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.

Reflections on human error - Matters of life and death

NASA Technical Reports Server (NTRS)

Wiener, Earl L.

1989-01-01

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

Definition of an Enhanced Map-Matching Algorithm for Urban Environments with Poor GNSS Signal Quality.

PubMed

Jiménez, Felipe; Monzón, Sergio; Naranjo, Jose Eugenio

2016-02-04

Vehicle positioning is a key factor for numerous information and assistance applications that are included in vehicles and for which satellite positioning is mainly used. However, this positioning process can result in errors and lead to measurement uncertainties. These errors come mainly from two sources: errors and simplifications of digital maps and errors in locating the vehicle. From that inaccurate data, the task of assigning the vehicle's location to a link on the digital map at every instant is carried out by map-matching algorithms. These algorithms have been developed to fulfil that need and attempt to amend these errors to offer the user a suitable positioning. In this research; an algorithm is developed that attempts to solve the errors in positioning when the Global Navigation Satellite System (GNSS) signal reception is frequently lost. The algorithm has been tested with satisfactory results in a complex urban environment of narrow streets and tall buildings where errors and signal reception losses of the GPS receiver are frequent.

Definition of an Enhanced Map-Matching Algorithm for Urban Environments with Poor GNSS Signal Quality

PubMed Central

Jiménez, Felipe; Monzón, Sergio; Naranjo, Jose Eugenio

2016-01-01

Vehicle positioning is a key factor for numerous information and assistance applications that are included in vehicles and for which satellite positioning is mainly used. However, this positioning process can result in errors and lead to measurement uncertainties. These errors come mainly from two sources: errors and simplifications of digital maps and errors in locating the vehicle. From that inaccurate data, the task of assigning the vehicle’s location to a link on the digital map at every instant is carried out by map-matching algorithms. These algorithms have been developed to fulfil that need and attempt to amend these errors to offer the user a suitable positioning. In this research; an algorithm is developed that attempts to solve the errors in positioning when the Global Navigation Satellite System (GNSS) signal reception is frequently lost. The algorithm has been tested with satisfactory results in a complex urban environment of narrow streets and tall buildings where errors and signal reception losses of the GPS receiver are frequent. PMID:26861320

Social influences of error monitoring in adolescent girls.

PubMed

Barker, Tyson V; Troller-Renfree, Sonya V; Bowman, Lindsay C; Pine, Daniel S; Fox, Nathan A

2018-04-22

Adolescence is a developmental period characterized by increased social motivation and a heightened concern of peer evaluation. However, little research has examined social influences on neural functioning in adolescence. One psychophysiological measure of motivation, the error-related negativity (ERN), is an ERP following an error. In adults, the ERN is enhanced by contextual factors that influence motivation, such as social observation and evaluation. The current study examined relations among age and neural responses in social contexts in adolescence. Seventy-six adolescent girls (9-17 years old) completed a flanker task under two different conditions. In the social condition, adolescent girls were informed that two other adolescents would be observing and providing feedback about their performance. In the nonsocial condition, adolescent girls completed a flanker task alone and were told feedback was computer generated. Results revealed that younger adolescents exhibited a larger ERN in social contexts than nonsocial contexts. In contrast, there were no differences in the ERN between contexts among older adolescents. In addition, enhancements of the ERN in social contexts among younger adolescents diminished the relation between the ERN and age. These findings suggest that the ERN is sensitive to social contexts in early adolescence, and developmental changes in the ERN may be partially explained by contextual factors that influence motivation. © 2018 Society for Psychophysiological Research.

Continuous quantum error correction for non-Markovian decoherence

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

Oreshkov, Ognyan; Brun, Todd A.; Communication Sciences Institute, University of Southern California, Los Angeles, California 90089

2007-08-15

We study the effect of continuous quantum error correction in the case where each qubit in a codeword is subject to a general Hamiltonian interaction with an independent bath. We first consider the scheme in the case of a trivial single-qubit code, which provides useful insights into the workings of continuous error correction and the difference between Markovian and non-Markovian decoherence. We then study the model of a bit-flip code with each qubit coupled to an independent bath qubit and subject to continuous correction, and find its solution. We show that for sufficiently large error-correction rates, the encoded state approximatelymore » follows an evolution of the type of a single decohering qubit, but with an effectively decreased coupling constant. The factor by which the coupling constant is decreased scales quadratically with the error-correction rate. This is compared to the case of Markovian noise, where the decoherence rate is effectively decreased by a factor which scales only linearly with the rate of error correction. The quadratic enhancement depends on the existence of a Zeno regime in the Hamiltonian evolution which is absent in purely Markovian dynamics. We analyze the range of validity of this result and identify two relevant time scales. Finally, we extend the result to more general codes and argue that the performance of continuous error correction will exhibit the same qualitative characteristics.« less

Effective connectivity associated with auditory error detection in musicians with absolute pitch

PubMed Central

Parkinson, Amy L.; Behroozmand, Roozbeh; Ibrahim, Nadine; Korzyukov, Oleg; Larson, Charles R.; Robin, Donald A.

2014-01-01

It is advantageous to study a wide range of vocal abilities in order to fully understand how vocal control measures vary across the full spectrum. Individuals with absolute pitch (AP) are able to assign a verbal label to musical notes and have enhanced abilities in pitch identification without reliance on an external referent. In this study we used dynamic causal modeling (DCM) to model effective connectivity of ERP responses to pitch perturbation in voice auditory feedback in musicians with relative pitch (RP), AP, and non-musician controls. We identified a network compromising left and right hemisphere superior temporal gyrus (STG), primary motor cortex (M1), and premotor cortex (PM). We specified nine models and compared two main factors examining various combinations of STG involvement in feedback pitch error detection/correction process. Our results suggest that modulation of left to right STG connections are important in the identification of self-voice error and sensory motor integration in AP musicians. We also identify reduced connectivity of left hemisphere PM to STG connections in AP and RP groups during the error detection and corrections process relative to non-musicians. We suggest that this suppression may allow for enhanced connectivity relating to pitch identification in the right hemisphere in those with more precise pitch matching abilities. Musicians with enhanced pitch identification abilities likely have an improved auditory error detection and correction system involving connectivity of STG regions. Our findings here also suggest that individuals with AP are more adept at using feedback related to pitch from the right hemisphere. PMID:24634644

Accelerated Brain DCE-MRI Using Iterative Reconstruction With Total Generalized Variation Penalty for Quantitative Pharmacokinetic Analysis: A Feasibility Study.

PubMed

Wang, Chunhao; Yin, Fang-Fang; Kirkpatrick, John P; Chang, Zheng

2017-08-01

To investigate the feasibility of using undersampled k-space data and an iterative image reconstruction method with total generalized variation penalty in the quantitative pharmacokinetic analysis for clinical brain dynamic contrast-enhanced magnetic resonance imaging. Eight brain dynamic contrast-enhanced magnetic resonance imaging scans were retrospectively studied. Two k-space sparse sampling strategies were designed to achieve a simulated image acquisition acceleration factor of 4. They are (1) a golden ratio-optimized 32-ray radial sampling profile and (2) a Cartesian-based random sampling profile with spatiotemporal-regularized sampling density constraints. The undersampled data were reconstructed to yield images using the investigated reconstruction technique. In quantitative pharmacokinetic analysis on a voxel-by-voxel basis, the rate constant K trans in the extended Tofts model and blood flow F B and blood volume V B from the 2-compartment exchange model were analyzed. Finally, the quantitative pharmacokinetic parameters calculated from the undersampled data were compared with the corresponding calculated values from the fully sampled data. To quantify each parameter's accuracy calculated using the undersampled data, error in volume mean, total relative error, and cross-correlation were calculated. The pharmacokinetic parameter maps generated from the undersampled data appeared comparable to the ones generated from the original full sampling data. Within the region of interest, most derived error in volume mean values in the region of interest was about 5% or lower, and the average error in volume mean of all parameter maps generated through either sampling strategy was about 3.54%. The average total relative error value of all parameter maps in region of interest was about 0.115, and the average cross-correlation of all parameter maps in region of interest was about 0.962. All investigated pharmacokinetic parameters had no significant differences between the result from original data and the reduced sampling data. With sparsely sampled k-space data in simulation of accelerated acquisition by a factor of 4, the investigated dynamic contrast-enhanced magnetic resonance imaging pharmacokinetic parameters can accurately estimate the total generalized variation-based iterative image reconstruction method for reliable clinical application.

A Novel Design for Drug-Drug Interaction Alerts Improves Prescribing Efficiency.

PubMed

Russ, Alissa L; Chen, Siying; Melton, Brittany L; Johnson, Elizabette G; Spina, Jeffrey R; Weiner, Michael; Zillich, Alan J

2015-09-01

Drug-drug interactions (DDIs) are common in clinical care and pose serious risks for patients. Electronic health records display DDI alerts that can influence prescribers, but the interface design of DDI alerts has largely been unstudied. In this study, the objective was to apply human factors engineering principles to alert design. It was hypothesized that redesigned DDI alerts would significantly improve prescribers' efficiency and reduce prescribing errors. In a counterbalanced, crossover study with prescribers, two DDI alert designs were evaluated. Department of Veterans Affairs (VA) prescribers were video recorded as they completed fictitious patient scenarios, which included DDI alerts of varying severity. Efficiency was measured from time-stamped recordings. Prescribing errors were evaluated against predefined criteria. Efficiency and prescribing errors were analyzed with the Wilcoxon signed-rank test. Other usability data were collected on the adequacy of alert content, prescribers' use of the DDI monograph, and alert navigation. Twenty prescribers completed patient scenarios for both designs. Prescribers resolved redesigned alerts in about half the time (redesign: 52 seconds versus original design: 97 seconds; p<.001). Prescribing errors were not significantly different between the two designs. Usability results indicate that DDI alerts might be enhanced by facilitating easier access to laboratory data and dosing information and by allowing prescribers to cancel either interacting medication directly from the alert. Results also suggest that neither design provided adequate information for decision making via the primary interface. Applying human factors principles to DDI alerts improved overall efficiency. Aspects of DDI alert design that could be further enhanced prior to implementation were also identified.

Factors that Enhance English-Speaking Speech-Language Pathologists' Transcription of Cantonese-Speaking Children's Consonants

ERIC Educational Resources Information Center

Lockart, Rebekah; McLeod, Sharynne

2013-01-01

Purpose: To investigate speech-language pathology students' ability to identify errors and transcribe typical and atypical speech in Cantonese, a nonnative language. Method: Thirty-three English-speaking speech-language pathology students completed 3 tasks in an experimental within-subjects design. Results: Task 1 (baseline) involved transcribing…

Human Factors Effecting Forensic Decision Making: Workplace Stress and Well-being.

PubMed

Jeanguenat, Amy M; Dror, Itiel E

2018-01-01

Over the past decade, there has been a growing openness about the importance of human factors in forensic work. However, most of it focused on cognitive bias, and neglected issues of workplace wellness and stress. Forensic scientists work in a dynamic environment that includes common workplace pressures such as workload volume, tight deadlines, lack of advancement, number of working hours, low salary, technology distractions, and fluctuating priorities. However, in addition, forensic scientists also encounter a number of industry-specific pressures, such as technique criticism, repeated exposure to crime scenes or horrific case details, access to funding, working in an adversarial legal system, and zero tolerance for "errors". Thus, stress is an important human factor to mitigate for overall error management, productivity and decision quality (not to mention the well-being of the examiners themselves). Techniques such as mindfulness can become powerful tools to enhance work and decision quality. © 2017 American Academy of Forensic Sciences.

Machine learning enhanced optical distance sensor

NASA Astrophysics Data System (ADS)

Amin, M. Junaid; Riza, N. A.

2018-01-01

Presented for the first time is a machine learning enhanced optical distance sensor. The distance sensor is based on our previously demonstrated distance measurement technique that uses an Electronically Controlled Variable Focus Lens (ECVFL) with a laser source to illuminate a target plane with a controlled optical beam spot. This spot with varying spot sizes is viewed by an off-axis camera and the spot size data is processed to compute the distance. In particular, proposed and demonstrated in this paper is the use of a regularized polynomial regression based supervised machine learning algorithm to enhance the accuracy of the operational sensor. The algorithm uses the acquired features and corresponding labels that are the actual target distance values to train a machine learning model. The optimized training model is trained over a 1000 mm (or 1 m) experimental target distance range. Using the machine learning algorithm produces a training set and testing set distance measurement errors of <0.8 mm and <2.2 mm, respectively. The test measurement error is at least a factor of 4 improvement over our prior sensor demonstration without the use of machine learning. Applications for the proposed sensor include industrial scenario distance sensing where target material specific training models can be generated to realize low <1% measurement error distance measurements.

Applying Intelligent Algorithms to Automate the Identification of Error Factors.

PubMed

Jin, Haizhe; Qu, Qingxing; Munechika, Masahiko; Sano, Masataka; Kajihara, Chisato; Duffy, Vincent G; Chen, Han

2018-05-03

Medical errors are the manifestation of the defects occurring in medical processes. Extracting and identifying defects as medical error factors from these processes are an effective approach to prevent medical errors. However, it is a difficult and time-consuming task and requires an analyst with a professional medical background. The issues of identifying a method to extract medical error factors and reduce the extraction difficulty need to be resolved. In this research, a systematic methodology to extract and identify error factors in the medical administration process was proposed. The design of the error report, extraction of the error factors, and identification of the error factors were analyzed. Based on 624 medical error cases across four medical institutes in both Japan and China, 19 error-related items and their levels were extracted. After which, they were closely related to 12 error factors. The relational model between the error-related items and error factors was established based on a genetic algorithm (GA)-back-propagation neural network (BPNN) model. Additionally, compared to GA-BPNN, BPNN, partial least squares regression and support vector regression, GA-BPNN exhibited a higher overall prediction accuracy, being able to promptly identify the error factors from the error-related items. The combination of "error-related items, their different levels, and the GA-BPNN model" was proposed as an error-factor identification technology, which could automatically identify medical error factors.

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.

Enhanced Pedestrian Navigation Based on Course Angle Error Estimation Using Cascaded Kalman Filters

PubMed Central

Park, Chan Gook

2018-01-01

An enhanced pedestrian dead reckoning (PDR) based navigation algorithm, which uses two cascaded Kalman filters (TCKF) for the estimation of course angle and navigation errors, is proposed. The proposed algorithm uses a foot-mounted inertial measurement unit (IMU), waist-mounted magnetic sensors, and a zero velocity update (ZUPT) based inertial navigation technique with TCKF. The first stage filter estimates the course angle error of a human, which is closely related to the heading error of the IMU. In order to obtain the course measurements, the filter uses magnetic sensors and a position-trace based course angle. For preventing magnetic disturbance from contaminating the estimation, the magnetic sensors are attached to the waistband. Because the course angle error is mainly due to the heading error of the IMU, and the characteristic error of the heading angle is highly dependent on that of the course angle, the estimated course angle error is used as a measurement for estimating the heading error in the second stage filter. At the second stage, an inertial navigation system-extended Kalman filter-ZUPT (INS-EKF-ZUPT) method is adopted. As the heading error is estimated directly by using course-angle error measurements, the estimation accuracy for the heading and yaw gyro bias can be enhanced, compared with the ZUPT-only case, which eventually enhances the position accuracy more efficiently. The performance enhancements are verified via experiments, and the way-point position error for the proposed method is compared with those for the ZUPT-only case and with other cases that use ZUPT and various types of magnetic heading measurements. The results show that the position errors are reduced by a maximum of 90% compared with the conventional ZUPT based PDR algorithms. PMID:29690539

Action Monitoring in boys with ADHD, their Nonaffected Siblings and Normal Controls: Evidence for an Endophenotype

PubMed Central

Albrecht, Bjoern; Brandeis, Daniel; Uebel, Henrik; Heinrich, Hartmut; Mueller, Ueli C.; Hasselhorn, Marcus; Steinhausen, Hans-Christoph; Rothenberger, Aribert; Banaschewski, Tobias

2008-01-01

Background Attention deficit/hyperactivity disorder is a very common and highly heritable child psychiatric disorder associated with dysfunctions in fronto-striatal networks that control attention and response organisation. Aim of this study was to investigate whether features of action monitoring related to dopaminergic functions represent endophenotypes which are brain functions on the pathway from genes and environmental risk factors to behaviour. Methods Action monitoring and error processing as indicated by behavioural and electrophysiological parameters during a flanker task were examined in boys with ADHD combined type according to DSM-IV (N=68), their nonaffected siblings (N=18) and healthy controls with no known family history of ADHD (N=22). Results Boys with ADHD displayed slower and more variable reaction-times. Error negativity (Ne) was smaller in boys with ADHD compared to healthy controls, while nonaffected siblings displayed intermediate amplitudes following a linear model predicted by genetic concordance. The three groups did not differ on error positivity (Pe). N2 amplitude enhancement due to conflict (incongruent flankers) was reduced in the ADHD group. Nonaffected siblings also displayed intermediate N2 enhancement. Conclusions Converging evidence from behavioural and ERP findings suggests that action monitoring and initial error processing, both related to dopaminergically modulated functions of anterior cingulate cortex, might be an endophenotype related to ADHD. PMID:18339358

Human Factors Directions for Civil Aviation

NASA Technical Reports Server (NTRS)

Hart, Sandra G.

2002-01-01

Despite considerable progress in understanding human capabilities and limitations, incorporating human factors into aircraft design, operation, and certification, and the emergence of new technologies designed to reduce workload and enhance human performance in the system, most aviation accidents still involve human errors. Such errors occur as a direct or indirect result of untimely, inappropriate, or erroneous actions (or inactions) by apparently well-trained and experienced pilots, controllers, and maintainers. The field of human factors has solved many of the more tractable problems related to simple ergonomics, cockpit layout, symbology, and so on. We have learned much about the relationships between people and machines, but know less about how to form successful partnerships between humans and the information technologies that are beginning to play a central role in aviation. Significant changes envisioned in the structure of the airspace, pilots and controllers' roles and responsibilities, and air/ground technologies will require a similarly significant investment in human factors during the next few decades to ensure the effective integration of pilots, controllers, dispatchers, and maintainers into the new system. Many of the topics that will be addressed are not new because progress in crucial areas, such as eliminating human error, has been slow. A multidisciplinary approach that capitalizes upon human studies and new classes of information, computational models, intelligent analytical tools, and close collaborations with organizations that build, operate, and regulate aviation technology will ensure that the field of human factors meets the challenge.

Stereotype susceptibility narrows the gender gap in imagined self-rotation performance.

PubMed

Wraga, Maryjane; Duncan, Lauren; Jacobs, Emily C; Helt, Molly; Church, Jessica

2006-10-01

Three studies examined the impact of stereotype messages on men's and women's performance of a mental rotation task involving imagined self-rotations. Experiment 1 established baseline differences between men and women; women made 12% more errors than did men. Experiment 2 found that exposure to a positive stereotype message enhanced women's performance in comparison with that of another group of women who received neutral information. In Experiment 3, men who were exposed to the same stereotype message emphasizing a female advantage made more errors than did male controls, and the magnitude of error was similar to that for women from Experiment 1. The results suggest that the gender gap in mental rotation performance is partially caused by experiential factors, particularly those induced by sociocultural stereotypes.

Alternating phase-shift mask and binary mask for 45-nm node and beyond: the impact on the mask error control

NASA Astrophysics Data System (ADS)

Kojima, Yosuke; Shirasaki, Masanori; Chiba, Kazuaki; Tanaka, Tsuyoshi; Inazuki, Yukio; Yoshikawa, Hiroki; Okazaki, Satoshi; Iwase, Kazuya; Ishikawa, Kiichi; Ozawa, Ken

2007-05-01

For 45 nm node and beyond, the alternating phase-shift mask (alt. PSM), one of the most expected resolution enhancement technologies (RET) because of its high image contrast and small mask error enhancement factor (MEEF), and the binary mask (BIM) attract attention. Reducing CD and registration errors and defect are their critical issues. As the solution, the new blank for alt. PSM and BIM is developed. The top film of new blank is thin Cr, and the antireflection film and shielding film composed of MoSi are deposited under the Cr film. The mask CD performance is evaluated for through pitch, CD linearity, CD uniformity, global loading, resolution and pattern fidelity, and the blank performance is evaluated for optical density, reflectivity, sheet resistance, flatness and defect level. It is found that the performance of new blank is equal to or better than that of conventional blank in all items. The mask CD performance shows significant improvement. The lithography performance of new blank is confirmed by wafer printing and AIMS measurement. The full dry type alt. PSM has been used as test plate, and the test results show that new blank can almost meet the specifications of pi-0 CD difference, CD uniformity and process margin for 45 nm node. Additionally, the new blank shows the better pattern fidelity than that of conventional blank on wafer. AIMS results are almost same as wafer results except for the narrowest pattern. Considering the result above, this new blank can reduce the mask error factors of alt. PSM and BIM for 45 nm node and beyond.

Enhancing adaptive sparse grid approximations and improving refinement strategies using adjoint-based a posteriori error estimates

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

Jakeman, J.D., E-mail: jdjakem@sandia.gov; Wildey, T.

2015-01-01

In this paper we present an algorithm for adaptive sparse grid approximations of quantities of interest computed from discretized partial differential equations. We use adjoint-based a posteriori error estimates of the physical discretization error and the interpolation error in the sparse grid to enhance the sparse grid approximation and to drive adaptivity of the sparse grid. Utilizing these error estimates provides significantly more accurate functional values for random samples of the sparse grid approximation. We also demonstrate that alternative refinement strategies based upon a posteriori error estimates can lead to further increases in accuracy in the approximation over traditional hierarchicalmore » surplus based strategies. Throughout this paper we also provide and test a framework for balancing the physical discretization error with the stochastic interpolation error of the enhanced sparse grid approximation.« less

Puzzles in modern biology. V. Why are genomes overwired?

PubMed

Frank, Steven A

2017-01-01

Many factors affect eukaryotic gene expression. Transcription factors, histone codes, DNA folding, and noncoding RNA modulate expression. Those factors interact in large, broadly connected regulatory control networks. An engineer following classical principles of control theory would design a simpler regulatory network. Why are genomes overwired? Neutrality or enhanced robustness may lead to the accumulation of additional factors that complicate network architecture. Dynamics progresses like a ratchet. New factors get added. Genomes adapt to the additional complexity. The newly added factors can no longer be removed without significant loss of fitness. Alternatively, highly wired genomes may be more malleable. In large networks, most genomic variants tend to have a relatively small effect on gene expression and trait values. Many small effects lead to a smooth gradient, in which traits may change steadily with respect to underlying regulatory changes. A smooth gradient may provide a continuous path from a starting point up to the highest peak of performance. A potential path of increasing performance promotes adaptability and learning. Genomes gain by the inductive process of natural selection, a trial and error learning algorithm that discovers general solutions for adapting to environmental challenge. Similarly, deeply and densely connected computational networks gain by various inductive trial and error learning procedures, in which the networks learn to reduce the errors in sequential trials. Overwiring alters the geometry of induction by smoothing the gradient along the inductive pathways of improving performance. Those overwiring benefits for induction apply to both natural biological networks and artificial deep learning networks.

Enhancing adaptive sparse grid approximations and improving refinement strategies using adjoint-based a posteriori error estimates

DOE PAGES

Jakeman, J. D.; Wildey, T.

2015-01-01

In this paper we present an algorithm for adaptive sparse grid approximations of quantities of interest computed from discretized partial differential equations. We use adjoint-based a posteriori error estimates of the interpolation error in the sparse grid to enhance the sparse grid approximation and to drive adaptivity. We show that utilizing these error estimates provides significantly more accurate functional values for random samples of the sparse grid approximation. We also demonstrate that alternative refinement strategies based upon a posteriori error estimates can lead to further increases in accuracy in the approximation over traditional hierarchical surplus based strategies. Throughout this papermore » we also provide and test a framework for balancing the physical discretization error with the stochastic interpolation error of the enhanced sparse grid approximation.« less

The ADRA2B gene in the production of false memories for affective information in healthy female volunteers.

PubMed

Fairfield, Beth; Mammarella, Nicola; Di Domenico, Alberto; D'Aurora, Marco; Stuppia, Liborio; Gatta, Valentina

2017-08-30

False memories are common memory distortions in everyday life and seem to increase with affectively connoted complex information. In line with recent studies showing a significant interaction between the noradrenergic system and emotional memory, we investigated whether healthy volunteer carriers of the deletion variant of the ADRA2B gene that codes for the α2b-adrenergic receptor are more prone to false memories than non-carriers. In this study, we collected genotype data from 212 healthy female volunteers; 91 ADRA2B carriers and 121 non-carriers. To assess gene effects on false memories for affective information, factorial mixed model analysis of variances (ANOVAs) were conducted with genotype as the between-subjects factor and type of memory error as the within-subjects factor. We found that although carriers and non-carriers made comparable numbers of false memory errors, they showed differences in the direction of valence biases, especially for inferential causal errors. Specifically, carriers produced fewer causal false memory errors for scripts with a negative outcome, whereas non-carriers showed a more general emotional effect and made fewer causal errors with both positive and negative outcomes. These findings suggest that putatively higher levels of noradrenaline in deletion carriers may enhance short-term consolidation of negative information and lead to fewer memory distortions when facing negative events. Copyright © 2017 Elsevier B.V. All rights reserved.

Full-chip level MEEF analysis using model based lithography verification

NASA Astrophysics Data System (ADS)

Kim, Juhwan; Wang, Lantian; Zhang, Daniel; Tang, Zongwu

2005-11-01

MEEF (Mask Error Enhancement Factor) has become a critical factor in CD uniformity control since optical lithography process moved to sub-resolution era. A lot of studies have been done by quantifying the impact of the mask CD (Critical Dimension) errors on the wafer CD errors1-2. However, the benefits from those studies were restricted only to small pattern areas of the full-chip data due to long simulation time. As fast turn around time can be achieved for the complicated verifications on very large data by linearly scalable distributed processing technology, model-based lithography verification becomes feasible for various types of applications such as post mask synthesis data sign off for mask tape out in production and lithography process development with full-chip data3,4,5. In this study, we introduced two useful methodologies for the full-chip level verification of mask error impact on wafer lithography patterning process. One methodology is to check MEEF distribution in addition to CD distribution through process window, which can be used for RET/OPC optimization at R&D stage. The other is to check mask error sensitivity on potential pinch and bridge hotspots through lithography process variation, where the outputs can be passed on to Mask CD metrology to add CD measurements on those hotspot locations. Two different OPC data were compared using the two methodologies in this study.

Relationships between evidence-based practice, quality improvement and clinical error experience of nurses in Korean hospitals.

PubMed

Hwang, Jee-In; Park, Hyeoun-Ae

2015-07-01

This study investigated individual and work-related factors associated with nurses' perceptions of evidence-based practice (EBP) and quality improvement (QI), and the relationships between evidence-based practice, quality improvement and clinical errors. Understanding the factors affecting evidence-based practice and quality improvement activities and their relationships with clinical errors is important for designing strategies to promote evidence-based practice, quality improvement and patient safety. A cross-sectional survey was conducted with 594 nurses in two Korean teaching hospitals using the evidence-based practice Questionnaire and quality improvement scale developed in this study. Four hundred and forty-three nurses (74.6%) returned the completed survey. Nurses' ages and educational levels were significantly associated with evidence-based practice scores whereas age and job position were associated with quality improvement scores. There were positive, moderate correlations between evidence-based practice and quality improvement scores. Nurses who had not made any clinical errors during the past 12 months had significantly higher quality improvement skills scores than those who had. The findings indicated the necessity of educational support regarding evidence-based practice and quality improvement for younger staff nurses who have no master degrees. Enhancing quality improvement skills may reduce clinical errors. Nurse managers should consider the characteristics of their staff when implementing educational and clinical strategies for evidence-based practice and quality improvement. © 2013 John Wiley & Sons Ltd.

Space charge enhanced plasma gradient effects on satellite electric field measurements

NASA Technical Reports Server (NTRS)

Diebold, Dan; Hershkowitz, Noah; Dekock, J.; Intrator, T.; Hsieh, M-K.

1991-01-01

It has been recognized that plasma gradients can cause error in magnetospheric electric field measurements made by double probes. Space charge enhanced Plasma Gradient Induced Error (PGIE) is discussed in general terms, presenting the results of a laboratory experiment designed to demonstrate this error, and deriving a simple expression that quantifies this error. Experimental conditions were not identical to magnetospheric conditions, although efforts were made to insure the relevant physics applied to both cases. The experimental data demonstrate some of the possible errors in electric field measurements made by strongly emitting probes due to space charge effects in the presence of plasma gradients. Probe errors in space and laboratory conditions are discussed, as well as experimental error. In the final section, theoretical aspects are examined and an expression is derived for the maximum steady state space charge enhanced PGIE taken by two identical current biased probes.

Towards an evaluation framework for Laboratory Information Systems.

PubMed

Yusof, Maryati M; Arifin, Azila

Laboratory testing and reporting are error-prone and redundant due to repeated, unnecessary requests and delayed or missed reactions to laboratory reports. Occurring errors may negatively affect the patient treatment process and clinical decision making. Evaluation on laboratory testing and Laboratory Information System (LIS) may explain the root cause to improve the testing process and enhance LIS in supporting the process. This paper discusses a new evaluation framework for LIS that encompasses the laboratory testing cycle and the socio-technical part of LIS. Literature review on discourses, dimensions and evaluation methods of laboratory testing and LIS. A critical appraisal of the Total Testing Process (TTP) and the human, organization, technology-fit factors (HOT-fit) evaluation frameworks was undertaken in order to identify error incident, its contributing factors and preventive action pertinent to laboratory testing process and LIS. A new evaluation framework for LIS using a comprehensive and socio-technical approach is outlined. Positive relationship between laboratory and clinical staff resulted in a smooth laboratory testing process, reduced errors and increased process efficiency whilst effective use of LIS streamlined the testing processes. The TTP-LIS framework could serve as an assessment as well as a problem-solving tool for the laboratory testing process and system. Copyright © 2016 King Saud Bin Abdulaziz University for Health Sciences. Published by Elsevier Ltd. All rights reserved.

Evaluation of SMART sensor displays for multidimensional precision control of Space Shuttle remote manipulator

NASA Technical Reports Server (NTRS)

Bejczy, A. K.; Brown, J. W.; Lewis, J. L.

1982-01-01

An enhanced proximity sensor and display system was developed at the Jet Propulsion Laboratory (JPL) and tested on the full scale Space Shuttle Remote Manipulator at the Johnson Space Center (JSC) Manipulator Development Facility (MDF). The sensor system, integrated with a four-claw end effector, measures range error up to 6 inches, and pitch and yaw alignment errors within + or 15 deg., and displays error data on both graphic and numeric displays. The errors are referenced to the end effector control axes through appropriate data processing by a dedicated microcomputer acting on the sensor data in real time. Both display boxes contain a green lamp which indicates whether the combination of range, pitch and yaw errors will assure a successful grapple. More than 200 test runs were completed in early 1980 by three operators at JSC for grasping static and capturing slowly moving targets. The tests have indicated that the use of graphic/numeric displays of proximity sensor information improves precision control of grasp/capture range by more than a factor of two for both static and dynamic grapple conditions.

Classification and reduction of pilot error

NASA Technical Reports Server (NTRS)

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

1989-01-01

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

Exploring the impact of forcing error characteristics on physically based snow simulations within a global sensitivity analysis framework

NASA Astrophysics Data System (ADS)

Raleigh, M. S.; Lundquist, J. D.; Clark, M. P.

2015-07-01

Physically based models provide insights into key hydrologic processes but are associated with uncertainties due to deficiencies in forcing data, model parameters, and model structure. Forcing uncertainty is enhanced in snow-affected catchments, where weather stations are scarce and prone to measurement errors, and meteorological variables exhibit high variability. Hence, there is limited understanding of how forcing error characteristics affect simulations of cold region hydrology and which error characteristics are most important. Here we employ global sensitivity analysis to explore how (1) different error types (i.e., bias, random errors), (2) different error probability distributions, and (3) different error magnitudes influence physically based simulations of four snow variables (snow water equivalent, ablation rates, snow disappearance, and sublimation). We use the Sobol' global sensitivity analysis, which is typically used for model parameters but adapted here for testing model sensitivity to coexisting errors in all forcings. We quantify the Utah Energy Balance model's sensitivity to forcing errors with 1 840 000 Monte Carlo simulations across four sites and five different scenarios. Model outputs were (1) consistently more sensitive to forcing biases than random errors, (2) generally less sensitive to forcing error distributions, and (3) critically sensitive to different forcings depending on the relative magnitude of errors. For typical error magnitudes found in areas with drifting snow, precipitation bias was the most important factor for snow water equivalent, ablation rates, and snow disappearance timing, but other forcings had a more dominant impact when precipitation uncertainty was due solely to gauge undercatch. Additionally, the relative importance of forcing errors depended on the model output of interest. Sensitivity analysis can reveal which forcing error characteristics matter most for hydrologic modeling.

Non-airborne conflicts: The causes and effects of runway transgressions

NASA Technical Reports Server (NTRS)

Tarrel, Richard J.

1985-01-01

The 1210 ASRS runway transgression reports are studied and expanded to yield descriptive statistics. Additionally, a one of three subset was studied in detail for purposes of evaluating the causes, risks, and consequences behind trangression events. Occurrences are subdivided by enabling factor and flight phase designations. It is concluded that a larger risk of collision is associated with controller enabled departure transgressions over all other categories. The influence of this type is especially evident during the period following the air traffic controllers' strike of 1981. Causal analysis indicates that, coincidentally, controller enabled departure transgressions also, show the strongest correlations between causal factors. It shows that departure errors occur more often when visibility is reduced, and when multiple takeoff runways or intersection takeoffs are employed. In general, runway transgressions attributable to both pilot and controller errors arise from three problem areas: information transfer, awareness, and spatial judgement. Enhanced awareness by controllers will probably reduce controller enabled incidents.

Learning from Errors in Dual Vocational Education: Video-Enhanced Instructional Strategies

ERIC Educational Resources Information Center

Cattaneo, Alberto A. P.; Boldrini, Elena

2017-01-01

Purpose: Starting from the identification of some theoretically driven instructional principles, this paper presents a set of empirical cases based on strategies to learn from errors. The purpose of this paper is to provide first evidence about the feasibility and the effectiveness for learning of video-enhanced error-based strategies in…

Evaluation of Phantom-Based Education System for Acupuncture Manipulation

PubMed Central

Lee, In-Seon; Lee, Ye-Seul; Park, Hi-Joon; Lee, Hyejung; Chae, Younbyoung

2015-01-01

Background Although acupuncture manipulation has been regarded as one of the important factors in clinical outcome, it has been difficult to train novice students to become skillful experts due to a lack of adequate educational program and tools. Objectives In the present study, we investigated whether newly developed phantom acupoint tools would be useful to practice-naïve acupuncture students for practicing the three different types of acupuncture manipulation to enhance their skills. Methods We recruited 12 novice students and had them practice acupuncture manipulations on the phantom acupoint (5% agarose gel). We used the Acusensor 2 and compared their acupuncture manipulation techniques, for which the target criteria were depth and time factors, at acupoint LI11 in the human body before and after 10 training sessions. The outcomes were depth of needle insertion, depth error from target criterion, time of rotating, lifting, and thrusting, time error from target criteria and the time ratio. Results After 10 training sessions, the students showed significantly improved outcomes in depth of needle, depth error (rotation, reducing lifting/thrusting), thumb-forward time error, thumb-backward time error (rotation), and lifting time (reinforcing lifting/thrusting). Conclusions The phantom acupoint tool could be useful in a phantom-based education program for acupuncture-manipulation training for students. For advanced education programs for acupuncture manipulation, we will need to collect additional information, such as patient responses, acupoint-specific anatomical characteristics, delicate tissue-like modeling, haptic and visual feedback, and data from an acupuncture practice simulator. PMID:25689598

Evaluation of phantom-based education system for acupuncture manipulation.

PubMed

Lee, In-Seon; Lee, Ye-Seul; Park, Hi-Joon; Lee, Hyejung; Chae, Younbyoung

2015-01-01

Although acupuncture manipulation has been regarded as one of the important factors in clinical outcome, it has been difficult to train novice students to become skillful experts due to a lack of adequate educational program and tools. In the present study, we investigated whether newly developed phantom acupoint tools would be useful to practice-naïve acupuncture students for practicing the three different types of acupuncture manipulation to enhance their skills. We recruited 12 novice students and had them practice acupuncture manipulations on the phantom acupoint (5% agarose gel). We used the Acusensor 2 and compared their acupuncture manipulation techniques, for which the target criteria were depth and time factors, at acupoint LI11 in the human body before and after 10 training sessions. The outcomes were depth of needle insertion, depth error from target criterion, time of rotating, lifting, and thrusting, time error from target criteria and the time ratio. After 10 training sessions, the students showed significantly improved outcomes in depth of needle, depth error (rotation, reducing lifting/thrusting), thumb-forward time error, thumb-backward time error (rotation), and lifting time (reinforcing lifting/thrusting). The phantom acupoint tool could be useful in a phantom-based education program for acupuncture-manipulation training for students. For advanced education programs for acupuncture manipulation, we will need to collect additional information, such as patient responses, acupoint-specific anatomical characteristics, delicate tissue-like modeling, haptic and visual feedback, and data from an acupuncture practice simulator.

The human factors of quality and QA in R D environments

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

Hill, S.G.

1990-01-01

Achieving quality is a human activity. It is therefore important to consider the human in the design, development and evaluation of work processes and environments in an effort to enhance human performance and minimize error. It is also important to allow for individual differences when considering human factors issues. Human Factors is the field of study which can provide information on integrating the human into the system. Human factors and quality are related for the customer of R D work, R D personnel who perform the work, and the quality professional who overviews the process of quality in the work.more » 18 refs., 1 fig.« less

Enhanced orbit determination filter sensitivity analysis: Error budget development

NASA Technical Reports Server (NTRS)

Estefan, J. A.; Burkhart, P. D.

1994-01-01

An error budget analysis is presented which quantifies the effects of different error sources in the orbit determination process when the enhanced orbit determination filter, recently developed, is used to reduce radio metric data. The enhanced filter strategy differs from more traditional filtering methods in that nearly all of the principal ground system calibration errors affecting the data are represented as filter parameters. Error budget computations were performed for a Mars Observer interplanetary cruise scenario for cases in which only X-band (8.4-GHz) Doppler data were used to determine the spacecraft's orbit, X-band ranging data were used exclusively, and a combined set in which the ranging data were used in addition to the Doppler data. In all three cases, the filter model was assumed to be a correct representation of the physical world. Random nongravitational accelerations were found to be the largest source of error contributing to the individual error budgets. Other significant contributors, depending on the data strategy used, were solar-radiation pressure coefficient uncertainty, random earth-orientation calibration errors, and Deep Space Network (DSN) station location uncertainty.

Fast Light Optical Gyroscopes

NASA Technical Reports Server (NTRS)

Smith, David D.

2015-01-01

Next-generation space missions are currently constrained by existing spacecraft navigation systems which are not fully autonomous. These systems suffer from accumulated dead-reckoning errors and must therefore rely on periodic corrections provided by supplementary technologies that depend on line-of-sight signals from Earth, satellites, or other celestial bodies for absolute attitude and position determination, which can be spoofed, incorrectly identified, occluded, obscured, attenuated, or insufficiently available. These dead-reckoning errors originate in the ring laser gyros themselves, which constitute inertial measurement units. Increasing the time for standalone spacecraft navigation therefore requires fundamental improvements in gyroscope technologies. One promising solution to enhance gyro sensitivity is to place an anomalous dispersion or fast light material inside the gyro cavity. The fast light essentially provides a positive feedback to the gyro response, resulting in a larger measured beat frequency for a given rotation rate as shown in figure 1. Game Changing Development has been investing in this idea through the Fast Light Optical Gyros (FLOG) project, a collaborative effort which began in FY 2013 between NASA Marshall Space Flight Center (MSFC), the U.S. Army Aviation and Missile Research, Development, and Engineering Center (AMRDEC), and Northwestern University. MSFC and AMRDEC are working on the development of a passive FLOG (PFLOG), while Northwestern is developing an active FLOG (AFLOG). The project has demonstrated new benchmarks in the state of the art for scale factor sensitivity enhancement. Recent results show cavity scale factor enhancements of approx.100 for passive cavities.

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

Aldegunde, Manuel, E-mail: M.A.Aldegunde-Rodriguez@warwick.ac.uk; Kermode, James R., E-mail: J.R.Kermode@warwick.ac.uk; Zabaras, Nicholas

This paper presents the development of a new exchange–correlation functional from the point of view of machine learning. Using atomization energies of solids and small molecules, we train a linear model for the exchange enhancement factor using a Bayesian approach which allows for the quantification of uncertainties in the predictions. A relevance vector machine is used to automatically select the most relevant terms of the model. We then test this model on atomization energies and also on bulk properties. The average model provides a mean absolute error of only 0.116 eV for the test points of the G2/97 set butmore » a larger 0.314 eV for the test solids. In terms of bulk properties, the prediction for transition metals and monovalent semiconductors has a very low test error. However, as expected, predictions for types of materials not represented in the training set such as ionic solids show much larger errors.« less

Defining near misses: towards a sharpened definition based on empirical data about error handling processes.

PubMed

Kessels-Habraken, Marieke; Van der Schaaf, Tjerk; De Jonge, Jan; Rutte, Christel

2010-05-01

Medical errors in health care still occur frequently. Unfortunately, errors cannot be completely prevented and 100% safety can never be achieved. Therefore, in addition to error reduction strategies, health care organisations could also implement strategies that promote timely error detection and correction. Reporting and analysis of so-called near misses - usually defined as incidents without adverse consequences for patients - are necessary to gather information about successful error recovery mechanisms. This study establishes the need for a clearer and more consistent definition of near misses to enable large-scale reporting and analysis in order to obtain such information. Qualitative incident reports and interviews were collected on four units of two Dutch general hospitals. Analysis of the 143 accompanying error handling processes demonstrated that different incident types each provide unique information about error handling. Specifically, error handling processes underlying incidents that did not reach the patient differed significantly from those of incidents that reached the patient, irrespective of harm, because of successful countermeasures that had been taken after error detection. We put forward two possible definitions of near misses and argue that, from a practical point of view, the optimal definition may be contingent on organisational context. Both proposed definitions could yield large-scale reporting of near misses. Subsequent analysis could enable health care organisations to improve the safety and quality of care proactively by (1) eliminating failure factors before real accidents occur, (2) enhancing their ability to intercept errors in time, and (3) improving their safety culture. Copyright 2010 Elsevier Ltd. All rights reserved.

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.

Performance-limiting factors for x-ray free electron laser oscillator as a highly coherent, high spectral purity x-ray source

NASA Astrophysics Data System (ADS)

Park, Gunn Tae

X-ray Free Electron Laser (XFEL) is a light source for coherent X-ray using the radiation from relativistic electrons and interaction between the two. In particular, XFEL oscillator(XFELO) uses optical cavity to repeatedly bring back the radiation to electron beam for the interaction. Its optimal performance, maximum single pass gain and minimum round trip loss, critically depends on cavity optics. In ideal case, the optimal performance would be achieved by the periodic radiation mode maximally overlapping with electron beam while the radiation mode is impinging on curved mirror that gives the radiation the focusing, below critical angle and angular divergence being kept small enough at each crystal for Bragg scattering, which is used for near-normal reflection. In reality, there exist various performance degrading factors in the cavity such as heat load on the crystal surface, misalignments of crystals and mirrors and mirror surface errors. In this thesis, we study via both analytic computation and numerical simulation the optimal design and performance of XFELO cavity in the presence of these factors. In optimal design, we implement asymmetric crystals into cavity to enhance the performance. In general, it has undesirable effect of pulse dilation. We present the configuration that avoids pulse length dilation. Then the effects of misalignments, focal length errors and mirror surface errors are to be evaluated and their tolerances are estimated. In particular, the simulation demonstrates that the effect of mirror surface errors on gain and round trip loss is well-within desired performance of XFELO.

How can we improve the recognition, reporting and resolution of medical device-related incidents in hospitals? A qualitative study of physicians and registered nurses.

PubMed

Polisena, Julie; Gagliardi, Anna; Clifford, Tammy

2015-06-06

To explore factors that influence and to identify initiatives to improve the recognition, reporting and resolution of device-related incidents. Semi-structured telephone interviews with 16 health professionals in two tertiary care hospitals were conducted. Purposive sampling was used to identify appropriate study participants. Transcribed interviews were read independently by one individual to identify, define and organize themes and verified by another reviewer. Themes related to incident recognition were the hospital staff's knowledge and professional experience, medical device performance and clinical manifestations of patients, while incident reporting was influenced by error severity, personal attitudes of clinicians, feedback received on the error reported. Physicians often discontinued using medical devices if they malfunctioned. Education and training and the implementation of registries were discussed as important initiatives to improve medical device surveillance in clinical practice. Results from the telephone interviews suggest that multiple factors that influence participation in medical device surveillance activities are consistent with results for medical errors as reported in previous studies. The study results helped to propose a conceptual framework for a medical device surveillance system in a hospital context that would enhance patient safety and health care delivery.

Why Ineffective Psychotherapies Appear to Work: A Taxonomy of Causes of Spurious Therapeutic Effectiveness.

PubMed

Lilienfeld, Scott O; Ritschel, Lorie A; Lynn, Steven Jay; Cautin, Robin L; Latzman, Robert D

2014-07-01

The past 40 years have generated numerous insights regarding errors in human reasoning. Arguably, clinical practice is the domain of applied psychology in which acknowledging and mitigating these errors is most crucial. We address one such set of errors here, namely, the tendency of some psychologists and other mental health professionals to assume that they can rely on informal clinical observations to infer whether treatments are effective. We delineate four broad, underlying cognitive impediments to accurately evaluating improvement in psychotherapy-naive realism, confirmation bias, illusory causation, and the illusion of control. We then describe 26 causes of spurious therapeutic effectiveness (CSTEs), organized into a taxonomy of three overarching categories: (a) the perception of client change in its actual absence, (b) misinterpretations of actual client change stemming from extratherapeutic factors, and (c) misinterpretations of actual client change stemming from nonspecific treatment factors. These inferential errors can lead clinicians, clients, and researchers to misperceive useless or even harmful psychotherapies as effective. We (a) examine how methodological safeguards help to control for different CSTEs, (b) delineate fruitful directions for research on CSTEs, and (c) consider the implications of CSTEs for everyday clinical practice. An enhanced appreciation of the inferential problems posed by CSTEs may narrow the science-practice gap and foster a heightened appreciation of the need for the methodological safeguards afforded by evidence-based practice. © The Author(s) 2014.

Frequency and Distribution of Refractive Error in Adult Life: Methodology and Findings of the UK Biobank Study

PubMed Central

Cumberland, Phillippa M.; Bao, Yanchun; Hysi, Pirro G.; Foster, Paul J.; Hammond, Christopher J.; Rahi, Jugnoo S.

2015-01-01

Purpose To report the methodology and findings of a large scale investigation of burden and distribution of refractive error, from a contemporary and ethnically diverse study of health and disease in adults, in the UK. Methods U K Biobank, a unique contemporary resource for the study of health and disease, recruited more than half a million people aged 40–69 years. A subsample of 107,452 subjects undertook an enhanced ophthalmic examination which provided autorefraction data (a measure of refractive error). Refractive error status was categorised using the mean spherical equivalent refraction measure. Information on socio-demographic factors (age, gender, ethnicity, educational qualifications and accommodation tenure) was reported at the time of recruitment by questionnaire and face-to-face interview. Results Fifty four percent of participants aged 40–69 years had refractive error. Specifically 27% had myopia (4% high myopia), which was more common amongst younger people, those of higher socio-economic status, higher educational attainment, or of White or Chinese ethnicity. The frequency of hypermetropia increased with age (7% at 40–44 years increasing to 46% at 65–69 years), was higher in women and its severity was associated with ethnicity (moderate or high hypermetropia at least 30% less likely in non-White ethnic groups compared to White). Conclusions Refractive error is a significant public health issue for the UK and this study provides contemporary data on adults for planning services, health economic modelling and monitoring of secular trends. Further investigation of risk factors is necessary to inform strategies for prevention. There is scope to do this through the planned longitudinal extension of the UK Biobank study. PMID:26430771

Restoration of the ASCA Source Position Accuracy

NASA Astrophysics Data System (ADS)

Gotthelf, E. V.; Ueda, Y.; Fujimoto, R.; Kii, T.; Yamaoka, K.

2000-11-01

We present a calibration of the absolute pointing accuracy of the Advanced Satellite for Cosmology and Astrophysics (ASCA) which allows us to compensate for a large error (up to 1') in the derived source coordinates. We parameterize a temperature dependent deviation of the attitude solution which is responsible for this error. By analyzing ASCA coordinates of 100 bright active galactic nuclei, we show that it is possible to reduce the uncertainty in the sky position for any given observation by a factor of 4. The revised 90% error circle radius is then 12", consistent with preflight specifications, effectively restoring the full ASCA pointing accuracy. Herein, we derive an algorithm which compensates for this attitude error and present an internet-based table to be used to correct post facto the coordinate of all ASCA observations. While the above error circle is strictly applicable to data taken with the on-board Solid-state Imaging Spectrometers (SISs), similar coordinate corrections are derived for data obtained with the Gas Imaging Spectrometers (GISs), which, however, have additional instrumental uncertainties. The 90% error circle radius for the central 20' diameter of the GIS is 24". The large reduction in the error circle area for the two instruments offers the opportunity to greatly enhance the search for X-ray counterparts at other wavelengths. This has important implications for current and future ASCA source catalogs and surveys.

Medication Errors: New EU Good Practice Guide on Risk Minimisation and Error Prevention.

PubMed

Goedecke, Thomas; Ord, Kathryn; Newbould, Victoria; Brosch, Sabine; Arlett, Peter

2016-06-01

A medication error is an unintended failure in the drug treatment process that leads to, or has the potential to lead to, harm to the patient. Reducing the risk of medication errors is a shared responsibility between patients, healthcare professionals, regulators and the pharmaceutical industry at all levels of healthcare delivery. In 2015, the EU regulatory network released a two-part good practice guide on medication errors to support both the pharmaceutical industry and regulators in the implementation of the changes introduced with the EU pharmacovigilance legislation. These changes included a modification of the 'adverse reaction' definition to include events associated with medication errors, and the requirement for national competent authorities responsible for pharmacovigilance in EU Member States to collaborate and exchange information on medication errors resulting in harm with national patient safety organisations. To facilitate reporting and learning from medication errors, a clear distinction has been made in the guidance between medication errors resulting in adverse reactions, medication errors without harm, intercepted medication errors and potential errors. This distinction is supported by an enhanced MedDRA(®) terminology that allows for coding all stages of the medication use process where the error occurred in addition to any clinical consequences. To better understand the causes and contributing factors, individual case safety reports involving an error should be followed-up with the primary reporter to gather information relevant for the conduct of root cause analysis where this may be appropriate. Such reports should also be summarised in periodic safety update reports and addressed in risk management plans. Any risk minimisation and prevention strategy for medication errors should consider all stages of a medicinal product's life-cycle, particularly the main sources and types of medication errors during product development. This article describes the key concepts of the EU good practice guidance for defining, classifying, coding, reporting, evaluating and preventing medication errors. This guidance should contribute to the safe and effective use of medicines for the benefit of patients and public health.

Dissipative quantum error correction and application to quantum sensing with trapped ions.

PubMed

Reiter, F; Sørensen, A S; Zoller, P; Muschik, C A

2017-11-28

Quantum-enhanced measurements hold the promise to improve high-precision sensing ranging from the definition of time standards to the determination of fundamental constants of nature. However, quantum sensors lose their sensitivity in the presence of noise. To protect them, the use of quantum error-correcting codes has been proposed. Trapped ions are an excellent technological platform for both quantum sensing and quantum error correction. Here we present a quantum error correction scheme that harnesses dissipation to stabilize a trapped-ion qubit. In our approach, always-on couplings to an engineered environment protect the qubit against spin-flips or phase-flips. Our dissipative error correction scheme operates in a continuous manner without the need to perform measurements or feedback operations. We show that the resulting enhanced coherence time translates into a significantly enhanced precision for quantum measurements. Our work constitutes a stepping stone towards the paradigm of self-correcting quantum information processing.

Piecewise compensation for the nonlinear error of fiber-optic gyroscope scale factor

NASA Astrophysics Data System (ADS)

Zhang, Yonggang; Wu, Xunfeng; Yuan, Shun; Wu, Lei

2013-08-01

Fiber-Optic Gyroscope (FOG) scale factor nonlinear error will result in errors in Strapdown Inertial Navigation System (SINS). In order to reduce nonlinear error of FOG scale factor in SINS, a compensation method is proposed in this paper based on curve piecewise fitting of FOG output. Firstly, reasons which can result in FOG scale factor error are introduced and the definition of nonlinear degree is provided. Then we introduce the method to divide the output range of FOG into several small pieces, and curve fitting is performed in each output range of FOG to obtain scale factor parameter. Different scale factor parameters of FOG are used in different pieces to improve FOG output precision. These parameters are identified by using three-axis turntable, and nonlinear error of FOG scale factor can be reduced. Finally, three-axis swing experiment of SINS verifies that the proposed method can reduce attitude output errors of SINS by compensating the nonlinear error of FOG scale factor and improve the precision of navigation. The results of experiments also demonstrate that the compensation scheme is easy to implement. It can effectively compensate the nonlinear error of FOG scale factor with slightly increased computation complexity. This method can be used in inertial technology based on FOG to improve precision.

Error Argumentation Enhance Adaptability in Adults With Low Motor Ability.

PubMed

Lee, Chi-Mei; Bo, Jin

2016-01-01

The authors focused on young adults with varying degrees of motor difficulties and examined their adaptability in a visuomotor adaptation task where the visual feedback of participants' movement error was presented with either 1:1 ratio (i.e., regular feedback schedule) or 1:2 ratio (i.e., enhanced feedback schedule). Within-subject design was used with two feedback schedules counter-balanced and separated for 10 days. Results revealed that participants with greater motor difficulties showed less adaptability than those with normal motor abilities in the regular feedback schedule; however, all participants demonstrated similar level of adaptability in the enhanced feedback schedule. The results suggest that error argumentation enhances adaptability in adults with low motor ability.

Rotational wind indicator enhances control of rotated displays

NASA Technical Reports Server (NTRS)

Cunningham, H. A.; Pavel, Misha

1991-01-01

Rotation by 108 deg of the spatial mapping between a visual display and a manual input device produces large spatial errors in a discrete aiming task. These errors are not easily corrected by voluntary mental effort, but the central nervous system does adapt gradually to the new mapping. Bernotat (1970) showed that adding true hand position to a 90 deg rotated display improved performance of a compensatory tracking task, but tracking error rose again upon removal of the explicit cue. This suggests that the explicit error signal did not induce changes in the neural mapping, but rather allowed the operator to reduce tracking error using a higher mental strategy. In this report, we describe an explicit visual display enhancement applied to a 108 deg rotated discrete aiming task. A 'wind indicator' corresponding to the effect of the mapping rotation is displayed on the operator-controlled cursor. The human operator is instructed to oppose the virtual force represented by the indicator, as one would do if flying an airplane in a crosswind. This enhancement reduces spatial aiming error in the first 10 minutes of practice by an average of 70 percent when compared to a no enhancement control condition. Moreover, it produces adaptation aftereffect, which is evidence of learning by neural adaptation rather than by mental strategy. Finally, aiming error does not rise upon removal of the explicit cue.

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

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

Nelson, W.R.

1999-01-01

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

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

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

Nelson, W.R.

1998-09-01

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

Seasonal prediction of Indian summer monsoon rainfall in NCEP CFSv2: forecast and predictability error

NASA Astrophysics Data System (ADS)

Pokhrel, Samir; Saha, Subodh Kumar; Dhakate, Ashish; Rahman, Hasibur; Chaudhari, Hemantkumar S.; Salunke, Kiran; Hazra, Anupam; Sujith, K.; Sikka, D. R.

2016-04-01

A detailed analysis of sensitivity to the initial condition for the simulation of the Indian summer monsoon using retrospective forecast by the latest version of the Climate Forecast System version-2 (CFSv2) is carried out. This study primarily focuses on the tropical region of Indian and Pacific Ocean basin, with special emphasis on the Indian land region. The simulated seasonal mean and the inter-annual standard deviations of rainfall, upper and lower level atmospheric circulations and Sea Surface Temperature (SST) tend to be more skillful as the lead forecast time decreases (5 month lead to 0 month lead time i.e. L5-L0). In general spatial correlation (bias) increases (decreases) as forecast lead time decreases. This is further substantiated by their averaged value over the selected study regions over the Indian and Pacific Ocean basins. The tendency of increase (decrease) of model bias with increasing (decreasing) forecast lead time also indicates the dynamical drift of the model. Large scale lower level circulation (850 hPa) shows enhancement of anomalous westerlies (easterlies) over the tropical region of the Indian Ocean (Western Pacific Ocean), which indicates the enhancement of model error with the decrease in lead time. At the upper level circulation (200 hPa) biases in both tropical easterly jet and subtropical westerlies jet tend to decrease as the lead time decreases. Despite enhancement of the prediction skill, mean SST bias seems to be insensitive to the initialization. All these biases are significant and together they make CFSv2 vulnerable to seasonal uncertainties in all the lead times. Overall the zeroth lead (L0) seems to have the best skill, however, in case of Indian summer monsoon rainfall (ISMR), the 3 month lead forecast time (L3) has the maximum ISMR prediction skill. This is valid using different independent datasets, wherein these maximum skill scores are 0.64, 0.42 and 0.57 with respect to the Global Precipitation Climatology Project, CPC Merged Analysis of Precipitation and the India Meteorological Department precipitation dataset respectively for L3. Despite significant El-Niño Southern Oscillation (ENSO) spring predictability barrier at L3, the ISMR skill score is highest at L3. Further, large scale zonal wind shear (Webster-Yang index) and SST over Niño3.4 region is best at L1 and L0. This implies that predictability aspect of ISMR is controlled by factors other than ENSO and Indian Ocean Dipole. Also, the model error (forecast error) outruns the error acquired by the inadequacies in the initial conditions (predictability error). Thus model deficiency is having more serious consequences as compared to the initial condition error for the seasonal forecast. All the model parameters show the increase in the predictability error as the lead decreases over the equatorial eastern Pacific basin and peaks at L2, then it further decreases. The dynamical consistency of both the forecast and the predictability error among all the variables indicates that these biases are purely systematic in nature and improvement of the physical processes in the CFSv2 may enhance the overall predictability.

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.

Taking the Error Term of the Factor Model into Account: The Factor Score Predictor Interval

ERIC Educational Resources Information Center

Beauducel, Andre

2013-01-01

The problem of factor score indeterminacy implies that the factor and the error scores cannot be completely disentangled in the factor model. It is therefore proposed to compute Harman's factor score predictor that contains an additive combination of factor and error variance. This additive combination is discussed in the framework of classical…

Visual error augmentation enhances learning in three dimensions.

PubMed

Sharp, Ian; Huang, Felix; Patton, James

2011-09-02

Because recent preliminary evidence points to the use of Error augmentation (EA) for motor learning enhancements, we visually enhanced deviations from a straight line path while subjects practiced a sensorimotor reversal task, similar to laparoscopic surgery. Our study asked 10 healthy subjects in two groups to perform targeted reaching in a simulated virtual reality environment, where the transformation of the hand position matrix was a complete reversal--rotated 180 degrees about an arbitrary axis (hence 2 of the 3 coordinates are reversed). Our data showed that after 500 practice trials, error-augmented-trained subjects reached the desired targets more quickly and with lower error (differences of 0.4 seconds and 0.5 cm Maximum Perpendicular Trajectory deviation) when compared to the control group. Furthermore, the manner in which subjects practiced was influenced by the error augmentation, resulting in more continuous motions for this group and smaller errors. Even with the extreme sensory discordance of a reversal, these data further support that distorted reality can promote more complete adaptation/learning when compared to regular training. Lastly, upon removing the flip all subjects quickly returned to baseline rapidly within 6 trials.

Factor Rotation and Standard Errors in Exploratory Factor Analysis

ERIC Educational Resources Information Center

Zhang, Guangjian; Preacher, Kristopher J.

2015-01-01

In this article, we report a surprising phenomenon: Oblique CF-varimax and oblique CF-quartimax rotation produced similar point estimates for rotated factor loadings and factor correlations but different standard error estimates in an empirical example. Influences of factor rotation on asymptotic standard errors are investigated using a numerical…

Quantum illumination for enhanced detection of Rayleigh-fading targets

NASA Astrophysics Data System (ADS)

Zhuang, Quntao; Zhang, Zheshen; Shapiro, Jeffrey H.

2017-08-01

Quantum illumination (QI) is an entanglement-enhanced sensing system whose performance advantage over a comparable classical system survives its usage in an entanglement-breaking scenario plagued by loss and noise. In particular, QI's error-probability exponent for discriminating between equally likely hypotheses of target absence or presence is 6 dB higher than that of the optimum classical system using the same transmitted power. This performance advantage, however, presumes that the target return, when present, has known amplitude and phase, a situation that seldom occurs in light detection and ranging (lidar) applications. At lidar wavelengths, most target surfaces are sufficiently rough that their returns are speckled, i.e., they have Rayleigh-distributed amplitudes and uniformly distributed phases. QI's optical parametric amplifier receiver—which affords a 3 dB better-than-classical error-probability exponent for a return with known amplitude and phase—fails to offer any performance gain for Rayleigh-fading targets. We show that the sum-frequency generation receiver [Zhuang et al., Phys. Rev. Lett. 118, 040801 (2017), 10.1103/PhysRevLett.118.040801]—whose error-probability exponent for a nonfading target achieves QI's full 6 dB advantage over optimum classical operation—outperforms the classical system for Rayleigh-fading targets. In this case, QI's advantage is subexponential: its error probability is lower than the classical system's by a factor of 1 /ln(M κ ¯NS/NB) , when M κ ¯NS/NB≫1 , with M ≫1 being the QI transmitter's time-bandwidth product, NS≪1 its brightness, κ ¯ the target return's average intensity, and NB the background light's brightness.

On a more rigorous gravity field processing for future LL-SST type gravity satellite missions

NASA Astrophysics Data System (ADS)

Daras, I.; Pail, R.; Murböck, M.

2013-12-01

In order to meet the augmenting demands of the user community concerning accuracies of temporal gravity field models, future gravity missions of low-low satellite-to-satellite tracking (LL-SST) type are planned to carry more precise sensors than their precedents. A breakthrough is planned with the improved LL-SST measurement link, where the traditional K-band microwave instrument of 1μm accuracy will be complemented by an inter-satellite ranging instrument of several nm accuracy. This study focuses on investigations concerning the potential performance of the new sensors and their impact in gravity field solutions. The processing methods for gravity field recovery have to meet the new sensor standards and be able to take full advantage of the new accuracies that they provide. We use full-scale simulations in a realistic environment to investigate whether the standard processing techniques suffice to fully exploit the new sensors standards. We achieve that by performing full numerical closed-loop simulations based on the Integral Equation approach. In our simulation scheme, we simulate dynamic orbits in a conventional tracking analysis to compute pseudo inter-satellite ranges or range-rates that serve as observables. Each part of the processing is validated separately with special emphasis on numerical errors and their impact in gravity field solutions. We demonstrate that processing with standard precision may be a limiting factor for taking full advantage of new generation sensors that future satellite missions will carry. Therefore we have created versions of our simulator with enhanced processing precision with primarily aim to minimize round-off system errors. Results using the enhanced precision show a big reduction of system errors that were present at the standard precision processing even for the error-free scenario, and reveal the improvements the new sensors will bring into the gravity field solutions. As a next step, we analyze the contribution of individual error sources to the system's error budget. More specifically we analyze sensor noise from the laser interferometer and the accelerometers, errors in the kinematic orbits and the background fields as well as temporal and spatial aliasing errors. We give special care on the assessment of error sources with stochastic behavior, such as the laser interferometer and the accelerometers, and their consistent stochastic modeling in frame of the adjustment process.

Oscillating-flow regenerator test rig: Woven screen and metal felt results

NASA Technical Reports Server (NTRS)

Gedeon, D.; Wood, J. G.

1992-01-01

We present correlating expressions, in terms of Reynolds or Peclet numbers, for friction factors, Nusselt numbers, enhanced axial conduction ratios, and overall heat flux ratios in four porous regenerator samples representative of stirling cycle regenerators: two woven screen samples and two random wire samples. Error estimates and comparison of data with others suggest our correlations are reliable, but we need to test more samples over a range of porosities before our results will become generally useful.

Using hyperentanglement to enhance resolution, signal-to-noise ratio, and measurement time

NASA Astrophysics Data System (ADS)

Smith, James F.

2017-03-01

A hyperentanglement-based atmospheric imaging/detection system involving only a signal and an ancilla photon will be considered for optical and infrared frequencies. Only the signal photon will propagate in the atmosphere and its loss will be classical. The ancilla photon will remain within the sensor experiencing low loss. Closed form expressions for the wave function, normalization, density operator, reduced density operator, symmetrized logarithmic derivative, quantum Fisher information, quantum Cramer-Rao lower bound, coincidence probabilities, probability of detection, probability of false alarm, probability of error after M measurements, signal-to-noise ratio, quantum Chernoff bound, time-on-target expressions related to probability of error, and resolution will be provided. The effect of noise in every mode will be included as well as loss. The system will provide the basic design for an imaging/detection system functioning at optical or infrared frequencies that offers better than classical angular and range resolution. Optimization for enhanced resolution will be included. The signal-to-noise ratio will be increased by a factor equal to the number of modes employed during the hyperentanglement process. Likewise, the measurement time can be reduced by the same factor. The hyperentanglement generator will typically make use of entanglement in polarization, energy-time, orbital angular momentum and so on. Mathematical results will be provided describing the system's performance as a function of loss mechanisms and noise.

Facilitating a just and trusting culture.

PubMed

Pattison, Jill; Kline, Theresa

2015-01-01

The purpose of this paper is to identify managerial and organizational characteristics and behaviors that facilitate the fostering of a just and trusting culture within the healthcare system. Two studies were conducted. The initial qualitative one was used to identify themes based on interviews with health care workers that facilitate a just and trusting culture. The quantitative one used a policy-capturing design to determine which factors were most likely to predict outcomes of manager and organizational trust. The factors of violation type (ability vs integrity), providing an explanation or not, blame vs no blame by manager, and blame vs no blame by organization were all significant predictors of perceptions of trust. Limitations to the generalizability of findings included both a small and non-representative sample from one health care region. The present findings can be useful in developing training systems for managers and organizational executive teams for managing medical error events in a manner that will help develop a just and trusting culture. A just and trusting culture should enhance the likelihood of reporting medical errors. Improved reporting, in turn, should enhance patient safety. This is the first field study experimentally manipulating aspects of organizational trust within the health care sector. The use of policy-capturing is a unique feature that sheds light into the decision-making of health care workers as to the efficaciousness of particular managerial and organizational characteristics that impact a just and trusting culture.

Dynamical decoupling of local transverse random telegraph noise in a two-qubit gate

NASA Astrophysics Data System (ADS)

D'Arrigo, A.; Falci, G.; Paladino, E.

2015-10-01

Achieving high-fidelity universal two-qubit gates is a central requisite of any implementation of quantum information processing. The presence of spurious fluctuators of various physical origin represents a limiting factor for superconducting nanodevices. Operating qubits at optimal points, where the qubit-fluctuator interaction is transverse with respect to the single qubit Hamiltonian, considerably improved single qubit gates. Further enhancement has been achieved by dynamical decoupling (DD). In this article we investigate DD of transverse random telegraph noise acting locally on each of the qubits forming an entangling gate. Our analysis is based on the exact numerical solution of the stochastic Schrödinger equation. We evaluate the gate error under local periodic, Carr-Purcell and Uhrig DD sequences. We find that a threshold value of the number, n, of pulses exists above which the gate error decreases with a sequence-specific power-law dependence on n. Below threshold, DD may even increase the error with respect to the unconditioned evolution, a behaviour reminiscent of the anti-Zeno effect.

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

PubMed

Hwang, Jee-In; Park, Hyeoun-Ae

2017-12-01

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

Error-Related Psychophysiology and Negative Affect

ERIC Educational Resources Information Center

Hajcak, G.; McDonald, N.; Simons, R.F.

2004-01-01

The error-related negativity (ERN/Ne) and error positivity (Pe) have been associated with error detection and response monitoring. More recently, heart rate (HR) and skin conductance (SC) have also been shown to be sensitive to the internal detection of errors. An enhanced ERN has consistently been observed in anxious subjects and there is some…

Surgical specimen handover from the operating theatre to laboratory-Can we improve patient safety by learning from aviation and other high-risk organisations?

PubMed

Brennan, Peter A; Brands, Marieke T; Caldwell, Lucy; Fonseca, Felipe Paiva; Turley, Nic; Foley, Susie; Rahimi, Siavash

2018-02-01

Essential communication between healthcare staff is considered one of the key requirements for both safety and quality care when patients are handed over from one clinical area to other. This is particularly important in environments such as the operating theatre and intensive care where mistakes can be devastating. Health care has learned from other high-risk organisations (HRO) such as aviation where the use of checklists and human factors awareness has virtually eliminated human error and mistakes. To our knowledge, little has been published around ways to improve pathology specimen handover following surgery, with pathology request forms often conveying the bare minimum of information to assist the laboratory staff. Furthermore, the request form might not warn staff about potential hazards. In this article, we provide a brief summary of the factors involved in human error and introduce a novel checklist that can be readily completed at the same time as the routine pathology request form. This additional measure enhances safety, can help to reduce processing and mislabelling errors and provides essential information in a structured way assisting both laboratory staff and pathologists when handling head and neck surgical specimens. © 2017 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.

An Enhanced Non-Coherent Pre-Filter Design for Tracking Error Estimation in GNSS Receivers.

PubMed

Luo, Zhibin; Ding, Jicheng; Zhao, Lin; Wu, Mouyan

2017-11-18

Tracking error estimation is of great importance in global navigation satellite system (GNSS) receivers. Any inaccurate estimation for tracking error will decrease the signal tracking ability of signal tracking loops and the accuracies of position fixing, velocity determination, and timing. Tracking error estimation can be done by traditional discriminator, or Kalman filter-based pre-filter. The pre-filter can be divided into two categories: coherent and non-coherent. This paper focuses on the performance improvements of non-coherent pre-filter. Firstly, the signal characteristics of coherent and non-coherent integration-which are the basis of tracking error estimation-are analyzed in detail. After that, the probability distribution of estimation noise of four-quadrant arctangent (ATAN2) discriminator is derived according to the mathematical model of coherent integration. Secondly, the statistical property of observation noise of non-coherent pre-filter is studied through Monte Carlo simulation to set the observation noise variance matrix correctly. Thirdly, a simple fault detection and exclusion (FDE) structure is introduced to the non-coherent pre-filter design, and thus its effective working range for carrier phase error estimation extends from (-0.25 cycle, 0.25 cycle) to (-0.5 cycle, 0.5 cycle). Finally, the estimation accuracies of discriminator, coherent pre-filter, and the enhanced non-coherent pre-filter are evaluated comprehensively through the carefully designed experiment scenario. The pre-filter outperforms traditional discriminator in estimation accuracy. In a highly dynamic scenario, the enhanced non-coherent pre-filter provides accuracy improvements of 41.6%, 46.4%, and 50.36% for carrier phase error, carrier frequency error, and code phase error estimation, respectively, when compared with coherent pre-filter. The enhanced non-coherent pre-filter outperforms the coherent pre-filter in code phase error estimation when carrier-to-noise density ratio is less than 28.8 dB-Hz, in carrier frequency error estimation when carrier-to-noise density ratio is less than 20 dB-Hz, and in carrier phase error estimation when carrier-to-noise density belongs to (15, 23) dB-Hz ∪ (26, 50) dB-Hz.

An Enhanced Non-Coherent Pre-Filter Design for Tracking Error Estimation in GNSS Receivers

PubMed Central

Luo, Zhibin; Ding, Jicheng; Zhao, Lin; Wu, Mouyan

2017-01-01

Tracking error estimation is of great importance in global navigation satellite system (GNSS) receivers. Any inaccurate estimation for tracking error will decrease the signal tracking ability of signal tracking loops and the accuracies of position fixing, velocity determination, and timing. Tracking error estimation can be done by traditional discriminator, or Kalman filter-based pre-filter. The pre-filter can be divided into two categories: coherent and non-coherent. This paper focuses on the performance improvements of non-coherent pre-filter. Firstly, the signal characteristics of coherent and non-coherent integration—which are the basis of tracking error estimation—are analyzed in detail. After that, the probability distribution of estimation noise of four-quadrant arctangent (ATAN2) discriminator is derived according to the mathematical model of coherent integration. Secondly, the statistical property of observation noise of non-coherent pre-filter is studied through Monte Carlo simulation to set the observation noise variance matrix correctly. Thirdly, a simple fault detection and exclusion (FDE) structure is introduced to the non-coherent pre-filter design, and thus its effective working range for carrier phase error estimation extends from (−0.25 cycle, 0.25 cycle) to (−0.5 cycle, 0.5 cycle). Finally, the estimation accuracies of discriminator, coherent pre-filter, and the enhanced non-coherent pre-filter are evaluated comprehensively through the carefully designed experiment scenario. The pre-filter outperforms traditional discriminator in estimation accuracy. In a highly dynamic scenario, the enhanced non-coherent pre-filter provides accuracy improvements of 41.6%, 46.4%, and 50.36% for carrier phase error, carrier frequency error, and code phase error estimation, respectively, when compared with coherent pre-filter. The enhanced non-coherent pre-filter outperforms the coherent pre-filter in code phase error estimation when carrier-to-noise density ratio is less than 28.8 dB-Hz, in carrier frequency error estimation when carrier-to-noise density ratio is less than 20 dB-Hz, and in carrier phase error estimation when carrier-to-noise density belongs to (15, 23) dB-Hz ∪ (26, 50) dB-Hz. PMID:29156581

How Angular Velocity Features and Different Gyroscope Noise Types Interact and Determine Orientation Estimation Accuracy.

PubMed

Pasciuto, Ilaria; Ligorio, Gabriele; Bergamini, Elena; Vannozzi, Giuseppe; Sabatini, Angelo Maria; Cappozzo, Aurelio

2015-09-18

In human movement analysis, 3D body segment orientation can be obtained through the numerical integration of gyroscope signals. These signals, however, are affected by errors that, for the case of micro-electro-mechanical systems, are mainly due to: constant bias, scale factor, white noise, and bias instability. The aim of this study is to assess how the orientation estimation accuracy is affected by each of these disturbances, and whether it is influenced by the angular velocity magnitude and 3D distribution across the gyroscope axes. Reference angular velocity signals, either constant or representative of human walking, were corrupted with each of the four noise types within a simulation framework. The magnitude of the angular velocity affected the error in the orientation estimation due to each noise type, except for the white noise. Additionally, the error caused by the constant bias was also influenced by the angular velocity 3D distribution. As the orientation error depends not only on the noise itself but also on the signal it is applied to, different sensor placements could enhance or mitigate the error due to each disturbance, and special attention must be paid in providing and interpreting measures of accuracy for orientation estimation algorithms.

How Angular Velocity Features and Different Gyroscope Noise Types Interact and Determine Orientation Estimation Accuracy

PubMed Central

Pasciuto, Ilaria; Ligorio, Gabriele; Bergamini, Elena; Vannozzi, Giuseppe; Sabatini, Angelo Maria; Cappozzo, Aurelio

2015-01-01

In human movement analysis, 3D body segment orientation can be obtained through the numerical integration of gyroscope signals. These signals, however, are affected by errors that, for the case of micro-electro-mechanical systems, are mainly due to: constant bias, scale factor, white noise, and bias instability. The aim of this study is to assess how the orientation estimation accuracy is affected by each of these disturbances, and whether it is influenced by the angular velocity magnitude and 3D distribution across the gyroscope axes. Reference angular velocity signals, either constant or representative of human walking, were corrupted with each of the four noise types within a simulation framework. The magnitude of the angular velocity affected the error in the orientation estimation due to each noise type, except for the white noise. Additionally, the error caused by the constant bias was also influenced by the angular velocity 3D distribution. As the orientation error depends not only on the noise itself but also on the signal it is applied to, different sensor placements could enhance or mitigate the error due to each disturbance, and special attention must be paid in providing and interpreting measures of accuracy for orientation estimation algorithms. PMID:26393606

Improving Exercise Performance with an Accelerometer-Based Smartphone App: A Randomized Controlled Trial.

PubMed

Bittel, Daniel C; Bittel, Adam J; Williams, Christine; Elazzazi, Ashraf

2017-05-01

Proper exercise form is critical for the safety and efficacy of therapeutic exercise. This research examines if a novel smartphone application, designed to monitor and provide real-time corrections during resistance training, can reduce performance errors and elicit a motor learning response. Forty-two participants aged 18 to 65 years were randomly assigned to treatment and control groups. Both groups were tested for the number of movement errors made during a 10-repetition set completed at baseline, immediately after, and 1 to 2 weeks after a single training session of knee extensions. The treatment group trained with real-time, smartphone-generated feedback, whereas the control subjects did not. Group performance (number of errors) was compared across test sets using a 2-factor mixed-model analysis of variance. No differences were observed between groups for age, sex, or resistance training experience. There was a significant interaction between test set and group. The treatment group demonstrated fewer errors on posttests 1 and 2 compared with pretest (P < 0.05). There was no reduction in the number of errors on any posttest for control subjects. Smartphone apps, such as the one used in this study, may enhance patient supervision, safety, and exercise efficacy across rehabilitation settings. A single training session with the app promoted motor learning and improved exercise performance.

Evaluating a medical error taxonomy.

PubMed

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

2002-01-01

Healthcare has been slow in using human factors principles to reduce medical errors. The Center for Devices and Radiological Health (CDRH) recognizes that a lack of attention to human factors during product development may lead to errors that have the potential for patient injury, or even death. In response to the need for reducing medication errors, the National Coordinating Council for Medication Errors Reporting and Prevention (NCC MERP) released the NCC MERP taxonomy that provides a standard language for reporting medication errors. This project maps the NCC MERP taxonomy of medication error to MedWatch medical errors involving infusion pumps. Of particular interest are human factors associated with medical device errors. The NCC MERP taxonomy of medication errors is limited in mapping information from MEDWATCH because of the focus on the medical device and the format of reporting.

Risk Factors for Increased Severity of Paediatric Medication Administration Errors

PubMed Central

Sears, Kim; Goodman, William M.

2012-01-01

Patients' risks from medication errors are widely acknowledged. Yet not all errors, if they occur, have the same risks for severe consequences. Facing resource constraints, policy makers could prioritize factors having the greatest severe–outcome risks. This study assists such prioritization by identifying work-related risk factors most clearly associated with more severe consequences. Data from three Canadian paediatric centres were collected, without identifiers, on actual or potential errors that occurred. Three hundred seventy-two errors were reported, with outcome severities ranging from time delays up to fatalities. Four factors correlated significantly with increased risk for more severe outcomes: insufficient training; overtime; precepting a student; and off-service patient. Factors' impacts on severity also vary with error class: for wrong-time errors, the factors precepting a student or working overtime significantly increase severe-outcomes risk. For other types, caring for an off-service patient has greatest severity risk. To expand such research, better standardization is needed for categorizing outcome severities. PMID:23968607

Error Estimation of An Ensemble Statistical Seasonal Precipitation Prediction Model

NASA Technical Reports Server (NTRS)

Shen, Samuel S. P.; Lau, William K. M.; Kim, Kyu-Myong; Li, Gui-Long

2001-01-01

This NASA Technical Memorandum describes an optimal ensemble canonical correlation forecasting model for seasonal precipitation. Each individual forecast is based on the canonical correlation analysis (CCA) in the spectral spaces whose bases are empirical orthogonal functions (EOF). The optimal weights in the ensemble forecasting crucially depend on the mean square error of each individual forecast. An estimate of the mean square error of a CCA prediction is made also using the spectral method. The error is decomposed onto EOFs of the predictand and decreases linearly according to the correlation between the predictor and predictand. Since new CCA scheme is derived for continuous fields of predictor and predictand, an area-factor is automatically included. Thus our model is an improvement of the spectral CCA scheme of Barnett and Preisendorfer. The improvements include (1) the use of area-factor, (2) the estimation of prediction error, and (3) the optimal ensemble of multiple forecasts. The new CCA model is applied to the seasonal forecasting of the United States (US) precipitation field. The predictor is the sea surface temperature (SST). The US Climate Prediction Center's reconstructed SST is used as the predictor's historical data. The US National Center for Environmental Prediction's optimally interpolated precipitation (1951-2000) is used as the predictand's historical data. Our forecast experiments show that the new ensemble canonical correlation scheme renders a reasonable forecasting skill. For example, when using September-October-November SST to predict the next season December-January-February precipitation, the spatial pattern correlation between the observed and predicted are positive in 46 years among the 50 years of experiments. The positive correlations are close to or greater than 0.4 in 29 years, which indicates excellent performance of the forecasting model. The forecasting skill can be further enhanced when several predictors are used.

Student Self-Assessment and Faculty Assessment of Performance in an Interprofessional Error Disclosure Simulation Training Program.

PubMed

Poirier, Therese I; Pailden, Junvie; Jhala, Ray; Ronald, Katie; Wilhelm, Miranda; Fan, Jingyang

2017-04-01

Objectives. To conduct a prospective evaluation for effectiveness of an error disclosure assessment tool and video recordings to enhance student learning and metacognitive skills while assessing the IPEC competencies. Design. The instruments for assessing performance (planning, communication, process, and team dynamics) in interprofessional error disclosure were developed. Student self-assessment of performance before and after viewing the recordings of their encounters were obtained. Faculty used a similar instrument to conduct real-time assessments. An instrument to assess achievement of the Interprofessional Education Collaborative (IPEC) core competencies was developed. Qualitative data was reviewed to determine student and faculty perceptions of the simulation. Assessment. The interprofessional simulation training involved a total of 233 students (50 dental, 109 nursing and 74 pharmacy). Use of video recordings made a significant difference in student self-assessment for communication and process categories of error disclosure. No differences in student self-assessments were noted among the different professions. There were differences among the family member affects for planning and communication for both pre-video and post-video data. There were significant differences between student self-assessment and faculty assessment for all paired comparisons, except communication in student post-video self-assessment. Students' perceptions of achievement of the IPEC core competencies were positive. Conclusion. The use of assessment instruments and video recordings may have enhanced students' metacognitive skills for assessing performance in interprofessional error disclosure. The simulation training was effective in enhancing perceptions on achievement of IPEC core competencies. This enhanced assessment process appeared to enhance learning about the skills needed for interprofessional error disclosure.

Test-Enhanced Learning in Competence-Based Predoctoral Orthodontics: A Four-Year Study.

PubMed

Freda, Nicolas M; Lipp, Mitchell J

2016-03-01

Dental educators intend to promote integration of knowledge, skills, and values toward professional competence. Studies report that retrieval, in the form of testing, results in better learning with retention than traditional studying. The aim of this study was to evaluate test-enhanced experiences on demonstrations of competence in diagnosis and management of malocclusion and skeletal problems. The study participants were all third-year dental students (2011 N=88, 2012 N=74, 2013 N=91, 2014 N=85) at New York University College of Dentistry. The 2013 and 2014 groups received the test-enhanced method emphasizing formative assessments with written and dialogic delayed feedback, while the 2011 and 2012 groups received the traditional approach emphasizing lectures and classroom exercises. The students received six two-hour sessions, spaced one week apart. At the final session, a summative assessment consisting of the same four cases was administered. Students constructed a problem list, treatment objectives, and a treatment plan for each case, scored according to the same criteria. Grades were based on the number of cases without critical errors: A=0 critical errors on four cases, A-=0 critical errors on three cases, B+=0 critical errors on two cases, B=0 critical errors on one case, F=critical errors on four cases. Performance grades were categorized as high quality (B+, A-, A) and low quality (F, B). The results showed that the test-enhanced groups demonstrated statistically significant benefits at 95% confidence intervals compared to the traditional groups when comparing low- and high-quality grades. These performance trends support the continued use of the test-enhanced approach.

Student Self-Assessment and Faculty Assessment of Performance in an Interprofessional Error Disclosure Simulation Training Program

PubMed Central

Pailden, Junvie; Jhala, Ray; Ronald, Katie; Wilhelm, Miranda; Fan, Jingyang

2017-01-01

Objectives. To conduct a prospective evaluation for effectiveness of an error disclosure assessment tool and video recordings to enhance student learning and metacognitive skills while assessing the IPEC competencies. Design. The instruments for assessing performance (planning, communication, process, and team dynamics) in interprofessional error disclosure were developed. Student self-assessment of performance before and after viewing the recordings of their encounters were obtained. Faculty used a similar instrument to conduct real-time assessments. An instrument to assess achievement of the Interprofessional Education Collaborative (IPEC) core competencies was developed. Qualitative data was reviewed to determine student and faculty perceptions of the simulation. Assessment. The interprofessional simulation training involved a total of 233 students (50 dental, 109 nursing and 74 pharmacy). Use of video recordings made a significant difference in student self-assessment for communication and process categories of error disclosure. No differences in student self-assessments were noted among the different professions. There were differences among the family member affects for planning and communication for both pre-video and post-video data. There were significant differences between student self-assessment and faculty assessment for all paired comparisons, except communication in student post-video self-assessment. Students’ perceptions of achievement of the IPEC core competencies were positive. Conclusion. The use of assessment instruments and video recordings may have enhanced students’ metacognitive skills for assessing performance in interprofessional error disclosure. The simulation training was effective in enhancing perceptions on achievement of IPEC core competencies. This enhanced assessment process appeared to enhance learning about the skills needed for interprofessional error disclosure. PMID:28496274

Informal learning from error in hospitals: what do we learn, how do we learn and how can informal learning be enhanced? A narrative review.

PubMed

de Feijter, Jeantine M; de Grave, Willem S; Koopmans, Richard P; Scherpbier, Albert J J A

2013-10-01

Learning from error is not just an individual endeavour. Organisations also learn from error. Hospitals provide many learning opportunities, which can be formal or informal. Informal learning from error in hospitals has not been researched in much depth so this narrative review focuses on five learning opportunities: morbidity and mortality conferences, incident reporting systems, patient claims and complaints, chart review and prospective risk analysis. For each of them we describe: (1) what can be learnt, categorised according to the seven CanMEDS competencies; (2) how it is possible to learn from them, analysed against a model of informal and incidental learning; and (3) how this learning can be enhanced. All CanMEDS competencies could be enhanced, but there was a particular focus on the roles of medical expert and manager. Informal learning occurred mostly through reflection and action and was often linked to the learning of others. Most important to enhance informal learning from these learning opportunities was the realisation of a climate of collaboration and trust. Possible new directions for future research on informal learning from error in hospitals might focus on ways to measure informal learning and the balance between formal and informal learning. Finally, 12 recommendations about how hospitals could enhance informal learning within their organisation are given.

Combined line-of-sight error and angular position to generate feedforward control for a charge-coupled device-based tracking loop

NASA Astrophysics Data System (ADS)

Tang, Tao; Cai, Huaxiang; Huang, Yongmei; Ren, Ge

2015-10-01

A feedforward control based on data fusion is proposed to enhance closed-loop performance. The target trajectory as the observed value of a Kalman filter is recovered by synthesizing line-of-sight error and angular position from the encoder. A Kalman filter based on a Singer acceleration model is employed to estimate the target velocity. In this control scheme, the control stability is influenced by the bandwidth of the Kalman filter and time misalignment. The transfer function of the Kalman filter in the frequency domain is built for analyzing the closed loop stability, which shows that the Kalman filter is the major factor that affects the control stability. The feedforward control proposed here is verified through simulations and experiments.

The use of a contextual, modal and psychological classification of medication errors in the emergency department: a retrospective descriptive study.

PubMed

Cabilan, C J; Hughes, James A; Shannon, Carl

2017-12-01

To describe the contextual, modal and psychological classification of medication errors in the emergency department to know the factors associated with the reported medication errors. The causes of medication errors are unique in every clinical setting; hence, error minimisation strategies are not always effective. For this reason, it is fundamental to understand the causes specific to the emergency department so that targeted strategies can be implemented. Retrospective analysis of reported medication errors in the emergency department. All voluntarily staff-reported medication-related incidents from 2010-2015 from the hospital's electronic incident management system were retrieved for analysis. Contextual classification involved the time, place and the type of medications involved. Modal classification pertained to the stage and issue (e.g. wrong medication, wrong patient). Psychological classification categorised the errors in planning (knowledge-based and rule-based errors) and skill (slips and lapses). There were 405 errors reported. Most errors occurred in the acute care area, short-stay unit and resuscitation area, during the busiest shifts (0800-1559, 1600-2259). Half of the errors involved high-alert medications. Many of the errors occurred during administration (62·7%), prescribing (28·6%) and commonly during both stages (18·5%). Wrong dose, wrong medication and omission were the issues that dominated. Knowledge-based errors characterised the errors that occurred in prescribing and administration. The highest proportion of slips (79·5%) and lapses (76·1%) occurred during medication administration. It is likely that some of the errors occurred due to the lack of adherence to safety protocols. Technology such as computerised prescribing, barcode medication administration and reminder systems could potentially decrease the medication errors in the emergency department. There was a possibility that some of the errors could be prevented if safety protocols were adhered to, which highlights the need to also address clinicians' attitudes towards safety. Technology can be implemented to help minimise errors in the ED, but this must be coupled with efforts to enhance the culture of safety. © 2017 John Wiley & Sons Ltd.

Mismeasurement and the resonance of strong confounders: correlated errors.

PubMed

Marshall, J R; Hastrup, J L; Ross, J S

1999-07-01

Confounding in epidemiology, and the limits of standard methods of control for an imperfectly measured confounder, have been understood for some time. However, most treatments of this problem are based on the assumption that errors of measurement in confounding and confounded variables are independent. This paper considers the situation in which a strong risk factor (confounder) and an inconsequential but suspected risk factor (confounded) are each measured with errors that are correlated; the situation appears especially likely to occur in the field of nutritional epidemiology. Error correlation appears to add little to measurement error as a source of bias in estimating the impact of a strong risk factor: it can add to, diminish, or reverse the bias induced by measurement error in estimating the impact of the inconsequential risk factor. Correlation of measurement errors can add to the difficulty involved in evaluating structures in which confounding and measurement error are present. In its presence, observed correlations among risk factors can be greater than, less than, or even opposite to the true correlations. Interpretation of multivariate epidemiologic structures in which confounding is likely requires evaluation of measurement error structures, including correlations among measurement errors.

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

NASA Astrophysics Data System (ADS)

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

2018-05-01

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

The Infinitesimal Jackknife with Exploratory Factor Analysis

ERIC Educational Resources Information Center

Zhang, Guangjian; Preacher, Kristopher J.; Jennrich, Robert I.

2012-01-01

The infinitesimal jackknife, a nonparametric method for estimating standard errors, has been used to obtain standard error estimates in covariance structure analysis. In this article, we adapt it for obtaining standard errors for rotated factor loadings and factor correlations in exploratory factor analysis with sample correlation matrices. Both…

Visuomotor adaptability in older adults with mild cognitive decline.

PubMed

Schaffert, Jeffrey; Lee, Chi-Mei; Neill, Rebecca; Bo, Jin

2017-02-01

The current study examined the augmentation of error feedback on visuomotor adaptability in older adults with varying degrees of cognitive decline (assessed by the Montreal Cognitive Assessment; MoCA). Twenty-three participants performed a center-out computerized visuomotor adaptation task when the visual feedback of their hand movement error was presented in a regular (ratio=1:1) or enhanced (ratio=1:2) error feedback schedule. Results showed that older adults with lower scores on the MoCA had less adaptability than those with higher MoCA scores during the regular feedback schedule. However, participants demonstrated similar adaptability during the enhanced feedback schedule, regardless of their cognitive ability. Furthermore, individuals with lower MoCA scores showed larger after-effects in spatial control during the enhanced schedule compared to the regular schedule, whereas individuals with higher MoCA scores displayed the opposite pattern. Additional neuro-cognitive assessments revealed that spatial working memory and processing speed were positively related to motor adaptability during the regular scheduled but negatively related to adaptability during the enhanced schedule. We argue that individuals with mild cognitive decline employed different adaptation strategies when encountering enhanced visual feedback, suggesting older adults with mild cognitive impairment (MCI) may benefit from enhanced visual error feedback during sensorimotor adaptation. Copyright © 2016 Elsevier B.V. All rights reserved.

Field Tolerances for the Triplet Quadrupoles of the LHC High Luminosity Lattice

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

Nosochkov, Yuri; Cai, Y.; Jiao, Y.

2012-06-25

It has been proposed to implement the so-called Achromatic Telescopic Squeezing (ATS) scheme in the LHC high luminosity (HL) lattice to reduce beta functions at the Interaction Points (IP) up to a factor of 8. As a result, the nominal 4.5 km peak beta functions reached in the Inner Triplets (IT) at collision will be increased by the same factor. This, therefore, justifies the installation of new, larger aperture, superconducting IT quadrupoles. The higher beta functions will enhance the effects of the triplet quadrupole field errors leading to smaller beam dynamic aperture (DA). To maintain the acceptable DA, the effectsmore » of the triplet field errors must be re-evaluated, thus specifying new tolerances. Such a study has been performed for the so-called '4444' collision option of the HL-LHC layout version SLHCV3.01, where the IP beta functions are reduced by a factor of 4 in both planes with respect to a pre-squeezed value of 60 cm at two collision points. The dynamic aperture calculations were performed using SixTrack. The impact on the triplet field quality is presented.« less

An Energy Saving Green Plug Device for Nonlinear Loads

NASA Astrophysics Data System (ADS)

Bloul, Albe; Sharaf, Adel; El-Hawary, Mohamed

2018-03-01

The paper presents a low cost a FACTS Based flexible fuzzy logic based modulated/switched tuned arm filter and Green Plug compensation (SFC-GP) scheme for single-phase nonlinear loads ensuring both voltage stabilization and efficient energy utilization. The new Green Plug-Switched filter compensator SFC modulated LC-Filter PWM Switched Capacitive Compensation Devices is controlled using a fuzzy logic regulator to enhance power quality, improve power factor at the source and reduce switching transients and inrush current conditions as well harmonic contents in source current. The FACTS based SFC-GP Device is a member of family of Green Plug/Filters/Compensation Schemes used for efficient energy utilization, power quality enhancement and voltage/inrush current/soft starting control using a dynamic error driven fuzzy logic controller (FLC). The device with fuzzy logic controller is validated using the Matlab / Simulink Software Environment for enhanced power quality (PQ), improved power factor and reduced inrush currents. This is achieved using modulated PWM Switching of the Filter-Capacitive compensation scheme to cope with dynamic type nonlinear and inrush cyclical loads..

Operational Interventions to Maintenance Error

NASA Technical Reports Server (NTRS)

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

1997-01-01

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

Reduction of Maintenance Error Through Focused Interventions

NASA Technical Reports Server (NTRS)

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

1997-01-01

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

The Neural-fuzzy Thermal Error Compensation Controller on CNC Machining Center

NASA Astrophysics Data System (ADS)

Tseng, Pai-Chung; Chen, Shen-Len

The geometric errors and structural thermal deformation are factors that influence the machining accuracy of Computer Numerical Control (CNC) machining center. Therefore, researchers pay attention to thermal error compensation technologies on CNC machine tools. Some real-time error compensation techniques have been successfully demonstrated in both laboratories and industrial sites. The compensation results still need to be enhanced. In this research, the neural-fuzzy theory has been conducted to derive a thermal prediction model. An IC-type thermometer has been used to detect the heat sources temperature variation. The thermal drifts are online measured by a touch-triggered probe with a standard bar. A thermal prediction model is then derived by neural-fuzzy theory based on the temperature variation and the thermal drifts. A Graphic User Interface (GUI) system is also built to conduct the user friendly operation interface with Insprise C++ Builder. The experimental results show that the thermal prediction model developed by neural-fuzzy theory methodology can improve machining accuracy from 80µm to 3µm. Comparison with the multi-variable linear regression analysis the compensation accuracy is increased from ±10µm to ±3µm.

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.

Contingency-based emotional resilience: effort-based reward training and flexible coping lead to adaptive responses to uncertainty in male rats

PubMed Central

Lambert, Kelly G.; Hyer, Molly M.; Rzucidlo, Amanda A.; Bergeron, Timothy; Landis, Timothy; Bardi, Massimo

2014-01-01

Emotional resilience enhances an animal's ability to maintain physiological allostasis and adaptive responses in the midst of challenges ranging from cognitive uncertainty to chronic stress. In the current study, neurobiological factors related to strategic responses to uncertainty produced by prediction errors were investigated by initially profiling male rats as passive, active or flexible copers (n = 12 each group) and assigning to either a contingency-trained or non-contingency trained group. Animals were subsequently trained in a spatial learning task so that problem solving strategies in the final probe task, as well-various biomarkers of brain activation and plasticity in brain areas associated with cognition and emotional regulation, could be assessed. Additionally, fecal samples were collected to further determine markers of stress responsivity and emotional resilience. Results indicated that contingency-trained rats exhibited more adaptive responses in the probe trial (e.g., fewer interrupted grooming sequences and more targeted search strategies) than the noncontingent-trained rats; additionally, increased DHEA/CORT ratios were observed in the contingent-trained animals. Diminished activation of the habenula (i.e., fos-immunoreactivity) was correlated with resilience factors such as increased levels of DHEA metabolites during cognitive training. Of the three coping profiles, flexible copers exhibited enhanced neuroplasticity (i.e., increased dentate gyrus doublecortin-immunoreactivity) compared to the more consistently responding active and passive copers. Thus, in the current study, contingency training via effort-based reward (EBR) training, enhanced by a flexible coping style, provided neurobiological resilience and adaptive responses to prediction errors in the final probe trial. These findings have implications for psychiatric illnesses that are influenced by altered stress responses and decision-making abilities (e.g., depression). PMID:24808837

Contingency-based emotional resilience: effort-based reward training and flexible coping lead to adaptive responses to uncertainty in male rats.

PubMed

Lambert, Kelly G; Hyer, Molly M; Rzucidlo, Amanda A; Bergeron, Timothy; Landis, Timothy; Bardi, Massimo

2014-01-01

Emotional resilience enhances an animal's ability to maintain physiological allostasis and adaptive responses in the midst of challenges ranging from cognitive uncertainty to chronic stress. In the current study, neurobiological factors related to strategic responses to uncertainty produced by prediction errors were investigated by initially profiling male rats as passive, active or flexible copers (n = 12 each group) and assigning to either a contingency-trained or non-contingency trained group. Animals were subsequently trained in a spatial learning task so that problem solving strategies in the final probe task, as well-various biomarkers of brain activation and plasticity in brain areas associated with cognition and emotional regulation, could be assessed. Additionally, fecal samples were collected to further determine markers of stress responsivity and emotional resilience. Results indicated that contingency-trained rats exhibited more adaptive responses in the probe trial (e.g., fewer interrupted grooming sequences and more targeted search strategies) than the noncontingent-trained rats; additionally, increased DHEA/CORT ratios were observed in the contingent-trained animals. Diminished activation of the habenula (i.e., fos-immunoreactivity) was correlated with resilience factors such as increased levels of DHEA metabolites during cognitive training. Of the three coping profiles, flexible copers exhibited enhanced neuroplasticity (i.e., increased dentate gyrus doublecortin-immunoreactivity) compared to the more consistently responding active and passive copers. Thus, in the current study, contingency training via effort-based reward (EBR) training, enhanced by a flexible coping style, provided neurobiological resilience and adaptive responses to prediction errors in the final probe trial. These findings have implications for psychiatric illnesses that are influenced by altered stress responses and decision-making abilities (e.g., depression).

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…

The Effects of Channel Curvature and Protrusion Height on Nucleate Boiling and the Critical Heat Flux of a Simulated Electronic Chip

DTIC Science & Technology

1994-05-01

parameters and geometry factor. 57 3.2 Laminar sublayer and buffer layer thicknesses for geometry of Mudawar and Maddox.ŝ 68 3.3 Correlation constants...transfer from simulated electronic chip heat sources that are flush with the flow channel wall. Mudawar and Maddox2" have studied enhanced surfaces...bias error was not estimated; however, the percentage of heat loss measured compares with that previously reported by Mudawar and Maddox19 for a

Just Culture: A Foundation for Balanced Accountability and Patient Safety

PubMed Central

Boysen, Philip G.

2013-01-01

Background The framework of a just culture ensures balanced accountability for both individuals and the organization responsible for designing and improving systems in the workplace. Engineering principles and human factors analysis influence the design of these systems so they are safe and reliable. Methods Approaches for improving patient safety introduced here are (1) analysis of error, (2) specific tools to enhance safety, and (3) outcome engineering. Conclusion The just culture is a learning culture that is constantly improving and oriented toward patient safety. PMID:24052772

Human Factors Process Task Analysis: Liquid Oxygen Pump Acceptance Test Procedure at the Advanced Technology Development Center

NASA Technical Reports Server (NTRS)

Diorio, Kimberly A.; Voska, Ned (Technical Monitor)

2002-01-01

This viewgraph presentation provides information on Human Factors Process Failure Modes and Effects Analysis (HF PFMEA). HF PFMEA includes the following 10 steps: Describe mission; Define System; Identify human-machine; List human actions; Identify potential errors; Identify factors that effect error; Determine likelihood of error; Determine potential effects of errors; Evaluate risk; Generate solutions (manage error). The presentation also describes how this analysis was applied to a liquid oxygen pump acceptance test.

Image enhancement by spectral-error correction for dual-energy computed tomography.

PubMed

Park, Kyung-Kook; Oh, Chang-Hyun; Akay, Metin

2011-01-01

Dual-energy CT (DECT) was reintroduced recently to use the additional spectral information of X-ray attenuation and aims for accurate density measurement and material differentiation. However, the spectral information lies in the difference between low and high energy images or measurements, so that it is difficult to acquire accurate spectral information due to amplification of high pixel noise in the resulting difference image. In this work, an image enhancement technique for DECT is proposed, based on the fact that the attenuation of a higher density material decreases more rapidly as X-ray energy increases. We define as spectral error the case when a pixel pair of low and high energy images deviates far from the expected attenuation trend. After analyzing the spectral-error sources of DECT images, we propose a DECT image enhancement method, which consists of three steps: water-reference offset correction, spectral-error correction, and anti-correlated noise reduction. It is the main idea of this work that makes spectral errors distributed like random noise over the true attenuation and suppressed by the well-known anti-correlated noise reduction. The proposed method suppressed noise of liver lesions and improved contrast between liver lesions and liver parenchyma in DECT contrast-enhanced abdominal images and their two-material decomposition.

Associations between errors and contributing factors in aircraft maintenance

NASA Technical Reports Server (NTRS)

Hobbs, Alan; Williamson, Ann

2003-01-01

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

An Empirically Derived Taxonomy of Factors Affecting Physicians' Willingness to Disclose Medical Errors

PubMed Central

Kaldjian, Lauris C; Jones, Elizabeth W; Rosenthal, Gary E; Tripp-Reimer, Toni; Hillis, Stephen L

2006-01-01

BACKGROUND Physician disclosure of medical errors to institutions, patients, and colleagues is important for patient safety, patient care, and professional education. However, the variables that may facilitate or impede disclosure are diverse and lack conceptual organization. OBJECTIVE To develop an empirically derived, comprehensive taxonomy of factors that affects voluntary disclosure of errors by physicians. DESIGN A mixed-methods study using qualitative data collection (structured literature search and exploratory focus groups), quantitative data transformation (sorting and hierarchical cluster analysis), and validation procedures (confirmatory focus groups and expert review). RESULTS Full-text review of 316 articles identified 91 impeding or facilitating factors affecting physicians' willingness to disclose errors. Exploratory focus groups identified an additional 27 factors. Sorting and hierarchical cluster analysis organized factors into 8 domains. Confirmatory focus groups and expert review relocated 6 factors, removed 2 factors, and modified 4 domain names. The final taxonomy contained 4 domains of facilitating factors (responsibility to patient, responsibility to self, responsibility to profession, responsibility to community), and 4 domains of impeding factors (attitudinal barriers, uncertainties, helplessness, fears and anxieties). CONCLUSIONS A taxonomy of facilitating and impeding factors provides a conceptual framework for a complex field of variables that affects physicians' willingness to disclose errors to institutions, patients, and colleagues. This taxonomy can be used to guide the design of studies to measure the impact of different factors on disclosure, to assist in the design of error-reporting systems, and to inform educational interventions to promote the disclosure of errors to patients. PMID:16918739

Understanding adverse events: human factors.

PubMed Central

Reason, J

1995-01-01

(1) Human rather than technical failures now represent the greatest threat to complex and potentially hazardous systems. This includes healthcare systems. (2) Managing the human risks will never be 100% effective. Human fallibility can be moderated, but it cannot be eliminated. (3) Different error types have different underlying mechanisms, occur in different parts of the organisation, and require different methods of risk management. The basic distinctions are between: Slips, lapses, trips, and fumbles (execution failures) and mistakes (planning or problem solving failures). Mistakes are divided into rule based mistakes and knowledge based mistakes. Errors (information-handling problems) and violations (motivational problems) Active versus latent failures. Active failures are committed by those in direct contact with the patient, latent failures arise in organisational and managerial spheres and their adverse effects may take a long time to become evident. (4) Safety significant errors occur at all levels of the system, not just at the sharp end. Decisions made in the upper echelons of the organisation create the conditions in the workplace that subsequently promote individual errors and violations. Latent failures are present long before an accident and are hence prime candidates for principled risk management. (5) Measures that involve sanctions and exhortations (that is, moralistic measures directed to those at the sharp end) have only very limited effectiveness, especially so in the case of highly trained professionals. (6) Human factors problems are a product of a chain of causes in which the individual psychological factors (that is, momentary inattention, forgetting, etc) are the last and least manageable links. Attentional "capture" (preoccupation or distraction) is a necessary condition for the commission of slips and lapses. Yet, its occurrence is almost impossible to predict or control effectively. The same is true of the factors associated with forgetting. States of mind contributing to error are thus extremely difficult to manage; they can happen to the best of people at any time. (7) People do not act in isolation. Their behaviour is shaped by circumstances. The same is true for errors and violations. The likelihood of an unsafe act being committed is heavily influenced by the nature of the task and by the local workplace conditions. These, in turn, are the product of "upstream" organisational factors. Great gains in safety can ve achieved through relatively small modifications of equipment and workplaces. (8) Automation and increasing advanced equipment do not cure human factors problems, they merely relocate them. In contrast, training people to work effectively in teams costs little, but has achieved significant enhancements of human performance in aviation. (9) Effective risk management depends critically on a confidential and preferable anonymous incident monitoring system that records the individual, task, situational, and organisational factors associated with incidents and near misses. (10) Effective risk management means the simultaneous and targeted deployment of limited remedial resources at different levels of the system: the individual or team, the task, the situation, and the organisation as a whole. PMID:10151618

Error disclosure: a new domain for safety culture assessment.

PubMed

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

2012-07-01

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

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.

Undergraduate medical students' perceptions and intentions regarding patient safety during clinical clerkship.

PubMed

Lee, Hoo-Yeon; Hahm, Myung-Il; Lee, Sang Gyu

2018-04-04

The purpose of this study was to examine undergraduate medical students' perceptions and intentions regarding patient safety during clinical clerkships. Cross-sectional study administered in face-to-face interviews using modified the Medical Student Safety Attitudes and Professionalism Survey (MSSAPS) from three colleges of medicine in Korea. We assessed medical students' perceptions of the cultures ('safety', 'teamwork', and 'error disclosure'), 'behavioural intentions' concerning patient safety issues and 'overall patient safety'. Confirmatory factor analysis and Spearman's correlation analyses was performed. In total, 194(91.9%) of the 211 third-year undergraduate students participated. 78% of medical students reported that the quality of care received by patients was impacted by teamwork during clinical rotations. Regarding error disclosure, positive scores ranged from 10% to 74%. Except for one question asking whether the disclosure of medical errors was an important component of patient safety (74%), the percentages of positive scores for all the other questions were below 20%. 41.2% of medical students have intention to disclose it when they saw a medical error committed by another team member. Many students had difficulty speaking up about medical errors. Error disclosure guidelines and educational efforts aimed at developing sophisticated communication skills are needed. This study may serve as a reference for other institutions planning patient safety education in their curricula. Assessing student perceptions of safety culture can provide clerkship directors and clinical service chiefs with information that enhances the educational environment and promotes patient safety.

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.

Medication errors as malpractice-a qualitative content analysis of 585 medication errors by nurses in Sweden.

PubMed

Björkstén, Karin Sparring; Bergqvist, Monica; Andersén-Karlsson, Eva; Benson, Lina; Ulfvarson, Johanna

2016-08-24

Many studies address the prevalence of medication errors but few address medication errors serious enough to be regarded as malpractice. Other studies have analyzed the individual and system contributory factor leading to a medication error. Nurses have a key role in medication administration, and there are contradictory reports on the nurses' work experience in relation to the risk and type for medication errors. All medication errors where a nurse was held responsible for malpractice (n = 585) during 11 years in Sweden were included. A qualitative content analysis and classification according to the type and the individual and system contributory factors was made. In order to test for possible differences between nurses' work experience and associations within and between the errors and contributory factors, Fisher's exact test was used, and Cohen's kappa (k) was performed to estimate the magnitude and direction of the associations. There were a total of 613 medication errors in the 585 cases, the most common being "Wrong dose" (41 %), "Wrong patient" (13 %) and "Omission of drug" (12 %). In 95 % of the cases, an average of 1.4 individual contributory factors was found; the most common being "Negligence, forgetfulness or lack of attentiveness" (68 %), "Proper protocol not followed" (25 %), "Lack of knowledge" (13 %) and "Practice beyond scope" (12 %). In 78 % of the cases, an average of 1.7 system contributory factors was found; the most common being "Role overload" (36 %), "Unclear communication or orders" (30 %) and "Lack of adequate access to guidelines or unclear organisational routines" (30 %). The errors "Wrong patient due to mix-up of patients" and "Wrong route" and the contributory factors "Lack of knowledge" and "Negligence, forgetfulness or lack of attentiveness" were more common in less experienced nurses. The experienced nurses were more prone to "Practice beyond scope of practice" and to make errors in spite of "Lack of adequate access to guidelines or unclear organisational routines". Medication errors regarded as malpractice in Sweden were of the same character as medication errors worldwide. A complex interplay between individual and system factors often contributed to the errors.

A superconducting gravity gradiometer for measurements from a moving vehicle.

PubMed

Moody, M V

2011-09-01

A gravity gradiometer designed for operation on an aircraft or ship has been tested in the laboratory. A noise level of 0.53 E (E ≡ 10(-9) s(-2)) rms over a 0.001 to 1 Hz bandwidth has been measured, and the primary error mechanisms have been analyzed and quantified. The design is a continuation in the development of superconducting accelerometer technology at the University of Maryland over more than three decades. A cryogenic instrument presents not only the benefit of reduced thermal noise, but also, the extraordinary stability of superconducting circuits and material properties at very low temperatures. This stability allows precise matching of scale factors and accurate rejection of dynamic errors. The design of the instrument incorporates a number of additional features that further enhance performance in a dynamically noisy environment. © 2011 American Institute of Physics

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.

NASTRAN maintenance and enhancement experiences

NASA Technical Reports Server (NTRS)

Schmitz, R. P.

1975-01-01

The current capability is described which includes isoparametric elements, optimization of grid point sequencing, and eigenvalue routine. Overlay and coding errors were corrected for cyclic symmetry, transient response, and differential stiffness rigid formats. Error corrections and program enhancements are discussed along with developments scheduled for the current year and a brief description of analyses being performed using the program.

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.

Creating an automated tool for measuring software cohesion

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

Tutton, J.M.; Zucconi, L.

1994-05-06

Program modules with high complexity tend to be more error prone and more difficult to understand. These factors increase maintenance and enhancement costs. Hence, a tool that can help programmers determine a key factor in module complexity should be very useful. Our goal is to create a software tool that will automatically give a quantitative measure of the cohesiveness of a given module, and hence give us an estimate of the {open_quotes}maintainability{close_quotes} of that module. The Tool will use a metric developed by Professors Linda M. Ott and James M. Bieman. The Ott/Bieman metric gives quantitative measures that indicate themore » degree of functional cohesion using abstract data slices.« less

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.

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

Measurement System Characterization in the Presence of Measurement Errors

NASA Technical Reports Server (NTRS)

Commo, Sean A.

2012-01-01

In the calibration of a measurement system, data are collected in order to estimate a mathematical model between one or more factors of interest and a response. Ordinary least squares is a method employed to estimate the regression coefficients in the model. The method assumes that the factors are known without error; yet, it is implicitly known that the factors contain some uncertainty. In the literature, this uncertainty is known as measurement error. The measurement error affects both the estimates of the model coefficients and the prediction, or residual, errors. There are some methods, such as orthogonal least squares, that are employed in situations where measurement errors exist, but these methods do not directly incorporate the magnitude of the measurement errors. This research proposes a new method, known as modified least squares, that combines the principles of least squares with knowledge about the measurement errors. This knowledge is expressed in terms of the variance ratio - the ratio of response error variance to measurement error variance.

Primary care physicians' use of an electronic medical record system: a cognitive task analysis.

PubMed

Shachak, Aviv; Hadas-Dayagi, Michal; Ziv, Amitai; Reis, Shmuel

2009-03-01

To describe physicians' patterns of using an Electronic Medical Record (EMR) system; to reveal the underlying cognitive elements involved in EMR use, possible resulting errors, and influences on patient-doctor communication; to gain insight into the role of expertise in incorporating EMRs into clinical practice in general and communicative behavior in particular. Cognitive task analysis using semi-structured interviews and field observations. Twenty-five primary care physicians from the northern district of the largest health maintenance organization (HMO) in Israel. The comprehensiveness, organization, and readability of data in the EMR system reduced physicians' need to recall information from memory and the difficulty of reading handwriting. Physicians perceived EMR use as reducing the cognitive load associated with clinical tasks. Automaticity of EMR use contributed to efficiency, but sometimes resulted in errors, such as the selection of incorrect medication or the input of data into the wrong patient's chart. EMR use interfered with patient-doctor communication. The main strategy for overcoming this problem involved separating EMR use from time spent communicating with patients. Computer mastery and enhanced physicians' communication skills also helped. There is a fine balance between the benefits and risks of EMR use. Automaticity, especially in combination with interruptions, emerged as the main cognitive factor contributing to errors. EMR use had a negative influence on communication, a problem that can be partially addressed by improving the spatial organization of physicians' offices and by enhancing physicians' computer and communication skills.

Primary Care Physicians’ Use of an Electronic Medical Record System: A Cognitive Task Analysis

PubMed Central

Hadas-Dayagi, Michal; Ziv, Amitai; Reis, Shmuel

2009-01-01

OBJECTIVE To describe physicians’ patterns of using an Electronic Medical Record (EMR) system; to reveal the underlying cognitive elements involved in EMR use, possible resulting errors, and influences on patient–doctor communication; to gain insight into the role of expertise in incorporating EMRs into clinical practice in general and communicative behavior in particular. DESIGN Cognitive task analysis using semi-structured interviews and field observations. PARTICIPANTS Twenty-five primary care physicians from the northern district of the largest health maintenance organization (HMO) in Israel. RESULTS The comprehensiveness, organization, and readability of data in the EMR system reduced physicians’ need to recall information from memory and the difficulty of reading handwriting. Physicians perceived EMR use as reducing the cognitive load associated with clinical tasks. Automaticity of EMR use contributed to efficiency, but sometimes resulted in errors, such as the selection of incorrect medication or the input of data into the wrong patient’s chart. EMR use interfered with patient–doctor communication. The main strategy for overcoming this problem involved separating EMR use from time spent communicating with patients. Computer mastery and enhanced physicians’ communication skills also helped. CONCLUSIONS There is a fine balance between the benefits and risks of EMR use. Automaticity, especially in combination with interruptions, emerged as the main cognitive factor contributing to errors. EMR use had a negative influence on communication, a problem that can be partially addressed by improving the spatial organization of physicians’ offices and by enhancing physicians’ computer and communication skills. PMID:19130148

Oily wastewater treatment by ultrafiltration using Taguchi experimental design.

PubMed

Salahi, A; Mohammadi, T

2011-01-01

In this research, results of an experimental investigation on separation of oil from a real oily wastewater using an ultrafiltration (UF) polymeric membrane are presented. In order to enhance the performance of UF in API separator effluent treatment and to get more permeation flux (PF), effects of operating factors on the yield of PF were studied. Five factors at four levels were investigated: trans-membrane pressure (TMP), temperature (T), cross flow velocity (CFV), pH and salt concentration (SC). Taguchi method (L(16) orthogonal array (OA)) was used. Analysis of variance (ANOVA) was applied to calculate sum of square, variance, error variance and contribution percentage of each factor on response. The optimal levels thus determined for the four influential factors were: TMP, 3 bar; T, 40˚C; CFV, 1.0 m/s; SC, 25 g/L and pH, 8. The results showed that CFV and SC are the most and the least effective factors on PF, respectively. Increasing CFV, TMP, T and pH caused the better performance of UF membrane process due to enhancement of driving force and fouling residence. Also, effects of oil concentration (OC) in the wastewater on PF and total organic carbon (TOC) rejection were investigated. Finally, the highest TOC rejection was found to be 85%.

Accelerating Convergence in Molecular Dynamics Simulations of Solutes in Lipid Membranes by Conducting a Random Walk along the Bilayer Normal.

PubMed

Neale, Chris; Madill, Chris; Rauscher, Sarah; Pomès, Régis

2013-08-13

All molecular dynamics simulations are susceptible to sampling errors, which degrade the accuracy and precision of observed values. The statistical convergence of simulations containing atomistic lipid bilayers is limited by the slow relaxation of the lipid phase, which can exceed hundreds of nanoseconds. These long conformational autocorrelation times are exacerbated in the presence of charged solutes, which can induce significant distortions of the bilayer structure. Such long relaxation times represent hidden barriers that induce systematic sampling errors in simulations of solute insertion. To identify optimal methods for enhancing sampling efficiency, we quantitatively evaluate convergence rates using generalized ensemble sampling algorithms in calculations of the potential of mean force for the insertion of the ionic side chain analog of arginine in a lipid bilayer. Umbrella sampling (US) is used to restrain solute insertion depth along the bilayer normal, the order parameter commonly used in simulations of molecular solutes in lipid bilayers. When US simulations are modified to conduct random walks along the bilayer normal using a Hamiltonian exchange algorithm, systematic sampling errors are eliminated more rapidly and the rate of statistical convergence of the standard free energy of binding of the solute to the lipid bilayer is increased 3-fold. We compute the ratio of the replica flux transmitted across a defined region of the order parameter to the replica flux that entered that region in Hamiltonian exchange simulations. We show that this quantity, the transmission factor, identifies sampling barriers in degrees of freedom orthogonal to the order parameter. The transmission factor is used to estimate the depth-dependent conformational autocorrelation times of the simulation system, some of which exceed the simulation time, and thereby identify solute insertion depths that are prone to systematic sampling errors and estimate the lower bound of the amount of sampling that is required to resolve these sampling errors. Finally, we extend our simulations and verify that the conformational autocorrelation times estimated by the transmission factor accurately predict correlation times that exceed the simulation time scale-something that, to our knowledge, has never before been achieved.

Reduced change blindness suggests enhanced attention to detail in individuals with autism.

PubMed

Smith, Hayley; Milne, Elizabeth

2009-03-01

The phenomenon of change blindness illustrates that a limited number of items within the visual scene are attended to at any one time. It has been suggested that individuals with autism focus attention on less contextually relevant aspects of the visual scene, show superior perceptual discrimination and notice details which are often ignored by typical observers. In this study we investigated change blindness in autism by asking participants to detect continuity errors deliberately introduced into a short film. Whether the continuity errors involved central/marginal or social/non-social aspects of the visual scene was varied. Thirty adolescent participants, 15 with autistic spectrum disorder (ASD) and 15 typically developing (TD) controls participated. The participants with ASD detected significantly more errors than the TD participants. Both groups identified more errors involving central rather than marginal aspects of the scene, although this effect was larger in the TD participants. There was no difference in the number of social or non-social errors detected by either group of participants. In line with previous data suggesting an abnormally broad attentional spotlight and enhanced perceptual function in individuals with ASD, the results of this study suggest enhanced awareness of the visual scene in ASD. The results of this study could reflect superior top-down control of visual search in autism, enhanced perceptual function, or inefficient filtering of visual information in ASD.

A Novel Hybrid Error Criterion-Based Active Control Method for on-Line Milling Vibration Suppression with Piezoelectric Actuators and Sensors

PubMed Central

Zhang, Xingwu; Wang, Chenxi; Gao, Robert X.; Yan, Ruqiang; Chen, Xuefeng; Wang, Shibin

2016-01-01

Milling vibration is one of the most serious factors affecting machining quality and precision. In this paper a novel hybrid error criterion-based frequency-domain LMS active control method is constructed and used for vibration suppression of milling processes by piezoelectric actuators and sensors, in which only one Fast Fourier Transform (FFT) is used and no Inverse Fast Fourier Transform (IFFT) is involved. The correction formulas are derived by a steepest descent procedure and the control parameters are analyzed and optimized. Then, a novel hybrid error criterion is constructed to improve the adaptability, reliability and anti-interference ability of the constructed control algorithm. Finally, based on piezoelectric actuators and acceleration sensors, a simulation of a spindle and a milling process experiment are presented to verify the proposed method. Besides, a protection program is added in the control flow to enhance the reliability of the control method in applications. The simulation and experiment results indicate that the proposed method is an effective and reliable way for on-line vibration suppression, and the machining quality can be obviously improved. PMID:26751448

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.

Predictions of biochar production and torrefaction performance from sugarcane bagasse using interpolation and regression analysis.

PubMed

Chen, Wei-Hsin; Hsu, Hung-Jen; Kumar, Gopalakrishnan; Budzianowski, Wojciech M; Ong, Hwai Chyuan

2017-12-01

This study focuses on the biochar formation and torrefaction performance of sugarcane bagasse, and they are predicted using the bilinear interpolation (BLI), inverse distance weighting (IDW) interpolation, and regression analysis. It is found that the biomass torrefied at 275°C for 60min or at 300°C for 30min or longer is appropriate to produce biochar as alternative fuel to coal with low carbon footprint, but the energy yield from the torrefaction at 300°C is too low. From the biochar yield, enhancement factor of HHV, and energy yield, the results suggest that the three methods are all feasible for predicting the performance, especially for the enhancement factor. The power parameter of unity in the IDW method provides the best predictions and the error is below 5%. The second order in regression analysis gives a more reasonable approach than the first order, and is recommended for the predictions. Copyright © 2017 Elsevier Ltd. All rights reserved.

A Pedagogical Alliance for Trust, Wellbeing and the Identification of Errors for Learning and Formative Assessment

ERIC Educational Resources Information Center

Leighton, Jacqueline P.; Bustos Gómez, María Clara

2018-01-01

Formative assessments and feedback are vital to enhancing learning outcomes but require that learners feel at ease identifying their errors, and receiving feedback from a trusted source--teachers. An experimental test of a new theoretical framework was conducted to cultivate a pedagogical alliance to enhance students' (a) trust in the teacher, (b)…

A new enhanced index tracking model in portfolio optimization with sum weighted approach

NASA Astrophysics Data System (ADS)

Siew, Lam Weng; Jaaman, Saiful Hafizah; Hoe, Lam Weng

2017-04-01

Index tracking is a portfolio management which aims to construct the optimal portfolio to achieve similar return with the benchmark index return at minimum tracking error without purchasing all the stocks that make up the index. Enhanced index tracking is an improved portfolio management which aims to generate higher portfolio return than the benchmark index return besides minimizing the tracking error. The objective of this paper is to propose a new enhanced index tracking model with sum weighted approach to improve the existing index tracking model for tracking the benchmark Technology Index in Malaysia. The optimal portfolio composition and performance of both models are determined and compared in terms of portfolio mean return, tracking error and information ratio. The results of this study show that the optimal portfolio of the proposed model is able to generate higher mean return than the benchmark index at minimum tracking error. Besides that, the proposed model is able to outperform the existing model in tracking the benchmark index. The significance of this study is to propose a new enhanced index tracking model with sum weighted apporach which contributes 67% improvement on the portfolio mean return as compared to the existing model.

[Epidemiology of refractive errors].

PubMed

Wolfram, C

2017-07-01

Refractive errors are very common and can lead to severe pathological changes in the eye. This article analyzes the epidemiology of refractive errors in the general population in Germany and worldwide and describes common definitions for refractive errors and clinical characteristics for pathologicaal changes. Refractive errors differ between age groups due to refractive changes during the life time and also due to generation-specific factors. Current research about the etiology of refractive errors has strengthened the influence of environmental factors, which led to new strategies for the prevention of refractive pathologies.

Factors effective on medication errors: A nursing view.

PubMed

Shahrokhi, Akram; Ebrahimpour, Fatemeh; Ghodousi, Arash

2013-01-01

Medication errors are the most common medical errors, which may result in some complications for patients. This study was carried out to investigate what influence medication errors by nurses from their viewpoint. In this descriptive study, 150 nurses who were working in Qazvin Medical University teaching hospitals were selected by proportional random sampling, and data were collected by means of a researcher-made questionnaire including demographic attributes (age, gender, working experience,…), and contributing factors in medication errors (in three categories including nurse-related, management-related, and environment-related factors). The mean age of the participant nurses was 30.7 ± 6.5 years. Most of them (87.1%) were female with a Bachelor of Sciences degree (86.7%) in nursing. The mean of their overtime working was 64.8 ± 38 h/month. The results showed that the nurse-related factors are the most effective factors (55.44 ± 9.14) while the factors related to the management system (52.84 ± 11.24) and the ward environment (44.0 ± 10.89) are respectively less effective. The difference between these three groups was significant (P = 0.000). In each aforementioned category, the most effective factor on medication error (ranked from the most effective to the least effective) were as follow: The nurse's inadequate attention (98.7%), the errors occurring in the transfer of medication orders from the patient's file to kardex (96.6%) and the ward's heavy workload (86.7%). In this study nurse-related factors were the most effective factors on medication errors, but nurses are one of the members of health-care providing team, so their performance must be considered in the context of the health-care system like work force condition, rules and regulations, drug manufacturing that might impact nurses performance, so it could not be possible to prevent medication errors without paying attention to our health-care system in a holistic approach.

Factors effective on medication errors: A nursing view

PubMed Central

Shahrokhi, Akram; Ebrahimpour, Fatemeh; Ghodousi, Arash

2013-01-01

Objective: Medication errors are the most common medical errors, which may result in some complications for patients. This study was carried out to investigate what influence medication errors by nurses from their viewpoint. Methods: In this descriptive study, 150 nurses who were working in Qazvin Medical University teaching hospitals were selected by proportional random sampling, and data were collected by means of a researcher-made questionnaire including demographic attributes (age, gender, working experience,…), and contributing factors in medication errors (in three categories including nurse-related, management-related, and environment-related factors). Findings: The mean age of the participant nurses was 30.7 ± 6.5 years. Most of them (87.1%) were female with a Bachelor of Sciences degree (86.7%) in nursing. The mean of their overtime working was 64.8 ± 38 h/month. The results showed that the nurse-related factors are the most effective factors (55.44 ± 9.14) while the factors related to the management system (52.84 ± 11.24) and the ward environment (44.0 ± 10.89) are respectively less effective. The difference between these three groups was significant (P = 0.000). In each aforementioned category, the most effective factor on medication error (ranked from the most effective to the least effective) were as follow: The nurse's inadequate attention (98.7%), the errors occurring in the transfer of medication orders from the patient's file to kardex (96.6%) and the ward's heavy workload (86.7%). Conclusion: In this study nurse-related factors were the most effective factors on medication errors, but nurses are one of the members of health-care providing team, so their performance must be considered in the context of the health-care system like work force condition, rules and regulations, drug manufacturing that might impact nurses performance, so it could not be possible to prevent medication errors without paying attention to our health-care system in a holistic approach. PMID:24991599

Performance Enhancement of a USV INS/CNS/DVL Integration Navigation System Based on an Adaptive Information Sharing Factor Federated Filter

PubMed Central

Wang, Qiuying; Cui, Xufei; Li, Yibing; Ye, Fang

2017-01-01

To improve the ability of autonomous navigation for Unmanned Surface Vehicles (USVs), multi-sensor integrated navigation based on Inertial Navigation System (INS), Celestial Navigation System (CNS) and Doppler Velocity Log (DVL) is proposed. The CNS position and the DVL velocity are introduced as the reference information to correct the INS divergence error. The autonomy of the integrated system based on INS/CNS/DVL is much better compared with the integration based on INS/GNSS alone. However, the accuracy of DVL velocity and CNS position are decreased by the measurement noise of DVL and bad weather, respectively. Hence, the INS divergence error cannot be estimated and corrected by the reference information. To resolve the problem, the Adaptive Information Sharing Factor Federated Filter (AISFF) is introduced to fuse data. The information sharing factor of the Federated Filter is adaptively adjusted to maintaining multiple component solutions usable as back-ups, which can improve the reliability of overall system. The effectiveness of this approach is demonstrated by simulation and experiment, the results show that for the INS/CNS/DVL integrated system, when the DVL velocity accuracy is decreased and the CNS cannot work under bad weather conditions, the INS/CNS/DVL integrated system can operate stably based on the AISFF method. PMID:28165369

Performance Enhancement of a USV INS/CNS/DVL Integration Navigation System Based on an Adaptive Information Sharing Factor Federated Filter.

PubMed

Wang, Qiuying; Cui, Xufei; Li, Yibing; Ye, Fang

2017-02-03

To improve the ability of autonomous navigation for Unmanned Surface Vehicles (USVs), multi-sensor integrated navigation based on Inertial Navigation System (INS), Celestial Navigation System (CNS) and Doppler Velocity Log (DVL) is proposed. The CNS position and the DVL velocity are introduced as the reference information to correct the INS divergence error. The autonomy of the integrated system based on INS/CNS/DVL is much better compared with the integration based on INS/GNSS alone. However, the accuracy of DVL velocity and CNS position are decreased by the measurement noise of DVL and bad weather, respectively. Hence, the INS divergence error cannot be estimated and corrected by the reference information. To resolve the problem, the Adaptive Information Sharing Factor Federated Filter (AISFF) is introduced to fuse data. The information sharing factor of the Federated Filter is adaptively adjusted to maintaining multiple component solutions usable as back-ups, which can improve the reliability of overall system. The effectiveness of this approach is demonstrated by simulation and experiment, the results show that for the INS/CNS/DVL integrated system, when the DVL velocity accuracy is decreased and the CNS cannot work under bad weather conditions, the INS/CNS/DVL integrated system can operate stably based on the AISFF method.

Financial errors in dementia: Testing a neuroeconomic conceptual framework

PubMed Central

Chiong, Winston; Hsu, Ming; Wudka, Danny; Miller, Bruce L.; Rosen, Howard J.

2013-01-01

Financial errors by patients with dementia can have devastating personal and family consequences. We developed and evaluated a neuroeconomic conceptual framework for understanding financial errors across different dementia syndromes, using a systematic, retrospective, blinded chart review of demographically-balanced cohorts of patients with Alzheimer’s disease (AD, n=100) and behavioral variant frontotemporal dementia (bvFTD, n=50). Reviewers recorded specific reports of financial errors according to a conceptual framework identifying patient cognitive and affective characteristics, and contextual influences, conferring susceptibility to each error. Specific financial errors were reported for 49% of AD and 70% of bvFTD patients (p = 0.012). AD patients were more likely than bvFTD patients to make amnestic errors (p< 0.001), while bvFTD patients were more likely to spend excessively (p = 0.004) and to exhibit other behaviors consistent with diminished sensitivity to losses and other negative outcomes (p< 0.001). Exploratory factor analysis identified a social/affective vulnerability factor associated with errors in bvFTD, and a cognitive vulnerability factor associated with errors in AD. Our findings highlight the frequency and functional importance of financial errors as symptoms of AD and bvFTD. A conceptual model derived from neuroeconomic literature identifies factors that influence vulnerability to different types of financial error in different dementia syndromes, with implications for early diagnosis and subsequent risk prevention. PMID:23550884

Descriptions of verbal communication errors between staff. An analysis of 84 root cause analysis-reports from Danish hospitals.

PubMed

Rabøl, Louise Isager; Andersen, Mette Lehmann; Østergaard, Doris; Bjørn, Brian; Lilja, Beth; Mogensen, Torben

2011-03-01

Poor teamwork and communication between healthcare staff are correlated to patient safety incidents. However, the organisational factors responsible for these issues are unexplored. Root cause analyses (RCA) use human factors thinking to analyse the systems behind severe patient safety incidents. The objective of this study is to review RCA reports (RCAR) for characteristics of verbal communication errors between hospital staff in an organisational perspective. Two independent raters analysed 84 RCARs, conducted in six Danish hospitals between 2004 and 2006, for descriptions and characteristics of verbal communication errors such as handover errors and error during teamwork. Raters found description of verbal communication errors in 44 reports (52%). These included handover errors (35 (86%)), communication errors between different staff groups (19 (43%)), misunderstandings (13 (30%)), communication errors between junior and senior staff members (11 (25%)), hesitance in speaking up (10 (23%)) and communication errors during teamwork (8 (18%)). The kappa values were 0.44-0.78. Unproceduralized communication and information exchange via telephone, related to transfer between units and consults from other specialties, were particularly vulnerable processes. With the risk of bias in mind, it is concluded that more than half of the RCARs described erroneous verbal communication between staff members as root causes of or contributing factors of severe patient safety incidents. The RCARs rich descriptions of the incidents revealed the organisational factors and needs related to these errors.

A validation procedure for a LADAR system radiometric simulation model

NASA Astrophysics Data System (ADS)

Leishman, Brad; Budge, Scott; Pack, Robert

2007-04-01

The USU LadarSIM software package is a ladar system engineering tool that has recently been enhanced to include the modeling of the radiometry of Ladar beam footprints. This paper will discuss our validation of the radiometric model and present a practical approach to future validation work. In order to validate complicated and interrelated factors affecting radiometry, a systematic approach had to be developed. Data for known parameters were first gathered then unknown parameters of the system were determined from simulation test scenarios. This was done in a way to isolate as many unknown variables as possible, then build on the previously obtained results. First, the appropriate voltage threshold levels of the discrimination electronics were set by analyzing the number of false alarms seen in actual data sets. With this threshold set, the system noise was then adjusted to achieve the appropriate number of dropouts. Once a suitable noise level was found, the range errors of the simulated and actual data sets were compared and studied. Predicted errors in range measurements were analyzed using two methods: first by examining the range error of a surface with known reflectivity and second by examining the range errors for specific detectors with known responsivities. This provided insight into the discrimination method and receiver electronics used in the actual system.

Cardiovascular risk factors and retinal microvascular signs in an adult Japanese population: the Funagata Study.

PubMed

Kawasaki, Ryo; Wang, Jie Jin; Rochtchina, Elena; Taylor, Bronwen; Wong, Tien Yin; Tominaga, Makoto; Kato, Takeo; Daimon, Makoto; Oizumi, Toshihide; Kawata, Sumio; Kayama, Takamasa; Yamashita, Hidetoshi; Mitchell, Paul

2006-08-01

To describe the prevalence of retinal vascular signs and their association with cardiovascular risk factors in a Japanese population. Population-based cross-sectional study. Adult persons aged 35 years or older from Funagata, Yamagata Prefecture, Japan (n = 1481). The Funagata Study is a Japanese population-based study of persons aged 35 years or older, and included 1961 nondiabetic participants (53.3% of 3676 eligible subjects). A nonmydriatic retinal photograph was taken of 1 eye to assess retinal microvascular signs. Retinal arteriolar wall signs (focal arteriolar narrowing, arteriovenous nicking, enhanced arteriolar wall reflex) and retinopathy were assessed in 1481 participants without diabetes (40.3% of eligible persons) using a standardized protocol. Using a computer-assisted method, retinal vessel diameters were measured in 921 participants with gradable retinal image (25.1% of eligible persons). Prevalence of retinal microvascular signs and their association with cardiovascular risk factors. Moderate or severe focal arteriolar narrowing, arteriovenous nicking, enhanced arteriolar wall reflex, and retinopathy were found in 8.3%, 15.2%, 18.7%, and 9.0%, respectively, of the study population. Mean (+/-standard error) values for retinal arteriolar diameter were 178.6+/-21.0 mum, and mean values (+/-standard error) for venular diameter were 214.9+/-20.6 mum. Older persons were more likely to have retinal arteriolar wall signs, retinopathy, and narrower retinal vessel diameters. After adjusting for multiple factors, each 10-mmHg increase in mean arterial blood pressure was associated with a 20% to 40% increased likelihood of retinal arteriolar signs and a 2.8-mum reduction in arteriolar diameter. Retinopathy was associated with higher body mass index and both impaired glucose tolerance and impaired fasting glucose. In nondiabetic Japanese adults, retinal arteriolar wall signs were associated with older age and increased blood pressure, whereas retinopathy was associated with older age, higher body mass index, impaired glucose tolerance, and impaired fasting glucose. These findings are comparable with data from white populations.

Robust iterative learning contouring controller with disturbance observer for machine tool feed drives.

PubMed

Simba, Kenneth Renny; Bui, Ba Dinh; Msukwa, Mathew Renny; Uchiyama, Naoki

2018-04-01

In feed drive systems, particularly machine tools, a contour error is more significant than the individual axial tracking errors from the view point of enhancing precision in manufacturing and production systems. The contour error must be within the permissible tolerance of given products. In machining complex or sharp-corner products, large contour errors occur mainly owing to discontinuous trajectories and the existence of nonlinear uncertainties. Therefore, it is indispensable to design robust controllers that can enhance the tracking ability of feed drive systems. In this study, an iterative learning contouring controller consisting of a classical Proportional-Derivative (PD) controller and disturbance observer is proposed. The proposed controller was evaluated experimentally by using a typical sharp-corner trajectory, and its performance was compared with that of conventional controllers. The results revealed that the maximum contour error can be reduced by about 37% on average. Copyright © 2018 ISA. Published by Elsevier Ltd. All rights reserved.

Intelligence moderates reinforcement learning: a mini-review of the neural evidence

PubMed Central

2014-01-01

Our understanding of the neural basis of reinforcement learning and intelligence, two key factors contributing to human strivings, has progressed significantly recently. However, the overlap of these two lines of research, namely, how intelligence affects neural responses during reinforcement learning, remains uninvestigated. A mini-review of three existing studies suggests that higher IQ (especially fluid IQ) may enhance the neural signal of positive prediction error in dorsolateral prefrontal cortex, dorsal anterior cingulate cortex, and striatum, several brain substrates of reinforcement learning or intelligence. PMID:25185818

Intelligence moderates reinforcement learning: a mini-review of the neural evidence.

PubMed

Chen, Chong

2015-06-01

Our understanding of the neural basis of reinforcement learning and intelligence, two key factors contributing to human strivings, has progressed significantly recently. However, the overlap of these two lines of research, namely, how intelligence affects neural responses during reinforcement learning, remains uninvestigated. A mini-review of three existing studies suggests that higher IQ (especially fluid IQ) may enhance the neural signal of positive prediction error in dorsolateral prefrontal cortex, dorsal anterior cingulate cortex, and striatum, several brain substrates of reinforcement learning or intelligence. Copyright © 2015 the American Physiological Society.

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.

Aerodynamic coefficient identification package dynamic data accuracy determinations: Lessons learned

NASA Technical Reports Server (NTRS)

Heck, M. L.; Findlay, J. T.; Compton, H. R.

1983-01-01

The errors in the dynamic data output from the Aerodynamic Coefficient Identification Packages (ACIP) flown on Shuttle flights 1, 3, 4, and 5 were determined using the output from the Inertial Measurement Units (IMU). A weighted least-squares batch algorithm was empolyed. Using an averaging technique, signal detection was enhanced; this allowed improved calibration solutions. Global errors as large as 0.04 deg/sec for the ACIP gyros, 30 mg for linear accelerometers, and 0.5 deg/sec squared in the angular accelerometer channels were detected and removed with a combination is bias, scale factor, misalignment, and g-sensitive calibration constants. No attempt was made to minimize local ACIP dynamic data deviations representing sensed high-frequency vibration or instrument noise. Resulting 1sigma calibrated ACIP global accuracies were within 0.003 eg/sec, 1.0 mg, and 0.05 deg/sec squared for the gyros, linear accelerometers, and angular accelerometers, respectively.

Cognitive emotion regulation enhances aversive prediction error activity while reducing emotional responses.

PubMed

Mulej Bratec, Satja; Xie, Xiyao; Schmid, Gabriele; Doll, Anselm; Schilbach, Leonhard; Zimmer, Claus; Wohlschläger, Afra; Riedl, Valentin; Sorg, Christian

2015-12-01

Cognitive emotion regulation is a powerful way of modulating emotional responses. However, despite the vital role of emotions in learning, it is unknown whether the effect of cognitive emotion regulation also extends to the modulation of learning. Computational models indicate prediction error activity, typically observed in the striatum and ventral tegmental area, as a critical neural mechanism involved in associative learning. We used model-based fMRI during aversive conditioning with and without cognitive emotion regulation to test the hypothesis that emotion regulation would affect prediction error-related neural activity in the striatum and ventral tegmental area, reflecting an emotion regulation-related modulation of learning. Our results show that cognitive emotion regulation reduced emotion-related brain activity, but increased prediction error-related activity in a network involving ventral tegmental area, hippocampus, insula and ventral striatum. While the reduction of response activity was related to behavioral measures of emotion regulation success, the enhancement of prediction error-related neural activity was related to learning performance. Furthermore, functional connectivity between the ventral tegmental area and ventrolateral prefrontal cortex, an area involved in regulation, was specifically increased during emotion regulation and likewise related to learning performance. Our data, therefore, provide first-time evidence that beyond reducing emotional responses, cognitive emotion regulation affects learning by enhancing prediction error-related activity, potentially via tegmental dopaminergic pathways. Copyright © 2015 Elsevier Inc. All rights reserved.

Accuracy Assessment of Digital Surface Models Based on WorldView-2 and ADS80 Stereo Remote Sensing Data

PubMed Central

Hobi, Martina L.; Ginzler, Christian

2012-01-01

Digital surface models (DSMs) are widely used in forest science to model the forest canopy. Stereo pairs of very high resolution satellite and digital aerial images are relatively new and their absolute accuracy for DSM generation is largely unknown. For an assessment of these input data two DSMs based on a WorldView-2 stereo pair and a ADS80 DSM were generated with photogrammetric instruments. Rational polynomial coefficients (RPCs) are defining the orientation of the WorldView-2 satellite images, which can be enhanced with ground control points (GCPs). Thus two WorldView-2 DSMs were distinguished: a WorldView-2 RPCs-only DSM and a WorldView-2 GCP-enhanced RPCs DSM. The accuracy of the three DSMs was estimated with GPS measurements, manual stereo-measurements, and airborne laser scanning data (ALS). With GCP-enhanced RPCs the WorldView-2 image orientation could be optimised to a root mean square error (RMSE) of 0.56 m in planimetry and 0.32 m in height. This improvement in orientation allowed for a vertical median error of −0.24 m for the WorldView-2 GCP-enhanced RPCs DSM in flat terrain. Overall, the DSM based on ADS80 images showed the highest accuracy of the three models with a median error of 0.08 m over bare ground. As the accuracy of a DSM varies with land cover three classes were distinguished: herb and grass, forests, and artificial areas. The study suggested the ADS80 DSM to best model actual surface height in all three land cover classes, with median errors <1.1 m. The WorldView-2 GCP-enhanced RPCs model achieved good accuracy, too, with median errors of −0.43 m for the herb and grass vegetation and −0.26 m for artificial areas. Forested areas emerged as the most difficult land cover type for height modelling; still, with median errors of −1.85 m for the WorldView-2 GCP-enhanced RPCs model and −1.12 m for the ADS80 model, the input data sets evaluated here are quite promising for forest canopy modelling. PMID:22778645

Accuracy assessment of digital surface models based on WorldView-2 and ADS80 stereo remote sensing data.

PubMed

Hobi, Martina L; Ginzler, Christian

2012-01-01

Digital surface models (DSMs) are widely used in forest science to model the forest canopy. Stereo pairs of very high resolution satellite and digital aerial images are relatively new and their absolute accuracy for DSM generation is largely unknown. For an assessment of these input data two DSMs based on a WorldView-2 stereo pair and a ADS80 DSM were generated with photogrammetric instruments. Rational polynomial coefficients (RPCs) are defining the orientation of the WorldView-2 satellite images, which can be enhanced with ground control points (GCPs). Thus two WorldView-2 DSMs were distinguished: a WorldView-2 RPCs-only DSM and a WorldView-2 GCP-enhanced RPCs DSM. The accuracy of the three DSMs was estimated with GPS measurements, manual stereo-measurements, and airborne laser scanning data (ALS). With GCP-enhanced RPCs the WorldView-2 image orientation could be optimised to a root mean square error (RMSE) of 0.56 m in planimetry and 0.32 m in height. This improvement in orientation allowed for a vertical median error of -0.24 m for the WorldView-2 GCP-enhanced RPCs DSM in flat terrain. Overall, the DSM based on ADS80 images showed the highest accuracy of the three models with a median error of 0.08 m over bare ground. As the accuracy of a DSM varies with land cover three classes were distinguished: herb and grass, forests, and artificial areas. The study suggested the ADS80 DSM to best model actual surface height in all three land cover classes, with median errors <1.1 m. The WorldView-2 GCP-enhanced RPCs model achieved good accuracy, too, with median errors of -0.43 m for the herb and grass vegetation and -0.26 m for artificial areas. Forested areas emerged as the most difficult land cover type for height modelling; still, with median errors of -1.85 m for the WorldView-2 GCP-enhanced RPCs model and -1.12 m for the ADS80 model, the input data sets evaluated here are quite promising for forest canopy modelling.

Constructivism, Factoring, and Beliefs.

ERIC Educational Resources Information Center

Rauff, James V.

1994-01-01

Discusses errors made by remedial intermediate algebra students in factoring polynomials in light of student definitions of factoring. Found certain beliefs about factoring to logically imply many of the errors made. Suggests that belief-based teaching can be successful in teaching factoring. (16 references) (Author/MKR)

Effective Compiler Error Message Enhancement for Novice Programming Students

ERIC Educational Resources Information Center

Becker, Brett A.; Glanville, Graham; Iwashima, Ricardo; McDonnell, Claire; Goslin, Kyle; Mooney, Catherine

2016-01-01

Programming is an essential skill that many computing students are expected to master. However, programming can be difficult to learn. Successfully interpreting compiler error messages (CEMs) is crucial for correcting errors and progressing toward success in programming. Yet these messages are often difficult to understand and pose a barrier to…

Using voluntary reports from physicians to learn from diagnostic errors in emergency medicine.

PubMed

Okafor, Nnaemeka; Payne, Velma L; Chathampally, Yashwant; Miller, Sara; Doshi, Pratik; Singh, Hardeep

2016-04-01

Diagnostic errors are common in the emergency department (ED), but few studies have comprehensively evaluated their types and origins. We analysed incidents reported by ED physicians to determine disease conditions, contributory factors and patient harm associated with ED-related diagnostic errors. Between 1 March 2009 and 31 December 2013, ED physicians reported 509 incidents using a department-specific voluntary incident-reporting system that we implemented at two large academic hospital-affiliated EDs. For this study, we analysed 209 incidents related to diagnosis. A quality assurance team led by an ED physician champion reviewed each incident and interviewed physicians when necessary to confirm the presence/absence of diagnostic error and to determine the contributory factors. We generated descriptive statistics quantifying disease conditions involved, contributory factors and patient harm from errors. Among the 209 incidents, we identified 214 diagnostic errors associated with 65 unique diseases/conditions, including sepsis (9.6%), acute coronary syndrome (9.1%), fractures (8.6%) and vascular injuries (8.6%). Contributory factors included cognitive (n=317), system related (n=192) and non-remedial (n=106). Cognitive factors included faulty information verification (41.3%) and faulty information processing (30.6%) whereas system factors included high workload (34.4%) and inefficient ED processes (40.1%). Non-remediable factors included atypical presentation (31.3%) and the patients' inability to provide a history (31.3%). Most errors (75%) involved multiple factors. Major harm was associated with 34/209 (16.3%) of reported incidents. Most diagnostic errors in ED appeared to relate to common disease conditions. While sustaining diagnostic error reporting programmes might be challenging, our analysis reveals the potential value of such systems in identifying targets for improving patient safety in the ED. 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/

Background Error Correlation Modeling with Diffusion Operators

DTIC Science & Technology

2013-01-01

RESPONSIBLE PERSON 19b. TELEPHONE NUMBER (Include area code) 07-10-2013 Book Chapter Background Error Correlation Modeling with Diffusion Operators...normalization Unclassified Unclassified Unclassified UU 27 Max Yaremchuk (228) 688-5259 Reset Chapter 8 Background error correlation modeling with diffusion ...field, then a structure like this simulates enhanced diffusive transport of model errors in the regions of strong cur- rents on the background of

Informal Learning from Error in Hospitals: What Do We Learn, How Do We Learn and How Can Informal Learning Be Enhanced? A Narrative Review

ERIC Educational Resources Information Center

de Feijter, Jeantine M.; de Grave, Willem S.; Koopmans, Richard P.; Scherpbier, Albert J. J. A.

2013-01-01

Learning from error is not just an individual endeavour. Organisations also learn from error. Hospitals provide many learning opportunities, which can be formal or informal. Informal learning from error in hospitals has not been researched in much depth so this narrative review focuses on five learning opportunities: morbidity and mortality…

Searching for the Final Answer: Factors Contributing to Medication Administration Errors.

ERIC Educational Resources Information Center

Pape, Tess M.

2001-01-01

Causal factors contributing to errors in medication administration should be thoroughly investigated, focusing on systems rather than individual nurses. Unless systemic causes are addressed, many errors will go unreported for fear of reprisal. (Contains 42 references.) (SK)

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.

Vision-Enhancing Interventions in Nursing Home Residents and Their Short-Term Impact on Physical and Cognitive Function

PubMed Central

Elliott, Amanda F.; McGwin, Gerald; Owsley, Cynthia

2009-01-01

OBJECTIVE To evaluate the effect of vision-enhancing interventions (i.e., cataract surgery or refractive error correction) on physical function and cognitive status in nursing home residents. DESIGN Longitudinal cohort study. SETTING Seventeen nursing homes in Birmingham, AL. PARTICIPANTS A total of 187 English-speaking older adults (>55 years of age). INTERVENTION Participants took part in one of two vision-enhancing interventions: cataract surgery or refractive error correction. Each group was compared against a control group (persons eligible for but who declined cataract surgery, or who received delayed correction of refractive error). MEASUREMENTS Physical function (i.e., ability to perform activities of daily living and mobility) was assessed with a series of self-report and certified nursing assistant ratings at baseline and at 2 months for the refractive error correction group, and at 4 months for the cataract surgery group. The Mini Mental State Exam was also administered. RESULTS No significant differences existed within or between groups from baseline to follow-up on any of the measures of physical function. Mental status scores significantly declined from baseline to follow-up for both the immediate (p= 0.05) and delayed (p< 0.02) refractive error correction groups and for the cataract surgery control group (p= 0.05). CONCLUSION Vision-enhancing interventions did not lead to short-term improvements in physical functioning or cognitive status in this sample of elderly nursing home residents. PMID:19170783

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

NASA Technical Reports Server (NTRS)

Alexander, Tiffaney Miller

2017-01-01

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

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

NASA Technical Reports Server (NTRS)

Alexander, Tiffaney Miller

2017-01-01

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

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

NASA Technical Reports Server (NTRS)

Alexander, Tiffaney Miller

2017-01-01

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

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

PubMed

Kraemer, Sara; Carayon, Pascale

2007-03-01

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

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

PubMed

Zabari, Mara Lynne; Southern, Nancy L

2018-04-17

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

[Innovative training for enhancing patient safety. Safety culture and integrated concepts].

PubMed

Rall, M; Schaedle, B; Zieger, J; Naef, W; Weinlich, M

2002-11-01

Patient safety is determined by the performance safety of the medical team. Errors in medicine are amongst the leading causes of death of hospitalized patients. These numbers call for action. Backgrounds, methods and new forms of training are introduced in this article. Concepts from safety research are transformed to the field of emergency medical treatment. Strategies from realistic patient simulator training sessions and innovative training concepts are discussed. The reasons for the high numbers of errors in medicine are not due to a lack of medical knowledge, but due to human factors and organisational circumstances. A first step towards an improved patient safety is to accept this. We always need to be prepared that errors will occur. A next step would be to separate "error" from guilt (culture of blame) allowing for a real analysis of accidents and establishment of meaningful incident reporting systems. Concepts with a good success record from aviation like "crew resource management" (CRM) training have been adapted my medicine and are ready to use. These concepts require theoretical education as well as practical training. Innovative team training sessions using realistic patient simulator systems with video taping (for self reflexion) and interactive debriefing following the sessions are very promising. As the need to reduce error rates in medicine is very high and the reasons, methods and training concepts are known, we are urged to implement these new training concepts widely and consequently. To err is human - not to counteract it is not.

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

PubMed

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

2016-01-01

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

Point-based warping with optimized weighting factors of displacement vectors

NASA Astrophysics Data System (ADS)

Pielot, Ranier; Scholz, Michael; Obermayer, Klaus; Gundelfinger, Eckart D.; Hess, Andreas

2000-06-01

The accurate comparison of inter-individual 3D image brain datasets requires non-affine transformation techniques (warping) to reduce geometric variations. Constrained by the biological prerequisites we use in this study a landmark-based warping method with weighted sums of displacement vectors, which is enhanced by an optimization process. Furthermore, we investigate fast automatic procedures for determining landmarks to improve the practicability of 3D warping. This combined approach was tested on 3D autoradiographs of Gerbil brains. The autoradiographs were obtained after injecting a non-metabolized radioactive glucose derivative into the Gerbil thereby visualizing neuronal activity in the brain. Afterwards the brain was processed with standard autoradiographical methods. The landmark-generator computes corresponding reference points simultaneously within a given number of datasets by Monte-Carlo-techniques. The warping function is a distance weighted exponential function with a landmark- specific weighting factor. These weighting factors are optimized by a computational evolution strategy. The warping quality is quantified by several coefficients (correlation coefficient, overlap-index, and registration error). The described approach combines a highly suitable procedure to automatically detect landmarks in autoradiographical brain images and an enhanced point-based warping technique, optimizing the local weighting factors. This optimization process significantly improves the similarity between the warped and the target dataset.

Absence of Mutagenic Activity of Hycanthone in Serratia marcescens,

DTIC Science & Technology

1986-05-29

repair system but is enhanced by the plasmid pKMl01, which mediates the inducible error-prone repair system. Hycanthone, like proflavin , .1...enhanced by the plasmid pKM10, which mediates the inducible error-prone repair system. Hycanthone, like proflavin , intercalates between the stacked bases...Roth (1974) lave suggested that proflavin , which has a planar triple ring structure similar to hycanthone, interacts with DNA, which upon replication

Blob-enhanced reconstruction technique

NASA Astrophysics Data System (ADS)

Castrillo, Giusy; Cafiero, Gioacchino; Discetti, Stefano; Astarita, Tommaso

2016-09-01

A method to enhance the quality of the tomographic reconstruction and, consequently, the 3D velocity measurement accuracy, is presented. The technique is based on integrating information on the objects to be reconstructed within the algebraic reconstruction process. A first guess intensity distribution is produced with a standard algebraic method, then the distribution is rebuilt as a sum of Gaussian blobs, based on location, intensity and size of agglomerates of light intensity surrounding local maxima. The blobs substitution regularizes the particle shape allowing a reduction of the particles discretization errors and of their elongation in the depth direction. The performances of the blob-enhanced reconstruction technique (BERT) are assessed with a 3D synthetic experiment. The results have been compared with those obtained by applying the standard camera simultaneous multiplicative reconstruction technique (CSMART) to the same volume. Several blob-enhanced reconstruction processes, both substituting the blobs at the end of the CSMART algorithm and during the iterations (i.e. using the blob-enhanced reconstruction as predictor for the following iterations), have been tested. The results confirm the enhancement in the velocity measurements accuracy, demonstrating a reduction of the bias error due to the ghost particles. The improvement is more remarkable at the largest tested seeding densities. Additionally, using the blobs distributions as a predictor enables further improvement of the convergence of the reconstruction algorithm, with the improvement being more considerable when substituting the blobs more than once during the process. The BERT process is also applied to multi resolution (MR) CSMART reconstructions, permitting simultaneously to achieve remarkable improvements in the flow field measurements and to benefit from the reduction in computational time due to the MR approach. Finally, BERT is also tested on experimental data, obtaining an increase of the signal-to-noise ratio in the reconstructed flow field and a higher value of the correlation factor in the velocity measurements with respect to the volume to which the particles are not replaced.

Post-error Brain Activity Correlates With Incidental Memory for Negative Words

PubMed Central

Senderecka, Magdalena; Ociepka, Michał; Matyjek, Magdalena; Kroczek, Bartłomiej

2018-01-01

The present study had three main objectives. First, we aimed to evaluate whether short-duration affective states induced by negative and positive words can lead to increased error-monitoring activity relative to a neutral task condition. Second, we intended to determine whether such an enhancement is limited to words of specific valence or is a general response to arousing material. Third, we wanted to assess whether post-error brain activity is associated with incidental memory for negative and/or positive words. Participants performed an emotional stop-signal task that required response inhibition to negative, positive or neutral nouns while EEG was recorded. Immediately after the completion of the task, they were instructed to recall as many of the presented words as they could in an unexpected free recall test. We observed significantly greater brain activity in the error-positivity (Pe) time window in both negative and positive trials. The error-related negativity amplitudes were comparable in both the neutral and emotional arousing trials, regardless of their valence. Regarding behavior, increased processing of emotional words was reflected in better incidental recall. Importantly, the memory performance for negative words was positively correlated with the Pe amplitude, particularly in the negative condition. The source localization analysis revealed that the subsequent memory recall for negative words was associated with widespread bilateral brain activity in the dorsal anterior cingulate cortex and in the medial frontal gyrus, which was registered in the Pe time window during negative trials. The present study has several important conclusions. First, it indicates that the emotional enhancement of error monitoring, as reflected by the Pe amplitude, may be induced by stimuli with symbolic, ontogenetically learned emotional significance. Second, it indicates that the emotion-related enhancement of the Pe occurs across both negative and positive conditions, thus it is preferentially driven by the arousal content of an affective stimuli. Third, our findings suggest that enhanced error monitoring and facilitated recall of negative words may both reflect responsivity to negative events. More speculatively, they can also indicate that post-error activity of the medial prefrontal cortex may selectively support encoding for negative stimuli and contribute to their privileged access to memory. PMID:29867408

Written Identification of Errors to Learn Professional Procedures in VET

ERIC Educational Resources Information Center

Boldrini, Elena; Cattaneo, Alberto

2013-01-01

Research has demonstrated that the use of worked-out examples to present errors has great potential for procedural knowledge acquirement. Nevertheless, the identification of errors alone does not directly enhance a deep learning process if it is not adequately scaffolded by written self-explanations. We hypothesised that in learning a professional…

Using Six Sigma to reduce medication errors in a home-delivery pharmacy service.

PubMed

Castle, Lon; Franzblau-Isaac, Ellen; Paulsen, Jim

2005-06-01

Medco Health Solutions, Inc. conducted a project to reduce medication errors in its home-delivery service, which is composed of eight prescription-processing pharmacies, three dispensing pharmacies, and six call-center pharmacies. Medco uses the Six Sigma methodology to reduce process variation, establish procedures to monitor the effectiveness of medication safety programs, and determine when these efforts do not achieve performance goals. A team reviewed the processes in home-delivery pharmacy and suggested strategies to improve the data-collection and medication-dispensing practices. A variety of improvement activities were implemented, including a procedure for developing, reviewing, and enhancing sound-alike/look-alike (SALA) alerts and system enhancements to improve processing consistency across the pharmacies. "External nonconformances" were reduced for several categories of medication errors, including wrong-drug selection (33%), wrong directions (49%), and SALA errors (69%). Control charts demonstrated evidence of sustained process improvement and actual reduction in specific medication error elements. Establishing a continuous quality improvement process to ensure that medication errors are minimized is critical to any health care organization providing medication services.

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.

National plan to enhance aviation safety through human factors improvements

NASA Technical Reports Server (NTRS)

Foushee, Clay

1990-01-01

The purpose of this section of the plan is to establish a development and implementation strategy plan for improving safety and efficiency in the Air Traffic Control (ATC) system. These improvements will be achieved through the proper applications of human factors considerations to the present and future systems. The program will have four basic goals: (1) prepare for the future system through proper hiring and training; (2) develop a controller work station team concept (managing human errors); (3) understand and address the human factors implications of negative system results; and (4) define the proper division of responsibilities and interactions between the human and the machine in ATC systems. This plan addresses six program elements which together address the overall purpose. The six program elements are: (1) determine principles of human-centered automation that will enhance aviation safety and the efficiency of the air traffic controller; (2) provide new and/or enhanced methods and techniques to measure, assess, and improve human performance in the ATC environment; (3) determine system needs and methods for information transfer between and within controller teams and between controller teams and the cockpit; (4) determine how new controller work station technology can optimally be applied and integrated to enhance safety and efficiency; (5) assess training needs and develop improved techniques and strategies for selection, training, and evaluation of controllers; and (6) develop standards, methods, and procedures for the certification and validation of human engineering in the design, testing, and implementation of any hardware or software system element which affects information flow to or from the human.

Assessment of workload using NASA Task Load Index in perianesthesia nursing.

PubMed

Young, Gloria; Zavelina, Lyubov; Hooper, Vallire

2008-04-01

According to the Institute of Medicine (IOM), as many as 44,000 to 98,000 people in the United States die in hospitals every year due to medical errors. Multiple physiological and psychological factors can impact the health care provider's attention span, making medical errors more likely. Some of these factors include increased workload, fatigue, cognitive overload, ineffective interpersonal communications, and faulty information processing. Postanesthesia nurses, responsible for providing care to unstable patients emerging from anesthesia with multiple life-threatening conditions, must make critical decisions on a minute-by-minute basis. The current ASPAN Patient Classification/Recommended Staffing Guidelines does not adequately take into account varying care requirements among the patients. If a tool could be found that effectively evaluated staff's workload, ongoing assessment would be enhanced and resources better used. The National Aeronautics and Space Administration-Task Load Index (NASA-TLX), a multifaceted tool for evaluating perceptual (subjective) workload, has seen extensive applications and is widely regarded as the strongest tool available for reporting perceptions of workload. This article will survey various uses of the NASA-TLX and consider the potential uses for this tool in perianesthesia nursing.

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

PubMed

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

2013-08-01

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

Analyzing Software Requirements Errors in Safety-Critical, Embedded Systems

NASA Technical Reports Server (NTRS)

Lutz, Robyn R.

1993-01-01

This paper analyzes the root causes of safety-related software errors in safety-critical, embedded systems. The results show that software errors identified as potentially hazardous to the system tend to be produced by different error mechanisms than non- safety-related software errors. Safety-related software errors are shown to arise most commonly from (1) discrepancies between the documented requirements specifications and the requirements needed for correct functioning of the system and (2) misunderstandings of the software's interface with the rest of the system. The paper uses these results to identify methods by which requirements errors can be prevented. The goal is to reduce safety-related software errors and to enhance the safety of complex, embedded systems.

Autonomous Quantum Error Correction with Application to Quantum Metrology

NASA Astrophysics Data System (ADS)

Reiter, Florentin; Sorensen, Anders S.; Zoller, Peter; Muschik, Christine A.

2017-04-01

We present a quantum error correction scheme that stabilizes a qubit by coupling it to an engineered environment which protects it against spin- or phase flips. Our scheme uses always-on couplings that run continuously in time and operates in a fully autonomous fashion without the need to perform measurements or feedback operations on the system. The correction of errors takes place entirely at the microscopic level through a build-in feedback mechanism. Our dissipative error correction scheme can be implemented in a system of trapped ions and can be used for improving high precision sensing. We show that the enhanced coherence time that results from the coupling to the engineered environment translates into a significantly enhanced precision for measuring weak fields. In a broader context, this work constitutes a stepping stone towards the paradigm of self-correcting quantum information processing.

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

PubMed

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

2006-01-01

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

Minimizing driver errors: examining factors leading to failed target tracking and detection.

DOT National Transportation Integrated Search

2013-06-01

Driving a motor vehicle is a common practice for many individuals. Although driving becomes : repetitive and a very habitual task, errors can occur that lead to accidents. One factor that can be a : cause for such errors is a lapse in attention or a ...

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

DOT National Transportation Integrated Search

2002-07-01

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

Calibration and error analysis of metal-oxide-semiconductor field-effect transistor dosimeters for computed tomography radiation dosimetry.

PubMed

Trattner, Sigal; Prinsen, Peter; Wiegert, Jens; Gerland, Elazar-Lars; Shefer, Efrat; Morton, Tom; Thompson, Carla M; Yagil, Yoad; Cheng, Bin; Jambawalikar, Sachin; Al-Senan, Rani; Amurao, Maxwell; Halliburton, Sandra S; Einstein, Andrew J

2017-12-01

Metal-oxide-semiconductor field-effect transistors (MOSFETs) serve as a helpful tool for organ radiation dosimetry and their use has grown in computed tomography (CT). While different approaches have been used for MOSFET calibration, those using the commonly available 100 mm pencil ionization chamber have not incorporated measurements performed throughout its length, and moreover, no previous work has rigorously evaluated the multiple sources of error involved in MOSFET calibration. In this paper, we propose a new MOSFET calibration approach to translate MOSFET voltage measurements into absorbed dose from CT, based on serial measurements performed throughout the length of a 100-mm ionization chamber, and perform an analysis of the errors of MOSFET voltage measurements and four sources of error in calibration. MOSFET calibration was performed at two sites, to determine single calibration factors for tube potentials of 80, 100, and 120 kVp, using a 100-mm-long pencil ion chamber and a cylindrical computed tomography dose index (CTDI) phantom of 32 cm diameter. The dose profile along the 100-mm ion chamber axis was sampled in 5 mm intervals by nine MOSFETs in the nine holes of the CTDI phantom. Variance of the absorbed dose was modeled as a sum of the MOSFET voltage measurement variance and the calibration factor variance, the latter being comprised of three main subcomponents: ionization chamber reading variance, MOSFET-to-MOSFET variation and a contribution related to the fact that the average calibration factor of a few MOSFETs was used as an estimate for the average value of all MOSFETs. MOSFET voltage measurement error was estimated based on sets of repeated measurements. The calibration factor overall voltage measurement error was calculated from the above analysis. Calibration factors determined were close to those reported in the literature and by the manufacturer (~3 mV/mGy), ranging from 2.87 to 3.13 mV/mGy. The error σ V of a MOSFET voltage measurement was shown to be proportional to the square root of the voltage V: σV=cV where c = 0.11 mV. A main contributor to the error in the calibration factor was the ionization chamber reading error with 5% error. The usage of a single calibration factor for all MOSFETs introduced an additional error of about 5-7%, depending on the number of MOSFETs that were used to determine the single calibration factor. The expected overall error in a high-dose region (~30 mGy) was estimated to be about 8%, compared to 6% when an individual MOSFET calibration was performed. For a low-dose region (~3 mGy), these values were 13% and 12%. A MOSFET calibration method was developed using a 100-mm pencil ion chamber and a CTDI phantom, accompanied by an absorbed dose error analysis reflecting multiple sources of measurement error. When using a single calibration factor, per tube potential, for different MOSFETs, only a small error was introduced into absorbed dose determinations, thus supporting the use of a single calibration factor for experiments involving many MOSFETs, such as those required to accurately estimate radiation effective dose. © 2017 American Association of Physicists in Medicine.

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.

Identifying Human Factors Issues in Aircraft Maintenance Operations

NASA Technical Reports Server (NTRS)

Veinott, Elizabeth S.; Kanki, Barbara G.; Shafto, Michael G. (Technical Monitor)

1995-01-01

Maintenance operations incidents submitted to the Aviation Safety Reporting System (ASRS) between 1986-1992 were systematically analyzed in order to identify issues relevant to human factors and crew coordination. This exploratory analysis involved 95 ASRS reports which represented a wide range of maintenance incidents. The reports were coded and analyzed according to the type of error (e.g, wrong part, procedural error, non-procedural error), contributing factors (e.g., individual, within-team, cross-team, procedure, tools), result of the error (e.g., aircraft damage or not) as well as the operational impact (e.g., aircraft flown to destination, air return, delay at gate). The main findings indicate that procedural errors were most common (48.4%) and that individual and team actions contributed to the errors in more than 50% of the cases. As for operational results, most errors were either corrected after landing at the destination (51.6%) or required the flight crew to stop enroute (29.5%). Interactions among these variables are also discussed. This analysis is a first step toward developing a taxonomy of crew coordination problems in maintenance. By understanding what variables are important and how they are interrelated, we may develop intervention strategies that are better tailored to the human factor issues involved.

Precision and accuracy of clinical quantification of myocardial blood flow by dynamic PET: A technical perspective.

PubMed

Moody, Jonathan B; Lee, Benjamin C; Corbett, James R; Ficaro, Edward P; Murthy, Venkatesh L

2015-10-01

A number of exciting advances in PET/CT technology and improvements in methodology have recently converged to enhance the feasibility of routine clinical quantification of myocardial blood flow and flow reserve. Recent promising clinical results are pointing toward an important role for myocardial blood flow in the care of patients. Absolute blood flow quantification can be a powerful clinical tool, but its utility will depend on maintaining precision and accuracy in the face of numerous potential sources of methodological errors. Here we review recent data and highlight the impact of PET instrumentation, image reconstruction, and quantification methods, and we emphasize (82)Rb cardiac PET which currently has the widest clinical application. It will be apparent that more data are needed, particularly in relation to newer PET technologies, as well as clinical standardization of PET protocols and methods. We provide recommendations for the methodological factors considered here. At present, myocardial flow reserve appears to be remarkably robust to various methodological errors; however, with greater attention to and more detailed understanding of these sources of error, the clinical benefits of stress-only blood flow measurement may eventually be more fully realized.

Perspectives on empirical approaches for ocean color remote sensing of chlorophyll in a changing climate.

PubMed

Dierssen, Heidi M

2010-10-05

Phytoplankton biomass and productivity have been continuously monitored from ocean color satellites for over a decade. Yet, the most widely used empirical approach for estimating chlorophyll a (Chl) from satellites can be in error by a factor of 5 or more. Such variability is due to differences in absorption and backscattering properties of phytoplankton and related concentrations of colored-dissolved organic matter (CDOM) and minerals. The empirical algorithms have built-in assumptions that follow the basic precept of biological oceanography--namely, oligotrophic regions with low phytoplankton biomass are populated with small phytoplankton, whereas more productive regions contain larger bloom-forming phytoplankton. With a changing world ocean, phytoplankton composition may shift in response to altered environmental forcing, and CDOM and mineral concentrations may become uncoupled from phytoplankton stocks, creating further uncertainty and error in the empirical approaches. Hence, caution is warranted when using empirically derived Chl to infer climate-related changes in ocean biology. The Southern Ocean is already experiencing climatic shifts and shows substantial errors in satellite-derived Chl for different phytoplankton assemblages. Accurate global assessments of phytoplankton will require improved technology and modeling, enhanced field observations, and ongoing validation of our "eyes in space."

Metacognitive Unawareness of the Errorful Generation Benefit and Its Effects on Self-Regulated Learning

ERIC Educational Resources Information Center

Yang, Chunliang; Potts, Rosalind; Shanks, David R.

2017-01-01

Generating errors followed by corrective feedback enhances retention more effectively than does reading--the benefit of errorful generation--but people tend to be unaware of this benefit. The current research explored this metacognitive unawareness, its effect on self-regulated learning, and how to alleviate or reverse it. People's beliefs about…

Enhanced intercarrier interference mitigation based on encoded bit-sequence distribution inside optical superchannels

NASA Astrophysics Data System (ADS)

Torres, Jhon James Granada; Soto, Ana María Cárdenas; González, Neil Guerrero

2016-10-01

In the context of gridless optical multicarrier systems, we propose a method for intercarrier interference (ICI) mitigation which allows bit error correction in scenarios of nonspectral flatness between the subcarriers composing the multicarrier system and sub-Nyquist carrier spacing. We propose a hybrid ICI mitigation technique which exploits the advantages of signal equalization at both levels: the physical level for any digital and analog pulse shaping, and the bit-data level and its ability to incorporate advanced correcting codes. The concatenation of these two complementary techniques consists of a nondata-aided equalizer applied to each optical subcarrier, and a hard-decision forward error correction applied to the sequence of bits distributed along the optical subcarriers regardless of prior subchannel quality assessment as performed in orthogonal frequency-division multiplexing modulations for the implementation of the bit-loading technique. The impact of the ICI is systematically evaluated in terms of bit-error-rate as a function of the carrier frequency spacing and the roll-off factor of the digital pulse-shaping filter for a simulated 3×32-Gbaud single-polarization quadrature phase shift keying Nyquist-wavelength division multiplexing system. After the ICI mitigation, a back-to-back error-free decoding was obtained for sub-Nyquist carrier spacings of 28.5 and 30 GHz and roll-off values of 0.1 and 0.4, respectively.

Application of round grating angle measurement composite error amendment in the online measurement accuracy improvement of large diameter

NASA Astrophysics Data System (ADS)

Wang, Biao; Yu, Xiaofen; Li, Qinzhao; Zheng, Yu

2008-10-01

The paper aiming at the influence factor of round grating dividing error, rolling-wheel produce eccentricity and surface shape errors provides an amendment method based on rolling-wheel to get the composite error model which includes all influence factors above, and then corrects the non-circle measurement angle error of the rolling-wheel. We make soft simulation verification and have experiment; the result indicates that the composite error amendment method can improve the diameter measurement accuracy with rolling-wheel theory. It has wide application prospect for the measurement accuracy higher than 5 μm/m.

Challenge and Error: Critical Events and Attention-Related Errors

ERIC Educational Resources Information Center

Cheyne, James Allan; Carriere, Jonathan S. A.; Solman, Grayden J. F.; Smilek, Daniel

2011-01-01

Attention lapses resulting from reactivity to task challenges and their consequences constitute a pervasive factor affecting everyday performance errors and accidents. A bidirectional model of attention lapses (error [image omitted] attention-lapse: Cheyne, Solman, Carriere, & Smilek, 2009) argues that errors beget errors by generating attention…

Treatment of ocean tide aliasing in the context of a next generation gravity field mission

NASA Astrophysics Data System (ADS)

Hauk, Markus; Pail, Roland

2018-07-01

Current temporal gravity field solutions from Gravity Recovery and Climate Experiment (GRACE) suffer from temporal aliasing errors due to undersampling of signal to be recovered (e.g. hydrology), uncertainties in the de-aliasing models (usually atmosphere and ocean) and imperfect ocean tide models. Especially the latter will be one of the most limiting factors in determining high-resolution temporal gravity fields from future gravity missions such as GRACE Follow-On and Next-Generation Gravity Missions (NGGM). In this paper a method to co-parametrize ocean tide parameters of the eight main tidal constituents over time spans of several years is analysed and assessed. Numerical closed-loop simulations of low-low satellite-to-satellite-tracking missions for a single polar pair and a double pair Bender-type formation are performed, using time variable geophysical background models and noise assumptions for new generation instrument technology. Compared to the single pair mission, results show a reduction of tide model errors up to 70 per cent for dedicated tidal constituents due to an enhanced spatial and temporal sampling and error isotropy for the double pair constellation. Extending the observation period from 1 to 3 yr leads to a further reduction of tidal errors up to 60 per cent for certain constituents, and considering non-tidal mass changes during the estimation process leads to reductions of tidal errors between 20 and 80 per cent. As part of a two-step approach, the estimated tide model is used for de-aliasing during gravity field retrieval in a second iteration, resulting in more than 50 per cent reduction of ocean tide aliasing errors for a NGGM Bender-type formation.

Treatment of ocean tide aliasing in the context of a next generation gravity field mission

NASA Astrophysics Data System (ADS)

Hauk, Markus; Pail, Roland

2018-04-01

Current temporal gravity field solutions from GRACE suffer from temporal aliasing errors due to under-sampling of signal to be recovered (e.g. hydrology), uncertainties in the de-aliasing models (usually atmosphere and ocean), and imperfect ocean tide models. Especially the latter will be one of the most limiting factors in determining high resolution temporal gravity fields from future gravity missions such as GRACE Follow-on and Next-Generation Gravity Missions (NGGM). In this paper a method to co-parameterize ocean tide parameters of the 8 main tidal constituents over time spans of several years is analysed and assessed. Numerical closed-loop simulations of low-low satellite-to-satellite-tracking missions for a single polar pair and a double pair Bender-type formation are performed, using time variable geophysical background models and noise assumptions for new generation instrument technology. Compared to the single pair mission, results show a reduction of tide model errors up to 70 per cent for dedicated tidal constituents due to an enhanced spatial and temporal sampling and error isotropy for the double pair constellation. Extending the observation period from one to three years leads to a further reduction of tidal errors up to 60 per cent for certain constituents, and considering non-tidal mass changes during the estimation process leads to reductions of tidal errors between 20 per cent and 80 per cent. As part of a two-step approach, the estimated tide model is used for de-aliasing during gravity field retrieval in a second iteration, resulting in more than 50 per cent reduction of ocean tide aliasing errors for a NGGM Bender-type formation.

[Effect of actoprotectors on the work capacity of operators during modeling of various factors of space flight].

PubMed

Bobkov, Iu G; Epishkin, A K

1988-01-01

This paper presents experimental findings indicating that bemithyl, an actoprotective agent, has a beneficial effect on the health status and work capacity of operators during simulated space flight and 56-hour continuous work. The drug enhanced psychophysiological tolerance of the operators and improved the quality of their work: the quality of their compensatory tracking was on the average 10% higher, the number of errors of their porsuit tracking was 1.8 times lower, and the time of visual signal detection was 2.4 times shorter as compared to the placebo controls.

Comparison of Resource Requirements for a Wind Tunnel Test Designed with Conventional vs. Modern Design of Experiments Methods

NASA Technical Reports Server (NTRS)

DeLoach, Richard; Micol, John R.

2011-01-01

The factors that determine data volume requirements in a typical wind tunnel test are identified. It is suggested that productivity in wind tunnel testing can be enhanced by managing the inference error risk associated with evaluating residuals in a response surface modeling experiment. The relationship between minimum data volume requirements and the factors upon which they depend is described and certain simplifications to this relationship are realized when specific model adequacy criteria are adopted. The question of response model residual evaluation is treated and certain practical aspects of response surface modeling are considered, including inference subspace truncation. A wind tunnel test plan developed by using the Modern Design of Experiments illustrates the advantages of an early estimate of data volume requirements. Comparisons are made with a representative One Factor At a Time (OFAT) wind tunnel test matrix developed to evaluate a surface to air missile.

A Sensemaking Perspective on Situation Awareness in Power Grid Operations

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

Greitzer, Frank L.; Schur, Anne; Paget, Mia L.

2008-07-21

With increasing complexity and interconnectivity of the electric power grid, the scope and complexity of grid operations continues to grow. New paradigms are needed to guide research to improve operations by enhancing situation awareness of operators. Research on human factors/situation awareness is described within a taxonomy of tools and approaches that address different levels of cognitive processing. While user interface features and visualization approaches represent the predominant focus of human factors studies of situation awareness, this paper argues that a complementary level, sensemaking, deserves further consideration by designers of decision support systems for power grid operations. A sensemaking perspective onmore » situation aware-ness may reveal new insights that complement ongoing human factors research, where the focus of the investigation of errors is to understand why the decision makers experienced the situation the way they did, or why what they saw made sense to them at the time.« less

Error Propagation Analysis in the SAE Architecture Analysis and Design Language (AADL) and the EDICT Tool Framework

NASA Technical Reports Server (NTRS)

LaValley, Brian W.; Little, Phillip D.; Walter, Chris J.

2011-01-01

This report documents the capabilities of the EDICT tools for error modeling and error propagation analysis when operating with models defined in the Architecture Analysis & Design Language (AADL). We discuss our experience using the EDICT error analysis capabilities on a model of the Scalable Processor-Independent Design for Enhanced Reliability (SPIDER) architecture that uses the Reliable Optical Bus (ROBUS). Based on these experiences we draw some initial conclusions about model based design techniques for error modeling and analysis of highly reliable computing architectures.

Resolution-enhancement and sampling error correction based on molecular absorption line in frequency scanning interferometry

NASA Astrophysics Data System (ADS)

Pan, Hao; Qu, Xinghua; Shi, Chunzhao; Zhang, Fumin; Li, Yating

2018-06-01

The non-uniform interval resampling method has been widely used in frequency modulated continuous wave (FMCW) laser ranging. In the large-bandwidth and long-distance measurements, the range peak is deteriorated due to the fiber dispersion mismatch. In this study, we analyze the frequency-sampling error caused by the mismatch and measure it using the spectroscopy of molecular frequency references line. By using the adjacent points' replacement and spline interpolation technique, the sampling errors could be eliminated. The results demonstrated that proposed method is suitable for resolution-enhancement and high-precision measurement. Moreover, using the proposed method, we achieved the precision of absolute distance less than 45 μm within 8 m.

Proposed Interventions to Decrease the Frequency of Missed Test Results

ERIC Educational Resources Information Center

Wahls, Terry L.; Cram, Peter

2009-01-01

Numerous studies have identified that delays in diagnosis related to the mishandling of abnormal test results are an import contributor to diagnostic errors. Factors contributing to missed results included organizational factors, provider factors and patient-related factors. At the diagnosis error conference continuing medical education conference…

Generalized approach for using unbiased symmetric metrics with negative values: normalized mean bias factor and normalized mean absolute error factor

EPA Science Inventory

Unbiased symmetric metrics provide a useful measure to quickly compare two datasets, with similar interpretations for both under and overestimations. Two examples include the normalized mean bias factor and normalized mean absolute error factor. However, the original formulations...

Defining the Relationship Between Human Error Classes and Technology Intervention Strategies

NASA Technical Reports Server (NTRS)

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

2002-01-01

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

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.

Factors contributing to young moped rider accidents in Denmark.

PubMed

Møller, Mette; Haustein, Sonja

2016-02-01

Young road users still constitute a high-risk group with regard to road traffic accidents. The crash rate of a moped is four times greater than that of a motorcycle, and the likelihood of being injured in a road traffic accident is 10-20 times higher among moped riders compared to car drivers. Nevertheless, research on the behaviour and accident involvement of young moped riders remains sparse. Based on analysis of 128 accident protocols, the purpose of this study was to increase knowledge about moped accidents. The study was performed in Denmark involving riders aged 16 or 17. A distinction was made between accident factors related to (1) the road and its surroundings, (2) the vehicle, and (3) the reported behaviour and condition of the road user. Thirteen accident factors were identified with the majority concerning the reported behaviour and condition of the road user. The average number of accident factors assigned per accident was 2.7. Riding speed was assigned in 45% of the accidents which made it the most frequently assigned factor on the part of the moped rider followed by attention errors (42%), a tuned up moped (29%) and position on the road (14%). For the other parties involved, attention error (52%) was the most frequently assigned accident factor. The majority (78%) of the accidents involved road rule breaching on the part of the moped rider. The results indicate that preventive measures should aim to eliminate violations and increase anticipatory skills among moped riders and awareness of mopeds among other road users. Due to their young age the effect of such measures could be enhanced by infrastructural measures facilitating safe interaction between mopeds and other road users. Copyright © 2015 Elsevier Ltd. All rights reserved.

An Enhanced MEMS Error Modeling Approach Based on Nu-Support Vector Regression

PubMed Central

Bhatt, Deepak; Aggarwal, Priyanka; Bhattacharya, Prabir; Devabhaktuni, Vijay

2012-01-01

Micro Electro Mechanical System (MEMS)-based inertial sensors have made possible the development of a civilian land vehicle navigation system by offering a low-cost solution. However, the accurate modeling of the MEMS sensor errors is one of the most challenging tasks in the design of low-cost navigation systems. These sensors exhibit significant errors like biases, drift, noises; which are negligible for higher grade units. Different conventional techniques utilizing the Gauss Markov model and neural network method have been previously utilized to model the errors. However, Gauss Markov model works unsatisfactorily in the case of MEMS units due to the presence of high inherent sensor errors. On the other hand, modeling the random drift utilizing Neural Network (NN) is time consuming, thereby affecting its real-time implementation. We overcome these existing drawbacks by developing an enhanced Support Vector Machine (SVM) based error model. Unlike NN, SVMs do not suffer from local minimisation or over-fitting problems and delivers a reliable global solution. Experimental results proved that the proposed SVM approach reduced the noise standard deviation by 10–35% for gyroscopes and 61–76% for accelerometers. Further, positional error drifts under static conditions improved by 41% and 80% in comparison to NN and GM approaches. PMID:23012552

New Integrated Modeling Capabilities: MIDAS' Recent Behavioral Enhancements

NASA Technical Reports Server (NTRS)

Gore, Brian F.; Jarvis, Peter A.

2005-01-01

The Man-machine Integration Design and Analysis System (MIDAS) is an integrated human performance modeling software tool that is based on mechanisms that underlie and cause human behavior. A PC-Windows version of MIDAS has been created that integrates the anthropometric character "Jack (TM)" with MIDAS' validated perceptual and attention mechanisms. MIDAS now models multiple simulated humans engaging in goal-related behaviors. New capabilities include the ability to predict situations in which errors and/or performance decrements are likely due to a variety of factors including concurrent workload and performance influencing factors (PIFs). This paper describes a new model that predicts the effects of microgravity on a mission specialist's performance, and its first application to simulating the task of conducting a Life Sciences experiment in space according to a sequential or parallel schedule of performance.

Noise-Enhanced Eversion Force Sense in Ankles With or Without Functional Instability.

PubMed

Ross, Scott E; Linens, Shelley W; Wright, Cynthia J; Arnold, Brent L

2015-08-01

Force sense impairments are associated with functional ankle instability. Stochastic resonance stimulation (SRS) may have implications for correcting these force sense deficits. To determine if SRS improved force sense. Case-control study. Research laboratory. Twelve people with functional ankle instability (age = 23 ± 3 years, height = 174 ± 8 cm, mass = 69 ± 10 kg) and 12 people with stable ankles (age = 22 ± 2 years, height = 170 ± 7 cm, mass = 64 ± 10 kg). The eversion force sense protocol required participants to reproduce a targeted muscle tension (10% of maximum voluntary isometric contraction). This protocol was assessed under SRSon and SRSoff (control) conditions. During SRSon, random subsensory mechanical noise was applied to the lower leg at a customized optimal intensity for each participant. Constant error, absolute error, and variable error measures quantified accuracy, overall performance, and consistency of force reproduction, respectively. With SRS, we observed main effects for force sense absolute error (SRSoff = 1.01 ± 0.67 N, SRSon = 0.69 ± 0.42 N) and variable error (SRSoff = 1.11 ± 0.64 N, SRSon = 0.78 ± 0.56 N) (P < .05). No other main effects or treatment-by-group interactions were found (P > .05). Although SRS reduced the overall magnitude (absolute error) and variability (variable error) of force sense errors, it had no effect on the directionality (constant error). Clinically, SRS may enhance muscle tension ability, which could have treatment implications for ankle stability.

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.

Far-side geometrical enhancement in surface-enhanced Raman scattering with Ag plasmonic films

NASA Astrophysics Data System (ADS)

Perera, M. Nilusha M. N.; Gibbs, W. E. Keith; Juodkazis, Saulius; Stoddart, Paul R.

2018-01-01

Surface-enhanced Raman scattering (SERS) is a surface sensitive technique where the large increase in scattering has primarily been attributed to electromagnetic and chemical enhancements. While smaller geometrical enhancements due to thin film interference and cavity resonances have also been reported, an additional enhancement in the SERS signal, referred to as the `far-side geometrical enhancement', occurs when the SERS substrate is excited through an underlying transparent dielectric substrate. Here the far-side geometrically-enhanced SERS signal has been explored experimentally in more detail. Thermally evaporated Ag plasmonic films functionalised with thiophenol were used to study the dependence of the geometrically-enhanced SERS signal on the excitation wavelength, supporting substrate material and excitation angle of incidence. The results were interpreted using a `geometrical enhancement factor' (GEF), defined as the ratio of far-side to near-side SERS signal intensity. The experimental results confirmed that the highest GEFs of 3.2-3.5× are seen closer to the localized surface plasmon resonance peak of the Ag metallic nanostructures. Interestingly, the GEF for Ag plasmonic films deposited on glass and sapphire were the same within the measurement errors, whereas increasing angle of incidence showed a decrease in the GEF. Given this improved understanding of the far-side geometrical SERS enhancement, the potential for further signal amplification and optimisation for practical sensing applications can now be considered, especially for SERS detection modes at the farend of optical fibre probes and through process windows.

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

Metacognitive Monitoring and the Hypercorrection Effect in Autism and the General Population: Relation to Autism(-Like) Traits and Mindreading

ERIC Educational Resources Information Center

Williams, David M.; Bergström, Zara; Grainger, Catherine

2018-01-01

Among neurotypical adults, errors made with high confidence (i.e. errors a person strongly believed they would not make) are corrected more reliably than errors made with low confidence. This 'hypercorrection effect' is thought to result from enhanced attention to information that reflects a 'metacognitive mismatch' between one's beliefs and…

Caffeine enhances real-world language processing: evidence from a proofreading task.

PubMed

Brunyé, Tad T; Mahoney, Caroline R; Rapp, David N; Ditman, Tali; Taylor, Holly A

2012-03-01

Caffeine has become the most prevalently consumed psychostimulant in the world, but its influences on daily real-world functioning are relatively unknown. The present work investigated the effects of caffeine (0 mg, 100 mg, 200 mg, 400 mg) on a commonplace language task that required readers to identify and correct 4 error types in extended discourse: simple local errors (misspelling 1- to 2-syllable words), complex local errors (misspelling 3- to 5-syllable words), simple global errors (incorrect homophones), and complex global errors (incorrect subject-verb agreement and verb tense). In 2 placebo-controlled, double-blind studies using repeated-measures designs, we found higher detection and repair rates for complex global errors, asymptoting at 200 mg in low consumers (Experiment 1) and peaking at 400 mg in high consumers (Experiment 2). In both cases, covariate analyses demonstrated that arousal state mediated the relationship between caffeine consumption and the detection and repair of complex global errors. Detection and repair rates for the other 3 error types were not affected by caffeine consumption. Taken together, we demonstrate that caffeine has differential effects on error detection and repair as a function of dose and error type, and this relationship is closely tied to caffeine's effects on subjective arousal state. These results support the notion that central nervous system stimulants may enhance global processing of language-based materials and suggest that such effects may originate in caffeine-related right hemisphere brain processes. Implications for understanding the relationships between caffeine consumption and real-world cognitive functioning are discussed. PsycINFO Database Record (c) 2012 APA, all rights reserved.

Cognitive error as the most frequent contributory factor in cases of medical injury: a study on verdict's judgment among closed claims in Japan.

PubMed

Tokuda, Yasuharu; Kishida, Naoki; Konishi, Ryota; Koizumi, Shunzo

2011-03-01

Cognitive errors in the course of clinical decision-making are prevalent in many cases of medical injury. We used information on verdict's judgment from closed claims files to determine the important cognitive factors associated with cases of medical injury. Data were collected from claims closed between 2001 to 2005 at district courts in Tokyo and Osaka, Japan. In each case, we recorded all the contributory cognitive, systemic, and patient-related factors judged in the verdicts to be causally related to the medical injury. We also analyzed the association between cognitive factors and cases involving paid compensation using a multivariable logistic regression model. Among 274 cases (mean age 49 years old; 45% women), there were 122 (45%) deaths and 67 (24%) major injuries (incomplete recovery within a year). In 103 cases (38%), the verdicts ordered hospitals to pay compensation (median; 8,000,000 Japanese Yen). An error in judgment (199/274, 73%) and failure of vigilance (177/274, 65%) were the most prevalent causative cognitive factors, and error in judgment was also significantly associated with paid compensation (odds ratio, 1.9; 95% confidence interval [CI], 1.0-3.4). Systemic causative factors including poor teamwork (11/274, 4%) and technology failure (5/274, 2%) were less common. The closed claims analysis based on verdict's judgment showed that cognitive errors were common in cases of medical injury, with an error in judgment being most prevalent and closely associated with compensation payment. Reduction of this type of error is required to produce safer healthcare. 2010 Society of Hospital Medicine.

Small refractive errors--their correction and practical importance.

PubMed

Skrbek, Matej; Petrová, Sylvie

2013-04-01

Small refractive errors present a group of specifc far-sighted refractive dispositions that are compensated by enhanced accommodative exertion and aren't exhibited by loss of the visual acuity. This paper should answer a few questions about their correction, flowing from theoretical presumptions and expectations of this dilemma. The main goal of this research was to (dis)confirm the hypothesis about convenience, efficiency and frequency of the correction that do not raise the visual acuity (or if the improvement isn't noticeable). The next goal was to examine the connection between this correction and other factors (age, size of the refractive error, etc.). The last aim was to describe the subjective personal rating of the correction of these small refractive errors, and to determine the minimal improvement of the visual acuity, that is attractive enough for the client to purchase the correction (glasses, contact lenses). It was confirmed, that there's an indispensable group of subjects with good visual acuity, where the correction is applicable, although it doesn't improve the visual acuity much. The main importance is to eliminate the asthenopia. The prime reason for acceptance of the correction is typically changing during the life, so as the accommodation is declining. Young people prefer the correction on the ground of the asthenopia, caused by small refractive error or latent strabismus; elderly people acquire the correction because of improvement of the visual acuity. Generally the correction was found useful in more than 30%, if the gain of the visual acuity was at least 0,3 of the decimal row.

Bootstrap Standard Error Estimates in Dynamic Factor Analysis

ERIC Educational Resources Information Center

Zhang, Guangjian; Browne, Michael W.

2010-01-01

Dynamic factor analysis summarizes changes in scores on a battery of manifest variables over repeated measurements in terms of a time series in a substantially smaller number of latent factors. Algebraic formulae for standard errors of parameter estimates are more difficult to obtain than in the usual intersubject factor analysis because of the…

Applications of tissue heterogeneity corrections and biologically effective dose volume histograms in assessing the doses for accelerated partial breast irradiation using an electronic brachytherapy source.

PubMed

Shi, Chengyu; Guo, Bingqi; Cheng, Chih-Yao; Eng, Tony; Papanikolaou, Nikos

2010-09-21

A low-energy electronic brachytherapy source (EBS), the model S700 Axxent x-ray device developed by Xoft Inc., has been used in high dose rate (HDR) intracavitary accelerated partial breast irradiation (APBI) as an alternative to an Ir-192 source. The prescription dose and delivery schema of the electronic brachytherapy APBI plan are the same as the Ir-192 plan. However, due to its lower mean energy than the Ir-192 source, an EBS plan has dosimetric and biological features different from an Ir-192 source plan. Current brachytherapy treatment planning methods may have large errors in treatment outcome prediction for an EBS plan. Two main factors contribute to the errors: the dosimetric influence of tissue heterogeneities and the enhancement of relative biological effectiveness (RBE) of electronic brachytherapy. This study quantified the effects of these two factors and revisited the plan quality of electronic brachytherapy APBI. The influence of tissue heterogeneities is studied by a Monte Carlo method and heterogeneous 'virtual patient' phantoms created from CT images and structure contours; the effect of RBE enhancement in the treatment outcome was estimated by biologically effective dose (BED) distribution. Ten electronic brachytherapy APBI cases were studied. The results showed that, for electronic brachytherapy cases, tissue heterogeneities and patient boundary effect decreased dose to the target and skin but increased dose to the bones. On average, the target dose coverage PTV V(100) reduced from 95.0% in water phantoms (planned) to only 66.7% in virtual patient phantoms (actual). The actual maximum dose to the ribs is 3.3 times higher than the planned dose; the actual mean dose to the ipsilateral breast and maximum dose to the skin were reduced by 22% and 17%, respectively. Combining the effect of tissue heterogeneities and RBE enhancement, BED coverage of the target was 89.9% in virtual patient phantoms with RBE enhancement (actual BED) as compared to 95.2% in water phantoms without RBE enhancement (planned BED). About 10% increase in the source output is required to raise BED PTV V(100) to 95%. As a conclusion, the composite effect of dose reduction in the target due to heterogeneities and RBE enhancement results in a net effect of 5.3% target BED coverage loss for electronic brachytherapy. Therefore, it is suggested that about 10% increase in the source output may be necessary to achieve sufficient target coverage higher than 95%.

Applications of tissue heterogeneity corrections and biologically effective dose volume histograms in assessing the doses for accelerated partial breast irradiation using an electronic brachytherapy source

NASA Astrophysics Data System (ADS)

Shi, Chengyu; Guo, Bingqi; Cheng, Chih-Yao; Eng, Tony; Papanikolaou, Nikos

2010-09-01

A low-energy electronic brachytherapy source (EBS), the model S700 Axxent™ x-ray device developed by Xoft Inc., has been used in high dose rate (HDR) intracavitary accelerated partial breast irradiation (APBI) as an alternative to an Ir-192 source. The prescription dose and delivery schema of the electronic brachytherapy APBI plan are the same as the Ir-192 plan. However, due to its lower mean energy than the Ir-192 source, an EBS plan has dosimetric and biological features different from an Ir-192 source plan. Current brachytherapy treatment planning methods may have large errors in treatment outcome prediction for an EBS plan. Two main factors contribute to the errors: the dosimetric influence of tissue heterogeneities and the enhancement of relative biological effectiveness (RBE) of electronic brachytherapy. This study quantified the effects of these two factors and revisited the plan quality of electronic brachytherapy APBI. The influence of tissue heterogeneities is studied by a Monte Carlo method and heterogeneous 'virtual patient' phantoms created from CT images and structure contours; the effect of RBE enhancement in the treatment outcome was estimated by biologically effective dose (BED) distribution. Ten electronic brachytherapy APBI cases were studied. The results showed that, for electronic brachytherapy cases, tissue heterogeneities and patient boundary effect decreased dose to the target and skin but increased dose to the bones. On average, the target dose coverage PTV V100 reduced from 95.0% in water phantoms (planned) to only 66.7% in virtual patient phantoms (actual). The actual maximum dose to the ribs is 3.3 times higher than the planned dose; the actual mean dose to the ipsilateral breast and maximum dose to the skin were reduced by 22% and 17%, respectively. Combining the effect of tissue heterogeneities and RBE enhancement, BED coverage of the target was 89.9% in virtual patient phantoms with RBE enhancement (actual BED) as compared to 95.2% in water phantoms without RBE enhancement (planned BED). About 10% increase in the source output is required to raise BED PTV V100 to 95%. As a conclusion, the composite effect of dose reduction in the target due to heterogeneities and RBE enhancement results in a net effect of 5.3% target BED coverage loss for electronic brachytherapy. Therefore, it is suggested that about 10% increase in the source output may be necessary to achieve sufficient target coverage higher than 95%.

Associations between task, training and social environmental factors and error types involved in rail incidents and accidents.

PubMed

Read, Gemma J M; Lenné, Michael G; Moss, Simon A

2012-09-01

Rail accidents can be understood in terms of the systemic and individual contributions to their causation. The current study was undertaken to determine whether errors and violations are more often associated with different local and organisational factors that contribute to rail accidents. The Contributing Factors Framework (CFF), a tool developed for the collection and codification of data regarding rail accidents and incidents, was applied to a sample of investigation reports. In addition, a more detailed categorisation of errors was undertaken. Ninety-six investigation reports into Australian accidents and incidents occurring between 1999 and 2008 were analysed. Each report was coded independently by two experienced coders. Task demand factors were significantly more often associated with skill-based errors, knowledge and training deficiencies significantly associated with mistakes, and violations significantly linked to social environmental factors. Copyright © 2012 Elsevier Ltd. All rights reserved.

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

PubMed

Scobie, Andrea

2011-04-01

To identify risk factors associated with self-reported medical, medication and laboratory error in eight countries. The Commonwealth Fund's 2008 International Health Policy Survey of chronically ill patients in eight countries. None. A multi-country telephone survey was conducted between 3 March and 30 May 2008 with patients in Australia, Canada, France, Germany, the Netherlands, New Zealand, the UK and the USA who self-reported being chronically ill. A bivariate analysis was performed to determine significant explanatory variables of medical, medication and laboratory error (P < 0.01) for inclusion in a binary logistic regression model. The final regression model included eight risk factors for self-reported error: age 65 and under, education level of some college or less, presence of two or more chronic conditions, high prescription drug use (four+ drugs), four or more doctors seen within 2 years, a care coordination problem, poor doctor-patient communication and use of an emergency department. Risk factors with the greatest ability to predict experiencing an error encompassed issues with coordination of care and provider knowledge of a patient's medical history. The identification of these risk factors could help policymakers and organizations to proactively reduce the likelihood of error through greater examination of system- and organization-level practices.

Dielectrophoresis enhances the whitening effect of carbamide peroxide on enamel.

PubMed

Ivanoff, Chris S; Hottel, Timothy L; Garcia-Godoy, Franklin; Riga, Alan T

2011-10-01

To compare the enamel whitening effect of a 20-minute dielectrophoresis enhanced electrochemical delivery to a 20-minute diffusion treatment. Forty freshly extracted human teeth without detectable caries or restoration were stored in distilled water at 4 degrees C and used within 1 month of extraction. Two different bleaching gels (Plus White 5 Minute Speed Whitening Gel and 35% Opalescence PF gel) were tested. The study had two parts: Part 1--Quantitative comparison of hydrogen peroxide (H2O2, HP) absorption--following application of an over-the-counter 35% HP whitening gel (Plus White 5 Minute Speed Whitening Gel) to 30 (n = 30) extracted human teeth by conventional diffusion or dielectrophoresis. The amount of H2O2 that diffused from the dentin was measured by a colorimetric oxidation-reduction reaction kit. HP concentration was measured by UV-Vis spectroscopy at 550 nm. Part 2--HP diffusion in stained teeth--35% carbamide peroxide whitening gel (35% Opalescence PF gel) was applied to 10 extracted human teeth (n = 10) stained by immersion in a black tea solution for 48 hours. The teeth were randomly assigned to the 20-minute dielectrophoresis or diffusion treatment group; whitening was evaluated by a dental spectrophotometer and macro-photography. Part 1: The analysis found significant differences between both groups with relative percent errors of 3% or less (a single outlier had an RPE of 12%). The average absorbance for the dielectrophoresis group in round 1 was 79% greater than the diffusion group. The average absorbance for the dielectrophoresis group in round 2 was 130% greater than the diffusion group. A single-factor ANOVA found a statistically significant difference between the diffusion and dielectrophoresis groups (P = 0.01). Part 2--The average change in Shade Guide Units (SGU) was 0.6 for the diffusion group, well under the error of measurement of 0.82 SGU. The average change in SGU for the dielectrophoresis group was 9, significantly above the error of measurement and 14 times or 1,400% greater than the diffusion group average. A single-factor ANOVA found a statistically significant difference between the diffusion and dielectrophoresis treatment groups (P < 0.001).

A Quatro-Based 65-nm Flip-Flop Circuit for Soft-Error Resilience

NASA Astrophysics Data System (ADS)

Li, Y.-Q.; Wang, H.-B.; Liu, R.; Chen, L.; Nofal, I.; Shi, S.-T.; He, A.-L.; Guo, G.; Baeg, S. H.; Wen, S.-J.; Wong, R.; Chen, M.; Wu, Q.

2017-06-01

A flip-flop circuit hardened against soft errors is presented in this paper. This design is an improved version of Quatro for further enhanced soft-error resilience by integrating the guard-gate technique. The proposed design, as well as reference Quatro and regular flip-flops, was implemented and manufactured in a 65-nm CMOS bulk technology. Experimental characterization results of their alpha and heavy ions soft-error rates verified the superior hardening performance of the proposed design over the other two circuits.

WE-G-BRA-04: Common Errors and Deficiencies in Radiation Oncology Practice

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

Kry, S; Dromgoole, L; Alvarez, P

Purpose: Dosimetric errors in radiotherapy dose delivery lead to suboptimal treatments and outcomes. This work reviews the frequency and severity of dosimetric and programmatic errors identified by on-site audits performed by the IROC Houston QA center. Methods: IROC Houston on-site audits evaluate absolute beam calibration, relative dosimetry data compared to the treatment planning system data, and processes such as machine QA. Audits conducted from 2000-present were abstracted for recommendations, including type of recommendation and magnitude of error when applicable. Dosimetric recommendations corresponded to absolute dose errors >3% and relative dosimetry errors >2%. On-site audits of 1020 accelerators at 409 institutionsmore » were reviewed. Results: A total of 1280 recommendations were made (average 3.1/institution). The most common recommendation was for inadequate QA procedures per TG-40 and/or TG-142 (82% of institutions) with the most commonly noted deficiency being x-ray and electron off-axis constancy versus gantry angle. Dosimetrically, the most common errors in relative dosimetry were in small-field output factors (59% of institutions), wedge factors (33% of institutions), off-axis factors (21% of institutions), and photon PDD (18% of institutions). Errors in calibration were also problematic: 20% of institutions had an error in electron beam calibration, 8% had an error in photon beam calibration, and 7% had an error in brachytherapy source calibration. Almost all types of data reviewed included errors up to 7% although 20 institutions had errors in excess of 10%, and 5 had errors in excess of 20%. The frequency of electron calibration errors decreased significantly with time, but all other errors show non-significant changes. Conclusion: There are many common and often serious errors made during the establishment and maintenance of a radiotherapy program that can be identified through independent peer review. Physicists should be cautious, particularly in areas highlighted herein that show a tendency for errors.« less

Barriers and facilitators to recovering from e-prescribing errors in community pharmacies.

PubMed

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

2015-01-01

To explore barriers and facilitators to recovery from e-prescribing errors in community pharmacies and to explore practical solutions for work system redesign to ensure successful recovery from errors. Cross-sectional qualitative design using direct observations, interviews, and focus groups. Five community pharmacies in Wisconsin. 13 pharmacists and 14 pharmacy technicians. Observational field notes and transcribed interviews and focus groups were subjected to thematic analysis guided by the Systems Engineering Initiative for Patient Safety (SEIPS) work system and patient safety model. Barriers and facilitators to recovering from e-prescription errors in community pharmacies. Organizational factors, such as communication, training, teamwork, and staffing levels, play an important role in recovering from e-prescription errors. Other factors that could positively or negatively affect recovery of e-prescription errors include level of experience, knowledge of the pharmacy personnel, availability or usability of tools and technology, interruptions and time pressure when performing tasks, and noise in the physical environment. The SEIPS model sheds light on key factors that may influence recovery from e-prescribing errors in pharmacies, including the environment, teamwork, communication, technology, tasks, and other organizational variables. To be successful in recovering from e-prescribing errors, pharmacies must provide the appropriate working conditions that support recovery from errors.

A rigorous analysis of digital pre-emphasis and DAC resolution for interleaved DAC Nyquist-WDM signal generation in high-speed coherent optical transmission systems

NASA Astrophysics Data System (ADS)

Weng, Yi; Wang, Junyi; He, Xuan; Pan, Zhongqi

2018-02-01

The Nyquist spectral shaping techniques facilitate a promising solution to enhance spectral efficiency (SE) and further reduce the cost-per-bit in high-speed wavelength-division multiplexing (WDM) transmission systems. Hypothetically, any Nyquist WDM signals with arbitrary shapes can be generated by the use of the digital signal processing (DSP) based electrical filters (E-filter). Nonetheless, in actual 100G/ 200G coherent systems, the performance as well as DSP complexity are increasingly restricted by cost and power consumption. Henceforward it is indispensable to optimize DSP to accomplish the preferred performance at the least complexity. In this paper, we systematically investigated the minimum requirements and challenges of Nyquist WDM signal generation, particularly for higher-order modulation formats, including 16 quadrature amplitude modulation (QAM) or 64QAM. A variety of interrelated parameters, such as channel spacing and roll-off factor, have been evaluated to optimize the requirements of the digital-to-analog converter (DAC) resolution and transmitter E-filter bandwidth. The impact of spectral pre-emphasis has been predominantly enhanced via the proposed interleaved DAC architecture by at least 4%, and hence reducing the required optical signal to noise ratio (OSNR) at a bit error rate (BER) of 10-3 by over 0.45 dB at a channel spacing of 1.05 symbol rate and an optimized roll-off factor of 0.1. Furthermore, the requirements of sampling rate for different types of super-Gaussian E-filters are discussed for 64QAM Nyquist WDM transmission systems. Finally, the impact of the non-50% duty cycle error between sub-DACs upon the quality of the generated signals for the interleaved DAC structure has been analyzed.

Security enhanced multi-factor biometric authentication scheme using bio-hash function.

PubMed

Choi, Younsung; Lee, Youngsook; Moon, Jongho; Won, Dongho

2017-01-01

With the rapid development of personal information and wireless communication technology, user authentication schemes have been crucial to ensure that wireless communications are secure. As such, various authentication schemes with multi-factor authentication have been proposed to improve the security of electronic communications. Multi-factor authentication involves the use of passwords, smart cards, and various biometrics to provide users with the utmost privacy and data protection. Cao and Ge analyzed various authentication schemes and found that Younghwa An's scheme was susceptible to a replay attack where an adversary masquerades as a legal server and a user masquerading attack where user anonymity is not provided, allowing an adversary to execute a password change process by intercepting the user's ID during login. Cao and Ge improved upon Younghwa An's scheme, but various security problems remained. This study demonstrates that Cao and Ge's scheme is susceptible to a biometric recognition error, slow wrong password detection, off-line password attack, user impersonation attack, ID guessing attack, a DoS attack, and that their scheme cannot provide session key agreement. Then, to address all weaknesses identified in Cao and Ge's scheme, this study proposes a security enhanced multi-factor biometric authentication scheme and provides a security analysis and formal analysis using Burrows-Abadi-Needham logic. Finally, the efficiency analysis reveals that the proposed scheme can protect against several possible types of attacks with only a slightly high computational cost.

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

PubMed

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

2018-01-01

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

Alterations in Neural Control of Constant Isometric Contraction with the Size of Error Feedback

PubMed Central

Hwang, Ing-Shiou; Lin, Yen-Ting; Huang, Wei-Min; Yang, Zong-Ru; Hu, Chia-Ling; Chen, Yi-Ching

2017-01-01

Discharge patterns from a population of motor units (MUs) were estimated with multi-channel surface electromyogram and signal processing techniques to investigate parametric differences in low-frequency force fluctuations, MU discharges, and force-discharge relation during static force-tracking with varying sizes of execution error presented via visual feedback. Fourteen healthy adults produced isometric force at 10% of maximal voluntary contraction through index abduction under three visual conditions that scaled execution errors with different amplification factors. Error-augmentation feedback that used a high amplification factor (HAF) to potentiate visualized error size resulted in higher sample entropy, mean frequency, ratio of high-frequency components, and spectral dispersion of force fluctuations than those of error-reducing feedback using a low amplification factor (LAF). In the HAF condition, MUs with relatively high recruitment thresholds in the dorsal interosseous muscle exhibited a larger coefficient of variation for inter-spike intervals and a greater spectral peak of the pooled MU coherence at 13–35 Hz than did those in the LAF condition. Manipulation of the size of error feedback altered the force-discharge relation, which was characterized with non-linear approaches such as mutual information and cross sample entropy. The association of force fluctuations and global discharge trace decreased with increasing error amplification factor. Our findings provide direct neurophysiological evidence that favors motor training using error-augmentation feedback. Amplification of the visualized error size of visual feedback could enrich force gradation strategies during static force-tracking, pertaining to selective increases in the discharge variability of higher-threshold MUs that receive greater common oscillatory inputs in the β-band. PMID:28125658

Transmission and storage of medical images with patient information.

PubMed

Acharya U, Rajendra; Subbanna Bhat, P; Kumar, Sathish; Min, Lim Choo

2003-07-01

Digital watermarking is a technique of hiding specific identification data for copyright authentication. This technique is adapted here for interleaving patient information with medical images, to reduce storage and transmission overheads. The text data is encrypted before interleaving with images to ensure greater security. The graphical signals are interleaved with the image. Two types of error control-coding techniques are proposed to enhance reliability of transmission and storage of medical images interleaved with patient information. Transmission and storage scenarios are simulated with and without error control coding and a qualitative as well as quantitative interpretation of the reliability enhancement resulting from the use of various commonly used error control codes such as repetitive, and (7,4) Hamming code is provided.

Absorption of Solar Radiation by the Cloudy Atmosphere: Further Interpretations of Collocated Aircraft Measurements

NASA Technical Reports Server (NTRS)

Cess, R. D.; Zhang, Minghua; Valero, Francisco P. J.; Pope, Shelly K.; Bucholtz, Anthony; Bush, Brett; Zender, Charles S.

1998-01-01

We have extended the interpretations made in two prior studies of the aircraft shortwave radiation measurements that were obtained as part of the Atmospheric Radiation Measurements (ARM) Enhanced Shortwave Experiments (ARESE). These extended interpretations use the 500 nm (10 nm bandwidth) measurements to minimize sampling errors in the broadband measurements. It is indicated that the clouds present during this experiment absorb more shortwave radiation than predicted by clear skies and thus by theoretical models, that at least some (less than or equal to 20%) of this enhanced cloud absorption occurs at wavelengths less than 680 nm, and that the observed cloud absorption does not appear to be an artifact of sampling errors nor of instrument calibration errors.

Symmetry boost of the fidelity of Shor factoring

NASA Astrophysics Data System (ADS)

Nam, Y. S.; Blümel, R.

2018-05-01

In Shor's algorithm quantum subroutines occur with the structure F U F-1 , where F is a unitary transform and U is performing a quantum computation. Examples are quantum adders and subunits of quantum modulo adders. In this paper we show, both analytically and numerically, that if, in analogy to spin echoes, F and F-1 can be implemented symmetrically when executing Shor's algorithm on actual, imperfect quantum hardware, such that F and F-1 have the same hardware errors, a symmetry boost in the fidelity of the combined F U F-1 quantum operation results when compared to the case in which the errors in F and F-1 are independently random. Running the complete gate-by-gate implemented Shor algorithm, we show that the symmetry-induced fidelity boost can be as large as a factor 4. While most of our analytical and numerical results concern the case of over- and under-rotation of controlled rotation gates, in the numerically accessible case of Shor's algorithm with a small number of qubits, we show explicitly that the symmetry boost is robust with respect to more general types of errors. While, expectedly, additional error types reduce the symmetry boost, we show explicitly, by implementing general off-diagonal SU (N ) errors (N =2 ,4 ,8 ), that the boost factor scales like a Lorentzian in δ /σ , where σ and δ are the error strengths of the diagonal over- and underrotation errors and the off-diagonal SU (N ) errors, respectively. The Lorentzian shape also shows that, while the boost factor may become small with increasing δ , it declines slowly (essentially like a power law) and is never completely erased. We also investigate the effect of diagonal nonunitary errors, which, in analogy to unitary errors, reduce but never erase the symmetry boost. Going beyond the case of small quantum processors, we present analytical scaling results that show that the symmetry boost persists in the practically interesting case of a large number of qubits. We illustrate this result explicitly for the case of Shor factoring of the semiprime RSA-1024, where, analytically, focusing on over- and underrotation errors, we obtain a boost factor of about 10. In addition, we provide a proof of the fidelity product formula, including its range of applicability.

Can You Multitask? Evidence and Limitations of Task Switching and Multitasking in Emergency Medicine.

PubMed

Skaugset, L Melissa; Farrell, Susan; Carney, Michele; Wolff, Margaret; Santen, Sally A; Perry, Marcia; Cico, Stephen John

2016-08-01

Emergency physicians work in a fast-paced environment that is characterized by frequent interruptions and the expectation that they will perform multiple tasks efficiently and without error while maintaining oversight of the entire emergency department. However, there is a lack of definition and understanding of the behaviors that constitute effective task switching and multitasking, as well as how to improve these skills. This article reviews the literature on task switching and multitasking in a variety of disciplines-including cognitive science, human factors engineering, business, and medicine-to define and describe the successful performance of task switching and multitasking in emergency medicine. Multitasking, defined as the performance of two tasks simultaneously, is not possible except when behaviors become completely automatic; instead, physicians rapidly switch between small tasks. This task switching causes disruption in the primary task and may contribute to error. A framework is described to enhance the understanding and practice of these behaviors. Copyright © 2015 American College of Emergency Physicians. Published by Elsevier Inc. All rights reserved.

Extending the applicability of the Arndt formula in wavelength modulation spectroscopy for absorbance in the lower percent range

NASA Astrophysics Data System (ADS)

Hartmann, A.; Strzoda, R.; Schrobenhauser, R.; Weigel, R.

2014-01-01

The Arndt formula for Lorentzian signals broadened by modulation is enhanced for the usage on 2f WMS (wavelength modulation spectroscopy) signals produced by spectroscopic lines with high absorption (percent range). Next to the first order approach of the Beer-Lambert law, which is covered by the Arndt formula, a second order term is included for a better approximation of the damped Lorentzian line shape. This second order approximation of the 2f signal can be described by a combination of several components created by the Arndt formula. The error of a pure Arndt evaluation and the improvement of the Arndt extended technique are illustrated in the example of a humidity measurement performed at 100 °C and up to 100 vol%. The energy transition at ν=10,526.274910 cm-1 is used in this setup. With the presented technique, the error is reduced by a factor of 90.

Human error in airway facilities.

DOT National Transportation Integrated Search

2001-01-01

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

First order error corrections in common introductory physics experiments

NASA Astrophysics Data System (ADS)

Beckey, Jacob; Baker, Andrew; Aravind, Vasudeva; Clarion Team

As a part of introductory physics courses, students perform different standard lab experiments. Almost all of these experiments are prone to errors owing to factors like friction, misalignment of equipment, air drag, etc. Usually these types of errors are ignored by students and not much thought is paid to the source of these errors. However, paying attention to these factors that give rise to errors help students make better physics models and understand physical phenomena behind experiments in more detail. In this work, we explore common causes of errors in introductory physics experiment and suggest changes that will mitigate the errors, or suggest models that take the sources of these errors into consideration. This work helps students build better and refined physical models and understand physics concepts in greater detail. We thank Clarion University undergraduate student grant for financial support involving this project.

Hypothesis Testing Using Factor Score Regression

PubMed Central

Devlieger, Ines; Mayer, Axel; Rosseel, Yves

2015-01-01

In this article, an overview is given of four methods to perform factor score regression (FSR), namely regression FSR, Bartlett FSR, the bias avoiding method of Skrondal and Laake, and the bias correcting method of Croon. The bias correcting method is extended to include a reliable standard error. The four methods are compared with each other and with structural equation modeling (SEM) by using analytic calculations and two Monte Carlo simulation studies to examine their finite sample characteristics. Several performance criteria are used, such as the bias using the unstandardized and standardized parameterization, efficiency, mean square error, standard error bias, type I error rate, and power. The results show that the bias correcting method, with the newly developed standard error, is the only suitable alternative for SEM. While it has a higher standard error bias than SEM, it has a comparable bias, efficiency, mean square error, power, and type I error rate. PMID:29795886

Hydraulic correction method (HCM) to enhance the efficiency of SRTM DEM in flood modeling

NASA Astrophysics Data System (ADS)

Chen, Huili; Liang, Qiuhua; Liu, Yong; Xie, Shuguang

2018-04-01

Digital Elevation Model (DEM) is one of the most important controlling factors determining the simulation accuracy of hydraulic models. However, the currently available global topographic data is confronted with limitations for application in 2-D hydraulic modeling, mainly due to the existence of vegetation bias, random errors and insufficient spatial resolution. A hydraulic correction method (HCM) for the SRTM DEM is proposed in this study to improve modeling accuracy. Firstly, we employ the global vegetation corrected DEM (i.e. Bare-Earth DEM), developed from the SRTM DEM to include both vegetation height and SRTM vegetation signal. Then, a newly released DEM, removing both vegetation bias and random errors (i.e. Multi-Error Removed DEM), is employed to overcome the limitation of height errors. Last, an approach to correct the Multi-Error Removed DEM is presented to account for the insufficiency of spatial resolution, ensuring flow connectivity of the river networks. The approach involves: (a) extracting river networks from the Multi-Error Removed DEM using an automated algorithm in ArcGIS; (b) correcting the location and layout of extracted streams with the aid of Google Earth platform and Remote Sensing imagery; and (c) removing the positive biases of the raised segment in the river networks based on bed slope to generate the hydraulically corrected DEM. The proposed HCM utilizes easily available data and tools to improve the flow connectivity of river networks without manual adjustment. To demonstrate the advantages of HCM, an extreme flood event in Huifa River Basin (China) is simulated on the original DEM, Bare-Earth DEM, Multi-Error removed DEM, and hydraulically corrected DEM using an integrated hydrologic-hydraulic model. A comparative analysis is subsequently performed to assess the simulation accuracy and performance of four different DEMs and favorable results have been obtained on the corrected DEM.

Secondary School Students Learning from Reflections on the Rationale behind Self-Made Errors: A Field Experiment

ERIC Educational Resources Information Center

Heemsoth, Tim; Heinze, Aiso

2016-01-01

Thus far, it is unclear how students can learn most effectively from their own errors. In this study, reflections on the rationale behind self-made errors are assumed to enhance knowledge acquisition. In a field experiment with pre/post/follow-up design, the authors practiced fractions with 174 seventh- and eighth-grade students who were randomly…

A median filter approach for correcting errors in a vector field

NASA Technical Reports Server (NTRS)

Schultz, H.

1985-01-01

Techniques are presented for detecting and correcting errors in a vector field. These methods employ median filters which are frequently used in image processing to enhance edges and remove noise. A detailed example is given for wind field maps produced by a spaceborne scatterometer. The error detection and replacement algorithm was tested with simulation data from the NASA Scatterometer (NSCAT) project.

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

PubMed

Alsulami, Zayed; Conroy, Sharon; Choonara, Imti

2013-04-01

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

Effect of Error Augmentation on Brain Activation and Motor Learning of a Complex Locomotor Task

PubMed Central

Marchal-Crespo, Laura; Michels, Lars; Jaeger, Lukas; López-Olóriz, Jorge; Riener, Robert

2017-01-01

Up to date, the functional gains obtained after robot-aided gait rehabilitation training are limited. Error augmenting strategies have a great potential to enhance motor learning of simple motor tasks. However, little is known about the effect of these error modulating strategies on complex tasks, such as relearning to walk after a neurologic accident. Additionally, neuroimaging evaluation of brain regions involved in learning processes could provide valuable information on behavioral outcomes. We investigated the effect of robotic training strategies that augment errors—error amplification and random force disturbance—and training without perturbations on brain activation and motor learning of a complex locomotor task. Thirty-four healthy subjects performed the experiment with a robotic stepper (MARCOS) in a 1.5 T MR scanner. The task consisted in tracking a Lissajous figure presented on a display by coordinating the legs in a gait-like movement pattern. Behavioral results showed that training without perturbations enhanced motor learning in initially less skilled subjects, while error amplification benefited better-skilled subjects. Training with error amplification, however, hampered transfer of learning. Randomly disturbing forces induced learning and promoted transfer in all subjects, probably because the unexpected forces increased subjects' attention. Functional MRI revealed main effects of training strategy and skill level during training. A main effect of training strategy was seen in brain regions typically associated with motor control and learning, such as, the basal ganglia, cerebellum, intraparietal sulcus, and angular gyrus. Especially, random disturbance and no perturbation lead to stronger brain activation in similar brain regions than error amplification. Skill-level related effects were observed in the IPS, in parts of the superior parietal lobe (SPL), i.e., precuneus, and temporal cortex. These neuroimaging findings indicate that gait-like motor learning depends on interplay between subcortical, cerebellar, and fronto-parietal brain regions. An interesting observation was the low activation observed in the brain's reward system after training with error amplification compared to training without perturbations. Our results suggest that to enhance learning of a locomotor task, errors should be augmented based on subjects' skill level. The impacts of these strategies on motor learning, brain activation, and motivation in neurological patients need further investigation. PMID:29021739

Suppression of vapor cell temperature error for spin-exchange-relaxation-free magnetometer

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

Lu, Jixi, E-mail: lujixi@buaa.edu.cn; Qian, Zheng; Fang, Jiancheng

2015-08-15

This paper presents a method to reduce the vapor cell temperature error of the spin-exchange-relaxation-free (SERF) magnetometer. The fluctuation of cell temperature can induce variations of the optical rotation angle, resulting in a scale factor error of the SERF magnetometer. In order to suppress this error, we employ the variation of the probe beam absorption to offset the variation of the optical rotation angle. The theoretical discussion of our method indicates that the scale factor error introduced by the fluctuation of the cell temperature could be suppressed by setting the optical depth close to one. In our experiment, we adjustmore » the probe frequency to obtain various optical depths and then measure the variation of scale factor with respect to the corresponding cell temperature changes. Our experimental results show a good agreement with our theoretical analysis. Under our experimental condition, the error has been reduced significantly compared with those when the probe wavelength is adjusted to maximize the probe signal. The cost of this method is the reduction of the scale factor of the magnetometer. However, according to our analysis, it only has minor effect on the sensitivity under proper operating parameters.« less

Factors contributing to registered nurse medication administration error: a narrative review.

PubMed

Parry, Angela M; Barriball, K Louise; While, Alison E

2015-01-01

To explore the factors contributing to Registered Nurse medication administration error behaviour. A narrative review. Electronic databases (Cochrane, CINAHL, MEDLINE, BNI, EmBase, and PsycINFO) were searched from 1 January 1999 to 31 December 2012 in the English language. 1127 papers were identified and 26 papers were included in the review. Data were extracted by one reviewer and checked by a second reviewer. A thematic analysis and narrative synthesis of the factors contributing to Registered Nurses' medication administration behaviour. Bandura's (1986) theory of reciprocal determinism was used as an organising framework. This theory proposes that there is a reciprocal interplay between the environment, the person and their behaviour. Medication administration error is an outcome of RN behaviour. The 26 papers reported studies conducted in 4 continents across 11 countries predominantly in North America and Europe, with one multi-national study incorporating 27 countries. Within both the environment and person domain of the reciprocal determinism framework, a number of factors emerged as influencing Registered Nurse medication administration error behaviour. Within the environment domain, two key themes of clinical workload and work setting emerged, and within the person domain the Registered Nurses' characteristics and their lived experience of work emerged as themes. Overall, greater attention has been given to the contribution of the environment domain rather than the person domain as contributing to error, with the literature viewing an error as an event rather than the outcome of behaviour. The interplay between factors that influence behaviour were poorly accounted for within the selected studies. It is proposed that a shift away from error as an event to a focus on the relationships between the person, the environment and Registered Nurse medication administration behaviour is needed to better understand medication administration error. Copyright © 2014 Elsevier Ltd. All rights reserved.

Iterative channel decoding of FEC-based multiple-description codes.

PubMed

Chang, Seok-Ho; Cosman, Pamela C; Milstein, Laurence B

2012-03-01

Multiple description coding has been receiving attention as a robust transmission framework for multimedia services. This paper studies the iterative decoding of FEC-based multiple description codes. The proposed decoding algorithms take advantage of the error detection capability of Reed-Solomon (RS) erasure codes. The information of correctly decoded RS codewords is exploited to enhance the error correction capability of the Viterbi algorithm at the next iteration of decoding. In the proposed algorithm, an intradescription interleaver is synergistically combined with the iterative decoder. The interleaver does not affect the performance of noniterative decoding but greatly enhances the performance when the system is iteratively decoded. We also address the optimal allocation of RS parity symbols for unequal error protection. For the optimal allocation in iterative decoding, we derive mathematical equations from which the probability distributions of description erasures can be generated in a simple way. The performance of the algorithm is evaluated over an orthogonal frequency-division multiplexing system. The results show that the performance of the multiple description codes is significantly enhanced.

Effects of measurement errors on psychometric measurements in ergonomics studies: Implications for correlations, ANOVA, linear regression, factor analysis, and linear discriminant analysis.

PubMed

Liu, Yan; Salvendy, Gavriel

2009-05-01

This paper aims to demonstrate the effects of measurement errors on psychometric measurements in ergonomics studies. A variety of sources can cause random measurement errors in ergonomics studies and these errors can distort virtually every statistic computed and lead investigators to erroneous conclusions. The effects of measurement errors on five most widely used statistical analysis tools have been discussed and illustrated: correlation; ANOVA; linear regression; factor analysis; linear discriminant analysis. It has been shown that measurement errors can greatly attenuate correlations between variables, reduce statistical power of ANOVA, distort (overestimate, underestimate or even change the sign of) regression coefficients, underrate the explanation contributions of the most important factors in factor analysis and depreciate the significance of discriminant function and discrimination abilities of individual variables in discrimination analysis. The discussions will be restricted to subjective scales and survey methods and their reliability estimates. Other methods applied in ergonomics research, such as physical and electrophysiological measurements and chemical and biomedical analysis methods, also have issues of measurement errors, but they are beyond the scope of this paper. As there has been increasing interest in the development and testing of theories in ergonomics research, it has become very important for ergonomics researchers to understand the effects of measurement errors on their experiment results, which the authors believe is very critical to research progress in theory development and cumulative knowledge in the ergonomics field.

Design the RS(255,239) encoder and interleaving in the space laser communication system

NASA Astrophysics Data System (ADS)

Lang, Yue; Tong, Shou-feng

2013-08-01

Space laser communication is researched by more and more countries. Space laser communication deserves to be researched. We can acquire higher transmission speed and better transmission quality between satellite and satellite, satellite and earth by setting up laser link. But in the space laser communication system，the reliability is under influences of many factors of atmosphere，detector noise, optical platform jitter and other factors. The intensity of the signal which is attenuated because of the long transmission distance is demanded to have higher intensity to acquire low BER. The channel code technology can enhance the anti-interference ability of the system. The theory of channel coding technology is that some redundancies is added to information codes. So it can make use of the checkout polynomial to correct errors at the sink port. It help the system to get low BER rate and coding gain. Reed-Solomon (RS) code is one of the channel code, and it is one kind of multi-ary BCH code, and it can correct both burst errors and random errors, and it is widely used in the error-control schemes. The new method of the RS encoder and interleaving based on the FPGA is proposed, aiming at satisfying the needs of the widely-used error control technology in the space laser communication field. An improved method for Finite Galois Field multiplier of encoding is proposed, and it is suitable for FPGA implementation. Comparison of the XOR gates cost between the optimization and original, the number of XOR gates is lessen more than 40% .Then give a new structure of interleaving by using the FPGA. By controlling the in-data stream and out-data stream of encoder, the asynchronous process of the whole frame is accomplished, while by using multi-level pipeline, the real-time transfer of the data is achieved. By controlling the read-address and write-address of the block RAM, the interleaving operation of the arbitrary depth is synchronously implemented. Compared with the normal method, it could reduce the complexity of the channel encoder and the hardware requirement effectively.

In Your Face: Risk of Punishment Enhances Cognitive Control and Error-Related Activity in the Corrugator Supercilii Muscle.

PubMed

Lindström, Björn R; Mattsson-Mårn, Isak Berglund; Golkar, Armita; Olsson, Andreas

2013-01-01

Cognitive control is needed when mistakes have consequences, especially when such consequences are potentially harmful. However, little is known about how the aversive consequences of deficient control affect behavior. To address this issue, participants performed a two-choice response time task where error commissions were expected to be punished by electric shocks during certain blocks. By manipulating (1) the perceived punishment risk (no, low, high) associated with error commissions, and (2) response conflict (low, high), we showed that motivation to avoid punishment enhanced performance during high response conflict. As a novel index of the processes enabling successful cognitive control under threat, we explored electromyographic activity in the corrugator supercilii (cEMG) muscle of the upper face. The corrugator supercilii is partially controlled by the anterior midcingulate cortex (aMCC) which is sensitive to negative affect, pain and cognitive control. As hypothesized, the cEMG exhibited several key similarities with the core temporal and functional characteristics of the Error-Related Negativity (ERN) ERP component, the hallmark index of cognitive control elicited by performance errors, and which has been linked to the aMCC. The cEMG was amplified within 100 ms of error commissions (the same time-window as the ERN), particularly during the high punishment risk condition where errors would be most aversive. Furthermore, similar to the ERN, the magnitude of error cEMG predicted post-error response time slowing. Our results suggest that cEMG activity can serve as an index of avoidance motivated control, which is instrumental to adaptive cognitive control when consequences are potentially harmful.

In Your Face: Risk of Punishment Enhances Cognitive Control and Error-Related Activity in the Corrugator Supercilii Muscle

PubMed Central

Lindström, Björn R.; Mattsson-Mårn, Isak Berglund; Golkar, Armita; Olsson, Andreas

2013-01-01

Cognitive control is needed when mistakes have consequences, especially when such consequences are potentially harmful. However, little is known about how the aversive consequences of deficient control affect behavior. To address this issue, participants performed a two-choice response time task where error commissions were expected to be punished by electric shocks during certain blocks. By manipulating (1) the perceived punishment risk (no, low, high) associated with error commissions, and (2) response conflict (low, high), we showed that motivation to avoid punishment enhanced performance during high response conflict. As a novel index of the processes enabling successful cognitive control under threat, we explored electromyographic activity in the corrugator supercilii (cEMG) muscle of the upper face. The corrugator supercilii is partially controlled by the anterior midcingulate cortex (aMCC) which is sensitive to negative affect, pain and cognitive control. As hypothesized, the cEMG exhibited several key similarities with the core temporal and functional characteristics of the Error-Related Negativity (ERN) ERP component, the hallmark index of cognitive control elicited by performance errors, and which has been linked to the aMCC. The cEMG was amplified within 100 ms of error commissions (the same time-window as the ERN), particularly during the high punishment risk condition where errors would be most aversive. Furthermore, similar to the ERN, the magnitude of error cEMG predicted post-error response time slowing. Our results suggest that cEMG activity can serve as an index of avoidance motivated control, which is instrumental to adaptive cognitive control when consequences are potentially harmful. PMID:23840356

Determinants of Standard Errors of MLEs in Confirmatory Factor Analysis

ERIC Educational Resources Information Center

Yuan, Ke-Hai; Cheng, Ying; Zhang, Wei

2010-01-01

This paper studies changes of standard errors (SE) of the normal-distribution-based maximum likelihood estimates (MLE) for confirmatory factor models as model parameters vary. Using logical analysis, simplified formulas and numerical verification, monotonic relationships between SEs and factor loadings as well as unique variances are found.…

Vision-based method for detecting driver drowsiness and distraction in driver monitoring system

NASA Astrophysics Data System (ADS)

Jo, Jaeik; Lee, Sung Joo; Jung, Ho Gi; Park, Kang Ryoung; Kim, Jaihie

2011-12-01

Most driver-monitoring systems have attempted to detect either driver drowsiness or distraction, although both factors should be considered for accident prevention. Therefore, we propose a new driver-monitoring method considering both factors. We make the following contributions. First, if the driver is looking ahead, drowsiness detection is performed; otherwise, distraction detection is performed. Thus, the computational cost and eye-detection error can be reduced. Second, we propose a new eye-detection algorithm that combines adaptive boosting, adaptive template matching, and blob detection with eye validation, thereby reducing the eye-detection error and processing time significantly, which is hardly achievable using a single method. Third, to enhance eye-detection accuracy, eye validation is applied after initial eye detection, using a support vector machine based on appearance features obtained by principal component analysis (PCA) and linear discriminant analysis (LDA). Fourth, we propose a novel eye state-detection algorithm that combines appearance features obtained using PCA and LDA, with statistical features such as the sparseness and kurtosis of the histogram from the horizontal edge image of the eye. Experimental results showed that the detection accuracies of the eye region and eye states were 99 and 97%, respectively. Both driver drowsiness and distraction were detected with a success rate of 98%.

Nature of nursing errors and their contributing factors in intensive care units.

PubMed

Eltaybani, Sameh; Mohamed, Nadia; Abdelwareth, Mona

2018-04-27

Errors tend to be multifactorial and so learning from nurses' experiences with them would be a powerful tool toward promoting patient safety. To identify the nature of nursing errors and their contributing factors in intensive care units (ICUs). A semi-structured interview with 112 critical care nurses to elicit the reports about their encountered errors followed by a content analysis. A total of 300 errors were reported. Most of them (94·3%) were classified in more than one error category, e.g. 'lack of intervention', 'lack of attentiveness' and 'documentation errors': these were the most frequently involved error categories. Approximately 40% of reported errors contributed to significant harm or death of the involved patients, with system-related factors being involved in 84·3% of them. More errors occur during the evening shift than the night and morning shifts (42·7% versus 28·7% and 16·7%, respectively). There is a statistically significant relation (p ≤ 0·001) between error disclosure to a nursing supervisor and its impact on the patient. Nurses are more likely to report their errors when they feel safe and when the reporting system is not burdensome, although an internationally standardized language to define and analyse nursing errors is needed. Improving the health care system, particularly the managerial and environmental aspects, might reduce nursing errors in ICUs in terms of their incidence and seriousness. Targeting error-liable times in the ICU, such as mid-evening and mid-night shifts, along with improved supervision and adequate staff reallocation, might tackle the incidence and seriousness of nursing errors. Development of individualized nursing interventions for patients with low health literacy and patients in isolation might create more meaningful dialogue for ICU health care safety. © 2018 British Association of Critical Care Nurses.

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.

Managerial process improvement: a lean approach to eliminating medication delivery.

PubMed

Hussain, Aftab; Stewart, LaShonda M; Rivers, Patrick A; Munchus, George

2015-01-01

Statistical evidence shows that medication errors are a major cause of injuries that concerns all health care oganizations. Despite all the efforts to improve the quality of care, the lack of understanding and inability of management to design a robust system that will strategically target those factors is a major cause of distress. The paper aims to discuss these issues. Achieving optimum organizational performance requires two key variables; work process factors and human performance factors. The approach is that healthcare administrators must take in account both variables in designing a strategy to reduce medication errors. However, strategies that will combat such phenomena require that managers and administrators understand the key factors that are causing medication delivery errors. The authors recommend that healthcare organizations implement the Toyota Production System (TPS) combined with human performance improvement (HPI) methodologies to eliminate medication delivery errors in hospitals. Despite all the efforts to improve the quality of care, there continues to be a lack of understanding and the ability of management to design a robust system that will strategically target those factors associated with medication errors. This paper proposes a solution to an ambiguous workflow process using the TPS combined with the HPI system.

Error-Related Brain Activity in Youth and Young Adults Before and After Treatment for Generalized or Social Anxiety Disorder

PubMed Central

Kujawa, Autumn; Weinberg, Anna; Bunford, Nora; Fitzgerald, Kate D.; Hanna, Gregory L.; Monk, Christopher S.; Kennedy, Amy E.; Klumpp, Heide; Hajcak, Greg; Phan, K. Luan

2016-01-01

Increased error monitoring, as measured by the error-related negativity (ERN), has been shown to persist after treatment for obsessive-compulsive disorder in youth and adults; however, no previous studies have examined the ERN following treatment for related anxiety disorders. We used a flanker task to elicit the ERN in 28 youth and young adults (8–26 years old) with primary diagnoses of generalized anxiety disorder (GAD) or social anxiety disorder (SAD) and 35 healthy controls. Patients were assessed before and after treatment with cognitive-behavioral therapy (CBT) or selective serotonin reuptake inhibitors (SSRI), and healthy controls were assessed at a comparable interval. The ERN increased across assessments in the combined sample. Patients with SAD exhibited an enhanced ERN relative to healthy controls prior to and following treatment, even when analyses were limited to SAD patients who responded to treatment. Patients with GAD did not significantly differ from healthy controls at either assessment. Results provide preliminary evidence that enhanced error monitoring persists following treatment for SAD in youth and young adults, and support conceptualizations of increased error monitoring as a trait-like vulnerability that may contribute to risk for recurrence and impaired functioning later in life. Future work is needed to further evaluate the ERN in GAD across development, including whether an enhanced ERN develops in adulthood or is most apparent when worries focus on internal sources of threat. PMID:27495356

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.

The Perception of Error in Production Plants of a Chemical Organisation

ERIC Educational Resources Information Center

Seifried, Jurgen; Hopfer, Eva

2013-01-01

There is considerable current interest in error-friendly corporate culture, one particular research question being how and under what conditions errors are learnt from in the workplace. This paper starts from the assumption that errors are inevitable and considers key factors which affect learning from errors in high responsibility organisations,…

An Intelligent Ensemble Neural Network Model for Wind Speed Prediction in Renewable Energy Systems.

PubMed

Ranganayaki, V; Deepa, S N

2016-01-01

Various criteria are proposed to select the number of hidden neurons in artificial neural network (ANN) models and based on the criterion evolved an intelligent ensemble neural network model is proposed to predict wind speed in renewable energy applications. The intelligent ensemble neural model based wind speed forecasting is designed by averaging the forecasted values from multiple neural network models which includes multilayer perceptron (MLP), multilayer adaptive linear neuron (Madaline), back propagation neural network (BPN), and probabilistic neural network (PNN) so as to obtain better accuracy in wind speed prediction with minimum error. The random selection of hidden neurons numbers in artificial neural network results in overfitting or underfitting problem. This paper aims to avoid the occurrence of overfitting and underfitting problems. The selection of number of hidden neurons is done in this paper employing 102 criteria; these evolved criteria are verified by the computed various error values. The proposed criteria for fixing hidden neurons are validated employing the convergence theorem. The proposed intelligent ensemble neural model is applied for wind speed prediction application considering the real time wind data collected from the nearby locations. The obtained simulation results substantiate that the proposed ensemble model reduces the error value to minimum and enhances the accuracy. The computed results prove the effectiveness of the proposed ensemble neural network (ENN) model with respect to the considered error factors in comparison with that of the earlier models available in the literature.

An Intelligent Ensemble Neural Network Model for Wind Speed Prediction in Renewable Energy Systems

PubMed Central

Ranganayaki, V.; Deepa, S. N.

2016-01-01

Various criteria are proposed to select the number of hidden neurons in artificial neural network (ANN) models and based on the criterion evolved an intelligent ensemble neural network model is proposed to predict wind speed in renewable energy applications. The intelligent ensemble neural model based wind speed forecasting is designed by averaging the forecasted values from multiple neural network models which includes multilayer perceptron (MLP), multilayer adaptive linear neuron (Madaline), back propagation neural network (BPN), and probabilistic neural network (PNN) so as to obtain better accuracy in wind speed prediction with minimum error. The random selection of hidden neurons numbers in artificial neural network results in overfitting or underfitting problem. This paper aims to avoid the occurrence of overfitting and underfitting problems. The selection of number of hidden neurons is done in this paper employing 102 criteria; these evolved criteria are verified by the computed various error values. The proposed criteria for fixing hidden neurons are validated employing the convergence theorem. The proposed intelligent ensemble neural model is applied for wind speed prediction application considering the real time wind data collected from the nearby locations. The obtained simulation results substantiate that the proposed ensemble model reduces the error value to minimum and enhances the accuracy. The computed results prove the effectiveness of the proposed ensemble neural network (ENN) model with respect to the considered error factors in comparison with that of the earlier models available in the literature. PMID:27034973

Modeling astronomical adaptive optics performance with temporally filtered Wiener reconstruction of slope data

NASA Astrophysics Data System (ADS)

Correia, Carlos M.; Bond, Charlotte Z.; Sauvage, Jean-François; Fusco, Thierry; Conan, Rodolphe; Wizinowich, Peter L.

2017-10-01

We build on a long-standing tradition in astronomical adaptive optics (AO) of specifying performance metrics and error budgets using linear systems modeling in the spatial-frequency domain. Our goal is to provide a comprehensive tool for the calculation of error budgets in terms of residual temporally filtered phase power spectral densities and variances. In addition, the fast simulation of AO-corrected point spread functions (PSFs) provided by this method can be used as inputs for simulations of science observations with next-generation instruments and telescopes, in particular to predict post-coronagraphic contrast improvements for planet finder systems. We extend the previous results and propose the synthesis of a distributed Kalman filter to mitigate both aniso-servo-lag and aliasing errors whilst minimizing the overall residual variance. We discuss applications to (i) analytic AO-corrected PSF modeling in the spatial-frequency domain, (ii) post-coronagraphic contrast enhancement, (iii) filter optimization for real-time wavefront reconstruction, and (iv) PSF reconstruction from system telemetry. Under perfect knowledge of wind velocities, we show that $\\sim$60 nm rms error reduction can be achieved with the distributed Kalman filter embodying anti- aliasing reconstructors on 10 m class high-order AO systems, leading to contrast improvement factors of up to three orders of magnitude at few ${\\lambda}/D$ separations ($\\sim1-5{\\lambda}/D$) for a 0 magnitude star and reaching close to one order of magnitude for a 12 magnitude star.

Diffraction analysis of sidelobe characteristics of optical elements with ripple error

NASA Astrophysics Data System (ADS)

Zhao, Lei; Luo, Yupeng; Bai, Jian; Zhou, Xiangdong; Du, Juan; Liu, Qun; Luo, Yujie

2018-03-01

The ripple errors of the lens lead to optical damage in high energy laser system. The analysis of sidelobe on the focal plane, caused by ripple error, provides a reference to evaluate the error and the imaging quality. In this paper, we analyze the diffraction characteristics of sidelobe of optical elements with ripple errors. First, we analyze the characteristics of ripple error and build relationship between ripple error and sidelobe. The sidelobe results from the diffraction of ripple errors. The ripple error tends to be periodic due to fabrication method on the optical surface. The simulated experiments are carried out based on angular spectrum method by characterizing ripple error as rotationally symmetric periodic structures. The influence of two major parameter of ripple including spatial frequency and peak-to-valley value to sidelobe is discussed. The results indicate that spatial frequency and peak-to-valley value both impact sidelobe at the image plane. The peak-tovalley value is the major factor to affect the energy proportion of the sidelobe. The spatial frequency is the major factor to affect the distribution of the sidelobe at the image plane.

Drone inflight mixing of biochemical samples.

PubMed

Katariya, Mayur; Chung, Dwayne Chung Kim; Minife, Tristan; Gupta, Harshit; Zahidi, Alifa Afiah Ahmad; Liew, Oi Wah; Ng, Tuck Wah

2018-03-15

Autonomous systems for sample transport to the laboratory for analysis can be improved in terms of timeliness, cost and error mitigation in the pre-analytical testing phase. Drones have been reported for outdoor sample transport but incorporating devices on them to attain homogenous mixing of reagents during flight to enhance sample processing timeliness is limited by payload issues. It is shown here that flipping maneuvers conducted with quadcopters are able to facilitate complete and gentle mixing. This capability incorporated during automated sample transport serves to address an important factor contributing to pre-analytical variability which ultimately impacts on test result reliability. Copyright © 2018 Elsevier Inc. All rights reserved.

Constraints as a destriping tool for Hires images

NASA Technical Reports Server (NTRS)

Cao, YU; Prince, Thomas A.

1994-01-01

Images produced from the Maximum Correlation Method sometimes suffer from visible striping artifacts, especially for areas of extended sources. Possible causes are different baseline levels and calibration errors in the detectors. We incorporated these factors into the MCM algorithm, and tested the effects of different constraints on the output image. The result shows significant visual improvement over the standard MCM Method. In some areas the new images show intelligible structures that are otherwise corrupted by striping artifacts, and the removal of these artifacts could enhance performance of object classification algorithms. The constraints were also tested on low surface brightness areas, and were found to be effective in reducing the noise level.

Using Fault Trees to Advance Understanding of Diagnostic Errors.

PubMed

Rogith, Deevakar; Iyengar, M Sriram; Singh, Hardeep

2017-11-01

Diagnostic errors annually affect at least 5% of adults in the outpatient setting in the United States. Formal analytic techniques are only infrequently used to understand them, in part because of the complexity of diagnostic processes and clinical work flows involved. In this article, diagnostic errors were modeled using fault tree analysis (FTA), a form of root cause analysis that has been successfully used in other high-complexity, high-risk contexts. How factors contributing to diagnostic errors can be systematically modeled by FTA to inform error understanding and error prevention is demonstrated. A team of three experts reviewed 10 published cases of diagnostic error and constructed fault trees. The fault trees were modeled according to currently available conceptual frameworks characterizing diagnostic error. The 10 trees were then synthesized into a single fault tree to identify common contributing factors and pathways leading to diagnostic error. FTA is a visual, structured, deductive approach that depicts the temporal sequence of events and their interactions in a formal logical hierarchy. The visual FTA enables easier understanding of causative processes and cognitive and system factors, as well as rapid identification of common pathways and interactions in a unified fashion. In addition, it enables calculation of empirical estimates for causative pathways. Thus, fault trees might provide a useful framework for both quantitative and qualitative analysis of diagnostic errors. Future directions include establishing validity and reliability by modeling a wider range of error cases, conducting quantitative evaluations, and undertaking deeper exploration of other FTA capabilities. Copyright © 2017 The Joint Commission. Published by Elsevier Inc. All rights reserved.

Paediatric Patient Safety and the Need for Aviation Black Box Thinking to Learn From and Prevent Medication Errors.

PubMed

Huynh, Chi; Wong, Ian C K; Correa-West, Jo; Terry, David; McCarthy, Suzanne

2017-04-01

Since the publication of To Err Is Human: Building a Safer Health System in 1999, there has been much research conducted into the epidemiology, nature and causes of medication errors in children, from prescribing and supply to administration. It is reassuring to see growing evidence of improving medication safety in children; however, based on media reports, it can be seen that serious and fatal medication errors still occur. This critical opinion article examines the problem of medication errors in children and provides recommendations for research, training of healthcare professionals and a culture shift towards dealing with medication errors. There are three factors that we need to consider to unravel what is missing and why fatal medication errors still occur. (1) Who is involved and affected by the medication error? (2) What factors hinder staff and organisations from learning from mistakes? Does the fear of litigation and criminal charges deter healthcare professionals from voluntarily reporting medication errors? (3) What are the educational needs required to prevent medication errors? It is important to educate future healthcare professionals about medication errors and human factors to prevent these from happening. Further research is required to apply aviation's 'black box' principles in healthcare to record and learn from near misses and errors to prevent future events. There is an urgent need for the black box investigations to be published and made public for the benefit of other organisations that may have similar potential risks for adverse events. International sharing of investigations and learning is also needed.

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.

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.

Proton irradiation effects on advanced digital and microwave III-V components

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

Hash, G.L.; Schwank, J.R.; Shaneyfelt, M.R.

1994-09-01

A wide range of advanced III-V components suitable for use in high-speed satellite communication systems were evaluated for displacement damage and single-event effects in high-energy, high-fluence proton environments. Transistors and integrated circuits (both digital and MMIC) were irradiated with protons at energies from 41 to 197 MeV and at fluences from 10{sup 10} to 2 {times} 10{sup 14} protons/cm{sup 2}. Large soft-error rates were measured for digital GaAs MESFET (3 {times} 10{sup {minus}5} errors/bit-day) and heterojunction bipolar circuits (10{sup {minus}5} errors/bit-day). No transient signals were detected from MMIC circuits. The largest degradation in transistor response caused by displacement damage wasmore » observed for 1.0-{mu}m depletion- and enhancement-mode MESFET transistors. Shorter gate length MESFET transistors and HEMT transistors exhibited less displacement-induced damage. These results show that memory-intensive GaAs digital circuits may result in significant system degradation due to single-event upset in natural and man-made space environments. However, displacement damage effects should not be a limiting factor for fluence levels up to 10{sup 14} protons/cm{sup 2} [equivalent to total doses in excess of 10 Mrad(GaAs)].« less

Proton irradiation effects on advanced digital and microwave III-V components

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

Hash, G.L.; Schwank, J.R.; Shaneyfelt, M.R.

1994-12-01

A wide range of advanced III-V components suitable for use in high-speed satellite communication systems were evaluated for displacement damage and single-event effects in high-energy, high-fluence proton environments. Transistors and integrated circuits (both digital and MMIC) were irradiated with protons at energies from 41 to 197 MeV and at fluences from 10[sup 10] to 2 [times] 10[sup 14] protons/cm[sup 2]. Large soft-error rates were measured for digital GaAs MESFET (3 [times] 10[sup [minus]5] errors/bit-day) and heterojunction bipolar circuits (10[sup [minus]5] errors/bit-day). No transient signals were detected from MMIC circuits. The largest degradation in transistor response caused by displacement damage wasmore » observed for 1.0-[mu]m depletion- and enhancement-mode MESFET transistors. Shorter gate length MESFET transistors and HEMT transistors exhibited less displacement-induced damage. These results show that memory-intensive GaAs digital circuits may result in significant system degradation due to single-event upset in natural and man-made space environments. However, displacement damage effects should not be a limiting factor for fluence levels up to 10[sup 14] protons/cm[sup 2] [equivalent to total doses in excess of 10 Mrad (GaAs)].« less

Identification of driver errors : overview and recommendations

DOT National Transportation Integrated Search

2002-08-01

Driver error is cited as a contributing factor in most automobile crashes, and although estimates vary by source, driver error is cited as the principal cause of from 45 to 75 percent of crashes. However, the specific errors that lead to crashes, and...

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

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

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

1995-05-01

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

A novel diagnosis method for a Hall plates-based rotary encoder with a magnetic concentrator.

PubMed

Meng, Bumin; Wang, Yaonan; Sun, Wei; Yuan, Xiaofang

2014-07-31

In the last few years, rotary encoders based on two-dimensional complementary metal oxide semiconductors (CMOS) Hall plates with a magnetic concentrator have been developed to measure contactless absolute angle. There are various error factors influencing the measuring accuracy, which are difficult to locate after the assembly of encoder. In this paper, a model-based rapid diagnosis method is presented. Based on an analysis of the error mechanism, an error model is built to compare minimum residual angle error and to quantify the error factors. Additionally, a modified particle swarm optimization (PSO) algorithm is used to reduce the calculated amount. The simulation and experimental results show that this diagnosis method is feasible to quantify the causes of the error and to reduce iteration significantly.

Reconsolidation from negative emotional pictures: is successful retrieval required?

PubMed

Finn, Bridgid; Roediger, Henry L; Rosenzweig, Emily

2012-10-01

Finn and Roediger (Psychological science 22:781-786, 2011) found that when a negative emotional picture was presented immediately after a successful retrieval, later test performance was enhanced as compared to when a neutral picture or a blank screen had been shown. This finding implicates the period immediately following retrieval as playing an important role in determining later retention via reconsolidation. In two new experiments, we investigated whether successful retrieval was required to show the enhancing effect of negative emotion on later recall. In both experiments, the participants studied Swahili-English vocabulary pairs, took an intervening cued-recall test, and were given a final cued-recall test on all items. In Experiment 1, we tested a distinctiveness explanation of the effect. The results showed that neither presentation of a negative picture just prior to successful retrieval nor presentation of a positive picture after successful retrieval produced the enhancing effect that was seen when negative pictures were presented after successful retrieval. In Experiment 2, we tested whether the enhancing effect would occur when a negative picture followed an unsuccessful retrieval attempt with feedback, and a larger enhancement effect occurred after errors of commission than after errors of omission. These results indicate that effort in retrieving is critical to the enhancing effect shown with negative pictures; whether the target is produced by the participant or given by an external source following a commission error does not matter. We interpret these results as support for semantic enrichment as a key element in producing the enhancing effect of negative pictures that are presented after a retrieval attempt.

Error Analysis and Validation for Insar Height Measurement Induced by Slant Range

NASA Astrophysics Data System (ADS)

Zhang, X.; Li, T.; Fan, W.; Geng, X.

2018-04-01

InSAR technique is an important method for large area DEM extraction. Several factors have significant influence on the accuracy of height measurement. In this research, the effect of slant range measurement for InSAR height measurement was analysis and discussed. Based on the theory of InSAR height measurement, the error propagation model was derived assuming no coupling among different factors, which directly characterise the relationship between slant range error and height measurement error. Then the theoretical-based analysis in combination with TanDEM-X parameters was implemented to quantitatively evaluate the influence of slant range error to height measurement. In addition, the simulation validation of InSAR error model induced by slant range was performed on the basis of SRTM DEM and TanDEM-X parameters. The spatial distribution characteristics and error propagation rule of InSAR height measurement were further discussed and evaluated.

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

NASA Astrophysics Data System (ADS)

Jamil, Jastini Mohd; Shaharanee, Izwan Nizal Mohd

2017-10-01

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

Numerical simulations to assess the tracer dilution method for measurement of landfill methane emissions.

PubMed

Taylor, Diane M; Chow, Fotini K; Delkash, Madjid; Imhoff, Paul T

2016-10-01

Landfills are a significant contributor to anthropogenic methane emissions, but measuring these emissions can be challenging. This work uses numerical simulations to assess the accuracy of the tracer dilution method, which is used to estimate landfill emissions. Atmospheric dispersion simulations with the Weather Research and Forecast model (WRF) are run over Sandtown Landfill in Delaware, USA, using observation data to validate the meteorological model output. A steady landfill methane emissions rate is used in the model, and methane and tracer gas concentrations are collected along various transects downwind from the landfill for use in the tracer dilution method. The calculated methane emissions are compared to the methane emissions rate used in the model to find the percent error of the tracer dilution method for each simulation. The roles of different factors are examined: measurement distance from the landfill, transect angle relative to the wind direction, speed of the transect vehicle, tracer placement relative to the hot spot of methane emissions, complexity of topography, and wind direction. Results show that percent error generally decreases with distance from the landfill, where the tracer and methane plumes become well mixed. Tracer placement has the largest effect on percent error, and topography and wind direction both have significant effects, with measurement errors ranging from -12% to 42% over all simulations. Transect angle and transect speed have small to negligible effects on the accuracy of the tracer dilution method. These tracer dilution method simulations provide insight into measurement errors that might occur in the field, enhance understanding of the method's limitations, and aid interpretation of field data. Copyright © 2016 Elsevier Ltd. All rights reserved.

Accuracy aspects of stereo side-looking radar. [analysis of its visual perception and binocular vision

NASA Technical Reports Server (NTRS)

Leberl, F. W.

1979-01-01

The geometry of the radar stereo model and factors affecting visual radar stereo perception are reviewed. Limits to the vertical exaggeration factor of stereo radar are defined. Radar stereo model accuracies are analyzed with respect to coordinate errors caused by errors of radar sensor position and of range, and with respect to errors of coordinate differences, i.e., cross-track distances and height differences.

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.

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.

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.

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.

Suboptimal schemes for atmospheric data assimilation based on the Kalman filter

NASA Technical Reports Server (NTRS)

Todling, Ricardo; Cohn, Stephen E.

1994-01-01

This work is directed toward approximating the evolution of forecast error covariances for data assimilation. The performance of different algorithms based on simplification of the standard Kalman filter (KF) is studied. These are suboptimal schemes (SOSs) when compared to the KF, which is optimal for linear problems with known statistics. The SOSs considered here are several versions of optimal interpolation (OI), a scheme for height error variance advection, and a simplified KF in which the full height error covariance is advected. To employ a methodology for exact comparison among these schemes, a linear environment is maintained, in which a beta-plane shallow-water model linearized about a constant zonal flow is chosen for the test-bed dynamics. The results show that constructing dynamically balanced forecast error covariances rather than using conventional geostrophically balanced ones is essential for successful performance of any SOS. A posteriori initialization of SOSs to compensate for model - data imbalance sometimes results in poor performance. Instead, properly constructed dynamically balanced forecast error covariances eliminate the need for initialization. When the SOSs studied here make use of dynamically balanced forecast error covariances, the difference among their performances progresses naturally from conventional OI to the KF. In fact, the results suggest that even modest enhancements of OI, such as including an approximate dynamical equation for height error variances while leaving height error correlation structure homogeneous, go a long way toward achieving the performance of the KF, provided that dynamically balanced cross-covariances are constructed and that model errors are accounted for properly. The results indicate that such enhancements are necessary if unconventional data are to have a positive impact.

Social aspects of clinical errors.

PubMed

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

2009-08-01

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

Network Adjustment of Orbit Errors in SAR Interferometry

NASA Astrophysics Data System (ADS)

Bahr, Hermann; Hanssen, Ramon

2010-03-01

Orbit errors can induce significant long wavelength error signals in synthetic aperture radar (SAR) interferograms and thus bias estimates of wide-scale deformation phenomena. The presented approach aims for correcting orbit errors in a preprocessing step to deformation analysis by modifying state vectors. Whereas absolute errors in the orbital trajectory are negligible, the influence of relative errors (baseline errors) is parametrised by their parallel and perpendicular component as a linear function of time. As the sensitivity of the interferometric phase is only significant with respect to the perpendicular base-line and the rate of change of the parallel baseline, the algorithm focuses on estimating updates to these two parameters. This is achieved by a least squares approach, where the unwrapped residual interferometric phase is observed and atmospheric contributions are considered to be stochastic with constant mean. To enhance reliability, baseline errors are adjusted in an overdetermined network of interferograms, yielding individual orbit corrections per acquisition.

Comprehensive Anti-error Study on Power Grid Dispatching Based on Regional Regulation and Integration

NASA Astrophysics Data System (ADS)

Zhang, Yunju; Chen, Zhongyi; Guo, Ming; Lin, Shunsheng; Yan, Yinyang

2018-01-01

With the large capacity of the power system, the development trend of the large unit and the high voltage, the scheduling operation is becoming more frequent and complicated, and the probability of operation error increases. This paper aims at the problem of the lack of anti-error function, single scheduling function and low working efficiency for technical support system in regional regulation and integration, the integrated construction of the error prevention of the integrated architecture of the system of dispatching anti - error of dispatching anti - error of power network based on cloud computing has been proposed. Integrated system of error prevention of Energy Management System, EMS, and Operation Management System, OMS have been constructed either. The system architecture has good scalability and adaptability, which can improve the computational efficiency, reduce the cost of system operation and maintenance, enhance the ability of regional regulation and anti-error checking with broad development prospects.

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.

Temporal subtraction contrast-enhanced dedicated breast CT

NASA Astrophysics Data System (ADS)

Gazi, Peymon M.; Aminololama-Shakeri, Shadi; Yang, Kai; Boone, John M.

2016-09-01

The development of a framework of deformable image registration and segmentation for the purpose of temporal subtraction contrast-enhanced breast CT is described. An iterative histogram-based two-means clustering method was used for the segmentation. Dedicated breast CT images were segmented into background (air), adipose, fibroglandular and skin components. Fibroglandular tissue was classified as either normal or contrast-enhanced then divided into tiers for the purpose of categorizing degrees of contrast enhancement. A variant of the Demons deformable registration algorithm, intensity difference adaptive Demons (IDAD), was developed to correct for the large deformation forces that stemmed from contrast enhancement. In this application, the accuracy of the proposed method was evaluated in both mathematically-simulated and physically-acquired phantom images. Clinical usage and accuracy of the temporal subtraction framework was demonstrated using contrast-enhanced breast CT datasets from five patients. Registration performance was quantified using normalized cross correlation (NCC), symmetric uncertainty coefficient, normalized mutual information (NMI), mean square error (MSE) and target registration error (TRE). The proposed method outperformed conventional affine and other Demons variations in contrast enhanced breast CT image registration. In simulation studies, IDAD exhibited improvement in MSE (0-16%), NCC (0-6%), NMI (0-13%) and TRE (0-34%) compared to the conventional Demons approaches, depending on the size and intensity of the enhancing lesion. As lesion size and contrast enhancement levels increased, so did the improvement. The drop in the correlation between the pre- and post-contrast images for the largest enhancement levels in phantom studies is less than 1.2% (150 Hounsfield units). Registration error, measured by TRE, shows only submillimeter mismatches between the concordant anatomical target points in all patient studies. The algorithm was implemented using a parallel processing architecture resulting in rapid execution time for the iterative segmentation and intensity-adaptive registration techniques. Characterization of contrast-enhanced lesions is improved using temporal subtraction contrast-enhanced dedicated breast CT. Adaptation of Demons registration forces as a function of contrast-enhancement levels provided a means to accurately align breast tissue in pre- and post-contrast image acquisitions, improving subtraction results. Spatial subtraction of the aligned images yields useful diagnostic information with respect to enhanced lesion morphology and uptake.

Some Results on Mean Square Error for Factor Score Prediction

ERIC Educational Resources Information Center

Krijnen, Wim P.

2006-01-01

For the confirmatory factor model a series of inequalities is given with respect to the mean square error (MSE) of three main factor score predictors. The eigenvalues of these MSE matrices are a monotonic function of the eigenvalues of the matrix gamma[subscript rho] = theta[superscript 1/2] lambda[subscript rho] 'psi[subscript rho] [superscript…

Preventing Errors in Clinical Practice: A Call for Self-Awareness

PubMed Central

Borrell-Carrió, Francesc; Epstein, Ronald M.

2004-01-01

While ascribing medical errors primarily to systems factors can free clinicians from individual blame, there are elements of medical errors that can and should be attributed to individual factors. These factors are related less commonly to lack of knowledge and skill than to the inability to apply the clinician’s abilities to situations under certain circumstances. In concert with efforts to improve health care systems, refining physicians’ emotional and cognitive capacities might also prevent many errors. In general, physicians have the sensation of making a mistake because of the interference of emotional elements. We propose a so-called rational-emotive model that emphasizes 2 factors in error causation: (1) difficulty in reframing the first hypothesis that goes to the physician’s mind in an automatic way, and (2) premature closure of the clinical act to avoid confronting inconsistencies, low-level decision rules, and emotions. We propose a teaching strategy based on developing the physician’s insight and self-awareness to detect the inappropriate use of low-level decision rules, as well as detecting the factors that limit a physician’s capacity to tolerate the tension of uncertainty and ambiguity. Emotional self-awareness and self-regulation of attention can be consciously cultivated as habits to help physicians function better in clinical situations. PMID:15335129

A Third Moment Adjusted Test Statistic for Small Sample Factor Analysis.

PubMed

Lin, Johnny; Bentler, Peter M

2012-01-01

Goodness of fit testing in factor analysis is based on the assumption that the test statistic is asymptotically chi-square; but this property may not hold in small samples even when the factors and errors are normally distributed in the population. Robust methods such as Browne's asymptotically distribution-free method and Satorra Bentler's mean scaling statistic were developed under the presumption of non-normality in the factors and errors. This paper finds new application to the case where factors and errors are normally distributed in the population but the skewness of the obtained test statistic is still high due to sampling error in the observed indicators. An extension of Satorra Bentler's statistic is proposed that not only scales the mean but also adjusts the degrees of freedom based on the skewness of the obtained test statistic in order to improve its robustness under small samples. A simple simulation study shows that this third moment adjusted statistic asymptotically performs on par with previously proposed methods, and at a very small sample size offers superior Type I error rates under a properly specified model. Data from Mardia, Kent and Bibby's study of students tested for their ability in five content areas that were either open or closed book were used to illustrate the real-world performance of this statistic.

Preventing errors in clinical practice: a call for self-awareness.

PubMed

Borrell-Carrió, Francesc; Epstein, Ronald M

2004-01-01

While ascribing medical errors primarily to systems factors can free clinicians from individual blame, there are elements of medical errors that can and should be attributed to individual factors. These factors are related less commonly to lack of knowledge and skill than to the inability to apply the clinician's abilities to situations under certain circumstances. In concert with efforts to improve health care systems, refining physicians' emotional and cognitive capacities might also prevent many errors. In general, physicians have the sensation of making a mistake because of the interference of emotional elements. We propose a so-called rational-emotive model that emphasizes 2 factors in error causation: (1) difficulty in reframing the first hypothesis that goes to the physician's mind in an automatic way, and (2) premature closure of the clinical act to avoid confronting inconsistencies, low-level decision rules, and emotions. We propose a teaching strategy based on developing the physician's insight and self-awareness to detect the inappropriate use of low-level decision rules, as well as detecting the factors that limit a physician's capacity to tolerate the tension of uncertainty and ambiguity. Emotional self-awareness and self-regulation of attention can be consciously cultivated as habits to help physicians function better in clinical situations.

Cognitive aspect of diagnostic errors.

PubMed

Phua, Dong Haur; Tan, Nigel C K

2013-01-01

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

Renal contrast-enhanced MR angiography: timing errors and accurate depiction of renal artery origins.

PubMed

Schmidt, Maria A; Morgan, Robert

2008-10-01

To investigate bolus timing artifacts that impair depiction of renal arteries at contrast material-enhanced magnetic resonance (MR) angiography and to determine the effect of contrast agent infusion rates on artifact generation. Renal contrast-enhanced MR angiography was simulated for a variety of infusion schemes, assuming both correct and incorrect timing between data acquisition and contrast agent injection. In addition, the ethics committee approved the retrospective evaluation of clinical breath-hold renal contrast-enhanced MR angiographic studies obtained with automated detection of contrast agent arrival. Twenty-two studies were evaluated for their ability to depict the origin of renal arteries in patent vessels and for any signs of timing errors. Simulations showed that a completely artifactual stenosis or an artifactual overestimation of an existing stenosis at the renal artery origin can be caused by timing errors of the order of 5 seconds in examinations performed with contrast agent infusion rates compatible with or higher than those of hand injections. Lower infusion rates make the studies more likely to accurately depict the origin of the renal arteries. In approximately one-third of all clinical examinations, different contrast agent uptake rates were detected on the left and right sides of the body, and thus allowed us to confirm that it is often impossible to optimize depiction of both renal arteries. In three renal arteries, a signal void was found at the origin in a patent vessel, and delayed contrast agent arrival was confirmed. Computer simulations and clinical examinations showed that timing errors impair the accurate depiction of renal artery origins. (c) RSNA, 2008.

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

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

Lon N. Haney; David I. Gertman

2003-04-01

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

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.

Error Detection Processes during Observational Learning

ERIC Educational Resources Information Center

Badets, Arnaud; Blandin, Yannick; Wright, David L.; Shea, Charles H.

2006-01-01

The purpose of this experiment was to determine whether a faded knowledge of results (KR) frequency during observation of a model's performance enhanced error detection capabilities. During the observation phase, participants observed a model performing a timing task and received KR about the model's performance on each trial or on one of two…

MR Imaging Radiomics Signatures for Predicting the Risk of Breast Cancer Recurrence as Given by Research Versions of MammaPrint, Oncotype DX, and PAM50 Gene Assays.

PubMed

Li, Hui; Zhu, Yitan; Burnside, Elizabeth S; Drukker, Karen; Hoadley, Katherine A; Fan, Cheng; Conzen, Suzanne D; Whitman, Gary J; Sutton, Elizabeth J; Net, Jose M; Ganott, Marie; Huang, Erich; Morris, Elizabeth A; Perou, Charles M; Ji, Yuan; Giger, Maryellen L

2016-11-01

Purpose To investigate relationships between computer-extracted breast magnetic resonance (MR) imaging phenotypes with multigene assays of MammaPrint, Oncotype DX, and PAM50 to assess the role of radiomics in evaluating the risk of breast cancer recurrence. Materials and Methods Analysis was conducted on an institutional review board-approved retrospective data set of 84 deidentified, multi-institutional breast MR examinations from the National Cancer Institute Cancer Imaging Archive, along with clinical, histopathologic, and genomic data from The Cancer Genome Atlas. The data set of biopsy-proven invasive breast cancers included 74 (88%) ductal, eight (10%) lobular, and two (2%) mixed cancers. Of these, 73 (87%) were estrogen receptor positive, 67 (80%) were progesterone receptor positive, and 19 (23%) were human epidermal growth factor receptor 2 positive. For each case, computerized radiomics of the MR images yielded computer-extracted tumor phenotypes of size, shape, margin morphology, enhancement texture, and kinetic assessment. Regression and receiver operating characteristic analysis were conducted to assess the predictive ability of the MR radiomics features relative to the multigene assay classifications. Results Multiple linear regression analyses demonstrated significant associations (R 2 = 0.25-0.32, r = 0.5-0.56, P < .0001) between radiomics signatures and multigene assay recurrence scores. Important radiomics features included tumor size and enhancement texture, which indicated tumor heterogeneity. Use of radiomics in the task of distinguishing between good and poor prognosis yielded area under the receiver operating characteristic curve values of 0.88 (standard error, 0.05), 0.76 (standard error, 0.06), 0.68 (standard error, 0.08), and 0.55 (standard error, 0.09) for MammaPrint, Oncotype DX, PAM50 risk of relapse based on subtype, and PAM50 risk of relapse based on subtype and proliferation, respectively, with all but the latter showing statistical difference from chance. Conclusion Quantitative breast MR imaging radiomics shows promise for image-based phenotyping in assessing the risk of breast cancer recurrence. © RSNA, 2016 Online supplemental material is available for this article.

Security enhanced multi-factor biometric authentication scheme using bio-hash function

PubMed Central

Lee, Youngsook; Moon, Jongho

2017-01-01

With the rapid development of personal information and wireless communication technology, user authentication schemes have been crucial to ensure that wireless communications are secure. As such, various authentication schemes with multi-factor authentication have been proposed to improve the security of electronic communications. Multi-factor authentication involves the use of passwords, smart cards, and various biometrics to provide users with the utmost privacy and data protection. Cao and Ge analyzed various authentication schemes and found that Younghwa An’s scheme was susceptible to a replay attack where an adversary masquerades as a legal server and a user masquerading attack where user anonymity is not provided, allowing an adversary to execute a password change process by intercepting the user’s ID during login. Cao and Ge improved upon Younghwa An’s scheme, but various security problems remained. This study demonstrates that Cao and Ge’s scheme is susceptible to a biometric recognition error, slow wrong password detection, off-line password attack, user impersonation attack, ID guessing attack, a DoS attack, and that their scheme cannot provide session key agreement. Then, to address all weaknesses identified in Cao and Ge’s scheme, this study proposes a security enhanced multi-factor biometric authentication scheme and provides a security analysis and formal analysis using Burrows-Abadi-Needham logic. Finally, the efficiency analysis reveals that the proposed scheme can protect against several possible types of attacks with only a slightly high computational cost. PMID:28459867

Spacecraft methods and structures with enhanced attitude control that facilitates gyroscope substitutions

NASA Technical Reports Server (NTRS)

Li, Rongsheng (Inventor); Kurland, Jeffrey A. (Inventor); Dawson, Alec M. (Inventor); Wu, Yeong-Wei A. (Inventor); Uetrecht, David S. (Inventor)

2004-01-01

Methods and structures are provided that enhance attitude control during gyroscope substitutions by insuring that a spacecraft's attitude control system does not drive its absolute-attitude sensors out of their capture ranges. In a method embodiment, an operational process-noise covariance Q of a Kalman filter is temporarily replaced with a substantially greater interim process-noise covariance Q. This replacement increases the weight given to the most recent attitude measurements and hastens the reduction of attitude errors and gyroscope bias errors. The error effect of the substituted gyroscopes is reduced and the absolute-attitude sensors are not driven out of their capture range. In another method embodiment, this replacement is preceded by the temporary replacement of an operational measurement-noise variance R with a substantially larger interim measurement-noise variance R to reduce transients during the gyroscope substitutions.

System review: a method for investigating medical errors in healthcare settings.

PubMed

Alexander, G L; Stone, T T

2000-01-01

System analysis is a process of evaluating objectives, resources, structure, and design of businesses. System analysis can be used by leaders to collaboratively identify breakthrough opportunities to improve system processes. In healthcare systems, system analysis can be used to review medical errors (system occurrences) that may place patients at risk for injury, disability, and/or death. This study utilizes a case management approach to identify medical errors. Utilizing an interdisciplinary approach, a System Review Team was developed to identify trends in system occurrences, facilitate communication, and enhance the quality of patient care by reducing medical errors.

Comparison between goal programming and cointegration approaches in enhanced index tracking

NASA Astrophysics Data System (ADS)

Lam, Weng Siew; Jamaan, Saiful Hafizah Hj.

2013-04-01

Index tracking is a popular form of passive fund management in stock market. Passive management is a buy-and-hold strategy that aims to achieve rate of return similar to the market return. Index tracking problem is a problem of reproducing the performance of a stock market index, without purchasing all of the stocks that make up the index. This can be done by establishing an optimal portfolio that minimizes risk or tracking error. An improved index tracking (enhanced index tracking) is a dual-objective optimization problem, a trade-off between maximizing the mean return and minimizing the tracking error. Enhanced index tracking aims to generate excess return over the return achieved by the index. The objective of this study is to compare the portfolio compositions and performances by using two different approaches in enhanced index tracking problem, which are goal programming and cointegration. The result of this study shows that the optimal portfolios for both approaches are able to outperform the Malaysia market index which is Kuala Lumpur Composite Index. Both approaches give different optimal portfolio compositions. Besides, the cointegration approach outperforms the goal programming approach because the cointegration approach gives higher mean return and lower risk or tracking error. Therefore, the cointegration approach is more appropriate for the investors in Malaysia.

Summary of evidence-based guideline update: Evaluation and management of concussion in sports

PubMed Central

Giza, Christopher C.; Kutcher, Jeffrey S.; Ashwal, Stephen; Barth, Jeffrey; Getchius, Thomas S.D.; Gioia, Gerard A.; Gronseth, Gary S.; Guskiewicz, Kevin; Mandel, Steven; Manley, Geoffrey; McKeag, Douglas B.; Thurman, David J.; Zafonte, Ross

2013-01-01

Objective: To update the 1997 American Academy of Neurology (AAN) practice parameter regarding sports concussion, focusing on 4 questions: 1) What factors increase/decrease concussion risk? 2) What diagnostic tools identify those with concussion and those at increased risk for severe/prolonged early impairments, neurologic catastrophe, or chronic neurobehavioral impairment? 3) What clinical factors identify those at increased risk for severe/prolonged early postconcussion impairments, neurologic catastrophe, recurrent concussions, or chronic neurobehavioral impairment? 4) What interventions enhance recovery, reduce recurrent concussion risk, or diminish long-term sequelae? The complete guideline on which this summary is based is available as an online data supplement to this article. Methods: We systematically reviewed the literature from 1955 to June 2012 for pertinent evidence. We assessed evidence for quality and synthesized into conclusions using a modified Grading of Recommendations Assessment, Development and Evaluation process. We used a modified Delphi process to develop recommendations. Results: Specific risk factors can increase or decrease concussion risk. Diagnostic tools to help identify individuals with concussion include graded symptom checklists, the Standardized Assessment of Concussion, neuropsychological assessments, and the Balance Error Scoring System. Ongoing clinical symptoms, concussion history, and younger age identify those at risk for postconcussion impairments. Risk factors for recurrent concussion include history of multiple concussions, particularly within 10 days after initial concussion. Risk factors for chronic neurobehavioral impairment include concussion exposure and APOE ε4 genotype. Data are insufficient to show that any intervention enhances recovery or diminishes long-term sequelae postconcussion. Practice recommendations are presented for preparticipation counseling, management of suspected concussion, and management of diagnosed concussion. PMID:23508730

Utilizing a Human Factors Nursing Worksystem Improvement Framework to Increase Nurses' Time at the Bedside and Enhance Safety.

PubMed

Probst, C Adam; Carter, Megan; Cadigan, Caton; Dalcour, Cortney; Cassity, Cindy; Quinn, Penny; Williams, Tiana; Montgomery, Donna Cook; Wilder, Claudia; Xiao, Yan

2017-02-01

The aim of this study is to increase nurses' time for direct patient care and improve safety via a novel human factors framework for nursing worksystem improvement. Time available for direct patient care influences outcomes, yet worksystem barriers prevent nurses adequate time at the bedside. A novel human factors framework was developed for worksystem improvement in 3 units at 2 facilities. Objectives included improving nurse efficiency as measured by time-and-motion studies, reducing missing medications and subsequent trips to medication rooms and improving medication safety. Worksystem improvement resulted in time savings of 16% to 32% per nurse per 12-hour shift. Requests for missing medications dropped from 3.2 to 1.3 per day. Nurse medication room trips were reduced by 30% and nurse-reported medication errors fell from a range of 1.2 to 0.8 and 6.3 to 4.0 per month. An innovative human factors framework for nursing worksystem improvement provided practical and high priority targets for interventions that significantly improved the nursing worksystem.

Real-Time Identification of Wheel Terrain Interaction Models for Enhanced Autonomous Vehicle Mobility

DTIC Science & Technology

2014-04-24

tim at io n Er ro r ( cm ) 0 2 4 6 8 10 Color Statistics Angelova...Color_Statistics_Error) / Average_Slip_Error Position Estimation Error: Global Pose Po si tio n Es tim at io n Er ro r ( cm ) 0 2 4 6 8 10 12 Color...get some kind of clearance for releasing pose and odometry data) collected at the following sites – Taylor, Gascola, Somerset, Fort Bliss and

Burnout is associated with changes in error and feedback processing.

PubMed

Gajewski, Patrick D; Boden, Sylvia; Freude, Gabriele; Potter, Guy G; Falkenstein, Michael

2017-10-01

Burnout is a pattern of complaints in individuals with emotionally demanding jobs that is often seen as a precursor of depression. One often reported symptom of burnout is cognitive decline. To analyze cognitive control and to differentiate between subclinical burnout and mild to moderate depression a double-blinded study was conducted that investigates changes in the processing of performance errors and feedback in a task switching paradigm. Fifty-one of 76 employees from emotionally demanding jobs showed a sufficient number of errors to be included in the analysis. The sample was subdivided into groups with low (EE-) and high (EE+) emotional exhaustion and no (DE-) and mild to moderate depression (DE+). The behavioral data did not significantly differ between the groups. In contrast, in the EE+ group, the error negativity (Ne/ERN) was enhanced while the error positivity (Pe) did not differ between the EE+ and EE- groups. After negative feedback the feedback-related negativity (FRN) was enhanced, while the subsequent positivity (FRP) was reduced in EE+ relative to EE-. None of these effects were observed in the DE+ vs. DE-. These results suggest an upregulation of error and negative feedback processing, while the later processing of negative feedback was attenuated in employees with subclinical burnout but not in mild to moderate depression. Copyright © 2017 Elsevier B.V. All rights reserved.

Addressing the Hard Factors for Command File Errors by Probabilistic Reasoning

NASA Technical Reports Server (NTRS)

Meshkat, Leila; Bryant, Larry

2014-01-01

Command File Errors (CFE) are managed using standard risk management approaches at the Jet Propulsion Laboratory. Over the last few years, more emphasis has been made on the collection, organization, and analysis of these errors for the purpose of reducing the CFE rates. More recently, probabilistic modeling techniques have been used for more in depth analysis of the perceived error rates of the DAWN mission and for managing the soft factors in the upcoming phases of the mission. We broadly classify the factors that can lead to CFE's as soft factors, which relate to the cognition of the operators and hard factors which relate to the Mission System which is composed of the hardware, software and procedures used for the generation, verification & validation and execution of commands. The focus of this paper is to use probabilistic models that represent multiple missions at JPL to determine the root cause and sensitivities of the various components of the mission system and develop recommendations and techniques for addressing them. The customization of these multi-mission models to a sample interplanetary spacecraft is done for this purpose.

Transient Faults in Computer Systems

NASA Technical Reports Server (NTRS)

Masson, Gerald M.

1993-01-01

A powerful technique particularly appropriate for the detection of errors caused by transient faults in computer systems was developed. The technique can be implemented in either software or hardware; the research conducted thus far primarily considered software implementations. The error detection technique developed has the distinct advantage of having provably complete coverage of all errors caused by transient faults that affect the output produced by the execution of a program. In other words, the technique does not have to be tuned to a particular error model to enhance error coverage. Also, the correctness of the technique can be formally verified. The technique uses time and software redundancy. The foundation for an effective, low-overhead, software-based certification trail approach to real-time error detection resulting from transient fault phenomena was developed.

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

PubMed

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

2012-02-01

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

Accuracy Enhancement of Inertial Sensors Utilizing High Resolution Spectral Analysis

PubMed Central

Noureldin, Aboelmagd; Armstrong, Justin; El-Shafie, Ahmed; Karamat, Tashfeen; McGaughey, Don; Korenberg, Michael; Hussain, Aini

2012-01-01

In both military and civilian applications, the inertial navigation system (INS) and the global positioning system (GPS) are two complementary technologies that can be integrated to provide reliable positioning and navigation information for land vehicles. The accuracy enhancement of INS sensors and the integration of INS with GPS are the subjects of widespread research. Wavelet de-noising of INS sensors has had limited success in removing the long-term (low-frequency) inertial sensor errors. The primary objective of this research is to develop a novel inertial sensor accuracy enhancement technique that can remove both short-term and long-term error components from inertial sensor measurements prior to INS mechanization and INS/GPS integration. A high resolution spectral analysis technique called the fast orthogonal search (FOS) algorithm is used to accurately model the low frequency range of the spectrum, which includes the vehicle motion dynamics and inertial sensor errors. FOS models the spectral components with the most energy first and uses an adaptive threshold to stop adding frequency terms when fitting a term does not reduce the mean squared error more than fitting white noise. The proposed method was developed, tested and validated through road test experiments involving both low-end tactical grade and low cost MEMS-based inertial systems. The results demonstrate that in most cases the position accuracy during GPS outages using FOS de-noised data is superior to the position accuracy using wavelet de-noising.

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

PubMed

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

2017-03-21

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

Enhanced fault-tolerant quantum computing in d-level systems.

PubMed

Campbell, Earl T

2014-12-05

Error-correcting codes protect quantum information and form the basis of fault-tolerant quantum computing. Leading proposals for fault-tolerant quantum computation require codes with an exceedingly rare property, a transversal non-Clifford gate. Codes with the desired property are presented for d-level qudit systems with prime d. The codes use n=d-1 qudits and can detect up to ∼d/3 errors. We quantify the performance of these codes for one approach to quantum computation known as magic-state distillation. Unlike prior work, we find performance is always enhanced by increasing d.

Sensitivity of the Enhanced Vegetation Index (EVI) and Normalized Difference Vegetation Index (NDVI) to Topographic Effects: A Case Study in High-density Cypress Forest.

PubMed

Matsushita, Bunkei; Yang, Wei; Chen, Jin; Onda, Yuyichi; Qiu, Guoyu

2007-11-05

Vegetation indices play an important role in monitoring variations in vegetation.The Enhanced Vegetation Index (EVI) proposed by the MODIS Land Discipline Groupand the Normalized Difference Vegetation Index (NDVI) are both global-based vegetationindices aimed at providing consistent spatial and temporal information regarding globalvegetation. However, many environmental factors such as atmospheric conditions and soilbackground may produce errors in these indices. The topographic effect is another veryimportant factor, especially when the indices are used in areas of rough terrain. In thispaper, we theoretically analyzed differences in the topographic effect on the EVI and theNDVI based on a non-Lambertian model and two airborne-based images acquired from amountainous area covered by high-density Japanese cypress plantation were used as a casestudy. The results indicate that the soil adjustment factor "L" in the EVI makes it moresensitive to topographic conditions than is the NDVI. Based on these results, we stronglyrecommend that the topographic effect should be removed in the reflectance data beforethe EVI was calculated-as well as from other vegetation indices that similarly include a term without a band ratio format (e.g., the PVI and SAVI)-when these indices are used in the area of rough terrain, where the topographic effect on the vegetation indices having only a band ratio format (e.g., the NDVI) can usually be ignored.

Sensitivity of thermal inertia calculations to variations in environmental factors. [in mapping of Earth's surface by remote sensing

NASA Technical Reports Server (NTRS)

Kahle, A. B.; Alley, R. E.; Schieldge, J. P.

1984-01-01

The sensitivity of thermal inertia (TI) calculations to errors in the measurement or parameterization of a number of environmental factors is considered here. The factors include effects of radiative transfer in the atmosphere, surface albedo and emissivity, variations in surface turbulent heat flux density, cloud cover, vegetative cover, and topography. The error analysis is based upon data from the Heat Capacity Mapping Mission (HCMM) satellite for July 1978 at three separate test sites in the deserts of the western United States. Results show that typical errors in atmospheric radiative transfer, cloud cover, and vegetative cover can individually cause root-mean-square (RMS) errors of about 10 percent (with atmospheric effects sometimes as large as 30-40 percent) in HCMM-derived thermal inertia images of 20,000-200,000 pixels.

Navigation accuracy comparing non-covered frame and use of plastic sterile drapes to cover the reference frame in 3D acquisition.

PubMed

Corenman, Donald S; Strauch, Eric L; Dornan, Grant J; Otterstrom, Eric; Zalepa King, Lisa

2017-09-01

Advancements in surgical navigation technology coupled with 3-dimensional (3D) radiographic data have significantly enhanced the accuracy and efficiency of spinal fusion implant placement. Increased usage of such technology has led to rising concerns regarding maintenance of the sterile field, as makeshift drape systems are fraught with breaches thus presenting increased risk of surgical site infections (SSIs). A clinical need exists for a sterile draping solution with these techniques. Our objective was to quantify expected accuracy error associated with 2MM and 4MM thickness Sterile-Z Patient Drape ® using Medtronic O-Arm ® Surgical Imaging with StealthStation ® S7 ® Navigation System. Camera distance to reference frame was investigated for contribution to accuracy error. A testing jig was placed on the radiolucent table and the Medtronic passive reference frame was attached to jig. The StealthStation ® S7 ® navigation camera was placed at various distances from testing jig and the geometry error of reference frame was captured for three different drape configurations: no drape, 2MM drape and 4MM drape. The O-Arm ® gantry location and StealthStation ® S7 ® camera position was maintained and seven 3D acquisitions for each of drape configurations were measured. Data was analyzed by a two-factor analysis of variance (ANOVA) and Bonferroni comparisons were used to assess the independent effects of camera angle and drape on accuracy error. Median (and maximum) measurement accuracy error was higher for the 2MM than for the 4MM drape for each camera distance. The most extreme error observed (4.6 mm) occurred when using the 2MM and the 'far' camera distance. The 4MM drape was found to induce an accuracy error of 0.11 mm (95% confidence interval, 0.06-0.15; P<0.001) relative to the no drape testing, regardless of camera distance. Medium camera distance produced lower accuracy error than either the close (additional 0.08 mm error; 95% CI, 0-0.15; P=0.035) or far (additional 0.21mm error; 95% CI, 0.13-0.28; P<0.001) camera distances, regardless of whether a drape was used. In comparison to the 'no drape' condition, the accuracy error of 0.11 mm when using a 4MM film drape is minimal and clinically insignificant.

The District Nursing Clinical Error Reduction Programme.

PubMed

McGraw, Caroline; Topping, Claire

2011-01-01

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

Measurement Error and Equating Error in Power Analysis

ERIC Educational Resources Information Center

Phillips, Gary W.; Jiang, Tao

2016-01-01

Power analysis is a fundamental prerequisite for conducting scientific research. Without power analysis the researcher has no way of knowing whether the sample size is large enough to detect the effect he or she is looking for. This paper demonstrates how psychometric factors such as measurement error and equating error affect the power of…

Slope Error Measurement Tool for Solar Parabolic Trough Collectors: Preprint

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

Stynes, J. K.; Ihas, B.

2012-04-01

The National Renewable Energy Laboratory (NREL) has developed an optical measurement tool for parabolic solar collectors that measures the combined errors due to absorber misalignment and reflector slope error. The combined absorber alignment and reflector slope errors are measured using a digital camera to photograph the reflected image of the absorber in the collector. Previous work using the image of the reflection of the absorber finds the reflector slope errors from the reflection of the absorber and an independent measurement of the absorber location. The accuracy of the reflector slope error measurement is thus dependent on the accuracy of themore » absorber location measurement. By measuring the combined reflector-absorber errors, the uncertainty in the absorber location measurement is eliminated. The related performance merit, the intercept factor, depends on the combined effects of the absorber alignment and reflector slope errors. Measuring the combined effect provides a simpler measurement and a more accurate input to the intercept factor estimate. The minimal equipment and setup required for this measurement technique make it ideal for field measurements.« less

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.

Contrast enhancement of transparencies

NASA Technical Reports Server (NTRS)

Shulman, A. R.; Lee, S. H.

1976-01-01

System can enhance or reduce contrast of photographic transparency for printing or projection by using constructive and destructive interference of collimated laser beam. System is potentially less expensive than electronic CRT methods and is more accurate than trial-and-error manual techniques.

Clinical review: Medication errors in critical care

PubMed Central

Moyen, Eric; Camiré, Eric; Stelfox, Henry Thomas

2008-01-01

Medication errors in critical care are frequent, serious, and predictable. Critically ill patients are prescribed twice as many medications as patients outside of the intensive care unit (ICU) and nearly all will suffer a potentially life-threatening error at some point during their stay. The aim of this article is to provide a basic review of medication errors in the ICU, identify risk factors for medication errors, and suggest strategies to prevent errors and manage their consequences. PMID:18373883

Binocular optical axis parallelism detection precision analysis based on Monte Carlo method

NASA Astrophysics Data System (ADS)

Ying, Jiaju; Liu, Bingqi

2018-02-01

According to the working principle of the binocular photoelectric instrument optical axis parallelism digital calibration instrument, and in view of all components of the instrument, the various factors affect the system precision is analyzed, and then precision analysis model is established. Based on the error distribution, Monte Carlo method is used to analyze the relationship between the comprehensive error and the change of the center coordinate of the circle target image. The method can further guide the error distribution, optimize control the factors which have greater influence on the comprehensive error, and improve the measurement accuracy of the optical axis parallelism digital calibration instrument.

Inherent Conservatism in Deterministic Quasi-Static Structural Analysis

NASA Technical Reports Server (NTRS)

Verderaime, V.

1997-01-01

The cause of the long-suspected excessive conservatism in the prevailing structural deterministic safety factor has been identified as an inherent violation of the error propagation laws when reducing statistical data to deterministic values and then combining them algebraically through successive structural computational processes. These errors are restricted to the applied stress computations, and because mean and variations of the tolerance limit format are added, the errors are positive, serially cumulative, and excessively conservative. Reliability methods circumvent these errors and provide more efficient and uniform safe structures. The document is a tutorial on the deficiencies and nature of the current safety factor and of its improvement and transition to absolute reliability.

SIMulation of Medication Error induced by Clinical Trial drug labeling: the SIMME-CT study.

PubMed

Dollinger, Cecile; Schwiertz, Vérane; Sarfati, Laura; Gourc-Berthod, Chloé; Guédat, Marie-Gabrielle; Alloux, Céline; Vantard, Nicolas; Gauthier, Noémie; He, Sophie; Kiouris, Elena; Caffin, Anne-Gaelle; Bernard, Delphine; Ranchon, Florence; Rioufol, Catherine

2016-06-01

To assess the impact of investigational drug labels on the risk of medication error in drug dispensing. A simulation-based learning program focusing on investigational drug dispensing was conducted. The study was undertaken in an Investigational Drugs Dispensing Unit of a University Hospital of Lyon, France. Sixty-three pharmacy workers (pharmacists, residents, technicians or students) were enrolled. Ten risk factors were selected concerning label information or the risk of confusion with another clinical trial. Each risk factor was scored independently out of 5: the higher the score, the greater the risk of error. From 400 labels analyzed, two groups were selected for the dispensing simulation: 27 labels with high risk (score ≥3) and 27 with low risk (score ≤2). Each question in the learning program was displayed as a simulated clinical trial prescription. Medication error was defined as at least one erroneous answer (i.e. error in drug dispensing). For each question, response times were collected. High-risk investigational drug labels correlated with medication error and slower response time. Error rates were significantly 5.5-fold higher for high-risk series. Error frequency was not significantly affected by occupational category or experience in clinical trials. SIMME-CT is the first simulation-based learning tool to focus on investigational drug labels as a risk factor for medication error. SIMME-CT was also used as a training tool for staff involved in clinical research, to develop medication error risk awareness and to validate competence in continuing medical education. © The Author 2016. Published by Oxford University Press in association with the International Society for Quality in Health Care; all rights reserved.

Factors influencing superimposition error of 3D cephalometric landmarks by plane orientation method using 4 reference points: 4 point superimposition error regression model.

PubMed

Hwang, Jae Joon; Kim, Kee-Deog; Park, Hyok; Park, Chang Seo; Jeong, Ho-Gul

2014-01-01

Superimposition has been used as a method to evaluate the changes of orthodontic or orthopedic treatment in the dental field. With the introduction of cone beam CT (CBCT), evaluating 3 dimensional changes after treatment became possible by superimposition. 4 point plane orientation is one of the simplest ways to achieve superimposition of 3 dimensional images. To find factors influencing superimposition error of cephalometric landmarks by 4 point plane orientation method and to evaluate the reproducibility of cephalometric landmarks for analyzing superimposition error, 20 patients were analyzed who had normal skeletal and occlusal relationship and took CBCT for diagnosis of temporomandibular disorder. The nasion, sella turcica, basion and midpoint between the left and the right most posterior point of the lesser wing of sphenoidal bone were used to define a three-dimensional (3D) anatomical reference co-ordinate system. Another 15 reference cephalometric points were also determined three times in the same image. Reorientation error of each landmark could be explained substantially (23%) by linear regression model, which consists of 3 factors describing position of each landmark towards reference axes and locating error. 4 point plane orientation system may produce an amount of reorientation error that may vary according to the perpendicular distance between the landmark and the x-axis; the reorientation error also increases as the locating error and shift of reference axes viewed from each landmark increases. Therefore, in order to reduce the reorientation error, accuracy of all landmarks including the reference points is important. Construction of the regression model using reference points of greater precision is required for the clinical application of this model.

Compound Stimulus Presentation Does Not Deepen Extinction in Human Causal Learning

PubMed Central

Griffiths, Oren; Holmes, Nathan; Westbrook, R. Fred

2017-01-01

Models of associative learning have proposed that cue-outcome learning critically depends on the degree of prediction error encountered during training. Two experiments examined the role of error-driven extinction learning in a human causal learning task. Target cues underwent extinction in the presence of additional cues, which differed in the degree to which they predicted the outcome, thereby manipulating outcome expectancy and, in the absence of any change in reinforcement, prediction error. These prediction error manipulations have each been shown to modulate extinction learning in aversive conditioning studies. While both manipulations resulted in increased prediction error during training, neither enhanced extinction in the present human learning task (one manipulation resulted in less extinction at test). The results are discussed with reference to the types of associations that are regulated by prediction error, the types of error terms involved in their regulation, and how these interact with parameters involved in training. PMID:28232809

The Influence of Guided Error-Based Learning on Motor Skills Self-Efficacy and Achievement.

PubMed

Chien, Kuei-Pin; Chen, Sufen

2018-01-01

The authors investigated the role of errors in motor skills teaching, specifically the influence of errors on skills self-efficacy and achievement. The participants were 75 undergraduate students enrolled in pétanque courses. The experimental group (guided error-based learning, n = 37) received a 6-week period of instruction based on the students' errors, whereas the control group (correct motion instruction, n = 38) received a 6-week period of instruction emphasizing correct motor skills. The experimental group had significantly higher scores in motor skills self-efficacy and outcomes than did the control group. Novices' errors reflect their schema in motor skills learning, which provides a basis for instructors to implement student-centered instruction and to facilitate the learning process. Guided error-based learning can effectively enhance beginners' skills self-efficacy and achievement in precision sports such as pétanque.

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.

Predictors of Hospital Nurses' Safety Practices: Work Environment, Workload, Job Satisfaction, and Error Reporting.

PubMed

Chiang, Hui-Ying; Hsiao, Ya-Chu; Lee, Huan-Fang

Nurses' safety practices of medication administration, prevention of falls and unplanned extubations, and handover are essentials to patient safety. This study explored the prediction between such safety practices and work environment factors, workload, job satisfaction, and error-reporting culture of 1429 Taiwanese nurses. Nurses' job satisfaction, error-reporting culture, and one environmental factor of nursing quality were found to be major predictors of safety practices. The other environment factors related to professional development and participation in hospital affairs and nurses' workload had limited predictive effects on the safety practices. Increasing nurses' attention to patient safety by improving these predictors is recommended.

Medial-Frontal Stimulation Enhances Learning in Schizophrenia by Restoring Prediction Error Signaling.

PubMed

Reinhart, Robert M G; Zhu, Julia; Park, Sohee; Woodman, Geoffrey F

2015-09-02

Posterror learning, associated with medial-frontal cortical recruitment in healthy subjects, is compromised in neuropsychiatric disorders. Here we report novel evidence for the mechanisms underlying learning dysfunctions in schizophrenia. We show that, by noninvasively passing direct current through human medial-frontal cortex, we could enhance the event-related potential related to learning from mistakes (i.e., the error-related negativity), a putative index of prediction error signaling in the brain. Following this causal manipulation of brain activity, the patients learned a new task at a rate that was indistinguishable from healthy individuals. Moreover, the severity of delusions interacted with the efficacy of the stimulation to improve learning. Our results demonstrate a causal link between disrupted prediction error signaling and inefficient learning in schizophrenia. These findings also demonstrate the feasibility of nonpharmacological interventions to address cognitive deficits in neuropsychiatric disorders. When there is a difference between what we expect to happen and what we actually experience, our brains generate a prediction error signal, so that we can map stimuli to responses and predict outcomes accurately. Theories of schizophrenia implicate abnormal prediction error signaling in the cognitive deficits of the disorder. Here, we combine noninvasive brain stimulation with large-scale electrophysiological recordings to establish a causal link between faulty prediction error signaling and learning deficits in schizophrenia. We show that it is possible to improve learning rate, as well as the neural signature of prediction error signaling, in patients to a level quantitatively indistinguishable from that of healthy subjects. The results provide mechanistic insight into schizophrenia pathophysiology and suggest a future therapy for this condition. Copyright © 2015 the authors 0270-6474/15/3512232-09$15.00/0.

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.

Human error and human factors engineering in health care.

PubMed

Welch, D L

1997-01-01

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

Children with ADHD Symptoms Are Less Susceptible to Gap-Filling Errors than Typically Developing Children

ERIC Educational Resources Information Center

Mirandola, C.; Paparella, G.; Re, A. M.; Ghetti, S.; Cornoldi, C.

2012-01-01

Enhanced semantic processing is associated with increased false recognition of items consistent with studied material, suggesting that children with poor semantic skills could produce fewer false memories. We examined whether memory errors differed in children with Attention Deficit/Hyperactivity Disorder (ADHD) and controls. Children viewed 18…

Using Video To Teach for Sociolinguistic Competence in the Foreign Language Classroom.

ERIC Educational Resources Information Center

Witten, Caryn

2000-01-01

This study worked to develop the sociolinguistic competence of college learners of first-year Spanish using input enhancement techniques that required learners to actively view video. Research shows that native speakers are more sensitive to sociolinguistic errors than to grammatical errors made by nonnative speakers. Therefore, the study…

Feasibility of a Recasting and Auditory Bombardment Treatment with Young Cochlear Implant Users

ERIC Educational Resources Information Center

Encinas, Danielle; Plante, Elena

2016-01-01

Purpose: There is little to guide clinicians in terms of evidence-based interventions for children with cochlear implants who demonstrate morpheme errors. This feasibility study tested the utility of a treatment targeting grammatical morpheme errors. Method: Three children (ages 4-5 years) received Enhanced Conversational Recast treatment, a…

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.

Mathematical analysis study for radar data processing and enhancement. Part 1: Radar data analysis

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 altiude 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 is in two parts. This is part 1, an analysis of radar data.

Motivational state controls the prediction error in Pavlovian appetitive-aversive interactions.

PubMed

Laurent, Vincent; Balleine, Bernard W; Westbrook, R Frederick

2018-01-01

Contemporary theories of learning emphasize the role of a prediction error signal in driving learning, but the nature of this signal remains hotly debated. Here, we used Pavlovian conditioning in rats to investigate whether primary motivational and emotional states interact to control prediction error. We initially generated cues that positively or negatively predicted an appetitive food outcome. We then assessed how these cues modulated aversive conditioning when a novel cue was paired with a foot shock. We found that a positive predictor of food enhances, whereas a negative predictor of that same food impairs, aversive conditioning. Critically, we also showed that the enhancement produced by the positive predictor is removed by reducing the value of its associated food. In contrast, the impairment triggered by the negative predictor remains insensitive to devaluation of its associated food. These findings provide compelling evidence that the motivational value attributed to a predicted food outcome can directly control appetitive-aversive interactions and, therefore, that motivational processes can modulate emotional processes to generate the final error term on which subsequent learning is based. Copyright © 2017 Elsevier Inc. All rights reserved.

Enhancing the sensitivity to new physics in the tt¯ invariant mass distribution

NASA Astrophysics Data System (ADS)

Álvarez, Ezequiel

2012-08-01

We propose selection cuts on the LHC tt¯ production sample which should enhance the sensitivity to new physics signals in the study of the tt¯ invariant mass distribution. We show that selecting events in which the tt¯ object has little transverse and large longitudinal momentum enlarges the quark-fusion fraction of the sample and therefore increases its sensitivity to new physics which couples to quarks and not to gluons. We find that systematic error bars play a fundamental role and assume a simple model for them. We check how a non-visible new particle would become visible after the selection cuts enhance its resonance bump. A final realistic analysis should be done by the experimental groups with a correct evaluation of the systematic error bars.

Effects of empty bins on image upscaling in capsule endoscopy

NASA Astrophysics Data System (ADS)

Rukundo, Olivier

2017-07-01

This paper presents a preliminary study of the effect of empty bins on image upscaling in capsule endoscopy. The presented study was conducted based on results of existing contrast enhancement and interpolation methods. A low contrast enhancement method based on pixels consecutiveness and modified bilinear weighting scheme has been developed to distinguish between necessary empty bins and unnecessary empty bins in the effort to minimize the number of empty bins in the input image, before further processing. Linear interpolation methods have been used for upscaling input images with stretched histograms. Upscaling error differences and similarity indices between pairs of interpolation methods have been quantified using the mean squared error and feature similarity index techniques. Simulation results demonstrated more promising effects using the developed method than other contrast enhancement methods mentioned.

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

DOT National Transportation Integrated Search

2001-02-01

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

Protecting Information

NASA Astrophysics Data System (ADS)

Loepp, Susan; Wootters, William K.

2006-09-01

For many everyday transmissions, it is essential to protect digital information from noise or eavesdropping. This undergraduate introduction to error correction and cryptography is unique in devoting several chapters to quantum cryptography and quantum computing, thus providing a context in which ideas from mathematics and physics meet. By covering such topics as Shor's quantum factoring algorithm, this text informs the reader about current thinking in quantum information theory and encourages an appreciation of the connections between mathematics and science.Of particular interest are the potential impacts of quantum physics:(i) a quantum computer, if built, could crack our currently used public-key cryptosystems; and (ii) quantum cryptography promises to provide an alternative to these cryptosystems, basing its security on the laws of nature rather than on computational complexity. No prior knowledge of quantum mechanics is assumed, but students should have a basic knowledge of complex numbers, vectors, and matrices. Accessible to readers familiar with matrix algebra, vector spaces and complex numbers First undergraduate text to cover cryptography, error-correction, and quantum computation together Features exercises designed to enhance understanding, including a number of computational problems, available from www.cambridge.org/9780521534765

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

PubMed

Sarter, Nadine

2008-06-01

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

A Third Moment Adjusted Test Statistic for Small Sample Factor Analysis

PubMed Central

Lin, Johnny; Bentler, Peter M.

2012-01-01

Goodness of fit testing in factor analysis is based on the assumption that the test statistic is asymptotically chi-square; but this property may not hold in small samples even when the factors and errors are normally distributed in the population. Robust methods such as Browne’s asymptotically distribution-free method and Satorra Bentler’s mean scaling statistic were developed under the presumption of non-normality in the factors and errors. This paper finds new application to the case where factors and errors are normally distributed in the population but the skewness of the obtained test statistic is still high due to sampling error in the observed indicators. An extension of Satorra Bentler’s statistic is proposed that not only scales the mean but also adjusts the degrees of freedom based on the skewness of the obtained test statistic in order to improve its robustness under small samples. A simple simulation study shows that this third moment adjusted statistic asymptotically performs on par with previously proposed methods, and at a very small sample size offers superior Type I error rates under a properly specified model. Data from Mardia, Kent and Bibby’s study of students tested for their ability in five content areas that were either open or closed book were used to illustrate the real-world performance of this statistic. PMID:23144511

Quantitative Estimation of Land Surface Characteristic Parameters and Actual Evapotranspiration in the Nagqu River Basin over the Tibetan Plateau

NASA Astrophysics Data System (ADS)

Zhong, L.; Ma, Y.; Ma, W.; Zou, M.; Hu, Y.

2016-12-01

Actual evapotranspiration (ETa) is an important component of the water cycle in the Tibetan Plateau. It is controlled by many hydrological and meteorological factors. Therefore, it is of great significance to estimate ETa accurately and continuously. It is also drawing much attention of scientific community to understand land surface parameters and land-atmosphere water exchange processes in small watershed-scale areas. Based on in-situ meteorological data in the Nagqu river basin and surrounding regions, the main meteorological factors affecting the evaporation process were quantitatively analyzed and the point-scale ETa estimation models in the study area were successfully built. On the other hand, multi-source satellite data (such as SPOT, MODIS, FY-2C) were used to derive the surface characteristics in the river basin. A time series processing technique was applied to remove cloud cover and reconstruct data series. Then improved land surface albedo, improved downward shortwave radiation flux and reconstructed normalized difference vegetation index (NDVI) were coupled into the topographical enhanced surface energy balance system to estimate ETa. The model-estimated results were compared with those ETa values determined by combinatory method. The results indicated that the model-estimated ETa agreed well with in-situ measurements with correlation coefficient, mean bias error and root mean square error of 0.836, 0.087 and 0.140 mm/h respectively.

A five-collector system for the simultaneous measurement of argon isotope ratios in a static mass spectrometer

USGS Publications Warehouse

Stacey, J.S.; Sherrill, N.D.; Dalrymple, G.B.; Lanphere, M.A.; Carpenter, N.V.

1981-01-01

A system is described that utilizes five separate Faraday-cup collector assemblies, aligned along the focal plane of a mass spectrometer, to collect simultaneous argon ion beams at masses 36-40. Each collector has its own electrometer amplifier and analog-to-digital measuring channel, the outputs of which are processed by a minicomputer that also controls the mass spectrometer. The mass spectrometer utilizes a 90?? sector magnetic analyzer with a radius of 23 cm, in which some degree of z-direction focussing is provided for all the ion beams by the fringe field of the magnet. Simultaneous measurement of the ion beams helps to eliminate mass-spectrometer memory as a significant source of measurement error during an analysis. Isotope ratios stabilize between 7 and 9 s after sample admission into the spectrometer, and thereafter changes in the measured ratios are linear, typically to within ??0.02%. Thus the multi-collector arrangement permits very short extrapolation times for computation of initial ratios, and also provides the advantages of simultaneous measurement of the ion currents in that errors due to variations in ion beam intensity are minimized. A complete analysis takes less than 10 min, so that sample throughput can be greatly enhanced. In this instrument, the factor limiting analytical precision now lies in short-term apparent variations in the interchannel calibration factors. ?? 1981.

[Errors in prescriptions and their preparation at the outpatient pharmacy of a regional hospital].

PubMed

Alvarado A, Carolina; Ossa G, Ximena; Bustos M, Luis

2017-01-01

Adverse effects of medications are an important cause of morbidity and hospital admissions. Errors in prescription or preparation of medications by pharmacy personnel are a factor that may influence these occurrence of the adverse effects Aim: To assess the frequency and type of errors in prescriptions and in their preparation at the pharmacy unit of a regional public hospital. Prescriptions received by ambulatory patients and those being discharged from the hospital, were reviewed using a 12-item checklist. The preparation of such prescriptions at the pharmacy unit was also reviewed using a seven item checklist. Seventy two percent of prescriptions had at least one error. The most common mistake was the impossibility of determining the concentration of the prescribed drug. Prescriptions for patients being discharged from the hospital had the higher number of errors. When a prescription had more than two drugs, the risk of error increased 2.4 times. Twenty four percent of prescription preparations had at least one error. The most common mistake was the labeling of drugs with incomplete medical indications. When a preparation included more than three drugs, the risk of preparation error increased 1.8 times. Prescription and preparation of medication delivered to patients had frequent errors. The most important risk factor for errors was the number of drugs prescribed.

An error taxonomy system for analysis of haemodialysis incidents.

PubMed

Gu, Xiuzhu; Itoh, Kenji; Suzuki, Satoshi

2014-12-01

This paper describes the development of a haemodialysis error taxonomy system for analysing incidents and predicting the safety status of a dialysis organisation. The error taxonomy system was developed by adapting an error taxonomy system which assumed no specific specialty to haemodialysis situations. Its application was conducted with 1,909 incident reports collected from two dialysis facilities in Japan. Over 70% of haemodialysis incidents were reported as problems or complications related to dialyser, circuit, medication and setting of dialysis condition. Approximately 70% of errors took place immediately before and after the four hours of haemodialysis therapy. Error types most frequently made in the dialysis unit were omission and qualitative errors. Failures or complications classified to staff human factors, communication, task and organisational factors were found in most dialysis incidents. Device/equipment/materials, medicine and clinical documents were most likely to be involved in errors. Haemodialysis nurses were involved in more incidents related to medicine and documents, whereas dialysis technologists made more errors with device/equipment/materials. This error taxonomy system is able to investigate incidents and adverse events occurring in the dialysis setting but is also able to estimate safety-related status of an organisation, such as reporting culture. © 2014 European Dialysis and Transplant Nurses Association/European Renal Care Association.

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

PubMed

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

2016-12-01

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

Learning time-dependent noise to reduce logical errors: real time error rate estimation in quantum error correction

NASA Astrophysics Data System (ADS)

Huo, Ming-Xia; Li, Ying

2017-12-01

Quantum error correction is important to quantum information processing, which allows us to reliably process information encoded in quantum error correction codes. Efficient quantum error correction benefits from the knowledge of error rates. We propose a protocol for monitoring error rates in real time without interrupting the quantum error correction. Any adaptation of the quantum error correction code or its implementation circuit is not required. The protocol can be directly applied to the most advanced quantum error correction techniques, e.g. surface code. A Gaussian processes algorithm is used to estimate and predict error rates based on error correction data in the past. We find that using these estimated error rates, the probability of error correction failures can be significantly reduced by a factor increasing with the code distance.

Reliability of Semi-Automated Segmentations in Glioblastoma.

PubMed

Huber, T; Alber, G; Bette, S; Boeckh-Behrens, T; Gempt, J; Ringel, F; Alberts, E; Zimmer, C; Bauer, J S

2017-06-01

In glioblastoma, quantitative volumetric measurements of contrast-enhancing or fluid-attenuated inversion recovery (FLAIR) hyperintense tumor compartments are needed for an objective assessment of therapy response. The aim of this study was to evaluate the reliability of a semi-automated, region-growing segmentation tool for determining tumor volume in patients with glioblastoma among different users of the software. A total of 320 segmentations of tumor-associated FLAIR changes and contrast-enhancing tumor tissue were performed by different raters (neuroradiologists, medical students, and volunteers). All patients underwent high-resolution magnetic resonance imaging including a 3D-FLAIR and a 3D-MPRage sequence. Segmentations were done using a semi-automated, region-growing segmentation tool. Intra- and inter-rater-reliability were addressed by intra-class-correlation (ICC). Root-mean-square error (RMSE) was used to determine the precision error. Dice score was calculated to measure the overlap between segmentations. Semi-automated segmentation showed a high ICC (> 0.985) for all groups indicating an excellent intra- and inter-rater-reliability. Significant smaller precision errors and higher Dice scores were observed for FLAIR segmentations compared with segmentations of contrast-enhancement. Single rater segmentations showed the lowest RMSE for FLAIR of 3.3 % (MPRage: 8.2 %). Both, single raters and neuroradiologists had the lowest precision error for longitudinal evaluation of FLAIR changes. Semi-automated volumetry of glioblastoma was reliably performed by all groups of raters, even without neuroradiologic expertise. Interestingly, segmentations of tumor-associated FLAIR changes were more reliable than segmentations of contrast enhancement. In longitudinal evaluations, an experienced rater can detect progressive FLAIR changes of less than 15 % reliably in a quantitative way which could help to detect progressive disease earlier.

A bottom-up model of spatial attention predicts human error patterns in rapid scene recognition.

PubMed

Einhäuser, Wolfgang; Mundhenk, T Nathan; Baldi, Pierre; Koch, Christof; Itti, Laurent

2007-07-20

Humans demonstrate a peculiar ability to detect complex targets in rapidly presented natural scenes. Recent studies suggest that (nearly) no focal attention is required for overall performance in such tasks. Little is known, however, of how detection performance varies from trial to trial and which stages in the processing hierarchy limit performance: bottom-up visual processing (attentional selection and/or recognition) or top-down factors (e.g., decision-making, memory, or alertness fluctuations)? To investigate the relative contribution of these factors, eight human observers performed an animal detection task in natural scenes presented at 20 Hz. Trial-by-trial performance was highly consistent across observers, far exceeding the prediction of independent errors. This consistency demonstrates that performance is not primarily limited by idiosyncratic factors but by visual processing. Two statistical stimulus properties, contrast variation in the target image and the information-theoretical measure of "surprise" in adjacent images, predict performance on a trial-by-trial basis. These measures are tightly related to spatial attention, demonstrating that spatial attention and rapid target detection share common mechanisms. To isolate the causal contribution of the surprise measure, eight additional observers performed the animal detection task in sequences that were reordered versions of those all subjects had correctly recognized in the first experiment. Reordering increased surprise before and/or after the target while keeping the target and distractors themselves unchanged. Surprise enhancement impaired target detection in all observers. Consequently, and contrary to several previously published findings, our results demonstrate that attentional limitations, rather than target recognition alone, affect the detection of targets in rapidly presented visual sequences.

Neural response to errors in combat-exposed returning veterans with and without post-traumatic stress disorder: a preliminary event-related potential study.

PubMed

Rabinak, Christine A; Holman, Alexis; Angstadt, Mike; Kennedy, Amy E; Hajcak, Greg; Phan, Kinh Luan

2013-07-30

Post-traumatic stress disorder (PTSD) is characterized by sustained anxiety, hypervigilance for potential threat, and hyperarousal. These symptoms may enhance self-perception of one's actions, particularly the detection of errors, which may threaten safety. The error-related negativity (ERN) is an electrocortical response to the commission of errors, and previous studies have shown that other anxiety disorders associated with exaggerated anxiety and enhanced action monitoring exhibit an enhanced ERN. However, little is known about how traumatic experience and PTSD would affect the ERN. To address this gap, we measured the ERN in returning Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) veterans with combat-related PTSD (PTSD group), combat-exposed OEF/OIF veterans without PTSD [combat-exposed control (CEC) group], and non-traumatized healthy participants [healthy control (HC) group]. Event-related potential and behavioral measures were recorded while 16 PTSD patients, 18 CEC, and 16 HC participants completed an arrow version of the flanker task. No difference in the magnitude of the ERN was observed between the PTSD and HC groups; however, in comparison with the PTSD and HC groups, the CEC group displayed a blunted ERN response. These findings suggest that (1) combat trauma itself does not affect the ERN response; (2) PTSD is not associated with an abnormal ERN response; and (3) an attenuated ERN in those previously exposed to combat trauma but who have not developed PTSD may reflect resilience to the disorder, less motivation to do the task, or a decrease in the significance or meaningfulness of 'errors,' which could be related to combat experience. Copyright © 2013 Elsevier Ireland Ltd. All rights reserved.

Advanced Dispersed Fringe Sensing Algorithm for Coarse Phasing Segmented Mirror Telescopes

NASA Technical Reports Server (NTRS)

Spechler, Joshua A.; Hoppe, Daniel J.; Sigrist, Norbert; Shi, Fang; Seo, Byoung-Joon; Bikkannavar, Siddarayappa A.

2013-01-01

Segment mirror phasing, a critical step of segment mirror alignment, requires the ability to sense and correct the relative pistons between segments from up to a few hundred microns to a fraction of wavelength in order to bring the mirror system to its full diffraction capability. When sampling the aperture of a telescope, using auto-collimating flats (ACFs) is more economical. The performance of a telescope with a segmented primary mirror strongly depends on how well those primary mirror segments can be phased. One such process to phase primary mirror segments in the axial piston direction is dispersed fringe sensing (DFS). DFS technology can be used to co-phase the ACFs. DFS is essentially a signal fitting and processing operation. It is an elegant method of coarse phasing segmented mirrors. DFS performance accuracy is dependent upon careful calibration of the system as well as other factors such as internal optical alignment, system wavefront errors, and detector quality. Novel improvements to the algorithm have led to substantial enhancements in DFS performance. The Advanced Dispersed Fringe Sensing (ADFS) Algorithm is designed to reduce the sensitivity to calibration errors by determining the optimal fringe extraction line. Applying an angular extraction line dithering procedure and combining this dithering process with an error function while minimizing the phase term of the fitted signal, defines in essence the ADFS algorithm.

Factors that enhance English-speaking speech-language pathologists' transcription of Cantonese-speaking children's consonants.

PubMed

Lockart, Rebekah; McLeod, Sharynne

2013-08-01

To investigate speech-language pathology students' ability to identify errors and transcribe typical and atypical speech in Cantonese, a nonnative language. Thirty-three English-speaking speech-language pathology students completed 3 tasks in an experimental within-subjects design. Task 1 (baseline) involved transcribing English words. In Task 2, students transcribed 25 words spoken by a Cantonese adult. An average of 59.1% consonants was transcribed correctly (72.9% when Cantonese-English transfer patterns were allowed). There was higher accuracy on shared English and Cantonese syllable-initial consonants /m,n,f,s,h,j,w,l/ and syllable-final consonants. In Task 3, students identified consonant errors and transcribed 100 words spoken by Cantonese-speaking children under 4 additive conditions: (1) baseline, (2) +adult model, (3) +information about Cantonese phonology, and (4) all variables (2 and 3 were counterbalanced). There was a significant improvement in the students' identification and transcription scores for conditions 2, 3, and 4, with a moderate effect size. Increased skill was not based on listeners' proficiency in speaking another language, perceived transcription skill, musicality, or confidence with multilingual clients. Speech-language pathology students, with no exposure to or specific training in Cantonese, have some skills to identify errors and transcribe Cantonese. Provision of a Cantonese-adult model and information about Cantonese phonology increased students' accuracy in transcribing Cantonese speech.

Computational Thermochemistry: Scale Factor Databases and Scale Factors for Vibrational Frequencies Obtained from Electronic Model Chemistries.

PubMed

Alecu, I M; Zheng, Jingjing; Zhao, Yan; Truhlar, Donald G

2010-09-14

Optimized scale factors for calculating vibrational harmonic and fundamental frequencies and zero-point energies have been determined for 145 electronic model chemistries, including 119 based on approximate functionals depending on occupied orbitals, 19 based on single-level wave function theory, three based on the neglect-of-diatomic-differential-overlap, two based on doubly hybrid density functional theory, and two based on multicoefficient correlation methods. Forty of the scale factors are obtained from large databases, which are also used to derive two universal scale factor ratios that can be used to interconvert between scale factors optimized for various properties, enabling the derivation of three key scale factors at the effort of optimizing only one of them. A reduced scale factor optimization model is formulated in order to further reduce the cost of optimizing scale factors, and the reduced model is illustrated by using it to obtain 105 additional scale factors. Using root-mean-square errors from the values in the large databases, we find that scaling reduces errors in zero-point energies by a factor of 2.3 and errors in fundamental vibrational frequencies by a factor of 3.0, but it reduces errors in harmonic vibrational frequencies by only a factor of 1.3. It is shown that, upon scaling, the balanced multicoefficient correlation method based on coupled cluster theory with single and double excitations (BMC-CCSD) can lead to very accurate predictions of vibrational frequencies. With a polarized, minimally augmented basis set, the density functionals with zero-point energy scale factors closest to unity are MPWLYP1M (1.009), τHCTHhyb (0.989), BB95 (1.012), BLYP (1.013), BP86 (1.014), B3LYP (0.986), MPW3LYP (0.986), and VSXC (0.986).

Sensitivity of Magnetospheric Multi-Scale (MMS) Mission Navigation Accuracy to Major Error Sources

NASA Technical Reports Server (NTRS)

Olson, Corwin; Long, Anne; Car[emter. Russell

2011-01-01

The Magnetospheric Multiscale (MMS) mission consists of four satellites flying in formation in highly elliptical orbits about the Earth, with a primary objective of studying magnetic reconnection. The baseline navigation concept is independent estimation of each spacecraft state using GPS pseudorange measurements referenced to an Ultra Stable Oscillator (USO) with accelerometer measurements included during maneuvers. MMS state estimation is performed onboard each spacecraft using the Goddard Enhanced Onboard Navigation System (GEONS), which is embedded in the Navigator GPS receiver. This paper describes the sensitivity of MMS navigation performance to two major error sources: USO clock errors and thrust acceleration knowledge errors.

Sensitivity of Magnetospheric Multi-Scale (MMS) Mission Naviation Accuracy to Major Error Sources

NASA Technical Reports Server (NTRS)

Olson, Corwin; Long, Anne; Carpenter, J. Russell

2011-01-01

The Magnetospheric Multiscale (MMS) mission consists of four satellites flying in formation in highly elliptical orbits about the Earth, with a primary objective of studying magnetic reconnection. The baseline navigation concept is independent estimation of each spacecraft state using GPS pseudorange measurements referenced to an Ultra Stable Oscillator (USO) with accelerometer measurements included during maneuvers. MMS state estimation is performed onboard each spacecraft using the Goddard Enhanced Onboard Navigation System (GEONS), which is embedded in the Navigator GPS receiver. This paper describes the sensitivity of MMS navigation performance to two major error sources: USO clock errors and thrust acceleration knowledge errors.

Increased User Satisfaction Through an Improved Message System

NASA Technical Reports Server (NTRS)

Weissert, C. L.

1997-01-01

With all of the enhancements in software methodology and testing, there is no guarantee that software can be delivered such that no user errors occur, How to handle these errors when they occur has become a major research topic within human-computer interaction (HCI). Users of the Multimission Spacecraft Analysis Subsystem(MSAS) at the Jet Propulsion Laboratory (JPL), a system of X and motif graphical user interfaces for analyzing spacecraft data, complained about the lack of information about the error cause and have suggested that recovery actions be included in the system error messages...The system was evaluated through usability surveys and was shown to be successful.

Prescribing errors during hospital inpatient care: factors influencing identification by pharmacists.

PubMed

Tully, Mary P; Buchan, Iain E

2009-12-01

To investigate the prevalence of prescribing errors identified by pharmacists in hospital inpatients and the factors influencing error identification rates by pharmacists throughout hospital admission. 880-bed university teaching hospital in North-west England. Data about prescribing errors identified by pharmacists (median: 9 (range 4-17) collecting data per day) when conducting routine work were prospectively recorded on 38 randomly selected days over 18 months. Proportion of new medication orders in which an error was identified; predictors of error identification rate, adjusted for workload and seniority of pharmacist, day of week, type of ward or stage of patient admission. 33,012 new medication orders were reviewed for 5,199 patients; 3,455 errors (in 10.5% of orders) were identified for 2,040 patients (39.2%; median 1, range 1-12). Most were problem orders (1,456, 42.1%) or potentially significant errors (1,748, 50.6%); 197 (5.7%) were potentially serious; 1.6% (n = 54) were potentially severe or fatal. Errors were 41% (CI: 28-56%) more likely to be identified at patient's admission than at other times, independent of confounders. Workload was the strongest predictor of error identification rates, with 40% (33-46%) less errors identified on the busiest days than at other times. Errors identified fell by 1.9% (1.5-2.3%) for every additional chart checked, independent of confounders. Pharmacists routinely identify errors but increasing workload may reduce identification rates. Where resources are limited, they may be better spent on identifying and addressing errors immediately after admission to hospital.

Respiratory-gated CT as a tool for the simulation of breathing artifacts in PET and PET/CT.

PubMed

Hamill, J J; Bosmans, G; Dekker, A

2008-02-01

Respiratory motion in PET and PET/CT blurs the images and can cause attenuation-related errors in quantitative parameters such as standard uptake values. In rare instances, this problem even causes localization errors and the disappearance of tumors that should be detectable. Attenuation errors are severe near the diaphragm and can be enhanced when the attenuation correction is based on a CT series acquired during a breath-hold. To quantify the errors and identify the parameters associated with them, the authors performed a simulated PET scan based on respiratory-gated CT studies of five lung cancer patients. Diaphragmatic motion ranged from 8 to 25 mm in the five patients. The CT series were converted to 511-keV attenuation maps which were forward-projected and exponentiated to form sinograms of PET attenuation factors at each phase of respiration. The CT images were also segmented to form a PET object, moving with the same motion as the CT series. In the moving PET object, spherical 20 mm mobile tumors were created in the vicinity of the dome of the liver and immobile 20 mm tumors in the midchest region. The moving PET objects were forward-projected and attenuated, then reconstructed in several ways: phase-matched PET and CT, gated PET with ungated CT, ungated PET with gated CT, and conventional PET. Spatial resolution and statistical noise were not modeled. In each case, tumor uptake recovery factor was defined by comparing the maximum reconstructed pixel value with the known correct value. Mobile 10 and 30 mm tumors were also simulated in the case of a patient with 11 mm of breathing motion. Phase-matched gated PET and CT gave essentially perfect PET reconstructions in the simulation. Gated PET with ungated CT gave tumors of the correct shape, but recovery was too large by an amount that depended on the extent of the motion, as much as 90% for mobile tumors and 60% for immobile tumors. Gated CT with ungated PET resulted in blurred tumors and caused recovery errors between -50% and +75%. Recovery in clinical scans would be 0%-20% lower than stated because spatial resolution was not included in the simulation. Mobile tumors near the dome of the liver were subject to the largest errors in either case. Conventional PET for 20 mm tumors was quantitative in cases of motion less than 15 mm because of canceling errors in blurring and attenuation, but the recovery factors were too low by as much as 30% in cases of motion greater than 15 mm. The 10 mm tumors were blurred by motion to a greater extent, causing a greater SUV underestimation than in the case of 20 mm tumors, and the 30 mm tumors were blurred less. Quantitative PET imaging near the diaphragm requires proper matching of attenuation information to the emission information. The problem of missed tumors near the diaphragm can be reduced by acquiring attenuation-correction information near end expiration. A simple PET/CT protocol requiring no gating equipment also addresses this problem.

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.

Temporal subtraction contrast-enhanced dedicated breast CT

PubMed Central

Gazi, Peymon M.; Aminololama-Shakeri, Shadi; Yang, Kai; Boone, John M.

2016-01-01

Purpose To develop a framework of deformable image registration and segmentation for the purpose of temporal subtraction contrast-enhanced breast CT is described. Methods An iterative histogram-based two-means clustering method was used for the segmentation. Dedicated breast CT images were segmented into background (air), adipose, fibroglandular and skin components. Fibroglandular tissue was classified as either normal or contrast-enhanced then divided into tiers for the purpose of categorizing degrees of contrast enhancement. A variant of the Demons deformable registration algorithm, Intensity Difference Adaptive Demons (IDAD), was developed to correct for the large deformation forces that stemmed from contrast enhancement. In this application, the accuracy of the proposed method was evaluated in both mathematically-simulated and physically-acquired phantom images. Clinical usage and accuracy of the temporal subtraction framework was demonstrated using contrast-enhanced breast CT datasets from five patients. Registration performance was quantified using Normalized Cross Correlation (NCC), Symmetric Uncertainty Coefficient (SUC), Normalized Mutual Information (NMI), Mean Square Error (MSE) and Target Registration Error (TRE). Results The proposed method outperformed conventional affine and other Demons variations in contrast enhanced breast CT image registration. In simulation studies, IDAD exhibited improvement in MSE(0–16%), NCC (0–6%), NMI (0–13%) and TRE (0–34%) compared to the conventional Demons approaches, depending on the size and intensity of the enhancing lesion. As lesion size and contrast enhancement levels increased, so did the improvement. The drop in the correlation between the pre- and post-contrast images for the largest enhancement levels in phantom studies is less than 1.2% (150 Hounsfield units). Registration error, measured by TRE, shows only submillimeter mismatches between the concordant anatomical target points in all patient studies. The algorithm was implemented using a parallel processing architecture resulting in rapid execution time for the iterative segmentation and intensity-adaptive registration techniques. Conclusion Characterization of contrast-enhanced lesions is improved using temporal subtraction contrast-enhanced dedicated breast CT. Adaptation of Demons registration forces as a function of contrast-enhancement levels provided a means to accurately align breast tissue in pre- and post-contrast image acquisitions, improving subtraction results. Spatial subtraction of the aligned images yields useful diagnostic information with respect to enhanced lesion morphology and uptake. PMID:27494376

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

PubMed

Wiegmann, D A; Shappell, S A

2001-11-01

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

Analysis of variance to assess statistical significance of Laplacian estimation accuracy improvement due to novel variable inter-ring distances concentric ring electrodes.

PubMed

Makeyev, Oleksandr; Joe, Cody; Lee, Colin; Besio, Walter G

2017-07-01

Concentric ring electrodes have shown promise in non-invasive electrophysiological measurement demonstrating their superiority to conventional disc electrodes, in particular, in accuracy of Laplacian estimation. Recently, we have proposed novel variable inter-ring distances concentric ring electrodes. Analytic and finite element method modeling results for linearly increasing distances electrode configurations suggested they may decrease the truncation error resulting in more accurate Laplacian estimates compared to currently used constant inter-ring distances configurations. This study assesses statistical significance of Laplacian estimation accuracy improvement due to novel variable inter-ring distances concentric ring electrodes. Full factorial design of analysis of variance was used with one categorical and two numerical factors: the inter-ring distances, the electrode diameter, and the number of concentric rings in the electrode. The response variables were the Relative Error and the Maximum Error of Laplacian estimation computed using a finite element method model for each of the combinations of levels of three factors. Effects of the main factors and their interactions on Relative Error and Maximum Error were assessed and the obtained results suggest that all three factors have statistically significant effects in the model confirming the potential of using inter-ring distances as a means of improving accuracy of Laplacian estimation.

Obstetric Neuraxial Drug Administration Errors: A Quantitative and Qualitative Analytical Review.

PubMed

Patel, Santosh; Loveridge, Robert

2015-12-01

Drug administration errors in obstetric neuraxial anesthesia can have devastating consequences. Although fully recognizing that they represent "only the tip of the iceberg," published case reports/series of these errors were reviewed in detail with the aim of estimating the frequency and the nature of these errors. We identified case reports and case series from MEDLINE and performed a quantitative analysis of the involved drugs, error setting, source of error, the observed complications, and any therapeutic interventions. We subsequently performed a qualitative analysis of the human factors involved and proposed modifications to practice. Twenty-nine cases were identified. Various drugs were given in error, but no direct effects on the course of labor, mode of delivery, or neonatal outcome were reported. Four maternal deaths from the accidental intrathecal administration of tranexamic acid were reported, all occurring after delivery of the fetus. A range of hemodynamic and neurologic signs and symptoms were noted, but the most commonly reported complication was the failure of the intended neuraxial anesthetic technique. Several human factors were present; most common factors were drug storage issues and similar drug appearance. Four practice recommendations were identified as being likely to have prevented the errors. The reported errors exposed latent conditions within health care systems. We suggest that the implementation of the following processes may decrease the risk of these types of drug errors: (1) Careful reading of the label on any drug ampule or syringe before the drug is drawn up or injected; (2) labeling all syringes; (3) checking labels with a second person or a device (such as a barcode reader linked to a computer) before the drug is drawn up or administered; and (4) use of non-Luer lock connectors on all epidural/spinal/combined spinal-epidural devices. Further study is required to determine whether routine use of these processes will reduce drug error.

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.

Human factors in aviation crashes involving older pilots.

PubMed

Li, Guohua; Baker, Susan P; Lamb, Margaret W; Grabowski, Jurek G; Rebok, George W

2002-02-01

Pilot errors are recognized as a contributing factor in as many as 80% of aviation crashes. Experimental studies using flight simulators indicate that due to decreased working memory capacity, older pilots are outperformed by their younger counterparts in communication tasks and flight summary scores. This study examines age-related differences in crash circumstances and pilot errors in a sample of pilots who flew commuter aircraft or air taxis and who were involved in airplane or helicopter crashes. A historical cohort of 3306 pilots who in 1987 flew commuter aircraft or air taxis and were 45-54 yr of age was constructed using the Federal Aviation Administration's airmen information system. Crash records of the study subjects for the years 1983-1997 were obtained from the National Transportation Safety Board (NTSB) by matching name and date of birth. NTSB's investigation reports were reviewed to identify pilot errors and other contributing factors. Comparisons of crash circumstances and human factors were made between pilots aged 40-49 yr and pilots aged 50-63 yr. A total of 165 crash records were studied, with 52% of these crashes involving pilots aged 50-63 yr. Crash circumstances, such as time and location of crash, type and phase of flight, and weather conditions, were similar between the two age groups. Pilot error was a contributing factor in 73% of the crashes involving younger pilots and in 69% of the crashes involving older pilots (p = 0.50). Age-related differences in the pattern of pilot errors were statistically insignificant. Overall, 23% of pilot errors were attributable to inattentiveness, 20% to flawed decisions, 18% to mishandled aircraft kinetics, and 18% to mishandled wind/runway conditions. Neither crash circumstances nor the prevalence and patterns of pilot errors appear to change significantly as age increases from the 40s to the 50s and early 60s.

Experiences from the testing of a theory for modelling groundwater flow in heterogeneous media

USGS Publications Warehouse

Christensen, S.; Cooley, R.L.

2002-01-01

Usually, small-scale model error is present in groundwater modelling because the model only represents average system characteristics having the same form as the drift and small-scale variability is neglected. These errors cause the true errors of a regression model to be correlated. Theory and an example show that the errors also contribute to bias in the estimates of model parameters. This bias originates from model nonlinearity. In spite of this bias, predictions of hydraulic head are nearly unbiased if the model intrinsic nonlinearity is small. Individual confidence and prediction intervals are accurate if the t-statistic is multiplied by a correction factor. The correction factor can be computed from the true error second moment matrix, which can be determined when the stochastic properties of the system characteristics are known.

Experience gained in testing a theory for modelling groundwater flow in heterogeneous media

USGS Publications Warehouse

Christensen, S.; Cooley, R.L.

2002-01-01

Usually, small-scale model error is present in groundwater modelling because the model only represents average system characteristics having the same form as the drift, and small-scale variability is neglected. These errors cause the true errors of a regression model to be correlated. Theory and an example show that the errors also contribute to bias in the estimates of model parameters. This bias originates from model nonlinearity. In spite of this bias, predictions of hydraulic head are nearly unbiased if the model intrinsic nonlinearity is small. Individual confidence and prediction intervals are accurate if the t-statistic is multiplied by a correction factor. The correction factor can be computed from the true error second moment matrix, which can be determined when the stochastic properties of the system characteristics are known.

Diction and Expression in Error Analysis Can Enhance Academic Writing of L2 University Students

ERIC Educational Resources Information Center

Sajid, Muhammad

2016-01-01

Without proper linguistic competence in English language, academic writing is one of the most challenging tasks, especially, in various genre specific disciplines by L2 novice writers. This paper examines the role of diction and expression through error analysis in English language of L2 novice writers' academic writing in interdisciplinary texts…

Enhancing Observability of Signal Composition and Error Signatures During Dynamic SEE Analog to Digital Device Testing

NASA Technical Reports Server (NTRS)

Berg, M.; Buchner, S.; Kim, H.; Friendlich, M.; Perez, C.; Phan, A.; Seidleck, C.; LaBel, K.; Kruckmeyer, K.

2010-01-01

A novel approach to dynamic SEE ADC testing is presented. The benefits of this test scheme versus prior implemented techniques include the ability to observe ADC SEE errors that are in the form of phase shifts, single bit upsets, bursts of disrupted signal composition, and device clock loss.

Comment on "Differential sensitivity to human communication in dogs, wolves, and human infants".

PubMed

Marshall-Pescini, S; Passalacqua, C; Valsecchi, P; Prato-Previde, E

2010-07-09

Topál et al. (Reports, 4 September 2009, p. 1269) showed that dogs, like infants but unlike wolves, make perseverative search errors that can be explained by the use of ostensive cues from the experimenter. We suggest that a simpler learning process, local enhancement, can account for errors made by dogs.

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.

Directional variance adjustment: bias reduction in covariance matrices based on factor analysis with an application to portfolio optimization.

PubMed

Bartz, Daniel; Hatrick, Kerr; Hesse, Christian W; Müller, Klaus-Robert; Lemm, Steven

2013-01-01

Robust and reliable covariance estimates play a decisive role in financial and many other applications. An important class of estimators is based on factor models. Here, we show by extensive Monte Carlo simulations that covariance matrices derived from the statistical Factor Analysis model exhibit a systematic error, which is similar to the well-known systematic error of the spectrum of the sample covariance matrix. Moreover, we introduce the Directional Variance Adjustment (DVA) algorithm, which diminishes the systematic error. In a thorough empirical study for the US, European, and Hong Kong stock market we show that our proposed method leads to improved portfolio allocation.

Directional Variance Adjustment: Bias Reduction in Covariance Matrices Based on Factor Analysis with an Application to Portfolio Optimization

PubMed Central

Bartz, Daniel; Hatrick, Kerr; Hesse, Christian W.; Müller, Klaus-Robert; Lemm, Steven

2013-01-01

Robust and reliable covariance estimates play a decisive role in financial and many other applications. An important class of estimators is based on factor models. Here, we show by extensive Monte Carlo simulations that covariance matrices derived from the statistical Factor Analysis model exhibit a systematic error, which is similar to the well-known systematic error of the spectrum of the sample covariance matrix. Moreover, we introduce the Directional Variance Adjustment (DVA) algorithm, which diminishes the systematic error. In a thorough empirical study for the US, European, and Hong Kong stock market we show that our proposed method leads to improved portfolio allocation. PMID:23844016

Measuring Dispersion Effects of Factors in Factorial Experiments.

DTIC Science & Technology

1988-01-01

error is MSE =i=l j=1 i n r (SSE/(N-p)), the sum of squares of pure error is SSPE = Z E Y i=1 j=1 and the mean square of pure error is MSPE - ( SSPE /n...the level of the factor in the ith run is 0. 3.1. First Measure We have n r n r SSPE = 1 Is it -yi) 2 + E r (1-8 )(yjj li-l j=l (iYjj +i= j=l l - i...The first component in SSPE corresponds to level I of the factor and has n degrees of freedom ( E 6i)(r-I). The second component corresponds to i=l n

Energy distribution functions of kilovolt ions in a modified Penning discharge

NASA Technical Reports Server (NTRS)

Roth, J. R.

1972-01-01

The distribution function of ion energy parallel to the magnetic field of a Penning discharge was measured with a retarding potential energy analyzer. Simultaneous measurements of the ion energy distribution function perpendicular to the magnetic field were made with a charge-exchange neutral detector. The ion energy distribution functions are approximately Maxwellian, and their kinetic temperatures are equal within experimental error. This suggests that turbulent processes previously observed Maxwellianize the velocity distribution along a radius in velocity space, and result in an isotropic energy distribution. The kinetic temperatures are on the order of kilovolts, and the tails of the ion energy distribution functions are Maxwellian up to a factor of 7 e-folds in energy. When the distributions depart from Maxwellian, they are enhanced above the Maxwellian tail. Above densities of about 10 to the 10th power particles/cc, this enhancement appears to be the result of a second, higher temperature Maxwellian distribution. At these high particle energies, only the ions perpendicular to the magnetic field lines were investigated.

Superhydrophobic Ag nanostructures on polyaniline membranes with strong SERS enhancement.

PubMed

Liu, Weiyu; Miao, Peng; Xiong, Lu; Du, Yunchen; Han, Xijiang; Xu, Ping

2014-11-07

We demonstrate here a facile fabrication of n-dodecyl mercaptan-modified superhydrophobic Ag nanostructures on polyaniline membranes for molecular detection based on SERS technique, which combines the superhydrophobic condensation effect and the high enhancement factor. It is calculated that the as-fabricated superhydrophobic substrate can exhibit a 21-fold stronger molecular condensation, and thus further amplifies the SERS signal to achieve more sensitive detection. The detection limit of the target molecule, methylene blue (MB), on this superhydrophobic substrate can be 1 order of magnitude higher than that on the hydrophilic substrate. With high reproducibility, the feasibility of using this SERS-active superhydrophobic substrate for quantitative molecular detection is explored. A partial least squares (PLS) model was established for the quantification of MB by SERS, with correlation coefficient R(2) = 95.1% and root-mean-squared error of prediction (RMSEP) = 0.226. We believe this superhydrophobic SERS substrate can be widely used in trace analysis due to its facile fabrication, high signal reproducibility and promising SERS performance.

Consumer concerns: motivating to action.

PubMed Central

Bruhn, C. M.

1997-01-01

Microbiologic safety is consumers' most frequently volunteered food safety concern. An increase in the level of concern in recent years suggests that consumers are more receptive to educational information. However, changing lifestyles have lessened the awareness of foodborne illness, especially among younger consumers. Failure to fully recognize the symptoms or sources of foodborne disease prevents consumers from taking corrective action. Consumer education messages should include the ubiquity of microorganisms, a comprehensive description of foodborne illnesses, and prevention strategies. Product labels should contain food-handling information and warnings for special populations, and foods processed by newer safety-enhancing technologies should be more widely available. Knowledge of the consequences of unsafe practices can enhance motivation and adherence to safety guidelines. When consumers mishandle food during preparation, the health community, food industry, regulators, and the media are ultimately responsible. Whether inappropriate temperature control, poor hygiene, or another factor, the error occurs because consumers have not been informed about how to handle food and protect themselves. The food safety message has not been delivered effectively. PMID:9366604

Multispectral image enhancement for H&E stained pathological tissue specimens

NASA Astrophysics Data System (ADS)

Bautista, Pinky A.; Abe, Tokiya; Yamaguchi, Masahiro; Ohyama, Nagaaki; Yagi, Yukako

2008-03-01

The presence of a liver disease such as cirrhosis can be determined by examining the proliferation of collagen fiber from a tissue slide stained with special stain such as the Masson's trichrome(MT) stain. Collagen fiber and smooth muscle, which are both stained the same in an H&E stained slide, are stained blue and pink respectively in an MT-stained slide. In this paper we show that with multispectral imaging the difference between collagen fiber and smooth muscle can be visualized even from an H&E stained image. In the method M KL bases are derived using the spectral data of those H&E stained tissue components which can be easily differentiated from each other, i.e. nucleus, cytoplasm, red blood cells, etc. and based on the spectral residual error of fiber weighting factors are determined to enhance spectral features at certain wavelengths. Results of our experiment demonstrate the capability of multispectral imaging and its advantage compared to the conventional RGB imaging systems to delineate tissue structures with subtle colorimetric difference.

Medication errors in residential aged care facilities: a distributed cognition analysis of the information exchange process.

PubMed

Tariq, Amina; Georgiou, Andrew; Westbrook, Johanna

2013-05-01

Medication safety is a pressing concern for residential aged care facilities (RACFs). Retrospective studies in RACF settings identify inadequate communication between RACFs, doctors, hospitals and community pharmacies as the major cause of medication errors. Existing literature offers limited insight about the gaps in the existing information exchange process that may lead to medication errors. The aim of this research was to explicate the cognitive distribution that underlies RACF medication ordering and delivery to identify gaps in medication-related information exchange which lead to medication errors in RACFs. The study was undertaken in three RACFs in Sydney, Australia. Data were generated through ethnographic field work over a period of five months (May-September 2011). Triangulated analysis of data primarily focused on examining the transformation and exchange of information between different media across the process. The findings of this study highlight the extensive scope and intense nature of information exchange in RACF medication ordering and delivery. Rather than attributing error to individual care providers, the explication of distributed cognition processes enabled the identification of gaps in three information exchange dimensions which potentially contribute to the occurrence of medication errors namely: (1) design of medication charts which complicates order processing and record keeping (2) lack of coordination mechanisms between participants which results in misalignment of local practices (3) reliance on restricted communication bandwidth channels mainly telephone and fax which complicates the information processing requirements. The study demonstrates how the identification of these gaps enhances understanding of medication errors in RACFs. Application of the theoretical lens of distributed cognition can assist in enhancing our understanding of medication errors in RACFs through identification of gaps in information exchange. Understanding the dynamics of the cognitive process can inform the design of interventions to manage errors and improve residents' safety. Copyright © 2012 Elsevier Ireland Ltd. All rights reserved.

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

PubMed Central

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

2014-01-01

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

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

PubMed

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

2014-10-01

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

Model reduction of dynamical systems by proper orthogonal decomposition: Error bounds and comparison of methods using snapshots from the solution and the time derivatives [Proper orthogonal decomposition model reduction of dynamical systems: error bounds and comparison of methods using snapshots from the solution and the time derivatives

DOE PAGES

Kostova-Vassilevska, Tanya; Oxberry, Geoffrey M.

2017-09-17

In this study, we consider two proper orthogonal decomposition (POD) methods for dimension reduction of dynamical systems. The first method (M1) uses only time snapshots of the solution, while the second method (M2) augments the snapshot set with time-derivative snapshots. The goal of the paper is to analyze and compare the approximation errors resulting from the two methods by using error bounds. We derive several new bounds of the error from POD model reduction by each of the two methods. The new error bounds involve a multiplicative factor depending on the time steps between the snapshots. For method M1 themore » factor depends on the second power of the time step, while for method 2 the dependence is on the fourth power of the time step, suggesting that method M2 can be more accurate for small between-snapshot intervals. However, three other factors also affect the size of the error bounds. These include (i) the norm of the second (for M1) and fourth derivatives (M2); (ii) the first neglected singular value and (iii) the spectral properties of the projection of the system’s Jacobian in the reduced space. Because of the interplay of these factors neither method is more accurate than the other in all cases. Finally, we present numerical examples demonstrating that when the number of collected snapshots is small and the first neglected singular value has a value of zero, method M2 results in a better approximation.« less

Comparing interval estimates for small sample ordinal CFA models

PubMed Central

Natesan, Prathiba

2015-01-01

Robust maximum likelihood (RML) and asymptotically generalized least squares (AGLS) methods have been recommended for fitting ordinal structural equation models. Studies show that some of these methods underestimate standard errors. However, these studies have not investigated the coverage and bias of interval estimates. An estimate with a reasonable standard error could still be severely biased. This can only be known by systematically investigating the interval estimates. The present study compares Bayesian, RML, and AGLS interval estimates of factor correlations in ordinal confirmatory factor analysis models (CFA) for small sample data. Six sample sizes, 3 factor correlations, and 2 factor score distributions (multivariate normal and multivariate mildly skewed) were studied. Two Bayesian prior specifications, informative and relatively less informative were studied. Undercoverage of confidence intervals and underestimation of standard errors was common in non-Bayesian methods. Underestimated standard errors may lead to inflated Type-I error rates. Non-Bayesian intervals were more positive biased than negatively biased, that is, most intervals that did not contain the true value were greater than the true value. Some non-Bayesian methods had non-converging and inadmissible solutions for small samples and non-normal data. Bayesian empirical standard error estimates for informative and relatively less informative priors were closer to the average standard errors of the estimates. The coverage of Bayesian credibility intervals was closer to what was expected with overcoverage in a few cases. Although some Bayesian credibility intervals were wider, they reflected the nature of statistical uncertainty that comes with the data (e.g., small sample). Bayesian point estimates were also more accurate than non-Bayesian estimates. The results illustrate the importance of analyzing coverage and bias of interval estimates, and how ignoring interval estimates can be misleading. Therefore, editors and policymakers should continue to emphasize the inclusion of interval estimates in research. PMID:26579002

Model reduction of dynamical systems by proper orthogonal decomposition: Error bounds and comparison of methods using snapshots from the solution and the time derivatives [Proper orthogonal decomposition model reduction of dynamical systems: error bounds and comparison of methods using snapshots from the solution and the time derivatives

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

Kostova-Vassilevska, Tanya; Oxberry, Geoffrey M.

In this study, we consider two proper orthogonal decomposition (POD) methods for dimension reduction of dynamical systems. The first method (M1) uses only time snapshots of the solution, while the second method (M2) augments the snapshot set with time-derivative snapshots. The goal of the paper is to analyze and compare the approximation errors resulting from the two methods by using error bounds. We derive several new bounds of the error from POD model reduction by each of the two methods. The new error bounds involve a multiplicative factor depending on the time steps between the snapshots. For method M1 themore » factor depends on the second power of the time step, while for method 2 the dependence is on the fourth power of the time step, suggesting that method M2 can be more accurate for small between-snapshot intervals. However, three other factors also affect the size of the error bounds. These include (i) the norm of the second (for M1) and fourth derivatives (M2); (ii) the first neglected singular value and (iii) the spectral properties of the projection of the system’s Jacobian in the reduced space. Because of the interplay of these factors neither method is more accurate than the other in all cases. Finally, we present numerical examples demonstrating that when the number of collected snapshots is small and the first neglected singular value has a value of zero, method M2 results in a better approximation.« less

Comparing interval estimates for small sample ordinal CFA models.

PubMed

Natesan, Prathiba

2015-01-01

Robust maximum likelihood (RML) and asymptotically generalized least squares (AGLS) methods have been recommended for fitting ordinal structural equation models. Studies show that some of these methods underestimate standard errors. However, these studies have not investigated the coverage and bias of interval estimates. An estimate with a reasonable standard error could still be severely biased. This can only be known by systematically investigating the interval estimates. The present study compares Bayesian, RML, and AGLS interval estimates of factor correlations in ordinal confirmatory factor analysis models (CFA) for small sample data. Six sample sizes, 3 factor correlations, and 2 factor score distributions (multivariate normal and multivariate mildly skewed) were studied. Two Bayesian prior specifications, informative and relatively less informative were studied. Undercoverage of confidence intervals and underestimation of standard errors was common in non-Bayesian methods. Underestimated standard errors may lead to inflated Type-I error rates. Non-Bayesian intervals were more positive biased than negatively biased, that is, most intervals that did not contain the true value were greater than the true value. Some non-Bayesian methods had non-converging and inadmissible solutions for small samples and non-normal data. Bayesian empirical standard error estimates for informative and relatively less informative priors were closer to the average standard errors of the estimates. The coverage of Bayesian credibility intervals was closer to what was expected with overcoverage in a few cases. Although some Bayesian credibility intervals were wider, they reflected the nature of statistical uncertainty that comes with the data (e.g., small sample). Bayesian point estimates were also more accurate than non-Bayesian estimates. The results illustrate the importance of analyzing coverage and bias of interval estimates, and how ignoring interval estimates can be misleading. Therefore, editors and policymakers should continue to emphasize the inclusion of interval estimates in research.

Abnormal Error Monitoring in Math-Anxious Individuals: Evidence from Error-Related Brain Potentials

PubMed Central

Suárez-Pellicioni, Macarena; Núñez-Peña, María Isabel; Colomé, Àngels

2013-01-01

This study used event-related brain potentials to investigate whether math anxiety is related to abnormal error monitoring processing. Seventeen high math-anxious (HMA) and seventeen low math-anxious (LMA) individuals were presented with a numerical and a classical Stroop task. Groups did not differ in terms of trait or state anxiety. We found enhanced error-related negativity (ERN) in the HMA group when subjects committed an error on the numerical Stroop task, but not on the classical Stroop task. Groups did not differ in terms of the correct-related negativity component (CRN), the error positivity component (Pe), classical behavioral measures or post-error measures. The amplitude of the ERN was negatively related to participants’ math anxiety scores, showing a more negative amplitude as the score increased. Moreover, using standardized low resolution electromagnetic tomography (sLORETA) we found greater activation of the insula in errors on a numerical task as compared to errors in a non-numerical task only for the HMA group. The results were interpreted according to the motivational significance theory of the ERN. PMID:24236212

Uncharted territory: measuring costs of diagnostic errors outside the medical record.

PubMed

Schwartz, Alan; Weiner, Saul J; Weaver, Frances; Yudkowsky, Rachel; Sharma, Gunjan; Binns-Calvey, Amy; Preyss, Ben; Jordan, Neil

2012-11-01

In a past study using unannounced standardised patients (USPs), substantial rates of diagnostic and treatment errors were documented among internists. Because the authors know the correct disposition of these encounters and obtained the physicians' notes, they can identify necessary treatment that was not provided and unnecessary treatment. They can also discern which errors can be identified exclusively from a review of the medical records. To estimate the avoidable direct costs incurred by physicians making errors in our previous study. In the study, USPs visited 111 internal medicine attending physicians. They presented variants of four previously validated cases that jointly manipulate the presence or absence of contextual and biomedical factors that could lead to errors in management if overlooked. For example, in a patient with worsening asthma symptoms, a complicating biomedical factor was the presence of reflux disease and a complicating contextual factor was inability to afford the currently prescribed inhaler. Costs of missed or unnecessary services were computed using Medicare cost-based reimbursement data. Fourteen practice locations, including two academic clinics, two community-based primary care networks with multiple sites, a core safety net provider, and three Veteran Administration government facilities. Contribution of errors to costs of care. Overall, errors in care resulted in predicted costs of approximately $174,000 across 399 visits, of which only $8745 was discernible from a review of the medical records alone (without knowledge of the correct diagnoses). The median cost of error per visit with an incorrect care plan differed by case and by presentation variant within case. Chart reviews alone underestimate costs of care because they typically reflect appropriate treatment decisions conditional on (potentially erroneous) diagnoses. Important information about patient context is often entirely missing from medical records. Experimental methods, including the use of USPs, reveal the substantial costs of these errors.

Tracking through laser-induced clutter for air-to-ground directed energy system

NASA Astrophysics Data System (ADS)

Belen'kii, Mikhail; Brinkley, Timothy; Hughes, Kevin; Tannenbaum, Allen

2003-09-01

The agility and speed with which directed energy can be retargeted and delivered to the target makes a laser weapon highly desirable in tactical battlefield environments. A directed energy system can effectively damage and possibly destroy relatively soft targets on the ground. In order to accurately point a high-energy beam at the target, the directed energy system must be able to acquire and track targets of interest in highly cluttered environments, under different weather, smoke, and camouflage conditions and in the presence of turbulence and thermal blooming. To meet these requirements, we proposed a concept of a multi spectral tracker, which integrates three sensors: SAR radar, a passive MWIR optical tracker, and a range-gated laser illuminated tracker. In this paper we evaluated the feasibility of the integrated optical tracker and arrived to the following conclusions: a) the contrast enhancement by mapping the original pixel distribution to the desired one enhances the target identification capability, b) a reduction of the divergence of the illuminating beam reduces rms pointing error of a laser tracker, c) a clutter removal algorithm based on active contours is capable of capturing targets in highly cluttered environments, d) the daytime rms pointing error caused by anisoplanatism of the track point to the aim point is comparable to the diffraction-limited beam spot size, f) the peak intensity shift from the optical axis caused by thermal blooming at 5 km range for the air-to-ground engagement scenario is on the order of 8 μrad, and it is 10 μrad at 10 km range, and e) the thermal blooming reduces the peak average power in a 2 cm bucket at 5 km range by a factor of 8, and it reduces the peak average power in the bucket at 10 km range by a factor of 22.

Merging bottom-up and top-down precipitation products using a stochastic error model

NASA Astrophysics Data System (ADS)

Maggioni, Viviana; Massari, Christian; Brocca, Luca; Ciabatta, Luca

2017-04-01

Accurate quantitative precipitation estimation is of great importance for water resources management, agricultural planning, and forecasting and monitoring of natural hazards such as flash floods and landslides. In situ observations are limited around the Earth, especially in remote areas (e.g., complex terrain, dense vegetation), but currently available satellite precipitation products are able to provide global precipitation estimates with an accuracy that depends upon many factors (e.g., type of storms, temporal sampling, season etc…). Recently, Brocca et al. (2014) have proposed an alternative approach (i.e., SM2RAIN) that allows to estimate rainfall from space by using satellite soil moisture observations. In contrast with classical satellite precipitation products which sense the cloud properties to retrieve the instantaneous precipitation, this new bottom-up approach makes use of two consecutive soil moisture measurements for obtaining an estimate of the fallen precipitation within the interval between two satellite passes. As a result, the nature of the measurement is different and complementary to the one of classical precipitation products and could provide a different valid perspective to improve current satellite rainfall estimates via appropriate integration between the products (i.e., SM2RAIN plus a classical satellite rainfall product). However, whether SM2RAIN is able or not to improve the performance of any state-of-the-art satellite rainfall product is much dependent upon an adequate quantification and characterization of the relative errors of the products. In this study, the stochastic rainfall error model SREM2D (Hossain et al. 2006) is used for characterizing the retrieval error of both SM2RAIN and a state-of-the-art satellite precipitation product (i.e., 3B42RT). The error characterization serves for an optimal integration between SM2RAIN and 3B42RT for enhancing the capability of the resulting integrated product (i.e. SM2RAIN+3B42RT) in operational hydrology. The study, conducted in Italy for a 5-yr period (2010-2014) using a dense network of raingauges (about 3000) as a benchmark, demonstrates that the integration is able to enhance the correlation and the root mean squared error of SM2RAIN+3B42RT with respect to the parent products. This suggests a potential benefit of merging SM2RAIN derived rainfall with state-of-the-art satellite precipitation estimates for creating a product characterized by higher accuracy and better performance when used in the contest of operational hydrology. REFERENCES 1. Brocca, L.; Ciabatta, L.; Massari, C.; Moramarco, T.; Hahn, S.; Hasenauer, S.; Kidd, R.; Dorigo, W.; Wagner, W.; Levizzani, V. Soil as a natural rain gauge: Estimating global rainfall from satellite soil moisture data. J. Geophys. Res. Atmos. 2014, 119, 5128-5141. 2. Hossain, F.; Anagnostou, E. N. A two-dimensional satellite rainfall error model. IEEE Trans. Geosci. Remote Sens. 2006, 44, 1511-1522.

Ideas for a pattern-oriented approach towards a VERA analysis ensemble

NASA Astrophysics Data System (ADS)

Gorgas, T.; Dorninger, M.

2010-09-01

Ideas for a pattern-oriented approach towards a VERA analysis ensemble For many applications in meteorology and especially for verification purposes it is important to have some information about the uncertainties of observation and analysis data. A high quality of these "reference data" is an absolute necessity as the uncertainties are reflected in verification measures. The VERA (Vienna Enhanced Resolution Analysis) scheme includes a sophisticated quality control tool which accounts for the correction of observational data and provides an estimation of the observation uncertainty. It is crucial for meteorologically and physically reliable analysis fields. VERA is based on a variational principle and does not need any first guess fields. It is therefore NWP model independent and can also be used as an unbiased reference for real time model verification. For downscaling purposes VERA uses an a priori knowledge on small-scale physical processes over complex terrain, the so called "fingerprint technique", which transfers information from rich to data sparse regions. The enhanced Joint D-PHASE and COPS data set forms the data base for the analysis ensemble study. For the WWRP projects D-PHASE and COPS a joint activity has been started to collect GTS and non-GTS data from the national and regional meteorological services in Central Europe for 2007. Data from more than 11.000 stations are available for high resolution analyses. The usage of random numbers as perturbations for ensemble experiments is a common approach in meteorology. In most implementations, like for NWP-model ensemble systems, the focus lies on error growth and propagation on the spatial and temporal scale. When defining errors in analysis fields we have to consider the fact that analyses are not time dependent and that no perturbation method aimed at temporal evolution is possible. Further, the method applied should respect two major sources of analysis errors: Observation errors AND analysis or interpolation errors. With the concept of an analysis ensemble we hope to get a more detailed sight on both sources of analysis errors. For the computation of the VERA ensemble members a sample of Gaussian random perturbations is produced for each station and parameter. The deviation of perturbations is based on the correction proposals by the VERA QC scheme to provide some "natural" limits for the ensemble. In order to put more emphasis on the weather situation we aim to integrate the main synoptic field structures as weighting factors for the perturbations. Two widely approved approaches are used for the definition of these main field structures: The Principal Component Analysis and a 2D-Discrete Wavelet Transform. The results of tests concerning the implementation of this pattern-supported analysis ensemble system and a comparison of the different approaches are given in the presentation.

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

PubMed

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

2016-01-01

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

Recognizing and managing errors of cognitive underspecification.

PubMed

Duthie, Elizabeth A

2014-03-01

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

Influence of Lexical Factors on Word-Finding Accuracy, Error Patterns, and Substitution Types

ERIC Educational Resources Information Center

Newman, Rochelle S.; German, Diane J.; Jagielko, Jennifer R.

2018-01-01

This retrospective, exploratory investigation examined the types of target words that 66 children with/without word-finding difficulties (WFD) had difficulty naming, and the types of errors they made. Words were studied with reference to lexical factors (LFs) that might influence naming performance: word frequency, familiarity, length, phonotactic…

Evaluating the Effectiveness of an Educational Intervention to Improve the Patient Safety Attitudes of Intern Pharmacists

PubMed Central

Fois, Romano A.; McLachlan, Andrew J.; Chen, Timothy F.

2017-01-01

Objective. To evaluate the effectiveness of a face-to-face educational intervention in improving the patient safety attitudes of intern pharmacists. Methods. A patient safety education program was delivered to intern pharmacists undertaking The University of Sydney Intern Training Program in 2014. Their patient safety attitudes were evaluated immediately prior to, immediately after, and three-months post-intervention. Underlying attitudinal factors were identified using exploratory factor analysis. Changes in factor scores were examined using analysis of variance. Results. Of the 120 interns enrolled, 95 (78.7%) completed all three surveys. Four underlying attitudinal factors were identified: attitudes towards addressing errors, questioning behaviors, blaming individuals, and reporting errors. Improvements in all attitudinal factors were evident immediately after the intervention. However, only improvements in attitudes towards blaming individuals involved in errors were sustained at three months post-intervention. Conclusion. The educational intervention was associated with short-term improvements in pharmacist interns’ patient safety attitudes. However, other factors likely influenced their attitudes in the longer term. PMID:28289295

Evaluating the Effectiveness of an Educational Intervention to Improve the Patient Safety Attitudes of Intern Pharmacists.

PubMed

Walpola, Ramesh L; Fois, Romano A; McLachlan, Andrew J; Chen, Timothy F

2017-02-25

Objective. To evaluate the effectiveness of a face-to-face educational intervention in improving the patient safety attitudes of intern pharmacists. Methods. A patient safety education program was delivered to intern pharmacists undertaking The University of Sydney Intern Training Program in 2014. Their patient safety attitudes were evaluated immediately prior to, immediately after, and three-months post-intervention. Underlying attitudinal factors were identified using exploratory factor analysis. Changes in factor scores were examined using analysis of variance. Results. Of the 120 interns enrolled, 95 (78.7%) completed all three surveys. Four underlying attitudinal factors were identified: attitudes towards addressing errors, questioning behaviors, blaming individuals, and reporting errors. Improvements in all attitudinal factors were evident immediately after the intervention. However, only improvements in attitudes towards blaming individuals involved in errors were sustained at three months post-intervention. Conclusion. The educational intervention was associated with short-term improvements in pharmacist interns' patient safety attitudes. However, other factors likely influenced their attitudes in the longer term.

Pilot-controller communication errors : an analysis of Aviation Safety Reporting System (ASRS) reports

DOT National Transportation Integrated Search

1998-08-01

The purpose of this study was to identify the factors that contribute to pilot-controller communication errors. Resports submitted to the Aviation Safety Reporting System (ASRS) offer detailed accounts of specific types of errors and a great deal of ...

STAMP-Based HRA Considering Causality Within a Sociotechnical System: A Case of Minuteman III Missile Accident.

PubMed

Rong, Hao; Tian, Jin

2015-05-01

The study contributes to human reliability analysis (HRA) by proposing a method that focuses more on human error causality within a sociotechnical system, illustrating its rationality and feasibility by using a case of the Minuteman (MM) III missile accident. Due to the complexity and dynamics within a sociotechnical system, previous analyses of accidents involving human and organizational factors clearly demonstrated that the methods using a sequential accident model are inadequate to analyze human error within a sociotechnical system. System-theoretic accident model and processes (STAMP) was used to develop a universal framework of human error causal analysis. To elaborate the causal relationships and demonstrate the dynamics of human error, system dynamics (SD) modeling was conducted based on the framework. A total of 41 contributing factors, categorized into four types of human error, were identified through the STAMP-based analysis. All factors are related to a broad view of sociotechnical systems, and more comprehensive than the causation presented in the accident investigation report issued officially. Recommendations regarding both technical and managerial improvement for a lower risk of the accident are proposed. The interests of an interdisciplinary approach provide complementary support between system safety and human factors. The integrated method based on STAMP and SD model contributes to HRA effectively. The proposed method will be beneficial to HRA, risk assessment, and control of the MM III operating process, as well as other sociotechnical systems. © 2014, Human Factors and Ergonomics Society.

Error reduction, patient safety and institutional ethics committees.

PubMed

Meaney, Mark E

2004-01-01

Institutional ethics committees remain largely absent from the literature on error reduction and patient safety. In this paper, the author endeavors to fill the gap. As noted in the Hastings Center's recent report, "Promoting Patient Safety," the occurrence of medical error involves complex web of multiple factors. Human misstep is certainly one such factor, but not the only one. This paper builds on the Hastings Center's report in arguing that institutional ethics committees ought to play an integral role in the transformation of a "culture of blame" to a "culture of safety" in healthcare delivery.

Effect of neoclassical toroidal viscosity on error-field penetration thresholds in tokamak plasmas.

PubMed

Cole, A J; Hegna, C C; Callen, J D

2007-08-10

A model for field-error penetration is developed that includes nonresonant as well as the usual resonant field-error effects. The nonresonant components cause a neoclassical toroidal viscous torque that keeps the plasma rotating at a rate comparable to the ion diamagnetic frequency. The new theory is used to examine resonant error-field penetration threshold scaling in Ohmic tokamak plasmas. Compared to previous theoretical results, we find the plasma is less susceptible to error-field penetration and locking, by a factor that depends on the nonresonant error-field amplitude.

Use of scan overlap redundancy to enhance multispectral aircraft scanner data

NASA Technical Reports Server (NTRS)

Lindenlaub, J. C.; Keat, J.

1973-01-01

Two criteria were suggested for optimizing the resolution error versus signal-to-noise-ratio tradeoff. The first criterion uses equal weighting coefficients and chooses n, the number of lines averaged, so as to make the average resolution error equal to the noise error. The second criterion adjusts both the number and relative sizes of the weighting coefficients so as to minimize the total error (resolution error plus noise error). The optimum set of coefficients depends upon the geometry of the resolution element, the number of redundant scan lines, the scan line increment, and the original signal-to-noise ratio of the channel. Programs were developed to find the optimum number and relative weights of the averaging coefficients. A working definition of signal-to-noise ratio was given and used to try line averaging on a typical set of data. Line averaging was evaluated only with respect to its effect on classification accuracy.

Embodying Others in Immersive Virtual Reality: Electro-Cortical Signatures of Monitoring the Errors in the Actions of an Avatar Seen from a First-Person Perspective.

PubMed

Pavone, Enea Francesco; Tieri, Gaetano; Rizza, Giulia; Tidoni, Emmanuele; Grisoni, Luigi; Aglioti, Salvatore Maria

2016-01-13

Brain monitoring of errors in one's own and other's actions is crucial for a variety of processes, ranging from the fine-tuning of motor skill learning to important social functions, such as reading out and anticipating the intentions of others. Here, we combined immersive virtual reality and EEG recording to explore whether embodying the errors of an avatar by seeing it from a first-person perspective may activate the error monitoring system in the brain of an onlooker. We asked healthy participants to observe, from a first- or third-person perspective, an avatar performing a correct or an incorrect reach-to-grasp movement toward one of two virtual mugs placed on a table. At the end of each trial, participants reported verbally how much they embodied the avatar's arm. Ratings were maximal in first-person perspective, indicating that immersive virtual reality can be a powerful tool to induce embodiment of an artificial agent, even through mere visual perception and in the absence of any cross-modal boosting. Observation of erroneous grasping from a first-person perspective enhanced error-related negativity and medial-frontal theta power in the trials where human onlookers embodied the virtual character, hinting at the tight link between early, automatic coding of error detection and sense of embodiment. Error positivity was similar in 1PP and 3PP, suggesting that conscious coding of errors is similar for self and other. Thus, embodiment plays an important role in activating specific components of the action monitoring system when others' errors are coded as if they are one's own errors. Detecting errors in other's actions is crucial for social functions, such as reading out and anticipating the intentions of others. Using immersive virtual reality and EEG recording, we explored how the brain of an onlooker reacted to the errors of an avatar seen from a first-person perspective. We found that mere observation of erroneous actions enhances electrocortical markers of error detection in the trials where human onlookers embodied the virtual character. Thus, the cerebral system for action monitoring is maximally activated when others' errors are coded as if they are one's own errors. The results have important implications for understanding how the brain can control the external world and thus creating new brain-computer interfaces. Copyright © 2016 the authors 0270-6474/16/360268-12$15.00/0.

Summary of evidence-based guideline update: evaluation and management of concussion in sports: report of the Guideline Development Subcommittee of the American Academy of Neurology.

PubMed

Giza, Christopher C; Kutcher, Jeffrey S; Ashwal, Stephen; Barth, Jeffrey; Getchius, Thomas S D; Gioia, Gerard A; Gronseth, Gary S; Guskiewicz, Kevin; Mandel, Steven; Manley, Geoffrey; McKeag, Douglas B; Thurman, David J; Zafonte, Ross

2013-06-11

To update the 1997 American Academy of Neurology (AAN) practice parameter regarding sports concussion, focusing on 4 questions: 1) What factors increase/decrease concussion risk? 2) What diagnostic tools identify those with concussion and those at increased risk for severe/prolonged early impairments, neurologic catastrophe, or chronic neurobehavioral impairment? 3) What clinical factors identify those at increased risk for severe/prolonged early postconcussion impairments, neurologic catastrophe, recurrent concussions, or chronic neurobehavioral impairment? 4) What interventions enhance recovery, reduce recurrent concussion risk, or diminish long-term sequelae? The complete guideline on which this summary is based is available as an online data supplement to this article. We systematically reviewed the literature from 1955 to June 2012 for pertinent evidence. We assessed evidence for quality and synthesized into conclusions using a modified Grading of Recommendations Assessment, Development and Evaluation process. We used a modified Delphi process to develop recommendations. Specific risk factors can increase or decrease concussion risk. Diagnostic tools to help identify individuals with concussion include graded symptom checklists, the Standardized Assessment of Concussion, neuropsychological assessments, and the Balance Error Scoring System. Ongoing clinical symptoms, concussion history, and younger age identify those at risk for postconcussion impairments. Risk factors for recurrent concussion include history of multiple concussions, particularly within 10 days after initial concussion. Risk factors for chronic neurobehavioral impairment include concussion exposure and APOE ε4 genotype. Data are insufficient to show that any intervention enhances recovery or diminishes long-term sequelae postconcussion. Practice recommendations are presented for preparticipation counseling, management of suspected concussion, and management of diagnosed concussion.

Nursing student medication errors: a retrospective review.

PubMed

Harding, Lorill; Petrick, Teresa

2008-01-01

This article presents the findings of a retrospective review of medication errors made and reported by nursing students in a 4-year baccalaureate program. Data were examined in relation to the semester of the program, kind of error according to the rights of medication administration, and contributing factors. Three categories of contributing factors were identified: rights violations, system factors, and knowledge and understanding. It became apparent that system factors, or the context in which medication administration takes place, are not fully considered when students are taught about medication administration. Teaching strategies need to account for the dynamic complexity of this process and incorporate experiential knowledge. This review raised several important questions about how this information guides our practice as educators in the clinical and classroom settings and how we can work collaboratively with practice partners to influence change and increase patient safety.

The effect of monetary punishment on error evaluation in a Go/No-go task.

PubMed

Maruo, Yuya; Sommer, Werner; Masaki, Hiroaki

2017-10-01

Little is known about the effects of the motivational significance of errors in Go/No-go tasks. We investigated the impact of monetary punishment on the error-related negativity (ERN) and error positivity (Pe) for both overt errors and partial errors, that is, no-go trials without overt responses but with covert muscle activities. We compared high and low punishment conditions where errors were penalized with 50 or 5 yen, respectively, and a control condition without monetary consequences for errors. Because we hypothesized that the partial-error ERN might overlap with the no-go N2, we compared ERPs between correct rejections (i.e., successful no-go trials) and partial errors in no-go trials. We also expected that Pe amplitudes should increase with the severity of the penalty for errors. Mean error rates were significantly lower in the high punishment than in the control condition. Monetary punishment did not influence the overt-error ERN and partial-error ERN in no-go trials. The ERN in no-go trials did not differ between partial errors and overt errors; in addition, ERPs for correct rejections in no-go trials without partial errors were of the same size as in go-trial. Therefore the overt-error ERN and the partial-error ERN may share similar error monitoring processes. Monetary punishment increased Pe amplitudes for overt errors, suggesting enhanced error evaluation processes. For partial errors an early Pe was observed, presumably representing inhibition processes. Interestingly, even partial errors elicited the Pe, suggesting that covert erroneous activities could be detected in Go/No-go tasks. Copyright © 2017 The Authors. Published by Elsevier B.V. All rights reserved.

Power Enhancement in High Dimensional Cross-Sectional Tests

PubMed Central

Fan, Jianqing; Liao, Yuan; Yao, Jiawei

2016-01-01

We propose a novel technique to boost the power of testing a high-dimensional vector H : θ = 0 against sparse alternatives where the null hypothesis is violated only by a couple of components. Existing tests based on quadratic forms such as the Wald statistic often suffer from low powers due to the accumulation of errors in estimating high-dimensional parameters. More powerful tests for sparse alternatives such as thresholding and extreme-value tests, on the other hand, require either stringent conditions or bootstrap to derive the null distribution and often suffer from size distortions due to the slow convergence. Based on a screening technique, we introduce a “power enhancement component”, which is zero under the null hypothesis with high probability, but diverges quickly under sparse alternatives. The proposed test statistic combines the power enhancement component with an asymptotically pivotal statistic, and strengthens the power under sparse alternatives. The null distribution does not require stringent regularity conditions, and is completely determined by that of the pivotal statistic. As specific applications, the proposed methods are applied to testing the factor pricing models and validating the cross-sectional independence in panel data models. PMID:26778846

Identifying the arterial input function from dynamic contrast-enhanced magnetic resonance images using an apex-seeking technique

NASA Astrophysics Data System (ADS)

Martel, Anne L.

2004-04-01

In order to extract quantitative information from dynamic contrast-enhanced MR images (DCE-MRI) it is usually necessary to identify an arterial input function. This is not a trivial problem if there are no major vessels present in the field of view. Most existing techniques rely on operator intervention or use various curve parameters to identify suitable pixels but these are often specific to the anatomical region or the acquisition method used. They also require the signal from several pixels to be averaged in order to improve the signal to noise ratio, however this introduces errors due to partial volume effects. We have described previously how factor analysis can be used to automatically separate arterial and venous components from DCE-MRI studies of the brain but although that method works well for single slice images through the brain when the blood brain barrier technique is intact, it runs into problems for multi-slice images with more complex dynamics. This paper will describe a factor analysis method that is more robust in such situations and is relatively insensitive to the number of physiological components present in the data set. The technique is very similar to that used to identify spectral end-members from multispectral remote sensing images.

The design and scale-up of spray dried particle delivery systems.

PubMed

Al-Khattawi, Ali; Bayly, Andrew; Phillips, Andrew; Wilson, David

2018-01-01

The rising demand for pharmaceutical particles with tailored physicochemical properties has opened new markets for spray drying especially for solubility enhancement, improving inhalation medicines and stabilization of biopharmaceuticals. Despite this, the spray drying literature is scattered and often does not address the principles underpinning robust development of pharmaceuticals. It is therefore necessary to present clearer picture of the field and highlight the factors influencing particle design and scale-up. Areas covered: The review presents a systematic analysis of the trends in development of particle delivery systems using spray drying. This is followed by exploring the mechanisms governing particle formation in the process stages. Particle design factors including those of equipment configurations and feed/process attributes were highlighted. Finally, the review summarises the current industrial approaches for upscaling pharmaceutical spray drying. Expert opinion: Spray drying provides the ability to design particles of the desired functionality. This greatly benefits the pharmaceutical sector especially as product specifications are becoming more encompassing and exacting. One of the biggest barriers to product translation remains one of scale-up/scale-down. A shift from trial and error approaches to model-based particle design helps to enhance control over product properties. To this end, process innovations and advanced manufacturing technologies are particularly welcomed.

Countering imbalanced datasets to improve adverse drug event predictive models in labor and delivery.

PubMed

Taft, L M; Evans, R S; Shyu, C R; Egger, M J; Chawla, N; Mitchell, J A; Thornton, S N; Bray, B; Varner, M

2009-04-01

The IOM report, Preventing Medication Errors, emphasizes the overall lack of knowledge of the incidence of adverse drug events (ADE). Operating rooms, emergency departments and intensive care units are known to have a higher incidence of ADE. Labor and delivery (L&D) is an emergency care unit that could have an increased risk of ADE, where reported rates remain low and under-reporting is suspected. Risk factor identification with electronic pattern recognition techniques could improve ADE detection rates. The objective of the present study is to apply Synthetic Minority Over Sampling Technique (SMOTE) as an enhanced sampling method in a sparse dataset to generate prediction models to identify ADE in women admitted for labor and delivery based on patient risk factors and comorbidities. By creating synthetic cases with the SMOTE algorithm and using a 10-fold cross-validation technique, we demonstrated improved performance of the Naïve Bayes and the decision tree algorithms. The true positive rate (TPR) of 0.32 in the raw dataset increased to 0.67 in the 800% over-sampled dataset. Enhanced performance from classification algorithms can be attained with the use of synthetic minority class oversampling techniques in sparse clinical datasets. Predictive models created in this manner can be used to develop evidence based ADE monitoring systems.

Disclosing Medical Errors to Patients: Attitudes and Practices of Physicians and Trainees

PubMed Central

Jones, Elizabeth W.; Wu, Barry J.; Forman-Hoffman, Valerie L.; Levi, Benjamin H.; Rosenthal, Gary E.

2007-01-01

BACKGROUND Disclosing errors to patients is an important part of patient care, but the prevalence of disclosure, and factors affecting it, are poorly understood. OBJECTIVE To survey physicians and trainees about their practices and attitudes regarding error disclosure to patients. DESIGN AND PARTICIPANTS Survey of faculty physicians, resident physicians, and medical students in Midwest, Mid-Atlantic, and Northeast regions of the United States. MEASUREMENTS Actual error disclosure; hypothetical error disclosure; attitudes toward disclosure; demographic factors. RESULTS Responses were received from 538 participants (response rate = 77%). Almost all faculty and residents responded that they would disclose a hypothetical error resulting in minor (97%) or major (93%) harm to a patient. However, only 41% of faculty and residents had disclosed an actual minor error (resulting in prolonged treatment or discomfort), and only 5% had disclosed an actual major error (resulting in disability or death). Moreover, 19% acknowledged not disclosing an actual minor error and 4% acknowledged not disclosing an actual major error. Experience with malpractice litigation was not associated with less actual or hypothetical error disclosure. Faculty were more likely than residents and students to disclose a hypothetical error and less concerned about possible negative consequences of disclosure. Several attitudes were associated with greater likelihood of hypothetical disclosure, including the belief that disclosure is right even if it comes at a significant personal cost. CONCLUSIONS There appears to be a gap between physicians’ attitudes and practices regarding error disclosure. Willingness to disclose errors was associated with higher training level and a variety of patient-centered attitudes, and it was not lessened by previous exposure to malpractice litigation. PMID:17473944

Two Enhancements of the Logarithmic Least-Squares Method for Analyzing Subjective Comparisons

DTIC Science & Technology

1989-03-25

error term. 1 For this model, the total sum of squares ( SSTO ), defined as n 2 SSTO = E (yi y) i=1 can be partitioned into error and regression sums...of the regression line around the mean value. Mathematically, for the model given by equation A.4, SSTO = SSE + SSR (A.6) A-4 where SSTO is the total...sum of squares (i.e., the variance of the yi’s), SSE is error sum of squares, and SSR is the regression sum of squares. SSTO , SSE, and SSR are given

Errors Affect Hypothetical Intertemporal Food Choice in Women

PubMed Central

Sellitto, Manuela; di Pellegrino, Giuseppe

2014-01-01

Growing evidence suggests that the ability to control behavior is enhanced in contexts in which errors are more frequent. Here we investigated whether pairing desirable food with errors could decrease impulsive choice during hypothetical temporal decisions about food. To this end, healthy women performed a Stop-signal task in which one food cue predicted high-error rate, and another food cue predicted low-error rate. Afterwards, we measured participants’ intertemporal preferences during decisions between smaller-immediate and larger-delayed amounts of food. We expected reduced sensitivity to smaller-immediate amounts of food associated with high-error rate. Moreover, taking into account that deprivational states affect sensitivity for food, we controlled for participants’ hunger. Results showed that pairing food with high-error likelihood decreased temporal discounting. This effect was modulated by hunger, indicating that, the lower the hunger level, the more participants showed reduced impulsive preference for the food previously associated with a high number of errors as compared with the other food. These findings reveal that errors, which are motivationally salient events that recruit cognitive control and drive avoidance learning against error-prone behavior, are effective in reducing impulsive choice for edible outcomes. PMID:25244534

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.

Performance monitoring and error significance in patients with obsessive-compulsive disorder.

PubMed

Endrass, Tanja; Schuermann, Beate; Kaufmann, Christan; Spielberg, Rüdiger; Kniesche, Rainer; Kathmann, Norbert

2010-05-01

Performance monitoring has been consistently found to be overactive in obsessive-compulsive disorder (OCD). The present study examines whether performance monitoring in OCD is adjusted with error significance. Therefore, errors in a flanker task were followed by neutral (standard condition) or punishment feedbacks (punishment condition). In the standard condition patients had significantly larger error-related negativity (ERN) and correct-related negativity (CRN) ampliudes than controls. But, in the punishment condition groups did not differ in ERN and CRN amplitudes. While healthy controls showed an amplitude enhancement between standard and punishment condition, OCD patients showed no variation. In contrast, group differences were not found for the error positivity (Pe): both groups had larger Pe amplitudes in the punishment condition. Results confirm earlier findings of overactive error monitoring in OCD. The absence of a variation with error significance might indicate that OCD patients are unable to down-regulate their monitoring activity according to external requirements. Copyright 2010 Elsevier B.V. All rights reserved.

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

Magnitude of pseudopotential localization errors in fixed node diffusion quantum Monte Carlo

DOE PAGES

Kent, Paul R.; Krogel, Jaron T.

2017-06-22

Growth in computational resources has lead to the application of real space diffusion quantum Monte Carlo to increasingly heavy elements. Although generally assumed to be small, we find that when using standard techniques, the pseudopotential localization error can be large, on the order of an electron volt for an isolated cerium atom. We formally show that the localization error can be reduced to zero with improvements to the Jastrow factor alone, and we define a metric of Jastrow sensitivity that may be useful in the design of pseudopotentials. We employ an extrapolation scheme to extract the bare fixed node energymore » and estimate the localization error in both the locality approximation and the T-moves schemes for the Ce atom in charge states 3+/4+. The locality approximation exhibits the lowest Jastrow sensitivity and generally smaller localization errors than T-moves although the locality approximation energy approaches the localization free limit from above/below for the 3+/4+ charge state. We find that energy minimized Jastrow factors including three-body electron-electron-ion terms are the most effective at reducing the localization error for both the locality approximation and T-moves for the case of the Ce atom. Less complex or variance minimized Jastrows are generally less effective. Finally, our results suggest that further improvements to Jastrow factors and trial wavefunction forms may be needed to reduce localization errors to chemical accuracy when medium core pseudopotentials are applied to heavy elements such as Ce.« less

Calculation of the Nucleon Axial Form Factor Using Staggered Lattice QCD

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

Meyer, Aaron S.; Hill, Richard J.; Kronfeld, Andreas S.

The nucleon axial form factor is a dominant contribution to errors in neutrino oscillation studies. Lattice QCD calculations can help control theory errors by providing first-principles information on nucleon form factors. In these proceedings, we present preliminary results on a blinded calculation ofmore » $$g_A$$ and the axial form factor using HISQ staggered baryons with 2+1+1 flavors of sea quarks. Calculations are done using physical light quark masses and are absolutely normalized. We discuss fitting form factor data with the model-independent $z$ expansion parametrization.« less

Generalized Structured Component Analysis with Uniqueness Terms for Accommodating Measurement Error

PubMed Central

Hwang, Heungsun; Takane, Yoshio; Jung, Kwanghee

2017-01-01

Generalized structured component analysis (GSCA) is a component-based approach to structural equation modeling (SEM), where latent variables are approximated by weighted composites of indicators. It has no formal mechanism to incorporate errors in indicators, which in turn renders components prone to the errors as well. We propose to extend GSCA to account for errors in indicators explicitly. This extension, called GSCAM, considers both common and unique parts of indicators, as postulated in common factor analysis, and estimates a weighted composite of indicators with their unique parts removed. Adding such unique parts or uniqueness terms serves to account for measurement errors in indicators in a manner similar to common factor analysis. Simulation studies are conducted to compare parameter recovery of GSCAM and existing methods. These methods are also applied to fit a substantively well-established model to real data. PMID:29270146

Monetary Incentives in Speeded Perceptual Decision: Effects of Penalizing Errors Versus Slow Responses

PubMed Central

Dambacher, Michael; Hübner, Ronald; Schlösser, Jan

2011-01-01

The influence of monetary incentives on performance has been widely investigated among various disciplines. While the results reveal positive incentive effects only under specific conditions, the exact nature, and the contribution of mediating factors are largely unexplored. The present study examined influences of payoff schemes as one of these factors. In particular, we manipulated penalties for errors and slow responses in a speeded categorization task. The data show improved performance for monetary over symbolic incentives when (a) penalties are higher for slow responses than for errors, and (b) neither slow responses nor errors are punished. Conversely, payoff schemes with stronger punishment for errors than for slow responses resulted in worse performance under monetary incentives. The findings suggest that an emphasis of speed is favorable for positive influences of monetary incentives, whereas an emphasis of accuracy under time pressure has the opposite effect. PMID:21980316

Throughput of Coded Optical CDMA Systems with AND Detectors

NASA Astrophysics Data System (ADS)

Memon, Kehkashan A.; Umrani, Fahim A.; Umrani, A. W.; Umrani, Naveed A.

2012-09-01

Conventional detection techniques used in optical code-division multiple access (OCDMA) systems are not optimal and result in poor bit error rate performance. This paper analyzes the coded performance of optical CDMA systems with AND detectors for enhanced throughput efficiencies and improved error rate performance. The results show that the use of AND detectors significantly improve the performance of an optical channel.

Lessons to be Learned from Evidence-based Medicine: Practice and Promise of Evidence-based Medicine and Evidence-based Education.

ERIC Educational Resources Information Center

Wolf, Fredric M.

2000-01-01

Presents statistics of deaths caused by medical errors and argues the effects of misconceptions in diagnosis and treatment. Suggests evidence-based medicine to enhance the quality of practice and minimize error rates. Presents 10 evidence-based lessons and discusses the possible benefits of evidence-based medicine to evidence-based education and…

Author Correction: Re-designing Interleukin-12 to enhance its safety and potential as an anti-tumor immunotherapeutic agent.

PubMed

Wang, Pengju; Li, Xiaozhu; Wang, Jiwei; Gao, Dongling; Li, Yuenan; Li, Haoze; Chu, Yongchao; Zhang, Zhongxian; Liu, Hongtao; Jiang, Guozhong; Cheng, Zhenguo; Wang, Shengdian; Dong, Jianzeng; Feng, Baisui; Chard, Louisa S; Lemoine, Nicholas R; Wang, Yaohe

2018-01-10

The originally published version of this Article contained errors in Figure 4. In panel b, the square and diamond labels associated with the uppermost survival curve were incorrectly displayed as 'n' and 'u', respectively. These errors have now been corrected in both the PDF and HTML versions of the Article.

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.

Enhanced storage capacity with errors in scale-free Hopfield neural networks: An analytical study.

PubMed

Kim, Do-Hyun; Park, Jinha; Kahng, Byungnam

2017-01-01

The Hopfield model is a pioneering neural network model with associative memory retrieval. The analytical solution of the model in mean field limit revealed that memories can be retrieved without any error up to a finite storage capacity of O(N), where N is the system size. Beyond the threshold, they are completely lost. Since the introduction of the Hopfield model, the theory of neural networks has been further developed toward realistic neural networks using analog neurons, spiking neurons, etc. Nevertheless, those advances are based on fully connected networks, which are inconsistent with recent experimental discovery that the number of connections of each neuron seems to be heterogeneous, following a heavy-tailed distribution. Motivated by this observation, we consider the Hopfield model on scale-free networks and obtain a different pattern of associative memory retrieval from that obtained on the fully connected network: the storage capacity becomes tremendously enhanced but with some error in the memory retrieval, which appears as the heterogeneity of the connections is increased. Moreover, the error rates are also obtained on several real neural networks and are indeed similar to that on scale-free model networks.

Standard Errors of Estimated Latent Variable Scores with Estimated Structural Parameters

ERIC Educational Resources Information Center

Hoshino, Takahiro; Shigemasu, Kazuo

2008-01-01

The authors propose a concise formula to evaluate the standard error of the estimated latent variable score when the true values of the structural parameters are not known and must be estimated. The formula can be applied to factor scores in factor analysis or ability parameters in item response theory, without bootstrap or Markov chain Monte…

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.

Emotions, Coping and Learning in Error Situations in the Workplace

ERIC Educational Resources Information Center

Rausch, Andreas; Seifried, Jürgen; Harteis, Christian

2017-01-01

Purpose: This paper aims to investigate the complex relationship between emotions, coping approaches and learning in error situations in the workplace. The study also examines the influence of individual error orientation, as well as psychological safety, and team learning behaviour as contextual factors. Design/methodology/approach: To measure…

Exploratory Factor Analysis of Reading, Spelling, and Math Errors

ERIC Educational Resources Information Center

O'Brien, Rebecca; Pan, Xingyu; Courville, Troy; Bray, Melissa A.; Breaux, Kristina; Avitia, Maria; Choi, Dowon

2017-01-01

Norm-referenced error analysis is useful for understanding individual differences in students' academic skill development and for identifying areas of skill strength and weakness. The purpose of the present study was to identify underlying connections between error categories across five language and math subtests of the Kaufman Test of…

Medication administration error: magnitude and associated factors among nurses in Ethiopia.

PubMed

Feleke, Senafikish Amsalu; Mulatu, Muluadam Abebe; Yesmaw, Yeshaneh Seyoum

2015-01-01

The significant impact of medication administration errors affect patients in terms of morbidity, mortality, adverse drug events, and increased length of hospital stay. It also increases costs for clinicians and healthcare systems. Due to this, assessing the magnitude and associated factors of medication administration error has a significant contribution for improving the quality of patient care. The aim of this study was to assess the magnitude and associated factors of medication administration errors among nurses at the Felege Hiwot Referral Hospital inpatient department. A prospective, observation-based, cross-sectional study was conducted from March 24-April 7, 2014 at the Felege Hiwot Referral Hospital inpatient department. A total of 82 nurses were interviewed using a pre-tested structured questionnaire, and observed while administering 360 medications by using a checklist supplemented with a review of medication charts. Data were analyzed by using SPSS version 20 software package and logistic regression was done to identify possible factors associated with medication administration error. The incidence of medication administration error was 199 (56.4 %). The majority (87.5 %) of the medications have documentation error, followed by technique error 263 (73.1 %) and time error 193 (53.6 %). Variables which were significantly associated with medication administration error include nurses between the ages of 18-25 years [Adjusted Odds Ratio (AOR) = 2.9, 95 % CI (1.65,6.38)], 26-30 years [AOR = 2.3, 95 % CI (1.55, 7.26)] and 31-40 years [AOR = 2.1, 95 % CI (1.07, 4.12)], work experience of less than or equal to 10 years [AOR = 1.7, 95 % CI (1.33, 4.99)], nurse to patient ratio of 7-10 [AOR = 1.6, 95 % CI (1.44, 3.19)] and greater than 10 [AOR = 1.5, 95 % CI (1.38, 3.89)], interruption of the respondent at the time of medication administration [AOR = 1.5, 95 % CI (1.14, 3.21)], night shift of medication administration [AOR = 3.1, 95 % CI (1.38, 9.66)] and age of the patients with less than 18 years [AOR = 2.3, 95 % CI (1.17, 4.62)]. In general, medication errors at the administration phase were highly prevalent in Felege Hiwot Referral Hospital. Documentation error is the most dominant type of error observed during the study. Increasing nurses' staffing levels, minimizing distraction and interruptions during medication administration by using no interruptions zones and "No-Talk" signage are recommended to overcome medication administration errors. Retaining experienced nurses from leaving to train and supervise inexperienced nurses with the focus on medication safety, in addition providing convenient sleep hours for nurses would be helpful in ensuring that medication errors don't occur as frequently as observed in this study.

PRESAGE: Protecting Structured Address Generation against Soft Errors

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

Sharma, Vishal C.; Gopalakrishnan, Ganesh; Krishnamoorthy, Sriram

Modern computer scaling trends in pursuit of larger component counts and power efficiency have, unfortunately, lead to less reliable hardware and consequently soft errors escaping into application data ("silent data corruptions"). Techniques to enhance system resilience hinge on the availability of efficient error detectors that have high detection rates, low false positive rates, and lower computational overhead. Unfortunately, efficient detectors to detect faults during address generation (to index large arrays) have not been widely researched. We present a novel lightweight compiler-driven technique called PRESAGE for detecting bit-flips affecting structured address computations. A key insight underlying PRESAGE is that any addressmore » computation scheme that flows an already incurred error is better than a scheme that corrupts one particular array access but otherwise (falsely) appears to compute perfectly. Enabling the flow of errors allows one to situate detectors at loop exit points, and helps turn silent corruptions into easily detectable error situations. Our experiments using PolyBench benchmark suite indicate that PRESAGE-based error detectors have a high error-detection rate while incurring low overheads.« less

PRESAGE: Protecting Structured Address Generation against Soft Errors

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

Sharma, Vishal C.; Gopalakrishnan, Ganesh; Krishnamoorthy, Sriram

Modern computer scaling trends in pursuit of larger component counts and power efficiency have, unfortunately, lead to less reliable hardware and consequently soft errors escaping into application data ("silent data corruptions"). Techniques to enhance system resilience hinge on the availability of efficient error detectors that have high detection rates, low false positive rates, and lower computational overhead. Unfortunately, efficient detectors to detect faults during address generation have not been widely researched (especially in the context of indexing large arrays). We present a novel lightweight compiler-driven technique called PRESAGE for detecting bit-flips affecting structured address computations. A key insight underlying PRESAGEmore » is that any address computation scheme that propagates an already incurred error is better than a scheme that corrupts one particular array access but otherwise (falsely) appears to compute perfectly. Ensuring the propagation of errors allows one to place detectors at loop exit points and helps turn silent corruptions into easily detectable error situations. Our experiments using the PolyBench benchmark suite indicate that PRESAGE-based error detectors have a high error-detection rate while incurring low overheads.« less

Comparison of Topographic Effects between the Enhanced Vegetation Index (EVI) and Normalized Difference Vegetation Index (NDVI)

NASA Astrophysics Data System (ADS)

Matsushita, B.; Yang, W.; Chen, J.; Onda, Y.

2007-12-01

Vegetation indices play an important role in monitoring variations in vegetation. The Enhanced Vegetation Index (EVI) proposed by the MODIS Land Discipline Group and the Normalized Difference Vegetation Index (NDVI) are both global-based vegetation indices aimed at providing consistent spatial and temporal information regarding global vegetation. However, many environmental factors such as atmospheric conditions and soil background may produce errors in these indices. The topographic effect is another very important factor, especially when the indices are used in areas of rough terrain. In this paper, we analyzed differences in the topographic effect between the EVI and the NDVI based on a non-Lambertian model and using two airborne-based images with a spatial resolution of 1.5m acquired from a mountainous area covered by a homogeneous Japanese cypress plantation. The results indicate that the soil adjustment factor "L" in the EVI makes it more sensitive to topographic conditions than is the NDVI. Based on these results, we strongly recommend that the topographic effect be removed from the EVI--as well as from other vegetation indices that similarly include a term without a band ratio format (e.g., the PVI and SAVI)--when these indices are used in conjunction with a high spatial resolution image of an area of rough terrain, where the topographic effect on the vegetarian indices having only a band ratio format (e.g., the NDVI) can usually be ignored.

Thermoelectric property measurements with computer controlled systems

NASA Technical Reports Server (NTRS)

Chmielewski, A. B.; Wood, C.

1984-01-01

A joint JPL-NASA program to develop an automated system to measure the thermoelectric properties of newly developed materials is described. Consideration is given to the difficulties created by signal drift in measurements of Hall voltage and the Large Delta T Seebeck coefficient. The benefits of a computerized system were examined with respect to error reduction and time savings for human operators. It is shown that the time required to measure Hall voltage can be reduced by a factor of 10 when a computer is used to fit a curve to the ratio of the measured signal and its standard deviation. The accuracy of measurements of the Large Delta T Seebeck coefficient and thermal diffusivity was also enhanced by the use of computers.

Reticle variation influence on manufacturing line and wafer device performance

NASA Astrophysics Data System (ADS)

Nistler, John L.; Spurlock, Kyle

1994-01-01

Cost effective manufacturing of devices at 0.5, 0.35 and 0.25μm geometries will be highly dependent on a companys' ability to obtain an economic return on investment. The high capital investment in equipment and facilities, not to mention the related chemical and wafer costs, for producing 200mm silicon wafers requires aspects of wafer processing to be tightly controlled. Reduction in errors and enhanced yield management requires early correction or avoidance of reticle problems. It is becoming increasingly important to recognize and track all pertinent factors impacting both the technical and financial viability of a wafer manufacturing fabrication area. Reticle related effects on wafer manufacturing can be costly and affect the total quality perceived by the device customer.

Strength conditions for the elastic structures with a stress error

NASA Astrophysics Data System (ADS)

Matveev, A. D.

2017-10-01

As is known, the constraints (strength conditions) for the safety factor of elastic structures and design details of a particular class, e.g. aviation structures are established, i.e. the safety factor values of such structures should be within the given range. It should be noted that the constraints are set for the safety factors corresponding to analytical (exact) solutions of elasticity problems represented for the structures. Developing the analytical solutions for most structures, especially irregular shape ones, is associated with great difficulties. Approximate approaches to solve the elasticity problems, e.g. the technical theories of deformation of homogeneous and composite plates, beams and shells, are widely used for a great number of structures. Technical theories based on the hypotheses give rise to approximate (technical) solutions with an irreducible error, with the exact value being difficult to be determined. In static calculations of the structural strength with a specified small range for the safety factors application of technical (by the Theory of Strength of Materials) solutions is difficult. However, there are some numerical methods for developing the approximate solutions of elasticity problems with arbitrarily small errors. In present paper, the adjusted reference (specified) strength conditions for the structural safety factor corresponding to approximate solution of the elasticity problem have been proposed. The stress error estimation is taken into account using the proposed strength conditions. It has been shown that, to fulfill the specified strength conditions for the safety factor of the given structure corresponding to an exact solution, the adjusted strength conditions for the structural safety factor corresponding to an approximate solution are required. The stress error estimation which is the basis for developing the adjusted strength conditions has been determined for the specified strength conditions. The adjusted strength conditions presented by allowable stresses are suggested. Adjusted strength conditions make it possible to determine the set of approximate solutions, whereby meeting the specified strength conditions. Some examples of the specified strength conditions to be satisfied using the technical (by the Theory of Strength of Materials) solutions and strength conditions have been given, as well as the examples of stress conditions to be satisfied using approximate solutions with a small error.

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.

Myopia in secondary school students in Mwanza City, Tanzania: the need for a national screening programme

PubMed Central

Wedner, S H; Ross, D A; Todd, J; Anemona, A; Balira, R; Foster, A

2002-01-01

Background/aims: The prevalence of significant refractive errors and other eye diseases was measured in 2511 secondary school students aged 11–27 years in Mwanza City, Tanzania. Risk factors for myopia were explored. Methods: A questionnaire assessed the students’ socioeconomic background and exposure to near work followed by visual acuity assessment and a full eye examination. Non-cycloplegic objective and subjective refraction was done on all participants with visual acuity of worse than 6/12 in either eye without an obvious cause. Results: 154 (6.1%) students had significant refractive errors. Myopia was the leading refractive error (5.6%). Amblyopia (0.4%), strabismus (0.2%), and other treatable eye disorders were uncommon. Only 30.3% of students with significant refractive errors wore spectacles before the survey. Age, sex, ethnicity, father’s educational status, and a family history of siblings with spectacles were significant independent risk factors for myopia. Conclusion: The prevalence of uncorrected significant refractive errors is high enough to justify a regular school eye screening programme in secondary schools in Tanzania. Risk factors for myopia are similar to those reported in European, North-American, and Asian populations. PMID:12386067

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.

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

Air-braked cycle ergometers: validity of the correction factor for barometric pressure.

PubMed

Finn, J P; Maxwell, B F; Withers, R T

2000-10-01

Barometric pressure exerts by far the greatest influence of the three environmental factors (barometric pressure, temperature and humidity) on power outputs from air-braked ergometers. The barometric pressure correction factor for power outputs from air-braked ergometers is in widespread use but apparently has never been empirically validated. Our experiment validated this correction factor by calibrating two air-braked cycle ergometers in a hypobaric chamber using a dynamic calibration rig. The results showed that if the power output correction for changes in air resistance at barometric pressures corresponding to altitudes of 38, 600, 1,200 and 1,800 m above mean sea level were applied, then the coefficients of variation were 0.8-1.9% over the range of 160-1,597 W. The overall mean error was 3.0 % but this included up to 0.73 % for the propagated error that was associated with errors in the measurement of: a) temperature b) relative humidity c) barometric pressure d) force, distance and angular velocity by the dynamic calibration rig. The overall mean error therefore approximated the +/- 2.0% of true load that was specified by the Laboratory Standards Assistance Scheme of the Australian Sports Commission. The validity of the correction factor for barometric pressure on power output was therefore demonstrated over the altitude range of 38-1,800 m.

The use of error-category mapping in pharmacokinetic model analysis of dynamic contrast-enhanced MRI data.

PubMed

Gill, Andrew B; Anandappa, Gayathri; Patterson, Andrew J; Priest, Andrew N; Graves, Martin J; Janowitz, Tobias; Jodrell, Duncan I; Eisen, Tim; Lomas, David J

2015-02-01

This study introduces the use of 'error-category mapping' in the interpretation of pharmacokinetic (PK) model parameter results derived from dynamic contrast-enhanced (DCE-) MRI data. Eleven patients with metastatic renal cell carcinoma were enrolled in a multiparametric study of the treatment effects of bevacizumab. For the purposes of the present analysis, DCE-MRI data from two identical pre-treatment examinations were analysed by application of the extended Tofts model (eTM), using in turn a model arterial input function (AIF), an individually-measured AIF and a sample-average AIF. PK model parameter maps were calculated. Errors in the signal-to-gadolinium concentration ([Gd]) conversion process and the model-fitting process itself were assigned to category codes on a voxel-by-voxel basis, thereby forming a colour-coded 'error-category map' for each imaged slice. These maps were found to be repeatable between patient visits and showed that the eTM converged adequately in the majority of voxels in all the tumours studied. However, the maps also clearly indicated sub-regions of low Gd uptake and of non-convergence of the model in nearly all tumours. The non-physical condition ve ≥ 1 was the most frequently indicated error category and appeared sensitive to the form of AIF used. This simple method for visualisation of errors in DCE-MRI could be used as a routine quality-control technique and also has the potential to reveal otherwise hidden patterns of failure in PK model applications. Copyright © 2015 The Authors. Published by Elsevier Inc. All rights reserved.

[Determination of the error of aerosol extinction coefficient measured by DOAS].

PubMed

Si, Fu-qi; Liu, Jian-guo; Xie, Pin-hua; Zhang, Yu-jun; Wang, Mian; Liu, Wen-qing; Hiroaki, Kuze; Liu, Cheng; Nobuo, Takeuchi

2006-10-01

The method of defining the error of aerosol extinction coefficient measured by differential optical absorption spectroscopy (DOAS) is described. Some factors which could bring errors to result, such as variation of source, integral time, atmospheric turbulence, calibration of system parameter, displacement of system, and back scattering of particles, are analyzed. The error of aerosol extinction coefficient, 0.03 km(-1), is determined by theoretical analysis and practical measurement.

Enhancement and evaluation of Skylab photography for potential land use inventories, part 1. [New York

NASA Technical Reports Server (NTRS)

Hardy, E. E. (Principal Investigator); Skaley, J. E.; Dawson, C. P.; Weiner, G. D.; Phillips, E. S.; Fisher, R. A.

1975-01-01

The author has identified the following significant results. Three sites were evaluated for land use inventory: Finger Lakes - Tompkins County, Lower Hudson Valley - Newburgh, and Suffolk County - Long Island. Special photo enhancement processes were developed to standardize the density range and contrast among S190A negatives. Enhanced black and white enlargements were converted to color by contact printing onto diazo film. A color prediction model related the density values on each spectral band for each category of land use to the spectral properties of the various diazo dyes. The S190A multispectral system proved to be almost as effective as the S190B high resolution camera for inventorying land use. Aggregate error for Level 1 averaged about 12% while Level 2 aggregate error averaged about 25%. The S190A system proved to be much superior to LANDSAT in inventorying land use, primarily because of increased resolution.

Enhancement of cooperation in the spatial prisoner's dilemma with a coherence-resonance effect through annealed randomness at a cooperator-defector boundary; comparison of two variant models

NASA Astrophysics Data System (ADS)

Tanimoto, Jun

2016-11-01

Inspired by the commonly observed real-world fact that people tend to behave in a somewhat random manner after facing interim equilibrium to break a stalemate situation whilst seeking a higher output, we established two models of the spatial prisoner's dilemma. One presumes that an agent commits action errors, while the other assumes that an agent refers to a payoff matrix with an added random noise instead of an original payoff matrix. A numerical simulation revealed that mechanisms based on the annealing of randomness due to either the action error or the payoff noise could significantly enhance the cooperation fraction. In this study, we explain the detailed enhancement mechanism behind the two models by referring to the concepts that we previously presented with respect to evolutionary dynamic processes under the names of enduring and expanding periods.

Features and Feedback: Enhancing Metamnemonic Knowledge at Retrieval Reduces Source-Monitoring Errors

ERIC Educational Resources Information Center

Lane, Sean M.; Roussel, Cristine C.; Villa, Diane; Morita, Shelby K.

2007-01-01

Three experiments explored the issue of whether enhanced metamnemonic knowledge at retrieval can improve participants' ability to make difficult source discriminations in the context of the eyewitness suggestibility paradigm. The 1st experiment documented differences in phenomenal experience between veridical and false memories. Experiment 2…

A self-calibration method in single-axis rotational inertial navigation system with rotating mechanism

NASA Astrophysics Data System (ADS)

Chen, Yuanpei; Wang, Lingcao; Li, Kui

2017-10-01

Rotary inertial navigation modulation mechanism can greatly improve the inertial navigation system (INS) accuracy through the rotation. Based on the single-axis rotational inertial navigation system (RINS), a self-calibration method is put forward. The whole system is applied with the rotation modulation technique so that whole inertial measurement unit (IMU) of system can rotate around the motor shaft without any external input. In the process of modulation, some important errors can be decoupled. Coupled with the initial position information and attitude information of the system as the reference, the velocity errors and attitude errors in the rotation are used as measurement to perform Kalman filtering to estimate part of important errors of the system after which the errors can be compensated into the system. The simulation results show that the method can complete the self-calibration of the single-axis RINS in 15 minutes and estimate gyro drifts of three-axis, the installation error angle of the IMU and the scale factor error of the gyro on z-axis. The calibration accuracy of optic gyro drifts could be about 0.003°/h (1σ) as well as the scale factor error could be about 1 parts per million (1σ). The errors estimate reaches the system requirements which can effectively improve the longtime navigation accuracy of the vehicle or the boat.

High-precision radiometric tracking for planetary approach and encounter in the inner solar system

NASA Technical Reports Server (NTRS)

Christensen, C. S.; Thurman, S. W.; Davidson, J. M.; Finger, M. H.; Folkner, W. M.

1989-01-01

The benefits of improved radiometric tracking data have been studied for planetary approach within the inner Solar System using the Mars Rover Sample Return trajectory as a model. It was found that the benefit of improved data to approach and encounter navigation was highly dependent on the a priori uncertainties assumed for several non-estimated parameters, including those for frame-tie, Earth orientation, troposphere delay, and station locations. With these errors at their current levels, navigational performance was found to be insensitive to enhancements in data accuracy. However, when expected improvements in these errors are modeled, performance with current-accuracy data significantly improves, with substantial further improvements possible with enhancements in data accuracy.

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

PubMed Central

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

2016-01-01

Objective To explore and understand participants’ perceptions and attitudes towards the reporting of medication errors (MEs). Methods A qualitative study using in-depth interviews of 31 healthcare practitioners from nine publicly funded, primary care clinics in three states in peninsular Malaysia was conducted for this study. The participants included family medicine specialists, doctors, pharmacists, pharmacist assistants, nurses and assistant medical officers. The interviews were audiotaped and transcribed verbatim. Analysis of the data was guided by the framework approach. Results Six themes and 28 codes were identified. Despite the availability of a reporting system, most of the participants agreed that MEs were underreported. The nature of the error plays an important role in determining the reporting. The reporting system, organisational factors, provider factors, reporter’s burden and benefit of reporting also were identified. Conclusions Healthcare practitioners in primary care clinics understood the importance of reporting MEs to improve patient safety. Their perceptions and attitudes towards reporting of MEs were influenced by many factors which affect the decision-making process of whether or not to report. Although the process is complex, it primarily is determined by the severity of the outcome of the errors. The participants voluntarily report the errors if they are familiar with the reporting system, what error to report, when to report and what form to use. PMID:27906960

The Influence of Training Phase on Error of Measurement in Jump Performance.

PubMed

Taylor, Kristie-Lee; Hopkins, Will G; Chapman, Dale W; Cronin, John B

2016-03-01

The purpose of this study was to calculate the coefficients of variation in jump performance for individual participants in multiple trials over time to determine the extent to which there are real differences in the error of measurement between participants. The effect of training phase on measurement error was also investigated. Six subjects participated in a resistance-training intervention for 12 wk with mean power from a countermovement jump measured 6 d/wk. Using a mixed-model meta-analysis, differences between subjects, within-subject changes between training phases, and the mean error values during different phases of training were examined. Small, substantial factor differences of 1.11 were observed between subjects; however, the finding was unclear based on the width of the confidence limits. The mean error was clearly higher during overload training than baseline training, by a factor of ×/÷ 1.3 (confidence limits 1.0-1.6). The random factor representing the interaction between subjects and training phases revealed further substantial differences of ×/÷ 1.2 (1.1-1.3), indicating that on average, the error of measurement in some subjects changes more than in others when overload training is introduced. The results from this study provide the first indication that within-subject variability in performance is substantially different between training phases and, possibly, different between individuals. The implications of these findings for monitoring individuals and estimating sample size are discussed.

Case-related factors affecting cutting errors of the proximal tibia in total knee arthroplasty assessed by computer navigation.

PubMed

Tsukeoka, Tadashi; Tsuneizumi, Yoshikazu; Yoshino, Kensuke; Suzuki, Mashiko

2018-05-01

The aim of this study was to determine factors that contribute to bone cutting errors of conventional instrumentation for tibial resection in total knee arthroplasty (TKA) as assessed by an image-free navigation system. The hypothesis is that preoperative varus alignment is a significant contributory factor to tibial bone cutting errors. This was a prospective study of a consecutive series of 72 TKAs. The amount of the tibial first-cut errors with reference to the planned cutting plane in both coronal and sagittal planes was measured by an image-free computer navigation system. Multiple regression models were developed with the amount of tibial cutting error in the coronal and sagittal planes as dependent variables and sex, age, disease, height, body mass index, preoperative alignment, patellar height (Insall-Salvati ratio) and preoperative flexion angle as independent variables. Multiple regression analysis showed that sex (male gender) (R = 0.25 p = 0.047) and preoperative varus alignment (R = 0.42, p = 0.001) were positively associated with varus tibial cutting errors in the coronal plane. In the sagittal plane, none of the independent variables was significant. When performing TKA in varus deformity, careful confirmation of the bone cutting surface should be performed to avoid varus alignment. The results of this study suggest technical considerations that can help a surgeon achieve more accurate component placement. IV.

Factors that influence the generation of autobiographical memory conjunction errors

PubMed Central

Devitt, Aleea L.; Monk-Fromont, Edwin; Schacter, Daniel L.; Addis, Donna Rose

2015-01-01

The constructive nature of memory is generally adaptive, allowing us to efficiently store, process and learn from life events, and simulate future scenarios to prepare ourselves for what may come. However, the cost of a flexibly constructive memory system is the occasional conjunction error, whereby the components of an event are authentic, but the combination of those components is false. Using a novel recombination paradigm, it was demonstrated that details from one autobiographical memory may be incorrectly incorporated into another, forming autobiographical memory conjunction errors that elude typical reality monitoring checks. The factors that contribute to the creation of these conjunction errors were examined across two experiments. Conjunction errors were more likely to occur when the corresponding details were partially rather than fully recombined, likely due to increased plausibility and ease of simulation of partially recombined scenarios. Brief periods of imagination increased conjunction error rates, in line with the imagination inflation effect. Subjective ratings suggest that this inflation is due to similarity of phenomenological experience between conjunction and authentic memories, consistent with a source monitoring perspective. Moreover, objective scoring of memory content indicates that increased perceptual detail may be particularly important for the formation of autobiographical memory conjunction errors. PMID:25611492

High-accuracy self-calibration method for dual-axis rotation-modulating RLG-INS

NASA Astrophysics Data System (ADS)

Wei, Guo; Gao, Chunfeng; Wang, Qi; Wang, Qun; Long, Xingwu

2017-05-01

Inertial navigation system has been the core component of both military and civil navigation systems. Dual-axis rotation modulation can completely eliminate the inertial elements constant errors of the three axes to improve the system accuracy. But the error caused by the misalignment angles and the scale factor error cannot be eliminated through dual-axis rotation modulation. And discrete calibration method cannot fulfill requirements of high-accurate calibration of the mechanically dithered ring laser gyroscope navigation system with shock absorbers. This paper has analyzed the effect of calibration error during one modulated period and presented a new systematic self-calibration method for dual-axis rotation-modulating RLG-INS. Procedure for self-calibration of dual-axis rotation-modulating RLG-INS has been designed. The results of self-calibration simulation experiment proved that: this scheme can estimate all the errors in the calibration error model, the calibration precision of the inertial sensors scale factor error is less than 1ppm and the misalignment is less than 5″. These results have validated the systematic self-calibration method and proved its importance for accuracy improvement of dual -axis rotation inertial navigation system with mechanically dithered ring laser gyroscope.

Experimental investigation of observation error in anuran call surveys

USGS Publications Warehouse

McClintock, B.T.; Bailey, L.L.; Pollock, K.H.; Simons, T.R.

2010-01-01

Occupancy models that account for imperfect detection are often used to monitor anuran and songbird species occurrence. However, presenceabsence data arising from auditory detections may be more prone to observation error (e.g., false-positive detections) than are sampling approaches utilizing physical captures or sightings of individuals. We conducted realistic, replicated field experiments using a remote broadcasting system to simulate simple anuran call surveys and to investigate potential factors affecting observation error in these studies. Distance, time, ambient noise, and observer abilities were the most important factors explaining false-negative detections. Distance and observer ability were the best overall predictors of false-positive errors, but ambient noise and competing species also affected error rates for some species. False-positive errors made up 5 of all positive detections, with individual observers exhibiting false-positive rates between 0.5 and 14. Previous research suggests false-positive errors of these magnitudes would induce substantial positive biases in standard estimators of species occurrence, and we recommend practices to mitigate for false positives when developing occupancy monitoring protocols that rely on auditory detections. These recommendations include additional observer training, limiting the number of target species, and establishing distance and ambient noise thresholds during surveys. ?? 2010 The Wildlife Society.

Propagation of angular errors in two-axis rotation systems

NASA Astrophysics Data System (ADS)

Torrington, Geoffrey K.

2003-10-01

Two-Axis Rotation Systems, or "goniometers," are used in diverse applications including telescope pointing, automotive headlamp testing, and display testing. There are three basic configurations in which a goniometer can be built depending on the orientation and order of the stages. Each configuration has a governing set of equations which convert motion between the system "native" coordinates to other base systems, such as direction cosines, optical field angles, or spherical-polar coordinates. In their simplest form, these equations neglect errors present in real systems. In this paper, a statistical treatment of error source propagation is developed which uses only tolerance data, such as can be obtained from the system mechanical drawings prior to fabrication. It is shown that certain error sources are fully correctable, partially correctable, or uncorrectable, depending upon the goniometer configuration and zeroing technique. The system error budget can be described by a root-sum-of-squares technique with weighting factors describing the sensitivity of each error source. This paper tabulates weighting factors at 67% (k=1) and 95% (k=2) confidence for various levels of maximum travel for each goniometer configuration. As a practical example, this paper works through an error budget used for the procurement of a system at Sandia National Laboratories.

A two-factor error model for quantitative steganalysis

NASA Astrophysics Data System (ADS)

Böhme, Rainer; Ker, Andrew D.

2006-02-01

Quantitative steganalysis refers to the exercise not only of detecting the presence of hidden stego messages in carrier objects, but also of estimating the secret message length. This problem is well studied, with many detectors proposed but only a sparse analysis of errors in the estimators. A deep understanding of the error model, however, is a fundamental requirement for the assessment and comparison of different detection methods. This paper presents a rationale for a two-factor model for sources of error in quantitative steganalysis, and shows evidence from a dedicated large-scale nested experimental set-up with a total of more than 200 million attacks. Apart from general findings about the distribution functions found in both classes of errors, their respective weight is determined, and implications for statistical hypothesis tests in benchmarking scenarios or regression analyses are demonstrated. The results are based on a rigorous comparison of five different detection methods under many different external conditions, such as size of the carrier, previous JPEG compression, and colour channel selection. We include analyses demonstrating the effects of local variance and cover saturation on the different sources of error, as well as presenting the case for a relative bias model for between-image error.

Factors that influence the generation of autobiographical memory conjunction errors.

PubMed

Devitt, Aleea L; Monk-Fromont, Edwin; Schacter, Daniel L; Addis, Donna Rose

2016-01-01

The constructive nature of memory is generally adaptive, allowing us to efficiently store, process and learn from life events, and simulate future scenarios to prepare ourselves for what may come. However, the cost of a flexibly constructive memory system is the occasional conjunction error, whereby the components of an event are authentic, but the combination of those components is false. Using a novel recombination paradigm, it was demonstrated that details from one autobiographical memory (AM) may be incorrectly incorporated into another, forming AM conjunction errors that elude typical reality monitoring checks. The factors that contribute to the creation of these conjunction errors were examined across two experiments. Conjunction errors were more likely to occur when the corresponding details were partially rather than fully recombined, likely due to increased plausibility and ease of simulation of partially recombined scenarios. Brief periods of imagination increased conjunction error rates, in line with the imagination inflation effect. Subjective ratings suggest that this inflation is due to similarity of phenomenological experience between conjunction and authentic memories, consistent with a source monitoring perspective. Moreover, objective scoring of memory content indicates that increased perceptual detail may be particularly important for the formation of AM conjunction errors.

Design and analysis of multihypothesis motion-compensated prediction (MHMCP) codec for error-resilient visual communications

NASA Astrophysics Data System (ADS)

Kung, Wei-Ying; Kim, Chang-Su; Kuo, C.-C. Jay

2004-10-01

A multi-hypothesis motion compensated prediction (MHMCP) scheme, which predicts a block from a weighted superposition of more than one reference blocks in the frame buffer, is proposed and analyzed for error resilient visual communication in this research. By combining these reference blocks effectively, MHMCP can enhance the error resilient capability of compressed video as well as achieve a coding gain. In particular, we investigate the error propagation effect in the MHMCP coder and analyze the rate-distortion performance in terms of the hypothesis number and hypothesis coefficients. It is shown that MHMCP suppresses the short-term effect of error propagation more effectively than the intra refreshing scheme. Simulation results are given to confirm the analysis. Finally, several design principles for the MHMCP coder are derived based on the analytical and experimental results.

Development of a simple system for simultaneously measuring 6DOF geometric motion errors of a linear guide.

PubMed

Qibo, Feng; Bin, Zhang; Cunxing, Cui; Cuifang, Kuang; Yusheng, Zhai; Fenglin, You

2013-11-04

A simple method for simultaneously measuring the 6DOF geometric motion errors of the linear guide was proposed. The mechanisms for measuring straightness and angular errors and for enhancing their resolution are described in detail. A common-path method for measuring the laser beam drift was proposed and it was used to compensate the errors produced by the laser beam drift in the 6DOF geometric error measurements. A compact 6DOF system was built. Calibration experiments with certain standard measurement meters showed that our system has a standard deviation of 0.5 µm in a range of ± 100 µm for the straightness measurements, and standard deviations of 0.5", 0.5", and 1.0" in the range of ± 100" for pitch, yaw, and roll measurements, respectively.

Improved motor control method with measurements of fiber optics gyro (FOG) for dual-axis rotational inertial navigation system (RINS).

PubMed

Song, Tianxiao; Wang, Xueyun; Liang, Wenwei; Xing, Li

2018-05-14

Benefiting from frame structure, RINS can improve the navigation accuracy by modulating the inertial sensor errors with proper rotation scheme. In the traditional motor control method, the measurements of the photoelectric encoder are always adopted to drive inertial measurement unit (IMU) to rotate. However, when carrier conducts heading motion, the inertial sensor errors may no longer be zero-mean in navigation coordinate. Meanwhile, some high-speed carriers like aircraft need to roll a certain angle to balance the centrifugal force during the heading motion, which may result in non-negligible coupling errors, caused by the FOG installation errors and scale factor errors. Moreover, the error parameters of FOG are susceptible to the temperature and magnetic field, and the pre-calibration is a time-consuming process which is difficult to completely suppress the FOG-related errors. In this paper, an improved motor control method with the measurements of FOG is proposed to address these problems, with which the outer frame can insulate the carrier's roll motion and the inner frame can simultaneously achieve the rotary modulation on the basis of insulating the heading motion. The results of turntable experiments indicate that the navigation performance of dual-axis RINS has been significantly improved over the traditional method, which could still be maintained even with large FOG installation errors and scale factor errors, proving that the proposed method can relax the requirements for the accuracy of FOG-related errors.

Autobiographical memory conjunction errors in younger and older adults: Evidence for a role of inhibitory ability

PubMed Central

Devitt, Aleea L.; Tippett, Lynette; Schacter, Daniel L.; Addis, Donna Rose

2016-01-01

Because of its reconstructive nature, autobiographical memory (AM) is subject to a range of distortions. One distortion involves the erroneous incorporation of features from one episodic memory into another, forming what are known as memory conjunction errors. Healthy aging has been associated with an enhanced susceptibility to conjunction errors for laboratory stimuli, yet it is unclear whether these findings translate to the autobiographical domain. We investigated the impact of aging on vulnerability to AM conjunction errors, and explored potential cognitive processes underlying the formation of these errors. An imagination recombination paradigm was used to elicit AM conjunction errors in young and older adults. Participants also completed a battery of neuropsychological tests targeting relational memory and inhibition ability. Consistent with findings using laboratory stimuli, older adults were more susceptible to AM conjunction errors than younger adults. However, older adults were not differentially vulnerable to the inflating effects of imagination. Individual variation in AM conjunction error vulnerability was attributable to inhibitory capacity. An inability to suppress the cumulative familiarity of individual AM details appears to contribute to the heightened formation of AM conjunction errors with age. PMID:27929343

Reliable estimation of orbit errors in spaceborne SAR interferometry. The network approach

NASA Astrophysics Data System (ADS)

Bähr, Hermann; Hanssen, Ramon F.

2012-12-01

An approach to improve orbital state vectors by orbit error estimates derived from residual phase patterns in synthetic aperture radar interferograms is presented. For individual interferograms, an error representation by two parameters is motivated: the baseline error in cross-range and the rate of change of the baseline error in range. For their estimation, two alternatives are proposed: a least squares approach that requires prior unwrapping and a less reliable gridsearch method handling the wrapped phase. In both cases, reliability is enhanced by mutual control of error estimates in an overdetermined network of linearly dependent interferometric combinations of images. Thus, systematic biases, e.g., due to unwrapping errors, can be detected and iteratively eliminated. Regularising the solution by a minimum-norm condition results in quasi-absolute orbit errors that refer to particular images. For the 31 images of a sample ENVISAT dataset, orbit corrections with a mutual consistency on the millimetre level have been inferred from 163 interferograms. The method itself qualifies by reliability and rigorous geometric modelling of the orbital error signal but does not consider interfering large scale deformation effects. However, a separation may be feasible in a combined processing with persistent scatterer approaches or by temporal filtering of the estimates.

A Parallel Decoding Algorithm for Short Polar Codes Based on Error Checking and Correcting

PubMed Central

Pan, Xiaofei; Pan, Kegang; Ye, Zhan; Gong, Chao

2014-01-01

We propose a parallel decoding algorithm based on error checking and correcting to improve the performance of the short polar codes. In order to enhance the error-correcting capacity of the decoding algorithm, we first derive the error-checking equations generated on the basis of the frozen nodes, and then we introduce the method to check the errors in the input nodes of the decoder by the solutions of these equations. In order to further correct those checked errors, we adopt the method of modifying the probability messages of the error nodes with constant values according to the maximization principle. Due to the existence of multiple solutions of the error-checking equations, we formulate a CRC-aided optimization problem of finding the optimal solution with three different target functions, so as to improve the accuracy of error checking. Besides, in order to increase the throughput of decoding, we use a parallel method based on the decoding tree to calculate probability messages of all the nodes in the decoder. Numerical results show that the proposed decoding algorithm achieves better performance than that of some existing decoding algorithms with the same code length. PMID:25540813

A Study on Mutil-Scale Background Error Covariances in 3D-Var Data Assimilation

NASA Astrophysics Data System (ADS)

Zhang, Xubin; Tan, Zhe-Min

2017-04-01

The construction of background error covariances is a key component of three-dimensional variational data assimilation. There are different scale background errors and interactions among them in the numerical weather Prediction. However, the influence of these errors and their interactions cannot be represented in the background error covariances statistics when estimated by the leading methods. So, it is necessary to construct background error covariances influenced by multi-scale interactions among errors. With the NMC method, this article firstly estimates the background error covariances at given model-resolution scales. And then the information of errors whose scales are larger and smaller than the given ones is introduced respectively, using different nesting techniques, to estimate the corresponding covariances. The comparisons of three background error covariances statistics influenced by information of errors at different scales reveal that, the background error variances enhance particularly at large scales and higher levels when introducing the information of larger-scale errors by the lateral boundary condition provided by a lower-resolution model. On the other hand, the variances reduce at medium scales at the higher levels, while those show slight improvement at lower levels in the nested domain, especially at medium and small scales, when introducing the information of smaller-scale errors by nesting a higher-resolution model. In addition, the introduction of information of larger- (smaller-) scale errors leads to larger (smaller) horizontal and vertical correlation scales of background errors. Considering the multivariate correlations, the Ekman coupling increases (decreases) with the information of larger- (smaller-) scale errors included, whereas the geostrophic coupling in free atmosphere weakens in both situations. The three covariances obtained in above work are used in a data assimilation and model forecast system respectively, and then the analysis-forecast cycles for a period of 1 month are conducted. Through the comparison of both analyses and forecasts from this system, it is found that the trends for variation in analysis increments with information of different scale errors introduced are consistent with those for variation in variances and correlations of background errors. In particular, introduction of smaller-scale errors leads to larger amplitude of analysis increments for winds at medium scales at the height of both high- and low- level jet. And analysis increments for both temperature and humidity are greater at the corresponding scales at middle and upper levels under this circumstance. These analysis increments improve the intensity of jet-convection system which includes jets at different levels and coupling between them associated with latent heat release, and these changes in analyses contribute to the better forecasts for winds and temperature in the corresponding areas. When smaller-scale errors are included, analysis increments for humidity enhance significantly at large scales at lower levels to moisten southern analyses. This humidification devotes to correcting dry bias there and eventually improves forecast skill of humidity. Moreover, inclusion of larger- (smaller-) scale errors is beneficial for forecast quality of heavy (light) precipitation at large (small) scales due to the amplification (diminution) of intensity and area in precipitation forecasts but tends to overestimate (underestimate) light (heavy) precipitation .

An FEC Adaptive Multicast MAC Protocol for Providing Reliability in WLANs

NASA Astrophysics Data System (ADS)

Basalamah, Anas; Sato, Takuro

For wireless multicast applications like multimedia conferencing, voice over IP and video/audio streaming, a reliable transmission of packets within short delivery delay is needed. Moreover, reliability is crucial to the performance of error intolerant applications like file transfer, distributed computing, chat and whiteboard sharing. Forward Error Correction (FEC) is frequently used in wireless multicast to enhance Packet Error Rate (PER) performance, but cannot assure full reliability unless coupled with Automatic Repeat Request forming what is knows as Hybrid-ARQ. While reliable FEC can be deployed at different levels of the protocol stack, it cannot be deployed on the MAC layer of the unreliable IEEE802.11 WLAN due to its inability to exchange ACKs with multiple recipients. In this paper, we propose a Multicast MAC protocol that enhances WLAN reliability by using Adaptive FEC and study it's performance through mathematical analysis and simulation. Our results show that our protocol can deliver high reliability and throughput performance.

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.

Heterogeneous reactions of HNO3(g) + NaCl(s) yields HCl(g) + NaNO3(s) and N2O5(g) + NaCl(s) yields ClNO2(g) + NaNO3(s)

NASA Technical Reports Server (NTRS)

Leu, Ming-Taun; Timonen, Raimo S.; Keyser, Leon F.; Yung, Yuk L.

1995-01-01

The heterogeneous reactions of HNO3(g) + NaCl(s) yields HCl(g) + NaNO3(s) (eq 1) and N2O5(g) + NaCl(s) yields ClNO2(g) + NaNO3(S) (eq 2) were investigated over the temperature range 223-296 K in a flow-tube reactor coupled to a quadrupole mass spectrometer. Either a chemical ionization mass spectrometer (CIMS) or an electron-impact ionization mass spectrometer (EIMS) was used to provide suitable detection sensitivity and selectivity. In order to mimic atmospheric conditions, partial pressures of HNO3 and N2O5 in the range 6 x 10(exp -8) - 2 x 10(exp -6) Torr were used. Granule sizes and surface roughness of the solid NaCl substrates were determined by using a scanning electron microscope. For dry NaCl substrates, decay rates of HNO3 were used to obtain gamma(1) = 0.013 +/- 0.004 (1sigma) at 296 K and > 0.008 at 223 K, respectively. The error quoted is the statistical error. After all corrections were made, the overall error, including systematic error, was estimated to be about a factor of 2. HCl was found to be the sole gas-phase product of reaction 1. The mechanism changed from heterogeneous reaction to predominantly physical adsorption when the reactor was cooled from 296 to 223 K. For reaction 2 using dry salts, gamma(2) was found to be less than 1.0 x 10(exp -4) at both 223 and 296 K. The gas-phase reaction product was identified as ClNO2 in previous studies using an infrared spectrometer. An enhancement in reaction probability was observed if water was not completely removed from salt surfaces, probably due to the reaction of N2O5(g) + H2O(s) yields 2HNO3(g). Our results are compared with previous literature values obtained using different experimental techniques and conditions. The implications of the present results for the enhancement of the hydrogen chloride column density in the lower stratosphere after the El Chichon volcanic eruption and for the chemistry of HCl and HNO3 in the marine troposphere are discussed.

Advanced Outage and Control Center: Strategies for Nuclear Plant Outage Work Status Capabilities

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

Gregory Weatherby

The research effort is a part of the Light Water Reactor Sustainability (LWRS) Program. LWRS is a research and development program sponsored by the Department of Energy, performed in close collaboration with industry to provide the technical foundations for licensing and managing the long-term, safe and economical operation of current nuclear power plants. The LWRS Program serves to help the US nuclear industry adopt new technologies and engineering solutions that facilitate the continued safe operation of the plants and extension of the current operating licenses. The Outage Control Center (OCC) Pilot Project was directed at carrying out the applied researchmore » for development and pilot of technology designed to enhance safe outage and maintenance operations, improve human performance and reliability, increase overall operational efficiency, and improve plant status control. Plant outage management is a high priority concern for the nuclear industry from cost and safety perspectives. Unfortunately, many of the underlying technologies supporting outage control are the same as those used in the 1980’s. They depend heavily upon large teams of staff, multiple work and coordination locations, and manual administrative actions that require large amounts of paper. Previous work in human reliability analysis suggests that many repetitive tasks, including paper work tasks, may have a failure rate of 1.0E-3 or higher (Gertman, 1996). With between 10,000 and 45,000 subtasks being performed during an outage (Gomes, 1996), the opportunity for human error of some consequence is a realistic concern. Although a number of factors exist that can make these errors recoverable, reducing and effectively coordinating the sheer number of tasks to be performed, particularly those that are error prone, has the potential to enhance outage efficiency and safety. Additionally, outage management requires precise coordination of work groups that do not always share similar objectives. Outage managers are concerned with schedule and cost, union workers are concerned with performing work that is commensurate with their trade, and support functions (safety, quality assurance, and radiological controls, etc.) are concerned with performing the work within the plants controls and procedures. Approaches to outage management should be designed to increase the active participation of work groups and managers in making decisions that closed the gap between competing objectives and the potential for error and process inefficiency.« less

Learning and mastery behaviours as risk factors to abandonment in a paediatric user of advanced single-switch access technology.

PubMed

Brian, Leung; Jessica A, Brian; Tom, Chau

2013-09-01

The present descriptive case study documents the behaviours of a child single-switch user in the community setting and draws attention to learning and mastery behaviours as risk factors to single-switch abandonment. Our observations were interpreted in the context of a longer term school-based evaluation of an advanced single-switch access technology with a nine year-old user with severe spastic quadriplegic cerebral palsy. The child completed 25 experiment sessions averaging a rate of three sessions every two weeks. During each session he worked on several blocks of single-switch computer activity using his vocal cord vibration switch. Despite high levels of single-switch sensitivity and specificity that suggested a good fit between the participant and the technology, the participant perceived a lower proficiency level of his own abilities, demonstrated impatience and intolerance to interaction errors, and was apprehensive of making mistakes when using his switch in public. The benefit of gaining some degree of independent physical access might not necessarily enhance resilience to interaction errors or bouts of poor task performance. On the other hand, the participant's behaviours were consistent with those of a typically developing child learning or mastering any new skill or task. Implications for Rehabilitation The attitude and behaviour of a paediatric switch user towards skill development can be risk factors to abandonment of an access technology, despite successful clinical trial with the device. Children with severe disabilities can be associated with the same types of skill development behaviour patterns and achievement motivation as their typically developing peers. Empirical observations of the case participant's switch use behaviours suggest that user training could be adaptive in order to account for individual differences in skill development and achievement motivation.

A Theory of False Cognitive Expectancies in Airline Pilots

NASA Astrophysics Data System (ADS)

Cortes, Antonio I.

The Theory of False Cognitive Expectancies was developed by studying high reliability flight operations. Airline pilots depend extensively on cognitive expectancies to perceive, understand, and predict actions and events. Out of 1,363 incident reports submitted by airline pilots to the National Aeronautics and Space Administration Aviation Safety Reporting System over a year's time, 110 reports were found to contain evidence of 127 false cognitive expectancies in pilots. A comprehensive taxonomy was developed with six categories of interest. The dataset of 127 false expectancies was used to initially code tentative taxon values for each category. Intermediate coding through constant comparative analysis completed the taxonomy. The taxonomy was used for the advanced coding of chronological context-dependent visualizations of expectancy factors, known as strands, which depict the major factors in the creation and propagation of each expectancy. Strands were mapped into common networks to detect highly represented expectancy processes. Theoretical integration established 11 sources of false expectancies, the most common expectancy errors, and those conspicuous factors worthy of future study. The most prevalent source of false cognitive expectancies within the dataset was determined to be unconscious individual modeling based on past events. Integrative analyses also revealed relationships between expectancies and flight deck automation, unresolved discrepancies, and levels of situation awareness. Particularly noteworthy were the findings that false expectancies can combine in three possible permutations to diminish situation awareness and examples of how false expectancies can be unwittingly transmitted from one person to another. The theory resulting from this research can enhance the error coding process used during aircraft line oriented safety audits, lays the foundation for developing expectancy management training programs, and will allow researchers to proffer hypotheses for human testing using flight simulators.

Five-Year Incidence of Visual Impairment in Middle-Aged Iranians: The Shahroud Eye Cohort Study.

PubMed

Hashemi, Hassan; Mehravaran, Shiva; Emamian, Mohammad Hassan; Fotouhi, Akbar

2017-02-01

To study the 5-year incidence of visual impairment and its causes and risk factors, in the middle-aged Iranian sample of the Shahroud Eye Cohort Study (ShECS). Data from subjects who had participated in both phases of the ShECS were used to determine age- and sex-specific incidence rates of visual impairment using the World Health Organization (WHO) definitions for bilateral low vision (visual acuity, VA, >0.5 and ≤1.3 LogMAR in the better eye) and blindness (VA worse than 1.3 LogMAR in the better eye). Risk ratios (RR) and 95% confidence intervals (CIs) were calculated using multivariable log-binomial regression. Of the 5079 ShECS I survivors, 4737 (93.3%) completed the 5-year follow-up. Their mean age at baseline was 50.9 ± 6.2 years, and 58.9% were female. The incidence of visual impairment was 1.12% (95% CI 0.82-1.42%) by presenting VA and 0.19% (95% CI 0.07-0.32%) by best-corrected VA; leading causes of the former were uncorrected refractive error (81.3%) and diabetic retinopathy (15.1%). In the multivariable model, risk factors for incident visual impairment by presenting VA were older age (RR 1.05, p = 0.044), lower education (RR 0.89, p = 0.002), and diabetes (RR 3.74, p < 0.001). This is the first incidence study of visual impairment in a middle-aged Iranian population. Since age is a major risk factor, the number of visually impaired is expected to increase as the population ages, and less treatable causes such as diabetic retinopathy begin to surface. Measures for tackling uncorrected refractive error and enhancing diabetes screening and preventive programs are recommended.

Factors influencing a nurse's decision to question medication administration in a neonatal clinical care unit.

PubMed

Aydon, Laurene; Hauck, Yvonne; Zimmer, Margo; Murdoch, Jamee

2016-09-01

The aim of this study was to identify factors that influence nurse's decisions to question concerning aspects of medication administration within the context of a neonatal clinical care unit. Medication error in the neonatal setting can be high with this particularly vulnerable population. As the care giver responsible for medication administration, nurses are deemed accountable for most errors. However, they are recognised as the forefront of prevention. Minimal evidence is available around reasoning, decision making and questioning around medication administration. Therefore, this study focuses upon addressing the gap in knowledge around what nurses believe influences their decision to question. A critical incident design was employed where nurses were asked to describe clinical incidents around their decision to question a medication issue. Nurses were recruited from a neonatal clinical care unit and participated in an individual digitally recorded interview. One hundred and three nurses participated between December 2013-August 2014. Use of the constant comparative method revealed commonalities within transcripts. Thirty-six categories were grouped into three major themes: 'Working environment', 'Doing the right thing' and 'Knowledge about medications'. Findings highlight factors that influence nurses' decision to question issues around medication administration. Nurses feel it is their responsibility to do the right thing and speak up for their vulnerable patients to enhance patient safety. Negative dimensions within the themes will inform planning of educational strategies to improve patient safety, whereas positive dimensions must be reinforced within the multidisciplinary team. The working environment must support nurses to question and ultimately provide safe patient care. Clear and up to date policies, formal and informal education, role modelling by senior nurses, effective use of communication skills and a team approach can facilitate nurses to appropriately question aspects around medication administration. © 2016 John Wiley & Sons Ltd.

An optimized OPC and MDP flow for reducing mask write time and mask cost

NASA Astrophysics Data System (ADS)

Yang, Ellyn; Li, Cheng He; Park, Se Jin; Zhu, Yu; Guo, Eric

2010-09-01

In the process of optical proximity correction, layout edge or fragment is migrating to proper position in order to minimize edge placement error (EPE). During this fragment migration, several factors other than EPE can be also taken into account as a part of cost function for optimal fragment displacement. Several factors are devised in favor of OPC stability, which can accommodate room for high mask error enhancement factor (MEEF), lack of process window, catastrophic pattern failure such as pinch/bridge and improper fragmentation. As technology node becomes finer, there happens conflict between OPC accuracy and stability. Especially for metal layers, OPC has focused on the stability by loss of accurate OPC results. On this purpose, several techniques have been introduced, which are target smoothing, process window aware OPC, model-based retargeting and adaptive OPC. By utilizing those techniques, OPC enables more stabilized patterning, instead of realizing design target exactly on wafer. Inevitably, post-OPC layouts become more complicated because those techniques invoke additional edge, or fragments prior to correction or during OPC iteration. As a result, jogs of post OPC layer can be dramatically increased, which results in huge number of shot count after data fracturing. In other words, there is trade-off relationship between data complexity and various methods for OPC stability. In this paper, those relationships have been investigated with respect to several technology nodes. The mask shot count reduction is achieved by reducing the number of jogs with which EPE difference are within pre-specified value. The effect of jog smoothing on OPC output - in view of OPC performance and mask data preparation - was studied quantitatively for respective technology nodes.

Predicting Coastal Flood Severity using Random Forest Algorithm

NASA Astrophysics Data System (ADS)

Sadler, J. M.; Goodall, J. L.; Morsy, M. M.; Spencer, K.

2017-12-01

Coastal floods have become more common recently and are predicted to further increase in frequency and severity due to sea level rise. Predicting floods in coastal cities can be difficult due to the number of environmental and geographic factors which can influence flooding events. Built stormwater infrastructure and irregular urban landscapes add further complexity. This paper demonstrates the use of machine learning algorithms in predicting street flood occurrence in an urban coastal setting. The model is trained and evaluated using data from Norfolk, Virginia USA from September 2010 - October 2016. Rainfall, tide levels, water table levels, and wind conditions are used as input variables. Street flooding reports made by city workers after named and unnamed storm events, ranging from 1-159 reports per event, are the model output. Results show that Random Forest provides predictive power in estimating the number of flood occurrences given a set of environmental conditions with an out-of-bag root mean squared error of 4.3 flood reports and a mean absolute error of 0.82 flood reports. The Random Forest algorithm performed much better than Poisson regression. From the Random Forest model, total daily rainfall was by far the most important factor in flood occurrence prediction, followed by daily low tide and daily higher high tide. The model demonstrated here could be used to predict flood severity based on forecast rainfall and tide conditions and could be further enhanced using more complete street flooding data for model training.

Genomic Prediction Accounting for Residual Heteroskedasticity

PubMed Central

Ou, Zhining; Tempelman, Robert J.; Steibel, Juan P.; Ernst, Catherine W.; Bates, Ronald O.; Bello, Nora M.

2015-01-01

Whole-genome prediction (WGP) models that use single-nucleotide polymorphism marker information to predict genetic merit of animals and plants typically assume homogeneous residual variance. However, variability is often heterogeneous across agricultural production systems and may subsequently bias WGP-based inferences. This study extends classical WGP models based on normality, heavy-tailed specifications and variable selection to explicitly account for environmentally-driven residual heteroskedasticity under a hierarchical Bayesian mixed-models framework. WGP models assuming homogeneous or heterogeneous residual variances were fitted to training data generated under simulation scenarios reflecting a gradient of increasing heteroskedasticity. Model fit was based on pseudo-Bayes factors and also on prediction accuracy of genomic breeding values computed on a validation data subset one generation removed from the simulated training dataset. Homogeneous vs. heterogeneous residual variance WGP models were also fitted to two quantitative traits, namely 45-min postmortem carcass temperature and loin muscle pH, recorded in a swine resource population dataset prescreened for high and mild residual heteroskedasticity, respectively. Fit of competing WGP models was compared using pseudo-Bayes factors. Predictive ability, defined as the correlation between predicted and observed phenotypes in validation sets of a five-fold cross-validation was also computed. Heteroskedastic error WGP models showed improved model fit and enhanced prediction accuracy compared to homoskedastic error WGP models although the magnitude of the improvement was small (less than two percentage points net gain in prediction accuracy). Nevertheless, accounting for residual heteroskedasticity did improve accuracy of selection, especially on individuals of extreme genetic merit. PMID:26564950

Human error in aviation operations

NASA Technical Reports Server (NTRS)

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

1974-01-01

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

Development of a Template Lesson Plan Based on 5e Model Enhanced with Computer Supported Applications and Conceptual Change Texts

ERIC Educational Resources Information Center

Seker, Burcu Sezginsoy; Erdem, Aliye

2017-01-01

Students learning a defined subject only perform by learning of thinking based on the concepts forming that subjects. Otherwise, students may move away from the scientific meaning of concepts and may fall into conceptual errors. Students' conceptual errors affect their following learning and cause them resist change. It is possible to prevent this…

SAMPLING DISTRIBUTIONS OF ERROR IN MULTIDIMENSIONAL SCALING.

ERIC Educational Resources Information Center

STAKE, ROBERT E.; AND OTHERS

AN EMPIRICAL STUDY WAS MADE OF THE ERROR FACTORS IN MULTIDIMENSIONAL SCALING (MDS) TO REFINE THE USE OF MDS FOR MORE EXPERT MANIPULATION OF SCALES USED IN EDUCATIONAL MEASUREMENT. THE PURPOSE OF THE RESEARCH WAS TO GENERATE TABLES OF THE SAMPLING DISTRIBUTIONS THAT ARE NECESSARY FOR DISCRIMINATING BETWEEN ERROR AND NONERROR MDS DIMENSIONS. THE…

Analysis of case-only studies accounting for genotyping error.

PubMed

Cheng, K F

2007-03-01

The case-only design provides one approach to assess possible interactions between genetic and environmental factors. It has been shown that if these factors are conditionally independent, then a case-only analysis is not only valid but also very efficient. However, a drawback of the case-only approach is that its conclusions may be biased by genotyping errors. In this paper, our main aim is to propose a method for analysis of case-only studies when these errors occur. We show that the bias can be adjusted through the use of internal validation data, which are obtained by genotyping some sampled individuals twice. Our analysis is based on a simple and yet highly efficient conditional likelihood approach. Simulation studies considered in this paper confirm that the new method has acceptable performance under genotyping errors.

Theta EEG dynamics of the error-related negativity.

PubMed

Trujillo, Logan T; Allen, John J B

2007-03-01

The error-related negativity (ERN) is a response-locked brain potential (ERP) occurring 80-100ms following response errors. This report contrasts three views of the genesis of the ERN, testing the classic view that time-locked phasic bursts give rise to the ERN against the view that the ERN arises from a pure phase-resetting of ongoing theta (4-7Hz) EEG activity and the view that the ERN is generated - at least in part - by a phase-resetting and amplitude enhancement of ongoing theta EEG activity. Time-domain ERP analyses were augmented with time-frequency investigations of phase-locked and non-phase-locked spectral power, and inter-trial phase coherence (ITPC) computed from individual EEG trials, examining time courses and scalp topographies. Simulations based on the assumptions of the classic, pure phase-resetting, and phase-resetting plus enhancement views, using parameters from each subject's empirical data, were used to contrast the time-frequency findings that could be expected if one or more of these hypotheses adequately modeled the data. Error responses produced larger amplitude activity than correct responses in time-domain ERPs immediately following responses, as expected. Time-frequency analyses revealed that significant error-related post-response increases in total spectral power (phase- and non-phase-locked), phase-locked power, and ITPC were primarily restricted to the theta range, with this effect located over midfrontocentral sites, with a temporal distribution from approximately 150-200ms prior to the button press and persisting up to 400ms post-button press. The increase in non-phase-locked power (total power minus phase-locked power) was larger than phase-locked power, indicating that the bulk of the theta event-related dynamics were not phase-locked to response. Results of the simulations revealed a good fit for data simulated according to the phase-locking with amplitude enhancement perspective, and a poor fit for data simulated according to the classic view and the pure phase-resetting view. Error responses produce not only phase-locked increases in theta EEG activity, but also increases in non-phase-locked theta, both of which share a similar topography. The findings are thus consistent with the notion advanced by Luu et al. [Luu P, Tucker DM, Makeig S. Frontal midline theta and the error-related negativity; neurophysiological mechanisms of action regulation. Clin Neurophysiol 2004;115:1821-35] that the ERN emerges, at least in part, from a phase-resetting and phase-locking of ongoing theta-band activity, in the context of a general increase in theta power following errors.

Human factors in aircraft incidents - Results of a 7-year study (Andre Allard Memorial Lecture)

NASA Technical Reports Server (NTRS)

Billings, C. E.; Reynard, W. D.

1984-01-01

It is pointed out that nearly all fatal aircraft accidents are preventable, and that most such accidents are due to human error. The present discussion is concerned with the results of a seven-year study of the data collected by the NASA Aviation Safety Reporting System (ASRS). The Aviation Safety Reporting System was designed to stimulate as large a flow as possible of information regarding errors and operational problems in the conduct of air operations. It was implemented in April, 1976. In the following 7.5 years, 35,000 reports have been received from pilots, controllers, and the armed forces. Human errors are found in more than 80 percent of these reports. Attention is given to the types of events reported, possible causal factors in incidents, the relationship of incidents and accidents, and sources of error in the data. ASRS reports include sufficient detail to permit authorities to institute changes in the national aviation system designed to minimize the likelihood of human error, and to insulate the system against the effects of errors.

Neural evidence for enhanced error detection in major depressive disorder.

PubMed

Chiu, Pearl H; Deldin, Patricia J

2007-04-01

Anomalies in error processing have been implicated in the etiology and maintenance of major depressive disorder. In particular, depressed individuals exhibit heightened sensitivity to error-related information and negative environmental cues, along with reduced responsivity to positive reinforcers. The authors examined the neural activation associated with error processing in individuals diagnosed with and without major depression and the sensitivity of these processes to modulation by monetary task contingencies. The error-related negativity and error-related positivity components of the event-related potential were used to characterize error monitoring in individuals with major depressive disorder and the degree to which these processes are sensitive to modulation by monetary reinforcement. Nondepressed comparison subjects (N=17) and depressed individuals (N=18) performed a flanker task under two external motivation conditions (i.e., monetary reward for correct responses and monetary loss for incorrect responses) and a nonmonetary condition. After each response, accuracy feedback was provided. The error-related negativity component assessed the degree of anomaly in initial error detection, and the error positivity component indexed recognition of errors. Across all conditions, the depressed participants exhibited greater amplitude of the error-related negativity component, relative to the comparison subjects, and equivalent error positivity amplitude. In addition, the two groups showed differential modulation by task incentives in both components. These data implicate exaggerated early error-detection processes in the etiology and maintenance of major depressive disorder. Such processes may then recruit excessive neural and cognitive resources that manifest as symptoms of depression.

Enhanced Optical Head Tracking for Cranial Radiation Therapy: Supporting Surface Registration by Cutaneous Structures

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

Wissel, Tobias, E-mail: wissel@rob.uni-luebeck.de; Graduate School for Computing in Medicine and Life Science, University of Lübeck, Lübeck; Stüber, Patrick

2016-06-01

Purpose: To support surface registration in cranial radiation therapy by structural information. The risk for spatial ambiguities is minimized by using tissue thickness variations predicted from backscattered near-infrared (NIR) light from the forehead. Methods and Materials: In a pilot study we recorded NIR surface scans by laser triangulation from 30 volunteers of different skin type. A ground truth for the soft-tissue thickness was segmented from MR scans. After initially matching the NIR scans to the MR reference, Gaussian processes were trained to predict tissue thicknesses from NIR backscatter. Moreover, motion starting from this initial registration was simulated by 5000 randommore » transformations of the NIR scan away from the MR reference. Re-registration to the MR scan was compared with and without tissue thickness support. Results: By adding prior knowledge to the backscatter features, such as incident angle and neighborhood information in the scanning grid, we showed that tissue thickness can be predicted with mean errors of <0.2 mm, irrespective of the skin type. With this additional information, the average registration error improved from 3.4 mm to 0.48 mm by a factor of 7. Misalignments of more than 1 mm were almost thoroughly (98.9%) pushed below 1 mm. Conclusions: For almost all cases tissue-enhanced matching achieved better results than purely spatial registration. Ambiguities can be minimized if the cutaneous structures do not agree. This valuable support for surface registration increases tracking robustness and avoids misalignment of tumor targets far from the registration site.« less

An experimental evaluation of the incidence of fitness-function/search-algorithm combinations on the classification performance of myoelectric control systems with iPCA tuning

PubMed Central

2013-01-01

Background The information of electromyographic signals can be used by Myoelectric Control Systems (MCSs) to actuate prostheses. These devices allow the performing of movements that cannot be carried out by persons with amputated limbs. The state of the art in the development of MCSs is based on the use of individual principal component analysis (iPCA) as a stage of pre-processing of the classifiers. The iPCA pre-processing implies an optimization stage which has not yet been deeply explored. Methods The present study considers two factors in the iPCA stage: namely A (the fitness function), and B (the search algorithm). The A factor comprises two levels, namely A1 (the classification error) and A2 (the correlation factor). Otherwise, the B factor has four levels, specifically B1 (the Sequential Forward Selection, SFS), B2 (the Sequential Floating Forward Selection, SFFS), B3 (Artificial Bee Colony, ABC), and B4 (Particle Swarm Optimization, PSO). This work evaluates the incidence of each one of the eight possible combinations between A and B factors over the classification error of the MCS. Results A two factor ANOVA was performed on the computed classification errors and determined that: (1) the interactive effects over the classification error are not significative (F0.01,3,72 = 4.0659 > f AB  = 0.09), (2) the levels of factor A have significative effects on the classification error (F0.02,1,72 = 5.0162 < f A  = 6.56), and (3) the levels of factor B over the classification error are not significative (F0.01,3,72 = 4.0659 > f B  = 0.08). Conclusions Considering the classification performance we found a superiority of using the factor A2 in combination with any of the levels of factor B. With respect to the time performance the analysis suggests that the PSO algorithm is at least 14 percent better than its best competitor. The latter behavior has been observed for a particular configuration set of parameters in the search algorithms. Future works will investigate the effect of these parameters in the classification performance, such as length of the reduced size vector, number of particles and bees used during optimal search, the cognitive parameters in the PSO algorithm as well as the limit of cycles to improve a solution in the ABC algorithm. PMID:24369728

Confirmatory factor analysis reveals a latent cognitive structure common to bipolar disorder, schizophrenia, and normal controls.

PubMed

Schretlen, David J; Peña, Javier; Aretouli, Eleni; Orue, Izaskun; Cascella, Nicola G; Pearlson, Godfrey D; Ojeda, Natalia

2013-06-01

We sought to determine whether a single hypothesized latent factor structure would characterize cognitive functioning in three distinct groups. We assessed 576 adults (340 community controls, 126 adults with bipolar disorder, and 110 adults with schizophrenia) using 15 measures derived from nine cognitive tests. Confirmatory factor analysis (CFA) was conducted to examine the fit of a hypothesized six-factor model. The hypothesized factors included attention, psychomotor speed, verbal memory, visual memory, ideational fluency, and executive functioning. The six-factor model provided an excellent fit for all three groups [for community controls, root mean square error of approximation (RMSEA) <0.048 and comparative fit index (CFI) = 0.99; for adults with bipolar disorder, RMSEA = 0.071 and CFI = 0.99; and for adults with schizophrenia, RMSEA = 0.06 and CFI = 0.98]. Alternate models that combined fluency with processing speed or verbal and visual memory reduced the goodness of fit. Multi-group CFA results supported factor invariance across the three groups. Confirmatory factor analysis supported a single six-factor structure of cognitive functioning among patients with schizophrenia or bipolar disorder and community controls. While the three groups clearly differ in level of performance, they share a common underlying architecture of information processing abilities. These cognitive factors could provide useful targets for clinical trials of treatments that aim to enhance information processing in persons with neurological and neuropsychiatric disorders. © 2013 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.

Laser damage metrology in biaxial nonlinear crystals using different test beams

NASA Astrophysics Data System (ADS)

Hildenbrand, Anne; Wagner, Frank R.; Akhouayri, Hassan; Natoli, Jean-Yves; Commandre, Mireille

2008-01-01

Laser damage measurements in nonlinear optical crystals, in particular in biaxial crystals, may be influenced by several effects proper to these materials or greatly enhanced in these materials. Before discussion of these effects, we address the topic of error bar determination for probability measurements. Error bars for the damage probabilities are important because nonlinear crystals are often small and expensive, thus only few sites are used for a single damage probability measurement. We present the mathematical basics and a flow diagram for the numerical calculation of error bars for probability measurements that correspond to a chosen confidence level. Effects that possibly modify the maximum intensity in a biaxial nonlinear crystal are: focusing aberration, walk-off and self-focusing. Depending on focusing conditions, propagation direction, polarization of the light and the position of the focus point in the crystal, strong aberrations may change the beam profile and drastically decrease the maximum intensity in the crystal. A correction factor for this effect is proposed, but quantitative corrections are not possible without taking into account the experimental beam profile after the focusing lens. The characteristics of walk-off and self-focusing have quickly been reviewed for the sake of completeness of this article. Finally, parasitic second harmonic generation may influence the laser damage behavior of crystals. The important point for laser damage measurements is that the amount of externally observed SHG after the crystal does not correspond to the maximum amount of second harmonic light inside the crystal.

Digital repeat analysis; setup and operation.

PubMed

Nol, J; Isouard, G; Mirecki, J

2006-06-01

Since the emergence of digital imaging, there have been questions about the necessity of continuing reject analysis programs in imaging departments to evaluate performance and quality. As a marketing strategy, most suppliers of digital technology focus on the supremacy of the technology and its ability to reduce the number of repeats, resulting in less radiation doses given to patients and increased productivity in the department. On the other hand, quality assurance radiographers and radiologists believe that repeats are mainly related to positioning skills, and repeat analysis is the main tool to plan training needs to up-skill radiographers. A comparative study between conventional and digital imaging was undertaken to compare outcomes and evaluate the need for reject analysis. However, digital technology still being at its early development stages, setting a credible reject analysis program became the major task of the study. It took the department, with the help of the suppliers of the computed radiography reader and the picture archiving and communication system, over 2 years of software enhancement to build a reliable digital repeat analysis system. The results were supportive of both philosophies; the number of repeats as a result of exposure factors was reduced dramatically; however, the percentage of repeats as a result of positioning skills was slightly on the increase for the simple reason that some rejects in the conventional system qualifying for both exposure and positioning errors were classified as exposure error. The ability of digitally adjusting dark or light images reclassified some of those images as positioning errors.

Effect of various digital processing algorithms on the measurement accuracy of endodontic file length.

PubMed

Kal, Betül Ilhan; Baksi, B Güniz; Dündar, Nesrin; Sen, Bilge Hakan

2007-02-01

The aim of this study was to compare the accuracy of endodontic file lengths after application of various image enhancement modalities. Endodontic files of three different ISO sizes were inserted in 20 single-rooted extracted permanent mandibular premolar teeth and standardized images were obtained. Original digital images were then enhanced using five processing algorithms. Six evaluators measured the length of each file on each image. The measurements from each processing algorithm and each file size were compared using repeated measures ANOVA and Bonferroni tests (P = 0.05). Paired t test was performed to compare the measurements with the true lengths of the files (P = 0.05). All of the processing algorithms provided significantly shorter measurements than the true length of each file size (P < 0.05). The threshold enhancement modality produced significantly higher mean error values (P < 0.05), while there was no significant difference among the other enhancement modalities (P > 0.05). Decrease in mean error value was observed with increasing file size (P < 0.05). Invert, contrast/brightness and edge enhancement algorithms may be recommended for accurate file length measurements when utilizing storage phosphor plates.

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

DTIC Science & Technology

2006-07-01

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

Data entry and error embedding system

NASA Technical Reports Server (NTRS)

Woo, Daniel N. (Inventor); Woo, Jr., John (Inventor)

1998-01-01

A data entry and error embedding system in which, first, a document is bitmapped and recorded in a first memory. Then, it is displayed, and portions of it to be replicated by data entry are underlayed by a window, into which window replicated data is entered in location and size such that it is juxtaposed just below that which is replicated, enhancing the accuracy of replication. Second, with this format in place, selected portions of the replicated data are altered by the insertion of character or word substitutions, thus the embedding of errors. Finally, a proofreader would endeavor to correct the error embedded data and a record of his or her changes recorded. In this manner, the skill level of the proofreader and accuracy of the data are computed.

Neurochemical enhancement of conscious error awareness.

PubMed

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

2012-02-22

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

[Risk and risk management in aviation].

PubMed

Müller, Manfred

2004-10-01

RISK MANAGEMENT: The large proportion of human errors in aviation accidents suggested the solution--at first sight brilliant--to replace the fallible human being by an "infallible" digitally-operating computer. However, even after the introduction of the so-called HITEC-airplanes, the factor human error still accounts for 75% of all accidents. Thus, if the computer is ruled out as the ultimate safety system, how else can complex operations involving quick and difficult decisions be controlled? OPTIMIZED TEAM INTERACTION/PARALLEL CONNECTION OF THOUGHT MACHINES: Since a single person is always "highly error-prone", support and control have to be guaranteed by a second person. The independent work of mind results in a safety network that more efficiently cushions human errors. NON-PUNITIVE ERROR MANAGEMENT: To be able to tackle the actual problems, the open discussion of intervened errors must not be endangered by the threat of punishment. It has been shown in the past that progress is primarily achieved by investigating and following up mistakes, failures and catastrophes shortly after they happened. HUMAN FACTOR RESEARCH PROJECT: A comprehensive survey showed the following result: By far the most frequent safety-critical situation (37.8% of all events) consists of the following combination of risk factors: 1. A complication develops. 2. In this situation of increased stress a human error occurs. 3. The negative effects of the error cannot be corrected or eased because there are deficiencies in team interaction on the flight deck. This means, for example, that a negative social climate has the effect of a "turbocharger" when a human error occurs. It needs to be pointed out that a negative social climate is not identical with a dispute. In many cases the working climate is burdened without the responsible person even noticing it: A first negative impression, too much or too little respect, contempt, misunderstandings, not expressing unclear concern, etc. can considerably reduce the efficiency of a team.