Sample records for errors occur frequently
-
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.
-
A description of medication errors reported by pharmacists in a neonatal intensive care unit.
Pawluk, Shane; Jaam, Myriam; Hazi, Fatima; Al Hail, Moza Sulaiman; El Kassem, Wessam; Khalifa, Hanan; Thomas, Binny; Abdul Rouf, Pallivalappila
2017-02-01
Background Patients in the Neonatal Intensive Care Unit (NICU) are at an increased risk for medication errors. Objective The objective of this study is to describe the nature and setting of medication errors occurring in patients admitted to an NICU in Qatar based on a standard electronic system reported by pharmacists. Setting Neonatal intensive care unit, Doha, Qatar. Method This was a retrospective cross-sectional study on medication errors reported electronically by pharmacists in the NICU between January 1, 2014 and April 30, 2015. Main outcome measure Data collected included patient information, and incident details including error category, medications involved, and follow-up completed. Results A total of 201 NICU pharmacists-reported medication errors were submitted during the study period. All reported errors did not reach the patient and did not cause harm. Of the errors reported, 98.5% occurred in the prescribing phase of the medication process with 58.7% being due to calculation errors. Overall, 53 different medications were documented in error reports with the anti-infective agents being the most frequently cited. The majority of incidents indicated that the primary prescriber was contacted and the error was resolved before reaching the next phase of the medication process. Conclusion Medication errors reported by pharmacists occur most frequently in the prescribing phase of the medication process. Our data suggest that error reporting systems need to be specific to the population involved. Special attention should be paid to frequently used medications in the NICU as these were responsible for the greatest numbers of medication errors.
-
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.
-
Jurgens, Anneke; Anderson, Angelika; Moore, Dennis W
2012-01-01
To investigate the integrity with which parents and carers implement PECS in naturalistic settings, utilizing a sample of videos obtained from YouTube. Twenty-one YouTube videos meeting selection criteria were identified. The videos were reviewed for instances of seven implementer errors and, where appropriate, presence of a physical prompter. Forty-three per cent of videos and 61% of PECS exchanges contained errors in parent implementation of specific teaching strategies of the PECS training protocol. Vocal prompts, incorrect error correction and the absence of timely reinforcement occurred most frequently, while gestural prompts, insistence on speech, incorrect use of the open hand prompt and not waiting for the learner to initiate occurred less frequently. Results suggest that parents engage in vocal prompting and incorrect use of the 4-step error correction strategy when using PECS with their children, errors likely to result in prompt dependence.
-
Macrae, Toby; Tyler, Ann A
2014-10-01
The authors compared preschool children with co-occurring speech sound disorder (SSD) and language impairment (LI) to children with SSD only in their numbers and types of speech sound errors. In this post hoc quasi-experimental study, independent samples t tests were used to compare the groups in the standard score from different tests of articulation/phonology, percent consonants correct, and the number of omission, substitution, distortion, typical, and atypical error patterns used in the production of different wordlists that had similar levels of phonetic and structural complexity. In comparison with children with SSD only, children with SSD and LI used similar numbers but different types of errors, including more omission patterns ( p < .001, d = 1.55) and fewer distortion patterns ( p = .022, d = 1.03). There were no significant differences in substitution, typical, and atypical error pattern use. Frequent omission error pattern use may reflect a more compromised linguistic system characterized by absent phonological representations for target sounds (see Shriberg et al., 2005). Research is required to examine the diagnostic potential of early frequent omission error pattern use in predicting later diagnoses of co-occurring SSD and LI and/or reading problems.
-
Error Analysis of Brailled Instructional Materials Produced by Public School Personnel in Texas
ERIC Educational Resources Information Center
Herzberg, Tina
2010-01-01
In this study, a detailed error analysis was performed to determine if patterns of errors existed in braille transcriptions. The most frequently occurring errors were the insertion of letters or words that were not contained in the original print material; the incorrect usage of the emphasis indicator; and the incorrect formatting of titles,…
-
Kalmár, Éva; Lasher, Jason Richard; Tarry, Thomas Dean; Myers, Andrea; Szakonyi, Gerda; Dombi, György; Baki, Gabriella; Alexander, Kenneth S.
2013-01-01
The availability of suppositories in Hungary, especially in clinical pharmacy practice, is usually provided by extemporaneous preparations. Due to the known advantages of rectal drug administration, its benefits are frequently utilized in pediatrics. However, errors during the extemporaneous manufacturing process can lead to non-homogenous drug distribution within the dosage units. To determine the root cause of these errors and provide corrective actions, we studied suppository samples prepared with exactly known errors using both cerimetric titration and HPLC technique. Our results show that the most frequent technological error occurs when the pharmacist fails to use the correct displacement factor in the calculations which could lead to a 4.6% increase/decrease in the assay in individual dosage units. The second most important source of error can occur when the molding excess is calculated solely for the suppository base. This can further dilute the final suppository drug concentration causing the assay to be as low as 80%. As a conclusion we emphasize that the application of predetermined displacement factors in calculations for the formulation of suppositories is highly important, which enables the pharmacist to produce a final product containing exactly the determined dose of an active substance despite the different densities of the components. PMID:25161378
-
Kalmár, Eva; Lasher, Jason Richard; Tarry, Thomas Dean; Myers, Andrea; Szakonyi, Gerda; Dombi, György; Baki, Gabriella; Alexander, Kenneth S
2014-09-01
The availability of suppositories in Hungary, especially in clinical pharmacy practice, is usually provided by extemporaneous preparations. Due to the known advantages of rectal drug administration, its benefits are frequently utilized in pediatrics. However, errors during the extemporaneous manufacturing process can lead to non-homogenous drug distribution within the dosage units. To determine the root cause of these errors and provide corrective actions, we studied suppository samples prepared with exactly known errors using both cerimetric titration and HPLC technique. Our results show that the most frequent technological error occurs when the pharmacist fails to use the correct displacement factor in the calculations which could lead to a 4.6% increase/decrease in the assay in individual dosage units. The second most important source of error can occur when the molding excess is calculated solely for the suppository base. This can further dilute the final suppository drug concentration causing the assay to be as low as 80%. As a conclusion we emphasize that the application of predetermined displacement factors in calculations for the formulation of suppositories is highly important, which enables the pharmacist to produce a final product containing exactly the determined dose of an active substance despite the different densities of the components.
-
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.
-
ERIC Educational Resources Information Center
Ludtke, Oliver; Marsh, Herbert W.; Robitzsch, Alexander; Trautwein, Ulrich
2011-01-01
In multilevel modeling, group-level variables (L2) for assessing contextual effects are frequently generated by aggregating variables from a lower level (L1). A major problem of contextual analyses in the social sciences is that there is no error-free measurement of constructs. In the present article, 2 types of error occurring in multilevel data…
-
Clinical errors that can occur in the treatment decision-making process in psychotherapy.
Park, Jake; Goode, Jonathan; Tompkins, Kelley A; Swift, Joshua K
2016-09-01
Clinical errors occur in the psychotherapy decision-making process whenever a less-than-optimal treatment or approach is chosen when working with clients. A less-than-optimal approach may be one that a client is unwilling to try or fully invest in based on his/her expectations and preferences, or one that may have little chance of success based on contraindications and/or limited research support. The doctor knows best and the independent choice models are two decision-making models that are frequently used within psychology, but both are associated with an increased likelihood of errors in the treatment decision-making process. In particular, these models fail to integrate all three components of the definition of evidence-based practice in psychology (American Psychological Association, 2006). In this article we describe both models and provide examples of clinical errors that can occur in each. We then introduce the shared decision-making model as an alternative that is less prone to clinical errors. PsycINFO Database Record (c) 2016 APA, all rights reserved
-
Exploring the initial steps of the testing process: frequency and nature of pre-preanalytic errors.
Carraro, Paolo; Zago, Tatiana; Plebani, Mario
2012-03-01
Few data are available on the nature of errors in the so-called pre-preanalytic phase, the initial steps of the testing process. We therefore sought to evaluate pre-preanalytic errors using a study design that enabled us to observe the initial procedures performed in the ward, from the physician's test request to the delivery of specimens in the clinical laboratory. After a 1-week direct observational phase designed to identify the operating procedures followed in 3 clinical wards, we recorded all nonconformities and errors occurring over a 6-month period. Overall, the study considered 8547 test requests, for which 15 917 blood sample tubes were collected and 52 982 tests undertaken. No significant differences in error rates were found between the observational phase and the overall study period, but underfilling of coagulation tubes was found to occur more frequently in the direct observational phase (P = 0.043). In the overall study period, the frequency of errors was found to be particularly high regarding order transmission [29 916 parts per million (ppm)] and hemolysed samples (2537 ppm). The frequency of patient misidentification was 352 ppm, and the most frequent nonconformities were test requests recorded in the diary without the patient's name and failure to check the patient's identity at the time of blood draw. The data collected in our study confirm the relative frequency of pre-preanalytic errors and underline the need to consensually prepare and adopt effective standard operating procedures in the initial steps of laboratory testing and to monitor compliance with these procedures over time.
-
How Do Simulated Error Experiences Impact Attitudes Related to Error Prevention?
Breitkreuz, Karen R; Dougal, Renae L; Wright, Melanie C
2016-10-01
The objective of this project was to determine whether simulated exposure to error situations changes attitudes in a way that may have a positive impact on error prevention behaviors. Using a stratified quasi-randomized experiment design, we compared risk perception attitudes of a control group of nursing students who received standard error education (reviewed medication error content and watched movies about error experiences) to an experimental group of students who reviewed medication error content and participated in simulated error experiences. Dependent measures included perceived memorability of the educational experience, perceived frequency of errors, and perceived caution with respect to preventing errors. Experienced nursing students perceived the simulated error experiences to be more memorable than movies. Less experienced students perceived both simulated error experiences and movies to be highly memorable. After the intervention, compared with movie participants, simulation participants believed errors occurred more frequently. Both types of education increased the participants' intentions to be more cautious and reported caution remained higher than baseline for medication errors 6 months after the intervention. This study provides limited evidence of an advantage of simulation over watching movies describing actual errors with respect to manipulating attitudes related to error prevention. Both interventions resulted in long-term impacts on perceived caution in medication administration. Simulated error experiences made participants more aware of how easily errors can occur, and the movie education made participants more aware of the devastating consequences of errors.
-
DOE Office of Scientific and Technical Information (OSTI.GOV)
Schotland, R.M.; Hartman, J.E.
1989-02-01
The accuracy in the determination of the solar constant by means of the Langley method is strongly influenced by the spatial inhomogeneities of the atmospheric aerosol. Volcanos frequently inject aerosol into the upper troposphere and lower stratosphere. This paper evaluates the solar constant error that would occur if observations had been taken throughout the plume of El Chichon observed by NASA aircraft in the fall of 1982 and the spring of 1983. A lidar method is suggested to minimize this error. 15 refs.
-
Performance Data Errors in Air Carrier Operations: Causes and Countermeasures
NASA Technical Reports Server (NTRS)
Berman, Benjamin A.; Dismukes, R Key; Jobe, Kimberly K.
2012-01-01
Several airline accidents have occurred in recent years as the result of erroneous weight or performance data used to calculate V-speeds, flap/trim settings, required runway lengths, and/or required climb gradients. In this report we consider 4 recent studies of performance data error, report our own study of ASRS-reported incidents, and provide countermeasures that can reduce vulnerability to accidents caused by performance data errors. Performance data are generated through a lengthy process involving several employee groups and computer and/or paper-based systems. Although much of the airline indUStry 's concern has focused on errors pilots make in entering FMS data, we determined that errors occur at every stage of the process and that errors by ground personnel are probably at least as frequent and certainly as consequential as errors by pilots. Most of the errors we examined could in principle have been trapped by effective use of existing procedures or technology; however, the fact that they were not trapped anywhere indicates the need for better countermeasures. Existing procedures are often inadequately designed to mesh with the ways humans process information. Because procedures often do not take into account the ways in which information flows in actual flight ops and time pressures and interruptions experienced by pilots and ground personnel, vulnerability to error is greater. Some aspects of NextGen operations may exacerbate this vulnerability. We identify measures to reduce the number of errors and to help catch the errors that occur.
-
Echeta, Genevieve; Moffett, Brady S; Checchia, Paul; Benton, Mary Kay; Klouda, Leda; Rodriguez, Fred H; Franklin, Wayne
2014-01-01
Adults with congenital heart disease (CHD) are often cared for at pediatric hospitals. There are no data describing the incidence or type of medication prescribing errors in adult patients admitted to a pediatric cardiovascular intensive care unit (CVICU). A review of patients >18 years of age admitted to the pediatric CVICU at our institution from 2009 to 2011 occurred. A comparator group <18 years of age but >70 kg (a typical adult weight) was identified. Medication prescribing errors were determined according to a commonly used adult drug reference. An independent panel consisting of a physician specializing in the care of adult CHD patients, a nurse, and a pharmacist evaluated all errors. Medication prescribing orders were classified as appropriate, underdose, overdose, or nonstandard (dosing per weight instead of standard adult dosing), and severity of error was classified. Eighty-five adult (74 patients) and 33 pediatric admissions (32 patients) met study criteria (mean age 27.5 ± 9.4 years, 53% male vs. 14.9 ± 1.8 years, 63% male). A cardiothoracic surgical procedure occurred in 81.4% of admissions. Adult admissions weighed less than pediatric admissions (72.8 ± 22.4 kg vs. 85.6 ± 14.9 kg, P < .01) but hospital length of stay was similar. (Adult 6 days [range 1-216 days]; pediatric 5 days [Range 2-123 days], P = .52.) A total of 112 prescribing errors were identified and they occurred less often in adults (42.4% of admissions vs. 66.7% of admissions, P = .02). Adults had a lower mean number of errors (0.7 errors per adult admission vs. 1.7 errors per pediatric admission, P < .01). Prescribing errors occurred most commonly with antimicrobials (n = 27). Underdosing was the most common category of prescribing error. Most prescribing errors were determined to have not caused harm to the patient. Prescribing errors occur frequently in adult patients admitted to a pediatric CVICU but occur more often in pediatric patients of adult weight. © 2013 Wiley Periodicals, Inc.
-
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.
-
Száz, Dénes; Farkas, Alexandra; Barta, András; Kretzer, Balázs; Egri, Ádám; Horváth, Gábor
2016-07-01
The theory of sky-polarimetric Viking navigation has been widely accepted for decades without any information about the accuracy of this method. Previously, we have measured the accuracy of the first and second steps of this navigation method in psychophysical laboratory and planetarium experiments. Now, we have tested the accuracy of the third step in a planetarium experiment, assuming that the first and second steps are errorless. Using the fists of their outstretched arms, 10 test persons had to estimate the elevation angles (measured in numbers of fists and fingers) of black dots (representing the position of the occluded Sun) projected onto the planetarium dome. The test persons performed 2400 elevation estimations, 48% of which were more accurate than ±1°. We selected three test persons with the (i) largest and (ii) smallest elevation errors and (iii) highest standard deviation of the elevation error. From the errors of these three persons, we calculated their error function, from which the North errors (the angles with which they deviated from the geographical North) were determined for summer solstice and spring equinox, two specific dates of the Viking sailing period. The range of possible North errors Δ ω N was the lowest and highest at low and high solar elevations, respectively. At high elevations, the maximal Δ ω N was 35.6° and 73.7° at summer solstice and 23.8° and 43.9° at spring equinox for the best and worst test person (navigator), respectively. Thus, the best navigator was twice as good as the worst one. At solstice and equinox, high elevations occur the most frequently during the day, thus high North errors could occur more frequently than expected before. According to our findings, the ideal periods for sky-polarimetric Viking navigation are immediately after sunrise and before sunset, because the North errors are the lowest at low solar elevations.
-
Száz, Dénes; Farkas, Alexandra; Barta, András; Kretzer, Balázs; Egri, Ádám
2016-01-01
The theory of sky-polarimetric Viking navigation has been widely accepted for decades without any information about the accuracy of this method. Previously, we have measured the accuracy of the first and second steps of this navigation method in psychophysical laboratory and planetarium experiments. Now, we have tested the accuracy of the third step in a planetarium experiment, assuming that the first and second steps are errorless. Using the fists of their outstretched arms, 10 test persons had to estimate the elevation angles (measured in numbers of fists and fingers) of black dots (representing the position of the occluded Sun) projected onto the planetarium dome. The test persons performed 2400 elevation estimations, 48% of which were more accurate than ±1°. We selected three test persons with the (i) largest and (ii) smallest elevation errors and (iii) highest standard deviation of the elevation error. From the errors of these three persons, we calculated their error function, from which the North errors (the angles with which they deviated from the geographical North) were determined for summer solstice and spring equinox, two specific dates of the Viking sailing period. The range of possible North errors ΔωN was the lowest and highest at low and high solar elevations, respectively. At high elevations, the maximal ΔωN was 35.6° and 73.7° at summer solstice and 23.8° and 43.9° at spring equinox for the best and worst test person (navigator), respectively. Thus, the best navigator was twice as good as the worst one. At solstice and equinox, high elevations occur the most frequently during the day, thus high North errors could occur more frequently than expected before. According to our findings, the ideal periods for sky-polarimetric Viking navigation are immediately after sunrise and before sunset, because the North errors are the lowest at low solar elevations. PMID:27493566
-
Evidence of Selection against Complex Mitotic-Origin Aneuploidy during Preimplantation Development
McCoy, Rajiv C.; Demko, Zachary P.; Ryan, Allison; Banjevic, Milena; Hill, Matthew; Sigurjonsson, Styrmir; Rabinowitz, Matthew; Petrov, Dmitri A.
2015-01-01
Whole-chromosome imbalances affect over half of early human embryos and are the leading cause of pregnancy loss. While these errors frequently arise in oocyte meiosis, many such whole-chromosome abnormalities affecting cleavage-stage embryos are the result of chromosome missegregation occurring during the initial mitotic cell divisions. The first wave of zygotic genome activation at the 4–8 cell stage results in the arrest of a large proportion of embryos, the vast majority of which contain whole-chromosome abnormalities. Thus, the full spectrum of meiotic and mitotic errors can only be detected by sampling after the initial cell divisions, but prior to this selective filter. Here, we apply 24-chromosome preimplantation genetic screening (PGS) to 28,052 single-cell day-3 blastomere biopsies and 18,387 multi-cell day-5 trophectoderm biopsies from 6,366 in vitro fertilization (IVF) cycles. We precisely characterize the rates and patterns of whole-chromosome abnormalities at each developmental stage and distinguish errors of meiotic and mitotic origin without embryo disaggregation, based on informative chromosomal signatures. We show that mitotic errors frequently involve multiple chromosome losses that are not biased toward maternal or paternal homologs. This outcome is characteristic of spindle abnormalities and chaotic cell division detected in previous studies. In contrast to meiotic errors, our data also show that mitotic errors are not significantly associated with maternal age. PGS patients referred due to previous IVF failure had elevated rates of mitotic error, while patients referred due to recurrent pregnancy loss had elevated rates of meiotic error, controlling for maternal age. These results support the conclusion that mitotic error is the predominant mechanism contributing to pregnancy losses occurring prior to blastocyst formation. This high-resolution view of the full spectrum of whole-chromosome abnormalities affecting early embryos provides insight into the cytogenetic mechanisms underlying their formation and the consequences for human fertility. PMID:26491874
-
Medication regimens of frail older adults after discharge from home health care
Lancaster, Rachelle; Marek, Karen Dorman; Bub, Linda Denison; Stetzer, Frank
2015-01-01
The purpose of this study was to examine the number and types of discrepancy errors present after discharge from home health care in older adults at risk for medication management problems following an episode of home healthcare. More than half of the 414 participants had at least one medication discrepancy error (53.2%, n=219) with the participant’s omission of a prescribed medication (n=118, 30.17%) occurring most frequently. The results of this study support the need for home health clinicians to perform frequent assessments of medication regimens to ensure that the older adults are aware of the regimen they are prescribed, and have systems in place to support them in managing their medications. PMID:25268528
-
Evaluation of drug administration errors in a teaching hospital
2012-01-01
Background Medication errors can occur at any of the three steps of the medication use process: prescribing, dispensing and administration. We aimed to determine the incidence, type and clinical importance of drug administration errors and to identify risk factors. Methods Prospective study based on disguised observation technique in four wards in a teaching hospital in Paris, France (800 beds). A pharmacist accompanied nurses and witnessed the preparation and administration of drugs to all patients during the three drug rounds on each of six days per ward. Main outcomes were number, type and clinical importance of errors and associated risk factors. Drug administration error rate was calculated with and without wrong time errors. Relationship between the occurrence of errors and potential risk factors were investigated using logistic regression models with random effects. Results Twenty-eight nurses caring for 108 patients were observed. Among 1501 opportunities for error, 415 administrations (430 errors) with one or more errors were detected (27.6%). There were 312 wrong time errors, ten simultaneously with another type of error, resulting in an error rate without wrong time error of 7.5% (113/1501). The most frequently administered drugs were the cardiovascular drugs (425/1501, 28.3%). The highest risks of error in a drug administration were for dermatological drugs. No potentially life-threatening errors were witnessed and 6% of errors were classified as having a serious or significant impact on patients (mainly omission). In multivariate analysis, the occurrence of errors was associated with drug administration route, drug classification (ATC) and the number of patient under the nurse's care. Conclusion Medication administration errors are frequent. The identification of its determinants helps to undertake designed interventions. PMID:22409837
-
Evaluation of drug administration errors in a teaching hospital.
Berdot, Sarah; Sabatier, Brigitte; Gillaizeau, Florence; Caruba, Thibaut; Prognon, Patrice; Durieux, Pierre
2012-03-12
Medication errors can occur at any of the three steps of the medication use process: prescribing, dispensing and administration. We aimed to determine the incidence, type and clinical importance of drug administration errors and to identify risk factors. Prospective study based on disguised observation technique in four wards in a teaching hospital in Paris, France (800 beds). A pharmacist accompanied nurses and witnessed the preparation and administration of drugs to all patients during the three drug rounds on each of six days per ward. Main outcomes were number, type and clinical importance of errors and associated risk factors. Drug administration error rate was calculated with and without wrong time errors. Relationship between the occurrence of errors and potential risk factors were investigated using logistic regression models with random effects. Twenty-eight nurses caring for 108 patients were observed. Among 1501 opportunities for error, 415 administrations (430 errors) with one or more errors were detected (27.6%). There were 312 wrong time errors, ten simultaneously with another type of error, resulting in an error rate without wrong time error of 7.5% (113/1501). The most frequently administered drugs were the cardiovascular drugs (425/1501, 28.3%). The highest risks of error in a drug administration were for dermatological drugs. No potentially life-threatening errors were witnessed and 6% of errors were classified as having a serious or significant impact on patients (mainly omission). In multivariate analysis, the occurrence of errors was associated with drug administration route, drug classification (ATC) and the number of patient under the nurse's care. Medication administration errors are frequent. The identification of its determinants helps to undertake designed interventions.
-
Hubbeling, Dieneke
2016-09-01
This paper addresses the concept of moral luck. Moral luck is discussed in the context of medical error, especially an error of omission that occurs frequently, but only rarely has adverse consequences. As an example, a failure to compare the label on a syringe with the drug chart results in the wrong medication being administered and the patient dies. However, this error may have previously occurred many times with no tragic consequences. Discussions on moral luck can highlight conflicting intuitions. Should perpetrators receive a harsher punishment because of an adverse outcome, or should they be dealt with in the same way as colleagues who have acted similarly, but with no adverse effects? An additional element to the discussion, specifically with medical errors, is that according to the evidence currently available, punishing individual practitioners does not seem to be effective in preventing future errors. The following discussion, using relevant philosophical and empirical evidence, posits a possible solution for the moral luck conundrum in the context of medical error: namely, making a distinction between the duty to make amends and assigning blame. Blame should be assigned on the basis of actual behavior, while the duty to make amends is dependent on the outcome.
-
Speech Production in Hearing-Impaired Children.
ERIC Educational Resources Information Center
Gold, Toni
1980-01-01
Investigations in recent years have indicated that only about 20% of the speech output of the deaf is understood by the "person on the street." This lack of intelligibility has been associated with some frequently occurring segmental and suprasegmental errors. Journal Availability: Elsevier North Holland, Inc., 52 Vanderbilt Avenue, New York, NY…
-
Lobb, M L; Stern, J A
1986-08-01
Sequential patterns of eye and eyelid motion were identified in seven subjects performing a modified serial probe recognition task under drowsy conditions. Using simultaneous EOG and video recordings, eyelid motion was divided into components above, within, and below the pupil and the durations in sequence were recorded. A serial probe recognition task was modified to allow for distinguishing decision errors from attention errors. Decision errors were found to be more frequent following a downward shift in the gaze angle which the eyelid closing sequence was reduced from a five element to a three element sequence. The velocity of the eyelid moving over the pupil during decision errors was slow in the closing and fast in the reopening phase, while on decision correct trials it was fast in closing and slower in reopening. Due to the high variability of eyelid motion under drowsy conditions these findings were only marginally significant. When a five element blink occurred, the velocity of the lid over pupil motion component of these endogenous eye blinks was significantly faster on decision correct than on decision error trials. Furthermore, the highly variable, long duration closings associated with the decision response produced slow eye movements in the horizontal plane (SEM) which were more frequent and significantly longer in duration on decision error versus decision correct responses.
-
Verbal Intrusions Precede Memory Decline in Adults with Down Syndrome
ERIC Educational Resources Information Center
Kittler, P.; Krinsky-McHale, S. J.; Devenny, D. A.
2006-01-01
Background: Verbal intrusion errors are irrelevant responses made in the course of verbal memory retrieval or language production that have been associated with disruption of executive functions and the prefrontal cortex. They have been observed to occur more frequently both with normal aging and with neurodegenerative diseases such as Alzheimer's…
-
Discriminative echolocation in a porpoise, 12
Turner, Ronald N.; Norris, Kenneth S.
1966-01-01
Operant conditioning techniques were used to establish a discriminative echolocation performance in a porpoise. Pairs of spheres of disparate diameters were presented in an under-water display, and the positions of the spheres were switched according to a scrambled sequence while the blindfolded porpoise responded on a pair of submerged response levers. Responses which identified the momentary state of the display were food-reinforced, while those which did not (errors) produced time out. Errors were then studied in relation to decreased disparity between the spheres. As disparity was decreased, errors which terminated runs of correct responses occurred more frequently and were followed by longer strings of consecutive errors. Increased errors and disruption of a stable pattern of collateral behavior were associated. Since some sources of error other than decreased disparity were present, the porpoise's final performance did not fully reflect the acuity of its echolocation channel. PMID:5964509
-
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.
-
Pourrain, Laure; Serin, Michel; Dautriche, Anne; Jacquetin, Fréderic; Jarny, Christophe; Ballenecker, Isabelle; Bahous, Mickaël; Sgro, Catherine
2018-06-07
Medication errors are the most frequent medical care adverse events in France. Their management process used in hospital remains poorly applied in primary ambulatory care. The main objective of our study was to assess medication error management in general ambulatory practice. The secondary objectives were the characterization of the errors and the analysis of their root causes in order to implement corrective measures. The study was performed in a pluriprofessionnal health care house, applying the stages and tools validated by the French high health authority, that we previously adapted to ambulatory medical cares. During the 3 months study 4712 medical consultations were performed and we collected 64 medication errors. Most of affected patients were at the extreme ages of life (9,4 % before 9 years and 64 % after 70 years). Medication errors occurred at home in 39,1 % of cases, at pluriprofessionnal health care house (25,0 %) or at drugstore (17,2 %). They led to serious clinical consequences (classified as major, critical or catastrophic) in 17,2 % of cases. Drug induced adverse effects occurred in 5 patients, 3 of them needing hospitalization (1 patient recovered, 1 displayed sequelae and 1 died). In more than half of cases, the errors occurred at prescribing stage. The most frequent type of errors was the use of a wrong drug, different from that indicated for the patient (37,5 %) and poor treatment adherence (18,75 %). The systemic reported causes were a care process dysfunction (in coordination or procedure), the health care action context (patient home, not planned act, professional overwork), human factors such as patient and professional condition. The professional team adherence to the study was excellent. Our study demonstrates, for the first time in France, that medication errors management in ambulatory general medical care can be implemented in a pluriprofessionnal health care house with two conditions: the presence of a trained team coordinator, and the use of validated adapted and simple processes and tools. This study also shows that medications errors in general practice are specific of the care process organization. We identified vulnerable points, as transferring and communication between home and care facilities or conversely, medical coordination and involvement of the patient himself in his care. Copyright © 2018 Société française de pharmacologie et de thérapeutique. Published by Elsevier Masson SAS. All rights reserved.
-
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.
-
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
-
First-year Analysis of the Operating Room Black Box Study.
Jung, James J; Jüni, Peter; Lebovic, Gerald; Grantcharov, Teodor
2018-06-18
To characterize intraoperative errors, events, and distractions, and measure technical skills of surgeons in minimally invasive surgery practice. Adverse events in the operating room (OR) are common contributors of morbidity and mortality in surgical patients. Adverse events often occur due to deviations in performance and environmental factors. Although comprehensive intraoperative data analysis and transparent disclosure have been advocated to better understand how to improve surgical safety, they have rarely been done. We conducted a prospective cohort study in 132 consecutive patients undergoing elective laparoscopic general surgery at an academic hospital during the first year after the definite implementation of a multiport data capture system called the OR Black Box to identify intraoperative errors, events, and distractions. Expert analysts characterized intraoperative distractions, errors, and events, and measured trainee involvement as main operator. Technical skills were compared, crude and risk-adjusted, among the attending surgeon and trainees. Auditory distractions occurred a median of 138 times per case [interquartile range (IQR) 96-190]. At least 1 cognitive distraction appeared in 84 cases (64%). Medians of 20 errors (IQR 14-36) and 8 events (IQR 4-12) were identified per case. Both errors and events occurred often in dissection and reconstruction phases of operation. Technical skills of residents were lower than those of the attending surgeon (P = 0.015). During elective laparoscopic operations, frequent intraoperative errors and events, variation in surgeons' technical skills, and a high amount of environmental distractions were identified using the OR Black Box.
-
Refractive errors in a Brazilian population: age and sex distribution.
Ferraz, Fabio H; Corrente, José E; Opromolla, Paula; Padovani, Carlos Roberto; Schellini, Silvana A
2015-01-01
To determine the prevalence of refractive errors and their distribution according to age and sex in a Brazilian population. This population-based cross-sectional study involved 7654 Brazilian inhabitants of nine municipalities of Sao Paulo State, Brazil, between March 2004 and July 2005. Participants aged >1 year were selected using a random, stratified, household cluster sampling technique, excluding individuals with previous refractive or cataract surgery. Myopia was defined as spherical equivalent (SE) ≤-0.5D, high myopia as SE ≤-3.0D, hyperopia as SE ≥+0.5D, high hyperopia as SE ≥+3D, astigmatism as ≤-0.5DC and anisometropia as ≥1.0D difference between eyes. Age, sex, complaints and a comprehensive eye examination including cycloplegic refraction test were collected and analysed using descriptive analysis, univariate and multivariate methods. The prevalence of astigmatism was 59.7%, hyperopia 33.8% and myopia was 25.3%. Astigmatism had a progressive increase with age. With-the-rule (WTR) axes of astigmatism were more frequently observed in the young participants and the against-the-rule (ATR) axes were more frequent in the older subjects. The onset of myopia occurred more frequently between the 2nd and 3rd decades of life. Anisometropia showed a prevalence of 13.2% (95% CI 12.4-13.9; p < 0.001). There was an association between age and all types of refractive error and hyperopia was also associated with sex. Hyperopia was associated with WTR axes (odds ratio 0.73; 95% CI: 0.6-0.8; p < 0.001) and myopia with ATR axes (odds ratio 0.66; 95% CI: 0.6-0.8; p < 0.001). Astigmatism was the most prevalent refractive error in a Brazilian population. There was a strong relationship between age and all refractive errors and between hyperopia and sex. WTR astigmatism was more frequently associated with hyperopia and ATR astigmatism with myopia. The vast majority of participants had low-grade refractive error, which favours planning aimed at correction of refractive error in the population. © 2014 The Authors Ophthalmic & Physiological Optics © 2014 The College of Optometrists.
-
Information technology and medication safety: what is the benefit?
Kaushal, R; Bates, D
2002-01-01
Medication errors occur frequently and have significant clinical and financial consequences. Several types of information technologies can be used to decrease rates of medication errors. Computerized physician order entry with decision support significantly reduces serious inpatient medication error rates in adults. Other available information technologies that may prove effective for inpatients include computerized medication administration records, robots, automated pharmacy systems, bar coding, "smart" intravenous devices, and computerized discharge prescriptions and instructions. In outpatients, computerization of prescribing and patient oriented approaches such as personalized web pages and delivery of web based information may be important. Public and private mandates for information technology interventions are growing, but further development, application, evaluation, and dissemination are required. PMID:12486992
-
Accuracy of references and quotations in veterinary journals.
Hinchcliff, K W; Bruce, N J; Powers, J D; Kipp, M L
1993-02-01
The accuracy of references and quotations used to substantiate statements of fact in articles published in 6 frequently cited veterinary journals was examined. Three hundred references were randomly selected, and the accuracy of each citation was examined. A subset of 100 references was examined for quotational accuracy; ie, the accuracy with which authors represented the work or assertions of the author being cited. Of the 300 references selected, 295 were located, and 125 major errors were found in 88 (29.8%) of them. Sixty-seven (53.6%) major errors were found involving authors, 12 (9.6%) involved the article title, 14 (11.2%) involved the book or journal title, and 32 (25.6%) involved the volume number, date, or page numbers. Sixty-eight minor errors were detected. The accuracy of 111 quotations from 95 citations in 65 articles was examined. Nine quotations were technical and not classified, 86 (84.3%) were classified as correct, 2 (1.9%) contained minor misquotations, and 14 (13.7%) contained major misquotations. We concluded that misquotations and errors in citations occur frequently in veterinary journals, but at a rate similar to that reported for other biomedical journals.
-
ERIC Educational Resources Information Center
VanDerHeyden, Amanda M.; Burns, Matthew K.; Bonifay, Wesley
2018-01-01
Screening is necessary to detect risk and prevent reading failure. Yet the amount of screening that commonly occurs in U.S. schools may undermine its value, creating more error in decision making and lost instructional opportunity. This 2-year longitudinal study examined the decision accuracy associated with collecting concurrent reading screening…
-
Utilizing measure-based feedback in control-mastery theory: A clinical error.
Snyder, John; Aafjes-van Doorn, Katie
2016-09-01
Clinical errors and ruptures are an inevitable part of clinical practice. Often times, therapists are unaware that a clinical error or rupture has occurred, leaving no space for repair, and potentially leading to patient dropout and/or less effective treatment. One way to overcome our blind spots is by frequently and systematically collecting measure-based feedback from the patient. Patient feedback measures that focus on the process of psychotherapy such as the Patient's Experience of Attunement and Responsiveness scale (PEAR) can be used in conjunction with treatment outcome measures such as the Outcome Questionnaire 45.2 (OQ-45.2) to monitor the patient's therapeutic experience and progress. The regular use of these types of measures can aid clinicians in the identification of clinical errors and the associated patient deterioration that might otherwise go unnoticed and unaddressed. The current case study describes an instance of clinical error that occurred during the 2-year treatment of a highly traumatized young woman. The clinical error was identified using measure-based feedback and subsequently understood and addressed from the theoretical standpoint of the control-mastery theory of psychotherapy. An alternative hypothetical response is also presented and explained using control-mastery theory. (PsycINFO Database Record (c) 2016 APA, all rights reserved).
-
DOE Office of Scientific and Technical Information (OSTI.GOV)
Hashii, Haruko, E-mail: haruko@pmrc.tsukuba.ac.jp; Hashimoto, Takayuki; Okawa, Ayako
2013-03-01
Purpose: Radiation therapy for cancer may be required for patients with implantable cardiac devices. However, the influence of secondary neutrons or scattered irradiation from high-energy photons (≥10 MV) on implantable cardioverter-defibrillators (ICDs) is unclear. This study was performed to examine this issue in 2 ICD models. Methods and Materials: ICDs were positioned around a water phantom under conditions simulating clinical radiation therapy. The ICDs were not irradiated directly. A control ICD was positioned 140 cm from the irradiation isocenter. Fractional irradiation was performed with 18-MV and 10-MV photon beams to give cumulative in-field doses of 600 Gy and 1600 Gy,more » respectively. Errors were checked after each fraction. Soft errors were defined as severe (change to safety back-up mode), moderate (memory interference, no changes in device parameters), and minor (slight memory change, undetectable by computer). Results: Hard errors were not observed. For the older ICD model, the incidences of severe, moderate, and minor soft errors at 18 MV were 0.75, 0.5, and 0.83/50 Gy at the isocenter. The corresponding data for 10 MV were 0.094, 0.063, and 0 /50 Gy. For the newer ICD model at 18 MV, these data were 0.083, 2.3, and 5.8 /50 Gy. Moderate and minor errors occurred at 18 MV in control ICDs placed 140 cm from the isocenter. The error incidences were 0, 1, and 0 /600 Gy at the isocenter for the newer model, and 0, 1, and 6 /600Gy for the older model. At 10 MV, no errors occurred in control ICDs. Conclusions: ICD errors occurred more frequently at 18 MV irradiation, which suggests that the errors were mainly caused by secondary neutrons. Soft errors of ICDs were observed with high energy photon beams, but most were not critical in the newer model. These errors may occur even when the device is far from the irradiation field.« less
-
Morbi, Abigail H M; Hamady, Mohamad S; Riga, Celia V; Kashef, Elika; Pearch, Ben J; Vincent, Charles; Moorthy, Krishna; Vats, Amit; Cheshire, Nicholas J W; Bicknell, Colin D
2012-08-01
To determine the type and frequency of errors during vascular interventional radiology (VIR) and design and implement an intervention to reduce error and improve efficiency in this setting. Ethical guidance was sought from the Research Services Department at Imperial College London. Informed consent was not obtained. Field notes were recorded during 55 VIR procedures by a single observer. Two blinded assessors identified failures from field notes and categorized them into one or more errors by using a 22-part classification system. The potential to cause harm, disruption to procedural flow, and preventability of each failure was determined. A preprocedural team rehearsal (PPTR) was then designed and implemented to target frequent preventable potential failures. Thirty-three procedures were observed subsequently to determine the efficacy of the PPTR. Nonparametric statistical analysis was used to determine the effect of intervention on potential failure rates, potential to cause harm and procedural flow disruption scores (Mann-Whitney U test), and number of preventable failures (Fisher exact test). Before intervention, 1197 potential failures were recorded, of which 54.6% were preventable. A total of 2040 errors were deemed to have occurred to produce these failures. Planning error (19.7%), staff absence (16.2%), equipment unavailability (12.2%), communication error (11.2%), and lack of safety consciousness (6.1%) were the most frequent errors, accounting for 65.4% of the total. After intervention, 352 potential failures were recorded. Classification resulted in 477 errors. Preventable failures decreased from 54.6% to 27.3% (P < .001) with implementation of PPTR. Potential failure rates per hour decreased from 18.8 to 9.2 (P < .001), with no increase in potential to cause harm or procedural flow disruption per failure. Failures during VIR procedures are largely because of ineffective planning, communication error, and equipment difficulties, rather than a result of technical or patient-related issues. Many of these potential failures are preventable. A PPTR is an effective means of targeting frequent preventable failures, reducing procedural delays and improving patient safety.
-
Word-initial rhotic clusters in Spanish-speaking preschoolers in Chile and Granada, Spain.
Perez, Denisse; Vivar, Pilar; Bernhardt, Barbara May; Mendoza, Elvira; Ávila, Carmen; Carballo, Gloria; Fresneda, Dolores; Muñoz, Juana; Vergara, Patricio
2018-01-01
The current paper describes Spanish acquisition of rhotic onset clusters. Data are also provided on related singleton taps/trills and /l/ as a singleton and in clusters. Participants included 9 typically developing (TD) toddlers and 30 TD preschoolers in Chile, and 30 TD preschoolers and 29 with protracted phonological development (PPD) in Granada, Spain. Results showed age and developmental group effects. Preservation of cluster timing units preceded segmental accuracy, especially in stressed syllables. Tap clusters versus singleton trills were variable in order of mastery, some children mastering clusters first, and others, the trill. Rhotics were acquired later than /l/. In early development, mismatches (errors) involved primarily deletion of taps; where substitutions occurred, [j] frequently replaced tap. In later development, [l] more frequently replaced tap; where taps did occur, vowel epenthesis sometimes occurred. The data serve as a criterion reference database for onset cluster acquisition in Chilean and Granada Spanish.
-
Muroi, Maki; Shen, Jay J; Angosta, Alona
2017-02-01
Registered nurses (RNs) play an important role in safe medication administration and patient safety. This study examined a total of 1276 medication error (ME) incident reports made by RNs in hospital inpatient settings in the southwestern region of the United States. The most common drug class associated with MEs was cardiovascular drugs (24.7%). Among this class, anticoagulants had the most errors (11.3%). The antimicrobials was the second most common drug class associated with errors (19.1%) and vancomycin was the most common antimicrobial that caused errors in this category (6.1%). MEs occurred more frequently in the medical-surgical and intensive care units than any other hospital units. Ten percent of MEs reached the patients with harm and 11% reached the patients with increased monitoring. Understanding the contributing factors related to MEs, addressing and eliminating risk of errors across hospital units, and providing education and resources for nurses may help reduce MEs. Copyright © 2016 Elsevier Inc. All rights reserved.
-
DOE Office of Scientific and Technical Information (OSTI.GOV)
Barbee, D; McCarthy, A; Galavis, P
Purpose: Errors found during initial physics plan checks frequently require replanning and reprinting, resulting decreased departmental efficiency. Additionally, errors may be missed during physics checks, resulting in potential treatment errors or interruption. This work presents a process control created using the Eclipse Scripting API (ESAPI) enabling dosimetrists and physicists to detect potential errors in the Eclipse treatment planning system prior to performing any plan approvals or printing. Methods: Potential failure modes for five categories were generated based on available ESAPI (v11) patient object properties: Images, Contours, Plans, Beams, and Dose. An Eclipse script plugin (PlanCheck) was written in C# tomore » check errors most frequently observed clinically in each of the categories. The PlanCheck algorithms were devised to check technical aspects of plans, such as deliverability (e.g. minimum EDW MUs), in addition to ensuring that policy and procedures relating to planning were being followed. The effect on clinical workflow efficiency was measured by tracking the plan document error rate and plan revision/retirement rates in the Aria database over monthly intervals. Results: The number of potential failure modes the PlanCheck script is currently capable of checking for in the following categories: Images (6), Contours (7), Plans (8), Beams (17), and Dose (4). Prior to implementation of the PlanCheck plugin, the observed error rates in errored plan documents and revised/retired plans in the Aria database was 20% and 22%, respectively. Error rates were seen to decrease gradually over time as adoption of the script improved. Conclusion: A process control created using the Eclipse scripting API enabled plan checks to occur within the planning system, resulting in reduction in error rates and improved efficiency. Future work includes: initiating full FMEA for planning workflow, extending categories to include additional checks outside of ESAPI via Aria database queries, and eventual automated plan checks.« less
-
Antidepressant and antipsychotic medication errors reported to United States poison control centers.
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.
-
Claims, errors, and compensation payments in medical malpractice litigation.
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.
-
Kessels-Habraken, Marieke; Van der Schaaf, Tjerk; De Jonge, Jan; Rutte, Christel
2010-05-01
Medical errors in health care still occur frequently. Unfortunately, errors cannot be completely prevented and 100% safety can never be achieved. Therefore, in addition to error reduction strategies, health care organisations could also implement strategies that promote timely error detection and correction. Reporting and analysis of so-called near misses - usually defined as incidents without adverse consequences for patients - are necessary to gather information about successful error recovery mechanisms. This study establishes the need for a clearer and more consistent definition of near misses to enable large-scale reporting and analysis in order to obtain such information. Qualitative incident reports and interviews were collected on four units of two Dutch general hospitals. Analysis of the 143 accompanying error handling processes demonstrated that different incident types each provide unique information about error handling. Specifically, error handling processes underlying incidents that did not reach the patient differed significantly from those of incidents that reached the patient, irrespective of harm, because of successful countermeasures that had been taken after error detection. We put forward two possible definitions of near misses and argue that, from a practical point of view, the optimal definition may be contingent on organisational context. Both proposed definitions could yield large-scale reporting of near misses. Subsequent analysis could enable health care organisations to improve the safety and quality of care proactively by (1) eliminating failure factors before real accidents occur, (2) enhancing their ability to intercept errors in time, and (3) improving their safety culture. Copyright 2010 Elsevier Ltd. All rights reserved.
-
Errors in clinical laboratories or errors in laboratory medicine?
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.
-
Schipler, Agnes; Iliakis, George
2013-09-01
Although the DNA double-strand break (DSB) is defined as a rupture in the double-stranded DNA molecule that can occur without chemical modification in any of the constituent building blocks, it is recognized that this form is restricted to enzyme-induced DSBs. DSBs generated by physical or chemical agents can include at the break site a spectrum of base alterations (lesions). The nature and number of such chemical alterations define the complexity of the DSB and are considered putative determinants for repair pathway choice and the probability that errors will occur during this processing. As the pathways engaged in DSB processing show distinct and frequently inherent propensities for errors, pathway choice also defines the error-levels cells opt to accept. Here, we present a classification of DSBs on the basis of increasing complexity and discuss how complexity may affect processing, as well as how it may cause lethal or carcinogenic processing errors. By critically analyzing the characteristics of DSB repair pathways, we suggest that all repair pathways can in principle remove lesions clustering at the DSB but are likely to fail when they encounter clusters of DSBs that cause a local form of chromothripsis. In the same framework, we also analyze the rational of DSB repair pathway choice.
-
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.
-
Wilde, M C; Boake, C; Sherer, M
2000-01-01
Final broken configuration errors on the Wechsler Adult Intelligence Scale-Revised (WAIS-R; Wechsler, 1981) Block Design subtest were examined in 50 moderate and severe nonpenetrating traumatically brain injured adults. Patients were divided into left (n = 15) and right hemisphere (n = 19) groups based on a history of unilateral craniotomy for treatment of an intracranial lesion and were compared to a group with diffuse or negative brain CT scan findings and no history of neurosurgery (n = 16). The percentage of final broken configuration errors was related to injury severity, Benton Visual Form Discrimination Test (VFD; Benton, Hamsher, Varney, & Spreen, 1983) total score and the number of VFD rotation and peripheral errors. The percentage of final broken configuration errors was higher in the patients with right craniotomies than in the left or no craniotomy groups, which did not differ. Broken configuration errors did not occur more frequently on designs without an embedded grid pattern. Right craniotomy patients did not show a greater percentage of broken configuration errors on nongrid designs as compared to grid designs.
-
Illusory conjunctions of pitch and duration in unfamiliar tone sequences.
Thompson, W F; Hall, M D; Pressing, J
2001-02-01
In 3 experiments, the authors examined short-term memory for pitch and duration in unfamiliar tone sequences. Participants were presented a target sequence consisting of 2 tones (Experiment 1) or 7 tones (Experiments 2 and 3) and then a probe tone. Participants indicated whether the probe tone matched 1 of the target tones in both pitch and duration. Error rates were relatively low if the probe tone matched 1 of the target tones or if it differed from target tones in pitch, duration, or both. Error rates were remarkably high, however, if the probe tone combined the pitch of 1 target tone with the duration of a different target tone. The results suggest that illusory conjunctions of these dimensions frequently occur. A mathematical model is presented that accounts for the relative contribution of pitch errors, duration errors, and illusory conjunctions of pitch and duration.
-
Medication errors in home care: a qualitative focus group study.
Berland, Astrid; Bentsen, Signe Berit
2017-11-01
To explore registered nurses' experiences of medication errors and patient safety in home care. The focus of care for older patients has shifted from institutional care towards a model of home care. Medication errors are common in this situation and can result in patient morbidity and mortality. An exploratory qualitative design with focus group interviews was used. Four focus group interviews were conducted with 20 registered nurses in home care. The data were analysed using content analysis. Five categories were identified as follows: lack of information, lack of competence, reporting medication errors, trade name products vs. generic name products, and improving routines. Medication errors occur frequently in home care and can threaten the safety of patients. Insufficient exchange of information and poor communication between the specialist and home-care health services, and between general practitioners and healthcare workers can lead to medication errors. A lack of competence in healthcare workers can also lead to medication errors. To prevent these, it is important that there should be up-to-date information and communication between healthcare workers during the transfer of patients from specialist to home care. Ensuring competence among healthcare workers with regard to medication is also important. In addition, there should be openness and accurate reporting of medication errors, as well as in setting routines for the preparation, alteration and administration of medicines. To prevent medication errors in home care, up-to-date information and communication between healthcare workers is important when patients are transferred from specialist to home care. It is also important to ensure adequate competence with regard to medication, and that there should be openness when medication errors occur, as well as in setting routines for the preparation, alteration and administration of medications. © 2017 John Wiley & Sons Ltd.
-
Fabbretti, G
2010-06-01
Because of its complex nature, surgical pathology practice is prone to error. In this report, we describe our methods for reducing error as much as possible during the pre-analytical and analytical phases. This was achieved by revising procedures, and by using computer technology and automation. Most mistakes are the result of human error in the identification and matching of patient and samples. To avoid faulty data interpretation, we employed a new comprehensive computer system that acquires all patient ID information directly from the hospital's database with a remote order entry; it also provides label and request forms via-Web where clinical information is required before sending the sample. Both patient and sample are identified directly and immediately at the site where the surgical procedures are performed. Barcode technology is used to input information at every step and automation is used for sample blocks and slides to avoid errors that occur when information is recorded or transferred by hand. Quality control checks occur at every step of the process to ensure that none of the steps are left to chance and that no phase is dependent on a single operator. The system also provides statistical analysis of errors so that new strategies can be implemented to avoid repetition. In addition, the staff receives frequent training on avoiding errors and new developments. The results have been shown promising results with a very low error rate (0.27%). None of these compromised patient health and all errors were detected before the release of the diagnosis report.
-
Vitamin D intoxication: case report
Marins, Tatiana Aporta; Galvão, Tatiana de Fátima Gonçalves; Korkes, Fernando; Malerbi, Domingos Augusto Cherino; Ganc, Arnaldo José; Korn, Davi; Wagner, Jairo; Guerra, João Carlos de Campos; Borges, Wladimir Mendes; Ferracini, Fábio Teixeira; Korkes, Hélio
2014-01-01
ABSTRACT Hypervitaminosis D is a rarely reported condition. In general it is only perceived when hypercalcemia is not resolved. The use of vitamin D has increased in recent years because of its benefits, but as a result, intoxication cases have occurred more frequently. This report describes a patient who presented worsening of renal function and hypercalcemia. After investigation, vitamin D intoxication was confirmed and it was due to an error in compounding. PMID:25003934
-
An error taxonomy system for analysis of haemodialysis incidents.
Gu, Xiuzhu; Itoh, Kenji; Suzuki, Satoshi
2014-12-01
This paper describes the development of a haemodialysis error taxonomy system for analysing incidents and predicting the safety status of a dialysis organisation. The error taxonomy system was developed by adapting an error taxonomy system which assumed no specific specialty to haemodialysis situations. Its application was conducted with 1,909 incident reports collected from two dialysis facilities in Japan. Over 70% of haemodialysis incidents were reported as problems or complications related to dialyser, circuit, medication and setting of dialysis condition. Approximately 70% of errors took place immediately before and after the four hours of haemodialysis therapy. Error types most frequently made in the dialysis unit were omission and qualitative errors. Failures or complications classified to staff human factors, communication, task and organisational factors were found in most dialysis incidents. Device/equipment/materials, medicine and clinical documents were most likely to be involved in errors. Haemodialysis nurses were involved in more incidents related to medicine and documents, whereas dialysis technologists made more errors with device/equipment/materials. This error taxonomy system is able to investigate incidents and adverse events occurring in the dialysis setting but is also able to estimate safety-related status of an organisation, such as reporting culture. © 2014 European Dialysis and Transplant Nurses Association/European Renal Care Association.
-
Schipler, Agnes; Iliakis, George
2013-01-01
Although the DNA double-strand break (DSB) is defined as a rupture in the double-stranded DNA molecule that can occur without chemical modification in any of the constituent building blocks, it is recognized that this form is restricted to enzyme-induced DSBs. DSBs generated by physical or chemical agents can include at the break site a spectrum of base alterations (lesions). The nature and number of such chemical alterations define the complexity of the DSB and are considered putative determinants for repair pathway choice and the probability that errors will occur during this processing. As the pathways engaged in DSB processing show distinct and frequently inherent propensities for errors, pathway choice also defines the error-levels cells opt to accept. Here, we present a classification of DSBs on the basis of increasing complexity and discuss how complexity may affect processing, as well as how it may cause lethal or carcinogenic processing errors. By critically analyzing the characteristics of DSB repair pathways, we suggest that all repair pathways can in principle remove lesions clustering at the DSB but are likely to fail when they encounter clusters of DSBs that cause a local form of chromothripsis. In the same framework, we also analyze the rational of DSB repair pathway choice. PMID:23804754
-
Paediatric Refractive Errors in an Eye Clinic in Osogbo, Nigeria.
Michaeline, Isawumi; Sheriff, Agboola; Bimbo, Ayegoro
2016-03-01
Paediatric ophthalmology is an emerging subspecialty in Nigeria and as such there is paucity of data on refractive errors in the country. This study set out to determine the pattern of refractive errors in children attending an eye clinic in South West Nigeria. A descriptive study of 180 consecutive subjects seen over a 2-year period. Presenting complaints, presenting visual acuity (PVA), age and sex were recorded. Clinical examination of the anterior and posterior segments of the eyes, extraocular muscle assessment and refraction were done. The types of refractive errors and their grades were determined. Corrected VA was obtained. Data was analysed using descriptive statistics in proportions, chi square with p value <0.05. The age range of subjects was between 3 and 16 years with mean age = 11.7 and SD = 0.51; with males making up 33.9%.The commonest presenting complaint was blurring of distant vision (40%), presenting visual acuity 6/9 (33.9%), normal vision constituted >75.0%, visual impairment20% and low vision 23.3%. Low grade spherical and cylindrical errors occurred most frequently (35.6% and 59.9% respectively). Regular astigmatism was significantly more common, P <0.001. The commonest diagnosis was simple myopic astigmatism (41.1%). Four cases of strabismus were seen. Simple spherical and cylindrical errors were the commonest types of refractive errors seen. Visual impairment and low vision occurred and could be a cause of absenteeism from school. Low-cost spectacle production or dispensing unit and health education are advocated for the prevention of visual impairment in a hospital set-up.
-
Automation, decision support, and expert systems in nephrology.
Soman, Sandeep; Zasuwa, Gerard; Yee, Jerry
2008-01-01
Increasing data suggest that errors in medicine occur frequently and result in substantial harm to the patient. The Institute of Medicine report described the magnitude of the problem, and public interest in this issue, which was already large, has grown. The traditional approach in medicine has been to identify the persons making the errors and recommend corrective strategies. However, it has become increasingly clear that it is more productive to focus on the systems and processes through which care is provided. If these systems are set up in ways that would both make errors less likely and identify those that do occur and, at the same time, improve efficiency, then safety and productivity would be substantially improved. Clinical decision support systems (CDSSs) are active knowledge systems that use 2 or more items of patient data to generate case specific recommendations. CDSSs are typically designed to integrate a medical knowledge base, patient data, and an inference engine to generate case specific advice. This article describes how automation, templating, and CDSS improve efficiency, patient care, and safety by reducing the frequency and consequences of medical errors in nephrology. We discuss practical applications of these in 3 settings: a computerized anemia-management program (CAMP, Henry Ford Health System, Detroit, MI), vascular access surveillance systems, and monthly capitation notes in the hemodialysis unit.
-
Strain accumulation in southern California, 1973-1980.
Savage, J.C.; Prescott, W.H.; Lisowski, M.; King, N.E.
1981-01-01
Frequent surveys of seven trilateration networks in southern California over the interval 1973-1980 suggest that a regional increment in strain may have occurred in 1978-1979. Prior to 1978 and after late 1979 the strain accumulation has been predominantly a uniaxial north-south compression. This secular trend was interrupted sometime in 1978-1979 by an increment in both north-south and east-west extension in five of the seven networks. The onset of this change appears to have occurred first in the networks farthest south. The changes occurred without any unusual seismicity within the networks, but the overall seismicity in southern California was unusually low prior to and has been unusually high since the occurrence. The average principal strain rates for the seven networks in the 1973-1980 interval are 0.17 mu strain/yr north- south contraction and 0.08 mu strain/yr east-west extension. Although the observed increment in strain could be related to unidentified systematic error in the measuring system, a careful review of the measurements and comparisons with three other measuring systems reveal no appreciable cumulative systematic error. -Authors
-
[Detection and classification of medication errors at Joan XXIII University Hospital].
Jornet Montaña, S; Canadell Vilarrasa, L; Calabuig Mũoz, M; Riera Sendra, G; Vuelta Arce, M; Bardají Ruiz, A; Gallart Mora, M J
2004-01-01
Medication errors are multifactorial and multidisciplinary, and may originate in processes such as drug prescription, transcription, dispensation, preparation and administration. The goal of this work was to measure the incidence of detectable medication errors that arise within a unit dose drug distribution and control system, from drug prescription to drug administration, by means of an observational method confined to the Pharmacy Department, as well as a voluntary, anonymous report system. The acceptance of this voluntary report system's implementation was also assessed. A prospective descriptive study was conducted. Data collection was performed at the Pharmacy Department from a review of prescribed medical orders, a review of pharmaceutical transcriptions, a review of dispensed medication and a review of medication returned in unit dose medication carts. A voluntary, anonymous report system centralized in the Pharmacy Department was also set up to detect medication errors. Prescription errors were the most frequent (1.12%), closely followed by dispensation errors (1.04%). Transcription errors (0.42%) and administration errors (0.69%) had the lowest overall incidence. Voluntary report involved only 4.25% of all detected errors, whereas unit dose medication cart review contributed the most to error detection. Recognizing the incidence and types of medication errors that occur in a health-care setting allows us to analyze their causes and effect changes in different stages of the process in order to ensure maximal patient safety.
-
Hasebe, Satoshi; Nonaka, Fumitaka; Ohtsuki, Hiroshi
2005-11-01
A model of the cross-link interactions between accommodation and convergence predicted that heterophoria can induce large accommodation errors (Schor, Ophthalmic Physiol. Opt. 1999;19:134-150). In 99 consecutive patients with intermittent tropia or decompensated phoria, we tested these interactions by comparing their accommodative responses to a 2.50-D target under binocular fused conditions (BFC) and monocular occluded conditions (MOC). The accommodative response in BFC frequently differed from that in MOC. The magnitude of the accommodative errors in BFC, ranging from an accommodative lag of 1.80 D (in an esophoric patient) to an accommodative lead of 1.56 D (in an exophoric patient), was correlated with distance heterophoria and uncorrected refractive errors. These results indicate that heterophoria affects the accuracy of accommodation to various degrees, as the model predicted, and that an accommodative error larger than the depth of focus of the eye occurs in exchange for binocular single vision in some heterophoric patients.
-
Ultrahigh Error Threshold for Surface Codes with Biased Noise
NASA Astrophysics Data System (ADS)
Tuckett, David K.; Bartlett, Stephen D.; Flammia, Steven T.
2018-02-01
We show that a simple modification of the surface code can exhibit an enormous gain in the error correction threshold for a noise model in which Pauli Z errors occur more frequently than X or Y errors. Such biased noise, where dephasing dominates, is ubiquitous in many quantum architectures. In the limit of pure dephasing noise we find a threshold of 43.7(1)% using a tensor network decoder proposed by Bravyi, Suchara, and Vargo. The threshold remains surprisingly large in the regime of realistic noise bias ratios, for example 28.2(2)% at a bias of 10. The performance is, in fact, at or near the hashing bound for all values of the bias. The modified surface code still uses only weight-4 stabilizers on a square lattice, but merely requires measuring products of Y instead of Z around the faces, as this doubles the number of useful syndrome bits associated with the dominant Z errors. Our results demonstrate that large efficiency gains can be found by appropriately tailoring codes and decoders to realistic noise models, even under the locality constraints of topological codes.
-
Heft Lemisphere: Exchanges Predominate in Segmental Speech Errors
ERIC Educational Resources Information Center
Nooteboom, Sieb G.; Quene, Hugo
2013-01-01
In most collections of segmental speech errors, exchanges are less frequent than anticipations and perseverations. However, it has been suggested that in inner speech exchanges might be more frequent than either anticipations or perseverations, because many half-way repaired errors (Yew...uhh...New York) are classified as repaired anticipations,…
-
Chaplain Corps Cadet Chapel Community Center Chapel Institutional Review Board Not Human Subjects Research Requirements 7 Not Human Subjects Research Form 8 Researcher Instructions - Activities Submitted to DoD IRB 9 Review 18 Not Human Subjects Errors 19 Exempt Research Most Frequent Errors 20 Most Frequent Errors for
-
Foster, Patricia L; Niccum, Brittany A; Popodi, Ellen; Townes, Jesse P; Lee, Heewook; MohammedIsmail, Wazim; Tang, Haixu
2018-06-15
Mismatch repair (MMR) is a major contributor to replication fidelity, but its impact varies with sequence context and the nature of the mismatch. Mutation accumulation experiments followed by whole-genome sequencing of MMR-defective E. coli strains yielded ≈30,000 base-pair substitutions, revealing mutational patterns across the entire chromosome. The base-pair substitution spectrum was dominated by A:T > G:C transitions, which occurred predominantly at the center base of 5'N A C3'+5'G T N3' triplets. Surprisingly, growth on minimal medium or at low temperature attenuated these mutations. Mononucleotide runs were also hotspots for base-pair substitutions, and the rate at which these occurred increased with run length. Comparison with ≈2000 base-pair substitutions accumulated in MMR-proficient strains revealed that both kinds of hotspots appeared in the wild-type spectrum and so are likely to be sites of frequent replication errors. In MMR-defective strains transitions were strand biased, occurring twice as often when A and C rather than T and G were on the lagging-strand template. Loss of nucleotide diphosphate kinase increases the cellular concentration of dCTP, which resulted in increased rates of mutations due to misinsertion of C opposite A and T. In an mmr ndk double mutant strain, these mutations were more frequent when the template A and T were on the leading strand, suggesting that lagging-strand synthesis was more error-prone or less well corrected by proofreading than was leading strand synthesis. Copyright © 2018, Genetics.
-
Using Computational Cognitive Modeling to Diagnose Possible Sources of Aviation Error
NASA Technical Reports Server (NTRS)
Byrne, M. D.; Kirlik, Alex
2003-01-01
We present a computational model of a closed-loop, pilot-aircraft-visual scene-taxiway system created to shed light on possible sources of taxi error. Creating the cognitive aspects of the model using ACT-R required us to conduct studies with subject matter experts to identify experiential adaptations pilots bring to taxiing. Five decision strategies were found, ranging from cognitively-intensive but precise, to fast, frugal but robust. We provide evidence for the model by comparing its behavior to a NASA Ames Research Center simulation of Chicago O'Hare surface operations. Decision horizons were highly variable; the model selected the most accurate strategy given time available. We found a signature in the simulation data of the use of globally robust heuristics to cope with short decision horizons as revealed by errors occurring most frequently at atypical taxiway geometries or clearance routes. These data provided empirical support for the model.
-
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).
-
Verleger, Rolf; Śmigasiewicz, Kamila
2016-01-01
The P3 component of event-related potentials increases when stimuli are rarely presented. It has been assumed that this oddball effect (rare-frequent difference) reflects the unexpectedness of rare stimuli. The assumption of unexpectedness and its link to P3 amplitude were tested here. A standard- oddball task requiring alternative key-press responses to frequent and rare stimuli was compared with an oddball-prediction task where stimuli had to be first predicted and then confirmed by key-pressing. Oddball effects in the prediction task depended on whether the frequent or the rare stimulus had been predicted. Oddball effects on P3 amplitudes and error rates in the standard oddball task closely resembled effects after frequent predictions. This corroborates the notion that these effects occur because frequent stimuli are expected and rare stimuli are unexpected. However, a closer look at the prediction task put this notion into doubt because the modifications of oddball effects on P3 by expectancies were entirely due to effects on frequent stimuli, whereas the large P3 amplitudes evoked by rare stimuli were insensitive to predictions (unlike response times and error rates). Therefore, rare stimuli cannot be said to evoke large P3 amplitudes because they are unexpected. We discuss these diverging effects of frequency and expectancy, as well as general differences between tasks, with respect to concepts and hypotheses about P3b’s function and conclude that each discussed concept or hypothesis encounters some problems, with a conception in terms of subjective relevance assigned to stimuli offering the most consistent account of these basic effects. PMID:27512527
-
How to conduct External Quality Assessment Schemes for the pre-analytical phase?
Kristensen, Gunn B B; Aakre, Kristin Moberg; Kristoffersen, Ann Helen; Sandberg, Sverre
2014-01-01
In laboratory medicine, several studies have described the most frequent errors in the different phases of the total testing process, and a large proportion of these errors occur in the pre-analytical phase. Schemes for registration of errors and subsequent feedback to the participants have been conducted for decades concerning the analytical phase by External Quality Assessment (EQA) organizations operating in most countries. The aim of the paper is to present an overview of different types of EQA schemes for the pre-analytical phase, and give examples of some existing schemes. So far, very few EQA organizations have focused on the pre-analytical phase, and most EQA organizations do not offer pre-analytical EQA schemes (EQAS). It is more difficult to perform and standardize pre-analytical EQAS and also, accreditation bodies do not ask the laboratories for results from such schemes. However, some ongoing EQA programs for the pre-analytical phase do exist, and some examples are given in this paper. The methods used can be divided into three different types; collecting information about pre-analytical laboratory procedures, circulating real samples to collect information about interferences that might affect the measurement procedure, or register actual laboratory errors and relate these to quality indicators. These three types have different focus and different challenges regarding implementation, and a combination of the three is probably necessary to be able to detect and monitor the wide range of errors occurring in the pre-analytical phase.
-
Neglect dyslexia: a review of the neuropsychological literature.
Vallar, Giuseppe; Burani, Cristina; Arduino, Lisa S
2010-10-01
Neglect dyslexia (ND) is reviewed, based on published single-patient and group studies. ND is frequently associated with right hemispheric damage and unilateral spatial neglect (USN), and typically involves the left side of the letter string. Left-brain-damaged patients showing ND, ipsilateral (left) or contralateral (right) to the side of the left-sided hemispheric lesion, have also been reported, as well as a few patients with bilateral damage, with more frequently left than right ND. As USN, ND is temporarily ameliorated by lateralized stimulations (vestibular caloric, visual prism adaptation). ND may occur independent of USN, suggesting the damage to specific visuospatial representational/attentional systems, supporting reading. ND errors comprise omission, substitution, and, less frequently, addition of letters on one side of the stimulus, resulting in words or nonwords, also with reference to the stimulus' linguistic features. Patients with ND may show preserved lexical-morphological effects and implicit processing, up to the semantic level, of the misread string. This preserved processing is a feature of ND, shared with the USN syndrome. The mechanisms modulating error type and lexical-morphological effects are partly independent of each other. Different levels of representation of the letter string may be affected, giving rise to egocentric, stimulus-centred, and word-centred patterns of impairment. The anatomical correlates of ND include the temporo-parieto-occipital regions.
-
Bradshaw, Kelsey M.; Donohue, Brad; Wilks, Chelsey
2014-01-01
Errors have been found to frequently occur in the management of case records within mental health service systems. In cases involving interpersonal violence, such errors have been found to negatively impact service implementation and lead to significant trauma and fatalities. In an effort to ensure adherence to specified standards of care, quality assurance programs (QA) have been developed to monitor and enhance service implementation. These programs have generally been successful in facilitating record management. However, these systems are rarely disseminated, and not well integrated. Therefore, within the context of interpersonal violence, we provide an extensive review of evidence supported record keeping practices, and methods to assist in assuring these practices are implemented with adherence. PMID:24976786
-
Piketty, Marie-Liesse; Polak, Michel; Flechtner, Isabelle; Gonzales-Briceño, Laura; Souberbielle, Jean-Claude
2017-05-01
Immunoassays are now commonly used for hormone measurement, in high throughput analytical platforms. Immunoassays are generally robust to interference. However, endogenous analytical error may occur in some patients; this may be encountered in biotin supplementation or in the presence of anti-streptavidin antibody, in immunoassays involving streptavidin-biotin interaction. In these cases, the interference may induce both false positive and false negative results, and simulate a seemingly coherent hormonal profile. It is to be feared that this type of errors will be more frequently observed. This review underlines the importance of keeping close interactions between biologists and clinicians to be able to correlate the hormonal assay results with the clinical picture.
-
Missed opportunities for diagnosis: lessons learned from diagnostic errors in primary care.
Goyder, Clare R; Jones, Caroline H D; Heneghan, Carl J; Thompson, Matthew J
2015-12-01
Because of the difficulties inherent in diagnosis in primary care, it is inevitable that diagnostic errors will occur. However, despite the important consequences associated with diagnostic errors and their estimated high prevalence, teaching and research on diagnostic error is a neglected area. To ascertain the key learning points from GPs' experiences of diagnostic errors and approaches to clinical decision making associated with these. Secondary analysis of 36 qualitative interviews with GPs in Oxfordshire, UK. Two datasets of semi-structured interviews were combined. Questions focused on GPs' experiences of diagnosis and diagnostic errors (or near misses) in routine primary care and out of hours. Interviews were audiorecorded, transcribed verbatim, and analysed thematically. Learning points include GPs' reliance on 'pattern recognition' and the failure of this strategy to identify atypical presentations; the importance of considering all potentially serious conditions using a 'restricted rule out' approach; and identifying and acting on a sense of unease. Strategies to help manage uncertainty in primary care were also discussed. Learning from previous examples of diagnostic errors is essential if these events are to be reduced in the future and this should be incorporated into GP training. At a practice level, learning points from experiences of diagnostic errors should be discussed more frequently; and more should be done to integrate these lessons nationally to understand and characterise diagnostic errors. © British Journal of General Practice 2015.
-
Evidence for rare capsular switching in Streptococcus agalactiae.
Martins, Elisabete Raquel; Melo-Cristino, José; Ramirez, Mário
2010-03-01
The polysaccharide capsule is a major antigenic factor in Streptococcus agalactiae (Lancefield group B streptococcus [GBS]). Previous observations suggest that exchange of capsular loci is likely to occur rather frequently in GBS, even though GBS is not known to be naturally transformable. We sought to identify and characterize putative capsular switching events, by means of a combination of phenotypic and genotypic methods, including pulsed-field gel electrophoretic profiling, multilocus sequence typing, and surface protein and pilus gene profiling. We show that capsular switching by horizontal gene transfer is not as frequent as previously suggested. Serotyping errors may be the main reason behind the overestimation of capsule switching, since phenotypic techniques are prone to errors of interpretation. The identified putative capsular transformants involved the acquisition of the entire capsular locus and were not restricted to the serotype-specific central genes, the previously suggested main mechanism underlying capsular switching. Our data, while questioning the frequency of capsular switching, provide clear evidence for in vivo capsular transformation in S. agalactiae, which may be of critical importance in planning future vaccination strategies against this pathogen.
-
Evidence for Rare Capsular Switching in Streptococcus agalactiae▿
Martins, Elisabete Raquel; Melo-Cristino, José; Ramirez, Mário
2010-01-01
The polysaccharide capsule is a major antigenic factor in Streptococcus agalactiae (Lancefield group B streptococcus [GBS]). Previous observations suggest that exchange of capsular loci is likely to occur rather frequently in GBS, even though GBS is not known to be naturally transformable. We sought to identify and characterize putative capsular switching events, by means of a combination of phenotypic and genotypic methods, including pulsed-field gel electrophoretic profiling, multilocus sequence typing, and surface protein and pilus gene profiling. We show that capsular switching by horizontal gene transfer is not as frequent as previously suggested. Serotyping errors may be the main reason behind the overestimation of capsule switching, since phenotypic techniques are prone to errors of interpretation. The identified putative capsular transformants involved the acquisition of the entire capsular locus and were not restricted to the serotype-specific central genes, the previously suggested main mechanism underlying capsular switching. Our data, while questioning the frequency of capsular switching, provide clear evidence for in vivo capsular transformation in S. agalactiae, which may be of critical importance in planning future vaccination strategies against this pathogen. PMID:20023016
-
NASA Astrophysics Data System (ADS)
Suparman, Yusep; Folmer, Henk; Oud, Johan H. L.
2014-01-01
Omitted variables and measurement errors in explanatory variables frequently occur in hedonic price models. Ignoring these problems leads to biased estimators. In this paper, we develop a constrained autoregression-structural equation model (ASEM) to handle both types of problems. Standard panel data models to handle omitted variables bias are based on the assumption that the omitted variables are time-invariant. ASEM allows handling of both time-varying and time-invariant omitted variables by constrained autoregression. In the case of measurement error, standard approaches require additional external information which is usually difficult to obtain. ASEM exploits the fact that panel data are repeatedly measured which allows decomposing the variance of a variable into the true variance and the variance due to measurement error. We apply ASEM to estimate a hedonic housing model for urban Indonesia. To get insight into the consequences of measurement error and omitted variables, we compare the ASEM estimates with the outcomes of (1) a standard SEM, which does not account for omitted variables, (2) a constrained autoregression model, which does not account for measurement error, and (3) a fixed effects hedonic model, which ignores measurement error and time-varying omitted variables. The differences between the ASEM estimates and the outcomes of the three alternative approaches are substantial.
-
[Risk and risk management in aviation].
Müller, Manfred
2004-10-01
RISK MANAGEMENT: The large proportion of human errors in aviation accidents suggested the solution--at first sight brilliant--to replace the fallible human being by an "infallible" digitally-operating computer. However, even after the introduction of the so-called HITEC-airplanes, the factor human error still accounts for 75% of all accidents. Thus, if the computer is ruled out as the ultimate safety system, how else can complex operations involving quick and difficult decisions be controlled? OPTIMIZED TEAM INTERACTION/PARALLEL CONNECTION OF THOUGHT MACHINES: Since a single person is always "highly error-prone", support and control have to be guaranteed by a second person. The independent work of mind results in a safety network that more efficiently cushions human errors. NON-PUNITIVE ERROR MANAGEMENT: To be able to tackle the actual problems, the open discussion of intervened errors must not be endangered by the threat of punishment. It has been shown in the past that progress is primarily achieved by investigating and following up mistakes, failures and catastrophes shortly after they happened. HUMAN FACTOR RESEARCH PROJECT: A comprehensive survey showed the following result: By far the most frequent safety-critical situation (37.8% of all events) consists of the following combination of risk factors: 1. A complication develops. 2. In this situation of increased stress a human error occurs. 3. The negative effects of the error cannot be corrected or eased because there are deficiencies in team interaction on the flight deck. This means, for example, that a negative social climate has the effect of a "turbocharger" when a human error occurs. It needs to be pointed out that a negative social climate is not identical with a dispute. In many cases the working climate is burdened without the responsible person even noticing it: A first negative impression, too much or too little respect, contempt, misunderstandings, not expressing unclear concern, etc. can considerably reduce the efficiency of a team.
-
ERIC Educational Resources Information Center
Stokes, Stephanie F.; Lau, Jessica Tse-Kay; Ciocca, Valter
2002-01-01
This study examined the interaction of ambient frequency and feature complexity in the diphthong errors produced by 13 Cantonese-speaking children with phonological disorders. Perceptual analysis of 611 diphthongs identified those most frequently and least frequently in error. Suggested treatment guidelines include consideration of three factors:…
-
Anderson, Ayana R; Welles, Wanda Lizak; Drew, James; Orr, Maureen F
2014-05-01
To keep swimming pool water clean and clear, consumers purchase, transport, store, use, and dispose of large amounts of potentially hazardous chemicals. Data about incidents due to the use of these chemicals and the resultant public health impacts are limited. The authors analyzed pool chemical release data from 17 states that participated in the Agency for Toxic Substances and Disease Registry's chemical event surveillance system during 2001-2009. In 400 pool chemical incidents, 60% resulted in injuries. Of the 732 injured persons, 67% were members of the public and 50% were under 18 years old. Incidents occurred most frequently in private residences (39%), but incidents with the most injured persons (34%) occurred at recreational facilities. Human error (71.9%) was the most frequent primary contributing factor, followed by equipment failure (22.8%). Interventions designed to mitigate the public health impact associated with pool chemical releases should target both private pool owners and public pool operators.
-
Foos, David H; Sehnert, W James; Reiner, Bruce; Siegel, Eliot L; Segal, Arthur; Waldman, David L
2009-03-01
Reject analysis was performed on 288,000 computed radiography (CR) image records collected from a university hospital (UH) and a large community hospital (CH). Each record contains image information, such as body part and view position, exposure level, technologist identifier, and--if the image was rejected--the reason for rejection. Extensive database filtering was required to ensure the integrity of the reject-rate calculations. The reject rate for CR across all departments and across all exam types was 4.4% at UH and 4.9% at CH. The most frequently occurring exam types with reject rates of 8% or greater were found to be common to both institutions (skull/facial bones, shoulder, hip, spines, in-department chest, pelvis). Positioning errors and anatomy cutoff were the most frequently occurring reasons for rejection, accounting for 45% of rejects at CH and 56% at UH. Improper exposure was the next most frequently occurring reject reason (14% of rejects at CH and 13% at UH), followed by patient motion (11% of rejects at CH and 7% at UH). Chest exams were the most frequently performed exam at both institutions (26% at UH and 45% at CH) with half captured in-department and half captured using portable x-ray equipment. A ninefold greater reject rate was found for in-department (9%) versus portable chest exams (1%). Problems identified with the integrity of the data used for reject analysis can be mitigated in the future by objectifying quality assurance (QA) procedures and by standardizing the nomenclature and definitions for QA deficiencies.
-
Hurford, Amy
2009-05-20
Movement data are frequently collected using Global Positioning System (GPS) receivers, but recorded GPS locations are subject to errors. While past studies have suggested methods to improve location accuracy, mechanistic movement models utilize distributions of turning angles and directional biases and these data present a new challenge in recognizing and reducing the effect of measurement error. I collected locations from a stationary GPS collar, analyzed a probabilistic model and used Monte Carlo simulations to understand how measurement error affects measured turning angles and directional biases. Results from each of the three methods were in complete agreement: measurement error gives rise to a systematic bias where a stationary animal is most likely to be measured as turning 180 degrees or moving towards a fixed point in space. These spurious effects occur in GPS data when the measured distance between locations is <20 meters. Measurement error must be considered as a possible cause of 180 degree turning angles in GPS data. Consequences of failing to account for measurement error are predicting overly tortuous movement, numerous returns to previously visited locations, inaccurately predicting species range, core areas, and the frequency of crossing linear features. By understanding the effect of GPS measurement error, ecologists are able to disregard false signals to more accurately design conservation plans for endangered wildlife.
-
Identification and correction of systematic error in high-throughput sequence data
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
-
Dialysis Facility Safety: Processes and Opportunities.
Garrick, Renee; Morey, Rishikesh
2015-01-01
Unintentional human errors are the source of most safety breaches in complex, high-risk environments. The environment of dialysis care is extremely complex. Dialysis patients have unique and changing physiology, and the processes required for their routine care involve numerous open-ended interfaces between providers and an assortment of technologically advanced equipment. Communication errors, both within the dialysis facility and during care transitions, and lapses in compliance with policies and procedures are frequent areas of safety risk. Some events, such as air emboli and needle dislodgments occur infrequently, but are serious risks. Other adverse events include medication errors, patient falls, catheter and access-related infections, access infiltrations and prolonged bleeding. A robust safety system should evaluate how multiple, sequential errors might align to cause harm. Systems of care can be improved by sharing the results of root cause analyses, and "good catches." Failure mode effects and analyses can be used to proactively identify and mitigate areas of highest risk, and methods drawn from cognitive psychology, simulation training, and human factor engineering can be used to advance facility safety. © 2015 Wiley Periodicals, Inc.
-
Programmable Infusion Pumps in ICUs: An Analysis of Corresponding Adverse Drug Events
Bower, Anthony G.; Paddock, Susan M.; Hilborne, Lee H.; Wallace, Peggy; Rothschild, Jeffrey M.; Griffin, Anne; Fairbanks, Rollin J.; Carlson, Beverly; Panzer, Robert J.; Brook, Robert H.
2007-01-01
Background Patients in intensive care units (ICUs) frequently experience adverse drug events involving intravenous medications (IV-ADEs), which are often preventable. Objectives To determine how frequently preventable IV-ADEs in ICUs match the safety features of a programmable infusion pump with safety software (“smart pump”) and to suggest potential improvements in smart-pump design. Design Using retrospective medical-record review, we examined preventable IV-ADEs in ICUs before and after 2 hospitals replaced conventional pumps with smart pumps. The smart pumps alerted users when programmed to deliver duplicate infusions or continuous-infusion doses outside hospital-defined ranges. Participants 4,604 critically ill adults at 1 academic and 1 nonacademic hospital. Measurements Preventable IV-ADEs matching smart-pump features and errors involved in preventable IV-ADEs. Results Of 100 preventable IV-ADEs identified, 4 involved errors matching smart-pump features. Two occurred before and 2 after smart-pump implementation. Overall, 29% of preventable IV-ADEs involved overdoses; 37%, failures to monitor for potential problems; and 45%, failures to intervene when problems appeared. Error descriptions suggested that expanding smart pumps’ capabilities might enable them to prevent more IV-ADEs. Conclusion The smart pumps we evaluated are unlikely to reduce preventable IV-ADEs in ICUs because they address only 4% of them. Expanding smart-pump capabilities might prevent more IV-ADEs. PMID:18095043
-
Schiefer, Ulrich; Kraus, Christina; Baumbach, Peter; Ungewiß, Judith; Michels, Ralf
2016-10-14
All over the world, refractive errors are among the most frequently occuring treatable distur - bances of visual function. Ametropias have a prevalence of nearly 70% among adults in Germany and are thus of great epidemiologic and socio-economic relevance. In the light of their own clinical experience, the authors review pertinent articles retrieved by a selective literature search employing the terms "ametropia, "anisometropia," "refraction," "visual acuity," and epidemiology." In 2011, only 31% of persons over age 16 in Germany did not use any kind of visual aid; 63.4% wore eyeglasses and 5.3% wore contact lenses. Refractive errors were the most common reason for consulting an ophthalmologist, accounting for 21.1% of all outpatient visits. A pinhole aperture (stenopeic slit) is a suitable instrument for the basic diagnostic evaluation of impaired visual function due to optical factors. Spherical refractive errors (myopia and hyperopia), cylindrical refractive errors (astigmatism), unequal refractive errors in the two eyes (anisometropia), and the typical optical disturbance of old age (presbyopia) cause specific functional limitations and can be detected by a physician who does not need to be an ophthalmologist. Simple functional tests can be used in everyday clinical practice to determine quickly, easily, and safely whether the patient is suffering from a benign and easily correctable type of visual impairment, or whether there are other, more serious underlying causes.
-
Errors in the ultrasound diagnosis of the kidneys, ureters and urinary bladder
Wieczorek, Andrzej Paweł; Tyloch, Janusz F.
2013-01-01
The article presents the most frequent errors made in the ultrasound diagnosis of the urinary system. They usually result from improper technique of ultrasound examination or its erroneous interpretation. Such errors are frequent effects of insufficient experience of the ultrasonographer, inadequate class of the scanner, insufficient knowledge of its operation as well as of wrong preparation of patients, their constitution, severe condition and the lack of cooperation during the examination. The reasons for misinterpretations of ultrasound images of the urinary system may lie in a large polymorphism of the kidney (defects and developmental variants) and may result from improper access to the organ as well as from the presence of artefacts. Errors may also result from the lack of knowledge concerning clinical and laboratory data. Moreover, mistakes in ultrasound diagnosis of the urinary system are frequently related to the lack of knowledge of the management algorithms and diagnostic possibilities of other imaging modalities. The paper lists errors in ultrasound diagnosis of the urinary system divided into: errors resulting from improper technique of examination, artefacts caused by incorrect preparation of patients for the examination or their constitution and errors resulting from misinterpretation of ultrasound images of the kidneys (such as their number, size, fluid spaces, pathological lesions and others), ureters and urinary bladder. Each physician performing kidney or bladder ultrasound examination should possess the knowledge of the most frequent errors and their causes which might help to avoid them. PMID:26674139
-
The stem cell division theory of cancer.
López-Lázaro, Miguel
2018-03-01
All cancer registries constantly show striking differences in cancer incidence by age and among tissues. For example, lung cancer is diagnosed hundreds of times more often at age 70 than at age 20, and lung cancer in nonsmokers occurs thousands of times more frequently than heart cancer in smokers. An analysis of these differences using basic concepts in cell biology indicates that cancer is the end-result of the accumulation of cell divisions in stem cells. In other words, the main determinant of carcinogenesis is the number of cell divisions that the DNA of a stem cell has accumulated in any type of cell from the zygote. Cell division, process by which a cell copies and separates its cellular components to finally split into two cells, is necessary to produce the large number of cells required for living. However, cell division can lead to a variety of cancer-promoting errors, such as mutations and epigenetic mistakes occurring during DNA replication, chromosome aberrations arising during mitosis, errors in the distribution of cell-fate determinants between the daughter cells, and failures to restore physical interactions with other tissue components. Some of these errors are spontaneous, others are promoted by endogenous DNA damage occurring during quiescence, and others are influenced by pathological and environmental factors. The cell divisions required for carcinogenesis are primarily caused by multiple local and systemic physiological signals rather than by errors in the DNA of the cells. As carcinogenesis progresses, the accumulation of DNA errors promotes cell division and eventually triggers cell division under permissive extracellular environments. The accumulation of cell divisions in stem cells drives not only the accumulation of the DNA alterations required for carcinogenesis, but also the formation and growth of the abnormal cell populations that characterize the disease. This model of carcinogenesis provides a new framework for understanding the disease and has important implications for cancer prevention and therapy. Copyright © 2018 Elsevier B.V. All rights reserved.
-
Endodontic Procedural Errors: Frequency, Type of Error, and the Most Frequently Treated Tooth.
Yousuf, Waqas; Khan, Moiz; Mehdi, Hasan
2015-01-01
Introduction. The aim of this study is to determine the most common endodontically treated tooth and the most common error produced during treatment and to note the association of particular errors with particular teeth. Material and Methods. Periapical radiographs were taken of all the included teeth and were stored and assessed using DIGORA Optime. Teeth in each group were evaluated for presence or absence of procedural errors (i.e., overfill, underfill, ledge formation, perforations, apical transportation, and/or instrument separation) and the most frequent tooth to undergo endodontic treatment was also noted. Results. A total of 1748 root canal treated teeth were assessed, out of which 574 (32.8%) contained a procedural error. Out of these 397 (22.7%) were overfilled, 155 (8.9%) were underfilled, 16 (0.9%) had instrument separation, and 7 (0.4%) had apical transportation. The most frequently treated tooth was right permanent mandibular first molar (11.3%). The least commonly treated teeth were the permanent mandibular third molars (0.1%). Conclusion. Practitioners should show greater care to maintain accuracy of the working length throughout the procedure, as errors in length accounted for the vast majority of errors and special care should be taken when working on molars.
-
Kuwabara, Masaru; Mansouri, Farshad A.; Buckley, Mark J.
2014-01-01
Monkeys were trained to select one of three targets by matching in color or matching in shape to a sample. Because the matching rule frequently changed and there were no cues for the currently relevant rule, monkeys had to maintain the relevant rule in working memory to select the correct target. We found that monkeys' error commission was not limited to the period after the rule change and occasionally occurred even after several consecutive correct trials, indicating that the task was cognitively demanding. In trials immediately after such error trials, monkeys' speed of selecting targets was slower. Additionally, in trials following consecutive correct trials, the monkeys' target selections for erroneous responses were slower than those for correct responses. We further found evidence for the involvement of the cortex in the anterior cingulate sulcus (ACCs) in these error-related behavioral modulations. First, ACCs cell activity differed between after-error and after-correct trials. In another group of ACCs cells, the activity differed depending on whether the monkeys were making a correct or erroneous decision in target selection. Second, bilateral ACCs lesions significantly abolished the response slowing both in after-error trials and in error trials. The error likelihood in after-error trials could be inferred by the error feedback in the previous trial, whereas the likelihood of erroneous responses after consecutive correct trials could be monitored only internally. These results suggest that ACCs represent both context-dependent and internally detected error likelihoods and promote modes of response selections in situations that involve these two types of error likelihood. PMID:24872558
-
A 62-year-old woman with skin cancer who experienced wrong-site surgery: review of medical error.
Gallagher, Thomas H
2009-08-12
After a life-threatening complication of an injection for neck pain several years ago, Ms W experienced a wrong-site surgery to remove a squamous cell lesion from her nose, followed by pain, distress, and shaken trust in clinicians. Her experience highlights the challenges of communicating with patients after errors. Harmful medical errors occur relatively frequently. Gaps exist between patients' expectations for disclosure and apology and physicians' ability to deliver disclosures well. This discrepancy reflects clinicians' fear of litigation, concern that disclosure might harm patients, and lack of confidence in disclosure skills. Many institutions are developing disclosure programs, and some are reporting success in coupling disclosures with early offers of compensation to patients. However, much has yet to be learned about effective disclosure strategies. Important future developments include increased emphasis on institutions' responsibility for disclosure, involving trainees and other team members in disclosure, and strengthening the relationship between disclosure and quality improvement.
-
Incidence of speech recognition errors in the emergency department.
Goss, Foster R; Zhou, Li; Weiner, Scott G
2016-09-01
Physician use of computerized speech recognition (SR) technology has risen in recent years due to its ease of use and efficiency at the point of care. However, error rates between 10 and 23% have been observed, raising concern about the number of errors being entered into the permanent medical record, their impact on quality of care and medical liability that may arise. Our aim was to determine the incidence and types of SR errors introduced by this technology in the emergency department (ED). Level 1 emergency department with 42,000 visits/year in a tertiary academic teaching hospital. A random sample of 100 notes dictated by attending emergency physicians (EPs) using SR software was collected from the ED electronic health record between January and June 2012. Two board-certified EPs annotated the notes and conducted error analysis independently. An existing classification schema was adopted to classify errors into eight errors types. Critical errors deemed to potentially impact patient care were identified. There were 128 errors in total or 1.3 errors per note, and 14.8% (n=19) errors were judged to be critical. 71% of notes contained errors, and 15% contained one or more critical errors. Annunciation errors were the highest at 53.9% (n=69), followed by deletions at 18.0% (n=23) and added words at 11.7% (n=15). Nonsense errors, homonyms and spelling errors were present in 10.9% (n=14), 4.7% (n=6), and 0.8% (n=1) of notes, respectively. There were no suffix or dictionary errors. Inter-annotator agreement was 97.8%. This is the first estimate at classifying speech recognition errors in dictated emergency department notes. Speech recognition errors occur commonly with annunciation errors being the most frequent. Error rates were comparable if not lower than previous studies. 15% of errors were deemed critical, potentially leading to miscommunication that could affect patient care. Copyright © 2016 Elsevier Ireland Ltd. All rights reserved.
-
Prescribing Errors Involving Medication Dosage Forms
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
-
Multidisciplinary optimization of an HSCT wing using a response surface methodology
DOE Office of Scientific and Technical Information (OSTI.GOV)
Giunta, A.A.; Grossman, B.; Mason, W.H.
1994-12-31
Aerospace vehicle design is traditionally divided into three phases: conceptual, preliminary, and detailed. Each of these design phases entails a particular level of accuracy and computational expense. While there are several computer programs which perform inexpensive conceptual-level aircraft multidisciplinary design optimization (MDO), aircraft MDO remains prohibitively expensive using preliminary- and detailed-level analysis tools. This occurs due to the expense of computational analyses and because gradient-based optimization requires the analysis of hundreds or thousands of aircraft configurations to estimate design sensitivity information. A further hindrance to aircraft MDO is the problem of numerical noise which occurs frequently in engineering computations. Computermore » models produce numerical noise as a result of the incomplete convergence of iterative processes, round-off errors, and modeling errors. Such numerical noise is typically manifested as a high frequency, low amplitude variation in the results obtained from the computer models. Optimization attempted using noisy computer models may result in the erroneous calculation of design sensitivities and may slow or prevent convergence to an optimal design.« less
-
Lüdtke, Oliver; Marsh, Herbert W; Robitzsch, Alexander; Trautwein, Ulrich
2011-12-01
In multilevel modeling, group-level variables (L2) for assessing contextual effects are frequently generated by aggregating variables from a lower level (L1). A major problem of contextual analyses in the social sciences is that there is no error-free measurement of constructs. In the present article, 2 types of error occurring in multilevel data when estimating contextual effects are distinguished: unreliability that is due to measurement error and unreliability that is due to sampling error. The fact that studies may or may not correct for these 2 types of error can be translated into a 2 × 2 taxonomy of multilevel latent contextual models comprising 4 approaches: an uncorrected approach, partial correction approaches correcting for either measurement or sampling error (but not both), and a full correction approach that adjusts for both sources of error. It is shown mathematically and with simulated data that the uncorrected and partial correction approaches can result in substantially biased estimates of contextual effects, depending on the number of L1 individuals per group, the number of groups, the intraclass correlation, the number of indicators, and the size of the factor loadings. However, the simulation study also shows that partial correction approaches can outperform full correction approaches when the data provide only limited information in terms of the L2 construct (i.e., small number of groups, low intraclass correlation). A real-data application from educational psychology is used to illustrate the different approaches.
-
Cross-modal illusory conjunctions between vision and touch.
Cinel, Caterina; Humphreys, Glyn W; Poli, Riccardo
2002-10-01
Cross-modal illusory conjunctions (ICs) happen when, under conditions of divided attention, felt textures are reported as being seen or vice versa. Experiments provided evidence for these errors, demonstrated that ICs are more frequent if tactile and visual stimuli are in the same hemispace, and showed that ICs still occur under forced-choice conditions but do not occur when attention to the felt texture is increased. Cross-modal ICs were also found in a patient with parietal damage even with relatively long presentations of visual stimuli. The data are consistent with there being cross-modal integration of sensory information, with the modality of origin sometimes being misattributed when attention is constrained. The empirical conclusions from the experiments are supported by formal models.
-
Medical Errors and Barriers to Reporting in Ten Hospitals in Southern Iran
Khammarnia, Mohammad; Ravangard, Ramin; Barfar, Eshagh; Setoodehzadeh, Fatemeh
2015-01-01
Background: International research shows that medical errors (MEs) are a major threat to patient safety. The present study aimed to describe MEs and barriers to reporting them in Shiraz public hospitals, Iran. Methods: A cross-sectional, retrospective study was conducted in 10 Shiraz public hospitals in the south of Iran, 2013. Using the standardised checklist of Shiraz University of Medical Sciences (referred to the Clinical Governance Department and recorded documentations) and Uribe questionnaire, we gathered the data in the hospitals. Results: A total of 4379 MEs were recorded in 10 hospitals. The highest frequency (27.1%) was related to systematic errors. Besides, most of the errors had occurred in the largest hospital (54.9%), internal wards (36.3%), and morning shifts (55.0%). The results revealed a significant association between the MEs and wards and hospitals (p < 0.001). Moreover, individual and organisational factors were the barriers to reporting ME in the studied hospitals. Also, a significant correlation was observed between the ME reporting barriers and the participants’ job experiences (p < 0.001). Conclusion: The medical errors were highly frequent in the studied hospitals especially in the larger hospitals, morning shift and in the nursing practice. Moreover, individual and organisational factors were considered as the barriers to reporting MEs. PMID:28729811
-
Examination of soldier target recognition with direct view optics
NASA Astrophysics Data System (ADS)
Long, Frederick H.; Larkin, Gabriella; Bisordi, Danielle; Dorsey, Shauna; Marianucci, Damien; Goss, Lashawnta; Bastawros, Michael; Misiuda, Paul; Rodgers, Glenn; Mazz, John P.
2017-10-01
Target recognition and identification is a problem of great military and scientific importance. To examine the correlation between target recognition and optical magnification, ten U.S. Army soldiers were tasked with identifying letters on targets at 800 and 1300 meters away. Letters were used since they are a standard method for measuring visual acuity. The letters were approximately 90 cm high, which is the size of a well-known rifle. Four direct view optics with angular magnifications of 1.5x, 4x, 6x, and 9x were used. The goal of this approach was to measure actual probabilities for correct target identification. Previous scientific literature suggests that target recognition can be modeled as a linear response problem in angular frequency space using the established values for the contrast sensitivity function for a healthy human eye and the experimentally measured modulation transfer function of the optic. At the 9x magnification, the soldiers could identify the letters with almost no errors (i.e., 97% probability of correct identification). At lower magnification, errors in letter identification were more frequent. The identification errors were not random but occurred most frequently with a few pairs of letters (e.g., O and Q), which is consistent with the literature for letter recognition. In addition, in the small subject sample of ten soldiers, there was considerable variation in the observer recognition capability at 1.5x and a range of 800 meters. This can be directly attributed to the variation in the observer visual acuity.
-
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
-
Assessment of Nonverbal and Verbal Apraxia in Patients with Parkinson's Disease
Olchik, Maira Rozenfeld; Shumacher Shuh, Artur Francisco; Rieder, Carlos R. M.
2015-01-01
Objective. To assess the presence of nonverbal and verbal apraxia in patients with Parkinson's disease (PD) and analyze the correlation between these conditions and patient age, education, duration of disease, and PD stage, as well as evaluate the correlation between the two types of apraxia and the frequency and types of verbal apraxic errors made by patients in the sample. Method. This was an observational prevalence study. The sample comprised 45 patients with PD seen at the Movement Disorders Clinic of the Clinical Hospital of Porto Alegre, Brazil. Patients were evaluated using the Speech Apraxia Assessment Protocol and PD stages were classified according to the Hoehn and Yahr scale. Results. The rate of nonverbal apraxia and verbal apraxia in the present sample was 24.4%. Verbal apraxia was significantly correlated with education (p ≤ 0.05). The most frequent types of verbal apraxic errors were omissions (70.8%). The analysis of manner and place of articulation showed that most errors occurred during the production of trill (57.7%) and dentoalveolar (92%) phonemes, consecutively. Conclusion. Patients with PD presented nonverbal and verbal apraxia and made several verbal apraxic errors. Verbal apraxia was correlated with education levels. PMID:26543663
-
Cheng, Jin-Mei; Li, Jian; Tang, Ji-Xin; Hao, Xiao-Xia; Wang, Zhi-Peng; Sun, Tie-Cheng; Wang, Xiu-Xia; Zhang, Yan; Chen, Su-Ren; Liu, Yi-Xun
2017-08-03
Mammalian oocyte chromosomes undergo 2 meiotic divisions to generate haploid gametes. The frequency of chromosome segregation errors during meiosis I increase with age. However, little attention has been paid to the question of how aging affects sister chromatid segregation during oocyte meiosis II. More importantly, how aneuploid metaphase II (MII) oocytes from aged mice evade the spindle assembly checkpoint (SAC) mechanism to complete later meiosis II to form aneuploid embryos remains unknown. Here, we report that MII oocytes from naturally aged mice exhibited substantial errors in chromosome arrangement and configuration compared with young MII oocytes. Interestingly, these errors in aged oocytes had no impact on anaphase II onset and completion as well as 2-cell formation after parthenogenetic activation. Further study found that merotelic kinetochore attachment occurred more frequently and could stabilize the kinetochore-microtubule interaction to ensure SAC inactivation and anaphase II onset in aged MII oocytes. This orientation could persist largely during anaphase II in aged oocytes, leading to severe chromosome lagging and trailing as well as delay of anaphase II completion. Therefore, merotelic kinetochore attachment in oocyte meiosis II exacerbates age-related genetic instability and is a key source of age-dependent embryo aneuploidy and dysplasia.
-
Assessment of microclimate conditions under artificial shades in a ginseng field.
Lee, Kyu Jong; Lee, Byun-Woo; Kang, Je Yong; Lee, Dong Yun; Jang, Soo Won; Kim, Kwang Soo
2016-01-01
Knowledge on microclimate conditions under artificial shades in a ginseng field would facilitate climate-aware management of ginseng production. Weather data were measured under the shade and outside the shade at two fields located in Gochang-gun and Jeongeup-si, Korea, in 2011 and 2012 seasons to assess temperature and humidity conditions under the shade. An empirical approach was developed and validated for the estimation of leaf wetness duration (LWD) using weather measurements outside the shade as inputs to the model. Air temperature and relative humidity were similar between under the shade and outside the shade. For example, temperature conditions favorable for ginseng growth, e.g., between 8°C and 27°C, occurred slightly less frequently in hours during night times under the shade (91%) than outside (92%). Humidity conditions favorable for development of a foliar disease, e.g., relative humidity > 70%, occurred slightly more frequently under the shade (84%) than outside (82%). Effectiveness of correction schemes to an empirical LWD model differed by rainfall conditions for the estimation of LWD under the shade using weather measurements outside the shade as inputs to the model. During dew eligible days, a correction scheme to an empirical LWD model was slightly effective (10%) in reducing estimation errors under the shade. However, another correction approach during rainfall eligible days reduced errors of LWD estimation by 17%. Weather measurements outside the shade and LWD estimates derived from these measurements would be useful as inputs for decision support systems to predict ginseng growth and disease development.
-
Assessment of microclimate conditions under artificial shades in a ginseng field
Lee, Kyu Jong; Lee, Byun-Woo; Kang, Je Yong; Lee, Dong Yun; Jang, Soo Won; Kim, Kwang Soo
2015-01-01
Background Knowledge on microclimate conditions under artificial shades in a ginseng field would facilitate climate-aware management of ginseng production. Methods Weather data were measured under the shade and outside the shade at two fields located in Gochang-gun and Jeongeup-si, Korea, in 2011 and 2012 seasons to assess temperature and humidity conditions under the shade. An empirical approach was developed and validated for the estimation of leaf wetness duration (LWD) using weather measurements outside the shade as inputs to the model. Results Air temperature and relative humidity were similar between under the shade and outside the shade. For example, temperature conditions favorable for ginseng growth, e.g., between 8°C and 27°C, occurred slightly less frequently in hours during night times under the shade (91%) than outside (92%). Humidity conditions favorable for development of a foliar disease, e.g., relative humidity > 70%, occurred slightly more frequently under the shade (84%) than outside (82%). Effectiveness of correction schemes to an empirical LWD model differed by rainfall conditions for the estimation of LWD under the shade using weather measurements outside the shade as inputs to the model. During dew eligible days, a correction scheme to an empirical LWD model was slightly effective (10%) in reducing estimation errors under the shade. However, another correction approach during rainfall eligible days reduced errors of LWD estimation by 17%. Conclusion Weather measurements outside the shade and LWD estimates derived from these measurements would be useful as inputs for decision support systems to predict ginseng growth and disease development. PMID:26843827
-
Frequent methodological errors in clinical research.
Silva Aycaguer, L C
2018-03-07
Several errors that are frequently present in clinical research are listed, discussed and illustrated. A distinction is made between what can be considered an "error" arising from ignorance or neglect, from what stems from a lack of integrity of researchers, although it is recognized and documented that it is not easy to establish when we are in a case and when in another. The work does not intend to make an exhaustive inventory of such problems, but focuses on those that, while frequent, are usually less evident or less marked in the various lists that have been published with this type of problems. It has been a decision to develop in detail the examples that illustrate the problems identified, instead of making a list of errors accompanied by an epidermal description of their characteristics. Copyright © 2018 Elsevier España, S.L.U. y SEMICYUC. All rights reserved.
-
Nature of nursing errors and their contributing factors in intensive care units.
Eltaybani, Sameh; Mohamed, Nadia; Abdelwareth, Mona
2018-04-27
Errors tend to be multifactorial and so learning from nurses' experiences with them would be a powerful tool toward promoting patient safety. To identify the nature of nursing errors and their contributing factors in intensive care units (ICUs). A semi-structured interview with 112 critical care nurses to elicit the reports about their encountered errors followed by a content analysis. A total of 300 errors were reported. Most of them (94·3%) were classified in more than one error category, e.g. 'lack of intervention', 'lack of attentiveness' and 'documentation errors': these were the most frequently involved error categories. Approximately 40% of reported errors contributed to significant harm or death of the involved patients, with system-related factors being involved in 84·3% of them. More errors occur during the evening shift than the night and morning shifts (42·7% versus 28·7% and 16·7%, respectively). There is a statistically significant relation (p ≤ 0·001) between error disclosure to a nursing supervisor and its impact on the patient. Nurses are more likely to report their errors when they feel safe and when the reporting system is not burdensome, although an internationally standardized language to define and analyse nursing errors is needed. Improving the health care system, particularly the managerial and environmental aspects, might reduce nursing errors in ICUs in terms of their incidence and seriousness. Targeting error-liable times in the ICU, such as mid-evening and mid-night shifts, along with improved supervision and adequate staff reallocation, might tackle the incidence and seriousness of nursing errors. Development of individualized nursing interventions for patients with low health literacy and patients in isolation might create more meaningful dialogue for ICU health care safety. © 2018 British Association of Critical Care Nurses.
-
A retrospective review of medical errors adjudicated in court between 2002 and 2012 in Spain.
Giraldo, Priscila; Sato, Luke; Sala, María; Comas, Merce; Dywer, Kathy; Castells, Xavier
2016-02-01
This paper describes verdicts in court involving injury-producing medical errors in Spain. A descriptive analysis of 1041 closed court verdicts from Spain between January 2002 and December 2012. It was determined whether a medical error had occurred, and among those with medical error (n = 270), characteristics and results of litigation were analyzed. Data on litigation were obtained from the Thomson Reuters Aranzadi Westlaw databases. All verdicts involving health system were reviewed and classified according to the presence of medical error. Among those, contributory factors, medical specialty involved, health impact (death, disability and severity) and results of litigation (resolution, time to verdict and economic compensations) were described. Medical errors were involved in 25.9% of court verdicts. The cause of medical error was a diagnosis-related problem in 25.1% and surgical treatment in 22.2%, and Obstetrics-Gynecology was the most frequent involved specialty (21%). Most of them were of high severity (59.4%), one-third (32%) caused death. The average time interval between the occurrence of the error and the verdict was 7.8 years. The average indemnity payment was €239 505.24; the highest was psychiatry (€7 585 075.86) and the lowest was Emergency Medicine (€69 871.19). This study indicates that in Spain medical errors are common among verdicts involving the health system, most of them causing high-severity adverse outcomes. The interval between the medical error and the verdict is excessive, and there is a wide range of economic compensation. © The Author 2015. Published by Oxford University Press in association with the International Society for Quality in Health Care; all rights reserved.
-
Mental representation of symbols as revealed by vocabulary errors in two bonobos (Pan paniscus).
Lyn, Heidi
2007-10-01
Error analysis has been used in humans to detect implicit representations and categories in language use. The present study utilizes the same technique to report on mental representations and categories in symbol use from two bonobos (Pan paniscus). These bonobos have been shown in published reports to comprehend English at the level of a two-and-a-half year old child and to use a keyboard with over 200 visuographic symbols (lexigrams). In this study, vocabulary test errors from over 10 years of data revealed auditory, visual, and spatio-temporal generalizations (errors were more likely items that looked like sounded like, or were frequently associated with the sample item in space or in time), as well as hierarchical and conceptual categorizations. These error data, like those of humans, are a result of spontaneous responding rather than specific training and do not solely depend upon the sample mode (e.g. auditory similarity errors are not universally more frequent with an English sample, nor were visual similarity errors universally more frequent with a photograph sample). However, unlike humans, these bonobos do not make errors based on syntactical confusions (e.g. confusing semantically unrelated nouns), suggesting that they may not separate syntactical and semantic information. These data suggest that apes spontaneously create a complex, hierarchical, web of representations when exposed to a symbol system.
-
Satellite mapping of Nile Delta coastal changes
NASA Technical Reports Server (NTRS)
Blodget, H. W.; Taylor, P. T.; Roark, J. H.
1989-01-01
Multitemporal, multispectral scanner (MSS) landsat data have been used to monitor erosion and sedimentation along the Rosetta Promontory of the Nile Delta. These processes have accelerated significantly since the completion of the Aswan High Dam in 1964. Digital differencing of four MSS data sets, using standard algorithms, show that changes observed over a single year period generally occur as strings of single mixed pixels along the coast. Therefore, these can only be used qualitatively to indicate areas where changes occur. Areas of change recorded over a multi-year period are generally larger and thus identified by clusters of pixels; this reduces errors introduced by mixed pixels. Satellites provide a synoptic perspective utilizing data acquired at frequent time intervals. This permits multiple year monitoring of delta evolution on a regional scale.
-
Pelham, Sabra D
2011-03-01
English-acquiring children frequently make pronoun case errors, while German-acquiring children rarely do. Nonetheless, German-acquiring children frequently make article case errors. It is proposed that when child-directed speech contains a high percentage of case-ambiguous forms, case errors are common in child language; when percentages are low, case errors are rare. Input to English and German children was analyzed for percentage of case-ambiguous personal pronouns on adult tiers of corpora from 24 English-acquiring and 24 German-acquiring children. Also analyzed for German was the percentage of case-ambiguous articles. Case-ambiguous pronouns averaged 63·3% in English, compared with 7·6% in German. The percentage of case-ambiguous articles in German was 77·0%. These percentages align with the children's errors reported in the literature. It appears children may be sensitive to levels of ambiguity such that low ambiguity may aid error-free acquisition, while high ambiguity may blind children to case distinctions, resulting in errors.
-
Jones, Jackie H; Treiber, Linda A
2018-04-23
Medication errors continue to occur too frequently in the United States. Although the five rights of medication administration have expanded to include several others, evidence that the number of errors has decreased is missing. This study suggests that medication rights for nurses as they administer medications are needed. The historical marginalization of the voice of nurses has been perpetuated with detrimental impacts to nurses and patients. In recent years, a focus on the creation of a just culture, with a balance of accountability and responsibility, has sought to bring a fairer and safer construct to the healthcare environment. This paper proposes that in order for a truly just culture to exist, the balance must also include nurses' authority. Only when a triumvirate of responsibility, accountability, and authority exists can an environment that supports reduced medication errors flourish. Through identification and implementation of Nurses Rights of Medication Administration, nurses' authority to control the administration process is both formalized and legitimized. Further study is needed to identify these rights and how to fully implement them. © 2018 Wiley Periodicals, Inc.
-
Delays in the operating room: signs of an imperfect system.
Wong, Janice; Khu, Kathleen Joy; Kaderali, Zul; Bernstein, Mark
2010-06-01
Delays in the operating room have a negative effect on its efficiency and the working environment. In this prospective study, we analyzed data on perioperative system delays. One neurosurgeon prospectively recorded all errors, including perioperative delays, for consecutive patients undergoing elective procedures from May 2000 to February 2009. We analyzed the prevalence, causes and impact of perioperative system delays that occurred in one neurosurgeon's practice. A total of 1531 elective surgical cases were performed during the study period. Delays were the most common type of error (33.6%), and more than half (51.4%) of all cases had at least 1 delay. The most common cause of delay was equipment failure. The first cases of the day and cranial cases had more delays than subsequent cases and spinal cases, respectively. A delay in starting the first case was associated with subsequent delays. Delays frequently occur in the operating room and have a major effect on patient flow and resource utilization. Thorough documentation of perioperative delays provides a basis for the development of solutions for improving operating room efficiency and illustrates the principles underlying the causes of operating room delays across surgical disciplines.
-
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…
-
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)
-
Douglas, Julie A.; Skol, Andrew D.; Boehnke, Michael
2002-01-01
Gene-mapping studies routinely rely on checking for Mendelian transmission of marker alleles in a pedigree, as a means of screening for genotyping errors and mutations, with the implicit assumption that, if a pedigree is consistent with Mendel’s laws of inheritance, then there are no genotyping errors. However, the occurrence of inheritance inconsistencies alone is an inadequate measure of the number of genotyping errors, since the rate of occurrence depends on the number and relationships of genotyped pedigree members, the type of errors, and the distribution of marker-allele frequencies. In this article, we calculate the expected probability of detection of a genotyping error or mutation as an inheritance inconsistency in nuclear-family data, as a function of both the number of genotyped parents and offspring and the marker-allele frequency distribution. Through computer simulation, we explore the sensitivity of our analytic calculations to the underlying error model. Under a random-allele–error model, we find that detection rates are 51%–77% for multiallelic markers and 13%–75% for biallelic markers; detection rates are generally lower when the error occurs in a parent than in an offspring, unless a large number of offspring are genotyped. Errors are especially difficult to detect for biallelic markers with equally frequent alleles, even when both parents are genotyped; in this case, the maximum detection rate is 34% for four-person nuclear families. Error detection in families in which parents are not genotyped is limited, even with multiallelic markers. Given these results, we recommend that additional error checking (e.g., on the basis of multipoint analysis) be performed, beyond routine checking for Mendelian consistency. Furthermore, our results permit assessment of the plausibility of an observed number of inheritance inconsistencies for a family, allowing the detection of likely pedigree—rather than genotyping—errors in the early stages of a genome scan. Such early assessments are valuable in either the targeting of families for resampling or discontinued genotyping. PMID:11791214
-
Sethuraman, Usha; Kannikeswaran, Nirupama; Murray, Kyle P; Zidan, Marwan A; Chamberlain, James M
2015-06-01
Prescription errors occur frequently in pediatric emergency departments (PEDs).The effect of computerized physician order entry (CPOE) with electronic medication alert system (EMAS) on these is unknown. The objective was to compare prescription errors rates before and after introduction of CPOE with EMAS in a PED. The hypothesis was that CPOE with EMAS would significantly reduce the rate and severity of prescription errors in the PED. A prospective comparison of a sample of outpatient, medication prescriptions 5 months before and after CPOE with EMAS implementation (7,268 before and 7,292 after) was performed. Error types and rates, alert types and significance, and physician response were noted. Medication errors were deemed significant if there was a potential to cause life-threatening injury, failure of therapy, or an adverse drug effect. There was a significant reduction in the errors per 100 prescriptions (10.4 before vs. 7.3 after; absolute risk reduction = 3.1, 95% confidence interval [CI] = 2.2 to 4.0). Drug dosing error rates decreased from 8 to 5.4 per 100 (absolute risk reduction = 2.6, 95% CI = 1.8 to 3.4). Alerts were generated for 29.6% of prescriptions, with 45% involving drug dose range checking. The sensitivity of CPOE with EMAS in identifying errors in prescriptions was 45.1% (95% CI = 40.8% to 49.6%), and the specificity was 57% (95% CI = 55.6% to 58.5%). Prescribers modified 20% of the dosing alerts, resulting in the error not reaching the patient. Conversely, 11% of true dosing alerts for medication errors were overridden by the prescribers: 88 (11.3%) resulted in medication errors, and 684 (88.6%) were false-positive alerts. A CPOE with EMAS was associated with a decrease in overall prescription errors in our PED. Further system refinements are required to reduce the high false-positive alert rates. © 2015 by the Society for Academic Emergency Medicine.
-
Shafto, M; MacKay, D G
2000-09-01
This study develops a new theory of the Moses illusion, observed in responses to general knowledge questions such as, "How many animals of each kind did Moses take on the Ark?" People often respond "two" rather than "zero" despite knowing that Noah, not Moses, launched the Ark. Our theory predicted two additional types of conceptual error demonstrated here: the Armstrong and mega-Moses illusions. The Armstrong illusion involved questions resembling, "What was the famous line uttered by Louis Armstrong when he first set foot on the moon?" People usually comprehend such questions as valid, despite knowing that Louis Armstrong was a jazz musician who never visited the moon. This Armstrong illusion was not due to misperceiving the critical words (Louis Armstrong), and occurred as frequently as the Moses illusion (with critical words embedded in identical sentential contexts), but less frequently than the mega-Moses illusion caused when Moses and Armstrong factors were combined.
-
F-16 Class A mishaps in the U.S. Air Force, 1975-93.
Knapp, C J; Johnson, R
1996-08-01
All USAF F-16 fighter Class A (major) aircraft mishaps from 1975-93 were analyzed, using records from the U.S. Air Force Safety Agency (AFSA). There were 190 Class A mishaps involving 204 F-16's and 217 aircrew during this 19-yr period. The overall Class A rate was 5.09 per 100,000 flight hours, more than double the overall USAF rate. The mishaps are categorized by year, month, time of day and model of aircraft in relation to mishap causes as determined and reported by AFSA. Formation position, phase of flight and primary cause of the mishap indicate that maneuvering, cruise and low-level phases account for the majority of the mishaps (71%), with air-to-air engagements associated with a higher proportion of pilot error (71%) than was air-to-ground (49%). Engine failure was the number one cause of mishaps (35%), and collision with the ground the next most frequent (24%). Pilot error was determined as causative in 55% of all the mishaps. Pilot error was often associated with other non-pilot related causes. Channelized attention, loss of situational awareness, and spatial disorientation accounted for approximately 30% of the total pilot error causes found. Pilot demographics, flight hour/sortie profiles, and aircrew injuries are also listed. Fatalities occurred in 27% of the mishaps, with 97% of those involving pilot errors.
-
[What Surgeons Should Know about Risk Management].
Strametz, R; Tannheimer, M; Rall, M
2017-02-01
Background: The fact that medical treatment is associated with errors has long been recognized. Based on the principle of "first do no harm", numerous efforts have since been made to prevent such errors or limit their impact. However, recent statistics show that these measures do not sufficiently prevent grave mistakes with serious consequences. Preventable mistakes such as wrong patient or wrong site surgery still frequently occur in error statistics. Methods: Based on insight from research on human error, in due consideration of recent legislative regulations in Germany, the authors give an overview of the clinical risk management tools needed to identify risks in surgery, analyse their causes, and determine adequate measures to manage those risks depending on their relevance. The use and limitations of critical incident reporting systems (CIRS), safety checklists and crisis resource management (CRM) are highlighted. Also the rationale for IT systems to support the risk management process is addressed. Results/Conclusion: No single tool of risk management can be effective as a standalone instrument, but unfolds its effect only when embedded in a superordinate risk management system, which integrates tailor-made elements to increase patient safety into the workflows of each organisation. Competence in choosing adequate tools, effective IT systems to support the risk management process as well as leadership and commitment to constructive handling of human error are crucial components to establish a safety culture in surgery. Georg Thieme Verlag KG Stuttgart · New York.
-
Experimental study on an FBG strain sensor
NASA Astrophysics Data System (ADS)
Liu, Hong-lin; Zhu, Zheng-wei; Zheng, Yong; Liu, Bang; Xiao, Feng
2018-01-01
Landslides and other geological disasters occur frequently and often cause high financial and humanitarian cost. The real-time, early-warning monitoring of landslides has important significance in reducing casualties and property losses. In this paper, by taking the high initial precision and high sensitivity advantage of FBG, an FBG strain sensor is designed combining FBGs with inclinometer. The sensor was regarded as a cantilever beam with one end fixed. According to the anisotropic material properties of the inclinometer, a theoretical formula between the FBG wavelength and the deflection of the sensor was established using the elastic mechanics principle. Accuracy of the formula established had been verified through laboratory calibration testing and model slope monitoring experiments. The displacement of landslide could be calculated by the established theoretical formula using the changing values of FBG central wavelength obtained by the demodulation instrument remotely. Results showed that the maximum error at different heights was 9.09%; the average of the maximum error was 6.35%, and its corresponding variance was 2.12; the minimum error was 4.18%; the average of the minimum error was 5.99%, and its corresponding variance was 0.50. The maximum error of the theoretical and the measured displacement decrease gradually, and the variance of the error also decreases gradually. This indicates that the theoretical results are more and more reliable. It also shows that the sensor and the theoretical formula established in this paper can be used for remote, real-time, high precision and early warning monitoring of the slope.
-
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.
-
Koch, Sven H; Weir, Charlene; Haar, Maral; Staggers, Nancy; Agutter, Jim; Görges, Matthias; Westenskow, Dwayne
2012-01-01
Fatal errors can occur in intensive care units (ICUs). Researchers claim that information integration at the bedside may improve nurses' situation awareness (SA) of patients and decrease errors. However, it is unclear which information should be integrated and in what form. Our research uses the theory of SA to analyze the type of tasks, and their associated information gaps. We aimed to provide recommendations for integrated, consolidated information displays to improve nurses' SA. Systematic observations methods were used to follow 19 ICU nurses for 38 hours in 3 clinical practice settings. Storyboard methods and concept mapping helped to categorize the observed tasks, the associated information needs, and the information gaps of the most frequent tasks by SA level. Consensus and discussion of the research team was used to propose recommendations to improve information displays at the bedside based on information deficits. Nurses performed 46 different tasks at a rate of 23.4 tasks per hour. The information needed to perform the most common tasks was often inaccessible, difficult to see at a distance or located on multiple monitoring devices. Current devices at the ICU bedside do not adequately support a nurse's information-gathering activities. Medication management was the most frequent category of tasks. Information gaps were present at all levels of SA and across most of the tasks. Using a theoretical model to understand information gaps can aid in designing functional requirements. Integrated information that enhances nurses' Situation Awareness may decrease errors and improve patient safety in the future.
-
Weir, Charlene; Haar, Maral; Staggers, Nancy; Agutter, Jim; Görges, Matthias; Westenskow, Dwayne
2012-01-01
Objective Fatal errors can occur in intensive care units (ICUs). Researchers claim that information integration at the bedside may improve nurses' situation awareness (SA) of patients and decrease errors. However, it is unclear which information should be integrated and in what form. Our research uses the theory of SA to analyze the type of tasks, and their associated information gaps. We aimed to provide recommendations for integrated, consolidated information displays to improve nurses' SA. Materials and Methods Systematic observations methods were used to follow 19 ICU nurses for 38 hours in 3 clinical practice settings. Storyboard methods and concept mapping helped to categorize the observed tasks, the associated information needs, and the information gaps of the most frequent tasks by SA level. Consensus and discussion of the research team was used to propose recommendations to improve information displays at the bedside based on information deficits. Results Nurses performed 46 different tasks at a rate of 23.4 tasks per hour. The information needed to perform the most common tasks was often inaccessible, difficult to see at a distance or located on multiple monitoring devices. Current devices at the ICU bedside do not adequately support a nurse's information-gathering activities. Medication management was the most frequent category of tasks. Discussion Information gaps were present at all levels of SA and across most of the tasks. Using a theoretical model to understand information gaps can aid in designing functional requirements. Conclusion Integrated information that enhances nurses' Situation Awareness may decrease errors and improve patient safety in the future. PMID:22437074
-
Concomitant prescribing and dispensing errors at a Brazilian hospital: a descriptive study
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
-
Nascimento, Eduarda Helena Leandro; Gaêta-Araujo, Hugo; Andrade, Maria Fernanda Silva; Freitas, Deborah Queiroz
2018-01-21
The aims of this study are to identify the most frequent technical errors in endodontically treated teeth and to determine which root canals were most often associated with those errors, as well as to relate endodontic technical errors and the presence of coronal restorations with periapical status by means of cone-beam computed tomography images. Six hundred eighteen endodontically treated teeth (1146 root canals) were evaluated for the quality of their endodontic treatment and for the presence of coronal restorations and periapical lesions. Each root canal was classified according to dental groups, and the endodontic technical errors were recorded. Chi-square's test and descriptive analyses were performed. Six hundred eighty root canals (59.3%) had periapical lesions. Maxillary molars and anterior teeth showed higher prevalence of periapical lesions (p < 0.05). Endodontic treatment quality and coronal restoration were associated with periapical status (p < 0.05). Underfilling was the most frequent technical error in all root canals, except for the second mesiobuccal root canal of maxillary molars and the distobuccal root canal of mandibular molars, which were non-filled in 78.4 and 30% of the cases, respectively. There is a high prevalence of apical radiolucencies, which increased in the presence of poor coronal restorations, endodontic technical errors, and when both conditions were concomitant. Underfilling was the most frequent technical error, followed by non-homogeneous and non-filled canals. Evaluation of endodontic treatment quality that considers every single root canal aims on warning dental practitioners of the prevalence of technical errors that could be avoided with careful treatment planning and execution.
-
Identifying medication error chains from critical incident reports: a new analytic approach.
Huckels-Baumgart, Saskia; Manser, Tanja
2014-10-01
Research into the distribution of medication errors usually focuses on isolated stages within the medication use process. Our study aimed to provide a novel process-oriented approach to medication incident analysis focusing on medication error chains. Our study was conducted across a 900-bed teaching hospital in Switzerland. All reported 1,591 medication errors 2009-2012 were categorized using the Medication Error Index NCC MERP and the WHO Classification for Patient Safety Methodology. In order to identify medication error chains, each reported medication incident was allocated to the relevant stage of the hospital medication use process. Only 25.8% of the reported medication errors were detected before they propagated through the medication use process. The majority of medication errors (74.2%) formed an error chain encompassing two or more stages. The most frequent error chain comprised preparation up to and including medication administration (45.2%). "Non-consideration of documentation/prescribing" during the drug preparation was the most frequent contributor for "wrong dose" during the administration of medication. Medication error chains provide important insights for detecting and stopping medication errors before they reach the patient. Existing and new safety barriers need to be extended to interrupt error chains and to improve patient safety. © 2014, The American College of Clinical Pharmacology.
-
Abou-Elsaad, Tamer; Baz, Hemmat; Afsah, Omayma; Mansy, Alzahraa
2015-09-01
Even with early surgical repair, the majority of cleft palate children demonstrate articulation errors and have typical cleft palate speech. Was to determine the nature of articulation errors of Arabic consonants in Egyptian Arabic-speaking children with velopharyngeal insufficiency (VPI). Thirty Egyptian Arabic-speaking children with VPI due to cleft palate (whether primary repaired or secondary repaired) were studied. Auditory perceptual assessment (APA) of children speech was conducted. Nasopharyngoscopy was done to assess the velopharyngeal port (VPP) movements while the child was repeating speech tasks. Mansoura Arabic Articulation test (MAAT) was performed to analyze the consonants articulation of these children. The most frequent type of articulatory errors observed was substitution, more specifically, backing. Pharyngealization of anterior fricatives was the most frequent substitution, especially for the /s/ sound. The most frequent substituting sounds for other sounds were /ʔ/ followed by /k/ and /n/ sounds. Significant correlations were found between the degrees of the open nasality and VPP closure and the articulation errors. On the other hand, the sounds (/ʔ/,/ħ/,/ʕ/,/n/,/w/,/j/) were normally articulated in all studied group. The determination of articulation errors in VPI children could guide the therapists for designing appropriate speech therapy programs for these cases. Copyright © 2015 Elsevier Ireland Ltd. All rights reserved.
-
Jiménez, Felipe; Monzón, Sergio; Naranjo, Jose Eugenio
2016-02-04
Vehicle positioning is a key factor for numerous information and assistance applications that are included in vehicles and for which satellite positioning is mainly used. However, this positioning process can result in errors and lead to measurement uncertainties. These errors come mainly from two sources: errors and simplifications of digital maps and errors in locating the vehicle. From that inaccurate data, the task of assigning the vehicle's location to a link on the digital map at every instant is carried out by map-matching algorithms. These algorithms have been developed to fulfil that need and attempt to amend these errors to offer the user a suitable positioning. In this research; an algorithm is developed that attempts to solve the errors in positioning when the Global Navigation Satellite System (GNSS) signal reception is frequently lost. The algorithm has been tested with satisfactory results in a complex urban environment of narrow streets and tall buildings where errors and signal reception losses of the GPS receiver are frequent.
-
Jiménez, Felipe; Monzón, Sergio; Naranjo, Jose Eugenio
2016-01-01
Vehicle positioning is a key factor for numerous information and assistance applications that are included in vehicles and for which satellite positioning is mainly used. However, this positioning process can result in errors and lead to measurement uncertainties. These errors come mainly from two sources: errors and simplifications of digital maps and errors in locating the vehicle. From that inaccurate data, the task of assigning the vehicle’s location to a link on the digital map at every instant is carried out by map-matching algorithms. These algorithms have been developed to fulfil that need and attempt to amend these errors to offer the user a suitable positioning. In this research; an algorithm is developed that attempts to solve the errors in positioning when the Global Navigation Satellite System (GNSS) signal reception is frequently lost. The algorithm has been tested with satisfactory results in a complex urban environment of narrow streets and tall buildings where errors and signal reception losses of the GPS receiver are frequent. PMID:26861320
-
Pezzetta, Rachele; Nicolardi, Valentina; Tidoni, Emmanuele; Aglioti, Salvatore Maria
2018-06-06
Detecting errors in one's own actions, and in the actions of others, is a crucial ability for adaptable and flexible behavior. Studies show that specific EEG signatures underpin the monitoring of observed erroneous actions (error-related negativity, error-positivity, mid-frontal theta oscillations). However, the majority of studies on action observation used sequences of trials where erroneous actions were less frequent than correct actions. Therefore, it was not possible to disentangle whether the activation of the performance monitoring system was due to an error - as a violation of the intended goal - or a surprise/novelty effect, associated with a rare and unexpected event. Combining EEG and immersive virtual reality (IVR-CAVE system), we recorded the neural signal of 25 young adults who observed in first-person perspective, simple reach-to-grasp actions performed by an avatar aiming for a glass. Importantly, the proportion of erroneous actions was higher than correct actions. Results showed that the observation of erroneous actions elicits the typical electro-cortical signatures of error monitoring and therefore the violation of the action goal is still perceived as a salient event. The observation of correct actions elicited stronger alpha suppression. This confirmed the role of the alpha frequency band in the general orienting response to novel and infrequent stimuli. Our data provides novel evidence that an observed goal error (the action slip) triggers the activity of the performance monitoring system even when erroneous actions, which are, typically, relevant events, occur more often than correct actions and thus are not salient because of their rarity.
-
Medication administration errors in nursing homes using an automated medication dispensing system.
van den Bemt, Patricia M L A; Idzinga, Jetske C; Robertz, Hans; Kormelink, Dennis Groot; Pels, Neske
2009-01-01
OBJECTIVE To identify the frequency of medication administration errors as well as their potential risk factors in nursing homes using a distribution robot. DESIGN The study was a prospective, observational study conducted within three nursing homes in the Netherlands caring for 180 individuals. MEASUREMENTS Medication errors were measured using the disguised observation technique. Types of medication errors were described. The correlation between several potential risk factors and the occurrence of medication errors was studied to identify potential causes for the errors. RESULTS In total 2,025 medication administrations to 127 clients were observed. In these administrations 428 errors were observed (21.2%). The most frequently occurring types of errors were use of wrong administration techniques (especially incorrect crushing of medication and not supervising the intake of medication) and wrong time errors (administering the medication at least 1 h early or late).The potential risk factors female gender (odds ratio (OR) 1.39; 95% confidence interval (CI) 1.05-1.83), ATC medication class antibiotics (OR 11.11; 95% CI 2.66-46.50), medication crushed (OR 7.83; 95% CI 5.40-11.36), number of dosages/day/client (OR 1.03; 95% CI 1.01-1.05), nursing home 2 (OR 3.97; 95% CI 2.86-5.50), medication not supplied by distribution robot (OR 2.92; 95% CI 2.04-4.18), time classes "7-10 am" (OR 2.28; 95% CI 1.50-3.47) and "10 am-2 pm" (OR 1.96; 1.18-3.27) and day of the week "Wednesday" (OR 1.46; 95% CI 1.03-2.07) are associated with a higher risk of administration errors. CONCLUSIONS Medication administration in nursing homes is prone to many errors. This study indicates that the handling of the medication after removing it from the robot packaging may contribute to this high error frequency, which may be reduced by training of nurse attendants, by automated clinical decision support and by measures to reduce workload.
-
Main visual symptoms associated to refractive errors and spectacle need in a Brazilian population
Schellini, Silvana; Ferraz, Fabio; Opromolla, Paula; Oliveira, Laryssa; Padovani, Carlos
2016-01-01
AIM To determine the main visual symptoms in a Brazilian population sample, associated to refractive errors (REs) and spectacle need to suggest priorities in preventive programs. METHODS A cross-sectional study was conducted in nine counties of the southeast region of Brazil, using a systematic sampling of households, between March 2004 and July 2005. The population was defined as individuals aged between 1 and 96y, inhabitants of 3600 residences to be evaluated and 3012 households were included, corresponding to 8010 subjects considered for participation in the survey, of whom 7654 underwent ophthalmic examinations. The individuals were evaluated according their demographic data, eye complaints and eye examination including the RE and the need to prescribe spectacles according to age. Statistical analysis was performed using SPSS software package and descriptive analysis using 95% confidence intervals (P<0.05). RESULTS The main symptom detected was asthenopia, most frequent in the 2nd and 3rd decades of life, with a significant decline after the 4th decade. Astigmatism was the RE most associated with asthenopia. Reduced near vision sight was more frequent in those ≥40y with a progressive decline thereafter. Spectacles were most frequently required in subjects of ≥40 years of age. CONCLUSION The main symptom related to the vision was asthenopia and was associated to astigmatism. The greatest need for spectacles prescription occurred after 40's, mainly to correct near vision. Subjects of ≥40 years old were determined to be at high risk of uncorrected REs. These observations can guide intervention programs for the Brazilian population. PMID:27990372
-
MS-READ: Quantitative measurement of amino acid incorporation.
Mohler, Kyle; Aerni, Hans-Rudolf; Gassaway, Brandon; Ling, Jiqiang; Ibba, Michael; Rinehart, Jesse
2017-11-01
Ribosomal protein synthesis results in the genetically programmed incorporation of amino acids into a growing polypeptide chain. Faithful amino acid incorporation that accurately reflects the genetic code is critical to the structure and function of proteins as well as overall proteome integrity. Errors in protein synthesis are generally detrimental to cellular processes yet emerging evidence suggest that proteome diversity generated through mistranslation may be beneficial under certain conditions. Cumulative translational error rates have been determined at the organismal level, however codon specific error rates and the spectrum of misincorporation errors from system to system remain largely unexplored. In particular, until recently technical challenges have limited the ability to detect and quantify comparatively rare amino acid misincorporation events, which occur orders of magnitude less frequently than canonical amino acid incorporation events. We now describe a technique for the quantitative analysis of amino acid incorporation that provides the sensitivity necessary to detect mistranslation events during translation of a single codon at frequencies as low as 1 in 10,000 for all 20 proteinogenic amino acids, as well as non-proteinogenic and modified amino acids. This article is part of a Special Issue entitled "Biochemistry of Synthetic Biology - Recent Developments" Guest Editor: Dr. Ilka Heinemann and Dr. Patrick O'Donoghue. Copyright © 2017 Elsevier B.V. All rights reserved.
-
A radio-aware routing algorithm for reliable directed diffusion in lossy wireless sensor networks.
Kim, Yong-Pyo; Jung, Euihyun; Park, Yong-Jin
2009-01-01
In Wireless Sensor Networks (WSNs), transmission errors occur frequently due to node failure, battery discharge, contention or interference by objects. Although Directed Diffusion has been considered as a prominent data-centric routing algorithm, it has some weaknesses due to unexpected network errors. In order to address these problems, we proposed a radio-aware routing algorithm to improve the reliability of Directed Diffusion in lossy WSNs. The proposed algorithm is aware of the network status based on the radio information from MAC and PHY layers using a cross-layer design. The cross-layer design can be used to get detailed information about current status of wireless network such as a link quality or transmission errors of communication links. The radio information indicating variant network conditions and link quality was used to determine an alternative route that provides reliable data transmission under lossy WSNs. According to the simulation result, the radio-aware reliable routing algorithm showed better performance in both grid and random topologies with various error rates. The proposed solution suggested the possibility of providing a reliable transmission method for QoS requests in lossy WSNs based on the radio-awareness. The energy and mobility issues will be addressed in the future work.
-
Arenas Jiménez, María Dolores; Ferre, Gabriel; Álvarez-Ude, Fernando
Haemodialysis (HD) patients are a high-risk population group. For these patients, an error could have catastrophic consequences. Therefore, systems that ensure the safety of these patients in an environment with high technology and great interaction of the human factor is a requirement. To show a systematic working approach, reproducible in any HD unit, which consists of recording the complications and errors that occurred during the HD session; defining which of those complications could be considered adverse event (AE), and therefore preventable; and carrying out a systematic analysis of them, as well as of underlying real or potential errors, evaluating their severity, frequency and detection; as well as establishing priorities for action (Failure Mode and Effects Analysis system [FMEA systems]). Retrospective analysis of the graphs of all HD sessions performed during one month (October 2015) on 97 patients, analysing all recorded complications. The consideration of these complications as AEs was based on a consensus among 13 health professionals and 2 patients. The severity, frequency and detection of each AE was evaluated by the FMEA system. We analysed 1303 HD treatments in 97 patients. A total of 383 complications (1 every 3.4 HD treatments) were recorded. Approximately 87.9% of them was deemed AEs and 23.7% complications related with patients' underlying pathology. There was one AE every 3.8 HD treatments. Hypertension and hypotension were the most frequent AEs (42.7 and 27.5% of all AEs recorded, respectively). Vascular-access related AEs were one every 68.5 HD treatments. A total of 21 errors (1 every 62 HD treatments), mainly related to the HD technique and to the administration of prescribed medication, were registered. The highest risk priority number, according to the FMEA, corresponded to errors related to patient body weight; dysfunction/rupture of the catheter; and needle extravasation. HD complications are frequent. Consideration of some of them as AEs could improve safety by facilitating the implementation of preventive measures. The application of the FMEA system allows stratifying real and potential errors in dialysis units and acting with the appropriate degree of urgency, developing and implementing the necessary preventive and improvement measures. Copyright © 2017 Sociedad Española de Nefrología. Published by Elsevier España, S.L.U. All rights reserved.
-
Lexical Errors and Accuracy in Foreign Language Writing. Second Language Acquisition
ERIC Educational Resources Information Center
del Pilar Agustin Llach, Maria
2011-01-01
Lexical errors are a determinant in gaining insight into vocabulary acquisition, vocabulary use and writing quality assessment. Lexical errors are very frequent in the written production of young EFL learners, but they decrease as learners gain proficiency. Misspellings are the most common category, but formal errors give way to semantic-based…
-
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.
-
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...
-
Clinical review: Medication errors in critical care
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.
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.
-
Validating Emergency Department Vital Signs Using a Data Quality Engine for Data Warehouse
Genes, N; Chandra, D; Ellis, S; Baumlin, K
2013-01-01
Background : Vital signs in our emergency department information system were entered into free-text fields for heart rate, respiratory rate, blood pressure, temperature and oxygen saturation. Objective : We sought to convert these text entries into a more useful form, for research and QA purposes, upon entry into a data warehouse. Methods : We derived a series of rules and assigned quality scores to the transformed values, conforming to physiologic parameters for vital signs across the age range and spectrum of illness seen in the emergency department. Results : Validating these entries revealed that 98% of free-text data had perfect quality scores, conforming to established vital sign parameters. Average vital signs varied as expected by age. Degradations in quality scores were most commonly attributed logging temperature in Fahrenheit instead of Celsius; vital signs with this error could still be transformed for use. Errors occurred more frequently during periods of high triage, though error rates did not correlate with triage volume. Conclusions : In developing a method for importing free-text vital sign data from our emergency department information system, we now have a data warehouse with a broad array of quality-checked vital signs, permitting analysis and correlation with demographics and outcomes. PMID:24403981
-
Validating emergency department vital signs using a data quality engine for data warehouse.
Genes, N; Chandra, D; Ellis, S; Baumlin, K
2013-01-01
Vital signs in our emergency department information system were entered into free-text fields for heart rate, respiratory rate, blood pressure, temperature and oxygen saturation. We sought to convert these text entries into a more useful form, for research and QA purposes, upon entry into a data warehouse. We derived a series of rules and assigned quality scores to the transformed values, conforming to physiologic parameters for vital signs across the age range and spectrum of illness seen in the emergency department. Validating these entries revealed that 98% of free-text data had perfect quality scores, conforming to established vital sign parameters. Average vital signs varied as expected by age. Degradations in quality scores were most commonly attributed logging temperature in Fahrenheit instead of Celsius; vital signs with this error could still be transformed for use. Errors occurred more frequently during periods of high triage, though error rates did not correlate with triage volume. In developing a method for importing free-text vital sign data from our emergency department information system, we now have a data warehouse with a broad array of quality-checked vital signs, permitting analysis and correlation with demographics and outcomes.
-
Kim, Changhwa; Shin, DongHyun
2017-01-01
There are wireless networks in which typically communications are unsafe. Most terrestrial wireless sensor networks belong to this category of networks. Another example of an unsafe communication network is an underwater acoustic sensor network (UWASN). In UWASNs in particular, communication failures occur frequently and the failure durations can range from seconds up to a few hours, days, or even weeks. These communication failures can cause data losses significant enough to seriously damage human life or property, depending on their application areas. In this paper, we propose a framework to reduce sensor data loss during communication failures and we present a formal approach to the Selection by Minimum Error and Pattern (SMEP) method that plays the most important role for the reduction in sensor data loss under the proposed framework. The SMEP method is compared with other methods to validate its effectiveness through experiments using real-field sensor data sets. Moreover, based on our experimental results and performance comparisons, the SMEP method has been validated to be better than others in terms of the average sensor data value error rate caused by sensor data loss. PMID:28498312
-
Kim, Changhwa; Shin, DongHyun
2017-05-12
There are wireless networks in which typically communications are unsafe. Most terrestrial wireless sensor networks belong to this category of networks. Another example of an unsafe communication network is an underwater acoustic sensor network (UWASN). In UWASNs in particular, communication failures occur frequently and the failure durations can range from seconds up to a few hours, days, or even weeks. These communication failures can cause data losses significant enough to seriously damage human life or property, depending on their application areas. In this paper, we propose a framework to reduce sensor data loss during communication failures and we present a formal approach to the Selection by Minimum Error and Pattern (SMEP) method that plays the most important role for the reduction in sensor data loss under the proposed framework. The SMEP method is compared with other methods to validate its effectiveness through experiments using real-field sensor data sets. Moreover, based on our experimental results and performance comparisons, the SMEP method has been validated to be better than others in terms of the average sensor data value error rate caused by sensor data loss.
-
Yago, Martín
2017-05-01
QC planning based on risk management concepts can reduce the probability of harming patients due to an undetected out-of-control error condition. It does this by selecting appropriate QC procedures to decrease the number of erroneous results reported. The selection can be easily made by using published nomograms for simple QC rules when the out-of-control condition results in increased systematic error. However, increases in random error also occur frequently and are difficult to detect, which can result in erroneously reported patient results. A statistical model was used to construct charts for the 1 ks and X /χ 2 rules. The charts relate the increase in the number of unacceptable patient results reported due to an increase in random error with the capability of the measurement procedure. They thus allow for QC planning based on the risk of patient harm due to the reporting of erroneous results. 1 ks Rules are simple, all-around rules. Their ability to deal with increases in within-run imprecision is minimally affected by the possible presence of significant, stable, between-run imprecision. X /χ 2 rules perform better when the number of controls analyzed during each QC event is increased to improve QC performance. Using nomograms simplifies the selection of statistical QC procedures to limit the number of erroneous patient results reported due to an increase in analytical random error. The selection largely depends on the presence or absence of stable between-run imprecision. © 2017 American Association for Clinical Chemistry.
-
Refractive errors and strabismus in Down's syndrome in Korea.
Han, Dae Heon; Kim, Kyun Hyung; Paik, Hae Jung
2012-12-01
The aims of this study were to examine the distribution of refractive errors and clinical characteristics of strabismus in Korean patients with Down's syndrome. A total of 41 Korean patients with Down's syndrome were screened for strabismus and refractive errors in 2009. A total of 41 patients with an average age of 11.9 years (range, 2 to 36 years) were screened. Eighteen patients (43.9%) had strabismus. Ten (23.4%) of 18 patients exhibited esotropia and the others had intermittent exotropia. The most frequently detected type of esotropia was acquired non-accommodative esotropia, and that of exotropia was the basic type. Fifteen patients (36.6%) had hypermetropia and 20 (48.8%) had myopia. The patients with esotropia had refractive errors of +4.89 diopters (D, ±3.73) and the patients with exotropia had refractive errors of -0.31 D (±1.78). Six of ten patients with esotropia had an accommodation weakness. Twenty one patients (63.4%) had astigmatism. Eleven (28.6%) of 21 patients had anisometropia and six (14.6%) of those had clinically significant anisometropia. In Korean patients with Down's syndrome, esotropia was more common than exotropia and hypermetropia more common than myopia. Especially, Down's syndrome patients with esotropia generally exhibit clinically significant hyperopic errors (>+3.00 D) and evidence of under-accommodation. Thus, hypermetropia and accommodation weakness could be possible factors in esotropia when it occurs in Down's syndrome patients. Based on the results of this study, eye examinations of Down's syndrome patients should routinely include a measure of accommodation at near distances, and bifocals should be considered for those with evidence of under-accommodation.
-
Charles, Rodolphe; Vallée, Josette; Tissot, Claire; Lucht, Frédéric; Botelho-Nevers, Elisabeth
2016-08-01
Vaccination is a common act in general practice in which, as in all procedures in medicine, errors may occur. To our best knowledge, in this area, few tools exist to prevent them. To create a checklist that could be used in general practice in order to avoid the main errors. From April to July 2013, we systematically searched for vaccination errors using three sources: a review of literature, individual interviews with 25 health care workers and supervised peer review groups meeting at the Medicine school of Saint-Etienne (France). The errors most frequently retrieved were used to create the checklist that was regularly submitted to interviewed caregivers to improve its construction and content; its stabilization has been conceived as an evidence of finalization. The checklist's draw-up included three parts allowing verification at each stage of the vaccination process: before, during and after the vaccine administration. Before the vaccination, items to be checked were mainly does my patient need and may he/she receive this vaccine in accordance with the national French vaccination guidelines? During the preparation and the administration of vaccination, items to be checked were are the patient and the practitioner comfortable? Is all the material needed correctly prepared? Is the appropriate route defined? Ultimately, after the vaccination, most items to be checked concerned traceability. This checklist seemed useful and usable by the panel of practitioners questioned. This vaccination checklist may be useful to prevent errors. Its efficacy and feasibility in clinical practice will require further testing. © The Author 2016. Published by Oxford University Press. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.
-
Death certificate completion skills of hospital physicians in a developing country.
Haque, Ahmed Suleman; Shamim, Kanza; Siddiqui, Najm Hasan; Irfan, Muhammad; Khan, Javaid Ahmed
2013-06-06
Death certificates (DC) can provide valuable health status data regarding disease incidence, prevalence and mortality in a community. It can guide local health policy and help in setting priorities. Incomplete and inaccurate DC data, on the other hand, can significantly impair the precision of a national health information database. In this study we evaluated the accuracy of death certificates at a tertiary care teaching hospital in a Karachi, Pakistan. A retrospective study conducted at Aga Khan University Hospital, Karachi, Pakistan for a period of six months. Medical records and death certificates of all patients who died under adult medical service were studied. The demographic characteristics, administrative details, co-morbidities and cause of death from death certificates were collected using an approved standardized form. Accuracy of this information was validated using their medical records. Errors in the death certificates were classified into six categories, from 0 to 5 according to increasing severity; a grade 0 was assigned if no errors were identified, and 5, if an incorrect cause of death was attributed or placed in an improper sequence. 223 deaths occurred during the study period. 9 certificates were not accessible and 12 patients had incomplete medical records. 202 certificates were finally analyzed. Most frequent errors pertaining to patients' demographics (92%) and cause/s of death (87%) were identified. 156 (77%) certificates had 3 or more errors and 124 (62%) certificates had a combination of errors that significantly changed the death certificate interpretation. Only 1% certificates were error free. A very high rate of errors was identified in death certificates completed at our academic institution. There is a pressing need for appropriate intervention/s to resolve this important issue.
-
Procedural errors in air traffic control: effects of traffic density, expertise, and automation.
Di Nocera, Francesco; Fabrizi, Roberto; Terenzi, Michela; Ferlazzo, Fabio
2006-06-01
Air traffic management requires operators to frequently shift between multiple tasks and/or goals with different levels of accomplishment. Procedural errors can occur when a controller accomplishes one of the tasks before the entire operation has been completed. The present study had two goals: first, to verify the occurrence of post-completion errors in air traffic control (ATC) tasks; and second, to assess effects on performance of medium term conflict detection (MTCD) tools. There were 18 military controllers who performed a simulated ATC task with and without automation support (MTCD vs. manual) in high and low air traffic density conditions. During the task, which consisted of managing several simulated flights in an enroute ATC scenario, a trace suddenly disappeared "after" the operator took the aircraft in charge, "during" the management of the trace, or "before" the pilot's first contact. In the manual condition, only the fault type "during" was found to be significantly different from the other two. On the contrary, when in the MTCD condition, the fault type "after" generated significantly less errors than the fault type "before." Additionally, automation was found to affect performance of junior controllers, whereas seniors' performance was not affected. Procedural errors can happen in ATC, but automation can mitigate this effect. Lack of benefits for the "before" fault type may be due to the fact that operators extend their reliance to a part of the task that is unsupported by the automated system.
-
Strategy optimization for mask rule check in wafer fab
NASA Astrophysics Data System (ADS)
Yang, Chuen Huei; Lin, Shaina; Lin, Roger; Wang, Alice; Lee, Rachel; Deng, Erwin
2015-07-01
Photolithography process is getting more and more sophisticated for wafer production following Moore's law. Therefore, for wafer fab, consolidated and close cooperation with mask house is a key to achieve silicon wafer success. However, generally speaking, it is not easy to preserve such partnership because many engineering efforts and frequent communication are indispensable. The inattentive connection is obvious in mask rule check (MRC). Mask houses will do their own MRC at job deck stage, but the checking is only for identification of mask process limitation including writing, etching, inspection, metrology, etc. No further checking in terms of wafer process concerned mask data errors will be implemented after data files of whole mask are composed in mask house. There are still many potential data errors even post-OPC verification has been done for main circuits. What mentioned here are the kinds of errors which will only occur as main circuits combined with frame and dummy patterns to form whole reticle. Therefore, strategy optimization is on-going in UMC to evaluate MRC especially for wafer fab concerned errors. The prerequisite is that no impact on mask delivery cycle time even adding this extra checking. A full-mask checking based on job deck in gds or oasis format is necessary in order to secure acceptable run time. Form of the summarized error report generated by this checking is also crucial because user friendly interface will shorten engineers' judgment time to release mask for writing. This paper will survey the key factors of MRC in wafer fab.
-
Maskens, Carolyn; Downie, Helen; Wendt, Alison; Lima, Ana; Merkley, Lisa; Lin, Yulia; Callum, Jeannie
2014-01-01
This report provides a comprehensive analysis of transfusion errors occurring at a large teaching hospital and aims to determine key errors that are threatening transfusion safety, despite implementation of safety measures. Errors were prospectively identified from 2005 to 2010. Error data were coded on a secure online database called the Transfusion Error Surveillance System. Errors were defined as any deviation from established standard operating procedures. Errors were identified by clinical and laboratory staff. Denominator data for volume of activity were used to calculate rates. A total of 15,134 errors were reported with a median number of 215 errors per month (range, 85-334). Overall, 9083 (60%) errors occurred on the transfusion service and 6051 (40%) on the clinical services. In total, 23 errors resulted in patient harm: 21 of these errors occurred on the clinical services and two in the transfusion service. Of the 23 harm events, 21 involved inappropriate use of blood. Errors with no harm were 657 times more common than events that caused harm. The most common high-severity clinical errors were sample labeling (37.5%) and inappropriate ordering of blood (28.8%). The most common high-severity error in the transfusion service was sample accepted despite not meeting acceptance criteria (18.3%). The cost of product and component loss due to errors was $593,337. Errors occurred at every point in the transfusion process, with the greatest potential risk of patient harm resulting from inappropriate ordering of blood products and errors in sample labeling. © 2013 American Association of Blood Banks (CME).
-
The accuracy of eyelid movement parameters for drowsiness detection.
Wilkinson, Vanessa E; Jackson, Melinda L; Westlake, Justine; Stevens, Bronwyn; Barnes, Maree; Swann, Philip; Rajaratnam, Shantha M W; Howard, Mark E
2013-12-15
Drowsiness is a major risk factor for motor vehicle and occupational accidents. Real-time objective indicators of drowsiness could potentially identify drowsy individuals with the goal of intervening before an accident occurs. Several ocular measures are promising objective indicators of drowsiness; however, there is a lack of studies evaluating their accuracy for detecting behavioral impairment due to drowsiness in real time. In this study, eye movement parameters were measured during vigilance tasks following restricted sleep and in a rested state (n = 33 participants) at three testing points (n = 71 data points) to compare ocular measures to a gold standard measure of drowsiness (OSLER). The utility of these parameters for detecting drowsiness-related errors was evaluated using receiver operating characteristic curves (ROC) (adjusted by clustering for participant) and identification of optimal cutoff levels for identifying frequent drowsiness-related errors (4 missed signals in a minute using OSLER). Their accuracy was tested for detecting increasing frequencies of behavioral lapses on a different task (psychomotor vigilance task [PVT]). Ocular variables which measured the average duration of eyelid closure (inter-event duration [IED]) and the ratio of the amplitude to velocity of eyelid closure were reliable indicators of frequent errors (area under the curve for ROC of 0.73 to 0.83, p < 0.05). IED produced a sensitivity and specificity of 71% and 88% for detecting ≥ 3 lapses (PVT) in a minute and 100% and 86% for ≥ 5 lapses. A composite measure of several eye movement characteristics (Johns Drowsiness Scale) provided sensitivities of 77% and 100% for detecting 3 and ≥ 5 lapses in a minute, with specificities of 85% and 83%, respectively. Ocular measures, particularly those measuring the average duration of episodes of eye closure are promising real-time indicators of drowsiness.
-
Johansson, Mikael; Mecklinger, Axel
2003-10-01
The focus of the present paper is a late posterior negative slow wave (LPN) that has frequently been reported in event-related potential (ERP) studies of memory. An overview of these studies suggests that two broad classes of experimental conditions tend to elicit this component: (a) item recognition tasks associated with enhanced action monitoring demands arising from response conflict and (b) memory tasks that require the binding of items with contextual information specifying the study episode. A combined stimulus- and response-locked analysis of data from two studies mapping onto these classes allowed a temporal and functional decomposition of the LPN. While only the LPN observed in the item recognition task could be attributed to the involvement of a posteriorly distributed response-locked error-related negativity (or error negativity; ERN/Ne) occurring immediately after the response, the source-memory task was associated with a stimulus-locked negative slow wave occurring prior and during response execution that was evident when data were matched for response latencies. We argue that the presence of the former reflects action monitoring due to high levels of response conflict, whereas the latter reflects retrieval processes that may act to reconstruct the prior study episode when task-relevant attribute conjunctions are not readily recovered or need continued evaluation.
-
Dual Processing and Diagnostic Errors
ERIC Educational Resources Information Center
Norman, Geoff
2009-01-01
In this paper, I review evidence from two theories in psychology relevant to diagnosis and diagnostic errors. "Dual Process" theories of thinking, frequently mentioned with respect to diagnostic error, propose that categorization decisions can be made with either a fast, unconscious, contextual process called System 1 or a slow, analytical,…
-
Single Event Effect Testing of the Analog Devices ADV212
NASA Technical Reports Server (NTRS)
Wilcox, Ted; Campola, Michael; Kadari, Madhu; Nadendla, Seshagiri R.
2017-01-01
The Analog Devices ADV212 was initially tested for single event effects (SEE) at the Texas AM University Cyclotron Facility (TAMU) in July of 2013. Testing revealed a sensitivity to device hang-ups classified as single event functional interrupts (SEFI), soft data errors classified as single event upsets (SEU), and, of particular concern, single event latch-ups (SEL). All error types occurred so frequently as to make accurate measurements of the exposure time, and thus total particle fluence, challenging. To mitigate some of the risk posed by single event latch-ups, circuitry was added to the electrical design to detect a high current event and automatically recycle power and reboot the device. An additional heavy-ion test was scheduled to validate the operation of the recovery circuitry and the continuing functionality of the ADV212 after a substantial number of latch-up events. As a secondary goal, more precise data would be gathered by an improved test method, described in this test report.
-
Errors in veterinary practice: preliminary lessons for building better veterinary teams.
Kinnison, T; Guile, D; May, S A
2015-11-14
Case studies in two typical UK veterinary practices were undertaken to explore teamwork, including interprofessional working. Each study involved one week of whole team observation based on practice locations (reception, operating theatre), one week of shadowing six focus individuals (veterinary surgeons, veterinary nurses and administrators) and a final week consisting of semistructured interviews regarding teamwork. Errors emerged as a finding of the study. The definition of errors was inclusive, pertaining to inputs or omitted actions with potential adverse outcomes for patients, clients or the practice. The 40 identified instances could be grouped into clinical errors (dosing/drugs, surgical preparation, lack of follow-up), lost item errors, and most frequently, communication errors (records, procedures, missing face-to-face communication, mistakes within face-to-face communication). The qualitative nature of the study allowed the underlying cause of the errors to be explored. In addition to some individual mistakes, system faults were identified as a major cause of errors. Observed examples and interviews demonstrated several challenges to interprofessional teamworking which may cause errors, including: lack of time, part-time staff leading to frequent handovers, branch differences and individual veterinary surgeon work preferences. Lessons are drawn for building better veterinary teams and implications for Disciplinary Proceedings considered. British Veterinary Association.
-
Hwang-Gu, Shoou-Lian; Lin, Hsiang-Yuan; Chen, Yu-Chi; Tseng, Yu-Han; Hsu, Wen-Yau; Chou, Miao-Chun; Chou, Wen-Jun; Wu, Yu-Yu; Gau, Susan Shur-Fen
2018-05-30
Increased intrasubject variability in reaction times (RT-ISV) is frequently found in individuals with autism spectrum disorder (ASD). However, how dimensional attention deficit/hyperactivity disorder (ADHD) symptoms impact RT-ISV in individuals with ASD remains elusive. We assessed 97 high-functioning youths with co-occurring ASD and ADHD (ASD+ADHD), 124 high-functioning youths with ASD only, 98 youths with ADHD only, and 249 typically developing youths, 8-18 years of age, using the Conners Continuous Performance Test (CCPT). We compared the conventional CCPT parameters (omission errors, commission errors, mean RT and RT standard error (RTSE) as well as the ex-Gaussian parameters of RT (mu, sigma, and tau) across the four groups. We also conducted regression analyses to assess the relationships between RT indices and symptoms of ADHD and ASD in the ASD group (i.e., the ASD+ADHD and ASD-only groups). The ASD+ADHD and ADHD-only groups had higher RT-ISV than the other two groups. RT-ISV, specifically RTSE and tau, was significantly associated with ADHD symptoms rather than autistic traits in the ASD group. Regression models also revealed that sex partly accounted for RT-ISV variance in the ASD group. A post hoc analysis showed girls with ASD had higher tau and RTSE values than their male counterparts. Our results suggest that RT-ISV is primarily associated with co-occurring ADHD symptoms/diagnosis in children and adolescents with ASD. These results do not support the hypothesis of response variability as a transdiagnostic phenotype for ASD and ADHD and warrant further validation at a neural level.
-
Expertise effects in the Moses illusion: detecting contradictions with stored knowledge.
Cantor, Allison D; Marsh, Elizabeth J
2017-02-01
People frequently miss contradictions with stored knowledge; for example, readers often fail to notice any problem with a reference to the Atlantic as the largest ocean. Critically, such effects occur even though participants later demonstrate knowing the Pacific is the largest ocean (the Moses Illusion) [Erickson, T. D., & Mattson, M. E. (1981). From words to meaning: A semantic illusion. Journal of Verbal Learning & Verbal Behavior, 20, 540-551]. We investigated whether such oversights disappear when erroneous references contradict information in one's expert domain, material which likely has been encountered many times and is particularly well-known. Biology and history graduate students monitored for errors while answering biology and history questions containing erroneous presuppositions ("In what US state were the forty-niners searching for oil?"). Expertise helped: participants were less susceptible to the illusion and less likely to later reproduce errors in their expert domain. However, expertise did not eliminate the illusion, even when errors were bolded and underlined, meaning that it was unlikely that people simply skipped over errors. The results support claims that people often use heuristics to judge truth, as opposed to directly retrieving information from memory, likely because such heuristics are adaptive and often lead to the correct answer. Even experts sometimes use such shortcuts, suggesting that overlearned and accessible knowledge does not guarantee retrieval of that information.
-
NASA Astrophysics Data System (ADS)
Ben Salah, Ahmed; Ragot, Nicolas; Paquet, Thierry
2013-01-01
The French National Library (BnF*) has launched many mass digitization projects in order to give access to its collection. The indexation of digital documents on Gallica (digital library of the BnF) is done through their textual content obtained thanks to service providers that use Optical Character Recognition softwares (OCR). OCR softwares have become increasingly complex systems composed of several subsystems dedicated to the analysis and the recognition of the elements in a page. However, the reliability of these systems is always an issue at stake. Indeed, in some cases, we can find errors in OCR outputs that occur because of an accumulation of several errors at different levels in the OCR process. One of the frequent errors in OCR outputs is the missed text components. The presence of such errors may lead to severe defects in digital libraries. In this paper, we investigate the detection of missed text components to control the OCR results from the collections of the French National Library. Our verification approach uses local information inside the pages based on Radon transform descriptors and Local Binary Patterns descriptors (LBP) coupled with OCR results to control their consistency. The experimental results show that our method detects 84.15% of the missed textual components, by comparing the OCR ALTO files outputs (produced by the service providers) to the images of the document.
-
Evaluation of the NASA GISS AR5 SCM/GCM at the ARM SGP Site using Self Organizing Maps
NASA Astrophysics Data System (ADS)
Kennedy, A. D.; Dong, X.; Xi, B.; Del Genio, A. D.; Wolf, A.
2011-12-01
Understanding and improving clouds in climate models requires moving beyond comparing annual and seasonal means. Errors can offset resulting in models getting the right long-term solution for the wrong reasons. For example, cloud parameterization errors may be balanced by the model incorrectly simulating the frequency distribution of atmospheric states. To faithfully evaluate climate models it is necessary to partition results into specific regimes. This has been completed in the past by evaluating models by their ability to produce cloud regimes as determined by observational products from satellites. An alternative approach is to first classify meteorological regimes (i.e., synoptic pattern and forcing) and then determine what types of clouds occur for each class. In this study, a competitive neural network known as the Self Organizing Map (SOM) is first used to classify synoptic patterns from a reanalysis over the Southern Great Plains (SGP) region during the period 1999-2008. These results are then used to evaluate simulated clouds from the AR5 version of the NASA GISS Model E Single Column Model (SCM). Unlike past studies that narrowed classes into several categories, this study assumes that the atmosphere is capable of producing an infinite amount of states. As a result, SOMs were generated with a large number of classes for specific months when model errors were found. With nearly ten years of forcing data, an adequate number of samples have been used to determine how cloud fraction varies across the SOM and to distinguish cloud errors. Barring major forcing errors, SCM studies can be thought of as what the GCM would simulate if the dynamics were perfect. As a result, simulated and observed CFs frequently occur for the same atmospheric states. For example, physically deep clouds during the winter months occur for a small number of classes in the SOM. Although the model produces clouds during the correct states, CFs are consistently too low. Instead, the model has a positive bias of thinner clouds during these classes that were associated with low-pressure systems and fronts. To determine if this and other SCM errors are present in the GCM, the Atmospheric Model Intercomparison Project (AMIP) run for the NASA GISS GCM will also be investigated. The SOM will be used to classify atmospheric states within the GCM to determine how well the GCM captures the PDF of observed atmospheric states. Together, these comparisons will allow for a thorough evaluation of the model at the ARM SGP site.
-
About errors, inaccuracies and sterotypes: Mistakes in media coverage - and how to reduce them
NASA Astrophysics Data System (ADS)
Scherzler, D.
2010-12-01
The main complaint made by scientists about the work of journalists is that there are mistakes and inaccuracies in TV programmes, radio or the print media. This seems to be an important reason why too few researchers want to deal with journalists. Such scientists regularly discover omissions, errors, exaggerations, distortions, stereotypes and sensationalism in the media. Surveys carried out on so-called accuracy research seem to concede this point as well. Errors frequently occur in journalism, and it is the task of the editorial offices to work very hard in order to keep the number of errors as low as possible. On closer inspection some errors, however, turn out to be simplifications and omissions. Both are obligatory in journalism and do not automatically cause factual errors. This paper examines the different kinds of mistakes and misleading information that scientists observe in the mass media. By giving a view from inside the mass media it tries to explain how errors come to exist in the journalist’s working routines. It outlines that the criteria of journalistic quality which scientists and science journalists apply differ substantially. The expectation of many scientists is that good science journalism passes on their results to the public in as “unadulterated” a form as possible. The author suggests, however, that quality criteria for journalism cannot be derived from how true to detail and how comprehensively it reports on science, nor to what extent the journalistic presentation is “correct” in the eyes of the researcher. The paper suggests in its main part that scientists who are contacted or interviewed by the mass media should not accept that errors just happen. On the contrary, they can do a lot to help preventing mistakes that might occur in the journalistic product. The author proposes several strategies how scientists and press information officers could identify possible errors, stereotypes and exaggeration by journalists in advance and how they could anticipate and prevent them to a remarkable extent. At the same time phenomena of the so called media society influence how appropriately science is portrayed by the mass media. So-called medialisation, overload scenarios and monopolistic influences on public opinion are the main terms that will shortly be discussed. A qualitatively demanding presentation of geosciences in the mass media is a goal which means a lot to good journalists as well as to scientists. Therefore, the paper argues, it is important that scientists do get involved when journalists are looking for an interview partner or have a question.
-
Medication Administration Errors in Nursing Homes Using an Automated Medication Dispensing System
van den Bemt, Patricia M.L.A.; Idzinga, Jetske C.; Robertz, Hans; Kormelink, Dennis Groot; Pels, Neske
2009-01-01
Objective To identify the frequency of medication administration errors as well as their potential risk factors in nursing homes using a distribution robot. Design The study was a prospective, observational study conducted within three nursing homes in the Netherlands caring for 180 individuals. Measurements Medication errors were measured using the disguised observation technique. Types of medication errors were described. The correlation between several potential risk factors and the occurrence of medication errors was studied to identify potential causes for the errors. Results In total 2,025 medication administrations to 127 clients were observed. In these administrations 428 errors were observed (21.2%). The most frequently occurring types of errors were use of wrong administration techniques (especially incorrect crushing of medication and not supervising the intake of medication) and wrong time errors (administering the medication at least 1 h early or late).The potential risk factors female gender (odds ratio (OR) 1.39; 95% confidence interval (CI) 1.05–1.83), ATC medication class antibiotics (OR 11.11; 95% CI 2.66–46.50), medication crushed (OR 7.83; 95% CI 5.40–11.36), number of dosages/day/client (OR 1.03; 95% CI 1.01–1.05), nursing home 2 (OR 3.97; 95% CI 2.86–5.50), medication not supplied by distribution robot (OR 2.92; 95% CI 2.04–4.18), time classes “7–10 am” (OR 2.28; 95% CI 1.50–3.47) and “10 am-2 pm” (OR 1.96; 1.18–3.27) and day of the week “Wednesday” (OR 1.46; 95% CI 1.03–2.07) are associated with a higher risk of administration errors. Conclusions Medication administration in nursing homes is prone to many errors. This study indicates that the handling of the medication after removing it from the robot packaging may contribute to this high error frequency, which may be reduced by training of nurse attendants, by automated clinical decision support and by measures to reduce workload. PMID:19390109
-
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.
-
Payne, Velma L; Medvedeva, Olga; Legowski, Elizabeth; Castine, Melissa; Tseytlin, Eugene; Jukic, Drazen; Crowley, Rebecca S
2009-11-01
Determine effects of a limited-enforcement intelligent tutoring system in dermatopathology on student errors, goals and solution paths. Determine if limited enforcement in a medical tutoring system inhibits students from learning the optimal and most efficient solution path. Describe the type of deviations from the optimal solution path that occur during tutoring, and how these deviations change over time. Determine if the size of the problem-space (domain scope), has an effect on learning gains when using a tutor with limited enforcement. Analyzed data mined from 44 pathology residents using SlideTutor-a Medical Intelligent Tutoring System in Dermatopathology that teaches histopathologic diagnosis and reporting skills based on commonly used diagnostic algorithms. Two subdomains were included in the study representing sub-algorithms of different sizes and complexities. Effects of the tutoring system on student errors, goal states and solution paths were determined. Students gradually increase the frequency of steps that match the tutoring system's expectation of expert performance. Frequency of errors gradually declines in all categories of error significance. Student performance frequently differs from the tutor-defined optimal path. However, as students continue to be tutored, they approach the optimal solution path. Performance in both subdomains was similar for both errors and goal differences. However, the rate at which students progress toward the optimal solution path differs between the two domains. Tutoring in superficial perivascular dermatitis, the larger and more complex domain was associated with a slower rate of approximation towards the optimal solution path. Students benefit from a limited-enforcement tutoring system that leverages diagnostic algorithms but does not prevent alternative strategies. Even with limited enforcement, students converge toward the optimal solution path.
-
Harland, Karisa K; Carney, Cher; McGehee, Daniel
2016-07-03
The objective of this study was to estimate the prevalence and odds of fleet driver errors and potentially distracting behaviors just prior to rear-end versus angle crashes. Analysis of naturalistic driving videos among fleet services drivers for errors and potentially distracting behaviors occurring in the 6 s before crash impact. Categorical variables were examined using the Pearson's chi-square test, and continuous variables, such as eyes-off-road time, were compared using the Student's t-test. Multivariable logistic regression was used to estimate the odds of a driver error or potentially distracting behavior being present in the seconds before rear-end versus angle crashes. Of the 229 crashes analyzed, 101 (44%) were rear-end and 128 (56%) were angle crashes. Driver age, gender, and presence of passengers did not differ significantly by crash type. Over 95% of rear-end crashes involved inadequate surveillance compared to only 52% of angle crashes (P < .0001). Almost 65% of rear-end crashes involved a potentially distracting driver behavior, whereas less than 40% of angle crashes involved these behaviors (P < .01). On average, drivers spent 4.4 s with their eyes off the road while operating or manipulating their cell phone. Drivers in rear-end crashes were at 3.06 (95% confidence interval [CI], 1.73-5.44) times adjusted higher odds of being potentially distracted than those in angle crashes. Fleet driver driving errors and potentially distracting behaviors are frequent. This analysis provides data to inform safe driving interventions for fleet services drivers. Further research is needed in effective interventions to reduce the likelihood of drivers' distracting behaviors and errors that may potentially reducing crashes.
-
Lenderink, Albert W.; Widdershoven, Jos W. M. G.; van den Bemt, Patricia M. L. A.
2010-01-01
Objective Heart failure patients are regularly admitted to hospital and frequently use multiple medication. Besides intentional changes in pharmacotherapy, unintentional changes may occur during hospitalisation. The aim of this study was to investigate the effect of a clinical pharmacist discharge service on medication discrepancies and prescription errors in patients with heart failure. Setting A general teaching hospital in Tilburg, the Netherlands. Method An open randomized intervention study was performed comparing an intervention group, with a control group receiving regular care by doctors and nurses. The clinical pharmacist discharge service consisted of review of discharge medication, communicating prescribing errors with the cardiologist, giving patients information, preparation of a written overview of the discharge medication and communication to both the community pharmacist and the general practitioner about this medication. Within 6 weeks after discharge all patients were routinely scheduled to visit the outpatient clinic and medication discrepancies were measured. Main outcome measure The primary endpoint was the frequency of prescription errors in the discharge medication and medication discrepancies after discharge combined. Results Forty-four patients were included in the control group and 41 in the intervention group. Sixty-eight percent of patients in the control group had at least one discrepancy or prescription error against 39% in the intervention group (RR 0.57 (95% CI 0.37–0.88)). The percentage of medications with a discrepancy or prescription error in the control group was 14.6% and in the intervention group it was 6.1% (RR 0.42 (95% CI 0.27–0.66)). Conclusion This clinical pharmacist discharge service significantly reduces the risk of discrepancies and prescription errors in medication of patients with heart failure in the 1st month after discharge. PMID:20809276
-
Implementation of Concept Mapping to Novices: Reasons for Errors, a Matter of Technique or Content?
ERIC Educational Resources Information Center
Conradty, Catherine; Bogner, Franz X.
2010-01-01
Concept mapping is discussed as a means to promote meaningful learning and in particular progress in reading comprehension skills. Its increasing implementation necessitates the acquisition of adequate knowledge about frequent errors in order to make available an effective introduction to the new learning method. To analyse causes of errors, 283…
-
Motor-Based Treatment with and without Ultrasound Feedback for Residual Speech-Sound Errors
ERIC Educational Resources Information Center
Preston, Jonathan L.; Leece, Megan C.; Maas, Edwin
2017-01-01
Background: There is a need to develop effective interventions and to compare the efficacy of different interventions for children with residual speech-sound errors (RSSEs). Rhotics (the r-family of sounds) are frequently in error American English-speaking children with RSSEs and are commonly targeted in treatment. One treatment approach involves…
-
Action errors, error management, and learning in organizations.
Frese, Michael; Keith, Nina
2015-01-03
Every organization is confronted with errors. Most errors are corrected easily, but some may lead to negative consequences. Organizations often focus on error prevention as a single strategy for dealing with errors. Our review suggests that error prevention needs to be supplemented by error management--an approach directed at effectively dealing with errors after they have occurred, with the goal of minimizing negative and maximizing positive error consequences (examples of the latter are learning and innovations). After defining errors and related concepts, we review research on error-related processes affected by error management (error detection, damage control). Empirical evidence on positive effects of error management in individuals and organizations is then discussed, along with emotional, motivational, cognitive, and behavioral pathways of these effects. Learning from errors is central, but like other positive consequences, learning occurs under certain circumstances--one being the development of a mind-set of acceptance of human error.
-
Yi, Yuseung; Koak, Jai-Young; Kim, Seong-Kyun; Lee, Shin-Jae; Heo, Seong-Joo
2018-04-01
The aim of this study was to compare the fracture of implant component behavior of external and internal type of implants to suggest directions for successful implant treatment. Data were collected from the clinical records of all patients who received WARANTEC implants at Seoul National University Dental Hospital from February 2002 to January 2014 for 12 years. Total number of implants was 1,289 and an average of 3.2 implants was installed per patient. Information about abutment connection type, implant locations, platform sizes was collected with presence of implant component fractures and their managements. SPSS statistics software (version 24.0, IBM) was used for the statistical analysis. Overall fracture was significantly more frequent in internal type. The most frequently fractured component was abutment in internal type implants, and screw fracture occurred most frequently in external type. Analyzing by fractured components, screw fracture was the most frequent in the maxillary anterior region and the most abutment fracture occurred in the maxillary posterior region and screw fractures occurred more frequently in NP (narrow platform) and abutment fractures occurred more frequently in RP (regular platform). In external type, screw fracture occurred most frequently, especially in the maxillary anterior region, and in internal type, abutment fracture occurred frequently in the posterior region. placement of an external type implant rather than an internal type is recommended for the posterior region where abutment fractures frequently occur.
-
Medication errors in anesthesia: unacceptable or unavoidable?
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.
-
Alsulami, Zayed; Choonara, Imti; Conroy, Sharon
2014-06-01
To evaluate how closely double-checking policies are followed by nurses in paediatric areas and also to identify the types, frequency and rates of medication administration errors that occur despite the double-checking process. Double-checking by two nurses is an intervention used in many UK hospitals to prevent or reduce medication administration errors. There is, however, insufficient evidence to either support or refute the practice of double-checking in terms of medication error risk reduction. Prospective observational study. This was a prospective observational study of paediatric nurses' adherence to the double-checking process for medication administration from April-July 2012. Drug dose administration events (n = 2000) were observed. Independent drug dose calculation, rate of administering intravenous bolus drugs and labelling of flush syringes were the steps with lowest adherence rates. Drug dose calculation was only double-checked independently in 591 (30%) drug administrations. There was a statistically significant difference in nurses' adherence rate to the double-checking steps between weekdays and weekends in nine of the 15 evaluated steps. Medication administration errors (n = 191) or deviations from policy were observed, at a rate of 9·6% of drug administrations. These included 64 drug doses, which were left for parents to administer without nurse observation. There was variation between paediatric nurses' adherence to double-checking steps during medication administration. The most frequent type of administration errors or deviation from policy involved the medicine being given to the parents to administer to the child when the nurse was not present. © 2013 John Wiley & Sons Ltd.
-
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.
-
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.
-
Phipps, Denham L; Tam, W Vanessa; Ashcroft, Darren M
2017-03-01
To explore the combined use of a critical incident database and work domain analysis to understand patient safety issues in a health-care setting. A retrospective review was conducted of incidents reported to the UK National Reporting and Learning System (NRLS) that involved community pharmacy between April 2005 and August 2010. A work domain analysis of community pharmacy was constructed using observational data from 5 community pharmacies, technical documentation, and a focus group with 6 pharmacists. Reports from the NRLS were mapped onto the model generated by the work domain analysis. Approximately 14,709 incident reports meeting the selection criteria were retrieved from the NRLS. Descriptive statistical analysis of these reports found that almost all of the incidents involved medication and that the most frequently occurring error types were dose/strength errors, incorrect medication, and incorrect formulation. The work domain analysis identified 4 overall purposes for community pharmacy: business viability, health promotion and clinical services, provision of medication, and use of medication. These purposes were served by lower-order characteristics of the work system (such as the functions, processes and objects). The tasks most frequently implicated in the incident reports were those involving medication storage, assembly, or patient medication records. Combining the insights from different analytical methods improves understanding of patient safety problems. Incident reporting data can be used to identify general patterns, whereas the work domain analysis can generate information about the contextual factors that surround a critical task.
-
Serrano Santos, Jose Manuel; Poland, Fiona; Wright, David; Longmore, Timothy
2016-10-30
In the UK, 69.5% of residents in care homes are exposed to one or more medication errors and 50% have some form of dysphagia. Hospital research identified that nurses frequently crush tablets to facilitate swallowing but this has not been explored in care homes. This project aimed to observe the administration of medicines to patients with dysphagia (PWD) and without in care homes. A convenient sample of general practitioners in North Yorkshire invited care homes with nursing, to participate in the study. A pharmacist specialised in dysphagia observed nurses during drug rounds and compared these practices with national guidelines. Deviations were classified as types of medication administration errors (MAEs). Overall, 738 administrations were observed from 166 patients of which 38 patients (22.9%) had dysphagia. MAE rates were 57.3% and 30.8% for PWD and those without respectively (p<0.001). PWD were more likely to experience inappropriate prescribing (IP). Signs of aspiration were more frequently observed in PWD when IP occurred (p<0.001). Observation of medication administration practices by independent pharmacists may enable the identification of potentially dangerous practices and be used as a method of staff support. Unidentified signs of aspiration suggest that nurses require training in dysphagia and need to communicate its presence to the resident's GP. Further research should explore the design of an effective training for nurses. Copyright © 2016 Elsevier B.V. All rights reserved.
-
Recognizing and managing errors of cognitive underspecification.
Duthie, Elizabeth A
2014-03-01
James Reason describes cognitive underspecification as incomplete communication that creates a knowledge gap. Errors occur when an information mismatch occurs in bridging that gap with a resulting lack of shared mental models during the communication process. There is a paucity of studies in health care examining this cognitive error and the role it plays in patient harm. The goal of the following case analyses is to facilitate accurate recognition, identify how it contributes to patient harm, and suggest appropriate management strategies. Reason's human error theory is applied in case analyses of errors of cognitive underspecification. Sidney Dekker's theory of human incident investigation is applied to event investigation to facilitate identification of this little recognized error. Contributory factors leading to errors of cognitive underspecification include workload demands, interruptions, inexperienced practitioners, and lack of a shared mental model. Detecting errors of cognitive underspecification relies on blame-free listening and timely incident investigation. Strategies for interception include two-way interactive communication, standardization of communication processes, and technological support to ensure timely access to documented clinical information. Although errors of cognitive underspecification arise at the sharp end with the care provider, effective management is dependent upon system redesign that mitigates the latent contributory factors. Cognitive underspecification is ubiquitous whenever communication occurs. Accurate identification is essential if effective system redesign is to occur.
-
Mistake proofing: changing designs to reduce error
Grout, J R
2006-01-01
Mistake proofing uses changes in the physical design of processes to reduce human error. It can be used to change designs in ways that prevent errors from occurring, to detect errors after they occur but before harm occurs, to allow processes to fail safely, or to alter the work environment to reduce the chance of errors. Effective mistake proofing design changes should initially be effective in reducing harm, be inexpensive, and easily implemented. Over time these design changes should make life easier and speed up the process. Ideally, the design changes should increase patients' and visitors' understanding of the process. These designs should themselves be mistake proofed and follow the good design practices of other disciplines. PMID:17142609
-
The Frame Constraint on Experimentally Elicited Speech Errors in Japanese.
Saito, Akie; Inoue, Tomoyoshi
2017-06-01
The so-called syllable position effect in speech errors has been interpreted as reflecting constraints posed by the frame structure of a given language, which is separately operating from linguistic content during speech production. The effect refers to the phenomenon that when a speech error occurs, replaced and replacing sounds tend to be in the same position within a syllable or word. Most of the evidence for the effect comes from analyses of naturally occurring speech errors in Indo-European languages, and there are few studies examining the effect in experimentally elicited speech errors and in other languages. This study examined whether experimentally elicited sound errors in Japanese exhibits the syllable position effect. In Japanese, the sub-syllabic unit known as "mora" is considered to be a basic sound unit in production. Results showed that the syllable position effect occurred in mora errors, suggesting that the frame constrains the ordering of sounds during speech production.
-
Detection of Common Errors in Turkish EFL Students' Writing through a Corpus Analytic Approach
ERIC Educational Resources Information Center
Demirel, Elif Tokdemir
2017-01-01
The present study aims to explore Turkish EFL students' major writing difficulties by analyzing the frequent writing errors in academic essays. Accordingly, the study examined errors in a corpus of 150 academic essays written by Turkish EFL students studying at the Department of English Language and Literature at a public university in Turkey. The…
-
ERIC Educational Resources Information Center
Tajeddin, Zia; Alemi, Minoo; Pashmforoosh, Roya
2017-01-01
Unlike linguistic fossilization, pragmatic fossilization has received scant attention in fossilization research. To bridge this gap, the present study adopted a typical-error method of fossilization research to identify the most frequent errors in pragmatic routines committed by Persian-speaking learners of L2 English and explore the sources of…
-
ERIC Educational Resources Information Center
Walker, Grant M.; Schwartz, Myrna F.; Kimberg, Daniel Y.; Faseyitan, Olufunsho; Brecher, Adelyn; Dell, Gary S.; Coslett, H. Branch
2011-01-01
Semantic errors in aphasia (e.g., naming a horse as "dog") frequently arise from faulty mapping of concepts onto lexical items. A recent study by our group used voxel-based lesion-symptom mapping (VLSM) methods with 64 patients with chronic aphasia to identify voxels that carry an association with semantic errors. The strongest associations were…
-
ERIC Educational Resources Information Center
Weinzierl, Christiane; Kerkhoff, Georg; van Eimeren, Lucia; Keller, Ingo; Stenneken, Prisca
2012-01-01
Unilateral spatial neglect frequently involves a lateralised reading disorder, neglect dyslexia (ND). Reading of single words in ND is characterised by left-sided omissions and substitutions of letters. However, it is unclear whether the distribution of error types and positions within a word shows a unique pattern of ND when directly compared to…
-
Suicide Mortality Trends in Four Provinces of Iran with the Highest Mortality, from 2006-2016.
Nazari Kangavari, Hajar; Shojaei, Ahmad; Hashemi Nazari, Seyed Saeed
2017-06-14
Suicide is a major cause of unnatural deaths in the world. Its incidence is higher in western provinces of Iran. So far, there has not been any time series analysis of suicide in western provinces. The purpose of this study was to analyze suicide mortality data from 2006 to 2016 as well as to forecast the number of suicides for 2017 in four provinces of Iran (Ilam, Kermanshah and Lorestan and Kohgiluyeh and Boyer-Ahmad). Descriptive-analytic study. Data were analyzed by time- series analysis using R software. Three automatic methods (Auto.arima, ETS (Error Transitional Seasonality) and time series linear model (TSLM)) were fitted on the data. The best model after cross validation according to the mean absolute error measure was selected for forecasting. Totally, 7004 suicidal deaths occurred of which, 4259 were male and 2745 were female. The mean age of the study population was (32.05 ± 15.48 yr). Hanging and self-immolation were the most frequent types of suicide in men and women, respectively. The maximum and minimum number of suicides was occurred in July and August as well as January respectively. It is suggested that intervention measures should be designed in order to decrease the suicide rate particularly in the age group of 15-29 yr, and implemented as a pilot study, especially in these four provinces of Iran, which have a relatively high suicide rate.
-
Just, Beth Haenke; Marc, David; Munns, Megan; Sandefer, Ryan
2016-01-01
Patient identification matching problems are a major contributor to data integrity issues within electronic health records. These issues impede the improvement of healthcare quality through health information exchange and care coordination, and contribute to deaths resulting from medical errors. Despite best practices in the area of patient access and medical record management to avoid duplicating patient records, duplicate records continue to be a significant problem in healthcare. This study examined the underlying causes of duplicate records using a multisite data set of 398,939 patient records with confirmed duplicates and analyzed multiple reasons for data discrepancies between those record matches. The field that had the greatest proportion of mismatches (nondefault values) was the middle name, accounting for 58.30 percent of mismatches. The Social Security number was the second most frequent mismatch, occurring in 53.54 percent of the duplicate pairs. The majority of the mismatches in the name fields were the result of misspellings (53.14 percent in first name and 33.62 percent in last name) or swapped last name/first name, first name/middle name, or last name/middle name pairs. The use of more sophisticated technologies is critical to improving patient matching. However, no amount of advanced technology or increased data capture will completely eliminate human errors. Thus, the establishment of policies and procedures (such as standard naming conventions or search routines) for front-end and back-end staff to follow is foundational for the overall data integrity process. Training staff on standard policies and procedures will result in fewer duplicates created on the front end and more accurate duplicate record matching and merging on the back end. Furthermore, monitoring, analyzing trends, and identifying errors that occur are proactive ways to identify data integrity issues. PMID:27134610
-
ERIC Educational Resources Information Center
El-khateeb, Mahmoud M. A.
2016-01-01
The purpose of this study aims to investigate the errors classes occurred by the Preparatory year students at King Saud University, through analysis student responses to the items of the study test, and to identify the varieties of the common errors and ratios of common errors that occurred in solving inequalities. In the collection of the data,…
-
Inborn Errors of Fructose Metabolism. What Can We Learn from Them?
Tran, Christel
2017-04-03
Fructose is one of the main sweetening agents in the human diet and its ingestion is increasing globally. Dietary sugar has particular effects on those whose capacity to metabolize fructose is limited. If intolerance to carbohydrates is a frequent finding in children, inborn errors of carbohydrate metabolism are rare conditions. Three inborn errors are known in the pathway of fructose metabolism; (1) essential or benign fructosuria due to fructokinase deficiency; (2) hereditary fructose intolerance; and (3) fructose-1,6-bisphosphatase deficiency. In this review the focus is set on the description of the clinical symptoms and biochemical anomalies in the three inborn errors of metabolism. The potential toxic effects of fructose in healthy humans also are discussed. Studies conducted in patients with inborn errors of fructose metabolism helped to understand fructose metabolism and its potential toxicity in healthy human. Influence of fructose on the glycolytic pathway and on purine catabolism is the cause of hypoglycemia, lactic acidosis and hyperuricemia. The discovery that fructose-mediated generation of uric acid may have a causal role in diabetes and obesity provided new understandings into pathogenesis for these frequent diseases.
-
Inborn Errors of Fructose Metabolism. What Can We Learn from Them?
Tran, Christel
2017-01-01
Fructose is one of the main sweetening agents in the human diet and its ingestion is increasing globally. Dietary sugar has particular effects on those whose capacity to metabolize fructose is limited. If intolerance to carbohydrates is a frequent finding in children, inborn errors of carbohydrate metabolism are rare conditions. Three inborn errors are known in the pathway of fructose metabolism; (1) essential or benign fructosuria due to fructokinase deficiency; (2) hereditary fructose intolerance; and (3) fructose-1,6-bisphosphatase deficiency. In this review the focus is set on the description of the clinical symptoms and biochemical anomalies in the three inborn errors of metabolism. The potential toxic effects of fructose in healthy humans also are discussed. Studies conducted in patients with inborn errors of fructose metabolism helped to understand fructose metabolism and its potential toxicity in healthy human. Influence of fructose on the glycolytic pathway and on purine catabolism is the cause of hypoglycemia, lactic acidosis and hyperuricemia. The discovery that fructose-mediated generation of uric acid may have a causal role in diabetes and obesity provided new understandings into pathogenesis for these frequent diseases. PMID:28368361
-
RACER: Effective Race Detection Using AspectJ
NASA Technical Reports Server (NTRS)
Bodden, Eric; Havelund, Klaus
2008-01-01
The limits of coding with joint constraints on detected and undetected error rates Programming errors occur frequently in large software systems, and even more so if these systems are concurrent. In the past, researchers have developed specialized programs to aid programmers detecting concurrent programming errors such as deadlocks, livelocks, starvation and data races. In this work we propose a language extension to the aspect-oriented programming language AspectJ, in the form of three new built-in pointcuts, lock(), unlock() and may be Shared(), which allow programmers to monitor program events where locks are granted or handed back, and where values are accessed that may be shared amongst multiple Java threads. We decide thread-locality using a static thread-local objects analysis developed by others. Using the three new primitive pointcuts, researchers can directly implement efficient monitoring algorithms to detect concurrent programming errors online. As an example, we expose a new algorithm which we call RACER, an adoption of the well-known ERASER algorithm to the memory model of Java. We implemented the new pointcuts as an extension to the Aspect Bench Compiler, implemented the RACER algorithm using this language extension and then applied the algorithm to the NASA K9 Rover Executive. Our experiments proved our implementation very effective. In the Rover Executive RACER finds 70 data races. Only one of these races was previously known.We further applied the algorithm to two other multi-threaded programs written by Computer Science researchers, in which we found races as well.
-
Rußig, Lorenz L; Schulze, Ralf K W
2013-12-01
The goal of the present study was to develop a theoretical analysis of errors in implant position, which can occur owing to minute registration errors of a reference marker in a cone beam computed tomography volume when inserting an implant with a surgical stent. A virtual dental-arch model was created using anatomic data derived from the literature. Basic trigonometry was used to compute effects of defined minute registration errors of only voxel size. The errors occurring at the implant's neck and apex both in horizontal as in vertical direction were computed for mean ±95%-confidence intervals of jaw width and length and typical implant lengths (8, 10 and 12 mm). Largest errors occur in vertical direction for larger voxel sizes and for greater arch dimensions. For a 10 mm implant in the frontal region, these can amount to a mean of 0.716 mm (range: 0.201-1.533 mm). Horizontal errors at the neck are negligible, with a mean overall deviation of 0.009 mm (range: 0.001-0.034 mm). Errors increase with distance to the registration marker and voxel size and are affected by implant length. Our study shows that minute and realistic errors occurring in the automated registration of a reference object have an impact on the implant's position and angulation. These errors occur in the fundamental initial step in the long planning chain; thus, they are critical and should be made aware to users of these systems. © 2012 John Wiley & Sons A/S.
-
NASA Astrophysics Data System (ADS)
Herrmann, Enrico; Makrushin, Andrey; Dittmann, Jana; Vielhauer, Claus; Langnickel, Mirko; Kraetzer, Christian
2010-01-01
Successful user discrimination in a vehicle environment may yield a reduction of the number of switches, thus significantly reducing costs while increasing user convenience. The personalization of individual controls permits conditional passenger enable/driver disable and vice versa options which may yield safety improvement. The authors propose a prototypic optical sensing system based on hand movement segmentation in near-infrared image sequences implemented in an Audi A6 Avant. Analyzing the number of movements in special regions, the system recognizes the direction of the forearm and hand motion and decides whether driver or front-seat passenger touch a control. The experimental evaluation is performed independently for uniformly and non-uniformly illuminated video data as well as for the complete video data set which includes both subsets. The general test results in error rates of up to 14.41% FPR / 16.82% FNR and 17.61% FPR / 14.77% FNR for driver and passenger respectively. Finally, the authors discuss the causes of the most frequently occurring errors as well as the prospects and limitations of optical sensing for user discrimination in passenger compartments.
-
Driving improvement in patient care: lessons from Toyota.
Thompson, Debra N; Wolf, Gail A; Spear, Steven J
2003-11-01
Nurses today are attempting to do more with less while grappling with faulty error-prone systems that do not focus on patients at the point of care. This struggle occurs against a backdrop of rising national concern over the incidence of medical errors in healthcare. In an effort to create greater value with scarce resources and fix broken systems that compromise quality care, UPMC Health System is beginning to master and implement the Toyota Production System (TPS)--a method of managing people engaged in work that emphasizes frequent rapid problem solving and work redesign that has become the global archetype for productivity and performance. The authors discuss the rationale for applying TPS to healthcare and implementation of the system through the development of "learning unit" model lines and initial outcomes, such as dramatic reductions in the number of missing medications and thousands of hours and dollars saved as a result of TPS-driven changes. Tracking data further suggest that TPS, with sufficient staff preparation and involvement, has the potential for continuous, lasting, and accelerated improvement in patient care.
-
A median filter approach for correcting errors in a vector field
NASA Technical Reports Server (NTRS)
Schultz, H.
1985-01-01
Techniques are presented for detecting and correcting errors in a vector field. These methods employ median filters which are frequently used in image processing to enhance edges and remove noise. A detailed example is given for wind field maps produced by a spaceborne scatterometer. The error detection and replacement algorithm was tested with simulation data from the NASA Scatterometer (NSCAT) project.
-
ERIC Educational Resources Information Center
Rodriguez, Uxio Perez; Lires, Maria Alvarez; Solino, Jorge Prieto
2008-01-01
This article analyzes how science textbooks used in secondary education (ages 12 and 13) in Spain have treated the subject of the historical evolution of the Universe. We have discovered many very important errors in the different textbooks that we reviewed. We focus on the errors that are committed most frequently. (Contains 1 table and 1 note.)
-
Clinical relevance of pharmacist intervention in an emergency department.
Pérez-Moreno, Maria Antonia; Rodríguez-Camacho, Juan Manuel; Calderón-Hernanz, Beatriz; Comas-Díaz, Bernardino; Tarradas-Torras, Jordi
2017-08-01
To evaluate the clinical relevance of pharmacist intervention on patient care in emergencies, to determine the severity of detected errors. Second, to analyse the most frequent types of interventions and type of drugs involved and to evaluate the clinical pharmacist's activity. A 6-month observational prospective study of pharmacist intervention in the Emergency Department (ED) at a 400-bed hospital in Spain was performed to record interventions carried out by the clinical pharmacists. We determined whether the intervention occurred in the process of medication reconciliation or another activity, and whether the drug involved belonged to the High-Alert Medications Institute for Safe Medication Practices (ISMP) list. To evaluate the severity of the errors detected and clinical relevance of the pharmacist intervention, a modified assessment scale of Overhage and Lukes was used. Relationship between clinical relevance of pharmacist intervention and the severity of medication errors was assessed using ORs and Spearman's correlation coefficient. During the observation period, pharmacists reviewed the pharmacotherapy history and medication orders of 2984 patients. A total of 991 interventions were recorded in 557 patients; 67.2% of the errors were detected during medication reconciliation. Medication errors were considered severe in 57.2% of cases and 64.9% of pharmacist intervention were considered relevant. About 10.9% of the drugs involved are in the High-Alert Medications ISMP list. The severity of the medication error and the clinical significance of the pharmacist intervention were correlated (Spearman's ρ=0.728/p<0.001). In this single centre study, the clinical pharmacists identified and intervened on a high number of severe medication errors. This suggests that emergency services will benefit from pharmacist-provided drug therapy services. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/.
-
Fletcher, M D
2015-01-01
Correction of limb alignment or length discrepancy by circular external fixation is an accepted technique which relies on the correct biomechanical application of the frame and precise corrections which are frequently delegated to the patient to perform. Errors can occur in the execution of the correction by the patient and may result in significant deformity that requires remedial intervention. A 67 Caucasian female underwent multifocal limb reconstruction of the lower limb utilising a complex Ilizarov frame. Attendance at follow-up visits did not occur and the patient presented at 6 months with severe deformity due to incorrect execution of the correction protocol which resulted in a 45 degree varus deformity of the tibia. Subsequent correction via acute tibial osteotomy and stabilisation with a stemmed total knee replacement resulted in a good outcome. Patient compliance with post-operative management is paramount with distraction osteogenesis and should be ensured prior to embarking on lengthening or deformity correction.
-
Siewert, Bettina; Brook, Olga R; Hochman, Mary; Eisenberg, Ronald L
2016-03-01
The purpose of this study is to analyze the impact of communication errors on patient care, customer satisfaction, and work-flow efficiency and to identify opportunities for quality improvement. We performed a search of our quality assurance database for communication errors submitted from August 1, 2004, through December 31, 2014. Cases were analyzed regarding the step in the imaging process at which the error occurred (i.e., ordering, scheduling, performance of examination, study interpretation, or result communication). The impact on patient care was graded on a 5-point scale from none (0) to catastrophic (4). The severity of impact between errors in result communication and those that occurred at all other steps was compared. Error evaluation was performed independently by two board-certified radiologists. Statistical analysis was performed using the chi-square test and kappa statistics. Three hundred eighty of 422 cases were included in the study. One hundred ninety-nine of the 380 communication errors (52.4%) occurred at steps other than result communication, including ordering (13.9%; n = 53), scheduling (4.7%; n = 18), performance of examination (30.0%; n = 114), and study interpretation (3.7%; n = 14). Result communication was the single most common step, accounting for 47.6% (181/380) of errors. There was no statistically significant difference in impact severity between errors that occurred during result communication and those that occurred at other times (p = 0.29). In 37.9% of cases (144/380), there was an impact on patient care, including 21 minor impacts (5.5%; result communication, n = 13; all other steps, n = 8), 34 moderate impacts (8.9%; result communication, n = 12; all other steps, n = 22), and 89 major impacts (23.4%; result communication, n = 45; all other steps, n = 44). In 62.1% (236/380) of cases, no impact was noted, but 52.6% (200/380) of cases had the potential for an impact. Among 380 communication errors in a radiology department, 37.9% had a direct impact on patient care, with an additional 52.6% having a potential impact. Most communication errors (52.4%) occurred at steps other than result communication, with similar severity of impact.
-
Gutiérrez, Alfonso; Prieto, Iván; Cancela, José M.
2009-01-01
The purpose of this study is to provide a tool, based on the knowledge of technical errors, which helps to improve the teaching and learning process of the Uki Goshi technique. With this aim, we set out to determine the most frequent errors made by 44 students when performing this technique and how these mistakes relate. In order to do so, an observational analysis was carried out using the OSJUDO-UKG instrument and the data were registered using Match Vision Studio (Castellano, Perea, Alday and Hernández, 2008). The results, analyzed through descriptive statistics, show that the absence of a correct initial unbalancing movement (45,5%), the lack of proper right-arm pull (56,8%), not blocking the faller’s body (Uke) against the thrower’s hip -Tori- (54,5%) and throwing the Uke through the Tori’s side are the most usual mistakes (72,7%). Through the sequencial analysis of T-Patterns obtained with the THÈME program (Magnusson, 1996, 2000) we have concluded that not blocking the body with the Tori’s hip provokes the Uke’s throw through the Tori’s side during the final phase of the technique (95,8%), and positioning the right arm on the dorsal region of the Uke’s back during the Tsukuri entails the absence of a subsequent pull of the Uke’s body (73,3%). Key Points In this study, the most frequent errors in the performance of the Uki Goshi technique have been determined and the existing relations among these mistakes have been shown through T-Patterns. The SOBJUDO-UKG is an observation instrument for detecting mistakes in the aforementioned technique. The results show that those mistakes related to the initial imbalancing movement and the main driving action of the technique are the most frequent. The use of T-Patterns turns out to be effective in order to obtain the most important relations among the observed errors. PMID:24474885
-
Structured methods for identifying and correcting potential human errors in aviation operations
DOE Office of Scientific and Technical Information (OSTI.GOV)
Nelson, W.R.
1997-10-01
Human errors have been identified as the source of approximately 60% of the incidents and accidents that occur in commercial aviation. It can be assumed that a very large number of human errors occur in aviation operations, even though in most cases the redundancies and diversities built into the design of aircraft systems prevent the errors from leading to serious consequences. In addition, when it is acknowledged that many system failures have their roots in human errors that occur in the design phase, it becomes apparent that the identification and elimination of potential human errors could significantly decrease the risksmore » of aviation operations. This will become even more critical during the design of advanced automation-based aircraft systems as well as next-generation systems for air traffic management. Structured methods to identify and correct potential human errors in aviation operations have been developed and are currently undergoing testing at the Idaho National Engineering and Environmental Laboratory (INEEL).« less
-
Relationship between Brazilian airline pilot errors and time of day.
de Mello, M T; Esteves, A M; Pires, M L N; Santos, D C; Bittencourt, L R A; Silva, R S; Tufik, S
2008-12-01
Flight safety is one of the most important and frequently discussed issues in aviation. Recent accident inquiries have raised questions as to how the work of flight crews is organized and the extent to which these conditions may have been contributing factors to accidents. Fatigue is based on physiologic limitations, which are reflected in performance deficits. The purpose of the present study was to provide an analysis of the periods of the day in which pilots working for a commercial airline presented major errors. Errors made by 515 captains and 472 co-pilots were analyzed using data from flight operation quality assurance systems. To analyze the times of day (shifts) during which incidents occurred, we divided the light-dark cycle (24:00) in four periods: morning, afternoon, night, and early morning. The differences of risk during the day were reported as the ratio of morning to afternoon, morning to night and morning to early morning error rates. For the purposes of this research, level 3 events alone were taken into account, since these were the most serious in which company operational limits were exceeded or when established procedures were not followed. According to airline flight schedules, 35% of flights take place in the morning period, 32% in the afternoon, 26% at night, and 7% in the early morning. Data showed that the risk of errors increased by almost 50% in the early morning relative to the morning period (ratio of 1:1.46). For the period of the afternoon, the ratio was 1:1.04 and for the night a ratio of 1:1.05 was found. These results showed that the period of the early morning represented a greater risk of attention problems and fatigue.
-
The Accuracy of Eyelid Movement Parameters for Drowsiness Detection
Wilkinson, Vanessa E.; Jackson, Melinda L.; Westlake, Justine; Stevens, Bronwyn; Barnes, Maree; Swann, Philip; Rajaratnam, Shantha M. W.; Howard, Mark E.
2013-01-01
Study Objectives: Drowsiness is a major risk factor for motor vehicle and occupational accidents. Real-time objective indicators of drowsiness could potentially identify drowsy individuals with the goal of intervening before an accident occurs. Several ocular measures are promising objective indicators of drowsiness; however, there is a lack of studies evaluating their accuracy for detecting behavioral impairment due to drowsiness in real time. Methods: In this study, eye movement parameters were measured during vigilance tasks following restricted sleep and in a rested state (n = 33 participants) at three testing points (n = 71 data points) to compare ocular measures to a gold standard measure of drowsiness (OSLER). The utility of these parameters for detecting drowsiness-related errors was evaluated using receiver operating characteristic curves (ROC) (adjusted by clustering for participant) and identification of optimal cutoff levels for identifying frequent drowsiness-related errors (4 missed signals in a minute using OSLER). Their accuracy was tested for detecting increasing frequencies of behavioral lapses on a different task (psychomotor vigilance task [PVT]). Results: Ocular variables which measured the average duration of eyelid closure (inter-event duration [IED]) and the ratio of the amplitude to velocity of eyelid closure were reliable indicators of frequent errors (area under the curve for ROC of 0.73 to 0.83, p < 0.05). IED produced a sensitivity and specificity of 71% and 88% for detecting ≥ 3 lapses (PVT) in a minute and 100% and 86% for ≥ 5 lapses. A composite measure of several eye movement characteristics (Johns Drowsiness Scale) provided sensitivities of 77% and 100% for detecting 3 and ≥ 5 lapses in a minute, with specificities of 85% and 83%, respectively. Conclusions: Ocular measures, particularly those measuring the average duration of episodes of eye closure are promising real-time indicators of drowsiness. Citation: Wilkinson VE; Jackson ML; Westlake J; Stevens B; Barnes M; Swann P; Rajaratnam SMW; Howard ME. The accuracy of eyelid movement parameters for drowsiness detection. J Clin Sleep Med 2013;9(12):1315-1324. PMID:24340294
-
Implementing smart infusion pumps with dose-error reduction software: real-world experiences.
Heron, Claire
2017-04-27
Intravenous (IV) drug administration, especially with 'smart pumps', is complex and susceptible to errors. Although errors can occur at any stage of the IV medication process, most errors occur during reconstitution and administration. Dose-error reduction software (DERS) loaded on to infusion pumps incorporates a drug library with predefined upper and lower drug dose limits and infusion rates, which can reduce IV infusion errors. Although this is an important advance for patient safety at the point of care, uptake is still relatively low. This article discuses the challenges and benefits of implementing DERS in clinical practice as experienced by three UK trusts.
-
Meyer-Massetti, Carla; Krummenacher, Evelyne; Hedinger-Grogg, Barbara; Luterbacher, Stephan; Hersberger, Kurt E
2016-09-01
Background: While drug-related problems are among the most frequent adverse events in health care, little is known about their type and prevalence in home care in the current literature. The use of a Critical Incident Reporting System (CIRS), known as an economic and efficient tool to record medication errors for subsequent analysis, is widely implemented in inpatient care, but less established in ambulatory care. Recommendations on a possible format are scarce. A manual CIRS was developed based on the literature and subsequently piloted and implemented in a Swiss home care organization. Aim: The aim of this work was to implement a critical incident reporting system specifically for medication safety in home care. Results: The final CIRS form was well accepted among staff. Requiring limited resources, it allowed preliminary identification and trending of medication errors in home care. The most frequent error reports addressed medication preparation at the patients’ home, encompassing the following errors: omission (30 %), wrong dose (17.5 %) and wrong time (15 %). The most frequent underlying causes were related to working conditions (37.9 %), lacking attention (68.2 %), time pressure (22.7 %) and interruptions by patients (9.1 %). Conclusions: A manual CIRS allowed efficient data collection and subsequent analysis of medication errors in order to plan future interventions for improvement of medication safety. The development of an electronic CIRS would allow a reduction of the expenditure of time regarding data collection and analysis. In addition, it would favour the development of a national CIRS network among home care institutions.
-
Giraldo, Priscila; Sato, Luke; Martínez-Sánchez, Jose M; Comas, Mercè; Dwyer, Kathy; Sala, Maria; Castells, Xavier
2016-01-01
Objectives To evaluate and compare the characteristics of court verdicts on medical errors allegedly harming patients in Spain and Massachusetts from 2002 to 2012. Design, setting and participants We reviewed 1041 closed court verdicts obtained from data on litigation in the Thomson Reuters Aranzadi Westlaw databases in Spain (Europe), and 370 closed court verdicts obtained from the Controlled Risk and Risk Management Foundation of Harvard Medical Institutions (CRICO/RMF) in Massachusetts (USA). We included closed court verdicts on medical errors. The definition of medical errors was based on that of the Institute of Medicine (USA). We excluded any agreements between parties before a judgement. Results Medical errors were involved in 25.9% of court verdicts in Spain and in 74% of those in Massachusetts. The most frequent cause of medical errors was a diagnosis-related problem (25.1%; 95% CI 20.7% to 31.1% in Spain; 35%; 95% CI 29.4% to 40.7% in Massachusetts). The proportion of medical errors classified as high severity was 34% higher in Spain than in Massachusetts (p=0.001). The most frequent factors contributing to medical errors in Spain were surgical and medical treatment (p=0.001). In Spain, 98.5% of medical errors resulted in compensation awards compared with only 6.9% in Massachusetts. Conclusions This study reveals wide differences in litigation rates and the award of indemnity payments in Spain and Massachusetts; however, common features of both locations are the high rates of diagnosis-related problems and the long time interval until resolution. PMID:27577585
-
Error Correction: A Cognitive-Affective Stance
ERIC Educational Resources Information Center
Saeed, Aziz Thabit
2007-01-01
This paper investigates the application of some of the most frequently used writing error correction techniques to see the extent to which this application takes learners' cognitive and affective characteristics into account. After showing how unlearned application of these styles could be discouraging and/or damaging to students, the paper…
-
Improving Student Results in the Crystal Violet Chemical Kinetics Experiment
ERIC Educational Resources Information Center
Kazmierczak, Nathanael; Vander Griend, Douglas A.
2017-01-01
Despite widespread use in general chemistry laboratories, the crystal violet chemical kinetics experiment frequently suffers from erroneous student results. Student calculations for the reaction order in hydroxide often contain large asymmetric errors, pointing to the presence of systematic error. Through a combination of "in silico"…
-
ERIC Educational Resources Information Center
Bryant, William D. A.
1994-01-01
Asserts that errors frequently are made in teaching about the second fundamental theorem of welfare economics. Describes how this issue usually is taught in undergraduate economics courses. Discusses how this interpretation contains errors and may hinder students' analysis of public policy regarding welfare systems. (CFR)
-
Maltreatment of Strongyloides infection: case series and worldwide physicians-in-training survey.
Boulware, David R; Stauffer, William M; Hendel-Paterson, Brett R; Rocha, Jaime Luís Lopes; Seet, Raymond Chee-Seong; Summer, Andrea P; Nield, Linda S; Supparatpinyo, Khuanchai; Chaiwarith, Romanee; Walker, Patricia F
2007-06-01
Strongyloidiasis infects hundreds of millions of people worldwide and is an important cause of mortality from intestinal helminth infection in developed countries. The persistence of infection, increasing international travel, lack of familiarity by health care providers, and potential for iatrogenic hyperinfection all make strongyloidiasis an important emerging infection. Two studies were performed. A retrospective chart review of Strongyloides stercoralis cases identified through microbiology laboratory records from 1993-2002 was conducted. Subsequently, 363 resident physicians in 15 training programs worldwide were queried with a case scenario of strongyloidiasis, presenting an immigrant with wheezing and eosinophilia. The evaluation focused on resident recognition and diagnostic recommendations. In 151 strongyloidiasis cases, stool ova and parasite sensitivity is poor (51%), and eosinophilia (>5% or >400 cells/microL) commonly present (84%). Diagnosis averaged 56 months (intra-quartile range: 4-72 months) after immigration. Presenting complaints were nonspecific, although 10% presented with wheezing. Hyperinfection occurred in 5 patients prescribed corticosteroids, with 2 deaths. Treatment errors occurred more often among providers unfamiliar with immigrant health (relative risk of error: 8.4; 95% confidence interval, 3.4-21.0; P <.001). When presented with a hypothetical case scenario, US physicians-in-training had poor recognition (9%) of the need for parasite screening and frequently advocated empiric corticosteroids (23%). International trainees had superior recognition at 56% (P <.001). Among US trainees, 41% were unable to choose any parasite causing pulmonary symptoms. Strongyloidiasis is present in US patients. Diagnostic consideration should occur with appropriate exposure, nonspecific symptoms including wheezing, or eosinophilia (>5% relative or >400 eosinophils/microL). US residents' helminth knowledge is limited and places immigrants in iatrogenic danger. Information about Strongyloides should be included in US training and continuing medical education programs.
-
Maltreatment of Strongyloides infection: Case series and worldwide physicians-in-training survey
Boulware, David R.; Stauffer, William M.; Hendel-Paterson, Brett R.; Rocha, Jaime Luís Lopes; Seet, Raymond Chee-Seong; Summer, Andrea P.; Nield, Linda S.; Supparatpinyo, Khuanchai; Chaiwarith, Romanee; Walker, Patricia F.
2007-01-01
Background Strongyloidiasis infects hundreds of millions of people worldwide and is an important cause of mortality from intestinal helminth infection in developed countries. The persistence of infection, increasing international travel, lack of familiarity by healthcare providers, and potential for iatrogenic hyperinfection, all make strongyloidiasis an important emerging infection. Design & Methods Two studies were performed. A retrospective chart review of Strongyloides stercoralis cases identified through microbiology laboratory records from 1993–2002 was conducted. Subsequently, 363 resident physicians in 15 training programs worldwide were queried with a case scenario of strongyloidiasis presenting an immigrant with wheezing and eosinophilia. The evaluation focused on resident recognition and diagnostic recommendations. Results In 151 strongyloidiasis cases, stool ova and parasite sensitivity is poor (51%), and eosinophilia (>5% or >400 cells/μL) commonly present (84%). Diagnosis averaged 56 months (Intra-quartile range: 4 to 72 months) after immigration. Presenting complaints were non-specific, although 10% presented with wheezing. Hyperinfection occurred in five patients prescribed corticosteroids with two deaths. Treatment errors occurred more often among providers unfamiliar with immigrant health (Relative Risk of Error: 8.4; 95% CI: 3.4 to 21.0; P<0.001). When presented a hypothetical case scenario, U.S. physicians-in-training had poor recognition (9%) of the need for parasite screening and frequently advocated empiric corticosteroids (23%). International trainees had superior recognition at 56% (P<0.001). Among U.S. trainees, 41% were unable to choose any parasite causing pulmonary symptoms. Conclusions Strongyloidiasis is present in U.S. patients. Diagnostic consideration should occur with appropriate exposure, non-specific symptoms including wheezing, or eosinophilia (>5% relative or >400 eosinophils/μL). U.S. residents’ helminth knowledge is limited and places immigrants in iatrogenic danger. Strongyloides should be included in U.S. training and continuing medical education programs. PMID:17524758
-
Clinical decision support alert malfunctions: analysis and empirically derived taxonomy.
Wright, Adam; Ai, Angela; Ash, Joan; Wiesen, Jane F; Hickman, Thu-Trang T; Aaron, Skye; McEvoy, Dustin; Borkowsky, Shane; Dissanayake, Pavithra I; Embi, Peter; Galanter, William; Harper, Jeremy; Kassakian, Steve Z; Ramoni, Rachel; Schreiber, Richard; Sirajuddin, Anwar; Bates, David W; Sittig, Dean F
2018-05-01
To develop an empirically derived taxonomy of clinical decision support (CDS) alert malfunctions. We identified CDS alert malfunctions using a mix of qualitative and quantitative methods: (1) site visits with interviews of chief medical informatics officers, CDS developers, clinical leaders, and CDS end users; (2) surveys of chief medical informatics officers; (3) analysis of CDS firing rates; and (4) analysis of CDS overrides. We used a multi-round, manual, iterative card sort to develop a multi-axial, empirically derived taxonomy of CDS malfunctions. We analyzed 68 CDS alert malfunction cases from 14 sites across the United States with diverse electronic health record systems. Four primary axes emerged: the cause of the malfunction, its mode of discovery, when it began, and how it affected rule firing. Build errors, conceptualization errors, and the introduction of new concepts or terms were the most frequent causes. User reports were the predominant mode of discovery. Many malfunctions within our database caused rules to fire for patients for whom they should not have (false positives), but the reverse (false negatives) was also common. Across organizations and electronic health record systems, similar malfunction patterns recurred. Challenges included updates to code sets and values, software issues at the time of system upgrades, difficulties with migration of CDS content between computing environments, and the challenge of correctly conceptualizing and building CDS. CDS alert malfunctions are frequent. The empirically derived taxonomy formalizes the common recurring issues that cause these malfunctions, helping CDS developers anticipate and prevent CDS malfunctions before they occur or detect and resolve them expediently.
-
Characteristics of Single-Event Upsets in a Fabric Switch (ADS151)
NASA Technical Reports Server (NTRS)
Buchner, Stephen; Carts, Martin A.; McMorrow, Dale; Kim, Hak; Marshall, Paul W.; LaBel, Kenneth A.
2003-01-01
Abstract-Two types of single event effects - bit errors and single event functional interrupts - were observed during heavy-ion testing of the AD8151 crosspoint switch. Bit errors occurred in bursts with the average number of bits in a burst being dependent on both the ion LET and on the data rate. A pulsed laser was used to identify the locations on the chip where the bit errors and single event functional interrupts occurred. Bit errors originated in the switches, drivers, and output buffers. Single event functional interrupts occurred when the laser was focused on the second rank latch containing the data specifying the state of each switch in the 33x17 matrix.
-
Helleringer, Stéphane; Pison, Gilles; Kanté, Almamy M.; Duthé, Géraldine; Andro, Armelle
2014-01-01
Estimates of adult mortality in countries with limited vital registration (e.g., sub-Saharan Africa) are often derived from information about the survival of a respondent’s siblings. We evaluated the completeness and accuracy of such data through a record linkage study conducted in Bandafassi, located in southeastern Senegal. We linked at the individual level retrospective siblings’ survival histories (SSH) reported by female respondents (n = 268) to prospective mortality data and genealogies collected through a health and demographic surveillance system (HDSS). Respondents often reported inaccurate lists of siblings. Additions to these lists were uncommon, but omissions were frequent: respondents omitted 3.8 % of their live sisters, 9.1 % of their deceased sisters, and 16.6 % of their sisters who had migrated out of the DSS area. Respondents underestimated the age at death of the siblings they reported during the interview, particularly among siblings who had died at older ages (≥45 years). Restricting SSH data to person-years and events having occurred during a recent reference period reduced list errors but not age and date errors. Overall, SSH data led to a 20 % underestimate of 45q15 relative to HDSS data. Our study suggests new quality improvement strategies for SSH data and demonstrates the potential use of HDSS data for the validation of “unconventional” demographic techniques. PMID:24493063
-
Helleringer, Stéphane; Pison, Gilles; Kanté, Almamy M; Duthé, Géraldine; Andro, Armelle
2014-04-01
Estimates of adult mortality in countries with limited vital registration (e.g., sub-Saharan Africa) are often derived from information about the survival of a respondent's siblings. We evaluated the completeness and accuracy of such data through a record linkage study conducted in Bandafassi, located in southeastern Senegal. We linked at the individual level retrospective siblings' survival histories (SSH) reported by female respondents (n = 268) to prospective mortality data and genealogies collected through a health and demographic surveillance system (HDSS). Respondents often reported inaccurate lists of siblings. Additions to these lists were uncommon, but omissions were frequent: respondents omitted 3.8 % of their live sisters, 9.1 % of their deceased sisters, and 16.6 % of their sisters who had migrated out of the DSS area. Respondents underestimated the age at death of the siblings they reported during the interview, particularly among siblings who had died at older ages (≥45 years). Restricting SSH data to person-years and events having occurred during a recent reference period reduced list errors but not age and date errors. Overall, SSH data led to a 20 % underestimate of 45 q 15 relative to HDSS data. Our study suggests new quality improvement strategies for SSH data and demonstrates the potential use of HDSS data for the validation of "unconventional" demographic techniques.
-
Hlavsa, Michele C; Roberts, Virginia A; Anderson, Ayana R; Hill, Vincent R; Kahler, Amy M; Orr, Maureen; Garrison, Laurel E; Hicks, Lauri A; Newton, Anna; Hilborn, Elizabeth D; Wade, Timothy J; Beach, Michael J; Yoder, Jonathan S
2011-09-23
Since 1978, CDC, the U.S. Environmental Protection Agency, and the Council of State and Territorial Epidemiologists have collaborated on the Waterborne Disease and Outbreak Surveillance System (WBDOSS) for collecting and reporting data on waterborne disease outbreaks associated with recreational water. This surveillance system is the primary source of data concerning the scope and health effects of waterborne disease outbreaks in the United States. In addition, data are collected on other select recreational water--associated health events, including pool chemical--associated health events and single cases of Vibrio wound infection and primary amebic meningoencephalitis (PAM). Data presented summarize recreational water--associated outbreaks and other health events that occurred during January 2007--December 2008. Previously unreported data on outbreaks that have occurred since 1978 also are presented. The WBDOSS database includes data on outbreaks associated with recreational water, drinking water, water not intended for drinking (excluding recreational water), and water use of unknown intent. Public health agencies in the states, the District of Columbia, U.S. territories, and Freely Associated States are primarily responsible for detecting and investigating waterborne disease outbreaks and voluntarily reporting them to CDC using a standard form. Only data on outbreaks associated with recreational water are summarized in this report. Data on other recreational water--associated health events reported to CDC, the Agency for Toxic Substances and Disease Registry (ATSDR), and the U.S. Consumer Product Safety Commission (CPSC) also are summarized. A total of 134 recreational water--associated outbreaks were reported by 38 states and Puerto Rico for 2007--2008. These outbreaks resulted in at least 13,966 cases. The median outbreak size was 11 cases (range: 2--5,697 cases). A total of 116 (86.6%) outbreaks were associated with treated recreational water (e.g., pools and interactive fountains) and resulted in 13,480 (96.5%) cases. Of the 134 outbreaks, 81 (60.4%) were outbreaks of acute gastrointestinal illness (AGI); 24 (17.9%) were outbreaks of dermatologic illnesses, conditions, or symptoms; and 17 (12.7%) were outbreaks of acute respiratory illness. Outbreaks of AGI resulted in 12,477 (89.3%) cases. The etiology was laboratory-confirmed for 105 (78.4%) of the 134 outbreaks. Of the 105 outbreaks with a laboratory-confirmed etiology, 68 (64.8%) were caused by parasites, 22 (21.0%) by bacteria, five (4.8%) by viruses, nine (8.6%) by chemicals or toxins, and one (1.0%) by multiple etiology types. Cryptosporidium was confirmed as the etiologic agent of 60 (44.8%) of 134 outbreaks, resulting in 12,154 (87.0%) cases; 58 (96.7%) of these outbreaks, resulting in a total of 12,137 (99.9%) cases, were associated with treated recreational water. A total of 32 pool chemical--associated health events that occurred in a public or residential setting were reported to WBDOSS by Maryland and Michigan. These events resulted in 48 cases of illness or injury; 26 (81.3%) events could be attributed at least partially to chemical handling errors (e.g., mixing incompatible chemicals). ATSDR's Hazardous Substance Emergency Events Surveillance System received 92 reports of hazardous substance events that occurred at aquatic facilities. More than half of these events (55 [59.8%]) involved injured persons; the most frequently reported primary contributing factor was human error. Estimates based on CPSC's National Electronic Injury Surveillance System (NEISS) data indicate that 4,574 (95% confidence interval [CI]: 2,703--6,446) emergency department (ED) visits attributable to pool chemical--associated injuries occurred in 2008; the most frequent diagnosis was poisoning (1,784 ED visits [95% CI: 585--2,984]). NEISS data indicate that pool chemical--associated health events occur frequently in residential settings. A total of 236 Vibrio wound infections were reported to be associated with recreational water exposure; 36 (48.6%) of the 74 hospitalized vibriosis patients and six (66.7%) of the nine vibriosis patients who died had V. vulnificus infections. Eight fatal cases of PAM occurred after exposure to warm untreated freshwater. The 134 recreational water--associated outbreaks reported for 2007--2008 represent a substantial increase over the 78 outbreaks reported for 2005--2006 and the largest number of outbreaks ever reported to WBDOSS for a 2-year period. Outbreaks, especially the largest ones, were most frequently associated with treated recreational water and characterized by AGI. Cryptosporidium remains the leading etiologic agent. Pool chemical--associated health events occur frequently but are preventable. Data on other select recreational water--associated health events further elucidate the epidemiology of U.S. waterborne disease by highlighting less frequently implicated types of recreational water (e.g., oceans) and detected types of recreational water--associated illness (i.e., not AGI). CDC uses waterborne disease outbreak surveillance data to 1) identify the types of etiologic agents, recreational water venues, and settings associated with waterborne disease outbreaks; 2) evaluate the adequacy of regulations and public awareness activities to promote healthy and safe swimming; and 3) establish public health priorities to improve prevention efforts, guidelines, and regulations at the local, state, and federal levels.
-
Refractive errors in a rural Korean adult population: the Namil Study.
Yoo, Y C; Kim, J M; Park, K H; Kim, C Y; Kim, T-W
2013-12-01
To assess the prevalence of refractive errors, including myopia, high myopia, hyperopia, astigmatism, and anisometropia, in rural adult Koreans. We identified 2027 residents aged 40 years or older in Namil-myeon, a rural town in central South Korea. Of 1928 eligible residents, 1532 subjects (79.5%) participated. Each subject underwent screening examinations including autorefractometry, corneal curvature measurement, and best-corrected visual acuity. Data from 1215 phakic right eyes were analyzed. The prevalence of myopia (spherical equivalent (SE) <-0.5 diopters (D)) was 20.5% (95% confidence interval (CI): 18.2-22.8%), of high myopia (SE <-6.0 D) was 1.0% (95% CI: 0.4-1.5%), of hyperopia (SE>+0.5 D) was 41.8% (95% CI: 38.9-44.4%), of astigmatism (cylinder <-0.5 D) was 63.7% (95% CI: 61.0-66.4%), and of anisometropia (difference in SE between eyes >1.0 D) was 13.8% (95% CI: 11.9-15.8%). Myopia prevalence decreased with age and tended to transition into hyperopia with age up to 60-69 years. In subjects older than this, the trend in SE refractive errors reversed with age. The prevalence of astigmatism and anisometropia increased consistently with age. The refractive status was not significantly different between males and females. The prevalence of myopia and hyperopia in rural adult Koreans was similar to that of rural Chinese. The prevalence of high myopia was lower in this Korean sample than in other East Asian populations, and astigmatism was the most frequently occurring refractive error.
-
Boquet, Albert J; Cohen, Tara N; Cabrera, Jennifer S; Litzinger, Tracy L; Captain, Kevin A; Fabian, Michael A; Miles, Steven G; Shappell, Scott A
2016-09-09
Historically, health care has relied on error management techniques to measure and reduce the occurrence of adverse events. This study proposes an alternative approach for identifying and analyzing hazardous events. Whereas previous research has concentrated on investigating individual flow disruptions, we maintain the industry should focus on threat windows, or the accumulation of these disruptions. This methodology, driven by the broken windows theory, allows us to identify process inefficiencies before they manifest and open the door for the occurrence of errors and adverse events. Medical human factors researchers observed disruptions during 34 trauma cases at a Level II trauma center. Data were collected during resuscitation and imaging and were classified using a human factors taxonomy: Realizing Improved Patient Care Through Human-Centered Operating Room Design for Threat Window Analysis (RIPCHORD-TWA). Of the 576 total disruptions observed, communication issues were the most prevalent (28%), followed by interruptions and coordination issues (24% each). Issues related to layout (16%), usability (5%), and equipment (2%) comprised the remainder of the observations. Disruptions involving communication issues were more prevalent during resuscitation, whereas coordination problems were observed more frequently during imaging. Rather than solely investigating errors and adverse events, we propose conceptualizing the accumulation of disruptions in terms of threat windows as a means to analyze potential threats to the integrity of the trauma care system. This approach allows for the improved identification of system weaknesses or threats, affording us the ability to address these inefficiencies and intervene before errors and adverse events may occur.
-
Yelland, Lisa N; Kahan, Brennan C; Dent, Elsa; Lee, Katherine J; Voysey, Merryn; Forbes, Andrew B; Cook, Jonathan A
2018-06-01
Background/aims In clinical trials, it is not unusual for errors to occur during the process of recruiting, randomising and providing treatment to participants. For example, an ineligible participant may inadvertently be randomised, a participant may be randomised in the incorrect stratum, a participant may be randomised multiple times when only a single randomisation is permitted or the incorrect treatment may inadvertently be issued to a participant at randomisation. Such errors have the potential to introduce bias into treatment effect estimates and affect the validity of the trial, yet there is little motivation for researchers to report these errors and it is unclear how often they occur. The aim of this study is to assess the prevalence of recruitment, randomisation and treatment errors and review current approaches for reporting these errors in trials published in leading medical journals. Methods We conducted a systematic review of individually randomised, phase III, randomised controlled trials published in New England Journal of Medicine, Lancet, Journal of the American Medical Association, Annals of Internal Medicine and British Medical Journal from January to March 2015. The number and type of recruitment, randomisation and treatment errors that were reported and how they were handled were recorded. The corresponding authors were contacted for a random sample of trials included in the review and asked to provide details on unreported errors that occurred during their trial. Results We identified 241 potentially eligible articles, of which 82 met the inclusion criteria and were included in the review. These trials involved a median of 24 centres and 650 participants, and 87% involved two treatment arms. Recruitment, randomisation or treatment errors were reported in 32 in 82 trials (39%) that had a median of eight errors. The most commonly reported error was ineligible participants inadvertently being randomised. No mention of recruitment, randomisation or treatment errors was found in the remaining 50 of 82 trials (61%). Based on responses from 9 of the 15 corresponding authors who were contacted regarding recruitment, randomisation and treatment errors, between 1% and 100% of the errors that occurred in their trials were reported in the trial publications. Conclusion Recruitment, randomisation and treatment errors are common in individually randomised, phase III trials published in leading medical journals, but reporting practices are inadequate and reporting standards are needed. We recommend researchers report all such errors that occurred during the trial and describe how they were handled in trial publications to improve transparency in reporting of clinical trials.
-
Kordel, Piotr; Kordel, Krzysztof
2014-11-01
The aim of the study was to present and analyze the verdicts of the Supreme Medical Court concerning professional misconduct among obstetrics and gynecology specialists between 2002-2012. Verdicts of the Supreme Medical Court from 84 cases concerning obstetrics and gynecology speciallsts, passed between 2002-20 12, were analyzed. The following categories were used to classify the types of professional misconduct: decisive erro, error in the performance of a medical procedure, organizational errol error of professional judgment, criminal offence, and unethical behavior. The largest group among the accused professionals were doctors working in private offices and on-call doctors in urban and district hospitals. The most frequent type of professional malpractice was decisive error and the most frequent type of case were obstetric labor complications. The analysis also showed a correlation between the type of case and the sentence in the Supreme Medical Court. A respective jurisdiction approach may be observed in the Supreme Medical Court ruling against cases concerning professional misconduct which are also criminal offences (i.e., illegal abortion, working under the influence). The most frequent types of professional misconduct should determine areas for professional training of obstetrics and gynecology specialists.
-
Altitude deviations: Breakdowns of an error-tolerant system
NASA Technical Reports Server (NTRS)
Palmer, Everett A.; Hutchins, Edwin L.; Ritter, Richard D.; Vancleemput, Inge
1993-01-01
Pilot reports of aviation incidents to the Aviation Safety Reporting System (ASRS) provide a window on the problems occurring in today's airline cockpits. The narratives of 10 pilot reports of errors made in the automation-assisted altitude-change task are used to illustrate some of the issues of pilots interacting with automatic systems. These narratives are then used to construct a description of the cockpit as an information processing system. The analysis concentrates on the error-tolerant properties of the system and on how breakdowns can occasionally occur. An error-tolerant system can detect and correct its internal processing errors. The cockpit system consists of two or three pilots supported by autoflight, flight-management, and alerting systems. These humans and machines have distributed access to clearance information and perform redundant processing of information. Errors can be detected as deviations from either expected behavior or as deviations from expected information. Breakdowns in this system can occur when the checking and cross-checking tasks that give the system its error-tolerant properties are not performed because of distractions or other task demands. Recommendations based on the analysis for improving the error tolerance of the cockpit system are given.
-
Regression Models For Multivariate Count Data
Zhang, Yiwen; Zhou, Hua; Zhou, Jin; Sun, Wei
2016-01-01
Data with multivariate count responses frequently occur in modern applications. The commonly used multinomial-logit model is limiting due to its restrictive mean-variance structure. For instance, analyzing count data from the recent RNA-seq technology by the multinomial-logit model leads to serious errors in hypothesis testing. The ubiquity of over-dispersion and complicated correlation structures among multivariate counts calls for more flexible regression models. In this article, we study some generalized linear models that incorporate various correlation structures among the counts. Current literature lacks a treatment of these models, partly due to the fact that they do not belong to the natural exponential family. We study the estimation, testing, and variable selection for these models in a unifying framework. The regression models are compared on both synthetic and real RNA-seq data. PMID:28348500
-
Regression Models For Multivariate Count Data.
Zhang, Yiwen; Zhou, Hua; Zhou, Jin; Sun, Wei
2017-01-01
Data with multivariate count responses frequently occur in modern applications. The commonly used multinomial-logit model is limiting due to its restrictive mean-variance structure. For instance, analyzing count data from the recent RNA-seq technology by the multinomial-logit model leads to serious errors in hypothesis testing. The ubiquity of over-dispersion and complicated correlation structures among multivariate counts calls for more flexible regression models. In this article, we study some generalized linear models that incorporate various correlation structures among the counts. Current literature lacks a treatment of these models, partly due to the fact that they do not belong to the natural exponential family. We study the estimation, testing, and variable selection for these models in a unifying framework. The regression models are compared on both synthetic and real RNA-seq data.
-
Erring and learning in clinical practice.
Hurwitz, Brian
2002-01-01
This paper discusses error type their possible consequences and the doctors who make them. There is no single, all-encompassing typology of medical errors. They are frequently multifactorial in origin and use from the mental processes of individuals; from defects in perception, thinking reasoning planning and interpretation and from failures of team-working omissions and poorly executed actions. They also arise from inadequately designed and operated healthcare systems or procedures. The paper considers error-truth relatedness, the approach of UK courts to medical errors, the learning opportunities which flow from error recognition and the need for personal and professional self awareness of clinical fallibilities. PMID:12389767
-
A Case Study of the Impact of AIRS Temperature Retrievals on Numerical Weather Prediction
NASA Technical Reports Server (NTRS)
Reale, O.; Atlas, R.; Jusem, J. C.
2004-01-01
Large errors in numerical weather prediction are often associated with explosive cyclogenesis. Most studes focus on the under-forecasting error, i.e. cases of rapidly developing cyclones which are poorly predicted in numerical models. However, the over-forecasting error (i.e., to predict an explosively developing cyclone which does not occur in reality) is a very common error that severely impacts the forecasting skill of all models and may also present economic costs if associated with operational forecasting. Unnecessary precautions taken by marine activities can result in severe economic loss. Moreover, frequent occurrence of over-forecasting can undermine the reliance on operational weather forecasting. Therefore, it is important to understand and reduce the prdctions of extreme weather associated with explosive cyclones which do not actually develop. In this study we choose a very prominent case of over-forecasting error in the northwestern Pacific. A 960 hPa cyclone develops in less than 24 hour in the 5-day forecast, with a deepening rate of about 30 hPa in one day. The cyclone is not versed in the analyses and is thus a case of severe over-forecasting. By assimilating AIRS data, the error is largely eliminated. By following the propagation of the anomaly that generates the spurious cyclone, it is found that a small mid-tropospheric geopotential height negative anomaly over the northern part of the Indian subcontinent in the initial conditions, propagates westward, is amplified by orography, and generates a very intense jet streak in the subtropical jet stream, with consequent explosive cyclogenesis over the Pacific. The AIRS assimilation eliminates this anomaly that may have been caused by erroneous upper-air data, and represents the jet stream more correctly. The energy associated with the jet is distributed over a much broader area and as a consequence a multiple, but much more moderate cyclogenesis is observed.
-
Wang, Peng; Bowler, Sarah L; Kantz, Serena F; Mettus, Roberta T; Guo, Yan; McElheny, Christi L; Doi, Yohei
2016-12-01
Treatment options for infections due to carbapenem-resistant Acinetobacter baumannii are extremely limited. Minocycline is a semisynthetic tetracycline derivative with activity against this pathogen. This study compared susceptibility testing methods that are used in clinical microbiology laboratories (Etest, disk diffusion, and Sensititre broth microdilution methods) for testing of minocycline, tigecycline, and doxycycline against 107 carbapenem-resistant A. baumannii clinical isolates. Susceptibility rates determined with the standard broth microdilution method using cation-adjusted Mueller-Hinton (MH) broth were 77.6% for minocycline and 29% for doxycycline, and 92.5% of isolates had tigecycline MICs of ≤2 μg/ml. Using MH agar from BD and Oxoid, susceptibility rates determined with the Etest method were 67.3% and 52.3% for minocycline, 21.5% and 18.7% for doxycycline, and 71% and 29.9% for tigecycline, respectively. With the disk diffusion method using MH agar from BD and Oxoid, susceptibility rates were 82.2% and 72.9% for minocycline and 34.6% and 34.6% for doxycycline, respectively, and rates of MICs of ≤2 μg/ml were 46.7% and 23.4% for tigecycline. In comparison with the standard broth microdilution results, very major rates were low (∼2.8%) for all three drugs across the methods, but major error rates were higher (∼5.6%), especially with the Etest method. For minocycline, minor error rates ranged from 14% to 37.4%. For tigecycline, minor error rates ranged from 6.5% to 69.2%. The majority of minor errors were due to susceptible results being reported as intermediate. For minocycline susceptibility testing of carbapenem-resistant A. baumannii strains, very major errors are rare, but major and minor errors overcalling strains as intermediate or resistant occur frequently with susceptibility testing methods that are feasible in clinical laboratories. Copyright © 2016, American Society for Microbiology. All Rights Reserved.
-
Morrison, Maeve; Cope, Vicki; Murray, Melanie
2018-05-15
Medication errors remain a commonly reported clinical incident in health care as highlighted by the World Health Organization's focus to reduce medication-related harm. This retrospective quantitative analysis examined medication errors reported by staff using an electronic Clinical Incident Management System (CIMS) during a 3-year period from April 2014 to April 2017 at a metropolitan mental health ward in Western Australia. The aim of the project was to identify types of medication errors and the context in which they occur and to consider recourse so that medication errors can be reduced. Data were retrieved from the Clinical Incident Management System database and concerned medication incidents from categorized tiers within the system. Areas requiring improvement were identified, and the quality of the documented data captured in the database was reviewed for themes pertaining to medication errors. Content analysis provided insight into the following issues: (i) frequency of problem, (ii) when the problem was detected, and (iii) characteristics of the error (classification of drug/s, where the error occurred, what time the error occurred, what day of the week it occurred, and patient outcome). Data were compared to the state-wide results published in the Your Safety in Our Hands (2016) report. Results indicated several areas upon which quality improvement activities could be focused. These include the following: structural changes; changes to policy and practice; changes to individual responsibilities; improving workplace culture to counteract underreporting of medication errors; and improvement in safety and quality administration of medications within a mental health setting. © 2018 Australian College of Mental Health Nurses Inc.
-
Comparison of medication safety effectiveness among nine critical access hospitals.
Cochran, Gary L; Haynatzki, Gleb
2013-12-15
The rates of medication errors across three different medication dispensing and administration systems frequently used in critical access hospitals (CAHs) were analyzed. Nine CAHs agreed to participate in this prospective study and were assigned to one of three groups based on similarities in their medication-use processes: (1) less than 10 hours per week of onsite pharmacy support and no bedside barcode system, (2) onsite pharmacy support for 40 hours per week and no bedside barcode system, and (3) onsite pharmacy support for 40 or more hours per week with a bedside barcode system. Errors were characterized by severity, phase of origination, type, and cause. Characteristics of the medication being administered and a number of best practices were collected for each medication pass. Logistic regression was used to identify significant predictors of errors. A total of 3103 medication passes were observed. More medication errors originated in hospitals that had onsite pharmacy support for less than 10 hours per week and no bedside barcode system than in other types of hospitals. A bedside barcode system had the greatest impact on lowering the odds of an error reaching the patient. Wrong dose and omission were common error types. Human factors and communication were the two most frequently identified causes of error for all three systems. Medication error rates were lower in CAHs with 40 or more hours per week of onsite pharmacy support with or without a bedside barcode system compared with hospitals with less than 10 hours per week of pharmacy support and no bedside barcode system.
-
De Oliveira, Gildasio S; Rahmani, Rod; Fitzgerald, Paul C; Chang, Ray; McCarthy, Robert J
2013-04-01
Poor supervision of physician trainees can be detrimental not only to resident education but also to patient care and safety. Inadequate supervision has been associated with more frequent deaths of patients under the care of junior residents. We hypothesized that residents reporting more medical errors would also report lower quality of supervision scores than the ones with lower reported medical errors. The primary objective of this study was to evaluate the association between the frequency of medical errors reported by residents and their perceived quality of faculty supervision. A cross-sectional nationwide survey was sent to 1000 residents randomly selected from anesthesiology training departments across the United States. Residents from 122 residency programs were invited to participate, the median (interquartile range) per institution was 7 (4-11). Participants were asked to complete a survey assessing demography, perceived quality of faculty supervision, and perceived causes of inadequate perceived supervision. Responses to the statements "I perform procedures for which I am not properly trained," "I make mistakes that have negative consequences for the patient," and "I have made a medication error (drug or incorrect dose) in the last year" were used to assess error rates. Average supervision scores were determined using the De Oliveira Filho et al. scale and compared among the frequency of self-reported error categories using the Kruskal-Wallis test. Six hundred four residents responded to the survey (60.4%). Forty-five (7.5%) of the respondents reported performing procedures for which they were not properly trained, 24 (4%) reported having made mistakes with negative consequences to patients, and 16 (3%) reported medication errors in the last year having occurred multiple times or often. Supervision scores were inversely correlated with the frequency of reported errors for all 3 questions evaluating errors. At a cutoff value of 3, supervision scores demonstrated an overall accuracy (area under the curve) (99% confidence interval) of 0.81 (0.73-0.86), 0.89 (0.77-0.95), and 0.93 (0.77-0.98) for predicting a response of multiple times or often to the question of performing procedures for which they were not properly trained, reported mistakes with negative consequences to patients, and reported medication errors in the last year, respectively. Anesthesiology trainees who reported a greater incidence of medical errors with negative consequences to patients and drug errors also reported lower scores for supervision by faculty. Our findings suggest that further studies of the association between supervision and patient safety are warranted. (Anesth Analg 2013;116:892-7).
-
Consciousness-Raising, Error Correction and Proofreading
ERIC Educational Resources Information Center
O'Brien, Josephine
2015-01-01
The paper discusses the impact of developing a consciousness-raising approach in error correction at the sentence level to improve students' proofreading ability. Learners of English in a foreign language environment often rely on translation as a composing tool and while this may act as a scaffold and provide some support, it frequently leads to…
-
ERIC Educational Resources Information Center
Peturson, Elizabeth D.; Cramer, Kenneth M.; Pomerleau, Chantal M.
2011-01-01
Observers frequently commit the fundamental attribution error by failing to make adequate allowance for contextual influences in favour of dispositional explanations. The present experiment tested whether people would attribute a quizmaster's knowledge of the quiz topic to personal factors (personally knowing the answers) or to situational factors…
-
The computer speed of SMVGEAR II was improved markedly on scalar and vector machines with relatively little loss in accuracy. The improvement was due to a method of frequently recalculating the absolute error tolerance instead of keeping it constant for a given set of chemistry. ...
-
Michaelson, M; Walsh, E; Bradley, C P; McCague, P; Owens, R; Sahm, L J
2017-08-01
Prescribing error may result in adverse clinical outcomes leading to increased patient morbidity, mortality and increased economic burden. Many errors occur during transitional care as patients move between different stages and settings of care. To conduct a review of medication information and identify prescribing error among an adult population in an urban hospital. Retrospective review of medication information was conducted. Part 1: an audit of discharge prescriptions which assessed: legibility, compliance with legal requirements, therapeutic errors (strength, dose and frequency) and drug interactions. Part 2: A review of all sources of medication information (namely pre-admission medication list, drug Kardex, discharge prescription, discharge letter) for 15 inpatients to identify unintentional prescription discrepancies, defined as: "undocumented and/or unjustified medication alteration" throughout the hospital stay. Part 1: of the 5910 prescribed items; 53 (0.9%) were deemed illegible. Of the controlled drug prescriptions 11.1% (n = 167) met all the legal requirements. Therapeutic errors occurred in 41% of prescriptions (n = 479) More than 1 in 5 patients (21.9%) received a prescription containing a drug interaction. Part 2: 175 discrepancies were identified across all sources of medication information; of which 78 were deemed unintentional. Of these: 10.2% (n = 8) occurred at the point of admission, whereby 76.9% (n = 60) occurred at the point of discharge. The study identified the time of discharge as a point at which prescribing errors are likely to occur. This has implications for patient safety and provider work load in both primary and secondary care.
-
Giraldo, Priscila; Sato, Luke; Martínez-Sánchez, Jose M; Comas, Mercè; Dwyer, Kathy; Sala, Maria; Castells, Xavier
2016-08-30
To evaluate and compare the characteristics of court verdicts on medical errors allegedly harming patients in Spain and Massachusetts from 2002 to 2012. We reviewed 1041 closed court verdicts obtained from data on litigation in the Thomson Reuters Aranzadi Westlaw databases in Spain (Europe), and 370 closed court verdicts obtained from the Controlled Risk and Risk Management Foundation of Harvard Medical Institutions (CRICO/RMF) in Massachusetts (USA). We included closed court verdicts on medical errors. The definition of medical errors was based on that of the Institute of Medicine (USA). We excluded any agreements between parties before a judgement. Medical errors were involved in 25.9% of court verdicts in Spain and in 74% of those in Massachusetts. The most frequent cause of medical errors was a diagnosis-related problem (25.1%; 95% CI 20.7% to 31.1% in Spain; 35%; 95% CI 29.4% to 40.7% in Massachusetts). The proportion of medical errors classified as high severity was 34% higher in Spain than in Massachusetts (p=0.001). The most frequent factors contributing to medical errors in Spain were surgical and medical treatment (p=0.001). In Spain, 98.5% of medical errors resulted in compensation awards compared with only 6.9% in Massachusetts. This study reveals wide differences in litigation rates and the award of indemnity payments in Spain and Massachusetts; however, common features of both locations are the high rates of diagnosis-related problems and the long time interval until resolution. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/
-
Kowal, Mikael A; van Steenbergen, Henk; Colzato, Lorenza S; Hazekamp, Arno; van der Wee, Nic J A; Manai, Meriem; Durieux, Jeffrey; Hommel, Bernhard
2015-11-01
Cannabis has been suggested to impair the capacity to recognize discrepancies between expected and executed actions. However, there is a lack of conclusive evidence regarding the acute impact of cannabis on the neural correlates of error monitoring. In order to contribute to the available knowledge, we used a randomized, double-blind, between-groups design to investigate the impact of administration of a low (5.5 mg THC) or high (22 mg THC) dose of vaporized cannabis vs. placebo on the amplitudes of the error-related negativity (ERN) and error positivity (Pe) in the context of the Flanker task, in a group of frequent cannabis users (required to use cannabis minimally 4 times a week, for at least 2 years). Subjects in the high dose group (n=18) demonstrated a significantly diminished ERN in comparison to the placebo condition (n=19), whereas a reduced Pe amplitude was observed in both the high and low dose (n=18) conditions, as compared to placebo. The results suggest that a high dose of cannabis may affect the neural correlates of both the conscious (late), as well as the initial automatic processes involved in error monitoring, while a low dose of cannabis might impact only the conscious (late) processing of errors. Copyright © 2015 Elsevier B.V. and ECNP. All rights reserved.
-
Fischer, Melissa A; Mazor, Kathleen M; Baril, Joann; Alper, Eric; DeMarco, Deborah; Pugnaire, Michele
2006-01-01
CONTEXT Trainees are exposed to medical errors throughout medical school and residency. Little is known about what facilitates and limits learning from these experiences. OBJECTIVE To identify major factors and areas of tension in trainees' learning from medical errors. DESIGN, SETTING, AND PARTICIPANTS Structured telephone interviews with 59 trainees (medical students and residents) from 1 academic medical center. Five authors reviewed transcripts of audiotaped interviews using content analysis. RESULTS Trainees were aware that medical errors occur from early in medical school. Many had an intense emotional response to the idea of committing errors in patient care. Students and residents noted variation and conflict in institutional recommendations and individual actions. Many expressed role confusion regarding whether and how to initiate discussion after errors occurred. Some noted the conflict between reporting errors to seniors who were responsible for their evaluation. Learners requested more open discussion of actual errors and faculty disclosure. No students or residents felt that they learned better from near misses than from actual errors, and many believed that they learned the most when harm was caused. CONCLUSIONS Trainees are aware of medical errors, but remaining tensions may limit learning. Institutions can immediately address variability in faculty response and local culture by disseminating clear, accessible algorithms to guide behavior when errors occur. Educators should develop longitudinal curricula that integrate actual cases and faculty disclosure. Future multi-institutional work should focus on identified themes such as teaching and learning in emotionally charged situations, learning from errors and near misses and balance between individual and systems responsibility. PMID:16704381
-
[Errors in Peruvian medical journals references].
Huamaní, Charles; Pacheco-Romero, José
2009-01-01
References are fundamental in our studies; an adequate selection is asimportant as an adequate description. To determine the number of errors in a sample of references found in Peruvian medical journals. We reviewed 515 scientific papers references selected by systematic randomized sampling and corroborated reference information with the original document or its citation in Pubmed, LILACS or SciELO-Peru. We found errors in 47,6% (245) of the references, identifying 372 types of errors; the most frequent were errors in presentation style (120), authorship (100) and title (100), mainly due to spelling mistakes (91). References error percentage was high, varied and multiple. We suggest systematic revision of references in the editorial process as well as to extend the discussion on this theme. references, periodicals, research, bibliometrics.
-
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...
-
Teachers' Choice and Learners' Preference of Corrective Feedback Types
ERIC Educational Resources Information Center
Yoshida, Reiko
2008-01-01
Corrective feedback (CF) has been investigated in relation to learners' error types that trigger CF and learners' responses to CF. These research findings generally suggest that recasts, the most frequently used type of CF, did not trigger learners' reformulation of their erroneous utterances very frequently. In these studies, however, teachers'…
-
Neuropsychological analysis of a typewriting disturbance following cerebral damage.
Boyle, M; Canter, G J
1987-01-01
Following a left CVA, a skilled professional typist sustained a disturbance of typing disproportionate to her handwriting disturbance. Typing errors were predominantly of the sequencing type, with spatial errors much less frequent, suggesting that the impairment was based on a relatively early (premotor) stage of processing. Depriving the subject of visual feedback during handwriting greatly increased her error rate. Similarly, interfering with auditory feedback during speech substantially reduced her self-correction of speech errors. These findings suggested that impaired ability to utilize somesthetic information--probably caused by the subject's parietal lobe lesion--may have been the basis of the typing disorder.
-
Human error in hospitals and industrial accidents: current concepts.
Spencer, F C
2000-10-01
Most data concerning errors and accidents are from industrial accidents and airline injuries. General Electric, Alcoa, and Motorola, among others, all have reported complex programs that resulted in a marked reduction in frequency of worker injuries. In the field of medicine, however, with the outstanding exception of anesthesiology, there is a paucity of information, most reports referring to the 1984 Harvard-New York State Study, more than 16 years ago. This scarcity of information indicates the complexity of the problem. It seems very unlikely that simple exhortation or additional regulations will help because the problem lies principally in the multiple human-machine interfaces that constitute modern medical care. The absence of success stories also indicates that the best methods have to be learned by experience. A liaison with industry should be helpful, although the varieties of human illness are far different from a standardized manufacturing process. Concurrent with the studies of industrial and nuclear accidents, cognitive psychologists have intensively studied how the brain stores and retrieves information. Several concepts have emerged. First, errors are not character defects to be treated by the classic approach of discipline and education, but are byproducts of normal thinking that occur frequently. Second, major accidents are rarely causedby a single error; instead, they are often a combination of chronic system errors, termed latent errors. Identifying and correcting these latent errors should be the principal focus for corrective planning rather than searching for an individual culprit. This nonpunitive concept of errors is a key basis for an effective reporting system, brilliantly demonstrated in aviation with the ASRS system developed more than 25 years ago. The ASRS currently receives more than 30,000 reports annually and is credited with the remarkable increase in safety of airplane travel. Adverse drug events constitute about 25% of hospital errors. In the future, the combination of new drugs and a vast amount of new information will additionally increase the possibilities for error. Two major advances in recent years have been computerization and active participation of the pharmacist with dispensing medications. Further investigation of hospital errors should concentrate primarily on latent system errors. Significant system changes will require broad staff participation throughout the hospital. This, in turn, should foster development of an institutional safety culture, rather than the popular attitude that patient safety responsibility is concentrated in the Quality Assurance-Risk Management division. Quality of service and patient safety are closely intertwined.
-
Performance Analysis: Work Control Events Identified January - August 2010
DOE Office of Scientific and Technical Information (OSTI.GOV)
De Grange, C E; Freeman, J W; Kerr, C E
2011-01-14
This performance analysis evaluated 24 events that occurred at LLNL from January through August 2010. The analysis identified areas of potential work control process and/or implementation weaknesses and several common underlying causes. Human performance improvement and safety culture factors were part of the causal analysis of each event and were analyzed. The collective significance of all events in 2010, as measured by the occurrence reporting significance category and by the proportion of events that have been reported to the DOE ORPS under the ''management concerns'' reporting criteria, does not appear to have increased in 2010. The frequency of reporting inmore » each of the significance categories has not changed in 2010 compared to the previous four years. There is no change indicating a trend in the significance category and there has been no increase in the proportion of occurrences reported in the higher significance category. Also, the frequency of events, 42 events reported through August 2010, is not greater than in previous years and is below the average of 63 occurrences per year at LLNL since 2006. Over the previous four years, an average of 43% of the LLNL's reported occurrences have been reported as either ''management concerns'' or ''near misses.'' In 2010, 29% of the occurrences have been reported as ''management concerns'' or ''near misses.'' This rate indicates that LLNL is now reporting fewer ''management concern'' and ''near miss'' occurrences compared to the previous four years. From 2008 to the present, LLNL senior management has undertaken a series of initiatives to strengthen the work planning and control system with the primary objective to improve worker safety. In 2008, the LLNL Deputy Director established the Work Control Integrated Project Team to develop the core requirements and graded elements of an institutional work planning and control system. By the end of that year this system was documented and implementation had begun. In 2009, training of the workforce began and as of the time of this report more than 50% of authorized Integration Work Sheets (IWS) use the activity-based planning process. In 2010, LSO independently reviewed the work planning and control process and confirmed to the Laboratory that the Integrated Safety Management (ISM) System was implemented. LLNL conducted a cross-directorate management self-assessment of work planning and control and is developing actions to respond to the issues identified. Ongoing efforts to strengthen the work planning and control process and to improve the quality of LLNL work packages are in progress: completion of remaining actions in response to the 2009 DOE Office of Health, Safety, and Security (HSS) evaluation of LLNL's ISM System; scheduling more than 14 work planning and control self-assessments in FY11; continuing to align subcontractor work control with the Institutional work planning and control system; and continuing to maintain the electronic IWS application. The 24 events included in this analysis were caused by errors in the first four of the five ISMS functions. The most frequent cause was errors in analyzing the hazards (Function 2). The second most frequent cause was errors occurring when defining the work (Function 1), followed by errors during the performance of work (Function 4). Interestingly, very few errors in developing controls (Function 3) resulted in events. This leads one to conclude that if improvements are made to defining the scope of work and analyzing the potential hazards, LLNL may reduce the frequency or severity of events. Analysis of the 24 events resulted in the identification of ten common causes. Some events had multiple causes, resulting in the mention of 39 causes being identified for the 24 events. The most frequent cause was workers, supervisors, or experts believing they understood the work and the hazards but their understanding was incomplete. The second most frequent cause was unclear, incomplete or confusing documents directing the work. Together, these two causes were mentioned 17 times and contributed to 13 of the events. All of the events with the cause of ''workers, supervisors, or experts believing they understood the work and the hazards but their understanding was incomplete'' had this error in the first two ISMS functions: define the work and analyze the hazard. This means that these causes result in the scope of work being ill-defined or the hazard(s) improperly analyzed. Incomplete implementation of these functional steps leads to the hazards not being controlled. The causes are then manifested in events when the work is conducted. The process to operate safely relies on accurately defining the scope of work. This review has identified a number of examples of latent organizational weakness in the execution of work control processes.« less
-
Worldwide Ocean Optics Database (WOOD)
2001-09-30
user can obtain values computed from empirical algorithms (e.g., beam attenuation estimated from diffuse attenuation and backscatter data). Error ...from empirical algorithms (e.g., beam attenuation estimated from diffuse attenuation and backscatter data). Error estimates will also be provided for...properties, including diffuse attenuation, beam attenuation, and scattering. The database shall be easy to use, Internet accessible, and frequently updated
-
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.
-
Articulation in schoolchildren and adults with neurofibromatosis type 1.
Cosyns, Marjan; Mortier, Geert; Janssens, Sandra; Bogaert, Famke; D'Hondt, Stephanie; Van Borsel, John
2012-01-01
Several authors mentioned the occurrence of articulation problems in the neurofibromatosis type 1 (NF1) population. However, few studies have undertaken a detailed analysis of the articulation skills of NF1 patients, especially in schoolchildren and adults. Therefore, the aim of the present study was to examine in depth the articulation skills of NF1 schoolchildren and adults, both phonetically and phonologically. Speech samples were collected from 43 Flemish NF1 patients (14 children and 29 adults), ranging in age between 7 and 53 years, using a standardized speech test in which all Flemish single speech sounds and most clusters occur in all their permissible syllable positions. Analyses concentrated on consonants only and included a phonetic inventory, a phonetic, and a phonological analysis. It was shown that phonetic inventories were incomplete in 16.28% (7/43) of participants, in which totally correct realizations of the sibilants /ʃ/ and/or /ʒ/ were missing. Phonetic analysis revealed that distortions were the predominant phonetic error type. Sigmatismus stridens, multiple ad- or interdentality, and, in children, rhotacismus non vibrans were frequently observed. From a phonological perspective, the most common error types were substitution and syllable structure errors. Particularly, devoicing, cluster simplification, and, in children, deletion of the final consonant of words were perceived. Further, it was demonstrated that significantly more men than women presented with an incomplete phonetic inventory, and that girls tended to display more articulation errors than boys. Additionally, children exhibited significantly more articulation errors than adults, suggesting that although the articulation skills of NF1 patients evolve positively with age, articulation problems do not resolve completely from childhood to adulthood. As such, the articulation errors made by NF1 adults may be regarded as residual articulation disorders. It can be concluded that the speech of NF1 patients is characterized by mild articulation disorders at an age where this is no longer expected. Readers will be able to describe neurofibromatosis type 1 (NF1) and explain the articulation errors displayed by schoolchildren and adults with this genetic syndrome. © 2011 Elsevier Inc. All rights reserved.
-
Naik, Aanand Dinkar; Rao, Raghuram; Petersen, Laura Ann
2008-01-01
Diagnostic errors are poorly understood despite being a frequent cause of medical errors. Recent efforts have aimed to advance the "basic science" of diagnostic error prevention by tracing errors to their most basic origins. Although a refined theory of diagnostic error prevention will take years to formulate, we focus on communication breakdown, a major contributor to diagnostic errors and an increasingly recognized preventable factor in medical mishaps. We describe a comprehensive framework that integrates the potential sources of communication breakdowns within the diagnostic process and identifies vulnerable steps in the diagnostic process where various types of communication breakdowns can precipitate error. We then discuss potential information technology-based interventions that may have efficacy in preventing one or more forms of these breakdowns. These possible intervention strategies include using new technologies to enhance communication between health providers and health systems, improve patient involvement, and facilitate management of information in the medical record. PMID:18373151
-
NASA Astrophysics Data System (ADS)
Zhang, Yunju; Chen, Zhongyi; Guo, Ming; Lin, Shunsheng; Yan, Yinyang
2018-01-01
With the large capacity of the power system, the development trend of the large unit and the high voltage, the scheduling operation is becoming more frequent and complicated, and the probability of operation error increases. This paper aims at the problem of the lack of anti-error function, single scheduling function and low working efficiency for technical support system in regional regulation and integration, the integrated construction of the error prevention of the integrated architecture of the system of dispatching anti - error of dispatching anti - error of power network based on cloud computing has been proposed. Integrated system of error prevention of Energy Management System, EMS, and Operation Management System, OMS have been constructed either. The system architecture has good scalability and adaptability, which can improve the computational efficiency, reduce the cost of system operation and maintenance, enhance the ability of regional regulation and anti-error checking with broad development prospects.
-
Improving operating room coordination: communication pattern assessment.
Moss, Jacqueline; Xiao, Yan
2004-02-01
To capture communication patterns in operating room (OR) management to characterize the information needs of OR coordination. Technological applications can be used to change system processes to improve communication and information access, thereby decreasing errors and adverse events. The successful design of such applications relies on an understanding of communication patterns among healthcare professionals. Charge nurse communication was observed and documented at four OR suites at three tertiary hospitals. The data collection tool allowed rapid coding of communication patterns in terms of duration, mode, target person, and the purpose of each communication episode. Most (69.24%) of the 2074 communication episodes observed occurred face to face. Coordinating equipment was the most frequently occurring purpose of communication (38.7%) in all suites. The frequency of other purposes in decreasing order were coordinating patient preparedness (25.7%), staffing (18.8%), room assignment (10.7%), and scheduling and rescheduling surgery (6.2%). The results of this study suggest that automating aspects of preparing patients for surgery and surgical equipment management has the potential to reduce information exchange, decreasing interruptions to clinicians and diminishing the possibility of adverse events in the clinical setting.
-
Fitzgerald, Michael G.; Karlinger, Michael R.
1983-01-01
Time-series models were constructed for analysis of daily runoff and sediment discharge data from selected rivers of the Eastern United States. Logarithmic transformation and first-order differencing of the data sets were necessary to produce second-order, stationary time series and remove seasonal trends. Cyclic models accounted for less than 42 percent of the variance in the water series and 31 percent in the sediment series. Analysis of the apparent oscillations of given frequencies occurring in the data indicates that frequently occurring storms can account for as much as 50 percent of the variation in sediment discharge. Components of the frequency analysis indicate that a linear representation is reasonable for the water-sediment system. Models that incorporate lagged water discharge as input prove superior to univariate techniques in modeling and prediction of sediment discharges. The random component of the models includes errors in measurement and model hypothesis and indicates no serial correlation. An index of sediment production within or between drain-gage basins can be calculated from model parameters.
-
Aktas, Nurettin; Gulacti, Umut; Lok, Ugur; Aydin, İrfan; Borta, Tayfun; Celik, Murat
2018-01-01
To identify errors in forensic reports and to describe the characteristics of traumatic medico-legal cases presenting to the emergency department (ED) at a tertiary care hospital. This study is a retrospective cross-sectional study. The study includes cases resulting in a forensic report among all traumatic patients presenting to the ED of Adiyaman University Training and Research Hospital, Adiyaman, Turkey during a 1-year period. We recorded the demographic characteristics of all the cases, time of presentation to the ED, traumatic characteristics of medico-legal cases, forms of suicide attempt, suspected poisonous substance exposure, the result of follow-up and the type of forensic report. A total of 4300 traumatic medico-legal cases were included in the study and 72% of these cases were male. Traumatic medico-legal cases occurred at the greatest frequency in July (10.1%) and 28.9% of all cases occurred in summer. The most frequent causes of traumatic medico-legal cases in the ED were traffic accidents (43.4%), violent crime (30.5%), and suicide attempt (7.2%). The most common method of attempted suicide was drug intake (86.4%). 12.3% of traumatic medico-legal cases were hospitalized and 24.2% of those hospitalized were admitted to the orthopedics service. The most common error in forensic reports was the incomplete recording of the patient's "cooperation" status (82.7%). Additionally, external traumatic lesions were not defined in 62.4% of forensic reports. The majority of traumatic medico-legal cases were male age 18-44 years, the most common source of trauma was traffic accidents and in the summer months. When writing a forensic report, emergency physicians made mistakes in noting physical examination findings and identifying external traumatic lesions. Physicians should make sure that the traumatic medico-legal patients they treat have adequate documentation for reference during legal proceedings. The legal duties and responsibilities of physicians should be emphasized with in-service training.
-
Context-dependent sequential effects of target selection for action.
Moher, Jeff; Song, Joo-Hyun
2013-07-11
Humans exhibit variation in behavior from moment to moment even when performing a simple, repetitive task. Errors are typically followed by cautious responses, minimizing subsequent distractor interference. However, less is known about how variation in the execution of an ultimately correct response affects subsequent behavior. We asked participants to reach toward a uniquely colored target presented among distractors and created two categories to describe participants' responses in correct trials based on analyses of movement trajectories; partial errors referred to trials in which observers initially selected a nontarget for action before redirecting the movement and accurately pointing to the target, and direct movements referred to trials in which the target was directly selected for action. We found that latency to initiate a hand movement was shorter in trials following partial errors compared to trials following direct movements. Furthermore, when the target and distractor colors were repeated, movement time and reach movement curvature toward distractors were greater following partial errors compared to direct movements. Finally, when the colors were repeated, partial errors were more frequent than direct movements following partial-error trials, and direct movements were more frequent following direct-movement trials. The dependence of these latter effects on repeated-task context indicates the involvement of higher-level cognitive mechanisms in an integrated attention-action system in which execution of a partial-error or direct-movement response affects memory representations that bias performance in subsequent trials. Altogether, these results demonstrate that whether a nontarget is selected for action or not has a measurable impact on subsequent behavior.
-
[Usefulness of imaging examinations in preoperative diagnosis of acute appendicitis].
Nitoń, Tomasz; Górecka-Nitoń, Aleksandra
2014-01-01
Acute appendicitis (AA) is the cause one of most operations perform in department of general surgery on emergency ward. Frequency of acute appendicitis range from 6-8% of population. Clinical presentation is frequently unspecified and despite common occurence leads to many difficulties in diagnosis. Diagnosis of acute appendicitis includes clinical examination, laboratory tests, diagnostic scoring systems, computer programs as physisian aids and imaging examinations. About 30-45% patients suspected of acute appendicitis have untypical clinical presentation and here use of US or CT is very helpful. Longstanding use of US resulted in high AA evaluation accuracy with high sensitivity (75-90%) and specificity (84-100%). CT demonstrates above 95% ratio of correct diagnoses, reduces negative appendectomy rates and perforation rates as well as unnecessary observations. CT sensitivity and specificity CT is estimated between 83-100% among different authors. Expedited AA diagnosis, surgery and reduced hospitalization time are possible advantages of imaging tests. Additionally these tests can detect alternative deseases imitating acute appnedicitis. Use of imaging tests especially CT is beneficial in fertile women because of frequent genito-urinary disorders leading to the most diagnostic errors. However thera are contraindications in use of CT, for example it can not be performed in early pregnancy etc...
-
Tactical Defenses Against Systematic Variation in Wind Tunnel Testing
NASA Technical Reports Server (NTRS)
DeLoach, Richard
2002-01-01
This paper examines the role of unexplained systematic variation on the reproducibility of wind tunnel test results. Sample means and variances estimated in the presence of systematic variations are shown to be susceptible to bias errors that are generally non-reproducible functions of those variations. Unless certain precautions are taken to defend against the effects of systematic variation, it is shown that experimental results can be difficult to duplicate and of dubious value for predicting system response with the highest precision or accuracy that could otherwise be achieved. Results are reported from an experiment designed to estimate how frequently systematic variations are in play in a representative wind tunnel experiment. These results suggest that significant systematic variation occurs frequently enough to cast doubts on the common assumption that sample observations can be reliably assumed to be independent. The consequences of ignoring correlation among observations induced by systematic variation are considered in some detail. Experimental tactics are described that defend against systematic variation. The effectiveness of these tactics is illustrated through computational experiments and real wind tunnel experimental results. Some tutorial information describes how to analyze experimental results that have been obtained using such quality assurance tactics.
-
Analysis of medication-related malpractice claims: causes, preventability, and costs.
Rothschild, Jeffrey M; Federico, Frank A; Gandhi, Tejal K; Kaushal, Rainu; Williams, Deborah H; Bates, David W
2002-11-25
Adverse drug events (ADEs) may lead to serious injury and may result in malpractice claims. While ADEs resulting in claims are not representative of all ADEs, such data provide a useful resource for studying ADEs. Therefore, we conducted a review of medication-related malpractice claims to study their frequency, nature, and costs and to assess the human factor failures associated with preventable ADEs. We also assessed the potential benefits of proved effective ADE prevention strategies on ADE claims prevention. We conducted a retrospective analysis of a New England malpractice insurance company claims records from January 1, 1990, to December 31, 1999. Cases were electronically screened for possible ADEs and followed up by independent review of abstracts by 2 physician reviewers (T.K.G. and R.K.). Additional in-depth claims file reviews identified potential human factor failures associated with ADEs. Adverse drug events represented 6.3% (129/2040) of claims. Adverse drug events were judged preventable in 73% (n = 94) of the cases and were nearly evenly divided between outpatient and inpatient settings. The most frequently involved medication classes were antibiotics, antidepressants or antipsychotics, cardiovascular drugs, and anticoagulants. Among these ADEs, 46% were life threatening or fatal. System deficiencies and performance errors were the most frequent cause of preventable ADEs. The mean costs of defending malpractice claims due to ADEs were comparable for nonpreventable inpatient and outpatient ADEs and preventable outpatient ADEs (mean, $64,700-74,200), but costs were considerably greater for preventable inpatient ADEs (mean, $376,500). Adverse drug events associated with malpractice claims were often severe, costly, and preventable, and about half occurred in outpatients. Many interventions could potentially have prevented ADEs, with error proofing and process standardization covering the greatest proportion of events.
-
An analysis of 5-day midtropospheric flow patterns for the South Pole: 1985-1989
NASA Astrophysics Data System (ADS)
Harris, Joyce M.
1992-09-01
An analysis of 5-day midtropospheric flow patterns for the South Pole during 1985-1989 is presented. Cluster analysis was used to summarize trajectories by year and by month. The results indicate that flow from the east was most often anticyclonic and light, occurring 8-18% of the time. Westerly flow patterns were the strongest and most frequent (37-51% occurrence). They were consistently cyclonic, usually reflecting storms in the Ross Sea area, the average center of the circumpolar vortex. Strong northerly flow occurred more often in 1987 than in other years. Year-to-year variability was also evident in southwesterly flow, which was enhanced in 1988, and weaker in 1987, compared with other years. The lightest winds over the South Pole occur during January, while the most vigorous long-range transport to South Pole occurs from July through October. Selected isentropic trajectories were examined to determine errors inherent in the isobaric estimates. Isentropic trajectories from the east showed little vertical motion and good agreement with isobaric ones. Over west Antarctica, however, isentropic trajectories consistently showed positive vertical motion. As a result, their isobaric counterparts were too long and overestimated the cyclonic curvature in the flow. Preferred transport from the west with warm-air advection results from the circumpolar vortex being asymmetrical, and the average isotherms, though roughly circular, being offset to the east of the South Pole.
-
Pediatric Nurses' Perceptions of Medication Safety and Medication Error: A Mixed Methods Study.
Alomari, Albara; Wilson, Val; Solman, Annette; Bajorek, Beata; Tinsley, Patricia
2018-06-01
This study aims to outline the current workplace culture of medication practice in a pediatric medical ward. The objective is to explore the perceptions of nurses in a pediatric clinical setting as to why medication administration errors occur. As nurses have a central role in the medication process, it is essential to explore nurses' perceptions of the factors influencing the medication process. Without this understanding, it is difficult to develop effective prevention strategies aimed at reducing medication administration errors. Previous studies were limited to exploring a single and specific aspect of medication safety. The methods used in these studies were limited to survey designs which may lead to incomplete or inadequate information being provided. This study is phase 1 on an action research project. Data collection included a direct observation of nurses during medication preparation and administration, audit based on the medication policy, and guidelines and focus groups with nursing staff. A thematic analysis was undertaken by each author independently to analyze the observation notes and focus group transcripts. Simple descriptive statistics were used to analyze the audit data. The study was conducted in a specialized pediatric medical ward. Four key themes were identified from the combined quantitative and qualitative data: (1) understanding medication errors, (2) the busy-ness of nurses, (3) the physical environment, and (4) compliance with medication policy and practice guidelines. Workload, frequent interruptions to process, poor physical environment design, lack of preparation space, and impractical medication policies are identified as barriers to safe medication practice. Overcoming these barriers requires organizations to review medication process policies and engage nurses more in medication safety research and in designing clinical guidelines for their own practice.
-
Rathert, Cheryl; May, Douglas R
2007-01-01
Experts continue to decry the lack of progress made in decreasing the alarming frequency of medical errors in health care organizations (Leape, L. L., & Berwick, D. M. (2005). Five years after to err is human: What have we learned?. Journal of the American Medical Association, 293(19), 2384-2390). At the same time, other experts are concerned about the lack of job satisfaction and turnover among nurses (. Keeping patients safe: Transforming the work environment of nurses. Washington, DC: National Academy Press). Research and theory suggest that a work environment that facilitates patient-centered care should increase patient safety and nurse satisfaction. The present study began with a conceptual model that specifies how work environment variables should be related to both nurse and patient outcomes. Specifically, we proposed that health care work units with climates for patient-centered care should have nurses who are more satisfied with their jobs. Such units should also have higher levels of patient safety, with fewer medication errors. We examined perceptions of nurses from three acute care hospitals in the eastern United States. Nurses who perceived their work units as more patient centered were significantly more satisfied with their jobs than were those whose units were perceived as less patient centered. Those whose work units were more patient centered reported that medication errors occurred less frequently in their units and said that they felt more comfortable reporting errors and near-misses than those in less patient-centered units. Patients and quality leaders continue to call for delivery of patient-centered care. If climates that facilitate such care are also related to improved patient safety and nurse satisfaction, proactive, patient-centered management of the work environment could result in improved patient, employee, and organizational outcomes.
-
Jarvis, Stuart; Kovacs, Caroline; Briggs, Jim; Meredith, Paul; Schmidt, Paul E; Featherstone, Peter I; Prytherch, David R; Smith, Gary B
2015-08-01
Although the weightings to be summed in an early warning score (EWS) calculation are small, calculation and other errors occur frequently, potentially impacting on hospital efficiency and patient care. Use of a simpler EWS has the potential to reduce errors. We truncated 36 published 'standard' EWSs so that, for each component, only two scores were possible: 0 when the standard EWS scored 0 and 1 when the standard EWS scored greater than 0. Using 1564,153 vital signs observation sets from 68,576 patient care episodes, we compared the discrimination (measured using the area under the receiver operator characteristic curve--AUROC) of each standard EWS and its truncated 'binary' equivalent. The binary EWSs had lower AUROCs than the standard EWSs in most cases, although for some the difference was not significant. One system, the binary form of the National Early Warning System (NEWS), had significantly better discrimination than all standard EWSs, except for NEWS. Overall, Binary NEWS at a trigger value of 3 would detect as many adverse outcomes as are detected by NEWS using a trigger of 5, but would require a 15% higher triggering rate. The performance of Binary NEWS is only exceeded by that of standard NEWS. It may be that Binary NEWS, as a simplified system, can be used with fewer errors. However, its introduction could lead to significant increases in workload for ward and rapid response team staff. The balance between fewer errors and a potentially greater workload needs further investigation. Copyright © 2015 Elsevier Ireland Ltd. All rights reserved.
-
Memory Errors Reveal a Bias to Spontaneously Generalize to Categories
Sutherland, Shelbie L.; Cimpian, Andrei; Leslie, Sarah-Jane; Gelman, Susan A.
2014-01-01
Much evidence suggests that, from a young age, humans are able to generalize information learned about a subset of a category to the category itself. Here, we propose that—beyond simply being able to perform such generalizations—people are biased to generalize to categories, such that they routinely make spontaneous, implicit category generalizations from information that licenses such generalizations. To demonstrate the existence of this bias, we asked participants to perform a task in which category generalizations would distract from the main goal of the task, leading to a characteristic pattern of errors. Specifically, participants were asked to memorize two types of novel facts: quantified facts about sets of kind members (e.g., facts about all or many stups) and generic facts about entire kinds (e.g., facts about zorbs as a kind). Moreover, half of the facts concerned properties that are typically generalizable to an animal kind (e.g., eating fruits and vegetables), and half concerned properties that are typically more idiosyncratic (e.g., getting mud in their hair). We predicted that—because of the hypothesized bias—participants would spontaneously generalize the quantified facts to the corresponding kinds, and would do so more frequently for the facts about generalizable (rather than idiosyncratic) properties. In turn, these generalizations would lead to a higher rate of quantified-to-generic memory errors for the generalizable properties. The results of four experiments (N = 449) supported this prediction. Moreover, the same generalizable-versus-idiosyncratic difference in memory errors occurred even under cognitive load, which suggests that the hypothesized bias operates unnoticed in the background, requiring few cognitive resources. In sum, this evidence suggests the presence of a powerful bias to draw generalizations about kinds. PMID:25327964
-
Refractive errors in a rural Korean adult population: the Namil Study
Yoo, Y C; Kim, J M; Park, K H; Kim, C Y; Kim, T-W
2013-01-01
Purpose To assess the prevalence of refractive errors, including myopia, high myopia, hyperopia, astigmatism, and anisometropia, in rural adult Koreans. Methods We identified 2027 residents aged 40 years or older in Namil-myeon, a rural town in central South Korea. Of 1928 eligible residents, 1532 subjects (79.5%) participated. Each subject underwent screening examinations including autorefractometry, corneal curvature measurement, and best-corrected visual acuity. Results Data from 1215 phakic right eyes were analyzed. The prevalence of myopia (spherical equivalent (SE) <−0.5 diopters (D)) was 20.5% (95% confidence interval (CI): 18.2−22.8%), of high myopia (SE <−6.0 D) was 1.0% (95% CI: 0.4−1.5%), of hyperopia (SE>+0.5 D) was 41.8% (95% CI: 38.9−44.4%), of astigmatism (cylinder <−0.5 D) was 63.7% (95% CI: 61.0−66.4%), and of anisometropia (difference in SE between eyes >1.0 D) was 13.8% (95% CI: 11.9−15.8%). Myopia prevalence decreased with age and tended to transition into hyperopia with age up to 60−69 years. In subjects older than this, the trend in SE refractive errors reversed with age. The prevalence of astigmatism and anisometropia increased consistently with age. The refractive status was not significantly different between males and females. Conclusions The prevalence of myopia and hyperopia in rural adult Koreans was similar to that of rural Chinese. The prevalence of high myopia was lower in this Korean sample than in other East Asian populations, and astigmatism was the most frequently occurring refractive error. PMID:24037232
-
An analysis of electronic health record-related patient safety incidents.
Palojoki, Sari; Mäkelä, Matti; Lehtonen, Lasse; Saranto, Kaija
2017-06-01
The aim of this study was to analyse electronic health record-related patient safety incidents in the patient safety incident reporting database in fully digital hospitals in Finland. We compare Finnish data to similar international data and discuss their content with regard to the literature. We analysed the types of electronic health record-related patient safety incidents that occurred at 23 hospitals during a 2-year period. A procedure of taxonomy mapping served to allow comparisons. This study represents a rare examination of patient safety risks in a fully digital environment. The proportion of electronic health record-related incidents was markedly higher in our study than in previous studies with similar data. Human-computer interaction problems were the most frequently reported. The results show the possibility of error arising from the complex interaction between clinicians and computers.
-
Schweizer, Tom A; Vogel-Sprott, Muriel
2008-06-01
Much research on the effects of a dose of alcohol has shown that motor skills recover from impairment as blood alcohol concentrations (BACs) decline and that acute tolerance to alcohol impairment can develop during the course of the dose. Comparable alcohol research on cognitive performance is sparse but has increased with the development of computerized cognitive tasks. This article reviews the results of recent research using these tasks to test the development of acute tolerance in cognitive performance and recovery from impairment during declining BACs. Results show that speed and accuracy do not necessarily agree in detecting cognitive impairment, and this mismatch most frequently occurs during declining BACs. Speed of cognitive performance usually recovers from impairment to drug-free levels during declining BACs, whereas alcohol-increased errors fail to diminish. As a consequence, speed of cognitive processing tends to develop acute tolerance, but no such tendency is shown in accuracy. This "acute protracted error" phenomenon has not previously been documented. The findings pose a challenge to the theory of alcohol tolerance on the basis of physiological adaptation and raise new research questions concerning the independence of speed and accuracy of cognitive processes, as well as hemispheric lateralization of alcohol effects. The occurrence of alcohol-induced protracted cognitive errors long after speed returned to normal is identified as a potential threat to the safety of social drinkers that requires urgent investigation.
-
The application of Aronson's taxonomy to medication errors in nursing.
Johnson, Maree; Young, Helen
2011-01-01
Medication administration is a frequent nursing activity that is prone to error. In this study of 318 self-reported medication incidents (including near misses), very few resulted in patient harm-7% required intervention or prolonged hospitalization or caused temporary harm. Aronson's classification system provided an excellent framework for analysis of the incidents with a close connection between the type of error and the change strategy to minimize medication incidents. Taking a behavioral approach to medication error classification has provided helpful strategies for nurses such as nurse-call cards on patient lockers when patients are absent and checking of medication sign-off by outgoing and incoming staff at handover.
-
van de Plas, Afke; Slikkerveer, Mariëlle; Hoen, Saskia; Schrijnemakers, Rick; Driessen, Johanna; de Vries, Frank; van den Bemt, Patricia
2017-01-01
In this controlled before-after study the effect of improvements, derived from Lean Six Sigma strategy, on parenteral medication administration errors and the potential risk of harm was determined. During baseline measurement, on control versus intervention ward, at least one administration error occurred in 14 (74%) and 6 (46%) administrations with potential risk of harm in 6 (32%) and 1 (8%) administrations. Most administration errors with high potential risk of harm occurred in bolus injections: 8 (57%) versus 2 (67%) bolus injections were injected too fast with a potential risk of harm in 6 (43%) and 1 (33%) bolus injections on control and intervention ward. Implemented improvement strategies, based on major causes of too fast administration of bolus injections, were: Substitution of bolus injections by infusions, education, availability of administration information and drug round tabards. Post intervention, on the control ward in 76 (76%) administrations at least one error was made (RR 1.03; CI95:0.77-1.38), with a potential risk of harm in 14 (14%) administrations (RR 0.45; CI95:0.20-1.02). In 40 (68%) administrations on the intervention ward at least one error occurred (RR 1.47; CI95:0.80-2.71) but no administrations were associated with a potential risk of harm. A shift in wrong duration administration errors from bolus injections to infusions, with a reduction of potential risk of harm, seems to have occurred on the intervention ward. Although data are insufficient to prove an effect, Lean Six Sigma was experienced as a suitable strategy to select tailored improvements. Further studies are required to prove the effect of the strategy on parenteral medication administration errors.
-
van de Plas, Afke; Slikkerveer, Mariëlle; Hoen, Saskia; Schrijnemakers, Rick; Driessen, Johanna; de Vries, Frank; van den Bemt, Patricia
2017-01-01
In this controlled before-after study the effect of improvements, derived from Lean Six Sigma strategy, on parenteral medication administration errors and the potential risk of harm was determined. During baseline measurement, on control versus intervention ward, at least one administration error occurred in 14 (74%) and 6 (46%) administrations with potential risk of harm in 6 (32%) and 1 (8%) administrations. Most administration errors with high potential risk of harm occurred in bolus injections: 8 (57%) versus 2 (67%) bolus injections were injected too fast with a potential risk of harm in 6 (43%) and 1 (33%) bolus injections on control and intervention ward. Implemented improvement strategies, based on major causes of too fast administration of bolus injections, were: Substitution of bolus injections by infusions, education, availability of administration information and drug round tabards. Post intervention, on the control ward in 76 (76%) administrations at least one error was made (RR 1.03; CI95:0.77-1.38), with a potential risk of harm in 14 (14%) administrations (RR 0.45; CI95:0.20-1.02). In 40 (68%) administrations on the intervention ward at least one error occurred (RR 1.47; CI95:0.80-2.71) but no administrations were associated with a potential risk of harm. A shift in wrong duration administration errors from bolus injections to infusions, with a reduction of potential risk of harm, seems to have occurred on the intervention ward. Although data are insufficient to prove an effect, Lean Six Sigma was experienced as a suitable strategy to select tailored improvements. Further studies are required to prove the effect of the strategy on parenteral medication administration errors. PMID:28674608
-
Updating expected action outcome in the medial frontal cortex involves an evaluation of error type.
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.
-
Analyzing communication errors in an air medical transport service.
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.
-
On the sensitivity of TG-119 and IROC credentialing to TPS commissioning errors.
McVicker, Drew; Yin, Fang-Fang; Adamson, Justus D
2016-01-08
We investigate the sensitivity of IMRT commissioning using the TG-119 C-shape phantom and credentialing with the IROC head and neck phantom to treatment planning system commissioning errors. We introduced errors into the various aspects of the commissioning process for a 6X photon energy modeled using the analytical anisotropic algorithm within a commercial treatment planning system. Errors were implemented into the various components of the dose calculation algorithm including primary photons, secondary photons, electron contamination, and MLC parameters. For each error we evaluated the probability that it could be committed unknowingly during the dose algorithm commissioning stage, and the probability of it being identified during the verification stage. The clinical impact of each commissioning error was evaluated using representative IMRT plans including low and intermediate risk prostate, head and neck, mesothelioma, and scalp; the sensitivity of the TG-119 and IROC phantoms was evaluated by comparing dosimetric changes to the dose planes where film measurements occur and change in point doses where dosimeter measurements occur. No commissioning errors were found to have both a low probability of detection and high clinical severity. When errors do occur, the IROC credentialing and TG 119 commissioning criteria are generally effective at detecting them; however, for the IROC phantom, OAR point-dose measurements are the most sensitive despite being currently excluded from IROC analysis. Point-dose measurements with an absolute dose constraint were the most effective at detecting errors, while film analysis using a gamma comparison and the IROC film distance to agreement criteria were less effective at detecting the specific commissioning errors implemented here.
-
Real-time transmission of digital video using variable-length coding
NASA Technical Reports Server (NTRS)
Bizon, Thomas P.; Shalkhauser, Mary JO; Whyte, Wayne A., Jr.
1993-01-01
Huffman coding is a variable-length lossless compression technique where data with a high probability of occurrence is represented with short codewords, while 'not-so-likely' data is assigned longer codewords. Compression is achieved when the high-probability levels occur so frequently that their benefit outweighs any penalty paid when a less likely input occurs. One instance where Huffman coding is extremely effective occurs when data is highly predictable and differential coding can be applied (as with a digital video signal). For that reason, it is desirable to apply this compression technique to digital video transmission; however, special care must be taken in order to implement a communication protocol utilizing Huffman coding. This paper addresses several of the issues relating to the real-time transmission of Huffman-coded digital video over a constant-rate serial channel. Topics discussed include data rate conversion (from variable to a fixed rate), efficient data buffering, channel coding, recovery from communication errors, decoder synchronization, and decoder architectures. A description of the hardware developed to execute Huffman coding and serial transmission is also included. Although this paper focuses on matters relating to Huffman-coded digital video, the techniques discussed can easily be generalized for a variety of applications which require transmission of variable-length data.
-
Nápoles, Anna M.; Santoyo-Olsson, Jasmine; Karliner, Leah S.; Gregorich, Steven E.; Pérez-Stable, Eliseo J.
2015-01-01
Background Limited English-proficient (LEP) patients suffer poorer quality of care and outcomes. Interpreters can ameliorate these disparities; however, evidence is lacking on the quality of different interpretation modes. Objective Compare accuracy of interpretation for in-person professional (IP), professional videoconferencing (VC), and ad hoc interpretation (AH). Design Cross-sectional study of transcribed audiotaped primary care visits Subjects 32 Spanish-speaking Latino patients; 14 clinicians Measures Independent coding of transcripts by four coders (two were internists) for accurate and inaccurate interpretation instances. Unit of analysis was a segment of continuous speech or text unit (TU). Two internists independently verified inaccurate interpretation instances and rated their clinical significance as clinically insignificant, mildly, moderately or highly clinically significant. Results Accurate interpretation made up 70% of total coded TUs and inaccurate interpretation (errors) made up 30%. Inaccurate interpretation occurred at twice the rate for AH (54% of coded TUs) versus IP (25%) and VC (23%) interpretation, due to more errors of omission (p<0.001) and answers for patient or clinician (p<0.001). Mean number of errors per visit was 27, with 7.1% of errors rated as moderately/highly clinically significant. In adjusted models, the odds of inaccurate interpretation were lower for IP (OR = −1.25, 95% CI −1.56, −0.95) and VC (OR = −1.05; 95% CI −1.26, −0.84) than for AH interpreted visits; the odds of a moderately/highly clinically significant error were lower for IP (OR = −0.06; 95% CI −1.05, 0.92) than for AH interpreted visits. Conclusions Inaccurate language interpretation in medical encounters is common and more frequent when untrained interpreters are used compared to professional in-person or via videoconferencing. Professional video conferencing interpretation may increase access to higher quality medical interpretation services. PMID:26465121
-
[Diagnostic Errors in Medicine].
Buser, Claudia; Bankova, Andriyana
2015-12-09
The recognition of diagnostic errors in everyday practice can help improve patient safety. The most common diagnostic errors are the cognitive errors, followed by system-related errors and no fault errors. The cognitive errors often result from mental shortcuts, known as heuristics. The rate of cognitive errors can be reduced by a better understanding of heuristics and the use of checklists. The autopsy as a retrospective quality assessment of clinical diagnosis has a crucial role in learning from diagnostic errors. Diagnostic errors occur more often in primary care in comparison to hospital settings. On the other hand, the inpatient errors are more severe than the outpatient errors.
-
Technical errors in planar bone scanning.
Naddaf, Sleiman Y; Collier, B David; Elgazzar, Abdelhamid H; Khalil, Magdy M
2004-09-01
Optimal technique for planar bone scanning improves image quality, which in turn improves diagnostic efficacy. Because planar bone scanning is one of the most frequently performed nuclear medicine examinations, maintaining high standards for this examination is a daily concern for most nuclear medicine departments. Although some problems such as patient motion are frequently encountered, the degraded images produced by many other deviations from optimal technique are rarely seen in clinical practice and therefore may be difficult to recognize. The objectives of this article are to list optimal techniques for 3-phase and whole-body bone scanning, to describe and illustrate a selection of deviations from these optimal techniques for planar bone scanning, and to explain how to minimize or avoid such technical errors.
-
Reducing patient identification errors related to glucose point-of-care testing.
Alreja, Gaurav; Setia, Namrata; Nichols, James; Pantanowitz, Liron
2011-01-01
Patient identification (ID) errors in point-of-care testing (POCT) can cause test results to be transferred to the wrong patient's chart or prevent results from being transmitted and reported. Despite the implementation of patient barcoding and ongoing operator training at our institution, patient ID errors still occur with glucose POCT. The aim of this study was to develop a solution to reduce identification errors with POCT. Glucose POCT was performed by approximately 2,400 clinical operators throughout our health system. Patients are identified by scanning in wristband barcodes or by manual data entry using portable glucose meters. Meters are docked to upload data to a database server which then transmits data to any medical record matching the financial number of the test result. With a new model, meters connect to an interface manager where the patient ID (a nine-digit account number) is checked against patient registration data from admission, discharge, and transfer (ADT) feeds and only matched results are transferred to the patient's electronic medical record. With the new process, the patient ID is checked prior to testing, and testing is prevented until ID errors are resolved. When averaged over a period of a month, ID errors were reduced to 3 errors/month (0.015%) in comparison with 61.5 errors/month (0.319%) before implementing the new meters. Patient ID errors may occur with glucose POCT despite patient barcoding. The verification of patient identification should ideally take place at the bedside before testing occurs so that the errors can be addressed in real time. The introduction of an ADT feed directly to glucose meters reduced patient ID errors in POCT.
-
Reducing patient identification errors related to glucose point-of-care testing
Alreja, Gaurav; Setia, Namrata; Nichols, James; Pantanowitz, Liron
2011-01-01
Background: Patient identification (ID) errors in point-of-care testing (POCT) can cause test results to be transferred to the wrong patient's chart or prevent results from being transmitted and reported. Despite the implementation of patient barcoding and ongoing operator training at our institution, patient ID errors still occur with glucose POCT. The aim of this study was to develop a solution to reduce identification errors with POCT. Materials and Methods: Glucose POCT was performed by approximately 2,400 clinical operators throughout our health system. Patients are identified by scanning in wristband barcodes or by manual data entry using portable glucose meters. Meters are docked to upload data to a database server which then transmits data to any medical record matching the financial number of the test result. With a new model, meters connect to an interface manager where the patient ID (a nine-digit account number) is checked against patient registration data from admission, discharge, and transfer (ADT) feeds and only matched results are transferred to the patient's electronic medical record. With the new process, the patient ID is checked prior to testing, and testing is prevented until ID errors are resolved. Results: When averaged over a period of a month, ID errors were reduced to 3 errors/month (0.015%) in comparison with 61.5 errors/month (0.319%) before implementing the new meters. Conclusion: Patient ID errors may occur with glucose POCT despite patient barcoding. The verification of patient identification should ideally take place at the bedside before testing occurs so that the errors can be addressed in real time. The introduction of an ADT feed directly to glucose meters reduced patient ID errors in POCT. PMID:21633490
-
Human error and the search for blame
NASA Technical Reports Server (NTRS)
Denning, Peter J.
1989-01-01
Human error is a frequent topic in discussions about risks in using computer systems. A rational analysis of human error leads through the consideration of mistakes to standards that designers use to avoid mistakes that lead to known breakdowns. The irrational side, however, is more interesting. It conditions people to think that breakdowns are inherently wrong and that there is ultimately someone who is responsible. This leads to a search for someone to blame which diverts attention from: learning from the mistakes; seeing the limitations of current engineering methodology; and improving the discourse of design.
-
Increased User Satisfaction Through an Improved Message System
NASA Technical Reports Server (NTRS)
Weissert, C. L.
1997-01-01
With all of the enhancements in software methodology and testing, there is no guarantee that software can be delivered such that no user errors occur, How to handle these errors when they occur has become a major research topic within human-computer interaction (HCI). Users of the Multimission Spacecraft Analysis Subsystem(MSAS) at the Jet Propulsion Laboratory (JPL), a system of X and motif graphical user interfaces for analyzing spacecraft data, complained about the lack of information about the error cause and have suggested that recovery actions be included in the system error messages...The system was evaluated through usability surveys and was shown to be successful.
-
Horri, J; Cransac, A; Quantin, C; Abrahamowicz, M; Ferdynus, C; Sgro, C; Robillard, P-Y; Iacobelli, S; Gouyon, J-B
2014-12-01
The risk of dosage Prescription Medication Error (PME) among manually written prescriptions within 'mixed' prescribing system (computerized physician order entry (CPOE) + manual prescriptions) has not been previously assessed in neonatology. This study aimed to evaluate the rate of dosage PME related to manual prescriptions in the high-risk population of very preterm infants (GA < 33 weeks) in a mixed prescription system. The study was based on a retrospective review of a random sample of manual daily prescriptions in two neonatal intensive care units (NICU) A and B, located in different French University hospitals (Dijon and La Reunion island). Daily prescription was defined as the set of all drugs manually prescribed on a single day for one patient. Dosage error was defined as a deviation of at least ±10% from the weight-appropriate recommended dose. The analyses were based on the assessment of 676 manually prescribed drugs from NICU A (58 different drugs from 93 newborns and 240 daily prescriptions) and 354 manually prescribed drugs from NICU B (73 different drugs from 131 newborns and 241 daily prescriptions). The dosage error rate per 100 manually prescribed drugs was similar in both NICU: 3·8% (95% CI: 2·5-5·6%) in NICU A and 3·1% (95% CI: 1·6-5·5%) in NICU B (P = 0·54). Among all the 37 identified dosage errors, the over-dosing was almost as frequent as the under-dosing (17 and 20 errors, respectively). Potentially severe dosage errors occurred in a total of seven drug prescriptions. None of the dosage PME was recorded in the corresponding medical files and information on clinical outcome was not sufficient to identify clinical conditions related to dosage PME. Overall, 46·8% of manually prescribed drugs were off label or unlicensed, with no significant differences between prescriptions with or without dosage error. The risk of a dosage PME increased significantly if the drug was included in the CPOE system but was manually prescribed (OR = 3·3; 95% CI: 1·6-7·0, P < 0·001). The presence of dosage PME in the manual prescriptions written within mixed prescription systems suggests that manual prescriptions should be totally avoided in neonatal units. © 2014 John Wiley & Sons Ltd.
-
Observations of cloud liquid water path over oceans: Optical and microwave remote sensing methods
NASA Technical Reports Server (NTRS)
Lin, Bing; Rossow, William B.
1994-01-01
Published estimates of cloud liquid water path (LWP) from satellite-measured microwave radiation show little agreement, even about the relative magnitudes of LWP in the tropics and midlatitudes. To understand these differences and to obtain more reliable estimate, optical and microwave LWP retrieval methods are compared using the International Satellite Cloud Climatology Project (ISCCP) and special sensor microwave/imager (SSM/I) data. Errors in microwave LWP retrieval associated with uncertainties in surface, atmosphere, and cloud properties are assessed. Sea surface temperature may not produce great LWP errors, if accurate contemporaneous measurements are used in the retrieval. An uncertainty of estimated near-surface wind speed as high as 2 m/s produces uncertainty in LWP of about 5 mg/sq cm. Cloud liquid water temperature has only a small effect on LWP retrievals (rms errors less than 2 mg/sq cm), if errors in the temperature are less than 5 C; however, such errors can produce spurious variations of LWP with latitude and season. Errors in atmospheric column water vapor (CWV) are strongly coupled with errors in LWP (for some retrieval methods) causing errors as large as 30 mg/sq cm. Because microwave radiation is much less sensitive to clouds with small LWP (less than 7 mg/sq cm) than visible wavelength radiation, the microwave results are very sensitive to the process used to separate clear and cloudy conditions. Different cloud detection sensitivities in different microwave retrieval methods bias estimated LWP values. Comparing ISCCP and SSM/I LWPs, we find that the two estimated values are consistent in global, zonal, and regional means for warm, nonprecipitating clouds, which have average LWP values of about 5 mg/sq cm and occur much more frequently than precipitating clouds. Ice water path (IWP) can be roughly estimated from the differences between ISCCP total water path and SSM/I LWP for cold, nonprecipitating clouds. IWP in the winter hemisphere is about 3 times the LWP but only half the LWP in the summer hemisphere. Precipitating clouds contribute significantly to monthly, zonal mean LWP values determined from microwave, especially in the intertropical convergence zone (ITCZ), because they have almost 10 times the liquid water (cloud plus precipitation) of nonprecipitating clouds on average. There are significant differences among microwave LWP estimates associated with the treatment of precipitating clouds.
-
Correcting AUC for Measurement Error.
Rosner, Bernard; Tworoger, Shelley; Qiu, Weiliang
2015-12-01
Diagnostic biomarkers are used frequently in epidemiologic and clinical work. The ability of a diagnostic biomarker to discriminate between subjects who develop disease (cases) and subjects who do not (controls) is often measured by the area under the receiver operating characteristic curve (AUC). The diagnostic biomarkers are usually measured with error. Ignoring measurement error can cause biased estimation of AUC, which results in misleading interpretation of the efficacy of a diagnostic biomarker. Several methods have been proposed to correct AUC for measurement error, most of which required the normality assumption for the distributions of diagnostic biomarkers. In this article, we propose a new method to correct AUC for measurement error and derive approximate confidence limits for the corrected AUC. The proposed method does not require the normality assumption. Both real data analyses and simulation studies show good performance of the proposed measurement error correction method.
-
Scaffolding--How Can Contingency Lead to Successful Learning When Dealing with Errors?
ERIC Educational Resources Information Center
Wischgoll, Anke; Pauli, Christine; Reusser, Kurt
2015-01-01
Errors indicate learners' misunderstanding and can provide learning opportunities. Providing learning support which is contingent on learners' needs when errors occur is considered effective for developing learners' understanding. The current investigation examines how tutors and tutees interact productively with errors when working on a…
-
Sultana, Shemaila; Solotchi, Mihai; Ramachandran, Aparna; Patel, Smita S
2017-11-03
Single-subunit RNA polymerases (RNAPs) are present in phage T7 and in mitochondria of all eukaryotes. This RNAP class plays important roles in biotechnology and cellular energy production, but we know little about its fidelity and error rates. Herein, we report the error rates of three single-subunit RNAPs measured from the catalytic efficiencies of correct and all possible incorrect nucleotides. The average error rates of T7 RNAP (2 × 10 -6 ), yeast mitochondrial Rpo41 (6 × 10 -6 ), and human mitochondrial POLRMT (RNA polymerase mitochondrial) (2 × 10 -5 ) indicate high accuracy/fidelity of RNA synthesis resembling those of replicative DNA polymerases. All three RNAPs exhibit a distinctly high propensity for GTP misincorporation opposite dT, predicting frequent A→G errors in RNA with rates of ∼10 -4 The A→C, G→A, A→U, C→U, G→U, U→C, and U→G errors mostly due to pyrimidine-purine mismatches were relatively frequent (10 -5 -10 -6 ), whereas C→G, U→A, G→C, and C→A errors from purine-purine and pyrimidine-pyrimidine mismatches were rare (10 -7 -10 -10 ). POLRMT also shows a high C→A error rate on 8-oxo-dG templates (∼10 -4 ). Strikingly, POLRMT shows a high mutagenic bypass rate, which is exacerbated by TEFM (transcription elongation factor mitochondrial). The lifetime of POLRMT on terminally mismatched elongation substrate is increased in the presence of TEFM, which allows POLRMT to efficiently bypass the error and continue with transcription. This investigation of nucleotide selectivity on normal and oxidatively damaged DNA by three single-subunit RNAPs provides the basic information to understand the error rates in mitochondria and, in the case of T7 RNAP, to assess the quality of in vitro transcribed RNAs. © 2017 by The American Society for Biochemistry and Molecular Biology, Inc.
-
Pesko, Kendra N; Fitzpatrick, Kelly A; Ryan, Elizabeth M; Shi, Pei-Yong; Zhang, Bo; Lennon, Niall J; Newman, Ruchi M; Henn, Matthew R; Ebel, Gregory D
2012-05-25
Most RNA viruses exist in their hosts as a heterogeneous population of related variants. Due to error prone replication, mutants are constantly generated which may differ in individual fitness from the population as a whole. Here we characterize three WNV isolates that contain, along with full-length genomes, mutants with large internal deletions to structural and nonstructural protein-coding regions. The isolates were all obtained from lorikeets that died from WNV at the Rio Grande Zoo in Albuquerque, NM between 2005 and 2007. The deletions are approximately 2kb, in frame, and result in the elimination of the complete envelope, and portions of the prM and NS-1 proteins. In Vero cell culture, these internally deleted WNV genomes function as defective interfering particles, reducing the production of full-length virus when introduced at high multiplicities of infection. In mosquitoes, the shortened WNV genomes reduced infection and dissemination rates, and virus titers overall, and were not detected in legs or salivary secretions at 14 or 21 days post-infection. In mice, inoculation with internally deleted genomes did not attenuate pathogenesis relative to full-length or infectious clone derived virus, and shortened genomes were not detected in mice at the time of death. These observations provide evidence that large deletions may occur within flavivirus populations more frequently than has generally been appreciated and suggest that they impact population phenotype minimally. Additionally, our findings suggest that highly similar mutants may frequently occur in particular vertebrate hosts. Copyright © 2012 Elsevier Inc. All rights reserved.
-
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…
-
ERIC Educational Resources Information Center
Idzinga, J. C.; de Jong, A. L.; van den Bemt, P. M. L. A.
2009-01-01
Background: Previous studies, both in hospitals and in institutions for clients with an intellectual disability (ID), have shown that medication errors at the administration stage are frequent, especially when medication has to be administered through an enteral feeding tube. In hospitals a specially designed intervention programme has proven to…
-
ERIC Educational Resources Information Center
Karoly, Adrienn
2012-01-01
This paper reports the findings of a study aiming to reveal the recurring patterns of lexical, syntactic and textual errors in student translations of a specialized EU genre from English into Hungarian. By comparing the student translations to the official translation of the text, this article uncovers the most frequent errors that students made…
-
NASA Model of "Threat and Error" in Pediatric Cardiac Surgery: Patterns of Error Chains.
Hickey, Edward; Pham-Hung, Eric; Nosikova, Yaroslavna; Halvorsen, Fredrik; Gritti, Michael; Schwartz, Steven; Caldarone, Christopher A; Van Arsdell, Glen
2017-04-01
We introduced the National Aeronautics and Space Association threat-and-error model to our surgical unit. All admissions are considered flights, which should pass through stepwise deescalations in risk during surgical recovery. We hypothesized that errors significantly influence risk deescalation and contribute to poor outcomes. Patient flights (524) were tracked in real time for threats, errors, and unintended states by full-time performance personnel. Expected risk deescalation was wean from mechanical support, sternal closure, extubation, intensive care unit (ICU) discharge, and discharge home. Data were accrued from clinical charts, bedside data, reporting mechanisms, and staff interviews. Infographics of flights were openly discussed weekly for consensus. In 12% (64 of 524) of flights, the child failed to deescalate sequentially through expected risk levels; unintended increments instead occurred. Failed deescalations were highly associated with errors (426; 257 flights; p < 0.0001). Consequential errors (263; 173 flights) were associated with a 29% rate of failed deescalation versus 4% in flights with no consequential error (p < 0.0001). The most dangerous errors were apical errors typically (84%) occurring in the operating room, which caused chains of propagating unintended states (n = 110): these had a 43% (47 of 110) rate of failed deescalation (versus 4%; p < 0.0001). Chains of unintended state were often (46%) amplified by additional (up to 7) errors in the ICU that would worsen clinical deviation. Overall, failed deescalations in risk were extremely closely linked to brain injury (n = 13; p < 0.0001) or death (n = 7; p < 0.0001). Deaths and brain injury after pediatric cardiac surgery almost always occur from propagating error chains that originate in the operating room and are often amplified by additional ICU errors. Copyright © 2017 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.
-
Schmidt, Frank L; Le, Huy; Ilies, Remus
2003-06-01
On the basis of an empirical study of measures of constructs from the cognitive domain, the personality domain, and the domain of affective traits, the authors of this study examine the implications of transient measurement error for the measurement of frequently studied individual differences variables. The authors clarify relevant reliability concepts as they relate to transient error and present a procedure for estimating the coefficient of equivalence and stability (L. J. Cronbach, 1947), the only classical reliability coefficient that assesses all 3 major sources of measurement error (random response, transient, and specific factor errors). The authors conclude that transient error exists in all 3 trait domains and is especially large in the domain of affective traits. Their findings indicate that the nearly universal use of the coefficient of equivalence (Cronbach's alpha; L. J. Cronbach, 1951), which fails to assess transient error, leads to overestimates of reliability and undercorrections for biases due to measurement error.
-
Latent error detection: A golden two hours for detection.
Saward, Justin R E; Stanton, Neville A
2017-03-01
Undetected error in safety critical contexts generates a latent condition that can contribute to a future safety failure. The detection of latent errors post-task completion is observed in naval air engineers using a diary to record work-related latent error detection (LED) events. A systems view is combined with multi-process theories to explore sociotechnical factors associated with LED. Perception of cues in different environments facilitates successful LED, for which the deliberate review of past tasks within two hours of the error occurring and whilst remaining in the same or similar sociotechnical environment to that which the error occurred appears most effective. Identified ergonomic interventions offer potential mitigation for latent errors; particularly in simple everyday habitual tasks. It is thought safety critical organisations should look to engineer further resilience through the application of LED techniques that engage with system cues across the entire sociotechnical environment, rather than relying on consistent human performance. Crown Copyright © 2016. Published by Elsevier Ltd. All rights reserved.
-
Risk Factors for Increased Severity of Paediatric Medication Administration Errors
Sears, Kim; Goodman, William M.
2012-01-01
Patients' risks from medication errors are widely acknowledged. Yet not all errors, if they occur, have the same risks for severe consequences. Facing resource constraints, policy makers could prioritize factors having the greatest severe–outcome risks. This study assists such prioritization by identifying work-related risk factors most clearly associated with more severe consequences. Data from three Canadian paediatric centres were collected, without identifiers, on actual or potential errors that occurred. Three hundred seventy-two errors were reported, with outcome severities ranging from time delays up to fatalities. Four factors correlated significantly with increased risk for more severe outcomes: insufficient training; overtime; precepting a student; and off-service patient. Factors' impacts on severity also vary with error class: for wrong-time errors, the factors precepting a student or working overtime significantly increase severe-outcomes risk. For other types, caring for an off-service patient has greatest severity risk. To expand such research, better standardization is needed for categorizing outcome severities. PMID:23968607
-
Medication administration error: magnitude and associated factors among nurses in Ethiopia.
Feleke, Senafikish Amsalu; Mulatu, Muluadam Abebe; Yesmaw, Yeshaneh Seyoum
2015-01-01
The significant impact of medication administration errors affect patients in terms of morbidity, mortality, adverse drug events, and increased length of hospital stay. It also increases costs for clinicians and healthcare systems. Due to this, assessing the magnitude and associated factors of medication administration error has a significant contribution for improving the quality of patient care. The aim of this study was to assess the magnitude and associated factors of medication administration errors among nurses at the Felege Hiwot Referral Hospital inpatient department. A prospective, observation-based, cross-sectional study was conducted from March 24-April 7, 2014 at the Felege Hiwot Referral Hospital inpatient department. A total of 82 nurses were interviewed using a pre-tested structured questionnaire, and observed while administering 360 medications by using a checklist supplemented with a review of medication charts. Data were analyzed by using SPSS version 20 software package and logistic regression was done to identify possible factors associated with medication administration error. The incidence of medication administration error was 199 (56.4 %). The majority (87.5 %) of the medications have documentation error, followed by technique error 263 (73.1 %) and time error 193 (53.6 %). Variables which were significantly associated with medication administration error include nurses between the ages of 18-25 years [Adjusted Odds Ratio (AOR) = 2.9, 95 % CI (1.65,6.38)], 26-30 years [AOR = 2.3, 95 % CI (1.55, 7.26)] and 31-40 years [AOR = 2.1, 95 % CI (1.07, 4.12)], work experience of less than or equal to 10 years [AOR = 1.7, 95 % CI (1.33, 4.99)], nurse to patient ratio of 7-10 [AOR = 1.6, 95 % CI (1.44, 3.19)] and greater than 10 [AOR = 1.5, 95 % CI (1.38, 3.89)], interruption of the respondent at the time of medication administration [AOR = 1.5, 95 % CI (1.14, 3.21)], night shift of medication administration [AOR = 3.1, 95 % CI (1.38, 9.66)] and age of the patients with less than 18 years [AOR = 2.3, 95 % CI (1.17, 4.62)]. In general, medication errors at the administration phase were highly prevalent in Felege Hiwot Referral Hospital. Documentation error is the most dominant type of error observed during the study. Increasing nurses' staffing levels, minimizing distraction and interruptions during medication administration by using no interruptions zones and "No-Talk" signage are recommended to overcome medication administration errors. Retaining experienced nurses from leaving to train and supervise inexperienced nurses with the focus on medication safety, in addition providing convenient sleep hours for nurses would be helpful in ensuring that medication errors don't occur as frequently as observed in this study.
-
Smoked Cannabis' Psychomotor and Neurocognitive Effects in Occasional and Frequent Smokers
Desrosiers, Nathalie A.; Ramaekers, Johannes G.; Chauchard, Emeline; Gorelick, David A.; Huestis, Marilyn A.
2015-01-01
Δ9-Tetrahydrocannabinol (THC), the primary psychoactive constituent in cannabis, impairs psychomotor performance, cognition and driving ability; thus, driving under the influence of cannabis is a public safety concern. We documented cannabis' psychomotor, neurocognitive, subjective and physiological effects in occasional and frequent smokers to investigate potential differences between these smokers. Fourteen frequent (≥4x/week) and 11 occasional (<2x/week) cannabis smokers entered a secure research unit ∼19 h prior to smoking one 6.8% THC cigarette. Cognitive and psychomotor performance was evaluated with the critical tracking (CTT), divided attention (DAT), n-back (working memory) and Balloon Analog Risk (BART) (risk-taking) tasks at −1.75, 1.5, 3.5, 5.5 and 22.5 h after starting smoking. GLM (General Linear Model) repeated measures ANOVA was utilized to compare scores. Occasional smokers had significantly more difficulty compensating for CTT tracking error compared with frequent smokers 1.5 h after smoking. Divided attention performance declined significantly especially in occasional smokers, with session × group effects for tracking error, hits, false alarms and reaction time. Cannabis smoking did not elicit session × group effects on the n-back or BART. Controlled cannabis smoking impaired psychomotor function, more so in occasional smokers, suggesting some tolerance to psychomotor impairment in frequent users. These data have implications for cannabis-associated impairment in driving under the influence of cannabis cases. PMID:25745105
-
Oliveira, Claudia Akemi Shiratori de; Hisatomi, Kenia Scrocaro; Leite, Cristiano Pinheiro; Schellini, Silvana Artioli; Padovani, Carlos Roberto; Padovani, Carlos Roberto Pereira
2009-01-01
To evaluate the refractive errors as cause of visual impairment in school children from the Botucatu region. A sectional study was conducted evaluating preschool and elementary school students, according to gender, refractive error, visual acuity and treatment. Four thousand six hundred and twenty-three (4,623) children were submitted to visual acuity evaluation and 8.1% of them were submitted to complete ocular examination. There were 63.2% hyperopic astigmatism, 15.7% myopic astigmatism, 12.5% astigmatism, 4.9% hyperopia and 3.7% myopia. Corrective lenses were prescribed for 48.7% of the evaluated children. The most frequent refractive error was hyperopic astigmatism and 50% of the children received treatment. The frequency of refractive errors was 3.9% of the studied population.
-
Error Analysis in Mathematics. Technical Report #1012
ERIC Educational Resources Information Center
Lai, Cheng-Fei
2012-01-01
Error analysis is a method commonly used to identify the cause of student errors when they make consistent mistakes. It is a process of reviewing a student's work and then looking for patterns of misunderstanding. Errors in mathematics can be factual, procedural, or conceptual, and may occur for a number of reasons. Reasons why students make…
-
Error Tendencies in Processing Student Feedback for Instructional Decision Making.
ERIC Educational Resources Information Center
Schermerhorn, John R., Jr.; And Others
1985-01-01
Seeks to assist instructors in recognizing two basic errors that can occur in processing student evaluation data on instructional development efforts; offers a research framework for future investigations of the error tendencies and related issues; and suggests ways in which instructors can confront and manage error tendencies in practice. (MBR)
-
Understanding EFL Students' Errors in Writing
ERIC Educational Resources Information Center
Phuket, Pimpisa Rattanadilok Na; Othman, Normah Binti
2015-01-01
Writing is the most difficult skill in English, so most EFL students tend to make errors in writing. In assisting the learners to successfully acquire writing skill, the analysis of errors and the understanding of their sources are necessary. This study attempts to explore the major sources of errors occurred in the writing of EFL students. It…
-
The impact of automation on workload and dispensing errors in a hospital pharmacy.
James, K Lynette; Barlow, Dave; Bithell, Anne; Hiom, Sarah; Lord, Sue; Pollard, Mike; Roberts, Dave; Way, Cheryl; Whittlesea, Cate
2013-04-01
To determine the effect of installing an original-pack automated dispensing system (ADS) on dispensary workload and prevented dispensing incidents in a hospital pharmacy. Data on dispensary workload and prevented dispensing incidents, defined as dispensing errors detected and reported before medication had left the pharmacy, were collected over 6 weeks at a National Health Service hospital in Wales before and after the installation of an ADS. Workload was measured by non-participant observation using the event recording technique. Prevented dispensing incidents were self-reported by pharmacy staff on standardised forms. Median workloads (measured as items dispensed/person/hour) were compared using Mann-Whitney U tests and rate of prevented dispensing incidents were compared using Chi-square test. Spearman's rank correlation was used to examine the association between workload and prevented dispensing incidents. A P value of ≤0.05 was considered statistically significant. Median dispensary workload was significantly lower pre-automation (9.20 items/person/h) compared to post-automation (13.17 items/person/h, P < 0.001). Rate of prevented dispensing incidents was significantly lower post-automation (0.28%) than pre-automation (0.64%, P < 0.0001) but there was no difference (P = 0.277) between the types of dispensing incidents. A positive association existed between workload and prevented dispensing incidents both pre- (ρ = 0.13, P = 0.015) and post-automation (ρ = 0.23, P < 0.001). Dispensing incidents were found to occur during prolonged periods of moderate workload or after a busy period. Study findings suggest that automation improves dispensing efficiency and reduces the rate of prevented dispensing incidents. It is proposed that prevented dispensing incidents frequently occurred during periods of high workload due to involuntary automaticity. Prevented dispensing incidents occurring after a busy period were attributed to staff experiencing fatigue after-effects. © 2012 The Authors. IJPP © 2012 Royal Pharmaceutical Society.
-
Shida, Kyoko; Suzuki, Toshiyasu; Sugahara, Kazuhiro; Sobue, Kazuya
2016-05-01
In the case of medication errors which are among the more frequent adverse events that occur in the hospital, there is a need for effective measures to prevent incidence. According to the Japan Society of Anesthesiologists study "Drug incident investigation 2005-2007 years", "Error of a syringe at the selection stage" was the most frequent (44.2%). The status of current measures and best practices implemented in Japanese hospitals was the focus of a subsequent investigation. Representative specialists in anesthesiology certified hospitals across the country were surveyed via a questionnaire sampling that lasted 46 days. Investigation method was via the Web with survey responses anonymous. With respect to preventive measures implemented to mitigate risk of medication errors in perioperative settings, responses included: incident and accident report (215 facilities, 70.3%), use of pre-filled syringes (180 facilities, 58.8%), devised the arrangement of dangerous drugs (154 facilities, 50.3%), use of the product with improper connection preventing mechanism (123 facilities, 40.2%), double-check (116 facilities, 37.9%), use of color barreled syringe (115 facilities, 37.6%), use of color label or color tape (89 facilities, 29.1%), presentation of medication such as placing the ampoule or syringe on a tray by dividing color code for drug class on a tray (54 facilities, 17.6%), the discontinuance of handwritten labels (23 facilities, 7.5%), use of a drug verification system that uses bar code (20 facilities, 6.5%), and facilities that have not implemented any means (11 facilities, 3.6%), others not mentioned (10 facilities, 3.3%), and use of carts that count/account the agents by drug type and record selection and number picked automatically (6 facilities, 2.0%). Drug name identification affixed to the syringe via perforated label torn from the ampoule/vial, etc. (245 facilities, 28.1%), handwriting directly to the syringe (208 facilities, 23.8%), use of the attached label (like that comes with the product) (187 facilities, 21.4%), handwriting on the plain tape (87 facilities, 10.0%), printing labels (62 facilities, 7.1%), printed color labels (44 facilities, 5.0%), handwriting on the color tape (27 facilities, 3.1%), machinery for printing the drug name by scanning bar code of the ampoule, etc.(10 facilities, 1.1%), others (3 facilities, 0.3%), no description on the prepared drug (0 facilities, 0%). The awareness of international standard color code, such as by the International Organization for Standardization (ISO), was only 18.6%. Targeting anesthesiology certified hospitals recognized by the Japan Society of Anesthesiologists, the result of the survey on the measures to prevent medication errors during perioperative procedures indicated that various measures were documented in use. However, many facilities still use hand written labels (a common cause for errors). Confirmation of the need for improved drug name and drug recognition on syringe was documented.
-
A pilot study of the safety implications of Australian nurses' sleep and work hours.
Dorrian, Jillian; Lamond, Nicole; van den Heuvel, Cameron; Pincombe, Jan; Rogers, Ann E; Dawson, Drew
2006-01-01
The frequency and severity of adverse events in Australian healthcare is under increasing scrutiny. A recent state government report identified 31 events involving "death or serious [patient] harm" and 452 "very high risk" incidents. Australia-wide, a previous study identified 2,324 adverse medical events (AME) in a single year, with more than half considered preventable. Despite the recognized link between fatigue and error in other industries, to date, few studies of medical errors have assessed the fatigue of the healthcare professionals involved. Nurses work extended and unpredictable hours with a lack of regular breaks and are therefore likely to experience elevated fatigue. Currently, there is very little available information on Australian nurses' sleep or fatigue levels, nor is there any information about whether this affects their performance. This study therefore aims to examine work hours, sleep, fatigue and error occurrence in Australian nurses. Using logbooks, 23 full-time nurses in a metropolitan hospital completed daily recordings for one month (644 days, 377 shifts) of their scheduled and actual work hours, sleep length and quality, sleepiness, and fatigue levels. Frequency and type of nursing errors, near errors, and observed errors (made by others) were recorded. Nurses reported struggling to remain awake during 36% of shifts. Moderate to high levels of stress, physical exhaustion, and mental exhaustion were reported on 23%, 40%, and 36% of shifts, respectively. Extreme drowsiness while driving or cycling home was reported on 45 occasions (11.5%), with three reports of near accidents. Overall, 20 errors, 13 near errors, and 22 observed errors were reported. The perceived potential consequences for the majority of errors were minor; however, 11 errors were associated with moderate and four with potentially severe consequences. Nurses reported that they had trouble falling asleep on 26.8% of days, had frequent arousals on 34.0% of days, and that work-related concerns were either partially or fully responsible for their sleep disruption on 12.5% of occasions. Fourteen out of the 23 nurses reported using a sleep aid. The most commonly reported sleep aids were prescription medications (62.7%), followed by alcohol (26.9%). Total sleep duration was significantly shorter on workdays than days off (p < 0.01). In comparison to other workdays, sleep was significantly shorter on days when an error (p < 0.05) or a near error (p < 0.01) was recorded. In contrast, sleep was higher on workdays when someone else's error was recorded (p = 0.08). Logistic regression analysis indicated that sleep duration was a significant predictor of error occurrence (chi2 = 6.739, p = 0.009, e beta = 0.727). The findings of this pilot study suggest that Australian nurses experience sleepiness and related physical symptoms at work and during their trip home. Further, a measurable number of errors occur of various types and severity. Less sleep may lead to the increased likelihood of making an error, and importantly, the decreased likelihood of catching someone else's error. These pilot results suggest that further investigation into the effects of sleep loss in nursing may be necessary for patient safety from an individual nurse perspective and from a healthcare team perspective.
-
Gay-Escoda, Cosme; Párraga-Manzol, Gabriela; Sánchez-Torres, Alba; Moreno-Arias, Gerardo
2015-10-01
Intense Pulsed Light (IPL) photodepilation is usually performed as a hair removal method. The treatment is recommended to be indicated by a physician, depending on each patient and on its characteristics. However, the use of laser devices by medical laypersons is frequent and it can suppose a risk of damage for the patients. Most side effects associated to IPL photodepilation are transient, minimal and disappear without sequelae. However, permanent side effects can occur. Some of the complications are laser related but many of them are caused by an operator error or mismanagement. In this work, we report a clinical case of a patient that developed a chronic neuropathic facial pain following IPL hair removal for unwanted hair in the upper lip. The specific diagnosis was painful post-traumatic trigeminal neuropathy, reference 13.1.2.3 according to the International Headache Society (IHS). Neuropathic facial pain, photodepilation, intense pulse light.
-
A new use of high resolution magnetograms. [solar activity and magnetic flux
NASA Technical Reports Server (NTRS)
Baum, P. J.; Bratenahl, A.
1978-01-01
Ground-based solar magnetograms are frequently in error by as much as twenty percent and contribute to the poor correlation between magnetic changes and solar flares. High resolution measurement of the magnetic field component, which is normal to the photosphere and measured at photospheric height, can be used to construct a magnetic flux partition function F. Therefore, dF/dt is an EMF which drives atmospheric currents in reconnecting solar active regions. With a high quality magnetograph, the solar probe can be used to obtain good estimates of F and dF/dt and thereby the energy stored as induced solar atmospheric currents during quiescent interflare periods. Should a flare occur during a favorable observing period, the present method of analysis should show characteristic signatures in F, DF/dt, and especially, in the stored flux computed from dF/dt.
-
Smoothing and gap-filling of high resolution multi-spectral time series: Example of Landsat data
NASA Astrophysics Data System (ADS)
Vuolo, Francesco; Ng, Wai-Tim; Atzberger, Clement
2017-05-01
This paper introduces a novel methodology for generating 15-day, smoothed and gap-filled time series of high spatial resolution data. The approach is based on templates from high quality observations to fill data gaps that are subsequently filtered. We tested our method for one large contiguous area (Bavaria, Germany) and for nine smaller test sites in different ecoregions of Europe using Landsat data. Overall, our results match the validation dataset to a high degree of accuracy with a mean absolute error (MAE) of 0.01 for visible bands, 0.03 for near-infrared and 0.02 for short-wave-infrared. Occasionally, the reconstructed time series are affected by artefacts due to undetected clouds. Less frequently, larger uncertainties occur as a result of extended periods of missing data. Reliable cloud masks are highly warranted for making full use of time series.
-
Conjunction Assessment Late-Notice High-Interest Event Investigation: Space Weather Aspects
NASA Technical Reports Server (NTRS)
Pachura, D.; Hejduk, M. D.
2016-01-01
Late-notice events usually driven by large changes in primary (protected) object or secondary object state. Main parameter to represent size of state change is component position difference divided by associated standard deviation (epsilon divided by sigma) from covariance. Investigation determined actual frequency of large state changes, in both individual and combined states. Compared them to theoretically expected frequencies. Found that large changes ( (epsilon divided by sigma) is greater than 3) in individual object states occur much more frequently than theory dictates. Effect is less pronounced in radial components and in events with probability of collision (Pc) greater than 1 (sup -5) (1e-5). Found combined state matched much closer to theoretical expectation, especially for radial and cross-track. In-track is expected to be the most vulnerable to modeling errors, so not surprising that non-compliance largest in this component.
-
[Recreational boating accidents--Part 1: Catamnestic study].
Lignitz, Eberhard; Lustig, Martina; Scheibe, Ernst
2014-01-01
Deaths on the water are common in the autopsy material of medicolegal institutes situated on the coast or big rivers and lakes (illustrated by the example of the Institute of Legal Medicine of Greifswald University). They mostly occur during recreational boating activities. Apart from hydro-meteorological influences, human error is the main cause of accidents. Often it is not sufficiently kept in mind whether the boat crew is fit for sailing and proper seamanship is ensured. Drowning (following initial hypothermia) is the most frequent cause of death. Medicolegal aspects are not decisive for ordering a forensic autopsy. As statistics are not compiled in a uniform way, a comparison of the data of different institutions engaged in investigating deaths at sea and during water sports activities is hardly possible, neither on a national nor an international basis--and the reconstruction of aquatic accidents is generally difficult. Fatal accidents can only be prevented by completely clarifying their causes.
-
Hazan, Valerie; Messaoud-Galusi, Souhila; Rosen, Stuart
2013-01-01
Purpose To determine whether children with dyslexia (DYS) are more affected than age-matched average readers (AR) by talker and intonation variability when perceiving speech in noise. Method Thirty-four DYS and 25 AR children were tested on their perception of consonants in naturally-produced consonant-vowel (CV) tokens in multi-talker babble. Twelve CVs were presented for identification in four conditions varying in the degree of talker and intonation variability. Consonant place (/bi/-/di/) and voicing (/bi/-/pi/) discrimination was investigated with the same conditions. Results DYS children made slightly more identification errors than AR children but only for conditions with variable intonation. Errors were more frequent for a subset of consonants, generally weakly-encoded for AR children, for tokens with intonation patterns (steady and rise-fall) that occur infrequently in connected discourse. In discrimination tasks, which have a greater memory and cognitive load, DYS children scored lower than AR children across all conditions. Conclusions Unusual intonation patterns had a disproportionate (but small) effect on consonant intelligibility in noise for DYS children but adding talker variability did not. DYS children do not appear to have a general problem in perceiving speech in degraded conditions, which makes it unlikely that they lack robust phonological representations. PMID:22761322
-
Hazan, Valerie; Messaoud-Galusi, Souhila; Rosen, Stuart
2013-02-01
In this study, the authors aimed to determine whether children with dyslexia (hereafter referred to as "DYS children") are more affected than children with average reading ability (hereafter referred to as "AR children") by talker and intonation variability when perceiving speech in noise. Thirty-four DYS and 25 AR children were tested on their perception of consonants in naturally produced CV tokens in multitalker babble. Twelve CVs were presented for identification in four conditions varying in the degree of talker and intonation variability. Consonant place (/bi/-/di/) and voicing (/bi/-/pi/) discrimination were investigated with the same conditions. DYS children made slightly more identification errors than AR children but only for conditions with variable intonation. Errors were more frequent for a subset of consonants, generally weakly encoded for AR children, for tokens with intonation patterns (steady and rise-fall) that occur infrequently in connected discourse. In discrimination tasks, which have a greater memory and cognitive load, DYS children scored lower than AR children across all conditions. Unusual intonation patterns had a disproportionate (but small) effect on consonant intelligibility in noise for DYS children, but adding talker variability did not. DYS children do not appear to have a general problem in perceiving speech in degraded conditions, which makes it unlikely that they lack robust phonological representations.
-
Allard, Jon; Bleakley, Alan; Hobbs, Adrian; Vinnell, Tina
2007-03-01
Accidents in health care are mainly due to systemic communication errors. Errors occur more frequently in the operating theatre (OT) than other clinical settings. Hence, it is important that preventive communication practices are adopted in OT teams. Formal team pre-briefing has been shown to improve safety in high risk settings such as aviation, but such briefing is not common practice in OT teams. This paper reviews key literature demonstrating the value of briefing in high-risk practices; presents and analyses the results of a questionnaire survey on the status of briefing after its introduction to OT teams in one UK hospital; and analyses processes that frustrate widespread adoption of briefing. In comparison with other OT practitioners, surgeons generally reported differing perceptions of the meaning and value of briefing, often holding broad notions of what constitutes a "brief", but also showing scepticism towards briefing. However, surgeons who had introduced briefing reported positive results such as greater efficiency, shared understanding, and increased team morale. Collaborative briefing that extends beyond the technical to include the interpersonal could be initiated in principle by any member of the OT team, but a number of factors inhibit this, and surgeons play a pivotal role in establishing briefing.
-
Turtle: identifying frequent k-mers with cache-efficient algorithms.
Roy, Rajat Shuvro; Bhattacharya, Debashish; Schliep, Alexander
2014-07-15
Counting the frequencies of k-mers in read libraries is often a first step in the analysis of high-throughput sequencing data. Infrequent k-mers are assumed to be a result of sequencing errors. The frequent k-mers constitute a reduced but error-free representation of the experiment, which can inform read error correction or serve as the input to de novo assembly methods. Ideally, the memory requirement for counting should be linear in the number of frequent k-mers and not in the, typically much larger, total number of k-mers in the read library. We present a novel method that balances time, space and accuracy requirements to efficiently extract frequent k-mers even for high-coverage libraries and large genomes such as human. Our method is designed to minimize cache misses in a cache-efficient manner by using a pattern-blocked Bloom filter to remove infrequent k-mers from consideration in combination with a novel sort-and-compact scheme, instead of a hash, for the actual counting. Although this increases theoretical complexity, the savings in cache misses reduce the empirical running times. A variant of method can resort to a counting Bloom filter for even larger savings in memory at the expense of false-negative rates in addition to the false-positive rates common to all Bloom filter-based approaches. A comparison with the state-of-the-art shows reduced memory requirements and running times. The tools are freely available for download at http://bioinformatics.rutgers.edu/Software/Turtle and http://figshare.com/articles/Turtle/791582. © The Author 2014. Published by Oxford University Press. All rights reserved. For Permissions, please e-mail: journals.permissions@oup.com.
-
Bernard, A M; Burgot, J L
1981-12-01
The reversibility of the determination reaction is the most frequent cause of deviations from linearity of thermometric titration curves. Because of this, determination of the equivalence point by the tangent method is associated with a systematic error. The authors propose a relationship which connects this error quantitatively with the equilibrium constant. The relation, verified experimentally, is deduced from a mathematical study of the thermograms and could probably be generalized to apply to other linear methods of determination.
-
Neural Prediction Errors Distinguish Perception and Misperception of Speech.
Blank, Helen; Spangenberg, Marlene; Davis, Matthew H
2018-06-11
Humans use prior expectations to improve perception, especially of sensory signals that are degraded or ambiguous. However, if sensory input deviates from prior expectations, correct perception depends on adjusting or rejecting prior expectations. Failure to adjust or reject the prior leads to perceptual illusions especially if there is partial overlap (hence partial mismatch) between expectations and input. With speech, "Slips of the ear" occur when expectations lead to misperception. For instance, a entomologist, might be more susceptible to hear "The ants are my friends" for "The answer, my friend" (in the Bob Dylan song "Blowing in the Wind"). Here, we contrast two mechanisms by which prior expectations may lead to misperception of degraded speech. Firstly, clear representations of the common sounds in the prior and input (i.e., expected sounds) may lead to incorrect confirmation of the prior. Secondly, insufficient representations of sounds that deviate between prior and input (i.e., prediction errors) could lead to deception. We used cross-modal predictions from written words that partially match degraded speech to compare neural responses when male and female human listeners were deceived into accepting the prior or correctly reject it. Combined behavioural and multivariate representational similarity analysis of functional magnetic resonance imaging data shows that veridical perception of degraded speech is signalled by representations of prediction error in the left superior temporal sulcus. Instead of using top-down processes to support perception of expected sensory input, our findings suggest that the strength of neural prediction error representations distinguishes correct perception and misperception. SIGNIFICANCE STATEMENT Misperceiving spoken words is an everyday experience with outcomes that range from shared amusement to serious miscommunication. For hearing-impaired individuals, frequent misperception can lead to social withdrawal and isolation with severe consequences for well-being. In this work, we specify the neural mechanisms by which prior expectations - which are so often helpful for perception - can lead to misperception of degraded sensory signals. Most descriptive theories of illusory perception explain misperception as arising from a clear sensory representation of features or sounds that are in common between prior expectations and sensory input. Our work instead provides support for a complementary proposal; namely that misperception occurs when there is an insufficient sensory representations of the deviation between expectations and sensory signals. Copyright © 2018 the authors.
-
Vaidyanathan, Subramanian; Hughes, Peter L; Soni, Bhakul M; Singh, Gurpreet; Mansour, Paul; Sett, Pradipkumar
2001-01-01
Background A delay in diagnosis or a misdiagnosis may occur in patients with spinal cord injury (SCI) or spinal bifida as typical symptoms of a clinical condition may be absent because of their neurological impairment. Case presentation A 29-year old male, who was born with spina bifida and hydrocephalus, became unwell and developed a swelling and large red mark in his left loin eighteen months ago. Pyonephrosis or perinephric abscess was suspected. X-ray of the abdomen showed left-sided staghorn calculus. Since ultrasound scan showed no features of pyonephrosis or perinephric abscess, he was prescribed a prolonged course of antibiotics for infection presumed to arise from the site of metal implant in spine. He developed a discharging sinus, following which the loin swelling and red mark subsided. About three months ago, he again developed a red mark and minimal swelling in the left loin. Ultrasound scan detected no abnormality in the renal or perinephric region. Therefore, the red mark and swelling were attributed to pressure from the backrest of his chair. Five weeks later, the swelling in the left loin burst open and a large stone was extruded spontaneously. An X-ray of the abdomen showed that he had extruded the central portion of the staghorn calculus from left kidney. With hindsight, the extruded renal calculus could be seen lying in the subcutaneous tissue of left loin lateral to the 10th rib in the X-ray of abdomen, which was taken when he presented with red mark and minimal swelling. Conclusion This case illustrates how mistakes in diagnosis could occur in spinal cord injury patients, and highlights the need for corrective measures to reduce urological errors in these patients. Voluntary reporting of urological errors is recommended to facilitate learning from our mistakes. In the patients who have marked spinal curvature, ultrasonography of kidneys and perinephric region may not be entirely reliable. As clinical symptoms and signs may be non-specific in SCI patients, they require prompt, detailed and occasionally, repeated investigations. A joint team approach by health professionals belonging to various medical disciplines, which is strengthened by frequent, informal and honest discussions of a patient's clinical condition, is likely to reduce urological errors in SCI patients. PMID:11801198
-
Medication errors: an overview for clinicians.
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.
-
Linguistic pattern analysis of misspellings of typically developing writers in grades 1-9.
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.
-
ERIC Educational Resources Information Center
Pouplier, Marianne; Marin, Stefania; Waltl, Susanne
2014-01-01
Purpose: Phonetic accommodation in speech errors has traditionally been used to identify the processing level at which an error has occurred. Recent studies have challenged the view that noncanonical productions may solely be due to phonetic, not phonological, processing irregularities, as previously assumed. The authors of the present study…
-
Multiple-generator errors are unavoidable under model misspecification.
Jewett, D L; Zhang, Z
1995-08-01
Model misspecification poses a major problem for dipole source localization (DSL) because it causes insidious multiple-generator errors (MulGenErrs) to occur in the fitted dipole parameters. This paper describes how and why this occurs, based upon simple algebraic considerations. MulGenErrs must occur, to some degree, in any DSL analysis of real data because there is model misspecification and mathematically the equations used for the simultaneously active generators must be of a different form than the equations for each generator active alone.
-
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.
-
Errors in radiation oncology: A study in pathways and dosimetric impact
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
-
Medication management of febrile children: a qualitative study on pharmacy employees' experiences.
Stakenborg, Jacqueline P G; de Bont, Eefje G P M; Peetoom, Kirsten K B; Nelissen-Vrancken, Marjorie H J M G; Cals, Jochen W L
2016-10-01
Background While fever is mostly self-limiting, antibiotic prescription rates for febrile children are high. Although every parent who receives a prescription visits a pharmacy, we have limited insight into pharmacy employees' experiences with these parents. Pharmacy employees do however exert an important role in ensuring children receive correct dosages and in advising parents on administration of antibiotics. Objective To describe pharmacists' and pharmacy assistants' experiences with parents contacting a pharmacy for their febrile child, and to identify ways of improving medication management of these children. Setting Community pharmacies in the Netherlands. Method A qualitative study including 24 Dutch pharmacy employees was conducted, performing four focus group discussions among pharmacy employees. Analysis was based on constant comparative technique using open and axial coding. Main outcome measure Pharmacy employees' experiences with parents contacting a pharmacy for their febrile child. Results Three categories were identified: (1) workload and general experience, (2) inconsistent information on antibiotic prescriptions, (3) improving communication and collaboration. Pharmacy employees experienced that dosing errors in antibiotic prescriptions occur frequently and doctors provide inconsistent information on prescriptions. Consequently, they have to contact doctors, resulting in a higher workload for both stakeholders. They believe this can be improved by providing the indication for antibiotics on prescriptions, especially when deviating from standard dosages. Conclusion Pharmacy employees experience a high amount of dosing errors in paediatric antibiotic prescriptions. Providing the indication for antibiotics in febrile children on prescriptions, especially when deviating from standard dosages, can potentially reduce dosage errors and miscommunication between doctors and pharmacy employees.
-
NASA Astrophysics Data System (ADS)
Krynski, Jan; Zak, Lukasz; Ziolkowski, Dariusz; Cisak, Jan; Lagiewska, Magdalena
2017-06-01
Time series of weekly and daily solutions for coordinates of permanent GNSS stations may indicate local deformations in Earth's crust or local seasonal changes in the atmosphere and hydrosphere. The errors of the determined changes are relatively large, frequently at the level of the signal. Satellite radar interferometry and especially Persistent Scatterer Interferometry (PSI) is a method of a very high accuracy. Its weakness is a relative nature of measurements as well as accumulation of errors which may occur in the case of PSI processing of large areas. It is thus beneficial to confront the results of PSI measurements with those from other techniques, such as GNSS and precise levelling. PSI and GNSS results were jointly processed recreating the history of surface deformation of the area of Warsaw metropolitan with the use of radar images from Envisat and Cosmo-SkyMed satellites. GNSS data from Borowa Gora and Jozefoslaw observatories as well as from WAT1 and CBKA permanent GNSS stations were used to validate the obtained results. Observations from 2000-2015 were processed with the Bernese v.5.0 software. Relative height changes between the GNSS stations were determined from GNSS data and relative height changes between the persistent scatterers located on the objects with GNSS stations were determined from the interferometric results. The consistency of results of the two methods was 3 to 4 times better than the theoretical accuracy of each. The joint use of both methods allows to extract a very small height change below the level of measurement error.
-
Yin, Lishi; Fan, Ling; Tan, Renfu; Yang, Guangjing; Jiang, Fenglin; Zhang, Chao; Ma, Jun; Yan, Yang; Zou, Yanhong; Zhang, Yaowen; Wang, Yamei; Zhang, Guifang
2018-06-04
The purpose of this research is to identify the bowel symptoms and self-care strategies for rectal cancer survivors during the recovery process following low anterior resection surgery. A total of 100 participants were investigated under the structured interview guide based on the dimensions of "symptom management theory". 92% of participants reported changes in bowel habits, the most common being the frequent bowel movements and narrower stools, which we named it finger-shaped consistency stools. The 6 most frequently reported bowel symptoms were excessive flatus (93%), clustering (86%), urgency (77%), straining (62%), bowel frequency (57%) and anal pendant expansion (53%). Periodic bowel movements occurred in 19% participants. For a group of 79 participants at 6 to 24 months post-operation, 86.1% reported a significant improvement of bowel symptoms. Among 68 participants of this subgroup with significant improvements, 70.5% participants reported the length of time it took was at least 6 months. Self-care strategies adopted by participants included diet, bowel medications, practice management and exercise. It is necessary to educate patients on the symptoms experienced following low anterior resection surgery. Through the process of trial and error, participants have acquired self-care strategies. Healthcare professionals should learn knowledge of such strategies and help them build effective interventions.
-
The local enhancement conundrum: in search of the adaptive value of a social learning mechanism.
Arbilly, Michal; Laland, Kevin N
2014-02-01
Social learning mechanisms are widely thought to vary in their degree of complexity as well as in their prevalence in the natural world. While learning the properties of a stimulus that generalize to similar stimuli at other locations (stimulus enhancement) prima facie appears more useful to an animal than learning about a specific stimulus at a specific location (local enhancement), empirical evidence suggests that the latter is much more widespread in nature. Simulating populations engaged in a producer-scrounger game, we sought to deploy mathematical models to identify the adaptive benefits of reliance on local enhancement and/or stimulus enhancement, and the alternative conditions favoring their evolution. Surprisingly, we found that while stimulus enhancement readily evolves, local enhancement is advantageous only under highly restricted conditions: when generalization of information was made unreliable or when error in social learning was high. Our results generate a conundrum over how seemingly conflicting empirical and theoretical findings can be reconciled. Perhaps the prevalence of local enhancement in nature is due to stimulus enhancement costs independent of the learning task itself (e.g. predation risk), perhaps natural habitats are often characterized by unreliable yet highly rewarding payoffs, or perhaps local enhancement occurs less frequently, and stimulus enhancement more frequently, than widely believed. Copyright © 2013 Elsevier Inc. All rights reserved.
-
[Error analysis of functional articulation disorders in children].
Zhou, Qiao-juan; Yin, Heng; Shi, Bing
2008-08-01
To explore the clinical characteristic of functional articulation disorders in children and provide more evidence for differential diagnosis and speech therapy. 172 children with functional articulation disorders were grouped by age. Children aged 4-5 years were assigned to one group, and those aged 6-10 years were to another group. Their phonological samples were collected and analyzed. In the two groups, substitution and omission (deletion) were the mainly articulation errors in these children, dental consonants were the main wrong sounds, and bilabial and labio-dental were rarely wrong. In age 4-5 group, sequence according to the error frequency from the highest to lowest was dental, velar, lingual, apical, bilabial, and labio-dental. In age 6-10 group, the sequence was dental, lingual, apical, velar, bilabial, labio-dental. Lateral misarticulation and palatalized misarticulation occurred more often in age 6-10 group than age 4-5 group and were only found in lingual and dental consonants in two groups. Misarticulation of functional articulation disorders mainly occurs in dental and rarely in bilabial and labio-dental. Substitution and omission are the most often occurred errors. Lateral misarticulation and palatalized misarticulation occur mainly in lingual and dental consonants.
-
A study of the standard brain in Japanese children: morphological comparison with the MNI template.
Uchiyama, Hitoshi T; Seki, Ayumi; Tanaka, Daisuke; Koeda, Tatsuya; Jcs Group
2013-03-01
Functional magnetic resonance imaging (MRI) studies involve normalization so that the brains of different subjects can be described using the same coordinate system. However, standard brain templates, including the Montreal Neurological Institute (MNI) template that is most frequently used at present, were created based on the brains of Western adults. Because morphological characteristics of the brain differ by race and ethnicity and between adults and children, errors are likely to occur when data from the brains of non-Western individuals are processed using these templates. Therefore, this study was conducted to collect basic data for the creation of a Japanese pediatric standard brain. Participants in this study were 45 healthy children (contributing 65 brain images) between the ages of 6 and 9 years, who had nothing notable in their perinatal and other histories and neurological findings, had normal physical findings and cognitive function, exhibited no behavioral abnormalities, and provided analyzable MR images. 3D-T1-weighted images were obtained using a 1.5-T MRI device, and images from each child were adjusted to the reference image by affine transformation using SPM8. The lengths were measured and compared with those of the MNI template. The Western adult standard brain and the Japanese pediatric standard brain obtained in this study differed greatly in size, particularly along the anteroposterior diameter and in height, suggesting that the correction rates are high, and that errors are likely to occur in the normalization of pediatric brain images. We propose that the use of the Japanese pediatric standard brain created in this study will improve the accuracy of identification of brain regions in functional brain imaging studies involving children. Copyright © 2012 The Japanese Society of Child Neurology. Published by Elsevier B.V. All rights reserved.
-
McCoy, Rajiv C; Newnham, Louise J; Ottolini, Christian S; Hoffmann, Eva R; Chatzimeletiou, Katerina; Cornejo, Omar E; Zhan, Qiansheng; Zaninovic, Nikica; Rosenwaks, Zev; Petrov, Dmitri A; Demko, Zachary P; Sigurjonsson, Styrmir; Handyside, Alan H
2018-04-24
Aneuploidy is prevalent in human embryos and is the leading cause of pregnancy loss. Many aneuploidies arise during oogenesis, increasing with maternal age. Superimposed on these meiotic aneuploidies are frequent errors occurring during early mitotic divisions, contributing to widespread chromosomal mosaicism. Here we reanalyzed a published dataset comprising preimplantation genetic testing for aneuploidy in 24,653 blastomere biopsies from day-3 cleavage-stage embryos, as well as 17,051 trophectoderm biopsies from day-5 blastocysts. We focused on complex abnormalities that affected multiple chromosomes simultaneously, seeking insights into their formation. In addition to well-described patterns such as triploidy and haploidy, we identified 4.7% of blastomeres possessing characteristic hypodiploid karyotypes. We inferred this signature to have arisen from tripolar chromosome segregation in normally-fertilized diploid zygotes or their descendant diploid cells. This could occur via segregation on a tripolar mitotic spindle or by rapid sequential bipolar mitoses without an intervening S-phase. Both models are consistent with time-lapse data from an intersecting set of 77 cleavage-stage embryos, which were enriched for the tripolar signature among embryos exhibiting abnormal cleavage. The tripolar signature was strongly associated with common maternal genetic variants spanning the centrosomal regulator PLK4, driving the association we previously reported with overall mitotic errors. Our findings are consistent with the known capacity of PLK4 to induce tripolar mitosis or precocious M-phase upon dysregulation. Together, our data support tripolar chromosome segregation as a key mechanism generating complex aneuploidy in cleavage-stage embryos and implicate maternal genotype at a quantitative trait locus spanning PLK4 as a factor influencing its occurrence.
-
Ironic Effects of Drawing Attention to Story Errors
Eslick, Andrea N.; Fazio, Lisa K.; Marsh, Elizabeth J.
2014-01-01
Readers learn errors embedded in fictional stories and use them to answer later general knowledge questions (Marsh, Meade, & Roediger, 2003). Suggestibility is robust and occurs even when story errors contradict well-known facts. The current study evaluated whether suggestibility is linked to participants’ inability to judge story content as correct versus incorrect. Specifically, participants read stories containing correct and misleading information about the world; some information was familiar (making error discovery possible), while some was more obscure. To improve participants’ monitoring ability, we highlighted (in red font) a subset of story phrases requiring evaluation; readers no longer needed to find factual information. Rather, they simply needed to evaluate its correctness. Readers were more likely to answer questions with story errors if they were highlighted in red font, even if they contradicted well-known facts. Though highlighting to-be-evaluated information freed cognitive resources for monitoring, an ironic effect occurred: Drawing attention to specific errors increased rather than decreased later suggestibility. Failure to monitor for errors, not failure to identify the information requiring evaluation, leads to suggestibility. PMID:21294039
-
Failure analysis and modeling of a VAXcluster system
NASA Technical Reports Server (NTRS)
Tang, Dong; Iyer, Ravishankar K.; Subramani, Sujatha S.
1990-01-01
This paper discusses the results of a measurement-based analysis of real error data collected from a DEC VAXcluster multicomputer system. In addition to evaluating basic system dependability characteristics such as error and failure distributions and hazard rates for both individual machines and for the VAXcluster, reward models were developed to analyze the impact of failures on the system as a whole. The results show that more than 46 percent of all failures were due to errors in shared resources. This is despite the fact that these errors have a recovery probability greater than 0.99. The hazard rate calculations show that not only errors, but also failures occur in bursts. Approximately 40 percent of all failures occur in bursts and involved multiple machines. This result indicates that correlated failures are significant. Analysis of rewards shows that software errors have the lowest reward (0.05 vs 0.74 for disk errors). The expected reward rate (reliability measure) of the VAXcluster drops to 0.5 in 18 hours for the 7-out-of-7 model and in 80 days for the 3-out-of-7 model.
-
NASA Astrophysics Data System (ADS)
Doshida, S.
2014-12-01
Various types of a landslide, such as a deep-seated landslide, a shallow landslide, and a debris flow, exist. And the risk and the damage area of a landslide change greatly with the types. Therefore it is very important to guess the type of a landslide generated in the future, in order to decrease the damage of a landslide. In this research, I investigated and studied the landslide disaster which occurred in the typhoon No.12 disaster in 2011 and the northern Kyusyu-island heavy rain disaster 2012, in Japan. The purpose of the study presumes the types of a landslide generated in the future by analyzing geographical and geological features. Many deep-seated landslides and shallow landslides (debris flows) occurred by the typhoon No.12, 2011 in Japan. The precipitation exceeds 1,800 mm in four days in part regionally. Landslides occurred frequently in the Totsukawa area (Northern part) and Nachi-Katsuura area (Southern part), both area were the precipitation of about 1000 mm in four days. In the Totsukawa area, deep-seated landslides occurred frequently, and in Nachi-Katsuura area, shallow landslides (debris flows) occurred frequently. On the other hand, many deep-seated landslides and shallow landslides occurred by the northern Kyusyu-island heavy rain disaster 2012 in Japan too. Landslides occurred frequently in the Hoshino village area (Northern part) and Asodani area (Southern part). In both area, the total precipitation exceeds 500 mm and the hourly precipitation is about 80 mm. In the Hoshino village area, deep-seated landslides occurred frequently, and in Asodani area, shallow landslides occurred frequently. The result compared with the deep-seated landslide area (Totsukawa and Hoshino village) and the shallow landslide area (Nachi-Katsuura and Asodani), area of landslide is larger and number of landslide is fewer in the deep-seated landslide area. In the shallow landslide area, the slope is steeper and the drainage network is more developed. It is surmised that these geographical differentiations are the geographical features formed of the past landslide. Therefore, it is important to read and analyze the past landslide disaster hysteresis from geographical feature for specifying the type of a landslide.
-
[Monitoring medication errors in an internal medicine service].
Smith, Ann-Loren M; Ruiz, Inés A; Jirón, Marcela A
2014-01-01
Patients admitted to internal medicine services receive multiple drugs and thus are at risk of medication errors. To determine the frequency of medication errors (ME) among patients admitted to an internal medicine service of a high complexity hospital. A prospective observational study conducted in 225 patients admitted to an internal medicine service. Each stage of drug utilization system (prescription, transcription, dispensing, preparation and administration) was directly observed by trained pharmacists not related to hospital staff during three months. ME were described and categorized according to the National Coordinating Council for Medication Error Reporting and Prevention. In each stage of medication use, the frequency of ME and their characteristics were determined. A total of 454 drugs were prescribed to the studied patients. In 138 (30,4%) indications, at least one ME occurred, involving 67 (29,8%) patients. Twenty four percent of detected ME occurred during administration, mainly due to wrong time schedules. Anticoagulants were the therapeutic group with the highest occurrence of ME. At least one ME occurred in approximately one third of patients studied, especially during the administration stage. These errors could affect the medication safety and avoid achieving therapeutic goals. Strategies to improve the quality and safe use of medications can be implemented using this information.
-
An approach to develop an algorithm to detect the climbing height in radial-axial ring rolling
NASA Astrophysics Data System (ADS)
Husmann, Simon; Hohmann, Magnus; Kuhlenkötter, Bernd
2017-10-01
Radial-axial ring rolling is the mainly used forming process to produce seamless rings, which are applied in miscellaneous industries like the energy sector, the aerospace technology or in the automotive industry. Due to the simultaneously forming in two opposite rolling gaps and the fact that ring rolling is a mass forming process, different errors could occur during the rolling process. Ring climbing is one of the most occurring process errors leading to a distortion of the ring's cross section and a deformation of the rings geometry. The conventional sensors of a radial-axial rolling machine could not detect this error. Therefore, it is a common strategy to roll a slightly bigger ring, so that random occurring process errors could be reduce afterwards by removing the additional material. The LPS installed an image processing system to the radial rolling gap of their ring rolling machine to enable the recognition and measurement of climbing rings and by this, to reduce the additional material. This paper presents the algorithm which enables the image processing system to detect the error of a climbing ring and ensures comparable reliable results for the measurement of the climbing height of the rings.
-
Formulation of a strategy for monitoring control integrity in critical digital control systems
NASA Technical Reports Server (NTRS)
Belcastro, Celeste M.; Fischl, Robert; Kam, Moshe
1991-01-01
Advanced aircraft will require flight critical computer systems for stability augmentation as well as guidance and control that must perform reliably in adverse, as well as nominal, operating environments. Digital system upset is a functional error mode that can occur in electromagnetically harsh environments, involves no component damage, can occur simultaneously in all channels of a redundant control computer, and is software dependent. A strategy is presented for dynamic upset detection to be used in the evaluation of critical digital controllers during the design and/or validation phases of development. Critical controllers must be able to be used in adverse environments that result from disturbances caused by an electromagnetic source such as lightning, high intensity radiated field (HIRF), and nuclear electromagnetic pulses (NEMP). The upset detection strategy presented provides dynamic monitoring of a given control computer for degraded functional integrity that can result from redundancy management errors and control command calculation error that could occur in an electromagnetically harsh operating environment. The use is discussed of Kalman filtering, data fusion, and decision theory in monitoring a given digital controller for control calculation errors, redundancy management errors, and control effectiveness.
-
Errors Affect Hypothetical Intertemporal Food Choice in Women
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
-
ERIC Educational Resources Information Center
Deutsch, Avital; Dank, Maya
2011-01-01
A common characteristic of subject-predicate agreement errors (usually termed attraction errors) in complex noun phrases is an asymmetrical pattern of error distribution, depending on the inflectional state of the nouns comprising the complex noun phrase. That is, attraction is most likely to occur when the head noun is the morphologically…
-
ERIC Educational Resources Information Center
van den Bemt, P. M. L. A.; Robertz, R.; de Jong, A. L.; van Roon, E. N.; Leufkens, H. G. M.
2007-01-01
Background: Medication errors can result in harm, unless barriers to prevent them are present. Drug administration errors are less likely to be prevented, because they occur in the last stage of the drug distribution process. This is especially the case in non-alert patients, as patients often form the final barrier to prevention of errors.…
-
Prevalence and cost of hospital medical errors in the general and elderly United States populations.
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.
-
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.
-
Local rollback for fault-tolerance in parallel computing systems
Blumrich, Matthias A [Yorktown Heights, NY; Chen, Dong [Yorktown Heights, NY; Gara, Alan [Yorktown Heights, NY; Giampapa, Mark E [Yorktown Heights, NY; Heidelberger, Philip [Yorktown Heights, NY; Ohmacht, Martin [Yorktown Heights, NY; Steinmacher-Burow, Burkhard [Boeblingen, DE; Sugavanam, Krishnan [Yorktown Heights, NY
2012-01-24
A control logic device performs a local rollback in a parallel super computing system. The super computing system includes at least one cache memory device. The control logic device determines a local rollback interval. The control logic device runs at least one instruction in the local rollback interval. The control logic device evaluates whether an unrecoverable condition occurs while running the at least one instruction during the local rollback interval. The control logic device checks whether an error occurs during the local rollback. The control logic device restarts the local rollback interval if the error occurs and the unrecoverable condition does not occur during the local rollback interval.
-
Lehmann, Ashton E; Kozin, Elliott D; Sethi, Rosh K V; Wong, Kevin; Lin, Brian M; Gray, Stacey T; Cunningham, Michael J
2018-05-01
Otolaryngology residents are often responsible for triaging after-hours patient calls. However, residents receive little training on this topic. Data are limited on the clinical content, reporting, and management of otolaryngology patient calls. This study aimed to characterize the patient concerns residents handle by phone and their subsequent management and reporting. Retrospective review. Five hundred consecutive after-hours patient calls in a tertiary pediatric hospital were reviewed. Data collected included patient and caller demographics, clinical concerns, surgical history, recommendations, and subsequent emergency department (ED) visits. On average, 3.7 calls occurred per shift, 2.8 on weekday and 5.9 on weekend shifts. Mean patient age was 6.6 years. Mothers (71%) called most frequently. The majority of calls were postoperative (64.2%). Of postoperative calls, most occurred within 3 days of surgery (52.3%). Most calls were for surgical site bleeding (19.9%). Residents recommended ED evaluation for 17.2% of calls, of which 20.9% returned to the primary institution ED. ED evaluation was recommended more frequently for postoperative patients (P = .040), particularly following adenotonsillectomy (51.2%) or surgical site bleeding (18.6%). With respect to documentation, 32.8% of medical record numbers were absent, 11.8% had name errors, and 2.2% of patients could not be identified. This is the first study to analyze the management and reporting of patient calls by otolaryngology residents. A wide array of clinical concerns are triaged by phone conversations. The study has implications for both resident and patient education. 4. Laryngoscope, 128:E163-E170, 2018. © 2017 The American Laryngological, Rhinological and Otological Society, Inc.
-
Minimizing driver errors: examining factors leading to failed target tracking and detection.
DOT National Transportation Integrated Search
2013-06-01
Driving a motor vehicle is a common practice for many individuals. Although driving becomes : repetitive and a very habitual task, errors can occur that lead to accidents. One factor that can be a : cause for such errors is a lapse in attention or a ...
-
Nurses' Behaviors and Visual Scanning Patterns May Reduce Patient Identification Errors
ERIC Educational Resources Information Center
Marquard, Jenna L.; Henneman, Philip L.; He, Ze; Jo, Junghee; Fisher, Donald L.; Henneman, Elizabeth A.
2011-01-01
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)…
-
A systems approach to accident causation in mining: an application of the HFACS method.
Lenné, Michael G; Salmon, Paul M; Liu, Charles C; Trotter, Margaret
2012-09-01
This project aimed to provide a greater understanding of the systemic factors involved in mining accidents, and to examine those organisational and supervisory failures that are predictive of sub-standard performance at operator level. A sample of 263 significant mining incidents in Australia across 2007-2008 were analysed using the Human Factors Analysis and Classification System (HFACS). Two human factors specialists independently undertook the analysis. Incidents occurred more frequently in operations concerning the use of surface mobile equipment (38%) and working at heights (21%), however injury was more frequently associated with electrical operations and vehicles and machinery. Several HFACS categories appeared frequently: skill-based errors (64%) and violations (57%), issues with the physical environment (56%), and organisational processes (65%). Focussing on the overall system, several factors were found to predict the presence of failures in other parts of the system, including planned inappropriate operations and team resource management; inadequate supervision and team resource management; and organisational climate and inadequate supervision. It is recommended that these associations deserve greater attention in future attempts to develop accident countermeasures, although other significant associations should not be ignored. In accordance with findings from previous HFACS-based analyses of aviation and medical incidents, efforts to reduce the frequency of unsafe acts or operations should be directed to a few critical HFACS categories at the higher levels: organisational climate, planned inadequate operations, and inadequate supervision. While remedial strategies are proposed it is important that future efforts evaluate the utility of the measures proposed in studies of system safety. Copyright © 2011. Published by Elsevier Ltd.
-
High Quality Maize Centromere 10 Sequence Reveals Evidence of Frequent Recombination Events
Wolfgruber, Thomas K.; Nakashima, Megan M.; Schneider, Kevin L.; Sharma, Anupma; Xie, Zidian; Albert, Patrice S.; Xu, Ronghui; Bilinski, Paul; Dawe, R. Kelly; Ross-Ibarra, Jeffrey; Birchler, James A.; Presting, Gernot G.
2016-01-01
The ancestral centromeres of maize contain long stretches of the tandemly arranged CentC repeat. The abundance of tandem DNA repeats and centromeric retrotransposons (CR) has presented a significant challenge to completely assembling centromeres using traditional sequencing methods. Here, we report a nearly complete assembly of the 1.85 Mb maize centromere 10 from inbred B73 using PacBio technology and BACs from the reference genome project. The error rates estimated from overlapping BAC sequences are 7 × 10−6 and 5 × 10−5 for mismatches and indels, respectively. The number of gaps in the region covered by the reassembly was reduced from 140 in the reference genome to three. Three expressed genes are located between 92 and 477 kb from the inferred ancestral CentC cluster, which lies within the region of highest centromeric repeat density. The improved assembly increased the count of full-length CR from 5 to 55 and revealed a 22.7 kb segmental duplication that occurred approximately 121,000 years ago. Our analysis provides evidence of frequent recombination events in the form of partial retrotransposons, deletions within retrotransposons, chimeric retrotransposons, segmental duplications including higher order CentC repeats, a deleted CentC monomer, centromere-proximal inversions, and insertion of mitochondrial sequences. Double-strand DNA break (DSB) repair is the most plausible mechanism for these events and may be the major driver of centromere repeat evolution and diversity. In many cases examined here, DSB repair appears to be mediated by microhomology, suggesting that tandem repeats may have evolved to efficiently repair frequent DSBs in centromeres. PMID:27047500
-
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.
-
Linguistic Pattern Analysis of Misspellings of Typically Developing Writers in Grades 1 to 9
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
-
Some practical problems in implementing randomization.
Downs, Matt; Tucker, Kathryn; Christ-Schmidt, Heidi; Wittes, Janet
2010-06-01
While often theoretically simple, implementing randomization to treatment in a masked, but confirmable, fashion can prove difficult in practice. At least three categories of problems occur in randomization: (1) bad judgment in the choice of method, (2) design and programming errors in implementing the method, and (3) human error during the conduct of the trial. This article focuses on these latter two types of errors, dealing operationally with what can go wrong after trial designers have selected the allocation method. We offer several case studies and corresponding recommendations for lessening the frequency of problems in allocating treatment or for mitigating the consequences of errors. Recommendations include: (1) reviewing the randomization schedule before starting a trial, (2) being especially cautious of systems that use on-demand random number generators, (3) drafting unambiguous randomization specifications, (4) performing thorough testing before entering a randomization system into production, (5) maintaining a dataset that captures the values investigators used to randomize participants, thereby allowing the process of treatment allocation to be reproduced and verified, (6) resisting the urge to correct errors that occur in individual treatment assignments, (7) preventing inadvertent unmasking to treatment assignments in kit allocations, and (8) checking a sample of study drug kits to allow detection of errors in drug packaging and labeling. Although we performed a literature search of documented randomization errors, the examples that we provide and the resultant recommendations are based largely on our own experience in industry-sponsored clinical trials. We do not know how representative our experience is or how common errors of the type we have seen occur. Our experience underscores the importance of verifying the integrity of the treatment allocation process before and during a trial. Clinical Trials 2010; 7: 235-245. http://ctj.sagepub.com.
-
Dual processing and diagnostic errors.
Norman, Geoff
2009-09-01
In this paper, I review evidence from two theories in psychology relevant to diagnosis and diagnostic errors. "Dual Process" theories of thinking, frequently mentioned with respect to diagnostic error, propose that categorization decisions can be made with either a fast, unconscious, contextual process called System 1 or a slow, analytical, conscious, and conceptual process, called System 2. Exemplar theories of categorization propose that many category decisions in everyday life are made by unconscious matching to a particular example in memory, and these remain available and retrievable individually. I then review studies of clinical reasoning based on these theories, and show that the two processes are equally effective; System 1, despite its reliance in idiosyncratic, individual experience, is no more prone to cognitive bias or diagnostic error than System 2. Further, I review evidence that instructions directed at encouraging the clinician to explicitly use both strategies can lead to consistent reduction in error rates.
-
Noise in two-color electronic distance meter measurements revisited
Langbein, J.
2004-01-01
Frequent, high-precision geodetic data have temporally correlated errors. Temporal correlations directly affect both the estimate of rate and its standard error; the rate of deformation is a key product from geodetic measurements made in tectonically active areas. Various models of temporally correlated errors are developed and these provide relations between the power spectral density and the data covariance matrix. These relations are applied to two-color electronic distance meter (EDM) measurements made frequently in California over the past 15-20 years. Previous analysis indicated that these data have significant random walk error. Analysis using the noise models developed here indicates that the random walk model is valid for about 30% of the data. A second 30% of the data can be better modeled with power law noise with a spectral index between 1 and 2, while another 30% of the data can be modeled with a combination of band-pass-filtered plus random walk noise. The remaining 10% of the data can be best modeled as a combination of band-pass-filtered plus power law noise. This band-pass-filtered noise is a product of an annual cycle that leaks into adjacent frequency bands. For time spans of more than 1 year these more complex noise models indicate that the precision in rate estimates is better than that inferred by just the simpler, random walk model of noise.
-
Claims for compensation after alleged birth asphyxia: a nationwide study covering 15 years.
Andreasen, Stine; Backe, Bjørn; Øian, Pål
2014-02-01
To analyze compensation claims with neurological sequela or death following alleged birth asphyxia. A cohort study. A nationwide study in Norway. All claims made to The Norwegian System of Compensation to Patients (NPE) concerning sequela related to alleged birth asphyxia, between 1994 and 2008. A total of 315 claims of which 161 were awarded compensation. Examination of hospital records, experts' assessments and the decisions made by the NPE, the appeal body and courts of law. Characteristics of deliveries resulting in intrapartum asphyxia and causes of substandard care categorized in eight groups. In the 161 compensated cases, 107 children survived (96 with neurological sequela), and 54 children died. Human error was a frequent reason of substandard care, seen as inadequate fetal monitoring (50%), lack of clinical knowledge and skills (14%), noncompliance with clinical guidelines (11%), failure in referral for senior medical help (10%) and error in drug administration (4%). System errors were registered in only 3%, seen as poor organization of the department, lack of guidelines and time conflicts. The health personnel held responsible for substandard care was an obstetrician in 49% and a midwife in 46%. Substandard care is common in birth asphyxia, and human error is the cause in most cases. Inadequate fetal monitoring and lack of clinical knowledge and skills are the most frequent reasons for compensation after birth asphyxia. © 2013 Nordic Federation of Societies of Obstetrics and Gynecology.
-
Clinical Dental Faculty Members' Perceptions of Diagnostic Errors and How to Avoid Them.
Nikdel, Cathy; Nikdel, Kian; Ibarra-Noriega, Ana; Kalenderian, Elsbeth; Walji, Muhammad F
2018-04-01
Diagnostic errors are increasingly recognized as a source of preventable harm in medicine, yet little is known about their occurrence in dentistry. The aim of this study was to gain a deeper understanding of clinical dental faculty members' perceptions of diagnostic errors, types of errors that may occur, and possible contributing factors. The authors conducted semi-structured interviews with ten domain experts at one U.S. dental school in May-August 2016 about their perceptions of diagnostic errors and their causes. The interviews were analyzed using an inductive process to identify themes and key findings. The results showed that the participants varied in their definitions of diagnostic errors. While all identified missed diagnosis and wrong diagnosis, only four participants perceived that a delay in diagnosis was a diagnostic error. Some participants perceived that an error occurs only when the choice of treatment leads to harm. Contributing factors associated with diagnostic errors included the knowledge and skills of the dentist, not taking adequate time, lack of communication among colleagues, and cognitive biases such as premature closure based on previous experience. Strategies suggested by the participants to prevent these errors were taking adequate time when investigating a case, forming study groups, increasing communication, and putting more emphasis on differential diagnosis. These interviews revealed differing perceptions of dental diagnostic errors among clinical dental faculty members. To address the variations, the authors recommend adopting shared language developed by the medical profession to increase understanding.
-
... retina, at the back of your eye. A refractive error If either your cornea or lens is egg ... too close to the television or squinting. Other refractive errors Astigmatism may occur in combination with other refractive ...
-
Reducing Wrong Patient Selection Errors: Exploring the Design Space of User Interface Techniques
Sopan, Awalin; Plaisant, Catherine; Powsner, Seth; Shneiderman, Ben
2014-01-01
Wrong patient selection errors are a major issue for patient safety; from ordering medication to performing surgery, the stakes are high. Widespread adoption of Electronic Health Record (EHR) and Computerized Provider Order Entry (CPOE) systems makes patient selection using a computer screen a frequent task for clinicians. Careful design of the user interface can help mitigate the problem by helping providers recall their patients’ identities, accurately select their names, and spot errors before orders are submitted. We propose a catalog of twenty seven distinct user interface techniques, organized according to a task analysis. An associated video demonstrates eighteen of those techniques. EHR designers who consider a wider range of human-computer interaction techniques could reduce selection errors, but verification of efficacy is still needed. PMID:25954415
-
Using mobile devices to improve the safety of medication administration processes.
Navas, H; Graffi Moltrasio, L; Ares, F; Strumia, G; Dourado, E; Alvarez, M
2015-01-01
Within preventable medical errors, those related to medications are frequent in every stage of the prescribing cycle. Nursing is responsible for maintaining each patients safety and care quality. Moreover, nurses are the last people who can detect an error in medication before its administration. Medication administration is one of the riskiest tasks in nursing. The use of information and communication technologies is related to a decrease in these errors. Including mobile devices related to 2D code reading of patients and medication will decrease the possibility of error when preparing and administering medication by nurses. A cross-platform software (iOS and Android) was developed to ensure the five Rights of the medication administration process (patient, medication, dose, route and schedule). Deployment in November showed 39% use.
-
Reducing wrong patient selection errors: exploring the design space of user interface techniques.
Sopan, Awalin; Plaisant, Catherine; Powsner, Seth; Shneiderman, Ben
2014-01-01
Wrong patient selection errors are a major issue for patient safety; from ordering medication to performing surgery, the stakes are high. Widespread adoption of Electronic Health Record (EHR) and Computerized Provider Order Entry (CPOE) systems makes patient selection using a computer screen a frequent task for clinicians. Careful design of the user interface can help mitigate the problem by helping providers recall their patients' identities, accurately select their names, and spot errors before orders are submitted. We propose a catalog of twenty seven distinct user interface techniques, organized according to a task analysis. An associated video demonstrates eighteen of those techniques. EHR designers who consider a wider range of human-computer interaction techniques could reduce selection errors, but verification of efficacy is still needed.
-
Evaluating the accuracy and large inaccuracy of two continuous glucose monitoring systems.
Leelarathna, Lalantha; Nodale, Marianna; Allen, Janet M; Elleri, Daniela; Kumareswaran, Kavita; Haidar, Ahmad; Caldwell, Karen; Wilinska, Malgorzata E; Acerini, Carlo L; Evans, Mark L; Murphy, Helen R; Dunger, David B; Hovorka, Roman
2013-02-01
This study evaluated the accuracy and large inaccuracy of the Freestyle Navigator (FSN) (Abbott Diabetes Care, Alameda, CA) and Dexcom SEVEN PLUS (DSP) (Dexcom, Inc., San Diego, CA) continuous glucose monitoring (CGM) systems during closed-loop studies. Paired CGM and plasma glucose values (7,182 data pairs) were collected, every 15-60 min, from 32 adults (36.2±9.3 years) and 20 adolescents (15.3±1.5 years) with type 1 diabetes who participated in closed-loop studies. Levels 1, 2, and 3 of large sensor error with increasing severity were defined according to absolute relative deviation greater than or equal to ±40%, ±50%, and ±60% at a reference glucose level of ≥6 mmol/L or absolute deviation greater than or equal to ±2.4 mmol/L,±3.0 mmol/L, and ±3.6 mmol/L at a reference glucose level of <6 mmol/L. Median absolute relative deviation was 9.9% for FSN and 12.6% for DSP. Proportions of data points in Zones A and B of Clarke error grid analysis were similar (96.4% for FSN vs. 97.8% for DSP). Large sensor over-reading, which increases risk of insulin over-delivery and hypoglycemia, occurred two- to threefold more frequently with DSP than FSN (once every 2.5, 4.6, and 10.7 days of FSN use vs. 1.2, 2.0, and 3.7 days of DSP use for Level 1-3 errors, respectively). At levels 2 and 3, large sensor errors lasting 1 h or longer were absent with FSN but persisted with DSP. FSN and DSP differ substantially in the frequency and duration of large inaccuracy despite only modest differences in conventional measures of numerical and clinical accuracy. Further evaluations are required to confirm that FSN is more suitable for integration into closed-loop delivery systems.
-
Comparing K-mer based methods for improved classification of 16S sequences.
Vinje, Hilde; Liland, Kristian Hovde; Almøy, Trygve; Snipen, Lars
2015-07-01
The need for precise and stable taxonomic classification is highly relevant in modern microbiology. Parallel to the explosion in the amount of sequence data accessible, there has also been a shift in focus for classification methods. Previously, alignment-based methods were the most applicable tools. Now, methods based on counting K-mers by sliding windows are the most interesting classification approach with respect to both speed and accuracy. Here, we present a systematic comparison on five different K-mer based classification methods for the 16S rRNA gene. The methods differ from each other both in data usage and modelling strategies. We have based our study on the commonly known and well-used naïve Bayes classifier from the RDP project, and four other methods were implemented and tested on two different data sets, on full-length sequences as well as fragments of typical read-length. The difference in classification error obtained by the methods seemed to be small, but they were stable and for both data sets tested. The Preprocessed nearest-neighbour (PLSNN) method performed best for full-length 16S rRNA sequences, significantly better than the naïve Bayes RDP method. On fragmented sequences the naïve Bayes Multinomial method performed best, significantly better than all other methods. For both data sets explored, and on both full-length and fragmented sequences, all the five methods reached an error-plateau. We conclude that no K-mer based method is universally best for classifying both full-length sequences and fragments (reads). All methods approach an error plateau indicating improved training data is needed to improve classification from here. Classification errors occur most frequent for genera with few sequences present. For improving the taxonomy and testing new classification methods, the need for a better and more universal and robust training data set is crucial.
-
Sensitivity and specificity of dosing alerts for dosing errors among hospitalized pediatric patients
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
-
L2 Spelling Errors in Italian Children with Dyslexia.
Palladino, Paola; Cismondo, Dhebora; Ferrari, Marcella; Ballagamba, Isabella; Cornoldi, Cesare
2016-05-01
The present study aimed to investigate L2 spelling skills in Italian children by administering an English word dictation task to 13 children with dyslexia (CD), 13 control children (comparable in age, gender, schooling and IQ) and a group of 10 children with an English learning difficulty, but no L1 learning disorder. Patterns of difficulties were examined for accuracy and type of errors, in spelling dictated short and long words (i.e. disyllables and three syllables). Notably, CD were poor in spelling English words. Furthermore, their errors were mainly related with phonological representation of words, as they made more 'phonologically' implausible errors than controls. In addition, CD errors were more frequent for short than long words. Conversely, the three groups did not differ in the number of plausible ('non-phonological') errors, that is, words that were incorrectly written, but whose reading could correspond to the dictated word via either Italian or English rules. Error analysis also showed syllable position differences in the spelling patterns of CD, children with and English learning difficulty and control children. Copyright © 2016 John Wiley & Sons, Ltd. Copyright © 2016 John Wiley & Sons, Ltd.
-
Kraemer, Sara; Carayon, Pascale
2007-03-01
This paper describes human errors and violations of end users and network administration in computer and information security. This information is summarized in a conceptual framework for examining the human and organizational factors contributing to computer and information security. This framework includes human error taxonomies to describe the work conditions that contribute adversely to computer and information security, i.e. to security vulnerabilities and breaches. The issue of human error and violation in computer and information security was explored through a series of 16 interviews with network administrators and security specialists. The interviews were audio taped, transcribed, and analyzed by coding specific themes in a node structure. The result is an expanded framework that classifies types of human error and identifies specific human and organizational factors that contribute to computer and information security. Network administrators tended to view errors created by end users as more intentional than unintentional, while errors created by network administrators as more unintentional than intentional. Organizational factors, such as communication, security culture, policy, and organizational structure, were the most frequently cited factors associated with computer and information security.
-
Error detection and reduction in blood banking.
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.
-
Effects of Programmed Teaching Errors on Acquisition and Durability of Self-Care Skills
ERIC Educational Resources Information Center
Donnelly, Maeve G.; Karsten, Amanda M.
2017-01-01
This investigation sheds light on necessary and sufficient conditions to establish self-care behavior chains among people with developmental disabilities. First, a descriptive assessment (DA) identified the types of teaching errors that occurred during self-care instruction. Second, the relative effects of three teaching errors observed during the…
-
An Evaluation of Programmed Treatment-integrity Errors during Discrete-trial Instruction
ERIC Educational Resources Information Center
Carroll, Regina A.; Kodak, Tiffany; Fisher, Wayne W.
2013-01-01
This study evaluated the effects of programmed treatment-integrity errors on skill acquisition for children with an autism spectrum disorder (ASD) during discrete-trial instruction (DTI). In Study 1, we identified common treatment-integrity errors that occur during academic instruction in schools. In Study 2, we simultaneously manipulated 3…
-
Kaplan, H S
2005-11-01
Safety and reliability in blood transfusion are not static, but are dynamic non-events. Since performance deviations continually occur in complex systems, their detection and correction must be accomplished over and over again. Non-conformance must be detected early enough to allow for recovery or mitigation. Near-miss events afford early detection of possible system weaknesses and provide an early chance at correction. National event reporting systems, both voluntary and involuntary, have begun to include near-miss reporting in their classification schemes, raising awareness for their detection. MERS-TM is a voluntary safety reporting initiative in transfusion. Currently 22 hospitals submit reports anonymously to a central database which supports analysis of a hospital's own data and that of an aggregate database. The system encourages reporting of near-miss events, where the patient is protected from receiving an unsuitable or incorrect blood component due to a planned or unplanned recovery step. MERS-TM data suggest approximately 90% of events are near-misses, with 10% caught after issue but before transfusion. Near-miss reporting may increase total reports ten-fold. The ratio of near-misses to events with harm is 339:1, consistent with other industries' ratio of 300:1, which has been proposed as a measure of reporting in event reporting systems. Use of a risk matrix and an event's relation to protective barriers allow prioritization of these events. Near-misses recovered by planned barriers occur ten times more frequently then unplanned recoveries. A bedside check of the patient's identity with that on the blood component is an essential, final barrier. How the typical two person check is performed, is critical. Even properly done, this check is ineffective against sampling and testing errors. Blood testing at bedside just prior to transfusion minimizes the risk of such upstream events. However, even with simple and well designed devices, training may be a critical issue. Sample errors account for more than half of reported events. The most dangerous miscollection is a blood sample passing acceptance with no previous patient results for comparison. Bar code labels or collection of a second sample may counter this upstream vulnerability. Further upstream barriers have been proposed to counter the precariousness of urgent blood sample collection in a changing unstable situation. One, a linking device, allows safer labeling of tubes away from the bedside, the second, a forcing function, prevents omission of critical patient identification steps. Errors in the blood bank itself account for 15% of errors with a high potential severity. In one such event, a component incorrectly issued, but safely detected prior to transfusion, focused attention on multitasking's contribution to laboratory error. In sum, use of near-miss information, by enhancing barriers supporting error prevention and mitigation, increases our capacity to get the right blood to the right patient.
-
McKaig, Donald; Collins, Christine; Elsaid, Khaled A
2014-09-01
A study was conducted to evaluate the impact of a reengineered approach to electronic error reporting at a 719-bed multidisciplinary urban medical center. The main outcome of interest was the monthly reported medication errors during the preimplementation (20 months) and postimplementation (26 months) phases. An interrupted time series analysis was used to describe baseline errors, immediate change following implementation of the current electronic error-reporting system (e-ERS), and trend of error reporting during postimplementation. Errors were categorized according to severity using the National Coordinating Council for Medication Error Reporting and Prevention (NCC MERP) Medication Error Index classifications. Reported errors were further analyzed by reporter and error site. During preimplementation, the monthly reported errors mean was 40.0 (95% confidence interval [CI]: 36.3-43.7). Immediately following e-ERS implementation, monthly reported errors significantly increased by 19.4 errors (95% CI: 8.4-30.5). The change in slope of reported errors trend was estimated at 0.76 (95% CI: 0.07-1.22). Near misses and no-patient-harm errors accounted for 90% of all errors, while errors that caused increased patient monitoring or temporary harm accounted for 9% and 1%, respectively. Nurses were the most frequent reporters, while physicians were more likely to report high-severity errors. Medical care units accounted for approximately half of all reported errors. Following the intervention, there was a significant increase in reporting of prevented errors and errors that reached the patient with no resultant harm. This improvement in reporting was sustained for 26 months and has contributed to designing and implementing quality improvement initiatives to enhance the safety of the medication use process.
-
Polythelia associated with disturbances of cardiac conduction.
Máté, K; Horváth, J; Schmidt, J; Kulcsár, M; Erdei, M; Bálint, Z S; Nagy, M
1979-01-01
The authors examined three groups of persons (hospitalized patients, outpatients, and school girls) and conclude that in the cases of polythelia the cardiac conduction disturbances occur considerably more frequently than in persons without polythelia. When polythelia and conduction disturbances occur frequently in a family, the coexistence of both disorders is most probably of hereditary origin.
-
[Errors in prescriptions and their preparation at the outpatient pharmacy of a regional hospital].
Alvarado A, Carolina; Ossa G, Ximena; Bustos M, Luis
2017-01-01
Adverse effects of medications are an important cause of morbidity and hospital admissions. Errors in prescription or preparation of medications by pharmacy personnel are a factor that may influence these occurrence of the adverse effects Aim: To assess the frequency and type of errors in prescriptions and in their preparation at the pharmacy unit of a regional public hospital. Prescriptions received by ambulatory patients and those being discharged from the hospital, were reviewed using a 12-item checklist. The preparation of such prescriptions at the pharmacy unit was also reviewed using a seven item checklist. Seventy two percent of prescriptions had at least one error. The most common mistake was the impossibility of determining the concentration of the prescribed drug. Prescriptions for patients being discharged from the hospital had the higher number of errors. When a prescription had more than two drugs, the risk of error increased 2.4 times. Twenty four percent of prescription preparations had at least one error. The most common mistake was the labeling of drugs with incomplete medical indications. When a preparation included more than three drugs, the risk of preparation error increased 1.8 times. Prescription and preparation of medication delivered to patients had frequent errors. The most important risk factor for errors was the number of drugs prescribed.
-
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
-
Mudge, Joseph F; Penny, Faith M; Houlahan, Jeff E
2012-12-01
Setting optimal significance levels that minimize Type I and Type II errors allows for more transparent and well-considered statistical decision making compared to the traditional α = 0.05 significance level. We use the optimal α approach to re-assess conclusions reached by three recently published tests of the pace-of-life syndrome hypothesis, which attempts to unify occurrences of different physiological, behavioral, and life history characteristics under one theory, over different scales of biological organization. While some of the conclusions reached using optimal α were consistent to those previously reported using the traditional α = 0.05 threshold, opposing conclusions were also frequently reached. The optimal α approach reduced probabilities of Type I and Type II errors, and ensured statistical significance was associated with biological relevance. Biologists should seriously consider their choice of α when conducting null hypothesis significance tests, as there are serious disadvantages with consistent reliance on the traditional but arbitrary α = 0.05 significance level. Copyright © 2012 WILEY Periodicals, Inc.
-
Effect of temporal sampling and timing for soil moisture measurements at field scale
NASA Astrophysics Data System (ADS)
Snapir, B.; Hobbs, S.
2012-04-01
Estimating soil moisture at field scale is valuable for various applications such as irrigation scheduling in cultivated watersheds, flood and drought prediction, waterborne disease spread assessment, or even determination of mobility with lightweight vehicles. Synthetic aperture radar on satellites in low Earth orbit can provide fine resolution images with a repeat time of a few days. For an Earth observing satellite, the choice of the orbit is driven in particular by the frequency of measurements required to meet a certain accuracy in retrieving the parameters of interest. For a given target, having only one image every week may not enable to capture the full dynamic range of soil moisture - soil moisture can change significantly within a day when rainfall occurs. Hence this study focuses on the effect of temporal sampling and timing of measurements in terms of error on the retrieved signal. All the analyses are based on in situ measurements of soil moisture (acquired every 30 min) from the OzNet Hydrological Monitoring Network in Australia for different fields over several years. The first study concerns sampling frequency. Measurements at different frequencies were simulated by sub-sampling the original data. Linear interpolation was used to estimate the missing intermediate values, and then this time series was compared to the original. The difference between these two signals is computed for different levels of sub-sampling. Results show that the error increases linearly when the interval is less than 1 day. For intervals longer than a day, a sinusoidal component appears on top of the linear growth due to the diurnal variation of surface soil moisture. Thus, for example, the error with measurements every 4.5 days can be slightly less than the error with measurements every 2 days. Next, for a given sampling interval, this study evaluated the effect of the time during the day at which measurements are made. Of course when measurements are very frequent the time of acquisition does not matter, but when few measurements are available (sampling interval > 1 day), the time of acquisition can be important. It is shown that with daily measurements the error can double depending on the time of acquisition. This result is very sensitive to the phase of the sinusoidal variation of soil moisture. For example, in autumn for a given field with soil moisture ranging from 7.08% to 11.44% (mean and standard deviation being respectively 8.68% and 0.74%), daily measurements at 2 pm lead to a mean error of 0.47% v/v, while daily measurements at 9 am/pm produce a mean error of 0.24% v/v. The minimum of the sinusoid occurs every afternoon around 2 pm, after interpolation, measurements acquired at this time underestimate soil moisture, whereas measurements around 9 am/pm correspond to nodes of the sinusoid, hence they represent the average soil moisture. These results concerning the frequency and the timing of measurements can potentially drive the schedule of satellite image acquisition over some fields.
-
How often are spectacle lenses not dispensed as prescribed?
Mohan, Kanwar; Sharma, Ashok
2012-01-01
Spectacles are routinely prescribed by the ophthalmologist and dispensed by the opticians. We investigated how frequently the spectacles are not dispensed as prescribed and whether the frequency of inaccurate spectacles would decrease if the patients, at the time of collecting spectacles, ask the optician to verify that the spectacles have been dispensed accurately. We found inaccurate spectacles in about one-third of our patients and incorrect spherocylinders more frequently with an error in the spherical element and cylinder axis. These inaccuracies decreased significantly when patients while collecting spectacles, asked the optician to verify the accuracy of the spectacles dispensed. It is suggested that while prescribing spectacles, the patients should be made aware of the possibility of dispensing errors. To decrease the frequency of incorrect spectacles, the patients while collecting spectacles, should ask the optician to check whether the spectacles have been dispensed accurately.
-
Facial lacerations in children.
Hwang, Kun; Huan, Fan; Hwang, Pil Joong; Sohn, In Ah
2013-03-01
The aim of this study was to evaluate the demographics and treatment of facial lacerations in pediatric patients. A retrospective record-based analysis was administered on 3783 patients (<15 years of age) presenting with facial lacerations from March 2002 to February 2011. Males were injured more frequently across all age groups (65.3%) and especially in the 13- to 15-year-old group (81.3%) (P = 0.012, Pearson χ). Overall, 48.9% of injuries occurred outdoors and 45.1% in homes. Only 6.0% occurred in schools or kindergartens. Injuries that occurred in schools or kindergarten increased with the age groups (from 2.3% for 0- to 3-year-olds to 19.1% for 13- to 15-year-olds). In the age groups younger than 12 years, injury occurred more frequently on the weekend. In the 13-to 15-year-old group, however, injury occurred more frequently on weekdays (odds ratio, 2.46). Injury occurred most frequently at the times of 7 to 9 PM and least frequently from midnight to 6 AM. The most frequent cause of injury in children was by being struck or by bumping something (32.5%), followed by slip-down (31.5%). Accidents involving furniture and stairs accounted for 9% each. Accidents caused by stairs decreased with age (from 10.2% for 0-3 years of age to 5.5% for 13-15 years of age, P = 0.000, Pearson χ). In a little less than half (47.2%) of the cases, parents accompanied their children at the time of injury. In the 13- to 15-year age group, only 17.9% of the children were accompanied by their parents. Foreheads (26.4%) took the brunt of most frequent injuries, followed by the eyelids (20.6%), eyebrows including the glabella (19.7%), and chin injuries (15.7%). Only 58 cases had associated injuries. Among 3783 cases of facial lacerations, 3745 patients did not have facial bone fractures or associated injuries and were managed under local anesthesia or through dressings only. A sound knowledge about the epidemiology of lacerations might be beneficial for the prevention of pediatric facial lacerations, which occurs more frequently than facial fractures. It is noteworthy that slip-down showed a peak in kindergarteners (4-6 years, 36.1%) and then decreased with age. The incidence of slip-down might be reduced if attention is paid when the kindergarteners are walking on steep stairs or steep flights of stairs. Injury at the educational institutions increases with the pupil's age, and therefore safety management in schools is important.
-
The Structure of Segmental Errors in the Speech of Deaf Children.
ERIC Educational Resources Information Center
Levitt, H.; And Others
1980-01-01
A quantitative description of the segmental errors occurring in the speech of deaf children is developed. Journal availability: Elsevier North Holland, Inc., 52 Vanderbilt Avenue, New York, NY 10017. (Author)
-
Method, apparatus and system to compensate for drift by physically unclonable function circuitry
Hamlet, Jason
2016-11-22
Techniques and mechanisms to detect and compensate for drift by a physically uncloneable function (PUF) circuit. In an embodiment, first state information is registered as reference information to be made available for subsequent evaluation of whether drift by PUF circuitry has occurred. The first state information is associated with a first error correction strength. The first state information is generated based on a first PUF value output by the PUF circuitry. In another embodiment, second state information is determined based on a second PUF value that is output by the PUF circuitry. An evaluation of whether drift has occurred is performed based on the first state information and the second state information, the evaluation including determining whether a threshold error correction strength is exceeded concurrent with a magnitude of error being less than the first error correction strength.
-
Evaluation of Parenteral Nutrition Errors in an Era of Drug Shortages.
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.
-
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.
-
Effects of learning climate and registered nurse staffing on medication errors.
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.
-
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.
-
Error begat error: design error analysis and prevention in social infrastructure projects.
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.
-
Computerized N-acetylcysteine physician order entry by template protocol for acetaminophen toxicity.
Thompson, Trevonne M; Lu, Jenny J; Blackwood, Louisa; Leikin, Jerrold B
2011-01-01
Some medication dosing protocols are logistically complex for traditional physician ordering. The use of computerized physician order entry (CPOE) with templates, or order sets, may be useful to reduce medication administration errors. This study evaluated the rate of medication administration errors using CPOE order sets for N-acetylcysteine (NAC) use in treating acetaminophen poisoning. An 18-month retrospective review of computerized inpatient pharmacy records for NAC use was performed. All patients who received NAC for the treatment of acetaminophen poisoning were included. Each record was analyzed to determine the form of NAC given and whether an administration error occurred. In the 82 cases of acetaminophen poisoning in which NAC was given, no medication administration errors were identified. Oral NAC was given in 31 (38%) cases; intravenous NAC was given in 51 (62%) cases. In this retrospective analysis of N-acetylcysteine administration using computerized physician order entry and order sets, no medication administration errors occurred. CPOE is an effective tool in safely executing complicated protocols in an inpatient setting.
-
Smoked cannabis' psychomotor and neurocognitive effects in occasional and frequent smokers.
Desrosiers, Nathalie A; Ramaekers, Johannes G; Chauchard, Emeline; Gorelick, David A; Huestis, Marilyn A
2015-05-01
Δ9-Tetrahydrocannabinol (THC), the primary psychoactive constituent in cannabis, impairs psychomotor performance, cognition and driving ability; thus, driving under the influence of cannabis is a public safety concern. We documented cannabis' psychomotor, neurocognitive, subjective and physiological effects in occasional and frequent smokers to investigate potential differences between these smokers. Fourteen frequent (≥4x/week) and 11 occasional (<2x/week) cannabis smokers entered a secure research unit ∼19 h prior to smoking one 6.8% THC cigarette. Cognitive and psychomotor performance was evaluated with the critical tracking (CTT), divided attention (DAT), n-back (working memory) and Balloon Analog Risk (BART) (risk-taking) tasks at -1.75, 1.5, 3.5, 5.5 and 22.5 h after starting smoking. GLM (General Linear Model) repeated measures ANOVA was utilized to compare scores. Occasional smokers had significantly more difficulty compensating for CTT tracking error compared with frequent smokers 1.5 h after smoking. Divided attention performance declined significantly especially in occasional smokers, with session × group effects for tracking error, hits, false alarms and reaction time. Cannabis smoking did not elicit session × group effects on the n-back or BART. Controlled cannabis smoking impaired psychomotor function, more so in occasional smokers, suggesting some tolerance to psychomotor impairment in frequent users. These data have implications for cannabis-associated impairment in driving under the influence of cannabis cases. Published by Oxford University Press 2015. This work is written by (a) US Government employee(s) and is in the public domain in the US.
-
Quality in laboratory medicine: 50years on.
Plebani, Mario
2017-02-01
The last 50years have seen substantial changes in the landscape of laboratory medicine: its role in modern medicine is in evolution and the quality of laboratory services is changing. The need to control and improve quality in clinical laboratories has grown hand in hand with the growth in technological developments leading to an impressive reduction of analytical errors over time. An essential cause of this impressive improvement has been the introduction and monitoring of quality indicators (QIs) such as the analytical performance specifications (in particular bias and imprecision) based on well-established goals. The evolving landscape of quality and errors in clinical laboratories moved first from analytical errors to all errors performed within the laboratory walls, subsequently to errors in laboratory medicine (including errors in test requesting and result interpretation), and finally, to a focus on errors more frequently associated with adverse events (laboratory-associated errors). After decades in which clinical laboratories have focused on monitoring and improving internal indicators of analytical quality, efficiency and productivity, it is time to shift toward indicators of total quality, clinical effectiveness and patient outcomes. Copyright © 2016 The Canadian Society of Clinical Chemists. Published by Elsevier Inc. All rights reserved.
-
Analysis of pork adulteration in beef meatball using Fourier transform infrared (FTIR) spectroscopy.
Rohman, A; Sismindari; Erwanto, Y; Che Man, Yaakob B
2011-05-01
Meatball is one of the favorite foods in Indonesia. The adulteration of pork in beef meatball is frequently occurring. This study was aimed to develop a fast and non destructive technique for the detection and quantification of pork in beef meatball using Fourier transform infrared (FTIR) spectroscopy and partial least square (PLS) calibration. The spectral bands associated with pork fat (PF), beef fat (BF), and their mixtures in meatball formulation were scanned, interpreted, and identified by relating them to those spectroscopically representative to pure PF and BF. For quantitative analysis, PLS regression was used to develop a calibration model at the selected fingerprint regions of 1200-1000 cm(-1). The equation obtained for the relationship between actual PF value and FTIR predicted values in PLS calibration model was y = 0.999x + 0.004, with coefficient of determination (R(2)) and root mean square error of calibration are 0.999 and 0.442, respectively. The PLS calibration model was subsequently used for the prediction of independent samples using laboratory made meatball samples containing the mixtures of BF and PF. Using 4 principal components, root mean square error of prediction is 0.742. The results showed that FTIR spectroscopy can be used for the detection and quantification of pork in beef meatball formulation for Halal verification purposes. Copyright © 2010 The American Meat Science Association. Published by Elsevier Ltd. All rights reserved.
-
Large-scale contamination of microbial isolate genomes by Illumina PhiX control.
Mukherjee, Supratim; Huntemann, Marcel; Ivanova, Natalia; Kyrpides, Nikos C; Pati, Amrita
2015-01-01
With the rapid growth and development of sequencing technologies, genomes have become the new go-to for exploring solutions to some of the world's biggest challenges such as searching for alternative energy sources and exploration of genomic dark matter. However, progress in sequencing has been accompanied by its share of errors that can occur during template or library preparation, sequencing, imaging or data analysis. In this study we screened over 18,000 publicly available microbial isolate genome sequences in the Integrated Microbial Genomes database and identified more than 1000 genomes that are contaminated with PhiX, a control frequently used during Illumina sequencing runs. Approximately 10% of these genomes have been published in literature and 129 contaminated genomes were sequenced under the Human Microbiome Project. Raw sequence reads are prone to contamination from various sources and are usually eliminated during downstream quality control steps. Detection of PhiX contaminated genomes indicates a lapse in either the application or effectiveness of proper quality control measures. The presence of PhiX contamination in several publicly available isolate genomes can result in additional errors when such data are used in comparative genomics analyses. Such contamination of public databases have far-reaching consequences in the form of erroneous data interpretation and analyses, and necessitates better measures to proofread raw sequences before releasing them to the broader scientific community.
-
[Velopharyngeal closure pattern and speech performance among submucous cleft palate patients].
Heng, Yin; Chunli, Guo; Bing, Shi; Yang, Li; Jingtao, Li
2017-06-01
To characterize the velopharyngeal closure patterns and speech performance among submucous cleft palate patients. Patients with submucous cleft palate visiting the Department of Cleft Lip and Palate Surgery, West China Hospital of Stomatology, Sichuan University between 2008 and 2016 were reviewed. Outcomes of subjective speech evaluation including velopharyngeal function, consonant articulation, and objective nasopharyngeal endoscopy including the mobility of soft palate, pharyngeal walls were retrospectively analyzed. A total of 353 cases were retrieved in this study, among which 138 (39.09%) demonstrated velopharyngeal competence, 176 (49.86%) velopharyngeal incompetence, and 39 (11.05%) marginal velopharyngeal incompetence. A total of 268 cases were subjected to nasopharyngeal endoscopy examination, where 167 (62.31%) demonstrated circular closure pattern, 89 (33.21%) coronal pattern, and 12 (4.48%) sagittal pattern. Passavant's ridge existed in 45.51% (76/167) patients with circular closure and 13.48% (12/89) patients with coronal closure. Among the 353 patients included in this study, 137 (38.81%) presented normal articulation, 124 (35.13%) consonant elimination, 51 (14.45%) compensatory articulation, 36 (10.20%) consonant weakening, 25 (7.08%) consonant replacement, and 36 (10.20%) multiple articulation errors. Circular closure was the most prevalent velopharyngeal closure pattern among patients with submucous cleft palate, and high-pressure consonant deletion was the most common articulation abnormality. Articulation error occurred more frequently among patients with a low velopharyngeal closure rate.
-
Unsafe from the Start: Serious Misuse of Car Safety Seats at Newborn Discharge.
Hoffman, Benjamin D; Gallardo, Adrienne R; Carlson, Kathleen F
2016-04-01
To estimate prevalence of car safety seat (CSS) misuse for newborns on hospital discharge; and to identify potential risk and protective factors for CSS misuse. We randomly sampled 291 mother-baby dyads from the newborn unit of an academic health center. Participants completed a survey and designated someone (themselves or another caregiver) to position their newborn in the CSS and install the CSS in their vehicle. Certified child passenger safety technicians assessed positioning and installation using nationally standardized criteria. To examine factors associated with CSS misuse, we used logistic regression to compute ORs and 95% CIs. A total of 291 families (81% of those eligible) participated. Nearly all (95%) CSSs were misused, with 1 or more errors in positioning (86%) and/or installation (77%). Serious CSS misuse occurred for 91% of all infants. Frequent misuses included harness and chest clip errors, incorrect recline angle, and seat belt/lower anchor use errors. Families with mothers of color (OR, 6.3; 95% CI, 1.8-21.6), non-English language (OR, 4.9; 95% CI, 1.1-21.2), Medicaid (OR, 10.3; 95% CI, 2.4-44.4), or lower educational level (OR, 4.5; 95% CI, 1.7-12.4) were more likely to misuse CSSs. However, families that worked with a child passenger safety technician before delivery were significantly less likely to misuse their CSSs (OR, 0.1; 95% CI, 0.0-0.4). Nearly all parents of newborn infants misused CSSs. Resources should be devoted to ensuring families with newborns leave the hospital correctly using their CSS. Copyright © 2016 Elsevier Inc. All rights reserved.
-
NASA Technical Reports Server (NTRS)
Maille, Nicolas P.; Statler, Irving C.; Ferryman, Thomas A.; Rosenthal, Loren; Shafto, Michael G.; Statler, Irving C.
2006-01-01
The objective of the Aviation System Monitoring and Modeling (ASMM) project of NASA s Aviation Safety and Security Program was to develop technologies that will enable proactive management of safety risk, which entails identifying the precursor events and conditions that foreshadow most accidents. This presents a particular challenge in the aviation system where people are key components and human error is frequently cited as a major contributing factor or cause of incidents and accidents. In the aviation "world", information about what happened can be extracted from quantitative data sources, but the experiential account of the incident reporter is the best available source of information about why an incident happened. This report describes a conceptual model and an approach to automated analyses of textual data sources for the subjective perspective of the reporter of the incident to aid in understanding why an incident occurred. It explores a first-generation process for routinely searching large databases of textual reports of aviation incident or accidents, and reliably analyzing them for causal factors of human behavior (the why of an incident). We have defined a generic structure of information that is postulated to be a sound basis for defining similarities between aviation incidents. Based on this structure, we have introduced the simplifying structure, which we call the Scenario as a pragmatic guide for identifying similarities of what happened based on the objective parameters that define the Context and the Outcome of a Scenario. We believe that it will be possible to design an automated analysis process guided by the structure of the Scenario that will aid aviation-safety experts to understand the systemic issues that are conducive to human error.
-
Kostopoulou, Olga; Delaney, Brendan
2007-04-01
To classify events of actual or potential harm to primary care patients using a multilevel taxonomy of cognitive and system factors. Observational study of patient safety events obtained via a confidential but not anonymous reporting system. Reports were followed up with interviews where necessary. Events were analysed for their causes and contributing factors using causal trees and were classified using the taxonomy. Five general medical practices in the West Midlands were selected to represent a range of sizes and types of patient population. All practice staff were invited to report patient safety events. Main outcome measures were frequencies of clinical types of events reported, cognitive types of error, types of detection and contributing factors; and relationship between types of error, practice size, patient consequences and detection. 78 reports were relevant to patient safety and analysable. They included 21 (27%) adverse events and 50 (64%) near misses. 16.7% (13/71) had serious patient consequences, including one death. 75.7% (59/78) had the potential for serious patient harm. Most reports referred to administrative errors (25.6%, 20/78). 60% (47/78) of the reports contained sufficient information to characterise cognition: "situation assessment and response selection" was involved in 45% (21/47) of these reports and was often linked to serious potential consequences. The most frequent contributing factor was work organisation, identified in 71 events. This included excessive task demands (47%, 37/71) and fragmentation (28%, 22/71). Even though most reported events were near misses, events with serious patient consequences were also reported. Failures in situation assessment and response selection, a cognitive activity that occurs in both clinical and administrative tasks, was related to serious potential harm.
-
Kostopoulou, Olga; Delaney, Brendan
2007-01-01
Objective To classify events of actual or potential harm to primary care patients using a multilevel taxonomy of cognitive and system factors. Methods Observational study of patient safety events obtained via a confidential but not anonymous reporting system. Reports were followed up with interviews where necessary. Events were analysed for their causes and contributing factors using causal trees and were classified using the taxonomy. Five general medical practices in the West Midlands were selected to represent a range of sizes and types of patient population. All practice staff were invited to report patient safety events. Main outcome measures were frequencies of clinical types of events reported, cognitive types of error, types of detection and contributing factors; and relationship between types of error, practice size, patient consequences and detection. Results 78 reports were relevant to patient safety and analysable. They included 21 (27%) adverse events and 50 (64%) near misses. 16.7% (13/71) had serious patient consequences, including one death. 75.7% (59/78) had the potential for serious patient harm. Most reports referred to administrative errors (25.6%, 20/78). 60% (47/78) of the reports contained sufficient information to characterise cognition: “situation assessment and response selection” was involved in 45% (21/47) of these reports and was often linked to serious potential consequences. The most frequent contributing factor was work organisation, identified in 71 events. This included excessive task demands (47%, 37/71) and fragmentation (28%, 22/71). Conclusions Even though most reported events were near misses, events with serious patient consequences were also reported. Failures in situation assessment and response selection, a cognitive activity that occurs in both clinical and administrative tasks, was related to serious potential harm. PMID:17403753
-
Validation of automatic joint space width measurements in hand radiographs in rheumatoid arthritis.
Schenk, Olga; Huo, Yinghe; Vincken, Koen L; van de Laar, Mart A; Kuper, Ina H H; Slump, Kees C H; Lafeber, Floris P J G; Bernelot Moens, Hein J
2016-10-01
Computerized methods promise quick, objective, and sensitive tools to quantify progression of radiological damage in rheumatoid arthritis (RA). Measurement of joint space width (JSW) in finger and wrist joints with these systems performed comparable to the Sharp-van der Heijde score (SHS). A next step toward clinical use, validation of precision and accuracy in hand joints with minimal damage, is described with a close scrutiny of sources of error. A recently developed system to measure metacarpophalangeal (MCP) and proximal interphalangeal (PIP) joints was validated in consecutive hand images of RA patients. To assess the impact of image acquisition, measurements on radiographs from a multicenter trial and from a recent prospective cohort in a single hospital were compared. Precision of the system was tested by comparing the joint space in mm in pairs of subsequent images with a short interval without progression of SHS. In case of incorrect measurements, the source of error was analyzed with a review by human experts. Accuracy was assessed by comparison with reported measurements with other systems. In the two series of radiographs, the system could automatically locate and measure 1003/1088 (92.2%) and 1143/1200 (95.3%) individual joints, respectively. In joints with a normal SHS, the average (SD) size of MCP joints was [Formula: see text] and [Formula: see text] in the two series of radiographs, and of PIP joints [Formula: see text] and [Formula: see text]. The difference in JSW between two serial radiographs with an interval of 6 to 12 months and unchanged SHS was [Formula: see text], indicating very good precision. Errors occurred more often in radiographs from the multicenter cohort than in a more recent series from a single hospital. Detailed analysis of the 55/1125 (4.9%) measurements that had a discrepant paired measurement revealed that variation in the process of image acquisition (exposure in 15% and repositioning in 57%) was a more frequent source of error than incorrect delineation by the software (25%). Various steps in the validation of an automated measurement system for JSW of MCP and PIP joints are described. The use of serial radiographs from different sources, with a short interval and limited damage, is helpful to detect sources of error. Image acquisition, in particular repositioning, is a dominant source of error.
-
Nowak, Michał S; Goś, Roman; Smigielski, Janusz
2008-01-01
To determine the prevalence of refractive errors in population. A retrospective review of medical examinations for entry to the military service from The Area Military Medical Commission in Lodz. Ophthalmic examinations were performed. We used statistic analysis to review the results. Statistic analysis revealed that refractive errors occurred in 21.68% of the population. The most commen refractive error was myopia. 1) The most commen ocular diseases are refractive errors, especially myopia (21.68% in total). 2) Refractive surgery and contact lenses should be allowed as the possible correction of refractive errors for military service.
-
Chua, S S; Tea, M H; Rahman, M H A
2009-04-01
Drug administration errors were the second most frequent type of medication errors, after prescribing errors but the latter were often intercepted hence, administration errors were more probably to reach the patients. Therefore, this study was conducted to determine the frequency and types of drug administration errors in a Malaysian hospital ward. This is a prospective study that involved direct, undisguised observations of drug administrations in a hospital ward. A researcher was stationed in the ward under study for 15 days to observe all drug administrations which were recorded in a data collection form and then compared with the drugs prescribed for the patient. A total of 1118 opportunities for errors were observed and 127 administrations had errors. This gave an error rate of 11.4 % [95% confidence interval (CI) 9.5-13.3]. If incorrect time errors were excluded, the error rate reduced to 8.7% (95% CI 7.1-10.4). The most common types of drug administration errors were incorrect time (25.2%), followed by incorrect technique of administration (16.3%) and unauthorized drug errors (14.1%). In terms of clinical significance, 10.4% of the administration errors were considered as potentially life-threatening. Intravenous routes were more likely to be associated with an administration error than oral routes (21.3% vs. 7.9%, P < 0.001). The study indicates that the frequency of drug administration errors in developing countries such as Malaysia is similar to that in the developed countries. Incorrect time errors were also the most common type of drug administration errors. A non-punitive system of reporting medication errors should be established to encourage more information to be documented so that risk management protocol could be developed and implemented.
-
Huynh, Chi; Wong, Ian C K; Correa-West, Jo; Terry, David; McCarthy, Suzanne
2017-04-01
Since the publication of To Err Is Human: Building a Safer Health System in 1999, there has been much research conducted into the epidemiology, nature and causes of medication errors in children, from prescribing and supply to administration. It is reassuring to see growing evidence of improving medication safety in children; however, based on media reports, it can be seen that serious and fatal medication errors still occur. This critical opinion article examines the problem of medication errors in children and provides recommendations for research, training of healthcare professionals and a culture shift towards dealing with medication errors. There are three factors that we need to consider to unravel what is missing and why fatal medication errors still occur. (1) Who is involved and affected by the medication error? (2) What factors hinder staff and organisations from learning from mistakes? Does the fear of litigation and criminal charges deter healthcare professionals from voluntarily reporting medication errors? (3) What are the educational needs required to prevent medication errors? It is important to educate future healthcare professionals about medication errors and human factors to prevent these from happening. Further research is required to apply aviation's 'black box' principles in healthcare to record and learn from near misses and errors to prevent future events. There is an urgent need for the black box investigations to be published and made public for the benefit of other organisations that may have similar potential risks for adverse events. International sharing of investigations and learning is also needed.
-
Role of Grammatical Gender and Semantics in German Word Production
ERIC Educational Resources Information Center
Vigliocco, Gabriella; Vinson, David P.; Indefrey, Peter; Levelt, Willem J. M.; Hellwig, Frauke
2004-01-01
Semantic substitution errors (e.g., saying "arm" when "leg" is intended) are among the most common types of errors occurring during spontaneous speech. It has been shown that grammatical gender of German target nouns is preserved in the errors (E. Mane, 1999). In 3 experiments, the authors explored different accounts of the grammatical gender…
-
ERIC Educational Resources Information Center
Harshman, Jordan; Yezierski, Ellen
2016-01-01
Determining the error of measurement is a necessity for researchers engaged in bench chemistry, chemistry education research (CER), and a multitude of other fields. Discussions regarding what constructs measurement error entails and how to best measure them have occurred, but the critiques about traditional measures have yielded few alternatives.…
-
The Frame Constraint on Experimentally Elicited Speech Errors in Japanese
ERIC Educational Resources Information Center
Saito, Akie; Inoue, Tomoyoshi
2017-01-01
The so-called syllable position effect in speech errors has been interpreted as reflecting constraints posed by the frame structure of a given language, which is separately operating from linguistic content during speech production. The effect refers to the phenomenon that when a speech error occurs, replaced and replacing sounds tend to be in the…
-
A Linguistic Analysis of Errors in the Compositions of Arba Minch University Students
ERIC Educational Resources Information Center
Tizazu, Yoseph
2014-01-01
This study reports the dominant linguistic errors that occur in the written productions of Arba Minch University (hereafter AMU) students. A sample of paragraphs was collected for two years from students ranging from freshmen to graduating level. The sampled compositions were then coded, described, and explained using error analysis method. Both…
-
Idea Evaluation: Error in Evaluating Highly Original Ideas
ERIC Educational Resources Information Center
Licuanan, Brian F.; Dailey, Lesley R.; Mumford, Michael D.
2007-01-01
Idea evaluation is a critical aspect of creative thought. However, a number of errors might occur in the evaluation of new ideas. One error commonly observed is the tendency to underestimate the originality of truly novel ideas. In the present study, an attempt was made to assess whether analysis of the process leading to the idea generation and…
-
ERIC Educational Resources Information Center
Ramos, Erica; Alfonso, Vincent C.; Schermerhorn, Susan M.
2009-01-01
The interpretation of cognitive test scores often leads to decisions concerning the diagnosis, educational placement, and types of interventions used for children. Therefore, it is important that practitioners administer and score cognitive tests without error. This study assesses the frequency and types of examiner errors that occur during the…
-
Code of Federal Regulations, 2010 CFR
2010-04-01
... this paragraph (b)(2) include the following— (i) A mathematical error; (ii) An entry on a document that... errors or omissions that occurred before the publication of these regulations. Any reasonable method used... February 24, 1994, will be considered proper, provided that the method is consistent with the rules of...
-
The Impact of Bar Code Medication Administration Technology on Reported Medication Errors
ERIC Educational Resources Information Center
Holecek, Andrea
2011-01-01
The use of bar-code medication administration technology is on the rise in acute care facilities in the United States. The technology is purported to decrease medication errors that occur at the point of administration. How significantly this technology affects actual rate and severity of error is unknown. This descriptive, longitudinal research…
-
PREVALENCE OF REFRACTIVE ERRORS IN MADRASSA STUDENTS OF HARIPUR DISTRICT.
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.
-
An Analysis of the Most Frequently Occurring Words in Spoken American English.
ERIC Educational Resources Information Center
Plant, Geoff
1999-01-01
A study analyzed frequency of occurrence of consonants, vowels, and diphthongs, syllabic structure of the words, and segmental structure of the 311 monosyllabic words of 500 words that occur most frequently in English. Three mannerisms of articulation accounted for nearly 75 percent of all consonant occurrences: stops, semi-vowels, and nasals.…
-
Using nurses and office staff to report prescribing errors in primary care.
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.
-
Analysis of the PLL phase error in presence of simulated ionospheric scintillation events
NASA Astrophysics Data System (ADS)
Forte, B.
2012-01-01
The functioning of standard phase locked loops (PLL), including those used to track radio signals from Global Navigation Satellite Systems (GNSS), is based on a linear approximation which holds in presence of small phase errors. Such an approximation represents a reasonable assumption in most of the propagation channels. However, in presence of a fading channel the phase error may become large, making the linear approximation no longer valid. The PLL is then expected to operate in a non-linear regime. As PLLs are generally designed and expected to operate in their linear regime, whenever the non-linear regime comes into play, they will experience a serious limitation in their capability to track the corresponding signals. The phase error and the performance of a typical PLL embedded into a commercial multiconstellation GNSS receiver were analyzed in presence of simulated ionospheric scintillation. Large phase errors occurred during scintillation-induced signal fluctuations although cycle slips only occurred during the signal re-acquisition after a loss of lock. Losses of lock occurred whenever the signal faded below the minimumC/N0threshold allowed for tracking. The simulations were performed for different signals (GPS L1C/A, GPS L2C, GPS L5 and Galileo L1). L5 and L2C proved to be weaker than L1. It appeared evident that the conditions driving the PLL phase error in the specific case of GPS receivers in presence of scintillation-induced signal perturbations need to be evaluated in terms of the combination of the minimumC/N0 tracking threshold, lock detector thresholds, possible cycle slips in the tracking PLL and accuracy of the observables (i.e. the error propagation onto the observables stage).
-
"Fragment errors" in deep dysgraphia: further support for a lexical hypothesis.
Bormann, Tobias; Wallesch, Claus-W; Blanken, Gerhard
2008-07-01
In addition to various lexical errors, the writing of patients with deep dysgraphia may include a large number of segmental spelling errors, which increase towards the end of the word. Frequently, these errors involve deletion of two or more letters resulting in so-called "fragment errors". Different positions have been brought forward regarding their origin, including rapid decay of activation in the graphemic buffer and an impairment of more central (i.e., lexical or semantic) processing. We present data from a patient (M.D.) with deep dysgraphia who showed an increase of segmental spelling errors towards the end of the word. Several tasks were carried out to explore M.D.'s underlying functional impairment. Errors affected word-final positions in tasks like backward spelling and fragment completion. In a delayed copying task, length of the delay had no influence. In addition, when asked to recall three serially presented letters, a task which had not been carried out before, M.D. exhibited a preference for the first and the third letter and poor performance for the second letter. M.D.'s performance on these tasks contradicts the rapid decay account and instead supports a lexical-semantic account of segmental errors in deep dysgraphia. In addition, the results fit well with an implemented computational model of deep dysgraphia and segmental spelling errors.
-
NASA Astrophysics Data System (ADS)
Dai, Liyun; Che, Tao; Ding, Yongjian; Hao, Xiaohua
2017-08-01
Snow cover on the Qinghai-Tibetan Plateau (QTP) plays a significant role in the global climate system and is an important water resource for rivers in the high-elevation region of Asia. At present, passive microwave (PMW) remote sensing data are the only efficient way to monitor temporal and spatial variations in snow depth at large scale. However, existing snow depth products show the largest uncertainties across the QTP. In this study, MODIS fractional snow cover product, point, line and intense sampling data are synthesized to evaluate the accuracy of snow cover and snow depth derived from PMW remote sensing data and to analyze the possible causes of uncertainties. The results show that the accuracy of snow cover extents varies spatially and depends on the fraction of snow cover. Based on the assumption that grids with MODIS snow cover fraction > 10 % are regarded as snow cover, the overall accuracy in snow cover is 66.7 %, overestimation error is 56.1 %, underestimation error is 21.1 %, commission error is 27.6 % and omission error is 47.4 %. The commission and overestimation errors of snow cover primarily occur in the northwest and southeast areas with low ground temperature. Omission error primarily occurs in cold desert areas with shallow snow, and underestimation error mainly occurs in glacier and lake areas. With the increase of snow cover fraction, the overestimation error decreases and the omission error increases. A comparison between snow depths measured in field experiments, measured at meteorological stations and estimated across the QTP shows that agreement between observation and retrieval improves with an increasing number of observation points in a PMW grid. The misclassification and errors between observed and retrieved snow depth are associated with the relatively coarse resolution of PMW remote sensing, ground temperature, snow characteristics and topography. To accurately understand the variation in snow depth across the QTP, new algorithms should be developed to retrieve snow depth with higher spatial resolution and should consider the variation in brightness temperatures at different frequencies emitted from ground with changing ground features.
-
Knowledge of healthcare professionals about medication errors in hospitals
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
-
Acute Chemical Incidents With Injured First Responders, 2002-2012.
Melnikova, Natalia; Wu, Jennifer; Yang, Alice; Orr, Maureen
2018-04-01
IntroductionFirst responders, including firefighters, police officers, emergency medical services, and company emergency response team members, have dangerous jobs that can bring them in contact with hazardous chemicals among other dangers. Limited information is available on responder injuries that occur during hazardous chemical incidents. We analyzed 2002-2012 data on acute chemical incidents with injured responders from 2 Agency for Toxic Substances and Disease Registry chemical incident surveillance programs. To learn more about such injuries, we performed descriptive analysis and looked for trends. The percentage of responders among all injured people in chemical incidents has not changed over the years. Firefighters were the most frequently injured group of responders, followed by police officers. Respiratory system problems were the most often reported injury, and the respiratory irritants, ammonia, methamphetamine-related chemicals, and carbon monoxide were the chemicals more often associated with injuries. Most of the incidents with responder injuries were caused by human error or equipment failure. Firefighters wore personal protective equipment (PPE) most frequently and police officers did so rarely. Police officers' injuries were mostly associated with exposure to ammonia and methamphetamine-related chemicals. Most responders did not receive basic awareness-level hazardous material training. All responders should have at least basic awareness-level hazardous material training to recognize and avoid exposure. Research on improving firefighter PPE should continue. (Disaster Med Public Health Preparedness. 2018;12:211-221).
-
Method and apparatus for detecting timing errors in a system oscillator
Gliebe, Ronald J.; Kramer, William R.
1993-01-01
A method of detecting timing errors in a system oscillator for an electronic device, such as a power supply, includes the step of comparing a system oscillator signal with a delayed generated signal and generating a signal representative of the timing error when the system oscillator signal is not identical to the delayed signal. An LED indicates to an operator that a timing error has occurred. A hardware circuit implements the above-identified method.
-
Brain connectome modularity in weight-restored anorexia nervosa and body dysmorphic disorder
Zhang, A; Leow, A; Zhan, L; GadElkarim, J; Moody, T; Khalsa, S; Strober, M; Feusner, JD
2017-01-01
Background Anorexia nervosa (AN) and body dysmorphic disorder (BDD) frequently co-occur, and have several overlapping phenomenological features. Little is known about their shared neurobiology. Aims To compare modular organization of brain structural connectivity. Methods We acquired diffusion-weighted magnetic resonance imaging data on unmedicated individuals with BDD (n=29), weight-restored AN (n=24), and healthy controls (HC) (n=31). We constructed connectivity matrices using whole-brain white matter tractography, and compared modular structures across groups. Results AN showed abnormal modularity involving frontal, basal ganglia, and posterior cingulate nodes. There was a trend in BDD for similar abnormalities, but no significant differences compared with AN. In AN, poor insight correlated with longer path length in right caudal anterior cingulate and right posterior cingulate. Conclusions Abnormal network organization patterns in AN, partially shared with BDD, may have implications for understanding integration between reward and habit/ritual formation, as well as conflict monitoring/error detection. PMID:27429183
-
Fatalities due to indigenous and exotic species in Florida.
Wolf, Barbara C; Harding, Brett E
2014-01-01
Florida's climate is suitable for many potentially hazardous animals, including both indigenous and exotic species, which are frequently kept as in zoos or as pets. This has resulted in many unforeseen fatal encounters between animals and the ever expanding human population. While the literature and knowledge pool for more common types of deaths referred to medical examiner/coroner's offices is abundant, the appreciation of wildlife and exotic pet-related deaths is far less widespread. We report seven animal attack-related deaths that occurred in Florida. The inflicted injuries included blunt and sharp force injuries, asphyxia, drowning, and envenomation. The underlying cause of death, however, was always a result of the human/animal interaction and in many cases related to human error and failure to appreciate the potentially dangerous behavior of nondomesticated species. These cases illustrate the varied circumstances and pathophysiologies associated with deaths due to indigenous and exotic species and the importance of the multidisciplinary approach in the medicolegal investigation of these cases. © 2013 American Academy of Forensic Sciences.
-
Párraga-Manzol, Gabriela; Sánchez-Torres, Alba; Moreno-Arias, Gerardo
2015-01-01
Intense Pulsed Light (IPL) photodepilation is usually performed as a hair removal method. The treatment is recommended to be indicated by a physician, depending on each patient and on its characteristics. However, the use of laser devices by medical laypersons is frequent and it can suppose a risk of damage for the patients. Most side effects associated to IPL photodepilation are transient, minimal and disappear without sequelae. However, permanent side effects can occur. Some of the complications are laser related but many of them are caused by an operator error or mismanagement. In this work, we report a clinical case of a patient that developed a chronic neuropathic facial pain following IPL hair removal for unwanted hair in the upper lip. The specific diagnosis was painful post-traumatic trigeminal neuropathy, reference 13.1.2.3 according to the International Headache Society (IHS). Key words:Neuropathic facial pain, photodepilation, intense pulse light. PMID:26535105
-
Forgetting What Was Where: The Fragility of Object-Location Binding
Pertzov, Yoni; Dong, Mia Yuan; Peich, Muy-Cheng; Husain, Masud
2012-01-01
Although we frequently take advantage of memory for objects locations in everyday life, understanding how an object’s identity is bound correctly to its location remains unclear. Here we examine how information about object identity, location and crucially object-location associations are differentially susceptible to forgetting, over variable retention intervals and memory load. In our task, participants relocated objects to their remembered locations using a touchscreen. When participants mislocalized objects, their reports were clustered around the locations of other objects in the array, rather than occurring randomly. These ‘swap’ errors could not be attributed to simple failure to remember either the identity or location of the objects, but rather appeared to arise from failure to bind object identity and location in memory. Moreover, such binding failures significantly contributed to decline in localization performance over retention time. We conclude that when objects are forgotten they do not disappear completely from memory, but rather it is the links between identity and location that are prone to be broken over time. PMID:23118956
-
Early screening of an infant's visual system
NASA Astrophysics Data System (ADS)
Costa, Manuel F. M.; Jorge, Jorge M.
1999-06-01
It is of utmost importance to the development of the child's visual system that she perceives clear focused retinal images. Furthermore if the refractive problems are not corrected in due time amblyopia may occur--myopia and hyperopia can only cause important problems in the future when they are significantly large, however for the astigmatism (rather frequent in infants) and anisometropia the problems tend to be more stringent. The early evaluation of the visual status of human infants is thus of critical importance. Photorefraction is a convenient technique for this kind of subjects. Essentially a light beam is delivered into the eyes. It is refracted by the ocular media, strikes the retina, focusing or not, reflects off and is collected by a camera. The photorefraction setup we established using new technological breakthroughs on the fields of imaging devices, digital image processing and fiber optics, allows a fast noninvasive evaluation of children visual status (refractive errors, accommodation, strabismus, ...). Results of the visual screening of a group of risk' child descents of blinds or amblyopes will be presented.
-
Consumer concerns: motivating to action.
Bruhn, C. M.
1997-01-01
Microbiologic safety is consumers' most frequently volunteered food safety concern. An increase in the level of concern in recent years suggests that consumers are more receptive to educational information. However, changing lifestyles have lessened the awareness of foodborne illness, especially among younger consumers. Failure to fully recognize the symptoms or sources of foodborne disease prevents consumers from taking corrective action. Consumer education messages should include the ubiquity of microorganisms, a comprehensive description of foodborne illnesses, and prevention strategies. Product labels should contain food-handling information and warnings for special populations, and foods processed by newer safety-enhancing technologies should be more widely available. Knowledge of the consequences of unsafe practices can enhance motivation and adherence to safety guidelines. When consumers mishandle food during preparation, the health community, food industry, regulators, and the media are ultimately responsible. Whether inappropriate temperature control, poor hygiene, or another factor, the error occurs because consumers have not been informed about how to handle food and protect themselves. The food safety message has not been delivered effectively. PMID:9366604
-
Recent advances in sequence assembly: principles and applications.
Chen, Qingfeng; Lan, Chaowang; Zhao, Liang; Wang, Jianxin; Chen, Baoshan; Chen, Yi-Ping Phoebe
2017-11-01
The application of advanced sequencing technologies and the rapid growth of various sequence data have led to increasing interest in DNA sequence assembly. However, repeats and polymorphism occur frequently in genomes, and each of these has different impacts on assembly. Further, many new applications for sequencing, such as metagenomics regarding multiple species, have emerged in recent years. These not only give rise to higher complexity but also prevent short-read assembly in an efficient way. This article reviews the theoretical foundations that underlie current mapping-based assembly and de novo-based assembly, and highlights the key issues and feasible solutions that need to be considered. It focuses on how individual processes, such as optimal k-mer determination and error correction in assembly, rely on intelligent strategies or high-performance computation. We also survey primary algorithms/software and offer a discussion on the emerging challenges in assembly. © The Author 2017. Published by Oxford University Press. All rights reserved. For permissions, please email: journals.permissions@oup.com.
-
Investigating an API for resilient exascale computing.
DOE Office of Scientific and Technical Information (OSTI.GOV)
Stearley, Jon R.; Tomkins, James; VanDyke, John P.
2013-05-01
Increased HPC capability comes with increased complexity, part counts, and fault occurrences. In- creasing the resilience of systems and applications to faults is a critical requirement facing the viability of exascale systems, as the overhead of traditional checkpoint/restart is projected to outweigh its bene ts due to fault rates outpacing I/O bandwidths. As faults occur and propagate throughout hardware and software layers, pervasive noti cation and handling mechanisms are necessary. This report describes an initial investigation of fault types and programming interfaces to mitigate them. Proof-of-concept APIs are presented for the frequent and important cases of memory errors and nodemore » failures, and a strategy proposed for lesystem failures. These involve changes to the operating system, runtime, I/O library, and application layers. While a single API for fault handling among hardware and OS and application system-wide remains elusive, the e ort increased our understanding of both the mountainous challenges and the promising trailheads. 3« less
-
Method and apparatus for faulty memory utilization
Cher, Chen-Yong; Andrade Costa, Carlos H.; Park, Yoonho; Rosenburg, Bryan S.; Ryu, Kyung D.
2016-04-19
A method for faulty memory utilization in a memory system includes: obtaining information regarding memory health status of at least one memory page in the memory system; determining an error tolerance of the memory page when the information regarding memory health status indicates that a failure is predicted to occur in an area of the memory system affecting the memory page; initiating a migration of data stored in the memory page when it is determined that the data stored in the memory page is non-error-tolerant; notifying at least one application regarding a predicted operating system failure and/or a predicted application failure when it is determined that data stored in the memory page is non-error-tolerant and cannot be migrated; and notifying at least one application regarding the memory failure predicted to occur when it is determined that data stored in the memory page is error-tolerant.
-
On the interaction of deaffrication and consonant harmony*
Dinnsen, Daniel A.; Gierut, Judith A.; Morrisette, Michele L.; Green, Christopher R.; Farris-Trimble, Ashley W.
2010-01-01
Error patterns in children’s phonological development are often described as simplifying processes that can interact with one another with different consequences. Some interactions limit the applicability of an error pattern, and others extend it to more words. Theories predict that error patterns interact to their full potential. While specific interactions have been documented for certain pairs of processes, no developmental study has shown that the range of typologically predicted interactions occurs for those processes. To determine whether this anomaly is an accidental gap or a systematic peculiarity of particular error patterns, two commonly occurring processes were considered, namely Deaffrication and Consonant Harmony. Results are reported from a cross-sectional and longitudinal study of 12 children (age 3;0 – 5;0) with functional phonological delays. Three interaction types were attested to varying degrees. The longitudinal results further instantiated the typology and revealed a characteristic trajectory of change. Implications of these findings are explored. PMID:20513256
-
Blind Braille readers mislocate tactile stimuli.
Sterr, Annette; Green, Lisa; Elbert, Thomas
2003-05-01
In a previous experiment, we observed that blind Braille readers produce errors when asked to identify on which finger of one hand a light tactile stimulus had occurred. With the present study, we aimed to specify the characteristics of this perceptual error in blind and sighted participants. The experiment confirmed that blind Braille readers mislocalised tactile stimuli more often than sighted controls, and that the localisation errors occurred significantly more often at the right reading hand than at the non-reading hand. Most importantly, we discovered that the reading fingers showed the smallest error frequency, but the highest rate of stimulus attribution. The dissociation of perceiving and locating tactile stimuli in the blind suggests altered tactile information processing. Neuroplasticity, changes in tactile attention mechanisms as well as the idea that blind persons may employ different strategies for tactile exploration and object localisation are discussed as possible explanations for the results obtained.
-
Medication Errors in Patients with Enteral Feeding Tubes in the Intensive Care Unit.
Sohrevardi, Seyed Mojtaba; Jarahzadeh, Mohammad Hossein; Mirzaei, Ehsan; Mirjalili, Mahtabalsadat; Tafti, Arefeh Dehghani; Heydari, Behrooz
2017-01-01
Most patients admitted to Intensive Care Units (ICU) have problems in using oral medication or ingesting solid forms of drugs. Selecting the most suitable dosage form in such patients is a challenge. The current study was conducted to assess the frequency and types of errors of oral medication administration in patients with enteral feeding tubes or suffering swallowing problems. A cross-sectional study was performed in the ICU of Shahid Sadoughi Hospital, Yazd, Iran. Patients were assessed for the incidence and types of medication errors occurring in the process of preparation and administration of oral medicines. Ninety-four patients were involved in this study and 10,250 administrations were observed. Totally, 4753 errors occurred among the studied patients. The most commonly used drugs were pantoprazole tablet, piracetam syrup, and losartan tablet. A total of 128 different types of drugs and nine different oral pharmaceutical preparations were prescribed for the patients. Forty-one (35.34%) out of 116 different solid drugs (except effervescent tablets and powders) could be substituted by liquid or injectable forms. The most common error was the wrong time of administration. Errors of wrong dose preparation and administration accounted for 24.04% and 25.31% of all errors, respectively. In this study, at least three-fourth of the patients experienced medication errors. The occurrence of these errors can greatly impair the quality of the patients' pharmacotherapy, and more attention should be paid to this issue.
-
Evaluation of causes and frequency of medication errors during information technology downtime.
Hanuscak, Tara L; Szeinbach, Sheryl L; Seoane-Vazquez, Enrique; Reichert, Brendan J; McCluskey, Charles F
2009-06-15
The causes and frequency of medication errors occurring during information technology downtime were evaluated. Individuals from a convenience sample of 78 hospitals who were directly responsible for supporting and maintaining clinical information systems (CISs) and automated dispensing systems (ADSs) were surveyed using an online tool between February 2007 and May 2007 to determine if medication errors were reported during periods of system downtime. The errors were classified using the National Coordinating Council for Medication Error Reporting and Prevention severity scoring index. The percentage of respondents reporting downtime was estimated. Of the 78 eligible hospitals, 32 respondents with CIS and ADS responsibilities completed the online survey for a response rate of 41%. For computerized prescriber order entry, patch installations and system upgrades caused an average downtime of 57% over a 12-month period. Lost interface and interface malfunction were reported for centralized and decentralized ADSs, with an average downtime response of 34% and 29%, respectively. The average downtime response was 31% for software malfunctions linked to clinical decision-support systems. Although patient harm did not result from 30 (54%) medication errors, the potential for harm was present for 9 (16%) of these errors. Medication errors occurred during CIS and ADS downtime despite the availability of backup systems and standard protocols to handle periods of system downtime. Efforts should be directed to reduce the frequency and length of down-time in order to minimize medication errors during such downtime.
-
Physician assistants and the disclosure of medical error.
Brock, Douglas M; Quella, Alicia; Lipira, Lauren; Lu, Dave W; Gallagher, Thomas H
2014-06-01
Evolving state law, professional societies, and national guidelines, including those of the American Medical Association and Joint Commission, recommend that patients receive transparent communication when a medical error occurs. Recommendations for error disclosure typically consist of an explanation that an error has occurred, delivery of an explicit apology, an explanation of the facts around the event, its medical ramifications and how care will be managed, and a description of how similar errors will be prevented in the future. Although error disclosure is widely endorsed in the medical and nursing literature, there is little discussion of the unique role that the physician assistant (PA) might play in these interactions. PAs are trained in the medical model and technically practice under the supervision of a physician. They are also commonly integrated into interprofessional health care teams in surgical and urgent care settings. PA practice is characterized by widely varying degrees of provider autonomy. How PAs should collaborate with physicians in sensitive error disclosure conversations with patients is unclear. With the number of practicing PAs growing rapidly in nearly all domains of medicine, their role in the error disclosure process warrants exploration. The authors call for educational societies and accrediting agencies to support policy to establish guidelines for PA disclosure of error. They encourage medical and PA researchers to explore and report best-practice disclosure roles for PAs. Finally, they recommend that PA educational programs implement trainings in disclosure skills, and hospitals and supervising physicians provide and support training for practicing PAs.
-
DOT National Transportation Integrated Search
2011-06-01
The unregulated hours and frequent night work characteristic of maintenance can produce significant levels of : employee fatigue, with a resultant risk of maintenance error. Fatigue Risk Management Systems (FRMS) are : widely used to manage fatigue a...
-
Heroic Reliability Improvement in Manned Space Systems
NASA Technical Reports Server (NTRS)
Jones, Harry W.
2017-01-01
System reliability can be significantly improved by a strong continued effort to identify and remove all the causes of actual failures. Newly designed systems often have unexpected high failure rates which can be reduced by successive design improvements until the final operational system has an acceptable failure rate. There are many causes of failures and many ways to remove them. New systems may have poor specifications, design errors, or mistaken operations concepts. Correcting unexpected problems as they occur can produce large early gains in reliability. Improved technology in materials, components, and design approaches can increase reliability. The reliability growth is achieved by repeatedly operating the system until it fails, identifying the failure cause, and fixing the problem. The failure rate reduction that can be obtained depends on the number and the failure rates of the correctable failures. Under the strong assumption that the failure causes can be removed, the decline in overall failure rate can be predicted. If a failure occurs at the rate of lambda per unit time, the expected time before the failure occurs and can be corrected is 1/lambda, the Mean Time Before Failure (MTBF). Finding and fixing a less frequent failure with the rate of lambda/2 per unit time requires twice as long, time of 1/(2 lambda). Cutting the failure rate in half requires doubling the test and redesign time and finding and eliminating the failure causes.Reducing the failure rate significantly requires a heroic reliability improvement effort.
-
Making Residents Part of the Safety Culture: Improving Error Reporting and Reducing Harms.
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.
-
Opioid errors in inpatient palliative care services: a retrospective review.
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.
-
Medication errors in a rural hospital.
Madegowda, Bharathi; Hill, Pamela D; Anderson, Mary Ann
2007-06-01
The purpose of this investigation was to compare and contrast three nursing shifts in a small rural Midwestern hospital with regard to the number of reported medication errors, the units on which they occurred, and the types and severity of errors. Results can be beneficial in planning and implementing a quality improvement program in the area of medication administration with the nursing staff.
-
Capio, C M; Poolton, J M; Sit, C H P; Eguia, K F; Masters, R S W
2013-04-01
Children with intellectual disabilities (ID) have been found to have inferior motor proficiencies in fundamental movement skills (FMS). This study examined the effects of training the FMS of overhand throwing by manipulating the amount of practice errors. Participants included 39 children with ID aged 4-11 years who were allocated into either an error-reduced (ER) training programme or a more typical programme in which errors were frequent (error-strewn, ES). Throwing movement form, throwing accuracy, and throwing frequency during free play were evaluated. The ER programme improved movement form, and increased throwing activity during free play to a greater extent than the ES programme. Furthermore, ER learners were found to be capable of engaging in a secondary cognitive task while manifesting robust throwing accuracy performance. The findings support the use of movement skills training programmes that constrain practice errors in children with ID, suggesting that such approach results in improved performance and heightened movement engagement in free play. © 2012 The Authors. Journal of Intellectual Disability Research © 2012 Blackwell Publishing Ltd.
-
Pioneer-Venus radio occultation (ORO) data reduction: Profiles of 13 cm absorptivity
NASA Technical Reports Server (NTRS)
Steffes, Paul G.
1990-01-01
In order to characterize possible variations in the abundance and distribution of subcloud sulfuric acid vapor, 13 cm radio occultation signals from 23 orbits that occurred in late 1986 and 1987 (Season 10) and 7 orbits that occurred in 1979 (Season 1) were processed. The data were inverted via inverse Abel transform to produce 13 cm absorptivity profiles. Pressure and temperature profiles obtained with the Pioneer-Venus night probe and the northern probe were used along with the absorptivity profiles to infer upper limits for vertical profiles of the abundance of gaseous H2SO4. In addition to inverting the data, error bars were placed on the absorptivity profiles and H2SO4 abundance profiles using the standard propagation of errors. These error bars were developed by considering the effects of statistical errors only. The profiles show a distinct pattern with regard to latitude which is consistent with latitude variations observed in data obtained during the occultation seasons nos. 1 and 2. However, when compared with the earlier data, the recent occultation studies suggest that the amount of sulfuric acid vapor occurring at and below the main cloud layer may have decreased between early 1979 and late 1986.
-
Warker, Jill A.
2013-01-01
Adults can rapidly learn artificial phonotactic constraints such as /f/ only occurs at the beginning of syllables by producing syllables that contain those constraints. This implicit learning is then reflected in their speech errors. However, second-order constraints in which the placement of a phoneme depends on another characteristic of the syllable (e.g., if the vowel is /æ/, /f/ occurs at the beginning of syllables and /s/ occurs at the end of syllables but if the vowel is /I/, the reverse is true) require a longer learning period. Two experiments question the transience of second-order learning and whether consolidation plays a role in learning phonological dependencies. Using speech errors as a measure of learning, Experiment 1 investigated the durability of learning, and Experiment 2 investigated the time-course of learning. Experiment 1 found that learning is still present in speech errors a week later. Experiment 2 looked at whether more time in the form of a consolidation period or more experience in the form of more trials was necessary for learning to be revealed in speech errors. Both consolidation and more trials led to learning; however, consolidation provided a more substantial benefit. PMID:22686839
-
An evaluation of programmed treatment-integrity errors during discrete-trial instruction.
Carroll, Regina A; Kodak, Tiffany; Fisher, Wayne W
2013-01-01
This study evaluated the effects of programmed treatment-integrity errors on skill acquisition for children with an autism spectrum disorder (ASD) during discrete-trial instruction (DTI). In Study 1, we identified common treatment-integrity errors that occur during academic instruction in schools. In Study 2, we simultaneously manipulated 3 integrity errors during DTI. In Study 3, we evaluated the effects of each of the 3 integrity errors separately on skill acquisition during DTI. Results showed that participants either demonstrated slower skill acquisition or did not acquire the target skills when instruction included treatment-integrity errors. © Society for the Experimental Analysis of Behavior.
-
Resiliency: Planning Ahead for Disasters - Continuum Magazine | NREL
a proactive approach to lessen the impacts of climate change as disasters occur more frequently and approach to lessen the impacts of climate change as disasters occur more frequently and with greater climate change. A photo of the silhouette of three men in construction uniforms as the walk toward the
-
Cha, DongHwan; Wang, Xin; Kim, Jeong Woo
2017-01-01
Hotspot analysis was implemented to find regions in the province of Alberta (Canada) with high frequency Cloud to Ground (CG) lightning strikes clustered together. Generally, hotspot regions are located in the central, central east, and south central regions of the study region. About 94% of annual lightning occurred during warm months (June to August) and the daily lightning frequency was influenced by the diurnal heating cycle. The association rule mining technique was used to investigate frequent CG lightning patterns, which were verified by similarity measurement to check the patterns’ consistency. The similarity coefficient values indicated that there were high correlations throughout the entire study period. Most wildfires (about 93%) in Alberta occurred in forests, wetland forests, and wetland shrub areas. It was also found that lightning and wildfires occur in two distinct areas: frequent wildfire regions with a high frequency of lightning, and frequent wild-fire regions with a low frequency of lightning. Further, the preference index (PI) revealed locations where the wildfires occurred more frequently than in other class regions. The wildfire hazard area was estimated with the CG lightning hazard map and specific land use types. PMID:29065564
-
Cha, DongHwan; Wang, Xin; Kim, Jeong Woo
2017-10-23
Hotspot analysis was implemented to find regions in the province of Alberta (Canada) with high frequency Cloud to Ground (CG) lightning strikes clustered together. Generally, hotspot regions are located in the central, central east, and south central regions of the study region. About 94% of annual lightning occurred during warm months (June to August) and the daily lightning frequency was influenced by the diurnal heating cycle. The association rule mining technique was used to investigate frequent CG lightning patterns, which were verified by similarity measurement to check the patterns' consistency. The similarity coefficient values indicated that there were high correlations throughout the entire study period. Most wildfires (about 93%) in Alberta occurred in forests, wetland forests, and wetland shrub areas. It was also found that lightning and wildfires occur in two distinct areas: frequent wildfire regions with a high frequency of lightning, and frequent wild-fire regions with a low frequency of lightning. Further, the preference index (PI) revealed locations where the wildfires occurred more frequently than in other class regions. The wildfire hazard area was estimated with the CG lightning hazard map and specific land use types.
-
Harada, Saki; Suzuki, Akio; Nishida, Shohei; Kobayashi, Ryo; Tamai, Sayuri; Kumada, Keisuke; Murakami, Nobuo; Itoh, Yoshinori
2017-06-01
Insulin is frequently used for glycemic control. Medication errors related to insulin are a common problem for medical institutions. Here, we prepared a standardized sliding scale insulin (SSI) order sheet and assessed the effect of its introduction. Observations before and after the introduction of the standardized SSI template were conducted at Gifu University Hospital. The incidence of medication errors, hyperglycemia, and hypoglycemia related to SSI were obtained from the electronic medical records. The introduction of the standardized SSI order sheet significantly reduced the incidence of medication errors related to SSI compared with that prior to its introduction (12/165 [7.3%] vs 4/159 [2.1%], P = .048). However, the incidence of hyperglycemia (≥250 mg/dL) and hypoglycemia (≤50 mg/dL) in patients who received SSI was not significantly different between the 2 groups. The introduction of the standardized SSI order sheet reduced the incidence of medication errors related to SSI. © 2016 John Wiley & Sons, Ltd.
-
Consistency errors in p-values reported in Spanish psychology journals.
Caperos, José Manuel; Pardo, Antonio
2013-01-01
Recent reviews have drawn attention to frequent consistency errors when reporting statistical results. We have reviewed the statistical results reported in 186 articles published in four Spanish psychology journals. Of these articles, 102 contained at least one of the statistics selected for our study: Fisher-F , Student-t and Pearson-c 2 . Out of the 1,212 complete statistics reviewed, 12.2% presented a consistency error, meaning that the reported p-value did not correspond to the reported value of the statistic and its degrees of freedom. In 2.3% of the cases, the correct calculation would have led to a different conclusion than the reported one. In terms of articles, 48% included at least one consistency error, and 17.6% would have to change at least one conclusion. In meta-analytical terms, with a focus on effect size, consistency errors can be considered substantial in 9.5% of the cases. These results imply a need to improve the quality and precision with which statistical results are reported in Spanish psychology journals.
-
Effect of patient positions on measurement errors of the knee-joint space on radiographs
NASA Astrophysics Data System (ADS)
Gilewska, Grazyna
2001-08-01
Osteoarthritis (OA) is one of the most important health problems these days. It is one of the most frequent causes of pain and disability of middle-aged and old people. Nowadays the radiograph is the most economic and available tool to evaluate changes in OA. Error of performance of radiographs of knee joint is the basic problem of their evaluation for clinical research. The purpose of evaluation of such radiographs in my study was measuring the knee-joint space on several radiographs performed at defined intervals. Attempt at evaluating errors caused by a radiologist of a patient was presented in this study. These errors resulted mainly from either incorrect conditions of performance or from a patient's fault. Once we have information about size of the errors, we will be able to assess which of these elements have the greatest influence on accuracy and repeatability of measurements of knee-joint space. And consequently we will be able to minimize their sources.
-
Effects of monetary reward and punishment on information checking behaviour.
Li, Simon Y W; Cox, Anna L; Or, Calvin; Blandford, Ann
2016-03-01
Two experiments were conducted to examine whether checking one's own work can be motivated by monetary reward and punishment. Participants were randomly assigned to one of three conditions: a flat-rate payment for completing the task (Control); payment increased for error-free performance (Reward); payment decreased for error performance (Punishment). Experiment 1 (N = 90) was conducted with liberal arts students, using a general data-entry task. Experiment 2 (N = 90) replicated Experiment 1 with clinical students and a safety-critical 'cover story' for the task. In both studies, Reward and Punishment resulted in significantly fewer errors, more frequent and longer checking, than Control. No such differences were obtained between the Reward and Punishment conditions. It is concluded that error consequences in terms of monetary reward and punishment can result in more accurate task performance and more rigorous checking behaviour than errors without consequences. However, whether punishment is more effective than reward, or vice versa, remains inconclusive. Copyright © 2015 Elsevier Ltd and The Ergonomics Society. All rights reserved.
-
Error monitoring issues for common channel signaling
NASA Astrophysics Data System (ADS)
Hou, Victor T.; Kant, Krishna; Ramaswami, V.; Wang, Jonathan L.
1994-04-01
Motivated by field data which showed a large number of link changeovers and incidences of link oscillations between in-service and out-of-service states in common channel signaling (CCS) networks, a number of analyses of the link error monitoring procedures in the SS7 protocol were performed by the authors. This paper summarizes the results obtained thus far and include the following: (1) results of an exact analysis of the performance of the error monitoring procedures under both random and bursty errors; (2) a demonstration that there exists a range of error rates within which the error monitoring procedures of SS7 may induce frequent changeovers and changebacks; (3) an analysis of the performance ofthe SS7 level-2 transmission protocol to determine the tolerable error rates within which the delay requirements can be met; (4) a demonstration that the tolerable error rate depends strongly on various link and traffic characteristics, thereby implying that a single set of error monitor parameters will not work well in all situations; (5) some recommendations on a customizable/adaptable scheme of error monitoring with a discussion on their implementability. These issues may be particularly relevant in the presence of anticipated increases in SS7 traffic due to widespread deployment of Advanced Intelligent Network (AIN) and Personal Communications Service (PCS) as well as for developing procedures for high-speed SS7 links currently under consideration by standards bodies.
-
DOE Office of Scientific and Technical Information (OSTI.GOV)
Elnahal, Shereef M., E-mail: selnaha1@jhmi.edu; Blackford, Amanda; Smith, Koren
Purpose: To describe radiation therapy cases during which voluntary incident reporting occurred; and identify patient- or treatment-specific factors that place patients at higher risk for incidents. Methods and Materials: We used our institution's incident learning system to build a database of patients with incident reports filed between January 2011 and December 2013. Patient- and treatment-specific data were reviewed for all patients with reported incidents, which were classified by step in the process and root cause. A control group of patients without events was generated for comparison. Summary statistics, likelihood ratios, and mixed-effect logistic regression models were used for group comparisons. Results:more » The incident and control groups comprised 794 and 499 patients, respectively. Common root causes included documentation errors (26.5%), communication (22.5%), technical treatment planning (37.5%), and technical treatment delivery (13.5%). Incidents were more frequently reported in minors (age <18 years) than in adult patients (37.7% vs 0.4%, P<.001). Patients with head and neck (16% vs 8%, P<.001) and breast (20% vs 15%, P=.03) primaries more frequently had incidents, whereas brain (18% vs 24%, P=.008) primaries were less frequent. Larger tumors (17% vs 10% had T4 lesions, P=.02), and cases on protocol (9% vs 5%, P=.005) or with intensity modulated radiation therapy/image guided intensity modulated radiation therapy (52% vs 43%, P=.001) were more likely to have incidents. Conclusions: We found several treatment- and patient-specific variables associated with incidents. These factors should be considered by treatment teams at the time of peer review to identify patients at higher risk. Larger datasets are required to recommend changes in care process standards, to minimize safety risks.« less
-
What errors do peer reviewers detect, and does training improve their ability to detect them?
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.
-
Basilakos, Alexandra; Rorden, Chris; Bonilha, Leonardo; Moser, Dana; Fridriksson, Julius
2015-01-01
Background and Purpose Acquired apraxia of speech (AOS) is a motor speech disorder caused by brain damage. AOS often co-occurs with aphasia, a language disorder in which patients may also demonstrate speech production errors. The overlap of speech production deficits in both disorders has raised questions regarding if AOS emerges from a unique pattern of brain damage or as a sub-element of the aphasic syndrome. The purpose of this study was to determine whether speech production errors in AOS and aphasia are associated with distinctive patterns of brain injury. Methods Forty-three patients with history of a single left-hemisphere stroke underwent comprehensive speech and language testing. The Apraxia of Speech Rating Scale was used to rate speech errors specific to AOS versus speech errors that can also be associated with AOS and/or aphasia. Localized brain damage was identified using structural MRI, and voxel-based lesion-impairment mapping was used to evaluate the relationship between speech errors specific to AOS, those that can occur in AOS and/or aphasia, and brain damage. Results The pattern of brain damage associated with AOS was most strongly associated with damage to cortical motor regions, with additional involvement of somatosensory areas. Speech production deficits that could be attributed to AOS and/or aphasia were associated with damage to the temporal lobe and the inferior pre-central frontal regions. Conclusion AOS likely occurs in conjunction with aphasia due to the proximity of the brain areas supporting speech and language, but the neurobiological substrate for each disorder differs. PMID:25908457
-
Basilakos, Alexandra; Rorden, Chris; Bonilha, Leonardo; Moser, Dana; Fridriksson, Julius
2015-06-01
Acquired apraxia of speech (AOS) is a motor speech disorder caused by brain damage. AOS often co-occurs with aphasia, a language disorder in which patients may also demonstrate speech production errors. The overlap of speech production deficits in both disorders has raised questions on whether AOS emerges from a unique pattern of brain damage or as a subelement of the aphasic syndrome. The purpose of this study was to determine whether speech production errors in AOS and aphasia are associated with distinctive patterns of brain injury. Forty-three patients with history of a single left-hemisphere stroke underwent comprehensive speech and language testing. The AOS Rating Scale was used to rate speech errors specific to AOS versus speech errors that can also be associated with both AOS and aphasia. Localized brain damage was identified using structural magnetic resonance imaging, and voxel-based lesion-impairment mapping was used to evaluate the relationship between speech errors specific to AOS, those that can occur in AOS or aphasia, and brain damage. The pattern of brain damage associated with AOS was most strongly associated with damage to cortical motor regions, with additional involvement of somatosensory areas. Speech production deficits that could be attributed to AOS or aphasia were associated with damage to the temporal lobe and the inferior precentral frontal regions. AOS likely occurs in conjunction with aphasia because of the proximity of the brain areas supporting speech and language, but the neurobiological substrate for each disorder differs. © 2015 American Heart Association, Inc.
-
Effect of bar-code technology on the safety of medication administration.
Poon, Eric G; Keohane, Carol A; Yoon, Catherine S; Ditmore, Matthew; Bane, Anne; Levtzion-Korach, Osnat; Moniz, Thomas; Rothschild, Jeffrey M; Kachalia, Allen B; Hayes, Judy; Churchill, William W; Lipsitz, Stuart; Whittemore, Anthony D; Bates, David W; Gandhi, Tejal K
2010-05-06
Serious medication errors are common in hospitals and often occur during order transcription or administration of medication. To help prevent such errors, technology has been developed to verify medications by incorporating bar-code verification technology within an electronic medication-administration system (bar-code eMAR). We conducted a before-and-after, quasi-experimental study in an academic medical center that was implementing the bar-code eMAR. We assessed rates of errors in order transcription and medication administration on units before and after implementation of the bar-code eMAR. Errors that involved early or late administration of medications were classified as timing errors and all others as nontiming errors. Two clinicians reviewed the errors to determine their potential to harm patients and classified those that could be harmful as potential adverse drug events. We observed 14,041 medication administrations and reviewed 3082 order transcriptions. Observers noted 776 nontiming errors in medication administration on units that did not use the bar-code eMAR (an 11.5% error rate) versus 495 such errors on units that did use it (a 6.8% error rate)--a 41.4% relative reduction in errors (P<0.001). The rate of potential adverse drug events (other than those associated with timing errors) fell from 3.1% without the use of the bar-code eMAR to 1.6% with its use, representing a 50.8% relative reduction (P<0.001). The rate of timing errors in medication administration fell by 27.3% (P<0.001), but the rate of potential adverse drug events associated with timing errors did not change significantly. Transcription errors occurred at a rate of 6.1% on units that did not use the bar-code eMAR but were completely eliminated on units that did use it. Use of the bar-code eMAR substantially reduced the rate of errors in order transcription and in medication administration as well as potential adverse drug events, although it did not eliminate such errors. Our data show that the bar-code eMAR is an important intervention to improve medication safety. (ClinicalTrials.gov number, NCT00243373.) 2010 Massachusetts Medical Society
-
Atwood, E.L.
1958-01-01
Response bias errors are studied by comparing questionnaire responses from waterfowl hunters using four large public hunting areas with actual hunting data from these areas during two hunting seasons. To the extent that the data permit, the sources of the error in the responses were studied and the contribution of each type to the total error was measured. Response bias errors, including both prestige and memory bias, were found to be very large as compared to non-response and sampling errors. Good fits were obtained with the seasonal kill distribution of the actual hunting data and the negative binomial distribution and a good fit was obtained with the distribution of total season hunting activity and the semi-logarithmic curve. A comparison of the actual seasonal distributions with the questionnaire response distributions revealed that the prestige and memory bias errors are both positive. The comparisons also revealed the tendency for memory bias errors to occur at digit frequencies divisible by five and for prestige bias errors to occur at frequencies which are multiples of the legal daily bag limit. A graphical adjustment of the response distributions was carried out by developing a smooth curve from those frequency classes not included in the predictable biased frequency classes referred to above. Group averages were used in constructing the curve, as suggested by Ezekiel [1950]. The efficiency of the technique described for reducing response bias errors in hunter questionnaire responses on seasonal waterfowl kill is high in large samples. The graphical method is not as efficient in removing response bias errors in hunter questionnaire responses on seasonal hunting activity where an average of 60 percent was removed.
-
Describing Phonological Paraphasias in Three Variants of Primary Progressive Aphasia.
Dalton, Sarah Grace Hudspeth; Shultz, Christine; Henry, Maya L; Hillis, Argye E; Richardson, Jessica D
2018-03-01
The purpose of this study was to describe the linguistic environment of phonological paraphasias in 3 variants of primary progressive aphasia (semantic, logopenic, and nonfluent) and to describe the profiles of paraphasia production for each of these variants. Discourse samples of 26 individuals diagnosed with primary progressive aphasia were investigated for phonological paraphasias using the criteria established for the Philadelphia Naming Test (Moss Rehabilitation Research Institute, 2013). Phonological paraphasias were coded for paraphasia type, part of speech of the target word, target word frequency, type of segment in error, word position of consonant errors, type of error, and degree of change in consonant errors. Eighteen individuals across the 3 variants produced phonological paraphasias. Most paraphasias were nonword, followed by formal, and then mixed, with errors primarily occurring on nouns and verbs, with relatively few on function words. Most errors were substitutions, followed by addition and deletion errors, and few sequencing errors. Errors were evenly distributed across vowels, consonant singletons, and clusters, with more errors occurring in initial and medial positions of words than in the final position of words. Most consonant errors consisted of only a single-feature change, with few 2- or 3-feature changes. Importantly, paraphasia productions by variant differed from these aggregate results, with unique production patterns for each variant. These results suggest that a system where paraphasias are coded as present versus absent may be insufficient to adequately distinguish between the 3 subtypes of PPA. The 3 variants demonstrate patterns that may be used to improve phenotyping and diagnostic sensitivity. These results should be integrated with recent findings on phonological processing and speech rate. Future research should attempt to replicate these results in a larger sample of participants with longer speech samples and varied elicitation tasks. https://doi.org/10.23641/asha.5558107.
-
2010-03-15
Swiss cheese model of human error causation. ................................................................... 3 2. Results for the classification of...based on Reason’s “ Swiss cheese ” model of human error (1990). Figure 1 describes how an accident is likely to occur when all of the errors, or “holes...align. A detailed description of HFACS can be found in Wiegmann and Shappell (2003). Figure 1. The Swiss cheese model of human error
-
DOE Office of Scientific and Technical Information (OSTI.GOV)
Wojahn, Christopher K.
2015-10-20
This HDL code (hereafter referred to as "software") implements circuitry in Xilinx Virtex-5QV Field Programmable Gate Array (FPGA) hardware. This software allows the device to self-check the consistency of its own configuration memory for radiation-induced errors. The software then provides the capability to correct any single-bit errors detected in the memory using the device's inherent circuitry, or reload corrupted memory frames when larger errors occur that cannot be corrected with the device's built-in error correction and detection scheme.
-
1984-06-01
space discretization error . 1. I 3 1. INTRODUCTION Reaction- diffusion processes occur in many branches of biology and physical chemistry. Examples...to model reaction- diffusion phenomena. The primary goal of this adaptive method is to keep a particular norm of the space discretization error less...AD-A142 253 AN ADAPTIVE MET6 OFD LNES WITH ERROR CONTROL FOR 1 INST FOR PHYSICAL SCIENCE AND TECH. I BABUSKAAAO C7 EA OH S UMR AN UNVC EEP R
-
Automated Classification of Phonological Errors in Aphasic Language
Ahuja, Sanjeev B.; Reggia, James A.; Berndt, Rita S.
1984-01-01
Using heuristically-guided state space search, a prototype program has been developed to simulate and classify phonemic errors occurring in the speech of neurologically-impaired patients. Simulations are based on an interchangeable rule/operator set of elementary errors which represent a theory of phonemic processing faults. This work introduces and evaluates a novel approach to error simulation and classification, it provides a prototype simulation tool for neurolinguistic research, and it forms the initial phase of a larger research effort involving computer modelling of neurolinguistic processes.
-
Armstrong, Gail E; Dietrich, Mary; Norman, Linda; Barnsteiner, Jane; Mion, Lorraine
Approximately a quarter of medication errors in the hospital occur at the administration phase, which is solely under the purview of the bedside nurse. The purpose of this study was to assess bedside nurses' perceived skills and attitudes about updated safety concepts and examine their impact on medication administration errors and adherence to safe medication administration practices. Findings support the premise that medication administration errors result from an interplay among system-, unit-, and nurse-level factors.
-
Horizon sensor errors calculated by computer models compared with errors measured in orbit
NASA Technical Reports Server (NTRS)
Ward, K. A.; Hogan, R.; Andary, J.
1982-01-01
Using a computer program to model the earth's horizon and to duplicate the signal processing procedure employed by the ESA (Earth Sensor Assembly), errors due to radiance variation have been computed for a particular time of the year. Errors actually occurring in flight at the same time of year are inferred from integrated rate gyro data for a satellite of the TIROS series of NASA weather satellites (NOAA-A). The predicted performance is compared with actual flight history.
-
Error quantification of abnormal extreme high waves in Operational Oceanographic System in Korea
NASA Astrophysics Data System (ADS)
Jeong, Sang-Hun; Kim, Jinah; Heo, Ki-Young; Park, Kwang-Soon
2017-04-01
In winter season, large-height swell-like waves have occurred on the East coast of Korea, causing property damages and loss of human life. It is known that those waves are generated by a local strong wind made by temperate cyclone moving to eastward in the East Sea of Korean peninsula. Because the waves are often occurred in the clear weather, in particular, the damages are to be maximized. Therefore, it is necessary to predict and forecast large-height swell-like waves to prevent and correspond to the coastal damages. In Korea, an operational oceanographic system (KOOS) has been developed by the Korea institute of ocean science and technology (KIOST) and KOOS provides daily basis 72-hours' ocean forecasts such as wind, water elevation, sea currents, water temperature, salinity, and waves which are computed from not only meteorological and hydrodynamic model (WRF, ROMS, MOM, and MOHID) but also wave models (WW-III and SWAN). In order to evaluate the model performance and guarantee a certain level of accuracy of ocean forecasts, a Skill Assessment (SA) system was established as a one of module in KOOS. It has been performed through comparison of model results with in-situ observation data and model errors have been quantified with skill scores. Statistics which are used in skill assessment are including a measure of both errors and correlations such as root-mean-square-error (RMSE), root-mean-square-error percentage (RMSE%), mean bias (MB), correlation coefficient (R), scatter index (SI), circular correlation (CC) and central frequency (CF) that is a frequency with which errors lie within acceptable error criteria. It should be utilized simultaneously not only to quantify an error but also to improve an accuracy of forecasts by providing a feedback interactively. However, in an abnormal phenomena such as high-height swell-like waves in the East coast of Korea, it requires more advanced and optimized error quantification method that allows to predict the abnormal waves well and to improve the accuracy of forecasts by supporting modification of physics and numeric on numerical models through sensitivity test. In this study, we proposed an appropriate method of error quantification especially on abnormal high waves which are occurred by local weather condition. Furthermore, we introduced that how the quantification errors are contributed to improve wind-wave modeling by applying data assimilation and utilizing reanalysis data.
-
2008-01-01
strategies, increasing the prevalence of both hypoglycemia and anemia in the ICU.14–20 The change in allogeneic blood transfusion practices occurred in...measurements in samples with low HCT levels.4,5,7,8,12 The error occurs because de- creased red blood cell causes less displacement of plasma, resulting...Nonlinear component regression was performed be- cause HCT has a nonlinear effect on accuracy of POC glucometers. A dual parameter correction factor was
-
Gastrointestinal Disorders in Children with Neurodevelopmental Disabilities
ERIC Educational Resources Information Center
Sullivan, Peter B.
2008-01-01
Children with neurodevelopmental disabilities such as cerebral palsy (CP), spina bifida, or inborn errors of metabolism frequently have associated gastrointestinal problems. These include oral motor dysfunction leading to feeding difficulties, risk of aspiration, prolonged feeding times, and malnutrition with its attendant physical compromise.…
-
The Relationship Between Work Commitment, Dynamic, and Medication Error.
Rezaiamin, Abdoolkarim; Pazokian, Marzieh; Zagheri Tafreshi, Mansoureh; Nasiri, Malihe
2017-05-01
Incidence of medication errors in intensive care unit (ICU) can cause irreparable damage for ICU patients. Therefore, it seems necessary to find the causes of medication errors in this section. Work commitment and dynamic might affect the incidence of medication errors in ICU. To assess the mentioned hypothesis, we performed a descriptive-analytical study which was carried out on 117 nurses working in ICU of educational hospitals in Tehran. Minick et al., Salyer et al., and Wakefield et al. scales were used for data gathering on work commitment, dynamic, and medication errors, respectively. Findings of the current study revealed that high work commitment in ICU nurses caused low number of medication errors, including intravenous and nonintravenous. We controlled the effects of confounding variables in detection of this relationship. In contrast, no significant association was found between work dynamic and different types of medication errors. Although the study did not observe any relationship between the dynamics and rate of medication errors, the training of nurses or nursing students to create a dynamic environment in hospitals can increase their interest in the profession and increase job satisfaction in them. Also they must have enough ability in work dynamic so that they don't confused and distracted result in frequent changes of orders, care plans, and procedures.
-
Vairy, Stephanie; Corny, Jennifer; Jamoulle, Olivier; Levy, Arielle; Lebel, Denis; Carceller, Ana
2017-12-01
A high rate of prescription errors exists in pediatric teaching hospitals, especially during initial training. To determine the effectiveness of a two-hour lecture by a pharmacist on rates of prescription errors and quality of prescriptions. A two-hour lecture led by a pharmacist was provided to 11 junior pediatric residents (PGY-1) as part of a one-month immersion program. A control group included 15 residents without the intervention. We reviewed charts to analyze the first 50 prescriptions of each resident. Data were collected from 1300 prescriptions involving 451 patients, 550 in the intervention group and 750 in the control group. The rate of prescription errors in the intervention group was 9.6% compared to 11.3% in the control group (p=0.32), affecting 106 patients. Statistically significant differences between both groups were prescriptions with unwritten doses (p=0.01) and errors involving overdosing (p=0.04). We identified many errors as well as issues surrounding quality of prescriptions. We found a 10.6% prescription error rate. This two-hour lecture seems insufficient to reduce prescription errors among junior pediatric residents. This study highlights the most frequent types of errors and prescription quality issues that should be targeted by future educational interventions.
-
A study for systematic errors of the GLA forecast model in tropical regions
NASA Technical Reports Server (NTRS)
Chen, Tsing-Chang; Baker, Wayman E.; Pfaendtner, James; Corrigan, Martin
1988-01-01
From the sensitivity studies performed with the Goddard Laboratory for Atmospheres (GLA) analysis/forecast system, it was revealed that the forecast errors in the tropics affect the ability to forecast midlatitude weather in some cases. Apparently, the forecast errors occurring in the tropics can propagate to midlatitudes. Therefore, the systematic error analysis of the GLA forecast system becomes a necessary step in improving the model's forecast performance. The major effort of this study is to examine the possible impact of the hydrological-cycle forecast error on dynamical fields in the GLA forecast system.
-
Cognitive processes in anesthesiology decision making.
Stiegler, Marjorie Podraza; Tung, Avery
2014-01-01
The quality and safety of health care are under increasing scrutiny. Recent studies suggest that medical errors, practice variability, and guideline noncompliance are common, and that cognitive error contributes significantly to delayed or incorrect diagnoses. These observations have increased interest in understanding decision-making psychology.Many nonrational (i.e., not purely based in statistics) cognitive factors influence medical decisions and may lead to error. The most well-studied include heuristics, preferences for certainty, overconfidence, affective (emotional) influences, memory distortions, bias, and social forces such as fairness or blame.Although the extent to which such cognitive processes play a role in anesthesia practice is unknown, anesthesia care frequently requires rapid, complex decisions that are most susceptible to decision errors. This review will examine current theories of human decision behavior, identify effects of nonrational cognitive processes on decision making, describe characteristic anesthesia decisions in this context, and suggest strategies to improve decision making.
-
Numerical stability in problems of linear algebra.
NASA Technical Reports Server (NTRS)
Babuska, I.
1972-01-01
Mathematical problems are introduced as mappings from the space of input data to that of the desired output information. Then a numerical process is defined as a prescribed recurrence of elementary operations creating the mapping of the underlying mathematical problem. The ratio of the error committed by executing the operations of the numerical process (the roundoff errors) to the error introduced by perturbations of the input data (initial error) gives rise to the concept of lambda-stability. As examples, several processes are analyzed from this point of view, including, especially, old and new processes for solving systems of linear algebraic equations with tridiagonal matrices. In particular, it is shown how such a priori information can be utilized as, for instance, a knowledge of the row sums of the matrix. Information of this type is frequently available where the system arises in connection with the numerical solution of differential equations.
-
Localized landslide risk assessment with multi pass L band DInSAR analysis
NASA Astrophysics Data System (ADS)
Yun, HyeWon; Rack Kim, Jung; Lin, Shih-Yuan; Choi, YunSoo
2014-05-01
In terms of data availability and error correction, landslide forecasting by Differential Interferometric SAR (DInSAR) analysis is not easy task. Especially, the landslides by the anthropogenic construction activities frequently occurred in the localized cutting side of mountainous area. In such circumstances, it is difficult to attain sufficient enough accuracy because of the external factors inducing the error component in electromagnetic wave propagation. For instance, the local climate characteristics such as orographic effect and the proximity to water source can produce the significant anomalies in the water vapor distribution and consequently result in the error components of InSAR phase angle measurements. Moreover the high altitude parts of target area cause the stratified tropospheric delay error in DInSAR measurement. The other obstacle in DInSAR observation over the potential landside site is the vegetation canopy which causes the decorrelation of InSAR phase. Thus rather than C band sensor such as ENVISAT, ERS and RADARSAT, DInSAR analysis with L band ALOS PLASAR is more recommendable. Together with the introduction of L band DInSAR analysis, the improved DInSAR technique to cope all above obstacles is necessary. Thus we employed two approaches i.e. StaMPS/MTI (Stanford Method for Persistent Scatterers/Multi-Temporal InSAR, Hopper et al., 2007) which was newly developed for extracting the reliable deformation values through time series analysis and two pass DInSAR with the error term compensation based on the external weather information in this study. Since the water vapor observation from spaceborne radiometer is not feasible by the temporal gap in this case, the quantities from weather Research Forecasting (WRF) with 1 km spatial resolution was used to address the atmospheric phase error in two pass DInSAR analysis. Also it was observed that base DEM offset with time dependent perpendicular baselines of InSAR time series produce a significant error even in the advanced time series techniques such as StaMPS/MTI. We tried to compensate with the algorithmic base together with the usage of high resolution LIDAR DEM. The target area of this study is the eastern part of Korean peninsula centered. In there, the landslide originated by the geomorphic factors such as high sloped topography and localized torrential down pour is critical issue. The surface deformations from error corrected two pass DInSAR and StaMPS/MTI are crossly compared and validated with the landslide triggering factors such as vegetation, slope and geological properties. The study will be further extended for the application of future SAR sensors by incorporating the dynamic analysis of topography to implement practical landslide forecasting scheme.
-
Neural correlates of performance monitoring in chronic cannabis users and cannabis-naïve controls
Fridberg, Daniel J; Skosnik, Patrick D; Hetrick, William P; O’Donnell, Brian F
2014-01-01
Chronic cannabis use is associated with residual negative effects on measures of executive functioning. However, little previous work has focused specifically on executive processes involved in performance monitoring in frequent cannabis users. The present study investigated event-related potential (ERP) correlates of performance monitoring in chronic cannabis users. The error-related negativity (ERN) and error positivity (Pe), ERPs sensitive to performance monitoring, were recorded from 30 frequent cannabis users (mean usage=5.52 days/week) and 32 cannabis-naïve control participants during a speeded stimulus discrimination task. The “oddball” P3 ERP was recorded as well. Users and controls did not differ on the amplitude or latency of the ERN; however, Pe amplitude was larger among users. Users also showed increased amplitude and reduced latency of the P3 in response to infrequent stimuli presented during the task. Among users, urinary cannabinoid metabolite levels at testing were unrelated to ERP outcomes. However, total years of cannabis use correlated negatively with P3 latency and positively with P3 amplitude, and age of first cannabis use correlated negatively with P3 amplitude. The results of this study suggest that chronic cannabis use is associated with alterations in neural activity related to the processing of motivationally-relevant stimuli (P3) and errors (Pe). PMID:23427191
-
ERIC Educational Resources Information Center
Micceri, Theodore; Parasher, Pradnya; Waugh, Gordon W.; Herreid, Charlene
2009-01-01
An extensive review of the research literature and a study comparing over 36,000 survey responses with archival true scores indicated that one should expect a minimum of at least three percent random error for the least ambiguous of self-report measures. The Gulliver Effect occurs when a small proportion of error in a sizable subpopulation exerts…
-
Optical Oversampled Analog-to-Digital Conversion
1992-06-29
hologram weights and interconnects in the digital image halftoning configuration. First, no temporal error diffusion occurs in the digital image... halftoning error diffusion ar- chitecture as demonstrated by Equation (6.1). Equation (6.2) ensures that the hologram weights sum to one so that the exact...optimum halftone image should be faster. Similarly, decreased convergence time suggests that an error diffusion filter with larger spatial dimensions
-
Finkel, Eli J; Eastwick, Paul W; Reis, Harry T
2015-02-01
In recent years, a robust movement has emerged within psychology to increase the evidentiary value of our science. This movement, which has analogs throughout the empirical sciences, is broad and diverse, but its primary emphasis has been on the reduction of statistical false positives. The present article addresses epistemological and pragmatic issues that we, as a field, must consider as we seek to maximize the scientific value of this movement. Regarding epistemology, this article contrasts the false-positives-reduction (FPR) approach with an alternative, the error balance (EB) approach, which argues that any serious consideration of optimal scientific practice must contend simultaneously with both false-positive and false-negative errors. Regarding pragmatics, the movement has devoted a great deal of attention to issues that frequently arise in laboratory experiments and one-shot survey studies, but it has devoted less attention to issues that frequently arise in intensive and/or longitudinal studies. We illustrate these epistemological and pragmatic considerations with the case of relationship science, one of the many research domains that frequently employ intensive and/or longitudinal methods. Specifically, we examine 6 research prescriptions that can help to reduce false-positive rates: preregistration, prepublication sharing of materials, postpublication sharing of data, close replication, avoiding piecemeal publication, and increasing sample size. For each, we offer concrete guidance not only regarding how researchers can improve their research practices and balance the risk of false-positive and false-negative errors, but also how the movement can capitalize upon insights from research practices within relationship science to make the movement stronger and more inclusive. PsycINFO Database Record (c) 2015 APA, all rights reserved.
-
Masked and unmasked error-related potentials during continuous control and feedback
NASA Astrophysics Data System (ADS)
Lopes Dias, Catarina; Sburlea, Andreea I.; Müller-Putz, Gernot R.
2018-06-01
The detection of error-related potentials (ErrPs) in tasks with discrete feedback is well established in the brain–computer interface (BCI) field. However, the decoding of ErrPs in tasks with continuous feedback is still in its early stages. Objective. We developed a task in which subjects have continuous control of a cursor’s position by means of a joystick. The cursor’s position was shown to the participants in two different modalities of continuous feedback: normal and jittered. The jittered feedback was created to mimic the instability that could exist if participants controlled the trajectory directly with brain signals. Approach. This paper studies the electroencephalographic (EEG)—measurable signatures caused by a loss of control over the cursor’s trajectory, causing a target miss. Main results. In both feedback modalities, time-locked potentials revealed the typical frontal-central components of error-related potentials. Errors occurring during the jittered feedback (masked errors) were delayed in comparison to errors occurring during normal feedback (unmasked errors). Masked errors displayed lower peak amplitudes than unmasked errors. Time-locked classification analysis allowed a good distinction between correct and error classes (average Cohen-, average TPR = 81.8% and average TNR = 96.4%). Time-locked classification analysis between masked error and unmasked error classes revealed results at chance level (average Cohen-, average TPR = 60.9% and average TNR = 58.3%). Afterwards, we performed asynchronous detection of ErrPs, combining both masked and unmasked trials. The asynchronous detection of ErrPs in a simulated online scenario resulted in an average TNR of 84.0% and in an average TPR of 64.9%. Significance. The time-locked classification results suggest that the masked and unmasked errors were indistinguishable in terms of classification. The asynchronous classification results suggest that the feedback modality did not hinder the asynchronous detection of ErrPs.
-
Death Certification Errors and the Effect on Mortality Statistics.
McGivern, Lauri; Shulman, Leanne; Carney, Jan K; Shapiro, Steven; Bundock, Elizabeth
Errors in cause and manner of death on death certificates are common and affect families, mortality statistics, and public health research. The primary objective of this study was to characterize errors in the cause and manner of death on death certificates completed by non-Medical Examiners. A secondary objective was to determine the effects of errors on national mortality statistics. We retrospectively compared 601 death certificates completed between July 1, 2015, and January 31, 2016, from the Vermont Electronic Death Registration System with clinical summaries from medical records. Medical Examiners, blinded to original certificates, reviewed summaries, generated mock certificates, and compared mock certificates with original certificates. They then graded errors using a scale from 1 to 4 (higher numbers indicated increased impact on interpretation of the cause) to determine the prevalence of minor and major errors. They also compared International Classification of Diseases, 10th Revision (ICD-10) codes on original certificates with those on mock certificates. Of 601 original death certificates, 319 (53%) had errors; 305 (51%) had major errors; and 59 (10%) had minor errors. We found no significant differences by certifier type (physician vs nonphysician). We did find significant differences in major errors in place of death ( P < .001). Certificates for deaths occurring in hospitals were more likely to have major errors than certificates for deaths occurring at a private residence (59% vs 39%, P < .001). A total of 580 (93%) death certificates had a change in ICD-10 codes between the original and mock certificates, of which 348 (60%) had a change in the underlying cause-of-death code. Error rates on death certificates in Vermont are high and extend to ICD-10 coding, thereby affecting national mortality statistics. Surveillance and certifier education must expand beyond local and state efforts. Simplifying and standardizing underlying literal text for cause of death may improve accuracy, decrease coding errors, and improve national mortality statistics.
-
Use of modeling to identify vulnerabilities to human error in laparoscopy.
Funk, Kenneth H; Bauer, James D; Doolen, Toni L; Telasha, David; Nicolalde, R Javier; Reeber, Miriam; Yodpijit, Nantakrit; Long, Myra
2010-01-01
This article describes an exercise to investigate the utility of modeling and human factors analysis in understanding surgical processes and their vulnerabilities to medical error. A formal method to identify error vulnerabilities was developed and applied to a test case of Veress needle insertion during closed laparoscopy. A team of 2 surgeons, a medical assistant, and 3 engineers used hierarchical task analysis and Integrated DEFinition language 0 (IDEF0) modeling to create rich models of the processes used in initial port creation. Using terminology from a standardized human performance database, detailed task descriptions were written for 4 tasks executed in the process of inserting the Veress needle. Key terms from the descriptions were used to extract from the database generic errors that could occur. Task descriptions with potential errors were translated back into surgical terminology. Referring to the process models and task descriptions, the team used a modified failure modes and effects analysis (FMEA) to consider each potential error for its probability of occurrence, its consequences if it should occur and be undetected, and its probability of detection. The resulting likely and consequential errors were prioritized for intervention. A literature-based validation study confirmed the significance of the top error vulnerabilities identified using the method. Ongoing work includes design and evaluation of procedures to correct the identified vulnerabilities and improvements to the modeling and vulnerability identification methods. Copyright 2010 AAGL. Published by Elsevier Inc. All rights reserved.
-
Karnon, Jonathan; Campbell, Fiona; Czoski-Murray, Carolyn
2009-04-01
Medication errors can lead to preventable adverse drug events (pADEs) that have significant cost and health implications. Errors often occur at care interfaces, and various interventions have been devised to reduce medication errors at the point of admission to hospital. The aim of this study is to assess the incremental costs and effects [measured as quality adjusted life years (QALYs)] of a range of such interventions for which evidence of effectiveness exists. A previously published medication errors model was adapted to describe the pathway of errors occurring at admission through to the occurrence of pADEs. The baseline model was populated using literature-based values, and then calibrated to observed outputs. Evidence of effects was derived from a systematic review of interventions aimed at preventing medication error at hospital admission. All five interventions, for which evidence of effectiveness was identified, are estimated to be extremely cost-effective when compared with the baseline scenario. Pharmacist-led reconciliation intervention has the highest expected net benefits, and a probability of being cost-effective of over 60% by a QALY value of pound10 000. The medication errors model provides reasonably strong evidence that some form of intervention to improve medicines reconciliation is a cost-effective use of NHS resources. The variation in the reported effectiveness of the few identified studies of medication error interventions illustrates the need for extreme attention to detail in the development of interventions, but also in their evaluation and may justify the primary evaluation of more than one specification of included interventions.
-
Applying lessons learned to enhance human performance and reduce human error for ISS operations
DOE Office of Scientific and Technical Information (OSTI.GOV)
Nelson, W.R.
1999-01-01
A major component of reliability, safety, and mission success for space missions is ensuring that the humans involved (flight crew, ground crew, mission control, etc.) perform their tasks and functions as required. This includes compliance with training and procedures during normal conditions, and successful compensation when malfunctions or unexpected conditions occur. A very significant issue that affects human performance in space flight is human error. Human errors can invalidate carefully designed equipment and procedures. If certain errors combine with equipment failures or design flaws, mission failure or loss of life can occur. The control of human error during operation ofmore » the International Space Station (ISS) will be critical to the overall success of the program. As experience from Mir operations has shown, human performance plays a vital role in the success or failure of long duration space missions. The Department of Energy{close_quote}s Idaho National Engineering and Environmental Laboratory (INEEL) is developing a systematic approach to enhance human performance and reduce human errors for ISS operations. This approach is based on the systematic identification and evaluation of lessons learned from past space missions such as Mir to enhance the design and operation of ISS. This paper will describe previous INEEL research on human error sponsored by NASA and how it can be applied to enhance human reliability for ISS. {copyright} {ital 1999 American Institute of Physics.}« less
-
Applying lessons learned to enhance human performance and reduce human error for ISS operations
DOE Office of Scientific and Technical Information (OSTI.GOV)
Nelson, W.R.
1998-09-01
A major component of reliability, safety, and mission success for space missions is ensuring that the humans involved (flight crew, ground crew, mission control, etc.) perform their tasks and functions as required. This includes compliance with training and procedures during normal conditions, and successful compensation when malfunctions or unexpected conditions occur. A very significant issue that affects human performance in space flight is human error. Human errors can invalidate carefully designed equipment and procedures. If certain errors combine with equipment failures or design flaws, mission failure or loss of life can occur. The control of human error during operation ofmore » the International Space Station (ISS) will be critical to the overall success of the program. As experience from Mir operations has shown, human performance plays a vital role in the success or failure of long duration space missions. The Department of Energy`s Idaho National Engineering and Environmental Laboratory (INEEL) is developed a systematic approach to enhance human performance and reduce human errors for ISS operations. This approach is based on the systematic identification and evaluation of lessons learned from past space missions such as Mir to enhance the design and operation of ISS. This paper describes previous INEEL research on human error sponsored by NASA and how it can be applied to enhance human reliability for ISS.« less
-
[Rehabilitation after anterior cruciate ligament suturing].
Andrtová, M; Chlupatá, I
1994-01-01
The authors discuss problems of rehabilitation after suture of the anterior cruciate ligament where frequently errors are committed and where inadequate rehabilitation may cause damage to the patient. Different periods of rehabilitation after LCA sutures are discussed and suitable methods of exercise for different periods are recommended.
-
DOT National Transportation Integrated Search
2015-07-01
Highway construction takes place in remote locations, making document control challenging. Frequent changes in a project can cause errors, : reworks, and schedule delays due to the time taken to disseminate these changes to the field or due to using ...
-
Badrick, Tony; Graham, Peter
2018-03-28
Internal Quality Control and External Quality Assurance are separate but related processes that have developed independently in laboratory medicine over many years. They have different sample frequencies, statistical interpretations and immediacy. Both processes have evolved absorbing new understandings of the concept of laboratory error, sample material matrix and assay capability. However, we do not believe at the coalface that either process has led to much improvement in patient outcomes recently. It is the increasing reliability and automation of analytical platforms along with improved stability of reagents that has reduced systematic and random error, which in turn has minimised the risk of running less frequent IQC. We suggest that it is time to rethink the role of both these processes and unite them into a single approach using an Average of Normals model supported by more frequent External Quality Assurance samples. This new paradigm may lead to less confusion for laboratory staff and quicker responses to and identification of out of control situations.
-
Savičiūtė, Eglė; Ambridge, Ben; Pine, Julian M
2018-05-01
Four- and five-year-old children took part in an elicited familiar and novel Lithuanian noun production task to test predictions of input-based accounts of the acquisition of inflectional morphology. Two major findings emerged. First, as predicted by input-based accounts, correct production rates were correlated with the input frequency of the target form, and with the phonological neighbourhood density of the noun. Second, the error patterns were not compatible with the systematic substitution of target forms by either (a) the most frequent form of that noun or (b) a single morphosyntactic default form, as might be predicted by naive versions of a constructivist and generativist account, respectively. Rather, most errors reflected near-miss substitutions of singular for plural, masculine for feminine, or nominative/accusative for a less frequent case. Together, these findings provide support for an input-based approach to morphological acquisition, but are not adequately explained by any single account in its current form.
-
Mathemagical Computing: Order of Operations and New Software.
ERIC Educational Resources Information Center
Ecker, Michael W.
1989-01-01
Describes mathematical problems which occur when using the computer as a calculator. Considers errors in BASIC calculation and the order of mathematical operations. Identifies errors in spreadsheet and calculator programs. Comments on sorting programs and provides a source for Mathemagical Black Holes. (MVL)
-
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.
-
Rate, causes and reporting of medication errors in Jordan: nurses' perspectives.
Mrayyan, Majd T; Shishani, Kawkab; Al-Faouri, Ibrahim
2007-09-01
The aim of the study was to describe Jordanian nurses' perceptions about various issues related to medication errors. This is the first nursing study about medication errors in Jordan. This was a descriptive study. A convenient sample of 799 nurses from 24 hospitals was obtained. Descriptive and inferential statistics were used for data analysis. Over the course of their nursing career, the average number of recalled committed medication errors per nurse was 2.2. Using incident reports, the rate of medication errors reported to nurse managers was 42.1%. Medication errors occurred mainly when medication labels/packaging were of poor quality or damaged. Nurses failed to report medication errors because they were afraid that they might be subjected to disciplinary actions or even lose their jobs. In the stepwise regression model, gender was the only predictor of medication errors in Jordan. Strategies to reduce or eliminate medication errors are required.
-
Identifying Patterns in Extreme Precipitation Risk and the Related Impacts
NASA Astrophysics Data System (ADS)
Schroeer, K.; Tye, M. R.
2017-12-01
Extreme precipitation can harm human life and assets through flooding, hail, landslides, or debris flows. Flood risk assessments typically concentrate on river or mountain torrent channels, using water depth, flow velocity, and/or sediment deposition to quantify the risk. In addition, extreme events with high recurrence intervals are often the main focus. However, damages from short-term and localized convective showers often occur away from watercourses. Also, damages from more frequent small scale extremes, although usually less disastrous, can accumulate to considerable financial burdens. Extreme convective precipitation is expected to intensify in a warmer climate, and vulnerability patterns might change in tandem with changes in the character of precipitation and flood types. This has consequences for adaptation planners who want to establish effective protection measures and reduce the cost from natural hazards. Here we merge hydrological and exposure data to identify patterns of risk under varying synoptic conditions. Exposure is calculated from a database of 76k damage claims reported to the national disaster fund in 480 municipalities in south eastern Austria from 1990-2015. Hydrological data comprise sub-daily precipitation (59 gauges) and streamflow (62 gauges) observations. We use synoptic circulation types to identify typical precipitation patterns. They indicate the character of precipitation even if a gauge is not in close proximity, facilitating potential future research with regional climate model data. Results show that more claims are reported under synoptic conditions favouring convective precipitation (on average 1.5-3 times more than on other days). For agrarian municipalities, convective precipitation damages are among the costliest after long low-intensity precipitation events. In contrast, Alpine communities are particularly vulnerable to convective high-intensity rainfall. In addition to possible observational error, uncertainty is present in damage reporting errors, claims from private insurers and adaptation effects after damaging events. As for the latter, preliminary results indicate that investments regularly occur after big events, which may skew subsequent damage claims. Their effectiveness, though, needs to be analyzed in future research.
-
NASA Technical Reports Server (NTRS)
Landon, Lauren Blackwell; Vessey, William B.; Barrett, Jamie D.
2015-01-01
A team is defined as: "two or more individuals who interact socially and adaptively, have shared or common goals, and hold meaningful task interdependences; it is hierarchically structured and has a limited life span; in it expertise and roles are distributed; and it is embedded within an organization/environmental context that influences and is influenced by ongoing processes and performance outcomes" (Salas, Stagl, Burke, & Goodwin, 2007, p. 189). From the NASA perspective, a team is commonly understood to be a collection of individuals that is assigned to support and achieve a particular mission. Thus, depending on context, this definition can encompass both the spaceflight crew and the individuals and teams in the larger multi-team system who are assigned to support that crew during a mission. The Team Risk outcomes of interest are predominantly performance related, with a secondary emphasis on long-term health; this is somewhat unique in the NASA HRP in that most Risk areas are medically related and primarily focused on long-term health consequences. In many operational environments (e.g., aviation), performance is assessed as the avoidance of errors. However, the research on performance errors is ambiguous. It implies that actions may be dichotomized into "correct" or "incorrect" responses, where incorrect responses or errors are always undesirable. Researchers have argued that this dichotomy is a harmful oversimplification, and it would be more productive to focus on the variability of human performance and how organizations can manage that variability (Hollnagel, Woods, & Leveson, 2006) (Category III1). Two problems occur when focusing on performance errors: 1) the errors are infrequent and, therefore, difficult to observe and record; and 2) the errors do not directly correspond to failure. Research reveals that humans are fairly adept at correcting or compensating for performance errors before such errors result in recognizable or recordable failures. Astronauts are notably adept high performers. Most failures are recorded only when multiple, small errors occur and humans are unable to recognize and correct or compensate for these errors in time to prevent a failure (Dismukes, Berman, Loukopoulos, 2007) (Category III). More commonly, observers record variability in levels of performance. Some teams commit no observable errors but fail to achieve performance objectives or perform only adequately, while other teams commit some errors but perform spectacularly. Successful performance, therefore, cannot be viewed as simply the absence of errors or the avoidance of failure Johnson Space Center (JSC) Joint Leadership Team, 2008). While failure is commonly attributed to making a major error, focusing solely on the elimination of error(s) does not significantly reduce the risk of failure. Failure may also occur when performance is simply insufficient or an effort is incapable of adjusting sufficiently to a contextual change (e.g., changing levels of autonomy).
-
Sheehan, David V; Giddens, Jennifer M; Sheehan, Kathy Harnett
2014-09-01
Standard international classification criteria require that classification categories be comprehensive to avoid type II error. Categories should be mutually exclusive and definitions should be clear and unambiguous (to avoid type I and type II errors). In addition, the classification system should be robust enough to last over time and provide comparability between data collections. This article was designed to evaluate the extent to which the classification system contained in the United States Food and Drug Administration 2012 Draft Guidance for the prospective assessment and classification of suicidal ideation and behavior in clinical trials meets these criteria. A critical review is used to assess the extent to which the proposed categories contained in the Food and Drug Administration 2012 Draft Guidance are comprehensive, unambiguous, and robust. Assumptions that underlie the classification system are also explored. The Food and Drug Administration classification system contained in the 2012 Draft Guidance does not capture the full range of suicidal ideation and behavior (type II error). Definitions, moreover, are frequently ambiguous (susceptible to multiple interpretations), and the potential for misclassification (type I and type II errors) is compounded by frequent mismatches in category titles and definitions. These issues have the potential to compromise data comparability within clinical trial sites, across sites, and over time. These problems need to be remedied because of the potential for flawed data output and consequent threats to public health, to research on the safety of medications, and to the search for effective medication treatments for suicidality.
-
Molecular Characterization of Indolent Prostate Cancer
2013-10-01
SUPPLEMENTARY NOTES 14. ABSTRACT Indolent prostate cancers that pose very low risk to aged men occur frequently and may be detected at biopsy, leading...Introduction Indolent prostate cancers that pose very low risk to aged men occur frequently and may be detected at biopsy, leading to the...cancer at the time of biopsy detection and thus meeting the entry criteria for active surveillance. The scope of the proposed research is: 1) to
-
da Silva, Brianna A; Krishnamurthy, Mahesh
2016-01-01
A 71-year-old female accidentally received thiothixene (Navane), an antipsychotic, instead of her anti-hypertensive medication amlodipine (Norvasc) for 3 months. She sustained physical and psychological harm including ambulatory dysfunction, tremors, mood swings, and personality changes. Despite the many opportunities for intervention, multiple health care providers overlooked her symptoms. Errors occurred at multiple care levels, including prescribing, initial pharmacy dispensation, hospitalization, and subsequent outpatient follow-up. This exemplifies the Swiss Cheese Model of how errors can occur within a system. Adverse drug events (ADEs) account for more than 3.5 million physician office visits and 1 million emergency department visits each year. It is believed that preventable medication errors impact more than 7 million patients and cost almost $21 billion annually across all care settings. About 30% of hospitalized patients have at least one discrepancy on discharge medication reconciliation. Medication errors and ADEs are an underreported burden that adversely affects patients, providers, and the economy. Medication reconciliation including an 'indication review' for each prescription is an important aspect of patient safety. The decreasing frequency of pill bottle reviews, suboptimal patient education, and poor communication between healthcare providers are factors that threaten patient safety. Medication error and ADEs cost billions of health care dollars and are detrimental to the provider-patient relationship.
-
Lobaugh, Lauren M Y; Martin, Lizabeth D; Schleelein, Laura E; Tyler, Donald C; Litman, Ronald S
2017-09-01
Wake Up Safe is a quality improvement initiative of the Society for Pediatric Anesthesia that contains a deidentified registry of serious adverse events occurring in pediatric anesthesia. The aim of this study was to describe and characterize reported medication errors to find common patterns amenable to preventative strategies. In September 2016, we analyzed approximately 6 years' worth of medication error events reported to Wake Up Safe. Medication errors were classified by: (1) medication category; (2) error type by phase of administration: prescribing, preparation, or administration; (3) bolus or infusion error; (4) provider type and level of training; (5) harm as defined by the National Coordinating Council for Medication Error Reporting and Prevention; and (6) perceived preventability. From 2010 to the time of our data analysis in September 2016, 32 institutions had joined and submitted data on 2087 adverse events during 2,316,635 anesthetics. These reports contained details of 276 medication errors, which comprised the third highest category of events behind cardiac and respiratory related events. Medication errors most commonly involved opioids and sedative/hypnotics. When categorized by phase of handling, 30 events occurred during preparation, 67 during prescribing, and 179 during administration. The most common error type was accidental administration of the wrong dose (N = 84), followed by syringe swap (accidental administration of the wrong syringe, N = 49). Fifty-seven (21%) reported medication errors involved medications prepared as infusions as opposed to 1 time bolus administrations. Medication errors were committed by all types of anesthesia providers, most commonly by attendings. Over 80% of reported medication errors reached the patient and more than half of these events caused patient harm. Fifteen events (5%) required a life sustaining intervention. Nearly all cases (97%) were judged to be either likely or certainly preventable. Our findings characterize the most common types of medication errors in pediatric anesthesia practice and provide guidance on future preventative strategies. Many of these errors will be almost entirely preventable with the use of prefilled medication syringes to avoid accidental ampule swap, bar-coding at the point of medication administration to prevent syringe swap and to confirm the proper dose, and 2-person checking of medication infusions for accuracy.
-
Yazıcı, Yüksel Aydın; Şen, Humman; Aliustaoğlu, Suheyla; Sezer, Yiğit; İnce, Cengiz Haluk
2015-05-01
Malpractice is an occasion that occurs due to defective treatment in the course of providing health services. Neither all of the errors within the medical practices are medical malpractices, nor all of the medical malpractices result in harm and judicial process. Injuries occurring at the time of treatment process may result from a complication or medical malpractice. This study aims to evaluate the reports of the controversial cases brought to trial with the claim of medical malpractice, compiled by The Council of Forensic Medicine. Our study includes all of the cases brought to the Ministry of Justice, Council of Forensic Medicine General Assembly with the claim of medical malpractice within a period of 11 years between 2000 and 2011 (n=330). In our study, we saw that 33.3% of the 330 cases were detected as "medical malpractice" by the General assembly. Within this 33.3% segment cases, 14.2% of them resulted from treatment errors such as wrong or incomplete treatment and surgery, use of wrong medication, running late for a true diagnosis after necessary examination, inappropriate medical processes as well as applied treatment having causality with an emergent injury to the patient. 9.7% of them emerged from diagnosis errors like failure to diagnose, wrong diagnosis, lack of consultation request, lack of transfer to a top centre, lack of intervention resulting from not recognizing the postoperative complication on time. 8.8% of them occurred because of careless intervention such as lack of necessary care and attention, lack of post operation follow-ups, lack of essential informing, absenteeism when called for a patient, intervention under suboptimal conditions. Whereas 0.3% of them developed from errors due to inexperience, 0.3% of them were detected to have occurred because of the administrative mistakes following malfunction of healthcare system. It is very important to analyze the errors properly in order to get the medical malpractice under control. Going through the errors, on which process of health service they occur and their owners; keeping the record of all examinations and treatments in the course of health service regularly and properly will be a cornerstone for both occupational and forensic medicine practices to be standardized.
-
Wind Power Forecasting Error Distributions: An International Comparison; Preprint
DOE Office of Scientific and Technical Information (OSTI.GOV)
Hodge, B. M.; Lew, D.; Milligan, M.
2012-09-01
Wind power forecasting is expected to be an important enabler for greater penetration of wind power into electricity systems. Because no wind forecasting system is perfect, a thorough understanding of the errors that do occur can be critical to system operation functions, such as the setting of operating reserve levels. This paper provides an international comparison of the distribution of wind power forecasting errors from operational systems, based on real forecast data. The paper concludes with an assessment of similarities and differences between the errors observed in different locations.
-
Scheidegger, D
2005-03-01
In medicine real severe mishaps are rare. On the other hand critical incidents are frequent. Anonymous critical incident reporting systems allow us to learn from these mishaps. This learning process will make our daily clinical work safer Unfortunately, before these systems can be used efficiently our professional culture has to be changed. Everyone in medicine has to admit that errors do occur to see the need for an open discussion. If we really want to learn from errors, we cannot punish the individual, who reported his or her mistake. The interest is primarily in what has happened and why it has happened and not who has committed this mistake. The cause for critical incidents in medicine is in over 80% the human factor Poor communication, work under enormous stress, conflicts and hierarchies are the main cause. This has been known for many years, therefore have already 15 years ago high-tech industries, like e.g. aviation, started to invest in special courses on team training. Medicine is a typical profession were until now only the individual performance decided about the professional career Communication, conflict management, stress management, decision making, risk management, team and team resource management were subjects that have never been taught during our preor postgraduate education. These points are the most important ones for an optimal teamwork. A multimodular course designed together with Swissair (Human Aspect Development medical, HADmedical) helps to cover, as in aviation, the soft factor and behavioural education in medicine and to prepare professionals in health care to work as a real team.
-
Schmidt, Lena; Depper, Lena; Kerkhoff, Georg
2013-01-01
Position sense is an important proprioceptive ability. Disorders of arm position sense (APS) often occur after unilateral stroke, and are associated with a negative functional outcome. In the present study we assessed horizontal APS by measuring angular deviations from a visually defined target separately for each arm in a large group of healthy subjects. We analyzed the accuracy and instability of horizontal APS as a function of age, sex and arm. Subjects were required to specify verbally the position of their unseen arm on a 0-90° circuit by comparing the current position with the target position indicated by a LED lamp, while the arm was passively moved by the examiner. Eighty-seven healthy subjects participated in the study, ranging from 20 to 77 years, subdivided into three age groups. The results revealed that APS was not a function of age or sex, but was significantly better in the non-dominant (left) arm in absolute errors (AE) but not in constant errors (CE) across all age groups of right-handed healthy subjects. This indicates a right-hemisphere superiority for left APS in right-handers and neatly fits to the more frequent and more severe left-sided body-related deficits in patients with unilateral stroke (i.e. impaired APS in left spatial neglect, somatoparaphrenia) or in individuals with abnormalities of the right cerebral hemisphere. These clinical issues will be discussed. PMID:24399962
-
NASA Astrophysics Data System (ADS)
Hapugoda, J. C.; Sooriyarachchi, M. R.
2017-09-01
Survival time of patients with a disease and the incidence of that particular disease (count) is frequently observed in medical studies with the data of a clustered nature. In many cases, though, the survival times and the count can be correlated in a way that, diseases that occur rarely could have shorter survival times or vice versa. Due to this fact, joint modelling of these two variables will provide interesting and certainly improved results than modelling these separately. Authors have previously proposed a methodology using Generalized Linear Mixed Models (GLMM) by joining the Discrete Time Hazard model with the Poisson Regression model to jointly model survival and count model. As Aritificial Neural Network (ANN) has become a most powerful computational tool to model complex non-linear systems, it was proposed to develop a new joint model of survival and count of Dengue patients of Sri Lanka by using that approach. Thus, the objective of this study is to develop a model using ANN approach and compare the results with the previously developed GLMM model. As the response variables are continuous in nature, Generalized Regression Neural Network (GRNN) approach was adopted to model the data. To compare the model fit, measures such as root mean square error (RMSE), absolute mean error (AME) and correlation coefficient (R) were used. The measures indicate the GRNN model fits the data better than the GLMM model.
-
Schmidt, Lena; Depper, Lena; Kerkhoff, Georg
2013-01-01
Position sense is an important proprioceptive ability. Disorders of arm position sense (APS) often occur after unilateral stroke, and are associated with a negative functional outcome. In the present study we assessed horizontal APS by measuring angular deviations from a visually defined target separately for each arm in a large group of healthy subjects. We analyzed the accuracy and instability of horizontal APS as a function of age, sex and arm. Subjects were required to specify verbally the position of their unseen arm on a 0-90° circuit by comparing the current position with the target position indicated by a LED lamp, while the arm was passively moved by the examiner. Eighty-seven healthy subjects participated in the study, ranging from 20 to 77 years, subdivided into three age groups. The results revealed that APS was not a function of age or sex, but was significantly better in the non-dominant (left) arm in absolute errors (AE) but not in constant errors (CE) across all age groups of right-handed healthy subjects. This indicates a right-hemisphere superiority for left APS in right-handers and neatly fits to the more frequent and more severe left-sided body-related deficits in patients with unilateral stroke (i.e. impaired APS in left spatial neglect, somatoparaphrenia) or in individuals with abnormalities of the right cerebral hemisphere. These clinical issues will be discussed.
-
The Mathematics of Computer Error.
ERIC Educational Resources Information Center
Wood, Eric
1988-01-01
Why a computer error occurred is considered by analyzing the binary system and decimal fractions. How the computer stores numbers is then described. Knowledge of the mathematics behind computer operation is important if one wishes to understand and have confidence in the results of computer calculations. (MNS)
-
Maassen, Gerard H
2010-08-01
In this Journal, Lewis and colleagues introduced a new Reliable Change Index (RCI(WSD)), which incorporated the within-subject standard deviation (WSD) of a repeated measurement design as the standard error. In this note, two opposite errors in using WSD this way are demonstrated. First, being the standard error of measurement of only a single assessment makes WSD too small when practice effects are absent. Then, too many individuals will be designated reliably changed. Second, WSD can grow unlimitedly to the extent that differential practice effects occur. This can even make RCI(WSD) unable to detect any reliable change.
-
Deetz, Carl O; Nolan, Debra K; Scott, Mitchell G
2012-01-01
A long-standing practice in clinical laboratories has been to automatically repeat laboratory tests when values trigger automated "repeat rules" in the laboratory information system such as a critical test result. We examined 25,553 repeated laboratory values for 30 common chemistry tests from December 1, 2010, to February 28, 2011, to determine whether this practice is necessary and whether it may be possible to reduce repeat testing to improve efficiency and turnaround time for reporting critical values. An "error" was defined to occur when the difference between the initial and verified values exceeded the College of American Pathologists/Clinical Laboratory Improvement Amendments allowable error limit. The initial values from 2.6% of all repeated tests (668) were errors. Of these 668 errors, only 102 occurred for values within the analytic measurement range. Median delays in reporting critical values owing to repeated testing ranged from 5 (blood gases) to 17 (glucose) minutes.
-
Buhay, W.M.; Simpson, S.; Thorleifson, H.; Lewis, M.; King, J.; Telka, A.; Wilkinson, Philip M.; Babb, J.; Timsic, S.; Bailey, D.
2009-01-01
A short sediment core (162 cm), covering the period AD 920-1999, was sampled from the south basin of Lake Winnipeg for a suite of multi-proxy analyses leading towards a detailed characterisation of the recent millennial lake environment and hydroclimate of southern Manitoba, Canada. Information on the frequency and duration of major dry periods in southern Manitoba, in light of the changes that are likely to occur as a result of an increasingly warming atmosphere, is of specific interest in this study. Intervals of relatively enriched lake sediment cellulose oxygen isotope values (??18Ocellulose) were found to occur from AD 1180 to 1230 (error range: AD 1104-1231 to 1160-1280), 1610-1640 (error range: AD 1571-1634 to 1603-1662), 1670-1720 (error range: AD 1643-1697 to 1692-1738) and 1750-1780 (error range: AD 1724-1766 to 1756-1794). Regional water balance, inferred from calculated Lake Winnipeg water oxygen isotope values (??18Oinf-lw), suggest that the ratio of lake evaporation to catchment input may have been 25-40% higher during these isotopically distinct periods. Associated with the enriched d??18Ocellulose intervals are some depleted carbon isotope values associated with more abundantly preserved sediment organic matter (d??13COM). These suggest reduced microbial oxidation of terrestrially derived organic matter and/or subdued lake productivity during periods of minimised input of nutrients from the catchment area. With reference to other corroborating evidence, it is suggested that the AD 1180-1230, 1610-1640, 1670-1720 and 1750-1780 intervals represent four distinctly drier periods (droughts) in southern Manitoba, Canada. Additionally, lower-magnitude and duration dry periods may have also occurred from 1320 to 1340 (error range: AD 1257-1363), 1530-1540 (error range: AD 1490-1565 to 1498-1572) and 1570-1580 (error range: AD 1531-1599 to 1539-1606). ?? 2009 John Wiley & Sons, Ltd.
-
Avoiding common pitfalls in qualitative data collection and transcription.
Easton, K L; McComish, J F; Greenberg, R
2000-09-01
The subjective nature of qualitative research necessitates scrupulous scientific methods to ensure valid results. Although qualitative methods such as grounded theory, phenomenology, and ethnography yield rich data, consumers of research need to be able to trust the findings reported in such studies. Researchers are responsible for establishing the trustworthiness of qualitative research through a variety of ways. Specific challenges faced in the field can seriously threaten the dependability of the data. However, by minimizing potential errors that can occur when doing fieldwork, researchers can increase the trustworthiness of the study. The purpose of this article is to present three of the pitfalls that can occur in qualitative research during data collection and transcription: equipment failure, environmental hazards, and transcription errors. Specific strategies to minimize the risk for avoidable errors will be discussed.
-
Found Poems, Member Checking and Crises of Representation
ERIC Educational Resources Information Center
Reilly, Rosemary C.
2013-01-01
In order to establish veracity, qualitative researchers frequently rely on member checks to insure credibility by giving participants opportunities to correct errors, challenge interpretations and assess results; however, member checks are not without drawbacks. This paper describes an innovative approach to conducting member checks. Six members…
-
Electromagnetic Emissions from a Modular Low Voltage Electro-Impulse De-Icing System
1989-03-01
composite wing section employed in these tests. Cy O’Young of the Boeing Commercial Airplance Company is thanked for his many he-pful suggestions during this...a voltage spike which occurred simultaneous wi’h the discharge of the coil. A 2.2 volt spike would be adequate to create a transmission error on a...signal was a voltage spike which occurs simultaneous with discharge of the coil. A 2.2 volt spike would be adequate to create an error on a digital
-
Trommer, J.T.; Loper, J.E.; Hammett, K.M.; Bowman, Georgia
1996-01-01
Hydrologists use several traditional techniques for estimating peak discharges and runoff volumes from ungaged watersheds. However, applying these techniques to watersheds in west-central Florida requires that empirical relationships be extrapolated beyond tested ranges. As a result there is some uncertainty as to their accuracy. Sixty-six storms in 15 west-central Florida watersheds were modeled using (1) the rational method, (2) the U.S. Geological Survey regional regression equations, (3) the Natural Resources Conservation Service (formerly the Soil Conservation Service) TR-20 model, (4) the Army Corps of Engineers HEC-1 model, and (5) the Environmental Protection Agency SWMM model. The watersheds ranged between fully developed urban and undeveloped natural watersheds. Peak discharges and runoff volumes were estimated using standard or recommended methods for determining input parameters. All model runs were uncalibrated and the selection of input parameters was not influenced by observed data. The rational method, only used to calculate peak discharges, overestimated 45 storms, underestimated 20 storms and estimated the same discharge for 1 storm. The mean estimation error for all storms indicates the method overestimates the peak discharges. Estimation errors were generally smaller in the urban watersheds and larger in the natural watersheds. The U.S. Geological Survey regression equations provide peak discharges for storms of specific recurrence intervals. Therefore, direct comparison with observed data was limited to sixteen observed storms that had precipitation equivalent to specific recurrence intervals. The mean estimation error for all storms indicates the method overestimates both peak discharges and runoff volumes. Estimation errors were smallest for the larger natural watersheds in Sarasota County, and largest for the small watersheds located in the eastern part of the study area. The Natural Resources Conservation Service TR-20 model, overestimated peak discharges for 45 storms and underestimated 21 storms, and overestimated runoff volumes for 44 storms and underestimated 22 storms. The mean estimation error for all storms modeled indicates that the model overestimates peak discharges and runoff volumes. The smaller estimation errors in both peak discharges and runoff volumes were for storms occurring in the urban watersheds, and the larger errors were for storms occurring in the natural watersheds. The HEC-1 model overestimated peak discharge rates for 55 storms and underestimated 11 storms. Runoff volumes were overestimated for 44 storms and underestimated for 22 storms using the Army Corps of Engineers HEC-1 model. The mean estimation error for all the storms modeled indicates that the model overestimates peak discharge rates and runoff volumes. Generally, the smaller estimation errors in peak discharges were for storms occurring in the urban watersheds, and the larger errors were for storms occurring in the natural watersheds. Estimation errors in runoff volumes; however, were smallest for the 3 natural watersheds located in the southernmost part of Sarasota County. The Environmental Protection Agency Storm Water Management model produced similar peak discharges and runoff volumes when using both the Green-Ampt and Horton infiltration methods. Estimated peak discharge and runoff volume data calculated with the Horton method was only slightly higher than those calculated with the Green-Ampt method. The mean estimation error for all the storms modeled indicates the model using the Green-Ampt infiltration method overestimates peak discharges and slightly underestimates runoff volumes. Using the Horton infiltration method, the model overestimates both peak discharges and runoff volumes. The smaller estimation errors in both peak discharges and runoff volumes were for storms occurring in the five natural watersheds in Sarasota County with the least amount of impervious cover and the lowest slopes. The largest er
-
Preanalytical Errors in Hematology Laboratory- an Avoidable Incompetence.
HarsimranKaur, Vikram Narang; Selhi, Pavneet Kaur; Sood, Neena; Singh, Aminder
2016-01-01
Quality assurance in the hematology laboratory is a must to ensure laboratory users of reliable test results with high degree of precision and accuracy. Even after so many advances in hematology laboratory practice, pre-analytical errors remain a challenge for practicing pathologists. This study was undertaken with an objective to evaluate the types and frequency of preanalytical errors in hematology laboratory of our center. All the samples received in the Hematology Laboratory of Dayanand Medical College and Hospital, Ludhiana, India over a period of one year (July 2013-July 2014) were included in the study and preanalytical variables like clotted samples, quantity not sufficient, wrong sample, without label, wrong label were studied. Of 471,006 samples received in the laboratory, preanalytical errors, as per the above mentioned categories was found in 1802 samples. The most common error was clotted samples (1332 samples, 0.28% of the total samples) followed by quantity not sufficient (328 sample, 0.06%), wrong sample (96 samples, 0.02%), without label (24 samples, 0.005%) and wrong label (22 samples, 0.005%). Preanalytical errors are frequent in laboratories and can be corrected by regular analysis of the variables involved. Rectification can be done by regular education of the staff.
-
Impact of Spatial Soil and Climate Input Data Aggregation on Regional Yield Simulations
Hoffmann, Holger; Zhao, Gang; Asseng, Senthold; Bindi, Marco; Biernath, Christian; Constantin, Julie; Coucheney, Elsa; Dechow, Rene; Doro, Luca; Eckersten, Henrik; Gaiser, Thomas; Grosz, Balázs; Heinlein, Florian; Kassie, Belay T.; Kersebaum, Kurt-Christian; Klein, Christian; Kuhnert, Matthias; Lewan, Elisabet; Moriondo, Marco; Nendel, Claas; Priesack, Eckart; Raynal, Helene; Roggero, Pier P.; Rötter, Reimund P.; Siebert, Stefan; Specka, Xenia; Tao, Fulu; Teixeira, Edmar; Trombi, Giacomo; Wallach, Daniel; Weihermüller, Lutz; Yeluripati, Jagadeesh; Ewert, Frank
2016-01-01
We show the error in water-limited yields simulated by crop models which is associated with spatially aggregated soil and climate input data. Crop simulations at large scales (regional, national, continental) frequently use input data of low resolution. Therefore, climate and soil data are often generated via averaging and sampling by area majority. This may bias simulated yields at large scales, varying largely across models. Thus, we evaluated the error associated with spatially aggregated soil and climate data for 14 crop models. Yields of winter wheat and silage maize were simulated under water-limited production conditions. We calculated this error from crop yields simulated at spatial resolutions from 1 to 100 km for the state of North Rhine-Westphalia, Germany. Most models showed yields biased by <15% when aggregating only soil data. The relative mean absolute error (rMAE) of most models using aggregated soil data was in the range or larger than the inter-annual or inter-model variability in yields. This error increased further when both climate and soil data were aggregated. Distinct error patterns indicate that the rMAE may be estimated from few soil variables. Illustrating the range of these aggregation effects across models, this study is a first step towards an ex-ante assessment of aggregation errors in large-scale simulations. PMID:27055028
-
Impact of Spatial Soil and Climate Input Data Aggregation on Regional Yield Simulations.
Hoffmann, Holger; Zhao, Gang; Asseng, Senthold; Bindi, Marco; Biernath, Christian; Constantin, Julie; Coucheney, Elsa; Dechow, Rene; Doro, Luca; Eckersten, Henrik; Gaiser, Thomas; Grosz, Balázs; Heinlein, Florian; Kassie, Belay T; Kersebaum, Kurt-Christian; Klein, Christian; Kuhnert, Matthias; Lewan, Elisabet; Moriondo, Marco; Nendel, Claas; Priesack, Eckart; Raynal, Helene; Roggero, Pier P; Rötter, Reimund P; Siebert, Stefan; Specka, Xenia; Tao, Fulu; Teixeira, Edmar; Trombi, Giacomo; Wallach, Daniel; Weihermüller, Lutz; Yeluripati, Jagadeesh; Ewert, Frank
2016-01-01
We show the error in water-limited yields simulated by crop models which is associated with spatially aggregated soil and climate input data. Crop simulations at large scales (regional, national, continental) frequently use input data of low resolution. Therefore, climate and soil data are often generated via averaging and sampling by area majority. This may bias simulated yields at large scales, varying largely across models. Thus, we evaluated the error associated with spatially aggregated soil and climate data for 14 crop models. Yields of winter wheat and silage maize were simulated under water-limited production conditions. We calculated this error from crop yields simulated at spatial resolutions from 1 to 100 km for the state of North Rhine-Westphalia, Germany. Most models showed yields biased by <15% when aggregating only soil data. The relative mean absolute error (rMAE) of most models using aggregated soil data was in the range or larger than the inter-annual or inter-model variability in yields. This error increased further when both climate and soil data were aggregated. Distinct error patterns indicate that the rMAE may be estimated from few soil variables. Illustrating the range of these aggregation effects across models, this study is a first step towards an ex-ante assessment of aggregation errors in large-scale simulations.
-
Reexamining our bias against heuristics.
McLaughlin, Kevin; Eva, Kevin W; Norman, Geoff R
2014-08-01
Using heuristics offers several cognitive advantages, such as increased speed and reduced effort when making decisions, in addition to allowing us to make decision in situations where missing data do not allow for formal reasoning. But the traditional view of heuristics is that they trade accuracy for efficiency. Here the authors discuss sources of bias in the literature implicating the use of heuristics in diagnostic error and highlight the fact that there are also data suggesting that under certain circumstances using heuristics may lead to better decisions that formal analysis. They suggest that diagnostic error is frequently misattributed to the use of heuristics and propose an alternative view whereby content knowledge is the root cause of diagnostic performance and heuristics lie on the causal pathway between knowledge and diagnostic error or success.
-
Adaptive decoding of convolutional codes
NASA Astrophysics Data System (ADS)
Hueske, K.; Geldmacher, J.; Götze, J.
2007-06-01
Convolutional codes, which are frequently used as error correction codes in digital transmission systems, are generally decoded using the Viterbi Decoder. On the one hand the Viterbi Decoder is an optimum maximum likelihood decoder, i.e. the most probable transmitted code sequence is obtained. On the other hand the mathematical complexity of the algorithm only depends on the used code, not on the number of transmission errors. To reduce the complexity of the decoding process for good transmission conditions, an alternative syndrome based decoder is presented. The reduction of complexity is realized by two different approaches, the syndrome zero sequence deactivation and the path metric equalization. The two approaches enable an easy adaptation of the decoding complexity for different transmission conditions, which results in a trade-off between decoding complexity and error correction performance.
-
Awareness of deficits and error processing after traumatic brain injury.
Larson, Michael J; Perlstein, William M
2009-10-28
Severe traumatic brain injury is frequently associated with alterations in performance monitoring, including reduced awareness of physical and cognitive deficits. We examined the relationship between awareness of deficits and electrophysiological indices of performance monitoring, including the error-related negativity and posterror positivity (Pe) components of the scalp-recorded event-related potential, in 16 traumatic brain injury survivors who completed a Stroop color-naming task while event-related potential measurements were recorded. Awareness of deficits was measured as the discrepancy between patient and significant-other ratings on the Frontal Systems Behavior Scale. The amplitude of the Pe, but not error-related negativity, was reliably associated with decreased awareness of deficits. Results indicate that Pe amplitude may serve as an electrophysiological indicator of awareness of abilities and deficits.
-
Heneka, Nicole; Shaw, Tim; Rowett, Debra; Phillips, Jane L
2016-06-01
Opioids are the primary pharmacological treatment for cancer pain and, in the palliative care setting, are routinely used to manage symptoms at the end of life. Opioids are one of the most frequently reported drug classes in medication errors causing patient harm. Despite their widespread use, little is known about the incidence and impact of opioid medication errors in oncology and palliative care settings. To determine the incidence, types and impact of reported opioid medication errors in adult oncology and palliative care patient settings. A systematic review. Five electronic databases and the grey literature were searched from 1980 to August 2014. Empirical studies published in English, reporting data on opioid medication error incidence, types or patient impact, within adult oncology and/or palliative care services, were included. Popay's narrative synthesis approach was used to analyse data. Five empirical studies were included in this review. Opioid error incidence rate was difficult to ascertain as each study focussed on a single narrow area of error. The predominant error type related to deviation from opioid prescribing guidelines, such as incorrect dosing intervals. None of the included studies reported the degree of patient harm resulting from opioid errors. This review has highlighted the paucity of the literature examining opioid error incidence, types and patient impact in adult oncology and palliative care settings. Defining, identifying and quantifying error reporting practices for these populations should be an essential component of future oncology and palliative care quality and safety initiatives. © The Author(s) 2015.
-
Error protection capability of space shuttle data bus designs
NASA Technical Reports Server (NTRS)
Proch, G. E.
1974-01-01
Error protection assurance in the reliability of digital data communications is discussed. The need for error protection on the space shuttle data bus system has been recognized and specified as a hardware requirement. The error protection techniques of particular concern are those designed into the Shuttle Main Engine Interface (MEI) and the Orbiter Multiplex Interface Adapter (MIA). The techniques and circuit design details proposed for these hardware are analyzed in this report to determine their error protection capability. The capability is calculated in terms of the probability of an undetected word error. Calculated results are reported for a noise environment that ranges from the nominal noise level stated in the hardware specifications to burst levels which may occur in extreme or anomalous conditions.