Accuracy Improvement of Multi-Axis Systems Based on Laser Correction of Volumetric Geometric Errors

NASA Astrophysics Data System (ADS)

Teleshevsky, V. I.; Sokolov, V. A.; Pimushkin, Ya I.

2018-04-01

The article describes a volumetric geometric errors correction method for CNC- controlled multi-axis systems (machine-tools, CMMs etc.). The Kalman’s concept of “Control and Observation” is used. A versatile multi-function laser interferometer is used as Observer in order to measure machine’s error functions. A systematic error map of machine’s workspace is produced based on error functions measurements. The error map results into error correction strategy. The article proposes a new method of error correction strategy forming. The method is based on error distribution within machine’s workspace and a CNC-program postprocessor. The postprocessor provides minimal error values within maximal workspace zone. The results are confirmed by error correction of precision CNC machine-tools.

A map overlay error model based on boundary geometry

USGS Publications Warehouse

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

2005-01-01

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

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

PubMed

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

2016-11-01

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

Trends in Health Information Technology Safety: From Technology-Induced Errors to Current Approaches for Ensuring Technology Safety

PubMed Central

2013-01-01

Objectives Health information technology (HIT) research findings suggested that new healthcare technologies could reduce some types of medical errors while at the same time introducing classes of medical errors (i.e., technology-induced errors). Technology-induced errors have their origins in HIT, and/or HIT contribute to their occurrence. The objective of this paper is to review current trends in the published literature on HIT safety. Methods A review and synthesis of the medical and life sciences literature focusing on the area of technology-induced error was conducted. Results There were four main trends in the literature on technology-induced error. The following areas were addressed in the literature: definitions of technology-induced errors; models, frameworks and evidence for understanding how technology-induced errors occur; a discussion of monitoring; and methods for preventing and learning about technology-induced errors. Conclusions The literature focusing on technology-induced errors continues to grow. Research has focused on the defining what an error is, models and frameworks used to understand these new types of errors, monitoring of such errors and methods that can be used to prevent these errors. More research will be needed to better understand and mitigate these types of errors. PMID:23882411

Error-compensation model for simultaneous measurement of five degrees of freedom motion errors of a rotary axis

NASA Astrophysics Data System (ADS)

Bao, Chuanchen; Li, Jiakun; Feng, Qibo; Zhang, Bin

2018-07-01

This paper introduces an error-compensation model for our measurement method to measure five motion errors of a rotary axis based on fibre laser collimation. The error-compensation model is established in a matrix form using the homogeneous coordinate transformation theory. The influences of the installation errors, error crosstalk, and manufacturing errors are analysed. The model is verified by both ZEMAX simulation and measurement experiments. The repeatability values of the radial and axial motion errors are significantly suppressed by more than 50% after compensation. The repeatability experiments of five degrees of freedom motion errors and the comparison experiments of two degrees of freedom motion errors of an indexing table were performed by our measuring device and a standard instrument. The results show that the repeatability values of the angular positioning error ε z and tilt motion error around the Y axis ε y are 1.2″ and 4.4″, and the comparison deviations of the two motion errors are 4.0″ and 4.4″, respectively. The repeatability values of the radial and axial motion errors, δ y and δ z , are 1.3 and 0.6 µm, respectively. The repeatability value of the tilt motion error around the X axis ε x is 3.8″.

Deep data fusion method for missile-borne inertial/celestial system

NASA Astrophysics Data System (ADS)

Zhang, Chunxi; Chen, Xiaofei; Lu, Jiazhen; Zhang, Hao

2018-05-01

Strap-down inertial-celestial integrated navigation system has the advantages of autonomy and high precision and is very useful for ballistic missiles. The star sensor installation error and inertial measurement error have a great influence for the system performance. Based on deep data fusion, this paper establishes measurement equations including star sensor installation error and proposes the deep fusion filter method. Simulations including misalignment error, star sensor installation error, IMU error are analyzed. Simulation results indicate that the deep fusion method can estimate the star sensor installation error and IMU error. Meanwhile, the method can restrain the misalignment errors caused by instrument errors.

Correcting for sequencing error in maximum likelihood phylogeny inference.

PubMed

Kuhner, Mary K; McGill, James

2014-11-04

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

Modeling coherent errors in quantum error correction

NASA Astrophysics Data System (ADS)

Greenbaum, Daniel; Dutton, Zachary

2018-01-01

Analysis of quantum error correcting codes is typically done using a stochastic, Pauli channel error model for describing the noise on physical qubits. However, it was recently found that coherent errors (systematic rotations) on physical data qubits result in both physical and logical error rates that differ significantly from those predicted by a Pauli model. Here we examine the accuracy of the Pauli approximation for noise containing coherent errors (characterized by a rotation angle ɛ) under the repetition code. We derive an analytic expression for the logical error channel as a function of arbitrary code distance d and concatenation level n, in the small error limit. We find that coherent physical errors result in logical errors that are partially coherent and therefore non-Pauli. However, the coherent part of the logical error is negligible at fewer than {ε }-({dn-1)} error correction cycles when the decoder is optimized for independent Pauli errors, thus providing a regime of validity for the Pauli approximation. Above this number of correction cycles, the persistent coherent logical error will cause logical failure more quickly than the Pauli model would predict, and this may need to be combated with coherent suppression methods at the physical level or larger codes.

Spelling Errors of Dyslexic Children in Bosnian Language with Transparent Orthography

ERIC Educational Resources Information Center

Duranovic, Mirela

2017-01-01

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

Coherent errors in quantum error correction

NASA Astrophysics Data System (ADS)

Greenbaum, Daniel; Dutton, Zachary

Analysis of quantum error correcting (QEC) codes is typically done using a stochastic, Pauli channel error model for describing the noise on physical qubits. However, it was recently found that coherent errors (systematic rotations) on physical data qubits result in both physical and logical error rates that differ significantly from those predicted by a Pauli model. We present analytic results for the logical error as a function of concatenation level and code distance for coherent errors under the repetition code. For data-only coherent errors, we find that the logical error is partially coherent and therefore non-Pauli. However, the coherent part of the error is negligible after two or more concatenation levels or at fewer than ɛ - (d - 1) error correction cycles. Here ɛ << 1 is the rotation angle error per cycle for a single physical qubit and d is the code distance. These results support the validity of modeling coherent errors using a Pauli channel under some minimum requirements for code distance and/or concatenation. We discuss extensions to imperfect syndrome extraction and implications for general QEC.

Factors associated with reporting of medication errors by Israeli nurses.

PubMed

Kagan, Ilya; Barnoy, Sivia

2008-01-01

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

Performance Metrics, Error Modeling, and Uncertainty Quantification

NASA Technical Reports Server (NTRS)

Tian, Yudong; Nearing, Grey S.; Peters-Lidard, Christa D.; Harrison, Kenneth W.; Tang, Ling

2016-01-01

A common set of statistical metrics has been used to summarize the performance of models or measurements-­ the most widely used ones being bias, mean square error, and linear correlation coefficient. They assume linear, additive, Gaussian errors, and they are interdependent, incomplete, and incapable of directly quantifying un­certainty. The authors demonstrate that these metrics can be directly derived from the parameters of the simple linear error model. Since a correct error model captures the full error information, it is argued that the specification of a parametric error model should be an alternative to the metrics-based approach. The error-modeling meth­odology is applicable to both linear and nonlinear errors, while the metrics are only meaningful for linear errors. In addition, the error model expresses the error structure more naturally, and directly quantifies uncertainty. This argument is further explained by highlighting the intrinsic connections between the performance metrics, the error model, and the joint distribution between the data and the reference.

Evaluation of drug administration errors in a teaching hospital

PubMed Central

2012-01-01

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

Evaluation of drug administration errors in a teaching hospital.

PubMed

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

2012-03-12

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

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

PubMed

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

2007-07-01

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

A Six Sigma Trial For Reduction of Error Rates in Pathology Laboratory.

PubMed

Tosuner, Zeynep; Gücin, Zühal; Kiran, Tuğçe; Büyükpinarbaşili, Nur; Turna, Seval; Taşkiran, Olcay; Arici, Dilek Sema

2016-01-01

A major target of quality assurance is the minimization of error rates in order to enhance patient safety. Six Sigma is a method targeting zero error (3.4 errors per million events) used in industry. The five main principles of Six Sigma are defining, measuring, analysis, improvement and control. Using this methodology, the causes of errors can be examined and process improvement strategies can be identified. The aim of our study was to evaluate the utility of Six Sigma methodology in error reduction in our pathology laboratory. The errors encountered between April 2014 and April 2015 were recorded by the pathology personnel. Error follow-up forms were examined by the quality control supervisor, administrative supervisor and the head of the department. Using Six Sigma methodology, the rate of errors was measured monthly and the distribution of errors at the preanalytic, analytic and postanalytical phases was analysed. Improvement strategies were reclaimed in the monthly intradepartmental meetings and the control of the units with high error rates was provided. Fifty-six (52.4%) of 107 recorded errors in total were at the pre-analytic phase. Forty-five errors (42%) were recorded as analytical and 6 errors (5.6%) as post-analytical. Two of the 45 errors were major irrevocable errors. The error rate was 6.8 per million in the first half of the year and 1.3 per million in the second half, decreasing by 79.77%. The Six Sigma trial in our pathology laboratory provided the reduction of the error rates mainly in the pre-analytic and analytic phases.

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

ERIC Educational Resources Information Center

Waggoner, Dori T.

2011-01-01

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

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

PubMed Central

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

2011-01-01

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

Error modeling and sensitivity analysis of a parallel robot with SCARA(selective compliance assembly robot arm) motions

NASA Astrophysics Data System (ADS)

Chen, Yuzhen; Xie, Fugui; Liu, Xinjun; Zhou, Yanhua

2014-07-01

Parallel robots with SCARA(selective compliance assembly robot arm) motions are utilized widely in the field of high speed pick-and-place manipulation. Error modeling for these robots generally simplifies the parallelogram structures included by the robots as a link. As the established error model fails to reflect the error feature of the parallelogram structures, the effect of accuracy design and kinematic calibration based on the error model come to be undermined. An error modeling methodology is proposed to establish an error model of parallel robots with parallelogram structures. The error model can embody the geometric errors of all joints, including the joints of parallelogram structures. Thus it can contain more exhaustively the factors that reduce the accuracy of the robot. Based on the error model and some sensitivity indices defined in the sense of statistics, sensitivity analysis is carried out. Accordingly, some atlases are depicted to express each geometric error's influence on the moving platform's pose errors. From these atlases, the geometric errors that have greater impact on the accuracy of the moving platform are identified, and some sensitive areas where the pose errors of the moving platform are extremely sensitive to the geometric errors are also figured out. By taking into account the error factors which are generally neglected in all existing modeling methods, the proposed modeling method can thoroughly disclose the process of error transmission and enhance the efficacy of accuracy design and calibration.

Error identification and recovery by student nurses using human patient simulation: opportunity to improve patient safety.

PubMed

Henneman, Elizabeth A; Roche, Joan P; Fisher, Donald L; Cunningham, Helene; Reilly, Cheryl A; Nathanson, Brian H; Henneman, Philip L

2010-02-01

This study examined types of errors that occurred or were recovered in a simulated environment by student nurses. Errors occurred in all four rule-based error categories, and all students committed at least one error. The most frequent errors occurred in the verification category. Another common error was related to physician interactions. The least common errors were related to coordinating information with the patient and family. Our finding that 100% of student subjects committed rule-based errors is cause for concern. To decrease errors and improve safe clinical practice, nurse educators must identify effective strategies that students can use to improve patient surveillance. Copyright 2010 Elsevier Inc. All rights reserved.

Sun compass error model

NASA Technical Reports Server (NTRS)

Blucker, T. J.; Ferry, W. W.

1971-01-01

An error model is described for the Apollo 15 sun compass, a contingency navigational device. Field test data are presented along with significant results of the test. The errors reported include a random error resulting from tilt in leveling the sun compass, a random error because of observer sighting inaccuracies, a bias error because of mean tilt in compass leveling, a bias error in the sun compass itself, and a bias error because the device is leveled to the local terrain slope.

The Relationship between Occurrence Timing of Dispensing Errors and Subsequent Danger to Patients under the Situation According to the Classification of Drugs by Efficacy.

PubMed

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.

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

PubMed

Maier, Martin E; Steinhauser, Marco

2013-10-02

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

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

NASA Astrophysics Data System (ADS)

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

2018-03-01

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

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

PubMed

Maier, Martin E; Steinhauser, Marco

2017-10-01

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

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

PubMed

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

2013-07-01

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

A methodology for translating positional error into measures of attribute error, and combining the two error sources

Treesearch

Yohay Carmel; Curtis Flather; Denis Dean

2006-01-01

This paper summarizes our efforts to investigate the nature, behavior, and implications of positional error and attribute error in spatiotemporal datasets. Estimating the combined influence of these errors on map analysis has been hindered by the fact that these two error types are traditionally expressed in different units (distance units, and categorical units,...

Automatic-repeat-request error control schemes

NASA Technical Reports Server (NTRS)

Lin, S.; Costello, D. J., Jr.; Miller, M. J.

1983-01-01

Error detection incorporated with automatic-repeat-request (ARQ) is widely used for error control in data communication systems. This method of error control is simple and provides high system reliability. If a properly chosen code is used for error detection, virtually error-free data transmission can be attained. Various types of ARQ and hybrid ARQ schemes, and error detection using linear block codes are surveyed.

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

NASA Astrophysics Data System (ADS)

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

2018-04-01

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

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

PubMed

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

2011-07-01

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

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

PubMed

Hicks, Rodney W; Becker, Shawn C

2006-01-01

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

Error response test system and method using test mask variable

NASA Technical Reports Server (NTRS)

Gender, Thomas K. (Inventor)

2006-01-01

An error response test system and method with increased functionality and improved performance is provided. The error response test system provides the ability to inject errors into the application under test to test the error response of the application under test in an automated and efficient manner. The error response system injects errors into the application through a test mask variable. The test mask variable is added to the application under test. During normal operation, the test mask variable is set to allow the application under test to operate normally. During testing, the error response test system can change the test mask variable to introduce an error into the application under test. The error response system can then monitor the application under test to determine whether the application has the correct response to the error.

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

NASA Astrophysics Data System (ADS)

Pernot, Pascal; Savin, Andreas

2018-06-01

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

Modeling Errors in Daily Precipitation Measurements: Additive or Multiplicative?

NASA Technical Reports Server (NTRS)

Tian, Yudong; Huffman, George J.; Adler, Robert F.; Tang, Ling; Sapiano, Matthew; Maggioni, Viviana; Wu, Huan

2013-01-01

The definition and quantification of uncertainty depend on the error model used. For uncertainties in precipitation measurements, two types of error models have been widely adopted: the additive error model and the multiplicative error model. This leads to incompatible specifications of uncertainties and impedes intercomparison and application.In this letter, we assess the suitability of both models for satellite-based daily precipitation measurements in an effort to clarify the uncertainty representation. Three criteria were employed to evaluate the applicability of either model: (1) better separation of the systematic and random errors; (2) applicability to the large range of variability in daily precipitation; and (3) better predictive skills. It is found that the multiplicative error model is a much better choice under all three criteria. It extracted the systematic errors more cleanly, was more consistent with the large variability of precipitation measurements, and produced superior predictions of the error characteristics. The additive error model had several weaknesses, such as non constant variance resulting from systematic errors leaking into random errors, and the lack of prediction capability. Therefore, the multiplicative error model is a better choice.

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

PubMed

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

2014-01-01

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

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

PubMed Central

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

2015-01-01

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

Impact of electronic chemotherapy order forms on prescribing errors at an urban medical center: results from an interrupted time-series analysis.

PubMed

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.

Error management for musicians: an interdisciplinary conceptual framework

PubMed Central

Kruse-Weber, Silke; Parncutt, Richard

2014-01-01

Musicians tend to strive for flawless performance and perfection, avoiding errors at all costs. Dealing with errors while practicing or performing is often frustrating and can lead to anger and despair, which can explain musicians’ generally negative attitude toward errors and the tendency to aim for flawless learning in instrumental music education. But even the best performances are rarely error-free, and research in general pedagogy and psychology has shown that errors provide useful information for the learning process. Research in instrumental pedagogy is still neglecting error issues; the benefits of risk management (before the error) and error management (during and after the error) are still underestimated. It follows that dealing with errors is a key aspect of music practice at home, teaching, and performance in public. And yet, to be innovative, or to make their performance extraordinary, musicians need to risk errors. Currently, most music students only acquire the ability to manage errors implicitly – or not at all. A more constructive, creative, and differentiated culture of errors would balance error tolerance and risk-taking against error prevention in ways that enhance music practice and music performance. The teaching environment should lay the foundation for the development of such an approach. In this contribution, we survey recent research in aviation, medicine, economics, psychology, and interdisciplinary decision theory that has demonstrated that specific error-management training can promote metacognitive skills that lead to better adaptive transfer and better performance skills. We summarize how this research can be applied to music, and survey-relevant research that is specifically tailored to the needs of musicians, including generic guidelines for risk and error management in music teaching and performance. On this basis, we develop a conceptual framework for risk management that can provide orientation for further music education and musicians at all levels. PMID:25120501

Self-calibration method without joint iteration for distributed small satellite SAR systems

NASA Astrophysics Data System (ADS)

Xu, Qing; Liao, Guisheng; Liu, Aifei; Zhang, Juan

2013-12-01

The performance of distributed small satellite synthetic aperture radar systems degrades significantly due to the unavoidable array errors, including gain, phase, and position errors, in real operating scenarios. In the conventional method proposed in (IEEE T Aero. Elec. Sys. 42:436-451, 2006), the spectrum components within one Doppler bin are considered as calibration sources. However, it is found in this article that the gain error estimation and the position error estimation in the conventional method can interact with each other. The conventional method may converge to suboptimal solutions in large position errors since it requires the joint iteration between gain-phase error estimation and position error estimation. In addition, it is also found that phase errors can be estimated well regardless of position errors when the zero Doppler bin is chosen. In this article, we propose a method obtained by modifying the conventional one, based on these two observations. In this modified method, gain errors are firstly estimated and compensated, which eliminates the interaction between gain error estimation and position error estimation. Then, by using the zero Doppler bin data, the phase error estimation can be performed well independent of position errors. Finally, position errors are estimated based on the Taylor-series expansion. Meanwhile, the joint iteration between gain-phase error estimation and position error estimation is not required. Therefore, the problem of suboptimal convergence, which occurs in the conventional method, can be avoided with low computational method. The modified method has merits of faster convergence and lower estimation error compared to the conventional one. Theoretical analysis and computer simulation results verified the effectiveness of the modified method.

Zero tolerance prescribing: a strategy to reduce prescribing errors on the paediatric intensive care unit.

PubMed

Booth, Rachelle; Sturgess, Emma; Taberner-Stokes, Alison; Peters, Mark

2012-11-01

To establish the baseline prescribing error rate in a tertiary paediatric intensive care unit (PICU) and to determine the impact of a zero tolerance prescribing (ZTP) policy incorporating a dedicated prescribing area and daily feedback of prescribing errors. A prospective, non-blinded, observational study was undertaken in a 12-bed tertiary PICU over a period of 134 weeks. Baseline prescribing error data were collected on weekdays for all patients for a period of 32 weeks, following which the ZTP policy was introduced. Daily error feedback was introduced after a further 12 months. Errors were sub-classified as 'clinical', 'non-clinical' and 'infusion prescription' errors and the effects of interventions considered separately. The baseline combined prescribing error rate was 892 (95 % confidence interval (CI) 765-1,019) errors per 1,000 PICU occupied bed days (OBDs), comprising 25.6 % clinical, 44 % non-clinical and 30.4 % infusion prescription errors. The combined interventions of ZTP plus daily error feedback were associated with a reduction in the combined prescribing error rate to 447 (95 % CI 389-504) errors per 1,000 OBDs (p < 0.0001), an absolute risk reduction of 44.5 % (95 % CI 40.8-48.0 %). Introduction of the ZTP policy was associated with a significant decrease in clinical and infusion prescription errors, while the introduction of daily error feedback was associated with a significant reduction in non-clinical prescribing errors. The combined interventions of ZTP and daily error feedback were associated with a significant reduction in prescribing errors in the PICU, in line with Department of Health requirements of a 40 % reduction within 5 years.

Error management for musicians: an interdisciplinary conceptual framework.

PubMed

Kruse-Weber, Silke; Parncutt, Richard

2014-01-01

Musicians tend to strive for flawless performance and perfection, avoiding errors at all costs. Dealing with errors while practicing or performing is often frustrating and can lead to anger and despair, which can explain musicians' generally negative attitude toward errors and the tendency to aim for flawless learning in instrumental music education. But even the best performances are rarely error-free, and research in general pedagogy and psychology has shown that errors provide useful information for the learning process. Research in instrumental pedagogy is still neglecting error issues; the benefits of risk management (before the error) and error management (during and after the error) are still underestimated. It follows that dealing with errors is a key aspect of music practice at home, teaching, and performance in public. And yet, to be innovative, or to make their performance extraordinary, musicians need to risk errors. Currently, most music students only acquire the ability to manage errors implicitly - or not at all. A more constructive, creative, and differentiated culture of errors would balance error tolerance and risk-taking against error prevention in ways that enhance music practice and music performance. The teaching environment should lay the foundation for the development of such an approach. In this contribution, we survey recent research in aviation, medicine, economics, psychology, and interdisciplinary decision theory that has demonstrated that specific error-management training can promote metacognitive skills that lead to better adaptive transfer and better performance skills. We summarize how this research can be applied to music, and survey-relevant research that is specifically tailored to the needs of musicians, including generic guidelines for risk and error management in music teaching and performance. On this basis, we develop a conceptual framework for risk management that can provide orientation for further music education and musicians at all levels.

Frequency and analysis of non-clinical errors made in radiology reports using the National Integrated Medical Imaging System voice recognition dictation software.

PubMed

Motyer, R E; Liddy, S; Torreggiani, W C; Buckley, O

2016-11-01

Voice recognition (VR) dictation of radiology reports has become the mainstay of reporting in many institutions worldwide. Despite benefit, such software is not without limitations, and transcription errors have been widely reported. Evaluate the frequency and nature of non-clinical transcription error using VR dictation software. Retrospective audit of 378 finalised radiology reports. Errors were counted and categorised by significance, error type and sub-type. Data regarding imaging modality, report length and dictation time was collected. 67 (17.72 %) reports contained ≥1 errors, with 7 (1.85 %) containing 'significant' and 9 (2.38 %) containing 'very significant' errors. A total of 90 errors were identified from the 378 reports analysed, with 74 (82.22 %) classified as 'insignificant', 7 (7.78 %) as 'significant', 9 (10 %) as 'very significant'. 68 (75.56 %) errors were 'spelling and grammar', 20 (22.22 %) 'missense' and 2 (2.22 %) 'nonsense'. 'Punctuation' error was most common sub-type, accounting for 27 errors (30 %). Complex imaging modalities had higher error rates per report and sentence. Computed tomography contained 0.040 errors per sentence compared to plain film with 0.030. Longer reports had a higher error rate, with reports >25 sentences containing an average of 1.23 errors per report compared to 0-5 sentences containing 0.09. These findings highlight the limitations of VR dictation software. While most error was deemed insignificant, there were occurrences of error with potential to alter report interpretation and patient management. Longer reports and reports on more complex imaging had higher error rates and this should be taken into account by the reporting radiologist.

Pointing error analysis of Risley-prism-based beam steering system.

PubMed

Zhou, Yuan; Lu, Yafei; Hei, Mo; Liu, Guangcan; Fan, Dapeng

2014-09-01

Based on the vector form Snell's law, ray tracing is performed to quantify the pointing errors of Risley-prism-based beam steering systems, induced by component errors, prism orientation errors, and assembly errors. Case examples are given to elucidate the pointing error distributions in the field of regard and evaluate the allowances of the error sources for a given pointing accuracy. It is found that the assembly errors of the second prism will result in more remarkable pointing errors in contrast with the first one. The pointing errors induced by prism tilt depend on the tilt direction. The allowances of bearing tilt and prism tilt are almost identical if the same pointing accuracy is planned. All conclusions can provide a theoretical foundation for practical works.

Error and Error Mitigation in Low-Coverage Genome Assemblies

PubMed Central

Hubisz, Melissa J.; Lin, Michael F.; Kellis, Manolis; Siepel, Adam

2011-01-01

The recent release of twenty-two new genome sequences has dramatically increased the data available for mammalian comparative genomics, but twenty of these new sequences are currently limited to ∼2× coverage. Here we examine the extent of sequencing error in these 2× assemblies, and its potential impact in downstream analyses. By comparing 2× assemblies with high-quality sequences from the ENCODE regions, we estimate the rate of sequencing error to be 1–4 errors per kilobase. While this error rate is fairly modest, sequencing error can still have surprising effects. For example, an apparent lineage-specific insertion in a coding region is more likely to reflect sequencing error than a true biological event, and the length distribution of coding indels is strongly distorted by error. We find that most errors are contributed by a small fraction of bases with low quality scores, in particular, by the ends of reads in regions of single-read coverage in the assembly. We explore several approaches for automatic sequencing error mitigation (SEM), making use of the localized nature of sequencing error, the fact that it is well predicted by quality scores, and information about errors that comes from comparisons across species. Our automatic methods for error mitigation cannot replace the need for additional sequencing, but they do allow substantial fractions of errors to be masked or eliminated at the cost of modest amounts of over-correction, and they can reduce the impact of error in downstream phylogenomic analyses. Our error-mitigated alignments are available for download. PMID:21340033

Error disclosure: a new domain for safety culture assessment.

PubMed

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

2012-07-01

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

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

NASA Astrophysics Data System (ADS)

Priyani, H. A.; Ekawati, R.

2018-01-01

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

Error Modeling of Multi-baseline Optical Truss. Part II; Application to SIM Metrology Truss Field Dependent Error

NASA Technical Reports Server (NTRS)

Zhang, Liwei Dennis; Milman, Mark; Korechoff, Robert

2004-01-01

The current design of the Space Interferometry Mission (SIM) employs a 19 laser-metrology-beam system (also called L19 external metrology truss) to monitor changes of distances between the fiducials of the flight system's multiple baselines. The function of the external metrology truss is to aid in the determination of the time-variations of the interferometer baseline. The largest contributor to truss error occurs in SIM wide-angle observations when the articulation of the siderostat mirrors (in order to gather starlight from different sky coordinates) brings to light systematic errors due to offsets at levels of instrument components (which include comer cube retro-reflectors, etc.). This error is labeled external metrology wide-angle field-dependent error. Physics-based model of field-dependent error at single metrology gauge level is developed and linearly propagated to errors in interferometer delay. In this manner delay error sensitivity to various error parameters or their combination can be studied using eigenvalue/eigenvector analysis. Also validation of physics-based field-dependent model on SIM testbed lends support to the present approach. As a first example, dihedral error model is developed for the comer cubes (CC) attached to the siderostat mirrors. Then the delay errors due to this effect can be characterized using the eigenvectors of composite CC dihedral error. The essence of the linear error model is contained in an error-mapping matrix. A corresponding Zernike component matrix approach is developed in parallel, first for convenience of describing the RMS of errors across the field-of-regard (FOR), and second for convenience of combining with additional models. Average and worst case residual errors are computed when various orders of field-dependent terms are removed from the delay error. Results of the residual errors are important in arriving at external metrology system component requirements. Double CCs with ideally co-incident vertices reside with the siderostat. The non-common vertex error (NCVE) is treated as a second example. Finally combination of models, and various other errors are discussed.

SU-E-T-377: Inaccurate Positioning Might Introduce Significant MapCheck Calibration Error in Flatten Filter Free Beams

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

Wang, S; Chao, C; Columbia University, NY, NY

2014-06-01

Purpose: This study investigates the calibration error of detector sensitivity for MapCheck due to inaccurate positioning of the device, which is not taken into account by the current commercial iterative calibration algorithm. We hypothesize the calibration is more vulnerable to the positioning error for the flatten filter free (FFF) beams than the conventional flatten filter flattened beams. Methods: MapCheck2 was calibrated with 10MV conventional and FFF beams, with careful alignment and with 1cm positioning error during calibration, respectively. Open fields of 37cmx37cm were delivered to gauge the impact of resultant calibration errors. The local calibration error was modeled as amore » detector independent multiplication factor, with which propagation error was estimated with positioning error from 1mm to 1cm. The calibrated sensitivities, without positioning error, were compared between the conventional and FFF beams to evaluate the dependence on the beam type. Results: The 1cm positioning error leads to 0.39% and 5.24% local calibration error in the conventional and FFF beams respectively. After propagating to the edges of MapCheck, the calibration errors become 6.5% and 57.7%, respectively. The propagation error increases almost linearly with respect to the positioning error. The difference of sensitivities between the conventional and FFF beams was small (0.11 ± 0.49%). Conclusion: The results demonstrate that the positioning error is not handled by the current commercial calibration algorithm of MapCheck. Particularly, the calibration errors for the FFF beams are ~9 times greater than those for the conventional beams with identical positioning error, and a small 1mm positioning error might lead to up to 8% calibration error. Since the sensitivities are only slightly dependent of the beam type and the conventional beam is less affected by the positioning error, it is advisable to cross-check the sensitivities between the conventional and FFF beams to detect potential calibration errors due to inaccurate positioning. This work was partially supported by a DOD Grant No.; DOD W81XWH1010862.« less

Technological Advancements and Error Rates in Radiation Therapy Delivery

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

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

2011-11-15

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

The Role of Model and Initial Condition Error in Numerical Weather Forecasting Investigated with an Observing System Simulation Experiment

NASA Technical Reports Server (NTRS)

Prive, Nikki C.; Errico, Ronald M.

2013-01-01

A series of experiments that explore the roles of model and initial condition error in numerical weather prediction are performed using an observing system simulation experiment (OSSE) framework developed at the National Aeronautics and Space Administration Global Modeling and Assimilation Office (NASA/GMAO). The use of an OSSE allows the analysis and forecast errors to be explicitly calculated, and different hypothetical observing networks can be tested with ease. In these experiments, both a full global OSSE framework and an 'identical twin' OSSE setup are utilized to compare the behavior of the data assimilation system and evolution of forecast skill with and without model error. The initial condition error is manipulated by varying the distribution and quality of the observing network and the magnitude of observation errors. The results show that model error has a strong impact on both the quality of the analysis field and the evolution of forecast skill, including both systematic and unsystematic model error components. With a realistic observing network, the analysis state retains a significant quantity of error due to systematic model error. If errors of the analysis state are minimized, model error acts to rapidly degrade forecast skill during the first 24-48 hours of forward integration. In the presence of model error, the impact of observation errors on forecast skill is small, but in the absence of model error, observation errors cause a substantial degradation of the skill of medium range forecasts.

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

NASA Astrophysics Data System (ADS)

Liu, Xing-fa; Cen, Ming

2007-12-01

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

Acoustic evidence for phonologically mismatched speech errors.

PubMed

Gormley, Andrea

2015-04-01

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

Challenge and Error: Critical Events and Attention-Related Errors

ERIC Educational Resources Information Center

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

2011-01-01

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

Accuracy Study of a Robotic System for MRI-guided Prostate Needle Placement

PubMed Central

Seifabadi, Reza; Cho, Nathan BJ.; Song, Sang-Eun; Tokuda, Junichi; Hata, Nobuhiko; Tempany, Clare M.; Fichtinger, Gabor; Iordachita, Iulian

2013-01-01

Background Accurate needle placement is the first concern in percutaneous MRI-guided prostate interventions. In this phantom study, different sources contributing to the overall needle placement error of a MRI-guided robot for prostate biopsy have been identified, quantified, and minimized to the possible extent. Methods and Materials The overall needle placement error of the system was evaluated in a prostate phantom. This error was broken into two parts: the error associated with the robotic system (called before-insertion error) and the error associated with needle-tissue interaction (called due-to-insertion error). The before-insertion error was measured directly in a soft phantom and different sources contributing into this part were identified and quantified. A calibration methodology was developed to minimize the 4-DOF manipulator’s error. The due-to-insertion error was indirectly approximated by comparing the overall error and the before-insertion error. The effect of sterilization on the manipulator’s accuracy and repeatability was also studied. Results The average overall system error in phantom study was 2.5 mm (STD=1.1mm). The average robotic system error in super soft phantom was 1.3 mm (STD=0.7 mm). Assuming orthogonal error components, the needle-tissue interaction error was approximated to be 2.13 mm thus having larger contribution to the overall error. The average susceptibility artifact shift was 0.2 mm. The manipulator’s targeting accuracy was 0.71 mm (STD=0.21mm) after robot calibration. The robot’s repeatability was 0.13 mm. Sterilization had no noticeable influence on the robot’s accuracy and repeatability. Conclusions The experimental methodology presented in this paper may help researchers to identify, quantify, and minimize different sources contributing into the overall needle placement error of an MRI-guided robotic system for prostate needle placement. In the robotic system analyzed here, the overall error of the studied system remained within the acceptable range. PMID:22678990

Accuracy study of a robotic system for MRI-guided prostate needle placement.

PubMed

Seifabadi, Reza; Cho, Nathan B J; Song, Sang-Eun; Tokuda, Junichi; Hata, Nobuhiko; Tempany, Clare M; Fichtinger, Gabor; Iordachita, Iulian

2013-09-01

Accurate needle placement is the first concern in percutaneous MRI-guided prostate interventions. In this phantom study, different sources contributing to the overall needle placement error of a MRI-guided robot for prostate biopsy have been identified, quantified and minimized to the possible extent. The overall needle placement error of the system was evaluated in a prostate phantom. This error was broken into two parts: the error associated with the robotic system (called 'before-insertion error') and the error associated with needle-tissue interaction (called 'due-to-insertion error'). Before-insertion error was measured directly in a soft phantom and different sources contributing into this part were identified and quantified. A calibration methodology was developed to minimize the 4-DOF manipulator's error. The due-to-insertion error was indirectly approximated by comparing the overall error and the before-insertion error. The effect of sterilization on the manipulator's accuracy and repeatability was also studied. The average overall system error in the phantom study was 2.5 mm (STD = 1.1 mm). The average robotic system error in the Super Soft plastic phantom was 1.3 mm (STD = 0.7 mm). Assuming orthogonal error components, the needle-tissue interaction error was found to be approximately 2.13 mm, thus making a larger contribution to the overall error. The average susceptibility artifact shift was 0.2 mm. The manipulator's targeting accuracy was 0.71 mm (STD = 0.21 mm) after robot calibration. The robot's repeatability was 0.13 mm. Sterilization had no noticeable influence on the robot's accuracy and repeatability. The experimental methodology presented in this paper may help researchers to identify, quantify and minimize different sources contributing into the overall needle placement error of an MRI-guided robotic system for prostate needle placement. In the robotic system analysed here, the overall error of the studied system remained within the acceptable range. Copyright © 2012 John Wiley & Sons, Ltd.

Using snowball sampling method with nurses to understand medication administration errors.

PubMed

Sheu, Shuh-Jen; Wei, Ien-Lan; Chen, Ching-Huey; Yu, Shu; Tang, Fu-In

2009-02-01

We aimed to encourage nurses to release information about drug administration errors to increase understanding of error-related circumstances and to identify high-alert situations. Drug administration errors represent the majority of medication errors, but errors are underreported. Effective ways are lacking to encourage nurses to actively report errors. Snowball sampling was conducted to recruit participants. A semi-structured questionnaire was used to record types of error, hospital and nurse backgrounds, patient consequences, error discovery mechanisms and reporting rates. Eighty-five nurses participated, reporting 328 administration errors (259 actual, 69 near misses). Most errors occurred in medical surgical wards of teaching hospitals, during day shifts, committed by nurses working fewer than two years. Leading errors were wrong drugs and doses, each accounting for about one-third of total errors. Among 259 actual errors, 83.8% resulted in no adverse effects; among remaining 16.2%, 6.6% had mild consequences and 9.6% had serious consequences (severe reaction, coma, death). Actual errors and near misses were discovered mainly through double-check procedures by colleagues and nurses responsible for errors; reporting rates were 62.5% (162/259) vs. 50.7% (35/69) and only 3.5% (9/259) vs. 0% (0/69) were disclosed to patients and families. High-alert situations included administration of 15% KCl, insulin and Pitocin; using intravenous pumps; and implementation of cardiopulmonary resuscitation (CPR). Snowball sampling proved to be an effective way to encourage nurses to release details concerning medication errors. Using empirical data, we identified high-alert situations. Strategies for reducing drug administration errors by nurses are suggested. Survey results suggest that nurses should double check medication administration in known high-alert situations. Nursing management can use snowball sampling to gather error details from nurses in a non-reprimanding atmosphere, helping to establish standard operational procedures for known high-alert situations.

Predictors of Errors of Novice Java Programmers

ERIC Educational Resources Information Center

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

2012-01-01

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

Model Error Estimation for the CPTEC Eta Model

NASA Technical Reports Server (NTRS)

Tippett, Michael K.; daSilva, Arlindo

1999-01-01

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

Evaluating a medical error taxonomy.

PubMed

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

2002-01-01

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

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

PubMed

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

2017-05-01

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

The pattern of the discovery of medication errors in a tertiary hospital in Hong Kong.

PubMed

Samaranayake, N R; Cheung, S T D; Chui, W C M; Cheung, B M Y

2013-06-01

The primary goal of reducing medication errors is to eliminate those that reach the patient. We aimed to study the pattern of interceptions to tackle medication errors along the medication use processes. Tertiary care hospital in Hong Kong. The 'Swiss Cheese Model' was used to explain the interceptions targeting medication error reporting over 5 years (2006-2010). Proportions of prescribing, dispensing and drug administration errors intercepted by pharmacists and nurses; proportions of prescribing, dispensing and drug administration errors that reached the patient. Our analysis included 1,268 in-patient medication errors, of which 53.4% were related to prescribing, 29.0% to administration and 17.6% to dispensing. 34.1% of all medication errors (4.9% prescribing, 26.8% drug administration and 2.4% dispensing) were not intercepted. Pharmacy staff intercepted 85.4% of the prescribing errors. Nurses detected 83.0% of dispensing and 5.0% of prescribing errors. However, 92.4% of all drug administration errors reached the patient. Having a preventive measure at each stage of the medication use process helps to prevent most errors. Most drug administration errors reach the patient as there is no defense against these. Therefore, more interventions to prevent drug administration errors are warranted.

Policies on documentation and disciplinary action in hospital pharmacies after a medication error.

PubMed

Bauman, A N; Pedersen, C A; Schommer, J C; Griffith, N L

2001-06-15

Hospital pharmacies were surveyed about policies on medication error documentation and actions taken against pharmacists involved in an error. The survey was mailed to 500 randomly selected hospital pharmacy directors in the United States. Data were collected on the existence of medication error reporting policies, what types of errors were documented and how, and hospital demographics. The response rate was 28%. Virtually all of the hospitals had policies and procedures for medication error reporting. Most commonly, documentation of oral and written reprimand was placed in the personnel file of a pharmacist involved in an error. One sixth of respondents had no policy on documentation or disciplinary action in the event of an error. Approximately one fourth of respondents reported that suspension or termination had been used as a form of disciplinary action; legal action was rarely used. Many respondents said errors that caused harm (42%) or death (40%) to the patient were documented in the personnel file, but 34% of hospitals did not document errors in the personnel file regardless of error type. Nearly three fourths of respondents differentiated between errors caught and not caught before a medication leaves the pharmacy and between errors caught and not caught before administration to the patient. More emphasis is needed on documentation of medication errors in hospital pharmacies.

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

PubMed

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

2010-07-01

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

Medical errors in primary care clinics – a cross sectional study

PubMed Central

2012-01-01

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

Opioid errors in inpatient palliative care services: a retrospective review.

PubMed

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

2018-06-01

Opioids are a high-risk medicine frequently used to manage palliative patients' cancer-related pain and other symptoms. Despite the high volume of opioid use in inpatient palliative care services, and the potential for patient harm, few studies have focused on opioid errors in this population. To (i) identify the number of opioid errors reported by inpatient palliative care services, (ii) identify reported opioid error characteristics and (iii) determine the impact of opioid errors on palliative patient outcomes. A 24-month retrospective review of opioid errors reported in three inpatient palliative care services in one Australian state. Of the 55 opioid errors identified, 84% reached the patient. Most errors involved morphine (35%) or hydromorphone (29%). Opioid administration errors accounted for 76% of reported opioid errors, largely due to omitted dose (33%) or wrong dose (24%) errors. Patients were more likely to receive a lower dose of opioid than ordered as a direct result of an opioid error (57%), with errors adversely impacting pain and/or symptom management in 42% of patients. Half (53%) of the affected patients required additional treatment and/or care as a direct consequence of the opioid error. This retrospective review has provided valuable insights into the patterns and impact of opioid errors in inpatient palliative care services. Iatrogenic harm related to opioid underdosing errors contributed to palliative patients' unrelieved pain. Better understanding the factors that contribute to opioid errors and the role of safety culture in the palliative care service context warrants further investigation. © 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.

Antiretroviral medication prescribing errors are common with hospitalization of HIV-infected patients.

PubMed

Commers, Tessa; Swindells, Susan; Sayles, Harlan; Gross, Alan E; Devetten, Marcel; Sandkovsky, Uriel

2014-01-01

Errors in prescribing antiretroviral therapy (ART) often occur with the hospitalization of HIV-infected patients. The rapid identification and prevention of errors may reduce patient harm and healthcare-associated costs. A retrospective review of hospitalized HIV-infected patients was carried out between 1 January 2009 and 31 December 2011. Errors were documented as omission, underdose, overdose, duplicate therapy, incorrect scheduling and/or incorrect therapy. The time to error correction was recorded. Relative risks (RRs) were computed to evaluate patient characteristics and error rates. A total of 289 medication errors were identified in 146/416 admissions (35%). The most common was drug omission (69%). At an error rate of 31%, nucleoside reverse transcriptase inhibitors were associated with an increased risk of error when compared with protease inhibitors (RR 1.32; 95% CI 1.04-1.69) and co-formulated drugs (RR 1.59; 95% CI 1.19-2.09). Of the errors, 31% were corrected within the first 24 h, but over half (55%) were never remedied. Admissions with an omission error were 7.4 times more likely to have all errors corrected within 24 h than were admissions without an omission. Drug interactions with ART were detected on 51 occasions. For the study population (n = 177), an increased risk of admission error was observed for black (43%) compared with white (28%) individuals (RR 1.53; 95% CI 1.16-2.03) but no significant differences were observed between white patients and other minorities or between men and women. Errors in inpatient ART were common, and the majority were never detected. The most common errors involved omission of medication, and nucleoside reverse transcriptase inhibitors had the highest rate of prescribing error. Interventions to prevent and correct errors are urgently needed.

The Influence of Observation Errors on Analysis Error and Forecast Skill Investigated with an Observing System Simulation Experiment

NASA Technical Reports Server (NTRS)

Prive, N. C.; Errico, R. M.; Tai, K.-S.

2013-01-01

The Global Modeling and Assimilation Office (GMAO) observing system simulation experiment (OSSE) framework is used to explore the response of analysis error and forecast skill to observation quality. In an OSSE, synthetic observations may be created that have much smaller error than real observations, and precisely quantified error may be applied to these synthetic observations. Three experiments are performed in which synthetic observations with magnitudes of applied observation error that vary from zero to twice the estimated realistic error are ingested into the Goddard Earth Observing System Model (GEOS-5) with Gridpoint Statistical Interpolation (GSI) data assimilation for a one-month period representing July. The analysis increment and observation innovation are strongly impacted by observation error, with much larger variances for increased observation error. The analysis quality is degraded by increased observation error, but the change in root-mean-square error of the analysis state is small relative to the total analysis error. Surprisingly, in the 120 hour forecast increased observation error only yields a slight decline in forecast skill in the extratropics, and no discernable degradation of forecast skill in the tropics.

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

PubMed

Steele-Johnson, Debra; Kalinoski, Zachary T

2014-01-01

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

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

NASA Technical Reports Server (NTRS)

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

2000-01-01

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

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

PubMed Central

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

2013-01-01

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

Asymmetric Memory Circuit Would Resist Soft Errors

NASA Technical Reports Server (NTRS)

Buehler, Martin G.; Perlman, Marvin

1990-01-01

Some nonlinear error-correcting codes more efficient in presence of asymmetry. Combination of circuit-design and coding concepts expected to make integrated-circuit random-access memories more resistant to "soft" errors (temporary bit errors, also called "single-event upsets" due to ionizing radiation). Integrated circuit of new type made deliberately more susceptible to one kind of bit error than to other, and associated error-correcting code adapted to exploit this asymmetry in error probabilities.

Clover: Compiler directed lightweight soft error resilience

DOE PAGES

Liu, Qingrui; Lee, Dongyoon; Jung, Changhee; ...

2015-05-01

This paper presents Clover, a compiler directed soft error detection and recovery scheme for lightweight soft error resilience. The compiler carefully generates soft error tolerant code based on idem-potent processing without explicit checkpoint. During program execution, Clover relies on a small number of acoustic wave detectors deployed in the processor to identify soft errors by sensing the wave made by a particle strike. To cope with DUE (detected unrecoverable errors) caused by the sensing latency of error detection, Clover leverages a novel selective instruction duplication technique called tail-DMR (dual modular redundancy). Once a soft error is detected by either themore » sensor or the tail-DMR, Clover takes care of the error as in the case of exception handling. To recover from the error, Clover simply redirects program control to the beginning of the code region where the error is detected. Lastly, the experiment results demonstrate that the average runtime overhead is only 26%, which is a 75% reduction compared to that of the state-of-the-art soft error resilience technique.« less

Evidence for aversive withdrawal response to own errors.

PubMed

Hochman, Eldad Yitzhak; Milman, Valery; Tal, Liron

2017-10-01

Recent model suggests that error detection gives rise to defensive motivation prompting protective behavior. Models of active avoidance behavior predict it should grow larger with threat imminence and avoidance. We hypothesized that in a task requiring left or right key strikes, error detection would drive an avoidance reflex manifested by rapid withdrawal of an erring finger growing larger with threat imminence and avoidance. In experiment 1, three groups differing by error-related threat imminence and avoidance performed a flanker task requiring left or right force sensitive-key strikes. As predicted, errors were followed by rapid force release growing faster with threat imminence and opportunity to evade threat. In experiment 2, we established a link between error key release time (KRT) and the subjective sense of inner-threat. In a simultaneous, multiple regression analysis of three error-related compensatory mechanisms (error KRT, flanker effect, error correction RT), only error KRT was significantly associated with increased compulsive checking tendencies. We propose that error response withdrawal reflects an error-withdrawal reflex. Copyright © 2017 Elsevier B.V. All rights reserved.

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

NASA Astrophysics Data System (ADS)

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

2018-01-01

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

A cognitive taxonomy of medical errors.

PubMed

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

2004-06-01

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

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

PubMed

Martinez, William; Lo, Bernard

2008-07-01

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

Implementing parallel spreadsheet models for health policy decisions: The impact of unintentional errors on model projections

PubMed Central

Bailey, Stephanie L.; Bono, Rose S.; Nash, Denis; Kimmel, April D.

2018-01-01

Background Spreadsheet software is increasingly used to implement systems science models informing health policy decisions, both in academia and in practice where technical capacity may be limited. However, spreadsheet models are prone to unintentional errors that may not always be identified using standard error-checking techniques. Our objective was to illustrate, through a methodologic case study analysis, the impact of unintentional errors on model projections by implementing parallel model versions. Methods We leveraged a real-world need to revise an existing spreadsheet model designed to inform HIV policy. We developed three parallel versions of a previously validated spreadsheet-based model; versions differed by the spreadsheet cell-referencing approach (named single cells; column/row references; named matrices). For each version, we implemented three model revisions (re-entry into care; guideline-concordant treatment initiation; immediate treatment initiation). After standard error-checking, we identified unintentional errors by comparing model output across the three versions. Concordant model output across all versions was considered error-free. We calculated the impact of unintentional errors as the percentage difference in model projections between model versions with and without unintentional errors, using +/-5% difference to define a material error. Results We identified 58 original and 4,331 propagated unintentional errors across all model versions and revisions. Over 40% (24/58) of original unintentional errors occurred in the column/row reference model version; most (23/24) were due to incorrect cell references. Overall, >20% of model spreadsheet cells had material unintentional errors. When examining error impact along the HIV care continuum, the percentage difference between versions with and without unintentional errors ranged from +3% to +16% (named single cells), +26% to +76% (column/row reference), and 0% (named matrices). Conclusions Standard error-checking techniques may not identify all errors in spreadsheet-based models. Comparing parallel model versions can aid in identifying unintentional errors and promoting reliable model projections, particularly when resources are limited. PMID:29570737

Error detection and reduction in blood banking.

PubMed

Motschman, T L; Moore, S B

1996-12-01

Error management plays a major role in facility process improvement efforts. By detecting and reducing errors, quality and, therefore, patient care improve. It begins with a strong organizational foundation of management attitude with clear, consistent employee direction and appropriate physical facilities. Clearly defined critical processes, critical activities, and SOPs act as the framework for operations as well as active quality monitoring. To assure that personnel can detect an report errors they must be trained in both operational duties and error management practices. Use of simulated/intentional errors and incorporation of error detection into competency assessment keeps employees practiced, confident, and diminishes fear of the unknown. Personnel can clearly see that errors are indeed used as opportunities for process improvement and not for punishment. The facility must have a clearly defined and consistently used definition for reportable errors. Reportable errors should include those errors with potentially harmful outcomes as well as those errors that are "upstream," and thus further away from the outcome. A well-written error report consists of who, what, when, where, why/how, and follow-up to the error. Before correction can occur, an investigation to determine the underlying cause of the error should be undertaken. Obviously, the best corrective action is prevention. Correction can occur at five different levels; however, only three of these levels are directed at prevention. Prevention requires a method to collect and analyze data concerning errors. In the authors' facility a functional error classification method and a quality system-based classification have been useful. An active method to search for problems uncovers them further upstream, before they can have disastrous outcomes. In the continual quest for improving processes, an error management program is itself a process that needs improvement, and we must strive to always close the circle of quality assurance. Ultimately, the goal of better patient care will be the reward.

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

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

Kry, S; Dromgoole, L; Alvarez, P

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

Laboratory errors and patient safety.

PubMed

Miligy, Dawlat A

2015-01-01

Laboratory data are extensively used in medical practice; consequently, laboratory errors have a tremendous impact on patient safety. Therefore, programs designed to identify and reduce laboratory errors, as well as, setting specific strategies are required to minimize these errors and improve patient safety. The purpose of this paper is to identify part of the commonly encountered laboratory errors throughout our practice in laboratory work, their hazards on patient health care and some measures and recommendations to minimize or to eliminate these errors. Recording the encountered laboratory errors during May 2008 and their statistical evaluation (using simple percent distribution) have been done in the department of laboratory of one of the private hospitals in Egypt. Errors have been classified according to the laboratory phases and according to their implication on patient health. Data obtained out of 1,600 testing procedure revealed that the total number of encountered errors is 14 tests (0.87 percent of total testing procedures). Most of the encountered errors lay in the pre- and post-analytic phases of testing cycle (representing 35.7 and 50 percent, respectively, of total errors). While the number of test errors encountered in the analytic phase represented only 14.3 percent of total errors. About 85.7 percent of total errors were of non-significant implication on patients health being detected before test reports have been submitted to the patients. On the other hand, the number of test errors that have been already submitted to patients and reach the physician represented 14.3 percent of total errors. Only 7.1 percent of the errors could have an impact on patient diagnosis. The findings of this study were concomitant with those published from the USA and other countries. This proves that laboratory problems are universal and need general standardization and bench marking measures. Original being the first data published from Arabic countries that evaluated the encountered laboratory errors and launch the great need for universal standardization and bench marking measures to control the laboratory work.

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

PubMed Central

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

2012-01-01

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

Implementing parallel spreadsheet models for health policy decisions: The impact of unintentional errors on model projections.

PubMed

Bailey, Stephanie L; Bono, Rose S; Nash, Denis; Kimmel, April D

2018-01-01

Spreadsheet software is increasingly used to implement systems science models informing health policy decisions, both in academia and in practice where technical capacity may be limited. However, spreadsheet models are prone to unintentional errors that may not always be identified using standard error-checking techniques. Our objective was to illustrate, through a methodologic case study analysis, the impact of unintentional errors on model projections by implementing parallel model versions. We leveraged a real-world need to revise an existing spreadsheet model designed to inform HIV policy. We developed three parallel versions of a previously validated spreadsheet-based model; versions differed by the spreadsheet cell-referencing approach (named single cells; column/row references; named matrices). For each version, we implemented three model revisions (re-entry into care; guideline-concordant treatment initiation; immediate treatment initiation). After standard error-checking, we identified unintentional errors by comparing model output across the three versions. Concordant model output across all versions was considered error-free. We calculated the impact of unintentional errors as the percentage difference in model projections between model versions with and without unintentional errors, using +/-5% difference to define a material error. We identified 58 original and 4,331 propagated unintentional errors across all model versions and revisions. Over 40% (24/58) of original unintentional errors occurred in the column/row reference model version; most (23/24) were due to incorrect cell references. Overall, >20% of model spreadsheet cells had material unintentional errors. When examining error impact along the HIV care continuum, the percentage difference between versions with and without unintentional errors ranged from +3% to +16% (named single cells), +26% to +76% (column/row reference), and 0% (named matrices). Standard error-checking techniques may not identify all errors in spreadsheet-based models. Comparing parallel model versions can aid in identifying unintentional errors and promoting reliable model projections, particularly when resources are limited.

Determining relative error bounds for the CVBEM

USGS Publications Warehouse

Hromadka, T.V.

1985-01-01

The Complex Variable Boundary Element Methods provides a measure of relative error which can be utilized to subsequently reduce the error or provide information for further modeling analysis. By maximizing the relative error norm on each boundary element, a bound on the total relative error for each boundary element can be evaluated. This bound can be utilized to test CVBEM convergence, to analyze the effects of additional boundary nodal points in reducing the modeling error, and to evaluate the sensitivity of resulting modeling error within a boundary element from the error produced in another boundary element as a function of geometric distance. ?? 1985.

An Investigation into Soft Error Detection Efficiency at Operating System Level

PubMed Central

Taheri, Hassan

2014-01-01

Electronic equipment operating in harsh environments such as space is subjected to a range of threats. The most important of these is radiation that gives rise to permanent and transient errors on microelectronic components. The occurrence rate of transient errors is significantly more than permanent errors. The transient errors, or soft errors, emerge in two formats: control flow errors (CFEs) and data errors. Valuable research results have already appeared in literature at hardware and software levels for their alleviation. However, there is the basic assumption behind these works that the operating system is reliable and the focus is on other system levels. In this paper, we investigate the effects of soft errors on the operating system components and compare their vulnerability with that of application level components. Results show that soft errors in operating system components affect both operating system and application level components. Therefore, by providing endurance to operating system level components against soft errors, both operating system and application level components gain tolerance. PMID:24574894

An investigation into soft error detection efficiency at operating system level.

PubMed

Asghari, Seyyed Amir; Kaynak, Okyay; Taheri, Hassan

2014-01-01

Electronic equipment operating in harsh environments such as space is subjected to a range of threats. The most important of these is radiation that gives rise to permanent and transient errors on microelectronic components. The occurrence rate of transient errors is significantly more than permanent errors. The transient errors, or soft errors, emerge in two formats: control flow errors (CFEs) and data errors. Valuable research results have already appeared in literature at hardware and software levels for their alleviation. However, there is the basic assumption behind these works that the operating system is reliable and the focus is on other system levels. In this paper, we investigate the effects of soft errors on the operating system components and compare their vulnerability with that of application level components. Results show that soft errors in operating system components affect both operating system and application level components. Therefore, by providing endurance to operating system level components against soft errors, both operating system and application level components gain tolerance.

An interpretation of radiosonde errors in the atmospheric boundary layer

Treesearch

Bernadette H. Connell; David R. Miller

1995-01-01

The authors review sources of error in radiosonde measurements in the atmospheric boundary layer and analyze errors of two radiosonde models manufactured by Atmospheric Instrumentation Research, Inc. The authors focus on temperature and humidity lag errors and wind errors. Errors in measurement of azimuth and elevation angles and pressure over short time intervals and...

Parametric Modulation of Error-Related ERP Components by the Magnitude of Visuo-Motor Mismatch

ERIC Educational Resources Information Center

Vocat, Roland; Pourtois, Gilles; Vuilleumier, Patrik

2011-01-01

Errors generate typical brain responses, characterized by two successive event-related potentials (ERP) following incorrect action: the error-related negativity (ERN) and the positivity error (Pe). However, it is unclear whether these error-related responses are sensitive to the magnitude of the error, or instead show all-or-none effects. We…

Finding Productive Talk around Errors in Intelligent Tutoring Systems

ERIC Educational Resources Information Center

Olsen, Jennifer K.; Rummel, Nikol; Aleven, Vincent

2015-01-01

To learn from an error, students must correct the error by engaging in sense-making activities around the error. Past work has looked at how supporting collaboration around errors affects learning. This paper attempts to shed further light on the role that collaboration can play in the process of overcoming an error. We found that good…

Relationships of Measurement Error and Prediction Error in Observed-Score Regression

ERIC Educational Resources Information Center

Moses, Tim

2012-01-01

The focus of this paper is assessing the impact of measurement errors on the prediction error of an observed-score regression. Measures are presented and described for decomposing the linear regression's prediction error variance into parts attributable to the true score variance and the error variances of the dependent variable and the predictor…

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

PubMed

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

2012-09-01

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

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

PubMed

Stultz, Jeremy S; Nahata, Milap C

2015-07-01

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

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

PubMed

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

2011-06-22

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

Medication administration errors from a nursing viewpoint: a formal consensus of definition and scenarios using a Delphi technique.

PubMed

Shawahna, Ramzi; Masri, Dina; Al-Gharabeh, Rawan; Deek, Rawan; Al-Thayba, Lama; Halaweh, Masa

2016-02-01

To develop and achieve formal consensus on a definition of medication administration errors and scenarios that should or should not be considered as medication administration errors in hospitalised patient settings. Medication administration errors occur frequently in hospitalised patient settings. Currently, there is no formal consensus on a definition of medication administration errors or scenarios that should or should not be considered as medication administration errors. This was a descriptive study using Delphi technique. A panel of experts (n = 50) recruited from major hospitals, nursing schools and universities in Palestine took part in the study. Three Delphi rounds were followed to achieve consensus on a proposed definition of medication administration errors and a series of 61 scenarios representing potential medication administration error situations formulated into a questionnaire. In the first Delphi round, key contact nurses' views on medication administration errors were explored. In the second Delphi round, consensus was achieved to accept the proposed definition of medication administration errors and to include 36 (59%) scenarios and exclude 1 (1·6%) as medication administration errors. In the third Delphi round, consensus was achieved to consider further 14 (23%) and exclude 2 (3·3%) as medication administration errors while the remaining eight (13·1%) were considered equivocal. Of the 61 scenarios included in the Delphi process, experts decided to include 50 scenarios as medication administration errors, exclude three scenarios and include or exclude eight scenarios depending on the individual clinical situation. Consensus on a definition and scenarios representing medication administration errors can be achieved using formal consensus techniques. Researchers should be aware that using different definitions of medication administration errors, inclusion or exclusion of medication administration error situations could significantly affect the rate of medication administration errors reported in their studies. Consensual definitions and medication administration error situations can be used in future epidemiology studies investigating medication administration errors in hospitalised patient settings which may permit and promote direct comparisons of different studies. © 2015 John Wiley & Sons Ltd.

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

PubMed

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

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

Optimizer convergence and local minima errors and their clinical importance

NASA Astrophysics Data System (ADS)

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

2003-09-01

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

Optimizer convergence and local minima errors and their clinical importance.

PubMed

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

2003-09-07

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

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

PubMed

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

2013-12-01

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

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

PubMed

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

2017-08-01

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

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

NASA Astrophysics Data System (ADS)

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

2015-07-01

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

Patterns of technical error among surgical malpractice claims: an analysis of strategies to prevent injury to surgical patients.

PubMed

Regenbogen, Scott E; Greenberg, Caprice C; Studdert, David M; Lipsitz, Stuart R; Zinner, Michael J; Gawande, Atul A

2007-11-01

To identify the most prevalent patterns of technical errors in surgery, and evaluate commonly recommended interventions in light of these patterns. The majority of surgical adverse events involve technical errors, but little is known about the nature and causes of these events. We examined characteristics of technical errors and common contributing factors among closed surgical malpractice claims. Surgeon reviewers analyzed 444 randomly sampled surgical malpractice claims from four liability insurers. Among 258 claims in which injuries due to error were detected, 52% (n = 133) involved technical errors. These technical errors were further analyzed with a structured review instrument designed by qualitative content analysis. Forty-nine percent of the technical errors caused permanent disability; an additional 16% resulted in death. Two-thirds (65%) of the technical errors were linked to manual error, 9% to errors in judgment, and 26% to both manual and judgment error. A minority of technical errors involved advanced procedures requiring special training ("index operations"; 16%), surgeons inexperienced with the task (14%), or poorly supervised residents (9%). The majority involved experienced surgeons (73%), and occurred in routine, rather than index, operations (84%). Patient-related complexities-including emergencies, difficult or unexpected anatomy, and previous surgery-contributed to 61% of technical errors, and technology or systems failures contributed to 21%. Most technical errors occur in routine operations with experienced surgeons, under conditions of increased patient complexity or systems failure. Commonly recommended interventions, including restricting high-complexity operations to experienced surgeons, additional training for inexperienced surgeons, and stricter supervision of trainees, are likely to address only a minority of technical errors. Surgical safety research should instead focus on improving decision-making and performance in routine operations for complex patients and circumstances.

Identification and correction of systematic error in high-throughput sequence data

PubMed Central

2011-01-01

Background A feature common to all DNA sequencing technologies is the presence of base-call errors in the sequenced reads. The implications of such errors are application specific, ranging from minor informatics nuisances to major problems affecting biological inferences. Recently developed "next-gen" sequencing technologies have greatly reduced the cost of sequencing, but have been shown to be more error prone than previous technologies. Both position specific (depending on the location in the read) and sequence specific (depending on the sequence in the read) errors have been identified in Illumina and Life Technology sequencing platforms. We describe a new type of systematic error that manifests as statistically unlikely accumulations of errors at specific genome (or transcriptome) locations. Results We characterize and describe systematic errors using overlapping paired reads from high-coverage data. We show that such errors occur in approximately 1 in 1000 base pairs, and that they are highly replicable across experiments. We identify motifs that are frequent at systematic error sites, and describe a classifier that distinguishes heterozygous sites from systematic error. Our classifier is designed to accommodate data from experiments in which the allele frequencies at heterozygous sites are not necessarily 0.5 (such as in the case of RNA-Seq), and can be used with single-end datasets. Conclusions Systematic errors can easily be mistaken for heterozygous sites in individuals, or for SNPs in population analyses. Systematic errors are particularly problematic in low coverage experiments, or in estimates of allele-specific expression from RNA-Seq data. Our characterization of systematic error has allowed us to develop a program, called SysCall, for identifying and correcting such errors. We conclude that correction of systematic errors is important to consider in the design and interpretation of high-throughput sequencing experiments. PMID:22099972

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

PubMed

Kiymaz, Dilek; Koç, Zeliha

2018-03-01

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

Global distortion of GPS networks associated with satellite antenna model errors

NASA Astrophysics Data System (ADS)

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

2007-07-01

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

Global Distortion of GPS Networks Associated with Satellite Antenna Model Errors

NASA Technical Reports Server (NTRS)

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

2007-01-01

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

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

PubMed

Huckels-Baumgart, Saskia; Manser, Tanja

2014-10-01

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

Computational fluid dynamics analysis and experimental study of a low measurement error temperature sensor used in climate observation.

PubMed

Yang, Jie; Liu, Qingquan; Dai, Wei

2017-02-01

To improve the air temperature observation accuracy, a low measurement error temperature sensor is proposed. A computational fluid dynamics (CFD) method is implemented to obtain temperature errors under various environmental conditions. Then, a temperature error correction equation is obtained by fitting the CFD results using a genetic algorithm method. The low measurement error temperature sensor, a naturally ventilated radiation shield, a thermometer screen, and an aspirated temperature measurement platform are characterized in the same environment to conduct the intercomparison. The aspirated platform served as an air temperature reference. The mean temperature errors of the naturally ventilated radiation shield and the thermometer screen are 0.74 °C and 0.37 °C, respectively. In contrast, the mean temperature error of the low measurement error temperature sensor is 0.11 °C. The mean absolute error and the root mean square error between the corrected results and the measured results are 0.008 °C and 0.01 °C, respectively. The correction equation allows the temperature error of the low measurement error temperature sensor to be reduced by approximately 93.8%. The low measurement error temperature sensor proposed in this research may be helpful to provide a relatively accurate air temperature result.

Medication errors in the obstetrics emergency ward in a low resource setting.

PubMed

Kandil, Mohamed; Sayyed, Tarek; Emarh, Mohamed; Ellakwa, Hamed; Masood, Alaa

2012-08-01

To investigate the patterns of medication errors in the obstetric emergency ward in a low resource setting. This prospective observational study included 10,000 women who presented at the obstetric emergency ward, department of Obstetrics and Gynecology, Menofyia University Hospital, Egypt between March and December 2010. All medications prescribed in the emergency ward were monitored for different types of errors. The head nurse in each shift was asked to monitor each pharmacologic order from the moment of prescribing till its administration. Retrospective review of the patients' charts and nurses' notes was carried out by the authors of this paper. Results were tabulated and statistically analyzed. A total of 1976 medication errors were detected. Administration errors were the commonest error reported. Omitted errors ranked second followed by unauthorized and prescription errors. Three administration errors resulted in three Cesareans were performed for fetal distress because of wrong doses of oxytocin infusion. The rest of errors did not cause patients harm but may have lead to an increase in monitoring. Most errors occurred during night shifts. The availability of automated infusion pumps will probably decrease administration errors significantly. There is a need for more obstetricians and nurses during the nightshifts to minimize errors resulting from working under stressful conditions.

Analyzing communication errors in an air medical transport service.

PubMed

Dalto, Joseph D; Weir, Charlene; Thomas, Frank

2013-01-01

Poor communication can result in adverse events. Presently, no standards exist for classifying and analyzing air medical communication errors. This study sought to determine the frequency and types of communication errors reported within an air medical quality and safety assurance reporting system. Of 825 quality assurance reports submitted in 2009, 278 were randomly selected and analyzed for communication errors. Each communication error was classified and mapped to Clark's communication level hierarchy (ie, levels 1-4). Descriptive statistics were performed, and comparisons were evaluated using chi-square analysis. Sixty-four communication errors were identified in 58 reports (21% of 278). Of the 64 identified communication errors, only 18 (28%) were classified by the staff to be communication errors. Communication errors occurred most often at level 1 (n = 42/64, 66%) followed by level 4 (21/64, 33%). Level 2 and 3 communication failures were rare (, 1%). Communication errors were found in a fifth of quality and safety assurance reports. The reporting staff identified less than a third of these errors. Nearly all communication errors (99%) occurred at either the lowest level of communication (level 1, 66%) or the highest level (level 4, 33%). An air medical communication ontology is necessary to improve the recognition and analysis of communication errors. Copyright © 2013 Air Medical Journal Associates. Published by Elsevier Inc. All rights reserved.

Procedural error monitoring and smart checklists

NASA Technical Reports Server (NTRS)

Palmer, Everett

1990-01-01

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

Finite Element A Posteriori Error Estimation for Heat Conduction. Degree awarded by George Washington Univ.

NASA Technical Reports Server (NTRS)

Lang, Christapher G.; Bey, Kim S. (Technical Monitor)

2002-01-01

This research investigates residual-based a posteriori error estimates for finite element approximations of heat conduction in single-layer and multi-layered materials. The finite element approximation, based upon hierarchical modelling combined with p-version finite elements, is described with specific application to a two-dimensional, steady state, heat-conduction problem. Element error indicators are determined by solving an element equation for the error with the element residual as a source, and a global error estimate in the energy norm is computed by collecting the element contributions. Numerical results of the performance of the error estimate are presented by comparisons to the actual error. Two methods are discussed and compared for approximating the element boundary flux. The equilibrated flux method provides more accurate results for estimating the error than the average flux method. The error estimation is applied to multi-layered materials with a modification to the equilibrated flux method to approximate the discontinuous flux along a boundary at the material interfaces. A directional error indicator is developed which distinguishes between the hierarchical modeling error and the finite element error. Numerical results are presented for single-layered materials which show that the directional indicators accurately determine which contribution to the total error dominates.

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

Elliott, C.J.; McVey, B.; Quimby, D.C.

The level of field errors in an FEL is an important determinant of its performance. We have computed 3D performance of a large laser subsystem subjected to field errors of various types. These calculations have been guided by simple models such as SWOOP. The technique of choice is utilization of the FELEX free electron laser code that now possesses extensive engineering capabilities. Modeling includes the ability to establish tolerances of various types: fast and slow scale field bowing, field error level, beam position monitor error level, gap errors, defocusing errors, energy slew, displacement and pointing errors. Many effects of thesemore » errors on relative gain and relative power extraction are displayed and are the essential elements of determining an error budget. The random errors also depend on the particular random number seed used in the calculation. The simultaneous display of the performance versus error level of cases with multiple seeds illustrates the variations attributable to stochasticity of this model. All these errors are evaluated numerically for comprehensive engineering of the system. In particular, gap errors are found to place requirements beyond mechanical tolerances of {plus minus}25{mu}m, and amelioration of these may occur by a procedure utilizing direct measurement of the magnetic fields at assembly time. 4 refs., 12 figs.« less

Emergency department discharge prescription errors in an academic medical center

PubMed Central

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

2017-01-01

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

Demonstration of a quantum error detection code using a square lattice of four superconducting qubits

PubMed Central

Córcoles, A.D.; Magesan, Easwar; Srinivasan, Srikanth J.; Cross, Andrew W.; Steffen, M.; Gambetta, Jay M.; Chow, Jerry M.

2015-01-01

The ability to detect and deal with errors when manipulating quantum systems is a fundamental requirement for fault-tolerant quantum computing. Unlike classical bits that are subject to only digital bit-flip errors, quantum bits are susceptible to a much larger spectrum of errors, for which any complete quantum error-correcting code must account. Whilst classical bit-flip detection can be realized via a linear array of qubits, a general fault-tolerant quantum error-correcting code requires extending into a higher-dimensional lattice. Here we present a quantum error detection protocol on a two-by-two planar lattice of superconducting qubits. The protocol detects an arbitrary quantum error on an encoded two-qubit entangled state via quantum non-demolition parity measurements on another pair of error syndrome qubits. This result represents a building block towards larger lattices amenable to fault-tolerant quantum error correction architectures such as the surface code. PMID:25923200

Demonstration of a quantum error detection code using a square lattice of four superconducting qubits.

PubMed

Córcoles, A D; Magesan, Easwar; Srinivasan, Srikanth J; Cross, Andrew W; Steffen, M; Gambetta, Jay M; Chow, Jerry M

2015-04-29

The ability to detect and deal with errors when manipulating quantum systems is a fundamental requirement for fault-tolerant quantum computing. Unlike classical bits that are subject to only digital bit-flip errors, quantum bits are susceptible to a much larger spectrum of errors, for which any complete quantum error-correcting code must account. Whilst classical bit-flip detection can be realized via a linear array of qubits, a general fault-tolerant quantum error-correcting code requires extending into a higher-dimensional lattice. Here we present a quantum error detection protocol on a two-by-two planar lattice of superconducting qubits. The protocol detects an arbitrary quantum error on an encoded two-qubit entangled state via quantum non-demolition parity measurements on another pair of error syndrome qubits. This result represents a building block towards larger lattices amenable to fault-tolerant quantum error correction architectures such as the surface code.

Triangulation Error Analysis for the Barium Ion Cloud Experiment. M.S. Thesis - North Carolina State Univ.

NASA Technical Reports Server (NTRS)

Long, S. A. T.

1973-01-01

The triangulation method developed specifically for the Barium Ion Cloud Project is discussed. Expression for the four displacement errors, the three slope errors, and the curvature error in the triangulation solution due to a probable error in the lines-of-sight from the observation stations to points on the cloud are derived. The triangulation method is then used to determine the effect of the following on these different errors in the solution: the number and location of the stations, the observation duration, east-west cloud drift, the number of input data points, and the addition of extra cameras to one of the stations. The pointing displacement errors, and the pointing slope errors are compared. The displacement errors in the solution due to a probable error in the position of a moving station plus the weighting factors for the data from the moving station are also determined.

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

PubMed

Cheng, Ching-Min; Hwang, Sheue-Ling

2015-03-01

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

Atmospheric refraction effects on baseline error in satellite laser ranging systems

NASA Technical Reports Server (NTRS)

Im, K. E.; Gardner, C. S.

1982-01-01

Because of the mathematical complexities involved in exact analyses of baseline errors, it is not easy to isolate atmospheric refraction effects; however, by making certain simplifying assumptions about the ranging system geometry, relatively simple expressions can be derived which relate the baseline errors directly to the refraction errors. The results indicate that even in the absence of other errors, the baseline error for intercontinental baselines can be more than an order of magnitude larger than the refraction error.

Analysis of quantum error correction with symmetric hypergraph states

NASA Astrophysics Data System (ADS)

Wagner, T.; Kampermann, H.; Bruß, D.

2018-03-01

Graph states have been used to construct quantum error correction codes for independent errors. Hypergraph states generalize graph states, and symmetric hypergraph states have been shown to allow for the correction of correlated errors. In this paper, it is shown that symmetric hypergraph states are not useful for the correction of independent errors, at least for up to 30 qubits. Furthermore, error correction for error models with protected qubits is explored. A class of known graph codes for this scenario is generalized to hypergraph codes.

An Empirical State Error Covariance Matrix Orbit Determination Example

NASA Technical Reports Server (NTRS)

Frisbee, Joseph H., Jr.

2015-01-01

State estimation techniques serve effectively to provide mean state estimates. However, the state error covariance matrices provided as part of these techniques suffer from some degree of lack of confidence in their ability to adequately describe the uncertainty in the estimated states. A specific problem with the traditional form of state error covariance matrices is that they represent only a mapping of the assumed observation error characteristics into the state space. Any errors that arise from other sources (environment modeling, precision, etc.) are not directly represented in a traditional, theoretical state error covariance matrix. First, consider that an actual observation contains only measurement error and that an estimated observation contains all other errors, known and unknown. Then it follows that a measurement residual (the difference between expected and observed measurements) contains all errors for that measurement. Therefore, a direct and appropriate inclusion of the actual measurement residuals in the state error covariance matrix of the estimate will result in an empirical state error covariance matrix. This empirical state error covariance matrix will fully include all of the errors in the state estimate. The empirical error covariance matrix is determined from a literal reinterpretation of the equations involved in the weighted least squares estimation algorithm. It is a formally correct, empirical state error covariance matrix obtained through use of the average form of the weighted measurement residual variance performance index rather than the usual total weighted residual form. Based on its formulation, this matrix will contain the total uncertainty in the state estimate, regardless as to the source of the uncertainty and whether the source is anticipated or not. It is expected that the empirical error covariance matrix will give a better, statistical representation of the state error in poorly modeled systems or when sensor performance is suspect. In its most straight forward form, the technique only requires supplemental calculations to be added to existing batch estimation algorithms. In the current problem being studied a truth model making use of gravity with spherical, J2 and J4 terms plus a standard exponential type atmosphere with simple diurnal and random walk components is used. The ability of the empirical state error covariance matrix to account for errors is investigated under four scenarios during orbit estimation. These scenarios are: exact modeling under known measurement errors, exact modeling under corrupted measurement errors, inexact modeling under known measurement errors, and inexact modeling under corrupted measurement errors. For this problem a simple analog of a distributed space surveillance network is used. The sensors in this network make only range measurements and with simple normally distributed measurement errors. The sensors are assumed to have full horizon to horizon viewing at any azimuth. For definiteness, an orbit at the approximate altitude and inclination of the International Space Station is used for the study. The comparison analyses of the data involve only total vectors. No investigation of specific orbital elements is undertaken. The total vector analyses will look at the chisquare values of the error in the difference between the estimated state and the true modeled state using both the empirical and theoretical error covariance matrices for each of scenario.

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

PubMed

Yamamoto, Loren; Kanemori, Joan

2010-06-01

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

Knowledge of healthcare professionals about medication errors in hospitals

PubMed Central

Abdel-Latif, Mohamed M. M.

2016-01-01

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

Online Error Reporting for Managing Quality Control Within Radiology.

PubMed

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

2016-06-01

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

New decoding methods of interleaved burst error-correcting codes

NASA Astrophysics Data System (ADS)

Nakano, Y.; Kasahara, M.; Namekawa, T.

1983-04-01

A probabilistic method of single burst error correction, using the syndrome correlation of subcodes which constitute the interleaved code, is presented. This method makes it possible to realize a high capability of burst error correction with less decoding delay. By generalizing this method it is possible to obtain probabilistic method of multiple (m-fold) burst error correction. After estimating the burst error positions using syndrome correlation of subcodes which are interleaved m-fold burst error detecting codes, this second method corrects erasure errors in each subcode and m-fold burst errors. The performance of these two methods is analyzed via computer simulation, and their effectiveness is demonstrated.

On the Limitations of Variational Bias Correction

NASA Technical Reports Server (NTRS)

Moradi, Isaac; Mccarty, Will; Gelaro, Ronald

2018-01-01

Satellite radiances are the largest dataset assimilated into Numerical Weather Prediction (NWP) models, however the data are subject to errors and uncertainties that need to be accounted for before assimilating into the NWP models. Variational bias correction uses the time series of observation minus background to estimate the observations bias. This technique does not distinguish between the background error, forward operator error, and observations error so that all these errors are summed up together and counted as observation error. We identify some sources of observations errors (e.g., antenna emissivity, non-linearity in the calibration, and antenna pattern) and show the limitations of variational bias corrections on estimating these errors.

Space-Borne Laser Altimeter Geolocation Error Analysis

NASA Astrophysics Data System (ADS)

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

2018-05-01

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

Counteracting structural errors in ensemble forecast of influenza outbreaks.

PubMed

Pei, Sen; Shaman, Jeffrey

2017-10-13

For influenza forecasts generated using dynamical models, forecast inaccuracy is partly attributable to the nonlinear growth of error. As a consequence, quantification of the nonlinear error structure in current forecast models is needed so that this growth can be corrected and forecast skill improved. Here, we inspect the error growth of a compartmental influenza model and find that a robust error structure arises naturally from the nonlinear model dynamics. By counteracting these structural errors, diagnosed using error breeding, we develop a new forecast approach that combines dynamical error correction and statistical filtering techniques. In retrospective forecasts of historical influenza outbreaks for 95 US cities from 2003 to 2014, overall forecast accuracy for outbreak peak timing, peak intensity and attack rate, are substantially improved for predicted lead times up to 10 weeks. This error growth correction method can be generalized to improve the forecast accuracy of other infectious disease dynamical models.Inaccuracy of influenza forecasts based on dynamical models is partly due to nonlinear error growth. Here the authors address the error structure of a compartmental influenza model, and develop a new improved forecast approach combining dynamical error correction and statistical filtering techniques.

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

PubMed

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

2010-01-01

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

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

PubMed

Schultze, A E; Irizarry, A R

2017-02-01

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

A simulation of GPS and differential GPS sensors

NASA Technical Reports Server (NTRS)

Rankin, James M.

1993-01-01

The Global Positioning System (GPS) is a revolutionary advance in navigation. Users can determine latitude, longitude, and altitude by receiving range information from at least four satellites. The statistical accuracy of the user's position is directly proportional to the statistical accuracy of the range measurement. Range errors are caused by clock errors, ephemeris errors, atmospheric delays, multipath errors, and receiver noise. Selective Availability, which the military uses to intentionally degrade accuracy for non-authorized users, is a major error source. The proportionality constant relating position errors to range errors is the Dilution of Precision (DOP) which is a function of the satellite geometry. Receivers separated by relatively short distances have the same satellite and atmospheric errors. Differential GPS (DGPS) removes these errors by transmitting pseudorange corrections from a fixed receiver to a mobile receiver. The corrected pseudorange at the moving receiver is now corrupted only by errors from the receiver clock, multipath, and measurement noise. This paper describes a software package that models position errors for various GPS and DGPS systems. The error model is used in the Real-Time Simulator and Cockpit Technology workstation simulations at NASA-LaRC. The GPS/DGPS sensor can simulate enroute navigation, instrument approaches, or on-airport navigation.

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

PubMed Central

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

2017-01-01

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

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

PubMed Central

Gagnon, Bernadine; Miozzo, Michele

2017-01-01

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

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

PubMed Central

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

2015-01-01

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

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

PubMed

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

2015-01-01

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

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

PubMed

Alsulami, Zayed; Conroy, Sharon; Choonara, Imti

2013-04-01

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

Is there any electrophysiological evidence for subliminal error processing?

PubMed

Shalgi, Shani; Deouell, Leon Y

2013-08-29

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

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

PubMed

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

2016-06-01

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

Errors Analysis of Students in Mathematics Department to Learn Plane Geometry

NASA Astrophysics Data System (ADS)

Mirna, M.

2018-04-01

This article describes the results of qualitative descriptive research that reveal the locations, types and causes of student error in answering the problem of plane geometry at the problem-solving level. Answers from 59 students on three test items informed that students showed errors ranging from understanding the concepts and principles of geometry itself to the error in applying it to problem solving. Their type of error consists of concept errors, principle errors and operational errors. The results of reflection with four subjects reveal the causes of the error are: 1) student learning motivation is very low, 2) in high school learning experience, geometry has been seen as unimportant, 3) the students' experience using their reasoning in solving the problem is very less, and 4) students' reasoning ability is still very low.

A concatenated coding scheme for error control

NASA Technical Reports Server (NTRS)

Kasami, T.; Fujiwara, T.; Lin, S.

1986-01-01

In this paper, a concatenated coding scheme for error control in data communications is presented and analyzed. In this scheme, the inner code is used for both error correction and detection; however, the outer code is used only for error detection. A retransmission is requested if either the inner code decoder fails to make a successful decoding or the outer code decoder detects the presence of errors after the inner code decoding. Probability of undetected error (or decoding error) of the proposed scheme is derived. An efficient method for computing this probability is presented. Throughput efficiency of the proposed error control scheme incorporated with a selective-repeat ARQ retransmission strategy is also analyzed. Three specific examples are presented. One of the examples is proposed for error control in the NASA Telecommand System.

Evaluation of Parenteral Nutrition Errors in an Era of Drug Shortages.

PubMed

Storey, Michael A; Weber, Robert J; Besco, Kelly; Beatty, Stuart; Aizawa, Kumiko; Mirtallo, Jay M

2016-04-01

Ingredient shortages have forced many organizations to change practices or use unfamiliar ingredients, which creates potential for error. Parenteral nutrition (PN) has been significantly affected, as every ingredient in PN has been impacted in recent years. Ingredient errors involving PN that were reported to the national anonymous MedMARx database between May 2009 and April 2011 were reviewed. Errors were categorized by ingredient, node, and severity. Categorization was validated by experts in medication safety and PN. A timeline of PN ingredient shortages was developed and compared with the PN errors to determine if events correlated with an ingredient shortage. This information was used to determine the prevalence and change in harmful PN errors during periods of shortage, elucidating whether a statistically significant difference exists in errors during shortage as compared with a control period (ie, no shortage). There were 1311 errors identified. Nineteen errors were associated with harm. Fat emulsions and electrolytes were the PN ingredients most frequently associated with error. Insulin was the ingredient most often associated with patient harm. On individual error review, PN shortages were described in 13 errors, most of which were associated with intravenous fat emulsions; none were associated with harm. There was no correlation of drug shortages with the frequency of PN errors. Despite the significant impact that shortages have had on the PN use system, no adverse impact on patient safety could be identified from these reported PN errors. © 2015 American Society for Parenteral and Enteral Nutrition.

Neural evidence for enhanced error detection in major depressive disorder.

PubMed

Chiu, Pearl H; Deldin, Patricia J

2007-04-01

Anomalies in error processing have been implicated in the etiology and maintenance of major depressive disorder. In particular, depressed individuals exhibit heightened sensitivity to error-related information and negative environmental cues, along with reduced responsivity to positive reinforcers. The authors examined the neural activation associated with error processing in individuals diagnosed with and without major depression and the sensitivity of these processes to modulation by monetary task contingencies. The error-related negativity and error-related positivity components of the event-related potential were used to characterize error monitoring in individuals with major depressive disorder and the degree to which these processes are sensitive to modulation by monetary reinforcement. Nondepressed comparison subjects (N=17) and depressed individuals (N=18) performed a flanker task under two external motivation conditions (i.e., monetary reward for correct responses and monetary loss for incorrect responses) and a nonmonetary condition. After each response, accuracy feedback was provided. The error-related negativity component assessed the degree of anomaly in initial error detection, and the error positivity component indexed recognition of errors. Across all conditions, the depressed participants exhibited greater amplitude of the error-related negativity component, relative to the comparison subjects, and equivalent error positivity amplitude. In addition, the two groups showed differential modulation by task incentives in both components. These data implicate exaggerated early error-detection processes in the etiology and maintenance of major depressive disorder. Such processes may then recruit excessive neural and cognitive resources that manifest as symptoms of depression.

General model for the pointing error analysis of Risley-prism system based on ray direction deviation in light refraction

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.

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

PubMed Central

Misagh, Pegah; Vazin, Afsaneh; Namazi, Soha

2018-01-01

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

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

PubMed

Adeoti, C O; Egbewale, B E

2008-06-01

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

Using EHR Data to Detect Prescribing Errors in Rapidly Discontinued Medication Orders.

PubMed

Burlison, Jonathan D; McDaniel, Robert B; Baker, Donald K; Hasan, Murad; Robertson, Jennifer J; Howard, Scott C; Hoffman, James M

2018-01-01

Previous research developed a new method for locating prescribing errors in rapidly discontinued electronic medication orders. Although effective, the prospective design of that research hinders its feasibility for regular use. Our objectives were to assess a method to retrospectively detect prescribing errors, to characterize the identified errors, and to identify potential improvement opportunities. Electronically submitted medication orders from 28 randomly selected days that were discontinued within 120 minutes of submission were reviewed and categorized as most likely errors, nonerrors, or not enough information to determine status. Identified errors were evaluated by amount of time elapsed from original submission to discontinuation, error type, staff position, and potential clinical significance. Pearson's chi-square test was used to compare rates of errors across prescriber types. In all, 147 errors were identified in 305 medication orders. The method was most effective for orders that were discontinued within 90 minutes. Duplicate orders were most common; physicians in training had the highest error rate ( p  < 0.001), and 24 errors were potentially clinically significant. None of the errors were voluntarily reported. It is possible to identify prescribing errors in rapidly discontinued medication orders by using retrospective methods that do not require interrupting prescribers to discuss order details. Future research could validate our methods in different clinical settings. Regular use of this measure could help determine the causes of prescribing errors, track performance, and identify and evaluate interventions to improve prescribing systems and processes. Schattauer GmbH Stuttgart.

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

PubMed

Chang, Yunkyung; Mark, Barbara

2011-01-01

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

Accuracy improvement of the H-drive air-levitating wafer inspection stage based on error analysis and compensation

NASA Astrophysics Data System (ADS)

Zhang, Fan; Liu, Pinkuan

2018-04-01

In order to improve the inspection precision of the H-drive air-bearing stage for wafer inspection, in this paper the geometric error of the stage is analyzed and compensated. The relationship between the positioning errors and error sources are initially modeled, and seven error components are identified that are closely related to the inspection accuracy. The most effective factor that affects the geometric error is identified by error sensitivity analysis. Then, the Spearman rank correlation method is applied to find the correlation between different error components, aiming at guiding the accuracy design and error compensation of the stage. Finally, different compensation methods, including the three-error curve interpolation method, the polynomial interpolation method, the Chebyshev polynomial interpolation method, and the B-spline interpolation method, are employed within the full range of the stage, and their results are compared. Simulation and experiment show that the B-spline interpolation method based on the error model has better compensation results. In addition, the research result is valuable for promoting wafer inspection accuracy and will greatly benefit the semiconductor industry.

Volumetric error modeling, identification and compensation based on screw theory for a large multi-axis propeller-measuring machine

NASA Astrophysics Data System (ADS)

Zhong, Xuemin; Liu, Hongqi; Mao, Xinyong; Li, Bin; He, Songping; Peng, Fangyu

2018-05-01

Large multi-axis propeller-measuring machines have two types of geometric error, position-independent geometric errors (PIGEs) and position-dependent geometric errors (PDGEs), which both have significant effects on the volumetric error of the measuring tool relative to the worktable. This paper focuses on modeling, identifying and compensating for the volumetric error of the measuring machine. A volumetric error model in the base coordinate system is established based on screw theory considering all the geometric errors. In order to fully identify all the geometric error parameters, a new method for systematic measurement and identification is proposed. All the PIGEs of adjacent axes and the six PDGEs of the linear axes are identified with a laser tracker using the proposed model. Finally, a volumetric error compensation strategy is presented and an inverse kinematic solution for compensation is proposed. The final measuring and compensation experiments have further verified the efficiency and effectiveness of the measuring and identification method, indicating that the method can be used in volumetric error compensation for large machine tools.

Reducing number entry errors: solving a widespread, serious problem.

PubMed

Thimbleby, Harold; Cairns, Paul

2010-10-06

Number entry is ubiquitous: it is required in many fields including science, healthcare, education, government, mathematics and finance. People entering numbers are to be expected to make errors, but shockingly few systems make any effort to detect, block or otherwise manage errors. Worse, errors may be ignored but processed in arbitrary ways, with unintended results. A standard class of error (defined in the paper) is an 'out by 10 error', which is easily made by miskeying a decimal point or a zero. In safety-critical domains, such as drug delivery, out by 10 errors generally have adverse consequences. Here, we expose the extent of the problem of numeric errors in a very wide range of systems. An analysis of better error management is presented: under reasonable assumptions, we show that the probability of out by 10 errors can be halved by better user interface design. We provide a demonstration user interface to show that the approach is practical.To kill an error is as good a service as, and sometimes even better than, the establishing of a new truth or fact. (Charles Darwin 1879 [2008], p. 229).

Video error concealment using block matching and frequency selective extrapolation algorithms

NASA Astrophysics Data System (ADS)

P. K., Rajani; Khaparde, Arti

2017-06-01

Error Concealment (EC) is a technique at the decoder side to hide the transmission errors. It is done by analyzing the spatial or temporal information from available video frames. It is very important to recover distorted video because they are used for various applications such as video-telephone, video-conference, TV, DVD, internet video streaming, video games etc .Retransmission-based and resilient-based methods, are also used for error removal. But these methods add delay and redundant data. So error concealment is the best option for error hiding. In this paper, the error concealment methods such as Block Matching error concealment algorithm is compared with Frequency Selective Extrapolation algorithm. Both the works are based on concealment of manually error video frames as input. The parameter used for objective quality measurement was PSNR (Peak Signal to Noise Ratio) and SSIM(Structural Similarity Index). The original video frames along with error video frames are compared with both the Error concealment algorithms. According to simulation results, Frequency Selective Extrapolation is showing better quality measures such as 48% improved PSNR and 94% increased SSIM than Block Matching Algorithm.

Medical error and related factors during internship and residency.

PubMed

Ahmadipour, Habibeh; Nahid, Mortazavi

2015-01-01

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

Error control for reliable digital data transmission and storage systems

NASA Technical Reports Server (NTRS)

Costello, D. J., Jr.; Deng, R. H.

1985-01-01

A problem in designing semiconductor memories is to provide some measure of error control without requiring excessive coding overhead or decoding time. In LSI and VLSI technology, memories are often organized on a multiple bit (or byte) per chip basis. For example, some 256K-bit DRAM's are organized in 32Kx8 bit-bytes. Byte oriented codes such as Reed Solomon (RS) codes can provide efficient low overhead error control for such memories. However, the standard iterative algorithm for decoding RS codes is too slow for these applications. In this paper we present some special decoding techniques for extended single-and-double-error-correcting RS codes which are capable of high speed operation. These techniques are designed to find the error locations and the error values directly from the syndrome without having to use the iterative alorithm to find the error locator polynomial. Two codes are considered: (1) a d sub min = 4 single-byte-error-correcting (SBEC), double-byte-error-detecting (DBED) RS code; and (2) a d sub min = 6 double-byte-error-correcting (DBEC), triple-byte-error-detecting (TBED) RS code.

Effect of bar-code technology on the safety of medication administration.

PubMed

Poon, Eric G; Keohane, Carol A; Yoon, Catherine S; Ditmore, Matthew; Bane, Anne; Levtzion-Korach, Osnat; Moniz, Thomas; Rothschild, Jeffrey M; Kachalia, Allen B; Hayes, Judy; Churchill, William W; Lipsitz, Stuart; Whittemore, Anthony D; Bates, David W; Gandhi, Tejal K

2010-05-06

Serious medication errors are common in hospitals and often occur during order transcription or administration of medication. To help prevent such errors, technology has been developed to verify medications by incorporating bar-code verification technology within an electronic medication-administration system (bar-code eMAR). We conducted a before-and-after, quasi-experimental study in an academic medical center that was implementing the bar-code eMAR. We assessed rates of errors in order transcription and medication administration on units before and after implementation of the bar-code eMAR. Errors that involved early or late administration of medications were classified as timing errors and all others as nontiming errors. Two clinicians reviewed the errors to determine their potential to harm patients and classified those that could be harmful as potential adverse drug events. We observed 14,041 medication administrations and reviewed 3082 order transcriptions. Observers noted 776 nontiming errors in medication administration on units that did not use the bar-code eMAR (an 11.5% error rate) versus 495 such errors on units that did use it (a 6.8% error rate)--a 41.4% relative reduction in errors (P<0.001). The rate of potential adverse drug events (other than those associated with timing errors) fell from 3.1% without the use of the bar-code eMAR to 1.6% with its use, representing a 50.8% relative reduction (P<0.001). The rate of timing errors in medication administration fell by 27.3% (P<0.001), but the rate of potential adverse drug events associated with timing errors did not change significantly. Transcription errors occurred at a rate of 6.1% on units that did not use the bar-code eMAR but were completely eliminated on units that did use it. Use of the bar-code eMAR substantially reduced the rate of errors in order transcription and in medication administration as well as potential adverse drug events, although it did not eliminate such errors. Our data show that the bar-code eMAR is an important intervention to improve medication safety. (ClinicalTrials.gov number, NCT00243373.) 2010 Massachusetts Medical Society

Understanding seasonal variability of uncertainty in hydrological prediction

NASA Astrophysics Data System (ADS)

Li, M.; Wang, Q. J.

2012-04-01

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

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

PubMed

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

2017-12-01

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

The role of model errors represented by nonlinear forcing singular vector tendency error in causing the "spring predictability barrier" within ENSO predictions

NASA Astrophysics Data System (ADS)

Duan, Wansuo; Zhao, Peng

2017-04-01

Within the Zebiak-Cane model, the nonlinear forcing singular vector (NFSV) approach is used to investigate the role of model errors in the "Spring Predictability Barrier" (SPB) phenomenon within ENSO predictions. NFSV-related errors have the largest negative effect on the uncertainties of El Niño predictions. NFSV errors can be classified into two types: the first is characterized by a zonal dipolar pattern of SST anomalies (SSTA), with the western poles centered in the equatorial central-western Pacific exhibiting positive anomalies and the eastern poles in the equatorial eastern Pacific exhibiting negative anomalies; and the second is characterized by a pattern almost opposite the first type. The first type of error tends to have the worst effects on El Niño growth-phase predictions, whereas the latter often yields the largest negative effects on decaying-phase predictions. The evolution of prediction errors caused by NFSV-related errors exhibits prominent seasonality, with the fastest error growth in the spring and/or summer seasons; hence, these errors result in a significant SPB related to El Niño events. The linear counterpart of NFSVs, the (linear) forcing singular vector (FSV), induces a less significant SPB because it contains smaller prediction errors. Random errors cannot generate a SPB for El Niño events. These results show that the occurrence of an SPB is related to the spatial patterns of tendency errors. The NFSV tendency errors cause the most significant SPB for El Niño events. In addition, NFSVs often concentrate these large value errors in a few areas within the equatorial eastern and central-western Pacific, which likely represent those areas sensitive to El Niño predictions associated with model errors. Meanwhile, these areas are also exactly consistent with the sensitive areas related to initial errors determined by previous studies. This implies that additional observations in the sensitive areas would not only improve the accuracy of the initial field but also promote the reduction of model errors to greatly improve ENSO forecasts.

At least some errors are randomly generated (Freud was wrong)

NASA Technical Reports Server (NTRS)

Sellen, A. J.; Senders, J. W.

1986-01-01

An experiment was carried out to expose something about human error generating mechanisms. In the context of the experiment, an error was made when a subject pressed the wrong key on a computer keyboard or pressed no key at all in the time allotted. These might be considered, respectively, errors of substitution and errors of omission. Each of seven subjects saw a sequence of three digital numbers, made an easily learned binary judgement about each, and was to press the appropriate one of two keys. Each session consisted of 1,000 presentations of randomly permuted, fixed numbers broken into 10 blocks of 100. One of two keys should have been pressed within one second of the onset of each stimulus. These data were subjected to statistical analyses in order to probe the nature of the error generating mechanisms. Goodness of fit tests for a Poisson distribution for the number of errors per 50 trial interval and for an exponential distribution of the length of the intervals between errors were carried out. There is evidence for an endogenous mechanism that may best be described as a random error generator. Furthermore, an item analysis of the number of errors produced per stimulus suggests the existence of a second mechanism operating on task driven factors producing exogenous errors. Some errors, at least, are the result of constant probability generating mechanisms with error rate idiosyncratically determined for each subject.

A Novel Error Model of Optical Systems and an On-Orbit Calibration Method for Star Sensors.

PubMed

Wang, Shuang; Geng, Yunhai; Jin, Rongyu

2015-12-12

In order to improve the on-orbit measurement accuracy of star sensors, the effects of image-plane rotary error, image-plane tilt error and distortions of optical systems resulting from the on-orbit thermal environment were studied in this paper. Since these issues will affect the precision of star image point positions, in this paper, a novel measurement error model based on the traditional error model is explored. Due to the orthonormal characteristics of image-plane rotary-tilt errors and the strong nonlinearity among these error parameters, it is difficult to calibrate all the parameters simultaneously. To solve this difficulty, for the new error model, a modified two-step calibration method based on the Extended Kalman Filter (EKF) and Least Square Methods (LSM) is presented. The former one is used to calibrate the main point drift, focal length error and distortions of optical systems while the latter estimates the image-plane rotary-tilt errors. With this calibration method, the precision of star image point position influenced by the above errors is greatly improved from 15.42% to 1.389%. Finally, the simulation results demonstrate that the presented measurement error model for star sensors has higher precision. Moreover, the proposed two-step method can effectively calibrate model error parameters, and the calibration precision of on-orbit star sensors is also improved obviously.

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

PubMed

Cao, Hui; Stetson, Peter; Hripcsak, George

2003-01-01

Many types of medical errors occur in and outside of hospitals, some of which have very serious consequences and increase cost. Identifying errors is a critical step for managing and preventing them. In this study, we assessed the explicit reporting of medical errors in the electronic record. We used five search terms "mistake," "error," "incorrect," "inadvertent," and "iatrogenic" to survey several sets of narrative reports including discharge summaries, sign-out notes, and outpatient notes from 1991 to 2000. We manually reviewed all the positive cases and identified them based on the reporting of physicians. We identified 222 explicitly reported medical errors. The positive predictive value varied with different keywords. In general, the positive predictive value for each keyword was low, ranging from 3.4 to 24.4%. Therapeutic-related errors were the most common reported errors and these reported therapeutic-related errors were mainly medication errors. Keyword searches combined with manual review indicated some medical errors that were reported in medical records. It had a low sensitivity and a moderate positive predictive value, which varied by search term. Physicians were most likely to record errors in the Hospital Course and History of Present Illness sections of discharge summaries. The reported errors in medical records covered a broad range and were related to several types of care providers as well as non-health care professionals.

Alteration of a motor learning rule under mirror-reversal transformation does not depend on the amplitude of visual error.

PubMed

Kasuga, Shoko; Kurata, Makiko; Liu, Meigen; Ushiba, Junichi

2015-05-01

Human's sophisticated motor learning system paradoxically interferes with motor performance when visual information is mirror-reversed (MR), because normal movement error correction further aggravates the error. This error-increasing mechanism makes performing even a simple reaching task difficult, but is overcome by alterations in the error correction rule during the trials. To isolate factors that trigger learners to change the error correction rule, we manipulated the gain of visual angular errors when participants made arm-reaching movements with mirror-reversed visual feedback, and compared the rule alteration timing between groups with normal or reduced gain. Trial-by-trial changes in the visual angular error was tracked to explain the timing of the change in the error correction rule. Under both gain conditions, visual angular errors increased under the MR transformation, and suddenly decreased after 3-5 trials with increase. The increase became degressive at different amplitude between the two groups, nearly proportional to the visual gain. The findings suggest that the alteration of the error-correction rule is not dependent on the amplitude of visual angular errors, and possibly determined by the number of trials over which the errors increased or statistical property of the environment. The current results encourage future intensive studies focusing on the exact rule-change mechanism. Copyright © 2014 Elsevier Ireland Ltd and the Japan Neuroscience Society. All rights reserved.

New double-byte error-correcting codes for memory systems

NASA Technical Reports Server (NTRS)

Feng, Gui-Liang; Wu, Xinen; Rao, T. R. N.

1996-01-01

Error-correcting or error-detecting codes have been used in the computer industry to increase reliability, reduce service costs, and maintain data integrity. The single-byte error-correcting and double-byte error-detecting (SbEC-DbED) codes have been successfully used in computer memory subsystems. There are many methods to construct double-byte error-correcting (DBEC) codes. In the present paper we construct a class of double-byte error-correcting codes, which are more efficient than those known to be optimum, and a decoding procedure for our codes is also considered.

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

NASA Technical Reports Server (NTRS)

Massey, J. L.

1976-01-01

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

Common but unappreciated sources of error in one, two, and multiple-color pyrometry

NASA Technical Reports Server (NTRS)

Spjut, R. Erik

1988-01-01

The most common sources of error in optical pyrometry are examined. They can be classified as either noise and uncertainty errors, stray radiation errors, or speed-of-response errors. Through judicious choice of detectors and optical wavelengths the effect of noise errors can be minimized, but one should strive to determine as many of the system properties as possible. Careful consideration of the optical-collection system can minimize stray radiation errors. Careful consideration must also be given to the slowest elements in a pyrometer when measuring rapid phenomena.

Errors detected in pediatric oral liquid medication doses prepared in an automated workflow management system.

PubMed

Bledsoe, Sarah; Van Buskirk, Alex; Falconer, R James; Hollon, Andrew; Hoebing, Wendy; Jokic, Sladan

2018-02-01

The effectiveness of barcode-assisted medication preparation (BCMP) technology on detecting oral liquid dose preparation errors. From June 1, 2013, through May 31, 2014, a total of 178,344 oral doses were processed at Children's Mercy, a 301-bed pediatric hospital, through an automated workflow management system. Doses containing errors detected by the system's barcode scanning system or classified as rejected by the pharmacist were further reviewed. Errors intercepted by the barcode-scanning system were classified as (1) expired product, (2) incorrect drug, (3) incorrect concentration, and (4) technological error. Pharmacist-rejected doses were categorized into 6 categories based on the root cause of the preparation error: (1) expired product, (2) incorrect concentration, (3) incorrect drug, (4) incorrect volume, (5) preparation error, and (6) other. Of the 178,344 doses examined, 3,812 (2.1%) errors were detected by either the barcode-assisted scanning system (1.8%, n = 3,291) or a pharmacist (0.3%, n = 521). The 3,291 errors prevented by the barcode-assisted system were classified most commonly as technological error and incorrect drug, followed by incorrect concentration and expired product. Errors detected by pharmacists were also analyzed. These 521 errors were most often classified as incorrect volume, preparation error, expired product, other, incorrect drug, and incorrect concentration. BCMP technology detected errors in 1.8% of pediatric oral liquid medication doses prepared in an automated workflow management system, with errors being most commonly attributed to technological problems or incorrect drugs. Pharmacists rejected an additional 0.3% of studied doses. Copyright © 2018 by the American Society of Health-System Pharmacists, Inc. All rights reserved.

National Aeronautics and Space Administration "threat and error" model applied to pediatric cardiac surgery: error cycles precede ∼85% of patient deaths.

PubMed

Hickey, Edward J; Nosikova, Yaroslavna; Pham-Hung, Eric; Gritti, Michael; Schwartz, Steven; Caldarone, Christopher A; Redington, Andrew; Van Arsdell, Glen S

2015-02-01

We hypothesized that the National Aeronautics and Space Administration "threat and error" model (which is derived from analyzing >30,000 commercial flights, and explains >90% of crashes) is directly applicable to pediatric cardiac surgery. We implemented a unit-wide performance initiative, whereby every surgical admission constitutes a "flight" and is tracked in real time, with the aim of identifying errors. The first 500 consecutive patients (524 flights) were analyzed, with an emphasis on the relationship between error cycles and permanent harmful outcomes. Among 524 patient flights (risk adjustment for congenital heart surgery category: 1-6; median: 2) 68 (13%) involved residual hemodynamic lesions, 13 (2.5%) permanent end-organ injuries, and 7 deaths (1.3%). Preoperatively, 763 threats were identified in 379 (72%) flights. Only 51% of patient flights (267) were error free. In the remaining 257 flights, 430 errors occurred, most commonly related to proficiency (280; 65%) or judgment (69, 16%). In most flights with errors (173 of 257; 67%), an unintended clinical state resulted, ie, the error was consequential. In 60% of consequential errors (n = 110; 21% of total), subsequent cycles of additional error/unintended states occurred. Cycles, particularly those containing multiple errors, were very significantly associated with permanent harmful end-states, including residual hemodynamic lesions (P < .0001), end-organ injury (P < .0001), and death (P < .0001). Deaths were almost always preceded by cycles (6 of 7; P < .0001). Human error, if not mitigated, often leads to cycles of error and unintended patient states, which are dangerous and precede the majority of harmful outcomes. Efforts to manage threats and error cycles (through crew resource management techniques) are likely to yield large increases in patient safety. Copyright © 2015. Published by Elsevier Inc.

Prevalence and pattern of prescription errors in a Nigerian kidney hospital.

PubMed

Babatunde, Kehinde M; Akinbodewa, Akinwumi A; Akinboye, Ayodele O; Adejumo, Ademola O

2016-12-01

To determine (i) the prevalence and pattern of prescription errors in our Centre and, (ii) appraise pharmacists' intervention and correction of identified prescription errors. A descriptive, single blinded cross-sectional study. Kidney Care Centre is a public Specialist hospital. The monthly patient load averages 60 General Out-patient cases and 17.4 in-patients. A total of 31 medical doctors (comprising of 2 Consultant Nephrologists, 15 Medical Officers, 14 House Officers), 40 nurses and 24 ward assistants participated in the study. One pharmacist runs the daily call schedule. Prescribers were blinded to the study. Prescriptions containing only galenicals were excluded. An error detection mechanism was set up to identify and correct prescription errors. Life-threatening prescriptions were discussed with the Quality Assurance Team of the Centre who conveyed such errors to the prescriber without revealing the on-going study. Prevalence of prescription errors, pattern of prescription errors, pharmacist's intervention. A total of 2,660 (75.0%) combined prescription errors were found to have one form of error or the other; illegitimacy 1,388 (52.18%), omission 1,221(45.90%), wrong dose 51(1.92%) and no error of style was detected. Life-threatening errors were low (1.1-2.2%). Errors were found more commonly among junior doctors and non-medical doctors. Only 56 (1.6%) of the errors were detected and corrected during the process of dispensing. Prescription errors related to illegitimacy and omissions were highly prevalent. There is a need to improve on patient-to-healthcare giver ratio. A medication quality assurance unit is needed in our hospitals. No financial support was received by any of the authors for this study.

Technology-related medication errors in a tertiary hospital: a 5-year analysis of reported medication incidents.

PubMed

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.

Automated error correction in IBM quantum computer and explicit generalization

NASA Astrophysics Data System (ADS)

Ghosh, Debjit; Agarwal, Pratik; Pandey, Pratyush; Behera, Bikash K.; Panigrahi, Prasanta K.

2018-06-01

Construction of a fault-tolerant quantum computer remains a challenging problem due to unavoidable noise and fragile quantum states. However, this goal can be achieved by introducing quantum error-correcting codes. Here, we experimentally realize an automated error correction code and demonstrate the nondestructive discrimination of GHZ states in IBM 5-qubit quantum computer. After performing quantum state tomography, we obtain the experimental results with a high fidelity. Finally, we generalize the investigated code for maximally entangled n-qudit case, which could both detect and automatically correct any arbitrary phase-change error, or any phase-flip error, or any bit-flip error, or combined error of all types of error.

Analyzing Software Requirements Errors in Safety-Critical, Embedded Systems

NASA Technical Reports Server (NTRS)

Lutz, Robyn R.

1993-01-01

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

Skylab water balance error analysis

NASA Technical Reports Server (NTRS)

Leonard, J. I.

1977-01-01

Estimates of the precision of the net water balance were obtained for the entire Skylab preflight and inflight phases as well as for the first two weeks of flight. Quantitative estimates of both total sampling errors and instrumentation errors were obtained. It was shown that measurement error is minimal in comparison to biological variability and little can be gained from improvement in analytical accuracy. In addition, a propagation of error analysis demonstrated that total water balance error could be accounted for almost entirely by the errors associated with body mass changes. Errors due to interaction between terms in the water balance equation (covariances) represented less than 10% of the total error. Overall, the analysis provides evidence that daily measurements of body water changes obtained from the indirect balance technique are reasonable, precise, and relaible. The method is not biased toward net retention or loss.

Technical Note: Introduction of variance component analysis to setup error analysis in radiotherapy

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

Matsuo, Yukinori, E-mail: ymatsuo@kuhp.kyoto-u.ac.

Purpose: The purpose of this technical note is to introduce variance component analysis to the estimation of systematic and random components in setup error of radiotherapy. Methods: Balanced data according to the one-factor random effect model were assumed. Results: Analysis-of-variance (ANOVA)-based computation was applied to estimate the values and their confidence intervals (CIs) for systematic and random errors and the population mean of setup errors. The conventional method overestimates systematic error, especially in hypofractionated settings. The CI for systematic error becomes much wider than that for random error. The ANOVA-based estimation can be extended to a multifactor model considering multiplemore » causes of setup errors (e.g., interpatient, interfraction, and intrafraction). Conclusions: Variance component analysis may lead to novel applications to setup error analysis in radiotherapy.« less

Quasi-eccentricity error modeling and compensation in vision metrology

NASA Astrophysics Data System (ADS)

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

2018-04-01

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

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.

Imagery of Errors in Typing

ERIC Educational Resources Information Center

Rieger, Martina; Martinez, Fanny; Wenke, Dorit

2011-01-01

Using a typing task we investigated whether insufficient imagination of errors and error corrections is related to duration differences between execution and imagination. In Experiment 1 spontaneous error imagination was investigated, whereas in Experiment 2 participants were specifically instructed to imagine errors. Further, in Experiment 2 we…

Automatic Error Analysis Using Intervals

ERIC Educational Resources Information Center

Rothwell, E. J.; Cloud, M. J.

2012-01-01

A technique for automatic error analysis using interval mathematics is introduced. A comparison to standard error propagation methods shows that in cases involving complicated formulas, the interval approach gives comparable error estimates with much less effort. Several examples are considered, and numerical errors are computed using the INTLAB…

Heuristic errors in clinical reasoning.

PubMed

Rylander, Melanie; Guerrasio, Jeannette

2016-08-01

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

After the Medication Error: Recent Nursing Graduates' Reflections on Adequacy of Education.

PubMed

Treiber, Linda A; Jones, Jackie H

2018-05-01

The purpose of this study was to better understand individual- and system-level factors surrounding making a medication error from the perspective of recent Bachelor of Science in Nursing graduates. Online survey mixed-methods items included perceptions of adequacy of preparatory nursing education, contributory variables, emotional responses, and treatment by employer following the error. Of the 168 respondents, 55% had made a medication error. Errors resulted from inexperience, rushing, technology, staffing, and patient acuity. Twenty-four percent did not report their errors. Key themes for improving education included more practice in varied clinical areas, intensive pharmacological preparation, practical instruction in functioning within the health care environment, and coping after making medication errors. Errors generally caused emotional distress in the error maker. Overall, perceived treatment after the error reflected supportive environments, where nurses were generally treated with respect, fair treatment, and understanding. Opportunities for nursing education include second victim awareness and reinforcing professional practice standards. [J Nurs Educ. 2018;57(5):275-280.]. Copyright 2018, SLACK Incorporated.

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

NASA Technical Reports Server (NTRS)

Morris, Nancy M.; Rouse, William B.

1988-01-01

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

Error coding simulations

NASA Technical Reports Server (NTRS)

Noble, Viveca K.

1993-01-01

There are various elements such as radio frequency interference (RFI) which may induce errors in data being transmitted via a satellite communication link. When a transmission is affected by interference or other error-causing elements, the transmitted data becomes indecipherable. It becomes necessary to implement techniques to recover from these disturbances. The objective of this research is to develop software which simulates error control circuits and evaluate the performance of these modules in various bit error rate environments. The results of the evaluation provide the engineer with information which helps determine the optimal error control scheme. The Consultative Committee for Space Data Systems (CCSDS) recommends the use of Reed-Solomon (RS) and convolutional encoders and Viterbi and RS decoders for error correction. The use of forward error correction techniques greatly reduces the received signal to noise needed for a certain desired bit error rate. The use of concatenated coding, e.g. inner convolutional code and outer RS code, provides even greater coding gain. The 16-bit cyclic redundancy check (CRC) code is recommended by CCSDS for error detection.

Issues with data and analyses: Errors, underlying themes, and potential solutions

PubMed Central

Allison, David B.

2018-01-01

Some aspects of science, taken at the broadest level, are universal in empirical research. These include collecting, analyzing, and reporting data. In each of these aspects, errors can and do occur. In this work, we first discuss the importance of focusing on statistical and data errors to continually improve the practice of science. We then describe underlying themes of the types of errors and postulate contributing factors. To do so, we describe a case series of relatively severe data and statistical errors coupled with surveys of some types of errors to better characterize the magnitude, frequency, and trends. Having examined these errors, we then discuss the consequences of specific errors or classes of errors. Finally, given the extracted themes, we discuss methodological, cultural, and system-level approaches to reducing the frequency of commonly observed errors. These approaches will plausibly contribute to the self-critical, self-correcting, ever-evolving practice of science, and ultimately to furthering knowledge. PMID:29531079

Classification and reduction of pilot error

NASA Technical Reports Server (NTRS)

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

1989-01-01

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

Mapping DNA polymerase errors by single-molecule sequencing

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

Lee, David F.; Lu, Jenny; Chang, Seungwoo

Genomic integrity is compromised by DNA polymerase replication errors, which occur in a sequence-dependent manner across the genome. Accurate and complete quantification of a DNA polymerase's error spectrum is challenging because errors are rare and difficult to detect. We report a high-throughput sequencing assay to map in vitro DNA replication errors at the single-molecule level. Unlike previous methods, our assay is able to rapidly detect a large number of polymerase errors at base resolution over any template substrate without quantification bias. To overcome the high error rate of high-throughput sequencing, our assay uses a barcoding strategy in which each replicationmore » product is tagged with a unique nucleotide sequence before amplification. Here, this allows multiple sequencing reads of the same product to be compared so that sequencing errors can be found and removed. We demonstrate the ability of our assay to characterize the average error rate, error hotspots and lesion bypass fidelity of several DNA polymerases.« less

Measurement System Characterization in the Presence of Measurement Errors

NASA Technical Reports Server (NTRS)

Commo, Sean A.

2012-01-01

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

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

PubMed

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

2016-01-01

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

Geographically correlated orbit error

NASA Technical Reports Server (NTRS)

Rosborough, G. W.

1989-01-01

The dominant error source in estimating the orbital position of a satellite from ground based tracking data is the modeling of the Earth's gravity field. The resulting orbit error due to gravity field model errors are predominantly long wavelength in nature. This results in an orbit error signature that is strongly correlated over distances on the size of ocean basins. Anderle and Hoskin (1977) have shown that the orbit error along a given ground track also is correlated to some degree with the orbit error along adjacent ground tracks. This cross track correlation is verified here and is found to be significant out to nearly 1000 kilometers in the case of TOPEX/POSEIDON when using the GEM-T1 gravity model. Finally, it was determined that even the orbit error at points where ascending and descending ground traces cross is somewhat correlated. The implication of these various correlations is that the orbit error due to gravity error is geographically correlated. Such correlations have direct implications when using altimetry to recover oceanographic signals.

Quantifying the impact of material-model error on macroscale quantities-of-interest using multiscale a posteriori error-estimation techniques

DOE PAGES

Brown, Judith A.; Bishop, Joseph E.

2016-07-20

An a posteriori error-estimation framework is introduced to quantify and reduce modeling errors resulting from approximating complex mesoscale material behavior with a simpler macroscale model. Such errors may be prevalent when modeling welds and additively manufactured structures, where spatial variations and material textures may be present in the microstructure. We consider a case where a <100> fiber texture develops in the longitudinal scanning direction of a weld. Transversely isotropic elastic properties are obtained through homogenization of a microstructural model with this texture and are considered the reference weld properties within the error-estimation framework. Conversely, isotropic elastic properties are considered approximatemore » weld properties since they contain no representation of texture. Errors introduced by using isotropic material properties to represent a weld are assessed through a quantified error bound in the elastic regime. Lastly, an adaptive error reduction scheme is used to determine the optimal spatial variation of the isotropic weld properties to reduce the error bound.« less

Mapping DNA polymerase errors by single-molecule sequencing

DOE PAGES

Lee, David F.; Lu, Jenny; Chang, Seungwoo; ...

2016-05-16

Genomic integrity is compromised by DNA polymerase replication errors, which occur in a sequence-dependent manner across the genome. Accurate and complete quantification of a DNA polymerase's error spectrum is challenging because errors are rare and difficult to detect. We report a high-throughput sequencing assay to map in vitro DNA replication errors at the single-molecule level. Unlike previous methods, our assay is able to rapidly detect a large number of polymerase errors at base resolution over any template substrate without quantification bias. To overcome the high error rate of high-throughput sequencing, our assay uses a barcoding strategy in which each replicationmore » product is tagged with a unique nucleotide sequence before amplification. Here, this allows multiple sequencing reads of the same product to be compared so that sequencing errors can be found and removed. We demonstrate the ability of our assay to characterize the average error rate, error hotspots and lesion bypass fidelity of several DNA polymerases.« less

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

PubMed

Steers, Jennifer M; Fraass, Benedick A

2016-04-01

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

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.

Preschool speech error patterns predict articulation and phonological awareness outcomes in children with histories of speech sound disorders.

PubMed

Preston, Jonathan L; Hull, Margaret; Edwards, Mary Louise

2013-05-01

To determine if speech error patterns in preschoolers with speech sound disorders (SSDs) predict articulation and phonological awareness (PA) outcomes almost 4 years later. Twenty-five children with histories of preschool SSDs (and normal receptive language) were tested at an average age of 4;6 (years;months) and were followed up at age 8;3. The frequency of occurrence of preschool distortion errors, typical substitution and syllable structure errors, and atypical substitution and syllable structure errors was used to predict later speech sound production, PA, and literacy outcomes. Group averages revealed below-average school-age articulation scores and low-average PA but age-appropriate reading and spelling. Preschool speech error patterns were related to school-age outcomes. Children for whom >10% of their speech sound errors were atypical had lower PA and literacy scores at school age than children who produced <10% atypical errors. Preschoolers who produced more distortion errors were likely to have lower school-age articulation scores than preschoolers who produced fewer distortion errors. Different preschool speech error patterns predict different school-age clinical outcomes. Many atypical speech sound errors in preschoolers may be indicative of weak phonological representations, leading to long-term PA weaknesses. Preschoolers' distortions may be resistant to change over time, leading to persisting speech sound production problems.

The Sustained Influence of an Error on Future Decision-Making.

PubMed

Schiffler, Björn C; Bengtsson, Sara L; Lundqvist, Daniel

2017-01-01

Post-error slowing (PES) is consistently observed in decision-making tasks after negative feedback. Yet, findings are inconclusive as to whether PES supports performance accuracy. We addressed the role of PES by employing drift diffusion modeling which enabled us to investigate latent processes of reaction times and accuracy on a large-scale dataset (>5,800 participants) of a visual search experiment with emotional face stimuli. In our experiment, post-error trials were characterized by both adaptive and non-adaptive decision processes. An adaptive increase in participants' response threshold was sustained over several trials post-error. Contrarily, an initial decrease in evidence accumulation rate, followed by an increase on the subsequent trials, indicates a momentary distraction of task-relevant attention and resulted in an initial accuracy drop. Higher values of decision threshold and evidence accumulation on the post-error trial were associated with higher accuracy on subsequent trials which further gives credence to these parameters' role in post-error adaptation. Finally, the evidence accumulation rate post-error decreased when the error trial presented angry faces, a finding suggesting that the post-error decision can be influenced by the error context. In conclusion, we demonstrate that error-related response adaptations are multi-component processes that change dynamically over several trials post-error.

Panel positioning error and support mechanism for a 30-m THz radio telescope

NASA Astrophysics Data System (ADS)

Yang, De-Hua; Okoh, Daniel; Zhou, Guo-Hua; Li, Ai-Hua; Li, Guo-Ping; Cheng, Jing-Quan

2011-06-01

A 30-m TeraHertz (THz) radio telescope is proposed to operate at 200 μm with an active primary surface. This paper presents sensitivity analysis of active surface panel positioning errors with optical performance in terms of the Strehl ratio. Based on Ruze's surface error theory and using a Monte Carlo simulation, the effects of six rigid panel positioning errors, such as piston, tip, tilt, radial, azimuthal and twist displacements, were directly derived. The optical performance of the telescope was then evaluated using the standard Strehl ratio. We graphically illustrated the various panel error effects by presenting simulations of complete ensembles of full reflector surface errors for the six different rigid panel positioning errors. Study of the panel error sensitivity analysis revealed that the piston error and tilt/tip errors are dominant while the other rigid errors are much less important. Furthermore, as indicated by the results, we conceived of an alternative Master-Slave Concept-based (MSC-based) active surface by implementating a special Series-Parallel Concept-based (SPC-based) hexapod as the active panel support mechanism. A new 30-m active reflector based on the two concepts was demonstrated to achieve correction for all the six rigid panel positioning errors in an economically feasible way.

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

PubMed

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

2017-11-01

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

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

PubMed

Alexander, William H; Brown, Joshua W

2010-02-15

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

Cognitive control of conscious error awareness: error awareness and error positivity (Pe) amplitude in moderate-to-severe traumatic brain injury (TBI)

PubMed Central

Logan, Dustin M.; Hill, Kyle R.; Larson, Michael J.

2015-01-01

Poor awareness has been linked to worse recovery and rehabilitation outcomes following moderate-to-severe traumatic brain injury (M/S TBI). The error positivity (Pe) component of the event-related potential (ERP) is linked to error awareness and cognitive control. Participants included 37 neurologically healthy controls and 24 individuals with M/S TBI who completed a brief neuropsychological battery and the error awareness task (EAT), a modified Stroop go/no-go task that elicits aware and unaware errors. Analyses compared between-group no-go accuracy (including accuracy between the first and second halves of the task to measure attention and fatigue), error awareness performance, and Pe amplitude by level of awareness. The M/S TBI group decreased in accuracy and maintained error awareness over time; control participants improved both accuracy and error awareness during the course of the task. Pe amplitude was larger for aware than unaware errors for both groups; however, consistent with previous research on the Pe and TBI, there were no significant between-group differences for Pe amplitudes. Findings suggest possible attention difficulties and low improvement of performance over time may influence specific aspects of error awareness in M/S TBI. PMID:26217212

A preliminary taxonomy of medical errors in family practice

PubMed Central

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

2002-01-01

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

A preliminary taxonomy of medical errors in family practice.

PubMed

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

2002-09-01

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

Quantifying Errors in TRMM-Based Multi-Sensor QPE Products Over Land in Preparation for GPM

NASA Technical Reports Server (NTRS)

Peters-Lidard, Christa D.; Tian, Yudong

2011-01-01

Determining uncertainties in satellite-based multi-sensor quantitative precipitation estimates over land of fundamental importance to both data producers and hydro climatological applications. ,Evaluating TRMM-era products also lays the groundwork and sets the direction for algorithm and applications development for future missions including GPM. QPE uncertainties result mostly from the interplay of systematic errors and random errors. In this work, we will synthesize our recent results quantifying the error characteristics of satellite-based precipitation estimates. Both systematic errors and total uncertainties have been analyzed for six different TRMM-era precipitation products (3B42, 3B42RT, CMORPH, PERSIANN, NRL and GSMap). For systematic errors, we devised an error decomposition scheme to separate errors in precipitation estimates into three independent components, hit biases, missed precipitation and false precipitation. This decomposition scheme reveals hydroclimatologically-relevant error features and provides a better link to the error sources than conventional analysis, because in the latter these error components tend to cancel one another when aggregated or averaged in space or time. For the random errors, we calculated the measurement spread from the ensemble of these six quasi-independent products, and thus produced a global map of measurement uncertainties. The map yields a global view of the error characteristics and their regional and seasonal variations, reveals many undocumented error features over areas with no validation data available, and provides better guidance to global assimilation of satellite-based precipitation data. Insights gained from these results and how they could help with GPM will be highlighted.

Economic measurement of medical errors using a hospital claims database.

PubMed

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

2013-01-01

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

A procedure for the significance testing of unmodeled errors in GNSS observations

NASA Astrophysics Data System (ADS)

Li, Bofeng; Zhang, Zhetao; Shen, Yunzhong; Yang, Ling

2018-01-01

It is a crucial task to establish a precise mathematical model for global navigation satellite system (GNSS) observations in precise positioning. Due to the spatiotemporal complexity of, and limited knowledge on, systematic errors in GNSS observations, some residual systematic errors would inevitably remain even after corrected with empirical model and parameterization. These residual systematic errors are referred to as unmodeled errors. However, most of the existing studies mainly focus on handling the systematic errors that can be properly modeled and then simply ignore the unmodeled errors that may actually exist. To further improve the accuracy and reliability of GNSS applications, such unmodeled errors must be handled especially when they are significant. Therefore, a very first question is how to statistically validate the significance of unmodeled errors. In this research, we will propose a procedure to examine the significance of these unmodeled errors by the combined use of the hypothesis tests. With this testing procedure, three components of unmodeled errors, i.e., the nonstationary signal, stationary signal and white noise, are identified. The procedure is tested by using simulated data and real BeiDou datasets with varying error sources. The results show that the unmodeled errors can be discriminated by our procedure with approximately 90% confidence. The efficiency of the proposed procedure is further reassured by applying the time-domain Allan variance analysis and frequency-domain fast Fourier transform. In summary, the spatiotemporally correlated unmodeled errors are commonly existent in GNSS observations and mainly governed by the residual atmospheric biases and multipath. Their patterns may also be impacted by the receiver.

The next organizational challenge: finding and addressing diagnostic error.

PubMed

Graber, Mark L; Trowbridge, Robert; Myers, Jennifer S; Umscheid, Craig A; Strull, William; Kanter, Michael H

2014-03-01

Although health care organizations (HCOs) are intensely focused on improving the safety of health care, efforts to date have almost exclusively targeted treatment-related issues. The literature confirms that the approaches HCOs use to identify adverse medical events are not effective in finding diagnostic errors, so the initial challenge is to identify cases of diagnostic error. WHY HEALTH CARE ORGANIZATIONS NEED TO GET INVOLVED: HCOs are preoccupied with many quality- and safety-related operational and clinical issues, including performance measures. The case for paying attention to diagnostic errors, however, is based on the following four points: (1) diagnostic errors are common and harmful, (2) high-quality health care requires high-quality diagnosis, (3) diagnostic errors are costly, and (4) HCOs are well positioned to lead the way in reducing diagnostic error. FINDING DIAGNOSTIC ERRORS: Current approaches to identifying diagnostic errors, such as occurrence screens, incident reports, autopsy, and peer review, were not designed to detect diagnostic issues (or problems of omission in general) and/or rely on voluntary reporting. The realization that the existing tools are inadequate has spurred efforts to identify novel tools that could be used to discover diagnostic errors or breakdowns in the diagnostic process that are associated with errors. New approaches--Maine Medical Center's case-finding of diagnostic errors by facilitating direct reports from physicians and Kaiser Permanente's electronic health record--based reports that detect process breakdowns in the followup of abnormal findings--are described in case studies. By raising awareness and implementing targeted programs that address diagnostic error, HCOs may begin to play an important role in addressing the problem of diagnostic error.

Predictive and Feedback Performance Errors are Signaled in the Simple Spike Discharge of Individual Purkinje Cells

PubMed Central

Popa, Laurentiu S.; Hewitt, Angela L.; Ebner, Timothy J.

2012-01-01

The cerebellum has been implicated in processing motor errors required for online control of movement and motor learning. The dominant view is that Purkinje cell complex spike discharge signals motor errors. This study investigated whether errors are encoded in the simple spike discharge of Purkinje cells in monkeys trained to manually track a pseudo-randomly moving target. Four task error signals were evaluated based on cursor movement relative to target movement. Linear regression analyses based on firing residuals ensured that the modulation with a specific error parameter was independent of the other error parameters and kinematics. The results demonstrate that simple spike firing in lobules IV–VI is significantly correlated with position, distance and directional errors. Independent of the error signals, the same Purkinje cells encode kinematics. The strongest error modulation occurs at feedback timing. However, in 72% of cells at least one of the R2 temporal profiles resulting from regressing firing with individual errors exhibit two peak R2 values. For these bimodal profiles, the first peak is at a negative τ (lead) and a second peak at a positive τ (lag), implying that Purkinje cells encode both prediction and feedback about an error. For the majority of the bimodal profiles, the signs of the regression coefficients or preferred directions reverse at the times of the peaks. The sign reversal results in opposing simple spike modulation for the predictive and feedback components. Dual error representations may provide the signals needed to generate sensory prediction errors used to update a forward internal model. PMID:23115173

Headaches associated with refractive errors: myth or reality?

PubMed

Gil-Gouveia, R; Martins, I P

2002-04-01

Headache and refractive errors are very common conditions in the general population, and those with headache often attribute their pain to a visual problem. The International Headache Society (IHS) criteria for the classification of headache includes an entity of headache associated with refractive errors (HARE), but indicates that its importance is widely overestimated. To compare overall headache frequency and HARE frequency in healthy subjects with uncorrected or miscorrected refractive errors and a control group. We interviewed 105 individuals with uncorrected refractive errors and a control group of 71 subjects (with properly corrected or without refractive errors) regarding their headache history. We compared the occurrence of headache and its diagnosis in both groups and assessed its relation to their habits of visual effort and type of refractive errors. Headache frequency was similar in both subjects and controls. Headache associated with refractive errors was the only headache type significantly more common in subjects with refractive errors than in controls (6.7% versus 0%). It was associated with hyperopia and was unrelated to visual effort or to the severity of visual error. With adequate correction, 72.5% of the subjects with headache and refractive error reported improvement in their headaches, and 38% had complete remission of headache. Regardless of the type of headache present, headache frequency was significantly reduced in these subjects (t = 2.34, P =.02). Headache associated with refractive errors was rarely identified in individuals with refractive errors. In those with chronic headache, proper correction of refractive errors significantly improved headache complaints and did so primarily by decreasing the frequency of headache episodes.

Medication errors in anesthesia: unacceptable or unavoidable?

PubMed

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

Medication errors are the common causes of patient morbidity and mortality. It adds financial burden to the institution as well. Though the impact varies from no harm to serious adverse effects including death, it needs attention on priority basis since medication errors' are preventable. In today's world where people are aware and medical claims are on the hike, it is of utmost priority that we curb this issue. Individual effort to decrease medication error alone might not be successful until a change in the existing protocols and system is incorporated. Often drug errors that occur cannot be reversed. The best way to 'treat' drug errors is to prevent them. Wrong medication (due to syringe swap), overdose (due to misunderstanding or preconception of the dose, pump misuse and dilution error), incorrect administration route, under dosing and omission are common causes of medication error that occur perioperatively. Drug omission and calculation mistakes occur commonly in ICU. Medication errors can occur perioperatively either during preparation, administration or record keeping. Numerous human and system errors can be blamed for occurrence of medication errors. The need of the hour is to stop the blame - game, accept mistakes and develop a safe and 'just' culture in order to prevent medication errors. The newly devised systems like VEINROM, a fluid delivery system is a novel approach in preventing drug errors due to most commonly used medications in anesthesia. Similar developments along with vigilant doctors, safe workplace culture and organizational support all together can help prevent these errors. Copyright © 2016. Published by Elsevier Editora Ltda.

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

PubMed

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

2008-10-01

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

Dispensing error rate after implementation of an automated pharmacy carousel system.

PubMed

Oswald, Scott; Caldwell, Richard

2007-07-01

A study was conducted to determine filling and dispensing error rates before and after the implementation of an automated pharmacy carousel system (APCS). The study was conducted in a 613-bed acute and tertiary care university hospital. Before the implementation of the APCS, filling and dispensing rates were recorded during October through November 2004 and January 2005. Postimplementation data were collected during May through June 2006. Errors were recorded in three areas of pharmacy operations: first-dose or missing medication fill, automated dispensing cabinet fill, and interdepartmental request fill. A filling error was defined as an error caught by a pharmacist during the verification step. A dispensing error was defined as an error caught by a pharmacist observer after verification by the pharmacist. Before implementation of the APCS, 422 first-dose or missing medication orders were observed between October 2004 and January 2005. Independent data collected in December 2005, approximately six weeks after the introduction of the APCS, found that filling and error rates had increased. The filling rate for automated dispensing cabinets was associated with the largest decrease in errors. Filling and dispensing error rates had decreased by December 2005. In terms of interdepartmental request fill, no dispensing errors were noted in 123 clinic orders dispensed before the implementation of the APCS. One dispensing error out of 85 clinic orders was identified after implementation of the APCS. The implementation of an APCS at a university hospital decreased medication filling errors related to automated cabinets only and did not affect other filling and dispensing errors.

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

PubMed

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

2017-02-01

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

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

PubMed

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

2017-02-01

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

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

PubMed

Tully, Mary P; Buchan, Iain E

2009-12-01

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

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

PubMed Central

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

2017-01-01

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

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

PubMed Central

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

2008-01-01

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

[Validation of a method for notifying and monitoring medication errors in pediatrics].

PubMed

Guerrero-Aznar, M D; Jiménez-Mesa, E; Cotrina-Luque, J; Villalba-Moreno, A; Cumplido-Corbacho, R; Fernández-Fernández, L

2014-12-01

To analyze the impact of a multidisciplinary and decentralized safety committee in the pediatric management unit, and the joint implementation of a computing network application for reporting medication errors, monitoring the follow-up of the errors, and an analysis of the improvements introduced. An observational, descriptive, cross-sectional, pre-post intervention study was performed. An analysis was made of medication errors reported to the central safety committee in the twelve months prior to introduction, and those reported to the decentralized safety committee in the management unit in the nine months after implementation, using the computer application, and the strategies generated by the analysis of reported errors. Number of reported errors/10,000 days of stay, number of reported errors with harm per 10,000 days of stay, types of error, categories based on severity, stage of the process, and groups involved in the notification of medication errors. Reported medication errors increased 4.6 -fold, from 7.6 notifications of medication errors per 10,000 days of stay in the pre-intervention period to 36 in the post-intervention, rate ratio 0.21 (95% CI; 0.11-0.39) (P<.001). The medication errors with harm or requiring monitoring reported per 10,000 days of stay, was virtually unchanged from one period to the other ratio rate 0,77 (95% IC; 0,31-1,91) (P>.05). The notification of potential errors or errors without harm per 10,000 days of stay increased 17.4-fold (rate ratio 0.005., 95% CI; 0.001-0.026, P<.001). The increase in medication errors notified in the post-intervention period is a reflection of an increase in the motivation of health professionals to report errors through this new method. Copyright © 2013 Asociación Española de Pediatría. Published by Elsevier Espana. All rights reserved.

The effects of center of rotation errors on cardiac SPECT imaging

NASA Astrophysics Data System (ADS)

Bai, Chuanyong; Shao, Ling; Ye, Jinghan; Durbin, M.

2003-10-01

In SPECT imaging, center of rotation (COR) errors lead to the misalignment of projection data and can potentially degrade the quality of the reconstructed images. In this work, we study the effects of COR errors on cardiac SPECT imaging using simulation, point source, cardiac phantom, and patient studies. For simulation studies, we generate projection data using a uniform MCAT phantom first without modeling any physical effects (NPH), then with the modeling of detector response effect (DR) alone. We then corrupt the projection data with simulated sinusoid and step COR errors. For other studies, we introduce sinusoid COR errors to projection data acquired on SPECT systems. An OSEM algorithm is used for image reconstruction without detector response correction, but with nonuniform attenuation correction when needed. The simulation studies show that, when COR errors increase from 0 to 0.96 cm: 1) sinusoid COR errors in axial direction lead to intensity decrease in the inferoapical region; 2) step COR errors in axial direction lead to intensity decrease in the distal anterior region. The intensity decrease is more severe in images reconstructed from projection data with NPH than with DR; and 3) the effects of COR errors in transaxial direction seem to be insignificant. In other studies, COR errors slightly degrade point source resolution; COR errors of 0.64 cm or above introduce visible but insignificant nonuniformity in the images of uniform cardiac phantom; COR errors up to 0.96 cm in transaxial direction affect the lesion-to-background contrast (LBC) insignificantly in the images of cardiac phantom with defects, and COR errors up to 0.64 cm in axial direction only slightly decrease the LBC. For the patient studies with COR errors up to 0.96 cm, images have the same diagnostic/prognostic values as those without COR errors. This work suggests that COR errors of up to 0.64 cm are not likely to change the clinical applications of cardiac SPECT imaging when using iterative reconstruction algorithm without detector response correction.

Error sensitivity analysis in 10-30-day extended range forecasting by using a nonlinear cross-prediction error model

NASA Astrophysics Data System (ADS)

Xia, Zhiye; Xu, Lisheng; Chen, Hongbin; Wang, Yongqian; Liu, Jinbao; Feng, Wenlan

2017-06-01

Extended range forecasting of 10-30 days, which lies between medium-term and climate prediction in terms of timescale, plays a significant role in decision-making processes for the prevention and mitigation of disastrous meteorological events. The sensitivity of initial error, model parameter error, and random error in a nonlinear crossprediction error (NCPE) model, and their stability in the prediction validity period in 10-30-day extended range forecasting, are analyzed quantitatively. The associated sensitivity of precipitable water, temperature, and geopotential height during cases of heavy rain and hurricane is also discussed. The results are summarized as follows. First, the initial error and random error interact. When the ratio of random error to initial error is small (10-6-10-2), minor variation in random error cannot significantly change the dynamic features of a chaotic system, and therefore random error has minimal effect on the prediction. When the ratio is in the range of 10-1-2 (i.e., random error dominates), attention should be paid to the random error instead of only the initial error. When the ratio is around 10-2-10-1, both influences must be considered. Their mutual effects may bring considerable uncertainty to extended range forecasting, and de-noising is therefore necessary. Second, in terms of model parameter error, the embedding dimension m should be determined by the factual nonlinear time series. The dynamic features of a chaotic system cannot be depicted because of the incomplete structure of the attractor when m is small. When m is large, prediction indicators can vanish because of the scarcity of phase points in phase space. A method for overcoming the cut-off effect ( m > 4) is proposed. Third, for heavy rains, precipitable water is more sensitive to the prediction validity period than temperature or geopotential height; however, for hurricanes, geopotential height is most sensitive, followed by precipitable water.

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

PubMed

Eltaybani, Sameh; Mohamed, Nadia; Abdelwareth, Mona

2018-04-27

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

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

PubMed

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

2014-11-01

Nurses are frequently interrupted during medication verification and administration; however, few interventions exist to mitigate resulting errors, and the impact of these interventions on medication safety is poorly understood. The study objectives were to (A) assess the effects of interruptions on medication verification and administration errors, and (B) design and test the effectiveness of targeted interventions at reducing these errors. The study focused on medication verification and administration in an ambulatory chemotherapy setting. A simulation laboratory experiment was conducted to determine interruption-related error rates during specific medication verification and administration tasks. Interventions to reduce these errors were developed through a participatory design process, and their error reduction effectiveness was assessed through a postintervention experiment. Significantly more nurses committed medication errors when interrupted than when uninterrupted. With use of interventions when interrupted, significantly fewer nurses made errors in verifying medication volumes contained in syringes (16/18; 89% preintervention error rate vs 11/19; 58% postintervention error rate; p=0.038; Fisher's exact test) and programmed in ambulatory pumps (17/18; 94% preintervention vs 11/19; 58% postintervention; p=0.012). The rate of error commission significantly decreased with use of interventions when interrupted during intravenous push (16/18; 89% preintervention vs 6/19; 32% postintervention; p=0.017) and pump programming (7/18; 39% preintervention vs 1/19; 5% postintervention; p=0.017). No statistically significant differences were observed for other medication verification tasks. Interruptions can lead to medication verification and administration errors. Interventions were highly effective at reducing unanticipated errors of commission in medication administration tasks, but showed mixed effectiveness at reducing predictable errors of detection in medication verification tasks. These findings can be generalised and adapted to mitigate interruption-related errors in other settings where medication verification and administration are required. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.

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

PubMed Central

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

2014-01-01

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

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

PubMed Central

Aljasmi, Fatema; Almalood, Fatema

2018-01-01

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

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

PubMed

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

2013-01-01

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

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

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

Gopan, O; Kalet, A; Smith, W

2016-06-15

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

Discretization vs. Rounding Error in Euler's Method

ERIC Educational Resources Information Center

Borges, Carlos F.

2011-01-01

Euler's method for solving initial value problems is an excellent vehicle for observing the relationship between discretization error and rounding error in numerical computation. Reductions in stepsize, in order to decrease discretization error, necessarily increase the number of steps and so introduce additional rounding error. The problem is…

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

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

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

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

Effect of patient setup errors on simultaneously integrated boost head and neck IMRT treatment plans

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

Siebers, Jeffrey V.; Keall, Paul J.; Wu Qiuwen

2005-10-01

Purpose: The purpose of this study is to determine dose delivery errors that could result from random and systematic setup errors for head-and-neck patients treated using the simultaneous integrated boost (SIB)-intensity-modulated radiation therapy (IMRT) technique. Methods and Materials: Twenty-four patients who participated in an intramural Phase I/II parotid-sparing IMRT dose-escalation protocol using the SIB treatment technique had their dose distributions reevaluated to assess the impact of random and systematic setup errors. The dosimetric effect of random setup error was simulated by convolving the two-dimensional fluence distribution of each beam with the random setup error probability density distribution. Random setup errorsmore » of {sigma} = 1, 3, and 5 mm were simulated. Systematic setup errors were simulated by randomly shifting the patient isocenter along each of the three Cartesian axes, with each shift selected from a normal distribution. Systematic setup error distributions with {sigma} = 1.5 and 3.0 mm along each axis were simulated. Combined systematic and random setup errors were simulated for {sigma} = {sigma} = 1.5 and 3.0 mm along each axis. For each dose calculation, the gross tumor volume (GTV) received by 98% of the volume (D{sub 98}), clinical target volume (CTV) D{sub 90}, nodes D{sub 90}, cord D{sub 2}, and parotid D{sub 50} and parotid mean dose were evaluated with respect to the plan used for treatment for the structure dose and for an effective planning target volume (PTV) with a 3-mm margin. Results: Simultaneous integrated boost-IMRT head-and-neck treatment plans were found to be less sensitive to random setup errors than to systematic setup errors. For random-only errors, errors exceeded 3% only when the random setup error {sigma} exceeded 3 mm. Simulated systematic setup errors with {sigma} = 1.5 mm resulted in approximately 10% of plan having more than a 3% dose error, whereas a {sigma} = 3.0 mm resulted in half of the plans having more than a 3% dose error and 28% with a 5% dose error. Combined random and systematic dose errors with {sigma} = {sigma} = 3.0 mm resulted in more than 50% of plans having at least a 3% dose error and 38% of the plans having at least a 5% dose error. Evaluation with respect to a 3-mm expanded PTV reduced the observed dose deviations greater than 5% for the {sigma} = {sigma} = 3.0 mm simulations to 5.4% of the plans simulated. Conclusions: Head-and-neck SIB-IMRT dosimetric accuracy would benefit from methods to reduce patient systematic setup errors. When GTV, CTV, or nodal volumes are used for dose evaluation, plans simulated including the effects of random and systematic errors deviate substantially from the nominal plan. The use of PTVs for dose evaluation in the nominal plan improves agreement with evaluated GTV, CTV, and nodal dose values under simulated setup errors. PTV concepts should be used for SIB-IMRT head-and-neck squamous cell carcinoma patients, although the size of the margins may be less than those used with three-dimensional conformal radiation therapy.« less

Introduction to the Application of Web-Based Surveys.

ERIC Educational Resources Information Center

Timmerman, Annemarie

This paper discusses some basic assumptions and issues concerning web-based surveys. Discussion includes: assumptions regarding cost and ease of use; disadvantages of web-based surveys, concerning the inability to compensate for four common errors of survey research: coverage error, sampling error, measurement error and nonresponse error; and…

49 CFR Appendix F to Part 240 - Medical Standards Guidelines

Code of Federal Regulations, 2010 CFR

2010-10-01

... greater guidance on the procedures that should be employed in administering the vision and hearing... more errors on plates 1-15. MULTIFUNCTION VISION TESTER Keystone Orthoscope Any error. OPTEC 2000 Any error. Titmus Vision Tester Any error. Titmus II Vision Tester Any error. (3) In administering any of...

49 CFR Appendix F to Part 240 - Medical Standards Guidelines

Code of Federal Regulations, 2011 CFR

2011-10-01

... greater guidance on the procedures that should be employed in administering the vision and hearing... more errors on plates 1-15. MULTIFUNCTION VISION TESTER Keystone Orthoscope Any error. OPTEC 2000 Any error. Titmus Vision Tester Any error. Titmus II Vision Tester Any error. (3) In administering any of...

32 CFR 1653.3 - Review by the National Appeal Board.

Code of Federal Regulations, 2011 CFR

2011-07-01

... review the file to insure that no procedural errors have occurred during the history of the current claim. Files containing procedural errors will be returned to the board where the errors occurred for any additional processing necessary to correct such errors. (c) Files containing procedural errors that were not...

Error model for the SAO 1969 standard earth.

NASA Technical Reports Server (NTRS)

Martin, C. F.; Roy, N. A.

1972-01-01

A method is developed for estimating an error model for geopotential coefficients using satellite tracking data. A single station's apparent timing error for each pass is attributed to geopotential errors. The root sum of the residuals for each station also depends on the geopotential errors, and these are used to select an error model. The model chosen is 1/4 of the difference between the SAO M1 and the APL 3.5 geopotential.

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

PubMed

Wu, Xue; Wu, Changxu

2017-01-01

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

Permanence analysis of a concatenated coding scheme for error control

NASA Technical Reports Server (NTRS)

Costello, D. J., Jr.; Lin, S.; Kasami, T.

1983-01-01

A concatenated coding scheme for error control in data communications is analyzed. In this scheme, the inner code is used for both error correction and detection, however, the outer code is used only for error detection. A retransmission is requested if the outer code detects the presence of errors after the inner code decoding. Probability of undetected error is derived and bounded. A particular example, proposed for the planetary program, is analyzed.

Probability of undetected error after decoding for a concatenated coding scheme

NASA Technical Reports Server (NTRS)

Costello, D. J., Jr.; Lin, S.

1984-01-01

A concatenated coding scheme for error control in data communications is analyzed. In this scheme, the inner code is used for both error correction and detection, however the outer code is used only for error detection. A retransmission is requested if the outer code detects the presence of errors after the inner code decoding. Probability of undetected error is derived and bounded. A particular example, proposed for NASA telecommand system is analyzed.

Parallel computers - Estimate errors caused by imprecise data

NASA Technical Reports Server (NTRS)

Kreinovich, Vladik; Bernat, Andrew; Villa, Elsa; Mariscal, Yvonne

1991-01-01

A new approach to the problem of estimating errors caused by imprecise data is proposed in the context of software engineering. A software device is used to produce an ideal solution to the problem, when the computer is capable of computing errors of arbitrary programs. The software engineering aspect of this problem is to describe a device for computing the error estimates in software terms and then to provide precise numbers with error estimates to the user. The feasibility of the program capable of computing both some quantity and its error estimate in the range of possible measurement errors is demonstrated.

Quantum error correction for continuously detected errors with any number of error channels per qubit

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

Ahn, Charlene; Wiseman, Howard; Jacobs, Kurt

2004-08-01

It was shown by Ahn, Wiseman, and Milburn [Phys. Rev. A 67, 052310 (2003)] that feedback control could be used as a quantum error correction process for errors induced by weak continuous measurement, given one perfectly measured error channel per qubit. Here we point out that this method can be easily extended to an arbitrary number of error channels per qubit. We show that the feedback protocols generated by our method encode n-2 logical qubits in n physical qubits, thus requiring just one more physical qubit than in the previous case.

A concatenated coding scheme for error control

NASA Technical Reports Server (NTRS)

Lin, S.

1985-01-01

A concatenated coding scheme for error contol in data communications was analyzed. The inner code is used for both error correction and detection, however the outer code is used only for error detection. A retransmission is requested if either the inner code decoder fails to make a successful decoding or the outer code decoder detects the presence of errors after the inner code decoding. Probability of undetected error of the proposed scheme is derived. An efficient method for computing this probability is presented. Throughout efficiency of the proposed error control scheme incorporated with a selective repeat ARQ retransmission strategy is analyzed.

Understanding human management of automation errors

PubMed Central

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

2013-01-01

Automation has the potential to aid humans with a diverse set of tasks and support overall system performance. Automated systems are not always reliable, and when automation errs, humans must engage in error management, which is the process of detecting, understanding, and correcting errors. However, this process of error management in the context of human-automation interaction is not well understood. Therefore, we conducted a systematic review of the variables that contribute to error management. We examined relevant research in human-automation interaction and human error to identify critical automation, person, task, and emergent variables. We propose a framework for management of automation errors to incorporate and build upon previous models. Further, our analysis highlights variables that may be addressed through design and training to positively influence error management. Additional efforts to understand the error management process will contribute to automation designed and implemented to support safe and effective system performance. PMID:25383042

Evaluation of a UMLS Auditing Process of Semantic Type Assignments

PubMed Central

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

2007-01-01

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

Calibration Method to Eliminate Zeroth Order Effect in Lateral Shearing Interferometry

NASA Astrophysics Data System (ADS)

Fang, Chao; Xiang, Yang; Qi, Keqi; Chen, Dawei

2018-04-01

In this paper, a calibration method is proposed which eliminates the zeroth order effect in lateral shearing interferometry. An analytical expression of the calibration error function is deduced, and the relationship between the phase-restoration error and calibration error is established. The analytical results show that the phase-restoration error introduced by the calibration error is proportional to the phase shifting error and zeroth order effect. The calibration method is verified using simulations and experiments. The simulation results show that the phase-restoration error is approximately proportional to the phase shift error and zeroth order effect, when the phase shifting error is less than 2° and the zeroth order effect is less than 0.2. The experimental result shows that compared with the conventional method with 9-frame interferograms, the calibration method with 5-frame interferograms achieves nearly the same restoration accuracy.

Statistical analysis of modeling error in structural dynamic systems

NASA Technical Reports Server (NTRS)

Hasselman, T. K.; Chrostowski, J. D.

1990-01-01

The paper presents a generic statistical model of the (total) modeling error for conventional space structures in their launch configuration. Modeling error is defined as the difference between analytical prediction and experimental measurement. It is represented by the differences between predicted and measured real eigenvalues and eigenvectors. Comparisons are made between pre-test and post-test models. Total modeling error is then subdivided into measurement error, experimental error and 'pure' modeling error, and comparisons made between measurement error and total modeling error. The generic statistical model presented in this paper is based on the first four global (primary structure) modes of four different structures belonging to the generic category of Conventional Space Structures (specifically excluding large truss-type space structures). As such, it may be used to evaluate the uncertainty of predicted mode shapes and frequencies, sinusoidal response, or the transient response of other structures belonging to the same generic category.

Clarification of terminology in medication errors: definitions and classification.

PubMed

Ferner, Robin E; Aronson, Jeffrey K

2006-01-01

We have previously described and analysed some terms that are used in drug safety and have proposed definitions. Here we discuss and define terms that are used in the field of medication errors, particularly terms that are sometimes misunderstood or misused. We also discuss the classification of medication errors. A medication error is a failure in the treatment process that leads to, or has the potential to lead to, harm to the patient. Errors can be classified according to whether they are mistakes, slips, or lapses. Mistakes are errors in the planning of an action. They can be knowledge based or rule based. Slips and lapses are errors in carrying out an action - a slip through an erroneous performance and a lapse through an erroneous memory. Classification of medication errors is important because the probabilities of errors of different classes are different, as are the potential remedies.

Quantum error-correcting code for ternary logic

NASA Astrophysics Data System (ADS)

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

2018-05-01

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

Understanding human management of automation errors.

PubMed

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

2014-01-01

Automation has the potential to aid humans with a diverse set of tasks and support overall system performance. Automated systems are not always reliable, and when automation errs, humans must engage in error management, which is the process of detecting, understanding, and correcting errors. However, this process of error management in the context of human-automation interaction is not well understood. Therefore, we conducted a systematic review of the variables that contribute to error management. We examined relevant research in human-automation interaction and human error to identify critical automation, person, task, and emergent variables. We propose a framework for management of automation errors to incorporate and build upon previous models. Further, our analysis highlights variables that may be addressed through design and training to positively influence error management. Additional efforts to understand the error management process will contribute to automation designed and implemented to support safe and effective system performance.

Swing arm profilometer: analytical solutions of misalignment errors for testing axisymmetric optics

NASA Astrophysics Data System (ADS)

Xiong, Ling; Luo, Xiao; Liu, Zhenyu; Wang, Xiaokun; Hu, Haixiang; Zhang, Feng; Zheng, Ligong; Zhang, Xuejun

2016-07-01

The swing arm profilometer (SAP) has been playing a very important role in testing large aspheric optics. As one of most significant error sources that affects the test accuracy, misalignment error leads to low-order errors such as aspherical aberrations and coma apart from power. In order to analyze the effect of misalignment errors, the relation between alignment parameters and test results of axisymmetric optics is presented. Analytical solutions of SAP system errors from tested mirror misalignment, arm length L deviation, tilt-angle θ deviation, air-table spin error, and air-table misalignment are derived, respectively; and misalignment tolerance is given to guide surface measurement. In addition, experiments on a 2-m diameter parabolic mirror are demonstrated to verify the model; according to the error budget, we achieve the SAP test for low-order errors except power with accuracy of 0.1 μm root-mean-square.

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

PubMed

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

2007-09-01

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

The effects of training on errors of perceived direction in perspective displays

NASA Technical Reports Server (NTRS)

Tharp, Gregory K.; Ellis, Stephen R.

1990-01-01

An experiment was conducted to determine the effects of training on the characteristic direction errors that are observed when subjects estimate exocentric directions on perspective displays. Changes in five subjects' perceptual errors were measured during a training procedure designed to eliminate the error. The training was provided by displaying to each subject both the sign and the direction of his judgment error. The feedback provided by the error display was found to decrease but not eliminate the error. A lookup table model of the source of the error was developed in which the judgement errors were attributed to overestimates of both the pitch and the yaw of the viewing direction used to produce the perspective projection. The model predicts the quantitative characteristics of the data somewhat better than previous models did. A mechanism is proposed for the observed learning, and further tests of the model are suggested.

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

PubMed

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

2008-04-22

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

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

PubMed Central

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

2008-01-01

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

Decoding of DBEC-TBED Reed-Solomon codes. [Double-Byte-Error-Correcting, Triple-Byte-Error-Detecting

NASA Technical Reports Server (NTRS)

Deng, Robert H.; Costello, Daniel J., Jr.

1987-01-01

A problem in designing semiconductor memories is to provide some measure of error control without requiring excessive coding overhead or decoding time. In LSI and VLSI technology, memories are often organized on a multiple bit (or byte) per chip basis. For example, some 256 K bit DRAM's are organized in 32 K x 8 bit-bytes. Byte-oriented codes such as Reed-Solomon (RS) codes can provide efficient low overhead error control for such memories. However, the standard iterative algorithm for decoding RS codes is too slow for these applications. The paper presents a special decoding technique for double-byte-error-correcting, triple-byte-error-detecting RS codes which is capable of high-speed operation. This technique is designed to find the error locations and the error values directly from the syndrome without having to use the iterative algorithm to find the error locator polynomial.

Error recovery to enable error-free message transfer between nodes of a computer network

DOEpatents

Blumrich, Matthias A.; Coteus, Paul W.; Chen, Dong; Gara, Alan; Giampapa, Mark E.; Heidelberger, Philip; Hoenicke, Dirk; Takken, Todd; Steinmacher-Burow, Burkhard; Vranas, Pavlos M.

2016-01-26

An error-recovery method to enable error-free message transfer between nodes of a computer network. A first node of the network sends a packet to a second node of the network over a link between the nodes, and the first node keeps a copy of the packet on a sending end of the link until the first node receives acknowledgment from the second node that the packet was received without error. The second node tests the packet to determine if the packet is error free. If the packet is not error free, the second node sets a flag to mark the packet as corrupt. The second node returns acknowledgement to the first node specifying whether the packet was received with or without error. When the packet is received with error, the link is returned to a known state and the packet is sent again to the second node.

Linguistic pattern analysis of misspellings of typically developing writers in grades 1-9.

PubMed

Bahr, Ruth Huntley; Sillian, Elaine R; Berninger, Virginia W; Dow, Michael

2012-12-01

A mixed-methods approach, evaluating triple word-form theory, was used to describe linguistic patterns of misspellings. Spelling errors were taken from narrative and expository writing samples provided by 888 typically developing students in Grades 1-9. Errors were coded by category (phonological, orthographic, and morphological) and specific linguistic feature affected. Grade-level effects were analyzed with trend analysis. Qualitative analyses determined frequent error types and how use of specific linguistic features varied across grades. Phonological, orthographic, and morphological errors were noted across all grades, but orthographic errors predominated. Linear trends revealed developmental shifts in error proportions for the orthographic and morphological categories between Grades 4 and 5. Similar error types were noted across age groups, but the nature of linguistic feature error changed with age. Triple word-form theory was supported. By Grade 1, orthographic errors predominated, and phonological and morphological error patterns were evident. Morphological errors increased in relative frequency in older students, probably due to a combination of word-formation issues and vocabulary growth. These patterns suggest that normal spelling development reflects nonlinear growth and that it takes a long time to develop a robust orthographic lexicon that coordinates phonology, orthography, and morphology and supports word-specific, conventional spelling.

Wavefront error budget and optical manufacturing tolerance analysis for 1.8m telescope system

NASA Astrophysics Data System (ADS)

Wei, Kai; Zhang, Xuejun; Xian, Hao; Rao, Changhui; Zhang, Yudong

2010-05-01

We present the wavefront error budget and optical manufacturing tolerance analysis for 1.8m telescope. The error budget accounts for aberrations induced by optical design residual, manufacturing error, mounting effects, and misalignments. The initial error budget has been generated from the top-down. There will also be an ongoing effort to track the errors from the bottom-up. This will aid in identifying critical areas of concern. The resolution of conflicts will involve a continual process of review and comparison of the top-down and bottom-up approaches, modifying both as needed to meet the top level requirements in the end. As we all know, the adaptive optical system will correct for some of the telescope system imperfections but it cannot be assumed that all errors will be corrected. Therefore, two kinds of error budgets will be presented, one is non-AO top-down error budget and the other is with-AO system error budget. The main advantage of the method is that at the same time it describes the final performance of the telescope, and gives to the optical manufacturer the maximum freedom to define and possibly modify its own manufacturing error budget.

Analysis of the “naming game” with learning errors in communications

NASA Astrophysics Data System (ADS)

Lou, Yang; Chen, Guanrong

2015-07-01

Naming game simulates the process of naming an objective by a population of agents organized in a certain communication network. By pair-wise iterative interactions, the population reaches consensus asymptotically. We study naming game with communication errors during pair-wise conversations, with error rates in a uniform probability distribution. First, a model of naming game with learning errors in communications (NGLE) is proposed. Then, a strategy for agents to prevent learning errors is suggested. To that end, three typical topologies of communication networks, namely random-graph, small-world and scale-free networks, are employed to investigate the effects of various learning errors. Simulation results on these models show that 1) learning errors slightly affect the convergence speed but distinctively increase the requirement for memory of each agent during lexicon propagation; 2) the maximum number of different words held by the population increases linearly as the error rate increases; 3) without applying any strategy to eliminate learning errors, there is a threshold of the learning errors which impairs the convergence. The new findings may help to better understand the role of learning errors in naming game as well as in human language development from a network science perspective.

Error estimation of deformable image registration of pulmonary CT scans using convolutional neural networks.

PubMed

Eppenhof, Koen A J; Pluim, Josien P W

2018-04-01

Error estimation in nonlinear medical image registration is a nontrivial problem that is important for validation of registration methods. We propose a supervised method for estimation of registration errors in nonlinear registration of three-dimensional (3-D) images. The method is based on a 3-D convolutional neural network that learns to estimate registration errors from a pair of image patches. By applying the network to patches centered around every voxel, we construct registration error maps. The network is trained using a set of representative images that have been synthetically transformed to construct a set of image pairs with known deformations. The method is evaluated on deformable registrations of inhale-exhale pairs of thoracic CT scans. Using ground truth target registration errors on manually annotated landmarks, we evaluate the method's ability to estimate local registration errors. Estimation of full domain error maps is evaluated using a gold standard approach. The two evaluation approaches show that we can train the network to robustly estimate registration errors in a predetermined range, with subvoxel accuracy. We achieved a root-mean-square deviation of 0.51 mm from gold standard registration errors and of 0.66 mm from ground truth landmark registration errors.

A Sensor Dynamic Measurement Error Prediction Model Based on NAPSO-SVM.

PubMed

Jiang, Minlan; Jiang, Lan; Jiang, Dingde; Li, Fei; Song, Houbing

2018-01-15

Dynamic measurement error correction is an effective way to improve sensor precision. Dynamic measurement error prediction is an important part of error correction, and support vector machine (SVM) is often used for predicting the dynamic measurement errors of sensors. Traditionally, the SVM parameters were always set manually, which cannot ensure the model's performance. In this paper, a SVM method based on an improved particle swarm optimization (NAPSO) is proposed to predict the dynamic measurement errors of sensors. Natural selection and simulated annealing are added in the PSO to raise the ability to avoid local optima. To verify the performance of NAPSO-SVM, three types of algorithms are selected to optimize the SVM's parameters: the particle swarm optimization algorithm (PSO), the improved PSO optimization algorithm (NAPSO), and the glowworm swarm optimization (GSO). The dynamic measurement error data of two sensors are applied as the test data. The root mean squared error and mean absolute percentage error are employed to evaluate the prediction models' performances. The experimental results show that among the three tested algorithms the NAPSO-SVM method has a better prediction precision and a less prediction errors, and it is an effective method for predicting the dynamic measurement errors of sensors.

Experimental determination of the navigation error of the 4-D navigation, guidance, and control systems on the NASA B-737 airplane

NASA Technical Reports Server (NTRS)

Knox, C. E.

1978-01-01

Navigation error data from these flights are presented in a format utilizing three independent axes - horizontal, vertical, and time. The navigation position estimate error term and the autopilot flight technical error term are combined to form the total navigation error in each axis. This method of error presentation allows comparisons to be made between other 2-, 3-, or 4-D navigation systems and allows experimental or theoretical determination of the navigation error terms. Position estimate error data are presented with the navigation system position estimate based on dual DME radio updates that are smoothed with inertial velocities, dual DME radio updates that are smoothed with true airspeed and magnetic heading, and inertial velocity updates only. The normal mode of navigation with dual DME updates that are smoothed with inertial velocities resulted in a mean error of 390 m with a standard deviation of 150 m in the horizontal axis; a mean error of 1.5 m low with a standard deviation of less than 11 m in the vertical axis; and a mean error as low as 252 m with a standard deviation of 123 m in the time axis.

Age effects shrink when motor learning is predominantly supported by nondeclarative, automatic memory processes: evidence from golf putting.

PubMed

Chauvel, Guillaume; Maquestiaux, François; Hartley, Alan A; Joubert, Sven; Didierjean, André; Masters, Rich S W

2012-01-01

Can motor learning be equivalent in younger and older adults? To address this question, 48 younger (M = 23.5 years) and 48 older (M = 65.0 years) participants learned to perform a golf-putting task in two different motor learning situations: one that resulted in infrequent errors or one that resulted in frequent errors. The results demonstrated that infrequent-error learning predominantly relied on nondeclarative, automatic memory processes whereas frequent-error learning predominantly relied on declarative, effortful memory processes: After learning, infrequent-error learners verbalized fewer strategies than frequent-error learners; at transfer, a concurrent, attention-demanding secondary task (tone counting) left motor performance of infrequent-error learners unaffected but impaired that of frequent-error learners. The results showed age-equivalent motor performance in infrequent-error learning but age deficits in frequent-error learning. Motor performance of frequent-error learners required more attention with age, as evidenced by an age deficit on the attention-demanding secondary task. The disappearance of age effects when nondeclarative, automatic memory processes predominated suggests that these processes are preserved with age and are available even early in motor learning.

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

PubMed

Griffiths, Lauren; Higham, Philip A

2018-02-01

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

At the cross-roads: an on-road examination of driving errors at intersections.

PubMed

Young, Kristie L; Salmon, Paul M; Lenné, Michael G

2013-09-01

A significant proportion of road trauma occurs at intersections. Understanding the nature of driving errors at intersections therefore has the potential to lead to significant injury reductions. To further understand how the complexity of modern intersections shapes behaviour of these errors are compared to errors made mid-block, and the role of wider systems failures in intersection error causation is investigated in an on-road study. Twenty-five participants drove a pre-determined urban route incorporating 25 intersections. Two in-vehicle observers recorded the errors made while a range of other data was collected, including driver verbal protocols, video, driver eye glance behaviour and vehicle data (e.g., speed, braking and lane position). Participants also completed a post-trial cognitive task analysis interview. Participants were found to make 39 specific error types, with speeding violations the most common. Participants made significantly more errors at intersections compared to mid-block, with misjudgement, action and perceptual/observation errors more commonly observed at intersections. Traffic signal configuration was found to play a key role in intersection error causation, with drivers making more errors at partially signalised compared to fully signalised intersections. Copyright © 2012 Elsevier Ltd. All rights reserved.

Analysis of the "naming game" with learning errors in communications.

PubMed

Lou, Yang; Chen, Guanrong

2015-07-16

Naming game simulates the process of naming an objective by a population of agents organized in a certain communication network. By pair-wise iterative interactions, the population reaches consensus asymptotically. We study naming game with communication errors during pair-wise conversations, with error rates in a uniform probability distribution. First, a model of naming game with learning errors in communications (NGLE) is proposed. Then, a strategy for agents to prevent learning errors is suggested. To that end, three typical topologies of communication networks, namely random-graph, small-world and scale-free networks, are employed to investigate the effects of various learning errors. Simulation results on these models show that 1) learning errors slightly affect the convergence speed but distinctively increase the requirement for memory of each agent during lexicon propagation; 2) the maximum number of different words held by the population increases linearly as the error rate increases; 3) without applying any strategy to eliminate learning errors, there is a threshold of the learning errors which impairs the convergence. The new findings may help to better understand the role of learning errors in naming game as well as in human language development from a network science perspective.

Effect of MLC leaf position, collimator rotation angle, and gantry rotation angle errors on intensity-modulated radiotherapy plans for nasopharyngeal carcinoma

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

Bai, Sen; Li, Guangjun; Wang, Maojie

The purpose of this study was to investigate the effect of multileaf collimator (MLC) leaf position, collimator rotation angle, and accelerator gantry rotation angle errors on intensity-modulated radiotherapy plans for nasopharyngeal carcinoma. To compare dosimetric differences between the simulating plans and the clinical plans with evaluation parameters, 6 patients with nasopharyngeal carcinoma were selected for simulation of systematic and random MLC leaf position errors, collimator rotation angle errors, and accelerator gantry rotation angle errors. There was a high sensitivity to dose distribution for systematic MLC leaf position errors in response to field size. When the systematic MLC position errors weremore » 0.5, 1, and 2 mm, respectively, the maximum values of the mean dose deviation, observed in parotid glands, were 4.63%, 8.69%, and 18.32%, respectively. The dosimetric effect was comparatively small for systematic MLC shift errors. For random MLC errors up to 2 mm and collimator and gantry rotation angle errors up to 0.5°, the dosimetric effect was negligible. We suggest that quality control be regularly conducted for MLC leaves, so as to ensure that systematic MLC leaf position errors are within 0.5 mm. Because the dosimetric effect of 0.5° collimator and gantry rotation angle errors is negligible, it can be concluded that setting a proper threshold for allowed errors of collimator and gantry rotation angle may increase treatment efficacy and reduce treatment time.« less

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

NASA Technical Reports Server (NTRS)

Barth, Timothy J.

2014-01-01

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

An error analysis perspective for patient alignment systems.

PubMed

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

2013-09-01

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

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

PubMed

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

2016-12-01

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

Exchange-Correlation Effects for Noncovalent Interactions in Density Functional Theory.

PubMed

Otero-de-la-Roza, A; DiLabio, Gino A; Johnson, Erin R

2016-07-12

In this article, we develop an understanding of how errors from exchange-correlation functionals affect the modeling of noncovalent interactions in dispersion-corrected density-functional theory. Computed CCSD(T) reference binding energies for a collection of small-molecule clusters are decomposed via a molecular many-body expansion and are used to benchmark density-functional approximations, including the effect of semilocal approximation, exact-exchange admixture, and range separation. Three sources of error are identified. Repulsion error arises from the choice of semilocal functional approximation. This error affects intermolecular repulsions and is present in all n-body exchange-repulsion energies with a sign that alternates with the order n of the interaction. Delocalization error is independent of the choice of semilocal functional but does depend on the exact exchange fraction. Delocalization error misrepresents the induction energies, leading to overbinding in all induction n-body terms, and underestimates the electrostatic contribution to the 2-body energies. Deformation error affects only monomer relaxation (deformation) energies and behaves similarly to bond-dissociation energy errors. Delocalization and deformation errors affect systems with significant intermolecular orbital interactions (e.g., hydrogen- and halogen-bonded systems), whereas repulsion error is ubiquitous. Many-body errors from the underlying exchange-correlation functional greatly exceed in general the magnitude of the many-body dispersion energy term. A functional built to accurately model noncovalent interactions must contain a dispersion correction, semilocal exchange, and correlation components that minimize the repulsion error independently and must also incorporate exact exchange in such a way that delocalization error is absent.

Using nurses and office staff to report prescribing errors in primary care.

PubMed

Kennedy, Amanda G; Littenberg, Benjamin; Senders, John W

2008-08-01

To implement a prescribing-error reporting system in primary care offices and analyze the reports. Descriptive analysis of a voluntary prescribing-error-reporting system Seven primary care offices in Vermont, USA. One hundred and three prescribers, managers, nurses and office staff. Nurses and office staff were asked to report all communications with community pharmacists regarding prescription problems. All reports were classified by severity category, setting, error mode, prescription domain and error-producing conditions. All practices submitted reports, although reporting decreased by 3.6 reports per month (95% CI, -2.7 to -4.4, P<0.001, by linear regression analysis). Two hundred and sixteen reports were submitted. Nearly 90% (142/165) of errors were severity Category B (errors that did not reach the patient) according to the National Coordinating Council for Medication Error Reporting and Prevention Index for Categorizing Medication Errors. Nineteen errors reached the patient without causing harm (Category C); and 4 errors caused temporary harm requiring intervention (Category E). Errors involving strength were found in 30% of reports, including 23 prescriptions written for strengths not commercially available. Antidepressants, narcotics and antihypertensives were the most frequent drug classes reported. Participants completed an exit survey with a response rate of 84.5% (87/103). Nearly 90% (77/87) of respondents were willing to continue reporting after the study ended, however none of the participants currently submit reports. Nurses and office staff are a valuable resource for reporting prescribing errors. However, without ongoing reminders, the reporting system is not sustainable.

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

PubMed

Styck, Kara M; Walsh, Shana M

2016-01-01

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

Information systems and human error in the lab.

PubMed

Bissell, Michael G

2004-01-01

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

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

PubMed

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

2018-05-01

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

Moments and Root-Mean-Square Error of the Bayesian MMSE Estimator of Classification Error in the Gaussian Model.

PubMed

Zollanvari, Amin; Dougherty, Edward R

2014-06-01

The most important aspect of any classifier is its error rate, because this quantifies its predictive capacity. Thus, the accuracy of error estimation is critical. Error estimation is problematic in small-sample classifier design because the error must be estimated using the same data from which the classifier has been designed. Use of prior knowledge, in the form of a prior distribution on an uncertainty class of feature-label distributions to which the true, but unknown, feature-distribution belongs, can facilitate accurate error estimation (in the mean-square sense) in circumstances where accurate completely model-free error estimation is impossible. This paper provides analytic asymptotically exact finite-sample approximations for various performance metrics of the resulting Bayesian Minimum Mean-Square-Error (MMSE) error estimator in the case of linear discriminant analysis (LDA) in the multivariate Gaussian model. These performance metrics include the first, second, and cross moments of the Bayesian MMSE error estimator with the true error of LDA, and therefore, the Root-Mean-Square (RMS) error of the estimator. We lay down the theoretical groundwork for Kolmogorov double-asymptotics in a Bayesian setting, which enables us to derive asymptotic expressions of the desired performance metrics. From these we produce analytic finite-sample approximations and demonstrate their accuracy via numerical examples. Various examples illustrate the behavior of these approximations and their use in determining the necessary sample size to achieve a desired RMS. The Supplementary Material contains derivations for some equations and added figures.

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

PubMed

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

2015-02-01

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

Experimental investigation of false positive errors in auditory species occurrence surveys

USGS Publications Warehouse

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.

Is there any electrophysiological evidence for subliminal error processing?

PubMed Central

Shalgi, Shani; Deouell, Leon Y.

2013-01-01

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

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

PubMed

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

2005-08-01

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

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

PubMed

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

2018-05-08

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

Disclosing Medical Errors to Patients: Attitudes and Practices of Physicians and Trainees

PubMed Central

Jones, Elizabeth W.; Wu, Barry J.; Forman-Hoffman, Valerie L.; Levi, Benjamin H.; Rosenthal, Gary E.

2007-01-01

BACKGROUND Disclosing errors to patients is an important part of patient care, but the prevalence of disclosure, and factors affecting it, are poorly understood. OBJECTIVE To survey physicians and trainees about their practices and attitudes regarding error disclosure to patients. DESIGN AND PARTICIPANTS Survey of faculty physicians, resident physicians, and medical students in Midwest, Mid-Atlantic, and Northeast regions of the United States. MEASUREMENTS Actual error disclosure; hypothetical error disclosure; attitudes toward disclosure; demographic factors. RESULTS Responses were received from 538 participants (response rate = 77%). Almost all faculty and residents responded that they would disclose a hypothetical error resulting in minor (97%) or major (93%) harm to a patient. However, only 41% of faculty and residents had disclosed an actual minor error (resulting in prolonged treatment or discomfort), and only 5% had disclosed an actual major error (resulting in disability or death). Moreover, 19% acknowledged not disclosing an actual minor error and 4% acknowledged not disclosing an actual major error. Experience with malpractice litigation was not associated with less actual or hypothetical error disclosure. Faculty were more likely than residents and students to disclose a hypothetical error and less concerned about possible negative consequences of disclosure. Several attitudes were associated with greater likelihood of hypothetical disclosure, including the belief that disclosure is right even if it comes at a significant personal cost. CONCLUSIONS There appears to be a gap between physicians’ attitudes and practices regarding error disclosure. Willingness to disclose errors was associated with higher training level and a variety of patient-centered attitudes, and it was not lessened by previous exposure to malpractice litigation. PMID:17473944

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

NASA Technical Reports Server (NTRS)

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

2006-01-01

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

The qualitative problem of major quotation errors, as illustrated by 10 different examples in the headache literature.

PubMed

Tfelt-Hansen, Peer

2015-03-01

There are two types of errors when references are used in the scientific literature: citation errors and quotation errors, and these errors have in reviews mainly been evaluated quantitatively. Quotation errors are the major problem, and 1 review reported 6% major quotation errors. The objective of this listing of quotation errors is to illustrate by qualitative analysis of different types of 10 major quotation errors how and possibly why authors misquote references. The author selected for review the first 10 different consecutive major quotation errors encountered from his reading of the headache literature. The characteristics of the 10 quotation errors ranged considerably. Thus, in a review of migraine therapy in a very prestigious medical journal, the superiority of a new treatment (sumatriptan) vs an old treatment (aspirin plus metoclopramide) was claimed despite no significant difference for the primary efficacy measure in the trial. One author, in a scientific debate, referred to the lack of dilation of the middle meningeal artery in spontaneous migraine despite the fact that only 1 migraine attack was studied. The possibility for creative major quotation errors in the medical literature is most likely infinite. Qualitative evaluations, as the present, of major quotation errors will hopefully result in more general awareness of quotation problems in the medical literature. Even if the final responsibility for correct use of quotations is with the authors, the referees, the experts with the knowledge needed to spot quotation errors, should be more involved in ensuring correct and fair use of references. Finally, this paper suggests that major misleading quotations, if pointed out by readers of the journal, should, as a rule, be corrected by way of an erratum statement. © 2015 American Headache Society.

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

PubMed Central

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

2007-01-01

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

Claims, errors, and compensation payments in medical malpractice litigation.

PubMed

Studdert, David M; Mello, Michelle M; Gawande, Atul A; Gandhi, Tejal K; Kachalia, Allen; Yoon, Catherine; Puopolo, Ann Louise; Brennan, Troyen A

2006-05-11

In the current debate over tort reform, critics of the medical malpractice system charge that frivolous litigation--claims that lack evidence of injury, substandard care, or both--is common and costly. Trained physicians reviewed a random sample of 1452 closed malpractice claims from five liability insurers to determine whether a medical injury had occurred and, if so, whether it was due to medical error. We analyzed the prevalence, characteristics, litigation outcomes, and costs of claims that lacked evidence of error. For 3 percent of the claims, there were no verifiable medical injuries, and 37 percent did not involve errors. Most of the claims that were not associated with errors (370 of 515 [72 percent]) or injuries (31 of 37 [84 percent]) did not result in compensation; most that involved injuries due to error did (653 of 889 [73 percent]). Payment of claims not involving errors occurred less frequently than did the converse form of inaccuracy--nonpayment of claims associated with errors. When claims not involving errors were compensated, payments were significantly lower on average than were payments for claims involving errors (313,205 dollars vs. 521,560 dollars, P=0.004). Overall, claims not involving errors accounted for 13 to 16 percent of the system's total monetary costs. For every dollar spent on compensation, 54 cents went to administrative expenses (including those involving lawyers, experts, and courts). Claims involving errors accounted for 78 percent of total administrative costs. Claims that lack evidence of error are not uncommon, but most are denied compensation. The vast majority of expenditures go toward litigation over errors and payment of them. The overhead costs of malpractice litigation are exorbitant. Copyright 2006 Massachusetts Medical Society.

A national physician survey of diagnostic error in paediatrics.

PubMed

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

2016-10-01

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

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

PubMed

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

2016-11-25

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

Visuomotor adaptation needs a validation of prediction error by feedback error

PubMed Central

Gaveau, Valérie; Prablanc, Claude; Laurent, Damien; Rossetti, Yves; Priot, Anne-Emmanuelle

2014-01-01

The processes underlying short-term plasticity induced by visuomotor adaptation to a shifted visual field are still debated. Two main sources of error can induce motor adaptation: reaching feedback errors, which correspond to visually perceived discrepancies between hand and target positions, and errors between predicted and actual visual reafferences of the moving hand. These two sources of error are closely intertwined and difficult to disentangle, as both the target and the reaching limb are simultaneously visible. Accordingly, the goal of the present study was to clarify the relative contributions of these two types of errors during a pointing task under prism-displaced vision. In “terminal feedback error” condition, viewing of their hand by subjects was allowed only at movement end, simultaneously with viewing of the target. In “movement prediction error” condition, viewing of the hand was limited to movement duration, in the absence of any visual target, and error signals arose solely from comparisons between predicted and actual reafferences of the hand. In order to prevent intentional corrections of errors, a subthreshold, progressive stepwise increase in prism deviation was used, so that subjects remained unaware of the visual deviation applied in both conditions. An adaptive aftereffect was observed in the “terminal feedback error” condition only. As far as subjects remained unaware of the optical deviation and self-assigned pointing errors, prediction error alone was insufficient to induce adaptation. These results indicate a critical role of hand-to-target feedback error signals in visuomotor adaptation; consistent with recent neurophysiological findings, they suggest that a combination of feedback and prediction error signals is necessary for eliciting aftereffects. They also suggest that feedback error updates the prediction of reafferences when a visual perturbation is introduced gradually and cognitive factors are eliminated or strongly attenuated. PMID:25408644

Error decomposition and estimation of inherent optical properties.

PubMed

Salama, Mhd Suhyb; Stein, Alfred

2009-09-10

We describe a methodology to quantify and separate the errors of inherent optical properties (IOPs) derived from ocean-color model inversion. Their total error is decomposed into three different sources, namely, model approximations and inversion, sensor noise, and atmospheric correction. Prior information on plausible ranges of observation, sensor noise, and inversion goodness-of-fit are employed to derive the posterior probability distribution of the IOPs. The relative contribution of each error component to the total error budget of the IOPs, all being of stochastic nature, is then quantified. The method is validated with the International Ocean Colour Coordinating Group (IOCCG) data set and the NASA bio-Optical Marine Algorithm Data set (NOMAD). The derived errors are close to the known values with correlation coefficients of 60-90% and 67-90% for IOCCG and NOMAD data sets, respectively. Model-induced errors inherent to the derived IOPs are between 10% and 57% of the total error, whereas atmospheric-induced errors are in general above 43% and up to 90% for both data sets. The proposed method is applied to synthesized and in situ measured populations of IOPs. The mean relative errors of the derived values are between 2% and 20%. A specific error table to the Medium Resolution Imaging Spectrometer (MERIS) sensor is constructed. It serves as a benchmark to evaluate the performance of the atmospheric correction method and to compute atmospheric-induced errors. Our method has a better performance and is more appropriate to estimate actual errors of ocean-color derived products than the previously suggested methods. Moreover, it is generic and can be applied to quantify the error of any derived biogeophysical parameter regardless of the used derivation.

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

PubMed Central

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

2018-01-01

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

Sensitivity and specificity of dosing alerts for dosing errors among hospitalized pediatric patients

PubMed Central

Stultz, Jeremy S; Porter, Kyle; Nahata, Milap C

2014-01-01

Objectives To determine the sensitivity and specificity of a dosing alert system for dosing errors and to compare the sensitivity of a proprietary system with and without institutional customization at a pediatric hospital. Methods A retrospective analysis of medication orders, orders causing dosing alerts, reported adverse drug events, and dosing errors during July, 2011 was conducted. Dosing errors with and without alerts were identified and the sensitivity of the system with and without customization was compared. Results There were 47 181 inpatient pediatric orders during the studied period; 257 dosing errors were identified (0.54%). The sensitivity of the system for identifying dosing errors was 54.1% (95% CI 47.8% to 60.3%) if customization had not occurred and increased to 60.3% (CI 54.0% to 66.3%) with customization (p=0.02). The sensitivity of the system for underdoses was 49.6% without customization and 60.3% with customization (p=0.01). Specificity of the customized system for dosing errors was 96.2% (CI 96.0% to 96.3%) with a positive predictive value of 8.0% (CI 6.8% to 9.3). All dosing errors had an alert over-ridden by the prescriber and 40.6% of dosing errors with alerts were administered to the patient. The lack of indication-specific dose ranges was the most common reason why an alert did not occur for a dosing error. Discussion Advances in dosing alert systems should aim to improve the sensitivity and positive predictive value of the system for dosing errors. Conclusions The dosing alert system had a low sensitivity and positive predictive value for dosing errors, but might have prevented dosing errors from reaching patients. Customization increased the sensitivity of the system for dosing errors. PMID:24496386

Error-Transparent Quantum Gates for Small Logical Qubit Architectures

NASA Astrophysics Data System (ADS)

Kapit, Eliot

2018-02-01

One of the largest obstacles to building a quantum computer is gate error, where the physical evolution of the state of a qubit or group of qubits during a gate operation does not match the intended unitary transformation. Gate error stems from a combination of control errors and random single qubit errors from interaction with the environment. While great strides have been made in mitigating control errors, intrinsic qubit error remains a serious problem that limits gate fidelity in modern qubit architectures. Simultaneously, recent developments of small error-corrected logical qubit devices promise significant increases in logical state lifetime, but translating those improvements into increases in gate fidelity is a complex challenge. In this Letter, we construct protocols for gates on and between small logical qubit devices which inherit the parent device's tolerance to single qubit errors which occur at any time before or during the gate. We consider two such devices, a passive implementation of the three-qubit bit flip code, and the author's own [E. Kapit, Phys. Rev. Lett. 116, 150501 (2016), 10.1103/PhysRevLett.116.150501] very small logical qubit (VSLQ) design, and propose error-tolerant gate sets for both. The effective logical gate error rate in these models displays superlinear error reduction with linear increases in single qubit lifetime, proving that passive error correction is capable of increasing gate fidelity. Using a standard phenomenological noise model for superconducting qubits, we demonstrate a realistic, universal one- and two-qubit gate set for the VSLQ, with error rates an order of magnitude lower than those for same-duration operations on single qubits or pairs of qubits. These developments further suggest that incorporating small logical qubits into a measurement based code could substantially improve code performance.

Clinical review: Medication errors in critical care

PubMed Central

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

2008-01-01

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

Frequency of pediatric medication administration errors and contributing factors.

PubMed

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

2011-01-01

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

Medication errors: an overview for clinicians.

PubMed

Wittich, Christopher M; Burkle, Christopher M; Lanier, William L

2014-08-01

Medication error is an important cause of patient morbidity and mortality, yet it can be a confusing and underappreciated concept. This article provides a review for practicing physicians that focuses on medication error (1) terminology and definitions, (2) incidence, (3) risk factors, (4) avoidance strategies, and (5) disclosure and legal consequences. A medication error is any error that occurs at any point in the medication use process. It has been estimated by the Institute of Medicine that medication errors cause 1 of 131 outpatient and 1 of 854 inpatient deaths. Medication factors (eg, similar sounding names, low therapeutic index), patient factors (eg, poor renal or hepatic function, impaired cognition, polypharmacy), and health care professional factors (eg, use of abbreviations in prescriptions and other communications, cognitive biases) can precipitate medication errors. Consequences faced by physicians after medication errors can include loss of patient trust, civil actions, criminal charges, and medical board discipline. Methods to prevent medication errors from occurring (eg, use of information technology, better drug labeling, and medication reconciliation) have been used with varying success. When an error is discovered, patients expect disclosure that is timely, given in person, and accompanied with an apology and communication of efforts to prevent future errors. Learning more about medication errors may enhance health care professionals' ability to provide safe care to their patients. Copyright © 2014 Mayo Foundation for Medical Education and Research. Published by Elsevier Inc. All rights reserved.

Improving patient safety through quality assurance.

PubMed

Raab, Stephen S

2006-05-01

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

It Pays to Go Off-Track: Practicing with Error-Augmenting Haptic Feedback Facilitates Learning of a Curve-Tracing Task

PubMed Central

Williams, Camille K.; Tremblay, Luc; Carnahan, Heather

2016-01-01

Researchers in the domain of haptic training are now entering the long-standing debate regarding whether or not it is best to learn a skill by experiencing errors. Haptic training paradigms provide fertile ground for exploring how various theories about feedback, errors and physical guidance intersect during motor learning. Our objective was to determine how error minimizing, error augmenting and no haptic feedback while learning a self-paced curve-tracing task impact performance on delayed (1 day) retention and transfer tests, which indicate learning. We assessed performance using movement time and tracing error to calculate a measure of overall performance – the speed accuracy cost function. Our results showed that despite exhibiting the worst performance during skill acquisition, the error augmentation group had significantly better accuracy (but not overall performance) than the error minimization group on delayed retention and transfer tests. The control group’s performance fell between that of the two experimental groups but was not significantly different from either on the delayed retention test. We propose that the nature of the task (requiring online feedback to guide performance) coupled with the error augmentation group’s frequent off-target experience and rich experience of error-correction promoted information processing related to error-detection and error-correction that are essential for motor learning. PMID:28082937

Research on Measurement Accuracy of Laser Tracking System Based on Spherical Mirror with Rotation Errors of Gimbal Mount Axes

NASA Astrophysics Data System (ADS)

Shi, Zhaoyao; Song, Huixu; Chen, Hongfang; Sun, Yanqiang

2018-02-01

This paper presents a novel experimental approach for confirming that spherical mirror of a laser tracking system can reduce the influences of rotation errors of gimbal mount axes on the measurement accuracy. By simplifying the optical system model of laser tracking system based on spherical mirror, we can easily extract the laser ranging measurement error caused by rotation errors of gimbal mount axes with the positions of spherical mirror, biconvex lens, cat's eye reflector, and measuring beam. The motions of polarization beam splitter and biconvex lens along the optical axis and vertical direction of optical axis are driven by error motions of gimbal mount axes. In order to simplify the experimental process, the motion of biconvex lens is substituted by the motion of spherical mirror according to the principle of relative motion. The laser ranging measurement error caused by the rotation errors of gimbal mount axes could be recorded in the readings of laser interferometer. The experimental results showed that the laser ranging measurement error caused by rotation errors was less than 0.1 μm if radial error motion and axial error motion were within ±10 μm. The experimental method simplified the experimental procedure and the spherical mirror could reduce the influences of rotation errors of gimbal mount axes on the measurement accuracy of the laser tracking system.

Medication errors reported to the National Medication Error Reporting System in Malaysia: a 4-year retrospective review (2009 to 2012).

PubMed

Samsiah, A; Othman, Noordin; Jamshed, Shazia; Hassali, Mohamed Azmi; Wan-Mohaina, W M

2016-12-01

Reporting and analysing the data on medication errors (MEs) is important and contributes to a better understanding of the error-prone environment. This study aims to examine the characteristics of errors submitted to the National Medication Error Reporting System (MERS) in Malaysia. A retrospective review of reports received from 1 January 2009 to 31 December 2012 was undertaken. Descriptive statistics method was applied. A total of 17,357 MEs reported were reviewed. The majority of errors were from public-funded hospitals. Near misses were classified in 86.3 % of the errors. The majority of errors (98.1 %) had no harmful effects on the patients. Prescribing contributed to more than three-quarters of the overall errors (76.1 %). Pharmacists detected and reported the majority of errors (92.1 %). Cases of erroneous dosage or strength of medicine (30.75 %) were the leading type of error, whilst cardiovascular (25.4 %) was the most common category of drug found. MERS provides rich information on the characteristics of reported MEs. Low contribution to reporting from healthcare facilities other than government hospitals and non-pharmacists requires further investigation. Thus, a feasible approach to promote MERS among healthcare providers in both public and private sectors needs to be formulated and strengthened. Preventive measures to minimise MEs should be directed to improve prescribing competency among the fallible prescribers identified.

Errors and conflict at the task level and the response level.

PubMed

Desmet, Charlotte; Fias, Wim; Hartstra, Egbert; Brass, Marcel

2011-01-26

In the last decade, research on error and conflict processing has become one of the most influential research areas in the domain of cognitive control. There is now converging evidence that a specific part of the posterior frontomedian cortex (pFMC), the rostral cingulate zone (RCZ), is crucially involved in the processing of errors and conflict. However, error-related research has focused primarily on a specific error type, namely, response errors. The aim of the present study was to investigate whether errors on the task level rely on the same neural and functional mechanisms. Here we report a dissociation of both error types in the pFMC: whereas response errors activate the RCZ, task errors activate the dorsal frontomedian cortex. Although this last region shows an overlap in activation for task and response errors on the group level, a closer inspection of the single-subject data is more in accordance with a functional anatomical dissociation. When investigating brain areas related to conflict on the task and response levels, a clear dissociation was perceived between areas associated with response conflict and with task conflict. Overall, our data support a dissociation between response and task levels of processing in the pFMC. In addition, we provide additional evidence for a dissociation between conflict and errors both at the response level and at the task level.

IMRT QA: Selecting gamma criteria based on error detection sensitivity

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

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

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

Is Comprehension Necessary for Error Detection? A Conflict-Based Account of Monitoring in Speech Production

ERIC Educational Resources Information Center

Nozari, Nazbanou; Dell, Gary S.; Schwartz, Myrna F.

2011-01-01

Despite the existence of speech errors, verbal communication is successful because speakers can detect (and correct) their errors. The standard theory of speech-error detection, the perceptual-loop account, posits that the comprehension system monitors production output for errors. Such a comprehension-based monitor, however, cannot explain the…

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…

Error-Related Psychophysiology and Negative Affect

ERIC Educational Resources Information Center

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

2004-01-01

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

Annotation of Korean Learner Corpora for Particle Error Detection

ERIC Educational Resources Information Center

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

2009-01-01

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

Effects of Correlated Errors on the Analysis of Space Geodetic Data

NASA Technical Reports Server (NTRS)

Romero-Wolf, Andres; Jacobs, C. S.

2011-01-01

As thermal errors are reduced instrumental and troposphere correlated errors will increasingly become more important. Work in progress shows that troposphere covariance error models improve data analysis results. We expect to see stronger effects with higher data rates. Temperature modeling of delay errors may further reduce temporal correlations in the data.

The Perception of Error in Production Plants of a Chemical Organisation

ERIC Educational Resources Information Center

Seifried, Jurgen; Hopfer, Eva

2013-01-01

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

Diagnostic Errors in Ambulatory Care: Dimensions and Preventive Strategies

ERIC Educational Resources Information Center

Singh, Hardeep; Weingart, Saul N.

2009-01-01

Despite an increasing focus on patient safety in ambulatory care, progress in understanding and reducing diagnostic errors in this setting lag behind many other safety concerns such as medication errors. To explore the extent and nature of diagnostic errors in ambulatory care, we identified five dimensions of ambulatory care from which errors may…

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

PubMed

Philippoff, Joanna; Baumgartner, Erin

2016-03-01

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

Impacts of motivational valence on the error-related negativity elicited by full and partial errors.

PubMed

Maruo, Yuya; Schacht, Annekathrin; Sommer, Werner; Masaki, Hiroaki

2016-02-01

Affect and motivation influence the error-related negativity (ERN) elicited by full errors; however, it is unknown whether they also influence ERNs to correct responses accompanied by covert incorrect response activation (partial errors). Here we compared a neutral condition with conditions, where correct responses were rewarded or where incorrect responses were punished with gains and losses of small amounts of money, respectively. Data analysis distinguished ERNs elicited by full and partial errors. In the reward and punishment conditions, ERN amplitudes to both full and partial errors were larger than in the neutral condition, confirming participants' sensitivity to the significance of errors. We also investigated the relationships between ERN amplitudes and the behavioral inhibition and activation systems (BIS/BAS). Regardless of reward/punishment condition, participants scoring higher on BAS showed smaller ERN amplitudes in full error trials. These findings provide further evidence that the ERN is related to motivational valence and that similar relationships hold for both full and partial errors. Copyright © 2015 The Authors. Published by Elsevier B.V. All rights reserved.

Distributions in the error space: goal-directed movements described in time and state-space representations.

PubMed

Fisher, Moria E; Huang, Felix C; Wright, Zachary A; Patton, James L

2014-01-01

Manipulation of error feedback has been of great interest to recent studies in motor control and rehabilitation. Typically, motor adaptation is shown as a change in performance with a single scalar metric for each trial, yet such an approach might overlook details about how error evolves through the movement. We believe that statistical distributions of movement error through the extent of the trajectory can reveal unique patterns of adaption and possibly reveal clues to how the motor system processes information about error. This paper describes different possible ordinate domains, focusing on representations in time and state-space, used to quantify reaching errors. We hypothesized that the domain with the lowest amount of variability would lead to a predictive model of reaching error with the highest accuracy. Here we showed that errors represented in a time domain demonstrate the least variance and allow for the highest predictive model of reaching errors. These predictive models will give rise to more specialized methods of robotic feedback and improve previous techniques of error augmentation.

Diffraction analysis of sidelobe characteristics of optical elements with ripple error

NASA Astrophysics Data System (ADS)

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

2018-03-01

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

Blood transfusion sampling and a greater role for error recovery.

PubMed

Oldham, Jane

Patient identification errors in pre-transfusion blood sampling ('wrong blood in tube') are a persistent area of risk. These errors can potentially result in life-threatening complications. Current measures to address root causes of incidents and near misses have not resolved this problem and there is a need to look afresh at this issue. PROJECT PURPOSE: This narrative review of the literature is part of a wider system-improvement project designed to explore and seek a better understanding of the factors that contribute to transfusion sampling error as a prerequisite to examining current and potential approaches to error reduction. A broad search of the literature was undertaken to identify themes relating to this phenomenon. KEY DISCOVERIES: Two key themes emerged from the literature. Firstly, despite multi-faceted causes of error, the consistent element is the ever-present potential for human error. Secondly, current focus on error prevention could potentially be augmented with greater attention to error recovery. Exploring ways in which clinical staff taking samples might learn how to better identify their own errors is proposed to add to current safety initiatives.

The ethics and practical importance of defining, distinguishing and disclosing nursing errors: a discussion paper.

PubMed

Johnstone, Megan-Jane; Kanitsaki, Olga

2006-03-01

Nurses globally are required and expected to report nursing errors. As is clearly demonstrated in the international literature, fulfilling this requirement is not, however, without risks. In this discussion paper, the notion of 'nursing error', the practical and moral importance of defining, distinguishing and disclosing nursing errors and how a distinct definition of 'nursing error' fits with the new 'system approach' to human-error management in health care are critiqued. Drawing on international literature and two key case exemplars from the USA and Australia, arguments are advanced to support the view that although it is 'right' for nurses to report nursing errors, it will be very difficult for them to do so unless a non-punitive approach to nursing-error management is adopted.

Error Discounting in Probabilistic Category Learning

PubMed Central

Craig, Stewart; Lewandowsky, Stephan; Little, Daniel R.

2011-01-01

Some current theories of probabilistic categorization assume that people gradually attenuate their learning in response to unavoidable error. However, existing evidence for this error discounting is sparse and open to alternative interpretations. We report two probabilistic-categorization experiments that investigated error discounting by shifting feedback probabilities to new values after different amounts of training. In both experiments, responding gradually became less responsive to errors, and learning was slowed for some time after the feedback shift. Both results are indicative of error discounting. Quantitative modeling of the data revealed that adding a mechanism for error discounting significantly improved the fits of an exemplar-based and a rule-based associative learning model, as well as of a recency-based model of categorization. We conclude that error discounting is an important component of probabilistic learning. PMID:21355666

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

PubMed

Alderete, John; Davies, Monica

2018-04-01

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

Radar error statistics for the space shuttle

NASA Technical Reports Server (NTRS)

Lear, W. M.

1979-01-01

Radar error statistics of C-band and S-band that are recommended for use with the groundtracking programs to process space shuttle tracking data are presented. The statistics are divided into two parts: bias error statistics, using the subscript B, and high frequency error statistics, using the subscript q. Bias errors may be slowly varying to constant. High frequency random errors (noise) are rapidly varying and may or may not be correlated from sample to sample. Bias errors were mainly due to hardware defects and to errors in correction for atmospheric refraction effects. High frequency noise was mainly due to hardware and due to atmospheric scintillation. Three types of atmospheric scintillation were identified: horizontal, vertical, and line of sight. This was the first time that horizontal and line of sight scintillations were identified.

Analysis of the impact of error detection on computer performance

NASA Technical Reports Server (NTRS)

Shin, K. C.; Lee, Y. H.

1983-01-01

Conventionally, reliability analyses either assume that a fault/error is detected immediately following its occurrence, or neglect damages caused by latent errors. Though unrealistic, this assumption was imposed in order to avoid the difficulty of determining the respective probabilities that a fault induces an error and the error is then detected in a random amount of time after its occurrence. As a remedy for this problem a model is proposed to analyze the impact of error detection on computer performance under moderate assumptions. Error latency, the time interval between occurrence and the moment of detection, is used to measure the effectiveness of a detection mechanism. This model is used to: (1) predict the probability of producing an unreliable result, and (2) estimate the loss of computation due to fault and/or error.

An investigation of error characteristics and coding performance

NASA Technical Reports Server (NTRS)

Ebel, William J.; Ingels, Frank M.

1993-01-01

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

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

PubMed Central

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

2015-01-01

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

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

NASA Astrophysics Data System (ADS)

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

2018-03-01

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

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

NASA Astrophysics Data System (ADS)

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

2018-03-01

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

Errors in radiation oncology: A study in pathways and dosimetric impact

PubMed Central

Drzymala, Robert E.; Purdy, James A.; Michalski, Jeff

2005-01-01

As complexity for treating patients increases, so does the risk of error. Some publications have suggested that record and verify (R&V) systems may contribute in propagating errors. Direct data transfer has the potential to eliminate most, but not all, errors. And although the dosimetric consequences may be obvious in some cases, a detailed study does not exist. In this effort, we examined potential errors in terms of scenarios, pathways of occurrence, and dosimetry. Our goal was to prioritize error prevention according to likelihood of event and dosimetric impact. For conventional photon treatments, we investigated errors of incorrect source‐to‐surface distance (SSD), energy, omitted wedge (physical, dynamic, or universal) or compensating filter, incorrect wedge or compensating filter orientation, improper rotational rate for arc therapy, and geometrical misses due to incorrect gantry, collimator or table angle, reversed field settings, and setup errors. For electron beam therapy, errors investigated included incorrect energy, incorrect SSD, along with geometric misses. For special procedures we examined errors for total body irradiation (TBI, incorrect field size, dose rate, treatment distance) and LINAC radiosurgery (incorrect collimation setting, incorrect rotational parameters). Likelihood of error was determined and subsequently rated according to our history of detecting such errors. Dosimetric evaluation was conducted by using dosimetric data, treatment plans, or measurements. We found geometric misses to have the highest error probability. They most often occurred due to improper setup via coordinate shift errors or incorrect field shaping. The dosimetric impact is unique for each case and depends on the proportion of fields in error and volume mistreated. These errors were short‐lived due to rapid detection via port films. The most significant dosimetric error was related to a reversed wedge direction. This may occur due to incorrect collimator angle or wedge orientation. For parallel‐opposed 60° wedge fields, this error could be as high as 80% to a point off‐axis. Other examples of dosimetric impact included the following: SSD, ~2%/cm for photons or electrons; photon energy (6 MV vs. 18 MV), on average 16% depending on depth, electron energy, ~0.5cm of depth coverage per MeV (mega‐electron volt). Of these examples, incorrect distances were most likely but rapidly detected by in vivo dosimetry. Errors were categorized by occurrence rate, methods and timing of detection, longevity, and dosimetric impact. Solutions were devised according to these criteria. To date, no one has studied the dosimetric impact of global errors in radiation oncology. Although there is heightened awareness that with increased use of ancillary devices and automation, there must be a parallel increase in quality check systems and processes, errors do and will continue to occur. This study has helped us identify and prioritize potential errors in our clinic according to frequency and dosimetric impact. For example, to reduce the use of an incorrect wedge direction, our clinic employs off‐axis in vivo dosimetry. To avoid a treatment distance setup error, we use both vertical table settings and optical distance indicator (ODI) values to properly set up fields. As R&V systems become more automated, more accurate and efficient data transfer will occur. This will require further analysis. Finally, we have begun examining potential intensity‐modulated radiation therapy (IMRT) errors according to the same criteria. PACS numbers: 87.53.Xd, 87.53.St PMID:16143793

Medical errors; causes, consequences, emotional response and resulting behavioral change

PubMed Central

Bari, Attia; Khan, Rehan Ahmed; Rathore, Ahsan Waheed

2016-01-01

Objective: To determine the causes of medical errors, the emotional and behavioral response of pediatric medicine residents to their medical errors and to determine their behavior change affecting their future training. Methods: One hundred thirty postgraduate residents were included in the study. Residents were asked to complete questionnaire about their errors and responses to their errors in three domains: emotional response, learning behavior and disclosure of the error. The names of the participants were kept confidential. Data was analyzed using SPSS version 20. Results: A total of 130 residents were included. Majority 128(98.5%) of these described some form of error. Serious errors that occurred were 24(19%), 63(48%) minor, 24(19%) near misses,2(2%) never encountered an error and 17(12%) did not mention type of error but mentioned causes and consequences. Only 73(57%) residents disclosed medical errors to their senior physician but disclosure to patient’s family was negligible 15(11%). Fatigue due to long duty hours 85(65%), inadequate experience 66(52%), inadequate supervision 58(48%) and complex case 58(45%) were common causes of medical errors. Negative emotions were common and were significantly associated with lack of knowledge (p=0.001), missing warning signs (p=<0.001), not seeking advice (p=0.003) and procedural complications (p=0.001). Medical errors had significant impact on resident’s behavior; 119(93%) residents became more careful, increased advice seeking from seniors 109(86%) and 109(86%) started paying more attention to details. Intrinsic causes of errors were significantly associated with increased information seeking behavior and vigilance (p=0.003) and (p=0.01) respectively. Conclusion: Medical errors committed by residents have inadequate disclosure to senior physicians and result in negative emotions but there was positive change in their behavior, which resulted in improvement in their future training and patient care. PMID:27375682

Barriers to medication error reporting among hospital nurses.

PubMed

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

2018-03-01

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

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

PubMed

Boyd, Janice D; Brightsmith, Donald J

2013-01-01

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

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

PubMed

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

2016-01-01

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

The prediction of satellite ephemeris errors as they result from surveillance system measurement errors

NASA Astrophysics Data System (ADS)

Simmons, B. E.

1981-08-01

This report derives equations predicting satellite ephemeris error as a function of measurement errors of space-surveillance sensors. These equations lend themselves to rapid computation with modest computer resources. They are applicable over prediction times such that measurement errors, rather than uncertainties of atmospheric drag and of Earth shape, dominate in producing ephemeris error. This report describes the specialization of these equations underlying the ANSER computer program, SEEM (Satellite Ephemeris Error Model). The intent is that this report be of utility to users of SEEM for interpretive purposes, and to computer programmers who may need a mathematical point of departure for limited generalization of SEEM.

Simultaneous treatment of unspecified heteroskedastic model error distribution and mismeasured covariates for restricted moment models.

PubMed

Garcia, Tanya P; Ma, Yanyuan

2017-10-01

We develop consistent and efficient estimation of parameters in general regression models with mismeasured covariates. We assume the model error and covariate distributions are unspecified, and the measurement error distribution is a general parametric distribution with unknown variance-covariance. We construct root- n consistent, asymptotically normal and locally efficient estimators using the semiparametric efficient score. We do not estimate any unknown distribution or model error heteroskedasticity. Instead, we form the estimator under possibly incorrect working distribution models for the model error, error-prone covariate, or both. Empirical results demonstrate robustness to different incorrect working models in homoscedastic and heteroskedastic models with error-prone covariates.

A function space approach to smoothing with applications to model error estimation for flexible spacecraft control

NASA Technical Reports Server (NTRS)

Rodriguez, G.

1981-01-01

A function space approach to smoothing is used to obtain a set of model error estimates inherent in a reduced-order model. By establishing knowledge of inevitable deficiencies in the truncated model, the error estimates provide a foundation for updating the model and thereby improving system performance. The function space smoothing solution leads to a specification of a method for computation of the model error estimates and development of model error analysis techniques for comparison between actual and estimated errors. The paper summarizes the model error estimation approach as well as an application arising in the area of modeling for spacecraft attitude control.

Model error estimation for distributed systems described by elliptic equations

NASA Technical Reports Server (NTRS)

Rodriguez, G.

1983-01-01

A function space approach is used to develop a theory for estimation of the errors inherent in an elliptic partial differential equation model for a distributed parameter system. By establishing knowledge of the inevitable deficiencies in the model, the error estimates provide a foundation for updating the model. The function space solution leads to a specification of a method for computation of the model error estimates and development of model error analysis techniques for comparison between actual and estimated errors. The paper summarizes the model error estimation approach as well as an application arising in the area of modeling for static shape determination of large flexible systems.

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

PubMed

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

2015-01-01

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

Critical older driver errors in a national sample of serious U.S. crashes.

PubMed

Cicchino, Jessica B; McCartt, Anne T

2015-07-01

Older drivers are at increased risk of crash involvement per mile traveled. The purpose of this study was to examine older driver errors in serious crashes to determine which errors are most prevalent. The National Highway Traffic Safety Administration's National Motor Vehicle Crash Causation Survey collected in-depth, on-scene data for a nationally representative sample of 5470 U.S. police-reported passenger vehicle crashes during 2005-2007 for which emergency medical services were dispatched. There were 620 crashes involving 647 drivers aged 70 and older, representing 250,504 crash-involved older drivers. The proportion of various critical errors made by drivers aged 70 and older were compared with those made by drivers aged 35-54. Driver error was the critical reason for 97% of crashes involving older drivers. Among older drivers who made critical errors, the most common were inadequate surveillance (33%) and misjudgment of the length of a gap between vehicles or of another vehicle's speed, illegal maneuvers, medical events, and daydreaming (6% each). Inadequate surveillance (33% vs. 22%) and gap or speed misjudgment errors (6% vs. 3%) were more prevalent among older drivers than middle-aged drivers. Seventy-one percent of older drivers' inadequate surveillance errors were due to looking and not seeing another vehicle or failing to see a traffic control rather than failing to look, compared with 40% of inadequate surveillance errors among middle-aged drivers. About two-thirds (66%) of older drivers' inadequate surveillance errors and 77% of their gap or speed misjudgment errors were made when turning left at intersections. When older drivers traveled off the edge of the road or traveled over the lane line, this was most commonly due to non-performance errors such as medical events (51% and 44%, respectively), whereas middle-aged drivers were involved in these crash types for other reasons. Gap or speed misjudgment errors and inadequate surveillance errors were significantly more prevalent among female older drivers than among female middle-aged drivers, but the prevalence of these errors did not differ significantly between older and middle-aged male drivers. These errors comprised 51% of errors among older female drivers but only 31% among older male drivers. Efforts to reduce older driver crash involvements should focus on diminishing the likelihood of the most common driver errors. Countermeasures that simplify or remove the need to make left turns across traffic such as roundabouts, protected left turn signals, and diverging diamond intersection designs could decrease the frequency of inadequate surveillance and gap or speed misjudgment errors. In the future, vehicle-to-vehicle and vehicle-to-infrastructure communications may also help protect older drivers from these errors. Copyright © 2015 Elsevier Ltd. All rights reserved.

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

PubMed

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

2017-06-01

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

Responding to serious medical error in general practice--consequences for the GPs involved: analysis of 75 cases from Germany.

PubMed

Fisseni, Gregor; Pentzek, Michael; Abholz, Heinz-Harald

2008-02-01

GPs' recollections about their 'most serious errors in treatment' and about the consequences for themselves. Does it make a difference, who (else) contributed to the error, or to its discovery or disclosure? Anonymous questionnaire study concerning the 'three most serious errors in your career as a GP'. The participating doctors were given an operational definition of 'serious error'. They applied a special recall technique, using patient-induced associations to bring to mind former 'serious errors'. The recall method and the semi-structured 25-item questionnaire used were developed and piloted by the authors. The items were analysed quantitatively and by qualitative content analysis. General practices in the North Rhine region in Germany: 32 GPs anonymously reported about 75 'most serious errors'. In more than half of the cases analysed, other people contributed considerably to the GPs' serious errors. Most of the errors were discovered and disclosed to the patient by doctors: either by the GPs themselves, or by colleagues. A lot of GPs suffered loss of reputation and loss of patients. However, the number of patients staying with their GP clearly exceeded the number leaving their GP, depending on who else contributed to the error, who discovered it and who disclosed it to the patient. The majority of patients still trusted their GP after a serious error, especially if the GP was not the only one who contributed to the error and if the GP played an active role in the discovery and disclosure or the error.

Assessing the Impact of Analytical Error on Perceived Disease Severity.

PubMed

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

2015-10-01

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

Using video recording to identify management errors in pediatric trauma resuscitation.

PubMed

Oakley, Ed; Stocker, Sergio; Staubli, Georg; Young, Simon

2006-03-01

To determine the ability of video recording to identify management errors in trauma resuscitation and to compare this method with medical record review. The resuscitation of children who presented to the emergency department of the Royal Children's Hospital between February 19, 2001, and August 18, 2002, for whom the trauma team was activated was video recorded. The tapes were analyzed, and management was compared with Advanced Trauma Life Support guidelines. Deviations from these guidelines were recorded as errors. Fifty video recordings were analyzed independently by 2 reviewers. Medical record review was undertaken for a cohort of the most seriously injured patients, and errors were identified. The errors detected with the 2 methods were compared. Ninety resuscitations were video recorded and analyzed. An average of 5.9 errors per resuscitation was identified with this method (range: 1-12 errors). Twenty-five children (28%) had an injury severity score of >11; there was an average of 2.16 errors per patient in this group. Only 10 (20%) of these errors were detected in the medical record review. Medical record review detected an additional 8 errors that were not evident on the video recordings. Concordance between independent reviewers was high, with 93% agreement. Video recording is more effective than medical record review in detecting management errors in pediatric trauma resuscitation. Management errors in pediatric trauma resuscitation are common and often involve basic resuscitation principles. Resuscitation of the most seriously injured children was associated with fewer errors. Video recording is a useful adjunct to trauma resuscitation auditing.

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

PubMed

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

2012-07-01

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

Poster - 49: Assessment of Synchrony respiratory compensation error for CyberKnife liver treatment

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

Liu, Ming; Cygler,

The goal of this work is to quantify respiratory motion compensation errors for liver tumor patients treated by the CyberKnife system with Synchrony tracking, to identify patients with the smallest tracking errors and to eventually help coach patient’s breathing patterns to minimize dose delivery errors. The accuracy of CyberKnife Synchrony respiratory motion compensation was assessed for 37 patients treated for liver lesions by analyzing data from system logfiles. A predictive model is used to modulate the direction of individual beams during dose delivery based on the positions of internally implanted fiducials determined using an orthogonal x-ray imaging system and themore » current location of LED external markers. For each x-ray pair acquired, system logfiles report the prediction error, the difference between the measured and predicted fiducial positions, and the delivery error, which is an estimate of the statistical error in the model overcoming the latency between x-ray acquisition and robotic repositioning. The total error was calculated at the time of each x-ray pair, for the number of treatment fractions and the number of patients, giving the average respiratory motion compensation error in three dimensions. The 99{sup th} percentile for the total radial error is 3.85 mm, with the highest contribution of 2.79 mm in superior/inferior (S/I) direction. The absolute mean compensation error is 1.78 mm radially with a 1.27 mm contribution in the S/I direction. Regions of high total error may provide insight into features predicting groups of patients with larger or smaller total errors.« less

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

PubMed

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

2006-01-01

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

Autonomous Control Modes and Optimized Path Guidance for Shipboard Landing in High Sea States

DTIC Science & Technology

2015-11-16

a degraded visual environment, workload during the landing task begins to approach the limits of a human pilot’s capability. It is a similarly...Figure 2. Approach Trajectory ±4 ft landing error ±8 ft landing error ±12 ft landing error Flight Path -3000...heave and yaw axes. Figure 5. Open loop system generation ±4 ft landing error ±8 ft landing error ±12 ft landing error -10 -8 -6 -4 -2 0 2 4

[Epidemiology of refractive errors].

PubMed

Wolfram, C

2017-07-01

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

Unforced errors and error reduction in tennis

PubMed Central

Brody, H

2006-01-01

Only at the highest level of tennis is the number of winners comparable to the number of unforced errors. As the average player loses many more points due to unforced errors than due to winners by an opponent, if the rate of unforced errors can be reduced, it should lead to an increase in points won. This article shows how players can improve their game by understanding and applying the laws of physics to reduce the number of unforced errors. PMID:16632568

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

PubMed

Cao, Hui; Stetson, Peter; Hripcsak, George

2003-01-01

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

Adaptive control system for pulsed megawatt klystrons

DOEpatents

Bolie, Victor W.

1992-01-01

The invention provides an arrangement for reducing waveform errors such as errors in phase or amplitude in output pulses produced by pulsed power output devices such as klystrons by generating an error voltage representing the extent of error still present in the trailing edge of the previous output pulse, using the error voltage to provide a stored control voltage, and applying the stored control voltage to the pulsed power output device to limit the extent of error in the leading edge of the next output pulse.

Preschool speech error patterns predict articulation and phonological awareness outcomes in children with histories of speech sound disorders

PubMed Central

Preston, Jonathan L.; Hull, Margaret; Edwards, Mary Louise

2012-01-01

Purpose To determine if speech error patterns in preschoolers with speech sound disorders (SSDs) predict articulation and phonological awareness (PA) outcomes almost four years later. Method Twenty-five children with histories of preschool SSDs (and normal receptive language) were tested at an average age of 4;6 and followed up at 8;3. The frequency of occurrence of preschool distortion errors, typical substitution and syllable structure errors, and atypical substitution and syllable structure errors were used to predict later speech sound production, PA, and literacy outcomes. Results Group averages revealed below-average school-age articulation scores and low-average PA, but age-appropriate reading and spelling. Preschool speech error patterns were related to school-age outcomes. Children for whom more than 10% of their speech sound errors were atypical had lower PA and literacy scores at school-age than children who produced fewer than 10% atypical errors. Preschoolers who produced more distortion errors were likely to have lower school-age articulation scores. Conclusions Different preschool speech error patterns predict different school-age clinical outcomes. Many atypical speech sound errors in preschool may be indicative of weak phonological representations, leading to long-term PA weaknesses. Preschool distortions may be resistant to change over time, leading to persisting speech sound production problems. PMID:23184137

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

NASA Technical Reports Server (NTRS)

Barth, Timothy J.

2016-01-01

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

A Sensor Dynamic Measurement Error Prediction Model Based on NAPSO-SVM

PubMed Central

Jiang, Minlan; Jiang, Lan; Jiang, Dingde; Li, Fei

2018-01-01

Dynamic measurement error correction is an effective way to improve sensor precision. Dynamic measurement error prediction is an important part of error correction, and support vector machine (SVM) is often used for predicting the dynamic measurement errors of sensors. Traditionally, the SVM parameters were always set manually, which cannot ensure the model’s performance. In this paper, a SVM method based on an improved particle swarm optimization (NAPSO) is proposed to predict the dynamic measurement errors of sensors. Natural selection and simulated annealing are added in the PSO to raise the ability to avoid local optima. To verify the performance of NAPSO-SVM, three types of algorithms are selected to optimize the SVM’s parameters: the particle swarm optimization algorithm (PSO), the improved PSO optimization algorithm (NAPSO), and the glowworm swarm optimization (GSO). The dynamic measurement error data of two sensors are applied as the test data. The root mean squared error and mean absolute percentage error are employed to evaluate the prediction models’ performances. The experimental results show that among the three tested algorithms the NAPSO-SVM method has a better prediction precision and a less prediction errors, and it is an effective method for predicting the dynamic measurement errors of sensors. PMID:29342942

Linguistic Pattern Analysis of Misspellings of Typically Developing Writers in Grades 1 to 9

PubMed Central

Bahr, Ruth Huntley; Silliman, Elaine R.; Berninger, Virginia W.; Dow, Michael

2012-01-01

Purpose A mixed methods approach, evaluating triple word form theory, was used to describe linguistic patterns of misspellings. Method Spelling errors were taken from narrative and expository writing samples provided by 888 typically developing students in grades 1–9. Errors were coded by category (phonological, orthographic, and morphological) and specific linguistic feature affected. Grade level effects were analyzed with trend analysis. Qualitative analyses determined frequent error types and how use of specific linguistic features varied across grades. Results Phonological, orthographic, and morphological errors were noted across all grades, but orthographic errors predominated. Linear trends revealed developmental shifts in error proportions for the orthographic and morphological categories between grades 4–5. Similar error types were noted across age groups but the nature of linguistic feature error changed with age. Conclusions Triple word-form theory was supported. By grade 1, orthographic errors predominated and phonological and morphological error patterns were evident. Morphological errors increased in relative frequency in older students, probably due to a combination of word-formation issues and vocabulary growth. These patterns suggest that normal spelling development reflects non-linear growth and that it takes a long time to develop a robust orthographic lexicon that coordinates phonology, orthography, and morphology and supports word-specific, conventional spelling. PMID:22473834

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

PubMed

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

2012-01-01

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

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

PubMed

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

2017-11-01

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

Is comprehension necessary for error detection? A conflict-based account of monitoring in speech production

PubMed Central

Nozari, Nazbanou; Dell, Gary S.; Schwartz, Myrna F.

2011-01-01

Despite the existence of speech errors, verbal communication is successful because speakers can detect (and correct) their errors. The standard theory of speech-error detection, the perceptual-loop account, posits that the comprehension system monitors production output for errors. Such a comprehension-based monitor, however, cannot explain the double dissociation between comprehension and error-detection ability observed in the aphasic patients. We propose a new theory of speech-error detection which is instead based on the production process itself. The theory borrows from studies of forced-choice-response tasks the notion that error detection is accomplished by monitoring response conflict via a frontal brain structure, such as the anterior cingulate cortex. We adapt this idea to the two-step model of word production, and test the model-derived predictions on a sample of aphasic patients. Our results show a strong correlation between patients’ error-detection ability and the model’s characterization of their production skills, and no significant correlation between error detection and comprehension measures, thus supporting a production-based monitor, generally, and the implemented conflict-based monitor in particular. The successful application of the conflict-based theory to error-detection in linguistic, as well as non-linguistic domains points to a domain-general monitoring system. PMID:21652015

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

PubMed

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

2014-07-10

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

Subaperture test of wavefront error of large telescopes: error sources and stitching performance simulations

NASA Astrophysics Data System (ADS)

Chen, Shanyong; Li, Shengyi; Wang, Guilin

2014-11-01

The wavefront error of large telescopes requires to be measured to check the system quality and also estimate the misalignment of the telescope optics including the primary, the secondary and so on. It is usually realized by a focal plane interferometer and an autocollimator flat (ACF) of the same aperture with the telescope. However, it is challenging for meter class telescopes due to high cost and technological challenges in producing the large ACF. Subaperture test with a smaller ACF is hence proposed in combination with advanced stitching algorithms. Major error sources include the surface error of the ACF, misalignment of the ACF and measurement noises. Different error sources have different impacts on the wavefront error. Basically the surface error of the ACF behaves like systematic error and the astigmatism will be cumulated and enlarged if the azimuth of subapertures remains fixed. It is difficult to accurately calibrate the ACF because it suffers considerable deformation induced by gravity or mechanical clamping force. Therefore a selfcalibrated stitching algorithm is employed to separate the ACF surface error from the subaperture wavefront error. We suggest the ACF be rotated around the optical axis of the telescope for subaperture test. The algorithm is also able to correct the subaperture tip-tilt based on the overlapping consistency. Since all subaperture measurements are obtained in the same imaging plane, lateral shift of the subapertures is always known and the real overlapping points can be recognized in this plane. Therefore lateral positioning error of subapertures has no impact on the stitched wavefront. In contrast, the angular positioning error changes the azimuth of the ACF and finally changes the systematic error. We propose an angularly uneven layout of subapertures to minimize the stitching error, which is very different from our knowledge. At last, measurement noises could never be corrected but be suppressed by means of averaging and environmental control. We simulate the performance of the stitching algorithm dealing with surface error and misalignment of the ACF, and noise suppression, which provides guidelines to optomechanical design of the stitching test system.

Procedural Error and Task Interruption

DTIC Science & Technology

2016-09-30

red for research on errors and individual differences . Results indicate predictive validity for fluid intelligence and specifi c forms of work...TERMS procedural error, task interruption, individual differences , fluid intelligence, sleep deprivation 16. SECURITY CLASSIFICATION OF: 17...and individual differences . It generates rich data on several kinds of errors, including procedural errors in which steps are skipped or repeated

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

ERIC Educational Resources Information Center

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

2012-01-01

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

Testing the Recognition and Perception of Errors in Context

ERIC Educational Resources Information Center

Brandenburg, Laura C.

2015-01-01

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

Exploring Measurement Error with Cookies: A Real and Virtual Approach via Interactive Excel

ERIC Educational Resources Information Center

Sinex, Scott A; Gage, Barbara A.; Beck, Peggy J.

2007-01-01

A simple, guided-inquiry investigation using stacked sandwich cookies is employed to develop a simple linear mathematical model and to explore measurement error by incorporating errors as part of the investigation. Both random and systematic errors are presented. The model and errors are then investigated further by engaging with an interactive…

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

ERIC Educational Resources Information Center

Bernstein, Stuart E.

2009-01-01

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

Variability in Post-Error Behavioral Adjustment Is Associated with Functional Abnormalities in the Temporal Cortex in Children with ADHD

ERIC Educational Resources Information Center

Spinelli, Simona; Vasa, Roma A.; Joel, Suresh; Nelson, Tess E.; Pekar, James J.; Mostofsky, Stewart H.

2011-01-01

Background: Error processing is reflected, behaviorally, by slower reaction times (RT) on trials immediately following an error (post-error). Children with attention-deficit hyperactivity disorder (ADHD) fail to show RT slowing and demonstrate increased intra-subject variability (ISV) on post-error trials. The neural correlates of these behavioral…

The Sources of Error in Spanish Writing.

ERIC Educational Resources Information Center

Justicia, Fernando; Defior, Sylvia; Pelegrina, Santiago; Martos, Francisco J.

1999-01-01

Determines the pattern of errors in Spanish spelling. Analyzes and proposes a classification system for the errors made by children in the initial stages of the acquisition of spelling skills. Finds the diverse forms of only 20 Spanish words produces 36% of the spelling errors in Spanish; and substitution is the most frequent type of error. (RS)

The Effects of Discrete-Trial Training Commission Errors on Learner Outcomes: An Extension

ERIC Educational Resources Information Center

Jenkins, Sarah R.; Hirst, Jason M.; DiGennaro Reed, Florence D.

2015-01-01

We conducted a parametric analysis of treatment integrity errors during discrete-trial training and investigated the effects of three integrity conditions (0, 50, or 100 % errors of commission) on performance in the presence and absence of programmed errors. The presence of commission errors impaired acquisition for three of four participants.…

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

ERIC Educational Resources Information Center

Hallin, Anna Eva; Reuterskiöld, Christina

2017-01-01

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

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

PubMed

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

2012-01-01

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

Human Error: A Concept Analysis

NASA Technical Reports Server (NTRS)

Hansen, Frederick D.

2007-01-01

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

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

PubMed

Chiu, Ming-Chuan; Hsieh, Min-Chih

2016-05-01

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

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

PubMed

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

2015-01-01

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

Putting into practice error management theory: Unlearning and learning to manage action errors in construction.

PubMed

Love, Peter E D; Smith, Jim; Teo, Pauline

2018-05-01

Error management theory is drawn upon to examine how a project-based organization, which took the form of a program alliance, was able to change its established error prevention mindset to one that enacted a learning mindfulness that provided an avenue to curtail its action errors. The program alliance was required to unlearn its existing routines and beliefs to accommodate the practices required to embrace error management. As a result of establishing an error management culture the program alliance was able to create a collective mindfulness that nurtured learning and supported innovation. The findings provide a much-needed context to demonstrate the relevance of error management theory to effectively address rework and safety problems in construction projects. The robust theoretical underpinning that is grounded in practice and presented in this paper provides a mechanism to engender learning from errors, which can be utilized by construction organizations to improve the productivity and performance of their projects. Copyright © 2018 Elsevier Ltd. All rights reserved.

An educational and audit tool to reduce prescribing error in intensive care.

PubMed

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.

The role of hand of error and stimulus orientation in the relationship between worry and error-related brain activity: Implications for theory and practice.

PubMed

Lin, Yanli; Moran, Tim P; Schroder, Hans S; Moser, Jason S

2015-10-01

Anxious apprehension/worry is associated with exaggerated error monitoring; however, the precise mechanisms underlying this relationship remain unclear. The current study tested the hypothesis that the worry-error monitoring relationship involves left-lateralized linguistic brain activity by examining the relationship between worry and error monitoring, indexed by the error-related negativity (ERN), as a function of hand of error (Experiment 1) and stimulus orientation (Experiment 2). Results revealed that worry was exclusively related to the ERN on right-handed errors committed by the linguistically dominant left hemisphere. Moreover, the right-hand ERN-worry relationship emerged only when stimuli were presented horizontally (known to activate verbal processes) but not vertically. Together, these findings suggest that the worry-ERN relationship involves left hemisphere verbal processing, elucidating a potential mechanism to explain error monitoring abnormalities in anxiety. Implications for theory and practice are discussed. © 2015 Society for Psychophysiological Research.

ASCERTAINMENT OF ON-ROAD SAFETY ERRORS BASED ON VIDEO REVIEW

PubMed Central

Dawson, Jeffrey D.; Uc, Ergun Y.; Anderson, Steven W.; Dastrup, Elizabeth; Johnson, Amy M.; Rizzo, Matthew

2011-01-01

Summary Using an instrumented vehicle, we have studied several aspects of the on-road performance of healthy and diseased elderly drivers. One goal from such studies is to ascertain the type and frequency of driving safety errors. Because the judgment of such errors is somewhat subjective, we applied a taxonomy system of 15 general safety error categories and 76 specific safety error types. We also employed and trained professional driving instructors to review the video data of the on-road drives. In this report, we illustrate our rating system on a group of 111 drivers, ages 65 to 89. These drivers made errors in 13 of the 15 error categories, comprising 42 of the 76 error types. A mean (SD) of 35.8 (12.8) safety errors per drive were noted, with 2.1 (1.7) of them being judged as serious. Our methodology may be useful in applications such as intervention studies, and in longitudinal studies of changes in driving abilities in patients with declining cognitive ability. PMID:24273753

A Study on Mutil-Scale Background Error Covariances in 3D-Var Data Assimilation

NASA Astrophysics Data System (ADS)

Zhang, Xubin; Tan, Zhe-Min

2017-04-01

The construction of background error covariances is a key component of three-dimensional variational data assimilation. There are different scale background errors and interactions among them in the numerical weather Prediction. However, the influence of these errors and their interactions cannot be represented in the background error covariances statistics when estimated by the leading methods. So, it is necessary to construct background error covariances influenced by multi-scale interactions among errors. With the NMC method, this article firstly estimates the background error covariances at given model-resolution scales. And then the information of errors whose scales are larger and smaller than the given ones is introduced respectively, using different nesting techniques, to estimate the corresponding covariances. The comparisons of three background error covariances statistics influenced by information of errors at different scales reveal that, the background error variances enhance particularly at large scales and higher levels when introducing the information of larger-scale errors by the lateral boundary condition provided by a lower-resolution model. On the other hand, the variances reduce at medium scales at the higher levels, while those show slight improvement at lower levels in the nested domain, especially at medium and small scales, when introducing the information of smaller-scale errors by nesting a higher-resolution model. In addition, the introduction of information of larger- (smaller-) scale errors leads to larger (smaller) horizontal and vertical correlation scales of background errors. Considering the multivariate correlations, the Ekman coupling increases (decreases) with the information of larger- (smaller-) scale errors included, whereas the geostrophic coupling in free atmosphere weakens in both situations. The three covariances obtained in above work are used in a data assimilation and model forecast system respectively, and then the analysis-forecast cycles for a period of 1 month are conducted. Through the comparison of both analyses and forecasts from this system, it is found that the trends for variation in analysis increments with information of different scale errors introduced are consistent with those for variation in variances and correlations of background errors. In particular, introduction of smaller-scale errors leads to larger amplitude of analysis increments for winds at medium scales at the height of both high- and low- level jet. And analysis increments for both temperature and humidity are greater at the corresponding scales at middle and upper levels under this circumstance. These analysis increments improve the intensity of jet-convection system which includes jets at different levels and coupling between them associated with latent heat release, and these changes in analyses contribute to the better forecasts for winds and temperature in the corresponding areas. When smaller-scale errors are included, analysis increments for humidity enhance significantly at large scales at lower levels to moisten southern analyses. This humidification devotes to correcting dry bias there and eventually improves forecast skill of humidity. Moreover, inclusion of larger- (smaller-) scale errors is beneficial for forecast quality of heavy (light) precipitation at large (small) scales due to the amplification (diminution) of intensity and area in precipitation forecasts but tends to overestimate (underestimate) light (heavy) precipitation .

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

NASA Technical Reports Server (NTRS)

Adler, Robert; Gu, Guojun; Huffman, George

2012-01-01

A procedure is described to estimate bias errors for mean precipitation by using multiple estimates from different algorithms, satellite sources, and merged products. The Global Precipitation Climatology Project (GPCP) monthly product is used as a base precipitation estimate, with other input products included when they are within +/- 50% of the GPCP estimates on a zonal-mean basis (ocean and land separately). The standard deviation s of the included products is then taken to be the estimated systematic, or bias, error. The results allow one to examine monthly climatologies and the annual climatology, producing maps of estimated bias errors, zonal-mean errors, and estimated errors over large areas such as ocean and land for both the tropics and the globe. For ocean areas, where there is the largest question as to absolute magnitude of precipitation, the analysis shows spatial variations in the estimated bias errors, indicating areas where one should have more or less confidence in the mean precipitation estimates. In the tropics, relative bias error estimates (s/m, where m is the mean precipitation) over the eastern Pacific Ocean are as large as 20%, as compared with 10%-15% in the western Pacific part of the ITCZ. An examination of latitudinal differences over ocean clearly shows an increase in estimated bias error at higher latitudes, reaching up to 50%. Over land, the error estimates also locate regions of potential problems in the tropics and larger cold-season errors at high latitudes that are due to snow. An empirical technique to area average the gridded errors (s) is described that allows one to make error estimates for arbitrary areas and for the tropics and the globe (land and ocean separately, and combined). Over the tropics this calculation leads to a relative error estimate for tropical land and ocean combined of 7%, which is considered to be an upper bound because of the lack of sign-of-the-error canceling when integrating over different areas with a different number of input products. For the globe the calculated relative error estimate from this study is about 9%, which is also probably a slight overestimate. These tropical and global estimated bias errors provide one estimate of the current state of knowledge of the planet's mean precipitation.

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

PubMed

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

2018-05-14

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

How common are cognitive errors in cases presented at emergency medicine resident morbidity and mortality conferences?

PubMed

Chu, David; Xiao, Jane; Shah, Payal; Todd, Brett

2018-06-20

Cognitive errors are a major contributor to medical error. Traditionally, medical errors at teaching hospitals are analyzed in morbidity and mortality (M&M) conferences. We aimed to describe the frequency of cognitive errors in relation to the occurrence of diagnostic and other error types, in cases presented at an emergency medicine (EM) resident M&M conference. We conducted a retrospective study of all cases presented at a suburban US EM residency monthly M&M conference from September 2011 to August 2016. Each case was reviewed using the electronic medical record (EMR) and notes from the M&M case by two EM physicians. Each case was categorized by type of primary medical error that occurred as described by Okafor et al. When a diagnostic error occurred, the case was reviewed for contributing cognitive and non-cognitive factors. Finally, when a cognitive error occurred, the case was classified into faulty knowledge, faulty data gathering or faulty synthesis, as described by Graber et al. Disagreements in error type were mediated by a third EM physician. A total of 87 M&M cases were reviewed; the two reviewers agreed on 73 cases, and 14 cases required mediation by a third reviewer. Forty-eight cases involved diagnostic errors, 47 of which were cognitive errors. Of these 47 cases, 38 involved faulty synthesis, 22 involved faulty data gathering and only 11 involved faulty knowledge. Twenty cases contained more than one type of cognitive error. Twenty-nine cases involved both a resident and an attending physician, while 17 cases involved only an attending physician. Twenty-one percent of the resident cases involved all three cognitive errors, while none of the attending cases involved all three. Forty-one percent of the resident cases and only 6% of the attending cases involved faulty knowledge. One hundred percent of the resident cases and 94% of the attending cases involved faulty synthesis. Our review of 87 EM M&M cases revealed that cognitive errors are commonly involved in cases presented, and that these errors are less likely due to deficient knowledge and more likely due to faulty synthesis. M&M conferences may therefore provide an excellent forum to discuss cognitive errors and how to reduce their occurrence.

47 CFR 87.145 - Acceptability of transmitters for licensing.

Code of Federal Regulations, 2014 CFR

2014-10-01

... square error which assumes zero error for the received ground earth station signal and includes the AES transmit/receive frequency reference error and the AES automatic frequency control residual errors.) The...

47 CFR 87.145 - Acceptability of transmitters for licensing.

Code of Federal Regulations, 2013 CFR

2013-10-01

... square error which assumes zero error for the received ground earth station signal and includes the AES transmit/receive frequency reference error and the AES automatic frequency control residual errors.) The...

47 CFR 87.145 - Acceptability of transmitters for licensing.

Code of Federal Regulations, 2012 CFR

2012-10-01

... square error which assumes zero error for the received ground earth station signal and includes the AES transmit/receive frequency reference error and the AES automatic frequency control residual errors.) The...

47 CFR 87.145 - Acceptability of transmitters for licensing.

Code of Federal Regulations, 2011 CFR

2011-10-01

... square error which assumes zero error for the received ground earth station signal and includes the AES transmit/receive frequency reference error and the AES automatic frequency control residual errors.) The...

Remediating Common Math Errors.

ERIC Educational Resources Information Center

Wagner, Rudolph F.

1981-01-01

Explanations and remediation suggestions for five types of mathematics errors due either to perceptual or cognitive difficulties are given. Error types include directionality problems, mirror writing, visually misperceived signs, diagnosed directionality problems, and mixed process errors. (CL)

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.

Metering error quantification under voltage and current waveform distortion

NASA Astrophysics Data System (ADS)

Wang, Tao; Wang, Jia; Xie, Zhi; Zhang, Ran

2017-09-01

With integration of more and more renewable energies and distortion loads into power grid, the voltage and current waveform distortion results in metering error in the smart meters. Because of the negative effects on the metering accuracy and fairness, it is an important subject to study energy metering combined error. In this paper, after the comparing between metering theoretical value and real recorded value under different meter modes for linear and nonlinear loads, a quantification method of metering mode error is proposed under waveform distortion. Based on the metering and time-division multiplier principles, a quantification method of metering accuracy error is proposed also. Analyzing the mode error and accuracy error, a comprehensive error analysis method is presented which is suitable for new energy and nonlinear loads. The proposed method has been proved by simulation.

Investigation on coupling error characteristics in angular rate matching based ship deformation measurement approach

NASA Astrophysics Data System (ADS)

Yang, Shuai; Wu, Wei; Wang, Xingshu; Xu, Zhiguang

2018-01-01

The coupling error in the measurement of ship hull deformation can significantly influence the attitude accuracy of the shipborne weapons and equipments. It is therefore important to study the characteristics of the coupling error. In this paper, an comprehensive investigation on the coupling error is reported, which has a potential of deducting the coupling error in the future. Firstly, the causes and characteristics of the coupling error are analyzed theoretically based on the basic theory of measuring ship deformation. Then, simulations are conducted for verifying the correctness of the theoretical analysis. Simulation results show that the cross-correlation between dynamic flexure and ship angular motion leads to the coupling error in measuring ship deformation, and coupling error increases with the correlation value between them. All the simulation results coincide with the theoretical analysis.

Impact of Measurement Error on Synchrophasor Applications

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

Liu, Yilu; Gracia, Jose R.; Ewing, Paul D.

2015-07-01

Phasor measurement units (PMUs), a type of synchrophasor, are powerful diagnostic tools that can help avert catastrophic failures in the power grid. Because of this, PMU measurement errors are particularly worrisome. This report examines the internal and external factors contributing to PMU phase angle and frequency measurement errors and gives a reasonable explanation for them. It also analyzes the impact of those measurement errors on several synchrophasor applications: event location detection, oscillation detection, islanding detection, and dynamic line rating. The primary finding is that dynamic line rating is more likely to be influenced by measurement error. Other findings include themore » possibility of reporting nonoscillatory activity as an oscillation as the result of error, failing to detect oscillations submerged by error, and the unlikely impact of error on event location and islanding detection.« less

Approximate error conjugation gradient minimization methods

DOEpatents

Kallman, Jeffrey S

2013-05-21

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

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

PubMed Central

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

2012-01-01

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

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

PubMed

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

2012-08-01

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

Ensemble-type numerical uncertainty information from single model integrations

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

Rauser, Florian, E-mail: florian.rauser@mpimet.mpg.de; Marotzke, Jochem; Korn, Peter

2015-07-01

We suggest an algorithm that quantifies the discretization error of time-dependent physical quantities of interest (goals) for numerical models of geophysical fluid dynamics. The goal discretization error is estimated using a sum of weighted local discretization errors. The key feature of our algorithm is that these local discretization errors are interpreted as realizations of a random process. The random process is determined by the model and the flow state. From a class of local error random processes we select a suitable specific random process by integrating the model over a short time interval at different resolutions. The weights of themore » influences of the local discretization errors on the goal are modeled as goal sensitivities, which are calculated via automatic differentiation. The integration of the weighted realizations of local error random processes yields a posterior ensemble of goal approximations from a single run of the numerical model. From the posterior ensemble we derive the uncertainty information of the goal discretization error. This algorithm bypasses the requirement of detailed knowledge about the models discretization to generate numerical error estimates. The algorithm is evaluated for the spherical shallow-water equations. For two standard test cases we successfully estimate the error of regional potential energy, track its evolution, and compare it to standard ensemble techniques. The posterior ensemble shares linear-error-growth properties with ensembles of multiple model integrations when comparably perturbed. The posterior ensemble numerical error estimates are of comparable size as those of a stochastic physics ensemble.« less

Subthreshold muscle twitches dissociate oscillatory neural signatures of conflicts from errors.

PubMed

Cohen, Michael X; van Gaal, Simon

2014-02-01

We investigated the neural systems underlying conflict detection and error monitoring during rapid online error correction/monitoring mechanisms. We combined data from four separate cognitive tasks and 64 subjects in which EEG and EMG (muscle activity from the thumb used to respond) were recorded. In typical neuroscience experiments, behavioral responses are classified as "error" or "correct"; however, closer inspection of our data revealed that correct responses were often accompanied by "partial errors" - a muscle twitch of the incorrect hand ("mixed correct trials," ~13% of the trials). We found that these muscle twitches dissociated conflicts from errors in time-frequency domain analyses of EEG data. In particular, both mixed-correct trials and full error trials were associated with enhanced theta-band power (4-9Hz) compared to correct trials. However, full errors were additionally associated with power and frontal-parietal synchrony in the delta band. Single-trial robust multiple regression analyses revealed a significant modulation of theta power as a function of partial error correction time, thus linking trial-to-trial fluctuations in power to conflict. Furthermore, single-trial correlation analyses revealed a qualitative dissociation between conflict and error processing, such that mixed correct trials were associated with positive theta-RT correlations whereas full error trials were associated with negative delta-RT correlations. These findings shed new light on the local and global network mechanisms of conflict monitoring and error detection, and their relationship to online action adjustment. © 2013.

Prediction of discretization error using the error transport equation

NASA Astrophysics Data System (ADS)

Celik, Ismail B.; Parsons, Don Roscoe

2017-06-01

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

Research on the error model of airborne celestial/inertial integrated navigation system

NASA Astrophysics Data System (ADS)

Zheng, Xiaoqiang; Deng, Xiaoguo; Yang, Xiaoxu; Dong, Qiang

2015-02-01

Celestial navigation subsystem of airborne celestial/inertial integrated navigation system periodically correct the positioning error and heading drift of the inertial navigation system, by which the inertial navigation system can greatly improve the accuracy of long-endurance navigation. Thus the navigation accuracy of airborne celestial navigation subsystem directly decides the accuracy of the integrated navigation system if it works for long time. By building the mathematical model of the airborne celestial navigation system based on the inertial navigation system, using the method of linear coordinate transformation, we establish the error transfer equation for the positioning algorithm of airborne celestial system. Based on these we built the positioning error model of the celestial navigation. And then, based on the positioning error model we analyze and simulate the positioning error which are caused by the error of the star tracking platform with the MATLAB software. Finally, the positioning error model is verified by the information of the star obtained from the optical measurement device in range and the device whose location are known. The analysis and simulation results show that the level accuracy and north accuracy of tracking platform are important factors that limit airborne celestial navigation systems to improve the positioning accuracy, and the positioning error have an approximate linear relationship with the level error and north error of tracking platform. The error of the verification results are in 1000m, which shows that the model is correct.

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

PubMed

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

2014-06-01

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

Reducing diagnostic errors in medicine: what's the goal?

PubMed

Graber, Mark; Gordon, Ruthanna; Franklin, Nancy

2002-10-01

This review considers the feasibility of reducing or eliminating the three major categories of diagnostic errors in medicine: "No-fault errors" occur when the disease is silent, presents atypically, or mimics something more common. These errors will inevitably decline as medical science advances, new syndromes are identified, and diseases can be detected more accurately or at earlier stages. These errors can never be eradicated, unfortunately, because new diseases emerge, tests are never perfect, patients are sometimes noncompliant, and physicians will inevitably, at times, choose the most likely diagnosis over the correct one, illustrating the concept of necessary fallibility and the probabilistic nature of choosing a diagnosis. "System errors" play a role when diagnosis is delayed or missed because of latent imperfections in the health care system. These errors can be reduced by system improvements, but can never be eliminated because these improvements lag behind and degrade over time, and each new fix creates the opportunity for novel errors. Tradeoffs also guarantee system errors will persist, when resources are just shifted. "Cognitive errors" reflect misdiagnosis from faulty data collection or interpretation, flawed reasoning, or incomplete knowledge. The limitations of human processing and the inherent biases in using heuristics guarantee that these errors will persist. Opportunities exist, however, for improving the cognitive aspect of diagnosis by adopting system-level changes (e.g., second opinions, decision-support systems, enhanced access to specialists) and by training designed to improve cognition or cognitive awareness. Diagnostic error can be substantially reduced, but never eradicated.

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

PubMed

Khorasani, Fahimeh; Beigi, Marjan

2017-01-01

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

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

PubMed Central

Stone, Jamie A.; Chui, Michelle A.

2014-01-01

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

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

PubMed

Anderson, B J; Ellis, J F

1999-01-01

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

Error estimation and adaptive mesh refinement for parallel analysis of shell structures

NASA Technical Reports Server (NTRS)

Keating, Scott C.; Felippa, Carlos A.; Park, K. C.

1994-01-01

The formulation and application of element-level, element-independent error indicators is investigated. This research culminates in the development of an error indicator formulation which is derived based on the projection of element deformation onto the intrinsic element displacement modes. The qualifier 'element-level' means that no information from adjacent elements is used for error estimation. This property is ideally suited for obtaining error values and driving adaptive mesh refinements on parallel computers where access to neighboring elements residing on different processors may incur significant overhead. In addition such estimators are insensitive to the presence of physical interfaces and junctures. An error indicator qualifies as 'element-independent' when only visible quantities such as element stiffness and nodal displacements are used to quantify error. Error evaluation at the element level and element independence for the error indicator are highly desired properties for computing error in production-level finite element codes. Four element-level error indicators have been constructed. Two of the indicators are based on variational formulation of the element stiffness and are element-dependent. Their derivations are retained for developmental purposes. The second two indicators mimic and exceed the first two in performance but require no special formulation of the element stiffness mesh refinement which we demonstrate for two dimensional plane stress problems. The parallelizing of substructures and adaptive mesh refinement is discussed and the final error indicator using two-dimensional plane-stress and three-dimensional shell problems is demonstrated.

Error reduction in EMG signal decomposition

PubMed Central

Kline, Joshua C.

2014-01-01

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

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

PubMed

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

2011-09-01

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

Making Residents Part of the Safety Culture: Improving Error Reporting and Reducing Harms.

PubMed

Fox, Michael D; Bump, Gregory M; Butler, Gabriella A; Chen, Ling-Wan; Buchert, Andrew R

2017-01-30

Reporting medical errors is a focus of the patient safety movement. As frontline physicians, residents are optimally positioned to recognize errors and flaws in systems of care. Previous work highlights the difficulty of engaging residents in identification and/or reduction of medical errors and in integrating these trainees into their institutions' cultures of safety. The authors describe the implementation of a longitudinal, discipline-based, multifaceted curriculum to enhance the reporting of errors by pediatric residents at Children's Hospital of Pittsburgh of University of Pittsburgh Medical Center. The key elements of this curriculum included providing the necessary education to identify medical errors with an emphasis on systems-based causes, modeling of error reporting by faculty, and integrating error reporting and discussion into the residents' daily activities. The authors tracked monthly error reporting rates by residents and other health care professionals, in addition to serious harm event rates at the institution. The interventions resulted in significant increases in error reports filed by residents, from 3.6 to 37.8 per month over 4 years (P < 0.0001). This increase in resident error reporting correlated with a decline in serious harm events, from 15.0 to 8.1 per month over 4 years (P = 0.01). Integrating patient safety into the everyday resident responsibilities encourages frequent reporting and discussion of medical errors and leads to improvements in patient care. Multiple simultaneous interventions are essential to making residents part of the safety culture of their training hospitals.

Computer calculated dose in paediatric prescribing.

PubMed

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

2005-01-01

Medication errors are an important cause of hospital-based morbidity and mortality. However, only a few medication error studies have been conducted in children. These have mainly quantified errors in the inpatient setting; there is very little data available on paediatric outpatient and emergency department medication errors and none on discharge medication. This deficiency is of concern because medication errors are more common in children and it has been suggested that the risk of an adverse drug event as a consequence of a medication error is higher in children than in adults. The aims of this study were to assess the rate of medication errors in predominantly ambulatory paediatric patients and the effect of computer calculated doses on medication error rates of two commonly prescribed drugs. This was a prospective cohort study performed in a paediatric unit in a university teaching hospital between March 2003 and August 2003. The hospital's existing computer clinical decision support system was modified so that doctors could choose the traditional prescription method or the enhanced method of computer calculated dose when prescribing paracetamol (acetaminophen) or promethazine. All prescriptions issued to children (<16 years of age) at the outpatient clinic, emergency department and at discharge from the inpatient service were analysed. A medication error was defined as to have occurred if there was an underdose (below the agreed value), an overdose (above the agreed value), no frequency of administration specified, no dose given or excessive total daily dose. The medication error rates and the factors influencing medication error rates were determined using SPSS version 12. From March to August 2003, 4281 prescriptions were issued. Seven prescriptions (0.16%) were excluded, hence 4274 prescriptions were analysed. Most prescriptions were issued by paediatricians (including neonatologists and paediatric surgeons) and/or junior doctors. The error rate in the children's emergency department was 15.7%, for outpatients was 21.5% and for discharge medication was 23.6%. Most errors were the result of an underdose (64%; 536/833). The computer calculated dose error rate was 12.6% compared with the traditional prescription error rate of 28.2%. Logistical regression analysis showed that computer calculated dose was an important and independent variable influencing the error rate (adjusted relative risk = 0.436, 95% CI 0.336, 0.520, p < 0.001). Other important independent variables were seniority and paediatric training of the person prescribing and the type of drug prescribed. Medication error, especially underdose, is common in outpatient, emergency department and discharge prescriptions. Computer calculated doses can significantly reduce errors, but other risk factors have to be concurrently addressed to achieve maximum benefit.

A model for the prediction of latent errors using data obtained during the development process

NASA Technical Reports Server (NTRS)

Gaffney, J. E., Jr.; Martello, S. J.

1984-01-01

A model implemented in a program that runs on the IBM PC for estimating the latent (or post ship) content of a body of software upon its initial release to the user is presented. The model employs the count of errors discovered at one or more of the error discovery processes during development, such as a design inspection, as the input data for a process which provides estimates of the total life-time (injected) error content and of the latent (or post ship) error content--the errors remaining a delivery. The model presented presumes that these activities cover all of the opportunities during the software development process for error discovery (and removal).

Notes on Accuracy of Finite-Volume Discretization Schemes on Irregular Grids

NASA Technical Reports Server (NTRS)

Diskin, Boris; Thomas, James L.

2011-01-01

Truncation-error analysis is a reliable tool in predicting convergence rates of discretization errors on regular smooth grids. However, it is often misleading in application to finite-volume discretization schemes on irregular (e.g., unstructured) grids. Convergence of truncation errors severely degrades on general irregular grids; a design-order convergence can be achieved only on grids with a certain degree of geometric regularity. Such degradation of truncation-error convergence does not necessarily imply a lower-order convergence of discretization errors. In these notes, irregular-grid computations demonstrate that the design-order discretization-error convergence can be achieved even when truncation errors exhibit a lower-order convergence or, in some cases, do not converge at all.

Corrective Techniques and Future Directions for Treatment of Residual Refractive Error Following Cataract Surgery

PubMed Central

Moshirfar, Majid; McCaughey, Michael V; Santiago-Caban, Luis

2015-01-01

Postoperative residual refractive error following cataract surgery is not an uncommon occurrence for a large proportion of modern-day patients. Residual refractive errors can be broadly classified into 3 main categories: myopic, hyperopic, and astigmatic. The degree to which a residual refractive error adversely affects a patient is dependent on the magnitude of the error, as well as the specific type of intraocular lens the patient possesses. There are a variety of strategies for resolving residual refractive errors that must be individualized for each specific patient scenario. In this review, the authors discuss contemporary methods for rectification of residual refractive error, along with their respective indications/contraindications, and efficacies. PMID:25663845

Corrective Techniques and Future Directions for Treatment of Residual Refractive Error Following Cataract Surgery.

PubMed

Moshirfar, Majid; McCaughey, Michael V; Santiago-Caban, Luis

2014-12-01

Postoperative residual refractive error following cataract surgery is not an uncommon occurrence for a large proportion of modern-day patients. Residual refractive errors can be broadly classified into 3 main categories: myopic, hyperopic, and astigmatic. The degree to which a residual refractive error adversely affects a patient is dependent on the magnitude of the error, as well as the specific type of intraocular lens the patient possesses. There are a variety of strategies for resolving residual refractive errors that must be individualized for each specific patient scenario. In this review, the authors discuss contemporary methods for rectification of residual refractive error, along with their respective indications/contraindications, and efficacies.

Fault-tolerant quantum error detection.

PubMed

Linke, Norbert M; Gutierrez, Mauricio; Landsman, Kevin A; Figgatt, Caroline; Debnath, Shantanu; Brown, Kenneth R; Monroe, Christopher

2017-10-01

Quantum computers will eventually reach a size at which quantum error correction becomes imperative. Quantum information can be protected from qubit imperfections and flawed control operations by encoding a single logical qubit in multiple physical qubits. This redundancy allows the extraction of error syndromes and the subsequent detection or correction of errors without destroying the logical state itself through direct measurement. We show the encoding and syndrome measurement of a fault-tolerantly prepared logical qubit via an error detection protocol on four physical qubits, represented by trapped atomic ions. This demonstrates the robustness of a logical qubit to imperfections in the very operations used to encode it. The advantage persists in the face of large added error rates and experimental calibration errors.

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

ERIC Educational Resources Information Center

Abedi, Razie; Latifi, Mehdi; Moinzadeh, Ahmad

2010-01-01

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

Control by model error estimation

NASA Technical Reports Server (NTRS)

Likins, P. W.; Skelton, R. E.

1976-01-01

Modern control theory relies upon the fidelity of the mathematical model of the system. Truncated modes, external disturbances, and parameter errors in linear system models are corrected by augmenting to the original system of equations an 'error system' which is designed to approximate the effects of such model errors. A Chebyshev error system is developed for application to the Large Space Telescope (LST).

Foot Structure in Japanese Speech Errors: Normal vs. Pathological

ERIC Educational Resources Information Center

Miyakoda, Haruko

2008-01-01

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

Error Sources in Asteroid Astrometry

NASA Technical Reports Server (NTRS)

Owen, William M., Jr.

2000-01-01

Asteroid astrometry, like any other scientific measurement process, is subject to both random and systematic errors, not all of which are under the observer's control. To design an astrometric observing program or to improve an existing one requires knowledge of the various sources of error, how different errors affect one's results, and how various errors may be minimized by careful observation or data reduction techniques.

C-band radar pulse Doppler error: Its discovery, modeling, and elimination

NASA Technical Reports Server (NTRS)

Krabill, W. B.; Dempsey, D. J.

1978-01-01

The discovery of a C Band radar pulse Doppler error is discussed and use of the GEOS 3 satellite's coherent transponder to isolate the error source is described. An analysis of the pulse Doppler tracking loop is presented and a mathematical model for the error was developed. Error correction techniques were developed and are described including implementation details.

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

ERIC Educational Resources Information Center

Waugh, Rebecca E.

2010-01-01

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

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

ERIC Educational Resources Information Center

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

2011-01-01

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

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

ERIC Educational Resources Information Center

Tulis, Maria; Steuer, Gabriele; Dresel, Markus

2018-01-01

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

Particle Filter with Novel Nonlinear Error Model for Miniature Gyroscope-Based Measurement While Drilling Navigation

PubMed Central

Li, Tao; Yuan, Gannan; Li, Wang

2016-01-01

The derivation of a conventional error model for the miniature gyroscope-based measurement while drilling (MGWD) system is based on the assumption that the errors of attitude are small enough so that the direction cosine matrix (DCM) can be approximated or simplified by the errors of small-angle attitude. However, the simplification of the DCM would introduce errors to the navigation solutions of the MGWD system if the initial alignment cannot provide precise attitude, especially for the low-cost microelectromechanical system (MEMS) sensors operated in harsh multilateral horizontal downhole drilling environments. This paper proposes a novel nonlinear error model (NNEM) by the introduction of the error of DCM, and the NNEM can reduce the propagated errors under large-angle attitude error conditions. The zero velocity and zero position are the reference points and the innovations in the states estimation of particle filter (PF) and Kalman filter (KF). The experimental results illustrate that the performance of PF is better than KF and the PF with NNEM can effectively restrain the errors of system states, especially for the azimuth, velocity, and height in the quasi-stationary condition. PMID:26999130

Errors Affect Hypothetical Intertemporal Food Choice in Women

PubMed Central

Sellitto, Manuela; di Pellegrino, Giuseppe

2014-01-01

Growing evidence suggests that the ability to control behavior is enhanced in contexts in which errors are more frequent. Here we investigated whether pairing desirable food with errors could decrease impulsive choice during hypothetical temporal decisions about food. To this end, healthy women performed a Stop-signal task in which one food cue predicted high-error rate, and another food cue predicted low-error rate. Afterwards, we measured participants’ intertemporal preferences during decisions between smaller-immediate and larger-delayed amounts of food. We expected reduced sensitivity to smaller-immediate amounts of food associated with high-error rate. Moreover, taking into account that deprivational states affect sensitivity for food, we controlled for participants’ hunger. Results showed that pairing food with high-error likelihood decreased temporal discounting. This effect was modulated by hunger, indicating that, the lower the hunger level, the more participants showed reduced impulsive preference for the food previously associated with a high number of errors as compared with the other food. These findings reveal that errors, which are motivationally salient events that recruit cognitive control and drive avoidance learning against error-prone behavior, are effective in reducing impulsive choice for edible outcomes. PMID:25244534

Magnetic Nanoparticle Thermometer: An Investigation of Minimum Error Transmission Path and AC Bias Error

PubMed Central

Du, Zhongzhou; Su, Rijian; Liu, Wenzhong; Huang, Zhixing

2015-01-01

The signal transmission module of a magnetic nanoparticle thermometer (MNPT) was established in this study to analyze the error sources introduced during the signal flow in the hardware system. The underlying error sources that significantly affected the precision of the MNPT were determined through mathematical modeling and simulation. A transfer module path with the minimum error in the hardware system was then proposed through the analysis of the variations of the system error caused by the significant error sources when the signal flew through the signal transmission module. In addition, a system parameter, named the signal-to-AC bias ratio (i.e., the ratio between the signal and AC bias), was identified as a direct determinant of the precision of the measured temperature. The temperature error was below 0.1 K when the signal-to-AC bias ratio was higher than 80 dB, and other system errors were not considered. The temperature error was below 0.1 K in the experiments with a commercial magnetic fluid (Sample SOR-10, Ocean Nanotechnology, Springdale, AR, USA) when the hardware system of the MNPT was designed with the aforementioned method. PMID:25875188

A Systematic Error Correction Method for TOVS Radiances

NASA Technical Reports Server (NTRS)

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

2000-01-01

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

Evaluating concentration estimation errors in ELISA microarray experiments

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

Daly, Don S.; White, Amanda M.; Varnum, Susan M.

Enzyme-linked immunosorbent assay (ELISA) is a standard immunoassay to predict a protein concentration in a sample. Deploying ELISA in a microarray format permits simultaneous prediction of the concentrations of numerous proteins in a small sample. These predictions, however, are uncertain due to processing error and biological variability. Evaluating prediction error is critical to interpreting biological significance and improving the ELISA microarray process. Evaluating prediction error must be automated to realize a reliable high-throughput ELISA microarray system. Methods: In this paper, we present a statistical method based on propagation of error to evaluate prediction errors in the ELISA microarray process. Althoughmore » propagation of error is central to this method, it is effective only when comparable data are available. Therefore, we briefly discuss the roles of experimental design, data screening, normalization and statistical diagnostics when evaluating ELISA microarray prediction errors. We use an ELISA microarray investigation of breast cancer biomarkers to illustrate the evaluation of prediction errors. The illustration begins with a description of the design and resulting data, followed by a brief discussion of data screening and normalization. In our illustration, we fit a standard curve to the screened and normalized data, review the modeling diagnostics, and apply propagation of error.« less

Research on effects of phase error in phase-shifting interferometer

NASA Astrophysics Data System (ADS)

Wang, Hongjun; Wang, Zhao; Zhao, Hong; Tian, Ailing; Liu, Bingcai

2007-12-01

Referring to phase-shifting interferometry technology, the phase shifting error from the phase shifter is the main factor that directly affects the measurement accuracy of the phase shifting interferometer. In this paper, the resources and sorts of phase shifting error were introduction, and some methods to eliminate errors were mentioned. Based on the theory of phase shifting interferometry, the effects of phase shifting error were analyzed in detail. The Liquid Crystal Display (LCD) as a new shifter has advantage as that the phase shifting can be controlled digitally without any mechanical moving and rotating element. By changing coded image displayed on LCD, the phase shifting in measuring system was induced. LCD's phase modulation characteristic was analyzed in theory and tested. Based on Fourier transform, the effect model of phase error coming from LCD was established in four-step phase shifting interferometry. And the error range was obtained. In order to reduce error, a new error compensation algorithm was put forward. With this method, the error can be obtained by process interferogram. The interferogram can be compensated, and the measurement results can be obtained by four-step phase shifting interferogram. Theoretical analysis and simulation results demonstrate the feasibility of this approach to improve measurement accuracy.

Error measuring system of rotary Inductosyn

NASA Astrophysics Data System (ADS)

Liu, Chengjun; Zou, Jibin; Fu, Xinghe

2008-10-01

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

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

PubMed

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

2017-07-01

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

Your Health Care May Kill You: Medical Errors.

PubMed

Anderson, James G; Abrahamson, Kathleen

2017-01-01

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

[Analysis of intrusion errors in free recall].

PubMed

Diesfeldt, H F A

2017-06-01

Extra-list intrusion errors during five trials of the eight-word list-learning task of the Amsterdam Dementia Screening Test (ADST) were investigated in 823 consecutive psychogeriatric patients (87.1% suffering from major neurocognitive disorder). Almost half of the participants (45.9%) produced one or more intrusion errors on the verbal recall test. Correct responses were lower when subjects made intrusion errors, but learning slopes did not differ between subjects who committed intrusion errors and those who did not so. Bivariate regression analyses revealed that participants who committed intrusion errors were more deficient on measures of eight-word recognition memory, delayed visual recognition and tests of executive control (the Behavioral Dyscontrol Scale and the ADST-Graphical Sequences as measures of response inhibition). Using hierarchical multiple regression, only free recall and delayed visual recognition retained an independent effect in the association with intrusion errors, such that deficient scores on tests of episodic memory were sufficient to explain the occurrence of intrusion errors. Measures of inhibitory control did not add significantly to the explanation of intrusion errors in free recall, which makes insufficient strength of memory traces rather than a primary deficit in inhibition the preferred account for intrusion errors in free recall.

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

NASA Astrophysics Data System (ADS)

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

2018-01-01

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

Executive Council lists and general practitioner files

PubMed Central

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

Mismeasurement and the resonance of strong confounders: correlated errors.

PubMed

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

1999-07-01

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

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.

Risk prediction and aversion by anterior cingulate cortex.

PubMed

Brown, Joshua W; Braver, Todd S

2007-12-01

The recently proposed error-likelihood hypothesis suggests that anterior cingulate cortex (ACC) and surrounding areas will become active in proportion to the perceived likelihood of an error. The hypothesis was originally derived from a computational model prediction. The same computational model now makes a further prediction that ACC will be sensitive not only to predicted error likelihood, but also to the predicted magnitude of the consequences, should an error occur. The product of error likelihood and predicted error consequence magnitude collectively defines the general "expected risk" of a given behavior in a manner analogous but orthogonal to subjective expected utility theory. New fMRI results from an incentivechange signal task now replicate the error-likelihood effect, validate the further predictions of the computational model, and suggest why some segments of the population may fail to show an error-likelihood effect. In particular, error-likelihood effects and expected risk effects in general indicate greater sensitivity to earlier predictors of errors and are seen in risk-averse but not risk-tolerant individuals. Taken together, the results are consistent with an expected risk model of ACC and suggest that ACC may generally contribute to cognitive control by recruiting brain activity to avoid risk.

Particle Filter with Novel Nonlinear Error Model for Miniature Gyroscope-Based Measurement While Drilling Navigation.

PubMed

Li, Tao; Yuan, Gannan; Li, Wang

2016-03-15

The derivation of a conventional error model for the miniature gyroscope-based measurement while drilling (MGWD) system is based on the assumption that the errors of attitude are small enough so that the direction cosine matrix (DCM) can be approximated or simplified by the errors of small-angle attitude. However, the simplification of the DCM would introduce errors to the navigation solutions of the MGWD system if the initial alignment cannot provide precise attitude, especially for the low-cost microelectromechanical system (MEMS) sensors operated in harsh multilateral horizontal downhole drilling environments. This paper proposes a novel nonlinear error model (NNEM) by the introduction of the error of DCM, and the NNEM can reduce the propagated errors under large-angle attitude error conditions. The zero velocity and zero position are the reference points and the innovations in the states estimation of particle filter (PF) and Kalman filter (KF). The experimental results illustrate that the performance of PF is better than KF and the PF with NNEM can effectively restrain the errors of system states, especially for the azimuth, velocity, and height in the quasi-stationary condition.

Backus Effect on a Perpendicular Errors in Harmonic Models of Real vs. Synthetic Data

NASA Technical Reports Server (NTRS)

Voorhies, C. V.; Santana, J.; Sabaka, T.

1999-01-01

Measurements of geomagnetic scalar intensity on a thin spherical shell alone are not enough to separate internal from external source fields; moreover, such scalar data are not enough for accurate modeling of the vector field from internal sources because of unmodeled fields and small data errors. Spherical harmonic models of the geomagnetic potential fitted to scalar data alone therefore suffer from well-understood Backus effect and perpendicular errors. Curiously, errors in some models of simulated 'data' are very much less than those in models of real data. We analyze select Magsat vector and scalar measurements separately to illustrate Backus effect and perpendicular errors in models of real scalar data. By using a model to synthesize 'data' at the observation points, and by adding various types of 'noise', we illustrate such errors in models of synthetic 'data'. Perpendicular errors prove quite sensitive to the maximum degree in the spherical harmonic expansion of the potential field model fitted to the scalar data. Small errors in models of synthetic 'data' are found to be an artifact of matched truncation levels. For example, consider scalar synthetic 'data' computed from a degree 14 model. A degree 14 model fitted to such synthetic 'data' yields negligible error, but amplifies 4 nT (rmss) added noise into a 60 nT error (rmss); however, a degree 12 model fitted to the noisy 'data' suffers a 492 nT error (rmms through degree 12). Geomagnetic measurements remain unaware of model truncation, so the small errors indicated by some simulations cannot be realized in practice. Errors in models fitted to scalar data alone approach 1000 nT (rmss) and several thousand nT (maximum).

Comparison of various error functions in predicting the optimum isotherm by linear and non-linear regression analysis for the sorption of basic red 9 by activated carbon.

PubMed

Kumar, K Vasanth; Porkodi, K; Rocha, F

2008-01-15

A comparison of linear and non-linear regression method in selecting the optimum isotherm was made to the experimental equilibrium data of basic red 9 sorption by activated carbon. The r(2) was used to select the best fit linear theoretical isotherm. In the case of non-linear regression method, six error functions namely coefficient of determination (r(2)), hybrid fractional error function (HYBRID), Marquardt's percent standard deviation (MPSD), the average relative error (ARE), sum of the errors squared (ERRSQ) and sum of the absolute errors (EABS) were used to predict the parameters involved in the two and three parameter isotherms and also to predict the optimum isotherm. Non-linear regression was found to be a better way to obtain the parameters involved in the isotherms and also the optimum isotherm. For two parameter isotherm, MPSD was found to be the best error function in minimizing the error distribution between the experimental equilibrium data and predicted isotherms. In the case of three parameter isotherm, r(2) was found to be the best error function to minimize the error distribution structure between experimental equilibrium data and theoretical isotherms. The present study showed that the size of the error function alone is not a deciding factor to choose the optimum isotherm. In addition to the size of error function, the theory behind the predicted isotherm should be verified with the help of experimental data while selecting the optimum isotherm. A coefficient of non-determination, K(2) was explained and was found to be very useful in identifying the best error function while selecting the optimum isotherm.

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

PubMed

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

2015-01-01

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

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

PubMed

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

2007-01-10

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

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

PubMed Central

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

2015-01-01

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

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

PubMed Central

Park, Chan Gook

2018-01-01

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

Prescribing Errors Involving Medication Dosage Forms

PubMed Central

Lesar, Timothy S

2002-01-01

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

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

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

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

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

Aberrant error processing in relation to symptom severity in obsessive–compulsive disorder: A multimodal neuroimaging study

PubMed Central

Agam, Yigal; Greenberg, Jennifer L.; Isom, Marlisa; Falkenstein, Martha J.; Jenike, Eric; Wilhelm, Sabine; Manoach, Dara S.

2014-01-01

Background Obsessive–compulsive disorder (OCD) is characterized by maladaptive repetitive behaviors that persist despite feedback. Using multimodal neuroimaging, we tested the hypothesis that this behavioral rigidity reflects impaired use of behavioral outcomes (here, errors) to adaptively adjust responses. We measured both neural responses to errors and adjustments in the subsequent trial to determine whether abnormalities correlate with symptom severity. Since error processing depends on communication between the anterior and the posterior cingulate cortex, we also examined the integrity of the cingulum bundle with diffusion tensor imaging. Methods Participants performed the same antisaccade task during functional MRI and electroencephalography sessions. We measured error-related activation of the anterior cingulate cortex (ACC) and the error-related negativity (ERN). We also examined post-error adjustments, indexed by changes in activation of the default network in trials surrounding errors. Results OCD patients showed intact error-related ACC activation and ERN, but abnormal adjustments in the post- vs. pre-error trial. Relative to controls, who responded to errors by deactivating the default network, OCD patients showed increased default network activation including in the rostral ACC (rACC). Greater rACC activation in the post-error trial correlated with more severe compulsions. Patients also showed increased fractional anisotropy (FA) in the white matter underlying rACC. Conclusions Impaired use of behavioral outcomes to adaptively adjust neural responses may contribute to symptoms in OCD. The rACC locus of abnormal adjustment and relations with symptoms suggests difficulty suppressing emotional responses to aversive, unexpected events (e.g., errors). Increased structural connectivity of this paralimbic default network region may contribute to this impairment. PMID:25057466

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

PubMed

MacKay, Donald G; Johnson, Laura W

2013-11-01

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

Unit of Measurement Used and Parent Medication Dosing Errors

PubMed Central

Dreyer, Benard P.; Ugboaja, Donna C.; Sanchez, Dayana C.; Paul, Ian M.; Moreira, Hannah A.; Rodriguez, Luis; Mendelsohn, Alan L.

2014-01-01

BACKGROUND AND OBJECTIVES: Adopting the milliliter as the preferred unit of measurement has been suggested as a strategy to improve the clarity of medication instructions; teaspoon and tablespoon units may inadvertently endorse nonstandard kitchen spoon use. We examined the association between unit used and parent medication errors and whether nonstandard instruments mediate this relationship. METHODS: Cross-sectional analysis of baseline data from a larger study of provider communication and medication errors. English- or Spanish-speaking parents (n = 287) whose children were prescribed liquid medications in 2 emergency departments were enrolled. Medication error defined as: error in knowledge of prescribed dose, error in observed dose measurement (compared to intended or prescribed dose); >20% deviation threshold for error. Multiple logistic regression performed adjusting for parent age, language, country, race/ethnicity, socioeconomic status, education, health literacy (Short Test of Functional Health Literacy in Adults); child age, chronic disease; site. RESULTS: Medication errors were common: 39.4% of parents made an error in measurement of the intended dose, 41.1% made an error in the prescribed dose. Furthermore, 16.7% used a nonstandard instrument. Compared with parents who used milliliter-only, parents who used teaspoon or tablespoon units had twice the odds of making an error with the intended (42.5% vs 27.6%, P = .02; adjusted odds ratio=2.3; 95% confidence interval, 1.2–4.4) and prescribed (45.1% vs 31.4%, P = .04; adjusted odds ratio=1.9; 95% confidence interval, 1.03–3.5) dose; associations greater for parents with low health literacy and non–English speakers. Nonstandard instrument use partially mediated teaspoon and tablespoon–associated measurement errors. CONCLUSIONS: Findings support a milliliter-only standard to reduce medication errors. PMID:25022742

Unit of measurement used and parent medication dosing errors.

PubMed

Yin, H Shonna; Dreyer, Benard P; Ugboaja, Donna C; Sanchez, Dayana C; Paul, Ian M; Moreira, Hannah A; Rodriguez, Luis; Mendelsohn, Alan L

2014-08-01

Adopting the milliliter as the preferred unit of measurement has been suggested as a strategy to improve the clarity of medication instructions; teaspoon and tablespoon units may inadvertently endorse nonstandard kitchen spoon use. We examined the association between unit used and parent medication errors and whether nonstandard instruments mediate this relationship. Cross-sectional analysis of baseline data from a larger study of provider communication and medication errors. English- or Spanish-speaking parents (n = 287) whose children were prescribed liquid medications in 2 emergency departments were enrolled. Medication error defined as: error in knowledge of prescribed dose, error in observed dose measurement (compared to intended or prescribed dose); >20% deviation threshold for error. Multiple logistic regression performed adjusting for parent age, language, country, race/ethnicity, socioeconomic status, education, health literacy (Short Test of Functional Health Literacy in Adults); child age, chronic disease; site. Medication errors were common: 39.4% of parents made an error in measurement of the intended dose, 41.1% made an error in the prescribed dose. Furthermore, 16.7% used a nonstandard instrument. Compared with parents who used milliliter-only, parents who used teaspoon or tablespoon units had twice the odds of making an error with the intended (42.5% vs 27.6%, P = .02; adjusted odds ratio=2.3; 95% confidence interval, 1.2-4.4) and prescribed (45.1% vs 31.4%, P = .04; adjusted odds ratio=1.9; 95% confidence interval, 1.03-3.5) dose; associations greater for parents with low health literacy and non-English speakers. Nonstandard instrument use partially mediated teaspoon and tablespoon-associated measurement errors. Findings support a milliliter-only standard to reduce medication errors. Copyright © 2014 by the American Academy of Pediatrics.

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

NASA Astrophysics Data System (ADS)

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

2006-06-01

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

Hardware-efficient bosonic quantum error-correcting codes based on symmetry operators

NASA Astrophysics Data System (ADS)

Niu, Murphy Yuezhen; Chuang, Isaac L.; Shapiro, Jeffrey H.

2018-03-01

We establish a symmetry-operator framework for designing quantum error-correcting (QEC) codes based on fundamental properties of the underlying system dynamics. Based on this framework, we propose three hardware-efficient bosonic QEC codes that are suitable for χ(2 )-interaction based quantum computation in multimode Fock bases: the χ(2 ) parity-check code, the χ(2 ) embedded error-correcting code, and the χ(2 ) binomial code. All of these QEC codes detect photon-loss or photon-gain errors by means of photon-number parity measurements, and then correct them via χ(2 ) Hamiltonian evolutions and linear-optics transformations. Our symmetry-operator framework provides a systematic procedure for finding QEC codes that are not stabilizer codes, and it enables convenient extension of a given encoding to higher-dimensional qudit bases. The χ(2 ) binomial code is of special interest because, with m ≤N identified from channel monitoring, it can correct m -photon-loss errors, or m -photon-gain errors, or (m -1 )th -order dephasing errors using logical qudits that are encoded in O (N ) photons. In comparison, other bosonic QEC codes require O (N2) photons to correct the same degree of bosonic errors. Such improved photon efficiency underscores the additional error-correction power that can be provided by channel monitoring. We develop quantum Hamming bounds for photon-loss errors in the code subspaces associated with the χ(2 ) parity-check code and the χ(2 ) embedded error-correcting code, and we prove that these codes saturate their respective bounds. Our χ(2 ) QEC codes exhibit hardware efficiency in that they address the principal error mechanisms and exploit the available physical interactions of the underlying hardware, thus reducing the physical resources required for implementing their encoding, decoding, and error-correction operations, and their universal encoded-basis gate sets.

Cirrus Cloud Retrieval Using Infrared Sounding Data: Multilevel Cloud Errors.

NASA Astrophysics Data System (ADS)

Baum, Bryan A.; Wielicki, Bruce A.

1994-01-01

In this study we perform an error analysis for cloud-top pressure retrieval using the High-Resolution Infrared Radiometric Sounder (HIRS/2) 15-µm CO2 channels for the two-layer case of transmissive cirrus overlying an overcast, opaque stratiform cloud. This analysis includes standard deviation and bias error due to instrument noise and the presence of two cloud layers, the lower of which is opaque. Instantaneous cloud pressure retrieval errors are determined for a range of cloud amounts (0.1 1.0) and cloud-top pressures (850250 mb). Large cloud-top pressure retrieval errors are found to occur when a lower opaque layer is present underneath an upper transmissive cloud layer in the satellite field of view (FOV). Errors tend to increase with decreasing upper-cloud elective cloud amount and with decreasing cloud height (increasing pressure). Errors in retrieved upper-cloud pressure result in corresponding errors in derived effective cloud amount. For the case in which a HIRS FOV has two distinct cloud layers, the difference between the retrieved and actual cloud-top pressure is positive in all casts, meaning that the retrieved upper-cloud height is lower than the actual upper-cloud height. In addition, errors in retrieved cloud pressure are found to depend upon the lapse rate between the low-level cloud top and the surface. We examined which sounder channel combinations would minimize the total errors in derived cirrus cloud height caused by instrument noise and by the presence of a lower-level cloud. We find that while the sounding channels that peak between 700 and 1000 mb minimize random errors, the sounding channels that peak at 300—500 mb minimize bias errors. For a cloud climatology, the bias errors are most critical.

Reduced error signalling in medication-naive children with ADHD: associations with behavioural variability and post-error adaptations

PubMed Central

Plessen, Kerstin J.; Allen, Elena A.; Eichele, Heike; van Wageningen, Heidi; Høvik, Marie Farstad; Sørensen, Lin; Worren, Marius Kalsås; Hugdahl, Kenneth; Eichele, Tom

2016-01-01

Background We examined the blood-oxygen level–dependent (BOLD) activation in brain regions that signal errors and their association with intraindividual behavioural variability and adaptation to errors in children with attention-deficit/hyperactivity disorder (ADHD). Methods We acquired functional MRI data during a Flanker task in medication-naive children with ADHD and healthy controls aged 8–12 years and analyzed the data using independent component analysis. For components corresponding to performance monitoring networks, we compared activations across groups and conditions and correlated them with reaction times (RT). Additionally, we analyzed post-error adaptations in behaviour and motor component activations. Results We included 25 children with ADHD and 29 controls in our analysis. Children with ADHD displayed reduced activation to errors in cingulo-opercular regions and higher RT variability, but no differences of interference control. Larger BOLD amplitude to error trials significantly predicted reduced RT variability across all participants. Neither group showed evidence of post-error response slowing; however, post-error adaptation in motor networks was significantly reduced in children with ADHD. This adaptation was inversely related to activation of the right-lateralized ventral attention network (VAN) on error trials and to task-driven connectivity between the cingulo-opercular system and the VAN. Limitations Our study was limited by the modest sample size and imperfect matching across groups. Conclusion Our findings show a deficit in cingulo-opercular activation in children with ADHD that could relate to reduced signalling for errors. Moreover, the reduced orienting of the VAN signal may mediate deficient post-error motor adaptions. Pinpointing general performance monitoring problems to specific brain regions and operations in error processing may help to guide the targets of future treatments for ADHD. PMID:26441332

Errors in otology.

PubMed

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.

The evolution of Crew Resource Management training in commercial aviation

NASA Technical Reports Server (NTRS)

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

1999-01-01

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

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

PubMed

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

2007-08-10

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

Evaluating software development characteristics: A comparison of software errors in different environments

NASA Technical Reports Server (NTRS)

Weiss, D. M.

1981-01-01

Error data obtained from two different software development environments are compared. To obtain data that was complete, accurate, and meaningful, a goal-directed data collection methodology was used. Changes made to software were monitored concurrently with its development. Similarities common to both environments are included: (1) the principal error was in the design and implementation of single routines; (2) few errors were the result of changes, required more than one attempt to correct, and resulted in other errors; (3) relatively few errors took more than a day to correct.

Moments of inclination error distribution computer program

NASA Technical Reports Server (NTRS)

Myler, T. R.

1981-01-01

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

Validation Relaxation: A Quality Assurance Strategy for Electronic Data Collection

PubMed Central

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

Validation Relaxation: A Quality Assurance Strategy for Electronic Data Collection.

PubMed

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.

SU-E-T-195: Gantry Angle Dependency of MLC Leaf Position Error

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

Ju, S; Hong, C; Kim, M

Purpose: The aim of this study was to investigate the gantry angle dependency of the multileaf collimator (MLC) leaf position error. Methods: An automatic MLC quality assurance system (AutoMLCQA) was developed to evaluate the gantry angle dependency of the MLC leaf position error using an electronic portal imaging device (EPID). To eliminate the EPID position error due to gantry rotation, we designed a reference maker (RM) that could be inserted into the wedge mount. After setting up the EPID, a reference image was taken of the RM using an open field. Next, an EPID-based picket-fence test (PFT) was performed withoutmore » the RM. These procedures were repeated at every 45° intervals of the gantry angle. A total of eight reference images and PFT image sets were analyzed using in-house software. The average MLC leaf position error was calculated at five pickets (-10, -5, 0, 5, and 10 cm) in accordance with general PFT guidelines using in-house software. This test was carried out for four linear accelerators. Results: The average MLC leaf position errors were within the set criterion of <1 mm (actual errors ranged from -0.7 to 0.8 mm) for all gantry angles, but significant gantry angle dependency was observed in all machines. The error was smaller at a gantry angle of 0° but increased toward the positive direction with gantry angle increments in the clockwise direction. The error reached a maximum value at a gantry angle of 90° and then gradually decreased until 180°. In the counter-clockwise rotation of the gantry, the same pattern of error was observed but the error increased in the negative direction. Conclusion: The AutoMLCQA system was useful to evaluate the MLC leaf position error for various gantry angles without the EPID position error. The Gantry angle dependency should be considered during MLC leaf position error analysis.« less

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

PubMed Central

2017-01-01

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

Errors in clinical laboratories or errors in laboratory medicine?

PubMed

Plebani, Mario

2006-01-01

Laboratory testing is a highly complex process and, although laboratory services are relatively safe, they are not as safe as they could or should be. Clinical laboratories have long focused their attention on quality control methods and quality assessment programs dealing with analytical aspects of testing. However, a growing body of evidence accumulated in recent decades demonstrates that quality in clinical laboratories cannot be assured by merely focusing on purely analytical aspects. The more recent surveys on errors in laboratory medicine conclude that in the delivery of laboratory testing, mistakes occur more frequently before (pre-analytical) and after (post-analytical) the test has been performed. Most errors are due to pre-analytical factors (46-68.2% of total errors), while a high error rate (18.5-47% of total errors) has also been found in the post-analytical phase. Errors due to analytical problems have been significantly reduced over time, but there is evidence that, particularly for immunoassays, interference may have a serious impact on patients. A description of the most frequent and risky pre-, intra- and post-analytical errors and advice on practical steps for measuring and reducing the risk of errors is therefore given in the present paper. Many mistakes in the Total Testing Process are called "laboratory errors", although these may be due to poor communication, action taken by others involved in the testing process (e.g., physicians, nurses and phlebotomists), or poorly designed processes, all of which are beyond the laboratory's control. Likewise, there is evidence that laboratory information is only partially utilized. A recent document from the International Organization for Standardization (ISO) recommends a new, broader definition of the term "laboratory error" and a classification of errors according to different criteria. In a modern approach to total quality, centered on patients' needs and satisfaction, the risk of errors and mistakes in pre- and post-examination steps must be minimized to guarantee the total quality of laboratory services.

The Application of Social Characteristic and L1 Optimization in the Error Correction for Network Coding in Wireless Sensor Networks

PubMed Central

Zhang, Guangzhi; Cai, Shaobin; Xiong, Naixue

2018-01-01

One of the remarkable challenges about Wireless Sensor Networks (WSN) is how to transfer the collected data efficiently due to energy limitation of sensor nodes. Network coding will increase network throughput of WSN dramatically due to the broadcast nature of WSN. However, the network coding usually propagates a single original error over the whole network. Due to the special property of error propagation in network coding, most of error correction methods cannot correct more than C/2 corrupted errors where C is the max flow min cut of the network. To maximize the effectiveness of network coding applied in WSN, a new error-correcting mechanism to confront the propagated error is urgently needed. Based on the social network characteristic inherent in WSN and L1 optimization, we propose a novel scheme which successfully corrects more than C/2 corrupted errors. What is more, even if the error occurs on all the links of the network, our scheme also can correct errors successfully. With introducing a secret channel and a specially designed matrix which can trap some errors, we improve John and Yi’s model so that it can correct the propagated errors in network coding which usually pollute exactly 100% of the received messages. Taking advantage of the social characteristic inherent in WSN, we propose a new distributed approach that establishes reputation-based trust among sensor nodes in order to identify the informative upstream sensor nodes. With referred theory of social networks, the informative relay nodes are selected and marked with high trust value. The two methods of L1 optimization and utilizing social characteristic coordinate with each other, and can correct the propagated error whose fraction is even exactly 100% in WSN where network coding is performed. The effectiveness of the error correction scheme is validated through simulation experiments. PMID:29401668

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

PubMed

Mogull, Scott A

2017-01-01

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

Detection and correction of prescription errors by an emergency department pharmacy service.

PubMed

Stasiak, Philip; Afilalo, Marc; Castelino, Tanya; Xue, Xiaoqing; Colacone, Antoinette; Soucy, Nathalie; Dankoff, Jerrald

2014-05-01

Emergency departments (EDs) are recognized as a high-risk setting for prescription errors. Pharmacist involvement may be important in reviewing prescriptions to identify and correct errors. The objectives of this study were to describe the frequency and type of prescription errors detected by pharmacists in EDs, determine the proportion of errors that could be corrected, and identify factors associated with prescription errors. This prospective observational study was conducted in a tertiary care teaching ED on 25 consecutive weekdays. Pharmacists reviewed all documented prescriptions and flagged and corrected errors for patients in the ED. We collected information on patient demographics, details on prescription errors, and the pharmacists' recommendations. A total of 3,136 ED prescriptions were reviewed. The proportion of prescriptions in which a pharmacist identified an error was 3.2% (99 of 3,136; 95% confidence interval [CI] 2.5-3.8). The types of identified errors were wrong dose (28 of 99, 28.3%), incomplete prescription (27 of 99, 27.3%), wrong frequency (15 of 99, 15.2%), wrong drug (11 of 99, 11.1%), wrong route (1 of 99, 1.0%), and other (17 of 99, 17.2%). The pharmacy service intervened and corrected 78 (78 of 99, 78.8%) errors. Factors associated with prescription errors were patient age over 65 (odds ratio [OR] 2.34; 95% CI 1.32-4.13), prescriptions with more than one medication (OR 5.03; 95% CI 2.54-9.96), and those written by emergency medicine residents compared to attending emergency physicians (OR 2.21, 95% CI 1.18-4.14). Pharmacists in a tertiary ED are able to correct the majority of prescriptions in which they find errors. Errors are more likely to be identified in prescriptions written for older patients, those containing multiple medication orders, and those prescribed by emergency residents.

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

PubMed

Taifoori, Ladan; Valiee, Sina

2015-09-01

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

The Application of Social Characteristic and L1 Optimization in the Error Correction for Network Coding in Wireless Sensor Networks.

PubMed

Zhang, Guangzhi; Cai, Shaobin; Xiong, Naixue

2018-02-03

One of the remarkable challenges about Wireless Sensor Networks (WSN) is how to transfer the collected data efficiently due to energy limitation of sensor nodes. Network coding will increase network throughput of WSN dramatically due to the broadcast nature of WSN. However, the network coding usually propagates a single original error over the whole network. Due to the special property of error propagation in network coding, most of error correction methods cannot correct more than C /2 corrupted errors where C is the max flow min cut of the network. To maximize the effectiveness of network coding applied in WSN, a new error-correcting mechanism to confront the propagated error is urgently needed. Based on the social network characteristic inherent in WSN and L1 optimization, we propose a novel scheme which successfully corrects more than C /2 corrupted errors. What is more, even if the error occurs on all the links of the network, our scheme also can correct errors successfully. With introducing a secret channel and a specially designed matrix which can trap some errors, we improve John and Yi's model so that it can correct the propagated errors in network coding which usually pollute exactly 100% of the received messages. Taking advantage of the social characteristic inherent in WSN, we propose a new distributed approach that establishes reputation-based trust among sensor nodes in order to identify the informative upstream sensor nodes. With referred theory of social networks, the informative relay nodes are selected and marked with high trust value. The two methods of L1 optimization and utilizing social characteristic coordinate with each other, and can correct the propagated error whose fraction is even exactly 100% in WSN where network coding is performed. The effectiveness of the error correction scheme is validated through simulation experiments.

SU-F-T-471: Simulated External Beam Delivery Errors Detection with a Large Area Ion Chamber Transmission Detector

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

Hoffman, D; Dyer, B; Kumaran Nair, C

Purpose: The Integral Quality Monitor (IQM), developed by iRT Systems GmbH (Koblenz, Germany) is a large-area, linac-mounted ion chamber used to monitor photon fluence during patient treatment. Our previous work evaluated the change of the ion chamber’s response to deviations from static 1×1 cm2 and 10×10 cm2 photon beams and other characteristics integral to use in external beam detection. The aim of this work is to simulate two external beam radiation delivery errors, quantify the detection of simulated errors and evaluate the reduction in patient harm resulting from detection. Methods: Two well documented radiation oncology delivery errors were selected formore » simulation. The first error was recreated by modifying a wedged whole breast treatment, removing the physical wedge and calculating the planned dose with Pinnacle TPS (Philips Radiation Oncology Systems, Fitchburg, WI). The second error was recreated by modifying a static-gantry IMRT pharyngeal tonsil plan to be delivered in 3 unmodulated fractions. A radiation oncologist evaluated the dose for simulated errors and predicted morbidity and mortality commiserate with the original reported toxicity, indicating that reported errors were approximately simulated. The ion chamber signal of unmodified treatments was compared to the simulated error signal and evaluated in Pinnacle TPS again with radiation oncologist prediction of simulated patient harm. Results: Previous work established that transmission detector system measurements are stable within 0.5% standard deviation (SD). Errors causing signal change greater than 20 SD (10%) were considered detected. The whole breast and pharyngeal tonsil IMRT simulated error increased signal by 215% and 969%, respectively, indicating error detection after the first fraction and IMRT segment, respectively. Conclusion: The transmission detector system demonstrated utility in detecting clinically significant errors and reducing patient toxicity/harm in simulated external beam delivery. Future work will evaluate detection of other smaller magnitude delivery errors.« less

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

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

Ma, T; Kumaraswamy, L

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

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

PubMed

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

2018-03-01

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

Analyzing the errors of DFT approximations for compressed water systems

NASA Astrophysics Data System (ADS)

Alfè, D.; Bartók, A. P.; Csányi, G.; Gillan, M. J.

2014-07-01

We report an extensive study of the errors of density functional theory (DFT) approximations for compressed water systems. The approximations studied are based on the widely used PBE and BLYP exchange-correlation functionals, and we characterize their errors before and after correction for 1- and 2-body errors, the corrections being performed using the methods of Gaussian approximation potentials. The errors of the uncorrected and corrected approximations are investigated for two related types of water system: first, the compressed liquid at temperature 420 K and density 1.245 g/cm3 where the experimental pressure is 15 kilobars; second, thermal samples of compressed water clusters from the trimer to the 27-mer. For the liquid, we report four first-principles molecular dynamics simulations, two generated with the uncorrected PBE and BLYP approximations and a further two with their 1- and 2-body corrected counterparts. The errors of the simulations are characterized by comparing with experimental data for the pressure, with neutron-diffraction data for the three radial distribution functions, and with quantum Monte Carlo (QMC) benchmarks for the energies of sets of configurations of the liquid in periodic boundary conditions. The DFT errors of the configuration samples of compressed water clusters are computed using QMC benchmarks. We find that the 2-body and beyond-2-body errors in the liquid are closely related to similar errors exhibited by the clusters. For both the liquid and the clusters, beyond-2-body errors of DFT make a substantial contribution to the overall errors, so that correction for 1- and 2-body errors does not suffice to give a satisfactory description. For BLYP, a recent representation of 3-body energies due to Medders, Babin, and Paesani [J. Chem. Theory Comput. 9, 1103 (2013)] gives a reasonably good way of correcting for beyond-2-body errors, after which the remaining errors are typically 0.5 mEh ≃ 15 meV/monomer for the liquid and the clusters.

Analyzing the errors of DFT approximations for compressed water systems

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

Alfè, D.; London Centre for Nanotechnology, UCL, London WC1H 0AH; Thomas Young Centre, UCL, London WC1H 0AH

We report an extensive study of the errors of density functional theory (DFT) approximations for compressed water systems. The approximations studied are based on the widely used PBE and BLYP exchange-correlation functionals, and we characterize their errors before and after correction for 1- and 2-body errors, the corrections being performed using the methods of Gaussian approximation potentials. The errors of the uncorrected and corrected approximations are investigated for two related types of water system: first, the compressed liquid at temperature 420 K and density 1.245 g/cm{sup 3} where the experimental pressure is 15 kilobars; second, thermal samples of compressed watermore » clusters from the trimer to the 27-mer. For the liquid, we report four first-principles molecular dynamics simulations, two generated with the uncorrected PBE and BLYP approximations and a further two with their 1- and 2-body corrected counterparts. The errors of the simulations are characterized by comparing with experimental data for the pressure, with neutron-diffraction data for the three radial distribution functions, and with quantum Monte Carlo (QMC) benchmarks for the energies of sets of configurations of the liquid in periodic boundary conditions. The DFT errors of the configuration samples of compressed water clusters are computed using QMC benchmarks. We find that the 2-body and beyond-2-body errors in the liquid are closely related to similar errors exhibited by the clusters. For both the liquid and the clusters, beyond-2-body errors of DFT make a substantial contribution to the overall errors, so that correction for 1- and 2-body errors does not suffice to give a satisfactory description. For BLYP, a recent representation of 3-body energies due to Medders, Babin, and Paesani [J. Chem. Theory Comput. 9, 1103 (2013)] gives a reasonably good way of correcting for beyond-2-body errors, after which the remaining errors are typically 0.5 mE{sub h} ≃ 15 meV/monomer for the liquid and the clusters.« less

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

PubMed

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

2007-03-01

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

Analysis of error-correction constraints in an optical disk.

PubMed

Roberts, J D; Ryley, A; Jones, D M; Burke, D

1996-07-10

The compact disk read-only memory (CD-ROM) is a mature storage medium with complex error control. It comprises four levels of Reed Solomon codes allied to a sequence of sophisticated interleaving strategies and 8:14 modulation coding. New storage media are being developed and introduced that place still further demands on signal processing for error correction. It is therefore appropriate to explore thoroughly the limit of existing strategies to assess future requirements. We describe a simulation of all stages of the CD-ROM coding, modulation, and decoding. The results of decoding the burst error of a prescribed number of modulation bits are discussed in detail. Measures of residual uncorrected error within a sector are displayed by C1, C2, P, and Q error counts and by the status of the final cyclic redundancy check (CRC). Where each data sector is encoded separately, it is shown that error-correction performance against burst errors depends critically on the position of the burst within a sector. The C1 error measures the burst length, whereas C2 errors reflect the burst position. The performance of Reed Solomon product codes is shown by the P and Q statistics. It is shown that synchronization loss is critical near the limits of error correction. An example is given of miscorrection that is identified by the CRC check.

Analysis of error-correction constraints in an optical disk

NASA Astrophysics Data System (ADS)

Roberts, Jonathan D.; Ryley, Alan; Jones, David M.; Burke, David

1996-07-01

The compact disk read-only memory (CD-ROM) is a mature storage medium with complex error control. It comprises four levels of Reed Solomon codes allied to a sequence of sophisticated interleaving strategies and 8:14 modulation coding. New storage media are being developed and introduced that place still further demands on signal processing for error correction. It is therefore appropriate to explore thoroughly the limit of existing strategies to assess future requirements. We describe a simulation of all stages of the CD-ROM coding, modulation, and decoding. The results of decoding the burst error of a prescribed number of modulation bits are discussed in detail. Measures of residual uncorrected error within a sector are displayed by C1, C2, P, and Q error counts and by the status of the final cyclic redundancy check (CRC). Where each data sector is encoded separately, it is shown that error-correction performance against burst errors depends critically on the position of the burst within a sector. The C1 error measures the burst length, whereas C2 errors reflect the burst position. The performance of Reed Solomon product codes is shown by the P and Q statistics. It is shown that synchronization loss is critical near the limits of error correction. An example is given of miscorrection that is identified by the CRC check.

Development and implementation of a human accuracy program in patient foodservice.

PubMed

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.

Error analysis in stereo vision for location measurement of 3D point

NASA Astrophysics Data System (ADS)

Li, Yunting; Zhang, Jun; Tian, Jinwen

2015-12-01

Location measurement of 3D point in stereo vision is subjected to different sources of uncertainty that propagate to the final result. For current methods of error analysis, most of them are based on ideal intersection model to calculate the uncertainty region of point location via intersecting two fields of view of pixel that may produce loose bounds. Besides, only a few of sources of error such as pixel error or camera position are taken into account in the process of analysis. In this paper we present a straightforward and available method to estimate the location error that is taken most of source of error into account. We summed up and simplified all the input errors to five parameters by rotation transformation. Then we use the fast algorithm of midpoint method to deduce the mathematical relationships between target point and the parameters. Thus, the expectations and covariance matrix of 3D point location would be obtained, which can constitute the uncertainty region of point location. Afterwards, we turned back to the error propagation of the primitive input errors in the stereo system and throughout the whole analysis process from primitive input errors to localization error. Our method has the same level of computational complexity as the state-of-the-art method. Finally, extensive experiments are performed to verify the performance of our methods.

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

PubMed

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

2016-01-01

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

PREVALENCE OF REFRACTIVE ERRORS IN MADRASSA STUDENTS OF HARIPUR DISTRICT.

PubMed

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

2015-01-01

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

Financial errors in dementia: Testing a neuroeconomic conceptual framework

PubMed Central

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

2013-01-01

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

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

PubMed

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

2011-03-01

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

Influence of precision of emission characteristic parameters on model prediction error of VOCs/formaldehyde from dry building material.

PubMed

Wei, Wenjuan; Xiong, Jianyin; Zhang, Yinping

2013-01-01

Mass transfer models are useful in predicting the emissions of volatile organic compounds (VOCs) and formaldehyde from building materials in indoor environments. They are also useful for human exposure evaluation and in sustainable building design. The measurement errors in the emission characteristic parameters in these mass transfer models, i.e., the initial emittable concentration (C 0), the diffusion coefficient (D), and the partition coefficient (K), can result in errors in predicting indoor VOC and formaldehyde concentrations. These errors have not yet been quantitatively well analyzed in the literature. This paper addresses this by using modelling to assess these errors for some typical building conditions. The error in C 0, as measured in environmental chambers and applied to a reference living room in Beijing, has the largest influence on the model prediction error in indoor VOC and formaldehyde concentration, while the error in K has the least effect. A correlation between the errors in D, K, and C 0 and the error in the indoor VOC and formaldehyde concentration prediction is then derived for engineering applications. In addition, the influence of temperature on the model prediction of emissions is investigated. It shows the impact of temperature fluctuations on the prediction errors in indoor VOC and formaldehyde concentrations to be less than 7% at 23±0.5°C and less than 30% at 23±2°C.

[Detection and classification of medication errors at Joan XXIII University Hospital].

PubMed

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.

Spectral Analysis of Forecast Error Investigated with an Observing System Simulation Experiment

NASA Technical Reports Server (NTRS)

Prive, N. C.; Errico, Ronald M.

2015-01-01

The spectra of analysis and forecast error are examined using the observing system simulation experiment (OSSE) framework developed at the National Aeronautics and Space Administration Global Modeling and Assimilation Office (NASAGMAO). A global numerical weather prediction model, the Global Earth Observing System version 5 (GEOS-5) with Gridpoint Statistical Interpolation (GSI) data assimilation, is cycled for two months with once-daily forecasts to 336 hours to generate a control case. Verification of forecast errors using the Nature Run as truth is compared with verification of forecast errors using self-analysis; significant underestimation of forecast errors is seen using self-analysis verification for up to 48 hours. Likewise, self analysis verification significantly overestimates the error growth rates of the early forecast, as well as mischaracterizing the spatial scales at which the strongest growth occurs. The Nature Run-verified error variances exhibit a complicated progression of growth, particularly for low wave number errors. In a second experiment, cycling of the model and data assimilation over the same period is repeated, but using synthetic observations with different explicitly added observation errors having the same error variances as the control experiment, thus creating a different realization of the control. The forecast errors of the two experiments become more correlated during the early forecast period, with correlations increasing for up to 72 hours before beginning to decrease.

Regionalized PM2.5 Community Multiscale Air Quality model performance evaluation across a continuous spatiotemporal domain.

PubMed

Reyes, Jeanette M; Xu, Yadong; Vizuete, William; Serre, Marc L

2017-01-01

The regulatory Community Multiscale Air Quality (CMAQ) model is a means to understanding the sources, concentrations and regulatory attainment of air pollutants within a model's domain. Substantial resources are allocated to the evaluation of model performance. The Regionalized Air quality Model Performance (RAMP) method introduced here explores novel ways of visualizing and evaluating CMAQ model performance and errors for daily Particulate Matter ≤ 2.5 micrometers (PM2.5) concentrations across the continental United States. The RAMP method performs a non-homogenous, non-linear, non-homoscedastic model performance evaluation at each CMAQ grid. This work demonstrates that CMAQ model performance, for a well-documented 2001 regulatory episode, is non-homogeneous across space/time. The RAMP correction of systematic errors outperforms other model evaluation methods as demonstrated by a 22.1% reduction in Mean Square Error compared to a constant domain wide correction. The RAMP method is able to accurately reproduce simulated performance with a correlation of r = 76.1%. Most of the error coming from CMAQ is random error with only a minority of error being systematic. Areas of high systematic error are collocated with areas of high random error, implying both error types originate from similar sources. Therefore, addressing underlying causes of systematic error will have the added benefit of also addressing underlying causes of random error.

Impact of gradient timing error on the tissue sodium concentration bioscale measured using flexible twisted projection imaging

NASA Astrophysics Data System (ADS)

Lu, Aiming; Atkinson, Ian C.; Vaughn, J. Thomas; Thulborn, Keith R.

2011-12-01

The rapid biexponential transverse relaxation of the sodium MR signal from brain tissue requires efficient k-space sampling for quantitative imaging in a time that is acceptable for human subjects. The flexible twisted projection imaging (flexTPI) sequence has been shown to be suitable for quantitative sodium imaging with an ultra-short echo time to minimize signal loss. The fidelity of the k-space center location is affected by the readout gradient timing errors on the three physical axes, which is known to cause image distortion for projection-based acquisitions. This study investigated the impact of these timing errors on the voxel-wise accuracy of the tissue sodium concentration (TSC) bioscale measured with the flexTPI sequence. Our simulations show greater than 20% spatially varying quantification errors when the gradient timing errors are larger than 10 μs on all three axes. The quantification is more tolerant of gradient timing errors on the Z-axis. An existing method was used to measure the gradient timing errors with <1 μs error. The gradient timing error measurement is shown to be RF coil dependent, and timing error differences of up to ˜16 μs have been observed between different RF coils used on the same scanner. The measured timing errors can be corrected prospectively or retrospectively to obtain accurate TSC values.

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

NASA Astrophysics Data System (ADS)

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

2016-03-01

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

ATC operational error analysis.

DOT National Transportation Integrated Search

1972-01-01

The primary causes of operational errors are discussed and the effects of these errors on an ATC system's performance are described. No attempt is made to specify possible error models for the spectrum of blunders that can occur although previous res...

Human error in airway facilities.

DOT National Transportation Integrated Search

2001-01-01

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

Multipath induced errors in meteorological Doppler/interferometer location systems

NASA Technical Reports Server (NTRS)

Wallace, R. G.

1984-01-01

One application of an RF interferometer aboard a low-orbiting spacecraft to determine the location of ground-based transmitters is in tracking high-altitude balloons for meteorological studies. A source of error in this application is reflection of the signal from the sea surface. Through propagating and signal analysis, the magnitude of the reflection-induced error in both Doppler frequency measurements and interferometer phase measurements was estimated. The theory of diffuse scattering from random surfaces was applied to obtain the power spectral density of the reflected signal. The processing of the combined direct and reflected signals was then analyzed to find the statistics of the measurement error. It was found that the error varies greatly during the satellite overpass and attains its maximum value at closest approach. The maximum values of interferometer phase error and Doppler frequency error found for the system configuration considered were comparable to thermal noise-induced error.

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

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

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

2015-01-01

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

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

NASA Astrophysics Data System (ADS)

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

2018-04-01

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

Social aspects of clinical errors.

PubMed

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

2009-08-01

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

First order error corrections in common introductory physics experiments

NASA Astrophysics Data System (ADS)

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

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