Sample records for error incidence rate
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Westbrook, Johanna I.; Li, Ling; Lehnbom, Elin C.; Baysari, Melissa T.; Braithwaite, Jeffrey; Burke, Rosemary; Conn, Chris; Day, Richard O.
2015-01-01
Objectives To (i) compare medication errors identified at audit and observation with medication incident reports; (ii) identify differences between two hospitals in incident report frequency and medication error rates; (iii) identify prescribing error detection rates by staff. Design Audit of 3291patient records at two hospitals to identify prescribing errors and evidence of their detection by staff. Medication administration errors were identified from a direct observational study of 180 nurses administering 7451 medications. Severity of errors was classified. Those likely to lead to patient harm were categorized as ‘clinically important’. Setting Two major academic teaching hospitals in Sydney, Australia. Main Outcome Measures Rates of medication errors identified from audit and from direct observation were compared with reported medication incident reports. Results A total of 12 567 prescribing errors were identified at audit. Of these 1.2/1000 errors (95% CI: 0.6–1.8) had incident reports. Clinically important prescribing errors (n = 539) were detected by staff at a rate of 218.9/1000 (95% CI: 184.0–253.8), but only 13.0/1000 (95% CI: 3.4–22.5) were reported. 78.1% (n = 421) of clinically important prescribing errors were not detected. A total of 2043 drug administrations (27.4%; 95% CI: 26.4–28.4%) contained ≥1 errors; none had an incident report. Hospital A had a higher frequency of incident reports than Hospital B, but a lower rate of errors at audit. Conclusions Prescribing errors with the potential to cause harm frequently go undetected. Reported incidents do not reflect the profile of medication errors which occur in hospitals or the underlying rates. This demonstrates the inaccuracy of using incident frequency to compare patient risk or quality performance within or across hospitals. New approaches including data mining of electronic clinical information systems are required to support more effective medication error detection and mitigation. PMID:25583702
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Westbrook, Johanna I; Li, Ling; Lehnbom, Elin C; Baysari, Melissa T; Braithwaite, Jeffrey; Burke, Rosemary; Conn, Chris; Day, Richard O
2015-02-01
To (i) compare medication errors identified at audit and observation with medication incident reports; (ii) identify differences between two hospitals in incident report frequency and medication error rates; (iii) identify prescribing error detection rates by staff. Audit of 3291 patient records at two hospitals to identify prescribing errors and evidence of their detection by staff. Medication administration errors were identified from a direct observational study of 180 nurses administering 7451 medications. Severity of errors was classified. Those likely to lead to patient harm were categorized as 'clinically important'. Two major academic teaching hospitals in Sydney, Australia. Rates of medication errors identified from audit and from direct observation were compared with reported medication incident reports. A total of 12 567 prescribing errors were identified at audit. Of these 1.2/1000 errors (95% CI: 0.6-1.8) had incident reports. Clinically important prescribing errors (n = 539) were detected by staff at a rate of 218.9/1000 (95% CI: 184.0-253.8), but only 13.0/1000 (95% CI: 3.4-22.5) were reported. 78.1% (n = 421) of clinically important prescribing errors were not detected. A total of 2043 drug administrations (27.4%; 95% CI: 26.4-28.4%) contained ≥ 1 errors; none had an incident report. Hospital A had a higher frequency of incident reports than Hospital B, but a lower rate of errors at audit. Prescribing errors with the potential to cause harm frequently go undetected. Reported incidents do not reflect the profile of medication errors which occur in hospitals or the underlying rates. This demonstrates the inaccuracy of using incident frequency to compare patient risk or quality performance within or across hospitals. New approaches including data mining of electronic clinical information systems are required to support more effective medication error detection and mitigation. © The Author 2015. Published by Oxford University Press in association with the International Society for Quality in Health Care.
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Kim, Myoung-Soo; Kim, Jung-Soon; Jung, In Sook; Kim, Young Hae; Kim, Ho Jung
2007-03-01
The purpose of this study was to develop and evaluate an error reporting promoting program(ERPP) to systematically reduce the incidence rate of nursing errors in operating room. A non-equivalent control group non-synchronized design was used. Twenty-six operating room nurses who were in one university hospital in Busan participated in this study. They were stratified into four groups according to their operating room experience and were allocated to the experimental and control groups using a matching method. Mann-Whitney U Test was used to analyze the differences pre and post incidence rates of nursing errors between the two groups. The incidence rate of nursing errors decreased significantly in the experimental group compared to the pre-test score from 28.4% to 15.7%. The incidence rate by domains, it decreased significantly in the 3 domains-"compliance of aseptic technique", "management of document", "environmental management" in the experimental group while it decreased in the control group which was applied ordinary error-reporting method. Error-reporting system can make possible to hold the errors in common and to learn from them. ERPP was effective to reduce the errors of recognition-related nursing activities. For the wake of more effective error-prevention, we will be better to apply effort of risk management along the whole health care system with this program.
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Application of human reliability analysis to nursing errors in hospitals.
Inoue, Kayoko; Koizumi, Akio
2004-12-01
Adverse events in hospitals, such as in surgery, anesthesia, radiology, intensive care, internal medicine, and pharmacy, are of worldwide concern and it is important, therefore, to learn from such incidents. There are currently no appropriate tools based on state-of-the art models available for the analysis of large bodies of medical incident reports. In this study, a new model was developed to facilitate medical error analysis in combination with quantitative risk assessment. This model enables detection of the organizational factors that underlie medical errors, and the expedition of decision making in terms of necessary action. Furthermore, it determines medical tasks as module practices and uses a unique coding system to describe incidents. This coding system has seven vectors for error classification: patient category, working shift, module practice, linkage chain (error type, direct threat, and indirect threat), medication, severity, and potential hazard. Such mathematical formulation permitted us to derive two parameters: error rates for module practices and weights for the aforementioned seven elements. The error rate of each module practice was calculated by dividing the annual number of incident reports of each module practice by the annual number of the corresponding module practice. The weight of a given element was calculated by the summation of incident report error rates for an element of interest. This model was applied specifically to nursing practices in six hospitals over a year; 5,339 incident reports with a total of 63,294,144 module practices conducted were analyzed. Quality assurance (QA) of our model was introduced by checking the records of quantities of practices and reproducibility of analysis of medical incident reports. For both items, QA guaranteed legitimacy of our model. Error rates for all module practices were approximately of the order 10(-4) in all hospitals. Three major organizational factors were found to underlie medical errors: "violation of rules" with a weight of 826 x 10(-4), "failure of labor management" with a weight of 661 x 10(-4), and "defects in the standardization of nursing practices" with a weight of 495 x 10(-4).
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DOE Office of Scientific and Technical Information (OSTI.GOV)
Arnold, Anthony, E-mail: anthony.arnold@sesiahs.health.nsw.gov.a; Delaney, Geoff P.; Cassapi, Lynette
Purpose: Radiotherapy is a common treatment for cancer patients. Although incidence of error is low, errors can be severe or affect significant numbers of patients. In addition, errors will often not manifest until long periods after treatment. This study describes the development of an incident reporting tool that allows categorical analysis and time trend reporting, covering first 3 years of use. Methods and Materials: A radiotherapy-specific incident analysis system was established. Staff members were encouraged to report actual errors and near-miss events detected at prescription, simulation, planning, or treatment phases of radiotherapy delivery. Trend reporting was reviewed monthly. Results: Reportsmore » were analyzed for the first 3 years of operation (May 2004-2007). A total of 688 reports was received during the study period. The actual error rate was 0.2% per treatment episode. During the study period, the actual error rates reduced significantly from 1% per year to 0.3% per year (p < 0.001), as did the total event report rates (p < 0.0001). There were 3.5 times as many near misses reported compared with actual errors. Conclusions: This system has allowed real-time analysis of events within a radiation oncology department to a reduced error rate through focus on learning and prevention from the near-miss reports. Plans are underway to develop this reporting tool for Australia and New Zealand.« less
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The incidence and severity of errors in pharmacist-written discharge medication orders.
Onatade, Raliat; Sawieres, Sara; Veck, Alexandra; Smith, Lindsay; Gore, Shivani; Al-Azeib, Sumiah
2017-08-01
Background Errors in discharge prescriptions are problematic. When hospital pharmacists write discharge prescriptions improvements are seen in the quality and efficiency of discharge. There is limited information on the incidence of errors in pharmacists' medication orders. Objective To investigate the extent and clinical significance of errors in pharmacist-written discharge medication orders. Setting 1000-bed teaching hospital in London, UK. Method Pharmacists in this London hospital routinely write discharge medication orders as part of the clinical pharmacy service. Convenient days, based on researcher availability, between October 2013 and January 2014 were selected. Pre-registration pharmacists reviewed all discharge medication orders written by pharmacists on these days and identified discrepancies between the medication history, inpatient chart, patient records and discharge summary. A senior clinical pharmacist confirmed the presence of an error. Each error was assigned a potential clinical significance rating (based on the NCCMERP scale) by a physician and an independent senior clinical pharmacist, working separately. Main outcome measure Incidence of errors in pharmacist-written discharge medication orders. Results 509 prescriptions, written by 51 pharmacists, containing 4258 discharge medication orders were assessed (8.4 orders per prescription). Ten prescriptions (2%), contained a total of ten erroneous orders (order error rate-0.2%). The pharmacist considered that one error had the potential to cause temporary harm (0.02% of all orders). The physician did not rate any of the errors with the potential to cause harm. Conclusion The incidence of errors in pharmacists' discharge medication orders was low. The quality, safety and policy implications of pharmacists routinely writing discharge medication orders should be further explored.
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Organizational safety culture and medical error reporting by Israeli nurses.
Kagan, Ilya; Barnoy, Sivia
2013-09-01
To investigate the association between patient safety culture (PSC) and the incidence and reporting rate of medical errors by Israeli nurses. Self-administered structured questionnaires were distributed to a convenience sample of 247 registered nurses enrolled in training programs at Tel Aviv University (response rate = 91%). The questionnaire's three sections examined the incidence of medication mistakes in clinical practice, the reporting rate for these errors, and the participants' views and perceptions of the safety culture in their workplace at three levels (organizational, departmental, and individual performance). Pearson correlation coefficients, t tests, and multiple regression analysis were used to analyze the data. Most nurses encountered medical errors from a daily to a weekly basis. Six percent of the sample never reported their own errors, while half reported their own errors "rarely or sometimes." The level of PSC was positively and significantly correlated with the error reporting rate. PSC, place of birth, error incidence, and not having an academic nursing degree were significant predictors of error reporting, together explaining 28% of variance. This study confirms the influence of an organizational safety climate on readiness to report errors. Senior healthcare executives and managers can make a major impact on safety culture development by creating and promoting a vision and strategy for quality and safety and fostering their employees' motivation to implement improvement programs at the departmental and individual level. A positive, carefully designed organizational safety culture can encourage error reporting by staff and so improve patient safety. © 2013 Sigma Theta Tau International.
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Families as Partners in Hospital Error and Adverse Event Surveillance
Khan, Alisa; Coffey, Maitreya; Litterer, Katherine P.; Baird, Jennifer D.; Furtak, Stephannie L.; Garcia, Briana M.; Ashland, Michele A.; Calaman, Sharon; Kuzma, Nicholas C.; O’Toole, Jennifer K.; Patel, Aarti; Rosenbluth, Glenn; Destino, Lauren A.; Everhart, Jennifer L.; Good, Brian P.; Hepps, Jennifer H.; Dalal, Anuj K.; Lipsitz, Stuart R.; Yoon, Catherine S.; Zigmont, Katherine R.; Srivastava, Rajendu; Starmer, Amy J.; Sectish, Theodore C.; Spector, Nancy D.; West, Daniel C.; Landrigan, Christopher P.
2017-01-01
IMPORTANCE Medical errors and adverse events (AEs) are common among hospitalized children. While clinician reports are the foundation of operational hospital safety surveillance and a key component of multifaceted research surveillance, patient and family reports are not routinely gathered. We hypothesized that a novel family-reporting mechanism would improve incident detection. OBJECTIVE To compare error and AE rates (1) gathered systematically with vs without family reporting, (2) reported by families vs clinicians, and (3) reported by families vs hospital incident reports. DESIGN, SETTING, AND PARTICIPANTS We conducted a prospective cohort study including the parents/caregivers of 989 hospitalized patients 17 years and younger (total 3902 patient-days) and their clinicians from December 2014 to July 2015 in 4 US pediatric centers. Clinician abstractors identified potential errors and AEs by reviewing medical records, hospital incident reports, and clinician reports as well as weekly and discharge Family Safety Interviews (FSIs). Two physicians reviewed and independently categorized all incidents, rating severity and preventability (agreement, 68%–90%; κ, 0.50–0.68). Discordant categorizations were reconciled. Rates were generated using Poisson regression estimated via generalized estimating equations to account for repeated measures on the same patient. MAIN OUTCOMES AND MEASURES Error and AE rates. RESULTS Overall, 746 parents/caregivers consented for the study. Of these, 717 completed FSIs. Their median (interquartile range) age was 32.5 (26–40) years; 380 (53.0%) were nonwhite, 566 (78.9%) were female, 603 (84.1%) were English speaking, and 380 (53.0%) had attended college. Of 717 parents/caregivers completing FSIs, 185 (25.8%) reported a total of 255 incidents, which were classified as 132 safety concerns (51.8%), 102 nonsafety-related quality concerns (40.0%), and 21 other concerns (8.2%). These included 22 preventable AEs (8.6%), 17 nonharmful medical errors (6.7%), and 11 nonpreventable AEs (4.3%) on the study unit. In total, 179 errors and 113 AEs were identified from all sources. Family reports included 8 otherwise unidentified AEs, including 7 preventable AEs. Error rates with family reporting (45.9 per 1000 patient-days) were 1.2-fold (95%CI, 1.1–1.2) higher than rates without family reporting (39.7 per 1000 patient-days). Adverse event rates with family reporting (28.7 per 1000 patient-days) were 1.1-fold (95%CI, 1.0–1.2; P=.006) higher than rates without (26.1 per 1000 patient-days). Families and clinicians reported similar rates of errors (10.0 vs 12.8 per 1000 patient-days; relative rate, 0.8; 95%CI, .5–1.2) and AEs (8.5 vs 6.2 per 1000 patient-days; relative rate, 1.4; 95%CI, 0.8–2.2). Family-reported error rates were 5.0-fold (95%CI, 1.9–13.0) higher and AE rates 2.9-fold (95% CI, 1.2–6.7) higher than hospital incident report rates. CONCLUSIONS AND RELEVANCE Families provide unique information about hospital safety and should be included in hospital safety surveillance in order to facilitate better design and assessment of interventions to improve safety. PMID:28241211
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Buckley, David; Bulger, David
2012-08-01
Studies on the rate of adverse events in hospitalized patients seldom examine temporal patterns. This study presents evidence of both weekly and annual cycles. The study is based on a large and diverse data set, with nearly 5 yrs of data from a voluntary staff-incident reporting system of a large public health care provider in rural southeastern Australia. The data of 63 health care facilities were included, ranging from large non-metropolitan hospitals to small community and aged health care facilities. Poisson regression incorporating an observation-driven autoregressive effect using the GLARMA framework was used to explain daily error counts with respect to long-term trend and weekly and annual effects, with procedural volume as an offset. The annual pattern was modeled using a first-order sinusoidal effect. The rate of errors reported demonstrated an increasing annual trend of 13.4% (95% confidence interval [CI] 10.6% to 16.3%); however, this trend was only significant for errors of minor or no harm to the patient. A strong "weekend effect" was observed. The incident rate ratio for the weekend versus weekdays was 2.74 (95% CI 2.55 to 2.93). The weekly pattern was consistent for incidents of all levels of severity, but it was more pronounced for less severe incidents. There was an annual cycle in the rate of incidents, the number of incidents peaking in October, on the 282 nd day of the year (spring in Australia), with an incident rate ratio 1.09 (95% CI 1.05 to 1.14) compared to the annual mean. There was no so-called "killing season" or "July effect," as the peak in incident rate was not related to the commencement of work by new medical school graduates. The major finding of this study is the rate of adverse events is greater on weekends and during spring. The annual pattern appears to be unrelated to the commencement of new graduates and potentially results from seasonal variation in the case mix of patients or the health of the medical workforce that alters health care performance. These mechanisms will need to be elucidated with further research.
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The Relationship between the Level of Nurse Staffing and Nursing Incidents
1992-01-01
1990). Nosocomial infection rates during a one-year period in a nursing home care unit of a Veterans Administration hospital. American Journal of...of Nursing Administration 18(7,8), 24-28. Hoffman, N., Jenkins, R., & Putney, K. (1990). Nosocomial infection rates during a one-year period in a...reported medication errors or treatment errors, falls, nosocomial infections , postpartum hemorrhages, IV-related incidents, blood and blood product
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Corrections of clinical chemistry test results in a laboratory information system.
Wang, Sihe; Ho, Virginia
2004-08-01
The recently released reports by the Institute of Medicine, To Err Is Human and Patient Safety, have received national attention because of their focus on the problem of medical errors. Although a small number of studies have reported on errors in general clinical laboratories, there are, to our knowledge, no reported studies that focus on errors in pediatric clinical laboratory testing. To characterize the errors that have caused corrections to have to be made in pediatric clinical chemistry results in the laboratory information system, Misys. To provide initial data on the errors detected in pediatric clinical chemistry laboratories in order to improve patient safety in pediatric health care. All clinical chemistry staff members were informed of the study and were requested to report in writing when a correction was made in the laboratory information system, Misys. Errors were detected either by the clinicians (the results did not fit the patients' clinical conditions) or by the laboratory technologists (the results were double-checked, and the worksheets were carefully examined twice a day). No incident that was discovered before or during the final validation was included. On each Monday of the study, we generated a report from Misys that listed all of the corrections made during the previous week. We then categorized the corrections according to the types and stages of the incidents that led to the corrections. A total of 187 incidents were detected during the 10-month study, representing a 0.26% error detection rate per requisition. The distribution of the detected incidents included 31 (17%) preanalytic incidents, 46 (25%) analytic incidents, and 110 (59%) postanalytic incidents. The errors related to noninterfaced tests accounted for 50% of the total incidents and for 37% of the affected tests and orderable panels, while the noninterfaced tests and panels accounted for 17% of the total test volume in our laboratory. This pilot study provided the rate and categories of errors detected in a pediatric clinical chemistry laboratory based on the corrections of results in the laboratory information system. A direct interface of the instruments to the laboratory information system showed that it had favorable effects on reducing laboratory errors.
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Oldland, Alan R.; May, Sondra K.; Barber, Gerard R.; Stolpman, Nancy M.
2015-01-01
Purpose: To measure the effects associated with sequential implementation of electronic medication storage and inventory systems and product verification devices on pharmacy technical accuracy and rates of potential medication dispensing errors in an academic medical center. Methods: During four 28-day periods of observation, pharmacists recorded all technical errors identified at the final visual check of pharmaceuticals prior to dispensing. Technical filling errors involving deviations from order-specific selection of product, dosage form, strength, or quantity were documented when dispensing medications using (a) a conventional unit dose (UD) drug distribution system, (b) an electronic storage and inventory system utilizing automated dispensing cabinets (ADCs) within the pharmacy, (c) ADCs combined with barcode (BC) verification, and (d) ADCs and BC verification utilized with changes in product labeling and individualized personnel training in systems application. Results: Using a conventional UD system, the overall incidence of technical error was 0.157% (24/15,271). Following implementation of ADCs, the comparative overall incidence of technical error was 0.135% (10/7,379; P = .841). Following implementation of BC scanning, the comparative overall incidence of technical error was 0.137% (27/19,708; P = .729). Subsequent changes in product labeling and intensified staff training in the use of BC systems was associated with a decrease in the rate of technical error to 0.050% (13/26,200; P = .002). Conclusions: Pharmacy ADCs and BC systems provide complementary effects that improve technical accuracy and reduce the incidence of potential medication dispensing errors if this technology is used with comprehensive personnel training. PMID:25684799
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Oldland, Alan R; Golightly, Larry K; May, Sondra K; Barber, Gerard R; Stolpman, Nancy M
2015-01-01
To measure the effects associated with sequential implementation of electronic medication storage and inventory systems and product verification devices on pharmacy technical accuracy and rates of potential medication dispensing errors in an academic medical center. During four 28-day periods of observation, pharmacists recorded all technical errors identified at the final visual check of pharmaceuticals prior to dispensing. Technical filling errors involving deviations from order-specific selection of product, dosage form, strength, or quantity were documented when dispensing medications using (a) a conventional unit dose (UD) drug distribution system, (b) an electronic storage and inventory system utilizing automated dispensing cabinets (ADCs) within the pharmacy, (c) ADCs combined with barcode (BC) verification, and (d) ADCs and BC verification utilized with changes in product labeling and individualized personnel training in systems application. Using a conventional UD system, the overall incidence of technical error was 0.157% (24/15,271). Following implementation of ADCs, the comparative overall incidence of technical error was 0.135% (10/7,379; P = .841). Following implementation of BC scanning, the comparative overall incidence of technical error was 0.137% (27/19,708; P = .729). Subsequent changes in product labeling and intensified staff training in the use of BC systems was associated with a decrease in the rate of technical error to 0.050% (13/26,200; P = .002). Pharmacy ADCs and BC systems provide complementary effects that improve technical accuracy and reduce the incidence of potential medication dispensing errors if this technology is used with comprehensive personnel training.
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Ultrasound transducer function: annual testing is not sufficient.
Mårtensson, Mattias; Olsson, Mats; Brodin, Lars-Åke
2010-10-01
The objective was to follow-up the study 'High incidence of defective ultrasound transducers in use in routine clinical practice' and evaluate if annual testing is good enough to reduce the incidence of defective ultrasound transducers in routine clinical practice to an acceptable level. A total of 299 transducers were tested in 13 clinics at five hospitals in the Stockholm area. Approximately 7000-15,000 ultrasound examinations are carried out at these clinics every year. The transducers tested in the study had been tested and classified as fully operational 1 year before and since then been in normal use in the routine clinical practice. The transducers were tested with the Sonora FirstCall Test System. There were 81 (27.1%) defective transducers found; giving a 95% confidence interval ranging from 22.1 to 32.1%. The most common transducer errors were 'delamination' of the ultrasound lens and 'break in the cable' which together constituted 82.7% of all transducer errors found. The highest error rate was found at the radiological clinics with a mean error rate of 36.0%. There was a significant difference in error rate between two observed ways the clinics handled the transducers. There was no significant difference in the error rates of the transducer brands or the transducers models. Annual testing is not sufficient to reduce the incidence of defective ultrasound transducers in routine clinical practice to an acceptable level and it is strongly advisable to create a user routine that minimizes the handling of the transducers.
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DOE Office of Scientific and Technical Information (OSTI.GOV)
Terezakis, Stephanie A., E-mail: stereza1@jhmi.edu; Harris, Kendra M.; Ford, Eric
Purpose: Systems to ensure patient safety are of critical importance. The electronic incident reporting systems (IRS) of 2 large academic radiation oncology departments were evaluated for events that may be suitable for submission to a national reporting system (NRS). Methods and Materials: All events recorded in the combined IRS were evaluated from 2007 through 2010. Incidents were graded for potential severity using the validated French Nuclear Safety Authority (ASN) 5-point scale. These incidents were categorized into 7 groups: (1) human error, (2) software error, (3) hardware error, (4) error in communication between 2 humans, (5) error at the human-software interface,more » (6) error at the software-hardware interface, and (7) error at the human-hardware interface. Results: Between the 2 systems, 4407 incidents were reported. Of these events, 1507 (34%) were considered to have the potential for clinical consequences. Of these 1507 events, 149 (10%) were rated as having a potential severity of ≥2. Of these 149 events, the committee determined that 79 (53%) of these events would be submittable to a NRS of which the majority was related to human error or to the human-software interface. Conclusions: A significant number of incidents were identified in this analysis. The majority of events in this study were related to human error and to the human-software interface, further supporting the need for a NRS to facilitate field-wide learning and system improvement.« less
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Li, Jian; Wu, Huan-Yu; Li, Yan-Ting; Jin, Hui-Ming; Gu, Bao-Ke; Yuan, Zheng-An
2010-01-01
To explore the feasibility of establishing and applying of autoregressive integrated moving average (ARIMA) model to predict the incidence rate of dysentery in Shanghai, so as to provide the theoretical basis for prevention and control of dysentery. ARIMA model was established based on the monthly incidence rate of dysentery of Shanghai from 1990 to 2007. The parameters of model were estimated through unconditional least squares method, the structure was determined according to criteria of residual un-correlation and conclusion, and the model goodness-of-fit was determined through Akaike information criterion (AIC) and Schwarz Bayesian criterion (SBC). The constructed optimal model was applied to predict the incidence rate of dysentery of Shanghai in 2008 and evaluate the validity of model through comparing the difference of predicted incidence rate and actual one. The incidence rate of dysentery in 2010 was predicted by ARIMA model based on the incidence rate from January 1990 to June 2009. The model ARIMA (1, 1, 1) (0, 1, 2)(12) had a good fitness to the incidence rate with both autoregressive coefficient (AR1 = 0.443) during the past time series, moving average coefficient (MA1 = 0.806) and seasonal moving average coefficient (SMA1 = 0.543, SMA2 = 0.321) being statistically significant (P < 0.01). AIC and SBC were 2.878 and 16.131 respectively and predicting error was white noise. The mathematic function was (1-0.443B) (1-B) (1-B(12))Z(t) = (1-0.806B) (1-0.543B(12)) (1-0.321B(2) x 12) micro(t). The predicted incidence rate in 2008 was consistent with the actual one, with the relative error of 6.78%. The predicted incidence rate of dysentery in 2010 based on the incidence rate from January 1990 to June 2009 would be 9.390 per 100 thousand. ARIMA model can be used to fit the changes of incidence rate of dysentery and to forecast the future incidence rate in Shanghai. It is a predicted model of high precision for short-time forecast.
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Heneka, Nicole; Shaw, Tim; Rowett, Debra; Phillips, Jane L
2016-06-01
Opioids are the primary pharmacological treatment for cancer pain and, in the palliative care setting, are routinely used to manage symptoms at the end of life. Opioids are one of the most frequently reported drug classes in medication errors causing patient harm. Despite their widespread use, little is known about the incidence and impact of opioid medication errors in oncology and palliative care settings. To determine the incidence, types and impact of reported opioid medication errors in adult oncology and palliative care patient settings. A systematic review. Five electronic databases and the grey literature were searched from 1980 to August 2014. Empirical studies published in English, reporting data on opioid medication error incidence, types or patient impact, within adult oncology and/or palliative care services, were included. Popay's narrative synthesis approach was used to analyse data. Five empirical studies were included in this review. Opioid error incidence rate was difficult to ascertain as each study focussed on a single narrow area of error. The predominant error type related to deviation from opioid prescribing guidelines, such as incorrect dosing intervals. None of the included studies reported the degree of patient harm resulting from opioid errors. This review has highlighted the paucity of the literature examining opioid error incidence, types and patient impact in adult oncology and palliative care settings. Defining, identifying and quantifying error reporting practices for these populations should be an essential component of future oncology and palliative care quality and safety initiatives. © The Author(s) 2015.
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Hayashino, Yasuaki; Utsugi-Ozaki, Makiko; Feldman, Mitchell D.; Fukuhara, Shunichi
2012-01-01
The presence of hope has been found to influence an individual's ability to cope with stressful situations. The objective of this study is to evaluate the relationship between medical errors, hope and burnout among practicing physicians using validated metrics. Prospective cohort study was conducted among hospital based physicians practicing in Japan (N = 836). Measures included the validated Burnout Scale, self-assessment of medical errors and Herth Hope Index (HHI). The main outcome measure was the frequency of self-perceived medical errors, and Poisson regression analysis was used to evaluate the association between hope and medical error. A total of 361 errors were reported in 836 physician-years. We observed a significant association between hope and self-report of medical errors. Compared with the lowest tertile category of HHI, incidence rate ratios (IRRs) of self-perceived medical errors of physicians in the highest category were 0.44 (95%CI, 0.34 to 0.58) and 0.54 (95%CI, 0.42 to 0.70) respectively, for the 2nd and 3rd tertile. In stratified analysis by hope score, among physicians with a low hope score, those who experienced higher burnout reported higher incidence of errors; physicians with high hope scores did not report high incidences of errors, even if they experienced high burnout. Self-perceived medical errors showed a strong association with physicians' hope, and hope modified the association between physicians' burnout and self-perceived medical errors. PMID:22530055
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Van de Vreede, Melita; McGrath, Anne; de Clifford, Jan
2018-05-14
Objective. The aim of the present study was to identify and quantify medication errors reportedly related to electronic medication management systems (eMMS) and those considered likely to occur more frequently with eMMS. This included developing a new classification system relevant to eMMS errors. Methods. Eight Victorian hospitals with eMMS participated in a retrospective audit of reported medication incidents from their incident reporting databases between May and July 2014. Site-appointed project officers submitted deidentified incidents they deemed new or likely to occur more frequently due to eMMS, together with the Incident Severity Rating (ISR). The authors reviewed and classified incidents. Results. There were 5826 medication-related incidents reported. In total, 93 (47 prescribing errors, 46 administration errors) were identified as new or potentially related to eMMS. Only one ISR2 (moderate) and no ISR1 (severe or death) errors were reported, so harm to patients in this 3-month period was minimal. The most commonly reported error types were 'human factors' and 'unfamiliarity or training' (70%) and 'cross-encounter or hybrid system errors' (22%). Conclusions. Although the results suggest that the errors reported were of low severity, organisations must remain vigilant to the risk of new errors and avoid the assumption that eMMS is the panacea to all medication error issues. What is known about the topic? eMMS have been shown to reduce some types of medication errors, but it has been reported that some new medication errors have been identified and some are likely to occur more frequently with eMMS. There are few published Australian studies that have reported on medication error types that are likely to occur more frequently with eMMS in more than one organisation and that include administration and prescribing errors. What does this paper add? This paper includes a new simple classification system for eMMS that is useful and outlines the most commonly reported incident types and can inform organisations and vendors on possible eMMS improvements. The paper suggests a new classification system for eMMS medication errors. What are the implications for practitioners? The results of the present study will highlight to organisations the need for ongoing review of system design, refinement of workflow issues, staff education and training and reporting and monitoring of errors.
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McElroy, Lisa M; Daud, Amna; Lapin, Brittany; Ross, Olivia; Woods, Donna M; Skaro, Anton I; Holl, Jane L; Ladner, Daniela P
2014-11-01
Rates of medical errors and adverse events remain high for patients who undergo kidney transplantation; they are particularly vulnerable because of the complexity of their disease and the kidney transplantation procedure. Although institutional incident-reporting systems are used in hospitals around the country, they often fail to capture a substantial proportion of medical errors. The goal of this study was to assess the ability of a proactive, web-based clinician safety debriefing to augment the information about medical errors and adverse events obtained via traditional incident reporting systems. Debriefings were sent to all individuals listed on operating room personnel reports for kidney transplantation surgeries between April 2010 and April 2011, and incident reports were collected for the same time period. The World Health Organization International Classification for Patient Safety was used to classify all issues reported. A total of 270 debriefings reported 334 patient safety issues (179 safety incidents, 155 contributing factors), and 57 incident reports reported 92 patient safety issues (56 safety incidents, 36 contributing factors). Compared with incident reports, more attending physicians completed the debriefings (32.0 vs 3.5%). The use of a proactive, web-based debriefing to augment an incident reporting system in assessing safety risks in kidney transplantation demonstrated increased information, more perspectives of a single safety issue, and increased breadth of participants. Copyright © 2014 Elsevier Inc. All rights reserved.
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Medication errors in the Middle East countries: a systematic review of the literature.
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.
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The impact of work-related stress on medication errors in Eastern Region Saudi Arabia.
Salam, Abdul; Segal, David M; Abu-Helalah, Munir Ahmad; Gutierrez, Mary Lou; Joosub, Imran; Ahmed, Wasim; Bibi, Rubina; Clarke, Elizabeth; Qarni, Ali Ahmed Al
2018-05-07
To examine the relationship between overall level and source-specific work-related stressors on medication errors rate. A cross-sectional study examined the relationship between overall levels of stress, 25 source-specific work-related stressors and medication error rate based on documented incident reports in Saudi Arabia (SA) hospital, using secondary databases. King Abdulaziz Hospital in Al-Ahsa, Eastern Region, SA. Two hundred and sixty-nine healthcare professionals (HCPs). The odds ratio (OR) and corresponding 95% confidence interval (CI) for HCPs documented incident report medication errors and self-reported sources of Job Stress Survey. Multiple logistic regression analysis identified source-specific work-related stress as significantly associated with HCPs who made at least one medication error per month (P < 0.05), including disruption to home life, pressure to meet deadlines, difficulties with colleagues, excessive workload, income over 10 000 riyals and compulsory night/weekend call duties either some or all of the time. Although not statistically significant, HCPs who reported overall stress were two times more likely to make at least one medication error per month than non-stressed HCPs (OR: 1.95, P = 0.081). This is the first study to use documented incident reports for medication errors rather than self-report to evaluate the level of stress-related medication errors in SA HCPs. Job demands, such as social stressors (home life disruption, difficulties with colleagues), time pressures, structural determinants (compulsory night/weekend call duties) and higher income, were significantly associated with medication errors whereas overall stress revealed a 2-fold higher trend.
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NASA Astrophysics Data System (ADS)
Zhang, Lai-xian; Sun, Hua-yan; Zhao, Yan-zhong; Zheng, Yong-hui; Shan, Cong-miao
2013-08-01
Based on the cat-eye effect of optical system, free space optical communication based on cat-eye modulating retro-reflector can build communication link rapidly. Compared to classical free space optical communication system, system based on cat-eye modulating retro-reflector has great advantages such as building communication link more rapidly, a passive terminal is smaller, lighter and lower power consuming. The incident angle is an important factor of cat-eye effect, so it will affect the retro-reflecting communication link. In this paper, the principle and work flow of free space optical communication based on cat-eye modulating retro-reflector were introduced. Then, using the theory of geometric optics, the equivalent model of modulating retro-reflector with incidence angle was presented. The analytical solution of active area and retro-reflected light intensity of cat-eye modulating retro-reflector were given. Noise of PIN photodetector was analyzed, based on which, bit error rate of free space optical communication based on cat-eye modulating retro-reflector was presented. Finally, simulations were done to study the effect of incidence angle to the communication. The simulation results show that the incidence angle has little effect on active area and retro-reflected light intensity when the incidence beam is in the active field angle of cat-eye modulating retro-reflector. With certain system and condition, the communication link can rapidly be built when the incidence light beam is in the field angle, and the bit error rate increases greatly with link range. When link range is smaller than 35Km, the bit error rate is less than 10-16.
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Chedoe, Indra; Molendijk, Harry; Hospes, Wobbe; Van den Heuvel, Edwin R; Taxis, Katja
2012-11-01
To examine the effect of a multifaceted educational intervention on the incidence of medication preparation and administration errors in a neonatal intensive care unit (NICU). Prospective study with a preintervention and postintervention measurement using direct observation. NICU in a tertiary hospital in the Netherlands. A multifaceted educational intervention including teaching and self-study. The incidence of medication preparation and administration errors. Clinical importance was assessed by three experts. The incidence of errors decreased from 49% (43-54%) (151 medications with one or more errors of 311 observations) to 31% (87 of 284) (25-36%). Preintervention, 0.3% (0-2%) medications contained severe errors, 26% (21-31%) moderate and 23% (18-28%) minor errors; postintervention, none 0% (0-2%) was severe, 23% (18-28%) moderate and 8% (5-12%) minor. A generalised estimating equations analysis provided an OR of 0.49 (0.29-0.84) for period (p=0.032), (route of administration (p=0.001), observer within period (p=0.036)). The multifaceted educational intervention seemed to have contributed to a significant reduction of the preparation and administration error rate, but other measures are needed to improve medication safety further.
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Fung, Wing Mei; Koh, Serena Siew Lin; Chow, Yeow Leng
Clinical incident reporting is an integral feature of risk management system in the healthcare sector. By reporting clinical incidents, nurses allow for learning from errors, identification of error patterns and development of error preventive strategies. The need to understand attitudes to reporting, perceived barriers and incident reporting patterns by nurses are the core highlights of this review. INCLUSION CRITERIA: This review considered descriptive quantitative studies that examined nurses' attitudes or perceived barriers towards incident reporting.The participants in this review were nurses working in acute care settings or step-down care settings. Studies that included non-nursing healthcare personnel were excluded.This review considered studies which examined nurses' attitudes towards incident reporting, perceived barriers and incident reporting practices.The outcomes of interest were the attitudes that nurses have towards incident reporting, perceived barriers and the types of reported incidents in correlation with nurses' attitudes and barriers. A three-step search strategy was utilised in this review. An initial limited search of CINAHL and MEDLINE was undertaken. Search strategies were then developed using identified keywords and index terms. Lastly, the reference lists of all identified articles were examined. All searches were limited to studies published in English, between 1991 and 2010. The studies were independently assessed by two reviewers using the Joanna Briggs Institute Critical Appraisal Checklist for Descriptive/ Case Series studies. The reviewers extracted data independently from included studies using the Joanna Briggs Institute Data Extraction Form for Descriptive/ Case Series studies. Due to the descriptive nature of the study designs, statistical pooling was not possible. Therefore, the findings of this systematic review are presented in a narrative summary. Fifty-five papers were identified from the searches based on their titles and abstracts. Nine studies were included in this review. Cultural and demographic factors were the most significant factors in affecting nurses' attitudes towards incident reporting. Major perceived barriers included fear, administrative issues, and the reporting process. Also, nurses were more likely to report incidents that caused direct harm, and if reporting was kept anonymous. This review demonstrated that attitudes of nurses towards incident reporting vary across different study settings, with perceived barriers hindering the reporting process. Using the findings, interventions can be customised to increase reporting rates can be developed to curb the problem of underreporting.A non-punitive culture towards incident reporting has to be cultivated, and nursing authorities should provide frequent positive feedback to staff who reported incidents. Investigating system errors should be the focus rather than individual blame.Further research should target the development and evaluation of strategies to increase rates of incident reporting. Any differences between actual and perceived reporting rates should also be explored.
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Rate, causes and reporting of medication errors in Jordan: nurses' perspectives.
Mrayyan, Majd T; Shishani, Kawkab; Al-Faouri, Ibrahim
2007-09-01
The aim of the study was to describe Jordanian nurses' perceptions about various issues related to medication errors. This is the first nursing study about medication errors in Jordan. This was a descriptive study. A convenient sample of 799 nurses from 24 hospitals was obtained. Descriptive and inferential statistics were used for data analysis. Over the course of their nursing career, the average number of recalled committed medication errors per nurse was 2.2. Using incident reports, the rate of medication errors reported to nurse managers was 42.1%. Medication errors occurred mainly when medication labels/packaging were of poor quality or damaged. Nurses failed to report medication errors because they were afraid that they might be subjected to disciplinary actions or even lose their jobs. In the stepwise regression model, gender was the only predictor of medication errors in Jordan. Strategies to reduce or eliminate medication errors are required.
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Beer, Idal; Hoppe-Tichy, Torsten; Trbovich, Patricia
2017-01-01
Objective To examine published evidence on intravenous admixture preparation errors (IAPEs) in healthcare settings. Methods Searches were conducted in three electronic databases (January 2005 to April 2017). Publications reporting rates of IAPEs and error types were reviewed and categorised into the following groups: component errors, dose/calculation errors, aseptic technique errors and composite errors. The methodological rigour of each study was assessed using the Hawker method. Results Of the 34 articles that met inclusion criteria, 28 reported the site of IAPEs: central pharmacies (n=8), nursing wards (n=14), both settings (n=4) and other sites (n=3). Using the Hawker criteria, 14% of the articles were of good quality, 74% were of fair quality and 12% were of poor quality. Error types and reported rates varied substantially, including wrong drug (~0% to 4.7%), wrong diluent solution (0% to 49.0%), wrong label (0% to 99.0%), wrong dose (0% to 32.6%), wrong concentration (0.3% to 88.6%), wrong diluent volume (0.06% to 49.0%) and inadequate aseptic technique (0% to 92.7%)%). Four studies directly compared incidence by preparation site and/or method, finding error incidence to be lower for doses prepared within a central pharmacy versus the nursing ward and lower for automated preparation versus manual preparation. Although eight studies (24%) reported ≥1 errors with the potential to cause patient harm, no study directly linked IAPE occurrences to specific adverse patient outcomes. Conclusions The available data suggest a need to continue to optimise the intravenous preparation process, focus on improving preparation workflow, design and implement preventive strategies, train staff on optimal admixture protocols and implement standardisation. Future research should focus on the development of consistent error subtype definitions, standardised reporting methodology and reliable, reproducible methods to track and link risk factors with the burden of harm associated with these errors. PMID:29288174
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Incidence of speech recognition errors in the emergency department.
Goss, Foster R; Zhou, Li; Weiner, Scott G
2016-09-01
Physician use of computerized speech recognition (SR) technology has risen in recent years due to its ease of use and efficiency at the point of care. However, error rates between 10 and 23% have been observed, raising concern about the number of errors being entered into the permanent medical record, their impact on quality of care and medical liability that may arise. Our aim was to determine the incidence and types of SR errors introduced by this technology in the emergency department (ED). Level 1 emergency department with 42,000 visits/year in a tertiary academic teaching hospital. A random sample of 100 notes dictated by attending emergency physicians (EPs) using SR software was collected from the ED electronic health record between January and June 2012. Two board-certified EPs annotated the notes and conducted error analysis independently. An existing classification schema was adopted to classify errors into eight errors types. Critical errors deemed to potentially impact patient care were identified. There were 128 errors in total or 1.3 errors per note, and 14.8% (n=19) errors were judged to be critical. 71% of notes contained errors, and 15% contained one or more critical errors. Annunciation errors were the highest at 53.9% (n=69), followed by deletions at 18.0% (n=23) and added words at 11.7% (n=15). Nonsense errors, homonyms and spelling errors were present in 10.9% (n=14), 4.7% (n=6), and 0.8% (n=1) of notes, respectively. There were no suffix or dictionary errors. Inter-annotator agreement was 97.8%. This is the first estimate at classifying speech recognition errors in dictated emergency department notes. Speech recognition errors occur commonly with annunciation errors being the most frequent. Error rates were comparable if not lower than previous studies. 15% of errors were deemed critical, potentially leading to miscommunication that could affect patient care. Copyright © 2016 Elsevier Ireland Ltd. All rights reserved.
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The impact of automation on workload and dispensing errors in a hospital pharmacy.
James, K Lynette; Barlow, Dave; Bithell, Anne; Hiom, Sarah; Lord, Sue; Pollard, Mike; Roberts, Dave; Way, Cheryl; Whittlesea, Cate
2013-04-01
To determine the effect of installing an original-pack automated dispensing system (ADS) on dispensary workload and prevented dispensing incidents in a hospital pharmacy. Data on dispensary workload and prevented dispensing incidents, defined as dispensing errors detected and reported before medication had left the pharmacy, were collected over 6 weeks at a National Health Service hospital in Wales before and after the installation of an ADS. Workload was measured by non-participant observation using the event recording technique. Prevented dispensing incidents were self-reported by pharmacy staff on standardised forms. Median workloads (measured as items dispensed/person/hour) were compared using Mann-Whitney U tests and rate of prevented dispensing incidents were compared using Chi-square test. Spearman's rank correlation was used to examine the association between workload and prevented dispensing incidents. A P value of ≤0.05 was considered statistically significant. Median dispensary workload was significantly lower pre-automation (9.20 items/person/h) compared to post-automation (13.17 items/person/h, P < 0.001). Rate of prevented dispensing incidents was significantly lower post-automation (0.28%) than pre-automation (0.64%, P < 0.0001) but there was no difference (P = 0.277) between the types of dispensing incidents. A positive association existed between workload and prevented dispensing incidents both pre- (ρ = 0.13, P = 0.015) and post-automation (ρ = 0.23, P < 0.001). Dispensing incidents were found to occur during prolonged periods of moderate workload or after a busy period. Study findings suggest that automation improves dispensing efficiency and reduces the rate of prevented dispensing incidents. It is proposed that prevented dispensing incidents frequently occurred during periods of high workload due to involuntary automaticity. Prevented dispensing incidents occurring after a busy period were attributed to staff experiencing fatigue after-effects. © 2012 The Authors. IJPP © 2012 Royal Pharmaceutical Society.
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Poon, Eric G; Cina, Jennifer L; Churchill, William W; Mitton, Patricia; McCrea, Michelle L; Featherstone, Erica; Keohane, Carol A; Rothschild, Jeffrey M; Bates, David W; Gandhi, Tejal K
2005-01-01
We performed a direct observation pre-post study to evaluate the impact of barcode technology on medication dispensing errors and potential adverse drug events in the pharmacy of a tertiary-academic medical center. We found that barcode technology significantly reduced the rate of target dispensing errors leaving the pharmacy by 85%, from 0.37% to 0.06%. The rate of potential adverse drug events (ADEs) due to dispensing errors was also significantly reduced by 63%, from 0.19% to 0.069%. In a 735-bed hospital where 6 million doses of medications are dispensed per year, this technology is expected to prevent about 13,000 dispensing errors and 6,000 potential ADEs per year. PMID:16779372
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Tsuji, Toshikazu; Nagata, Kenichiro; Kawashiri, Takehiro; Yamada, Takaaki; Irisa, Toshihiro; Murakami, Yuko; Kanaya, Akiko; Egashira, Nobuaki; Masuda, Satohiro
2016-01-01
There are many reports regarding various medical institutions' attempts at the prevention of dispensing errors. However, the relationship between occurrence timing of dispensing errors and subsequent danger to patients has not been studied under the situation according to the classification of drugs by efficacy. Therefore, we analyzed the relationship between position and time regarding the occurrence of dispensing errors. Furthermore, we investigated the relationship between occurrence timing of them and danger to patients. In this study, dispensing errors and incidents in three categories (drug name errors, drug strength errors, drug count errors) were classified into two groups in terms of its drug efficacy (efficacy similarity (-) group, efficacy similarity (+) group), into three classes in terms of the occurrence timing of dispensing errors (initial phase errors, middle phase errors, final phase errors). Then, the rates of damage shifting from "dispensing errors" to "damage to patients" were compared as an index of danger between two groups and among three classes. Consequently, the rate of damage in "efficacy similarity (-) group" was significantly higher than that in "efficacy similarity (+) group". Furthermore, the rate of damage is the highest in "initial phase errors", the lowest in "final phase errors" among three classes. From the results of this study, it became clear that the earlier the timing of dispensing errors occurs, the more severe the damage to patients becomes.
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Hedlund, Nancy; Beer, Idal; Hoppe-Tichy, Torsten; Trbovich, Patricia
2017-12-28
To examine published evidence on intravenous admixture preparation errors (IAPEs) in healthcare settings. Searches were conducted in three electronic databases (January 2005 to April 2017). Publications reporting rates of IAPEs and error types were reviewed and categorised into the following groups: component errors, dose/calculation errors, aseptic technique errors and composite errors. The methodological rigour of each study was assessed using the Hawker method. Of the 34 articles that met inclusion criteria, 28 reported the site of IAPEs: central pharmacies (n=8), nursing wards (n=14), both settings (n=4) and other sites (n=3). Using the Hawker criteria, 14% of the articles were of good quality, 74% were of fair quality and 12% were of poor quality. Error types and reported rates varied substantially, including wrong drug (~0% to 4.7%), wrong diluent solution (0% to 49.0%), wrong label (0% to 99.0%), wrong dose (0% to 32.6%), wrong concentration (0.3% to 88.6%), wrong diluent volume (0.06% to 49.0%) and inadequate aseptic technique (0% to 92.7%)%). Four studies directly compared incidence by preparation site and/or method, finding error incidence to be lower for doses prepared within a central pharmacy versus the nursing ward and lower for automated preparation versus manual preparation. Although eight studies (24%) reported ≥1 errors with the potential to cause patient harm, no study directly linked IAPE occurrences to specific adverse patient outcomes. The available data suggest a need to continue to optimise the intravenous preparation process, focus on improving preparation workflow, design and implement preventive strategies, train staff on optimal admixture protocols and implement standardisation. Future research should focus on the development of consistent error subtype definitions, standardised reporting methodology and reliable, reproducible methods to track and link risk factors with the burden of harm associated with these errors. © Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2017. All rights reserved. No commercial use is permitted unless otherwise expressly granted.
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An error taxonomy system for analysis of haemodialysis incidents.
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.
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Polisena, Julie; Gagliardi, Anna; Urbach, David; Clifford, Tammy; Fiander, Michelle
2015-03-29
Medical devices have improved the treatment of many medical conditions. Despite their benefit, the use of devices can lead to unintended incidents, potentially resulting in unnecessary harm, injury or complications to the patient, a complaint, loss or damage. Devices are used in hospitals on a routine basis. Research to date, however, has been primarily limited to describing incidents rates, so the optimal design of a hospital-based surveillance system remains unclear. Our research objectives were twofold: i) to explore factors that influence device-related incident recognition, reporting and resolution and ii) to investigate interventions or strategies to improve the recognition, reporting and resolution of medical device-related incidents. We searched the bibliographic databases: MEDLINE, Embase, the Cochrane Central Register of Controlled Trials and PsycINFO database. Grey literature (literature that is not commercially available) was searched for studies on factors that influence incident recognition, reporting and resolution published and interventions or strategies for their improvement from 2003 to 2014. Although we focused on medical devices, other health technologies were eligible for inclusion. Thirty studies were included in our systematic review, but most studies were concentrated on other health technologies. The study findings indicate that fear of punishment, uncertainty of what should be reported and how incident reports will be used and time constraints to incident reporting are common barriers to incident recognition and reporting. Relevant studies on the resolution of medical errors were not found. Strategies to improve error reporting include the use of an electronic error reporting system, increased training and feedback to frontline clinicians about the reported error. The available evidence on factors influencing medical device-related incident recognition, reporting and resolution by healthcare professionals can inform data collection and analysis in future studies. Since evidence gaps on medical device-related incidents exist, telephone interviews with frontline clinicians will be conducted to solicit information about their experiences with medical devices and suggested strategies for device surveillance improvement in a hospital context. Further research also should investigate the impact of human, system, organizational and education factors on the development and implementation of local medical device surveillance systems.
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Howell, Ann-Marie; Burns, Elaine M; Bouras, George; Donaldson, Liam J; Athanasiou, Thanos; Darzi, Ara
2015-01-01
The National Reporting and Learning System (NRLS) collects reports about patient safety incidents in England. Government regulators use NRLS data to assess the safety of hospitals. This study aims to examine whether annual hospital incident reporting rates can be used as a surrogate indicator of individual hospital safety. Secondly assesses which hospital characteristics are correlated with high incident reporting rates and whether a high reporting hospital is safer than those lower reporting hospitals. Finally, it assesses which health-care professionals report more incidents of patient harm, which report more near miss incidents and what hospital factors encourage reporting. These findings may suggest methods for increasing the utility of reporting systems. This study used a mix methods approach for assessing NRLS data. The data were investigated using Pareto analysis and regression models to establish which patients are most vulnerable to reported harm. Hospital factors were correlated with institutional reporting rates over one year to examine what factors influenced reporting. Staff survey findings regarding hospital safety culture were correlated with reported rates of incidents causing harm; no harm and death to understand what barriers influence error disclosure. 5,879,954 incident reports were collected from acute hospitals over the decade. 70.3% of incidents produced no harm to the patient and 0.9% were judged by the reporter to have caused severe harm or death. Obstetrics and Gynaecology reported the most no harm events [OR 1.61(95%CI: 1.12 to 2.27), p<0.01] and pharmacy was the hospital location where most near-misses were captured [OR 3.03(95%CI: 2.04 to 4.55), p<0.01]. Clinicians were significantly more likely to report death than other staff [OR 3.04(95%CI: 2.43 to 3.80) p<0.01]. A higher ratio of clinicians to beds correlated with reduced rate of harm reported [RR = -1.78(95%Cl: -3.33 to -0.23), p = 0.03]. Litigation claims per bed were significantly negatively associated with incident reports. Patient satisfaction and mortality outcomes were not significantly associated with reporting rates. Staff survey responses revealed that keeping reports confidential, keeping staff informed about incidents and giving feedback on safety initiatives increased reporting rates [r = 0.26 (p<0.01), r = 0.17 (p = 0.04), r = 0.23 (p = 0.01), r = 0.20 (p = 0.02)]. The NRLS is the largest patient safety reporting system in the world. This study did not demonstrate many hospital characteristics to significantly influence overall reporting rate. There were no association between size of hospital, number of staff, mortality outcomes or patient satisfaction outcomes and incident reporting rate. The study did show that hospitals where staff reported more incidents had reduced litigation claims and when clinician staffing is increased fewer incidents reporting patient harm are reported, whilst near misses remain the same. Certain specialties report more near misses than others, and doctors report more harm incidents than near misses. Staff survey results showed that open environments and reduced fear of punitive response increases incident reporting. We suggest that reporting rates should not be used to assess hospital safety. Different healthcare professionals focus on different types of safety incidents and focusing on these areas whilst creating a responsive, confidential learning environment will increase staff engagement with error disclosure.
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NASA Astrophysics Data System (ADS)
Henry, William; Jefferson Lab Hall A Collaboration
2017-09-01
Jefferson Lab's cutting-edge parity-violating electron scattering program has increasingly stringent requirements for systematic errors. Beam polarimetry is often one of the dominant systematic errors in these experiments. A new Møller Polarimeter in Hall A of Jefferson Lab (JLab) was installed in 2015 and has taken first measurements for a polarized scattering experiment. Upcoming parity violation experiments in Hall A include CREX, PREX-II, MOLLER and SOLID with the latter two requiring <0.5% precision on beam polarization measurements. The polarimeter measures the Møller scattering rates of the polarized electron beam incident upon an iron target placed in a saturating magnetic field. The spectrometer consists of four focusing quadrapoles and one momentum selection dipole. The detector is designed to measure the scattered and knock out target electrons in coincidence. Beam polarization is extracted by constructing an asymmetry from the scattering rates when the incident electron spin is parallel and anti-parallel to the target electron spin. Initial data will be presented. Sources of systematic errors include target magnetization, spectrometer acceptance, the Levchuk effect, and radiative corrections which will be discussed. National Science Foundation.
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The Relationship Between Work Commitment, Dynamic, and Medication Error.
Rezaiamin, Abdoolkarim; Pazokian, Marzieh; Zagheri Tafreshi, Mansoureh; Nasiri, Malihe
2017-05-01
Incidence of medication errors in intensive care unit (ICU) can cause irreparable damage for ICU patients. Therefore, it seems necessary to find the causes of medication errors in this section. Work commitment and dynamic might affect the incidence of medication errors in ICU. To assess the mentioned hypothesis, we performed a descriptive-analytical study which was carried out on 117 nurses working in ICU of educational hospitals in Tehran. Minick et al., Salyer et al., and Wakefield et al. scales were used for data gathering on work commitment, dynamic, and medication errors, respectively. Findings of the current study revealed that high work commitment in ICU nurses caused low number of medication errors, including intravenous and nonintravenous. We controlled the effects of confounding variables in detection of this relationship. In contrast, no significant association was found between work dynamic and different types of medication errors. Although the study did not observe any relationship between the dynamics and rate of medication errors, the training of nurses or nursing students to create a dynamic environment in hospitals can increase their interest in the profession and increase job satisfaction in them. Also they must have enough ability in work dynamic so that they don't confused and distracted result in frequent changes of orders, care plans, and procedures.
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Samaranayake, N R; Cheung, S T D; Chui, W C M; Cheung, B M Y
2012-12-01
Healthcare technology is meant to reduce medication errors. The objective of this study was to assess unintended errors related to technologies in the medication use process. Medication incidents reported from 2006 to 2010 in a main tertiary care hospital were analysed by a pharmacist and technology-related errors were identified. Technology-related errors were further classified as socio-technical errors and device errors. This analysis was conducted using data from medication incident reports which may represent only a small proportion of medication errors that actually takes place in a hospital. Hence, interpretation of results must be tentative. 1538 medication incidents were reported. 17.1% of all incidents were technology-related, of which only 1.9% were device errors, whereas most were socio-technical errors (98.1%). Of these, 61.2% were linked to computerised prescription order entry, 23.2% to bar-coded patient identification labels, 7.2% to infusion pumps, 6.8% to computer-aided dispensing label generation and 1.5% to other technologies. The immediate causes for technology-related errors included, poor interface between user and computer (68.1%), improper procedures or rule violations (22.1%), poor interface between user and infusion pump (4.9%), technical defects (1.9%) and others (3.0%). In 11.4% of the technology-related incidents, the error was detected after the drug had been administered. A considerable proportion of all incidents were technology-related. Most errors were due to socio-technical issues. Unintended and unanticipated errors may happen when using technologies. Therefore, when using technologies, system improvement, awareness, training and monitoring are needed to minimise medication errors. Copyright © 2012 Elsevier Ireland Ltd. All rights reserved.
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Katzenellenbogen, Judith M; Sanfilippo, Frank M; Hobbs, Michael S T; Briffa, Tom G; Ridout, Steve C; Knuiman, Matthew W; Dimer, Lyn; Taylor, Kate P; Thompson, Peter L; Thompson, Sandra C
2011-06-01
To investigate the impact of prevalence correction of population denominators on myocardial infarction (MI) incidence rates, rate ratios, and rate differences in Aboriginal vs. non-Aboriginal Western Australians aged 25-74 years during the study period 2000-2004. Person-based linked hospital and mortality data sets were used to estimate the number of prevalent and first-ever MI cases each year from 2000 to 2004 using a 15-year look-back period. Age-specific and -standardized MI incidence rates were calculated using both prevalence-corrected and -uncorrected population denominators, by sex and Aboriginality. The impact of prevalence correction on rates increased with age, was higher for men than women, and substantially greater for Aboriginal than non-Aboriginal people. Despite the systematic underestimation of incidence, prevalence correction had little impact on the Aboriginal to non-Aboriginal age-standardized rate ratios (6% and 4% underestimate in men and women, respectively), although the impact on rate differences was more marked (12% and 6%, respectively). The percentage underestimate of differentials was greater at older ages. Prevalence correction of denominators, while more accurate, is difficult to apply and may add modestly to the quantification of relative disparities in MI incidence between populations. Absolute incidence disparities using uncorrected denominators may have an error >10%. Copyright © 2011 Elsevier Inc. All rights reserved.
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Hashimoto, S; Murakami, Y; Taniguchi, K; Nagai, M
1999-12-01
Our purpose was to determine the number of monitoring stations (medical institutions) necessary for estimating incidence rates in the surveillance system of infectious diseases in Japan. Infectious diseases were selected by the type of monitoring stations: 15 diseases in pediatrics stations, influenza in influenza stations, 3 diseases in ophthalmology stations and 5 diseases in the stations of sexually transmitted diseases (STD). For each type of monitoring station, 5 cases of the number of monitoring stations in each health center, including the number determined from presently established standards and the actual number in 1997, were given. It was assumed that monitoring stations were randomly selected among medical institutions in health centers. For each infectious disease, each case and each type of monitoring station, standard error rates of estimated numbers of incidence cases in the whole country were calculated in 1993-1997 using the data of the surveillance of infectious diseases. Among 5 cases of monitoring stations, the case satisfied the condition that those standard error rates were lower than the critical values, was selected. The critical values were 5% in pediatrics and influenza stations, and 10% in ophthalmology and STD stations. The numbers of monitoring stations in the selected cases were 3,000 in pediatrics stations, 5,000 in influenza stations (including all pediatrics stations), 605 in ophthalmology stations and 900 in STD stations.
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Error monitoring issues for common channel signaling
NASA Astrophysics Data System (ADS)
Hou, Victor T.; Kant, Krishna; Ramaswami, V.; Wang, Jonathan L.
1994-04-01
Motivated by field data which showed a large number of link changeovers and incidences of link oscillations between in-service and out-of-service states in common channel signaling (CCS) networks, a number of analyses of the link error monitoring procedures in the SS7 protocol were performed by the authors. This paper summarizes the results obtained thus far and include the following: (1) results of an exact analysis of the performance of the error monitoring procedures under both random and bursty errors; (2) a demonstration that there exists a range of error rates within which the error monitoring procedures of SS7 may induce frequent changeovers and changebacks; (3) an analysis of the performance ofthe SS7 level-2 transmission protocol to determine the tolerable error rates within which the delay requirements can be met; (4) a demonstration that the tolerable error rate depends strongly on various link and traffic characteristics, thereby implying that a single set of error monitor parameters will not work well in all situations; (5) some recommendations on a customizable/adaptable scheme of error monitoring with a discussion on their implementability. These issues may be particularly relevant in the presence of anticipated increases in SS7 traffic due to widespread deployment of Advanced Intelligent Network (AIN) and Personal Communications Service (PCS) as well as for developing procedures for high-speed SS7 links currently under consideration by standards bodies.
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Vadera, Sumeet; Griffith, Sandra D; Rosenbaum, Benjamin P; Chan, Alvin Y; Thompson, Nicolas R; Kshettry, Varun R; Kelly, Michael L; Weil, Robert J; Bingaman, William; Jehi, Lara
2015-01-01
The Accreditation Council for Graduate Medical Education (ACGME) established duty-hour regulations for accredited residency programs on July 1, 2003. It is unclear what changes occurred in the national incidence of medication errors in surgical patients before and after ACGME regulations. Patient and hospital characteristics for pre- and post-duty-hour reform were evaluated, comparing teaching and nonteaching hospitals. A difference-in-differences study design was used to assess the association between duty-hour reform and medication errors in teaching hospitals. We used the Nationwide Inpatient Sample database, which consists of approximately annual 20% stratified sample of all the United States nonfederal hospital inpatient admissions. A query of the database, including 4 years before (2000-2003) and 8 years after (2003-2011) the ACGME duty-hour reform of July 2003, was performed to extract surgical inpatient hospitalizations (N = 13,933,326). The years 2003 and 2004 were discarded in the analysis to allow for a wash-out period during duty-hour reform (though we still provide medication error rates). The Nationwide Inpatient Sample estimated the total national surgical inpatients (N = 135,092,013) in nonfederal hospitals during these time periods with 68,736,863 patients in teaching hospitals and 66,355,150 in nonteaching hospitals. Shortly after duty-hour reform (2004 and 2006), teaching hospitals had a statistically significant increase in rate of medication error (p = 0.019 and 0.006, respectively) when compared with nonteaching hospitals even after accounting for trends across all hospitals during this period. After 2007, no further statistically significant difference was noted. After ACGME duty-hour reform, medication error rates increased in teaching hospitals, which diminished over time. This decrease in errors may be related to changes in training program structure to accommodate duty-hour reform. Copyright © 2015 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.
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[Medical errors: inevitable but preventable].
Giard, R W
2001-10-27
Medical errors are increasingly reported in the lay press. Studies have shown dramatic error rates of 10 percent or even higher. From a methodological point of view, studying the frequency and causes of medical errors is far from simple. Clinical decisions on diagnostic or therapeutic interventions are always taken within a clinical context. Reviewing outcomes of interventions without taking into account both the intentions and the arguments for a particular action will limit the conclusions from a study on the rate and preventability of errors. The interpretation of the preventability of medical errors is fraught with difficulties and probably highly subjective. Blaming the doctor personally does not do justice to the actual situation and especially the organisational framework. Attention for and improvement of the organisational aspects of error are far more important then litigating the person. To err is and will remain human and if we want to reduce the incidence of faults we must be able to learn from our mistakes. That requires an open attitude towards medical mistakes, a continuous effort in their detection, a sound analysis and, where feasible, the institution of preventive measures.
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A day in the life of a volunteer incident commander: errors, pressures and mitigating strategies.
Bearman, Christopher; Bremner, Peter A
2013-05-01
To meet an identified gap in the literature this paper investigates the tasks that a volunteer incident commander needs to carry out during an incident, the errors that can be made and the way that errors are managed. In addition, pressure from goal seduction and situation aversion were also examined. Volunteer incident commanders participated in a two-part interview consisting of a critical decision method interview and discussions about a hierarchical task analysis constructed by the authors. A SHERPA analysis was conducted to further identify potential errors. The results identified the key tasks, errors with extreme risk, pressures from strong situations and mitigating strategies for errors and pressures. The errors and pressures provide a basic set of issues that need to be managed by both volunteer incident commanders and fire agencies. The mitigating strategies identified here suggest some ways that this can be done. Copyright © 2012 Elsevier Ltd and The Ergonomics Society. All rights reserved.
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Patient Safety Incidents and Nursing Workload 1
Carlesi, Katya Cuadros; Padilha, Kátia Grillo; Toffoletto, Maria Cecília; Henriquez-Roldán, Carlos; Juan, Monica Andrea Canales
2017-01-01
ABSTRACT Objective: to identify the relationship between the workload of the nursing team and the occurrence of patient safety incidents linked to nursing care in a public hospital in Chile. Method: quantitative, analytical, cross-sectional research through review of medical records. The estimation of workload in Intensive Care Units (ICUs) was performed using the Therapeutic Interventions Scoring System (TISS-28) and for the other services, we used the nurse/patient and nursing assistant/patient ratios. Descriptive univariate and multivariate analysis were performed. For the multivariate analysis we used principal component analysis and Pearson correlation. Results: 879 post-discharge clinical records and the workload of 85 nurses and 157 nursing assistants were analyzed. The overall incident rate was 71.1%. It was found a high positive correlation between variables workload (r = 0.9611 to r = 0.9919) and rate of falls (r = 0.8770). The medication error rates, mechanical containment incidents and self-removal of invasive devices were not correlated with the workload. Conclusions: the workload was high in all units except the intermediate care unit. Only the rate of falls was associated with the workload. PMID:28403334
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Paediatric in-patient prescribing errors in Malaysia: a cross-sectional multicentre study.
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.
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Meurier, C E
2000-07-01
Human errors are common in clinical practice, but they are under-reported. As a result, very little is known of the types, antecedents and consequences of errors in nursing practice. This limits the potential to learn from errors and to make improvement in the quality and safety of nursing care. The aim of this study was to use an Organizational Accident Model to analyse critical incidents of errors in nursing. Twenty registered nurses were invited to produce a critical incident report of an error (which had led to an adverse event or potentially could have led to an adverse event) they had made in their professional practice and to write down their responses to the error using a structured format. Using Reason's Organizational Accident Model, supplemental information was then collected from five of the participants by means of an individual in-depth interview to explore further issues relating to the incidents they had reported. The detailed analysis of one of the incidents is discussed in this paper, demonstrating the effectiveness of this approach in providing insight into the chain of events which may lead to an adverse event. The case study approach using critical incidents of clinical errors was shown to provide relevant information regarding the interaction of organizational factors, local circumstances and active failures (errors) in producing an adverse or potentially adverse event. It is suggested that more use should be made of this approach to understand how errors are made in practice and to take appropriate preventative measures.
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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.
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Online patient safety education programme for junior doctors: is it worthwhile?
McCarthy, S E; O'Boyle, C A; O'Shaughnessy, A; Walsh, G
2016-02-01
Increasing demand exists for blended approaches to the development of professionalism. Trainees of the Royal College of Physicians of Ireland participated in an online patient safety programme. Study aims were: (1) to determine whether the programme improved junior doctors' knowledge, attitudes and skills relating to error reporting, open communication and care for the second victim and (2) to establish whether the methodology facilitated participants' learning. 208 junior doctors who completed the programme completed a pre-online questionnaire. Measures were "patient safety knowledge and attitudes", "medical safety climate" and "experience of learning". Sixty-two completed the post-questionnaire, representing a 30 % matched response rate. Participating in the programme resulted in immediate (p < 0.01) improvement in skills such as knowing when and how to complete incident forms and disclosing errors to patients, in self-rated knowledge (p < 0.01) and attitudes towards error reporting (p < 0.01). Sixty-three per cent disagreed that doctors routinely report medical errors and 42 % disagreed that doctors routinely share information about medical errors and what caused them. Participants rated interactive features as the most positive elements of the programme. An online training programme on medical error improved self-rated knowledge, attitudes and skills in junior doctors and was deemed an effective learning tool. Perceptions of work issues such as a poor culture of error reporting among doctors may prevent improved attitudes being realised in practice. Online patient safety education has a role in practice-based initiatives aimed at developing professionalism and improving safety.
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Analysis of general aviation accidents during operations under instrument flight rules
NASA Technical Reports Server (NTRS)
Bennett, C. T.; Schwirzke, Martin; Harm, C.
1990-01-01
A report is presented to describe some of the errors that pilots make during flight under IFR. The data indicate that there is less risk during the approach and landing phase of IFR flights, as compared to VFR operations. Single-pilot IFR accident rates continue to be higher than two-pilot IFR incident rates, reflecting the high work load of IFR operations.
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Medication Incidents Involving Antiepileptic Drugs in Canadian Hospitals: A Multi-Incident Analysis.
Cheng, Roger; Yang, Yu Daisy; Chan, Matthew; Patel, Tejal
2017-01-01
Medication errors involving antiepileptic drugs (AEDs) are not well studied but have the potential to cause significant harm. We investigated the occurrence of medication incidents in Canadian hospitals that involve AEDs, their severity and contributing factors by analyzing data from two national databases. Our multi-incident analysis revealed that while medication errors were rarely fatal, errors do occur of which some are serious. Medication incidents were most commonly caused by dose omissions, the dose or its frequency being incorrect and the wrong AED being given. Our analysis could augment quality-improvement initiatives by medication safety administrators to reduce AED medication incidents in hospitals.
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Zhou, Wen-Jun; Zhang, Yong-Ye; Li, Hua; Wu, Yu-Fei; Xu, Ji; Lv, Sha; Li, Ge; Liu, Shi-Chun; Song, Sheng-Fang
2016-01-01
Background To determine the change in refractive error and the incidence of myopia among school-aged children in the Yongchuan District of Chongqing City, Western China. Methods A population-based cross-sectional survey was initially conducted in 2006 among 3070 children aged 6 to 15 years. A longitudinal follow-up study was then conducted 5 years later between November 2011 and March 2012. Refractive error was measured under cycloplegia with autorefraction. Age, sex, and baseline refractive error were evaluated as risk factors for progression of refractive error and incidence of myopia. Results Longitudinal data were available for 1858 children (60.5%). The cumulative mean change in refractive error was −2.21 (standard deviation [SD], 1.87) diopters (D) for the entire study population, with an annual progression of refraction in a myopic direction of −0.43 D. Myopic progression of refractive error was associated with younger age, female sex, and higher myopic or hyperopic refractive error at baseline. The cumulative incidence of myopia, defined as a spherical equivalent refractive error of −0.50 D or more, among initial emmetropes and hyperopes was 54.9% (95% confidence interval [CI], 45.2%–63.5%), with an annual incidence of 10.6% (95% CI, 8.7%–13.1%). Myopia was found more likely to happen in female and older children. Conclusions In Western China, both myopic progression and incidence of myopia were higher than those of children from most other locations in China and from the European Caucasian population. Compared with a previous study in China, there was a relative increase in annual myopia progression and annual myopia incidence, a finding which is consistent with the increasing trend on prevalence of myopia in China. PMID:26875599
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Zhou, Wen-Jun; Zhang, Yong-Ye; Li, Hua; Wu, Yu-Fei; Xu, Ji; Lv, Sha; Li, Ge; Liu, Shi-Chun; Song, Sheng-Fang
2016-07-05
To determine the change in refractive error and the incidence of myopia among school-aged children in the Yongchuan District of Chongqing City, Western China. A population-based cross-sectional survey was initially conducted in 2006 among 3070 children aged 6 to 15 years. A longitudinal follow-up study was then conducted 5 years later between November 2011 and March 2012. Refractive error was measured under cycloplegia with autorefraction. Age, sex, and baseline refractive error were evaluated as risk factors for progression of refractive error and incidence of myopia. Longitudinal data were available for 1858 children (60.5%). The cumulative mean change in refractive error was -2.21 (standard deviation [SD], 1.87) diopters (D) for the entire study population, with an annual progression of refraction in a myopic direction of -0.43 D. Myopic progression of refractive error was associated with younger age, female sex, and higher myopic or hyperopic refractive error at baseline. The cumulative incidence of myopia, defined as a spherical equivalent refractive error of -0.50 D or more, among initial emmetropes and hyperopes was 54.9% (95% confidence interval [CI], 45.2%-63.5%), with an annual incidence of 10.6% (95% CI, 8.7%-13.1%). Myopia was found more likely to happen in female and older children. In Western China, both myopic progression and incidence of myopia were higher than those of children from most other locations in China and from the European Caucasian population. Compared with a previous study in China, there was a relative increase in annual myopia progression and annual myopia incidence, a finding which is consistent with the increasing trend on prevalence of myopia in China.
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Interferometry On Grazing Incidence Optics
NASA Astrophysics Data System (ADS)
Geary, Joseph; Maeda, Riki
1988-08-01
A preliminary interferometric procedure is described showing potential for obtaining surface figure error maps of grazing incidence optics at normal incidence. The latter are found in some laser resonator configurations, and in Wolter type X-ray optics. The procedure makes use of cylindrical wavefronts and error subtraction techniques over subapertures. The surface error maps obtained will provide critical information to opticians in the fabrication process.
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Interferometry on grazing incidence optics
NASA Astrophysics Data System (ADS)
Geary, Joseph M.; Maeda, Riki
1987-12-01
An interfeormetric procedure is described that shows potential for obtaining surface figure error maps of grazing incidence optics at normal incidence. Such optics are found in some laser resonator configurations and in Wolter-type X-ray optics. The procedure makes use of cylindrical wavefronts and error subtraction techniques over subapertures. The surface error maps obtained will provide critical information to opticians for the fabrication process.
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Univariate Analysis of Multivariate Outcomes in Educational Psychology.
ERIC Educational Resources Information Center
Hubble, L. M.
1984-01-01
The author examined the prevalence of multiple operational definitions of outcome constructs and an estimate of the incidence of Type I error rates when univariate procedures were applied to multiple variables in educational psychology. Multiple operational definitions of constructs were advocated and wider use of multivariate analysis was…
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The contribution of low-energy protons to the total on-orbit SEU rate
Dodds, Nathaniel Anson; Martinez, Marino J.; Dodd, Paul E.; ...
2015-11-10
Low- and high-energy proton experimental data and error rate predictions are presented for many bulk Si and SOI circuits from the 20-90 nm technology nodes to quantify how much low-energy protons (LEPs) can contribute to the total on-orbit single-event upset (SEU) rate. Every effort was made to predict LEP error rates that are conservatively high; even secondary protons generated in the spacecraft shielding have been included in the analysis. Across all the environments and circuits investigated, and when operating within 10% of the nominal operating voltage, LEPs were found to increase the total SEU rate to up to 4.3 timesmore » as high as it would have been in the absence of LEPs. Therefore, the best approach to account for LEP effects may be to calculate the total error rate from high-energy protons and heavy ions, and then multiply it by a safety margin of 5. If that error rate can be tolerated then our findings suggest that it is justified to waive LEP tests in certain situations. Trends were observed in the LEP angular responses of the circuits tested. As a result, grazing angles were the worst case for the SOI circuits, whereas the worst-case angle was at or near normal incidence for the bulk circuits.« less
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Testing for carryover effects after cessation of treatments: a design approach.
Sturdevant, S Gwynn; Lumley, Thomas
2016-08-02
Recently, trials addressing noisy measurements with diagnosis occurring by exceeding thresholds (such as diabetes and hypertension) have been published which attempt to measure carryover - the impact that treatment has on an outcome after cessation. The design of these trials has been criticised and simulations have been conducted which suggest that the parallel-designs used are not adequate to test this hypothesis; two solutions are that either a differing parallel-design or a cross-over design could allow for diagnosis of carryover. We undertook a systematic simulation study to determine the ability of a cross-over or a parallel-group trial design to detect carryover effects on incident hypertension in a population with prehypertension. We simulated blood pressure and focused on varying criteria to diagnose systolic hypertension. Using the difference in cumulative incidence hypertension to analyse parallel-group or cross-over trials resulted in none of the designs having acceptable Type I error rate. Under the null hypothesis of no carryover the difference is well above the nominal 5 % error rate. When a treatment is effective during the intervention period, reliable testing for a carryover effect is difficult. Neither parallel-group nor cross-over designs using the difference in cumulative incidence appear to be a feasible approach. Future trials should ensure their design and analysis is validated by simulation.
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Data Mining on Numeric Error in Computerized Physician Order Entry System Prescriptions.
Wu, Xue; Wu, Changxu
2017-01-01
This study revealed the numeric error patterns related to dosage when doctors prescribed in computerized physician order entry system. Error categories showed that the '6','7', and '9' key produced a higher incidence of errors in Numpad typing, while the '2','3', and '0' key produced a higher incidence of errors in main keyboard digit line typing. Errors categorized as omission and substitution were higher in prevalence than transposition and intrusion.
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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.
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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.
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[Adverse events in general surgery. A prospective analysis of 13,950 consecutive patients].
Rebasa, Pere; Mora, Laura; Vallverdú, Helena; Luna, Alexis; Montmany, Sandra; Romaguera, Andreu; Navarro, Salvador
2011-11-01
Adverse event (AE) rates in General Surgery vary, according to different authors and recording methods, between 2% and 30%. Six years ago we designed a prospective AE recording system to change patient safety culture in our Department. We present the results of this work after a 6 year follow-up. The AE, sequelae and health care errors in a University Hospital surgery department were recorded. An analysis of each incident recorded was performed by a reviewer. The data was entered into data base for rapid access and consultation. The results were routinely presented in Departmental morbidity-mortality sessions. A total of 13,950 patients had suffered 11,254 AE, which affected 5142 of them (36.9% of admissions). A total of 920 patients were subjected to at least one health care error (6.6% of admissions). This meant that 6.6% of our patients suffered an avoidable AE. The overall mortality at 5 years in our department was 2.72% (380 deaths). An adverse event was implicated in the death of the patient in 180 cases (1.29% of admissions). In 49 cases (0.35% of admissions), mortality could be attributed to an avoidable AE. After 6 years there tends to be an increasingly lower incidence of errors. The exhaustive and prospective recording of AE leads to changes in patient safety culture in a Surgery Department and helps decrease the incidence of health care errors. Copyright © 2011 AEC. Published by Elsevier Espana. All rights reserved.
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Ion beam figuring of high-slope surfaces based on figure error compensation algorithm.
Dai, Yifan; Liao, Wenlin; Zhou, Lin; Chen, Shanyong; Xie, Xuhui
2010-12-01
In a deterministic figuring process, it is critical to guarantee high stability of the removal function as well as the accuracy of the dwell time solution, which directly influence the convergence of the figuring process. Hence, when figuring steep optics, the ion beam is required to keep a perpendicular incidence, and a five-axis figuring machine is typically utilized. In this paper, however, a method for high-precision figuring of high-slope optics is proposed with a linear three-axis machine, allowing for inclined beam incidence. First, the changing rule of the removal function and the normal removal rate with the incidence angle is analyzed according to the removal characteristics of ion beam figuring (IBF). Then, we propose to reduce the influence of varying removal function and projection distortion on the dwell time solution by means of figure error compensation. Consequently, the incident ion beam is allowed to keep parallel to the optical axis. Simulations and experiments are given to verify the removal analysis. Finally, a figuring experiment is conducted on a linear three-axis IBF machine, which proves the validity of the method for high-slope surfaces. It takes two iterations and about 9 min to successfully figure a fused silica sample, whose aperture is 21.3 mm and radius of curvature is 16 mm. The root-mean-square figure error of the convex surface is reduced from 13.13 to 5.86 nm.
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DOE Office of Scientific and Technical Information (OSTI.GOV)
Yang, F; Cao, N; Young, L
2014-06-15
Purpose: Though FMEA (Failure Mode and Effects Analysis) is becoming more widely adopted for risk assessment in radiation therapy, to our knowledge it has never been validated against actual incident learning data. The objective of this study was to perform an FMEA analysis of an SBRT (Stereotactic Body Radiation Therapy) treatment planning process and validate this against data recorded within an incident learning system. Methods: FMEA on the SBRT treatment planning process was carried out by a multidisciplinary group including radiation oncologists, medical physicists, and dosimetrists. Potential failure modes were identified through a systematic review of the workflow process. Failuremore » modes were rated for severity, occurrence, and detectability on a scale of 1 to 10 and RPN (Risk Priority Number) was computed. Failure modes were then compared with historical reports identified as relevant to SBRT planning within a departmental incident learning system that had been active for two years. Differences were identified. Results: FMEA identified 63 failure modes. RPN values for the top 25% of failure modes ranged from 60 to 336. Analysis of the incident learning database identified 33 reported near-miss events related to SBRT planning. FMEA failed to anticipate 13 of these events, among which 3 were registered with severity ratings of severe or critical in the incident learning system. Combining both methods yielded a total of 76 failure modes, and when scored for RPN the 13 events missed by FMEA ranked within the middle half of all failure modes. Conclusion: FMEA, though valuable, is subject to certain limitations, among them the limited ability to anticipate all potential errors for a given process. This FMEA exercise failed to identify a significant number of possible errors (17%). Integration of FMEA with retrospective incident data may be able to render an improved overview of risks within a process.« less
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DOE Office of Scientific and Technical Information (OSTI.GOV)
Gopan, O; Kalet, A; Smith, W
2016-06-15
Purpose: A standard tool for ensuring the quality of radiation therapy treatments is the initial physics plan review. However, little is known about its performance in practice. The goal of this study is to measure the effectiveness of physics plan review by introducing simulated errors into “mock” treatment plans and measuring the performance of plan review by physicists. Methods: We generated six mock treatment plans containing multiple errors. These errors were based on incident learning system data both within the department and internationally (SAFRON). These errors were scored for severity and frequency. Those with the highest scores were included inmore » the simulations (13 errors total). Observer bias was minimized using a multiple co-correlated distractor approach. Eight physicists reviewed these plans for errors, with each physicist reviewing, on average, 3/6 plans. The confidence interval for the proportion of errors detected was computed using the Wilson score interval. Results: Simulated errors were detected in 65% of reviews [51–75%] (95% confidence interval [CI] in brackets). The following error scenarios had the highest detection rates: incorrect isocenter in DRRs/CBCT (91% [73–98%]) and a planned dose different from the prescribed dose (100% [61–100%]). Errors with low detection rates involved incorrect field parameters in record and verify system (38%, [18–61%]) and incorrect isocenter localization in planning system (29% [8–64%]). Though pre-treatment QA failure was reliably identified (100%), less than 20% of participants reported the error that caused the failure. Conclusion: This is one of the first quantitative studies of error detection. Although physics plan review is a key safety measure and can identify some errors with high fidelity, others errors are more challenging to detect. This data will guide future work on standardization and automation. Creating new checks or improving existing ones (i.e., via automation) will help in detecting those errors with low detection rates.« less
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Effects of a preceptorship programme on turnover rate, cost, quality and professional development.
Lee, Tso-Ying; Tzeng, Wen-Chii; Lin, Chia-Huei; Yeh, Mei-Ling
2009-04-01
The purpose of the present study was to design a preceptorship programme and to evaluate its effects on turnover rate, turnover cost, quality of care and professional development. A high turnover rate of nurses is a common global problem. How to improve nurses' willingness to stay in their jobs and reduce the high turnover rate has become a focus. Well-designed preceptorship programmes could possibly decrease turnover rates and improve professional development. A quasi-experimental research design was used. First, a preceptorship programme was designed to establish the role and responsibilities of preceptors in instructing new nurses. Second, a quasi-experimental design was used to evaluate the preceptorship programme. Data on new nurses' turnover rate, turnover cost, quality of nursing care, satisfaction of preceptor's teaching and preceptor's perception were measured. After conducting the preceptorship programme, the turnover rate was 46.5% less than the previous year. The turnover cost was decreased by US$186,102. Additionally, medication error rates made by new nurses dropped from 50-0% and incident rates of adverse events and falls decreased. All new nurses were satisfied with preceptor guidance. The preceptorship programme effectively lowered the turnover rate of new nurses, reduced turnover costs and enhanced the quality of nursing care, especially by reducing medication error incidents. Positive feedback about the programme was received from new nurses. Study findings may offer healthcare administrators another option for retaining new nurses, controlling costs, improving quality and fostering professional development. In addition, incentives and effective support from the organisation must be considered when preceptors perform preceptorship responsibilities.
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Using voluntary reports from physicians to learn from diagnostic errors in emergency medicine.
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/
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Reduction in chemotherapy order errors with computerized physician order entry.
Meisenberg, Barry R; Wright, Robert R; Brady-Copertino, Catherine J
2014-01-01
To measure the number and type of errors associated with chemotherapy order composition associated with three sequential methods of ordering: handwritten orders, preprinted orders, and computerized physician order entry (CPOE) embedded in the electronic health record. From 2008 to 2012, a sample of completed chemotherapy orders were reviewed by a pharmacist for the number and type of errors as part of routine performance improvement monitoring. Error frequencies for each of the three distinct methods of composing chemotherapy orders were compared using statistical methods. The rate of problematic order sets-those requiring significant rework for clarification-was reduced from 30.6% with handwritten orders to 12.6% with preprinted orders (preprinted v handwritten, P < .001) to 2.2% with CPOE (preprinted v CPOE, P < .001). The incidence of errors capable of causing harm was reduced from 4.2% with handwritten orders to 1.5% with preprinted orders (preprinted v handwritten, P < .001) to 0.1% with CPOE (CPOE v preprinted, P < .001). The number of problem- and error-containing chemotherapy orders was reduced sequentially by preprinted order sets and then by CPOE. CPOE is associated with low error rates, but it did not eliminate all errors, and the technology can introduce novel types of errors not seen with traditional handwritten or preprinted orders. Vigilance even with CPOE is still required to avoid patient harm.
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Evaluation of drug administration errors in a teaching hospital
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
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Evaluation of drug administration errors in a teaching hospital.
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.
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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.
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Elsaid, K; Truong, T; Monckeberg, M; McCarthy, H; Butera, J; Collins, C
2013-12-01
To evaluate the impact of electronic standardized chemotherapy templates on incidence and types of prescribing errors. A quasi-experimental interrupted time series with segmented regression. A 700-bed multidisciplinary tertiary care hospital with an ambulatory cancer center. A multidisciplinary team including oncology physicians, nurses, pharmacists and information technologists. Standardized, regimen-specific, chemotherapy prescribing forms were developed and implemented over a 32-month period. Trend of monthly prevented prescribing errors per 1000 chemotherapy doses during the pre-implementation phase (30 months), immediate change in the error rate from pre-implementation to implementation and trend of errors during the implementation phase. Errors were analyzed according to their types: errors in communication or transcription, errors in dosing calculation and errors in regimen frequency or treatment duration. Relative risk (RR) of errors in the post-implementation phase (28 months) compared with the pre-implementation phase was computed with 95% confidence interval (CI). Baseline monthly error rate was stable with 16.7 prevented errors per 1000 chemotherapy doses. A 30% reduction in prescribing errors was observed with initiating the intervention. With implementation, a negative change in the slope of prescribing errors was observed (coefficient = -0.338; 95% CI: -0.612 to -0.064). The estimated RR of transcription errors was 0.74; 95% CI (0.59-0.92). The estimated RR of dosing calculation errors was 0.06; 95% CI (0.03-0.10). The estimated RR of chemotherapy frequency/duration errors was 0.51; 95% CI (0.42-0.62). Implementing standardized chemotherapy-prescribing templates significantly reduced all types of prescribing errors and improved chemotherapy safety.
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Influence of incident angle on the decoding in laser polarization encoding guidance
NASA Astrophysics Data System (ADS)
Zhou, Muchun; Chen, Yanru; Zhao, Qi; Xin, Yu; Wen, Hongyuan
2009-07-01
Dynamic detection of polarization states is very important for laser polarization coding guidance systems. In this paper, a set of dynamic polarization decoding and detection system used in laser polarization coding guidance was designed. Detection process of the normal incident polarized light is analyzed with Jones Matrix; the system can effectively detect changes in polarization. Influence of non-normal incident light on performance of polarization decoding and detection system is studied; analysis showed that changes in incident angle will have a negative impact on measure results, the non-normal incident influence is mainly caused by second-order birefringence and polarization sensitivity effect generated in the phase delay and beam splitter prism. Combined with Fresnel formula, decoding errors of linearly polarized light, elliptically polarized light and circularly polarized light with different incident angles into the detector are calculated respectively, the results show that the decoding errors increase with increase of incident angle. Decoding errors have relations with geometry parameters, material refractive index of wave plate, polarization beam splitting prism. Decoding error can be reduced by using thin low-order wave-plate. Simulation of detection of polarized light with different incident angle confirmed the corresponding conclusions.
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Elimination of Emergency Department Medication Errors Due To Estimated Weights.
Greenwalt, Mary; Griffen, David; Wilkerson, Jim
2017-01-01
From 7/2014 through 6/2015, 10 emergency department (ED) medication dosing errors were reported through the electronic incident reporting system of an urban academic medical center. Analysis of these medication errors identified inaccurate estimated weight on patients as the root cause. The goal of this project was to reduce weight-based dosing medication errors due to inaccurate estimated weights on patients presenting to the ED. Chart review revealed that 13.8% of estimated weights documented on admitted ED patients varied more than 10% from subsequent actual admission weights recorded. A random sample of 100 charts containing estimated weights revealed 2 previously unreported significant medication dosage errors (.02 significant error rate). Key improvements included removing barriers to weighing ED patients, storytelling to engage staff and change culture, and removal of the estimated weight documentation field from the ED electronic health record (EHR) forms. With these improvements estimated weights on ED patients, and the resulting medication errors, were eliminated.
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Errors as a Means of Reducing Impulsive Food Choice.
Sellitto, Manuela; di Pellegrino, Giuseppe
2016-06-05
Nowadays, the increasing incidence of eating disorders due to poor self-control has given rise to increased obesity and other chronic weight problems, and ultimately, to reduced life expectancy. The capacity to refrain from automatic responses is usually high in situations in which making errors is highly likely. The protocol described here aims at reducing imprudent preference in women during hypothetical intertemporal choices about appetitive food by associating it with errors. First, participants undergo an error task where two different edible stimuli are associated with two different error likelihoods (high and low). Second, they make intertemporal choices about the two edible stimuli, separately. As a result, this method decreases the discount rate for future amounts of the edible reward that cued higher error likelihood, selectively. This effect is under the influence of the self-reported hunger level. The present protocol demonstrates that errors, well known as motivationally salient events, can induce the recruitment of cognitive control, thus being ultimately useful in reducing impatient choices for edible commodities.
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Errors as a Means of Reducing Impulsive Food Choice
Sellitto, Manuela; di Pellegrino, Giuseppe
2016-01-01
Nowadays, the increasing incidence of eating disorders due to poor self-control has given rise to increased obesity and other chronic weight problems, and ultimately, to reduced life expectancy. The capacity to refrain from automatic responses is usually high in situations in which making errors is highly likely. The protocol described here aims at reducing imprudent preference in women during hypothetical intertemporal choices about appetitive food by associating it with errors. First, participants undergo an error task where two different edible stimuli are associated with two different error likelihoods (high and low). Second, they make intertemporal choices about the two edible stimuli, separately. As a result, this method decreases the discount rate for future amounts of the edible reward that cued higher error likelihood, selectively. This effect is under the influence of the self-reported hunger level. The present protocol demonstrates that errors, well known as motivationally salient events, can induce the recruitment of cognitive control, thus being ultimately useful in reducing impatient choices for edible commodities. PMID:27341281
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Goovaerts, Pierre
2006-01-01
Boundary analysis of cancer maps may highlight areas where causative exposures change through geographic space, the presence of local populations with distinct cancer incidences, or the impact of different cancer control methods. Too often, such analysis ignores the spatial pattern of incidence or mortality rates and overlooks the fact that rates computed from sparsely populated geographic entities can be very unreliable. This paper proposes a new methodology that accounts for the uncertainty and spatial correlation of rate data in the detection of significant edges between adjacent entities or polygons. Poisson kriging is first used to estimate the risk value and the associated standard error within each polygon, accounting for the population size and the risk semivariogram computed from raw rates. The boundary statistic is then defined as half the absolute difference between kriged risks. Its reference distribution, under the null hypothesis of no boundary, is derived through the generation of multiple realizations of the spatial distribution of cancer risk values. This paper presents three types of neutral models generated using methods of increasing complexity: the common random shuffle of estimated risk values, a spatial re-ordering of these risks, or p-field simulation that accounts for the population size within each polygon. The approach is illustrated using age-adjusted pancreatic cancer mortality rates for white females in 295 US counties of the Northeast (1970–1994). Simulation studies demonstrate that Poisson kriging yields more accurate estimates of the cancer risk and how its value changes between polygons (i.e. boundary statistic), relatively to the use of raw rates or local empirical Bayes smoother. When used in conjunction with spatial neutral models generated by p-field simulation, the boundary analysis based on Poisson kriging estimates minimizes the proportion of type I errors (i.e. edges wrongly declared significant) while the frequency of these errors is predicted well by the p-value of the statistical test. PMID:19023455
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DOE Office of Scientific and Technical Information (OSTI.GOV)
Zheng, Y; Johnson, R; Zhao, L
2015-06-15
Purpose: Incident learning has been proven to improve patient safety and treatment quality in conventional radiation therapy. However, its application in proton therapy has not been reported yet to our knowledge. In this study, we report our experience in developing and implementation of an in-house incident learning system. Methods: An incident learning system was developed based on published principles and tailored for our clinical practice and available resource about 18 months ago. The system includes four layers of error detection and report: 1) dosimetry peer review; 2) physicist plan quality assurance (QA); 3) treatment delivery issue on call and record;more » and 4) other incident report. The first two layers of QA and report were mandatory for each treatment plan through easy-to-use spreadsheets that are only accessible by the dosimetry and physicist departments. The treatment delivery issues were recorded case by case by the on call physicist. All other incidents were reported through an online incident report system, which can be anonymous. The incident report includes near misses on planning and delivery, process deviation, machine issues, work flow and documentation. Periodic incident reviews were performed. Results: In total, about 116 errors were reported through dosimetry review, 137 errors through plan QA, 83 treatment issues through physics on call record, and 30 through the online incident report. Only 8 incidents (2.2%) were considered to have a clinical impact to patients, and the rest of errors were either detected before reaching patients or had negligible dosimetric impact (<5% dose variance). Personnel training & process improvements were implemented upon periodic incident review. Conclusion: An incident learning system can be helpful in personnel training, error reduction, and patient safety and treatment quality improvement. The system needs to be catered for each clinic’s practice and available resources. Incident and knowledge sharing among proton centers are encouraged.« less
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DOE Office of Scientific and Technical Information (OSTI.GOV)
Ford, Eric C.; Smith, Koren; Harris, Kendra
2012-11-15
Purpose: A series of examples are presented in which potential errors in the delivery of radiation therapy were prevented through use of incident learning. These examples underscore the value of reporting near miss incidents. Methods: Using a departmental incident learning system, eight incidents were noted over a two-year period in which fields were treated 'out-of-sequence,' that is, fields from a boost phase were treated, while the patient was still in the initial phase of treatment. As a result, an error-prevention policy was instituted in which radiation treatment fields are 'hidden' within the oncology information system (OIS) when they are notmore » in current use. In this way, fields are only available to be treated in the intended sequence and, importantly, old fields cannot be activated at the linear accelerator control console. Results: No out-of-sequence treatments have been reported in more than two years since the policy change. Furthermore, at least three near-miss incidents were detected and corrected as a result of the policy change. In the first two, the policy operated as intended to directly prevent an error in field scheduling. In the third near-miss, the policy operated 'off target' to prevent a type of error scenario that it was not directly intended to prevent. In this incident, an incorrect digitally reconstructed radiograph (DRR) was scheduled in the OIS for a patient receiving lung cancer treatment. The incorrect DRR had an isocenter which was misplaced by approximately two centimeters. The error was a result of a field from an old plan being scheduled instead of the intended new plan. As a result of the policy described above, the DRR field could not be activated for treatment however and the error was discovered and corrected. Other quality control barriers in place would have been unlikely to have detected this error. Conclusions: In these examples, a policy was adopted based on incident learning, which prevented several errors, at least one of which was potentially severe. These examples underscore the need for a rigorous, systematic incident learning process within each clinic. The experiences reported in this technical note demonstrate the value of near-miss incident reporting to improve patient safety.« less
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Audits and critical incident reporting in paediatric anaesthesia: lessons from 75,331 anaesthetics.
Wan, Sharon; Siow, Yew Nam; Lee, Su Min; Ng, Agnes
2013-02-01
This study reports our experience of audit and critical incidents observed by paediatric anaesthetics from 2000 to 2010 at a paediatric teaching hospital in Singapore. Data pertaining to patient demographics, practices and critical incidents during anaesthesia and in the perioperative period were prospectively collected via an audit form and retrospectively analysed thereafter. A total of 2,519 incidents were noted at the 75,331 anaesthetics performed during the study period. There were nine deaths reported. The majority of incidents reported were respiratory critical incidents (n = 1,757, 69.8%), followed by cardiovascular incidents (n = 238, 9.5%). Risk factors for critical incidents included age less than one year, and preterm and former preterm children. Critical incident reporting has value, as it provides insights into the system and helps to identify active and system errors, thus enabling the formulation of effective preventive strategies. By creating and maintaining an environment that encourages reporting, we have maintained a high and consistent reporting rate through the years. The teaching of analysis of critical incidents should be regarded by all clinicians as an important tool for improving patient safety.
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Aziz, Muhammad Tahir; Ur-Rehman, Tofeeq; Qureshi, Sadia; Bukhari, Nadeem Irfan
Medication errors in chemotherapy are frequent and lead to patient morbidity and mortality, as well as increased rates of re-admission and length of stay, and considerable extra costs. Objective: This study investigated the proposition that computerised chemotherapy ordering reduces the incidence and severity of chemotherapy protocol errors. A computerised physician order entry of chemotherapy order (C-CO) with clinical decision support system was developed in-house, including standardised chemotherapy protocol definitions, automation of pharmacy distribution, clinical checks, labeling and invoicing. A prospective study was then conducted in a C-CO versus paper based chemotherapy order (P-CO) in a 30-bed chemotherapy bay of a tertiary hospital. Both C-CO and P-CO orders, including pharmacoeconomic analysis and the severity of medication errors, were checked and validated by a clinical pharmacist. A group analysis and field trial were also conducted to assess clarity, feasibility and decision making. The C-CO was very usable in terms of its clarity and feasibility. The incidence of medication errors was significantly lower in the C-CO compared with the P-CO (10/3765 [0.26%] versus 134/5514 [2.4%]). There was also a reduction in dispensing time of chemotherapy protocols in the C-CO. The chemotherapy computerisation with clinical decision support system resulted in a significant decrease in the occurrence and severity of medication errors, improvements in chemotherapy dispensing and administration times, and reduction of chemotherapy cost.
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Assessment of legibility and completeness of handwritten and electronic prescriptions.
Albarrak, Ahmed I; Al Rashidi, Eman Abdulrahman; Fatani, Rwaa Kamil; Al Ageel, Shoog Ibrahim; Mohammed, Rafiuddin
2014-12-01
To assess the legibility and completeness of handwritten prescriptions and compare with electronic prescription system for medication errors. Prospective study. King Khalid University Hospital (KKUH), Riyadh, Saudi Arabia. Handwritten prescriptions were received from clinical units of Medicine Outpatient Department (MOPD), Primary Care Clinic (PCC) and Surgery Outpatient Department (SOPD) whereas electronic prescriptions were collected from the pediatric ward. The handwritten prescription was assessed for completeness by the checklist designed according to the hospital prescription and evaluated for legibility by two pharmacists. The comparison between handwritten and electronic prescription errors was evaluated based on the validated checklist adopted from previous studies. Legibility and completeness of prescriptions. 398 prescriptions (199 handwritten and 199 e-prescriptions) were assessed. About 71 (35.7%) of handwritten and 5 (2.5%) of electronic prescription errors were identified. A significant statistical difference (P < 0.001) was observed between handwritten and e-prescriptions in omitted dose and omitted route of administration category of error distribution. The rate of completeness in patient identification in handwritten prescriptions was 80.97% in MOPD, 76.36% in PCC and 85.93% in SOPD clinic units. Assessment of medication prescription completeness was 91.48% in MOPD, 88.48% in PCC, and 89.28% in SOPD. This study revealed a high incidence of prescribing errors in handwritten prescriptions. The use of e-prescription system showed a significant decline in the incidence of errors. The legibility of handwritten prescriptions was relatively good whereas the level of completeness was very low.
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Near Misses in Financial Trading: Skills for Capturing and Averting Error.
Leaver, Meghan; Griffiths, Alex; Reader, Tom
2018-05-01
The aims of this study were (a) to determine whether near-miss incidents in financial trading contain information on the operator skills and systems that detect and prevent near misses and the patterns and trends revealed by these data and (b) to explore if particular operator skills and systems are found as important for avoiding particular types of error on the trading floor. In this study, we examine a cohort of near-miss incidents collected from a financial trading organization using the Financial Incident Analysis System and report on the nontechnical skills and systems that are used to detect and prevent error in this domain. One thousand near-miss incidents are analyzed using distribution, mean, chi-square, and associative analysis to describe the data; reliability is provided. Slips/lapses (52%) and human-computer interface problems (21%) often occur alone and are the main contributors to error causation, whereas the prevention of error is largely a result of teamwork (65%) and situation awareness (46%) skills. No matter the cause of error, situation awareness and teamwork skills are used most often to detect and prevent the error. Situation awareness and teamwork skills appear universally important as a "last line" of defense for capturing error, and data from incident-monitoring systems can be analyzed in a fashion more consistent with a "Safety-II" approach. This research provides data for ameliorating risk within financial trading organizations, with implications for future risk management programs and regulation.
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Residents' numeric inputting error in computerized physician order entry prescription.
Wu, Xue; Wu, Changxu; Zhang, Kan; Wei, Dong
2016-04-01
Computerized physician order entry (CPOE) system with embedded clinical decision support (CDS) can significantly reduce certain types of prescription error. However, prescription errors still occur. Various factors such as the numeric inputting methods in human computer interaction (HCI) produce different error rates and types, but has received relatively little attention. This study aimed to examine the effects of numeric inputting methods and urgency levels on numeric inputting errors of prescription, as well as categorize the types of errors. Thirty residents participated in four prescribing tasks in which two factors were manipulated: numeric inputting methods (numeric row in the main keyboard vs. numeric keypad) and urgency levels (urgent situation vs. non-urgent situation). Multiple aspects of participants' prescribing behavior were measured in sober prescribing situations. The results revealed that in urgent situations, participants were prone to make mistakes when using the numeric row in the main keyboard. With control of performance in the sober prescribing situation, the effects of the input methods disappeared, and urgency was found to play a significant role in the generalized linear model. Most errors were either omission or substitution types, but the proportion of transposition and intrusion error types were significantly higher than that of the previous research. Among numbers 3, 8, and 9, which were the less common digits used in prescription, the error rate was higher, which was a great risk to patient safety. Urgency played a more important role in CPOE numeric typing error-making than typing skills and typing habits. It was recommended that inputting with the numeric keypad had lower error rates in urgent situation. An alternative design could consider increasing the sensitivity of the keys with lower frequency of occurrence and decimals. To improve the usability of CPOE, numeric keyboard design and error detection could benefit from spatial incidence of errors found in this study. Copyright © 2016 Elsevier Ireland Ltd. All rights reserved.
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Adnan, Tassha Hilda; Hashim, Nadiah Hanis; Mohan, Kirubashni; Kim Liong, Ang; Ahmad, Ghazali; Bak Leong, Goh; Bavanandan, Sunita; Haniff, Jamaiyah
2017-01-01
Background. The incidence of patients with end-stage renal disease (ESRD) requiring dialysis has been growing rapidly in Malaysia from 18 per million population (pmp) in 1993 to 231 pmp in 2013. Objective. To forecast the incidence and prevalence of ESRD patients who will require dialysis treatment in Malaysia until 2040. Methodology. Univariate forecasting models using the number of new and current dialysis patients, by the Malaysian Dialysis and Transplant Registry from 1993 to 2013 were used. Four forecasting models were evaluated, and the model with the smallest error was selected for the prediction. Result. ARIMA (0, 2, 1) modeling with the lowest error was selected to predict both the incidence (RMSE = 135.50, MAPE = 2.85, and MAE = 87.71) and the prevalence (RMSE = 158.79, MAPE = 1.29, and MAE = 117.21) of dialysis patients. The estimated incidences of new dialysis patients in 2020 and 2040 are 10,208 and 19,418 cases, respectively, while the estimated prevalence is 51,269 and 106,249 cases. Conclusion. The growth of ESRD patients on dialysis in Malaysia can be expected to continue at an alarming rate. Effective steps to address and curb further increase in new patients requiring dialysis are urgently needed, in order to mitigate the expected financial and health catastrophes associated with the projected increase of such patients. PMID:28348890
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The application of Aronson's taxonomy to medication errors in nursing.
Johnson, Maree; Young, Helen
2011-01-01
Medication administration is a frequent nursing activity that is prone to error. In this study of 318 self-reported medication incidents (including near misses), very few resulted in patient harm-7% required intervention or prolonged hospitalization or caused temporary harm. Aronson's classification system provided an excellent framework for analysis of the incidents with a close connection between the type of error and the change strategy to minimize medication incidents. Taking a behavioral approach to medication error classification has provided helpful strategies for nurses such as nurse-call cards on patient lockers when patients are absent and checking of medication sign-off by outgoing and incoming staff at handover.
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DOE Office of Scientific and Technical Information (OSTI.GOV)
Yang, R; Wang, J
2014-06-15
Purpose: To explore the implementation and effectiveness of incident learning for the safety and quality of radiotherapy in a new established radiotherapy program with advanced technology. Methods: Reference to the consensus recommendations by American Association of Physicist in Medicine, an incident learning system was specifically designed for reporting, investigating, and learning of individual radiotherapy incidents in a new established radiotherapy program, with 4D CBCT, Ultrasound guided radiotherapy, VMAT, gated treatment delivered on two new installed linacs. The incidents occurring in external beam radiotherapy from February, 2012 to January, 2014 were reported. Results: A total of 33 reports were analyzed, includingmore » 28 near misses and 5 incidents. Among them, 5 originated in imaging for planning, 25 in planning, 1 in plan transfer, 1 in commissioning and 1 in treatment delivery. Among them, three near misses originated in the safety barrier of the radiotherapy process. In terms of error type, 1 incident was classified as wrong patient, 7 near misses/incidents as wrong site, 6 as wrong laterality, 5 as wrong dose, 7 as wrong prescription, and 7 as suboptimal plan quality. 5 incidents were all classified as grade 1/2 of dosimetric severity, 1 as grade 0, and the other 4 as grade 1 of medical severity. For the causes/contributory factors, negligence, policy not followed, inadequate training, failure to develop an effective plan, and communication contributed to 19, 15, 12, 5 and 3 near misses/incidents, respectively. The average incident rate per 100 patients treated was 0.4; this rate fell to 0.28% in the second year from 0.56% in the first year. The rate of near miss fell to 1.24% from 2.22%. Conclusion: Effective incident learning can reduce the occurrence of near miss/incidents, enhance the culture of safety. Incident learning is an effective proactive method for improving the quality and safety of radiotherapy.« less
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Error management training and simulation education.
Gardner, Aimee; Rich, Michelle
2014-12-01
The integration of simulation into the training of health care professionals provides context for decision making and procedural skills in a high-fidelity environment, without risk to actual patients. It was hypothesised that a novel approach to simulation-based education - error management training - would produce higher performance ratings compared with traditional step-by-step instruction. Radiology technology students were randomly assigned to participate in traditional procedural-based instruction (n = 11) or vicarious error management training (n = 11). All watched an instructional video and discussed how well each incident was handled (traditional instruction group) or identified where the errors were made (vicarious error management training). Students then participated in a 30-minute case-based simulation. Simulations were videotaped for performance analysis. Blinded experts evaluated performance using a predefined evaluation tool created specifically for the scenario. Blinded experts evaluated performance using a predefined evaluation tool created specifically for the scenario The vicarious error management group scored higher on observer-rated performance (Mean = 9.49) than students in the traditional instruction group (Mean = 9.02; p < 0.01). These findings suggest that incorporating the discussion of errors and how to handle errors during the learning session will better equip students when performing hands-on procedures and skills. This pilot study provides preliminary evidence for integrating error management skills into medical curricula and for the design of learning goals in simulation-based education. © 2014 John Wiley & Sons Ltd.
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A national physician survey of diagnostic error in paediatrics.
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.
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Harada, Saki; Suzuki, Akio; Nishida, Shohei; Kobayashi, Ryo; Tamai, Sayuri; Kumada, Keisuke; Murakami, Nobuo; Itoh, Yoshinori
2017-06-01
Insulin is frequently used for glycemic control. Medication errors related to insulin are a common problem for medical institutions. Here, we prepared a standardized sliding scale insulin (SSI) order sheet and assessed the effect of its introduction. Observations before and after the introduction of the standardized SSI template were conducted at Gifu University Hospital. The incidence of medication errors, hyperglycemia, and hypoglycemia related to SSI were obtained from the electronic medical records. The introduction of the standardized SSI order sheet significantly reduced the incidence of medication errors related to SSI compared with that prior to its introduction (12/165 [7.3%] vs 4/159 [2.1%], P = .048). However, the incidence of hyperglycemia (≥250 mg/dL) and hypoglycemia (≤50 mg/dL) in patients who received SSI was not significantly different between the 2 groups. The introduction of the standardized SSI order sheet reduced the incidence of medication errors related to SSI. © 2016 John Wiley & Sons, Ltd.
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Mechanical Ventilation-Related Safety Incidents in General Care Wards and ICU Settings.
Kamio, Tadashi; Masamune, Ken
2018-05-29
Although the ICU is the most appropriate place to care for mechanically ventilated patients, a considerable number are ventilated in general medical care wards all over the world. However, adverse events focusing on mechanically ventilated patients in general care have not been explored. Data from the Japan Council for Quality Health Care database were analyzed. Patient safety incidents from January 2010 to November 2017 regarding mechanical ventilation were collected, and comparisons of patient safety incidents between ICUs/high care units (HCUs) and general care wards were made. We identified 261 adverse events (with at least 20 adverse events resulting in death) and 702 near-miss events related to mechanical ventilation in Japan between 2010 and 2017. Furthermore, among all adverse events, 19% (49 of 261 events) caused serious harm (residual disability or death). Human-factor issues were most frequent in both ICU/HCU and general care settings (55% and 53%, respectively), while knowledge-based errors were higher in the general care setting. Human-factor issues were the most frequent reasons in both settings, while knowledge-based error rates were higher in general care. Our results suggest that proper education and training is needed to minimize patient safety incidents in facilities without respiratory therapists. Copyright © 2018 by Daedalus Enterprises.
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Identifying medication error chains from critical incident reports: a new analytic approach.
Huckels-Baumgart, Saskia; Manser, Tanja
2014-10-01
Research into the distribution of medication errors usually focuses on isolated stages within the medication use process. Our study aimed to provide a novel process-oriented approach to medication incident analysis focusing on medication error chains. Our study was conducted across a 900-bed teaching hospital in Switzerland. All reported 1,591 medication errors 2009-2012 were categorized using the Medication Error Index NCC MERP and the WHO Classification for Patient Safety Methodology. In order to identify medication error chains, each reported medication incident was allocated to the relevant stage of the hospital medication use process. Only 25.8% of the reported medication errors were detected before they propagated through the medication use process. The majority of medication errors (74.2%) formed an error chain encompassing two or more stages. The most frequent error chain comprised preparation up to and including medication administration (45.2%). "Non-consideration of documentation/prescribing" during the drug preparation was the most frequent contributor for "wrong dose" during the administration of medication. Medication error chains provide important insights for detecting and stopping medication errors before they reach the patient. Existing and new safety barriers need to be extended to interrupt error chains and to improve patient safety. © 2014, The American College of Clinical Pharmacology.
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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.
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Using incident reports to inform the prevention of medication administration errors.
Härkänen, Marja; Saano, Susanna; Vehviläinen-Julkunen, Katri
2017-11-01
To describe ways of preventing medication administration errors based on reporters' views expressed in medication administration incident reports. Medication administration errors are very common, and nurses play important roles in committing and in preventing such errors. Thus far, incident reporters' perceptions of how to prevent medication administration errors have rarely been analysed. This is a qualitative, descriptive study using an inductive content analysis of the incident reports related to medication administration errors (n = 1012). These free-text descriptions include reporters' views on preventing the reoccurrence of medication administration errors. The data were collected from two hospitals in Finland and pertain to incidents that were reported between 1 January 2013 and 31 December 2014. Reporters' views on preventing medication administration errors were divided into three main categories related to individuals (health professionals), teams and organisations. The following categories related to individuals in preventing medication administration errors were identified: (1) accuracy and preciseness; (2) verification; and (3) following the guidelines, responsibility and attitude towards work. The team categories were as follows: (1) distribution of work; (2) flow of information and cooperation; and (3) documenting and marking the drug information. The categories related to organisation were as follows: (1) work environment; (2) resources; (3) training; (4) guidelines; and (5) development of the work. Health professionals should administer medication with a high moral awareness and an attempt to concentrate on the task. Nonetheless, the system should support health professionals by providing a reasonable work environment and encouraging collaboration among the providers to facilitate the safe administration of medication. Although there are numerous approaches to supporting medication safety, approaches that support the ability of individual health professionals to manage daily medications should be prioritised. © 2017 John Wiley & Sons Ltd.
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The Effect of Administrative Boundaries and Geocoding Error on Cancer Rates in California
Goldberg, Daniel W.; Cockburn, Myles G.
2012-01-01
Geocoding is often used to produce maps of disease rates from the diagnosis addresses of incident cases to assist with disease surveillance, prevention, and control. In this process, diagnosis addresses are converted into latitude/longitude pairs which are then aggregated to produce rates at varying geographic scales such as Census tracts, neighborhoods, cities, counties, and states. The specific techniques used within geocoding systems have an impact on where the output geocode is located and can therefore have an effect on the derivation of disease rates at different geographic aggregations. This paper investigates how county-level cancer rates are affected by the choice of interpolation method when case data are geocoded to the ZIP code level. Four commonly used areal unit interpolation techniques are applied and the output of each is used to compute crude county-level five-year incidence rates of all cancers in California. We found that the rates observed for 44 out of the 58 counties in California vary based on which interpolation method is used, with rates in some counties increasing by nearly 400% between interpolation methods. PMID:22469490
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DOE Office of Scientific and Technical Information (OSTI.GOV)
Kalapurakal, John A., E-mail: j-kalapurakal@northwestern.edu; Zafirovski, Aleksandar; Smith, Jeffery
Purpose: This report describes the value of a voluntary error reporting system and the impact of a series of quality assurance (QA) measures including checklists and timeouts on reported error rates in patients receiving radiation therapy. Methods and Materials: A voluntary error reporting system was instituted with the goal of recording errors, analyzing their clinical impact, and guiding the implementation of targeted QA measures. In response to errors committed in relation to treatment of the wrong patient, wrong treatment site, and wrong dose, a novel initiative involving the use of checklists and timeouts for all staff was implemented. The impactmore » of these and other QA initiatives was analyzed. Results: From 2001 to 2011, a total of 256 errors in 139 patients after 284,810 external radiation treatments (0.09% per treatment) were recorded in our voluntary error database. The incidence of errors related to patient/tumor site, treatment planning/data transfer, and patient setup/treatment delivery was 9%, 40.2%, and 50.8%, respectively. The compliance rate for the checklists and timeouts initiative was 97% (P<.001). These and other QA measures resulted in a significant reduction in many categories of errors. The introduction of checklists and timeouts has been successful in eliminating errors related to wrong patient, wrong site, and wrong dose. Conclusions: A comprehensive QA program that regularly monitors staff compliance together with a robust voluntary error reporting system can reduce or eliminate errors that could result in serious patient injury. We recommend the adoption of these relatively simple QA initiatives including the use of checklists and timeouts for all staff to improve the safety of patients undergoing radiation therapy in the modern era.« less
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Assessment of legibility and completeness of handwritten and electronic prescriptions
Albarrak, Ahmed I; Al Rashidi, Eman Abdulrahman; Fatani, Rwaa Kamil; Al Ageel, Shoog Ibrahim; Mohammed, Rafiuddin
2014-01-01
Objectives To assess the legibility and completeness of handwritten prescriptions and compare with electronic prescription system for medication errors. Design Prospective study. Setting King Khalid University Hospital (KKUH), Riyadh, Saudi Arabia. Subjects and methods Handwritten prescriptions were received from clinical units of Medicine Outpatient Department (MOPD), Primary Care Clinic (PCC) and Surgery Outpatient Department (SOPD) whereas electronic prescriptions were collected from the pediatric ward. The handwritten prescription was assessed for completeness by the checklist designed according to the hospital prescription and evaluated for legibility by two pharmacists. The comparison between handwritten and electronic prescription errors was evaluated based on the validated checklist adopted from previous studies. Main outcome measures Legibility and completeness of prescriptions. Results 398 prescriptions (199 handwritten and 199 e-prescriptions) were assessed. About 71 (35.7%) of handwritten and 5 (2.5%) of electronic prescription errors were identified. A significant statistical difference (P < 0.001) was observed between handwritten and e-prescriptions in omitted dose and omitted route of administration category of error distribution. The rate of completeness in patient identification in handwritten prescriptions was 80.97% in MOPD, 76.36% in PCC and 85.93% in SOPD clinic units. Assessment of medication prescription completeness was 91.48% in MOPD, 88.48% in PCC, and 89.28% in SOPD. Conclusions This study revealed a high incidence of prescribing errors in handwritten prescriptions. The use of e-prescription system showed a significant decline in the incidence of errors. The legibility of handwritten prescriptions was relatively good whereas the level of completeness was very low. PMID:25561864
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Shift work in nursing: is it really a risk factor for nurses' health and patients' safety?
Admi, Hanna; Tzischinsky, Orna; Epstein, Rachel; Herer, Paula; Lavie, Peretz
2008-01-01
There is evidence in the scientific literature of the adverse physiological and psychological effects of shift work, including disruption to biological rhythm, sleep disorders, health problems, diminished performance at work, job dissatisfaction, and social isolation. In this study, the results of health problems and sleep disorders between female and male nurses, between daytime and shift nurses, and between sleep-adjusted and non-sleep-adjusted shift nurses were compared. Also the relationship between adjustment to shift work and organizational outcomes (errors and incidents and absenteeism from work) was analyzed. Gender, age, and weight were more significant factors than shift work in determining the well-being of nurses. Shift work by itself was not found to be a risk factor for nurses' health and organizational outcomes in this study. Moreover, nurses who were identified as being "non-adaptive" to shift work were found to work as effectively and safely as their adaptive colleagues in terms of absenteeism from work and involvement in professional errors and accidents. This research adds two additional findings to the field of shift work studies. The first finding is that female shift workers complain significantly more about sleep disorders than male shift workers. Second, although high rates of nurses whose sleep was not adapted to shift work were found, this did not have a more adverse impact on their health, absenteeism rates, or performance (reported errors and incidents), compared to their "adaptive" and "daytime" colleagues.
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Methods developed to elucidate nursing related adverse events in Japan.
Yamagishi, Manaho; Kanda, Katsuya; Takemura, Yukie
2003-05-01
Financial resources for quality assurance in Japanese hospitals are limited and few hospitals have quality monitoring systems of nursing service systems. However, recently its necessity has been recognized. This study has cost effectively used adverse event occurrence rates as indicators of the quality of nursing service, and audited methods of collecting data on adverse events to elucidate their approximate true numbers. Data collection was conducted in July, August and November 2000 at a hospital in Tokyo that administered both primary and secondary health care services (281 beds, six wards, average length of stay 23 days). We collected adverse events through incident reports, logs, check-lists, nurse interviews, medication error questionnaires, urine leucocyte tests, patient interviews and medical records. Adverse events included the unplanned removals of invasive lines, medication errors, falls, pressure sores, skin deficiencies, physical restraints, and nosocomial infections. After evaluating the time and useful outcomes of each source, it soon became clear that we could elucidate adverse events most consistently and cost-effectively through incident reports, check lists, nurse interviews, urine leucocyte tests and medication error questionnaires. This study suggests that many hospitals in Japan could monitor the quality of the nursing service using these sources.
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Blindness following bleb-related infection in open angle glaucoma.
Yamada, Hiroki; Sawada, Akira; Kuwayama, Yasuaki; Yamamoto, Tetsuya
2014-11-01
To estimate the risk of blindness following bleb-related infection after trabeculectomy with mitomycin C in open angle glaucoma, utilizing data obtained from two prospective multicenter studies. The incidence of bleb-related infection in open angle glaucoma after the first or second glaucoma surgery was calculated using a Kaplan-Meier analysis and data from the Collaborative Bleb-related Infection Incidence and Treatment Study (CBIITS). The rate of blindness following bleb-related infection was calculated using data from the Japan Glaucoma Society Survey of Bleb-related Infection (JGSSBI). Finally, the rate of blindness following bleb-related infection after filtering surgery was estimated based on the above two data sets. Blindness was defined as an eye with a visual acuity of 0.04 or less. The incidences of development of bleb-related infection at 5 years were 2.6 ± 0.7 % (calculated cumulative incidence ± standard error) for all infections and 0.9 ± 0.4 % for endophthalmitis in all cases in the CBIITS data. The rates of blindness in the JGSSBI data were 14 % for the total cases with bleb-related infection and 30 % for the endophthalmitis subgroup. The rate of blindness developing within 5 years following trabeculectomy was estimated to be approximately 0.24-0.36 %. The rate of blindness following bleb-related infection within 5 years after trabeculectomy is considerable and thus careful consideration must be given to the indication for trabeculectomy and the selection of surgical techniques.
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Doytchev, Doytchin E; Szwillus, Gerd
2009-11-01
Understanding the reasons for incident and accident occurrence is important for an organization's safety. Different methods have been developed to achieve this goal. To better understand the human behaviour in incident occurrence we propose an analysis concept that combines Fault Tree Analysis (FTA) and Task Analysis (TA). The former method identifies the root causes of an accident/incident, while the latter analyses the way people perform the tasks in their work environment and how they interact with machines or colleagues. These methods were complemented with the use of the Human Error Identification in System Tools (HEIST) methodology and the concept of Performance Shaping Factors (PSF) to deepen the insight into the error modes of an operator's behaviour. HEIST shows the external error modes that caused the human error and the factors that prompted the human to err. To show the validity of the approach, a case study at a Bulgarian Hydro power plant was carried out. An incident - the flooding of the plant's basement - was analysed by combining the afore-mentioned methods. The case study shows that Task Analysis in combination with other methods can be applied successfully to human error analysis, revealing details about erroneous actions in a realistic situation.
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A Real-Time Safety and Quality Reporting System: Assessment of Clinical Data and Staff Participation
DOE Office of Scientific and Technical Information (OSTI.GOV)
Rahn, Douglas A.; Kim, Gwe-Ya; Mundt, Arno J.
Purpose: To report on the use of an incident learning system in a radiation oncology clinic, along with a review of staff participation. Methods and Materials: On September 24, 2010, our department initiated an online real-time voluntary reporting system for safety issues, called the Radiation Oncology Quality Reporting System (ROQRS). We reviewed these reports from the program's inception through January 18, 2013 (2 years, 3 months, 25 days) to assess error reports (defined as both near-misses and incidents of inaccurate treatment). Results: During the study interval, there were 60,168 fractions of external beam radiation therapy and 955 brachytherapy procedures. There were 298 entriesmore » in the ROQRS system, among which 108 errors were reported. There were 31 patients with near-misses reported and 27 patients with incidents of inaccurate treatment reported. These incidents of inaccurate treatment occurred in 68 total treatment fractions (0.11% of treatments delivered during the study interval). None of these incidents of inaccurate treatment resulted in deviation from the prescription by 5% or more. A solution to the errors was documented in ROQRS in 65% of the cases. Errors occurred as repeated errors in 22% of the cases. A disproportionate number of the incidents of inaccurate treatment were due to improper patient setup at the linear accelerator (P<.001). Physician participation in ROQRS was nonexistent initially, but improved after an education program. Conclusions: Incident learning systems are a useful and practical means of improving safety and quality in patient care.« less
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Errors, near misses and adverse events in the emergency department: what can patients tell us?
Friedman, Steven M; Provan, David; Moore, Shannon; Hanneman, Kate
2008-09-01
We sought to determine whether patients or their families could identify adverse events in the emergency department (ED), to characterize patient reports of errors and to compare patient reports to events recorded by health care providers. This was a prospective cohort study in a quaternary care inner city teaching hospital with approximately 40,000 annual visits. ED patients were recruited for participation in a standardized interview within 24 hours of ED discharge and a follow-up interview 3-7 days after discharge. Responses regarding events were tabulated and compared with physician and nurse notations in the medical record and hospital event reporting system. Of 292 eligible patients, 201 (69%) were interviewed within 24 hours of ED discharge, and 143 (71% of interviewees) underwent a follow-up interview 3-7 days after discharge. Interviewees did not differ from the base ED population in terms of age, sex or language. Analysis of patient interviews identified 10 adverse events (5% incident rate; 95% confidence interval [CI] 2.41%-8.96%), 8 near misses (4% incident rate; 95% CI 1.73%-7.69%) and no medical errors. Of the 10 adverse events, 6 (60%) were characterized as preventable (2 raters; kappa=0.78, standard error [SE] 0.20; 95% CI 0.39-1.00; p=0.01). Adverse events were primarily related to delayed or inadequate analgesia. Only 4 out of 8 (50%) near misses were intercepted by hospital personnel. The secondary interview elicited 2 out of 10 adverse events and 3 out of 8 near misses that had not been identified in the primary interview. No designation (0 out of 10) of an adverse event was recorded in the ED medical record or in the confidential hospital event reporting system. ED patients can identify adverse events affecting their care. Moreover, many of these events are not recorded in the medical record. Engaging patients and their family members in identification of errors may enhance patient safety.
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DOE Office of Scientific and Technical Information (OSTI.GOV)
Bojechko, Casey; Phillps, Mark; Kalet, Alan
Purpose: Complex treatments in radiation therapy require robust verification in order to prevent errors that can adversely affect the patient. For this purpose, the authors estimate the effectiveness of detecting errors with a “defense in depth” system composed of electronic portal imaging device (EPID) based dosimetry and a software-based system composed of rules-based and Bayesian network verifications. Methods: The authors analyzed incidents with a high potential severity score, scored as a 3 or 4 on a 4 point scale, recorded in an in-house voluntary incident reporting system, collected from February 2012 to August 2014. The incidents were categorized into differentmore » failure modes. The detectability, defined as the number of incidents that are detectable divided total number of incidents, was calculated for each failure mode. Results: In total, 343 incidents were used in this study. Of the incidents 67% were related to photon external beam therapy (EBRT). The majority of the EBRT incidents were related to patient positioning and only a small number of these could be detected by EPID dosimetry when performed prior to treatment (6%). A large fraction could be detected by in vivo dosimetry performed during the first fraction (74%). Rules-based and Bayesian network verifications were found to be complimentary to EPID dosimetry, able to detect errors related to patient prescriptions and documentation, and errors unrelated to photon EBRT. Combining all of the verification steps together, 91% of all EBRT incidents could be detected. Conclusions: This study shows that the defense in depth system is potentially able to detect a large majority of incidents. The most effective EPID-based dosimetry verification is in vivo measurements during the first fraction and is complemented by rules-based and Bayesian network plan checking.« less
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Image defects from surface and alignment errors in grazing incidence telescopes
NASA Technical Reports Server (NTRS)
Saha, Timo T.
1989-01-01
The rigid body motions and low frequency surface errors of grazing incidence Wolter telescopes are studied. The analysis is based on surface error descriptors proposed by Paul Glenn. In his analysis, the alignment and surface errors are expressed in terms of Legendre-Fourier polynomials. Individual terms in the expression correspond to rigid body motions (decenter and tilt) and low spatial frequency surface errors of mirrors. With the help of the Legendre-Fourier polynomials and the geometry of grazing incidence telescopes, exact and approximated first order equations are derived in this paper for the components of the ray intercepts at the image plane. These equations are then used to calculate the sensitivities of Wolter type I and II telescopes for the rigid body motions and surface deformations. The rms spot diameters calculated from this theory and OSAC ray tracing code agree very well. This theory also provides a tool to predict how rigid body motions and surface errors of the mirrors compensate each other.
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Lemcke, J; Meier, U; Müller, C; Fritsch, M; Eymann, R; Kiefer, M; Kehler, U; Langer, N; Rohde, V; Ludwig, H-Ch; Weber, F; Remenez, V; Schuhmann, M; Stengel, D
2010-01-01
Overdrainage is a common complication observed after shunting patients with idiopathic normal-pressure hydrocephalus (iNPH), with an estimated incidence up to 25%. Gravitational units that counterbalance intracranial pressure changes were developed to overcome this problem. We will set out to investigate whether the combination of a programmable valve and a gravitational unit (proGAV, Aesculap/Miethke, Germany) is capable of reducing the incidence of overdrainage and improving patient-centered outcomes compared to a conventional programmable valve (Medos-Codman, Johnson & Johnson, Germany). SVASONA is a pragmatic randomized controlled trial conducted at seven centers in Germany. Patients with a high probability of iNPH (based on clinical signs and symptoms, lumbar infusion and/or tap test, cranial computed tomography [CCT]) and no contraindications for surgical drainage will randomly be assigned to receive (1) a shunt assistant valve (proGAV) or (2) a conventional, programmable shunt valve (programmable Medos-Codman).We will test the primary hypothesis that the experimental device reduces the rate of overdrainage from 25% to 10%. As secondary analyses, we will measure iNPH-specific outcomes (i.e., the Black grading scale and the NPH Recovery Rate), generic quality of life (Short Form 36), and complications and serious adverse events (SAE). One planned interim analysis for safety and efficacy will be performed halfway through the study. To detect the hypothesized difference in the incidence of overdrainage with a type I error of 5% and a type II error of 20%, correcting for multiple testing and an anticipated dropout rate of 10%, 200 patients will be enrolled.The presented trial is currently recruiting patients, with the first results predicted to be available in late 2008.
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Proton upsets in LSI memories in space
NASA Technical Reports Server (NTRS)
Mcnulty, P. J.; Wyatt, R. C.; Filz, R. C.; Rothwell, P. L.; Farrell, G. E.
1980-01-01
Two types of large scale integrated dynamic random access memory devices were tested and found to be subject to soft errors when exposed to protons incident at energies between 18 and 130 MeV. These errors are shown to differ significantly from those induced in the same devices by alphas from an Am-241 source. There is considerable variation among devices in their sensitivity to proton-induced soft errors, even among devices of the same type. For protons incident at 130 MeV, the soft error cross sections measured in these experiments varied from 10 to the -8th to 10 to the -6th sq cm/proton. For individual devices, however, the soft error cross section consistently increased with beam energy from 18-130 MeV. Analysis indicates that the soft errors induced by energetic protons result from spallation interactions between the incident protons and the nuclei of the atoms comprising the device. Because energetic protons are the most numerous of both the galactic and solar cosmic rays and form the inner radiation belt, proton-induced soft errors have potentially serious implications for many electronic systems flown in space.
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Morrison, Maeve; Cope, Vicki; Murray, Melanie
2018-05-15
Medication errors remain a commonly reported clinical incident in health care as highlighted by the World Health Organization's focus to reduce medication-related harm. This retrospective quantitative analysis examined medication errors reported by staff using an electronic Clinical Incident Management System (CIMS) during a 3-year period from April 2014 to April 2017 at a metropolitan mental health ward in Western Australia. The aim of the project was to identify types of medication errors and the context in which they occur and to consider recourse so that medication errors can be reduced. Data were retrieved from the Clinical Incident Management System database and concerned medication incidents from categorized tiers within the system. Areas requiring improvement were identified, and the quality of the documented data captured in the database was reviewed for themes pertaining to medication errors. Content analysis provided insight into the following issues: (i) frequency of problem, (ii) when the problem was detected, and (iii) characteristics of the error (classification of drug/s, where the error occurred, what time the error occurred, what day of the week it occurred, and patient outcome). Data were compared to the state-wide results published in the Your Safety in Our Hands (2016) report. Results indicated several areas upon which quality improvement activities could be focused. These include the following: structural changes; changes to policy and practice; changes to individual responsibilities; improving workplace culture to counteract underreporting of medication errors; and improvement in safety and quality administration of medications within a mental health setting. © 2018 Australian College of Mental Health Nurses Inc.
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Performance analysis of air-water quantum key distribution with an irregular sea surface
NASA Astrophysics Data System (ADS)
Xu, Hua-bin; Zhou, Yuan-yuan; Zhou, Xue-jun; Wang, Lian
2018-05-01
In the air-water quantum key distribution (QKD), the irregular sea surface has some influence on the photon polarization state. The wind is considered as the main factor causing the irregularity, so the model of irregular sea surface based on the wind speed is adopted. The relationships of the quantum bit error rate with the wind speed and the initial incident angle are simulated. Therefore, the maximum secure transmission depth of QKD is confirmed, and the limitation of the wind speed and the initial incident angle is determined. The simulation results show that when the wind speed and the initial incident angle increase, the performance of QKD will fall down. Under the intercept-resend attack condition, the maximum safe transmission depth of QKD is up to 105 m. To realize safe communications in the safe diving depth of submarines (100 m), the initial incident angle is requested to be not exceeding 26°, and with the initial incident angle increased, the limitation of wind speed is decreased.
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[Detection and classification of medication errors at Joan XXIII University Hospital].
Jornet Montaña, S; Canadell Vilarrasa, L; Calabuig Mũoz, M; Riera Sendra, G; Vuelta Arce, M; Bardají Ruiz, A; Gallart Mora, M J
2004-01-01
Medication errors are multifactorial and multidisciplinary, and may originate in processes such as drug prescription, transcription, dispensation, preparation and administration. The goal of this work was to measure the incidence of detectable medication errors that arise within a unit dose drug distribution and control system, from drug prescription to drug administration, by means of an observational method confined to the Pharmacy Department, as well as a voluntary, anonymous report system. The acceptance of this voluntary report system's implementation was also assessed. A prospective descriptive study was conducted. Data collection was performed at the Pharmacy Department from a review of prescribed medical orders, a review of pharmaceutical transcriptions, a review of dispensed medication and a review of medication returned in unit dose medication carts. A voluntary, anonymous report system centralized in the Pharmacy Department was also set up to detect medication errors. Prescription errors were the most frequent (1.12%), closely followed by dispensation errors (1.04%). Transcription errors (0.42%) and administration errors (0.69%) had the lowest overall incidence. Voluntary report involved only 4.25% of all detected errors, whereas unit dose medication cart review contributed the most to error detection. Recognizing the incidence and types of medication errors that occur in a health-care setting allows us to analyze their causes and effect changes in different stages of the process in order to ensure maximal patient safety.
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Physiological Factors Analysis in Unpressurized Aircraft Cabins
NASA Astrophysics Data System (ADS)
Patrao, Luis; Zorro, Sara; Silva, Jorge
2016-11-01
Amateur and sports flight is an activity with growing numbers worldwide. However, the main cause of flight incidents and accidents is increasingly pilot error, for a number of reasons. Fatigue, sleep issues and hypoxia, among many others, are some that can be avoided, or, at least, mitigated. This article describes the analysis of psychological and physiological parameters during flight in unpressurized aircraft cabins. It relates cerebral oximetry and heart rate with altitude, as well as with flight phase. The study of those parameters might give clues on which variations represent a warning sign to the pilot, thus preventing incidents and accidents due to human factors. Results show that both cerebral oximetry and heart rate change along the flight and altitude in the alert pilot. The impaired pilot might not reveal these variations and, if this is detected, he can be warned in time.
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The effect of administrative boundaries and geocoding error on cancer rates in California.
Goldberg, Daniel W; Cockburn, Myles G
2012-04-01
Geocoding is often used to produce maps of disease rates from the diagnosis addresses of incident cases to assist with disease surveillance, prevention, and control. In this process, diagnosis addresses are converted into latitude/longitude pairs which are then aggregated to produce rates at varying geographic scales such as Census tracts, neighborhoods, cities, counties, and states. The specific techniques used within geocoding systems have an impact on where the output geocode is located and can therefore have an effect on the derivation of disease rates at different geographic aggregations. This paper investigates how county-level cancer rates are affected by the choice of interpolation method when case data are geocoded to the ZIP code level. Four commonly used areal unit interpolation techniques are applied and the output of each is used to compute crude county-level five-year incidence rates of all cancers in California. We found that the rates observed for 44 out of the 58 counties in California vary based on which interpolation method is used, with rates in some counties increasing by nearly 400% between interpolation methods. Copyright © 2012 Elsevier Ltd. All rights reserved.
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Application of a Hybrid Model for Predicting the Incidence of Tuberculosis in Hubei, China
Zhang, Guoliang; Huang, Shuqiong; Duan, Qionghong; Shu, Wen; Hou, Yongchun; Zhu, Shiyu; Miao, Xiaoping; Nie, Shaofa; Wei, Sheng; Guo, Nan; Shan, Hua; Xu, Yihua
2013-01-01
Background A prediction model for tuberculosis incidence is needed in China which may be used as a decision-supportive tool for planning health interventions and allocating health resources. Methods The autoregressive integrated moving average (ARIMA) model was first constructed with the data of tuberculosis report rate in Hubei Province from Jan 2004 to Dec 2011.The data from Jan 2012 to Jun 2012 were used to validate the model. Then the generalized regression neural network (GRNN)-ARIMA combination model was established based on the constructed ARIMA model. Finally, the fitting and prediction accuracy of the two models was evaluated. Results A total of 465,960 cases were reported between Jan 2004 and Dec 2011 in Hubei Province. The report rate of tuberculosis was highest in 2005 (119.932 per 100,000 population) and lowest in 2010 (84.724 per 100,000 population). The time series of tuberculosis report rate show a gradual secular decline and a striking seasonal variation. The ARIMA (2, 1, 0) × (0, 1, 1)12 model was selected from several plausible ARIMA models. The residual mean square error of the GRNN-ARIMA model and ARIMA model were 0.4467 and 0.6521 in training part, and 0.0958 and 0.1133 in validation part, respectively. The mean absolute error and mean absolute percentage error of the hybrid model were also less than the ARIMA model. Discussion and Conclusions The gradual decline in tuberculosis report rate may be attributed to the effect of intensive measures on tuberculosis. The striking seasonal variation may have resulted from several factors. We suppose that a delay in the surveillance system may also have contributed to the variation. According to the fitting and prediction accuracy, the hybrid model outperforms the traditional ARIMA model, which may facilitate the allocation of health resources in China. PMID:24223232
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Ground Taxi Navigation Problems and Training Solutions
NASA Technical Reports Server (NTRS)
Quinn, Cheryl; Walter, Kim E.; Rosekind, Mark (Technical Monitor)
1997-01-01
Adverse weather conditions can put considerable strain on the National Airspace System. Even small decreases in visibility on the airport surface can create delays, hinder safe movement and lead to errors. Studies of Aviation Safety Reporting System (ASRS) surface movement incidents support the need for technologies and procedures to improve ground operations in low-visibility conditions. This study examined 139 ASRS reports of low-visibility surface movement incidents at 10 major U.S. airports. Errors were characterized in terms of incident type, contributing factors and consequences. The incidents in the present sample were comprised of runway transgressions, taxiway excursions and ground conflicts. The primary contributing factors were Airport Layout and Markings, Communication and Distraction. In half the incidents the controller issued a new clearance or the flight crew took an evasive action and in the remaining half, no recovery attempt was made because the error was detected after the fact. By gaining a better understanding the factors that affect crew navigation in low visibility and the types of errors that are likely to occur, it will be possible to develop more robust technologies to aid pilots in the ground taxi task. Implications for crew training and procedure development for low-visibility ground taxi are also discussed.
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Learning to Fail in Aphasia: An Investigation of Error Learning in Naming
Middleton, Erica L.; Schwartz, Myrna F.
2013-01-01
Purpose To determine if the naming impairment in aphasia is influenced by error learning and if error learning is related to type of retrieval strategy. Method Nine participants with aphasia and ten neurologically-intact controls named familiar proper noun concepts. When experiencing tip-of-the-tongue naming failure (TOT) in an initial TOT-elicitation phase, participants were instructed to adopt phonological or semantic self-cued retrieval strategies. In the error learning manipulation, items evoking TOT states during TOT-elicitation were randomly assigned to a short or long time condition where participants were encouraged to continue to try to retrieve the name for either 20 seconds (short interval) or 60 seconds (long). The incidence of TOT on the same items was measured on a post test after 48-hours. Error learning was defined as a higher rate of recurrent TOTs (TOT at both TOT-elicitation and post test) for items assigned to the long (versus short) time condition. Results In the phonological condition, participants with aphasia showed error learning whereas controls showed a pattern opposite to error learning. There was no evidence for error learning in the semantic condition for either group. Conclusion Error learning is operative in aphasia, but dependent on the type of strategy employed during naming failure. PMID:23816662
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Five-Year Incidence of Visual Impairment in Middle-Aged Iranians: The Shahroud Eye Cohort Study.
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.
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Rashed, Anan; Hamdan, Motasem
2015-06-22
Underreporting of incidents that happen in health care services undermines the ability of the systems to improve patient safety. This study assessed the attitudes of physicians and nurses toward incident reporting and the factors influencing reporting in Palestinian hospitals. It also examined clinicians' views about the preferred features of incident reporting system. Cross-sectional self-administered survey of 475 participants, 152 physicians and 323 nurses, from 11 public hospitals in the West Bank; response rate, 81.3%. There was a low level of event reporting among participants in the past year (40.3%). Adjusted for sex and age, physicians were 2.1 times more likely to report incidents than nurses (95% confidence interval, 1.32-3.417; P = 0.002). Perceived main barriers for reporting were grouped under lack of proper structure for reporting, prevalence of blame, and punitive environment. The clinicians indicated fear of administrative sanctions, social and legal liability, and of their competence being questioned (P > 0.05). Getting help for patients, learning from mistakes, and ethical obligation were equally indicated motivators for reporting (P > 0.05). Meanwhile, clinicians prefer formal reporting (77.8%) of all type of errors (65.5%), disclosure of reporters (52.7%), using reports to improve patient safety (80.3%), and willingness to report to immediate supervisors (57.6%). Clinicians acknowledge the importance of reporting incidents; however, prevalence of punitive culture and inadequate reporting systems are key barriers. Improving feedback about reported errors, simplifying procedures, providing clear guidelines on what and who should report, and avoiding blame are essential to enhance reporting. Moreover, health care organizations should consider the opinions of the clinicians in developing reporting systems.
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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.
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Wavefront Sensing Analysis of Grazing Incidence Optical Systems
NASA Technical Reports Server (NTRS)
Rohrbach, Scott; Saha, Timo
2012-01-01
Wavefront sensing is a process by which optical system errors are deduced from the aberrations in the image of an ideal source. The method has been used successfully in near-normal incidence, but not for grazing incidence systems. This innovation highlights the ability to examine out-of-focus images from grazing incidence telescopes (typically operating in the x-ray wavelengths, but integrated using optical wavelengths) and determine the lower-order deformations. This is important because as a metrology tool, this method would allow the integration of high angular resolution optics without the use of normal incidence interferometry, which requires direct access to the front surface of each mirror. Measuring the surface figure of mirror segments in a highly nested x-ray telescope mirror assembly is difficult due to the tight packing of elements and blockage of all but the innermost elements to normal incidence light. While this can be done on an individual basis in a metrology mount, once the element is installed and permanently bonded into the assembly, it is impossible to verify the figure of each element and ensure that the necessary imaging quality will be maintained. By examining on-axis images of an ideal point source, one can gauge the low-order figure errors of individual elements, even when integrated into an assembly. This technique is known as wavefront sensing (WFS). By shining collimated light down the optical axis of the telescope and looking at out-of-focus images, the blur due to low-order figure errors of individual elements can be seen, and the figure error necessary to produce that blur can be calculated. The method avoids the problem of requiring normal incidence access to the surface of each mirror segment. Mirror figure errors span a wide range of spatial frequencies, from the lowest-order bending to the highest order micro-roughness. While all of these can be measured in normal incidence, only the lowest-order contributors can be determined through this WFS technique.
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Yang, Shu-Hui; Jerng, Jih-Shuin; Chen, Li-Chin; Li, Yu-Tsu; Huang, Hsiao-Fang; Wu, Chao-Ling; Chan, Jing-Yuan; Huang, Szu-Fen; Liang, Huey-Wen; Sun, Jui-Sheng
2017-11-03
Intra-hospital transportation (IHT) might compromise patient safety because of different care settings and higher demand on the human operation. Reports regarding the incidence of IHT-related patient safety events and human failures remain limited. To perform a retrospective analysis of IHT-related events, human failures and unsafe acts. A hospital-wide process for the IHT and database from the incident reporting system in a medical centre in Taiwan. All eligible IHT-related patient safety events between January 2010 to December 2015 were included. Incidence rate of IHT-related patient safety events, human failure modes, and types of unsafe acts. There were 206 patient safety events in 2 009 013 IHT sessions (102.5 per 1 000 000 sessions). Most events (n=148, 71.8%) did not involve patient harm, and process events (n=146, 70.9%) were most common. Events at the location of arrival (n=101, 49.0%) were most frequent; this location accounted for 61.0% and 44.2% of events with patient harm and those without harm, respectively (p<0.001). Of the events with human failures (n=186), the most common related process step was the preparation of the transportation team (n=91, 48.9%). Contributing unsafe acts included perceptual errors (n=14, 7.5%), decision errors (n=56, 30.1%), skill-based errors (n=48, 25.8%), and non-compliance (n=68, 36.6%). Multivariate analysis showed that human failure found in the arrival and hand-off sub-process (OR 4.84, p<0.001) was associated with increased patient harm, whereas the presence of omission (OR 0.12, p<0.001) was associated with less patient harm. This study shows a need to reduce human failures to prevent patient harm during intra-hospital transportation. We suggest that the transportation team pay specific attention to the sub-process at the location of arrival and prevent errors other than omissions. Long-term monitoring of IHT-related events is also warranted. © Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2017. All rights reserved. No commercial use is permitted unless otherwise expressly granted.
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Cancer incidence rates in the Kurdistan region/Iraq from 2007-2009.
Othman, Ramadhan T; Abdulljabar, Rezvan; Saeed, Abdullah; Kittani, Sarwar Sadiq; Sulaiman, Hushyar M; Mohammed, Sami A; Rashid, Rekawt M; Hussein, Nawfal R
2011-01-01
Cancer is a disease of gradual increase in incidence overall the world. Kurdistan Region in Iraq has been exposed to several carcinogenic hazards. There are few reports about the increased risk of cancer in different cities in Iraq. These reports did not cover Kurdistan region. The aim of this paper was to study cancer incidence and to identify possible risks of cancer in this region. Cancer registries from 9 hospitals in three cities of Kurdistan were used as a source of data. Information on these cases was subjected to careful verification regarding repetition, place of residence and other possible errors. Overall registered cases in 2007, 2008 and 2009 were 1444, 2081, 2356 respectively. 49% of registered cases were males and 51% were female. The Age Standardized Rate of cancer was 89.83/100 000 among male and 83.93/100 000 among female. The results showed major variation in incidence rates of different types of cancer in the three governorates of Kurdistan. Furthermore, there was evidence of increased risks of cancer in Kurdistan Region in Iraq. Hematological malignancies were the most common cancer among male (21.13% of all cancer in males) and second most common in female (18.8% of all cancer in female), only exceeded by breast cancer. To reach sound conclusions about extent and determinants of cancer in Kurdistan, enormous multi-spectrum efforts are now needed.
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Freeman, Vincent L; Boylan, Emma E; Pugach, Oksana; Mclafferty, Sara L; Tossas-Milligan, Katherine Y; Watson, Karriem S; Winn, Robert A
2017-10-01
To address locally relevant cancer-related health issues, health departments frequently need data beyond that contained in standard census area-based statistics. We describe a geographic information system-based method for calculating age-standardized cancer incidence rates in non-census defined geographical areas using publically available data. Aggregated records of cancer cases diagnosed from 2009 through 2013 in each of Chicago's 77 census-defined community areas were obtained from the Illinois State Cancer Registry. Areal interpolation through dasymetric mapping of census blocks was used to redistribute populations and case counts from community areas to Chicago's 50 politically defined aldermanic wards, and ward-level age-standardized 5-year cumulative incidence rates were calculated. Potential errors in redistributing populations between geographies were limited to <1.5% of the total population, and agreement between our ward population estimates and those from a frequently cited reference set of estimates was high (Pearson correlation r = 0.99, mean difference = -4 persons). A map overlay of safety-net primary care clinic locations and ward-level incidence rates for advanced-staged cancers revealed potential pathways for prevention. Areal interpolation through dasymetric mapping can estimate cancer rates in non-census defined geographies. This can address gaps in local cancer-related health data, inform health resource advocacy, and guide community-centered cancer prevention and control.
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Rain rate range profiling from a spaceborne radar
NASA Technical Reports Server (NTRS)
Meneghini, R.
1980-01-01
At certain frequencies and incidence angles the relative invariance of the surface scattering properites over land can be used to estimate the total attenuation and the integrated rain from a spaceborne attenuation-wavelength radar. The technique is generalized so that rain rate profiles along the radar beam can be estimated, i.e., rain rate determination at each range bin. This is done by modifying the standard algorithm for an attenuating-wavelength radar to include in it the measurement of the total attenuation. Simple error analyses of the estimates show that this type of profiling is possible if the total attenuation can be measured with a modest degree of accuracy.
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Human Factors in Financial Trading: An Analysis of Trading Incidents.
Leaver, Meghan; Reader, Tom W
2016-09-01
This study tests the reliability of a system (FINANS) to collect and analyze incident reports in the financial trading domain and is guided by a human factors taxonomy used to describe error in the trading domain. Research indicates the utility of applying human factors theory to understand error in finance, yet empirical research is lacking. We report on the development of the first system for capturing and analyzing human factors-related issues in operational trading incidents. In the first study, 20 incidents are analyzed by an expert user group against a referent standard to establish the reliability of FINANS. In the second study, 750 incidents are analyzed using distribution, mean, pathway, and associative analysis to describe the data. Kappa scores indicate that categories within FINANS can be reliably used to identify and extract data on human factors-related problems underlying trading incidents. Approximately 1% of trades (n = 750) lead to an incident. Slip/lapse (61%), situation awareness (51%), and teamwork (40%) were found to be the most common problems underlying incidents. For the most serious incidents, problems in situation awareness and teamwork were most common. We show that (a) experts in the trading domain can reliably and accurately code human factors in incidents, (b) 1% of trades incur error, and (c) poor teamwork skills and situation awareness underpin the most critical incidents. This research provides data crucial for ameliorating risk within financial trading organizations, with implications for regulation and policy. © 2016, Human Factors and Ergonomics Society.
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Maly, Friedrich E; Fried, Roman; Spannagl, Michael
2014-01-01
INSTAND e.V. has provided Molecular Genetics Multi-Analyte EQA schemes since 2006. EQA participation and performance were assessed from 2006 - 2012. From 2006 to 2012, the number of analytes in the Multi-Analyte EQA schemes rose from 17 to 53. Total number of results returned rose from 168 in January 2006 to 824 in August 2012. The overall error rate was 1.40 +/- 0.84% (mean +/- SD, N = 24 EQA dates). From 2006 to 2012, no analyte was reported 100% correctly. Individual participant performance was analysed for one common analyte, Lactase (LCT) T-13910C. From 2006 to 2012, 114 laboratories participated in this EQA. Of these, 10 laboratories (8.8%) reported at least one wrong result during the whole observation period. All laboratories reported correct results after their failure incident. In spite of the low overall error rate, EQA will continue to be important for Molecular Genetics.
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Detecting wrong notes in advance: neuronal correlates of error monitoring in pianists.
Ruiz, María Herrojo; Jabusch, Hans-Christian; Altenmüller, Eckart
2009-11-01
Music performance is an extremely rapid process with low incidence of errors even at the fast rates of production required. This is possible only due to the fast functioning of the self-monitoring system. Surprisingly, no specific data about error monitoring have been published in the music domain. Consequently, the present study investigated the electrophysiological correlates of executive control mechanisms, in particular error detection, during piano performance. Our target was to extend the previous research efforts on understanding of the human action-monitoring system by selecting a highly skilled multimodal task. Pianists had to retrieve memorized music pieces at a fast tempo in the presence or absence of auditory feedback. Our main interest was to study the interplay between auditory and sensorimotor information in the processes triggered by an erroneous action, considering only wrong pitches as errors. We found that around 70 ms prior to errors a negative component is elicited in the event-related potentials and is generated by the anterior cingulate cortex. Interestingly, this component was independent of the auditory feedback. However, the auditory information did modulate the processing of the errors after their execution, as reflected in a larger error positivity (Pe). Our data are interpreted within the context of feedforward models and the auditory-motor coupling.
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Development of steady-state model for MSPT and detailed analyses of receiver
NASA Astrophysics Data System (ADS)
Yuasa, Minoru; Sonoda, Masanori; Hino, Koichi
2016-05-01
Molten salt parabolic trough system (MSPT) uses molten salt as heat transfer fluid (HTF) instead of synthetic oil. The demonstration plant of MSPT was constructed by Chiyoda Corporation and Archimede Solar Energy in Italy in 2013. Chiyoda Corporation developed a steady-state model for predicting the theoretical behavior of the demonstration plant. The model was designed to calculate the concentrated solar power and heat loss using ray tracing of incident solar light and finite element modeling of thermal energy transferred into the medium. This report describes the verification of the model using test data on the demonstration plant, detailed analyses on the relation between flow rate and temperature difference on the metal tube of receiver and the effect of defocus angle on concentrated power rate, for solar collector assembly (SCA) development. The model is accurate to an extent of 2.0% as systematic error and 4.2% as random error. The relationships between flow rate and temperature difference on metal tube and the effect of defocus angle on concentrated power rate are shown.
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Cohen, Trevor; Blatter, Brett; Almeida, Carlos; Patel, Vimla L.
2007-01-01
Objective Contemporary error research suggests that the quest to eradicate error is misguided. Error commission, detection, and recovery are an integral part of cognitive work, even at the expert level. In collaborative workspaces, the perception of potential error is directly observable: workers discuss and respond to perceived violations of accepted practice norms. As perceived violations are captured and corrected preemptively, they do not fit Reason’s widely accepted definition of error as “failure to achieve an intended outcome.” However, perceived violations suggest the aversion of potential error, and consequently have implications for error prevention. This research aims to identify and describe perceived violations of the boundaries of accepted procedure in a psychiatric emergency department (PED), and how they are resolved in practice. Design Clinical discourse from fourteen PED patient rounds was audio-recorded. Excerpts from recordings suggesting perceived violations or incidents of miscommunication were extracted and analyzed using qualitative coding methods. The results are interpreted in relation to prior research on vulnerabilities to error in the PED. Results Thirty incidents of perceived violations or miscommunication are identified and analyzed. Of these, only one medication error was formally reported. Other incidents would not have been detected by a retrospective analysis. Conclusions The analysis of perceived violations expands the data available for error analysis beyond occasional reported adverse events. These data are prospective: responses are captured in real time. This analysis supports a set of recommendations to improve the quality of care in the PED and other critical care contexts. PMID:17329728
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Wang, Li-Yun; Chen, Nien-I; Chen, Pin-Wen; Chiang, Shu-Chuan; Hwu, Wuh-Liang; Lee, Ni-Chung; Chien, Yin-Hsiu
2013-02-10
Tandem mass spectrometry (MS/MS) analysis is a powerful tool for newborn screening, and many rare inborn errors of metabolism are currently screened using MS/MS. However, the sensitivity of MS/MS screening for several inborn errors, including citrin deficiency (screened by citrulline level) and carnitine uptake defect (CUD, screened by free carnitine level), is not satisfactory. This study was conducted to determine whether a second-tier molecular test could improve the sensitivity of citrin deficiency and CUD detection without increasing the false-positive rate. Three mutations in the SLC25A13 gene (for citrin deficiency) and one mutation in the SLC22A5 gene (for CUD) were analyzed in newborns who demonstrated an inconclusive primary screening result (with levels between the screening and diagnostic cutoffs). The results revealed that 314 of 46 699 newborns received a second-tier test for citrin deficiency, and two patients were identified; 206 of 30 237 newborns received a second-tier testing for CUD, and one patient was identified. No patients were identified using the diagnostic cutoffs. Although the incidences for citrin deficiency (1:23 350) and CUD (1:30 000) detected by screening are still lower than the incidences calculated from the mutation carrier rates, the second-tier molecular test increases the sensitivity of newborn screening for citrin deficiency and CUD without increasing the false-positive rate. Utilizing a molecular second-tier test for citrin deficiency and carnitine transporter deficiency is feasible.
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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.
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NASA Astrophysics Data System (ADS)
Li, Xin; Zhou, Shihong; Ma, Jing; Tan, Liying; Shen, Tao
2013-08-01
CMOS is a good candidate tracking detector for satellite optical communications systems with outstanding feature of sub-window for the development of APS (Active Pixel Sensor) technology. For inter-satellite optical communications it is critical to estimate the direction of incident laser beam precisely by measuring the centroid position of incident beam spot. The presence of detector noise results in measurement error, which degrades the tracking performance of systems. In this research, the measurement error of CMOS is derived taking consideration of detector noise. It is shown that the measurement error depends on pixel noise, size of the tracking sub-window (pixels number), intensity of incident laser beam, relative size of beam spot. The influences of these factors are analyzed by numerical simulation. We hope the results obtained in this research will be helpful in the design of CMOS detector satellite optical communications systems.
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Azeez, Adeboye; Obaromi, Davies; Odeyemi, Akinwumi; Ndege, James; Muntabayi, Ruffin
2016-07-26
Tuberculosis (TB) is a deadly infectious disease caused by Mycobacteria tuberculosis. Tuberculosis as a chronic and highly infectious disease is prevalent in almost every part of the globe. More than 95% of TB mortality occurs in low/middle income countries. In 2014, approximately 10 million people were diagnosed with active TB and two million died from the disease. In this study, our aim is to compare the predictive powers of the seasonal autoregressive integrated moving average (SARIMA) and neural network auto-regression (SARIMA-NNAR) models of TB incidence and analyse its seasonality in South Africa. TB incidence cases data from January 2010 to December 2015 were extracted from the Eastern Cape Health facility report of the electronic Tuberculosis Register (ERT.Net). A SARIMA model and a combined model of SARIMA model and a neural network auto-regression (SARIMA-NNAR) model were used in analysing and predicting the TB data from 2010 to 2015. Simulation performance parameters of mean square error (MSE), root mean square error (RMSE), mean absolute error (MAE), mean percent error (MPE), mean absolute scaled error (MASE) and mean absolute percentage error (MAPE) were applied to assess the better performance of prediction between the models. Though practically, both models could predict TB incidence, the combined model displayed better performance. For the combined model, the Akaike information criterion (AIC), second-order AIC (AICc) and Bayesian information criterion (BIC) are 288.56, 308.31 and 299.09 respectively, which were lower than the SARIMA model with corresponding values of 329.02, 327.20 and 341.99, respectively. The seasonality trend of TB incidence was forecast to have a slightly increased seasonal TB incidence trend from the SARIMA-NNAR model compared to the single model. The combined model indicated a better TB incidence forecasting with a lower AICc. The model also indicates the need for resolute intervention to reduce infectious disease transmission with co-infection with HIV and other concomitant diseases, and also at festival peak periods.
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Randmaa, Maria; Mårtensson, Gunilla; Leo Swenne, Christine; Engström, Maria
2014-01-21
We aimed to examine staff members' perceptions of communication within and between different professions, safety attitudes and psychological empowerment, prior to and after implementation of the communication tool Situation-Background-Assessment-Recommendation (SBAR) at an anaesthetic clinic. The aim was also to study whether there was any change in the proportion of incident reports caused by communication errors. A prospective intervention study with comparison group using preassessments and postassessments. Questionnaire data were collected from staff in an intervention (n=100) and a comparison group (n=69) at the anaesthetic clinic in two hospitals prior to (2011) and after (2012) implementation of SBAR. The proportion of incident reports due to communication errors was calculated during a 1-year period prior to and after implementation. Anaesthetic clinics at two hospitals in Sweden. All licensed practical nurses, registered nurses and physicians working in the operating theatres, intensive care units and postanaesthesia care units at anaesthetic clinics in two hospitals were invited to participate. Implementation of SBAR in an anaesthetic clinic. The primary outcomes were staff members' perception of communication within and between different professions, as well as their perceptions of safety attitudes. Secondary outcomes were psychological empowerment and incident reports due to error of communication. In the intervention group, there were statistically significant improvements in the factors 'Between-group communication accuracy' (p=0.039) and 'Safety climate' (p=0.011). The proportion of incident reports due to communication errors decreased significantly (p<0.0001) in the intervention group, from 31% to 11%. Implementing the communication tool SBAR in anaesthetic clinics was associated with improvement in staff members' perception of communication between professionals and their perception of the safety climate as well as with a decreased proportion of incident reports related to communication errors. ISRCTN37251313.
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The famous five factors in teamwork: a case study of fratricide.
Rafferty, Laura A; Stanton, Neville A; Walker, Guy H
2010-10-01
The purpose of this paper is to propose foundations for a theory of errors in teamwork based upon analysis of a case study of fratricide alongside a review of the existing literature. This approach may help to promote a better understanding of interactions within complex systems and help in the formulation of hypotheses and predictions concerning errors in teamwork, particularly incidents of fratricide. It is proposed that a fusion of concepts drawn from error models, with common causal categories taken from teamwork models, could allow for an in-depth exploration of incidents of fratricide. It is argued that such a model has the potential to explore the core causal categories identified as present in an incident of fratricide. This view marks fratricide as a process of errors occurring throughout the military system as a whole, particularly due to problems in teamwork within this complex system. Implications of this viewpoint for the development of a new theory of fratricide are offered. STATEMENT OF RELEVANCE: This article provides an insight into the fusion of existing error and teamwork models for the analysis of an incident of fratricide. Within this paper, a number of commonalities among models of teamwork have been identified allowing for the development of a model.
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Human Factors in Financial Trading
Leaver, Meghan; Reader, Tom W.
2016-01-01
Objective This study tests the reliability of a system (FINANS) to collect and analyze incident reports in the financial trading domain and is guided by a human factors taxonomy used to describe error in the trading domain. Background Research indicates the utility of applying human factors theory to understand error in finance, yet empirical research is lacking. We report on the development of the first system for capturing and analyzing human factors–related issues in operational trading incidents. Method In the first study, 20 incidents are analyzed by an expert user group against a referent standard to establish the reliability of FINANS. In the second study, 750 incidents are analyzed using distribution, mean, pathway, and associative analysis to describe the data. Results Kappa scores indicate that categories within FINANS can be reliably used to identify and extract data on human factors–related problems underlying trading incidents. Approximately 1% of trades (n = 750) lead to an incident. Slip/lapse (61%), situation awareness (51%), and teamwork (40%) were found to be the most common problems underlying incidents. For the most serious incidents, problems in situation awareness and teamwork were most common. Conclusion We show that (a) experts in the trading domain can reliably and accurately code human factors in incidents, (b) 1% of trades incur error, and (c) poor teamwork skills and situation awareness underpin the most critical incidents. Application This research provides data crucial for ameliorating risk within financial trading organizations, with implications for regulation and policy. PMID:27142394
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DOE Office of Scientific and Technical Information (OSTI.GOV)
Novak, A; Nyflot, M; Sponseller, P
2014-06-01
Purpose: Radiation treatment planning involves a complex workflow that can make safety improvement efforts challenging. This study utilizes an incident reporting system to identify detection points of near-miss errors, in order to guide our departmental safety improvement efforts. Previous studies have examined where errors arise, but not where they are detected or their patterns. Methods: 1377 incidents were analyzed from a departmental nearmiss error reporting system from 3/2012–10/2013. All incidents were prospectively reviewed weekly by a multi-disciplinary team, and assigned a near-miss severity score ranging from 0–4 reflecting potential harm (no harm to critical). A 98-step consensus workflow was usedmore » to determine origination and detection points of near-miss errors, categorized into 7 major steps (patient assessment/orders, simulation, contouring/treatment planning, pre-treatment plan checks, therapist/on-treatment review, post-treatment checks, and equipment issues). Categories were compared using ANOVA. Results: In the 7-step workflow, 23% of near-miss errors were detected within the same step in the workflow, while an additional 37% were detected by the next step in the workflow, and 23% were detected two steps downstream. Errors detected further from origination were more severe (p<.001; Figure 1). The most common source of near-miss errors was treatment planning/contouring, with 476 near misses (35%). Of those 476, only 72(15%) were found before leaving treatment planning, 213(45%) were found at physics plan checks, and 191(40%) were caught at the therapist pre-treatment chart review or on portal imaging. Errors that passed through physics plan checks and were detected by therapists were more severe than other errors originating in contouring/treatment planning (1.81 vs 1.33, p<0.001). Conclusion: Errors caught by radiation treatment therapists tend to be more severe than errors caught earlier in the workflow, highlighting the importance of safety checks in dosimetry and physics. We are utilizing our findings to improve manual and automated checklists for dosimetry and physics.« less
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Yousef, Nadin; Yousef, Farah
2017-09-04
Whereas one of the predominant causes of medication errors is a drug administration error, a previous study related to our investigations and reviews estimated that the incidences of medication errors constituted 6.7 out of 100 administrated medication doses. Therefore, we aimed by using six sigma approach to propose a way that reduces these errors to become less than 1 out of 100 administrated medication doses by improving healthcare professional education and clearer handwritten prescriptions. The study was held in a General Government Hospital. First, we systematically studied the current medication use process. Second, we used six sigma approach by utilizing the five-step DMAIC process (Define, Measure, Analyze, Implement, Control) to find out the real reasons behind such errors. This was to figure out a useful solution to avoid medication error incidences in daily healthcare professional practice. Data sheet was used in Data tool and Pareto diagrams were used in Analyzing tool. In our investigation, we reached out the real cause behind administrated medication errors. As Pareto diagrams used in our study showed that the fault percentage in administrated phase was 24.8%, while the percentage of errors related to prescribing phase was 42.8%, 1.7 folds. This means that the mistakes in prescribing phase, especially because of the poor handwritten prescriptions whose percentage in this phase was 17.6%, are responsible for the consequent) mistakes in this treatment process later on. Therefore, we proposed in this study an effective low cost strategy based on the behavior of healthcare workers as Guideline Recommendations to be followed by the physicians. This method can be a prior caution to decrease errors in prescribing phase which may lead to decrease the administrated medication error incidences to less than 1%. This improvement way of behavior can be efficient to improve hand written prescriptions and decrease the consequent errors related to administrated medication doses to less than the global standard; as a result, it enhances patient safety. However, we hope other studies will be made later in hospitals to practically evaluate how much effective our proposed systematic strategy really is in comparison with other suggested remedies in this field.
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Improved Conflict Detection for Reducing Operational Errors in Air Traffic Control
NASA Technical Reports Server (NTRS)
Paielli, Russell A.; Erzberger, Hainz
2003-01-01
An operational error is an incident in which an air traffic controller allows the separation between two aircraft to fall below the minimum separation standard. The rates of such errors in the US have increased significantly over the past few years. This paper proposes new detection methods that can help correct this trend by improving on the performance of Conflict Alert, the existing software in the Host Computer System that is intended to detect and warn controllers of imminent conflicts. In addition to the usual trajectory based on the flight plan, a "dead-reckoning" trajectory (current velocity projection) is also generated for each aircraft and checked for conflicts. Filters for reducing common types of false alerts were implemented. The new detection methods were tested in three different ways. First, a simple flightpath command language was developed t o generate precisely controlled encounters for the purpose of testing the detection software. Second, written reports and tracking data were obtained for actual operational errors that occurred in the field, and these were "replayed" to test the new detection algorithms. Finally, the detection methods were used to shadow live traffic, and performance was analysed, particularly with regard to the false-alert rate. The results indicate that the new detection methods can provide timely warnings of imminent conflicts more consistently than Conflict Alert.
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Drug error in paediatric anaesthesia: current status and where to go now.
Anderson, Brian J
2018-06-01
Medication errors in paediatric anaesthesia and the perioperative setting continue to occur despite widespread recognition of the problem and published advice for reduction of this predicament at international, national, local and individual levels. Current literature was reviewed to ascertain drug error rates and to appraise causes and proposed solutions to reduce these errors. The medication error incidence remains high. There is documentation of reduction through identification of causes with consequent education and application of safety analytics and quality improvement programs in anaesthesia departments. Children remain at higher risk than adults because of additional complexities such as drug dose calculations, increased susceptibility to some adverse effects and changes associated with growth and maturation. Major improvements are best made through institutional system changes rather than a commitment to do better on the part of each practitioner. Medication errors in paediatric anaesthesia represent an important risk to children and most are avoidable. There is now an understanding of the genesis of adverse drug events and this understanding should facilitate the implementation of known effective countermeasures. An institution-wide commitment and strategy are the basis for a worthwhile and sustained improvement in medication safety.
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Shanks, Leslie; Bil, Karla; Fernhout, Jena
2015-01-01
Objective To analyse the results from the first 3 years of implementation of a medical error reporting system in Médecins Sans Frontières-Operational Centre Amsterdam (MSF) programs. Methodology A medical error reporting policy was developed with input from frontline workers and introduced to the organisation in June 2010. The definition of medical error used was “the failure of a planned action to be completed as intended or the use of a wrong plan to achieve an aim.” All confirmed error reports were entered into a database without the use of personal identifiers. Results 179 errors were reported from 38 projects in 18 countries over the period of June 2010 to May 2013. The rate of reporting was 31, 42, and 106 incidents/year for reporting year 1, 2 and 3 respectively. The majority of errors were categorized as dispensing errors (62 cases or 34.6%), errors or delays in diagnosis (24 cases or 13.4%) and inappropriate treatment (19 cases or 10.6%). The impact of the error was categorized as no harm (58, 32.4%), harm (70, 39.1%), death (42, 23.5%) and unknown in 9 (5.0%) reports. Disclosure to the patient took place in 34 cases (19.0%), did not take place in 46 (25.7%), was not applicable for 5 (2.8%) cases and not reported for 94 (52.5%). Remedial actions introduced at headquarters level included guideline revisions and changes to medical supply procedures. At field level improvements included increased training and supervision, adjustments in staffing levels, and adaptations to the organization of the pharmacy. Conclusion It was feasible to implement a voluntary reporting system for medical errors despite the complex contexts in which MSF intervenes. The reporting policy led to system changes that improved patient safety and accountability to patients. Challenges remain in achieving widespread acceptance of the policy as evidenced by the low reporting and disclosure rates. PMID:26381622
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NASA Astrophysics Data System (ADS)
Partsinevelos, Panagiotis; Kallimani, Christina; Tripolitsiotis, Achilleas
2015-06-01
Rockfall incidents affect civil security and hamper the sustainable growth of hard to access mountainous areas due to casualties, injuries and infrastructure loss. Rockfall occurrences cannot be easily prevented, whereas previous studies for rockfall multiple sensor early detection systems have focused on large scale incidents. However, even a single rock may cause the loss of a human life along transportation routes thus, it is highly important to establish methods for the early detection of small-scale rockfall incidents. Terrestrial photogrammetric techniques are prone to a series of errors leading to false alarm incidents, including vegetation, wind, and non relevant change in the scene under consideration. In this study, photogrammetric monitoring of rockfall prone slopes is established and the resulting multi-temporal change imagery is processed in order to minimize false alarm incidents. Integration of remote sensing imagery analysis techniques is hereby applied to enhance early detection of a rockfall. Experimental data demonstrated that an operational system able to identify a 10-cm rock movement within a 10% false alarm rate is technically feasible.
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Workflow Enhancement (WE) Improves Safety in Radiation Oncology: Putting the WE and Team Together
DOE Office of Scientific and Technical Information (OSTI.GOV)
Chao, Samuel T., E-mail: chaos@ccf.org; Rose Ella Burkhardt Brain Tumor and Neuro-oncology Center, Cleveland Clinic, Cleveland, Ohio; Meier, Tim
Purpose: To review the impact of a workflow enhancement (WE) team in reducing treatment errors that reach patients within radiation oncology. Methods and Materials: It was determined that flaws in our workflow and processes resulted in errors reaching the patient. The process improvement team (PIT) was developed in 2010 to reduce errors and was later modified in 2012 into the current WE team. Workflow issues and solutions were discussed in PIT and WE team meetings. Due to tensions within PIT that resulted in employee dissatisfaction, there was a 6-month hiatus between the end of PIT and initiation of the renamed/redesigned WEmore » team. In addition to the PIT/WE team forms, the department had separate incident forms to document treatment errors reaching the patient. These incident forms are rapidly reviewed and monitored by our departmental and institutional quality and safety groups, reflecting how seriously these forms are treated. The number of these incident forms was compared before and after instituting the WE team. Results: When PIT was disbanded, a number of errors seemed to occur in succession, requiring reinstitution and redesign of this team, rebranded the WE team. Interestingly, the number of incident forms per patient visits did not change when comparing 6 months during the PIT, 6 months during the hiatus, and the first 6 months after instituting the WE team (P=.85). However, 6 to 12 months after instituting the WE team, the number of incident forms per patient visits decreased (P=.028). After the WE team, employee satisfaction and commitment to quality increased as demonstrated by Gallup surveys, suggesting a correlation to the WE team. Conclusions: A team focused on addressing workflow and improving processes can reduce the number of errors reaching the patient. Time is necessary before a reduction in errors reaching patients will be seen.« less
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DOE Office of Scientific and Technical Information (OSTI.GOV)
Cao, Junjie; Jia, Hongzhi, E-mail: hzjia@usst.edu.cn
2015-11-15
We propose error analysis using a rotating coordinate system with three parameters of linearly polarized light—incidence angle, azimuth angle on the front surface, and angle between the incidence and vibration planes—and demonstrate the method on a rotating birefringent prism system. The transmittance and angles are calculated plane-by-plane using a birefringence ellipsoid model and the final transmitted intensity equation is deduced. The effects of oblique incidence, light interference, beam convergence, and misalignment of the rotation and prism axes are discussed. We simulate the entire error model using MATLAB and conduct experiments based on a built polarimeter. The simulation and experimental resultsmore » are consistent and demonstrate the rationality and validity of this method.« less
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Expanded Newborn Screening Program in Saudi Arabia: Incidence of screened disorders.
Alfadhel, Majid; Al Othaim, Ali; Al Saif, Saif; Al Mutairi, Fuad; Alsayed, Moeenaldeen; Rahbeeni, Zuhair; Alzaidan, Hamad; Alowain, Mohammed; Al-Hassnan, Zuhair; Saeedi, Mohamad; Aljohery, Saeed; Alasmari, Ali; Faqeih, Eissa; Alwakeel, Mansour; AlMashary, Maher; Almohameed, Sulaiman; Alzahrani, Mohammed; Migdad, Abeer; Al-Dirbashi, Osama Y; Rashed, Mohamed; Alamoudi, Mohamed; Jacob, Minnie; Alahaidib, Lujane; El-Badaoui, Fahd; Saadallah, Amal; Alsulaiman, Ayman; Eyaid, Wafaa; Al-Odaib, Ali
2017-06-01
To address the implementation of the National Newborn Screening Program (NBS) in Saudi Arabia and stratify the incidence of the screened disorders. A retrospective study conducted between 1 August 2005 and 31 December 2012, total of 775 000 newborns were screened from 139 hospitals distributed among all regions of Saudi Arabia. The NBS Program screens for 16 disorders from a selective list of inborn errors of metabolism (IEM) and endocrine disorders. Heel prick dry blood spot samples were obtained from all newborns for biochemical and immunoassay testing. Recall screening testing was performed for Initial positive results and confirmed by specific biochemical assays. A total of 743 cases were identified giving an overall incidence of 1:1043. Frequently detected disorders nationwide were congenital hypothyroidism and congenital adrenal hyperplasia with an incidence of 1:7175 and 1:7908 correspondingly. The highest incidence among the IEM was propionic acidaemia with an incidence rate of 1:14 000. The article highlights the experience of the NBS Program in Saudi Arabia and providing data on specific regional incidences of all the screened disorders included in the programme; and showed that the incidence of these disorders is one of the highest reported so far world-wide. © 2017 Paediatrics and Child Health Division (The Royal Australasian College of Physicians).
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Yang, F; Cao, N; Young, L; Howard, J; Logan, W; Arbuckle, T; Sponseller, P; Korssjoen, T; Meyer, J; Ford, E
2015-06-01
Though failure mode and effects analysis (FMEA) is becoming more widely adopted for risk assessment in radiation therapy, to our knowledge, its output has never been validated against data on errors that actually occur. The objective of this study was to perform FMEA of a stereotactic body radiation therapy (SBRT) treatment planning process and validate the results against data recorded within an incident learning system. FMEA on the SBRT treatment planning process was carried out by a multidisciplinary group including radiation oncologists, medical physicists, dosimetrists, and IT technologists. Potential failure modes were identified through a systematic review of the process map. Failure modes were rated for severity, occurrence, and detectability on a scale of one to ten and risk priority number (RPN) was computed. Failure modes were then compared with historical reports identified as relevant to SBRT planning within a departmental incident learning system that has been active for two and a half years. Differences between FMEA anticipated failure modes and existing incidents were identified. FMEA identified 63 failure modes. RPN values for the top 25% of failure modes ranged from 60 to 336. Analysis of the incident learning database identified 33 reported near-miss events related to SBRT planning. Combining both methods yielded a total of 76 possible process failures, of which 13 (17%) were missed by FMEA while 43 (57%) identified by FMEA only. When scored for RPN, the 13 events missed by FMEA ranked within the lower half of all failure modes and exhibited significantly lower severity relative to those identified by FMEA (p = 0.02). FMEA, though valuable, is subject to certain limitations. In this study, FMEA failed to identify 17% of actual failure modes, though these were of lower risk. Similarly, an incident learning system alone fails to identify a large number of potentially high-severity process errors. Using FMEA in combination with incident learning may render an improved overview of risks within a process.
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Kuang, T-M; Tsai, S-Y; Liu, C J-L; Ko, Y-C; Lee, S-M; Chou, P
2016-01-01
Purpose To report the 7-year incidence of uncorrected refractive error in a metropolitan Chinese elderly population. Methods The Shihpai Eye Study 2006 included 460/824 (55.8%) subjects (age range 72–94 years old) of 1361 participants in the 1999 baseline survey for a follow-up eye examination. Visual acuity was assessed using a Snellen chart, uncorrected refractive error was defined as presenting visual acuity (naked eye if without spectacles and with distance spectacles if worn) in the better eye of <6/12 that improved to no impairment (≥6/12) after refractive correction. Results The 7-year incidence of uncorrected refractive error was 10.5% (95% confidence interval (CI): 7.6–13.4%). 92.7% of participants with uncorrection and 77.8% with undercorrection were able to improve at least two lines of visual acuity by refractive correction. In multivariate analysis controlling for covariates, uncorrected refractive error was significantly related to myopia (relative risk (RR): 3.15; 95% CI: 1.31–7.58) and living alone (RR: 2.94; 95% CI 1.14–7.53), whereas distance spectacles worn during examination was protective (RR: 0.35; 95% CI: 0.14–0.88). Conclusion Our study indicated that the incidence of uncorrected refractive error was high (10.5%) in this elderly Chinese population. Living alone and myopia are predisposing factors, whereas wearing distance spectacles at examination is protective. PMID:26795416
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Classifying nursing errors in clinical management within an Australian hospital.
Tran, D T; Johnson, M
2010-12-01
Although many classification systems relating to patient safety exist, no taxonomy was identified that classified nursing errors in clinical management. To develop a classification system for nursing errors relating to clinical management (NECM taxonomy) and to describe contributing factors and patient consequences. We analysed 241 (11%) self-reported incidents relating to clinical management in nursing in a metropolitan hospital. Descriptive analysis of numeric data and content analysis of text data were undertaken to derive the NECM taxonomy, contributing factors and consequences for patients. Clinical management incidents represented 1.63 incidents per 1000 occupied bed days. The four themes of the NECM taxonomy were nursing care process (67%), communication (22%), administrative process (5%), and knowledge and skill (6%). Half of the incidents did not cause any patient harm. Contributing factors (n=111) included the following: patient clinical, social conditions and behaviours (27%); resources (22%); environment and workload (18%); other health professionals (15%); communication (13%); and nurse's knowledge and experience (5%). The NECM taxonomy provides direction to clinicians and managers on areas in clinical management that are most vulnerable to error, and therefore, priorities for system change management. Any nurses who wish to classify nursing errors relating to clinical management could use these types of errors. This study informs further research into risk management behaviour, and self-assessment tools for clinicians. Globally, nurses need to continue to monitor and act upon patient safety issues. © 2010 The Authors. International Nursing Review © 2010 International Council of Nurses.
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Uy, Raymonde Charles Y; Kury, Fabricio P; Fontelo, Paul A
2015-01-01
The standard of safe medication practice requires strict observance of the five rights of medication administration: the right patient, drug, time, dose, and route. Despite adherence to these guidelines, medication errors remain a public health concern that has generated health policies and hospital processes that leverage automation and computerization to reduce these errors. Bar code, RFID, biometrics and pharmacy automation technologies have been demonstrated in literature to decrease the incidence of medication errors by minimizing human factors involved in the process. Despite evidence suggesting the effectivity of these technologies, adoption rates and trends vary across hospital systems. The objective of study is to examine the state and adoption trends of automatic identification and data capture (AIDC) methods and pharmacy automation technologies in U.S. hospitals. A retrospective descriptive analysis of survey data from the HIMSS Analytics® Database was done, demonstrating an optimistic growth in the adoption of these patient safety solutions.
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DOE Office of Scientific and Technical Information (OSTI.GOV)
Cournoyer, Michael E.; Trujillo, Stanley; Lawton, Cindy M.
A traditional view of incidents is that they are caused by shortcomings in human competence, attention, or attitude. It may be under the label of “loss of situational awareness,” procedure “violation,” or “poor” management. A different view is that human error is not the cause of failure, but a symptom of failure – trouble deeper inside the system. In this perspective, human error is not the conclusion, but rather the starting point of investigations. During an investigation, three types of information are gathered: physical, documentary, and human (recall/experience). Through the causal analysis process, apparent cause or apparent causes are identifiedmore » as the most probable cause or causes of an incident or condition that management has the control to fix and for which effective recommendations for corrective actions can be generated. A causal analysis identifies relevant human performance factors. In the following presentation, the anatomy of a radiological incident is discussed, and one case study is presented. We analyzed the contributing factors that caused a radiological incident. When underlying conditions, decisions, actions, and inactions that contribute to the incident are identified. This includes weaknesses that may warrant improvements that tolerate error. Measures that reduce consequences or likelihood of recurrence are discussed.« less
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Cournoyer, Michael E.; Trujillo, Stanley; Lawton, Cindy M.; ...
2016-03-23
A traditional view of incidents is that they are caused by shortcomings in human competence, attention, or attitude. It may be under the label of “loss of situational awareness,” procedure “violation,” or “poor” management. A different view is that human error is not the cause of failure, but a symptom of failure – trouble deeper inside the system. In this perspective, human error is not the conclusion, but rather the starting point of investigations. During an investigation, three types of information are gathered: physical, documentary, and human (recall/experience). Through the causal analysis process, apparent cause or apparent causes are identifiedmore » as the most probable cause or causes of an incident or condition that management has the control to fix and for which effective recommendations for corrective actions can be generated. A causal analysis identifies relevant human performance factors. In the following presentation, the anatomy of a radiological incident is discussed, and one case study is presented. We analyzed the contributing factors that caused a radiological incident. When underlying conditions, decisions, actions, and inactions that contribute to the incident are identified. This includes weaknesses that may warrant improvements that tolerate error. Measures that reduce consequences or likelihood of recurrence are discussed.« less
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A continuous quality improvement project to reduce medication error in the emergency department.
Lee, Sara Bc; Lee, Larry Ly; Yeung, Richard Sd; Chan, Jimmy Ts
2013-01-01
Medication errors are a common source of adverse healthcare incidents particularly in the emergency department (ED) that has a number of factors that make it prone to medication errors. This project aims to reduce medication errors and improve the health and economic outcomes of clinical care in Hong Kong ED. In 2009, a task group was formed to identify problems that potentially endanger medication safety and developed strategies to eliminate these problems. Responsible officers were assigned to look after seven error-prone areas. Strategies were proposed, discussed, endorsed and promulgated to eliminate the problems identified. A reduction of medication incidents (MI) from 16 to 6 was achieved before and after the improvement work. This project successfully established a concrete organizational structure to safeguard error-prone areas of medication safety in a sustainable manner.
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Introduction of a prehospital critical incident monitoring system--pilot project results.
Stella, Julian; Davis, Anna; Jennings, Paul; Bartley, Bruce
2008-01-01
Hospital medical incident monitoring improves preventable morbidity and mortality rates. Error management systems have been adopted widely in this setting. Data relating to incident monitoring in the prehospital setting is limited. Implementation of an incident monitoring process in a prehospital setting. This is a prospective, descriptive study of the pilot phase of the implementation of an incident monitoring process in a regional prehospital setting, with a focus on trauma care. Paramedics and emergency department staff submitted anonymous incident reports, and a chart review was performed on patients who met major trauma criteria. Selected trauma cases were analyzed by a structured interview/debriefing process to elucidate undocumented incidents. A project committee coded and logged all incidents and developed recommendations. Of 4,429 ambulance responses, 41 cases were analyzed. Twenty-four (58.5%; 95% CI = 49.7-67.4%) were reported anonymously, and the rest were major trauma patients. A total of 77 incidents were identified (mean per case = 1.8; CI = 1.03-2.57). Anonymous cases revealed 26 incidents (mean = 1.1; CI = 0.98-1.22); eight trauma debriefings revealed 38 incidents (mean = 4.8; CI = 0.91-8.69) and nine trauma chart reviews revealed 13 incidents (mean = 1.6; CI = 1.04-2.16). A total of 56 of 77 (72.7%; CI = 65.5-80.0%) incidents related to system inadequacies, and 15 (57.7%; CI = 46.7-68.6%) anonymously reported incidents related to resource problems. A total of 35 of 77 (45.5%; CI = 40.4-50.5%) incidents had minimal or no impact on the patients' outcomes. Thirty-four of 77 (44.2%; CI = 39.3-49.1%) incidents were considered mitigated by circumstance. Incident monitoring led to generalized feedback in most cases (65 of 77; 84.4%; CI = 77.6-91.3%); in three cases (3.9%; CI = 3.7-4.1%), specific education occurred; two cases were reported to an external body (2.6%; CI = 2.5-2.7%); three cases resulted in remedial action (3.9%; CI = 3.7-4.1%); four for trend/further observation and analysis responses (5.2%; CI = 4.9-5.5%). The pilot project demonstrates successful implementation of an incident monitoring system within a regional, prehospital environment. The combination of incident detecting techniques has a high yield with potential to capture different error types. The large proportion of incidents in the "near miss" category allows analysis of incidents without patient harm. The majority of incidents were system related and many were mitigated by circumstance. The model used is appropriate for ongoing incident monitoring in this setting.
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Error rates in forensic DNA analysis: definition, numbers, impact and communication.
Kloosterman, Ate; Sjerps, Marjan; Quak, Astrid
2014-09-01
Forensic DNA casework is currently regarded as one of the most important types of forensic evidence, and important decisions in intelligence and justice are based on it. However, errors occasionally occur and may have very serious consequences. In other domains, error rates have been defined and published. The forensic domain is lagging behind concerning this transparency for various reasons. In this paper we provide definitions and observed frequencies for different types of errors at the Human Biological Traces Department of the Netherlands Forensic Institute (NFI) over the years 2008-2012. Furthermore, we assess their actual and potential impact and describe how the NFI deals with the communication of these numbers to the legal justice system. We conclude that the observed relative frequency of quality failures is comparable to studies from clinical laboratories and genetic testing centres. Furthermore, this frequency is constant over the five-year study period. The most common causes of failures related to the laboratory process were contamination and human error. Most human errors could be corrected, whereas gross contamination in crime samples often resulted in irreversible consequences. Hence this type of contamination is identified as the most significant source of error. Of the known contamination incidents, most were detected by the NFI quality control system before the report was issued to the authorities, and thus did not lead to flawed decisions like false convictions. However in a very limited number of cases crucial errors were detected after the report was issued, sometimes with severe consequences. Many of these errors were made in the post-analytical phase. The error rates reported in this paper are useful for quality improvement and benchmarking, and contribute to an open research culture that promotes public trust. However, they are irrelevant in the context of a particular case. Here case-specific probabilities of undetected errors are needed. These should be reported, separately from the match probability, when requested by the court or when there are internal or external indications for error. It should also be made clear that there are various other issues to consider, like DNA transfer. Forensic statistical models, in particular Bayesian networks, may be useful to take the various uncertainties into account and demonstrate their effects on the evidential value of the forensic DNA results. Copyright © 2014 Elsevier Ireland Ltd. All rights reserved.
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A New Method for Assessing How Sensitivity and Specificity of Linkage Studies Affects Estimation
Moore, Cecilia L.; Amin, Janaki; Gidding, Heather F.; Law, Matthew G.
2014-01-01
Background While the importance of record linkage is widely recognised, few studies have attempted to quantify how linkage errors may have impacted on their own findings and outcomes. Even where authors of linkage studies have attempted to estimate sensitivity and specificity based on subjects with known status, the effects of false negatives and positives on event rates and estimates of effect are not often described. Methods We present quantification of the effect of sensitivity and specificity of the linkage process on event rates and incidence, as well as the resultant effect on relative risks. Formulae to estimate the true number of events and estimated relative risk adjusted for given linkage sensitivity and specificity are then derived and applied to data from a prisoner mortality study. The implications of false positive and false negative matches are also discussed. Discussion Comparisons of the effect of sensitivity and specificity on incidence and relative risks indicate that it is more important for linkages to be highly specific than sensitive, particularly if true incidence rates are low. We would recommend that, where possible, some quantitative estimates of the sensitivity and specificity of the linkage process be performed, allowing the effect of these quantities on observed results to be assessed. PMID:25068293
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Stern, Shani; Biron, David; Moses, Elisha
2016-07-11
Down syndrome incidence in humans increases dramatically with maternal age. This is mainly the result of increased meiotic errors, but factors such as differences in abortion rate may play a role as well. Since the meiotic error rate increases almost exponentially after a certain age, its contribution to the overall incidence aneuploidy may mask the contribution of other processes. To focus on such selection mechanisms we investigated transmission in trisomic females, using data from mouse models and from Down syndrome humans. In trisomic females the a-priori probability for trisomy is independent of meiotic errors and thus approximately constant in the early embryo. Despite this, the rate of transmission of the extra chromosome decreases with age in females of the Ts65Dn and, as we show, for the Tc1 mouse models for Down syndrome. Evaluating progeny of 73 Tc1 births and 112 Ts65Dn births from females aged 130 days to 250 days old showed that both models exhibit a 3-fold reduction of the probability to transmit the trisomy with increased maternal ageing. This is concurrent with a 2-fold reduction of litter size with maternal ageing. Furthermore, analysis of previously reported 30 births in Down syndrome women shows a similar tendency with an almost three fold reduction in the probability to have a Down syndrome child between a 20 and 30 years old Down syndrome woman. In the two types of mice models for Down syndrome that were used for this study, and in human Down syndrome, older females have significantly lower probability to transmit the trisomy to the offspring. Our findings, taken together with previous reports of decreased supportive environment of the older uterus, add support to the notion that an older uterus negatively selects the less fit trisomic embryos.
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Crawford, Charles H; Glassman, Steven D; Gum, Jeffrey L; Carreon, Leah Y
2017-01-01
Advancements in the understanding of adult spinal deformity have led to a greater awareness of the role of the pelvis in maintaining sagittal balance and alignment. Pelvic incidence has emerged as a key radiographic measure and should closely match lumbar lordosis. As proper measurement of the pelvic incidence requires accurate identification of the S-1 endplate, lumbosacral transitional anatomy may lead to errors. The purpose of this study is to demonstrate how lumbosacral transitional anatomy may lead to errors in the measurement of pelvic parameters. The current case highlights one of the potential complications that can be avoided with awareness. The authors report the case of a 61-year-old man who had undergone prior lumbar surgeries and then presented with symptomatic lumbar stenosis and sagittal malalignment. Radiographs showed a lumbarized S-1. Prior numbering of the segments in previous surgical and radiology reports led to a pelvic incidence calculation of 61°. Corrected numbering of the segments using the lumbarized S-1 endplate led to a pelvic incidence calculation of 48°. Without recognition of the lumbosacral anatomy, overcorrection of the lumbar lordosis might have led to negative sagittal balance and the propensity to develop proximal junction failure. This case illustrates that improper identification of lumbosacral transitional anatomy may lead to errors that could affect clinical outcome. Awareness of this potential error may help improve patient outcomes.
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[Application of wavelet neural networks model to forecast incidence of syphilis].
Zhou, Xian-Feng; Feng, Zi-Jian; Yang, Wei-Zhong; Li, Xiao-Song
2011-07-01
To apply Wavelet Neural Networks (WNN) model to forecast incidence of Syphilis. Back Propagation Neural Network (BPNN) and WNN were developed based on the monthly incidence of Syphilis in Sichuan province from 2004 to 2008. The accuracy of forecast was compared between the two models. In the training approximation, the mean absolute error (MAE), rooted mean square error (RMSE) and mean absolute percentage error (MAPE) were 0.0719, 0.0862 and 11.52% respectively for WNN, and 0.0892, 0.1183 and 14.87% respectively for BPNN. The three indexes for generalization of models were 0.0497, 0.0513 and 4.60% for WNN, and 0.0816, 0.1119 and 7.25% for BPNN. WNN is a better model for short-term forecasting of Syphilis.
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Collins, Susan J; Newhouse, Robin; Porter, Jody; Talsma, AkkeNeel
2014-07-01
Approximately 2,700 patients are harmed by wrong-site surgery each year. The World Health Organization created the surgical safety checklist to reduce the incidence of wrong-site surgery. A project team conducted a narrative review of the literature to determine the effectiveness of the surgical safety checklist in correcting and preventing errors in the OR. Team members used Swiss cheese model of error by Reason to analyze the findings. Analysis of results indicated the effectiveness of the surgical checklist in reducing the incidence of wrong-site surgeries and other medical errors; however, checklists alone will not prevent all errors. Successful implementation requires perioperative stakeholders to understand the nature of errors, recognize the complex dynamic between systems and individuals, and create a just culture that encourages a shared vision of patient safety. Copyright © 2014 AORN, Inc. Published by Elsevier Inc. All rights reserved.
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Reach distance but not judgment error is associated with falls in older people.
Butler, Annie A; Lord, Stephen R; Fitzpatrick, Richard C
2011-08-01
Reaching is a vital action requiring precise motor coordination and attempting to reach for objects that are too far away can destabilize balance and result in falls and injury. This could be particularly important for many elderly people with age-related loss of sensorimotor function and a reduced ability to recover balance. Here, we investigate the interaction between reaching ability, errors in judging reach, and the incidence of falling (retrospectively and prospectively) in a large cohort of older people. Participants (n = 415, 70-90 years) had to estimate the furthest distance they could reach to retrieve a broomstick hanging in front of them. In an iterative dialog with the experimenter, the stick was moved until it was at the furthest distance they estimated to be reached successfully. At this point, participants were asked to attempt to retrieve the stick. Actual maximal reach was then measured. The difference between attempted reach and actual maximal reach provided a measure of judgment error. One-year retrospective fall rates were obtained at initial assessment and prospective falls were monitored by monthly calendar. Participants with poor maximal reach attempted shorter reaches than those who had good reaching ability. Those with the best reaching ability most accurately judged their maximal reach, whereas poor performers were dichotomous and either underestimated or overestimated their reach with few judging exactly. Fall rates were significantly associated with reach distance but not with reach judgment error. Maximal reach but not error in perceived reach is associated with falls in older people.
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Daverio, Marco; Fino, Giuliana; Luca, Brugnaro; Zaggia, Cristina; Pettenazzo, Andrea; Parpaiola, Antonella; Lago, Paola; Amigoni, Angela
2015-12-01
Errors in are estimated to occur with an incidence of 3.7-16.6% in hospitalized patients. The application of systems for detection of adverse events is becoming a widespread reality in healthcare. Incident reporting (IR) and failure mode and effective analysis (FMEA) are strategies widely used to detect errors, but no studies have combined them in the setting of a pediatric intensive care unit (PICU). The aim of our study was to describe the trend of IR in a PICU and evaluate the effect of FMEA application on the number and severity of the errors detected. With this prospective observational study, we evaluated the frequency IR documented in standard IR forms completed from January 2009 to December 2012 in the PICU of Woman's and Child's Health Department of Padova. On the basis of their severity, errors were classified as: without outcome (55%), with minor outcome (16%), with moderate outcome (10%), and with major outcome (3%); 16% of reported incidents were 'near misses'. We compared the data before and after the introduction of FMEA. Sixty-nine errors were registered, 59 (86%) concerning drug therapy (83% during prescription). Compared to 2009-2010, in 2011-2012, we noted an increase of reported errors (43 vs 26) with a reduction of their severity (21% vs 8% 'near misses' and 65% vs 38% errors with no outcome). With the introduction of FMEA, we obtained an increased awareness in error reporting. Application of these systems will improve the quality of healthcare services. © 2015 John Wiley & Sons Ltd.
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Hohenstein, Christian; Rupp, Peter; Fleischmann, Thomas
2011-02-01
We wanted to identify incidents that led or could have led to patient harm during prehospital cardiopulmonary resuscitation. A nationwide anonymous and Internet-based critical incident reporting system gave the data. During a 4-year period we received 548 reports of which 74 occurred during cardiopulmonary resuscitation. Human error was responsible for 85% of the incidents, whereas equipment failure contributed to 15% of the reports. Equipment failure was considered to be preventable in 61% of all the cases, whereas incidents because of human error could have been prevented in almost all the cases. In most cases, prevention can be accomplished by simple strategies with the Poka-Yoke technique. Insufficient training of emergency medical service physicians in Germany requires special attention. The critical incident reports raise concerns regarding the level of expertize provided by emergency medical service doctors.
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Tan, Ting; Chen, Lizhang; Liu, Fuqiang
2014-11-01
To establish multiple seasonal autoregressive integrated moving average model (ARIMA) according to the hand-foot-mouth disease incidence in Changsha, and to explore the feasibility of the multiple seasonal ARIMA in predicting the hand-foot-mouth disease incidence. EVIEWS 6.0 was used to establish multiple seasonal ARIMA according to the hand-foot- mouth disease incidence from May 2008 to August 2013 in Changsha, and the data of the hand- foot-mouth disease incidence from September 2013 to February 2014 were served as the examined samples of the multiple seasonal ARIMA, then the errors were compared between the forecasted incidence and the real value. Finally, the incidence of hand-foot-mouth disease from March 2014 to August 2014 was predicted by the model. After the data sequence was handled by smooth sequence, model identification and model diagnosis, the multiple seasonal ARIMA (1, 0, 1)×(0, 1, 1)12 was established. The R2 value of the model fitting degree was 0.81, the root mean square prediction error was 8.29 and the mean absolute error was 5.83. The multiple seasonal ARIMA is a good prediction model, and the fitting degree is good. It can provide reference for the prevention and control work in hand-foot-mouth disease.
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Evaluation of a Web-based Error Reporting Surveillance System in a Large Iranian Hospital.
Askarian, Mehrdad; Ghoreishi, Mahboobeh; Akbari Haghighinejad, Hourvash; Palenik, Charles John; Ghodsi, Maryam
2017-08-01
Proper reporting of medical errors helps healthcare providers learn from adverse incidents and improve patient safety. A well-designed and functioning confidential reporting system is an essential component to this process. There are many error reporting methods; however, web-based systems are often preferred because they can provide; comprehensive and more easily analyzed information. This study addresses the use of a web-based error reporting system. This interventional study involved the application of an in-house designed "voluntary web-based medical error reporting system." The system has been used since July 2014 in Nemazee Hospital, Shiraz University of Medical Sciences. The rate and severity of errors reported during the year prior and a year after system launch were compared. The slope of the error report trend line was steep during the first 12 months (B = 105.727, P = 0.00). However, it slowed following launch of the web-based reporting system and was no longer statistically significant (B = 15.27, P = 0.81) by the end of the second year. Most recorded errors were no-harm laboratory types and were due to inattention. Usually, they were reported by nurses and other permanent employees. Most reported errors occurred during morning shifts. Using a standardized web-based error reporting system can be beneficial. This study reports on the performance of an in-house designed reporting system, which appeared to properly detect and analyze medical errors. The system also generated follow-up reports in a timely and accurate manner. Detection of near-miss errors could play a significant role in identifying areas of system defects.
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Cancer Incidence in Appalachia, 2004-2011.
Wilson, Reda J; Ryerson, A Blythe; Singh, Simple D; King, Jessica B
2016-02-01
Limited literature is available about cancer in the Appalachian Region. This is the only known analysis of all cancers for Appalachia and non-Appalachia covering 100% of the US population. Appalachian cancer incidence and trends were evaluated by state, sex, and race and compared with those found in non-Appalachian regions. US counties were identified as Appalachian or non-Appalachian. Age-adjusted cancer incidence rates, standard errors, and confidence intervals were calculated using the most recent data from the United States Cancer Statistics for 2004 to 2011. Generally, Appalachia carries a higher cancer burden compared with non-Appalachia, particularly for tobacco-related cancers. For all cancer sites combined, Appalachia has higher rates regardless of sex, race, or region. The Appalachia and non-Appalachia cancer incidence gap has narrowed, with the exception of oral cavity and pharynx, larynx, lung and bronchus, and thyroid cancers. Higher cancer incidence continues in Appalachia and appears at least in part to reflect high tobacco use and potential differences in socioeconomic status, other risk factors, patient health care utilization, or provider practices. It is important to continue to evaluate this population to monitor results from screening and early detection programs, understand behavioral risk factors related to cancer incidence, increase efforts to reduce tobacco use and increase cancer screening, and identify other areas where effective interventions may mediate disparities. Surveillance and evaluation of special populations provide means to monitor screening and early detection programs, understand behavioral risk factors, and increase efforts to reduce tobacco use to mediate disparities. ©2016 American Association for Cancer Research.
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Cantu-Brito, Carlos; Majersik, Jennifer J; Sánchez, Brisa N; Ruano, Angel; Becerra-Mendoza, Daniela; Wing, Jeffrey J; Morgenstern, Lewis B
2011-03-01
Stroke incidence and prevalence estimates in developing countries should include stroke cases not presenting to hospital. We performed door-to-door stroke case ascertainment in Durango Municipality, Mexico, to estimate stroke incidence and prevalence and to determine the error made by only ascertaining hospital cases. Between September 2008 and March 2009, 1996 housing units were randomly sampled to screen for stroke in Durango Municipality residents 35 years of age and older. Field workers utilized a validated screening tool. Those screening positive were referred to a neurologist for history and examination and a head CT scan. Prevalence and cumulative incidence from the door-to-door surveillance were calculated and compared with previously reported hospitalization rates during the same defined time. Respondents included 2437 subjects from 1419 homes. The refusal rate was 3.8%. Twenty subjects had verified or probable stroke. The prevalence of probable or verified stroke was 7.7 per 1000 (95% CI, 4.3 per 1000-11.2 per 1000). Five patients had a stroke during the time of the hospital surveillance, yielding a cumulative incidence of 232.3 per 100 000 (95% CI, 27.8-436.9). Two of the 5 cases were captured by door-to-door surveillance but not by hospital surveillance. This study provides the first community-based stroke prevalence and incidence estimates in Mexico. The wide confidence intervals, despite the large number of surveyed housing units, suggest the need for more advanced sampling strategies for stroke surveillance in the developing world.
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Cantu-Brito, Carlos; Majersik, Jennifer J; Sánchez, Brisa N; Ruano, Angel; Becerra-Mendoza, Daniela; Wing, Jeffrey J; Morgenstern, Lewis B
2011-01-01
Background and Purpose Stroke incidence and prevalence estimates in developing countries should include stroke cases not presenting to hospital. We performed door-to-door stroke case ascertainment in Durango Municipality, Mexico to estimate stroke incidence and prevalence, and to determine the error made by only ascertaining hospital cases. Methods Between September 2008 and March 2009, 1996 housing units were randomly sampled to screen for stroke in Durango Municipality residents ≥35 years of age. Field workers utilized a validated screening tool. Those screening positive were referred to a neurologist for history and examination and if confirmed, a head CT scan. Prevalence and cumulative incidence from the door-to-door surveillance were calculated and compared with previously reported hospitalization rates during the same defined time. Results Respondents included 2437 subjects from 1419 homes. The refusal rate was 3.8%. Twenty subjects had verified or probable stroke. The prevalence of probable or verified stroke was 7.7/1000 (95% CI: 4.3/1000, 11.2/1000). Five patients had a stroke during the time of the hospital surveillance, yielding a cumulative incidence of 232.3/100,000 (95% CI: 27.8, 436.9). Two of the 5 cases were captured by door-to-door surveillance but not by hospital surveillance. Conclusions This study provides the first community-based stroke prevalence and incidence estimates in Mexico. The wide confidence intervals, despite the large number of surveyed housing units, suggest the need for more advanced sampling strategies for stroke surveillance in the developing world. PMID:21212398
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2014-01-01
Background Few studies have investigated the association between whole-grain intake and colorectal cancer. Because whole-grain intake estimation might be prone to measurement errors, more objective measures (eg, biomarkers) could assist in investigating such associations. Methods The association between alkylresorcinols, biomarkers of whole-grain rye and wheat intake, and colorectal cancer incidence were investigated using prediagnostic plasma samples from colorectal cancer case patients and matched control subjects nested within the European Prospective Investigation into Cancer and Nutrition. We included 1372 incident colorectal cancer case patients and 1372 individual matched control subjects and calculated the incidence rate ratios (IRRs) for overall and anatomical subsites of colorectal cancer using conditional logistic regression adjusted for potential confounders. Regional differences (Scandinavia, the Mediterranean, Central Europe) were also explored. Results High plasma total alkylresorcinol concentration was associated with lower incidence of distal colon cancer; the adjusted incidence rate ratio of distal colon cancer for the highest vs lowest quartile of plasma total alkylresorcinols was 0.48 (95% confidence interval [CI] = 0.28 to 0.83). An inverse association between plasma total alkylresorcinol concentrations and colon cancer was found for Scandinavian participants (IRR per doubling = 0.83; 95% CI = 0.70 to 0.98). However, plasma total alkylresorcinol concentrations were not associated with overall colorectal cancer, proximal colon cancer, or rectal cancer. Plasma alkylresorcinols concentrations were associated with colon and distal colon cancer only in Central Europe and Scandinavia (ie, areas where alkylresorcinol levels were higher). Conclusions High concentrations of plasma alkylresorcinols were associated with a lower incidence of distal colon cancer but not with overall colorectal cancer, proximal colon cancer, and rectal cancer. PMID:24317181
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A circadian rhythm in skill-based errors in aviation maintenance.
Hobbs, Alan; Williamson, Ann; Van Dongen, Hans P A
2010-07-01
In workplaces where activity continues around the clock, human error has been observed to exhibit a circadian rhythm, with a characteristic peak in the early hours of the morning. Errors are commonly distinguished by the nature of the underlying cognitive failure, particularly the level of intentionality involved in the erroneous action. The Skill-Rule-Knowledge (SRK) framework of Rasmussen is used widely in the study of industrial errors and accidents. The SRK framework describes three fundamental types of error, according to whether behavior is under the control of practiced sensori-motor skill routines with minimal conscious awareness; is guided by implicit or explicit rules or expertise; or where the planning of actions requires the conscious application of domain knowledge. Up to now, examinations of circadian patterns of industrial errors have not distinguished between different types of error. Consequently, it is not clear whether all types of error exhibit the same circadian rhythm. A survey was distributed to aircraft maintenance personnel in Australia. Personnel were invited to anonymously report a safety incident and were prompted to describe, in detail, the human involvement (if any) that contributed to it. A total of 402 airline maintenance personnel reported an incident, providing 369 descriptions of human error in which the time of the incident was reported and sufficient detail was available to analyze the error. Errors were categorized using a modified version of the SRK framework, in which errors are categorized as skill-based, rule-based, or knowledge-based, or as procedure violations. An independent check confirmed that the SRK framework had been applied with sufficient consistency and reliability. Skill-based errors were the most common form of error, followed by procedure violations, rule-based errors, and knowledge-based errors. The frequency of errors was adjusted for the estimated proportion of workers present at work/each hour of the day, and the 24 h pattern of each error type was examined. Skill-based errors exhibited a significant circadian rhythm, being most prevalent in the early hours of the morning. Variation in the frequency of rule-based errors, knowledge-based errors, and procedure violations over the 24 h did not reach statistical significance. The results suggest that during the early hours of the morning, maintenance technicians are at heightened risk of "absent minded" errors involving failures to execute action plans as intended.
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EPs welcome new focus on reducing diagnostic errors.
2015-12-01
Emergency medicine leaders welcome a major new report from the Institute of Medicine (IOM) calling on providers, policy makers, and government agencies to institute changes to reduce the incidence of diagnostic errors. The 369-page report, "Improving Diagnosis in Health Care," states that the rate of diagnostic errors in this country is unacceptably high and offers a long list of recommendations aimed at addressing the problem. These include large, systemic changes that involve improvements in multiple areas, including health information technology (HIT), professional education, teamwork, and payment reform. Further, of particular interest to emergency physicians are recommended changes to the liability system. The authors of the IOM report state that while most people will likely experience a significant diagnostic error in their lifetime, the importance of this problem is under-appreciated. According to conservative estimates, the report says 5% of adults who seek outpatient care each year experience a diagnostic error. The report also notes that research over many decades shows diagnostic errors contribute to roughly 10% of all.deaths. The report says more steps need to be taken to facilitate inter-professional and intra-professional teamwork throughout the diagnostic process. Experts concur with the report's finding that mechanisms need to be developed so that providers receive ongoing feedback on their diagnostic performance.
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Active full-shell grazing-incidence optics
NASA Astrophysics Data System (ADS)
Roche, Jacqueline M.; Elsner, Ronald F.; Ramsey, Brian D.; O'Dell, Stephen L.; Kolodziejczak, Jeffrey J.; Weisskopf, Martin C.; Gubarev, Mikhail V.
2016-09-01
MSFC has a long history of developing full-shell grazing-incidence x-ray optics for both narrow (pointed) and wide field (surveying) applications. The concept presented in this paper shows the potential to use active optics to switch between narrow and wide-field geometries, while maintaining large effective area and high angular resolution. In addition, active optics has the potential to reduce errors due to mounting and manufacturing lightweight optics. The design presented corrects low spatial frequency error and has significantly fewer actuators than other concepts presented thus far in the field of active x-ray optics. Using a finite element model, influence functions are calculated using active components on a full-shell grazing-incidence optic. Next, the ability of the active optic to effect a change of optical prescription and to correct for errors due to manufacturing and mounting is modeled.
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Active Full-Shell Grazing-Incidence Optics
NASA Technical Reports Server (NTRS)
Davis, Jacqueline M.; Elsner, Ronald F.; Ramsey, Brian D.; O'Dell, Stephen L.; Kolodziejczak, Jeffery; Weisskopf, Martin C.; Gubarev, Mikhail V.
2016-01-01
MSFC has a long history of developing full-shell grazing-incidence x-ray optics for both narrow (pointed) and wide field (surveying) applications. The concept presented in this paper shows the potential to use active optics to switch between narrow and wide-field geometries, while maintaining large effective area and high angular resolution. In addition, active optics has the potential to reduce errors due to mounting and manufacturing lightweight optics. The design presented corrects low spatial frequency error and has significantly fewer actuators than other concepts presented thus far in the field of active x-ray optics. Using a finite element model, influence functions are calculated using active components on a full-shell grazing-incidence optic. Next, the ability of the active optic to effect a change of optical prescription and to correct for errors due to manufacturing and mounting is modeled.
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Human Error In Complex Systems
NASA Technical Reports Server (NTRS)
Morris, Nancy M.; Rouse, William B.
1991-01-01
Report presents results of research aimed at understanding causes of human error in such complex systems as aircraft, nuclear powerplants, and chemical processing plants. Research considered both slips (errors of action) and mistakes (errors of intention), and influence of workload on them. Results indicated that: humans respond to conditions in which errors expected by attempting to reduce incidence of errors; and adaptation to conditions potent influence on human behavior in discretionary situations.
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Song, Yongze; Ge, Yong; Wang, Jinfeng; Ren, Zhoupeng; Liao, Yilan; Peng, Junhuan
2016-07-07
Malaria is one of the most severe parasitic diseases in the world. Spatial distribution estimation of malaria and its future scenarios are important issues for malaria control and elimination. Furthermore, sophisticated nonlinear relationships for prediction between malaria incidence and potential variables have not been well constructed in previous research. This study aims to estimate these nonlinear relationships and predict future malaria scenarios in northern China. Nonlinear relationships between malaria incidence and predictor variables were constructed using a genetic programming (GP) method, to predict the spatial distributions of malaria under climate change scenarios. For this, the examples of monthly average malaria incidence were used in each county of northern China from 2004 to 2010. Among the five variables at county level, precipitation rate and temperature are used for projections, while elevation, water density index, and gross domestic product are held at their present-day values. Average malaria incidence was 0.107 ‰ per annum in northern China, with incidence characteristics in significant spatial clustering. A GP-based model fit the relationships with average relative error (ARE) = 8.127 % for training data (R(2) = 0.825) and 17.102 % for test data (R(2) = 0.532). The fitness of GP results are significantly improved compared with those by generalized additive models (GAM) and linear regressions. With the future precipitation rate and temperature conditions in Special Report on Emission Scenarios (SRES) family B1, A1B and A2 scenarios, spatial distributions and changes in malaria incidences in 2020, 2030, 2040 and 2050 were predicted and mapped. The GP method increases the precision of predicting the spatial distribution of malaria incidence. With the assumption of varied precipitation rate and temperature, and other variables controlled, the relationships between incidence and the varied variables appear sophisticated nonlinearity and spatially differentiation. Using the future fluctuated precipitation and the increased temperature, median malaria incidence in 2020, 2030, 2040 and 2050 would significantly increase that it might increase 19 to 29 % in 2020, but currently China is in the malaria elimination phase, indicating that the effective strategies and actions had been taken. While the mean incidences will not increase even reduce due to the incidence reduction in high-risk regions but the simultaneous expansion of the high-risk areas.
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A critical incident reporting system in anaesthesia.
Madzimbamuto, F D; Chiware, R
2001-01-01
To audit the recently established Critical Incident Reporting System in the Department of Anaesthesia and Critical Care Medicine, University of Zimbabwe Medical School. The system was set up with the purpose of improving the quality of care delivered by the department. Cross sectional study. A critical incident was defined as 'any adverse and reversible event in theatre, during or immediately after surgery that if it persisted without correction would cause harm to the patient'. The anaesthetic or recovery room staff filled a critical incident form anonymously. Data was collected from critical incident reporting forms for analysis. The anaesthetic service in the two teaching hospitals of Harare Central and Parirenyatwa General Hospitals. Between May and October 2000, 62 completed critical incident forms were collected. The nature of the incident and the monitoring used were recorded, the cause was classified as human, equipment or monitoring failure and the outcome for each patient reported. There was no formal system for reminding staff to fill in their critical incident forms. A total of 14,165 operations were performed over the reporting period: 62 critical incident forms were collected, reporting 130 incidents, giving a rate of 0.92% (130/14,165). Of these, 42 patients were emergencies and 20 elective. The incidents were hypotension, hypoxia, bradycardia, ECG changes, aspiration, laryngospasm, high spinal, and cardiac arrest. Monitoring present on patients who had critical incidents was: capnography 57%, oxymetry 90% and ECG 100%. Other monitors are not reported. Human error contributed in 32/62 of patients and equipment failure in 31/62 of patients. Patient outcome showed 15% died, 23% were unplanned admissions to HDU while 62% were discharged to the ward with little or no adverse outcome. Despite some under reporting, the critical incident rate was within the range reported in the literature. Supervision of juniors is not adequate, especially on call. The stress under which everyone has to work includes poor morale, drug shortages, poor equipment and power cuts with no backup generator. Despite this, the challenge for senior personnel is to improve quality of care. In other countries similar audits have led to change of practice and improvement in the safety features of the service provided by the hospital and staff.
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Implementation of a critical incident reporting system in a neurosurgical department.
Kantelhardt, P; Müller, M; Giese, A; Rohde, V; Kantelhardt, S R
2011-02-01
Critical incident monitoring is an important tool for quality improvement and the maintenance of high safety standards. It was developed for aviation safety and is now widely accepted as a useful tool to reduce medical care-related morbidity and mortality. Despite this widespread acceptance, the literature has no reports on any neurosurgical applications of critical incident monitoring. We describe the introduction of a mono-institutional critical incident reporting system in a neurosurgical department. Furthermore, we have developed a formula to assess possible counterstrategies. All staff members of a neurosurgical department were advised to report critical incidents. The anonymous reporting form contained a box for the description of the incident, several multiple-choice questions on specific risk factors, place and reason for occurrence of the incident, severity of the consequences and suggested counterstrategies. The incident data was entered into an online documentation system (ADKA DokuPik) and evaluated by an external specialist. For data analysis we applied a modified assessment scheme initially designed for flight safety. Data collection was started in September 2008. The average number of reported incidents was 18 per month (currently 216 in total). Most incidents occurred on the neurosurgical ward (64%). Human error was involved in 86% of the reported incidents. The largest group of incidents consisted of medication-related problems. Accordingly, counterstrategies were developed, resulting in a decrease in the relative number of reported medication-related incidents from 42% (March 09) to 30% (September 09). Implementation of the critical incident reporting system presented no technical problems. The reporting rate was high compared to that reported in the current literature. The formulation, evaluation and introduction of specific counterstrategies to guard against selected groups of incidents may improve patient safety in neurosurgical departments. © Georg Thieme Verlag KG Stuttgart · New York.
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Ahmadpanah, J; Ghavi Hossein-Zadeh, N; Shadparvar, A A; Pakdel, A
2017-02-01
1. The objectives of the current study were to investigate the effect of incidence rate (5%, 10%, 20%, 30% and 50%) of ascites syndrome on the expression of genetic characteristics for body weight at 5 weeks of age (BW5) and AS and to compare different methods of genetic parameter estimation for these traits. 2. Based on stochastic simulation, a population with discrete generations was created in which random mating was used for 10 generations. Two methods of restricted maximum likelihood and Bayesian approach via Gibbs sampling were used for the estimation of genetic parameters. A bivariate model including maternal effects was used. The root mean square error for direct heritabilities was also calculated. 3. The results showed that when incidence rates of ascites increased from 5% to 30%, the heritability of AS increased from 0.013 and 0.005 to 0.110 and 0.162 for linear and threshold models, respectively. 4. Maternal effects were significant for both BW5 and AS. Genetic correlations were decreased by increasing incidence rates of ascites in the population from 0.678 and 0.587 at 5% level of ascites to 0.393 and -0.260 at 50% occurrence for linear and threshold models, respectively. 5. The RMSE of direct heritability from true values for BW5 was greater based on a linear-threshold model compared with the linear model of analysis (0.0092 vs. 0.0015). The RMSE of direct heritability from true values for AS was greater based on a linear-linear model (1.21 vs. 1.14). 6. In order to rank birds for ascites incidence, it is recommended to use a threshold model because it resulted in higher heritability estimates compared with the linear model and that BW5 could be one of the main components of selection goals.
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Panesar, Sukhmeet S; Netuveli, Gopalakrishnan; Carson-Stevens, Andrew; Javad, Sundas; Patel, Bhavesh; Parry, Gareth; Donaldson, Liam J; Sheikh, Aziz
2013-11-21
The Orthopaedic Error Index for hospitals aims to provide the first national assessment of the relative safety of provision of orthopaedic surgery. Cross-sectional study (retrospective analysis of records in a database). The National Reporting and Learning System is the largest national repository of patient-safety incidents in the world with over eight million error reports. It offers a unique opportunity to develop novel approaches to enhancing patient safety, including investigating the relative safety of different healthcare providers and specialties. We extracted all orthopaedic error reports from the system over 1 year (2009-2010). The Orthopaedic Error Index was calculated as a sum of the error propensity and severity. All relevant hospitals offering orthopaedic surgery in England were then ranked by this metric to identify possible outliers that warrant further attention. 155 hospitals reported 48 971 orthopaedic-related patient-safety incidents. The mean Orthopaedic Error Index was 7.09/year (SD 2.72); five hospitals were identified as outliers. Three of these units were specialist tertiary hospitals carrying out complex surgery; the remaining two outlier hospitals had unusually high Orthopaedic Error Indexes: mean 14.46 (SD 0.29) and 15.29 (SD 0.51), respectively. The Orthopaedic Error Index has enabled identification of hospitals that may be putting patients at disproportionate risk of orthopaedic-related iatrogenic harm and which therefore warrant further investigation. It provides the prototype of a summary index of harm to enable surveillance of unsafe care over time across institutions. Further validation and scrutiny of the method will be required to assess its potential to be extended to other hospital specialties in the UK and also internationally to other health systems that have comparable national databases of patient-safety incidents.
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Shilkrut, Mark; Merrick, Gregory S; McLaughlin, P William; Stenmark, Matthew H; Abu-Isa, Eyad; Vance, Sean M; Sandler, Howard M; Feng, Felix Y; Hamstra, Daniel A
2013-02-01
The objective of this study was to determine whether the addition of low-dose-rate brachytherapy or androgen-deprivation therapy (ADT) improves clinical outcome in patients with high-risk prostate cancer (HiRPCa) who received dose-escalated radiotherapy (RT). Between 1995 and 2010, 958 patients with HiRPCa were treated at Schiffler Cancer Center (n = 484) or at the University of Michigan (n = 474) by receiving either dose-escalated external-beam RT (EBRT) (n = 510; minimum prescription dose, 75 grays [Gy]; median dose, 78 Gy) or combined-modality RT (CMRT) consisting of (103) Pd implants (n = 369) or (125) I implants (n = 79) both with pelvic irradiation (median prescription dose, 45 Gy). The cumulative incidences of biochemical failure (BF) and prostate cancer-specific mortality (PCSM) were estimated by using the Kaplan-Meier method and Fine and Gray regression analysis. The median follow-up was 63.2 months (interquartile range, 35.4-99.0 months), and 250 patients were followed for >8 years. Compared with CMRT, patients who received EBRT had higher prostate-specific antigen levels, higher tumor classification, lower Gleason sum, and more frequent receipt of ADT for a longer duration. The 8-year incidence BF and PCSM among patients who received EBRT was 40% (standard error, 38%-44%) and 13% (standard error, 11%-15%) compared with 14% (standard error, 12%-16%; P < .0001) and 7% (standard error 6%-9%; P = .003) among patients who received CMRT. On multivariate analysis, the hazard ratios (HRs) for BF and PCSM were 0.35 (95% confidence interval [CI], 0.23-0.52; P < .0001) and 0.41 (95% CI, 0.23-0.75; P < .003), favoring CMRT. Increasing duration of ADT predicted decreased BF (P = .04) and PCSM (P = .001), which was greatest with long-term ADT (BF: HR, 0.33; P < .0001; 95% CI, 0.21-0.52; PCSM: HR, 0.30; P = .001; 95% CI, 0.15-0.6) even in the subgroup that received CMRT. In this retrospective comparison, both low-dose-rate brachytherapy boost and ADT were associated with decreased risks of BF and PCSM compared with EBRT. Copyright © 2012 American Cancer Society.
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A Theoretical Foundation for the Study of Inferential Error in Decision-Making Groups.
ERIC Educational Resources Information Center
Gouran, Dennis S.
To provide a theoretical base for investigating the influence of inferential error on group decision making, current literature on both inferential error and decision making is reviewed and applied to the Watergate incident. Although groups tend to make fewer inferential errors because members' inferences are generally not biased in the same…
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A classification on human factor accident/incident of China civil aviation in recent twelve years.
Luo, Xiao-li
2004-10-01
To study human factor accident/incident occurred during 1990-2001 using new classification standard. The human factor accident/incident classification standard is developed on the basis of Reason's Model, combining with CAAC's traditional classifying method, and applied to the classified statistical analysis for 361 flying incidents and 35 flight accidents of China civil aviation, which is induced by human factors and occurred from 1990 to 2001. 1) the incident percentage of taxi and cruise is higher than that of takeoff, climb and descent. 2) The dominating type of flight incidents is diverging of runway, overrunning, near-miss, tail/wingtip/engine strike and ground obstacle impacting. 3) The top three accidents are out of control caused by crew, mountain collision and over runway. 4) Crew's basic operating skill is lower than what we imagined, the mostly representation is poor correcting ability when flight error happened. 5) Crew errors can be represented by incorrect control, regulation and procedure violation, disorientation and diverging percentage of correct flight level. The poor CRM skill is the dominant factor impacting China civil aviation safety, this result has a coincidence with previous study, but there is much difference and distinct characteristic in top incident phase, the type of crew error and behavior performance compared with that of advanced countries. We should strengthen CRM training for all of pilots aiming at the Chinese pilot behavior characteristic in order to improve the safety level of China civil aviation.
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Kearney, Nicole; Denham, Gary
2016-12-01
When a radiation incident occurs in nuclear medicine in Australia, the incident is reported to the relevant state or territory authority, which performs an investigation and sends its findings to the Australian Radiation Protection and Nuclear Safety Agency. The agency then includes these data in its Australian Radiation Incident Register and makes them available to the public as an annual summary report on its website. The aim of this study was to analyze the radiation incidents included in these annual reports and in the publically available state and territory registers, identify any recurring themes, and make recommendations to minimize future incidents. A multidisciplinary team comprising a nuclear medicine technologist, a radiation therapist, and a diagnostic radiographer analyzed all nuclear medicine technology-, radiation therapy-, and diagnostic radiography-related incidents recorded in the Australian Radiation Incident Register and in the registers of New South Wales, Western Australia, Victoria, South Australia, and Tasmania between 2003 and 2015. Each incident was placed into 1 of 18 categories, and each category was examined to determine any recurring causes of the incidents. We analyzed 209 nuclear medicine incidents. Their primary cause was failure to comply with time-out protocols (85.6%). By analyzing both the causes and the rates of radiation incidents, we were able to recommend ways to help prevent them from being repeated. Information drawn from the Australian Radiation Incident Register and 5 state registers has revealed steps that can be taken by any nuclear medicine department to prevent repetition of the incidents that have already occurred. © 2016 by the Society of Nuclear Medicine and Molecular Imaging, Inc.
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NASA Technical Reports Server (NTRS)
Maille, Nicolas P.; Statler, Irving C.; Ferryman, Thomas A.; Rosenthal, Loren; Shafto, Michael G.; Statler, Irving C.
2006-01-01
The objective of the Aviation System Monitoring and Modeling (ASMM) project of NASA s Aviation Safety and Security Program was to develop technologies that will enable proactive management of safety risk, which entails identifying the precursor events and conditions that foreshadow most accidents. This presents a particular challenge in the aviation system where people are key components and human error is frequently cited as a major contributing factor or cause of incidents and accidents. In the aviation "world", information about what happened can be extracted from quantitative data sources, but the experiential account of the incident reporter is the best available source of information about why an incident happened. This report describes a conceptual model and an approach to automated analyses of textual data sources for the subjective perspective of the reporter of the incident to aid in understanding why an incident occurred. It explores a first-generation process for routinely searching large databases of textual reports of aviation incident or accidents, and reliably analyzing them for causal factors of human behavior (the why of an incident). We have defined a generic structure of information that is postulated to be a sound basis for defining similarities between aviation incidents. Based on this structure, we have introduced the simplifying structure, which we call the Scenario as a pragmatic guide for identifying similarities of what happened based on the objective parameters that define the Context and the Outcome of a Scenario. We believe that it will be possible to design an automated analysis process guided by the structure of the Scenario that will aid aviation-safety experts to understand the systemic issues that are conducive to human error.
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Uy, Raymonde Charles Y.; Kury, Fabricio P.; Fontelo, Paul A.
2015-01-01
The standard of safe medication practice requires strict observance of the five rights of medication administration: the right patient, drug, time, dose, and route. Despite adherence to these guidelines, medication errors remain a public health concern that has generated health policies and hospital processes that leverage automation and computerization to reduce these errors. Bar code, RFID, biometrics and pharmacy automation technologies have been demonstrated in literature to decrease the incidence of medication errors by minimizing human factors involved in the process. Despite evidence suggesting the effectivity of these technologies, adoption rates and trends vary across hospital systems. The objective of study is to examine the state and adoption trends of automatic identification and data capture (AIDC) methods and pharmacy automation technologies in U.S. hospitals. A retrospective descriptive analysis of survey data from the HIMSS Analytics® Database was done, demonstrating an optimistic growth in the adoption of these patient safety solutions. PMID:26958264
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Sové, Richard J; Drakos, Nicole E; Fraser, Graham M; Ellis, Christopher G
2018-05-25
Red blood cell oxygen saturation is an important indicator of oxygen supply to tissues in the body. Oxygen saturation can be measured by taking advantage of spectroscopic properties of hemoglobin. When this technique is applied to transmission microscopy, the calculation of saturation requires determination of incident light intensity at each pixel occupied by the red blood cell; this value is often approximated from a sequence of images as the maximum intensity over time. This method often fails when the red blood cells are moving too slowly, or if hematocrit is too large since there is not a large enough gap between the cells to accurately calculate the incident intensity value. A new method of approximating incident light intensity is proposed using digital inpainting. This novel approach estimates incident light intensity with an average percent error of approximately 3%, which exceeds the accuracy of the maximum intensity based method in most cases. The error in incident light intensity corresponds to a maximum error of approximately 2% saturation. Therefore, though this new method is computationally more demanding than the traditional technique, it can be used in cases where the maximum intensity-based method fails (e.g. stationary cells), or when higher accuracy is required. This article is protected by copyright. All rights reserved. This article is protected by copyright. All rights reserved.
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Novak, Avrey; Nyflot, Matthew J; Ermoian, Ralph P; Jordan, Loucille E; Sponseller, Patricia A; Kane, Gabrielle M; Ford, Eric C; Zeng, Jing
2016-05-01
Radiation treatment planning involves a complex workflow that has multiple potential points of vulnerability. This study utilizes an incident reporting system to identify the origination and detection points of near-miss errors, in order to guide their departmental safety improvement efforts. Previous studies have examined where errors arise, but not where they are detected or applied a near-miss risk index (NMRI) to gauge severity. From 3/2012 to 3/2014, 1897 incidents were analyzed from a departmental incident learning system. All incidents were prospectively reviewed weekly by a multidisciplinary team and assigned a NMRI score ranging from 0 to 4 reflecting potential harm to the patient (no potential harm to potential critical harm). Incidents were classified by point of incident origination and detection based on a 103-step workflow. The individual steps were divided among nine broad workflow categories (patient assessment, imaging for radiation therapy (RT) planning, treatment planning, pretreatment plan review, treatment delivery, on-treatment quality management, post-treatment completion, equipment/software quality management, and other). The average NMRI scores of incidents originating or detected within each broad workflow area were calculated. Additionally, out of 103 individual process steps, 35 were classified as safety barriers, the process steps whose primary function is to catch errors. The safety barriers which most frequently detected incidents were identified and analyzed. Finally, the distance between event origination and detection was explored by grouping events by the number of broad workflow area events passed through before detection, and average NMRI scores were compared. Near-miss incidents most commonly originated within treatment planning (33%). However, the incidents with the highest average NMRI scores originated during imaging for RT planning (NMRI = 2.0, average NMRI of all events = 1.5), specifically during the documentation of patient positioning and localization of the patient. Incidents were most frequently detected during treatment delivery (30%), and incidents identified at this point also had higher severity scores than other workflow areas (NMRI = 1.6). Incidents identified during on-treatment quality management were also more severe (NMRI = 1.7), and the specific process steps of reviewing portal and CBCT images tended to catch highest-severity incidents. On average, safety barriers caught 46% of all incidents, most frequently at physics chart review, therapist's chart check, and the review of portal images; however, most of the incidents that pass through a particular safety barrier are not designed to be capable of being captured at that barrier. Incident learning systems can be used to assess the most common points of error origination and detection in radiation oncology. This can help tailor safety improvement efforts and target the highest impact portions of the workflow. The most severe near-miss events tend to originate during simulation, with the most severe near-miss events detected at the time of patient treatment. Safety barriers can be improved to allow earlier detection of near-miss events.
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Development of Biological Acoustic Impedance Microscope and its Error Estimation
NASA Astrophysics Data System (ADS)
Hozumi, Naohiro; Nakano, Aiko; Terauchi, Satoshi; Nagao, Masayuki; Yoshida, Sachiko; Kobayashi, Kazuto; Yamamoto, Seiji; Saijo, Yoshifumi
This report deals with the scanning acoustic microscope for imaging cross sectional acoustic impedance of biological soft tissues. A focused acoustic beam was transmitted to the tissue object mounted on the "rear surface" of plastic substrate. A cerebellum tissue of rat and a reference material were observed at the same time under the same condition. As the incidence is not vertical, not only longitudinal wave but also transversal wave is generated in the substrate. The error in acoustic impedance assuming vertical incidence was estimated. It was proved that the error can precisely be compensated, if the beam pattern and acoustic parameters of coupling medium and substrate had been known.
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Identifying inaccuracies on emergency medicine residency applications
Katz, Eric D; Shockley, Lee; Kass, Lawrence; Howes, David; Tupesis, Janis P; Weaver, Christopher; Sayan, Osman R; Hogan, Victoria; Begue, Jason; Vrocher, Diamond; Frazer, Jackie; Evans, Timothy; Hern, Gene; Riviello, Ralph; Rivera, Antonio; Kinoshita, Keith; Ferguson, Edward
2005-01-01
Background Previous trials have showed a 10–30% rate of inaccuracies on applications to individual residency programs. No studies have attempted to corroborate this on a national level. Attempts by residency programs to diminish the frequency of inaccuracies on applications have not been reported. We seek to clarify the national incidence of inaccuracies on applications to emergency medicine residency programs. Methods This is a multi-center, single-blinded, randomized, cohort study of all applicants from LCME accredited schools to involved EM residency programs. Applications were randomly selected to investigate claims of AOA election, advanced degrees and publications. Errors were reported to applicants' deans and the NRMP. Results Nine residencies reviewed 493 applications (28.6% of all applicants who applied to any EM program). 56 applications (11.4%, 95%CI 8.6–14.2%) contained at least one error. Excluding "benign" errors, 9.8% (95% CI 7.2–12.4%), contained at least one error. 41% (95% CI 35.0–47.0%) of all publications contained an error. All AOA membership claims were verified, but 13.7% (95%CI 4.4–23.1%) of claimed advanced degrees were inaccurate. Inter-rater reliability of evaluations was good. Investigators were reluctant to notify applicants' dean's offices and the NRMP. Conclusion This is the largest study to date of accuracy on application for residency and the first such multi-centered trial. High rates of incorrect data were found on applications. This data will serve as a baseline for future years of the project, with emphasis on reporting inaccuracies and warning applicants of the project's goals. PMID:16105178
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Incidence and Risk Factors for Volar Wrist Ganglia in the U.S. Military and Civilian Populations.
Balazs, George C; Dworak, Theodora C; Tropf, Jordan; Nanos, George P; Tintle, Scott M
2016-11-01
To identify the incidence and demographic factors associated with volar wrist ganglia in both military and civilian beneficiary populations. The U.S. Department of Defense Management Analysis and Reporting Tool (M2) accesses a comprehensive database of all health care visits by military personnel and their dependents. Because there is no specific code for ganglions of the wrist, the database was searched for all military personnel and civilian beneficiaries with an International Classification of Diseases, 9th Revision, diagnosis of 727.41 (ganglion of a joint) or 727.43 (ganglion, unspecified location) between 2009 and 2014. Two random samples of 1000 patients were selected from both the military and the civilian beneficiary cohorts, and their electronic medical records were examined to identify those with volar wrist ganglia. The proportion of volar wrist ganglia was then applied to the overall population data to estimate the total incidence with a 95% confidence interval and 5% margin of error. Unadjusted incidence rates and adjusted incidence rate ratios were determined using Poisson regression, controlling for age, sex, branch of military service, and military seniority. The unadjusted incidence of volar wrist ganglia is 3.72 per 10,000 person-years (0.04%/y) in female civilian beneficiaries, 1.04 per 10,000 person-years (0.01%/y) in male civilian beneficiaries, 7.98 per 10,000 person-years (0.08%/y) in female military personnel, and 3.73 per 10,000 person-years (0.04%/y) in male military personnel. When controlled for age, military personnel have a 2.5-times increased rate of volar wrist ganglia, and women have a 2.3-times increased rate. In the military cohort, female sex, branch of service, and seniority were significantly associated with the diagnosis of a volar wrist ganglion when controlled for age. In the civilian beneficiary cohort, only female sex was significant. Military service members have higher rates of volar wrist ganglia diagnoses than their age- and sex-matched civilian counterparts. Women are significantly more likely to be diagnosed with a volar wrist ganglion, regardless of age or military status. The epidemiology of volar wrist ganglia is poorly defined, and few studies have firmly defined demographic factors associated with the diagnosis. We provide the overall incidence rate of the diagnosis and report a significant association with female sex even when controlled for age. Copyright © 2016 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.
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Error Propagation in a System Model
NASA Technical Reports Server (NTRS)
Schloegel, Kirk (Inventor); Bhatt, Devesh (Inventor); Oglesby, David V. (Inventor); Madl, Gabor (Inventor)
2015-01-01
Embodiments of the present subject matter can enable the analysis of signal value errors for system models. In an example, signal value errors can be propagated through the functional blocks of a system model to analyze possible effects as the signal value errors impact incident functional blocks. This propagation of the errors can be applicable to many models of computation including avionics models, synchronous data flow, and Kahn process networks.
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Frequency of pediatric medication administration errors and contributing factors.
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.
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Using the Delphi method to develop nursing-sensitive quality indicators for the NICU.
Chen, Lin; Huang, Li-Hua; Xing, Mei-Yuan; Feng, Zhi-Xian; Shao, Le-Wen; Zhang, Mei-Yun; Shao, Rong-Ya
2017-02-01
To develop nursing-sensitive quality indicators consistent with current medical practices in Chinese neonatal intensive care units. The development of nursing-sensitive quality indicators has become a top priority in nursing management. To the best of our knowledge, there has been no objective, scientific and sensitive evaluation of the quality of neonatal intensive care unit nursing in China. A modified Delphi technique was used to seek opinions from experts about what should be used and prioritised as indicators of quality care in neonatal intensive care unit nursing. Based on a literature review, we identified 21 indicators of nursing-sensitive quality in the neonatal intensive care unit. Our group of 11 consultants chose 13 indicators to be discussed using the Delphi method. In October and November 2014, 39 neonatal intensive care unit experts in 18 tertiary hospitals spread across six provinces participated in two rounds of Delphi panels. Of the 13 indicators discussed, 11 were identified as indicators of nursing-sensitive quality in the neonatal intensive care unit: rate of nosocomial infections, rate of accidental endotracheal extubation, rate of errors in medication administration, rate of treatment for pain, rate of peripheral venous extravasation, rate of compliance with handwashing techniques, incidence of pressure ulcers, incidence of noise, the bed-to-care ratio, the proportion of nurses with greater than five years neonatal intensive care unit experience and incidence of retinopathy. The 11 neonatal intensive care unit nursing-sensitive indicators identified by the Delphi method integrated with basic Chinese practices provide a basis for nursing management and the monitoring of nursing quality. This study identified nursing-sensitive quality indicators for neonatal intensive care unit care that are suitable for current clinical practice in China. © 2016 John Wiley & Sons Ltd.
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Guffey, Patrick; Szolnoki, Judit; Caldwell, James; Polaner, David
2011-07-01
Current incident reporting systems encourage retrospective reporting of morbidity and mortality and have low participation rates. A near miss is an event that did not cause patient harm, but had the potential to. By tracking and analyzing near misses, systems improvements can be targeted appropriately, and future errors may be prevented. An electronic, web based, secure, anonymous reporting system for anesthesiologists was designed and instituted at The Children's Hospital, Denver. This portal was compared to an existing hospital incident reporting system. A total of 150 incidents were reported in the first 3 months of operation, compared to four entered in the same time period 1 year ago. An anesthesia-specific anonymous near-miss reporting system, which eases and facilitates data entry and can prospectively identify processes and practices that place patients at risk, was implemented at a large, academic, freestanding children's hospital. This resulted in a dramatic increase in reported events and provided data to target and drive quality and process improvement. © 2011 Blackwell Publishing Ltd.
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NASA Astrophysics Data System (ADS)
Zhang, Hao; Yuan, Yan; Su, Lijuan; Huang, Fengzhen; Bai, Qing
2016-09-01
The Risley-prism-based light beam steering apparatus delivers superior pointing accuracy and it is used in imaging LIDAR and imaging microscopes. A general model for pointing error analysis of the Risley prisms is proposed in this paper, based on ray direction deviation in light refraction. This model captures incident beam deviation, assembly deflections, and prism rotational error. We derive the transmission matrixes of the model firstly. Then, the independent and cumulative effects of different errors are analyzed through this model. Accuracy study of the model shows that the prediction deviation of pointing error for different error is less than 4.1×10-5° when the error amplitude is 0.1°. Detailed analyses of errors indicate that different error sources affect the pointing accuracy to varying degree, and the major error source is the incident beam deviation. The prism tilting has a relative big effect on the pointing accuracy when prism tilts in the principal section. The cumulative effect analyses of multiple errors represent that the pointing error can be reduced by tuning the bearing tilting in the same direction. The cumulative effect of rotational error is relative big when the difference of these two prism rotational angles equals 0 or π, while it is relative small when the difference equals π/2. The novelty of these results suggests that our analysis can help to uncover the error distribution and aid in measurement calibration of Risley-prism systems.
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NASA Technical Reports Server (NTRS)
Silva-Martinez, Jackelynne; Ellenberger, Richard; Dory, Jonathan
2017-01-01
This project aims to identify poor human factors design decisions that led to error-prone systems, or did not facilitate the flight crew making the right choices; and to verify that NASA is effectively preventing similar incidents from occurring again. This analysis was performed by reviewing significant incidents and close calls in human spaceflight identified by the NASA Johnson Space Center Safety and Mission Assurance Flight Safety Office. The review of incidents shows whether the identified human errors were due to the operational phase (flight crew and ground control) or if they initiated at the design phase (includes manufacturing and test). This classification was performed with the aid of the NASA Human Systems Integration domains. This in-depth analysis resulted in a tool that helps with the human factors classification of significant incidents and close calls in human spaceflight, which can be used to identify human errors at the operational level, and how they were or should be minimized. Current governing documents on human systems integration for both government and commercial crew were reviewed to see if current requirements, processes, training, and standard operating procedures protect the crew and ground control against these issues occurring in the future. Based on the findings, recommendations to target those areas are provided.
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Learning from Errors: Critical Incident Reporting in Nursing
ERIC Educational Resources Information Center
Gartmeier, Martin; Ottl, Eva; Bauer, Johannes; Berberat, Pascal Oliver
2017-01-01
Purpose: The purpose of this paper is to conceptualize error reporting as a strategy for informal workplace learning and investigate nurses' error reporting cost/benefit evaluations and associated behaviors. Design/methodology/approach: A longitudinal survey study was carried out in a hospital setting with two measurements (time 1 [t1]:…
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Human Error: The Stakes Are Raised.
ERIC Educational Resources Information Center
Greenberg, Joel
1980-01-01
Mistakes related to the operation of nuclear power plants and other technologically complex systems are discussed. Recommendations are given for decreasing the chance of human error in the operation of nuclear plants. The causes of the Three Mile Island incident are presented in terms of the human error element. (SA)
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Intravenous Chemotherapy Compounding Errors in a Follow-Up Pan-Canadian Observational Study.
Gilbert, Rachel E; Kozak, Melissa C; Dobish, Roxanne B; Bourrier, Venetia C; Koke, Paul M; Kukreti, Vishal; Logan, Heather A; Easty, Anthony C; Trbovich, Patricia L
2018-05-01
Intravenous (IV) compounding safety has garnered recent attention as a result of high-profile incidents, awareness efforts from the safety community, and increasingly stringent practice standards. New research with more-sensitive error detection techniques continues to reinforce that error rates with manual IV compounding are unacceptably high. In 2014, our team published an observational study that described three types of previously unrecognized and potentially catastrophic latent chemotherapy preparation errors in Canadian oncology pharmacies that would otherwise be undetectable. We expand on this research and explore whether additional potential human failures are yet to be addressed by practice standards. Field observations were conducted in four cancer center pharmacies in four Canadian provinces from January 2013 to February 2015. Human factors specialists observed and interviewed pharmacy managers, oncology pharmacists, pharmacy technicians, and pharmacy assistants as they carried out their work. Emphasis was on latent errors (potential human failures) that could lead to outcomes such as wrong drug, dose, or diluent. Given the relatively short observational period, no active failures or actual errors were observed. However, 11 latent errors in chemotherapy compounding were identified. In terms of severity, all 11 errors create the potential for a patient to receive the wrong drug or dose, which in the context of cancer care, could lead to death or permanent loss of function. Three of the 11 practices were observed in our previous study, but eight were new. Applicable Canadian and international standards and guidelines do not explicitly address many of the potentially error-prone practices observed. We observed a significant degree of risk for error in manual mixing practice. These latent errors may exist in other regions where manual compounding of IV chemotherapy takes place. Continued efforts to advance standards, guidelines, technological innovation, and chemical quality testing are needed.
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Evitts, Paul M; Starmer, Heather; Teets, Kristine; Montgomery, Christen; Calhoun, Lauren; Schulze, Allison; MacKenzie, Jenna; Adams, Lauren
2016-11-01
There is currently minimal information on the impact of dysphonia secondary to phonotrauma on listeners. Considering the high incidence of voice disorders with professional voice users, it is important to understand the impact of a dysphonic voice on their audiences. Ninety-one healthy listeners (39 men, 52 women; mean age = 23.62 years) were presented with speech stimuli from 5 healthy speakers and 5 speakers diagnosed with dysphonia secondary to phonotrauma. Dependent variables included processing speed (reaction time [RT] ratio), speech intelligibility, and listener comprehension. Voice quality ratings were also obtained for all speakers by 3 expert listeners. Statistical results showed significant differences between RT ratio and number of speech intelligibility errors between healthy and dysphonic voices. There was not a significant difference in listener comprehension errors. Multiple regression analyses showed that voice quality ratings from the Consensus Assessment Perceptual Evaluation of Voice (Kempster, Gerratt, Verdolini Abbott, Barkmeier-Kraemer, & Hillman, 2009) were able to predict RT ratio and speech intelligibility but not listener comprehension. Results of the study suggest that although listeners require more time to process and have more intelligibility errors when presented with speech stimuli from speakers with dysphonia secondary to phonotrauma, listener comprehension may not be affected.
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DOE Office of Scientific and Technical Information (OSTI.GOV)
Novak, Avrey; Nyflot, Matthew J.; Ermoian, Ralph P.
Purpose: Radiation treatment planning involves a complex workflow that has multiple potential points of vulnerability. This study utilizes an incident reporting system to identify the origination and detection points of near-miss errors, in order to guide their departmental safety improvement efforts. Previous studies have examined where errors arise, but not where they are detected or applied a near-miss risk index (NMRI) to gauge severity. Methods: From 3/2012 to 3/2014, 1897 incidents were analyzed from a departmental incident learning system. All incidents were prospectively reviewed weekly by a multidisciplinary team and assigned a NMRI score ranging from 0 to 4 reflectingmore » potential harm to the patient (no potential harm to potential critical harm). Incidents were classified by point of incident origination and detection based on a 103-step workflow. The individual steps were divided among nine broad workflow categories (patient assessment, imaging for radiation therapy (RT) planning, treatment planning, pretreatment plan review, treatment delivery, on-treatment quality management, post-treatment completion, equipment/software quality management, and other). The average NMRI scores of incidents originating or detected within each broad workflow area were calculated. Additionally, out of 103 individual process steps, 35 were classified as safety barriers, the process steps whose primary function is to catch errors. The safety barriers which most frequently detected incidents were identified and analyzed. Finally, the distance between event origination and detection was explored by grouping events by the number of broad workflow area events passed through before detection, and average NMRI scores were compared. Results: Near-miss incidents most commonly originated within treatment planning (33%). However, the incidents with the highest average NMRI scores originated during imaging for RT planning (NMRI = 2.0, average NMRI of all events = 1.5), specifically during the documentation of patient positioning and localization of the patient. Incidents were most frequently detected during treatment delivery (30%), and incidents identified at this point also had higher severity scores than other workflow areas (NMRI = 1.6). Incidents identified during on-treatment quality management were also more severe (NMRI = 1.7), and the specific process steps of reviewing portal and CBCT images tended to catch highest-severity incidents. On average, safety barriers caught 46% of all incidents, most frequently at physics chart review, therapist’s chart check, and the review of portal images; however, most of the incidents that pass through a particular safety barrier are not designed to be capable of being captured at that barrier. Conclusions: Incident learning systems can be used to assess the most common points of error origination and detection in radiation oncology. This can help tailor safety improvement efforts and target the highest impact portions of the workflow. The most severe near-miss events tend to originate during simulation, with the most severe near-miss events detected at the time of patient treatment. Safety barriers can be improved to allow earlier detection of near-miss events.« less
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A survey of community members' perceptions of medical errors in Oman
Al-Mandhari, Ahmed S; Al-Shafaee, Mohammed A; Al-Azri, Mohammed H; Al-Zakwani, Ibrahim S; Khan, Mushtaq; Al-Waily, Ahmed M; Rizvi, Syed
2008-01-01
Background Errors have been the concern of providers and consumers of health care services. However, consumers' perception of medical errors in developing countries is rarely explored. The aim of this study is to assess community members' perceptions about medical errors and to analyse the factors affecting this perception in one Middle East country, Oman. Methods Face to face interviews were conducted with heads of 212 households in two villages in North Al-Batinah region of Oman selected because of close proximity to the Sultan Qaboos University (SQU), Muscat, Oman. Participants' perceived knowledge about medical errors was assessed. Responses were coded and categorised. Analyses were performed using Pearson's χ2, Fisher's exact tests, and multivariate logistic regression model wherever appropriate. Results Seventy-eight percent (n = 165) of participants believed they knew what was meant by medical errors. Of these, 34% and 26.5% related medical errors to wrong medications or diagnoses, respectively. Understanding of medical errors was correlated inversely with age and positively with family income. Multivariate logistic regression revealed that a one-year increase in age was associated with a 4% reduction in perceived knowledge of medical errors (CI: 1% to 7%; p = 0.045). The study found that 49% of those who believed they knew the meaning of medical errors had experienced such errors. The most common consequence of the errors was severe pain (45%). Of the 165 informed participants, 49% felt that an uncaring health care professional was the main cause of medical errors. Younger participants were able to list more possible causes of medical errors than were older subjects (Incident Rate Ratio of 0.98; p < 0.001). Conclusion The majority of participants believed they knew the meaning of medical errors. Younger participants were more likely to be aware of such errors and could list one or more causes. PMID:18664245
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Recognizing and managing errors of cognitive underspecification.
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.
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Retinal dysfunction and refractive errors: an electrophysiological study of children
Flitcroft, D I; Adams, G G W; Robson, A G; Holder, G E
2005-01-01
Aims: To evaluate the relation between refractive error and electrophysiological retinal abnormalities in children referred for investigation of reduced vision. Methods: The study group comprised 123 consecutive patients referred over a 14 month period from the paediatric service of Moorfields Eye Hospital for electrophysiological investigation of reduced vision. Subjects were divided into five refractive categories according to their spectacle correction: high myopia (⩽−6D), low myopia (>−6D and ⩽−0.75D), emmetropia (>−0.75 and <1.5D), low hyperopia (⩾1.5 and <6D), and high hyperopia (⩾6D). Patients with a specific diagnosis at the time of electrophysiological testing were excluded. Only the first member of any one family was included if more than one sibling had been tested. All tests were performed to incorporate ISCEV standards, using gold foil corneal electrodes where possible. In younger patients skin electrodes and an abbreviated protocol were employed. Results: The mean age of patients was 7.1 years with an overall incidence of abnormal electrophysiological findings of 29.3%. The incidence of abnormality was higher in high ametropes (13/25, 52%) compared to the other groups (23/98, 23.5%). This difference was statistically significant (χ2 test, p = 0.005). There was also a significant association between high astigmatism (>1.5D) and ERG abnormalities (18/35 with high astigmatism v 20/88 without, χ2 test, p = 0.002). There was no significant variation in frequency of abnormalities between low myopes, emmetropes, and low hyperopes. The rate of abnormalities was very similar in both high myopes (8/15) and high hyperopes (5/10). Conclusions: High ametropia and astigmatism in children being investigated for poor vision are associated with a higher rate of retinal electrophysiological abnormalities. An increased rate of refractive errors in the presence of retinal pathology is consistent with the hypothesis that the retina is involved in the process of emmetropisation. Electrophysiological testing should be considered in cases of high ametropia in childhood to rule out associated retinal pathology. PMID:15774929
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An exploration of Australian hospital pharmacists' attitudes to patient safety.
Lalor, Daniel J; Chen, Timothy F; Walpola, Ramesh; George, Rachel A; Ashcroft, Darren M; Fois, Romano A
2015-02-01
To explore the attitudes of Australian hospital pharmacists towards patient safety in their work settings. A safety climate questionnaire was administered to all 2347 active members of the Society of Hospital Pharmacists of Australia in 2010. Part of the survey elicited free-text comments about patient safety, error and incident reporting. The comments were subjected to thematic analysis to determine the attitudes held by respondents in relation to patient safety and its quality management in their work settings. Two hundred and ten (210) of 643 survey respondents provided comments on safety and quality issues related to their work settings. The responses contained a number of dominant themes including issues of workforce and working conditions, incident reporting systems, the response when errors occur, the presence or absence of a blame culture, hospital management support for safety initiatives, openness about errors and the value of teamwork. A number of pharmacists described the development of a mature patient-safety culture - one that is open about reporting errors and active in reducing their occurrence. Others described work settings in which a culture of blame persists, stifling error reporting and ultimately compromising patient safety. Australian hospital pharmacists hold a variety of attitudes that reflect diverse workplace cultures towards patient safety, error and incident reporting. This study has provided an insight into these attitudes and the actions that are needed to improve the patient-safety culture within Australian hospital pharmacy work settings. © 2014 Royal Pharmaceutical Society.
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DOE Office of Scientific and Technical Information (OSTI.GOV)
Ford, Eric C., E-mail: eford@uw.edu; Terezakis, Stephanie; Souranis, Annette
Purpose: To quantify the error-detection effectiveness of commonly used quality control (QC) measures. Methods: We analyzed incidents from 2007-2010 logged into a voluntary in-house, electronic incident learning systems at 2 academic radiation oncology clinics. None of the incidents resulted in patient harm. Each incident was graded for potential severity using the French Nuclear Safety Authority scoring scale; high potential severity incidents (score >3) were considered, along with a subset of 30 randomly chosen low severity incidents. Each report was evaluated to identify which of 15 common QC checks could have detected it. The effectiveness was calculated, defined as the percentagemore » of incidents that each QC measure could detect, both for individual QC checks and for combinations of checks. Results: In total, 4407 incidents were reported, 292 of which had high-potential severity. High- and low-severity incidents were detectable by 4.0 {+-} 2.3 (mean {+-} SD) and 2.6 {+-} 1.4 QC checks, respectively (P<.001). All individual checks were less than 50% sensitive with the exception of pretreatment plan review by a physicist (63%). An effectiveness of 97% was achieved with 7 checks used in combination and was not further improved with more checks. The combination of checks with the highest effectiveness includes physics plan review, physician plan review, Electronic Portal Imaging Device-based in vivo portal dosimetry, radiation therapist timeout, weekly physics chart check, the use of checklists, port films, and source-to-skin distance checks. Some commonly used QC checks such as pretreatment intensity modulated radiation therapy QA do not substantially add to the ability to detect errors in these data. Conclusions: The effectiveness of QC measures in radiation oncology depends sensitively on which checks are used and in which combinations. A small percentage of errors cannot be detected by any of the standard formal QC checks currently in broad use, suggesting that further improvements are needed. These data require confirmation with a broader incident-reporting database.« less
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Figuring process of potassium dihydrogen phosphate crystal using ion beam figuring technology.
Li, Furen; Xie, Xuhui; Tie, Guipeng; Hu, Hao; Zhou, Lin
2017-09-01
Currently, ion beam figuring (IBF) technology has presented many excellent performances in figuring potassium dihydrogen phosphate (KDP) crystals, such as it is a noncontact figuring process and it does not require polishing fluid. So, it is a very clean figuring process and does not introduce any impurities. However, the ion beam energy deposited on KDP crystal will heat the KDP crystal and may generate cracks on it. So, it is difficult directly using IBF technology to figure KDP crystal, as oblique incident IBF (OI-IBF) has lower heat deposition, higher removal rate, and smoother surface roughness compared to normal incident IBF. This paper studied the process of using OI-IBF to figure KDP crystal. Removal rates and removal functions at different incident angles were first investigated. Then heat depositions on a test work piece were obtained through experiments. To validate the figuring process, a KDP crystal with a size of 200 mm×200 mm×12 mm was figured by OI-IBF. After three iterations using the OI-IBF process, the surface error decreases from the initial values with PV 1.986λ RMS 0.438λ to PV 0.215λ RMS 0.035λ. Experimental results indicate that OI-IBF is feasible and effective to figure KDP crystals.
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Incidence of Amblyopia and Its Risk Factors in Children With Isolated Metopic Craniosynostosis.
Nguyen, Thuan B; Shock, Leslie A; Missoi, Tara G; Muzaffar, Arshad R
2016-01-01
Ophthalmic abnormalities in children with syndromic craniosynostosis have been reported previously, and referral of these children to a pediatric ophthalmologist is recommended. However, it is not as clear whether a child with nonsyndromic synostosis needs to be referred to a pediatric ophthalmologist. The aim of this study is to report the incidence of amblyopia and its risk factors in children with isolated metopic craniosynostosis. An institutional review board-approved, retrospective review was performed on 91 children diagnosed with isolated metopic craniosynostosis. Ophthalmologic records were reviewed for diagnoses of amblyopia, strabismus, and refractive error. Of the 91 children, 19 (20.9%) had astigmatism, eight (8.8%) had amblyopia, eight (8.8%) had strabismus, five had myopia (5.5%), five had hyperopia (5.5%), and five had anisometropia (5.5%). The incidence of amblyopia and its risk factors found in our study are higher than the rate found in the clinically normal pediatric population. In our patient population, children with isolated metopic craniosynostosis demonstrate an increased rate of amblyopia and its risk factors. Amblyopia is best treated early in life to achieve a successful outcome. A referral to a pediatric ophthalmologist for a formal eye exam and potential treatment is therefore recommended for children with isolated metopic craniosynostosis.
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The measurement of radiation exposure of astronauts by radiochemical techniques
NASA Technical Reports Server (NTRS)
Brodzinski, R. L.
1971-01-01
The concentrations of 23 major, minor, and trace elements in the fecal samples from the Apollo 12 and 13 astronauts are reported. Most elemental excretion rates are comparable to rates reported for earlier missions. Exceptions are noted for calcium, iron, and tin. Body calcium and iron losses appear to be reduced during the Apollo 12 and 13 missions such that losses now seem to be insignificant. Refined measurements of tin excretion rates agree with normal dietary intakes. Earlier reported tin values are in error. A new passive dosimetry canister was designed which contains foils of tantalum, copper, titanium, iron, cobalt, aluminum, and scandium. By measuring the concentrations of the various products of nuclear reactions in these metals after space exposure, the characteristics of the incident cosmic particles can be determined.
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Are "Human Factors" the Primary Cause of Complications in the Field of Implant Dentistry?
Renouard, Franck; Amalberti, René; Renouard, Erell
Complications in medicine and dentistry are usually analyzed from a purely technical point of view. Rarely is the role of human behavior or judgment considered as a reason for adverse outcomes. When the role of human factors is considered, these are usually described in general terms rather than specifically identifying the factors responsible for an adverse event. The impact of cognitive and behavioral factors in the explanation of adverse events has been studied in other high-stakes areas such as aviation and nuclear power. Specific protocols have been developed to reduce rates of human error, and, where human error is unavoidable, to lessen its impact. This approach has dramatically reduced the incidence of accidents in these fields. This article aims to review how a similar approach may prove valuable in the reduction of complications in implant dentistry.
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Defining and measuring patient safety.
Pronovost, Peter J; Thompson, David A; Holzmueller, Christine G; Lubomski, Lisa H; Morlock, Laura L
2005-01-01
Despite the growing demand for improved safety in health care, debate remains regarding the magnitude of the problem and the degree to which harm is preventable. To a great extent, this debate stems from variation in the definition and methods for measuring safety, its "shadow" error, and the degree of preventability. This article reviews the definition of safety and error, discusses approaches to measuring safety, and provides a framework for investigating incidents that unveils how the systems under which care is delivered may contribute to adverse incidents.
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Ono, Yohei; Kashihara, Rina; Yasojima, Nobutoshi; Kasahara, Hideki; Shimizu, Yuka; Tamura, Kenichi; Tsutsumi, Kaori; Sutherland, Kenneth; Koike, Takao; Kamishima, Tamotsu
2016-06-01
Accurate evaluation of joint space width (JSW) is important in the assessment of rheumatoid arthritis (RA). In clinical radiography of bilateral hands, the oblique incidence of X-rays is unavoidable, which may cause perceptional or measurement error of JSW. The objective of this study was to examine whether tomosynthesis, a recently developed modality, can facilitate a more accurate evaluation of JSW than radiography under the condition of oblique incidence of X-rays. We investigated quantitative errors derived from the oblique incidence of X-rays by imaging phantoms simulating various finger joint spaces using radiographs and tomosynthesis images. We then compared the qualitative results of the modified total Sharp score of a total of 320 joints from 20 patients with RA between these modalities. A quantitative error was prominent when the location of the phantom was shifted along the JSW direction. Modified total Sharp scores of tomosynthesis images were significantly higher than those of radiography, that is to say JSW was regarded as narrower in tomosynthesis than in radiography when finger joints were located where the oblique incidence of X-rays is expected in the JSW direction. Tomosynthesis can facilitate accurate evaluation of JSW in finger joints of patients with RA, even with oblique incidence of X-rays. Accurate evaluation of JSW is necessary for the management of patients with RA. Through phantom and clinical studies, we demonstrate that tomosynthesis may achieve more accurate evaluation of JSW.
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Incident reporting: Its role in aviation safety and the acquisition of human error data
NASA Technical Reports Server (NTRS)
Reynard, W. D.
1983-01-01
The rationale for aviation incident reporting systems is presented and contrasted to some of the shortcomings of accident investigation procedures. The history of the United State's Aviation Safety Reporting System (ASRS) is outlined and the program's character explained. The planning elements that resulted in the ASRS program's voluntary, confidential, and non-punitive design are discussed. Immunity, from enforcement action and misuse of the volunteered data, is explained and evaluated. Report generation techniques and the ASRS data analysis process are described; in addition, examples of the ASRS program's output and accomplishments are detailed. Finally, the value of incident reporting for the acquisition of safety information, particularly human error data, is explored.
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Attention to Form or Meaning? Error Treatment in the Bangalore Project.
ERIC Educational Resources Information Center
Beretta, Alan
1989-01-01
Reports on an evaluation of the Bangalore/Madras Communicational Teaching Project (CTP), a content-based approach to language learning. Analysis of 21 lesson transcripts revealed a greater incidence of error treatment of content than linguistic error, consonant with the CTP focus on meaning rather than form. (26 references) (Author/CB)
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Galván Núñez, Pablo; Santander Barrios, María Dolores; Villa Álvarez, María Cristina; Castro Delgado, Rafael; Alonso Lorenzo, Julio C; Arcos González, Pedro
2016-06-01
To describe the reported incidents and adverse events in the emergency medical services of Asturias, Spain, and assess their consequences, delays caused, and preventability. Prospective, observational study of incidents reported by the staff of the emergency medical services of Asturias after implementation of a system devised by the researchers. Incident reports were received for 0.48% (95% CI, 0.41%-0.54%) of the emergencies attended. Patient safety was compromised in 74.7% of the reported incidents. Problems arising in the emergency response coordination center (ERCC) accounted for 37.6% of the incidents, transport problems for 13.4%, vehicular problems for 10.8%, and communication problems for 8.8%. Seventy percent of the reported incidents caused delays in care; 55% of the reported incidents that put patients at risk (according to severity assessment code ratings) corresponded to problems related to human or material resources. A total of 88.1% of the incidents reported were considered avoidable. Some type of intervention was required to attenuate the effects of 46.2% of the adverse events reported. The measures that staff members most often proposed to prevent adverse events were to increase human and material resources (28.3%), establish protocols (14.5%), and comply with quality of care recommendations (9.7%). It is important to promote a culture of safety and incident reporting among health care staff in Asturias given the number of serious adverse events. Reporting is necessary for understanding the errors made and taking steps to prevent them. The ERCC is the point in the system where incidents are particularly likely to appear and be noticed and reported.
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NASA Technical Reports Server (NTRS)
Gubarev, Mikhail V.; Kilaru, Kirenmayee; Ramsey, Brian D.
2009-01-01
We are investigating differential deposition as a way of correcting small figure errors inside full-shell grazing-incidence x-ray optics. The optics in our study are fabricated using the electroformed-nickel-replication technique, and the figure errors arise from fabrication errors in the mandrel, from which the shells are replicated, as well as errors induced during the electroforming process. Combined, these give sub-micron-scale figure deviations which limit the angular resolution of the optics to approx. 10 arcsec. Sub-micron figure errors can be corrected by selectively depositing (physical vapor deposition) material inside the shell. The requirements for this filler material are that it must not degrade the ultra-smooth surface finish necessary for efficient x-ray reflection (approx. 5 A rms), and must not be highly stressed. In addition, a technique must be found to produce well controlled and defined beams within highly constrained geometries, as some of our mirror shells are less than 3 cm in diameter.
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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.
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Transparent and Open Discussion of Errors Does Not Increase Malpractice Risk in Trauma Patients
Stewart, Ronald M.; Corneille, Michael G.; Johnston, Joe; Geoghegan, Kathy; Myers, John G.; Dent, Daniel L.; McFarland, Marilyn; Alley, Joshua; Pruitt, Basil A.; Cohn, Stephen M.
2006-01-01
Objective: We set out to determine if there is an increased medical malpractice lawsuit rate when trauma patient cases are presented at an open, multidisciplinary morbidity and mortality conference (M&M). Introduction: Patient safety proponents emphasize the importance of transparency with respect to medical errors. In contrast, the tort system focuses on blame and punishment, which encourages secrecy. Our question: Can the goals of the patient safety movement be met without placing care providers and healthcare institutions at unacceptably high malpractice risk? Methods: The trauma registry, a risk management database, along with the written minutes of the trauma morbidity and mortality conference (M&M) were used to determine the number and incidence of malpractice suits filed following full discussion at an open M&M conference at an academic level I trauma center. Results: A total of 20,749 trauma patients were admitted. A total of 412 patients were discussed at M&M conference and a total of seven lawsuits were filed. Six of the patients were not discussed at M&M prior to the lawsuit being filed. One patient was discussed at M&M prior to the lawsuit being filed. The incidence of lawsuit was calculated in three groups: all trauma patients, all trauma patients with complications, and all patients presented at trauma M&M conference. The ratio of lawsuits filed to patients admitted and incidence in the three groups is as follows: All Patients, 7 lawsuits/20,479 patients (4.25 lawsuits/100,000 patients/year); M&M Presentation, 1 lawsuit/421 patients (29.6 lawsuits/100,000 patients/year); All Trauma Complications, 7 lawsuits/6,225 patients (14 lawsuits/100,000 patients/year). Patients with a complication were more likely to sue (P < 0.01); otherwise, there were no statistical differences between groups. Conclusions: A transparent discussion of errors, complications, and deaths does not appear to lead to an increased risk of lawsuit. PMID:16632999
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A description of medication errors reported by pharmacists in a neonatal intensive care unit.
Pawluk, Shane; Jaam, Myriam; Hazi, Fatima; Al Hail, Moza Sulaiman; El Kassem, Wessam; Khalifa, Hanan; Thomas, Binny; Abdul Rouf, Pallivalappila
2017-02-01
Background Patients in the Neonatal Intensive Care Unit (NICU) are at an increased risk for medication errors. Objective The objective of this study is to describe the nature and setting of medication errors occurring in patients admitted to an NICU in Qatar based on a standard electronic system reported by pharmacists. Setting Neonatal intensive care unit, Doha, Qatar. Method This was a retrospective cross-sectional study on medication errors reported electronically by pharmacists in the NICU between January 1, 2014 and April 30, 2015. Main outcome measure Data collected included patient information, and incident details including error category, medications involved, and follow-up completed. Results A total of 201 NICU pharmacists-reported medication errors were submitted during the study period. All reported errors did not reach the patient and did not cause harm. Of the errors reported, 98.5% occurred in the prescribing phase of the medication process with 58.7% being due to calculation errors. Overall, 53 different medications were documented in error reports with the anti-infective agents being the most frequently cited. The majority of incidents indicated that the primary prescriber was contacted and the error was resolved before reaching the next phase of the medication process. Conclusion Medication errors reported by pharmacists occur most frequently in the prescribing phase of the medication process. Our data suggest that error reporting systems need to be specific to the population involved. Special attention should be paid to frequently used medications in the NICU as these were responsible for the greatest numbers of medication errors.
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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.
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Cervical lacerations in planned versus labor cerclage removal: a systematic review.
Simonazzi, Giuliana; Curti, Alessandra; Bisulli, Maria; Seravalli, Viola; Saccone, Gabriele; Berghella, Vincenzo
2015-10-01
The aim of this study was to evaluate the incidence of cervical lacerations with cerclage removal planned before labor compared to after the onset of labor by a systematic review of published studies. Searches were performed in electronic databases from inception of each database to November 2014. We identified all studies reporting the rate of cervical lacerations and the timing of cerclage removal (either before or after the onset of labor). The primary outcome was the incidence of spontaneous and clinically significant intrapartum cervical lacerations (i.e. lacerations requiring suturing). Six studies, which met the inclusion criteria, were included in the analysis. The overall incidence of cervical lacerations was 8.9% (32/359). There were 23/280 (6.4%) cervical lacerations in the planned removal group, and 9/79 (11.4%) in the removal after labor group (odds ratio 0.70, 95% confidence interval 0.31-1.57). In summary, planned removal of cerclage before labor was not shown to be associated with statistically significant reduction in the incidence of cervical lacerations. However, since that our data probably did not reach statistical significance because of a type II error, further studies are needed. Copyright © 2015 Elsevier Ireland Ltd. All rights reserved.
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Zhu, Yu; Xia, Jie-lai; Wang, Jing
2009-09-01
Application of the 'single auto regressive integrated moving average (ARIMA) model' and the 'ARIMA-generalized regression neural network (GRNN) combination model' in the research of the incidence of scarlet fever. Establish the auto regressive integrated moving average model based on the data of the monthly incidence on scarlet fever of one city, from 2000 to 2006. The fitting values of the ARIMA model was used as input of the GRNN, and the actual values were used as output of the GRNN. After training the GRNN, the effect of the single ARIMA model and the ARIMA-GRNN combination model was then compared. The mean error rate (MER) of the single ARIMA model and the ARIMA-GRNN combination model were 31.6%, 28.7% respectively and the determination coefficient (R(2)) of the two models were 0.801, 0.872 respectively. The fitting efficacy of the ARIMA-GRNN combination model was better than the single ARIMA, which had practical value in the research on time series data such as the incidence of scarlet fever.
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CREME96 and Related Error Rate Prediction Methods
NASA Technical Reports Server (NTRS)
Adams, James H., Jr.
2012-01-01
Predicting the rate of occurrence of single event effects (SEEs) in space requires knowledge of the radiation environment and the response of electronic devices to that environment. Several analytical models have been developed over the past 36 years to predict SEE rates. The first error rate calculations were performed by Binder, Smith and Holman. Bradford and Pickel and Blandford, in their CRIER (Cosmic-Ray-Induced-Error-Rate) analysis code introduced the basic Rectangular ParallelePiped (RPP) method for error rate calculations. For the radiation environment at the part, both made use of the Cosmic Ray LET (Linear Energy Transfer) spectra calculated by Heinrich for various absorber Depths. A more detailed model for the space radiation environment within spacecraft was developed by Adams and co-workers. This model, together with a reformulation of the RPP method published by Pickel and Blandford, was used to create the CR ME (Cosmic Ray Effects on Micro-Electronics) code. About the same time Shapiro wrote the CRUP (Cosmic Ray Upset Program) based on the RPP method published by Bradford. It was the first code to specifically take into account charge collection from outside the depletion region due to deformation of the electric field caused by the incident cosmic ray. Other early rate prediction methods and codes include the Single Event Figure of Merit, NOVICE, the Space Radiation code and the effective flux method of Binder which is the basis of the SEFA (Scott Effective Flux Approximation) model. By the early 1990s it was becoming clear that CREME and the other early models needed Revision. This revision, CREME96, was completed and released as a WWW-based tool, one of the first of its kind. The revisions in CREME96 included improved environmental models and improved models for calculating single event effects. The need for a revision of CREME also stimulated the development of the CHIME (CRRES/SPACERAD Heavy Ion Model of the Environment) and MACREE (Modeling and Analysis of Cosmic Ray Effects in Electronics). The Single Event Figure of Merit method was also revised to use the solar minimum galactic cosmic ray spectrum and extended to circular orbits down to 200 km at any inclination. More recently a series of commercial codes was developed by TRAD (Test & Radiations) which includes the OMERE code which calculates single event effects. There are other error rate prediction methods which use Monte Carlo techniques. In this chapter the analytic methods for estimating the environment within spacecraft will be discussed.
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Kartush, J M
1996-11-01
Practicing medicine successfully requires that errors in diagnosis and treatment be minimized. Malpractice laws encourage litigators to ascribe all medical errors to incompetence and negligence. There are, however, many other causes of unintended outcomes. This article describes common causes of errors and suggests ways to minimize mistakes in otologic practice. Widespread dissemination of knowledge about common errors and their precursors can reduce the incidence of their occurrence. Consequently, laws should be passed to allow for a system of non-punitive, confidential reporting of errors and "near misses" that can be shared by physicians nationwide.
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Bidulescu, Aurelian; Chambless, Lloyd E; Siega-Riz, Anna Maria; Zeisel, Steven H; Heiss, Gerardo
2007-01-01
Background Low dietary intake of the essential nutrient choline and its metabolite betaine may increase atherogenesis both through effects on homocysteine methylation pathways as well as through choline's antioxidants properties. Nutrient values for many common foods for choline and betaine have recently become available in the U.S. nutrient composition database. Our objective was to assess the association of dietary intake of choline and betaine with incident coronary heart disease (CHD), adjusting for dietary intake measurement error. Methods We conducted a prospective investigation of the relation between usual intake of choline and betaine with the risk of CHD in 14,430 middle-aged men and women of the biethnic Atherosclerosis Risk in Communities study. A semi-quantitative food frequency questionnaire was used to assess nutrient intake. Proportional hazard regression models were used to calculate the risk of incident CHD. A regression calibration method was used to adjust for measurement error. Results During an average 14 years of follow-up (1987–2002), 1,072 incident CHD events were documented. Compared with the lowest quartile of intake, incident CHD risk was slightly and non-significantly higher in the highest quartile of choline and choline plus betaine, HR = 1.22 (0.91, 1.64) and HR = 1.14 (0.85, 1.53), controlling for age, sex, education, total energy intake, dietary intakes of folate, methionine and vitamin B6. No association was found between dietary choline intake and incident CHD when correcting for measurement error. Conclusion Higher intakes of choline and betaine were not protective for incident CHD. Similar investigations in other populations are of interest. PMID:17629908
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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.
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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.
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[Knowledge of nurses about medication doses at pediatric urgency departament].
Guerrero-Márquez, Gloria; Martínez-Serrano, Ana; Míguez-Navarro, Concepción; López-Mirón, Juan Antonio; Espartosa-Larrayad, Marta
2016-01-01
Errors in drug administration are the second cause of errors in hospitalized patients. Children are a high risk group. Besides, pressure in care interventions at emergency department leads to increase incidence errors. Determining nurses' knowledge about the most common drug doses at pediatric urgency department. Descriptive transversal study. We collected data from nurses of 14 pediatric emergency departments of Madrid. With an "ad hoc" questionnaire we collected the following data during five days in January of 2014: demographic, knowledge of responsibility in administration and doses of drugs. Global descriptive analysis was made and it was stratified by hospital and work experience. The answer rate was 114 (34.9%). Only 80 (70.8%) of nurses confirm doses before their administration; 20 (18.6%) think that a wrong prescription that they administer is not their responsibility. There is a high knowledge in the group with more than five years of work experience, except for sedative-analgesic drugs (p<0.05). The average score obtained was 3.8 of 10 (1.99). Nurses' knowledge about drug doses is low. Copyright © 2016 Elsevier España, S.L.U. All rights reserved.
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[Improving blood safety: errors management in transfusion medicine].
Bujandrić, Nevenka; Grujić, Jasmina; Krga-Milanović, Mirjana
2014-01-01
The concept of blood safety includes the entire transfusion chain starting with the collection of blood from the blood donor, and ending with blood transfusion to the patient. The concept involves quality management system as the systematic monitoring of adverse reactions and incidents regarding the blood donor or patient. Monitoring of near-miss errors show the critical points in the working process and increase transfusion safety. The aim of the study was to present the analysis results of adverse and unexpected events in transfusion practice with a potential risk to the health of blood donors and patients. One-year retrospective study was based on the collection, analysis and interpretation of written reports on medical errors in the Blood Transfusion Institute of Vojvodina. Errors were distributed according to the type, frequency and part of the working process where they occurred. Possible causes and corrective actions were described for each error. The study showed that there were not errors with potential health consequences for the blood donor/patient. Errors with potentially damaging consequences for patients were detected throughout the entire transfusion chain. Most of the errors were identified in the preanalytical phase. The human factor was responsible for the largest number of errors. Error reporting system has an important role in the error management and the reduction of transfusion-related risk of adverse events and incidents. The ongoing analysis reveals the strengths and weaknesses of the entire process and indicates the necessary changes. Errors in transfusion medicine can be avoided in a large percentage and prevention is cost-effective, systematic and applicable.
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Zwart, Dorien L M; Heddema, Wendelien S; Vermeulen, Margit I; van Rensen, Elizabeth L J; Verheij, Theo J M; Kalkman, Cor J
2011-10-01
There is an inherent tension between allowing trainees in general practice (GP) to feel comfortable to report and learn from errors in a blame-free environment while still assuring high-quality and safe patient care. Unfortunately, little is known about the types and potential severity of incidents that may confront GP trainees. Furthermore, incident reporting by resident trainees is hindered by their concern that such transparency might result in more negative performance evaluations. To explore the number and nature of incidents that were reported by GP trainees and to determine whether there were differences between the reporters and non-reporters based on their performance evaluations. Prospective cohort study. Confidential and voluntary incident reporting was implemented in GP vocational training of the University Medical Center Utrecht, the Netherlands. Seventy-nine GP trainees were asked to report incidents over 6 months. Mixed methods were used to analyse the data. 24 trainees reported a total of 44 incidents. 23 incidents concerned the work process and 17 concerned problems with diagnosis or therapy. Three-quarters (34/44) of incidents were determined to be not specifically related to the inexperience of the GP trainees. While actual patient harm was determined to be minimal or absent in two-thirds of incidents (29/44), the potential for moderate, major, or catastrophic harm was 89% (39/44). Trainees performing best on their performance assessment in the domain of clinical expertise reported incidents more often (43% vs 18%, p<0.03) than those who performed at a lower level. GP trainees rated highly by their faculty voluntarily reported incidents in the delivery of clinical care when given a safe, blame-free, and confidential reporting process. Most incidents were not found to be directly related to the inexperience of the trainee, but were caused by failing organisational processes in the healthcare delivery system. Moreover, the trainees who tended to report these incidents were those whose performance was highly evaluated in the domain of clinical expertise.
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Confidential Clinician-reported Surveillance of Adverse Events Among Medical Inpatients
Weingart, Saul N; Ship, Amy N; Aronson, Mark D
2000-01-01
BACKGROUND Although iatrogenic injury poses a significant risk to hospitalized patients, detection of adverse events (AEs) is costly and difficult. METHODS The authors developed a confidential reporting method for detecting AEs on a medicine unit of a teaching hospital. Adverse events were defined as patient injuries. Potential adverse events (PAEs) represented errors that could have, but did not result in harm. Investigators interviewed house officers during morning rounds and by e-mail, asking them to identify obstacles to high quality care and iatrogenic injuries. They compared house officer reports with hospital incident reports and patients' medical records. A multivariate regression model identified correlates of reporting. RESULTS One hundred ten events occurred, affecting 84 patients. Queries by e-mail (incidence rate ratio [IRR ]=0.16; 95% confidence interval [95% CI], 0.05 to 0.49) and on days when house officers rotated to a new service (IRR =0.12; 95% CI, 0.02 to 0.91) resulted in fewer reports. The most commonly reported process of care problems were inadequate evaluation of the patient (16.4%), failure to monitor or follow up (12.7%), and failure of the laboratory to perform a test (12.7%). Respondents identified 29 (26.4%) AEs, 52 (47.3%) PAEs, and 29 (26.4%) other house officer-identified quality problems. An AE occurred in 2.6% of admissions. The hospital incident reporting system detected only one house officer-reported event. Chart review corroborated 72.9% of events. CONCLUSIONS House officers detect many AEs among inpatients. Confidential peer interviews of front-line providers is a promising method for identifying medical errors and substandard quality. PMID:10940133
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Developing High-Throughput HIV Incidence Assay with Pyrosequencing Platform
Park, Sung Yong; Goeken, Nolan; Lee, Hyo Jin; Bolan, Robert; Dubé, Michael P.
2014-01-01
ABSTRACT Human immunodeficiency virus (HIV) incidence is an important measure for monitoring the epidemic and evaluating the efficacy of intervention and prevention trials. This study developed a high-throughput, single-measure incidence assay by implementing a pyrosequencing platform. We devised a signal-masking bioinformatics pipeline, which yielded a process error rate of 5.8 × 10−4 per base. The pipeline was then applied to analyze 18,434 envelope gene segments (HXB2 7212 to 7601) obtained from 12 incident and 24 chronic patients who had documented HIV-negative and/or -positive tests. The pyrosequencing data were cross-checked by using the single-genome-amplification (SGA) method to independently obtain 302 sequences from 13 patients. Using two genomic biomarkers that probe for the presence of similar sequences, the pyrosequencing platform correctly classified all 12 incident subjects (100% sensitivity) and 23 of 24 chronic subjects (96% specificity). One misclassified subject's chronic infection was correctly classified by conducting the same analysis with SGA data. The biomarkers were statistically associated across the two platforms, suggesting the assay's reproducibility and robustness. Sampling simulations showed that the biomarkers were tolerant of sequencing errors and template resampling, two factors most likely to affect the accuracy of pyrosequencing results. We observed comparable biomarker scores between AIDS and non-AIDS chronic patients (multivariate analysis of variance [MANOVA], P = 0.12), indicating that the stage of HIV disease itself does not affect the classification scheme. The high-throughput genomic HIV incidence marks a significant step toward determining incidence from a single measure in cross-sectional surveys. IMPORTANCE Annual HIV incidence, the number of newly infected individuals within a year, is the key measure of monitoring the epidemic's rise and decline. Developing reliable assays differentiating recent from chronic infections has been a long-standing quest in the HIV community. Over the past 15 years, these assays have traditionally measured various HIV-specific antibodies, but recent technological advancements have expanded the diversity of proposed accurate, user-friendly, and financially viable tools. Here we designed a high-throughput genomic HIV incidence assay based on the signature imprinted in the HIV gene sequence population. By combining next-generation sequencing techniques with bioinformatics analysis, we demonstrated that genomic fingerprints are capable of distinguishing recently infected patients from chronically infected patients with high precision. Our high-throughput platform is expected to allow us to process many patients' samples from a single experiment, permitting the assay to be cost-effective for routine surveillance. PMID:24371062
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Byrne, Eamonn; Bury, Gerard
2018-02-08
Incident reporting is vital to identifying pre-hospital medication safety issues because literature suggests that the majority of errors pre-hospital are self-identified. In 2016, the National Ambulance Service (NAS) reported 11 medication errors to the national body with responsibility for risk management and insurance cover. The Health Information and Quality Authority in 2014 stated that reporting of clinical incidents, of which medication errors are a subset, was not felt to be representative of the actual events occurring. Even though reporting systems are in place, the levels appear to be well below what might be expected. Little data is available to explain this apparent discrepancy. To identify, investigate and document the barriers to medication error reporting within the NAS. An independent moderator led four focus groups in March of 2016. A convenience sample of 18 frontline Paramedics and Advanced Paramedics from Cork City and County discussed medication errors and the medication error reporting process. The sessions were recorded and anonymised, and the data was analysed using a process of thematic analysis. Practitioners understood the value of reporting errors. Barriers to reporting included fear of consequences and ridicule, procedural ambiguity, lack of feedback and a perceived lack of both consistency and confidentiality. The perceived consequences for making an error included professional, financial, litigious and psychological. Staff appeared willing to admit errors in a psychologically safe environment. Barriers to reporting are in line with international evidence. Time constraints prevented achievement of thematic saturation. Further study is warranted.
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Solar cell angle of incidence corrections
NASA Technical Reports Server (NTRS)
Burger, Dale R.; Mueller, Robert L.
1995-01-01
Literature on solar array angle of incidence corrections was found to be sparse and contained no tabular data for support. This lack along with recent data on 27 GaAs/Ge 4 cm by 4 cm cells initiated the analysis presented in this paper. The literature cites seven possible contributors to angle of incidence effects: cosine, optical front surface, edge, shadowing, UV degradation, particulate soiling, and background color. Only the first three are covered in this paper due to lack of sufficient data. The cosine correction is commonly used but is not sufficient when the incident angle is large. Fresnel reflection calculations require knowledge of the index of refraction of the coverglass front surface. The absolute index of refraction for the coverglass front surface was not known nor was it measured due to lack of funds. However, a value for the index of refraction was obtained by examining how the prediction errors varied with different assumed indices and selecting the best fit to the set of measured values. Corrections using front surface Fresnel reflection along with the cosine correction give very good predictive results when compared to measured data, except there is a definite trend away from predicted values at the larger incident angles. This trend could be related to edge effects and is illustrated by a use of a box plot of the errors and by plotting the deviation of the mean against incidence angle. The trend is for larger deviations at larger incidence angles and there may be a fourth order effect involved in the trend. A chi-squared test was used to determine if the measurement errors were normally distributed. At 10 degrees the chi-squared test failed, probably due to the very small numbers involved or a bias from the measurement procedure. All other angles showed a good fit to the normal distribution with increasing goodness-of-fit as the angles increased which reinforces the very small numbers hypothesis. The contributed data only went to 65 degrees from normal which prevented any firm conclusions about extreme angle effects although a trend in the right direction was seen. Measurement errors were estimated and found to be consistent with the conclusions that were drawn. A controlled experiment using coverglasses and cells from the same lots and extending to larger incidence angles would probably lead to further insight into the subject area.
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Warm, D; Edwards, P
2012-01-01
Interest in the field of patient safety incident reporting and analysis with respect to Health Information Technology (HIT) has been growing over recent years as the development, implementation and reliance on HIT systems becomes ever more prevalent. One of the rationales for capturing patient safety incidents is to learn from failures in the delivery of care and must form part of a feedback loop which also includes analysis; investigation and monitoring. With the advent of new technologies and organizational programs of delivery the emphasis is increasingly upon analyzing HIT incidents. This thematic review had two objectives, to test the applicability of a framework specifically designed to categorize HIT incidents and to review the Welsh incidents as communicated via the national incident reporting system in order to understand their implications for healthcare. The incidents were those reported as IT/ telecommunications failure/ overload. Incidents were searched for within a national reporting system using a standardized search strategy for incidents occurring between 1(st) January 2009 and 31(st) May 2011. 149 incident reports were identified and classified. The majority (77%) of which were machine related (technical problems) such as access problems; computer system down/too slow; display issues; and software malfunctions. A further 10% (n = 15) of incidents were down to human-computer interaction issues and 13% (n = 19) incidents, mainly telephone related, could not be classified using the framework being tested. On the basis of this review of incidents, it is recommended that the framework be expanded to include hardware malfunctions and the wrong record retrieved/missing data associated with a machine output error (as opposed to human error). In terms of the implications for clinical practice, the incidents reviewed highlighted critical issues including the access problems particularly relating to the use of mobile technologies.
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Practice increases procedural errors after task interruption.
Altmann, Erik M; Hambrick, David Z
2017-05-01
Positive effects of practice are ubiquitous in human performance, but a finding from memory research suggests that negative effects are possible also. The finding is that memory for items on a list depends on the time interval between item presentations. This finding predicts a negative effect of practice on procedural performance under conditions of task interruption. As steps of a procedure are performed more quickly, memory for past performance should become less accurate, increasing the rate of skipped or repeated steps after an interruption. We found this effect, with practice generally improving speed and accuracy, but impairing accuracy after interruptions. The results show that positive effects of practice can interact with architectural constraints on episodic memory to have negative effects on performance. In practical terms, the results suggest that practice can be a risk factor for procedural errors in task environments with a high incidence of task interruption. (PsycINFO Database Record (c) 2017 APA, all rights reserved).
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Parity Nonconservation in Proton-Proton and Proton-Water Scattering at 1.5 GeV/c
DOE R&D Accomplishments Database
Mischke, R. E.; Bowman, J. D.; Carlini, R.; MacArthur, D.; Nagle, D. E.; Frauenfelder, H.; Harper, R. W.; Yuan, V.; McDonald, A. B.; Talaga, R. L.
1984-07-01
Experiments searching for parity nonconservation in the scattering of 1.5 GeV/c (800 MeV) polarized protons from an unpolarized water target and a liquid hydrogen target are described. The intensity of the incident proton beam was measured upstream and downstream of the target by a pair of ionization detectors. The beam helicity was reversed at a 30-Hz rate. Auxiliary detectors monitored beam properties that could give rise to false effects. The result for the longitudinal asymmetry from the water is A{sub L} = (1.7 +- 3.3 +- 1.4) x 10{sup -7}, where the first error is statistical and the second is an estimate of systematic effects. The hydrogen data yield a preliminary result of A{sub L} = (1.0 +- 1.6) x 10{sup -7}. The systematic errors for p-p are expected to be < 1 x 10{sup -7}.
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Cost-benefit analysis: newborn screening for inborn errors of metabolism in Lebanon.
Khneisser, I; Adib, S; Assaad, S; Megarbane, A; Karam, P
2015-12-01
Few countries in the Middle East-North Africa region have adopted national newborn screening for inborn errors of metabolism by tandem mass spectrometry (MS/MS). We aimed to evaluate the cost-benefit of newborn screening for such disorders in Lebanon, as a model for other developing countries in the region. Average costs of expected care for inborn errors of metabolism cases as a group, between ages 0 and 18, early and late diagnosed, were calculated from 2007 to 2013. The monetary value of early detection using MS/MS was compared with that of clinical "late detection", including cost of diagnosis and hospitalizations. During this period, 126000 newborns were screened. Incidence of detected cases was 1/1482, which can be explained by high consanguinity rates in Lebanon. A reduction by half of direct cost of care, reaching on average 31,631 USD per detected case was shown. This difference more than covers the expense of starting a newborn screening programme. Although this model does not take into consideration the indirect benefits of the better quality of life of those screened early, it can be argued that direct and indirect costs saved through early detection of these disorders are important enough to justify universal publicly-funded screening, especially in developing countries with high consanguinity rates, as shown through this data from Lebanon. © The Author(s) 2015.
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Reversal and Rotation Errors by Normal and Retarded Readers
ERIC Educational Resources Information Center
Black, F. William
1973-01-01
Reports an investigation of the incidence of and relationships among word and letter reversals in writing and Bender-Gestalt rotation errors in matched samples of normal and retarded readers. No significant diffenences were found in the two groups. (TO)
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Lyme Disease Testing in a High-Incidence State: Clinician Knowledge and Patterns.
Conant, Joanna L; Powers, Julia; Sharp, Gregory; Mead, Paul S; Nelson, Christina A
2018-02-17
Lyme disease (LD) incidence is increasing, but data suggest some clinicians are not fully aware of recommended procedures for ordering and interpreting diagnostic tests. The study objective was to assess clinicians' knowledge and practices regarding LD testing in a high-incidence region. We distributed surveys to 1,142 clinicians in the University of Vermont Medical Center region, of which 144 were completed (12.6% response rate). We also examined LD laboratory test results and logs of calls to laboratory customer service over a period of 2.5 years and 6 months, respectively. Most clinicians demonstrated basic knowledge of diagnostic protocols, but many misinterpreted Western blot results. For example, 42.4% incorrectly interpreted a positive immunoglobulin M result as an overall positive test in a patient with longstanding symptoms. Many also reported receiving patient requests for unvalidated tests. Additional education and modifications to LD test ordering and reporting systems would likely reduce errors and improve patient care. © American Society for Clinical Pathology, 2018. This work is written by (a) US Government employee(s) and is in the public domain in the US.
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Using failure mode and effects analysis to improve the safety of neonatal parenteral nutrition.
Arenas Villafranca, Jose Javier; Gómez Sánchez, Araceli; Nieto Guindo, Miriam; Faus Felipe, Vicente
2014-07-15
Failure mode and effects analysis (FMEA) was used to identify potential errors and to enable the implementation of measures to improve the safety of neonatal parenteral nutrition (PN). FMEA was used to analyze the preparation and dispensing of neonatal PN from the perspective of the pharmacy service in a general hospital. A process diagram was drafted, illustrating the different phases of the neonatal PN process. Next, the failures that could occur in each of these phases were compiled and cataloged, and a questionnaire was developed in which respondents were asked to rate the following aspects of each error: incidence, detectability, and severity. The highest scoring failures were considered high risk and identified as priority areas for improvements to be made. The evaluation process detected a total of 82 possible failures. Among the phases with the highest number of possible errors were transcription of the medical order, formulation of the PN, and preparation of material for the formulation. After the classification of these 82 possible failures and of their relative importance, a checklist was developed to achieve greater control in the error-detection process. FMEA demonstrated that use of the checklist reduced the level of risk and improved the detectability of errors. FMEA was useful for detecting medication errors in the PN preparation process and enabling corrective measures to be taken. A checklist was developed to reduce errors in the most critical aspects of the process. Copyright © 2014 by the American Society of Health-System Pharmacists, Inc. All rights reserved.
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Correcting for sequencing error in maximum likelihood phylogeny inference.
Kuhner, Mary K; McGill, James
2014-11-04
Accurate phylogenies are critical to taxonomy as well as studies of speciation processes and other evolutionary patterns. Accurate branch lengths in phylogenies are critical for dating and rate measurements. Such accuracy may be jeopardized by unacknowledged sequencing error. We use simulated data to test a correction for DNA sequencing error in maximum likelihood phylogeny inference. Over a wide range of data polymorphism and true error rate, we found that correcting for sequencing error improves recovery of the branch lengths, even if the assumed error rate is up to twice the true error rate. Low error rates have little effect on recovery of the topology. When error is high, correction improves topological inference; however, when error is extremely high, using an assumed error rate greater than the true error rate leads to poor recovery of both topology and branch lengths. The error correction approach tested here was proposed in 2004 but has not been widely used, perhaps because researchers do not want to commit to an estimate of the error rate. This study shows that correction with an approximate error rate is generally preferable to ignoring the issue. Copyright © 2014 Kuhner and McGill.
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Ford, Eric C; Terezakis, Stephanie; Souranis, Annette; Harris, Kendra; Gay, Hiram; Mutic, Sasa
2012-11-01
To quantify the error-detection effectiveness of commonly used quality control (QC) measures. We analyzed incidents from 2007-2010 logged into a voluntary in-house, electronic incident learning systems at 2 academic radiation oncology clinics. None of the incidents resulted in patient harm. Each incident was graded for potential severity using the French Nuclear Safety Authority scoring scale; high potential severity incidents (score >3) were considered, along with a subset of 30 randomly chosen low severity incidents. Each report was evaluated to identify which of 15 common QC checks could have detected it. The effectiveness was calculated, defined as the percentage of incidents that each QC measure could detect, both for individual QC checks and for combinations of checks. In total, 4407 incidents were reported, 292 of which had high-potential severity. High- and low-severity incidents were detectable by 4.0 ± 2.3 (mean ± SD) and 2.6 ± 1.4 QC checks, respectively (P<.001). All individual checks were less than 50% sensitive with the exception of pretreatment plan review by a physicist (63%). An effectiveness of 97% was achieved with 7 checks used in combination and was not further improved with more checks. The combination of checks with the highest effectiveness includes physics plan review, physician plan review, Electronic Portal Imaging Device-based in vivo portal dosimetry, radiation therapist timeout, weekly physics chart check, the use of checklists, port films, and source-to-skin distance checks. Some commonly used QC checks such as pretreatment intensity modulated radiation therapy QA do not substantially add to the ability to detect errors in these data. The effectiveness of QC measures in radiation oncology depends sensitively on which checks are used and in which combinations. A small percentage of errors cannot be detected by any of the standard formal QC checks currently in broad use, suggesting that further improvements are needed. These data require confirmation with a broader incident-reporting database. Copyright © 2012 Elsevier Inc. All rights reserved.
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Blindness and cataract surgical services in Atsinanana region, Madagascar.
Randrianaivo, Jean-Baptiste; Anholt, R Michele; Tendrisoa, Diarimirindra Lazaharivony; Margiano, Nestor Jean; Courtright, Paul; Lewallen, Susan
2014-01-01
To assess the prevalence and causes of avoidable blindness in Atsinanana Region, Madagascar, with the Rapid Assessment of Avoidable Blindness (RAAB) survey. We analyzed the hospital records to supplement the findings for public health care planning. Only villages within a two-hour walk from a road, about half of the population of Atsinanana was included. Seventy-two villages were selected by population-proportional-to-size sampling. In each village, compact segment sampling was used to select 50 people over age 50 for eye examination using standard RAAB methods. Records at the two hospitals providing cataract surgery in the region were analyzed for information on patients who underwent cataract surgery in 2010. Cataract incidence rate and target cataract surgery rate (CSR) was modeled from age-specific prevalence of cataract. The participation rate was 87% and the sample prevalence of blindness was 1.96%. Cataract was responsible for 64% and 85.7% of blindness and severe visual impairment, respectively. Visual impairment was due to cataract (69.4%) and refractive error (14.1%). There was a strong positive correlation between cataract surgical rate by district and the proportion of people living within 2 hours of a road. There were marked differences in the profiles of the cataract patients at the two facilities. The estimated incidence of cataract at the 6/18 level was 2.4 eyes per 100 people over age 50 per year. Although the survey included only people with reasonable access, the main cause of visual impairment was still cataract. The incidence of cataract is such that it ought to be possible to eliminate it as a cause of visual impairment, but changes in service delivery at hospitals and strategies to improve access will be necessary for this change.
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Weight fluctuation, mortality and vascular disease in Pima Indians.
Hanson, R L; Jacobsson, L T; McCance, D R; Narayan, K M; Pettitt, D J; Bennett, P H; Knowler, W C
1996-05-01
To examine the relationship of weight fluctuation to mortality rates and incidence of vascular disease. A cohort of Pima Indians, 572 of whom had non-insulin-dependent diabetes mellitus and 766 without diabetes. Individuals were invited biennially to research examinations. The root mean square error (RMSE) of the linear trend of weight with time for the first four examinations after age 20 years was used as an index of weight fluctuation. Subjects were followed from the fourth examination until death or until 31 December 1991. The mortality rate ratio (MRR) and its 95% confidence interval (CI) for those with a high weight fluctuation index relative to those with a lower value were determined. The median duration of follow up was 9.3 (range 0.1-22.6) years. All cause mortality (n = 356); incidence of diabetic retinopathy (n = 145), diabetic nephropathy (n = 132) and electrocardiographic abnormalities (n = 82). There was no significant relationship between weight fluctuation and mortality for diabetic subjects (MRR = 1.0, 95% CI 0.8-1.3, p = 0.91). Nondiabetic subjects with a high weight fluctuation index had a higher mortality rate than those with a lower index (MRR = 1.5, 95% CI 1.0-2.1, p = 0.03); the association was stronger among men than among women. The excess mortality in the high weight fluctuation group was not due to cardiovascular diseases, but to noncardiovascular causes and the risk for alcohol-related death was particularly increased. Weight fluctuation was not associated with the incidence of diabetic retinopathy, nephropathy or electrocardiographic abnormalities. A high weight fluctuation index was associated with higher mortality rates in nondiabetic, but not in diabetic, Pima Indians. The excess mortality is largely due to noncardiovascular causes of death and may reflect lifestyle factors associated with weight fluctuation, rather than its metabolic effects.
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Control of Angular Intervals for Angle-Multiplexed Holographic Memory
NASA Astrophysics Data System (ADS)
Kinoshita, Nobuhiro; Muroi, Tetsuhiko; Ishii, Norihiko; Kamijo, Koji; Shimidzu, Naoki
2009-03-01
In angle-multiplexed holographic memory, the full width at half maximum of the Bragg selectivity curves is dependent on the angle formed between the medium and incident laser beams. This indicates the possibility of high density and high multiplexing number by varying the angular intervals between adjacent holograms. We propose an angular interval scheduling for closely stacking holograms into medium even when the angle range is limited. We obtained bit error rates of the order of 10-4 under the following conditions: medium thickness of 1 mm, laser beam wavelength of 532 nm, and angular multiplexing number of 300.
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NASA Astrophysics Data System (ADS)
Granot, Er'el; Zaibel, Reuven; Narkiss, Niv; Ben-Ezra, Shalva; Chayet, Haim; Shahar, Nir; Sternklar, Shmuel; Tsadka, Sagie; Prucnal, Paul R.
2005-12-01
In this paper we investigate the wavelength conversion and regeneration properties of a tunable all-optical signal regenerator (TASR). In the TASR, the wavelength conversion is done by a semiconductor optical amplifier, which is incorporated in an asymmetric Sagnac loop (ASL). We demonstrate both theoretically and experimentally that the ASL regenerates the incident signal's bit pattern, reduces its noise, increases the extinction ratio (which in many aspects is equivalent to noise reduction) and improves its bit-error rate. We also demonstrate the general behavior of the TASR with a numerical simulation.
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Unsafe acts and unsafe outcomes in aircraft maintenance
NASA Technical Reports Server (NTRS)
Hobbs, Alan; Williamson, Ann
2002-01-01
Road safety studies using the Driver Behaviour Questionnaire (DBQ) have provided support for a three-way distinction between violations, skill-based errors and mistakes, and have indicated that a tendency to commit driving violations is associated with an increased risk of accident involvement. The aims of this study were to examine whether the three-way distinction of unsafe acts is applicable in the context of aircraft maintenance, and whether involvement in maintenance safety occurrences can be predicted on the basis of self-reported unsafe acts. A Maintenance Behaviour Questionnaire (MBQ) was developed to explore patterns of unsafe acts committed by aircraft maintenance mechanics. The MBQ was completed anonymously by over 1300 Australian aviation mechanics, who also provided information on their involvement in workplace accidents and incidents. Four factors were identified: routine violations, skill-based errors, mistakes and exceptional violations. Violations and mistakes were related significantly to the occurrence of incidents that jeopardized the quality of aircraft maintenance, but were not related to workplace injuries. Skill-based errors, while not related to work quality incidents, were related to workplace injuries. The results are consistent with the three-way typology of unsafe acts described by Reason et al. (1990) and with the DBQ research indicating an association between self-reported violations and accidents. The current findings suggest that interventions addressed at maintenance quality incidents should take into account the role of violations and mistakes, and the factors that promote them. In contrast, interventions directed at reducing workplace injury are likely to require a focus on skill-based errors.
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Li, Qi; Melton, Kristin; Lingren, Todd; Kirkendall, Eric S; Hall, Eric; Zhai, Haijun; Ni, Yizhao; Kaiser, Megan; Stoutenborough, Laura; Solti, Imre
2014-01-01
Although electronic health records (EHRs) have the potential to provide a foundation for quality and safety algorithms, few studies have measured their impact on automated adverse event (AE) and medical error (ME) detection within the neonatal intensive care unit (NICU) environment. This paper presents two phenotyping AE and ME detection algorithms (ie, IV infiltrations, narcotic medication oversedation and dosing errors) and describes manual annotation of airway management and medication/fluid AEs from NICU EHRs. From 753 NICU patient EHRs from 2011, we developed two automatic AE/ME detection algorithms, and manually annotated 11 classes of AEs in 3263 clinical notes. Performance of the automatic AE/ME detection algorithms was compared to trigger tool and voluntary incident reporting results. AEs in clinical notes were double annotated and consensus achieved under neonatologist supervision. Sensitivity, positive predictive value (PPV), and specificity are reported. Twelve severe IV infiltrates were detected. The algorithm identified one more infiltrate than the trigger tool and eight more than incident reporting. One narcotic oversedation was detected demonstrating 100% agreement with the trigger tool. Additionally, 17 narcotic medication MEs were detected, an increase of 16 cases over voluntary incident reporting. Automated AE/ME detection algorithms provide higher sensitivity and PPV than currently used trigger tools or voluntary incident-reporting systems, including identification of potential dosing and frequency errors that current methods are unequipped to detect. 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.
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Rajih, Emad; Tholomier, Côme; Cormier, Beatrice; Samouëlian, Vanessa; Warkus, Thomas; Liberman, Moishe; Widmer, Hugues; Lattouf, Jean-Baptiste; Alenizi, Abdullah M.; Meskawi, Malek; Valdivieso, Roger; Hueber, Pierre-Alain; Karakewicz, Pierre I.; El-Hakim, Assaad; Zorn, Kevin C.
2017-01-01
Introduction The goal of the study is to evaluate and report on the third-generation da Vinci surgical (Si) system malfunctions. Methods A total of 1228 robotic surgeries were performed between January 2012 and December 2015 at our academic centre. All cases were performed by using a single, dual console, four-arm, da Vinci Si robot system. The three specialties included urology, gynecology, and thoracic surgery. Studied outcomes included the robotic surgical error types, immediate consequences, and operative side effects. Error rate trend with time was also examined. Results Overall robotic malfunctions were documented on the da Vinci Si systems event log in 4.97% (61/1228) of the cases. The most common error was related to pressure sensors in the robotic arms indicating out of limit output. This recoverable fault was noted in 2.04% (25/1228) of cases. Other errors included unrecoverable electronic communication-related in 1.06% (13/1228) of cases, failed encoder error in 0.57% (7/1228), illuminator-related in 0.33% (4/1228), faulty switch in 0.24% (3/1228), battery-related failures in 0.24% (3/1228), and software/hardware error in 0.08% (1/1228) of cases. Surgical delay was reported only in one patient. No conversion to either open or laparoscopic occurred secondary to robotic malfunctions. In 2015, the incidence of robotic error rose to 1.71% (21/1228) from 0.81% (10/1228) in 2014. Conclusions Robotic malfunction is not infrequent in the current era of robotic surgery in various surgical subspecialties, but rarely consequential. Their seldom occurrence does not seem to affect patient safety or surgical outcome. PMID:28503234
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Rajih, Emad; Tholomier, Côme; Cormier, Beatrice; Samouëlian, Vanessa; Warkus, Thomas; Liberman, Moishe; Widmer, Hugues; Lattouf, Jean-Baptiste; Alenizi, Abdullah M; Meskawi, Malek; Valdivieso, Roger; Hueber, Pierre-Alain; Karakewicz, Pierre I; El-Hakim, Assaad; Zorn, Kevin C
2017-05-01
The goal of the study is to evaluate and report on the third-generation da Vinci surgical (Si) system malfunctions. A total of 1228 robotic surgeries were performed between January 2012 and December 2015 at our academic centre. All cases were performed by using a single, dual console, four-arm, da Vinci Si robot system. The three specialties included urology, gynecology, and thoracic surgery. Studied outcomes included the robotic surgical error types, immediate consequences, and operative side effects. Error rate trend with time was also examined. Overall robotic malfunctions were documented on the da Vinci Si systems event log in 4.97% (61/1228) of the cases. The most common error was related to pressure sensors in the robotic arms indicating out of limit output. This recoverable fault was noted in 2.04% (25/1228) of cases. Other errors included unrecoverable electronic communication-related in 1.06% (13/1228) of cases, failed encoder error in 0.57% (7/1228), illuminator-related in 0.33% (4/1228), faulty switch in 0.24% (3/1228), battery-related failures in 0.24% (3/1228), and software/hardware error in 0.08% (1/1228) of cases. Surgical delay was reported only in one patient. No conversion to either open or laparoscopic occurred secondary to robotic malfunctions. In 2015, the incidence of robotic error rose to 1.71% (21/1228) from 0.81% (10/1228) in 2014. Robotic malfunction is not infrequent in the current era of robotic surgery in various surgical subspecialties, but rarely consequential. Their seldom occurrence does not seem to affect patient safety or surgical outcome.
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Does herpes zoster predispose to giant cell arteritis: a geo-epidemiologic study.
Ing, Edsel B; Ing, Royce; Liu, Xinyang; Zhang, Angela; Torun, Nurhan; Sey, Michael; Pagnoux, Christian
2018-01-01
Giant cell arteritis (GCA) is the most common systemic vasculitis in the elderly and can cause irreversible blindness and aortitis. Varicella zoster (VZ), which is potentially preventable by vaccination, has been proposed as a possible immune trigger for GCA, but this is controversial. The incidence of GCA varies widely by country. If VZ virus contributes to the immunopathogenesis of GCA we hypothesized that nations with increased incidence of GCA would also have increased incidence of herpes zoster (HZ). We conducted an ecologic analysis to determine the relationship between the incidence of HZ and GCA in different countries. A literature search for the incidence rates (IRs) of GCA and HZ from different countries was conducted. Correlation and linear regression was performed comparing the disease IR of each country for subjects 50 years of age or older. We found the IR for GCA and HZ from 14 countries. Comparing the IRs for GCA and HZ in 50-year-olds, the Pearson product-moment correlation ( r ) was -0.51, with linear regression coefficient (β) -2.92 (95% CI -5.41, -0.43; p =0.025) using robust standard errors. Comparing the IRs for GCA and HZ in 70-year-olds, r was -0.40, with β -1.78, which was not statistically significant (95% CI -4.10, 0.53; p =0.12). Although this geo-epidemiologic study has potential for aggregation and selection biases, there was no positive biologic gradient between the incidence of clinically evident HZ and GCA.
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Comparative study of four time series methods in forecasting typhoid fever incidence in China.
Zhang, Xingyu; Liu, Yuanyuan; Yang, Min; Zhang, Tao; Young, Alistair A; Li, Xiaosong
2013-01-01
Accurate incidence forecasting of infectious disease is critical for early prevention and for better government strategic planning. In this paper, we present a comprehensive study of different forecasting methods based on the monthly incidence of typhoid fever. The seasonal autoregressive integrated moving average (SARIMA) model and three different models inspired by neural networks, namely, back propagation neural networks (BPNN), radial basis function neural networks (RBFNN), and Elman recurrent neural networks (ERNN) were compared. The differences as well as the advantages and disadvantages, among the SARIMA model and the neural networks were summarized and discussed. The data obtained for 2005 to 2009 and for 2010 from the Chinese Center for Disease Control and Prevention were used as modeling and forecasting samples, respectively. The performances were evaluated based on three metrics: mean absolute error (MAE), mean absolute percentage error (MAPE), and mean square error (MSE). The results showed that RBFNN obtained the smallest MAE, MAPE and MSE in both the modeling and forecasting processes. The performances of the four models ranked in descending order were: RBFNN, ERNN, BPNN and the SARIMA model.
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Comparative Study of Four Time Series Methods in Forecasting Typhoid Fever Incidence in China
Zhang, Xingyu; Liu, Yuanyuan; Yang, Min; Zhang, Tao; Young, Alistair A.; Li, Xiaosong
2013-01-01
Accurate incidence forecasting of infectious disease is critical for early prevention and for better government strategic planning. In this paper, we present a comprehensive study of different forecasting methods based on the monthly incidence of typhoid fever. The seasonal autoregressive integrated moving average (SARIMA) model and three different models inspired by neural networks, namely, back propagation neural networks (BPNN), radial basis function neural networks (RBFNN), and Elman recurrent neural networks (ERNN) were compared. The differences as well as the advantages and disadvantages, among the SARIMA model and the neural networks were summarized and discussed. The data obtained for 2005 to 2009 and for 2010 from the Chinese Center for Disease Control and Prevention were used as modeling and forecasting samples, respectively. The performances were evaluated based on three metrics: mean absolute error (MAE), mean absolute percentage error (MAPE), and mean square error (MSE). The results showed that RBFNN obtained the smallest MAE, MAPE and MSE in both the modeling and forecasting processes. The performances of the four models ranked in descending order were: RBFNN, ERNN, BPNN and the SARIMA model. PMID:23650546
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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.
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Quantitative assessment of driving performance in Parkinson's disease
Wood, J; Worringham, C; Kerr, G; Mallon, K; Silburn, P
2005-01-01
Objectives: The primary aim of this study was to determine how Parkinson's disease (PD) affects driving performance. It also examined whether changes in driver safety were related to specific clinical disease markers or an individual's self rating of driving ability. Methods: The driving performance of 25 patients with idiopathic PD and 21 age matched controls was assessed on a standardised open road route by an occupational therapist and driving instructor, to provide overall safety ratings and specific driving error scores. Results: The drivers with PD were rated as significantly less safe (p<0.05) than controls, and more than half of the drivers with PD would not have passed a state based driving test. The driver safety ratings were more strongly related to disease duration (r = –0.60) than to their on time Unified Parkinson's Disease Rating Scale (r = –0.24). Drivers with PD made significantly more errors than the control group during manoeuvres that involved changing lanes and lane keeping, monitoring their blind spot, reversing, car parking, and traffic light controlled intersections. The driving instructor also had to intervene to avoid an incident significantly more often for drivers with PD than for controls. Interestingly, driver safety ratings were unrelated to an individual's rating of their own driving performance, and this was the case for all participants. Conclusions: As a group, drivers with PD are less safe to drive than age matched controls. Standard clinical markers cannot reliably predict driver safety. Further studies are required to ascertain whether the identified driving difficulties can be ameliorated. PMID:15654027
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Kessels-Habraken, Marieke; De Jonge, Jan; Van der Schaaf, Tjerk; Rutte, Christel
2010-05-01
Hospitals can apply prospective and retrospective methods to reduce the large number of medical errors. Retrospective methods are used to identify errors after they occur and to facilitate learning. Prospective methods aim to determine, assess and minimise risks before incidents happen. This paper questions whether the order of implementation of those two methods influences the resultant impact on incident reporting behaviour. From November 2007 until June 2008, twelve wards of two Dutch general hospitals participated in a quasi-experimental reversed-treatment non-equivalent control group design. The six units of Hospital 1 first conducted a prospective analysis, after which a sophisticated incident reporting and analysis system was implemented. On the six units of Hospital 2 the two methods were implemented in reverse order. Data from the incident reporting and analysis system and from a questionnaire were used to assess between-hospital differences regarding the number of reported incidents, the spectrum of reported incident types, and the profession of reporters. The results show that carrying out a prospective analysis first can improve incident reporting behaviour in terms of a wider spectrum of reported incident types and a larger proportion of incidents reported by doctors. However, the proposed order does not necessarily yield a larger number of reported incidents. This study fills an important gap in safety management research regarding the order of the implementation of prospective and retrospective methods, and contributes to literature on incident reporting. This research also builds on the network theory of social contagion. The results might indicate that health care employees can disseminate their risk perceptions through communication with their direct colleagues. Copyright 2010 Elsevier Ltd. All rights reserved.
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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.
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Automated drug dispensing system reduces medication errors in an intensive care setting.
Chapuis, Claire; Roustit, Matthieu; Bal, Gaëlle; Schwebel, Carole; Pansu, Pascal; David-Tchouda, Sandra; Foroni, Luc; Calop, Jean; Timsit, Jean-François; Allenet, Benoît; Bosson, Jean-Luc; Bedouch, Pierrick
2010-12-01
We aimed to assess the impact of an automated dispensing system on the incidence of medication errors related to picking, preparation, and administration of drugs in a medical intensive care unit. We also evaluated the clinical significance of such errors and user satisfaction. Preintervention and postintervention study involving a control and an intervention medical intensive care unit. Two medical intensive care units in the same department of a 2,000-bed university hospital. Adult medical intensive care patients. After a 2-month observation period, we implemented an automated dispensing system in one of the units (study unit) chosen randomly, with the other unit being the control. The overall error rate was expressed as a percentage of total opportunities for error. The severity of errors was classified according to National Coordinating Council for Medication Error Reporting and Prevention categories by an expert committee. User satisfaction was assessed through self-administered questionnaires completed by nurses. A total of 1,476 medications for 115 patients were observed. After automated dispensing system implementation, we observed a reduced percentage of total opportunities for error in the study compared to the control unit (13.5% and 18.6%, respectively; p<.05); however, no significant difference was observed before automated dispensing system implementation (20.4% and 19.3%, respectively; not significant). Before-and-after comparisons in the study unit also showed a significantly reduced percentage of total opportunities for error (20.4% and 13.5%; p<.01). An analysis of detailed opportunities for error showed a significant impact of the automated dispensing system in reducing preparation errors (p<.05). Most errors caused no harm (National Coordinating Council for Medication Error Reporting and Prevention category C). The automated dispensing system did not reduce errors causing harm. Finally, the mean for working conditions improved from 1.0±0.8 to 2.5±0.8 on the four-point Likert scale. The implementation of an automated dispensing system reduced overall medication errors related to picking, preparation, and administration of drugs in the intensive care unit. Furthermore, most nurses favored the new drug dispensation organization.
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Nature of nursing errors and their contributing factors in intensive care units.
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.
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2010-03-15
Swiss cheese model of human error causation. ................................................................... 3 2. Results for the classification of...based on Reason’s “ Swiss cheese ” model of human error (1990). Figure 1 describes how an accident is likely to occur when all of the errors, or “holes...align. A detailed description of HFACS can be found in Wiegmann and Shappell (2003). Figure 1. The Swiss cheese model of human error
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Haller, U; Welti, S; Haenggi, D; Fink, D
2005-06-01
The number of liability cases but also the size of individual claims due to alleged treatment errors are increasing steadily. Spectacular sentences, especially in the USA, encourage this trend. Wherever human beings work, errors happen. The health care system is particularly susceptible and shows a high potential for errors. Therefore risk management has to be given top priority in hospitals. Preparing the introduction of critical incident reporting (CIR) as the means to notify errors is time-consuming and calls for a change in attitude because in many places the necessary base of trust has to be created first. CIR is not made to find the guilty and punish them but to uncover the origins of errors in order to eliminate them. The Department of Anesthesiology of the University Hospital of Basel has developed an electronic error notification system, which, in collaboration with the Swiss Medical Association, allows each specialist society to participate electronically in a CIR system (CIRS) in order to create the largest database possible and thereby to allow statements concerning the extent and type of error sources in medicine. After a pilot project in 2000-2004, the Swiss Society of Gynecology and Obstetrics is now progressively introducing the 'CIRS Medical' of the Swiss Medical Association. In our country, such programs are vulnerable to judicial intervention due to the lack of explicit legal guarantees of protection. High-quality data registration and skillful counseling are all the more important. Hospital directors and managers are called upon to examine those incidents which are based on errors inherent in the system.
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The Impact of Incident Disclosure Behaviors on Medical Malpractice Claims.
Giraldo, Priscila; Sato, Luke; Castells, Xavier
2017-06-30
To provide preliminary estimates of incident disclosure behaviors on medical malpractice claims. We conducted a descriptive analysis of data on medical malpractice claims obtained from the Controlled Risk Insurance Company and Risk Management Foundation of Harvard Medical Institutions (Cambridge, Massachusetts) between 2012 and 2013 (n = 434). The characteristics of disclosure and apology after medical errors were analyzed. Of 434 medical malpractice claims, 4.6% (n = 20) medical errors had been disclosed to the patient at the time of the error, and 5.9% (n = 26) had been followed by disclosure and apology. The highest number of disclosed injuries occurred in 2011 (23.9%; n = 11) and 2012 (34.8%; n = 16). There was no incremental increase during the financial years studied (2012-2013). The mean age of informed patients was 52.96 years, 58.7 % of the patients were female, and 52.2% were inpatients. Of the disclosed errors, 26.1% led to an adverse reaction, and 17.4% were fatal. The cause of disclosed medical error was improper surgical performance in 17.4% (95% confidence interval, 6.4-28.4). Disclosed medical errors were classified as medium severity in 67.4%. No apology statement was issued in 54.5% of medical errors classified as high severity. At the health-care centers studied, when a claim followed a medical error, providers infrequently disclosed medical errors or apologized to the patient or relatives. Most of the medical errors followed by disclosure and apology were classified as being of high and medium severity. No changes were detected in the volume of lawsuits over time.
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Abdel-Qader, Derar H; Harper, Lindsay; Cantrill, Judith A; Tully, Mary P
2010-11-01
Pharmacists have an essential role in improving drug usage and preventing prescribing errors (PEs). PEs at the interface of care are common, sometimes leading to adverse drug events (ADEs). This was the first study to investigate, using a computerized search method, the number, types, severity, pharmacists' impact on PEs and predictors of PEs in the context of electronic prescribing (e-prescribing) at hospital discharge. This was a retrospective, observational, 4-week study, carried out in 2008 in the Medical and Elderly Care wards of a 904-bed teaching hospital in the northwest of England, operating an e-prescribing system at discharge. Details were obtained, using a systematic computerized search of the system, of medication orders either entered by doctors and discontinued by pharmacists or entered by pharmacists. Meetings were conducted within 5 days of data extraction with pharmacists doing their routine clinical work, who categorized the occurrence, type and severity of their interventions using a scale. An independent senior pharmacist retrospectively rated the severity and potential impact, and subjectively judged, based on experience, whether any error was a computer-related error (CRE). Discrepancies were resolved by multidisciplinary discussion. The Statistical Package for Social Sciences was used for descriptive data analysis. For the PE predictors, a multivariate logistic regression was performed using STATA 7. Nine predictors were selected a priori from available prescribers', patients' and drug data. There were 7920 medication orders entered for 1038 patients (doctors entered 7712 orders; pharmacists entered 208 omitted orders). There were 675 (8.5% of 7920) interventions by pharmacists; 11 were not associated with PEs. Incidences of erroneous orders and patients with error were 8.0% (95% CI 7.4, 8.5 [n = 630/7920]) and 20.4% (95% CI 18.1, 22.9 [n = 212/1038]), respectively. The PE incidence was 8.4% (95% CI 7.8, 9.0 [n = 664/7920]). The top three medications associated with PEs were paracetamol (acetaminophen; 30 [4.8%]), salbutamol (albuterol; 28 [4.4%]) and omeprazole (25 [4.0%]). Pharmacists intercepted 524 (83.2%) erroneous orders without referring to doctors, and 70% of erroneous orders within 24 hours. Omission (31.0%), drug selection (29.4%) and dosage regimen (18.1%) error types accounted for >75% of PEs. There were 18 (2.9%) serious, 481 (76.3%) significant and 131 (20.8%) minor erroneous orders. Most erroneous orders (469 [74.4%]) were rated as of significant severity and significant impact of pharmacists on PEs. CREs (n = 279) accounted for 44.3% of erroneous orders. There was a significant difference in severity between CREs and non-CREs (χ2 = 38.88; df = 4; p < 0.001), with CREs being less severe than non-CREs. Drugs with multiple oral formulations (odds ratio [OR] 2.1; 95% CI 1.25, 3.37; p = 0.004) and prescribing by junior doctors (OR 2.54; 95% CI 1.08, 5.99; p = 0.03) were significant predictors of PEs. PEs commonly occur at hospital discharge, even with the use of an e-prescribing system. User and computer factors both appeared to contribute to the high error rate. The e-prescribing system facilitated the systematic extraction of data to investigate PEs in hospital practice. Pharmacists play an important role in rapidly documenting and preventing PEs before they reach and possibly harm patients. Pharmacists should understand CREs, so they complement, rather than duplicate, the e-prescribing system's strengths.
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Caruso, Pedro; Denari, Silvia; Ruiz, Soraia A L; Demarzo, Sergio E; Deheinzelin, Daniel
2009-01-01
To compare the incidence of ventilator-associated pneumonia (VAP) with or without isotonic saline instillation before tracheal suctioning. As a secondary objective, we compared the incidence of endotracheal tube occlusion and atelectasis. Randomized clinical trial. The study was conducted in a medical surgical intensive care unit of an oncologic hospital. We selected consecutive patients needing mechanical ventilation for >72 hrs. Patients were allocated into two groups: a saline group that received instillation of 8 mL of saline before tracheal suctioning and a control group which did not. VAP was diagnosed based on clinical suspicion and confirmed by bronchoalveolar lavage quantitative culture. The incidence of atelectasis on daily chest radiography and endotracheal tube occlusions were recorded. The sample size was calculated to a power of 80% and a type I error probability of 5%. One hundred thirty patients were assigned to the saline group and 132 to the control group. The baseline demographic variables were similar between groups. The rate of clinically suspected VAP was similar in both groups. The incidence of microbiological proven VAP was significantly lower in the saline group (23.5% x 10.8%; p = 0.008) (incidence density/1.000 days of ventilation 21.22 x 9.62; p < 0.01). Using the Kaplan-Meier curve analysis, the proportion of patients remaining without VAP was higher in the saline group (p = 0.02, log-rank test). The relative risk reduction of VAP in the saline instillation group was 54% (95% confidence interval, 18%-74%) and the number needed to treat was eight (95% confidence interval, 5-27). The incidence of atelectases and endotracheal tube occlusion were similar between groups. Instillation of isotonic saline before tracheal suctioning decreases the incidence of microbiological proven VAP.
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Verification of a SEU model for advanced 1-micron CMOS structures using heavy ions
NASA Technical Reports Server (NTRS)
Cable, J. S.; Carter, J. R.; Witteles, A. A.
1986-01-01
Modeling and test results are reported for 1 micron CMOS circuits. Analytical predictions are correlated with experimental data, and sensitivities to process and design variations are discussed. Unique features involved in predicting the SEU performance of these devices are described. The results show that the critical charge for upset exhibits a strong dependence on pulse width for very fast devices, and upset predictions must factor in the pulse shape. Acceptable SEU error rates can be achieved for a 1 micron bulk CMOS process. A thin retrograde well provides complete SEU immunity for N channel hits at normal incidence angle. Source interconnect resistance can be important parameter in determining upset rates, and Cf-252 testing can be a valuable tool for cost-effective SEU testing.
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Measurable improvement in patient safety culture: A departmental experience with incident learning.
Kusano, Aaron S; Nyflot, Matthew J; Zeng, Jing; Sponseller, Patricia A; Ermoian, Ralph; Jordan, Loucille; Carlson, Joshua; Novak, Avrey; Kane, Gabrielle; Ford, Eric C
2015-01-01
Rigorous use of departmental incident learning is integral to improving patient safety and quality of care. The goal of this study was to quantify the impact of a high-volume, departmental incident learning system on patient safety culture. A prospective, voluntary, electronic incident learning system was implemented in February 2012 with the intent of tracking near-miss/no-harm incidents. All incident reports were reviewed weekly by a multiprofessional team with regular department-wide feedback. Patient safety culture was measured at baseline with validated patient safety culture survey questions. A repeat survey was conducted after 1 and 2 years of departmental incident learning. Proportional changes were compared by χ(2) or Fisher exact test, where appropriate. Between 2012 and 2014, a total of 1897 error/near-miss incidents were reported, representing an average of 1 near-miss report per patient treated. Reports were filed by a cross section of staff, with the majority of incidents reported by therapists, dosimetrists, and physicists. Survey response rates at baseline and 1 and 2 years were 78%, 80%, and 80%, respectively. Statistically significant and sustained improvements were noted in several safety metrics, including belief that the department was openly discussing ways to improve safety, the sense that reports were being used for safety improvement, and the sense that changes were being evaluated for effectiveness. None of the surveyed dimensions of patient safety culture worsened. Fewer punitive concerns were noted, with statistically significant decreases in the worry of embarrassment in front of colleagues and fear of getting colleagues in trouble. A comprehensive incident learning system can identify many areas for improvement and is associated with significant and sustained improvements in patient safety culture. These data provide valuable guidance as incident learning systems become more widely used in radiation oncology. Copyright © 2015 American Society for Radiation Oncology. Published by Elsevier Inc. All rights reserved.
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Meyer-Massetti, Carla; Krummenacher, Evelyne; Hedinger-Grogg, Barbara; Luterbacher, Stephan; Hersberger, Kurt E
2016-09-01
Background: While drug-related problems are among the most frequent adverse events in health care, little is known about their type and prevalence in home care in the current literature. The use of a Critical Incident Reporting System (CIRS), known as an economic and efficient tool to record medication errors for subsequent analysis, is widely implemented in inpatient care, but less established in ambulatory care. Recommendations on a possible format are scarce. A manual CIRS was developed based on the literature and subsequently piloted and implemented in a Swiss home care organization. Aim: The aim of this work was to implement a critical incident reporting system specifically for medication safety in home care. Results: The final CIRS form was well accepted among staff. Requiring limited resources, it allowed preliminary identification and trending of medication errors in home care. The most frequent error reports addressed medication preparation at the patients’ home, encompassing the following errors: omission (30 %), wrong dose (17.5 %) and wrong time (15 %). The most frequent underlying causes were related to working conditions (37.9 %), lacking attention (68.2 %), time pressure (22.7 %) and interruptions by patients (9.1 %). Conclusions: A manual CIRS allowed efficient data collection and subsequent analysis of medication errors in order to plan future interventions for improvement of medication safety. The development of an electronic CIRS would allow a reduction of the expenditure of time regarding data collection and analysis. In addition, it would favour the development of a national CIRS network among home care institutions.
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Traverse, Charles C.
2017-01-01
ABSTRACT Advances in sequencing technologies have enabled direct quantification of genome-wide errors that occur during RNA transcription. These errors occur at rates that are orders of magnitude higher than rates during DNA replication, but due to technical difficulties such measurements have been limited to single-base substitutions and have not yet quantified the scope of transcription insertions and deletions. Previous reporter gene assay findings suggested that transcription indels are produced exclusively by elongation complex slippage at homopolymeric runs, so we enumerated indels across the protein-coding transcriptomes of Escherichia coli and Buchnera aphidicola, which differ widely in their genomic base compositions and incidence of repeat regions. As anticipated from prior assays, transcription insertions prevailed in homopolymeric runs of A and T; however, transcription deletions arose in much more complex sequences and were rarely associated with homopolymeric runs. By reconstructing the relocated positions of the elongation complex as inferred from the sequences inserted or deleted during transcription, we show that continuation of transcription after slippage hinges on the degree of nucleotide complementarity within the RNA:DNA hybrid at the new DNA template location. PMID:28851848
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[Tracing the map of medication errors outside the hospital environment in the Madrid Community].
Taravilla-Cerdán, Belén; Larrubia-Muñoz, Olga; de la Corte-García, María; Cruz-Martos, Encarnación
2011-12-01
Preparation of a map of medication errors reported by health professionals outside hospitals within the framework of Medication Errors Reporting for the Community of Madrid during the period 2008-2009. Retrospective observational study. Notification database of medication errors in the Community of Madrid. Notifications sent to the web page: Safe Use of Medicines and Health Products of the Community of Madrid. Information on the originator of the report, date of incident, shift, type of error and causes, outcome, patient characteristics, stage, place where it was produced and detected, if the medication was administered, lot number, expiry date and the general nature of the drug and a brief description of the incident. There were 5470 medication errors analysed, of which 3412 came from outside hospitals (62%), occurring mainly in the prescription stage (56.92%) and being more reported pharmacists. No harm was done in 92.9% of cases, but there was harm in 4.8% and in 2.3% there was an error that could not be followed up. The centralization of information has led to the confirmation that the prescription is a vulnerable point in the chain of drug therapy. Cleaning up prescription databases, preventing the marketing of commercial presentations that give rise to confusion, enhanced information to professionals and patients, and establishing standardised procedures, and avoiding the use of ambiguous prescriptions, illegible, or abbreviations, are useful strategies to try to minimise these errors. Copyright © 2010 Elsevier España, S.L. All rights reserved.
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Developing a dengue forecast model using machine learning: A case study in China.
Guo, Pi; Liu, Tao; Zhang, Qin; Wang, Li; Xiao, Jianpeng; Zhang, Qingying; Luo, Ganfeng; Li, Zhihao; He, Jianfeng; Zhang, Yonghui; Ma, Wenjun
2017-10-01
In China, dengue remains an important public health issue with expanded areas and increased incidence recently. Accurate and timely forecasts of dengue incidence in China are still lacking. We aimed to use the state-of-the-art machine learning algorithms to develop an accurate predictive model of dengue. Weekly dengue cases, Baidu search queries and climate factors (mean temperature, relative humidity and rainfall) during 2011-2014 in Guangdong were gathered. A dengue search index was constructed for developing the predictive models in combination with climate factors. The observed year and week were also included in the models to control for the long-term trend and seasonality. Several machine learning algorithms, including the support vector regression (SVR) algorithm, step-down linear regression model, gradient boosted regression tree algorithm (GBM), negative binomial regression model (NBM), least absolute shrinkage and selection operator (LASSO) linear regression model and generalized additive model (GAM), were used as candidate models to predict dengue incidence. Performance and goodness of fit of the models were assessed using the root-mean-square error (RMSE) and R-squared measures. The residuals of the models were examined using the autocorrelation and partial autocorrelation function analyses to check the validity of the models. The models were further validated using dengue surveillance data from five other provinces. The epidemics during the last 12 weeks and the peak of the 2014 large outbreak were accurately forecasted by the SVR model selected by a cross-validation technique. Moreover, the SVR model had the consistently smallest prediction error rates for tracking the dynamics of dengue and forecasting the outbreaks in other areas in China. The proposed SVR model achieved a superior performance in comparison with other forecasting techniques assessed in this study. The findings can help the government and community respond early to dengue epidemics.
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DOT National Transportation Integrated Search
1992-02-01
This report covers the activities related to the description, classification and : analysis of the types and kinds of flight crew errors, incidents and actions, as : reported to the Aviation Safety Reporting System (ASRS) database, that can occur as ...
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Nuttall, Gregory A; Abenstein, John P; Stubbs, James R; Santrach, Paula; Ereth, Mark H; Johnson, Pamela M; Douglas, Emily; Oliver, William C
2013-04-01
To determine whether the use of a computerized bar code-based blood identification system resulted in a reduction in transfusion errors or near-miss transfusion episodes. Our institution instituted a computerized bar code-based blood identification system in October 2006. After institutional review board approval, we performed a retrospective study of transfusion errors from January 1, 2002, through December 31, 2005, and from January 1, 2007, through December 31, 2010. A total of 388,837 U were transfused during the 2002-2005 period. There were 6 misidentification episodes of a blood product being transfused to the wrong patient during that period (incidence of 1 in 64,806 U or 1.5 per 100,000 transfusions; 95% CI, 0.6-3.3 per 100,000 transfusions). There was 1 reported near-miss transfusion episode (incidence of 0.3 per 100,000 transfusions; 95% CI, <0.1-1.4 per 100,000 transfusions). A total of 304,136 U were transfused during the 2007-2010 period. There was 1 misidentification episode of a blood product transfused to the wrong patient during that period when the blood bag and patient's armband were scanned after starting to transfuse the unit (incidence of 1 in 304,136 U or 0.3 per 100,000 transfusions; 95% CI, <0.1-1.8 per 100,000 transfusions; P=.14). There were 34 reported near-miss transfusion errors (incidence of 11.2 per 100,000 transfusions; 95% CI, 7.7-15.6 per 100,000 transfusions; P<.001). Institution of a computerized bar code-based blood identification system was associated with a large increase in discovered near-miss events. Copyright © 2013 Mayo Foundation for Medical Education and Research. Published by Elsevier Inc. All rights reserved.
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Liang, Hao; Gao, Lian; Liang, Bingyu; Huang, Jiegang; Zang, Ning; Liao, Yanyan; Yu, Jun; Lai, Jingzhen; Qin, Fengxiang; Su, Jinming; Ye, Li; Chen, Hui
2016-01-01
Background Hepatitis is a serious public health problem with increasing cases and property damage in Heng County. It is necessary to develop a model to predict the hepatitis epidemic that could be useful for preventing this disease. Methods The autoregressive integrated moving average (ARIMA) model and the generalized regression neural network (GRNN) model were used to fit the incidence data from the Heng County CDC (Center for Disease Control and Prevention) from January 2005 to December 2012. Then, the ARIMA-GRNN hybrid model was developed. The incidence data from January 2013 to December 2013 were used to validate the models. Several parameters, including mean absolute error (MAE), root mean square error (RMSE), mean absolute percentage error (MAPE) and mean square error (MSE), were used to compare the performance among the three models. Results The morbidity of hepatitis from Jan 2005 to Dec 2012 has seasonal variation and slightly rising trend. The ARIMA(0,1,2)(1,1,1)12 model was the most appropriate one with the residual test showing a white noise sequence. The smoothing factor of the basic GRNN model and the combined model was 1.8 and 0.07, respectively. The four parameters of the hybrid model were lower than those of the two single models in the validation. The parameters values of the GRNN model were the lowest in the fitting of the three models. Conclusions The hybrid ARIMA-GRNN model showed better hepatitis incidence forecasting in Heng County than the single ARIMA model and the basic GRNN model. It is a potential decision-supportive tool for controlling hepatitis in Heng County. PMID:27258555
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Magrabi, Farah; Liaw, Siaw Teng; Arachi, Diana; Runciman, William; Coiera, Enrico; Kidd, Michael R
2016-11-01
To identify the categories of problems with information technology (IT), which affect patient safety in general practice. General practitioners (GPs) reported incidents online or by telephone between May 2012 and November 2013. Incidents were reviewed against an existing classification for problems associated with IT and the clinical process impacted. 87 GPs across Australia. Types of problems, consequences and clinical processes. GPs reported 90 incidents involving IT which had an observable impact on the delivery of care, including actual patient harm as well as near miss events. Practice systems and medications were the most affected clinical processes. Problems with IT disrupted clinical workflow, wasted time and caused frustration. Issues with user interfaces, routine updates to software packages and drug databases, and the migration of records from one package to another generated clinical errors that were unique to IT; some could affect many patients at once. Human factors issues gave rise to some errors that have always existed with paper records but are more likely to occur and cause harm with IT. Such errors were linked to slips in concentration, multitasking, distractions and interruptions. Problems with patient identification and hybrid records generated errors that were in principle no different to paper records. Problems associated with IT include perennial risks with paper records, but additional disruptions in workflow and hazards for patients unique to IT, occasionally affecting multiple patients. Surveillance for such hazards may have general utility, but particularly in the context of migrating historical records to new systems and software updates to existing systems. 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/.
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[Second victim : Critical incident stress management in clinical medicine].
Schiechtl, B; Hunger, M S; Schwappach, D L; Schmidt, C E; Padosch, S A
2013-09-01
Critical incidents in clinical medicine can have far-reaching consequences on patient health. In cases of severe medical errors they can seriously harm the patient or even lead to death. The involvement in such an event can result in a stress reaction, a so-called acute posttraumatic stress disorder in the healthcare provider, the so-called second victim of an adverse event. Psychological distress may not only have a long lasting impact on quality of life of the physician or caregiver involved but it may also affect the ability to provide safe patient care in the aftermath of adverse events. A literature review was performed to obtain information on care giver responses to medical errors and to determine possible supportive strategies to mitigate negative consequences of an adverse event on the second victim. An internet search and a search in Medline/Pubmed for scientific studies were conducted using the key words "second victim, "medical error", "critical incident stress management" (CISM) and "critical incident stress reporting system" (CIRS). Sources from academic medical societies and public institutions which offer crisis management programs where analyzed. The data were sorted by main categories and relevance for hospitals. Analysis was carried out using descriptive measures. In disaster medicine and aviation navigation services the implementation of a CISM program is an efficient intervention to help staff to recover after a traumatic event and to return to normal functioning and behavior. Several other concepts for a clinical crisis management plan were identified. The integration of CISM and CISM-related programs in a clinical setting may provide efficient support in an acute crisis and may help the caregiver to deal effectively with future error events and employee safety.
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Death certificate completion skills of hospital physicians in a developing country.
Haque, Ahmed Suleman; Shamim, Kanza; Siddiqui, Najm Hasan; Irfan, Muhammad; Khan, Javaid Ahmed
2013-06-06
Death certificates (DC) can provide valuable health status data regarding disease incidence, prevalence and mortality in a community. It can guide local health policy and help in setting priorities. Incomplete and inaccurate DC data, on the other hand, can significantly impair the precision of a national health information database. In this study we evaluated the accuracy of death certificates at a tertiary care teaching hospital in a Karachi, Pakistan. A retrospective study conducted at Aga Khan University Hospital, Karachi, Pakistan for a period of six months. Medical records and death certificates of all patients who died under adult medical service were studied. The demographic characteristics, administrative details, co-morbidities and cause of death from death certificates were collected using an approved standardized form. Accuracy of this information was validated using their medical records. Errors in the death certificates were classified into six categories, from 0 to 5 according to increasing severity; a grade 0 was assigned if no errors were identified, and 5, if an incorrect cause of death was attributed or placed in an improper sequence. 223 deaths occurred during the study period. 9 certificates were not accessible and 12 patients had incomplete medical records. 202 certificates were finally analyzed. Most frequent errors pertaining to patients' demographics (92%) and cause/s of death (87%) were identified. 156 (77%) certificates had 3 or more errors and 124 (62%) certificates had a combination of errors that significantly changed the death certificate interpretation. Only 1% certificates were error free. A very high rate of errors was identified in death certificates completed at our academic institution. There is a pressing need for appropriate intervention/s to resolve this important issue.
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Genetic epidemiology of single gene defects in Chile.
Cruz-Coke, R; Moreno, R S
1994-01-01
We have studied the correlation between the ethnic structure and the prevalence of single gene defects in Chile. At present the Chilean population is approximately 64% white and 35% Amerindian with traces of other admixture. Fewer than 4% of the Chilean population are foreign born. Investigations indicate that all severe diseases and many others without impaired reproduction have mutation rates within the range of the white population. Classical ethnic diseases are very rare. Autosomal recessive disorders have a wide range of variability: cystic fibrosis has a low incidence and PKU has a similar incidence to English rates. Only 30% of the inborn errors of metabolism have been described in Chilean medical publications. In addition, no Chilean haemoglobin or haptoglobin variants have been described. Some rare inherited diseases in Chilean human isolates have been described, including achromatopsia, chondrocalcinosis, and Creutzfeldt-Jakob disease. The prevalence of intrahepatic cholestasis of pregnancy and supernumerary nipples is the highest in the world and they are associated with aboriginal origin. Single gene defects in Chile are probably shaped by factors related to its ethnic population structure. These local rare single gene defects may be good markers of population admixture for genetic epidemiological studies. PMID:7815439
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Do we need a national incident reporting system for medical imaging?
Itri, Jason N; Krishnaraj, Arun
2012-05-01
The essential role of an incident reporting system as a tool to improve safety and reliability has been described in high-risk industries such as aviation and nuclear power, with anesthesia being the first medical specialty to successfully integrate incident reporting into a comprehensive quality improvement strategy. Establishing an incident reporting system for medical imaging that effectively captures system errors and drives improvement in the delivery of imaging services is a key component of developing and evaluating national quality improvement initiatives in radiology. Such a national incident reporting system would be most effective if implemented as one piece of a comprehensive quality improvement strategy designed to enhance knowledge about safety, identify and learn from errors, raise standards and expectations for improvement, and create safer systems through implementation of safe practices. The potential benefits of a national incident reporting system for medical imaging include reduced morbidity and mortality, improved patient and referring physician satisfaction, reduced health care expenses and medical liability costs, and improved radiologist satisfaction. The purposes of this article are to highlight the positive impact of external reporting systems, discuss how similar advancements in quality and safety can be achieved with an incident reporting system for medical imaging in the United States, and describe current efforts within the imaging community toward achieving this goal. Copyright © 2012 American College of Radiology. Published by Elsevier Inc. All rights reserved.
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Reflective properties of randomly rough surfaces under large incidence angles.
Qiu, J; Zhang, W J; Liu, L H; Hsu, P-f; Liu, L J
2014-06-01
The reflective properties of randomly rough surfaces at large incidence angles have been reported due to their potential applications in some of the radiative heat transfer research areas. The main purpose of this work is to investigate the formation mechanism of the specular reflection peak of rough surfaces at large incidence angles. The bidirectional reflectance distribution function (BRDF) of rough aluminum surfaces with different roughnesses at different incident angles is measured by a three-axis automated scatterometer. This study used a validated and accurate computational model, the rigorous coupled-wave analysis (RCWA) method, to compare and analyze the measurement BRDF results. It is found that the RCWA results show the same trend of specular peak as the measurement. This paper mainly focuses on the relative roughness at the range of 0.16<σ/λ<5.35. As the relative roughness decreases, the specular peak enhancement dramatically increases and the scattering region significantly reduces, especially under large incidence angles. The RCWA and the Rayleigh criterion results have been compared, showing that the relative error of the total integrated scatter increases as the roughness of the surface increases at large incidence angles. In addition, the zero-order diffractive power calculated by RCWA and the reflectance calculated by Fresnel equations are compared. The comparison shows that the relative error declines sharply when the incident angle is large and the roughness is small.
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[Analysis of an incident notification system and register in a critical care unit].
Murillo-Pérez, M A; García-Iglesias, M; Palomino-Sánchez, I; Cano Ruiz, G; Cuenca Solanas, M; Alted López, E
2016-01-01
To analyse the incident communicated through a notification system and register in a critical care unit. A cross-sectional descriptive study was conducted by performing an analysis of the records of incidents communicated anonymously and voluntarily from January 2007 to December 2013 in a critical care unit of adult patients with severe trauma. incident type and class, professional reports, and suggestions for improvement measures. A descriptive analysis was performed on the variables. Out of a total of 275 incidents reported, 58.5% of them were adverse events. Incident distributed by classes: medication, 33.7%; vascular access-drainage-catheter-sensor, 19.6%; devices-equipment, 13.3%, procedures, 11.5%; airway tract and mechanical ventilation, 10%; nursing care, 4.1%; inter-professional communication, 3%; diagnostic test, 3%; patient identification, 1.1%, and transfusion 0.7%. In the medication group, administrative errors accounted for a total of 62%; in vascular access-drainage-catheter-sensor group, central venous lines, a total of 27%; in devices and equipment group, respirators, a total of 46.9%; in airway self-extubations, a total of 32.1%. As regards to medication errors, 62% were incidents without damage. Incident notification by profession: doctors, 43%, residents, 5.6%, nurses, 51%, and technical assistants, 0.4%. Adverse events are the most communicated incidents. The events related to medication administration are the most frequent, although most of them were without damage. Nurses and doctors communicate the incidents with the same frequency. In order to highlight the low incident notification despite it being an anonymous and volunteer system, therefore, it is suggested to study measurements to increase the level of communication. Copyright © 2016 Elsevier España, S.L.U. y SEEIUC. All rights reserved.
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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.
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Clarke, D L; Kong, V Y; Naidoo, L C; Furlong, H; Aldous, C
2013-01-01
Acute surgical patients are particularly vulnerable to human error. The Acute Physiological Support Team (APST) was created with the twin objectives of identifying high-risk acute surgical patients in the general wards and reducing both the incidence of error and impact of error on these patients. A number of error taxonomies were used to understand the causes of human error and a simple risk stratification system was adopted to identify patients who are particularly at risk of error. During the period November 2012-January 2013 a total of 101 surgical patients were cared for by the APST at Edendale Hospital. The average age was forty years. There were 36 females and 65 males. There were 66 general surgical patients and 35 trauma patients. Fifty-six patients were referred on the day of their admission. The average length of stay in the APST was four days. Eleven patients were haemo-dynamically unstable on presentation and twelve were clinically septic. The reasons for referral were sepsis,(4) respiratory distress,(3) acute kidney injury AKI (38), post-operative monitoring (39), pancreatitis,(3) ICU down-referral,(7) hypoxia,(5) low GCS,(1) coagulopathy.(1) The mortality rate was 13%. A total of thirty-six patients experienced 56 errors. A total of 143 interventions were initiated by the APST. These included institution or adjustment of intravenous fluids (101), blood transfusion,(12) antibiotics,(9) the management of neutropenic sepsis,(1) central line insertion,(3) optimization of oxygen therapy,(7) correction of electrolyte abnormality,(8) correction of coagulopathy.(2) CONCLUSION: Our intervention combined current taxonomies of error with a simple risk stratification system and is a variant of the defence in depth strategy of error reduction. We effectively identified and corrected a significant number of human errors in high-risk acute surgical patients. This audit has helped understand the common sources of error in the general surgical wards and will inform on-going error reduction initiatives. Copyright © 2013 Surgical Associates Ltd. Published by Elsevier Ltd. All rights reserved.
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[Innovative training for enhancing patient safety. Safety culture and integrated concepts].
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.
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[Patient safety and errors in medicine: development, prevention and analyses of incidents].
Rall, M; Manser, T; Guggenberger, H; Gaba, D M; Unertl, K
2001-06-01
"Patient safety" and "errors in medicine" are issues gaining more and more prominence in the eyes of the public. According to newer studies, errors in medicine are among the ten major causes of death in association with the whole area of health care. A new era has begun incorporating attention to a "systems" approach to deal with errors and their causes in the health system. In other high-risk domains with a high demand for safety (such as the nuclear power industry and aviation) many strategies to enhance safety have been established. It is time to study these strategies, to adapt them if necessary and apply them to the field of medicine. These strategies include: to teach people how errors evolve in complex working domains and how types of errors are classified; the introduction of critical incident reporting systems that are free of negative consequences for the reporters; the promotion of continuous medical education; and the development of generic problem-solving skills incorporating the extensive use of realistic simulators wherever possible. Interestingly, the field of anesthesiology--within which realistic simulators were developed--is referred to as a model for the new patient safety movement. Despite this proud track record in recent times though, there is still much to be done even in the field of anesthesiology. Overall though, the most important strategy towards a long-term improvement in patient safety will be a change of "culture" throughout the entire health care system. The "culture of blame" focused on individuals should be replaced by a "safety culture", that sees errors and critical incidents as a problem of the whole organization. The acceptance of human fallability and an open-minded non-punitive analysis of errors in the sense of a "preventive and proactive safety culture" should lead to solutions at the systemic level. This change in culture can only be achieved with a strong commitment from the highest levels of an organization. Patient safety must have the highest priority in the goals of the institution: "Primum nihil nocere"--"First, do not harm".
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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.
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Study of the retardance of a birefringent waveplate at tilt incidence by Mueller matrix ellipsometer
NASA Astrophysics Data System (ADS)
Gu, Honggang; Chen, Xiuguo; Zhang, Chuanwei; Jiang, Hao; Liu, Shiyuan
2018-01-01
Birefringent waveplates are indispensable optical elements for polarization state modification in various optical systems. The retardance of a birefringent waveplate will change significantly when the incident angle of the light varies. Therefore, it is of great importance to study such field-of-view errors on the polarization properties, especially the retardance of a birefringent waveplate, for the performance improvement of the system. In this paper, we propose a generalized retardance formula at arbitrary incidence and azimuth for a general plane-parallel composite waveplate consisting of multiple aligned single waveplates. An efficient method and corresponding experimental set-up have been developed to characterize the retardance versus the field-of-view angle based on a constructed spectroscopic Mueller matrix ellipsometer. Both simulations and experiments on an MgF2 biplate over an incident angle of 0°-8° and an azimuthal angle of 0°-360° are presented as an example, and the dominant experimental errors are discussed and corrected. The experimental results strongly agree with the simulations with a maximum difference of 0.15° over the entire field of view, which indicates the validity and great potential of the presented method for birefringent waveplate characterization at tilt incidence.
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Hui, Shisheng; Chen, Lizhang; Liu, Fuqiang; Ouyang, Yanhao
2015-12-01
To establish multiple seasonal autoregressive integrated moving average model(ARIMA) according to mumps disease incidence in Hunan province, and to predict the mumps incidence from May 2015 to April 2016 in Hunan province by the model. The data were downloaded from "Disease Surveillance Information Reporting Management System" in China Information System for Disease Control and Prevention. The monthly incidence of mumps in Hunan province was collected from January 2004 to April 2015 according to the onset date, including clinical diagnosis and laboratory confirmed cases. The predictive analysis method was the ARIMA model in SPSS 18.0 software, the ARIMA model was established on the monthly incidence of mumps from January 2004 to April 2014, and the date from May 2014 to April 2015 was used as the testing sample, Box-Ljung Q test was used to test the residual of the selected model. Finally, the monthly incidence of mumps from May 2015 to April 2016 was predicted by the model. The peak months of the mumps incidence were May to July every year, and the secondary peak months were November to January of the following year, during January 2004 to April 2014 in Hunan province. After the data sequence was handled by smooth sequence, model identification, establishment and diagnosis, the ARIMA(2,1,1) × (0,1,1)(12) was established, Box-Ljung Q test found, Q=8.40, P=0.868, the residual sequence was white noise, the established model to the data information extraction was complete, the model was reasonable. The R(2) value of the model fitting degree was 0.871, and the value of BIC was -1.646, while the average absolute error of the predicted value and the actual value was 0.025/100 000, the average relative error was 13.004%. The relative error of the model for the prediction of the mumps incidence in Hunan province was small, and the predicting results were reliable. Using the ARIMA(2,1,1) ×(0,1,1)(12) model to predict the mumps incidence from April 2016 to May 2015 in Hunan province, the peak months of the mumps incidence were May to July, and the secondary peak months were November to January of the following year, the incidence of the peak month was close to the same period. The ARIMA(2,1,1)×(0,1,1)(12) model is well fitted the trend of the mumps disease incidence in Hunan province, it has some practical value for the prevention and control of the disease.
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Wang, K W; Deng, C; Li, J P; Zhang, Y Y; Li, X Y; Wu, M C
2017-04-01
Tuberculosis (TB) affects people globally and is being reconsidered as a serious public health problem in China. Reliable forecasting is useful for the prevention and control of TB. This study proposes a hybrid model combining autoregressive integrated moving average (ARIMA) with a nonlinear autoregressive (NAR) neural network for forecasting the incidence of TB from January 2007 to March 2016. Prediction performance was compared between the hybrid model and the ARIMA model. The best-fit hybrid model was combined with an ARIMA (3,1,0) × (0,1,1)12 and NAR neural network with four delays and 12 neurons in the hidden layer. The ARIMA-NAR hybrid model, which exhibited lower mean square error, mean absolute error, and mean absolute percentage error of 0·2209, 0·1373, and 0·0406, respectively, in the modelling performance, could produce more accurate forecasting of TB incidence compared to the ARIMA model. This study shows that developing and applying the ARIMA-NAR hybrid model is an effective method to fit the linear and nonlinear patterns of time-series data, and this model could be helpful in the prevention and control of TB.
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NASA Technical Reports Server (NTRS)
Davidson, Frederic M.; Sun, Xiaoli
1992-01-01
The performance of a 220 Mbps quaternary pulse position modulation (QPPM) optical communication receiver with a 'Slik' silicon avalanche photodiode (APD) and a wideband transimpedance preamplifier in a small hybrid circuit module was measured. The receiver performance had been poor due to the lack of a wideband and low noise transimpedance preamplifier. With the new APB preamplifier module, the receiver achieved a bit error rate (BER) of 10 exp -6 at an average received input optical signal power of 4.2 nW, which corresponds to an average of 80 received (incident) signal photons per information bit.
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The effect of microchannel plate gain depression on PAPA photon counting cameras
NASA Astrophysics Data System (ADS)
Sams, Bruce J., III
1991-03-01
PAPA (precision analog photon address) cameras are photon counting imagers which employ microchannel plates (MCPs) for image intensification. They have been used extensively in astronomical speckle imaging. The PAPA camera can produce artifacts when light incident on its MCP is highly concentrated. The effect is exacerbated by adjusting the strobe detection level too low, so that the camera accepts very small MCP pulses. The artifacts can occur even at low total count rates if the image has highly a concentrated bright spot. This paper describes how to optimize PAPA camera electronics, and describes six techniques which can avoid or minimize addressing errors.
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Does herpes zoster predispose to giant cell arteritis: a geo-epidemiologic study
Ing, Edsel B; Ing, Royce; Liu, Xinyang; Zhang, Angela; Torun, Nurhan; Sey, Michael; Pagnoux, Christian
2018-01-01
Purpose Giant cell arteritis (GCA) is the most common systemic vasculitis in the elderly and can cause irreversible blindness and aortitis. Varicella zoster (VZ), which is potentially preventable by vaccination, has been proposed as a possible immune trigger for GCA, but this is controversial. The incidence of GCA varies widely by country. If VZ virus contributes to the immunopathogenesis of GCA we hypothesized that nations with increased incidence of GCA would also have increased incidence of herpes zoster (HZ). We conducted an ecologic analysis to determine the relationship between the incidence of HZ and GCA in different countries. Methods A literature search for the incidence rates (IRs) of GCA and HZ from different countries was conducted. Correlation and linear regression was performed comparing the disease IR of each country for subjects 50 years of age or older. Results We found the IR for GCA and HZ from 14 countries. Comparing the IRs for GCA and HZ in 50-year-olds, the Pearson product-moment correlation (r) was −0.51, with linear regression coefficient (β) −2.92 (95% CI −5.41, −0.43; p=0.025) using robust standard errors. Comparing the IRs for GCA and HZ in 70-year-olds, r was −0.40, with β −1.78, which was not statistically significant (95% CI −4.10, 0.53; p=0.12). Conclusion Although this geo-epidemiologic study has potential for aggregation and selection biases, there was no positive biologic gradient between the incidence of clinically evident HZ and GCA. PMID:29391771
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A multifaceted program for improving quality of care in intensive care units: IATROREF study.
Garrouste-Orgeas, Maite; Soufir, Lilia; Tabah, Alexis; Schwebel, Carole; Vesin, Aurelien; Adrie, Christophe; Thuong, Marie; Timsit, Jean Francois
2012-02-01
To test the effects of three multifaceted safety programs designed to decrease insulin administration errors, anticoagulant prescription and administration errors, and errors leading to accidental removal of endotracheal tubes and central venous catheters, respectively. Medical errors and adverse events are associated with increased mortality in intensive care patients, indicating an urgent need for prevention programs. Multicenter cluster-randomized study. One medical intensive care unit in a university hospital and two medical-surgical intensive care units in community hospitals belonging to the Outcomerea Study Group. Consecutive patients >18 yrs admitted from January 2007 to January 2008 to the intensive care units. We tested three multifaceted safety programs vs. standard care in random order, each over 2.5 months, after a 1.5-month observation period. Incidence rates of medical errors/1000 patient-days in the multifaceted safety program and standard-care groups were compared using adjusted hierarchical models. In 2117 patients with 15,014 patient-days, 8520 medical errors (567.5/1000 patient-days) were reported, including 1438 adverse events (16.9%, 95.8/1000 patient-days). The insulin multifaceted safety program significantly decreased errors during implementation (risk ratio 0.65; 95% confidence interval [CI] 0.52-0.82; p = .0003) and after implementation (risk ratio 0.51; 95% CI 0.35-0.73; p = .0004). A significant Hawthorne effect was found. The accidental tube/catheter removal multifaceted safety program decreased errors significantly during implementation (odds ratio [OR] 0.34; 95% CI 0.15-0.81; p = .01]) and nonsignificantly after implementation (OR 1.65; 95% CI 0.78-3.48). The anticoagulation multifaceted safety program was not significantly effective (OR 0.64; 95% CI 0.26-1.59) but produced a significant Hawthorne effect. A multifaceted program was effective in preventing insulin errors and accidental tube/catheter removal. Significant Hawthorne effects occurred, emphasizing the need for appropriately designed studies before definitively implementing strategies. clinicaltrials.gov Identifier: NCT00461461.
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Hafezi-Nejad, Nima; Rahimi-Movaghar, Afarin; Motevalian, Abbas; Amin-Esmaeili, Masoumeh; Sharifi, Vandad; Hajebi, Ahmad; Radgoodarzi, Reza; Hefazi, Mitra; Eslami, Vahid; Karimi, Hasti; Saadat, Soheil; Mohammad, Kazem; Rahimi-Movaghar, Vafa
2015-05-01
To investigate the incidence and determinants of non-fatal injuries, and the cost imposed on victims in an Iranian population aged 15-64 years. Cross-sectional household survey. Three-stage probability sampling was conducted for selection of a representative sample of Iranians. Data on the demographics, history and cost of injury were obtained from face-to-face interviews and telephone calls. In total, 7886 subjects were included in this study. The annual incidence rate of all injuries was 905 (95% confidence interval 853-957) per 1000 population (approximately nine injuries per ten Iranians). The mean (±standard error) incidence rates of first aid injuries (FAIs; medical care not required) and medical-attended injuries (MAIs; medical treatment sought) were 737 ± 24 and 168 ± 12 per 1000 population, respectively. Young, urban females were at highest risk for FAIs, and single males were at highest risk for MAIs. The most common injury description was as follows: non-paid work (activity), home (place), inanimate mechanical force (mechanism), upper limb (site of injury) and open wound (type of injury). For MAIs, the most common place of treatment was hospital. Traffic-related injuries had the highest total cost and the lowest out-of-pocket cost. Total and out-of-pocket costs of non-fatal injuries in Iran in 2011 have been estimated to be US$6,111,138,000 and US$1,480,411,000, respectively. Non-fatal injuries are an under-recognized public health problem. Cost-control policies are essential to reduce the out-of-pocket cost of injuries. Copyright © 2015 The Royal Society for Public Health. Published by Elsevier Ltd. All rights reserved.
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Tomita, Minoru; Sotoyama, Yuko; Yukawa, Satoshi; Nakamura, Tadayuki
2013-01-01
Purpose To compare the incidence of diffuse lamellar keratitis (DLK) after laser in situ keratomileusis (LASIK) with flap creation using the Femto LDV and IntraLase™ FS60 femtosecond lasers.0 Methods A total of 818 consecutive myopic eyes had LASIK performed using either Femto LDV or IntraLase FS60 for flap creation. The same excimer laser, the Allegretto Wave® Eye-Q Laser, was used for correcting refractive errors for all patients. In the preoperative examination, uncorrected distance visual acuity, corrected distance visual acuity, and manifest refraction spherical equivalent were measured. At the postop examination, the same examinations were performed along with a slit-lamp biomicroscopic examination, and patients with DLK were classified into stages. For the statistical analysis of the DLK occurrence rate and the visual and refractive outcomes, the Mann-Whitney’s U-test was used. Results In the Femto LDV group with 514 eyes, 42 (8.17%) had DLK. In the IntraLase FS60 group with 304 eyes, 114 (37.5%) had DLK. There was a statistically significant difference in the DLK incidence rate between these groups (P < 0.0001). Both groups had excellent visual and refractive outcomes. Although low levels of DLK were observed for both groups, they did not affect visual acuity. Conclusion While there were significantly fewer incidences of low level DLK when using Femto LDV, neither femtosecond laser induced high levels of DLK, and any postoperative DLK cleared up within 1 week. Therefore, both lasers provide excellent results, with no clinical differences, and both excel at flap creation for LASIK. PMID:23874077
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Wing, S; Richardson, D; Armstrong, D; Crawford-Brown, D
1997-01-01
Previous studies concluded that there was no evidence that the 1979 nuclear accident at Three Mile Island (TMI) affected cancer incidence in the surrounding area; however, there were logical and methodological problems in earlier reports that led us to reconsider data previously collected. A 10-mile area around TMI was divided into 69 study tracts, which were assigned radiation dose estimates based on radiation reading and models of atmospheric dispersion. Incident cancers from 1975 to 1985 were ascertained from hospital records and assigned to study tracts. Associations between accident doses and incidence rates of leukemia, lung cancer, and all cancer were assessed using relative dose estimates calculated by the earlier investigators. Adjustments were made for age, sex, socioeconomic characteristics, and preaccident variation in incidence. Considering a 2-year latency, the estimated percent increase per dose unit +/- standard error was 0.020 +/- 0.012 for all cancer, 0.082 +/- 0.032 for lung cancer, and 0.116 +/- 0.067 for leukemia. Adjustment for socioeconomic variables increased the estimates to 0.034 +/- 0.013, 0.103 +/- 0.035, and 0.139 +/- 0.073 for all cancer, lung cancer, and leukemia, respectively. Associations were generally larger considering a 5-year latency, but were based on smaller numbers of cases. Results support the hypothesis that radiation doses are related to increased cancer incidence around TMI. The analysis avoids medical detection bias, but suffers from inaccurate dose classification; therefore, results may underestimate the magnitude of the association between radiation and cancer incidence. These associations would not be expected, based on previous estimates of near-background levels of radiation exposure following the accident.
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An investigation of reports of Controlled Flight Toward Terrain (CFTT)
NASA Technical Reports Server (NTRS)
Porter, R. F.; Loomis, J. P.
1981-01-01
Some 258 reports from more than 23,000 documents in the files of the Aviation Safety Reporting System (ASRS) were found to be to the hazard of flight into terrain with no prior awareness by the crew of impending disaster. Examination of the reports indicate that human error was a casual factor in 64% of the incidents in which some threat of terrain conflict was experienced. Approximately two-thirds of the human errors were attributed to controllers, the most common discrepancy being a radar vector below the Minimum Vector Altitude (MVA). Errors by pilots were of a much diverse nature and include a few instances of gross deviations from their assigned altitudes. The ground proximity warning system and the minimum safe altitude warning equipment were the initial recovery factor in some 18 serious incidents and were apparently the sole warning in six reported instances which otherwise would most probably have ended in disaster.
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Oviedo de la Fuente, Manuel; Febrero-Bande, Manuel; Muñoz, María Pilar; Domínguez, Àngela
2018-01-01
This paper proposes a novel approach that uses meteorological information to predict the incidence of influenza in Galicia (Spain). It extends the Generalized Least Squares (GLS) methods in the multivariate framework to functional regression models with dependent errors. These kinds of models are useful when the recent history of the incidence of influenza are readily unavailable (for instance, by delays on the communication with health informants) and the prediction must be constructed by correcting the temporal dependence of the residuals and using more accessible variables. A simulation study shows that the GLS estimators render better estimations of the parameters associated with the regression model than they do with the classical models. They obtain extremely good results from the predictive point of view and are competitive with the classical time series approach for the incidence of influenza. An iterative version of the GLS estimator (called iGLS) was also proposed that can help to model complicated dependence structures. For constructing the model, the distance correlation measure [Formula: see text] was employed to select relevant information to predict influenza rate mixing multivariate and functional variables. These kinds of models are extremely useful to health managers in allocating resources in advance to manage influenza epidemics.
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Epidemic of mumps in a partially immune population.
Lewis, J E; Chernesky, M A; Rawls, M L; Rawls, W E
1979-01-01
The incidence of mumps in vaccinated and nonvaccinated schoolchildren was studied after a recent epidemic. Information was collected by telephone interviews with the parents and a review of the physicians' records. The vaccine appeared to be effective, for the incidence of mumps in the 145 vaccinated children--5.5%, or 8 cases--was significantly less (P less than 0.001) than the incidence in the 350 children considered susceptible to infection--21.7%, or 76 cases. The percentage of children who had been immunized decreased with increasing age, and acquisition of immunity through natural infection had the reverse trend; thus, the proportions of children susceptible to infection in each age group were about the same, and the age-specific attack rates were similar. Although the mothers were accurate in indicating absence of vaccination, they incorrectly indicated vaccination of their children 43.0% of the time; this error in reporting could influence vaccine administration in older children. Our findings suggest that mumps vaccination may substitute for natural illness in immunizing populations, and that more extensive use of the vaccine over a broader age range is required to prevent similar epidemics in the future. PMID:519614
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Gupta, A; Davidson, C M; McIsaac, M A
2016-08-01
Surveys that collect information on injuries often focus on the single "most serious" event to help limit recall error and reduce survey length. However, this can mask less serious injuries and result in biased incidence estimates for specific injury subcategories. Data from the 2002 Health Behaviour in School-aged Children (HBSC) survey and from the Canadian Hospitals Injury Reporting and Prevention Program (CHIRPP) were used to compare estimates of sports injury incidence in Canadian children. HBSC data indicate that 6.7% of children report sustaining a sports injury that required an emergency department (ED) visit. However, details were only collected on a child's "most serious" injury, so children who had multiple injuries requiring an ED visit may have had sports injuries that went unreported. The rate of 6.7% can be seen to be an underestimate by as much as 4.3%. Corresponding CHIRPP surveillance data indicate an incidence of 9.9%. Potential masking bias is also highlighted in our analysis of injuries attended by other health care providers. The "one most serious injury" line of questioning induces potentially substantial masking bias in the estimation of sports injury incidence, which limits researchers' ability to quantify the burden of sports injury. Longer survey recall periods naturally lead to greater masking. The design of future surveys should take these issues into account. In order to accurately inform policy decisions and the direction of future research, researchers must be aware of these limitations.
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Guidotti, T L; Abercrombie, S
1994-12-01
We studied the responses of leaders in a suburban community in western Canada near Edmonton, Alberta, that was affected by a false allegation of increased cancer risk. In 1986, a cancer agency responded to community concerns by conducting a study of cancer incidence (1979-1983) and reported elevations on the order of 25 per cent over expected for most sites. Reanalysis of these data several months later revealed an error in the population figure used to calculate the rates. Correction brought the rates into line with Alberta as a whole and comparable to those for other communities surrounding Edmonton. We interviewed elected and appointed public officials in one affected community as well as non-official community leaders and realtors to determine their subjective impression regarding the effect of the incident on their communities and to rule out alternative explanations for the drop in housing prices in association with the incident we have reported elsewhere. Their narrative responses were particularly interesting and articulate, and are quoted at length. Their collective perceptions appear to confirm the impression of a profound impact on the community, reflected in housing prices, and attribute at least part of the impact to the disclosure that a high official in the community was afflicted by cancer. Most felt that there remained a great deal of latent concern in the community and at least some felt that a subsequent public issue involving transmission line rights-of-way near the community reactivated this latent concern.
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Consanguinity, endogamy and inborn errors of metabolism in Oman: a cross-sectional study.
Al-Thihli, Khalid; Al-Murshedi, Fathiya; Al-Hashmi, Nadia; Al-Mamari, Watfa; Islam, M Mazharul; Al-Yahyaee, Said A
2014-01-01
The Sultanate of Oman, like many other Arab countries, has relatively high rates of consanguinity. Reports suggest that the incidence of inborn errors of metabolism (IEM) is also high in Oman. This retrospective cross-sectional study was designed to evaluate the number of patients with IEM being followed at the only two tertiary centers in Oman treating such patients, and to calculate the consanguinity rates among these families. The electronic medical records of all patients were reviewed for demographic and clinical characteristics. A total of 285 patients with IEM were being followed at the 2 centers involved; 162 (56.8%) were male and 123 (43.2%) were female. The history of consanguinity was documented or available for 241 patients: 229 patients (95%) were born to consanguineous parents related as second cousins or closer. First-cousin marriages were reported in 191 families (79.3%), while 31 patients (12.9%) were born to second cousins. The parents of 5 patients (2%) were related as double first cousins, and 2 patients (1%) were born to first cousins once removed. The average coefficient of inbreeding (F) in our study was 0.081. Seventeen patients (6%) had associated comorbid conditions other than IEM. Our study highlights the clinical burden of IEM in Oman and emphasizes the high consanguinity rates among the parents of affected patients. © 2014 S. Karger AG, Basel
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Long-term neuromuscular training and ankle joint position sense.
Kynsburg, A; Pánics, G; Halasi, T
2010-06-01
Preventive effect of proprioceptive training is proven by decreasing injury incidence, but its proprioceptive mechanism is not. Major hypothesis: the training has a positive long-term effect on ankle joint position sense in athletes of a high-risk sport (handball). Ten elite-level female handball-players represented the intervention group (training-group), 10 healthy athletes of other sports formed the control-group. Proprioceptive training was incorporated into the regular training regimen of the training-group. Ankle joint position sense function was measured with the "slope-box" test, first described by Robbins et al. Testing was performed one day before the intervention and 20 months later. Mean absolute estimate errors were processed for statistical analysis. Proprioceptive sensory function improved regarding all four directions with a high significance (p<0.0001; avg. mean estimate error improvement: 1.77 degrees). This was also highly significant (p< or =0.0002) in each single directions, with avg. mean estimate error improvement between 1.59 degrees (posterior) and 2.03 degrees (anterior). Mean absolute estimate errors at follow-up (2.24 degrees +/-0.88 degrees) were significantly lower than in uninjured controls (3.29 degrees +/-1.15 degrees) (p<0.0001). Long-term neuromuscular training has improved ankle joint position sense function in the investigated athletes. This joint position sense improvement can be one of the explanations for injury rate reduction effect of neuromuscular training.
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Simultaneous Control of Error Rates in fMRI Data Analysis
Kang, Hakmook; Blume, Jeffrey; Ombao, Hernando; Badre, David
2015-01-01
The key idea of statistical hypothesis testing is to fix, and thereby control, the Type I error (false positive) rate across samples of any size. Multiple comparisons inflate the global (family-wise) Type I error rate and the traditional solution to maintaining control of the error rate is to increase the local (comparison-wise) Type II error (false negative) rates. However, in the analysis of human brain imaging data, the number of comparisons is so large that this solution breaks down: the local Type II error rate ends up being so large that scientifically meaningful analysis is precluded. Here we propose a novel solution to this problem: allow the Type I error rate to converge to zero along with the Type II error rate. It works because when the Type I error rate per comparison is very small, the accumulation (or global) Type I error rate is also small. This solution is achieved by employing the Likelihood paradigm, which uses likelihood ratios to measure the strength of evidence on a voxel-by-voxel basis. In this paper, we provide theoretical and empirical justification for a likelihood approach to the analysis of human brain imaging data. In addition, we present extensive simulations that show the likelihood approach is viable, leading to ‘cleaner’ looking brain maps and operationally superiority (lower average error rate). Finally, we include a case study on cognitive control related activation in the prefrontal cortex of the human brain. PMID:26272730
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Torres-Sepúlveda, María del Rosario; Martínez-de Villarreal, Laura E; Esmer, Carmen; González-Alanís, Rogerio; Ruiz-Herrera, Consuelo; Sánchez-Peña, Alejandra; Mendoza-Cruz, José Alberto; Villarreal-Pérez, Jesús Z
2008-01-01
To initiate a statewide expanded metabolic screening program in neonates with the purpose of identifying the most common inborn errors of metabolism. From March 2002 through February 2004, a blood sample was obtained between 24 and 48 hours after delivery from every consecutive child born in public hospitals in Nuevo León. It was spotted on filter paper and analyzed by tandem mass spectrometry for expanded metabolic screening. A total of 42 264 samples were analyzed. Were obtained seven positive results, one for each disorder: homocystinuria, hyperphenylalaninemia, citrulinemia, transient tyrosinemia, 3-methylcrotonyl CoA carboxylase deficiency, 3-hydroxy-3-methylglutaryl CoA deficiency, and classic galactosemia. The estimated incidence of inborn errors of metabolism is 1:5 000, with a false positive rate of 0.22%. The program permitted the identification of metabolic disorders in the newborn, allowing an early intervention and prevention of life-threatening events and permanent neurological damage.
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[Medication errors in a neonatal unit: One of the main adverse events].
Esqué Ruiz, M T; Moretones Suñol, M G; Rodríguez Miguélez, J M; Sánchez Ortiz, E; Izco Urroz, M; de Lamo Camino, M; Figueras Aloy, J
2016-04-01
Neonatal units are one of the hospital areas most exposed to the committing of treatment errors. A medication error (ME) is defined as the avoidable incident secondary to drug misuse that causes or may cause harm to the patient. The aim of this paper is to present the incidence of ME (including feeding) reported in our neonatal unit and its characteristics and possible causal factors. A list of the strategies implemented for prevention is presented. An analysis was performed on the ME declared in a neonatal unit. A total of 511 MEs have been reported over a period of seven years in the neonatal unit. The incidence in the critical care unit was 32.2 per 1000 hospital days or 20 per 100 patients, of which 0.22 per 1000 days had serious repercussions. The ME reported were, 39.5% prescribing errors, 68.1% administration errors, 0.6% were adverse drug reactions. Around two-thirds (65.4%) were produced by drugs, with 17% being intercepted. The large majority (89.4%) had no impact on the patient, but 0.6% caused permanent damage or death. Nurses reported 65.4% of MEs. The most commonly implicated causal factor was distraction (59%). Simple corrective action (alerts), and intermediate (protocols, clinical sessions and courses) and complex actions (causal analysis, monograph) were performed. It is essential to determine the current state of ME, in order to establish preventive measures and, together with teamwork and good practices, promote a climate of safety. Copyright © 2015 Asociación Española de Pediatría. Published by Elsevier España, S.L.U. All rights reserved.
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Chen, Jin-hong; Wu, Hai-yun; He, Kun-lun; He, Yao; Qin, Yin-he
2010-10-01
To establish and verify the prediction model for ischemic cardiovascular disease (ICVD) among the elderly population who were under the current health care programs. Statistical analysis on data from physical examination, hospitalization of the past years, from questionnaire and telephone interview was carried out in May, 2003. Data was from a hospital which implementing a health care program. Baseline population with a proportion of 4:1 was randomly selected to generate both module group and verification group. Baseline data was induced to make the verification group into regression model of module group and to generate the predictive value. Distinguished ability with area under ROC curve and the predictive veracity were verified through comparing the predictive incidence rate and actual incidence rate of every deciles group by Hosmer-Lemeshow test. Predictive veracity of the prediction model at population level was verified through comparing the predictive 6-year incidence rates of ICVD with actual 6-year accumulative incidence rates of ICVD with error rate calculated. The samples included 2271 males over the age of 65 with 1817 people for modeling population and 454 for verified population. All of the samples were stratified into two layers to establish hierarchical Cox proportional hazard regression model, including one advanced age group (greater than or equal to 75 years old), and another elderly group (less than 75 years old). Data from the statically analysis showed that the risk factors in aged group were age, systolic blood pressure, serum creatinine level, fasting blood glucose level, while protective factor was high density lipoprotein;in advanced age group, the risk factors were body weight index, systolic blood pressure, serum total cholesterol level, serum creatinine level, fasting blood glucose level, while protective factor was HDL-C. The area under the ROC curve (AUC) and 95%CI were 0.723 and 0.687 - 0.759 respectively. Discriminating power was good. All individual predictive ICVD cumulative incidence and actual incidence were analyzed using Hosmer-Lemeshow test, χ(2) = 1.43, P = 0.786, showing that the predictive veracity was good. The stratified Cox Hazards Regression model was used to establish prediction model of the aged male population under a certain health care program. The common prediction factor of the two age groups were: systolic blood pressure, serum creatinine level, fasting blood glucose level and HDL-C. The area under the ROC curve of the verification group was 0.723, showing that the distinguished ability was good and the predict ability at the individual level and at the group level were also satisfactory. It was feasible to using Cox Proportional Hazards Regression Model for predicting the population groups.
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NASA Astrophysics Data System (ADS)
Allured, Ryan; Okajima, Takashi; Soufli, Regina; Fernández-Perea, Mónica; Daly, Ryan O.; Marlowe, Hannah; Griffiths, Scott T.; Pivovaroff, Michael J.; Kaaret, Philip
2012-10-01
The Bragg Reflection Polarimeter (BRP) on the NASA Gravity and Extreme Magnetism Small Explorer Mission is designed to measure the linear polarization of astrophysical sources in a narrow band centered at about 500 eV. X-rays are focused by Wolter I mirrors through a 4.5 m focal length to a time projection chamber (TPC) polarimeter, sensitive between 2{10 keV. In this optical path lies the BRP multilayer reflector at a nominal 45 degree incidence angle. The reflector reflects soft X-rays to the BRP detector and transmits hard X-rays to the TPC. As the spacecraft rotates about the optical axis, the reflected count rate will vary depending on the polarization of the incident beam. However, false polarization signals may be produced due to misalignments and spacecraft pointing wobble. Monte-Carlo simulations have been carried out, showing that the false modulation is below the statistical uncertainties for the expected focal plane offsets of < 2 mm.
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Simulation approach for the evaluation of tracking accuracy in radiotherapy: a preliminary study.
Tanaka, Rie; Ichikawa, Katsuhiro; Mori, Shinichiro; Sanada, Sigeru
2013-01-01
Real-time tumor tracking in external radiotherapy can be achieved by diagnostic (kV) X-ray imaging with a dynamic flat-panel detector (FPD). It is important to keep the patient dose as low as possible while maintaining tracking accuracy. A simulation approach would be helpful to optimize the imaging conditions. This study was performed to develop a computer simulation platform based on a noise property of the imaging system for the evaluation of tracking accuracy at any noise level. Flat-field images were obtained using a direct-type dynamic FPD, and noise power spectrum (NPS) analysis was performed. The relationship between incident quantum number and pixel value was addressed, and a conversion function was created. The pixel values were converted into a map of quantum number using the conversion function, and the map was then input into the random number generator to simulate image noise. Simulation images were provided at different noise levels by changing the incident quantum numbers. Subsequently, an implanted marker was tracked automatically and the maximum tracking errors were calculated at different noise levels. The results indicated that the maximum tracking error increased with decreasing incident quantum number in flat-field images with an implanted marker. In addition, the range of errors increased with decreasing incident quantum number. The present method could be used to determine the relationship between image noise and tracking accuracy. The results indicated that the simulation approach would aid in determining exposure dose conditions according to the necessary tracking accuracy.
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Desapriya, Ediriweera; Fujiwara, Takeo; Scime, Giulia; Sasges, Deborah; Pike, Ian; Shimizu, Shinji
2009-10-01
International studies have shown a significant association between alcohol availability and traffic crashes that involve alcohol-impaired drivers. A key limitation to previous alcohol availability and motor vehicle crash (MVC) evaluation research is the assumption of population homogeneity in responding to the policies. The present analysis focuses on the evaluation of the impact of alcohol availability on different segments of the Japanese population by comparing MVC fatality rates from before and after implementation of the alcohol deregulation policy in 1994. Poisson regression with robust standard error was used to model the before-to-after change in incidence rate ratios (IRR) in adult males, adult females, teenage males and teenage females. To control potential confounders, unemployment rate, vehicle miles of travel (VMT), vehicle registration, and number of drivers licensed in Japan were added to the model. The exponents of the fitted coefficients are equivalent to incidence rate ratios. Implementation of the policy deregulating alcohol sales and production did not appear to increase traffic fatalities among adult or teenage males or females in Japan. We found that male adult fatalities demonstrated a statistically significant decline following enactment of the deregulation policy in 1994. Contrary to previous research, the findings of this study demonstrated lower rates of fatalities and higher compliance with alcohol-related driving legislation in Japanese society following implementation of the deregulation policy in 1994. Further well designed, nonaligned studies on alcohol availability and traffic fatalities in other countries are urgently needed.
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Phipps, Denham L; Tam, W Vanessa; Ashcroft, Darren M
2017-03-01
To explore the combined use of a critical incident database and work domain analysis to understand patient safety issues in a health-care setting. A retrospective review was conducted of incidents reported to the UK National Reporting and Learning System (NRLS) that involved community pharmacy between April 2005 and August 2010. A work domain analysis of community pharmacy was constructed using observational data from 5 community pharmacies, technical documentation, and a focus group with 6 pharmacists. Reports from the NRLS were mapped onto the model generated by the work domain analysis. Approximately 14,709 incident reports meeting the selection criteria were retrieved from the NRLS. Descriptive statistical analysis of these reports found that almost all of the incidents involved medication and that the most frequently occurring error types were dose/strength errors, incorrect medication, and incorrect formulation. The work domain analysis identified 4 overall purposes for community pharmacy: business viability, health promotion and clinical services, provision of medication, and use of medication. These purposes were served by lower-order characteristics of the work system (such as the functions, processes and objects). The tasks most frequently implicated in the incident reports were those involving medication storage, assembly, or patient medication records. Combining the insights from different analytical methods improves understanding of patient safety problems. Incident reporting data can be used to identify general patterns, whereas the work domain analysis can generate information about the contextual factors that surround a critical task.
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Classical Galactosaemia in Ireland: incidence, complications and outcomes of treatment.
Coss, K P; Doran, P P; Owoeye, C; Codd, M B; Hamid, N; Mayne, P D; Crushell, E; Knerr, I; Monavari, A A; Treacy, E P
2013-01-01
Newborn screening for the inborn error of metabolism, classical galactosaemia prevents life-threatening complications in the neonatal period. It does not however influence the development of long-term complications and the complex pathophysiology of this rare disease remains poorly understood. The objective of this study was to report the development of a healthcare database (using Distiller Version 2.1) to review the epidemiology of classical galactosaemia in Ireland since initiation of newborn screening in 1972 and the long-term clinical outcomes of all patients attending the National Centre for Inherited Metabolic Disorders (NCIMD). Since 1982, the average live birth incidence rate of classical galactosaemia in the total Irish population was approximately 1:16,476 births. This reflects a high incidence in the Irish 'Traveller' population, with an estimated birth incidence of 1:33,917 in the non-Traveller Irish population. Despite early initiation of treatment (dietary galactose restriction), the long-term outcomes of classical galactosaemia in the Irish patient population are poor; 30.6 % of patients ≥ 6 yrs have IQs <70, 49.6 % of patients ≥ 2.5 yrs have speech or language impairments and 91.2 % of females ≥ 13 yrs suffer from hypergonadotrophic hypogonadism (HH) possibly leading to decreased fertility. These findings are consistent with the international experience. This emphasizes the requirement for continued clinical research in this complex disorder.
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A cascaded coding scheme for error control and its performance analysis
NASA Technical Reports Server (NTRS)
Lin, Shu; Kasami, Tadao; Fujiwara, Tohru; Takata, Toyoo
1986-01-01
A coding scheme is investigated for error control in data communication systems. The scheme is obtained by cascading two error correcting codes, called the inner and outer codes. The error performance of the scheme is analyzed for a binary symmetric channel with bit error rate epsilon <1/2. It is shown that if the inner and outer codes are chosen properly, extremely high reliability can be attained even for a high channel bit error rate. Various specific example schemes with inner codes ranging form high rates to very low rates and Reed-Solomon codes as inner codes are considered, and their error probabilities are evaluated. They all provide extremely high reliability even for very high bit error rates. Several example schemes are being considered by NASA for satellite and spacecraft down link error control.
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HIITE: HIV-1 incidence and infection time estimator.
Park, Sung Yong; Love, Tanzy M T; Kapoor, Shivankur; Lee, Ha Youn
2018-06-15
Around 2.1 million new HIV-1 infections were reported in 2015, alerting that the HIV-1 epidemic remains a significant global health challenge. Precise incidence assessment strengthens epidemic monitoring efforts and guides strategy optimization for prevention programs. Estimating the onset time of HIV-1 infection can facilitate optimal clinical management and identify key populations largely responsible for epidemic spread and thereby infer HIV-1 transmission chains. Our goal is to develop a genomic assay estimating the incidence and infection time in a single cross-sectional survey setting. We created a web-based platform, HIV-1 incidence and infection time estimator (HIITE), which processes envelope gene sequences using hierarchical clustering algorithms and informs the stage of infection, along with time since infection for incident cases. HIITE's performance was evaluated using 585 incident and 305 chronic specimens' envelope gene sequences collected from global cohorts including HIV-1 vaccine trial participants. HIITE precisely identified chronically infected individuals as being chronic with an error less than 1% and correctly classified 94% of recently infected individuals as being incident. Using a mixed-effect model, an incident specimen's time since infection was estimated from its single lineage diversity, showing 14% prediction error for time since infection. HIITE is the first algorithm to inform two key metrics from a single time point sequence sample. HIITE has the capacity for assessing not only population-level epidemic spread but also individual-level transmission events from a single survey, advancing HIV prevention and intervention programs. Web-based HIITE and source code of HIITE are available at http://www.hayounlee.org/software.html. Supplementary data are available at Bioinformatics online.
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Habibovic, Azra; Tivesten, Emma; Uchida, Nobuyuki; Bärgman, Jonas; Ljung Aust, Mikael
2013-01-01
To develop relevant road safety countermeasures, it is necessary to first obtain an in-depth understanding of how and why safety-critical situations such as incidents, near-crashes, and crashes occur. Video-recordings from naturalistic driving studies provide detailed information on events and circumstances prior to such situations that is difficult to obtain from traditional crash investigations, at least when it comes to the observable driver behavior. This study analyzed causation in 90 video-recordings of car-to-pedestrian incidents captured by onboard cameras in a naturalistic driving study in Japan. The Driving Reliability and Error Analysis Method (DREAM) was modified and used to identify contributing factors and causation patterns in these incidents. Two main causation patterns were found. In intersections, drivers failed to recognize the presence of the conflict pedestrian due to visual obstructions and/or because their attention was allocated towards something other than the conflict pedestrian. In incidents away from intersections, this pattern reoccurred along with another pattern showing that pedestrians often behaved in unexpected ways. These patterns indicate that an interactive advanced driver assistance system (ADAS) able to redirect the driver's attention could have averted many of the intersection incidents, while autonomous systems may be needed away from intersections. Cooperative ADAS may be needed to address issues raised by visual obstructions. Copyright © 2012 Elsevier Ltd. All rights reserved.
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45 CFR 98.100 - Error Rate Report.
Code of Federal Regulations, 2013 CFR
2013-10-01
... 45 Public Welfare 1 2013-10-01 2013-10-01 false Error Rate Report. 98.100 Section 98.100 Public Welfare DEPARTMENT OF HEALTH AND HUMAN SERVICES GENERAL ADMINISTRATION CHILD CARE AND DEVELOPMENT FUND Error Rate Reporting § 98.100 Error Rate Report. (a) Applicability—The requirements of this subpart...
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45 CFR 98.100 - Error Rate Report.
Code of Federal Regulations, 2014 CFR
2014-10-01
... 45 Public Welfare 1 2014-10-01 2014-10-01 false Error Rate Report. 98.100 Section 98.100 Public Welfare Department of Health and Human Services GENERAL ADMINISTRATION CHILD CARE AND DEVELOPMENT FUND Error Rate Reporting § 98.100 Error Rate Report. (a) Applicability—The requirements of this subpart...
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45 CFR 98.100 - Error Rate Report.
Code of Federal Regulations, 2012 CFR
2012-10-01
... 45 Public Welfare 1 2012-10-01 2012-10-01 false Error Rate Report. 98.100 Section 98.100 Public Welfare DEPARTMENT OF HEALTH AND HUMAN SERVICES GENERAL ADMINISTRATION CHILD CARE AND DEVELOPMENT FUND Error Rate Reporting § 98.100 Error Rate Report. (a) Applicability—The requirements of this subpart...
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45 CFR 98.100 - Error Rate Report.
Code of Federal Regulations, 2011 CFR
2011-10-01
... 45 Public Welfare 1 2011-10-01 2011-10-01 false Error Rate Report. 98.100 Section 98.100 Public Welfare DEPARTMENT OF HEALTH AND HUMAN SERVICES GENERAL ADMINISTRATION CHILD CARE AND DEVELOPMENT FUND Error Rate Reporting § 98.100 Error Rate Report. (a) Applicability—The requirements of this subpart...
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Physician attitudes and practices related to voluntary error and near-miss reporting.
Smith, Koren S; Harris, Kendra M; Potters, Louis; Sharma, Rajiv; Mutic, Sasa; Gay, Hiram A; Wright, Jean; Samuels, Michael; Ye, Xiaobu; Ford, Eric; Terezakis, Stephanie
2014-09-01
Incident learning systems are important tools to improve patient safety in radiation oncology, but physician participation in these systems is poor. To understand reporting practices and attitudes, a survey was sent to staff members of four large academic radiation oncology centers, all of which have in-house reporting systems. Institutional review board approval was obtained to send a survey to employees including physicians, dosimetrists, nurses, physicists, and radiation therapists. The survey evaluated barriers to reporting, perceptions of errors, and reporting practices. The responses of physicians were compared with those of other professional groups. There were 274 respondents to the survey, with a response rate of 81.3%. Physicians and other staff agreed that errors and near-misses were happening in their clinics (93.8% v 88.7%, respectively) and that they have a responsibility to report (97% overall). Physicians were significantly less likely to report minor near-misses (P = .001) and minor errors (P = .024) than other groups. Physicians were significantly more concerned about getting colleagues in trouble (P = .015), liability (P = .009), effect on departmental reputation (P = .006), and embarrassment (P < .001) than their colleagues. Regression analysis identified embarrassment among physicians as a critical barrier. If not embarrassed, participants were 2.5 and 4.5 times more likely to report minor errors and major near-miss events, respectively. All members of the radiation oncology team observe errors and near-misses. Physicians, however, are significantly less likely to report events than other colleagues. There are important, specific barriers to physician reporting that need to be addressed to encourage reporting and create a fair culture around reporting. Copyright © 2014 by American Society of Clinical Oncology.
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Buchini, Sara; Quattrin, Rosanna
2012-04-01
To record the frequency of interruptions and their causes, to identify 'avoidable' interruptions and to build an improvement project to reduce 'avoidable' interruptions. In Italy each year 30,000-35,000 deaths per year are attributed to health-care system errors, of which 19% are caused by medication errors. The factors that contribute to drug management error also include interruptions and carelessness during treatment administration. A descriptive study design was used to record the frequency of interruptions and their causes and to identify 'avoidable' interruptions in an intensive rehabilitation ward in Northern Italy. A data collection grid was used to record the data over a 6-month period. A total of 3000 work hours were observed. During the study period 1170 interruptions were observed. The study identified 14 causes of interruption. The study shows that of the 14 cases of interruptions at least nine can be defined as 'avoidable'. An improvement project has been proposed to reduce unnecessary interruptions and distractions to avoid making errors. An additional useful step to reduce the incidence of treatment errors would be to implement the use of a single patient medication sheet for the recording of drug prescription, preparation and administration and also the incident reporting. © 2011 Blackwell Publishing Ltd.
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An educational and audit tool to reduce prescribing error in intensive care.
Thomas, A N; Boxall, E M; Laha, S K; Day, A J; Grundy, D
2008-10-01
To reduce prescribing errors in an intensive care unit by providing prescriber education in tutorials, ward-based teaching and feedback in 3-monthly cycles with each new group of trainee medical staff. Prescribing audits were conducted three times in each 3-month cycle, once pretraining, once post-training and a final audit after 6 weeks. The audit information was fed back to prescribers with their correct prescribing rates, rates for individual error types and total error rates together with anonymised information about other prescribers' error rates. The percentage of prescriptions with errors decreased over each 3-month cycle (pretraining 25%, 19%, (one missing data point), post-training 23%, 6%, 11%, final audit 7%, 3%, 5% (p<0.0005)). The total number of prescriptions and error rates varied widely between trainees (data collection one; cycle two: range of prescriptions written: 1-61, median 18; error rate: 0-100%; median: 15%). Prescriber education and feedback reduce manual prescribing errors in intensive care.
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A Six Sigma Trial For Reduction of Error Rates in Pathology Laboratory.
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.
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Data Analysis & Statistical Methods for Command File Errors
NASA Technical Reports Server (NTRS)
Meshkat, Leila; Waggoner, Bruce; Bryant, Larry
2014-01-01
This paper explains current work on modeling for managing the risk of command file errors. It is focused on analyzing actual data from a JPL spaceflight mission to build models for evaluating and predicting error rates as a function of several key variables. We constructed a rich dataset by considering the number of errors, the number of files radiated, including the number commands and blocks in each file, as well as subjective estimates of workload and operational novelty. We have assessed these data using different curve fitting and distribution fitting techniques, such as multiple regression analysis, and maximum likelihood estimation to see how much of the variability in the error rates can be explained with these. We have also used goodness of fit testing strategies and principal component analysis to further assess our data. Finally, we constructed a model of expected error rates based on the what these statistics bore out as critical drivers to the error rate. This model allows project management to evaluate the error rate against a theoretically expected rate as well as anticipate future error rates.
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NASA Technical Reports Server (NTRS)
Kummerow, Christian; Poyner, Philip; Berg, Wesley; Thomas-Stahle, Jody
2007-01-01
Passive microwave rainfall estimates that exploit the emission signal of raindrops in the atmosphere are sensitive to the inhomogeneity of rainfall within the satellite field of view (FOV). In particular, the concave nature of the brightness temperature (T(sub b)) versus rainfall relations at frequencies capable of detecting the blackbody emission of raindrops cause retrieval algorithms to systematically underestimate precipitation unless the rainfall is homogeneous within a radiometer FOV, or the inhomogeneity is accounted for explicitly. This problem has a long history in the passive microwave community and has been termed the beam-filling error. While not a true error, correcting for it requires a priori knowledge about the actual distribution of the rainfall within the satellite FOV, or at least a statistical representation of this inhomogeneity. This study first examines the magnitude of this beam-filling correction when slant-path radiative transfer calculations are used to account for the oblique incidence of current radiometers. Because of the horizontal averaging that occurs away from the nadir direction, the beam-filling error is found to be only a fraction of what has been reported previously in the literature based upon plane-parallel calculations. For a FOV representative of the 19-GHz radiometer channel (18 km X 28 km) aboard the Tropical Rainfall Measuring Mission (TRMM), the mean beam-filling correction computed in this study for tropical atmospheres is 1.26 instead of 1.52 computed from plane-parallel techniques. The slant-path solution is also less sensitive to finescale rainfall inhomogeneity and is, thus, able to make use of 4-km radar data from the TRMM Precipitation Radar (PR) in order to map regional and seasonal distributions of observed rainfall inhomogeneity in the Tropics. The data are examined to assess the expected errors introduced into climate rainfall records by unresolved changes in rainfall inhomogeneity. Results show that global mean monthly errors introduced by not explicitly accounting for rainfall inhomogeneity do not exceed 0.5% if the beam-filling error is allowed to be a function of rainfall rate and freezing level and does not exceed 2% if a universal beam-filling correction is applied that depends only upon the freezing level. Monthly regional errors can be significantly larger. Over the Indian Ocean, errors as large as 8% were found if the beam-filling correction is allowed to vary with rainfall rate and freezing level while errors of 15% were found if a universal correction is used.
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TU-CD-BRD-00: Incident Learning / RO-ILS
DOE Office of Scientific and Technical Information (OSTI.GOV)
NONE
2015-06-15
It has long been standard practice in radiation oncology to report internally when a patient’s treatment has not gone as planned and to report events to regulatory agencies when legally required. Most potential errors are caught early and never affect the patient. Quality assurance steps routinely prevent errors from reaching the patient, and these “near misses” are much more frequent than treatment errors. A growing number of radiation oncology facilities have implemented incident learning systems to report and analyze both errors and near misses. Using the term “incident learning” instead of “event reporting” emphasizes the need to use these experiencesmore » to change the practice and make future errors less likely and promote an educational, non-punitive environment. There are challenges in making such a system practical and effective. Speakers from institutions of different sizes and practice environments will share their experiences on how to make such a system work and what benefits their clinics have accrued. Questions that will be addressed include: How to create a system that is easy for front line staff to access How to motivate staff to report How to promote the system as positive and educational and not punitive or demeaning How to organize the team for reviewing and responding to reports How to prioritize which reports to discuss in depth How not to dismiss the rest How to identify underlying causes How to design corrective actions and implement change How to develop useful statistics and analysis tools How to coordinate a departmental system with a larger risk management system How to do this without a dedicated quality manager Some speakers’ experience is with in-house systems and some will share experience with the AAPM/ASTRO national Radiation Oncology Incident Learning System (RO-ILS). Reports intended to be of value nationally need to be comprehensible to outsiders; examples of useful reports will be shown. There will be ample time set aside for audience members to contribute to the discussion. Learning Objectives: Learn how to promote the use of an incident learning system in a clinic. Learn how to convert “event reporting” into “incident learning”. See examples of practice changes that have come out of learning systems. Learn how the RO-ILS system can be used as a primary internal learning system. Learn how to create succinct, meaningful reports useful to outside readers. Gary Ezzell chairs the AAPM committee overseeing RO-ILS and has received an honorarium from ASTRO for working on the committee reviewing RO-ILS reports. Derek Brown is a director of http://TreatSafely.org . Brett Miller has previously received travel expenses and an honorarium from Varian. Phillip Beron has nothing to report.« less
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Detecting Signatures of GRACE Sensor Errors in Range-Rate Residuals
NASA Astrophysics Data System (ADS)
Goswami, S.; Flury, J.
2016-12-01
In order to reach the accuracy of the GRACE baseline, predicted earlier from the design simulations, efforts are ongoing since a decade. GRACE error budget is highly dominated by noise from sensors, dealiasing models and modeling errors. GRACE range-rate residuals contain these errors. Thus, their analysis provides an insight to understand the individual contribution to the error budget. Hence, we analyze the range-rate residuals with focus on contribution of sensor errors due to mis-pointing and bad ranging performance in GRACE solutions. For the analysis of pointing errors, we consider two different reprocessed attitude datasets with differences in pointing performance. Then range-rate residuals are computed from these two datasetsrespectively and analysed. We further compare the system noise of four K-and Ka- band frequencies of the two spacecrafts, with range-rate residuals. Strong signatures of mis-pointing errors can be seen in the range-rate residuals. Also, correlation between range frequency noise and range-rate residuals are seen.
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Britt, H; Miller, G C; Steven, I D; Howarth, G C; Nicholson, P A; Bhasale, A L; Norton, K J
1997-04-01
The prediction and subsequent prevention of errors, which are an integral element of human behaviour, require an understanding of their cause. The incident monitoring technique was developed in the study of aviation errors in the Second World War and has been applied more recently in the field of anaesthetics. This pilot study represents one of the first attempts to apply the incident monitoring technique in the general practice environment. A total of 297 GPs across Australia anonymously reported details of unintended events which harmed or could have harmed the patient. Reports were contemporaneously recorded on prepared forms which allowed a free text description of the incident, and structured responses for contributing and mitigating factors, immediate and long-term out-comes, additional costs etc. The first 500 reports were analysed using both of qualitative and quantitative methods and a brief overview of results is presented. The methodological issues arising in the application of this technique to such a large, widely spread profession, in which episodes of care are not necessarily confined to a single consultation, are discussed. This study demonstrated that the incident monitoring technique can be successfully applied in general practice and that the resulting information can facilitate the identification of common factors contributing to such events and allow the development of preventive interventions.
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ERIC Educational Resources Information Center
Hanson, James H.; Brophy, Patrick D.
2012-01-01
Not all knowledge and skills that educators want to pass to students exists yet in textbooks. Some still resides only in the experiences of practicing engineers (e.g., how engineers create new products, how designers identify errors in calculations). The critical incident technique, CIT, is an established method for cognitive task analysis. It is…
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ERIC Educational Resources Information Center
Kalahar, Kory G.
2011-01-01
Student failure is a prominent issue in many comprehensive secondary schools nationwide. Researchers studying error, reliability, and performance in organizations have developed and employed a method known as critical incident technique (CIT) for investigating failure. Adopting an action research model, this study involved gathering and analyzing…
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A cascaded coding scheme for error control and its performance analysis
NASA Technical Reports Server (NTRS)
Lin, S.
1986-01-01
A coding scheme for error control in data communication systems is investigated. The scheme is obtained by cascading two error correcting codes, called the inner and the outer codes. The error performance of the scheme is analyzed for a binary symmetric channel with bit error rate epsilon < 1/2. It is shown that, if the inner and outer codes are chosen properly, extremely high reliability can be attained even for a high channel bit error rate. Various specific example schemes with inner codes ranging from high rates to very low rates and Reed-Solomon codes are considered, and their probabilities are evaluated. They all provide extremely high reliability even for very high bit error rates, say 0.1 to 0.01. Several example schemes are being considered by NASA for satellite and spacecraft down link error control.
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Ren, Hong; Li, Jian; Yuan, Zheng-An; Hu, Jia-Yu; Yu, Yan; Lu, Yi-Han
2013-09-08
Sporadic hepatitis E has become an important public health concern in China. Accurate forecasting of the incidence of hepatitis E is needed to better plan future medical needs. Few mathematical models can be used because hepatitis E morbidity data has both linear and nonlinear patterns. We developed a combined mathematical model using an autoregressive integrated moving average model (ARIMA) and a back propagation neural network (BPNN) to forecast the incidence of hepatitis E. The morbidity data of hepatitis E in Shanghai from 2000 to 2012 were retrieved from the China Information System for Disease Control and Prevention. The ARIMA-BPNN combined model was trained with 144 months of morbidity data from January 2000 to December 2011, validated with 12 months of data January 2012 to December 2012, and then employed to forecast hepatitis E incidence January 2013 to December 2013 in Shanghai. Residual analysis, Root Mean Square Error (RMSE), normalized Bayesian Information Criterion (BIC), and stationary R square methods were used to compare the goodness-of-fit among ARIMA models. The Bayesian regularization back-propagation algorithm was used to train the network. The mean error rate (MER) was used to assess the validity of the combined model. A total of 7,489 hepatitis E cases was reported in Shanghai from 2000 to 2012. Goodness-of-fit (stationary R2=0.531, BIC= -4.768, Ljung-Box Q statistics=15.59, P=0.482) and parameter estimates were used to determine the best-fitting model as ARIMA (0,1,1)×(0,1,1)12. Predicted morbidity values in 2012 from best-fitting ARIMA model and actual morbidity data from 2000 to 2011 were used to further construct the combined model. The MER of the ARIMA model and the ARIMA-BPNN combined model were 0.250 and 0.176, respectively. The forecasted incidence of hepatitis E in 2013 was 0.095 to 0.372 per 100,000 population. There was a seasonal variation with a peak during January-March and a nadir during August-October. Time series analysis suggested a seasonal pattern of hepatitis E morbidity in Shanghai, China. An ARIMA-BPNN combined model was used to fit the linear and nonlinear patterns of time series data, and accurately forecast hepatitis E infections.
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A Simple Exact Error Rate Analysis for DS-CDMA with Arbitrary Pulse Shape in Flat Nakagami Fading
NASA Astrophysics Data System (ADS)
Rahman, Mohammad Azizur; Sasaki, Shigenobu; Kikuchi, Hisakazu; Harada, Hiroshi; Kato, Shuzo
A simple exact error rate analysis is presented for random binary direct sequence code division multiple access (DS-CDMA) considering a general pulse shape and flat Nakagami fading channel. First of all, a simple model is developed for the multiple access interference (MAI). Based on this, a simple exact expression of the characteristic function (CF) of MAI is developed in a straight forward manner. Finally, an exact expression of error rate is obtained following the CF method of error rate analysis. The exact error rate so obtained can be much easily evaluated as compared to the only reliable approximate error rate expression currently available, which is based on the Improved Gaussian Approximation (IGA).
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Wong, Martin C S; Goggins, William B; Wang, Harry H X; Fung, Franklin D H; Leung, Colette; Wong, Samuel Y S; Ng, Chi Fai; Sung, Joseph J Y
2016-11-01
Prostate cancer (PCa) is a leading cause of mortality and morbidity globally, but its specific geographic patterns and temporal trends are under-researched. To test the hypotheses that PCa incidence is higher and PCa mortality is lower in countries with higher socioeconomic development, and that temporal trends for PCa incidence have increased while mortality has decreased over time. Data on age-standardized incidence and mortality rates in 2012 were retrieved from the GLOBOCAN database. Temporal patterns were assessed for 36 countries using data obtained from Cancer incidence in five continents volumes I-X and the World Health Organization mortality database. Correlations between incidence or mortality rates and socioeconomic indicators (human development index [HDI] and gross domestic product [GDP]) were evaluated. The average annual percent change in PCa incidence and mortality in the most recent 10 yr according to join-point regression. Reported PCa incidence rates varied more than 25-fold worldwide in 2012, with the highest incidence rates observed in Micronesia/Polynesia, the USA, and European countries. Mortality rates paralleled the incidence rates except for Africa, where PCa mortality rates were the highest. Countries with higher HDI (r=0.58) and per capita GDP (r=0.62) reported greater incidence rates. According to the most recent 10-yr temporal data available, most countries experienced increases in incidence, with sharp rises in incidence rates in Asia and Northern and Western Europe. A substantial reduction in mortality rates was reported in most countries, except in some Asian countries and Eastern Europe, where mortality increased. Data in regional registries could be underestimated. PCa incidence has increased while PCa mortality has decreased in most countries. The reported incidence was higher in countries with higher socioeconomic development. The incidence of prostate cancer has shown high variations geographically and over time, with smaller variations in mortality. Copyright © 2016 European Association of Urology. Published by Elsevier B.V. All rights reserved.
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Li, Yan; An, Zhijie; Yin, Dapeng; Liu, Yanmin; Huang, Zhuoying; Xu, Jianfang; Ma, Yujie; Tu, Qiufeng; Li, Qi; Wang, Huaqing
2016-01-01
To understand the disease burden due to Herpes Zoster (HZ) among people aged ≥50 years old in China and provide baseline data for future similar studies, and provide evidence for development of herpes zoster vaccination strategy. Retrospective cohort study was conducted in 4 townships and one community. A questionnaire was used to collect information on incidence and cost of HZ among people aged ≥ 50 years old. The cumulative incidence rate was 22.6/1,000 among people aged ≥ 50 years old. The average annual incidence rate of HZ was 3.43/1,000 among people aged ≥ 50 years old in 2010-2012. Cumulative incidence and average annual incidence rate increased with age: the cumulative incidence of HZ among people aged ≥ 80 years old was 3.34 times of that among 50-years old (52.3/1000 vs 15.7/1,000); average annual incidence rate rises from 2.66/1,000 among 50-years old to 8.55/1,000 among 80-year old. Cumulative incidence and average annual incidence rate for females were higher than that for males (cumulative incidence, 26.5/1000 vs 18.7/1,000; annual incidence rate, 3.95/1000 vs 2.89/1,000). Cumulative incidence and average annual incidence rate in urban were higher than in rural (cumulative incidence, 39.5/1000 vs 17.2/1,000; annual incidence rate, 7.65/1000 vs 2.06/1,000). The hospitalization rate of HZ was 4.53%. And with the increase of age, the rate has an increasing trend. HZ costs 945,709.5 RMB in total, corresponding to 840.6 RMB per patient with a median cost of 385 RMB (interquartile range 171.7-795.6). Factors associated with cost included the first onset year, area, whether hospitalized and whether sequelae left. Incidence rate, complications, hospitalization rate and average cost of HZ increase with age. We recommend that the HZ vaccinations should target people aged ≥50 years old if Zoster vaccine is licensed in China.
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Effect of bar-code technology on the safety of medication administration.
Poon, Eric G; Keohane, Carol A; Yoon, Catherine S; Ditmore, Matthew; Bane, Anne; Levtzion-Korach, Osnat; Moniz, Thomas; Rothschild, Jeffrey M; Kachalia, Allen B; Hayes, Judy; Churchill, William W; Lipsitz, Stuart; Whittemore, Anthony D; Bates, David W; Gandhi, Tejal K
2010-05-06
Serious medication errors are common in hospitals and often occur during order transcription or administration of medication. To help prevent such errors, technology has been developed to verify medications by incorporating bar-code verification technology within an electronic medication-administration system (bar-code eMAR). We conducted a before-and-after, quasi-experimental study in an academic medical center that was implementing the bar-code eMAR. We assessed rates of errors in order transcription and medication administration on units before and after implementation of the bar-code eMAR. Errors that involved early or late administration of medications were classified as timing errors and all others as nontiming errors. Two clinicians reviewed the errors to determine their potential to harm patients and classified those that could be harmful as potential adverse drug events. We observed 14,041 medication administrations and reviewed 3082 order transcriptions. Observers noted 776 nontiming errors in medication administration on units that did not use the bar-code eMAR (an 11.5% error rate) versus 495 such errors on units that did use it (a 6.8% error rate)--a 41.4% relative reduction in errors (P<0.001). The rate of potential adverse drug events (other than those associated with timing errors) fell from 3.1% without the use of the bar-code eMAR to 1.6% with its use, representing a 50.8% relative reduction (P<0.001). The rate of timing errors in medication administration fell by 27.3% (P<0.001), but the rate of potential adverse drug events associated with timing errors did not change significantly. Transcription errors occurred at a rate of 6.1% on units that did not use the bar-code eMAR but were completely eliminated on units that did use it. Use of the bar-code eMAR substantially reduced the rate of errors in order transcription and in medication administration as well as potential adverse drug events, although it did not eliminate such errors. Our data show that the bar-code eMAR is an important intervention to improve medication safety. (ClinicalTrials.gov number, NCT00243373.) 2010 Massachusetts Medical Society
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Development and implementation of a human accuracy program in patient foodservice.
Eden, S H; Wood, S M; Ptak, K M
1987-04-01
For many years, industry has utilized the concept of human error rates to monitor and minimize human errors in the production process. A consistent quality-controlled product increases consumer satisfaction and repeat purchase of product. Administrative dietitians have applied the concepts of using human error rates (the number of errors divided by the number of opportunities for error) at four hospitals, with a total bed capacity of 788, within a tertiary-care medical center. Human error rate was used to monitor and evaluate trayline employee performance and to evaluate layout and tasks of trayline stations, in addition to evaluating employees in patient service areas. Long-term employees initially opposed the error rate system with some hostility and resentment, while newer employees accepted the system. All employees now believe that the constant feedback given by supervisors enhances their self-esteem and productivity. Employee error rates are monitored daily and are used to counsel employees when necessary; they are also utilized during annual performance evaluation. Average daily error rates for a facility staffed by new employees decreased from 7% to an acceptable 3%. In a facility staffed by long-term employees, the error rate increased, reflecting improper error documentation. Patient satisfaction surveys reveal satisfaction, for tray accuracy increased from 88% to 92% in the facility staffed by long-term employees and has remained above the 90% standard in the facility staffed by new employees.
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NASA Technical Reports Server (NTRS)
Natarajan, Suresh; Gardner, C. S.
1987-01-01
Receiver timing synchronization of an optical Pulse-Position Modulation (PPM) communication system can be achieved using a phased-locked loop (PLL), provided the photodetector output is suitably processed. The magnitude of the PLL phase error is a good indicator of the timing error at the receiver decoder. The statistics of the phase error are investigated while varying several key system parameters such as PPM order, signal and background strengths, and PPL bandwidth. A practical optical communication system utilizing a laser diode transmitter and an avalanche photodiode in the receiver is described, and the sampled phase error data are presented. A linear regression analysis is applied to the data to obtain estimates of the relational constants involving the phase error variance and incident signal power.
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Retractions in the scientific literature: is the incidence of research fraud increasing?
Steen, R Grant
2011-04-01
Scientific papers are retracted for many reasons including fraud (data fabrication or falsification) or error (plagiarism, scientific mistake, ethical problems). Growing attention to fraud in the lay press suggests that the incidence of fraud is increasing. The reasons for retracting 742 English language research papers retracted from the PubMed database between 2000 and 2010 were evaluated. Reasons for retraction were initially dichotomised as fraud or error and then analysed to determine specific reasons for retraction. Error was more common than fraud (73.5% of papers were retracted for error (or an undisclosed reason) vs 26.6% retracted for fraud). Eight reasons for retraction were identified; the most common reason was scientific mistake in 234 papers (31.5%), but 134 papers (18.1%) were retracted for ambiguous reasons. Fabrication (including data plagiarism) was more common than text plagiarism. Total papers retracted per year have increased sharply over the decade (r=0.96; p<0.001), as have retractions specifically for fraud (r=0.89; p<0.001). Journals now reach farther back in time to retract, both for fraud (r=0.87; p<0.001) and for scientific mistakes (r=0.95; p<0.001). Journals often fail to alert the naïve reader; 31.8% of retracted papers were not noted as retracted in any way. Levels of misconduct appear to be higher than in the past. This may reflect either a real increase in the incidence of fraud or a greater effort on the part of journals to police the literature. However, research bias is rarely cited as a reason for retraction.
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Medication errors: immunisation.
Bird, Sara
2006-09-01
Case histories are based on actual medical negligence claims or medicolegal referrals, however certain facts have been omitted or changed by the author to ensure the anonymity of the parties involved. This article outlines a medication error involving childhood immunisation and examines the underlying causes of the incident. Advice about how to deal with a patient and their family when things go wrong is provided.
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Spectroscopic ellipsometer based on direct measurement of polarization ellipticity.
Watkins, Lionel R
2011-06-20
A polarizer-sample-Wollaston prism analyzer ellipsometer is described in which the ellipsometric angles ψ and Δ are determined by direct measurement of the elliptically polarized light reflected from the sample. With the Wollaston prism initially set to transmit p- and s-polarized light, the azimuthal angle P of the polarizer is adjusted until the two beams have equal intensity. This condition yields ψ=±P and ensures that the reflected elliptically polarized light has an azimuthal angle of ±45° and maximum ellipticity. Rotating the Wollaston prism through 45° and adjusting the analyzer azimuth until the two beams again have equal intensity yields the ellipticity that allows Δ to be determined via a simple linear relationship. The errors produced by nonideal components are analyzed. We show that the polarizer dominates these errors but that for most practical purposes, the error in ψ is negligible and the error in Δ may be corrected exactly. A native oxide layer on a silicon substrate was measured at a single wavelength and multiple angles of incidence and spectroscopically at a single angle of incidence. The best fit film thicknesses obtained were in excellent agreement with those determined using a traditional null ellipsometer.
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[Prospective study in 2 hospitals].
Jiménez-Buñuales, M T; Martínez-Sáenz, M S; González-Diego, P; Vallejo-García, M; Gallardo-Anciano, J; Cestafe-Martínez, A
2016-06-01
The purpose of this study is to know the incidence rate of medication reconciliation at admission and discharge in patients of La Rioja and to improve the patient safety on medication reconciliation. An observational prospective study, part of the Joint Action PaSQ, Work Package 5, European Union Network for Patient Safety and Quality of Care. The study has taken into account the definitions of the Institute for Safe Medication Practices. Any unintended discrepancy in medication between chronic treatment and the treatment prescribed in the hospital was considered as a reconciliation error. A total of 750 patients were included, 9 (1.2%) of whom showed at least one discrepancy. The patients had a total of 3,156 mediations registered: 2,313 prescriptions (73.4%) showed no differences, while 821 prescriptions (26%) were intended discrepancies and 21 prescriptions (0.6%) unintended discrepancies were considered by the physician as reconciliation errors. A percentage of 1.2 of the patients, which represents 0.6% of the medicines (one in 166 medications registered) had reconciliation errors during their hospital stay. A proceeding has been implemented by means of the physician doing the medication reconciliation and reviewing it with the help of a medication reconciliation form. The medication reconciliation is a priority strategic objective to improve the safety of patients. Copyright © 2016 SECA. Published by Elsevier Espana. All rights reserved.
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Coval: Improving Alignment Quality and Variant Calling Accuracy for Next-Generation Sequencing Data
Kosugi, Shunichi; Natsume, Satoshi; Yoshida, Kentaro; MacLean, Daniel; Cano, Liliana; Kamoun, Sophien; Terauchi, Ryohei
2013-01-01
Accurate identification of DNA polymorphisms using next-generation sequencing technology is challenging because of a high rate of sequencing error and incorrect mapping of reads to reference genomes. Currently available short read aligners and DNA variant callers suffer from these problems. We developed the Coval software to improve the quality of short read alignments. Coval is designed to minimize the incidence of spurious alignment of short reads, by filtering mismatched reads that remained in alignments after local realignment and error correction of mismatched reads. The error correction is executed based on the base quality and allele frequency at the non-reference positions for an individual or pooled sample. We demonstrated the utility of Coval by applying it to simulated genomes and experimentally obtained short-read data of rice, nematode, and mouse. Moreover, we found an unexpectedly large number of incorrectly mapped reads in ‘targeted’ alignments, where the whole genome sequencing reads had been aligned to a local genomic segment, and showed that Coval effectively eliminated such spurious alignments. We conclude that Coval significantly improves the quality of short-read sequence alignments, thereby increasing the calling accuracy of currently available tools for SNP and indel identification. Coval is available at http://sourceforge.net/projects/coval105/. PMID:24116042
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Wang, Yong; Chen, Xiang-Mei; Cai, Guang-Yan; Li, Wen-Ge; Zhang, Ai-Hua; Hao, Li-Rong; Shi, Ming; Wang, Rong; Jiang, Hong-Li; Luo, Hui-Min; Zhang, Dong; Sun, Xue-Feng
2017-08-02
To evaluate the in vivo and in vitro performance of a China-made dialysis machine (SWS-4000). This was a multi-center prospective controlled study consisting of both long-term in vitro evaluations and cross-over in vivo tests in 132 patients. The China-made SWS-4000 dialysis machine was compared with a German-made dialysis machine (Fresenius 4008) with regard to Kt/V values, URR values, and dialysis-related adverse reactions in patients on maintenance hemodialysis, as well as the ultrafiltration rate, the concentration of electrolytes in the proportioned dialysate, the rate of heparin injection, the flow rate of the blood pump, and the rate of malfunction. The Kt/V and URR values at the 1st and 4th weeks of dialysis as well as the incidence of adverse effects did not differ between the two groups in cross-over in vivo tests (P > 0.05). There were no significant differences between the two groups in the error values of the ultrafiltration rate, the rate of heparin injection or the concentrations of electrolytes in the proportioned dialysate at different time points under different parameter settings. At weeks 2 and 24, with the flow rate of the blood pump set at 300 mL/min, the actual error of the SWS-4000 dialysis machine was significantly higher than that of the Fresenius 4008 dialysis machine (P < 0.05), but there was no significant difference at other time points or under other settings (P > 0.05). The malfunction rate was higher in the SWS-4000 group than in the Fresenius 4008 group (P < 0.05). The in vivo performance of the SWS-4000 dialysis machine is roughly comparable to that of the Fresenius 4008 dialysis machine; however, the malfunction rate of the former is higher than that of the latter in in vitro tests. The stability and long-term accuracy of the SWS-4000 dialysis machine remain to be improved.
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Gordon, Morris; Parakh, Dillan
2017-10-01
Errors in healthcare are a major patient safety issue, with incident reporting a key solution. The incident reporting system has been integrated within a new medical curriculum, encouraging medical students to take part in this key safety process. The aim of this study was to describe the system and assess how students perceived the reporting system with regards to its role in enhancing safety. Employing a thematic analysis, this study used interviews with medical students at the end of the first year. Thematic indices were developed according to the information emerging from the data. Through open, axial and then selective stages of coding, an understanding of how the system was perceived was established. Analysis of the interview specified five core themes: (1) Aims of the incident reporting system; (2) internalized cognition of the system; (3) the impact of the reporting system; (4) threshold for reporting; (5) feedback on the systems operation. Selective analysis revealed three overriding findings: lack of error awareness and error wisdom as underpinned by key theoretical constructs, student support of the principle of safety, and perceptions of a blame culture. Students did not interpret reporting as a manner to support institutional learning and safety, rather many perceived it as a tool for a blame culture. The impact reporting had on students was unexpected and may give insight into how other undergraduates and early graduates interpret such a system. Future studies should aim to produce interventions that can support a reporting culture.
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Bodina, A; Demarchi, A; Castaldi, S
2014-01-01
A web-based incident reporting system (IRS) is a tool allowing healthcare workers to voluntary and anonymously report adverse events/near misses. In 2010, this system was introduced in a research and teaching hospital in metropolitan area in the North part of Italy, in order to detect errors and to learn from failures in care delivery. The aim of this paper is to assess whether and how IRS has proved to be a valuable tool to manage clinical risk and improve healthcare quality. Adverse events are reported anonymously by staff members with the use of an online template form available in the hospital intranet. We retrospectively reviewed the recorded data for each incident/near miss reported between January 2011 and December 2012. The number of reported incidents/near misses was 521 in 2011 and 442 in 2012. In the two years the admissions were 36.974 and 36.107 respectively. We noticed that nursing staff made more use of IRS and that reported errors were basically related to prescription and administration of medications. Much international literature reports that adverse events and near misses are 10% of admissions. Our data are far from that number, thus meaning that a failure in reporting adverse events exists. This consideration, together with the high number of near misses in comparison with occurred errors, leads us to speculate that adverse events with serious consequences for patients are marginally reported. Probably the lack of a strong leadership considering IRS as an instrument for improving quality and operators' reluctance to overcome the culture of blame may negatively affect IRS.
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The influence of the structure and culture of medical group practices on prescription drug errors.
Kralewski, John E; Dowd, Bryan E; Heaton, Alan; Kaissi, Amer
2005-08-01
This project was designed to identify the magnitude of prescription drug errors in medical group practices and to explore the influence of the practice structure and culture on those error rates. Seventy-eight practices serving an upper Midwest managed care (Care Plus) plan during 2001 were included in the study. Using Care Plus claims data, prescription drug error rates were calculated at the enrollee level and then were aggregated to the group practice that each enrollee selected to provide and manage their care. Practice structure and culture data were obtained from surveys of the practices. Data were analyzed using multivariate regression. Both the culture and the structure of these group practices appear to influence prescription drug error rates. Seeing more patients per clinic hour, more prescriptions per patient, and being cared for in a rural clinic were all strongly associated with more errors. Conversely, having a case manager program is strongly related to fewer errors in all of our analyses. The culture of the practices clearly influences error rates, but the findings are mixed. Practices with cohesive cultures have lower error rates but, contrary to our hypothesis, cultures that value physician autonomy and individuality also have lower error rates than those with a more organizational orientation. Our study supports the contention that there are a substantial number of prescription drug errors in the ambulatory care sector. Even by the strictest definition, there were about 13 errors per 100 prescriptions for Care Plus patients in these group practices during 2001. Our study demonstrates that the structure of medical group practices influences prescription drug error rates. In some cases, this appears to be a direct relationship, such as the effects of having a case manager program on fewer drug errors, but in other cases the effect appears to be indirect through the improvement of drug prescribing practices. An important aspect of this study is that it provides insights into the relationships of the structure and culture of medical group practices and prescription drug errors and provides direction for future research. Research focused on the factors influencing the high error rates in rural areas and how the interaction of practice structural and cultural attributes influence error rates would add important insights into our findings. For medical practice directors, our data show that they should focus on patient care coordination to reduce errors.
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Emergency department discharge prescription errors in an academic medical center
Belanger, April; Devine, Lauren T.; Lane, Aaron; Condren, Michelle E.
2017-01-01
This study described discharge prescription medication errors written for emergency department patients. This study used content analysis in a cross-sectional design to systematically categorize prescription errors found in a report of 1000 discharge prescriptions submitted in the electronic medical record in February 2015. Two pharmacy team members reviewed the discharge prescription list for errors. Open-ended data were coded by an additional rater for agreement on coding categories. Coding was based upon majority rule. Descriptive statistics were used to address the study objective. Categories evaluated were patient age, provider type, drug class, and type and time of error. The discharge prescription error rate out of 1000 prescriptions was 13.4%, with “incomplete or inadequate prescription” being the most commonly detected error (58.2%). The adult and pediatric error rates were 11.7% and 22.7%, respectively. The antibiotics reviewed had the highest number of errors. The highest within-class error rates were with antianginal medications, antiparasitic medications, antacids, appetite stimulants, and probiotics. Emergency medicine residents wrote the highest percentage of prescriptions (46.7%) and had an error rate of 9.2%. Residents of other specialties wrote 340 prescriptions and had an error rate of 20.9%. Errors occurred most often between 10:00 am and 6:00 pm. PMID:28405061
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Youn, Jin-Sung; Lee, Myung-Jae; Park, Kang-Yeob; Rücker, Holger; Choi, Woo-Young
2012-12-17
An optoelectronic integrated circuit (OEIC) receiver is realized with standard 0.25-μm SiGe BiCMOS technology for 850-nm optical interconnect applications. The OEIC receiver consists of a Si avalanche photodetector, a transimpedance amplifier with a DC-balanced buffer, a tunable equalizer, and a limiting amplifier. The fabricated OEIC receiver successfully detects 12.5-Gb/s 2(31)-1 pseudorandom bit sequence optical data with the bit-error rate less than 10(-12) at incident optical power of -7 dBm. The OEIC core has 1000 μm x 280 μm chip area, and consumes 59 mW from 2.5-V supply. To the best of our knowledge, this OEIC receiver achieves the highest data rate with the smallest sensitivity as well as the best power efficiency among integrated OEIC receivers fabricated with standard Si technology.
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Wu, Jie; Yang, Shigui; Xu, Kaijin; Ding, Cheng; Zhou, Yuqing; Fu, Xiaofang; Li, Yiping; Deng, Min; Wang, Chencheng; Liu, Xiaoxiao; Li, Lanjuan
2018-05-01
We examined temporal trends in liver cancer incidence rates overall and by histological type from 1983 through 2007. We predict trends in liver cancer incidence rates through 2030 for selected Eastern and Southeastern Asian countries. Data on yearly liver cancer incident cases by age group and sex were drawn from 6 major selected Eastern and Southeastern Asian countries or regions with cancer registries available in the CI5plus database, including China, Japan, Hong Kong Special Administrative Region (SAR), the Philippines, Singapore, and Thailand. We also analyzed data for the United States and Australia for comparative purposes. Age-standardized incidence rates were calculated and plotted from 1983 through 2007. Numbers of new cases and incidence rates were predicted through 2030 by fitting and extrapolating age-period-cohort models. The incidence rates of liver cancer have been decreasing, and decreases will continue in all selected Eastern and Southeastern Asian countries, except for Thailand, whose liver cancer incidence rate will increase due to the increasing incidence rate of intrahepatic cholangiocarcinomas. Even though the incidence rates of liver cancer are predicted to decrease in most Eastern and Southeastern Asian countries, the burden, in terms of new cases, will continue to increase because of population growth and aging. Based on an analysis of data from cancer registries from Asian countries, incidence rates of liver cancer are expected to decrease through 2030 in most Eastern and Southeastern Asian countries. However, in Thailand, the incidence rate of intrahepatic cholangiocarcinomas is predicted to increase, so health education programs are necessary. Copyright © 2018 AGA Institute. Published by Elsevier Inc. All rights reserved.
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The use of DFDR information in the analysis of a turbulence incident over Greenland
NASA Technical Reports Server (NTRS)
Lester, Peter F.; Sen, Orhan; Bach, R. E., Jr.
1989-01-01
Digital flight data recorder (DFDR) tapes from commercial aircraft can provide useful information about the mesoscale environment of severe turbulence incidents. Air motion computations from these data and their errors are briefly described. An example of mesoscale meteorological information available from DFDR tapes is presented for a case of turbulence in mountain waves over the Greenland icecap.
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Performance of univariate forecasting on seasonal diseases: the case of tuberculosis.
Permanasari, Adhistya Erna; Rambli, Dayang Rohaya Awang; Dominic, P Dhanapal Durai
2011-01-01
The annual disease incident worldwide is desirable to be predicted for taking appropriate policy to prevent disease outbreak. This chapter considers the performance of different forecasting method to predict the future number of disease incidence, especially for seasonal disease. Six forecasting methods, namely linear regression, moving average, decomposition, Holt-Winter's, ARIMA, and artificial neural network (ANN), were used for disease forecasting on tuberculosis monthly data. The model derived met the requirement of time series with seasonality pattern and downward trend. The forecasting performance was compared using similar error measure in the base of the last 5 years forecast result. The findings indicate that ARIMA model was the most appropriate model since it obtained the less relatively error than the other model.
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Schroeder, Scott R; Salomon, Meghan M; Galanter, William L; Schiff, Gordon D; Vaida, Allen J; Gaunt, Michael J; Bryson, Michelle L; Rash, Christine; Falck, Suzanne; Lambert, Bruce L
2017-01-01
Background Drug name confusion is a common type of medication error and a persistent threat to patient safety. In the USA, roughly one per thousand prescriptions results in the wrong drug being filled, and most of these errors involve drug names that look or sound alike. Prior to approval, drug names undergo a variety of tests to assess their potential for confusability, but none of these preapproval tests has been shown to predict real-world error rates. Objectives We conducted a study to assess the association between error rates in laboratory-based tests of drug name memory and perception and real-world drug name confusion error rates. Methods Eighty participants, comprising doctors, nurses, pharmacists, technicians and lay people, completed a battery of laboratory tests assessing visual perception, auditory perception and short-term memory of look-alike and sound-alike drug name pairs (eg, hydroxyzine/hydralazine). Results Laboratory test error rates (and other metrics) significantly predicted real-world error rates obtained from a large, outpatient pharmacy chain, with the best-fitting model accounting for 37% of the variance in real-world error rates. Cross-validation analyses confirmed these results, showing that the laboratory tests also predicted errors from a second pharmacy chain, with 45% of the variance being explained by the laboratory test data. Conclusions Across two distinct pharmacy chains, there is a strong and significant association between drug name confusion error rates observed in the real world and those observed in laboratory-based tests of memory and perception. Regulators and drug companies seeking a validated preapproval method for identifying confusing drug names ought to consider using these simple tests. By using a standard battery of memory and perception tests, it should be possible to reduce the number of confusing look-alike and sound-alike drug name pairs that reach the market, which will help protect patients from potentially harmful medication errors. PMID:27193033
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Economic Disparities and Syphilis Incidence in Massachusetts, 2001-2013.
Smock, Laura; Caten, Evan; Hsu, Katherine; DeMaria, Alfred
We used area-level indicators of poverty to describe economic disparities in the incidence rate of infectious syphilis in Massachusetts to (1) determine whether methods developed in earlier AIDS analyses in Massachusetts could be applied to syphilis and (2) characterize syphilis trends during a time of increased rates of syphilis incidence. Using census tract data and population counts from the US Census Bureau and Massachusetts data on syphilis, we analyzed the incidence rate of syphilis infection from 2001 to 2013 by the poverty level of the census tract in which people with syphilis resided, stratified by age, sex, and race/ethnicity. The syphilis incidence rate increased in all census tract groups in Massachusetts from 2001 to 2013, and disparities in incidence rates by area poverty level persisted over time. The overall incidence rate of syphilis increased 6.9-fold from 2001 to 2013 in all census tract poverty-level groupings (from 1.5 to 10.3 per 100 000 population), but the rise in rate was especially high in the poorest census tracts (from 5.6 to 31.0 per 100 000 population) and among men (from 2.2 to 19.4 per 100 000 population). The highest syphilis incidence rate was among non-Hispanic black people. The largest changes in incidence rate occurred after 2010. One region had a disproportionate increase in incidence rates and a disproportionate impact on the statewide trend. Census tract poverty analyses can inform the targeting of interventions that make progress toward reducing disparities in rates of syphilis incidence possible.
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Methodological choices affect cancer incidence rates: a cohort study.
Brooke, Hannah L; Talbäck, Mats; Feychting, Maria; Ljung, Rickard
2017-01-19
Incidence rates are fundamental to epidemiology, but their magnitude and interpretation depend on methodological choices. We aimed to examine the extent to which the definition of the study population affects cancer incidence rates. All primary cancer diagnoses in Sweden between 1958 and 2010 were identified from the national Cancer Register. Age-standardized and age-specific incidence rates of 29 cancer subtypes between 2000 and 2010 were calculated using four definitions of the study population: persons resident in Sweden 1) based on general population statistics; 2) with no previous subtype-specific cancer diagnosis; 3) with no previous cancer diagnosis except non-melanoma skin cancer; and 4) with no previous cancer diagnosis of any type. We calculated absolute and relative differences between methods. Age-standardized incidence rates calculated using general population statistics ranged from 6% lower (prostate cancer, incidence rate difference: -13.5/100,000 person-years) to 8% higher (breast cancer in women, incidence rate difference: 10.5/100,000 person-years) than incidence rates based on individuals with no previous subtype-specific cancer diagnosis. Age-standardized incidence rates in persons with no previous cancer of any type were up to 10% lower (bladder cancer in women) than rates in those with no previous subtype-specific cancer diagnosis; however, absolute differences were <5/100,000 person-years for all cancer subtypes. For some cancer subtypes incidence rates vary depending on the definition of the study population. For these subtypes, standardized incidence ratios calculated using general population statistics could be misleading. Moreover, etiological arguments should be used to inform methodological choices during study design.
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Patterson, M E; Marken, P; Zhong, Y; Simon, S D; Ketcherside, W
2014-01-01
Regulatory standards for 30-day readmissions incentivize hospitals to improve quality of care. Implementing comprehensive electronic health record systems potentially decreases readmission rates by improving medication reconciliation at discharge, demonstrating the additional benefits of inpatient EHRs beyond improved safety and decreased errors. To compare 30-day all-cause readmission incidence rates within Medicare fee-for-service with heart failure discharged from hospitals with full implementation levels of comprehensive EHR systems versus those without. This retrospective cohort study uses data from the American Hospital Association Health IT survey and Medicare Part A claims to measure associations between hospital EHR implementation levels and beneficiary readmissions. Multivariable Cox regressions estimate the hazard ratio of 30-day all-cause readmissions within beneficiaries discharged from hospitals implementing comprehensive EHRs versus those without, controlling for beneficiary health status and hospital organizational factors. Propensity scores are used to account for selection bias. The proportion of heart failure patients with 30-day all-cause readmissions was 30%, 29%, and 32% for those discharged from hospitals with full, some, and no comprehensive EHR systems. Heart failure patients discharged from hospitals with fully implemented comprehensive EHRs compared to those with no comprehensive EHR systems had equivalent 30-day readmission incidence rates (HR = 0.97, 95% CI 0.73 - 1.3). Implementation of comprehensive electronic health record systems does not necessarily improve a hospital's ability to decrease 30-day readmission rates. Improving the efficiency of post-acute care will require more coordination of information systems between inpatient and ambulatory providers.
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[Errors in medicine. Causes, impact and improvement measures to improve patient safety].
Waeschle, R M; Bauer, M; Schmidt, C E
2015-09-01
The guarantee of quality of care and patient safety is of major importance in hospitals even though increased economic pressure and work intensification are ubiquitously present. Nevertheless, adverse events still occur in 3-4 % of hospital stays and of these 25-50 % are estimated to be avoidable. The identification of possible causes of error and the development of measures for the prevention of medical errors are essential for patient safety. The implementation and continuous development of a constructive culture of error tolerance are fundamental.The origins of errors can be differentiated into systemic latent and individual active causes and components of both categories are typically involved when an error occurs. Systemic causes are, for example out of date structural environments, lack of clinical standards and low personnel density. These causes arise far away from the patient, e.g. management decisions and can remain unrecognized for a long time. Individual causes involve, e.g. confirmation bias, error of fixation and prospective memory failure. These causes have a direct impact on patient care and can result in immediate injury to patients. Stress, unclear information, complex systems and a lack of professional experience can promote individual causes. Awareness of possible causes of error is a fundamental precondition to establishing appropriate countermeasures.Error prevention should include actions directly affecting the causes of error and includes checklists and standard operating procedures (SOP) to avoid fixation and prospective memory failure and team resource management to improve communication and the generation of collective mental models. Critical incident reporting systems (CIRS) provide the opportunity to learn from previous incidents without resulting in injury to patients. Information technology (IT) support systems, such as the computerized physician order entry system, assist in the prevention of medication errors by providing information on dosage, pharmacological interactions, side effects and contraindications of medications.The major challenges for quality and risk management, for the heads of departments and the executive board is the implementation and support of the described actions and a sustained guidance of the staff involved in the modification management process. The global trigger tool is suitable for improving transparency and objectifying the frequency of medical errors.
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Estimated Probability of a Cervical Spine Injury During an ISS Mission
NASA Technical Reports Server (NTRS)
Brooker, John E.; Weaver, Aaron S.; Myers, Jerry G.
2013-01-01
Introduction: The Integrated Medical Model (IMM) utilizes historical data, cohort data, and external simulations as input factors to provide estimates of crew health, resource utilization and mission outcomes. The Cervical Spine Injury Module (CSIM) is an external simulation designed to provide the IMM with parameter estimates for 1) a probability distribution function (PDF) of the incidence rate, 2) the mean incidence rate, and 3) the standard deviation associated with the mean resulting from injury/trauma of the neck. Methods: An injury mechanism based on an idealized low-velocity blunt impact to the superior posterior thorax of an ISS crewmember was used as the simulated mission environment. As a result of this impact, the cervical spine is inertially loaded from the mass of the head producing an extension-flexion motion deforming the soft tissues of the neck. A multibody biomechanical model was developed to estimate the kinematic and dynamic response of the head-neck system from a prescribed acceleration profile. Logistic regression was performed on a dataset containing AIS1 soft tissue neck injuries from rear-end automobile collisions with published Neck Injury Criterion values producing an injury transfer function (ITF). An injury event scenario (IES) was constructed such that crew 1 is moving through a primary or standard translation path transferring large volume equipment impacting stationary crew 2. The incidence rate for this IES was estimated from in-flight data and used to calculate the probability of occurrence. The uncertainty in the model input factors were estimated from representative datasets and expressed in terms of probability distributions. A Monte Carlo Method utilizing simple random sampling was employed to propagate both aleatory and epistemic uncertain factors. Scatterplots and partial correlation coefficients (PCC) were generated to determine input factor sensitivity. CSIM was developed in the SimMechanics/Simulink environment with a Monte Carlo wrapper (MATLAB) used to integrate the components of the module. Results: The probability of generating an AIS1 soft tissue neck injury from the extension/flexion motion induced by a low-velocity blunt impact to the superior posterior thorax was fitted with a lognormal PDF with mean 0.26409, standard deviation 0.11353, standard error of mean 0.00114, and 95% confidence interval [0.26186, 0.26631]. Combining the probability of an AIS1 injury with the probability of IES occurrence was fitted with a Johnson SI PDF with mean 0.02772, standard deviation 0.02012, standard error of mean 0.00020, and 95% confidence interval [0.02733, 0.02812]. The input factor sensitivity analysis in descending order was IES incidence rate, ITF regression coefficient 1, impactor initial velocity, ITF regression coefficient 2, and all others (equipment mass, crew 1 body mass, crew 2 body mass) insignificant. Verification and Validation (V&V): The IMM V&V, based upon NASA STD 7009, was implemented which included an assessment of the data sets used to build CSIM. The documentation maintained includes source code comments and a technical report. The software code and documentation is under Subversion configuration management. Kinematic validation was performed by comparing the biomechanical model output to established corridors.
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Nesher, Gideon; Ben-Chetrit, Eli; Mazal, Bracha; Breuer, Gabriel S
2016-06-01
The incidence of primary systemic vasculitides varies among different geographic regions and ethnic origins. The aim of this study was to examine the incidence rates of vasculitides in the Jerusalem Jewish population, and to examine possible trends in incidence rates over a 20-year period. The clinical databases of inpatients at the 2 medical centers in Jerusalem were searched for patients with vasculitis diagnosed between 1990-2009. Individual records were then reviewed by one of the authors. The significance of trends in incidence rates throughout the study period was evaluated by Pearson correlation coefficient. The average annual incidence rate of polyarteritis nodosa was 3.6/million adults (95% CI 1.6-4.7). Incidence rates did not change significantly during this period (r = 0.39, p = 0.088). The incidence of granulomatosis with polyangiitis (GPA) was 4.1 (2.2-5.9) for the whole period, during which it increased significantly (r = 0.53, p < 0.05). The incidence of microscopic polyangiitis (MPA) was lower: 2.3 (1.2-3.5)/million. It also increased significantly (r = 0.55, p < 0.05). The incidence of eosinophilic granulomatosis with polyangiitis was 1.2 (0.4-1.9), which remained stable throughout the study period. The incidence of Takayasu arteritis was 2.1/million (95% CI 1.2-2.9), and it also remained stable. Giant cell arteritis (GCA) incidence was 8.1 (5.7-10.6)/100,000 population aged 50 years or older. In sharp contrast with other vasculitides, its incidence decreased significantly throughout the study period (r = -0.61, p < 0.01). The incidence rates of vasculitides in the Jewish population of Jerusalem are in the lower range of global incidence rates. While GPA and MPA incidence are increasing, GCA incidence is decreasing.
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Kukush, Alexander; Shklyar, Sergiy; Masiuk, Sergii; Likhtarov, Illya; Kovgan, Lina; Carroll, Raymond J; Bouville, Andre
2011-02-16
With a binary response Y, the dose-response model under consideration is logistic in flavor with pr(Y=1 | D) = R (1+R)(-1), R = λ(0) + EAR D, where λ(0) is the baseline incidence rate and EAR is the excess absolute risk per gray. The calculated thyroid dose of a person i is expressed as Dimes=fiQi(mes)/Mi(mes). Here, Qi(mes) is the measured content of radioiodine in the thyroid gland of person i at time t(mes), Mi(mes) is the estimate of the thyroid mass, and f(i) is the normalizing multiplier. The Q(i) and M(i) are measured with multiplicative errors Vi(Q) and ViM, so that Qi(mes)=Qi(tr)Vi(Q) (this is classical measurement error model) and Mi(tr)=Mi(mes)Vi(M) (this is Berkson measurement error model). Here, Qi(tr) is the true content of radioactivity in the thyroid gland, and Mi(tr) is the true value of the thyroid mass. The error in f(i) is much smaller than the errors in ( Qi(mes), Mi(mes)) and ignored in the analysis. By means of Parametric Full Maximum Likelihood and Regression Calibration (under the assumption that the data set of true doses has lognormal distribution), Nonparametric Full Maximum Likelihood, Nonparametric Regression Calibration, and by properly tuned SIMEX method we study the influence of measurement errors in thyroid dose on the estimates of λ(0) and EAR. The simulation study is presented based on a real sample from the epidemiological studies. The doses were reconstructed in the framework of the Ukrainian-American project on the investigation of Post-Chernobyl thyroid cancers in Ukraine, and the underlying subpolulation was artificially enlarged in order to increase the statistical power. The true risk parameters were given by the values to earlier epidemiological studies, and then the binary response was simulated according to the dose-response model.
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Dispensing error rate after implementation of an automated pharmacy carousel system.
Oswald, Scott; Caldwell, Richard
2007-07-01
A study was conducted to determine filling and dispensing error rates before and after the implementation of an automated pharmacy carousel system (APCS). The study was conducted in a 613-bed acute and tertiary care university hospital. Before the implementation of the APCS, filling and dispensing rates were recorded during October through November 2004 and January 2005. Postimplementation data were collected during May through June 2006. Errors were recorded in three areas of pharmacy operations: first-dose or missing medication fill, automated dispensing cabinet fill, and interdepartmental request fill. A filling error was defined as an error caught by a pharmacist during the verification step. A dispensing error was defined as an error caught by a pharmacist observer after verification by the pharmacist. Before implementation of the APCS, 422 first-dose or missing medication orders were observed between October 2004 and January 2005. Independent data collected in December 2005, approximately six weeks after the introduction of the APCS, found that filling and error rates had increased. The filling rate for automated dispensing cabinets was associated with the largest decrease in errors. Filling and dispensing error rates had decreased by December 2005. In terms of interdepartmental request fill, no dispensing errors were noted in 123 clinic orders dispensed before the implementation of the APCS. One dispensing error out of 85 clinic orders was identified after implementation of the APCS. The implementation of an APCS at a university hospital decreased medication filling errors related to automated cabinets only and did not affect other filling and dispensing errors.
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Evrendilek, Fatih
2007-12-12
This study aims at quantifying spatio-temporal dynamics of monthly mean dailyincident photosynthetically active radiation (PAR) over a vast and complex terrain such asTurkey. The spatial interpolation method of universal kriging, and the combination ofmultiple linear regression (MLR) models and map algebra techniques were implemented togenerate surface maps of PAR with a grid resolution of 500 x 500 m as a function of fivegeographical and 14 climatic variables. Performance of the geostatistical and MLR modelswas compared using mean prediction error (MPE), root-mean-square prediction error(RMSPE), average standard prediction error (ASE), mean standardized prediction error(MSPE), root-mean-square standardized prediction error (RMSSPE), and adjustedcoefficient of determination (R² adj. ). The best-fit MLR- and universal kriging-generatedmodels of monthly mean daily PAR were validated against an independent 37-year observeddataset of 35 climate stations derived from 160 stations across Turkey by the Jackknifingmethod. The spatial variability patterns of monthly mean daily incident PAR were moreaccurately reflected in the surface maps created by the MLR-based models than in thosecreated by the universal kriging method, in particular, for spring (May) and autumn(November). The MLR-based spatial interpolation algorithms of PAR described in thisstudy indicated the significance of the multifactor approach to understanding and mappingspatio-temporal dynamics of PAR for a complex terrain over meso-scales.
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Using warnings to reduce categorical false memories in younger and older adults.
Carmichael, Anna M; Gutchess, Angela H
2016-07-01
Warnings about memory errors can reduce their incidence, although past work has largely focused on associative memory errors. The current study sought to explore whether warnings could be tailored to specifically reduce false recall of categorical information in both younger and older populations. Before encoding word pairs designed to induce categorical false memories, half of the younger and older participants were warned to avoid committing these types of memory errors. Older adults who received a warning committed fewer categorical memory errors, as well as other types of semantic memory errors, than those who did not receive a warning. In contrast, young adults' memory errors did not differ for the warning versus no-warning groups. Our findings provide evidence for the effectiveness of warnings at reducing categorical memory errors in older adults, perhaps by supporting source monitoring, reduction in reliance on gist traces, or through effective metacognitive strategies.
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Addressing Medical Errors in Hand Surgery
Johnson, Shepard P.; Adkinson, Joshua M.; Chung, Kevin C.
2014-01-01
Influential think-tank such as the Institute of Medicine has raised awareness about the implications of medical errors. In response, organizations, medical societies, and institutions have initiated programs to decrease the incidence and effects of these errors. Surgeons deal with the direct implications of adverse events involving patients. In addition to managing the physical consequences, they are confronted with ethical and social issues when caring for a harmed patient. Although there is considerable effort to implement system-wide changes, there is little guidance for hand surgeons on how to address medical errors. Admitting an error is difficult, but a transparent environment where patients are notified of errors and offered consolation and compensation is essential to maintain trust. Further, equipping hand surgeons with a guide for addressing medical errors will promote compassionate patient interaction, help identify system failures, provide learning points for safety improvement, and demonstrate a commitment to ethically responsible medical care. PMID:25154576
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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.
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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.
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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.
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Increased incidence of gonorrhoea and chlamydia in Greenland 1990-2012.
Johansen, Mila Broby; Koch, Anders; Wohlfahrt, Jan; Kamper-Jørgensen, Mads; Hoffmann, Steen; Soborg, Bolette
2017-01-01
Since the 1970s, Greenland has presented the highest reported incidence rates of the sexually transmitted infections (STIs) gonorrhoea and chlamydia in the Arctic regions. This study aims to describe sex- and age-specific incidence rates of gonorrhoea and chlamydia from 1990 to 2012 in Greenland, and to evaluate if changes in case definitions, diagnostic procedures and implementation of STI interventions during the period coincide with rate changes. Gonorrhoea and chlamydia cases were identified from the national STI surveillance. For 1990-2008, STI cases were identified from weekly notified aggregated data. For 2009-2012, cases were identified in person-identifiable national registers. We used log-linear Poisson regression to calculate incidence rates (IRs) and incidence rate ratios (IRRs) with 95% confidence intervals (95% CI). Analyses were stratified according to sex, age and calendar period. Gonorrhoea and chlamydia incidence rates have increased since 1995 to reach 2,555 per 100,000 person-years (PY) for gonorrhoea and 6,403 per 100,000 PY for chlamydia in 2012. From 2006 to 2012, the incidence rates among young adults aged 15-19 years were 8,187 and 22,515 per 100,000 PY for gonorrhoea and chlamydia, respectively. Changes in surveillance reporting did not seem to influence the incidence rates for either disease, whereas a change in diagnostic test coincided with an increased incidence of chlamydia. Overall, the incidence of chlamydia in Greenland increased during the study period, whereas the incidence of gonorrhoea decreased until 1995 but increased thereafter. Young adults aged 15-24 years were at highest risk of infection. The increase in incidence rates was independent of changes in case definitions, whereas an observed increase in chlamydia incidence in 2005 coincided with a change in diagnostic test. None of the STI interventions launched after 1995 seemed to coincide with decreasing national incidence rates.
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Dufour, S; Dohoo, I R; Barkema, H W; Descôteaux, L; Devries, T J; Reyher, K K; Roy, J-P; Scholl, D T
2012-06-01
Objectives of this study were to identify the manageable risk factors associated with the lactational incidence, elimination, and prevalence of coagulase-negative staphylococci (CNS) intramammary infections (IMI) while taking into account the difficulties inherent to their diagnosis. A second objective was to evaluate the effect of CNS IMI misclassification in mastitis research. A cohort of 90 Canadian dairy herds was followed throughout 2007 to 2008. In each herd, series of quarter milk samples were collected from a subsample of cows and bacteriological culture was performed to identify prevalent, incident, and eliminated CNS IMI. Practices used on farms were captured using direct observations and a validated questionnaire. The relationships between herd CNS IMI prevalence and herd incidence and elimination rates were explored using linear regression. Manageable risk factors associated with the prevalence, incidence, or elimination of CNS IMI were identified via Bayesian analyses using a latent class model approach, allowing adjustment of the estimates for the imperfect sensitivity and specificity of bacteriological culture. After adjustment for the diagnostic test limitations, a mean CNS IMI quarter prevalence of 42.7% [95% confidence interval (CI): 34.7, 50.1] and incidence and elimination rates of 0.29 new IMI/quarter-month (95% CI: 0.21, 0.37) and 0.79 eliminated IMI/quarter-month (95% CI: 0.66, 0.91), respectively, were observed. Considerable biases of the estimates were observed when CNS IMI misclassification was ignored. These biases were important for measures of association with risk factors, were almost always toward the null value, and led to both type I and type II errors. Coagulase-negative staphylococci IMI incidence appeared to be a stronger determinant of herd IMI prevalence than IMI elimination rate. The majority of herds followed were already using blanket dry cow treatment and postmilking teat disinfection. A holistic approach considering associations with all 3 outcomes was used to interpret associations between manageable risk factors and CNS IMI. Sand and wood-based product bedding showed desirable associations with CNS IMI compared with straw bedding. Quarters of cows that had access to pasture during the sampling period had lower odds of acquiring a new CNS IMI and of having a prevalent CNS IMI. Many practices showed an association with only one of the CNS outcomes and should, therefore, be considered with caution. Copyright © 2012 American Dairy Science Association. Published by Elsevier Inc. All rights reserved.
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Medical error and related factors during internship and residency.
Ahmadipour, Habibeh; Nahid, Mortazavi
2015-01-01
It is difficult to determine the real incidence of medical errors due to the lack of a precise definition of errors, as well as the failure to report them under certain circumstances. We carried out a cross- sectional study in Kerman University of Medical Sciences, Iran in 2013. The participants were selected through the census method. The data were collected using a self-administered questionnaire, which consisted of questions on the participants' demographic data and questions on the medical errors committed. The data were analysed by SPSS 19. It was found that 270 participants had committed medical errors. There was no significant difference in the frequency of errors committed by interns and residents. In the case of residents, the most common error was misdiagnosis and in that of interns, errors related to history-taking and physical examination. Considering that medical errors are common in the clinical setting, the education system should train interns and residents to prevent the occurrence of errors. In addition, the system should develop a positive attitude among them so that they can deal better with medical errors.
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Blanck, Oliver; Masi, Laura; Chan, Mark K H; Adamczyk, Sebastian; Albrecht, Christian; Damme, Marie-Christin; Loutfi-Krauss, Britta; Alraun, Manfred; Fehr, Roman; Ramm, Ulla; Siebert, Frank-Andre; Stelljes, Tenzin Sonam; Poppinga, Daniela; Poppe, Björn
2016-06-01
High precision radiosurgery demands comprehensive delivery-quality-assurance techniques. The use of a liquid-filled ion-chamber-array for robotic-radiosurgery delivery-quality-assurance was investigated and validated using several test scenarios and routine patient plans. Preliminary evaluation consisted of beam profile validation and analysis of source-detector-distance and beam-incidence-angle response dependence. The delivery-quality-assurance analysis is performed in four steps: (1) Array-to-plan registration, (2) Evaluation with standard Gamma-Index criteria (local-dose-difference⩽2%, distance-to-agreement⩽2mm, pass-rate⩾90%), (3) Dose profile alignment and dose distribution shift until maximum pass-rate is found, and (4) Final evaluation with 1mm distance-to-agreement criterion. Test scenarios consisted of intended phantom misalignments, dose miscalibrations, and undelivered Monitor Units. Preliminary method validation was performed on 55 clinical plans in five institutions. The 1000SRS profile measurements showed sufficient agreement compared with a microDiamond detector for all collimator sizes. The relative response changes can be up to 2.2% per 10cm source-detector-distance change, but remains within 1% for the clinically relevant source-detector-distance range. Planned and measured dose under different beam-incidence-angles showed deviations below 1% for angles between 0° and 80°. Small-intended errors were detected by 1mm distance-to-agreement criterion while 2mm criteria failed to reveal some of these deviations. All analyzed delivery-quality-assurance clinical patient plans were within our tight tolerance criteria. We demonstrated that a high-resolution liquid-filled ion-chamber-array can be suitable for robotic radiosurgery delivery-quality-assurance and that small errors can be detected with tight distance-to-agreement criterion. Further improvement may come from beam specific correction for incidence angle and source-detector-distance response. Copyright © 2016 Associazione Italiana di Fisica Medica. Published by Elsevier Ltd. All rights reserved.
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Developing a dengue forecast model using machine learning: A case study in China
Zhang, Qin; Wang, Li; Xiao, Jianpeng; Zhang, Qingying; Luo, Ganfeng; Li, Zhihao; He, Jianfeng; Zhang, Yonghui; Ma, Wenjun
2017-01-01
Background In China, dengue remains an important public health issue with expanded areas and increased incidence recently. Accurate and timely forecasts of dengue incidence in China are still lacking. We aimed to use the state-of-the-art machine learning algorithms to develop an accurate predictive model of dengue. Methodology/Principal findings Weekly dengue cases, Baidu search queries and climate factors (mean temperature, relative humidity and rainfall) during 2011–2014 in Guangdong were gathered. A dengue search index was constructed for developing the predictive models in combination with climate factors. The observed year and week were also included in the models to control for the long-term trend and seasonality. Several machine learning algorithms, including the support vector regression (SVR) algorithm, step-down linear regression model, gradient boosted regression tree algorithm (GBM), negative binomial regression model (NBM), least absolute shrinkage and selection operator (LASSO) linear regression model and generalized additive model (GAM), were used as candidate models to predict dengue incidence. Performance and goodness of fit of the models were assessed using the root-mean-square error (RMSE) and R-squared measures. The residuals of the models were examined using the autocorrelation and partial autocorrelation function analyses to check the validity of the models. The models were further validated using dengue surveillance data from five other provinces. The epidemics during the last 12 weeks and the peak of the 2014 large outbreak were accurately forecasted by the SVR model selected by a cross-validation technique. Moreover, the SVR model had the consistently smallest prediction error rates for tracking the dynamics of dengue and forecasting the outbreaks in other areas in China. Conclusion and significance The proposed SVR model achieved a superior performance in comparison with other forecasting techniques assessed in this study. The findings can help the government and community respond early to dengue epidemics. PMID:29036169
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Differential detection in quadrature-quadrature phase shift keying (Q2PSK) systems
NASA Astrophysics Data System (ADS)
El-Ghandour, Osama M.; Saha, Debabrata
1991-05-01
A generalized quadrature-quadrature phase shift keying (Q2PSK) signaling format is considered for differential encoding and differential detection. Performance in the presence of additive white Gaussian noise (AWGN) is analyzed. Symbol error rate is found to be approximately twice the symbol error rate in a quaternary DPSK system operating at the same Eb/N0. However, the bandwidth efficiency of differential Q2PSK is substantially higher than that of quaternary DPSK. When the error is due to AWGN, the ratio of double error rate to single error rate can be very high, and the ratio may approach zero at high SNR. To improve error rate, differential detection through maximum-likelihood decoding based on multiple or N symbol observations is considered. If N and SNR are large this decoding gives a 3-dB advantage in error rate over conventional N = 2 differential detection, fully recovering the energy loss (as compared to coherent detection) if the observation is extended to a large number of symbol durations.
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Error Correction using Quantum Quasi-Cyclic Low-Density Parity-Check(LDPC) Codes
NASA Astrophysics Data System (ADS)
Jing, Lin; Brun, Todd; Quantum Research Team
Quasi-cyclic LDPC codes can approach the Shannon capacity and have efficient decoders. Manabu Hagiwara et al., 2007 presented a method to calculate parity check matrices with high girth. Two distinct, orthogonal matrices Hc and Hd are used. Using submatrices obtained from Hc and Hd by deleting rows, we can alter the code rate. The submatrix of Hc is used to correct Pauli X errors, and the submatrix of Hd to correct Pauli Z errors. We simulated this system for depolarizing noise on USC's High Performance Computing Cluster, and obtained the block error rate (BER) as a function of the error weight and code rate. From the rates of uncorrectable errors under different error weights we can extrapolate the BER to any small error probability. Our results show that this code family can perform reasonably well even at high code rates, thus considerably reducing the overhead compared to concatenated and surface codes. This makes these codes promising as storage blocks in fault-tolerant quantum computation. Error Correction using Quantum Quasi-Cyclic Low-Density Parity-Check(LDPC) Codes.
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NASA Technical Reports Server (NTRS)
Mishchenko, M. I.; Lacis, A. A.; Travis, L. D.
1994-01-01
Although neglecting polarization and replacing the rigorous vector radiative transfer equation by its approximate scalar counterpart has no physical background, it is a widely used simplification when the incident light is unpolarized and only the intensity of the reflected light is to be computed. We employ accurate vector and scalar multiple-scattering calculations to perform a systematic study of the errors induced by the neglect of polarization in radiance calculations for a homogeneous, plane-parallel Rayleigh-scattering atmosphere (with and without depolarization) above a Lambertian surface. Specifically, we calculate percent errors in the reflected intensity for various directions of light incidence and reflection, optical thicknesses of the atmosphere, single-scattering albedos, depolarization factors, and surface albedos. The numerical data displayed can be used to decide whether or not the scalar approximation may be employed depending on the parameters of the problem. We show that the errors decrease with increasing depolarization factor and/or increasing surface albedo. For conservative or nearly conservative scattering and small surface albedos, the errors are maximum at optical thicknesses of about 1. The calculated errors may be too large for some practical applications, and, therefore, rigorous vector calculations should be employed whenever possible. However, if approximate scalar calculations are used, we recommend to avoid geometries involving phase angles equal or close to 0 deg and 90 deg, where the errors are especially significant. We propose a theoretical explanation of the large vector/scalar differences in the case of Rayleigh scattering. According to this explanation, the differences are caused by the particular structure of the Rayleigh scattering matrix and come from lower-order (except first-order) light scattering paths involving right scattering angles and right-angle rotations of the scattering plane.
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Executive Council lists and general practitioner files
Farmer, R. D. T.; Knox, E. G.; Cross, K. W.; Crombie, D. L.
1974-01-01
An investigation of the accuracy of general practitioner and Executive Council files was approached by a comparison of the two. High error rates were found, including both file errors and record errors. On analysis it emerged that file error rates could not be satisfactorily expressed except in a time-dimensioned way, and we were unable to do this within the context of our study. Record error rates and field error rates were expressible as proportions of the number of records on both the lists; 79·2% of all records exhibited non-congruencies and particular information fields had error rates ranging from 0·8% (assignation of sex) to 68·6% (assignation of civil state). Many of the errors, both field errors and record errors, were attributable to delayed updating of mutable information. It is concluded that the simple transfer of Executive Council lists to a computer filing system would not solve all the inaccuracies and would not in itself permit Executive Council registers to be used for any health care applications requiring high accuracy. For this it would be necessary to design and implement a purpose designed health care record system which would include, rather than depend upon, the general practitioner remuneration system. PMID:4816588
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Hoffmann, B; Müller, V; Rochon, J; Gondan, M; Müller, B; Albay, Z; Weppler, K; Leifermann, M; Mießner, C; Güthlin, C; Parker, D; Hofinger, G; Gerlach, F M
2014-01-01
The measurement of safety culture in healthcare is generally regarded as a first step towards improvement. Based on a self-assessment of safety culture, the Frankfurt Patient Safety Matrix (FraTrix) aims to enable healthcare teams to improve safety culture in their organisations. In this study we assessed the effects of FraTrix on safety culture in general practice. We conducted an open randomised controlled trial in 60 general practices. FraTrix was applied over a period of 9 months during three facilitated team sessions in intervention practices. At baseline and after 12 months, scores were allocated for safety culture as expressed in practice structure and processes (indicators), in safety climate and in patient safety incident reporting. The primary outcome was the indicator error management. During the team sessions, practice teams reflected on their safety culture and decided on about 10 actions per practice to improve it. After 12 months, no significant differences were found between intervention and control groups in terms of error management (competing probability=0.48, 95% CI 0.34 to 0.63, p=0.823), 11 further patient safety culture indicators and safety climate scales. Intervention practices showed better reporting of patient safety incidents, reflected in a higher number of incident reports (mean (SD) 4.85 (4.94) vs 3.10 (5.42), p=0.045) and incident reports of higher quality (scoring 2.27 (1.93) vs 1.49 (1.67), p=0.038) than control practices. Applied as a team-based instrument to assess safety culture, FraTrix did not lead to measurable improvements in error management. Comparable studies with more positive results had less robust study designs. In future research, validated combined methods to measure safety culture will be required. In addition, more attention should be paid to evaluation of process parameters. Implemented actions and incident reporting may be more appropriate target endpoints. German Clinical Trials Register (Deutsches Register Klinischer Studien, DRKS) No. DRKS00000145.
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Bolton-Maggs, P H B
2016-12-01
The Annual SHOT Report for incidents reported in 2015 was published on 7 July at the SHOT symposium. Once again, the majority of reports (77·7%) were associated with mistakes ('human factors'). Pressures and stress in the hospital environment contributed to several error reports. There were 26 deaths where transfusion played a part, one due to haemolysis from anti-Wr a (units issued electronically). The incidence of haemolysis due to this antibody has increased in recent years. Transfusion-associated circulatory overload is the most common contributor to death and major morbidity. Reports of delays to transfusion have increased, some caused by the failure of correct patient identification. There were seven ABO-incompatible red cell transfusions (one death) with an additional six to allogeneic stem cell transplant recipients. Near-miss reporting and analysis is useful and demonstrated nearly 300 instances of wrong blood in tube, which could have resulted in ABO-incompatible transfusion had the error not been detected. Errors with anti-D immunoglobulin continue, and preliminary data from the new survey of new anti-D found in pregnancy has shown that sensitisation occurs in some women even with apparently 'ideal' care. For the first time, the SHOT report now incorporates a chapter on donor events. © 2016 British Blood Transfusion Society.
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Autoimmunity: a decision theory model.
Morris, J A
1987-01-01
Concepts from statistical decision theory were used to analyse the detection problem faced by the body's immune system in mounting immune responses to bacteria of the normal body flora. Given that these bacteria are potentially harmful, that there can be extensive cross reaction between bacterial antigens and host tissues, and that the decisions are made in uncertainty, there is a finite chance of error in immune response leading to autoimmune disease. A model of ageing in the immune system is proposed that is based on random decay in components of the decision process, leading to a steep age dependent increase in the probability of error. The age incidence of those autoimmune diseases which peak in early and middle life can be explained as the resultant of two processes: an exponentially falling curve of incidence of first contact with common bacteria, and a rapidly rising error function. Epidemiological data on the variation of incidence with social class, sibship order, climate and culture can be used to predict the likely site of carriage and mode of spread of the causative bacteria. Furthermore, those autoimmune diseases precipitated by common viral respiratory tract infections might represent reactions to nasopharyngeal bacterial overgrowth, and this theory can be tested using monoclonal antibodies to search the bacterial isolates for cross reacting antigens. If this model is correct then prevention of autoimmune disease by early exposure to low doses of bacteria might be possible. PMID:3818985
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Effect of rain on Ku-band scatterometer wind measurements
NASA Technical Reports Server (NTRS)
Spencer, Michael; Shimada, Masanobu
1991-01-01
The impact of precipitation on scatterometer wind measurements is investigated. A model is developed which includes the effects of rain attenuation, rain backscatter, and storm horizontal structure. Rain attenuation is found to be the dominant error source at low radar incidence angles and high wind speeds. Volume backscatter from the rain-loaded atmosphere, however, is found to dominate for high incidence angles and low wind speeds.
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ERIC Educational Resources Information Center
Forteza Fernandez, Rafael Filiberto; Korneeva, Larisa I.
2017-01-01
Based on Selinker's hypothesis of five psycholinguistic processes shaping interlanguage (1972), the paper focuses attention on the Russian L2-learners' overreliance on the L1 as the main factor hindering their development. The research problem is, therefore, the high incidence of L1 transfer in the spoken and written English language output of…
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PREVAIL: Predicting Recovery through Estimation and Visualization of Active and Incident Lesions.
Dworkin, Jordan D; Sweeney, Elizabeth M; Schindler, Matthew K; Chahin, Salim; Reich, Daniel S; Shinohara, Russell T
2016-01-01
The goal of this study was to develop a model that integrates imaging and clinical information observed at lesion incidence for predicting the recovery of white matter lesions in multiple sclerosis (MS) patients. Demographic, clinical, and magnetic resonance imaging (MRI) data were obtained from 60 subjects with MS as part of a natural history study at the National Institute of Neurological Disorders and Stroke. A total of 401 lesions met the inclusion criteria and were used in the study. Imaging features were extracted from the intensity-normalized T1-weighted (T1w) and T2-weighted sequences as well as magnetization transfer ratio (MTR) sequence acquired at lesion incidence. T1w and MTR signatures were also extracted from images acquired one-year post-incidence. Imaging features were integrated with clinical and demographic data observed at lesion incidence to create statistical prediction models for long-term damage within the lesion. The performance of the T1w and MTR predictions was assessed in two ways: first, the predictive accuracy was measured quantitatively using leave-one-lesion-out cross-validated (CV) mean-squared predictive error. Then, to assess the prediction performance from the perspective of expert clinicians, three board-certified MS clinicians were asked to individually score how similar the CV model-predicted one-year appearance was to the true one-year appearance for a random sample of 100 lesions. The cross-validated root-mean-square predictive error was 0.95 for normalized T1w and 0.064 for MTR, compared to the estimated measurement errors of 0.48 and 0.078 respectively. The three expert raters agreed that T1w and MTR predictions closely resembled the true one-year follow-up appearance of the lesions in both degree and pattern of recovery within lesions. This study demonstrates that by using only information from a single visit at incidence, we can predict how a new lesion will recover using relatively simple statistical techniques. The potential to visualize the likely course of recovery has implications for clinical decision-making, as well as trial enrichment.
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DOE Office of Scientific and Technical Information (OSTI.GOV)
Hashii, Haruko, E-mail: haruko@pmrc.tsukuba.ac.jp; Hashimoto, Takayuki; Okawa, Ayako
2013-03-01
Purpose: Radiation therapy for cancer may be required for patients with implantable cardiac devices. However, the influence of secondary neutrons or scattered irradiation from high-energy photons (≥10 MV) on implantable cardioverter-defibrillators (ICDs) is unclear. This study was performed to examine this issue in 2 ICD models. Methods and Materials: ICDs were positioned around a water phantom under conditions simulating clinical radiation therapy. The ICDs were not irradiated directly. A control ICD was positioned 140 cm from the irradiation isocenter. Fractional irradiation was performed with 18-MV and 10-MV photon beams to give cumulative in-field doses of 600 Gy and 1600 Gy,more » respectively. Errors were checked after each fraction. Soft errors were defined as severe (change to safety back-up mode), moderate (memory interference, no changes in device parameters), and minor (slight memory change, undetectable by computer). Results: Hard errors were not observed. For the older ICD model, the incidences of severe, moderate, and minor soft errors at 18 MV were 0.75, 0.5, and 0.83/50 Gy at the isocenter. The corresponding data for 10 MV were 0.094, 0.063, and 0 /50 Gy. For the newer ICD model at 18 MV, these data were 0.083, 2.3, and 5.8 /50 Gy. Moderate and minor errors occurred at 18 MV in control ICDs placed 140 cm from the isocenter. The error incidences were 0, 1, and 0 /600 Gy at the isocenter for the newer model, and 0, 1, and 6 /600Gy for the older model. At 10 MV, no errors occurred in control ICDs. Conclusions: ICD errors occurred more frequently at 18 MV irradiation, which suggests that the errors were mainly caused by secondary neutrons. Soft errors of ICDs were observed with high energy photon beams, but most were not critical in the newer model. These errors may occur even when the device is far from the irradiation field.« less
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Relationship between Brazilian airline pilot errors and time of day.
de Mello, M T; Esteves, A M; Pires, M L N; Santos, D C; Bittencourt, L R A; Silva, R S; Tufik, S
2008-12-01
Flight safety is one of the most important and frequently discussed issues in aviation. Recent accident inquiries have raised questions as to how the work of flight crews is organized and the extent to which these conditions may have been contributing factors to accidents. Fatigue is based on physiologic limitations, which are reflected in performance deficits. The purpose of the present study was to provide an analysis of the periods of the day in which pilots working for a commercial airline presented major errors. Errors made by 515 captains and 472 co-pilots were analyzed using data from flight operation quality assurance systems. To analyze the times of day (shifts) during which incidents occurred, we divided the light-dark cycle (24:00) in four periods: morning, afternoon, night, and early morning. The differences of risk during the day were reported as the ratio of morning to afternoon, morning to night and morning to early morning error rates. For the purposes of this research, level 3 events alone were taken into account, since these were the most serious in which company operational limits were exceeded or when established procedures were not followed. According to airline flight schedules, 35% of flights take place in the morning period, 32% in the afternoon, 26% at night, and 7% in the early morning. Data showed that the risk of errors increased by almost 50% in the early morning relative to the morning period (ratio of 1:1.46). For the period of the afternoon, the ratio was 1:1.04 and for the night a ratio of 1:1.05 was found. These results showed that the period of the early morning represented a greater risk of attention problems and fatigue.
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Levesque, Eric; Hoti, Emir; de La Serna, Sofia; Habouchi, Houssam; Ichai, Philippe; Saliba, Faouzi; Samuel, Didier; Azoulay, Daniel
2013-03-01
In the French healthcare system, the intensive care budget allocated is directly dependent on the activity level of the center. To evaluate this activity level, it is necessary to code the medical diagnoses and procedures performed on Intensive Care Unit (ICU) patients. The aim of this study was to evaluate the effects of using an Intensive Care Information System (ICIS) on the incidence of coding errors and its impact on the ICU budget allocated. Since 2005, the documentation on and monitoring of every patient admitted to our ICU has been carried out using an ICIS. However, the coding process was performed manually until 2008. This study focused on two periods: the period of manual coding (year 2007) and the period of computerized coding (year 2008) which covered a total of 1403 ICU patients. The time spent on the coding process, the rate of coding errors (defined as patients missed/not coded or wrongly identified as undergoing major procedure/s) and the financial impact were evaluated for these two periods. With computerized coding, the time per admission decreased significantly (from 6.8 ± 2.8 min in 2007 to 3.6 ± 1.9 min in 2008, p<0.001). Similarly, a reduction in coding errors was observed (7.9% vs. 2.2%, p<0.001). This decrease in coding errors resulted in a reduced difference between the potential and real ICU financial supplements obtained in the respective years (€194,139 loss in 2007 vs. a €1628 loss in 2008). Using specific computer programs improves the intensive process of manual coding by shortening the time required as well as reducing errors, which in turn positively impacts the ICU budget allocation. Copyright © 2012 Elsevier Ireland Ltd. All rights reserved.
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Statistical text classifier to detect specific type of medical incidents.
Wong, Zoie Shui-Yee; Akiyama, Masanori
2013-01-01
WHO Patient Safety has put focus to increase the coherence and expressiveness of patient safety classification with the foundation of International Classification for Patient Safety (ICPS). Text classification and statistical approaches has showed to be successful to identifysafety problems in the Aviation industryusing incident text information. It has been challenging to comprehend the taxonomy of medical incidents in a structured manner. Independent reporting mechanisms for patient safety incidents have been established in the UK, Canada, Australia, Japan, Hong Kong etc. This research demonstrates the potential to construct statistical text classifiers to detect specific type of medical incidents using incident text data. An illustrative example for classifying look-alike sound-alike (LASA) medication incidents using structured text from 227 advisories related to medication errors from Global Patient Safety Alerts (GPSA) is shown in this poster presentation. The classifier was built using logistic regression model. ROC curve and the AUC value indicated that this is a satisfactory good model.
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Regional geographic variations in kidney cancer incidence rates in European countries.
Li, Peng; Znaor, Ariana; Holcatova, Ivana; Fabianova, Eleonora; Mates, Dana; Wozniak, Magdalena B; Ferlay, Jacques; Scelo, Ghislaine
2015-06-01
Marked unexplained national variations in incidence rates of kidney cancer have been observed for decades in Europe. To investigate geographic variations at the regional level and identify European regions with high incidence rates of kidney cancer. Regional- and national-level incidence data were extracted from the Cancer Incidence in Five Continents databases, local cancer registry databases, and local published reports. World population age-standardised rates (ASRs) were calculated for the periods 2003-2007 and 1988-1992. Rates by period and sex were compared using map visualisation. During 2003-2007, the highest ASR was found in the Plzen region, Czech Republic (31.4/100,000 person-years in men). Other regions of the Czech Republic had ASRs of 18.6-27.5/100,000 in men, with a tendency for higher rates in regions south of Prague. Surrounding regions, including eastern Germany and regions of Slovakia and Austria, had medium-to-high incidence rates (13.0-16.8/100,000 in men). Three other areas in Europe showed higher incidence rates in men compared with the rest of the continent: Lithuania, Estonia, Latvia, and Belarus (15.0-17.6/100,000); Iceland (13.5/100,000), and northern Italy (up to 16.0/100,000). Similar regional differences were observed among women, with rates approximately half of those observed in men in the same region. In general, these regional geographic variations remained stable over the periods 1988-1992 and 2003-2007, although higher incidence rates were detected in the Baltic countries in 2003-2007. Several European regions show particularly high rates of kidney cancer incidence. Large variations were observed within countries covered by national health-care systems, implying that overdetection is not the major factor. We present regional geographic variations in kidney cancer incidence rates in Europe. We highlight several regions with high incidence rates where further studies should be conducted for cancer control and prevention. Copyright © 2014 European Association of Urology. Published by Elsevier B.V. All rights reserved.
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Recent trends and patterns in breast cancer incidence among Eastern and Southeastern Asian women.
Shin, Hai-Rim; Joubert, Clementine; Boniol, Mathieu; Hery, Clarisse; Ahn, Sei Hyun; Won, Young-Joo; Nishino, Yoshikazu; Sobue, Tomotaka; Chen, Chien-Jen; You, San-Lin; Mirasol-Lumague, Maria Rica; Law, Stephen Chun-Key; Mang, Oscar; Xiang, Yong-Bing; Chia, Kee-Seng; Rattanamongkolgul, Suthee; Chen, Jian-Guo; Curado, Maria Paula; Autier, Philippe
2010-11-01
Incidence of breast cancer is rising in Asian countries, and breast cancer is the most common cancer among Asian women. However, there are few recent descriptive reports on the epidemiology of breast cancer among Eastern and Southeastern Asian populations. We examined incidence trends for invasive breast cancer in women aged ≥20 years from 15 registries in Eastern (China, Japan, the Republic of Korea, Taiwan) and Southeastern Asia (the Philippines, Singapore, Thailand) for the period 1993-2002 mainly using data from Cancer Incidence in Five Continents, Volumes VIII and IX. We compared trends in annual incidence rates and age-specific incidence curves over a 10-year period. We also compared the incidence rates of Asian-Americans with the rates of their Asian counterparts. Breast cancer incidence rates increased gradually over time in all study populations. Rates were relatively high in Southeastern Asia and became progressively lower along a south-to-north gradient, with a fourfold geographic variation within the study populations. Age-specific incidence curves showed patterns that gradually changed according to incidence rates. Breast cancer incidence among Asian women living in the United States was 1.5-4 times higher than the corresponding incidence rate in the women's respective countries of origin. Breast cancer incidence is expected to continue to increase for the next 10 years in Asia and may approach rates reported among Asian-Americans. The number and mean age of breast cancer cases is expected to increase as the female Asian population ages, the prevalence of certain risk factors changes (early menarche, late menopause, low parity, late age at first live birth, and low prevalence of breastfeeding), and as Asian countries introduce mass screening programs.
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Nakano, Tadashi; Hayashi, Takeshi; Nakagawa, Toru; Honda, Toru; Owada, Satoshi; Endo, Hitoshi; Tatemichi, Masayuki
2018-04-05
This retrospective cohort study primarily aimed to investigate the possible association of computer use with visual field abnormalities (VFA) among Japanese workers. The study included 2,377 workers (mean age 45.7 [standard deviation, 8.3] years; 2,229 men and 148 women) who initially exhibited no VFA during frequency doubling technology perimetry (FDT) testing. Subjects then underwent annual follow-up FDT testing for 7 years, and VFA were determined using a FDT-test protocol (FDT-VFA). Subjects with FDT-VFA were examined by ophthalmologists. Baseline data about the mean duration of computer use during a 5-year period and refractive errors were obtained via self-administered questionnaire and evaluations for refractive errors (use of eyeglasses or contact lenses), respectively. A Cox proportional hazard analysis demonstrated that heavy computer users (>8 hr/day) had a significantly increased risk of FDT-VFA (hazard ratio [HR] 2.85; 95% confidence interval [CI], 1.26-6.48) relative to light users (<4 hr/day), and this association was strengthened among subjects with refractive errors (HR 4.48; 95% CI, 1.87-10.74). The computer usage history also significantly correlated with FDT-VFA among subject with refractive errors (P < 0.05), and 73.1% of subjects with FDT-VFA and refractive errors were diagnosed with glaucoma or ocular hypertension. The incidence of FDT-VFA appears to be increased among Japanese workers who are heavy computer users, particularly if they have refractive errors. Further investigations of epidemiology and causality are warranted.
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Successful remediation of patient safety incidents: a tale of two medication errors.
Helmchen, Lorens A; Richards, Michael R; McDonald, Timothy B
2011-01-01
As patient safety acquires strategic importance for all stakeholders in the health care delivery chain, one promising mechanism centers on the proactive disclosure of medical errors to patients. Yet, disclosure and apology alone will not be effective in fully addressing patients' concerns after an adverse event unless they are paired with a remediation component. The purpose of this study was to identify key features of successful remediation efforts that accompany the proactive disclosure of medical errors to patients. We describe and contrast two recent and very similar cases of preventable medical error involving inappropriate medication at a large tertiary-care academic medical center in the Midwestern United States. Despite their similarity, the two medical errors led to very different health outcomes and remediation trajectories for the injured patients. Although one error causing no permanent harm was mismanaged to the lasting dissatisfaction of the patient, the other resulted in the death of the patient but was remediated to the point of allowing the family to come to terms with the loss and even restored a modicum of trust in the providers' sincerity. To maximize the opportunities for successful remediation, as soon as possible after the incident, providers should pledge to injured patients and their relatives that they will assist and accompany them in their recovery as long as necessary and then follow through on their pledge. As the two case studies show, it takes training and vigilance to ensure adherence to these principles and reach an optimal outcome for patients and their relatives.
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Blood transfusion sampling and a greater role for error recovery.
Oldham, Jane
Patient identification errors in pre-transfusion blood sampling ('wrong blood in tube') are a persistent area of risk. These errors can potentially result in life-threatening complications. Current measures to address root causes of incidents and near misses have not resolved this problem and there is a need to look afresh at this issue. PROJECT PURPOSE: This narrative review of the literature is part of a wider system-improvement project designed to explore and seek a better understanding of the factors that contribute to transfusion sampling error as a prerequisite to examining current and potential approaches to error reduction. A broad search of the literature was undertaken to identify themes relating to this phenomenon. KEY DISCOVERIES: Two key themes emerged from the literature. Firstly, despite multi-faceted causes of error, the consistent element is the ever-present potential for human error. Secondly, current focus on error prevention could potentially be augmented with greater attention to error recovery. Exploring ways in which clinical staff taking samples might learn how to better identify their own errors is proposed to add to current safety initiatives.
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Schroeder, Scott R; Salomon, Meghan M; Galanter, William L; Schiff, Gordon D; Vaida, Allen J; Gaunt, Michael J; Bryson, Michelle L; Rash, Christine; Falck, Suzanne; Lambert, Bruce L
2017-05-01
Drug name confusion is a common type of medication error and a persistent threat to patient safety. In the USA, roughly one per thousand prescriptions results in the wrong drug being filled, and most of these errors involve drug names that look or sound alike. Prior to approval, drug names undergo a variety of tests to assess their potential for confusability, but none of these preapproval tests has been shown to predict real-world error rates. We conducted a study to assess the association between error rates in laboratory-based tests of drug name memory and perception and real-world drug name confusion error rates. Eighty participants, comprising doctors, nurses, pharmacists, technicians and lay people, completed a battery of laboratory tests assessing visual perception, auditory perception and short-term memory of look-alike and sound-alike drug name pairs (eg, hydroxyzine/hydralazine). Laboratory test error rates (and other metrics) significantly predicted real-world error rates obtained from a large, outpatient pharmacy chain, with the best-fitting model accounting for 37% of the variance in real-world error rates. Cross-validation analyses confirmed these results, showing that the laboratory tests also predicted errors from a second pharmacy chain, with 45% of the variance being explained by the laboratory test data. Across two distinct pharmacy chains, there is a strong and significant association between drug name confusion error rates observed in the real world and those observed in laboratory-based tests of memory and perception. Regulators and drug companies seeking a validated preapproval method for identifying confusing drug names ought to consider using these simple tests. By using a standard battery of memory and perception tests, it should be possible to reduce the number of confusing look-alike and sound-alike drug name pairs that reach the market, which will help protect patients from potentially harmful medication errors. 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/.
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Romero, Adolfo; Cobos, Andrés; Gómez, Juan; Muñoz, Manuel
2012-01-18
The presence of pre-analytical errors (PE) is a usual contingency in laboratories. The incidence may increase where it is difficult to control that period, as it is the case with samples sent from primary care (PC) to clinical reference laboratory. Detection of a large number of PE in PC samples in our Institution led to the development and implementation of preventive strategies. The first of these has been the realization of a cycle of educational sessions for PC nurses, followed by the evaluation of their impact on PE number. The incidence of PE was assessed in two periods, before (October-November 2007) and after (October-November, 2009) the implementation of educational sessions. Eleven PC centers in the urban area and 17 in the rural area participated. In the urban area, samples were withdrawn by any PC nurse; in the rural area, samples were obtained by the patient's reference nurse. The types of analyzed PE included missed sample (MS), hemolyzed sample (HS), coagulated sample (CS), incorrect sample (ISV) and others (OPE), such as lipemic or icteric serum or plasma. In the former period, we received 52,669 blood samples and 18,852 urine samples, detecting 3885 (7.5%) and 1567 (8.3%) PEs, respectively. After the educational intervention, there were 52,659 and 19,048 samples with 5057 (9.6%) and 1.256 (6.5%) PEs, respectively (p<0.001). According to the type of PE, the incidents compared before and after compared incidences were: MS, 4.8% vs. 3.8%, p<0.001; HS, 1.97% vs. 3.9%, p<0.001; CS, 0.54% vs. 0.25%, p<0.001; ISV, 0.15% vs. 0.19% p=0.08; and OPE, 0.3% vs. 0.42%, p<0.001. Surprisingly the PE incidence increased after the educational intervention, although it should be noted that it was primarily due to the increase of HS, as the other EP incidence decreased (MS and CS) or remained unchanged (ISV). This seems to indicate the need for a comprehensive approach to reduce the incidence of errors in the pre-analytical period, as one stage interventions do not seem to be effective enough. Copyright © 2011 Elsevier B.V. All rights reserved.
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Gnädinger, Markus; Conen, Dieter; Herzig, Lilli; Puhan, Milo A; Staehelin, Alfred; Zoller, Marco; Ceschi, Alessandro
2017-07-26
To describe the type, frequency, seasonal and regional distribution of medication incidents in primary care in Switzerland and to elucidate possible risk factors for medication incidents. Prospective surveillance study. Swiss primary healthcare, Swiss Sentinel Surveillance Network. Patients with drug treatment who experienced any erroneous event related to the medication process and interfering with normal treatment course, as judged by their physician. The 180 physicians in the study were general practitioners or paediatricians participating in the Swiss Federal Sentinel reporting system in 2015. Primary: medication incidents; secondary: potential risk factors like age, gender, polymedication, morbidity, care-dependency, previous hospitalisation. The mean rates of detected medication incidents were 2.07 per general practitioner per year (46.5 per 1 00 000 contacts) and 0.15 per paediatrician per year (2.8 per 1 00 000 contacts), respectively. The following factors were associated with medication incidents (OR, 95% CI): higher age 1.004 per year (1.001; 1.006), care by community nurse 1.458 (1.025; 2.073) and care by an institution 1.802 (1.399; 2.323), chronic conditions 1.052 (1.029; 1.075) per condition, medications 1.052 (1.030; 1.074) per medication, as well as Thurgau Morbidity Index for stage 4: 1.292 (1.004; 1.662), stage 5: 1.420 (1.078; 1.868) and stage 6: 1.680 (1.178; 2.396), respectively. Most cases were linked to an incorrect dosage for a given patient, while prescription of an erroneous medication was the second most common error. Medication incidents are common in adult primary care, whereas they rarely occur in paediatrics. Older and multimorbid patients are at a particularly high risk for medication incidents. Reasons for medication incidents are diverse but often seem to be linked to communication problems. © Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2017. All rights reserved. No commercial use is permitted unless otherwise expressly granted.
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Towards a Framework for Managing Risk Associated with Technology-Induced Error.
Borycki, Elizabeth M; Kushniruk, Andre W
2017-01-01
Health information technologies (HIT) promised to streamline and modernize healthcare processes. However, a growing body of research has indicated that if such technologies are not designed, implemented or maintained properly this may lead to an increased incidence of new types of errors which the authors have referred to as "technology-induced errors". In this paper, framework is presented that can be used to manage HIT risk. The framework considers the reduction of technology-induced errors at different stages by managing risks associated with the implementation of HIT. Frameworks that allow health information technology managers to employ proactive and preventative approaches that can be used to manage the risks associated with technology-induced errors are critical to improving HIT safety and managing risk associated with implementing new technologies.
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A review of in-flight emergencies in the ASRS data base
NASA Technical Reports Server (NTRS)
Porter, R. F.
1981-01-01
A series of 154 in-flight emergencies as reported to the Aviation Safety Reporting System are described. The various types of emergencies are examined and an attempt is made to determine the human errors and other factors associated with each incident, as well as the measures taken to resolve the emergency. It is concluded that nearly one half of those emergencies reported were related to failure or malfunction of aircraft subsystems. Of all the emergencies, nearly one quarter were associated with power plant failure. Other frequently encountered emergency types are associated with operation in instrument meteorological conditions without appropriate clearance or qualification, and with low fuel state situations. Human error is prominently featured in many of the incidents, appearing in the actions of pilots and air traffic controllers.
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Air-ground information transfer in the National Airspace System
NASA Technical Reports Server (NTRS)
Lee, Alfred T.; Lozito, Sandra
1989-01-01
This paper reviews NASA's Aviation Safety Reporting System incident data for a two-year period in order to identify the frequency of air-ground information transfer errors and the factors associated with their occurrence. Of the more than 14,000 primary reports received during the 1985 and 1986 reporting period, one out of four reports concerned problems of information transfer between aircraft and ATC. Approximately half of these errors were associated directly or indirectly with aircraft deviations from assigned heading or altitude. The majority of incidents cited some human-system problem such as workload, cockpit distractions, etc., as the primary contributing factor. Improvements in air-ground information transfer using existing and future (e.g., data link) technology are proposed centering on the development and application of user-centered information management principles.
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NASA Technical Reports Server (NTRS)
Khan, Gufran Sayeed; Gubarev, Mikhail; Speegle, Chet; Ramsey, Brian
2010-01-01
The presentation includes grazing incidence X-ray optics, motivation and challenges, mid spatial frequency generation in cylindrical polishing, design considerations for polishing lap, simulation studies and experimental results, future scope, and summary. Topics include current status of replication optics technology, cylindrical polishing process using large size polishing lap, non-conformance of polishin lap to the optics, development of software and polishing machine, deterministic prediction of polishing, polishing experiment under optimum conditions, and polishing experiment based on known error profile. Future plans include determination of non-uniformity in the polishing lap compliance, development of a polishing sequence based on a known error profile of the specimen, software for generating a mandrel polishing sequence, design an development of a flexible polishing lap, and computer controlled localized polishing process.
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Classification based upon gene expression data: bias and precision of error rates.
Wood, Ian A; Visscher, Peter M; Mengersen, Kerrie L
2007-06-01
Gene expression data offer a large number of potentially useful predictors for the classification of tissue samples into classes, such as diseased and non-diseased. The predictive error rate of classifiers can be estimated using methods such as cross-validation. We have investigated issues of interpretation and potential bias in the reporting of error rate estimates. The issues considered here are optimization and selection biases, sampling effects, measures of misclassification rate, baseline error rates, two-level external cross-validation and a novel proposal for detection of bias using the permutation mean. Reporting an optimal estimated error rate incurs an optimization bias. Downward bias of 3-5% was found in an existing study of classification based on gene expression data and may be endemic in similar studies. Using a simulated non-informative dataset and two example datasets from existing studies, we show how bias can be detected through the use of label permutations and avoided using two-level external cross-validation. Some studies avoid optimization bias by using single-level cross-validation and a test set, but error rates can be more accurately estimated via two-level cross-validation. In addition to estimating the simple overall error rate, we recommend reporting class error rates plus where possible the conditional risk incorporating prior class probabilities and a misclassification cost matrix. We also describe baseline error rates derived from three trivial classifiers which ignore the predictors. R code which implements two-level external cross-validation with the PAMR package, experiment code, dataset details and additional figures are freely available for non-commercial use from http://www.maths.qut.edu.au/profiles/wood/permr.jsp
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Rodríguez-Cerrillo, Matilde; Fernández-Diaz, Eddita; Iñurrieta-Romero, Amaia; Poza-Montoro, Ana
2012-01-01
The purpose of this paper is to describe changes and results obtained after implementation of a quality management system (QMS) according to ISO standards in a Hospital in the Home (HIH) Unit. The paper describes changes made and outcomes achieved. This took part in the HiH Unit, Clinico Hospital, Madrid, Spain, and looked at admissions, mean stay, patient satisfaction, adverse events, returns to hospital, no admitted referrals, complaints, compliance to protocols, equipment failures and resolution of urgent consultations. In June 2008, HiH Unit, Clinico Hospital obtained ISO certification. The main results achieved are as follows. There was an increase in patients' satisfaction--in June 2008, assessment of the quality of care provided by staff was scored at 4.7 (on a scale of 1 to 5); in 2010 it has been scored at 4.96. Patient satisfaction rate has increased from 92 percent to 98.8 percent. No complaints from patients were received. Unscheduled returns to hospital have decreased from 7 percent to 3 percent. There were no medical equipment failures. External suppliers' performance has improved. Material and medication needed by staff was available when necessary. The number of admissions has increased. Compliance to protocols has reached 97 percent. Inappropriate referrals have decreased by 8 percent. Six medications-related incidents were detected; in two cases the incident was not due to an error. In the other four cases error could have been detected before reaching the patient. Implementations of an ISO quality management system allow improved quality of care and patient satisfaction in a HIH Unit.
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Do Errors on Classroom Reading Tasks Slow Growth in Reading? Technical Report No. 404.
ERIC Educational Resources Information Center
Anderson, Richard C.; And Others
A pervasive finding from research on teaching and classroom learning is that a low rate of error on classroom tasks is associated with large year to year gains in achievement, particularly for reading in the primary grades. The finding of a negative relationship between error rate, especially rate of oral reading errors, and gains in reading…
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Estimating genotype error rates from high-coverage next-generation sequence data.
Wall, Jeffrey D; Tang, Ling Fung; Zerbe, Brandon; Kvale, Mark N; Kwok, Pui-Yan; Schaefer, Catherine; Risch, Neil
2014-11-01
Exome and whole-genome sequencing studies are becoming increasingly common, but little is known about the accuracy of the genotype calls made by the commonly used platforms. Here we use replicate high-coverage sequencing of blood and saliva DNA samples from four European-American individuals to estimate lower bounds on the error rates of Complete Genomics and Illumina HiSeq whole-genome and whole-exome sequencing. Error rates for nonreference genotype calls range from 0.1% to 0.6%, depending on the platform and the depth of coverage. Additionally, we found (1) no difference in the error profiles or rates between blood and saliva samples; (2) Complete Genomics sequences had substantially higher error rates than Illumina sequences had; (3) error rates were higher (up to 6%) for rare or unique variants; (4) error rates generally declined with genotype quality (GQ) score, but in a nonlinear fashion for the Illumina data, likely due to loss of specificity of GQ scores greater than 60; and (5) error rates increased with increasing depth of coverage for the Illumina data. These findings, especially (3)-(5), suggest that caution should be taken in interpreting the results of next-generation sequencing-based association studies, and even more so in clinical application of this technology in the absence of validation by other more robust sequencing or genotyping methods. © 2014 Wall et al.; Published by Cold Spring Harbor Laboratory Press.
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Critical incident reporting and learning.
Mahajan, R P
2010-07-01
The success of incident reporting in improving safety, although obvious in aviation and other high-risk industries, is yet to be seen in health-care systems. An incident reporting system which would improve patient safety would allow front-end clinicians to have easy access for reporting an incident with an understanding that their report will be handled in a non-punitive manner, and that it will lead to enhanced learning regarding the causation of the incident and systemic changes which will prevent it from recurring. At present, significant problems remain with local and national incident reporting systems. These include fear of punitive action, poor safety culture in an organization, lack of understanding among clinicians about what should be reported, lack of awareness of how the reported incidents will be analysed, and how will the reports ultimately lead to changes which will improve patient safety. In particular, lack of systematic analysis of the reports and feedback directly to the clinicians are seen as major barriers to clinical engagement. In this review, robust systematic methodology of analysing incidents is discussed. This methodology is based on human factors model, and the learning paradigm which emphasizes significant shift from traditional judicial approach to understanding how 'latent errors' may play a role in a chain of events which can set up an 'active error' to occur. Feedback directly to the clinicians is extremely important for keeping them 'in the loop' for their continued engagement, and it should target different levels of analyses. In addition to high-level information on the types of incidents, the feedback should incorporate results of the analyses of active and latent factors. Finally, it should inform what actions, and at what level/stage, have been taken in response to the reported incidents. For this, local and national systems will be required to work in close cooperation, so that the lessons can be learnt and actions taken within an organization, and across organizations. In the UK, a recently introduced speciality-specific incident reporting system for anaesthesia aims to incorporate the elements of successful reporting system, as presented in this review, to achieve enhanced clinical engagement and improved patient safety.
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Speech Errors across the Lifespan
ERIC Educational Resources Information Center
Vousden, Janet I.; Maylor, Elizabeth A.
2006-01-01
Dell, Burger, and Svec (1997) proposed that the proportion of speech errors classified as anticipations (e.g., "moot and mouth") can be predicted solely from the overall error rate, such that the greater the error rate, the lower the anticipatory proportion (AP) of errors. We report a study examining whether this effect applies to changes in error…
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Computer calculated dose in paediatric prescribing.
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.
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DOE Office of Scientific and Technical Information (OSTI.GOV)
Ezzell, G.
It has long been standard practice in radiation oncology to report internally when a patient’s treatment has not gone as planned and to report events to regulatory agencies when legally required. Most potential errors are caught early and never affect the patient. Quality assurance steps routinely prevent errors from reaching the patient, and these “near misses” are much more frequent than treatment errors. A growing number of radiation oncology facilities have implemented incident learning systems to report and analyze both errors and near misses. Using the term “incident learning” instead of “event reporting” emphasizes the need to use these experiencesmore » to change the practice and make future errors less likely and promote an educational, non-punitive environment. There are challenges in making such a system practical and effective. Speakers from institutions of different sizes and practice environments will share their experiences on how to make such a system work and what benefits their clinics have accrued. Questions that will be addressed include: How to create a system that is easy for front line staff to access How to motivate staff to report How to promote the system as positive and educational and not punitive or demeaning How to organize the team for reviewing and responding to reports How to prioritize which reports to discuss in depth How not to dismiss the rest How to identify underlying causes How to design corrective actions and implement change How to develop useful statistics and analysis tools How to coordinate a departmental system with a larger risk management system How to do this without a dedicated quality manager Some speakers’ experience is with in-house systems and some will share experience with the AAPM/ASTRO national Radiation Oncology Incident Learning System (RO-ILS). Reports intended to be of value nationally need to be comprehensible to outsiders; examples of useful reports will be shown. There will be ample time set aside for audience members to contribute to the discussion. Learning Objectives: Learn how to promote the use of an incident learning system in a clinic. Learn how to convert “event reporting” into “incident learning”. See examples of practice changes that have come out of learning systems. Learn how the RO-ILS system can be used as a primary internal learning system. Learn how to create succinct, meaningful reports useful to outside readers. Gary Ezzell chairs the AAPM committee overseeing RO-ILS and has received an honorarium from ASTRO for working on the committee reviewing RO-ILS reports. Derek Brown is a director of http://TreatSafely.org . Brett Miller has previously received travel expenses and an honorarium from Varian. Phillip Beron has nothing to report.« less
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TU-CD-BRD-04: UCLA Experience, with Focus On Developing Metrics and Using RO-ILS
DOE Office of Scientific and Technical Information (OSTI.GOV)
Beron, P.
2015-06-15
It has long been standard practice in radiation oncology to report internally when a patient’s treatment has not gone as planned and to report events to regulatory agencies when legally required. Most potential errors are caught early and never affect the patient. Quality assurance steps routinely prevent errors from reaching the patient, and these “near misses” are much more frequent than treatment errors. A growing number of radiation oncology facilities have implemented incident learning systems to report and analyze both errors and near misses. Using the term “incident learning” instead of “event reporting” emphasizes the need to use these experiencesmore » to change the practice and make future errors less likely and promote an educational, non-punitive environment. There are challenges in making such a system practical and effective. Speakers from institutions of different sizes and practice environments will share their experiences on how to make such a system work and what benefits their clinics have accrued. Questions that will be addressed include: How to create a system that is easy for front line staff to access How to motivate staff to report How to promote the system as positive and educational and not punitive or demeaning How to organize the team for reviewing and responding to reports How to prioritize which reports to discuss in depth How not to dismiss the rest How to identify underlying causes How to design corrective actions and implement change How to develop useful statistics and analysis tools How to coordinate a departmental system with a larger risk management system How to do this without a dedicated quality manager Some speakers’ experience is with in-house systems and some will share experience with the AAPM/ASTRO national Radiation Oncology Incident Learning System (RO-ILS). Reports intended to be of value nationally need to be comprehensible to outsiders; examples of useful reports will be shown. There will be ample time set aside for audience members to contribute to the discussion. Learning Objectives: Learn how to promote the use of an incident learning system in a clinic. Learn how to convert “event reporting” into “incident learning”. See examples of practice changes that have come out of learning systems. Learn how the RO-ILS system can be used as a primary internal learning system. Learn how to create succinct, meaningful reports useful to outside readers. Gary Ezzell chairs the AAPM committee overseeing RO-ILS and has received an honorarium from ASTRO for working on the committee reviewing RO-ILS reports. Derek Brown is a director of http://TreatSafely.org . Brett Miller has previously received travel expenses and an honorarium from Varian. Phillip Beron has nothing to report.« less
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TU-CD-BRD-03: UCSD Experience, with Focus On Implementing Change
DOE Office of Scientific and Technical Information (OSTI.GOV)
Brown, D.
2015-06-15
It has long been standard practice in radiation oncology to report internally when a patient’s treatment has not gone as planned and to report events to regulatory agencies when legally required. Most potential errors are caught early and never affect the patient. Quality assurance steps routinely prevent errors from reaching the patient, and these “near misses” are much more frequent than treatment errors. A growing number of radiation oncology facilities have implemented incident learning systems to report and analyze both errors and near misses. Using the term “incident learning” instead of “event reporting” emphasizes the need to use these experiencesmore » to change the practice and make future errors less likely and promote an educational, non-punitive environment. There are challenges in making such a system practical and effective. Speakers from institutions of different sizes and practice environments will share their experiences on how to make such a system work and what benefits their clinics have accrued. Questions that will be addressed include: How to create a system that is easy for front line staff to access How to motivate staff to report How to promote the system as positive and educational and not punitive or demeaning How to organize the team for reviewing and responding to reports How to prioritize which reports to discuss in depth How not to dismiss the rest How to identify underlying causes How to design corrective actions and implement change How to develop useful statistics and analysis tools How to coordinate a departmental system with a larger risk management system How to do this without a dedicated quality manager Some speakers’ experience is with in-house systems and some will share experience with the AAPM/ASTRO national Radiation Oncology Incident Learning System (RO-ILS). Reports intended to be of value nationally need to be comprehensible to outsiders; examples of useful reports will be shown. There will be ample time set aside for audience members to contribute to the discussion. Learning Objectives: Learn how to promote the use of an incident learning system in a clinic. Learn how to convert “event reporting” into “incident learning”. See examples of practice changes that have come out of learning systems. Learn how the RO-ILS system can be used as a primary internal learning system. Learn how to create succinct, meaningful reports useful to outside readers. Gary Ezzell chairs the AAPM committee overseeing RO-ILS and has received an honorarium from ASTRO for working on the committee reviewing RO-ILS reports. Derek Brown is a director of http://TreatSafely.org . Brett Miller has previously received travel expenses and an honorarium from Varian. Phillip Beron has nothing to report.« less
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TU-CD-BRD-02: Henry Ford Hospital System Experience, with Focus On Motivating and Reviewing
DOE Office of Scientific and Technical Information (OSTI.GOV)
Miller, B.
It has long been standard practice in radiation oncology to report internally when a patient’s treatment has not gone as planned and to report events to regulatory agencies when legally required. Most potential errors are caught early and never affect the patient. Quality assurance steps routinely prevent errors from reaching the patient, and these “near misses” are much more frequent than treatment errors. A growing number of radiation oncology facilities have implemented incident learning systems to report and analyze both errors and near misses. Using the term “incident learning” instead of “event reporting” emphasizes the need to use these experiencesmore » to change the practice and make future errors less likely and promote an educational, non-punitive environment. There are challenges in making such a system practical and effective. Speakers from institutions of different sizes and practice environments will share their experiences on how to make such a system work and what benefits their clinics have accrued. Questions that will be addressed include: How to create a system that is easy for front line staff to access How to motivate staff to report How to promote the system as positive and educational and not punitive or demeaning How to organize the team for reviewing and responding to reports How to prioritize which reports to discuss in depth How not to dismiss the rest How to identify underlying causes How to design corrective actions and implement change How to develop useful statistics and analysis tools How to coordinate a departmental system with a larger risk management system How to do this without a dedicated quality manager Some speakers’ experience is with in-house systems and some will share experience with the AAPM/ASTRO national Radiation Oncology Incident Learning System (RO-ILS). Reports intended to be of value nationally need to be comprehensible to outsiders; examples of useful reports will be shown. There will be ample time set aside for audience members to contribute to the discussion. Learning Objectives: Learn how to promote the use of an incident learning system in a clinic. Learn how to convert “event reporting” into “incident learning”. See examples of practice changes that have come out of learning systems. Learn how the RO-ILS system can be used as a primary internal learning system. Learn how to create succinct, meaningful reports useful to outside readers. Gary Ezzell chairs the AAPM committee overseeing RO-ILS and has received an honorarium from ASTRO for working on the committee reviewing RO-ILS reports. Derek Brown is a director of http://TreatSafely.org . Brett Miller has previously received travel expenses and an honorarium from Varian. Phillip Beron has nothing to report.« less
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Kapur, Ajay; Goode, Gina; Riehl, Catherine; Zuvic, Petrina; Joseph, Sherin; Adair, Nilda; Interrante, Michael; Bloom, Beatrice; Lee, Lucille; Sharma, Rajiv; Sharma, Anurag; Antone, Jeffrey; Riegel, Adam; Vijeh, Lili; Zhang, Honglai; Cao, Yijian; Morgenstern, Carol; Montchal, Elaine; Cox, Brett; Potters, Louis
2013-01-01
By combining incident learning and process failure-mode-and-effects-analysis (FMEA) in a structure-process-outcome framework we have created a risk profile for our radiation medicine practice and implemented evidence-based risk-mitigation initiatives focused on patient safety. Based on reactive reviews of incidents reported in our departmental incident-reporting system and proactive FMEA, high safety-risk procedures in our paperless radiation medicine process and latent risk factors were identified. Six initiatives aimed at the mitigation of associated severity, likelihood-of-occurrence, and detectability risks were implemented. These were the standardization of care pathways and toxicity grading, pre-treatment-planning peer review, a policy to thwart delay-rushed processes, an electronic whiteboard to enhance coordination, and the use of six sigma metrics to monitor operational efficiencies. The effectiveness of these initiatives over a 3-years period was assessed using process and outcome specific metrics within the framework of the department structure. There has been a 47% increase in incident-reporting, with no increase in adverse events. Care pathways have been used with greater than 97% clinical compliance rate. The implementation of peer review prior to treatment-planning and use of the whiteboard have provided opportunities for proactive detection and correction of errors. There has been a twofold drop in the occurrence of high-risk procedural delays. Patient treatment start delays are routinely enforced on cases that would have historically been rushed. Z-scores for high-risk procedures have steadily improved from 1.78 to 2.35. The initiatives resulted in sustained reductions of failure-mode risks as measured by a set of evidence-based metrics over a 3-years period. These augment or incorporate many of the published recommendations for patient safety in radiation medicine by translating them to clinical practice. PMID:24380074
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Trabert, B; Chen, J; Devesa, S S; Bray, F; McGlynn, K A
2015-01-01
Incidence rates of testicular cancer in Northern European and North American countries have been widely reported, whereas rates in other populations, such as Eastern Europe, Central/South America, Asia, and Africa, have been less frequently evaluated. We examined testicular cancer incidence rates overall and by histologic type by calendar time and birth cohort for selected global populations 1973-2007. Age-standardized incidence rates over succeeding 5-year periods were calculated from volumes 4-9 of Cancer Incidence in Five Continents electronic database (CI5plus) and the newly released CI5X (volume 10) database. Annual percent change over the 35-year period was calculated using weighted least squares regression. Age-period-cohort analyses were performed and observed rates and fitted rate ratios presented by birth cohort. Incidence rates of testicular cancer increased between 1973-1977 and 2003-2007 in most populations evaluated worldwide. Of note, incidence rates in Eastern European countries rose rapidly and approached rates in Northern European countries. Rates in Central and South America also increased and are now intermediate to the high rates among men of European ancestry and low rates among men of Asian or African descent. Some heterogeneity in the trends in seminoma and nonseminoma were observed in Denmark, the United Kingdom, and among US whites, particularly in recent generations, with rapid and uniform increases in the incidence of both histologic types in Slovakia. Reasons for the rising incidence rates among European and American populations remain unexplained; however, changing distributions in the prevalence of risk factors for testicular cancer cannot be ruled out. © 2014 American Society of Andrology and European Academy of Andrology.
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Angular rate optimal design for the rotary strapdown inertial navigation system.
Yu, Fei; Sun, Qian
2014-04-22
Due to the characteristics of high precision for a long duration, the rotary strapdown inertial navigation system (RSINS) has been widely used in submarines and surface ships. Nowadays, the core technology, the rotating scheme, has been studied by numerous researchers. It is well known that as one of the key technologies, the rotating angular rate seriously influences the effectiveness of the error modulating. In order to design the optimal rotating angular rate of the RSINS, the relationship between the rotating angular rate and the velocity error of the RSINS was analyzed in detail based on the Laplace transform and the inverse Laplace transform in this paper. The analysis results showed that the velocity error of the RSINS depends on not only the sensor error, but also the rotating angular rate. In order to minimize the velocity error, the rotating angular rate of the RSINS should match the sensor error. One optimal design method for the rotating rate of the RSINS was also proposed in this paper. Simulation and experimental results verified the validity and superiority of this optimal design method for the rotating rate of the RSINS.
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Bulik, Catharine C.; Fauntleroy, Kathy A.; Jenkins, Stephen G.; Abuali, Mayssa; LaBombardi, Vincent J.; Nicolau, David P.; Kuti, Joseph L.
2010-01-01
We describe the levels of agreement between broth microdilution, Etest, Vitek 2, Sensititre, and MicroScan methods to accurately define the meropenem MIC and categorical interpretation of susceptibility against carbapenemase-producing Klebsiella pneumoniae (KPC). A total of 46 clinical K. pneumoniae isolates with KPC genotypes, all modified Hodge test and blaKPC positive, collected from two hospitals in NY were included. Results obtained by each method were compared with those from broth microdilution (the reference method), and agreement was assessed based on MICs and Clinical Laboratory Standards Institute (CLSI) interpretative criteria using 2010 susceptibility breakpoints. Based on broth microdilution, 0%, 2.2%, and 97.8% of the KPC isolates were classified as susceptible, intermediate, and resistant to meropenem, respectively. Results from MicroScan demonstrated the most agreement with those from broth microdilution, with 95.6% agreement based on the MIC and 2.2% classified as minor errors, and no major or very major errors. Etest demonstrated 82.6% agreement with broth microdilution MICs, a very major error rate of 2.2%, and a minor error rate of 2.2%. Vitek 2 MIC agreement was 30.4%, with a 23.9% very major error rate and a 39.1% minor error rate. Sensititre demonstrated MIC agreement for 26.1% of isolates, with a 3% very major error rate and a 26.1% minor error rate. Application of FDA breakpoints had little effect on minor error rates but increased very major error rates to 58.7% for Vitek 2 and Sensititre. Meropenem MIC results and categorical interpretations for carbapenemase-producing K. pneumoniae differ by methodology. Confirmation of testing results is encouraged when an accurate MIC is required for antibiotic dosing optimization. PMID:20484603
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The spectrum of medical errors: when patients sue
Kels, Barry D; Grant-Kels, Jane M
2012-01-01
Inarguably medical errors constitute a serious, dangerous, and expensive problem for the twenty-first-century US health care system. This review examines the incidence, nature, and complexity of alleged medical negligence and medical malpractice. The authors hope this will constitute a road map to medical providers so that they can better understand the present climate and hopefully avoid the “Scylla and Charybdis” of medical errors and medical malpractice. Despite some documented success in reducing medical errors, adverse events and medical errors continue to represent an indelible stain upon the practice, reputation, and success of the US health care industry. In that regard, what may be required to successfully attack the unacceptably high severity and volume of medical errors is a locally directed and organized initiative sponsored by individual health care organizations that is coordinated, supported, and guided by state and federal governmental and nongovernmental agencies. PMID:22924008
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Human Reliability and the Cost of Doing Business
NASA Technical Reports Server (NTRS)
DeMott, D. L.
2014-01-01
Human error cannot be defined unambiguously in advance of it happening, it often becomes an error after the fact. The same action can result in a tragic accident for one situation or a heroic action given a more favorable outcome. People often forget that we employ humans in business and industry for the flexibility and capability to change when needed. In complex systems, operations are driven by their specifications of the system and the system structure. People provide the flexibility to make it work. Human error has been reported as being responsible for 60%-80% of failures, accidents and incidents in high-risk industries. We don't have to accept that all human errors are inevitable. Through the use of some basic techniques, many potential human error events can be addressed. There are actions that can be taken to reduce the risk of human error.
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Backward-gazing method for measuring solar concentrators shape errors.
Coquand, Mathieu; Henault, François; Caliot, Cyril
2017-03-01
This paper describes a backward-gazing method for measuring the optomechanical errors of solar concentrating surfaces. It makes use of four cameras placed near the solar receiver and simultaneously recording images of the sun reflected by the optical surfaces. Simple data processing then allows reconstructing the slope and shape errors of the surfaces. The originality of the method is enforced by the use of generalized quad-cell formulas and approximate mathematical relations between the slope errors of the mirrors and their reflected wavefront in the case of sun-tracking heliostats at high-incidence angles. Numerical simulations demonstrate that the measurement accuracy is compliant with standard requirements of solar concentrating optics in the presence of noise or calibration errors. The method is suited to fine characterization of the optical and mechanical errors of heliostats and their facets, or to provide better control for real-time sun tracking.
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Shahly, Victoria; Berglund, Patricia A; Coulouvrat, Catherine; Fitzgerald, Timothy; Hajak, Goeran; Roth, Thomas; Shillington, Alicia C; Stephenson, Judith J; Walsh, James K; Kessler, Ronald C
2012-10-01
Insomnia is a common and seriously impairing condition that often goes unrecognized. To examine associations of broadly defined insomnia (ie, meeting inclusion criteria for a diagnosis from International Statistical Classification of Diseases, 10th Revision, DSM-IV, or Research Diagnostic Criteria/International Classification of Sleep Disorders, Second Edition) with costly workplace accidents and errors after excluding other chronic conditions among workers in the America Insomnia Survey (AIS). A national cross-sectional telephone survey (65.0% cooperation rate) of commercially insured health plan members selected from the more than 34 million in the HealthCore Integrated Research Database. Four thousand nine hundred ninety-one employed AIS respondents. Costly workplace accidents or errors in the 12 months before the AIS interview were assessed with one question about workplace accidents "that either caused damage or work disruption with a value of $500 or more" and another about other mistakes "that cost your company $500 or more." Current insomnia with duration of at least 12 months was assessed with the Brief Insomnia Questionnaire, a validated (area under the receiver operating characteristic curve, 0.86 compared with diagnoses based on blinded clinical reappraisal interviews), fully structured diagnostic interview. Eighteen other chronic conditions were assessed with medical/pharmacy claims records and validated self-report scales. Insomnia had a significant odds ratio with workplace accidents and/or errors controlled for other chronic conditions (1.4). The odds ratio did not vary significantly with respondent age, sex, educational level, or comorbidity. The average costs of insomnia-related accidents and errors ($32 062) were significantly higher than those of other accidents and errors ($21 914). Simulations estimated that insomnia was associated with 7.2% of all costly workplace accidents and errors and 23.7% of all the costs of these incidents. These proportions are higher than for any other chronic condition, with annualized US population projections of 274 000 costly insomnia-related workplace accidents and errors having a combined value of US $31.1 billion. Effectiveness trials are needed to determine whether expanded screening, outreach, and treatment of workers with insomnia would yield a positive return on investment for employers.
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Colon cancer in Chile before and after the start of the flour fortification program with folic acid.
Hirsch, Sandra; Sanchez, Hugo; Albala, Cecilia; de la Maza, María Pía; Barrera, Gladys; Leiva, Laura; Bunout, Daniel
2009-04-01
Folate depletion is associated with an increased risk of colorectal carcinogenesis. A temporal association between folic acid fortification of enriched cereal grains and an increase in the incidence of colorectal cancer in the USA and Canada has, however, been recently reported. To compare the rates of hospital discharges owing to colon cancer in Chile before and after the start of the mandatory flour fortification program with 220 microg of synthetic folic acid/100 g of wheat flour. Cancer and cardiovascular hospital discharge rates were compared using rate ratios between two study periods, 1992-1996, before folic acid fortification and 2001-2004, after the flour fortification with folic acid was established in the country. Standard errors of the log rate ratio to derive confidence intervals, and to test the null hypothesis of no difference, were calculated. The highest rate ratio between the two periods was for colon cancer in the group aged 45-64 years (rate ratio: 2.6, confidence interval: 99% 2.93-2.58) and in the 65-79 years (rate ratio: 2.9, confidence interval: 99% 3.25-2.86). Our data provide new evidence that a folate fortification program could be associated with an additional risk of colon cancer.
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Suicide Mortality Trends in Four Provinces of Iran with the Highest Mortality, from 2006-2016.
Nazari Kangavari, Hajar; Shojaei, Ahmad; Hashemi Nazari, Seyed Saeed
2017-06-14
Suicide is a major cause of unnatural deaths in the world. Its incidence is higher in western provinces of Iran. So far, there has not been any time series analysis of suicide in western provinces. The purpose of this study was to analyze suicide mortality data from 2006 to 2016 as well as to forecast the number of suicides for 2017 in four provinces of Iran (Ilam, Kermanshah and Lorestan and Kohgiluyeh and Boyer-Ahmad). Descriptive-analytic study. Data were analyzed by time- series analysis using R software. Three automatic methods (Auto.arima, ETS (Error Transitional Seasonality) and time series linear model (TSLM)) were fitted on the data. The best model after cross validation according to the mean absolute error measure was selected for forecasting. Totally, 7004 suicidal deaths occurred of which, 4259 were male and 2745 were female. The mean age of the study population was (32.05 ± 15.48 yr). Hanging and self-immolation were the most frequent types of suicide in men and women, respectively. The maximum and minimum number of suicides was occurred in July and August as well as January respectively. It is suggested that intervention measures should be designed in order to decrease the suicide rate particularly in the age group of 15-29 yr, and implemented as a pilot study, especially in these four provinces of Iran, which have a relatively high suicide rate.
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Validation Relaxation: A Quality Assurance Strategy for Electronic Data Collection
Gordon, Nicholas; Griffiths, Thomas; Kraemer, John D; Siedner, Mark J
2017-01-01
Background The use of mobile devices for data collection in developing world settings is becoming increasingly common and may offer advantages in data collection quality and efficiency relative to paper-based methods. However, mobile data collection systems can hamper many standard quality assurance techniques due to the lack of a hardcopy backup of data. Consequently, mobile health data collection platforms have the potential to generate datasets that appear valid, but are susceptible to unidentified database design flaws, areas of miscomprehension by enumerators, and data recording errors. Objective We describe the design and evaluation of a strategy for estimating data error rates and assessing enumerator performance during electronic data collection, which we term “validation relaxation.” Validation relaxation involves the intentional omission of data validation features for select questions to allow for data recording errors to be committed, detected, and monitored. Methods We analyzed data collected during a cluster sample population survey in rural Liberia using an electronic data collection system (Open Data Kit). We first developed a classification scheme for types of detectable errors and validation alterations required to detect them. We then implemented the following validation relaxation techniques to enable data error conduct and detection: intentional redundancy, removal of “required” constraint, and illogical response combinations. This allowed for up to 11 identifiable errors to be made per survey. The error rate was defined as the total number of errors committed divided by the number of potential errors. We summarized crude error rates and estimated changes in error rates over time for both individuals and the entire program using logistic regression. Results The aggregate error rate was 1.60% (125/7817). Error rates did not differ significantly between enumerators (P=.51), but decreased for the cohort with increasing days of application use, from 2.3% at survey start (95% CI 1.8%-2.8%) to 0.6% at day 45 (95% CI 0.3%-0.9%; OR=0.969; P<.001). The highest error rate (84/618, 13.6%) occurred for an intentional redundancy question for a birthdate field, which was repeated in separate sections of the survey. We found low error rates (0.0% to 3.1%) for all other possible errors. Conclusions A strategy of removing validation rules on electronic data capture platforms can be used to create a set of detectable data errors, which can subsequently be used to assess group and individual enumerator error rates, their trends over time, and categories of data collection that require further training or additional quality control measures. This strategy may be particularly useful for identifying individual enumerators or systematic data errors that are responsive to enumerator training and is best applied to questions for which errors cannot be prevented through training or software design alone. Validation relaxation should be considered as a component of a holistic data quality assurance strategy. PMID:28821474
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Validation Relaxation: A Quality Assurance Strategy for Electronic Data Collection.
Kenny, Avi; Gordon, Nicholas; Griffiths, Thomas; Kraemer, John D; Siedner, Mark J
2017-08-18
The use of mobile devices for data collection in developing world settings is becoming increasingly common and may offer advantages in data collection quality and efficiency relative to paper-based methods. However, mobile data collection systems can hamper many standard quality assurance techniques due to the lack of a hardcopy backup of data. Consequently, mobile health data collection platforms have the potential to generate datasets that appear valid, but are susceptible to unidentified database design flaws, areas of miscomprehension by enumerators, and data recording errors. We describe the design and evaluation of a strategy for estimating data error rates and assessing enumerator performance during electronic data collection, which we term "validation relaxation." Validation relaxation involves the intentional omission of data validation features for select questions to allow for data recording errors to be committed, detected, and monitored. We analyzed data collected during a cluster sample population survey in rural Liberia using an electronic data collection system (Open Data Kit). We first developed a classification scheme for types of detectable errors and validation alterations required to detect them. We then implemented the following validation relaxation techniques to enable data error conduct and detection: intentional redundancy, removal of "required" constraint, and illogical response combinations. This allowed for up to 11 identifiable errors to be made per survey. The error rate was defined as the total number of errors committed divided by the number of potential errors. We summarized crude error rates and estimated changes in error rates over time for both individuals and the entire program using logistic regression. The aggregate error rate was 1.60% (125/7817). Error rates did not differ significantly between enumerators (P=.51), but decreased for the cohort with increasing days of application use, from 2.3% at survey start (95% CI 1.8%-2.8%) to 0.6% at day 45 (95% CI 0.3%-0.9%; OR=0.969; P<.001). The highest error rate (84/618, 13.6%) occurred for an intentional redundancy question for a birthdate field, which was repeated in separate sections of the survey. We found low error rates (0.0% to 3.1%) for all other possible errors. A strategy of removing validation rules on electronic data capture platforms can be used to create a set of detectable data errors, which can subsequently be used to assess group and individual enumerator error rates, their trends over time, and categories of data collection that require further training or additional quality control measures. This strategy may be particularly useful for identifying individual enumerators or systematic data errors that are responsive to enumerator training and is best applied to questions for which errors cannot be prevented through training or software design alone. Validation relaxation should be considered as a component of a holistic data quality assurance strategy. ©Avi Kenny, Nicholas Gordon, Thomas Griffiths, John D Kraemer, Mark J Siedner. Originally published in the Journal of Medical Internet Research (http://www.jmir.org), 18.08.2017.
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Safety in the operating theatre--part 1: interpersonal relationships and team performance
NASA Technical Reports Server (NTRS)
Schaefer, H. G.; Helmreich, R. L.; Scheidegger, D.
1995-01-01
The authors examine the application of interpersonal human factors training on operating room (OR) personnel. Mortality studies of OR deaths and critical incident studies of anesthesia are examined to determine the role of human error in OR incidents. Theoretical models of system vulnerability to accidents are presented with emphasis on a systems approach to OR performance. Input, process, and outcome factors are discussed in detail.
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EHR Improvement Using Incident Reports.
Teame, Tesfay; Stålhane, Tor; Nytrø, Øystein
2017-01-01
This paper discusses reactive improvement of clinical software using methods for incident analysis. We used the "Five Whys" method because we had only descriptive data and depended on a domain expert for the analysis. The analysis showed that there are two major root causes for EHR software failure, and that they are related to human and organizational errors. A main identified improvement is allocating more resources to system maintenance and user training.
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Cui, Kai; Shen, Fuhai; Han, Bing; Yuan, Juxiang; Suo, Xia; Qin, Tianbang; Liu, Hongbo; Chen, Jie
2015-01-01
The purpose of this study was to identify differences in the incidence characteristics of coal workers’ pneumoconiosis (CWP) based on data from four large state-owned colliery groups of China, by comparing the cumulative incidence rates of CWP. We investigated 87,904 coal workers from the Datong, Kailuan, Fuxin, and Tiefa Colliery Groups, who were exposed to dust for at least 1 year. The cumulative incidence rate of CWP was calculated with the life-table method and stratified analysis among coal workers with different occupational categories during different years of first dust exposure. Our results showed the cumulative incidence rate of Datong was higher than that of any other colliery group among workers with different occupational categories during different years of first dust exposure. For Datong workers who started their dust exposure in the 1970s, the cumulative incidence rates of CWP among tunneling, mining, combining, and helping workers were 34.77%, 10.20%, 34.59%, and 4.91% during the observed time of 34 years, respectively. For those in the 1980s, the cumulative incidence rates were 32.29%, 13.51%, 2.98%, and 0.47%, respectively. The cumulative incidence rates of Fuxin and Tiefa were the lowest. In conclusion, the Datong colliery has the highest cumulative incidence rate of CWP among the four studied collieries, followed by Kailuan. The cumulative incidence rates of Fuxin and Tiefa were the lowest. Additional dust-proofing measures for decreasing dust concentrations are still necessary. PMID:26133134
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Kawado, Miyuki; Hashimoto, Shuji; Murakami, Yoshitaka; Izumida, Michiko; Ohta, Akiko; Tada, Yuki; Shigematsu, Mika; Yasui, Yoshinori; Taniguchi, Kiyosu; Nagai, Masaki
2008-01-01
BACKGROUND The method for estimating incidence of infectious diseases from sentinel surveillance data has been proposed. In Japan, although the annual incidence rates of influenza and pediatric diseases estimated using the method were reported, their weekly incidence rates have not. METHODS The weekly sex- and age-specific numbers of cases in the sentinel medical institutions in the National Epidemiological Surveillance of Infectious Diseases in Japan in 2002-2005 were used. Annual and weekly incidence rates of influenza and 12 pediatric diseases were estimated by the above-mentioned method, under the assumption that sentinels are randomly selected from all medical institutions. RESULTS The annual incidence rate of influenza in 2002-2005 was 57.7-142.6 per 1,000 population. The highest weekly incidence rate was 7.4 at week 8 in 2002, 14.9 at week 4 in 2003, 14.1 at week 5 in 2004, and 21.2 at week 9 in 2005. The annual incidence rate per 1,000 population of 0-14 years old in 2002-2005 was less than 5.0 for pertussis, rubella and measles, 293.2-320.8 for infectious gastroenteritis, and 5.3-89.6 for 8 other diseases. The highest weekly incidence rate was less than 1.0 for exanthem subitum, and was more than 5.0 for infectious gastroenteritis, hand-foot-mouth disease and herpangina. CONCLUSION We estimated annual and weekly incidence rates of influenza and pediatric diseases in Japan in 2002-2005, and described their temporal variation. PMID:18239340
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Goldberg, Kenneth A; Yashchuk, Valeriy V
2016-05-01
For glancing-incidence optical systems, such as short-wavelength optics used for nano-focusing, incorporating physical factors in the calculations used for shape optimization can improve performance. Wavefront metrology, including the measurement of a mirror's shape or slope, is routinely used as input for mirror figure optimization on mirrors that can be bent, actuated, positioned, or aligned. Modeling shows that when the incident power distribution, distance from focus, angle of incidence, and the spatially varying reflectivity are included in the optimization, higher Strehl ratios can be achieved. Following the works of Maréchal and Mahajan, optimization of the Strehl ratio (for peak intensity with a coherently illuminated system) occurs when the expectation value of the phase error's variance is minimized. We describe an optimization procedure based on regression analysis that incorporates these physical parameters. This approach is suitable for coherently illuminated systems of nearly diffraction-limited quality. Mathematically, this work is an enhancement of the methods commonly applied for ex situ alignment based on uniform weighting of all points on the surface (or a sub-region of the surface). It follows a similar approach to the optimization of apodized and non-uniformly illuminated optical systems. Significantly, it reaches a different conclusion than a more recent approach based on minimization of focal plane ray errors.
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NASA Technical Reports Server (NTRS)
Olson, William S.; Kummerow, Christian D.; Yang, Song; Petty, Grant W.; Tao, Wei-Kuo; Bell, Thomas L.; Braun, Scott A.; Wang, Yansen; Lang, Stephen E.; Johnson, Daniel E.;
2006-01-01
A revised Bayesian algorithm for estimating surface rain rate, convective rain proportion, and latent heating profiles from satellite-borne passive microwave radiometer observations over ocean backgrounds is described. The algorithm searches a large database of cloud-radiative model simulations to find cloud profiles that are radiatively consistent with a given set of microwave radiance measurements. The properties of these radiatively consistent profiles are then composited to obtain best estimates of the observed properties. The revised algorithm is supported by an expanded and more physically consistent database of cloud-radiative model simulations. The algorithm also features a better quantification of the convective and nonconvective contributions to total rainfall, a new geographic database, and an improved representation of background radiances in rain-free regions. Bias and random error estimates are derived from applications of the algorithm to synthetic radiance data, based upon a subset of cloud-resolving model simulations, and from the Bayesian formulation itself. Synthetic rain-rate and latent heating estimates exhibit a trend of high (low) bias for low (high) retrieved values. The Bayesian estimates of random error are propagated to represent errors at coarser time and space resolutions, based upon applications of the algorithm to TRMM Microwave Imager (TMI) data. Errors in TMI instantaneous rain-rate estimates at 0.5 -resolution range from approximately 50% at 1 mm/h to 20% at 14 mm/h. Errors in collocated spaceborne radar rain-rate estimates are roughly 50%-80% of the TMI errors at this resolution. The estimated algorithm random error in TMI rain rates at monthly, 2.5deg resolution is relatively small (less than 6% at 5 mm day.1) in comparison with the random error resulting from infrequent satellite temporal sampling (8%-35% at the same rain rate). Percentage errors resulting from sampling decrease with increasing rain rate, and sampling errors in latent heating rates follow the same trend. Averaging over 3 months reduces sampling errors in rain rates to 6%-15% at 5 mm day.1, with proportionate reductions in latent heating sampling errors.
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Epidemiology of traumatic spinal cord injuries in Austria 2002-2012.
Majdan, Marek; Brazinova, Alexandra; Mauritz, Walter
2016-01-01
The aim of this study was to analyse the epidemiological patterns (mortality, incidence of non-fatal cases and overall incidence), of traumatic spinal cord injuries (TSCI) in 2002-2012 in Austria. TSCI-related deaths and hospital admissions in Austria 2002-2012 were obtained from Statistics Austria and analysed. Mortality rates, as well as non-fatal and overall incidence rates were calculated and compared across the age spectrum and by sex. Additionally, the main causes and demographic characteristics of victims were analysed. The crude overall incidence rate of TSCI was 16.96, CI 95 % 16.95-16.97 and the standardized incidence rate was 13.98, CI 95 % 13.97-13.99 per million (annual average rate). An annual increase in fatality rates was observed occurring mostly in the age group >65 years (Kendall's Tau = 0.1). Falls (mortality rate 19.58, CI 95 % 19.57-19.59) and injuries at home (incidence rate 56.57, CI 95 % 56.56-56.58) were the principal causes of fatal and non-fatal TSCI, respectively. Injuries to the neck region were the most common. All indicators were the highest for the age group >65 years: non-fatal incidence rate 23.55, CI 95 % 23.54-23.56; mortality rate 21.4, CI 95 % 21.39-21.41; and overall incidence rate 47.9, CI 95 % 47.89-47.91. A clear male dominance was observed (incidence rate ratio 1.9, CI 95 % 1.4-2.7). The population >65 years has been at the highest risk of TSCI in Austria for the analysed period and therefore preventive activities should be focused on this group. The increasing overall incidence of TSCI was driven by the increasing mortality rates that were highest in the age group >65 years. We advocate harmonization of epidemiological reporting especially regarding aetiology of TSCI in order to better inform policy makers and prevention.
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De Oliveira, Gildasio S; Rahmani, Rod; Fitzgerald, Paul C; Chang, Ray; McCarthy, Robert J
2013-04-01
Poor supervision of physician trainees can be detrimental not only to resident education but also to patient care and safety. Inadequate supervision has been associated with more frequent deaths of patients under the care of junior residents. We hypothesized that residents reporting more medical errors would also report lower quality of supervision scores than the ones with lower reported medical errors. The primary objective of this study was to evaluate the association between the frequency of medical errors reported by residents and their perceived quality of faculty supervision. A cross-sectional nationwide survey was sent to 1000 residents randomly selected from anesthesiology training departments across the United States. Residents from 122 residency programs were invited to participate, the median (interquartile range) per institution was 7 (4-11). Participants were asked to complete a survey assessing demography, perceived quality of faculty supervision, and perceived causes of inadequate perceived supervision. Responses to the statements "I perform procedures for which I am not properly trained," "I make mistakes that have negative consequences for the patient," and "I have made a medication error (drug or incorrect dose) in the last year" were used to assess error rates. Average supervision scores were determined using the De Oliveira Filho et al. scale and compared among the frequency of self-reported error categories using the Kruskal-Wallis test. Six hundred four residents responded to the survey (60.4%). Forty-five (7.5%) of the respondents reported performing procedures for which they were not properly trained, 24 (4%) reported having made mistakes with negative consequences to patients, and 16 (3%) reported medication errors in the last year having occurred multiple times or often. Supervision scores were inversely correlated with the frequency of reported errors for all 3 questions evaluating errors. At a cutoff value of 3, supervision scores demonstrated an overall accuracy (area under the curve) (99% confidence interval) of 0.81 (0.73-0.86), 0.89 (0.77-0.95), and 0.93 (0.77-0.98) for predicting a response of multiple times or often to the question of performing procedures for which they were not properly trained, reported mistakes with negative consequences to patients, and reported medication errors in the last year, respectively. Anesthesiology trainees who reported a greater incidence of medical errors with negative consequences to patients and drug errors also reported lower scores for supervision by faculty. Our findings suggest that further studies of the association between supervision and patient safety are warranted. (Anesth Analg 2013;116:892-7).
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Levy, Michael; Leclerc, Bernard-Simon
2012-04-01
It has been suggested that fluoride in drinking water may increase the risk of osteosarcoma in children and adolescents, although the evidence is inconclusive. We investigated the association between community water fluoridation (CWF) and osteosarcoma in childhood and adolescence in the continental U.S. We used the cumulative osteosarcoma incidence rate data from the CDC Wonder database for 1999-2006, categorized by age group, sex and states. States were categorized as low (≤30%) or high (≥85%) according to the percentage of the population receiving CWF between 1992 and 2006. Confidence intervals for the incidence rates were calculated using the Gamma distribution and the incidence rates were compared between groups using Poisson regression models. We found no sex-specific statistical differences in the national incidence rates in the younger groups (5-9, 10-14), although 15-19 males were at higher risk to osteosarcoma than females in the same age group (p<0.001). Sex and age group specific incidence rates were similar in both CWF state categories. The higher incidence rates among 15-19 year old males vs females was not associated with the state fluoridation status. We also compared sex and age specific osteosarcoma incidence rates cumulated from 1973 to 2007 from the SEER 9 Cancer Registries for single age groups from 5 to 19. There were no statistical differences between sexes for 5-14 year old children although incidence rates for single age groups for 15-19 year old males were significantly higher than for females. Our ecological analysis suggests that the water fluoridation status in the continental U.S. has no influence on osteosarcoma incidence rates during childhood and adolescence. Copyright © 2011 Elsevier Ltd. All rights reserved.
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Mogensen, Kris M; Andrew, Benjamin Y; Corona, Jasmine C; Robinson, Malcolm K
2016-07-01
The Society of Critical Care Medicine (SCCM) and American Society for Parenteral and Enteral Nutrition (ASPEN) recommend that obese, critically ill patients receive 11-14 kcal/kg/d using actual body weight (ABW) or 22-25 kcal/kg/d using ideal body weight (IBW), because feeding these patients 50%-70% maintenance needs while administering high protein may improve outcomes. It is unknown whether these equations achieve this target when validated against indirect calorimetry, perform equally across all degrees of obesity, or compare well with other equations. Measured resting energy expenditure (MREE) was determined in obese (body mass index [BMI] ≥30 kg/m(2)), critically ill patients. Resting energy expenditure was predicted (PREE) using several equations: 12.5 kcal/kg ABW (ASPEN-Actual BW), 23.5 kcal/kg IBW (ASPEN-Ideal BW), Harris-Benedict (adjusted-weight and 1.5 stress-factor), and Ireton-Jones for obesity. Correlation of PREE to 65% MREE, predictive accuracy, precision, bias, and large error incidence were calculated. All equations were significantly correlated with 65% MREE but had poor predictive accuracy, had excessive large error incidence, were imprecise, and were biased in the entire cohort (N = 31). In the obesity cohort (n = 20, BMI 30-50 kg/m(2)), ASPEN-Actual BW had acceptable predictive accuracy and large error incidence, was unbiased, and was nearly precise. In super obesity (n = 11, BMI >50 kg/m(2)), ASPEN-Ideal BW had acceptable predictive accuracy and large error incidence and was precise and unbiased. SCCM/ASPEN-recommended body weight equations are reasonable predictors of 65% MREE depending on the equation and degree of obesity. Assuming that feeding 65% MREE is appropriate, this study suggests that patients with a BMI 30-50 kg/m(2) should receive 11-14 kcal/kg/d using ABW and those with a BMI >50 kg/m(2) should receive 22-25 kcal/kg/d using IBW. © 2015 American Society for Parenteral and Enteral Nutrition.
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Analysis of significant factors for dengue fever incidence prediction.
Siriyasatien, Padet; Phumee, Atchara; Ongruk, Phatsavee; Jampachaisri, Katechan; Kesorn, Kraisak
2016-04-16
Many popular dengue forecasting techniques have been used by several researchers to extrapolate dengue incidence rates, including the K-H model, support vector machines (SVM), and artificial neural networks (ANN). The time series analysis methodology, particularly ARIMA and SARIMA, has been increasingly applied to the field of epidemiological research for dengue fever, dengue hemorrhagic fever, and other infectious diseases. The main drawback of these methods is that they do not consider other variables that are associated with the dependent variable. Additionally, new factors correlated to the disease are needed to enhance the prediction accuracy of the model when it is applied to areas of similar climates, where weather factors such as temperature, total rainfall, and humidity are not substantially different. Such drawbacks may consequently lower the predictive power for the outbreak. The predictive power of the forecasting model-assessed by Akaike's information criterion (AIC), Bayesian information criterion (BIC), and the mean absolute percentage error (MAPE)-is improved by including the new parameters for dengue outbreak prediction. This study's selected model outperforms all three other competing models with the lowest AIC, the lowest BIC, and a small MAPE value. The exclusive use of climate factors from similar locations decreases a model's prediction power. The multivariate Poisson regression, however, effectively forecasts even when climate variables are slightly different. Female mosquitoes and seasons were strongly correlated with dengue cases. Therefore, the dengue incidence trends provided by this model will assist the optimization of dengue prevention. The present work demonstrates the important roles of female mosquito infection rates from the previous season and climate factors (represented as seasons) in dengue outbreaks. Incorporating these two factors in the model significantly improves the predictive power of dengue hemorrhagic fever forecasting models, as confirmed by AIC, BIC, and MAPE.
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Jatoi, Aminah; Dakhil, Shaker R; Sloan, Jeff A; Kugler, John W; Rowland, Kendrith M; Schaefer, Paul L; Novotny, Paul J; Wender, Donald B; Gross, Howard M; Loprinzi, Charles L
2011-10-01
Previous studies suggest tetracycline and other antibiotics lessen the severity of epidermal growth factor receptor (EGFR) inhibitor-induced rash. This study sought to confirm such findings. Patients starting an EGFR inhibitor were eligible for this randomized, double-blinded, placebo-controlled study and had to be rash-free. They were then randomly assigned to tetracycline 500 mg orally twice a day for 28 days versus a placebo. Rash development and severity (monthly physician assessment and weekly patient-reported questionnaires), quality of life (SKINDEX-16), and adverse events were monitored during the 4-week intervention and then for an additional 4 weeks. The primary objective was to compare the incidence of grade 2 or worse rash between study arms; 32 patients per group provided a 90% probability of detecting a 40% difference in incidence with a type I error rate of 0.05 (two-sided). Sixty-five patients were enrolled, and groups were balanced on baseline characteristics. During the first 4 weeks, healthcare provider-reported data found that 27 tetracycline-treated patients (82%) and 24 placebo-exposed patients (75%) developed a rash. This rash was a grade 2+ in 17 (52%) and 14 (44%), respectively (p = 0.62). Comparable grade 2+ rash rates were observed during weeks 5 through 8 as well as with patient-reported rash data throughout the study period. Quality of life was comparable across study arms, and tetracycline was well tolerated. Although previous studies suggest otherwise, this randomized, double-blinded, placebo-controlled study did not find that tetracycline lessened rash incidence or severity in patients who were taking EGFR inhibitors.
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An error criterion for determining sampling rates in closed-loop control systems
NASA Technical Reports Server (NTRS)
Brecher, S. M.
1972-01-01
The determination of an error criterion which will give a sampling rate for adequate performance of linear, time-invariant closed-loop, discrete-data control systems was studied. The proper modelling of the closed-loop control system for characterization of the error behavior, and the determination of an absolute error definition for performance of the two commonly used holding devices are discussed. The definition of an adequate relative error criterion as a function of the sampling rate and the parameters characterizing the system is established along with the determination of sampling rates. The validity of the expressions for the sampling interval was confirmed by computer simulations. Their application solves the problem of making a first choice in the selection of sampling rates.
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Experimental investigation of false positive errors in auditory species occurrence surveys
Miller, David A.W.; Weir, Linda A.; McClintock, Brett T.; Grant, Evan H. Campbell; Bailey, Larissa L.; Simons, Theodore R.
2012-01-01
False positive errors are a significant component of many ecological data sets, which in combination with false negative errors, can lead to severe biases in conclusions about ecological systems. We present results of a field experiment where observers recorded observations for known combinations of electronically broadcast calling anurans under conditions mimicking field surveys to determine species occurrence. Our objectives were to characterize false positive error probabilities for auditory methods based on a large number of observers, to determine if targeted instruction could be used to reduce false positive error rates, and to establish useful predictors of among-observer and among-species differences in error rates. We recruited 31 observers, ranging in abilities from novice to expert, that recorded detections for 12 species during 180 calling trials (66,960 total observations). All observers made multiple false positive errors and on average 8.1% of recorded detections in the experiment were false positive errors. Additional instruction had only minor effects on error rates. After instruction, false positive error probabilities decreased by 16% for treatment individuals compared to controls with broad confidence interval overlap of 0 (95% CI: -46 to 30%). This coincided with an increase in false negative errors due to the treatment (26%; -3 to 61%). Differences among observers in false positive and in false negative error rates were best predicted by scores from an online test and a self-assessment of observer ability completed prior to the field experiment. In contrast, years of experience conducting call surveys was a weak predictor of error rates. False positive errors were also more common for species that were played more frequently, but were not related to the dominant spectral frequency of the call. Our results corroborate other work that demonstrates false positives are a significant component of species occurrence data collected by auditory methods. Instructing observers to only report detections they are completely certain are correct is not sufficient to eliminate errors. As a result, analytical methods that account for false positive errors will be needed, and independent testing of observer ability is a useful predictor for among-observer variation in observation error rates.
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Chi, Jen-Hao; Wu, Sheng-Hung; Shu, Chi-Min
2009-11-15
In the past, process incidents attributed to organic peroxides (OPs) that involved near misses, over-pressures, runaway reactions, and thermal explosions occurred because of poor training, human error, incorrect kinetic assumptions, insufficient change management, and inadequate chemical knowledge in the manufacturing process. Calorimetric applications were employed broadly to test organic peroxides on a small-scale because of their thermal hazards, such as exothermic behavior and self-accelerating decomposition in the laboratory. In essence, methyl ethyl ketone peroxide (MEKPO) is highly reactive and exothermically unstable. In recent years, it has undergone many thermal explosions and runaway reaction incidents in the manufacturing process. Differential scanning calorimetry (DSC), vent sizing package 2 (VSP2), and thermal activity monitor (TAM) were employed to analyze thermokinetic parameters and safety index. The intent of the analyses was to facilitate the use of various auto-alarm equipments to detect over-pressure, over-temperature, and hazardous materials leaks for a wide spectrum of operations. Results indicated that MEKPO decomposition is detected at low temperatures (30-40 degrees C), and the rate of decomposition was shown to exponentially increase with temperature and pressure. Determining time to maximum rate (TMR), self-accelerating decomposition temperature (SADT), maximum temperature (T(max)), exothermic onset temperature (T(0)), and heat of decomposition (DeltaH(d)) was essential for identifying early-stage runaway reactions effectively for industries.
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... Cited for MBC Statistics for Metastatic Breast Cancer Incidence and Incidence Rates Staging Trends Who Gets Breast Cancer? Death & ... Cited for MBC Statistics for Metastatic Breast Cancer Incidence and Incidence Rates Staging Trends Who Gets Breast ...
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[Improvement of team competence in the operating room : Training programs from aviation].
Schmidt, C E; Hardt, F; Möller, J; Malchow, B; Schmidt, K; Bauer, M
2010-08-01
Growing attention has been drawn to patient safety during recent months due to media reports of clinical errors. To date only clinical incident reporting systems have been implemented in acute care hospitals as instruments of risk management. However, these systems only have a limited impact on human factors which account for the majority of all errors in medicine. Crew resource management (CRM) starts here. For the commissioning of a new hospital in Minden, training programs were installed in order to maintain patient safety in a new complex environment. The training was planned in three parts: All relevant processes were defined as standard operating procedures (SOP), visualized and then simulated in the new building. In addition, staff members (trainers) in leading positions were trained in CRM in order to train the complete staff. The training programs were analyzed by questionnaires. Selection of topics, relevance for practice and mode of presentation were rated as very good by 73% of the participants. The staff members ranked the topics communication in crisis situations, individual errors and compensating measures as most important followed by case studies and teamwork. Employees improved in compliance to the SOP, team competence and communication. In high technology environments with escalating workloads and interdisciplinary organization, staff members are confronted with increasing demands in knowledge and skills. To reduce errors under such working conditions relevant processes should be standardized and trained for the emergency situation. Human performance can be supported by well-trained interpersonal skills which are evolved in CRM training. In combination these training programs make a significant contribution to maintaining patient safety.
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Pressure Ulcers in Elderly Hip Fracture Patients Across the Continuum of Care
Baumgarten, Mona; Margolis, David J.; Orwig, Denise L.; Shardell, Michelle D.; Hawkes, William G.; Langenberg, Patricia; Palmer, Mary H.; Jones, Patricia S.; McArdle, Patrick F.; Sterling, Robert; Kinosian, Bruce P.; Rich, Shayna E.; Sowinski, Janice; Magaziner, Jay
2012-01-01
Objectives The aim of this study was to identify care settings associated with increased pressure ulcer risk among elderly hip fracture patients in the post-fracture period. Design Prospective cohort study. Setting Nine hospitals that participate in the Baltimore Hip Studies network and 105 postacute facilities to which patients from these hospitals were discharged. Participants Hip fracture patients age ≥65 years who underwent surgery for hip fracture. Measurements A full-body skin examination was conducted at baseline (as soon as possible after hospital admission) and repeated on alternating days for 21 days. Patients were deemed to have an acquired pressure ulcer (APU) if they developed ≥1 new pressure ulcers stage 2 or higher following hospital admission. Results Among 658 study participants, the APU cumulative incidence at 32 days after initial hospital admission was 36.1% (standard error 2.5%). Compared to home, the adjusted APU incidence rate was highest during the initial acute hospital stay (relative rate [RR] 2.2, 95% confidence interval [CI] 1.3–3.7) and during re-admission to the acute hospital (RR 2.2, 95% CI 1.1–4.2). The relative rates in rehabilitation and nursing home settings were 1.4 (95% CI 0.8–2.3) and 1.3 (95% CI 0.8–2.1), respectively. Conclusion Approximately one-third of hip fracture patients developed an APU during the study period. The rate was highest in the acute setting, a finding that is significant in light of Medicare’s policy of not reimbursing hospitals for the treatment of hospital-acquired pressure ulcers. Hip fracture patients constitute an important group to target for pressure ulcer prevention in hospitals. PMID:19484841
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Grady, Sue C; Enander, Helen
2009-01-01
Background Infant mortality is a major public health problem in the State of Michigan and the United States. The primary adverse reproductive outcome underlying infant mortality is low birthweight. Visualizing and exploring the spatial patterns of low birthweight and infant mortality rates and standardized incidence and mortality ratios is important for generating mechanistic hypotheses, targeting high-risk neighborhoods for monitoring and implementing maternal and child health intervention and prevention programs and evaluating the need for health care services. This study investigates the spatial patterns of low birthweight and infant mortality in the State of Michigan using automated zone matching (AZM) methodology and minimum case and population threshold recommendations provided by the National Center for Health Statistics and the US Census Bureau to calculate stable rates and standardized incidence and mortality ratios at the Zip Code (n = 896) level. The results from this analysis are validated using SaTScan. Vital statistics birth (n = 370,587) and linked infant death (n = 2,972) records obtained from the Michigan Department of Community Health and aggregated for the years 2004 to 2006 are utilized. Results For a majority of Zip Codes the relative standard errors (RSEs) of rates calculated prior to AZM were greater than 20%. Spurious results were the result of too few case and birth counts. Applying AZM with a target population of 25 cases and minimum threshold of 20 cases resulted in the reconstruction of zones with at least 50 births and RSEs of rates 20–22% and below respectively, demonstrating the stability reliability of these new estimates. Other AZM parameters included homogeneity constraints on maternal race and maximum shape compactness of zones to minimize potential confounding. AZM identified areas with elevated low birthweight and infant mortality rates and standardized incidence and mortality ratios. Most but not all of these areas were also detected by SaTScan. Conclusion Understanding the spatial patterns of low birthweight and infant deaths in Michigan was an important first step in conducting a geographic evaluation of the State's reported high infant mortality rates. AZM proved to be a useful tool for visualizing and exploring the spatial patterns of low birthweight and infant deaths for public health surveillance. Future research should also consider AZM as a tool for health services research. PMID:19224644
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Grady, Sue C; Enander, Helen
2009-02-18
Infant mortality is a major public health problem in the State of Michigan and the United States. The primary adverse reproductive outcome underlying infant mortality is low birthweight. Visualizing and exploring the spatial patterns of low birthweight and infant mortality rates and standardized incidence and mortality ratios is important for generating mechanistic hypotheses, targeting high-risk neighborhoods for monitoring and implementing maternal and child health intervention and prevention programs and evaluating the need for health care services. This study investigates the spatial patterns of low birthweight and infant mortality in the State of Michigan using automated zone matching (AZM) methodology and minimum case and population threshold recommendations provided by the National Center for Health Statistics and the US Census Bureau to calculate stable rates and standardized incidence and mortality ratios at the Zip Code (n = 896) level. The results from this analysis are validated using SaTScan. Vital statistics birth (n = 370,587) and linked infant death (n = 2,972) records obtained from the Michigan Department of Community Health and aggregated for the years 2004 to 2006 are utilized. For a majority of Zip Codes the relative standard errors (RSEs) of rates calculated prior to AZM were greater than 20%. Spurious results were the result of too few case and birth counts. Applying AZM with a target population of 25 cases and minimum threshold of 20 cases resulted in the reconstruction of zones with at least 50 births and RSEs of rates 20-22% and below respectively, demonstrating the stability reliability of these new estimates. Other AZM parameters included homogeneity constraints on maternal race and maximum shape compactness of zones to minimize potential confounding. AZM identified areas with elevated low birthweight and infant mortality rates and standardized incidence and mortality ratios. Most but not all of these areas were also detected by SaTScan. Understanding the spatial patterns of low birthweight and infant deaths in Michigan was an important first step in conducting a geographic evaluation of the State's reported high infant mortality rates. AZM proved to be a useful tool for visualizing and exploring the spatial patterns of low birthweight and infant deaths for public health surveillance. Future research should also consider AZM as a tool for health services research.
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Technological Advancements and Error Rates in Radiation Therapy Delivery
DOE Office of Scientific and Technical Information (OSTI.GOV)
Margalit, Danielle N., E-mail: dmargalit@partners.org; Harvard Cancer Consortium and Brigham and Women's Hospital/Dana Farber Cancer Institute, Boston, MA; Chen, Yu-Hui
2011-11-15
Purpose: Technological advances in radiation therapy (RT) delivery have the potential to reduce errors via increased automation and built-in quality assurance (QA) safeguards, yet may also introduce new types of errors. Intensity-modulated RT (IMRT) is an increasingly used technology that is more technically complex than three-dimensional (3D)-conformal RT and conventional RT. We determined the rate of reported errors in RT delivery among IMRT and 3D/conventional RT treatments and characterized the errors associated with the respective techniques to improve existing QA processes. Methods and Materials: All errors in external beam RT delivery were prospectively recorded via a nonpunitive error-reporting system atmore » Brigham and Women's Hospital/Dana Farber Cancer Institute. Errors are defined as any unplanned deviation from the intended RT treatment and are reviewed during monthly departmental quality improvement meetings. We analyzed all reported errors since the routine use of IMRT in our department, from January 2004 to July 2009. Fisher's exact test was used to determine the association between treatment technique (IMRT vs. 3D/conventional) and specific error types. Effect estimates were computed using logistic regression. Results: There were 155 errors in RT delivery among 241,546 fractions (0.06%), and none were clinically significant. IMRT was commonly associated with errors in machine parameters (nine of 19 errors) and data entry and interpretation (six of 19 errors). IMRT was associated with a lower rate of reported errors compared with 3D/conventional RT (0.03% vs. 0.07%, p = 0.001) and specifically fewer accessory errors (odds ratio, 0.11; 95% confidence interval, 0.01-0.78) and setup errors (odds ratio, 0.24; 95% confidence interval, 0.08-0.79). Conclusions: The rate of errors in RT delivery is low. The types of errors differ significantly between IMRT and 3D/conventional RT, suggesting that QA processes must be uniquely adapted for each technique. There was a lower error rate with IMRT compared with 3D/conventional RT, highlighting the need for sustained vigilance against errors common to more traditional treatment techniques.« less
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Error Rate Comparison during Polymerase Chain Reaction by DNA Polymerase
McInerney, Peter; Adams, Paul; Hadi, Masood Z.
2014-01-01
As larger-scale cloning projects become more prevalent, there is an increasing need for comparisons among high fidelity DNA polymerases used for PCR amplification. All polymerases marketed for PCR applications are tested for fidelity properties (i.e., error rate determination) by vendors, and numerous literature reports have addressed PCR enzyme fidelity. Nonetheless, it is often difficult to make direct comparisons among different enzymes due to numerous methodological and analytical differences from study to study. We have measured the error rates for 6 DNA polymerases commonly used in PCR applications, including 3 polymerases typically used for cloning applications requiring high fidelity. Error ratemore » measurement values reported here were obtained by direct sequencing of cloned PCR products. The strategy employed here allows interrogation of error rate across a very large DNA sequence space, since 94 unique DNA targets were used as templates for PCR cloning. The six enzymes included in the study, Taq polymerase, AccuPrime-Taq High Fidelity, KOD Hot Start, cloned Pfu polymerase, Phusion Hot Start, and Pwo polymerase, we find the lowest error rates with Pfu , Phusion, and Pwo polymerases. Error rates are comparable for these 3 enzymes and are >10x lower than the error rate observed with Taq polymerase. Mutation spectra are reported, with the 3 high fidelity enzymes displaying broadly similar types of mutations. For these enzymes, transition mutations predominate, with little bias observed for type of transition.« less
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NASA Astrophysics Data System (ADS)
Rahmat, R. F.; Nasution, F. R.; Seniman; Syahputra, M. F.; Sitompul, O. S.
2018-02-01
Weather is condition of air in a certain region at a relatively short period of time, measured with various parameters such as; temperature, air preasure, wind velocity, humidity and another phenomenons in the atmosphere. In fact, extreme weather due to global warming would lead to drought, flood, hurricane and other forms of weather occasion, which directly affects social andeconomic activities. Hence, a forecasting technique is to predict weather with distinctive output, particullary mapping process based on GIS with information about current weather status in certain cordinates of each region with capability to forecast for seven days afterward. Data used in this research are retrieved in real time from the server openweathermap and BMKG. In order to obtain a low error rate and high accuracy of forecasting, the authors use Bayesian Model Averaging (BMA) method. The result shows that the BMA method has good accuracy. Forecasting error value is calculated by mean square error shows (MSE). The error value emerges at minumum temperature rated at 0.28 and maximum temperature rated at 0.15. Meanwhile, the error value of minimum humidity rates at 0.38 and the error value of maximum humidity rates at 0.04. Afterall, the forecasting error rate of wind speed is at 0.076. The lower the forecasting error rate, the more optimized the accuracy is.
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Schwantes-An, Tae-Hwi; Sung, Heejong; Sabourin, Jeremy A; Justice, Cristina M; Sorant, Alexa J M; Wilson, Alexander F
2016-01-01
In this study, the effects of (a) the minor allele frequency of the single nucleotide variant (SNV), (b) the degree of departure from normality of the trait, and (c) the position of the SNVs on type I error rates were investigated in the Genetic Analysis Workshop (GAW) 19 whole exome sequence data. To test the distribution of the type I error rate, 5 simulated traits were considered: standard normal and gamma distributed traits; 2 transformed versions of the gamma trait (log 10 and rank-based inverse normal transformations); and trait Q1 provided by GAW 19. Each trait was tested with 313,340 SNVs. Tests of association were performed with simple linear regression and average type I error rates were determined for minor allele frequency classes. Rare SNVs (minor allele frequency < 0.05) showed inflated type I error rates for non-normally distributed traits that increased as the minor allele frequency decreased. The inflation of average type I error rates increased as the significance threshold decreased. Normally distributed traits did not show inflated type I error rates with respect to the minor allele frequency for rare SNVs. There was no consistent effect of transformation on the uniformity of the distribution of the location of SNVs with a type I error.
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Estimating Rain Rates from Tipping-Bucket Rain Gauge Measurements
NASA Technical Reports Server (NTRS)
Wang, Jianxin; Fisher, Brad L.; Wolff, David B.
2007-01-01
This paper describes the cubic spline based operational system for the generation of the TRMM one-minute rain rate product 2A-56 from Tipping Bucket (TB) gauge measurements. Methodological issues associated with applying the cubic spline to the TB gauge rain rate estimation are closely examined. A simulated TB gauge from a Joss-Waldvogel (JW) disdrometer is employed to evaluate effects of time scales and rain event definitions on errors of the rain rate estimation. The comparison between rain rates measured from the JW disdrometer and those estimated from the simulated TB gauge shows good overall agreement; however, the TB gauge suffers sampling problems, resulting in errors in the rain rate estimation. These errors are very sensitive to the time scale of rain rates. One-minute rain rates suffer substantial errors, especially at low rain rates. When one minute rain rates are averaged to 4-7 minute or longer time scales, the errors dramatically reduce. The rain event duration is very sensitive to the event definition but the event rain total is rather insensitive, provided that the events with less than 1 millimeter rain totals are excluded. Estimated lower rain rates are sensitive to the event definition whereas the higher rates are not. The median relative absolute errors are about 22% and 32% for 1-minute TB rain rates higher and lower than 3 mm per hour, respectively. These errors decrease to 5% and 14% when TB rain rates are used at 7-minute scale. The radar reflectivity-rainrate (Ze-R) distributions drawn from large amount of 7-minute TB rain rates and radar reflectivity data are mostly insensitive to the event definition.
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Structured methods for identifying and correcting potential human errors in aviation operations
DOE Office of Scientific and Technical Information (OSTI.GOV)
Nelson, W.R.
1997-10-01
Human errors have been identified as the source of approximately 60% of the incidents and accidents that occur in commercial aviation. It can be assumed that a very large number of human errors occur in aviation operations, even though in most cases the redundancies and diversities built into the design of aircraft systems prevent the errors from leading to serious consequences. In addition, when it is acknowledged that many system failures have their roots in human errors that occur in the design phase, it becomes apparent that the identification and elimination of potential human errors could significantly decrease the risksmore » of aviation operations. This will become even more critical during the design of advanced automation-based aircraft systems as well as next-generation systems for air traffic management. Structured methods to identify and correct potential human errors in aviation operations have been developed and are currently undergoing testing at the Idaho National Engineering and Environmental Laboratory (INEEL).« less
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Muroi, Maki; Shen, Jay J; Angosta, Alona
2017-02-01
Registered nurses (RNs) play an important role in safe medication administration and patient safety. This study examined a total of 1276 medication error (ME) incident reports made by RNs in hospital inpatient settings in the southwestern region of the United States. The most common drug class associated with MEs was cardiovascular drugs (24.7%). Among this class, anticoagulants had the most errors (11.3%). The antimicrobials was the second most common drug class associated with errors (19.1%) and vancomycin was the most common antimicrobial that caused errors in this category (6.1%). MEs occurred more frequently in the medical-surgical and intensive care units than any other hospital units. Ten percent of MEs reached the patients with harm and 11% reached the patients with increased monitoring. Understanding the contributing factors related to MEs, addressing and eliminating risk of errors across hospital units, and providing education and resources for nurses may help reduce MEs. Copyright © 2016 Elsevier Inc. All rights reserved.
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Risk factors for near-miss events and safety incidents in pediatric radiation therapy.
Baig, Nimrah; Wang, Jiangxia; Elnahal, Shereef; McNutt, Todd; Wright, Jean; DeWeese, Theodore; Terezakis, Stephanie
2018-05-01
Factors contributing to safety- or quality-related incidents (e.g. variances) in children are unknown. We identified clinical and RT treatment variables associated with risk for variances in a pediatric cohort. Using our institution's incident learning system, 81 patients age ≤21 years old who experienced variances were compared to 191 pediatric patients without variances. Clinical and RT treatment variables were evaluated as potential predictors for variances using univariate and multivariate analyses. Variances were primarily documentation errors (n = 46, 57%) and were most commonly detected during treatment planning (n = 14, 21%). Treatment planning errors constituted the majority (n = 16 out of 29, 55%) of near-misses and safety incidents (NMSI), which excludes workflow incidents. Therapists reported the majority of variances (n = 50, 62%). Physician cross-coverage (OR = 2.1, 95% CI = 1.04-4.38) and 3D conformal RT (OR = 2.3, 95% CI = 1.11-4.69) increased variance risk. Conversely, age >14 years (OR = 0.5, 95% CI = 0.28-0.88) and diagnosis of abdominal tumor (OR = 0.2, 95% CI = 0.04-0.59) decreased variance risk. Variances in children occurred in early treatment phases, but were detected at later workflow stages. Quality measures should be implemented during early treatment phases with a focus on younger children and those cared for by cross-covering physicians. Copyright © 2018 Elsevier B.V. All rights reserved.
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Learning from adverse incidents involving medical devices.
Amoore, John; Ingram, Paula
While an adverse event involving a medical device is often ascribed to either user error or device failure, the causes are typically multifactorial. A number of incidents involving medical devices are explored using this approach to investigate the various causes of the incident and the protective barriers that minimised or prevented adverse consequences. User factors, including mistakes, omissions and lack of training, conspired with background factors--device controls and device design, storage conditions, hidden device damage and physical layout of equipment when in use--to cause the adverse events. Protective barriers that prevented or minimised the consequences included staff vigilance, operating procedures and alarms.
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Panzica, M; Krettek, C; Cartes, M
2011-09-01
The probability that an inpatient will be harmed by a medical procedure is at least 3% of all patients. As a consequence, hospital risk management has become a central management task in the health care sector. The critical incident reporting system (CIRS) as a voluntary instrument for reporting (near) incidents plays a key role in the implementation of a risk management system. The goal of the CIRS is to register system errors without assigning guilt or meting out punishment and at the same time increasing the number of voluntary reports.
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[Analysis of Incidence and Mortality of Thyroid Cancer in China, 2013].
Yang, L; Zheng, R S; Wang, N; Zeng, H M; Yuan, Y N; Zhang, S W; Li, H C; Liu, S; Chen, W Q; He, J
2017-11-23
Objective: To evaluate the incidence and mortality status of thyroid cancer in China, 2013. Methods: Incidence and mortality data of thyroid cancer were derived from 255 population-based cancer registries in China. Age-specific and age standardized incidence and mortality rates of thyroid cancer in different areas (urban and rural) with different gender were calculated based on the stratification of area (urban and rural), gender, age and tumor position. Chinese census in 2000 and the world Segi's population were used for age-standardized incidence/mortality rates. The incident cases and deaths were estimated using age-specific rates and national population data in 2013. Results: The estimates of new cancer incident cases and deaths were 143.9 thousand and 6 500, respectively. The crude incidence rate was 10.58/100 000 (Male 5.12/100 000, Female 16.32/100 000). Age-standardized incidence rates by Chinese standard population (ASIRC, 2000) and by world standard population (ASIRW) were 8.82/100 000 and 7.67/100 000, respectively. Male to female ratio was 1∶3.2. The crude incidence rate in urban and rural areas were 15.03/100 000 and 5.41/100 000, respectively. After adjustment by China standard population, the rate in urban areas was 2.57 times higher than that of rural areas. The crude mortality rate of thyroid cancer was 0.48/100 000 (Male 0.33/100 000, Female 0.63/100 000). Age-standardized mortality rates by Chinese standard population (ASIRC, 2000) and by world standard population (ASIRW) were 0.33/100 000 and 0.32/100 000, respectively. The crude mortality rate in urban and rural areas were 0.57/100 000 and 0.38/100 000, respectively. After adjustment by China standard population, the rate in urban areas was 1.41 times higher than that of rural areas. The cumulative incidence and mortality rates (0-74 years old) were 0.74% and 0.03%, respectively. According to the data from 255 cancer registries, papillary carcinoma is the main pathology type, which accounted for 89.9% of all malignant tumors. Conclusions: The disease burden of thyroid cancer in urban areas is higher than that in rural areas. Females have the higher incidence rate than that of males. The reasons related to the higher incidence rate of thyroid cancer should be further investigated to provide evidence for appropriate cancer control strategies and policies to be made in China.
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Investigation of a “Sharps” Incident
Cournoyer, Michael Edward; Trujillo, Stanley; Schreiber, Stephen Bruce
2016-08-03
Special nuclear material research, process development, technology demonstration, and manufacturing capabilities are provided at the Los Alamos National Laboratory Plutonium Facility. Engineered barriers provide the most effective protection from radioactive and hazardous materials. The Worker Safety Security Team augments these passive safety feature by investigating incidents to identify appropriate prevention and mitigation measures. “Learning Teams” facilitate employee feedback loop and integration toward process improvement. Here, this article reports an investigation of a “Sharps” incident and reviews a case study of a technician that cuts his left thumb while making a gasket. Causal analysis of the sharps incident uncovered contributing factorsmore » that created the environment in which the incident occurred. Finally, latent organizational conditions that created error-likely situations or weakened defenses were identified and controlled. Effective improvements that reduce the probability or consequence of similar sharps incidents were implemented.« less
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Approximation of Bit Error Rates in Digital Communications
2007-06-01
and Technology Organisation DSTO—TN—0761 ABSTRACT This report investigates the estimation of bit error rates in digital communi- cations, motivated by...recent work in [6]. In the latter, bounds are used to construct estimates for bit error rates in the case of differentially coherent quadrature phase
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Computer-aided diagnosis with potential application to rapid detection of disease outbreaks.
Burr, Tom; Koster, Frederick; Picard, Rick; Forslund, Dave; Wokoun, Doug; Joyce, Ed; Brillman, Judith; Froman, Phil; Lee, Jack
2007-04-15
Our objectives are to quickly interpret symptoms of emergency patients to identify likely syndromes and to improve population-wide disease outbreak detection. We constructed a database of 248 syndromes, each syndrome having an estimated probability of producing any of 85 symptoms, with some two-way, three-way, and five-way probabilities reflecting correlations among symptoms. Using these multi-way probabilities in conjunction with an iterative proportional fitting algorithm allows estimation of full conditional probabilities. Combining these conditional probabilities with misdiagnosis error rates and incidence rates via Bayes theorem, the probability of each syndrome is estimated. We tested a prototype of computer-aided differential diagnosis (CADDY) on simulated data and on more than 100 real cases, including West Nile Virus, Q fever, SARS, anthrax, plague, tularaemia and toxic shock cases. We conclude that: (1) it is important to determine whether the unrecorded positive status of a symptom means that the status is negative or that the status is unknown; (2) inclusion of misdiagnosis error rates produces more realistic results; (3) the naive Bayes classifier, which assumes all symptoms behave independently, is slightly outperformed by CADDY, which includes available multi-symptom information on correlations; as more information regarding symptom correlations becomes available, the advantage of CADDY over the naive Bayes classifier should increase; (4) overlooking low-probability, high-consequence events is less likely if the standard output summary is augmented with a list of rare syndromes that are consistent with observed symptoms, and (5) accumulating patient-level probabilities across a larger population can aid in biosurveillance for disease outbreaks. c 2007 John Wiley & Sons, Ltd.
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Miraldi Utz, Virginia
2017-01-01
Myopia is the most common eye disorder and major cause of visual impairment worldwide. As the incidence of myopia continues to rise, the need to further understand the complex roles of molecular and environmental factors controlling variation in refractive error is of increasing importance. Tkatchenko and colleagues applied a systematic approach using a combination of gene set enrichment analysis, genome-wide association studies, and functional analysis of a murine model to identify a myopia susceptibility gene, APLP2. Differential expression of refractive error was associated with time spent reading for those with low frequency variants in this gene. This provides support for the longstanding hypothesis of gene-environment interactions in refractive error development.
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The key incident monitoring and management system - history and role in quality improvement.
Badrick, Tony; Gay, Stephanie; Mackay, Mark; Sikaris, Ken
2018-01-26
The determination of reliable, practical Quality Indicators (QIs) from presentation of the patient with a pathology request form through to the clinician receiving the report (the Total Testing Process or TTP) is a key step in identifying areas where improvement is necessary in laboratories. The Australasian QIs programme Key Incident Monitoring and Management System (KIMMS) began in 2008. It records incidents (process defects) and episodes (occasions at which incidents may occur) to calculate incident rates. KIMMS also uses the Failure Mode Effects Analysis (FMEA) to assign quantified risk to each incident type. The system defines risk as incident frequency multiplied by both a harm rating (on a 1-10 scale) and detection difficulty score (also a 1-10 scale). Between 2008 and 2016, laboratories participating rose from 22 to 69. Episodes rose from 13.2 to 43.4 million; incidents rose from 114,082 to 756,432. We attribute the rise in incident rate from 0.86% to 1.75% to increased monitoring. Haemolysis shows the highest incidence (22.6% of total incidents) and the highest risk (26.68% of total risk). "Sample is suspected to be from the wrong patient" has the second lowest frequency, but receives the highest harm rating (10/10) and detection difficulty score (10/10), so it is calculated to be the 8th highest risk (2.92%). Similarly, retracted (incorrect) reports QI has the 10th highest frequency (3.9%) but the harm/difficulty calculation confers the second highest risk (11.17%). TTP incident rates are generally low (less than 2% of observed episodes), however, incident risks, their frequencies multiplied by both ratings of harm and discovery difficulty scores, concentrate improvement attention and resources on the monitored incident types most important to manage.
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Yu, W M; Hussain, S S M
2009-10-01
To evaluate the literature and to compare published data on age-standardised incidence rates of nasopharyngeal carcinoma in Chinese people living in and outside China. Systematic review of incidence rate studies and statistical incidence data concerning nasopharyngeal carcinoma in Chinese populations from 1960 to 2008. Sixteen papers were identified from the PubMed, Embase and Scopus electronic databases and from a hand search of the reference lists of the retrieved papers. Further searches for raw data on age-specific and age-standardised incidence rates of nasopharyngeal carcinoma were conducted. Textbooks on relevant subjects were referred to for background information. A total of 19 papers met the inclusion criteria. Seven studies included raw data on age-specific and age-standardised incidence rates of nasopharyngeal carcinoma in Chinese people. Twelve other studies reported on changes in the incidence of nasopharyngeal carcinoma in Chinese populations in selected countries or regions. Studies on age-specific and age-standardised rates obtained data from individual registries. Studies on incidence rates obtained data from hospital records, cancer notifications (from all sections of the medical profession), pathology records and death certificates. The results showed a decline in age-standardised incidence rates of nasopharyngeal carcinoma in Chinese immigrant populations, compared with Chinese people in China. There was also a trend towards decreasing incidence the further the population had immigrated. Thus, the incidence of nasopharyngeal carcinoma in Singaporean Chinese was higher than that in Hawaiian Chinese, and that in Hawaiian Chinese was higher than that in Californian Chinese. This review found a decreasing trend in the incidence of nasopharyngeal carcinoma in Chinese migrants living in countries with a low risk of the disease.
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Arba-Mosquera, Samuel; Aslanides, Ioannis M.
2012-01-01
Purpose To analyze the effects of Eye-Tracker performance on the pulse positioning errors during refractive surgery. Methods A comprehensive model, which directly considers eye movements, including saccades, vestibular, optokinetic, vergence, and miniature, as well as, eye-tracker acquisition rate, eye-tracker latency time, scanner positioning time, laser firing rate, and laser trigger delay have been developed. Results Eye-tracker acquisition rates below 100 Hz correspond to pulse positioning errors above 1.5 mm. Eye-tracker latency times to about 15 ms correspond to pulse positioning errors of up to 3.5 mm. Scanner positioning times to about 9 ms correspond to pulse positioning errors of up to 2 mm. Laser firing rates faster than eye-tracker acquisition rates basically duplicate pulse-positioning errors. Laser trigger delays to about 300 μs have minor to no impact on pulse-positioning errors. Conclusions The proposed model can be used for comparison of laser systems used for ablation processes. Due to the pseudo-random nature of eye movements, positioning errors of single pulses are much larger than observed decentrations in the clinical settings. There is no single parameter that ‘alone’ minimizes the positioning error. It is the optimal combination of the several parameters that minimizes the error. The results of this analysis are important to understand the limitations of correcting very irregular ablation patterns.
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Failure analysis and modeling of a multicomputer system. M.S. Thesis
NASA Technical Reports Server (NTRS)
Subramani, Sujatha Srinivasan
1990-01-01
This thesis describes the results of an extensive measurement-based analysis of real error data collected from a 7-machine DEC VaxCluster multicomputer system. In addition to evaluating basic system error and failure characteristics, we develop reward models to analyze the impact of failures and errors on the system. The results show that, although 98 percent of errors in the shared resources recover, they result in 48 percent of all system failures. The analysis of rewards shows that the expected reward rate for the VaxCluster decreases to 0.5 in 100 days for a 3 out of 7 model, which is well over a 100 times that for a 7-out-of-7 model. A comparison of the reward rates for a range of k-out-of-n models indicates that the maximum increase in reward rate (0.25) occurs in going from the 6-out-of-7 model to the 5-out-of-7 model. The analysis also shows that software errors have the lowest reward (0.2 vs. 0.91 for network errors). The large loss in reward rate for software errors is due to the fact that a large proportion (94 percent) of software errors lead to failure. In comparison, the high reward rate for network errors is due to fast recovery from a majority of these errors (median recovery duration is 0 seconds).
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Small area estimation for estimating the number of infant mortality in West Java, Indonesia
NASA Astrophysics Data System (ADS)
Anggreyani, Arie; Indahwati, Kurnia, Anang
2016-02-01
Demographic and Health Survey Indonesia (DHSI) is a national designed survey to provide information regarding birth rate, mortality rate, family planning and health. DHSI was conducted by BPS in cooperation with National Population and Family Planning Institution (BKKBN), Indonesia Ministry of Health (KEMENKES) and USAID. Based on the publication of DHSI 2012, the infant mortality rate for a period of five years before survey conducted is 32 for 1000 birth lives. In this paper, Small Area Estimation (SAE) is used to estimate the number of infant mortality in districts of West Java. SAE is a special model of Generalized Linear Mixed Models (GLMM). In this case, the incidence of infant mortality is a Poisson distribution which has equdispersion assumption. The methods to handle overdispersion are binomial negative and quasi-likelihood model. Based on the results of analysis, quasi-likelihood model is the best model to overcome overdispersion problem. The basic model of the small area estimation used basic area level model. Mean square error (MSE) which based on resampling method is used to measure the accuracy of small area estimates.
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Mahara, Gehendra; Wang, Chao; Yang, Kun; Chen, Sipeng; Guo, Jin; Gao, Qi; Wang, Wei; Wang, Quanyi; Guo, Xiuhua
2016-01-01
(1) Background: Evidence regarding scarlet fever and its relationship with meteorological, including air pollution factors, is not very available. This study aimed to examine the relationship between ambient air pollutants and meteorological factors with scarlet fever occurrence in Beijing, China. (2) Methods: A retrospective ecological study was carried out to distinguish the epidemic characteristics of scarlet fever incidence in Beijing districts from 2013 to 2014. Daily incidence and corresponding air pollutant and meteorological data were used to develop the model. Global Moran’s I statistic and Anselin’s local Moran’s I (LISA) were applied to detect the spatial autocorrelation (spatial dependency) and clusters of scarlet fever incidence. The spatial lag model (SLM) and spatial error model (SEM) including ordinary least squares (OLS) models were then applied to probe the association between scarlet fever incidence and meteorological including air pollution factors. (3) Results: Among the 5491 cases, more than half (62%) were male, and more than one-third (37.8%) were female, with the annual average incidence rate 14.64 per 100,000 population. Spatial autocorrelation analysis exhibited the existence of spatial dependence; therefore, we applied spatial regression models. After comparing the values of R-square, log-likelihood and the Akaike information criterion (AIC) among the three models, the OLS model (R2 = 0.0741, log likelihood = −1819.69, AIC = 3665.38), SLM (R2 = 0.0786, log likelihood = −1819.04, AIC = 3665.08) and SEM (R2 = 0.0743, log likelihood = −1819.67, AIC = 3665.36), identified that the spatial lag model (SLM) was best for model fit for the regression model. There was a positive significant association between nitrogen oxide (p = 0.027), rainfall (p = 0.036) and sunshine hour (p = 0.048), while the relative humidity (p = 0.034) had an adverse association with scarlet fever incidence in SLM. (4) Conclusions: Our findings indicated that meteorological, as well as air pollutant factors may increase the incidence of scarlet fever; these findings may help to guide scarlet fever control programs and targeting the intervention. PMID:27827946
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Mahara, Gehendra; Wang, Chao; Yang, Kun; Chen, Sipeng; Guo, Jin; Gao, Qi; Wang, Wei; Wang, Quanyi; Guo, Xiuhua
2016-11-04
(1) Background: Evidence regarding scarlet fever and its relationship with meteorological, including air pollution factors, is not very available. This study aimed to examine the relationship between ambient air pollutants and meteorological factors with scarlet fever occurrence in Beijing, China. (2) Methods: A retrospective ecological study was carried out to distinguish the epidemic characteristics of scarlet fever incidence in Beijing districts from 2013 to 2014. Daily incidence and corresponding air pollutant and meteorological data were used to develop the model. Global Moran's I statistic and Anselin's local Moran's I (LISA) were applied to detect the spatial autocorrelation (spatial dependency) and clusters of scarlet fever incidence. The spatial lag model (SLM) and spatial error model (SEM) including ordinary least squares (OLS) models were then applied to probe the association between scarlet fever incidence and meteorological including air pollution factors. (3) Results: Among the 5491 cases, more than half (62%) were male, and more than one-third (37.8%) were female, with the annual average incidence rate 14.64 per 100,000 population. Spatial autocorrelation analysis exhibited the existence of spatial dependence; therefore, we applied spatial regression models. After comparing the values of R-square, log-likelihood and the Akaike information criterion (AIC) among the three models, the OLS model (R² = 0.0741, log likelihood = -1819.69, AIC = 3665.38), SLM (R² = 0.0786, log likelihood = -1819.04, AIC = 3665.08) and SEM (R² = 0.0743, log likelihood = -1819.67, AIC = 3665.36), identified that the spatial lag model (SLM) was best for model fit for the regression model. There was a positive significant association between nitrogen oxide ( p = 0.027), rainfall ( p = 0.036) and sunshine hour ( p = 0.048), while the relative humidity ( p = 0.034) had an adverse association with scarlet fever incidence in SLM. (4) Conclusions: Our findings indicated that meteorological, as well as air pollutant factors may increase the incidence of scarlet fever; these findings may help to guide scarlet fever control programs and targeting the intervention.
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New methodology for adjusting rotating shadowband irradiometer measurements
NASA Astrophysics Data System (ADS)
Vignola, Frank; Peterson, Josh; Wilbert, Stefan; Blanc, Philippe; Geuder, Norbert; Kern, Chris
2017-06-01
A new method is developed for correcting systematic errors found in rotating shadowband irradiometer measurements. Since the responsivity of photodiode-based pyranometers typically utilized for RST sensors is dependent upon the wavelength of the incident radiation and the spectral distribution of the incident radiation is different for the Direct Normal Trradiance and the Diffuse Horizontal Trradiance, spectral effects have to be considered. These cause the most problematic errors when applying currently available correction functions to RST measurements. Hence, direct normal and diffuse contributions are analyzed and modeled separately. An additional advantage of this methodology is that it provides a prescription for how to modify the adjustment algorithms to locations with different atmospheric characteristics from the location where the calibration and adjustment algorithms were developed. A summary of results and areas for future efforts are then discussed.
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Improving the safety of vaccine delivery.
Evans, Huw P; Cooper, Alison; Williams, Huw; Carson-Stevens, Andrew
2016-05-03
Vaccines save millions of lives per annum as an integral part of community primary care provision worldwide. Adverse events due to the vaccine delivery process outnumber those arising from the pharmacological properties of the vaccines themselves. Whilst one in three patients receiving a vaccine will encounter some form of error, little is known about their underlying causes and how to mitigate them in practice. Patient safety incident reporting systems and adverse drug event surveillance offer a rich opportunity for understanding the underlying causes of those errors. Reducing harm relies on the identification and implementation of changes to improve vaccine safety at multiple levels: from patient interventions through to organizational actions at local, national and international levels. Here we highlight the potential for maximizing learning from patient safety incident reports to improve the quality and safety of vaccine delivery.
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Ciprofloxacin Resistance and Gonorrhea Incidence Rates in 17 Cities, United States, 1991–2006
Kirkcaldy, Robert D.; Gift, Thomas L.; Owusu-Edusei, Kwame; Weinstock, Hillard S.
2014-01-01
Antimicrobial drug resistance can hinder gonorrhea prevention and control efforts. In this study, we analyzed historical ciprofloxacin resistance data and gonorrhea incidence data to examine the possible effect of antimicrobial drug resistance on gonorrhea incidence at the population level. We analyzed data from the Gonococcal Isolate Surveillance Project and city-level gonorrhea incidence rates from surveillance data for 17 cities during 1991–2006. We found a strong positive association between ciprofloxacin resistance and gonorrhea incidence rates at the city level during this period. Their association was consistent with predictions of mathematical models in which resistance to treatment can increase gonorrhea incidence rates through factors such as increased duration of infection. These findings highlight the possibility of future increases in gonorrhea incidence caused by emerging cephalosporin resistance. PMID:24655615
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Angular Rate Optimal Design for the Rotary Strapdown Inertial Navigation System
Yu, Fei; Sun, Qian
2014-01-01
Due to the characteristics of high precision for a long duration, the rotary strapdown inertial navigation system (RSINS) has been widely used in submarines and surface ships. Nowadays, the core technology, the rotating scheme, has been studied by numerous researchers. It is well known that as one of the key technologies, the rotating angular rate seriously influences the effectiveness of the error modulating. In order to design the optimal rotating angular rate of the RSINS, the relationship between the rotating angular rate and the velocity error of the RSINS was analyzed in detail based on the Laplace transform and the inverse Laplace transform in this paper. The analysis results showed that the velocity error of the RSINS depends on not only the sensor error, but also the rotating angular rate. In order to minimize the velocity error, the rotating angular rate of the RSINS should match the sensor error. One optimal design method for the rotating rate of the RSINS was also proposed in this paper. Simulation and experimental results verified the validity and superiority of this optimal design method for the rotating rate of the RSINS. PMID:24759115
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Reverse Transcription Errors and RNA-DNA Differences at Short Tandem Repeats.
Fungtammasan, Arkarachai; Tomaszkiewicz, Marta; Campos-Sánchez, Rebeca; Eckert, Kristin A; DeGiorgio, Michael; Makova, Kateryna D
2016-10-01
Transcript variation has important implications for organismal function in health and disease. Most transcriptome studies focus on assessing variation in gene expression levels and isoform representation. Variation at the level of transcript sequence is caused by RNA editing and transcription errors, and leads to nongenetically encoded transcript variants, or RNA-DNA differences (RDDs). Such variation has been understudied, in part because its detection is obscured by reverse transcription (RT) and sequencing errors. It has only been evaluated for intertranscript base substitution differences. Here, we investigated transcript sequence variation for short tandem repeats (STRs). We developed the first maximum-likelihood estimator (MLE) to infer RT error and RDD rates, taking next generation sequencing error rates into account. Using the MLE, we empirically evaluated RT error and RDD rates for STRs in a large-scale DNA and RNA replicated sequencing experiment conducted in a primate species. The RT error rates increased exponentially with STR length and were biased toward expansions. The RDD rates were approximately 1 order of magnitude lower than the RT error rates. The RT error rates estimated with the MLE from a primate data set were concordant with those estimated with an independent method, barcoded RNA sequencing, from a Caenorhabditis elegans data set. Our results have important implications for medical genomics, as STR allelic variation is associated with >40 diseases. STR nonallelic transcript variation can also contribute to disease phenotype. The MLE and empirical rates presented here can be used to evaluate the probability of disease-associated transcripts arising due to RDD. © The Author 2016. Published by Oxford University Press on behalf of the Society for Molecular Biology and Evolution.
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Zhang, Jiayu; Li, Jie; Zhang, Xi; Che, Xiaorui; Huang, Yugang; Feng, Kaiqiang
2018-05-04
The Semi-Strapdown Inertial Navigation System (SSINS) provides a new solution to attitude measurement of a high-speed rotating missile. However, micro-electro-mechanical-systems (MEMS) inertial measurement unit (MIMU) outputs are corrupted by significant sensor errors. In order to improve the navigation precision, a rotation modulation technology method called Rotation Semi-Strapdown Inertial Navigation System (RSSINS) is introduced into SINS. In fact, the stability of the modulation angular rate is difficult to achieve in a high-speed rotation environment. The changing rotary angular rate has an impact on the inertial sensor error self-compensation. In this paper, the influence of modulation angular rate error, including acceleration-deceleration process, and instability of the angular rate on the navigation accuracy of RSSINS is deduced and the error characteristics of the reciprocating rotation scheme are analyzed. A new compensation method is proposed to remove or reduce sensor errors so as to make it possible to maintain high precision autonomous navigation performance by MIMU when there is no external aid. Experiments have been carried out to validate the performance of the method. In addition, the proposed method is applicable for modulation angular rate error compensation under various dynamic conditions.
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45 CFR 98.102 - Content of Error Rate Reports.
Code of Federal Regulations, 2013 CFR
2013-10-01
....102 Public Welfare DEPARTMENT OF HEALTH AND HUMAN SERVICES GENERAL ADMINISTRATION CHILD CARE AND DEVELOPMENT FUND Error Rate Reporting § 98.102 Content of Error Rate Reports. (a) Baseline Submission Report... payments by the total dollar amount of child care payments that the State, the District of Columbia or...
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45 CFR 98.102 - Content of Error Rate Reports.
Code of Federal Regulations, 2014 CFR
2014-10-01
....102 Public Welfare Department of Health and Human Services GENERAL ADMINISTRATION CHILD CARE AND DEVELOPMENT FUND Error Rate Reporting § 98.102 Content of Error Rate Reports. (a) Baseline Submission Report... payments by the total dollar amount of child care payments that the State, the District of Columbia or...
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45 CFR 98.102 - Content of Error Rate Reports.
Code of Federal Regulations, 2012 CFR
2012-10-01
....102 Public Welfare DEPARTMENT OF HEALTH AND HUMAN SERVICES GENERAL ADMINISTRATION CHILD CARE AND DEVELOPMENT FUND Error Rate Reporting § 98.102 Content of Error Rate Reports. (a) Baseline Submission Report... payments by the total dollar amount of child care payments that the State, the District of Columbia or...
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45 CFR 98.102 - Content of Error Rate Reports.
Code of Federal Regulations, 2011 CFR
2011-10-01
....102 Public Welfare DEPARTMENT OF HEALTH AND HUMAN SERVICES GENERAL ADMINISTRATION CHILD CARE AND DEVELOPMENT FUND Error Rate Reporting § 98.102 Content of Error Rate Reports. (a) Baseline Submission Report... payments by the total dollar amount of child care payments that the State, the District of Columbia or...
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Chen, Cynthia; Naidoo, Nasheen; Yang, Qian; Hartman, Mikael; Verkooijen, Helena M; Loy, En Yun; Bouchardy, Christine; Chia, Kee Seng; Chia, Sin Eng
2012-06-06
Prostate cancer is the most commonly diagnosed malignancy in men in Sweden and Geneva, and the third most common in men in Singapore. This population-based study describes trends in the incidence and mortality rates of prostate cancer in Singapore, Sweden and Geneva (Switzerland) from 1973 to 2006 and explores possible explanations for these different trends. Data from patients diagnosed with prostate cancer were extracted from national cancer registries in Singapore (n = 5,172), Sweden (n = 188,783) and Geneva (n = 5,755) from 1973 to 2006. Trends of incidence and mortality were reported using the Poisson and negative binomial regression models. The age, period and birth-cohort were tested as predictors of incidence and mortality rates of prostate cancer. Incidence rates of prostate cancer increased over all time periods for all three populations. Based on the age-period-cohort analysis, older age and later period of diagnosis were associated with a higher incidence of prostate cancer, whereas older age and earlier period were associated with higher mortality rates for prostate cancer in all three countries. This study demonstrated an overall increase in incidence rates and decrease in mortality rates in Singapore, Sweden and Geneva. Both incidence and mortality rates were much lower in Singapore. The period effect is a stronger predictor of incidence and mortality of prostate cancer than the birth-cohort effect.
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Impact of an antiretroviral stewardship strategy on medication error rates.
Shea, Katherine M; Hobbs, Athena Lv; Shumake, Jason D; Templet, Derek J; Padilla-Tolentino, Eimeira; Mondy, Kristin E
2018-05-02
The impact of an antiretroviral stewardship strategy on medication error rates was evaluated. This single-center, retrospective, comparative cohort study included patients at least 18 years of age infected with human immunodeficiency virus (HIV) who were receiving antiretrovirals and admitted to the hospital. A multicomponent approach was developed and implemented and included modifications to the order-entry and verification system, pharmacist education, and a pharmacist-led antiretroviral therapy checklist. Pharmacists performed prospective audits using the checklist at the time of order verification. To assess the impact of the intervention, a retrospective review was performed before and after implementation to assess antiretroviral errors. Totals of 208 and 24 errors were identified before and after the intervention, respectively, resulting in a significant reduction in the overall error rate ( p < 0.001). In the postintervention group, significantly lower medication error rates were found in both patient admissions containing at least 1 medication error ( p < 0.001) and those with 2 or more errors ( p < 0.001). Significant reductions were also identified in each error type, including incorrect/incomplete medication regimen, incorrect dosing regimen, incorrect renal dose adjustment, incorrect administration, and the presence of a major drug-drug interaction. A regression tree selected ritonavir as the only specific medication that best predicted more errors preintervention ( p < 0.001); however, no antiretrovirals reliably predicted errors postintervention. An antiretroviral stewardship strategy for hospitalized HIV patients including prospective audit by staff pharmacists through use of an antiretroviral medication therapy checklist at the time of order verification decreased error rates. Copyright © 2018 by the American Society of Health-System Pharmacists, Inc. All rights reserved.
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Roche, Lisa M; Niu, Xiaoling; Pawlish, Karen S; Henry, Kevin A
2011-01-01
The study's purpose was to investigate thyroid cancer incidence time trends, birth cohort effects, and association with socioeconomic status (SES) in New Jersey (NJ), a high incidence state, using NJ State Cancer Registry data. Thyroid cancer incidence rates in each sex, nearly all age groups, two major histologies and all stages significantly increased between 1979 and 2006. For each sex, age-specific incidence rates began greatly increasing in the 1924 birth cohort and, generally, the highest thyroid cancer incidence rate for each five-year age group occurred in the latest birth cohort and diagnosis period. Thyroid cancer incidence rates were significantly higher in NJ Census tracts with higher SES and in counties with a higher percentage of insured residents. These results support further investigation into the relationship between rising thyroid cancer incidence and increasing population exposure to medical (including diagnostic) radiation, as well as widespread use of more sensitive diagnostic techniques.
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Schommers, Philipp; Gillor, Daniel; Hentrich, Marcus; Wyen, Christoph; Wolf, Timo; Oette, Mark; Zoufaly, Alexander; Wasmuth, Jan-Christian; Bogner, Johannes R; Müller, Markus; Esser, Stefan; Schleicher, Alisa; Jensen, Björn; Stoehr, Albrecht; Behrens, Georg; Schultze, Alexander; Siehl, Jan; Thoden, Jan; Taylor, Ninon; Hoffmann, Christian
2018-05-01
Outcome of HIV-infected patients with AIDS-related lymphomas has improved during recent years. However, data on incidence, risk factors, and outcome of relapses in AIDS-related lymphomas after achieving complete remission are still limited. This prospective observational multicenter study includes HIV-infected patients with biopsy- or cytology-proven malignant lymphomas since 2005. Data on HIV infection and lymphoma characteristics, treatment and outcome were recorded. For this analysis, AIDS-related lymphomas patients in complete remission were analyzed in terms of their relapse- free survival and potential risk factors for relapses. In total, 254 of 399 (63.7%) patients with AIDS-related lymphomas reached a complete remission with their first-line chemotherapy. After a median follow up of 4.6 years, 5-year overall survival of the 254 patients was 87.8% (Standard Error 3.1%). Twenty-nine patients relapsed (11.4%). Several factors were independently associated with a higher relapse rate, including an unclassifiable histology, a stage III or IV according to the Ann Arbor Staging System, no concomitant combined antiretroviral therapy during chemotherapy and R-CHOP-based compared to more intensive chemotherapy regimens in Burkitt lymphomas. In conclusion, complete remission and relapse rates observed in our study are similar to those reported in HIV-negative non-Hodgkin lymphomas. These data provide further evidence for the use of concomitant combined antiretroviral therapy during chemotherapy and a benefit from more intensive chemotherapy regimens in Burkitt lymphomas. Modifications to the chemotherapy regimen appear to have only a limited impact on relapse rate. Copyright © 2018 Ferrata Storti Foundation.
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Ten-year incidence of dementia in a rural elderly US community population: the MoVIES Project.
Ganguli, M; Dodge, H H; Chen, P; Belle, S; DeKosky, S T
2000-03-14
To determine incidence rates by age, sex, and education of overall dementia and probable/ possible AD in a largely rural community. Ten-year prospective study of a randomly selected community sample aged 65+; biennial cognitive screening followed by standardized clinical evaluation. Incidence rates were estimated for overall dementia (Diagnostic and Statistical Manual of Mental Disorders, 3rd ed., revised, criteria and Clinical Dementia Rating [CDR]) and for probable/possible AD (National Institute of Neurological and Communicative Disorders and Stroke-Alzheimer's Disease and Related Disorders Association criteria). The cohort consisted of 1,298 individuals free of dementia at study entry. Among these, 199 incident (new) cases of overall (all-cause) dementia with CDR stage > or = 0.5, including 110 with CDR > or = 1, were detected during follow-up. Among the incident cases, 153 (76.9%) had probable/ possible AD. Age-specific incidence rates are reported for all dementia and for probable/possible AD, by sex and CDR stage. Among all-cause dementias with CDR = 0.5, controlling for age and education, men had a higher incidence rate than women. In the same group, those with less than high school education had significantly higher incidence rates than those with more education. Rates did not vary significantly by sex or education for probable/possible AD or for dementia with CDR > or = 1. Incidence rates of all dementias and of AD increased with age; men and those with lesser education had higher rates of possible/incipient dementia (CDR = 0.5) in this community. Potential explanations for these sex and education effects are discussed.
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Breast cancer incidence rates in U.S. women are no longer declining.
DeSantis, Carol; Howlader, Nadia; Cronin, Kathleen A; Jemal, Ahmedin
2011-05-01
Several publications reported breast cancer incidence rates continued to decrease among white women, following the decline of about 7% from 2002 to 2003. However, none of these reports exclusively examined the trend after 2003. In this paper, we examined breast cancer incidence rates among non-Hispanic (NH) white women from 2003 to 2007 to determine whether the decrease in breast cancer incidence rates indeed persisted through 2007. In addition, we present breast cancer incidence trends for NH black and Hispanic women and postmenopausal hormone use for all three racial/ethnic groups. Breast cancer incidence rates were calculated by race/ethnicity, age and ER status using data from the Surveillance, Epidemiology, and End Results (SEER) 12 registries for 2000 to 2007. Prevalence of postmenopausal hormone use was calculated using National Health Interview Survey data from 2000, 2005, and 2008. From 2003 to 2007, overall breast cancer incidence rates did not change significantly among NH white women in any age group. However, rates increased (2.7% per year) for ER+ breast cancers in ages 40 to 49, and decreased for ER- breast cancers in ages 40 to 49 and 60 to 69. Similarly, overall breast cancer incidence rates did not change significantly for black and Hispanic women. Hormone use continued to decrease from 2005 to 2008 in all groups, although the decreases were smaller compared to those from 2000 to 2005. The sharp decline in breast cancer incidence rates that occurred from 2002 to 2003 among NH white women did not continue through 2007. Further studies are needed to better understand the recent breast cancer trends. ©2011 AACR.
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Skills, rules and knowledge in aircraft maintenance: errors in context
NASA Technical Reports Server (NTRS)
Hobbs, Alan; Williamson, Ann
2002-01-01
Automatic or skill-based behaviour is generally considered to be less prone to error than behaviour directed by conscious control. However, researchers who have applied Rasmussen's skill-rule-knowledge human error framework to accidents and incidents have sometimes found that skill-based errors appear in significant numbers. It is proposed that this is largely a reflection of the opportunities for error which workplaces present and does not indicate that skill-based behaviour is intrinsically unreliable. In the current study, 99 errors reported by 72 aircraft mechanics were examined in the light of a task analysis based on observations of the work of 25 aircraft mechanics. The task analysis identified the opportunities for error presented at various stages of maintenance work packages and by the job as a whole. Once the frequency of each error type was normalized in terms of the opportunities for error, it became apparent that skill-based performance is more reliable than rule-based performance, which is in turn more reliable than knowledge-based performance. The results reinforce the belief that industrial safety interventions designed to reduce errors would best be directed at those aspects of jobs that involve rule- and knowledge-based performance.
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Spencer, Bruce D
2012-06-01
Latent class models are increasingly used to assess the accuracy of medical diagnostic tests and other classifications when no gold standard is available and the true state is unknown. When the latent class is treated as the true class, the latent class models provide measures of components of accuracy including specificity and sensitivity and their complements, type I and type II error rates. The error rates according to the latent class model differ from the true error rates, however, and empirical comparisons with a gold standard suggest the true error rates often are larger. We investigate conditions under which the true type I and type II error rates are larger than those provided by the latent class models. Results from Uebersax (1988, Psychological Bulletin 104, 405-416) are extended to accommodate random effects and covariates affecting the responses. The results are important for interpreting the results of latent class analyses. An error decomposition is presented that incorporates an error component from invalidity of the latent class model. © 2011, The International Biometric Society.
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Han, Mira V; Thomas, Gregg W C; Lugo-Martinez, Jose; Hahn, Matthew W
2013-08-01
Current sequencing methods produce large amounts of data, but genome assemblies constructed from these data are often fragmented and incomplete. Incomplete and error-filled assemblies result in many annotation errors, especially in the number of genes present in a genome. This means that methods attempting to estimate rates of gene duplication and loss often will be misled by such errors and that rates of gene family evolution will be consistently overestimated. Here, we present a method that takes these errors into account, allowing one to accurately infer rates of gene gain and loss among genomes even with low assembly and annotation quality. The method is implemented in the newest version of the software package CAFE, along with several other novel features. We demonstrate the accuracy of the method with extensive simulations and reanalyze several previously published data sets. Our results show that errors in genome annotation do lead to higher inferred rates of gene gain and loss but that CAFE 3 sufficiently accounts for these errors to provide accurate estimates of important evolutionary parameters.
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Derivation of an analytic expression for the error associated with the noise reduction rating
NASA Astrophysics Data System (ADS)
Murphy, William J.
2005-04-01
Hearing protection devices are assessed using the Real Ear Attenuation at Threshold (REAT) measurement procedure for the purpose of estimating the amount of noise reduction provided when worn by a subject. The rating number provided on the protector label is a function of the mean and standard deviation of the REAT results achieved by the test subjects. If a group of subjects have a large variance, then it follows that the certainty of the rating should be correspondingly lower. No estimate of the error of a protector's rating is given by existing standards or regulations. Propagation of errors was applied to the Noise Reduction Rating to develop an analytic expression for the hearing protector rating error term. Comparison of the analytic expression for the error to the standard deviation estimated from Monte Carlo simulation of subject attenuations yielded a linear relationship across several protector types and assumptions for the variance of the attenuations.
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The incidence of duodenal and gastric ulcers in a large health maintenance organization.
Kurata, J H; Honda, G D; Frankl, H
1985-06-01
We report the incidence of peptic ulcers (duodenal, pyloric canal, gastric, and combined) verified by radiologic, endoscopic, or surgical evidence in a large Health Maintenance Organization (HMO) in Los Angeles, California. For members age 15 and above, the peptic ulcer incidence rate was 0.86 per 1,000 person-years (p-y) (males 1.10, females 0.63). The male to female sex ratio was 1.7. Two hundred twenty-two duodenal, 17 pyloric canal, 89 gastric, and 21 combined first-time diagnosed ulcer cases were located. For duodenal and pyloric canal ulcer, the incidence rate for members age 15 and above was 0.58 per 1,000 p-y (males 0.76, females 0.40). For gastric ulcer, the incidence rate for members age 15 and above was 0.21 per 1,000 p-y (males 0.23, females 0.18). The combined ulcer rate was 0.05 per 1,000 p-y (males 0.07, females 0.02). Gastric ulcer rates were two times higher in 1980 than in 1977. Peptic ulcer age-specific incidence rates increased with age. Incidence rates were much lower than those reported in previous studies, but the gastric to duodenal ulcer ratio and the age and sex relation to ulcer incidence were similar to those previously reported.
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Errors in laboratory medicine: practical lessons to improve patient safety.
Howanitz, Peter J
2005-10-01
Patient safety is influenced by the frequency and seriousness of errors that occur in the health care system. Error rates in laboratory practices are collected routinely for a variety of performance measures in all clinical pathology laboratories in the United States, but a list of critical performance measures has not yet been recommended. The most extensive databases describing error rates in pathology were developed and are maintained by the College of American Pathologists (CAP). These databases include the CAP's Q-Probes and Q-Tracks programs, which provide information on error rates from more than 130 interlaboratory studies. To define critical performance measures in laboratory medicine, describe error rates of these measures, and provide suggestions to decrease these errors, thereby ultimately improving patient safety. A review of experiences from Q-Probes and Q-Tracks studies supplemented with other studies cited in the literature. Q-Probes studies are carried out as time-limited studies lasting 1 to 4 months and have been conducted since 1989. In contrast, Q-Tracks investigations are ongoing studies performed on a yearly basis and have been conducted only since 1998. Participants from institutions throughout the world simultaneously conducted these studies according to specified scientific designs. The CAP has collected and summarized data for participants about these performance measures, including the significance of errors, the magnitude of error rates, tactics for error reduction, and willingness to implement each of these performance measures. A list of recommended performance measures, the frequency of errors when these performance measures were studied, and suggestions to improve patient safety by reducing these errors. Error rates for preanalytic and postanalytic performance measures were higher than for analytic measures. Eight performance measures were identified, including customer satisfaction, test turnaround times, patient identification, specimen acceptability, proficiency testing, critical value reporting, blood product wastage, and blood culture contamination. Error rate benchmarks for these performance measures were cited and recommendations for improving patient safety presented. Not only has each of the 8 performance measures proven practical, useful, and important for patient care, taken together, they also fulfill regulatory requirements. All laboratories should consider implementing these performance measures and standardizing their own scientific designs, data analysis, and error reduction strategies according to findings from these published studies.
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Cumulative Incidence of Cancer among HIV-infected Individuals in North America
Silverberg, Michael J.; Lau, Bryan; Achenbach, Chad J.; Jing, Yuezhou; Althoff, Keri N.; D’Souza, Gypsyamber; Engels, Eric A.; Hessol, Nancy; Brooks, John T.; Burchell, Ann N.; Gill, M. John; Goedert, James J.; Hogg, Robert; Horberg, Michael A.; Kirk, Gregory D.; Kitahata, Mari M.; Korthuis, Phillip T.; Mathews, William C.; Mayor, Angel; Modur, Sharada P.; Napravnik, Sonia; Novak, Richard M.; Patel, Pragna; Rachlis, Anita R.; Sterling, Timothy R.; Willig, James H.; Justice, Amy C.; Moore, Richard D.; Dubrow, Robert
2016-01-01
Background Cancer is increasingly common among HIV patients given improved survival. Objective To examine calendar trends in cumulative cancer incidence and hazard rate by HIV status. Design Cohort study Setting North American AIDS Cohort Collaboration on Research and Design during 1996–2009 Patients 86,620 HIV-infected and 196,987 uninfected adults Measurements We estimated cancer-type-specific cumulative incidence by age 75 years by HIV status and calendar era, and examined calendar trends in cumulative incidence and hazard rates. Results Cumulative incidences (%) of cancer by age 75 (HIV+/HIV−) were: Kaposi sarcoma (KS), 4.4/0.01; non-Hodgkin’s lymphoma (NHL), 4.5/0.7; lung, 3.4/2.8; anal, 1.5/0.1; colorectal, 1.0/1.5; liver, 1.1/0.4; Hodgkin lymphoma (HL), 0.9/0.1; melanoma, 0.5/0.6; and oral cavity/pharyngeal, 0.8/0.8. Among HIV-infected subjects, we observed decreasing calendar trends in cumulative incidence and hazard rate for KS and NHL. For anal, colorectal and liver cancers, increasing cumulative incidence, but not hazard rate trends, were due to the decreasing mortality rate trend (−9% per year), allowing greater opportunity to be diagnosed with these cancer types. Despite decreasing hazard rate trends for lung, HL, and melanoma, we did not observe cumulative incidence trends due to the compensating effect of the declining mortality rate on cumulative incidence. Limitations Secular trends in screening, smoking, and viral co-infections were not evaluated. Conclusions Our analytic approach helped disentangle the effects of improved survival and changing cancer-specific hazard rates on cumulative incidence trends among HIV patients. Cumulative cancer incidence by age 75, approximating lifetime risk in HIV patients, may have clinical utility in this population. The high cumulative incidences by age 75 for KS, NHL, and lung cancer supports early and sustained ART and smoking cessation. Primary Funding Source National Institutes of Health PMID:26436616
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An analysis of electronic health record-related patient safety incidents.
Palojoki, Sari; Mäkelä, Matti; Lehtonen, Lasse; Saranto, Kaija
2017-06-01
The aim of this study was to analyse electronic health record-related patient safety incidents in the patient safety incident reporting database in fully digital hospitals in Finland. We compare Finnish data to similar international data and discuss their content with regard to the literature. We analysed the types of electronic health record-related patient safety incidents that occurred at 23 hospitals during a 2-year period. A procedure of taxonomy mapping served to allow comparisons. This study represents a rare examination of patient safety risks in a fully digital environment. The proportion of electronic health record-related incidents was markedly higher in our study than in previous studies with similar data. Human-computer interaction problems were the most frequently reported. The results show the possibility of error arising from the complex interaction between clinicians and computers.
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NASA Astrophysics Data System (ADS)
Azzam, R. M. A.; Howlader, M. M. K.; Georgiou, T. Y.
1995-08-01
A transparent or absorbing substrate can be coated with a transparent thin film to produce a linear reflectance-versus-angle-of-incidence response over a certain range of angles. Linearization at and near normal incidence is a special case that leads to a maximally flat response for p -polarized, s -polarized, or unpolarized light. For midrange and high-range linearization with moderate and high slopes, respectively, the best results are obtained when the incident light is s polarized. Application to a Si substrate that is coated with a SiO2 film leads to novel passive and active reflection rotation sensors. Experimental results and an error analysis of this rotation sensor are presented.
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Desapriya, Ediriweera; Fujiwara, Takeo; Dutt, Namrata; Arason, Neil; Pike, Ian
2012-09-01
. Many studies have demonstrated a strong relationship between alcohol availability and traffic crashes involving alcohol-impaired drivers. The present analysis focuses on the evaluation of the impact of alcohol availability on the Japanese population by comparing fatal and nonfatal motor vehicle crash rates before and after implementation of the alcohol deregulation policy in 1994. Participants and method. Poisson regression with robust standard error was used to model the before-to-after change in incidence rate ratios (IRRs) in the population. To control for potential confounders, per capita alcohol consumption, unemployment rate, and vehicle miles travelled (VMT) were also added to the model. The exponents of the fitted coefficients are equivalent to the IRRs. . Implementation of the policy deregulating alcohol sales and production did not appear to increase traffic fatalities and other traffic crashes in Japan. In the overall study results, nighttime fatalities were reduced statistically significantly by 6% since the implementation of the alcohol deregulation policy in 1994. Discussion. Contrary to previous research, the findings of this study demonstrated lower rates of fatalities and higher compliance with alcohol-related driving legislation. Further well-designed, nonaligned studies on alcohol availability and traffic fatalities in other countries are urgently needed.
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Oh, Chang-Mo; Jung, Kyu-Won; Won, Young-Joo; Shin, Aesun; Kong, Hyun-Joo; Jun, Jae Kwan; Park, Sang-yoon
2013-01-01
Objective Our study aims to describe changes in carcinoma in situ (CIS) and invasive cervical carcinoma (ICC) in Korean women diagnosed between 1993 and 2009. Methods All cases of CIS and invasive cervical carcinoma diagnosed from 1993 to 2009 in the Korean National Cancer Incidence database were analyzed. Age-standardized rates (ASRs) and annual percent changes (APCs) in incidence rates were compared according to age and histological type. Additionally, we used Korea National Health and Nutrition Examination Survey (KNHANES) to know the association between screening rate for cervical cancer and incidence rate of cervical cancer. Results Between 1993 and 2009, 72,240 cases of ICC were reported in Korea. Total incidence rate of ICC was 14.7 per 100,000 females. ASRs of ICC declined 3.8% per year, from 19.3 per 100,000 in 1993 to 10.5 per 100,000 in 2009. Although the overall incidence rate of adenocarcinoma remained stable, invasive squamous cell carcinoma showed a decreasing trend (APC −4.2%). For women aged 60–79 years, ASRs for squamous cell carcinoma increased from 1993 to 2001, and decreased from 2001 to 2009 (APC: −4.6%). Total 62,300 cases of CIS were diagnosed from 1993 to 2009. Total incidence rate of CIS was 12.2 per 100,000 females. ASRs of CIS increased 5.7% per year, from 7.5 per 100,000 in 1993 to 19.0 per 100,000 in 2009. Adenocarcinoma in situ increased 13.2% per year. There was a strong positive correlation between screening rate for cervical cancer and incidence rate for CIS (p-value = 0.03) whereas screening rate showed a strong negative correlation with incidence rate for squamous ICC (p-value = 0.04). Conclusions The increasing trend in CIS, coupled with a decreasing trend in ICC, suggests the important role of cervix cancer screening. The incidence of adenocarcinoma showed a plateau, but the incidence of adenocarcinoma in situ showed an increasing trend. PMID:23977194
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The statistical validity of nursing home survey findings.
Woolley, Douglas C
2011-11-01
The Medicare nursing home survey is a high-stakes process whose findings greatly affect nursing homes, their current and potential residents, and the communities they serve. Therefore, survey findings must achieve high validity. This study looked at the validity of one key assessment made during a nursing home survey: the observation of the rate of errors in administration of medications to residents (med-pass). Statistical analysis of the case under study and of alternative hypothetical cases. A skilled nursing home affiliated with a local medical school. The nursing home administrators and the medical director. Observational study. The probability that state nursing home surveyors make a Type I or Type II error in observing med-pass error rates, based on the current case and on a series of postulated med-pass error rates. In the common situation such as our case, where med-pass errors occur at slightly above a 5% rate after 50 observations, and therefore trigger a citation, the chance that the true rate remains above 5% after a large number of observations is just above 50%. If the true med-pass error rate were as high as 10%, and the survey team wished to achieve 75% accuracy in determining that a citation was appropriate, they would have to make more than 200 med-pass observations. In the more common situation where med pass errors are closer to 5%, the team would have to observe more than 2000 med-passes to achieve even a modest 75% accuracy in their determinations. In settings where error rates are low, large numbers of observations of an activity must be made to reach acceptable validity of estimates for the true rates of errors. In observing key nursing home functions with current methodology, the State Medicare nursing home survey process does not adhere to well-known principles of valid error determination. Alternate approaches in survey methodology are discussed. Copyright © 2011 American Medical Directors Association. Published by Elsevier Inc. All rights reserved.
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How does aging affect the types of error made in a visual short-term memory ‘object-recall’ task?
Sapkota, Raju P.; van der Linde, Ian; Pardhan, Shahina
2015-01-01
This study examines how normal aging affects the occurrence of different types of incorrect responses in a visual short-term memory (VSTM) object-recall task. Seventeen young (Mean = 23.3 years, SD = 3.76), and 17 normally aging older (Mean = 66.5 years, SD = 6.30) adults participated. Memory stimuli comprised two or four real world objects (the memory load) presented sequentially, each for 650 ms, at random locations on a computer screen. After a 1000 ms retention interval, a test display was presented, comprising an empty box at one of the previously presented two or four memory stimulus locations. Participants were asked to report the name of the object presented at the cued location. Errors rates wherein participants reported the names of objects that had been presented in the memory display but not at the cued location (non-target errors) vs. objects that had not been presented at all in the memory display (non-memory errors) were compared. Significant effects of aging, memory load and target recency on error type and absolute error rates were found. Non-target error rate was higher than non-memory error rate in both age groups, indicating that VSTM may have been more often than not populated with partial traces of previously presented items. At high memory load, non-memory error rate was higher in young participants (compared to older participants) when the memory target had been presented at the earliest temporal position. However, non-target error rates exhibited a reversed trend, i.e., greater error rates were found in older participants when the memory target had been presented at the two most recent temporal positions. Data are interpreted in terms of proactive interference (earlier examined non-target items interfering with more recent items), false memories (non-memory items which have a categorical relationship to presented items, interfering with memory targets), slot and flexible resource models, and spatial coding deficits. PMID:25653615
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How does aging affect the types of error made in a visual short-term memory 'object-recall' task?
Sapkota, Raju P; van der Linde, Ian; Pardhan, Shahina
2014-01-01
This study examines how normal aging affects the occurrence of different types of incorrect responses in a visual short-term memory (VSTM) object-recall task. Seventeen young (Mean = 23.3 years, SD = 3.76), and 17 normally aging older (Mean = 66.5 years, SD = 6.30) adults participated. Memory stimuli comprised two or four real world objects (the memory load) presented sequentially, each for 650 ms, at random locations on a computer screen. After a 1000 ms retention interval, a test display was presented, comprising an empty box at one of the previously presented two or four memory stimulus locations. Participants were asked to report the name of the object presented at the cued location. Errors rates wherein participants reported the names of objects that had been presented in the memory display but not at the cued location (non-target errors) vs. objects that had not been presented at all in the memory display (non-memory errors) were compared. Significant effects of aging, memory load and target recency on error type and absolute error rates were found. Non-target error rate was higher than non-memory error rate in both age groups, indicating that VSTM may have been more often than not populated with partial traces of previously presented items. At high memory load, non-memory error rate was higher in young participants (compared to older participants) when the memory target had been presented at the earliest temporal position. However, non-target error rates exhibited a reversed trend, i.e., greater error rates were found in older participants when the memory target had been presented at the two most recent temporal positions. Data are interpreted in terms of proactive interference (earlier examined non-target items interfering with more recent items), false memories (non-memory items which have a categorical relationship to presented items, interfering with memory targets), slot and flexible resource models, and spatial coding deficits.
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Clinical biochemistry laboratory rejection rates due to various types of preanalytical errors.
Atay, Aysenur; Demir, Leyla; Cuhadar, Serap; Saglam, Gulcan; Unal, Hulya; Aksun, Saliha; Arslan, Banu; Ozkan, Asuman; Sutcu, Recep
2014-01-01
Preanalytical errors, along the process from the beginning of test requests to the admissions of the specimens to the laboratory, cause the rejection of samples. The aim of this study was to better explain the reasons of rejected samples, regarding to their rates in certain test groups in our laboratory. This preliminary study was designed on the rejected samples in one-year period, based on the rates and types of inappropriateness. Test requests and blood samples of clinical chemistry, immunoassay, hematology, glycated hemoglobin, coagulation and erythrocyte sedimentation rate test units were evaluated. Types of inappropriateness were evaluated as follows: improperly labelled samples, hemolysed, clotted specimen, insufficient volume of specimen and total request errors. A total of 5,183,582 test requests from 1,035,743 blood collection tubes were considered. The total rejection rate was 0.65 %. The rejection rate of coagulation group was significantly higher (2.28%) than the other test groups (P < 0.001) including insufficient volume of specimen error rate as 1.38%. Rejection rates of hemolysis, clotted specimen and insufficient volume of sample error were found to be 8%, 24% and 34%, respectively. Total request errors, particularly, for unintelligible requests were 32% of the total for inpatients. The errors were especially attributable to unintelligible requests of inappropriate test requests, improperly labelled samples for inpatients and blood drawing errors especially due to insufficient volume of specimens in a coagulation test group. Further studies should be performed after corrective and preventive actions to detect a possible decrease in rejecting samples.
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DOE Office of Scientific and Technical Information (OSTI.GOV)
Kertzscher, Gustavo, E-mail: guke@dtu.dk; Andersen, Claus E., E-mail: clan@dtu.dk; Tanderup, Kari, E-mail: karitand@rm.dk
Purpose: This study presents an adaptive error detection algorithm (AEDA) for real-timein vivo point dosimetry during high dose rate (HDR) or pulsed dose rate (PDR) brachytherapy (BT) where the error identification, in contrast to existing approaches, does not depend on an a priori reconstruction of the dosimeter position. Instead, the treatment is judged based on dose rate comparisons between measurements and calculations of the most viable dosimeter position provided by the AEDA in a data driven approach. As a result, the AEDA compensates for false error cases related to systematic effects of the dosimeter position reconstruction. Given its nearly exclusivemore » dependence on stable dosimeter positioning, the AEDA allows for a substantially simplified and time efficient real-time in vivo BT dosimetry implementation. Methods: In the event of a measured potential treatment error, the AEDA proposes the most viable dosimeter position out of alternatives to the original reconstruction by means of a data driven matching procedure between dose rate distributions. If measured dose rates do not differ significantly from the most viable alternative, the initial error indication may be attributed to a mispositioned or misreconstructed dosimeter (false error). However, if the error declaration persists, no viable dosimeter position can be found to explain the error, hence the discrepancy is more likely to originate from a misplaced or misreconstructed source applicator or from erroneously connected source guide tubes (true error). Results: The AEDA applied on twoin vivo dosimetry implementations for pulsed dose rate BT demonstrated that the AEDA correctly described effects responsible for initial error indications. The AEDA was able to correctly identify the major part of all permutations of simulated guide tube swap errors and simulated shifts of individual needles from the original reconstruction. Unidentified errors corresponded to scenarios where the dosimeter position was sufficiently symmetric with respect to error and no-error source position constellations. The AEDA was able to correctly identify all false errors represented by mispositioned dosimeters contrary to an error detection algorithm relying on the original reconstruction. Conclusions: The study demonstrates that the AEDA error identification during HDR/PDR BT relies on a stable dosimeter position rather than on an accurate dosimeter reconstruction, and the AEDA’s capacity to distinguish between true and false error scenarios. The study further shows that the AEDA can offer guidance in decision making in the event of potential errors detected with real-timein vivo point dosimetry.« less
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Khazaei, Salman; Rezaeian, Shahab; Soheylizad, Mokhtar; Khazaei, Somayeh; Biderafsh, Azam
2016-01-01
Stomach cancer (SC) is the second leading cause of cancer death with the rate of 10.4% in the world. The correlation between the incidence and mortality rates of SC and human development index (HDI) has not been globally determined. Therefore, this study aimed to determine the association between the incidence and mortality rates of SC and HDI in various regions. In this global ecological study, we used the data about the incidence and mortality rate of SC and HDI from the global cancer project and the United Nations Development Programme database, respectively. In 2012, SCs were estimated to have affected a total of 951,594 individuals (crude rate: 13.5 per 100,000 individuals) with a male/female ratio of 1.97, and caused 723,073 deaths worldwide (crude rate: 10.2 per 100,000 individuals). There was a positive correlation between the HDI and both incidence (r=0.28, <0.05) and mortality rates of SC (r=0.13, P = 0.1) in the world in 2012. The high incidence and mortality rates of SC in countries with high and very high HDI is remarkable which should be the top priority of interventions for global health policymakers. In addition, health programs should be provided to reduce the burden of this disease in the regions with high incidence and mortality rates of SC.
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Error rate information in attention allocation pilot models
NASA Technical Reports Server (NTRS)
Faulkner, W. H.; Onstott, E. D.
1977-01-01
The Northrop urgency decision pilot model was used in a command tracking task to compare the optimized performance of multiaxis attention allocation pilot models whose urgency functions were (1) based on tracking error alone, and (2) based on both tracking error and error rate. A matrix of system dynamics and command inputs was employed, to create both symmetric and asymmetric two axis compensatory tracking tasks. All tasks were single loop on each axis. Analysis showed that a model that allocates control attention through nonlinear urgency functions using only error information could not achieve performance of the full model whose attention shifting algorithm included both error and error rate terms. Subsequent to this analysis, tracking performance predictions for the full model were verified by piloted flight simulation. Complete model and simulation data are presented.
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Age-Specific Incidence Rates for Self-Reported Uterine Leiomyomata in the Black Women’s Health Study
Wise, Lauren A.; Palmer, Julie R.; Stewart, Elizabeth A.; Rosenberg, Lynn
2007-01-01
OBJECTIVE Uterine leiomyomata represent a major public health problem for black women in the United States, but limited data are available on age–incidence curves in this high-risk population. We estimated overall and age-specific incidence rates for self-reported uterine leiomyomata in a large cohort of African-American women in the United States. METHODS Data were derived from the Black Women’s Health Study, an ongoing prospective cohort study of 59,000 black women from across the United States who were aged 21–69 years at baseline (ie, 1995). From March 1997 through March 2001, we followed up 22,895 premenopausal women with no prior diagnosis of uterine leiomyoma. Poisson regression was used to estimate overall and age-specific incidence rates and 95% confidence intervals (CIs) for self-reported uterine leiomyoma. In a subset of 248 patients who were selected randomly from the total case group, the self-reported diagnosis was verified in 96% of cases who released their medical records. RESULTS During 76,711 woman-years of follow-up, 2,637 incident cases of uterine leiomyomata reported as confirmed by pelvic examination (n = 358), ultrasonography (n = 2,006), or hysterectomy (n = 273) were observed. Incidence rates per 1,000 woman-years were 34.4 (95% CI 33.1–35.7) for all cases combined, 29.7 (95% CI 28.5–30.9) for cases confirmed by ultrasonography or hysterectomy, and 3.6 (95% CI 3.2–4.0) for cases confirmed by hysterectomy. The incidence rate peaked at ages 40–44 years for all cases combined (incidence rate 45.6, 95% CI 42.0–49.5) and for cases confirmed by ultrasonography or hysterectomy (incidence rate 39.8, 95% CI 36.5–43.4), and peaked at ages 45–49 years for cases confirmed by hysterectomy (incidence rate 8.3, 95% CI 6.4–10.7). CONCLUSION Overall incidence rates for self-reported uterine leiomyomata were consistent with other U.S studies in black women and confirmed a high burden of disease in this population. Age-specific incidence rates showed a later peak incidence than that observed among U.S. black women in previous studies. LEVEL OF EVIDENCE II-2 PMID:15738025
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Cervical cancer incidence in the United States in the US-Mexico border region, 1998-2003.
Coughlin, Steven S; Richards, Thomas B; Nasseri, Kiumarss; Weiss, Nancy S; Wiggins, Charles L; Saraiya, Mona; Stinchcomb, David G; Vensor, Veronica M; Nielson, Carrie M
2008-11-15
Cervical cancer mortality rates have declined in the United States, primarily because of Papanicolaou testing. However, limited information is available about the incidence of the disease in the US-Mexico border region, where some of the poorest counties in the United States are located. This study was undertaken to help compare the patterns of cervical cancer incidence among women in the US-Mexico border region and other parts of the United States. Age-adjusted cervical cancer incidence rates for border counties in the states bordering Mexico (California, Arizona, New Mexico, Texas) for the years 1998 to 2003 were compared with the rates for nonborder counties of the border states and with those of nonborder states. Differences were examined by age, race, ethnicity, rural residence, educational attainment, poverty, migration, stage of disease, and histology. Overall, Hispanic women had almost twice the cervical cancer incidence of non-Hispanic women in border counties, and Hispanic women in the border states had higher rates than did non-Hispanic women in nonborder states. In contrast, cervical cancer incidence rates among black women in the border counties were lower than those among black women in the nonborder states. Among white women, however, incidence rates were higher among those in nonborder states. Differences in cervical cancer incidence rates by geographic locality were also evident by age, urban/rural residence, migration from outside the United States, and stage of disease. Disparities in cervical cancer incidence in the US-Mexico border counties, when the incidence is compared with that of other counties and geographic regions, are evident. Of particular concern are the higher rates of late-stage cervical cancer diagnosed among women in the border states, especially because such cervical cancer is preventable.
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7 CFR 275.23 - Determination of State agency program performance.
Code of Federal Regulations, 2011 CFR
2011-01-01
... NUTRITION SERVICE, DEPARTMENT OF AGRICULTURE FOOD STAMP AND FOOD DISTRIBUTION PROGRAM PERFORMANCE REPORTING... section, the adjusted regressed payment error rate shall be calculated to yield the State agency's payment error rate. The adjusted regressed payment error rate is given by r 1″ + r 2″. (ii) If FNS determines...
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Tuberculosis in Mexico and the USA, Comparison of Trends Over Time 1990-2010.
Hernández-Garduño, Eduardo; Mendoza-Damián, Fabiola; Garduño-Alanís, Adriana; Ayón-Garibaldo, Salvador
2015-07-01
The aim was to compare tuberculosis trends in Mexico and United States and to evaluate Mexican diagnostic methods and contact investigation. Retrospective comparative study of tuberculosis cases and incidence rates between both countries (1990-2010). Diagnostic methods and contact investigations were also evaluated for Mexico. Estimates were obtained from official websites. In Mexico, no clear trend was found over time for cases. Pulmonary (PTB) and all forms of tuberculosis (AFTB) incidence decreased 2.0% annually. There was a negative correlation between the mean contacts examined per case and AFTB incidence (r(2)=-0.44, p=0.01) with a 33% reduction in AFTB incidence. In United States, PTB and AFTB cases have been decreasing 6.0% and 5.6% annually, respectively. The incidence decreased 7.3% and 6.8%, respectively. The incidence of tuberculosis in Mexico is decreasing slightly over time at 2% annually. In the United States, cases and incidence rates have been decreasing at a higher rate (5% to 7% annually). The inverse association between number of contacts examined per state and incidence rates in Mexico underscore the importance of reinforcing and improving contact investigations with the likely translation of a decrease of TB incidence at a higher rate.
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Derks, E M; Zwinderman, A H; Gamazon, E R
2017-05-01
Population divergence impacts the degree of population stratification in Genome Wide Association Studies. We aim to: (i) investigate type-I error rate as a function of population divergence (F ST ) in multi-ethnic (admixed) populations; (ii) evaluate the statistical power and effect size estimates; and (iii) investigate the impact of population stratification on the results of gene-based analyses. Quantitative phenotypes were simulated. Type-I error rate was investigated for Single Nucleotide Polymorphisms (SNPs) with varying levels of F ST between the ancestral European and African populations. Type-II error rate was investigated for a SNP characterized by a high value of F ST . In all tests, genomic MDS components were included to correct for population stratification. Type-I and type-II error rate was adequately controlled in a population that included two distinct ethnic populations but not in admixed samples. Statistical power was reduced in the admixed samples. Gene-based tests showed no residual inflation in type-I error rate.