Prevalence and cost of hospital medical errors in the general and elderly United States populations.

PubMed

Mallow, Peter J; Pandya, Bhavik; Horblyuk, Ruslan; Kaplan, Harold S

2013-12-01

The primary objective of this study was to quantify the differences in the prevalence rate and costs of hospital medical errors between the general population and an elderly population aged ≥65 years. Methods from an actuarial study of medical errors were modified to identify medical errors in the Premier Hospital Database using data from 2009. Visits with more than four medical errors were removed from the population to avoid over-estimation of cost. Prevalence rates were calculated based on the total number of inpatient visits. There were 3,466,596 total inpatient visits in 2009. Of these, 1,230,836 (36%) occurred in people aged ≥ 65. The prevalence rate was 49 medical errors per 1000 inpatient visits in the general cohort and 79 medical errors per 1000 inpatient visits for the elderly cohort. The top 10 medical errors accounted for more than 80% of the total in the general cohort and the 65+ cohort. The most costly medical error for the general population was postoperative infection ($569,287,000). Pressure ulcers were most costly ($347,166,257) in the elderly population. This study was conducted with a hospital administrative database, and assumptions were necessary to identify medical errors in the database. Further, there was no method to identify errors of omission or misdiagnoses within the database. This study indicates that prevalence of hospital medical errors for the elderly is greater than the general population and the associated cost of medical errors in the elderly population is quite substantial. Hospitals which further focus their attention on medical errors in the elderly population may see a significant reduction in costs due to medical errors as a disproportionate percentage of medical errors occur in this age group.

Identification of factors which affect the tendency towards and attitudes of emergency unit nurses to make medical errors.

PubMed

Kiymaz, Dilek; Koç, Zeliha

2018-03-01

To determine individual and professional factors affecting the tendency of emergency unit nurses to make medical errors and their attitudes towards these errors in Turkey. Compared with other units, the emergency unit is an environment where there is an increased tendency for making medical errors due to its intensive and rapid pace, noise and complex and dynamic structure. A descriptive cross-sectional study. The study was carried out from 25 July 2014-16 September 2015 with the participation of 284 nurses who volunteered to take part in the study. Data were gathered using the data collection survey for nurses, the Medical Error Tendency Scale and the Medical Error Attitude Scale. It was determined that 40.1% of the nurses previously witnessed medical errors, 19.4% made a medical error in the last year, 17.6% of medical errors were caused by medication errors where the wrong medication was administered in the wrong dose, and none of the nurses filled out a case report form about the medical errors they made. Regarding the factors that caused medical errors in the emergency unit, 91.2% of the nurses stated excessive workload as a cause; 85.1% stated an insufficient number of nurses; and 75.4% stated fatigue, exhaustion and burnout. The study showed that nurses who loved their job were satisfied with their unit and who always worked during day shifts had a lower medical error tendency. It is suggested to consider the following actions: increase awareness about medical errors, organise training to reduce errors in medication administration, develop procedures and protocols specific to the emergency unit health care and create an environment which is not punitive wherein nurses can safely report medical errors. © 2017 John Wiley & Sons Ltd.

An evaluation of programmed treatment-integrity errors during discrete-trial instruction.

PubMed

Carroll, Regina A; Kodak, Tiffany; Fisher, Wayne W

2013-01-01

This study evaluated the effects of programmed treatment-integrity errors on skill acquisition for children with an autism spectrum disorder (ASD) during discrete-trial instruction (DTI). In Study 1, we identified common treatment-integrity errors that occur during academic instruction in schools. In Study 2, we simultaneously manipulated 3 integrity errors during DTI. In Study 3, we evaluated the effects of each of the 3 integrity errors separately on skill acquisition during DTI. Results showed that participants either demonstrated slower skill acquisition or did not acquire the target skills when instruction included treatment-integrity errors. © Society for the Experimental Analysis of Behavior.

Rate, causes and reporting of medication errors in Jordan: nurses' perspectives.

PubMed

Mrayyan, Majd T; Shishani, Kawkab; Al-Faouri, Ibrahim

2007-09-01

The aim of the study was to describe Jordanian nurses' perceptions about various issues related to medication errors. This is the first nursing study about medication errors in Jordan. This was a descriptive study. A convenient sample of 799 nurses from 24 hospitals was obtained. Descriptive and inferential statistics were used for data analysis. Over the course of their nursing career, the average number of recalled committed medication errors per nurse was 2.2. Using incident reports, the rate of medication errors reported to nurse managers was 42.1%. Medication errors occurred mainly when medication labels/packaging were of poor quality or damaged. Nurses failed to report medication errors because they were afraid that they might be subjected to disciplinary actions or even lose their jobs. In the stepwise regression model, gender was the only predictor of medication errors in Jordan. Strategies to reduce or eliminate medication errors are required.

Prevalence of medication errors in primary health care at Bahrain Defence Force Hospital – prescription-based study

PubMed Central

Aljasmi, Fatema; Almalood, Fatema

2018-01-01

Background One of the important activities that physicians – particularly general practitioners – perform is prescribing. It occurs in most health care facilities and especially in primary health care (PHC) settings. Objectives This study aims to determine what types of prescribing errors are made in PHC at Bahrain Defence Force (BDF) Hospital, and how common they are. Methods This was a retrospective study of data from PHC at BDF Hospital. The data consisted of 379 prescriptions randomly selected from the pharmacy between March and May 2013, and errors in the prescriptions were classified into five types: major omission, minor omission, commission, integration, and skill-related errors. Results Of the total prescriptions, 54.4% (N=206) were given to male patients and 45.6% (N=173) to female patients; 24.8% were given to patients under the age of 10 years. On average, there were 2.6 drugs per prescription. In the prescriptions, 8.7% of drugs were prescribed by their generic names, and 28% (N=106) of prescriptions included an antibiotic. Out of the 379 prescriptions, 228 had an error, and 44.3% (N=439) of the 992 prescribed drugs contained errors. The proportions of errors were as follows: 9.9% (N=38) were minor omission errors; 73.6% (N=323) were major omission errors; 9.3% (N=41) were commission errors; and 17.1% (N=75) were skill-related errors. Conclusion This study provides awareness of the presence of prescription errors and frequency of the different types of errors that exist in this hospital. Understanding the different types of errors could help future studies explore the causes of specific errors and develop interventions to reduce them. Further research should be conducted to understand the causes of these errors and demonstrate whether the introduction of electronic prescriptions has an effect on patient outcomes. PMID:29445304

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.

Error Type and Lexical Frequency Effects: Error Detection in Swedish Children with Language Impairment

ERIC Educational Resources Information Center

Hallin, Anna Eva; Reuterskiöld, Christina

2017-01-01

Purpose: The first aim of this study was to investigate if Swedish-speaking school-age children with language impairment (LI) show specific morphosyntactic vulnerabilities in error detection. The second aim was to investigate the effects of lexical frequency on error detection, an overlooked aspect of previous error detection studies. Method:…

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

PubMed

Rinke, Michael L; Shore, Andrew D; Morlock, Laura; Hicks, Rodney W; Miller, Marlene R

2007-07-01

Little is known regarding chemotherapy medication errors in pediatrics despite studies suggesting high rates of overall pediatric medication errors. In this study, the authors examined patterns in pediatric chemotherapy errors. The authors queried the United States Pharmacopeia MEDMARX database, a national, voluntary, Internet-accessible error reporting system, for all error reports from 1999 through 2004 that involved chemotherapy medications and patients aged <18 years. Of the 310 pediatric chemotherapy error reports, 85% reached the patient, and 15.6% required additional patient monitoring or therapeutic intervention. Forty-eight percent of errors originated in the administering phase of medication delivery, and 30% originated in the drug-dispensing phase. Of the 387 medications cited, 39.5% were antimetabolites, 14.0% were alkylating agents, 9.3% were anthracyclines, and 9.3% were topoisomerase inhibitors. The most commonly involved chemotherapeutic agents were methotrexate (15.3%), cytarabine (12.1%), and etoposide (8.3%). The most common error types were improper dose/quantity (22.9% of 327 cited error types), wrong time (22.6%), omission error (14.1%), and wrong administration technique/wrong route (12.2%). The most common error causes were performance deficit (41.3% of 547 cited error causes), equipment and medication delivery devices (12.4%), communication (8.8%), knowledge deficit (6.8%), and written order errors (5.5%). Four of the 5 most serious errors occurred at community hospitals. Pediatric chemotherapy errors often reached the patient, potentially were harmful, and differed in quality between outpatient and inpatient areas. This study indicated which chemotherapeutic agents most often were involved in errors and that administering errors were common. Investigation is needed regarding targeted medication administration safeguards for these high-risk medications. Copyright (c) 2007 American Cancer Society.

Evaluating the Effective Factors for Reporting Medical Errors among Midwives Working at Teaching Hospitals Affiliated to Isfahan University of Medical Sciences.

PubMed

Khorasani, Fahimeh; Beigi, Marjan

2017-01-01

Recently, evaluation and accreditation system of hospitals has had a special emphasis on reporting malpractices and sharing errors or lessons learnt from errors, but still due to lack of promotion of systematic approach for solving problems from the same system, this issue has remained unattended. This study was conducted to determine the effective factors for reporting medical errors among midwives. This project was a descriptive cross-sectional observational study. Data gathering tools were a standard checklist and two researcher-made questionnaires. Sampling for this study was conducted from all the midwives who worked at teaching hospitals affiliated to Isfahan University of Medical Sciences through census method (convenient) and lasted for 3 months. Data were analyzed using descriptive and inferential statistics through SPSS 16. Results showed that 79.1% of the staff reported errors and the highest rate of errors was in the process of patients' tests. In this study, the mean score of midwives' knowledge about the errors was 79.1 and the mean score of their attitude toward reporting errors was 70.4. There was a direct relation between the score of errors' knowledge and attitude in the midwifery staff and reporting errors. Based on the results of this study about the appropriate knowledge and attitude of midwifery staff regarding errors and action toward reporting them, it is recommended to strengthen the system when it comes to errors and hospitals risks.

Error management in blood establishments: results of eight years of experience (2003–2010) at the Croatian Institute of Transfusion Medicine

PubMed Central

Vuk, Tomislav; Barišić, Marijan; Očić, Tihomir; Mihaljević, Ivanka; Šarlija, Dorotea; Jukić, Irena

2012-01-01

Background. Continuous and efficient error management, including procedures from error detection to their resolution and prevention, is an important part of quality management in blood establishments. At the Croatian Institute of Transfusion Medicine (CITM), error management has been systematically performed since 2003. Materials and methods. Data derived from error management at the CITM during an 8-year period (2003–2010) formed the basis of this study. Throughout the study period, errors were reported to the Department of Quality Assurance. In addition to surveys and the necessary corrective activities, errors were analysed and classified according to the Medical Event Reporting System for Transfusion Medicine (MERS-TM). Results. During the study period, a total of 2,068 errors were recorded, including 1,778 (86.0%) in blood bank activities and 290 (14.0%) in blood transfusion services. As many as 1,744 (84.3%) errors were detected before issue of the product or service. Among the 324 errors identified upon release from the CITM, 163 (50.3%) errors were detected by customers and reported as complaints. In only five cases was an error detected after blood product transfusion however without any harmful consequences for the patients. All errors were, therefore, evaluated as “near miss” and “no harm” events. Fifty-two (2.5%) errors were evaluated as high-risk events. With regards to blood bank activities, the highest proportion of errors occurred in the processes of labelling (27.1%) and blood collection (23.7%). With regards to blood transfusion services, errors related to blood product issuing prevailed (24.5%). Conclusion. This study shows that comprehensive management of errors, including near miss errors, can generate data on the functioning of transfusion services, which is a precondition for implementation of efficient corrective and preventive actions that will ensure further improvement of the quality and safety of transfusion treatment. PMID:22395352

Proximal antecedents and correlates of adopted error approach: a self-regulatory perspective.

PubMed

Van Dyck, Cathy; Van Hooft, Edwin; De Gilder, Dick; Liesveld, Lillian

2010-01-01

The current study aims to further investigate earlier established advantages of an error mastery approach over an error aversion approach. The two main purposes of the study relate to (1) self-regulatory traits (i.e., goal orientation and action-state orientation) that may predict which error approach (mastery or aversion) is adopted, and (2) proximal, psychological processes (i.e., self-focused attention and failure attribution) that relate to adopted error approach. In the current study participants' goal orientation and action-state orientation were assessed, after which they worked on an error-prone task. Results show that learning goal orientation related to error mastery, while state orientation related to error aversion. Under a mastery approach, error occurrence did not result in cognitive resources "wasted" on self-consciousness. Rather, attention went to internal-unstable, thus controllable, improvement oriented causes of error. Participants that had adopted an aversion approach, in contrast, experienced heightened self-consciousness and attributed failure to internal-stable or external causes. These results imply that when working on an error-prone task, people should be stimulated to take on a mastery rather than an aversion approach towards errors.

Global distortion of GPS networks associated with satellite antenna model errors

NASA Astrophysics Data System (ADS)

Cardellach, E.; Elósegui, P.; Davis, J. L.

2007-07-01

Recent studies of the GPS satellite phase center offsets (PCOs) suggest that these have been in error by ˜1 m. Previous studies had shown that PCO errors are absorbed mainly by parameters representing satellite clock and the radial components of site position. On the basis of the assumption that the radial errors are equal, PCO errors will therefore introduce an error in network scale. However, PCO errors also introduce distortions, or apparent deformations, within the network, primarily in the radial (vertical) component of site position that cannot be corrected via a Helmert transformation. Using numerical simulations to quantify the effects of PCO errors, we found that these PCO errors lead to a vertical network distortion of 6-12 mm per meter of PCO error. The network distortion depends on the minimum elevation angle used in the analysis of the GPS phase observables, becoming larger as the minimum elevation angle increases. The steady evolution of the GPS constellation as new satellites are launched, age, and are decommissioned, leads to the effects of PCO errors varying with time that introduce an apparent global-scale rate change. We demonstrate here that current estimates for PCO errors result in a geographically variable error in the vertical rate at the 1-2 mm yr-1 level, which will impact high-precision crustal deformation studies.

Global Distortion of GPS Networks Associated with Satellite Antenna Model Errors

NASA Technical Reports Server (NTRS)

Cardellach, E.; Elosequi, P.; Davis, J. L.

2007-01-01

Recent studies of the GPS satellite phase center offsets (PCOs) suggest that these have been in error by approx.1 m. Previous studies had shown that PCO errors are absorbed mainly by parameters representing satellite clock and the radial components of site position. On the basis of the assumption that the radial errors are equal, PCO errors will therefore introduce an error in network scale. However, PCO errors also introduce distortions, or apparent deformations, within the network, primarily in the radial (vertical) component of site position that cannot be corrected via a Helmert transformation. Using numerical simulations to quantify the effects of PC0 errors, we found that these PCO errors lead to a vertical network distortion of 6-12 mm per meter of PCO error. The network distortion depends on the minimum elevation angle used in the analysis of the GPS phase observables, becoming larger as the minimum elevation angle increases. The steady evolution of the GPS constellation as new satellites are launched, age, and are decommissioned, leads to the effects of PCO errors varying with time that introduce an apparent global-scale rate change. We demonstrate here that current estimates for PCO errors result in a geographically variable error in the vertical rate at the 1-2 mm/yr level, which will impact high-precision crustal deformation studies.

Emergency department discharge prescription errors in an academic medical center

PubMed Central

Belanger, April; Devine, Lauren T.; Lane, Aaron; Condren, Michelle E.

2017-01-01

This study described discharge prescription medication errors written for emergency department patients. This study used content analysis in a cross-sectional design to systematically categorize prescription errors found in a report of 1000 discharge prescriptions submitted in the electronic medical record in February 2015. Two pharmacy team members reviewed the discharge prescription list for errors. Open-ended data were coded by an additional rater for agreement on coding categories. Coding was based upon majority rule. Descriptive statistics were used to address the study objective. Categories evaluated were patient age, provider type, drug class, and type and time of error. The discharge prescription error rate out of 1000 prescriptions was 13.4%, with “incomplete or inadequate prescription” being the most commonly detected error (58.2%). The adult and pediatric error rates were 11.7% and 22.7%, respectively. The antibiotics reviewed had the highest number of errors. The highest within-class error rates were with antianginal medications, antiparasitic medications, antacids, appetite stimulants, and probiotics. Emergency medicine residents wrote the highest percentage of prescriptions (46.7%) and had an error rate of 9.2%. Residents of other specialties wrote 340 prescriptions and had an error rate of 20.9%. Errors occurred most often between 10:00 am and 6:00 pm. PMID:28405061

Errors in laboratory medicine: practical lessons to improve patient safety.

PubMed

Howanitz, Peter J

2005-10-01

Patient safety is influenced by the frequency and seriousness of errors that occur in the health care system. Error rates in laboratory practices are collected routinely for a variety of performance measures in all clinical pathology laboratories in the United States, but a list of critical performance measures has not yet been recommended. The most extensive databases describing error rates in pathology were developed and are maintained by the College of American Pathologists (CAP). These databases include the CAP's Q-Probes and Q-Tracks programs, which provide information on error rates from more than 130 interlaboratory studies. To define critical performance measures in laboratory medicine, describe error rates of these measures, and provide suggestions to decrease these errors, thereby ultimately improving patient safety. A review of experiences from Q-Probes and Q-Tracks studies supplemented with other studies cited in the literature. Q-Probes studies are carried out as time-limited studies lasting 1 to 4 months and have been conducted since 1989. In contrast, Q-Tracks investigations are ongoing studies performed on a yearly basis and have been conducted only since 1998. Participants from institutions throughout the world simultaneously conducted these studies according to specified scientific designs. The CAP has collected and summarized data for participants about these performance measures, including the significance of errors, the magnitude of error rates, tactics for error reduction, and willingness to implement each of these performance measures. A list of recommended performance measures, the frequency of errors when these performance measures were studied, and suggestions to improve patient safety by reducing these errors. Error rates for preanalytic and postanalytic performance measures were higher than for analytic measures. Eight performance measures were identified, including customer satisfaction, test turnaround times, patient identification, specimen acceptability, proficiency testing, critical value reporting, blood product wastage, and blood culture contamination. Error rate benchmarks for these performance measures were cited and recommendations for improving patient safety presented. Not only has each of the 8 performance measures proven practical, useful, and important for patient care, taken together, they also fulfill regulatory requirements. All laboratories should consider implementing these performance measures and standardizing their own scientific designs, data analysis, and error reduction strategies according to findings from these published studies.

Spelling Errors of Dyslexic Children in Bosnian Language with Transparent Orthography

ERIC Educational Resources Information Center

Duranovic, Mirela

2017-01-01

The purpose of this study was to explore the nature of spelling errors made by children with dyslexia in Bosnian language with transparent orthography. Three main error categories were distinguished: phonological, orthographic, and grammatical errors. An analysis of error type showed 86% of phonological errors, 10% of orthographic errors, and 4%…

Frequency of pediatric medication administration errors and contributing factors.

PubMed

Ozkan, Suzan; Kocaman, Gulseren; Ozturk, Candan; Seren, Seyda

2011-01-01

This study examined the frequency of pediatric medication administration errors and contributing factors. This research used the undisguised observation method and Critical Incident Technique. Errors and contributing factors were classified through the Organizational Accident Model. Errors were made in 36.5% of the 2344 doses that were observed. The most frequent errors were those associated with administration at the wrong time. According to the results of this study, errors arise from problems within the system.

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.

Big Data and Large Sample Size: A Cautionary Note on the Potential for Bias

PubMed Central

Chambers, David A.; Glasgow, Russell E.

2014-01-01

Abstract A number of commentaries have suggested that large studies are more reliable than smaller studies and there is a growing interest in the analysis of “big data” that integrates information from many thousands of persons and/or different data sources. We consider a variety of biases that are likely in the era of big data, including sampling error, measurement error, multiple comparisons errors, aggregation error, and errors associated with the systematic exclusion of information. Using examples from epidemiology, health services research, studies on determinants of health, and clinical trials, we conclude that it is necessary to exercise greater caution to be sure that big sample size does not lead to big inferential errors. Despite the advantages of big studies, large sample size can magnify the bias associated with error resulting from sampling or study design. Clin Trans Sci 2014; Volume #: 1–5 PMID:25043853

Foot Structure in Japanese Speech Errors: Normal vs. Pathological

ERIC Educational Resources Information Center

Miyakoda, Haruko

2008-01-01

Although many studies of speech errors have been presented in the literature, most have focused on errors occurring at either the segmental or feature level. Few, if any, studies have dealt with the prosodic structure of errors. This paper aims to fill this gap by taking up the issue of prosodic structure in Japanese speech errors, with a focus on…

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

PubMed

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

2016-01-01

Medication administration is the final step/phase of medication process in which its error directly affects the patient health. Due to the central role of nurses in medication administration, whether they are the source of an error, a contributor, or an observer they have the professional, legal and ethical responsibility to recognize and report. The aim of this study was to assess the prevalence of medication administration error reporting and associated factors among nurses working at The University of Gondar Referral Hospital, Northwest Ethiopia. Institution based quantitative cross - sectional study was conducted among 282 Nurses. Data were collected using semi-structured, self-administered questionnaire of the Medication Administration Errors Reporting (MAERs). Binary logistic regression with 95 % confidence interval was used to identify factors associated with medication administration errors reporting. The estimated medication administration error reporting was found to be 29.1 %. The perceived rates of medication administration errors reporting for non-intravenous related medications were ranged from 16.8 to 28.6 % and for intravenous-related from 20.6 to 33.4 %. Education status (AOR =1.38, 95 % CI: 4.009, 11.128), disagreement over time - error definition (AOR = 0.44, 95 % CI: 0.468, 0.990), administrative reason (AOR = 0.35, 95 % CI: 0.168, 0.710) and fear (AOR = 0.39, 95 % CI: 0.257, 0.838) were factors statistically significant for the refusal of reporting medication administration errors at p-value <0.05. In this study, less than one third of the study participants reported medication administration errors. Educational status, disagreement over time - error definition, administrative reason and fear were factors statistically significant for the refusal of errors reporting at p-value <0.05. Therefore, the results of this study suggest strategies that enhance the cultures of error reporting such as providing a clear definition of reportable errors and strengthen the educational status of nurses by the health care organization.

Analyzing students’ errors on fractions in the number line

NASA Astrophysics Data System (ADS)

Widodo, S.; Ikhwanudin, T.

2018-05-01

The objectives of this study are to know the type of students’ errors when they deal with fractions on the number line. This study used qualitative with a descriptive method, and involved 31 sixth grade students at one of the primary schools in Purwakarta, Indonesia. The results of this study are as follow, there are four types of student’s errors: unit confusion, tick mark interpretation error, partitioning and un partitioning error, and estimation error. We recommend that teachers should: strengthen unit understanding to the students when studying fractions, make students understand about tick mark interpretation, remind student of the importance of partitioning and un-partitioning strategy and teaches effective estimation strategies.

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

NASA Astrophysics Data System (ADS)

Priyani, H. A.; Ekawati, R.

2018-01-01

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

Valuing Errors for Learning: Espouse or Enact?

ERIC Educational Resources Information Center

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

2017-01-01

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

Long-term care physical environments--effect on medication errors.

PubMed

Mahmood, Atiya; Chaudhury, Habib; Gaumont, Alana; Rust, Tiana

2012-01-01

Few studies examine physical environmental factors and their effects on staff health, effectiveness, work errors and job satisfaction. To address this gap, this study aims to examine environmental features and their role in medication and nursing errors in long-term care facilities. A mixed methodological strategy was used. Data were collected via focus groups, observing medication preparation and administration, and a nursing staff survey in four facilities. The paper reveals that, during the medication preparation phase, physical design, such as medication room layout, is a major source of potential errors. During medication administration, social environment is more likely to contribute to errors. Interruptions, noise and staff shortages were particular problems. The survey's relatively small sample size needs to be considered when interpreting the findings. Also, actual error data could not be included as existing records were incomplete. The study offers several relatively low-cost recommendations to help staff reduce medication errors. Physical environmental factors are important when addressing measures to reduce errors. The findings of this study underscore the fact that the physical environment's influence on the possibility of medication errors is often neglected. This study contributes to the scarce empirical literature examining the relationship between physical design and patient safety.

Correcting for sequencing error in maximum likelihood phylogeny inference.

PubMed

Kuhner, Mary K; McGill, James

2014-11-04

Accurate phylogenies are critical to taxonomy as well as studies of speciation processes and other evolutionary patterns. Accurate branch lengths in phylogenies are critical for dating and rate measurements. Such accuracy may be jeopardized by unacknowledged sequencing error. We use simulated data to test a correction for DNA sequencing error in maximum likelihood phylogeny inference. Over a wide range of data polymorphism and true error rate, we found that correcting for sequencing error improves recovery of the branch lengths, even if the assumed error rate is up to twice the true error rate. Low error rates have little effect on recovery of the topology. When error is high, correction improves topological inference; however, when error is extremely high, using an assumed error rate greater than the true error rate leads to poor recovery of both topology and branch lengths. The error correction approach tested here was proposed in 2004 but has not been widely used, perhaps because researchers do not want to commit to an estimate of the error rate. This study shows that correction with an approximate error rate is generally preferable to ignoring the issue. Copyright © 2014 Kuhner and McGill.

Effects of Listening Conditions, Error Types, and Ensemble Textures on Error Detection Skills

ERIC Educational Resources Information Center

Waggoner, Dori T.

2011-01-01

This study was designed with three main purposes: (a) to investigate the effects of two listening conditions on error detection accuracy, (b) to compare error detection responses for rhythm errors and pitch errors, and (c) to examine the influences of texture on error detection accuracy. Undergraduate music education students (N = 18) listened to…

Frequency and types of the medication errors in an academic emergency department in Iran: The emergent need for clinical pharmacy services in emergency departments.

PubMed

Zeraatchi, Alireza; Talebian, Mohammad-Taghi; Nejati, Amir; Dashti-Khavidaki, Simin

2013-07-01

Emergency departments (EDs) are characterized by simultaneous care of multiple patients with various medical conditions. Due to a large number of patients with complex diseases, speed and complexity of medication use, working in under-staffing and crowded environment, medication errors are commonly perpetrated by emergency care providers. This study was designed to evaluate the incidence of medication errors among patients attending to an ED in a teaching hospital in Iran. In this cross-sectional study, a total of 500 patients attending to ED were randomly assessed for incidence and types of medication errors. Some factors related to medication errors such as working shift, weekdays and schedule of the educational program of trainee were also evaluated. Nearly, 22% of patients experienced at least one medication error. The rate of medication errors were 0.41 errors per patient and 0.16 errors per ordered medication. The frequency of medication errors was higher in men, middle age patients, first weekdays, night-time work schedules and the first semester of educational year of new junior emergency medicine residents. More than 60% of errors were prescription errors by physicians and the remaining were transcription or administration errors by nurses. More than 35% of the prescribing errors happened during the selection of drug dose and frequency. The most common medication errors by nurses during the administration were omission error (16.2%) followed by unauthorized drug (6.4%). Most of the medication errors happened for anticoagulants and thrombolytics (41.2%) followed by antimicrobial agents (37.7%) and insulin (7.4%). In this study, at least one-fifth of the patients attending to ED experienced medication errors resulting from multiple factors. More common prescription errors happened during ordering drug dose and frequency. More common administration errors included dug omission or unauthorized drug.

Probabilistic performance estimators for computational chemistry methods: The empirical cumulative distribution function of absolute errors

NASA Astrophysics Data System (ADS)

Pernot, Pascal; Savin, Andreas

2018-06-01

Benchmarking studies in computational chemistry use reference datasets to assess the accuracy of a method through error statistics. The commonly used error statistics, such as the mean signed and mean unsigned errors, do not inform end-users on the expected amplitude of prediction errors attached to these methods. We show that, the distributions of model errors being neither normal nor zero-centered, these error statistics cannot be used to infer prediction error probabilities. To overcome this limitation, we advocate for the use of more informative statistics, based on the empirical cumulative distribution function of unsigned errors, namely, (1) the probability for a new calculation to have an absolute error below a chosen threshold and (2) the maximal amplitude of errors one can expect with a chosen high confidence level. Those statistics are also shown to be well suited for benchmarking and ranking studies. Moreover, the standard error on all benchmarking statistics depends on the size of the reference dataset. Systematic publication of these standard errors would be very helpful to assess the statistical reliability of benchmarking conclusions.

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

The effects of recall errors and of selection bias in epidemiologic studies of mobile phone use and cancer risk.

PubMed

Vrijheid, Martine; Deltour, Isabelle; Krewski, Daniel; Sanchez, Marie; Cardis, Elisabeth

2006-07-01

This paper examines the effects of systematic and random errors in recall and of selection bias in case-control studies of mobile phone use and cancer. These sensitivity analyses are based on Monte-Carlo computer simulations and were carried out within the INTERPHONE Study, an international collaborative case-control study in 13 countries. Recall error scenarios simulated plausible values of random and systematic, non-differential and differential recall errors in amount of mobile phone use reported by study subjects. Plausible values for the recall error were obtained from validation studies. Selection bias scenarios assumed varying selection probabilities for cases and controls, mobile phone users, and non-users. Where possible these selection probabilities were based on existing information from non-respondents in INTERPHONE. Simulations used exposure distributions based on existing INTERPHONE data and assumed varying levels of the true risk of brain cancer related to mobile phone use. Results suggest that random recall errors of plausible levels can lead to a large underestimation in the risk of brain cancer associated with mobile phone use. Random errors were found to have larger impact than plausible systematic errors. Differential errors in recall had very little additional impact in the presence of large random errors. Selection bias resulting from underselection of unexposed controls led to J-shaped exposure-response patterns, with risk apparently decreasing at low to moderate exposure levels. The present results, in conjunction with those of the validation studies conducted within the INTERPHONE study, will play an important role in the interpretation of existing and future case-control studies of mobile phone use and cancer risk, including the INTERPHONE study.

Preventability of Voluntarily Reported or Trigger Tool-Identified Medication Errors in a Pediatric Institution by Information Technology: A Retrospective Cohort Study.

PubMed

Stultz, Jeremy S; Nahata, Milap C

2015-07-01

Information technology (IT) has the potential to prevent medication errors. While many studies have analyzed specific IT technologies and preventable adverse drug events, no studies have identified risk factors for errors still occurring that are not preventable by IT. The objective of this study was to categorize reported or trigger tool-identified errors and adverse events (AEs) at a pediatric tertiary care institution. Also, we sought to identify medication errors preventable by IT, determine why IT-preventable errors occurred, and to identify risk factors for errors that were not preventable by IT. This was a retrospective analysis of voluntarily reported or trigger tool-identified errors and AEs occurring from 1 July 2011 to 30 June 2012. Medication errors reaching the patients were categorized based on the origin, severity, and location of the error, the month in which they occurred, and the age of the patient involved. Error characteristics were included in a multivariable logistic regression model to determine independent risk factors for errors occurring that were not preventable by IT. A medication error was defined as a medication-related failure of a planned action to be completed as intended or the use of a wrong plan to achieve an aim. An IT-preventable error was defined as having an IT system in place to aid in prevention of the error at the phase and location of its origin. There were 936 medication errors (identified by voluntarily reporting or a trigger tool system) included and analyzed. Drug administration errors were identified most frequently (53.4% ), but prescribing errors most frequently caused harm (47.2 % of harmful errors). There were 470 (50.2 %) errors that were IT preventable at their origin, including 155 due to IT system bypasses, 103 due to insensitivity of IT alerting systems, and 47 with IT alert overrides. Dispensing, administration, and documentation errors had higher odds than prescribing errors for being not preventable by IT [odds ratio (OR) 8.0, 95 % CI 4.4-14.6; OR 2.4, 95 % CI 1.7-3.7; and OR 6.7, 95 % CI 3.3-14.5, respectively; all p < 0.001). Errors occurring in the operating room and in the outpatient setting had higher odds than intensive care units for being not preventable by IT (OR 10.4, 95 % CI 4.0-27.2, and OR 2.6, 95 % CI 1.3-5.0, respectively; all p ≤ 0.004). Despite extensive IT implementation at the studied institution, approximately one-half of the medication errors identified by voluntarily reporting or a trigger tool system were not preventable by the utilized IT systems. Inappropriate use of IT systems was a common cause of errors. The identified risk factors represent areas where IT safety features were lacking.

Predictors of Errors of Novice Java Programmers

ERIC Educational Resources Information Center

Bringula, Rex P.; Manabat, Geecee Maybelline A.; Tolentino, Miguel Angelo A.; Torres, Edmon L.

2012-01-01

This descriptive study determined which of the sources of errors would predict the errors committed by novice Java programmers. Descriptive statistics revealed that the respondents perceived that they committed the identified eighteen errors infrequently. Thought error was perceived to be the main source of error during the laboratory programming…

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

PubMed

Cheng, Ching-Min; Hwang, Sheue-Ling

2015-03-01

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

Female residents experiencing medical errors in general internal medicine: a qualitative study.

PubMed

Mankaka, Cindy Ottiger; Waeber, Gérard; Gachoud, David

2014-07-10

Doctors, especially doctors-in-training such as residents, make errors. They have to face the consequences even though today's approach to errors emphasizes systemic factors. Doctors' individual characteristics play a role in how medical errors are experienced and dealt with. The role of gender has previously been examined in a few quantitative studies that have yielded conflicting results. In the present study, we sought to qualitatively explore the experience of female residents with respect to medical errors. In particular, we explored the coping mechanisms displayed after an error. This study took place in the internal medicine department of a Swiss university hospital. Within a phenomenological framework, semi-structured interviews were conducted with eight female residents in general internal medicine. All interviews were audiotaped, fully transcribed, and thereafter analyzed. Seven main themes emerged from the interviews: (1) A perception that there is an insufficient culture of safety and error; (2) The perceived main causes of errors, which included fatigue, work overload, inadequate level of competences in relation to assigned tasks, and dysfunctional communication; (3) Negative feelings in response to errors, which included different forms of psychological distress; (4) Variable attitudes of the hierarchy toward residents involved in an error; (5) Talking about the error, as the core coping mechanism; (6) Defensive and constructive attitudes toward one's own errors; and (7) Gender-specific experiences in relation to errors. Such experiences consisted in (a) perceptions that male residents were more confident and therefore less affected by errors than their female counterparts and (b) perceptions that sexist attitudes among male supervisors can occur and worsen an already painful experience. This study offers an in-depth account of how female residents specifically experience and cope with medical errors. Our interviews with female residents convey the sense that gender possibly influences the experience with errors, including the kind of coping mechanisms displayed. However, we acknowledge that the lack of a direct comparison between female and male participants represents a limitation while aiming to explore the role of gender.

Spelling Errors of Dyslexic Children in Bosnian Language With Transparent Orthography.

PubMed

Duranović, Mirela

The purpose of this study was to explore the nature of spelling errors made by children with dyslexia in Bosnian language with transparent orthography. Three main error categories were distinguished: phonological, orthographic, and grammatical errors. An analysis of error type showed 86% of phonological errors,10% of orthographic errors, and 4% of grammatical errors. Furthermore, the majority errors were the omissions and substitutions, followed by the insertions, omission of rules of assimilation by voicing, and errors with utilization of suffix. We can conclude that phonological errors were dominant in children with dyslexia at all grade levels.

What is the epidemiology of medication errors, error-related adverse events and risk factors for errors in adults managed in community care contexts? A systematic review of the international literature.

PubMed

Assiri, Ghadah Asaad; Shebl, Nada Atef; Mahmoud, Mansour Adam; Aloudah, Nouf; Grant, Elizabeth; Aljadhey, Hisham; Sheikh, Aziz

2018-05-05

To investigate the epidemiology of medication errors and error-related adverse events in adults in primary care, ambulatory care and patients' homes. Systematic review. Six international databases were searched for publications between 1 January 2006 and 31 December 2015. Two researchers independently extracted data from eligible studies and assessed the quality of these using established instruments. Synthesis of data was informed by an appreciation of the medicines' management process and the conceptual framework from the International Classification for Patient Safety. 60 studies met the inclusion criteria, of which 53 studies focused on medication errors, 3 on error-related adverse events and 4 on risk factors only. The prevalence of prescribing errors was reported in 46 studies: prevalence estimates ranged widely from 2% to 94%. Inappropriate prescribing was the most common type of error reported. Only one study reported the prevalence of monitoring errors, finding that incomplete therapeutic/safety laboratory-test monitoring occurred in 73% of patients. The incidence of preventable adverse drug events (ADEs) was estimated as 15/1000 person-years, the prevalence of drug-drug interaction-related adverse drug reactions as 7% and the prevalence of preventable ADE as 0.4%. A number of patient, healthcare professional and medication-related risk factors were identified, including the number of medications used by the patient, increased patient age, the number of comorbidities, use of anticoagulants, cases where more than one physician was involved in patients' care and care being provided by family physicians/general practitioners. A very wide variation in the medication error and error-related adverse events rates is reported in the studies, this reflecting heterogeneity in the populations studied, study designs employed and outcomes evaluated. This review has identified important limitations and discrepancies in the methodologies used and gaps in the literature on the epidemiology and outcomes of medication errors in community settings. © 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.

Accuracy of cited “facts” in medical research articles: A review of study methodology and recalculation of quotation error rate

PubMed Central

2017-01-01

Previous reviews estimated that approximately 20 to 25% of assertions cited from original research articles, or “facts,” are inaccurately quoted in the medical literature. These reviews noted that the original studies were dissimilar and only began to compare the methods of the original studies. The aim of this review is to examine the methods of the original studies and provide a more specific rate of incorrectly cited assertions, or quotation errors, in original research articles published in medical journals. Additionally, the estimate of quotation errors calculated here is based on the ratio of quotation errors to quotations examined (a percent) rather than the more prevalent and weighted metric of quotation errors to the references selected. Overall, this resulted in a lower estimate of the quotation error rate in original medical research articles. A total of 15 studies met the criteria for inclusion in the primary quantitative analysis. Quotation errors were divided into two categories: content ("factual") or source (improper indirect citation) errors. Content errors were further subdivided into major and minor errors depending on the degree that the assertion differed from the original source. The rate of quotation errors recalculated here is 14.5% (10.5% to 18.6% at a 95% confidence interval). These content errors are predominantly, 64.8% (56.1% to 73.5% at a 95% confidence interval), major errors or cited assertions in which the referenced source either fails to substantiate, is unrelated to, or contradicts the assertion. Minor errors, which are an oversimplification, overgeneralization, or trivial inaccuracies, are 35.2% (26.5% to 43.9% at a 95% confidence interval). Additionally, improper secondary (or indirect) citations, which are distinguished from calculations of quotation accuracy, occur at a rate of 10.4% (3.4% to 17.5% at a 95% confidence interval). PMID:28910404

Accuracy of cited "facts" in medical research articles: A review of study methodology and recalculation of quotation error rate.

PubMed

Mogull, Scott A

2017-01-01

Previous reviews estimated that approximately 20 to 25% of assertions cited from original research articles, or "facts," are inaccurately quoted in the medical literature. These reviews noted that the original studies were dissimilar and only began to compare the methods of the original studies. The aim of this review is to examine the methods of the original studies and provide a more specific rate of incorrectly cited assertions, or quotation errors, in original research articles published in medical journals. Additionally, the estimate of quotation errors calculated here is based on the ratio of quotation errors to quotations examined (a percent) rather than the more prevalent and weighted metric of quotation errors to the references selected. Overall, this resulted in a lower estimate of the quotation error rate in original medical research articles. A total of 15 studies met the criteria for inclusion in the primary quantitative analysis. Quotation errors were divided into two categories: content ("factual") or source (improper indirect citation) errors. Content errors were further subdivided into major and minor errors depending on the degree that the assertion differed from the original source. The rate of quotation errors recalculated here is 14.5% (10.5% to 18.6% at a 95% confidence interval). These content errors are predominantly, 64.8% (56.1% to 73.5% at a 95% confidence interval), major errors or cited assertions in which the referenced source either fails to substantiate, is unrelated to, or contradicts the assertion. Minor errors, which are an oversimplification, overgeneralization, or trivial inaccuracies, are 35.2% (26.5% to 43.9% at a 95% confidence interval). Additionally, improper secondary (or indirect) citations, which are distinguished from calculations of quotation accuracy, occur at a rate of 10.4% (3.4% to 17.5% at a 95% confidence interval).

Incorporating Measurement Error from Modeled Air Pollution Exposures into Epidemiological Analyses.

PubMed

Samoli, Evangelia; Butland, Barbara K

2017-12-01

Outdoor air pollution exposures used in epidemiological studies are commonly predicted from spatiotemporal models incorporating limited measurements, temporal factors, geographic information system variables, and/or satellite data. Measurement error in these exposure estimates leads to imprecise estimation of health effects and their standard errors. We reviewed methods for measurement error correction that have been applied in epidemiological studies that use model-derived air pollution data. We identified seven cohort studies and one panel study that have employed measurement error correction methods. These methods included regression calibration, risk set regression calibration, regression calibration with instrumental variables, the simulation extrapolation approach (SIMEX), and methods under the non-parametric or parameter bootstrap. Corrections resulted in small increases in the absolute magnitude of the health effect estimate and its standard error under most scenarios. Limited application of measurement error correction methods in air pollution studies may be attributed to the absence of exposure validation data and the methodological complexity of the proposed methods. Future epidemiological studies should consider in their design phase the requirements for the measurement error correction method to be later applied, while methodological advances are needed under the multi-pollutants setting.

Anxiety and Error Monitoring: Increased Error Sensitivity or Altered Expectations?

ERIC Educational Resources Information Center

Compton, Rebecca J.; Carp, Joshua; Chaddock, Laura; Fineman, Stephanie L.; Quandt, Lorna C.; Ratliff, Jeffrey B.

2007-01-01

This study tested the prediction that the error-related negativity (ERN), a physiological measure of error monitoring, would be enhanced in anxious individuals, particularly in conditions with threatening cues. Participants made gender judgments about faces whose expressions were either happy, angry, or neutral. Replicating prior studies, midline…

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.

Effects of sharing information on drug administration errors in pediatric wards: a pre–post intervention study

PubMed Central

Chua, Siew-Siang; Choo, Sim-Mei; Sulaiman, Che Zuraini; Omar, Asma; Thong, Meow-Keong

2017-01-01

Background and purpose Drug administration errors are more likely to reach the patient than other medication errors. The main aim of this study was to determine whether the sharing of information on drug administration errors among health care providers would reduce such problems. Patients and methods This study involved direct, undisguised observations of drug administrations in two pediatric wards of a major teaching hospital in Kuala Lumpur, Malaysia. This study consisted of two phases: Phase 1 (pre-intervention) and Phase 2 (post-intervention). Data were collected by two observers over a 40-day period in both Phase 1 and Phase 2 of the study. Both observers were pharmacy graduates: Observer 1 just completed her undergraduate pharmacy degree, whereas Observer 2 was doing her one-year internship as a provisionally registered pharmacist in the hospital under study. A drug administration error was defined as a discrepancy between the drug regimen received by the patient and that intended by the prescriber and also drug administration procedures that did not follow standard hospital policies and procedures. Results from Phase 1 of the study were analyzed, presented and discussed with the ward staff before commencement of data collection in Phase 2. Results A total of 1,284 and 1,401 doses of drugs were administered in Phase 1 and Phase 2, respectively. The rate of drug administration errors reduced significantly from Phase 1 to Phase 2 (44.3% versus 28.6%, respectively; P<0.001). Logistic regression analysis showed that the adjusted odds of drug administration errors in Phase 1 of the study were almost three times that in Phase 2 (P<0.001). The most common types of errors were incorrect administration technique and incorrect drug preparation. Nasogastric and intravenous routes of drug administration contributed significantly to the rate of drug administration errors. Conclusion This study showed that sharing of the types of errors that had occurred was significantly associated with a reduction in drug administration errors. PMID:28356748

Reflection of medical error highlighted on media in Turkey: A retrospective study

PubMed Central

Isik, Oguz; Bayin, Gamze; Ugurluoglu, Ozgur

2016-01-01

Objective: This study was performed with the aim of identifying how news on medical errors have be transmitted, and how the types, reasons, and conclusions of medical errors have been reflected to by the media in Turkey. Methods: A content analysis method was used in the study, and in this context, the data for the study was acquired by scanning five newspapers with the top editions on the national basis between the years 2012 and 2015 for the news about medical errors. Some specific selection criteria was used for the scanning of resulted news, and 116 news items acquired as a result of all the eliminations. Results: According to the results of the study; the vast majority of medical errors (40.5%) transmitted by the news resulted from the negligence of the medical staff. The medical errors were caused by physicians in the ratio of 74.1%, they most commonly occurred in state hospitals (31.9%). Another important result of the research was that medical errors resulted in either patient death to a large extent (51.7%), or permanent damage and disability to patients (25.0%). Conclusion: The news concerning medical errors provided information about the types, causes, and the results of these medical errors. It also reflected the media point of view on the issue. The examination of the content of the medical errors reported by the media were important which calls for appropriate interventions to avoid and minimize the occurrence of medical errors by improving the healthcare delivery system. PMID:27882026

An Analysis of Errors in Written English Sentences: A Case Study of Thai EFL Students

ERIC Educational Resources Information Center

Sermsook, Kanyakorn; Liamnimit, Jiraporn; Pochakorn, Rattaneekorn

2017-01-01

The purposes of the present study were to examine the language errors in a writing of English major students in a Thai university and to explore the sources of the errors. This study focused mainly on sentences because the researcher found that errors in Thai EFL students' sentence construction may lead to miscommunication. 104 pieces of writing…

Errors, error detection, error correction and hippocampal-region damage: data and theories.

PubMed

MacKay, Donald G; Johnson, Laura W

2013-11-01

This review and perspective article outlines 15 observational constraints on theories of errors, error detection, and error correction, and their relation to hippocampal-region (HR) damage. The core observations come from 10 studies with H.M., an amnesic with cerebellar and HR damage but virtually no neocortical damage. Three studies examined the detection of errors planted in visual scenes (e.g., a bird flying in a fish bowl in a school classroom) and sentences (e.g., I helped themselves to the birthday cake). In all three experiments, H.M. detected reliably fewer errors than carefully matched memory-normal controls. Other studies examined the detection and correction of self-produced errors, with controls for comprehension of the instructions, impaired visual acuity, temporal factors, motoric slowing, forgetting, excessive memory load, lack of motivation, and deficits in visual scanning or attention. In these studies, H.M. corrected reliably fewer errors than memory-normal and cerebellar controls, and his uncorrected errors in speech, object naming, and reading aloud exhibited two consistent features: omission and anomaly. For example, in sentence production tasks, H.M. omitted one or more words in uncorrected encoding errors that rendered his sentences anomalous (incoherent, incomplete, or ungrammatical) reliably more often than controls. Besides explaining these core findings, the theoretical principles discussed here explain H.M.'s retrograde amnesia for once familiar episodic and semantic information; his anterograde amnesia for novel information; his deficits in visual cognition, sentence comprehension, sentence production, sentence reading, and object naming; and effects of aging on his ability to read isolated low frequency words aloud. These theoretical principles also explain a wide range of other data on error detection and correction and generate new predictions for future test. Copyright © 2013 Elsevier Ltd. All rights reserved.

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

PubMed

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

2017-11-01

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

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

PubMed

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

2017-07-01

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

Factors associated with reporting of medication errors by Israeli nurses.

PubMed

Kagan, Ilya; Barnoy, Sivia

2008-01-01

This study investigated medication error reporting among Israeli nurses, the relationship between nurses' personal views about error reporting, and the impact of the safety culture of the ward and hospital on this reporting. Nurses (n = 201) completed a questionnaire related to different aspects of error reporting (frequency, organizational norms of dealing with errors, and personal views on reporting). The higher the error frequency, the more errors went unreported. If the ward nurse manager corrected errors on the ward, error self-reporting decreased significantly. Ward nurse managers have to provide good role models.

Comparing the Effectiveness of Error-Correction Strategies in Discrete Trial Training

ERIC Educational Resources Information Center

Turan, Michelle K.; Moroz, Lianne; Croteau, Natalie Paquet

2012-01-01

Error-correction strategies are essential considerations for behavior analysts implementing discrete trial training with children with autism. The research literature, however, is still lacking in the number of studies that compare and evaluate error-correction procedures. The purpose of this study was to compare two error-correction strategies:…

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

PubMed

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

2017-02-01

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

Response Monitoring and Adjustment: Differential Relations with Psychopathic Traits

PubMed Central

Bresin, Konrad; Finy, M. Sima; Sprague, Jenessa; Verona, Edelyn

2014-01-01

Studies on the relation between psychopathy and cognitive functioning often show mixed results, partially because different factors of psychopathy have not been considered fully. Based on previous research, we predicted divergent results based on a two-factor model of psychopathy (interpersonal-affective traits and impulsive-antisocial traits). Specifically, we predicted that the unique variance of interpersonal-affective traits would be related to increased monitoring (i.e., error-related negativity) and adjusting to errors (i.e., post-error slowing), whereas impulsive-antisocial traits would be related to reductions in these processes. Three studies using a diverse selection of assessment tools, samples, and methods are presented to identify response monitoring correlates of the two main factors of psychopathy. In Studies 1 (undergraduates), 2 (adolescents), and 3 (offenders), interpersonal-affective traits were related to increased adjustment following errors and, in Study 3, to enhanced monitoring of errors. Impulsive-antisocial traits were not consistently related to error adjustment across the studies, although these traits were related to a deficient monitoring of errors in Study 3. The results may help explain previous mixed findings and advance implications for etiological models of psychopathy. PMID:24933282

The impact of response measurement error on the analysis of designed experiments

DOE PAGES

Anderson-Cook, Christine Michaela; Hamada, Michael Scott; Burr, Thomas Lee

2016-11-01

This study considers the analysis of designed experiments when there is measurement error in the true response or so-called response measurement error. We consider both additive and multiplicative response measurement errors. Through a simulation study, we investigate the impact of ignoring the response measurement error in the analysis, that is, by using a standard analysis based on t-tests. In addition, we examine the role of repeat measurements in improving the quality of estimation and prediction in the presence of response measurement error. We also study a Bayesian approach that accounts for the response measurement error directly through the specification ofmore » the model, and allows including additional information about variability in the analysis. We consider the impact on power, prediction, and optimization. Copyright © 2015 John Wiley & Sons, Ltd.« less

The impact of response measurement error on the analysis of designed experiments

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

Anderson-Cook, Christine Michaela; Hamada, Michael Scott; Burr, Thomas Lee

This study considers the analysis of designed experiments when there is measurement error in the true response or so-called response measurement error. We consider both additive and multiplicative response measurement errors. Through a simulation study, we investigate the impact of ignoring the response measurement error in the analysis, that is, by using a standard analysis based on t-tests. In addition, we examine the role of repeat measurements in improving the quality of estimation and prediction in the presence of response measurement error. We also study a Bayesian approach that accounts for the response measurement error directly through the specification ofmore » the model, and allows including additional information about variability in the analysis. We consider the impact on power, prediction, and optimization. Copyright © 2015 John Wiley & Sons, Ltd.« less

Concomitant prescribing and dispensing errors at a Brazilian hospital: a descriptive study

PubMed Central

Silva, Maria das Dores Graciano; Rosa, Mário Borges; Franklin, Bryony Dean; Reis, Adriano Max Moreira; Anchieta, Lêni Márcia; Mota, Joaquim Antônio César

2011-01-01

OBJECTIVE: To analyze the prevalence and types of prescribing and dispensing errors occurring with high-alert medications and to propose preventive measures to avoid errors with these medications. INTRODUCTION: The prevalence of adverse events in health care has increased, and medication errors are probably the most common cause of these events. Pediatric patients are known to be a high-risk group and are an important target in medication error prevention. METHODS: Observers collected data on prescribing and dispensing errors occurring with high-alert medications for pediatric inpatients in a university hospital. In addition to classifying the types of error that occurred, we identified cases of concomitant prescribing and dispensing errors. RESULTS: One or more prescribing errors, totaling 1,632 errors, were found in 632 (89.6%) of the 705 high-alert medications that were prescribed and dispensed. We also identified at least one dispensing error in each high-alert medication dispensed, totaling 1,707 errors. Among these dispensing errors, 723 (42.4%) content errors occurred concomitantly with the prescribing errors. A subset of dispensing errors may have occurred because of poor prescription quality. The observed concomitancy should be examined carefully because improvements in the prescribing process could potentially prevent these problems. CONCLUSION: The system of drug prescribing and dispensing at the hospital investigated in this study should be improved by incorporating the best practices of medication safety and preventing medication errors. High-alert medications may be used as triggers for improving the safety of the drug-utilization system. PMID:22012039

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

PubMed

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

2017-05-01

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

Technology and medication errors: impact in nursing homes.

PubMed

Baril, Chantal; Gascon, Viviane; St-Pierre, Liette; Lagacé, Denis

2014-01-01

The purpose of this paper is to study a medication distribution technology's (MDT) impact on medication errors reported in public nursing homes in Québec Province. The work was carried out in six nursing homes (800 patients). Medication error data were collected from nursing staff through a voluntary reporting process before and after MDT was implemented. The errors were analysed using: totals errors; medication error type; severity and patient consequences. A statistical analysis verified whether there was a significant difference between the variables before and after introducing MDT. The results show that the MDT detected medication errors. The authors' analysis also indicates that errors are detected more rapidly resulting in less severe consequences for patients. MDT is a step towards safer and more efficient medication processes. Our findings should convince healthcare administrators to implement technology such as electronic prescriber or bar code medication administration systems to improve medication processes and to provide better healthcare to patients. Few studies have been carried out in long-term healthcare facilities such as nursing homes. The authors' study extends what is known about MDT's impact on medication errors in nursing homes.

Pattern of refractive errors among the Nepalese population: a retrospective study.

PubMed

Shrestha, S P; Bhat, K S; Binu, V S; Barthakur, R; Natarajan, M; Subba, S H

2010-01-01

Refractive errors are a major cause of visual impairment in the population. To find the pattern of refractive errors among patients evaluated in a tertiary care hospital in the western region of Nepal. The present hospital-based retrospective study was conducted in the Department of Ophthalmology of the Manipal Teaching Hospital, situated in Pokhara, Nepal. Patients who had refractive error of at least 0.5 D (dioptre) were included for the study. During the study period, 15,410 patients attended the outpatient department and 10.8% of the patients were identified as having refractive error. The age of the patients in the present study ranged between 5 - 90 years. Myopia was the commonest refractive error followed by hypermetropia. There was no difference in the frequency of the type of refractive errors when they were defined using right the eye, the left eye or both the eyes. Males predominated among myopics and females predominated among hypermetropics. The majority of spherical errors was less than or equal to 2 D. Astigmatic power above 1D was rarely seen with hypermetropic astigmatism and was seen in around 13 % with myopic astigmatism. "Astigmatism against the rule" was more common than "astigmatism with the rule", irrespective of age. Refractive errors progressively shift along myopia up to the third decade and change to hypermetropia till the seventh decade. Hyperopic shift in the refractive error in young adults should be well noted while planning any refractive surgery in younger patients with myopia. © Nepal Ophthalmic Society.

Evaluation of a UMLS Auditing Process of Semantic Type Assignments

PubMed Central

Gu, Huanying; Hripcsak, George; Chen, Yan; Morrey, C. Paul; Elhanan, Gai; Cimino, James J.; Geller, James; Perl, Yehoshua

2007-01-01

The UMLS is a terminological system that integrates many source terminologies. Each concept in the UMLS is assigned one or more semantic types from the Semantic Network, an upper level ontology for biomedicine. Due to the complexity of the UMLS, errors exist in the semantic type assignments. Finding assignment errors may unearth modeling errors. Even with sophisticated tools, discovering assignment errors requires manual review. In this paper we describe the evaluation of an auditing project of UMLS semantic type assignments. We studied the performance of the auditors who reviewed potential errors. We found that four auditors, interacting according to a multi-step protocol, identified a high rate of errors (one or more errors in 81% of concepts studied) and that results were sufficiently reliable (0.67 to 0.70) for the two most common types of errors. However, reliability was low for each individual auditor, suggesting that review of potential errors is resource-intensive. PMID:18693845

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.

Synchronization Design and Error Analysis of Near-Infrared Cameras in Surgical Navigation.

PubMed

Cai, Ken; Yang, Rongqian; Chen, Huazhou; Huang, Yizhou; Wen, Xiaoyan; Huang, Wenhua; Ou, Shanxing

2016-01-01

The accuracy of optical tracking systems is important to scientists. With the improvements reported in this regard, such systems have been applied to an increasing number of operations. To enhance the accuracy of these systems further and to reduce the effect of synchronization and visual field errors, this study introduces a field-programmable gate array (FPGA)-based synchronization control method, a method for measuring synchronous errors, and an error distribution map in field of view. Synchronization control maximizes the parallel processing capability of FPGA, and synchronous error measurement can effectively detect the errors caused by synchronization in an optical tracking system. The distribution of positioning errors can be detected in field of view through the aforementioned error distribution map. Therefore, doctors can perform surgeries in areas with few positioning errors, and the accuracy of optical tracking systems is considerably improved. The system is analyzed and validated in this study through experiments that involve the proposed methods, which can eliminate positioning errors attributed to asynchronous cameras and different fields of view.

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

PubMed

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

2017-03-01

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

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

PubMed

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

2015-01-01

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

Is there any electrophysiological evidence for subliminal error processing?

PubMed

Shalgi, Shani; Deouell, Leon Y

2013-08-29

The role of error awareness in executive control and modification of behavior is not fully understood. In line with many recent studies showing that conscious awareness is unnecessary for numerous high-level processes such as strategic adjustments and decision making, it was suggested that error detection can also take place unconsciously. The Error Negativity (Ne) component, long established as a robust error-related component that differentiates between correct responses and errors, was a fine candidate to test this notion: if an Ne is elicited also by errors which are not consciously detected, it would imply a subliminal process involved in error monitoring that does not necessarily lead to conscious awareness of the error. Indeed, for the past decade, the repeated finding of a similar Ne for errors which became aware and errors that did not achieve awareness, compared to the smaller negativity elicited by correct responses (Correct Response Negativity; CRN), has lent the Ne the prestigious status of an index of subliminal error processing. However, there were several notable exceptions to these findings. The study in the focus of this review (Shalgi and Deouell, 2012) sheds new light on both types of previous results. We found that error detection as reflected by the Ne is correlated with subjective awareness: when awareness (or more importantly lack thereof) is more strictly determined using the wagering paradigm, no Ne is elicited without awareness. This result effectively resolves the issue of why there are many conflicting findings regarding the Ne and error awareness. The average Ne amplitude appears to be influenced by individual criteria for error reporting and therefore, studies containing different mixtures of participants who are more confident of their own performance or less confident, or paradigms that either encourage or don't encourage reporting low confidence errors will show different results. Based on this evidence, it is no longer possible to unquestioningly uphold the notion that the amplitude of the Ne is unrelated to subjective awareness, and therefore, that errors are detected without conscious awareness.

Bayesian adjustment for measurement error in continuous exposures in an individually matched case-control study.

PubMed

Espino-Hernandez, Gabriela; Gustafson, Paul; Burstyn, Igor

2011-05-14

In epidemiological studies explanatory variables are frequently subject to measurement error. The aim of this paper is to develop a Bayesian method to correct for measurement error in multiple continuous exposures in individually matched case-control studies. This is a topic that has not been widely investigated. The new method is illustrated using data from an individually matched case-control study of the association between thyroid hormone levels during pregnancy and exposure to perfluorinated acids. The objective of the motivating study was to examine the risk of maternal hypothyroxinemia due to exposure to three perfluorinated acids measured on a continuous scale. Results from the proposed method are compared with those obtained from a naive analysis. Using a Bayesian approach, the developed method considers a classical measurement error model for the exposures, as well as the conditional logistic regression likelihood as the disease model, together with a random-effect exposure model. Proper and diffuse prior distributions are assigned, and results from a quality control experiment are used to estimate the perfluorinated acids' measurement error variability. As a result, posterior distributions and 95% credible intervals of the odds ratios are computed. A sensitivity analysis of method's performance in this particular application with different measurement error variability was performed. The proposed Bayesian method to correct for measurement error is feasible and can be implemented using statistical software. For the study on perfluorinated acids, a comparison of the inferences which are corrected for measurement error to those which ignore it indicates that little adjustment is manifested for the level of measurement error actually exhibited in the exposures. Nevertheless, a sensitivity analysis shows that more substantial adjustments arise if larger measurement errors are assumed. In individually matched case-control studies, the use of conditional logistic regression likelihood as a disease model in the presence of measurement error in multiple continuous exposures can be justified by having a random-effect exposure model. The proposed method can be successfully implemented in WinBUGS to correct individually matched case-control studies for several mismeasured continuous exposures under a classical measurement error model.

Beyond alpha: an empirical examination of the effects of different sources of measurement error on reliability estimates for measures of individual differences constructs.

PubMed

Schmidt, Frank L; Le, Huy; Ilies, Remus

2003-06-01

On the basis of an empirical study of measures of constructs from the cognitive domain, the personality domain, and the domain of affective traits, the authors of this study examine the implications of transient measurement error for the measurement of frequently studied individual differences variables. The authors clarify relevant reliability concepts as they relate to transient error and present a procedure for estimating the coefficient of equivalence and stability (L. J. Cronbach, 1947), the only classical reliability coefficient that assesses all 3 major sources of measurement error (random response, transient, and specific factor errors). The authors conclude that transient error exists in all 3 trait domains and is especially large in the domain of affective traits. Their findings indicate that the nearly universal use of the coefficient of equivalence (Cronbach's alpha; L. J. Cronbach, 1951), which fails to assess transient error, leads to overestimates of reliability and undercorrections for biases due to measurement error.

Differences among Job Positions Related to Communication Errors at Construction Sites

NASA Astrophysics Data System (ADS)

Takahashi, Akiko; Ishida, Toshiro

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

Impact and quantification of the sources of error in DNA pooling designs.

PubMed

Jawaid, A; Sham, P

2009-01-01

The analysis of genome wide variation offers the possibility of unravelling the genes involved in the pathogenesis of disease. Genome wide association studies are also particularly useful for identifying and validating targets for therapeutic intervention as well as for detecting markers for drug efficacy and side effects. The cost of such large-scale genetic association studies may be reduced substantially by the analysis of pooled DNA from multiple individuals. However, experimental errors inherent in pooling studies lead to a potential increase in the false positive rate and a loss in power compared to individual genotyping. Here we quantify various sources of experimental error using empirical data from typical pooling experiments and corresponding individual genotyping counts using two statistical methods. We provide analytical formulas for calculating these different errors in the absence of complete information, such as replicate pool formation, and for adjusting for the errors in the statistical analysis. We demonstrate that DNA pooling has the potential of estimating allele frequencies accurately, and adjusting the pooled allele frequency estimates for differential allelic amplification considerably improves accuracy. Estimates of the components of error show that differential allelic amplification is the most important contributor to the error variance in absolute allele frequency estimation, followed by allele frequency measurement and pool formation errors. Our results emphasise the importance of minimising experimental errors and obtaining correct error estimates in genetic association studies.

The influence of the structure and culture of medical group practices on prescription drug errors.

PubMed

Kralewski, John E; Dowd, Bryan E; Heaton, Alan; Kaissi, Amer

2005-08-01

This project was designed to identify the magnitude of prescription drug errors in medical group practices and to explore the influence of the practice structure and culture on those error rates. Seventy-eight practices serving an upper Midwest managed care (Care Plus) plan during 2001 were included in the study. Using Care Plus claims data, prescription drug error rates were calculated at the enrollee level and then were aggregated to the group practice that each enrollee selected to provide and manage their care. Practice structure and culture data were obtained from surveys of the practices. Data were analyzed using multivariate regression. Both the culture and the structure of these group practices appear to influence prescription drug error rates. Seeing more patients per clinic hour, more prescriptions per patient, and being cared for in a rural clinic were all strongly associated with more errors. Conversely, having a case manager program is strongly related to fewer errors in all of our analyses. The culture of the practices clearly influences error rates, but the findings are mixed. Practices with cohesive cultures have lower error rates but, contrary to our hypothesis, cultures that value physician autonomy and individuality also have lower error rates than those with a more organizational orientation. Our study supports the contention that there are a substantial number of prescription drug errors in the ambulatory care sector. Even by the strictest definition, there were about 13 errors per 100 prescriptions for Care Plus patients in these group practices during 2001. Our study demonstrates that the structure of medical group practices influences prescription drug error rates. In some cases, this appears to be a direct relationship, such as the effects of having a case manager program on fewer drug errors, but in other cases the effect appears to be indirect through the improvement of drug prescribing practices. An important aspect of this study is that it provides insights into the relationships of the structure and culture of medical group practices and prescription drug errors and provides direction for future research. Research focused on the factors influencing the high error rates in rural areas and how the interaction of practice structural and cultural attributes influence error rates would add important insights into our findings. For medical practice directors, our data show that they should focus on patient care coordination to reduce errors.

Comparisons of refractive errors between twins and singletons in Chinese school-age samples.

PubMed

Hur, Yoon-Mi; Zheng, Yingfeng; Huang, Wenyong; Ding, Xiaohu; He, Mingguang

2009-02-01

Studies have reported that refractive errors are associated with premature births. As twins have higher prevalence of prematurity than singletons, it is important to assess similarity of the prevalence of refractive errors in twins and singletons for proper interpretations and generalizations of the findings from twin studies. We compared refractive errors and diopter hours between 561 pairs of twins and 3757 singletons who are representative of school-age children (7-15 years) residing in an urban area of southern China. We found that the means and variances of the continuous measurement of spherical equivalent refractive error and diopter hours were not significantly different between twins and singletons. Although the prevalence of myopia was comparable between twins and singletons, that of hyperopia and astigmatism was slightly but significantly higher in twins than in singletons. These results are inconsistent with those of adult studies that showed no differences in refractive errors between twins and singletons. Given that the sample size of twins is relatively small and that this study is the first to demonstrate minor differences in refractive errors between twins and singletons, future replications are necessary to determine whether the slightly higher prevalence of refractive errors in twins than in singletons found in this study was due to a sampling error or to the developmental delay often observed in twins in childhood.

Impact of exposure measurement error in air pollution epidemiology: effect of error type in time-series studies.

PubMed

Goldman, Gretchen T; Mulholland, James A; Russell, Armistead G; Strickland, Matthew J; Klein, Mitchel; Waller, Lance A; Tolbert, Paige E

2011-06-22

Two distinctly different types of measurement error are Berkson and classical. Impacts of measurement error in epidemiologic studies of ambient air pollution are expected to depend on error type. We characterize measurement error due to instrument imprecision and spatial variability as multiplicative (i.e. additive on the log scale) and model it over a range of error types to assess impacts on risk ratio estimates both on a per measurement unit basis and on a per interquartile range (IQR) basis in a time-series study in Atlanta. Daily measures of twelve ambient air pollutants were analyzed: NO2, NOx, O3, SO2, CO, PM10 mass, PM2.5 mass, and PM2.5 components sulfate, nitrate, ammonium, elemental carbon and organic carbon. Semivariogram analysis was applied to assess spatial variability. Error due to this spatial variability was added to a reference pollutant time-series on the log scale using Monte Carlo simulations. Each of these time-series was exponentiated and introduced to a Poisson generalized linear model of cardiovascular disease emergency department visits. Measurement error resulted in reduced statistical significance for the risk ratio estimates for all amounts (corresponding to different pollutants) and types of error. When modelled as classical-type error, risk ratios were attenuated, particularly for primary air pollutants, with average attenuation in risk ratios on a per unit of measurement basis ranging from 18% to 92% and on an IQR basis ranging from 18% to 86%. When modelled as Berkson-type error, risk ratios per unit of measurement were biased away from the null hypothesis by 2% to 31%, whereas risk ratios per IQR were attenuated (i.e. biased toward the null) by 5% to 34%. For CO modelled error amount, a range of error types were simulated and effects on risk ratio bias and significance were observed. For multiplicative error, both the amount and type of measurement error impact health effect estimates in air pollution epidemiology. By modelling instrument imprecision and spatial variability as different error types, we estimate direction and magnitude of the effects of error over a range of error types.

Article Errors in the English Writing of Saudi EFL Preparatory Year Students

ERIC Educational Resources Information Center

Alhaisoni, Eid; Gaudel, Daya Ram; Al-Zuoud, Khalid M.

2017-01-01

This study aims at providing a comprehensive account of the types of errors produced by Saudi EFL students enrolled in the preparatory year programe in their use of articles, based on the Surface Structure Taxonomies (SST) of errors. The study describes the types, frequency and sources of the definite and indefinite article errors in writing…

Identifying Novice Student Programming Misconceptions and Errors from Summative Assessments

ERIC Educational Resources Information Center

Veerasamy, Ashok Kumar; D'Souza, Daryl; Laakso, Mikko-Jussi

2016-01-01

This article presents a study aimed at examining the novice student answers in an introductory programming final e-exam to identify misconceptions and types of errors. Our study used the Delphi concept inventory to identify student misconceptions and skill, rule, and knowledge-based errors approach to identify the types of errors made by novices…

The Nature of Error in Adolescent Student Writing

ERIC Educational Resources Information Center

Wilcox, Kristen Campbell; Yagelski, Robert; Yu, Fang

2014-01-01

This study examined the nature and frequency of error in high school native English speaker (L1) and English learner (L2) writing. Four main research questions were addressed: Are there significant differences in students' error rates in English language arts (ELA) and social studies? Do the most common errors made by students differ in ELA…

Generation 1.5 Written Error Patterns: A Comparative Study

ERIC Educational Resources Information Center

Doolan, Stephen M.; Miller, Donald

2012-01-01

In an attempt to contribute to existing research on Generation 1.5 students, the current study uses quantitative and qualitative methods to compare error patterns in a corpus of Generation 1.5, L1, and L2 community college student writing. This error analysis provides one important way to determine if error patterns in Generation 1.5 student…

A study for systematic errors of the GLA forecast model in tropical regions

NASA Technical Reports Server (NTRS)

Chen, Tsing-Chang; Baker, Wayman E.; Pfaendtner, James; Corrigan, Martin

1988-01-01

From the sensitivity studies performed with the Goddard Laboratory for Atmospheres (GLA) analysis/forecast system, it was revealed that the forecast errors in the tropics affect the ability to forecast midlatitude weather in some cases. Apparently, the forecast errors occurring in the tropics can propagate to midlatitudes. Therefore, the systematic error analysis of the GLA forecast system becomes a necessary step in improving the model's forecast performance. The major effort of this study is to examine the possible impact of the hydrological-cycle forecast error on dynamical fields in the GLA forecast system.

Error monitoring and empathy: Explorations within a neurophysiological context.

PubMed

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

2017-06-01

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

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.

Correcting the Standard Errors of 2-Stage Residual Inclusion Estimators for Mendelian Randomization Studies

PubMed Central

Palmer, Tom M; Holmes, Michael V; Keating, Brendan J; Sheehan, Nuala A

2017-01-01

Abstract Mendelian randomization studies use genotypes as instrumental variables to test for and estimate the causal effects of modifiable risk factors on outcomes. Two-stage residual inclusion (TSRI) estimators have been used when researchers are willing to make parametric assumptions. However, researchers are currently reporting uncorrected or heteroscedasticity-robust standard errors for these estimates. We compared several different forms of the standard error for linear and logistic TSRI estimates in simulations and in real-data examples. Among others, we consider standard errors modified from the approach of Newey (1987), Terza (2016), and bootstrapping. In our simulations Newey, Terza, bootstrap, and corrected 2-stage least squares (in the linear case) standard errors gave the best results in terms of coverage and type I error. In the real-data examples, the Newey standard errors were 0.5% and 2% larger than the unadjusted standard errors for the linear and logistic TSRI estimators, respectively. We show that TSRI estimators with modified standard errors have correct type I error under the null. Researchers should report TSRI estimates with modified standard errors instead of reporting unadjusted or heteroscedasticity-robust standard errors. PMID:29106476

Identification and Remediation of Phonological and Motor Errors in Acquired Sound Production Impairment

PubMed Central

Gagnon, Bernadine; Miozzo, Michele

2017-01-01

Purpose This study aimed to test whether an approach to distinguishing errors arising in phonological processing from those arising in motor planning also predicts the extent to which repetition-based training can lead to improved production of difficult sound sequences. Method Four individuals with acquired speech production impairment who produced consonant cluster errors involving deletion were examined using a repetition task. We compared the acoustic details of productions with deletion errors in target consonant clusters to singleton consonants. Changes in accuracy over the course of the study were also compared. Results Two individuals produced deletion errors consistent with a phonological locus of the errors, and 2 individuals produced errors consistent with a motoric locus of the errors. The 2 individuals who made phonologically driven errors showed no change in performance on a repetition training task, whereas the 2 individuals with motoric errors improved in their production of both trained and untrained items. Conclusions The results extend previous findings about a metric for identifying the source of sound production errors in individuals with both apraxia of speech and aphasia. In particular, this work may provide a tool for identifying predominant error types in individuals with complex deficits. PMID:28655044

The computation of equating errors in international surveys in education.

PubMed

Monseur, Christian; Berezner, Alla

2007-01-01

Since the IEA's Third International Mathematics and Science Study, one of the major objectives of international surveys in education has been to report trends in achievement. The names of the two current IEA surveys reflect this growing interest: Trends in International Mathematics and Science Study (TIMSS) and Progress in International Reading Literacy Study (PIRLS). Similarly a central concern of the OECD's PISA is with trends in outcomes over time. To facilitate trend analyses these studies link their tests using common item equating in conjunction with item response modelling methods. IEA and PISA policies differ in terms of reporting the error associated with trends. In IEA surveys, the standard errors of the trend estimates do not include the uncertainty associated with the linking step while PISA does include a linking error component in the standard errors of trend estimates. In other words, PISA implicitly acknowledges that trend estimates partly depend on the selected common items, while the IEA's surveys do not recognise this source of error. Failing to recognise the linking error leads to an underestimation of the standard errors and thus increases the Type I error rate, thereby resulting in reporting of significant changes in achievement when in fact these are not significant. The growing interest of policy makers in trend indicators and the impact of the evaluation of educational reforms appear to be incompatible with such underestimation. However, the procedure implemented by PISA raises a few issues about the underlying assumptions for the computation of the equating error. After a brief introduction, this paper will describe the procedure PISA implemented to compute the linking error. The underlying assumptions of this procedure will then be discussed. Finally an alternative method based on replication techniques will be presented, based on a simulation study and then applied to the PISA 2000 data.

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

PubMed

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

2015-11-14

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

Evidence for specificity of the impact of punishment on error-related brain activity in high versus low trait anxious individuals.

PubMed

Meyer, Alexandria; Gawlowska, Magda

2017-10-01

A previous study suggests that when participants were punished with a loud noise after committing errors, the error-related negativity (ERN) was enhanced in high trait anxious individuals. The current study sought to extend these findings by examining the ERN in conditions when punishment was related and unrelated to error commission as a function of individual differences in trait anxiety symptoms; further, the current study utilized an electric shock as an aversive unconditioned stimulus. Results confirmed that the ERN was increased when errors were punished among high trait anxious individuals compared to low anxious individuals; this effect was not observed when punishment was unrelated to errors. Findings suggest that the threat-value of errors may underlie the association between certain anxious traits and punishment-related increases in the ERN. Copyright © 2017 Elsevier B.V. All rights reserved.

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

PubMed

Huckels-Baumgart, Saskia; Manser, Tanja

2014-10-01

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

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.

Nurses' attitude and intention of medication administration error reporting.

PubMed

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

2016-02-01

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

Hope Modified the Association between Distress and Incidence of Self-Perceived Medical Errors among Practicing Physicians: Prospective Cohort Study

PubMed Central

Hayashino, Yasuaki; Utsugi-Ozaki, Makiko; Feldman, Mitchell D.; Fukuhara, Shunichi

2012-01-01

The presence of hope has been found to influence an individual's ability to cope with stressful situations. The objective of this study is to evaluate the relationship between medical errors, hope and burnout among practicing physicians using validated metrics. Prospective cohort study was conducted among hospital based physicians practicing in Japan (N = 836). Measures included the validated Burnout Scale, self-assessment of medical errors and Herth Hope Index (HHI). The main outcome measure was the frequency of self-perceived medical errors, and Poisson regression analysis was used to evaluate the association between hope and medical error. A total of 361 errors were reported in 836 physician-years. We observed a significant association between hope and self-report of medical errors. Compared with the lowest tertile category of HHI, incidence rate ratios (IRRs) of self-perceived medical errors of physicians in the highest category were 0.44 (95%CI, 0.34 to 0.58) and 0.54 (95%CI, 0.42 to 0.70) respectively, for the 2nd and 3rd tertile. In stratified analysis by hope score, among physicians with a low hope score, those who experienced higher burnout reported higher incidence of errors; physicians with high hope scores did not report high incidences of errors, even if they experienced high burnout. Self-perceived medical errors showed a strong association with physicians' hope, and hope modified the association between physicians' burnout and self-perceived medical errors. PMID:22530055

Prediction of discretization error using the error transport equation

NASA Astrophysics Data System (ADS)

Celik, Ismail B.; Parsons, Don Roscoe

2017-06-01

This study focuses on an approach to quantify the discretization error associated with numerical solutions of partial differential equations by solving an error transport equation (ETE). The goal is to develop a method that can be used to adequately predict the discretization error using the numerical solution on only one grid/mesh. The primary problem associated with solving the ETE is the formulation of the error source term which is required for accurately predicting the transport of the error. In this study, a novel approach is considered which involves fitting the numerical solution with a series of locally smooth curves and then blending them together with a weighted spline approach. The result is a continuously differentiable analytic expression that can be used to determine the error source term. Once the source term has been developed, the ETE can easily be solved using the same solver that is used to obtain the original numerical solution. The new methodology is applied to the two-dimensional Navier-Stokes equations in the laminar flow regime. A simple unsteady flow case is also considered. The discretization error predictions based on the methodology presented in this study are in good agreement with the 'true error'. While in most cases the error predictions are not quite as accurate as those from Richardson extrapolation, the results are reasonable and only require one numerical grid. The current results indicate that there is much promise going forward with the newly developed error source term evaluation technique and the ETE.

Medication errors in paediatric care: a systematic review of epidemiology and an evaluation of evidence supporting reduction strategy recommendations

PubMed Central

Miller, Marlene R; Robinson, Karen A; Lubomski, Lisa H; Rinke, Michael L; Pronovost, Peter J

2007-01-01

Background Although children are at the greatest risk for medication errors, little is known about the overall epidemiology of these errors, where the gaps are in our knowledge, and to what extent national medication error reduction strategies focus on children. Objective To synthesise peer reviewed knowledge on children's medication errors and on recommendations to improve paediatric medication safety by a systematic literature review. Data sources PubMed, Embase and Cinahl from 1 January 2000 to 30 April 2005, and 11 national entities that have disseminated recommendations to improve medication safety. Study selection Inclusion criteria were peer reviewed original data in English language. Studies that did not separately report paediatric data were excluded. Data extraction Two reviewers screened articles for eligibility and for data extraction, and screened all national medication error reduction strategies for relevance to children. Data synthesis From 358 articles identified, 31 were included for data extraction. The definition of medication error was non‐uniform across the studies. Dispensing and administering errors were the most poorly and non‐uniformly evaluated. Overall, the distributional epidemiological estimates of the relative percentages of paediatric error types were: prescribing 3–37%, dispensing 5–58%, administering 72–75%, and documentation 17–21%. 26 unique recommendations for strategies to reduce medication errors were identified; none were based on paediatric evidence. Conclusions Medication errors occur across the entire spectrum of prescribing, dispensing, and administering, are common, and have a myriad of non‐evidence based potential reduction strategies. Further research in this area needs a firmer standardisation for items such as dose ranges and definitions of medication errors, broader scope beyond inpatient prescribing errors, and prioritisation of implementation of medication error reduction strategies. PMID:17403758

A simulation study to quantify the impacts of exposure measurement error on air pollution health risk estimates in copollutant time-series models.

PubMed

Dionisio, Kathie L; Chang, Howard H; Baxter, Lisa K

2016-11-25

Exposure measurement error in copollutant epidemiologic models has the potential to introduce bias in relative risk (RR) estimates. A simulation study was conducted using empirical data to quantify the impact of correlated measurement errors in time-series analyses of air pollution and health. ZIP-code level estimates of exposure for six pollutants (CO, NO x , EC, PM 2.5 , SO 4 , O 3 ) from 1999 to 2002 in the Atlanta metropolitan area were used to calculate spatial, population (i.e. ambient versus personal), and total exposure measurement error. Empirically determined covariance of pollutant concentration pairs and the associated measurement errors were used to simulate true exposure (exposure without error) from observed exposure. Daily emergency department visits for respiratory diseases were simulated using a Poisson time-series model with a main pollutant RR = 1.05 per interquartile range, and a null association for the copollutant (RR = 1). Monte Carlo experiments were used to evaluate the impacts of correlated exposure errors of different copollutant pairs. Substantial attenuation of RRs due to exposure error was evident in nearly all copollutant pairs studied, ranging from 10 to 40% attenuation for spatial error, 3-85% for population error, and 31-85% for total error. When CO, NO x or EC is the main pollutant, we demonstrated the possibility of false positives, specifically identifying significant, positive associations for copollutants based on the estimated type I error rate. The impact of exposure error must be considered when interpreting results of copollutant epidemiologic models, due to the possibility of attenuation of main pollutant RRs and the increased probability of false positives when measurement error is present.

Resection plane-dependent error in computed tomography volumetry of the right hepatic lobe in living liver donors

PubMed Central

Kwon, Heon-Ju; Kim, Bohyun; Kim, So Yeon; Lee, Chul Seung; Lee, Jeongjin; Song, Gi Won; Lee, Sung Gyu

2018-01-01

Background/Aims Computed tomography (CT) hepatic volumetry is currently accepted as the most reliable method for preoperative estimation of graft weight in living donor liver transplantation (LDLT). However, several factors can cause inaccuracies in CT volumetry compared to real graft weight. The purpose of this study was to determine the frequency and degree of resection plane-dependent error in CT volumetry of the right hepatic lobe in LDLT. Methods Forty-six living liver donors underwent CT before donor surgery and on postoperative day 7. Prospective CT volumetry (VP) was measured via the assumptive hepatectomy plane. Retrospective liver volume (VR) was measured using the actual plane by comparing preoperative and postoperative CT. Compared with intraoperatively measured weight (W), errors in percentage (%) VP and VR were evaluated. Plane-dependent error in VP was defined as the absolute difference between VP and VR. % plane-dependent error was defined as follows: |VP–VR|/W∙100. Results Mean VP, VR, and W were 761.9 mL, 755.0 mL, and 696.9 g. Mean and % errors in VP were 73.3 mL and 10.7%. Mean error and % error in VR were 64.4 mL and 9.3%. Mean plane-dependent error in VP was 32.4 mL. Mean % plane-dependent error was 4.7%. Plane-dependent error in VP exceeded 10% of W in approximately 10% of the subjects in our study. Conclusions There was approximately 5% plane-dependent error in liver VP on CT volumetry. Plane-dependent error in VP exceeded 10% of W in approximately 10% of LDLT donors in our study. This error should be considered, especially when CT volumetry is performed by a less experienced operator who is not well acquainted with the donor hepatectomy plane. PMID:28759989

PREVALENCE OF REFRACTIVE ERRORS IN MADRASSA STUDENTS OF HARIPUR DISTRICT.

PubMed

Atta, Zoia; Arif, Abdus Salam; Ahmed, Iftikhar; Farooq, Umer

2015-01-01

Visual impairment due to refractive errors is one of the most common problems among school-age children and is the second leading cause of treatable blindness. The Right to Sight, a global initiative launched by a coalition of non-government organizations and the World Health Organization (WHO), aims to eliminate avoidable visual impairment and blindness at a global level. In order to achieve this goal it is important to know the prevalence of different refractive errors in a community. Children and teenagers are the most susceptible groups to be affected by refractive errors. So, this population needs to be screened for different types of refractive errors. The study was done with the objective to find the frequency of different types of refractive errors in students of madrassas between the ages of 5-20 years in Haripur. This cross sectional study was done with 300 students between ages of 5-20 years in Madrassas of Haripur. The students were screened for refractive errors and the types of the errors were noted. After screening for refractive errors-the glasses were prescribed to the students. Myopia being 52.6% was the most frequent refractive error in students, followed by hyperopia 28.4% and astigmatism 19%. This study showed that myopia is an important problem in madrassa population. Females and males are almost equally affected. Spectacle correction of refractive errors is the cheapest and easy solution of this problem.

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

Barriers to Medical Error Reporting for Physicians and Nurses.

PubMed

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

2017-10-01

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

A predictability study of Lorenz's 28-variable model as a dynamical system

NASA Technical Reports Server (NTRS)

Krishnamurthy, V.

1993-01-01

The dynamics of error growth in a two-layer nonlinear quasi-geostrophic model has been studied to gain an understanding of the mathematical theory of atmospheric predictability. The growth of random errors of varying initial magnitudes has been studied, and the relation between this classical approach and the concepts of the nonlinear dynamical systems theory has been explored. The local and global growths of random errors have been expressed partly in terms of the properties of an error ellipsoid and the Liapunov exponents determined by linear error dynamics. The local growth of small errors is initially governed by several modes of the evolving error ellipsoid but soon becomes dominated by the longest axis. The average global growth of small errors is exponential with a growth rate consistent with the largest Liapunov exponent. The duration of the exponential growth phase depends on the initial magnitude of the errors. The subsequent large errors undergo a nonlinear growth with a steadily decreasing growth rate and attain saturation that defines the limit of predictability. The degree of chaos and the largest Liapunov exponent show considerable variation with change in the forcing, which implies that the time variation in the external forcing can introduce variable character to the predictability.

The intention to disclose medical errors among doctors in a referral hospital in North Malaysia.

PubMed

Hs, Arvinder-Singh; Rashid, Abdul

2017-01-23

In this study, medical errors are defined as unintentional patient harm caused by a doctor's mistake. This topic, due to limited research, is poorly understood in Malaysia. The objective of this study was to determine the proportion of doctors intending to disclose medical errors, and their attitudes/perception pertaining to medical errors. This cross-sectional study was conducted at a tertiary public hospital from July- December 2015 among 276 randomly selected doctors. Data was collected using a standardized and validated self-administered questionnaire intending to measure disclosure and attitudes/perceptions. The scale had four vignettes in total two medical and two surgical. Each vignette consisted of five questions and each question measured the disclosure. Disclosure was categorised as "No Disclosure", "Partial Disclosure" or "Full Disclosure". Data was keyed in and analysed using STATA v 13.0. Only 10.1% (n = 28) intended to disclose medical errors. Most respondents felt that they possessed an attitude/perception of adequately disclosing errors to patients. There was a statistically significant difference (p < 0.001) when comparing the intention of disclosure with perceived disclosures. Most respondents were in common agreement that disclosing an error would make them less likely to get sued, that minor errors should be reported and that they experienced relief from disclosing errors. Most doctors in this study would not disclose medical errors although they perceived that the errors were serious and felt responsible for it. Poor disclosure could be due the fear of litigations and improper mechanisms/procedures available for disclosure.

Quantifying the burden of opioid medication errors in adult oncology and palliative care settings: A systematic review.

PubMed

Heneka, Nicole; Shaw, Tim; Rowett, Debra; Phillips, Jane L

2016-06-01

Opioids are the primary pharmacological treatment for cancer pain and, in the palliative care setting, are routinely used to manage symptoms at the end of life. Opioids are one of the most frequently reported drug classes in medication errors causing patient harm. Despite their widespread use, little is known about the incidence and impact of opioid medication errors in oncology and palliative care settings. To determine the incidence, types and impact of reported opioid medication errors in adult oncology and palliative care patient settings. A systematic review. Five electronic databases and the grey literature were searched from 1980 to August 2014. Empirical studies published in English, reporting data on opioid medication error incidence, types or patient impact, within adult oncology and/or palliative care services, were included. Popay's narrative synthesis approach was used to analyse data. Five empirical studies were included in this review. Opioid error incidence rate was difficult to ascertain as each study focussed on a single narrow area of error. The predominant error type related to deviation from opioid prescribing guidelines, such as incorrect dosing intervals. None of the included studies reported the degree of patient harm resulting from opioid errors. This review has highlighted the paucity of the literature examining opioid error incidence, types and patient impact in adult oncology and palliative care settings. Defining, identifying and quantifying error reporting practices for these populations should be an essential component of future oncology and palliative care quality and safety initiatives. © The Author(s) 2015.

Quantifying Carbon Flux Estimation Errors

NASA Astrophysics Data System (ADS)

Wesloh, D.

2017-12-01

Atmospheric Bayesian inversions have been used to estimate surface carbon dioxide (CO2) fluxes from global to sub-continental scales using atmospheric mixing ratio measurements. These inversions use an atmospheric transport model, coupled to a set of fluxes, in order to simulate mixing ratios that can then be compared to the observations. The comparison is then used to update the fluxes to better match the observations in a manner consistent with the uncertainties prescribed for each. However, inversion studies disagree with each other at continental scales, prompting further investigations to examine the causes of these differences. Inter-comparison studies have shown that the errors resulting from atmospheric transport inaccuracies are comparable to those from the errors in the prior fluxes. However, not as much effort has gone into studying the origins of the errors induced by errors in the transport as by errors in the prior distribution. This study uses a mesoscale transport model to evaluate the effects of representation errors in the observations and of incorrect descriptions of the transport. To obtain realizations of these errors, we performed an Observing System Simulation Experiments (OSSEs), with the transport model used for the inversion operating at two resolutions, one typical of a global inversion and the other of a mesoscale, and with various prior flux distributions to. Transport error covariances are inferred from an ensemble of perturbed mesoscale simulations while flux error covariances are computed using prescribed distributions and magnitudes. We examine how these errors can be diagnosed in the inversion process using aircraft, ground-based, and satellite observations of meteorological variables and CO2.

A simulation test of the effectiveness of several methods for error-checking non-invasive genetic data

USGS Publications Warehouse

Roon, David A.; Waits, L.P.; Kendall, K.C.

2005-01-01

Non-invasive genetic sampling (NGS) is becoming a popular tool for population estimation. However, multiple NGS studies have demonstrated that polymerase chain reaction (PCR) genotyping errors can bias demographic estimates. These errors can be detected by comprehensive data filters such as the multiple-tubes approach, but this approach is expensive and time consuming as it requires three to eight PCR replicates per locus. Thus, researchers have attempted to correct PCR errors in NGS datasets using non-comprehensive error checking methods, but these approaches have not been evaluated for reliability. We simulated NGS studies with and without PCR error and 'filtered' datasets using non-comprehensive approaches derived from published studies and calculated mark-recapture estimates using CAPTURE. In the absence of data-filtering, simulated error resulted in serious inflations in CAPTURE estimates; some estimates exceeded N by ??? 200%. When data filters were used, CAPTURE estimate reliability varied with per-locus error (E??). At E?? = 0.01, CAPTURE estimates from filtered data displayed < 5% deviance from error-free estimates. When E?? was 0.05 or 0.09, some CAPTURE estimates from filtered data displayed biases in excess of 10%. Biases were positive at high sampling intensities; negative biases were observed at low sampling intensities. We caution researchers against using non-comprehensive data filters in NGS studies, unless they can achieve baseline per-locus error rates below 0.05 and, ideally, near 0.01. However, we suggest that data filters can be combined with careful technique and thoughtful NGS study design to yield accurate demographic information. ?? 2005 The Zoological Society of London.

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

A Study of Reading Errors Using Goodman's Miscue Analysis and Cloze Procedure.

ERIC Educational Resources Information Center

Farren, Sean N.

A study of 11 boys, aged 12 to 14 with low reading ability, was conducted to discover what kinds of errors they made and whether or not differences might exist between error patterns in silent and oral reading. Miscue analysis was used to test oral reading while cloze procedures were used to test silent reading. Errors were categorized according…

Errors Made by Elementary Fourth Grade Students When Modelling Word Problems and the Elimination of Those Errors through Scaffolding

ERIC Educational Resources Information Center

Ulu, Mustafa

2017-01-01

This study aims to identify errors made by primary school students when modelling word problems and to eliminate those errors through scaffolding. A 10-question problem-solving achievement test was used in the research. The qualitative and quantitative designs were utilized together. The study group of the quantitative design comprises 248…

Orifice-induced pressure error studies in Langley 7- by 10-foot high-speed tunnel

NASA Technical Reports Server (NTRS)

Plentovich, E. B.; Gloss, B. B.

1986-01-01

For some time it has been known that the presence of a static pressure measuring hole will disturb the local flow field in such a way that the sensed static pressure will be in error. The results of previous studies aimed at studying the error induced by the pressure orifice were for relatively low Reynolds number flows. Because of the advent of high Reynolds number transonic wind tunnels, a study was undertaken to assess the magnitude of this error at high Reynolds numbers than previously published and to study a possible method of eliminating this pressure error. This study was conducted in the Langley 7- by 10-Foot High-Speed Tunnel on a flat plate. The model was tested at Mach numbers from 0.40 to 0.72 and at Reynolds numbers from 7.7 x 1,000,000 to 11 x 1,000,000 per meter (2.3 x 1,000,000 to 3.4 x 1,000,000 per foot), respectively. The results indicated that as orifice size increased, the pressure error also increased but that a porous metal (sintered metal) plug inserted in an orifice could greatly reduce the pressure error induced by the orifice.

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.

A cognitive taxonomy of medical errors.

PubMed

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

2004-06-01

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

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.

Error-related negativities elicited by monetary loss and cues that predict loss.

PubMed

Dunning, Jonathan P; Hajcak, Greg

2007-11-19

Event-related potential studies have reported error-related negativity following both error commission and feedback indicating errors or monetary loss. The present study examined whether error-related negativities could be elicited by a predictive cue presented prior to both the decision and subsequent feedback in a gambling task. Participants were presented with a cue that indicated the probability of reward on the upcoming trial (0, 50, and 100%). Results showed a negative deflection in the event-related potential in response to loss cues compared with win cues; this waveform shared a similar latency and morphology with the traditional feedback error-related negativity.

A Fast Surrogate-facilitated Data-driven Bayesian Approach to Uncertainty Quantification of a Regional Groundwater Flow Model with Structural Error

NASA Astrophysics Data System (ADS)

Xu, T.; Valocchi, A. J.; Ye, M.; Liang, F.

2016-12-01

Due to simplification and/or misrepresentation of the real aquifer system, numerical groundwater flow and solute transport models are usually subject to model structural error. During model calibration, the hydrogeological parameters may be overly adjusted to compensate for unknown structural error. This may result in biased predictions when models are used to forecast aquifer response to new forcing. In this study, we extend a fully Bayesian method [Xu and Valocchi, 2015] to calibrate a real-world, regional groundwater flow model. The method uses a data-driven error model to describe model structural error and jointly infers model parameters and structural error. In this study, Bayesian inference is facilitated using high performance computing and fast surrogate models. The surrogate models are constructed using machine learning techniques to emulate the response simulated by the computationally expensive groundwater model. We demonstrate in the real-world case study that explicitly accounting for model structural error yields parameter posterior distributions that are substantially different from those derived by the classical Bayesian calibration that does not account for model structural error. In addition, the Bayesian with error model method gives significantly more accurate prediction along with reasonable credible intervals.

The causes of and factors associated with prescribing errors in hospital inpatients: a systematic review.

PubMed

Tully, Mary P; Ashcroft, Darren M; Dornan, Tim; Lewis, Penny J; Taylor, David; Wass, Val

2009-01-01

Prescribing errors are common, they result in adverse events and harm to patients and it is unclear how best to prevent them because recommendations are more often based on surmized rather than empirically collected data. The aim of this systematic review was to identify all informative published evidence concerning the causes of and factors associated with prescribing errors in specialist and non-specialist hospitals, collate it, analyse it qualitatively and synthesize conclusions from it. Seven electronic databases were searched for articles published between 1985-July 2008. The reference lists of all informative studies were searched for additional citations. To be included, a study had to be of handwritten prescriptions for adult or child inpatients that reported empirically collected data on the causes of or factors associated with errors. Publications in languages other than English and studies that evaluated errors for only one disease, one route of administration or one type of prescribing error were excluded. Seventeen papers reporting 16 studies, selected from 1268 papers identified by the search, were included in the review. Studies from the US and the UK in university-affiliated hospitals predominated (10/16 [62%]). The definition of a prescribing error varied widely and the included studies were highly heterogeneous. Causes were grouped according to Reason's model of accident causation into active failures, error-provoking conditions and latent conditions. The active failure most frequently cited was a mistake due to inadequate knowledge of the drug or the patient. Skills-based slips and memory lapses were also common. Where error-provoking conditions were reported, there was at least one per error. These included lack of training or experience, fatigue, stress, high workload for the prescriber and inadequate communication between healthcare professionals. Latent conditions included reluctance to question senior colleagues and inadequate provision of training. Prescribing errors are often multifactorial, with several active failures and error-provoking conditions often acting together to cause them. In the face of such complexity, solutions addressing a single cause, such as lack of knowledge, are likely to have only limited benefit. Further rigorous study, seeking potential ways of reducing error, needs to be conducted. Multifactorial interventions across many parts of the system are likely to be required.

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.

Impact of automated dispensing cabinets on medication selection and preparation error rates in an emergency department: a prospective and direct observational before-and-after study.

PubMed

Fanning, Laura; Jones, Nick; Manias, Elizabeth

2016-04-01

The implementation of automated dispensing cabinets (ADCs) in healthcare facilities appears to be increasing, in particular within Australian hospital emergency departments (EDs). While the investment in ADCs is on the increase, no studies have specifically investigated the impacts of ADCs on medication selection and preparation error rates in EDs. Our aim was to assess the impact of ADCs on medication selection and preparation error rates in an ED of a tertiary teaching hospital. Pre intervention and post intervention study involving direct observations of nurses completing medication selection and preparation activities before and after the implementation of ADCs in the original and new emergency departments within a 377-bed tertiary teaching hospital in Australia. Medication selection and preparation error rates were calculated and compared between these two periods. Secondary end points included the impact on medication error type and severity. A total of 2087 medication selection and preparations were observed among 808 patients pre and post intervention. Implementation of ADCs in the new ED resulted in a 64.7% (1.96% versus 0.69%, respectively, P = 0.017) reduction in medication selection and preparation errors. All medication error types were reduced in the post intervention study period. There was an insignificant impact on medication error severity as all errors detected were categorised as minor. The implementation of ADCs could reduce medication selection and preparation errors and improve medication safety in an ED setting. © 2015 John Wiley & Sons, Ltd.

Advancing the research agenda for diagnostic error reduction.

PubMed

Zwaan, Laura; Schiff, Gordon D; Singh, Hardeep

2013-10-01

Diagnostic errors remain an underemphasised and understudied area of patient safety research. We briefly summarise the methods that have been used to conduct research on epidemiology, contributing factors and interventions related to diagnostic error and outline directions for future research. Research methods that have studied epidemiology of diagnostic error provide some estimate on diagnostic error rates. However, there appears to be a large variability in the reported rates due to the heterogeneity of definitions and study methods used. Thus, future methods should focus on obtaining more precise estimates in different settings of care. This would lay the foundation for measuring error rates over time to evaluate improvements. Research methods have studied contributing factors for diagnostic error in both naturalistic and experimental settings. Both approaches have revealed important and complementary information. Newer conceptual models from outside healthcare are needed to advance the depth and rigour of analysis of systems and cognitive insights of causes of error. While the literature has suggested many potentially fruitful interventions for reducing diagnostic errors, most have not been systematically evaluated and/or widely implemented in practice. Research is needed to study promising intervention areas such as enhanced patient involvement in diagnosis, improving diagnosis through the use of electronic tools and identification and reduction of specific diagnostic process 'pitfalls' (eg, failure to conduct appropriate diagnostic evaluation of a breast lump after a 'normal' mammogram). The last decade of research on diagnostic error has made promising steps and laid a foundation for more rigorous methods to advance the field.

Addressing the Problem of Negative Lexical Transfer Errors in Chilean University Students

ERIC Educational Resources Information Center

Dissington, Paul Anthony

2018-01-01

Studies of second language learning have revealed a connection between first language transfer and errors in second language production. This paper describes an action research study carried out among Chilean university students studying English as part of their degree programmes. The study focuses on common lexical errors made by Chilean…

Exposure Measurement Error in PM2.5 Health Effects Studies: A Pooled Analysis of Eight Personal Exposure Validation Studies

EPA Science Inventory

Background: Exposure measurement error is a concern in long-term PM2.5 health studies using ambient concentrations as exposures. We assessed error magnitude by estimating calibration coefficients as the association between personal PM2.5 exposures from validation studies and typ...

Speech Errors across the Lifespan

ERIC Educational Resources Information Center

Vousden, Janet I.; Maylor, Elizabeth A.

2006-01-01

Dell, Burger, and Svec (1997) proposed that the proportion of speech errors classified as anticipations (e.g., "moot and mouth") can be predicted solely from the overall error rate, such that the greater the error rate, the lower the anticipatory proportion (AP) of errors. We report a study examining whether this effect applies to changes in error…

Annotation of Korean Learner Corpora for Particle Error Detection

ERIC Educational Resources Information Center

Lee, Sun-Hee; Jang, Seok Bae; Seo, Sang-Kyu

2009-01-01

In this study, we focus on particle errors and discuss an annotation scheme for Korean learner corpora that can be used to extract heuristic patterns of particle errors efficiently. We investigate different properties of particle errors so that they can be later used to identify learner errors automatically, and we provide resourceful annotation…

Addressing Common Student Technical Errors in Field Data Collection: An Analysis of a Citizen-Science Monitoring Project.

PubMed

Philippoff, Joanna; Baumgartner, Erin

2016-03-01

The scientific value of citizen-science programs is limited when the data gathered are inconsistent, erroneous, or otherwise unusable. Long-term monitoring studies, such as Our Project In Hawai'i's Intertidal (OPIHI), have clear and consistent procedures and are thus a good model for evaluating the quality of participant data. The purpose of this study was to examine the kinds of errors made by student researchers during OPIHI data collection and factors that increase or decrease the likelihood of these errors. Twenty-four different types of errors were grouped into four broad error categories: missing data, sloppiness, methodological errors, and misidentification errors. "Sloppiness" was the most prevalent error type. Error rates decreased with field trip experience and student age. We suggest strategies to reduce data collection errors applicable to many types of citizen-science projects including emphasizing neat data collection, explicitly addressing and discussing the problems of falsifying data, emphasizing the importance of using standard scientific vocabulary, and giving participants multiple opportunities to practice to build their data collection techniques and skills.

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.

Metrological Software Test for Simulating the Method of Determining the Thermocouple Error in Situ During Operation

NASA Astrophysics Data System (ADS)

Chen, Jingliang; Su, Jun; Kochan, Orest; Levkiv, Mariana

2018-04-01

The simplified metrological software test (MST) for modeling the method of determining the thermocouple (TC) error in situ during operation is considered in the paper. The interaction between the proposed MST and a temperature measuring system is also reflected in order to study the error of determining the TC error in situ during operation. The modelling studies of the random error influence of the temperature measuring system, as well as interference magnitude (both the common and normal mode noises) on the error of determining the TC error in situ during operation using the proposed MST, have been carried out. The noise and interference of the order of 5-6 μV cause the error of about 0.2-0.3°C. It is shown that high noise immunity is essential for accurate temperature measurements using TCs.

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

PubMed

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

2015-01-01

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

Selection of neural network structure for system error correction of electro-optical tracker system with horizontal gimbal

NASA Astrophysics Data System (ADS)

Liu, Xing-fa; Cen, Ming

2007-12-01

Neural Network system error correction method is more precise than lest square system error correction method and spheric harmonics function system error correction method. The accuracy of neural network system error correction method is mainly related to the frame of Neural Network. Analysis and simulation prove that both BP neural network system error correction method and RBF neural network system error correction method have high correction accuracy; it is better to use RBF Network system error correction method than BP Network system error correction method for little studying stylebook considering training rate and neural network scale.

Beyond hypercorrection: remembering corrective feedback for low-confidence errors.

PubMed

Griffiths, Lauren; Higham, Philip A

2018-02-01

Correcting errors based on corrective feedback is essential to successful learning. Previous studies have found that corrections to high-confidence errors are better remembered than low-confidence errors (the hypercorrection effect). The aim of this study was to investigate whether corrections to low-confidence errors can also be successfully retained in some cases. Participants completed an initial multiple-choice test consisting of control, trick and easy general-knowledge questions, rated their confidence after answering each question, and then received immediate corrective feedback. After a short delay, they were given a cued-recall test consisting of the same questions. In two experiments, we found high-confidence errors to control questions were better corrected on the second test compared to low-confidence errors - the typical hypercorrection effect. However, low-confidence errors to trick questions were just as likely to be corrected as high-confidence errors. Most surprisingly, we found that memory for the feedback and original responses, not confidence or surprise, were significant predictors of error correction. We conclude that for some types of material, there is an effortful process of elaboration and problem solving prior to making low-confidence errors that facilitates memory of corrective feedback.

Medication Errors in Patients with Enteral Feeding Tubes in the Intensive Care Unit.

PubMed

Sohrevardi, Seyed Mojtaba; Jarahzadeh, Mohammad Hossein; Mirzaei, Ehsan; Mirjalili, Mahtabalsadat; Tafti, Arefeh Dehghani; Heydari, Behrooz

2017-01-01

Most patients admitted to Intensive Care Units (ICU) have problems in using oral medication or ingesting solid forms of drugs. Selecting the most suitable dosage form in such patients is a challenge. The current study was conducted to assess the frequency and types of errors of oral medication administration in patients with enteral feeding tubes or suffering swallowing problems. A cross-sectional study was performed in the ICU of Shahid Sadoughi Hospital, Yazd, Iran. Patients were assessed for the incidence and types of medication errors occurring in the process of preparation and administration of oral medicines. Ninety-four patients were involved in this study and 10,250 administrations were observed. Totally, 4753 errors occurred among the studied patients. The most commonly used drugs were pantoprazole tablet, piracetam syrup, and losartan tablet. A total of 128 different types of drugs and nine different oral pharmaceutical preparations were prescribed for the patients. Forty-one (35.34%) out of 116 different solid drugs (except effervescent tablets and powders) could be substituted by liquid or injectable forms. The most common error was the wrong time of administration. Errors of wrong dose preparation and administration accounted for 24.04% and 25.31% of all errors, respectively. In this study, at least three-fourth of the patients experienced medication errors. The occurrence of these errors can greatly impair the quality of the patients' pharmacotherapy, and more attention should be paid to this issue.

Random measurement error: Why worry? An example of cardiovascular risk factors.

PubMed

Brakenhoff, Timo B; van Smeden, Maarten; Visseren, Frank L J; Groenwold, Rolf H H

2018-01-01

With the increased use of data not originally recorded for research, such as routine care data (or 'big data'), measurement error is bound to become an increasingly relevant problem in medical research. A common view among medical researchers on the influence of random measurement error (i.e. classical measurement error) is that its presence leads to some degree of systematic underestimation of studied exposure-outcome relations (i.e. attenuation of the effect estimate). For the common situation where the analysis involves at least one exposure and one confounder, we demonstrate that the direction of effect of random measurement error on the estimated exposure-outcome relations can be difficult to anticipate. Using three example studies on cardiovascular risk factors, we illustrate that random measurement error in the exposure and/or confounder can lead to underestimation as well as overestimation of exposure-outcome relations. We therefore advise medical researchers to refrain from making claims about the direction of effect of measurement error in their manuscripts, unless the appropriate inferential tools are used to study or alleviate the impact of measurement error from the analysis.

Correcting the Standard Errors of 2-Stage Residual Inclusion Estimators for Mendelian Randomization Studies.

PubMed

Palmer, Tom M; Holmes, Michael V; Keating, Brendan J; Sheehan, Nuala A

2017-11-01

Mendelian randomization studies use genotypes as instrumental variables to test for and estimate the causal effects of modifiable risk factors on outcomes. Two-stage residual inclusion (TSRI) estimators have been used when researchers are willing to make parametric assumptions. However, researchers are currently reporting uncorrected or heteroscedasticity-robust standard errors for these estimates. We compared several different forms of the standard error for linear and logistic TSRI estimates in simulations and in real-data examples. Among others, we consider standard errors modified from the approach of Newey (1987), Terza (2016), and bootstrapping. In our simulations Newey, Terza, bootstrap, and corrected 2-stage least squares (in the linear case) standard errors gave the best results in terms of coverage and type I error. In the real-data examples, the Newey standard errors were 0.5% and 2% larger than the unadjusted standard errors for the linear and logistic TSRI estimators, respectively. We show that TSRI estimators with modified standard errors have correct type I error under the null. Researchers should report TSRI estimates with modified standard errors instead of reporting unadjusted or heteroscedasticity-robust standard errors. © The Author(s) 2017. Published by Oxford University Press on behalf of the Johns Hopkins Bloomberg School of Public Health.

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

PubMed

Alexander, William H; Brown, Joshua W

2010-02-15

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

Barriers to medication error reporting among hospital nurses.

PubMed

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

2018-03-01

The study purpose was to report medication error reporting barriers among hospital nurses, and to determine validity and reliability of an existing medication error reporting barriers questionnaire. Hospital medication errors typically occur between ordering of a medication to its receipt by the patient with subsequent staff monitoring. To decrease medication errors, factors surrounding medication errors must be understood; this requires reporting by employees. Under-reporting can compromise patient safety by disabling improvement efforts. This 2017 descriptive study was part of a larger workforce engagement study at a faith-based Magnet ® -accredited community hospital in California (United States). Registered nurses (~1,000) were invited to participate in the online survey via email. Reported here are sample demographics (n = 357) and responses to the 20-item medication error reporting barriers questionnaire. Using factor analysis, four factors that accounted for 67.5% of the variance were extracted. These factors (subscales) were labelled Fear, Cultural Barriers, Lack of Knowledge/Feedback and Practical/Utility Barriers; each demonstrated excellent internal consistency. The medication error reporting barriers questionnaire, originally developed in long-term care, demonstrated good validity and excellent reliability among hospital nurses. Substantial proportions of American hospital nurses (11%-48%) considered specific factors as likely reporting barriers. Average scores on most barrier items were categorised "somewhat unlikely." The highest six included two barriers concerning the time-consuming nature of medication error reporting and four related to nurses' fear of repercussions. Hospitals need to determine the presence of perceived barriers among nurses using questionnaires such as the medication error reporting barriers and work to encourage better reporting. Barriers to medication error reporting make it less likely that nurses will report medication errors, especially errors where patient harm is not apparent or where an error might be hidden. Such under-reporting impedes collection of accurate medication error data and prevents hospitals from changing harmful practices. © 2018 John Wiley & Sons Ltd.

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

Is there any electrophysiological evidence for subliminal error processing?

PubMed Central

Shalgi, Shani; Deouell, Leon Y.

2013-01-01

The role of error awareness in executive control and modification of behavior is not fully understood. In line with many recent studies showing that conscious awareness is unnecessary for numerous high-level processes such as strategic adjustments and decision making, it was suggested that error detection can also take place unconsciously. The Error Negativity (Ne) component, long established as a robust error-related component that differentiates between correct responses and errors, was a fine candidate to test this notion: if an Ne is elicited also by errors which are not consciously detected, it would imply a subliminal process involved in error monitoring that does not necessarily lead to conscious awareness of the error. Indeed, for the past decade, the repeated finding of a similar Ne for errors which became aware and errors that did not achieve awareness, compared to the smaller negativity elicited by correct responses (Correct Response Negativity; CRN), has lent the Ne the prestigious status of an index of subliminal error processing. However, there were several notable exceptions to these findings. The study in the focus of this review (Shalgi and Deouell, 2012) sheds new light on both types of previous results. We found that error detection as reflected by the Ne is correlated with subjective awareness: when awareness (or more importantly lack thereof) is more strictly determined using the wagering paradigm, no Ne is elicited without awareness. This result effectively resolves the issue of why there are many conflicting findings regarding the Ne and error awareness. The average Ne amplitude appears to be influenced by individual criteria for error reporting and therefore, studies containing different mixtures of participants who are more confident of their own performance or less confident, or paradigms that either encourage or don't encourage reporting low confidence errors will show different results. Based on this evidence, it is no longer possible to unquestioningly uphold the notion that the amplitude of the Ne is unrelated to subjective awareness, and therefore, that errors are detected without conscious awareness. PMID:24009548

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

PubMed

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

2017-08-01

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

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

PubMed

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

2014-10-01

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

[Improving blood safety: errors management in transfusion medicine].

PubMed

Bujandrić, Nevenka; Grujić, Jasmina; Krga-Milanović, Mirjana

2014-01-01

The concept of blood safety includes the entire transfusion chain starting with the collection of blood from the blood donor, and ending with blood transfusion to the patient. The concept involves quality management system as the systematic monitoring of adverse reactions and incidents regarding the blood donor or patient. Monitoring of near-miss errors show the critical points in the working process and increase transfusion safety. The aim of the study was to present the analysis results of adverse and unexpected events in transfusion practice with a potential risk to the health of blood donors and patients. One-year retrospective study was based on the collection, analysis and interpretation of written reports on medical errors in the Blood Transfusion Institute of Vojvodina. Errors were distributed according to the type, frequency and part of the working process where they occurred. Possible causes and corrective actions were described for each error. The study showed that there were not errors with potential health consequences for the blood donor/patient. Errors with potentially damaging consequences for patients were detected throughout the entire transfusion chain. Most of the errors were identified in the preanalytical phase. The human factor was responsible for the largest number of errors. Error reporting system has an important role in the error management and the reduction of transfusion-related risk of adverse events and incidents. The ongoing analysis reveals the strengths and weaknesses of the entire process and indicates the necessary changes. Errors in transfusion medicine can be avoided in a large percentage and prevention is cost-effective, systematic and applicable.

Types of diagnostic errors in neurological emergencies in the emergency department.

PubMed

Dubosh, Nicole M; Edlow, Jonathan A; Lefton, Micah; Pope, Jennifer V

2015-02-01

Neurological emergencies often pose diagnostic challenges for emergency physicians because these patients often present with atypical symptoms and standard imaging tests are imperfect. Misdiagnosis occurs due to a variety of errors. These can be classified as knowledge gaps, cognitive errors, and systems-based errors. The goal of this study was to describe these errors through review of quality assurance (QA) records. This was a retrospective pilot study of patients with neurological emergency diagnoses that were missed or delayed at one urban, tertiary academic emergency department. Cases meeting inclusion criteria were identified through review of QA records. Three emergency physicians independently reviewed each case and determined the type of error that led to the misdiagnosis. Proportions, confidence intervals, and a reliability coefficient were calculated. During the study period, 1168 cases were reviewed. Forty-two cases were found to include a neurological misdiagnosis and twenty-nine were determined to be the result of an error. The distribution of error types was as follows: knowledge gap 45.2% (95% CI 29.2, 62.2), cognitive error 29.0% (95% CI 15.9, 46.8), and systems-based error 25.8% (95% CI 13.5, 43.5). Cerebellar strokes were the most common type of stroke misdiagnosed, accounting for 27.3% of missed strokes. All three error types contributed to the misdiagnosis of neurological emergencies. Misdiagnosis of cerebellar lesions and erroneous radiology resident interpretations of neuroimaging were the most common mistakes. Understanding the types of errors may enable emergency physicians to develop possible solutions and avoid them in the future.

The Observational Determination of the Primordial Helium Abundance: a Y2K Status Report

NASA Astrophysics Data System (ADS)

Skillman, Evan D.

I review observational progress and assess the current state of the determination of the primordial helium abundance, Yp. At present there are two determinations with non-overlapping errors. My impression is that the errors have been under-estimated in both studies. I review recent work on errors assessment and give suggestions for decreasing systematic errors in future studies.

Errors Analysis of Solving Linear Inequalities among the Preparatory Year Students at King Saud University

ERIC Educational Resources Information Center

El-khateeb, Mahmoud M. A.

2016-01-01

The purpose of this study aims to investigate the errors classes occurred by the Preparatory year students at King Saud University, through analysis student responses to the items of the study test, and to identify the varieties of the common errors and ratios of common errors that occurred in solving inequalities. In the collection of the data,…

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

PubMed Central

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

2015-01-01

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

Using total quality management approach to improve patient safety by preventing medication error incidences*.

PubMed

Yousef, Nadin; Yousef, Farah

2017-09-04

Whereas one of the predominant causes of medication errors is a drug administration error, a previous study related to our investigations and reviews estimated that the incidences of medication errors constituted 6.7 out of 100 administrated medication doses. Therefore, we aimed by using six sigma approach to propose a way that reduces these errors to become less than 1 out of 100 administrated medication doses by improving healthcare professional education and clearer handwritten prescriptions. The study was held in a General Government Hospital. First, we systematically studied the current medication use process. Second, we used six sigma approach by utilizing the five-step DMAIC process (Define, Measure, Analyze, Implement, Control) to find out the real reasons behind such errors. This was to figure out a useful solution to avoid medication error incidences in daily healthcare professional practice. Data sheet was used in Data tool and Pareto diagrams were used in Analyzing tool. In our investigation, we reached out the real cause behind administrated medication errors. As Pareto diagrams used in our study showed that the fault percentage in administrated phase was 24.8%, while the percentage of errors related to prescribing phase was 42.8%, 1.7 folds. This means that the mistakes in prescribing phase, especially because of the poor handwritten prescriptions whose percentage in this phase was 17.6%, are responsible for the consequent) mistakes in this treatment process later on. Therefore, we proposed in this study an effective low cost strategy based on the behavior of healthcare workers as Guideline Recommendations to be followed by the physicians. This method can be a prior caution to decrease errors in prescribing phase which may lead to decrease the administrated medication error incidences to less than 1%. This improvement way of behavior can be efficient to improve hand written prescriptions and decrease the consequent errors related to administrated medication doses to less than the global standard; as a result, it enhances patient safety. However, we hope other studies will be made later in hospitals to practically evaluate how much effective our proposed systematic strategy really is in comparison with other suggested remedies in this field.

[Surveillance of health care errors. An overview of the published data in Argentina].

PubMed

Codermatz, Marcela A; Trillo, Carolina; Berenstein, Graciela; Ortiz, Zulma

2006-01-01

In the last decades, public health surveillance extended its scope of study to new fields, such as medical errors, in order to improve patient safety. This study was aimed to review all the evidence produced in Argentina about the surveillance of medical errors. An exhaustive literature search was performed. A total of 4656 abstracts were assessed (150 MEDLINE, 145 LILACS, and 4361 hand searched abstracts). Of them, 52 were analysed and 8 were considered relevant for health care error surveillance. Different approaches were used to study medical errors. Some of them have focused on patient safety and others on medical malpractice. There is still a need to improve the surveillance of this type of event. Mainly, the quality reports of study design and surveillance attributes were unclear. A critical appraisal and synthesis of all relevant studies on health care errors may help to understand not only the state of the art, but also to define research priorities.

Investigation of experimental pole-figure errors by simulation of individual spectra

NASA Astrophysics Data System (ADS)

Lychagina, T. A.; Nikolaev, D. I.

2007-09-01

The errors in measuring the crystallographic texture described by pole figures are studied. A set of diffraction spectra for a sample of the MA2-1 alloy (Mg + 4.5% Al + 1% Zn) are measured, simulation of individual spectra on the basis of which the pole figures were obtained is performed, and their errors are determined. The conclusion about the possibility of determining the effect of errors of the diffraction peak half-width on the pole figure errors that was drawn in our previous studies is confirmed.

Evaluation of Faculty and Non-faculty Physicians’ Medication Errors in Outpatients’ Prescriptions in Shiraz, Iran

PubMed Central

Misagh, Pegah; Vazin, Afsaneh; Namazi, Soha

2018-01-01

This study was aimed at finding the occurrence rate of prescription errors in the outpatients› prescriptions written by faculty and non-faculty physicians practicing in Shiraz, Iran. In this cross-sectional study 2000 outpatient prescriptions were randomly collected from pharmacies affiliated with Shiraz University of Medical Sciences (SUMS) and social security insurance in Shiraz, Iran. Patient information including age, weight, diagnosis and chief complain were recorded. Physicians ‘characteristics were extracted from prescriptions. Prescription errors including errors in spelling, instruction, strength, dosage form and quantity as well as drug-drug interactions and contraindications were identified. The mean ± SD age of patients was 37.91 ± 21.10 years. Most of the patients were male (77.15%) and 81.50% of patients were adults. The average total number of drugs per prescription was 3.19 ± 1.60. The mean ± SD of prescription errors was 7.38 ± 4.06. Spelling error (26.4%), instruction error (21.03%), and strength error (19.18%) were the most frequent prescription errors. The mean ± SD of prescription errors was 7.83 ± 4.2 and 6.93 ± 3.88 in non-faculty and faculty physicians, respectively (P < 0.05). Number of prescription errors increased significantly as the number of prescribed drugs increased. All prescriptions had at least one error. The rate of prescription errors was higher in non-faculty physicians. Number of prescription errors related with the prescribed drugs in the prescription.

Refractive errors in Mercyland Specialist Hospital, Osogbo, Western Nigeria.

PubMed

Adeoti, C O; Egbewale, B E

2008-06-01

The study was conducted to determine the magnitude and pattern of refractive errors in order to provide facilities for its management. A prospective study of 3601 eyes of 1824 consective patients was conducted. Information obtained included age, sex, occupation, visual acuity, type and degree of refractive error. The data was analysed using Statistical Package for Social Sciences 11.0 version) Computer Software. Refractive error was found in 1824(53.71%) patients. There were 832(45.61%) males and 992(54.39%) females with a mean age of 35.55. Myopia was the commonest (1412(39.21% eyes). Others include hypermetropia (840(23.33% eyes), astigmatism (785(21.80%) and 820 patients (1640 eyes) had presbyopia. Anisometropia was present in 791(44.51%) of 1777 patients that had bilateral refractive errors. Two thousand two hundred and fifty two eyes has spherical errors. Out of 2252 eyes with spherical errors, 1308 eyes (58.08%) had errors -0.50 to +0.50 dioptres, 567 eyes (25.18%) had errors less than -0.50 dioptres of whom 63 eyes (2.80%) had errors less than -5.00 dioptres while 377 eyes (16.74%) had errors greater than +0.50 dioptres of whom 81 eyes (3.60%) had errors greater than +2.00 dioptres. The highest error was 20.00 dioptres for myopia and 18.00 dioptres for hypermetropia. Refractive error is common in this environment. Adequate provision should be made for its correction bearing in mind the common types and degrees.

Effects of learning climate and registered nurse staffing on medication errors.

PubMed

Chang, Yunkyung; Mark, Barbara

2011-01-01

Despite increasing recognition of the significance of learning from errors, little is known about how learning climate contributes to error reduction. The purpose of this study was to investigate whether learning climate moderates the relationship between error-producing conditions and medication errors. A cross-sectional descriptive study was done using data from 279 nursing units in 146 randomly selected hospitals in the United States. Error-producing conditions included work environment factors (work dynamics and nurse mix), team factors (communication with physicians and nurses' expertise), personal factors (nurses' education and experience), patient factors (age, health status, and previous hospitalization), and medication-related support services. Poisson models with random effects were used with the nursing unit as the unit of analysis. A significant negative relationship was found between learning climate and medication errors. It also moderated the relationship between nurse mix and medication errors: When learning climate was negative, having more registered nurses was associated with fewer medication errors. However, no relationship was found between nurse mix and medication errors at either positive or average levels of learning climate. Learning climate did not moderate the relationship between work dynamics and medication errors. The way nurse mix affects medication errors depends on the level of learning climate. Nursing units with fewer registered nurses and frequent medication errors should examine their learning climate. Future research should be focused on the role of learning climate as related to the relationships between nurse mix and medication errors.

A modified technique to reduce tibial keel cutting errors during an Oxford unicompartmental knee arthroplasty.

PubMed

Inui, Hiroshi; Taketomi, Shuji; Tahara, Keitarou; Yamagami, Ryota; Sanada, Takaki; Tanaka, Sakae

2017-03-01

Bone cutting errors can cause malalignment of unicompartmental knee arthroplasties (UKA). Although the extent of tibial malalignment due to horizontal cutting errors has been well reported, there is a lack of studies evaluating malalignment as a consequence of keel cutting errors, particularly in the Oxford UKA. The purpose of this study was to examine keel cutting errors during Oxford UKA placement using a navigation system and to clarify whether two different tibial keel cutting techniques would have different error rates. The alignment of the tibial cut surface after a horizontal osteotomy and the surface of the tibial trial component was measured with a navigation system. Cutting error was defined as the angular difference between these measurements. The following two techniques were used: the standard "pushing" technique in 83 patients (group P) and a modified "dolphin" technique in 41 patients (group D). In all 123 patients studied, the mean absolute keel cutting error was 1.7° and 1.4° in the coronal and sagittal planes, respectively. In group P, there were 22 outlier patients (27 %) in the coronal plane and 13 (16 %) in the sagittal plane. Group D had three outlier patients (8 %) in the coronal plane and none (0 %) in the sagittal plane. Significant differences were observed in the outlier ratio of these techniques in both the sagittal (P = 0.014) and coronal (P = 0.008) planes. Our study demonstrated overall keel cutting errors of 1.7° in the coronal plane and 1.4° in the sagittal plane. The "dolphin" technique was found to significantly reduce keel cutting errors on the tibial side. This technique will be useful for accurate component positioning and therefore improve the longevity of Oxford UKAs. Retrospective comparative study, Level III.

Alterations in Error-Related Brain Activity and Post-Error Behavior over Time

ERIC Educational Resources Information Center

Themanson, Jason R.; Rosen, Peter J.; Pontifex, Matthew B.; Hillman, Charles H.; McAuley, Edward

2012-01-01

This study examines the relation between the error-related negativity (ERN) and post-error behavior over time in healthy young adults (N = 61). Event-related brain potentials were collected during two sessions of an identical flanker task. Results indicated changes in ERN and post-error accuracy were related across task sessions, with more…

Testing the Recognition and Perception of Errors in Context

ERIC Educational Resources Information Center

Brandenburg, Laura C.

2015-01-01

This study tests the recognition of errors in context and whether the presence of errors affects the reader's perception of the writer's ethos. In an experimental, posttest only design, participants were randomly assigned a memo to read in an online survey: one version with errors and one version without. Of the six intentional errors in version…

Phonology, Decoding, and Lexical Compensation in Vowel Spelling Errors Made by Children with Dyslexia

ERIC Educational Resources Information Center

Bernstein, Stuart E.

2009-01-01

A descriptive study of vowel spelling errors made by children first diagnosed with dyslexia (n = 79) revealed that phonological errors, such as "bet" for "bat", outnumbered orthographic errors, such as "bate" for "bait". These errors were more frequent in nonwords than words, suggesting that lexical context helps with vowel spelling. In a second…

A simulation study to quantify the impacts of exposure ...

EPA Pesticide Factsheets

BackgroundExposure measurement error in copollutant epidemiologic models has the potential to introduce bias in relative risk (RR) estimates. A simulation study was conducted using empirical data to quantify the impact of correlated measurement errors in time-series analyses of air pollution and health.MethodsZIP-code level estimates of exposure for six pollutants (CO, NOx, EC, PM2.5, SO4, O3) from 1999 to 2002 in the Atlanta metropolitan area were used to calculate spatial, population (i.e. ambient versus personal), and total exposure measurement error.Empirically determined covariance of pollutant concentration pairs and the associated measurement errors were used to simulate true exposure (exposure without error) from observed exposure. Daily emergency department visits for respiratory diseases were simulated using a Poisson time-series model with a main pollutant RR = 1.05 per interquartile range, and a null association for the copollutant (RR = 1). Monte Carlo experiments were used to evaluate the impacts of correlated exposure errors of different copollutant pairs.ResultsSubstantial attenuation of RRs due to exposure error was evident in nearly all copollutant pairs studied, ranging from 10 to 40% attenuation for spatial error, 3–85% for population error, and 31–85% for total error. When CO, NOx or EC is the main pollutant, we demonstrated the possibility of false positives, specifically identifying significant, positive associations for copoll

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

PubMed

Yamamoto, Loren; Kanemori, Joan

2010-06-01

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

Knowledge of healthcare professionals about medication errors in hospitals

PubMed Central

Abdel-Latif, Mohamed M. M.

2016-01-01

Context: Medication errors are the most common types of medical errors in hospitals and leading cause of morbidity and mortality among patients. Aims: The aim of the present study was to assess the knowledge of healthcare professionals about medication errors in hospitals. Settings and Design: A self-administered questionnaire was distributed to randomly selected healthcare professionals in eight hospitals in Madinah, Saudi Arabia. Subjects and Methods: An 18-item survey was designed and comprised questions on demographic data, knowledge of medication errors, availability of reporting systems in hospitals, attitudes toward error reporting, causes of medication errors. Statistical Analysis Used: Data were analyzed with Statistical Package for the Social Sciences software Version 17. Results: A total of 323 of healthcare professionals completed the questionnaire with 64.6% response rate of 138 (42.72%) physicians, 34 (10.53%) pharmacists, and 151 (46.75%) nurses. A majority of the participants had a good knowledge about medication errors concept and their dangers on patients. Only 68.7% of them were aware of reporting systems in hospitals. Healthcare professionals revealed that there was no clear mechanism available for reporting of errors in most hospitals. Prescribing (46.5%) and administration (29%) errors were the main causes of errors. The most frequently encountered medication errors were anti-hypertensives, antidiabetics, antibiotics, digoxin, and insulin. Conclusions: This study revealed differences in the awareness among healthcare professionals toward medication errors in hospitals. The poor knowledge about medication errors emphasized the urgent necessity to adopt appropriate measures to raise awareness about medication errors in Saudi hospitals. PMID:27330261

Online Error Reporting for Managing Quality Control Within Radiology.

PubMed

Golnari, Pedram; Forsberg, Daniel; Rosipko, Beverly; Sunshine, Jeffrey L

2016-06-01

Information technology systems within health care, such as picture archiving and communication system (PACS) in radiology, can have a positive impact on production but can also risk compromising quality. The widespread use of PACS has removed the previous feedback loop between radiologists and technologists. Instead of direct communication of quality discrepancies found for an examination, the radiologist submitted a paper-based quality-control report. A web-based issue-reporting tool can help restore some of the feedback loop and also provide possibilities for more detailed analysis of submitted errors. The purpose of this study was to evaluate the hypothesis that data from use of an online error reporting software for quality control can focus our efforts within our department. For the 372,258 radiologic examinations conducted during the 6-month period study, 930 errors (390 exam protocol, 390 exam validation, and 150 exam technique) were submitted, corresponding to an error rate of 0.25 %. Within the category exam protocol, technologist documentation had the highest number of submitted errors in ultrasonography (77 errors [44 %]), while imaging protocol errors were the highest subtype error for computed tomography modality (35 errors [18 %]). Positioning and incorrect accession had the highest errors in the exam technique and exam validation error category, respectively, for nearly all of the modalities. An error rate less than 1 % could signify a system with a very high quality; however, a more likely explanation is that not all errors were detected or reported. Furthermore, staff reception of the error reporting system could also affect the reporting rate.

Nature of the refractive errors in rhesus monkeys (Macaca mulatta) with experimentally induced ametropias.

PubMed

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

2010-08-23

We analyzed the contribution of individual ocular components to vision-induced ametropias in 210 rhesus monkeys. The primary contribution to refractive-error development came from vitreous chamber depth; a minor contribution from corneal power was also detected. However, there was no systematic relationship between refractive error and anterior chamber depth or between refractive error and any crystalline lens parameter. Our results are in good agreement with previous studies in humans, suggesting that the refractive errors commonly observed in humans are created by vision-dependent mechanisms that are similar to those operating in monkeys. This concordance emphasizes the applicability of rhesus monkeys in refractive-error studies. Copyright 2010 Elsevier Ltd. All rights reserved.

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

PubMed Central

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

2010-01-01

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

Data Mining on Numeric Error in Computerized Physician Order Entry System Prescriptions.

PubMed

Wu, Xue; Wu, Changxu

2017-01-01

This study revealed the numeric error patterns related to dosage when doctors prescribed in computerized physician order entry system. Error categories showed that the '6','7', and '9' key produced a higher incidence of errors in Numpad typing, while the '2','3', and '0' key produced a higher incidence of errors in main keyboard digit line typing. Errors categorized as omission and substitution were higher in prevalence than transposition and intrusion.

Prevalence and risk factors of undercorrected refractive errors among Singaporean Malay adults: the Singapore Malay Eye Study.

PubMed

Rosman, Mohamad; Wong, Tien Y; Tay, Wan-Ting; Tong, Louis; Saw, Seang-Mei

2009-08-01

To describe the prevalence and the risk factors of undercorrected refractive error in an adult urban Malay population. This population-based, cross-sectional study was conducted in Singapore in 3280 Malay adults, aged 40 to 80 years. All individuals were examined at a centralized clinic and underwent standardized interviews and assessment of refractive errors and presenting and best corrected visual acuities. Distance presenting visual acuity was monocularly measured by using a logarithm of the minimum angle of resolution (logMAR) number chart at a distance of 4 m, with the participants wearing their "walk-in" optical corrections (spectacles or contact lenses), if any. Refraction was determined by subjective refraction by trained, certified study optometrists. Best corrected visual acuity was monocularly assessed and recorded in logMAR scores using the same test protocol as was used for presenting visual acuity. Undercorrected refractive error was defined as an improvement of at least 0.2 logMAR (2 lines equivalent) in the best corrected visual acuity compared with the presenting visual acuity in the better eye. The mean age of the subjects included in our study was 58 +/- 11 years, and 52% of the subjects were women. The prevalence rate of undercorrected refractive error among Singaporean Malay adults in our study (n = 3115) was 20.4% (age-standardized prevalence rate, 18.3%). More of the women had undercorrected refractive error than the men (21.8% vs. 18.8%, P = 0.04). Undercorrected refractive error was also more common in subjects older than 50 years than in subjects aged 40 to 49 years (22.6% vs. 14.3%, P < 0.001). Non-spectacle wearers were more likely to have undercorrected refractive errors than were spectacle wearers (24.4% vs. 14.4%, P < 0.001). Persons with primary school education or less were 1.89 times (P = 0.03) more likely to have undercorrected refractive errors than those with post-secondary school education or higher. In contrast, persons with a history of eye disease were 0.74 times (P = 0.003) less likely to have undercorrected refractive errors. The proportion of undercorrected refractive error among the Singaporean Malay adults with refractive errors was higher than that of the Singaporean Chinese adults with refractive errors. Undercorrected refractive error is a significant cause of correctable visual impairment among Singaporean Malay adults, affecting one in five persons.

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.

Errors in Focus? Native and Non-Native Perceptions of Error Salience in Hong Kong Student English - A Case Study.

ERIC Educational Resources Information Center

Newbrook, Mark

1990-01-01

A study compared the perceptions of two experts from different cultural backgrounds concerning salience of a variety of errors typical of the English written by Hong Kong secondary and college students. A book on English error types written by a Hong-Kong born, fluent Chinese-English bilingual linguist was analyzed for its emphases, and a list of…

Refractive errors in children and adolescents in Bucaramanga (Colombia).

PubMed

Galvis, Virgilio; Tello, Alejandro; Otero, Johanna; Serrano, Andrés A; Gómez, Luz María; Castellanos, Yuly

2017-01-01

The aim of this study was to establish the frequency of refractive errors in children and adolescents aged between 8 and 17 years old, living in the metropolitan area of Bucaramanga (Colombia). This study was a secondary analysis of two descriptive cross-sectional studies that applied sociodemographic surveys and assessed visual acuity and refraction. Ametropias were classified as myopic errors, hyperopic errors, and mixed astigmatism. Eyes were considered emmetropic if none of these classifications were made. The data were collated using free software and analyzed with STATA/IC 11.2. One thousand two hundred twenty-eight individuals were included in this study. Girls showed a higher rate of ametropia than boys. Hyperopic refractive errors were present in 23.1% of the subjects, and myopic errors in 11.2%. Only 0.2% of the eyes had high myopia (≤-6.00 D). Mixed astigmatism and anisometropia were uncommon, and myopia frequency increased with age. There were statistically significant steeper keratometric readings in myopic compared to hyperopic eyes. The frequency of refractive errors that we found of 36.7% is moderate compared to the global data. The rates and parameters statistically differed by sex and age groups. Our findings are useful for establishing refractive error rate benchmarks in low-middle-income countries and as a baseline for following their variation by sociodemographic factors.

ERM model analysis for adaptation to hydrological model errors

NASA Astrophysics Data System (ADS)

Baymani-Nezhad, M.; Han, D.

2018-05-01

Hydrological conditions are changed continuously and these phenomenons generate errors on flood forecasting models and will lead to get unrealistic results. Therefore, to overcome these difficulties, a concept called model updating is proposed in hydrological studies. Real-time model updating is one of the challenging processes in hydrological sciences and has not been entirely solved due to lack of knowledge about the future state of the catchment under study. Basically, in terms of flood forecasting process, errors propagated from the rainfall-runoff model are enumerated as the main source of uncertainty in the forecasting model. Hence, to dominate the exciting errors, several methods have been proposed by researchers to update the rainfall-runoff models such as parameter updating, model state updating, and correction on input data. The current study focuses on investigations about the ability of rainfall-runoff model parameters to cope with three types of existing errors, timing, shape and volume as the common errors in hydrological modelling. The new lumped model, the ERM model, has been selected for this study to evaluate its parameters for its use in model updating to cope with the stated errors. Investigation about ten events proves that the ERM model parameters can be updated to cope with the errors without the need to recalibrate the model.

The statistical significance of error probability as determined from decoding simulations for long codes

NASA Technical Reports Server (NTRS)

Massey, J. L.

1976-01-01

The very low error probability obtained with long error-correcting codes results in a very small number of observed errors in simulation studies of practical size and renders the usual confidence interval techniques inapplicable to the observed error probability. A natural extension of the notion of a 'confidence interval' is made and applied to such determinations of error probability by simulation. An example is included to show the surprisingly great significance of as few as two decoding errors in a very large number of decoding trials.

An Evaluation of Programmed Treatment-integrity Errors during Discrete-trial Instruction

ERIC Educational Resources Information Center

Carroll, Regina A.; Kodak, Tiffany; Fisher, Wayne W.

2013-01-01

This study evaluated the effects of programmed treatment-integrity errors on skill acquisition for children with an autism spectrum disorder (ASD) during discrete-trial instruction (DTI). In Study 1, we identified common treatment-integrity errors that occur during academic instruction in schools. In Study 2, we simultaneously manipulated 3…

Implications of Error Analysis Studies for Academic Interventions

ERIC Educational Resources Information Center

Mather, Nancy; Wendling, Barbara J.

2017-01-01

We reviewed 13 studies that focused on analyzing student errors on achievement tests from the Kaufman Test of Educational Achievement-Third edition (KTEA-3). The intent was to determine what instructional implications could be derived from in-depth error analysis. As we reviewed these studies, several themes emerged. We explain how a careful…

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

PubMed

Hicks, Rodney W; Becker, Shawn C

2006-01-01

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

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

PubMed

Taifoori, Ladan; Valiee, Sina

2015-09-01

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

Resection plane-dependent error in computed tomography volumetry of the right hepatic lobe in living liver donors.

PubMed

Kwon, Heon-Ju; Kim, Kyoung Won; Kim, Bohyun; Kim, So Yeon; Lee, Chul Seung; Lee, Jeongjin; Song, Gi Won; Lee, Sung Gyu

2018-03-01

Computed tomography (CT) hepatic volumetry is currently accepted as the most reliable method for preoperative estimation of graft weight in living donor liver transplantation (LDLT). However, several factors can cause inaccuracies in CT volumetry compared to real graft weight. The purpose of this study was to determine the frequency and degree of resection plane-dependent error in CT volumetry of the right hepatic lobe in LDLT. Forty-six living liver donors underwent CT before donor surgery and on postoperative day 7. Prospective CT volumetry (V P ) was measured via the assumptive hepatectomy plane. Retrospective liver volume (V R ) was measured using the actual plane by comparing preoperative and postoperative CT. Compared with intraoperatively measured weight (W), errors in percentage (%) V P and V R were evaluated. Plane-dependent error in V P was defined as the absolute difference between V P and V R . % plane-dependent error was defined as follows: |V P -V R |/W∙100. Mean V P , V R , and W were 761.9 mL, 755.0 mL, and 696.9 g. Mean and % errors in V P were 73.3 mL and 10.7%. Mean error and % error in V R were 64.4 mL and 9.3%. Mean plane-dependent error in V P was 32.4 mL. Mean % plane-dependent error was 4.7%. Plane-dependent error in V P exceeded 10% of W in approximately 10% of the subjects in our study. There was approximately 5% plane-dependent error in liver V P on CT volumetry. Plane-dependent error in V P exceeded 10% of W in approximately 10% of LDLT donors in our study. This error should be considered, especially when CT volumetry is performed by a less experienced operator who is not well acquainted with the donor hepatectomy plane.

Mean Bias in Seasonal Forecast Model and ENSO Prediction Error.

PubMed

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

2017-07-20

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

Medication administration errors in nursing homes using an automated medication dispensing system.

PubMed

van den Bemt, Patricia M L A; Idzinga, Jetske C; Robertz, Hans; Kormelink, Dennis Groot; Pels, Neske

2009-01-01

OBJECTIVE To identify the frequency of medication administration errors as well as their potential risk factors in nursing homes using a distribution robot. DESIGN The study was a prospective, observational study conducted within three nursing homes in the Netherlands caring for 180 individuals. MEASUREMENTS Medication errors were measured using the disguised observation technique. Types of medication errors were described. The correlation between several potential risk factors and the occurrence of medication errors was studied to identify potential causes for the errors. RESULTS In total 2,025 medication administrations to 127 clients were observed. In these administrations 428 errors were observed (21.2%). The most frequently occurring types of errors were use of wrong administration techniques (especially incorrect crushing of medication and not supervising the intake of medication) and wrong time errors (administering the medication at least 1 h early or late).The potential risk factors female gender (odds ratio (OR) 1.39; 95% confidence interval (CI) 1.05-1.83), ATC medication class antibiotics (OR 11.11; 95% CI 2.66-46.50), medication crushed (OR 7.83; 95% CI 5.40-11.36), number of dosages/day/client (OR 1.03; 95% CI 1.01-1.05), nursing home 2 (OR 3.97; 95% CI 2.86-5.50), medication not supplied by distribution robot (OR 2.92; 95% CI 2.04-4.18), time classes "7-10 am" (OR 2.28; 95% CI 1.50-3.47) and "10 am-2 pm" (OR 1.96; 1.18-3.27) and day of the week "Wednesday" (OR 1.46; 95% CI 1.03-2.07) are associated with a higher risk of administration errors. CONCLUSIONS Medication administration in nursing homes is prone to many errors. This study indicates that the handling of the medication after removing it from the robot packaging may contribute to this high error frequency, which may be reduced by training of nurse attendants, by automated clinical decision support and by measures to reduce workload.

Systematic evidence review of rates and burden of harm of intravenous admixture drug preparation errors in healthcare settings

PubMed Central

Beer, Idal; Hoppe-Tichy, Torsten; Trbovich, Patricia

2017-01-01

Objective To examine published evidence on intravenous admixture preparation errors (IAPEs) in healthcare settings. Methods Searches were conducted in three electronic databases (January 2005 to April 2017). Publications reporting rates of IAPEs and error types were reviewed and categorised into the following groups: component errors, dose/calculation errors, aseptic technique errors and composite errors. The methodological rigour of each study was assessed using the Hawker method. Results Of the 34 articles that met inclusion criteria, 28 reported the site of IAPEs: central pharmacies (n=8), nursing wards (n=14), both settings (n=4) and other sites (n=3). Using the Hawker criteria, 14% of the articles were of good quality, 74% were of fair quality and 12% were of poor quality. Error types and reported rates varied substantially, including wrong drug (~0% to 4.7%), wrong diluent solution (0% to 49.0%), wrong label (0% to 99.0%), wrong dose (0% to 32.6%), wrong concentration (0.3% to 88.6%), wrong diluent volume (0.06% to 49.0%) and inadequate aseptic technique (0% to 92.7%)%). Four studies directly compared incidence by preparation site and/or method, finding error incidence to be lower for doses prepared within a central pharmacy versus the nursing ward and lower for automated preparation versus manual preparation. Although eight studies (24%) reported ≥1 errors with the potential to cause patient harm, no study directly linked IAPE occurrences to specific adverse patient outcomes. Conclusions The available data suggest a need to continue to optimise the intravenous preparation process, focus on improving preparation workflow, design and implement preventive strategies, train staff on optimal admixture protocols and implement standardisation. Future research should focus on the development of consistent error subtype definitions, standardised reporting methodology and reliable, reproducible methods to track and link risk factors with the burden of harm associated with these errors. PMID:29288174

Adaptive error detection for HDR/PDR brachytherapy: Guidance for decision making during real-time in vivo point dosimetry

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

Kertzscher, Gustavo, E-mail: guke@dtu.dk; Andersen, Claus E., E-mail: clan@dtu.dk; Tanderup, Kari, E-mail: karitand@rm.dk

Purpose: This study presents an adaptive error detection algorithm (AEDA) for real-timein vivo point dosimetry during high dose rate (HDR) or pulsed dose rate (PDR) brachytherapy (BT) where the error identification, in contrast to existing approaches, does not depend on an a priori reconstruction of the dosimeter position. Instead, the treatment is judged based on dose rate comparisons between measurements and calculations of the most viable dosimeter position provided by the AEDA in a data driven approach. As a result, the AEDA compensates for false error cases related to systematic effects of the dosimeter position reconstruction. Given its nearly exclusivemore » dependence on stable dosimeter positioning, the AEDA allows for a substantially simplified and time efficient real-time in vivo BT dosimetry implementation. Methods: In the event of a measured potential treatment error, the AEDA proposes the most viable dosimeter position out of alternatives to the original reconstruction by means of a data driven matching procedure between dose rate distributions. If measured dose rates do not differ significantly from the most viable alternative, the initial error indication may be attributed to a mispositioned or misreconstructed dosimeter (false error). However, if the error declaration persists, no viable dosimeter position can be found to explain the error, hence the discrepancy is more likely to originate from a misplaced or misreconstructed source applicator or from erroneously connected source guide tubes (true error). Results: The AEDA applied on twoin vivo dosimetry implementations for pulsed dose rate BT demonstrated that the AEDA correctly described effects responsible for initial error indications. The AEDA was able to correctly identify the major part of all permutations of simulated guide tube swap errors and simulated shifts of individual needles from the original reconstruction. Unidentified errors corresponded to scenarios where the dosimeter position was sufficiently symmetric with respect to error and no-error source position constellations. The AEDA was able to correctly identify all false errors represented by mispositioned dosimeters contrary to an error detection algorithm relying on the original reconstruction. Conclusions: The study demonstrates that the AEDA error identification during HDR/PDR BT relies on a stable dosimeter position rather than on an accurate dosimeter reconstruction, and the AEDA’s capacity to distinguish between true and false error scenarios. The study further shows that the AEDA can offer guidance in decision making in the event of potential errors detected with real-timein vivo point dosimetry.« less

The Effect of Error Correction vs. Error Detection on Iranian Pre-Intermediate EFL Learners' Writing Achievement

ERIC Educational Resources Information Center

Abedi, Razie; Latifi, Mehdi; Moinzadeh, Ahmad

2010-01-01

This study tries to answer some ever-existent questions in writing fields regarding approaching the most effective ways to give feedback to students' errors in writing by comparing the effect of error correction and error detection on the improvement of students' writing ability. In order to achieve this goal, 60 pre-intermediate English learners…

Effects of Error Correction during Assessment Probes on the Acquisition of Sight Words for Students with Moderate Intellectual Disabilities

ERIC Educational Resources Information Center

Waugh, Rebecca E.

2010-01-01

Simultaneous prompting is an errorless learning strategy designed to reduce the number of errors students make; however, research has shown a disparity in the number of errors students make during instructional versus probe trials. This study directly examined the effects of error correction versus no error correction during probe trials on the…

Effects of Error Correction during Assessment Probes on the Acquisition of Sight Words for Students with Moderate Intellectual Disabilities

ERIC Educational Resources Information Center

Waugh, Rebecca E.; Alberto, Paul A.; Fredrick, Laura D.

2011-01-01

Simultaneous prompting is an errorless learning strategy designed to reduce the number of errors students make; however, research has shown a disparity in the number of errors students make during instructional versus probe trials. This study directly examined the effects of error correction versus no error correction during probe trials on the…

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

ERIC Educational Resources Information Center

Tulis, Maria; Steuer, Gabriele; Dresel, Markus

2018-01-01

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

Your Health Care May Kill You: Medical Errors.

PubMed

Anderson, James G; Abrahamson, Kathleen

2017-01-01

Recent studies of medical errors have estimated errors may account for as many as 251,000 deaths annually in the United States (U.S)., making medical errors the third leading cause of death. Error rates are significantly higher in the U.S. than in other developed countries such as Canada, Australia, New Zealand, Germany and the United Kingdom (U.K). At the same time less than 10 percent of medical errors are reported. This study describes the results of an investigation of the effectiveness of the implementation of the MEDMARX Medication Error Reporting system in 25 hospitals in Pennsylvania. Data were collected on 17,000 errors reported by participating hospitals over a 12-month period. Latent growth curve analysis revealed that reporting of errors by health care providers increased significantly over the four quarters. At the same time, the proportion of corrective actions taken by the hospitals remained relatively constant over the 12 months. A simulation model was constructed to examine the effect of potential organizational changes resulting from error reporting. Four interventions were simulated. The results suggest that improving patient safety requires more than voluntary reporting. Organizational changes need to be implemented and institutionalized as well.

Error Analysis of Indonesian Junior High School Student in Solving Space and Shape Content PISA Problem Using Newman Procedure

NASA Astrophysics Data System (ADS)

Sumule, U.; Amin, S. M.; Fuad, Y.

2018-01-01

This study aims to determine the types and causes of errors, as well as efforts being attempted to overcome the mistakes made by junior high school students in completing PISA content space and shape. Two subjects were selected based on the mathematical ability test results with the most error, yet they are able to communicate orally and in writing. Two selected subjects then worked on the PISA ability test question and the subjects were interviewed to find out the type and cause of the error and then given a scaffolding based on the type of mistake made.The results of this study obtained the type of error that students do are comprehension and transformation error. The reasons are students was not able to identify the keywords in the question, write down what is known or given, specify formulas or device a plan. To overcome this error, students were given scaffolding. Scaffolding that given to overcome misunderstandings were reviewing and restructuring. While to overcome the transformation error, scaffolding given were reviewing, restructuring, explaining and developing representational tools. Teachers are advised to use scaffolding to resolve errors so that the students are able to avoid these errors.

Improving patient safety through quality assurance.

PubMed

Raab, Stephen S

2006-05-01

Anatomic pathology laboratories use several quality assurance tools to detect errors and to improve patient safety. To review some of the anatomic pathology laboratory patient safety quality assurance practices. Different standards and measures in anatomic pathology quality assurance and patient safety were reviewed. Frequency of anatomic pathology laboratory error, variability in the use of specific quality assurance practices, and use of data for error reduction initiatives. Anatomic pathology error frequencies vary according to the detection method used. Based on secondary review, a College of American Pathologists Q-Probes study showed that the mean laboratory error frequency was 6.7%. A College of American Pathologists Q-Tracks study measuring frozen section discrepancy found that laboratories improved the longer they monitored and shared data. There is a lack of standardization across laboratories even for governmentally mandated quality assurance practices, such as cytologic-histologic correlation. The National Institutes of Health funded a consortium of laboratories to benchmark laboratory error frequencies, perform root cause analysis, and design error reduction initiatives, using quality assurance data. Based on the cytologic-histologic correlation process, these laboratories found an aggregate nongynecologic error frequency of 10.8%. Based on gynecologic error data, the laboratory at my institution used Toyota production system processes to lower gynecologic error frequencies and to improve Papanicolaou test metrics. Laboratory quality assurance practices have been used to track error rates, and laboratories are starting to use these data for error reduction initiatives.

Impact of Stewardship Interventions on Antiretroviral Medication Errors in an Urban Medical Center: A 3-Year, Multiphase Study.

PubMed

Zucker, Jason; Mittal, Jaimie; Jen, Shin-Pung; Cheng, Lucy; Cennimo, David

2016-03-01

There is a high prevalence of HIV infection in Newark, New Jersey, with University Hospital admitting approximately 600 HIV-infected patients per year. Medication errors involving antiretroviral therapy (ART) could significantly affect treatment outcomes. The goal of this study was to evaluate the effectiveness of various stewardship interventions in reducing the prevalence of prescribing errors involving ART. This was a retrospective review of all inpatients receiving ART for HIV treatment during three distinct 6-month intervals over a 3-year period. During the first year, the baseline prevalence of medication errors was determined. During the second year, physician and pharmacist education was provided, and a computerized order entry system with drug information resources and prescribing recommendations was implemented. Prospective audit of ART orders with feedback was conducted in the third year. Analyses and comparisons were made across the three phases of this study. Of the 334 patients with HIV admitted in the first year, 45% had at least one antiretroviral medication error and 38% had uncorrected errors at the time of discharge. After education and computerized order entry, significant reductions in medication error rates were observed compared to baseline rates; 36% of 315 admissions had at least one error and 31% had uncorrected errors at discharge. While the prevalence of antiretroviral errors in year 3 was similar to that of year 2 (37% of 276 admissions), there was a significant decrease in the prevalence of uncorrected errors at discharge (12%) with the use of prospective review and intervention. Interventions, such as education and guideline development, can aid in reducing ART medication errors, but a committed stewardship program is necessary to elicit the greatest impact. © 2016 Pharmacotherapy Publications, Inc.

Space-Borne Laser Altimeter Geolocation Error Analysis

NASA Astrophysics Data System (ADS)

Wang, Y.; Fang, J.; Ai, Y.

2018-05-01

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

Prevention of prescription errors by computerized, on-line, individual patient related surveillance of drug order entry.

PubMed

Oliven, A; Zalman, D; Shilankov, Y; Yeshurun, D; Odeh, M

2002-01-01

Computerized prescription of drugs is expected to reduce the number of many preventable drug ordering errors. In the present study we evaluated the usefullness of a computerized drug order entry (CDOE) system in reducing prescription errors. A department of internal medicine using a comprehensive CDOE, which included also patient-related drug-laboratory, drug-disease and drug-allergy on-line surveillance was compared to a similar department in which drug orders were handwritten. CDOE reduced prescription errors to 25-35%. The causes of errors remained similar, and most errors, on both departments, were associated with abnormal renal function and electrolyte balance. Residual errors remaining on the CDOE-using department were due to handwriting on the typed order, failure to feed patients' diseases, and system failures. The use of CDOE was associated with a significant reduction in mean hospital stay and in the number of changes performed in the prescription. The findings of this study both quantity the impact of comprehensive CDOE on prescription errors and delineate the causes for remaining errors.

Evaluating the prevalence and impact of examiner errors on the Wechsler scales of intelligence: A meta-analysis.

PubMed

Styck, Kara M; Walsh, Shana M

2016-01-01

The purpose of the present investigation was to conduct a meta-analysis of the literature on examiner errors for the Wechsler scales of intelligence. Results indicate that a mean of 99.7% of protocols contained at least 1 examiner error when studies that included a failure to record examinee responses as an error were combined and a mean of 41.2% of protocols contained at least 1 examiner error when studies that ignored errors of omission were combined. Furthermore, graduate student examiners were significantly more likely to make at least 1 error on Wechsler intelligence test protocols than psychologists. However, psychologists made significantly more errors per protocol than graduate student examiners regardless of the inclusion or exclusion of failure to record examinee responses as errors. On average, 73.1% of Full-Scale IQ (FSIQ) scores changed as a result of examiner errors, whereas 15.8%-77.3% of scores on the Verbal Comprehension Index (VCI), Perceptual Reasoning Index (PRI), Working Memory Index (WMI), and Processing Speed Index changed as a result of examiner errors. In addition, results suggest that examiners tend to overestimate FSIQ scores and underestimate VCI scores. However, no strong pattern emerged for the PRI and WMI. It can be concluded that examiner errors occur frequently and impact index and FSIQ scores. Consequently, current estimates for the standard error of measurement of popular IQ tests may not adequately capture the variance due to the examiner. (c) 2016 APA, all rights reserved).

Mixtures of Berkson and classical covariate measurement error in the linear mixed model: Bias analysis and application to a study on ultrafine particles.

PubMed

Deffner, Veronika; Küchenhoff, Helmut; Breitner, Susanne; Schneider, Alexandra; Cyrys, Josef; Peters, Annette

2018-05-01

The ultrafine particle measurements in the Augsburger Umweltstudie, a panel study conducted in Augsburg, Germany, exhibit measurement error from various sources. Measurements of mobile devices show classical possibly individual-specific measurement error; Berkson-type error, which may also vary individually, occurs, if measurements of fixed monitoring stations are used. The combination of fixed site and individual exposure measurements results in a mixture of the two error types. We extended existing bias analysis approaches to linear mixed models with a complex error structure including individual-specific error components, autocorrelated errors, and a mixture of classical and Berkson error. Theoretical considerations and simulation results show, that autocorrelation may severely change the attenuation of the effect estimations. Furthermore, unbalanced designs and the inclusion of confounding variables influence the degree of attenuation. Bias correction with the method of moments using data with mixture measurement error partially yielded better results compared to the usage of incomplete data with classical error. Confidence intervals (CIs) based on the delta method achieved better coverage probabilities than those based on Bootstrap samples. Moreover, we present the application of these new methods to heart rate measurements within the Augsburger Umweltstudie: the corrected effect estimates were slightly higher than their naive equivalents. The substantial measurement error of ultrafine particle measurements has little impact on the results. The developed methodology is generally applicable to longitudinal data with measurement error. © 2018 WILEY-VCH Verlag GmbH & Co. KGaA, Weinheim.

Error floor behavior study of LDPC codes for concatenated codes design

NASA Astrophysics Data System (ADS)

Chen, Weigang; Yin, Liuguo; Lu, Jianhua

2007-11-01

Error floor behavior of low-density parity-check (LDPC) codes using quantized decoding algorithms is statistically studied with experimental results on a hardware evaluation platform. The results present the distribution of the residual errors after decoding failure and reveal that the number of residual error bits in a codeword is usually very small using quantized sum-product (SP) algorithm. Therefore, LDPC code may serve as the inner code in a concatenated coding system with a high code rate outer code and thus an ultra low error floor can be achieved. This conclusion is also verified by the experimental results.

Speech errors of amnesic H.M.: unlike everyday slips-of-the-tongue.

PubMed

MacKay, Donald G; James, Lori E; Hadley, Christopher B; Fogler, Kethera A

2011-03-01

Three language production studies indicate that amnesic H.M. produces speech errors unlike everyday slips-of-the-tongue. Study 1 was a naturalistic task: H.M. and six controls closely matched for age, education, background and IQ described what makes captioned cartoons funny. Nine judges rated the descriptions blind to speaker identity and gave reliably more negative ratings for coherence, vagueness, comprehensibility, grammaticality, and adequacy of humor-description for H.M. than the controls. Study 2 examined "major errors", a novel type of speech error that is uncorrected and reduces the coherence, grammaticality, accuracy and/or comprehensibility of an utterance. The results indicated that H.M. produced seven types of major errors reliably more often than controls: substitutions, omissions, additions, transpositions, reading errors, free associations, and accuracy errors. These results contradict recent claims that H.M. retains unconscious or implicit language abilities and produces spoken discourse that is "sophisticated," "intact" and "without major errors." Study 3 examined whether three classical types of errors (omissions, additions, and substitutions of words and phrases) differed for H.M. versus controls in basic nature and relative frequency by error type. The results indicated that omissions, and especially multi-word omissions, were relatively more common for H.M. than the controls; and substitutions violated the syntactic class regularity (whereby, e.g., nouns substitute with nouns but not verbs) relatively more often for H.M. than the controls. These results suggest that H.M.'s medial temporal lobe damage impaired his ability to rapidly form new connections between units in the cortex, a process necessary to form complete and coherent internal representations for novel sentence-level plans. In short, different brain mechanisms underlie H.M.'s major errors (which reflect incomplete and incoherent sentence-level plans) versus everyday slips-of-the tongue (which reflect errors in activating pre-planned units in fully intact sentence-level plans). Implications of the results of Studies 1-3 are discussed for systems theory, binding theory and relational memory theories. Copyright © 2010 Elsevier Srl. All rights reserved.

Economic measurement of medical errors using a hospital claims database.

PubMed

David, Guy; Gunnarsson, Candace L; Waters, Heidi C; Horblyuk, Ruslan; Kaplan, Harold S

2013-01-01

The primary objective of this study was to estimate the occurrence and costs of medical errors from the hospital perspective. Methods from a recent actuarial study of medical errors were used to identify medical injuries. A visit qualified as an injury visit if at least 1 of 97 injury groupings occurred at that visit, and the percentage of injuries caused by medical error was estimated. Visits with more than four injuries were removed from the population to avoid overestimation of cost. Population estimates were extrapolated from the Premier hospital database to all US acute care hospitals. There were an estimated 161,655 medical errors in 2008 and 170,201 medical errors in 2009. Extrapolated to the entire US population, there were more than 4 million unique injury visits containing more than 1 million unique medical errors each year. This analysis estimated that the total annual cost of measurable medical errors in the United States was $985 million in 2008 and just over $1 billion in 2009. The median cost per error to hospitals was $892 for 2008 and rose to $939 in 2009. Nearly one third of all medical injuries were due to error in each year. Medical errors directly impact patient outcomes and hospitals' profitability, especially since 2008 when Medicare stopped reimbursing hospitals for care related to certain preventable medical errors. Hospitals must rigorously analyze causes of medical errors and implement comprehensive preventative programs to reduce their occurrence as the financial burden of medical errors shifts to hospitals. Copyright © 2013 International Society for Pharmacoeconomics and Outcomes Research (ISPOR). Published by Elsevier Inc. All rights reserved.

What errors do peer reviewers detect, and does training improve their ability to detect them?

PubMed

Schroter, Sara; Black, Nick; Evans, Stephen; Godlee, Fiona; Osorio, Lyda; Smith, Richard

2008-10-01

To analyse data from a trial and report the frequencies with which major and minor errors are detected at a general medical journal, the types of errors missed and the impact of training on error detection. 607 peer reviewers at the BMJ were randomized to two intervention groups receiving different types of training (face-to-face training or a self-taught package) and a control group. Each reviewer was sent the same three test papers over the study period, each of which had nine major and five minor methodological errors inserted. BMJ peer reviewers. The quality of review, assessed using a validated instrument, and the number and type of errors detected before and after training. The number of major errors detected varied over the three papers. The interventions had small effects. At baseline (Paper 1) reviewers found an average of 2.58 of the nine major errors, with no notable difference between the groups. The mean number of errors reported was similar for the second and third papers, 2.71 and 3.0, respectively. Biased randomization was the error detected most frequently in all three papers, with over 60% of reviewers rejecting the papers identifying this error. Reviewers who did not reject the papers found fewer errors and the proportion finding biased randomization was less than 40% for each paper. Editors should not assume that reviewers will detect most major errors, particularly those concerned with the context of study. Short training packages have only a slight impact on improving error detection.

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.

Uncorrected refractive errors.

PubMed

Naidoo, Kovin S; Jaggernath, Jyoti

2012-01-01

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

Measurement-based analysis of error latency. [in computer operating system

NASA Technical Reports Server (NTRS)

Chillarege, Ram; Iyer, Ravishankar K.

1987-01-01

This paper demonstrates a practical methodology for the study of error latency under a real workload. The method is illustrated with sampled data on the physical memory activity, gathered by hardware instrumentation on a VAX 11/780 during the normal workload cycle of the installation. These data are used to simulate fault occurrence and to reconstruct the error discovery process in the system. The technique provides a means to study the system under different workloads and for multiple days. An approach to determine the percentage of undiscovered errors is also developed and a verification of the entire methodology is performed. This study finds that the mean error latency, in the memory containing the operating system, varies by a factor of 10 to 1 (in hours) between the low and high workloads. It is found that of all errors occurring within a day, 70 percent are detected in the same day, 82 percent within the following day, and 91 percent within the third day. The increase in failure rate due to latency is not so much a function of remaining errors but is dependent on whether or not there is a latent error.

A toolkit for measurement error correction, with a focus on nutritional epidemiology

PubMed Central

Keogh, Ruth H; White, Ian R

2014-01-01

Exposure measurement error is a problem in many epidemiological studies, including those using biomarkers and measures of dietary intake. Measurement error typically results in biased estimates of exposure-disease associations, the severity and nature of the bias depending on the form of the error. To correct for the effects of measurement error, information additional to the main study data is required. Ideally, this is a validation sample in which the true exposure is observed. However, in many situations, it is not feasible to observe the true exposure, but there may be available one or more repeated exposure measurements, for example, blood pressure or dietary intake recorded at two time points. The aim of this paper is to provide a toolkit for measurement error correction using repeated measurements. We bring together methods covering classical measurement error and several departures from classical error: systematic, heteroscedastic and differential error. The correction methods considered are regression calibration, which is already widely used in the classical error setting, and moment reconstruction and multiple imputation, which are newer approaches with the ability to handle differential error. We emphasize practical application of the methods in nutritional epidemiology and other fields. We primarily consider continuous exposures in the exposure-outcome model, but we also outline methods for use when continuous exposures are categorized. The methods are illustrated using the data from a study of the association between fibre intake and colorectal cancer, where fibre intake is measured using a diet diary and repeated measures are available for a subset. © 2014 The Authors. PMID:24497385

[Investigating phonological planning processes in speech production through a speech-error induction technique].

PubMed

Nakayama, Masataka; Saito, Satoru

2015-08-01

The present study investigated principles of phonological planning, a common serial ordering mechanism for speech production and phonological short-term memory. Nakayama and Saito (2014) have investigated the principles by using a speech-error induction technique, in which participants were exposed to an auditory distracIor word immediately before an utterance of a target word. They demonstrated within-word adjacent mora exchanges and serial position effects on error rates. These findings support, respectively, the temporal distance and the edge principles at a within-word level. As this previous study induced errors using word distractors created by exchanging adjacent morae in the target words, it is possible that the speech errors are expressions of lexical intrusions reflecting interactive activation of phonological and lexical/semantic representations. To eliminate this possibility, the present study used nonword distractors that had no lexical or semantic representations. This approach successfully replicated the error patterns identified in the abovementioned study, further confirming that the temporal distance and edge principles are organizing precepts in phonological planning.

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.

The GEnes in Myopia (GEM) study in understanding the aetiology of refractive errors.

PubMed

Baird, Paul N; Schäche, Maria; Dirani, Mohamed

2010-11-01

Refractive errors represent the leading cause of correctable vision impairment and blindness in the world with an estimated 2 billion people affected. Refractive error refers to a group of refractive conditions including hypermetropia, myopia, astigmatism and presbyopia but relatively little is known about their aetiology. In order to explore the potential role of genetic determinants in refractive error the "GEnes in Myopia (GEM) study" was established in 2004. The findings that have resulted from this study have not only provided greater insight into the role of genes and other factors involved in myopia but have also gone some way to uncovering the aetiology of other refractive errors. This review will describe some of the major findings of the GEM study and their relative contribution to the literature, illuminate where the deficiencies are in our understanding of the development of refractive errors and how we will advance this field in the future. Copyright © 2010 Elsevier Ltd. All rights reserved.

Medication prescribing errors in the medical intensive care unit of Tikur Anbessa Specialized Hospital, Addis Ababa, Ethiopia.

PubMed

Sada, Oumer; Melkie, Addisu; Shibeshi, Workineh

2015-09-16

Medication errors (MEs) are important problems in all hospitalized populations, especially in intensive care unit (ICU). Little is known about the prevalence of medication prescribing errors in the ICU of hospitals in Ethiopia. The aim of this study was to assess medication prescribing errors in the ICU of Tikur Anbessa Specialized Hospital using retrospective cross-sectional analysis of patient cards and medication charts. About 220 patient charts were reviewed with a total of 1311 patient-days, and 882 prescription episodes. 359 MEs were detected; with prevalence of 40 per 100 orders. Common prescribing errors were omission errors 154 (42.89%), 101 (28.13%) wrong combination, 48 (13.37%) wrong abbreviation, 30 (8.36%) wrong dose, wrong frequency 18 (5.01%) and wrong indications 8 (2.23%). The present study shows that medication errors are common in medical ICU of Tikur Anbessa Specialized Hospital. These results suggest future targets of prevention strategies to reduce the rate of medication error.

Wind power error estimation in resource assessments.

PubMed

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

2015-01-01

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

Wind Power Error Estimation in Resource Assessments

PubMed Central

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

2015-01-01

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

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

PubMed

Kim, Jun Sik; Jeong, Byung Yong

2018-05-03

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

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

Error detection and response adjustment in youth with mild spastic cerebral palsy: an event-related brain potential study.

PubMed

Hakkarainen, Elina; Pirilä, Silja; Kaartinen, Jukka; van der Meere, Jaap J

2013-06-01

This study evaluated the brain activation state during error making in youth with mild spastic cerebral palsy and a peer control group while carrying out a stimulus recognition task. The key question was whether patients were detecting their own errors and subsequently improving their performance in a future trial. Findings indicated that error responses of the group with cerebral palsy were associated with weak motor preparation, as indexed by the amplitude of the late contingent negative variation. However, patients were detecting their errors as indexed by the amplitude of the response-locked negativity and thus improved their performance in a future trial. Findings suggest that the consequence of error making on future performance is intact in a sample of youth with mild spastic cerebral palsy. Because the study group is small, the present findings need replication using a larger sample.

An Experimental Study of Medical Error Explanations: Do Apology, Empathy, Corrective Action, and Compensation Alter Intentions and Attitudes?

PubMed

Nazione, Samantha; Pace, Kristin

2015-01-01

Medical malpractice lawsuits are a growing problem in the United States, and there is much controversy regarding how to best address this problem. The medical error disclosure framework suggests that apologizing, expressing empathy, engaging in corrective action, and offering compensation after a medical error may improve the provider-patient relationship and ultimately help reduce the number of medical malpractice lawsuits patients bring to medical providers. This study provides an experimental examination of the medical error disclosure framework and its effect on amount of money requested in a lawsuit, negative intentions, attitudes, and anger toward the provider after a medical error. Results suggest empathy may play a large role in providing positive outcomes after a medical error.

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

PubMed

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

2016-10-01

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

Local indicators of geocoding accuracy (LIGA): theory and application

PubMed Central

Jacquez, Geoffrey M; Rommel, Robert

2009-01-01

Background Although sources of positional error in geographic locations (e.g. geocoding error) used for describing and modeling spatial patterns are widely acknowledged, research on how such error impacts the statistical results has been limited. In this paper we explore techniques for quantifying the perturbability of spatial weights to different specifications of positional error. Results We find that a family of curves describes the relationship between perturbability and positional error, and use these curves to evaluate sensitivity of alternative spatial weight specifications to positional error both globally (when all locations are considered simultaneously) and locally (to identify those locations that would benefit most from increased geocoding accuracy). We evaluate the approach in simulation studies, and demonstrate it using a case-control study of bladder cancer in south-eastern Michigan. Conclusion Three results are significant. First, the shape of the probability distributions of positional error (e.g. circular, elliptical, cross) has little impact on the perturbability of spatial weights, which instead depends on the mean positional error. Second, our methodology allows researchers to evaluate the sensitivity of spatial statistics to positional accuracy for specific geographies. This has substantial practical implications since it makes possible routine sensitivity analysis of spatial statistics to positional error arising in geocoded street addresses, global positioning systems, LIDAR and other geographic data. Third, those locations with high perturbability (most sensitive to positional error) and high leverage (that contribute the most to the spatial weight being considered) will benefit the most from increased positional accuracy. These are rapidly identified using a new visualization tool we call the LIGA scatterplot. Herein lies a paradox for spatial analysis: For a given level of positional error increasing sample density to more accurately follow the underlying population distribution increases perturbability and introduces error into the spatial weights matrix. In some studies positional error may not impact the statistical results, and in others it might invalidate the results. We therefore must understand the relationships between positional accuracy and the perturbability of the spatial weights in order to have confidence in a study's results. PMID:19863795

Acoustic evidence for phonologically mismatched speech errors.

PubMed

Gormley, Andrea

2015-04-01

Speech errors are generally said to accommodate to their new phonological context. This accommodation has been validated by several transcription studies. The transcription methodology is not the best choice for detecting errors at this level, however, as this type of error can be difficult to perceive. This paper presents an acoustic analysis of speech errors that uncovers non-accommodated or mismatch errors. A mismatch error is a sub-phonemic error that results in an incorrect surface phonology. This type of error could arise during the processing of phonological rules or they could be made at the motor level of implementation. The results of this work have important implications for both experimental and theoretical research. For experimentalists, it validates the tools used for error induction and the acoustic determination of errors free of the perceptual bias. For theorists, this methodology can be used to test the nature of the processes proposed in language production.

Assessing explicit error reporting in the narrative electronic medical record using keyword searching.

PubMed

Cao, Hui; Stetson, Peter; Hripcsak, George

2003-01-01

In this study, we assessed the explicit reporting of medical errors in the electronic record. We looked for cases in which the provider explicitly stated that he or she or another provider had committed an error. The advantage of the technique is that it is not limited to a specific type of error. Our goals were to 1) measure the rate at which medical errors were documented in medical records, and 2) characterize the types of errors that were reported.

Review of medication errors that are new or likely to occur more frequently with electronic medication management systems.

PubMed

Van de Vreede, Melita; McGrath, Anne; de Clifford, Jan

2018-05-14

Objective. The aim of the present study was to identify and quantify medication errors reportedly related to electronic medication management systems (eMMS) and those considered likely to occur more frequently with eMMS. This included developing a new classification system relevant to eMMS errors. Methods. Eight Victorian hospitals with eMMS participated in a retrospective audit of reported medication incidents from their incident reporting databases between May and July 2014. Site-appointed project officers submitted deidentified incidents they deemed new or likely to occur more frequently due to eMMS, together with the Incident Severity Rating (ISR). The authors reviewed and classified incidents. Results. There were 5826 medication-related incidents reported. In total, 93 (47 prescribing errors, 46 administration errors) were identified as new or potentially related to eMMS. Only one ISR2 (moderate) and no ISR1 (severe or death) errors were reported, so harm to patients in this 3-month period was minimal. The most commonly reported error types were 'human factors' and 'unfamiliarity or training' (70%) and 'cross-encounter or hybrid system errors' (22%). Conclusions. Although the results suggest that the errors reported were of low severity, organisations must remain vigilant to the risk of new errors and avoid the assumption that eMMS is the panacea to all medication error issues. What is known about the topic? eMMS have been shown to reduce some types of medication errors, but it has been reported that some new medication errors have been identified and some are likely to occur more frequently with eMMS. There are few published Australian studies that have reported on medication error types that are likely to occur more frequently with eMMS in more than one organisation and that include administration and prescribing errors. What does this paper add? This paper includes a new simple classification system for eMMS that is useful and outlines the most commonly reported incident types and can inform organisations and vendors on possible eMMS improvements. The paper suggests a new classification system for eMMS medication errors. What are the implications for practitioners? The results of the present study will highlight to organisations the need for ongoing review of system design, refinement of workflow issues, staff education and training and reporting and monitoring of errors.

Routine cognitive errors: a trait-like predictor of individual differences in anxiety and distress.

PubMed

Fetterman, Adam K; Robinson, Michael D

2011-02-01

Five studies (N=361) sought to model a class of errors--namely, those in routine tasks--that several literatures have suggested may predispose individuals to higher levels of emotional distress. Individual differences in error frequency were assessed in choice reaction-time tasks of a routine cognitive type. In Study 1, it was found that tendencies toward error in such tasks exhibit trait-like stability over time. In Study 3, it was found that tendencies toward error exhibit trait-like consistency across different tasks. Higher error frequency, in turn, predicted higher levels of negative affect, general distress symptoms, displayed levels of negative emotion during an interview, and momentary experiences of negative emotion in daily life (Studies 2-5). In all cases, such predictive relations remained significant with individual differences in neuroticism controlled. The results thus converge on the idea that error frequency in simple cognitive tasks is a significant and consequential predictor of emotional distress in everyday life. The results are novel, but discussed within the context of the wider literatures that informed them. © 2010 Psychology Press, an imprint of the Taylor & Francis Group, an Informa business

A cascaded coding scheme for error control

NASA Technical Reports Server (NTRS)

Kasami, T.; Lin, S.

1985-01-01

A cascaded coding scheme for error control was investigated. The scheme employs a combination of hard and soft decisions in decoding. Error performance is analyzed. If the inner and outer codes are chosen properly, extremely high reliability can be attained even for a high channel bit-error-rate. Some example schemes are studied which seem to be quite suitable for satellite down-link error control.

The Frame Constraint on Experimentally Elicited Speech Errors in Japanese.

PubMed

Saito, Akie; Inoue, Tomoyoshi

2017-06-01

The so-called syllable position effect in speech errors has been interpreted as reflecting constraints posed by the frame structure of a given language, which is separately operating from linguistic content during speech production. The effect refers to the phenomenon that when a speech error occurs, replaced and replacing sounds tend to be in the same position within a syllable or word. Most of the evidence for the effect comes from analyses of naturally occurring speech errors in Indo-European languages, and there are few studies examining the effect in experimentally elicited speech errors and in other languages. This study examined whether experimentally elicited sound errors in Japanese exhibits the syllable position effect. In Japanese, the sub-syllabic unit known as "mora" is considered to be a basic sound unit in production. Results showed that the syllable position effect occurred in mora errors, suggesting that the frame constrains the ordering of sounds during speech production.

A system dynamics approach to analyze laboratory test errors.

PubMed

Guo, Shijing; Roudsari, Abdul; Garcez, Artur d'Avila

2015-01-01

Although many researches have been carried out to analyze laboratory test errors during the last decade, it still lacks a systemic view of study, especially to trace errors during test process and evaluate potential interventions. This study implements system dynamics modeling into laboratory errors to trace the laboratory error flows and to simulate the system behaviors while changing internal variable values. The change of the variables may reflect a change in demand or a proposed intervention. A review of literature on laboratory test errors was given and provided as the main data source for the system dynamics model. Three "what if" scenarios were selected for testing the model. System behaviors were observed and compared under different scenarios over a period of time. The results suggest system dynamics modeling has potential effectiveness of helping to understand laboratory errors, observe model behaviours, and provide a risk-free simulation experiments for possible strategies.

Transient fault behavior in a microprocessor: A case study

NASA Technical Reports Server (NTRS)

Duba, Patrick

1989-01-01

An experimental analysis is described which studies the susceptibility of a microprocessor based jet engine controller to upsets caused by current and voltage transients. A design automation environment which allows the run time injection of transients and the tracing from their impact device to the pin level is described. The resulting error data are categorized by the charge levels of the injected transients by location and by their potential to cause logic upsets, latched errors, and pin errors. The results show a 3 picoCouloumb threshold, below which the transients have little impact. An Arithmetic and Logic Unit transient is most likely to result in logic upsets and pin errors (i.e., impact the external environment). The transients in the countdown unit are potentially serious since they can result in latched errors, thus causing latent faults. Suggestions to protect the processor against these errors, by incorporating internal error detection and transient suppression techniques, are also made.

Spelling in adolescents with dyslexia: errors and modes of assessment.

PubMed

Tops, Wim; Callens, Maaike; Bijn, Evi; Brysbaert, Marc

2014-01-01

In this study we focused on the spelling of high-functioning students with dyslexia. We made a detailed classification of the errors in a word and sentence dictation task made by 100 students with dyslexia and 100 matched control students. All participants were in the first year of their bachelor's studies and had Dutch as mother tongue. Three main error categories were distinguished: phonological, orthographic, and grammatical errors (on the basis of morphology and language-specific spelling rules). The results indicated that higher-education students with dyslexia made on average twice as many spelling errors as the controls, with effect sizes of d ≥ 2. When the errors were classified as phonological, orthographic, or grammatical, we found a slight dominance of phonological errors in students with dyslexia. Sentence dictation did not provide more information than word dictation in the correct classification of students with and without dyslexia. © Hammill Institute on Disabilities 2012.

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

A review of setup error in supine breast radiotherapy using cone-beam computed tomography

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

Batumalai, Vikneswary, E-mail: Vikneswary.batumalai@sswahs.nsw.gov.au; Liverpool and Macarthur Cancer Therapy Centres, New South Wales; Ingham Institute of Applied Medical Research, Sydney, New South Wales

2016-10-01

Setup error in breast radiotherapy (RT) measured with 3-dimensional cone-beam computed tomography (CBCT) is becoming more common. The purpose of this study is to review the literature relating to the magnitude of setup error in breast RT measured with CBCT. The different methods of image registration between CBCT and planning computed tomography (CT) scan were also explored. A literature search, not limited by date, was conducted using Medline and Google Scholar with the following key words: breast cancer, RT, setup error, and CBCT. This review includes studies that reported on systematic and random errors, and the methods used when registeringmore » CBCT scans with planning CT scan. A total of 11 relevant studies were identified for inclusion in this review. The average magnitude of error is generally less than 5 mm across a number of studies reviewed. The common registration methods used when registering CBCT scans with planning CT scan are based on bony anatomy, soft tissue, and surgical clips. No clear relationships between the setup errors detected and methods of registration were observed from this review. Further studies are needed to assess the benefit of CBCT over electronic portal image, as CBCT remains unproven to be of wide benefit in breast RT.« less

[Comparison of Google and Yahoo applications for geocoding of postal addresses in epidemiological studies].

PubMed

Quesada, Jose Antonio; Nolasco, Andreu; Moncho, Joaquín

2013-01-01

Geocoding is the assignment of geographic coordinates to spatial points, which often are postal addresses. The error made in applying this process can introduce bias in estimates of spatiotemporal models in epidemiological studies. No studies have been found to measure the error made in applying this process in Spanish cities. The objective is to evaluate the errors in magnitude and direction from two free sources (Google and Yahoo) with regard to a GPS in two Spanish cities. 30 addresses were geocoded with those two sources and the GPS in Santa Pola (Alicante) and Alicante city. The distances were calculated in metres (median, CI95%) between the sources and the GPS, globally and according to the status reported by each source. The directionality of the error was evaluated by calculating the location quadrant and applying a Chi-Square test. The GPS error was evaluated by geocoding 11 addresses twice at 4 days interval. The overall median in Google-GPS was 23,2 metres (16,0-32,1) for Santa Pola, and 21,4 meters (14,9-31,1) for Alicante. The overall median in Yahoo was 136,0 meters (19,2-318,5) for Santa Pola, and 23,8 meters (13,6- 29,2) for Alicante. Between the 73% and 90% were geocoded by status as "exact or interpolated" (minor error), where Goggle and Yahoo had a median error between 19 and 23 metres in the two cities. The GPS had a median error of 13.8 meters (6,7-17,8). No error directionality was detected. Google error is acceptable and stable in the two cities, so that it is a reliable source for Para medir elgeocoding addresses in Spain in epidemiological studies.

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

PubMed

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

2011-07-01

Medication errors are widely reported for hospitalised patients, but limited data are available for medication errors that occur in community-based and clinical settings. Epidemiological data from poisons information centres enable characterisation of trends in medication errors occurring across the healthcare spectrum. The objective of this study was to characterise the epidemiology and type of medication errors reported to the National Poisons Information Centre (NPIC) of Ireland. A 3-year prospective study on medication errors reported to the NPIC was conducted from 1 January 2007 to 31 December 2009 inclusive. Data on patient demographics, enquiry source, location, pharmaceutical agent(s), type of medication error, and treatment advice were collated from standardised call report forms. Medication errors were categorised as (i) prescribing error (i.e. physician error), (ii) dispensing error (i.e. pharmacy error), and (iii) administration error involving the wrong medication, the wrong dose, wrong route, or the wrong time. Medication errors were reported for 2348 individuals, representing 9.56% of total enquiries to the NPIC over 3 years. In total, 1220 children and adolescents under 18 years of age and 1128 adults (≥ 18 years old) experienced a medication error. The majority of enquiries were received from healthcare professionals, but members of the public accounted for 31.3% (n = 736) of enquiries. Most medication errors occurred in a domestic setting (n = 2135), but a small number occurred in healthcare facilities: nursing homes (n = 110, 4.68%), hospitals (n = 53, 2.26%), and general practitioner surgeries (n = 32, 1.36%). In children, medication errors with non-prescription pharmaceuticals predominated (n = 722) and anti-pyretics and non-opioid analgesics, anti-bacterials, and cough and cold preparations were the main pharmaceutical classes involved. Medication errors with prescription medication predominated for adults (n = 866) and the major medication classes included anti-pyretics and non-opioid analgesics, psychoanaleptics, and psychleptic agents. Approximately 97% (n = 2279) of medication errors were as a result of drug administration errors (comprising a double dose [n = 1040], wrong dose [n = 395], wrong medication [n = 597], wrong route [n = 133], and wrong time [n = 110]). Prescribing and dispensing errors accounted for 0.68% (n = 16) and 2.26% (n = 53) of errors, respectively. Empirical data from poisons information centres facilitate the characterisation of medication errors occurring in the community and across the healthcare spectrum. Poison centre data facilitate the detection of subtle trends in medication errors and can contribute to pharmacovigilance. Collaboration between pharmaceutical manufacturers, consumers, medical, and regulatory communities is needed to advance patient safety and reduce medication errors.

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

NASA Astrophysics Data System (ADS)

Delgado-Loperena, Dharma

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

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

PubMed

Steers, Jennifer M; Fraass, Benedick A

2016-04-01

The gamma comparison is widely used to evaluate the agreement between measurements and treatment planning system calculations in patient-specific intensity modulated radiation therapy (IMRT) quality assurance (QA). However, recent publications have raised concerns about the lack of sensitivity when employing commonly used gamma criteria. Understanding the actual sensitivity of a wide range of different gamma criteria may allow the definition of more meaningful gamma criteria and tolerance limits in IMRT QA. We present a method that allows the quantitative determination of gamma criteria sensitivity to induced errors which can be applied to any unique combination of device, delivery technique, and software utilized in a specific clinic. A total of 21 DMLC IMRT QA measurements (ArcCHECK®, Sun Nuclear) were compared to QA plan calculations with induced errors. Three scenarios were studied: MU errors, multi-leaf collimator (MLC) errors, and the sensitivity of the gamma comparison to changes in penumbra width. Gamma comparisons were performed between measurements and error-induced calculations using a wide range of gamma criteria, resulting in a total of over 20 000 gamma comparisons. Gamma passing rates for each error class and case were graphed against error magnitude to create error curves in order to represent the range of missed errors in routine IMRT QA using 36 different gamma criteria. This study demonstrates that systematic errors and case-specific errors can be detected by the error curve analysis. Depending on the location of the error curve peak (e.g., not centered about zero), 3%/3 mm threshold = 10% at 90% pixels passing may miss errors as large as 15% MU errors and ±1 cm random MLC errors for some cases. As the dose threshold parameter was increased for a given %Diff/distance-to-agreement (DTA) setting, error sensitivity was increased by up to a factor of two for select cases. This increased sensitivity with increasing dose threshold was consistent across all studied combinations of %Diff/DTA. Criteria such as 2%/3 mm and 3%/2 mm with a 50% threshold at 90% pixels passing are shown to be more appropriately sensitive without being overly strict. However, a broadening of the penumbra by as much as 5 mm in the beam configuration was difficult to detect with commonly used criteria, as well as with the previously mentioned criteria utilizing a threshold of 50%. We have introduced the error curve method, an analysis technique which allows the quantitative determination of gamma criteria sensitivity to induced errors. The application of the error curve method using DMLC IMRT plans measured on the ArcCHECK® device demonstrated that large errors can potentially be missed in IMRT QA with commonly used gamma criteria (e.g., 3%/3 mm, threshold = 10%, 90% pixels passing). Additionally, increasing the dose threshold value can offer dramatic increases in error sensitivity. This approach may allow the selection of more meaningful gamma criteria for IMRT QA and is straightforward to apply to other combinations of devices and treatment techniques.

The Effects of Bar-coding Technology on Medication Errors: A Systematic Literature Review.

PubMed

Hutton, Kevin; Ding, Qian; Wellman, Gregory

2017-02-24

The bar-coding technology adoptions have risen drastically in U.S. health systems in the past decade. However, few studies have addressed the impact of bar-coding technology with strong prospective methodologies and the research, which has been conducted from both in-pharmacy and bedside implementations. This systematic literature review is to examine the effectiveness of bar-coding technology on preventing medication errors and what types of medication errors may be prevented in the hospital setting. A systematic search of databases was performed from 1998 to December 2016. Studies measuring the effect of bar-coding technology on medication errors were included in a full-text review. Studies with the outcomes other than medication errors such as efficiency or workarounds were excluded. The outcomes were measured and findings were summarized for each retained study. A total of 2603 articles were initially identified and 10 studies, which used prospective before-and-after study design, were fully reviewed in this article. Of the 10 included studies, 9 took place in the United States, whereas the remaining was conducted in the United Kingdom. One research article focused on bar-coding implementation in a pharmacy setting, whereas the other 9 focused on bar coding within patient care areas. All 10 studies showed overall positive effects associated with bar-coding implementation. The results of this review show that bar-coding technology may reduce medication errors in hospital settings, particularly on preventing targeted wrong dose, wrong drug, wrong patient, unauthorized drug, and wrong route errors.

Sustained Attention is Associated with Error Processing Impairment: Evidence from Mental Fatigue Study in Four-Choice Reaction Time Task

PubMed Central

Xiao, Yi; Ma, Feng; Lv, Yixuan; Cai, Gui; Teng, Peng; Xu, FengGang; Chen, Shanguang

2015-01-01

Attention is important in error processing. Few studies have examined the link between sustained attention and error processing. In this study, we examined how error-related negativity (ERN) of a four-choice reaction time task was reduced in the mental fatigue condition and investigated the role of sustained attention in error processing. Forty-one recruited participants were divided into two groups. In the fatigue experiment group, 20 subjects performed a fatigue experiment and an additional continuous psychomotor vigilance test (PVT) for 1 h. In the normal experiment group, 21 subjects only performed the normal experimental procedures without the PVT test. Fatigue and sustained attention states were assessed with a questionnaire. Event-related potential results showed that ERN (p < 0.005) and peak (p < 0.05) mean amplitudes decreased in the fatigue experiment. ERN amplitudes were significantly associated with the attention and fatigue states in electrodes Fz, FC1, Cz, and FC2. These findings indicated that sustained attention was related to error processing and that decreased attention is likely the cause of error processing impairment. PMID:25756780

Performance Analysis of Amplify-and-Forward Relaying FSO/SC-QAM Systems over Weak Turbulence Channels and Pointing Error Impairments

NASA Astrophysics Data System (ADS)

Trung, Ha Duyen

2017-12-01

In this paper, the end-to-end performance of free-space optical (FSO) communication system combining with Amplify-and-Forward (AF)-assisted or fixed-gain relaying technology using subcarrier quadrature amplitude modulation (SC-QAM) over weak atmospheric turbulence channels modeled by log-normal distribution with pointing error impairments is studied. More specifically, unlike previous studies on AF relaying FSO communication systems without pointing error effects; the pointing error effect is studied by taking into account the influence of beamwidth, aperture size and jitter variance. In addition, a combination of these models to analyze the combined effect of atmospheric turbulence and pointing error to AF relaying FSO/SC-QAM systems is used. Finally, an analytical expression is derived to evaluate the average symbol error rate (ASER) performance of such systems. The numerical results show that the impact of pointing error on the performance of AF relaying FSO/SC-QAM systems and how we use proper values of aperture size and beamwidth to improve the performance of such systems. Some analytical results are confirmed by Monte-Carlo simulations.

[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.

Exploring Senior Residents' Intraoperative Error Management Strategies: A Potential Measure of Performance Improvement.

PubMed

Law, Katherine E; Ray, Rebecca D; D'Angelo, Anne-Lise D; Cohen, Elaine R; DiMarco, Shannon M; Linsmeier, Elyse; Wiegmann, Douglas A; Pugh, Carla M

The study aim was to determine whether residents' error management strategies changed across 2 simulated laparoscopic ventral hernia (LVH) repair procedures after receiving feedback on their initial performance. We hypothesize that error detection and recovery strategies would improve during the second procedure without hands-on practice. Retrospective review of participant procedural performances of simulated laparoscopic ventral herniorrhaphy. A total of 3 investigators reviewed procedure videos to identify surgical errors. Errors were deconstructed. Error management events were noted, including error identification and recovery. Residents performed the simulated LVH procedures during a course on advanced laparoscopy. Participants had 30 minutes to complete a LVH procedure. After verbal and simulator feedback, residents returned 24 hours later to perform a different, more difficult simulated LVH repair. Senior (N = 7; postgraduate year 4-5) residents in attendance at the course participated in this study. In the first LVH procedure, residents committed 121 errors (M = 17.14, standard deviation = 4.38). Although the number of errors increased to 146 (M = 20.86, standard deviation = 6.15) during the second procedure, residents progressed further in the second procedure. There was no significant difference in the number of errors committed for both procedures, but errors shifted to the late stage of the second procedure. Residents changed the error types that they attempted to recover (χ 2 5 =24.96, p<0.001). For the second procedure, recovery attempts increased for action and procedure errors, but decreased for strategy errors. Residents also recovered the most errors in the late stage of the second procedure (p < 0.001). Residents' error management strategies changed between procedures following verbal feedback on their initial performance and feedback from the simulator. Errors and recovery attempts shifted to later steps during the second procedure. This may reflect residents' error management success in the earlier stages, which allowed further progression in the second simulation. Incorporating error recognition and management opportunities into surgical training could help track residents' learning curve and provide detailed, structured feedback on technical and decision-making skills. Copyright © 2016 Association of Program Directors in Surgery. 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…

Error Orientation and Reflection at Work

ERIC Educational Resources Information Center

Hetzner, Stefanie; Gartmeier, Martin; Heid, Helmut; Gruber, Hans

2011-01-01

Reflection on events at work, including errors is often as a means to learn effectively through work. In a cross-sectional field study in the banking sector, we investigated attitudes towards workplace errors (i.e. error orientation) as predictors of reflective activity. We assumed the organisational climate for psychological safety to have a…

Effects of Error Experience When Learning to Simulate Hypernasality

ERIC Educational Resources Information Center

Wong, Andus W.-K.; Tse, Andy C.-Y.; Ma, Estella P.-M.; Whitehill, Tara L.; Masters, Rich S. W.

2013-01-01

Purpose: The purpose of this study was to evaluate the effects of error experience on the acquisition of hypernasal speech. Method: Twenty-eight healthy participants were asked to simulate hypernasality in either an "errorless learning" condition (in which the possibility for errors was limited) or an "errorful learning"…

Mathematical Writing Errors in Expository Writings of College Mathematics Students

ERIC Educational Resources Information Center

Guce, Ivee K.

2017-01-01

Despite the efforts to confirm the effectiveness of writing in learning mathematics, analysis on common errors in mathematical writings has not received sufficient attention. This study aimed to provide an account of the students' procedural explanations in terms of their commonly committed errors in mathematical writing. Nine errors in…

Errors in Bibliographic Citations: A Continuing Problem.

ERIC Educational Resources Information Center

Sweetland, James H.

1989-01-01

Summarizes studies examining citation errors and illustrates errors resulting from a lack of standardization, misunderstanding of foreign languages, failure to examine the document cited, and general lack of training in citation norms. It is argued that the failure to detect and correct citation errors is due to diffusion of responsibility in the…

Reducing the Familiarity of Conjunction Lures with Pictures

ERIC Educational Resources Information Center

Lloyd, Marianne E.

2013-01-01

Four experiments were conducted to test whether conjunction errors were reduced after pictorial encoding and whether the semantic overlap between study and conjunction items would impact error rates. Across 4 experiments, compound words studied with a single-picture had lower conjunction error rates during a recognition test than those words…

Grammatical Errors Produced by English Majors: The Translation Task

ERIC Educational Resources Information Center

Mohaghegh, Hamid; Zarandi, Fatemeh Mahmoudi; Shariati, Mohammad

2011-01-01

This study investigated the frequency of the grammatical errors related to the four categories of preposition, relative pronoun, article, and tense using the translation task. In addition, the frequencies of these grammatical errors in different categories and in each category were examined. The quantitative component of the study further looked…

E-prescribing errors in community pharmacies: exploring consequences and contributing factors.

PubMed

Odukoya, Olufunmilola K; Stone, Jamie A; Chui, Michelle A

2014-06-01

To explore types of e-prescribing errors in community pharmacies and their potential consequences, as well as the factors that contribute to e-prescribing errors. Data collection involved performing 45 total hours of direct observations in five pharmacies. Follow-up interviews were conducted with 20 study participants. Transcripts from observations and interviews were subjected to content analysis using NVivo 10. Pharmacy staff detected 75 e-prescription errors during the 45 h observation in pharmacies. The most common e-prescribing errors were wrong drug quantity, wrong dosing directions, wrong duration of therapy, and wrong dosage formulation. Participants estimated that 5 in 100 e-prescriptions have errors. Drug classes that were implicated in e-prescribing errors were antiinfectives, inhalers, ophthalmic, and topical agents. The potential consequences of e-prescribing errors included increased likelihood of the patient receiving incorrect drug therapy, poor disease management for patients, additional work for pharmacy personnel, increased cost for pharmacies and patients, and frustrations for patients and pharmacy staff. Factors that contribute to errors included: technology incompatibility between pharmacy and clinic systems, technology design issues such as use of auto-populate features and dropdown menus, and inadvertently entering incorrect information. Study findings suggest that a wide range of e-prescribing errors is encountered in community pharmacies. Pharmacists and technicians perceive that causes of e-prescribing errors are multidisciplinary and multifactorial, that is to say e-prescribing errors can originate from technology used in prescriber offices and pharmacies. Copyright © 2014 Elsevier Ireland Ltd. All rights reserved.

E-Prescribing Errors in Community Pharmacies: Exploring Consequences and Contributing Factors

PubMed Central

Stone, Jamie A.; Chui, Michelle A.

2014-01-01

Objective To explore types of e-prescribing errors in community pharmacies and their potential consequences, as well as the factors that contribute to e-prescribing errors. Methods Data collection involved performing 45 total hours of direct observations in five pharmacies. Follow-up interviews were conducted with 20 study participants. Transcripts from observations and interviews were subjected to content analysis using NVivo 10. Results Pharmacy staff detected 75 e-prescription errors during the 45 hour observation in pharmacies. The most common e-prescribing errors were wrong drug quantity, wrong dosing directions, wrong duration of therapy, and wrong dosage formulation. Participants estimated that 5 in 100 e-prescriptions have errors. Drug classes that were implicated in e-prescribing errors were antiinfectives, inhalers, ophthalmic, and topical agents. The potential consequences of e-prescribing errors included increased likelihood of the patient receiving incorrect drug therapy, poor disease management for patients, additional work for pharmacy personnel, increased cost for pharmacies and patients, and frustrations for patients and pharmacy staff. Factors that contribute to errors included: technology incompatibility between pharmacy and clinic systems, technology design issues such as use of auto-populate features and dropdown menus, and inadvertently entering incorrect information. Conclusion Study findings suggest that a wide range of e-prescribing errors are encountered in community pharmacies. Pharmacists and technicians perceive that causes of e-prescribing errors are multidisciplinary and multifactorial, that is to say e-prescribing errors can originate from technology used in prescriber offices and pharmacies. PMID:24657055

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

PubMed

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

2006-01-01

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

The effectiveness of the error reporting promoting program on the nursing error incidence rate in Korean operating rooms.

PubMed

Kim, Myoung-Soo; Kim, Jung-Soon; Jung, In Sook; Kim, Young Hae; Kim, Ho Jung

2007-03-01

The purpose of this study was to develop and evaluate an error reporting promoting program(ERPP) to systematically reduce the incidence rate of nursing errors in operating room. A non-equivalent control group non-synchronized design was used. Twenty-six operating room nurses who were in one university hospital in Busan participated in this study. They were stratified into four groups according to their operating room experience and were allocated to the experimental and control groups using a matching method. Mann-Whitney U Test was used to analyze the differences pre and post incidence rates of nursing errors between the two groups. The incidence rate of nursing errors decreased significantly in the experimental group compared to the pre-test score from 28.4% to 15.7%. The incidence rate by domains, it decreased significantly in the 3 domains-"compliance of aseptic technique", "management of document", "environmental management" in the experimental group while it decreased in the control group which was applied ordinary error-reporting method. Error-reporting system can make possible to hold the errors in common and to learn from them. ERPP was effective to reduce the errors of recognition-related nursing activities. For the wake of more effective error-prevention, we will be better to apply effort of risk management along the whole health care system with this program.

Twice cutting method reduces tibial cutting error in unicompartmental knee arthroplasty.

PubMed

Inui, Hiroshi; Taketomi, Shuji; Yamagami, Ryota; Sanada, Takaki; Tanaka, Sakae

2016-01-01

Bone cutting error can be one of the causes of malalignment in unicompartmental knee arthroplasty (UKA). The amount of cutting error in total knee arthroplasty has been reported. However, none have investigated cutting error in UKA. The purpose of this study was to reveal the amount of cutting error in UKA when open cutting guide was used and clarify whether cutting the tibia horizontally twice using the same cutting guide reduced the cutting errors in UKA. We measured the alignment of the tibial cutting guides, the first-cut cutting surfaces and the second cut cutting surfaces using the navigation system in 50 UKAs. Cutting error was defined as the angular difference between the cutting guide and cutting surface. The mean absolute first-cut cutting error was 1.9° (1.1° varus) in the coronal plane and 1.1° (0.6° anterior slope) in the sagittal plane, whereas the mean absolute second-cut cutting error was 1.1° (0.6° varus) in the coronal plane and 1.1° (0.4° anterior slope) in the sagittal plane. Cutting the tibia horizontally twice reduced the cutting errors in the coronal plane significantly (P<0.05). Our study demonstrated that in UKA, cutting the tibia horizontally twice using the same cutting guide reduced cutting error in the coronal plane. Copyright © 2014 Elsevier B.V. All rights reserved.

Sensitivity in error detection of patient specific QA tools for IMRT plans

NASA Astrophysics Data System (ADS)

Lat, S. Z.; Suriyapee, S.; Sanghangthum, T.

2016-03-01

The high complexity of dose calculation in treatment planning and accurate delivery of IMRT plan need high precision of verification method. The purpose of this study is to investigate error detection capability of patient specific QA tools for IMRT plans. The two H&N and two prostate IMRT plans with MapCHECK2 and portal dosimetry QA tools were studied. Measurements were undertaken for original and modified plans with errors introduced. The intentional errors composed of prescribed dose (±2 to ±6%) and position shifting in X-axis and Y-axis (±1 to ±5mm). After measurement, gamma pass between original and modified plans were compared. The average gamma pass for original H&N and prostate plans were 98.3% and 100% for MapCHECK2 and 95.9% and 99.8% for portal dosimetry, respectively. In H&N plan, MapCHECK2 can detect position shift errors starting from 3mm while portal dosimetry can detect errors started from 2mm. Both devices showed similar sensitivity in detection of position shift error in prostate plan. For H&N plan, MapCHECK2 can detect dose errors starting at ±4%, whereas portal dosimetry can detect from ±2%. For prostate plan, both devices can identify dose errors starting from ±4%. Sensitivity of error detection depends on type of errors and plan complexity.

Antidepressant and antipsychotic medication errors reported to United States poison control centers.

PubMed

Kamboj, Alisha; Spiller, Henry A; Casavant, Marcel J; Chounthirath, Thitphalak; Hodges, Nichole L; Smith, Gary A

2018-05-08

To investigate unintentional therapeutic medication errors associated with antidepressant and antipsychotic medications in the United States and expand current knowledge on the types of errors commonly associated with these medications. A retrospective analysis of non-health care facility unintentional therapeutic errors associated with antidepressant and antipsychotic medications was conducted using data from the National Poison Data System. From 2000 to 2012, poison control centers received 207 670 calls reporting unintentional therapeutic errors associated with antidepressant or antipsychotic medications that occurred outside of a health care facility, averaging 15 975 errors annually. The rate of antidepressant-related errors increased by 50.6% from 2000 to 2004, decreased by 6.5% from 2004 to 2006, and then increased 13.0% from 2006 to 2012. The rate of errors related to antipsychotic medications increased by 99.7% from 2000 to 2004 and then increased by 8.8% from 2004 to 2012. Overall, 70.1% of reported errors occurred among adults, and 59.3% were among females. The medications most frequently associated with errors were selective serotonin reuptake inhibitors (30.3%), atypical antipsychotics (24.1%), and other types of antidepressants (21.5%). Most medication errors took place when an individual inadvertently took or was given a medication twice (41.0%), inadvertently took someone else's medication (15.6%), or took the wrong medication (15.6%). This study provides a comprehensive overview of non-health care facility unintentional therapeutic errors associated with antidepressant and antipsychotic medications. The frequency and rate of these errors increased significantly from 2000 to 2012. Given that use of these medications is increasing in the US, this study provides important information about the epidemiology of the associated medication errors. Copyright © 2018 John Wiley & Sons, Ltd.

Terrestrial Water Mass Load Changes from Gravity Recovery and Climate Experiment (GRACE)

NASA Technical Reports Server (NTRS)

Seo, K.-W.; Wilson, C. R.; Famiglietti, J. S.; Chen, J. L.; Rodell M.

2006-01-01

Recent studies show that data from the Gravity Recovery and Climate Experiment (GRACE) is promising for basin- to global-scale water cycle research. This study provides varied assessments of errors associated with GRACE water storage estimates. Thirteen monthly GRACE gravity solutions from August 2002 to December 2004 are examined, along with synthesized GRACE gravity fields for the same period that incorporate simulated errors. The synthetic GRACE fields are calculated using numerical climate models and GRACE internal error estimates. We consider the influence of measurement noise, spatial leakage error, and atmospheric and ocean dealiasing (AOD) model error as the major contributors to the error budget. Leakage error arises from the limited range of GRACE spherical harmonics not corrupted by noise. AOD model error is due to imperfect correction for atmosphere and ocean mass redistribution applied during GRACE processing. Four methods of forming water storage estimates from GRACE spherical harmonics (four different basin filters) are applied to both GRACE and synthetic data. Two basin filters use Gaussian smoothing, and the other two are dynamic basin filters which use knowledge of geographical locations where water storage variations are expected. Global maps of measurement noise, leakage error, and AOD model errors are estimated for each basin filter. Dynamic basin filters yield the smallest errors and highest signal-to-noise ratio. Within 12 selected basins, GRACE and synthetic data show similar amplitudes of water storage change. Using 53 river basins, covering most of Earth's land surface excluding Antarctica and Greenland, we document how error changes with basin size, latitude, and shape. Leakage error is most affected by basin size and latitude, and AOD model error is most dependent on basin latitude.

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.

A Collective Case Study of the Influence of Teachers' Beliefs and Knowledge on Error-Handling Practices during Class Discussion of Mathematics

ERIC Educational Resources Information Center

Bray, Wendy S.

2011-01-01

This collective case study examines the influence of 4 third-grade teachers' beliefs and knowledge on their error-handling practices during class discussion of mathematics. Study findings suggest that, although teachers' ways of handling student errors during class discussion of mathematics are clearly linked to both teacher beliefs and teacher…

Analysis of Errors Committed by Physics Students in Secondary Schools in Ilorin Metropolis, Nigeria

ERIC Educational Resources Information Center

Omosewo, Esther Ore; Akanbi, Abdulrasaq Oladimeji

2013-01-01

The study attempt to find out the types of error committed and influence of gender on the type of error committed by senior secondary school physics students in metropolis. Six (6) schools were purposively chosen for the study. One hundred and fifty five students' scripts were randomly sampled for the study. Joint Mock physics essay questions…

Detection of Common Errors in Turkish EFL Students' Writing through a Corpus Analytic Approach

ERIC Educational Resources Information Center

Demirel, Elif Tokdemir

2017-01-01

The present study aims to explore Turkish EFL students' major writing difficulties by analyzing the frequent writing errors in academic essays. Accordingly, the study examined errors in a corpus of 150 academic essays written by Turkish EFL students studying at the Department of English Language and Literature at a public university in Turkey. The…

A Review of Research on Error Detection. Technical Report No. 540.

ERIC Educational Resources Information Center

Meyer, Linda A.

A review was conducted of the research on error detection studies completed with children, adolescents, and young adults to determine at what age children begin to detect errors in texts. The studies were grouped according to the subjects' ages. The focus of the review was on the following aspects of each study: the hypothesis that guided the…

Student Errors in Fractions and Possible Causes of These Errors

ERIC Educational Resources Information Center

Aksoy, Nuri Can; Yazlik, Derya Ozlem

2017-01-01

In this study, it was aimed to determine the errors and misunderstandings of 5th and 6th grade middle school students in fractions and operations with fractions. For this purpose, the case study model, which is a qualitative research design, was used in the research. In the study, maximum diversity sampling, which is a purposeful sampling method,…

Component Analysis of Errors on PERSIANN Precipitation Estimates over Urmia Lake Basin, IRAN

NASA Astrophysics Data System (ADS)

Ghajarnia, N.; Daneshkar Arasteh, P.; Liaghat, A. M.; Araghinejad, S.

2016-12-01

In this study, PERSIANN daily dataset is evaluated from 2000 to 2011 in 69 pixels over Urmia Lake basin in northwest of Iran. Different analytical approaches and indexes are used to examine PERSIANN precision in detection and estimation of rainfall rate. The residuals are decomposed into Hit, Miss and FA estimation biases while continues decomposition of systematic and random error components are also analyzed seasonally and categorically. New interpretation of estimation accuracy named "reliability on PERSIANN estimations" is introduced while the changing manners of existing categorical/statistical measures and error components are also seasonally analyzed over different rainfall rate categories. This study yields new insights into the nature of PERSIANN errors over Urmia lake basin as a semi-arid region in the middle-east, including the followings: - The analyzed contingency table indexes indicate better detection precision during spring and fall. - A relatively constant level of error is generally observed among different categories. The range of precipitation estimates at different rainfall rate categories is nearly invariant as a sign for the existence of systematic error. - Low level of reliability is observed on PERSIANN estimations at different categories which are mostly associated with high level of FA error. However, it is observed that as the rate of precipitation increase, the ability and precision of PERSIANN in rainfall detection also increases. - The systematic and random error decomposition in this area shows that PERSIANN has more difficulty in modeling the system and pattern of rainfall rather than to have bias due to rainfall uncertainties. The level of systematic error also considerably increases in heavier rainfalls. It is also important to note that PERSIANN error characteristics at each season varies due to the condition and rainfall patterns of that season which shows the necessity of seasonally different approach for the calibration of this product. Overall, we believe that different error component's analysis performed in this study, can substantially help any further local studies for post-calibration and bias reduction of PERSIANN estimations.

Impact of Internally Developed Electronic Prescription on Prescribing Errors at Discharge from the Emergency Department

PubMed Central

Hitti, Eveline; Tamim, Hani; Bakhti, Rinad; Zebian, Dina; Mufarrij, Afif

2017-01-01

Introduction Medication errors are common, with studies reporting at least one error per patient encounter. At hospital discharge, medication errors vary from 15%–38%. However, studies assessing the effect of an internally developed electronic (E)-prescription system at discharge from an emergency department (ED) are comparatively minimal. Additionally, commercially available electronic solutions are cost-prohibitive in many resource-limited settings. We assessed the impact of introducing an internally developed, low-cost E-prescription system, with a list of commonly prescribed medications, on prescription error rates at discharge from the ED, compared to handwritten prescriptions. Methods We conducted a pre- and post-intervention study comparing error rates in a randomly selected sample of discharge prescriptions (handwritten versus electronic) five months pre and four months post the introduction of the E-prescription. The internally developed, E-prescription system included a list of 166 commonly prescribed medications with the generic name, strength, dose, frequency and duration. We included a total of 2,883 prescriptions in this study: 1,475 in the pre-intervention phase were handwritten (HW) and 1,408 in the post-intervention phase were electronic. We calculated rates of 14 different errors and compared them between the pre- and post-intervention period. Results Overall, E-prescriptions included fewer prescription errors as compared to HW-prescriptions. Specifically, E-prescriptions reduced missing dose (11.3% to 4.3%, p <0.0001), missing frequency (3.5% to 2.2%, p=0.04), missing strength errors (32.4% to 10.2%, p <0.0001) and legibility (0.7% to 0.2%, p=0.005). E-prescriptions, however, were associated with a significant increase in duplication errors, specifically with home medication (1.7% to 3%, p=0.02). Conclusion A basic, internally developed E-prescription system, featuring commonly used medications, effectively reduced medication errors in a low-resource setting where the costs of sophisticated commercial electronic solutions are prohibitive. PMID:28874948

Impact of Internally Developed Electronic Prescription on Prescribing Errors at Discharge from the Emergency Department.

PubMed

Hitti, Eveline; Tamim, Hani; Bakhti, Rinad; Zebian, Dina; Mufarrij, Afif

2017-08-01

Medication errors are common, with studies reporting at least one error per patient encounter. At hospital discharge, medication errors vary from 15%-38%. However, studies assessing the effect of an internally developed electronic (E)-prescription system at discharge from an emergency department (ED) are comparatively minimal. Additionally, commercially available electronic solutions are cost-prohibitive in many resource-limited settings. We assessed the impact of introducing an internally developed, low-cost E-prescription system, with a list of commonly prescribed medications, on prescription error rates at discharge from the ED, compared to handwritten prescriptions. We conducted a pre- and post-intervention study comparing error rates in a randomly selected sample of discharge prescriptions (handwritten versus electronic) five months pre and four months post the introduction of the E-prescription. The internally developed, E-prescription system included a list of 166 commonly prescribed medications with the generic name, strength, dose, frequency and duration. We included a total of 2,883 prescriptions in this study: 1,475 in the pre-intervention phase were handwritten (HW) and 1,408 in the post-intervention phase were electronic. We calculated rates of 14 different errors and compared them between the pre- and post-intervention period. Overall, E-prescriptions included fewer prescription errors as compared to HW-prescriptions. Specifically, E-prescriptions reduced missing dose (11.3% to 4.3%, p <0.0001), missing frequency (3.5% to 2.2%, p=0.04), missing strength errors (32.4% to 10.2%, p <0.0001) and legibility (0.7% to 0.2%, p=0.005). E-prescriptions, however, were associated with a significant increase in duplication errors, specifically with home medication (1.7% to 3%, p=0.02). A basic, internally developed E-prescription system, featuring commonly used medications, effectively reduced medication errors in a low-resource setting where the costs of sophisticated commercial electronic solutions are prohibitive.

Errors in preparation and administration of parenteral drugs in neonatology: evaluation and corrective actions.

PubMed

Hasni, Nesrine; Ben Hamida, Emira; Ben Jeddou, Khouloud; Ben Hamida, Sarra; Ayadi, Imene; Ouahchi, Zeineb; Marrakchi, Zahra

2016-12-01

The medication iatrogenic risk is quite unevaluated in neonatology Objective: Assessment of errors that occurred during the preparation and administration of injectable medicines in a neonatal unit in order to implement corrective actions to reduce the occurrence of these errors. A prospective, observational study was performed in a neonatal unit over a period of one month. The practice of preparing and administering injectable medications were identified through a standardized data collection form. These practices were compared with summaries of the characteristics of each product (RCP) and the bibliography. One hundred preparations were observed of 13 different drugs. 85 errors during preparations and administration steps were detected. These errors were divided into preparation errors in 59% of cases such as changing the dilution protocol (32%), the use of bad solvent (11%) and administration errors in 41% of cases as errors timing of administration (18%) or omission of administration (9%). This study showed a high rate of errors during stages of preparation and administration of injectable drugs. In order to optimize the care of newborns and reduce the risk of medication errors, corrective actions have been implemented through the establishment of a quality assurance system which consisted of the development of injectable drugs preparation procedures, the introduction of a labeling system and staff training.

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.

Obligation towards medical errors disclosure at a tertiary care hospital in Dubai, UAE

PubMed Central

Zaghloul, Ashraf Ahmad; Rahman, Syed Azizur; Abou El-Enein, Nagwa Younes

2016-01-01

OBJECTIVE: The study aimed to identify healthcare providers’ obligation towards medical errors disclosure as well as to study the association between the severity of the medical error and the intention to disclose the error to the patients and their families. DESIGN: A cross-sectional study design was followed to identify the magnitude of disclosure among healthcare providers in different departments at a randomly selected tertiary care hospital in Dubai. SETTING AND PARTICIPANTS: The total sample size accounted for 106 respondents. Data were collected using a questionnaire composed of two sections namely; demographic variables of the respondents and a section which included variables relevant to medical error disclosure. RESULTS: Statistical analysis yielded significant association between the obligation to disclose medical errors with male healthcare providers (X2 = 5.1), and being a physician (X2 = 19.3). Obligation towards medical errors disclosure was significantly associated with those healthcare providers who had not committed any medical errors during the past year (X2 = 9.8), and any type of medical error regardless the cause, extent of harm (X2 = 8.7). Variables included in the binary logistic regression model were; status (Exp β (Physician) = 0.39, 95% CI 0.16–0.97), gender (Exp β (Male) = 4.81, 95% CI 1.84–12.54), and medical errors during the last year (Exp β (None) = 2.11, 95% CI 0.6–2.3). CONCLUSION: Education and training of physicians about disclosure conversations needs to start as early as medical school. Like the training in other competencies required of physicians, education in communicating about medical errors could help reduce physicians’ apprehension and make them more comfortable with disclosure conversations. PMID:27567766

Increasing skepticism toward potential liars: effects of existential threat on veracity judgments and the moderating role of honesty norm activation

PubMed Central

Schindler, Simon; Reinhard, Marc-André

2015-01-01

With the present research, we investigated effects of existential threat on veracity judgments. According to several meta-analyses, people judge potentially deceptive messages of other people as true rather than as false (so-called truth bias). This judgmental bias has been shown to depend on how people weigh the error of judging a true message as a lie (error 1) and the error of judging a lie as a true message (error 2). The weight of these errors has been further shown to be affected by situational variables. Given that research on terror management theory has found evidence that mortality salience (MS) increases the sensitivity toward the compliance of cultural norms, especially when they are of focal attention, we assumed that when the honesty norm is activated, MS affects judgmental error weighing and, consequently, judgmental biases. Specifically, activating the norm of honesty should decrease the weight of error 1 (the error of judging a true message as a lie) and increase the weight of error 2 (the error of judging a lie as a true message) when mortality is salient. In a first study, we found initial evidence for this assumption. Furthermore, the change in error weighing should reduce the truth bias, automatically resulting in better detection accuracy of actual lies and worse accuracy of actual true statements. In two further studies, we manipulated MS and honesty norm activation before participants judged several videos containing actual truths or lies. Results revealed evidence for our prediction. Moreover, in Study 3, the truth bias was increased after MS when group solidarity was previously emphasized. PMID:26388815

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

PubMed

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

2018-05-01

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

Observer detection of image degradation caused by irreversible data compression processes

NASA Astrophysics Data System (ADS)

Chen, Ji; Flynn, Michael J.; Gross, Barry; Spizarny, David

1991-05-01

Irreversible data compression methods have been proposed to reduce the data storage and communication requirements of digital imaging systems. In general, the error produced by compression increases as an algorithm''s compression ratio is increased. We have studied the relationship between compression ratios and the detection of induced error using radiologic observers. The nature of the errors was characterized by calculating the power spectrum of the difference image. In contrast with studies designed to test whether detected errors alter diagnostic decisions, this study was designed to test whether observers could detect the induced error. A paired-film observer study was designed to test whether induced errors were detected. The study was conducted with chest radiographs selected and ranked for subtle evidence of interstitial disease, pulmonary nodules, or pneumothoraces. Images were digitized at 86 microns (4K X 5K) and 2K X 2K regions were extracted. A full-frame discrete cosine transform method was used to compress images at ratios varying between 6:1 and 60:1. The decompressed images were reprinted next to the original images in a randomized order with a laser film printer. The use of a film digitizer and a film printer which can reproduce all of the contrast and detail in the original radiograph makes the results of this study insensitive to instrument performance and primarily dependent on radiographic image quality. The results of this study define conditions for which errors associated with irreversible compression cannot be detected by radiologic observers. The results indicate that an observer can detect the errors introduced by this compression algorithm for compression ratios of 10:1 (1.2 bits/pixel) or higher.

Adverse Drug Events and Medication Errors in African Hospitals: A Systematic Review.

PubMed

Mekonnen, Alemayehu B; Alhawassi, Tariq M; McLachlan, Andrew J; Brien, Jo-Anne E

2018-03-01

Medication errors and adverse drug events are universal problems contributing to patient harm but the magnitude of these problems in Africa remains unclear. The objective of this study was to systematically investigate the literature on the extent of medication errors and adverse drug events, and the factors contributing to medication errors in African hospitals. We searched PubMed, MEDLINE, EMBASE, Web of Science and Global Health databases from inception to 31 August, 2017 and hand searched the reference lists of included studies. Original research studies of any design published in English that investigated adverse drug events and/or medication errors in any patient population in the hospital setting in Africa were included. Descriptive statistics including median and interquartile range were presented. Fifty-one studies were included; of these, 33 focused on medication errors, 15 on adverse drug events, and three studies focused on medication errors and adverse drug events. These studies were conducted in nine (of the 54) African countries. In any patient population, the median (interquartile range) percentage of patients reported to have experienced any suspected adverse drug event at hospital admission was 8.4% (4.5-20.1%), while adverse drug events causing admission were reported in 2.8% (0.7-6.4%) of patients but it was reported that a median of 43.5% (20.0-47.0%) of the adverse drug events were deemed preventable. Similarly, the median mortality rate attributed to adverse drug events was reported to be 0.1% (interquartile range 0.0-0.3%). The most commonly reported types of medication errors were prescribing errors, occurring in a median of 57.4% (interquartile range 22.8-72.8%) of all prescriptions and a median of 15.5% (interquartile range 7.5-50.6%) of the prescriptions evaluated had dosing problems. Major contributing factors for medication errors reported in these studies were individual practitioner factors (e.g. fatigue and inadequate knowledge/training) and environmental factors, such as workplace distraction and high workload. Medication errors in the African healthcare setting are relatively common, and the impact of adverse drug events is substantial but many are preventable. This review supports the design and implementation of preventative strategies targeting the most likely contributing factors.

Development and Assessment of a Medication Safety Measurement Program in a Long-Term Care Pharmacy.

PubMed

Hertig, John B; Hultgren, Kyle E; Parks, Scott; Rondinelli, Rick

2016-02-01

Medication errors continue to be a major issue in the health care system, including in long-term care facilities. While many hospitals and health systems have developed methods to identify, track, and prevent these errors, long-term care facilities historically have not invested in these error-prevention strategies. The objective of this study was two-fold: 1) to develop a set of medication-safety process measures for dispensing in a long-term care pharmacy, and 2) to analyze the data from those measures to determine the relative safety of the process. The study was conducted at In Touch Pharmaceuticals in Valparaiso, Indiana. To assess the safety of the medication-use system, each step was documented using a comprehensive flowchart (process flow map) tool. Once completed and validated, the flowchart was used to complete a "failure modes and effects analysis" (FMEA) identifying ways a process may fail. Operational gaps found during FMEA were used to identify points of measurement. The research identified a set of eight measures as potential areas of failure; data were then collected on each one of these. More than 133,000 medication doses (opportunities for errors) were included in the study during the research time frame (April 1, 2014, and ended on June 4, 2014). Overall, there was an approximate order-entry error rate of 15.26%, with intravenous errors at 0.37%. A total of 21 errors migrated through the entire medication-use system. These 21 errors in 133,000 opportunities resulted in a final check error rate of 0.015%. A comprehensive medication-safety measurement program was designed and assessed. This study demonstrated the ability to detect medication errors in a long-term pharmacy setting, thereby making process improvements measureable. Future, larger, multi-site studies should be completed to test this measurement program.

Patients' perception of types of errors in palliative care - results from a qualitative interview study.

PubMed

Kiesewetter, Isabel; Schulz, Christian; Bausewein, Claudia; Fountain, Rita; Schmitz, Andrea

2016-08-11

Medical errors have been recognized as a relevant public health concern and research efforts to improve patient safety have increased. In palliative care, however, studies on errors are rare and mainly focus on quantitative measures. We aimed to explore how palliative care patients perceive and think about errors in palliative care and to generate an understanding of patients' perception of errors in that specialty. A semistructured qualitative interview study was conducted with patients who had received at least 1 week of palliative care in an inpatient or outpatient setting. All interviews were transcribed verbatim and analysed according to qualitative content analysis. Twelve patients from two centers were interviewed (7 women, median age 63.5 years, range 22-90 years). Eleven patients suffered from a malignancy. Days in palliative care ranged from 10 to 180 days (median 28 days). 96 categories emerged which were summed up under 11 umbrella terms definition, difference, type, cause, consequence, meaning, recognition, handling, prevention, person causing and affected person. A deductive model was developed assigning umbrella terms to error-theory-based factor levels (definition, type and process-related factors). 23 categories for type of error were identified, including 12 categories that can be considered as palliative care specific. On the level of process-related factors 3 palliative care specific categories emerged (recognition, meaning and consequence of errors). From the patients' perspective, there are some aspects of errors that could be considered as specific to palliative care. As the results of our study suggest, these palliative care-specific aspects seem to be very important from the patients' point of view and should receive further investigation. Moreover, the findings of this study can serve as a guide to further assess single aspects or categories of errors in palliative care in future research.

Systematic review of statistical approaches to quantify, or correct for, measurement error in a continuous exposure in nutritional epidemiology.

PubMed

Bennett, Derrick A; Landry, Denise; Little, Julian; Minelli, Cosetta

2017-09-19

Several statistical approaches have been proposed to assess and correct for exposure measurement error. We aimed to provide a critical overview of the most common approaches used in nutritional epidemiology. MEDLINE, EMBASE, BIOSIS and CINAHL were searched for reports published in English up to May 2016 in order to ascertain studies that described methods aimed to quantify and/or correct for measurement error for a continuous exposure in nutritional epidemiology using a calibration study. We identified 126 studies, 43 of which described statistical methods and 83 that applied any of these methods to a real dataset. The statistical approaches in the eligible studies were grouped into: a) approaches to quantify the relationship between different dietary assessment instruments and "true intake", which were mostly based on correlation analysis and the method of triads; b) approaches to adjust point and interval estimates of diet-disease associations for measurement error, mostly based on regression calibration analysis and its extensions. Two approaches (multiple imputation and moment reconstruction) were identified that can deal with differential measurement error. For regression calibration, the most common approach to correct for measurement error used in nutritional epidemiology, it is crucial to ensure that its assumptions and requirements are fully met. Analyses that investigate the impact of departures from the classical measurement error model on regression calibration estimates can be helpful to researchers in interpreting their findings. With regard to the possible use of alternative methods when regression calibration is not appropriate, the choice of method should depend on the measurement error model assumed, the availability of suitable calibration study data and the potential for bias due to violation of the classical measurement error model assumptions. On the basis of this review, we provide some practical advice for the use of methods to assess and adjust for measurement error in nutritional epidemiology.

Decrease in medical command errors with use of a "standing orders" protocol system.

PubMed

Holliman, C J; Wuerz, R C; Meador, S A

1994-05-01

The purpose of this study was to determine the physician medical command error rates and paramedic error rates after implementation of a "standing orders" protocol system for medical command. These patient-care error rates were compared with the previously reported rates for a "required call-in" medical command system (Ann Emerg Med 1992; 21(4):347-350). A secondary aim of the study was to determine if the on-scene time interval was increased by the standing orders system. Prospectively conducted audit of prehospital advanced life support (ALS) trip sheets was made at an urban ALS paramedic service with on-line physician medical command from three local hospitals. All ALS run sheets from the start time of the standing orders system (April 1, 1991) for a 1-year period ending on March 30, 1992 were reviewed as part of an ongoing quality assurance program. Cases were identified as nonjustifiably deviating from regional emergency medical services (EMS) protocols as judged by agreement of three physician reviewers (the same methodology as a previously reported command error study in the same ALS system). Medical command and paramedic errors were identified from the prehospital ALS run sheets and categorized. Two thousand one ALS runs were reviewed; 24 physician errors (1.2% of the 1,928 "command" runs) and eight paramedic errors (0.4% of runs) were identified. The physician error rate was decreased from the 2.6% rate in the previous study (P < .0001 by chi 2 analysis). The on-scene time interval did not increase with the "standing orders" system.(ABSTRACT TRUNCATED AT 250 WORDS)

Exploring Situational Awareness in Diagnostic Errors in Primary Care

PubMed Central

Singh, Hardeep; Giardina, Traber Davis; Petersen, Laura A.; Smith, Michael; Wilson, Lindsey; Dismukes, Key; Bhagwath, Gayathri; Thomas, Eric J.

2013-01-01

Objective Diagnostic errors in primary care are harmful but poorly studied. To facilitate understanding of diagnostic errors in real-world primary care settings using electronic health records (EHRs), this study explored the use of the Situational Awareness (SA) framework from aviation human factors research. Methods A mixed-methods study was conducted involving reviews of EHR data followed by semi-structured interviews of selected providers from two institutions in the US. The study population included 380 consecutive patients with colorectal and lung cancers diagnosed between February 2008 and January 2009. Using a pre-tested data collection instrument, trained physicians identified diagnostic errors, defined as lack of timely action on one or more established indications for diagnostic work-up for lung and colorectal cancers. Twenty-six providers involved in cases with and without errors were interviewed. Interviews probed for providers' lack of SA and how this may have influenced the diagnostic process. Results Of 254 cases meeting inclusion criteria, errors were found in 30 (32.6%) of 92 lung cancer cases and 56 (33.5%) of 167 colorectal cancer cases. Analysis of interviews related to error cases revealed evidence of lack of one of four levels of SA applicable to primary care practice: information perception, information comprehension, forecasting future events, and choosing appropriate action based on the first three levels. In cases without error, the application of the SA framework provided insight into processes involved in attention management. Conclusions A framework of SA can help analyze and understand diagnostic errors in primary care settings that use EHRs. PMID:21890757

Failure mode and effective analysis ameliorate awareness of medical errors: a 4-year prospective observational study in critically ill children.

PubMed

Daverio, Marco; Fino, Giuliana; Luca, Brugnaro; Zaggia, Cristina; Pettenazzo, Andrea; Parpaiola, Antonella; Lago, Paola; Amigoni, Angela

2015-12-01

Errors in are estimated to occur with an incidence of 3.7-16.6% in hospitalized patients. The application of systems for detection of adverse events is becoming a widespread reality in healthcare. Incident reporting (IR) and failure mode and effective analysis (FMEA) are strategies widely used to detect errors, but no studies have combined them in the setting of a pediatric intensive care unit (PICU). The aim of our study was to describe the trend of IR in a PICU and evaluate the effect of FMEA application on the number and severity of the errors detected. With this prospective observational study, we evaluated the frequency IR documented in standard IR forms completed from January 2009 to December 2012 in the PICU of Woman's and Child's Health Department of Padova. On the basis of their severity, errors were classified as: without outcome (55%), with minor outcome (16%), with moderate outcome (10%), and with major outcome (3%); 16% of reported incidents were 'near misses'. We compared the data before and after the introduction of FMEA. Sixty-nine errors were registered, 59 (86%) concerning drug therapy (83% during prescription). Compared to 2009-2010, in 2011-2012, we noted an increase of reported errors (43 vs 26) with a reduction of their severity (21% vs 8% 'near misses' and 65% vs 38% errors with no outcome). With the introduction of FMEA, we obtained an increased awareness in error reporting. Application of these systems will improve the quality of healthcare services. © 2015 John Wiley & Sons Ltd.

A survey of community members' perceptions of medical errors in Oman

PubMed Central

Al-Mandhari, Ahmed S; Al-Shafaee, Mohammed A; Al-Azri, Mohammed H; Al-Zakwani, Ibrahim S; Khan, Mushtaq; Al-Waily, Ahmed M; Rizvi, Syed

2008-01-01

Background Errors have been the concern of providers and consumers of health care services. However, consumers' perception of medical errors in developing countries is rarely explored. The aim of this study is to assess community members' perceptions about medical errors and to analyse the factors affecting this perception in one Middle East country, Oman. Methods Face to face interviews were conducted with heads of 212 households in two villages in North Al-Batinah region of Oman selected because of close proximity to the Sultan Qaboos University (SQU), Muscat, Oman. Participants' perceived knowledge about medical errors was assessed. Responses were coded and categorised. Analyses were performed using Pearson's χ2, Fisher's exact tests, and multivariate logistic regression model wherever appropriate. Results Seventy-eight percent (n = 165) of participants believed they knew what was meant by medical errors. Of these, 34% and 26.5% related medical errors to wrong medications or diagnoses, respectively. Understanding of medical errors was correlated inversely with age and positively with family income. Multivariate logistic regression revealed that a one-year increase in age was associated with a 4% reduction in perceived knowledge of medical errors (CI: 1% to 7%; p = 0.045). The study found that 49% of those who believed they knew the meaning of medical errors had experienced such errors. The most common consequence of the errors was severe pain (45%). Of the 165 informed participants, 49% felt that an uncaring health care professional was the main cause of medical errors. Younger participants were able to list more possible causes of medical errors than were older subjects (Incident Rate Ratio of 0.98; p < 0.001). Conclusion The majority of participants believed they knew the meaning of medical errors. Younger participants were more likely to be aware of such errors and could list one or more causes. PMID:18664245

Mitigating errors caused by interruptions during medication verification and administration: interventions in a simulated ambulatory chemotherapy setting.

PubMed

Prakash, Varuna; Koczmara, Christine; Savage, Pamela; Trip, Katherine; Stewart, Janice; McCurdie, Tara; Cafazzo, Joseph A; Trbovich, Patricia

2014-11-01

Nurses are frequently interrupted during medication verification and administration; however, few interventions exist to mitigate resulting errors, and the impact of these interventions on medication safety is poorly understood. The study objectives were to (A) assess the effects of interruptions on medication verification and administration errors, and (B) design and test the effectiveness of targeted interventions at reducing these errors. The study focused on medication verification and administration in an ambulatory chemotherapy setting. A simulation laboratory experiment was conducted to determine interruption-related error rates during specific medication verification and administration tasks. Interventions to reduce these errors were developed through a participatory design process, and their error reduction effectiveness was assessed through a postintervention experiment. Significantly more nurses committed medication errors when interrupted than when uninterrupted. With use of interventions when interrupted, significantly fewer nurses made errors in verifying medication volumes contained in syringes (16/18; 89% preintervention error rate vs 11/19; 58% postintervention error rate; p=0.038; Fisher's exact test) and programmed in ambulatory pumps (17/18; 94% preintervention vs 11/19; 58% postintervention; p=0.012). The rate of error commission significantly decreased with use of interventions when interrupted during intravenous push (16/18; 89% preintervention vs 6/19; 32% postintervention; p=0.017) and pump programming (7/18; 39% preintervention vs 1/19; 5% postintervention; p=0.017). No statistically significant differences were observed for other medication verification tasks. Interruptions can lead to medication verification and administration errors. Interventions were highly effective at reducing unanticipated errors of commission in medication administration tasks, but showed mixed effectiveness at reducing predictable errors of detection in medication verification tasks. These findings can be generalised and adapted to mitigate interruption-related errors in other settings where medication verification and administration are required. 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.

Mitigating errors caused by interruptions during medication verification and administration: interventions in a simulated ambulatory chemotherapy setting

PubMed Central

Prakash, Varuna; Koczmara, Christine; Savage, Pamela; Trip, Katherine; Stewart, Janice; McCurdie, Tara; Cafazzo, Joseph A; Trbovich, Patricia

2014-01-01

Background Nurses are frequently interrupted during medication verification and administration; however, few interventions exist to mitigate resulting errors, and the impact of these interventions on medication safety is poorly understood. Objective The study objectives were to (A) assess the effects of interruptions on medication verification and administration errors, and (B) design and test the effectiveness of targeted interventions at reducing these errors. Methods The study focused on medication verification and administration in an ambulatory chemotherapy setting. A simulation laboratory experiment was conducted to determine interruption-related error rates during specific medication verification and administration tasks. Interventions to reduce these errors were developed through a participatory design process, and their error reduction effectiveness was assessed through a postintervention experiment. Results Significantly more nurses committed medication errors when interrupted than when uninterrupted. With use of interventions when interrupted, significantly fewer nurses made errors in verifying medication volumes contained in syringes (16/18; 89% preintervention error rate vs 11/19; 58% postintervention error rate; p=0.038; Fisher's exact test) and programmed in ambulatory pumps (17/18; 94% preintervention vs 11/19; 58% postintervention; p=0.012). The rate of error commission significantly decreased with use of interventions when interrupted during intravenous push (16/18; 89% preintervention vs 6/19; 32% postintervention; p=0.017) and pump programming (7/18; 39% preintervention vs 1/19; 5% postintervention; p=0.017). No statistically significant differences were observed for other medication verification tasks. Conclusions Interruptions can lead to medication verification and administration errors. Interventions were highly effective at reducing unanticipated errors of commission in medication administration tasks, but showed mixed effectiveness at reducing predictable errors of detection in medication verification tasks. These findings can be generalised and adapted to mitigate interruption-related errors in other settings where medication verification and administration are required. PMID:24906806

Using Healthcare Failure Mode and Effect Analysis to reduce medication errors in the process of drug prescription, validation and dispensing in hospitalised patients.

PubMed

Vélez-Díaz-Pallarés, Manuel; Delgado-Silveira, Eva; Carretero-Accame, María Emilia; Bermejo-Vicedo, Teresa

2013-01-01

To identify actions to reduce medication errors in the process of drug prescription, validation and dispensing, and to evaluate the impact of their implementation. A Health Care Failure Mode and Effect Analysis (HFMEA) was supported by a before-and-after medication error study to measure the actual impact on error rate after the implementation of corrective actions in the process of drug prescription, validation and dispensing in wards equipped with computerised physician order entry (CPOE) and unit-dose distribution system (788 beds out of 1080) in a Spanish university hospital. The error study was carried out by two observers who reviewed medication orders on a daily basis to register prescription errors by physicians and validation errors by pharmacists. Drugs dispensed in the unit-dose trolleys were reviewed for dispensing errors. Error rates were expressed as the number of errors for each process divided by the total opportunities for error in that process times 100. A reduction in prescription errors was achieved by providing training for prescribers on CPOE, updating prescription procedures, improving clinical decision support and automating the software connection to the hospital census (relative risk reduction (RRR), 22.0%; 95% CI 12.1% to 31.8%). Validation errors were reduced after optimising time spent in educating pharmacy residents on patient safety, developing standardised validation procedures and improving aspects of the software's database (RRR, 19.4%; 95% CI 2.3% to 36.5%). Two actions reduced dispensing errors: reorganising the process of filling trolleys and drawing up a protocol for drug pharmacy checking before delivery (RRR, 38.5%; 95% CI 14.1% to 62.9%). HFMEA facilitated the identification of actions aimed at reducing medication errors in a healthcare setting, as the implementation of several of these led to a reduction in errors in the process of drug prescription, validation and dispensing.

WE-H-BRC-09: Simulated Errors in Mock Radiotherapy Plans to Quantify the Effectiveness of the Physics Plan Review

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

Gopan, O; Kalet, A; Smith, W

2016-06-15

Purpose: A standard tool for ensuring the quality of radiation therapy treatments is the initial physics plan review. However, little is known about its performance in practice. The goal of this study is to measure the effectiveness of physics plan review by introducing simulated errors into “mock” treatment plans and measuring the performance of plan review by physicists. Methods: We generated six mock treatment plans containing multiple errors. These errors were based on incident learning system data both within the department and internationally (SAFRON). These errors were scored for severity and frequency. Those with the highest scores were included inmore » the simulations (13 errors total). Observer bias was minimized using a multiple co-correlated distractor approach. Eight physicists reviewed these plans for errors, with each physicist reviewing, on average, 3/6 plans. The confidence interval for the proportion of errors detected was computed using the Wilson score interval. Results: Simulated errors were detected in 65% of reviews [51–75%] (95% confidence interval [CI] in brackets). The following error scenarios had the highest detection rates: incorrect isocenter in DRRs/CBCT (91% [73–98%]) and a planned dose different from the prescribed dose (100% [61–100%]). Errors with low detection rates involved incorrect field parameters in record and verify system (38%, [18–61%]) and incorrect isocenter localization in planning system (29% [8–64%]). Though pre-treatment QA failure was reliably identified (100%), less than 20% of participants reported the error that caused the failure. Conclusion: This is one of the first quantitative studies of error detection. Although physics plan review is a key safety measure and can identify some errors with high fidelity, others errors are more challenging to detect. This data will guide future work on standardization and automation. Creating new checks or improving existing ones (i.e., via automation) will help in detecting those errors with low detection rates.« less

A pilot study of the safety implications of Australian nurses' sleep and work hours.

PubMed

Dorrian, Jillian; Lamond, Nicole; van den Heuvel, Cameron; Pincombe, Jan; Rogers, Ann E; Dawson, Drew

2006-01-01

The frequency and severity of adverse events in Australian healthcare is under increasing scrutiny. A recent state government report identified 31 events involving "death or serious [patient] harm" and 452 "very high risk" incidents. Australia-wide, a previous study identified 2,324 adverse medical events (AME) in a single year, with more than half considered preventable. Despite the recognized link between fatigue and error in other industries, to date, few studies of medical errors have assessed the fatigue of the healthcare professionals involved. Nurses work extended and unpredictable hours with a lack of regular breaks and are therefore likely to experience elevated fatigue. Currently, there is very little available information on Australian nurses' sleep or fatigue levels, nor is there any information about whether this affects their performance. This study therefore aims to examine work hours, sleep, fatigue and error occurrence in Australian nurses. Using logbooks, 23 full-time nurses in a metropolitan hospital completed daily recordings for one month (644 days, 377 shifts) of their scheduled and actual work hours, sleep length and quality, sleepiness, and fatigue levels. Frequency and type of nursing errors, near errors, and observed errors (made by others) were recorded. Nurses reported struggling to remain awake during 36% of shifts. Moderate to high levels of stress, physical exhaustion, and mental exhaustion were reported on 23%, 40%, and 36% of shifts, respectively. Extreme drowsiness while driving or cycling home was reported on 45 occasions (11.5%), with three reports of near accidents. Overall, 20 errors, 13 near errors, and 22 observed errors were reported. The perceived potential consequences for the majority of errors were minor; however, 11 errors were associated with moderate and four with potentially severe consequences. Nurses reported that they had trouble falling asleep on 26.8% of days, had frequent arousals on 34.0% of days, and that work-related concerns were either partially or fully responsible for their sleep disruption on 12.5% of occasions. Fourteen out of the 23 nurses reported using a sleep aid. The most commonly reported sleep aids were prescription medications (62.7%), followed by alcohol (26.9%). Total sleep duration was significantly shorter on workdays than days off (p < 0.01). In comparison to other workdays, sleep was significantly shorter on days when an error (p < 0.05) or a near error (p < 0.01) was recorded. In contrast, sleep was higher on workdays when someone else's error was recorded (p = 0.08). Logistic regression analysis indicated that sleep duration was a significant predictor of error occurrence (chi2 = 6.739, p = 0.009, e beta = 0.727). The findings of this pilot study suggest that Australian nurses experience sleepiness and related physical symptoms at work and during their trip home. Further, a measurable number of errors occur of various types and severity. Less sleep may lead to the increased likelihood of making an error, and importantly, the decreased likelihood of catching someone else's error. These pilot results suggest that further investigation into the effects of sleep loss in nursing may be necessary for patient safety from an individual nurse perspective and from a healthcare team perspective.

A map overlay error model based on boundary geometry

USGS Publications Warehouse

Gaeuman, D.; Symanzik, J.; Schmidt, J.C.

2005-01-01

An error model for quantifying the magnitudes and variability of errors generated in the areas of polygons during spatial overlay of vector geographic information system layers is presented. Numerical simulation of polygon boundary displacements was used to propagate coordinate errors to spatial overlays. The model departs from most previous error models in that it incorporates spatial dependence of coordinate errors at the scale of the boundary segment. It can be readily adapted to match the scale of error-boundary interactions responsible for error generation on a given overlay. The area of error generated by overlay depends on the sinuosity of polygon boundaries, as well as the magnitude of the coordinate errors on the input layers. Asymmetry in boundary shape has relatively little effect on error generation. Overlay errors are affected by real differences in boundary positions on the input layers, as well as errors in the boundary positions. Real differences between input layers tend to compensate for much of the error generated by coordinate errors. Thus, the area of change measured on an overlay layer produced by the XOR overlay operation will be more accurate if the area of real change depicted on the overlay is large. The model presented here considers these interactions, making it especially useful for estimating errors studies of landscape change over time. ?? 2005 The Ohio State University.

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.

Uncorrected refractive errors

PubMed Central

Naidoo, Kovin S; Jaggernath, Jyoti

2012-01-01

Global estimates indicate that more than 2.3 billion people in the world suffer from poor vision due to refractive error; of which 670 million people are considered visually impaired because they do not have access to corrective treatment. Refractive errors, if uncorrected, results in an impaired quality of life for millions of people worldwide, irrespective of their age, sex and ethnicity. Over the past decade, a series of studies using a survey methodology, referred to as Refractive Error Study in Children (RESC), were performed in populations with different ethnic origins and cultural settings. These studies confirmed that the prevalence of uncorrected refractive errors is considerably high for children in low-and-middle-income countries. Furthermore, uncorrected refractive error has been noted to have extensive social and economic impacts, such as limiting educational and employment opportunities of economically active persons, healthy individuals and communities. The key public health challenges presented by uncorrected refractive errors, the leading cause of vision impairment across the world, require urgent attention. To address these issues, it is critical to focus on the development of human resources and sustainable methods of service delivery. This paper discusses three core pillars to addressing the challenges posed by uncorrected refractive errors: Human Resource (HR) Development, Service Development and Social Entrepreneurship. PMID:22944755

The Relationship Between Work Commitment, Dynamic, and Medication Error.

PubMed

Rezaiamin, Abdoolkarim; Pazokian, Marzieh; Zagheri Tafreshi, Mansoureh; Nasiri, Malihe

2017-05-01

Incidence of medication errors in intensive care unit (ICU) can cause irreparable damage for ICU patients. Therefore, it seems necessary to find the causes of medication errors in this section. Work commitment and dynamic might affect the incidence of medication errors in ICU. To assess the mentioned hypothesis, we performed a descriptive-analytical study which was carried out on 117 nurses working in ICU of educational hospitals in Tehran. Minick et al., Salyer et al., and Wakefield et al. scales were used for data gathering on work commitment, dynamic, and medication errors, respectively. Findings of the current study revealed that high work commitment in ICU nurses caused low number of medication errors, including intravenous and nonintravenous. We controlled the effects of confounding variables in detection of this relationship. In contrast, no significant association was found between work dynamic and different types of medication errors. Although the study did not observe any relationship between the dynamics and rate of medication errors, the training of nurses or nursing students to create a dynamic environment in hospitals can increase their interest in the profession and increase job satisfaction in them. Also they must have enough ability in work dynamic so that they don't confused and distracted result in frequent changes of orders, care plans, and procedures.

Sleep quality, but not quantity, is associated with self-perceived minor error rates among emergency department nurses.

PubMed

Weaver, Amy L; Stutzman, Sonja E; Supnet, Charlene; Olson, DaiWai M

2016-03-01

The emergency department (ED) is demanding and high risk. The impact of sleep quantity has been hypothesized to impact patient care. This study investigated the hypothesis that fatigue and impaired mentation, due to sleep disturbance and shortened overall sleeping hours, would lead to increased nursing errors. This is a prospective observational study of 30 ED nurses using self-administered survey and sleep architecture measured by wrist actigraphy as predictors of self-reported error rates. An actigraphy device was worn prior to working a 12-hour shift and nurses completed the Pittsburgh Sleep Quality Index (PSQI). Error rates were reported on a visual analog scale at the end of a 12-hour shift. The PSQI responses indicated that 73.3% of subjects had poor sleep quality. Lower sleep quality measured by actigraphy (hours asleep/hours in bed) was associated with higher self-perceived minor errors. Sleep quantity (total hours slept) was not associated with minor, moderate, nor severe errors. Our study found that ED nurses' sleep quality, immediately prior to a working 12-hour shift, is more predictive of error than sleep quantity. These results present evidence that a "good night's sleep" prior to working a nursing shift in the ED is beneficial for reducing minor errors. Copyright © 2016 Elsevier Ltd. All rights reserved.

Understanding seasonal variability of uncertainty in hydrological prediction

NASA Astrophysics Data System (ADS)

Li, M.; Wang, Q. J.

2012-04-01

Understanding uncertainty in hydrological prediction can be highly valuable for improving the reliability of streamflow prediction. In this study, a monthly water balance model, WAPABA, in a Bayesian joint probability with error models are presented to investigate the seasonal dependency of prediction error structure. A seasonal invariant error model, analogous to traditional time series analysis, uses constant parameters for model error and account for no seasonal variations. In contrast, a seasonal variant error model uses a different set of parameters for bias, variance and autocorrelation for each individual calendar month. Potential connection amongst model parameters from similar months is not considered within the seasonal variant model and could result in over-fitting and over-parameterization. A hierarchical error model further applies some distributional restrictions on model parameters within a Bayesian hierarchical framework. An iterative algorithm is implemented to expedite the maximum a posterior (MAP) estimation of a hierarchical error model. Three error models are applied to forecasting streamflow at a catchment in southeast Australia in a cross-validation analysis. This study also presents a number of statistical measures and graphical tools to compare the predictive skills of different error models. From probability integral transform histograms and other diagnostic graphs, the hierarchical error model conforms better to reliability when compared to the seasonal invariant error model. The hierarchical error model also generally provides the most accurate mean prediction in terms of the Nash-Sutcliffe model efficiency coefficient and the best probabilistic prediction in terms of the continuous ranked probability score (CRPS). The model parameters of the seasonal variant error model are very sensitive to each cross validation, while the hierarchical error model produces much more robust and reliable model parameters. Furthermore, the result of the hierarchical error model shows that most of model parameters are not seasonal variant except for error bias. The seasonal variant error model is likely to use more parameters than necessary to maximize the posterior likelihood. The model flexibility and robustness indicates that the hierarchical error model has great potential for future streamflow predictions.

Errors in fluid therapy in medical wards.

PubMed

Mousavi, Maryam; Khalili, Hossein; Dashti-Khavidaki, Simin

2012-04-01

Intravenous fluid therapy remains an essential part of patients' care during hospitalization. There are only few studies that focused on fluid therapy in the hospitalized patients, and there is not any consensus statement about fluid therapy in patients who are hospitalized in medical wards. The aim of the present study was to assess intravenous fluid therapy status and related errors in the patients during the course of hospitalization in the infectious diseases wards of a referral teaching hospital. This study was conducted in the infectious diseases wards of Imam Khomeini Complex Hospital, Tehran, Iran. During a retrospective study, data related to intravenous fluid therapy were collected by two clinical pharmacists of infectious diseases from 2008 to 2010. Intravenous fluid therapy information including indication, type, volume and rate of fluid administration was recorded for each patient. An internal protocol for intravenous fluid therapy was designed based on literature review and available recommendations. The data related to patients' fluid therapy were compared with this protocol. The fluid therapy was considered appropriate if it was compatible with the protocol regarding indication of intravenous fluid therapy, type, electrolyte content and rate of fluid administration. Any mistake in the selection of fluid type, content, volume and rate of administration was considered as intravenous fluid therapy errors. Five hundred and ninety-six of medication errors were detected during the study period in the patients. Overall rate of fluid therapy errors was 1.3 numbers per patient during hospitalization. Errors in the rate of fluid administration (29.8%), incorrect fluid volume calculation (26.5%) and incorrect type of fluid selection (24.6%) were the most common types of errors. The patients' male sex, old age, baseline renal diseases, diabetes co-morbidity, and hospitalization due to endocarditis, HIV infection and sepsis are predisposing factors for the occurrence of fluid therapy errors in the patients. Our result showed that intravenous fluid therapy errors occurred commonly in the hospitalized patients especially in the medical wards. Improvement in knowledge and attention of health-care workers about these errors are essential for preventing of medication errors in aspect of fluid therapy.

The evolution of Crew Resource Management training in commercial aviation

NASA Technical Reports Server (NTRS)

Helmreich, R. L.; Merritt, A. C.; Wilhelm, J. A.

1999-01-01

In this study, we describe changes in the nature of Crew Resource Management (CRM) training in commercial aviation, including its shift from cockpit to crew resource management. Validation of the impact of CRM is discussed. Limitations of CRM, including lack of cross-cultural generality are considered. An overarching framework that stresses error management to increase acceptance of CRM concepts is presented. The error management approach defines behavioral strategies taught in CRM as error countermeasures that are employed to avoid error, to trap errors committed, and to mitigate the consequences of error.

Awareness of technology-induced errors and processes for identifying and preventing such errors.

PubMed

Bellwood, Paule; Borycki, Elizabeth M; Kushniruk, Andre W

2015-01-01

There is a need to determine if organizations working with health information technology are aware of technology-induced errors and how they are addressing and preventing them. The purpose of this study was to: a) determine the degree of technology-induced error awareness in various Canadian healthcare organizations, and b) identify those processes and procedures that are currently in place to help address, manage, and prevent technology-induced errors. We identified a lack of technology-induced error awareness among participants. Participants identified there was a lack of well-defined procedures in place for reporting technology-induced errors, addressing them when they arise, and preventing them.

Medical errors and uncertainty in primary healthcare: A comparative study of coping strategies among young and experienced GPs

PubMed Central

Kuikka, Liisa; Pitkälä, Kaisu

2014-01-01

Abstract Objective. To study coping differences between young and experienced GPs in primary care who experience medical errors and uncertainty. Design. Questionnaire-based survey (self-assessment) conducted in 2011. Setting. Finnish primary practice offices in Southern Finland. Subjects. Finnish GPs engaged in primary health care from two different respondent groups: young (working experience ≤ 5years, n = 85) and experienced (working experience > 5 years, n = 80). Main outcome measures. Outcome measures included experiences and attitudes expressed by the included participants towards medical errors and tolerance of uncertainty, their coping strategies, and factors that may influence (positively or negatively) sources of errors. Results. In total, 165/244 GPs responded (response rate: 68%). Young GPs expressed significantly more often fear of committing a medical error (70.2% vs. 48.1%, p = 0.004) and admitted more often than experienced GPs that they had committed a medical error during the past year (83.5% vs. 68.8%, p = 0.026). Young GPs were less prone to apologize to a patient for an error (44.7% vs. 65.0%, p = 0.009) and found, more often than their more experienced colleagues, on-site consultations and electronic databases useful for avoiding mistakes. Conclusion. Experienced GPs seem to better tolerate uncertainty and also seem to fear medical errors less than their young colleagues. Young and more experienced GPs use different coping strategies for dealing with medical errors. Implications. When GPs become more experienced, they seem to get better at coping with medical errors. Means to support these skills should be studied in future research. PMID:24914458

Separate Medication Preparation Rooms Reduce Interruptions and Medication Errors in the Hospital Setting: A Prospective Observational Study.

PubMed

Huckels-Baumgart, Saskia; Baumgart, André; Buschmann, Ute; Schüpfer, Guido; Manser, Tanja

2016-12-21

Interruptions and errors during the medication process are common, but published literature shows no evidence supporting whether separate medication rooms are an effective single intervention in reducing interruptions and errors during medication preparation in hospitals. We tested the hypothesis that the rate of interruptions and reported medication errors would decrease as a result of the introduction of separate medication rooms. Our aim was to evaluate the effect of separate medication rooms on interruptions during medication preparation and on self-reported medication error rates. We performed a preintervention and postintervention study using direct structured observation of nurses during medication preparation and daily structured medication error self-reporting of nurses by questionnaires in 2 wards at a major teaching hospital in Switzerland. A volunteer sample of 42 nurses was observed preparing 1498 medications for 366 patients over 17 hours preintervention and postintervention on both wards. During 122 days, nurses completed 694 reporting sheets containing 208 medication errors. After the introduction of the separate medication room, the mean interruption rate decreased significantly from 51.8 to 30 interruptions per hour (P < 0.01), and the interruption-free preparation time increased significantly from 1.4 to 2.5 minutes (P < 0.05). Overall, the mean medication error rate per day was also significantly reduced after implementation of the separate medication room from 1.3 to 0.9 errors per day (P < 0.05). The present study showed the positive effect of a hospital-based intervention; after the introduction of the separate medication room, the interruption and medication error rates decreased significantly.

Potential benefit of electronic pharmacy claims data to prevent medication history errors and resultant inpatient order errors

PubMed Central

Palmer, Katherine A; Shane, Rita; Wu, Cindy N; Bell, Douglas S; Diaz, Frank; Cook-Wiens, Galen; Jackevicius, Cynthia A

2016-01-01

Objective We sought to assess the potential of a widely available source of electronic medication data to prevent medication history errors and resultant inpatient order errors. Methods We used admission medication history (AMH) data from a recent clinical trial that identified 1017 AMH errors and 419 resultant inpatient order errors among 194 hospital admissions of predominantly older adult patients on complex medication regimens. Among the subset of patients for whom we could access current Surescripts electronic pharmacy claims data (SEPCD), two pharmacists independently assessed error severity and our main outcome, which was whether SEPCD (1) was unrelated to the medication error; (2) probably would not have prevented the error; (3) might have prevented the error; or (4) probably would have prevented the error. Results Seventy patients had both AMH errors and current, accessible SEPCD. SEPCD probably would have prevented 110 (35%) of 315 AMH errors and 46 (31%) of 147 resultant inpatient order errors. When we excluded the least severe medication errors, SEPCD probably would have prevented 99 (47%) of 209 AMH errors and 37 (61%) of 61 resultant inpatient order errors. SEPCD probably would have prevented at least one AMH error in 42 (60%) of 70 patients. Conclusion When current SEPCD was available for older adult patients on complex medication regimens, it had substantial potential to prevent AMH errors and resultant inpatient order errors, with greater potential to prevent more severe errors. Further study is needed to measure the benefit of SEPCD in actual use at hospital admission. PMID:26911817

Quantifying the Contributions of Environmental Parameters to Ceres Surface Net Radiation Error in China

NASA Astrophysics Data System (ADS)

Pan, X.; Yang, Y.; Liu, Y.; Fan, X.; Shan, L.; Zhang, X.

2018-04-01

Error source analyses are critical for the satellite-retrieved surface net radiation (Rn) products. In this study, we evaluate the Rn error sources in the Clouds and the Earth's Radiant Energy System (CERES) project at 43 sites from July in 2007 to December in 2007 in China. The results show that cloud fraction (CF), land surface temperature (LST), atmospheric temperature (AT) and algorithm error dominate the Rn error, with error contributions of -20, 15, 10 and 10 W/m2 (net shortwave (NSW)/longwave (NLW) radiation), respectively. For NSW, the dominant error source is algorithm error (more than 10 W/m2), particularly in spring and summer with abundant cloud. For NLW, due to the high sensitivity of algorithm and large LST/CF error, LST and CF are the largest error sources, especially in northern China. The AT influences the NLW error large in southern China because of the large AT error in there. The total precipitable water has weak influence on Rn error even with the high sensitivity of algorithm. In order to improve Rn quality, CF and LST (AT) error in northern (southern) China should be decreased.

Medication Administration Errors in Nursing Homes Using an Automated Medication Dispensing System

PubMed Central

van den Bemt, Patricia M.L.A.; Idzinga, Jetske C.; Robertz, Hans; Kormelink, Dennis Groot; Pels, Neske

2009-01-01

Objective To identify the frequency of medication administration errors as well as their potential risk factors in nursing homes using a distribution robot. Design The study was a prospective, observational study conducted within three nursing homes in the Netherlands caring for 180 individuals. Measurements Medication errors were measured using the disguised observation technique. Types of medication errors were described. The correlation between several potential risk factors and the occurrence of medication errors was studied to identify potential causes for the errors. Results In total 2,025 medication administrations to 127 clients were observed. In these administrations 428 errors were observed (21.2%). The most frequently occurring types of errors were use of wrong administration techniques (especially incorrect crushing of medication and not supervising the intake of medication) and wrong time errors (administering the medication at least 1 h early or late).The potential risk factors female gender (odds ratio (OR) 1.39; 95% confidence interval (CI) 1.05–1.83), ATC medication class antibiotics (OR 11.11; 95% CI 2.66–46.50), medication crushed (OR 7.83; 95% CI 5.40–11.36), number of dosages/day/client (OR 1.03; 95% CI 1.01–1.05), nursing home 2 (OR 3.97; 95% CI 2.86–5.50), medication not supplied by distribution robot (OR 2.92; 95% CI 2.04–4.18), time classes “7–10 am” (OR 2.28; 95% CI 1.50–3.47) and “10 am-2 pm” (OR 1.96; 1.18–3.27) and day of the week “Wednesday” (OR 1.46; 95% CI 1.03–2.07) are associated with a higher risk of administration errors. Conclusions Medication administration in nursing homes is prone to many errors. This study indicates that the handling of the medication after removing it from the robot packaging may contribute to this high error frequency, which may be reduced by training of nurse attendants, by automated clinical decision support and by measures to reduce workload. PMID:19390109

Systematic evidence review of rates and burden of harm of intravenous admixture drug preparation errors in healthcare settings.

PubMed

Hedlund, Nancy; Beer, Idal; Hoppe-Tichy, Torsten; Trbovich, Patricia

2017-12-28

To examine published evidence on intravenous admixture preparation errors (IAPEs) in healthcare settings. Searches were conducted in three electronic databases (January 2005 to April 2017). Publications reporting rates of IAPEs and error types were reviewed and categorised into the following groups: component errors, dose/calculation errors, aseptic technique errors and composite errors. The methodological rigour of each study was assessed using the Hawker method. Of the 34 articles that met inclusion criteria, 28 reported the site of IAPEs: central pharmacies (n=8), nursing wards (n=14), both settings (n=4) and other sites (n=3). Using the Hawker criteria, 14% of the articles were of good quality, 74% were of fair quality and 12% were of poor quality. Error types and reported rates varied substantially, including wrong drug (~0% to 4.7%), wrong diluent solution (0% to 49.0%), wrong label (0% to 99.0%), wrong dose (0% to 32.6%), wrong concentration (0.3% to 88.6%), wrong diluent volume (0.06% to 49.0%) and inadequate aseptic technique (0% to 92.7%)%). Four studies directly compared incidence by preparation site and/or method, finding error incidence to be lower for doses prepared within a central pharmacy versus the nursing ward and lower for automated preparation versus manual preparation. Although eight studies (24%) reported ≥1 errors with the potential to cause patient harm, no study directly linked IAPE occurrences to specific adverse patient outcomes. The available data suggest a need to continue to optimise the intravenous preparation process, focus on improving preparation workflow, design and implement preventive strategies, train staff on optimal admixture protocols and implement standardisation. Future research should focus on the development of consistent error subtype definitions, standardised reporting methodology and reliable, reproducible methods to track and link risk factors with the burden of harm associated with these errors. © Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2017. All rights reserved. No commercial use is permitted unless otherwise expressly granted.

Acoustic Evidence for Phonologically Mismatched Speech Errors

ERIC Educational Resources Information Center

Gormley, Andrea

2015-01-01

Speech errors are generally said to accommodate to their new phonological context. This accommodation has been validated by several transcription studies. The transcription methodology is not the best choice for detecting errors at this level, however, as this type of error can be difficult to perceive. This paper presents an acoustic analysis of…

Error Detection/Correction in Collaborative Writing

ERIC Educational Resources Information Center

Pilotti, Maura; Chodorow, Martin

2009-01-01

In the present study, we examined error detection/correction during collaborative writing. Subjects were asked to identify and correct errors in two contexts: a passage written by the subject (familiar text) and a passage written by a person other than the subject (unfamiliar text). A computer program inserted errors in function words prior to the…

Information-Gathering Patterns Associated with Higher Rates of Diagnostic Error

ERIC Educational Resources Information Center

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

2009-01-01

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

Perceptual Bias in Speech Error Data Collection: Insights from Spanish Speech Errors

ERIC Educational Resources Information Center

Perez, Elvira; Santiago, Julio; Palma, Alfonso; O'Seaghdha, Padraig G.

2007-01-01

This paper studies the reliability and validity of naturalistic speech errors as a tool for language production research. Possible biases when collecting naturalistic speech errors are identified and specific predictions derived. These patterns are then contrasted with published reports from Germanic languages (English, German and Dutch) and one…

Understanding EFL Students' Errors in Writing

ERIC Educational Resources Information Center

Phuket, Pimpisa Rattanadilok Na; Othman, Normah Binti

2015-01-01

Writing is the most difficult skill in English, so most EFL students tend to make errors in writing. In assisting the learners to successfully acquire writing skill, the analysis of errors and the understanding of their sources are necessary. This study attempts to explore the major sources of errors occurred in the writing of EFL students. It…

Spatial autocorrelation among automated geocoding errors and its effects on testing for disease clustering

PubMed Central

Li, Jie; Fang, Xiangming

2010-01-01

Automated geocoding of patient addresses is an important data assimilation component of many spatial epidemiologic studies. Inevitably, the geocoding process results in positional errors. Positional errors incurred by automated geocoding tend to reduce the power of tests for disease clustering and otherwise affect spatial analytic methods. However, there are reasons to believe that the errors may often be positively spatially correlated and that this may mitigate their deleterious effects on spatial analyses. In this article, we demonstrate explicitly that the positional errors associated with automated geocoding of a dataset of more than 6000 addresses in Carroll County, Iowa are spatially autocorrelated. Furthermore, through two simulation studies of disease processes, including one in which the disease process is overlain upon the Carroll County addresses, we show that spatial autocorrelation among geocoding errors maintains the power of two tests for disease clustering at a level higher than that which would occur if the errors were independent. Implications of these results for cluster detection, privacy protection, and measurement-error modeling of geographic health data are discussed. PMID:20087879

Using Automated Writing Evaluation to Reduce Grammar Errors in Writing

ERIC Educational Resources Information Center

Liao, Hui-Chuan

2016-01-01

Despite the recent development of automated writing evaluation (AWE) technology and the growing interest in applying this technology to language classrooms, few studies have looked at the effects of using AWE on reducing grammatical errors in L2 writing. This study identified the primary English grammatical error types made by 66 Taiwanese…

A simulation study to quantify the impacts of exposure measurement error on air pollution health risk estimates in copollutant time-series models.

EPA Science Inventory

BackgroundExposure measurement error in copollutant epidemiologic models has the potential to introduce bias in relative risk (RR) estimates. A simulation study was conducted using empirical data to quantify the impact of correlated measurement errors in time-series analyses of a...

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

ERIC Educational Resources Information Center

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

2011-01-01

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

Students' Mathematical Work on Absolute Value: Focusing on Conceptions, Errors and Obstacles

ERIC Educational Resources Information Center

Elia, Iliada; Özel, Serkan; Gagatsis, Athanasios; Panaoura, Areti; Özel, Zeynep Ebrar Yetkiner

2016-01-01

This study investigates students' conceptions of absolute value (AV), their performance in various items on AV, their errors in these items and the relationships between students' conceptions and their performance and errors. The Mathematical Working Space (MWS) is used as a framework for studying students' mathematical work on AV and the…

Multipollutant measurement error in air pollution epidemiology studies arising from predicting exposures with penalized regression splines

PubMed Central

Bergen, Silas; Sheppard, Lianne; Kaufman, Joel D.; Szpiro, Adam A.

2016-01-01

Summary Air pollution epidemiology studies are trending towards a multi-pollutant approach. In these studies, exposures at subject locations are unobserved and must be predicted using observed exposures at misaligned monitoring locations. This induces measurement error, which can bias the estimated health effects and affect standard error estimates. We characterize this measurement error and develop an analytic bias correction when using penalized regression splines to predict exposure. Our simulations show bias from multi-pollutant measurement error can be severe, and in opposite directions or simultaneously positive or negative. Our analytic bias correction combined with a non-parametric bootstrap yields accurate coverage of 95% confidence intervals. We apply our methodology to analyze the association of systolic blood pressure with PM2.5 and NO2 in the NIEHS Sister Study. We find that NO2 confounds the association of systolic blood pressure with PM2.5 and vice versa. Elevated systolic blood pressure was significantly associated with increased PM2.5 and decreased NO2. Correcting for measurement error bias strengthened these associations and widened 95% confidence intervals. PMID:27789915

Long-term academic stress increases the late component of error processing: an ERP study.

PubMed

Wu, Jianhui; Yuan, Yiran; Duan, Hongxia; Qin, Shaozheng; Buchanan, Tony W; Zhang, Kan; Zhang, Liang

2014-05-01

Exposure to long-term stress has a variety of consequences on the brain and cognition. Few studies have examined the influence of long-term stress on event related potential (ERP) indices of error processing. The current study investigated how long-term academic stress modulates the error related negativity (Ne or ERN) and the error positivity (Pe) components of error processing. Forty-one male participants undergoing preparation for a major academic examination and 20 non-exam participants completed a Go-NoGo task while ERP measures were collected. The exam group reported higher perceived stress levels and showed increased Pe amplitude compared with the non-exam group. Participants' rating of the importance of the exam was positively associated with the amplitude of Pe, but these effects were not found for the Ne/ERN. These results suggest that long-term academic stress leads to greater motivational assessment of and higher emotional response to errors. Copyright © 2014 Elsevier B.V. All rights reserved.

Medicine and aviation: a review of the comparison.

PubMed

Randell, R

2003-01-01

This paper aims to understand the nature of medical error in highly technological environments and argues that a comparison with aviation can blur its real understanding. This study is a comparative study between the notion of error in health care and aviation based on the author's own ethnographic study in intensive care units and findings from the research literature on errors in aviation. Failures in the use of medical technology are common. In attempts to understand the area of medical error, much attention has focused on how we can learn from aviation. This paper argues that such a comparison is not always useful, on the basis that (i) the type of work and technology is very different in the two domains; (ii) different issues are involved in training and procurement; and (iii) attitudes to error vary between the domains. Therefore, it is necessary to look closely at the subject of medical error and resolve those questions left unanswered by the lessons of aviation.

Quasi-eccentricity error modeling and compensation in vision metrology

NASA Astrophysics Data System (ADS)

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

2018-04-01

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

Data entry errors and design for model-based tight glycemic control in critical care.

PubMed

Ward, Logan; Steel, James; Le Compte, Aaron; Evans, Alicia; Tan, Chia-Siong; Penning, Sophie; Shaw, Geoffrey M; Desaive, Thomas; Chase, J Geoffrey

2012-01-01

Tight glycemic control (TGC) has shown benefits but has been difficult to achieve consistently. Model-based methods and computerized protocols offer the opportunity to improve TGC quality but require human data entry, particularly of blood glucose (BG) values, which can be significantly prone to error. This study presents the design and optimization of data entry methods to minimize error for a computerized and model-based TGC method prior to pilot clinical trials. To minimize data entry error, two tests were carried out to optimize a method with errors less than the 5%-plus reported in other studies. Four initial methods were tested on 40 subjects in random order, and the best two were tested more rigorously on 34 subjects. The tests measured entry speed and accuracy. Errors were reported as corrected and uncorrected errors, with the sum comprising a total error rate. The first set of tests used randomly selected values, while the second set used the same values for all subjects to allow comparisons across users and direct assessment of the magnitude of errors. These research tests were approved by the University of Canterbury Ethics Committee. The final data entry method tested reduced errors to less than 1-2%, a 60-80% reduction from reported values. The magnitude of errors was clinically significant and was typically by 10.0 mmol/liter or an order of magnitude but only for extreme values of BG < 2.0 mmol/liter or BG > 15.0-20.0 mmol/liter, both of which could be easily corrected with automated checking of extreme values for safety. The data entry method selected significantly reduced data entry errors in the limited design tests presented, and is in use on a clinical pilot TGC study. The overall approach and testing methods are easily performed and generalizable to other applications and protocols. © 2012 Diabetes Technology Society.

IMRT QA: Selecting gamma criteria based on error detection sensitivity

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

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

Purpose: The gamma comparison is widely used to evaluate the agreement between measurements and treatment planning system calculations in patient-specific intensity modulated radiation therapy (IMRT) quality assurance (QA). However, recent publications have raised concerns about the lack of sensitivity when employing commonly used gamma criteria. Understanding the actual sensitivity of a wide range of different gamma criteria may allow the definition of more meaningful gamma criteria and tolerance limits in IMRT QA. We present a method that allows the quantitative determination of gamma criteria sensitivity to induced errors which can be applied to any unique combination of device, delivery technique,more » and software utilized in a specific clinic. Methods: A total of 21 DMLC IMRT QA measurements (ArcCHECK®, Sun Nuclear) were compared to QA plan calculations with induced errors. Three scenarios were studied: MU errors, multi-leaf collimator (MLC) errors, and the sensitivity of the gamma comparison to changes in penumbra width. Gamma comparisons were performed between measurements and error-induced calculations using a wide range of gamma criteria, resulting in a total of over 20 000 gamma comparisons. Gamma passing rates for each error class and case were graphed against error magnitude to create error curves in order to represent the range of missed errors in routine IMRT QA using 36 different gamma criteria. Results: This study demonstrates that systematic errors and case-specific errors can be detected by the error curve analysis. Depending on the location of the error curve peak (e.g., not centered about zero), 3%/3 mm threshold = 10% at 90% pixels passing may miss errors as large as 15% MU errors and ±1 cm random MLC errors for some cases. As the dose threshold parameter was increased for a given %Diff/distance-to-agreement (DTA) setting, error sensitivity was increased by up to a factor of two for select cases. This increased sensitivity with increasing dose threshold was consistent across all studied combinations of %Diff/DTA. Criteria such as 2%/3 mm and 3%/2 mm with a 50% threshold at 90% pixels passing are shown to be more appropriately sensitive without being overly strict. However, a broadening of the penumbra by as much as 5 mm in the beam configuration was difficult to detect with commonly used criteria, as well as with the previously mentioned criteria utilizing a threshold of 50%. Conclusions: We have introduced the error curve method, an analysis technique which allows the quantitative determination of gamma criteria sensitivity to induced errors. The application of the error curve method using DMLC IMRT plans measured on the ArcCHECK® device demonstrated that large errors can potentially be missed in IMRT QA with commonly used gamma criteria (e.g., 3%/3 mm, threshold = 10%, 90% pixels passing). Additionally, increasing the dose threshold value can offer dramatic increases in error sensitivity. This approach may allow the selection of more meaningful gamma criteria for IMRT QA and is straightforward to apply to other combinations of devices and treatment techniques.« less

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

PubMed

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

2014-09-01

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

Working memory load impairs the evaluation of behavioral errors in the medial frontal cortex.

PubMed

Maier, Martin E; Steinhauser, Marco

2017-10-01

Early error monitoring in the medial frontal cortex enables error detection and the evaluation of error significance, which helps prioritize adaptive control. This ability has been assumed to be independent from central capacity, a limited pool of resources assumed to be involved in cognitive control. The present study investigated whether error evaluation depends on central capacity by measuring the error-related negativity (Ne/ERN) in a flanker paradigm while working memory load was varied on two levels. We used a four-choice flanker paradigm in which participants had to classify targets while ignoring flankers. Errors could be due to responding either to the flankers (flanker errors) or to none of the stimulus elements (nonflanker errors). With low load, the Ne/ERN was larger for flanker errors than for nonflanker errors-an effect that has previously been interpreted as reflecting differential significance of these error types. With high load, no such effect of error type on the Ne/ERN was observable. Our findings suggest that working memory load does not impair the generation of an Ne/ERN per se but rather impairs the evaluation of error significance. They demonstrate that error monitoring is composed of capacity-dependent and capacity-independent mechanisms. © 2017 Society for Psychophysiological Research.

Evaluating mixed samples as a source of error in non-invasive genetic studies using microsatellites

USGS Publications Warehouse

Roon, David A.; Thomas, M.E.; Kendall, K.C.; Waits, L.P.

2005-01-01

The use of noninvasive genetic sampling (NGS) for surveying wild populations is increasing rapidly. Currently, only a limited number of studies have evaluated potential biases associated with NGS. This paper evaluates the potential errors associated with analysing mixed samples drawn from multiple animals. Most NGS studies assume that mixed samples will be identified and removed during the genotyping process. We evaluated this assumption by creating 128 mixed samples of extracted DNA from brown bear (Ursus arctos) hair samples. These mixed samples were genotyped and screened for errors at six microsatellite loci according to protocols consistent with those used in other NGS studies. Five mixed samples produced acceptable genotypes after the first screening. However, all mixed samples produced multiple alleles at one or more loci, amplified as only one of the source samples, or yielded inconsistent electropherograms by the final stage of the error-checking process. These processes could potentially reduce the number of individuals observed in NGS studies, but errors should be conservative within demographic estimates. Researchers should be aware of the potential for mixed samples and carefully design gel analysis criteria and error checking protocols to detect mixed samples.

Medication errors in chemotherapy preparation and administration: a survey conducted among oncology nurses in Turkey.

PubMed

Ulas, Arife; Silay, Kamile; Akinci, Sema; Dede, Didem Sener; Akinci, Muhammed Bulent; Sendur, Mehmet Ali Nahit; Cubukcu, Erdem; Coskun, Hasan Senol; Degirmenci, Mustafa; Utkan, Gungor; Ozdemir, Nuriye; Isikdogan, Abdurrahman; Buyukcelik, Abdullah; Inanc, Mevlude; Bilici, Ahmet; Odabasi, Hatice; Cihan, Sener; Avci, Nilufer; Yalcin, Bulent

2015-01-01

Medication errors in oncology may cause severe clinical problems due to low therapeutic indices and high toxicity of chemotherapeutic agents. We aimed to investigate unintentional medication errors and underlying factors during chemotherapy preparation and administration based on a systematic survey conducted to reflect oncology nurses experience. This study was conducted in 18 adult chemotherapy units with volunteer participation of 206 nurses. A survey developed by primary investigators and medication errors (MAEs) defined preventable errors during prescription of medication, ordering, preparation or administration. The survey consisted of 4 parts: demographic features of nurses; workload of chemotherapy units; errors and their estimated monthly number during chemotherapy preparation and administration; and evaluation of the possible factors responsible from ME. The survey was conducted by face to face interview and data analyses were performed with descriptive statistics. Chi-square or Fisher exact tests were used for a comparative analysis of categorical data. Some 83.4% of the 210 nurses reported one or more than one error during chemotherapy preparation and administration. Prescribing or ordering wrong doses by physicians (65.7%) and noncompliance with administration sequences during chemotherapy administration (50.5%) were the most common errors. The most common estimated average monthly error was not following the administration sequence of the chemotherapeutic agents (4.1 times/month, range 1-20). The most important underlying reasons for medication errors were heavy workload (49.7%) and insufficient number of staff (36.5%). Our findings suggest that the probability of medication error is very high during chemotherapy preparation and administration, the most common involving prescribing and ordering errors. Further studies must address the strategies to minimize medication error in chemotherapy receiving patients, determine sufficient protective measures and establishing multistep control mechanisms.

Modeling the probability distribution of positional errors incurred by residential address geocoding.

PubMed

Zimmerman, Dale L; Fang, Xiangming; Mazumdar, Soumya; Rushton, Gerard

2007-01-10

The assignment of a point-level geocode to subjects' residences is an important data assimilation component of many geographic public health studies. Often, these assignments are made by a method known as automated geocoding, which attempts to match each subject's address to an address-ranged street segment georeferenced within a streetline database and then interpolate the position of the address along that segment. Unfortunately, this process results in positional errors. Our study sought to model the probability distribution of positional errors associated with automated geocoding and E911 geocoding. Positional errors were determined for 1423 rural addresses in Carroll County, Iowa as the vector difference between each 100%-matched automated geocode and its true location as determined by orthophoto and parcel information. Errors were also determined for 1449 60%-matched geocodes and 2354 E911 geocodes. Huge (> 15 km) outliers occurred among the 60%-matched geocoding errors; outliers occurred for the other two types of geocoding errors also but were much smaller. E911 geocoding was more accurate (median error length = 44 m) than 100%-matched automated geocoding (median error length = 168 m). The empirical distributions of positional errors associated with 100%-matched automated geocoding and E911 geocoding exhibited a distinctive Greek-cross shape and had many other interesting features that were not capable of being fitted adequately by a single bivariate normal or t distribution. However, mixtures of t distributions with two or three components fit the errors very well. Mixtures of bivariate t distributions with few components appear to be flexible enough to fit many positional error datasets associated with geocoding, yet parsimonious enough to be feasible for nascent applications of measurement-error methodology to spatial epidemiology.

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

Evaluation of seasonal and spatial variations of lumped water balance model sensitivity to precipitation data errors

NASA Astrophysics Data System (ADS)

Xu, Chong-yu; Tunemar, Liselotte; Chen, Yongqin David; Singh, V. P.

2006-06-01

Sensitivity of hydrological models to input data errors have been reported in the literature for particular models on a single or a few catchments. A more important issue, i.e. how model's response to input data error changes as the catchment conditions change has not been addressed previously. This study investigates the seasonal and spatial effects of precipitation data errors on the performance of conceptual hydrological models. For this study, a monthly conceptual water balance model, NOPEX-6, was applied to 26 catchments in the Mälaren basin in Central Sweden. Both systematic and random errors were considered. For the systematic errors, 5-15% of mean monthly precipitation values were added to the original precipitation to form the corrupted input scenarios. Random values were generated by Monte Carlo simulation and were assumed to be (1) independent between months, and (2) distributed according to a Gaussian law of zero mean and constant standard deviation that were taken as 5, 10, 15, 20, and 25% of the mean monthly standard deviation of precipitation. The results show that the response of the model parameters and model performance depends, among others, on the type of the error, the magnitude of the error, physical characteristics of the catchment, and the season of the year. In particular, the model appears less sensitive to the random error than to the systematic error. The catchments with smaller values of runoff coefficients were more influenced by input data errors than were the catchments with higher values. Dry months were more sensitive to precipitation errors than were wet months. Recalibration of the model with erroneous data compensated in part for the data errors by altering the model parameters.

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.

Error properties of Argos satellite telemetry locations using least squares and Kalman filtering.

PubMed

Boyd, Janice D; Brightsmith, Donald J

2013-01-01

Study of animal movements is key for understanding their ecology and facilitating their conservation. The Argos satellite system is a valuable tool for tracking species which move long distances, inhabit remote areas, and are otherwise difficult to track with traditional VHF telemetry and are not suitable for GPS systems. Previous research has raised doubts about the magnitude of position errors quoted by the satellite service provider CLS. In addition, no peer-reviewed publications have evaluated the usefulness of the CLS supplied error ellipses nor the accuracy of the new Kalman filtering (KF) processing method. Using transmitters hung from towers and trees in southeastern Peru, we show the Argos error ellipses generally contain <25% of the true locations and therefore do not adequately describe the true location errors. We also find that KF processing does not significantly increase location accuracy. The errors for both LS and KF processing methods were found to be lognormally distributed, which has important repercussions for error calculation, statistical analysis, and data interpretation. In brief, "good" positions (location codes 3, 2, 1, A) are accurate to about 2 km, while 0 and B locations are accurate to about 5-10 km. However, due to the lognormal distribution of the errors, larger outliers are to be expected in all location codes and need to be accounted for in the user's data processing. We evaluate five different empirical error estimates and find that 68% lognormal error ellipses provided the most useful error estimates. Longitude errors are larger than latitude errors by a factor of 2 to 3, supporting the use of elliptical error ellipses. Numerous studies over the past 15 years have also found fault with the CLS-claimed error estimates yet CLS has failed to correct their misleading information. We hope this will be reversed in the near future.

Slow Learner Errors Analysis in Solving Fractions Problems in Inclusive Junior High School Class

NASA Astrophysics Data System (ADS)

Novitasari, N.; Lukito, A.; Ekawati, R.

2018-01-01

A slow learner whose IQ is between 71 and 89 will have difficulties in solving mathematics problems that often lead to errors. The errors could be analyzed to where the errors may occur and its type. This research is qualitative descriptive which aims to describe the locations, types, and causes of slow learner errors in the inclusive junior high school class in solving the fraction problem. The subject of this research is one slow learner of seventh-grade student which was selected through direct observation by the researcher and through discussion with mathematics teacher and special tutor which handles the slow learner students. Data collection methods used in this study are written tasks and semistructured interviews. The collected data was analyzed by Newman’s Error Analysis (NEA). Results show that there are four locations of errors, namely comprehension, transformation, process skills, and encoding errors. There are four types of errors, such as concept, principle, algorithm, and counting errors. The results of this error analysis will help teachers to identify the causes of the errors made by the slow learner.

Flux control coefficients determined by inhibitor titration: the design and analysis of experiments to minimize errors.

PubMed Central

Small, J R

1993-01-01

This paper is a study into the effects of experimental error on the estimated values of flux control coefficients obtained using specific inhibitors. Two possible techniques for analysing the experimental data are compared: a simple extrapolation method (the so-called graph method) and a non-linear function fitting method. For these techniques, the sources of systematic errors are identified and the effects of systematic and random errors are quantified, using both statistical analysis and numerical computation. It is shown that the graph method is very sensitive to random errors and, under all conditions studied, that the fitting method, even under conditions where the assumptions underlying the fitted function do not hold, outperformed the graph method. Possible ways of designing experiments to minimize the effects of experimental errors are analysed and discussed. PMID:8257434

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

NASA Astrophysics Data System (ADS)

Jin, Aiyan; Peipei, Gao; Shang, Xiaomei

2014-04-01

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

[Responsibility due to medication errors in France: a study based on SHAM insurance data].

PubMed

Theissen, A; Orban, J-C; Fuz, F; Guerin, J-P; Flavin, P; Albertini, S; Maricic, S; Saquet, D; Niccolai, P

2015-03-01

The safe medication practices at the hospital constitute a major public health problem. Drug supply chain is a complex process, potentially source of errors and damages for the patient. SHAM insurances are the biggest French provider of medical liability insurances and a relevant source of data on the health care complications. The main objective of the study was to analyze the type and cause of medication errors declared to SHAM and having led to a conviction by a court. We did a retrospective study on insurance claims provided by SHAM insurances with a medication error and leading to a condemnation over a 6-year period (between 2005 and 2010). Thirty-one cases were analysed, 21 for scheduled activity and 10 for emergency activity. Consequences of claims were mostly serious (12 deaths, 14 serious complications, 5 simple complications). The types of medication errors were a drug monitoring error (11 cases), an administration error (5 cases), an overdose (6 cases), an allergy (4 cases), a contraindication (3 cases) and an omission (2 cases). Intravenous route of administration was involved in 19 of 31 cases (61%). The causes identified by the court expert were an error related to service organization (11), an error related to medical practice (11) or nursing practice (13). Only one claim was due to the hospital pharmacy. The claim related to drug supply chain is infrequent but potentially serious. These data should help strengthen quality approach in risk management. Copyright © 2014 Elsevier Masson SAS. All rights reserved.

Recognition of medical errors’ reporting system dimensions in educational hospitals

PubMed Central

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

2014-01-01

Introduction and Objective: Nowadays medical errors are one of the serious issues in the health-care system and carry to account of the patient's safety threat. The most important step for achieving safety promotion is identifying errors and their causes in order to recognize, correct and omit them. Concerning about repeating medical errors and harms, which were received via theses errors concluded to designing and establishing medical error reporting systems for hospitals and centers that are presenting therapeutic services. The aim of this study is the recognition of medical errors’ reporting system dimensions in educational hospitals. Materials and Methods: This research is a descriptive-analytical and qualities’ study, which has been carried out in Shahid Beheshti educational therapeutic center in Isfahan during 2012. In this study, relevant information was collected through 15 face to face interviews. That each of interviews take place in about 1hr and creation of five focused discussion groups through 45 min for each section, they were composed of Metron, educational supervisor, health officer, health education, and all of the head nurses. Concluded data interviews and discussion sessions were coded, then achieved results were extracted in the presence of clear-sighted persons and after their feedback perception, they were categorized. In order to make sure of information correctness, tables were presented to the research's interviewers and final the corrections were confirmed based on their view. Finding: The extracted information from interviews and discussion groups have been divided into nine main categories after content analyzing and subject coding and their subsets have been completely expressed. Achieved dimensions are composed of nine domains of medical error concept, error cases according to nurses’ prospection, medical error reporting barriers, employees’ motivational factors for error reporting, purposes of medical error reporting system, error reporting's challenges and opportunities, a desired system characteristics, and the quality of error experiences’ transmission in the health-care system. Conclusion: Although, appropriate achievements have been assured in Shahid Beheshti Hospital, but it seems necessary that in order to immune promotion not only in this hospital, but in the other organizations, necessary infrastructures have been provided for an error reporting system performance. An appropriate medical error reporting system could be educated and prevent the occurrence of repeated errors. PMID:25250342

Event-related potentials for post-error and post-conflict slowing.

PubMed

Chang, Andrew; Chen, Chien-Chung; Li, Hsin-Hung; Li, Chiang-Shan R

2014-01-01

In a reaction time task, people typically slow down following an error or conflict, each called post-error slowing (PES) and post-conflict slowing (PCS). Despite many studies of the cognitive mechanisms, the neural responses of PES and PCS continue to be debated. In this study, we combined high-density array EEG and a stop-signal task to examine event-related potentials of PES and PCS in sixteen young adult participants. The results showed that the amplitude of N2 is greater during PES but not PCS. In contrast, the peak latency of N2 is longer for PCS but not PES. Furthermore, error-positivity (Pe) but not error-related negativity (ERN) was greater in the stop error trials preceding PES than non-PES trials, suggesting that PES is related to participants' awareness of the error. Together, these findings extend earlier work of cognitive control by specifying the neural correlates of PES and PCS in the stop signal task.

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 grasping side of post-error slowing.

PubMed

Ceccarini, Francesco; Castiello, Umberto

2018-06-07

A common finding across many speeded reaction time (RT) tasks is that people tend to respond more slowly after making an error. This phenomenon, known as post-error slowing (PES), has been traditionally hypothesized to reflect a strategic increase in response caution, aimed at preventing the occurrence of new errors. However, this interpretation of PES has been challenged on multiple fronts. Firstly, recent investigations have suggested that errors may produce a decrement in performance accuracy and that PES might occur because error processing has a detrimental effect on subsequent information processing. Secondly, previous research has been criticized because of the limited ecological validity of speeded RT tasks. In the present study, we investigated error-reactivity in the context of goal-directed actions, in order to examine the extent to which PES effects impact on realistic and complex movements. Specifically, we investigated the effect of errors on the reach to grasp movement (Experiment 1). In addition to RTs, we performed a kinematical analysis in order to explore the underlying reorganization of the movements after an error. The results of the present study showed that error reactivity strategically influences the grasping component of the action, whereas the reaching component appears to be impermeable to PES. The resistance of the reaching component to PES was confirmed in a second 'only reaching' experiment (Experiment 2). These finding supports the hypothesis that error reactivity is a flexible process whose effects on behavior also depend on the motor components involved in the action. Copyright © 2018 Elsevier B.V. All rights reserved.

Imaging phased telescope array study

NASA Technical Reports Server (NTRS)

Harvey, James E.

1989-01-01

The problems encountered in obtaining a wide field-of-view with large, space-based direct imaging phased telescope arrays were considered. After defining some of the critical systems issues, previous relevant work in the literature was reviewed and summarized. An extensive list was made of potential error sources and the error sources were categorized in the form of an error budget tree including optical design errors, optical fabrication errors, assembly and alignment errors, and environmental errors. After choosing a top level image quality requirment as a goal, a preliminary tops-down error budget allocation was performed; then, based upon engineering experience, detailed analysis, or data from the literature, a bottoms-up error budget reallocation was performed in an attempt to achieve an equitable distribution of difficulty in satisfying the various allocations. This exercise provided a realistic allocation for residual off-axis optical design errors in the presence of state-of-the-art optical fabrication and alignment errors. Three different computational techniques were developed for computing the image degradation of phased telescope arrays due to aberrations of the individual telescopes. Parametric studies and sensitivity analyses were then performed for a variety of subaperture configurations and telescope design parameters in an attempt to determine how the off-axis performance of a phased telescope array varies as the telescopes are scaled up in size. The Air Force Weapons Laboratory (AFWL) multipurpose telescope testbed (MMTT) configuration was analyzed in detail with regard to image degradation due to field curvature and distortion of the individual telescopes as they are scaled up in size.

Performance Data Errors in Air Carrier Operations: Causes and Countermeasures

NASA Technical Reports Server (NTRS)

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

2012-01-01

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

Systematic Error Study for ALICE charged-jet v2 Measurement

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

Heinz, M.; Soltz, R.

We study the treatment of systematic errors in the determination of v 2 for charged jets in √ sNN = 2:76 TeV Pb-Pb collisions by the ALICE Collaboration. Working with the reported values and errors for the 0-5% centrality data we evaluate the Χ 2 according to the formulas given for the statistical and systematic errors, where the latter are separated into correlated and shape contributions. We reproduce both the Χ 2 and p-values relative to a null (zero) result. We then re-cast the systematic errors into an equivalent co-variance matrix and obtain identical results, demonstrating that the two methodsmore » are equivalent.« less

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.

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

PubMed

Kim, Myoungsoo

2010-04-01

The purpose of this study was to examine the impact of strategies to promote reporting of errors on nurses' attitude to reporting errors, organizational culture related to patient safety, intention to report and reporting rate in hospital nurses. A nonequivalent control group non-synchronized design was used for this study. The program was developed and then administered to the experimental group for 12 weeks. Data were analyzed using descriptive analysis, X(2)-test, t-test, and ANCOVA with the SPSS 12.0 program. After the intervention, the experimental group showed significantly higher scores for nurses' attitude to reporting errors (experimental: 20.73 vs control: 20.52, F=5.483, p=.021) and reporting rate (experimental: 3.40 vs control: 1.33, F=1998.083, p<.001). There was no significant difference in some categories for organizational culture and intention to report. The study findings indicate that strategies that promote reporting of errors play an important role in producing positive attitudes to reporting errors and improving behavior of reporting. Further advanced strategies for reporting errors that can lead to improved patient safety should be developed and applied in a broad range of hospitals.

Updating expected action outcome in the medial frontal cortex involves an evaluation of error type.

PubMed

Maier, Martin E; Steinhauser, Marco

2013-10-02

Forming expectations about the outcome of an action is an important prerequisite for action control and reinforcement learning in the human brain. The medial frontal cortex (MFC) has been shown to play an important role in the representation of outcome expectations, particularly when an update of expected outcome becomes necessary because an error is detected. However, error detection alone is not always sufficient to compute expected outcome because errors can occur in various ways and different types of errors may be associated with different outcomes. In the present study, we therefore investigate whether updating expected outcome in the human MFC is based on an evaluation of error type. Our approach was to consider an electrophysiological correlate of MFC activity on errors, the error-related negativity (Ne/ERN), in a task in which two types of errors could occur. Because the two error types were associated with different amounts of monetary loss, updating expected outcomes on error trials required an evaluation of error type. Our data revealed a pattern of Ne/ERN amplitudes that closely mirrored the amount of monetary loss associated with each error type, suggesting that outcome expectations are updated based on an evaluation of error type. We propose that this is achieved by a proactive evaluation process that anticipates error types by continuously monitoring error sources or by dynamically representing possible response-outcome relations.

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

NASA Astrophysics Data System (ADS)

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

2018-03-01

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

Sensitivity analysis of periodic errors in heterodyne interferometry

NASA Astrophysics Data System (ADS)

Ganguly, Vasishta; Kim, Nam Ho; Kim, Hyo Soo; Schmitz, Tony

2011-03-01

Periodic errors in heterodyne displacement measuring interferometry occur due to frequency mixing in the interferometer. These nonlinearities are typically characterized as first- and second-order periodic errors which cause a cyclical (non-cumulative) variation in the reported displacement about the true value. This study implements an existing analytical periodic error model in order to identify sensitivities of the first- and second-order periodic errors to the input parameters, including rotational misalignments of the polarizing beam splitter and mixing polarizer, non-orthogonality of the two laser frequencies, ellipticity in the polarizations of the two laser beams, and different transmission coefficients in the polarizing beam splitter. A local sensitivity analysis is first conducted to examine the sensitivities of the periodic errors with respect to each input parameter about the nominal input values. Next, a variance-based approach is used to study the global sensitivities of the periodic errors by calculating the Sobol' sensitivity indices using Monte Carlo simulation. The effect of variation in the input uncertainty on the computed sensitivity indices is examined. It is seen that the first-order periodic error is highly sensitive to non-orthogonality of the two linearly polarized laser frequencies, while the second-order error is most sensitive to the rotational misalignment between the laser beams and the polarizing beam splitter. A particle swarm optimization technique is finally used to predict the possible setup imperfections based on experimentally generated values for periodic errors.

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.

Context Specificity of Post-Error and Post-Conflict Cognitive Control Adjustments

PubMed Central

Forster, Sarah E.; Cho, Raymond Y.

2014-01-01

There has been accumulating evidence that cognitive control can be adaptively regulated by monitoring for processing conflict as an index of online control demands. However, it is not yet known whether top-down control mechanisms respond to processing conflict in a manner specific to the operative task context or confer a more generalized benefit. While previous studies have examined the taskset-specificity of conflict adaptation effects, yielding inconsistent results, control-related performance adjustments following errors have been largely overlooked. This gap in the literature underscores recent debate as to whether post-error performance represents a strategic, control-mediated mechanism or a nonstrategic consequence of attentional orienting. In the present study, evidence of generalized control following both high conflict correct trials and errors was explored in a task-switching paradigm. Conflict adaptation effects were not found to generalize across tasksets, despite a shared response set. In contrast, post-error slowing effects were found to extend to the inactive taskset and were predictive of enhanced post-error accuracy. In addition, post-error performance adjustments were found to persist for several trials and across multiple task switches, a finding inconsistent with attentional orienting accounts of post-error slowing. These findings indicate that error-related control adjustments confer a generalized performance benefit and suggest dissociable mechanisms of post-conflict and post-error control. PMID:24603900

Single molecule counting and assessment of random molecular tagging errors with transposable giga-scale error-correcting barcodes.

PubMed

Lau, Billy T; Ji, Hanlee P

2017-09-21

RNA-Seq measures gene expression by counting sequence reads belonging to unique cDNA fragments. Molecular barcodes commonly in the form of random nucleotides were recently introduced to improve gene expression measures by detecting amplification duplicates, but are susceptible to errors generated during PCR and sequencing. This results in false positive counts, leading to inaccurate transcriptome quantification especially at low input and single-cell RNA amounts where the total number of molecules present is minuscule. To address this issue, we demonstrated the systematic identification of molecular species using transposable error-correcting barcodes that are exponentially expanded to tens of billions of unique labels. We experimentally showed random-mer molecular barcodes suffer from substantial and persistent errors that are difficult to resolve. To assess our method's performance, we applied it to the analysis of known reference RNA standards. By including an inline random-mer molecular barcode, we systematically characterized the presence of sequence errors in random-mer molecular barcodes. We observed that such errors are extensive and become more dominant at low input amounts. We described the first study to use transposable molecular barcodes and its use for studying random-mer molecular barcode errors. Extensive errors found in random-mer molecular barcodes may warrant the use of error correcting barcodes for transcriptome analysis as input amounts decrease.

Voice Onset Time in Consonant Cluster Errors: Can Phonetic Accommodation Differentiate Cognitive from Motor Errors?

ERIC Educational Resources Information Center

Pouplier, Marianne; Marin, Stefania; Waltl, Susanne

2014-01-01

Purpose: Phonetic accommodation in speech errors has traditionally been used to identify the processing level at which an error has occurred. Recent studies have challenged the view that noncanonical productions may solely be due to phonetic, not phonological, processing irregularities, as previously assumed. The authors of the present study…

A Learner Corpus-Based Study on Verb Errors of Turkish EFL Learners

ERIC Educational Resources Information Center

Can, Cem

2017-01-01

As learner corpora have presently become readily accessible, it is practicable to examine interlanguage errors and carry out error analysis (EA) on learner-generated texts. The data available in a learner corpus enable researchers to investigate authentic learner errors and their respective frequencies in terms of types and tokens as well as…

Error Analysis in Composition of Iranian Lower Intermediate Students

ERIC Educational Resources Information Center

Taghavi, Mehdi

2012-01-01

Learners make errors during the process of learning languages. This study examines errors in writing task of twenty Iranian lower intermediate male students aged between 13 and 15. A subject was given to the participants was a composition about the seasons of a year. All of the errors were identified and classified. Corder's classification (1967)…

An Analysis of Computational Errors in the Use of Division Algorithms by Fourth-Grade Students.

ERIC Educational Resources Information Center

Stefanich, Greg P.; Rokusek, Teri

1992-01-01

Presents a study that analyzed errors made by randomly chosen fourth grade students (25 of 57) while using the division algorithm and investigated the effect of remediation on identified systematic errors. Results affirm that error pattern diagnosis and directed remediation lead to new learning and long-term retention. (MDH)

Approaching Error-Free Customer Satisfaction through Process Change and Feedback Systems

ERIC Educational Resources Information Center

Berglund, Kristin M.; Ludwig, Timothy D.

2009-01-01

Employee-based errors result in quality defects that can often impact customer satisfaction. This study examined the effects of a process change and feedback system intervention on error rates of 3 teams of retail furniture distribution warehouse workers. Archival records of error codes were analyzed and aggregated as the measure of quality. The…

Critical Neural Substrates for Correcting Unexpected Trajectory Errors and Learning from Them

ERIC Educational Resources Information Center

Mutha, Pratik K.; Sainburg, Robert L.; Haaland, Kathleen Y.

2011-01-01

Our proficiency at any skill is critically dependent on the ability to monitor our performance, correct errors and adapt subsequent movements so that errors are avoided in the future. In this study, we aimed to dissociate the neural substrates critical for correcting unexpected trajectory errors and learning to adapt future movements based on…

A Theoretical Foundation for the Study of Inferential Error in Decision-Making Groups.

ERIC Educational Resources Information Center

Gouran, Dennis S.

To provide a theoretical base for investigating the influence of inferential error on group decision making, current literature on both inferential error and decision making is reviewed and applied to the Watergate incident. Although groups tend to make fewer inferential errors because members' inferences are generally not biased in the same…

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

ERIC Educational Resources Information Center

Herzberg, Tina

2010-01-01

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

An Analysis of Spanish and German Learners' Errors. Working Papers on Bilingualism, No. 7.

ERIC Educational Resources Information Center

LoCoco, Veronica Gonzalez-Mena

This study analyzes Spanish and German errors committed by adult native speakers of English enrolled in elementary and intermediate levels. Four written samples were collected for each target language, over a period of five months. Errors were categorized according to their possible source. Types of errors were ordered according to their…

The Relevance of Second Language Acquisition Theory to the Written Error Correction Debate

ERIC Educational Resources Information Center

Polio, Charlene

2012-01-01

The controversies surrounding written error correction can be traced to Truscott (1996) in his polemic against written error correction. He claimed that empirical studies showed that error correction was ineffective and that this was to be expected "given the nature of the correction process and "the nature of language learning" (p. 328, emphasis…

Phonological Errors Predominate in Arabic Spelling across Grades 1-9

ERIC Educational Resources Information Center

Abu-Rabia, Salim; Taha, Haitham

2006-01-01

Most of the spelling error analysis has been conducted in Latin orthographies and rarely conducted in other orthographies like Arabic. Two hundred and eighty-eight students in grades 1-9 participated in the study. They were presented nine lists of words to test their spelling skills. Their spelling errors were analyzed by error categories. The…

Classification based upon gene expression data: bias and precision of error rates.

PubMed

Wood, Ian A; Visscher, Peter M; Mengersen, Kerrie L

2007-06-01

Gene expression data offer a large number of potentially useful predictors for the classification of tissue samples into classes, such as diseased and non-diseased. The predictive error rate of classifiers can be estimated using methods such as cross-validation. We have investigated issues of interpretation and potential bias in the reporting of error rate estimates. The issues considered here are optimization and selection biases, sampling effects, measures of misclassification rate, baseline error rates, two-level external cross-validation and a novel proposal for detection of bias using the permutation mean. Reporting an optimal estimated error rate incurs an optimization bias. Downward bias of 3-5% was found in an existing study of classification based on gene expression data and may be endemic in similar studies. Using a simulated non-informative dataset and two example datasets from existing studies, we show how bias can be detected through the use of label permutations and avoided using two-level external cross-validation. Some studies avoid optimization bias by using single-level cross-validation and a test set, but error rates can be more accurately estimated via two-level cross-validation. In addition to estimating the simple overall error rate, we recommend reporting class error rates plus where possible the conditional risk incorporating prior class probabilities and a misclassification cost matrix. We also describe baseline error rates derived from three trivial classifiers which ignore the predictors. R code which implements two-level external cross-validation with the PAMR package, experiment code, dataset details and additional figures are freely available for non-commercial use from http://www.maths.qut.edu.au/profiles/wood/permr.jsp

New Methods for Assessing and Reducing Uncertainty in Microgravity Studies

NASA Astrophysics Data System (ADS)

Giniaux, J. M.; Hooper, A. J.; Bagnardi, M.

2017-12-01

Microgravity surveying, also known as dynamic or 4D gravimetry is a time-dependent geophysical method used to detect mass fluctuations within the shallow crust, by analysing temporal changes in relative gravity measurements. We present here a detailed uncertainty analysis of temporal gravity measurements, considering for the first time all possible error sources, including tilt, error in drift estimations and timing errors. We find that some error sources that are actually ignored, can have a significant impact on the total error budget and it is therefore likely that some gravity signals may have been misinterpreted in previous studies. Our analysis leads to new methods for reducing some of the uncertainties associated with residual gravity estimation. In particular, we propose different approaches for drift estimation and free air correction depending on the survey set up. We also provide formulae to recalculate uncertainties for past studies and lay out a framework for best practice in future studies. We demonstrate our new approach on volcanic case studies, which include Kilauea in Hawaii and Askja in Iceland.

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

PubMed

Steele-Johnson, Debra; Kalinoski, Zachary T

2014-01-01

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

Influence of Tooth Spacing Error on Gears With and Without Profile Modifications

NASA Technical Reports Server (NTRS)

Padmasolala, Giri; Lin, Hsiang H.; Oswald, Fred B.

2000-01-01

A computer simulation was conducted to investigate the effectiveness of profile modification for reducing dynamic loads in gears with different tooth spacing errors. The simulation examined varying amplitudes of spacing error and differences in the span of teeth over which the error occurs. The modification considered included both linear and parabolic tip relief. The analysis considered spacing error that varies around most of the gear circumference (similar to a typical sinusoidal error pattern) as well as a shorter span of spacing errors that occurs on only a few teeth. The dynamic analysis was performed using a revised version of a NASA gear dynamics code, modified to add tooth spacing errors to the analysis. Results obtained from the investigation show that linear tip relief is more effective in reducing dynamic loads on gears with small spacing errors but parabolic tip relief becomes more effective as the amplitude of spacing error increases. In addition, the parabolic modification is more effective for the more severe error case where the error is spread over a longer span of teeth. The findings of this study can be used to design robust tooth profile modification for improving dynamic performance of gear sets with different tooth spacing errors.

Error Analysis of Present Simple Tense in the Interlanguage of Adult Arab English Language Learners

ERIC Educational Resources Information Center

Muftah, Muneera; Rafik-Galea, Shameem

2013-01-01

The present study analyses errors on present simple tense among adult Arab English language learners. It focuses on the error on 3sg "-s" (the third person singular present tense agreement morpheme "-s"). The learners are undergraduate adult Arabic speakers learning English as a foreign language. The study gathered data from…

Error Consistency in Acquired Apraxia of Speech with Aphasia: Effects of the Analysis Unit

ERIC Educational Resources Information Center

Haley, Katarina L.; Cunningham, Kevin T.; Eaton, Catherine Torrington; Jacks, Adam

2018-01-01

Purpose: Diagnostic recommendations for acquired apraxia of speech (AOS) have been contradictory concerning whether speech sound errors are consistent or variable. Studies have reported divergent findings that, on face value, could argue either for or against error consistency as a diagnostic criterion. The purpose of this study was to explain…

Treatment of Anomia Using Errorless Versus Errorful Learning: Are Frontal Executive Skills and Feedback Important?

ERIC Educational Resources Information Center

Fillingham, Joanne; Sage, Karen; Ralph, Matthew Lambon

2005-01-01

Background: Studies from the amnesia literature suggest that errorless learning can produce superior results to errorful learning. However, it was found in a previous investigation by the present authors that errorless and errorful therapy produced equivalent results for patients with aphasic word-finding difficulties. A study in the academic…

Applying recovery biomarkers to calibrate self-report measures of sodium and potassium in the Hispanic Community Health Study/Study of Latinos

USDA-ARS?s Scientific Manuscript database

Measurement error in assessment of sodium and potassium intake obscures associations with health outcomes. The level of this error in a diverse US Hispanic/Latino population is unknown. We investigated the measurement error in self-reported dietary intake of sodium and potassium and examined differe...

Developmental Changes in Error Monitoring: An Event-Related Potential Study

ERIC Educational Resources Information Center

Wiersema, Jan R.; van der Meere, Jacob J.; Roeyers, Herbert

2007-01-01

The aim of the study was to investigate the developmental trajectory of error monitoring. For this purpose, children (age 7-8), young adolescents (age 13-14) and adults (age 23-24) performed a Go/No-Go task and were compared on overt reaction time (RT) performance and on event-related potentials (ERPs), thought to reflect error detection…

The Relationship of Error Rate and Comprehension in Second and Third Grade Oral Reading Fluency

ERIC Educational Resources Information Center

Abbott, Mary; Wills, Howard; Miller, Angela; Kaufman, Journ

2012-01-01

This study explored the relationships of oral reading speed and error rate on comprehension with second and third grade students with identified reading risk. The study included 920 second and 974 third graders. Results found a significant relationship between error rate, oral reading fluency, and reading comprehension performance, and…

Secondary School Students' Errors in the Translation of Algebraic Statements

ERIC Educational Resources Information Center

Molina, Marta; Rodríguez-Domingo, Susana; Cañadas, María Consuelo; Castro, Encarnación

2017-01-01

In this article, we present the results of a research study that explores secondary students' capacity to perform translations of algebraic statements between the verbal and symbolic representation systems through the lens of errors. We classify and compare the errors made by 2 groups of students: 1 at the beginning of their studies in school…

Factors Influencing Error Recovery in Collections Databases: A Museum Case Study

ERIC Educational Resources Information Center

Marty, Paul F.

2005-01-01

This article offers an analysis of the process of error recovery as observed in the development and use of collections databases in a university museum. It presents results from a longitudinal case study of the development of collaborative systems and practices designed to reduce the number of errors found in the museum's databases as museum…

A Corpus Based Study on the Preposition Error Types in Turkish EFL Learners' Essays

ERIC Educational Resources Information Center

Tunaz, Mehmet; Muyan, Emrah; Muratoglu, Nursel

2016-01-01

The purpose of this study was to investigate the categories of preposition errors made by EFL learners of elementary and intermediate proficiency levels by comparing the rate of preposition errors (addition, omission, substitution) to their total preposition uses in their essays, and by comparing the overall preposition usage of learners of both…

Software error data collection and categorization

NASA Technical Reports Server (NTRS)

Ostrand, T. J.; Weyuker, E. J.

1982-01-01

Software errors detected during development of an interactive special purpose editor system were studied. This product was followed during nine months of coding, unit testing, function testing, and system testing. A new error categorization scheme was developed.

Effects of skilled nursing facility structure and process factors on medication errors during nursing home admission.

PubMed

Lane, Sandi J; Troyer, Jennifer L; Dienemann, Jacqueline A; Laditka, Sarah B; Blanchette, Christopher M

2014-01-01

Older adults are at greatest risk of medication errors during the transition period of the first 7 days after admission and readmission to a skilled nursing facility (SNF). The aim of this study was to evaluate structure- and process-related factors that contribute to medication errors and harm during transition periods at a SNF. Data for medication errors and potential medication errors during the 7-day transition period for residents entering North Carolina SNFs were from the Medication Error Quality Initiative-Individual Error database from October 2006 to September 2007. The impact of SNF structure and process measures on the number of reported medication errors and harm from errors were examined using bivariate and multivariate model methods. A total of 138 SNFs reported 581 transition period medication errors; 73 (12.6%) caused harm. Chain affiliation was associated with a reduction in the volume of errors during the transition period. One third of all reported transition errors occurred during the medication administration phase of the medication use process, where dose omissions were the most common type of error; however, dose omissions caused harm less often than wrong-dose errors did. Prescribing errors were much less common than administration errors but were much more likely to cause harm. Both structure and process measures of quality were related to the volume of medication errors.However, process quality measures may play a more important role in predicting harm from errors during the transition of a resident into an SNF. Medication errors during transition could be reduced by improving both prescribing processes and transcription and documentation of orders.

Investigating Perceptual Biases, Data Reliability, and Data Discovery in a Methodology for Collecting Speech Errors From Audio Recordings.

PubMed

Alderete, John; Davies, Monica

2018-04-01

This work describes a methodology of collecting speech errors from audio recordings and investigates how some of its assumptions affect data quality and composition. Speech errors of all types (sound, lexical, syntactic, etc.) were collected by eight data collectors from audio recordings of unscripted English speech. Analysis of these errors showed that: (i) different listeners find different errors in the same audio recordings, but (ii) the frequencies of error patterns are similar across listeners; (iii) errors collected "online" using on the spot observational techniques are more likely to be affected by perceptual biases than "offline" errors collected from audio recordings; and (iv) datasets built from audio recordings can be explored and extended in a number of ways that traditional corpus studies cannot be.

An investigation of error characteristics and coding performance

NASA Technical Reports Server (NTRS)

Ebel, William J.; Ingels, Frank M.

1993-01-01

The first year's effort on NASA Grant NAG5-2006 was an investigation to characterize typical errors resulting from the EOS dorn link. The analysis methods developed for this effort were used on test data from a March 1992 White Sands Terminal Test. The effectiveness of a concatenated coding scheme of a Reed Solomon outer code and a convolutional inner code versus a Reed Solomon only code scheme has been investigated as well as the effectiveness of a Periodic Convolutional Interleaver in dispersing errors of certain types. The work effort consisted of development of software that allows simulation studies with the appropriate coding schemes plus either simulated data with errors or actual data with errors. The software program is entitled Communication Link Error Analysis (CLEAN) and models downlink errors, forward error correcting schemes, and interleavers.

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

NASA Astrophysics Data System (ADS)

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

2018-03-01

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

Thermal Error Test and Intelligent Modeling Research on the Spindle of High Speed CNC Machine Tools

NASA Astrophysics Data System (ADS)

Luo, Zhonghui; Peng, Bin; Xiao, Qijun; Bai, Lu

2018-03-01

Thermal error is the main factor affecting the accuracy of precision machining. Through experiments, this paper studies the thermal error test and intelligent modeling for the spindle of vertical high speed CNC machine tools in respect of current research focuses on thermal error of machine tool. Several testing devices for thermal error are designed, of which 7 temperature sensors are used to measure the temperature of machine tool spindle system and 2 displacement sensors are used to detect the thermal error displacement. A thermal error compensation model, which has a good ability in inversion prediction, is established by applying the principal component analysis technology, optimizing the temperature measuring points, extracting the characteristic values closely associated with the thermal error displacement, and using the artificial neural network technology.

Coding for reliable satellite communications

NASA Technical Reports Server (NTRS)

Gaarder, N. T.; Lin, S.

1986-01-01

This research project was set up to study various kinds of coding techniques for error control in satellite and space communications for NASA Goddard Space Flight Center. During the project period, researchers investigated the following areas: (1) decoding of Reed-Solomon codes in terms of dual basis; (2) concatenated and cascaded error control coding schemes for satellite and space communications; (3) use of hybrid coding schemes (error correction and detection incorporated with retransmission) to improve system reliability and throughput in satellite communications; (4) good codes for simultaneous error correction and error detection, and (5) error control techniques for ring and star networks.

Analysis of DSN software anomalies

NASA Technical Reports Server (NTRS)

Galorath, D. D.; Hecht, H.; Hecht, M.; Reifer, D. J.

1981-01-01

A categorized data base of software errors which were discovered during the various stages of development and operational use of the Deep Space Network DSN/Mark 3 System was developed. A study team identified several existing error classification schemes (taxonomies), prepared a detailed annotated bibliography of the error taxonomy literature, and produced a new classification scheme which was tuned to the DSN anomaly reporting system and encapsulated the work of others. Based upon the DSN/RCI error taxonomy, error data on approximately 1000 reported DSN/Mark 3 anomalies were analyzed, interpreted and classified. Next, error data are summarized and histograms were produced highlighting key tendencies.

[Character of refractive errors in population study performed by the Area Military Medical Commission in Lodz].

PubMed

Nowak, Michał S; Goś, Roman; Smigielski, Janusz

2008-01-01

To determine the prevalence of refractive errors in population. A retrospective review of medical examinations for entry to the military service from The Area Military Medical Commission in Lodz. Ophthalmic examinations were performed. We used statistic analysis to review the results. Statistic analysis revealed that refractive errors occurred in 21.68% of the population. The most commen refractive error was myopia. 1) The most commen ocular diseases are refractive errors, especially myopia (21.68% in total). 2) Refractive surgery and contact lenses should be allowed as the possible correction of refractive errors for military service.

Students’ errors in solving combinatorics problems observed from the characteristics of RME modeling

NASA Astrophysics Data System (ADS)

Meika, I.; Suryadi, D.; Darhim

2018-01-01

This article was written based on the learning evaluation results of students’ errors in solving combinatorics problems observed from the characteristics of Realistic Mathematics Education (RME); that is modeling. Descriptive method was employed by involving 55 students from two international-based pilot state senior high schools in Banten. The findings of the study suggested that the students still committed errors in simplifying the problem as much 46%; errors in making mathematical model (horizontal mathematization) as much 60%; errors in finishing mathematical model (vertical mathematization) as much 65%; and errors in interpretation as well as validation as much 66%.

Implementation of an experimental program to investigate the performance characteristics of OMEGA navigation

NASA Technical Reports Server (NTRS)

Baxa, E. G., Jr.

1974-01-01

A theoretical formulation of differential and composite OMEGA error is presented to establish hypotheses about the functional relationships between various parameters and OMEGA navigational errors. Computer software developed to provide for extensive statistical analysis of the phase data is described. Results from the regression analysis used to conduct parameter sensitivity studies on differential OMEGA error tend to validate the theoretically based hypothesis concerning the relationship between uncorrected differential OMEGA error and receiver separation range and azimuth. Limited results of measurement of receiver repeatability error and line of position measurement error are also presented.

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.

Error Cost Escalation Through the Project Life Cycle

NASA Technical Reports Server (NTRS)

Stecklein, Jonette M.; Dabney, Jim; Dick, Brandon; Haskins, Bill; Lovell, Randy; Moroney, Gregory

2004-01-01

It is well known that the costs to fix errors increase as the project matures, but how fast do those costs build? A study was performed to determine the relative cost of fixing errors discovered during various phases of a project life cycle. This study used three approaches to determine the relative costs: the bottom-up cost method, the total cost breakdown method, and the top-down hypothetical project method. The approaches and results described in this paper presume development of a hardware/software system having project characteristics similar to those used in the development of a large, complex spacecraft, a military aircraft, or a small communications satellite. The results show the degree to which costs escalate, as errors are discovered and fixed at later and later phases in the project life cycle. If the cost of fixing a requirements error discovered during the requirements phase is defined to be 1 unit, the cost to fix that error if found during the design phase increases to 3 - 8 units; at the manufacturing/build phase, the cost to fix the error is 7 - 16 units; at the integration and test phase, the cost to fix the error becomes 21 - 78 units; and at the operations phase, the cost to fix the requirements error ranged from 29 units to more than 1500 units

Factors correlated with traffic accidents as a basis for evaluating Advanced Driver Assistance Systems.

PubMed

Staubach, Maria

2009-09-01

This study aims to identify factors which influence and cause errors in traffic accidents and to use these as a basis for information to guide the application and design of driver assistance systems. A total of 474 accidents were examined in depth for this study by means of a psychological survey, data from accident reports, and technical reconstruction information. An error analysis was subsequently carried out, taking into account the driver, environment, and vehicle sub-systems. Results showed that all accidents were influenced by errors as a consequence of distraction and reduced activity. For crossroad accidents, there were further errors resulting from sight obstruction, masked stimuli, focus errors, and law infringements. Lane departure crashes were additionally caused by errors as a result of masked stimuli, law infringements, expectation errors as well as objective and action slips, while same direction accidents occurred additionally because of focus errors, expectation errors, and objective and action slips. Most accidents were influenced by multiple factors. There is a safety potential for Advanced Driver Assistance Systems (ADAS), which support the driver in information assimilation and help to avoid distraction and reduced activity. The design of the ADAS is dependent on the specific influencing factors of the accident type.

Post-error response inhibition in high math-anxious individuals: Evidence from a multi-digit addition task.

PubMed

Núñez-Peña, M Isabel; Tubau, Elisabet; Suárez-Pellicioni, Macarena

2017-06-01

The aim of the study was to investigate how high math-anxious (HMA) individuals react to errors in an arithmetic task. Twenty HMA and 19 low math-anxious (LMA) individuals were presented with a multi-digit addition verification task and were given response feedback. Post-error adjustment measures (response time and accuracy) were analyzed in order to study differences between groups when faced with errors in an arithmetical task. Results showed that both HMA and LMA individuals were slower to respond following an error than following a correct answer. However, post-error accuracy effects emerged only for the HMA group, showing that they were also less accurate after having committed an error than after giving the right answer. Importantly, these differences were observed only when individuals needed to repeat the same response given in the previous trial. These results suggest that, for HMA individuals, errors caused reactive inhibition of the erroneous response, facilitating performance if the next problem required the alternative response but hampering it if the response was the same. This stronger reaction to errors could be a factor contributing to the difficulties that HMA individuals experience in learning math and doing math tasks. Copyright © 2017 Elsevier B.V. All rights reserved.

Dysfunctional error-related processing in female psychopathy

PubMed Central

Steele, Vaughn R.; Edwards, Bethany G.; Bernat, Edward M.; Calhoun, Vince D.; Kiehl, Kent A.

2016-01-01

Neurocognitive studies of psychopathy have predominantly focused on male samples. Studies have shown that female psychopaths exhibit similar affective deficits as their male counterparts, but results are less consistent across cognitive domains including response modulation. As such, there may be potential gender differences in error-related processing in psychopathic personality. Here we investigate response-locked event-related potential (ERP) components [the error-related negativity (ERN/Ne) related to early error-detection processes and the error-related positivity (Pe) involved in later post-error processing] in a sample of incarcerated adult female offenders (n = 121) who performed a response inhibition Go/NoGo task. Psychopathy was assessed using the Hare Psychopathy Checklist-Revised (PCL-R). The ERN/Ne and Pe were analyzed with classic windowed ERP components and principal component analysis (PCA). Consistent with previous research performed in psychopathic males, female psychopaths exhibited specific deficiencies in the neural correlates of post-error processing (as indexed by reduced Pe amplitude) but not in error monitoring (as indexed by intact ERN/Ne amplitude). Specifically, psychopathic traits reflecting interpersonal and affective dysfunction remained significant predictors of both time-domain and PCA measures reflecting reduced Pe mean amplitude. This is the first evidence to suggest that incarcerated female psychopaths exhibit similar dysfunctional post-error processing as male psychopaths. PMID:26060326

Kinematic Analysis of Speech Sound Sequencing Errors Induced by Delayed Auditory Feedback.

PubMed

Cler, Gabriel J; Lee, Jackson C; Mittelman, Talia; Stepp, Cara E; Bohland, Jason W

2017-06-22

Delayed auditory feedback (DAF) causes speakers to become disfluent and make phonological errors. Methods for assessing the kinematics of speech errors are lacking, with most DAF studies relying on auditory perceptual analyses, which may be problematic, as errors judged to be categorical may actually represent blends of sounds or articulatory errors. Eight typical speakers produced nonsense syllable sequences under normal and DAF (200 ms). Lip and tongue kinematics were captured with electromagnetic articulography. Time-locked acoustic recordings were transcribed, and the kinematics of utterances with and without perceived errors were analyzed with existing and novel quantitative methods. New multivariate measures showed that for 5 participants, kinematic variability for productions perceived to be error free was significantly increased under delay; these results were validated by using the spatiotemporal index measure. Analysis of error trials revealed both typical productions of a nontarget syllable and productions with articulatory kinematics that incorporated aspects of both the target and the perceived utterance. This study is among the first to characterize articulatory changes under DAF and provides evidence for different classes of speech errors, which may not be perceptually salient. New methods were developed that may aid visualization and analysis of large kinematic data sets. https://doi.org/10.23641/asha.5103067.

Data driven CAN node reliability assessment for manufacturing system

NASA Astrophysics Data System (ADS)

Zhang, Leiming; Yuan, Yong; Lei, Yong

2017-01-01

The reliability of the Controller Area Network(CAN) is critical to the performance and safety of the system. However, direct bus-off time assessment tools are lacking in practice due to inaccessibility of the node information and the complexity of the node interactions upon errors. In order to measure the mean time to bus-off(MTTB) of all the nodes, a novel data driven node bus-off time assessment method for CAN network is proposed by directly using network error information. First, the corresponding network error event sequence for each node is constructed using multiple-layer network error information. Then, the generalized zero inflated Poisson process(GZIP) model is established for each node based on the error event sequence. Finally, the stochastic model is constructed to predict the MTTB of the node. The accelerated case studies with different error injection rates are conducted on a laboratory network to demonstrate the proposed method, where the network errors are generated by a computer controlled error injection system. Experiment results show that the MTTB of nodes predicted by the proposed method agree well with observations in the case studies. The proposed data driven node time to bus-off assessment method for CAN networks can successfully predict the MTTB of nodes by directly using network error event data.

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

Kinematic Analysis of Speech Sound Sequencing Errors Induced by Delayed Auditory Feedback

PubMed Central

Lee, Jackson C.; Mittelman, Talia; Stepp, Cara E.; Bohland, Jason W.

2017-01-01

Purpose Delayed auditory feedback (DAF) causes speakers to become disfluent and make phonological errors. Methods for assessing the kinematics of speech errors are lacking, with most DAF studies relying on auditory perceptual analyses, which may be problematic, as errors judged to be categorical may actually represent blends of sounds or articulatory errors. Method Eight typical speakers produced nonsense syllable sequences under normal and DAF (200 ms). Lip and tongue kinematics were captured with electromagnetic articulography. Time-locked acoustic recordings were transcribed, and the kinematics of utterances with and without perceived errors were analyzed with existing and novel quantitative methods. Results New multivariate measures showed that for 5 participants, kinematic variability for productions perceived to be error free was significantly increased under delay; these results were validated by using the spatiotemporal index measure. Analysis of error trials revealed both typical productions of a nontarget syllable and productions with articulatory kinematics that incorporated aspects of both the target and the perceived utterance. Conclusions This study is among the first to characterize articulatory changes under DAF and provides evidence for different classes of speech errors, which may not be perceptually salient. New methods were developed that may aid visualization and analysis of large kinematic data sets. Supplemental Material https://doi.org/10.23641/asha.5103067 PMID:28655038

Quantum error-correcting code for ternary logic

NASA Astrophysics Data System (ADS)

Majumdar, Ritajit; Basu, Saikat; Ghosh, Shibashis; Sur-Kolay, Susmita

2018-05-01

Ternary quantum systems are being studied because they provide more computational state space per unit of information, known as qutrit. A qutrit has three basis states, thus a qubit may be considered as a special case of a qutrit where the coefficient of one of the basis states is zero. Hence both (2 ×2 ) -dimensional and (3 ×3 ) -dimensional Pauli errors can occur on qutrits. In this paper, we (i) explore the possible (2 ×2 ) -dimensional as well as (3 ×3 ) -dimensional Pauli errors in qutrits and show that any pairwise bit swap error can be expressed as a linear combination of shift errors and phase errors, (ii) propose a special type of error called a quantum superposition error and show its equivalence to arbitrary rotation, (iii) formulate a nine-qutrit code which can correct a single error in a qutrit, and (iv) provide its stabilizer and circuit realization.

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

PubMed

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

2008-04-22

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

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

PubMed Central

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

2008-01-01

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

Medication errors: a prospective cohort study of hand-written and computerised physician order entry in the intensive care unit.

PubMed

Shulman, Rob; Singer, Mervyn; Goldstone, John; Bellingan, Geoff

2005-10-05

The study aimed to compare the impact of computerised physician order entry (CPOE) without decision support with hand-written prescribing (HWP) on the frequency, type and outcome of medication errors (MEs) in the intensive care unit. Details of MEs were collected before, and at several time points after, the change from HWP to CPOE. The study was conducted in a London teaching hospital's 22-bedded general ICU. The sampling periods were 28 weeks before and 2, 10, 25 and 37 weeks after introduction of CPOE. The unit pharmacist prospectively recorded details of MEs and the total number of drugs prescribed daily during the data collection periods, during the course of his normal chart review. The total proportion of MEs was significantly lower with CPOE (117 errors from 2429 prescriptions, 4.8%) than with HWP (69 errors from 1036 prescriptions, 6.7%) (p < 0.04). The proportion of errors reduced with time following the introduction of CPOE (p < 0.001). Two errors with CPOE led to patient harm requiring an increase in length of stay and, if administered, three prescriptions with CPOE could potentially have led to permanent harm or death. Differences in the types of error between systems were noted. There was a reduction in major/moderate patient outcomes with CPOE when non-intercepted and intercepted errors were combined (p = 0.01). The mean baseline APACHE II score did not differ significantly between the HWP and the CPOE periods (19.4 versus 20.0, respectively, p = 0.71). Introduction of CPOE was associated with a reduction in the proportion of MEs and an improvement in the overall patient outcome score (if intercepted errors were included). Moderate and major errors, however, remain a significant concern with CPOE.

Patient safety priorities in mental healthcare in Switzerland: a modified Delphi study.

PubMed

Mascherek, Anna C; Schwappach, David L B

2016-08-05

Identifying patient safety priorities in mental healthcare is an emerging issue. A variety of aspects of patient safety in medical care apply for patient safety in mental care as well. However, specific aspects may be different as a consequence of special characteristics of patients, setting and treatment. The aim of the present study was to combine knowledge from the field and research and bundle existing initiatives and projects to define patient safety priorities in mental healthcare in Switzerland. The present study draws on national expert panels, namely, round-table discussion and modified Delphi consensus method. As preparation for the modified Delphi questionnaire, two round-table discussions and one semistructured questionnaire were conducted. Preparative work was conducted between May 2015 and October 2015. The modified Delphi was conducted to gauge experts' opinion on priorities in patient safety in mental healthcare in Switzerland. In two independent rating rounds, experts made private ratings. The modified Delphi was conducted in winter 2015. Nine topics were defined along the treatment pathway: diagnostic errors, non-drug treatment errors, medication errors, errors related to coercive measures, errors related to aggression management against self and others, errors in treatment of suicidal patients, communication errors, errors at interfaces of care and structural errors. Patient safety is considered as an important topic of quality in mental healthcare among experts, but it has been seriously neglected up until now. Activities in research and in practice are needed. Structural errors and diagnostics were given highest priority. From the topics identified, some are overlapping with important aspects of patient safety in medical care; however, some core aspects are unique. 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/

Accounting for the measurement error of spectroscopically inferred soil carbon data for improved precision of spatial predictions.

PubMed

Somarathna, P D S N; Minasny, Budiman; Malone, Brendan P; Stockmann, Uta; McBratney, Alex B

2018-08-01

Spatial modelling of environmental data commonly only considers spatial variability as the single source of uncertainty. In reality however, the measurement errors should also be accounted for. In recent years, infrared spectroscopy has been shown to offer low cost, yet invaluable information needed for digital soil mapping at meaningful spatial scales for land management. However, spectrally inferred soil carbon data are known to be less accurate compared to laboratory analysed measurements. This study establishes a methodology to filter out the measurement error variability by incorporating the measurement error variance in the spatial covariance structure of the model. The study was carried out in the Lower Hunter Valley, New South Wales, Australia where a combination of laboratory measured, and vis-NIR and MIR inferred topsoil and subsoil soil carbon data are available. We investigated the applicability of residual maximum likelihood (REML) and Markov Chain Monte Carlo (MCMC) simulation methods to generate parameters of the Matérn covariance function directly from the data in the presence of measurement error. The results revealed that the measurement error can be effectively filtered-out through the proposed technique. When the measurement error was filtered from the data, the prediction variance almost halved, which ultimately yielded a greater certainty in spatial predictions of soil carbon. Further, the MCMC technique was successfully used to define the posterior distribution of measurement error. This is an important outcome, as the MCMC technique can be used to estimate the measurement error if it is not explicitly quantified. Although this study dealt with soil carbon data, this method is amenable for filtering the measurement error of any kind of continuous spatial environmental data. Copyright © 2018 Elsevier B.V. All rights reserved.

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

Nicotine-induced activation of caudate and anterior cingulate cortex in response to errors in schizophrenia.

PubMed

Moran, Lauren V; Stoeckel, Luke E; Wang, Kristina; Caine, Carolyn E; Villafuerte, Rosemond; Calderon, Vanessa; Baker, Justin T; Ongur, Dost; Janes, Amy C; Evins, A Eden; Pizzagalli, Diego A

2018-03-01

Nicotine improves attention and processing speed in individuals with schizophrenia. Few studies have investigated the effects of nicotine on cognitive control. Prior functional magnetic resonance imaging (fMRI) research demonstrates blunted activation of dorsal anterior cingulate cortex (dACC) and rostral anterior cingulate cortex (rACC) in response to error and decreased post-error slowing in schizophrenia. Participants with schizophrenia (n = 13) and healthy controls (n = 12) participated in a randomized, placebo-controlled, crossover study of the effects of transdermal nicotine on cognitive control. For each drug condition, participants underwent fMRI while performing the stop signal task where participants attempt to inhibit prepotent responses to "go (motor activation)" signals when an occasional "stop (motor inhibition)" signal appears. Error processing was evaluated by comparing "stop error" trials (failed response inhibition) to "go" trials. Resting-state fMRI data were collected prior to the task. Participants with schizophrenia had increased nicotine-induced activation of right caudate in response to errors compared to controls (DRUG × GROUP effect: p corrected  < 0.05). Both groups had significant nicotine-induced activation of dACC and rACC in response to errors. Using right caudate activation to errors as a seed for resting-state functional connectivity analysis, relative to controls, participants with schizophrenia had significantly decreased connectivity between the right caudate and dACC/bilateral dorsolateral prefrontal cortices. In sum, we replicated prior findings of decreased post-error slowing in schizophrenia and found that nicotine was associated with more adaptive (i.e., increased) post-error reaction time (RT). This proof-of-concept pilot study suggests a role for nicotinic agents in targeting cognitive control deficits in schizophrenia.

Patient safety priorities in mental healthcare in Switzerland: a modified Delphi study

PubMed Central

Mascherek, Anna C

2016-01-01

Objective Identifying patient safety priorities in mental healthcare is an emerging issue. A variety of aspects of patient safety in medical care apply for patient safety in mental care as well. However, specific aspects may be different as a consequence of special characteristics of patients, setting and treatment. The aim of the present study was to combine knowledge from the field and research and bundle existing initiatives and projects to define patient safety priorities in mental healthcare in Switzerland. The present study draws on national expert panels, namely, round-table discussion and modified Delphi consensus method. Design As preparation for the modified Delphi questionnaire, two round-table discussions and one semistructured questionnaire were conducted. Preparative work was conducted between May 2015 and October 2015. The modified Delphi was conducted to gauge experts' opinion on priorities in patient safety in mental healthcare in Switzerland. In two independent rating rounds, experts made private ratings. The modified Delphi was conducted in winter 2015. Results Nine topics were defined along the treatment pathway: diagnostic errors, non-drug treatment errors, medication errors, errors related to coercive measures, errors related to aggression management against self and others, errors in treatment of suicidal patients, communication errors, errors at interfaces of care and structural errors. Conclusions Patient safety is considered as an important topic of quality in mental healthcare among experts, but it has been seriously neglected up until now. Activities in research and in practice are needed. Structural errors and diagnostics were given highest priority. From the topics identified, some are overlapping with important aspects of patient safety in medical care; however, some core aspects are unique. PMID:27496233

Restrictions on surgical resident shift length does not impact type of medical errors.

PubMed

Anderson, Jamie E; Goodman, Laura F; Jensen, Guy W; Salcedo, Edgardo S; Galante, Joseph M

2017-05-15

In 2011, resident duty hours were restricted in an attempt to improve patient safety and resident education. With the goal of reducing fatigue, shorter shift length leads to more patient handoffs, raising concerns about adverse effects on patient safety. This study seeks to determine whether differences in duty-hour restrictions influence types of errors made by residents. This is a nested retrospective cohort study at a surgery department in an academic medical center. During 2013-14, standard 2011 duty hours were in place for residents. In 2014-15, duty-hour restrictions at the study site were relaxed ("flexible") with no restrictions on shift length. We reviewed all morbidity and mortality submissions from July 1, 2013-June 30, 2015 and compared differences in types of errors between these periods. A total of 383 patients experienced adverse events, including 59 deaths (15.4%). Comparing standard versus flexible periods, there was no difference in mortality (15.7% versus 12.6%, P = 0.479) or complication rates (2.6% versus 2.5%, P = 0.696). There was no difference in types of errors between periods (P = 0.050-0.808). The most number of errors were due to cognitive failures (229, 59.6%), whereas the fewest number of errors were due to team failure (127, 33.2%). By subset, technical errors resulted in the highest number of errors (169, 44.1%). There were no differences between types of errors of cases that were nonelective, at night, or involving residents. Among adverse events reported in this departmental surgical morbidity and mortality, there were no differences in types of errors when resident duty hours were less restrictive. Copyright © 2017 Elsevier Inc. All rights reserved.

A study of digital holographic filters generation. Phase 2: Digital data communication system, volume 1

NASA Technical Reports Server (NTRS)

Ingels, F. M.; Mo, C. D.

1978-01-01

An empirical study of the performance of the Viterbi decoders in bursty channels was carried out and an improved algebraic decoder for nonsystematic codes was developed. The hybrid algorithm was simulated for the (2,1), k = 7 code on a computer using 20 channels having various error statistics, ranging from pure random error to pure bursty channels. The hybrid system outperformed both the algebraic and the Viterbi decoders in every case, except the 1% random error channel where the Viterbi decoder had one bit less decoding error.

Error threshold for color codes and random three-body Ising models.

PubMed

Katzgraber, Helmut G; Bombin, H; Martin-Delgado, M A

2009-08-28

We study the error threshold of color codes, a class of topological quantum codes that allow a direct implementation of quantum Clifford gates suitable for entanglement distillation, teleportation, and fault-tolerant quantum computation. We map the error-correction process onto a statistical mechanical random three-body Ising model and study its phase diagram via Monte Carlo simulations. The obtained error threshold of p(c) = 0.109(2) is very close to that of Kitaev's toric code, showing that enhanced computational capabilities do not necessarily imply lower resistance to noise.

Fluorescence errors in integrating sphere measurements of remote phosphor type LED light sources

NASA Astrophysics Data System (ADS)

Keppens, A.; Zong, Y.; Podobedov, V. B.; Nadal, M. E.; Hanselaer, P.; Ohno, Y.

2011-05-01

The relative spectral radiant flux error caused by phosphor fluorescence during integrating sphere measurements is investigated both theoretically and experimentally. Integrating sphere and goniophotometer measurements are compared and used for model validation, while a case study provides additional clarification. Criteria for reducing fluorescence errors to a degree of negligibility as well as a fluorescence error correction method based on simple matrix algebra are presented. Only remote phosphor type LED light sources are studied because of their large phosphor surfaces and high application potential in general lighting.

Modeling of a bubble-memory organization with self-checking translators to achieve high reliability.

NASA Technical Reports Server (NTRS)

Bouricius, W. G.; Carter, W. C.; Hsieh, E. P.; Wadia, A. B.; Jessep, D. C., Jr.

1973-01-01

Study of the design and modeling of a highly reliable bubble-memory system that has the capabilities of: (1) correcting a single 16-adjacent bit-group error resulting from failures in a single basic storage module (BSM), and (2) detecting with a probability greater than 0.99 any double errors resulting from failures in BSM's. The results of the study justify the design philosophy adopted of employing memory data encoding and a translator to correct single group errors and detect double group errors to enhance the overall system reliability.

The pattern of the discovery of medication errors in a tertiary hospital in Hong Kong.

PubMed

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

2013-06-01

The primary goal of reducing medication errors is to eliminate those that reach the patient. We aimed to study the pattern of interceptions to tackle medication errors along the medication use processes. Tertiary care hospital in Hong Kong. The 'Swiss Cheese Model' was used to explain the interceptions targeting medication error reporting over 5 years (2006-2010). Proportions of prescribing, dispensing and drug administration errors intercepted by pharmacists and nurses; proportions of prescribing, dispensing and drug administration errors that reached the patient. Our analysis included 1,268 in-patient medication errors, of which 53.4% were related to prescribing, 29.0% to administration and 17.6% to dispensing. 34.1% of all medication errors (4.9% prescribing, 26.8% drug administration and 2.4% dispensing) were not intercepted. Pharmacy staff intercepted 85.4% of the prescribing errors. Nurses detected 83.0% of dispensing and 5.0% of prescribing errors. However, 92.4% of all drug administration errors reached the patient. Having a preventive measure at each stage of the medication use process helps to prevent most errors. Most drug administration errors reach the patient as there is no defense against these. Therefore, more interventions to prevent drug administration errors are warranted.

Study on the refractive errors of school going children of Pokhara city in Nepal.

PubMed

Niroula, D R; Saha, C G

Refractive errors are the one of the most common visual disorders found worldwide in school going children and also it is one of the causes of blindness. It can easily be prevented, if timely proper measures are taken. In Kathmandu valley and Mechi Zone of Nepal, the distribution of refractive errors was found to be very high. No records are available from the Western part of Nepal. Considering the importance of the refractive errors the present study had been undertaken in Pokhara city. 964 subjects (474 boys, 490 girls) were selected between age groups 10 to 19 years from 6 schools representing different region of Pokhara. After Preliminary examination: on acuity of vision with Snellen's and Jaeger's charts, the subjects were referred to the Manipal Teaching Hospital, Pokhara for confirmation of the refractive errors. Sixty two schools children (6.43%), out of 964 had refractive errors. The myopia was found to be most common (4.05%). The refractive errors were found more in Private school children (9.29%) than Government school children (4.23%), which is statistically significant (P < 0.05). More boys (7.59%) were found to have suffered from refractive errors than girls (5.31%). Further, children with vegetarian diet (10.52%) had greater number of refractive errors than non-vegetarian diet children (6.17%). In the present study, percentage distribution of myopia was found to be higher (4.05%) than the hyperopia (1.24%) and astigmatism (1.14%). Interestingly, in the present study the refractive errors were found significantly higher in Private schools children than Government schools because the children who read in Private schools have higher socioeconomic status; spend more time in home work, watching Television and Computer as compared to government schools children. These near activities of the eyes causes stress on eyes of the children and might be one of the causes of developing myopia.

CME Velocity and Acceleration Error Estimates Using the Bootstrap Method

NASA Technical Reports Server (NTRS)

Michalek, Grzegorz; Gopalswamy, Nat; Yashiro, Seiji

2017-01-01

The bootstrap method is used to determine errors of basic attributes of coronal mass ejections (CMEs) visually identified in images obtained by the Solar and Heliospheric Observatory (SOHO) mission's Large Angle and Spectrometric Coronagraph (LASCO) instruments. The basic parameters of CMEs are stored, among others, in a database known as the SOHO/LASCO CME catalog and are widely employed for many research studies. The basic attributes of CMEs (e.g. velocity and acceleration) are obtained from manually generated height-time plots. The subjective nature of manual measurements introduces random errors that are difficult to quantify. In many studies the impact of such measurement errors is overlooked. In this study we present a new possibility to estimate measurements errors in the basic attributes of CMEs. This approach is a computer-intensive method because it requires repeating the original data analysis procedure several times using replicate datasets. This is also commonly called the bootstrap method in the literature. We show that the bootstrap approach can be used to estimate the errors of the basic attributes of CMEs having moderately large numbers of height-time measurements. The velocity errors are in the vast majority small and depend mostly on the number of height-time points measured for a particular event. In the case of acceleration, the errors are significant, and for more than half of all CMEs, they are larger than the acceleration itself.

Error Rate Comparison during Polymerase Chain Reaction by DNA Polymerase

DOE PAGES

McInerney, Peter; Adams, Paul; Hadi, Masood Z.

2014-01-01

As larger-scale cloning projects become more prevalent, there is an increasing need for comparisons among high fidelity DNA polymerases used for PCR amplification. All polymerases marketed for PCR applications are tested for fidelity properties (i.e., error rate determination) by vendors, and numerous literature reports have addressed PCR enzyme fidelity. Nonetheless, it is often difficult to make direct comparisons among different enzymes due to numerous methodological and analytical differences from study to study. We have measured the error rates for 6 DNA polymerases commonly used in PCR applications, including 3 polymerases typically used for cloning applications requiring high fidelity. Error ratemore » measurement values reported here were obtained by direct sequencing of cloned PCR products. The strategy employed here allows interrogation of error rate across a very large DNA sequence space, since 94 unique DNA targets were used as templates for PCR cloning. The six enzymes included in the study, Taq polymerase, AccuPrime-Taq High Fidelity, KOD Hot Start, cloned Pfu polymerase, Phusion Hot Start, and Pwo polymerase, we find the lowest error rates with Pfu , Phusion, and Pwo polymerases. Error rates are comparable for these 3 enzymes and are >10x lower than the error rate observed with Taq polymerase. Mutation spectra are reported, with the 3 high fidelity enzymes displaying broadly similar types of mutations. For these enzymes, transition mutations predominate, with little bias observed for type of transition.« less

Quotation accuracy in medical journal articles-a systematic review and meta-analysis.

PubMed

Jergas, Hannah; Baethge, Christopher

2015-01-01

Background. Quotations and references are an indispensable element of scientific communication. They should support what authors claim or provide important background information for readers. Studies indicate, however, that quotations not serving their purpose-quotation errors-may be prevalent. Methods. We carried out a systematic review, meta-analysis and meta-regression of quotation errors, taking account of differences between studies in error ascertainment. Results. Out of 559 studies screened we included 28 in the main analysis, and estimated major, minor and total quotation error rates of 11,9%, 95% CI [8.4, 16.6] 11.5% [8.3, 15.7], and 25.4% [19.5, 32.4]. While heterogeneity was substantial, even the lowest estimate of total quotation errors was considerable (6.7%). Indirect references accounted for less than one sixth of all quotation problems. The findings remained robust in a number of sensitivity and subgroup analyses (including risk of bias analysis) and in meta-regression. There was no indication of publication bias. Conclusions. Readers of medical journal articles should be aware of the fact that quotation errors are common. Measures against quotation errors include spot checks by editors and reviewers, correct placement of citations in the text, and declarations by authors that they have checked cited material. Future research should elucidate if and to what degree quotation errors are detrimental to scientific progress.

Risk factors for refractive errors in primary school children (6-12 years old) in Nakhon Pathom Province.

PubMed

Yingyong, Penpimol

2010-11-01

Refractive error is one of the leading causes of visual impairment in children. An analysis of risk factors for refractive error is required to reduce and prevent this common eye disease. To identify the risk factors associated with refractive errors in primary school children (6-12 year old) in Nakhon Pathom province. A population-based cross-sectional analytic study was conducted between October 2008 and September 2009 in Nakhon Pathom. Refractive error, parental refractive status, and hours per week of near activities (studying, reading books, watching television, playing with video games, or working on the computer) were assessed in 377 children who participated in this study. The most common type of refractive error in primary school children was myopia. Myopic children were more likely to have parents with myopia. Children with myopia spend more time at near activities. The multivariate odds ratio (95% confidence interval)for two myopic parents was 6.37 (2.26-17.78) and for each diopter-hour per week of near work was 1.019 (1.005-1.033). Multivariate logistic regression models show no confounding effects between parental myopia and near work suggesting that each factor has an independent association with myopia. Statistical analysis by logistic regression revealed that family history of refractive error and hours of near-work were significantly associated with refractive error in primary school children.

Crosslinking EEG time-frequency decomposition and fMRI in error monitoring.

PubMed

Hoffmann, Sven; Labrenz, Franziska; Themann, Maria; Wascher, Edmund; Beste, Christian

2014-03-01

Recent studies implicate a common response monitoring system, being active during erroneous and correct responses. Converging evidence from time-frequency decompositions of the response-related ERP revealed that evoked theta activity at fronto-central electrode positions differentiates correct from erroneous responses in simple tasks, but also in more complex tasks. However, up to now it is unclear how different electrophysiological parameters of error processing, especially at the level of neural oscillations are related, or predictive for BOLD signal changes reflecting error processing at a functional-neuroanatomical level. The present study aims to provide crosslinks between time domain information, time-frequency information, MRI BOLD signal and behavioral parameters in a task examining error monitoring due to mistakes in a mental rotation task. The results show that BOLD signal changes reflecting error processing on a functional-neuroanatomical level are best predicted by evoked oscillations in the theta frequency band. Although the fMRI results in this study account for an involvement of the anterior cingulate cortex, middle frontal gyrus, and the Insula in error processing, the correlation of evoked oscillations and BOLD signal was restricted to a coupling of evoked theta and anterior cingulate cortex BOLD activity. The current results indicate that although there is a distributed functional-neuroanatomical network mediating error processing, only distinct parts of this network seem to modulate electrophysiological properties of error monitoring.

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

Yu, Juan; Beltran, Chris J., E-mail: beltran.chris@mayo.edu; Herman, Michael G.

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

After the Medication Error: Recent Nursing Graduates' Reflections on Adequacy of Education.

PubMed

Treiber, Linda A; Jones, Jackie H

2018-05-01

The purpose of this study was to better understand individual- and system-level factors surrounding making a medication error from the perspective of recent Bachelor of Science in Nursing graduates. Online survey mixed-methods items included perceptions of adequacy of preparatory nursing education, contributory variables, emotional responses, and treatment by employer following the error. Of the 168 respondents, 55% had made a medication error. Errors resulted from inexperience, rushing, technology, staffing, and patient acuity. Twenty-four percent did not report their errors. Key themes for improving education included more practice in varied clinical areas, intensive pharmacological preparation, practical instruction in functioning within the health care environment, and coping after making medication errors. Errors generally caused emotional distress in the error maker. Overall, perceived treatment after the error reflected supportive environments, where nurses were generally treated with respect, fair treatment, and understanding. Opportunities for nursing education include second victim awareness and reinforcing professional practice standards. [J Nurs Educ. 2018;57(5):275-280.]. Copyright 2018, SLACK Incorporated.

Detection and correction of prescription errors by an emergency department pharmacy service.

PubMed

Stasiak, Philip; Afilalo, Marc; Castelino, Tanya; Xue, Xiaoqing; Colacone, Antoinette; Soucy, Nathalie; Dankoff, Jerrald

2014-05-01

Emergency departments (EDs) are recognized as a high-risk setting for prescription errors. Pharmacist involvement may be important in reviewing prescriptions to identify and correct errors. The objectives of this study were to describe the frequency and type of prescription errors detected by pharmacists in EDs, determine the proportion of errors that could be corrected, and identify factors associated with prescription errors. This prospective observational study was conducted in a tertiary care teaching ED on 25 consecutive weekdays. Pharmacists reviewed all documented prescriptions and flagged and corrected errors for patients in the ED. We collected information on patient demographics, details on prescription errors, and the pharmacists' recommendations. A total of 3,136 ED prescriptions were reviewed. The proportion of prescriptions in which a pharmacist identified an error was 3.2% (99 of 3,136; 95% confidence interval [CI] 2.5-3.8). The types of identified errors were wrong dose (28 of 99, 28.3%), incomplete prescription (27 of 99, 27.3%), wrong frequency (15 of 99, 15.2%), wrong drug (11 of 99, 11.1%), wrong route (1 of 99, 1.0%), and other (17 of 99, 17.2%). The pharmacy service intervened and corrected 78 (78 of 99, 78.8%) errors. Factors associated with prescription errors were patient age over 65 (odds ratio [OR] 2.34; 95% CI 1.32-4.13), prescriptions with more than one medication (OR 5.03; 95% CI 2.54-9.96), and those written by emergency medicine residents compared to attending emergency physicians (OR 2.21, 95% CI 1.18-4.14). Pharmacists in a tertiary ED are able to correct the majority of prescriptions in which they find errors. Errors are more likely to be identified in prescriptions written for older patients, those containing multiple medication orders, and those prescribed by emergency residents.

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

Analyzing the errors of DFT approximations for compressed water systems

NASA Astrophysics Data System (ADS)

Alfè, D.; Bartók, A. P.; Csányi, G.; Gillan, M. J.

2014-07-01

We report an extensive study of the errors of density functional theory (DFT) approximations for compressed water systems. The approximations studied are based on the widely used PBE and BLYP exchange-correlation functionals, and we characterize their errors before and after correction for 1- and 2-body errors, the corrections being performed using the methods of Gaussian approximation potentials. The errors of the uncorrected and corrected approximations are investigated for two related types of water system: first, the compressed liquid at temperature 420 K and density 1.245 g/cm3 where the experimental pressure is 15 kilobars; second, thermal samples of compressed water clusters from the trimer to the 27-mer. For the liquid, we report four first-principles molecular dynamics simulations, two generated with the uncorrected PBE and BLYP approximations and a further two with their 1- and 2-body corrected counterparts. The errors of the simulations are characterized by comparing with experimental data for the pressure, with neutron-diffraction data for the three radial distribution functions, and with quantum Monte Carlo (QMC) benchmarks for the energies of sets of configurations of the liquid in periodic boundary conditions. The DFT errors of the configuration samples of compressed water clusters are computed using QMC benchmarks. We find that the 2-body and beyond-2-body errors in the liquid are closely related to similar errors exhibited by the clusters. For both the liquid and the clusters, beyond-2-body errors of DFT make a substantial contribution to the overall errors, so that correction for 1- and 2-body errors does not suffice to give a satisfactory description. For BLYP, a recent representation of 3-body energies due to Medders, Babin, and Paesani [J. Chem. Theory Comput. 9, 1103 (2013)] gives a reasonably good way of correcting for beyond-2-body errors, after which the remaining errors are typically 0.5 mEh ≃ 15 meV/monomer for the liquid and the clusters.

Analyzing the errors of DFT approximations for compressed water systems

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

Alfè, D.; London Centre for Nanotechnology, UCL, London WC1H 0AH; Thomas Young Centre, UCL, London WC1H 0AH

We report an extensive study of the errors of density functional theory (DFT) approximations for compressed water systems. The approximations studied are based on the widely used PBE and BLYP exchange-correlation functionals, and we characterize their errors before and after correction for 1- and 2-body errors, the corrections being performed using the methods of Gaussian approximation potentials. The errors of the uncorrected and corrected approximations are investigated for two related types of water system: first, the compressed liquid at temperature 420 K and density 1.245 g/cm{sup 3} where the experimental pressure is 15 kilobars; second, thermal samples of compressed watermore » clusters from the trimer to the 27-mer. For the liquid, we report four first-principles molecular dynamics simulations, two generated with the uncorrected PBE and BLYP approximations and a further two with their 1- and 2-body corrected counterparts. The errors of the simulations are characterized by comparing with experimental data for the pressure, with neutron-diffraction data for the three radial distribution functions, and with quantum Monte Carlo (QMC) benchmarks for the energies of sets of configurations of the liquid in periodic boundary conditions. The DFT errors of the configuration samples of compressed water clusters are computed using QMC benchmarks. We find that the 2-body and beyond-2-body errors in the liquid are closely related to similar errors exhibited by the clusters. For both the liquid and the clusters, beyond-2-body errors of DFT make a substantial contribution to the overall errors, so that correction for 1- and 2-body errors does not suffice to give a satisfactory description. For BLYP, a recent representation of 3-body energies due to Medders, Babin, and Paesani [J. Chem. Theory Comput. 9, 1103 (2013)] gives a reasonably good way of correcting for beyond-2-body errors, after which the remaining errors are typically 0.5 mE{sub h} ≃ 15 meV/monomer for the liquid and the clusters.« less

Carbapenem Susceptibility Testing Errors Using Three Automated Systems, Disk Diffusion, Etest, and Broth Microdilution and Carbapenem Resistance Genes in Isolates of Acinetobacter baumannii-calcoaceticus Complex

DTIC Science & Technology

2011-10-01

Phoenix, and Vitek 2 systems). Discordant results were categorized as very major errors (VME), major errors (ME), and minor errors (mE). DNA sequences...01 OCT 2011 2 . REPORT TYPE N/A 3. DATES COVERED - 4. TITLE AND SUBTITLE Carbapenem Susceptibility Testing Errors Using Three Automated...FDA standards required for device approval (11). The Vitek 2 method was the only automated susceptibility method in our study that satisfied FDA

Analog-digital simulation of transient-induced logic errors and upset susceptibility of an advanced control system

NASA Technical Reports Server (NTRS)

Carreno, Victor A.; Choi, G.; Iyer, R. K.

1990-01-01

A simulation study is described which predicts the susceptibility of an advanced control system to electrical transients resulting in logic errors, latched errors, error propagation, and digital upset. The system is based on a custom-designed microprocessor and it incorporates fault-tolerant techniques. The system under test and the method to perform the transient injection experiment are described. Results for 2100 transient injections are analyzed and classified according to charge level, type of error, and location of injection.

Error analysis of finite element method for Poisson–Nernst–Planck equations

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

Sun, Yuzhou; Sun, Pengtao; Zheng, Bin

A priori error estimates of finite element method for time-dependent Poisson-Nernst-Planck equations are studied in this work. We obtain the optimal error estimates in L∞(H1) and L2(H1) norms, and suboptimal error estimates in L∞(L2) norm, with linear element, and optimal error estimates in L∞(L2) norm with quadratic or higher-order element, for both semi- and fully discrete finite element approximations. Numerical experiments are also given to validate the theoretical results.

Modeling error distributions of growth curve models through Bayesian methods.

PubMed

Zhang, Zhiyong

2016-06-01

Growth curve models are widely used in social and behavioral sciences. However, typical growth curve models often assume that the errors are normally distributed although non-normal data may be even more common than normal data. In order to avoid possible statistical inference problems in blindly assuming normality, a general Bayesian framework is proposed to flexibly model normal and non-normal data through the explicit specification of the error distributions. A simulation study shows when the distribution of the error is correctly specified, one can avoid the loss in the efficiency of standard error estimates. A real example on the analysis of mathematical ability growth data from the Early Childhood Longitudinal Study, Kindergarten Class of 1998-99 is used to show the application of the proposed methods. Instructions and code on how to conduct growth curve analysis with both normal and non-normal error distributions using the the MCMC procedure of SAS are provided.

The importance of intra-hospital pharmacovigilance in the detection of medication errors

PubMed

Villegas, Francisco; Figueroa-Montero, David; Barbero-Becerra, Varenka; Juárez-Hernández, Eva; Uribe, Misael; Chávez-Tapia, Norberto; González-Chon, Octavio

2018-01-01

Hospitalized patients are susceptible to medication errors, which represent between the fourth and the sixth cause of death. The department of intra-hospital pharmacovigilance intervenes in the entire process of medication with the purpose to prevent, repair and assess damages. To analyze medication errors reported by Mexican Fundación Clínica Médica Sur pharmacovigilance system and their impact on patients. Prospective study carried out from 2012 to 2015, where medication prescriptions given to patients were recorded. Owing to heterogeneity, data were described as absolute numbers in a logarithmic scale. 292 932 prescriptions of 56 368 patients were analyzed, and 8.9% of medication errors were identified. The treating physician was responsible of 83.32% of medication errors, residents of 6.71% and interns of 0.09%. No error caused permanent damage or death. This is the pharmacovigilance study with the largest sample size reported. Copyright: © 2018 SecretarÍa de Salud.

A theoretical basis for the analysis of multiversion software subject to coincident errors

NASA Technical Reports Server (NTRS)

Eckhardt, D. E., Jr.; Lee, L. D.

1985-01-01

Fundamental to the development of redundant software techniques (known as fault-tolerant software) is an understanding of the impact of multiple joint occurrences of errors, referred to here as coincident errors. A theoretical basis for the study of redundant software is developed which: (1) provides a probabilistic framework for empirically evaluating the effectiveness of a general multiversion strategy when component versions are subject to coincident errors, and (2) permits an analytical study of the effects of these errors. An intensity function, called the intensity of coincident errors, has a central role in this analysis. This function describes the propensity of programmers to introduce design faults in such a way that software components fail together when executing in the application environment. A condition under which a multiversion system is a better strategy than relying on a single version is given.

Students’ Errors in Geometry Viewed from Spatial Intelligence

NASA Astrophysics Data System (ADS)

Riastuti, N.; Mardiyana, M.; Pramudya, I.

2017-09-01

Geometry is one of the difficult materials because students must have ability to visualize, describe images, draw shapes, and know the kind of shapes. This study aim is to describe student error based on Newmans’ Error Analysis in solving geometry problems viewed from spatial intelligence. This research uses descriptive qualitative method by using purposive sampling technique. The datas in this research are the result of geometri material test and interview by the 8th graders of Junior High School in Indonesia. The results of this study show that in each category of spatial intelligence has a different type of error in solving the problem on the material geometry. Errors are mostly made by students with low spatial intelligence because they have deficiencies in visual abilities. Analysis of student error viewed from spatial intelligence is expected to help students do reflection in solving the problem of geometry.

A Six Sigma Trial For Reduction of Error Rates in Pathology Laboratory.

PubMed

Tosuner, Zeynep; Gücin, Zühal; Kiran, Tuğçe; Büyükpinarbaşili, Nur; Turna, Seval; Taşkiran, Olcay; Arici, Dilek Sema

2016-01-01

A major target of quality assurance is the minimization of error rates in order to enhance patient safety. Six Sigma is a method targeting zero error (3.4 errors per million events) used in industry. The five main principles of Six Sigma are defining, measuring, analysis, improvement and control. Using this methodology, the causes of errors can be examined and process improvement strategies can be identified. The aim of our study was to evaluate the utility of Six Sigma methodology in error reduction in our pathology laboratory. The errors encountered between April 2014 and April 2015 were recorded by the pathology personnel. Error follow-up forms were examined by the quality control supervisor, administrative supervisor and the head of the department. Using Six Sigma methodology, the rate of errors was measured monthly and the distribution of errors at the preanalytic, analytic and postanalytical phases was analysed. Improvement strategies were reclaimed in the monthly intradepartmental meetings and the control of the units with high error rates was provided. Fifty-six (52.4%) of 107 recorded errors in total were at the pre-analytic phase. Forty-five errors (42%) were recorded as analytical and 6 errors (5.6%) as post-analytical. Two of the 45 errors were major irrevocable errors. The error rate was 6.8 per million in the first half of the year and 1.3 per million in the second half, decreasing by 79.77%. The Six Sigma trial in our pathology laboratory provided the reduction of the error rates mainly in the pre-analytic and analytic phases.

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.

Impact of Communication Errors in Radiology on Patient Care, Customer Satisfaction, and Work-Flow Efficiency.

PubMed

Siewert, Bettina; Brook, Olga R; Hochman, Mary; Eisenberg, Ronald L

2016-03-01

The purpose of this study is to analyze the impact of communication errors on patient care, customer satisfaction, and work-flow efficiency and to identify opportunities for quality improvement. We performed a search of our quality assurance database for communication errors submitted from August 1, 2004, through December 31, 2014. Cases were analyzed regarding the step in the imaging process at which the error occurred (i.e., ordering, scheduling, performance of examination, study interpretation, or result communication). The impact on patient care was graded on a 5-point scale from none (0) to catastrophic (4). The severity of impact between errors in result communication and those that occurred at all other steps was compared. Error evaluation was performed independently by two board-certified radiologists. Statistical analysis was performed using the chi-square test and kappa statistics. Three hundred eighty of 422 cases were included in the study. One hundred ninety-nine of the 380 communication errors (52.4%) occurred at steps other than result communication, including ordering (13.9%; n = 53), scheduling (4.7%; n = 18), performance of examination (30.0%; n = 114), and study interpretation (3.7%; n = 14). Result communication was the single most common step, accounting for 47.6% (181/380) of errors. There was no statistically significant difference in impact severity between errors that occurred during result communication and those that occurred at other times (p = 0.29). In 37.9% of cases (144/380), there was an impact on patient care, including 21 minor impacts (5.5%; result communication, n = 13; all other steps, n = 8), 34 moderate impacts (8.9%; result communication, n = 12; all other steps, n = 22), and 89 major impacts (23.4%; result communication, n = 45; all other steps, n = 44). In 62.1% (236/380) of cases, no impact was noted, but 52.6% (200/380) of cases had the potential for an impact. Among 380 communication errors in a radiology department, 37.9% had a direct impact on patient care, with an additional 52.6% having a potential impact. Most communication errors (52.4%) occurred at steps other than result communication, with similar severity of impact.

Error-Related Brain Activity in Young Children: Associations with Parental Anxiety and Child Temperamental Negative Emotionality

ERIC Educational Resources Information Center

Torpey, Dana C.; Hajcak, Greg; Kim, Jiyon; Kujawa, Autumn J.; Dyson, Margaret W.; Olino, Thomas M.; Klein, Daniel N.

2013-01-01

Background: There is increasing interest in error-related brain activity in anxiety disorders. The error-related negativity (ERN) is a negative deflection in the event-related potential approximately 50 [milliseconds] after errors compared to correct responses. Recent studies suggest that the ERN may be a biomarker for anxiety, as it is positively…

Citation Help in Databases: The More Things Change, the More They Stay the Same

ERIC Educational Resources Information Center

Van Ullen, Mary; Kessler, Jane

2012-01-01

In 2005, the authors reviewed citation help in databases and found an error rate of 4.4 errors per citation. This article describes a follow-up study that revealed a modest improvement in the error rate to 3.4 errors per citation, still unacceptably high. The most problematic area was retrieval statements. The authors conclude that librarians…

Modeling Multiplicative Error Variance: An Example Predicting Tree Diameter from Stump Dimensions in Baldcypress

Treesearch

Bernard R. Parresol

1993-01-01

In the context of forest modeling, it is often reasonable to assume a multiplicative heteroscedastic error structure to the data. Under such circumstances ordinary least squares no longer provides minimum variance estimates of the model parameters. Through study of the error structure, a suitable error variance model can be specified and its parameters estimated. This...

Network problem threshold

NASA Technical Reports Server (NTRS)

Gejji, Raghvendra, R.

1992-01-01

Network transmission errors such as collisions, CRC errors, misalignment, etc. are statistical in nature. Although errors can vary randomly, a high level of errors does indicate specific network problems, e.g. equipment failure. In this project, we have studied the random nature of collisions theoretically as well as by gathering statistics, and established a numerical threshold above which a network problem is indicated with high probability.

Some Deep Structure Manifestations in Second Language Errors of English Voiced and Voiceless "th."

ERIC Educational Resources Information Center

Moustafa, Margaret Heiss

Native speakers of Egyptian Arabic make errors in their pronunciation of English that cannot always be accounted for by a contrastive analysis of Egyptian analysis of Egyptain Arabic and English. This study focuses on three types of errors in the pronunciation of voiced and voiceless "th" made by fluent speakers of English. These errors were noted…

Drug Administration Errors in an Institution for Individuals with Intellectual Disability: An Observational Study

ERIC Educational Resources Information Center

van den Bemt, P. M. L. A.; Robertz, R.; de Jong, A. L.; van Roon, E. N.; Leufkens, H. G. M.

2007-01-01

Background: Medication errors can result in harm, unless barriers to prevent them are present. Drug administration errors are less likely to be prevented, because they occur in the last stage of the drug distribution process. This is especially the case in non-alert patients, as patients often form the final barrier to prevention of errors.…

Sources of Student Errors and Misconceptions in Algebra and Effectiveness of Classroom Practice Remediation in Machakos County--Kenya

ERIC Educational Resources Information Center

Mulungye, Mary M.; O'Connor, Miheso; Ndethiu, S.

2016-01-01

This paper is based on a study which sought to examine the various errors and misconceptions committed by students in algebra with the view to exposing the nature and origin of the errors and misconceptions in secondary schools in Machakos district. Teachers' knowledge on students' errors was investigated together with strategies for remedial…

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,…

Distortion Representation of Forecast Errors for Model Skill Assessment and Objective Analysis

NASA Technical Reports Server (NTRS)

Hoffman, Ross N.; Nehrkorn, Thomas; Grassotti, Christopher

1996-01-01

We study a novel characterization of errors for numerical weather predictions. In its simplest form we decompose the error into a part attributable to phase errors and a remainder. The phase error is represented in the same fashion as a velocity field and will be required to vary slowly and smoothly with position. A general distortion representation allows for the displacement and a bias correction of forecast anomalies. In brief, the distortion is determined by minimizing the objective function by varying the displacement and bias correction fields. In the present project we use a global or hemispheric domain, and spherical harmonics to represent these fields. In this project we are initially focusing on the assessment application, restricted to a realistic but univariate 2-dimensional situation. Specifically we study the forecast errors of the 500 hPa geopotential height field for forecasts of the short and medium range. The forecasts are those of the Goddard Earth Observing System data assimilation system. Results presented show that the methodology works, that a large part of the total error may be explained by a distortion limited to triangular truncation at wavenumber 10, and that the remaining residual error contains mostly small spatial scales.

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.

Validation of Multiple Tools for Flat Plate Photovoltaic Modeling Against Measured Data

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

Freeman, J.; Whitmore, J.; Blair, N.

2014-08-01

This report expands upon a previous work by the same authors, published in the 40th IEEE Photovoltaic Specialists conference. In this validation study, comprehensive analysis is performed on nine photovoltaic systems for which NREL could obtain detailed performance data and specifications, including three utility-scale systems and six commercial scale systems. Multiple photovoltaic performance modeling tools were used to model these nine systems, and the error of each tool was analyzed compared to quality-controlled measured performance data. This study shows that, excluding identified outliers, all tools achieve annual errors within +/-8% and hourly root mean squared errors less than 7% formore » all systems. It is further shown using SAM that module model and irradiance input choices can change the annual error with respect to measured data by as much as 6.6% for these nine systems, although all combinations examined still fall within an annual error range of +/-8.5%. Additionally, a seasonal variation in monthly error is shown for all tools. Finally, the effects of irradiance data uncertainty and the use of default loss assumptions on annual error are explored, and two approaches to reduce the error inherent in photovoltaic modeling are proposed.« less

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

PubMed

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

2009-02-01

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

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

NASA Astrophysics Data System (ADS)

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

2016-10-01

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

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).

Prevalence of refractive error and visual impairment among rural school-age children of Goro District, Gurage Zone, Ethiopia.

PubMed

Kedir, Jafer; Girma, Abonesh

2014-10-01

Refractive error is one of the major causes of blindness and visual impairment in children; but community based studies are scarce especially in rural parts of Ethiopia. So, this study aims to assess the prevalence of refractive error and its magnitude as a cause of visual impairment among school-age children of rural community. This community-based cross-sectional descriptive study was conducted from March 1 to April 30, 2009 in rural villages of Goro district of Gurage Zone, found south west of Addis Ababa, the capital of Ethiopia. A multistage cluster sampling method was used with simple random selection of representative villages in the district. Chi-Square and t-tests were used in the data analysis. A total of 570 school-age children (age 7-15) were evaluated, 54% boys and 46% girls. The prevalence of refractive error was 3.5% (myopia 2.6% and hyperopia 0.9%). Refractive error was the major cause of visual impairment accounting for 54% of all causes in the study group. No child was found wearing corrective spectacles during the study period. Refractive error was the commonest cause of visual impairment in children of the district, but no measures were taken to reduce the burden in the community. So, large scale community level screening for refractive error should be conducted and integrated with regular school eye screening programs. Effective strategies need to be devised to provide low cost corrective spectacles in the rural community.

Renal Drug Dosing

PubMed Central

Vogel, Erin A.; Billups, Sarah J.; Herner, Sheryl J.

2016-01-01

Summary Objective The purpose of this study was to compare the effectiveness of an outpatient renal dose adjustment alert via a computerized provider order entry (CPOE) clinical decision support system (CDSS) versus a CDSS with alerts made to dispensing pharmacists. Methods This was a retrospective analysis of patients with renal impairment and 30 medications that are contraindicated or require dose-adjustment in such patients. The primary outcome was the rate of renal dosing errors for study medications that were dispensed between August and December 2013, when a pharmacist-based CDSS was in place, versus August through December 2014, when a prescriber-based CDSS was in place. A dosing error was defined as a prescription for one of the study medications dispensed to a patient where the medication was contraindicated or improperly dosed based on the patient’s renal function. The denominator was all prescriptions for the study medications dispensed during each respective study period. Results During the pharmacist- and prescriber-based CDSS study periods, 49,054 and 50,678 prescriptions, respectively, were dispensed for one of the included medications. Of these, 878 (1.8%) and 758 (1.5%) prescriptions were dispensed to patients with renal impairment in the respective study periods. Patients in each group were similar with respect to age, sex, and renal function stage. Overall, the five-month error rate was 0.38%. Error rates were similar between the two groups: 0.36% and 0.40% in the pharmacist- and prescriber-based CDSS, respectively (p=0.523). The medication with the highest error rate was dofetilide (0.51% overall) while the medications with the lowest error rate were dabigatran, fondaparinux, and spironolactone (0.00% overall). Conclusions Prescriber- and pharmacist-based CDSS provided comparable, low rates of potential medication errors. Future studies should be undertaken to examine patient benefits of the prescriber-based CDSS. PMID:27466041

Individual differences in error monitoring in healthy adults: psychological symptoms and antisocial personality characteristics.

PubMed

Chang, Wen-Pin; Davies, Patricia L; Gavin, William J

2010-10-01

Recent studies have investigated the relationship between psychological symptoms and personality traits and error monitoring measured by error-related negativity (ERN) and error positivity (Pe) event-related potential (ERP) components, yet there remains a paucity of studies examining the collective simultaneous effects of psychological symptoms and personality traits on error monitoring. This present study, therefore, examined whether measures of hyperactivity-impulsivity, depression, anxiety and antisocial personality characteristics could collectively account for significant interindividual variability of both ERN and Pe amplitudes, in 29 healthy adults with no known disorders, ages 18-30 years. The bivariate zero-order correlation analyses found that only the anxiety measure was significantly related to both ERN and Pe amplitudes. However, multiple regression analyses that included all four characteristic measures while controlling for number of segments in the ERP average revealed that both depression and antisocial personality characteristics were significant predictors for the ERN amplitudes whereas antisocial personality was the only significant predictor for the Pe amplitude. These findings suggest that psychological symptoms and personality traits are associated with individual variations in error monitoring in healthy adults, and future studies should consider these variables when comparing group difference in error monitoring between adults with and without disabilities. © 2010 The Authors. European Journal of Neuroscience © 2010 Federation of European Neuroscience Societies and Blackwell Publishing Ltd.

On the validity and robustness of the scale error phenomenon in early childhood.

PubMed

DeLoache, Judy S; LoBue, Vanessa; Vanderborght, Mieke; Chiong, Cynthia

2013-02-01

Scale errors is a term referring to very young children's serious efforts to perform actions on miniature replica objects that are impossible due to great differences in the size of the child's body and the size of the target objects. We report three studies providing further documentation of scale errors and investigating the validity and robustness of the phenomenon. In the first, we establish that 2-year-olds' behavior in response to prompts to "pretend" with miniature replica objects differs dramatically from scale errors. The second and third studies address the robustness of the phenomenon and its relative imperviousness to attempts to influence the rate of scale errors. Copyright © 2012 Elsevier Inc. All rights reserved.

Stochastic Evolution Equations Driven by Fractional Noises

DTIC Science & Technology

2016-11-28

rate of convergence to zero or the error and the limit in distribution of the error fluctuations. We have studied time discrete numerical schemes...error fluctuations. We have studied time discrete numerical schemes based on Taylor expansions for rough differential equations and for stochastic...variations of the time discrete Taylor schemes for rough differential equations and for stochastic differential equations driven by fractional Brownian

"Coded and Uncoded Error Feedback: Effects on Error Frequencies in Adult Colombian EFL Learners' Writing"

ERIC Educational Resources Information Center

Sampson, Andrew

2012-01-01

This paper reports on a small-scale study into the effects of uncoded correction (writing the correct forms above each error) and coded annotations (writing symbols that encourage learners to self-correct) on Colombian university-level EFL learners' written work. The study finds that while both coded annotations and uncoded correction appear to…

Association between split selection instability and predictive error in survival trees.

PubMed

Radespiel-Tröger, M; Gefeller, O; Rabenstein, T; Hothorn, T

2006-01-01

To evaluate split selection instability in six survival tree algorithms and its relationship with predictive error by means of a bootstrap study. We study the following algorithms: logrank statistic with multivariate p-value adjustment without pruning (LR), Kaplan-Meier distance of survival curves (KM), martingale residuals (MR), Poisson regression for censored data (PR), within-node impurity (WI), and exponential log-likelihood loss (XL). With the exception of LR, initial trees are pruned by using split-complexity, and final trees are selected by means of cross-validation. We employ a real dataset from a clinical study of patients with gallbladder stones. The predictive error is evaluated using the integrated Brier score for censored data. The relationship between split selection instability and predictive error is evaluated by means of box-percentile plots, covariate and cutpoint selection entropy, and cutpoint selection coefficients of variation, respectively, in the root node. We found a positive association between covariate selection instability and predictive error in the root node. LR yields the lowest predictive error, while KM and MR yield the highest predictive error. The predictive error of survival trees is related to split selection instability. Based on the low predictive error of LR, we recommend the use of this algorithm for the construction of survival trees. Unpruned survival trees with multivariate p-value adjustment can perform equally well compared to pruned trees. The analysis of split selection instability can be used to communicate the results of tree-based analyses to clinicians and to support the application of survival trees.

Narrative-compression coding for a channel with errors. Professional paper for period ending June 1987

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

Bond, J.W.

1988-01-01

Data-compression codes offer the possibility of improving the thruput of existing communication systems in the near term. This study was undertaken to determine if data-compression codes could be utilized to provide message compression in a channel with up to a 0.10-bit error rate. The data-compression capabilities of codes were investigated by estimating the average number of bits-per-character required to transmit narrative files. The performance of the codes in a channel with errors (a noisy channel) was investigated in terms of the average numbers of characters-decoded-in-error and of characters-printed-in-error-per-bit-error. Results were obtained by encoding four narrative files, which were resident onmore » an IBM-PC and use a 58-character set. The study focused on Huffman codes and suffix/prefix comma-free codes. Other data-compression codes, in particular, block codes and some simple variants of block codes, are briefly discussed to place the study results in context. Comma-free codes were found to have the most-promising data compression because error propagation due to bit errors are limited to a few characters for these codes. A technique was found to identify a suffix/prefix comma-free code giving nearly the same data compressions as a Huffman code with much less error propagation than the Huffman codes. Greater data compression can be achieved through the use of this comma-free code word assignments based on conditioned probabilities of character occurrence.« less

Uncorrected and corrected refractive error experiences of Nepalese adults: a qualitative study.

PubMed

Kandel, Himal; Khadka, Jyoti; Shrestha, Mohan Krishna; Sharma, Sadhana; Neupane Kandel, Sandhya; Dhungana, Purushottam; Pradhan, Kishore; Nepal, Bhagavat P; Thapa, Suman; Pesudovs, Konrad

2018-04-01

The aim of this study was to explore the impact of corrected and uncorrected refractive error (URE) on Nepalese people's quality of life (QoL), and to compare the QoL status between refractive error subgroups. Participants were recruited from Tilganga Institute of Ophthalmology and Dhulikhel Hospital, Nepal. Semi-structured in-depth interviews were conducted with 101 people with refractive error. Thematic analysis was used with matrices produced to compare the occurrence of themes and categories across participants. Themes were identified using an inductive approach. Seven major themes emerged that determined refractive error-specific QoL: activity limitation, inconvenience, health concerns, psycho-social impact, economic impact, general and ocular comfort symptoms, and visual symptoms. Activity limitation, economic impact, and symptoms were the most important themes for the participants with URE, whereas inconvenience associated with wearing glasses was the most important issue in glasses wearers. Similarly, possibilities of having side effects or complications were the major concerns for participants wearing contact lens. In general, refractive surgery addressed socio-emotional impact of wearing glasses or contact lens. However, the surgery participants had concerns such as possibility of having to wear glasses again due to relapse of refractive error. Impact of refractive error on people's QoL is multifaceted. Significance of the identified themes varies by refractive error subgroups. Refractive correction may not always address QoL impact of URE but often add unique QoL issues. This study findings also provide content for developing an item-bank for quantitatively measuring refractive error-specific QoL in developing country setting.

A survey of the prevalence of refractive errors among children in lower primary schools in Kampala district.

PubMed

Kawuma, Medi; Mayeku, Robert

2002-08-01

Refractive errors are a known cause of visual impairment and may cause blindness worldwide. In children, refractive errors may prevent those afflicted from progressing with their studies. In Uganda, like in many developing countries, there is no established vision-screening programme for children on commencement of school, such that those with early onset of such errors will have many years of poor vision. Over all, there is limited information on refractive errors among children in Africa. To determine the prevalence of refractive errors among school children attending lower primary in Kampala district; the frequency of the various types of refractive errors, and their relationship to sexuality and ethnicity. A cross-sectional descriptive study. Kampala district, Uganda A total of 623 children aged between 6 and 9 years had a visual acuity testing done at school using the same protocol; of these 301 (48.3%) were boys and 322 (51.7%) girls. Seventy-three children had a significant refractive error of +/-0.50 or worse in one or both eyes, giving a prevalence of 11.6% and the commonest single refractive error was astigmatism, which accounted for 52% of all errors. This was followed by hypermetropia, and myopia was the least common. Significant refractive errors occur among primary school children aged 6 to 9 years at a prevalence of approximately 12%. Therefore, there is a need to have regular and simple vision testing in primary school children at least at the commencement of school so as to defect those who may suffer from these disabilities.

Trial-to-trial adaptation in control of arm reaching and standing posture

PubMed Central

Pienciak-Siewert, Alison; Horan, Dylan P.

2016-01-01

Classical theories of motor learning hypothesize that adaptation is driven by sensorimotor error; this is supported by studies of arm and eye movements that have shown that trial-to-trial adaptation increases with error. Studies of postural control have shown that anticipatory postural adjustments increase with the magnitude of a perturbation. However, differences in adaptation have been observed between the two modalities, possibly due to either the inherent instability or sensory uncertainty in standing posture. Therefore, we hypothesized that trial-to-trial adaptation in posture should be driven by error, similar to what is observed in arm reaching, but the nature of the relationship between error and adaptation may differ. Here we investigated trial-to-trial adaptation of arm reaching and postural control concurrently; subjects made reaching movements in a novel dynamic environment of varying strengths, while standing and holding the handle of a force-generating robotic arm. We found that error and adaptation increased with perturbation strength in both arm and posture. Furthermore, in both modalities, adaptation showed a significant correlation with error magnitude. Our results indicate that adaptation scales proportionally with error in the arm and near proportionally in posture. In posture only, adaptation was not sensitive to small error sizes, which were similar in size to errors experienced in unperturbed baseline movements due to inherent variability. This finding may be explained as an effect of uncertainty about the source of small errors. Our findings suggest that in rehabilitation, postural error size should be considered relative to the magnitude of inherent movement variability. PMID:27683888

Trial-to-trial adaptation in control of arm reaching and standing posture.

PubMed

Pienciak-Siewert, Alison; Horan, Dylan P; Ahmed, Alaa A

2016-12-01

Classical theories of motor learning hypothesize that adaptation is driven by sensorimotor error; this is supported by studies of arm and eye movements that have shown that trial-to-trial adaptation increases with error. Studies of postural control have shown that anticipatory postural adjustments increase with the magnitude of a perturbation. However, differences in adaptation have been observed between the two modalities, possibly due to either the inherent instability or sensory uncertainty in standing posture. Therefore, we hypothesized that trial-to-trial adaptation in posture should be driven by error, similar to what is observed in arm reaching, but the nature of the relationship between error and adaptation may differ. Here we investigated trial-to-trial adaptation of arm reaching and postural control concurrently; subjects made reaching movements in a novel dynamic environment of varying strengths, while standing and holding the handle of a force-generating robotic arm. We found that error and adaptation increased with perturbation strength in both arm and posture. Furthermore, in both modalities, adaptation showed a significant correlation with error magnitude. Our results indicate that adaptation scales proportionally with error in the arm and near proportionally in posture. In posture only, adaptation was not sensitive to small error sizes, which were similar in size to errors experienced in unperturbed baseline movements due to inherent variability. This finding may be explained as an effect of uncertainty about the source of small errors. Our findings suggest that in rehabilitation, postural error size should be considered relative to the magnitude of inherent movement variability. Copyright © 2016 the American Physiological Society.

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.

Screening for refractive error among primary school children in Bayelsa state, Nigeria

PubMed Central

Opubiri, Ibeinmo; Pedro-Egbe, Chinyere

2013-01-01

Introduction Vision screening study in primary school children has not been done in Bayelsa State. This study aims to screen for refractive error among primary school children in Bayelsa State and use the data to plan for school Eye Health Program. Methods A cross sectional study on screening for refractive error in school children was carried out in Yenagoa Local Government Area of Bayelsa State in June 2009. A multistage sampling technique was used to select the study population (pupils aged between 5-15 years). Visual acuity (VA) for each eye, was assessed outside the classroom at a distance of 6 meters. Those with VA ≤6/9 were presented with a pinhole and the test repeated. Funduscopy was done inside a poorly lit classroom. An improvement of the VA with pinhole was considered refractive error. Data was analyzed with EPI INFO version 6. Results A total of 1,242 school children consisting of 658 females and 584 males were examined.About 97.7% of pupils had normal VA (VA of 6/6) while 56 eyes had VAs ≤ 6/9. Of these 56 eyes, the visual acuity in 49 eyes (87.5%) improved with pinhole. Twenty seven pupils had refractive error, giving a prevalence of 2.2%. Refractive error involved both eyes in 22 pupils (81.5%) and the 8-10 years age range had the highest proportion (40.7%) of cases of refractive error followed by the 9-13 year-old age range (37%). Conclusion The prevalence of refractive error was 2.2% and most eyes (97.7%) had normal vision. PMID:23646210

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.

Metering error quantification under voltage and current waveform distortion

NASA Astrophysics Data System (ADS)

Wang, Tao; Wang, Jia; Xie, Zhi; Zhang, Ran

2017-09-01

With integration of more and more renewable energies and distortion loads into power grid, the voltage and current waveform distortion results in metering error in the smart meters. Because of the negative effects on the metering accuracy and fairness, it is an important subject to study energy metering combined error. In this paper, after the comparing between metering theoretical value and real recorded value under different meter modes for linear and nonlinear loads, a quantification method of metering mode error is proposed under waveform distortion. Based on the metering and time-division multiplier principles, a quantification method of metering accuracy error is proposed also. Analyzing the mode error and accuracy error, a comprehensive error analysis method is presented which is suitable for new energy and nonlinear loads. The proposed method has been proved by simulation.

Investigation on coupling error characteristics in angular rate matching based ship deformation measurement approach

NASA Astrophysics Data System (ADS)

Yang, Shuai; Wu, Wei; Wang, Xingshu; Xu, Zhiguang

2018-01-01

The coupling error in the measurement of ship hull deformation can significantly influence the attitude accuracy of the shipborne weapons and equipments. It is therefore important to study the characteristics of the coupling error. In this paper, an comprehensive investigation on the coupling error is reported, which has a potential of deducting the coupling error in the future. Firstly, the causes and characteristics of the coupling error are analyzed theoretically based on the basic theory of measuring ship deformation. Then, simulations are conducted for verifying the correctness of the theoretical analysis. Simulation results show that the cross-correlation between dynamic flexure and ship angular motion leads to the coupling error in measuring ship deformation, and coupling error increases with the correlation value between them. All the simulation results coincide with the theoretical analysis.

Prevalence of refraction errors and color blindness in heavy vehicle drivers.

PubMed

Erdoğan, Haydar; Ozdemir, Levent; Arslan, Seher; Cetin, Ilhan; Ozeç, Ayşe Vural; Cetinkaya, Selma; Sümer, Haldun

2011-01-01

To investigate the frequency of eye disorders in heavy vehicle drivers. A cross-sectional type study was conducted between November 2004 and September 2006 in 200 driver and 200 non-driver persons. A complete ophthalmologic examination was performed, including visual acuity, and dilated examination of the posterior segment. We used the auto refractometer for determining refractive errors. According to eye examination results, the prevalence of the refractive error was 21.5% and 31.3% in study and control groups respectively (P<0.05). The most common type of refraction error in the study group was myopic astigmatism (8.3%) while in the control group simple myopia (12.8%). Prevalence of dyschromatopsia in the rivers, control group and total group was 2.2%, 2.8% and 2.6% respectively. A considerably high number of drivers are in lack of optimal visual acuity. Refraction errors in drivers may impair the traffic security.

Prevalence of refraction errors and color blindness in heavy vehicle drivers

PubMed Central

Erdoğan, Haydar; Özdemir, Levent; Arslan, Seher; Çetin, Ilhan; Özeç, Ayşe Vural; Çetinkaya, Selma; Sümer, Haldun

2011-01-01

AIM To investigate the frequency of eye disorders in heavy vehicle drivers. METHODS A cross-sectional type study was conducted between November 2004 and September 2006 in 200 driver and 200 non-driver persons. A complete ophthalmologic examination was performed, including visual acuity, and dilated examination of the posterior segment. We used the auto refractometer for determining refractive errors. RESULTS According to eye examination results, the prevalence of the refractive error was 21.5% and 31.3% in study and control groups respectively (P<0.05). The most common type of refraction error in the study group was myopic astigmatism (8.3%) while in the control group simple myopia (12.8%). Prevalence of dyschromatopsia in the rivers, control group and total group was 2.2%, 2.8% and 2.6% respectively. CONCLUSION A considerably high number of drivers are in lack of optimal visual acuity. Refraction errors in drivers may impair the traffic security. PMID:22553671

Increased errors and decreased performance at night: A systematic review of the evidence concerning shift work and quality.

PubMed

de Cordova, Pamela B; Bradford, Michelle A; Stone, Patricia W

2016-02-15

Shift workers have worse health outcomes than employees who work standard business hours. However, it is unclear how this poorer health shift may be related to employee work productivity. The purpose of this systematic review is to assess the relationship between shift work and errors and performance. Searches of MEDLINE/PubMed, EBSCOhost, and CINAHL were conducted to identify articles that examined the relationship between shift work, errors, quality, productivity, and performance. All articles were assessed for study quality. A total of 435 abstracts were screened with 13 meeting inclusion criteria. Eight studies were rated to be of strong, methodological quality. Nine studies demonstrated a positive relationship that night shift workers committed more errors and had decreased performance. Night shift workers have worse health that may contribute to errors and decreased performance in the workplace.

Incidence of speech recognition errors in the emergency department.

PubMed

Goss, Foster R; Zhou, Li; Weiner, Scott G

2016-09-01

Physician use of computerized speech recognition (SR) technology has risen in recent years due to its ease of use and efficiency at the point of care. However, error rates between 10 and 23% have been observed, raising concern about the number of errors being entered into the permanent medical record, their impact on quality of care and medical liability that may arise. Our aim was to determine the incidence and types of SR errors introduced by this technology in the emergency department (ED). Level 1 emergency department with 42,000 visits/year in a tertiary academic teaching hospital. A random sample of 100 notes dictated by attending emergency physicians (EPs) using SR software was collected from the ED electronic health record between January and June 2012. Two board-certified EPs annotated the notes and conducted error analysis independently. An existing classification schema was adopted to classify errors into eight errors types. Critical errors deemed to potentially impact patient care were identified. There were 128 errors in total or 1.3 errors per note, and 14.8% (n=19) errors were judged to be critical. 71% of notes contained errors, and 15% contained one or more critical errors. Annunciation errors were the highest at 53.9% (n=69), followed by deletions at 18.0% (n=23) and added words at 11.7% (n=15). Nonsense errors, homonyms and spelling errors were present in 10.9% (n=14), 4.7% (n=6), and 0.8% (n=1) of notes, respectively. There were no suffix or dictionary errors. Inter-annotator agreement was 97.8%. This is the first estimate at classifying speech recognition errors in dictated emergency department notes. Speech recognition errors occur commonly with annunciation errors being the most frequent. Error rates were comparable if not lower than previous studies. 15% of errors were deemed critical, potentially leading to miscommunication that could affect patient care. Copyright © 2016 Elsevier Ireland Ltd. All rights reserved.

Mathematical analysis study for radar data processing and enchancement. Part 2: Modeling of propagation path errors

NASA Technical Reports Server (NTRS)

James, R.; Brownlow, J. D.

1985-01-01

A study is performed under NASA contract to evaluate data from an AN/FPS-16 radar installed for support of flight programs at Dryden Flight Research Facility of NASA Ames Research Center. The purpose of this study is to provide information necessary for improving post-flight data reduction and knowledge of accuracy of derived radar quantities. Tracking data from six flights are analyzed. Noise and bias errors in raw tracking data are determined for each of the flights. A discussion of an altitude bias error during all of the tracking missions is included. This bias error is defined by utilizing pressure altitude measurements made during survey flights. Four separate filtering methods, representative of the most widely used optimal estimation techniques for enhancement of radar tracking data, are analyzed for suitability in processing both real-time and post-mission data. Additional information regarding the radar and its measurements, including typical noise and bias errors in the range and angle measurements, is also presented. This report is in two parts. This is part 2, a discussion of the modeling of propagation path errors.

Computational fluid dynamics analysis and experimental study of a low measurement error temperature sensor used in climate observation.

PubMed

Yang, Jie; Liu, Qingquan; Dai, Wei

2017-02-01

To improve the air temperature observation accuracy, a low measurement error temperature sensor is proposed. A computational fluid dynamics (CFD) method is implemented to obtain temperature errors under various environmental conditions. Then, a temperature error correction equation is obtained by fitting the CFD results using a genetic algorithm method. The low measurement error temperature sensor, a naturally ventilated radiation shield, a thermometer screen, and an aspirated temperature measurement platform are characterized in the same environment to conduct the intercomparison. The aspirated platform served as an air temperature reference. The mean temperature errors of the naturally ventilated radiation shield and the thermometer screen are 0.74 °C and 0.37 °C, respectively. In contrast, the mean temperature error of the low measurement error temperature sensor is 0.11 °C. The mean absolute error and the root mean square error between the corrected results and the measured results are 0.008 °C and 0.01 °C, respectively. The correction equation allows the temperature error of the low measurement error temperature sensor to be reduced by approximately 93.8%. The low measurement error temperature sensor proposed in this research may be helpful to provide a relatively accurate air temperature result.

Medication errors in the obstetrics emergency ward in a low resource setting.

PubMed

Kandil, Mohamed; Sayyed, Tarek; Emarh, Mohamed; Ellakwa, Hamed; Masood, Alaa

2012-08-01

To investigate the patterns of medication errors in the obstetric emergency ward in a low resource setting. This prospective observational study included 10,000 women who presented at the obstetric emergency ward, department of Obstetrics and Gynecology, Menofyia University Hospital, Egypt between March and December 2010. All medications prescribed in the emergency ward were monitored for different types of errors. The head nurse in each shift was asked to monitor each pharmacologic order from the moment of prescribing till its administration. Retrospective review of the patients' charts and nurses' notes was carried out by the authors of this paper. Results were tabulated and statistically analyzed. A total of 1976 medication errors were detected. Administration errors were the commonest error reported. Omitted errors ranked second followed by unauthorized and prescription errors. Three administration errors resulted in three Cesareans were performed for fetal distress because of wrong doses of oxytocin infusion. The rest of errors did not cause patients harm but may have lead to an increase in monitoring. Most errors occurred during night shifts. The availability of automated infusion pumps will probably decrease administration errors significantly. There is a need for more obstetricians and nurses during the nightshifts to minimize errors resulting from working under stressful conditions.

Analyzing communication errors in an air medical transport service.

PubMed

Dalto, Joseph D; Weir, Charlene; Thomas, Frank

2013-01-01

Poor communication can result in adverse events. Presently, no standards exist for classifying and analyzing air medical communication errors. This study sought to determine the frequency and types of communication errors reported within an air medical quality and safety assurance reporting system. Of 825 quality assurance reports submitted in 2009, 278 were randomly selected and analyzed for communication errors. Each communication error was classified and mapped to Clark's communication level hierarchy (ie, levels 1-4). Descriptive statistics were performed, and comparisons were evaluated using chi-square analysis. Sixty-four communication errors were identified in 58 reports (21% of 278). Of the 64 identified communication errors, only 18 (28%) were classified by the staff to be communication errors. Communication errors occurred most often at level 1 (n = 42/64, 66%) followed by level 4 (21/64, 33%). Level 2 and 3 communication failures were rare (, 1%). Communication errors were found in a fifth of quality and safety assurance reports. The reporting staff identified less than a third of these errors. Nearly all communication errors (99%) occurred at either the lowest level of communication (level 1, 66%) or the highest level (level 4, 33%). An air medical communication ontology is necessary to improve the recognition and analysis of communication errors. Copyright © 2013 Air Medical Journal Associates. Published by Elsevier Inc. All rights reserved.

Computational investigations and grid refinement study of 3D transient flow in a cylindrical tank using OpenFOAM

NASA Astrophysics Data System (ADS)

Mohd Sakri, F.; Mat Ali, M. S.; Sheikh Salim, S. A. Z.

2016-10-01

The study of physic fluid for a liquid draining inside a tank is easily accessible using numerical simulation. However, numerical simulation is expensive when the liquid draining involves the multi-phase problem. Since an accurate numerical simulation can be obtained if a proper method for error estimation is accomplished, this paper provides systematic assessment of error estimation due to grid convergence error using OpenFOAM. OpenFOAM is an open source CFD-toolbox and it is well-known among the researchers and institutions because of its free applications and ready to use. In this study, three types of grid resolution are used: coarse, medium and fine grids. Grid Convergence Index (GCI) is applied to estimate the error due to the grid sensitivity. A monotonic convergence condition is obtained in this study that shows the grid convergence error has been progressively reduced. The fine grid has the GCI value below 1%. The extrapolated value from Richardson Extrapolation is in the range of the GCI obtained.

Errors analysis of problem solving using the Newman stage after applying cooperative learning of TTW type

NASA Astrophysics Data System (ADS)

Rr Chusnul, C.; Mardiyana, S., Dewi Retno

2017-12-01

Problem solving is the basis of mathematics learning. Problem solving teaches us to clarify an issue coherently in order to avoid misunderstanding information. Sometimes there may be mistakes in problem solving due to misunderstanding the issue, choosing a wrong concept or misapplied concept. The problem-solving test was carried out after students were given treatment on learning by using cooperative learning of TTW type. The purpose of this study was to elucidate student problem regarding to problem solving errors after learning by using cooperative learning of TTW type. Newman stages were used to identify problem solving errors in this study. The new research used a descriptive method to find out problem solving errors in students. The subject in this study were students of Vocational Senior High School (SMK) in 10th grade. Test and interview was conducted for data collection. Thus, the results of this study suggested problem solving errors in students after learning by using cooperative learning of TTW type for Newman stages.

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

PubMed

Byrne, Eamonn; Bury, Gerard

2018-02-08

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

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

PubMed

Lee, Eunjoo

2016-09-01

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

Pilot age and error in air taxi crashes.

PubMed

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

2009-07-01

The associations of pilot error with the type of flight operations and basic weather conditions are well documented. The correlation between pilot characteristics and error is less clear. This study aims to examine whether pilot age is associated with the prevalence and patterns of pilot error in air taxi crashes. Investigation reports from the National Transportation Safety Board for crashes involving non-scheduled Part 135 operations (i.e., air taxis) in the United States between 1983 and 2002 were reviewed to identify pilot error and other contributing factors. Crash circumstances and the presence and type of pilot error were analyzed in relation to pilot age using Chi-square tests. Of the 1751 air taxi crashes studied, 28% resulted from mechanical failure, 25% from loss of control at landing or takeoff, 7% from visual flight rule conditions into instrument meteorological conditions, 7% from fuel starvation, 5% from taxiing, and 28% from other causes. Crashes among older pilots were more likely to occur during the daytime rather than at night and off airport than on airport. The patterns of pilot error in air taxi crashes were similar across age groups. Of the errors identified, 27% were flawed decisions, 26% were inattentiveness, 23% mishandled aircraft kinetics, 15% mishandled wind and/or runway conditions, and 11% were others. Pilot age is associated with crash circumstances but not with the prevalence and patterns of pilot error in air taxi crashes. Lack of age-related differences in pilot error may be attributable to the "safe worker effect."

Association between workarounds and medication administration errors in bar-code-assisted medication administration in hospitals.

PubMed

van der Veen, Willem; van den Bemt, Patricia M L A; Wouters, Hans; Bates, David W; Twisk, Jos W R; de Gier, Johan J; Taxis, Katja; Duyvendak, Michiel; Luttikhuis, Karen Oude; Ros, Johannes J W; Vasbinder, Erwin C; Atrafi, Maryam; Brasse, Bjorn; Mangelaars, Iris

2018-04-01

To study the association of workarounds with medication administration errors using barcode-assisted medication administration (BCMA), and to determine the frequency and types of workarounds and medication administration errors. A prospective observational study in Dutch hospitals using BCMA to administer medication. Direct observation was used to collect data. Primary outcome measure was the proportion of medication administrations with one or more medication administration errors. Secondary outcome was the frequency and types of workarounds and medication administration errors. Univariate and multivariate multilevel logistic regression analysis were used to assess the association between workarounds and medication administration errors. Descriptive statistics were used for the secondary outcomes. We included 5793 medication administrations for 1230 inpatients. Workarounds were associated with medication administration errors (adjusted odds ratio 3.06 [95% CI: 2.49-3.78]). Most commonly, procedural workarounds were observed, such as not scanning at all (36%), not scanning patients because they did not wear a wristband (28%), incorrect medication scanning, multiple medication scanning, and ignoring alert signals (11%). Common types of medication administration errors were omissions (78%), administration of non-ordered drugs (8.0%), and wrong doses given (6.0%). Workarounds are associated with medication administration errors in hospitals using BCMA. These data suggest that BCMA needs more post-implementation evaluation if it is to achieve the intended benefits for medication safety. In hospitals using barcode-assisted medication administration, workarounds occurred in 66% of medication administrations and were associated with large numbers of medication administration errors.

Task motivation influences alpha suppression following errors.

PubMed

Compton, Rebecca J; Bissey, Bryn; Worby-Selim, Sharoda

2014-07-01

The goal of the present research is to examine the influence of motivation on a novel error-related neural marker, error-related alpha suppression (ERAS). Participants completed an attentionally demanding flanker task under conditions that emphasized either speed or accuracy or under conditions that manipulated the monetary value of errors. Conditions in which errors had greater motivational value produced greater ERAS, that is, greater alpha suppression following errors compared to correct trials. A second study found that a manipulation of task difficulty did not affect ERAS. Together, the results confirm that ERAS is both a robust phenomenon and one that is sensitive to motivational factors. Copyright © 2014 Society for Psychophysiological Research.

Using Audit Information to Adjust Parameter Estimates for Data Errors in Clinical Trials

PubMed Central

Shepherd, Bryan E.; Shaw, Pamela A.; Dodd, Lori E.

2013-01-01

Background Audits are often performed to assess the quality of clinical trial data, but beyond detecting fraud or sloppiness, the audit data is generally ignored. In earlier work using data from a non-randomized study, Shepherd and Yu (2011) developed statistical methods to incorporate audit results into study estimates, and demonstrated that audit data could be used to eliminate bias. Purpose In this manuscript we examine the usefulness of audit-based error-correction methods in clinical trial settings where a continuous outcome is of primary interest. Methods We demonstrate the bias of multiple linear regression estimates in general settings with an outcome that may have errors and a set of covariates for which some may have errors and others, including treatment assignment, are recorded correctly for all subjects. We study this bias under different assumptions including independence between treatment assignment, covariates, and data errors (conceivable in a double-blinded randomized trial) and independence between treatment assignment and covariates but not data errors (possible in an unblinded randomized trial). We review moment-based estimators to incorporate the audit data and propose new multiple imputation estimators. The performance of estimators is studied in simulations. Results When treatment is randomized and unrelated to data errors, estimates of the treatment effect using the original error-prone data (i.e., ignoring the audit results) are unbiased. In this setting, both moment and multiple imputation estimators incorporating audit data are more variable than standard analyses using the original data. In contrast, in settings where treatment is randomized but correlated with data errors and in settings where treatment is not randomized, standard treatment effect estimates will be biased. And in all settings, parameter estimates for the original, error-prone covariates will be biased. Treatment and covariate effect estimates can be corrected by incorporating audit data using either the multiple imputation or moment-based approaches. Bias, precision, and coverage of confidence intervals improve as the audit size increases. Limitations The extent of bias and the performance of methods depend on the extent and nature of the error as well as the size of the audit. This work only considers methods for the linear model. Settings much different than those considered here need further study. Conclusions In randomized trials with continuous outcomes and treatment assignment independent of data errors, standard analyses of treatment effects will be unbiased and are recommended. However, if treatment assignment is correlated with data errors or other covariates, naive analyses may be biased. In these settings, and when covariate effects are of interest, approaches for incorporating audit results should be considered. PMID:22848072

Use of machine learning methods to reduce predictive error of groundwater models.

PubMed

Xu, Tianfang; Valocchi, Albert J; Choi, Jaesik; Amir, Eyal

2014-01-01

Quantitative analyses of groundwater flow and transport typically rely on a physically-based model, which is inherently subject to error. Errors in model structure, parameter and data lead to both random and systematic error even in the output of a calibrated model. We develop complementary data-driven models (DDMs) to reduce the predictive error of physically-based groundwater models. Two machine learning techniques, the instance-based weighting and support vector regression, are used to build the DDMs. This approach is illustrated using two real-world case studies of the Republican River Compact Administration model and the Spokane Valley-Rathdrum Prairie model. The two groundwater models have different hydrogeologic settings, parameterization, and calibration methods. In the first case study, cluster analysis is introduced for data preprocessing to make the DDMs more robust and computationally efficient. The DDMs reduce the root-mean-square error (RMSE) of the temporal, spatial, and spatiotemporal prediction of piezometric head of the groundwater model by 82%, 60%, and 48%, respectively. In the second case study, the DDMs reduce the RMSE of the temporal prediction of piezometric head of the groundwater model by 77%. It is further demonstrated that the effectiveness of the DDMs depends on the existence and extent of the structure in the error of the physically-based model. © 2013, National GroundWater Association.

Performance of GPS-devices for environmental exposure assessment.

PubMed

Beekhuizen, Johan; Kromhout, Hans; Huss, Anke; Vermeulen, Roel

2013-01-01

Integration of individual time-location patterns with spatially resolved exposure maps enables a more accurate estimation of personal exposures to environmental pollutants than using estimates at fixed locations. Current global positioning system (GPS) devices can be used to track an individual's location. However, information on GPS-performance in environmental exposure assessment is largely missing. We therefore performed two studies. First, a commute-study, where the commute of 12 individuals was tracked twice, testing GPS-performance for five transport modes and two wearing modes. Second, an urban-tracking study, where one individual was tracked repeatedly through different areas, focused on the effect of building obstruction on GPS-performance. The median error from the true path for walking was 3.7 m, biking 2.9 m, train 4.8 m, bus 4.9 m, and car 3.3 m. Errors were larger in a high-rise commercial area (median error=7.1 m) compared with a low-rise residential area (median error=2.2 m). Thus, GPS-performance largely depends on the transport mode and urban built-up. Although ~85% of all errors were <10 m, almost 1% of the errors were >50 m. Modern GPS-devices are useful tools for environmental exposure assessment, but large GPS-errors might affect estimates of exposures with high spatial variability.

Limitations of Surface Mapping Technology in Accurately Identifying Critical Errors in Dental Students' Crown Preparations.

PubMed

Furness, Alan R; Callan, Richard S; Mackert, J Rodway; Mollica, Anthony G

2018-01-01

The aim of this study was to evaluate the effectiveness of the Planmeca Compare software in identifying and quantifying a common critical error in dental students' crown preparations. In 2014-17, a study was conducted at one U.S. dental school that evaluated an ideal crown prep made by a faculty member on a dentoform to modified preps. Two types of preparation errors were created by the addition of flowable composite to the occlusal surface of identical dies of the preparations to represent the underreduction of the distolingual cusp. The error was divided into two classes: the minor class allowed for 1 mm of occlusal clearance, and the major class allowed for no occlusal clearance. The preparations were then digitally evaluated against the ideal preparation using Planmeca Compare. Percent comparison values were obtained from each trial and averaged together. False positives and false negatives were also identified and used to determine the accuracy of the evaluation. Critical errors that did not involve a substantial change in the surface area of the preparation were inconsistently identified. Within the limitations of this study, the authors concluded that the Compare software was unable to consistently identify common critical errors within an acceptable degree of error.

Joint nonparametric correction estimator for excess relative risk regression in survival analysis with exposure measurement error

PubMed Central

Wang, Ching-Yun; Cullings, Harry; Song, Xiao; Kopecky, Kenneth J.

2017-01-01

SUMMARY Observational epidemiological studies often confront the problem of estimating exposure-disease relationships when the exposure is not measured exactly. In the paper, we investigate exposure measurement error in excess relative risk regression, which is a widely used model in radiation exposure effect research. In the study cohort, a surrogate variable is available for the true unobserved exposure variable. The surrogate variable satisfies a generalized version of the classical additive measurement error model, but it may or may not have repeated measurements. In addition, an instrumental variable is available for individuals in a subset of the whole cohort. We develop a nonparametric correction (NPC) estimator using data from the subcohort, and further propose a joint nonparametric correction (JNPC) estimator using all observed data to adjust for exposure measurement error. An optimal linear combination estimator of JNPC and NPC is further developed. The proposed estimators are nonparametric, which are consistent without imposing a covariate or error distribution, and are robust to heteroscedastic errors. Finite sample performance is examined via a simulation study. We apply the developed methods to data from the Radiation Effects Research Foundation, in which chromosome aberration is used to adjust for the effects of radiation dose measurement error on the estimation of radiation dose responses. PMID:29354018

Mismeasurement and the resonance of strong confounders: uncorrelated errors.

PubMed

Marshall, J R; Hastrup, J L

1996-05-15

Greenland first documented (Am J Epidemiol 1980; 112:564-9) that error in the measurement of a confounder could resonate--that it could bias estimates of other study variables, and that the bias could persist even with statistical adjustment for the confounder as measured. An important question is raised by this finding: can such bias be more than trivial within the bounds of realistic data configurations? The authors examine several situations involving dichotomous and continuous data in which a confounder and a null variable are measured with error, and they assess the extent of resultant bias in estimates of the effect of the null variable. They show that, with continuous variables, measurement error amounting to 40% of observed variance in the confounder could cause the observed impact of the null study variable to appear to alter risk by as much as 30%. Similarly, they show, with dichotomous independent variables, that 15% measurement error in the form of misclassification could lead the null study variable to appear to alter risk by as much as 50%. Such bias would result only from strong confounding. Measurement error would obscure the evidence that strong confounding is a likely problem. These results support the need for every epidemiologic inquiry to include evaluations of measurement error in each variable considered.

A posteriori error estimates in voice source recovery

NASA Astrophysics Data System (ADS)

Leonov, A. S.; Sorokin, V. N.

2017-12-01

The inverse problem of voice source pulse recovery from a segment of a speech signal is under consideration. A special mathematical model is used for the solution that relates these quantities. A variational method of solving inverse problem of voice source recovery for a new parametric class of sources, that is for piecewise-linear sources (PWL-sources), is proposed. Also, a technique for a posteriori numerical error estimation for obtained solutions is presented. A computer study of the adequacy of adopted speech production model with PWL-sources is performed in solving the inverse problems for various types of voice signals, as well as corresponding study of a posteriori error estimates. Numerical experiments for speech signals show satisfactory properties of proposed a posteriori error estimates, which represent the upper bounds of possible errors in solving the inverse problem. The estimate of the most probable error in determining the source-pulse shapes is about 7-8% for the investigated speech material. It is noted that a posteriori error estimates can be used as a criterion of the quality for obtained voice source pulses in application to speaker recognition.

Experimental study of an adaptive CFRC reflector for high order wave-front error correction

NASA Astrophysics Data System (ADS)

Lan, Lan; Fang, Houfei; Wu, Ke; Jiang, Shuidong; Zhou, Yang

2018-03-01

The recent radio frequency communication system developments are generating the need for creating space antennas with lightweight and high precision. The carbon fiber reinforced composite (CFRC) materials have been used to manufacture the high precision reflector. The wave-front errors caused by fabrication and on-orbit distortion are inevitable. The adaptive CFRC reflector has received much attention to do the wave-front error correction. Due to uneven stress distribution that is introduced by actuation force and fabrication, the high order wave-front errors such as print-through error is found on the reflector surface. However, the adaptive CFRC reflector with PZT actuators basically has no control authority over the high order wave-front errors. A new design architecture assembled secondary ribs at the weak triangular surfaces is presented in this paper. The virtual experimental study of the new adaptive CFRC reflector has conducted. The controllability of the original adaptive CFRC reflector and the new adaptive CFRC reflector with secondary ribs are investigated. The virtual experimental investigation shows that the new adaptive CFRC reflector is feasible and efficient to diminish the high order wave-front error.

Temperature-dependent errors in nuclear lattice simulations

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

Lee, Dean; Thomson, Richard

2007-06-15

We study the temperature dependence of discretization errors in nuclear lattice simulations. We find that for systems with strong attractive interactions the predominant error arises from the breaking of Galilean invariance. We propose a local 'well-tempered' lattice action which eliminates much of this error. The well-tempered action can be readily implemented in lattice simulations for nuclear systems as well as cold atomic Fermi systems.

An Analysis of Lexical Errors of Korean Language Learners: Some American College Learners' Case

ERIC Educational Resources Information Center

Kang, Manjin

2014-01-01

There has been a huge amount of research on errors of language learners. However, most of them have focused on syntactic errors and those about lexical errors are not found easily despite the importance of lexical learning for the language learners. The case is even rarer for Korean language. In line with this background, this study was designed…

Learning from Errors at Work: A Replication Study in Elder Care Nursing

ERIC Educational Resources Information Center

Leicher, Veronika; Mulder, Regina H.; Bauer, Johannes

2013-01-01

Learning from errors is an important way of learning at work. In this article, we analyse conditions under which elder care nurses use errors as a starting point for the engagement in social learning activities (ESLA) in the form of joint reflection with colleagues on potential causes of errors and ways to prevent them in future. The goal of our…

Why Don't We Learn to Accurately Forecast Feelings? How Misremembering Our Predictions Blinds Us to Past Forecasting Errors

ERIC Educational Resources Information Center

Meyvis, Tom; Ratner, Rebecca K.; Levav, Jonathan

2010-01-01

Why do affective forecasting errors persist in the face of repeated disconfirming evidence? Five studies demonstrate that people misremember their forecasts as consistent with their experience and thus fail to perceive the extent of their forecasting error. As a result, people do not learn from past forecasting errors and fail to adjust subsequent…

An Empirical State Error Covariance Matrix Orbit Determination Example

NASA Technical Reports Server (NTRS)

Frisbee, Joseph H., Jr.

2015-01-01

State estimation techniques serve effectively to provide mean state estimates. However, the state error covariance matrices provided as part of these techniques suffer from some degree of lack of confidence in their ability to adequately describe the uncertainty in the estimated states. A specific problem with the traditional form of state error covariance matrices is that they represent only a mapping of the assumed observation error characteristics into the state space. Any errors that arise from other sources (environment modeling, precision, etc.) are not directly represented in a traditional, theoretical state error covariance matrix. First, consider that an actual observation contains only measurement error and that an estimated observation contains all other errors, known and unknown. Then it follows that a measurement residual (the difference between expected and observed measurements) contains all errors for that measurement. Therefore, a direct and appropriate inclusion of the actual measurement residuals in the state error covariance matrix of the estimate will result in an empirical state error covariance matrix. This empirical state error covariance matrix will fully include all of the errors in the state estimate. The empirical error covariance matrix is determined from a literal reinterpretation of the equations involved in the weighted least squares estimation algorithm. It is a formally correct, empirical state error covariance matrix obtained through use of the average form of the weighted measurement residual variance performance index rather than the usual total weighted residual form. Based on its formulation, this matrix will contain the total uncertainty in the state estimate, regardless as to the source of the uncertainty and whether the source is anticipated or not. It is expected that the empirical error covariance matrix will give a better, statistical representation of the state error in poorly modeled systems or when sensor performance is suspect. In its most straight forward form, the technique only requires supplemental calculations to be added to existing batch estimation algorithms. In the current problem being studied a truth model making use of gravity with spherical, J2 and J4 terms plus a standard exponential type atmosphere with simple diurnal and random walk components is used. The ability of the empirical state error covariance matrix to account for errors is investigated under four scenarios during orbit estimation. These scenarios are: exact modeling under known measurement errors, exact modeling under corrupted measurement errors, inexact modeling under known measurement errors, and inexact modeling under corrupted measurement errors. For this problem a simple analog of a distributed space surveillance network is used. The sensors in this network make only range measurements and with simple normally distributed measurement errors. The sensors are assumed to have full horizon to horizon viewing at any azimuth. For definiteness, an orbit at the approximate altitude and inclination of the International Space Station is used for the study. The comparison analyses of the data involve only total vectors. No investigation of specific orbital elements is undertaken. The total vector analyses will look at the chisquare values of the error in the difference between the estimated state and the true modeled state using both the empirical and theoretical error covariance matrices for each of scenario.

Field evaluation of distance-estimation error during wetland-dependent bird surveys

USGS Publications Warehouse

Nadeau, Christopher P.; Conway, Courtney J.

2012-01-01

Context: The most common methods to estimate detection probability during avian point-count surveys involve recording a distance between the survey point and individual birds detected during the survey period. Accurately measuring or estimating distance is an important assumption of these methods; however, this assumption is rarely tested in the context of aural avian point-count surveys. Aims: We expand on recent bird-simulation studies to document the error associated with estimating distance to calling birds in a wetland ecosystem. Methods: We used two approaches to estimate the error associated with five surveyor's distance estimates between the survey point and calling birds, and to determine the factors that affect a surveyor's ability to estimate distance. Key results: We observed biased and imprecise distance estimates when estimating distance to simulated birds in a point-count scenario (x̄error = -9 m, s.d.error = 47 m) and when estimating distances to real birds during field trials (x̄error = 39 m, s.d.error = 79 m). The amount of bias and precision in distance estimates differed among surveyors; surveyors with more training and experience were less biased and more precise when estimating distance to both real and simulated birds. Three environmental factors were important in explaining the error associated with distance estimates, including the measured distance from the bird to the surveyor, the volume of the call and the species of bird. Surveyors tended to make large overestimations to birds close to the survey point, which is an especially serious error in distance sampling. Conclusions: Our results suggest that distance-estimation error is prevalent, but surveyor training may be the easiest way to reduce distance-estimation error. Implications: The present study has demonstrated how relatively simple field trials can be used to estimate the error associated with distance estimates used to estimate detection probability during avian point-count surveys. Evaluating distance-estimation errors will allow investigators to better evaluate the accuracy of avian density and trend estimates. Moreover, investigators who evaluate distance-estimation errors could employ recently developed models to incorporate distance-estimation error into analyses. We encourage further development of such models, including the inclusion of such models into distance-analysis software.

Zero tolerance prescribing: a strategy to reduce prescribing errors on the paediatric intensive care unit.

PubMed

Booth, Rachelle; Sturgess, Emma; Taberner-Stokes, Alison; Peters, Mark

2012-11-01

To establish the baseline prescribing error rate in a tertiary paediatric intensive care unit (PICU) and to determine the impact of a zero tolerance prescribing (ZTP) policy incorporating a dedicated prescribing area and daily feedback of prescribing errors. A prospective, non-blinded, observational study was undertaken in a 12-bed tertiary PICU over a period of 134 weeks. Baseline prescribing error data were collected on weekdays for all patients for a period of 32 weeks, following which the ZTP policy was introduced. Daily error feedback was introduced after a further 12 months. Errors were sub-classified as 'clinical', 'non-clinical' and 'infusion prescription' errors and the effects of interventions considered separately. The baseline combined prescribing error rate was 892 (95 % confidence interval (CI) 765-1,019) errors per 1,000 PICU occupied bed days (OBDs), comprising 25.6 % clinical, 44 % non-clinical and 30.4 % infusion prescription errors. The combined interventions of ZTP plus daily error feedback were associated with a reduction in the combined prescribing error rate to 447 (95 % CI 389-504) errors per 1,000 OBDs (p < 0.0001), an absolute risk reduction of 44.5 % (95 % CI 40.8-48.0 %). Introduction of the ZTP policy was associated with a significant decrease in clinical and infusion prescription errors, while the introduction of daily error feedback was associated with a significant reduction in non-clinical prescribing errors. The combined interventions of ZTP and daily error feedback were associated with a significant reduction in prescribing errors in the PICU, in line with Department of Health requirements of a 40 % reduction within 5 years.

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

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.

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.

Dissociable Genetic Contributions to Error Processing: A Multimodal Neuroimaging Study

PubMed Central

Agam, Yigal; Vangel, Mark; Roffman, Joshua L.; Gallagher, Patience J.; Chaponis, Jonathan; Haddad, Stephen; Goff, Donald C.; Greenberg, Jennifer L.; Wilhelm, Sabine; Smoller, Jordan W.; Manoach, Dara S.

2014-01-01

Background Neuroimaging studies reliably identify two markers of error commission: the error-related negativity (ERN), an event-related potential, and functional MRI activation of the dorsal anterior cingulate cortex (dACC). While theorized to reflect the same neural process, recent evidence suggests that the ERN arises from the posterior cingulate cortex not the dACC. Here, we tested the hypothesis that these two error markers also have different genetic mediation. Methods We measured both error markers in a sample of 92 comprised of healthy individuals and those with diagnoses of schizophrenia, obsessive-compulsive disorder or autism spectrum disorder. Participants performed the same task during functional MRI and simultaneously acquired magnetoencephalography and electroencephalography. We examined the mediation of the error markers by two single nucleotide polymorphisms: dopamine D4 receptor (DRD4) C-521T (rs1800955), which has been associated with the ERN and methylenetetrahydrofolate reductase (MTHFR) C677T (rs1801133), which has been associated with error-related dACC activation. We then compared the effects of each polymorphism on the two error markers modeled as a bivariate response. Results We replicated our previous report of a posterior cingulate source of the ERN in healthy participants in the schizophrenia and obsessive-compulsive disorder groups. The effect of genotype on error markers did not differ significantly by diagnostic group. DRD4 C-521T allele load had a significant linear effect on ERN amplitude, but not on dACC activation, and this difference was significant. MTHFR C677T allele load had a significant linear effect on dACC activation but not ERN amplitude, but the difference in effects on the two error markers was not significant. Conclusions DRD4 C-521T, but not MTHFR C677T, had a significant differential effect on two canonical error markers. Together with the anatomical dissociation between the ERN and error-related dACC activation, these findings suggest that these error markers have different neural and genetic mediation. PMID:25010186

How do Community Pharmacies Recover from E-prescription Errors?

PubMed Central

Odukoya, Olufunmilola K.; Stone, Jamie A.; Chui, Michelle A.

2014-01-01

Background The use of e-prescribing is increasing annually, with over 788 million e-prescriptions received in US pharmacies in 2012. Approximately 9% of e-prescriptions have medication errors. Objective To describe the process used by community pharmacy staff to detect, explain, and correct e-prescription errors. Methods The error recovery conceptual framework was employed for data collection and analysis. 13 pharmacists and 14 technicians from five community pharmacies in Wisconsin participated in the study. A combination of data collection methods were utilized, including direct observations, interviews, and focus groups. The transcription and content analysis of recordings were guided by the three-step error recovery model. Results Most of the e-prescription errors were detected during the entering of information into the pharmacy system. These errors were detected by both pharmacists and technicians using a variety of strategies which included: (1) performing double checks of e-prescription information; (2) printing the e-prescription to paper and confirming the information on the computer screen with information from the paper printout; and (3) using colored pens to highlight important information. Strategies used for explaining errors included: (1) careful review of patient’ medication history; (2) pharmacist consultation with patients; (3) consultation with another pharmacy team member; and (4) use of online resources. In order to correct e-prescription errors, participants made educated guesses of the prescriber’s intent or contacted the prescriber via telephone or fax. When e-prescription errors were encountered in the community pharmacies, the primary goal of participants was to get the order right for patients by verifying the prescriber’s intent. Conclusion Pharmacists and technicians play an important role in preventing e-prescription errors through the detection of errors and the verification of prescribers’ intent. Future studies are needed to examine factors that facilitate or hinder recovery from e-prescription errors. PMID:24373898

The effect of the electronic transmission of prescriptions on dispensing errors and prescription enhancements made in English community pharmacies: a naturalistic stepped wedge study

PubMed Central

Franklin, Bryony Dean; Reynolds, Matthew; Sadler, Stacey; Hibberd, Ralph; Avery, Anthony J; Armstrong, Sarah J; Mehta, Rajnikant; Boyd, Matthew J; Barber, Nick

2014-01-01

Objectives To compare prevalence and types of dispensing errors and pharmacists’ labelling enhancements, for prescriptions transmitted electronically versus paper prescriptions. Design Naturalistic stepped wedge study. Setting 15 English community pharmacies. Intervention Electronic transmission of prescriptions between prescriber and pharmacy. Main outcome measures Prevalence of labelling errors, content errors and labelling enhancements (beneficial additions to the instructions), as identified by researchers visiting each pharmacy. Results Overall, we identified labelling errors in 5.4% of 16 357 dispensed items, and content errors in 1.4%; enhancements were made for 13.6%. Pharmacists also edited the label for a further 21.9% of electronically transmitted items. Electronically transmitted prescriptions had a higher prevalence of labelling errors (7.4% of 3733 items) than other prescriptions (4.8% of 12 624); OR 1.46 (95% CI 1.21 to 1.76). There was no difference for content errors or enhancements. The increase in labelling errors was mainly accounted for by errors (mainly at one pharmacy) involving omission of the indication, where specified by the prescriber, from the label. A sensitivity analysis in which these cases (n=158) were not considered errors revealed no remaining difference between prescription types. Conclusions We identified a higher prevalence of labelling errors for items transmitted electronically, but this was predominantly accounted for by local practice in a single pharmacy, independent of prescription type. Community pharmacists made labelling enhancements to about one in seven dispensed items, whether electronically transmitted or not. Community pharmacists, prescribers, professional bodies and software providers should work together to agree how items should be dispensed and labelled to best reap the benefits of electronically transmitted prescriptions. Community pharmacists need to ensure their computer systems are promptly updated to help reduce errors. PMID:24742778

The effect of the electronic transmission of prescriptions on dispensing errors and prescription enhancements made in English community pharmacies: a naturalistic stepped wedge study.

PubMed

Franklin, Bryony Dean; Reynolds, Matthew; Sadler, Stacey; Hibberd, Ralph; Avery, Anthony J; Armstrong, Sarah J; Mehta, Rajnikant; Boyd, Matthew J; Barber, Nick

2014-08-01

To compare prevalence and types of dispensing errors and pharmacists' labelling enhancements, for prescriptions transmitted electronically versus paper prescriptions. Naturalistic stepped wedge study. 15 English community pharmacies. Electronic transmission of prescriptions between prescriber and pharmacy. Prevalence of labelling errors, content errors and labelling enhancements (beneficial additions to the instructions), as identified by researchers visiting each pharmacy. Overall, we identified labelling errors in 5.4% of 16,357 dispensed items, and content errors in 1.4%; enhancements were made for 13.6%. Pharmacists also edited the label for a further 21.9% of electronically transmitted items. Electronically transmitted prescriptions had a higher prevalence of labelling errors (7.4% of 3733 items) than other prescriptions (4.8% of 12,624); OR 1.46 (95% CI 1.21 to 1.76). There was no difference for content errors or enhancements. The increase in labelling errors was mainly accounted for by errors (mainly at one pharmacy) involving omission of the indication, where specified by the prescriber, from the label. A sensitivity analysis in which these cases (n=158) were not considered errors revealed no remaining difference between prescription types. We identified a higher prevalence of labelling errors for items transmitted electronically, but this was predominantly accounted for by local practice in a single pharmacy, independent of prescription type. Community pharmacists made labelling enhancements to about one in seven dispensed items, whether electronically transmitted or not. Community pharmacists, prescribers, professional bodies and software providers should work together to agree how items should be dispensed and labelled to best reap the benefits of electronically transmitted prescriptions. Community pharmacists need to ensure their computer systems are promptly updated to help reduce errors. 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.

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.

EEG Theta Dynamics within Frontal and Parietal Cortices for Error Processing during Reaching Movements in a Prism Adaptation Study Altering Visuo-Motor Predictive Planning

PubMed Central

Bonfiglio, Luca; Minichilli, Fabrizio; Cantore, Nicoletta; Carboncini, Maria Chiara; Piccotti, Emily; Rossi, Bruno

2016-01-01

Modulation of frontal midline theta (fmθ) is observed during error commission, but little is known about the role of theta oscillations in correcting motor behaviours. We investigate EEG activity of healthy partipants executing a reaching task under variable degrees of prism-induced visuo-motor distortion and visual occlusion of the initial arm trajectory. This task introduces directional errors of different magnitudes. The discrepancy between predicted and actual movement directions (i.e. the error), at the time when visual feedback (hand appearance) became available, elicits a signal that triggers on-line movement correction. Analysis were performed on 25 EEG channels. For each participant, the median value of the angular error of all reaching trials was used to partition the EEG epochs into high- and low-error conditions. We computed event-related spectral perturbations (ERSP) time-locked either to visual feedback or to the onset of movement correction. ERSP time-locked to the onset of visual feedback showed that fmθ increased in the high- but not in the low-error condition with an approximate time lag of 200 ms. Moreover, when single epochs were sorted by the degree of motor error, fmθ started to increase when a certain level of error was exceeded and, then, scaled with error magnitude. When ERSP were time-locked to the onset of movement correction, the fmθ increase anticipated this event with an approximate time lead of 50 ms. During successive trials, an error reduction was observed which was associated with indices of adaptations (i.e., aftereffects) suggesting the need to explore if theta oscillations may facilitate learning. To our knowledge this is the first study where the EEG signal recorded during reaching movements was time-locked to the onset of the error visual feedback. This allowed us to conclude that theta oscillations putatively generated by anterior cingulate cortex activation are implicated in error processing in semi-naturalistic motor behaviours. PMID:26963919

EEG Theta Dynamics within Frontal and Parietal Cortices for Error Processing during Reaching Movements in a Prism Adaptation Study Altering Visuo-Motor Predictive Planning.

PubMed

Arrighi, Pieranna; Bonfiglio, Luca; Minichilli, Fabrizio; Cantore, Nicoletta; Carboncini, Maria Chiara; Piccotti, Emily; Rossi, Bruno; Andre, Paolo

2016-01-01

Modulation of frontal midline theta (fmθ) is observed during error commission, but little is known about the role of theta oscillations in correcting motor behaviours. We investigate EEG activity of healthy partipants executing a reaching task under variable degrees of prism-induced visuo-motor distortion and visual occlusion of the initial arm trajectory. This task introduces directional errors of different magnitudes. The discrepancy between predicted and actual movement directions (i.e. the error), at the time when visual feedback (hand appearance) became available, elicits a signal that triggers on-line movement correction. Analysis were performed on 25 EEG channels. For each participant, the median value of the angular error of all reaching trials was used to partition the EEG epochs into high- and low-error conditions. We computed event-related spectral perturbations (ERSP) time-locked either to visual feedback or to the onset of movement correction. ERSP time-locked to the onset of visual feedback showed that fmθ increased in the high- but not in the low-error condition with an approximate time lag of 200 ms. Moreover, when single epochs were sorted by the degree of motor error, fmθ started to increase when a certain level of error was exceeded and, then, scaled with error magnitude. When ERSP were time-locked to the onset of movement correction, the fmθ increase anticipated this event with an approximate time lead of 50 ms. During successive trials, an error reduction was observed which was associated with indices of adaptations (i.e., aftereffects) suggesting the need to explore if theta oscillations may facilitate learning. To our knowledge this is the first study where the EEG signal recorded during reaching movements was time-locked to the onset of the error visual feedback. This allowed us to conclude that theta oscillations putatively generated by anterior cingulate cortex activation are implicated in error processing in semi-naturalistic motor behaviours.

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.

Prescription Errors in Older Individuals with an Intellectual Disability: Prevalence and Risk Factors in the Healthy Ageing and Intellectual Disability Study

ERIC Educational Resources Information Center

Zaal, Rianne J.; van der Kaaij, Annemieke D. M.; Evenhuis, Heleen M.; van den Bemt, Patricia M. L. A.

2013-01-01

Prescribing pharmacotherapy for older individuals with an intellectual disability (ID) is a complex process, possibly leading to an increased risk of prescription errors. The objectives of this study were (1) to determine the prevalence of older individuals with an intellectual disability with at least one prescription error and (2) to identify…

Quantitative modeling of the accuracy in registering preoperative patient-specific anatomic models into left atrial cardiac ablation procedures

PubMed Central

Rettmann, Maryam E.; Holmes, David R.; Kwartowitz, David M.; Gunawan, Mia; Johnson, Susan B.; Camp, Jon J.; Cameron, Bruce M.; Dalegrave, Charles; Kolasa, Mark W.; Packer, Douglas L.; Robb, Richard A.

2014-01-01

Purpose: In cardiac ablation therapy, accurate anatomic guidance is necessary to create effective tissue lesions for elimination of left atrial fibrillation. While fluoroscopy, ultrasound, and electroanatomic maps are important guidance tools, they lack information regarding detailed patient anatomy which can be obtained from high resolution imaging techniques. For this reason, there has been significant effort in incorporating detailed, patient-specific models generated from preoperative imaging datasets into the procedure. Both clinical and animal studies have investigated registration and targeting accuracy when using preoperative models; however, the effect of various error sources on registration accuracy has not been quantitatively evaluated. Methods: Data from phantom, canine, and patient studies are used to model and evaluate registration accuracy. In the phantom studies, data are collected using a magnetically tracked catheter on a static phantom model. Monte Carlo simulation studies were run to evaluate both baseline errors as well as the effect of different sources of error that would be present in a dynamic in vivo setting. Error is simulated by varying the variance parameters on the landmark fiducial, physical target, and surface point locations in the phantom simulation studies. In vivo validation studies were undertaken in six canines in which metal clips were placed in the left atrium to serve as ground truth points. A small clinical evaluation was completed in three patients. Landmark-based and combined landmark and surface-based registration algorithms were evaluated in all studies. In the phantom and canine studies, both target registration error and point-to-surface error are used to assess accuracy. In the patient studies, no ground truth is available and registration accuracy is quantified using point-to-surface error only. Results: The phantom simulation studies demonstrated that combined landmark and surface-based registration improved landmark-only registration provided the noise in the surface points is not excessively high. Increased variability on the landmark fiducials resulted in increased registration errors; however, refinement of the initial landmark registration by the surface-based algorithm can compensate for small initial misalignments. The surface-based registration algorithm is quite robust to noise on the surface points and continues to improve landmark registration even at high levels of noise on the surface points. Both the canine and patient studies also demonstrate that combined landmark and surface registration has lower errors than landmark registration alone. Conclusions: In this work, we describe a model for evaluating the impact of noise variability on the input parameters of a registration algorithm in the context of cardiac ablation therapy. The model can be used to predict both registration error as well as assess which inputs have the largest effect on registration accuracy. PMID:24506630