementary statistical errors and incentives to use the guidance. Implementation of reporting guidelines for authors and reviewers by journals such as Clinical Therapeutics may be a good approach to reduce the rate of statistical errors. Copyright © 2015 Elsevier HS Journals, Inc. All rights reserved.

Algorithm for correcting the keratometric error in the estimation of the corneal power in eyes with previous myopic laser refractive surgery.

PubMed

Camps, Vicente J; Piñero, David P; Mateo, Veronica; Ribera, David; de Fez, Dolores; Blanes-Mompó, Francisco J; Alzamora-Rodríguez, Antonio

2013-11-01

To calculate theoretically the errors in the estimation of corneal power when using the keratometric index (nk) in eyes that underwent laser refractive surgery for the correction of myopia and to define and validate clinically an algorithm for minimizing such errors. Differences between corneal power estimation by using the classical nk and by using the Gaussian equation in eyes that underwent laser myopic refractive surgery were simulated and evaluated theoretically. Additionally, an adjusted keratometric index (nkadj) model dependent on r1c was developed for minimizing these differences. The model was validated clinically by retrospectively using the data from 32 myopic eyes [range, -1.00 to -6.00 diopters (D)] that had undergone laser in situ keratomileusis using a solid-state laser platform. The agreement between Gaussian (Pc) and adjusted keratometric (Pkadj) corneal powers in such eyes was evaluated. It was found that overestimations of corneal power up to 3.5 D were possible for nk = 1.3375 according to our simulations. The nk value to avoid the keratometric error ranged between 1.2984 and 1.3297. The following nkadj models were obtained: nkadj = -0.0064286r1c + 1.37688 (Gullstrand eye model) and nkadj = -0.0063804r1c + 1.37806 (Le Grand). The mean difference between Pkadj and Pc was 0.00 D, with limits of agreement of -0.45 and +0.46 D. This difference correlated significantly with the posterior corneal radius (r = -0.94, P < 0.01). The use of a single nk for estimating the corneal power in eyes that underwent a laser myopic refractive surgery can lead to significant errors. These errors can be minimized by using a variable nk dependent on r1c.

Normalized Movement Quality Measures for Therapeutic Robots Strongly Correlate With Clinical Motor Impairment Measures

PubMed Central

Celik, Ozkan; O’Malley, Marcia K.; Boake, Corwin; Levin, Harvey S.; Yozbatiran, Nuray; Reistetter, Timothy A.

2016-01-01

In this paper, we analyze the correlations between four clinical measures (Fugl–Meyer upper extremity scale, Motor Activity Log, Action Research Arm Test, and Jebsen-Taylor Hand Function Test) and four robotic measures (smoothness of movement, trajectory error, average number of target hits per minute, and mean tangential speed), used to assess motor recovery. Data were gathered as part of a hybrid robotic and traditional upper extremity rehabilitation program for nine stroke patients. Smoothness of movement and trajectory error, temporally and spatially normalized measures of movement quality defined for point-to-point movements, were found to have significant moderate to strong correlations with all four of the clinical measures. The strong correlations suggest that smoothness of movement and trajectory error may be used to compare outcomes of different rehabilitation protocols and devices effectively, provide improved resolution for tracking patient progress compared to only pre-and post-treatment measurements, enable accurate adaptation of therapy based on patient progress, and deliver immediate and useful feedback to the patient and therapist. PMID:20388607

Simultaneous localization and calibration for electromagnetic tracking systems.

PubMed

Sadjadi, Hossein; Hashtrudi-Zaad, Keyvan; Fichtinger, Gabor

2016-06-01

In clinical environments, field distortion can cause significant electromagnetic tracking errors. Therefore, dynamic calibration of electromagnetic tracking systems is essential to compensate for measurement errors. It is proposed to integrate the motion model of the tracked instrument with redundant EM sensor observations and to apply a simultaneous localization and mapping algorithm in order to accurately estimate the pose of the instrument and create a map of the field distortion in real-time. Experiments were conducted in the presence of ferromagnetic and electrically-conductive field distorting objects and results compared with those of a conventional sensor fusion approach. The proposed method reduced the tracking error from 3.94±1.61 mm to 1.82±0.62 mm in the presence of steel, and from 0.31±0.22 mm to 0.11±0.14 mm in the presence of aluminum. With reduced tracking error and independence from external tracking devices or pre-operative calibrations, the approach is promising for reliable EM navigation in various clinical procedures. Copyright © 2015 John Wiley & Sons, Ltd. Copyright © 2015 John Wiley & Sons, Ltd.

Precision of a CAD/CAM-engineered surgical template based on a facebow for orthognathic surgery: an experiment with a rapid prototyping maxillary model.

PubMed

Lee, Jae-Won; Lim, Se-Ho; Kim, Moon-Key; Kang, Sang-Hoon

2015-12-01

We examined the precision of a computer-aided design/computer-aided manufacturing-engineered, manufactured, facebow-based surgical guide template (facebow wafer) by comparing it with a bite splint-type orthognathic computer-aided design/computer-aided manufacturing-engineered surgical guide template (bite wafer). We used 24 rapid prototyping (RP) models of the craniofacial skeleton with maxillary deformities. Twelve RP models each were used for the facebow wafer group and the bite wafer group (experimental group). Experimental maxillary orthognathic surgery was performed on the RP models of both groups. Errors were evaluated through comparisons with surgical simulations. We measured the minimum distances from 3 planes of reference to determine the vertical, lateral, and anteroposterior errors at specific measurement points. The measured errors were compared between experimental groups using a t test. There were significant intergroup differences in the lateral error when we compared the absolute values of the 3-D linear distance, as well as vertical, lateral, and anteroposterior errors between experimental groups. The bite wafer method exhibited little lateral error overall and little error in the anterior tooth region. The facebow wafer method exhibited very little vertical error in the posterior molar region. The clinical precision of the facebow wafer method did not significantly exceed that of the bite wafer method. Copyright © 2015 Elsevier Inc. All rights reserved.

Diagnostic decision-making and strategies to improve diagnosis.

PubMed

Thammasitboon, Satid; Cutrer, William B

2013-10-01

A significant portion of diagnostic errors arises through cognitive errors resulting from inadequate knowledge, faulty data gathering, and/or faulty verification. Experts estimate that 75% of diagnostic failures can be attributed to clinician diagnostic thinking failure. The cognitive processes that underlie diagnostic thinking of clinicians are complex and intriguing, and it is imperative that clinicians acquire explicit appreciation and application of different cognitive approaches to make decisions better. A dual-process model that unifies many theories of decision-making has emerged as a promising template for understanding how clinicians think and judge efficiently in a diagnostic reasoning process. The identification and implementation of strategies for decreasing or preventing such diagnostic errors has become a growing area of interest and research. Suggested strategies to decrease diagnostic error incidence include increasing clinician's clinical expertise and avoiding inherent cognitive errors to make decisions better. Implementing Interventions focused solely on avoiding errors may work effectively for patient safety issues such as medication errors. Addressing cognitive errors, however, requires equal effort on expanding the individual clinician's expertise. Providing cognitive support to clinicians for robust diagnostic decision-making serves as the final strategic target for decreasing diagnostic errors. Clinical guidelines and algorithms offer another method for streamlining decision-making and decreasing likelihood of cognitive diagnostic errors. Addressing cognitive processing errors is undeniably the most challenging task in reducing diagnostic errors. While many suggested approaches exist, they are mostly based on theories and sciences in cognitive psychology, decision-making, and education. The proposed interventions are primarily suggestions and very few of them have been tested in the actual practice settings. Collaborative research effort is required to effectively address cognitive processing errors. Researchers in various areas, including patient safety/quality improvement, decision-making, and problem solving, must work together to make medical diagnosis more reliable. © 2013 Mosby, Inc. All rights reserved.

NASA Model of "Threat and Error" in Pediatric Cardiac Surgery: Patterns of Error Chains.

PubMed

Hickey, Edward; Pham-Hung, Eric; Nosikova, Yaroslavna; Halvorsen, Fredrik; Gritti, Michael; Schwartz, Steven; Caldarone, Christopher A; Van Arsdell, Glen

2017-04-01

We introduced the National Aeronautics and Space Association threat-and-error model to our surgical unit. All admissions are considered flights, which should pass through stepwise deescalations in risk during surgical recovery. We hypothesized that errors significantly influence risk deescalation and contribute to poor outcomes. Patient flights (524) were tracked in real time for threats, errors, and unintended states by full-time performance personnel. Expected risk deescalation was wean from mechanical support, sternal closure, extubation, intensive care unit (ICU) discharge, and discharge home. Data were accrued from clinical charts, bedside data, reporting mechanisms, and staff interviews. Infographics of flights were openly discussed weekly for consensus. In 12% (64 of 524) of flights, the child failed to deescalate sequentially through expected risk levels; unintended increments instead occurred. Failed deescalations were highly associated with errors (426; 257 flights; p < 0.0001). Consequential errors (263; 173 flights) were associated with a 29% rate of failed deescalation versus 4% in flights with no consequential error (p < 0.0001). The most dangerous errors were apical errors typically (84%) occurring in the operating room, which caused chains of propagating unintended states (n = 110): these had a 43% (47 of 110) rate of failed deescalation (versus 4%; p < 0.0001). Chains of unintended state were often (46%) amplified by additional (up to 7) errors in the ICU that would worsen clinical deviation. Overall, failed deescalations in risk were extremely closely linked to brain injury (n = 13; p < 0.0001) or death (n = 7; p < 0.0001). Deaths and brain injury after pediatric cardiac surgery almost always occur from propagating error chains that originate in the operating room and are often amplified by additional ICU errors. Copyright © 2017 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.

Clinical implementation and failure mode and effects analysis of HDR skin brachytherapy using Valencia and Leipzig surface applicators.

PubMed

Sayler, Elaine; Eldredge-Hindy, Harriet; Dinome, Jessie; Lockamy, Virginia; Harrison, Amy S

2015-01-01

The planning procedure for Valencia and Leipzig surface applicators (VLSAs) (Nucletron, Veenendaal, The Netherlands) differs substantially from CT-based planning; the unfamiliarity could lead to significant errors. This study applies failure modes and effects analysis (FMEA) to high-dose-rate (HDR) skin brachytherapy using VLSAs to ensure safety and quality. A multidisciplinary team created a protocol for HDR VLSA skin treatments and applied FMEA. Failure modes were identified and scored by severity, occurrence, and detectability. The clinical procedure was then revised to address high-scoring process nodes. Several key components were added to the protocol to minimize risk probability numbers. (1) Diagnosis, prescription, applicator selection, and setup are reviewed at weekly quality assurance rounds. Peer review reduces the likelihood of an inappropriate treatment regime. (2) A template for HDR skin treatments was established in the clinic's electronic medical record system to standardize treatment instructions. This reduces the chances of miscommunication between the physician and planner as well as increases the detectability of an error. (3) A screen check was implemented during the second check to increase detectability of an error. (4) To reduce error probability, the treatment plan worksheet was designed to display plan parameters in a format visually similar to the treatment console display, facilitating data entry and verification. (5) VLSAs are color coded and labeled to match the electronic medical record prescriptions, simplifying in-room selection and verification. Multidisciplinary planning and FMEA increased detectability and reduced error probability during VLSA HDR brachytherapy. This clinical model may be useful to institutions implementing similar procedures. Copyright © 2015 American Brachytherapy Society. Published by Elsevier Inc. All rights reserved.

Reproducibility of the six-minute walking test in chronic heart failure patients.

PubMed

Pinna, G D; Opasich, C; Mazza, A; Tangenti, A; Maestri, R; Sanarico, M

2000-11-30

The six-minute walking test (WT) is used in trials and clinical practice as an easy tool to evaluate the functional capacity of chronic heart failure (CHF) patients. As WT measurements are highly variable both between and within individuals, this study aims at assessing the contribution of the different sources of variation and estimating the reproducibility of the test. A statistical model describing WT measurements as a function of fixed and random effects is proposed and its parameters estimated. We considered 202 stable CHF patients who performed two baseline WTs separated by a 30 minute rest; 49 of them repeated the two tests 3 months later (follow-up control). They had no changes in therapy or major clinical events. Another 31 subjects performed two baseline tests separated by 24 hours. Collected data were analysed using a mixed model methodology. There was no significant difference between measurements taken 30 minutes and 24 hours apart (p = 0.99). A trend effect of 17 (1.4) m (mean (SE)) was consistently found between duplicate tests (p < 0.001). REML estimates of variance components were: 5189 (674) for subject differences in the error-free value; 1280 (304) for subject differences in spontaneous clinical evolution between baseline and follow-up control, and 266 (23) for the within-subject error. Hence, the standard error of measurement was 16.3 m, namely 4 per cent of the average WT performance (403 m) in this sample. The intraclass correlation coefficient was 0.96. We conclude that WT measurements are characterized by good intrasubject reproducibility and excellent reliability. When follow-up studies > or = 3 months are performed, unpredictable changes in individual walking performance due to spontaneous clinical evolution are to be expected. Their clinical significance, however, is not known. Copyright 2000 John Wiley & Sons, Ltd.

Quality in laboratory medicine: 50years on.

PubMed

Plebani, Mario

2017-02-01

The last 50years have seen substantial changes in the landscape of laboratory medicine: its role in modern medicine is in evolution and the quality of laboratory services is changing. The need to control and improve quality in clinical laboratories has grown hand in hand with the growth in technological developments leading to an impressive reduction of analytical errors over time. An essential cause of this impressive improvement has been the introduction and monitoring of quality indicators (QIs) such as the analytical performance specifications (in particular bias and imprecision) based on well-established goals. The evolving landscape of quality and errors in clinical laboratories moved first from analytical errors to all errors performed within the laboratory walls, subsequently to errors in laboratory medicine (including errors in test requesting and result interpretation), and finally, to a focus on errors more frequently associated with adverse events (laboratory-associated errors). After decades in which clinical laboratories have focused on monitoring and improving internal indicators of analytical quality, efficiency and productivity, it is time to shift toward indicators of total quality, clinical effectiveness and patient outcomes. Copyright © 2016 The Canadian Society of Clinical Chemists. Published by Elsevier Inc. All rights reserved.

Handheld vs. laptop computers for electronic data collection in clinical research: a crossover randomized trial.

PubMed

Haller, Guy; Haller, Dagmar M; Courvoisier, Delphine S; Lovis, Christian

2009-01-01

To compare users' speed, number of entry errors and satisfaction in using two current devices for electronic data collection in clinical research: handheld and laptop computers. The authors performed a randomized cross-over trial using 160 different paper-based questionnaires and representing altogether 45,440 variables. Four data coders were instructed to record, according to a random predefined and equally balanced sequence, the content of these questionnaires either on a laptop or on a handheld computer. Instructions on the kind of device to be used were provided to data-coders in individual sealed and opaque envelopes. Study conditions were controlled and the data entry process performed in a quiet environment. The authors compared the duration of the data recording process, the number of errors and users' satisfaction with the two devices. The authors divided errors into two separate categories, typing and missing data errors. The original paper-based questionnaire was used as a gold-standard. The overall duration of the recording process was significantly reduced (2.0 versus 3.3 min) when data were recorded on the laptop computer (p < 0.001). Data accuracy also improved. There were 5.8 typing errors per 1,000 entries with the laptop compared to 8.4 per 1,000 with the handheld computer (p < 0.001). The difference was even more important for missing data which decreased from 22.8 to 2.9 per 1,000 entries when a laptop was used (p < 0.001). Users found the laptop easier, faster and more satisfying to use than the handheld computer. Despite the increasing use of handheld computers for electronic data collection in clinical research, these devices should be used with caution. They double the duration of the data entry process and significantly increase the risk of typing errors and missing data. This may become a particularly crucial issue in studies where these devices are provided to patients or healthcare workers, unfamiliar with computer technologies, for self-reporting or research data collection processes.

Handheld vs. Laptop Computers for Electronic Data Collection in Clinical Research: A Crossover Randomized Trial

PubMed Central

Haller, Guy; Haller, Dagmar M.; Courvoisier, Delphine S.; Lovis, Christian

2009-01-01

Objective To compare users' speed, number of entry errors and satisfaction in using two current devices for electronic data collection in clinical research: handheld and laptop computers. Design The authors performed a randomized cross-over trial using 160 different paper-based questionnaires and representing altogether 45,440 variables. Four data coders were instructed to record, according to a random predefined and equally balanced sequence, the content of these questionnaires either on a laptop or on a handheld computer. Instructions on the kind of device to be used were provided to data-coders in individual sealed and opaque envelopes. Study conditions were controlled and the data entry process performed in a quiet environment. Measurements The authors compared the duration of the data recording process, the number of errors and users' satisfaction with the two devices. The authors divided errors into two separate categories, typing and missing data errors. The original paper-based questionnaire was used as a gold-standard. Results The overall duration of the recording process was significantly reduced (2.0 versus 3.3 min) when data were recorded on the laptop computer (p < 0.001). Data accuracy also improved. There were 5.8 typing errors per 1,000 entries with the laptop compared to 8.4 per 1,000 with the handheld computer (p < 0.001). The difference was even more important for missing data which decreased from 22.8 to 2.9 per 1,000 entries when a laptop was used (p < 0.001). Users found the laptop easier, faster and more satisfying to use than the handheld computer. Conclusions Despite the increasing use of handheld computers for electronic data collection in clinical research, these devices should be used with caution. They double the duration of the data entry process and significantly increase the risk of typing errors and missing data. This may become a particularly crucial issue in studies where these devices are provided to patients or healthcare workers, unfamiliar with Computer Technologies, for self-reporting or research data collection processes. PMID:19567799

Cognitive Impairments in Occupational Burnout – Error Processing and Its Indices of Reactive and Proactive Control

PubMed Central

Golonka, Krystyna; Mojsa-Kaja, Justyna; Gawlowska, Magda; Popiel, Katarzyna

2017-01-01

The presented study refers to cognitive aspects of burnout as the effects of long-term work-related stress. The purpose of the study was to investigate electrophysiological correlates of burnout to explain the mechanisms of the core burnout symptoms: exhaustion and depersonalization/cynicism. The analyzed error-related electrophysiological markers shed light on impaired cognitive mechanisms and the specific changes in information-processing in burnout. In the EEG study design (N = 80), two components of error-related potential (ERP), error-related negativity (ERN), and error positivity (Pe), were analyzed. In the non-clinical burnout group (N = 40), a significant increase in ERN amplitude and a decrease in Pe amplitude were observed compared to controls (N = 40). Enhanced error detection, indexed by increased ERN amplitude, and diminished response monitoring, indexed by decreased Pe amplitude, reveal emerging cognitive problems in the non-clinical burnout group. Cognitive impairments in burnout subjects relate to both reactive and unconscious (ERN) and proactive and conscious (Pe) aspects of error processing. The results indicate a stronger ‘reactive control mode’ that can deplete resources for proactive control and the ability to actively maintain goals. The analysis refers to error processing and specific task demands, thus should not be extended to cognitive processes in general. The characteristics of ERP patterns in burnout resemble psychophysiological indexes of anxiety (increased ERN) and depressive symptoms (decreased Pe), showing to some extent an overlapping effect of burnout and related symptoms and disorders. The results support the scarce existing data on the psychobiological nature of burnout, while extending and specifying its cognitive characteristics. PMID:28507528

Clinical biochemistry laboratory rejection rates due to various types of preanalytical errors.

PubMed

Atay, Aysenur; Demir, Leyla; Cuhadar, Serap; Saglam, Gulcan; Unal, Hulya; Aksun, Saliha; Arslan, Banu; Ozkan, Asuman; Sutcu, Recep

2014-01-01

Preanalytical errors, along the process from the beginning of test requests to the admissions of the specimens to the laboratory, cause the rejection of samples. The aim of this study was to better explain the reasons of rejected samples, regarding to their rates in certain test groups in our laboratory. This preliminary study was designed on the rejected samples in one-year period, based on the rates and types of inappropriateness. Test requests and blood samples of clinical chemistry, immunoassay, hematology, glycated hemoglobin, coagulation and erythrocyte sedimentation rate test units were evaluated. Types of inappropriateness were evaluated as follows: improperly labelled samples, hemolysed, clotted specimen, insufficient volume of specimen and total request errors. A total of 5,183,582 test requests from 1,035,743 blood collection tubes were considered. The total rejection rate was 0.65 %. The rejection rate of coagulation group was significantly higher (2.28%) than the other test groups (P < 0.001) including insufficient volume of specimen error rate as 1.38%. Rejection rates of hemolysis, clotted specimen and insufficient volume of sample error were found to be 8%, 24% and 34%, respectively. Total request errors, particularly, for unintelligible requests were 32% of the total for inpatients. The errors were especially attributable to unintelligible requests of inappropriate test requests, improperly labelled samples for inpatients and blood drawing errors especially due to insufficient volume of specimens in a coagulation test group. Further studies should be performed after corrective and preventive actions to detect a possible decrease in rejecting samples.

Evoking visual neglect-like deficits in healthy volunteers - an investigation by repetitive navigated transcranial magnetic stimulation.

PubMed

Giglhuber, Katrin; Maurer, Stefanie; Zimmer, Claus; Meyer, Bernhard; Krieg, Sandro M

2017-02-01

In clinical practice, repetitive navigated transcranial magnetic stimulation (rTMS) is of particular interest for non-invasive mapping of cortical language areas. Yet, rTMS studies try to detect further cortical functions. Damage to the underlying network of visuospatial attention function can result in visual neglect-a severe neurological deficit and influencing factor for a significantly reduced functional outcome. This investigation aims to evaluate the use of rTMS for evoking visual neglect in healthy volunteers and the potential of specifically locating cortical areas that can be assigned for the function of visuospatial attention. Ten healthy, right-handed subjects underwent rTMS visual neglect mapping. Repetitive trains of 5 Hz and 10 pulses were applied to 52 pre-defined cortical spots on each hemisphere; each cortical spot was stimulated 10 times. Visuospatial attention was tested time-locked to rTMS pulses by a landmark task. Task pictures were displayed tachistoscopically for 50 ms. The subjects' performance was analyzed by video, and errors were referenced to cortical spots. We observed visual neglect-like deficits during the stimulation of both hemispheres. Errors were categorized into leftward, rightward, and no response errors. Rightward errors occurred significantly more often during stimulation of the right hemisphere than during stimulation of the left hemisphere (mean rightward error rate (ER) 1.6 ± 1.3 % vs. 1.0 ± 1.0 %, p = 0.0141). Within the left hemisphere, we observed predominantly leftward errors rather than rightward errors (mean leftward ER 2.0 ± 1.3 % vs. rightward ER 1.0 ± 1.0 %; p = 0.0005). Visual neglect can be elicited non-invasively by rTMS, and cortical areas eloquent for visuospatial attention can be detected. Yet, the correlation of this approach with clinical findings has to be shown in upcoming steps.

Evaluate the ability of clinical decision support systems (CDSSs) to improve clinical practice.

PubMed

Ajami, Sima; Amini, Fatemeh

2013-01-01

Prevalence of new diseases, medical science promotion and increase of referring to health care centers, provide a good situation for medical errors growth. Errors can involve medicines, surgery, diagnosis, equipment, or lab reports. Medical errors can occur anywhere in the health care system: In hospitals, clinics, surgery centers, doctors' offices, nursing homes, pharmacies, and patients' homes. According to the Institute of Medicine (IOM), 98,000 people die every year from preventable medical errors. In 2010 from all referred medical error records to Iran Legal Medicine Organization, 46/5% physician and medical team members were known as delinquent. One of new technologies that can reduce medical errors is clinical decision support systems (CDSSs). This study was unsystematic-review study. The literature was searched on evaluate the "ability of clinical decision support systems to improve clinical practice" with the help of library, books, conference proceedings, data bank, and also searches engines available at Google, Google scholar. For our searches, we employed the following keywords and their combinations: medical error, clinical decision support systems, Computer-Based Clinical Decision Support Systems, information technology, information system, health care quality, computer systems in the searching areas of title, keywords, abstract, and full text. In this study, more than 100 articles and reports were collected and 38 of them were selected based on their relevancy. The CDSSs are computer programs, designed for help to health care careers. These systems as a knowledge-based tool could help health care manager in analyze evaluation, improvement and selection of effective solutions in clinical decisions. Therefore, it has a main role in medical errors reduction. The aim of this study was to express ability of the CDSSs to improve

Accuracy of Digital vs Conventional Implant Impression Approach: A Three-Dimensional Comparative In Vitro Analysis.

PubMed

Basaki, Kinga; Alkumru, Hasan; De Souza, Grace; Finer, Yoav

To assess the three-dimensional (3D) accuracy and clinical acceptability of implant definitive casts fabricated using a digital impression approach and to compare the results with those of a conventional impression method in a partially edentulous condition. A mandibular reference model was fabricated with implants in the first premolar and molar positions to simulate a patient with bilateral posterior edentulism. Ten implant-level impressions per method were made using either an intraoral scanner with scanning abutments for the digital approach or an open-tray technique and polyvinylsiloxane material for the conventional approach. 3D analysis and comparison of implant location on resultant definitive casts were performed using laser scanner and quality control software. The inter-implant distances and interimplant angulations for each implant pair were measured for the reference model and for each definitive cast (n = 20 per group); these measurements were compared to calculate the magnitude of error in 3D for each definitive cast. The influence of implant angulation on definitive cast accuracy was evaluated for both digital and conventional approaches. Statistical analysis was performed using t test (α = .05) for implant position and angulation. Clinical qualitative assessment of accuracy was done via the assessment of the passivity of a master verification stent for each implant pair, and significance was analyzed using chi-square test (α = .05). A 3D error of implant positioning was observed for the two impression techniques vs the reference model, with mean ± standard deviation (SD) error of 116 ± 94 μm and 56 ± 29 μm for the digital and conventional approaches, respectively (P = .01). In contrast, the inter-implant angulation errors were not significantly different between the two techniques (P = .83). Implant angulation did not have a significant influence on definitive cast accuracy within either technique (P = .64). The verification stent demonstrated acceptable passive fit for 11 out of 20 casts and 18 out of 20 casts for the digital and conventional methods, respectively (P = .01). Definitive casts fabricated using the digital impression approach were less accurate than those fabricated from the conventional impression approach for this simulated clinical scenario. A significant number of definitive casts generated by the digital technique did not meet clinically acceptable accuracy for the fabrication of a multiple implant-supported restoration.

The Relevance of Proprioception to Chronic Neck Pain: A Correlational Analysis of Flexor Muscle Size and Endurance, Clinical Neck Pain Characteristics, and Proprioception.

PubMed

Amiri Arimi, Somayeh; Ghamkhar, Leila; Kahlaee, Amir H

2018-01-02

Impairment in the cervical proprioception and deep flexor muscle function and morphology have been regarded to be associated with chronic neck pain (CNP).  The aim of the study is to assess the relationship between proprioception and flexor endurance capacity and size and clinical CNP characteristics.  This was an observational, cross-sectional study.  Rehabilitation hospital laboratory.  Sixty subjects with or without CNP participated in the study.  Joint position error, clinical deep flexor endurance test score, longus colli/capitis and sternocleidomastoid muscle size, pain intensity, neck pain-related disability, and fear of movement were assessed. Multivariate analysis of variance and Pearson correlation tests were used to compare the groups and quantify the strength of the associations among variables, respectively. Logistic regression analysis was performed to test the predictive value of the dependent variables for the development of neck pain.  CNP patients showed lower flexor endurance (P = 0.01) and smaller longus colli size (P < 0.01). The joint position error was not statistically different between the groups. Longus colli size was correlated with local flexor endurance in both CNP (P = 0.01) and control (P = 0.04) groups. Among clinical CNP characteristics, kinesiophobia showed fair correlation with joint position error (r = 0.39, P = 0.03). Left rotation error and local flexor endurance were significant predictors of CNP development (β = 1.22, P = 0.02, and β = 0.97, P = 0.02, respectively).  The results indicated that cervical proprioception was associated neither with deep flexor muscle structure/function nor with clinical CNP characteristics. Left rotation error and local flexor endurance were found relevant to neck pain development. © 2017 American Academy of Pain Medicine. All rights reserved. For Permissions, please e-mail: journals.permissions@oup.com

Evaluation of Analytical Errors in a Clinical Chemistry Laboratory: A 3 Year Experience

PubMed Central

Sakyi, AS; Laing, EF; Ephraim, RK; Asibey, OF; Sadique, OK

2015-01-01

Background: Proficient laboratory service is the cornerstone of modern healthcare systems and has an impact on over 70% of medical decisions on admission, discharge, and medications. In recent years, there is an increasing awareness of the importance of errors in laboratory practice and their possible negative impact on patient outcomes. Aim: We retrospectively analyzed data spanning a period of 3 years on analytical errors observed in our laboratory. The data covered errors over the whole testing cycle including pre-, intra-, and post-analytical phases and discussed strategies pertinent to our settings to minimize their occurrence. Materials and Methods: We described the occurrence of pre-analytical, analytical and post-analytical errors observed at the Komfo Anokye Teaching Hospital clinical biochemistry laboratory during a 3-year period from January, 2010 to December, 2012. Data were analyzed with Graph Pad Prism 5(GraphPad Software Inc. CA USA). Results: A total of 589,510 tests was performed on 188,503 outpatients and hospitalized patients. The overall error rate for the 3 years was 4.7% (27,520/58,950). Pre-analytical, analytical and post-analytical errors contributed 3.7% (2210/58,950), 0.1% (108/58,950), and 0.9% (512/58,950), respectively. The number of tests reduced significantly over the 3-year period, but this did not correspond with a reduction in the overall error rate (P = 0.90) along with the years. Conclusion: Analytical errors are embedded within our total process setup especially pre-analytical and post-analytical phases. Strategic measures including quality assessment programs for staff involved in pre-analytical processes should be intensified. PMID:25745569

Vector velocity volume flow estimation: Sources of error and corrections applied for arteriovenous fistulas.

PubMed

Jensen, Jonas; Olesen, Jacob Bjerring; Stuart, Matthias Bo; Hansen, Peter Møller; Nielsen, Michael Bachmann; Jensen, Jørgen Arendt

2016-08-01

A method for vector velocity volume flow estimation is presented, along with an investigation of its sources of error and correction of actual volume flow measurements. Volume flow errors are quantified theoretically by numerical modeling, through flow phantom measurements, and studied in vivo. This paper investigates errors from estimating volumetric flow using a commercial ultrasound scanner and the common assumptions made in the literature. The theoretical model shows, e.g. that volume flow is underestimated by 15%, when the scan plane is off-axis with the vessel center by 28% of the vessel radius. The error sources were also studied in vivo under realistic clinical conditions, and the theoretical results were applied for correcting the volume flow errors. Twenty dialysis patients with arteriovenous fistulas were scanned to obtain vector flow maps of fistulas. When fitting an ellipsis to cross-sectional scans of the fistulas, the major axis was on average 10.2mm, which is 8.6% larger than the minor axis. The ultrasound beam was on average 1.5mm from the vessel center, corresponding to 28% of the semi-major axis in an average fistula. Estimating volume flow with an elliptical, rather than circular, vessel area and correcting the ultrasound beam for being off-axis, gave a significant (p=0.008) reduction in error from 31.2% to 24.3%. The error is relative to the Ultrasound Dilution Technique, which is considered the gold standard for volume flow estimation for dialysis patients. The study shows the importance of correcting for volume flow errors, which are often made in clinical practice. Copyright © 2016 Elsevier B.V. All rights reserved.

Main sources of errors in diagnosis of chronic radiation sickness (in Russian)

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

Soldatova, V.A.

1973-11-01

With the aim of finding out the main sources of errors in the diagnosis of chronic radiation sickness, the author analyzed a total of 500 cases of this sickness in roenigenologists and radiologists sent to the clinic to be examined according to occupational indications. lt was shown that the main source of errors when interpreting the observed deviations as occupational was underestimation of etiological significance of functional and organic diseases of the nervous system, endocrinevascular dystonia and also such diseases as hypochromic anemia and chronic infection. The majority of diagnostic errors is explained by insufficient knowledge of the main regularitymore » of forming the picture of chronic radiation sickness and by the absence of the necessary differential diagnosis with general somatic diseases. (auth)« less

The Relationship Between Technical Errors and Decision Making Skills in the Junior Resident

PubMed Central

Nathwani, J. N.; Fiers, R.M.; Ray, R.D.; Witt, A.K.; Law, K. E.; DiMarco, S.M.; Pugh, C.M.

2017-01-01

Objective The purpose of this study is to co-evaluate resident technical errors and decision-making capabilities during placement of a subclavian central venous catheter (CVC). We hypothesize that there will be significant correlations between scenario based decision making skills, and technical proficiency in central line insertion. We also predict residents will have problems in anticipating common difficulties and generating solutions associated with line placement. Design Participants were asked to insert a subclavian central line on a simulator. After completion, residents were presented with a real life patient photograph depicting CVC placement and asked to anticipate difficulties and generate solutions. Error rates were analyzed using chi-square tests and a 5% expected error rate. Correlations were sought by comparing technical errors and scenario based decision making. Setting This study was carried out at seven tertiary care centers. Participants Study participants (N=46) consisted of largely first year research residents that could be followed longitudinally. Second year research and clinical residents were not excluded. Results Six checklist errors were committed more often than anticipated. Residents performed an average of 1.9 errors, significantly more than the 1 error, at most, per person expected (t(44)=3.82, p<.001). The most common error was performance of the procedure steps in the wrong order (28.5%, P<.001). Some of the residents (24%) had no errors, 30% committed one error, and 46 % committed more than one error. The number of technical errors committed negatively correlated with the total number of commonly identified difficulties and generated solutions (r(33)= −.429, p=.021, r(33)= −.383, p=.044 respectively). Conclusions Almost half of the surgical residents committed multiple errors while performing subclavian CVC placement. The correlation between technical errors and decision making skills suggests a critical need to train residents in both technique and error management. ACGME Competencies Medical Knowledge, Practice Based Learning and Improvement, Systems Based Practice PMID:27671618

Financial and clinical governance implications of clinical coding accuracy in neurosurgery: a multidisciplinary audit.

PubMed

Haliasos, N; Rezajooi, K; O'neill, K S; Van Dellen, J; Hudovsky, Anita; Nouraei, Sar

2010-04-01

Clinical coding is the translation of documented clinical activities during an admission to a codified language. Healthcare Resource Groupings (HRGs) are derived from coding data and are used to calculate payment to hospitals in England, Wales and Scotland and to conduct national audit and benchmarking exercises. Coding is an error-prone process and an understanding of its accuracy within neurosurgery is critical for financial, organizational and clinical governance purposes. We undertook a multidisciplinary audit of neurosurgical clinical coding accuracy. Neurosurgeons trained in coding assessed the accuracy of 386 patient episodes. Where clinicians felt a coding error was present, the case was discussed with an experienced clinical coder. Concordance between the initial coder-only clinical coding and the final clinician-coder multidisciplinary coding was assessed. At least one coding error occurred in 71/386 patients (18.4%). There were 36 diagnosis and 93 procedure errors and in 40 cases, the initial HRG changed (10.4%). Financially, this translated to pound111 revenue-loss per patient episode and projected to pound171,452 of annual loss to the department. 85% of all coding errors were due to accumulation of coding changes that occurred only once in the whole data set. Neurosurgical clinical coding is error-prone. This is financially disadvantageous and with the coding data being the source of comparisons within and between departments, coding inaccuracies paint a distorted picture of departmental activity and subspecialism in audit and benchmarking. Clinical engagement improves accuracy and is encouraged within a clinical governance framework.

Automated Communication Tools and Computer-Based Medication Reconciliation to Decrease Hospital Discharge Medication Errors.

PubMed

Smith, Kenneth J; Handler, Steven M; Kapoor, Wishwa N; Martich, G Daniel; Reddy, Vivek K; Clark, Sunday

2016-07-01

This study sought to determine the effects of automated primary care physician (PCP) communication and patient safety tools, including computerized discharge medication reconciliation, on discharge medication errors and posthospitalization patient outcomes, using a pre-post quasi-experimental study design, in hospitalized medical patients with ≥2 comorbidities and ≥5 chronic medications, at a single center. The primary outcome was discharge medication errors, compared before and after rollout of these tools. Secondary outcomes were 30-day rehospitalization, emergency department visit, and PCP follow-up visit rates. This study found that discharge medication errors were lower post intervention (odds ratio = 0.57; 95% confidence interval = 0.44-0.74; P < .001). Clinically important errors, with the potential for serious or life-threatening harm, and 30-day patient outcomes were not significantly different between study periods. Thus, automated health system-based communication and patient safety tools, including computerized discharge medication reconciliation, decreased hospital discharge medication errors in medically complex patients. © The Author(s) 2015.

Development of an Ontology to Model Medical Errors, Information Needs, and the Clinical Communication Space

PubMed Central

Stetson, Peter D.; McKnight, Lawrence K.; Bakken, Suzanne; Curran, Christine; Kubose, Tate T.; Cimino, James J.

2002-01-01

Medical errors are common, costly and often preventable. Work in understanding the proximal causes of medical errors demonstrates that systems failures predispose to adverse clinical events. Most of these systems failures are due to lack of appropriate information at the appropriate time during the course of clinical care. Problems with clinical communication are common proximal causes of medical errors. We have begun a project designed to measure the impact of wireless computing on medical errors. We report here on our efforts to develop an ontology representing the intersection of medical errors, information needs and the communication space. We will use this ontology to support the collection, storage and interpretation of project data. The ontology’s formal representation of the concepts in this novel domain will help guide the rational deployment of our informatics interventions. A real-life scenario is evaluated using the ontology in order to demonstrate its utility.

TH-B-BRC-00: How to Identify and Resolve Potential Clinical Errors Before They Impact Patients Treatment: Lessons Learned

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

NONE

2016-06-15

Radiation treatment consists of a chain of events influenced by the quality of machine operation, beam data commissioning, machine calibration, patient specific data, simulation, treatment planning, imaging and treatment delivery. There is always a chance that the clinical medical physicist may make or fail to detect an error in one of the events that may impact on the patient’s treatment. In the clinical scenario, errors may be systematic and, without peer review, may have a low detectability because they are not part of routine QA procedures. During treatment, there might be errors on machine that needs attention. External reviews ofmore » some of the treatment delivery components by independent reviewers, like IROC, can detect errors, but may not be timely. The goal of this session is to help junior clinical physicists identify potential errors as well as the approach of quality assurance to perform a root cause analysis to find and eliminate an error and to continually monitor for errors. A compilation of potential errors will be presented by examples of the thought process required to spot the error and determine the root cause. Examples may include unusual machine operation, erratic electrometer reading, consistent lower electron output, variation in photon output, body parts inadvertently left in beam, unusual treatment plan, poor normalization, hot spots etc. Awareness of the possibility and detection of error in any link of the treatment process chain will help improve the safe and accurate delivery of radiation to patients. Four experts will discuss how to identify errors in four areas of clinical treatment. D. Followill, NIH grant CA 180803.« less

TH-B-BRC-01: How to Identify and Resolve Potential Clinical Errors

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

Das, I.

2016-06-15

Radiation treatment consists of a chain of events influenced by the quality of machine operation, beam data commissioning, machine calibration, patient specific data, simulation, treatment planning, imaging and treatment delivery. There is always a chance that the clinical medical physicist may make or fail to detect an error in one of the events that may impact on the patient’s treatment. In the clinical scenario, errors may be systematic and, without peer review, may have a low detectability because they are not part of routine QA procedures. During treatment, there might be errors on machine that needs attention. External reviews ofmore » some of the treatment delivery components by independent reviewers, like IROC, can detect errors, but may not be timely. The goal of this session is to help junior clinical physicists identify potential errors as well as the approach of quality assurance to perform a root cause analysis to find and eliminate an error and to continually monitor for errors. A compilation of potential errors will be presented by examples of the thought process required to spot the error and determine the root cause. Examples may include unusual machine operation, erratic electrometer reading, consistent lower electron output, variation in photon output, body parts inadvertently left in beam, unusual treatment plan, poor normalization, hot spots etc. Awareness of the possibility and detection of error in any link of the treatment process chain will help improve the safe and accurate delivery of radiation to patients. Four experts will discuss how to identify errors in four areas of clinical treatment. D. Followill, NIH grant CA 180803.« less

Technological Advancements and Error Rates in Radiation Therapy Delivery

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

Margalit, Danielle N., E-mail: dmargalit@partners.org; Harvard Cancer Consortium and Brigham and Women's Hospital/Dana Farber Cancer Institute, Boston, MA; Chen, Yu-Hui

2011-11-15

Purpose: Technological advances in radiation therapy (RT) delivery have the potential to reduce errors via increased automation and built-in quality assurance (QA) safeguards, yet may also introduce new types of errors. Intensity-modulated RT (IMRT) is an increasingly used technology that is more technically complex than three-dimensional (3D)-conformal RT and conventional RT. We determined the rate of reported errors in RT delivery among IMRT and 3D/conventional RT treatments and characterized the errors associated with the respective techniques to improve existing QA processes. Methods and Materials: All errors in external beam RT delivery were prospectively recorded via a nonpunitive error-reporting system atmore » Brigham and Women's Hospital/Dana Farber Cancer Institute. Errors are defined as any unplanned deviation from the intended RT treatment and are reviewed during monthly departmental quality improvement meetings. We analyzed all reported errors since the routine use of IMRT in our department, from January 2004 to July 2009. Fisher's exact test was used to determine the association between treatment technique (IMRT vs. 3D/conventional) and specific error types. Effect estimates were computed using logistic regression. Results: There were 155 errors in RT delivery among 241,546 fractions (0.06%), and none were clinically significant. IMRT was commonly associated with errors in machine parameters (nine of 19 errors) and data entry and interpretation (six of 19 errors). IMRT was associated with a lower rate of reported errors compared with 3D/conventional RT (0.03% vs. 0.07%, p = 0.001) and specifically fewer accessory errors (odds ratio, 0.11; 95% confidence interval, 0.01-0.78) and setup errors (odds ratio, 0.24; 95% confidence interval, 0.08-0.79). Conclusions: The rate of errors in RT delivery is low. The types of errors differ significantly between IMRT and 3D/conventional RT, suggesting that QA processes must be uniquely adapted for each technique. There was a lower error rate with IMRT compared with 3D/conventional RT, highlighting the need for sustained vigilance against errors common to more traditional treatment techniques.« less

The distribution of refractive errors among children attending Lumbini Eye Institute, Nepal.

PubMed

Rai, S; Thapa, H B; Sharma, M K; Dhakhwa, K; Karki, R

2012-01-01

Uncorrected refractive error is an important cause of childhood blindness and visual impairment. To describe the patterns of refractive errors among children attending the outpatient clinic at the Department of Pediatric Ophthalmology, Lumbini Eye Institute, Bhairahawa, Nepal. Records of 133 children with refractive errors aged 5 - 15 years from both the urban and rural areas of Nepal and the adjacent territory of India attending the hospital between September and November 2010 were examined for patterns of refractive errors. The SPSS statistical software was used to perform data analysis. The commonest type of refractive error among the children was astigmatism (47 %) followed by myopia (34 %) and hyperopia (15 %). The refractive error was more prevalent among children of both the genders of age group 11-15 years as compared to their younger counterparts (RR = 1.22, 95 % CI = 0.66 - 2.25). The refractive error was more common (70 %) in the rural than the urban children (26 %). The rural females had a higher (38 %) prevalence of myopia than urban females (18 %). Among the children with refractive errors, only 57 % were using spectacles at the initial presentation. Astigmatism is the commonest type of refractive error among the children of age 5 - 15 years followed by hypermetropia and myopia. Refractive error remains uncorrected in a significant number of children. © NEPjOPH.

High-resolution, low-delay, and error-resilient medical ultrasound video communication using H.264/AVC over mobile WiMAX networks.

PubMed

Panayides, Andreas; Antoniou, Zinonas C; Mylonas, Yiannos; Pattichis, Marios S; Pitsillides, Andreas; Pattichis, Constantinos S

2013-05-01

In this study, we describe an effective video communication framework for the wireless transmission of H.264/AVC medical ultrasound video over mobile WiMAX networks. Medical ultrasound video is encoded using diagnostically-driven, error resilient encoding, where quantization levels are varied as a function of the diagnostic significance of each image region. We demonstrate how our proposed system allows for the transmission of high-resolution clinical video that is encoded at the clinical acquisition resolution and can then be decoded with low-delay. To validate performance, we perform OPNET simulations of mobile WiMAX Medium Access Control (MAC) and Physical (PHY) layers characteristics that include service prioritization classes, different modulation and coding schemes, fading channels conditions, and mobility. We encode the medical ultrasound videos at the 4CIF (704 × 576) resolution that can accommodate clinical acquisition that is typically performed at lower resolutions. Video quality assessment is based on both clinical (subjective) and objective evaluations.

The visual and functional impacts of astigmatism and its clinical management.

PubMed

Read, Scott A; Vincent, Stephen J; Collins, Michael J

2014-05-01

To provide a comprehensive overview of research examining the impact of astigmatism on clinical and functional measures of vision, the short and longer term adaptations to astigmatism that occur in the visual system, and the currently available clinical options for the management of patients with astigmatism. The presence of astigmatism can lead to substantial reductions in visual performance in a variety of clinical vision measures and functional visual tasks. Recent evidence demonstrates that astigmatic blur results in short-term adaptations in the visual system that appear to reduce the perceived impact of astigmatism on vision. In the longer term, uncorrected astigmatism in childhood can also significantly impact on visual development, resulting in amblyopia. Astigmatism is also associated with the development of spherical refractive errors. Although the clinical correction of small magnitudes of astigmatism is relatively straightforward, the precise, reliable correction of astigmatism (particularly high astigmatism) can be challenging. A wide variety of refractive corrections are now available for the patient with astigmatism, including spectacle, contact lens and surgical options. Astigmatism is one of the most common refractive errors managed in clinical ophthalmic practice. The significant visual and functional impacts of astigmatism emphasise the importance of its reliable clinical management. With continued improvements in ocular measurement techniques and developments in a range of different refractive correction technologies, the future promises the potential for more precise and comprehensive correction options for astigmatic patients. © 2014 The Authors Ophthalmic & Physiological Optics © 2014 The College of Optometrists.

Identifying types and causes of errors in mortality data in a clinical registry using multiple information systems.

PubMed

Koetsier, Antonie; Peek, Niels; de Keizer, Nicolette

2012-01-01

Errors may occur in the registration of in-hospital mortality, making it less reliable as a quality indicator. We assessed the types of errors made in in-hospital mortality registration in the clinical quality registry National Intensive Care Evaluation (NICE) by comparing its mortality data to data from a national insurance claims database. Subsequently, we performed site visits at eleven Intensive Care Units (ICUs) to investigate the number, types and causes of errors made in in-hospital mortality registration. A total of 255 errors were found in the NICE registry. Two different types of software malfunction accounted for almost 80% of the errors. The remaining 20% were five types of manual transcription errors and human failures to record outcome data. Clinical registries should be aware of the possible existence of errors in recorded outcome data and understand their causes. In order to prevent errors, we recommend to thoroughly verify the software that is used in the registration process.

Low power and type II errors in recent ophthalmology research.

PubMed

Khan, Zainab; Milko, Jordan; Iqbal, Munir; Masri, Moness; Almeida, David R P

2016-10-01

To investigate the power of unpaired t tests in prospective, randomized controlled trials when these tests failed to detect a statistically significant difference and to determine the frequency of type II errors. Systematic review and meta-analysis. We examined all prospective, randomized controlled trials published between 2010 and 2012 in 4 major ophthalmology journals (Archives of Ophthalmology, British Journal of Ophthalmology, Ophthalmology, and American Journal of Ophthalmology). Studies that used unpaired t tests were included. Power was calculated using the number of subjects in each group, standard deviations, and α = 0.05. The difference between control and experimental means was set to be (1) 20% and (2) 50% of the absolute value of the control's initial conditions. Power and Precision version 4.0 software was used to carry out calculations. Finally, the proportion of articles with type II errors was calculated. β = 0.3 was set as the largest acceptable value for the probability of type II errors. In total, 280 articles were screened. Final analysis included 50 prospective, randomized controlled trials using unpaired t tests. The median power of tests to detect a 50% difference between means was 0.9 and was the same for all 4 journals regardless of the statistical significance of the test. The median power of tests to detect a 20% difference between means ranged from 0.26 to 0.9 for the 4 journals. The median power of these tests to detect a 50% and 20% difference between means was 0.9 and 0.5 for tests that did not achieve statistical significance. A total of 14% and 57% of articles with negative unpaired t tests contained results with β > 0.3 when power was calculated for differences between means of 50% and 20%, respectively. A large portion of studies demonstrate high probabilities of type II errors when detecting small differences between means. The power to detect small difference between means varies across journals. It is, therefore, worthwhile for authors to mention the minimum clinically important difference for individual studies. Journals can consider publishing statistical guidelines for authors to use. Day-to-day clinical decisions rely heavily on the evidence base formed by the plethora of studies available to clinicians. Prospective, randomized controlled clinical trials are highly regarded as a robust study and are used to make important clinical decisions that directly affect patient care. The quality of study designs and statistical methods in major clinical journals is improving overtime, 1 and researchers and journals are being more attentive to statistical methodologies incorporated by studies. The results of well-designed ophthalmic studies with robust methodologies, therefore, have the ability to modify the ways in which diseases are managed. Copyright © 2016 Canadian Ophthalmological Society. Published by Elsevier Inc. All rights reserved.

The validity of two clinical tests of visual-motor perception.

PubMed

Wallbrown, J D; Wallbrown, F H; Engin, A W

1977-04-01

The study investigated the relative efficiency of the Bender and MPD as assessors of achievement-related errors in visual-motor perception. Clinical experience with these two tests suggests that beyond first grade the MPD is more sensitive than the Bender for purposes of measuring deficits in visual-motor perception that interfere with effective classroom learning. The sample was composed of 153 third-grade children from two upper-middle-class elementary schools in a surburban school system in central Ohio. For three of the four achievement criteria, the results were clearly congruent with the hypothesis stated above. That is, SpCD errors from the MPD not only showed significantly higher negative rs with the criteria (reading vocabulary, reading comprehension, and mathematics computation) than Koppitz errors from the Bender, but also accounted for a much higher proportion of the variance in these criteria. Thus, the findings suggest that psychologists engaged in the assessment of older children seriously should consider adding the MPD to their assessment battery.

FMEA: a model for reducing medical errors.

PubMed

Chiozza, Maria Laura; Ponzetti, Clemente

2009-06-01

Patient safety is a management issue, in view of the fact that clinical risk management has become an important part of hospital management. Failure Mode and Effect Analysis (FMEA) is a proactive technique for error detection and reduction, firstly introduced within the aerospace industry in the 1960s. Early applications in the health care industry dating back to the 1990s included critical systems in the development and manufacture of drugs and in the prevention of medication errors in hospitals. In 2008, the Technical Committee of the International Organization for Standardization (ISO), licensed a technical specification for medical laboratories suggesting FMEA as a method for prospective risk analysis of high-risk processes. Here we describe the main steps of the FMEA process and review data available on the application of this technique to laboratory medicine. A significant reduction of the risk priority number (RPN) was obtained when applying FMEA to blood cross-matching, to clinical chemistry analytes, as well as to point-of-care testing (POCT).

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

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

PubMed

Snyder, John; Aafjes-van Doorn, Katie

2016-09-01

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

Assessment of Nonverbal and Verbal Apraxia in Patients with Parkinson's Disease

PubMed Central

Olchik, Maira Rozenfeld; Shumacher Shuh, Artur Francisco; Rieder, Carlos R. M.

2015-01-01

Objective. To assess the presence of nonverbal and verbal apraxia in patients with Parkinson's disease (PD) and analyze the correlation between these conditions and patient age, education, duration of disease, and PD stage, as well as evaluate the correlation between the two types of apraxia and the frequency and types of verbal apraxic errors made by patients in the sample. Method. This was an observational prevalence study. The sample comprised 45 patients with PD seen at the Movement Disorders Clinic of the Clinical Hospital of Porto Alegre, Brazil. Patients were evaluated using the Speech Apraxia Assessment Protocol and PD stages were classified according to the Hoehn and Yahr scale. Results. The rate of nonverbal apraxia and verbal apraxia in the present sample was 24.4%. Verbal apraxia was significantly correlated with education (p ≤ 0.05). The most frequent types of verbal apraxic errors were omissions (70.8%). The analysis of manner and place of articulation showed that most errors occurred during the production of trill (57.7%) and dentoalveolar (92%) phonemes, consecutively. Conclusion. Patients with PD presented nonverbal and verbal apraxia and made several verbal apraxic errors. Verbal apraxia was correlated with education levels. PMID:26543663

Broadening our understanding of clinical quality: from attribution error to situated cognition.

PubMed

Artino, A R; Durning, S J; Waechter, D M; Leary, K L; Gilliland, W R

2012-02-01

The tendency to overestimate the influence of personal characteristics on outcomes, and to underestimate the influence of situational factors, is known as the fundamental attribution error. We argue that medical-education researchers and policy makers may be guilty of this error in their quest to understand clinical quality. We suggest that to truly understand clinical quality, they must examine situational factors, which often have a strong influence on the quality of clinical encounters.

The effect of video game "warm-up" on performance of laparoscopic surgery tasks.

PubMed

Rosser, James C; Gentile, Douglas A; Hanigan, Kevin; Danner, Omar K

2012-01-01

Performing laparoscopic procedures requires special training and has been documented as a significant source of surgical errors. "Warming up" before performing a task has been shown to enhance performance. This study investigates whether surgeons benefit from "warming up" using select video games immediately before performing laparoscopic partial tasks and clinical tasks. This study included 303 surgeons (249 men and 54 women). Participants were split into a control (n=180) and an experimental group (n=123). The experimental group played 3 previously validated video games for 6 minutes before task sessions. The Cobra Rope partial task and suturing exercises were performed immediately after the warm-up sessions. Surgeons who played video games prior to the Cobra Rope drill were significantly faster on their first attempt and across all 10 trials. The experimental and control groups were significantly different in their total suturing scores (t=2.28, df=288, P<.05). The overall Top Gun score showed that the experimental group performed marginally better overall. This study demonstrates that subjects completing "warming-up" sessions with select video games prior to performing laparoscopic partial and clinical tasks (intracorporeal suturing) were faster and had fewer errors than participants not engaging in "warm-up." More study is needed to determine whether this translates into superior procedural execution in the clinical setting.

Cognitive Vulnerability in Patients with Generalized Anxiety Disorder, Dysthymic Disorder and Normal Individuals.

PubMed

Al-Ghorabaie, Fateme Moin; Noferesti, Azam; Fadaee, Mahdi; Ganji, Nima

2016-08-01

The purpose of this study was to assess cognitive vulnerability and response style in clinical and normal individuals. A sample of 90 individuals was selected for each of the 3 groups of Generalized Anxiety disorder, Dysthymic disorder and normal individuals. They completed MCQ and RSQ. Results analyzed by MANOVA and post hoc showed significant differences among groups. Dysthymic group and GAD reported higher scores on cognitive confidence compared to the normal group. Individuals with GAD showed highly negative beliefs about need to control thought, compared to the other groups, but in cognitive self-consciousness they have no differences with the normal group. In regard to uncontrollability, danger and positive beliefs, GAD group had higher levels than the other groups. Although normal and GAD group didn't show any significant differences in response style, there was a significant difference between Dysthymic group and other groups in all response styles.  Beliefs and meta-cognitive strategies can be distinguished between clinical and non clinical individuals. Also, findings support the Self-Regulatory Executive Function model. ary committee was effective in recognizing, designing and implementing tailored interventions for reduction of medication errors. A systematic approach is urgently needed to decrease organizational susceptibility to errors, through providing required resources to monitor, analyze and implement effective interventions.

Evaluation of complications of root canal treatment performed by undergraduate dental students.

PubMed

AlRahabi, Mothanna K

2017-12-01

This study evaluated the technical quality of root canal treatment (RCT) and detected iatrogenic errors in an undergraduate dental clinic at the College of Dentistry, Taibah University, Saudi Arabia. Dental records of 280 patients who received RCT between 2013 and 2016 undertaken by dental students were investigated by retrospective chart review. Root canal obturation was evaluated on the basis of the length of obturation being ≤2 mm from the radiographic apex, with uniform radiodensity and good adaptation to root canal walls. Inadequate root canal obturation included cases containing procedural errors such as furcal perforation, ledge, canal transportation, strip perforation, root perforation, instrument separation, voids in the obturation, or underfilling or overfilling of the obturation. In 193 (68.9%) teeth, RCT was adequate and without procedural errors. However, in 87 (31.1%) teeth, RCT was inadequate and contained procedural errors. The frequency of procedural errors in the entire sample was 31.1% as follows: underfilling, 49.9%; overfilling, 24.1%; voids, 12.6%; broken instruments, 9.2%; apical perforation, 2.3%; and root canal transportation, 2.3%. There were no significant differences (p > 0.05) in the type or frequency of procedural errors between the fourth- and fifth-year students. Lower molars (43.1%) and upper incisors (19.2%) exhibited the highest and lowest frequencies of procedural errors, respectively. The technical quality of RCT performed by undergraduate dental students was classified as 'adequate' in 68.9% of the cases. There is a need for improvement in the training of students at the preclinical and clinical levels.

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

PubMed

Carraro, Paolo; Zago, Tatiana; Plebani, Mario

2012-03-01

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

Validation of simplified centre of mass models during gait in individuals with chronic stroke.

PubMed

Huntley, Andrew H; Schinkel-Ivy, Alison; Aqui, Anthony; Mansfield, Avril

2017-10-01

The feasibility of using a multiple segment (full-body) kinematic model in clinical gait assessment is difficult when considering obstacles such as time and cost constraints. While simplified gait models have been explored in healthy individuals, no such work to date has been conducted in a stroke population. The aim of this study was to quantify the errors of simplified kinematic models for chronic stroke gait assessment. Sixteen individuals with chronic stroke (>6months), outfitted with full body kinematic markers, performed a series of gait trials. Three centre of mass models were computed: (i) 13-segment whole-body model, (ii) 3 segment head-trunk-pelvis model, and (iii) 1 segment pelvis model. Root mean squared error differences were compared between models, along with correlations to measures of stroke severity. Error differences revealed that, while both models were similar in the mediolateral direction, the head-trunk-pelvis model had less error in the anteroposterior direction and the pelvis model had less error in the vertical direction. There was some evidence that the head-trunk-pelvis model error is influenced in the mediolateral direction for individuals with more severe strokes, as a few significant correlations were observed between the head-trunk-pelvis model and measures of stroke severity. These findings demonstrate the utility and robustness of the pelvis model for clinical gait assessment in individuals with chronic stroke. Low error in the mediolateral and vertical directions is especially important when considering potential stability analyses during gait for this population, as lateral stability has been previously linked to fall risk. Copyright © 2017 Elsevier Ltd. All rights reserved.

Corrections of clinical chemistry test results in a laboratory information system.

PubMed

Wang, Sihe; Ho, Virginia

2004-08-01

The recently released reports by the Institute of Medicine, To Err Is Human and Patient Safety, have received national attention because of their focus on the problem of medical errors. Although a small number of studies have reported on errors in general clinical laboratories, there are, to our knowledge, no reported studies that focus on errors in pediatric clinical laboratory testing. To characterize the errors that have caused corrections to have to be made in pediatric clinical chemistry results in the laboratory information system, Misys. To provide initial data on the errors detected in pediatric clinical chemistry laboratories in order to improve patient safety in pediatric health care. All clinical chemistry staff members were informed of the study and were requested to report in writing when a correction was made in the laboratory information system, Misys. Errors were detected either by the clinicians (the results did not fit the patients' clinical conditions) or by the laboratory technologists (the results were double-checked, and the worksheets were carefully examined twice a day). No incident that was discovered before or during the final validation was included. On each Monday of the study, we generated a report from Misys that listed all of the corrections made during the previous week. We then categorized the corrections according to the types and stages of the incidents that led to the corrections. A total of 187 incidents were detected during the 10-month study, representing a 0.26% error detection rate per requisition. The distribution of the detected incidents included 31 (17%) preanalytic incidents, 46 (25%) analytic incidents, and 110 (59%) postanalytic incidents. The errors related to noninterfaced tests accounted for 50% of the total incidents and for 37% of the affected tests and orderable panels, while the noninterfaced tests and panels accounted for 17% of the total test volume in our laboratory. This pilot study provided the rate and categories of errors detected in a pediatric clinical chemistry laboratory based on the corrections of results in the laboratory information system. A direct interface of the instruments to the laboratory information system showed that it had favorable effects on reducing laboratory errors.

Refractive errors in Aminu Kano Teaching Hospital, Kano Nigeria.

PubMed

Lawan, Abdu; Eme, Okpo

2011-12-01

The aim of the study is to retrospectively determine the pattern of refractive errors seen in the eye clinic of Aminu Kano Teaching Hospital, Kano-Nigeria from January to December, 2008. The clinic refraction register was used to retrieve the case folders of all patients refracted during the review period. Information extracted includes patient's age, sex, and types of refractive error. All patients had basic eye examination (to rule out other causes of subnormal vision) including intra ocular pressure measurement and streak retinoscopy at two third meter working distance. The final subjective refraction correction given to the patients was used to categorise the type of refractive error. Refractive errors was observed in 1584 patients and accounted for 26.9% of clinic attendance. There were more females than males (M: F=1.0: 1.2). The common types of refractive errors are presbyopia in 644 patients (40%), various types of astigmatism in 527 patients (33%), myopia in 216 patients (14%), hypermetropia in 171 patients (11%) and aphakia in 26 patients (2%). Refractive errors are common causes of presentation in the eye clinic. Identification and correction of refractive errors should be an integral part of eye care delivery.

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.

Validating the Accuracy of Reaction Time Assessment on Computer-Based Tablet Devices.

PubMed

Schatz, Philip; Ybarra, Vincent; Leitner, Donald

2015-08-01

Computer-based assessment has evolved to tablet-based devices. Despite the availability of tablets and "apps," there is limited research validating their use. We documented timing delays between stimulus presentation and (simulated) touch response on iOS devices (3rd- and 4th-generation Apple iPads) and Android devices (Kindle Fire, Google Nexus, Samsung Galaxy) at response intervals of 100, 250, 500, and 1,000 milliseconds (ms). Results showed significantly greater timing error on Google Nexus and Samsung tablets (81-97 ms), than Kindle Fire and Apple iPads (27-33 ms). Within Apple devices, iOS 7 obtained significantly lower timing error than iOS 6. Simple reaction time (RT) trials (250 ms) on tablet devices represent 12% to 40% error (30-100 ms), depending on the device, which decreases considerably for choice RT trials (3-5% error at 1,000 ms). Results raise implications for using the same device for serial clinical assessment of RT using tablets, as well as the need for calibration of software and hardware. © The Author(s) 2015.

Assessment of the knowledge and attitudes of intern doctors to medication prescribing errors in a Nigeria tertiary hospital

PubMed Central

Ajemigbitse, Adetutu A.; Omole, Moses Kayode; Ezike, Nnamdi Chika; Erhun, Wilson O.

2013-01-01

Context: Junior doctors are reported to make most of the prescribing errors in the hospital setting. Aims: The aim of the following study is to determine the knowledge intern doctors have about prescribing errors and circumstances contributing to making them. Settings and Design: A structured questionnaire was distributed to intern doctors in National Hospital Abuja Nigeria. Subjects and Methods: Respondents gave information about their experience with prescribing medicines, the extent to which they agreed with the definition of a clinically meaningful prescribing error and events that constituted such. Their experience with prescribing certain categories of medicines was also sought. Statistical Analysis Used: Data was analyzed with Statistical Package for the Social Sciences (SPSS) software version 17 (SPSS Inc Chicago, Ill, USA). Chi-squared analysis contrasted differences in proportions; P < 0.05 was considered to be statistically significant. Results: The response rate was 90.9% and 27 (90%) had <1 year of prescribing experience. 17 (56.7%) respondents totally agreed with the definition of a clinically meaningful prescribing error. Most common reasons for prescribing mistakes were a failure to check prescriptions with a reference source (14, 25.5%) and failure to check for adverse drug interactions (14, 25.5%). Omitting some essential information such as duration of therapy (13, 20%), patient age (14, 21.5%) and dosage errors (14, 21.5%) were the most common types of prescribing errors made. Respondents considered workload (23, 76.7%), multitasking (19, 63.3%), rushing (18, 60.0%) and tiredness/stress (16, 53.3%) as important factors contributing to prescribing errors. Interns were least confident prescribing antibiotics (12, 25.5%), opioid analgesics (12, 25.5%) cytotoxics (10, 21.3%) and antipsychotics (9, 19.1%) unsupervised. Conclusions: Respondents seemed to have a low awareness of making prescribing errors. Principles of rational prescribing and events that constitute prescribing errors should be taught in the practice setting. PMID:24808682

Assessment of the knowledge and attitudes of intern doctors to medication prescribing errors in a Nigeria tertiary hospital.

PubMed

Ajemigbitse, Adetutu A; Omole, Moses Kayode; Ezike, Nnamdi Chika; Erhun, Wilson O

2013-12-01

Junior doctors are reported to make most of the prescribing errors in the hospital setting. The aim of the following study is to determine the knowledge intern doctors have about prescribing errors and circumstances contributing to making them. A structured questionnaire was distributed to intern doctors in National Hospital Abuja Nigeria. Respondents gave information about their experience with prescribing medicines, the extent to which they agreed with the definition of a clinically meaningful prescribing error and events that constituted such. Their experience with prescribing certain categories of medicines was also sought. Data was analyzed with Statistical Package for the Social Sciences (SPSS) software version 17 (SPSS Inc Chicago, Ill, USA). Chi-squared analysis contrasted differences in proportions; P < 0.05 was considered to be statistically significant. The response rate was 90.9% and 27 (90%) had <1 year of prescribing experience. 17 (56.7%) respondents totally agreed with the definition of a clinically meaningful prescribing error. Most common reasons for prescribing mistakes were a failure to check prescriptions with a reference source (14, 25.5%) and failure to check for adverse drug interactions (14, 25.5%). Omitting some essential information such as duration of therapy (13, 20%), patient age (14, 21.5%) and dosage errors (14, 21.5%) were the most common types of prescribing errors made. Respondents considered workload (23, 76.7%), multitasking (19, 63.3%), rushing (18, 60.0%) and tiredness/stress (16, 53.3%) as important factors contributing to prescribing errors. Interns were least confident prescribing antibiotics (12, 25.5%), opioid analgesics (12, 25.5%) cytotoxics (10, 21.3%) and antipsychotics (9, 19.1%) unsupervised. Respondents seemed to have a low awareness of making prescribing errors. Principles of rational prescribing and events that constitute prescribing errors should be taught in the practice setting.

The effect of a multifaceted educational intervention on medication preparation and administration errors in neonatal intensive care.

PubMed

Chedoe, Indra; Molendijk, Harry; Hospes, Wobbe; Van den Heuvel, Edwin R; Taxis, Katja

2012-11-01

To examine the effect of a multifaceted educational intervention on the incidence of medication preparation and administration errors in a neonatal intensive care unit (NICU). Prospective study with a preintervention and postintervention measurement using direct observation. NICU in a tertiary hospital in the Netherlands. A multifaceted educational intervention including teaching and self-study. The incidence of medication preparation and administration errors. Clinical importance was assessed by three experts. The incidence of errors decreased from 49% (43-54%) (151 medications with one or more errors of 311 observations) to 31% (87 of 284) (25-36%). Preintervention, 0.3% (0-2%) medications contained severe errors, 26% (21-31%) moderate and 23% (18-28%) minor errors; postintervention, none 0% (0-2%) was severe, 23% (18-28%) moderate and 8% (5-12%) minor. A generalised estimating equations analysis provided an OR of 0.49 (0.29-0.84) for period (p=0.032), (route of administration (p=0.001), observer within period (p=0.036)). The multifaceted educational intervention seemed to have contributed to a significant reduction of the preparation and administration error rate, but other measures are needed to improve medication safety further.

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

PubMed Central

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

2015-01-01

Objectives To (i) compare medication errors identified at audit and observation with medication incident reports; (ii) identify differences between two hospitals in incident report frequency and medication error rates; (iii) identify prescribing error detection rates by staff. Design Audit of 3291patient records at two hospitals to identify prescribing errors and evidence of their detection by staff. Medication administration errors were identified from a direct observational study of 180 nurses administering 7451 medications. Severity of errors was classified. Those likely to lead to patient harm were categorized as ‘clinically important’. Setting Two major academic teaching hospitals in Sydney, Australia. Main Outcome Measures Rates of medication errors identified from audit and from direct observation were compared with reported medication incident reports. Results A total of 12 567 prescribing errors were identified at audit. Of these 1.2/1000 errors (95% CI: 0.6–1.8) had incident reports. Clinically important prescribing errors (n = 539) were detected by staff at a rate of 218.9/1000 (95% CI: 184.0–253.8), but only 13.0/1000 (95% CI: 3.4–22.5) were reported. 78.1% (n = 421) of clinically important prescribing errors were not detected. A total of 2043 drug administrations (27.4%; 95% CI: 26.4–28.4%) contained ≥1 errors; none had an incident report. Hospital A had a higher frequency of incident reports than Hospital B, but a lower rate of errors at audit. Conclusions Prescribing errors with the potential to cause harm frequently go undetected. Reported incidents do not reflect the profile of medication errors which occur in hospitals or the underlying rates. This demonstrates the inaccuracy of using incident frequency to compare patient risk or quality performance within or across hospitals. New approaches including data mining of electronic clinical information systems are required to support more effective medication error detection and mitigation. PMID:25583702

Death Certification Errors and the Effect on Mortality Statistics.

PubMed

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

Errors in cause and manner of death on death certificates are common and affect families, mortality statistics, and public health research. The primary objective of this study was to characterize errors in the cause and manner of death on death certificates completed by non-Medical Examiners. A secondary objective was to determine the effects of errors on national mortality statistics. We retrospectively compared 601 death certificates completed between July 1, 2015, and January 31, 2016, from the Vermont Electronic Death Registration System with clinical summaries from medical records. Medical Examiners, blinded to original certificates, reviewed summaries, generated mock certificates, and compared mock certificates with original certificates. They then graded errors using a scale from 1 to 4 (higher numbers indicated increased impact on interpretation of the cause) to determine the prevalence of minor and major errors. They also compared International Classification of Diseases, 10th Revision (ICD-10) codes on original certificates with those on mock certificates. Of 601 original death certificates, 319 (53%) had errors; 305 (51%) had major errors; and 59 (10%) had minor errors. We found no significant differences by certifier type (physician vs nonphysician). We did find significant differences in major errors in place of death ( P < .001). Certificates for deaths occurring in hospitals were more likely to have major errors than certificates for deaths occurring at a private residence (59% vs 39%, P < .001). A total of 580 (93%) death certificates had a change in ICD-10 codes between the original and mock certificates, of which 348 (60%) had a change in the underlying cause-of-death code. Error rates on death certificates in Vermont are high and extend to ICD-10 coding, thereby affecting national mortality statistics. Surveillance and certifier education must expand beyond local and state efforts. Simplifying and standardizing underlying literal text for cause of death may improve accuracy, decrease coding errors, and improve national mortality statistics.

Cognitive flexibility correlates with gambling severity in young adults.

PubMed

Leppink, Eric W; Redden, Sarah A; Chamberlain, Samuel R; Grant, Jon E

2016-10-01

Although gambling disorder (GD) is often characterized as a problem of impulsivity, compulsivity has recently been proposed as a potentially important feature of addictive disorders. The present analysis assessed the neurocognitive and clinical relationship between compulsivity on gambling behavior. A sample of 552 non-treatment seeking gamblers age 18-29 was recruited from the community for a study on gambling in young adults. Gambling severity levels included both casual and disordered gamblers. All participants completed the Intra/Extra-Dimensional Set Shift (IED) task, from which the total adjusted errors were correlated with gambling severity measures, and linear regression modeling was used to assess three error measures from the task. The present analysis found significant positive correlations between problems with cognitive flexibility and gambling severity (reflected by the number of DSM-5 criteria, gambling frequency, amount of money lost in the past year, and gambling urge/behavior severity). IED errors also showed a positive correlation with self-reported compulsive behavior scores. A significant correlation was also found between IED errors and non-planning impulsivity from the BIS. Linear regression models based on total IED errors, extra-dimensional (ED) shift errors, or pre-ED shift errors indicated that these factors accounted for a significant portion of the variance noted in several variables. These findings suggest that cognitive flexibility may be an important consideration in the assessment of gamblers. Results from correlational and linear regression analyses support this possibility, but the exact contributions of both impulsivity and cognitive flexibility remain entangled. Future studies will ideally be able to assess the longitudinal relationships between gambling, compulsivity, and impulsivity, helping to clarify the relative contributions of both impulsive and compulsive features. Copyright © 2016 Elsevier Ltd. All rights reserved.

Research Design and Statistical Methods in Indian Medical Journals: A Retrospective Survey

PubMed Central

Hassan, Shabbeer; Yellur, Rajashree; Subramani, Pooventhan; Adiga, Poornima; Gokhale, Manoj; Iyer, Manasa S.; Mayya, Shreemathi S.

2015-01-01

Good quality medical research generally requires not only an expertise in the chosen medical field of interest but also a sound knowledge of statistical methodology. The number of medical research articles which have been published in Indian medical journals has increased quite substantially in the past decade. The aim of this study was to collate all evidence on study design quality and statistical analyses used in selected leading Indian medical journals. Ten (10) leading Indian medical journals were selected based on impact factors and all original research articles published in 2003 (N = 588) and 2013 (N = 774) were categorized and reviewed. A validated checklist on study design, statistical analyses, results presentation, and interpretation was used for review and evaluation of the articles. Main outcomes considered in the present study were – study design types and their frequencies, error/defects proportion in study design, statistical analyses, and implementation of CONSORT checklist in RCT (randomized clinical trials). From 2003 to 2013: The proportion of erroneous statistical analyses did not decrease (χ2=0.592, Φ=0.027, p=0.4418), 25% (80/320) in 2003 compared to 22.6% (111/490) in 2013. Compared with 2003, significant improvement was seen in 2013; the proportion of papers using statistical tests increased significantly (χ2=26.96, Φ=0.16, p<0.0001) from 42.5% (250/588) to 56.7 % (439/774). The overall proportion of errors in study design decreased significantly (χ2=16.783, Φ=0.12 p<0.0001), 41.3% (243/588) compared to 30.6% (237/774). In 2013, randomized clinical trials designs has remained very low (7.3%, 43/588) with majority showing some errors (41 papers, 95.3%). Majority of the published studies were retrospective in nature both in 2003 [79.1% (465/588)] and in 2013 [78.2% (605/774)]. Major decreases in error proportions were observed in both results presentation (χ2=24.477, Φ=0.17, p<0.0001), 82.2% (263/320) compared to 66.3% (325/490) and interpretation (χ2=25.616, Φ=0.173, p<0.0001), 32.5% (104/320) compared to 17.1% (84/490), though some serious ones were still present. Indian medical research seems to have made no major progress regarding using correct statistical analyses, but error/defects in study designs have decreased significantly. Randomized clinical trials are quite rarely published and have high proportion of methodological problems. PMID:25856194

Research design and statistical methods in Indian medical journals: a retrospective survey.

PubMed

Hassan, Shabbeer; Yellur, Rajashree; Subramani, Pooventhan; Adiga, Poornima; Gokhale, Manoj; Iyer, Manasa S; Mayya, Shreemathi S

2015-01-01

Good quality medical research generally requires not only an expertise in the chosen medical field of interest but also a sound knowledge of statistical methodology. The number of medical research articles which have been published in Indian medical journals has increased quite substantially in the past decade. The aim of this study was to collate all evidence on study design quality and statistical analyses used in selected leading Indian medical journals. Ten (10) leading Indian medical journals were selected based on impact factors and all original research articles published in 2003 (N = 588) and 2013 (N = 774) were categorized and reviewed. A validated checklist on study design, statistical analyses, results presentation, and interpretation was used for review and evaluation of the articles. Main outcomes considered in the present study were - study design types and their frequencies, error/defects proportion in study design, statistical analyses, and implementation of CONSORT checklist in RCT (randomized clinical trials). From 2003 to 2013: The proportion of erroneous statistical analyses did not decrease (χ2=0.592, Φ=0.027, p=0.4418), 25% (80/320) in 2003 compared to 22.6% (111/490) in 2013. Compared with 2003, significant improvement was seen in 2013; the proportion of papers using statistical tests increased significantly (χ2=26.96, Φ=0.16, p<0.0001) from 42.5% (250/588) to 56.7 % (439/774). The overall proportion of errors in study design decreased significantly (χ2=16.783, Φ=0.12 p<0.0001), 41.3% (243/588) compared to 30.6% (237/774). In 2013, randomized clinical trials designs has remained very low (7.3%, 43/588) with majority showing some errors (41 papers, 95.3%). Majority of the published studies were retrospective in nature both in 2003 [79.1% (465/588)] and in 2013 [78.2% (605/774)]. Major decreases in error proportions were observed in both results presentation (χ2=24.477, Φ=0.17, p<0.0001), 82.2% (263/320) compared to 66.3% (325/490) and interpretation (χ2=25.616, Φ=0.173, p<0.0001), 32.5% (104/320) compared to 17.1% (84/490), though some serious ones were still present. Indian medical research seems to have made no major progress regarding using correct statistical analyses, but error/defects in study designs have decreased significantly. Randomized clinical trials are quite rarely published and have high proportion of methodological problems.

Error disclosure: a new domain for safety culture assessment.

PubMed

Etchegaray, Jason M; Gallagher, Thomas H; Bell, Sigall K; Dunlap, Ben; Thomas, Eric J

2012-07-01

To (1) develop and test survey items that measure error disclosure culture, (2) examine relationships among error disclosure culture, teamwork culture and safety culture and (3) establish predictive validity for survey items measuring error disclosure culture. All clinical faculty from six health institutions (four medical schools, one cancer centre and one health science centre) in The University of Texas System were invited to anonymously complete an electronic survey containing questions about safety culture and error disclosure. The authors found two factors to measure error disclosure culture: one factor is focused on the general culture of error disclosure and the second factor is focused on trust. Both error disclosure culture factors were unique from safety culture and teamwork culture (correlations were less than r=0.85). Also, error disclosure general culture and error disclosure trust culture predicted intent to disclose a hypothetical error to a patient (r=0.25, p<0.001 and r=0.16, p<0.001, respectively) while teamwork and safety culture did not predict such an intent (r=0.09, p=NS and r=0.12, p=NS). Those who received prior error disclosure training reported significantly higher levels of error disclosure general culture (t=3.7, p<0.05) and error disclosure trust culture (t=2.9, p<0.05). The authors created and validated a new measure of error disclosure culture that predicts intent to disclose an error better than other measures of healthcare culture. This measure fills an existing gap in organisational assessments by assessing transparent communication after medical error, an important aspect of culture.

Physicians and pharmacists: collaboration to improve the quality of prescriptions in primary care in Mexico.

PubMed

Mino-León, Dolores; Reyes-Morales, Hortensia; Jasso, Luis; Douvoba, Svetlana Vladislavovna

2012-06-01

Inappropriate prescription is a relevant problem in primary health care settings in Mexico, with potentially harmful consequences for patients. To evaluate the effectiveness of incorporating a pharmacist into primary care health team to reduce prescription errors for patients with diabetes and/or hypertension. One Family Medicine Clinic from the Mexican Institute of Social Security in Mexico City. A "pharmacotherapy intervention" provided by pharmacists through a quasi experimental (before-after) design was carried out. Physicians who allowed access to their diabetes and/or hypertensive patients' medical records and prescriptions were included in the study. Prescription errors were classified as "filling", "clinical" or "both". Descriptive analysis, identification of potential drug-drug interactions (pD-DI), and comparison of the proportion of patients with prescriptions with errors detected "before" and "after" intervention were performed. Decrease in the proportion of patients who received prescriptions with errors after the intervention. Pharmacists detected at least one type of error in 79 out of 160 patients. Errors were "clinical", "both" and "filling" in 47, 21 and 11 of these patient's prescriptions respectively. Predominant errors were, in the subgroup of patient's prescriptions with "clinical" errors, pD-DI; in the subgroup of "both" errors, lack of information on dosing interval and pD-DI; and in the "filling" subgroup, lack of information on dosing interval. The pD-DI caused 50 % of the errors detected, from which 19 % were of major severity. The impact of the correction of errors post-intervention was observed in 19 % of patients who had erroneous prescriptions before the intervention of the pharmacist (49.3-30.3 %, p < 0.05). The impact of the intervention was relevant from a clinical point of view for the public health services in Mexico. The implementation of early warning systems of the most widely prescribed drugs is an alternative for reducing prescription errors and consequently the risks they may cause.

Factors associated with disclosure of medical errors by housestaff.

PubMed

Kronman, Andrea C; Paasche-Orlow, Michael; Orlander, Jay D

2012-04-01

Attributes of the organisational culture of residency training programmes may impact patient safety. Training environments are complex, composed of clinical teams, residency programmes, and clinical units. We examined the relationship between residents' perceptions of their training environment and disclosure of or apology for their worst error. Anonymous, self-administered surveys were distributed to Medicine and Surgery residents at Boston Medical Center in 2005. Surveys asked residents to describe their worst medical error, and to answer selected questions from validated surveys measuring elements of working environments that promote learning from error. Subscales measured the microenvironments of the clinical team, residency programme, and clinical unit. Univariate and bivariate statistical analyses examined relationships between trainee characteristics, their perceived learning environment(s), and their responses to the error. Out of 109 surveys distributed to residents, 99 surveys were returned (91% overall response rate), two incomplete surveys were excluded, leaving 97: 61% internal medicine, 39% surgery, 59% male residents. While 31% reported apologising for the situation associated with the error, only 17% reported disclosing the error to patients and/or family. More male residents disclosed the error than female residents (p=0.04). Surgery residents scored higher on the subscales of safety culture pertaining to the residency programme (p=0.02) and managerial commitment to safety (p=0.05). Our Medical Culture Summary score was positively associated with disclosure (p=0.04) and apology (p=0.05). Factors in the learning environments of residents are associated with responses to medical errors. Organisational safety culture can be measured, and used to evaluate environmental attributes of clinical training that are associated with disclosure of, and apology for, medical error.

Classifying nursing errors in clinical management within an Australian hospital.

PubMed

Tran, D T; Johnson, M

2010-12-01

Although many classification systems relating to patient safety exist, no taxonomy was identified that classified nursing errors in clinical management. To develop a classification system for nursing errors relating to clinical management (NECM taxonomy) and to describe contributing factors and patient consequences. We analysed 241 (11%) self-reported incidents relating to clinical management in nursing in a metropolitan hospital. Descriptive analysis of numeric data and content analysis of text data were undertaken to derive the NECM taxonomy, contributing factors and consequences for patients. Clinical management incidents represented 1.63 incidents per 1000 occupied bed days. The four themes of the NECM taxonomy were nursing care process (67%), communication (22%), administrative process (5%), and knowledge and skill (6%). Half of the incidents did not cause any patient harm. Contributing factors (n=111) included the following: patient clinical, social conditions and behaviours (27%); resources (22%); environment and workload (18%); other health professionals (15%); communication (13%); and nurse's knowledge and experience (5%). The NECM taxonomy provides direction to clinicians and managers on areas in clinical management that are most vulnerable to error, and therefore, priorities for system change management. Any nurses who wish to classify nursing errors relating to clinical management could use these types of errors. This study informs further research into risk management behaviour, and self-assessment tools for clinicians. Globally, nurses need to continue to monitor and act upon patient safety issues. © 2010 The Authors. International Nursing Review © 2010 International Council of Nurses.

Lean six sigma methodologies improve clinical laboratory efficiency and reduce turnaround times.

PubMed

Inal, Tamer C; Goruroglu Ozturk, Ozlem; Kibar, Filiz; Cetiner, Salih; Matyar, Selcuk; Daglioglu, Gulcin; Yaman, Akgun

2018-01-01

Organizing work flow is a major task of laboratory management. Recently, clinical laboratories have started to adopt methodologies such as Lean Six Sigma and some successful implementations have been reported. This study used Lean Six Sigma to simplify the laboratory work process and decrease the turnaround time by eliminating non-value-adding steps. The five-stage Six Sigma system known as define, measure, analyze, improve, and control (DMAIC) is used to identify and solve problems. The laboratory turnaround time for individual tests, total delay time in the sample reception area, and percentage of steps involving risks of medical errors and biological hazards in the overall process are measured. The pre-analytical process in the reception area was improved by eliminating 3 h and 22.5 min of non-value-adding work. Turnaround time also improved for stat samples from 68 to 59 min after applying Lean. Steps prone to medical errors and posing potential biological hazards to receptionists were reduced from 30% to 3%. Successful implementation of Lean Six Sigma significantly improved all of the selected performance metrics. This quality-improvement methodology has the potential to significantly improve clinical laboratories. © 2017 Wiley Periodicals, Inc.

Smartphone virtual reality to increase clinical balance assessment responsiveness.

PubMed

Rausch, Matthew; Simon, Janet E; Starkey, Chad; Grooms, Dustin R

2018-05-22

To determine if a low cost smartphone based, clinically applicable virtual reality (VR) modification to the standard Balance Error Scoring System (BESS) can challenge postural stability beyond the traditional BESS. Cross-sectional study. University research laboratory. 28 adults (mean age 23.36 ± 2.38 years, mean height 1.74 m ± 0.13, mean weight 77.95 kg ± 16.63). BESS postural control errors and center of pressure (CoP) velocity were recorded during the BESS test and a VR modified BESS (VR-BESS). The VR-BESS used a headset and phone to display a rollercoaster ride to induce a visual and vestibular challenge to postural stability. The VR-BESS significantly increased total errors (20.93 vs. 11.42, p < 0.05) and CoP velocity summed across all stances and surfaces (52.96 cm/s vs. 37.73 cm/s, p < 0.05) beyond the traditional BESS. The VR-BESS provides a standardized, and effective way to increase postural stability challenge in the clinical setting. The VR-BESS can use any smartphone technology to induce postural stability deficits that may otherwise normalize with traditional testing. Thus, providing a unique relatively inexpensive and simple to operate clinical assessment tool and∖or training stimulus. Copyright © 2018 Elsevier Ltd. All rights reserved.

Adverse Drug Events caused by Serious Medication Administration Errors

PubMed Central

Sawarkar, Abhivyakti; Keohane, Carol A.; Maviglia, Saverio; Gandhi, Tejal K; Poon, Eric G

2013-01-01

OBJECTIVE To determine how often serious or life-threatening medication administration errors with the potential to cause patient harm (or potential adverse drug events) result in actual patient harm (or adverse drug events (ADEs)) in the hospital setting. DESIGN Retrospective chart review of clinical events that transpired following observed medication administration errors. BACKGROUND Medication errors are common at the medication administration stage for hospitalized patients. While many of these errors are considered capable of causing patient harm, it is not clear how often patients are actually harmed by these errors. METHODS In a previous study where 14,041 medication administrations in an acute-care hospital were directly observed, investigators discovered 1271 medication administration errors, of which 133 had the potential to cause serious or life-threatening harm to patients and were considered serious or life-threatening potential ADEs. In the current study, clinical reviewers conducted detailed chart reviews of cases where a serious or life-threatening potential ADE occurred to determine if an actual ADE developed following the potential ADE. Reviewers further assessed the severity of the ADE and attribution to the administration error. RESULTS Ten (7.5% [95% C.I. 6.98, 8.01]) actual adverse drug events or ADEs resulted from the 133 serious and life-threatening potential ADEs, of which 6 resulted in significant, three in serious, and one life threatening injury. Therefore 4 (3% [95% C.I. 2.12, 3.6]) serious and life threatening potential ADEs led to serious or life threatening ADEs. Half of the ten actual ADEs were caused by dosage or monitoring errors for anti-hypertensives. The life threatening ADE was caused by an error that was both a transcription and a timing error. CONCLUSION Potential ADEs at the medication administration stage can cause serious patient harm. Given previous estimates of serious or life-threatening potential ADE of 1.33 per 100 medication doses administered, in a hospital where 6 million doses are administered per year, about 4000 preventable ADEs would be attributable to medication administration errors annually. PMID:22791691

Complex contexts and relationships affect clinical decisions in group therapy.

PubMed

Tasca, Giorgio A; Mcquaid, Nancy; Balfour, Louise

2016-09-01

Clinical errors tend to be underreported even though examining them can provide important training and professional development opportunities. The group therapy context may be prone to clinician errors because of the added complexity within which therapists work and patients receive treatment. We discuss clinical errors that occurred within a group therapy in which a patient for whom group was not appropriate was admitted to the treatment and then was not removed by the clinicians. This was countertherapeutic for both patient and group. Two clinicians were involved: a clinical supervisor who initially assessed and admitted the patient to the group, and a group therapist. To complicate matters, the group therapy occurred within the context of a clinical research trial. The errors, possible solutions, and recommendations are discussed within Reason's Organizational Accident Model (Reason, 2000). In particular, we discuss clinician errors in the context of countertransference and clinician heuristics, group therapy as a local work condition that complicates clinical decision-making, and the impact of the research context as a latent organizational factor. We also present clinical vignettes from the pregroup preparation, group therapy, and supervision. Group therapists are more likely to avoid errors in clinical decisions if they engage in reflective practice about their internal experiences and about the impact of the context in which they work. Therapists must keep in mind the various levels of group functioning, especially related to the group-as-a-whole (i.e., group composition, cohesion, group climate, and safety) when making complex clinical decisions in order to optimize patient outcomes. (PsycINFO Database Record (c) 2016 APA, all rights reserved).

An observational study of drug administration errors in a Malaysian hospital (study of drug administration errors).

PubMed

Chua, S S; Tea, M H; Rahman, M H A

2009-04-01

Drug administration errors were the second most frequent type of medication errors, after prescribing errors but the latter were often intercepted hence, administration errors were more probably to reach the patients. Therefore, this study was conducted to determine the frequency and types of drug administration errors in a Malaysian hospital ward. This is a prospective study that involved direct, undisguised observations of drug administrations in a hospital ward. A researcher was stationed in the ward under study for 15 days to observe all drug administrations which were recorded in a data collection form and then compared with the drugs prescribed for the patient. A total of 1118 opportunities for errors were observed and 127 administrations had errors. This gave an error rate of 11.4 % [95% confidence interval (CI) 9.5-13.3]. If incorrect time errors were excluded, the error rate reduced to 8.7% (95% CI 7.1-10.4). The most common types of drug administration errors were incorrect time (25.2%), followed by incorrect technique of administration (16.3%) and unauthorized drug errors (14.1%). In terms of clinical significance, 10.4% of the administration errors were considered as potentially life-threatening. Intravenous routes were more likely to be associated with an administration error than oral routes (21.3% vs. 7.9%, P < 0.001). The study indicates that the frequency of drug administration errors in developing countries such as Malaysia is similar to that in the developed countries. Incorrect time errors were also the most common type of drug administration errors. A non-punitive system of reporting medication errors should be established to encourage more information to be documented so that risk management protocol could be developed and implemented.

Effects of monetary reward and punishment on information checking behaviour.

PubMed

Li, Simon Y W; Cox, Anna L; Or, Calvin; Blandford, Ann

2016-03-01

Two experiments were conducted to examine whether checking one's own work can be motivated by monetary reward and punishment. Participants were randomly assigned to one of three conditions: a flat-rate payment for completing the task (Control); payment increased for error-free performance (Reward); payment decreased for error performance (Punishment). Experiment 1 (N = 90) was conducted with liberal arts students, using a general data-entry task. Experiment 2 (N = 90) replicated Experiment 1 with clinical students and a safety-critical 'cover story' for the task. In both studies, Reward and Punishment resulted in significantly fewer errors, more frequent and longer checking, than Control. No such differences were obtained between the Reward and Punishment conditions. It is concluded that error consequences in terms of monetary reward and punishment can result in more accurate task performance and more rigorous checking behaviour than errors without consequences. However, whether punishment is more effective than reward, or vice versa, remains inconclusive. Copyright © 2015 Elsevier Ltd and The Ergonomics Society. All rights reserved.

Preventability of early vs. late readmissions in an academic medical center

PubMed Central

Graham, Kelly L.; Dike, Ogechi; Doctoroff, Lauren; Jupiter, Marisa; Vanka, Anita

2017-01-01

Background It is unclear if the 30-day unplanned hospital readmission rate is a plausible accountability metric. Objective Compare preventability of hospital readmissions, between an early period [0–7 days post-discharge] and a late period [8–30 days post-discharge]. Compare causes of readmission, and frequency of markers of clinical instability 24h prior to discharge between early and late readmissions. Design, setting, patients 120 patient readmissions in an academic medical center between 1/1/2009-12/31/2010 Measures Sum-score based on a standard algorithm that assesses preventability of each readmission based on blinded hospitalist review; average causation score for seven types of adverse events; rates of markers of clinical instability within 24h prior to discharge. Results Readmissions were significantly more preventable in the early compared to the late period [median preventability sum score 8.5 vs. 8.0, p = 0.03]. There were significantly more management errors as causative events for the readmission in the early compared to the late period [mean causation score [scale 1–6, 6 most causal] 2.0 vs. 1.5, p = 0.04], and these errors were significantly more preventable in the early compared to the late period [mean preventability score 1.9 vs 1.5, p = 0.03]. Patients readmitted in the early period were significantly more likely to have mental status changes documented 24h prior to hospital discharge than patients readmitted in the late period [12% vs. 0%, p = 0.01]. Conclusions Readmissions occurring in the early period were significantly more preventable. Early readmissions were associated with more management errors, and mental status changes 24h prior to discharge. Seven-day readmissions may be a better accountability measure. PMID:28622384

Crystal Genetics, Inc.

PubMed

Kermani, Bahram G

2016-07-01

Crystal Genetics, Inc. is an early-stage genetic test company, focused on achieving the highest possible clinical-grade accuracy and comprehensiveness for detecting germline (e.g., in hereditary cancer) and somatic (e.g., in early cancer detection) mutations. Crystal's mission is to significantly improve the health status of the population, by providing high accuracy, comprehensive, flexible and affordable genetic tests, primarily in cancer. Crystal's philosophy is that when it comes to detecting mutations that are strongly correlated with life-threatening diseases, the detection accuracy of every single mutation counts: a single false-positive error could cause severe anxiety for the patient. And, more importantly, a single false-negative error could potentially cost the patient's life. Crystal's objective is to eliminate both of these error types.

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

PubMed

Carnes, Debra; Kilpatrick, Sue; Iedema, Rick

2015-12-01

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

Medical Errors and Barriers to Reporting in Ten Hospitals in Southern Iran

PubMed Central

Khammarnia, Mohammad; Ravangard, Ramin; Barfar, Eshagh; Setoodehzadeh, Fatemeh

2015-01-01

Background: International research shows that medical errors (MEs) are a major threat to patient safety. The present study aimed to describe MEs and barriers to reporting them in Shiraz public hospitals, Iran. Methods: A cross-sectional, retrospective study was conducted in 10 Shiraz public hospitals in the south of Iran, 2013. Using the standardised checklist of Shiraz University of Medical Sciences (referred to the Clinical Governance Department and recorded documentations) and Uribe questionnaire, we gathered the data in the hospitals. Results: A total of 4379 MEs were recorded in 10 hospitals. The highest frequency (27.1%) was related to systematic errors. Besides, most of the errors had occurred in the largest hospital (54.9%), internal wards (36.3%), and morning shifts (55.0%). The results revealed a significant association between the MEs and wards and hospitals (p < 0.001). Moreover, individual and organisational factors were the barriers to reporting ME in the studied hospitals. Also, a significant correlation was observed between the ME reporting barriers and the participants’ job experiences (p < 0.001). Conclusion: The medical errors were highly frequent in the studied hospitals especially in the larger hospitals, morning shift and in the nursing practice. Moreover, individual and organisational factors were considered as the barriers to reporting MEs. PMID:28729811

Adaptive control of theophylline therapy: importance of blood sampling times.

PubMed

D'Argenio, D Z; Khakmahd, K

1983-10-01

A two-observation protocol for estimating theophylline clearance during a constant-rate intravenous infusion is used to examine the importance of blood sampling schedules with regard to the information content of resulting concentration data. Guided by a theory for calculating maximally informative sample times, population simulations are used to assess the effect of specific sampling times on the precision of resulting clearance estimates and subsequent predictions of theophylline plasma concentrations. The simulations incorporated noise terms for intersubject variability, dosing errors, sample collection errors, and assay error. Clearance was estimated using Chiou's method, least squares, and a Bayesian estimation procedure. The results of these simulations suggest that clinically significant estimation and prediction errors may result when using the above two-point protocol for estimating theophylline clearance if the time separating the two blood samples is less than one population mean elimination half-life.

Using virtual reality to assess theory of mind subprocesses and error types in early and chronic schizophrenia.

PubMed

Canty, Allana L; Neumann, David L; Shum, David H K

2017-12-01

Individuals with schizophrenia often demonstrate theory of mind (ToM) impairment relative to healthy adults. However, the exact nature of this impairment (first- vs. second-order ToM and cognitive vs. affective ToM) and the extent to which ToM abilities deteriorate with illness chronicity is unclear. Furthermore, little is known about the relationships between clinical symptoms and ToM error types (overmentalising, reduced mentalising and no ToM) in early and chronic schizophrenia. This study examined the nature and types of ToM impairment in individuals with early ( n  = 26) and chronic schizophrenia ( n  = 32) using a novel virtual reality task. Clinical participants and demographically-matched controls were administered the Virtual Assessment of Mentalising Ability, which provides indices of first- and second-order cognitive and affective ToM, and quantifies three different types of mentalising errors (viz., overmentalising, reduced mentalising, and no ToM). Individuals with early schizophrenia performed significantly poorer than healthy controls on first-order affective and second-order cognitive and affective ToM, but significantly higher than individuals with chronic schizophrenia on all ToM subscales. Whereas a lack of mental state concept was associated with negative symptoms, overmentalising was associated with positive symptoms. These findings suggest that ToM abilities selectively deteriorate with illness chronicity and error types are related to these individuals' presenting symptomology. An implication of the findings is that social-cognitive interventions for schizophrenia need to consider the nature, time course and symptomatology of the presenting patient.

Simple prescribing errors and allergy documentation in medical hospital admissions in Australia and New Zealand.

PubMed

Barton, Lorna; Futtermenger, Judith; Gaddi, Yash; Kang, Angela; Rivers, Jon; Spriggs, David; Jenkins, Paul F; Thompson, Campbell H; Thomas, Josephine S

2012-04-01

This study aimed to quantify and compare the prevalence of simple prescribing errors made by clinicians in the first 24 hours of a general medical patient's hospital admission. Four public or private acute care hospitals across Australia and New Zealand each audited 200 patients' drug charts. Patient demographics, pharmacist review and pre-defined prescribing errors were recorded. At least one simple error was present on the medication charts of 672/715 patients, with a linear relationship between the number of medications prescribed and the number of errors (r = 0.571, p < 0.001). The four sites differed significantly in the prevalence of different types of simple prescribing errors. Pharmacists were more likely to review patients aged > or = 75 years (39.9% vs 26.0%; p < 0.001) and those with more than 10 drug prescriptions (39.4% vs 25.7%; p < 0.001). Patients reviewed by a pharmacist were less likely to have inadequate documentation of allergies (13.5% vs 29.4%, p < 0.001). Simple prescribing errors are common, although their nature differs from site to site. Clinical pharmacists target patients with the most complex health situations, and their involvement leads to improved documentation.

Students' self-explanations while solving unfamiliar cases: the role of biomedical knowledge.

PubMed

Chamberland, Martine; Mamede, Sílvia; St-Onge, Christina; Rivard, Marc-Antoine; Setrakian, Jean; Lévesque, Annie; Lanthier, Luc; Schmidt, Henk G; Rikers, Remy M J P

2013-11-01

General guidelines for teaching clinical reasoning have received much attention, despite a paucity of instructional approaches with demonstrated effectiveness. As suggested in a recent experimental study, self-explanation while solving clinical cases may be an effective strategy to foster reasoning in clinical clerks dealing with less familiar cases. However, the mechanisms that mediate this benefit have not been specifically investigated. The aim of this study was to explore the types of knowledge used by students when solving familiar and less familiar clinical cases with self-explanation. In a previous study, 36 third-year medical students diagnosed familiar and less familiar clinical cases either by engaging in self-explanation or not. Based on an analysis of previously collected data, the present study compared the content of self-explanation protocols generated by seven randomly selected students while solving four familiar and four less familiar cases. In total, 56 verbal protocols (28 familiar and 28 less familiar) were segmented and coded using the following categories: paraphrases, biomedical inferences, clinical inferences, monitoring statements and errors. Students provided more self-explanation segments from less familiar cases (M = 275.29) than from familiar cases (M = 248.71, p = 0.046). They provided significantly more paraphrases (p = 0.001) and made more errors (p = 0.008). A significant interaction was found between familiarity and the type of inferences (biomedical versus clinical, p = 0.016). When self-explaining less familiar cases, students provided significantly more biomedical inferences than familiar cases. Lack of familiarity with a case seems to stimulate medical students to engage in more extensive thinking during self-explanation. Less familiar cases seem to activate students' biomedical knowledge, which in turn helps them to create new links between biomedical and clinical knowledge, and eventually construct a more coherent mental representation of diseases. This may clarify the previously found positive effect that self-explanation has on the diagnosis of unfamiliar cases. © 2013 John Wiley & Sons Ltd.

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 children's emergency department was 15.7%, for outpatients was 21.5% and for discharge medication was 23.6%. Most errors were the result of an underdose (64%; 536/833). The computer calculated dose error rate was 12.6% compared with the traditional prescription error rate of 28.2%. Logistical regression analysis showed that computer calculated dose was an important and independent variable influencing the error rate (adjusted relative risk = 0.436, 95% CI 0.336, 0.520, p < 0.001). Other important independent variables were seniority and paediatric training of the person prescribing and the type of drug prescribed. Medication error, especially underdose, is common in outpatient, emergency department and discharge prescriptions. Computer calculated doses can significantly reduce errors, but other risk factors have to be concurrently addressed to achieve maximum benefit.

A five-year experience with throat cultures.

PubMed

Shank, J C; Powell, T A

1984-06-01

This study addresses the usefulness of the throat culture in a family practice residency setting and explores the following questions: (1) Do faculty physicians clinically identify streptococcal pharyngitis better than residents? (2) With time, will residents and faculty physicians improve in their diagnostic accuracy? (3) Should the throat culture be used always, selectively, or never? A total of 3,982 throat cultures were obtained over a five-year study period with 16 percent positive for beta-hemolytic streptococci. The results were compared with the physician's clinical diagnosis of either "nonstreptococcal" (category A) or "streptococcal" (category B). Within category A, 363 of 3,023 patients had positive cultures (12 percent clinical diagnostic error rate). Within category B, 665 of 959 patients had negative cultures (69 percent clinical diagnostic error rate). Faculty were significantly better than residents in diagnosing streptococcal pharyngitis, but not in diagnosing nonstreptococcal sore throats. Neither faculty nor residents improved their diagnostic accuracy over time. Regarding age-specific recommendations, the findings support utilizing a throat culture in all children aged 2 to 15 years with sore throat, but in adults only when the physician suspects streptococcal pharyngitis.

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

PubMed

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

2012-08-01

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

Nurses' behaviors and visual scanning patterns may reduce patient identification errors.

PubMed

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

2011-09-01

Patient identification (ID) errors occurring during the medication administration process can be fatal. The aim of this study is to determine whether differences in nurses' behaviors and visual scanning patterns during the medication administration process influence their capacities to identify patient ID errors. Nurse participants (n = 20) administered medications to 3 patients in a simulated clinical setting, with 1 patient having an embedded ID error. Error-identifying nurses tended to complete more process steps in a similar amount of time than non-error-identifying nurses and tended to scan information across artifacts (e.g., ID band, patient chart, medication label) rather than fixating on several pieces of information on a single artifact before fixating on another artifact. Non-error-indentifying nurses tended to increase their durations of off-topic conversations-a type of process interruption-over the course of the trials; the difference between groups was significant in the trial with the embedded ID error. Error-identifying nurses tended to have their most fixations in a row on the patient's chart, whereas non-error-identifying nurses did not tend to have a single artifact on which they consistently fixated. Finally, error-identifying nurses tended to have predictable eye fixation sequences across artifacts, whereas non-error-identifying nurses tended to have seemingly random eye fixation sequences. This finding has implications for nurse training and the design of tools and technologies that support nurses as they complete the medication administration process. (c) 2011 APA, all rights reserved.

Gesture production and comprehension in children with specific language impairment.

PubMed

Botting, Nicola; Riches, Nicholas; Gaynor, Marguerite; Morgan, Gary

2010-03-01

Children with specific language impairment (SLI) have difficulties with spoken language. However, some recent research suggests that these impairments reflect underlying cognitive limitations. Studying gesture may inform us clinically and theoretically about the nature of the association between language and cognition. A total of 20 children with SLI and 19 typically developing (TD) peers were assessed on a novel measure of gesture production. Children were also assessed for sentence comprehension errors in a speech-gesture integration task. Children with SLI performed equally to peers on gesture production but performed less well when comprehending integrated speech and gesture. Error patterns revealed a significant group interaction: children with SLI made more gesture-based errors, whilst TD children made semantically based ones. Children with SLI accessed and produced lexically encoded gestures despite having impaired spoken vocabulary and this group also showed stronger associations between gesture and language than TD children. When SLI comprehension breaks down, gesture may be relied on over speech, whilst TD children have a preference for spoken cues. The findings suggest that for children with SLI, gesture scaffolds are still more related to language development than for TD peers who have out-grown earlier reliance on gestures. Future clinical implications may include standardized assessment of symbolic gesture and classroom based gesture support for clinical groups.

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

PubMed

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

2015-02-01

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

In-hospital fellow coverage reduces communication errors in the surgical intensive care unit.

PubMed

Williams, Mallory; Alban, Rodrigo F; Hardy, James P; Oxman, David A; Garcia, Edward R; Hevelone, Nathanael; Frendl, Gyorgy; Rogers, Selwyn O

2014-06-01

Staff coverage strategies of intensive care units (ICUs) impact clinical outcomes. High-intensity staff coverage strategies are associated with lower morbidity and mortality. Accessible clinical expertise, team work, and effective communication have all been attributed to the success of this coverage strategy. We evaluate the impact of in-hospital fellow coverage (IHFC) on improving communication of cardiorespiratory events. A prospective observational study performed in an academic tertiary care center with high-intensity staff coverage. The main outcome measure was resident to fellow communication of cardiorespiratory events during IHFC vs home coverage (HC) periods. Three hundred twelve cardiorespiratory events were collected in 114 surgical ICU patients in 134 study days. Complete data were available for 306 events. One hundred three communication errors occurred. IHFC was associated with significantly better communication of events compared to HC (P<.0001). Residents communicated 89% of events during IHFC vs 51% of events during HC (P<.001). Communication patterns of junior and midlevel residents were similar. Midlevel residents communicated 68% of all on-call events (87% IHFC vs 50% HC, P<.001). Junior residents communicated 66% of events (94% IHFC vs 52% HC, P<.001). Communication errors were lower in all ICUs during IHFC (P<.001). IHFC reduced communication errors. Copyright © 2014 Elsevier Inc. All rights reserved.

The reliability and validity of a portfolio designed as a programmatic assessment of performance in an integrated clinical placement.

PubMed

Roberts, Chris; Shadbolt, Narelle; Clark, Tyler; Simpson, Phillip

2014-09-20

Little is known about the technical adequacy of portfolios in reporting multiple complex academic and performance-based assessments. We explored, first, the influencing factors on the precision of scoring within a programmatic assessment of student learning outcomes within an integrated clinical placement. Second, the degree to which validity evidence supported interpretation of student scores. Within generalisability theory, we estimated the contribution that each wanted factor (i.e. student capability) and unwanted factors (e.g. the impact of assessors) made to the variation in portfolio task scores. Relative and absolute standard errors of measurement provided a confidence interval around a pre-determined pass/fail standard for all six tasks. Validity evidence was sought through demonstrating the internal consistency of the portfolio and exploring the relationship of student scores with clinical experience. The mean portfolio mark for 257 students, across 372 raters, based on six tasks, was 75.56 (SD, 6.68). For a single student on one assessment task, 11% of the variance in scores was due to true differences in student capability. The most significant interaction was context specificity (49%), the tendency for one student to engage with one task and not engage with another task. Rater subjectivity was 29%. An absolute standard error of measurement of 4.74%, gave a 95% CI of +/- 9.30%, and a 68% CI of +/- 4.74% around a pass/fail score of 57%. Construct validity was supported by demonstration of an assessment framework, the internal consistency of the portfolio tasks, and higher scores for students who did the clinical placement later in the academic year. A portfolio designed as a programmatic assessment of an integrated clinical placement has sufficient evidence of validity to support a specific interpretation of student scores around passing a clinical placement. It has modest precision in assessing students' achievement of a competency standard. There were identifiable areas for reducing measurement error and providing more certainty around decision-making. Reducing the measurement error would require engaging with the student body on the value of the tasks, more focussed academic and clinical supervisor training, and revisiting the rubric of the assessment in the light of feedback.

TU-C-BRE-05: Clinical Implications of AAA Commissioning Errors and Ability of Common Commissioning ' Credentialing Procedures to Detect Them

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

McVicker, A; Oldham, M; Yin, F

2014-06-15

Purpose: To test the ability of the TG-119 commissioning process and RPC credentialing to detect errors in the commissioning process for a commercial Treatment Planning System (TPS). Methods: We introduced commissioning errors into the commissioning process for the Anisotropic Analytical Algorithm (AAA) within the Eclipse TPS. We included errors in Dosimetric Leaf Gap (DLG), electron contamination, flattening filter material, and beam profile measurement with an inappropriately large farmer chamber (simulated using sliding window smoothing of profiles). We then evaluated the clinical impact of these errors on clinical intensity modulated radiation therapy (IMRT) plans (head and neck, low and intermediate riskmore » prostate, mesothelioma, and scalp) by looking at PTV D99, and mean and max OAR dose. Finally, for errors with substantial clinical impact we determined sensitivity of the RPC IMRT film analysis at the midpoint between PTV and OAR using a 4mm distance to agreement metric, and of a 7% TLD dose comparison. We also determined sensitivity of the 3 dose planes of the TG-119 C-shape IMRT phantom using gamma criteria of 3% 3mm. Results: The largest clinical impact came from large changes in the DLG with a change of 1mm resulting in up to a 5% change in the primary PTV D99. This resulted in a discrepancy in the RPC TLDs in the PTVs and OARs of 7.1% and 13.6% respectively, which would have resulted in detection. While use of incorrect flattening filter caused only subtle errors (<1%) in clinical plans, the effect was most pronounced for the RPC TLDs in the OARs (>6%). Conclusion: The AAA commissioning process within the Eclipse TPS is surprisingly robust to user error. When errors do occur, the RPC and TG-119 commissioning credentialing criteria are effective at detecting them; however OAR TLDs are the most sensitive despite the RPC currently excluding them from analysis.« less

Emergency nurse practitioners: a three part study in clinical and cost effectiveness

PubMed Central

Sakr, M; Kendall, R; Angus, J; Saunders, A; Nicholl, J; Wardrope, J

2003-01-01

Aims: To compare the clinical effectiveness and costs of minor injury services provided by nurse practitioners with minor injury care provided by an accident and emergency (A&E) department. Methods: A three part prospective study in a city where an A&E department was closing and being replaced by a nurse led minor injury unit (MIU). The first part of the study took a sample of patients attending the A&E department. The second part of the study was a sample of patients from a nurse led MIU that had replaced the A&E department. In each of these samples the clinical effectiveness was judged by comparing the "gold standard" of a research assessment with the clinical assessment. Primary outcome measures were the number of errors in clinical assessment, treatment, and disposal. The third part of the study used routine data whose collection had been prospectively configured to assess the costs and cost consequences of both models of care. Results: The minor injury unit produced a safe service where the total package of care was equal to or in some cases better than the A&E care. Significant process errors were made in 191 of 1447 (13.2%) patients treated by medical staff in the A&E department and 126 of 1313 (9.6%) of patients treated by nurse practitioners in the MIU. Very significant errors were rare (one error). Waiting times were much better at the MIU (mean MIU 19 minutes, A&E department 56.4 minutes). The revenue costs were greater in the MIU (MIU £41.1, A&E department £40.01) and there was a great difference in the rates of follow up and with the nurses referring 47% of patients for follow up and the A&E department referring only 27%. Thus the costs and cost consequences were greater for MIU care compared with A&E care (MIU £12.7 per minor injury case, A&E department £9.66 per minor injury case). Conclusion: A nurse practitioner minor injury service can provide a safe and effective service for the treatment of minor injury. However, the costs of such a service are greater and there seems to be an increased use of outpatient services. PMID:12642530

Peptidic β-sheet binding with Congo Red allows both reduction of error variance and signal amplification for immunoassays.

PubMed

Wang, Yunyun; Liu, Ye; Deng, Xinli; Cong, Yulong; Jiang, Xingyu

2016-12-15

Although conventional enzyme-linked immunosorbent assays (ELISA) and related assays have been widely applied for the diagnosis of diseases, many of them suffer from large error variance for monitoring the concentration of targets over time, and insufficient limit of detection (LOD) for assaying dilute targets. We herein report a readout mode of ELISA based on the binding between peptidic β-sheet structure and Congo Red. The formation of peptidic β-sheet structure is triggered by alkaline phosphatase (ALP). For the detection of P-Selectin which is a crucial indicator for evaluating thrombus diseases in clinic, the 'β-sheet and Congo Red' mode significantly decreases both the error variance and the LOD (from 9.7ng/ml to 1.1 ng/ml) of detection, compared with commercial ELISA (an existing gold-standard method for detecting P-Selectin in clinic). Considering the wide range of ALP-based antibodies for immunoassays, such novel method could be applicable to the analysis of many types of targets. Copyright © 2016 Elsevier B.V. All rights reserved.

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.

A classification of errors in lay comprehension of medical documents.

PubMed

Keselman, Alla; Smith, Catherine Arnott

2012-12-01

Emphasis on participatory medicine requires that patients and consumers participate in tasks traditionally reserved for healthcare providers. This includes reading and comprehending medical documents, often but not necessarily in the context of interacting with Personal Health Records (PHRs). Research suggests that while giving patients access to medical documents has many benefits (e.g., improved patient-provider communication), lay people often have difficulty understanding medical information. Informatics can address the problem by developing tools that support comprehension; this requires in-depth understanding of the nature and causes of errors that lay people make when comprehending clinical documents. The objective of this study was to develop a classification scheme of comprehension errors, based on lay individuals' retellings of two documents containing clinical text: a description of a clinical trial and a typical office visit note. While not comprehensive, the scheme can serve as a foundation of further development of a taxonomy of patients' comprehension errors. Eighty participants, all healthy volunteers, read and retold two medical documents. A data-driven content analysis procedure was used to extract and classify retelling errors. The resulting hierarchical classification scheme contains nine categories and 23 subcategories. The most common error made by the participants involved incorrectly recalling brand names of medications. Other common errors included misunderstanding clinical concepts, misreporting the objective of a clinical research study and physician's findings during a patient's visit, and confusing and misspelling clinical terms. A combination of informatics support and health education is likely to improve the accuracy of lay comprehension of medical documents. Published by Elsevier Inc.

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

PubMed

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

2016-03-01

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

Frequency of dosage prescribing medication errors associated with manual prescriptions for very preterm infants.

PubMed

Horri, J; Cransac, A; Quantin, C; Abrahamowicz, M; Ferdynus, C; Sgro, C; Robillard, P-Y; Iacobelli, S; Gouyon, J-B

2014-12-01

The risk of dosage Prescription Medication Error (PME) among manually written prescriptions within 'mixed' prescribing system (computerized physician order entry (CPOE) + manual prescriptions) has not been previously assessed in neonatology. This study aimed to evaluate the rate of dosage PME related to manual prescriptions in the high-risk population of very preterm infants (GA < 33 weeks) in a mixed prescription system. The study was based on a retrospective review of a random sample of manual daily prescriptions in two neonatal intensive care units (NICU) A and B, located in different French University hospitals (Dijon and La Reunion island). Daily prescription was defined as the set of all drugs manually prescribed on a single day for one patient. Dosage error was defined as a deviation of at least ±10% from the weight-appropriate recommended dose. The analyses were based on the assessment of 676 manually prescribed drugs from NICU A (58 different drugs from 93 newborns and 240 daily prescriptions) and 354 manually prescribed drugs from NICU B (73 different drugs from 131 newborns and 241 daily prescriptions). The dosage error rate per 100 manually prescribed drugs was similar in both NICU: 3·8% (95% CI: 2·5-5·6%) in NICU A and 3·1% (95% CI: 1·6-5·5%) in NICU B (P = 0·54). Among all the 37 identified dosage errors, the over-dosing was almost as frequent as the under-dosing (17 and 20 errors, respectively). Potentially severe dosage errors occurred in a total of seven drug prescriptions. None of the dosage PME was recorded in the corresponding medical files and information on clinical outcome was not sufficient to identify clinical conditions related to dosage PME. Overall, 46·8% of manually prescribed drugs were off label or unlicensed, with no significant differences between prescriptions with or without dosage error. The risk of a dosage PME increased significantly if the drug was included in the CPOE system but was manually prescribed (OR = 3·3; 95% CI: 1·6-7·0, P < 0·001). The presence of dosage PME in the manual prescriptions written within mixed prescription systems suggests that manual prescriptions should be totally avoided in neonatal units. © 2014 John Wiley & Sons Ltd.

Design and Development of a Clinical Risk Management Tool Using Radio Frequency Identification (RFID)

PubMed Central

Pourasghar, Faramarz; Tabrizi, Jafar Sadegh; Yarifard, Khadijeh

2016-01-01

Background: Patient safety is one of the most important elements of quality of healthcare. It means preventing any harm to the patients during medical care process. Objective: This paper introduces a cost-effective tool in which the Radio Frequency Identification (RFID) technology is used to identify medical errors in hospital. Methods: The proposed clinical error management system (CEMS) is consisted of a reader device, a transfer/receiver device, a database and managing software. The reader device works using radio waves and is wireless. The reader sends and receives data to/from the database via the transfer/receiver device which is connected to the computer via USB port. The database contains data about patients’ medication orders. Results: The CEMS has the ability to identify the clinical errors before they occur and then warns the care-giver with voice and visual messages to prevent the error. This device reduces the errors and thus improves the patient safety. Conclusion: A new tool including software and hardware was developed in this study. Application of this tool in clinical settings can help the nurses prevent medical errors. It can also be a useful tool for clinical risk management. Using this device can improve the patient safety to a considerable extent and thus improve the quality of healthcare. PMID:27147802

Design and Development of a Clinical Risk Management Tool Using Radio Frequency Identification (RFID).

PubMed

Pourasghar, Faramarz; Tabrizi, Jafar Sadegh; Yarifard, Khadijeh

2016-04-01

Patient safety is one of the most important elements of quality of healthcare. It means preventing any harm to the patients during medical care process. This paper introduces a cost-effective tool in which the Radio Frequency Identification (RFID) technology is used to identify medical errors in hospital. The proposed clinical error management system (CEMS) is consisted of a reader device, a transfer/receiver device, a database and managing software. The reader device works using radio waves and is wireless. The reader sends and receives data to/from the database via the transfer/receiver device which is connected to the computer via USB port. The database contains data about patients' medication orders. The CEMS has the ability to identify the clinical errors before they occur and then warns the care-giver with voice and visual messages to prevent the error. This device reduces the errors and thus improves the patient safety. A new tool including software and hardware was developed in this study. Application of this tool in clinical settings can help the nurses prevent medical errors. It can also be a useful tool for clinical risk management. Using this device can improve the patient safety to a considerable extent and thus improve the quality of healthcare.

Impact of Extended-Duration Shifts on Medical Errors, Adverse Events, and Attentional Failures

PubMed Central

Barger, Laura K; Ayas, Najib T; Cade, Brian E; Cronin, John W; Rosner, Bernard; Speizer, Frank E; Czeisler, Charles A

2006-01-01

Background A recent randomized controlled trial in critical-care units revealed that the elimination of extended-duration work shifts (≥24 h) reduces the rates of significant medical errors and polysomnographically recorded attentional failures. This raised the concern that the extended-duration shifts commonly worked by interns may contribute to the risk of medical errors being made, and perhaps to the risk of adverse events more generally. Our current study assessed whether extended-duration shifts worked by interns are associated with significant medical errors, adverse events, and attentional failures in a diverse population of interns across the United States. Methods and Findings We conducted a Web-based survey, across the United States, in which 2,737 residents in their first postgraduate year (interns) completed 17,003 monthly reports. The association between the number of extended-duration shifts worked in the month and the reporting of significant medical errors, preventable adverse events, and attentional failures was assessed using a case-crossover analysis in which each intern acted as his/her own control. Compared to months in which no extended-duration shifts were worked, during months in which between one and four extended-duration shifts and five or more extended-duration shifts were worked, the odds ratios of reporting at least one fatigue-related significant medical error were 3.5 (95% confidence interval [CI], 3.3–3.7) and 7.5 (95% CI, 7.2–7.8), respectively. The respective odds ratios for fatigue-related preventable adverse events, 8.7 (95% CI, 3.4–22) and 7.0 (95% CI, 4.3–11), were also increased. Interns working five or more extended-duration shifts per month reported more attentional failures during lectures, rounds, and clinical activities, including surgery and reported 300% more fatigue-related preventable adverse events resulting in a fatality. Conclusions In our survey, extended-duration work shifts were associated with an increased risk of significant medical errors, adverse events, and attentional failures in interns across the United States. These results have important public policy implications for postgraduate medical education. PMID:17194188

Role of the pharmacist in reducing healthcare costs: current insights

PubMed Central

Dalton, Kieran; Byrne, Stephen

2017-01-01

Global healthcare expenditure is escalating at an unsustainable rate. Money spent on medicines and managing medication-related problems continues to grow. The high prevalence of medication errors and inappropriate prescribing is a major issue within healthcare systems, and can often contribute to adverse drug events, many of which are preventable. As a result, there is a huge opportunity for pharmacists to have a significant impact on reducing healthcare costs, as they have the expertise to detect, resolve, and prevent medication errors and medication-related problems. The development of clinical pharmacy practice in recent decades has resulted in an increased number of pharmacists working in clinically advanced roles worldwide. Pharmacist-provided services and clinical interventions have been shown to reduce the risk of potential adverse drug events and improve patient outcomes, and the majority of published studies show that these pharmacist activities are cost-effective or have a good cost:benefit ratio. This review demonstrates that pharmacists can contribute to substantial healthcare savings across a variety of settings. However, there is a paucity of evidence in the literature highlighting the specific aspects of pharmacists’ work which are the most effective and cost-effective. Future high-quality economic evaluations with robust methodologies and study design are required to investigate what pharmacist services have significant clinical benefits to patients and substantiate the greatest cost savings for healthcare budgets. PMID:29354549

[Clinical economics: a concept to optimize healthcare services].

PubMed

Porzsolt, F; Bauer, K; Henne-Bruns, D

2012-03-01

Clinical economics strives to support healthcare decisions by economic considerations. Making economic decisions does not mean saving costs but rather comparing the gained added value with the burden which has to be accepted. The necessary rules are offered in various disciplines, such as economy, epidemiology and ethics. Medical doctors have recognized these rules but are not applying them in daily clinical practice. This lacking orientation leads to preventable errors. Examples of these errors are shown for diagnosis, screening, prognosis and therapy. As these errors can be prevented by application of clinical economic principles the possible consequences for optimization of healthcare are discussed.

Effectiveness of screening aqueous contrast swallow in detecting clinically significant anastomotic leaks after esophagectomy.

PubMed

Tirnaksiz, M B; Deschamps, C; Allen, M S; Johnson, D C; Pairolero, P C

2005-01-01

Aqueous contrast swallow study is recommended as a screening procedure for the evaluation of esophageal anastomotic integrity following esophagectomy. The aim of this study was to assess the accuracy of water-soluble contrast swallow screening as a predictor of clinically significant anastomotic leak in patients with esophagectomy. The records of 505 consecutive patients undergoing esophagectomy in Mayo Clinic from January 1991 through December 1995 were retrospectively reviewed. 464 (92%) patients had water-soluble contrast swallows performed in the early postoperative period (median postoperative day 7, range 4-11 days). A total of 39 radiological leaks were obtained but only 17 of these had clinical signs of anastomotic leakage. Furthermore, 25 patients who had normal swallow study developed a clinical anastomotic leak. There were therefore 22 (4.7%) false positive and 25 (5.4%) false negative results giving values for the specificity, sensitivity and false negative error rate of the radiological examination of 94.7, 40.4, and 59.5% respectively. Aspiration of the contrast agent was noted on fluoroscopy in 30 (6.5%) patients. Only 2 (0.4%) patients developed aqueous contrast agent-caused aspiration pneumonia. There was no procedure-related mortality. While radiological assessment of esophageal anastomoses in the early postoperative period using aqueous contrast agents appears to be a relatively safe procedure, the poor sensitivity and high false negative error rate of this technique, when performed on postoperative day 7 and in a series with clinical anastomotic leak rate of 9%, is insufficient for it to be worthwhile as a screening procedure. Copyright (c) 2005 S. Karger AG, Basel.

Association between reading speed, cycloplegic refractive error, and oculomotor function in reading disabled children versus controls.

PubMed

Quaid, Patrick; Simpson, Trefford

2013-01-01

Approximately one in ten students aged 6 to 16 in Ontario (Canada) school boards have an individual education plan (IEP) in place due to various learning disabilities, many of which are specific to reading difficulties. The relationship between reading (specifically objectively determined reading speed and eye movement data), refractive error, and binocular vision related clinical measurements remain elusive. One hundred patients were examined in this study (50 IEP and 50 controls, age range 6 to 16 years). IEP patients were referred by three local school boards, with controls being recruited from the routine clinic population (non-IEP patients in the same age group). A comprehensive eye examination was performed on all subjects, in addition to a full binocular vision work-up and cycloplegic refraction. In addition to the cycloplegic refractive error, the following binocular vision related data was also acquired: vergence facility, vergence amplitudes, accommodative facility, accommodative amplitudes, near point of convergence, stereopsis, and a standardized symptom scoring scale. Both the IEP and control groups were also examined using the Visagraph III system, which permits recording of the following reading parameters objectively: (i) reading speed, both raw values and values compared to grade normative data, and (ii) the number of eye movements made per 100 words read. Comprehension was assessed via a questionnaire administered at the end of the reading task, with each subject requiring 80% or greater comprehension. The IEP group had significantly greater hyperopia compared to the control group on cycloplegic examination. Vergence facility was significantly correlated to (i) reading speed, (ii) number of eye movements made when reading, and (iii) a standardized symptom scoring system. Vergence facility was also significantly reduced in the IEP group versus controls. Significant differences in several other binocular vision related scores were also found. This research indicates there are significant associations between reading speed, refractive error, and in particular vergence facility. It appears sensible that students being considered for reading specific IEP status should have a full eye examination (including cycloplegia), in addition to a comprehensive binocular vision evaluation.

A preliminary taxonomy of medical errors in family practice

PubMed Central

Dovey, S; Meyers, D; Phillips, R; Green, L; Fryer, G; Galliher, J; Kappus, J; Grob, P

2002-01-01

Objective: To develop a preliminary taxonomy of primary care medical errors. Design: Qualitative analysis to identify categories of error reported during a randomized controlled trial of computer and paper reporting methods. Setting: The National Network for Family Practice and Primary Care Research. Participants: Family physicians. Main outcome measures: Medical error category, context, and consequence. Results: Forty two physicians made 344 reports: 284 (82.6%) arose from healthcare systems dysfunction; 46 (13.4%) were errors due to gaps in knowledge or skills; and 14 (4.1%) were reports of adverse events, not errors. The main subcategories were: administrative failures (102; 30.9% of errors), investigation failures (82; 24.8%), treatment delivery lapses (76; 23.0%), miscommunication (19; 5.8%), payment systems problems (4; 1.2%), error in the execution of a clinical task (19; 5.8%), wrong treatment decision (14; 4.2%), and wrong diagnosis (13; 3.9%). Most reports were of errors that were recognized and occurred in reporters' practices. Affected patients ranged in age from 8 months to 100 years, were of both sexes, and represented all major US ethnic groups. Almost half the reports were of events which had adverse consequences. Ten errors resulted in patients being admitted to hospital and one patient died. Conclusions: This medical error taxonomy, developed from self-reports of errors observed by family physicians during their routine clinical practice, emphasizes problems in healthcare processes and acknowledges medical errors arising from shortfalls in clinical knowledge and skills. Patient safety strategies with most effect in primary care settings need to be broader than the current focus on medication errors. PMID:12486987

A preliminary taxonomy of medical errors in family practice.

PubMed

Dovey, S M; Meyers, D S; Phillips, R L; Green, L A; Fryer, G E; Galliher, J M; Kappus, J; Grob, P

2002-09-01

To develop a preliminary taxonomy of primary care medical errors. Qualitative analysis to identify categories of error reported during a randomized controlled trial of computer and paper reporting methods. The National Network for Family Practice and Primary Care Research. Family physicians. Medical error category, context, and consequence. Forty two physicians made 344 reports: 284 (82.6%) arose from healthcare systems dysfunction; 46 (13.4%) were errors due to gaps in knowledge or skills; and 14 (4.1%) were reports of adverse events, not errors. The main subcategories were: administrative failure (102; 30.9% of errors), investigation failures (82; 24.8%), treatment delivery lapses (76; 23.0%), miscommunication (19; 5.8%), payment systems problems (4; 1.2%), error in the execution of a clinical task (19; 5.8%), wrong treatment decision (14; 4.2%), and wrong diagnosis (13; 3.9%). Most reports were of errors that were recognized and occurred in reporters' practices. Affected patients ranged in age from 8 months to 100 years, were of both sexes, and represented all major US ethnic groups. Almost half the reports were of events which had adverse consequences. Ten errors resulted in patients being admitted to hospital and one patient died. This medical error taxonomy, developed from self-reports of errors observed by family physicians during their routine clinical practice, emphasizes problems in healthcare processes and acknowledges medical errors arising from shortfalls in clinical knowledge and skills. Patient safety strategies with most effect in primary care settings need to be broader than the current focus on medication errors.

Frequency and Type of Situational Awareness Errors Contributing to Death and Brain Damage: A Closed Claims Analysis.

PubMed

Schulz, Christian M; Burden, Amanda; Posner, Karen L; Mincer, Shawn L; Steadman, Randolph; Wagner, Klaus J; Domino, Karen B

2017-08-01

Situational awareness errors may play an important role in the genesis of patient harm. The authors examined closed anesthesia malpractice claims for death or brain damage to determine the frequency and type of situational awareness errors. Surgical and procedural anesthesia death and brain damage claims in the Anesthesia Closed Claims Project database were analyzed. Situational awareness error was defined as failure to perceive relevant clinical information, failure to comprehend the meaning of available information, or failure to project, anticipate, or plan. Patient and case characteristics, primary damaging events, and anesthesia payments in claims with situational awareness errors were compared to other death and brain damage claims from 2002 to 2013. Anesthesiologist situational awareness errors contributed to death or brain damage in 198 of 266 claims (74%). Respiratory system damaging events were more common in claims with situational awareness errors (56%) than other claims (21%, P < 0.001). The most common specific respiratory events in error claims were inadequate oxygenation or ventilation (24%), difficult intubation (11%), and aspiration (10%). Payments were made in 85% of situational awareness error claims compared to 46% in other claims (P = 0.001), with no significant difference in payment size. Among 198 claims with anesthesia situational awareness error, perception errors were most common (42%), whereas comprehension errors (29%) and projection errors (29%) were relatively less common. Situational awareness error definitions were operationalized for reliable application to real-world anesthesia cases. Situational awareness errors may have contributed to catastrophic outcomes in three quarters of recent anesthesia malpractice claims.Situational awareness errors resulting in death or brain damage remain prevalent causes of malpractice claims in the 21st century.

Racial Variations in the Prevalence of Refractive Errors in the United States: The Multi-Ethnic Study of Atherosclerosis

PubMed Central

PAN, CHEN-WEI; KLEIN, BARBARA E.K.; COTCH, MARY FRANCES; SHRAGER, SANDI; KLEIN, RONALD; FOLSOM, AARON; KRONMAL, RICHARD; SHEA, STEVEN J.; BURKE, GREGORY L.; SAW, SEANG-MEI; WONG, TIEN Y.

2013-01-01

PURPOSE To describe racial variations in the prevalence of refractive errors among adult white, Chinese, Hispanic, and black subjects in the United States. DESIGN Cross-sectional data from a prospective cohort study—the Multi-Ethnic Study of Atherosclerosis (MESA). METHODS A total of 6000 adults aged 45 to 84 years living in the United States participated in the study. Refractive error was assessed, without cycloplegia, in both eyes of all participants using an autorefractor. After excluding eyes with cataract, cataract surgery, or previous refractive surgery, the eye with the larger absolute spherical equivalent (SE) value for each participant was used to classify refractive error. Any myopia was defined as SE of −1.0 diopters (D) or less; high myopia was defined as SE of −5.0 D or less; any hyperopia was defined as SE of +1.0 D or more; clinically significant hyperopia was defined as SE of +3.0 D or more. Astigmatism was defined as a cylinder value of +1.0 D or more. RESULTS After excluding 508 participants with cataracts in both eyes, 838 participants with cataract surgery, 90 participants with laser refractive surgery, and 134 participants who refused to remove their contact lenses for the refraction measurement, 4430 adults with refractive error assessment in at least 1 eye contributed to the analysis. The prevalence of myopia among MESA participants was 25.1%, with lowest rates in Hispanic participants (14.2%), followed by black (21.5%) and white participants (31.0%), and highest rates in Chinese participants (37.2%). The overall rates of high myopia and astigmatism were 4.6% and 45.0%, respectively, with Chinese subjects also having the highest rates of high myopia (11.8%) and astigmatism (53.4%). The overall prevalence of any hyperopia was 38.2% and clinically significant hyperopia was 6.1%, with Hispanic participants having the highest rates of hyperopia (50.2%) and clinically significant hyperopia (8.8%). In multivariate analyses adjusting for age, sex, race, and study site, higher education level, being employed, and being taller were associated with a higher prevalence of myopia. In contrast, lower educational level and being shorter were associated with a higher prevalence of hyperopia. CONCLUSIONS Myopia and astigmatism were most prevalent in the Chinese population, with Chinese subjects having 3 times the prevalence of myopia as Hispanic subjects. Hyperopia was most common in Hispanic subjects. These findings provide further insights into variations in refractive errors among different racial groups and have important implications for the eye care services in the United States. PMID:23453694

Racial variations in the prevalence of refractive errors in the United States: the multi-ethnic study of atherosclerosis.

PubMed

Pan, Chen-Wei; Klein, Barbara E K; Cotch, Mary Frances; Shrager, Sandi; Klein, Ronald; Folsom, Aaron; Kronmal, Richard; Shea, Steven J; Burke, Gregory L; Saw, Seang-Mei; Wong, Tien Y

2013-06-01

To describe racial variations in the prevalence of refractive errors among adult white, Chinese, Hispanic, and black subjects in the United States. Cross-sectional data from a prospective cohort study-the Multi-Ethnic Study of Atherosclerosis (MESA). A total of 6000 adults aged 45 to 84 years living in the United States participated in the study. Refractive error was assessed, without cycloplegia, in both eyes of all participants using an autorefractor. After excluding eyes with cataract, cataract surgery, or previous refractive surgery, the eye with the larger absolute spherical equivalent (SE) value for each participant was used to classify refractive error. Any myopia was defined as SE of -1.0 diopters (D) or less; high myopia was defined as SE of -5.0 D or less; any hyperopia was defined as SE of +1.0 D or more; clinically significant hyperopia was defined as SE of +3.0 D or more. Astigmatism was defined as a cylinder value of +1.0 D or more. After excluding 508 participants with cataracts in both eyes, 838 participants with cataract surgery, 90 participants with laser refractive surgery, and 134 participants who refused to remove their contact lenses for the refraction measurement, 4430 adults with refractive error assessment in at least 1 eye contributed to the analysis. The prevalence of myopia among MESA participants was 25.1%, with lowest rates in Hispanic participants (14.2%), followed by black (21.5%) and white participants (31.0%), and highest rates in Chinese participants (37.2%). The overall rates of high myopia and astigmatism were 4.6% and 45.0%, respectively, with Chinese subjects also having the highest rates of high myopia (11.8%) and astigmatism (53.4%). The overall prevalence of any hyperopia was 38.2% and clinically significant hyperopia was 6.1%, with Hispanic participants having the highest rates of hyperopia (50.2%) and clinically significant hyperopia (8.8%). In multivariate analyses adjusting for age, sex, race, and study site, higher education level, being employed, and being taller were associated with a higher prevalence of myopia. In contrast, lower educational level and being shorter were associated with a higher prevalence of hyperopia. Myopia and astigmatism were most prevalent in the Chinese population, with Chinese subjects having 3 times the prevalence of myopia as Hispanic subjects. Hyperopia was most common in Hispanic subjects. These findings provide further insights into variations in refractive errors among different racial groups and have important implications for the eye care services in the United States. Copyright © 2013 Elsevier Inc. All rights reserved.

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

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.

Ametropias in school-age children in Fada N'Gourma (Burkina Faso, Africa).

PubMed

Jiménez, Raimundo; Soler, Margarita; Anera, Rosario G; Castro, José J; Pérez, M Angustias; Salas, Carlos

2012-01-01

To assess epidemiological aspects of refractive errors in school-age children in Burkina Faso (west-central Africa). A total of 315 school children (ranging from 6 to 16 years of age and belonging to different ethnic groups) taken at random from two urban schools in eastern Burkina Faso were examined to assess their refractive error, which was determined by non-cycloplegic retinoscopy with optical fogging. The standard Refractive Error Study in Children (RESC) definitions of refractive errors were used: myopia ≤-0.5 D spherical equivalent (SE) in at least one eye, hyperopia ≥2 D SE in at least one eye, astigmatism ≤-0.75 D cylinder in at least one eye, and anisometropia ≥1 D SE difference between the two eyes. Unilateral myopia and bilateral myopia were found in 2.5 and 1%, respectively; unilateral hyperopia in 17.1%, bilateral hyperopia in 8.6%; astigmatism in at least one eye in 11.7%. The highest prevalence value (18.4%) of astigmatism (≤-0.75 D) in at least one eye was found in the Gourmantché ethnic group. The low prevalence of large refractive errors makes visual acuity in these children very good (visual acuity logarithm of the minimum angle of resolution -0.073 ± 0.123 SD). There was a low prevalence of myopia in these African school children. Clinically significant high hyperopia (≥+2 D SE) was also uncommon. There were no significant differences between the distributions of refractive errors according to gender or ethnicity. With respect to age groups, the prevalences of hyperopia and astigmatism were significantly higher in the younger age groups.

[Evaluation of accuracy of virtual occlusal definition in Angle class I molar relationship].

PubMed

Wu, L; Liu, X J; Li, Z L; Wang, X

2018-02-18

To evaluate the accuracy of virtual occlusal definition in non-Angle class I molar relationship, and to evaluate the clinical feasibility. Twenty pairs of models of orthognathic patients were included in this study. The inclusion criteria were: (1) finished with pre-surgical orthodontic treatment and (2) stable final occlusion. The exclusion criteria were: (1) existence of distorted teeth, (2) needs for segmentation, (3) defect of dentition except for orthodontic extraction ones, and (4) existence of tooth space. The tooth-extracted test group included 10 models with two premolars extracted during preoperative orthodontic treatment. Their molar relationships were not Angle class I relationship. The non-tooth-extracted test group included another 10 models without teeth extracted, therefore their molar relationships were Angle class I. To define the final occlusion in virtual environment, two steps were included: (1) The morphology data of upper and lower dentition were digitalized by surface scanner (Smart Optics/Activity 102; Model-Tray GmbH, Hamburg, Germany); (2) the virtual relationships were defined using 3Shape software. The control standard of final occlusion was manually defined using gypsum models and then digitalized by surface scanner. The final occlusion of test group and control standard were overlapped according to lower dentition morphology. Errors were evaluated by calculating the distance between the corresponding reference points of testing group and control standard locations. The overall errors for upper dentition between test group and control standard location were (0.51±0.18) mm in non-tooth-extracted test group and (0.60±0.36) mm in tooth-extracted test group. The errors were significantly different between these two test groups (P<0.05). However, in both test groups, the errors of each tooth in a single dentition does not differ from one another. There was no significant difference between errors in tooth-extracted test group and 1 mm (P>0.05); and the accuracy of non-tooth-extracted group was significantly smaller than 1 mm (P<0.05). The error of virtual occlusal definition of none class I molar relationship is higher than that of class I relationship, with an accuracy of 1 mm. However, its accuracy is still feasible for clinical application.

Hospital medication errors in a pharmacovigilance system in Colombia.

PubMed

Machado Alba, Jorge Enrique; Moreno Gutiérrez, Paula Andrea; Moncada Escobar, Juan Carlos

2015-11-01

this study analyzes the medication errors reported to a pharmacovigilance system by 26 hospitals for patients in the healthcare system of Colombia. this retrospective study analyzed the medication errors reported to a systematized database between 1 January 2008 and 12 September 2013. The medication is dispensed by the company Audifarma S.A. to hospitals and clinics around Colombia. Data were classified according to the taxonomy of the National Coordinating Council for Medication Error Reporting and Prevention (NCC MERP). The data analysis was performed using SPSS 22.0 for Windows, considering p-values < 0.05 significant. there were 9 062 medication errors in 45 hospital pharmacies. Real errors accounted for 51.9% (n = 4 707), of which 12.0% (n = 567) reached the patient (Categories C to I) and caused harm (Categories E to I) to 17 subjects (0.36%). The main process involved in errors that occurred (categories B to I) was prescription (n = 1 758, 37.3%), followed by dispensation (n = 1 737, 36.9%), transcription (n = 970, 20.6%) and administration (n = 242, 5.1%). The errors in the administration process were 45.2 times more likely to reach the patient (CI 95%: 20.2-100.9). medication error reporting systems and prevention strategies should be widespread in hospital settings, prioritizing efforts to address the administration process. Copyright AULA MEDICA EDICIONES 2014. Published by AULA MEDICA. All rights reserved.

Evaluation of robotic training forces that either enhance or reduce error in chronic hemiparetic stroke survivors.

PubMed

Patton, James L; Stoykov, Mary Ellen; Kovic, Mark; Mussa-Ivaldi, Ferdinando A

2006-01-01

This investigation is one in a series of studies that address the possibility of stroke rehabilitation using robotic devices to facilitate "adaptive training." Healthy subjects, after training in the presence of systematically applied forces, typically exhibit a predictable "after-effect." A critical question is whether this adaptive characteristic is preserved following stroke so that it might be exploited for restoring function. Another important question is whether subjects benefit more from training forces that enhance their errors than from forces that reduce their errors. We exposed hemiparetic stroke survivors and healthy age-matched controls to a pattern of disturbing forces that have been found by previous studies to induce a dramatic adaptation in healthy individuals. Eighteen stroke survivors made 834 movements in the presence of a robot-generated force field that pushed their hands proportional to its speed and perpendicular to its direction of motion--either clockwise or counterclockwise. We found that subjects could adapt, as evidenced by significant after-effects. After-effects were not correlated with the clinical scores that we used for measuring motor impairment. Further examination revealed that significant improvements occurred only when the training forces magnified the original errors, and not when the training forces reduced the errors or were zero. Within this constrained experimental task we found that error-enhancing therapy (as opposed to guiding the limb closer to the correct path) to be more effective than therapy that assisted the subject.

Assessment of Grating Acuity in Infants and Toddlers Using an Electronic Acuity Card: The Dobson Card.

PubMed

Mohan, Kathleen M; Miller, Joseph M; Harvey, Erin M; Gerhart, Kimberly D; Apple, Howard P; Apple, Deborah; Smith, Jordana M; Davis, Amy L; Leonard-Green, Tina; Campus, Irene; Dennis, Leslie K

2016-01-01

To determine if testing binocular visual acuity in infants and toddlers using the Acuity Card Procedure (ACP) with electronic grating stimuli yields clinically useful data. Participants were infants and toddlers ages 5 to 36.7 months referred by pediatricians due to failed automated vision screening. The ACP was used to test binocular grating acuity. Stimuli were presented on the Dobson Card. The Dobson Card consists of a handheld matte-black plexiglass frame with two flush-mounted tablet computers and is similar in size and form to commercially available printed grating acuity testing stimuli (Teller Acuity Cards II [TACII]; Stereo Optical, Inc., Chicago, IL). On each trial, one tablet displayed a square-wave grating and the other displayed a luminance-matched uniform gray patch. Stimuli were roughly equivalent to the stimuli available in the printed TACII stimuli. After acuity testing, each child received a cycloplegic eye examination. Based on cycloplegic retinoscopy, patients were categorized as having high or low refractive error per American Association for Pediatric Ophthalmology and Strabismus vision screening referral criteria. Mean acuities for high and low refractive error groups were compared using analysis of covariance, controlling for age. Mean visual acuity was significantly poorer in children with high refractive error than in those with low refractive error (P = .015). Electronic stimuli presented using the ACP can yield clinically useful measurements of grating acuity in infants and toddlers. Further research is needed to determine the optimal conditions and procedures for obtaining accurate and clinically useful automated measurements of visual acuity in infants and toddlers. Copyright 2016, SLACK Incorporated.

Goldmann tonometer error correcting prism: clinical evaluation.

PubMed

McCafferty, Sean; Lim, Garrett; Duncan, William; Enikov, Eniko T; Schwiegerling, Jim; Levine, Jason; Kew, Corin

2017-01-01

Clinically evaluate a modified applanating surface Goldmann tonometer prism designed to substantially negate errors due to patient variability in biomechanics. A modified Goldmann prism with a correcting applanation tonometry surface (CATS) was mathematically optimized to minimize the intraocular pressure (IOP) measurement error due to patient variability in corneal thickness, stiffness, curvature, and tear film adhesion force. A comparative clinical study of 109 eyes measured IOP with CATS and Goldmann prisms. The IOP measurement differences between the CATS and Goldmann prisms were correlated to corneal thickness, hysteresis, and curvature. The CATS tonometer prism in correcting for Goldmann central corneal thickness (CCT) error demonstrated a reduction to <±2 mmHg in 97% of a standard CCT population. This compares to only 54% with CCT error <±2 mmHg using the Goldmann prism. Equal reductions of ~50% in errors due to corneal rigidity and curvature were also demonstrated. The results validate the CATS prism's improved accuracy and expected reduced sensitivity to Goldmann errors without IOP bias as predicted by mathematical modeling. The CATS replacement for the Goldmann prism does not change Goldmann measurement technique or interpretation.

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.

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

Fuangrod, T; Simpson, J; Greer, P

Purpose: A real-time patient treatment delivery verification system using EPID (Watchdog) has been developed as an advanced patient safety tool. In a pilot study data was acquired for 119 prostate and head and neck (HN) IMRT patient deliveries to generate body-site specific action limits using statistical process control. The purpose of this study is to determine the sensitivity of Watchdog to detect clinically significant errors during treatment delivery. Methods: Watchdog utilizes a physics-based model to generate a series of predicted transit cine EPID images as a reference data set, and compares these in real-time to measured transit cine-EPID images acquiredmore » during treatment using chi comparison (4%, 4mm criteria) after the initial 2s of treatment to allow for dose ramp-up. Four study cases were used; dosimetric (monitor unit) errors in prostate (7 fields) and HN (9 fields) IMRT treatments of (5%, 7%, 10%) and positioning (systematic displacement) errors in the same treatments of (5mm, 7mm, 10mm). These errors were introduced by modifying the patient CT scan and re-calculating the predicted EPID data set. The error embedded predicted EPID data sets were compared to the measured EPID data acquired during patient treatment. The treatment delivery percentage (measured from 2s) where Watchdog detected the error was determined. Results: Watchdog detected all simulated errors for all fields during delivery. The dosimetric errors were detected at average treatment delivery percentage of (4%, 0%, 0%) and (7%, 0%, 0%) for prostate and HN respectively. For patient positional errors, the average treatment delivery percentage was (52%, 43%, 25%) and (39%, 16%, 6%). Conclusion: These results suggest that Watchdog can detect significant dosimetric and positioning errors in prostate and HN IMRT treatments in real-time allowing for treatment interruption. Displacements of the patient require longer to detect however incorrect body site or very large geographic misses will be detected rapidly.« less

Refractive errors among children, adolescents and adults attending eye clinics in Mexico.

PubMed

Gomez-Salazar, Francisco; Campos-Romero, Abraham; Gomez-Campaña, Humberto; Cruz-Zamudio, Cinthia; Chaidez-Felix, Mariano; Leon-Sicairos, Nidia; Velazquez-Roman, Jorge; Flores-Villaseñor, Hector; Muro-Amador, Secundino; Guadron-Llanos, Alma Marlene; Martinez-Garcia, Javier J; Murillo-Llanes, Joel; Sanchez-Cuen, Jaime; Llausas-Vargas, Alejando; Alapizco-Castro, Gerardo; Irineo-Cabrales, Ana; Graue-Hernandez, Enrique; Ramirez-Luquin, Tito; Canizalez-Roman, Adrian

2017-01-01

To assess the proportion of refractive errors in the Mexican population that visited primary care optometry clinics in fourteen states of Mexico. Refractive data from 676 856 patients aged 6 to 90y were collected from optometry clinics in fourteen states of Mexico between 2014 and 2015. The refractive errors were classified by the spherical equivalent (SE), as follows: sphere+½ cylinder. Myopia (SE>-0.50 D), hyperopia (SE>+0.50 D), emmetropia (-0.50≤SE≤+0.50), and astigmatism alone (cylinder≥-0.25 D). A negative cylinder was selected as a notation. The proportion (95% confidence interval) among all of the subjects was hyperopia 21.0% (20.9-21.0), emmetropia 40.7% (40.5-40.8), myopia 24.8% (24.7-24.9) and astigmatism alone 13.5% (13.4-13.5). Myopia was the most common refractive error and frequency seemed to increase among the young population (10 to 29 years old), however, hyperopia increased among the aging population (40 to 79 years old), and astigmatism alone showed a decreasing trend with age (6 to 90y; from 19.7% to 10.8%). There was a relationship between age and all refractive errors (approximately 60%, aged 50 and older). The proportion of any clinically important refractive error was higher in males (61.2%) than in females (58.3%; P <0.0001). From fourteen states that collected information, the proportion of refractive error showed variability in different geographical areas of Mexico. Myopia is the most common refractive error in the population studied. This study provides the first data on refractive error in Mexico. Further programs and studies must be developed to address the refractive errors needs of the Mexican population.

Refractive errors among children, adolescents and adults attending eye clinics in Mexico

PubMed Central

Gomez-Salazar, Francisco; Campos-Romero, Abraham; Gomez-Campaña, Humberto; Cruz-Zamudio, Cinthia; Chaidez-Felix, Mariano; Leon-Sicairos, Nidia; Velazquez-Roman, Jorge; Flores-Villaseñor, Hector; Muro-Amador, Secundino; Guadron-Llanos, Alma Marlene; Martinez-Garcia, Javier J.; Murillo-Llanes, Joel; Sanchez-Cuen, Jaime; Llausas-Vargas, Alejando; Alapizco-Castro, Gerardo; Irineo-Cabrales, Ana; Graue-Hernandez, Enrique; Ramirez-Luquin, Tito; Canizalez-Roman, Adrian

2017-01-01

AIM To assess the proportion of refractive errors in the Mexican population that visited primary care optometry clinics in fourteen states of Mexico. METHODS Refractive data from 676 856 patients aged 6 to 90y were collected from optometry clinics in fourteen states of Mexico between 2014 and 2015. The refractive errors were classified by the spherical equivalent (SE), as follows: sphere+½ cylinder. Myopia (SE>-0.50 D), hyperopia (SE>+0.50 D), emmetropia (-0.50≤SE≤+0.50), and astigmatism alone (cylinder≥-0.25 D). A negative cylinder was selected as a notation. RESULTS The proportion (95% confidence interval) among all of the subjects was hyperopia 21.0% (20.9-21.0), emmetropia 40.7% (40.5-40.8), myopia 24.8% (24.7-24.9) and astigmatism alone 13.5% (13.4-13.5). Myopia was the most common refractive error and frequency seemed to increase among the young population (10 to 29 years old), however, hyperopia increased among the aging population (40 to 79 years old), and astigmatism alone showed a decreasing trend with age (6 to 90y; from 19.7% to 10.8%). There was a relationship between age and all refractive errors (approximately 60%, aged 50 and older). The proportion of any clinically important refractive error was higher in males (61.2%) than in females (58.3%; P<0.0001). From fourteen states that collected information, the proportion of refractive error showed variability in different geographical areas of Mexico. CONCLUSION Myopia is the most common refractive error in the population studied. This study provides the first data on refractive error in Mexico. Further programs and studies must be developed to address the refractive errors needs of the Mexican population. PMID:28546940

The 3 faces of clinical reasoning: Epistemological explorations of disparate error reduction strategies.

PubMed

Monteiro, Sandra; Norman, Geoff; Sherbino, Jonathan

2018-06-01

There is general consensus that clinical reasoning involves 2 stages: a rapid stage where 1 or more diagnostic hypotheses are advanced and a slower stage where these hypotheses are tested or confirmed. The rapid hypothesis generation stage is considered inaccessible for analysis or observation. Consequently, recent research on clinical reasoning has focused specifically on improving the accuracy of the slower, hypothesis confirmation stage. Three perspectives have developed in this line of research, and each proposes different error reduction strategies for clinical reasoning. This paper considers these 3 perspectives and examines the underlying assumptions. Additionally, this paper reviews the evidence, or lack of, behind each class of error reduction strategies. The first perspective takes an epidemiological stance, appealing to the benefits of incorporating population data and evidence-based medicine in every day clinical reasoning. The second builds on the heuristic and bias research programme, appealing to a special class of dual process reasoning models that theorizes a rapid error prone cognitive process for problem solving with a slower more logical cognitive process capable of correcting those errors. Finally, the third perspective borrows from an exemplar model of categorization that explicitly relates clinical knowledge and experience to diagnostic accuracy. © 2018 John Wiley & Sons, Ltd.

A Retrospective Survey of Research Design and Statistical Analyses in Selected Chinese Medical Journals in 1998 and 2008

PubMed Central

Jin, Zhichao; Yu, Danghui; Zhang, Luoman; Meng, Hong; Lu, Jian; Gao, Qingbin; Cao, Yang; Ma, Xiuqiang; Wu, Cheng; He, Qian; Wang, Rui; He, Jia

2010-01-01

Background High quality clinical research not only requires advanced professional knowledge, but also needs sound study design and correct statistical analyses. The number of clinical research articles published in Chinese medical journals has increased immensely in the past decade, but study design quality and statistical analyses have remained suboptimal. The aim of this investigation was to gather evidence on the quality of study design and statistical analyses in clinical researches conducted in China for the first decade of the new millennium. Methodology/Principal Findings Ten (10) leading Chinese medical journals were selected and all original articles published in 1998 (N = 1,335) and 2008 (N = 1,578) were thoroughly categorized and reviewed. A well-defined and validated checklist on study design, statistical analyses, results presentation, and interpretation was used for review and evaluation. Main outcomes were the frequencies of different types of study design, error/defect proportion in design and statistical analyses, and implementation of CONSORT in randomized clinical trials. From 1998 to 2008: The error/defect proportion in statistical analyses decreased significantly ( = 12.03, p<0.001), 59.8% (545/1,335) in 1998 compared to 52.2% (664/1,578) in 2008. The overall error/defect proportion of study design also decreased ( = 21.22, p<0.001), 50.9% (680/1,335) compared to 42.40% (669/1,578). In 2008, design with randomized clinical trials remained low in single digit (3.8%, 60/1,578) with two-third showed poor results reporting (defects in 44 papers, 73.3%). Nearly half of the published studies were retrospective in nature, 49.3% (658/1,335) in 1998 compared to 48.2% (761/1,578) in 2008. Decreases in defect proportions were observed in both results presentation ( = 93.26, p<0.001), 92.7% (945/1,019) compared to 78.2% (1023/1,309) and interpretation ( = 27.26, p<0.001), 9.7% (99/1,019) compared to 4.3% (56/1,309), some serious ones persisted. Conclusions/Significance Chinese medical research seems to have made significant progress regarding statistical analyses, but there remains ample room for improvement regarding study designs. Retrospective clinical studies are the most often used design, whereas randomized clinical trials are rare and often show methodological weaknesses. Urgent implementation of the CONSORT statement is imperative. PMID:20520824

An evaluation of clinical treatment of convergence insufficiency for children with reading difficulties.

PubMed

Dusek, Wolfgang A; Pierscionek, Barbara K; McClelland, Julie F

2011-08-11

The present study investigates two different treatment options for convergence insufficiency CI for a group of children with reading difficulties referred by educational institutes to a specialist eye clinic in Vienna. One hundred and thirty four subjects (aged 7-14 years) with reading difficulties were referred from an educational institute in Vienna, Austria for visual assessment. Each child was given either 8Δ base-in reading spectacles (n=51) or computerised home vision therapy (HTS) (n=51). Thirty two participants refused all treatment offered (clinical control group). A full visual assessment including reading speed and accuracy were conducted pre- and post-treatment. Factorial analyses demonstrated statistically significant changes between results obtained for visits 1 and 2 for total reading time, reading error score, amplitude of accommodation and binocular accommodative facility (within subjects effects) (p<0.05). Significant differences were also demonstrated between treatment groups for total reading time, reading error score and binocular accommodative facility (between subjects effects) (p<0.05). Reading difficulties with no apparent intellectual or psychological foundation may be due to a binocular vision anomaly such as convergence insufficiency. Both the HTS and prismatic correction are highly effective treatment options for convergence insufficiency. Prismatic correction can be considered an effective alternative to HTS.

The detection of problem analytes in a single proficiency test challenge in the absence of the Health Care Financing Administration rule violations.

PubMed

Cembrowski, G S; Hackney, J R; Carey, N

1993-04-01

The Clinical Laboratory Improvement Act of 1988 (CLIA 88) has dramatically changed proficiency testing (PT) practices having mandated (1) satisfactory PT for certain analytes as a condition of laboratory operation, (2) fixed PT limits for many of these "regulated" analytes, and (3) an increased number of PT specimens (n = 5) for each testing cycle. For many of these analytes, the fixed limits are much broader than the previously employed Standard Deviation Index (SDI) criteria. Paradoxically, there may be less incentive to identify and evaluate analytically significant outliers to improve the analytical process. Previously described "control rules" to evaluate these PT results are unworkable as they consider only two or three results. We used Monte Carlo simulations of Kodak Ektachem analyzers participating in PT to determine optimal control rules for the identification of PT results that are inconsistent with those from other laboratories using the same methods. The analysis of three representative analytes, potassium, creatine kinase, and iron was simulated with varying intrainstrument and interinstrument standard deviations (si and sg, respectively) obtained from the College of American Pathologists (Northfield, Ill) Quality Assurance Services data and Proficiency Test data, respectively. Analytical errors were simulated in each of the analytes and evaluated in terms of multiples of the interlaboratory SDI. Simple control rules for detecting systematic and random error were evaluated with power function graphs, graphs of probability of error detected vs magnitude of error. Based on the simulation results, we recommend screening all analytes for the occurrence of two or more observations exceeding the same +/- 1 SDI limit. For any analyte satisfying this condition, the mean of the observations should be calculated. For analytes with sg/si ratios between 1.0 and 1.5, a significant systematic error is signaled by the mean exceeding 1.0 SDI. Significant random error is signaled by one observation exceeding the +/- 3-SDI limit or the range of the observations exceeding 4 SDIs. For analytes with higher sg/si, significant systematic or random error is signaled by violation of the screening rule (having at least two observations exceeding the same +/- 1 SDI limit). Random error can also be signaled by one observation exceeding the +/- 1.5-SDI limit or the range of the observations exceeding 3 SDIs. We present a practical approach to the workup of apparent PT errors.

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 calculation skills. Of the 33 studies reviewed only five articles specifically recorded information relating to calculation errors and only two of these detected errors using the direct observational approach. The literature suggests that there are other more pressing aspects of nurses' preparation and administration of medications which are contributing to medication errors in practice that require more urgent attention and calls into question the current focus on calculation and numeracy skills of pre registration and qualified nurses (NMC 2008). However, more research is required into the calculation errors in practice. In particular there is a need for a direct observational study on paediatric nurses as there are presently none examining this area of practice.

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

PubMed

Kunac, Desireé L; Tatley, Michael V

2011-01-01

Despite the traditional focus being adverse drug reactions (ADRs), pharmacovigilance centres have recently been identified as a potentially rich and important source of medication error data. To identify medication errors in the New Zealand Pharmacovigilance database (Centre for Adverse Reactions Monitoring [CARM]), and to describe the frequency and characteristics of these events. A retrospective analysis of the CARM pharmacovigilance database operated by the New Zealand Pharmacovigilance Centre was undertaken for the year 1 January-31 December 2007. All reports, excluding those relating to vaccines, clinical trials and pharmaceutical company reports, underwent a preventability assessment using predetermined criteria. Those events deemed preventable were subsequently classified to identify the degree of patient harm, type of error, stage of medication use process where the error occurred and origin of the error. A total of 1412 reports met the inclusion criteria and were reviewed, of which 4.3% (61/1412) were deemed preventable. Not all errors resulted in patient harm: 29.5% (18/61) were 'no harm' errors but 65.5% (40/61) of errors were deemed to have been associated with some degree of patient harm (preventable adverse drug events [ADEs]). For 5.0% (3/61) of events, the degree of patient harm was unable to be determined as the patient outcome was unknown. The majority of preventable ADEs (62.5% [25/40]) occurred in adults aged 65 years and older. The medication classes most involved in preventable ADEs were antibacterials for systemic use and anti-inflammatory agents, with gastrointestinal and respiratory system disorders the most common adverse events reported. For both preventable ADEs and 'no harm' events, most errors were incorrect dose and drug therapy monitoring problems consisting of failures in detection of significant drug interactions, past allergies or lack of necessary clinical monitoring. Preventable events were mostly related to the prescribing and administration stages of the medication use process, with the majority of errors 82.0% (50/61) deemed to have originated in the community setting. The CARM pharmacovigilance database includes medication errors, many of which were found to originate in the community setting and reported as ADRs. Error-prone situations were able to be identified, providing greater opportunity to improve patient safety. However, to enhance detection of medication errors by pharmacovigilance centres, reports should be prospectively reviewed for preventability and the reporting form revised to facilitate capture of important information that will provide meaningful insight into the nature of the underlying systems defects that caused the error.

Development of a scale of executive functioning for the RBANS.

PubMed

Spencer, Robert J; Kitchen Andren, Katherine A; Tolle, Kathryn A

2018-01-01

The Repeatable Battery for the Assessment of Neuropsychological Status (RBANS) is a cognitive battery that contains scales of several cognitive abilities, but no scale in the instrument is exclusively dedicated to executive functioning. Although the subtests allow for observation of executive-type errors, each error is of fairly low base rate, and healthy and clinical normative data are lacking on the frequency of these types of errors, making their significance difficult to interpret in isolation. The aim of this project was to create an RBANS executive errors scale (RBANS EE) with items comprised of qualitatively dysexecutive errors committed throughout the test. Participants included Veterans referred for outpatient neuropsychological testing. Items were initially selected based on theoretical literature and were retained based on item-total correlations. The RBANS EE (a percentage calculated by dividing the number of dysexecutive errors by the total number of responses) was moderately related to each of seven established measures of executive functioning and was strongly predictive of dichotomous classification of executive impairment. Thus, the scale had solid concurrent validity, justifying its use as a supplementary scale. The RBANS EE requires no additional administration time and can provide a quantified measure of otherwise unmeasured aspects of executive functioning.

Dual-energy X-ray absorptiometry: analysis of pediatric fat estimate errors due to tissue hydration effects.

PubMed

Testolin, C G; Gore, R; Rivkin, T; Horlick, M; Arbo, J; Wang, Z; Chiumello, G; Heymsfield, S B

2000-12-01

Dual-energy X-ray absorptiometry (DXA) percent (%) fat estimates may be inaccurate in young children, who typically have high tissue hydration levels. This study was designed to provide a comprehensive analysis of pediatric tissue hydration effects on DXA %fat estimates. Phase 1 was experimental and included three in vitro studies to establish the physical basis of DXA %fat-estimation models. Phase 2 extended phase 1 models and consisted of theoretical calculations to estimate the %fat errors emanating from previously reported pediatric hydration effects. Phase 1 experiments supported the two-compartment DXA soft tissue model and established that pixel ratio of low to high energy (R values) are a predictable function of tissue elemental content. In phase 2, modeling of reference body composition values from birth to age 120 mo revealed that %fat errors will arise if a "constant" adult lean soft tissue R value is applied to the pediatric population; the maximum %fat error, approximately 0.8%, would be present at birth. High tissue hydration, as observed in infants and young children, leads to errors in DXA %fat estimates. The magnitude of these errors based on theoretical calculations is small and may not be of clinical or research significance.

Correlation of clinical predictions and surgical results in maxillary superior repositioning.

PubMed

Tabrizi, Reza; Zamiri, Barbad; Kazemi, Hamidreza

2014-05-01

This is a prospective study to evaluate the accuracy of clinical predictions related to surgical results in subjects who underwent maxillary superior repositioning without anterior-posterior movement. Surgeons' predictions according to clinical (tooth show at rest and at the maximum smile) and cephalometric evaluation were documented for the amount of maxillary superior repositioning. Overcorrection or undercorrection was documented for every subject 1 year after the operations. Receiver operating characteristic curve test was used to find a cutoff point in prediction errors and to determine positive predictive value (PPV) and negative predictive value. Forty subjects (14 males and 26 females) were studied. Results showed a significant difference between changes in the tooth show at rest and at the maximum smile line before and after surgery. Analysis of the data demonstrated no correlation between the predictive data and the surgical results. The incidence of undercorrection (25%) was more common than overcorrection (7.5%). The cutoff point for errors in predictions was 5 mm for tooth show at rest and 15 mm at the maximum smile. When the amount of the presurgical tooth show at rest was more than 5 mm, 50.5% of clinical predictions did not match the clinical results (PPV), and 75% of clinical predictions showed the same results when the tooth show was less than 5 mm (negative predictive value). When the amount of presurgical tooth shown in the maximum smile line was more than 15 mm, 75% of clinical predictions did not match with clinical results (PPV), and 25% of the predictions had the same results because the tooth show at the maximum smile was lower than 15 mm. Clinical predictions according to the tooth show at rest and at the maximum smile have a poor correlation with clinical results in maxillary superior repositioning for vertical maxillary excess. The risk of errors in predictions increased when the amount of superior repositioning of the maxilla increased. Generally, surgeons have a tendency to undercorrect rather than overcorrect, although clinical prediction is an original guideline for surgeons, and it may be associated with variable clinical results.

[Second wave of the French drug harmonisation programme to prevent medication errors: overall appreciation of healthcare professionals].

PubMed

Benhamou, D; Nacry, R; Journois, D; Auroy, Y; Durand, D; Arnoux, A; Olier, L; Castot, A

2012-01-01

Medication errors are a significant cause of severe healthcare-associated complications. In December 2006, the French Health Products Agency (Afssaps) has issued a protocol to harmonise labeling of injectable drugs vials. In 2007, a first change was launched for four drugs and was followed in 2008-2009 by a second wave concerning 42 active drugs. The present study describes how healthcare professionals have perceived this change and their overall appreciation of the drug harmonisation programme. A survey using an electronic questionnaire was distributed to medical and non-medical professionals in anaesthesia and intensive care and pharmacists in a representative sample of 200 French hospitals. The harmonisation procedure was felt as being overall satisfactory by 53% of professionals who had responded but it was recognised that the new procedure is associated with improved readability and understanding of drug dosage. The use of colour coding was also well accepted by the personnel of clinical units. Respondents expressed significant criticisms regarding both the communication plan and the way the plan was implemented locally in hospitals. Old and new labeling coexisted in 66% of responding hospitals and many respondents described being aware of errors or near-misses that were considered related to the transition. For many important topics, pharmacists had views that were significantly different from clinicians. This national survey describing the perception of healthcare professionals regarding the new harmonisation procedure for injectable drugs highlighted some progress but also a number of deficiencies, notably regarding communication and implementation of the change in clinical units. This survey will be used by the French Health Products Agency to improve future steps of the long-lasting campaign against medication errors. Copyright © 2011 Société française d’anesthésie et de réanimation (Sfar). Published by Elsevier SAS. All rights reserved.

Clinical Dental Faculty Members' Perceptions of Diagnostic Errors and How to Avoid Them.

PubMed

Nikdel, Cathy; Nikdel, Kian; Ibarra-Noriega, Ana; Kalenderian, Elsbeth; Walji, Muhammad F

2018-04-01

Diagnostic errors are increasingly recognized as a source of preventable harm in medicine, yet little is known about their occurrence in dentistry. The aim of this study was to gain a deeper understanding of clinical dental faculty members' perceptions of diagnostic errors, types of errors that may occur, and possible contributing factors. The authors conducted semi-structured interviews with ten domain experts at one U.S. dental school in May-August 2016 about their perceptions of diagnostic errors and their causes. The interviews were analyzed using an inductive process to identify themes and key findings. The results showed that the participants varied in their definitions of diagnostic errors. While all identified missed diagnosis and wrong diagnosis, only four participants perceived that a delay in diagnosis was a diagnostic error. Some participants perceived that an error occurs only when the choice of treatment leads to harm. Contributing factors associated with diagnostic errors included the knowledge and skills of the dentist, not taking adequate time, lack of communication among colleagues, and cognitive biases such as premature closure based on previous experience. Strategies suggested by the participants to prevent these errors were taking adequate time when investigating a case, forming study groups, increasing communication, and putting more emphasis on differential diagnosis. These interviews revealed differing perceptions of dental diagnostic errors among clinical dental faculty members. To address the variations, the authors recommend adopting shared language developed by the medical profession to increase understanding.

The development and validation of the clinicians' awareness towards cognitive errors (CATChES) in clinical decision making questionnaire tool.

PubMed

Chew, Keng Sheng; Kueh, Yee Cheng; Abdul Aziz, Adlihafizi

2017-03-21

Despite their importance on diagnostic accuracy, there is a paucity of literature on questionnaire tools to assess clinicians' awareness toward cognitive errors. A validation study was conducted to develop a questionnaire tool to evaluate the Clinician's Awareness Towards Cognitive Errors (CATChES) in clinical decision making. This questionnaire is divided into two parts. Part A is to evaluate the clinicians' awareness towards cognitive errors in clinical decision making while Part B is to evaluate their perception towards specific cognitive errors. Content validation for both parts was first determined followed by construct validation for Part A. Construct validation for Part B was not determined as the responses were set in a dichotomous format. For content validation, all items in both Part A and Part B were rated as "excellent" in terms of their relevance in clinical settings. For construct validation using exploratory factor analysis (EFA) for Part A, a two-factor model with total variance extraction of 60% was determined. Two items were deleted. Then, the EFA was repeated showing that all factor loadings are above the cut-off value of >0.5. The Cronbach's alpha for both factors are above 0.6. The CATChES questionnaire tool is a valid questionnaire tool aimed to evaluate the awareness among clinicians toward cognitive errors in clinical decision making.

Trueness verification of actual creatinine assays in the European market demonstrates a disappointing variability that needs substantial improvement. An international study in the framework of the EC4 creatinine standardization working group.

PubMed

Delanghe, Joris R; Cobbaert, Christa; Galteau, Marie-Madeleine; Harmoinen, Aimo; Jansen, Rob; Kruse, Rolf; Laitinen, Päivi; Thienpont, Linda M; Wuyts, Birgitte; Weykamp, Cas; Panteghini, Mauro

2008-01-01

The European In Vitro Diagnostics (IVD) directive requires traceability to reference methods and materials of analytes. It is a task of the profession to verify the trueness of results and IVD compatibility. The results of a trueness verification study by the European Communities Confederation of Clinical Chemistry (EC4) working group on creatinine standardization are described, in which 189 European laboratories analyzed serum creatinine in a commutable serum-based material, using analytical systems from seven companies. Values were targeted using isotope dilution gas chromatography/mass spectrometry. Results were tested on their compliance to a set of three criteria: trueness, i.e., no significant bias relative to the target value, between-laboratory variation and within-laboratory variation relative to the maximum allowable error. For the lower and intermediate level, values differed significantly from the target value in the Jaffe and the dry chemistry methods. At the high level, dry chemistry yielded higher results. Between-laboratory coefficients of variation ranged from 4.37% to 8.74%. Total error budget was mainly consumed by the bias. Non-compensated Jaffe methods largely exceeded the total error budget. Best results were obtained for the enzymatic method. The dry chemistry method consumed a large part of its error budget due to calibration bias. Despite the European IVD directive and the growing needs for creatinine standardization, an unacceptable inter-laboratory variation was observed, which was mainly due to calibration differences. The calibration variation has major clinical consequences, in particular in pediatrics, where reference ranges for serum and plasma creatinine are low, and in the estimation of glomerular filtration rate.

Ultralow dose dentomaxillofacial CT imaging and iterative reconstruction techniques: variability of Hounsfield units and contrast-to-noise ratio

PubMed Central

Bischel, Alexander; Stratis, Andreas; Kakar, Apoorv; Bosmans, Hilde; Jacobs, Reinhilde; Gassner, Eva-Maria; Puelacher, Wolfgang; Pauwels, Ruben

2016-01-01

Objective: The aim of this study was to evaluate whether application of ultralow dose protocols and iterative reconstruction technology (IRT) influence quantitative Hounsfield units (HUs) and contrast-to-noise ratio (CNR) in dentomaxillofacial CT imaging. Methods: A phantom with inserts of five types of materials was scanned using protocols for (a) a clinical reference for navigated surgery (CT dose index volume 36.58 mGy), (b) low-dose sinus imaging (18.28 mGy) and (c) four ultralow dose imaging (4.14, 2.63, 0.99 and 0.53 mGy). All images were reconstructed using: (i) filtered back projection (FBP); (ii) IRT: adaptive statistical iterative reconstruction-50 (ASIR-50), ASIR-100 and model-based iterative reconstruction (MBIR); and (iii) standard (std) and bone kernel. Mean HU, CNR and average HU error after recalibration were determined. Each combination of protocols was compared using Friedman analysis of variance, followed by Dunn's multiple comparison test. Results: Pearson's sample correlation coefficients were all >0.99. Ultralow dose protocols using FBP showed errors of up to 273 HU. Std kernels had less HU variability than bone kernels. MBIR reduced the error value for the lowest dose protocol to 138 HU and retained the highest relative CNR. ASIR could not demonstrate significant advantages over FBP. Conclusions: Considering a potential dose reduction as low as 1.5% of a std protocol, ultralow dose protocols and IRT should be further tested for clinical dentomaxillofacial CT imaging. Advances in knowledge: HU as a surrogate for bone density may vary significantly in CT ultralow dose imaging. However, use of std kernels and MBIR technology reduce HU error values and may retain the highest CNR. PMID:26859336

A national physician survey of diagnostic error in paediatrics.

PubMed

Perrem, Lucy M; Fanshawe, Thomas R; Sharif, Farhana; Plüddemann, Annette; O'Neill, Michael B

2016-10-01

This cross-sectional survey explored paediatric physician perspectives regarding diagnostic errors. All paediatric consultants and specialist registrars in Ireland were invited to participate in this anonymous online survey. The response rate for the study was 54 % (n = 127). Respondents had a median of 9-year clinical experience (interquartile range (IQR) 4-20 years). A diagnostic error was reported at least monthly by 19 (15.0 %) respondents. Consultants reported significantly less diagnostic errors compared to trainees (p value = 0.01). Cognitive error was the top-ranked contributing factor to diagnostic error, with incomplete history and examination considered to be the principal cognitive error. Seeking a second opinion and close follow-up of patients to ensure that the diagnosis is correct were the highest-ranked, clinician-based solutions to diagnostic error. Inadequate staffing levels and excessive workload were the most highly ranked system-related and situational factors. Increased access to and availability of consultants and experts was the most highly ranked system-based solution to diagnostic error. We found a low level of self-perceived diagnostic error in an experienced group of paediatricians, at variance with the literature and warranting further clarification. The results identify perceptions on the major cognitive, system-related and situational factors contributing to diagnostic error and also key preventative strategies. • Diagnostic errors are an important source of preventable patient harm and have an estimated incidence of 10-15 %. • They are multifactorial in origin and include cognitive, system-related and situational factors. What is New: • We identified a low rate of self-perceived diagnostic error in contrast to the existing literature. • Incomplete history and examination, inadequate staffing levels and excessive workload are cited as the principal contributing factors to diagnostic error in this study.

The relationship between somatic and cognitive-affective depression symptoms and error-related ERP’s

PubMed Central

Bridwell, David A.; Steele, Vaughn R.; Maurer, J. Michael; Kiehl, Kent A.; Calhoun, Vince D.

2014-01-01

Background The symptoms that contribute to the clinical diagnosis of depression likely emerge from, or are related to, underlying cognitive deficits. To understand this relationship further, we examined the relationship between self-reported somatic and cognitive-affective Beck’s Depression Inventory-II (BDI-II) symptoms and aspects of cognitive control reflected in error event-related potential (ERP) responses. Methods Task and assessment data were analyzed within 51 individuals. The group contained a broad distribution of depressive symptoms, as assessed by BDI-II scores. ERP’s were collected following error responses within a go/no-go task. Individual error ERP amplitudes were estimated by conducting group independent component analysis (ICA) on the electroencephalographic (EEG) time series and analyzing the individual reconstructed source epochs. Source error amplitudes were correlated with the subset of BDI-II scores representing somatic and cognitive-affective symptoms. Results We demonstrate a negative relationship between somatic depression symptoms (i.e. fatigue or loss of energy) (after regressing out cognitive-affective scores, age and IQ) and the central-parietal ERP response that peaks at 359 ms. The peak amplitudes within this ERP response were not significantly related to cognitive-affective symptom severity (after regressing out the somatic symptom scores, age, and IQ). Limitations These findings were obtained within a population of female adults from a maximum-security correctional facility. Thus, additional research is required to verify that they generalize to the broad population. Conclusions These results suggest that individuals with greater somatic depression symptoms demonstrate a reduced awareness of behavioral errors, and help clarify the relationship between clinical measures of self-reported depression symptoms and cognitive control. PMID:25451400

The relationship between somatic and cognitive-affective depression symptoms and error-related ERPs.

PubMed

Bridwell, David A; Steele, Vaughn R; Maurer, J Michael; Kiehl, Kent A; Calhoun, Vince D

2015-02-01

The symptoms that contribute to the clinical diagnosis of depression likely emerge from, or are related to, underlying cognitive deficits. To understand this relationship further, we examined the relationship between self-reported somatic and cognitive-affective Beck'sDepression Inventory-II (BDI-II) symptoms and aspects of cognitive control reflected in error event-related potential (ERP) responses. Task and assessment data were analyzed within 51 individuals. The group contained a broad distribution of depressive symptoms, as assessed by BDI-II scores. ERPs were collected following error responses within a go/no-go task. Individual error ERP amplitudes were estimated by conducting group independent component analysis (ICA) on the electroencephalographic (EEG) time series and analyzing the individual reconstructed source epochs. Source error amplitudes were correlated with the subset of BDI-II scores representing somatic and cognitive-affective symptoms. We demonstrate a negative relationship between somatic depression symptoms (i.e. fatigue or loss of energy) (after regressing out cognitive-affective scores, age and IQ) and the central-parietal ERP response that peaks at 359 ms. The peak amplitudes within this ERP response were not significantly related to cognitive-affective symptom severity (after regressing out the somatic symptom scores, age, and IQ). These findings were obtained within a population of female adults from a maximum-security correctional facility. Thus, additional research is required to verify that they generalize to the broad population. These results suggest that individuals with greater somatic depression symptoms demonstrate a reduced awareness of behavioral errors, and help clarify the relationship between clinical measures of self-reported depression symptoms and cognitive control. Copyright © 2014 Elsevier B.V. All rights reserved.

Who Do Hospital Physicians and Nurses Go to for Advice About Medications? A Social Network Analysis and Examination of Prescribing Error Rates.

PubMed

Creswick, Nerida; Westbrook, Johanna Irene

2015-09-01

To measure the weekly medication advice-seeking networks of hospital staff, to compare patterns across professional groups, and to examine these in the context of prescribing error rates. A social network analysis was conducted. All 101 staff in 2 wards in a large, academic teaching hospital in Sydney, Australia, were surveyed (response rate, 90%) using a detailed social network questionnaire. The extent of weekly medication advice seeking was measured by density of connections, proportion of reciprocal relationships by reciprocity, number of colleagues to whom each person provided advice by in-degree, and perceptions of amount and impact of advice seeking between physicians and nurses. Data on prescribing error rates from the 2 wards were compared. Weekly medication advice-seeking networks were sparse (density: 7% ward A and 12% ward B). Information sharing across professional groups was modest, and rates of reciprocation of advice were low (9% ward A, 14% ward B). Pharmacists provided advice to most people, and junior physicians also played central roles. Senior physicians provided medication advice to few people. Many staff perceived that physicians rarely sought advice from nurses when prescribing, but almost all believed that an increase in communication between physicians and nurses about medications would improve patient safety. The medication networks in ward B had higher measures for density, reciprocation, and fewer senior physicians who were isolates. Ward B had a significantly lower rate of both procedural and clinical prescribing errors than ward A (0.63 clinical prescribing errors per admission [95%CI, 0.47-0.79] versus 1.81/ admission [95%CI, 1.49-2.13]). Medication advice-seeking networks among staff on hospital wards are limited. Hubs of advice provision include pharmacists, junior physicians, and senior nurses. Senior physicians are poorly integrated into medication advice networks. Strategies to improve the advice-giving networks between senior and junior physicians may be a fruitful area for intervention to improve medication safety. We found that one ward with stronger networks also had a significantly lower prescribing error rate, suggesting a promising area for further investigation.

eDrugCalc: an online self-assessment package to enhance medical students' drug dose calculation skills.

PubMed

McQueen, Daniel S; Begg, Michael J; Maxwell, Simon R J

2010-10-01

Dose calculation errors can cause serious life-threatening clinical incidents. We designed eDrugCalc as an online self-assessment tool to develop and evaluate calculation skills among medical students. We undertook a prospective uncontrolled study involving 1727 medical students in years 1-5 at the University of Edinburgh. Students had continuous access to eDrugCalc and were encouraged to practise. Voluntary self-assessment was undertaken by answering the 20 questions on six occasions over 30 months. Questions remained fixed but numerical variables changed so each visit required a fresh calculation. Feedback was provided following each answer. Final-year students had a significantly higher mean score in test 6 compared with test 1 [16.6, 95% confidence interval (CI) 16.2, 17.0 vs. 12.6, 95% CI 11.9, 13.4; n= 173, P < 0.0001 Wilcoxon matched pairs test] and made a median of three vs. seven errors. Performance was highly variable in all tests with 2.7% of final-year students scoring < 10/20 in test 6. Graduating students in 2009 (30 months' exposure) achieved significantly better scores than those in 2007 (only 6 months): mean 16.5, 95% CI 16.0, 17.0, n= 184 vs. 15.1, 95% CI 14.5, 15.6, n= 187; P < 0.0001, Mann-Whitney test. Calculations based on percentage concentrations and infusion rates were poorly performed. Feedback showed that eDrugCalc increased confidence in calculating doses and was highly rated as a learning tool. Medical student performance of dose calculations improved significantly after repeated exposure to an online formative dose-calculation package and encouragement to develop their numeracy. Further research is required to establish whether eDrugCalc reduces calculation errors made in clinical practice. © 2010 The Authors. British Journal of Clinical Pharmacology © 2010 The British Pharmacological Society.

Systematic changes in position sense accompany normal aging across adulthood.

PubMed

Herter, Troy M; Scott, Stephen H; Dukelow, Sean P

2014-03-25

Development of clinical neurological assessments aimed at separating normal from abnormal capabilities requires a comprehensive understanding of how basic neurological functions change (or do not change) with increasing age across adulthood. In the case of proprioception, the research literature has failed to conclusively determine whether or not position sense in the upper limb deteriorates in elderly individuals. The present study was conducted a) to quantify whether upper limb position sense deteriorates with increasing age, and b) to generate a set of normative data that can be used for future comparisons with clinical populations. We examined position sense in 209 healthy males and females between the ages of 18 and 90 using a robotic arm position-matching task that is both objective and reliable. In this task, the robot moved an arm to one of nine positions and subjects attempted to mirror-match that position with the opposite limb. Measures of position sense were recorded by the robotic apparatus in hand-and joint-based coordinates, and linear regressions were used to quantify age-related changes and percentile boundaries of normal behaviour. For clinical comparisons, we also examined influences of sex (male versus female) and test-hand (dominant versus non-dominant) on all measures of position sense. Analyses of hand-based parameters identified several measures of position sense (Variability, Shift, Spatial Contraction, Absolute Error) with significant effects of age, sex, and test-hand. Joint-based parameters at the shoulder (Absolute Error) and elbow (Variability, Shift, Absolute Error) also exhibited significant effects of age and test-hand. The present study provides strong evidence that several measures of upper extremity position sense exhibit declines with age. Furthermore, this data provides a basis for quantifying when changes in position sense are related to normal aging or alternatively, pathology.

Erring and learning in clinical practice.

PubMed Central

Hurwitz, Brian

2002-01-01

This paper discusses error type their possible consequences and the doctors who make them. There is no single, all-encompassing typology of medical errors. They are frequently multifactorial in origin and use from the mental processes of individuals; from defects in perception, thinking reasoning planning and interpretation and from failures of team-working omissions and poorly executed actions. They also arise from inadequately designed and operated healthcare systems or procedures. The paper considers error-truth relatedness, the approach of UK courts to medical errors, the learning opportunities which flow from error recognition and the need for personal and professional self awareness of clinical fallibilities. PMID:12389767

The effect of toe marker placement error on joint kinematics and muscle forces using OpenSim gait simulation.

PubMed

Xu, Hang; Merryweather, Andrew; Bloswick, Donald; Mao, Qi; Wang, Tong

2015-01-01

Marker placement can be a significant source of error in biomechanical studies of human movement. The toe marker placement error is amplified by footwear since the toe marker placement on the shoe only relies on an approximation of underlying anatomical landmarks. Three total knee replacement subjects were recruited and three self-speed gait trials per subject were collected. The height variation between toe and heel markers of four types of footwear was evaluated from the results of joint kinematics and muscle forces using OpenSim. The reference condition was considered as the same vertical height of toe and heel markers. The results showed that the residual variances for joint kinematics had an approximately linear relationship with toe marker placement error for lower limb joints. Ankle dorsiflexion/plantarflexion is most sensitive to toe marker placement error. The influence of toe marker placement error is generally larger for hip flexion/extension and rotation than hip abduction/adduction and knee flexion/extension. The muscle forces responded to the residual variance of joint kinematics to various degrees based on the muscle function for specific joint kinematics. This study demonstrates the importance of evaluating marker error for joint kinematics and muscle forces when explaining relative clinical gait analysis and treatment intervention.

Profile of refractive errors in European Caucasian children with Autistic Spectrum Disorder; increased prevalence and magnitude of astigmatism.

PubMed

Anketell, Pamela M; Saunders, Kathryn J; Gallagher, Stephen; Bailey, Clare; Little, Julie-Anne

2016-07-01

Autistic Spectrum Disorder (ASD) is a common neurodevelopmental disorder characterised by impairment of communication, social interaction and repetitive behaviours. Only a small number of studies have investigated fundamental clinical measures of vision including refractive error. The aim of this study was to describe the refractive profile of a population of children with ASD compared to typically developing (TD) children. Refractive error was assessed using the Shin-Nippon NVision-K 5001 open-field autorefractor following the instillation of cyclopentolate hydrochloride 1% eye drops. A total of 128 participants with ASD (mean age 10.9 ± 3.3 years) and 206 typically developing participants (11.5 ± 3.1 years) were recruited. There was no significant difference in median refractive error, either by spherical equivalent or most ametropic meridian between the ASD and TD groups (Spherical equivalent, Mann-Whitney U307 = 1.15, p = 0.25; Most Ametropic Meridian, U305 = 0.52, p = 0.60). Median refractive astigmatism was -0.50DC (range 0.00 to -3.50DC) for the ASD group and -0.50DC (Range 0.00 to -2.25DC) for the TD group. Magnitude and prevalence of refractive astigmatism (defined as astigmatism ≥1.00DC) was significantly greater in the ASD group compared to the typically developing group (ASD 26%, TD 8%, magnitude U305 = 3.86, p = 0.0001; prevalence (χ12=17.71 , p < 0.0001). This is the first study to describe the refractive profile of a population of European Caucasian children with ASD compared to a TD population of children. Unlike other neurodevelopmental conditions, there was no increased prevalence of spherical refractive errors in ASD but astigmatic errors were significantly greater in magnitude and prevalence. This highlights the need to examine refractive errors in this population. © 2016 The Authors Ophthalmic & Physiological Optics © 2016 The College of Optometrists.

Computer-socket manufacturing error: How much before it is clinically apparent?

PubMed Central

Sanders, Joan E.; Severance, Michael R.; Allyn, Kathryn J.

2015-01-01

The purpose of this research was to pursue quality standards for computer-manufacturing of prosthetic sockets for people with transtibial limb loss. Thirty-three duplicates of study participants’ normally used sockets were fabricated using central fabrication facilities. Socket-manufacturing errors were compared with clinical assessments of socket fit. Of the 33 sockets tested, 23 were deemed clinically to need modification. All 13 sockets with mean radial error (MRE) greater than 0.25 mm were clinically unacceptable, and 11 of those were deemed in need of sizing reduction. Of the remaining 20 sockets, 5 sockets with interquartile range (IQR) greater than 0.40 mm were deemed globally or regionally oversized and in need of modification. Of the remaining 15 sockets, 5 sockets with closed contours of elevated surface normal angle error (SNAE) were deemed clinically to need shape modification at those closed contour locations. The remaining 10 sockets were deemed clinically acceptable and not in need modification. MRE, IQR, and SNAE may serve as effective metrics to characterize quality of computer-manufactured prosthetic sockets, helping facilitate the development of quality standards for the socket manufacturing industry. PMID:22773260

The Causes of Errors in Clinical Reasoning: Cognitive Biases, Knowledge Deficits, and Dual Process Thinking.

PubMed

Norman, Geoffrey R; Monteiro, Sandra D; Sherbino, Jonathan; Ilgen, Jonathan S; Schmidt, Henk G; Mamede, Silvia

2017-01-01

Contemporary theories of clinical reasoning espouse a dual processing model, which consists of a rapid, intuitive component (Type 1) and a slower, logical and analytical component (Type 2). Although the general consensus is that this dual processing model is a valid representation of clinical reasoning, the causes of diagnostic errors remain unclear. Cognitive theories about human memory propose that such errors may arise from both Type 1 and Type 2 reasoning. Errors in Type 1 reasoning may be a consequence of the associative nature of memory, which can lead to cognitive biases. However, the literature indicates that, with increasing expertise (and knowledge), the likelihood of errors decreases. Errors in Type 2 reasoning may result from the limited capacity of working memory, which constrains computational processes. In this article, the authors review the medical literature to answer two substantial questions that arise from this work: (1) To what extent do diagnostic errors originate in Type 1 (intuitive) processes versus in Type 2 (analytical) processes? (2) To what extent are errors a consequence of cognitive biases versus a consequence of knowledge deficits?The literature suggests that both Type 1 and Type 2 processes contribute to errors. Although it is possible to experimentally induce cognitive biases, particularly availability bias, the extent to which these biases actually contribute to diagnostic errors is not well established. Educational strategies directed at the recognition of biases are ineffective in reducing errors; conversely, strategies focused on the reorganization of knowledge to reduce errors have small but consistent benefits.

Error identification in a high-volume clinical chemistry laboratory: Five-year experience.

PubMed

Jafri, Lena; Khan, Aysha Habib; Ghani, Farooq; Shakeel, Shahid; Raheem, Ahmed; Siddiqui, Imran

2015-07-01

Quality indicators for assessing the performance of a laboratory require a systematic and continuous approach in collecting and analyzing data. The aim of this study was to determine the frequency of errors utilizing the quality indicators in a clinical chemistry laboratory and to convert errors to the Sigma scale. Five-year quality indicator data of a clinical chemistry laboratory was evaluated to describe the frequency of errors. An 'error' was defined as a defect during the entire testing process from the time requisition was raised and phlebotomy was done until the result dispatch. An indicator with a Sigma value of 4 was considered good but a process for which the Sigma value was 5 (i.e. 99.977% error-free) was considered well controlled. In the five-year period, a total of 6,792,020 specimens were received in the laboratory. Among a total of 17,631,834 analyses, 15.5% were from within hospital. Total error rate was 0.45% and of all the quality indicators used in this study the average Sigma level was 5.2. Three indicators - visible hemolysis, failure of proficiency testing and delay in stat tests - were below 5 on the Sigma scale and highlight the need to rigorously monitor these processes. Using Six Sigma metrics quality in a clinical laboratory can be monitored more effectively and it can set benchmarks for improving efficiency.

Safety culture perceptions of pharmacists in Malaysian hospitals and health clinics: a multicentre assessment using the Safety Attitudes Questionnaire

PubMed Central

Samsuri, Srima Elina; Pei Lin, Lua; Fahrni, Mathumalar Loganathan

2015-01-01

Objective To assess the safety attitudes of pharmacists, provide a profile of their domains of safety attitude and correlate their attitudes with self-reported rates of medication errors. Design A cross-sectional study utilising the Safety Attitudes Questionnaire (SAQ). Setting 3 public hospitals and 27 health clinics. Participants 117 pharmacists. Main outcome measure(s) Safety culture mean scores, variation in scores across working units and between hospitals versus health clinics, predictors of safety culture, and medication errors and their correlation. Results Response rate was 83.6% (117 valid questionnaires returned). Stress recognition (73.0±20.4) and working condition (54.8±17.4) received the highest and lowest mean scores, respectively. Pharmacists exhibited positive attitudes towards: stress recognition (58.1%), job satisfaction (46.2%), teamwork climate (38.5%), safety climate (33.3%), perception of management (29.9%) and working condition (15.4%). With the exception of stress recognition, those who worked in health clinics scored higher than those in hospitals (p<0.05) and higher scores (overall score as well as score for each domain except for stress recognition) correlated negatively with reported number of medication errors. Conversely, those working in hospital (versus health clinic) were 8.9 times more likely (p<0.01) to report a medication error (OR 8.9, CI 3.08 to 25.7). As stress recognition increased, the number of medication errors reported increased (p=0.023). Years of work experience (p=0.017) influenced the number of medication errors reported. For every additional year of work experience, pharmacists were 0.87 times less likely to report a medication error (OR 0.87, CI 0.78 to 0.98). Conclusions A minority (20.5%) of the pharmacists working in hospitals and health clinics was in agreement with the overall SAQ questions and scales. Pharmacists in outpatient and ambulatory units and those in health clinics had better perceptions of safety culture. As perceptions improved, the number of medication errors reported decreased. Group-specific interventions that target specific domains are necessary to improve the safety culture. PMID:26610761

[News items about clinical errors and safety perceptions in hospital patients].

PubMed

Mira, José Joaquín; Guilabert, Mercedes; Ortíz, Lidia; Navarro, Isabel María; Pérez-Jover, María Virtudes; Aranaz, Jesús María

2010-01-01

To analyze how news items about clinical errors are treated by the press in Spain and their influence on patients. We performed a quantitative and qualitative study. Firstly, news items published between April and November 2007 in six newspapers were analyzed. Secondly, 829 patients from five hospitals in four autonomous regions were surveyed. We analyzed 90 cases generating 128 news items, representing a mean of 16 items per month. In 91 news items (71.1%) the source was checked. In 78 items (60.9%) the author could be identified. The impact of these news items was -4.86 points (95% confidence interval [95%CI]: -4.15-5.57). In 59 cases (57%) the error was attributed to the system, in 27 (21.3%) to health professionals, and in 41 (32.3%) to both. Neither the number of columns (p=0.702), nor the inclusion of a sub-header (p=0.195), nor a complementary image (p=0.9) were found to be related to the effect of the error on safety perceptions. Of the 829 patients, 515 (62.1%; 95%CI: 58.8-65.4%) claimed to have recently seen or heard news about clinical errors in the press, on the radio or on television. The perception of safety decreased when the same person was worried about being the victim of a clinical error and had seen a recent news item about such adverse events (chi(2)=15.17; p=0.001). Every week news items about clinical errors are published or broadcast. The way in which newspapers report legal claims over alleged medical errors is similar to the way they report judicial sentences for negligence causing irreparable damage or harm. News about errors generates insecurity in patients. It is advisable to create interfaces between journalists and health professionals. Copyright 2009 SESPAS. Published by Elsevier Espana. All rights reserved.

Teaching concepts of clinical measurement variation to medical students.

PubMed

Hodder, R A; Longfield, J N; Cruess, D F; Horton, J A

1982-09-01

An exercise in clinical epidemiology was developed for medical students to demonstrate the process and limitations of scientific measurement using models that simulate common clinical experiences. All scales of measurement (nominal, ordinal and interval) were used to illustrate concepts of intra- and interobserver variation, systematic error, recording error, and procedural error. In a laboratory, students a) determined blood pressures on six videotaped subjects, b) graded sugar content of unknown solutions from 0 to 4+ using Clinitest tablets, c) measured papules that simulated PPD reactions, d) measured heart and kidney size on X-rays and, e) described a model skin lesion (melanoma). Traditionally, measurement variation is taught in biostatistics or epidemiology courses using previously collected data. Use of these models enables students to produce their own data using measurements commonly employed by the clinician. The exercise provided material for a meaningful discussion of the implications of measurement error in clinical decision-making.

Value-based HR practices, i-deals and clinical error control with CSR as a moderator.

PubMed

Luu, Tuan; Rowley, Chris; Siengthai, Sununta; Thanh Thao, Vo

2017-05-08

Purpose Notwithstanding the rising magnitude of system factors in patient safety improvement, "human factors" such as idiosyncratic deals (i-deals) which also contribute to the adjustment of system deficiencies should not be neglected. The purpose of this paper is to investigate the role of value-based HR practices in catalyzing i-deals, which then influence clinical error control. The research further examines the moderating role of corporate social responsibility (CSR) on the effect of value-based HR practices on i-deals. Design/methodology/approach The data were collected from middle-level clinicians from hospitals in the Vietnam context. Findings The research results confirmed the effect chain from value-based HR practices through i-deals to clinical error control with CSR as a moderator. Originality/value The HRM literature is expanded through enlisting i-deals and clinical error control as the outcomes of HR practices.

Clinical errors that can occur in the treatment decision-making process in psychotherapy.

PubMed

Park, Jake; Goode, Jonathan; Tompkins, Kelley A; Swift, Joshua K

2016-09-01

Clinical errors occur in the psychotherapy decision-making process whenever a less-than-optimal treatment or approach is chosen when working with clients. A less-than-optimal approach may be one that a client is unwilling to try or fully invest in based on his/her expectations and preferences, or one that may have little chance of success based on contraindications and/or limited research support. The doctor knows best and the independent choice models are two decision-making models that are frequently used within psychology, but both are associated with an increased likelihood of errors in the treatment decision-making process. In particular, these models fail to integrate all three components of the definition of evidence-based practice in psychology (American Psychological Association, 2006). In this article we describe both models and provide examples of clinical errors that can occur in each. We then introduce the shared decision-making model as an alternative that is less prone to clinical errors. PsycINFO Database Record (c) 2016 APA, all rights reserved

High definition video teaching module for learning neck dissection.

PubMed

Mendez, Adrian; Seikaly, Hadi; Ansari, Kal; Murphy, Russell; Cote, David

2014-03-25

Video teaching modules are proven effective tools for enhancing student competencies and technical skills in the operating room. Integration into post-graduate surgical curricula, however, continues to pose a challenge in modern surgical education. To date, video teaching modules for neck dissection have yet to be described in the literature. To develop and validate an HD video-based teaching module (HDVM) to help instruct post-graduate otolaryngology trainees in performing neck dissection. This prospective study included 6 intermediate to senior otolaryngology residents. All consented subjects first performed a control selective neck dissection. Subjects were then exposed to the video teaching module. Following a washout period, a repeat procedure was performed. Recordings of the both sets of neck dissections were de-identified and reviewed by an independent evaluator and scored using the Observational Clinical Human Reliability Assessment (OCHRA) system. In total 91 surgical errors were made prior to the HDVM and 41 after exposure, representing a 55% decrease in error occurrence. The two groups were found to be significantly different. Similarly, 66 and 24 staff takeover events occurred pre and post HDVM exposure, respectively, representing a statistically significant 64% decrease. HDVM is a useful adjunct to classical surgical training. Residents performed significantly less errors following exposure to the HD-video module. Similarly, significantly less staff takeover events occurred following exposure to the HDVM.

Contextualizing individual differences in error monitoring: Links with impulsivity, negative affect, and conscientiousness.

PubMed

Hill, Kaylin E; Samuel, Douglas B; Foti, Dan

2016-08-01

The error-related negativity (ERN) is a neural measure of error processing that has been implicated as a neurobehavioral trait and has transdiagnostic links with psychopathology. Few studies, however, have contextualized this traitlike component with regard to dimensions of personality that, as intermediate constructs, may aid in contextualizing links with psychopathology. Accordingly, the aim of this study was to examine the interrelationships between error monitoring and dimensions of personality within a large adult sample (N = 208). Building on previous research, we found that the ERN relates to a combination of negative affect, impulsivity, and conscientiousness. At low levels of conscientiousness, negative urgency (i.e., impulsivity in the context of negative affect) predicted an increased ERN; at high levels of conscientiousness, the effect of negative urgency was not significant. This relationship was driven specifically by the conscientiousness facets of competence, order, and deliberation. Links between personality measures and error positivity amplitude were weaker and nonsignificant. Post-error slowing was also related to conscientiousness, as well as a different facet of impulsivity: lack of perseverance. These findings suggest that, in the general population, error processing is modulated by the joint combination of negative affect, impulsivity, and conscientiousness (i.e., the profile across traits), perhaps more so than any one dimension alone. This work may inform future research concerning aberrant error processing in clinical populations. © 2016 Society for Psychophysiological Research.

A navigation system for percutaneous needle interventions based on PET/CT images: design, workflow and error analysis of soft tissue and bone punctures.

PubMed

Oliveira-Santos, Thiago; Klaeser, Bernd; Weitzel, Thilo; Krause, Thomas; Nolte, Lutz-Peter; Peterhans, Matthias; Weber, Stefan

2011-01-01

Percutaneous needle intervention based on PET/CT images is effective, but exposes the patient to unnecessary radiation due to the increased number of CT scans required. Computer assisted intervention can reduce the number of scans, but requires handling, matching and visualization of two different datasets. While one dataset is used for target definition according to metabolism, the other is used for instrument guidance according to anatomical structures. No navigation systems capable of handling such data and performing PET/CT image-based procedures while following clinically approved protocols for oncologic percutaneous interventions are available. The need for such systems is emphasized in scenarios where the target can be located in different types of tissue such as bone and soft tissue. These two tissues require different clinical protocols for puncturing and may therefore give rise to different problems during the navigated intervention. Studies comparing the performance of navigated needle interventions targeting lesions located in these two types of tissue are not often found in the literature. Hence, this paper presents an optical navigation system for percutaneous needle interventions based on PET/CT images. The system provides viewers for guiding the physician to the target with real-time visualization of PET/CT datasets, and is able to handle targets located in both bone and soft tissue. The navigation system and the required clinical workflow were designed taking into consideration clinical protocols and requirements, and the system is thus operable by a single person, even during transition to the sterile phase. Both the system and the workflow were evaluated in an initial set of experiments simulating 41 lesions (23 located in bone tissue and 18 in soft tissue) in swine cadavers. We also measured and decomposed the overall system error into distinct error sources, which allowed for the identification of particularities involved in the process as well as highlighting the differences between bone and soft tissue punctures. An overall average error of 4.23 mm and 3.07 mm for bone and soft tissue punctures, respectively, demonstrated the feasibility of using this system for such interventions. The proposed system workflow was shown to be effective in separating the preparation from the sterile phase, as well as in keeping the system manageable by a single operator. Among the distinct sources of error, the user error based on the system accuracy (defined as the distance from the planned target to the actual needle tip) appeared to be the most significant. Bone punctures showed higher user error, whereas soft tissue punctures showed higher tissue deformation error.

[Failure mode and effects analysis on computerized drug prescriptions].

PubMed

Paredes-Atenciano, J A; Roldán-Aviña, J P; González-García, Mercedes; Blanco-Sánchez, M C; Pinto-Melero, M A; Pérez-Ramírez, C; Calvo Rubio-Burgos, Miguel; Osuna-Navarro, F J; Jurado-Carmona, A M

2015-01-01

To identify and analyze errors in drug prescriptions of patients treated in a "high resolution" hospital by applying a Failure mode and effects analysis (FMEA).Material and methods A multidisciplinary group of medical specialties and nursing analyzed medical records where drug prescriptions were held in free text format. An FMEA was developed in which the risk priority index (RPI) was obtained from a cross-sectional observational study using an audit of the medical records, carried out in 2 phases: 1) Pre-intervention testing, and (2) evaluation of improvement actions after the first analysis. An audit sample size of 679 medical records from a total of 2,096 patients was calculated using stratified sampling and random selection of clinical events. Prescription errors decreased by 22.2% in the second phase. FMEA showed a greater RPI in "unspecified route of administration" and "dosage unspecified", with no significant decreases observed in the second phase, although it did detect, "incorrect dosing time", "contraindication due to drug allergy", "wrong patient" or "duplicate prescription", which resulted in the improvement of prescriptions. Drug prescription errors have been identified and analyzed by FMEA methodology, improving the clinical safety of these prescriptions. This tool allows updates of electronic prescribing to be monitored. To avoid such errors would require the mandatory completion of all sections of a prescription. Copyright © 2014 SECA. Published by Elsevier Espana. All rights reserved.

Ultra-deep mutant spectrum profiling: improving sequencing accuracy using overlapping read pairs.

PubMed

Chen-Harris, Haiyin; Borucki, Monica K; Torres, Clinton; Slezak, Tom R; Allen, Jonathan E

2013-02-12

High throughput sequencing is beginning to make a transformative impact in the area of viral evolution. Deep sequencing has the potential to reveal the mutant spectrum within a viral sample at high resolution, thus enabling the close examination of viral mutational dynamics both within- and between-hosts. The challenge however, is to accurately model the errors in the sequencing data and differentiate real viral mutations, particularly those that exist at low frequencies, from sequencing errors. We demonstrate that overlapping read pairs (ORP) -- generated by combining short fragment sequencing libraries and longer sequencing reads -- significantly reduce sequencing error rates and improve rare variant detection accuracy. Using this sequencing protocol and an error model optimized for variant detection, we are able to capture a large number of genetic mutations present within a viral population at ultra-low frequency levels (<0.05%). Our rare variant detection strategies have important implications beyond viral evolution and can be applied to any basic and clinical research area that requires the identification of rare mutations.

The immediate effects of therapeutic keyboard music playing for finger training in adults undergoing hand rehabilitation.

PubMed

Zhang, Xiaoying; Liu, Songhuai; Yang, Degang; Du, Liangjie; Wang, Ziyuan

2016-08-01

[Purpose] The purpose of this study was to examine the immediate effects of therapeutic keyboard music playing on the finger function of subjects' hands through measurements of the joint position error test, surface electromyography, probe reaction time, and writing time. [Subjects and Methods] Ten subjects were divided randomly into experimental and control groups. The experimental group used therapeutic keyboard music playing and the control group used grip training. All subjects were assessed and evaluated by the joint position error test, surface electromyography, probe reaction time, and writing time. [Results] After accomplishing therapeutic keyboard music playing and grip training, surface electromyography of the two groups showed no significant change, but joint position error test, probe reaction time, and writing time obviously improved. [Conclusion] These results suggest that therapeutic keyboard music playing is an effective and novel treatment for improving joint position error test scores, probe reaction time, and writing time, and it should be promoted widely in clinics.

Rapid Measurement and Correction of Phase Errors from B0 Eddy Currents: Impact on Image Quality for Non-Cartesian Imaging

PubMed Central

Brodsky, Ethan K.; Klaers, Jessica L.; Samsonov, Alexey A.; Kijowski, Richard; Block, Walter F.

2014-01-01

Non-Cartesian imaging sequences and navigational methods can be more sensitive to scanner imperfections that have little impact on conventional clinical sequences, an issue which has repeatedly complicated the commercialization of these techniques by frustrating transitions to multi-center evaluations. One such imperfection is phase errors caused by resonant frequency shifts from eddy currents induced in the cryostat by time-varying gradients, a phenomemon known as B0 eddy currents. These phase errors can have a substantial impact on sequences that use ramp sampling, bipolar gradients, and readouts at varying azimuthal angles. We present a method for measuring and correcting phase errors from B0 eddy currents and examine the results on two different scanner models. This technique yields significant improvements in image quality for high-resolution joint imaging on certain scanners. The results suggest that correction of short time B0 eddy currents in manufacturer provided service routines would simplify adoption of non-Cartesian sampling methods. PMID:22488532

Distinguishing between statistical significance and practical/clinical meaningfulness using statistical inference.

PubMed

Wilkinson, Michael

2014-03-01

Decisions about support for predictions of theories in light of data are made using statistical inference. The dominant approach in sport and exercise science is the Neyman-Pearson (N-P) significance-testing approach. When applied correctly it provides a reliable procedure for making dichotomous decisions for accepting or rejecting zero-effect null hypotheses with known and controlled long-run error rates. Type I and type II error rates must be specified in advance and the latter controlled by conducting an a priori sample size calculation. The N-P approach does not provide the probability of hypotheses or indicate the strength of support for hypotheses in light of data, yet many scientists believe it does. Outcomes of analyses allow conclusions only about the existence of non-zero effects, and provide no information about the likely size of true effects or their practical/clinical value. Bayesian inference can show how much support data provide for different hypotheses, and how personal convictions should be altered in light of data, but the approach is complicated by formulating probability distributions about prior subjective estimates of population effects. A pragmatic solution is magnitude-based inference, which allows scientists to estimate the true magnitude of population effects and how likely they are to exceed an effect magnitude of practical/clinical importance, thereby integrating elements of subjective Bayesian-style thinking. While this approach is gaining acceptance, progress might be hastened if scientists appreciate the shortcomings of traditional N-P null hypothesis significance testing.

Internal quality control: best practice.

PubMed

Kinns, Helen; Pitkin, Sarah; Housley, David; Freedman, Danielle B

2013-12-01

There is a wide variation in laboratory practice with regard to implementation and review of internal quality control (IQC). A poor approach can lead to a spectrum of scenarios from validation of incorrect patient results to over investigation of falsely rejected analytical runs. This article will provide a practical approach for the routine clinical biochemistry laboratory to introduce an efficient quality control system that will optimise error detection and reduce the rate of false rejection. Each stage of the IQC system is considered, from selection of IQC material to selection of IQC rules, and finally the appropriate action to follow when a rejection signal has been obtained. The main objective of IQC is to ensure day-to-day consistency of an analytical process and thus help to determine whether patient results are reliable enough to be released. The required quality and assay performance varies between analytes as does the definition of a clinically significant error. Unfortunately many laboratories currently decide what is clinically significant at the troubleshooting stage. Assay-specific IQC systems will reduce the number of inappropriate sample-run rejections compared with the blanket use of one IQC rule. In practice, only three or four different IQC rules are required for the whole of the routine biochemistry repertoire as assays are assigned into groups based on performance. The tools to categorise performance and assign IQC rules based on that performance are presented. Although significant investment of time and education is required prior to implementation, laboratories have shown that such systems achieve considerable reductions in cost and labour.

An Analysis of Plan Robustness for Esophageal Tumors: Comparing Volumetric Modulated Arc Therapy Plans and Spot Scanning Proton Planning

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

Warren, Samantha, E-mail: samantha.warren@oncology.ox.ac.uk; Partridge, Mike; Bolsi, Alessandra

Purpose: Planning studies to compare x-ray and proton techniques and to select the most suitable technique for each patient have been hampered by the nonequivalence of several aspects of treatment planning and delivery. A fair comparison should compare similarly advanced delivery techniques from current clinical practice and also assess the robustness of each technique. The present study therefore compared volumetric modulated arc therapy (VMAT) and single-field optimization (SFO) spot scanning proton therapy plans created using a simultaneous integrated boost (SIB) for dose escalation in midesophageal cancer and analyzed the effect of setup and range uncertainties on these plans. Methods andmore » Materials: For 21 patients, SIB plans with a physical dose prescription of 2 Gy or 2.5 Gy/fraction in 25 fractions to planning target volume (PTV){sub 50Gy} or PTV{sub 62.5Gy} (primary tumor with 0.5 cm margins) were created and evaluated for robustness to random setup errors and proton range errors. Dose–volume metrics were compared for the optimal and uncertainty plans, with P<.05 (Wilcoxon) considered significant. Results: SFO reduced the mean lung dose by 51.4% (range 35.1%-76.1%) and the mean heart dose by 40.9% (range 15.0%-57.4%) compared with VMAT. Proton plan robustness to a 3.5% range error was acceptable. For all patients, the clinical target volume D{sub 98} was 95.0% to 100.4% of the prescribed dose and gross tumor volume (GTV) D{sub 98} was 98.8% to 101%. Setup error robustness was patient anatomy dependent, and the potential minimum dose per fraction was always lower with SFO than with VMAT. The clinical target volume D{sub 98} was lower by 0.6% to 7.8% of the prescribed dose, and the GTV D{sub 98} was lower by 0.3% to 2.2% of the prescribed GTV dose. Conclusions: The SFO plans achieved significant sparing of normal tissue compared with the VMAT plans for midesophageal cancer. The target dose coverage in the SIB proton plans was less robust to random setup errors and might be unacceptable for certain patients. Robust optimization to ensure adequate target coverage of SIB proton plans might be beneficial.« less

An Analysis of Plan Robustness for Esophageal Tumors: Comparing Volumetric Modulated Arc Therapy Plans and Spot Scanning Proton Planning

PubMed Central

Warren, Samantha; Partridge, Mike; Bolsi, Alessandra; Lomax, Anthony J.; Hurt, Chris; Crosby, Thomas; Hawkins, Maria A.

2016-01-01

Purpose Planning studies to compare x-ray and proton techniques and to select the most suitable technique for each patient have been hampered by the nonequivalence of several aspects of treatment planning and delivery. A fair comparison should compare similarly advanced delivery techniques from current clinical practice and also assess the robustness of each technique. The present study therefore compared volumetric modulated arc therapy (VMAT) and single-field optimization (SFO) spot scanning proton therapy plans created using a simultaneous integrated boost (SIB) for dose escalation in midesophageal cancer and analyzed the effect of setup and range uncertainties on these plans. Methods and Materials For 21 patients, SIB plans with a physical dose prescription of 2 Gy or 2.5 Gy/fraction in 25 fractions to planning target volume (PTV)50Gy or PTV62.5Gy (primary tumor with 0.5 cm margins) were created and evaluated for robustness to random setup errors and proton range errors. Dose–volume metrics were compared for the optimal and uncertainty plans, with P<.05 (Wilcoxon) considered significant. Results SFO reduced the mean lung dose by 51.4% (range 35.1%-76.1%) and the mean heart dose by 40.9% (range 15.0%-57.4%) compared with VMAT. Proton plan robustness to a 3.5% range error was acceptable. For all patients, the clinical target volume D98 was 95.0% to 100.4% of the prescribed dose and gross tumor volume (GTV) D98 was 98.8% to 101%. Setup error robustness was patient anatomy dependent, and the potential minimum dose per fraction was always lower with SFO than with VMAT. The clinical target volume D98 was lower by 0.6% to 7.8% of the prescribed dose, and the GTV D98 was lower by 0.3% to 2.2% of the prescribed GTV dose. Conclusions The SFO plans achieved significant sparing of normal tissue compared with the VMAT plans for midesophageal cancer. The target dose coverage in the SIB proton plans was less robust to random setup errors and might be unacceptable for certain patients. Robust optimization to ensure adequate target coverage of SIB proton plans might be beneficial. PMID:27084641

An Analysis of Plan Robustness for Esophageal Tumors: Comparing Volumetric Modulated Arc Therapy Plans and Spot Scanning Proton Planning.

PubMed

Warren, Samantha; Partridge, Mike; Bolsi, Alessandra; Lomax, Anthony J; Hurt, Chris; Crosby, Thomas; Hawkins, Maria A

2016-05-01

Planning studies to compare x-ray and proton techniques and to select the most suitable technique for each patient have been hampered by the nonequivalence of several aspects of treatment planning and delivery. A fair comparison should compare similarly advanced delivery techniques from current clinical practice and also assess the robustness of each technique. The present study therefore compared volumetric modulated arc therapy (VMAT) and single-field optimization (SFO) spot scanning proton therapy plans created using a simultaneous integrated boost (SIB) for dose escalation in midesophageal cancer and analyzed the effect of setup and range uncertainties on these plans. For 21 patients, SIB plans with a physical dose prescription of 2 Gy or 2.5 Gy/fraction in 25 fractions to planning target volume (PTV)50Gy or PTV62.5Gy (primary tumor with 0.5 cm margins) were created and evaluated for robustness to random setup errors and proton range errors. Dose-volume metrics were compared for the optimal and uncertainty plans, with P<.05 (Wilcoxon) considered significant. SFO reduced the mean lung dose by 51.4% (range 35.1%-76.1%) and the mean heart dose by 40.9% (range 15.0%-57.4%) compared with VMAT. Proton plan robustness to a 3.5% range error was acceptable. For all patients, the clinical target volume D98 was 95.0% to 100.4% of the prescribed dose and gross tumor volume (GTV) D98 was 98.8% to 101%. Setup error robustness was patient anatomy dependent, and the potential minimum dose per fraction was always lower with SFO than with VMAT. The clinical target volume D98 was lower by 0.6% to 7.8% of the prescribed dose, and the GTV D98 was lower by 0.3% to 2.2% of the prescribed GTV dose. The SFO plans achieved significant sparing of normal tissue compared with the VMAT plans for midesophageal cancer. The target dose coverage in the SIB proton plans was less robust to random setup errors and might be unacceptable for certain patients. Robust optimization to ensure adequate target coverage of SIB proton plans might be beneficial. Copyright © 2016 The Authors. Published by Elsevier Inc. All rights reserved.

Prescribing Errors Involving Medication Dosage Forms

PubMed Central

Lesar, Timothy S

2002-01-01

CONTEXT Prescribing errors involving medication dose formulations have been reported to occur frequently in hospitals. No systematic evaluations of the characteristics of errors related to medication dosage formulation have been performed. OBJECTIVE To quantify the characteristics, frequency, and potential adverse patient effects of prescribing errors involving medication dosage forms . DESIGN Evaluation of all detected medication prescribing errors involving or related to medication dosage forms in a 631-bed tertiary care teaching hospital. MAIN OUTCOME MEASURES Type, frequency, and potential for adverse effects of prescribing errors involving or related to medication dosage forms. RESULTS A total of 1,115 clinically significant prescribing errors involving medication dosage forms were detected during the 60-month study period. The annual number of detected errors increased throughout the study period. Detailed analysis of the 402 errors detected during the last 16 months of the study demonstrated the most common errors to be: failure to specify controlled release formulation (total of 280 cases; 69.7%) both when prescribing using the brand name (148 cases; 36.8%) and when prescribing using the generic name (132 cases; 32.8%); and prescribing controlled delivery formulations to be administered per tube (48 cases; 11.9%). The potential for adverse patient outcome was rated as potentially “fatal or severe” in 3 cases (0.7%), and “serious” in 49 cases (12.2%). Errors most commonly involved cardiovascular agents (208 cases; 51.7%). CONCLUSIONS Hospitalized patients are at risk for adverse outcomes due to prescribing errors related to inappropriate use of medication dosage forms. This information should be considered in the development of strategies to prevent adverse patient outcomes resulting from such errors. PMID:12213138

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

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

Kalapurakal, John A., E-mail: j-kalapurakal@northwestern.edu; Zafirovski, Aleksandar; Smith, Jeffery

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

Comparison of the performance of rapid prescreening, 10% random review, and clinical risk criteria as methods of internal quality control in cervical cytopathology.

PubMed

Tavares, Suelene B N; Alves de Sousa, Nadja L; Manrique, Edna J C; Pinheiro de Albuquerque, Zair B; Zeferino, Luiz C; Amaral, Rita G

2008-06-25

Rapid prescreening (RPS) is an internal quality-control (IQC) method that is used both to reduce errors in the laboratory and to measure the sensitivity of routine screening (RS). Little direct comparison data are available comparing RPS with other more widely used IQC methods. The authors compared the performance of RPS, 10% random review of negative smears (R-10%), and directed rescreening of negative smears based on clinical risk criteria (RCRC) over 1 year in a community clinic setting. In total, 6,135 smears were evaluated. The sensitivity of RS alone was 71.3%. RPS detected significantly more (132 cases) false-negative (FN) cases than either R-10% (7 cases) or RCRC (32 cases). RPS significantly improved the overall sensitivity of the laboratory (71.3-92.2%; P = .001); neither R-10% nor RCRC significantly changed the sensitivity of RS. RPS was not as specific as the other methods, although nearly 68% of all abnormalities detected by RPS were verified as real. RPS of 100% of smears required the same amount of time as RCRC but required twice as much time as R-10%. The current results demonstrated that RPS is a much more effective IQC method than either R-10% or RCRC. RPS detects significantly more errors and can improve the overall sensitivity of a laboratory with either a modest increase or no increase in overall time spent on IQC. R-10% is an insensitive IQC method, and neither R-10% nor RCRC can significantly improve the overall sensitivity of a laboratory. (c) 2008 American Cancer Society.

Effect of endorectal balloon positioning errors on target deformation and dosimetric quality during prostate SBRT

NASA Astrophysics Data System (ADS)

Jones, Bernard L.; Gan, Gregory; Kavanagh, Brian; Miften, Moyed

2013-11-01

An inflatable endorectal balloon (ERB) is often used during stereotactic body radiation therapy (SBRT) for treatment of prostate cancer in order to reduce both intrafraction motion of the target and risk of rectal toxicity. However, the ERB can exert significant force on the prostate, and this work assessed the impact of ERB position errors on deformation of the prostate and treatment dose metrics. Seventy-one cone-beam computed tomography (CBCT) image datasets of nine patients with clinical stage T1cN0M0 prostate cancer were studied. An ERB (Flexi-Cuff, EZ-EM, Westbury, NY) inflated with 60 cm3 of air was used during simulation and treatment, and daily kilovoltage (kV) CBCT imaging was performed to localize the prostate. The shape of the ERB in each CBCT was analyzed to determine errors in position, size, and shape. A deformable registration algorithm was used to track the dose received by (and deformation of) the prostate, and dosimetric values such as D95, PTV coverage, and Dice coefficient for the prostate were calculated. The average balloon position error was 0.5 cm in the inferior direction, with errors ranging from 2 cm inferiorly to 1 cm superiorly. The prostate was deformed primarily in the AP direction, and tilted primarily in the anterior-posterior/superior-inferior plane. A significant correlation was seen between errors in depth of ERB insertion (DOI) and mean voxel-wise deformation, prostate tilt, Dice coefficient, and planning-to-treatment prostate inter-surface distance (p < 0.001). Dosimetrically, DOI is negatively correlated with prostate D95 and PTV coverage (p < 0.001). For the model of ERB studied, error in ERB position can cause deformations in the prostate that negatively affect treatment, and this additional aspect of setup error should be considered when ERBs are used for prostate SBRT. Before treatment, the ERB position should be verified, and the ERB should be adjusted if the error is observed to exceed tolerable values.

Dosimetric Implications of Residual Tracking Errors During Robotic SBRT of Liver Metastases

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

Chan, Mark; Tuen Mun Hospital, Hong Kong; Grehn, Melanie

Purpose: Although the metric precision of robotic stereotactic body radiation therapy in the presence of breathing motion is widely known, we investigated the dosimetric implications of breathing phase–related residual tracking errors. Methods and Materials: In 24 patients (28 liver metastases) treated with the CyberKnife, we recorded the residual correlation, prediction, and rotational tracking errors from 90 fractions and binned them into 10 breathing phases. The average breathing phase errors were used to shift and rotate the clinical tumor volume (CTV) and planning target volume (PTV) for each phase to calculate a pseudo 4-dimensional error dose distribution for comparison with themore » original planned dose distribution. Results: The median systematic directional correlation, prediction, and absolute aggregate rotation errors were 0.3 mm (range, 0.1-1.3 mm), 0.01 mm (range, 0.00-0.05 mm), and 1.5° (range, 0.4°-2.7°), respectively. Dosimetrically, 44%, 81%, and 92% of all voxels differed by less than 1%, 3%, and 5% of the planned local dose, respectively. The median coverage reduction for the PTV was 1.1% (range in coverage difference, −7.8% to +0.8%), significantly depending on correlation (P=.026) and rotational (P=.005) error. With a 3-mm PTV margin, the median coverage change for the CTV was 0.0% (range, −1.0% to +5.4%), not significantly depending on any investigated parameter. In 42% of patients, the 3-mm margin did not fully compensate for the residual tracking errors, resulting in a CTV coverage reduction of 0.1% to 1.0%. Conclusions: For liver tumors treated with robotic stereotactic body radiation therapy, a safety margin of 3 mm is not always sufficient to cover all residual tracking errors. Dosimetrically, this translates into only small CTV coverage reductions.« less

Monitoring gait in multiple sclerosis with novel wearable motion sensors.

PubMed

Moon, Yaejin; McGinnis, Ryan S; Seagers, Kirsten; Motl, Robert W; Sheth, Nirav; Wright, John A; Ghaffari, Roozbeh; Sosnoff, Jacob J

2017-01-01

Mobility impairment is common in people with multiple sclerosis (PwMS) and there is a need to assess mobility in remote settings. Here, we apply a novel wireless, skin-mounted, and conformal inertial sensor (BioStampRC, MC10 Inc.) to examine gait characteristics of PwMS under controlled conditions. We determine the accuracy and precision of BioStampRC in measuring gait kinematics by comparing to contemporary research-grade measurement devices. A total of 45 PwMS, who presented with diverse walking impairment (Mild MS = 15, Moderate MS = 15, Severe MS = 15), and 15 healthy control subjects participated in the study. Participants completed a series of clinical walking tests. During the tests participants were instrumented with BioStampRC and MTx (Xsens, Inc.) sensors on their shanks, as well as an activity monitor GT3X (Actigraph, Inc.) on their non-dominant hip. Shank angular velocity was simultaneously measured with the inertial sensors. Step number and temporal gait parameters were calculated from the data recorded by each sensor. Visual inspection and the MTx served as the reference standards for computing the step number and temporal parameters, respectively. Accuracy (error) and precision (variance of error) was assessed based on absolute and relative metrics. Temporal parameters were compared across groups using ANOVA. Mean accuracy±precision for the BioStampRC was 2±2 steps error for step number, 6±9ms error for stride time and 6±7ms error for step time (0.6-2.6% relative error). Swing time had the least accuracy±precision (25±19ms error, 5±4% relative error) among the parameters. GT3X had the least accuracy±precision (8±14% relative error) in step number estimate among the devices. Both MTx and BioStampRC detected significantly distinct gait characteristics between PwMS with different disability levels (p<0.01). BioStampRC sensors accurately and precisely measure gait parameters in PwMS across diverse walking impairment levels and detected differences in gait characteristics by disability level in PwMS. This technology has the potential to provide granular monitoring of gait both inside and outside the clinic.

A retrospective survey of research design and statistical analyses in selected Chinese medical journals in 1998 and 2008.

PubMed

Jin, Zhichao; Yu, Danghui; Zhang, Luoman; Meng, Hong; Lu, Jian; Gao, Qingbin; Cao, Yang; Ma, Xiuqiang; Wu, Cheng; He, Qian; Wang, Rui; He, Jia

2010-05-25

High quality clinical research not only requires advanced professional knowledge, but also needs sound study design and correct statistical analyses. The number of clinical research articles published in Chinese medical journals has increased immensely in the past decade, but study design quality and statistical analyses have remained suboptimal. The aim of this investigation was to gather evidence on the quality of study design and statistical analyses in clinical researches conducted in China for the first decade of the new millennium. Ten (10) leading Chinese medical journals were selected and all original articles published in 1998 (N = 1,335) and 2008 (N = 1,578) were thoroughly categorized and reviewed. A well-defined and validated checklist on study design, statistical analyses, results presentation, and interpretation was used for review and evaluation. Main outcomes were the frequencies of different types of study design, error/defect proportion in design and statistical analyses, and implementation of CONSORT in randomized clinical trials. From 1998 to 2008: The error/defect proportion in statistical analyses decreased significantly ( = 12.03, p<0.001), 59.8% (545/1,335) in 1998 compared to 52.2% (664/1,578) in 2008. The overall error/defect proportion of study design also decreased ( = 21.22, p<0.001), 50.9% (680/1,335) compared to 42.40% (669/1,578). In 2008, design with randomized clinical trials remained low in single digit (3.8%, 60/1,578) with two-third showed poor results reporting (defects in 44 papers, 73.3%). Nearly half of the published studies were retrospective in nature, 49.3% (658/1,335) in 1998 compared to 48.2% (761/1,578) in 2008. Decreases in defect proportions were observed in both results presentation ( = 93.26, p<0.001), 92.7% (945/1,019) compared to 78.2% (1023/1,309) and interpretation ( = 27.26, p<0.001), 9.7% (99/1,019) compared to 4.3% (56/1,309), some serious ones persisted. Chinese medical research seems to have made significant progress regarding statistical analyses, but there remains ample room for improvement regarding study designs. Retrospective clinical studies are the most often used design, whereas randomized clinical trials are rare and often show methodological weaknesses. Urgent implementation of the CONSORT statement is imperative.

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.

The impact of computerized physician order entry on prescription orders: A quasi-experimental study in Iran

PubMed Central

Khammarnia, Mohammad; Sharifian, Roxana; Zand, Farid; Barati, Omid; Keshtkaran, Ali; Sabetian, Golnar; Shahrokh, , Nasim; Setoodezadeh, Fatemeh

2017-01-01

Background: One way to reduce medical errors associated with physician orders is computerized physician order entry (CPOE) software. This study was conducted to compare prescription orders between 2 groups before and after CPOE implementation in a hospital. Methods: We conducted a before-after prospective study in 2 intensive care unit (ICU) wards (as intervention and control wards) in the largest tertiary public hospital in South of Iran during 2014 and 2016. All prescription orders were validated by a clinical pharmacist and an ICU physician. The rates of ordering the errors in medical orders were compared before (manual ordering) and after implementation of the CPOE. A standard checklist was used for data collection. For the data analysis, SPSS Version 21, descriptive statistics, and analytical tests such as McNemar, chi-square, and logistic regression were used. Results: The CPOE significantly decreased 2 types of errors, illegible orders and lack of writing the drug form, in the intervention ward compared to the control ward (p< 0.05); however, the 2 errors increased due to the defect in the CPOE (p< 0.001). The use of CPOE decreased the prescription errors from 19% to 3% (p= 0.001), However, no differences were observed in the control ward (p<0.05). In addition, more errors occurred in the morning shift (p< 0.001). Conclusion: In general, the use of CPOE significantly reduced the prescription errors. Nonetheless, more caution should be exercised in the use of this system, and its deficiencies should be resolved. Furthermore, it is recommended that CPOE be used to improve the quality of delivered services in hospitals. PMID:29445698

The impact of computerized physician order entry on prescription orders: A quasi-experimental study in Iran.

PubMed

Khammarnia, Mohammad; Sharifian, Roxana; Zand, Farid; Barati, Omid; Keshtkaran, Ali; Sabetian, Golnar; Shahrokh, Nasim; Setoodezadeh, Fatemeh

2017-01-01

Background: One way to reduce medical errors associated with physician orders is computerized physician order entry (CPOE) software. This study was conducted to compare prescription orders between 2 groups before and after CPOE implementation in a hospital. Methods: We conducted a before-after prospective study in 2 intensive care unit (ICU) wards (as intervention and control wards) in the largest tertiary public hospital in South of Iran during 2014 and 2016. All prescription orders were validated by a clinical pharmacist and an ICU physician. The rates of ordering the errors in medical orders were compared before (manual ordering) and after implementation of the CPOE. A standard checklist was used for data collection. For the data analysis, SPSS Version 21, descriptive statistics, and analytical tests such as McNemar, chi-square, and logistic regression were used. Results: The CPOE significantly decreased 2 types of errors, illegible orders and lack of writing the drug form, in the intervention ward compared to the control ward (p< 0.05); however, the 2 errors increased due to the defect in the CPOE (p< 0.001). The use of CPOE decreased the prescription errors from 19% to 3% (p= 0.001), However, no differences were observed in the control ward (p<0.05). In addition, more errors occurred in the morning shift (p< 0.001). Conclusion: In general, the use of CPOE significantly reduced the prescription errors. Nonetheless, more caution should be exercised in the use of this system, and its deficiencies should be resolved. Furthermore, it is recommended that CPOE be used to improve the quality of delivered services in hospitals.

Quality of Impressions and Work Authorizations Submitted by Dental Students Supervised by Prosthodontists and General Dentists.

PubMed

Imbery, Terence A; Diaz, Nicholas; Greenfield, Kristy; Janus, Charles; Best, Al M

2016-10-01

Preclinical fixed prosthodontics is taught by Department of Prosthodontics faculty members at Virginia Commonwealth University School of Dentistry; however, 86% of all clinical cases in academic year 2012 were staffed by faculty members from the Department of General Practice. The aims of this retrospective study were to quantify the quality of impressions, accuracy of laboratory work authorizations, and most common errors and to determine if there were differences between the rate of errors in cases supervised by the prosthodontists and the general dentists. A total of 346 Fixed Prosthodontic Laboratory Tracking Sheets for the 2012 academic year were reviewed. The results showed that, overall, 73% of submitted impressions were acceptable at initial evaluation, 16% had to be poured first and re-evaluated for quality prior to pindexing, 7% had multiple impressions submitted for transfer dies, and 4% were rejected for poor quality. There were higher acceptance rates for impressions and work authorizations for cases staffed by prosthodontists than by general dentists, but the differences were not statistically significant (p=0.0584 and p=0.0666, respectively). Regarding the work authorizations, 43% overall did not provide sufficient information or had technical errors that delayed prosthesis fabrication. The most common errors were incorrect mountings, absence of solid casts, inadequate description of margins for porcelain fused to metal crowns, inaccurate die trimming, and margin marking. The percentages of errors in cases supervised by general dentists and prosthodontists were similar for 17 of the 18 types of errors identified; only for margin description was the percentage of errors statistically significantly higher for general dentist-supervised than prosthodontist-supervised cases. These results highlighted the ongoing need for faculty development and calibration to ensure students receive the highest quality education from all faculty members teaching fixed prosthodontics.

Evaluation of quality indicators in a laboratory supporting tertiary cancer care facilities in India.

PubMed

Kumar, Savitha Anil; Jayanna, Prashanth; Prabhudesai, Shilpa; Kumar, Ajai

2014-01-01

To collect and tabulate errors and nonconformities in the preanalytical, analytical, and postanalytical process phases in a diagnostic clinical laboratory that supports a super-specialty cancer center in India, and identify areas of potential improvement in patient services. We collected data from our laboratory during a period of 24 months. Departments in the study included clinical biochemistry, hematology, clinical pathology, microbiology and serology, surgical pathology, and molecular pathology. We had initiated quality assessment based on international standards in our laboratory in 2010, with the aim of obtaining accreditation by national and international governing bodies. We followed the guidelines specified by International Organization for Standardization (ISO) 15189:2007 to identify noncompliant elements of our processes. Among a total of 144,030 specimens that our referral laboratory received during the 2-year period of our study, we uncovered an overall error rate for all 3 process phases of 1.23%; all of our error rates closely approximated the results from our peer institutions. Errors were most common in the preanalytical phase in both years of study; preanalytical- and postanalytical-phase errors constituted more than 90% of all errors. Further improvements are warranted in laboratory services and are contingent on adequate training and interdepartmental communication and cooperation. Copyright© by the American Society for Clinical Pathology (ASCP).

Evaluation of an in-practice wet-chemistry analyzer using canine and feline serum samples.

PubMed

Irvine, Katherine L; Burt, Kay; Papasouliotis, Kostas

2016-01-01

A wet-chemistry biochemical analyzer was assessed for in-practice veterinary use. Its small size may mean a cost-effective method for low-throughput in-house biochemical analyses for first-opinion practice. The objectives of our study were to determine imprecision, total observed error, and acceptability of the analyzer for measurement of common canine and feline serum analytes, and to compare clinical sample results to those from a commercial reference analyzer. Imprecision was determined by within- and between-run repeatability for canine and feline pooled samples, and manufacturer-supplied quality control material (QCM). Total observed error (TEobs) was determined for pooled samples and QCM. Performance was assessed for canine and feline pooled samples by sigma metric determination. Agreement and errors between the in-practice and reference analyzers were determined for canine and feline clinical samples by Bland-Altman and Deming regression analyses. Within- and between-run precision was high for most analytes, and TEobs(%) was mostly lower than total allowable error. Performance based on sigma metrics was good (σ > 4) for many analytes and marginal (σ > 3) for most of the remainder. Correlation between the analyzers was very high for most canine analytes and high for most feline analytes. Between-analyzer bias was generally attributed to high constant error. The in-practice analyzer showed good overall performance, with only calcium and phosphate analyses identified as significantly problematic. Agreement for most analytes was insufficient for transposition of reference intervals, and we recommend that in-practice-specific reference intervals be established in the laboratory. © 2015 The Author(s).

Limited Documentation and Treatment Quality of Glycemic Inpatient Care in Relation to Structural Deficits of Heterogeneous Insulin Charts at a Large University Hospital.

PubMed

Kopanz, Julia; Lichtenegger, Katharina M; Sendlhofer, Gerald; Semlitsch, Barbara; Cuder, Gerald; Pak, Andreas; Pieber, Thomas R; Tax, Christa; Brunner, Gernot; Plank, Johannes

2018-02-09

Insulin charts represent a key component in the inpatient glycemic management process. The aim was to evaluate the quality of structure, documentation, and treatment of diabetic inpatient care to design a new standardized insulin chart for a large university hospital setting. Historically grown blank insulin charts in use at 39 general wards were collected and evaluated for quality structure features. Documentation and treatment quality were evaluated in a consecutive snapshot audit of filled-in charts. The primary end point was the percentage of charts with any medication error. Overall, 20 different blank insulin charts with variable designs and significant structural deficits were identified. A medication error occurred in 55% of the 102 audited filled-in insulin charts, consisting of prescription and management errors in 48% and 16%, respectively. Charts of insulin-treated patients had more medication errors relative to patients treated with oral medication (P < 0.01). Chart design did support neither clinical authorization of individual insulin prescription (10%), nor insulin administration confirmed by nurses' signature (25%), nor treatment of hypoglycemia (0%), which resulted in a reduced documentation and treatment quality in clinical practice 7%, 30%, 25%, respectively. A multitude of charts with variable design characteristics and structural deficits were in use across the inpatient wards. More than half of the inpatients had a chart displaying a medication error. Lack of structure quality features of the charts had an impact on documentation and treatment quality. Based on identified deficits and international standards, a new insulin chart was developed to overcome these quality hurdles.

Inhibitory saccadic dysfunction is associated with cerebellar injury in multiple sclerosis.

PubMed

Kolbe, Scott C; Kilpatrick, Trevor J; Mitchell, Peter J; White, Owen; Egan, Gary F; Fielding, Joanne

2014-05-01

Cognitive dysfunction is common in patients with multiple sclerosis (MS). Saccadic eye movement paradigms such as antisaccades (AS) can sensitively interrogate cognitive function, in particular, the executive and attentional processes of response selection and inhibition. Although we have previously demonstrated significant deficits in the generation of AS in MS patients, the neuropathological changes underlying these deficits were not elucidated. In this study, 24 patients with relapsing-remitting MS underwent testing using an AS paradigm. Rank correlation and multiple regression analyses were subsequently used to determine whether AS errors in these patients were associated with: (i) neurological and radiological abnormalities, as measured by standard clinical techniques, (ii) cognitive dysfunction, and (iii) regionally specific cerebral white and gray-matter damage. Although AS error rates in MS patients did not correlate with clinical disability (using the Expanded Disability Status Score), T2 lesion load or brain parenchymal fraction, AS error rate did correlate with performance on the Paced Auditory Serial Addition Task and the Symbol Digit Modalities Test, neuropsychological tests commonly used in MS. Further, voxel-wise regression analyses revealed associations between AS errors and reduced fractional anisotropy throughout most of the cerebellum, and increased mean diffusivity in the cerebellar vermis. Region-wise regression analyses confirmed that AS errors also correlated with gray-matter atrophy in the cerebellum right VI subregion. These results support the use of the AS paradigm as a marker for cognitive dysfunction in MS and implicate structural and microstructural changes to the cerebellum as a contributing mechanism for AS deficits in these patients. Copyright © 2013 Wiley Periodicals, Inc.

Application of the clinical version of the narrow path walking test to identify elderly fallers.

PubMed

Gimmon, Yoav; Barash, Avi; Debi, Ronen; Snir, Yoram; Bar David, Yair; Grinshpon, Jacob; Melzer, Itshak

2016-01-01

Falling during walking is a common problem among the older population. Hence, the challenge facing clinicians is identifying who is at risk of falling during walking, for providing an effective intervention to reduce that risk. We aimed to assess whether the clinical version of the narrow path walking test (NPWT) could identify older adults who are reported falls. A total of 160 older adults were recruited and asked to recall fall events during the past year. Subjects were instructed to walk in the laboratory at a comfortable pace within a 6 meter long narrow path, 3 trials under single task (ST) and 3 trials dual task (DT) conditions without stepping outside the path (i.e., step errors). The average trial time, number of steps, trial velocity, number of step errors, and number of cognitive task errors were calculated for ST and DT. Fear of falling, performance oriented mobility assessment (POMA) and mini-metal state examination (MMSE) were measured as well. Sixty-one subjects reported that they had fallen during the past year and 99 did not. Fallers performed more steps, and were slower than non-fallers. There were no significant differences, however, in the number of steps errors, the cognitive task errors in ST and DT in POMA and MMSE. Our data demonstrates slower gait speed and more steps during the NPWT in ST and DT in fallers. There is no added value of DT over the ST for identification of faller's older adults. Copyright © 2015 Elsevier Ireland Ltd. All rights reserved.

Associations between intrusive thoughts, reality discrimination and hallucination-proneness in healthy young adults.

PubMed

Smailes, David; Meins, Elizabeth; Fernyhough, Charles

2015-01-01

People who experience intrusive thoughts are at increased risk of developing hallucinatory experiences, as are people who have weak reality discrimination skills. No study has yet examined whether these two factors interact to make a person especially prone to hallucinatory experiences. The present study examined this question in a non-clinical sample. Participants were 160 students, who completed a reality discrimination task, as well as self-report measures of cannabis use, negative affect, intrusive thoughts and auditory hallucination-proneness. The possibility of an interaction between reality discrimination performance and level of intrusive thoughts was assessed using multiple regression. The number of reality discrimination errors and level of intrusive thoughts were independent predictors of hallucination-proneness. The reality discrimination errors × intrusive thoughts interaction term was significant, with participants who made many reality discrimination errors and reported high levels of intrusive thoughts being especially prone to hallucinatory experiences. Hallucinatory experiences are more likely to occur in people who report high levels of intrusive thoughts and have weak reality discrimination skills. If applicable to clinical samples, these findings suggest that improving patients' reality discrimination skills and reducing the number of intrusive thoughts they experience may reduce the frequency of hallucinatory experiences.

Promises and pitfalls of Illumina sequencing for HIV resistance genotyping.

PubMed

Brumme, Chanson J; Poon, Art F Y

2017-07-15

Genetic sequencing ("genotyping") plays a critical role in the modern clinical management of HIV infection. This virus evolves rapidly within patients because of its error-prone reverse transcriptase and short generation time. Consequently, HIV variants with mutations that confer resistance to one or more antiretroviral drugs can emerge during sub-optimal treatment. There are now multiple HIV drug resistance interpretation algorithms that take the region of the HIV genome encoding the major drug targets as inputs; expert use of these algorithms can significantly improve to clinical outcomes in HIV treatment. Next-generation sequencing has the potential to revolutionize HIV resistance genotyping by lowering the threshold that rare but clinically significant HIV variants can be detected reproducibly, and by conferring improved cost-effectiveness in high-throughput scenarios. In this review, we discuss the relative merits and challenges of deploying the Illumina MiSeq instrument for clinical HIV genotyping. Copyright © 2016 Elsevier B.V. All rights reserved.

An Evaluation of Departmental Radiation Oncology Incident Reports: Anticipating a National Reporting System

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

Terezakis, Stephanie A., E-mail: stereza1@jhmi.edu; Harris, Kendra M.; Ford, Eric

Purpose: Systems to ensure patient safety are of critical importance. The electronic incident reporting systems (IRS) of 2 large academic radiation oncology departments were evaluated for events that may be suitable for submission to a national reporting system (NRS). Methods and Materials: All events recorded in the combined IRS were evaluated from 2007 through 2010. Incidents were graded for potential severity using the validated French Nuclear Safety Authority (ASN) 5-point scale. These incidents were categorized into 7 groups: (1) human error, (2) software error, (3) hardware error, (4) error in communication between 2 humans, (5) error at the human-software interface,more » (6) error at the software-hardware interface, and (7) error at the human-hardware interface. Results: Between the 2 systems, 4407 incidents were reported. Of these events, 1507 (34%) were considered to have the potential for clinical consequences. Of these 1507 events, 149 (10%) were rated as having a potential severity of ≥2. Of these 149 events, the committee determined that 79 (53%) of these events would be submittable to a NRS of which the majority was related to human error or to the human-software interface. Conclusions: A significant number of incidents were identified in this analysis. The majority of events in this study were related to human error and to the human-software interface, further supporting the need for a NRS to facilitate field-wide learning and system improvement.« less

Prescription errors in the National Health Services, time to change practice.

PubMed

Hamid, Tahir; Harper, Luke; Rose, Samman; Petkar, Sanjive; Fienman, Richard; Athar, Syed M; Cushley, Michael

2016-02-01

Medication error is a major source of iatrogenic illness. Error in prescription is the most common form of avoidable medication error. We present our study, performed at two, UK, National Health Services Hospitals. The prescription practice of junior doctor's working on general medical and surgical wards in National Health Service District General and University Teaching Hospitals in the UK was reviewed. Practice was assessed against standard hospital prescription charts, developed in accordance with local pharmacy guidance. A total of 407 prescription charts were reviewed in both initial audit and re-audit one year later. In the District General Hospital, documentation of allergy, weight and capital-letter prescription was achieved in 31, 5 and 40% of charts, respectively. Forty-nine per cent of discontinued prescriptions were properly deleted and signed for. In re-audit significant improvement was noted in documentation of the patient's name 100%, gender 54%, allergy status 51% and use of generic drug name 71%. Similarly, in the University Teaching Hospital, 82, 63 and 65% compliance was achieved in documentation of age, generic drug name prescription and capital-letter prescription, respectively. Prescription practice was reassessed one year later after recommendations and changes in the prescription practice, leading to significant improvement in documentation of unit number, generic drug name prescription, insulin prescription and documentation of the patient's ward. Prescription error remains an important, modifiable form of medical error, which may be rectified by introducing multidisciplinary assessment of practice, nationwide standardised prescription charts and revision of current prescribing clinical training. © The Author(s) 2016.

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

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

Boehnke, E McKenzie; DeMarco, J; Steers, J

2016-06-15

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

The precision of a special purpose analog computer in clinical cardiac output determination.

PubMed Central

Sullivan, F J; Mroz, E A; Miller, R E

1975-01-01

Three hundred dye-dilution curves taken during our first year of clinical experience with the Waters CO-4 cardiac output computer were analyzed to estimate the errors involved in its use. Provided that calibration is accurate and 5.0 mg of dye are injected for each curve, then the percentage standard deviation of measurement using this computer is about 8.7%. Included in this are the errors inherent in the computer, errors due to baseline drift, errors in the injection of dye and acutal variation of cardiac output over a series of successive determinations. The size of this error is comparable to that involved in manual calculation. The mean value of five successive curves will be within 10% of the real value in 99 cases out of 100. Advances in methodology and equipment are discussed which make calibration simpler and more accurate, and which should also improve the quality of computer determination. A list of suggestions is given to minimize the errors involved in the clinical use of this equipment. Images Fig. 4. PMID:1089394

The associations of insomnia with costly workplace accidents and errors: results from the America Insomnia Survey.

PubMed

Shahly, Victoria; Berglund, Patricia A; Coulouvrat, Catherine; Fitzgerald, Timothy; Hajak, Goeran; Roth, Thomas; Shillington, Alicia C; Stephenson, Judith J; Walsh, James K; Kessler, Ronald C

2012-10-01

Insomnia is a common and seriously impairing condition that often goes unrecognized. To examine associations of broadly defined insomnia (ie, meeting inclusion criteria for a diagnosis from International Statistical Classification of Diseases, 10th Revision, DSM-IV, or Research Diagnostic Criteria/International Classification of Sleep Disorders, Second Edition) with costly workplace accidents and errors after excluding other chronic conditions among workers in the America Insomnia Survey (AIS). A national cross-sectional telephone survey (65.0% cooperation rate) of commercially insured health plan members selected from the more than 34 million in the HealthCore Integrated Research Database. Four thousand nine hundred ninety-one employed AIS respondents. Costly workplace accidents or errors in the 12 months before the AIS interview were assessed with one question about workplace accidents "that either caused damage or work disruption with a value of $500 or more" and another about other mistakes "that cost your company $500 or more." Current insomnia with duration of at least 12 months was assessed with the Brief Insomnia Questionnaire, a validated (area under the receiver operating characteristic curve, 0.86 compared with diagnoses based on blinded clinical reappraisal interviews), fully structured diagnostic interview. Eighteen other chronic conditions were assessed with medical/pharmacy claims records and validated self-report scales. Insomnia had a significant odds ratio with workplace accidents and/or errors controlled for other chronic conditions (1.4). The odds ratio did not vary significantly with respondent age, sex, educational level, or comorbidity. The average costs of insomnia-related accidents and errors ($32 062) were significantly higher than those of other accidents and errors ($21 914). Simulations estimated that insomnia was associated with 7.2% of all costly workplace accidents and errors and 23.7% of all the costs of these incidents. These proportions are higher than for any other chronic condition, with annualized US population projections of 274 000 costly insomnia-related workplace accidents and errors having a combined value of US $31.1 billion. Effectiveness trials are needed to determine whether expanded screening, outreach, and treatment of workers with insomnia would yield a positive return on investment for employers.

SU-E-T-210: Surviving a Visit by the Radiological Physics Center.

PubMed

Grant, W; Mcgary, J; Rosen, I; Nitsch, P; Davidson, S

2012-06-01

To demonstrate an objective approach to determining if a negative report from the Radiological Physics Center (RPC) of greater than 10% error is valid or has clinical significance. The discrepancy involved the clinical activity (mgRaEq) of Cs-137 sources, some manufactured by 3M and some by Amersham. Measurements were made in the proprietary RPC Well Counter calibrated by the MD Anderson ADCL and our Well Counter (CNMC, Model 44D) calibrated by the same laboratory as well as the University of Wisconsin ADCL. In addition, we possess an Amersham Cs-137 Check Source that had been calibrated by the UW-ADCL in 2002. All clinical sources were checked in both Well Counters on the first visit. One clinical source and the Check Source were measured in a second visit that occurred 51 days later. On the initial RPC visit, 9 of 25 sources had a minimum of an 8% discrepancy between the RPC and the Institution, with a maximum of 11%. Contributing errors included using the incorrect straw position by us, an unexplained 2.3% error in the RPC data identified 73 days post-visit, a 2% variation in Chamber Factors for our Well Counter from the two ADCL's. When we use the 2004 value of Air Kerma Strength for the Check Source to determine a Calibration Factor of the Well Counter, all sources were within 0.5% of their decayed value established in 2002. This work emphasizes the value of having simple Constancy Check systems in a Quality Assurance program as 'Accuracy' has error bars. The disagreement in calibration data between the ADCL Laboratories, which was at the 2% maximum quoted in their Calibration Reports, is a reminder that there is uncertainty in measurements. Constancy Checks allow one to sort out discrepancies and to answer challenges to the validity of your program. © 2012 American Association of Physicists in Medicine.

Technical Quality of Root Canal Treatment Performed by Undergraduate Clinical Students of Isfahan Dental School.

PubMed

Saatchi, Masoud; Mohammadi, Golshan; Vali Sichani, Armita; Moshkforoush, Saba

2018-01-01

The aim of the present study was to evaluate the radiographic quality of RCTs performed by undergraduate clinical students of Dental School of Isfahan University of Medical Sciences. In this cross sectional study, records and periapical radiographs of 1200 root filled teeth were randomly selected from the records of patients who had received RCTs in Dental School of Isfahan University of Medical Sciences from 2013 to 2015. After excluding 416 records, the final sample consisted of 784 root-treated teeth (1674 root canals). Two variables including the length and the density of the root fillings were examined. Moreover, the presence of ledge, foramen perforation, root perforation and fractured instruments were also evaluated as procedural errors. Descriptive statistics were used for expressing the frequencies of criteria and chi square test was used for comparing tooth types, tooth locations and academic level of students ( P <0.05). The frequency of root canals with acceptable filling was 54.1%. Overfilling was found in 11% of root canals, underfilling in 8.3% and inadequate density in 34.6%. No significant difference was found between the frequency of acceptable root fillings in the maxilla and mandible ( P =0.072). More acceptable fillings were found in the root canals of premolars (61.3%) than molars (51.3%) ( P =0.001). The frequency of procedural errors was 18.6%. Ledge was found in 12.5% of root canals, foramen perforation in 2%, root perforation in 2.4% and fractured instrument in 2%. Procedural errors were more frequent in the root canals of molars (22.5%) than the anterior teeth (12.3%) ( P =0.003) and the premolars (9.5%) ( P <0.001). Technical quality of RCTs performed by clinical students was not satisfactory and incidence of procedural errors was considerable.

Comparison of the clinical information provided by the FreeStyle Navigator continuous interstitial glucose monitor versus traditional blood glucose readings.

PubMed

McGarraugh, Geoffrey V; Clarke, William L; Kovatchev, Boris P

2010-05-01

The purpose of the analysis was to compare the clinical utility of data from traditional self-monitoring of blood glucose (SMBG) to that of continuous glucose monitoring (CGM). A clinical study of the clinical accuracy of the FreeStyle Navigator CGM System (Abbott Diabetes Care, Alameda, CA), which includes SMBG capabilities, was conducted by comparison to the YSI blood glucose analyzer (YSI Inc., Yellow Springs, OH) using 58 subjects with type 1 diabetes. The Continuous Glucose-Error Grid Analysis (CG-EGA) was used as the analytical tool. Using CG-EGA, the "clinically accurate," "benign errors," and "clinical errors" were 86.8%, 8.7%, and 4.5% for SMBG and 92.7%, 3.7%, and 3.6% for CGM, respectively. If blood glucose is viewed as a process in time, SMBG would provide accurate information about this process 86.8% of the time, whereas CGM would provide accurate information about this process 92.7% of the time (P < 0.0001). In the hypoglycemic range, however, SMBG is more accurate as the "clinically accurate," "benign errors," and "clinical errors" were 83.5%, 6.4%, and 10.1% for SMBG and 57.1%, 8.4%, and 34.5% (P < 0.0001) for CGM, respectively. While SMBG produces more accurate instantaneous glucose values than CGM, control of blood glucose involves a system in flux, and CGM provides more detailed insight into the dynamics of that system. In the normal and elevated glucose ranges, the additional information about the direction and rate of glucose change provided by the FreeStyle Navigator CGM System increases the ability to make correct clinical decisions when compared to episodic SMBG tests.

Assessing data quality and the variability of source data verification auditing methods in clinical research settings.

PubMed

Houston, Lauren; Probst, Yasmine; Martin, Allison

2018-05-18

Data audits within clinical settings are extensively used as a major strategy to identify errors, monitor study operations and ensure high-quality data. However, clinical trial guidelines are non-specific in regards to recommended frequency, timing and nature of data audits. The absence of a well-defined data quality definition and method to measure error undermines the reliability of data quality assessment. This review aimed to assess the variability of source data verification (SDV) auditing methods to monitor data quality in a clinical research setting. The scientific databases MEDLINE, Scopus and Science Direct were searched for English language publications, with no date limits applied. Studies were considered if they included data from a clinical trial or clinical research setting and measured and/or reported data quality using a SDV auditing method. In total 15 publications were included. The nature and extent of SDV audit methods in the articles varied widely, depending upon the complexity of the source document, type of study, variables measured (primary or secondary), data audit proportion (3-100%) and collection frequency (6-24 months). Methods for coding, classifying and calculating error were also inconsistent. Transcription errors and inexperienced personnel were the main source of reported error. Repeated SDV audits using the same dataset demonstrated ∼40% improvement in data accuracy and completeness over time. No description was given in regards to what determines poor data quality in clinical trials. A wide range of SDV auditing methods are reported in the published literature though no uniform SDV auditing method could be determined for "best practice" in clinical trials. Published audit methodology articles are warranted for the development of a standardised SDV auditing method to monitor data quality in clinical research settings. Copyright © 2018. Published by Elsevier Inc.

Progressive sampling-based Bayesian optimization for efficient and automatic machine learning model selection.

PubMed

Zeng, Xueqiang; Luo, Gang

2017-12-01

Machine learning is broadly used for clinical data analysis. Before training a model, a machine learning algorithm must be selected. Also, the values of one or more model parameters termed hyper-parameters must be set. Selecting algorithms and hyper-parameter values requires advanced machine learning knowledge and many labor-intensive manual iterations. To lower the bar to machine learning, miscellaneous automatic selection methods for algorithms and/or hyper-parameter values have been proposed. Existing automatic selection methods are inefficient on large data sets. This poses a challenge for using machine learning in the clinical big data era. To address the challenge, this paper presents progressive sampling-based Bayesian optimization, an efficient and automatic selection method for both algorithms and hyper-parameter values. We report an implementation of the method. We show that compared to a state of the art automatic selection method, our method can significantly reduce search time, classification error rate, and standard deviation of error rate due to randomization. This is major progress towards enabling fast turnaround in identifying high-quality solutions required by many machine learning-based clinical data analysis tasks.

Quantitative evaluation of patient-specific quality assurance using online dosimetry system

NASA Astrophysics Data System (ADS)

Jung, Jae-Yong; Shin, Young-Ju; Sohn, Seung-Chang; Min, Jung-Whan; Kim, Yon-Lae; Kim, Dong-Su; Choe, Bo-Young; Suh, Tae-Suk

2018-01-01

In this study, we investigated the clinical performance of an online dosimetry system (Mobius FX system, MFX) by 1) dosimetric plan verification using gamma passing rates and dose volume metrics and 2) error-detection capability evaluation by deliberately introduced machine error. Eighteen volumetric modulated arc therapy (VMAT) plans were studied. To evaluate the clinical performance of the MFX, we used gamma analysis and dose volume histogram (DVH) analysis. In addition, to evaluate the error-detection capability, we used gamma analysis and DVH analysis utilizing three types of deliberately introduced errors (Type 1: gantry angle-independent multi-leaf collimator (MLC) error, Type 2: gantry angle-dependent MLC error, and Type 3: gantry angle error). A dosimetric verification comparison of physical dosimetry system (Delt4PT) and online dosimetry system (MFX), gamma passing rates of the two dosimetry systems showed very good agreement with treatment planning system (TPS) calculation. For the average dose difference between the TPS calculation and the MFX measurement, most of the dose metrics showed good agreement within a tolerance of 3%. For the error-detection comparison of Delta4PT and MFX, the gamma passing rates of the two dosimetry systems did not meet the 90% acceptance criterion with the magnitude of error exceeding 2 mm and 1.5 ◦, respectively, for error plans of Types 1, 2, and 3. For delivery with all error types, the average dose difference of PTV due to error magnitude showed good agreement between calculated TPS and measured MFX within 1%. Overall, the results of the online dosimetry system showed very good agreement with those of the physical dosimetry system. Our results suggest that a log file-based online dosimetry system is a very suitable verification tool for accurate and efficient clinical routines for patient-specific quality assurance (QA).

Perceptions of the 2011 ACGME duty hour requirements among residents in all core programs at a large academic medical center.

PubMed

Sandefur, Benjamin J; Shewmaker, Diana M; Lohse, Christine M; Rose, Steven H; Colletti, James E

2017-11-10

The Accreditation Council for Graduate Medical Education (ACGME) implemented revisions to resident duty hour requirements (DHRs) in 2011 to improve patient safety and resident well-being. Perceptions of DHRs have been reported to vary by training stage and specialty among internal medicine and general surgery residents. The authors explored perceptions of DHRs among all residents at a large academic medical center. The authors administered an anonymous cross-sectional survey about DHRs to residents enrolled in all ACGME-accredited core residency programs at their institution. Residents were categorized as medical and pediatric, surgery, or other. In total, 736 residents representing 24 core specialty residency programs were surveyed. The authors received responses from 495 residents (67%). A majority reported satisfaction (78%) with DHRs and believed DHRs positively affect their training (73%). Residents in surgical specialties and in advanced stages of training were significantly less likely to view DHRs favorably. Most respondents believed fatigue contributes to errors (89%) and DHRs reduce both fatigue (80%) and performance of clinical duties while fatigued (74%). A minority of respondents (37%) believed that DHRs decrease medical errors. This finding may reflect beliefs that handovers contribute more to errors than fatigue (41%). Negative perceived effects included diminished patient familiarity and continuity of care (62%) and diminished clinical educational experiences for residents (41%). A majority of residents reported satisfaction with the 2011 DHRs, although satisfaction was significantly less among residents in surgical specialties and those in advanced stages of training.

Significance of acceleration period in a dynamic strength testing study.

PubMed

Chen, W L; Su, F C; Chou, Y L

1994-06-01

The acceleration period that occurs during isokinetic tests may provide valuable information regarding neuromuscular readiness to produce maximal contraction. The purpose of this study was to collect the normative data of acceleration time during isokinetic knee testing, to calculate the acceleration work (Wacc), and to determine the errors (ERexp, ERwork, ERpower) due to ignoring Wacc during explosiveness, total work, and average power measurements. Seven male and 13 female subjects attended the test by using the Cybex 325 system and electronic stroboscope machine for 10 testing speeds (30-300 degrees/sec). A three-way ANOVA was used to assess gender, direction, and speed factors on acceleration time, Wacc, and errors. The results indicated that acceleration time was significantly affected by speed and direction; Wacc and ERexp by speed, direction, and gender; and ERwork and ERpower by speed and gender. The errors appeared to increase when testing the female subjects, during the knee flexion test, or when speed increased. To increase validity in clinical testing, it is important to consider the acceleration phase effect, especially in higher velocity isokinetic testing or for weaker muscle groups.

Modelling category goodness judgments in children with residual sound errors.

PubMed

Dugan, Sarah Hamilton; Silbert, Noah; McAllister, Tara; Preston, Jonathan L; Sotto, Carolyn; Boyce, Suzanne E

2018-05-24

This study investigates category goodness judgments of /r/ in adults and children with and without residual speech errors (RSEs) using natural speech stimuli. Thirty adults, 38 children with RSE (ages 7-16) and 35 age-matched typically developing (TD) children provided category goodness judgments on whole words, recorded from 27 child speakers, with /r/ in various phonetic environments. The salient acoustic property of /r/ - the lowered third formant (F3) - was normalized in two ways. A logistic mixed-effect model quantified the relationships between listeners' responses and the third formant frequency, vowel context and clinical group status. Goodness judgments from the adult group showed a statistically significant interaction with the F3 parameter when compared to both child groups (p < 0.001) using both normalization methods. The RSE group did not differ significantly from the TD group in judgments of /r/. All listeners were significantly more likely to judge /r/ as correct in a front-vowel context. Our results suggest that normalized /r/ F3 is a statistically significant predictor of category goodness judgments for both adults and children, but children do not appear to make adult-like judgments. Category goodness judgments do not have a clear relationship with /r/ production abilities in children with RSE. These findings may have implications for clinical activities that include category goodness judgments in natural speech, especially for recorded productions.

[Diagnostic Errors in Medicine].

PubMed

Buser, Claudia; Bankova, Andriyana

2015-12-09

The recognition of diagnostic errors in everyday practice can help improve patient safety. The most common diagnostic errors are the cognitive errors, followed by system-related errors and no fault errors. The cognitive errors often result from mental shortcuts, known as heuristics. The rate of cognitive errors can be reduced by a better understanding of heuristics and the use of checklists. The autopsy as a retrospective quality assessment of clinical diagnosis has a crucial role in learning from diagnostic errors. Diagnostic errors occur more often in primary care in comparison to hospital settings. On the other hand, the inpatient errors are more severe than the outpatient errors.

Cue-induced craving in patients with cocaine use disorder predicts cognitive control deficits toward cocaine cues.

PubMed

DiGirolamo, Gregory J; Smelson, David; Guevremont, Nathan

2015-08-01

Cue-induced craving is a clinically important aspect of cocaine addiction influencing ongoing use and sobriety. However, little is known about the relationship between cue-induced craving and cognitive control toward cocaine cues. While studies suggest that cocaine users have an attentional bias toward cocaine cues, the present study extends this research by testing if cocaine use disorder patients (CDPs) can control their eye movements toward cocaine cues and whether their response varied by cue-induced craving intensity. Thirty CDPs underwent a cue exposure procedure to dichotomize them into high and low craving groups followed by a modified antisaccade task in which subjects were asked to control their eye movements toward either a cocaine or neutral drug cue by looking away from the suddenly presented cue. The relationship between breakdowns in cognitive control (as measured by eye errors) and cue-induced craving (changes in self-reported craving following cocaine cue exposure) was investigated. CDPs overall made significantly more errors toward cocaine cues compared to neutral cues, with higher cravers making significantly more errors than lower cravers even though they did not differ significantly in addiction severity, impulsivity, anxiety, or depression levels. Cue-induced craving was the only specific and significant predictor of subsequent errors toward cocaine cues. Cue-induced craving directly and specifically relates to breakdowns of cognitive control toward cocaine cues in CDPs, with higher cravers being more susceptible. Hence, it may be useful identifying high cravers and target treatment toward curbing craving to decrease the likelihood of a subsequent breakdown in control. Copyright © 2015 Elsevier Ltd. All rights reserved.

Multimodal system designed to reduce errors in recording and administration of drugs in anaesthesia: prospective randomised clinical evaluation.

PubMed

Merry, Alan F; Webster, Craig S; Hannam, Jacqueline; Mitchell, Simon J; Henderson, Robert; Reid, Papaarangi; Edwards, Kylie-Ellen; Jardim, Anisoara; Pak, Nick; Cooper, Jeremy; Hopley, Lara; Frampton, Chris; Short, Timothy G

2011-09-22

To clinically evaluate a new patented multimodal system (SAFERSleep) designed to reduce errors in the recording and administration of drugs in anaesthesia. Prospective randomised open label clinical trial. Five designated operating theatres in a major tertiary referral hospital. Eighty nine consenting anaesthetists managing 1075 cases in which there were 10,764 drug administrations. Use of the new system (which includes customised drug trays and purpose designed drug trolley drawers to promote a well organised anaesthetic workspace and aseptic technique; pre-filled syringes for commonly used anaesthetic drugs; large legible colour coded drug labels; a barcode reader linked to a computer, speakers, and touch screen to provide automatic auditory and visual verification of selected drugs immediately before each administration; automatic compilation of an anaesthetic record; an on-screen and audible warning if an antibiotic has not been administered within 15 minutes of the start of anaesthesia; and certain procedural rules-notably, scanning the label before each drug administration) versus conventional practice in drug administration with a manually compiled anaesthetic record. Primary: composite of errors in the recording and administration of intravenous drugs detected by direct observation and by detailed reconciliation of the contents of used drug vials against recorded administrations; and lapses in responding to an intermittent visual stimulus (vigilance latency task). Secondary: outcomes in patients; analyses of anaesthetists' tasks and assessments of workload; evaluation of the legibility of anaesthetic records; evaluation of compliance with the procedural rules of the new system; and questionnaire based ratings of the respective systems by participants. The overall mean rate of drug errors per 100 administrations was 9.1 (95% confidence interval 6.9 to 11.4) with the new system (one in 11 administrations) and 11.6 (9.3 to 13.9) with conventional methods (one in nine administrations) (P = 0.045 for difference). Most were recording errors, and, though fewer drug administration errors occurred with the new system, the comparison with conventional methods did not reach significance. Rates of errors in drug administration were lower when anaesthetists consistently applied two key principles of the new system (scanning the drug barcode before administering each drug and keeping the voice prompt active) than when they did not: mean 6.0 (3.1 to 8.8) errors per 100 administrations v 9.7 (8.4 to 11.1) respectively (P = 0.004). Lapses in the vigilance latency task occurred in 12% (58/471) of cases with the new system and 9% (40/473) with conventional methods (P = 0.052). The records generated by the new system were more legible, and anaesthetists preferred the new system, particularly in relation to long, complex, and emergency cases. There were no differences between new and conventional systems in respect of outcomes in patients or anaesthetists' workload. The new system was associated with a reduction in errors in the recording and administration of drugs in anaesthesia, attributable mainly to a reduction in recording errors. Automatic compilation of the anaesthetic record increased legibility but also increased lapses in a vigilance latency task and decreased time spent watching monitors. Trial registration Australian New Zealand Clinical Trials Registry No 12608000068369.

Use of error grid analysis to evaluate acceptability of a point of care prothrombin time meter.

PubMed

Petersen, John R; Vonmarensdorf, Hans M; Weiss, Heidi L; Elghetany, M Tarek

2010-02-01

Statistical methods (linear regression, correlation analysis, etc.) are frequently employed in comparing methods in the central laboratory (CL). Assessing acceptability of point of care testing (POCT) equipment, however, is more difficult because statistically significant biases may not have an impact on clinical care. We showed how error grid (EG) analysis can be used to evaluate POCT PT INR with the CL. We compared results from 103 patients seen in an anti-coagulation clinic that were on Coumadin maintenance therapy using fingerstick samples for POCT (Roche CoaguChek XS and S) and citrated venous blood samples for CL (Stago STAR). To compare clinical acceptability of results we developed an EG with zones A, B, C and D. Using 2nd order polynomial equation analysis, POCT results highly correlate with the CL for CoaguChek XS (R(2)=0. 955) and CoaguChek S (R(2)=0. 93), respectively but does not indicate if POCT results are clinically interchangeable with the CL. Using EG it is readily apparent which levels can be considered clinically identical to the CL despite analytical bias. We have demonstrated the usefulness of EG in determining acceptability of POCT PT INR testing and how it can be used to determine cut-offs where differences in POCT results may impact clinical care. Copyright 2009 Elsevier B.V. All rights reserved.

The effectiveness of risk management program on pediatric nurses' medication error.

PubMed

Dehghan-Nayeri, Nahid; Bayat, Fariba; Salehi, Tahmineh; Faghihzadeh, Soghrat

2013-09-01

Medication therapy is one of the most complex and high-risk clinical processes that nurses deal with. Medication error is the most common type of error that brings about damage and death to patients, especially pediatric ones. However, these errors are preventable. Identifying and preventing undesirable events leading to medication errors are the main risk management activities. The aim of this study was to investigate the effectiveness of a risk management program on the pediatric nurses' medication error rate. This study is a quasi-experimental one with a comparison group. In this study, 200 nurses were recruited from two main pediatric hospitals in Tehran. In the experimental hospital, we applied the risk management program for a period of 6 months. Nurses of the control hospital did the hospital routine schedule. A pre- and post-test was performed to measure the frequency of the medication error events. SPSS software, t-test, and regression analysis were used for data analysis. After the intervention, the medication error rate of nurses at the experimental hospital was significantly lower (P < 0.001) and the error-reporting rate was higher (P < 0.007) compared to before the intervention and also in comparison to the nurses of the control hospital. Based on the results of this study and taking into account the high-risk nature of the medical environment, applying the quality-control programs such as risk management can effectively prevent the occurrence of the hospital undesirable events. Nursing mangers can reduce the medication error rate by applying risk management programs. However, this program cannot succeed without nurses' cooperation.

An electrophysiological signal that precisely tracks the emergence of error awareness

PubMed Central

Murphy, Peter R.; Robertson, Ian H.; Allen, Darren; Hester, Robert; O'Connell, Redmond G.

2012-01-01

Recent electrophysiological research has sought to elucidate the neural mechanisms necessary for the conscious awareness of action errors. Much of this work has focused on the error positivity (Pe), a neural signal that is specifically elicited by errors that have been consciously perceived. While awareness appears to be an essential prerequisite for eliciting the Pe, the precise functional role of this component has not been identified. Twenty-nine participants performed a novel variant of the Go/No-go Error Awareness Task (EAT) in which awareness of commission errors was indicated via a separate speeded manual response. Independent component analysis (ICA) was used to isolate the Pe from other stimulus- and response-evoked signals. Single-trial analysis revealed that Pe peak latency was highly correlated with the latency at which awareness was indicated. Furthermore, the Pe was more closely related to the timing of awareness than it was to the initial erroneous response. This finding was confirmed in a separate study which derived IC weights from a control condition in which no indication of awareness was required, thus ruling out motor confounds. A receiver-operating-characteristic (ROC) curve analysis showed that the Pe could reliably predict whether an error would be consciously perceived up to 400 ms before the average awareness response. Finally, Pe latency and amplitude were found to be significantly correlated with overall error awareness levels between subjects. Our data show for the first time that the temporal dynamics of the Pe trace the emergence of error awareness. These findings have important implications for interpreting the results of clinical EEG studies of error processing. PMID:22470332

Comparison of electronic data capture (EDC) with the standard data capture method for clinical trial data.

PubMed

Walther, Brigitte; Hossin, Safayet; Townend, John; Abernethy, Neil; Parker, David; Jeffries, David

2011-01-01

Traditionally, clinical research studies rely on collecting data with case report forms, which are subsequently entered into a database to create electronic records. Although well established, this method is time-consuming and error-prone. This study compares four electronic data capture (EDC) methods with the conventional approach with respect to duration of data capture and accuracy. It was performed in a West African setting, where clinical trials involve data collection from urban, rural and often remote locations. Three types of commonly available EDC tools were assessed in face-to-face interviews; netbook, PDA, and tablet PC. EDC performance during telephone interviews via mobile phone was evaluated as a fourth method. The Graeco Latin square study design allowed comparison of all four methods to standard paper-based recording followed by data double entry while controlling simultaneously for possible confounding factors such as interview order, interviewer and interviewee. Over a study period of three weeks the error rates decreased considerably for all EDC methods. In the last week of the study the data accuracy for the netbook (5.1%, CI95%: 3.5-7.2%) and the tablet PC (5.2%, CI95%: 3.7-7.4%) was not significantly different from the accuracy of the conventional paper-based method (3.6%, CI95%: 2.2-5.5%), but error rates for the PDA (7.9%, CI95%: 6.0-10.5%) and telephone (6.3%, CI95% 4.6-8.6%) remained significantly higher. While EDC-interviews take slightly longer, data become readily available after download, making EDC more time effective. Free text and date fields were associated with higher error rates than numerical, single select and skip fields. EDC solutions have the potential to produce similar data accuracy compared to paper-based methods. Given the considerable reduction in the time from data collection to database lock, EDC holds the promise to reduce research-associated costs. However, the successful implementation of EDC requires adjustment of work processes and reallocation of resources.

Comparison of Electronic Data Capture (EDC) with the Standard Data Capture Method for Clinical Trial Data

PubMed Central

Walther, Brigitte; Hossin, Safayet; Townend, John; Abernethy, Neil; Parker, David; Jeffries, David

2011-01-01

Background Traditionally, clinical research studies rely on collecting data with case report forms, which are subsequently entered into a database to create electronic records. Although well established, this method is time-consuming and error-prone. This study compares four electronic data capture (EDC) methods with the conventional approach with respect to duration of data capture and accuracy. It was performed in a West African setting, where clinical trials involve data collection from urban, rural and often remote locations. Methodology/Principal Findings Three types of commonly available EDC tools were assessed in face-to-face interviews; netbook, PDA, and tablet PC. EDC performance during telephone interviews via mobile phone was evaluated as a fourth method. The Graeco Latin square study design allowed comparison of all four methods to standard paper-based recording followed by data double entry while controlling simultaneously for possible confounding factors such as interview order, interviewer and interviewee. Over a study period of three weeks the error rates decreased considerably for all EDC methods. In the last week of the study the data accuracy for the netbook (5.1%, CI95%: 3.5–7.2%) and the tablet PC (5.2%, CI95%: 3.7–7.4%) was not significantly different from the accuracy of the conventional paper-based method (3.6%, CI95%: 2.2–5.5%), but error rates for the PDA (7.9%, CI95%: 6.0–10.5%) and telephone (6.3%, CI95% 4.6–8.6%) remained significantly higher. While EDC-interviews take slightly longer, data become readily available after download, making EDC more time effective. Free text and date fields were associated with higher error rates than numerical, single select and skip fields. Conclusions EDC solutions have the potential to produce similar data accuracy compared to paper-based methods. Given the considerable reduction in the time from data collection to database lock, EDC holds the promise to reduce research-associated costs. However, the successful implementation of EDC requires adjustment of work processes and reallocation of resources. PMID:21966505

The accuracy of home glucose meters in hypoglycemia.

PubMed

Sonmez, Alper; Yilmaz, Zeynep; Uckaya, Gokhan; Kilic, Selim; Tapan, Serkan; Taslipinar, Abdullah; Aydogdu, Aydogan; Yazici, Mahmut; Yilmaz, Mahmut Ilker; Serdar, Muhittin; Erbil, M Kemal; Kutlu, Mustafa

2010-08-01

Home glucose meters (HGMs) may not be accurate enough to sense hypoglycemia. We evaluated the accuracy and the capillary and venous comparability of five different HGMs (Optium Xceed [Abbott Diabetes Care, Alameda, CA, USA], Contour TS [Bayer Diabetes Care, Basel, Switzerland], Accu-Chek Go [Roche Ltd., Basel, Switzerland], OneTouch Select [Lifescan, Milpitas, CA, USA], and EZ Smart [Tyson Bioresearch Inc., Chu-Nan, Taiwan]) in an adult population. The insulin hypoglycemia test was performed to 59 subjects (56 males; 23.6 +/- 3.2 years old). Glucose was measured from forearm venous blood and finger capillary samples both before and after regular insulin (0.1 U/kg) was injected. Venous samples were analyzed in the reference laboratory by the hexokinase method. In vitro tests for method comparison and precision analyses were also performed by spiking the glucose-depleted venous blood. All HGMs failed to sense hypoglycemia to some extend. EZ Smart was significantly inferior in critical error Zone D, and OneTouch Select was significantly inferior in the clinically unimportant error Zone B. Accu-Chek Go, Optium Xceed, and Contour TS had similar performances and were significantly better than the other two HGMs according to error grid analysis or International Organization for Standardization criteria. The in vitro tests were consistent with the above clinical data. The capillary and venous consistencies of Accu-Chek Go and OneTouch Select were better than the other HGMs. The present results show that not all the HGMs are accurate enough in low blood glucose levels. The patients and the caregivers should be aware of these restrictions of the HGMs and give more credit to the symptoms of hypoglycemia than the values obtained by the HGMs. Finally, these results indicate that there is a need for the revision of the accuracy standards of HGMs in low blood glucose levels.

Diagnostic Discrepancies in Mandatory Slide Review of Extradepartmental Head and Neck Cases: Experience at a Large Academic Center.

PubMed

Mehrad, Mitra; Chernock, Rebecca D; El-Mofty, Samir K; Lewis, James S

2015-12-01

Medical error is a significant problem in the United States, and pathologic diagnoses are a significant source of errors. Prior studies have shown that second-opinion pathology review results in clinically major diagnosis changes in approximately 0.6% to 5.8% of patients. The few studies specifically on head and neck pathology have suggested rates of changed diagnoses that are even higher. Objectives .- To evaluate the diagnostic discrepancy rates in patients referred to our institution, where all such cases are reviewed by a head and neck subspecialty service, and to identify specific areas with more susceptibility to errors. Five hundred consecutive, scanned head and neck pathology reports from patients referred to our institution were compared for discrepancies between the outside and in-house diagnoses. Major discrepancies were defined as those resulting in a significant change in patient clinical management and/or prognosis. Major discrepancies occurred in 20 cases (4% overall). Informative follow-up material was available on 11 of the 20 patients (55.0%), among whom, the second opinion was supported in 11 of 11 cases (100%). Dysplasia versus invasive squamous cell carcinoma was the most common (7 of 20; 35%) area of discrepancy, and by anatomic subsite, the sinonasal tract (4 of 21; 19.0%) had the highest rate of discrepant diagnoses. Of the major discrepant diagnoses, 12 (12 of 20; 60%) involved a change from benign to malignant, one a change from malignant to benign (1 of 20; 5%), and 6 involved tumor classification (6 of 20; 30%). Head and neck pathology is a relatively high-risk area, prone to erroneous diagnoses in a small fraction of patients. This study supports the importance of second-opinion review by subspecialized pathologists for the best care of patients.

Effects of room environment and nursing experience on clinical blood pressure measurement: an observational study.

PubMed

Zhang, Meng; Zhang, Xuemei; Chen, Fei; Dong, Birong; Chen, Aiqing; Zheng, Dingchang

2017-04-01

This study aimed to examine the effects of measurement room environment and nursing experience on the accuracy of manual auscultatory blood pressure (BP) measurement. A training database with 32 Korotkoff sounds recordings from the British Hypertension Society was played randomly to 20 observers who were divided into four groups according to the years of their nursing experience (i.e. ≥10 years, 1-9 years, nursing students with frequent training, and those without any medical background; five observers in each group). All the observers were asked to determine manual auscultatory systolic blood pressure (SBP) and diastolic blood pressure (DBP) both in a quiet clinical assessment room and in a noisy nurse station area. This procedure was repeated on another day, yielding a total of four measurements from each observer (i.e. two room environments and two repeated determinations on 2 separate days) for each Korotkoff sound. The measurement error was then calculated against the reference answer, with the effects of room environment and nursing experience of the observer investigated. Our results showed that there was no statistically significant difference for BPs measured under both quiet and noisy environments (P>0.80 for both SBP and DBP). However, there was a significant effect on the measurement accuracy between the observer groups (P<0.001 for both SBP and DBP). The nursing students performed best with overall SBP and DBP errors of -0.8±2.4 and 0.1±1.8 mmHg, respectively. The SBP measurement error from the nursing students was significantly smaller than that for each of the other three groups (all P<0.001). Our results indicate that frequent nursing trainings are important for nurses to achieve accurate manual auscultatory BP measurement.

Concussion History and Time Since Concussion Do not Influence Static and Dynamic Balance in Collegiate Athletes.

PubMed

Merritt, Eric D; Brown, Cathleen N; Queen, Robin M; Simpson, Kathy J; Schmidt, Julianne D

2017-11-01

Dynamic balance deficits exist following a concussion, sometimes years after injury. However, clinicians lack practical tools for assessing dynamic balance. To determine if there are significant differences in static and dynamic balance performance between individuals with and without a history of concussion. Cross sectional. Clinical research laboratory. 45 collegiate student-athletes with a history of concussion (23 males, 22 females; age = 20.0 ± 1.4 y; height = 175.8 ± 11.6 cm; mass = 76.4 ± 19.2 kg) and 45 matched controls with no history of concussion (23 males, 22 females; age = 20.0 ± 1.3 y; height = 178.8 ± 13.2 cm; mass = 75.7 ± 18.2 kg). Participants completed a static (Balance Error Scoring System) and dynamic (Y Balance Test-Lower Quarter) balance assessment. A composite score was calculated from the mean normalized Y Balance Test-Lower Quarter reach distances. Firm, foam, and overall errors were counted during the Balance Error Scoring System by a single reliable rater. One-way ANOVAs were used to compare balance performance between groups. Pearson's correlations were performed to determine the relationship between the time since the most recent concussion and balance performance. A Bonferonni adjusted a priori α < 0.025 was used for all analyses. Static and dynamic balance performance did not significantly differ between groups. No significant correlation was found between the time since the most recent concussion and balance performance. Collegiate athletes with a history of concussion do not present with static or dynamic balance deficits when measured using clinical assessments. More research is needed to determine whether the Y Balance Test-Lower Quarter is sensitive to acute balance deficits following concussion.

Confidence and Information Access in Clinical Decision-Making: An Examination of the Cognitive Processes that affect the Information-seeking Behavior of Physicians.

PubMed

Uy, Raymonde Charles; Sarmiento, Raymond Francis; Gavino, Alex; Fontelo, Paul

2014-01-01

Clinical decision-making involves the interplay between cognitive processes and physicians' perceptions of confidence in the context of their information-seeking behavior. The objectives of the study are: to examine how these concepts interact, to determine whether physician confidence, defined in relation to information need, affects clinical decision-making, and if information access improves decision accuracy. We analyzed previously collected data about resident physicians' perceptions of information need from a study comparing abstracts and full-text articles in clinical decision accuracy. We found that there is a significant relation between confidence and accuracy (φ=0.164, p<0.01). We also found various differences in the alignment of confidence and accuracy, demonstrating the concepts of underconfidence and overconfidence across years of clinical experience. Access to online literature also has a significant effect on accuracy (p<0.001). These results highlight possible CDSS strategies to reduce medical errors.

Cognitive aspect of diagnostic errors.

PubMed

Phua, Dong Haur; Tan, Nigel C K

2013-01-01

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

Automatic detection of MLC relative position errors for VMAT using the EPID-based picket fence test

NASA Astrophysics Data System (ADS)

Christophides, Damianos; Davies, Alex; Fleckney, Mark

2016-12-01

Multi-leaf collimators (MLCs) ensure the accurate delivery of treatments requiring complex beam fluences like intensity modulated radiotherapy and volumetric modulated arc therapy. The purpose of this work is to automate the detection of MLC relative position errors  ⩾0.5 mm using electronic portal imaging device-based picket fence tests and compare the results to the qualitative assessment currently in use. Picket fence tests with and without intentional MLC errors were measured weekly on three Varian linacs. The picket fence images analysed covered a time period ranging between 14-20 months depending on the linac. An algorithm was developed that calculated the MLC error for each leaf-pair present in the picket fence images. The baseline error distributions of each linac were characterised for an initial period of 6 months and compared with the intentional MLC errors using statistical metrics. The distributions of median and one-sample Kolmogorov-Smirnov test p-value exhibited no overlap between baseline and intentional errors and were used retrospectively to automatically detect MLC errors in routine clinical practice. Agreement was found between the MLC errors detected by the automatic method and the fault reports during clinical use, as well as interventions for MLC repair and calibration. In conclusion the method presented provides for full automation of MLC quality assurance, based on individual linac performance characteristics. The use of the automatic method has been shown to provide early warning for MLC errors that resulted in clinical downtime.

Multicenter Assessment of Gram Stain Error Rates.

PubMed

Samuel, Linoj P; Balada-Llasat, Joan-Miquel; Harrington, Amanda; Cavagnolo, Robert

2016-06-01

Gram stains remain the cornerstone of diagnostic testing in the microbiology laboratory for the guidance of empirical treatment prior to availability of culture results. Incorrectly interpreted Gram stains may adversely impact patient care, and yet there are no comprehensive studies that have evaluated the reliability of the technique and there are no established standards for performance. In this study, clinical microbiology laboratories at four major tertiary medical care centers evaluated Gram stain error rates across all nonblood specimen types by using standardized criteria. The study focused on several factors that primarily contribute to errors in the process, including poor specimen quality, smear preparation, and interpretation of the smears. The number of specimens during the evaluation period ranged from 976 to 1,864 specimens per site, and there were a total of 6,115 specimens. Gram stain results were discrepant from culture for 5% of all specimens. Fifty-eight percent of discrepant results were specimens with no organisms reported on Gram stain but significant growth on culture, while 42% of discrepant results had reported organisms on Gram stain that were not recovered in culture. Upon review of available slides, 24% (63/263) of discrepant results were due to reader error, which varied significantly based on site (9% to 45%). The Gram stain error rate also varied between sites, ranging from 0.4% to 2.7%. The data demonstrate a significant variability between laboratories in Gram stain performance and affirm the need for ongoing quality assessment by laboratories. Standardized monitoring of Gram stains is an essential quality control tool for laboratories and is necessary for the establishment of a quality benchmark across laboratories. Copyright © 2016, American Society for Microbiology. All Rights Reserved.

Multicenter Assessment of Gram Stain Error Rates

PubMed Central

Balada-Llasat, Joan-Miquel; Harrington, Amanda; Cavagnolo, Robert

2016-01-01

Gram stains remain the cornerstone of diagnostic testing in the microbiology laboratory for the guidance of empirical treatment prior to availability of culture results. Incorrectly interpreted Gram stains may adversely impact patient care, and yet there are no comprehensive studies that have evaluated the reliability of the technique and there are no established standards for performance. In this study, clinical microbiology laboratories at four major tertiary medical care centers evaluated Gram stain error rates across all nonblood specimen types by using standardized criteria. The study focused on several factors that primarily contribute to errors in the process, including poor specimen quality, smear preparation, and interpretation of the smears. The number of specimens during the evaluation period ranged from 976 to 1,864 specimens per site, and there were a total of 6,115 specimens. Gram stain results were discrepant from culture for 5% of all specimens. Fifty-eight percent of discrepant results were specimens with no organisms reported on Gram stain but significant growth on culture, while 42% of discrepant results had reported organisms on Gram stain that were not recovered in culture. Upon review of available slides, 24% (63/263) of discrepant results were due to reader error, which varied significantly based on site (9% to 45%). The Gram stain error rate also varied between sites, ranging from 0.4% to 2.7%. The data demonstrate a significant variability between laboratories in Gram stain performance and affirm the need for ongoing quality assessment by laboratories. Standardized monitoring of Gram stains is an essential quality control tool for laboratories and is necessary for the establishment of a quality benchmark across laboratories. PMID:26888900

Missed lung cancer: when, where, and why?

PubMed Central

del Ciello, Annemilia; Franchi, Paola; Contegiacomo, Andrea; Cicchetti, Giuseppe; Bonomo, Lorenzo; Larici, Anna Rita

2017-01-01

Missed lung cancer is a source of concern among radiologists and an important medicolegal challenge. In 90% of the cases, errors in diagnosis of lung cancer occur on chest radiographs. It may be challenging for radiologists to distinguish a lung lesion from bones, pulmonary vessels, mediastinal structures, and other complex anatomical structures on chest radiographs. Nevertheless, lung cancer can also be overlooked on computed tomography (CT) scans, regardless of the context, either if a clinical or radiologic suspect exists or for other reasons. Awareness of the possible causes of overlooking a pulmonary lesion can give radiologists a chance to reduce the occurrence of this eventuality. Various factors contribute to a misdiagnosis of lung cancer on chest radiographs and on CT, often very similar in nature to each other. Observer error is the most significant one and comprises scanning error, recognition error, decision-making error, and satisfaction of search. Tumor characteristics such as lesion size, conspicuity, and location are also crucial in this context. Even technical aspects can contribute to the probability of skipping lung cancer, including image quality and patient positioning and movement. Albeit it is hard to remove missed lung cancer completely, strategies to reduce observer error and methods to improve technique and automated detection may be valuable in reducing its likelihood. PMID:28206951

Goldmann Tonometer Prism with an Optimized Error Correcting Applanation Surface.

PubMed

McCafferty, Sean; Lim, Garrett; Duncan, William; Enikov, Eniko; Schwiegerling, Jim

2016-09-01

We evaluate solutions for an applanating surface modification to the Goldmann tonometer prism, which substantially negates the errors due to patient variability in biomechanics. A modified Goldmann or correcting applanation tonometry surface (CATS) prism is presented which was optimized to minimize the intraocular pressure (IOP) error due to corneal thickness, stiffness, curvature, and tear film. Mathematical modeling with finite element analysis (FEA) and manometric IOP referenced cadaver eyes were used to optimize and validate the design. Mathematical modeling of the optimized CATS prism indicates an approximate 50% reduction in each of the corneal biomechanical and tear film errors. Manometric IOP referenced pressure in cadaveric eyes demonstrates substantial equivalence to GAT in nominal eyes with the CATS prism as predicted by modeling theory. A CATS modified Goldmann prism is theoretically able to significantly improve the accuracy of IOP measurement without changing Goldmann measurement technique or interpretation. Clinical validation is needed but the analysis indicates a reduction in CCT error alone to less than ±2 mm Hg using the CATS prism in 100% of a standard population compared to only 54% less than ±2 mm Hg error with the present Goldmann prism. This article presents an easily adopted novel approach and critical design parameters to improve the accuracy of a Goldmann applanating tonometer.

The effectiveness of computerized order entry at reducing preventable adverse drug events and medication errors in hospital settings: a systematic review and meta-analysis

PubMed Central

2014-01-01

Background The Health Information Technology for Economic and Clinical Health (HITECH) Act subsidizes implementation by hospitals of electronic health records with computerized provider order entry (CPOE), which may reduce patient injuries caused by medication errors (preventable adverse drug events, pADEs). Effects on pADEs have not been rigorously quantified, and effects on medication errors have been variable. The objectives of this analysis were to assess the effectiveness of CPOE at reducing pADEs in hospital-related settings, and examine reasons for heterogeneous effects on medication errors. Methods Articles were identified using MEDLINE, Cochrane Library, Econlit, web-based databases, and bibliographies of previous systematic reviews (September 2013). Eligible studies compared CPOE with paper-order entry in acute care hospitals, and examined diverse pADEs or medication errors. Studies on children or with limited event-detection methods were excluded. Two investigators extracted data on events and factors potentially associated with effectiveness. We used random effects models to pool data. Results Sixteen studies addressing medication errors met pooling criteria; six also addressed pADEs. Thirteen studies used pre-post designs. Compared with paper-order entry, CPOE was associated with half as many pADEs (pooled risk ratio (RR) = 0.47, 95% CI 0.31 to 0.71) and medication errors (RR = 0.46, 95% CI 0.35 to 0.60). Regarding reasons for heterogeneous effects on medication errors, five intervention factors and two contextual factors were sufficiently reported to support subgroup analyses or meta-regression. Differences between commercial versus homegrown systems, presence and sophistication of clinical decision support, hospital-wide versus limited implementation, and US versus non-US studies were not significant, nor was timing of publication. Higher baseline rates of medication errors predicted greater reductions (P < 0.001). Other context and implementation variables were seldom reported. Conclusions In hospital-related settings, implementing CPOE is associated with a greater than 50% decline in pADEs, although the studies used weak designs. Decreases in medication errors are similar and robust to variations in important aspects of intervention design and context. This suggests that CPOE implementation, as subsidized under the HITECH Act, may benefit public health. More detailed reporting of the context and process of implementation could shed light on factors associated with greater effectiveness. PMID:24894078

Safety culture perceptions of pharmacists in Malaysian hospitals and health clinics: a multicentre assessment using the Safety Attitudes Questionnaire.

PubMed

Samsuri, Srima Elina; Pei Lin, Lua; Fahrni, Mathumalar Loganathan

2015-11-26

To assess the safety attitudes of pharmacists, provide a profile of their domains of safety attitude and correlate their attitudes with self-reported rates of medication errors. A cross-sectional study utilising the Safety Attitudes Questionnaire (SAQ). 3 public hospitals and 27 health clinics. 117 pharmacists. Safety culture mean scores, variation in scores across working units and between hospitals versus health clinics, predictors of safety culture, and medication errors and their correlation. Response rate was 83.6% (117 valid questionnaires returned). Stress recognition (73.0±20.4) and working condition (54.8±17.4) received the highest and lowest mean scores, respectively. Pharmacists exhibited positive attitudes towards: stress recognition (58.1%), job satisfaction (46.2%), teamwork climate (38.5%), safety climate (33.3%), perception of management (29.9%) and working condition (15.4%). With the exception of stress recognition, those who worked in health clinics scored higher than those in hospitals (p<0.05) and higher scores (overall score as well as score for each domain except for stress recognition) correlated negatively with reported number of medication errors. Conversely, those working in hospital (versus health clinic) were 8.9 times more likely (p<0.01) to report a medication error (OR 8.9, CI 3.08 to 25.7). As stress recognition increased, the number of medication errors reported increased (p=0.023). Years of work experience (p=0.017) influenced the number of medication errors reported. For every additional year of work experience, pharmacists were 0.87 times less likely to report a medication error (OR 0.87, CI 0.78 to 0.98). A minority (20.5%) of the pharmacists working in hospitals and health clinics was in agreement with the overall SAQ questions and scales. Pharmacists in outpatient and ambulatory units and those in health clinics had better perceptions of safety culture. As perceptions improved, the number of medication errors reported decreased. Group-specific interventions that target specific domains are necessary to improve the safety culture. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/

Population-based assessment of sensitivity and specificity of a pinhole for detection of significant refractive errors in the community.

PubMed

Marmamula, Srinivas; Keeffe, Jill E; Narsaiah, Saggam; Khanna, Rohit C; Rao, Gullapalli N

2014-11-01

Measurements of refractive errors through subjective or automated refraction are not always possible in rapid assessment studies and community vision screening programs; however, measurements of vision with habitual correction and with a pinhole can easily be made. Although improvements in vision with a pinhole are assumed to mean that a refractive error is present, no studies have investigated the magnitude of improvement in vision with pinhole that is predictive of refractive error. The aim was to measure the sensitivity and specificity of 'vision improvement with pinhole' in predicting the presence of refractive error in a community setting. Vision and vision with pinhole were measured using a logMAR chart for 488 of 582 individuals aged 15 to 50 years. Refractive errors were measured using non-cycloplegic autorefraction and subjective refraction. The presence of refractive error was defined using spherical equivalent refraction (SER) at two levels: SER greater than ± 0.50 D sphere (DS) and SER greater than ±1.00 DS. Three definitions for significant improvement in vision with a pinhole were used: 1. Presenting vision less than 6/12 and improving to 6/12 or better, 2. Improvement in vision of more than one logMAR line and 3. Improvement in vision of more than two logMAR lines. For refractive error defined as spherical equivalent refraction greater than ± 0.50 DS, the sensitivities and specificities for the pinhole test predicting the presence of refractive error were 83.9 per cent (95% CI: 74.5 to 90.9) and 98.8 per cent (95% CI: 97.1 to 99.6), respectively for definition 1. Definition 2 had a sensitivity 89.7 per cent (95% CI: 81.3 to 95.2) and specificity 88.0 per cent (95% CI: 4.4 to 91.0). Definition 3 had a sensitivity of 75.9 per cent (95% CI: 65.5 to 84.4) and specificity of 97.8 per cent (95% CI: 95.8 to 99.0). Similar results were found with spherical equivalent refraction greater than ±1.00 DS, when tested against the three pinhole-based definitions. Refractive error definitions based on improvement in vision with the pinhole shows good sensitivity and specificity at predicting the presence of significant refractive errors. These definitions can be used in rapid assessment surveys and community-based vision screenings. © 2014 The Authors. Clinical and Experimental Optometry © 2014 Optometrists Association Australia.

Cost-Effectiveness Analysis of an Automated Medication System Implemented in a Danish Hospital Setting.

PubMed

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

To evaluate the cost-effectiveness of an automated medication system (AMS) implemented in a Danish hospital setting. An economic evaluation was performed alongside a controlled before-and-after effectiveness study with one control ward and one intervention ward. The primary outcome measure was the number of errors in the medication administration process observed prospectively before and after implementation. To determine the difference in proportion of errors after implementation of the AMS, logistic regression was applied with the presence of error(s) as the dependent variable. Time, group, and interaction between time and group were the independent variables. The cost analysis used the hospital perspective with a short-term incremental costing approach. The total 6-month costs with and without the AMS were calculated as well as the incremental costs. The number of avoided administration errors was related to the incremental costs to obtain the cost-effectiveness ratio expressed as the cost per avoided administration error. The AMS resulted in a statistically significant reduction in the proportion of errors in the intervention ward compared with the control ward. The cost analysis showed that the AMS increased the ward's 6-month cost by €16,843. The cost-effectiveness ratio was estimated at €2.01 per avoided administration error, €2.91 per avoided procedural error, and €19.38 per avoided clinical error. The AMS was effective in reducing errors in the medication administration process at a higher overall cost. The cost-effectiveness analysis showed that the AMS was associated with affordable cost-effectiveness rates. Copyright © 2017 International Society for Pharmacoeconomics and Outcomes Research (ISPOR). Published by Elsevier Inc. All rights reserved.

Economic impact of medication error: a systematic review.

PubMed

Walsh, Elaine K; Hansen, Christina Raae; Sahm, Laura J; Kearney, Patricia M; Doherty, Edel; Bradley, Colin P

2017-05-01

Medication error is a significant source of morbidity and mortality among patients. Clinical and cost-effectiveness evidence are required for the implementation of quality of care interventions. Reduction of error-related cost is a key potential benefit of interventions addressing medication error. The aim of this review was to describe and quantify the economic burden associated with medication error. PubMed, Cochrane, Embase, CINAHL, EconLit, ABI/INFORM, Business Source Complete were searched. Studies published 2004-2016 assessing the economic impact of medication error were included. Cost values were expressed in Euro 2015. A narrative synthesis was performed. A total of 4572 articles were identified from database searching, and 16 were included in the review. One study met all applicable quality criteria. Fifteen studies expressed economic impact in monetary terms. Mean cost per error per study ranged from €2.58 to €111 727.08. Healthcare costs were used to measure economic impact in 15 of the included studies with one study measuring litigation costs. Four studies included costs incurred in primary care with the remaining 12 measuring hospital costs. Five studies looked at general medication error in a general population with 11 studies reporting the economic impact of an individual type of medication error or error within a specific patient population. Considerable variability existed between studies in terms of financial cost, patients, settings and errors included. Many were of poor quality. Assessment of economic impact was conducted predominantly in the hospital setting with little assessment of primary care impact. Limited parameters were used to establish economic impact. Copyright © 2017 John Wiley & Sons, Ltd. Copyright © 2017 John Wiley & Sons, Ltd.

MO-FG-202-06: Improving the Performance of Gamma Analysis QA with Radiomics- Based Image Analysis

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

Wootton, L; Nyflot, M; Ford, E

2016-06-15

Purpose: The use of gamma analysis for IMRT quality assurance has well-known limitations. Traditionally, a simple thresholding technique is used to evaluated passing criteria. However, like any image the gamma distribution is rich in information which thresholding mostly discards. We therefore propose a novel method of analyzing gamma images that uses quantitative image features borrowed from radiomics, with the goal of improving error detection. Methods: 368 gamma images were generated from 184 clinical IMRT beams. For each beam the dose to a phantom was measured with EPID dosimetry and compared to the TPS dose calculated with and without normally distributedmore » (2mm sigma) errors in MLC positions. The magnitude of 17 intensity histogram and size-zone radiomic features were derived from each image. The features that differed most significantly between image sets were determined with ROC analysis. A linear machine-learning model was trained on these features to classify images as with or without errors on 180 gamma images.The model was then applied to an independent validation set of 188 additional gamma distributions, half with and half without errors. Results: The most significant features for detecting errors were histogram kurtosis (p=0.007) and three size-zone metrics (p<1e-6 for each). The sizezone metrics detected clusters of high gamma-value pixels under mispositioned MLCs. The model applied to the validation set had an AUC of 0.8, compared to 0.56 for traditional gamma analysis with the decision threshold restricted to 98% or less. Conclusion: A radiomics-based image analysis method was developed that is more effective in detecting error than traditional gamma analysis. Though the pilot study here considers only MLC position errors, radiomics-based methods for other error types are being developed, which may provide better error detection and useful information on the source of detected errors. This work was partially supported by a grant from the Agency for Healthcare Research and Quality, grant number R18 HS022244-01.« less

Quality of Best Possible Medication History upon Admission to Hospital: Comparison of Nurses and Pharmacy Students and Consideration of National Quality Indicators.

PubMed

Sproul, Ashley; Goodine, Carole; Moore, David; McLeod, Amy; Gordon, Jacqueline; Digby, Jennifer; Stoica, George

2018-01-01

Medication reconciliation at transitions of care increases patient safety. Collection of an accurate best possible medication history (BPMH) on admission is a key step. National quality indicators are used as surrogate markers for BPMH quality, but no literature on their accuracy exists. Obtaining a high-quality BPMH is often labour- and resource-intensive. Pharmacy students are now being assigned to obtain BPMHs, as a cost-effective means to increase BPMH completion, despite limited information to support the quality of BPMHs obtained by students relative to other health care professionals. To determine whether the national quality indicator of using more than one source to complete a BPMH is a true marker of quality and to assess whether BPMHs obtained by pharmacy students were of quality equal to those obtained by nurses. This prospective trial compared BPMHs for the same group of patients collected by nurses and by trained pharmacy students in the emergency departments of 2 sites within a large health network over a 2-month period (July and August 2016). Discrepancies between the 2 versions were identified by a pharmacist, who determined which party (nurse, pharmacy student, or both) had made an error. A panel of experts reviewed the errors and ranked their severity. BPMHs were prepared for a total of 40 patients. Those prepared by nurses were more likely to contain an error than those prepared by pharmacy students (171 versus 43 errors, p = 0.006). There was a nonsignificant trend toward less severe errors in BPMHs completed by pharmacy students. There was no significant difference in the mean number of errors in relation to the specified quality indicator (mean of 2.7 errors for BPMHs prepared from 1 source versus 4.8 errors for BPMHs prepared from ≥ 2 sources, p = 0.08). The surrogate marker (number of BPMH sources) may not reflect BPMH quality. However, it appears that BPMHs prepared by pharmacy students had fewer errors and were of similar quality (in terms of clinically significant errors) relative to those prepared by nurses.

Effect of Clothing on Measurement of Bone Mineral Density.

PubMed

McNamara, Elizabeth A; Feldman, Anna Z; Malabanan, Alan O; Abate, Ejigayehu G; Whittaker, LaTarsha G; Yano-Litwin, Amanda; Dorazio, Jolene; Rosen, Harold N

2016-01-01

It is unknown whether allowing patients to have BMD (bone mineral density) studies acquired while wearing radiolucent clothing adlib contributes appreciably to the measurement error seen. To examine this question, a spine phantom was scanned 30 times without any clothing, while draped with a gown, and while draped with heavy winter clothing. The effect on mean BMD and on SD (standard deviation) was assessed. The effect of clothing on mean or SD of the area was not significant. The effect of clothing on mean and SD for BMD was small but significant and was around 1.6% for the mean. However, the effect on BMD precision was much more clinically important. Without clothing the spine phantom had an least significant change of 0.0077 gm/cm(2), while when introducing variability of clothing the least significant change rose as high as 0.0305 gm/cm(2). We conclude that, adding clothing to the spine phantom had a small but statistically significant effect on the mean BMD and on variance of the measurement. It is unlikely that the effect on mean BMD has any clinical significance, but the effect on the reproducibility (precision) of the result is likely clinically significant. Copyright © 2016 The International Society for Clinical Densitometry. Published by Elsevier Inc. All rights reserved.

Phonological and Motor Errors in Individuals with Acquired Sound Production Impairment

ERIC Educational Resources Information Center

Buchwald, Adam; Miozzo, Michele

2012-01-01

Purpose: This study aimed to compare sound production errors arising due to phonological processing impairment with errors arising due to motor speech impairment. Method: Two speakers with similar clinical profiles who produced similar consonant cluster simplification errors were examined using a repetition task. We compared both overall accuracy…

Hospital staff registered nurses' perception of horizontal violence, peer relationships, and the quality and safety of patient care.

PubMed

Purpora, Christina; Blegen, Mary A; Stotts, Nancy A

2015-01-01

To test hypotheses from a horizontal violence and quality and safety of patient care model: horizontal violence (negative behavior among peers) is inversely related to peer relations, quality of care and it is positively related to errors and adverse events. Additionally, the association between horizontal violence, peer relations, quality of care, errors and adverse events, and nurse and work characteristics were determined. A random sample (n= 175) of hospital staff Registered Nurses working in California. Nurses participated via survey. Bivariate and multivariate analyses tested the study hypotheses. Hypotheses were supported. Horizontal violence was inversely related to peer relations and quality of care, and positively related to errors and adverse events. Including peer relations in the analyses altered the relationship between horizontal violence and quality of care but not between horizontal violence, errors and adverse events. Nurse and hospital characteristics were not related to other variables. Clinical area contributed significantly in predicting the quality of care, errors and adverse events but not peer relationships. Horizontal violence affects peer relationships and the quality and safety of patient care as perceived by participating nurses. Supportive peer relationships are important to mitigate the impact of horizontal violence on quality of care.

In Vivo Precision of Digital Topological Skeletonization Based Individual Trabecula Segmentation (ITS) Analysis of Trabecular Microstructure at the Distal Radius and Tibia by HR-pQCT.

PubMed

Zhou, Bin; Zhang, Zhendong; Wang, Ji; Yu, Y Eric; Liu, Xiaowei Sherry; Nishiyama, Kyle K; Rubin, Mishaela R; Shane, Elizabeth; Bilezikian, John P; Guo, X Edward

2016-06-01

Trabecular plate and rod microstructure plays a dominant role in the apparent mechanical properties of trabecular bone. With high-resolution computed tomography (CT) images, digital topological analysis (DTA) including skeletonization and topological classification was applied to transform the trabecular three-dimensional (3D) network into surface and curve skeletons. Using the DTA-based topological analysis and a new reconstruction/recovery scheme, individual trabecula segmentation (ITS) was developed to segment individual trabecular plates and rods and quantify the trabecular plate- and rod-related morphological parameters. High-resolution peripheral quantitative computed tomography (HR-pQCT) is an emerging in vivo imaging technique to visualize 3D bone microstructure. Based on HR-pQCT images, ITS was applied to various HR-pQCT datasets to examine trabecular plate- and rod-related microstructure and has demonstrated great potential in cross-sectional and longitudinal clinical applications. However, the reproducibility of ITS has not been fully determined. The aim of the current study is to quantify the precision errors of ITS plate-rod microstructural parameters. In addition, we utilized three different frequently used contour techniques to separate trabecular and cortical bone and to evaluate their effect on ITS measurements. Overall, good reproducibility was found for the standard HR-pQCT parameters with precision errors for volumetric BMD and bone size between 0.2%-2.0%, and trabecular bone microstructure between 4.9%-6.7% at the radius and tibia. High reproducibility was also achieved for ITS measurements using all three different contour techniques. For example, using automatic contour technology, low precision errors were found for plate and rod trabecular number (pTb.N, rTb.N, 0.9% and 3.6%), plate and rod trabecular thickness (pTb.Th, rTb.Th, 0.6% and 1.7%), plate trabecular surface (pTb.S, 3.4%), rod trabecular length (rTb.ℓ, 0.8%), and plate-plate junction density (P-P Junc.D, 2.3%) at the tibia. The precision errors at the radius were similar to those at the tibia. In addition, precision errors were affected by the contour technique. At the tibia, precision error by the manual contour method was significantly different from automatic and standard contour methods for pTb.N, rTb.N and rTb.Th. Precision error using the manual contour method was also significantly different from the standard contour method for rod trabecular number (rTb.N), rod trabecular thickness (rTb.Th), rod-rod and plate-rod junction densities (R-R Junc.D and P-R Junc.D) at the tibia. At the radius, the precision error was similar between the three different contour methods. Image quality was also found to significantly affect the ITS reproducibility. We concluded that ITS parameters are highly reproducible, giving assurance that future cross-sectional and longitudinal clinical HR-pQCT studies are feasible in the context of limited sample sizes.

pyAmpli: an amplicon-based variant filter pipeline for targeted resequencing data.

PubMed

Beyens, Matthias; Boeckx, Nele; Van Camp, Guy; Op de Beeck, Ken; Vandeweyer, Geert

2017-12-14

Haloplex targeted resequencing is a popular method to analyze both germline and somatic variants in gene panels. However, involved wet-lab procedures may introduce false positives that need to be considered in subsequent data-analysis. No variant filtering rationale addressing amplicon enrichment related systematic errors, in the form of an all-in-one package, exists to our knowledge. We present pyAmpli, a platform independent parallelized Python package that implements an amplicon-based germline and somatic variant filtering strategy for Haloplex data. pyAmpli can filter variants for systematic errors by user pre-defined criteria. We show that pyAmpli significantly increases specificity, without reducing sensitivity, essential for reporting true positive clinical relevant mutations in gene panel data. pyAmpli is an easy-to-use software tool which increases the true positive variant call rate in targeted resequencing data. It specifically reduces errors related to PCR-based enrichment of targeted regions.

Misadministration of radiation therapy in veterinary medicine: a case report and literature review.

PubMed

Arkans, M M; Gieger, T L; Nolan, M W

2017-03-01

Recent technical advancements in radiation therapy have allowed for improved targeting of tumours and sparing nearby normal tissues, while simultaneously decreasing the risk for medical errors by incorporating additional safety checks into electronic medical record keeping systems. The benefits of these new technologies, however, depends on their proper integration and use in the oncology clinic. Despite the advancement of technology for treatment delivery and medical record keeping, misadministration errors have a significant impact on patient care in veterinary oncology. The first part of this manuscript describes a medical incident that occurred at an academic veterinary referral hospital, in a dog receiving a combination of stereotactic radiation therapy and full-course intensity-modulated, image-guided radiation therapy. The second part of the report is a literature review, which explores misadministration errors and novel challenges which arise with the implementation of advancing technologies in veterinary radiation oncology. © 2015 John Wiley & Sons Ltd.

Insight into biases and sequencing errors for amplicon sequencing with the Illumina MiSeq platform.

PubMed

Schirmer, Melanie; Ijaz, Umer Z; D'Amore, Rosalinda; Hall, Neil; Sloan, William T; Quince, Christopher

2015-03-31

With read lengths of currently up to 2 × 300 bp, high throughput and low sequencing costs Illumina's MiSeq is becoming one of the most utilized sequencing platforms worldwide. The platform is manageable and affordable even for smaller labs. This enables quick turnaround on a broad range of applications such as targeted gene sequencing, metagenomics, small genome sequencing and clinical molecular diagnostics. However, Illumina error profiles are still poorly understood and programs are therefore not designed for the idiosyncrasies of Illumina data. A better knowledge of the error patterns is essential for sequence analysis and vital if we are to draw valid conclusions. Studying true genetic variation in a population sample is fundamental for understanding diseases, evolution and origin. We conducted a large study on the error patterns for the MiSeq based on 16S rRNA amplicon sequencing data. We tested state-of-the-art library preparation methods for amplicon sequencing and showed that the library preparation method and the choice of primers are the most significant sources of bias and cause distinct error patterns. Furthermore we tested the efficiency of various error correction strategies and identified quality trimming (Sickle) combined with error correction (BayesHammer) followed by read overlapping (PANDAseq) as the most successful approach, reducing substitution error rates on average by 93%. © The Author(s) 2015. Published by Oxford University Press on behalf of Nucleic Acids Research.

Retinal Image Quality During Accommodation

PubMed Central

López-Gil, N.; Martin, J.; Liu, T.; Bradley, A.; Díaz-Muñoz, D.; Thibos, L.

2013-01-01

Purpose We asked if retinal image quality is maximum during accommodation, or sub-optimal due to accommodative error, when subjects perform an acuity task. Methods Subjects viewed a monochromatic (552nm), high-contrast letter target placed at various viewing distances. Wavefront aberrations of the accommodating eye were measured near the endpoint of an acuity staircase paradigm. Refractive state, defined as the optimum target vergence for maximising retinal image quality, was computed by through-focus wavefront analysis to find the power of the virtual correcting lens that maximizes visual Strehl ratio. Results Despite changes in ocular aberrations and pupil size during binocular viewing, retinal image quality and visual acuity typically remain high for all target vergences. When accommodative errors lead to sub-optimal retinal image quality, acuity and measured image quality both decline. However, the effect of accommodation errors of on visual acuity are mitigated by pupillary constriction associated with accommodation and binocular convergence and also to binocular summation of dissimilar retinal image blur. Under monocular viewing conditions some subjects displayed significant accommodative lag that reduced visual performance, an effect that was exacerbated by pharmacological dilation of the pupil. Conclusions Spurious measurement of accommodative error can be avoided when the image quality metric used to determine refractive state is compatible with the focusing criteria used by the visual system to control accommodation. Real focusing errors of the accommodating eye do not necessarily produce a reliably measurable loss of image quality or clinically significant loss of visual performance, probably because of increased depth-of-focus due to pupil constriction. When retinal image quality is close to maximum achievable (given the eye’s higher-order aberrations), acuity is also near maximum. A combination of accommodative lag, reduced image quality, and reduced visual function may be a useful sign for diagnosing functionally-significant accommodative errors indicating the need for therapeutic intervention. PMID:23786386

Retinal image quality during accommodation.

PubMed

López-Gil, Norberto; Martin, Jesson; Liu, Tao; Bradley, Arthur; Díaz-Muñoz, David; Thibos, Larry N

2013-07-01

We asked if retinal image quality is maximum during accommodation, or sub-optimal due to accommodative error, when subjects perform an acuity task. Subjects viewed a monochromatic (552 nm), high-contrast letter target placed at various viewing distances. Wavefront aberrations of the accommodating eye were measured near the endpoint of an acuity staircase paradigm. Refractive state, defined as the optimum target vergence for maximising retinal image quality, was computed by through-focus wavefront analysis to find the power of the virtual correcting lens that maximizes visual Strehl ratio. Despite changes in ocular aberrations and pupil size during binocular viewing, retinal image quality and visual acuity typically remain high for all target vergences. When accommodative errors lead to sub-optimal retinal image quality, acuity and measured image quality both decline. However, the effect of accommodation errors of on visual acuity are mitigated by pupillary constriction associated with accommodation and binocular convergence and also to binocular summation of dissimilar retinal image blur. Under monocular viewing conditions some subjects displayed significant accommodative lag that reduced visual performance, an effect that was exacerbated by pharmacological dilation of the pupil. Spurious measurement of accommodative error can be avoided when the image quality metric used to determine refractive state is compatible with the focusing criteria used by the visual system to control accommodation. Real focusing errors of the accommodating eye do not necessarily produce a reliably measurable loss of image quality or clinically significant loss of visual performance, probably because of increased depth-of-focus due to pupil constriction. When retinal image quality is close to maximum achievable (given the eye's higher-order aberrations), acuity is also near maximum. A combination of accommodative lag, reduced image quality, and reduced visual function may be a useful sign for diagnosing functionally-significant accommodative errors indicating the need for therapeutic intervention. © 2013 The Authors Ophthalmic & Physiological Optics © 2013 The College of Optometrists.

Demonstration of accuracy and clinical versatility of mutual information for automatic multimodality image fusion using affine and thin-plate spline warped geometric deformations.

PubMed

Meyer, C R; Boes, J L; Kim, B; Bland, P H; Zasadny, K R; Kison, P V; Koral, K; Frey, K A; Wahl, R L

1997-04-01

This paper applies and evaluates an automatic mutual information-based registration algorithm across a broad spectrum of multimodal volume data sets. The algorithm requires little or no pre-processing, minimal user input and easily implements either affine, i.e. linear or thin-plate spline (TPS) warped registrations. We have evaluated the algorithm in phantom studies as well as in selected cases where few other algorithms could perform as well, if at all, to demonstrate the value of this new method. Pairs of multimodal gray-scale volume data sets were registered by iteratively changing registration parameters to maximize mutual information. Quantitative registration errors were assessed in registrations of a thorax phantom using PET/CT and in the National Library of Medicine's Visible Male using MRI T2-/T1-weighted acquisitions. Registrations of diverse clinical data sets were demonstrated including rotate-translate mapping of PET/MRI brain scans with significant missing data, full affine mapping of thoracic PET/CT and rotate-translate mapping of abdominal SPECT/CT. A five-point thin-plate spline (TPS) warped registration of thoracic PET/CT is also demonstrated. The registration algorithm converged in times ranging between 3.5 and 31 min for affine clinical registrations and 57 min for TPS warping. Mean error vector lengths for rotate-translate registrations were measured to be subvoxel in phantoms. More importantly the rotate-translate algorithm performs well even with missing data. The demonstrated clinical fusions are qualitatively excellent at all levels. We conclude that such automatic, rapid, robust algorithms significantly increase the likelihood that multimodality registrations will be routinely used to aid clinical diagnoses and post-therapeutic assessment in the near future.

Reduction in Hospital-Wide Clinical Laboratory Specimen Identification Errors following Process Interventions: A 10-Year Retrospective Observational Study

PubMed Central

Ning, Hsiao-Chen; Lin, Chia-Ni; Chiu, Daniel Tsun-Yee; Chang, Yung-Ta; Wen, Chiao-Ni; Peng, Shu-Yu; Chu, Tsung-Lan; Yu, Hsin-Ming; Wu, Tsu-Lan

2016-01-01

Background Accurate patient identification and specimen labeling at the time of collection are crucial steps in the prevention of medical errors, thereby improving patient safety. Methods All patient specimen identification errors that occurred in the outpatient department (OPD), emergency department (ED), and inpatient department (IPD) of a 3,800-bed academic medical center in Taiwan were documented and analyzed retrospectively from 2005 to 2014. To reduce such errors, the following series of strategies were implemented: a restrictive specimen acceptance policy for the ED and IPD in 2006; a computer-assisted barcode positive patient identification system for the ED and IPD in 2007 and 2010, and automated sample labeling combined with electronic identification systems introduced to the OPD in 2009. Results Of the 2000345 specimens collected in 2005, 1023 (0.0511%) were identified as having patient identification errors, compared with 58 errors (0.0015%) among 3761238 specimens collected in 2014, after serial interventions; this represents a 97% relative reduction. The total number (rate) of institutional identification errors contributed from the ED, IPD, and OPD over a 10-year period were 423 (0.1058%), 556 (0.0587%), and 44 (0.0067%) errors before the interventions, and 3 (0.0007%), 52 (0.0045%) and 3 (0.0001%) after interventions, representing relative 99%, 92% and 98% reductions, respectively. Conclusions Accurate patient identification is a challenge of patient safety in different health settings. The data collected in our study indicate that a restrictive specimen acceptance policy, computer-generated positive identification systems, and interdisciplinary cooperation can significantly reduce patient identification errors. PMID:27494020

Medication administration errors from a nursing viewpoint: a formal consensus of definition and scenarios using a Delphi technique.

PubMed

Shawahna, Ramzi; Masri, Dina; Al-Gharabeh, Rawan; Deek, Rawan; Al-Thayba, Lama; Halaweh, Masa

2016-02-01

To develop and achieve formal consensus on a definition of medication administration errors and scenarios that should or should not be considered as medication administration errors in hospitalised patient settings. Medication administration errors occur frequently in hospitalised patient settings. Currently, there is no formal consensus on a definition of medication administration errors or scenarios that should or should not be considered as medication administration errors. This was a descriptive study using Delphi technique. A panel of experts (n = 50) recruited from major hospitals, nursing schools and universities in Palestine took part in the study. Three Delphi rounds were followed to achieve consensus on a proposed definition of medication administration errors and a series of 61 scenarios representing potential medication administration error situations formulated into a questionnaire. In the first Delphi round, key contact nurses' views on medication administration errors were explored. In the second Delphi round, consensus was achieved to accept the proposed definition of medication administration errors and to include 36 (59%) scenarios and exclude 1 (1·6%) as medication administration errors. In the third Delphi round, consensus was achieved to consider further 14 (23%) and exclude 2 (3·3%) as medication administration errors while the remaining eight (13·1%) were considered equivocal. Of the 61 scenarios included in the Delphi process, experts decided to include 50 scenarios as medication administration errors, exclude three scenarios and include or exclude eight scenarios depending on the individual clinical situation. Consensus on a definition and scenarios representing medication administration errors can be achieved using formal consensus techniques. Researchers should be aware that using different definitions of medication administration errors, inclusion or exclusion of medication administration error situations could significantly affect the rate of medication administration errors reported in their studies. Consensual definitions and medication administration error situations can be used in future epidemiology studies investigating medication administration errors in hospitalised patient settings which may permit and promote direct comparisons of different studies. © 2015 John Wiley & Sons Ltd.

Association of resident fatigue and distress with perceived medical errors.

PubMed

West, Colin P; Tan, Angelina D; Habermann, Thomas M; Sloan, Jeff A; Shanafelt, Tait D

2009-09-23

Fatigue and distress have been separately shown to be associated with medical errors. The contribution of each factor when assessed simultaneously is unknown. To determine the association of fatigue and distress with self-perceived major medical errors among resident physicians using validated metrics. Prospective longitudinal cohort study of categorical and preliminary internal medicine residents at Mayo Clinic, Rochester, Minnesota. Data were provided by 380 of 430 eligible residents (88.3%). Participants began training from 2003 to 2008 and completed surveys quarterly through February 2009. Surveys included self-assessment of medical errors, linear analog self-assessment of overall quality of life (QOL) and fatigue, the Maslach Burnout Inventory, the PRIME-MD depression screening instrument, and the Epworth Sleepiness Scale. Frequency of self-perceived, self-defined major medical errors was recorded. Associations of fatigue, QOL, burnout, and symptoms of depression with a subsequently reported major medical error were determined using generalized estimating equations for repeated measures. The mean response rate to individual surveys was 67.5%. Of the 356 participants providing error data (93.7%), 139 (39%) reported making at least 1 major medical error during the study period. In univariate analyses, there was an association of subsequent self-reported error with the Epworth Sleepiness Scale score (odds ratio [OR], 1.10 per unit increase; 95% confidence interval [CI], 1.03-1.16; P = .002) and fatigue score (OR, 1.14 per unit increase; 95% CI, 1.08-1.21; P < .001). Subsequent error was also associated with burnout (ORs per 1-unit change: depersonalization OR, 1.09; 95% CI, 1.05-1.12; P < .001; emotional exhaustion OR, 1.06; 95% CI, 1.04-1.08; P < .001; lower personal accomplishment OR, 0.94; 95% CI, 0.92-0.97; P < .001), a positive depression screen (OR, 2.56; 95% CI, 1.76-3.72; P < .001), and overall QOL (OR, 0.84 per unit increase; 95% CI, 0.79-0.91; P < .001). Fatigue and distress variables remained statistically significant when modeled together with little change in the point estimates of effect. Sleepiness and distress, when modeled together, showed little change in point estimates of effect, but sleepiness no longer had a statistically significant association with errors when adjusted for burnout or depression. Among internal medicine residents, higher levels of fatigue and distress are independently associated with self-perceived medical errors.

SU-F-T-471: Simulated External Beam Delivery Errors Detection with a Large Area Ion Chamber Transmission Detector

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

Hoffman, D; Dyer, B; Kumaran Nair, C

Purpose: The Integral Quality Monitor (IQM), developed by iRT Systems GmbH (Koblenz, Germany) is a large-area, linac-mounted ion chamber used to monitor photon fluence during patient treatment. Our previous work evaluated the change of the ion chamber’s response to deviations from static 1×1 cm2 and 10×10 cm2 photon beams and other characteristics integral to use in external beam detection. The aim of this work is to simulate two external beam radiation delivery errors, quantify the detection of simulated errors and evaluate the reduction in patient harm resulting from detection. Methods: Two well documented radiation oncology delivery errors were selected formore » simulation. The first error was recreated by modifying a wedged whole breast treatment, removing the physical wedge and calculating the planned dose with Pinnacle TPS (Philips Radiation Oncology Systems, Fitchburg, WI). The second error was recreated by modifying a static-gantry IMRT pharyngeal tonsil plan to be delivered in 3 unmodulated fractions. A radiation oncologist evaluated the dose for simulated errors and predicted morbidity and mortality commiserate with the original reported toxicity, indicating that reported errors were approximately simulated. The ion chamber signal of unmodified treatments was compared to the simulated error signal and evaluated in Pinnacle TPS again with radiation oncologist prediction of simulated patient harm. Results: Previous work established that transmission detector system measurements are stable within 0.5% standard deviation (SD). Errors causing signal change greater than 20 SD (10%) were considered detected. The whole breast and pharyngeal tonsil IMRT simulated error increased signal by 215% and 969%, respectively, indicating error detection after the first fraction and IMRT segment, respectively. Conclusion: The transmission detector system demonstrated utility in detecting clinically significant errors and reducing patient toxicity/harm in simulated external beam delivery. Future work will evaluate detection of other smaller magnitude delivery errors.« less

Traditional Nurse Triage vs. Physician Tele-Presence in a Pediatric Emergency Department

PubMed Central

Marconi, Greg P.; Chang, Todd; Pham, Phung K.; Grajower, Daniel N.; Nager, Alan L.

2014-01-01

Objectives To compare traditional nurse triage (TNT) in a Pediatric Emergency Department (PED) to physician tele-presence (PTP). Methods Prospective, 2×2 crossover study with random assignment using a sample of walk-in patients seeking care in a PED at a large, tertiary care children’s hospital, from May 2012 to January 2013. Outcomes of triage times, documentation errors, triage scores, and survey responses were compared between TNT and PTP. Comparison between PTP to actual treating PED physicians regarding the accuracy of ordering blood and urine tests, throat cultures, and radiologic imaging was also studied. Results Paired samples t-tests showed a statistically significant difference in triage time between TNT and PTP (p=0.03), but no significant difference in documentation errors (p=0.10). Triage scores of TNT were 71% accurate, compared to PTP, which were 95% accurate. Both parents and children had favorable scores regarding PTP and the majority indicated they would prefer PTP again at their next PED visit. PTP diagnostic ordering was comparable to the actual PED physician ordering, showing no statistical differences. Conclusions Utilizing physician tele-presence technology to remotely perform triage is a feasible alternative to traditional nurse triage, with no clinically significant differences in time, triage scores, errors and patient and parent satisfaction. PMID:24445223

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.

[Practical aspects regarding sample size in clinical research].

PubMed

Vega Ramos, B; Peraza Yanes, O; Herrera Correa, G; Saldívar Toraya, S

1996-01-01

The knowledge of the right sample size let us to be sure if the published results in medical papers had a suitable design and a proper conclusion according to the statistics analysis. To estimate the sample size we must consider the type I error, type II error, variance, the size of the effect, significance and power of the test. To decide what kind of mathematics formula will be used, we must define what kind of study we have, it means if its a prevalence study, a means values one or a comparative one. In this paper we explain some basic topics of statistics and we describe four simple samples of estimation of sample size.

In vivo estimation of target registration errors during augmented reality laparoscopic surgery.

PubMed

Thompson, Stephen; Schneider, Crispin; Bosi, Michele; Gurusamy, Kurinchi; Ourselin, Sébastien; Davidson, Brian; Hawkes, David; Clarkson, Matthew J

2018-06-01

Successful use of augmented reality for laparoscopic surgery requires that the surgeon has a thorough understanding of the likely accuracy of any overlay. Whilst the accuracy of such systems can be estimated in the laboratory, it is difficult to extend such methods to the in vivo clinical setting. Herein we describe a novel method that enables the surgeon to estimate in vivo errors during use. We show that the method enables quantitative evaluation of in vivo data gathered with the SmartLiver image guidance system. The SmartLiver system utilises an intuitive display to enable the surgeon to compare the positions of landmarks visible in both a projected model and in the live video stream. From this the surgeon can estimate the system accuracy when using the system to locate subsurface targets not visible in the live video. Visible landmarks may be either point or line features. We test the validity of the algorithm using an anatomically representative liver phantom, applying simulated perturbations to achieve clinically realistic overlay errors. We then apply the algorithm to in vivo data. The phantom results show that using projected errors of surface features provides a reliable predictor of subsurface target registration error for a representative human liver shape. Applying the algorithm to in vivo data gathered with the SmartLiver image-guided surgery system shows that the system is capable of accuracies around 12 mm; however, achieving this reliably remains a significant challenge. We present an in vivo quantitative evaluation of the SmartLiver image-guided surgery system, together with a validation of the evaluation algorithm. This is the first quantitative in vivo analysis of an augmented reality system for laparoscopic surgery.

Anatomy of emotion: a 3D study of facial mimicry.

PubMed

Ferrario, V F; Sforza, C

2007-01-01

Alterations in facial motion severely impair the quality of life and social interaction of patients, and an objective grading of facial function is necessary. A method for the non-invasive detection of 3D facial movements was developed. Sequences of six standardized facial movements (maximum smile; free smile; surprise with closed mouth; surprise with open mouth; right side eye closure; left side eye closure) were recorded in 20 healthy young adults (10 men, 10 women) using an optoelectronic motion analyzer. For each subject, 21 cutaneous landmarks were identified by 2-mm reflective markers, and their 3D movements during each facial animation were computed. Three repetitions of each expression were recorded (within-session error), and four separate sessions were used (between-session error). To assess the within-session error, the technical error of the measurement (random error, TEM) was computed separately for each sex, movement and landmark. To assess the between-session repeatability, the standard deviation among the mean displacements of each landmark (four independent sessions) was computed for each movement. TEM for the single landmarks ranged between 0.3 and 9.42 mm (intrasession error). The sex- and movement-related differences were statistically significant (two-way analysis of variance, p=0.003 for sex comparison, p=0.009 for the six movements, p<0.001 for the sex x movement interaction). Among four different (independent) sessions, the left eye closure had the worst repeatability, the right eye closure had the best one; the differences among various movements were statistically significant (one-way analysis of variance, p=0.041). In conclusion, the current protocol demonstrated a sufficient repeatability for a future clinical application. Great care should be taken to assure a consistent marker positioning in all the subjects.

Errors in radiation oncology: A study in pathways and dosimetric impact

PubMed Central

Drzymala, Robert E.; Purdy, James A.; Michalski, Jeff

2005-01-01

As complexity for treating patients increases, so does the risk of error. Some publications have suggested that record and verify (R&V) systems may contribute in propagating errors. Direct data transfer has the potential to eliminate most, but not all, errors. And although the dosimetric consequences may be obvious in some cases, a detailed study does not exist. In this effort, we examined potential errors in terms of scenarios, pathways of occurrence, and dosimetry. Our goal was to prioritize error prevention according to likelihood of event and dosimetric impact. For conventional photon treatments, we investigated errors of incorrect source‐to‐surface distance (SSD), energy, omitted wedge (physical, dynamic, or universal) or compensating filter, incorrect wedge or compensating filter orientation, improper rotational rate for arc therapy, and geometrical misses due to incorrect gantry, collimator or table angle, reversed field settings, and setup errors. For electron beam therapy, errors investigated included incorrect energy, incorrect SSD, along with geometric misses. For special procedures we examined errors for total body irradiation (TBI, incorrect field size, dose rate, treatment distance) and LINAC radiosurgery (incorrect collimation setting, incorrect rotational parameters). Likelihood of error was determined and subsequently rated according to our history of detecting such errors. Dosimetric evaluation was conducted by using dosimetric data, treatment plans, or measurements. We found geometric misses to have the highest error probability. They most often occurred due to improper setup via coordinate shift errors or incorrect field shaping. The dosimetric impact is unique for each case and depends on the proportion of fields in error and volume mistreated. These errors were short‐lived due to rapid detection via port films. The most significant dosimetric error was related to a reversed wedge direction. This may occur due to incorrect collimator angle or wedge orientation. For parallel‐opposed 60° wedge fields, this error could be as high as 80% to a point off‐axis. Other examples of dosimetric impact included the following: SSD, ~2%/cm for photons or electrons; photon energy (6 MV vs. 18 MV), on average 16% depending on depth, electron energy, ~0.5cm of depth coverage per MeV (mega‐electron volt). Of these examples, incorrect distances were most likely but rapidly detected by in vivo dosimetry. Errors were categorized by occurrence rate, methods and timing of detection, longevity, and dosimetric impact. Solutions were devised according to these criteria. To date, no one has studied the dosimetric impact of global errors in radiation oncology. Although there is heightened awareness that with increased use of ancillary devices and automation, there must be a parallel increase in quality check systems and processes, errors do and will continue to occur. This study has helped us identify and prioritize potential errors in our clinic according to frequency and dosimetric impact. For example, to reduce the use of an incorrect wedge direction, our clinic employs off‐axis in vivo dosimetry. To avoid a treatment distance setup error, we use both vertical table settings and optical distance indicator (ODI) values to properly set up fields. As R&V systems become more automated, more accurate and efficient data transfer will occur. This will require further analysis. Finally, we have begun examining potential intensity‐modulated radiation therapy (IMRT) errors according to the same criteria. PACS numbers: 87.53.Xd, 87.53.St PMID:16143793

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

PubMed

Morrison, Maeve; Cope, Vicki; Murray, Melanie

2018-05-15

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

A Novel Methodology to Validate the Accuracy of Extraoral Dental Scanners and Digital Articulation Systems.

PubMed

Ellakwa, A; Elnajar, S; Littlefair, D; Sara, G

2018-05-03

The aim of the current study is to develop a novel method to investigate the accuracy of 3D scanners and digital articulation systems. An upper and a lower poured stone model were created by taking impression of fully dentate male (fifty years old) participant. Titanium spheres were added to the models to allow for an easily recognisable geometric shape for measurement after scanning and digital articulation. Measurements were obtained using a Coordinate Measuring Machine to record volumetric error, articulation error and clinical effect error. Three scanners were compared, including the Imetric 3D iScan d104i, Shining 3D AutoScan-DS100 and 3Shape D800, as well as their respective digital articulation software packages. Stoneglass Industries PDC digital articulation system was also applied to the Imetric scans for comparison with the CMM measurements. All the scans displayed low volumetric error (p⟩0.05), indicating that the scanners themselves had a minor contribution to the articulation and clinical effect errors. The PDC digital articulation system was found to deliver the lowest average errors, with good repeatability of results. The new measuring technique in the current study was able to assess the scanning and articulation accuracy of the four systems investigated. The PDC digital articulation system using Imetric scans was recommended as it displayed the lowest articulation error and clinical effect error with good repeatability. The low errors from the PDC system may have been due to its use of a 3D axis for alignment rather than the use of a best fit. Copyright© 2018 Dennis Barber Ltd.

Effect of bar-code technology on the safety of medication administration.

PubMed

Poon, Eric G; Keohane, Carol A; Yoon, Catherine S; Ditmore, Matthew; Bane, Anne; Levtzion-Korach, Osnat; Moniz, Thomas; Rothschild, Jeffrey M; Kachalia, Allen B; Hayes, Judy; Churchill, William W; Lipsitz, Stuart; Whittemore, Anthony D; Bates, David W; Gandhi, Tejal K

2010-05-06

Serious medication errors are common in hospitals and often occur during order transcription or administration of medication. To help prevent such errors, technology has been developed to verify medications by incorporating bar-code verification technology within an electronic medication-administration system (bar-code eMAR). We conducted a before-and-after, quasi-experimental study in an academic medical center that was implementing the bar-code eMAR. We assessed rates of errors in order transcription and medication administration on units before and after implementation of the bar-code eMAR. Errors that involved early or late administration of medications were classified as timing errors and all others as nontiming errors. Two clinicians reviewed the errors to determine their potential to harm patients and classified those that could be harmful as potential adverse drug events. We observed 14,041 medication administrations and reviewed 3082 order transcriptions. Observers noted 776 nontiming errors in medication administration on units that did not use the bar-code eMAR (an 11.5% error rate) versus 495 such errors on units that did use it (a 6.8% error rate)--a 41.4% relative reduction in errors (P<0.001). The rate of potential adverse drug events (other than those associated with timing errors) fell from 3.1% without the use of the bar-code eMAR to 1.6% with its use, representing a 50.8% relative reduction (P<0.001). The rate of timing errors in medication administration fell by 27.3% (P<0.001), but the rate of potential adverse drug events associated with timing errors did not change significantly. Transcription errors occurred at a rate of 6.1% on units that did not use the bar-code eMAR but were completely eliminated on units that did use it. Use of the bar-code eMAR substantially reduced the rate of errors in order transcription and in medication administration as well as potential adverse drug events, although it did not eliminate such errors. Our data show that the bar-code eMAR is an important intervention to improve medication safety. (ClinicalTrials.gov number, NCT00243373.) 2010 Massachusetts Medical Society

Virtual reality robotic surgery warm-up improves task performance in a dry laboratory environment: a prospective randomized controlled study.

PubMed

Lendvay, Thomas S; Brand, Timothy C; White, Lee; Kowalewski, Timothy; Jonnadula, Saikiran; Mercer, Laina D; Khorsand, Derek; Andros, Justin; Hannaford, Blake; Satava, Richard M

2013-06-01

Preoperative simulation warm-up has been shown to improve performance and reduce errors in novice and experienced surgeons, yet existing studies have only investigated conventional laparoscopy. We hypothesized that a brief virtual reality (VR) robotic warm-up would enhance robotic task performance and reduce errors. In a 2-center randomized trial, 51 residents and experienced minimally invasive surgery faculty in General Surgery, Urology, and Gynecology underwent a validated robotic surgery proficiency curriculum on a VR robotic simulator and on the da Vinci surgical robot (Intuitive Surgical Inc). Once they successfully achieved performance benchmarks, surgeons were randomized to either receive a 3- to 5-minute VR simulator warm-up or read a leisure book for 10 minutes before performing similar and dissimilar (intracorporeal suturing) robotic surgery tasks. The primary outcomes compared were task time, tool path length, economy of motion, technical, and cognitive errors. Task time (-29.29 seconds, p = 0.001; 95% CI, -47.03 to -11.56), path length (-79.87 mm; p = 0.014; 95% CI, -144.48 to -15.25), and cognitive errors were reduced in the warm-up group compared with the control group for similar tasks. Global technical errors in intracorporeal suturing (0.32; p = 0.020; 95% CI, 0.06-0.59) were reduced after the dissimilar VR task. When surgeons were stratified by earlier robotic and laparoscopic clinical experience, the more experienced surgeons (n = 17) demonstrated significant improvements from warm-up in task time (-53.5 seconds; p = 0.001; 95% CI, -83.9 to -23.0) and economy of motion (0.63 mm/s; p = 0.007; 95% CI, 0.18-1.09), and improvement in these metrics was not statistically significantly appreciated in the less-experienced cohort (n = 34). We observed significant performance improvement and error reduction rates among surgeons of varying experience after VR warm-up for basic robotic surgery tasks. In addition, the VR warm-up reduced errors on a more complex task (robotic suturing), suggesting the generalizability of the warm-up. Copyright © 2013 American College of Surgeons. All rights reserved.

Virtual Reality Robotic Surgery Warm-Up Improves Task Performance in a Dry Lab Environment: A Prospective Randomized Controlled Study

PubMed Central

Lendvay, Thomas S.; Brand, Timothy C.; White, Lee; Kowalewski, Timothy; Jonnadula, Saikiran; Mercer, Laina; Khorsand, Derek; Andros, Justin; Hannaford, Blake; Satava, Richard M.

2014-01-01

Background Pre-operative simulation “warm-up” has been shown to improve performance and reduce errors in novice and experienced surgeons, yet existing studies have only investigated conventional laparoscopy. We hypothesized a brief virtual reality (VR) robotic warm-up would enhance robotic task performance and reduce errors. Study Design In a two-center randomized trial, fifty-one residents and experienced minimally invasive surgery faculty in General Surgery, Urology, and Gynecology underwent a validated robotic surgery proficiency curriculum on a VR robotic simulator and on the da Vinci surgical robot. Once successfully achieving performance benchmarks, surgeons were randomized to either receive a 3-5 minute VR simulator warm-up or read a leisure book for 10 minutes prior to performing similar and dissimilar (intracorporeal suturing) robotic surgery tasks. The primary outcomes compared were task time, tool path length, economy of motion, technical and cognitive errors. Results Task time (-29.29sec, p=0.001, 95%CI-47.03,-11.56), path length (-79.87mm, p=0.014, 95%CI -144.48,-15.25), and cognitive errors were reduced in the warm-up group compared to the control group for similar tasks. Global technical errors in intracorporeal suturing (0.32, p=0.020, 95%CI 0.06,0.59) were reduced after the dissimilar VR task. When surgeons were stratified by prior robotic and laparoscopic clinical experience, the more experienced surgeons(n=17) demonstrated significant improvements from warm-up in task time (-53.5sec, p=0.001, 95%CI -83.9,-23.0) and economy of motion (0.63mm/sec, p=0.007, 95%CI 0.18,1.09), whereas improvement in these metrics was not statistically significantly appreciated in the less experienced cohort(n=34). Conclusions We observed a significant performance improvement and error reduction rate among surgeons of varying experience after VR warm-up for basic robotic surgery tasks. In addition, the VR warm-up reduced errors on a more complex task (robotic suturing) suggesting the generalizability of the warm-up. PMID:23583618

Therapeutic self-disclosure in integrative psychotherapy: When is this a clinical error?

PubMed

Ziv-Beiman, Sharon; Shahar, Golan

2016-09-01

Ascending to prominence in virtually all forms of psychotherapy, therapist self-disclosure (TSD) has recently been identified as a primarily integrative intervention (Ziv-Beiman, 2013). In the present article, we discuss various instances in which using TSD in integrative psychotherapy might constitute a clinical error. First, we briefly review extant theory and empirical research on TSD, followed by our preferred version of integrative psychotherapy (i.e., a version of Wachtel's Cyclical Psychodynamics [Wachtel, 1977, 1997, 2014]), which we title cognitive existential psychodynamics. Next, we provide and discuss three examples in which implementing TSD constitutes a clinical error. In essence, we submit that using TSD constitutes an error when patients, constrained by their representational structures (object relations), experience the subjectivity of the other as impinging, and thus propels them to "react" instead of "emerge." (PsycINFO Database Record (c) 2016 APA, all rights reserved).

An algorithm for management of deep brain stimulation battery replacements: devising a web-based battery estimator and clinical symptom approach.

PubMed

Montuno, Michael A; Kohner, Andrew B; Foote, Kelly D; Okun, Michael S

2013-01-01

Deep brain stimulation (DBS) is an effective technique that has been utilized to treat advanced and medication-refractory movement and psychiatric disorders. In order to avoid implanted pulse generator (IPG) failure and consequent adverse symptoms, a better understanding of IPG battery longevity and management is necessary. Existing methods for battery estimation lack the specificity required for clinical incorporation. Technical challenges prevent higher accuracy longevity estimations, and a better approach to managing end of DBS battery life is needed. The literature was reviewed and DBS battery estimators were constructed by the authors and made available on the web at http://mdc.mbi.ufl.edu/surgery/dbs-battery-estimator. A clinical algorithm for management of DBS battery life was constructed. The algorithm takes into account battery estimations and clinical symptoms. Existing methods of DBS battery life estimation utilize an interpolation of averaged current drains to calculate how long a battery will last. Unfortunately, this technique can only provide general approximations. There are inherent errors in this technique, and these errors compound with each iteration of the battery estimation. Some of these errors cannot be accounted for in the estimation process, and some of the errors stem from device variation, battery voltage dependence, battery usage, battery chemistry, impedance fluctuations, interpolation error, usage patterns, and self-discharge. We present web-based battery estimators along with an algorithm for clinical management. We discuss the perils of using a battery estimator without taking into account the clinical picture. Future work will be needed to provide more reliable management of implanted device batteries; however, implementation of a clinical algorithm that accounts for both estimated battery life and for patient symptoms should improve the care of DBS patients. © 2012 International Neuromodulation Society.

The prevalence of refractive conditions in Puerto Rican adults attending an eye clinic system

PubMed Central

Rodriguez, Neisha M.; Romero, Angel. F.

2014-01-01

Purpose To determine the prevalence of refractive conditions in the adult population that visited primary care optometry clinics in Puerto Rico. Methods A retrospective cross-sectional study of patients examined at the Inter American University of Puerto Rico School of Optometry Eye Institute Clinics between 2004 and 2010. Subjects considered had best corrected visual acuity by standardized subjective refraction of 20/40 or better. The refractive errors were classified by the spherical equivalent (SE): sphere+½ cylinder. Myopia was classified as a SE>−0.50 D, hyperopia as a SE>+0.50  D, and emmetropia as a SE between −0.50 and +0.50, both included. Astigmatism equal or higher than 0.25 D in minus cylinder form was used. Patients with documented history of cataract extraction (pseudophakia or aphakia), amblyopia, refractive surgery or other corneal/ocular surgery were excluded from the study. Results A total of 784 randomly selected subjects older than 40 years of age were selected. The estimated prevalence (95%, confidence interval) among all subjects was hyperopia 51.5% (48.0–55.0), emmetropia 33.8% (30.5–37.2), myopia 14.7% (12.1–17.2) and astigmatism 69.6% (68.8–73.3). Hyperopia was more common in females than males although the difference was not statistically significant. The mean spherical equivalent values was hyperopic until 70 y/o and decreased slightly as the population ages. Conclusion Hyperopia is the most common refractive error and its prevalence and seems to increase among the aging population who visited the clinics. Further programs and studies must be developed to address the refractive errors needs of the adult Puerto Rican population. PMID:25000872

Manual Dexterity in Schizophrenia—A Neglected Clinical Marker?

PubMed Central

Térémetz, Maxime; Carment, Loïc; Brénugat-Herne, Lindsay; Croca, Marta; Bleton, Jean-Pierre; Krebs, Marie-Odile; Maier, Marc A.; Amado, Isabelle; Lindberg, Påvel G.

2017-01-01

Impaired manual dexterity is commonly observed in schizophrenia. However, a quantitative description of key sensorimotor components contributing to impaired dexterity is lacking. Whether the key components of dexterity are differentially affected and how they relate to clinical characteristics also remains unclear. We quantified the degree of dexterity in 35 stabilized patients with schizophrenia and in 20 age-matched control subjects using four visuomotor tasks: (i) force tracking to quantify visuomotor precision, (ii) sequential finger tapping to measure motor sequence recall, (iii) single-finger tapping to assess temporal regularity, and (iv) multi-finger tapping to measure independence of finger movements. Diverse clinical and neuropsychological tests were also applied. A patient subgroup (N = 15) participated in a 14-week cognitive remediation protocol and was assessed before and after remediation. Compared to control subjects, patients with schizophrenia showed greater error in force tracking, poorer recall of tapping sequences, decreased tapping regularity, and reduced degree of finger individuation. A composite performance measure discriminated patients from controls with sensitivity = 0.79 and specificity = 0.9. Aside from force-tracking error, no other dexterity components correlated with antipsychotic medication. In patients, some dexterity components correlated with neurological soft signs, Positive and Negative Syndrome Scale (PANSS), or neuropsychological scores. This suggests differential cognitive contributions to these components. Cognitive remediation lead to significant improvement in PANSS, tracking error, and sequence recall (without change in medication). These findings show that multiple aspects of sensorimotor control contribute to impaired manual dexterity in schizophrenia. Only visuomotor precision was related to antipsychotic medication. Good diagnostic accuracy and responsiveness to treatment suggest that manual dexterity may represent a useful clinical marker in schizophrenia. PMID:28740470

Relative and absolute reliability of the clinical version of the Narrow Path Walking Test (NPWT) under single and dual task conditions.

PubMed

Gimmon, Yoav; Jacob, Grinshpon; Lenoble-Hoskovec, Constanze; Büla, Christophe; Melzer, Itshak

2013-01-01

Decline in gait stability has been associated with increased fall risk in older adults. Reliable and clinically feasible methods of gait instability assessment are needed. This study evaluated the relative and absolute reliability and concurrent validity of the testing procedure of the clinical version of the Narrow Path Walking Test (NPWT) under single task (ST) and dual task (DT) conditions. Thirty independent community-dwelling older adults (65-87 years) were tested twice. Participants were instructed to walk within the 6-m narrow path without stepping out. Trial time, number of steps, trial velocity, number of step errors, and number of cognitive task errors were determined. Intraclass correlation coefficients (ICCs) were calculated as indices of agreement, and a graphic approach called "mountain plot" was applied to help interpret the direction and magnitude of disagreements between testing procedures. Smallest detectable change and smallest real difference (SRD) were computed to determine clinically relevant improvement at group and individual levels, respectively. Concurrent validity was assessed using Performance Oriented Mobility Assessment Tool (POMA) and the Short Physical Performance Battery (SPPB). Test-retest agreement (ICC1,2) varied from 0.77 to 0.92 in ST and from 0.78 to 0.92 in DT conditions, with no apparent systematic differences between testing procedures demonstrated by the mountain plot graphs. Smallest detectable change and smallest real change were small for motor task performance and larger for cognitive errors. Significant correlations were observed for trial velocity and trial time with POMA and SPPB. The present results indicate that the NPWT testing procedure is highly reliable and reproducible. Copyright © 2013 Elsevier Ireland Ltd. All rights reserved.

Navigation accuracy comparing non-covered frame and use of plastic sterile drapes to cover the reference frame in 3D acquisition.

PubMed

Corenman, Donald S; Strauch, Eric L; Dornan, Grant J; Otterstrom, Eric; Zalepa King, Lisa

2017-09-01

Advancements in surgical navigation technology coupled with 3-dimensional (3D) radiographic data have significantly enhanced the accuracy and efficiency of spinal fusion implant placement. Increased usage of such technology has led to rising concerns regarding maintenance of the sterile field, as makeshift drape systems are fraught with breaches thus presenting increased risk of surgical site infections (SSIs). A clinical need exists for a sterile draping solution with these techniques. Our objective was to quantify expected accuracy error associated with 2MM and 4MM thickness Sterile-Z Patient Drape ® using Medtronic O-Arm ® Surgical Imaging with StealthStation ® S7 ® Navigation System. Camera distance to reference frame was investigated for contribution to accuracy error. A testing jig was placed on the radiolucent table and the Medtronic passive reference frame was attached to jig. The StealthStation ® S7 ® navigation camera was placed at various distances from testing jig and the geometry error of reference frame was captured for three different drape configurations: no drape, 2MM drape and 4MM drape. The O-Arm ® gantry location and StealthStation ® S7 ® camera position was maintained and seven 3D acquisitions for each of drape configurations were measured. Data was analyzed by a two-factor analysis of variance (ANOVA) and Bonferroni comparisons were used to assess the independent effects of camera angle and drape on accuracy error. Median (and maximum) measurement accuracy error was higher for the 2MM than for the 4MM drape for each camera distance. The most extreme error observed (4.6 mm) occurred when using the 2MM and the 'far' camera distance. The 4MM drape was found to induce an accuracy error of 0.11 mm (95% confidence interval, 0.06-0.15; P<0.001) relative to the no drape testing, regardless of camera distance. Medium camera distance produced lower accuracy error than either the close (additional 0.08 mm error; 95% CI, 0-0.15; P=0.035) or far (additional 0.21mm error; 95% CI, 0.13-0.28; P<0.001) camera distances, regardless of whether a drape was used. In comparison to the 'no drape' condition, the accuracy error of 0.11 mm when using a 4MM film drape is minimal and clinically insignificant.

Clinical review: Medication errors in critical care

PubMed Central

Moyen, Eric; Camiré, Eric; Stelfox, Henry Thomas

2008-01-01

Medication errors in critical care are frequent, serious, and predictable. Critically ill patients are prescribed twice as many medications as patients outside of the intensive care unit (ICU) and nearly all will suffer a potentially life-threatening error at some point during their stay. The aim of this article is to provide a basic review of medication errors in the ICU, identify risk factors for medication errors, and suggest strategies to prevent errors and manage their consequences. PMID:18373883

Effects of Hip Strengthening on Neuromuscular Control, Hip Strength, and Self-Reported Functional Deficits in Individuals With Chronic Ankle Instability.

PubMed

Smith, Brent I; Curtis, Denice; Docherty, Carrie L

2018-06-12

Deficits in ankle and hip strength and lower-extremity postural control are associated with chronic ankle instability (CAI). Following strength training, muscle groups demonstrate increased strength. This change is partially credited to improved neuromuscular control, and many studies have investigated ankle protocols for subjects with CAI. The effects of isolating hip musculature in strength training protocols in this population are not well understood. To examine the effects of hip strengthening on clinical and self-reported outcomes in patients with CAI. Prospective randomized controlled clinical trial. Athletic training facility. Twenty-six participants with CAI (12 males and 14 females; age = 20.9 [1.5] y, height = 170.0 [12.7] cm, and mass = 77.5 [17.5] kg) were randomly assigned to training or control groups. Participants completed either 4 weeks of supervised hip strengthening (resistance bands 3 times a week) or no intervention. Participants were assessed on 4 clinical measures (Star Excursion Balance Test in the anterior, posteromedial, and posterolateral directions; Balance Error Scoring System; hip external rotation strength; and hip abduction strength) and a patient-reported measure (the Foot and Ankle Ability Measure activities of daily living and sports subscales) before and after the 4-week training period. The training group displayed significantly improved posttest measures compared with the control group for hip abduction strength (training: 446.3 [77.4] N, control: 314.7 [49.6] N, P < .01); hip external rotation strength (training: 222.1 [48.7] N, control: 169.4 [34.6] N, P < .01); Star Excursion Balance Test reach in the anterior (training: 93.1% [7.4%], control: 90.2% [7.9%], P < .01), posteromedial (training: 96.3% [8.9%], control: 88.0% [8.8%], P < .01), and posterolateral (training: 95.4% [11.1%], control: 86.6% [9.6%], P < .01) directions; Balance Error Scoring System total errors (training: 9.9 [6.3] errors, control: 21.2 [6.3] errors, P < .01); and the Foot and Ankle Ability Measure-sports score (training: 88.0 [12.6], control: 84.8 [10.9], P < .01). Improved clinical and patient-reported outcomes in the training group suggest hip strengthening is beneficial in the management and prevention of recurrent symptoms associated with CAI.

Comparison of MLC error sensitivity of various commercial devices for VMAT pre-treatment quality assurance.

PubMed

Saito, Masahide; Sano, Naoki; Shibata, Yuki; Kuriyama, Kengo; Komiyama, Takafumi; Marino, Kan; Aoki, Shinichi; Ashizawa, Kazunari; Yoshizawa, Kazuya; Onishi, Hiroshi

2018-05-01

The purpose of this study was to compare the MLC error sensitivity of various measurement devices for VMAT pre-treatment quality assurance (QA). This study used four QA devices (Scandidos Delta4, PTW 2D-array, iRT systems IQM, and PTW Farmer chamber). Nine retrospective VMAT plans were used and nine MLC error plans were generated for all nine original VMAT plans. The IQM and Farmer chamber were evaluated using the cumulative signal difference between the baseline and error-induced measurements. In addition, to investigate the sensitivity of the Delta4 device and the 2D-array, global gamma analysis (1%/1, 2%/2, and 3%/3 mm), dose difference (1%, 2%, and 3%) were used between the baseline and error-induced measurements. Some deviations of the MLC error sensitivity for the evaluation metrics and MLC error ranges were observed. For the two ionization devices, the sensitivity of the IQM was significantly better than that of the Farmer chamber (P < 0.01) while both devices had good linearly correlation between the cumulative signal difference and the magnitude of MLC errors. The pass rates decreased as the magnitude of the MLC error increased for both Delta4 and 2D-array. However, the small MLC error for small aperture sizes, such as for lung SBRT, could not be detected using the loosest gamma criteria (3%/3 mm). Our results indicate that DD could be more useful than gamma analysis for daily MLC QA, and that a large-area ionization chamber has a greater advantage for detecting systematic MLC error because of the large sensitive volume, while the other devices could not detect this error for some cases with a small range of MLC error. © 2018 The Authors. Journal of Applied Clinical Medical Physics published by Wiley Periodicals, Inc. on behalf of American Association of Physicists in Medicine.

Monitoring gait in multiple sclerosis with novel wearable motion sensors

PubMed Central

McGinnis, Ryan S.; Seagers, Kirsten; Motl, Robert W.; Sheth, Nirav; Wright, John A.; Ghaffari, Roozbeh; Sosnoff, Jacob J.

2017-01-01

Background Mobility impairment is common in people with multiple sclerosis (PwMS) and there is a need to assess mobility in remote settings. Here, we apply a novel wireless, skin-mounted, and conformal inertial sensor (BioStampRC, MC10 Inc.) to examine gait characteristics of PwMS under controlled conditions. We determine the accuracy and precision of BioStampRC in measuring gait kinematics by comparing to contemporary research-grade measurement devices. Methods A total of 45 PwMS, who presented with diverse walking impairment (Mild MS = 15, Moderate MS = 15, Severe MS = 15), and 15 healthy control subjects participated in the study. Participants completed a series of clinical walking tests. During the tests participants were instrumented with BioStampRC and MTx (Xsens, Inc.) sensors on their shanks, as well as an activity monitor GT3X (Actigraph, Inc.) on their non-dominant hip. Shank angular velocity was simultaneously measured with the inertial sensors. Step number and temporal gait parameters were calculated from the data recorded by each sensor. Visual inspection and the MTx served as the reference standards for computing the step number and temporal parameters, respectively. Accuracy (error) and precision (variance of error) was assessed based on absolute and relative metrics. Temporal parameters were compared across groups using ANOVA. Results Mean accuracy±precision for the BioStampRC was 2±2 steps error for step number, 6±9ms error for stride time and 6±7ms error for step time (0.6–2.6% relative error). Swing time had the least accuracy±precision (25±19ms error, 5±4% relative error) among the parameters. GT3X had the least accuracy±precision (8±14% relative error) in step number estimate among the devices. Both MTx and BioStampRC detected significantly distinct gait characteristics between PwMS with different disability levels (p<0.01). Conclusion BioStampRC sensors accurately and precisely measure gait parameters in PwMS across diverse walking impairment levels and detected differences in gait characteristics by disability level in PwMS. This technology has the potential to provide granular monitoring of gait both inside and outside the clinic. PMID:28178288

An 802.11 n wireless local area network transmission scheme for wireless telemedicine applications.

PubMed

Lin, C F; Hung, S I; Chiang, I H

2010-10-01

In this paper, an 802.11 n transmission scheme is proposed for wireless telemedicine applications. IEEE 802.11n standards, a power assignment strategy, space-time block coding (STBC), and an object composition Petri net (OCPN) model are adopted. With the proposed wireless system, G.729 audio bit streams, Joint Photographic Experts Group 2000 (JPEG 2000) clinical images, and Moving Picture Experts Group 4 (MPEG-4) video bit streams achieve a transmission bit error rate (BER) of 10-7, 10-4, and 103 simultaneously. The proposed system meets the requirements prescribed for wireless telemedicine applications. An essential feature of this proposed transmission scheme is that clinical information that requires a high quality of service (QoS) is transmitted at a high power transmission rate with significant error protection. For maximizing resource utilization and minimizing the total transmission power, STBC and adaptive modulation techniques are used in the proposed 802.11 n wireless telemedicine system. Further, low power, direct mapping (DM), low-error protection scheme, and high-level modulation are adopted for messages that can tolerate a high BER. With the proposed transmission scheme, the required reliability of communication can be achieved. Our simulation results have shown that the proposed 802.11 n transmission scheme can be used for developing effective wireless telemedicine systems.

Implementing a laboratory automation system: experience of a large clinical laboratory.

PubMed

Lam, Choong Weng; Jacob, Edward

2012-02-01

Laboratories today face increasing pressure to automate their operations as they are challenged by a continuing increase in workload, need to reduce expenditure, and difficulties in recruitment of experienced technical staff. Was the implementation of a laboratory automation system (LAS) in the Clinical Biochemistry Laboratory at Singapore General Hospital successful? There is no simple answer, so the following topics comparing and contrasting pre- and post-LAS have been explored: turnaround time (TAT), laboratory errors, and staff satisfaction. The benefits and limitations of LAS from the laboratory experience were also reviewed. The mean TAT for both stat and routine samples decreased post-LAS (30% and 13.4%, respectively). In the 90th percentile TAT chart, a 29% reduction was seen in the processing of stat samples on the LAS. However, no significant difference in the 90th percentile TAT was observed with routine samples. It was surprising to note that laboratory errors increased post-LAS. Considerable effort was needed to overcome the initial difficulties associated with adjusting to a new system, new software, and new working procedures. Although some of the known advantages and limitations of LAS have been validated, the claimed benefits such as improvements in TAT, laboratory errors, and staff morale were not evident in the initial months.

Endoscopic non-technical skills team training: the next step in quality assurance of endoscopy training.

PubMed

Matharoo, Manmeet; Haycock, Adam; Sevdalis, Nick; Thomas-Gibson, Siwan

2014-12-14

To investigate whether novel, non-technical skills training for Bowel Cancer Screening (BCS) endoscopy teams enhanced patient safety knowledge and attitudes. A novel endoscopy team training intervention for BCS teams was developed and evaluated as a pre-post intervention study. Four multi-disciplinary BCS teams constituting BCS endoscopist(s), specialist screening practitioners, endoscopy nurses and administrative staff (A) from English BCS training centres participated. No patients were involved in this study. Expert multidisciplinary faculty delivered a single day's training utilising real clinical examples. Pre and post-course evaluation comprised participants' patient safety awareness, attitudes, and knowledge. Global course evaluations were also collected. Twenty-three participants attended and their patient safety knowledge improved significantly from 43%-55% (P ≤ 0.001) following the training intervention. 12/41 (29%) of the safety attitudes items significantly improved in the areas of perceived patient safety knowledge and awareness. The remaining safety attitude items: perceived influence on patient safety, attitudes towards error management, error management actions and personal views following an error were unchanged following training. Both qualitative and quantitative global course evaluations were positive: 21/23 (91%) participants strongly agreed/agreed that they were satisfied with the course. Qualitative evaluation included mandating such training for endoscopy teams outside BCS and incorporating team training within wider endoscopy training. Limitations of the study include no measure of increased patient safety in clinical practice following training. A novel comprehensive training package addressing patient safety, non-technical skills and adverse event analysis was successful in improving multi-disciplinary teams' knowledge and safety attitudes.

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.

Assessment of performance of professionals in immunohematology proficiency tests of the public blood bank network of the state of Minas Gerais.

PubMed

Brener, Stela; Ferreira, Angela Melgaço; de Carvalho, Ricardo Vilas Freire; do Valle, Marcele Cunha Ribeiro; Souza, Helio Moraes

2012-01-01

Despite significant advances, the practice of blood transfusion is still a complex process and subject to risks. Factors that influence the safety of blood transfusion include technical skill and knowledge in hemotherapy mainly obtained by the qualification and training of teams. This study aimed to investigate the relationship between professional categories working in transfusion services of the public blood bank network in the State of Minas Gerais and their performance in proficiency tests. This was an observational cross-sectional study (2007-2008) performed using a specific instrument, based on evidence and the results of immunohematology proficiency tests as mandated by law. The error rates in ABO and RhD phenotyping, irregular antibody screening and cross-matching were 12.5%, 9.6%, 43.8% and 20.1%, respectively. When considering the number of tests performed, the error rates were 4.6%, 4.2%, 26.7% and 11.0%, respectively. The error rates varied for different professional categories: biochemists, biologists and biomedical scientists (65.0%), clinical pathology technicians (44.1%) and laboratory assistants, nursing technicians and assistant nurses (74.6%). A statistically significant difference was observed when the accuracy of clinical pathology technicians was compared with those of other professionals with only high school education (p-value < 0.001). This was not seen for professionals with university degrees (p-value = 0.293). These results reinforce the need to invest in training, improvement of educational programs, new teaching methods and tools for periodic evaluations, contributing to increase transfusion safety and improve hemotherapy in Brazil.

Endoscopic non-technical skills team training: The next step in quality assurance of endoscopy training

PubMed Central

Matharoo, Manmeet; Haycock, Adam; Sevdalis, Nick; Thomas-Gibson, Siwan

2014-01-01

AIM: To investigate whether novel, non-technical skills training for Bowel Cancer Screening (BCS) endoscopy teams enhanced patient safety knowledge and attitudes. METHODS: A novel endoscopy team training intervention for BCS teams was developed and evaluated as a pre-post intervention study. Four multi-disciplinary BCS teams constituting BCS endoscopist(s), specialist screening practitioners, endoscopy nurses and administrative staff (A) from English BCS training centres participated. No patients were involved in this study. Expert multidisciplinary faculty delivered a single day’s training utilising real clinical examples. Pre and post-course evaluation comprised participants’ patient safety awareness, attitudes, and knowledge. Global course evaluations were also collected. RESULTS: Twenty-three participants attended and their patient safety knowledge improved significantly from 43%-55% (P ≤ 0.001) following the training intervention. 12/41 (29%) of the safety attitudes items significantly improved in the areas of perceived patient safety knowledge and awareness. The remaining safety attitude items: perceived influence on patient safety, attitudes towards error management, error management actions and personal views following an error were unchanged following training. Both qualitative and quantitative global course evaluations were positive: 21/23 (91%) participants strongly agreed/agreed that they were satisfied with the course. Qualitative evaluation included mandating such training for endoscopy teams outside BCS and incorporating team training within wider endoscopy training. Limitations of the study include no measure of increased patient safety in clinical practice following training. CONCLUSION: A novel comprehensive training package addressing patient safety, non-technical skills and adverse event analysis was successful in improving multi-disciplinary teams’ knowledge and safety attitudes. PMID:25516665

Driving Performance Under Alcohol in Simulated Representative Driving Tasks

PubMed Central

Kenntner-Mabiala, Ramona; Kaussner, Yvonne; Jagiellowicz-Kaufmann, Monika; Hoffmann, Sonja; Krüger, Hans-Peter

2015-01-01

Abstract Comparing drug-induced driving impairments with the effects of benchmark blood alcohol concentrations (BACs) is an approved approach to determine the clinical relevance of findings for traffic safety. The present study aimed to collect alcohol calibration data to validate findings of clinical trials that were derived from a representative test course in a dynamic driving simulator. The driving performance of 24 healthy volunteers under placebo and with 0.05% and 0.08% BACs was measured in a double-blind, randomized, crossover design. Trained investigators assessed the subjects’ driving performance and registered their driving errors. Various driving parameters that were recorded during the simulation were also analyzed. Generally, the participants performed worse on the test course (P < 0.05 for the investigators’ assessment) under the influence of alcohol. Consistent with the relevant literature, lane-keeping performance parameters were sensitive to the investigated BACs. There were significant differences between the alcohol and placebo conditions in most of the parameters analyzed. However, the total number of errors was the only parameter discriminating significantly between all three BAC conditions. In conclusion, data show that the present experimental setup is suitable for future psychopharmacological research. Thereby, for each drug to be investigated, we recommend to assess a profile of various parameters that address different levels of driving. On the basis of this performance profile, the total number of driving errors is recommended as the primary endpoint. However, this overall endpoint should be completed by a specifically sensitive parameter that is chosen depending on the effect known to be induced by the tested drug. PMID:25689289

A female advantage in the serial production of non-representational learned gestures.

PubMed

Chipman, Karen; Hampson, Elizabeth

2006-01-01

Clinical research has demonstrated a sex difference in the neuroanatomical organization of the limb praxis system. To test for a corresponding sex difference in the functioning of this system, we compared healthy men and women on a gesture production task modeled after those used in apraxia research. In two separate studies, participants were taught to perform nine non-representational gestures in response to computer-generated color cues. After extensive practice with the gestures, the color cues were placed on a timer and presented in randomized sequences at progressively faster speeds. A detailed videotape analysis revealed that women in both studies committed significantly fewer 'praxic' errors than men (i.e., errors that resembled those seen in limb apraxia). This was true during both the untimed practice trials and the speeded trials of the task, despite equivalent numbers of errors between the sexes in the 'non-praxic' (i.e., executory) error categories. Women in both studies also performed the task at significantly faster speeds than men. This finding was not accounted for by a female advantage in extraneous elements of the task, i.e., speed of color processing, associative retrieval, or motor execution. Together, the two studies provide convergent support for a female advantage in the efficiency of forelimb gesture production. They are consistent with emerging evidence of a sex difference in the anatomical organization of the praxis system.

Logic-based assessment of the compatibility of UMLS ontology sources

PubMed Central

2011-01-01

Background The UMLS Metathesaurus (UMLS-Meta) is currently the most comprehensive effort for integrating independently-developed medical thesauri and ontologies. UMLS-Meta is being used in many applications, including PubMed and ClinicalTrials.gov. The integration of new sources combines automatic techniques, expert assessment, and auditing protocols. The automatic techniques currently in use, however, are mostly based on lexical algorithms and often disregard the semantics of the sources being integrated. Results In this paper, we argue that UMLS-Meta’s current design and auditing methodologies could be significantly enhanced by taking into account the logic-based semantics of the ontology sources. We provide empirical evidence suggesting that UMLS-Meta in its 2009AA version contains a significant number of errors; these errors become immediately apparent if the rich semantics of the ontology sources is taken into account, manifesting themselves as unintended logical consequences that follow from the ontology sources together with the information in UMLS-Meta. We then propose general principles and specific logic-based techniques to effectively detect and repair such errors. Conclusions Our results suggest that the methodologies employed in the design of UMLS-Meta are not only very costly in terms of human effort, but also error-prone. The techniques presented here can be useful for both reducing human effort in the design and maintenance of UMLS-Meta and improving the quality of its contents. PMID:21388571

Undergraduate medical students' perceptions and intentions regarding patient safety during clinical clerkship.

PubMed

Lee, Hoo-Yeon; Hahm, Myung-Il; Lee, Sang Gyu

2018-04-04

The purpose of this study was to examine undergraduate medical students' perceptions and intentions regarding patient safety during clinical clerkships. Cross-sectional study administered in face-to-face interviews using modified the Medical Student Safety Attitudes and Professionalism Survey (MSSAPS) from three colleges of medicine in Korea. We assessed medical students' perceptions of the cultures ('safety', 'teamwork', and 'error disclosure'), 'behavioural intentions' concerning patient safety issues and 'overall patient safety'. Confirmatory factor analysis and Spearman's correlation analyses was performed. In total, 194(91.9%) of the 211 third-year undergraduate students participated. 78% of medical students reported that the quality of care received by patients was impacted by teamwork during clinical rotations. Regarding error disclosure, positive scores ranged from 10% to 74%. Except for one question asking whether the disclosure of medical errors was an important component of patient safety (74%), the percentages of positive scores for all the other questions were below 20%. 41.2% of medical students have intention to disclose it when they saw a medical error committed by another team member. Many students had difficulty speaking up about medical errors. Error disclosure guidelines and educational efforts aimed at developing sophisticated communication skills are needed. This study may serve as a reference for other institutions planning patient safety education in their curricula. Assessing student perceptions of safety culture can provide clerkship directors and clinical service chiefs with information that enhances the educational environment and promotes patient safety.

Autoregressive Modeling of Drift and Random Error to Characterize a Continuous Intravascular Glucose Monitoring Sensor.

PubMed

Zhou, Tony; Dickson, Jennifer L; Geoffrey Chase, J

2018-01-01

Continuous glucose monitoring (CGM) devices have been effective in managing diabetes and offer potential benefits for use in the intensive care unit (ICU). Use of CGM devices in the ICU has been limited, primarily due to the higher point accuracy errors over currently used traditional intermittent blood glucose (BG) measures. General models of CGM errors, including drift and random errors, are lacking, but would enable better design of protocols to utilize these devices. This article presents an autoregressive (AR) based modeling method that separately characterizes the drift and random noise of the GlySure CGM sensor (GlySure Limited, Oxfordshire, UK). Clinical sensor data (n = 33) and reference measurements were used to generate 2 AR models to describe sensor drift and noise. These models were used to generate 100 Monte Carlo simulations based on reference blood glucose measurements. These were then compared to the original CGM clinical data using mean absolute relative difference (MARD) and a Trend Compass. The point accuracy MARD was very similar between simulated and clinical data (9.6% vs 9.9%). A Trend Compass was used to assess trend accuracy, and found simulated and clinical sensor profiles were similar (simulated trend index 11.4° vs clinical trend index 10.9°). The model and method accurately represents cohort sensor behavior over patients, providing a general modeling approach to any such sensor by separately characterizing each type of error that can arise in the data. Overall, it enables better protocol design based on accurate expected CGM sensor behavior, as well as enabling the analysis of what level of each type of sensor error would be necessary to obtain desired glycemic control safety and performance with a given protocol.

Initial clinical experience with a video-based patient positioning system.

PubMed

Johnson, L S; Milliken, B D; Hadley, S W; Pelizzari, C A; Haraf, D J; Chen, G T

1999-08-01

To report initial clinical experience with an interactive, video-based patient positioning system that is inexpensive, quick, accurate, and easy to use. System hardware includes two black-and-white CCD cameras, zoom lenses, and a PC equipped with a frame grabber. Custom software is used to acquire and archive video images, as well as to display real-time subtraction images revealing patient misalignment in multiple views. Two studies are described. In the first study, video is used to document the daily setup histories of 5 head and neck patients. Time-lapse cine loops are generated for each patient and used to diagnose and correct common setup errors. In the second study, 6 twice-daily (BID) head and neck patients are positioned according to the following protocol: at AM setups conventional treatment room lasers are used; at PM setups lasers are used initially and then video is used for 1-2 minutes to fine-tune the patient position. Lateral video images and lateral verification films are registered off-line to compare the distribution of setup errors per patient, with and without video assistance. In the first study, video images were used to determine the accuracy of our conventional head and neck setup technique, i.e., alignment of lightcast marks and surface anatomy to treatment room lasers and the light field. For this initial cohort of patients, errors ranged from sigma = 5 to 7 mm and were patient-specific. Time-lapse cine loops of the images revealed sources of the error, and as a result, our localization techniques and immobilization device were modified to improve setup accuracy. After the improvements, conventional setup errors were reduced to sigma = 3 to 5 mm. In the second study, when a stereo pair of live subtraction images were introduced to perform daily "on-line" setup correction, errors were reduced to sigma = 1 to 3 mm. Results depended on patient health and cooperation and the length of time spent fine-tuning the position. An interactive, video-based patient positioning system was shown to reduce setup errors to within 1 to 3 mm in head and neck patients, without a significant increase in overall treatment time or labor-intensive procedures. Unlike retrospective portal image analysis, use of two live-video images provides the therapists with immediate feedback and allows for true 3-D positioning and correction of out-of-plane rotation before radiation is delivered. With significant improvement in head and neck alignment and the elimination of setup errors greater than 3 to 5 mm, margins associated with treatment volumes potentially can be reduced, thereby decreasing normal tissue irradiation.

New clinical validation method for automated sphygmomanometer: a proposal by Japan ISO-WG for sphygmomanometer standard.

PubMed

Shirasaki, Osamu; Asou, Yosuke; Takahashi, Yukio

2007-12-01

Owing to fast or stepwise cuff deflation, or measuring at places other than the upper arm, the clinical accuracy of most recent automated sphygmomanometers (auto-BPMs) cannot be validated by one-arm simultaneous comparison, which would be the only accurate validation method based on auscultation. Two main alternative methods are provided by current standards, that is, two-arm simultaneous comparison (method 1) and one-arm sequential comparison (method 2); however, the accuracy of these validation methods might not be sufficient to compensate for the suspicious accuracy in lateral blood pressure (BP) differences (LD) and/or BP variations (BPV) between the device and reference readings. Thus, the Japan ISO-WG for sphygmomanometer standards has been studying a new method that might improve validation accuracy (method 3). The purpose of this study is to determine the appropriateness of method 3 by comparing immunity to LD and BPV with those of the current validation methods (methods 1 and 2). The validation accuracy of the above three methods was assessed in human participants [N=120, 45+/-15.3 years (mean+/-SD)]. An oscillometric automated monitor, Omron HEM-762, was used as the tested device. When compared with the others, methods 1 and 3 showed a smaller intra-individual standard deviation of device error (SD1), suggesting their higher reproducibility of validation. The SD1 by method 2 (P=0.004) significantly correlated with the participant's BP, supporting our hypothesis that the increased SD of device error by method 2 is at least partially caused by essential BPV. Method 3 showed a significantly (P=0.0044) smaller interparticipant SD of device error (SD2), suggesting its higher interparticipant consistency of validation. Among the methods of validation of the clinical accuracy of auto-BPMs, method 3, which showed the highest reproducibility and highest interparticipant consistency, can be proposed as being the most appropriate.

Adaptive Offset Correction for Intracortical Brain Computer Interfaces

PubMed Central

Homer, Mark L.; Perge, János A.; Black, Michael J.; Harrison, Matthew T.; Cash, Sydney S.; Hochberg, Leigh R.

2014-01-01

Intracortical brain computer interfaces (iBCIs) decode intended movement from neural activity for the control of external devices such as a robotic arm. Standard approaches include a calibration phase to estimate decoding parameters. During iBCI operation, the statistical properties of the neural activity can depart from those observed during calibration, sometimes hindering a user’s ability to control the iBCI. To address this problem, we adaptively correct the offset terms within a Kalman filter decoder via penalized maximum likelihood estimation. The approach can handle rapid shifts in neural signal behavior (on the order of seconds) and requires no knowledge of the intended movement. The algorithm, called MOCA, was tested using simulated neural activity and evaluated retrospectively using data collected from two people with tetraplegia operating an iBCI. In 19 clinical research test cases, where a nonadaptive Kalman filter yielded relatively high decoding errors, MOCA significantly reduced these errors (10.6 ±10.1%; p<0.05, pairwise t-test). MOCA did not significantly change the error in the remaining 23 cases where a nonadaptive Kalman filter already performed well. These results suggest that MOCA provides more robust decoding than the standard Kalman filter for iBCIs. PMID:24196868

Adaptive offset correction for intracortical brain-computer interfaces.

PubMed

Homer, Mark L; Perge, Janos A; Black, Michael J; Harrison, Matthew T; Cash, Sydney S; Hochberg, Leigh R

2014-03-01

Intracortical brain-computer interfaces (iBCIs) decode intended movement from neural activity for the control of external devices such as a robotic arm. Standard approaches include a calibration phase to estimate decoding parameters. During iBCI operation, the statistical properties of the neural activity can depart from those observed during calibration, sometimes hindering a user's ability to control the iBCI. To address this problem, we adaptively correct the offset terms within a Kalman filter decoder via penalized maximum likelihood estimation. The approach can handle rapid shifts in neural signal behavior (on the order of seconds) and requires no knowledge of the intended movement. The algorithm, called multiple offset correction algorithm (MOCA), was tested using simulated neural activity and evaluated retrospectively using data collected from two people with tetraplegia operating an iBCI. In 19 clinical research test cases, where a nonadaptive Kalman filter yielded relatively high decoding errors, MOCA significantly reduced these errors ( 10.6 ± 10.1% ; p < 0.05, pairwise t-test). MOCA did not significantly change the error in the remaining 23 cases where a nonadaptive Kalman filter already performed well. These results suggest that MOCA provides more robust decoding than the standard Kalman filter for iBCIs.

[Epidemiology of refractive errors].

PubMed

Wolfram, C

2017-07-01

Refractive errors are very common and can lead to severe pathological changes in the eye. This article analyzes the epidemiology of refractive errors in the general population in Germany and worldwide and describes common definitions for refractive errors and clinical characteristics for pathologicaal changes. Refractive errors differ between age groups due to refractive changes during the life time and also due to generation-specific factors. Current research about the etiology of refractive errors has strengthened the influence of environmental factors, which led to new strategies for the prevention of refractive pathologies.

ERP components on reaction errors and their functional significance: a tutorial.

PubMed

Falkenstein, M; Hoormann, J; Christ, S; Hohnsbein, J

2000-01-01

Some years ago we described a negative (Ne) and a later positive (Pe) deflection in the event-related brain potentials (ERPs) of incorrect choice reactions [Falkenstein, M., Hohnsbein, J., Hoormann, J., Blanke, L., 1990. In: Brunia, C.H.M., Gaillard, A.W.K., Kok, A. (Eds.), Psychophysiological Brain Research. Tilburg Univesity Press, Tilburg, pp. 192-195. Falkenstein, M., Hohnsbein, J., Hoormann, J., 1991. Electroencephalography and Clinical Neurophysiology, 78, 447-455]. Originally we assumed the Ne to represent a correlate of error detection in the sense of a mismatch signal when representations of the actual response and the required response are compared. This hypothesis was supported by the results of a variety of experiments from our own laboratory and that of Coles [Gehring, W. J., Goss, B., Coles, M.G.H., Meyer, D.E., Donchin, E., 1993. Psychological Science 4, 385-390. Bernstein, P.S., Scheffers, M.K., Coles, M.G.H., 1995. Journal of Experimental Psychology: Human Perception and Performance 21, 1312-1322. Scheffers, M.K., Coles, M. G.H., Bernstein, P., Gehring, W.J., Donchin, E., 1996. Psychophysiology 33, 42-54]. However, new data from our laboratory and that of Vidal et al. [Vidal, F., Hasbroucq, T., Bonnet, M., 1999. Biological Psychology, 2000] revealed a small negativity similar to the Ne also after correct responses. Since the above mentioned comparison process is also required after correct responses it is conceivable that the Ne reflects this comparison process itself rather than its outcome. As to the Pe, our results suggest that this is a further error-specific component, which is independent of the Ne, and hence associated with a later aspect of error processing or post-error processing. Our new results with different age groups argue against the hypotheses that the Pe reflects conscious error processing or the post-error adjustment of response strategies. Further research is necessary to specify the functional significance of the Pe.

Cracking the code: the accuracy of coding shoulder procedures and the repercussions.

PubMed

Clement, N D; Murray, I R; Nie, Y X; McBirnie, J M

2013-05-01

Coding of patients' diagnosis and surgical procedures is subject to error levels of up to 40% with consequences on distribution of resources and financial recompense. Our aim was to explore and address reasons behind coding errors of shoulder diagnosis and surgical procedures and to evaluate a potential solution. A retrospective review of 100 patients who had undergone surgery was carried out. Coding errors were identified and the reasons explored. A coding proforma was designed to address these errors and was prospectively evaluated for 100 patients. The financial implications were also considered. Retrospective analysis revealed the correct primary diagnosis was assigned in 54 patients (54%) had an entirely correct diagnosis, and only 7 (7%) patients had a correct procedure code assigned. Coders identified indistinct clinical notes and poor clarity of procedure codes as reasons for errors. The proforma was significantly more likely to assign the correct diagnosis (odds ratio 18.2, p < 0.0001) and the correct procedure code (odds ratio 310.0, p < 0.0001). Using the proforma resulted in a £28,562 increase in revenue for the 100 patients evaluated relative to the income generated from the coding department. High error levels for coding are due to misinterpretation of notes and ambiguity of procedure codes. This can be addressed by allowing surgeons to assign the diagnosis and procedure using a simplified list that is passed directly to coding.

Augmenting intracortical brain-machine interface with neurally driven error detectors

NASA Astrophysics Data System (ADS)

Even-Chen, Nir; Stavisky, Sergey D.; Kao, Jonathan C.; Ryu, Stephen I.; Shenoy, Krishna V.

2017-12-01

Objective. Making mistakes is inevitable, but identifying them allows us to correct or adapt our behavior to improve future performance. Current brain-machine interfaces (BMIs) make errors that need to be explicitly corrected by the user, thereby consuming time and thus hindering performance. We hypothesized that neural correlates of the user perceiving the mistake could be used by the BMI to automatically correct errors. However, it was unknown whether intracortical outcome error signals were present in the premotor and primary motor cortices, brain regions successfully used for intracortical BMIs. Approach. We report here for the first time a putative outcome error signal in spiking activity within these cortices when rhesus macaques performed an intracortical BMI computer cursor task. Main results. We decoded BMI trial outcomes shortly after and even before a trial ended with 96% and 84% accuracy, respectively. This led us to develop and implement in real-time a first-of-its-kind intracortical BMI error ‘detect-and-act’ system that attempts to automatically ‘undo’ or ‘prevent’ mistakes. The detect-and-act system works independently and in parallel to a kinematic BMI decoder. In a challenging task that resulted in substantial errors, this approach improved the performance of a BMI employing two variants of the ubiquitous Kalman velocity filter, including a state-of-the-art decoder (ReFIT-KF). Significance. Detecting errors in real-time from the same brain regions that are commonly used to control BMIs should improve the clinical viability of BMIs aimed at restoring motor function to people with paralysis.

Effect of Increased Inpatient Attending Physician Supervision on Medical Errors, Patient Safety, and Resident Education: A Randomized Clinical Trial.

PubMed

Finn, Kathleen M; Metlay, Joshua P; Chang, Yuchiao; Nagarur, Amulya; Yang, Shaun; Landrigan, Christopher P; Iyasere, Christiana

2018-06-04

While the relationship between resident work hours and patient safety has been extensively studied, little research has evaluated the role of attending physician supervision on patient safety. To determine the effect of increased attending physician supervision on an inpatient resident general medical service on patient safety and educational outcomes. This 9-month randomized clinical trial performed on an inpatient general medical service of a large academic medical center used a crossover design. Participants were clinical teaching attending physicians and residents in an internal medicine residency program. Twenty-two faculty provided either (1) increased direct supervision in which attending physicians joined work rounds on previously admitted patients or (2) standard supervision in which attending physicians were available but did not join work rounds. Each faculty member participated in both arms in random order. The primary safety outcome was rate of medical errors. Resident education was evaluated via a time-motion study to assess resident participation on rounds and via surveys to measure resident and attending physician educational ratings. Of the 22 attending physicians, 8 (36%) were women, with 15 (68%) having more than 5 years of experience. A total of 1259 patients (5772 patient-days) were included in the analysis. The medical error rate was not significantly different between standard vs increased supervision (107.6; 95% CI, 85.8-133.7 vs 91.1; 95% CI, 76.9-104.0 per 1000 patient-days; P = .21). Time-motion analysis of 161 work rounds found no difference in mean length of time spent discussing established patients in the 2 models (202; 95% CI, 192-212 vs 202; 95% CI, 189-215 minutes; P = .99). Interns spoke less when an attending physician joined rounds (64; 95% CI, 60-68 vs 55; 95% CI, 49-60 minutes; P = .008). In surveys, interns reported feeling less efficient (41 [55%] vs 68 [73%]; P = .02) and less autonomous (53 [72%] vs 86 [91%]; P = .001) with an attending physician present and residents felt less autonomous (11 [58%] vs 30 [97%]; P < .001). Conversely, attending physicians rated the quality of care higher when they participated on work rounds (20 [100%] vs 16 [80%]; P = .04). Increased direct attending physician supervision did not significantly reduce the medical error rate. In designing morning work rounds, residency programs should reconsider their balance of patient safety, learning needs, and resident autonomy. ClinicalTrials.gov Identifier: NCT03318198.

Skin-deep diagnosis: affective bias and zebra retreat complicating the diagnosis of systemic sclerosis.

PubMed

Miller, Chad S

2013-01-01

Nearly half of medical errors can be attributed to an error of clinical reasoning or decision making. It is estimated that the correct diagnosis is missed or delayed in between 5% and 14% of acute hospital admissions. Through understanding why and how physicians make these errors, it is hoped that strategies can be developed to decrease the number of these errors. In the present case, a patient presented with dyspnea, gastrointestinal symptoms and weight loss; the diagnosis was initially missed when the treating physicians took mental short cuts and used heuristics as in this case. Heuristics have an inherent bias that can lead to faulty reasoning or conclusions, especially in complex or difficult cases. Affective bias, which is the overinvolvement of emotion in clinical decision making, limited the available information for diagnosis because of the hesitancy to acquire a full history and perform a complete physical examination in this patient. Zebra retreat, another type of bias, is when a rare diagnosis figures prominently on the differential diagnosis but the physician retreats for various reasons. Zebra retreat also factored in the delayed diagnosis. Through the description of these clinical reasoning errors in an actual case, it is hoped that future errors can be prevented or inspiration for additional research in this area will develop.

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

PubMed

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

2016-01-01

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

Demonstrating the robustness of population surveillance data: implications of error rates on demographic and mortality estimates.

PubMed

Fottrell, Edward; Byass, Peter; Berhane, Yemane

2008-03-25

As in any measurement process, a certain amount of error may be expected in routine population surveillance operations such as those in demographic surveillance sites (DSSs). Vital events are likely to be missed and errors made no matter what method of data capture is used or what quality control procedures are in place. The extent to which random errors in large, longitudinal datasets affect overall health and demographic profiles has important implications for the role of DSSs as platforms for public health research and clinical trials. Such knowledge is also of particular importance if the outputs of DSSs are to be extrapolated and aggregated with realistic margins of error and validity. This study uses the first 10-year dataset from the Butajira Rural Health Project (BRHP) DSS, Ethiopia, covering approximately 336,000 person-years of data. Simple programmes were written to introduce random errors and omissions into new versions of the definitive 10-year Butajira dataset. Key parameters of sex, age, death, literacy and roof material (an indicator of poverty) were selected for the introduction of errors based on their obvious importance in demographic and health surveillance and their established significant associations with mortality. Defining the original 10-year dataset as the 'gold standard' for the purposes of this investigation, population, age and sex compositions and Poisson regression models of mortality rate ratios were compared between each of the intentionally erroneous datasets and the original 'gold standard' 10-year data. The composition of the Butajira population was well represented despite introducing random errors, and differences between population pyramids based on the derived datasets were subtle. Regression analyses of well-established mortality risk factors were largely unaffected even by relatively high levels of random errors in the data. The low sensitivity of parameter estimates and regression analyses to significant amounts of randomly introduced errors indicates a high level of robustness of the dataset. This apparent inertia of population parameter estimates to simulated errors is largely due to the size of the dataset. Tolerable margins of random error in DSS data may exceed 20%. While this is not an argument in favour of poor quality data, reducing the time and valuable resources spent on detecting and correcting random errors in routine DSS operations may be justifiable as the returns from such procedures diminish with increasing overall accuracy. The money and effort currently spent on endlessly correcting DSS datasets would perhaps be better spent on increasing the surveillance population size and geographic spread of DSSs and analysing and disseminating research findings.

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.

Automation bias in electronic prescribing.

PubMed

Lyell, David; Magrabi, Farah; Raban, Magdalena Z; Pont, L G; Baysari, Melissa T; Day, Richard O; Coiera, Enrico

2017-03-16

Clinical decision support (CDS) in e-prescribing can improve safety by alerting potential errors, but introduces new sources of risk. Automation bias (AB) occurs when users over-rely on CDS, reducing vigilance in information seeking and processing. Evidence of AB has been found in other clinical tasks, but has not yet been tested with e-prescribing. This study tests for the presence of AB in e-prescribing and the impact of task complexity and interruptions on AB. One hundred and twenty students in the final two years of a medical degree prescribed medicines for nine clinical scenarios using a simulated e-prescribing system. Quality of CDS (correct, incorrect and no CDS) and task complexity (low, low + interruption and high) were varied between conditions. Omission errors (failure to detect prescribing errors) and commission errors (acceptance of false positive alerts) were measured. Compared to scenarios with no CDS, correct CDS reduced omission errors by 38.3% (p < .0001, n = 120), 46.6% (p < .0001, n = 70), and 39.2% (p < .0001, n = 120) for low, low + interrupt and high complexity scenarios respectively. Incorrect CDS increased omission errors by 33.3% (p < .0001, n = 120), 24.5% (p < .009, n = 82), and 26.7% (p < .0001, n = 120). Participants made commission errors, 65.8% (p < .0001, n = 120), 53.5% (p < .0001, n = 82), and 51.7% (p < .0001, n = 120). Task complexity and interruptions had no impact on AB. This study found evidence of AB omission and commission errors in e-prescribing. Verification of CDS alerts is key to avoiding AB errors. However, interventions focused on this have had limited success to date. Clinicians should remain vigilant to the risks of CDS failures and verify CDS.

Epinephrine Auto-Injector Versus Drawn Up Epinephrine for Anaphylaxis Management: A Scoping Review.

PubMed

Chime, Nnenna O; Riese, Victoria G; Scherzer, Daniel J; Perretta, Julianne S; McNamara, LeAnn; Rosen, Michael A; Hunt, Elizabeth A

2017-08-01

Anaphylaxis is a life-threatening event. Most clinical symptoms of anaphylaxis can be reversed by prompt intramuscular administration of epinephrine using an auto-injector or epinephrine drawn up in a syringe and delays and errors may be fatal. The aim of this scoping review is to identify and compare errors associated with use of epinephrine drawn up in a syringe versus epinephrine auto-injectors in order to assist hospitals as they choose which approach minimizes risk of adverse events for their patients. PubMed, Embase, CINAHL, Web of Science, and the Cochrane Library were searched using terms agreed to a priori. We reviewed human and simulation studies reporting errors associated with the use of epinephrine in anaphylaxis. There were multiple screening stages with evolving feedback. Each study was independently assessed by two reviewers for eligibility. Data were extracted using an instrument modeled from the Zaza et al instrument and grouped into themes. Three main themes were noted: 1) ergonomics, 2) dosing errors, and 3) errors due to route of administration. Significant knowledge gaps in the operation of epinephrine auto-injectors among healthcare providers, patients, and caregivers were identified. For epinephrine in a syringe, there were more frequent reports of incorrect dosing and erroneous IV administration with associated adverse cardiac events. For the epinephrine auto-injector, unintentional administration to the digit was an error reported on multiple occasions. This scoping review highlights knowledge gaps and a diverse set of errors regardless of the approach to epinephrine preparation during management of anaphylaxis. There are more potentially life-threatening errors reported for epinephrine drawn up in a syringe than with the auto-injectors. The impact of these knowledge gaps and potentially fatal errors on patient outcomes, cost, and quality of care is worthy of further investigation.

Eliminating US hospital medical errors.

PubMed

Kumar, Sameer; Steinebach, Marc

2008-01-01

Healthcare costs in the USA have continued to rise steadily since the 1980s. Medical errors are one of the major causes of deaths and injuries of thousands of patients every year, contributing to soaring healthcare costs. The purpose of this study is to examine what has been done to deal with the medical-error problem in the last two decades and present a closed-loop mistake-proof operation system for surgery processes that would likely eliminate preventable medical errors. The design method used is a combination of creating a service blueprint, implementing the six sigma DMAIC cycle, developing cause-and-effect diagrams as well as devising poka-yokes in order to develop a robust surgery operation process for a typical US hospital. In the improve phase of the six sigma DMAIC cycle, a number of poka-yoke techniques are introduced to prevent typical medical errors (identified through cause-and-effect diagrams) that may occur in surgery operation processes in US hospitals. It is the authors' assertion that implementing the new service blueprint along with the poka-yokes, will likely result in the current medical error rate to significantly improve to the six-sigma level. Additionally, designing as many redundancies as possible in the delivery of care will help reduce medical errors. Primary healthcare providers should strongly consider investing in adequate doctor and nurse staffing, and improving their education related to the quality of service delivery to minimize clinical errors. This will lead to an increase in higher fixed costs, especially in the shorter time frame. This paper focuses additional attention needed to make a sound technical and business case for implementing six sigma tools to eliminate medical errors that will enable hospital managers to increase their hospital's profitability in the long run and also ensure patient safety.

A Neurobehavioral Mechanism Linking Behaviorally Inhibited Temperament and Later Adolescent Social Anxiety.

PubMed

Buzzell, George A; Troller-Renfree, Sonya V; Barker, Tyson V; Bowman, Lindsay C; Chronis-Tuscano, Andrea; Henderson, Heather A; Kagan, Jerome; Pine, Daniel S; Fox, Nathan A

2017-12-01

Behavioral inhibition (BI) is a temperament identified in early childhood that is a risk factor for later social anxiety. However, mechanisms underlying the development of social anxiety remain unclear. To better understand the emergence of social anxiety, longitudinal studies investigating changes at behavioral neural levels are needed. BI was assessed in the laboratory at 2 and 3 years of age (N = 268). Children returned at 12 years, and an electroencephalogram was recorded while children performed a flanker task under 2 conditions: once while believing they were being observed by peers and once while not being observed. This methodology isolated changes in error monitoring (error-related negativity) and behavior (post-error reaction time slowing) as a function of social context. At 12 years, current social anxiety symptoms and lifetime diagnoses of social anxiety were obtained. Childhood BI prospectively predicted social-specific error-related negativity increases and social anxiety symptoms in adolescence; these symptoms directly related to clinical diagnoses. Serial mediation analysis showed that social error-related negativity changes explained relations between BI and social anxiety symptoms (n = 107) and diagnosis (n = 92), but only insofar as social context also led to increased post-error reaction time slowing (a measure of error preoccupation); this model was not significantly related to generalized anxiety. Results extend prior work on socially induced changes in error monitoring and error preoccupation. These measures could index a neurobehavioral mechanism linking BI to adolescent social anxiety symptoms and diagnosis. This mechanism could relate more strongly to social than to generalized anxiety in the peri-adolescent period. Copyright © 2017 American Academy of Child and Adolescent Psychiatry. All rights reserved.

Dispensing error rate after implementation of an automated pharmacy carousel system.

PubMed

Oswald, Scott; Caldwell, Richard

2007-07-01

A study was conducted to determine filling and dispensing error rates before and after the implementation of an automated pharmacy carousel system (APCS). The study was conducted in a 613-bed acute and tertiary care university hospital. Before the implementation of the APCS, filling and dispensing rates were recorded during October through November 2004 and January 2005. Postimplementation data were collected during May through June 2006. Errors were recorded in three areas of pharmacy operations: first-dose or missing medication fill, automated dispensing cabinet fill, and interdepartmental request fill. A filling error was defined as an error caught by a pharmacist during the verification step. A dispensing error was defined as an error caught by a pharmacist observer after verification by the pharmacist. Before implementation of the APCS, 422 first-dose or missing medication orders were observed between October 2004 and January 2005. Independent data collected in December 2005, approximately six weeks after the introduction of the APCS, found that filling and error rates had increased. The filling rate for automated dispensing cabinets was associated with the largest decrease in errors. Filling and dispensing error rates had decreased by December 2005. In terms of interdepartmental request fill, no dispensing errors were noted in 123 clinic orders dispensed before the implementation of the APCS. One dispensing error out of 85 clinic orders was identified after implementation of the APCS. The implementation of an APCS at a university hospital decreased medication filling errors related to automated cabinets only and did not affect other filling and dispensing errors.

SU-C-BRD-02: A Team Focused Clinical Implementation and Failure Mode and Effects Analysis of HDR Skin Brachytherapy Using Valencia and Leipzig Surface Applicators

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

Sayler, E; Harrison, A; Eldredge-Hindy, H

Purpose: and Leipzig applicators (VLAs) are single-channel brachytherapy surface applicators used to treat skin lesions up to 2cm diameter. Source dwell times can be calculated and entered manually after clinical set-up or ultrasound. This procedure differs dramatically from CT-based planning; the novelty and unfamiliarity could lead to severe errors. To build layers of safety and ensure quality, a multidisciplinary team created a protocol and applied Failure Modes and Effects Analysis (FMEA) to the clinical procedure for HDR VLA skin treatments. Methods: team including physicists, physicians, nurses, therapists, residents, and administration developed a clinical procedure for VLA treatment. The procedure wasmore » evaluated using FMEA. Failure modes were identified and scored by severity, occurrence, and detection. The clinical procedure was revised to address high-scoring process nodes. Results: Several key components were added to the clinical procedure to minimize risk probability numbers (RPN): -Treatments are reviewed at weekly QA rounds, where physicians discuss diagnosis, prescription, applicator selection, and set-up. Peer review reduces the likelihood of an inappropriate treatment regime. -A template for HDR skin treatments was established in the clinical EMR system to standardize treatment instructions. This reduces the chances of miscommunication between the physician and planning physicist, and increases the detectability of an error during the physics second check. -A screen check was implemented during the second check to increase detectability of an error. -To reduce error probability, the treatment plan worksheet was designed to display plan parameters in a format visually similar to the treatment console display. This facilitates data entry and verification. -VLAs are color-coded and labeled to match the EMR prescriptions, which simplifies in-room selection and verification. Conclusion: Multidisciplinary planning and FMEA increased delectability and reduced error probability during VLA HDR Brachytherapy. This clinical model may be useful to institutions implementing similar procedures.« less

An alternative clinical routine for subjective refraction based on power vectors with trial frames.

PubMed

María Revert, Antonia; Conversa, Maria Amparo; Albarrán Diego, César; Micó, Vicente

2017-01-01

Subjective refraction determines the final point of refractive error assessment in most clinical environments and its foundations have remained unchanged for decades. The purpose of this paper is to compare the results obtained when monocular subjective refraction is assessed in trial frames by a new clinical procedure based on a pure power vector interpretation with conventional clinical refraction procedures. An alternative clinical routine is described that uses power vector interpretation with implementation in trial frames. Refractive error is determined in terms of: (i) the spherical equivalent (M component), and (ii) a pair of Jackson Crossed Cylinder lenses oriented at 0°/90° (J 0 component) and 45°/135° (J 45 component) for determination of astigmatism. This vector subjective refraction result (VR) is compared separately for right and left eyes of 25 subjects (mean age, 35 ± 4 years) against conventional sphero-cylindrical subjective refraction (RX) using a phoropter. The VR procedure was applied with both conventional tumbling E optotypes (VR1) and modified optotypes with oblique orientation (VR2). Bland-Altman plots and intra-class correlation coefficient showed good agreement between VR, and RX (with coefficient values above 0.82) and anova showed no significant differences in any of the power vector components between RX and VR. VR1 and VR2 procedure results were similar (p ≥ 0.77). The proposed routine determines the three components of refractive error in power vector notation [M, J 0 , J 45 ], with a refraction time similar to the one used in conventional subjective procedures. The proposed routine could be helpful for inexperienced clinicians and for experienced clinicians in those cases where it is difficult to get a valid starting point for conventional RX (irregular corneas, media opacities, etc.) and for refractive situations/places with inadequate refractive facilities/equipment. © 2016 The Authors Ophthalmic & Physiological Optics © 2016 The College of Optometrists.

Beyond Readability: Investigating Coherence of Clinical Text for Consumers

PubMed Central

Hetzel, Scott; Dalrymple, Prudence; Keselman, Alla

2011-01-01

Background A basic tenet of consumer health informatics is that understandable health resources empower the public. Text comprehension holds great promise for helping to characterize consumer problems in understanding health texts. The need for efficient ways to assess consumer-oriented health texts and the availability of computationally supported tools led us to explore the effect of various text characteristics on readers’ understanding of health texts, as well as to develop novel approaches to assessing these characteristics. Objective The goal of this study was to compare the impact of two different approaches to enhancing readability, and three interventions, on individuals’ comprehension of short, complex passages of health text. Methods Participants were 80 university staff, faculty, or students. Each participant was asked to “retell” the content of two health texts: one a clinical trial in the domain of diabetes mellitus, and the other typical Visit Notes. These texts were transformed for the intervention arms of the study. Two interventions provided terminology support via (1) standard dictionary or (2) contextualized vocabulary definitions. The third intervention provided coherence improvement. We assessed participants’ comprehension of the clinical texts through propositional analysis, an open-ended questionnaire, and analysis of the number of errors made. Results For the clinical trial text, the effect of text condition was not significant in any of the comparisons, suggesting no differences in recall, despite the varying levels of support (P = .84). For the Visit Note, however, the difference in the median total propositions recalled between the Coherent and the (Original + Dictionary) conditions was significant (P = .04). This suggests that participants in the Coherent condition recalled more of the original Visit Notes content than did participants in the Original and the Dictionary conditions combined. However, no difference was seen between (Original + Dictionary) and Vocabulary (P = .36) nor Coherent and Vocabulary (P = .62). No statistically significant effect of any document transformation was found either in the open-ended questionnaire (clinical trial: P = .86, Visit Note: P = .20) or in the error rate (clinical trial: P = .47, Visit Note: P = .25). However, post hoc power analysis suggested that increasing the sample size by approximately 6 participants per condition would result in a significant difference for the Visit Note, but not for the clinical trial text. Conclusions Statistically, the results of this study attest that improving coherence has a small effect on consumer comprehension of clinical text, but the task is extremely labor intensive and not scalable. Further research is needed using texts from more diverse clinical domains and more heterogeneous participants, including actual patients. Since comprehensibility of clinical text appears difficult to automate, informatics support tools may most productively support the health care professionals tasked with making clinical information understandable to patients. PMID:22138127

Real-time registration of 3D to 2D ultrasound images for image-guided prostate biopsy.

PubMed

Gillies, Derek J; Gardi, Lori; De Silva, Tharindu; Zhao, Shuang-Ren; Fenster, Aaron

2017-09-01

During image-guided prostate biopsy, needles are targeted at tissues that are suspicious of cancer to obtain specimen for histological examination. Unfortunately, patient motion causes targeting errors when using an MR-transrectal ultrasound (TRUS) fusion approach to augment the conventional biopsy procedure. This study aims to develop an automatic motion correction algorithm approaching the frame rate of an ultrasound system to be used in fusion-based prostate biopsy systems. Two modes of operation have been investigated for the clinical implementation of the algorithm: motion compensation using a single user initiated correction performed prior to biopsy, and real-time continuous motion compensation performed automatically as a background process. Retrospective 2D and 3D TRUS patient images acquired prior to biopsy gun firing were registered using an intensity-based algorithm utilizing normalized cross-correlation and Powell's method for optimization. 2D and 3D images were downsampled and cropped to estimate the optimal amount of image information that would perform registrations quickly and accurately. The optimal search order during optimization was also analyzed to avoid local optima in the search space. Error in the algorithm was computed using target registration errors (TREs) from manually identified homologous fiducials in a clinical patient dataset. The algorithm was evaluated for real-time performance using the two different modes of clinical implementations by way of user initiated and continuous motion compensation methods on a tissue mimicking prostate phantom. After implementation in a TRUS-guided system with an image downsampling factor of 4, the proposed approach resulted in a mean ± std TRE and computation time of 1.6 ± 0.6 mm and 57 ± 20 ms respectively. The user initiated mode performed registrations with in-plane, out-of-plane, and roll motions computation times of 108 ± 38 ms, 60 ± 23 ms, and 89 ± 27 ms, respectively, and corresponding registration errors of 0.4 ± 0.3 mm, 0.2 ± 0.4 mm, and 0.8 ± 0.5°. The continuous method performed registration significantly faster (P < 0.05) than the user initiated method, with observed computation times of 35 ± 8 ms, 43 ± 16 ms, and 27 ± 5 ms for in-plane, out-of-plane, and roll motions, respectively, and corresponding registration errors of 0.2 ± 0.3 mm, 0.7 ± 0.4 mm, and 0.8 ± 1.0°. The presented method encourages real-time implementation of motion compensation algorithms in prostate biopsy with clinically acceptable registration errors. Continuous motion compensation demonstrated registration accuracy with submillimeter and subdegree error, while performing < 50 ms computation times. Image registration technique approaching the frame rate of an ultrasound system offers a key advantage to be smoothly integrated to the clinical workflow. In addition, this technique could be used further for a variety of image-guided interventional procedures to treat and diagnose patients by improving targeting accuracy. © 2017 American Association of Physicists in Medicine.

Errors in the Extra-Analytical Phases of Clinical Chemistry Laboratory Testing.

PubMed

Zemlin, Annalise E

2018-04-01

The total testing process consists of various phases from the pre-preanalytical to the post-postanalytical phase, the so-called brain-to-brain loop. With improvements in analytical techniques and efficient quality control programmes, most laboratory errors now occur in the extra-analytical phases. There has been recent interest in these errors with numerous publications highlighting their effect on service delivery, patient care and cost. This interest has led to the formation of various working groups whose mission is to develop standardized quality indicators which can be used to measure the performance of service of these phases. This will eventually lead to the development of external quality assessment schemes to monitor these phases in agreement with ISO15189:2012 recommendations. This review focuses on potential errors in the extra-analytical phases of clinical chemistry laboratory testing, some of the studies performed to assess the severity and impact of these errors and processes that are in place to address these errors. The aim of this review is to highlight the importance of these errors for the requesting clinician.

[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.

Anatomic, Clinical, and Neuropsychological Correlates of Spelling Errors in Primary Progressive Aphasia

ERIC Educational Resources Information Center

Shim, HyungSub; Hurley, Robert S.; Rogalski, Emily; Mesulam, M.-Marsel

2012-01-01

This study evaluates spelling errors in the three subtypes of primary progressive aphasia (PPA): agrammatic (PPA-G), logopenic (PPA-L), and semantic (PPA-S). Forty-one PPA patients and 36 age-matched healthy controls were administered a test of spelling. The total number of errors and types of errors in spelling to dictation of regular words,…

Robotic Assistance for Ultrasound-Guided Prostate Brachytherapy

PubMed Central

Fichtinger, Gabor; Fiene, Jonathan P.; Kennedy, Christopher W.; Kronreif, Gernot; Iordachita, Iulian; Song, Danny Y.; Burdette, Everette C.; Kazanzides, Peter

2016-01-01

We present a robotically assisted prostate brachytherapy system and test results in training phantoms and Phase-I clinical trials. The system consists of a transrectal ultrasound (TRUS) and a spatially co-registered robot, fully integrated with an FDA-approved commercial treatment planning system. The salient feature of the system is a small parallel robot affixed to the mounting posts of the template. The robot replaces the template interchangeably, using the same coordinate system. Established clinical hardware, workflow and calibration remain intact. In all phantom experiments, we recorded the first insertion attempt without adjustment. All clinically relevant locations in the prostate were reached. Non-parallel needle trajectories were achieved. The pre-insertion transverse and rotational errors (measured with a Polaris optical tracker relative to the template’s coordinate frame) were 0.25mm (STD=0.17mm) and 0.75° (STD=0.37°). In phantoms, needle tip placement errors measured in TRUS were 1.04mm (STD=0.50mm). A Phase-I clinical feasibility and safety trial has been successfully completed with the system. We encountered needle tip positioning errors of a magnitude greater than 4mm in only 2 out of 179 robotically guided needles, in contrast to manual template guidance where errors of this magnitude are much more common. Further clinical trials are necessary to determine whether the apparent benefits of the robotic assistant will lead to improvements in clinical efficacy and outcomes. PMID:18650122

WISC-R Examiner Errors: Cause for Concern.

ERIC Educational Resources Information Center

Slate, John R.; Chick, David

1989-01-01

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

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

Zhang, JY; Hong, DL

Purpose: The purpose of this study is to investigate the patient set-up error and interfraction target coverage in cervical cancer using image-guided adaptive radiotherapy (IGART) with cone-beam computed tomography (CBCT). Methods: Twenty cervical cancer patients undergoing intensity modulated radiotherapy (IMRT) were randomly selected. All patients were matched to the isocenter using laser with the skin markers. Three dimensional CBCT projections were acquired by the Varian Truebeam treatment system. Set-up errors were evaluated by radiation oncologists, after CBCT correction. The clinical target volume (CTV) was delineated on each CBCT, and the planning target volume (PTV) coverage of each CBCT-CTVs was analyzed.more » Results: A total of 152 CBCT scans were acquired from twenty cervical cancer patients, the mean set-up errors in the longitudinal, vertical, and lateral direction were 3.57, 2.74 and 2.5mm respectively, without CBCT corrections. After corrections, these were decreased to 1.83, 1.44 and 0.97mm. For the target coverage, CBCT-CTV coverage without CBCT correction was 94% (143/152), and 98% (149/152) with correction. Conclusion: Use of CBCT verfication to measure patient setup errors could be applied to improve the treatment accuracy. In addition, the set-up error corrections significantly improve the CTV coverage for cervical cancer patients.« less

Impact of Standardized Communication Techniques on Errors during Simulated Neonatal Resuscitation.

PubMed

Yamada, Nicole K; Fuerch, Janene H; Halamek, Louis P

2016-03-01

Current patterns of communication in high-risk clinical situations, such as resuscitation, are imprecise and prone to error. We hypothesized that the use of standardized communication techniques would decrease the errors committed by resuscitation teams during neonatal resuscitation. In a prospective, single-blinded, matched pairs design with block randomization, 13 subjects performed as a lead resuscitator in two simulated complex neonatal resuscitations. Two nurses assisted each subject during the simulated resuscitation scenarios. In one scenario, the nurses used nonstandard communication; in the other, they used standardized communication techniques. The performance of the subjects was scored to determine errors committed (defined relative to the Neonatal Resuscitation Program algorithm), time to initiation of positive pressure ventilation (PPV), and time to initiation of chest compressions (CC). In scenarios in which subjects were exposed to standardized communication techniques, there was a trend toward decreased error rate, time to initiation of PPV, and time to initiation of CC. While not statistically significant, there was a 1.7-second improvement in time to initiation of PPV and a 7.9-second improvement in time to initiation of CC. Should these improvements in human performance be replicated in the care of real newborn infants, they could improve patient outcomes and enhance patient safety. Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

Identification of proteomic biomarkers predicting prostate cancer aggressiveness and lethality despite biopsy-sampling error.

PubMed

Shipitsin, M; Small, C; Choudhury, S; Giladi, E; Friedlander, S; Nardone, J; Hussain, S; Hurley, A D; Ernst, C; Huang, Y E; Chang, H; Nifong, T P; Rimm, D L; Dunyak, J; Loda, M; Berman, D M; Blume-Jensen, P

2014-09-09

Key challenges of biopsy-based determination of prostate cancer aggressiveness include tumour heterogeneity, biopsy-sampling error, and variations in biopsy interpretation. The resulting uncertainty in risk assessment leads to significant overtreatment, with associated costs and morbidity. We developed a performance-based strategy to identify protein biomarkers predictive of prostate cancer aggressiveness and lethality regardless of biopsy-sampling variation. Prostatectomy samples from a large patient cohort with long follow-up were blindly assessed by expert pathologists who identified the tissue regions with the highest and lowest Gleason grade from each patient. To simulate biopsy-sampling error, a core from a high- and a low-Gleason area from each patient sample was used to generate a 'high' and a 'low' tumour microarray, respectively. Using a quantitative proteomics approach, we identified from 160 candidates 12 biomarkers that predicted prostate cancer aggressiveness (surgical Gleason and TNM stage) and lethal outcome robustly in both high- and low-Gleason areas. Conversely, a previously reported lethal outcome-predictive marker signature for prostatectomy tissue was unable to perform under circumstances of maximal sampling error. Our results have important implications for cancer biomarker discovery in general and development of a sampling error-resistant clinical biopsy test for prediction of prostate cancer aggressiveness.

Ultrasound speckle tracking for radial, longitudinal and circumferential strain estimation of the carotid artery--an in vitro validation via sonomicrometry using clinical and high-frequency ultrasound.

PubMed

Larsson, Matilda; Heyde, Brecht; Kremer, Florence; Brodin, Lars-Åke; D'hooge, Jan

2015-02-01

Ultrasound speckle tracking for carotid strain assessment has in the past decade gained interest in studies of arterial stiffness and cardiovascular diseases. The aim of this study was to validate and directly contrast carotid strain assessment by speckle tracking applied on clinical and high-frequency ultrasound images in vitro. Four polyvinyl alcohol phantoms mimicking the carotid artery were constructed with different mechanical properties and connected to a pump generating carotid flow profiles. Gray-scale ultrasound long- and short-axis images of the phantoms were obtained using a standard clinical ultrasound system, Vivid 7 (GE Healthcare, Horten, Norway) and a high-frequency ultrasound system, Vevo 2100 (FUJIFILM, VisualSonics, Toronto, Canada) with linear-array transducers (12L/MS250). Radial, longitudinal and circumferential strains were estimated using an in-house speckle tracking algorithm and compared with reference strain acquired by sonomicrometry. Overall, the estimated strain corresponded well with the reference strain. The correlation between estimated peak strain in clinical ultrasound images and reference strain was 0.91 (p<0.001) for radial strain, 0.73 (p<0.001) for longitudinal strain and 0.90 (p<0.001) for circumferential strain and for high-frequency ultrasound images 0.95 (p<0.001) for radial strain, 0.93 (p<0.001) for longitudinal strain and 0.90 (p<0.001) for circumferential strain. A significant larger bias and root mean square error was found for circumferential strain estimation on clinical ultrasound images compared to high frequency ultrasound images, but no significant difference in bias and root mean square error was found for radial and longitudinal strain when comparing estimation on clinical and high-frequency ultrasound images. The agreement between sonomicrometry and speckle tracking demonstrates that carotid strain assessment by ultrasound speckle tracking is feasible. Copyright © 2014 The Authors. Published by Elsevier B.V. All rights reserved.

Horizontal plane localization in single-sided deaf adults fitted with a bone-anchored hearing aid (Baha).

PubMed

Grantham, D Wesley; Ashmead, Daniel H; Haynes, David S; Hornsby, Benjamin W Y; Labadie, Robert F; Ricketts, Todd A

2012-01-01

: One purpose of this investigation was to evaluate the effect of a unilateral bone-anchored hearing aid (Baha) on horizontal plane localization performance in single-sided deaf adults who had either a conductive or sensorineural hearing loss in their impaired ear. The use of a 33-loudspeaker array allowed for a finer response measure than has previously been used to investigate localization in this population. In addition, a detailed analysis of error patterns allowed an evaluation of the contribution of random error and bias error to the total rms error computed in the various conditions studied. A second purpose was to investigate the effect of stimulus duration and head-turning on localization performance. : Two groups of single-sided deaf adults were tested in a localization task in which they had to identify the direction of a spoken phrase on each trial. One group had a sensorineural hearing loss (SNHL group; N = 7), and the other group had a conductive hearing loss (CHL group; N = 5). In addition, a control group of four normal-hearing adults was tested. The spoken phrase was either 1250 msec in duration (a male saying "Where am I coming from now?") or 341 msec in duration (the same male saying "Where?"). For the longer-duration phrase, subjects were tested in conditions in which they either were or were not allowed to move their heads before the termination of the phrase. The source came from one of nine positions in the front horizontal plane (from -79° to +79°). The response range included 33 choices (from -90° to +90°, separated by 5.6°). Subjects were tested in all stimulus conditions, both with and without the Baha device. Overall rms error was computed for each condition. Contributions of random error and bias error to the overall error were also computed. : There was considerable intersubject variability in all conditions. However, for the CHL group, the average overall error was significantly smaller when the Baha was on than when it was off. Further analysis of error patterns indicated that this improvement was primarily based on reduced response bias when the device was on; that is, the average response azimuth was nearer to the source azimuth when the device was on than when it was off. The SNHL group, on the other hand, had significantly greater overall error when the Baha was on than when it was off. Collapsed across listening conditions and groups, localization performance was significantly better with the 1250 msec stimulus than with the 341 msec stimulus. However, for the longer-duration stimulus, there was no significant beneficial effect of head-turning. Error scores in all conditions for both groups were considerably larger than those in the normal-hearing control group. : On average, single-sided deaf adults with CHL showed improved localization ability when using the Baha, whereas single-sided deaf adults with SNHL showed a decrement in performance when using the device. These results may have implications for clinical counseling for patients with unilateral hearing impairment.

Avoidable errors in dealing with anaphylactoid reactions to iodinated contrast media.

PubMed

Segal, Arthur J; Bush, William H

2011-03-01

Contrast reactions are much less common today than in the past. This is principally because of the current and predominant use of low and iso-osmolar contrast media compared with the prior use of high osmolality contrast media. As a result of the significantly diminished frequency, there are now fewer opportunities for physicians to recognize and appropriately treat such adverse reactions. In review of the literature combined with our own clinical and legal experience, 12 potential errors were identified and these are reviewed in detail so that they can be avoided by the physician-in-charge. Basic treatment considerations are presented along with a plan to systematize an approach to contrast reactions, simplify treatment options and plans, and schedule periodic drills.

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

PubMed

Sykut-Cegielska, Jolanta

2015-01-01

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

Follow-up of negative MRI-targeted prostate biopsies: when are we missing cancer?

PubMed

Gold, Samuel A; Hale, Graham R; Bloom, Jonathan B; Smith, Clayton P; Rayn, Kareem N; Valera, Vladimir; Wood, Bradford J; Choyke, Peter L; Turkbey, Baris; Pinto, Peter A

2018-05-21

Multiparametric magnetic resonance imaging (mpMRI) has improved clinicians' ability to detect clinically significant prostate cancer (csPCa). Combining or fusing these images with the real-time imaging of transrectal ultrasound (TRUS) allows urologists to better sample lesions with a targeted biopsy (Tbx) leading to the detection of greater rates of csPCa and decreased rates of low-risk PCa. In this review, we evaluate the technical aspects of the mpMRI-guided Tbx procedure to identify possible sources of error and provide clinical context to a negative Tbx. A literature search was conducted of possible reasons for false-negative TBx. This includes discussion on false-positive mpMRI findings, termed "PCa mimics," that may incorrectly suggest high likelihood of csPCa as well as errors during Tbx resulting in inexact image fusion or biopsy needle placement. Despite the strong negative predictive value associated with Tbx, concerns of missed disease often remain, especially with MR-visible lesions. This raises questions about what to do next after a negative Tbx result. Potential sources of error can arise from each step in the targeted biopsy process ranging from "PCa mimics" or technical errors during mpMRI acquisition to failure to properly register MRI and TRUS images on a fusion biopsy platform to technical or anatomic limits on needle placement accuracy. A better understanding of these potential pitfalls in the mpMRI-guided Tbx procedure will aid interpretation of a negative Tbx, identify areas for improving technical proficiency, and improve both physician understanding of negative Tbx and patient-management options.

[Improvement of team competence in the operating room : Training programs from aviation].

PubMed

Schmidt, C E; Hardt, F; Möller, J; Malchow, B; Schmidt, K; Bauer, M

2010-08-01

Growing attention has been drawn to patient safety during recent months due to media reports of clinical errors. To date only clinical incident reporting systems have been implemented in acute care hospitals as instruments of risk management. However, these systems only have a limited impact on human factors which account for the majority of all errors in medicine. Crew resource management (CRM) starts here. For the commissioning of a new hospital in Minden, training programs were installed in order to maintain patient safety in a new complex environment. The training was planned in three parts: All relevant processes were defined as standard operating procedures (SOP), visualized and then simulated in the new building. In addition, staff members (trainers) in leading positions were trained in CRM in order to train the complete staff. The training programs were analyzed by questionnaires. Selection of topics, relevance for practice and mode of presentation were rated as very good by 73% of the participants. The staff members ranked the topics communication in crisis situations, individual errors and compensating measures as most important followed by case studies and teamwork. Employees improved in compliance to the SOP, team competence and communication. In high technology environments with escalating workloads and interdisciplinary organization, staff members are confronted with increasing demands in knowledge and skills. To reduce errors under such working conditions relevant processes should be standardized and trained for the emergency situation. Human performance can be supported by well-trained interpersonal skills which are evolved in CRM training. In combination these training programs make a significant contribution to maintaining patient safety.

Beauty from the beast: Avoiding errors in responding to client questions.

PubMed

Waehler, Charles A; Grandy, Natalie M

2016-09-01

Those rare moments when clients ask direct questions of their therapists likely represent a point when they are particularly open to new considerations, thereby representing an opportunity for substantial therapeutic gains. However, clinical errors abound in this area because clients' questions often engender apprehension in therapists, causing therapists to respond with too little or too much information or shutting down the discussion prematurely. These response types can damage the therapeutic relationship, the psychotherapy process, or both. We explore the nature of these clinical errors in response to client questions by providing examples from our own clinical work, suggesting potential reasons why clinicians may not make optimal use of client questions, and discussing how the mixed psychological literature further complicates the issue. We also present four guidelines designed to help therapists, trainers, and supervisors respond constructively to clinical questions in order to create constructive interactions. (PsycINFO Database Record (c) 2016 APA, all rights reserved).

Dermoscopy as a useful supportive tool for the diagnosis of pityriasis amiantacea-like tinea capitis.

PubMed

Errichetti, Enzo; Stinco, Giuseppe

2016-07-01

Clinical distinction between pityriasis amiantacea-like tinea capitis and pityriasis amiantacea due to noninfectious inflammatory diseases is a troublesome task, with a significant likelihood of diagnostic errors/delays and prescription of inappropriate therapies. We report a case of pityriasis amiantacea-like tinea capitis with its dermoscopic findings in order to highlight the usefulness of dermoscopy in improving the recognition of such a condition.

Variant myopia: A new presentation?

PubMed Central

Hussaindeen, Jameel Rizwana; Anand, Mithra; Sivaraman, Viswanathan; Ramani, Krishna Kumar; Allen, Peter M

2018-01-01

Purpose: Variant myopia (VM) presents as a discrepancy of >1 diopter (D) between subjective and objective refraction, without the presence of any accommodative dysfunction. The purpose of this study is to create a clinical profile of VM. Methods: Fourteen eyes of 12 VM patients who had a discrepancy of >1D between retinoscopy and subjective acceptance under both cycloplegic and noncycloplegic conditions were included in the study. Fourteen eyes of 14 age- and refractive error-matched participants served as controls. Potential participants underwent a comprehensive orthoptic examination followed by retinoscopy (Ret), closed-field autorefractor (CA), subjective acceptance (SA), choroidal and retinal thickness, ocular biometry, and higher order spherical aberrations measurements. Results: In the VM eyes, a statistically and clinically significant difference was noted between the Ret and CA and Ret and SA under both cycloplegic and noncycloplegic conditions (multivariate repeated measures analysis of variance, P < 0.0001). A statistically significant difference was observed between the VM eyes, non-VM eyes, and controls for choroidal thickness in all the quadrants (Univariate ANOVA P < 0.05). The VM eyes had thinner choroids (197.21 ± 13.04 μ) compared to the non-VM eyes (249.25 ± 53.70 μ) and refractive error-matched controls (264.62 ± 12.53 μ). No statistically significant differences between groups in root mean square of total higher order aberrations and spherical aberration were observed. Conclusion: Accommodative etiology does not play a role in the refractive discrepancy seen in individuals with the variant myopic presentation. These individuals have thinner choroids in the eye with variant myopic presentation compared to the fellow eyes and controls. Hypotheses and clinical implications of variant myopia are discussed. PMID:29785987

Water displacement leg volumetry in clinical studies - A discussion of error sources

PubMed Central

2010-01-01

Background Water displacement leg volumetry is a highly reproducible method, allowing the confirmation of efficacy of vasoactive substances. Nevertheless errors of its execution and the selection of unsuitable patients are likely to negatively affect the outcome of clinical studies in chronic venous insufficiency (CVI). Discussion Placebo controlled double-blind drug studies in CVI were searched (Cochrane Review 2005, MedLine Search until December 2007) and assessed with regard to efficacy (volume reduction of the leg), patient characteristics, and potential methodological error sources. Almost every second study reported only small drug effects (≤ 30 mL volume reduction). As the most relevant error source the conduct of volumetry was identified. Because the practical use of available equipment varies, volume differences of more than 300 mL - which is a multifold of a potential treatment effect - have been reported between consecutive measurements. Other potential error sources were insufficient patient guidance or difficulties with the transition from the Widmer CVI classification to the CEAP (Clinical Etiological Anatomical Pathophysiological) grading. Summary Patients should be properly diagnosed with CVI and selected for stable oedema and further clinical symptoms relevant for the specific study. Centres require a thorough training on the use of the volumeter and on patient guidance. Volumetry should be performed under constant conditions. The reproducibility of short term repeat measurements has to be ensured. PMID:20070899

Overconfidence across the psychosis continuum: a calibration approach.

PubMed

Balzan, Ryan P; Woodward, Todd S; Delfabbro, Paul; Moritz, Steffen

2016-11-01

An 'overconfidence in errors' bias has been consistently observed in people with schizophrenia relative to healthy controls, however, the bias is seldom found to be associated with delusional ideation. Using a more precise confidence-accuracy calibration measure of overconfidence, the present study aimed to explore whether the overconfidence bias is greater in people with higher delusional ideation. A sample of 25 participants with schizophrenia and 50 non-clinical controls (25 high- and 25 low-delusion-prone) completed 30 difficult trivia questions (accuracy <75%); 15 'half-scale' items required participants to indicate their level of confidence for accuracy, and the remaining 'confidence-range' items asked participants to provide lower/upper bounds in which they were 80% confident the true answer lay within. There was a trend towards higher overconfidence for half-scale items in the schizophrenia and high-delusion-prone groups, which reached statistical significance for confidence-range items. However, accuracy was particularly low in the two delusional groups and a significant negative correlation between clinical delusional scores and overconfidence was observed for half-scale items within the schizophrenia group. Evidence in support of an association between overconfidence and delusional ideation was therefore mixed. Inflated confidence-accuracy miscalibration for the two delusional groups may be better explained by their greater unawareness of their underperformance, rather than representing genuinely inflated overconfidence in errors.

An examination of the usefulness of repeat testing practices in a large hospital clinical chemistry laboratory.

PubMed

Deetz, Carl O; Nolan, Debra K; Scott, Mitchell G

2012-01-01

A long-standing practice in clinical laboratories has been to automatically repeat laboratory tests when values trigger automated "repeat rules" in the laboratory information system such as a critical test result. We examined 25,553 repeated laboratory values for 30 common chemistry tests from December 1, 2010, to February 28, 2011, to determine whether this practice is necessary and whether it may be possible to reduce repeat testing to improve efficiency and turnaround time for reporting critical values. An "error" was defined to occur when the difference between the initial and verified values exceeded the College of American Pathologists/Clinical Laboratory Improvement Amendments allowable error limit. The initial values from 2.6% of all repeated tests (668) were errors. Of these 668 errors, only 102 occurred for values within the analytic measurement range. Median delays in reporting critical values owing to repeated testing ranged from 5 (blood gases) to 17 (glucose) minutes.

Two-dimensional simulation of eccentric photorefraction images for ametropes: factors influencing the measurement.

PubMed

Wu, Yifei; Thibos, Larry N; Candy, T Rowan

2018-05-07

Eccentric photorefraction and Purkinje image tracking are used to estimate refractive state and eye position simultaneously. Beyond vision screening, they provide insight into typical and atypical visual development. Systematic analysis of the effect of refractive error and spectacles on photorefraction data is needed to gauge the accuracy and precision of the technique. Simulation of two-dimensional, double-pass eccentric photorefraction was performed (Zemax). The inward pass included appropriate light sources, lenses and a single surface pupil plane eye model to create an extended retinal image that served as the source for the outward pass. Refractive state, as computed from the luminance gradient in the image of the pupil captured by the model's camera, was evaluated for a range of refractive errors (-15D to +15D), pupil sizes (3 mm to 7 mm) and two sets of higher-order monochromatic aberrations. Instrument calibration was simulated using -8D to +8D trial lenses at the spectacle plane for: (1) vertex distances from 3 mm to 23 mm, (2) uncorrected and corrected hyperopic refractive errors of +4D and +7D, and (3) uncorrected and corrected astigmatism of 4D at four different axes. Empirical calibration of a commercial photorefractor was also compared with a wavefront aberrometer for human eyes. The pupil luminance gradient varied linearly with refractive state for defocus less than approximately 4D (5 mm pupil). For larger errors, the gradient magnitude saturated and then reduced, leading to under-estimation of refractive state. Additional inaccuracy (up to 1D for 8D of defocus) resulted from spectacle magnification in the pupil image, which would reduce precision in situations where vertex distance is variable. The empirical calibration revealed a constant offset between the two clinical instruments. Computational modelling demonstrates the principles and limitations of photorefraction to help users avoid potential measurement errors. Factors that could cause clinically significant errors in photorefraction estimates include high refractive error, vertex distance and magnification effects of a spectacle lens, increased higher-order monochromatic aberrations, and changes in primary spherical aberration with accommodation. The impact of these errors increases with increasing defocus. © 2018 The Authors Ophthalmic & Physiological Optics © 2018 The College of Optometrists.

Impact of time-of-flight PET on quantification errors in MR imaging-based attenuation correction.

PubMed

Mehranian, Abolfazl; Zaidi, Habib

2015-04-01

Time-of-flight (TOF) PET/MR imaging is an emerging imaging technology with great capabilities offered by TOF to improve image quality and lesion detectability. We assessed, for the first time, the impact of TOF image reconstruction on PET quantification errors induced by MR imaging-based attenuation correction (MRAC) using simulation and clinical PET/CT studies. Standard 4-class attenuation maps were derived by segmentation of CT images of 27 patients undergoing PET/CT examinations into background air, lung, soft-tissue, and fat tissue classes, followed by the assignment of predefined attenuation coefficients to each class. For each patient, 4 PET images were reconstructed: non-TOF and TOF both corrected for attenuation using reference CT-based attenuation correction and the resulting 4-class MRAC maps. The relative errors between non-TOF and TOF MRAC reconstructions were compared with their reference CT-based attenuation correction reconstructions. The bias was locally and globally evaluated using volumes of interest (VOIs) defined on lesions and normal tissues and CT-derived tissue classes containing all voxels in a given tissue, respectively. The impact of TOF on reducing the errors induced by metal-susceptibility and respiratory-phase mismatch artifacts was also evaluated using clinical and simulation studies. Our results show that TOF PET can remarkably reduce attenuation correction artifacts and quantification errors in the lungs and bone tissues. Using classwise analysis, it was found that the non-TOF MRAC method results in an error of -3.4% ± 11.5% in the lungs and -21.8% ± 2.9% in bones, whereas its TOF counterpart reduced the errors to -2.9% ± 7.1% and -15.3% ± 2.3%, respectively. The VOI-based analysis revealed that the non-TOF and TOF methods resulted in an average overestimation of 7.5% and 3.9% in or near lung lesions (n = 23) and underestimation of less than 5% for soft tissue and in or near bone lesions (n = 91). Simulation results showed that as TOF resolution improves, artifacts and quantification errors are substantially reduced. TOF PET substantially reduces artifacts and improves significantly the quantitative accuracy of standard MRAC methods. Therefore, MRAC should be less of a concern on future TOF PET/MR scanners with improved timing resolution. © 2015 by the Society of Nuclear Medicine and Molecular Imaging, Inc.

Comparison of community and hospital pharmacists' attitudes and behaviors on medication error disclosure to the patient: A pilot study.

PubMed

Kim, ChungYun; Mazan, Jennifer L; Quiñones-Boex, Ana C

To determine pharmacists' attitudes and behaviors on medication errors and their disclosure and to compare community and hospital pharmacists on such views. An online questionnaire was developed from previous studies on physicians' disclosure of errors. Questionnaire items included demographics, environment, personal experiences, and attitudes on medication errors and the disclosure process. An invitation to participate along with the link to the questionnaire was electronically distributed to members of two Illinois pharmacy associations. A follow-up reminder was sent 4 weeks after the original message. Data were collected for 3 months, and statistical analyses were performed with the use of IBM SPSS version 22.0. The overall response rate was 23.3% (n = 422). The average employed respondent was a 51-year-old white woman with a BS Pharmacy degree working in a hospital pharmacy as a clinical staff member. Regardless of practice settings, pharmacist respondents agreed that medication errors were inevitable and that a disclosure process is necessary. Respondents from community and hospital settings were further analyzed to assess any differences. Community pharmacist respondents were more likely to agree that medication errors were inevitable and that pharmacists should address the patient's emotions when disclosing an error. Community pharmacist respondents were also more likely to agree that the health care professional most closely involved with the error should disclose the error to the patient and thought that it was the pharmacists' responsibility to disclose the error. Hospital pharmacist respondents were more likely to agree that it was important to include all details in a disclosure process and more likely to disagree on putting a "positive spin" on the event. Regardless of practice setting, responding pharmacists generally agreed that errors should be disclosed to patients. There were, however, significant differences in their attitudes and behaviors depending on their particular practice setting. Copyright © 2017 American Pharmacists Association®. Published by Elsevier Inc. All rights reserved.

Evaluation of real-time data obtained from gravimetric preparation of antineoplastic agents shows medication errors with possible critical therapeutic impact: Results of a large-scale, multicentre, multinational, retrospective study.

PubMed

Terkola, R; Czejka, M; Bérubé, J

2017-08-01

Medication errors are a significant cause of morbidity and mortality especially with antineoplastic drugs, owing to their narrow therapeutic index. Gravimetric workflow software systems have the potential to reduce volumetric errors during intravenous antineoplastic drug preparation which may occur when verification is reliant on visual inspection. Our aim was to detect medication errors with possible critical therapeutic impact as determined by the rate of prevented medication errors in chemotherapy compounding after implementation of gravimetric measurement. A large-scale, retrospective analysis of data was carried out, related to medication errors identified during preparation of antineoplastic drugs in 10 pharmacy services ("centres") in five European countries following the introduction of an intravenous workflow software gravimetric system. Errors were defined as errors in dose volumes outside tolerance levels, identified during weighing stages of preparation of chemotherapy solutions which would not otherwise have been detected by conventional visual inspection. The gravimetric system detected that 7.89% of the 759 060 doses of antineoplastic drugs prepared at participating centres between July 2011 and October 2015 had error levels outside the accepted tolerance range set by individual centres, and prevented these doses from reaching patients. The proportion of antineoplastic preparations with deviations >10% ranged from 0.49% to 5.04% across sites, with a mean of 2.25%. The proportion of preparations with deviations >20% ranged from 0.21% to 1.27% across sites, with a mean of 0.71%. There was considerable variation in error levels for different antineoplastic agents. Introduction of a gravimetric preparation system for antineoplastic agents detected and prevented dosing errors which would not have been recognized with traditional methods and could have resulted in toxicity or suboptimal therapeutic outcomes for patients undergoing anticancer treatment. © 2017 The Authors. Journal of Clinical Pharmacy and Therapeutics Published by John Wiley & Sons Ltd.

Reaction Time Is Negatively Associated with Corpus Callosum Area in the Early Stages of CADASIL.

PubMed

Delorme, S; De Guio, F; Reyes, S; Jabouley, A; Chabriat, H; Jouvent, E

2017-11-01

Reaction time was recently recognized as a marker of subtle cognitive and behavioral alterations in the early clinical stages of CADASIL, a monogenic cerebral small-vessel disease. In unselected patients with CADASIL, brain atrophy and lacunes are the main imaging correlates of disease severity, but MR imaging correlates of reaction time in mildly affected patients are unknown. We hypothesized that reaction time is independently associated with the corpus callosum area in the early clinical stages of CADASIL. Twenty-six patients with CADASIL without dementia (Mini-Mental State Examination score > 24 and no cognitive symptoms) and without disability (modified Rankin Scale score ≤ 1) were compared with 29 age- and sex-matched controls. Corpus callosum area was determined on 3D-T1 MR imaging sequences with validated methodology. Between-group comparisons were performed with t tests or χ 2 tests when appropriate. Relationships between reaction time and corpus callosum area were tested using linear regression modeling. Reaction time was significantly related to corpus callosum area in patients (estimate = -7.4 × 10 3 , standard error = 3.3 × 10 3 , P = .03) even after adjustment for age, sex, level of education, and scores of depression and apathy (estimate = -12.2 × 10 3 , standard error = 3.8 × 10 3 , P = .005). No significant relationship was observed in controls. Corpus callosum area, a simple and robust imaging parameter, appears to be an independent correlate of reaction time at the early clinical stages of CADASIL. Further studies will determine whether corpus callosum area can be used as an outcome in future clinical trials in CADASIL or in more prevalent small-vessel diseases. © 2017 by American Journal of Neuroradiology.

The effect of computerized provider order entry systems on clinical care and work processes in emergency departments: a systematic review of the quantitative literature.

PubMed

Georgiou, Andrew; Prgomet, Mirela; Paoloni, Richard; Creswick, Nerida; Hordern, Antonia; Walter, Scott; Westbrook, Johanna

2013-06-01

We undertake a systematic review of the quantitative literature related to the effect of computerized provider order entry systems in the emergency department (ED). We searched MEDLINE, EMBASE, Inspec, CINAHL, and CPOE.org for English-language studies published between January 1990 and May 2011. We identified 1,063 articles, of which 22 met our inclusion criteria. Sixteen used a pre/post design; 2 were randomized controlled trials. Twelve studies reported outcomes related to patient flow/clinical work, 7 examined decision support systems, and 6 reported effects on patient safety. There were no studies that measured decision support systems and its effect on patient flow/clinical work. Computerized provider order entry was associated with an increase in time spent on computers (up to 16.2% for nurses and 11.3% for physicians), with no significant change in time spent on patient care. Computerized provider order entry with decision support systems was related to significant decreases in prescribing errors (ranging from 17 to 201 errors per 100 orders), potential adverse drug events (0.9 per 100 orders), and prescribing of excessive dosages (31% decrease for a targeted set of renal disease medications). There are tangible benefits associated with computerized provider order entry/decision support systems in the ED environment. Nevertheless, when considered as part of a framework of technical, clinical, and organizational components of the ED, the evidence base is neither consistent nor comprehensive. Multimethod research approaches (including qualitative research) can contribute to understanding of the multiple dimensions of ED care delivery, not as separate entities but as essential components of a highly integrated system of care. Copyright © 2013 American College of Emergency Physicians. Published by Mosby, Inc. All rights reserved.

[The quality of epidemiological research on pediatric refractive error and amblyopia in China needs to be improved].

PubMed

He, M G

2017-01-11

Over the past decade, great progress has been made in the clinical and epidemiological studies on refractive error and amblyopia in children with research findings published in international peer reviewed journals. This article reviews some of the essential publications so that the research findings could be learnt extensively, understood critically and objectively, and applied effectively to clinical practice. We aim to address the current limitations and shed light on clinical practice. (Chin J Ophthalmol, 2017, 53: 3-6) .

Detecting imipenem resistance in Acinetobacter baumannii by automated systems (BD Phoenix, Microscan WalkAway, Vitek 2); high error rates with Microscan WalkAway

PubMed Central

2009-01-01

Background Increasing reports of carbapenem resistant Acinetobacter baumannii infections are of serious concern. Reliable susceptibility testing results remains a critical issue for the clinical outcome. Automated systems are increasingly used for species identification and susceptibility testing. This study was organized to evaluate the accuracies of three widely used automated susceptibility testing methods for testing the imipenem susceptibilities of A. baumannii isolates, by comparing to the validated test methods. Methods Selected 112 clinical isolates of A. baumanii collected between January 2003 and May 2006 were tested to confirm imipenem susceptibility results. Strains were tested against imipenem by the reference broth microdilution (BMD), disk diffusion (DD), Etest, BD Phoenix, MicroScan WalkAway and Vitek 2 automated systems. Data were analysed by comparing the results from each test method to those produced by the reference BMD test. Results MicroScan performed true identification of all A. baumannii strains while Vitek 2 unidentified one strain, Phoenix unidentified two strains and misidentified two strains. Eighty seven of the strains (78%) were resistant to imipenem by BMD. Etest, Vitek 2 and BD Phoenix produced acceptable error rates when tested against imipenem. Etest showed the best performance with only two minor errors (1.8%). Vitek 2 produced eight minor errors(7.2%). BD Phoenix produced three major errors (2.8%). DD produced two very major errors (1.8%) (slightly higher (0.3%) than the acceptable limit) and three major errors (2.7%). MicroScan showed the worst performance in susceptibility testing with unacceptable error rates; 28 very major (25%) and 50 minor errors (44.6%). Conclusion Reporting errors for A. baumannii against imipenem do exist in susceptibility testing systems. We suggest clinical laboratories using MicroScan system for routine use should consider using a second, independent antimicrobial susceptibility testing method to validate imipenem susceptibility. Etest, whereever available, may be used as an easy method to confirm imipenem susceptibility. PMID:19291298

Resident Physicians' Clinical Training and Error Rate: The Roles of Autonomy, Consultation, and Familiarity with the Literature

ERIC Educational Resources Information Center

Naveh, Eitan; Katz-Navon, Tal; Stern, Zvi

2015-01-01

Resident physicians' clinical training poses unique challenges for the delivery of safe patient care. Residents face special risks of involvement in medical errors since they have tremendous responsibility for patient care, yet they are novice practitioners in the process of learning and mastering their profession. The present study explores…

Precision and accuracy of clinical quantification of myocardial blood flow by dynamic PET: A technical perspective.

PubMed

Moody, Jonathan B; Lee, Benjamin C; Corbett, James R; Ficaro, Edward P; Murthy, Venkatesh L

2015-10-01

A number of exciting advances in PET/CT technology and improvements in methodology have recently converged to enhance the feasibility of routine clinical quantification of myocardial blood flow and flow reserve. Recent promising clinical results are pointing toward an important role for myocardial blood flow in the care of patients. Absolute blood flow quantification can be a powerful clinical tool, but its utility will depend on maintaining precision and accuracy in the face of numerous potential sources of methodological errors. Here we review recent data and highlight the impact of PET instrumentation, image reconstruction, and quantification methods, and we emphasize (82)Rb cardiac PET which currently has the widest clinical application. It will be apparent that more data are needed, particularly in relation to newer PET technologies, as well as clinical standardization of PET protocols and methods. We provide recommendations for the methodological factors considered here. At present, myocardial flow reserve appears to be remarkably robust to various methodological errors; however, with greater attention to and more detailed understanding of these sources of error, the clinical benefits of stress-only blood flow measurement may eventually be more fully realized.

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

Kwon, Deukwoo; Little, Mark P.; Miller, Donald L.

Purpose: To determine more accurate regression formulas for estimating peak skin dose (PSD) from reference air kerma (RAK) or kerma-area product (KAP). Methods: After grouping of the data from 21 procedures into 13 clinically similar groups, assessments were made of optimal clustering using the Bayesian information criterion to obtain the optimal linear regressions of (log-transformed) PSD vs RAK, PSD vs KAP, and PSD vs RAK and KAP. Results: Three clusters of clinical groups were optimal in regression of PSD vs RAK, seven clusters of clinical groups were optimal in regression of PSD vs KAP, and six clusters of clinical groupsmore » were optimal in regression of PSD vs RAK and KAP. Prediction of PSD using both RAK and KAP is significantly better than prediction of PSD with either RAK or KAP alone. The regression of PSD vs RAK provided better predictions of PSD than the regression of PSD vs KAP. The partial-pooling (clustered) method yields smaller mean squared errors compared with the complete-pooling method.Conclusion: PSD distributions for interventional radiology procedures are log-normal. Estimates of PSD derived from RAK and KAP jointly are most accurate, followed closely by estimates derived from RAK alone. Estimates of PSD derived from KAP alone are the least accurate. Using a stochastic search approach, it is possible to cluster together certain dissimilar types of procedures to minimize the total error sum of squares.« less

Medication-related clinical decision support in computerized provider order entry systems: a review.

PubMed

Kuperman, Gilad J; Bobb, Anne; Payne, Thomas H; Avery, Anthony J; Gandhi, Tejal K; Burns, Gerard; Classen, David C; Bates, David W

2007-01-01

While medications can improve patients' health, the process of prescribing them is complex and error prone, and medication errors cause many preventable injuries. Computer provider order entry (CPOE) with clinical decision support (CDS), can improve patient safety and lower medication-related costs. To realize the medication-related benefits of CDS within CPOE, one must overcome significant challenges. Healthcare organizations implementing CPOE must understand what classes of CDS their CPOE systems can support, assure that clinical knowledge underlying their CDS systems is reasonable, and appropriately represent electronic patient data. These issues often influence to what extent an institution will succeed with its CPOE implementation and achieve its desired goals. Medication-related decision support is probably best introduced into healthcare organizations in two stages, basic and advanced. Basic decision support includes drug-allergy checking, basic dosing guidance, formulary decision support, duplicate therapy checking, and drug-drug interaction checking. Advanced decision support includes dosing support for renal insufficiency and geriatric patients, guidance for medication-related laboratory testing, drug-pregnancy checking, and drug-disease contraindication checking. In this paper, the authors outline some of the challenges associated with both basic and advanced decision support and discuss how those challenges might be addressed. The authors conclude with summary recommendations for delivering effective medication-related clinical decision support addressed to healthcare organizations, application and knowledge base vendors, policy makers, and researchers.

Trunk repositioning errors are increased in balance-impaired older adults.

PubMed

Goldberg, Allon; Hernandez, Manuel Enrique; Alexander, Neil B

2005-10-01

Controlling the flexing trunk is critical in recovering from a loss of balance and avoiding a fall. To investigate the relationship between trunk control and balance in older adults, we measured trunk repositioning accuracy in young and balance-impaired and unimpaired older adults. Young adults (N = 8, mean age 24.3 years) and two groups of community-dwelling older adults defined by unipedal stance time (UST)-a balance-unimpaired group (UST > 30 seconds, N = 7, mean age 73.9 years) and a balance-impaired group (UST < 5 seconds, N = 8, mean age 79.6 years)-were tested in standing trunk control ability by reproducing a approximately 30 degrees trunk flexion angle under three visual-surface conditions: eyes opened and closed on the floor, and eyes opened on foam. Errors in reproducing the angle were defined as trunk repositioning errors (TREs). Clinical measures related to balance, trunk extensor strength, and self-reported disability were obtained. TREs were significantly greater in the balance-impaired group than in the other groups, even when controlling for trunk extensor strength and body mass. In older adults, there were significant correlations between TREs and three clinical measures of balance and fall risk, UST and maximum step length (-0.65 to -0.75), and Timed Up & Go score (0.55), and between TREs and age (0.63-0.76). In each group TREs were similar under the three visual-surface conditions. Test-retest reliability for TREs was good to excellent (intraclass correlation coefficients > or =0.74). Older balance-impaired adults have larger TREs, and thus poorer trunk control, than do balance-unimpaired older individuals. TREs are reliable and valid measures of underlying balance impairment in older adults, and may eventually prove to be useful in predicting the ability to recover from losses of balance and to avoid falls.

Atomoxetine could improve intra-individual variability in drug-naïve adults with attention-deficit/hyperactivity disorder comparably with methylphenidate: A head-to-head randomized clinical trial.

PubMed

Ni, Hsing-Chang; Hwang Gu, Shoou-Lian; Lin, Hsiang-Yuan; Lin, Yu-Ju; Yang, Li-Kuang; Huang, Hui-Chun; Gau, Susan Shur-Fen

2016-05-01

Intra-individual variability in reaction time (IIV-RT) is common in individuals with attention-deficit/hyperactivity disorder (ADHD). It can be improved by stimulants. However, the effects of atomoxetine on IIV-RT are inconclusive. We aimed to investigate the effects of atomoxetine on IIV-RT, and directly compared its efficacy with methylphenidate in adults with ADHD. An 8-10 week, open-label, head-to-head, randomized clinical trial was conducted in 52 drug-naïve adults with ADHD, who were randomly assigned to two treatment groups: immediate-release methylphenidate (n=26) thrice daily (10-20 mg per dose) and atomoxetine once daily (n=26) (0.5-1.2 mg/kg/day). IIV-RT, derived from the Conners' continuous performance test (CCPT), was represented by the Gaussian (reaction time standard error, RTSE) and ex-Gaussian models (sigma and tau). Other neuropsychological functions, including response errors and mean of reaction time, were also measured. Participants received CCPT assessments at baseline and week 8-10 (60.4±6.3 days). We found comparable improvements in performances of CCPT between the immediate-release methylphenidate- and atomoxetine-treated groups. Both medications significantly improved IIV-RT in terms of reducing tau values with comparable efficacy. In addition, both medications significantly improved inhibitory control by reducing commission errors. Our results provide evidence to support that atomoxetine could improve IIV-RT and inhibitory control, of comparable efficacy with immediate-release methylphenidate, in drug-naïve adults with ADHD. Shared and unique mechanisms underpinning these medication effects on IIV-RT awaits further investigation. © The Author(s) 2016.

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

PubMed Central

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

2016-01-01

Objective To explore and understand participants’ perceptions and attitudes towards the reporting of medication errors (MEs). Methods A qualitative study using in-depth interviews of 31 healthcare practitioners from nine publicly funded, primary care clinics in three states in peninsular Malaysia was conducted for this study. The participants included family medicine specialists, doctors, pharmacists, pharmacist assistants, nurses and assistant medical officers. The interviews were audiotaped and transcribed verbatim. Analysis of the data was guided by the framework approach. Results Six themes and 28 codes were identified. Despite the availability of a reporting system, most of the participants agreed that MEs were underreported. The nature of the error plays an important role in determining the reporting. The reporting system, organisational factors, provider factors, reporter’s burden and benefit of reporting also were identified. Conclusions Healthcare practitioners in primary care clinics understood the importance of reporting MEs to improve patient safety. Their perceptions and attitudes towards reporting of MEs were influenced by many factors which affect the decision-making process of whether or not to report. Although the process is complex, it primarily is determined by the severity of the outcome of the errors. The participants voluntarily report the errors if they are familiar with the reporting system, what error to report, when to report and what form to use. PMID:27906960

Improving cancer patient emergency room utilization: A New Jersey state assessment.

PubMed

Scholer, Anthony J; Mahmoud, Omar M; Ghosh, Debopyria; Schwartzman, Jacob; Farooq, Mohammed; Cabrera, Javier; Wieder, Robert; Adam, Nabil R; Chokshi, Ravi J

2017-12-01

Due to its increasing incidence and its major contribution to healthcare costs, cancer is a major public health problem in the United States. The impact across different services is not well documented and utilization of emergency departments (ED) by cancer patients is not well characterized. The aim of our study was to identify factors that can be addressed to improve the appropriate delivery of quality cancer care thereby reducing ED utilization, decreasing hospitalizations and reducing the related healthcare costs. The New Jersey State Inpatient and Emergency Department Databases were used to identify the primary outcome variables; patient disposition and readmission rates. The independent variables were demographics, payer and clinical characteristics. Multivariable unconditional logistic regression models using clinical and demographic data were used to predict hospital admission or emergency department return. A total of 37,080 emergency department visits were cancer related with the most common diagnosis attributed to lung cancer (30.0%) and the most common presentation was pain. The disposition of patients who visit the ED due to cancer related issues is significantly affected by the factors of race (African American OR=0.6, p value=0.02 and Hispanic OR=0.5, p value=0.02, respectively), age aged 65 to 75years (SNF/ICF OR 2.35, p value=0.00 and Home Healthcare Service OR 5.15, p value=0.01, respectively), number of diagnoses (OR 1.26, p value=0.00), insurance payer (SNF/ICF OR 2.2, p value=0.02 and Home Healthcare Services OR 2.85, p value=0.07, respectively) and type of cancer (breast OR 0.54, p value=0.01, prostate OR 0.56, p value=0.01, uterine OR 0.37, p value=0.02, and other OR 0.62, p value=0.05, respectively). In addition, comorbidities increased the likelihood of death, being transferred to SNF/ICF, or utilization of home healthcare services (OR 1.6, p value=0.00, OR 1.18, p value=0.00, and OR 1.16, p value=0.04, respectively). Readmission is significantly affected by race (American Americans OR 0.41, standard error 0.08, p value=0.001 and Hispanics OR 0.29, standard error 0.11, p value=0.01, respectively), income (Quartile 2 OR 0.98, standard error 0.14, p value 0.01, Quartile 3 OR 1.07, standard error 0.13, p value 0.01, and Quartile 4 OR 0.88, standard error 0.12, p value 0.01, respectively), and type of cancer (prostate OR 0.25, standard error 0.09, p value=0.001). Web based symptom questionnaires, patient navigators, end of life nursing and clinical cancer pathways can identify, guide and prompt early initiation of treat before progression of symptoms in cancer patients most likely to visit the ED. Thus, improving cancer patient satisfaction, outcomes and reduce health care costs. Published by Elsevier Ltd.

A simplified chair-side remount technique using customized mounting platforms.

PubMed

Chauhan, Mamta Devendrakumar; Dange, Shankar Pandharinath; Khalikar, Arun Narayan; Vaidya, Smita Padmakar

2012-08-01

Correct occlusal relationships are part of the successful prosthetic treatment for edentulous patients. Fabrication of complete dentures comprises of clinical and laboratory procedures that should be executed accurately for achieving success with fabricated dentures. Errors occurring during the clinical and laboratory procedures of a denture may subsequently lead to the occlusal errors in the final prosthesis. These occlusal errors can be corrected in two ways: i) in patient's mouth ii) by recording new centric relation and remounting dentures on an articulator. The latter method is more feasible because the mobility of denture base on the mucosa in oral cavity does not permit the identification of premature contacts in centric occlusion and tooth guided eccentric excursions. This article describes a modest and effective clinical chair-side remount procedure using customized mounting platforms.

A simplified chair-side remount technique using customized mounting platforms

PubMed Central

Dange, Shankar Pandharinath; Khalikar, Arun Narayan; Vaidya, Smita Padmakar

2012-01-01

Correct occlusal relationships are part of the successful prosthetic treatment for edentulous patients. Fabrication of complete dentures comprises of clinical and laboratory procedures that should be executed accurately for achieving success with fabricated dentures. Errors occurring during the clinical and laboratory procedures of a denture may subsequently lead to the occlusal errors in the final prosthesis. These occlusal errors can be corrected in two ways: i) in patient's mouth ii) by recording new centric relation and remounting dentures on an articulator. The latter method is more feasible because the mobility of denture base on the mucosa in oral cavity does not permit the identification of premature contacts in centric occlusion and tooth guided eccentric excursions. This article describes a modest and effective clinical chair-side remount procedure using customized mounting platforms. PMID:22977726

Clinical errors and therapist discomfort with client disclosure of troublesome pornography use: Implications for clinical practice and error reduction.

PubMed

Walters, Nathan T; Spengler, Paul M

2016-09-01

Mental health professionals are increasingly aware of the need for competence in the treatment of clients with pornography-related concerns. However, while researchers have recently sought to explore efficacious treatments for pornography-related concerns, few explorations of potential clinical judgment issues have occurred. Due to the sensitive, and at times uncomfortable, nature of client disclosures of sexual concerns within therapy, therapists are required to manage their own discomfort while retaining fidelity to treatment. The present paper explores clinician examples of judgment errors that may result from feelings of discomfort, and specifically from client use of pornography. Issues of potential bias, bias management techniques, and therapeutic implications are discussed. (PsycINFO Database Record (c) 2016 APA, all rights reserved).

Wireless clinical alerts and patient outcomes in the surgical intensive care unit.

PubMed

Major, Kevin; Shabot, M Michael; Cunneen, Scott

2002-12-01

Errors in medicine have gained public interest since the Institute of Medicine published its 1999 report on this subject. Although errors of commission are frequently cited, errors of omission can be equally serious. A computerized surgical intensive care unit (SICU) information system when coupled to an event-driven alerting engine has the potential to reduce errors of omission for critical intensive care unit events. Automated alerts and patient outcomes were prospectively collected for all patients admitted to a tertiary-care SICU for a 2-year period. During the study period 3,973 patients were admitted to the SICU and received 13,608 days of care. A total of 15,066 alert pages were sent including alerts for physiologic condition (6,163), laboratory data (4,951), blood gas (3,774), drug allergy (130), and toxic drug levels (48). Admission Simplified Acute Physiology Score and Acute Physiology and Chronic Health Evaluation II score, SICU lengths of stay, and overall mortality rates were significantly higher in patients who triggered the alerting system. Patients triggering the alert paging system were 49.4 times more likely to die in the SICU compared with patients who did not generate an alert. Even after transfer to floor care the patients who triggered the alerting system were 5.7 times more likely to die in the hospital. An alert page identifies patients who will stay in the SICU longer and have a significantly higher chance of death compared with patients who do not trigger the alerting system.

Evidence and evidence gaps in therapies of nasal obstruction and rhinosinusitis

PubMed Central

Rotter, Nicole

2016-01-01

Therapeutic decisions in otorhinolaryngology are based on clinical experience, surgical skills, and scientific evidence. Recently, evidence-based therapies have gained increased attention and importance due to their potential to improve the individual patient’s treatment and their potential at the same time to reduce treatment costs. In clinical practice, it is almost impossible to stay ahead of the increasing mass of literature and on the other hand critically assess the presented data. A solid scientific and statistical knowledge as well as a significant amount of spare time are required to detect systematic bias and other errors in study designs, also with respect to assessing whether or not a study should be part of an individual therapeutic decision. Meta-analyses, reviews, and clinical guidelines are, therefore, of increasing importance for evidence-based therapy in clinical practice. This review is an update of the availability of external evidence for the treatment of nasal obstruction and rhinosinusitis. It becomes evident that both groups of diseases differ significantly in the availability of external evidence. Furthermore, it becomes obvious that surgical treatment options are normally based on evidence of significantly lower quality than medical treatment options. PMID:28025606

Clinical Detection of Pre-Cataractous Lens Protein Changes using Dynamic Light Scattering

PubMed Central

Datiles, Manuel B.; Ansari, Rafat R.; Suh, Kwang I.; Vitale, Susan; Reed, George F.; Zigler, J. Samuel; Ferris., Frederick L.

2008-01-01

Purpose To use Dynamic Light Scattering (DLS) to clinically assess early pre-cataractous lens protein changes. Methods We performed a cross sectional study in 380 eyes of 235 subjects aged 7–86 years with AREDS clinical lens nuclear grades ranging from 0–3.8. A DLS device was used to assess α-crystallin, a molecular chaperone protein shown to bind other damaged lens proteins, preventing their aggregation. The outcome measure was the α-crystallin index (ACI), a measure of unbound α-crystallin in each lens. The association of ACI with increasing nuclear opacity and aging was determined. Results There was a significant decrease in ACI associated with increasing grades of lens nuclear opacity (p<0.0001). There are significant losses of α-crystallin even in clinically clear lenses associated with aging (p<0.0001). The standard error of measurement was 3%. Conclusions DLS clinically detects loss of α-crystallin proteins even in clinically clear lenses. ACI measurements may be useful in identifying patients at high risk for developing cataract, and as an outcome variable in clinical lens studies. Clinical Relevance Our studies suggest that the ACI may be a useful measure of the protective α-crystallin molecular chaperone reserve present in a lens, analogous to creatinine clearance in estimating renal function reserve. PMID:19064850

Characteristics of patients making serious inhaler errors with a dry powder inhaler and association with asthma-related events in a primary care setting

PubMed Central

Westerik, Janine A. M.; Carter, Victoria; Chrystyn, Henry; Burden, Anne; Thompson, Samantha L.; Ryan, Dermot; Gruffydd-Jones, Kevin; Haughney, John; Roche, Nicolas; Lavorini, Federico; Papi, Alberto; Infantino, Antonio; Roman-Rodriguez, Miguel; Bosnic-Anticevich, Sinthia; Lisspers, Karin; Ställberg, Björn; Henrichsen, Svein Høegh; van der Molen, Thys; Hutton, Catherine; Price, David B.

2016-01-01

Abstract Objective: Correct inhaler technique is central to effective delivery of asthma therapy. The study aim was to identify factors associated with serious inhaler technique errors and their prevalence among primary care patients with asthma using the Diskus dry powder inhaler (DPI). Methods: This was a historical, multinational, cross-sectional study (2011–2013) using the iHARP database, an international initiative that includes patient- and healthcare provider-reported questionnaires from eight countries. Patients with asthma were observed for serious inhaler errors by trained healthcare providers as predefined by the iHARP steering committee. Multivariable logistic regression, stepwise reduced, was used to identify clinical characteristics and asthma-related outcomes associated with ≥1 serious errors. Results: Of 3681 patients with asthma, 623 (17%) were using a Diskus (mean [SD] age, 51 [14]; 61% women). A total of 341 (55%) patients made ≥1 serious errors. The most common errors were the failure to exhale before inhalation, insufficient breath-hold at the end of inhalation, and inhalation that was not forceful from the start. Factors significantly associated with ≥1 serious errors included asthma-related hospitalization the previous year (odds ratio [OR] 2.07; 95% confidence interval [CI], 1.26–3.40); obesity (OR 1.75; 1.17–2.63); poor asthma control the previous 4 weeks (OR 1.57; 1.04–2.36); female sex (OR 1.51; 1.08–2.10); and no inhaler technique review during the previous year (OR 1.45; 1.04–2.02). Conclusions: Patients with evidence of poor asthma control should be targeted for a review of their inhaler technique even when using a device thought to have a low error rate. PMID:26810934

Performance Evaluation of Three Blood Glucose Monitoring Systems Using ISO 15197: 2013 Accuracy Criteria, Consensus and Surveillance Error Grid Analyses, and Insulin Dosing Error Modeling in a Hospital Setting.

PubMed

Bedini, José Luis; Wallace, Jane F; Pardo, Scott; Petruschke, Thorsten

2015-10-07

Blood glucose monitoring is an essential component of diabetes management. Inaccurate blood glucose measurements can severely impact patients' health. This study evaluated the performance of 3 blood glucose monitoring systems (BGMS), Contour® Next USB, FreeStyle InsuLinx®, and OneTouch® Verio™ IQ, under routine hospital conditions. Venous blood samples (N = 236) obtained for routine laboratory procedures were collected at a Spanish hospital, and blood glucose (BG) concentrations were measured with each BGMS and with the available reference (hexokinase) method. Accuracy of the 3 BGMS was compared according to ISO 15197:2013 accuracy limit criteria, by mean absolute relative difference (MARD), consensus error grid (CEG) and surveillance error grid (SEG) analyses, and an insulin dosing error model. All BGMS met the accuracy limit criteria defined by ISO 15197:2013. While all measurements of the 3 BGMS were within low-risk zones in both error grid analyses, the Contour Next USB showed significantly smaller MARDs between reference values compared to the other 2 BGMS. Insulin dosing errors were lowest for the Contour Next USB than compared to the other systems. All BGMS fulfilled ISO 15197:2013 accuracy limit criteria and CEG criterion. However, taking together all analyses, differences in performance of potential clinical relevance may be observed. Results showed that Contour Next USB had lowest MARD values across the tested glucose range, as compared with the 2 other BGMS. CEG and SEG analyses as well as calculation of the hypothetical bolus insulin dosing error suggest a high accuracy of the Contour Next USB. © 2015 Diabetes Technology Society.

Cognitive error as the most frequent contributory factor in cases of medical injury: a study on verdict's judgment among closed claims in Japan.

PubMed

Tokuda, Yasuharu; Kishida, Naoki; Konishi, Ryota; Koizumi, Shunzo

2011-03-01

Cognitive errors in the course of clinical decision-making are prevalent in many cases of medical injury. We used information on verdict's judgment from closed claims files to determine the important cognitive factors associated with cases of medical injury. Data were collected from claims closed between 2001 to 2005 at district courts in Tokyo and Osaka, Japan. In each case, we recorded all the contributory cognitive, systemic, and patient-related factors judged in the verdicts to be causally related to the medical injury. We also analyzed the association between cognitive factors and cases involving paid compensation using a multivariable logistic regression model. Among 274 cases (mean age 49 years old; 45% women), there were 122 (45%) deaths and 67 (24%) major injuries (incomplete recovery within a year). In 103 cases (38%), the verdicts ordered hospitals to pay compensation (median; 8,000,000 Japanese Yen). An error in judgment (199/274, 73%) and failure of vigilance (177/274, 65%) were the most prevalent causative cognitive factors, and error in judgment was also significantly associated with paid compensation (odds ratio, 1.9; 95% confidence interval [CI], 1.0-3.4). Systemic causative factors including poor teamwork (11/274, 4%) and technology failure (5/274, 2%) were less common. The closed claims analysis based on verdict's judgment showed that cognitive errors were common in cases of medical injury, with an error in judgment being most prevalent and closely associated with compensation payment. Reduction of this type of error is required to produce safer healthcare. 2010 Society of Hospital Medicine.

The biasing effect of clinical history on physical examination diagnostic accuracy.

PubMed

Sibbald, Matthew; Cavalcanti, Rodrigo B

2011-08-01

Literature on diagnostic test interpretation has shown that access to clinical history can both enhance diagnostic accuracy and increase diagnostic error. Knowledge of clinical history has also been shown to enhance the more complex cognitive task of physical examination diagnosis, possibly by enabling early hypothesis generation. However, it is unclear whether clinicians adhere to these early hypotheses in the face of unexpected physical findings, thus resulting in diagnostic error. A sample of 180 internal medicine residents received a short clinical history and conducted a cardiac physical examination on a high-fidelity simulator. Resident Doctors (Residents) were randomised to three groups based on the physical findings in the simulator. The concordant group received physical examination findings consistent with the diagnosis that was most probable based on the clinical history. Discordant groups received findings associated with plausible alternative diagnoses which either lacked expected findings (indistinct discordant) or contained unexpected findings (distinct discordant). Physical examination diagnostic accuracy and physical examination findings were analysed. Physical examination diagnostic accuracy varied significantly among groups (75 ± 44%, 2 ± 13% and 31 ± 47% in the concordant, indistinct discordant and distinct discordant groups, respectively (F(2,177)  = 53, p < 0.0001). Of the 115 Residents who were diagnostically unsuccessful, 33% adhered to their original incorrect hypotheses. Residents verbalised an average of 12 findings (interquartile range: 10-14); 58 ± 17% were correct and the percentage of correct findings was similar in all three groups (p = 0.44). Residents showed substantially decreased diagnostic accuracy when faced with discordant physical findings. The majority of trainees given discordant physical findings rejected their initial hypotheses, but were still diagnostically unsuccessful. These results suggest that overcoming the bias induced by a misleading clinical history may involve two independent steps: rejection of the incorrect initial hypothesis, and selection of the correct diagnosis. Educational strategies focused solely on prompting clinicians to re-examine their hypotheses may be insufficient to reduce diagnostic error. © Blackwell Publishing Ltd 2011.

A machine learning approach for gait speed estimation using skin-mounted wearable sensors: From healthy controls to individuals with multiple sclerosis.

PubMed

McGinnis, Ryan S; Mahadevan, Nikhil; Moon, Yaejin; Seagers, Kirsten; Sheth, Nirav; Wright, John A; DiCristofaro, Steven; Silva, Ikaro; Jortberg, Elise; Ceruolo, Melissa; Pindado, Jesus A; Sosnoff, Jacob; Ghaffari, Roozbeh; Patel, Shyamal

2017-01-01

Gait speed is a powerful clinical marker for mobility impairment in patients suffering from neurological disorders. However, assessment of gait speed in coordination with delivery of comprehensive care is usually constrained to clinical environments and is often limited due to mounting demands on the availability of trained clinical staff. These limitations in assessment design could give rise to poor ecological validity and limited ability to tailor interventions to individual patients. Recent advances in wearable sensor technologies have fostered the development of new methods for monitoring parameters that characterize mobility impairment, such as gait speed, outside the clinic, and therefore address many of the limitations associated with clinical assessments. However, these methods are often validated using normal gait patterns; and extending their utility to subjects with gait impairments continues to be a challenge. In this paper, we present a machine learning method for estimating gait speed using a configurable array of skin-mounted, conformal accelerometers. We establish the accuracy of this technique on treadmill walking data from subjects with normal gait patterns and subjects with multiple sclerosis-induced gait impairments. For subjects with normal gait, the best performing model systematically overestimates speed by only 0.01 m/s, detects changes in speed to within less than 1%, and achieves a root-mean-square-error of 0.12 m/s. Extending these models trained on normal gait to subjects with gait impairments yields only minor changes in model performance. For example, for subjects with gait impairments, the best performing model systematically overestimates speed by 0.01 m/s, quantifies changes in speed to within 1%, and achieves a root-mean-square-error of 0.14 m/s. Additional analyses demonstrate that there is no correlation between gait speed estimation error and impairment severity, and that the estimated speeds maintain the clinical significance of ground truth speed in this population. These results support the use of wearable accelerometer arrays for estimating walking speed in normal subjects and their extension to MS patient cohorts with gait impairment.

Delivery of tidal volume from four anaesthesia ventilators during volume-controlled ventilation: a bench study.

PubMed

Wallon, G; Bonnet, A; Guérin, C

2013-06-01

Tidal volume (V(T)) must be accurately delivered by anaesthesia ventilators in the volume-controlled ventilation mode in order for lung protective ventilation to be effective. However, the impact of fresh gas flow (FGF) and lung mechanics on delivery of V(T) by the newest anaesthesia ventilators has not been reported. We measured delivered V(T) (V(TI)) from four anaesthesia ventilators (Aisys™, Flow-i™, Primus™, and Zeus™) on a pneumatic test lung set with three combinations of lung compliance (C, ml cm H2O(-1)) and resistance (R, cm H2O litre(-1) s(-2)): C60R5, C30R5, C60R20. For each CR, three FGF rates (0.5, 3, 10 litre min(-1)) were investigated at three set V(T)s (300, 500, 800 ml) and two values of PEEP (0 and 10 cm H2O). The volume error = [(V(TI) - V(Tset))/V(Tset)] ×100 was computed in body temperature and pressure-saturated conditions and compared using analysis of variance. For each CR and each set V(T), the absolute value of the volume error significantly declined from Aisys™ to Flow-i™, Zeus™, and Primus™. For C60R5, these values were 12.5% for Aisys™, 5% for Flow-i™ and Zeus™, and 0% for Primus™. With an increase in FGF, absolute values of the volume error increased only for Aisys™ and Zeus™. However, in C30R5, the volume error was minimal at mid-FGF for Aisys™. The results were similar at PEEP 10 cm H2O. Under experimental conditions, the volume error differed significantly between the four new anaesthesia ventilators tested and was influenced by FGF, although this effect may not be clinically relevant.

Analytical interference of HBOC-201 (Hemopure, a synthetic hemoglobin-based oxygen carrier) on four common clinical chemistry platforms.

PubMed

Korte, Erik A; Pozzi, Nicole; Wardrip, Nina; Ayyoubi, M Tayyeb; Jortani, Saeed A

2018-07-01

There are 13 million blood transfusions each year in the US. Limitations in the donor pool, storage capabilities, mass casualties, access in remote locations and reactivity of donors all limit the availability of transfusable blood products to patients. HBOC-201 (Hemopure®) is a second-generation glutaraldehyde-polymer of bovine hemoglobin, which can serve as an "oxygen bridge" to maintain oxygen carrying capacity while transfusion products are unavailable. Hemopure presents the advantages of extended shelf life, ambient storage, and limited reactive potential, but its extracellular location can also cause significant interference in modern laboratory analyzers similar to severe hemolysis. Observed error in 26 commonly measured analytes was determined on 4 different analytical platforms in plasma from a patient therapeutically transfused Hemopure as well as donor blood spiked with Hemopure at a level equivalent to the therapeutic loading dose (10% v/v). Significant negative error ratios >50% of the total allowable error (>0.5tAE) were reported in 23/104 assays (22.1%), positive bias of >0.5tAE in 26/104 assays (25.0%), and acceptable bias between -0.5tAE and 0.5tAE error ratio was reported in 44/104 (42.3%). Analysis failed in the presence of Hemopure in 11/104 (10.6%). Observed error is further subdivided by platform, wavelength, dilution and reaction method. Administration of Hemopure (or other hemoglobin-based oxygen carriers) presents a challenge to laboratorians tasked with analyzing patient specimens. We provide laboratorians with a reference to evaluate patient samples, select optimal analytical platforms for specific analytes, and predict possible bias beyond the 4 analytical platforms included in this study. Copyright © 2018 Elsevier B.V. All rights reserved.

Sensitivity of digital dental photo CIE L*a*b* analysis compared to spectrophotometer clinical assessments over 6 months.

PubMed

Sluzker, Ariel; Knösel, Michael; Athanasiou, Athanasios E

2011-10-01

To assess the sensitivity of digital dental photo CIE L*a*b* analysis compared to clinical spectrophotometer assessments over 6 months. CIE L*a*b* values for the upper right central incisors of 14 predoctoral dental students subjected to certain color-relevant exclusion criteria were recorded at baseline (T0), after 6 months (T1), and 1 week later (T2), using (Method 1) a spectrophotometer and (Method 2) a method of digital photo analysis. Statistical analysis of color and lightness data between both methods and time points were assessed using the Shapiro-Wilk test, Pearson's correlation coefficient (r), Dahlberg's formula for method error calculation, and paired samples t-tests, adopting a level of significance alpha = 0.05. Between T0 - T1, the spectrophotometer recorded significant changes in lightness (75.51 > 77.75) and color values (a*: 3.25 > 2.38; b*: 18.47 > 17.31), whereas significant changes with Method 2 were only seen for b* (21.51 > 20.57). No significant changes for overall color and lightness changes deltaE to deltaE2 were found for either of the methods. The error of the method (T1-T2) and corresponding correlation coefficients r for values L*a*b* were found to be 1.44 / 0.43 / 0.62 (r: 0.69; P = 0.007/0.64; P = 0.14/0.9; P < 0.001) for Method 1 and 0.97/0.67/1.25 (r : 0.87; P < 0.001/0.63; P = 0.17/0.57, P = 0.04) for Method 2, respectively.

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

PubMed

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

2018-06-01

Background/aims In clinical trials, it is not unusual for errors to occur during the process of recruiting, randomising and providing treatment to participants. For example, an ineligible participant may inadvertently be randomised, a participant may be randomised in the incorrect stratum, a participant may be randomised multiple times when only a single randomisation is permitted or the incorrect treatment may inadvertently be issued to a participant at randomisation. Such errors have the potential to introduce bias into treatment effect estimates and affect the validity of the trial, yet there is little motivation for researchers to report these errors and it is unclear how often they occur. The aim of this study is to assess the prevalence of recruitment, randomisation and treatment errors and review current approaches for reporting these errors in trials published in leading medical journals. Methods We conducted a systematic review of individually randomised, phase III, randomised controlled trials published in New England Journal of Medicine, Lancet, Journal of the American Medical Association, Annals of Internal Medicine and British Medical Journal from January to March 2015. The number and type of recruitment, randomisation and treatment errors that were reported and how they were handled were recorded. The corresponding authors were contacted for a random sample of trials included in the review and asked to provide details on unreported errors that occurred during their trial. Results We identified 241 potentially eligible articles, of which 82 met the inclusion criteria and were included in the review. These trials involved a median of 24 centres and 650 participants, and 87% involved two treatment arms. Recruitment, randomisation or treatment errors were reported in 32 in 82 trials (39%) that had a median of eight errors. The most commonly reported error was ineligible participants inadvertently being randomised. No mention of recruitment, randomisation or treatment errors was found in the remaining 50 of 82 trials (61%). Based on responses from 9 of the 15 corresponding authors who were contacted regarding recruitment, randomisation and treatment errors, between 1% and 100% of the errors that occurred in their trials were reported in the trial publications. Conclusion Recruitment, randomisation and treatment errors are common in individually randomised, phase III trials published in leading medical journals, but reporting practices are inadequate and reporting standards are needed. We recommend researchers report all such errors that occurred during the trial and describe how they were handled in trial publications to improve transparency in reporting of clinical trials.

Fuzzy modelling and efficiency in health care systems.

PubMed

Ozok, Ahmet F

2012-01-01

American Medical Institute reports that each year, because of the medical error, minimum fifty thousand people are dead. For a safety and quality medical system, it is important that information systems are used in health care systems. Health information applications help us to reduce the human error and to support patient care systems. Recently, it is reported that medical information systems applications have also some negative effect on all medical integral elements. The cost of health care information systems is about 4.6% of the total cost. In this paper, it is tried a risk determination model according to principles of fuzzy logic. The improvement of health care systems has become a very popular topic in Turkey recent years. Using necessary information system; it became possible to care patients in a safer way. However, using the necessary HIS tools to manage of administrative and clinical processes at hospitals became more important than before. For example; clinical work flows and communication among pharmacists, nurses and physicians are still not enough investigated. We use fuzzy modeling as a research strategy and developed sum fuzzy membership functions to minimize human error. In application in Turkey the results are significantly related with each other. Besides, the sign differences in health care information systems strongly effects of risk magnitude. The obtained results are discussed and some comments are added.

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

PubMed

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

2009-01-01

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

Longitudinal Improvement in Balance Error Scoring System Scores among NCAA Division-I Football Athletes.

PubMed

Mathiasen, Ross; Hogrefe, Christopher; Harland, Kari; Peterson, Andrew; Smoot, M Kyle

2018-02-15

The Balance Error Scoring System (BESS) is a commonly used concussion assessment tool. Recent studies have questioned the stability and reliability of baseline BESS scores. The purpose of this longitudinal prospective cohort study is to examine differences in yearly baseline BESS scores in athletes participating on an NCAA Division-I football team. NCAA Division-I freshman football athletes were videotaped performing the BESS test at matriculation and after 1 year of participation in the football program. Twenty-three athletes were enrolled in year 1 of the study, and 25 athletes were enrolled in year 2. Those athletes enrolled in year 1 were again videotaped after year 2 of the study. The paired t-test was used to assess for change in score over time for the firm surface, foam surface, and the cumulative BESS score. Additionally, inter- and intrarater reliability values were calculated. Cumulative errors on the BESS significantly decreased from a mean of 20.3 at baseline to 16.8 after 1 year of participation. The mean number of errors following the second year of participation was 15.0. Inter-rater reliability for the cumulative score ranged from 0.65 to 0.75. Intrarater reliability was 0.81. After 1 year of participation, there is a statistically and clinically significant improvement in BESS scores in an NCAA Division-I football program. Although additional improvement in BESS scores was noted after a second year of participation, it did not reach statistical significance. Football athletes should undergo baseline BESS testing at least yearly if the BESS is to be optimally useful as a diagnostic test for concussion.

Preference, satisfaction and critical errors with Genuair and Breezhaler inhalers in patients with COPD: a randomised, cross-over, multicentre study

PubMed Central

Pascual, Sergi; Feimer, Jan; De Soyza, Anthony; Sauleda Roig, Jaume; Haughney, John; Padullés, Laura; Seoane, Beatriz; Rekeda, Ludmyla; Ribera, Anna; Chrystyn, Henry

2015-01-01

Background: The specific attributes of inhaler devices can influence patient use, satisfaction and treatment compliance, and may ultimately impact on clinical outcomes in patients with chronic obstructive pulmonary disease (COPD). Aims: To assess patient preference, satisfaction and critical inhaler technique errors with Genuair (a multidose inhaler) and Breezhaler (a single-dose inhaler) after 2 weeks of daily use. Methods: Patients with COPD and moderate to severe airflow obstruction were randomised in a cross-over, open-label, multicentre study to consecutive once-daily inhalations of placebo via Genuair and Breezhaler, in addition to current COPD medication. The primary end point was the proportion of patients who preferred Genuair versus Breezhaler after 2 weeks (Patient Satisfaction and Preference Questionnaire). Other end points included overall satisfaction and correct use of the inhalers after 2 weeks, and willingness to continue with each device. Results: Of the 128 patients enrolled, 127 were included in the safety population (male n=91; mean age 67.6 years). Of the 110 of the 123 patients in the intent-to-treat population who indicated an inhaler preference, statistically significantly more patients preferred Genuair than Breezhaler (72.7 vs. 27.3%; P<0.001). Mean overall satisfaction scores were also greater for Genuair than for Breezhaler (5.9 vs. 5.3, respectively; P<0.001). After 2 weeks, there was no statistically significant difference in the number of patients who made ⩾1 critical inhaler technique error with Breezhaler than with Genuair (7.3 vs. 3.3%, respectively). Conclusions: Patient overall preference and satisfaction was significantly higher with Genuair compared with Breezhaler. The proportion of patients making critical inhaler technique errors was low with Genuair and Breezhaler. PMID:25927321

Refractive errors in patients with newly diagnosed diabetes mellitus.

PubMed

Yarbağ, Abdülhekim; Yazar, Hayrullah; Akdoğan, Mehmet; Pekgör, Ahmet; Kaleli, Suleyman

2015-01-01

Diabetes mellitus is a complex metabolic disorder that involves the small blood vessels, often causing widespread damage to tissues, including the eyes' optic refractive error. In patients with newly diagnosed diabetes mellitus who have unstable blood glucose levels, refraction may be incorrect. We aimed to investigate refraction in patients who were recently diagnosed with diabetes and treated at our centre. This prospective study was performed from February 2013 to January 2014. Patients were diagnosed with diabetes mellitus using laboratory biochemical tests and clinical examination. Venous fasting plasma glucose (fpg) levels were measured along with refractive errors. Two measurements were taken: initially and after four weeks. The last difference between the initial and end refractive measurements were evaluated. Our patients were 100 males and 30 females who had been newly diagnosed with type II DM. The refractive and fpg levels were measured twice in all patients. The average values of the initial measurements were as follows: fpg level, 415 mg/dl; average refractive value, +2.5 D (Dioptres). The average end of period measurements were fpg, 203 mg/dl; average refractive value, +0.75 D. There is a statistically significant difference between after four weeks measurements with initially measurements of fasting plasma glucose (fpg) levels (p<0.05) and there is a statistically significant relationship between changes in fpg changes with glasses ID (p<0.05) and the disappearance of blurred vision (to be greater than 50% success rate) were statistically significant (p<0.05). Also, were detected upon all these results the absence of any age and sex effects (p>0.05). Refractive error is affected in patients with newly diagnosed diabetes mellitus; therefore, plasma glucose levels should be considered in the selection of glasses.

Trial Sequential Analysis in systematic reviews with meta-analysis.

PubMed

Wetterslev, Jørn; Jakobsen, Janus Christian; Gluud, Christian

2017-03-06

Most meta-analyses in systematic reviews, including Cochrane ones, do not have sufficient statistical power to detect or refute even large intervention effects. This is why a meta-analysis ought to be regarded as an interim analysis on its way towards a required information size. The results of the meta-analyses should relate the total number of randomised participants to the estimated required meta-analytic information size accounting for statistical diversity. When the number of participants and the corresponding number of trials in a meta-analysis are insufficient, the use of the traditional 95% confidence interval or the 5% statistical significance threshold will lead to too many false positive conclusions (type I errors) and too many false negative conclusions (type II errors). We developed a methodology for interpreting meta-analysis results, using generally accepted, valid evidence on how to adjust thresholds for significance in randomised clinical trials when the required sample size has not been reached. The Lan-DeMets trial sequential monitoring boundaries in Trial Sequential Analysis offer adjusted confidence intervals and restricted thresholds for statistical significance when the diversity-adjusted required information size and the corresponding number of required trials for the meta-analysis have not been reached. Trial Sequential Analysis provides a frequentistic approach to control both type I and type II errors. We define the required information size and the corresponding number of required trials in a meta-analysis and the diversity (D 2 ) measure of heterogeneity. We explain the reasons for using Trial Sequential Analysis of meta-analysis when the actual information size fails to reach the required information size. We present examples drawn from traditional meta-analyses using unadjusted naïve 95% confidence intervals and 5% thresholds for statistical significance. Spurious conclusions in systematic reviews with traditional meta-analyses can be reduced using Trial Sequential Analysis. Several empirical studies have demonstrated that the Trial Sequential Analysis provides better control of type I errors and of type II errors than the traditional naïve meta-analysis. Trial Sequential Analysis represents analysis of meta-analytic data, with transparent assumptions, and better control of type I and type II errors than the traditional meta-analysis using naïve unadjusted confidence intervals.

The effect of misclassification errors on case mix measurement.

PubMed

Sutherland, Jason M; Botz, Chas K

2006-12-01

Case mix systems have been implemented for hospital reimbursement and performance measurement across Europe and North America. Case mix categorizes patients into discrete groups based on clinical information obtained from patient charts in an attempt to identify clinical or cost difference amongst these groups. The diagnosis related group (DRG) case mix system is the most common methodology, with variants adopted in many countries. External validation studies of coding quality have confirmed that widespread variability exists between originally recorded diagnoses and re-abstracted clinical information. DRG assignment errors in hospitals that share patient level cost data for the purpose of establishing cost weights affects cost weight accuracy. The purpose of this study is to estimate bias in cost weights due to measurement error of reported clinical information. DRG assignment error rates are simulated based on recent clinical re-abstraction study results. Our simulation study estimates that 47% of cost weights representing the least severe cases are over weight by 10%, while 32% of cost weights representing the most severe cases are under weight by 10%. Applying the simulated weights to a cross-section of hospitals, we find that teaching hospitals tend to be under weight. Since inaccurate cost weights challenges the ability of case mix systems to accurately reflect patient mix and may lead to potential distortions in hospital funding, bias in hospital case mix measurement highlights the role clinical data quality plays in hospital funding in countries that use DRG-type case mix systems. Quality of clinical information should be carefully considered from hospitals that contribute financial data for establishing cost weights.

Maintaining data integrity in a rural clinical trial.

PubMed

Van den Broeck, Jan; Mackay, Melanie; Mpontshane, Nontobeko; Kany Kany Luabeya, Angelique; Chhagan, Meera; Bennish, Michael L

2007-01-01

Clinical trials conducted in rural resource-poor settings face special challenges in ensuring quality of data collection and handling. The variable nature of these challenges, ways to overcome them, and the resulting data quality are rarely reported in the literature. To provide a detailed example of establishing local data handling capacity for a clinical trial conducted in a rural area, highlight challenges and solutions in establishing such capacity, and to report the data quality obtained by the trial. We provide a descriptive case study of a data system for biological samples and questionnaire data, and the problems encountered during its implementation. To determine the quality of data we analyzed test-retest studies using Kappa statistics of inter- and intra-observer agreement on categorical data. We calculated Technical Errors of Measurement of anthropometric measurements, audit trail analysis was done to assess error correction rates, and residual error rates were calculated by database-to-source document comparison. Initial difficulties included the unavailability of experienced research nurses, programmers and data managers in this rural area and the difficulty of designing new software tools and a complex database while making them error-free. National and international collaboration and external monitoring helped ensure good data handling and implementation of good clinical practice. Data collection, fieldwork supervision and query handling depended on streamlined transport over large distances. The involvement of a community advisory board was helpful in addressing cultural issues and establishing community acceptability of data collection methods. Data accessibility for safety monitoring required special attention. Kappa values and Technical Errors of Measurement showed acceptable values. Residual error rates in key variables were low. The article describes the experience of a single-site trial and does not address challenges particular to multi-site trials. Obtaining and maintaining data integrity in rural clinical trials is feasible, can result in acceptable data quality and can be used to develop capacity in developing country sites. It does, however, involve special challenges and requirements.

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

PubMed

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

2018-05-18

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

The utility of quantitative electroencephalography and Integrated Visual and Auditory Continuous Performance Test as auxiliary tools for the Attention Deficit Hyperactivity Disorder diagnosis.

PubMed

Kim, JunWon; Lee, YoungSik; Han, DougHyun; Min, KyungJoon; Kim, DoHyun; Lee, ChangWon

2015-03-01

This study investigated the clinical utility of quantitative electroencephalography (QEEG) and the Integrated Visual and Auditory Continuous Performance Test (IVA+CPT) as auxiliary tools for assessing Attention Deficit Hyperactivity Disorder (ADHD). All of 157 subjects were assessed using the Korean version of the Diagnostic Interview Schedule for Children Version IV (DISC-IV). We measured EGG absolute power in 21 channels and conducted IVA+CPT. We analyzed QEEG according to the Hz range: delta (1-4Hz), theta (4-8Hz), slow alpha (8-10Hz), fast alpha (10-13.5Hz), and beta (13.5-30Hz). To remove artifacts, independent component analysis was conducted (ICA), and the tester confirmed the results again. All of the IVA+CPT quotients showed significant differences between the ADHD and control groups. The ADHD group showed significantly increased delta and theta activity compared with the control group. The z-scores of theta were negatively correlated with the scores of IVA+CPT in ADHD combined type, and those of beta were positively correlated. IVA+CPT and QEEG significantly discriminated between ADHD and control groups. The commission error of IVA+CPT showed an accuracy of 82.1%, and the omission error of IVA+CPT showed an accuracy of 78.6%. The IVA+CPT and QEEG are expected to be valuable tools for aiding ADHD diagnosis accurately. Copyright © 2014 International Federation of Clinical Neurophysiology. Published by Elsevier Ireland Ltd. All rights reserved.

Nurses' clinical reasoning practices that support safe medication administration: An integrative review of the literature.

PubMed

Rohde, Emily; Domm, Elizabeth

2018-02-01

To review the current literature about nurses' clinical reasoning practices that support safe medication administration. The literature about medication administration frequently focuses on avoiding medication errors. Nurses' clinical reasoning used during medication administration to maintain medication safety receives less attention in the literature. As healthcare professionals, nurses work closely with patients, assessing and intervening to promote mediation safety prior to, during and after medication administration. They also provide discharge teaching about using medication safely. Nurses' clinical reasoning and practices that support medication safety are often invisible when the focus is medication errors avoidance. An integrative literature review was guided by Whittemore and Knafl's (Journal of Advanced Nursing, 5, 2005 and 546) five-stage review of the 11 articles that met review criteria. This review is modelled after Gaffney et al.'s (Journal of Clinical Nursing, 25, 2016 and 906) integrative review on medical error recovery. Health databases were accessed and systematically searched for research reporting nurses' clinical reasoning practices that supported safe medication administration. The level and quality of evidence of the included research articles were assessed using The Johns Hopkins Nursing Evidence-Based Practice Rating Scale©. Nurses have a central role in safe medication administration, including but not limited to risk awareness about the potential for medication errors. Nurses assess patients and their medication and use knowledge and clinical reasoning to administer medication safely. Results indicated nurses' use of clinical reasoning to maintain safe medication administration was inadequately articulated in 10 of 11 studies reviewed. Nurses are primarily responsible for safe medication administration. Nurses draw from their foundational knowledge of patient conditions and organisational processes and use clinical reasoning that supports safe medication practice. There was minimal evidence clearly articulating nurses' clinical reasoning used to support medication safety. This review focused on finding evidence of nurses' clinical reasoning that supported safe medication administration. © 2017 John Wiley & Sons Ltd.

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

PubMed

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

2013-01-01

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

Clinical outcomes of Transepithelial photorefractive keratectomy to treat low to moderate myopic astigmatism.

PubMed

Xi, Lei; Zhang, Chen; He, Yanling

2018-05-09

To evaluate the refractive and visual outcomes of Transepithelial photorefractive keratectomy (TransPRK) in the treatment of low to moderate myopic astigmatism. This retrospective study enrolled a total of 47 eyes that had undergone Transepithelial photorefractive keratectomy. Preoperative cylinder diopters ranged from - 0.75D to - 2.25D (mean - 1.11 ± 0.40D), and the sphere was between - 1.50D to - 5.75D. Visual outcomes and vector analysis of astigmatism that included error ratio (ER), correction ratio (CR), error of magnitude (EM) and error of angle (EA) were evaluated. At 6 months after TransPRK, all eyes had an uncorrected distance visual acuity of 20/20 or better, no eyes lost ≥2 lines of corrected distant visual acuity (CDVA), and 93.6% had residual refractive cylinder within ±0.50D of intended correction. On vector analysis, the mean correction ratio for refractive cylinder was 1.03 ± 0.30. The mean error magnitude was - 0.04 ± 0.36. The mean error of angle was 0.44° ± 7.42°and 80.9% of eyes had axis shift within ±10°. The absolute astigmatic error of magnitude was statistically significantly correlated with the intended cylinder correction (r = 0.48, P < 0.01). TransPRK showed safe, effective and predictable results in the correction of low to moderate astigmatism and myopia.

"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.

Maximizing the probability of satisfying the clinical goals in radiation therapy treatment planning under setup uncertainty

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

Fredriksson, Albin, E-mail: albin.fredriksson@raysearchlabs.com; Hårdemark, Björn; Forsgren, Anders

2015-07-15

Purpose: This paper introduces a method that maximizes the probability of satisfying the clinical goals in intensity-modulated radiation therapy treatments subject to setup uncertainty. Methods: The authors perform robust optimization in which the clinical goals are constrained to be satisfied whenever the setup error falls within an uncertainty set. The shape of the uncertainty set is included as a variable in the optimization. The goal of the optimization is to modify the shape of the uncertainty set in order to maximize the probability that the setup error will fall within the modified set. Because the constraints enforce the clinical goalsmore » to be satisfied under all setup errors within the uncertainty set, this is equivalent to maximizing the probability of satisfying the clinical goals. This type of robust optimization is studied with respect to photon and proton therapy applied to a prostate case and compared to robust optimization using an a priori defined uncertainty set. Results: Slight reductions of the uncertainty sets resulted in plans that satisfied a larger number of clinical goals than optimization with respect to a priori defined uncertainty sets, both within the reduced uncertainty sets and within the a priori, nonreduced, uncertainty sets. For the prostate case, the plans taking reduced uncertainty sets into account satisfied 1.4 (photons) and 1.5 (protons) times as many clinical goals over the scenarios as the method taking a priori uncertainty sets into account. Conclusions: Reducing the uncertainty sets enabled the optimization to find better solutions with respect to the errors within the reduced as well as the nonreduced uncertainty sets and thereby achieve higher probability of satisfying the clinical goals. This shows that asking for a little less in the optimization sometimes leads to better overall plan quality.« less

MASTER: a model to improve and standardize clinical breakpoints for antimicrobial susceptibility testing using forecast probabilities.

PubMed

Blöchliger, Nicolas; Keller, Peter M; Böttger, Erik C; Hombach, Michael

2017-09-01

The procedure for setting clinical breakpoints (CBPs) for antimicrobial susceptibility has been poorly standardized with respect to population data, pharmacokinetic parameters and clinical outcome. Tools to standardize CBP setting could result in improved antibiogram forecast probabilities. We propose a model to estimate probabilities for methodological categorization errors and defined zones of methodological uncertainty (ZMUs), i.e. ranges of zone diameters that cannot reliably be classified. The impact of ZMUs on methodological error rates was used for CBP optimization. The model distinguishes theoretical true inhibition zone diameters from observed diameters, which suffer from methodological variation. True diameter distributions are described with a normal mixture model. The model was fitted to observed inhibition zone diameters of clinical Escherichia coli strains. Repeated measurements for a quality control strain were used to quantify methodological variation. For 9 of 13 antibiotics analysed, our model predicted error rates of < 0.1% applying current EUCAST CBPs. Error rates were > 0.1% for ampicillin, cefoxitin, cefuroxime and amoxicillin/clavulanic acid. Increasing the susceptible CBP (cefoxitin) and introducing ZMUs (ampicillin, cefuroxime, amoxicillin/clavulanic acid) decreased error rates to < 0.1%. ZMUs contained low numbers of isolates for ampicillin and cefuroxime (3% and 6%), whereas the ZMU for amoxicillin/clavulanic acid contained 41% of all isolates and was considered not practical. We demonstrate that CBPs can be improved and standardized by minimizing methodological categorization error rates. ZMUs may be introduced if an intermediate zone is not appropriate for pharmacokinetic/pharmacodynamic or drug dosing reasons. Optimized CBPs will provide a standardized antibiotic susceptibility testing interpretation at a defined level of probability. © The Author 2017. Published by Oxford University Press on behalf of the British Society for Antimicrobial Chemotherapy. All rights reserved. For Permissions, please email: journals.permissions@oup.com.

Structured patient handoff on an internal medicine ward: A cluster randomized control trial.

PubMed

Tam, Penny; Nijjar, Aman P; Fok, Mark; Little, Chris; Shingina, Alexandra; Bittman, Jesse; Raghavan, Rashmi; Khan, Nadia A

2018-01-01

The effect of a multi-faceted handoff strategy in a high volume internal medicine inpatient setting on process and patient outcomes has not been clearly established. We set out to determine if a multi-faceted handoff intervention consisting of education, standardized handoff procedures, including fixed time and location for face-to-face handoff would result in improved rates of handoff compared with usual practice. We also evaluated resident satisfaction, health resource utilization and clinical outcomes. This was a cluster randomized controlled trial in a large academic tertiary care center with 18 inpatient internal medicine ward teams from January-April 2013. We randomized nine inpatient teams to an intervention where they received an education session standardizing who and how to handoff patients, with practice and feedback from facilitators. The control group of 9 teams continued usual non-standardized handoffs. The primary process outcome was the rate of patients handed over per 1000 patient nights. Other process outcomes included perceptions of inadequate handoff by overnight physicians, resource utilization overnight and hospital length of stay. Clinical outcomes included medical errors, frequency of patients requiring higher level of care overnight, and in-hospital mortality. The intervention group demonstrated a significant increase in the rate of patients handed over to the overnight physician (62.90/1000 person-nights vs. 46.86/1000 person-nights, p = 0.002). There was no significant difference in other process outcomes except resource utilization was increased in the intervention group (26.35/1000 person-days vs. 17.57/1000 person-days, p-value = 0.01). There was no significant difference between groups in medical errors (4.8% vs. 4.1%), need for higher level of care or in hospital mortality. Limitations include a dependence of accurate record keeping by the overnight physician, the possibility of cross-contamination in the handoff process, analysis at the cluster level and an overall low number of clinical events. Implementation of a multi-faceted resident handoff intervention did not result in a significant improvement in patient safety although did improve number of patients handed off. Novel methods to improve handoff need to be explored. Registered at ClinicalTrials.gov: NCT01796756.

Risk Factors for Visual Impairment in an Uninsured Population and the Impact of the Affordable Care Act.

PubMed

Guo, Weixia; Woodward, Maria A; Heisler, Michele; Blachley, Taylor; Corneail, Leah; Cederna, Jean; Kaplan, Ariane D; Newman Casey, Paula Anne

2016-01-01

To assess risk factors for visual impairment in a high-risk population of people: those without medical insurance. Secondarily, we assessed risk factors for remaining uninsured after implementation of the Affordable Care Act (ACA) and evaluated whether the ACA changed demand for local safety net ophthalmology clinic services one year after its implementation. In a retrospective cohort study of patients who attended a community-academic partnership free ophthalmology clinic in Southeastern, Michigan between September 2012 - March 2015, we assessed the prevalence of presenting with visual impairment, the most common causes of presenting with visual impairment and used logistic regression to assess socio-demographic risk factors for visual impairment. We assessed the initial impact of the ACA on clinic utilization. We also analyzed risk factors for remaining uninsured one year after implementation of the ACA private insurance marketplace and Medicaid expansion in the state of Michigan. Among 335 patients, one-fifth (22%) presented with visual impairment; refractive error was the leading cause for presenting with visual impairment. Unemployment was the single significant risk factor for presenting with visual impairment after adjusting for multiple confounding factors (OR = 3.05, 95% CI 1.19-7.87, p=0.01). There was no difference in proportion of visual impairment or type of vision-threatening disease between the insured and uninsured (p=0.26). Seventy six percent of patients remained uninsured one year after ACA implementation. Patients who were white, spoke English as a first language and were US Citizens were more likely to gain insurance coverage through the ACA in our population (p≤ 0.01). There was a non-significant decline in the mean number of patient treated per clinic (52 to 43) before and after ACA implementation (p=0.69). Refractive error was a leading cause for presenting with visual impairment in this vulnerable population, and being unemployed significantly increased the risk for presenting with visual impairment. The ACA did not significantly reduce the need for our free ophthalmology services. It is critically important to continue to support safety net specialty care initiatives and policy change to provide care for those in need.

Risk Factors for Visual Impairment in an Uninsured Population and the Impact of the Affordable Care Act

PubMed Central

Guo, Weixia; Woodward, Maria A; Heisler, Michele; Blachley, Taylor; Corneail, Leah; Cederna, Jean; Kaplan, Ariane D; Newman Casey, Paula Anne

2017-01-01

Purpose To assess risk factors for visual impairment in a high-risk population of people: those without medical insurance. Secondarily, we assessed risk factors for remaining uninsured after implementation of the Affordable Care Act (ACA) and evaluated whether the ACA changed demand for local safety net ophthalmology clinic services one year after its implementation. Methods In a retrospective cohort study of patients who attended a community-academic partnership free ophthalmology clinic in Southeastern, Michigan between September 2012 – March 2015, we assessed the prevalence of presenting with visual impairment, the most common causes of presenting with visual impairment and used logistic regression to assess socio-demographic risk factors for visual impairment. We assessed the initial impact of the ACA on clinic utilization. We also analyzed risk factors for remaining uninsured one year after implementation of the ACA private insurance marketplace and Medicaid expansion in the state of Michigan. Results Among 335 patients, one-fifth (22%) presented with visual impairment; refractive error was the leading cause for presenting with visual impairment. Unemployment was the single significant risk factor for presenting with visual impairment after adjusting for multiple confounding factors (OR = 3.05, 95% CI 1.19–7.87, p=0.01). There was no difference in proportion of visual impairment or type of vision-threatening disease between the insured and uninsured (p=0.26). Seventy six percent of patients remained uninsured one year after ACA implementation. Patients who were white, spoke English as a first language and were US Citizens were more likely to gain insurance coverage through the ACA in our population (p≤ 0.01). There was a non-significant decline in the mean number of patient treated per clinic (52 to 43) before and after ACA implementation (p=0.69). Conclusion Refractive error was a leading cause for presenting with visual impairment in this vulnerable population, and being unemployed significantly increased the risk for presenting with visual impairment. The ACA did not significantly reduce the need for our free ophthalmology services. It is critically important to continue to support safety net specialty care initiatives and policy change to provide care for those in need. PMID:28593201

Why Current Statistics of Complementary Alternative Medicine Clinical Trials is Invalid.

PubMed

Pandolfi, Maurizio; Carreras, Giulia

2018-06-07

It is not sufficiently known that frequentist statistics cannot provide direct information on the probability that the research hypothesis tested is correct. The error resulting from this misunderstanding is compounded when the hypotheses under scrutiny have precarious scientific bases, which, generally, those of complementary alternative medicine (CAM) are. In such cases, it is mandatory to use inferential statistics, considering the prior probability that the hypothesis tested is true, such as the Bayesian statistics. The authors show that, under such circumstances, no real statistical significance can be achieved in CAM clinical trials. In this respect, CAM trials involving human material are also hardly defensible from an ethical viewpoint.

Using Clinical Decision Support Software in Health Insurance Company

NASA Astrophysics Data System (ADS)

Konovalov, R.; Kumlander, Deniss

This paper proposes the idea to use Clinical Decision Support software in Health Insurance Company as a tool to reduce the expenses related to Medication Errors. As a prove that this class of software will help insurance companies reducing the expenses, the research was conducted in eight hospitals in United Arab Emirates to analyze the amount of preventable common Medication Errors in drug prescription.

Application of Intra-Oral Dental Scanners in the Digital Workflow of Implantology

PubMed Central

van der Meer, Wicher J.; Andriessen, Frank S.; Wismeijer, Daniel; Ren, Yijin

2012-01-01

Intra-oral scanners will play a central role in digital dentistry in the near future. In this study the accuracy of three intra-oral scanners was compared. Materials and methods: A master model made of stone was fitted with three high precision manufactured PEEK cylinders and scanned with three intra-oral scanners: the CEREC (Sirona), the iTero (Cadent) and the Lava COS (3M). In software the digital files were imported and the distance between the centres of the cylinders and the angulation between the cylinders was assessed. These values were compared to the measurements made on a high accuracy 3D scan of the master model. Results: The distance errors were the smallest and most consistent for the Lava COS. The distance errors for the Cerec were the largest and least consistent. All the angulation errors were small. Conclusions: The Lava COS in combination with a high accuracy scanning protocol resulted in the smallest and most consistent errors of all three scanners tested when considering mean distance errors in full arch impressions both in absolute values and in consistency for both measured distances. For the mean angulation errors, the Lava COS had the smallest errors between cylinders 1–2 and the largest errors between cylinders 1–3, although the absolute difference with the smallest mean value (iTero) was very small (0,0529°). An expected increase in distance and/or angular errors over the length of the arch due to an accumulation of registration errors of the patched 3D surfaces could be observed in this study design, but the effects were statistically not significant. Clinical relevance For making impressions of implant cases for digital workflows, the most accurate scanner with the scanning protocol that will ensure the most accurate digital impression should be used. In our study model that was the Lava COS with the high accuracy scanning protocol. PMID:22937030

Ultrasound fusion image error correction using subject-specific liver motion model and automatic image registration.

PubMed

Yang, Minglei; Ding, Hui; Zhu, Lei; Wang, Guangzhi

2016-12-01

Ultrasound fusion imaging is an emerging tool and benefits a variety of clinical applications, such as image-guided diagnosis and treatment of hepatocellular carcinoma and unresectable liver metastases. However, respiratory liver motion-induced misalignment of multimodal images (i.e., fusion error) compromises the effectiveness and practicability of this method. The purpose of this paper is to develop a subject-specific liver motion model and automatic registration-based method to correct the fusion error. An online-built subject-specific motion model and automatic image registration method for 2D ultrasound-3D magnetic resonance (MR) images were combined to compensate for the respiratory liver motion. The key steps included: 1) Build a subject-specific liver motion model for current subject online and perform the initial registration of pre-acquired 3D MR and intra-operative ultrasound images; 2) During fusion imaging, compensate for liver motion first using the motion model, and then using an automatic registration method to further correct the respiratory fusion error. Evaluation experiments were conducted on liver phantom and five subjects. In the phantom study, the fusion error (superior-inferior axis) was reduced from 13.90±2.38mm to 4.26±0.78mm by using the motion model only. The fusion error further decreased to 0.63±0.53mm by using the registration method. The registration method also decreased the rotation error from 7.06±0.21° to 1.18±0.66°. In the clinical study, the fusion error was reduced from 12.90±9.58mm to 6.12±2.90mm by using the motion model alone. Moreover, the fusion error decreased to 1.96±0.33mm by using the registration method. The proposed method can effectively correct the respiration-induced fusion error to improve the fusion image quality. This method can also reduce the error correction dependency on the initial registration of ultrasound and MR images. Overall, the proposed method can improve the clinical practicability of ultrasound fusion imaging. Copyright © 2016 Elsevier Ltd. All rights reserved.

A multidisciplinary audit of clinical coding accuracy in otolaryngology: financial, managerial and clinical governance considerations under payment-by-results.

PubMed

Nouraei, S A R; O'Hanlon, S; Butler, C R; Hadovsky, A; Donald, E; Benjamin, E; Sandhu, G S

2009-02-01

To audit the accuracy of otolaryngology clinical coding and identify ways of improving it. Prospective multidisciplinary audit, using the 'national standard clinical coding audit' methodology supplemented by 'double-reading and arbitration'. Teaching-hospital otolaryngology and clinical coding departments. Otolaryngology inpatient and day-surgery cases. Concordance between initial coding performed by a coder (first cycle) and final coding by a clinician-coder multidisciplinary team (MDT; second cycle) for primary and secondary diagnoses and procedures, and Health Resource Groupings (HRG) assignment. 1250 randomly-selected cases were studied. Coding errors occurred in 24.1% of cases (301/1250). The clinician-coder MDT reassigned 48 primary diagnoses and 186 primary procedures and identified a further 209 initially-missed secondary diagnoses and procedures. In 203 cases, patient's initial HRG changed. Incorrect coding caused an average revenue loss of 174.90 pounds per patient (14.7%) of which 60% of the total income variance was due to miscoding of a eight highly-complex head and neck cancer cases. The 'HRG drift' created the appearance of disproportionate resource utilisation when treating 'simple' cases. At our institution the total cost of maintaining a clinician-coder MDT was 4.8 times lower than the income regained through the double-reading process. This large audit of otolaryngology practice identifies a large degree of error in coding on discharge. This leads to significant loss of departmental revenue, and given that the same data is used for benchmarking and for making decisions about resource allocation, it distorts the picture of clinical practice. These can be rectified through implementing a cost-effective clinician-coder double-reading multidisciplinary team as part of a data-assurance clinical governance framework which we recommend should be established in hospitals.

Qualitative Analysis of the Interdisciplinary Interaction between Data Analysis Specialists and Novice Clinical Researchers

PubMed Central

Zammar, Guilherme Roberto; Shah, Jatin; Bonilauri Ferreira, Ana Paula; Cofiel, Luciana; Lyles, Kenneth W.; Pietrobon, Ricardo

2010-01-01

Background The inherent complexity of statistical methods and clinical phenomena compel researchers with diverse domains of expertise to work in interdisciplinary teams, where none of them have a complete knowledge in their counterpart's field. As a result, knowledge exchange may often be characterized by miscommunication leading to misinterpretation, ultimately resulting in errors in research and even clinical practice. Though communication has a central role in interdisciplinary collaboration and since miscommunication can have a negative impact on research processes, to the best of our knowledge, no study has yet explored how data analysis specialists and clinical researchers communicate over time. Methods/Principal Findings We conducted qualitative analysis of encounters between clinical researchers and data analysis specialists (epidemiologist, clinical epidemiologist, and data mining specialist). These encounters were recorded and systematically analyzed using a grounded theory methodology for extraction of emerging themes, followed by data triangulation and analysis of negative cases for validation. A policy analysis was then performed using a system dynamics methodology looking for potential interventions to improve this process. Four major emerging themes were found. Definitions using lay language were frequently employed as a way to bridge the language gap between the specialties. Thought experiments presented a series of “what if” situations that helped clarify how the method or information from the other field would behave, if exposed to alternative situations, ultimately aiding in explaining their main objective. Metaphors and analogies were used to translate concepts across fields, from the unfamiliar to the familiar. Prolepsis was used to anticipate study outcomes, thus helping specialists understand the current context based on an understanding of their final goal. Conclusion/Significance The communication between clinical researchers and data analysis specialists presents multiple challenges that can lead to errors. PMID:20195374

Novel method to predict body weight in children based on age and morphological facial features.

PubMed

Huang, Ziyin; Barrett, Jeffrey S; Barrett, Kyle; Barrett, Ryan; Ng, Chee M

2015-04-01

A new and novel approach of predicting the body weight of children based on age and morphological facial features using a three-layer feed-forward artificial neural network (ANN) model is reported. The model takes in four parameters, including age-based CDC-inferred median body weight and three facial feature distances measured from digital facial images. In this study, thirty-nine volunteer subjects with age ranging from 6-18 years old and BW ranging from 18.6-96.4 kg were used for model development and validation. The final model has a mean prediction error of 0.48, a mean squared error of 18.43, and a coefficient of correlation of 0.94. The model shows significant improvement in prediction accuracy over several age-based body weight prediction methods. Combining with a facial recognition algorithm that can detect, extract and measure the facial features used in this study, mobile applications that incorporate this body weight prediction method may be developed for clinical investigations where access to scales is limited. © 2014, The American College of Clinical Pharmacology.

Comparison of the Effect of Cycloplegia on Astigmatism Measurements in a Pediatric Amblyopic Population: A Prospective Study.

PubMed

Goyal, Sunali; Phillips, Paul H; Rettiganti, Mallikarjuna; Gossett, Jeffrey M; Lowery, R Scott

2018-06-18

To study the effect of cycloplegia on astigmatism measurements in pediatric patients with amblyopia. This was a prospective comparative clinical study. Participants 4 to 17 years old were recruited from the patient population at the Arkansas Children's Hospital eye clinic after informed consent was obtained. Autorefractor measurements were used to obtain values of refractive error in amblyopic and non-amblyopic patients before and after cycloplegia. The groups were subdivided into myopia and hyperopia and with and without underlying amblyopia. The refractive error was expressed as sphere, cylinder, axis of astigmatism, and spherical equivalent. The treatment effect was summarized as the mean difference (95% confidence interval) for each outcome. No statistically significant difference was found on the axis and power of astigmatism before and after cycloplegia in the patients with amblyopia (P = .28 and .99, respectively). Non-cycloplegic autorefraction measurements may be considered safe for refining astigmatism power and axis in pediatric patients with amblyopia. [J Pediatr Ophthalmol Strabismus. 201X; XX(X):XXXX.]. Copyright 2018, SLACK Incorporated.

Refractive regression after laser in situ keratomileusis.

PubMed

Yan, Mabel K; Chang, John Sm; Chan, Tommy Cy

2018-04-26

Uncorrected refractive errors are a leading cause of visual impairment across the world. In today's society, laser in situ keratomileusis (LASIK) has become the most commonly performed surgical procedure to correct refractive errors. However, regression of the initially achieved refractive correction has been a widely observed phenomenon following LASIK since its inception more than two decades ago. Despite technological advances in laser refractive surgery and various proposed management strategies, post-LASIK regression is still frequently observed and has significant implications for the long-term visual performance and quality of life of patients. This review explores the mechanism of refractive regression after both myopic and hyperopic LASIK, predisposing risk factors and its clinical course. In addition, current preventative strategies and therapies are also reviewed. © 2018 Royal Australian and New Zealand College of Ophthalmologists.

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

Covington, E; Younge, K; Chen, X

Purpose: To evaluate the effectiveness of an automated plan check tool to improve first-time plan quality as well as standardize and document performance of physics plan checks. Methods: The Plan Checker Tool (PCT) uses the Eclipse Scripting API to check and compare data from the treatment planning system (TPS) and treatment management system (TMS). PCT was created to improve first-time plan quality, reduce patient delays, increase efficiency of our electronic workflow, and to standardize and partially automate plan checks in the TPS. A framework was developed which can be configured with different reference values and types of checks. One examplemore » is the prescribed dose check where PCT flags the user when the planned dose and the prescribed dose disagree. PCT includes a comprehensive checklist of automated and manual checks that are documented when performed by the user. A PDF report is created and automatically uploaded into the TMS. Prior to and during PCT development, errors caught during plan checks and also patient delays were tracked in order to prioritize which checks should be automated. The most common and significant errors were determined. Results: Nineteen of 33 checklist items were automated with data extracted with the PCT. These include checks for prescription, reference point and machine scheduling errors which are three of the top six causes of patient delays related to physics and dosimetry. Since the clinical roll-out, no delays have been due to errors that are automatically flagged by the PCT. Development continues to automate the remaining checks. Conclusion: With PCT, 57% of the physics plan checklist has been partially or fully automated. Treatment delays have declined since release of the PCT for clinical use. By tracking delays and errors, we have been able to measure the effectiveness of automating checks and are using this information to prioritize future development. This project was supported in part by P01CA059827.« less

Clinical laboratory: bigger is not always better.

PubMed

Plebani, Mario

2018-06-27

Laboratory services around the world are undergoing substantial consolidation and changes through mechanisms ranging from mergers, acquisitions and outsourcing, primarily based on expectations to improve efficiency, increasing volumes and reducing the cost per test. However, the relationship between volume and costs is not linear and numerous variables influence the end cost per test. In particular, the relationship between volumes and costs does not span the entire platter of clinical laboratories: high costs are associated with low volumes up to a threshold of 1 million test per year. Over this threshold, there is no linear association between volumes and costs, as laboratory organization rather than test volume more significantly affects the final costs. Currently, data on laboratory errors and associated diagnostic errors and risk for patient harm emphasize the need for a paradigmatic shift: from a focus on volumes and efficiency to a patient-centered vision restoring the nature of laboratory services as an integral part of the diagnostic and therapy process. Process and outcome quality indicators are effective tools to measure and improve laboratory services, by stimulating a competition based on intra- and extra-analytical performance specifications, intermediate outcomes and customer satisfaction. Rather than competing with economic value, clinical laboratories should adopt a strategy based on a set of harmonized quality indicators and performance specifications, active laboratory stewardship, and improved patient safety.

A Semiautomatic Method for Multiple Sclerosis Lesion Segmentation on Dual-Echo MR Imaging: Application in a Multicenter Context.

PubMed

Storelli, L; Pagani, E; Rocca, M A; Horsfield, M A; Gallo, A; Bisecco, A; Battaglini, M; De Stefano, N; Vrenken, H; Thomas, D L; Mancini, L; Ropele, S; Enzinger, C; Preziosa, P; Filippi, M

2016-07-21

The automatic segmentation of MS lesions could reduce time required for image processing together with inter- and intraoperator variability for research and clinical trials. A multicenter validation of a proposed semiautomatic method for hyperintense MS lesion segmentation on dual-echo MR imaging is presented. The classification technique used is based on a region-growing approach starting from manual lesion identification by an expert observer with a final segmentation-refinement step. The method was validated in a cohort of 52 patients with relapsing-remitting MS, with dual-echo images acquired in 6 different European centers. We found a mathematic expression that made the optimization of the method independent of the need for a training dataset. The automatic segmentation was in good agreement with the manual segmentation (dice similarity coefficient = 0.62 and root mean square error = 2 mL). Assessment of the segmentation errors showed no significant differences in algorithm performance between the different MR scanner manufacturers (P > .05). The method proved to be robust, and no center-specific training of the algorithm was required, offering the possibility for application in a clinical setting. Adoption of the method should lead to improved reliability and less operator time required for image analysis in research and clinical trials in MS. © 2016 American Society of Neuroradiology.

Text-based phenotypic profiles incorporating biochemical phenotypes of inborn errors of metabolism improve phenomics-based diagnosis.

PubMed

Lee, Jessica J Y; Gottlieb, Michael M; Lever, Jake; Jones, Steven J M; Blau, Nenad; van Karnebeek, Clara D M; Wasserman, Wyeth W

2018-05-01

Phenomics is the comprehensive study of phenotypes at every level of biology: from metabolites to organisms. With high throughput technologies increasing the scope of biological discoveries, the field of phenomics has been developing rapid and precise methods to collect, catalog, and analyze phenotypes. Such methods have allowed phenotypic data to be widely used in medical applications, from assisting clinical diagnoses to prioritizing genomic diagnoses. To channel the benefits of phenomics into the field of inborn errors of metabolism (IEM), we have recently launched IEMbase, an expert-curated knowledgebase of IEM and their disease-characterizing phenotypes. While our efforts with IEMbase have realized benefits, taking full advantage of phenomics requires a comprehensive curation of IEM phenotypes in core phenomics projects, which is dependent upon contributions from the IEM clinical and research community. Here, we assess the inclusion of IEM biochemical phenotypes in a core phenomics project, the Human Phenotype Ontology. We then demonstrate the utility of biochemical phenotypes using a text-based phenomics method to predict gene-disease relationships, showing that the prediction of IEM genes is significantly better using biochemical rather than clinical profiles. The findings herein provide a motivating goal for the IEM community to expand the computationally accessible descriptions of biochemical phenotypes associated with IEM in phenomics resources.

Emergency Physician Estimation of Blood Loss

PubMed Central

Ashburn, Jeffery C.; Harrison, Tamara; Ham, James J.; Strote, Jared

2012-01-01

Introduction Emergency physicians (EP) frequently estimate blood loss, which can have implications for clinical care. The objectives of this study were to examine EP accuracy in estimating blood loss on different surfaces and compare attending physician and resident performance. Methods A sample of 56 emergency department (ED) physicians (30 attending physicians and 26 residents) were asked to estimate the amount of moulage blood present in 4 scenarios: 500 mL spilled onto an ED cot; 25 mL spilled onto a 10-pack of 4 × 4-inch gauze; 100 mL on a T-shirt; and 150 mL in a commode filled with water. Standard estimate error (the absolute value of (estimated volume − actual volume)/actual volume × 100) was calculated for each estimate. Results The mean standard error for all estimates was 116% with a range of 0% to 1233%. Only 8% of estimates were within 20% of the true value. Estimates were most accurate for the sheet scenario and worst for the commode scenario. Residents and attending physicians did not perform significantly differently (P > 0.05). Conclusion Emergency department physicians do not estimate blood loss well in a variety of scenarios. Such estimates could potentially be misleading if used in clinical decision making. Clinical experience does not appear to improve estimation ability in this limited study. PMID:22942938

Documentation of study medication dispensing in a prospective large randomized clinical trial: experiences from the ARISTOTLE Trial.

PubMed

Alexander, John H; Levy, Elliott; Lawrence, Jack; Hanna, Michael; Waclawski, Anthony P; Wang, Junyuan; Califf, Robert M; Wallentin, Lars; Granger, Christopher B

2013-09-01

In ARISTOTLE, apixaban resulted in a 21% reduction in stroke, a 31% reduction in major bleeding, and an 11% reduction in death. However, approval of apixaban was delayed to investigate a statement in the clinical study report that "7.3% of subjects in the apixaban group and 1.2% of subjects in the warfarin group received, at some point during the study, a container of the wrong type." Rates of study medication dispensing error were characterized through reviews of study medication container tear-off labels in 6,520 participants from randomly selected study sites. The potential effect of dispensing errors on study outcomes was statistically simulated in sensitivity analyses in the overall population. The rate of medication dispensing error resulting in treatment error was 0.04%. Rates of participants receiving at least 1 incorrect container were 1.04% (34/3,273) in the apixaban group and 0.77% (25/3,247) in the warfarin group. Most of the originally reported errors were data entry errors in which the correct medication container was dispensed but the wrong container number was entered into the case report form. Sensitivity simulations in the overall trial population showed no meaningful effect of medication dispensing error on the main efficacy and safety outcomes. Rates of medication dispensing error were low and balanced between treatment groups. The initially reported dispensing error rate was the result of data recording and data management errors and not true medication dispensing errors. These analyses confirm the previously reported results of ARISTOTLE. © 2013.

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

PubMed

Meurier, C E

2000-07-01

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

Measuring the relationship between interruptions, multitasking and prescribing errors in an emergency department: a study protocol

PubMed Central

Raban, Magdalena Z; Walter, Scott R; Douglas, Heather E; Strumpman, Dana; Mackenzie, John; Westbrook, Johanna I

2015-01-01

Introduction Interruptions and multitasking are frequent in clinical settings, and have been shown in the cognitive psychology literature to affect performance, increasing the risk of error. However, comparatively less is known about their impact on errors in clinical work. This study will assess the relationship between prescribing errors, interruptions and multitasking in an emergency department (ED) using direct observations and chart review. Methods and analysis The study will be conducted in an ED of a 440-bed teaching hospital in Sydney, Australia. Doctors will be shadowed at proximity by observers for 2 h time intervals while they are working on day shift (between 0800 and 1800). Time stamped data on tasks, interruptions and multitasking will be recorded on a handheld computer using the validated Work Observation Method by Activity Timing (WOMBAT) tool. The prompts leading to interruptions and multitasking will also be recorded. When doctors prescribe medication, type of chart and chart sections written on, along with the patient's medical record number (MRN) will be recorded. A clinical pharmacist will access patient records and assess the medication orders for prescribing errors. The prescribing error rate will be calculated per prescribing task and is defined as the number of errors divided by the number of medication orders written during the prescribing task. The association between prescribing error rates, and rates of prompts, interruptions and multitasking will be assessed using statistical modelling. Ethics and dissemination Ethics approval has been obtained from the hospital research ethics committee. Eligible doctors will be provided with written information sheets and written consent will be obtained if they agree to participate. Doctor details and MRNs will be kept separate from the data on prescribing errors, and will not appear in the final data set for analysis. Study results will be disseminated in publications and feedback to the ED. PMID:26463224

Measuring the relationship between interruptions, multitasking and prescribing errors in an emergency department: a study protocol.

PubMed

Raban, Magdalena Z; Walter, Scott R; Douglas, Heather E; Strumpman, Dana; Mackenzie, John; Westbrook, Johanna I

2015-10-13

Interruptions and multitasking are frequent in clinical settings, and have been shown in the cognitive psychology literature to affect performance, increasing the risk of error. However, comparatively less is known about their impact on errors in clinical work. This study will assess the relationship between prescribing errors, interruptions and multitasking in an emergency department (ED) using direct observations and chart review. The study will be conducted in an ED of a 440-bed teaching hospital in Sydney, Australia. Doctors will be shadowed at proximity by observers for 2 h time intervals while they are working on day shift (between 0800 and 1800). Time stamped data on tasks, interruptions and multitasking will be recorded on a handheld computer using the validated Work Observation Method by Activity Timing (WOMBAT) tool. The prompts leading to interruptions and multitasking will also be recorded. When doctors prescribe medication, type of chart and chart sections written on, along with the patient's medical record number (MRN) will be recorded. A clinical pharmacist will access patient records and assess the medication orders for prescribing errors. The prescribing error rate will be calculated per prescribing task and is defined as the number of errors divided by the number of medication orders written during the prescribing task. The association between prescribing error rates, and rates of prompts, interruptions and multitasking will be assessed using statistical modelling. Ethics approval has been obtained from the hospital research ethics committee. Eligible doctors will be provided with written information sheets and written consent will be obtained if they agree to participate. Doctor details and MRNs will be kept separate from the data on prescribing errors, and will not appear in the final data set for analysis. Study results will be disseminated in publications and feedback to the ED. 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.

Clinical Research Methodology 2: Observational Clinical Research.

PubMed

Sessler, Daniel I; Imrey, Peter B

2015-10-01

Case-control and cohort studies are invaluable research tools and provide the strongest feasible research designs for addressing some questions. Case-control studies usually involve retrospective data collection. Cohort studies can involve retrospective, ambidirectional, or prospective data collection. Observational studies are subject to errors attributable to selection bias, confounding, measurement bias, and reverse causation-in addition to errors of chance. Confounding can be statistically controlled to the extent that potential factors are known and accurately measured, but, in practice, bias and unknown confounders usually remain additional potential sources of error, often of unknown magnitude and clinical impact. Causality-the most clinically useful relation between exposure and outcome-can rarely be definitively determined from observational studies because intentional, controlled manipulations of exposures are not involved. In this article, we review several types of observational clinical research: case series, comparative case-control and cohort studies, and hybrid designs in which case-control analyses are performed on selected members of cohorts. We also discuss the analytic issues that arise when groups to be compared in an observational study, such as patients receiving different therapies, are not comparable in other respects.