Palinspastic reconstruction of structure maps: an automated finite element approach with heterogeneous strain

NASA Astrophysics Data System (ADS)

Dunbar, John A.; Cook, Richard W.

2003-07-01

Existing methods for the palinspastic reconstruction of structure maps do not adequately account for heterogeneous rock strain and hence cannot accurately treat features such as fault terminations and non-cylindrical folds. We propose a new finite element formulation of the map reconstruction problem that treats such features explicitly. In this approach, a model of the map surface, with internal openings that honor the topology of the fault-gap network, is constructed of triangular finite elements. Both model building and reconstruction algorithms are guided by rules relating fault-gap topology to the kinematics of fault motion and are fully automated. We represent the total strain as the sum of a prescribed component of locally homogeneous simple shear and a minimum amount of heterogeneous residual strain. The region within which a particular orientation of simple shear is treated as homogenous can be as small as an individual element or as large as the entire map. For residual strain calculations, we treat the map surface as a hyperelastic membrane. A globally optimum reconstruction is found that unfolds the map while faithfully honoring assigned strain mechanisms, closes fault gaps without overlap or gap and imparts the least possible residual strain in the restored surface. The amount and distribution of the residual strain serves as a diagnostic tool for identifying mapping errors. The method can be used to reconstruct maps offset by any number of faults that terminate, branch and offset each other in arbitrarily complex ways.

A prospective audit of a nurse independent prescribing within critical care.

PubMed

Carberry, Martin; Connelly, Sarah; Murphy, Jennifer

2013-05-01

To determine the prescribing activity of different staff groups within intensive care unit (ICU) and combined high dependency unit (HDU), namely trainee and consultant medical staff and advanced nurse practitioners in critical care (ANPCC); to determine the number and type of prescription errors; to compare error rates between prescribing groups and to raise awareness of prescribing activity within critical care. The introduction of government legislation has led to the development of non-medical prescribing roles in acute care. This has facilitated an opportunity for the ANPCC working in critical care to develop a prescribing role. The audit was performed over 7 days (Monday-Sunday), on rolling days over a 7-week period in September and October 2011 in three ICUs. All drug entries made on the ICU prescription by the three groups, trainee medical staff, ANPCCs and consultant anaesthetists, were audited once for errors. Data were collected by reviewing all drug entries for errors namely, patient data, drug dose, concentration, rate and frequency, legibility and prescriber signature. A paper data collection tool was used initially; data was later entered onto a Microsoft Access data base. A total of 1418 drug entries were audited from 77 patient prescription Cardexes. Error rates were reported as, 40 errors in 1418 prescriptions (2·8%): ANPCC errors, n = 2 in 388 prescriptions (0·6%); trainee medical staff errors, n = 33 in 984 (3·4%); consultant errors, n = 5 in 73 (6·8%). The error rates were significantly different for different prescribing groups (p < 0·01). This audit shows that prescribing error rates were low (2·8%). Having the lowest error rate, the nurse practitioners are at least as effective as other prescribing groups within this audit, in terms of errors only, in prescribing diligence. National data is required in order to benchmark independent nurse prescribing practice in critical care. These findings could be used to inform research and role development within the critical care. © 2012 The Authors. Nursing in Critical Care © 2012 British Association of Critical Care Nurses.

Making electronic prescribing alerts more effective: scenario-based experimental study in junior doctors

PubMed Central

Shah, Priya; Wyatt, Jeremy C; Makubate, Boikanyo; Cross, Frank W

2011-01-01

Objective Expert authorities recommend clinical decision support systems to reduce prescribing error rates, yet large numbers of insignificant on-screen alerts presented in modal dialog boxes persistently interrupt clinicians, limiting the effectiveness of these systems. This study compared the impact of modal and non-modal electronic (e-) prescribing alerts on prescribing error rates, to help inform the design of clinical decision support systems. Design A randomized study of 24 junior doctors each performing 30 simulated prescribing tasks in random order with a prototype e-prescribing system. Using a within-participant design, doctors were randomized to be shown one of three types of e-prescribing alert (modal, non-modal, no alert) during each prescribing task. Measurements The main outcome measure was prescribing error rate. Structured interviews were performed to elicit participants' preferences for the prescribing alerts and their views on clinical decision support systems. Results Participants exposed to modal alerts were 11.6 times less likely to make a prescribing error than those not shown an alert (OR 11.56, 95% CI 6.00 to 22.26). Those shown a non-modal alert were 3.2 times less likely to make a prescribing error (OR 3.18, 95% CI 1.91 to 5.30) than those not shown an alert. The error rate with non-modal alerts was 3.6 times higher than with modal alerts (95% CI 1.88 to 7.04). Conclusions Both kinds of e-prescribing alerts significantly reduced prescribing error rates, but modal alerts were over three times more effective than non-modal alerts. This study provides new evidence about the relative effects of modal and non-modal alerts on prescribing outcomes. PMID:21836158

Implementation of an experimental fault-tolerant memory system

NASA Technical Reports Server (NTRS)

Carter, W. C.; Mccarthy, C. E.

1976-01-01

The experimental fault-tolerant memory system described in this paper has been designed to enable the modular addition of spares, to validate the theoretical fault-secure and self-testing properties of the translator/corrector, to provide a basis for experiments using the new testing and correction processes for recovery, and to determine the practicality of such systems. The hardware design and implementation are described, together with methods of fault insertion. The hardware/software interface, including a restricted single error correction/double error detection (SEC/DED) code, is specified. Procedures are carefully described which, (1) test for specified physical faults, (2) ensure that single error corrections are not miscorrections due to triple faults, and (3) enable recovery from double errors.

Fault Tolerance Middleware for a Multi-Core System

NASA Technical Reports Server (NTRS)

Some, Raphael R.; Springer, Paul L.; Zima, Hans P.; James, Mark; Wagner, David A.

2012-01-01

Fault Tolerance Middleware (FTM) provides a framework to run on a dedicated core of a multi-core system and handles detection of single-event upsets (SEUs), and the responses to those SEUs, occurring in an application running on multiple cores of the processor. This software was written expressly for a multi-core system and can support different kinds of fault strategies, such as introspection, algorithm-based fault tolerance (ABFT), and triple modular redundancy (TMR). It focuses on providing fault tolerance for the application code, and represents the first step in a plan to eventually include fault tolerance in message passing and the FTM itself. In the multi-core system, the FTM resides on a single, dedicated core, separate from the cores used by the application. This is done in order to isolate the FTM from application faults and to allow it to swap out any application core for a substitute. The structure of the FTM consists of an interface to a fault tolerant strategy module, a responder module, a fault manager module, an error factory, and an error mapper that determines the severity of the error. In the present reference implementation, the only fault tolerant strategy implemented is introspection. The introspection code waits for an application node to send an error notification to it. It then uses the error factory to create an error object, and at this time, a severity level is assigned to the error. The introspection code uses its built-in knowledge base to generate a recommended response to the error. Responses might include ignoring the error, logging it, rolling back the application to a previously saved checkpoint, swapping in a new node to replace a bad one, or restarting the application. The original error and recommended response are passed to the top-level fault manager module, which invokes the response. The responder module also notifies the introspection module of the generated response. This provides additional information to the introspection module that it can use in generating its next response. For example, if the responder triggers an application rollback and errors are still occurring, the introspection module may decide to recommend an application restart.

[The error, source of learning].

PubMed

Joyeux, Stéphanie; Bohic, Valérie

2016-05-01

The error itself is not recognised as a fault. It is the intentionality which differentiates between an error and a fault. An error is unintentional while a fault is a failure to respect known rules. The risk of error is omnipresent in health institutions. Public authorities have therefore set out a series of measures to reduce this risk. Copyright © 2016 Elsevier Masson SAS. All rights reserved.

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

PubMed

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

2013-06-01

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

Feedback on prescribing errors to junior doctors: exploring views, problems and preferred methods.

PubMed

Bertels, Jeroen; Almoudaris, Alex M; Cortoos, Pieter-Jan; Jacklin, Ann; Franklin, Bryony Dean

2013-06-01

Prescribing errors are common in hospital inpatients. However, the literature suggests that doctors are often unaware of their errors as they are not always informed of them. It has been suggested that providing more feedback to prescribers may reduce subsequent error rates. Only few studies have investigated the views of prescribers towards receiving such feedback, or the views of hospital pharmacists as potential feedback providers. Our aim was to explore the views of junior doctors and hospital pharmacists regarding feedback on individual doctors' prescribing errors. Objectives were to determine how feedback was currently provided and any associated problems, to explore views on other approaches to feedback, and to make recommendations for designing suitable feedback systems. A large London NHS hospital trust. To explore views on current and possible feedback mechanisms, self-administered questionnaires were given to all junior doctors and pharmacists, combining both 5-point Likert scale statements and open-ended questions. Agreement scores for statements regarding perceived prescribing error rates, opinions on feedback, barriers to feedback, and preferences for future practice. Response rates were 49% (37/75) for junior doctors and 57% (57/100) for pharmacists. In general, doctors did not feel threatened by feedback on their prescribing errors. They felt that feedback currently provided was constructive but often irregular and insufficient. Most pharmacists provided feedback in various ways; however some did not or were inconsistent. They were willing to provide more feedback, but did not feel it was always effective or feasible due to barriers such as communication problems and time constraints. Both professional groups preferred individual feedback with additional regular generic feedback on common or serious errors. Feedback on prescribing errors was valued and acceptable to both professional groups. From the results, several suggested methods of providing feedback on prescribing errors emerged. Addressing barriers such as the identification of individual prescribers would facilitate feedback in practice. Research investigating whether or not feedback reduces the subsequent error rate is now needed.

Analysis of a hardware and software fault tolerant processor for critical applications

NASA Technical Reports Server (NTRS)

Dugan, Joanne B.

1993-01-01

Computer systems for critical applications must be designed to tolerate software faults as well as hardware faults. A unified approach to tolerating hardware and software faults is characterized by classifying faults in terms of duration (transient or permanent) rather than source (hardware or software). Errors arising from transient faults can be handled through masking or voting, but errors arising from permanent faults require system reconfiguration to bypass the failed component. Most errors which are caused by software faults can be considered transient, in that they are input-dependent. Software faults are triggered by a particular set of inputs. Quantitative dependability analysis of systems which exhibit a unified approach to fault tolerance can be performed by a hierarchical combination of fault tree and Markov models. A methodology for analyzing hardware and software fault tolerant systems is applied to the analysis of a hypothetical system, loosely based on the Fault Tolerant Parallel Processor. The models consider both transient and permanent faults, hardware and software faults, independent and related software faults, automatic recovery, and reconfiguration.

Medication safety at the interface: evaluating risks associated with discharge prescriptions from mental health hospitals.

PubMed

Keers, R N; Williams, S D; Vattakatuchery, J J; Brown, P; Miller, J; Prescott, L; Ashcroft, D M

2015-12-01

When compared to general hospitals, relatively little is known about the quality and safety of discharge prescriptions from specialist mental health settings. We aimed to investigate the quality and safety of discharge prescriptions written at mental health hospitals. This study was undertaken on acute adult and later life inpatient units at three National Health Service (NHS) mental health trusts. Trained pharmacy teams prospectively reviewed all newly written discharge prescriptions over a 6-week period, recording the number of prescribing errors, clerical errors and errors involving lack of communication about medicines stopped during hospital admission. All prescribing errors were reviewed and validated by a multidisciplinary panel. Main outcome measures were the prevalence (95% CI) of prescribing errors, clerical errors and errors involving a lack of details about medicines stopped. Risk factors for prescribing and clerical errors were examined via logistic regression and results presented as odds ratios (OR) with corresponding 95% CI. Of 274 discharge prescriptions, 259 contained a total of 1456 individually prescribed items. One in five [20·8% (95%CI 15·9-25·8%)] eligible discharge prescriptions and one in twenty [5·1% (95%CI 4·0-6·2%)] prescribed or omitted items were affected by at least one prescribing error. One or more clerical errors were found in 71·9% (95%CI 66·5-77·3%) of discharge prescriptions, and more than two-thirds [68·8% (95%CI 56·6-78·8%)] of eligible discharge prescriptions erroneously lacked information on medicines discontinued during hospital admission. Logistic regression analyses revealed that middle-grade [whole discharge prescription level OR 3·28 (3·03-3·56)] and senior [whole discharge OR 1·43 (1·04-1·96)] prescribers as well as electronic discharge prescription pro formas [whole discharge OR 2·43 (2·08-2·83)] were all associated with significantly higher risks of prescribing errors than junior prescribers and handwritten discharges, respectively. Similar findings were reported at the individually prescribed item level. Middle-grade prescribers were also more likely to make both non-psychotropic and psychotropic prescribing errors than their junior colleagues [individual item OR 4·24 (2·14-8·40) and OR 1·70 (1·16-2·48), respectively]. Discharge prescriptions issued by mental health NHS hospitals are affected by high levels of prescribing, clerical and communication errors. Important targets for intervention have been identified to improve medication safety problems at care transfer. © 2015 John Wiley & Sons Ltd.

Hospital prescribing errors: epidemiological assessment of predictors

PubMed Central

Fijn, R; Van den Bemt, P M L A; Chow, M; De Blaey, C J; De Jong-Van den Berg, L T W; Brouwers, J R B J

2002-01-01

Aims To demonstrate an epidemiological method to assess predictors of prescribing errors. Methods A retrospective case-control study, comparing prescriptions with and without errors. Results Only prescriber and drug characteristics were associated with errors. Prescriber characteristics were medical specialty (e.g. orthopaedics: OR: 3.4, 95% CI 2.1, 5.4) and prescriber status (e.g. verbal orders transcribed by nursing staff: OR: 2.5, 95% CI 1.8, 3.6). Drug characteristics were dosage form (e.g. inhalation devices: OR: 4.1, 95% CI 2.6, 6.6), therapeutic area (e.g. gastrointestinal tract: OR: 1.7, 95% CI 1.2, 2.4) and continuation of preadmission treatment (Yes: OR: 1.7, 95% CI 1.3, 2.3). Conclusions Other hospitals could use our epidemiological framework to identify their own error predictors. Our findings suggest a focus on specific prescribers, dosage forms and therapeutic areas. We also found that prescriptions originating from general practitioners involved errors and therefore, these should be checked when patients are hospitalized. PMID:11874397

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

PubMed Central

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

2014-01-01

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

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

PubMed

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

2014-10-01

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

Prescribing errors in adult congenital heart disease patients admitted to a pediatric cardiovascular intensive care unit.

PubMed

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.

Transient Faults in Computer Systems

NASA Technical Reports Server (NTRS)

Masson, Gerald M.

1993-01-01

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

Encoder fault analysis system based on Moire fringe error signal

NASA Astrophysics Data System (ADS)

Gao, Xu; Chen, Wei; Wan, Qiu-hua; Lu, Xin-ran; Xie, Chun-yu

2018-02-01

Aiming at the problem of any fault and wrong code in the practical application of photoelectric shaft encoder, a fast and accurate encoder fault analysis system is researched from the aspect of Moire fringe photoelectric signal processing. DSP28335 is selected as the core processor and high speed serial A/D converter acquisition card is used. And temperature measuring circuit using AD7420 is designed. Discrete data of Moire fringe error signal is collected at different temperatures and it is sent to the host computer through wireless transmission. The error signal quality index and fault type is displayed on the host computer based on the error signal identification method. The error signal quality can be used to diagnosis the state of error code through the human-machine interface.

Preventing medical errors by designing benign failures.

PubMed

Grout, John R

2003-07-01

One way to successfully reduce medical errors is to design health care systems that are more resistant to the tendencies of human beings to err. One interdisciplinary approach entails creating design changes, mitigating human errors, and making human error irrelevant to outcomes. This approach is intended to facilitate the creation of benign failures, which have been called mistake-proofing devices and forcing functions elsewhere. USING FAULT TREES TO DESIGN FORCING FUNCTIONS: A fault tree is a graphical tool used to understand the relationships that either directly cause or contribute to the cause of a particular failure. A careful analysis of a fault tree enables the analyst to anticipate how the process will behave after the change. EXAMPLE OF AN APPLICATION: A scenario in which a patient is scalded while bathing can serve as an example of how multiple fault trees can be used to design forcing functions. The first fault tree shows the undesirable event--patient scalded while bathing. The second fault tree has a benign event--no water. Adding a scald valve changes the outcome from the undesirable event ("patient scalded while bathing") to the benign event ("no water") Analysis of fault trees does not ensure or guarantee that changes necessary to eliminate error actually occur. Most mistake-proofing is used to prevent simple errors and to create well-defended processes, but complex errors can also result. The utilization of mistake-proofing or forcing functions can be thought of as changing the logic of a process. Errors that formerly caused undesirable failures can be converted into the causes of benign failures. The use of fault trees can provide a variety of insights into the design of forcing functions that will improve patient safety.

Using Fault Trees to Advance Understanding of Diagnostic Errors.

PubMed

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

2017-11-01

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

Studying the Effects of Transparent vs. Opaque Shallow Thrust Faults Using Synthetic P and SH Seismograms

NASA Astrophysics Data System (ADS)

Smith, D. E.; Aagaard, B. T.; Heaton, T. H.

2001-12-01

It has been hypothesized (Brune, 1996) that teleseismic inversions may underestimate the moment of shallow thrust fault earthquakes if energy becomes trapped in the hanging wall of the fault, i.e. if the fault boundary becomes opaque. We address this by creating and analyzing synthetic P and SH seismograms for a variety of friction models. There are a total of five models: (1) crack model (slip weakening) with instantaneous healing (2) crack model without healing (3) crack model with zero sliding friction (4) pulse model (slip and rate weakening) (5) prescribed model (Haskell-like rupture with the same final slip and peak slip-rate as model 4). Models 1-4 are all dynamic models where fault friction laws determine the rupture history. This allows feedback between the ongoing rupture and waves from the beginning of the rupture that hit the surface and reflect downwards. Hence, models 1-4 can exhibit opaque fault characteristics. Model 5, a prescribed rupture, allows for no interaction between the rupture and reflected waves, therefore, it is a transparent fault. We first produce source time functions for the different friction models by rupturing shallow thrust faults in 3-D dynamic finite-element simulations. The source time functions are used as point dislocations in a teleseismic body-wave code. We examine the P and SH waves for different azimuths and epicentral distances. The peak P and S first arrival displacement amplitudes for the crack, crack with healing and pulse models are all very similar. These dynamic models with opaque faults produce smaller peak P and S first arrivals than the prescribed, transparent fault. For example, a fault with strike = 90 degrees, azimuth = 45 degrees has P arrivals smaller by about 30% and S arrivals smaller by about 15%. The only dynamic model that doesn't fit this pattern is the crack model with zero sliding friction. It oscillates around its equilibrium position; therefore, it overshoots and yields an excessively large peak first arrival. In general, it appears that the dynamic, opaque faults have smaller peak teleseismic displacements that would lead to lower moment estimates by a modest amount.

Physicians' medication prescribing in primary care . in Riyadh City, Saudi Arabia. Literature review, part 3: prescribing errors.

PubMed

Qureshi, N A; Neyaz, Y; Khoja, T; Magzoub, M A; Haycox, A; Walley, T

2011-02-01

Medication errors are globally huge in magnitude and associated with high morbidity and mortality together with high costs and legal problems. Medication errors are caused by multiple factors related to health providers, consumers and health system, but most prescribing errors are preventable. This paper is the third of 3 review articles that form the background for a series of 5 interconnected studies of prescribing patterns and medication errors in the public and private primary health care sectors of Saudi Arabia. A MEDLINE search was conducted to identify papers published in peer-reviewed journals over the previous 3 decades. The paper reviews the etiology, prevention strategies, reporting mechanisms and the myriad consequences of medication errors.

Automation bias in electronic prescribing.

PubMed

Lyell, David; Magrabi, Farah; Raban, Magdalena Z; Pont, L G; Baysari, Melissa T; Day, Richard O; Coiera, Enrico

2017-03-16

Clinical decision support (CDS) in e-prescribing can improve safety by alerting potential errors, but introduces new sources of risk. Automation bias (AB) occurs when users over-rely on CDS, reducing vigilance in information seeking and processing. Evidence of AB has been found in other clinical tasks, but has not yet been tested with e-prescribing. This study tests for the presence of AB in e-prescribing and the impact of task complexity and interruptions on AB. One hundred and twenty students in the final two years of a medical degree prescribed medicines for nine clinical scenarios using a simulated e-prescribing system. Quality of CDS (correct, incorrect and no CDS) and task complexity (low, low + interruption and high) were varied between conditions. Omission errors (failure to detect prescribing errors) and commission errors (acceptance of false positive alerts) were measured. Compared to scenarios with no CDS, correct CDS reduced omission errors by 38.3% (p < .0001, n = 120), 46.6% (p < .0001, n = 70), and 39.2% (p < .0001, n = 120) for low, low + interrupt and high complexity scenarios respectively. Incorrect CDS increased omission errors by 33.3% (p < .0001, n = 120), 24.5% (p < .009, n = 82), and 26.7% (p < .0001, n = 120). Participants made commission errors, 65.8% (p < .0001, n = 120), 53.5% (p < .0001, n = 82), and 51.7% (p < .0001, n = 120). Task complexity and interruptions had no impact on AB. This study found evidence of AB omission and commission errors in e-prescribing. Verification of CDS alerts is key to avoiding AB errors. However, interventions focused on this have had limited success to date. Clinicians should remain vigilant to the risks of CDS failures and verify CDS.

Quantum Error Correction

NASA Astrophysics Data System (ADS)

Lidar, Daniel A.; Brun, Todd A.

2013-09-01

Prologue; Preface; Part I. Background: 1. Introduction to decoherence and noise in open quantum systems Daniel Lidar and Todd Brun; 2. Introduction to quantum error correction Dave Bacon; 3. Introduction to decoherence-free subspaces and noiseless subsystems Daniel Lidar; 4. Introduction to quantum dynamical decoupling Lorenza Viola; 5. Introduction to quantum fault tolerance Panos Aliferis; Part II. Generalized Approaches to Quantum Error Correction: 6. Operator quantum error correction David Kribs and David Poulin; 7. Entanglement-assisted quantum error-correcting codes Todd Brun and Min-Hsiu Hsieh; 8. Continuous-time quantum error correction Ognyan Oreshkov; Part III. Advanced Quantum Codes: 9. Quantum convolutional codes Mark Wilde; 10. Non-additive quantum codes Markus Grassl and Martin Rötteler; 11. Iterative quantum coding systems David Poulin; 12. Algebraic quantum coding theory Andreas Klappenecker; 13. Optimization-based quantum error correction Andrew Fletcher; Part IV. Advanced Dynamical Decoupling: 14. High order dynamical decoupling Zhen-Yu Wang and Ren-Bao Liu; 15. Combinatorial approaches to dynamical decoupling Martin Rötteler and Pawel Wocjan; Part V. Alternative Quantum Computation Approaches: 16. Holonomic quantum computation Paolo Zanardi; 17. Fault tolerance for holonomic quantum computation Ognyan Oreshkov, Todd Brun and Daniel Lidar; 18. Fault tolerant measurement-based quantum computing Debbie Leung; Part VI. Topological Methods: 19. Topological codes Héctor Bombín; 20. Fault tolerant topological cluster state quantum computing Austin Fowler and Kovid Goyal; Part VII. Applications and Implementations: 21. Experimental quantum error correction Dave Bacon; 22. Experimental dynamical decoupling Lorenza Viola; 23. Architectures Jacob Taylor; 24. Error correction in quantum communication Mark Wilde; Part VIII. Critical Evaluation of Fault Tolerance: 25. Hamiltonian methods in QEC and fault tolerance Eduardo Novais, Eduardo Mucciolo and Harold Baranger; 26. Critique of fault-tolerant quantum information processing Robert Alicki; References; Index.

Simple prescribing errors and allergy documentation in medical hospital admissions in Australia and New Zealand.

PubMed

Barton, Lorna; Futtermenger, Judith; Gaddi, Yash; Kang, Angela; Rivers, Jon; Spriggs, David; Jenkins, Paul F; Thompson, Campbell H; Thomas, Josephine S

2012-04-01

This study aimed to quantify and compare the prevalence of simple prescribing errors made by clinicians in the first 24 hours of a general medical patient's hospital admission. Four public or private acute care hospitals across Australia and New Zealand each audited 200 patients' drug charts. Patient demographics, pharmacist review and pre-defined prescribing errors were recorded. At least one simple error was present on the medication charts of 672/715 patients, with a linear relationship between the number of medications prescribed and the number of errors (r = 0.571, p < 0.001). The four sites differed significantly in the prevalence of different types of simple prescribing errors. Pharmacists were more likely to review patients aged > or = 75 years (39.9% vs 26.0%; p < 0.001) and those with more than 10 drug prescriptions (39.4% vs 25.7%; p < 0.001). Patients reviewed by a pharmacist were less likely to have inadequate documentation of allergies (13.5% vs 29.4%, p < 0.001). Simple prescribing errors are common, although their nature differs from site to site. Clinical pharmacists target patients with the most complex health situations, and their involvement leads to improved documentation.

Task errors by emergency physicians are associated with interruptions, multitasking, fatigue and working memory capacity: a prospective, direct observation study.

PubMed

Westbrook, Johanna I; Raban, Magdalena Z; Walter, Scott R; Douglas, Heather

2018-01-09

Interruptions and multitasking have been demonstrated in experimental studies to reduce individuals' task performance. These behaviours are frequently used by clinicians in high-workload, dynamic clinical environments, yet their effects have rarely been studied. To assess the relative contributions of interruptions and multitasking by emergency physicians to prescribing errors. 36 emergency physicians were shadowed over 120 hours. All tasks, interruptions and instances of multitasking were recorded. Physicians' working memory capacity (WMC) and preference for multitasking were assessed using the Operation Span Task (OSPAN) and Inventory of Polychronic Values. Following observation, physicians were asked about their sleep in the previous 24 hours. Prescribing errors were used as a measure of task performance. We performed multivariate analysis of prescribing error rates to determine associations with interruptions and multitasking, also considering physician seniority, age, psychometric measures, workload and sleep. Physicians experienced 7.9 interruptions/hour. 28 clinicians were observed prescribing 239 medication orders which contained 208 prescribing errors. While prescribing, clinicians were interrupted 9.4 times/hour. Error rates increased significantly if physicians were interrupted (rate ratio (RR) 2.82; 95% CI 1.23 to 6.49) or multitasked (RR 1.86; 95% CI 1.35 to 2.56) while prescribing. Having below-average sleep showed a >15-fold increase in clinical error rate (RR 16.44; 95% CI 4.84 to 55.81). WMC was protective against errors; for every 10-point increase on the 75-point OSPAN, a 19% decrease in prescribing errors was observed. There was no effect of polychronicity, workload, physician gender or above-average sleep on error rates. Interruptions, multitasking and poor sleep were associated with significantly increased rates of prescribing errors among emergency physicians. WMC mitigated the negative influence of these factors to an extent. These results confirm experimental findings in other fields and raise questions about the acceptability of the high rates of multitasking and interruption in clinical environments. © 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.

Measuring the relationship between interruptions, multitasking and prescribing errors in an emergency department: a study protocol

PubMed Central

Raban, Magdalena Z; Walter, Scott R; Douglas, Heather E; Strumpman, Dana; Mackenzie, John; Westbrook, Johanna I

2015-01-01

Introduction Interruptions and multitasking are frequent in clinical settings, and have been shown in the cognitive psychology literature to affect performance, increasing the risk of error. However, comparatively less is known about their impact on errors in clinical work. This study will assess the relationship between prescribing errors, interruptions and multitasking in an emergency department (ED) using direct observations and chart review. Methods and analysis The study will be conducted in an ED of a 440-bed teaching hospital in Sydney, Australia. Doctors will be shadowed at proximity by observers for 2 h time intervals while they are working on day shift (between 0800 and 1800). Time stamped data on tasks, interruptions and multitasking will be recorded on a handheld computer using the validated Work Observation Method by Activity Timing (WOMBAT) tool. The prompts leading to interruptions and multitasking will also be recorded. When doctors prescribe medication, type of chart and chart sections written on, along with the patient's medical record number (MRN) will be recorded. A clinical pharmacist will access patient records and assess the medication orders for prescribing errors. The prescribing error rate will be calculated per prescribing task and is defined as the number of errors divided by the number of medication orders written during the prescribing task. The association between prescribing error rates, and rates of prompts, interruptions and multitasking will be assessed using statistical modelling. Ethics and dissemination Ethics approval has been obtained from the hospital research ethics committee. Eligible doctors will be provided with written information sheets and written consent will be obtained if they agree to participate. Doctor details and MRNs will be kept separate from the data on prescribing errors, and will not appear in the final data set for analysis. Study results will be disseminated in publications and feedback to the ED. PMID:26463224

Measuring the relationship between interruptions, multitasking and prescribing errors in an emergency department: a study protocol.

PubMed

Raban, Magdalena Z; Walter, Scott R; Douglas, Heather E; Strumpman, Dana; Mackenzie, John; Westbrook, Johanna I

2015-10-13

Interruptions and multitasking are frequent in clinical settings, and have been shown in the cognitive psychology literature to affect performance, increasing the risk of error. However, comparatively less is known about their impact on errors in clinical work. This study will assess the relationship between prescribing errors, interruptions and multitasking in an emergency department (ED) using direct observations and chart review. The study will be conducted in an ED of a 440-bed teaching hospital in Sydney, Australia. Doctors will be shadowed at proximity by observers for 2 h time intervals while they are working on day shift (between 0800 and 1800). Time stamped data on tasks, interruptions and multitasking will be recorded on a handheld computer using the validated Work Observation Method by Activity Timing (WOMBAT) tool. The prompts leading to interruptions and multitasking will also be recorded. When doctors prescribe medication, type of chart and chart sections written on, along with the patient's medical record number (MRN) will be recorded. A clinical pharmacist will access patient records and assess the medication orders for prescribing errors. The prescribing error rate will be calculated per prescribing task and is defined as the number of errors divided by the number of medication orders written during the prescribing task. The association between prescribing error rates, and rates of prompts, interruptions and multitasking will be assessed using statistical modelling. Ethics approval has been obtained from the hospital research ethics committee. Eligible doctors will be provided with written information sheets and written consent will be obtained if they agree to participate. Doctor details and MRNs will be kept separate from the data on prescribing errors, and will not appear in the final data set for analysis. Study results will be disseminated in publications and feedback to the ED. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.

Software-implemented fault insertion: An FTMP example

NASA Technical Reports Server (NTRS)

Czeck, Edward W.; Siewiorek, Daniel P.; Segall, Zary Z.

1987-01-01

This report presents a model for fault insertion through software; describes its implementation on a fault-tolerant computer, FTMP; presents a summary of fault detection, identification, and reconfiguration data collected with software-implemented fault insertion; and compares the results to hardware fault insertion data. Experimental results show detection time to be a function of time of insertion and system workload. For the fault detection time, there is no correlation between software-inserted faults and hardware-inserted faults; this is because hardware-inserted faults must manifest as errors before detection, whereas software-inserted faults immediately exercise the error detection mechanisms. In summary, the software-implemented fault insertion is able to be used as an evaluation technique for the fault-handling capabilities of a system in fault detection, identification and recovery. Although the software-inserted faults do not map directly to hardware-inserted faults, experiments show software-implemented fault insertion is capable of emulating hardware fault insertion, with greater ease and automation.

The impact of a closed-loop electronic prescribing and administration system on prescribing errors, administration errors and staff time: a before-and-after study.

PubMed

Franklin, Bryony Dean; O'Grady, Kara; Donyai, Parastou; Jacklin, Ann; Barber, Nick

2007-08-01

To assess the impact of a closed-loop electronic prescribing, automated dispensing, barcode patient identification and electronic medication administration record (EMAR) system on prescribing and administration errors, confirmation of patient identity before administration, and staff time. Before-and-after study in a surgical ward of a teaching hospital, involving patients and staff of that ward. Closed-loop electronic prescribing, automated dispensing, barcode patient identification and EMAR system. Percentage of new medication orders with a prescribing error, percentage of doses with medication administration errors (MAEs) and percentage given without checking patient identity. Time spent prescribing and providing a ward pharmacy service. Nursing time on medication tasks. Prescribing errors were identified in 3.8% of 2450 medication orders pre-intervention and 2.0% of 2353 orders afterwards (p<0.001; chi(2) test). MAEs occurred in 7.0% of 1473 non-intravenous doses pre-intervention and 4.3% of 1139 afterwards (p = 0.005; chi(2) test). Patient identity was not checked for 82.6% of 1344 doses pre-intervention and 18.9% of 1291 afterwards (p<0.001; chi(2) test). Medical staff required 15 s to prescribe a regular inpatient drug pre-intervention and 39 s afterwards (p = 0.03; t test). Time spent providing a ward pharmacy service increased from 68 min to 98 min each weekday (p = 0.001; t test); 22% of drug charts were unavailable pre-intervention. Time per drug administration round decreased from 50 min to 40 min (p = 0.006; t test); nursing time on medication tasks outside of drug rounds increased from 21.1% to 28.7% (p = 0.006; chi(2) test). A closed-loop electronic prescribing, dispensing and barcode patient identification system reduced prescribing errors and MAEs, and increased confirmation of patient identity before administration. Time spent on medication-related tasks increased.

Methods and apparatus using commutative error detection values for fault isolation in multiple node computers

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

Almasi, Gheorghe; Blumrich, Matthias Augustin; Chen, Dong

Methods and apparatus perform fault isolation in multiple node computing systems using commutative error detection values for--example, checksums--to identify and to isolate faulty nodes. When information associated with a reproducible portion of a computer program is injected into a network by a node, a commutative error detection value is calculated. At intervals, node fault detection apparatus associated with the multiple node computer system retrieve commutative error detection values associated with the node and stores them in memory. When the computer program is executed again by the multiple node computer system, new commutative error detection values are created and stored inmore » memory. The node fault detection apparatus identifies faulty nodes by comparing commutative error detection values associated with reproducible portions of the application program generated by a particular node from different runs of the application program. Differences in values indicate a possible faulty node.« less

Fault detection and isolation in motion monitoring system.

PubMed

Kim, Duk-Jin; Suk, Myoung Hoon; Prabhakaran, B

2012-01-01

Pervasive computing becomes very active research field these days. A watch that can trace human movement to record motion boundary as well as to study of finding social life pattern by one's localized visiting area. Pervasive computing also helps patient monitoring. A daily monitoring system helps longitudinal study of patient monitoring such as Alzheimer's and Parkinson's or obesity monitoring. Due to the nature of monitoring sensor (on-body wireless sensor), however, signal noise or faulty sensors errors can be present at any time. Many research works have addressed these problems any with a large amount of sensor deployment. In this paper, we present the faulty sensor detection and isolation using only two on-body sensors. We have been investigating three different types of sensor errors: the SHORT error, the CONSTANT error, and the NOISY SENSOR error (see more details on section V). Our experimental results show that the success rate of isolating faulty signals are an average of over 91.5% on fault type 1, over 92% on fault type 2, and over 99% on fault type 3 with the fault prior of 30% sensor errors.

General linear codes for fault-tolerant matrix operations on processor arrays

NASA Technical Reports Server (NTRS)

Nair, V. S. S.; Abraham, J. A.

1988-01-01

Various checksum codes have been suggested for fault-tolerant matrix computations on processor arrays. Use of these codes is limited due to potential roundoff and overflow errors. Numerical errors may also be misconstrued as errors due to physical faults in the system. In this a set of linear codes is identified which can be used for fault-tolerant matrix operations such as matrix addition, multiplication, transposition, and LU-decomposition, with minimum numerical error. Encoding schemes are given for some of the example codes which fall under the general set of codes. With the help of experiments, a rule of thumb for the selection of a particular code for a given application is derived.

Impact of device level faults in a digital avionic processor

NASA Technical Reports Server (NTRS)

Suk, Ho Kim

1989-01-01

This study describes an experimental analysis of the impact of gate and device-level faults in the processor of a Bendix BDX-930 flight control system. Via mixed mode simulation, faults were injected at the gate (stuck-at) and at the transistor levels and, their propagation through the chip to the output pins was measured. The results show that there is little correspondence between a stuck-at and a device-level fault model, as far as error activity or detection within a functional unit is concerned. In so far as error activity outside the injected unit and at the output pins are concerned, the stuck-at and device models track each other. The stuck-at model, however, overestimates, by over 100 percent, the probability of fault propagation to the output pins. An evaluation of the Mean Error Durations and the Mean Time Between Errors at the output pins shows that the stuck-at model significantly underestimates (by 62 percent) the impact of an internal chip fault on the output pins. Finally, the study also quantifies the impact of device fault by location, both internally and at the output pins.

A Method to Simultaneously Detect the Current Sensor Fault and Estimate the State of Energy for Batteries in Electric Vehicles

PubMed Central

Xu, Jun; Wang, Jing; Li, Shiying; Cao, Binggang

2016-01-01

Recently, State of energy (SOE) has become one of the most fundamental parameters for battery management systems in electric vehicles. However, current information is critical in SOE estimation and current sensor is usually utilized to obtain the latest current information. However, if the current sensor fails, the SOE estimation may be confronted with large error. Therefore, this paper attempts to make the following contributions: Current sensor fault detection and SOE estimation method is realized simultaneously. Through using the proportional integral observer (PIO) based method, the current sensor fault could be accurately estimated. By taking advantage of the accurate estimated current sensor fault, the influence caused by the current sensor fault can be eliminated and compensated. As a result, the results of the SOE estimation will be influenced little by the fault. In addition, the simulation and experimental workbench is established to verify the proposed method. The results indicate that the current sensor fault can be estimated accurately. Simultaneously, the SOE can also be estimated accurately and the estimation error is influenced little by the fault. The maximum SOE estimation error is less than 2%, even though the large current error caused by the current sensor fault still exists. PMID:27548183

A Method to Simultaneously Detect the Current Sensor Fault and Estimate the State of Energy for Batteries in Electric Vehicles.

PubMed

Xu, Jun; Wang, Jing; Li, Shiying; Cao, Binggang

2016-08-19

Recently, State of energy (SOE) has become one of the most fundamental parameters for battery management systems in electric vehicles. However, current information is critical in SOE estimation and current sensor is usually utilized to obtain the latest current information. However, if the current sensor fails, the SOE estimation may be confronted with large error. Therefore, this paper attempts to make the following contributions: Current sensor fault detection and SOE estimation method is realized simultaneously. Through using the proportional integral observer (PIO) based method, the current sensor fault could be accurately estimated. By taking advantage of the accurate estimated current sensor fault, the influence caused by the current sensor fault can be eliminated and compensated. As a result, the results of the SOE estimation will be influenced little by the fault. In addition, the simulation and experimental workbench is established to verify the proposed method. The results indicate that the current sensor fault can be estimated accurately. Simultaneously, the SOE can also be estimated accurately and the estimation error is influenced little by the fault. The maximum SOE estimation error is less than 2%, even though the large current error caused by the current sensor fault still exists.

Fault Modeling of Extreme Scale Applications Using Machine Learning

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

Vishnu, Abhinav; Dam, Hubertus van; Tallent, Nathan R.

Faults are commonplace in large scale systems. These systems experience a variety of faults such as transient, permanent and intermittent. Multi-bit faults are typically not corrected by the hardware resulting in an error. Here, this paper attempts to answer an important question: Given a multi-bit fault in main memory, will it result in an application error — and hence a recovery algorithm should be invoked — or can it be safely ignored? We propose an application fault modeling methodology to answer this question. Given a fault signature (a set of attributes comprising of system and application state), we use machinemore » learning to create a model which predicts whether a multibit permanent/transient main memory fault will likely result in error. We present the design elements such as the fault injection methodology for covering important data structures, the application and system attributes which should be used for learning the model, the supervised learning algorithms (and potentially ensembles), and important metrics. Lastly, we use three applications — NWChem, LULESH and SVM — as examples for demonstrating the effectiveness of the proposed fault modeling methodology.« less

Fault Modeling of Extreme Scale Applications Using Machine Learning

DOE PAGES

Vishnu, Abhinav; Dam, Hubertus van; Tallent, Nathan R.; ...

2016-05-01

Faults are commonplace in large scale systems. These systems experience a variety of faults such as transient, permanent and intermittent. Multi-bit faults are typically not corrected by the hardware resulting in an error. Here, this paper attempts to answer an important question: Given a multi-bit fault in main memory, will it result in an application error — and hence a recovery algorithm should be invoked — or can it be safely ignored? We propose an application fault modeling methodology to answer this question. Given a fault signature (a set of attributes comprising of system and application state), we use machinemore » learning to create a model which predicts whether a multibit permanent/transient main memory fault will likely result in error. We present the design elements such as the fault injection methodology for covering important data structures, the application and system attributes which should be used for learning the model, the supervised learning algorithms (and potentially ensembles), and important metrics. Lastly, we use three applications — NWChem, LULESH and SVM — as examples for demonstrating the effectiveness of the proposed fault modeling methodology.« less

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

PubMed Central

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

2015-01-01

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

Analysis of the impact of error detection on computer performance

NASA Technical Reports Server (NTRS)

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

1983-01-01

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

Prescribers' expectations and barriers to electronic prescribing of controlled substances

PubMed Central

Kim, Meelee; McDonald, Ann; Kreiner, Peter; Kelleher, Stephen J; Blackman, Michael B; Kaufman, Peter N; Carrow, Grant M

2011-01-01

Objective To better understand barriers associated with the adoption and use of electronic prescribing of controlled substances (EPCS), a practice recently established by US Drug Enforcement Administration regulation. Materials and methods Prescribers of controlled substances affiliated with a regional health system were surveyed regarding current electronic prescribing (e-prescribing) activities, current prescribing of controlled substances, and expectations and barriers to the adoption of EPCS. Results 246 prescribers (response rate of 64%) represented a range of medical specialties, with 43.1% of these prescribers current users of e-prescribing for non-controlled substances. Reported issues with controlled substances included errors, pharmacy call-backs, and diversion; most prescribers expected EPCS to address many of these problems, specifically reduce medical errors, improve work flow and efficiency of practice, help identify prescription diversion or misuse, and improve patient treatment management. Prescribers expected, however, that it would be disruptive to practice, and over one-third of respondents reported that carrying a security authentication token at all times would be so burdensome as to discourage adoption. Discussion Although adoption of e-prescribing has been shown to dramatically reduce medication errors, challenges to efficient processes and errors still persist from the perspective of the prescriber, that may interfere with the adoption of EPCS. Most prescribers regarded EPCS security measures as a small or moderate inconvenience (other than carrying a security token), with advantages outweighing the burden. Conclusion Prescribers are optimistic about the potential for EPCS to improve practice, but view certain security measures as a burden and potential barrier. PMID:21946239

Measurement and analysis of operating system fault tolerance

NASA Technical Reports Server (NTRS)

Lee, I.; Tang, D.; Iyer, R. K.

1992-01-01

This paper demonstrates a methodology to model and evaluate the fault tolerance characteristics of operational software. The methodology is illustrated through case studies on three different operating systems: the Tandem GUARDIAN fault-tolerant system, the VAX/VMS distributed system, and the IBM/MVS system. Measurements are made on these systems for substantial periods to collect software error and recovery data. In addition to investigating basic dependability characteristics such as major software problems and error distributions, we develop two levels of models to describe error and recovery processes inside an operating system and on multiple instances of an operating system running in a distributed environment. Based on the models, reward analysis is conducted to evaluate the loss of service due to software errors and the effect of the fault-tolerance techniques implemented in the systems. Software error correlation in multicomputer systems is also investigated.

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

PubMed

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

2008-08-01

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

Fault-tolerant measurement-based quantum computing with continuous-variable cluster states.

PubMed

Menicucci, Nicolas C

2014-03-28

A long-standing open question about Gaussian continuous-variable cluster states is whether they enable fault-tolerant measurement-based quantum computation. The answer is yes. Initial squeezing in the cluster above a threshold value of 20.5 dB ensures that errors from finite squeezing acting on encoded qubits are below the fault-tolerance threshold of known qubit-based error-correcting codes. By concatenating with one of these codes and using ancilla-based error correction, fault-tolerant measurement-based quantum computation of theoretically indefinite length is possible with finitely squeezed cluster states.

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

PubMed Central

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

2015-01-01

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

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

PubMed

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

2015-04-29

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

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

PubMed

Sada, Oumer; Melkie, Addisu; Shibeshi, Workineh

2015-09-16

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

A Technological Innovation to Reduce Prescribing Errors Based on Implementation Intentions: The Acceptability and Feasibility of MyPrescribe.

PubMed

Keyworth, Chris; Hart, Jo; Thoong, Hong; Ferguson, Jane; Tully, Mary

2017-08-01

Although prescribing of medication in hospitals is rarely an error-free process, prescribers receive little feedback on their mistakes and ways to change future practices. Audit and feedback interventions may be an effective approach to modifying the clinical practice of health professionals, but these may pose logistical challenges when used in hospitals. Moreover, such interventions are often labor intensive. Consequently, there is a need to develop effective and innovative interventions to overcome these challenges and to improve the delivery of feedback on prescribing. Implementation intentions, which have been shown to be effective in changing behavior, link critical situations with an appropriate response; however, these have rarely been used in the context of improving prescribing practices. Semistructured qualitative interviews were conducted to evaluate the acceptability and feasibility of providing feedback on prescribing errors via MyPrescribe, a mobile-compatible website informed by implementation intentions. Data relating to 200 prescribing errors made by 52 junior doctors were collected by 11 hospital pharmacists. These errors were populated into MyPrescribe, where prescribers were able to construct their own personalized action plans. Qualitative interviews with a subsample of 15 junior doctors were used to explore issues regarding feasibility and acceptability of MyPrescribe and their experiences of using implementation intentions to construct prescribing action plans. Framework analysis was used to identify prominent themes, with findings mapped to the behavioral components of the COM-B model (capability, opportunity, motivation, and behavior) to inform the development of future interventions. MyPrescribe was perceived to be effective in providing opportunities for critical reflection on prescribing errors and to complement existing training (such as junior doctors' e-portfolio). The participants were able to provide examples of how they would use "If-Then" plans for patient management. Technology, as opposed to other methods of learning (eg, traditional "paper based" learning), was seen as a positive advancement for continued learning. MyPrescribe was perceived as an acceptable and feasible learning tool for changing prescribing practices, with participants suggesting that it would make an important addition to medical prescribers' training in reflective practice. MyPrescribe is a novel theory-based technological innovation that provides the platform for doctors to create personalized implementation intentions. Applying the COM-B model allows for a more detailed understanding of the perceived mechanisms behind prescribing practices and the ways in which interventions aimed at changing professional practice can be implemented. ©Chris Keyworth, Jo Hart, Hong Thoong, Jane Ferguson, Mary Tully. Originally published in JMIR Human Factors (http://humanfactors.jmir.org), 01.08.2017.

Thrust-wrench fault interference in a brittle medium: new insights from analogue modelling experiments

NASA Astrophysics Data System (ADS)

Rosas, Filipe; Duarte, Joao; Schellart, Wouter; Tomas, Ricardo; Grigorova, Vili; Terrinha, Pedro

2015-04-01

We present analogue modelling experimental results concerning thrust-wrench fault interference in a brittle medium, to try to evaluate the influence exerted by different prescribed interference angles in the formation of morpho-structural interference fault patterns. All the experiments were conceived to simulate simultaneous reactivation of confining strike-slip and thrust faults defining a (corner) zone of interference, contrasting with previously reported discrete (time and space) superposition of alternating thrust and strike-slip events. Different interference angles of 60°, 90° and 120° were experimentally investigated by comparing the specific structural configurations obtained in each case. Results show that a deltoid-shaped morpho-structural pattern is consistently formed in the fault interference (corner) zone, exhibiting a specific geometry that is fundamentally determined by the different prescribed fault interference angle. Such angle determines the orientation of the displacement vector shear component along the main frontal thrust direction, determining different fault confinement conditions in each case, and imposing a complying geometry and kinematics of the interference deltoid structure. Model comparison with natural examples worldwide shows good geometric and kinematic similarity, pointing to the existence of matching underlying dynamic process. Acknowledgments This work was sponsored by the Fundação para a Ciência e a Tecnologia (FCT) through project MODELINK EXPL/GEO-GEO/0714/2013.

A survey of the criteria for prescribing in cases of borderline refractive errors

PubMed Central

Shneor, Einat; Evans, Bruce John William; Fine, Yael; Shapira, Yehudit; Gantz, Liat; Gordon-Shaag, Ariela

2015-01-01

Purpose This research investigated the reported optometric prescribing criteria of Israeli optometrists. Methods An online questionnaire based on previous studies was distributed via email and social networking sites to optometrists in Israel. The questionnaire surveyed the level of refractive error at which respondents would prescribe for different types of refractive error at various ages with and without symptoms. Results 124 responses were obtained, yielding a response rate of approximately 12–22%, 92% of whom had trained in Israel. For all refractive errors, the presence of symptoms strongly influenced prescribing criteria. For example, for 10–20 year old patients the degree of hyperopia for which 50% of practitioners would prescribe is +0.75 D in the presence of symptoms but twice this value (+1.50 D) in the absence of symptoms. As might be expected, optometrists prescribed at lower degrees of hyperopia for older compared with younger patients. There was a trend for more experienced practitioners to be less likely to prescribe for lower degrees of myopia and presbyopia. Practitioner gender, country of training, the type of practice environment, and financial incentives were not strongly related to prescribing criteria. Conclusions The prescribing criteria found in this study are broadly comparable with those in previous studies and with published prescribing guidelines. Subtle indications suggest that optometrists may become more conservative in their prescribing criteria with experience. PMID:26520884

A Technological Innovation to Reduce Prescribing Errors Based on Implementation Intentions: The Acceptability and Feasibility of MyPrescribe

PubMed Central

Hart, Jo; Thoong, Hong; Ferguson, Jane; Tully, Mary

2017-01-01

Background Although prescribing of medication in hospitals is rarely an error-free process, prescribers receive little feedback on their mistakes and ways to change future practices. Audit and feedback interventions may be an effective approach to modifying the clinical practice of health professionals, but these may pose logistical challenges when used in hospitals. Moreover, such interventions are often labor intensive. Consequently, there is a need to develop effective and innovative interventions to overcome these challenges and to improve the delivery of feedback on prescribing. Implementation intentions, which have been shown to be effective in changing behavior, link critical situations with an appropriate response; however, these have rarely been used in the context of improving prescribing practices. Objective Semistructured qualitative interviews were conducted to evaluate the acceptability and feasibility of providing feedback on prescribing errors via MyPrescribe, a mobile-compatible website informed by implementation intentions. Methods Data relating to 200 prescribing errors made by 52 junior doctors were collected by 11 hospital pharmacists. These errors were populated into MyPrescribe, where prescribers were able to construct their own personalized action plans. Qualitative interviews with a subsample of 15 junior doctors were used to explore issues regarding feasibility and acceptability of MyPrescribe and their experiences of using implementation intentions to construct prescribing action plans. Framework analysis was used to identify prominent themes, with findings mapped to the behavioral components of the COM-B model (capability, opportunity, motivation, and behavior) to inform the development of future interventions. Results MyPrescribe was perceived to be effective in providing opportunities for critical reflection on prescribing errors and to complement existing training (such as junior doctors’ e-portfolio). The participants were able to provide examples of how they would use “If-Then” plans for patient management. Technology, as opposed to other methods of learning (eg, traditional “paper based” learning), was seen as a positive advancement for continued learning. Conclusions MyPrescribe was perceived as an acceptable and feasible learning tool for changing prescribing practices, with participants suggesting that it would make an important addition to medical prescribers’ training in reflective practice. MyPrescribe is a novel theory-based technological innovation that provides the platform for doctors to create personalized implementation intentions. Applying the COM-B model allows for a more detailed understanding of the perceived mechanisms behind prescribing practices and the ways in which interventions aimed at changing professional practice can be implemented. PMID:28765104

Integrated analysis of error detection and recovery

NASA Technical Reports Server (NTRS)

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

1985-01-01

An integrated modeling and analysis of error detection and recovery is presented. When fault latency and/or error latency exist, the system may suffer from multiple faults or error propagations which seriously deteriorate the fault-tolerant capability. Several detection models that enable analysis of the effect of detection mechanisms on the subsequent error handling operations and the overall system reliability were developed. Following detection of the faulty unit and reconfiguration of the system, the contaminated processes or tasks have to be recovered. The strategies of error recovery employed depend on the detection mechanisms and the available redundancy. Several recovery methods including the rollback recovery are considered. The recovery overhead is evaluated as an index of the capabilities of the detection and reconfiguration mechanisms.

The impact of a closed‐loop electronic prescribing and administration system on prescribing errors, administration errors and staff time: a before‐and‐after study

PubMed Central

Franklin, Bryony Dean; O'Grady, Kara; Donyai, Parastou; Jacklin, Ann; Barber, Nick

2007-01-01

Objectives To assess the impact of a closed‐loop electronic prescribing, automated dispensing, barcode patient identification and electronic medication administration record (EMAR) system on prescribing and administration errors, confirmation of patient identity before administration, and staff time. Design, setting and participants Before‐and‐after study in a surgical ward of a teaching hospital, involving patients and staff of that ward. Intervention Closed‐loop electronic prescribing, automated dispensing, barcode patient identification and EMAR system. Main outcome measures Percentage of new medication orders with a prescribing error, percentage of doses with medication administration errors (MAEs) and percentage given without checking patient identity. Time spent prescribing and providing a ward pharmacy service. Nursing time on medication tasks. Results Prescribing errors were identified in 3.8% of 2450 medication orders pre‐intervention and 2.0% of 2353 orders afterwards (p<0.001; χ2 test). MAEs occurred in 7.0% of 1473 non‐intravenous doses pre‐intervention and 4.3% of 1139 afterwards (p = 0.005; χ2 test). Patient identity was not checked for 82.6% of 1344 doses pre‐intervention and 18.9% of 1291 afterwards (p<0.001; χ2 test). Medical staff required 15 s to prescribe a regular inpatient drug pre‐intervention and 39 s afterwards (p = 0.03; t test). Time spent providing a ward pharmacy service increased from 68 min to 98 min each weekday (p = 0.001; t test); 22% of drug charts were unavailable pre‐intervention. Time per drug administration round decreased from 50 min to 40 min (p = 0.006; t test); nursing time on medication tasks outside of drug rounds increased from 21.1% to 28.7% (p = 0.006; χ2 test). Conclusions A closed‐loop electronic prescribing, dispensing and barcode patient identification system reduced prescribing errors and MAEs, and increased confirmation of patient identity before administration. Time spent on medication‐related tasks increased. PMID:17693676

Safe prescribing: a titanic challenge

PubMed Central

Routledge, Philip A

2012-01-01

The challenge to achieve safe prescribing merits the adjective ‘titanic’. The organisational and human errors leading to poor prescribing (e.g. underprescribing, overprescribing, misprescribing or medication errors) have parallels in the organisational and human errors that led to the loss of the Titanic 100 years ago this year. Prescribing can be adversely affected by communication failures, critical conditions, complacency, corner cutting, callowness and a lack of courage of conviction, all of which were also factors leading to the Titanic tragedy. These issues need to be addressed by a commitment to excellence, the final component of the ‘Seven C's’. Optimal prescribing is dependent upon close communication and collaborative working between highly trained health professionals, whose role is to ensure maximum clinical effectiveness, whilst also protecting their patients from avoidable harm. Since humans are prone to error, and the environments in which they work are imperfect, it is not surprising that medication errors are common, occurring more often during the prescribing stage than during dispensing or administration. A commitment to excellence in prescribing includes a continued focus on lifelong learning (including interprofessional learning) in pharmacology and therapeutics. This should be accompanied by improvements in the clinical working environment of prescribers, and the encouragement of a strong safety culture (including reporting of adverse incidents as well as suspected adverse drug reactions whenever appropriate). Finally, members of the clinical team must be prepared to challenge each other, when necessary, to ensure that prescribing combines the highest likelihood of benefit with the lowest potential for harm. PMID:22738396

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

PubMed

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

2015-02-01

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

The SCEC/USGS dynamic earthquake rupture code verification exercise

USGS Publications Warehouse

Harris, R.A.; Barall, M.; Archuleta, R.; Dunham, E.; Aagaard, Brad T.; Ampuero, J.-P.; Bhat, H.; Cruz-Atienza, Victor M.; Dalguer, L.; Dawson, P.; Day, S.; Duan, B.; Ely, G.; Kaneko, Y.; Kase, Y.; Lapusta, N.; Liu, Yajing; Ma, S.; Oglesby, D.; Olsen, K.; Pitarka, A.; Song, S.; Templeton, E.

2009-01-01

Numerical simulations of earthquake rupture dynamics are now common, yet it has been difficult to test the validity of these simulations because there have been few field observations and no analytic solutions with which to compare the results. This paper describes the Southern California Earthquake Center/U.S. Geological Survey (SCEC/USGS) Dynamic Earthquake Rupture Code Verification Exercise, where codes that simulate spontaneous rupture dynamics in three dimensions are evaluated and the results produced by these codes are compared using Web-based tools. This is the first time that a broad and rigorous examination of numerous spontaneous rupture codes has been performed—a significant advance in this science. The automated process developed to attain this achievement provides for a future where testing of codes is easily accomplished.Scientists who use computer simulations to understand earthquakes utilize a range of techniques. Most of these assume that earthquakes are caused by slip at depth on faults in the Earth, but hereafter the strategies vary. Among the methods used in earthquake mechanics studies are kinematic approaches and dynamic approaches.The kinematic approach uses a computer code that prescribes the spatial and temporal evolution of slip on the causative fault (or faults). These types of simulations are very helpful, especially since they can be used in seismic data inversions to relate the ground motions recorded in the field to slip on the fault(s) at depth. However, these kinematic solutions generally provide no insight into the physics driving the fault slip or information about why the involved fault(s) slipped that much (or that little). In other words, these kinematic solutions may lack information about the physical dynamics of earthquake rupture that will be most helpful in forecasting future events.To help address this issue, some researchers use computer codes to numerically simulate earthquakes and construct dynamic, spontaneous rupture (hereafter called “spontaneous rupture”) solutions. For these types of numerical simulations, rather than prescribing the slip function at each location on the fault(s), just the friction constitutive properties and initial stress conditions are prescribed. The subsequent stresses and fault slip spontaneously evolve over time as part of the elasto-dynamic solution. Therefore, spontaneous rupture computer simulations of earthquakes allow us to include everything that we know, or think that we know, about earthquake dynamics and to test these ideas against earthquake observations.

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

PubMed

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

2015-09-01

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

Fault latency in the memory - An experimental study on VAX 11/780

NASA Technical Reports Server (NTRS)

Chillarege, Ram; Iyer, Ravishankar K.

1986-01-01

Fault latency is the time between the physical occurrence of a fault and its corruption of data, causing an error. The measure of this time is difficult to obtain because the time of occurrence of a fault and the exact moment of generation of an error are not known. This paper describes an experiment to accurately study the fault latency in the memory subsystem. The experiment employs real memory data from a VAX 11/780 at the University of Illinois. Fault latency distributions are generated for s-a-0 and s-a-1 permanent fault models. Results show that the mean fault latency of a s-a-0 fault is nearly 5 times that of the s-a-1 fault. Large variations in fault latency are found for different regions in memory. An analysis of a variance model to quantify the relative influence of various workload measures on the evaluated latency is also given.

Which non-technical skills do junior doctors require to prescribe safely? A systematic review.

PubMed

Dearden, Effie; Mellanby, Edward; Cameron, Helen; Harden, Jeni

2015-12-01

Prescribing errors are a major source of avoidable morbidity and mortality. Junior doctors write most in-hospital prescriptions and are the least experienced members of the healthcare team. This puts them at high risk of error and makes them attractive targets for interventions to improve prescription safety. Error analysis has shown a background of complex environments with multiple contributory conditions. Similar conditions in other high risk industries, such as aviation, have led to an increased understanding of so-called human factors and the use of non-technical skills (NTS) training to try to reduce error. To date no research has examined the NTS required for safe prescribing. The aim of this review was to develop a prototype NTS taxonomy for safe prescribing, by junior doctors, in hospital settings. A systematic search identified 14 studies analyzing prescribing behaviours and errors by junior doctors. Framework analysis was used to extract data from the studies and identify behaviours related to categories of NTS that might be relevant to safe and effective prescribing performance by junior doctors. Categories were derived from existing literature and inductively from the data. A prototype taxonomy of relevant categories (situational awareness, decision making, communication and team working, and task management) and elements was constructed. This prototype will form the basis of future work to create a tool that can be used for training and assessment of medical students and junior doctors to reduce prescribing error in the future. © 2015 The British Pharmacological Society.

A survey of the criteria for prescribing in cases of borderline refractive errors.

PubMed

Shneor, Einat; Evans, Bruce John William; Fine, Yael; Shapira, Yehudit; Gantz, Liat; Gordon-Shaag, Ariela

2016-01-01

This research investigated the reported optometric prescribing criteria of Israeli optometrists. An online questionnaire based on previous studies was distributed via email and social networking sites to optometrists in Israel. The questionnaire surveyed the level of refractive error at which respondents would prescribe for different types of refractive error at various ages with and without symptoms. 124 responses were obtained, yielding a response rate of approximately 12-22%, 92% of whom had trained in Israel. For all refractive errors, the presence of symptoms strongly influenced prescribing criteria. For example, for 10-20 year old patients the degree of hyperopia for which 50% of practitioners would prescribe is +0.75 D in the presence of symptoms but twice this value (+1.50 D) in the absence of symptoms. As might be expected, optometrists prescribed at lower degrees of hyperopia for older compared with younger patients. There was a trend for more experienced practitioners to be less likely to prescribe for lower degrees of myopia and presbyopia. Practitioner gender, country of training, the type of practice environment, and financial incentives were not strongly related to prescribing criteria. The prescribing criteria found in this study are broadly comparable with those in previous studies and with published prescribing guidelines. Subtle indications suggest that optometrists may become more conservative in their prescribing criteria with experience. Copyright © 2015 Spanish General Council of Optometry. Published by Elsevier Espana. All rights reserved.

Evolving geometrical heterogeneities of fault trace data

NASA Astrophysics Data System (ADS)

Wechsler, Neta; Ben-Zion, Yehuda; Christofferson, Shari

2010-08-01

We perform a systematic comparative analysis of geometrical fault zone heterogeneities using derived measures from digitized fault maps that are not very sensitive to mapping resolution. We employ the digital GIS map of California faults (version 2.0) and analyse the surface traces of active strike-slip fault zones with evidence of Quaternary and historic movements. Each fault zone is broken into segments that are defined as a continuous length of fault bounded by changes of angle larger than 1°. Measurements of the orientations and lengths of fault zone segments are used to calculate the mean direction and misalignment of each fault zone from the local plate motion direction, and to define several quantities that represent the fault zone disorder. These include circular standard deviation and circular standard error of segments, orientation of long and short segments with respect to the mean direction, and normal separation distances of fault segments. We examine the correlations between various calculated parameters of fault zone disorder and the following three potential controlling variables: cumulative slip, slip rate and fault zone misalignment from the plate motion direction. The analysis indicates that the circular standard deviation and circular standard error of segments decrease overall with increasing cumulative slip and increasing slip rate of the fault zones. The results imply that the circular standard deviation and error, quantifying the range or dispersion in the data, provide effective measures of the fault zone disorder, and that the cumulative slip and slip rate (or more generally slip rate normalized by healing rate) represent the fault zone maturity. The fault zone misalignment from plate motion direction does not seem to play a major role in controlling the fault trace heterogeneities. The frequency-size statistics of fault segment lengths can be fitted well by an exponential function over the entire range of observations.

Outpatient CPOE orders discontinued due to 'erroneous entry': prospective survey of prescribers' explanations for errors.

PubMed

Hickman, Thu-Trang T; Quist, Arbor Jessica Lauren; Salazar, Alejandra; Amato, Mary G; Wright, Adam; Volk, Lynn A; Bates, David W; Schiff, Gordon

2018-04-01

Computerised prescriber order entry (CPOE) systems users often discontinue medications because the initial order was erroneous. To elucidate error types by querying prescribers about their reasons for discontinuing outpatient medication orders that they had self-identified as erroneous. During a nearly 3 year retrospective data collection period, we identified 57 972 drugs discontinued with the reason 'Error (erroneous entry)." Because chart reviews revealed limited information about these errors, we prospectively studied consecutive, discontinued erroneous orders by querying prescribers in near-real-time to learn more about the erroneous orders. From January 2014 to April 2014, we prospectively emailed prescribers about outpatient drug orders that they had discontinued due to erroneous initial order entry. Of 2 50 806 medication orders in these 4 months, 1133 (0.45%) of these were discontinued due to error. From these 1133, we emailed 542 unique prescribers to ask about their reason(s) for discontinuing these mediation orders in error. We received 312 responses (58% response rate). We categorised these responses using a previously published taxonomy. The top reasons for these discontinued erroneous orders included: medication ordered for wrong patient (27.8%, n=60); wrong drug ordered (18.5%, n=40); and duplicate order placed (14.4%, n=31). Other common discontinued erroneous orders related to drug dosage and formulation (eg, extended release versus not). Oxycodone (3%) was the most frequent drug discontinued error. Drugs are not infrequently discontinued 'in error.' Wrong patient and wrong drug errors constitute the leading types of erroneous prescriptions recognised and discontinued by prescribers. Data regarding erroneous medication entries represent an important source of intelligence about how CPOE systems are functioning and malfunctioning, providing important insights regarding areas for designing CPOE more safely in the future. © 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.

Safe prescribing: a titanic challenge.

PubMed

Routledge, Philip A

2012-10-01

The challenge to achieve safe prescribing merits the adjective 'titanic'. The organisational and human errors leading to poor prescribing (e.g. underprescribing, overprescribing, misprescribing or medication errors) have parallels in the organisational and human errors that led to the loss of the Titanic 100 years ago this year. Prescribing can be adversely affected by communication failures, critical conditions, complacency, corner cutting, callowness and a lack of courage of conviction, all of which were also factors leading to the Titanic tragedy. These issues need to be addressed by a commitment to excellence, the final component of the 'Seven C's'. Optimal prescribing is dependent upon close communication and collaborative working between highly trained health professionals, whose role is to ensure maximum clinical effectiveness, whilst also protecting their patients from avoidable harm. Since humans are prone to error, and the environments in which they work are imperfect, it is not surprising that medication errors are common, occurring more often during the prescribing stage than during dispensing or administration. A commitment to excellence in prescribing includes a continued focus on lifelong learning (including interprofessional learning) in pharmacology and therapeutics. This should be accompanied by improvements in the clinical working environment of prescribers, and the encouragement of a strong safety culture (including reporting of adverse incidents as well as suspected adverse drug reactions whenever appropriate). Finally, members of the clinical team must be prepared to challenge each other, when necessary, to ensure that prescribing combines the highest likelihood of benefit with the lowest potential for harm. © 2012 The Author. British Journal of Clinical Pharmacology © 2012 The British Pharmacological Society.

Unit of Measurement Used and Parent Medication Dosing Errors

PubMed Central

Dreyer, Benard P.; Ugboaja, Donna C.; Sanchez, Dayana C.; Paul, Ian M.; Moreira, Hannah A.; Rodriguez, Luis; Mendelsohn, Alan L.

2014-01-01

BACKGROUND AND OBJECTIVES: Adopting the milliliter as the preferred unit of measurement has been suggested as a strategy to improve the clarity of medication instructions; teaspoon and tablespoon units may inadvertently endorse nonstandard kitchen spoon use. We examined the association between unit used and parent medication errors and whether nonstandard instruments mediate this relationship. METHODS: Cross-sectional analysis of baseline data from a larger study of provider communication and medication errors. English- or Spanish-speaking parents (n = 287) whose children were prescribed liquid medications in 2 emergency departments were enrolled. Medication error defined as: error in knowledge of prescribed dose, error in observed dose measurement (compared to intended or prescribed dose); >20% deviation threshold for error. Multiple logistic regression performed adjusting for parent age, language, country, race/ethnicity, socioeconomic status, education, health literacy (Short Test of Functional Health Literacy in Adults); child age, chronic disease; site. RESULTS: Medication errors were common: 39.4% of parents made an error in measurement of the intended dose, 41.1% made an error in the prescribed dose. Furthermore, 16.7% used a nonstandard instrument. Compared with parents who used milliliter-only, parents who used teaspoon or tablespoon units had twice the odds of making an error with the intended (42.5% vs 27.6%, P = .02; adjusted odds ratio=2.3; 95% confidence interval, 1.2–4.4) and prescribed (45.1% vs 31.4%, P = .04; adjusted odds ratio=1.9; 95% confidence interval, 1.03–3.5) dose; associations greater for parents with low health literacy and non–English speakers. Nonstandard instrument use partially mediated teaspoon and tablespoon–associated measurement errors. CONCLUSIONS: Findings support a milliliter-only standard to reduce medication errors. PMID:25022742

Unit of measurement used and parent medication dosing errors.

PubMed

Yin, H Shonna; Dreyer, Benard P; Ugboaja, Donna C; Sanchez, Dayana C; Paul, Ian M; Moreira, Hannah A; Rodriguez, Luis; Mendelsohn, Alan L

2014-08-01

Adopting the milliliter as the preferred unit of measurement has been suggested as a strategy to improve the clarity of medication instructions; teaspoon and tablespoon units may inadvertently endorse nonstandard kitchen spoon use. We examined the association between unit used and parent medication errors and whether nonstandard instruments mediate this relationship. Cross-sectional analysis of baseline data from a larger study of provider communication and medication errors. English- or Spanish-speaking parents (n = 287) whose children were prescribed liquid medications in 2 emergency departments were enrolled. Medication error defined as: error in knowledge of prescribed dose, error in observed dose measurement (compared to intended or prescribed dose); >20% deviation threshold for error. Multiple logistic regression performed adjusting for parent age, language, country, race/ethnicity, socioeconomic status, education, health literacy (Short Test of Functional Health Literacy in Adults); child age, chronic disease; site. Medication errors were common: 39.4% of parents made an error in measurement of the intended dose, 41.1% made an error in the prescribed dose. Furthermore, 16.7% used a nonstandard instrument. Compared with parents who used milliliter-only, parents who used teaspoon or tablespoon units had twice the odds of making an error with the intended (42.5% vs 27.6%, P = .02; adjusted odds ratio=2.3; 95% confidence interval, 1.2-4.4) and prescribed (45.1% vs 31.4%, P = .04; adjusted odds ratio=1.9; 95% confidence interval, 1.03-3.5) dose; associations greater for parents with low health literacy and non-English speakers. Nonstandard instrument use partially mediated teaspoon and tablespoon-associated measurement errors. Findings support a milliliter-only standard to reduce medication errors. Copyright © 2014 by the American Academy of Pediatrics.

Novel prescribed performance neural control of a flexible air-breathing hypersonic vehicle with unknown initial errors.

PubMed

Bu, Xiangwei; Wu, Xiaoyan; Zhu, Fujing; Huang, Jiaqi; Ma, Zhen; Zhang, Rui

2015-11-01

A novel prescribed performance neural controller with unknown initial errors is addressed for the longitudinal dynamic model of a flexible air-breathing hypersonic vehicle (FAHV) subject to parametric uncertainties. Different from traditional prescribed performance control (PPC) requiring that the initial errors have to be known accurately, this paper investigates the tracking control without accurate initial errors via exploiting a new performance function. A combined neural back-stepping and minimal learning parameter (MLP) technology is employed for exploring a prescribed performance controller that provides robust tracking of velocity and altitude reference trajectories. The highlight is that the transient performance of velocity and altitude tracking errors is satisfactory and the computational load of neural approximation is low. Finally, numerical simulation results from a nonlinear FAHV model demonstrate the efficacy of the proposed strategy. Copyright © 2015 ISA. Published by Elsevier Ltd. All rights reserved.

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

PubMed

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

2009-01-01

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

Analyzing Software Errors in Safety-Critical Embedded Systems

NASA Technical Reports Server (NTRS)

Lutz, Robyn R.

1994-01-01

This paper analyzes the root causes of safty-related software faults identified as potentially hazardous to the system are distributed somewhat differently over the set of possible error causes than non-safety-related software faults.

Medication errors: problems and recommendations from a consensus meeting

PubMed Central

Agrawal, Abha; Aronson, Jeffrey K; Britten, Nicky; Ferner, Robin E; de Smet, Peter A; Fialová, Daniela; Fitzgerald, Richard J; Likić, Robert; Maxwell, Simon R; Meyboom, Ronald H; Minuz, Pietro; Onder, Graziano; Schachter, Michael; Velo, Giampaolo

2009-01-01

Here we discuss 15 recommendations for reducing the risks of medication errors: Provision of sufficient undergraduate learning opportunities to make medical students safe prescribers. Provision of opportunities for students to practise skills that help to reduce errors. Education of students about common types of medication errors and how to avoid them. Education of prescribers in taking accurate drug histories. Assessment in medical schools of prescribing knowledge and skills and demonstration that newly qualified doctors are safe prescribers. European harmonization of prescribing and safety recommendations and regulatory measures, with regular feedback about rational drug use. Comprehensive assessment of elderly patients for declining function. Exploration of low-dose regimens for elderly patients and preparation of special formulations as required. Training for all health-care professionals in drug use, adverse effects, and medication errors in elderly people. More involvement of pharmacists in clinical practice. Introduction of integrated prescription forms and national implementation in individual countries. Development of better monitoring systems for detecting medication errors, based on classification and analysis of spontaneous reports of previous reactions, and for investigating the possible role of medication errors when patients die. Use of IT systems, when available, to provide methods of avoiding medication errors; standardization, proper evaluation, and certification of clinical information systems. Nonjudgmental communication with patients about their concerns and elicitation of symptoms that they perceive to be adverse drug reactions. Avoidance of defensive reactions if patients mention symptoms resulting from medication errors. PMID:19594525

A methodology for testing fault-tolerant software

NASA Technical Reports Server (NTRS)

Andrews, D. M.; Mahmood, A.; Mccluskey, E. J.

1985-01-01

A methodology for testing fault tolerant software is presented. There are problems associated with testing fault tolerant software because many errors are masked or corrected by voters, limiter, or automatic channel synchronization. This methodology illustrates how the same strategies used for testing fault tolerant hardware can be applied to testing fault tolerant software. For example, one strategy used in testing fault tolerant hardware is to disable the redundancy during testing. A similar testing strategy is proposed for software, namely, to move the major emphasis on testing earlier in the development cycle (before the redundancy is in place) thus reducing the possibility that undetected errors will be masked when limiters and voters are added.

Fuzzy Inference System Approach for Locating Series, Shunt, and Simultaneous Series-Shunt Faults in Double Circuit Transmission Lines

PubMed Central

Swetapadma, Aleena; Yadav, Anamika

2015-01-01

Many schemes are reported for shunt fault location estimation, but fault location estimation of series or open conductor faults has not been dealt with so far. The existing numerical relays only detect the open conductor (series) fault and give the indication of the faulty phase(s), but they are unable to locate the series fault. The repair crew needs to patrol the complete line to find the location of series fault. In this paper fuzzy based fault detection/classification and location schemes in time domain are proposed for both series faults, shunt faults, and simultaneous series and shunt faults. The fault simulation studies and fault location algorithm have been developed using Matlab/Simulink. Synchronized phasors of voltage and current signals of both the ends of the line have been used as input to the proposed fuzzy based fault location scheme. Percentage of error in location of series fault is within 1% and shunt fault is 5% for all the tested fault cases. Validation of percentage of error in location estimation is done using Chi square test with both 1% and 5% level of significance. PMID:26413088

Runtime Verification in Context : Can Optimizing Error Detection Improve Fault Diagnosis

NASA Technical Reports Server (NTRS)

Dwyer, Matthew B.; Purandare, Rahul; Person, Suzette

2010-01-01

Runtime verification has primarily been developed and evaluated as a means of enriching the software testing process. While many researchers have pointed to its potential applicability in online approaches to software fault tolerance, there has been a dearth of work exploring the details of how that might be accomplished. In this paper, we describe how a component-oriented approach to software health management exposes the connections between program execution, error detection, fault diagnosis, and recovery. We identify both research challenges and opportunities in exploiting those connections. Specifically, we describe how recent approaches to reducing the overhead of runtime monitoring aimed at error detection might be adapted to reduce the overhead and improve the effectiveness of fault diagnosis.

Step-by-step magic state encoding for efficient fault-tolerant quantum computation

PubMed Central

Goto, Hayato

2014-01-01

Quantum error correction allows one to make quantum computers fault-tolerant against unavoidable errors due to decoherence and imperfect physical gate operations. However, the fault-tolerant quantum computation requires impractically large computational resources for useful applications. This is a current major obstacle to the realization of a quantum computer. In particular, magic state distillation, which is a standard approach to universality, consumes the most resources in fault-tolerant quantum computation. For the resource problem, here we propose step-by-step magic state encoding for concatenated quantum codes, where magic states are encoded step by step from the physical level to the logical one. To manage errors during the encoding, we carefully use error detection. Since the sizes of intermediate codes are small, it is expected that the resource overheads will become lower than previous approaches based on the distillation at the logical level. Our simulation results suggest that the resource requirements for a logical magic state will become comparable to those for a single logical controlled-NOT gate. Thus, the present method opens a new possibility for efficient fault-tolerant quantum computation. PMID:25511387

Step-by-step magic state encoding for efficient fault-tolerant quantum computation.

PubMed

Goto, Hayato

2014-12-16

Quantum error correction allows one to make quantum computers fault-tolerant against unavoidable errors due to decoherence and imperfect physical gate operations. However, the fault-tolerant quantum computation requires impractically large computational resources for useful applications. This is a current major obstacle to the realization of a quantum computer. In particular, magic state distillation, which is a standard approach to universality, consumes the most resources in fault-tolerant quantum computation. For the resource problem, here we propose step-by-step magic state encoding for concatenated quantum codes, where magic states are encoded step by step from the physical level to the logical one. To manage errors during the encoding, we carefully use error detection. Since the sizes of intermediate codes are small, it is expected that the resource overheads will become lower than previous approaches based on the distillation at the logical level. Our simulation results suggest that the resource requirements for a logical magic state will become comparable to those for a single logical controlled-NOT gate. Thus, the present method opens a new possibility for efficient fault-tolerant quantum computation.

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

PubMed

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

2015-01-01

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

Accounting for uncertain fault geometry in earthquake source inversions - I: theory and simplified application

NASA Astrophysics Data System (ADS)

Ragon, Théa; Sladen, Anthony; Simons, Mark

2018-05-01

The ill-posed nature of earthquake source estimation derives from several factors including the quality and quantity of available observations and the fidelity of our forward theory. Observational errors are usually accounted for in the inversion process. Epistemic errors, which stem from our simplified description of the forward problem, are rarely dealt with despite their potential to bias the estimate of a source model. In this study, we explore the impact of uncertainties related to the choice of a fault geometry in source inversion problems. The geometry of a fault structure is generally reduced to a set of parameters, such as position, strike and dip, for one or a few planar fault segments. While some of these parameters can be solved for, more often they are fixed to an uncertain value. We propose a practical framework to address this limitation by following a previously implemented method exploring the impact of uncertainties on the elastic properties of our models. We develop a sensitivity analysis to small perturbations of fault dip and position. The uncertainties in fault geometry are included in the inverse problem under the formulation of the misfit covariance matrix that combines both prediction and observation uncertainties. We validate this approach with the simplified case of a fault that extends infinitely along strike, using both Bayesian and optimization formulations of a static inversion. If epistemic errors are ignored, predictions are overconfident in the data and source parameters are not reliably estimated. In contrast, inclusion of uncertainties in fault geometry allows us to infer a robust posterior source model. Epistemic uncertainties can be many orders of magnitude larger than observational errors for great earthquakes (Mw > 8). Not accounting for uncertainties in fault geometry may partly explain observed shallow slip deficits for continental earthquakes. Similarly, ignoring the impact of epistemic errors can also bias estimates of near surface slip and predictions of tsunamis induced by megathrust earthquakes. (Mw > 8)

Unrealized potential and residual consequences of electronic prescribing on pharmacy workflow in the outpatient pharmacy.

PubMed

Nanji, Karen C; Rothschild, Jeffrey M; Boehne, Jennifer J; Keohane, Carol A; Ash, Joan S; Poon, Eric G

2014-01-01

Electronic prescribing systems have often been promoted as a tool for reducing medication errors and adverse drug events. Recent evidence has revealed that adoption of electronic prescribing systems can lead to unintended consequences such as the introduction of new errors. The purpose of this study is to identify and characterize the unrealized potential and residual consequences of electronic prescribing on pharmacy workflow in an outpatient pharmacy. A multidisciplinary team conducted direct observations of workflow in an independent pharmacy and semi-structured interviews with pharmacy staff members about their perceptions of the unrealized potential and residual consequences of electronic prescribing systems. We used qualitative methods to iteratively analyze text data using a grounded theory approach, and derive a list of major themes and subthemes related to the unrealized potential and residual consequences of electronic prescribing. We identified the following five themes: Communication, workflow disruption, cost, technology, and opportunity for new errors. These contained 26 unique subthemes representing different facets of our observations and the pharmacy staff's perceptions of the unrealized potential and residual consequences of electronic prescribing. We offer targeted solutions to improve electronic prescribing systems by addressing the unrealized potential and residual consequences that we identified. These recommendations may be applied not only to improve staff perceptions of electronic prescribing systems but also to improve the design and/or selection of these systems in order to optimize communication and workflow within pharmacies while minimizing both cost and the potential for the introduction of new errors.

The mechanics of fault-bend folding and tear-fault systems in the Niger Delta

NASA Astrophysics Data System (ADS)

Benesh, Nathan Philip

This dissertation investigates the mechanics of fault-bend folding using the discrete element method (DEM) and explores the nature of tear-fault systems in the deep-water Niger Delta fold-and-thrust belt. In Chapter 1, we employ the DEM to investigate the development of growth structures in anticlinal fault-bend folds. This work was inspired by observations that growth strata in active folds show a pronounced upward decrease in bed dip, in contrast to traditional kinematic fault-bend fold models. Our analysis shows that the modeled folds grow largely by parallel folding as specified by the kinematic theory; however, the process of folding over a broad axial surface zone yields a component of fold growth by limb rotation that is consistent with the patterns observed in natural folds. This result has important implications for how growth structures can he used to constrain slip and paleo-earthquake ages on active blind-thrust faults. In Chapter 2, we expand our DEM study to investigate the development of a wider range of fault-bend folds. We examine the influence of mechanical stratigraphy and quantitatively compare our models with the relationships between fold and fault shape prescribed by the kinematic theory. While the synclinal fault-bend models closely match the kinematic theory, the modeled anticlinal fault-bend folds show robust behavior that is distinct from the kinematic theory. Specifically, we observe that modeled structures maintain a linear relationship between fold shape (gamma) and fault-horizon cutoff angle (theta), rather than expressing the non-linear relationship with two distinct modes of anticlinal folding that is prescribed by the kinematic theory. These observations lead to a revised quantitative relationship for fault-bend folds that can serve as a useful interpretation tool. Finally, in Chapter 3, we examine the 3D relationships of tear- and thrust-fault systems in the western, deep-water Niger Delta. Using 3D seismic reflection data and new map-based structural restoration techniques, we find that the tear faults have distinct displacement patterns that distinguish them from conventional strike-slip faults and reflect their roles in accommodating displacement gradients within the fold-and-thrust belt.

An experimental study of fault propagation in a jet-engine controller. M.S. Thesis

NASA Technical Reports Server (NTRS)

Choi, Gwan Seung

1990-01-01

An experimental analysis of the impact of transient faults on a microprocessor-based jet engine controller, used in the Boeing 747 and 757 aircrafts is described. A hierarchical simulation environment which allows the injection of transients during run-time and the tracing of their impact is described. Verification of the accuracy of this approach is also provided. A determination of the probability that a transient results in latch, pin or functional errors is made. Given a transient fault, there is approximately an 80 percent chance that there is no impact on the chip. An empirical model to depict the process of error exploration and degeneration in the target system is derived. The model shows that, if no latch errors occur within eight clock cycles, no significant damage is likely to happen. Thus, the overall impact of a transient is well contained. A state transition model is also derived from the measured data, to describe the error propagation characteristics within the chip, and to quantify the impact of transients on the external environment. The model is used to identify and isolate the critical fault propagation paths, the module most sensitive to fault propagation and the module with the highest potential of causing external pin errors.

Fault Tolerance for VLSI Multicomputers

DTIC Science & Technology

1985-08-01

that consists of hundreds or thousands of VLSI computation nodes interconnected by dedicated links. Some important applications of high-end computers...technology, and intended applications . A proposed fault tolerance scheme combines hardware that performs error detection and system-level protocols for...order to recover from the error and resume correct operation, a valid system state must be restored. A low-overhead, application -transparent error

Advanced Information Processing System - Fault detection and error handling

NASA Technical Reports Server (NTRS)

Lala, J. H.

1985-01-01

The Advanced Information Processing System (AIPS) is designed to provide a fault tolerant and damage tolerant data processing architecture for a broad range of aerospace vehicles, including tactical and transport aircraft, and manned and autonomous spacecraft. A proof-of-concept (POC) system is now in the detailed design and fabrication phase. This paper gives an overview of a preliminary fault detection and error handling philosophy in AIPS.

Near field communications technology and the potential to reduce medication errors through multidisciplinary application

PubMed Central

Pegler, Joe; Lehane, Elaine; Livingstone, Vicki; McCarthy, Nora; Sahm, Laura J.; Tabirca, Sabin; O’Driscoll, Aoife; Corrigan, Mark

2016-01-01

Background Patient safety requires optimal management of medications. Electronic systems are encouraged to reduce medication errors. Near field communications (NFC) is an emerging technology that may be used to develop novel medication management systems. Methods An NFC-based system was designed to facilitate prescribing, administration and review of medications commonly used on surgical wards. Final year medical, nursing, and pharmacy students were recruited to test the electronic system in a cross-over observational setting on a simulated ward. Medication errors were compared against errors recorded using a paper-based system. Results A significant difference in the commission of medication errors was seen when NFC and paper-based medication systems were compared. Paper use resulted in a mean of 4.09 errors per prescribing round while NFC prescribing resulted in a mean of 0.22 errors per simulated prescribing round (P=0.000). Likewise, medication administration errors were reduced from a mean of 2.30 per drug round with a Paper system to a mean of 0.80 errors per round using NFC (P<0.015). A mean satisfaction score of 2.30 was reported by users, (rated on seven-point scale with 1 denoting total satisfaction with system use and 7 denoting total dissatisfaction). Conclusions An NFC based medication system may be used to effectively reduce medication errors in a simulated ward environment. PMID:28293602

Near field communications technology and the potential to reduce medication errors through multidisciplinary application.

PubMed

O'Connell, Emer; Pegler, Joe; Lehane, Elaine; Livingstone, Vicki; McCarthy, Nora; Sahm, Laura J; Tabirca, Sabin; O'Driscoll, Aoife; Corrigan, Mark

2016-01-01

Patient safety requires optimal management of medications. Electronic systems are encouraged to reduce medication errors. Near field communications (NFC) is an emerging technology that may be used to develop novel medication management systems. An NFC-based system was designed to facilitate prescribing, administration and review of medications commonly used on surgical wards. Final year medical, nursing, and pharmacy students were recruited to test the electronic system in a cross-over observational setting on a simulated ward. Medication errors were compared against errors recorded using a paper-based system. A significant difference in the commission of medication errors was seen when NFC and paper-based medication systems were compared. Paper use resulted in a mean of 4.09 errors per prescribing round while NFC prescribing resulted in a mean of 0.22 errors per simulated prescribing round (P=0.000). Likewise, medication administration errors were reduced from a mean of 2.30 per drug round with a Paper system to a mean of 0.80 errors per round using NFC (P<0.015). A mean satisfaction score of 2.30 was reported by users, (rated on seven-point scale with 1 denoting total satisfaction with system use and 7 denoting total dissatisfaction). An NFC based medication system may be used to effectively reduce medication errors in a simulated ward environment.

Fault and Error Latency Under Real Workload: an Experimental Study. Ph.D. Thesis

NASA Technical Reports Server (NTRS)

Chillarege, Ram

1986-01-01

A practical methodology for the study of fault and error latency is demonstrated under a real workload. This is the first study that measures and quantifies the latency under real workload and fills a major gap in the current understanding of workload-failure relationships. The methodology is based on low level data gathered on a VAX 11/780 during the normal workload conditions of the installation. Fault occurrence is simulated on the data, and the error generation and discovery process is reconstructed to determine latency. The analysis proceeds to combine the low level activity data with high level machine performance data to yield a better understanding of the phenomena. A strong relationship exists between latency and workload and that relationship is quantified. The sampling and reconstruction techniques used are also validated. Error latency in the memory where the operating system resides was studied using data on the physical memory access. Fault latency in the paged section of memory was determined using data from physical memory scans. Error latency in the microcontrol store was studied using data on the microcode access and usage.

Software fault-tolerance by design diversity DEDIX: A tool for experiments

NASA Technical Reports Server (NTRS)

Avizienis, A.; Gunningberg, P.; Kelly, J. P. J.; Lyu, R. T.; Strigini, L.; Traverse, P. J.; Tso, K. S.; Voges, U.

1986-01-01

The use of multiple versions of a computer program, independently designed from a common specification, to reduce the effects of an error is discussed. If these versions are designed by independent programming teams, it is expected that a fault in one version will not have the same behavior as any fault in the other versions. Since the errors in the output of the versions are different and uncorrelated, it is possible to run the versions concurrently, cross-check their results at prespecified points, and mask errors. A DEsign DIversity eXperiments (DEDIX) testbed was implemented to study the influence of common mode errors which can result in a failure of the entire system. The layered design of DEDIX and its decision algorithm are described.

Periodic Application of Concurrent Error Detection in Processor Array Architectures. PhD. Thesis -

NASA Technical Reports Server (NTRS)

Chen, Paul Peichuan

1993-01-01

Processor arrays can provide an attractive architecture for some applications. Featuring modularity, regular interconnection and high parallelism, such arrays are well-suited for VLSI/WSI implementations, and applications with high computational requirements, such as real-time signal processing. Preserving the integrity of results can be of paramount importance for certain applications. In these cases, fault tolerance should be used to ensure reliable delivery of a system's service. One aspect of fault tolerance is the detection of errors caused by faults. Concurrent error detection (CED) techniques offer the advantage that transient and intermittent faults may be detected with greater probability than with off-line diagnostic tests. Applying time-redundant CED techniques can reduce hardware redundancy costs. However, most time-redundant CED techniques degrade a system's performance.

Error rates and resource overheads of encoded three-qubit gates

NASA Astrophysics Data System (ADS)

Takagi, Ryuji; Yoder, Theodore J.; Chuang, Isaac L.

2017-10-01

A non-Clifford gate is required for universal quantum computation, and, typically, this is the most error-prone and resource-intensive logical operation on an error-correcting code. Small, single-qubit rotations are popular choices for this non-Clifford gate, but certain three-qubit gates, such as Toffoli or controlled-controlled-Z (ccz), are equivalent options that are also more suited for implementing some quantum algorithms, for instance, those with coherent classical subroutines. Here, we calculate error rates and resource overheads for implementing logical ccz with pieceable fault tolerance, a nontransversal method for implementing logical gates. We provide a comparison with a nonlocal magic-state scheme on a concatenated code and a local magic-state scheme on the surface code. We find the pieceable fault-tolerance scheme particularly advantaged over magic states on concatenated codes and in certain regimes over magic states on the surface code. Our results suggest that pieceable fault tolerance is a promising candidate for fault tolerance in a near-future quantum computer.

High-resolution image of Calaveras fault seismicity

USGS Publications Warehouse

Schaff, D.P.; Bokelmann, G.H.R.; Beroza, G.C.; Waldhauser, F.; Ellsworth, W.L.

2002-01-01

By measuring relative earthquake arrival times using waveform cross correlation and locating earthquakes using the double difference technique, we are able to reduce hypocentral errors by 1 to 2 orders of magnitude over routine locations for nearly 8000 events along a 35-km section of the Calaveras Fault. This represents ~92% of all seismicity since 1984 and includes the rupture zone of the M 6.2 1984 Morgan Hill, California, earthquake. The relocated seismicity forms highly organized structures that were previously obscured by location errors. There are abundant repeating earthquake sequences as well as linear clusters of earthquakes. Large voids in seismicity appear with dimensions of kilometers that have been aseismic over the 30-year time interval, suggesting that these portions of the fault are either locked or creeping. The area of greatest slip in the Morgan Hill main shock coincides with the most prominent of these voids, suggesting that this part of the fault may be locked between large earthquakes. We find that the Calaveras Fault at depth is extremely thin, with an average upper bound on fault zone width of 75 m. Given the location error, however, this width is not resolvably different from zero. The relocations reveal active secondary faults, which we use to solve for the stress field in the immediate vicinity of the Calaveras Fault. We find that the maximum compressive stress is at a high angle, only 13 from the fault normal, supporting previous interpretations that this fault is weak.

A long-term follow-up evaluation of electronic health record prescribing safety

PubMed Central

Abramson, Erika L; Malhotra, Sameer; Osorio, S Nena; Edwards, Alison; Cheriff, Adam; Cole, Curtis; Kaushal, Rainu

2013-01-01

Objective To be eligible for incentives through the Electronic Health Record (EHR) Incentive Program, many providers using older or locally developed EHRs will be transitioning to new, commercial EHRs. We previously evaluated prescribing errors made by providers in the first year following transition from a locally developed EHR with minimal prescribing clinical decision support (CDS) to a commercial EHR with robust CDS. Following system refinements, we conducted this study to assess the rates and types of errors 2 years after transition and determine the evolution of errors. Materials and methods We conducted a mixed methods cross-sectional case study of 16 physicians at an academic-affiliated ambulatory clinic from April to June 2010. We utilized standardized prescription and chart review to identify errors. Fourteen providers also participated in interviews. Results We analyzed 1905 prescriptions. The overall prescribing error rate was 3.8 per 100 prescriptions (95% CI 2.8 to 5.1). Error rates were significantly lower 2 years after transition (p<0.001 compared to pre-implementation, 12 weeks and 1 year after transition). Rates of near misses remained unchanged. Providers positively appreciated most system refinements, particularly reduced alert firing. Discussion Our study suggests that over time and with system refinements, use of a commercial EHR with advanced CDS can lead to low prescribing error rates, although more serious errors may require targeted interventions to eliminate them. Reducing alert firing frequency appears particularly important. Our results provide support for federal efforts promoting meaningful use of EHRs. Conclusions Ongoing error monitoring can allow CDS to be optimally tailored and help achieve maximal safety benefits. Clinical Trials Registration ClinicalTrials.gov, Identifier: NCT00603070. PMID:23578816

Fault-tolerant, high-level quantum circuits: form, compilation and description

NASA Astrophysics Data System (ADS)

Paler, Alexandru; Polian, Ilia; Nemoto, Kae; Devitt, Simon J.

2017-06-01

Fault-tolerant quantum error correction is a necessity for any quantum architecture destined to tackle interesting, large-scale problems. Its theoretical formalism has been well founded for nearly two decades. However, we still do not have an appropriate compiler to produce a fault-tolerant, error-corrected description from a higher-level quantum circuit for state-of the-art hardware models. There are many technical hurdles, including dynamic circuit constructions that occur when constructing fault-tolerant circuits with commonly used error correcting codes. We introduce a package that converts high-level quantum circuits consisting of commonly used gates into a form employing all decompositions and ancillary protocols needed for fault-tolerant error correction. We call this form the (I)initialisation, (C)NOT, (M)measurement form (ICM) and consists of an initialisation layer of qubits into one of four distinct states, a massive, deterministic array of CNOT operations and a series of time-ordered X- or Z-basis measurements. The form allows a more flexible approach towards circuit optimisation. At the same time, the package outputs a standard circuit or a canonical geometric description which is a necessity for operating current state-of-the-art hardware architectures using topological quantum codes.

An Analysis of 34,218 Pediatric Outpatient Controlled Substance Prescriptions.

PubMed

George, Jessica A; Park, Paul S; Hunsberger, Joanne; Shay, Joanne E; Lehmann, Christoph U; White, Elizabeth D; Lee, Benjamin H; Yaster, Myron

2016-03-01

Prescription errors are among the most common types of iatrogenic errors. Because of a previously reported 82% error rate in handwritten discharge narcotic prescriptions, we developed a computerized, web-based, controlled substance prescription writer that includes weight-based dosing logic and alerts to reduce the error rate to (virtually) zero. Over the past 7 years, >34,000 prescriptions have been created by hospital providers using this platform. We sought to determine the ongoing efficacy of the program in prescription error reduction and the patterns with which providers prescribe controlled substances for children and young adults (ages 0-21 years) at hospital discharge. We examined a database of 34,218 controlled substance discharge prescriptions written by our institutional providers from January 1, 2007 to February 14, 2014, for demographic information, including age and weight, type of medication prescribed based on patient age, formulation of dispensed medication, and amount of drug to be dispensed at hospital discharge. In addition, we randomly regenerated 2% (700) of prescriptions based on stored data and analyzed them for errors using previously established error criteria. Weights that were manually entered into the prescription writer by the prescriber were compared with the patient's weight in the hospital's electronic medical record. Patients in the database averaged 9 ± 6.1 (range, 0-21) years of age and 36.7 ± 24.9 (1-195) kg. Regardless of age, the most commonly prescribed opioid was oxycodone (73%), which was prescribed as a single agent uncombined with acetaminophen. Codeine was prescribed to 7% of patients and always in a formulation containing acetaminophen. Liquid formulations were prescribed to 98% of children <6 years of age and to 16% of children >12 years of age (the remaining 84% received tablet formulations). Regardless of opioid prescribed, the amount of liquid dispensed averaged 106 ± 125 (range, 2-3240) mL, and the number of tablets dispensed averaged 51 ± 51 (range, 1-1080). Of the subset of 700 regenerated prescriptions, all were legible (drug, amount dispensed, dose, patient demographics, and provider name) and used best prescribing practice (e.g., no trailing zero after a decimal point, leading zero for doses <1). Twenty-five of the 700 (3.6%) had incorrectly entered weights compared with the most recent weight in the chart. Of these, 14 varied by 10% or less and only 2 varied by >15%. Of these, 1 resulted in underdosing (true weight 80 kg prescribed for a weight of 50 kg) and the other in overdosing (true weight 10 kg prescribed for a weight of 30 kg). A computerized prescription writer eliminated most but not all the errors common to handwritten prescriptions. Oxycodone has supplanted codeine as the most commonly prescribed oral opioid in current pediatric pain practice and, independent of formulation, is dispensed in large quantities. This study underscores the need for liquid opioid formulations in the pediatric population and, because of their abuse potential, the urgent need to determine how much of the prescribed medication is actually used by patients.

Frequency of dosage prescribing medication errors associated with manual prescriptions for very preterm infants.

PubMed

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.

FTAPE: A fault injection tool to measure fault tolerance

NASA Technical Reports Server (NTRS)

Tsai, Timothy K.; Iyer, Ravishankar K.

1995-01-01

The paper introduces FTAPE (Fault Tolerance And Performance Evaluator), a tool that can be used to compare fault-tolerant computers. The tool combines system-wide fault injection with a controllable workload. A workload generator is used to create high stress conditions for the machine. Faults are injected based on this workload activity in order to ensure a high level of fault propagation. The errors/fault ratio and performance degradation are presented as measures of fault tolerance.

Association rule mining on grid monitoring data to detect error sources

NASA Astrophysics Data System (ADS)

Maier, Gerhild; Schiffers, Michael; Kranzlmueller, Dieter; Gaidioz, Benjamin

2010-04-01

Error handling is a crucial task in an infrastructure as complex as a grid. There are several monitoring tools put in place, which report failing grid jobs including exit codes. However, the exit codes do not always denote the actual fault, which caused the job failure. Human time and knowledge is required to manually trace back errors to the real fault underlying an error. We perform association rule mining on grid job monitoring data to automatically retrieve knowledge about the grid components' behavior by taking dependencies between grid job characteristics into account. Therewith, problematic grid components are located automatically and this information - expressed by association rules - is visualized in a web interface. This work achieves a decrease in time for fault recovery and yields an improvement of a grid's reliability.

Noise Threshold and Resource Cost of Fault-Tolerant Quantum Computing with Majorana Fermions in Hybrid Systems.

PubMed

Li, Ying

2016-09-16

Fault-tolerant quantum computing in systems composed of both Majorana fermions and topologically unprotected quantum systems, e.g., superconducting circuits or quantum dots, is studied in this Letter. Errors caused by topologically unprotected quantum systems need to be corrected with error-correction schemes, for instance, the surface code. We find that the error-correction performance of such a hybrid topological quantum computer is not superior to a normal quantum computer unless the topological charge of Majorana fermions is insusceptible to noise. If errors changing the topological charge are rare, the fault-tolerance threshold is much higher than the threshold of a normal quantum computer and a surface-code logical qubit could be encoded in only tens of topological qubits instead of about 1,000 normal qubits.

Soft error evaluation and vulnerability analysis in Xilinx Zynq-7010 system-on chip

NASA Astrophysics Data System (ADS)

Du, Xuecheng; He, Chaohui; Liu, Shuhuan; Zhang, Yao; Li, Yonghong; Xiong, Ceng; Tan, Pengkang

2016-09-01

Radiation-induced soft errors are an increasingly important threat to the reliability of modern electronic systems. In order to evaluate system-on chip's reliability and soft error, the fault tree analysis method was used in this work. The system fault tree was constructed based on Xilinx Zynq-7010 All Programmable SoC. Moreover, the soft error rates of different components in Zynq-7010 SoC were tested by americium-241 alpha radiation source. Furthermore, some parameters that used to evaluate the system's reliability and safety were calculated using Isograph Reliability Workbench 11.0, such as failure rate, unavailability and mean time to failure (MTTF). According to fault tree analysis for system-on chip, the critical blocks and system reliability were evaluated through the qualitative and quantitative analysis.

Reliable Channel-Adapted Error Correction: Bacon-Shor Code Recovery from Amplitude Damping

NASA Astrophysics Data System (ADS)

Piedrafita, Álvaro; Renes, Joseph M.

2017-12-01

We construct two simple error correction schemes adapted to amplitude damping noise for Bacon-Shor codes and investigate their prospects for fault-tolerant implementation. Both consist solely of Clifford gates and require far fewer qubits, relative to the standard method, to achieve exact correction to a desired order in the damping rate. The first, employing one-bit teleportation and single-qubit measurements, needs only one-fourth as many physical qubits, while the second, using just stabilizer measurements and Pauli corrections, needs only half. The improvements stem from the fact that damping events need only be detected, not corrected, and that effective phase errors arising due to undamped qubits occur at a lower rate than damping errors. For error correction that is itself subject to damping noise, we show that existing fault-tolerance methods can be employed for the latter scheme, while the former can be made to avoid potential catastrophic errors and can easily cope with damping faults in ancilla qubits.

A framework for software fault tolerance in real-time systems

NASA Technical Reports Server (NTRS)

Anderson, T.; Knight, J. C.

1983-01-01

A classification scheme for errors and a technique for the provision of software fault tolerance in cyclic real-time systems is presented. The technique requires that the process structure of a system be represented by a synchronization graph which is used by an executive as a specification of the relative times at which they will communicate during execution. Communication between concurrent processes is severely limited and may only take place between processes engaged in an exchange. A history of error occurrences is maintained by an error handler. When an error is detected, the error handler classifies it using the error history information and then initiates appropriate recovery action.

Fault-tolerant quantum error detection.

PubMed

Linke, Norbert M; Gutierrez, Mauricio; Landsman, Kevin A; Figgatt, Caroline; Debnath, Shantanu; Brown, Kenneth R; Monroe, Christopher

2017-10-01

Quantum computers will eventually reach a size at which quantum error correction becomes imperative. Quantum information can be protected from qubit imperfections and flawed control operations by encoding a single logical qubit in multiple physical qubits. This redundancy allows the extraction of error syndromes and the subsequent detection or correction of errors without destroying the logical state itself through direct measurement. We show the encoding and syndrome measurement of a fault-tolerantly prepared logical qubit via an error detection protocol on four physical qubits, represented by trapped atomic ions. This demonstrates the robustness of a logical qubit to imperfections in the very operations used to encode it. The advantage persists in the face of large added error rates and experimental calibration errors.

Software fault tolerance for real-time avionics systems

NASA Technical Reports Server (NTRS)

Anderson, T.; Knight, J. C.

1983-01-01

Avionics systems have very high reliability requirements and are therefore prime candidates for the inclusion of fault tolerance techniques. In order to provide tolerance to software faults, some form of state restoration is usually advocated as a means of recovery. State restoration can be very expensive for systems which utilize concurrent processes. The concurrency present in most avionics systems and the further difficulties introduced by timing constraints imply that providing tolerance for software faults may be inordinately expensive or complex. A straightforward pragmatic approach to software fault tolerance which is believed to be applicable to many real-time avionics systems is proposed. A classification system for software errors is presented together with approaches to recovery and continued service for each error type.

Prescribing error at hospital discharge: a retrospective review of medication information in an Irish hospital.

PubMed

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.

General Monte Carlo reliability simulation code including common mode failures and HARP fault/error-handling

NASA Technical Reports Server (NTRS)

Platt, M. E.; Lewis, E. E.; Boehm, F.

1991-01-01

A Monte Carlo Fortran computer program was developed that uses two variance reduction techniques for computing system reliability applicable to solving very large highly reliable fault-tolerant systems. The program is consistent with the hybrid automated reliability predictor (HARP) code which employs behavioral decomposition and complex fault-error handling models. This new capability is called MC-HARP which efficiently solves reliability models with non-constant failures rates (Weibull). Common mode failure modeling is also a specialty.

Imperfect construction of microclusters

NASA Astrophysics Data System (ADS)

Schneider, E.; Zhou, K.; Gilbert, G.; Weinstein, Y. S.

2014-01-01

Microclusters are the basic building blocks used to construct cluster states capable of supporting fault-tolerant quantum computation. In this paper, we explore the consequences of errors on microcluster construction using two error models. To quantify the effect of the errors we calculate the fidelity of the constructed microclusters and the fidelity with which two such microclusters can be fused together. Such simulations are vital for gauging the capability of an experimental system to achieve fault tolerance.

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

PubMed

Alsulami, Zayed; Conroy, Sharon; Choonara, Imti

2013-04-01

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

An experiment in software reliability

NASA Technical Reports Server (NTRS)

Dunham, J. R.; Pierce, J. L.

1986-01-01

The results of a software reliability experiment conducted in a controlled laboratory setting are reported. The experiment was undertaken to gather data on software failures and is one in a series of experiments being pursued by the Fault Tolerant Systems Branch of NASA Langley Research Center to find a means of credibly performing reliability evaluations of flight control software. The experiment tests a small sample of implementations of radar tracking software having ultra-reliability requirements and uses n-version programming for error detection, and repetitive run modeling for failure and fault rate estimation. The experiment results agree with those of Nagel and Skrivan in that the program error rates suggest an approximate log-linear pattern and the individual faults occurred with significantly different error rates. Additional analysis of the experimental data raises new questions concerning the phenomenon of interacting faults. This phenomenon may provide one explanation for software reliability decay.

Statistical relations among earthquake magnitude, surface rupture length, and surface fault displacement

USGS Publications Warehouse

Bonilla, M.G.; Mark, R.K.; Lienkaemper, J.J.

1984-01-01

In order to refine correlations of surface-wave magnitude, fault rupture length at the ground surface, and fault displacement at the surface by including the uncertainties in these variables, the existing data were critically reviewed and a new data base was compiled. Earthquake magnitudes were redetermined as necessary to make them as consistent as possible with the Gutenberg methods and results, which necessarily make up much of the data base. Measurement errors were estimated for the three variables for 58 moderate to large shallow-focus earthquakes. Regression analyses were then made utilizing the estimated measurement errors. The regression analysis demonstrates that the relations among the variables magnitude, length, and displacement are stochastic in nature. The stochastic variance, introduced in part by incomplete surface expression of seismogenic faulting, variation in shear modulus, and regional factors, dominates the estimated measurement errors. Thus, it is appropriate to use ordinary least squares for the regression models, rather than regression models based upon an underlying deterministic relation with the variance resulting from measurement errors. Significant differences exist in correlations of certain combinations of length, displacement, and magnitude when events are qrouped by fault type or by region, including attenuation regions delineated by Evernden and others. Subdivision of the data results in too few data for some fault types and regions, and for these only regressions using all of the data as a group are reported. Estimates of the magnitude and the standard deviation of the magnitude of a prehistoric or future earthquake associated with a fault can be made by correlating M with the logarithms of rupture length, fault displacement, or the product of length and displacement. Fault rupture area could be reliably estimated for about 20 of the events in the data set. Regression of MS on rupture area did not result in a marked improvement over regressions that did not involve rupture area. Because no subduction-zone earthquakes are included in this study, the reported results do not apply to such zones.

Fault-tolerant quantum error detection

PubMed Central

Linke, Norbert M.; Gutierrez, Mauricio; Landsman, Kevin A.; Figgatt, Caroline; Debnath, Shantanu; Brown, Kenneth R.; Monroe, Christopher

2017-01-01

Quantum computers will eventually reach a size at which quantum error correction becomes imperative. Quantum information can be protected from qubit imperfections and flawed control operations by encoding a single logical qubit in multiple physical qubits. This redundancy allows the extraction of error syndromes and the subsequent detection or correction of errors without destroying the logical state itself through direct measurement. We show the encoding and syndrome measurement of a fault-tolerantly prepared logical qubit via an error detection protocol on four physical qubits, represented by trapped atomic ions. This demonstrates the robustness of a logical qubit to imperfections in the very operations used to encode it. The advantage persists in the face of large added error rates and experimental calibration errors. PMID:29062889

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

PubMed Central

Aljasmi, Fatema; Almalood, Fatema

2018-01-01

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

HL7 Structured Product Labeling - electronic prescribing information for provider order entry decision support.

PubMed

Schadow, Gunther

2005-01-01

Prescribing errors are an important cause of adverse events, and lack of knowledge of the drug is a root cause for prescribing errors. The FDA is issuing new regulations that will make the drug labels much more useful not only to physicians, but also to computerized order entry systems that support physicians to practice safe prescribing. For this purpose, FDA works with HL7 to create the Structured Product Label (SPL) standard that includes a document format as well as a drug knowledge representation, this poster introduces the basic concepts of SPL.

Fuzzy Adaptive Compensation Control of Uncertain Stochastic Nonlinear Systems With Actuator Failures and Input Hysteresis.

PubMed

Wang, Jianhui; Liu, Zhi; Chen, C L Philip; Zhang, Yun

2017-10-12

Hysteresis exists ubiquitously in physical actuators. Besides, actuator failures/faults may also occur in practice. Both effects would deteriorate the transient tracking performance, and even trigger instability. In this paper, we consider the problem of compensating for actuator failures and input hysteresis by proposing a fuzzy control scheme for stochastic nonlinear systems. Compared with the existing research on stochastic nonlinear uncertain systems, it is found that how to guarantee a prescribed transient tracking performance when taking into account actuator failures and hysteresis simultaneously also remains to be answered. Our proposed control scheme is designed on the basis of the fuzzy logic system and backstepping techniques for this purpose. It is proven that all the signals remain bounded and the tracking error is ensured to be within a preestablished bound with the failures of hysteretic actuator. Finally, simulations are provided to illustrate the effectiveness of the obtained theoretical results.

Renal Drug Dosing

PubMed Central

Vogel, Erin A.; Billups, Sarah J.; Herner, Sheryl J.

2016-01-01

Summary Objective The purpose of this study was to compare the effectiveness of an outpatient renal dose adjustment alert via a computerized provider order entry (CPOE) clinical decision support system (CDSS) versus a CDSS with alerts made to dispensing pharmacists. Methods This was a retrospective analysis of patients with renal impairment and 30 medications that are contraindicated or require dose-adjustment in such patients. The primary outcome was the rate of renal dosing errors for study medications that were dispensed between August and December 2013, when a pharmacist-based CDSS was in place, versus August through December 2014, when a prescriber-based CDSS was in place. A dosing error was defined as a prescription for one of the study medications dispensed to a patient where the medication was contraindicated or improperly dosed based on the patient’s renal function. The denominator was all prescriptions for the study medications dispensed during each respective study period. Results During the pharmacist- and prescriber-based CDSS study periods, 49,054 and 50,678 prescriptions, respectively, were dispensed for one of the included medications. Of these, 878 (1.8%) and 758 (1.5%) prescriptions were dispensed to patients with renal impairment in the respective study periods. Patients in each group were similar with respect to age, sex, and renal function stage. Overall, the five-month error rate was 0.38%. Error rates were similar between the two groups: 0.36% and 0.40% in the pharmacist- and prescriber-based CDSS, respectively (p=0.523). The medication with the highest error rate was dofetilide (0.51% overall) while the medications with the lowest error rate were dabigatran, fondaparinux, and spironolactone (0.00% overall). Conclusions Prescriber- and pharmacist-based CDSS provided comparable, low rates of potential medication errors. Future studies should be undertaken to examine patient benefits of the prescriber-based CDSS. PMID:27466041

A testing-coverage software reliability model considering fault removal efficiency and error generation.

PubMed

Li, Qiuying; Pham, Hoang

2017-01-01

In this paper, we propose a software reliability model that considers not only error generation but also fault removal efficiency combined with testing coverage information based on a nonhomogeneous Poisson process (NHPP). During the past four decades, many software reliability growth models (SRGMs) based on NHPP have been proposed to estimate the software reliability measures, most of which have the same following agreements: 1) it is a common phenomenon that during the testing phase, the fault detection rate always changes; 2) as a result of imperfect debugging, fault removal has been related to a fault re-introduction rate. But there are few SRGMs in the literature that differentiate between fault detection and fault removal, i.e. they seldom consider the imperfect fault removal efficiency. But in practical software developing process, fault removal efficiency cannot always be perfect, i.e. the failures detected might not be removed completely and the original faults might still exist and new faults might be introduced meanwhile, which is referred to as imperfect debugging phenomenon. In this study, a model aiming to incorporate fault introduction rate, fault removal efficiency and testing coverage into software reliability evaluation is developed, using testing coverage to express the fault detection rate and using fault removal efficiency to consider the fault repair. We compare the performance of the proposed model with several existing NHPP SRGMs using three sets of real failure data based on five criteria. The results exhibit that the model can give a better fitting and predictive performance.

Underlying risk factors for prescribing errors in long-term aged care: a qualitative study.

PubMed

Tariq, Amina; Georgiou, Andrew; Raban, Magdalena; Baysari, Melissa Therese; Westbrook, Johanna

2016-09-01

To identify system-related risk factors perceived to contribute to prescribing errors in Australian long-term care settings, that is, residential aged care facilities (RACFs). The study used qualitative methods to explore factors that contribute to unsafe prescribing in RACFs. Data were collected at three RACFs in metropolitan Sydney, Australia between May and November 2011. Participants included RACF managers, doctors, pharmacists and RACF staff actively involved in prescribing-related processes. Methods included non-participant observations (74 h), in-depth semistructured interviews (n=25) and artefact analysis. Detailed process activity models were developed for observed prescribing episodes supplemented by triangulated analysis using content analysis methods. System-related factors perceived to increase the risk of prescribing errors in RACFs were classified into three overarching themes: communication systems, team coordination and staff management. Factors associated with communication systems included limited point-of-care access to information, inadequate handovers, information storage across different media (paper, electronic and memory), poor legibility of charts, information double handling, multiple faxing of medication charts and reliance on manual chart reviews. Team factors included lack of established lines of responsibility, inadequate team communication and limited participation of doctors in multidisciplinary initiatives like medication advisory committee meetings. Factors related to staff management and workload included doctors' time constraints and their accessibility, lack of trained RACF staff and high RACF staff turnover. The study highlights several system-related factors including laborious methods for exchanging medication information, which often act together to contribute to prescribing errors. Multiple interventions (eg, technology systems, team communication protocols) are required to support the collaborative nature of RACF prescribing. 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/

Fault tolerance with noisy and slow measurements and preparation.

PubMed

Paz-Silva, Gerardo A; Brennen, Gavin K; Twamley, Jason

2010-09-03

It is not so well known that measurement-free quantum error correction protocols can be designed to achieve fault-tolerant quantum computing. Despite their potential advantages in terms of the relaxation of accuracy, speed, and addressing requirements, they have usually been overlooked since they are expected to yield a very bad threshold. We show that this is not the case. We design fault-tolerant circuits for the 9-qubit Bacon-Shor code and find an error threshold for unitary gates and preparation of p((p,g)thresh)=3.76×10(-5) (30% of the best known result for the same code using measurement) while admitting up to 1/3 error rates for measurements and allocating no constraints on measurement speed. We further show that demanding gate error rates sufficiently below the threshold pushes the preparation threshold up to p((p)thresh)=1/3.

Universal fault-tolerant quantum computation with only transversal gates and error correction.

PubMed

Paetznick, Adam; Reichardt, Ben W

2013-08-30

Transversal implementations of encoded unitary gates are highly desirable for fault-tolerant quantum computation. Though transversal gates alone cannot be computationally universal, they can be combined with specially distilled resource states in order to achieve universality. We show that "triorthogonal" stabilizer codes, introduced for state distillation by Bravyi and Haah [Phys. Rev. A 86, 052329 (2012)], admit transversal implementation of the controlled-controlled-Z gate. We then construct a universal set of fault-tolerant gates without state distillation by using only transversal controlled-controlled-Z, transversal Hadamard, and fault-tolerant error correction. We also adapt the distillation procedure of Bravyi and Haah to Toffoli gates, improving on existing Toffoli distillation schemes.

Computer calculated dose in paediatric prescribing.

PubMed

Kirk, Richard C; Li-Meng Goh, Denise; Packia, Jeya; Min Kam, Huey; Ong, Benjamin K C

2005-01-01

Medication errors are an important cause of hospital-based morbidity and mortality. However, only a few medication error studies have been conducted in children. These have mainly quantified errors in the inpatient setting; there is very little data available on paediatric outpatient and emergency department medication errors and none on discharge medication. This deficiency is of concern because medication errors are more common in children and it has been suggested that the risk of an adverse drug event as a consequence of a medication error is higher in children than in adults. The aims of this study were to assess the rate of medication errors in predominantly ambulatory paediatric patients and the effect of computer calculated doses on medication error rates of two commonly prescribed drugs. This was a prospective cohort study performed in a paediatric unit in a university teaching hospital between March 2003 and August 2003. The hospital's existing computer clinical decision support system was modified so that doctors could choose the traditional prescription method or the enhanced method of computer calculated dose when prescribing paracetamol (acetaminophen) or promethazine. All prescriptions issued to children (<16 years of age) at the outpatient clinic, emergency department and at discharge from the inpatient service were analysed. A medication error was defined as to have occurred if there was an underdose (below the agreed value), an overdose (above the agreed value), no frequency of administration specified, no dose given or excessive total daily dose. The medication error rates and the factors influencing medication error rates were determined using SPSS version 12. From March to August 2003, 4281 prescriptions were issued. Seven prescriptions (0.16%) were excluded, hence 4274 prescriptions were analysed. Most prescriptions were issued by paediatricians (including neonatologists and paediatric surgeons) and/or junior doctors. The error rate in the children's emergency department was 15.7%, for outpatients was 21.5% and for discharge medication was 23.6%. Most errors were the result of an underdose (64%; 536/833). The computer calculated dose error rate was 12.6% compared with the traditional prescription error rate of 28.2%. Logistical regression analysis showed that computer calculated dose was an important and independent variable influencing the error rate (adjusted relative risk = 0.436, 95% CI 0.336, 0.520, p < 0.001). Other important independent variables were seniority and paediatric training of the person prescribing and the type of drug prescribed. Medication error, especially underdose, is common in outpatient, emergency department and discharge prescriptions. Computer calculated doses can significantly reduce errors, but other risk factors have to be concurrently addressed to achieve maximum benefit.

The detection error of thermal test low-frequency cable based on M sequence correlation algorithm

NASA Astrophysics Data System (ADS)

Wu, Dongliang; Ge, Zheyang; Tong, Xin; Du, Chunlin

2018-04-01

The problem of low accuracy and low efficiency of off-line detecting on thermal test low-frequency cable faults could be solved by designing a cable fault detection system, based on FPGA export M sequence code(Linear feedback shift register sequence) as pulse signal source. The design principle of SSTDR (Spread spectrum time-domain reflectometry) reflection method and hardware on-line monitoring setup figure is discussed in this paper. Testing data show that, this detection error increases with fault location of thermal test low-frequency cable.

A renormalization group model for the stick-slip behavior of faults

NASA Technical Reports Server (NTRS)

Smalley, R. F., Jr.; Turcotte, D. L.; Solla, S. A.

1983-01-01

A fault which is treated as an array of asperities with a prescribed statistical distribution of strengths is described. For a linear array the stress is transferred to a single adjacent asperity and for a two dimensional array to three ajacent asperities. It is shown that the solutions bifurcate at a critical applied stress. At stresses less than the critical stress virtually no asperities fail on a large scale and the fault is locked. At the critical stress the solution bifurcates and asperity failure cascades away from the nucleus of failure. It is found that the stick slip behavior of most faults can be attributed to the distribution of asperities on the fault. The observation of stick slip behavior on faults rather than stable sliding, why the observed level of seismicity on a locked fault is very small, and why the stress on a fault is less than that predicted by a standard value of the coefficient of friction are outlined.

Common errors of drug administration in infants: causes and avoidance.

PubMed

Anderson, B J; Ellis, J F

1999-01-01

Drug administration errors are common in infants. Although the infant population has a high exposure to drugs, there are few data concerning pharmacokinetics or pharmacodynamics, or the influence of paediatric diseases on these processes. Children remain therapeutic orphans. Formulations are often suitable only for adults; in addition, the lack of maturation of drug elimination processes, alteration of body composition and influence of size render the calculation of drug doses complex in infants. The commonest drug administration error in infants is one of dose, and the commonest hospital site for this error is the intensive care unit. Drug errors are a consequence of system error, and preventive strategies are possible through system analysis. The goal of a zero drug error rate should be aggressively sought, with systems in place that aim to eliminate the effects of inevitable human error. This involves review of the entire system from drug manufacture to drug administration. The nuclear industry, telecommunications and air traffic control services all practise error reduction policies with zero error as a clear goal, not by finding fault in the individual, but by identifying faults in the system and building into that system mechanisms for picking up faults before they occur. Such policies could be adapted to medicine using interventions both specific (the production of formulations which are for children only and clearly labelled, regular audit by pharmacists, legible prescriptions, standardised dose tables) and general (paediatric drug trials, education programmes, nonpunitive error reporting) to reduce the number of errors made in giving medication to infants.

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

PubMed

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

2016-12-01

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

Residents' numeric inputting error in computerized physician order entry prescription.

PubMed

Wu, Xue; Wu, Changxu; Zhang, Kan; Wei, Dong

2016-04-01

Computerized physician order entry (CPOE) system with embedded clinical decision support (CDS) can significantly reduce certain types of prescription error. However, prescription errors still occur. Various factors such as the numeric inputting methods in human computer interaction (HCI) produce different error rates and types, but has received relatively little attention. This study aimed to examine the effects of numeric inputting methods and urgency levels on numeric inputting errors of prescription, as well as categorize the types of errors. Thirty residents participated in four prescribing tasks in which two factors were manipulated: numeric inputting methods (numeric row in the main keyboard vs. numeric keypad) and urgency levels (urgent situation vs. non-urgent situation). Multiple aspects of participants' prescribing behavior were measured in sober prescribing situations. The results revealed that in urgent situations, participants were prone to make mistakes when using the numeric row in the main keyboard. With control of performance in the sober prescribing situation, the effects of the input methods disappeared, and urgency was found to play a significant role in the generalized linear model. Most errors were either omission or substitution types, but the proportion of transposition and intrusion error types were significantly higher than that of the previous research. Among numbers 3, 8, and 9, which were the less common digits used in prescription, the error rate was higher, which was a great risk to patient safety. Urgency played a more important role in CPOE numeric typing error-making than typing skills and typing habits. It was recommended that inputting with the numeric keypad had lower error rates in urgent situation. An alternative design could consider increasing the sensitivity of the keys with lower frequency of occurrence and decimals. To improve the usability of CPOE, numeric keyboard design and error detection could benefit from spatial incidence of errors found in this study. Copyright © 2016 Elsevier Ireland Ltd. All rights reserved.

Statistical relations among earthquake magnitude, surface rupture length, and surface fault displacement

USGS Publications Warehouse

Bonilla, Manuel G.; Mark, Robert K.; Lienkaemper, James J.

1984-01-01

In order to refine correlations of surface-wave magnitude, fault rupture length at the ground surface, and fault displacement at the surface by including the uncertainties in these variables, the existing data were critically reviewed and a new data base was compiled. Earthquake magnitudes were redetermined as necessary to make them as consistent as possible with the Gutenberg methods and results, which make up much of the data base. Measurement errors were estimated for the three variables for 58 moderate to large shallow-focus earthquakes. Regression analyses were then made utilizing the estimated measurement errors.The regression analysis demonstrates that the relations among the variables magnitude, length, and displacement are stochastic in nature. The stochastic variance, introduced in part by incomplete surface expression of seismogenic faulting, variation in shear modulus, and regional factors, dominates the estimated measurement errors. Thus, it is appropriate to use ordinary least squares for the regression models, rather than regression models based upon an underlying deterministic relation in which the variance results primarily from measurement errors.Significant differences exist in correlations of certain combinations of length, displacement, and magnitude when events are grouped by fault type or by region, including attenuation regions delineated by Evernden and others.Estimates of the magnitude and the standard deviation of the magnitude of a prehistoric or future earthquake associated with a fault can be made by correlating Ms with the logarithms of rupture length, fault displacement, or the product of length and displacement.Fault rupture area could be reliably estimated for about 20 of the events in the data set. Regression of Ms on rupture area did not result in a marked improvement over regressions that did not involve rupture area. Because no subduction-zone earthquakes are included in this study, the reported results do not apply to such zones.

Fault tolerant software modules for SIFT

NASA Technical Reports Server (NTRS)

Hecht, M.; Hecht, H.

1982-01-01

The implementation of software fault tolerance is investigated for critical modules of the Software Implemented Fault Tolerance (SIFT) operating system to support the computational and reliability requirements of advanced fly by wire transport aircraft. Fault tolerant designs generated for the error reported and global executive are examined. A description of the alternate routines, implementation requirements, and software validation are included.

Medication errors with electronic prescribing (eP): Two views of the same picture

PubMed Central

2010-01-01

Background Quantitative prospective methods are widely used to evaluate the impact of new technologies such as electronic prescribing (eP) on medication errors. However, they are labour-intensive and it is not always feasible to obtain pre-intervention data. Our objective was to compare the eP medication error picture obtained with retrospective quantitative and qualitative methods. Methods The study was carried out at one English district general hospital approximately two years after implementation of an integrated electronic prescribing, administration and records system. Quantitative: A structured retrospective analysis was carried out of clinical records and medication orders for 75 randomly selected patients admitted to three wards (medicine, surgery and paediatrics) six months after eP implementation. Qualitative: Eight doctors, 6 nurses, 8 pharmacy staff and 4 other staff at senior, middle and junior grades, and 19 adult patients on acute surgical and medical wards were interviewed. Staff interviews explored experiences of developing and working with the system; patient interviews focused on experiences of medicine prescribing and administration on the ward. Interview transcripts were searched systematically for accounts of medication incidents. A classification scheme was developed and applied to the errors identified in the records review. Results The two approaches produced similar pictures of the drug use process. Interviews identified types of error identified in the retrospective notes review plus two eP-specific errors which were not detected by record review. Interview data took less time to collect than record review, and provided rich data on the prescribing process, and reasons for delays or non-administration of medicines, including "once only" orders and "as required" medicines. Conclusions The qualitative approach provided more understanding of processes, and some insights into why medication errors can happen. The method is cost-effective and could be used to supplement information from anonymous error reporting schemes. PMID:20497532

Fault-Tolerant Computing: An Overview

DTIC Science & Technology

1991-06-01

Addison Wesley:, Reading, MA) 1984. [8] J. Wakerly , Error Detecting Codes, Self-Checking Circuits and Applications , (Elsevier North Holland, Inc.- New York... applicable to bit-sliced organi- zations of hardware. In the first time step, the normal computation is performed on the operands and the results...for error detection and fault tolerance in parallel processor systems while perform- ing specific computation-intensive applications [111. Contrary to

Study on fault-tolerant processors for advanced launch system

NASA Technical Reports Server (NTRS)

Shin, Kang G.; Liu, Jyh-Charn

1990-01-01

Issues related to the reliability of a redundant system with large main memory are addressed. The Fault-Tolerant Processor (FTP) for the Advanced Launch System (ALS) is used as a basis for the presentation. When the system is free of latent faults, the probability of system crash due to multiple channel faults is shown to be insignificant even when voting on the outputs of computing channels is infrequent. Using channel error maskers (CEMs) is shown to improve reliability more effectively than increasing redundancy or the number of channels for applications with long mission times. Even without using a voter, most memory errors can be immediately corrected by those CEMs implemented with conventional coding techniques. In addition to their ability to enhance system reliability, CEMs (with a very low hardware overhead) can be used to dramatically reduce not only the need of memory realignment, but also the time required to realign channel memories in case, albeit rare, such a need arises. Using CEMs, two different schemes were developed to solve the memory realignment problem. In both schemes, most errors are corrected by CEMs, and the remaining errors are masked by a voter.

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

Sharma, Vishal C.; Gopalakrishnan, Ganesh; Krishnamoorthy, Sriram

The systems resilience research community has developed methods to manually insert additional source-program level assertions to trap errors, and also devised tools to conduct fault injection studies for scalar program codes. In this work, we contribute the first vector oriented LLVM-level fault injector VULFI to help study the effects of faults in vector architectures that are of growing importance, especially for vectorizing loops. Using VULFI, we conduct a resiliency study of nine real-world vector benchmarks using Intel’s AVX and SSE extensions as the target vector instruction sets, and offer the first reported understanding of how faults affect vector instruction sets.more » We take this work further toward automating the insertion of resilience assertions during compilation. This is based on our observation that during intermediate (e.g., LLVM-level) code generation to handle full and partial vectorization, modern compilers exploit (and explicate in their code-documentation) critical invariants. These invariants are turned into error-checking code. We confirm the efficacy of these automatically inserted low-overhead error detectors for vectorized for-loops.« less

Who Do Hospital Physicians and Nurses Go to for Advice About Medications? A Social Network Analysis and Examination of Prescribing Error Rates.

PubMed

Creswick, Nerida; Westbrook, Johanna Irene

2015-09-01

To measure the weekly medication advice-seeking networks of hospital staff, to compare patterns across professional groups, and to examine these in the context of prescribing error rates. A social network analysis was conducted. All 101 staff in 2 wards in a large, academic teaching hospital in Sydney, Australia, were surveyed (response rate, 90%) using a detailed social network questionnaire. The extent of weekly medication advice seeking was measured by density of connections, proportion of reciprocal relationships by reciprocity, number of colleagues to whom each person provided advice by in-degree, and perceptions of amount and impact of advice seeking between physicians and nurses. Data on prescribing error rates from the 2 wards were compared. Weekly medication advice-seeking networks were sparse (density: 7% ward A and 12% ward B). Information sharing across professional groups was modest, and rates of reciprocation of advice were low (9% ward A, 14% ward B). Pharmacists provided advice to most people, and junior physicians also played central roles. Senior physicians provided medication advice to few people. Many staff perceived that physicians rarely sought advice from nurses when prescribing, but almost all believed that an increase in communication between physicians and nurses about medications would improve patient safety. The medication networks in ward B had higher measures for density, reciprocation, and fewer senior physicians who were isolates. Ward B had a significantly lower rate of both procedural and clinical prescribing errors than ward A (0.63 clinical prescribing errors per admission [95%CI, 0.47-0.79] versus 1.81/ admission [95%CI, 1.49-2.13]). Medication advice-seeking networks among staff on hospital wards are limited. Hubs of advice provision include pharmacists, junior physicians, and senior nurses. Senior physicians are poorly integrated into medication advice networks. Strategies to improve the advice-giving networks between senior and junior physicians may be a fruitful area for intervention to improve medication safety. We found that one ward with stronger networks also had a significantly lower prescribing error rate, suggesting a promising area for further investigation.

Microseismicity Studies in Northern Baja California: General Results.

NASA Astrophysics Data System (ADS)

Frez, J.; Acosta, J.; Gonzalez, J.; Nava, F.; Suarez, F.

2005-12-01

Between 1997 and 2003, we installed local seismological networks in northern Baja California with digital, three-component, Reftek instruments, and with 100-125 Hz sampling. Each local network had from 15 to 40 stations over an area approximately of 50 x 50 km2. Surveys have been carried out for the Mexicali seismic zone and the Ojos Negros region (1997), the San Miguel fault system (1998), the Pacific coast between Tijuana and Ensenada (1999), the Agua Blanca and Vallecito fault systems (2001), the Sierra Juarez fault system (2002), and other smaller areas (2001 and 2003). These detailed microseismicity surveys are complemented with seismograms and arrival times from regional networks (RESNOM and SCSN). Selected locations presented here have errors (formal errors from HYPO71) less than 1 km. Phase reading errors are estimated at less than or about 0.03 s. Most of the activity is located between mapped fault traces, along alignments which do not follow the fault traces, and where tectonic alignments intersect. The results suggests an orthogonal pattern at various scales. Depth distributions generally have two maxima, one secondary maximum, at about 5 km; the other, located at 12-17 km. The Agua Blanca fault is essentially inactive for earthquakes with ML > 1.7. Most focal mechanisms are strike-slip with a minor normal component; the others are dominantly normal; the resulting pattern indicates a regional extensional regime for all the regions with an average NS azimuth for the P-axes. Fracture directions, obtained from directivity measurements, show orthogonal directions, one of which approximately coincides with the azimuth of mapped fault traces. These results indicate that the Pacific-North American interplate motion is not being entirely accommodated by the NW trending faults, but rather is creating a complex system of conjugate faults.

A testing-coverage software reliability model considering fault removal efficiency and error generation

PubMed Central

Li, Qiuying; Pham, Hoang

2017-01-01

In this paper, we propose a software reliability model that considers not only error generation but also fault removal efficiency combined with testing coverage information based on a nonhomogeneous Poisson process (NHPP). During the past four decades, many software reliability growth models (SRGMs) based on NHPP have been proposed to estimate the software reliability measures, most of which have the same following agreements: 1) it is a common phenomenon that during the testing phase, the fault detection rate always changes; 2) as a result of imperfect debugging, fault removal has been related to a fault re-introduction rate. But there are few SRGMs in the literature that differentiate between fault detection and fault removal, i.e. they seldom consider the imperfect fault removal efficiency. But in practical software developing process, fault removal efficiency cannot always be perfect, i.e. the failures detected might not be removed completely and the original faults might still exist and new faults might be introduced meanwhile, which is referred to as imperfect debugging phenomenon. In this study, a model aiming to incorporate fault introduction rate, fault removal efficiency and testing coverage into software reliability evaluation is developed, using testing coverage to express the fault detection rate and using fault removal efficiency to consider the fault repair. We compare the performance of the proposed model with several existing NHPP SRGMs using three sets of real failure data based on five criteria. The results exhibit that the model can give a better fitting and predictive performance. PMID:28750091

Improving Patient Safety With Error Identification in Chemotherapy Orders by Verification Nurses.

PubMed

Baldwin, Abigail; Rodriguez, Elizabeth S

2016-02-01

The prevalence of medication errors associated with chemotherapy administration is not precisely known. Little evidence exists concerning the extent or nature of errors; however, some evidence demonstrates that errors are related to prescribing. This article demonstrates how the review of chemotherapy orders by a designated nurse known as a verification nurse (VN) at a National Cancer Institute-designated comprehensive cancer center helps to identify prescribing errors that may prevent chemotherapy administration mistakes and improve patient safety in outpatient infusion units. This article will describe the role of the VN and details of the verification process. To identify benefits of the VN role, a retrospective review and analysis of chemotherapy near-miss events from 2009-2014 was performed. A total of 4,282 events related to chemotherapy were entered into the Reporting to Improve Safety and Quality system. A majority of the events were categorized as near-miss events, or those that, because of chance, did not result in patient injury, and were identified at the point of prescribing.

Using concatenated quantum codes for universal fault-tolerant quantum gates.

PubMed

Jochym-O'Connor, Tomas; Laflamme, Raymond

2014-01-10

We propose a method for universal fault-tolerant quantum computation using concatenated quantum error correcting codes. The concatenation scheme exploits the transversal properties of two different codes, combining them to provide a means to protect against low-weight arbitrary errors. We give the required properties of the error correcting codes to ensure universal fault tolerance and discuss a particular example using the 7-qubit Steane and 15-qubit Reed-Muller codes. Namely, other than computational basis state preparation as required by the DiVincenzo criteria, our scheme requires no special ancillary state preparation to achieve universality, as opposed to schemes such as magic state distillation. We believe that optimizing the codes used in such a scheme could provide a useful alternative to state distillation schemes that exhibit high overhead costs.

New constraints on slip rates and locking depths of the San Andreas Fault System from Sentinel-1A InSAR and GAGE GPS observations

NASA Astrophysics Data System (ADS)

Ward, L. A.; Smith-Konter, B. R.; Higa, J. T.; Xu, X.; Tong, X.; Sandwell, D. T.

2017-12-01

After over a decade of operation, the EarthScope (GAGE) Facility has now accumulated a wealth of GPS and InSAR data, that when successfully integrated, make it possible to image the entire San Andreas Fault System (SAFS) with unprecedented spatial coverage and resolution. Resulting surface velocity and deformation time series products provide critical boundary conditions needed for improving our understanding of how faults are loaded across a broad range of temporal and spatial scales. Moreover, our understanding of how earthquake cycle deformation is influenced by fault zone strength and crust/mantle rheology is still developing. To further study these processes, we construct a new 4D earthquake cycle model of the SAFS representing the time-dependent 3D velocity field associated with interseismic strain accumulation, co-seismic slip, and postseismic viscoelastic relaxation. This high-resolution California statewide model, spanning the Cerro Prieto fault to the south to the Maacama fault to the north, is constructed on a 500 m spaced grid and comprises variable slip and locking depths along 42 major fault segments. Secular deep slip is prescribed from the base of the locked zone to the base of the elastic plate while episodic shallow slip is prescribed from the historical earthquake record and geologic recurrence intervals. Locking depths and slip rates for all 42 fault segments are constrained by the newest GAGE Facility geodetic observations; 3169 horizontal GPS velocity measurements, combined with over 53,000 line-of-sight (LOS) InSAR velocity observations from Sentinel-1A, are used in a weighted least-squares inversion. To assess slip rate and locking depth sensitivity of a heterogeneous rheology model, we also implement variations in crustal rigidity throughout the plate boundary, assuming a coarse representation of shear modulus variability ranging from 20-40 GPa throughout the (low rigidity) Salton Trough and Basin and Range and the (high rigidity) Central Valley and ocean lithosphere.

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

PubMed

Campbell, Earl T

2014-12-05

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

Examples of Nonconservatism in the CARE 3 Program

NASA Technical Reports Server (NTRS)

Dotson, Kelly J.

1988-01-01

This paper presents parameter regions in the CARE 3 (Computer-Aided Reliability Estimation version 3) computer program where the program overestimates the reliability of a modeled system without warning the user. Five simple models of fault-tolerant computer systems are analyzed; and, the parameter regions where reliability is overestimated are given. The source of the error in the reliability estimates for models which incorporate transient fault occurrences was not readily apparent. However, the source of much of the error for models with permanent and intermittent faults can be attributed to the choice of values for the run-time parameters of the program.

A fault-tolerant information processing concept for space vehicles.

NASA Technical Reports Server (NTRS)

Hopkins, A. L., Jr.

1971-01-01

A distributed fault-tolerant information processing system is proposed, comprising a central multiprocessor, dedicated local processors, and multiplexed input-output buses connecting them together. The processors in the multiprocessor are duplicated for error detection, which is felt to be less expensive than using coded redundancy of comparable effectiveness. Error recovery is made possible by a triplicated scratchpad memory in each processor. The main multiprocessor memory uses replicated memory for error detection and correction. Local processors use any of three conventional redundancy techniques: voting, duplex pairs with backup, and duplex pairs in independent subsystems.

MO-E-9A-01: Risk Based Quality Management: TG100 In Action

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

Huq, M; Palta, J; Dunscombe, P

2014-06-15

One of the goals of quality management in radiation therapy is to gain high confidence that patients will receive the prescribed treatment correctly. To accomplish these goals professional societies such as the American Association of Physicists in Medicine (AAPM) has published many quality assurance (QA), quality control (QC), and quality management (QM) guidance documents. In general, the recommendations provided in these documents have emphasized on performing device-specific QA at the expense of process flow and protection of the patient against catastrophic errors. Analyses of radiation therapy incidents find that they are most often caused by flaws in the overall therapymore » process, from initial consult through final treatment, than by isolated hardware or computer failures detectable by traditional physics QA. This challenge is shared by many intrinsically hazardous industries. Risk assessment tools and analysis techniques have been developed to define, identify, and eliminate known and/or potential failures, problems, or errors, from a system, process and/or service before they reach the customer. These include, but are not limited to, process mapping, failure modes and effects analysis (FMEA), fault tree analysis (FTA), and establishment of a quality management program that best avoids the faults and risks that have been identified in the overall process. These tools can be easily adapted to radiation therapy practices because of their simplicity and effectiveness to provide efficient ways to enhance the safety and quality of treatment processes. Task group 100 (TG100) of AAPM has developed a risk-based quality management program that uses these tools. This session will be devoted to a discussion of these tools and how these tools can be used in a given radiotherapy clinic to develop a risk based QM program. Learning Objectives: Learn how to design a process map for a radiotherapy process. Learn how to perform a FMEA analysis for a given process. Learn what Fault tree analysis is all about. Learn how to design a quality management program based upon the information obtained from process mapping, FMEA and FTA.« less

Convergence and objective functions of some fault/noise-injection-based online learning algorithms for RBF networks.

PubMed

Ho, Kevin I-J; Leung, Chi-Sing; Sum, John

2010-06-01

In the last two decades, many online fault/noise injection algorithms have been developed to attain a fault tolerant neural network. However, not much theoretical works related to their convergence and objective functions have been reported. This paper studies six common fault/noise-injection-based online learning algorithms for radial basis function (RBF) networks, namely 1) injecting additive input noise, 2) injecting additive/multiplicative weight noise, 3) injecting multiplicative node noise, 4) injecting multiweight fault (random disconnection of weights), 5) injecting multinode fault during training, and 6) weight decay with injecting multinode fault. Based on the Gladyshev theorem, we show that the convergence of these six online algorithms is almost sure. Moreover, their true objective functions being minimized are derived. For injecting additive input noise during training, the objective function is identical to that of the Tikhonov regularizer approach. For injecting additive/multiplicative weight noise during training, the objective function is the simple mean square training error. Thus, injecting additive/multiplicative weight noise during training cannot improve the fault tolerance of an RBF network. Similar to injective additive input noise, the objective functions of other fault/noise-injection-based online algorithms contain a mean square error term and a specialized regularization term.

Evaluating Application Resilience with XRay

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

Chen, Sui; Bronevetsky, Greg; Li, Bin

2015-05-07

The rising count and shrinking feature size of transistors within modern computers is making them increasingly vulnerable to various types of soft faults. This problem is especially acute in high-performance computing (HPC) systems used for scientific computing, because these systems include many thousands of compute cores and nodes, all of which may be utilized in a single large-scale run. The increasing vulnerability of HPC applications to errors induced by soft faults is motivating extensive work on techniques to make these applications more resiilent to such faults, ranging from generic techniques such as replication or checkpoint/restart to algorithmspecific error detection andmore » tolerance techniques. Effective use of such techniques requires a detailed understanding of how a given application is affected by soft faults to ensure that (i) efforts to improve application resilience are spent in the code regions most vulnerable to faults and (ii) the appropriate resilience technique is applied to each code region. This paper presents XRay, a tool to view the application vulnerability to soft errors, and illustrates how XRay can be used in the context of a representative application. In addition to providing actionable insights into application behavior XRay automatically selects the number of fault injection experiments required to provide an informative view of application behavior, ensuring that the information is statistically well-grounded without performing unnecessary experiments.« less

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

PubMed

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

2017-02-01

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

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

PubMed

Tully, Mary P; Buchan, Iain E

2009-12-01

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

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

PubMed

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

2014-01-01

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

From experiment to design -- Fault characterization and detection in parallel computer systems using computational accelerators

NASA Astrophysics Data System (ADS)

Yim, Keun Soo

This dissertation summarizes experimental validation and co-design studies conducted to optimize the fault detection capabilities and overheads in hybrid computer systems (e.g., using CPUs and Graphics Processing Units, or GPUs), and consequently to improve the scalability of parallel computer systems using computational accelerators. The experimental validation studies were conducted to help us understand the failure characteristics of CPU-GPU hybrid computer systems under various types of hardware faults. The main characterization targets were faults that are difficult to detect and/or recover from, e.g., faults that cause long latency failures (Ch. 3), faults in dynamically allocated resources (Ch. 4), faults in GPUs (Ch. 5), faults in MPI programs (Ch. 6), and microarchitecture-level faults with specific timing features (Ch. 7). The co-design studies were based on the characterization results. One of the co-designed systems has a set of source-to-source translators that customize and strategically place error detectors in the source code of target GPU programs (Ch. 5). Another co-designed system uses an extension card to learn the normal behavioral and semantic execution patterns of message-passing processes executing on CPUs, and to detect abnormal behaviors of those parallel processes (Ch. 6). The third co-designed system is a co-processor that has a set of new instructions in order to support software-implemented fault detection techniques (Ch. 7). The work described in this dissertation gains more importance because heterogeneous processors have become an essential component of state-of-the-art supercomputers. GPUs were used in three of the five fastest supercomputers that were operating in 2011. Our work included comprehensive fault characterization studies in CPU-GPU hybrid computers. In CPUs, we monitored the target systems for a long period of time after injecting faults (a temporally comprehensive experiment), and injected faults into various types of program states that included dynamically allocated memory (to be spatially comprehensive). In GPUs, we used fault injection studies to demonstrate the importance of detecting silent data corruption (SDC) errors that are mainly due to the lack of fine-grained protections and the massive use of fault-insensitive data. This dissertation also presents transparent fault tolerance frameworks and techniques that are directly applicable to hybrid computers built using only commercial off-the-shelf hardware components. This dissertation shows that by developing understanding of the failure characteristics and error propagation paths of target programs, we were able to create fault tolerance frameworks and techniques that can quickly detect and recover from hardware faults with low performance and hardware overheads.

Fault Injection Techniques and Tools

NASA Technical Reports Server (NTRS)

Hsueh, Mei-Chen; Tsai, Timothy K.; Iyer, Ravishankar K.

1997-01-01

Dependability evaluation involves the study of failures and errors. The destructive nature of a crash and long error latency make it difficult to identify the causes of failures in the operational environment. It is particularly hard to recreate a failure scenario for a large, complex system. To identify and understand potential failures, we use an experiment-based approach for studying the dependability of a system. Such an approach is applied not only during the conception and design phases, but also during the prototype and operational phases. To take an experiment-based approach, we must first understand a system's architecture, structure, and behavior. Specifically, we need to know its tolerance for faults and failures, including its built-in detection and recovery mechanisms, and we need specific instruments and tools to inject faults, create failures or errors, and monitor their effects.

Experimental Demonstration of Fault-Tolerant State Preparation with Superconducting Qubits.

PubMed

Takita, Maika; Cross, Andrew W; Córcoles, A D; Chow, Jerry M; Gambetta, Jay M

2017-11-03

Robust quantum computation requires encoding delicate quantum information into degrees of freedom that are hard for the environment to change. Quantum encodings have been demonstrated in many physical systems by observing and correcting storage errors, but applications require not just storing information; we must accurately compute even with faulty operations. The theory of fault-tolerant quantum computing illuminates a way forward by providing a foundation and collection of techniques for limiting the spread of errors. Here we implement one of the smallest quantum codes in a five-qubit superconducting transmon device and demonstrate fault-tolerant state preparation. We characterize the resulting code words through quantum process tomography and study the free evolution of the logical observables. Our results are consistent with fault-tolerant state preparation in a protected qubit subspace.

Havens: Explicit Reliable Memory Regions for HPC Applications

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

Hukerikar, Saurabh; Engelmann, Christian

2016-01-01

Supporting error resilience in future exascale-class supercomputing systems is a critical challenge. Due to transistor scaling trends and increasing memory density, scientific simulations are expected to experience more interruptions caused by transient errors in the system memory. Existing hardware-based detection and recovery techniques will be inadequate to manage the presence of high memory fault rates. In this paper we propose a partial memory protection scheme based on region-based memory management. We define the concept of regions called havens that provide fault protection for program objects. We provide reliability for the regions through a software-based parity protection mechanism. Our approach enablesmore » critical program objects to be placed in these havens. The fault coverage provided by our approach is application agnostic, unlike algorithm-based fault tolerance techniques.« less

Demonstration of qubit operations below a rigorous fault tolerance threshold with gate set tomography

DOE PAGES

Blume-Kohout, Robin; Gamble, John King; Nielsen, Erik; ...

2017-02-15

Quantum information processors promise fast algorithms for problems inaccessible to classical computers. But since qubits are noisy and error-prone, they will depend on fault-tolerant quantum error correction (FTQEC) to compute reliably. Quantum error correction can protect against general noise if—and only if—the error in each physical qubit operation is smaller than a certain threshold. The threshold for general errors is quantified by their diamond norm. Until now, qubits have been assessed primarily by randomized benchmarking, which reports a different error rate that is not sensitive to all errors, and cannot be compared directly to diamond norm thresholds. Finally, we usemore » gate set tomography to completely characterize operations on a trapped-Yb +-ion qubit and demonstrate with greater than 95% confidence that they satisfy a rigorous threshold for FTQEC (diamond norm ≤6.7 × 10 -4).« less

Transient fault behavior in a microprocessor: A case study

NASA Technical Reports Server (NTRS)

Duba, Patrick

1989-01-01

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

Demonstration of qubit operations below a rigorous fault tolerance threshold with gate set tomography

PubMed Central

Blume-Kohout, Robin; Gamble, John King; Nielsen, Erik; Rudinger, Kenneth; Mizrahi, Jonathan; Fortier, Kevin; Maunz, Peter

2017-01-01

Quantum information processors promise fast algorithms for problems inaccessible to classical computers. But since qubits are noisy and error-prone, they will depend on fault-tolerant quantum error correction (FTQEC) to compute reliably. Quantum error correction can protect against general noise if—and only if—the error in each physical qubit operation is smaller than a certain threshold. The threshold for general errors is quantified by their diamond norm. Until now, qubits have been assessed primarily by randomized benchmarking, which reports a different error rate that is not sensitive to all errors, and cannot be compared directly to diamond norm thresholds. Here we use gate set tomography to completely characterize operations on a trapped-Yb+-ion qubit and demonstrate with greater than 95% confidence that they satisfy a rigorous threshold for FTQEC (diamond norm ≤6.7 × 10−4). PMID:28198466

Demonstration of qubit operations below a rigorous fault tolerance threshold with gate set tomography

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

Blume-Kohout, Robin; Gamble, John King; Nielsen, Erik

Quantum information processors promise fast algorithms for problems inaccessible to classical computers. But since qubits are noisy and error-prone, they will depend on fault-tolerant quantum error correction (FTQEC) to compute reliably. Quantum error correction can protect against general noise if—and only if—the error in each physical qubit operation is smaller than a certain threshold. The threshold for general errors is quantified by their diamond norm. Until now, qubits have been assessed primarily by randomized benchmarking, which reports a different error rate that is not sensitive to all errors, and cannot be compared directly to diamond norm thresholds. Finally, we usemore » gate set tomography to completely characterize operations on a trapped-Yb +-ion qubit and demonstrate with greater than 95% confidence that they satisfy a rigorous threshold for FTQEC (diamond norm ≤6.7 × 10 -4).« less

Single Event Analysis and Fault Injection Techniques Targeting Complex Designs Implemented in Xilinx-Virtex Family Field Programmable Gate Array (FPGA) Devices

NASA Technical Reports Server (NTRS)

Berg, Melanie D.; LaBel, Kenneth; Kim, Hak

2014-01-01

An informative session regarding SRAM FPGA basics. Presenting a framework for fault injection techniques applied to Xilinx Field Programmable Gate Arrays (FPGAs). Introduce an overlooked time component that illustrates fault injection is impractical for most real designs as a stand-alone characterization tool. Demonstrate procedures that benefit from fault injection error analysis.

Improved prescribed performance control for air-breathing hypersonic vehicles with unknown deadzone input nonlinearity.

PubMed

Wang, Yingyang; Hu, Jianbo

2018-05-19

An improved prescribed performance controller is proposed for the longitudinal model of an air-breathing hypersonic vehicle (AHV) subject to uncertain dynamics and input nonlinearity. Different from the traditional non-affine model requiring non-affine functions to be differentiable, this paper utilizes a semi-decomposed non-affine model with non-affine functions being locally semi-bounded and possibly in-differentiable. A new error transformation combined with novel prescribed performance functions is proposed to bypass complex deductions caused by conventional error constraint approaches and circumvent high frequency chattering in control inputs. On the basis of backstepping technique, the improved prescribed performance controller with low structural and computational complexity is designed. The methodology guarantees the altitude and velocity tracking error within transient and steady state performance envelopes and presents excellent robustness against uncertain dynamics and deadzone input nonlinearity. Simulation results demonstrate the efficacy of the proposed method. Copyright © 2018 ISA. Published by Elsevier Ltd. All rights reserved.

Ground Motion Synthetics For Spontaneous Versus Prescribed Rupture On A 45(o) Thrust Fault

NASA Astrophysics Data System (ADS)

Gottschämmer, E.; Olsen, K. B.

We have compared prescribed (kinematic) and spontaneous dynamic rupture propaga- tion on a 45(o) dipping thrust fault buried up to 5 km in a half-space model, as well as ground motions on the free surface for frequencies less than 1 Hz. The computa- tions are carried out using a 3D finite-difference method with rate-and-state friction on a planar, 20 km by 20 km fault. We use a slip-weakening distance of 15 cm and a slip- velocity weakening distance of 9.2 cm/s, similar to those for the dynamic study for the 1994 M6.7 Northridge earthquake by Nielsen and Olsen (2000) which generated satis- factory fits to selected strong motion data in the San Fernando Valley. The prescribed rupture propagation was designed to mimic that of the dynamic simulation at depth in order to isolate the dynamic free-surface effects. In this way, the results reflect the dy- namic (normal-stress) interaction with the free surface for various depths of burial of the fault. We find that the moment, peak slip and peak sliprate for the rupture breaking the surface are increased by up to 60%, 80%, and 10%, respectively, compared to the values for the scenario buried 5 km. The inclusion of these effects increases the peak displacements and velocities above the fault by factors up 3.4 and 2.9 including the increase in moment due to normal-stress effects at the free surface, and up to 2.1 and 2.0 when scaled to a Northridge-size event with surface rupture. Similar differences were found by Aagaard et al. (2001). Significant dynamic effects on the ground mo- tions include earlier arrival times caused by super-shear rupture velocities (break-out phases), in agreement with the dynamic finite-element simulations by Oglesby et al. (1998, 2000). The presence of shallow low-velocity layers tend to increase the rup- ture time and the sliprate. In particular, they promote earlier transitions to super-shear velocities and decrease the rupture velocity within the layers. Our results suggest that dynamic interaction with the free surface can significantly affect the ground motion for faults buried less than 1-3 km. We therefore recommend that strong ground motion for these scenarios be computed including such dynamic rupture effects.

A Log-Scaling Fault Tolerant Agreement Algorithm for a Fault Tolerant MPI

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

Hursey, Joshua J; Naughton, III, Thomas J; Vallee, Geoffroy R

The lack of fault tolerance is becoming a limiting factor for application scalability in HPC systems. The MPI does not provide standardized fault tolerance interfaces and semantics. The MPI Forum's Fault Tolerance Working Group is proposing a collective fault tolerant agreement algorithm for the next MPI standard. Such algorithms play a central role in many fault tolerant applications. This paper combines a log-scaling two-phase commit agreement algorithm with a reduction operation to provide the necessary functionality for the new collective without any additional messages. Error handling mechanisms are described that preserve the fault tolerance properties while maintaining overall scalability.

The impact of pharmacy services on opioid prescribing in dental practice.

PubMed

Stewart, Autumn; Zborovancik, Kelsey J; Stiely, Kara L

To compare rates of dental opioid prescribing between periods of full and partial integration of pharmacy services and periods of no integration. This observational study used a retrospective chart review of opioid prescriptions written by dental providers practicing in a free dental clinic for the medically underserved over a period of 74 months. Pharmacy services were fully integrated into the practice model for 48 of the 74 months under study. During this time frame, all dental opioid orders required review by the pharmacy department before prescribing. Outcomes related to prescribing rates and errors were compared between groups, which were defined by the level of integrated pharmacy services. Demographic and prescription-specific data (drug name, dose, quantity, directions, professional designation of individual entering order) and clinic appointment data were collected and analyzed with the use of descriptive and inferential statistics. A total of 102 opioids were prescribed to 89 patients; hydrocodone-acetaminophen combination products were the most frequently used. Opioid prescribing rates were 5 times greater when pharmacy services were not integrated (P <0.001); and dentists were 81% less likely to prescribe opioids when pharmacy was fully integrated (odds ratio 0.19, 95% confidence interval 0.124-0.293; P <0.001). Frequency of hydrocodone use compared with other opioids did not decrease after the rescheduling of hydrocodone to a Schedule II controlled substance. The frequency of prescribing errors was not statistically different between groups, although there were numerically fewer errors with integrated pharmacy services. The literature reports that dentists are the third most frequent prescribers of opioids. The findings from this study suggest that collaboration between pharmacists and dentists has the potential to decrease opioid utilization in primary dental practice. Copyright © 2017 American Pharmacists Association®. Published by Elsevier Inc. All rights reserved.

The Earth isn't flat: The (large) influence of topography on geodetic fault slip imaging.

NASA Astrophysics Data System (ADS)

Thompson, T. B.; Meade, B. J.

2017-12-01

While earthquakes both occur near and generate steep topography, most geodetic slip inversions assume that the Earth's surface is flat. We have developed a new boundary element tool, Tectosaur, with the capability to study fault and earthquake problems including complex fault system geometries, topography, material property contrasts, and millions of elements. Using Tectosaur, we study the model error induced by neglecting topography in both idealized synthetic fault models and for the cases of the MW=7.3 Landers and MW=8.0 Wenchuan earthquakes. Near the steepest topography, we find the use of flat Earth dislocation models may induce errors of more than 100% in the inferred slip magnitude and rake. In particular, neglecting topographic effects leads to an inferred shallow slip deficit. Thus, we propose that the shallow slip deficit observed in several earthquakes may be an artefact resulting from the systematic use of elastic dislocation models assuming a flat Earth. Finally, using this study as an example, we emphasize the dangerous potential for forward model errors to be amplified by an order of magnitude in inverse problems.

A simulation of the San Andreas fault experiment

NASA Technical Reports Server (NTRS)

Agreen, R. W.; Smith, D. E.

1973-01-01

The San Andreas Fault Experiment, which employs two laser tracking systems for measuring the relative motion of two points on opposite sides of the fault, was simulated for an eight year observation period. The two tracking stations are located near San Diego on the western side of the fault and near Quincy on the eastern side; they are roughly 900 kilometers apart. Both will simultaneously track laser reflector equipped satellites as they pass near the stations. Tracking of the Beacon Explorer C Spacecraft was simulated for these two stations during August and September for eight consecutive years. An error analysis of the recovery of the relative location of Quincy from the data was made, allowing for model errors in the mass of the earth, the gravity field, solar radiation pressure, atmospheric drag, errors in the position of the San Diego site, and laser systems range biases and noise. The results of this simulation indicate that the distance of Quincy from San Diego will be determined each year with a precision of about 10 centimeters. This figure is based on the accuracy of earth models and other parameters available in 1972.

Fault recovery characteristics of the fault tolerant multi-processor

NASA Technical Reports Server (NTRS)

Padilla, Peter A.

1990-01-01

The fault handling performance of the fault tolerant multiprocessor (FTMP) was investigated. Fault handling errors detected during fault injection experiments were characterized. In these fault injection experiments, the FTMP disabled a working unit instead of the faulted unit once every 500 faults, on the average. System design weaknesses allow active faults to exercise a part of the fault management software that handles byzantine or lying faults. It is pointed out that these weak areas in the FTMP's design increase the probability that, for any hardware fault, a good LRU (line replaceable unit) is mistakenly disabled by the fault management software. It is concluded that fault injection can help detect and analyze the behavior of a system in the ultra-reliable regime. Although fault injection testing cannot be exhaustive, it has been demonstrated that it provides a unique capability to unmask problems and to characterize the behavior of a fault-tolerant system.

Displacement-length relationship of normal faults in Acheron Fossae, Mars: new observations with HRSC.

NASA Astrophysics Data System (ADS)

Charalambakis, E.; Hauber, E.; Knapmeyer, M.; Grott, M.; Gwinner, K.

2007-08-01

For Earth, data sets and models have shown that for a fault loaded by a constant remote stress, the maximum displacement on the fault is linearly related to its length by d = gamma · l [1]. The scaling and structure is self-similar through time [1]. The displacement-length relationship can provide useful information about the tectonic regime.We intend to use it to estimate the seismic moment released during the formation of Martian fault systems and to improve the seismicity model [2]. Only few data sets have been measured for extraterrestrial faults. One reason is the limited number of reliable topographic data sets. We used high-resolution Digital Elevation Models (DEM) [3] derived from HRSC image data taken from Mars Express orbit 1437. This orbit covers an area in the Acheron Fossae region, a rift-like graben system north of Olympus Mons with a "banana"-shaped topography [4]. It has a fault trend which runs approximately WNW-ESE. With an interactive IDL-based software tool [5] we measured the fault length and the vertical offset for 34 faults. We evaluated the height profile by plotting the fault lengths l vs. their observed maximum displacement (dmax-model). Additionally, we computed the maximum displacement of an elliptical fault scarp where the plane has the same area as in the observed case (elliptical model). The integration over the entire fault length necessary for the computation of the area supresses the "noise" introduced by local topographic effects like erosion or cratering. We should also mention that fault planes dipping 60 degree are usually assumed for Mars [e.g., 6] and even shallower dips have been found for normal fault planes [7]. This dip angle is used to compute displacement from vertical offset via d = h/(h*sinα), where h is the observed topographic step height, and ? is the fault dip angle. If fault dip angles of 30 degree are considered, the displacement differs by 40% from the one of dip angles of 60 degree. Depending on the data quality, especially the lighting conditions in the region, different errors can be made by determining the various values. Based on our experiences, we estimate that the error measuring the length of the fault is smaller than 10% and that the measurement error of the offset is smaller than 5%. Furthermore the horizontal resolution of the HRSC images is 12.5 m/pixel or 25 m/pixel and of the DEM derived from HRSC images 50 m/pixel because of re-sampling. That means that image resolution does not introduce a significant error at fault lengths in kilometer range. For the case of Mars it is known that in the growth of fault populations linkage is an essential process [8]. We obtained the d/l-values from selected examples of faults that were connected via a relay ramp. The error of ignoring an existing fault linkage is 20% to 50% if the elliptical fault model is used and 30% to 50% if only the dmax value is used to determine d l . This shows an advantage of the elliptic model. The error increases if more faults are linked, because the underestimation of the relevant length gets worse the longer the linked system is. We obtained a value of gamma=d/l of about 2 · 10-2 for the elliptic model and a value of approximately 2.7 · 10-2 for the dmax-model. The data show a relatively large scatter, but they can be compared to data from terrestrial faults ( d/l= ~1 · 10-2...5 · 10-2; [9] and references therein). In a first inspection of the Acheron Fossae 2 region in the orbit 1437 we could confirm our first observations [10]. If we consider fault linkage the d/l values shift towards lower d/l-ratios, since linkage means that d remains essentially constant, but l increases significantly. We will continue to measure other faults and obtain values for linked faults and relay ramps. References: [1] Cowie, P. A. and Scholz, C. H. (1992) JSG, 14, 1133-1148. [2] Knapmeyer, M. et al. (2006) JGR, 111, E11006. [3] Neukum, G. et al. (2004) ESA SP-1240, 17-35. [4] Kronberg, P. et al. (2007) J. Geophys. Res., 112, E04005, doi:10.1029/2006JE002780. [5] Hauber, E. et al. (2007) LPSC, XXXVIII, abstract 1338. [6] Wilkins, S. J. et al. (2002) GRL, 29, 1884, doi: 10.1029/2002GL015391. [7] Fueten, F. et al. (2007) LPSC, XXXVIII, abstract 1388. [8] Schultz, R. A. (2000) Tectonophysics, 316, 169-193. [9] Schultz, R. A. et al. (2006) JSG, 28, 2182-2193. [10] Hauber, E. et al. (2007) 7th Mars Conference, submitted.

Pharmacists' interventions in prescribing errors at hospital discharge: an observational study in the context of an electronic prescribing system in a UK teaching hospital.

PubMed

Abdel-Qader, Derar H; Harper, Lindsay; Cantrill, Judith A; Tully, Mary P

2010-11-01

Pharmacists have an essential role in improving drug usage and preventing prescribing errors (PEs). PEs at the interface of care are common, sometimes leading to adverse drug events (ADEs). This was the first study to investigate, using a computerized search method, the number, types, severity, pharmacists' impact on PEs and predictors of PEs in the context of electronic prescribing (e-prescribing) at hospital discharge. This was a retrospective, observational, 4-week study, carried out in 2008 in the Medical and Elderly Care wards of a 904-bed teaching hospital in the northwest of England, operating an e-prescribing system at discharge. Details were obtained, using a systematic computerized search of the system, of medication orders either entered by doctors and discontinued by pharmacists or entered by pharmacists. Meetings were conducted within 5 days of data extraction with pharmacists doing their routine clinical work, who categorized the occurrence, type and severity of their interventions using a scale. An independent senior pharmacist retrospectively rated the severity and potential impact, and subjectively judged, based on experience, whether any error was a computer-related error (CRE). Discrepancies were resolved by multidisciplinary discussion. The Statistical Package for Social Sciences was used for descriptive data analysis. For the PE predictors, a multivariate logistic regression was performed using STATA 7. Nine predictors were selected a priori from available prescribers', patients' and drug data. There were 7920 medication orders entered for 1038 patients (doctors entered 7712 orders; pharmacists entered 208 omitted orders). There were 675 (8.5% of 7920) interventions by pharmacists; 11 were not associated with PEs. Incidences of erroneous orders and patients with error were 8.0% (95% CI 7.4, 8.5 [n = 630/7920]) and 20.4% (95% CI 18.1, 22.9 [n = 212/1038]), respectively. The PE incidence was 8.4% (95% CI 7.8, 9.0 [n = 664/7920]). The top three medications associated with PEs were paracetamol (acetaminophen; 30 [4.8%]), salbutamol (albuterol; 28 [4.4%]) and omeprazole (25 [4.0%]). Pharmacists intercepted 524 (83.2%) erroneous orders without referring to doctors, and 70% of erroneous orders within 24 hours. Omission (31.0%), drug selection (29.4%) and dosage regimen (18.1%) error types accounted for >75% of PEs. There were 18 (2.9%) serious, 481 (76.3%) significant and 131 (20.8%) minor erroneous orders. Most erroneous orders (469 [74.4%]) were rated as of significant severity and significant impact of pharmacists on PEs. CREs (n = 279) accounted for 44.3% of erroneous orders. There was a significant difference in severity between CREs and non-CREs (χ2 = 38.88; df = 4; p < 0.001), with CREs being less severe than non-CREs. Drugs with multiple oral formulations (odds ratio [OR] 2.1; 95% CI 1.25, 3.37; p = 0.004) and prescribing by junior doctors (OR 2.54; 95% CI 1.08, 5.99; p = 0.03) were significant predictors of PEs. PEs commonly occur at hospital discharge, even with the use of an e-prescribing system. User and computer factors both appeared to contribute to the high error rate. The e-prescribing system facilitated the systematic extraction of data to investigate PEs in hospital practice. Pharmacists play an important role in rapidly documenting and preventing PEs before they reach and possibly harm patients. Pharmacists should understand CREs, so they complement, rather than duplicate, the e-prescribing system's strengths.

Procedural errors in air traffic control: effects of traffic density, expertise, and automation.

PubMed

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.

Preliminary design of the redundant software experiment

NASA Technical Reports Server (NTRS)

Campbell, Roy; Deimel, Lionel; Eckhardt, Dave, Jr.; Kelly, John; Knight, John; Lauterbach, Linda; Lee, Larry; Mcallister, Dave; Mchugh, John

1985-01-01

The goal of the present experiment is to characterize the fault distributions of highly reliable software replicates, constructed using techniques and environments which are similar to those used in comtemporary industrial software facilities. The fault distributions and their effect on the reliability of fault tolerant configurations of the software will be determined through extensive life testing of the replicates against carefully constructed randomly generated test data. Each detected error will be carefully analyzed to provide insight in to their nature and cause. A direct objective is to develop techniques for reducing the intensity of coincident errors, thus increasing the reliability gain which can be achieved with fault tolerance. Data on the reliability gains realized, and the cost of the fault tolerant configurations can be used to design a companion experiment to determine the cost effectiveness of the fault tolerant strategy. Finally, the data and analysis produced by this experiment will be valuable to the software engineering community as a whole because it will provide a useful insight into the nature and cause of hard to find, subtle faults which escape standard software engineering validation techniques and thus persist far into the software life cycle.

Fault tolerant architectures for integrated aircraft electronics systems

NASA Technical Reports Server (NTRS)

Levitt, K. N.; Melliar-Smith, P. M.; Schwartz, R. L.

1983-01-01

Work into possible architectures for future flight control computer systems is described. Ada for Fault-Tolerant Systems, the NETS Network Error-Tolerant System architecture, and voting in asynchronous systems are covered.

Efficient preparation of large-block-code ancilla states for fault-tolerant quantum computation

NASA Astrophysics Data System (ADS)

Zheng, Yi-Cong; Lai, Ching-Yi; Brun, Todd A.

2018-03-01

Fault-tolerant quantum computation (FTQC) schemes that use multiqubit large block codes can potentially reduce the resource overhead to a great extent. A major obstacle is the requirement for a large number of clean ancilla states of different types without correlated errors inside each block. These ancilla states are usually logical stabilizer states of the data-code blocks, which are generally difficult to prepare if the code size is large. Previously, we have proposed an ancilla distillation protocol for Calderbank-Shor-Steane (CSS) codes by classical error-correcting codes. It was assumed that the quantum gates in the distillation circuit were perfect; however, in reality, noisy quantum gates may introduce correlated errors that are not treatable by the protocol. In this paper, we show that additional postselection by another classical error-detecting code can be applied to remove almost all correlated errors. Consequently, the revised protocol is fully fault tolerant and capable of preparing a large set of stabilizer states sufficient for FTQC using large block codes. At the same time, the yield rate can be boosted from O (t-2) to O (1 ) in practice for an [[n ,k ,d =2 t +1

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

PubMed Central

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

2007-01-01

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

Automatically generated acceptance test: A software reliability experiment

NASA Technical Reports Server (NTRS)

Protzel, Peter W.

1988-01-01

This study presents results of a software reliability experiment investigating the feasibility of a new error detection method. The method can be used as an acceptance test and is solely based on empirical data about the behavior of internal states of a program. The experimental design uses the existing environment of a multi-version experiment previously conducted at the NASA Langley Research Center, in which the launch interceptor problem is used as a model. This allows the controlled experimental investigation of versions with well-known single and multiple faults, and the availability of an oracle permits the determination of the error detection performance of the test. Fault interaction phenomena are observed that have an amplifying effect on the number of error occurrences. Preliminary results indicate that all faults examined so far are detected by the acceptance test. This shows promise for further investigations, and for the employment of this test method on other applications.

A hierarchically distributed architecture for fault isolation expert systems on the space station

NASA Technical Reports Server (NTRS)

Miksell, Steve; Coffer, Sue

1987-01-01

The Space Station Axiomatic Fault Isolating Expert Systems (SAFTIES) system deals with the hierarchical distribution of control and knowledge among independent expert systems doing fault isolation and scheduling of Space Station subsystems. On its lower level, fault isolation is performed on individual subsystems. These fault isolation expert systems contain knowledge about the performance requirements of their particular subsystem and corrective procedures which may be involved in repsonse to certain performance errors. They can control the functions of equipment in their system and coordinate system task schedules. On a higher level, the Executive contains knowledge of all resources, task schedules for all systems, and the relative priority of all resources and tasks. The executive can override any subsystem task schedule in order to resolve use conflicts or resolve errors that require resources from multiple subsystems. Interprocessor communication is implemented using the SAFTIES Communications Interface (SCI). The SCI is an application layer protocol which supports the SAFTIES distributed multi-level architecture.

Combining principles of Cognitive Load Theory and diagnostic error analysis for designing job aids: Effects on motivation and diagnostic performance in a process control task.

PubMed

Kluge, Annette; Grauel, Britta; Burkolter, Dina

2013-03-01

Two studies are presented in which the design of a procedural aid and the impact of an additional decision aid for process control were assessed. In Study 1, a procedural aid was developed that avoids imposing unnecessary extraneous cognitive load on novices when controlling a complex technical system. This newly designed procedural aid positively affected germane load, attention, satisfaction, motivation, knowledge acquisition and diagnostic speed for novel faults. In Study 2, the effect of a decision aid for use before the procedural aid was investigated, which was developed based on an analysis of diagnostic errors committed in Study 1. Results showed that novices were able to diagnose both novel faults and practised faults, and were even faster at diagnosing novel faults. This research contributes to the question of how to optimally support novices in dealing with technical faults in process control. Copyright © 2012 Elsevier Ltd and The Ergonomics Society. All rights reserved.

A theoretical basis for the analysis of multiversion software subject to coincident errors

NASA Technical Reports Server (NTRS)

Eckhardt, D. E., Jr.; Lee, L. D.

1985-01-01

Fundamental to the development of redundant software techniques (known as fault-tolerant software) is an understanding of the impact of multiple joint occurrences of errors, referred to here as coincident errors. A theoretical basis for the study of redundant software is developed which: (1) provides a probabilistic framework for empirically evaluating the effectiveness of a general multiversion strategy when component versions are subject to coincident errors, and (2) permits an analytical study of the effects of these errors. An intensity function, called the intensity of coincident errors, has a central role in this analysis. This function describes the propensity of programmers to introduce design faults in such a way that software components fail together when executing in the application environment. A condition under which a multiversion system is a better strategy than relying on a single version is given.

Analysis of typical fault-tolerant architectures using HARP

NASA Technical Reports Server (NTRS)

Bavuso, Salvatore J.; Bechta Dugan, Joanne; Trivedi, Kishor S.; Rothmann, Elizabeth M.; Smith, W. Earl

1987-01-01

Difficulties encountered in the modeling of fault-tolerant systems are discussed. The Hybrid Automated Reliability Predictor (HARP) approach to modeling fault-tolerant systems is described. The HARP is written in FORTRAN, consists of nearly 30,000 lines of codes and comments, and is based on behavioral decomposition. Using the behavioral decomposition, the dependability model is divided into fault-occurrence/repair and fault/error-handling models; the characteristics and combining of these two models are examined. Examples in which the HARP is applied to the modeling of some typical fault-tolerant systems, including a local-area network, two fault-tolerant computer systems, and a flight control system, are presented.

Performance and evaluation of real-time multicomputer control systems

NASA Technical Reports Server (NTRS)

Shin, K. G.

1985-01-01

Three experiments on fault tolerant multiprocessors (FTMP) were begun. They are: (1) measurement of fault latency in FTMP; (2) validation and analysis of FTMP synchronization protocols; and investigation of error propagation in FTMP.

Robust model reference adaptive output feedback tracking for uncertain linear systems with actuator fault based on reinforced dead-zone modification.

PubMed

Bagherpoor, H M; Salmasi, Farzad R

2015-07-01

In this paper, robust model reference adaptive tracking controllers are considered for Single-Input Single-Output (SISO) and Multi-Input Multi-Output (MIMO) linear systems containing modeling uncertainties, unknown additive disturbances and actuator fault. Two new lemmas are proposed for both SISO and MIMO, under which dead-zone modification rule is improved such that the tracking error for any reference signal tends to zero in such systems. In the conventional approach, adaption of the controller parameters is ceased inside the dead-zone region which results tracking error, while preserving the system stability. In the proposed scheme, control signal is reinforced with an additive term based on tracking error inside the dead-zone which results in full reference tracking. In addition, no Fault Detection and Diagnosis (FDD) unit is needed in the proposed approach. Closed loop system stability and zero tracking error are proved by considering a suitable Lyapunov functions candidate. It is shown that the proposed control approach can assure that all the signals of the close loop system are bounded in faulty conditions. Finally, validity and performance of the new schemes have been illustrated through numerical simulations of SISO and MIMO systems in the presence of actuator faults, modeling uncertainty and output disturbance. Copyright © 2015 ISA. Published by Elsevier Ltd. All rights reserved.

A data-driven modeling approach to stochastic computation for low-energy biomedical devices.

PubMed

Lee, Kyong Ho; Jang, Kuk Jin; Shoeb, Ali; Verma, Naveen

2011-01-01

Low-power devices that can detect clinically relevant correlations in physiologically-complex patient signals can enable systems capable of closed-loop response (e.g., controlled actuation of therapeutic stimulators, continuous recording of disease states, etc.). In ultra-low-power platforms, however, hardware error sources are becoming increasingly limiting. In this paper, we present how data-driven methods, which allow us to accurately model physiological signals, also allow us to effectively model and overcome prominent hardware error sources with nearly no additional overhead. Two applications, EEG-based seizure detection and ECG-based arrhythmia-beat classification, are synthesized to a logic-gate implementation, and two prominent error sources are introduced: (1) SRAM bit-cell errors and (2) logic-gate switching errors ('stuck-at' faults). Using patient data from the CHB-MIT and MIT-BIH databases, performance similar to error-free hardware is achieved even for very high fault rates (up to 0.5 for SRAMs and 7 × 10(-2) for logic) that cause computational bit error rates as high as 50%.

Self-checking self-repairing computer nodes using the mirror processor

NASA Technical Reports Server (NTRS)

Tamir, Yuval

1992-01-01

Circuitry added to fault-tolerant systems for concurrent error deduction usually reduces performance. Using a technique called micro rollback, it is possible to eliminate most of the performance penalty of concurrent error detection. Error detection is performed in parallel with intermodule communication, and erroneous state changes are later undone. The author reports on the design and implementation of a VLSI RISC microprocessor, called the Mirror Processor (MP), which is capable of micro rollback. In order to achieve concurrent error detection, two MP chips operate in lockstep, comparing external signals and a signature of internal signals every clock cycle. If a mismatch is detected, both processors roll back to the beginning of the cycle when the error occurred. In some cases the erroneous state is corrected by copying a value from the fault-free processor to the faulty processor. The architecture, microarchitecture, and VLSI implementation of the MP, emphasizing its error-detection, error-recovery, and self-diagnosis capabilities, are described.

Using UAVSAR to Estimate Creep Along the Superstition Hills Fault, Southern California

NASA Astrophysics Data System (ADS)

Donnellan, A.; Parker, J. W.; Pierce, M.; Wang, J.

2012-12-01

UAVSAR data were first acquired over the Salton Trough region, just north of the Mexican border in October 2009. Second passes of data were acquired on 12 and 13 April 2010, about one week following the 5 April 2010 M 7.2 El Mayor - Cucapah earthquake. The earthquake resulted in creep on several faults north of the main rupture, including the Yuha, Imperial, and Superstition Hills faults. The UAVSAR platform acquires data about every six meters in swaths about 15 km wide. Tropospheric effects and residual aircraft motion contribute to error in the estimation of surface deformation in the Repeat Pass Interferometry products. The Superstition Hills fault shows clearly in the associated radar interferogram; however, error in the data product makes it difficult to infer deformation from long profiles that cross the fault. Using the QuakeSim InSAR Profile tool we extracted line of site profiles on either side of the fault delineated in the interferogram. We were able to remove much of the correlated error by differencing profiles 250 m on either side of the fault. The result shows right-lateral creep of 1.5±.4 mm along the northern 7 km of the fault in the interferogram. The amount of creep abruptly changes to 8.4±.4 mm of right lateral creep along at least 9 km of the fault covered in the image to the south. The transition occurs within less than 100 m along the fault. We also extracted 2 km long line of site profiles perpendicular to this section of the fault. Averaging these profiles shows a step across the fault of 14.9±.3 mm with greater creep on the order of 20 mm on the northern two profiles and lower creep of about 10 mm on the southern two profiles. Nearby GPS stations P503 and P493 are consistent with this result. They also confirm that the creep event occurred at the time of the El Mayor - Cucapah earthquake. By removing regional deformation resulting from the main rupture we were able to invert for the depth of creep from the surface. Results indicate that the slip occurred from the surface to 10-20 km, not shallowly, as previously suggested.

An analysis of errors, discrepancies, and variation in opioid prescriptions for adult outpatients at a teaching hospital

PubMed Central

Bicket, Mark C.; Kattail, Deepa; Yaster, Myron; Wu, Christopher L.; Pronovost, Peter

2017-01-01

Objective To determine opioid prescribing patterns and rate of three types of errors, discrepancies, and variation from ideal practice. Design Retrospective review of opioid prescriptions processed at an outpatient pharmacy Setting Tertiary institutional medical center Patients We examined 510 consecutive opioid medication prescriptions for adult patients processed at an institutional outpatient pharmacy in June 2016 for patient, provider, and prescription characteristics. Main Outcome Measure(s) We analyzed prescriptions for deviation from best practice guidelines, lack of two patient identifiers, and noncompliance with Drug Enforcement Agency (DEA) rules. Results Mean patient age (SD) was 47.5 years (17.4). The most commonly prescribed opioid was oxycodone (71%), usually not combined with acetaminophen. Practitioners prescribed tablet formulation to 92% of the sample, averaging 57 (47) pills. We identified at least one error on 42% of prescriptions. Among all prescriptions, 9% deviated from best practice guidelines, 21% failed to include two patient identifiers, and 41% were noncompliant with DEA rules. Errors occurred in 89% of handwritten prescriptions, 0% of electronic health record (EHR) computer-generated prescriptions, and 12% of non-EHR computer-generated prescriptions. Inter-rater reliability by kappa was 0.993. Conclusions Inconsistencies in opioid prescribing remain common. Handwritten prescriptions continue to demonstrate higher associations of errors, discrepancies, and variation from ideal practice and government regulations. All computer-generated prescriptions adhered to best practice guidelines and contained two patient identifiers, and all EHR prescriptions were fully compliant with DEA rules. PMID:28345746

Multiple Embedded Processors for Fault-Tolerant Computing

NASA Technical Reports Server (NTRS)

Bolotin, Gary; Watson, Robert; Katanyoutanant, Sunant; Burke, Gary; Wang, Mandy

2005-01-01

A fault-tolerant computer architecture has been conceived in an effort to reduce vulnerability to single-event upsets (spurious bit flips caused by impingement of energetic ionizing particles or photons). As in some prior fault-tolerant architectures, the redundancy needed for fault tolerance is obtained by use of multiple processors in one computer. Unlike prior architectures, the multiple processors are embedded in a single field-programmable gate array (FPGA). What makes this new approach practical is the recent commercial availability of FPGAs that are capable of having multiple embedded processors. A working prototype (see figure) consists of two embedded IBM PowerPC 405 processor cores and a comparator built on a Xilinx Virtex-II Pro FPGA. This relatively simple instantiation of the architecture implements an error-detection scheme. A planned future version, incorporating four processors and two comparators, would correct some errors in addition to detecting them.

DEPEND: A simulation-based environment for system level dependability analysis

NASA Technical Reports Server (NTRS)

Goswami, Kumar; Iyer, Ravishankar K.

1992-01-01

The design and evaluation of highly reliable computer systems is a complex issue. Designers mostly develop such systems based on prior knowledge and experience and occasionally from analytical evaluations of simplified designs. A simulation-based environment called DEPEND which is especially geared for the design and evaluation of fault-tolerant architectures is presented. DEPEND is unique in that it exploits the properties of object-oriented programming to provide a flexible framework with which a user can rapidly model and evaluate various fault-tolerant systems. The key features of the DEPEND environment are described, and its capabilities are illustrated with a detailed analysis of a real design. In particular, DEPEND is used to simulate the Unix based Tandem Integrity fault-tolerance and evaluate how well it handles near-coincident errors caused by correlated and latent faults. Issues such as memory scrubbing, re-integration policies, and workload dependent repair times which affect how the system handles near-coincident errors are also evaluated. Issues such as the method used by DEPEND to simulate error latency and the time acceleration technique that provides enormous simulation speed up are also discussed. Unlike any other simulation-based dependability studies, the use of these approaches and the accuracy of the simulation model are validated by comparing the results of the simulations, with measurements obtained from fault injection experiments conducted on a production Tandem Integrity machine.

Modeling and Measurement Constraints in Fault Diagnostics for HVAC Systems

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

Najafi, Massieh; Auslander, David M.; Bartlett, Peter L.

2010-05-30

Many studies have shown that energy savings of five to fifteen percent are achievable in commercial buildings by detecting and correcting building faults, and optimizing building control systems. However, in spite of good progress in developing tools for determining HVAC diagnostics, methods to detect faults in HVAC systems are still generally undeveloped. Most approaches use numerical filtering or parameter estimation methods to compare data from energy meters and building sensors to predictions from mathematical or statistical models. They are effective when models are relatively accurate and data contain few errors. In this paper, we address the case where models aremore » imperfect and data are variable, uncertain, and can contain error. We apply a Bayesian updating approach that is systematic in managing and accounting for most forms of model and data errors. The proposed method uses both knowledge of first principle modeling and empirical results to analyze the system performance within the boundaries defined by practical constraints. We demonstrate the approach by detecting faults in commercial building air handling units. We find that the limitations that exist in air handling unit diagnostics due to practical constraints can generally be effectively addressed through the proposed approach.« less

Error Mitigation of Point-to-Point Communication for Fault-Tolerant Computing

NASA Technical Reports Server (NTRS)

Akamine, Robert L.; Hodson, Robert F.; LaMeres, Brock J.; Ray, Robert E.

2011-01-01

Fault tolerant systems require the ability to detect and recover from physical damage caused by the hardware s environment, faulty connectors, and system degradation over time. This ability applies to military, space, and industrial computing applications. The integrity of Point-to-Point (P2P) communication, between two microcontrollers for example, is an essential part of fault tolerant computing systems. In this paper, different methods of fault detection and recovery are presented and analyzed.

Software Fault Tolerance: A Tutorial

NASA Technical Reports Server (NTRS)

Torres-Pomales, Wilfredo

2000-01-01

Because of our present inability to produce error-free software, software fault tolerance is and will continue to be an important consideration in software systems. The root cause of software design errors is the complexity of the systems. Compounding the problems in building correct software is the difficulty in assessing the correctness of software for highly complex systems. After a brief overview of the software development processes, we note how hard-to-detect design faults are likely to be introduced during development and how software faults tend to be state-dependent and activated by particular input sequences. Although component reliability is an important quality measure for system level analysis, software reliability is hard to characterize and the use of post-verification reliability estimates remains a controversial issue. For some applications software safety is more important than reliability, and fault tolerance techniques used in those applications are aimed at preventing catastrophes. Single version software fault tolerance techniques discussed include system structuring and closure, atomic actions, inline fault detection, exception handling, and others. Multiversion techniques are based on the assumption that software built differently should fail differently and thus, if one of the redundant versions fails, it is expected that at least one of the other versions will provide an acceptable output. Recovery blocks, N-version programming, and other multiversion techniques are reviewed.

Software fault tolerance in computer operating systems

NASA Technical Reports Server (NTRS)

Iyer, Ravishankar K.; Lee, Inhwan

1994-01-01

This chapter provides data and analysis of the dependability and fault tolerance for three operating systems: the Tandem/GUARDIAN fault-tolerant system, the VAX/VMS distributed system, and the IBM/MVS system. Based on measurements from these systems, basic software error characteristics are investigated. Fault tolerance in operating systems resulting from the use of process pairs and recovery routines is evaluated. Two levels of models are developed to analyze error and recovery processes inside an operating system and interactions among multiple instances of an operating system running in a distributed environment. The measurements show that the use of process pairs in Tandem systems, which was originally intended for tolerating hardware faults, allows the system to tolerate about 70% of defects in system software that result in processor failures. The loose coupling between processors which results in the backup execution (the processor state and the sequence of events occurring) being different from the original execution is a major reason for the measured software fault tolerance. The IBM/MVS system fault tolerance almost doubles when recovery routines are provided, in comparison to the case in which no recovery routines are available. However, even when recovery routines are provided, there is almost a 50% chance of system failure when critical system jobs are involved.

Fatal overdoses involving hydromorphone and morphine among inpatients: a case series

PubMed Central

Lowe, Amanda; Hamilton, Michael; Greenall BScPhm MHSc, Julie; Ma, Jessica; Dhalla, Irfan; Persaud, Nav

2017-01-01

Background: Opioids have narrow therapeutic windows, and errors in ordering or administration can be fatal. The purpose of this study was to describe deaths involving hydromorphone and morphine, which have similar-sounding names, but different potencies. Methods: In this case series, we describe deaths of patients admitted to hospital or residents of long-term care facilities that involved hydromorphone and morphine. We searched for deaths referred to the Patient Safety Review Committee of the Office of the Chief Coroner for Ontario between 2007 and 2012, and subsequently reviewed by 2014. We reviewed each case to identify intervention points where errors could have been prevented. Results: We identified 8 cases involving decedents aged 19 to 91 years. The cases involved errors in prescribing, order processing and transcription, dispensing, administration and monitoring. For 7 of the 8 cases, there were multiple (2 or more) possible intervention points. Six cases may have been prevented by additional patient monitoring, and 5 cases involved dispensing errors. Interpretation: Opioid toxicity deaths in patients living in institutions can be prevented at multiple points in the prescribing and dispensing processes. Interventions aimed at preventing errors in hydromorphone and morphine prescribing, administration and patient monitoring should be implemented and rigorously evaluated. PMID:28401133

Fatal overdoses involving hydromorphone and morphine among inpatients: a case series.

PubMed

Lowe, Amanda; Hamilton, Michael; Greenall BScPhm MHSc, Julie; Ma, Jessica; Dhalla, Irfan; Persaud, Nav

2017-01-01

Opioids have narrow therapeutic windows, and errors in ordering or administration can be fatal. The purpose of this study was to describe deaths involving hydromorphone and morphine, which have similar-sounding names, but different potencies. In this case series, we describe deaths of patients admitted to hospital or residents of long-term care facilities that involved hydromorphone and morphine. We searched for deaths referred to the Patient Safety Review Committee of the Office of the Chief Coroner for Ontario between 2007 and 2012, and subsequently reviewed by 2014. We reviewed each case to identify intervention points where errors could have been prevented. We identified 8 cases involving decedents aged 19 to 91 years. The cases involved errors in prescribing, order processing and transcription, dispensing, administration and monitoring. For 7 of the 8 cases, there were multiple (2 or more) possible intervention points. Six cases may have been prevented by additional patient monitoring, and 5 cases involved dispensing errors. Opioid toxicity deaths in patients living in institutions can be prevented at multiple points in the prescribing and dispensing processes. Interventions aimed at preventing errors in hydromorphone and morphine prescribing, administration and patient monitoring should be implemented and rigorously evaluated.

An Efficient Silent Data Corruption Detection Method with Error-Feedback Control and Even Sampling for HPC Applications

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

Di, Sheng; Berrocal, Eduardo; Cappello, Franck

The silent data corruption (SDC) problem is attracting more and more attentions because it is expected to have a great impact on exascale HPC applications. SDC faults are hazardous in that they pass unnoticed by hardware and can lead to wrong computation results. In this work, we formulate SDC detection as a runtime one-step-ahead prediction method, leveraging multiple linear prediction methods in order to improve the detection results. The contributions are twofold: (1) we propose an error feedback control model that can reduce the prediction errors for different linear prediction methods, and (2) we propose a spatial-data-based even-sampling method tomore » minimize the detection overheads (including memory and computation cost). We implement our algorithms in the fault tolerance interface, a fault tolerance library with multiple checkpoint levels, such that users can conveniently protect their HPC applications against both SDC errors and fail-stop errors. We evaluate our approach by using large-scale traces from well-known, large-scale HPC applications, as well as by running those HPC applications on a real cluster environment. Experiments show that our error feedback control model can improve detection sensitivity by 34-189% for bit-flip memory errors injected with the bit positions in the range [20,30], without any degradation on detection accuracy. Furthermore, memory size can be reduced by 33% with our spatial-data even-sampling method, with only a slight and graceful degradation in the detection sensitivity.« less

Experience of automation failures in training: effects on trust, automation bias, complacency and performance.

PubMed

Sauer, Juergen; Chavaillaz, Alain; Wastell, David

2016-06-01

This work examined the effects of operators' exposure to various types of automation failures in training. Forty-five participants were trained for 3.5 h on a simulated process control environment. During training, participants either experienced a fully reliable, automatic fault repair facility (i.e. faults detected and correctly diagnosed), a misdiagnosis-prone one (i.e. faults detected but not correctly diagnosed) or a miss-prone one (i.e. faults not detected). One week after training, participants were tested for 3 h, experiencing two types of automation failures (misdiagnosis, miss). The results showed that automation bias was very high when operators trained on miss-prone automation encountered a failure of the diagnostic system. Operator errors resulting from automation bias were much higher when automation misdiagnosed a fault than when it missed one. Differences in trust levels that were instilled by the different training experiences disappeared during the testing session. Practitioner Summary: The experience of automation failures during training has some consequences. A greater potential for operator errors may be expected when an automatic system failed to diagnose a fault than when it failed to detect one.

Measurement and analysis of workload effects on fault latency in real-time systems

NASA Technical Reports Server (NTRS)

Woodbury, Michael H.; Shin, Kang G.

1990-01-01

The authors demonstrate the need to address fault latency in highly reliable real-time control computer systems. It is noted that the effectiveness of all known recovery mechanisms is greatly reduced in the presence of multiple latent faults. The presence of multiple latent faults increases the possibility of multiple errors, which could result in coverage failure. The authors present experimental evidence indicating that the duration of fault latency is dependent on workload. A synthetic workload generator is used to vary the workload, and a hardware fault injector is applied to inject transient faults of varying durations. This method makes it possible to derive the distribution of fault latency duration. Experimental results obtained from the fault-tolerant multiprocessor at the NASA Airlab are presented and discussed.

A theoretical basis for the analysis of redundant software subject to coincident errors

NASA Technical Reports Server (NTRS)

Eckhardt, D. E., Jr.; Lee, L. D.

1985-01-01

Fundamental to the development of redundant software techniques fault-tolerant software, is an understanding of the impact of multiple-joint occurrences of coincident errors. A theoretical basis for the study of redundant software is developed which provides a probabilistic framework for empirically evaluating the effectiveness of the general (N-Version) strategy when component versions are subject to coincident errors, and permits an analytical study of the effects of these errors. The basic assumptions of the model are: (1) independently designed software components are chosen in a random sample; and (2) in the user environment, the system is required to execute on a stationary input series. The intensity of coincident errors, has a central role in the model. This function describes the propensity to introduce design faults in such a way that software components fail together when executing in the user environment. The model is used to give conditions under which an N-Version system is a better strategy for reducing system failure probability than relying on a single version of software. A condition which limits the effectiveness of a fault-tolerant strategy is studied, and it is posted whether system failure probability varies monotonically with increasing N or whether an optimal choice of N exists.

Slip rates on San Francisco Bay area faults from anelastic deformation of the continental lithosphere

USGS Publications Warehouse

Geist, E.L.; Andrews, D.J.

2000-01-01

Long-term slip rates on major faults in the San Francisco Bay area are predicted by modeling the anelastic deformation of the continental lithosphere in response to regional relative plate motion. The model developed by Bird and Kong [1994] is used to simulate lithospheric deformation according to a Coulomb frictional rheology of the upper crust and a dislocation creep rheology at depth. The focus of this study is the long-term motion of faults in a region extending from the creeping section of the San Andreas fault to the south up to the latitude of Cape Mendocino to the north. Boundary conditions are specified by the relative motion between the Pacific plate and the Sierra Nevada - Great Valley microplate [Argus and Gordon, 2000]. Rheologic-frictional parameters are specified as independent variables, and prediction errors are calculated with respect to geologic estimates of slip rates and maximum compressive stress directions. The model that best explains the region-wide observations is one in which the coefficient of friction on all of the major faults is less than 0.15, with the coefficient of friction for the San Andreas fault being approximately 0.09, consistent with previous inferences of San Andreas fault friction. Prediction error increases with lower fault friction on the San Andreas, indicating a lower bound of ??SAF > 0.08. Discrepancies with respect to previous slip rate estimates include a higher than expected slip rate along the peninsula segment of the San Andreas fault and a slightly lower than expected slip rate along the San Gregorio fault.

Fault detection and isolation for complex system

NASA Astrophysics Data System (ADS)

Jing, Chan Shi; Bayuaji, Luhur; Samad, R.; Mustafa, M.; Abdullah, N. R. H.; Zain, Z. M.; Pebrianti, Dwi

2017-07-01

Fault Detection and Isolation (FDI) is a method to monitor, identify, and pinpoint the type and location of system fault in a complex multiple input multiple output (MIMO) non-linear system. A two wheel robot is used as a complex system in this study. The aim of the research is to construct and design a Fault Detection and Isolation algorithm. The proposed method for the fault identification is using hybrid technique that combines Kalman filter and Artificial Neural Network (ANN). The Kalman filter is able to recognize the data from the sensors of the system and indicate the fault of the system in the sensor reading. Error prediction is based on the fault magnitude and the time occurrence of fault. Additionally, Artificial Neural Network (ANN) is another algorithm used to determine the type of fault and isolate the fault in the system.

Experimental magic state distillation for fault-tolerant quantum computing.

PubMed

Souza, Alexandre M; Zhang, Jingfu; Ryan, Colm A; Laflamme, Raymond

2011-01-25

Any physical quantum device for quantum information processing (QIP) is subject to errors in implementation. In order to be reliable and efficient, quantum computers will need error-correcting or error-avoiding methods. Fault-tolerance achieved through quantum error correction will be an integral part of quantum computers. Of the many methods that have been discovered to implement it, a highly successful approach has been to use transversal gates and specific initial states. A critical element for its implementation is the availability of high-fidelity initial states, such as |0〉 and the 'magic state'. Here, we report an experiment, performed in a nuclear magnetic resonance (NMR) quantum processor, showing sufficient quantum control to improve the fidelity of imperfect initial magic states by distilling five of them into one with higher fidelity.

Simulated fault injection - A methodology to evaluate fault tolerant microprocessor architectures

NASA Technical Reports Server (NTRS)

Choi, Gwan S.; Iyer, Ravishankar K.; Carreno, Victor A.

1990-01-01

A simulation-based fault-injection method for validating fault-tolerant microprocessor architectures is described. The approach uses mixed-mode simulation (electrical/logic analysis), and injects transient errors in run-time to assess the resulting fault impact. As an example, a fault-tolerant architecture which models the digital aspects of a dual-channel real-time jet-engine controller is used. The level of effectiveness of the dual configuration with respect to single and multiple transients is measured. The results indicate 100 percent coverage of single transients. Approximately 12 percent of the multiple transients affect both channels; none result in controller failure since two additional levels of redundancy exist.

Viscoelastic shear zone model of a strike-slip earthquake cycle

USGS Publications Warehouse

Pollitz, F.F.

2001-01-01

I examine the behavior of a two-dimensional (2-D) strike-slip fault system embedded in a 1-D elastic layer (schizosphere) overlying a uniform viscoelastic half-space (plastosphere) and within the boundaries of a finite width shear zone. The viscoelastic coupling model of Savage and Prescott [1978] considers the viscoelastic response of this system, in the absence of the shear zone boundaries, to an earthquake occurring within the upper elastic layer, steady slip beneath a prescribed depth, and the superposition of the responses of multiple earthquakes with characteristic slip occurring at regular intervals. So formulated, the viscoelastic coupling model predicts that sufficiently long after initiation of the system, (1) average fault-parallel velocity at any point is the average slip rate of that side of the fault and (2) far-field velocities equal the same constant rate. Because of the sensitivity to the mechanical properties of the schizosphere-plastosphere system (i.e., elastic layer thickness, plastosphere viscosity), this model has been used to infer such properties from measurements of interseismic velocity. Such inferences exploit the predicted behavior at a known time within the earthquake cycle. By modifying the viscoelastic coupling model to satisfy the additional constraint that the absolute velocity at prescribed shear zone boundaries is constant, I find that even though the time-averaged behavior remains the same, the spatiotemporal pattern of surface deformation (particularly its temporal variation within an earthquake cycle) is markedly different from that predicted by the conventional viscoelastic coupling model. These differences are magnified as plastosphere viscosity is reduced or as the recurrence interval of periodic earthquakes is lengthened. Application to the interseismic velocity field along the Mojave section of the San Andreas fault suggests that the region behaves mechanically like a ???600-km-wide shear zone accommodating 50 mm/yr fault-parallel motion distributed between the San Andreas fault system and Eastern California Shear Zone. Copyright 2001 by the American Geophysical Union.

RedThreads: An Interface for Application-Level Fault Detection/Correction Through Adaptive Redundant Multithreading

DOE PAGES

Hukerikar, Saurabh; Teranishi, Keita; Diniz, Pedro C.; ...

2017-02-11

In the presence of accelerated fault rates, which are projected to be the norm on future exascale systems, it will become increasingly difficult for high-performance computing (HPC) applications to accomplish useful computation. Due to the fault-oblivious nature of current HPC programming paradigms and execution environments, HPC applications are insufficiently equipped to deal with errors. We believe that HPC applications should be enabled with capabilities to actively search for and correct errors in their computations. The redundant multithreading (RMT) approach offers lightweight replicated execution streams of program instructions within the context of a single application process. Furthermore, the use of completemore » redundancy incurs significant overhead to the application performance.« less

RedThreads: An Interface for Application-Level Fault Detection/Correction Through Adaptive Redundant Multithreading

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

Hukerikar, Saurabh; Teranishi, Keita; Diniz, Pedro C.

In the presence of accelerated fault rates, which are projected to be the norm on future exascale systems, it will become increasingly difficult for high-performance computing (HPC) applications to accomplish useful computation. Due to the fault-oblivious nature of current HPC programming paradigms and execution environments, HPC applications are insufficiently equipped to deal with errors. We believe that HPC applications should be enabled with capabilities to actively search for and correct errors in their computations. The redundant multithreading (RMT) approach offers lightweight replicated execution streams of program instructions within the context of a single application process. Furthermore, the use of completemore » redundancy incurs significant overhead to the application performance.« less

Study of fault tolerant software technology for dynamic systems

NASA Technical Reports Server (NTRS)

Caglayan, A. K.; Zacharias, G. L.

1985-01-01

The major aim of this study is to investigate the feasibility of using systems-based failure detection isolation and compensation (FDIC) techniques in building fault-tolerant software and extending them, whenever possible, to the domain of software fault tolerance. First, it is shown that systems-based FDIC methods can be extended to develop software error detection techniques by using system models for software modules. In particular, it is demonstrated that systems-based FDIC techniques can yield consistency checks that are easier to implement than acceptance tests based on software specifications. Next, it is shown that systems-based failure compensation techniques can be generalized to the domain of software fault tolerance in developing software error recovery procedures. Finally, the feasibility of using fault-tolerant software in flight software is investigated. In particular, possible system and version instabilities, and functional performance degradation that may occur in N-Version programming applications to flight software are illustrated. Finally, a comparative analysis of N-Version and recovery block techniques in the context of generic blocks in flight software is presented.

Exploiting data representation for fault tolerance

DOE PAGES

Hoemmen, Mark Frederick; Elliott, J.; Sandia National Lab.; ...

2015-01-06

Incorrect computer hardware behavior may corrupt intermediate computations in numerical algorithms, possibly resulting in incorrect answers. Prior work models misbehaving hardware by randomly flipping bits in memory. We start by accepting this premise, and present an analytic model for the error introduced by a bit flip in an IEEE 754 floating-point number. We then relate this finding to the linear algebra concepts of normalization and matrix equilibration. In particular, we present a case study illustrating that normalizing both vector inputs of a dot product minimizes the probability of a single bit flip causing a large error in the dot product'smore » result. Moreover, the absolute error is either less than one or very large, which allows detection of large errors. Then, we apply this to the GMRES iterative solver. We count all possible errors that can be introduced through faults in arithmetic in the computationally intensive orthogonalization phase of GMRES, and show that when the matrix is equilibrated, the absolute error is bounded above by one.« less

Study on advanced information processing system

NASA Technical Reports Server (NTRS)

Shin, Kang G.; Liu, Jyh-Charn

1992-01-01

Issues related to the reliability of a redundant system with large main memory are addressed. In particular, the Fault-Tolerant Processor (FTP) for Advanced Launch System (ALS) is used as a basis for our presentation. When the system is free of latent faults, the probability of system crash due to nearly-coincident channel faults is shown to be insignificant even when the outputs of computing channels are infrequently voted on. In particular, using channel error maskers (CEMs) is shown to improve reliability more effectively than increasing the number of channels for applications with long mission times. Even without using a voter, most memory errors can be immediately corrected by CEMs implemented with conventional coding techniques. In addition to their ability to enhance system reliability, CEMs--with a low hardware overhead--can be used to reduce not only the need of memory realignment, but also the time required to realign channel memories in case, albeit rare, such a need arises. Using CEMs, we have developed two schemes, called Scheme 1 and Scheme 2, to solve the memory realignment problem. In both schemes, most errors are corrected by CEMs, and the remaining errors are masked by a voter.

Analogue modelling of thrust systems: Passive vs. active hanging wall strain accommodation and sharp vs. smooth fault-ramp geometries

NASA Astrophysics Data System (ADS)

Rosas, F. M.; Duarte, J. C.; Almeida, P.; Schellart, W. P.; Riel, N.; Terrinha, P.

2017-06-01

We present new analogue modelling results of crustal thrust-systems in which a deformable (brittle) hanging wall is assumed to endure passive internal deformation during thrusting, i.e. exclusively as a consequence of having to adapt its shape to the variable geometry of a rigid footwall. Building on previous experimental contributions, we specifically investigate the role of two so far overlooked critical variables: a) concave-convex (CC) vs. flat-ramp-flat (FRF) thrust ramp geometry; and b) presence vs. absence of a basal velocity discontinuity (VD). Regarding the first variable, we compare new results for considered (CC) smoother ramp types against classical experiments in which (FRF) sharp ramp geometries are always prescribed. Our results show that the considered sharp vs. smooth variation in the thrust-ramp geometry produces important differences in the distribution of the local stress field in the deformable hanging wall above both (lower and upper) fault bends, with corresponding styles of strain accommodation being expressed by marked differences in measured morpho-structural parameters. Regarding the second variable, we for the first time report analogue modelling results of this type of experiments in which basal VDs are experimentally prescribed to be absent. Our results critically show that true passive hanging wall deformation is only possible to simulate in the absence of any basal VD, since active shortening accommodation always necessarily occurs in the hanging wall above such a discontinuity (i.e. above the lower fault bend). In addition, we show that the morpho-structural configuration of model thrust-wedges formed for prescribed VD absence conditions complies well with natural examples of major overthrusts, wherein conditions must occur that approximate a frictionless state along the main basal thrust-plane.

Equivalent strike-slip earthquake cycles in half-space and lithosphere-asthenosphere earth models

USGS Publications Warehouse

Savage, J.C.

1990-01-01

By virtue of the images used in the dislocation solution, the deformation at the free surface produced throughout the earthquake cycle by slippage on a long strike-slip fault in an Earth model consisting of an elastic plate (lithosphere) overlying a viscoelastic half-space (asthenosphere) can be duplicated by prescribed slip on a vertical fault embedded in an elastic half-space. Inversion of 1973-1988 geodetic measurements of deformation across the segment of the San Andreas fault in the Transverse Ranges north of Los Angeles for the half-space equivalent slip distribution suggests no significant slip on the fault above 30 km and a uniform slip rate of 36 mm/yr below 30 km. One equivalent lithosphere-asthenosphere model would have a 30-km thick lithosphere and an asthenosphere relaxation time greater than 33 years, but other models are possible. -from Author

Quantum Error Correction with Biased Noise

NASA Astrophysics Data System (ADS)

Brooks, Peter

Quantum computing offers powerful new techniques for speeding up the calculation of many classically intractable problems. Quantum algorithms can allow for the efficient simulation of physical systems, with applications to basic research, chemical modeling, and drug discovery; other algorithms have important implications for cryptography and internet security. At the same time, building a quantum computer is a daunting task, requiring the coherent manipulation of systems with many quantum degrees of freedom while preventing environmental noise from interacting too strongly with the system. Fortunately, we know that, under reasonable assumptions, we can use the techniques of quantum error correction and fault tolerance to achieve an arbitrary reduction in the noise level. In this thesis, we look at how additional information about the structure of noise, or "noise bias," can improve or alter the performance of techniques in quantum error correction and fault tolerance. In Chapter 2, we explore the possibility of designing certain quantum gates to be extremely robust with respect to errors in their operation. This naturally leads to structured noise where certain gates can be implemented in a protected manner, allowing the user to focus their protection on the noisier unprotected operations. In Chapter 3, we examine how to tailor error-correcting codes and fault-tolerant quantum circuits in the presence of dephasing biased noise, where dephasing errors are far more common than bit-flip errors. By using an appropriately asymmetric code, we demonstrate the ability to improve the amount of error reduction and decrease the physical resources required for error correction. In Chapter 4, we analyze a variety of protocols for distilling magic states, which enable universal quantum computation, in the presence of faulty Clifford operations. Here again there is a hierarchy of noise levels, with a fixed error rate for faulty gates, and a second rate for errors in the distilled states which decreases as the states are distilled to better quality. The interplay of of these different rates sets limits on the achievable distillation and how quickly states converge to that limit.

How often are spectacle lenses not dispensed as prescribed?

PubMed

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.

The effect of the electronic transmission of prescriptions on dispensing errors and prescription enhancements made in English community pharmacies: a naturalistic stepped wedge study

PubMed Central

Franklin, Bryony Dean; Reynolds, Matthew; Sadler, Stacey; Hibberd, Ralph; Avery, Anthony J; Armstrong, Sarah J; Mehta, Rajnikant; Boyd, Matthew J; Barber, Nick

2014-01-01

Objectives To compare prevalence and types of dispensing errors and pharmacists’ labelling enhancements, for prescriptions transmitted electronically versus paper prescriptions. Design Naturalistic stepped wedge study. Setting 15 English community pharmacies. Intervention Electronic transmission of prescriptions between prescriber and pharmacy. Main outcome measures Prevalence of labelling errors, content errors and labelling enhancements (beneficial additions to the instructions), as identified by researchers visiting each pharmacy. Results Overall, we identified labelling errors in 5.4% of 16 357 dispensed items, and content errors in 1.4%; enhancements were made for 13.6%. Pharmacists also edited the label for a further 21.9% of electronically transmitted items. Electronically transmitted prescriptions had a higher prevalence of labelling errors (7.4% of 3733 items) than other prescriptions (4.8% of 12 624); OR 1.46 (95% CI 1.21 to 1.76). There was no difference for content errors or enhancements. The increase in labelling errors was mainly accounted for by errors (mainly at one pharmacy) involving omission of the indication, where specified by the prescriber, from the label. A sensitivity analysis in which these cases (n=158) were not considered errors revealed no remaining difference between prescription types. Conclusions We identified a higher prevalence of labelling errors for items transmitted electronically, but this was predominantly accounted for by local practice in a single pharmacy, independent of prescription type. Community pharmacists made labelling enhancements to about one in seven dispensed items, whether electronically transmitted or not. Community pharmacists, prescribers, professional bodies and software providers should work together to agree how items should be dispensed and labelled to best reap the benefits of electronically transmitted prescriptions. Community pharmacists need to ensure their computer systems are promptly updated to help reduce errors. PMID:24742778

The effect of the electronic transmission of prescriptions on dispensing errors and prescription enhancements made in English community pharmacies: a naturalistic stepped wedge study.

PubMed

Franklin, Bryony Dean; Reynolds, Matthew; Sadler, Stacey; Hibberd, Ralph; Avery, Anthony J; Armstrong, Sarah J; Mehta, Rajnikant; Boyd, Matthew J; Barber, Nick

2014-08-01

To compare prevalence and types of dispensing errors and pharmacists' labelling enhancements, for prescriptions transmitted electronically versus paper prescriptions. Naturalistic stepped wedge study. 15 English community pharmacies. Electronic transmission of prescriptions between prescriber and pharmacy. Prevalence of labelling errors, content errors and labelling enhancements (beneficial additions to the instructions), as identified by researchers visiting each pharmacy. Overall, we identified labelling errors in 5.4% of 16,357 dispensed items, and content errors in 1.4%; enhancements were made for 13.6%. Pharmacists also edited the label for a further 21.9% of electronically transmitted items. Electronically transmitted prescriptions had a higher prevalence of labelling errors (7.4% of 3733 items) than other prescriptions (4.8% of 12,624); OR 1.46 (95% CI 1.21 to 1.76). There was no difference for content errors or enhancements. The increase in labelling errors was mainly accounted for by errors (mainly at one pharmacy) involving omission of the indication, where specified by the prescriber, from the label. A sensitivity analysis in which these cases (n=158) were not considered errors revealed no remaining difference between prescription types. We identified a higher prevalence of labelling errors for items transmitted electronically, but this was predominantly accounted for by local practice in a single pharmacy, independent of prescription type. Community pharmacists made labelling enhancements to about one in seven dispensed items, whether electronically transmitted or not. Community pharmacists, prescribers, professional bodies and software providers should work together to agree how items should be dispensed and labelled to best reap the benefits of electronically transmitted prescriptions. Community pharmacists need to ensure their computer systems are promptly updated to help reduce errors. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.

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

PubMed

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

2017-12-01

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

Fault tolerance in an inner-outer solver: A GVR-enabled case study

DOE PAGES

Zhang, Ziming; Chien, Andrew A.; Teranishi, Keita

2015-04-18

Resilience is a major challenge for large-scale systems. It is particularly important for iterative linear solvers, since they take much of the time of many scientific applications. We show that single bit flip errors in the Flexible GMRES iterative linear solver can lead to high computational overhead or even failure to converge to the right answer. Informed by these results, we design and evaluate several strategies for fault tolerance in both inner and outer solvers appropriate across a range of error rates. We implement them, extending Trilinos’ solver library with the Global View Resilience (GVR) programming model, which provides multi-streammore » snapshots, multi-version data structures with portable and rich error checking/recovery. Lastly, experimental results validate correct execution with low performance overhead under varied error conditions.« less

Fault tolerant architectures for integrated aircraft electronics systems, task 2

NASA Technical Reports Server (NTRS)

Levitt, K. N.; Melliar-Smith, P. M.; Schwartz, R. L.

1984-01-01

The architectural basis for an advanced fault tolerant on-board computer to succeed the current generation of fault tolerant computers is examined. The network error tolerant system architecture is studied with particular attention to intercluster configurations and communication protocols, and to refined reliability estimates. The diagnosis of faults, so that appropriate choices for reconfiguration can be made is discussed. The analysis relates particularly to the recognition of transient faults in a system with tasks at many levels of priority. The demand driven data-flow architecture, which appears to have possible application in fault tolerant systems is described and work investigating the feasibility of automatic generation of aircraft flight control programs from abstract specifications is reported.

Study on UKF based federal integrated navigation for high dynamic aviation

NASA Astrophysics Data System (ADS)

Zhao, Gang; Shao, Wei; Chen, Kai; Yan, Jie

2011-08-01

High dynamic aircraft is a very attractive new generation vehicles, in which provides near space aviation with large flight envelope both speed and altitude, for example the hypersonic vehicles. The complex flight environments for high dynamic vehicles require high accuracy and stability navigation scheme. Since the conventional Strapdown Inertial Navigation System (SINS) and Global Position System (GPS) federal integrated scheme based on EKF (Extended Kalman Filter) is invalidation in GPS single blackout situation because of high speed flight, a new high precision and stability integrated navigation approach is presented in this paper, in which the SINS, GPS and Celestial Navigation System (CNS) is combined as a federal information fusion configuration based on nonlinear Unscented Kalman Filter (UKF) algorithm. Firstly, the new integrated system state error is modeled. According to this error model, the SINS system is used as the navigation solution mathematic platform. The SINS combine with GPS constitute one error estimation filter subsystem based on UKF to obtain local optimal estimation, and the SINS combine with CNS constitute another error estimation subsystem. A non-reset federated configuration filter based on partial information is proposed to fuse two local optimal estimations to get global optimal error estimation, and the global optimal estimation is used to correct the SINS navigation solution. The χ 2 fault detection method is used to detect the subsystem fault, and the fault subsystem is isolation through fault interval to protect system away from the divergence. The integrated system takes advantages of SINS, GPS and CNS to an immense improvement for high accuracy and reliably high dynamic navigation application. Simulation result shows that federated fusion of using GPS and CNS to revise SINS solution is reasonable and availably with good estimation performance, which are satisfied with the demands of high dynamic flight navigation. The UKF is superior than EKF based integrated scheme, in which has smaller estimation error and quickly convergence rate.

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

PubMed

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

2012-08-01

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

Electronic prescribing in pediatrics: toward safer and more effective medication management.

PubMed

Johnson, Kevin B; Lehmann, Christoph U

2013-04-01

This technical report discusses recent advances in electronic prescribing (e-prescribing) systems, including the evidence base supporting their limitations and potential benefits. Specifically, this report acknowledges that there are limited but positive pediatric data supporting the role of e-prescribing in mitigating medication errors, improving communication with dispensing pharmacists, and improving medication adherence. On the basis of these data and on the basis of federal statutes that provide incentives for the use of e-prescribing systems, the American Academy of Pediatrics recommends the adoption of e-prescribing systems with pediatric functionality. This report supports the accompanying policy statement from the American Academy of Pediatrics recommending the adoption of e-prescribing by pediatric health care providers.

Flexible kinematic earthquake rupture inversion of tele-seismic waveforms: Application to the 2013 Balochistan, Pakistan earthquake

NASA Astrophysics Data System (ADS)

Shimizu, K.; Yagi, Y.; Okuwaki, R.; Kasahara, A.

2017-12-01

The kinematic earthquake rupture models are useful to derive statistics and scaling properties of the large and great earthquakes. However, the kinematic rupture models for the same earthquake are often different from one another. Such sensitivity of the modeling prevents us to understand the statistics and scaling properties of the earthquakes. Yagi and Fukahata (2011) introduces the uncertainty of Green's function into the tele-seismic waveform inversion, and shows that the stable spatiotemporal distribution of slip-rate can be obtained by using an empirical Bayesian scheme. One of the unsolved problems in the inversion rises from the modeling error originated from an uncertainty of a fault-model setting. Green's function near the nodal plane of focal mechanism is known to be sensitive to the slight change of the assumed fault geometry, and thus the spatiotemporal distribution of slip-rate should be distorted by the modeling error originated from the uncertainty of the fault model. We propose a new method accounting for the complexity in the fault geometry by additionally solving the focal mechanism on each space knot. Since a solution of finite source inversion gets unstable with an increasing of flexibility of the model, we try to estimate a stable spatiotemporal distribution of focal mechanism in the framework of Yagi and Fukahata (2011). We applied the proposed method to the 52 tele-seismic P-waveforms of the 2013 Balochistan, Pakistan earthquake. The inverted-potency distribution shows unilateral rupture propagation toward southwest of the epicenter, and the spatial variation of the focal mechanisms shares the same pattern as the fault-curvature along the tectonic fabric. On the other hand, the broad pattern of rupture process, including the direction of rupture propagation, cannot be reproduced by an inversion analysis under the assumption that the faulting occurred on a single flat plane. These results show that the modeling error caused by simplifying the fault model is non-negligible in the tele-seismic waveform inversion of the 2013 Balochistan, Pakistan earthquake.

Modeling Crustal Deformation Due to the Landers, Hector Mine Earthquakes Using the SCEC Community Fault Model

NASA Astrophysics Data System (ADS)

Gable, C. W.; Fialko, Y.; Hager, B. H.; Plesch, A.; Williams, C. A.

2006-12-01

More realistic models of crustal deformation are possible due to advances in measurements and modeling capabilities. This study integrates various data to constrain a finite element model of stress and strain in the vicinity of the 1992 Landers earthquake and the 1999 Hector Mine earthquake. The geometry of the model is designed to incorporate the Southern California Earthquake Center (SCEC), Community Fault Model (CFM) to define fault geometry. The Hector Mine fault is represented by a single surface that follows the trace of the Hector Mine fault, is vertical and has variable depth. The fault associated with the Landers earthquake is a set of seven surfaces that capture the geometry of the splays and echelon offsets of the fault. A three dimensional finite element mesh of tetrahedral elements is built that closely maintains the geometry of these fault surfaces. The spatially variable coseismic slip on faults is prescribed based on an inversion of geodetic (Synthetic Aperture Radar and Global Positioning System) data. Time integration of stress and strain is modeled with the finite element code Pylith. As a first step the methodology of incorporating all these data is described. Results of the time history of the stress and strain transfer between 1992 and 1999 are analyzed as well as the time history of deformation from 1999 to the present.

FPGA-Based, Self-Checking, Fault-Tolerant Computers

NASA Technical Reports Server (NTRS)

Some, Raphael; Rennels, David

2004-01-01

A proposed computer architecture would exploit the capabilities of commercially available field-programmable gate arrays (FPGAs) to enable computers to detect and recover from bit errors. The main purpose of the proposed architecture is to enable fault-tolerant computing in the presence of single-event upsets (SEUs). [An SEU is a spurious bit flip (also called a soft error) caused by a single impact of ionizing radiation.] The architecture would also enable recovery from some soft errors caused by electrical transients and, to some extent, from intermittent and permanent (hard) errors caused by aging of electronic components. A typical FPGA of the current generation contains one or more complete processor cores, memories, and highspeed serial input/output (I/O) channels, making it possible to shrink a board-level processor node to a single integrated-circuit chip. Custom, highly efficient microcontrollers, general-purpose computers, custom I/O processors, and signal processors can be rapidly and efficiently implemented by use of FPGAs. Unfortunately, FPGAs are susceptible to SEUs. Prior efforts to mitigate the effects of SEUs have yielded solutions that degrade performance of the system and require support from external hardware and software. In comparison with other fault-tolerant- computing architectures (e.g., triple modular redundancy), the proposed architecture could be implemented with less circuitry and lower power demand. Moreover, the fault-tolerant computing functions would require only minimal support from circuitry outside the central processing units (CPUs) of computers, would not require any software support, and would be largely transparent to software and to other computer hardware. There would be two types of modules: a self-checking processor module and a memory system (see figure). The self-checking processor module would be implemented on a single FPGA and would be capable of detecting its own internal errors. It would contain two CPUs executing identical programs in lock step, with comparison of their outputs to detect errors. It would also contain various cache local memory circuits, communication circuits, and configurable special-purpose processors that would use self-checking checkers. (The basic principle of the self-checking checker method is to utilize logic circuitry that generates error signals whenever there is an error in either the checker or the circuit being checked.) The memory system would comprise a main memory and a hardware-controlled check-pointing system (CPS) based on a buffer memory denoted the recovery cache. The main memory would contain random-access memory (RAM) chips and FPGAs that would, in addition to everything else, implement double-error-detecting and single-error-correcting memory functions to enable recovery from single-bit errors.

Prescribed performance distributed consensus control for nonlinear multi-agent systems with unknown dead-zone input

NASA Astrophysics Data System (ADS)

Cui, Guozeng; Xu, Shengyuan; Ma, Qian; Li, Yongmin; Zhang, Zhengqiang

2018-05-01

In this paper, the problem of prescribed performance distributed output consensus for higher-order non-affine nonlinear multi-agent systems with unknown dead-zone input is investigated. Fuzzy logical systems are utilised to identify the unknown nonlinearities. By introducing prescribed performance, the transient and steady performance of synchronisation errors are guaranteed. Based on Lyapunov stability theory and the dynamic surface control technique, a new distributed consensus algorithm for non-affine nonlinear multi-agent systems is proposed, which ensures cooperatively uniformly ultimately boundedness of all signals in the closed-loop systems and enables the output of each follower to synchronise with the leader within predefined bounded error. Finally, simulation examples are provided to demonstrate the effectiveness of the proposed control scheme.

Coherent Oscillations inside a Quantum Manifold Stabilized by Dissipation

NASA Astrophysics Data System (ADS)

Touzard, S.; Grimm, A.; Leghtas, Z.; Mundhada, S. O.; Reinhold, P.; Axline, C.; Reagor, M.; Chou, K.; Blumoff, J.; Sliwa, K. M.; Shankar, S.; Frunzio, L.; Schoelkopf, R. J.; Mirrahimi, M.; Devoret, M. H.

2018-04-01

Manipulating the state of a logical quantum bit (qubit) usually comes at the expense of exposing it to decoherence. Fault-tolerant quantum computing tackles this problem by manipulating quantum information within a stable manifold of a larger Hilbert space, whose symmetries restrict the number of independent errors. The remaining errors do not affect the quantum computation and are correctable after the fact. Here we implement the autonomous stabilization of an encoding manifold spanned by Schrödinger cat states in a superconducting cavity. We show Zeno-driven coherent oscillations between these states analogous to the Rabi rotation of a qubit protected against phase flips. Such gates are compatible with quantum error correction and hence are crucial for fault-tolerant logical qubits.

Negligence, genuine error, and litigation

PubMed Central

Sohn, David H

2013-01-01

Not all medical injuries are the result of negligence. In fact, most medical injuries are the result either of the inherent risk in the practice of medicine, or due to system errors, which cannot be prevented simply through fear of disciplinary action. This paper will discuss the differences between adverse events, negligence, and system errors; the current medical malpractice tort system in the United States; and review current and future solutions, including medical malpractice reform, alternative dispute resolution, health courts, and no-fault compensation systems. The current political environment favors investigation of non-cap tort reform remedies; investment into more rational oversight systems, such as health courts or no-fault systems may reap both quantitative and qualitative benefits for a less costly and safer health system. PMID:23426783

Development and validation of techniques for improving software dependability

NASA Technical Reports Server (NTRS)

Knight, John C.

1992-01-01

A collection of document abstracts are presented on the topic of improving software dependability through NASA grant NAG-1-1123. Specific topics include: modeling of error detection; software inspection; test cases; Magnetic Stereotaxis System safety specifications and fault trees; and injection of synthetic faults into software.

A model of methods for influencing prescribing: Part I. A review of prescribing models, persuasion theories, and administrative and educational methods.

PubMed

Raisch, D W

1990-04-01

The purpose of this literature review is to develop a model of methods to be used to influence prescribing. Four bodies of literature were identified as being important for developing the model: (1) Theoretical prescribing models furnish information concerning factors that affect prescribing and how prescribing decisions are made. (2) Theories of persuasion provide insight into important components of educational communications. (3) Research articles of programs to improve prescribing identify types of programs that have been found to be successful. (4) Theories of human inference describe how judgments are formulated and identify errors in judgment that can play a role in prescribing. This review is presented in two parts. This article reviews prescribing models, theories of persuasion, studies of administrative programs to control prescribing, and sub-optimally designed studies of educational efforts to influence drug prescribing.

Predeployment validation of fault-tolerant systems through software-implemented fault insertion

NASA Technical Reports Server (NTRS)

Czeck, Edward W.; Siewiorek, Daniel P.; Segall, Zary Z.

1989-01-01

Fault injection-based automated testing (FIAT) environment, which can be used to experimentally characterize and evaluate distributed realtime systems under fault-free and faulted conditions is described. A survey is presented of validation methodologies. The need for fault insertion based on validation methodologies is demonstrated. The origins and models of faults, and motivation for the FIAT concept are reviewed. FIAT employs a validation methodology which builds confidence in the system through first providing a baseline of fault-free performance data and then characterizing the behavior of the system with faults present. Fault insertion is accomplished through software and allows faults or the manifestation of faults to be inserted by either seeding faults into memory or triggering error detection mechanisms. FIAT is capable of emulating a variety of fault-tolerant strategies and architectures, can monitor system activity, and can automatically orchestrate experiments involving insertion of faults. There is a common system interface which allows ease of use to decrease experiment development and run time. Fault models chosen for experiments on FIAT have generated system responses which parallel those observed in real systems under faulty conditions. These capabilities are shown by two example experiments each using a different fault-tolerance strategy.

[Diagnostic Errors in Medicine].

PubMed

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.

Rates and patterns of surface deformation from laser scanning following the South Napa earthquake, California

USGS Publications Warehouse

DeLong, Stephen B.; Lienkaemper, James J.; Pickering, Alexandra J; Avdievitch, Nikita N.

2015-01-01

The A.D. 2014 M6.0 South Napa earthquake, despite its moderate magnitude, caused significant damage to the Napa Valley in northern California (USA). Surface rupture occurred along several mapped and unmapped faults. Field observations following the earthquake indicated that the magnitude of postseismic surface slip was likely to approach or exceed the maximum coseismic surface slip and as such presented ongoing hazard to infrastructure. Using a laser scanner, we monitored postseismic deformation in three dimensions through time along 0.5 km of the main surface rupture. A key component of this study is the demonstration of proper alignment of repeat surveys using point cloud–based methods that minimize error imposed by both local survey errors and global navigation satellite system georeferencing errors. Using solid modeling of natural and cultural features, we quantify dextral postseismic displacement at several hundred points near the main fault trace. We also quantify total dextral displacement of initially straight cultural features. Total dextral displacement from both coseismic displacement and the first 2.5 d of postseismic displacement ranges from 0.22 to 0.29 m. This range increased to 0.33–0.42 m at 59 d post-earthquake. Furthermore, we estimate up to 0.15 m of vertical deformation during the first 2.5 d post-earthquake, which then increased by ∼0.02 m at 59 d post-earthquake. This vertical deformation is not expressed as a distinct step or scarp at the fault trace but rather as a broad up-to-the-west zone of increasing elevation change spanning the fault trace over several tens of meters, challenging common notions about fault scarp development in strike-slip systems. Integrating these analyses provides three-dimensional mapping of surface deformation and identifies spatial variability in slip along the main fault trace that we attribute to distributed slip via subtle block rotation. These results indicate the benefits of laser scanner surveys along active faults and demonstrate that fine-scale variability in fault slip has been missed by traditional earthquake response methods.

Robust fault tolerant control based on sliding mode method for uncertain linear systems with quantization.

PubMed

Hao, Li-Ying; Yang, Guang-Hong

2013-09-01

This paper is concerned with the problem of robust fault-tolerant compensation control problem for uncertain linear systems subject to both state and input signal quantization. By incorporating novel matrix full-rank factorization technique with sliding surface design successfully, the total failure of certain actuators can be coped with, under a special actuator redundancy assumption. In order to compensate for quantization errors, an adjustment range of quantization sensitivity for a dynamic uniform quantizer is given through the flexible choices of design parameters. Comparing with the existing results, the derived inequality condition leads to the fault tolerance ability stronger and much wider scope of applicability. With a static adjustment policy of quantization sensitivity, an adaptive sliding mode controller is then designed to maintain the sliding mode, where the gain of the nonlinear unit vector term is updated automatically to compensate for the effects of actuator faults, quantization errors, exogenous disturbances and parameter uncertainties without the need for a fault detection and isolation (FDI) mechanism. Finally, the effectiveness of the proposed design method is illustrated via a model of a rocket fairing structural-acoustic. Copyright © 2013 ISA. Published by Elsevier Ltd. All rights reserved.

A multiple fault rupture model of the November 13 2016, M 7.8 Kaikoura earthquake, New Zealand

NASA Astrophysics Data System (ADS)

Benites, R. A.; Francois-Holden, C.; Langridge, R. M.; Kaneko, Y.; Fry, B.; Kaiser, A. E.; Caldwell, T. G.

2017-12-01

The rupture-history of the November 13 2016 MW7.8 Kaikoura earthquake recorded by near- and intermediate-field strong-motion seismometers and 2 high-rate GPS stations reveals a complex cascade of multiple crustal fault rupture. In spite of such complexity, we show that the rupture history of each fault is well approximated by simple kinematic model with uniform slip and rupture velocity. Using 9 faults embedded in a crustal layer 19 km thick, each with a prescribed slip vector and rupture velocity, this model accurately reproduces the displacement waveforms recorded at the near-field strong-motion and GPS stations. This model includes the `Papatea Fault' with a mixed thrust and strike-slip mechanism based on in-situ geological observations with up to 8 m of uplift observed. Although the kinematic model fits the ground-motion at the nearest strong station, it doesn not reproduce the one sided nature of the static deformation field observed geodetically. This suggests a dislocation based approach does not completely capture the mechanical response of the Papatea Fault. The fault system as a whole extends for approximately 150 km along the eastern side of the Marlborough fault system in the South Island of New Zealand. The total duration of the rupture was 74 seconds. The timing and location of each fault's rupture suggests fault interaction and triggering resulting in a northward cascade crustal ruptures. Our model does not require rupture of the underlying subduction interface to explain the data.

Low-Power Fault Tolerance for Spacecraft FPGA-Based Numerical Computing

DTIC Science & Technology

2006-09-01

Ranganathan , “Power Management – Guest Lecture for CS4135, NPS,” Naval Postgraduate School, Nov 2004 [32] R. L. Phelps, “Operational Experiences with the...4302, and to the Office of Management and Budget, Paperwork Reduction Project (0704-0188) Washington DC 20503. 1. AGENCY USE ONLY (Leave blank) 2...undesirable, are not necessarily harmful. Our intent is to prevent errors by properly managing faults. This research focuses on developing fault-tolerant

Managing systems faults on the commercial flight deck: Analysis of pilots' organization and prioritization of fault management information

NASA Technical Reports Server (NTRS)

Rogers, William H.

1993-01-01

In rare instances, flight crews of commercial aircraft must manage complex systems faults in addition to all their normal flight tasks. Pilot errors in fault management have been attributed, at least in part, to an incomplete or inaccurate awareness of the fault situation. The current study is part of a program aimed at assuring that the types of information potentially available from an intelligent fault management aiding concept developed at NASA Langley called 'Faultfinde' (see Abbott, Schutte, Palmer, and Ricks, 1987) are an asset rather than a liability: additional information should improve pilot performance and aircraft safety, but it should not confuse, distract, overload, mislead, or generally exacerbate already difficult circumstances.

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

PubMed Central

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

2017-01-01

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

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

PubMed

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

2017-08-01

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

An advanced SEU tolerant latch based on error detection

NASA Astrophysics Data System (ADS)

Xu, Hui; Zhu, Jianwei; Lu, Xiaoping; Li, Jingzhao

2018-05-01

This paper proposes a latch that can mitigate SEUs via an error detection circuit. The error detection circuit is hardened by a C-element and a stacked PMOS. In the hold state, a particle strikes the latch or the error detection circuit may cause a fault logic state of the circuit. The error detection circuit can detect the upset node in the latch and the fault output will be corrected. The upset node in the error detection circuit can be corrected by the C-element. The power dissipation and propagation delay of the proposed latch are analyzed by HSPICE simulations. The proposed latch consumes about 77.5% less energy and 33.1% less propagation delay than the triple modular redundancy (TMR) latch. Simulation results demonstrate that the proposed latch can mitigate SEU effectively. Project supported by the National Natural Science Foundation of China (Nos. 61404001, 61306046), the Anhui Province University Natural Science Research Major Project (No. KJ2014ZD12), the Huainan Science and Technology Program (No. 2013A4011), and the National Natural Science Foundation of China (No. 61371025).

Detection and Correction of Silent Data Corruption for Large-Scale High-Performance Computing

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

Fiala, David J; Mueller, Frank; Engelmann, Christian

Faults have become the norm rather than the exception for high-end computing on clusters with 10s/100s of thousands of cores. Exacerbating this situation, some of these faults remain undetected, manifesting themselves as silent errors that corrupt memory while applications continue to operate and report incorrect results. This paper studies the potential for redundancy to both detect and correct soft errors in MPI message-passing applications. Our study investigates the challenges inherent to detecting soft errors within MPI application while providing transparent MPI redundancy. By assuming a model wherein corruption in application data manifests itself by producing differing MPI message data betweenmore » replicas, we study the best suited protocols for detecting and correcting MPI data that is the result of corruption. To experimentally validate our proposed detection and correction protocols, we introduce RedMPI, an MPI library which resides in the MPI profiling layer. RedMPI is capable of both online detection and correction of soft errors that occur in MPI applications without requiring any modifications to the application source by utilizing either double or triple redundancy. Our results indicate that our most efficient consistency protocol can successfully protect applications experiencing even high rates of silent data corruption with runtime overheads between 0% and 30% as compared to unprotected applications without redundancy. Using our fault injector within RedMPI, we observe that even a single soft error can have profound effects on running applications, causing a cascading pattern of corruption in most cases causes that spreads to all other processes. RedMPI's protection has been shown to successfully mitigate the effects of soft errors while allowing applications to complete with correct results even in the face of errors.« less

Human Factors Risk Analyses of a Doffing Protocol for Ebola-Level Personal Protective Equipment: Mapping Errors to Contamination.

PubMed

Mumma, Joel M; Durso, Francis T; Ferguson, Ashley N; Gipson, Christina L; Casanova, Lisa; Erukunuakpor, Kimberly; Kraft, Colleen S; Walsh, Victoria L; Zimring, Craig; DuBose, Jennifer; Jacob, Jesse T

2018-03-05

Doffing protocols for personal protective equipment (PPE) are critical for keeping healthcare workers (HCWs) safe during care of patients with Ebola virus disease. We assessed the relationship between errors and self-contamination during doffing. Eleven HCWs experienced with doffing Ebola-level PPE participated in simulations in which HCWs donned PPE marked with surrogate viruses (ɸ6 and MS2), completed a clinical task, and were assessed for contamination after doffing. Simulations were video recorded, and a failure modes and effects analysis and fault tree analyses were performed to identify errors during doffing, quantify their risk (risk index), and predict contamination data. Fifty-one types of errors were identified, many having the potential to spread contamination. Hand hygiene and removing the powered air purifying respirator (PAPR) hood had the highest total risk indexes (111 and 70, respectively) and number of types of errors (9 and 13, respectively). ɸ6 was detected on 10% of scrubs and the fault tree predicted a 10.4% contamination rate, likely occurring when the PAPR hood inadvertently contacted scrubs during removal. MS2 was detected on 10% of hands, 20% of scrubs, and 70% of inner gloves and the predicted rates were 7.3%, 19.4%, 73.4%, respectively. Fault trees for MS2 and ɸ6 contamination suggested similar pathways. Ebola-level PPE can both protect and put HCWs at risk for self-contamination throughout the doffing process, even among experienced HCWs doffing with a trained observer. Human factors methodologies can identify error-prone steps, delineate the relationship between errors and self-contamination, and suggest remediation strategies.

Reliability of clinical impact grading by healthcare professionals of common prescribing error and optimisation cases in critical care patients.

PubMed

Bourne, Richard S; Shulman, Rob; Tomlin, Mark; Borthwick, Mark; Berry, Will; Mills, Gary H

2017-04-01

To identify between and within profession-rater reliability of clinical impact grading for common critical care prescribing error and optimisation cases. To identify representative clinical impact grades for each individual case. Electronic questionnaire. 5 UK NHS Trusts. 30 Critical care healthcare professionals (doctors, pharmacists and nurses). Participants graded severity of clinical impact (5-point categorical scale) of 50 error and 55 optimisation cases. Case between and within profession-rater reliability and modal clinical impact grading. Between and within profession rater reliability analysis used linear mixed model and intraclass correlation, respectively. The majority of error and optimisation cases (both 76%) had a modal clinical severity grade of moderate or higher. Error cases: doctors graded clinical impact significantly lower than pharmacists (-0.25; P < 0.001) and nurses (-0.53; P < 0.001), with nurses significantly higher than pharmacists (0.28; P < 0.001). Optimisation cases: doctors graded clinical impact significantly lower than nurses and pharmacists (-0.39 and -0.5; P < 0.001, respectively). Within profession reliability grading was excellent for pharmacists (0.88 and 0.89; P < 0.001) and doctors (0.79 and 0.83; P < 0.001) but only fair to good for nurses (0.43 and 0.74; P < 0.001), for optimisation and error cases, respectively. Representative clinical impact grades for over 100 common prescribing error and optimisation cases are reported for potential clinical practice and research application. The between professional variability highlights the importance of multidisciplinary perspectives in assessment of medication error and optimisation cases in clinical practice and research. © The Author 2017. Published by Oxford University Press in association with the International Society for Quality in Health Care. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com

22 CFR 34.18 - Waivers of indebtedness.

Code of Federal Regulations, 2010 CFR

2010-04-01

... there exists in connection with the claim an indication of fraud, misrepresentation, fault, or lack of... known through the exercise of due diligence that an error existed but failed to take corrective action... payment. (iv) If the deciding official finds no indication of fraud, misrepresentation, fault, or lack of...

Systemic fluoroquinolone prescriptions for hospitalized children in Belgium, results of a multicenter retrospective drug utilization study.

PubMed

Meesters, Kevin; Mauel, Reiner; Dhont, Evelyn; Walle, Johan Vande; De Bruyne, Pauline

2018-02-23

Fluoroquinolones (FQ) are increasingly prescribed for children, despite being labeled for only a limited number of labeled pediatric indications. In this multicenter retrospective drug utilization study, we analyzed indications for systemic FQ prescriptions in hospitalized children and the appropriateness of the prescribed dose. Using data obtained from electronic medical files, the study included all children who received a systemic FQ prescription in two Belgian university children's hospitals between 2010 and 2013. Two authors reviewed prescribed daily doses. Univariate and multivariate logistic regression models were used to analyze risk factors for inadequately dosing. Results262 FQ prescriptions for individual patients were included for analysis. 16.8% of these prescriptions were for labeled indications, and 35.1% were guided by bacteriological findings. Prescribed daily dose was considered to be inappropriate in 79 prescriptions (30.2%). Other FQ than ciprofloxacin accounted for 9 prescriptions (3.4%), of which 8 were correctly dosed. Underdosing represented 45 (56.9%) dosing errors. Infants and preschool children were at particular risk for dosing errors, with associated adjusted OR of 0.263 (0.097-0.701) and 0.254 (0.106-0.588) respectively. FQ were often prescribed off-label and not guided by bacteriological findings in our study population. Dosing errors were common, particularly in infants and preschool children. FQ prescriptions for children should be improved by specific pediatric antimicrobial stewardship teams. Furthermore, pharmacokinetic studies should optimise dosing recommendations for children.

A smart medication recommendation model for the electronic prescription.

PubMed

Syed-Abdul, Shabbir; Nguyen, Alex; Huang, Frank; Jian, Wen-Shan; Iqbal, Usman; Yang, Vivian; Hsu, Min-Huei; Li, Yu-Chuan

2014-11-01

The report from the Institute of Medicine, To Err Is Human: Building a Safer Health System in 1999 drew a special attention towards preventable medical errors and patient safety. The American Reinvestment and Recovery Act of 2009 and federal criteria of 'Meaningful use' stage 1 mandated e-prescribing to be used by eligible providers in order to access Medicaid and Medicare incentive payments. Inappropriate prescribing has been identified as a preventable cause of at least 20% of drug-related adverse events. A few studies reported system-related errors and have offered targeted recommendations on improving and enhancing e-prescribing system. This study aims to enhance efficiency of the e-prescribing system by shortening the medication list, reducing the risk of inappropriate selection of medication, as well as in reducing the prescribing time of physicians. 103.48 million prescriptions from Taiwan's national health insurance claim data were used to compute Diagnosis-Medication association. Furthermore, 100,000 prescriptions were randomly selected to develop a smart medication recommendation model by using association rules of data mining. The important contribution of this model is to introduce a new concept called Mean Prescription Rank (MPR) of prescriptions and Coverage Rate (CR) of prescriptions. A proactive medication list (PML) was computed using MPR and CR. With this model the medication drop-down menu is significantly shortened, thereby reducing medication selection errors and prescription times. The physicians will still select relevant medications even in the case of inappropriate (unintentional) selection. Copyright © 2014 Elsevier Ireland Ltd. All rights reserved.

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

PubMed

Wu, Xue; Wu, Changxu

2017-01-01

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

Application of a Bank of Kalman Filters for Aircraft Engine Fault Diagnostics

NASA Technical Reports Server (NTRS)

Kobayashi, Takahisa; Simon, Donald L.

2003-01-01

In this paper, a bank of Kalman filters is applied to aircraft gas turbine engine sensor and actuator fault detection and isolation (FDI) in conjunction with the detection of component faults. This approach uses multiple Kalman filters, each of which is designed for detecting a specific sensor or actuator fault. In the event that a fault does occur, all filters except the one using the correct hypothesis will produce large estimation errors, thereby isolating the specific fault. In the meantime, a set of parameters that indicate engine component performance is estimated for the detection of abrupt degradation. The proposed FDI approach is applied to a nonlinear engine simulation at nominal and aged conditions, and the evaluation results for various engine faults at cruise operating conditions are given. The ability of the proposed approach to reliably detect and isolate sensor and actuator faults is demonstrated.

Automatic Generation Control Study in Two Area Reheat Thermal Power System

NASA Astrophysics Data System (ADS)

Pritam, Anita; Sahu, Sibakanta; Rout, Sushil Dev; Ganthia, Sibani; Prasad Ganthia, Bibhu

2017-08-01

Due to industrial pollution our living environment destroyed. An electric grid system has may vital equipment like generator, motor, transformers and loads. There is always be an imbalance between sending end and receiving end system which cause system unstable. So this error and fault causing problem should be solved and corrected as soon as possible else it creates faults and system error and fall of efficiency of the whole power system. The main problem developed from this fault is deviation of frequency cause instability to the power system and may cause permanent damage to the system. Therefore this mechanism studied in this paper make the system stable and balance by regulating frequency at both sending and receiving end power system using automatic generation control using various controllers taking a two area reheat thermal power system into account.

Adaptive robust fault tolerant control design for a class of nonlinear uncertain MIMO systems with quantization.

PubMed

Ao, Wei; Song, Yongdong; Wen, Changyun

2017-05-01

In this paper, we investigate the adaptive control problem for a class of nonlinear uncertain MIMO systems with actuator faults and quantization effects. Under some mild conditions, an adaptive robust fault-tolerant control is developed to compensate the affects of uncertainties, actuator failures and errors caused by quantization, and a range of the parameters for these quantizers is established. Furthermore, a Lyapunov-like approach is adopted to demonstrate that the ultimately uniformly bounded output tracking error is guaranteed by the controller, and the signals of the closed-loop system are ensured to be bounded, even in the presence of at most m-q actuators stuck or outage. Finally, numerical simulations are provided to verify and illustrate the effectiveness of the proposed adaptive schemes. Copyright © 2017 ISA. Published by Elsevier Ltd. All rights reserved.

Technical Basis for Evaluating Software-Related Common-Cause Failures

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

Muhlheim, Michael David; Wood, Richard

2016-04-01

The instrumentation and control (I&C) system architecture at a nuclear power plant (NPP) incorporates protections against common-cause failures (CCFs) through the use of diversity and defense-in-depth. Even for well-established analog-based I&C system designs, the potential for CCFs of multiple systems (or redundancies within a system) constitutes a credible threat to defeating the defense-in-depth provisions within the I&C system architectures. The integration of digital technologies into the I&C systems provides many advantages compared to the aging analog systems with respect to reliability, maintenance, operability, and cost effectiveness. However, maintaining the diversity and defense-in-depth for both the hardware and software within themore » digital system is challenging. In fact, the introduction of digital technologies may actually increase the potential for CCF vulnerabilities because of the introduction of undetected systematic faults. These systematic faults are defined as a “design fault located in a software component” and at a high level, are predominately the result of (1) errors in the requirement specification, (2) inadequate provisions to account for design limits (e.g., environmental stress), or (3) technical faults incorporated in the internal system (or architectural) design or implementation. Other technology-neutral CCF concerns include hardware design errors, equipment qualification deficiencies, installation or maintenance errors, instrument loop scaling and setpoint mistakes.« less

An Intelligent Actuator Fault Reconstruction Scheme for Robotic Manipulators.

PubMed

Xiao, Bing; Yin, Shen

2018-02-01

This paper investigates a difficult problem of reconstructing actuator faults for robotic manipulators. An intelligent approach with fast reconstruction property is developed. This is achieved by using observer technique. This scheme is capable of precisely reconstructing the actual actuator fault. It is shown by Lyapunov stability analysis that the reconstruction error can converge to zero after finite time. A perfect reconstruction performance including precise and fast properties can be provided for actuator fault. The most important feature of the scheme is that, it does not depend on control law, dynamic model of actuator, faults' type, and also their time-profile. This super reconstruction performance and capability of the proposed approach are further validated by simulation and experimental results.

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

PubMed

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

2017-01-01

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

Applying fault tree analysis to the prevention of wrong-site surgery.

PubMed

Abecassis, Zachary A; McElroy, Lisa M; Patel, Ronak M; Khorzad, Rebeca; Carroll, Charles; Mehrotra, Sanjay

2015-01-01

Wrong-site surgery (WSS) is a rare event that occurs to hundreds of patients each year. Despite national implementation of the Universal Protocol over the past decade, development of effective interventions remains a challenge. We performed a systematic review of the literature reporting root causes of WSS and used the results to perform a fault tree analysis to assess the reliability of the system in preventing WSS and identifying high-priority targets for interventions aimed at reducing WSS. Process components where a single error could result in WSS were labeled with OR gates; process aspects reinforced by verification were labeled with AND gates. The overall redundancy of the system was evaluated based on prevalence of AND gates and OR gates. In total, 37 studies described risk factors for WSS. The fault tree contains 35 faults, most of which fall into five main categories. Despite the Universal Protocol mandating patient verification, surgical site signing, and a brief time-out, a large proportion of the process relies on human transcription and verification. Fault tree analysis provides a standardized perspective of errors or faults within the system of surgical scheduling and site confirmation. It can be adapted by institutions or specialties to lead to more targeted interventions to increase redundancy and reliability within the preoperative process. Copyright © 2015 Elsevier Inc. All rights reserved.

Algorithm-Based Fault Tolerance Integrated with Replication

NASA Technical Reports Server (NTRS)

Some, Raphael; Rennels, David

2008-01-01

In a proposed approach to programming and utilization of commercial off-the-shelf computing equipment, a combination of algorithm-based fault tolerance (ABFT) and replication would be utilized to obtain high degrees of fault tolerance without incurring excessive costs. The basic idea of the proposed approach is to integrate ABFT with replication such that the algorithmic portions of computations would be protected by ABFT, and the logical portions by replication. ABFT is an extremely efficient, inexpensive, high-coverage technique for detecting and mitigating faults in computer systems used for algorithmic computations, but does not protect against errors in logical operations surrounding algorithms.

Clinical review: Medication errors in critical care

PubMed Central

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

2008-01-01

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

Probabilistic evaluation of on-line checks in fault-tolerant multiprocessor systems

NASA Technical Reports Server (NTRS)

Nair, V. S. S.; Hoskote, Yatin V.; Abraham, Jacob A.

1992-01-01

The analysis of fault-tolerant multiprocessor systems that use concurrent error detection (CED) schemes is much more difficult than the analysis of conventional fault-tolerant architectures. Various analytical techniques have been proposed to evaluate CED schemes deterministically. However, these approaches are based on worst-case assumptions related to the failure of system components. Often, the evaluation results do not reflect the actual fault tolerance capabilities of the system. A probabilistic approach to evaluate the fault detecting and locating capabilities of on-line checks in a system is developed. The various probabilities associated with the checking schemes are identified and used in the framework of the matrix-based model. Based on these probabilistic matrices, estimates for the fault tolerance capabilities of various systems are derived analytically.

Conjugated π electron engineering of generalized stacking fault in graphene and h-BN.

PubMed

Ouyang, Bin; Chen, Cheng; Song, J

2018-03-02

Generalized-stacking-fault energy (GSFE) serves as an important metric that prescribes dislocation behaviors in materials. In this paper, utilizing first-principle calculations and chemical bonding analysis, we studied the behaviors of generalized stacking fault in graphene and h-BN. It has been shown that the π bond formation plays a critical role in the existence of metastable stacking fault (MSF) in graphene and h-BN lattice along certain slip directions. Chemical functionalization was then proposed as an effective means to engineer the π bond, and subsequently MSF along dislocation slips within graphene and h-BN. Taking hydrogenation as a representative functionalization method, we demonstrated that, with the preferential adsorption of hydrogen along the slip line, π electrons along the slip would be saturated by adsorbed hydrogen atoms, leading to the moderation or elimination of MSF. Our study elucidates the atomic mechanism of MSF formation in graphene-like materials, and more generally, provides important insights towards predictive tuning of mechanic properties in two-dimensional nanomaterials.

Conjugated π electron engineering of generalized stacking fault in graphene and h-BN

NASA Astrophysics Data System (ADS)

Ouyang, Bin; Chen, Cheng; Song, J.

2018-03-01

Generalized-stacking-fault energy (GSFE) serves as an important metric that prescribes dislocation behaviors in materials. In this paper, utilizing first-principle calculations and chemical bonding analysis, we studied the behaviors of generalized stacking fault in graphene and h-BN. It has been shown that the π bond formation plays a critical role in the existence of metastable stacking fault (MSF) in graphene and h-BN lattice along certain slip directions. Chemical functionalization was then proposed as an effective means to engineer the π bond, and subsequently MSF along dislocation slips within graphene and h-BN. Taking hydrogenation as a representative functionalization method, we demonstrated that, with the preferential adsorption of hydrogen along the slip line, π electrons along the slip would be saturated by adsorbed hydrogen atoms, leading to the moderation or elimination of MSF. Our study elucidates the atomic mechanism of MSF formation in graphene-like materials, and more generally, provides important insights towards predictive tuning of mechanic properties in two-dimensional nanomaterials.

High-Threshold Fault-Tolerant Quantum Computation with Analog Quantum Error Correction

NASA Astrophysics Data System (ADS)

Fukui, Kosuke; Tomita, Akihisa; Okamoto, Atsushi; Fujii, Keisuke

2018-04-01

To implement fault-tolerant quantum computation with continuous variables, the Gottesman-Kitaev-Preskill (GKP) qubit has been recognized as an important technological element. However, it is still challenging to experimentally generate the GKP qubit with the required squeezing level, 14.8 dB, of the existing fault-tolerant quantum computation. To reduce this requirement, we propose a high-threshold fault-tolerant quantum computation with GKP qubits using topologically protected measurement-based quantum computation with the surface code. By harnessing analog information contained in the GKP qubits, we apply analog quantum error correction to the surface code. Furthermore, we develop a method to prevent the squeezing level from decreasing during the construction of the large-scale cluster states for the topologically protected, measurement-based, quantum computation. We numerically show that the required squeezing level can be relaxed to less than 10 dB, which is within the reach of the current experimental technology. Hence, this work can considerably alleviate this experimental requirement and take a step closer to the realization of large-scale quantum computation.

Resolution analysis of finite fault source inversion using one- and three-dimensional Green's functions 2. Combining seismic and geodetic data

USGS Publications Warehouse

Wald, D.J.; Graves, R.W.

2001-01-01

Using numerical tests for a prescribed heterogeneous earthquake slip distribution, we examine the importance of accurate Green's functions (GF) for finite fault source inversions which rely on coseismic GPS displacements and leveling line uplift alone and in combination with near-source strong ground motions. The static displacements, while sensitive to the three-dimensional (3-D) structure, are less so than seismic waveforms and thus are an important contribution, particularly when used in conjunction with waveform inversions. For numerical tests of an earthquake source and data distribution modeled after the 1994 Northridge earthquake, a joint geodetic and seismic inversion allows for reasonable recovery of the heterogeneous slip distribution on the fault. In contrast, inaccurate 3-D GFs or multiple 1-D GFs allow only partial recovery of the slip distribution given strong motion data alone. Likewise, using just the GPS and leveling line data requires significant smoothing for inversion stability, and hence, only a blurred vision of the prescribed slip is recovered. Although the half-space approximation for computing the surface static deformation field is no longer justifiable based on the high level of accuracy for current GPS data acquisition and the computed differences between 3-D and half-space surface displacements, a layered 1-D approximation to 3-D Earth structure provides adequate representation of the surface displacement field. However, even with the half-space approximation, geodetic data can provide additional slip resolution in the joint seismic and geodetic inversion provided a priori fault location and geometry are correct. Nevertheless, the sensitivity of the static displacements to the Earth structure begs caution for interpretation of surface displacements, particularly those recorded at monuments located in or near basin environments. Copyright 2001 by the American Geophysical Union.

Drug utilization, prescription errors and potential drug-drug interactions: an experience in rural Sri Lanka.

PubMed

Rathish, Devarajan; Bahini, Sivaswamy; Sivakumar, Thanikai; Thiranagama, Thilani; Abarajithan, Tharmarajah; Wijerathne, Buddhika; Jayasumana, Channa; Siribaddana, Sisira

2016-06-25

Prescription writing is a process which transfers the therapeutic message from the prescriber to the patient through the pharmacist. Prescribing errors, drug duplication and potential drug-drug interactions (pDDI) in prescriptions lead to medication error. Assessment of the above was made in prescriptions dispensed at State Pharmaceutical Corporation (SPC), Anuradhapura, Sri Lanka. A cross sectional study was conducted. Drugs were classified according to the WHO anatomical, therapeutic chemical classification system. A three point Likert scale, a checklist and Medscape online drug interaction checker were used to assess legibility, completeness and pDDIs respectively. Thousand prescriptions were collected. Majority were hand written (99.8 %) and from the private sector (73 %). The most frequently prescribed substance and subgroup were atorvastatin (4 %, n = 3668) and proton pump inhibitors (7 %, n = 3668) respectively. Out of the substances prescribed from the government and private sectors, 59 and 50 % respectively were available in the national list of essential medicines, Sri Lanka. Patients address (5 %), Sri Lanka Medical Council (SLMC) registration number (35 %), route (7 %), generic name (16 %), treatment symbol (48 %), diagnosis (41 %) and refill information (6 %) were seen in less than half of the prescriptions. Most were legible with effort (65 %) and illegibility was seen in 9 %. There was significant difference in omission and/or errors of generic name (P = 0.000), dose (P = 0.000), SLMC registration number (P = 0.000), and in evidence of pDDI (P = 0.009) with regards to the sector of prescribing. The commonest subgroup involved in duplication was non-steroidal anti-inflammatory drugs (NSAIDs) (43 %; 56/130). There were 1376 potential drug interactions (466/887 prescriptions). Most common pair causing pDDI was aspirin with losartan (4 %, n = 1376). Atorvastatin was the most frequently prescribed substance. Fifteen percent of the prescriptions originate from government sector. SLMC registration number and trade names were seen more in prescriptions originating from the private sector. Most prescriptions were legible with effort. NSAIDs were the commonest implicated in drug class duplication. Fifty three percent of prescriptions have pDDI.

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

PubMed

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

2014-01-01

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

[Dietetic assessment of patients with gastroenterologic diseases at the out-patient service of the Institute National of Sciences Medicine and Nutrition Salvador Zubiran].

PubMed

de la Cruz Góngora, Vanesa Vianey; Pando Aguilar, Nancy Esther; Milke García, Pilar; Vargas-Voráková, Florencia

2003-01-01

Assessment of dietetic management is necessary for detection/correction of faults and best care of patients. Our aim was to evaluate dietetic management and nutritional status of gastroenterologic patients. Anthropometric, clinical-nutritional, biochemical, and dietetic parameters were assessed in 110 patients (150 with liver cirrhosis [LC], 30 with inflammatory bowel disease [IBD], and 30 with chronic and skin. In CP, prescribed energy, g and % carbohydrates and lipids were less than ideal and proteins were greater; in cirrhotics, less proteins and a great % of carbohydrates were prescribed; in IBD fewer lipids and more proteins than ideal were prescribed. Cirrhotics usually consumed less fat (g) and more proteins than prescribed, and patients with CP and IBD a greater amount of carbohydrates than prescribed. Cirrhotics consumed more % carbohydrates and < % lipids than ideal; CP patients lipid intake was less and protein intake above ideal and in IBD, carbohydrate intake was greater and lipid intake lower than ideal. Anthropometric and biochemical parameters were not useful for assessment of these patients. Prescribed diet was too restricted regarding proteins in LC and was inadequate in energy/nutrients in patients with CP. Fewer lipids and more proteins were prescribed in IBD. The inadequacy of prescripted diet, lack of information regarding the person who prescribed it, and lack of constant supervision may cause non-adherence to diet and thus may affect nutritional status.

Fault detection for hydraulic pump based on chaotic parallel RBF network

NASA Astrophysics Data System (ADS)

Lu, Chen; Ma, Ning; Wang, Zhipeng

2011-12-01

In this article, a parallel radial basis function network in conjunction with chaos theory (CPRBF network) is presented, and applied to practical fault detection for hydraulic pump, which is a critical component in aircraft. The CPRBF network consists of a number of radial basis function (RBF) subnets connected in parallel. The number of input nodes for each RBF subnet is determined by different embedding dimension based on chaotic phase-space reconstruction. The output of CPRBF is a weighted sum of all RBF subnets. It was first trained using the dataset from normal state without fault, and then a residual error generator was designed to detect failures based on the trained CPRBF network. Then, failure detection can be achieved by the analysis of the residual error. Finally, two case studies are introduced to compare the proposed CPRBF network with traditional RBF networks, in terms of prediction and detection accuracy.

Fault-tolerant clock synchronization validation methodology. [in computer systems

NASA Technical Reports Server (NTRS)

Butler, Ricky W.; Palumbo, Daniel L.; Johnson, Sally C.

1987-01-01

A validation method for the synchronization subsystem of a fault-tolerant computer system is presented. The high reliability requirement of flight-crucial systems precludes the use of most traditional validation methods. The method presented utilizes formal design proof to uncover design and coding errors and experimentation to validate the assumptions of the design proof. The experimental method is described and illustrated by validating the clock synchronization system of the Software Implemented Fault Tolerance computer. The design proof of the algorithm includes a theorem that defines the maximum skew between any two nonfaulty clocks in the system in terms of specific system parameters. Most of these parameters are deterministic. One crucial parameter is the upper bound on the clock read error, which is stochastic. The probability that this upper bound is exceeded is calculated from data obtained by the measurement of system parameters. This probability is then included in a detailed reliability analysis of the system.

Interseismic strain accumulation across the Ashkabad fault (NE Iran) from MERIS-corrected ASAR data

NASA Astrophysics Data System (ADS)

Walters, R. J.; Elliott, J. R.; Li, Z.; Parsons, B. E.

2011-12-01

The right-lateral Ashkabad Fault separates deforming NE Iran from the stable Turkmenistan platform to the north, and also facilitates the north-westwards extrusion of the South Caspian block (along with the left-lateral Shahrud fault zone). The fault represents the northernmost boundary of significant deformation of the Arabia-Eurasia collision in NE Iran. The 1948 M 7.3 Ashkabad earthquake, which killed around 110,000 people and was the deadliest earthquake to hit Europe or the Middle East in the 20th Century, also possibly occurred on this fault. However, the slip rate and therefore the seismic hazard that the Ashkabad fault represents are not well known. GPS data in NE Iran are sparse, and there are no direct geological or quaternary rates for the main strand of the fault. We use Envisat ASAR data acquired between 2003 and 2010 to measure interseismic strain accumulation across the fault, and hence estimate the slip rate across it. Due to the proximity of this region to the Caspian Sea and the presence of highly variable weather systems, we use data from Envisat's Medium Resolution Imaging Spectrometer (MERIS) instrument, as well as modelled weather data from the European Centre for Medium-Range Weather Forecasting (ECMWF), to correct interferograms for differences in water vapour and atmospheric pressure. We mitigate the effects of remaining noise by summing the 13 corrected interferograms that cover the fault, effectively creating a 30 year interferogram with improved signal-to-noise ratio, and we empirically correct for orbital errors. Our measurements of rates of displacement are consistent with an interseismic model for the Ashkabad fault where deformation occurs at depth on a narrow shear zone below a layer in which the fault is locked. We invert the data to solve for best fitting model parameters, estimating both the slip rate and the depth to which the fault is locked. Our measurements show that the Ashkabad fault is accumulating strain at a rate of 9 mm/yr below a locking depth of 15 km. We use a Monte Carlo approach to estimate the errors on our best fit solution and find our data is consistent with 6-12 mm/yr slip rate and 8-25 km locking depth. Using an alternative jacknife approach we obtain ranges of 4-11 mm/yr and 9-18 km. Lyberis and Manby (1999, AAPG Bulletin 83: 1135-1160) proposed a slip rate of 3-8 mm/yr for the Ashkabad fault, based on an estimated offset and a likely age of onset for the fault. Masson et al. (2007, GJI 170:436-440) estimated a slip rate of 2-4 mm/yr from GPS data. Our best fit solution is higher, but within error our results are compatible with both of these previous estimates. In addition, GPS data from an unpublished PhD Thesis (Tavakoli, 2007, PhD Thesis, LGIT Grenoble) suggest slip rates of around 9 mm/yr, supporting our best fit slip rate.

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

PubMed Central

Misagh, Pegah; Vazin, Afsaneh; Namazi, Soha

2018-01-01

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

Comparative analysis of techniques for evaluating the effectiveness of aircraft computing systems

NASA Technical Reports Server (NTRS)

Hitt, E. F.; Bridgman, M. S.; Robinson, A. C.

1981-01-01

Performability analysis is a technique developed for evaluating the effectiveness of fault-tolerant computing systems in multiphase missions. Performability was evaluated for its accuracy, practical usefulness, and relative cost. The evaluation was performed by applying performability and the fault tree method to a set of sample problems ranging from simple to moderately complex. The problems involved as many as five outcomes, two to five mission phases, permanent faults, and some functional dependencies. Transient faults and software errors were not considered. A different analyst was responsible for each technique. Significantly more time and effort were required to learn performability analysis than the fault tree method. Performability is inherently as accurate as fault tree analysis. For the sample problems, fault trees were more practical and less time consuming to apply, while performability required less ingenuity and was more checkable. Performability offers some advantages for evaluating very complex problems.

Validation techniques for fault emulation of SRAM-based FPGAs

DOE PAGES

Quinn, Heather; Wirthlin, Michael

2015-08-07

A variety of fault emulation systems have been created to study the effect of single-event effects (SEEs) in static random access memory (SRAM) based field-programmable gate arrays (FPGAs). These systems are useful for augmenting radiation-hardness assurance (RHA) methodologies for verifying the effectiveness for mitigation techniques; understanding error signatures and failure modes in FPGAs; and failure rate estimation. For radiation effects researchers, it is important that these systems properly emulate how SEEs manifest in FPGAs. If the fault emulation systems does not mimic the radiation environment, the system will generate erroneous data and incorrect predictions of behavior of the FPGA inmore » a radiation environment. Validation determines whether the emulated faults are reasonable analogs to the radiation-induced faults. In this study we present methods for validating fault emulation systems and provide several examples of validated FPGA fault emulation systems.« less

Indirect adaptive fuzzy fault-tolerant tracking control for MIMO nonlinear systems with actuator and sensor failures.

PubMed

Bounemeur, Abdelhamid; Chemachema, Mohamed; Essounbouli, Najib

2018-05-10

In this paper, an active fuzzy fault tolerant tracking control (AFFTTC) scheme is developed for a class of multi-input multi-output (MIMO) unknown nonlinear systems in the presence of unknown actuator faults, sensor failures and external disturbance. The developed control scheme deals with four kinds of faults for both sensors and actuators. The bias, drift, and loss of accuracy additive faults are considered along with the loss of effectiveness multiplicative fault. A fuzzy adaptive controller based on back-stepping design is developed to deal with actuator failures and unknown system dynamics. However, an additional robust control term is added to deal with sensor faults, approximation errors, and external disturbances. Lyapunov theory is used to prove the stability of the closed loop system. Numerical simulations on a quadrotor are presented to show the effectiveness of the proposed approach. Copyright © 2018 ISA. Published by Elsevier Ltd. All rights reserved.

[Prospective assessment of medication errors in critically ill patients in a university hospital].

PubMed

Salazar L, Nicole; Jirón A, Marcela; Escobar O, Leslie; Tobar, Eduardo; Romero, Carlos

2011-11-01

Critically ill patients are especially vulnerable to medication errors (ME) due to their severe clinical situation and the complexities of their management. To determine the frequency and characteristics of ME and identify shortcomings in the processes of medication management in an Intensive Care Unit. During a 3 months period, an observational prospective and randomized study was carried out in the ICU of a university hospital. Every step of patient's medication management (prescription, transcription, dispensation, preparation and administration) was evaluated by an external trained professional. Steps with higher frequency of ME and their therapeutic groups involved were identified. Medications errors were classified according to the National Coordinating Council for Medication Error Reporting and Prevention. In 52 of 124 patients evaluated, 66 ME were found in 194 drugs prescribed. In 34% of prescribed drugs, there was at least 1 ME during its use. Half of ME occurred during medication administration, mainly due to problems in infusion rates and schedule times. Antibacterial drugs had the highest rate of ME. We found a 34% rate of ME per drug prescribed, which is in concordance with international reports. The identification of those steps more prone to ME in the ICU, will allow the implementation of an intervention program to improve the quality and security of medication management.

Analog-digital simulation of transient-induced logic errors and upset susceptibility of an advanced control system

NASA Technical Reports Server (NTRS)

Carreno, Victor A.; Choi, G.; Iyer, R. K.

1990-01-01

A simulation study is described which predicts the susceptibility of an advanced control system to electrical transients resulting in logic errors, latched errors, error propagation, and digital upset. The system is based on a custom-designed microprocessor and it incorporates fault-tolerant techniques. The system under test and the method to perform the transient injection experiment are described. Results for 2100 transient injections are analyzed and classified according to charge level, type of error, and location of injection.

An experiment in software reliability: Additional analyses using data from automated replications

NASA Technical Reports Server (NTRS)

Dunham, Janet R.; Lauterbach, Linda A.

1988-01-01

A study undertaken to collect software error data of laboratory quality for use in the development of credible methods for predicting the reliability of software used in life-critical applications is summarized. The software error data reported were acquired through automated repetitive run testing of three independent implementations of a launch interceptor condition module of a radar tracking problem. The results are based on 100 test applications to accumulate a sufficient sample size for error rate estimation. The data collected is used to confirm the results of two Boeing studies reported in NASA-CR-165836 Software Reliability: Repetitive Run Experimentation and Modeling, and NASA-CR-172378 Software Reliability: Additional Investigations into Modeling With Replicated Experiments, respectively. That is, the results confirm the log-linear pattern of software error rates and reject the hypothesis of equal error rates per individual fault. This rejection casts doubt on the assumption that the program's failure rate is a constant multiple of the number of residual bugs; an assumption which underlies some of the current models of software reliability. data raises new questions concerning the phenomenon of interacting faults.

Sliding Mode Fault Tolerant Control with Adaptive Diagnosis for Aircraft Engines

NASA Astrophysics Data System (ADS)

Xiao, Lingfei; Du, Yanbin; Hu, Jixiang; Jiang, Bin

2018-03-01

In this paper, a novel sliding mode fault tolerant control method is presented for aircraft engine systems with uncertainties and disturbances on the basis of adaptive diagnostic observer. By taking both sensors faults and actuators faults into account, the general model of aircraft engine control systems which is subjected to uncertainties and disturbances, is considered. Then, the corresponding augmented dynamic model is established in order to facilitate the fault diagnosis and fault tolerant controller design. Next, a suitable detection observer is designed to detect the faults effectively. Through creating an adaptive diagnostic observer and based on sliding mode strategy, the sliding mode fault tolerant controller is constructed. Robust stabilization is discussed and the closed-loop system can be stabilized robustly. It is also proven that the adaptive diagnostic observer output errors and the estimations of faults converge to a set exponentially, and the converge rate greater than some value which can be adjusted by choosing designable parameters properly. The simulation on a twin-shaft aircraft engine verifies the applicability of the proposed fault tolerant control method.

Simultaneous fault detection and control design for switched systems with two quantized signals.

PubMed

Li, Jian; Park, Ju H; Ye, Dan

2017-01-01

The problem of simultaneous fault detection and control design for switched systems with two quantized signals is presented in this paper. Dynamic quantizers are employed, respectively, before the output is passed to fault detector, and before the control input is transmitted to the switched system. Taking the quantized errors into account, the robust performance for this kind of system is given. Furthermore, sufficient conditions for the existence of fault detector/controller are presented in the framework of linear matrix inequalities, and fault detector/controller gains and the supremum of quantizer range are derived by a convex optimized method. Finally, two illustrative examples demonstrate the effectiveness of the proposed method. Copyright © 2016 ISA. Published by Elsevier Ltd. All rights reserved.

A review of the factors influencing antimicrobial prescribing.

PubMed

Calbo, Esther; Alvarez-Rocha, Luis; Gudiol, Francisco; Pasquau, Juan

2013-09-01

There are multiple benefits of appropriate antimicrobial prescribing: it has a direct impact on clinical outcomes, avoids adverse effects, is cost effective and, perhaps most importantly, it helps to prevent the emergence of resistance. However, any physician can prescribe antibiotics, which is not the case with other clinically relevant drugs. There is great variability in the prescribing physician's (PP) training, motivation, workload and setting, including accessibility to infectious diseases consultants and/or diagnostic techniques, and therefore there is a high risk of inappropriate prescription. Many antibiotic prescribing errors occur around the selection and duration of treatment. This includes a low threshold for the indication of antibiotics, delayed initiation of treatment when indicated, limited knowledge of local antimicrobial resistance patterns by the PPs, errors in the final choice of dose, route or drug and a lack of de-escalation. Similarly, the prescription of prophylactic antibiotics to prevent surgical site infections, despite being commonly accepted, is suboptimal. Factors that may explain suboptimal use are related to the absence of well-defined protocols, poor knowledge of prophylactic protocols, miscommunication or disagreement between physicians, logistical problems, and a lack of audits. A proper understanding of the prescribing process can guide interventions to improve the PP's practices. Some of the potential interventions included in a stewardship program are education in antimicrobial prescribing, information on the local resistance patterns and accessibility to a qualified infectious diseases consultant. Copyright © 2013 Elsevier España, S.L. All rights reserved.

An Autonomous Self-Aware and Adaptive Fault Tolerant Routing Technique for Wireless Sensor Networks

PubMed Central

Abba, Sani; Lee, Jeong-A

2015-01-01

We propose an autonomous self-aware and adaptive fault-tolerant routing technique (ASAART) for wireless sensor networks. We address the limitations of self-healing routing (SHR) and self-selective routing (SSR) techniques for routing sensor data. We also examine the integration of autonomic self-aware and adaptive fault detection and resiliency techniques for route formation and route repair to provide resilience to errors and failures. We achieved this by using a combined continuous and slotted prioritized transmission back-off delay to obtain local and global network state information, as well as multiple random functions for attaining faster routing convergence and reliable route repair despite transient and permanent node failure rates and efficient adaptation to instantaneous network topology changes. The results of simulations based on a comparison of the ASAART with the SHR and SSR protocols for five different simulated scenarios in the presence of transient and permanent node failure rates exhibit a greater resiliency to errors and failure and better routing performance in terms of the number of successfully delivered network packets, end-to-end delay, delivered MAC layer packets, packet error rate, as well as efficient energy conservation in a highly congested, faulty, and scalable sensor network. PMID:26295236

An Autonomous Self-Aware and Adaptive Fault Tolerant Routing Technique for Wireless Sensor Networks.

PubMed

Abba, Sani; Lee, Jeong-A

2015-08-18

We propose an autonomous self-aware and adaptive fault-tolerant routing technique (ASAART) for wireless sensor networks. We address the limitations of self-healing routing (SHR) and self-selective routing (SSR) techniques for routing sensor data. We also examine the integration of autonomic self-aware and adaptive fault detection and resiliency techniques for route formation and route repair to provide resilience to errors and failures. We achieved this by using a combined continuous and slotted prioritized transmission back-off delay to obtain local and global network state information, as well as multiple random functions for attaining faster routing convergence and reliable route repair despite transient and permanent node failure rates and efficient adaptation to instantaneous network topology changes. The results of simulations based on a comparison of the ASAART with the SHR and SSR protocols for five different simulated scenarios in the presence of transient and permanent node failure rates exhibit a greater resiliency to errors and failure and better routing performance in terms of the number of successfully delivered network packets, end-to-end delay, delivered MAC layer packets, packet error rate, as well as efficient energy conservation in a highly congested, faulty, and scalable sensor network.

Sensor fault detection and recovery in satellite attitude control

NASA Astrophysics Data System (ADS)

Nasrolahi, Seiied Saeed; Abdollahi, Farzaneh

2018-04-01

This paper proposes an integrated sensor fault detection and recovery for the satellite attitude control system. By introducing a nonlinear observer, the healthy sensor measurements are provided. Considering attitude dynamics and kinematic, a novel observer is developed to detect the fault in angular rate as well as attitude sensors individually or simultaneously. There is no limit on type and configuration of attitude sensors. By designing a state feedback based control signal and Lyapunov stability criterion, the uniformly ultimately boundedness of tracking errors in the presence of sensor faults is guaranteed. Finally, simulation results are presented to illustrate the performance of the integrated scheme.

A method to compute SEU fault probabilities in memory arrays with error correction

NASA Technical Reports Server (NTRS)

Gercek, Gokhan

1994-01-01

With the increasing packing densities in VLSI technology, Single Event Upsets (SEU) due to cosmic radiations are becoming more of a critical issue in the design of space avionics systems. In this paper, a method is introduced to compute the fault (mishap) probability for a computer memory of size M words. It is assumed that a Hamming code is used for each word to provide single error correction. It is also assumed that every time a memory location is read, single errors are corrected. Memory is read randomly whose distribution is assumed to be known. In such a scenario, a mishap is defined as two SEU's corrupting the same memory location prior to a read. The paper introduces a method to compute the overall mishap probability for the entire memory for a mission duration of T hours.

Reliability and coverage analysis of non-repairable fault-tolerant memory systems

NASA Technical Reports Server (NTRS)

Cox, G. W.; Carroll, B. D.

1976-01-01

A method was developed for the construction of probabilistic state-space models for nonrepairable systems. Models were developed for several systems which achieved reliability improvement by means of error-coding, modularized sparing, massive replication and other fault-tolerant techniques. From the models developed, sets of reliability and coverage equations for the systems were developed. Comparative analyses of the systems were performed using these equation sets. In addition, the effects of varying subunit reliabilities on system reliability and coverage were described. The results of these analyses indicated that a significant gain in system reliability may be achieved by use of combinations of modularized sparing, error coding, and software error control. For sufficiently reliable system subunits, this gain may far exceed the reliability gain achieved by use of massive replication techniques, yet result in a considerable saving in system cost.

Fault tolerant control of multivariable processes using auto-tuning PID controller.

PubMed

Yu, Ding-Li; Chang, T K; Yu, Ding-Wen

2005-02-01

Fault tolerant control of dynamic processes is investigated in this paper using an auto-tuning PID controller. A fault tolerant control scheme is proposed composing an auto-tuning PID controller based on an adaptive neural network model. The model is trained online using the extended Kalman filter (EKF) algorithm to learn system post-fault dynamics. Based on this model, the PID controller adjusts its parameters to compensate the effects of the faults, so that the control performance is recovered from degradation. The auto-tuning algorithm for the PID controller is derived with the Lyapunov method and therefore, the model predicted tracking error is guaranteed to converge asymptotically. The method is applied to a simulated two-input two-output continuous stirred tank reactor (CSTR) with various faults, which demonstrate the applicability of the developed scheme to industrial processes.

Investigation of the applicability of a functional programming model to fault-tolerant parallel processing for knowledge-based systems

NASA Technical Reports Server (NTRS)

Harper, Richard

1989-01-01

In a fault-tolerant parallel computer, a functional programming model can facilitate distributed checkpointing, error recovery, load balancing, and graceful degradation. Such a model has been implemented on the Draper Fault-Tolerant Parallel Processor (FTPP). When used in conjunction with the FTPP's fault detection and masking capabilities, this implementation results in a graceful degradation of system performance after faults. Three graceful degradation algorithms have been implemented and are presented. A user interface has been implemented which requires minimal cognitive overhead by the application programmer, masking such complexities as the system's redundancy, distributed nature, variable complement of processing resources, load balancing, fault occurrence and recovery. This user interface is described and its use demonstrated. The applicability of the functional programming style to the Activation Framework, a paradigm for intelligent systems, is then briefly described.

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

Quinn, Heather; Wirthlin, Michael

A variety of fault emulation systems have been created to study the effect of single-event effects (SEEs) in static random access memory (SRAM) based field-programmable gate arrays (FPGAs). These systems are useful for augmenting radiation-hardness assurance (RHA) methodologies for verifying the effectiveness for mitigation techniques; understanding error signatures and failure modes in FPGAs; and failure rate estimation. For radiation effects researchers, it is important that these systems properly emulate how SEEs manifest in FPGAs. If the fault emulation systems does not mimic the radiation environment, the system will generate erroneous data and incorrect predictions of behavior of the FPGA inmore » a radiation environment. Validation determines whether the emulated faults are reasonable analogs to the radiation-induced faults. In this study we present methods for validating fault emulation systems and provide several examples of validated FPGA fault emulation systems.« less

Robust Fault Detection for Aircraft Using Mixed Structured Singular Value Theory and Fuzzy Logic

NASA Technical Reports Server (NTRS)

Collins, Emmanuel G.

2000-01-01

The purpose of fault detection is to identify when a fault or failure has occurred in a system such as an aircraft or expendable launch vehicle. The faults may occur in sensors, actuators, structural components, etc. One of the primary approaches to model-based fault detection relies on analytical redundancy. That is the output of a computer-based model (actually a state estimator) is compared with the sensor measurements of the actual system to determine when a fault has occurred. Unfortunately, the state estimator is based on an idealized mathematical description of the underlying plant that is never totally accurate. As a result of these modeling errors, false alarms can occur. This research uses mixed structured singular value theory, a relatively recent and powerful robustness analysis tool, to develop robust estimators and demonstrates the use of these estimators in fault detection. To allow qualitative human experience to be effectively incorporated into the detection process fuzzy logic is used to predict the seriousness of the fault that has occurred.

Formal Validation of Fault Management Design Solutions

NASA Technical Reports Server (NTRS)

Gibson, Corrina; Karban, Robert; Andolfato, Luigi; Day, John

2013-01-01

The work presented in this paper describes an approach used to develop SysML modeling patterns to express the behavior of fault protection, test the model's logic by performing fault injection simulations, and verify the fault protection system's logical design via model checking. A representative example, using a subset of the fault protection design for the Soil Moisture Active-Passive (SMAP) system, was modeled with SysML State Machines and JavaScript as Action Language. The SysML model captures interactions between relevant system components and system behavior abstractions (mode managers, error monitors, fault protection engine, and devices/switches). Development of a method to implement verifiable and lightweight executable fault protection models enables future missions to have access to larger fault test domains and verifiable design patterns. A tool-chain to transform the SysML model to jpf-Statechart compliant Java code and then verify the generated code via model checking was established. Conclusions and lessons learned from this work are also described, as well as potential avenues for further research and development.

An observational study of drug administration errors in a Malaysian hospital (study of drug administration errors).

PubMed

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.

Adaptive Neural Networks Decentralized FTC Design for Nonstrict-Feedback Nonlinear Interconnected Large-Scale Systems Against Actuator Faults.

PubMed

Li, Yongming; Tong, Shaocheng

The problem of active fault-tolerant control (FTC) is investigated for the large-scale nonlinear systems in nonstrict-feedback form. The nonstrict-feedback nonlinear systems considered in this paper consist of unstructured uncertainties, unmeasured states, unknown interconnected terms, and actuator faults (e.g., bias fault and gain fault). A state observer is designed to solve the unmeasurable state problem. Neural networks (NNs) are used to identify the unknown lumped nonlinear functions so that the problems of unstructured uncertainties and unknown interconnected terms can be solved. By combining the adaptive backstepping design principle with the combination Nussbaum gain function property, a novel NN adaptive output-feedback FTC approach is developed. The proposed FTC controller can guarantee that all signals in all subsystems are bounded, and the tracking errors for each subsystem converge to a small neighborhood of zero. Finally, numerical results of practical examples are presented to further demonstrate the effectiveness of the proposed control strategy.The problem of active fault-tolerant control (FTC) is investigated for the large-scale nonlinear systems in nonstrict-feedback form. The nonstrict-feedback nonlinear systems considered in this paper consist of unstructured uncertainties, unmeasured states, unknown interconnected terms, and actuator faults (e.g., bias fault and gain fault). A state observer is designed to solve the unmeasurable state problem. Neural networks (NNs) are used to identify the unknown lumped nonlinear functions so that the problems of unstructured uncertainties and unknown interconnected terms can be solved. By combining the adaptive backstepping design principle with the combination Nussbaum gain function property, a novel NN adaptive output-feedback FTC approach is developed. The proposed FTC controller can guarantee that all signals in all subsystems are bounded, and the tracking errors for each subsystem converge to a small neighborhood of zero. Finally, numerical results of practical examples are presented to further demonstrate the effectiveness of the proposed control strategy.

Robust estimation-free prescribed performance back-stepping control of air-breathing hypersonic vehicles without affine models

NASA Astrophysics Data System (ADS)

Bu, Xiangwei; Wu, Xiaoyan; Huang, Jiaqi; Wei, Daozhi

2016-11-01

This paper investigates the design of a novel estimation-free prescribed performance non-affine control strategy for the longitudinal dynamics of an air-breathing hypersonic vehicle (AHV) via back-stepping. The proposed control scheme is capable of guaranteeing tracking errors of velocity, altitude, flight-path angle, pitch angle and pitch rate with prescribed performance. By prescribed performance, we mean that the tracking error is limited to a predefined arbitrarily small residual set, with convergence rate no less than a certain constant, exhibiting maximum overshoot less than a given value. Unlike traditional back-stepping designs, there is no need of an affine model in this paper. Moreover, both the tedious analytic and numerical computations of time derivatives of virtual control laws are completely avoided. In contrast to estimation-based strategies, the presented estimation-free controller possesses much lower computational costs, while successfully eliminating the potential problem of parameter drifting. Owing to its independence on an accurate AHV model, the studied methodology exhibits excellent robustness against system uncertainties. Finally, simulation results from a fully nonlinear model clarify and verify the design.

Medication dosing errors and associated factors in hospitalized pediatric patients from the South Area of the West Bank - Palestine.

PubMed

Al-Ramahi, Rowa'; Hmedat, Bayan; Alnjajrah, Eman; Manasrah, Israa; Radwan, Iqbal; Alkhatib, Maram

2017-09-01

Medication dosing errors are a significant global concern and can cause serious medical consequences for patients. Pediatric patients are at increased risk of dosing errors due to differences in medication pharmacodynamics and pharmacokinetics. The aims of this study were to find the rate of medication dosing errors in hospitalized pediatric patients and possible associated factors. The study was an observational cohort study including pediatric inpatients less than 16 years from three governmental hospitals from the West Bank/Palestine during one month in 2014, and sample size was 400 pediatric inpatients from these three hospitals. Pediatric patients' medical records were reviewed. Patients' weight, age, medical conditions, all prescribed medications, their doses and frequency were documented. Then the doses of medications were evaluated. Among 400 patients, the medications prescribed were 949 medications, 213 of them (22.4%) were out of the recommended range, and 160 patients (40.0%) were prescribed one or more potentially inappropriate doses. The most common cause of hospital admission was sepsis which presented 14.3% of cases, followed by fever (13.5%) and meningitis (10.0%). The most commonly used medications were ampicillin in 194 cases (20.4%), ceftriaxone in 182 cases (19.2%), and cefotaxime in 144 cases (12.0%). No significant association was found between potentially inappropriate doses and gender or hospital (chi-square test p -value > 0.05).The results showed that patients with lower body weight, who had a higher number of medications and stayed in hospital for a longer time, were more likely to have inappropriate doses. Potential medication dosing errors were high among pediatric hospitalized patients in Palestine. Younger patients, patients with lower body weight, who were prescribed higher number of medications and stayed in hospital for a longer time were more likely to have inappropriate doses, so these populations require special care. Many children were hospitalized for infectious causes and antibiotics were widely used. Strategies to reduce pediatric medication dosing errors are recommended.

An examination of the operational error database for air route traffic control centers.

DOT National Transportation Integrated Search

1993-12-01

Monitoring the frequency and determining the causes of operational errors - defined as the loss of prescribed separation between aircraft - is one approach to assessing the operational safety of the air traffic control system. The Federal Aviation Ad...

The effect of a computerized prescribing and calculating system on hypo- and hyperglycemias and on prescribing time efficiency in neonatal intensive care patients.

PubMed

Maat, Barbara; Rademaker, Carin M A; Oostveen, Marloes I; Krediet, Tannette G; Egberts, Toine C G; Bollen, Casper W

2013-01-01

Prescribing glucose requires complex calculations because glucose is present in parenteral and enteral nutrition and drug vehicles, making it error prone and contributing to the burden of prescribing errors. Evaluation of the impact of a computerized physician order entry (CPOE) system with clinical decision support (CDS) for glucose control in neonatal intensive care patients (NICU) focusing on hypo- and hyperglycemic episodes and prescribing time efficiency. An interrupted time-series design to examine the effect of CPOE on hypo- and hyperglycemias and a crossover simulation study to examine the influence of CPOE on prescribing time efficiency. NICU patients at risk for glucose imbalance hospitalized at the University Medical Center Utrecht during 2001-2007 were selected. The risks of hypo- and hyperglycemias were expressed as incidences per 100 patient days in consecutive 3-month intervals during 3 years before and after CPOE implementation. To assess prescribing time efficiency, time needed to calculate glucose intake with and without CPOE was measured. No significant difference was found between pre- and post-CPOE mean incidences of hypo- and hyperglycemias per 100 hospital days of neonates at risk in every 3-month period (hypoglycemias, 4.0 [95% confidence interval, 3.2-4.8] pre-CPOE and 3.1 [2.7-3.5] post-CPOE, P = .88; hyperglycemias, 6.0 [4.3-7.7] pre-CPOE and 5.0 [3.7-6.3] post-CPOE, P = .75). CPOE led to a significant time reduction of 16% (1.3 [0.3-2.3] minutes) for simple and 60% (8.6 [5.1-12.1] minutes) for complex calculations. CPOE including a special CDS tool preserved accuracy for calculation and control of glucose intake and increased prescribing time efficiency.

Evaluation of Hand Written and Computerized Out-Patient Prescriptions in Urban Part of Central Gujarat.

PubMed

Joshi, Anuradha; Buch, Jatin; Kothari, Nitin; Shah, Nishal

2016-06-01

Prescription order is an important therapeutic transaction between physician and patient. A good quality prescription is an extremely important factor for minimizing errors in dispensing medication and it should be adherent to guidelines for prescription writing for benefit of the patient. To evaluate frequency and type of prescription errors in outpatient prescriptions and find whether prescription writing abides with WHO standards of prescription writing. A cross-sectional observational study was conducted at Anand city. Allopathic private practitioners practising at Anand city of different specialities were included in study. Collection of prescriptions was started a month after the consent to minimize bias in prescription writing. The prescriptions were collected from local pharmacy stores of Anand city over a period of six months. Prescriptions were analysed for errors in standard information, according to WHO guide to good prescribing. Descriptive analysis was performed to estimate frequency of errors, data were expressed as numbers and percentage. Total 749 (549 handwritten and 200 computerised) prescriptions were collected. Abundant omission errors were identified in handwritten prescriptions e.g., OPD number was mentioned in 6.19%, patient's age was mentioned in 25.50%, gender in 17.30%, address in 9.29% and weight of patient mentioned in 11.29%, while in drug items only 2.97% drugs were prescribed by generic name. Route and Dosage form was mentioned in 77.35%-78.15%, dose mentioned in 47.25%, unit in 13.91%, regimens were mentioned in 72.93% while signa (direction for drug use) in 62.35%. Total 4384 errors out of 549 handwritten prescriptions and 501 errors out of 200 computerized prescriptions were found in clinicians and patient details. While in drug item details, total number of errors identified were 5015 and 621 in handwritten and computerized prescriptions respectively. As compared to handwritten prescriptions, computerized prescriptions appeared to be associated with relatively lower rates of error. Since out-patient prescription errors are abundant and often occur in handwritten prescriptions, prescribers need to adapt themselves to computerized prescription order entry in their daily practice.

Evaluation of Hand Written and Computerized Out-Patient Prescriptions in Urban Part of Central Gujarat

PubMed Central

Buch, Jatin; Kothari, Nitin; Shah, Nishal

2016-01-01

Introduction Prescription order is an important therapeutic transaction between physician and patient. A good quality prescription is an extremely important factor for minimizing errors in dispensing medication and it should be adherent to guidelines for prescription writing for benefit of the patient. Aim To evaluate frequency and type of prescription errors in outpatient prescriptions and find whether prescription writing abides with WHO standards of prescription writing. Materials and Methods A cross-sectional observational study was conducted at Anand city. Allopathic private practitioners practising at Anand city of different specialities were included in study. Collection of prescriptions was started a month after the consent to minimize bias in prescription writing. The prescriptions were collected from local pharmacy stores of Anand city over a period of six months. Prescriptions were analysed for errors in standard information, according to WHO guide to good prescribing. Statistical Analysis Descriptive analysis was performed to estimate frequency of errors, data were expressed as numbers and percentage. Results Total 749 (549 handwritten and 200 computerised) prescriptions were collected. Abundant omission errors were identified in handwritten prescriptions e.g., OPD number was mentioned in 6.19%, patient’s age was mentioned in 25.50%, gender in 17.30%, address in 9.29% and weight of patient mentioned in 11.29%, while in drug items only 2.97% drugs were prescribed by generic name. Route and Dosage form was mentioned in 77.35%-78.15%, dose mentioned in 47.25%, unit in 13.91%, regimens were mentioned in 72.93% while signa (direction for drug use) in 62.35%. Total 4384 errors out of 549 handwritten prescriptions and 501 errors out of 200 computerized prescriptions were found in clinicians and patient details. While in drug item details, total number of errors identified were 5015 and 621 in handwritten and computerized prescriptions respectively. Conclusion As compared to handwritten prescriptions, computerized prescriptions appeared to be associated with relatively lower rates of error. Since out-patient prescription errors are abundant and often occur in handwritten prescriptions, prescribers need to adapt themselves to computerized prescription order entry in their daily practice. PMID:27504305

Preventing medication errors in cancer chemotherapy.

PubMed

Cohen, M R; Anderson, R W; Attilio, R M; Green, L; Muller, R J; Pruemer, J M

1996-04-01

Recommendations for preventing medication errors in cancer chemotherapy are made. Before a health care provider is granted privileges to prescribe, dispense, or administer antineoplastic agents, he or she should undergo a tailored educational program and possibly testing or certification. Appropriate reference materials should be developed. Each institution should develop a dose-verification process with as many independent checks as possible. A detailed checklist covering prescribing, transcribing, dispensing, and administration should be used. Oral orders are not acceptable. All doses should be calculated independently by the physician, the pharmacist, and the nurse. Dosage limits should be established and a review process set up for doses that exceed the limits. These limits should be entered into pharmacy computer systems, listed on preprinted order forms, stated on the product packaging, placed in strategic locations in the institution, and communicated to employees. The prescribing vocabulary must be standardized. Acronyms, abbreviations, and brand names must be avoided and steps taken to avoid other sources of confusion in the written orders, such as trailing zeros. Preprinted antineoplastic drug order forms containing checklists can help avoid errors. Manufacturers should be encouraged to avoid or eliminate ambiguities in drug names and dosing information. Patients must be educated about all aspects of their cancer chemotherapy, as patients represent a last line of defense against errors. An interdisciplinary team at each practice site should review every medication error reported. Pharmacists should be involved at all sites where antineoplastic agents are dispensed. Although it may not be possible to eliminate all medication errors in cancer chemotherapy, the risk can be minimized through specific steps. Because of their training and experience, pharmacists should take the lead in this effort.

A SVM framework for fault detection of the braking system in a high speed train

NASA Astrophysics Data System (ADS)

Liu, Jie; Li, Yan-Fu; Zio, Enrico

2017-03-01

In April 2015, the number of operating High Speed Trains (HSTs) in the world has reached 3603. An efficient, effective and very reliable braking system is evidently very critical for trains running at a speed around 300 km/h. Failure of a highly reliable braking system is a rare event and, consequently, informative recorded data on fault conditions are scarce. This renders the fault detection problem a classification problem with highly unbalanced data. In this paper, a Support Vector Machine (SVM) framework, including feature selection, feature vector selection, model construction and decision boundary optimization, is proposed for tackling this problem. Feature vector selection can largely reduce the data size and, thus, the computational burden. The constructed model is a modified version of the least square SVM, in which a higher cost is assigned to the error of classification of faulty conditions than the error of classification of normal conditions. The proposed framework is successfully validated on a number of public unbalanced datasets. Then, it is applied for the fault detection of braking systems in HST: in comparison with several SVM approaches for unbalanced datasets, the proposed framework gives better results.

Injecting Artificial Memory Errors Into a Running Computer Program

NASA Technical Reports Server (NTRS)

Bornstein, Benjamin J.; Granat, Robert A.; Wagstaff, Kiri L.

2008-01-01

Single-event upsets (SEUs) or bitflips are computer memory errors caused by radiation. BITFLIPS (Basic Instrumentation Tool for Fault Localized Injection of Probabilistic SEUs) is a computer program that deliberately injects SEUs into another computer program, while the latter is running, for the purpose of evaluating the fault tolerance of that program. BITFLIPS was written as a plug-in extension of the open-source Valgrind debugging and profiling software. BITFLIPS can inject SEUs into any program that can be run on the Linux operating system, without needing to modify the program s source code. Further, if access to the original program source code is available, BITFLIPS offers fine-grained control over exactly when and which areas of memory (as specified via program variables) will be subjected to SEUs. The rate of injection of SEUs is controlled by specifying either a fault probability or a fault rate based on memory size and radiation exposure time, in units of SEUs per byte per second. BITFLIPS can also log each SEU that it injects and, if program source code is available, report the magnitude of effect of the SEU on a floating-point value or other program variable.

Fault-tolerant simple quantum-bit commitment unbreakable by individual attacks

NASA Astrophysics Data System (ADS)

Shimizu, Kaoru; Imoto, Nobuyuki

2002-03-01

This paper proposes a simple scheme for quantum-bit commitment that is secure against individual particle attacks, where a sender is unable to use quantum logical operations to manipulate multiparticle entanglement for performing quantum collective and coherent attacks. Our scheme employs a cryptographic quantum communication channel defined in a four-dimensional Hilbert space and can be implemented by using single-photon interference. For an ideal case of zero-loss and noiseless quantum channels, our basic scheme relies only on the physical features of quantum states. Moreover, as long as the bit-flip error rates are sufficiently small (less than a few percent), we can improve our scheme and make it fault tolerant by adopting simple error-correcting codes with a short length. Compared with the well-known Brassard-Crepeau-Jozsa-Langlois 1993 (BCJL93) protocol, our scheme is mathematically far simpler, more efficient in terms of transmitted photon number, and better tolerant of bit-flip errors.

Certification of computational results

NASA Technical Reports Server (NTRS)

Sullivan, Gregory F.; Wilson, Dwight S.; Masson, Gerald M.

1993-01-01

A conceptually novel and powerful technique to achieve fault detection and fault tolerance in hardware and software systems is described. When used for software fault detection, this new technique uses time and software redundancy and can be outlined as follows. In the initial phase, a program is run to solve a problem and store the result. In addition, this program leaves behind a trail of data called a certification trail. In the second phase, another program is run which solves the original problem again. This program, however, has access to the certification trail left by the first program. Because of the availability of the certification trail, the second phase can be performed by a less complex program and can execute more quickly. In the final phase, the two results are compared and if they agree the results are accepted as correct; otherwise an error is indicated. An essential aspect of this approach is that the second program must always generate either an error indication or a correct output even when the certification trail it receives from the first program is incorrect. The certification trail approach to fault tolerance is formalized and realizations of it are illustrated by considering algorithms for the following problems: convex hull, sorting, and shortest path. Cases in which the second phase can be run concurrently with the first and act as a monitor are discussed. The certification trail approach are compared to other approaches to fault tolerance.

Impact of Installation Faults on Heat Pump Performance

DOE PAGES

Hourahan, Glenn; Baxter, Van D.

2015-01-01

Numerous studies and surveys indicate that typically-installed HVAC equipment operate inefficiently and waste considerable energy due to varied installation errors (faults) such as improper refrigerant charge, incorrect airflow, oversized equipment, and leaky ducts. This article summarizes the results of a large United States (U.S.) experimental/analytical study (U.S. contribution to IEA HPP Annex 36) of the impact that different faults have on the performance of an air-source heat pump (ASHP) in a typical U.S. single-family house. It combines building effects, equipment effects, and climate effects in an evaluation of the faults impact on seasonal energy consumption through simulations of the house/ASHPmore » pump system.« less

Faults Discovery By Using Mined Data

NASA Technical Reports Server (NTRS)

Lee, Charles

2005-01-01

Fault discovery in the complex systems consist of model based reasoning, fault tree analysis, rule based inference methods, and other approaches. Model based reasoning builds models for the systems either by mathematic formulations or by experiment model. Fault Tree Analysis shows the possible causes of a system malfunction by enumerating the suspect components and their respective failure modes that may have induced the problem. The rule based inference build the model based on the expert knowledge. Those models and methods have one thing in common; they have presumed some prior-conditions. Complex systems often use fault trees to analyze the faults. Fault diagnosis, when error occurs, is performed by engineers and analysts performing extensive examination of all data gathered during the mission. International Space Station (ISS) control center operates on the data feedback from the system and decisions are made based on threshold values by using fault trees. Since those decision-making tasks are safety critical and must be done promptly, the engineers who manually analyze the data are facing time challenge. To automate this process, this paper present an approach that uses decision trees to discover fault from data in real-time and capture the contents of fault trees as the initial state of the trees.

Modification of wave-cut and faulting-controlled landforms.

USGS Publications Warehouse

Hanks, T.C.; Bucknam, R.C.; Lajoie, K.R.; Wallace, R.E.

1984-01-01

From a casual observation that the form of degraded fault scarps resembles the error function, this investigation proceeds through an elementary diffusion equation representation of landform evolution to the application of the resulting equations to the modern topography of scarplike landforms. The value of K = 1 GKG (K = 'mass diffusivity'; 1 GKG = 1m2/ka) may be generally applicable as a good first approximation, to the modification of alluvial terranes within the semiarid regions of the western United States. The Lake Bonneville shoreline K is the basis for dating four sets of fault scarps in west-central Utah. The Drum Mountains fault scarps date at 3.6 to 5.7 ka BP. Fault scarps along the eastern base of the Fish Springs Range are very young, 3 ka BP. We estimate the age of fault scarps along the western flank of the Oquirrh Mountains to be 32 ka B.P. Fault scarps along the NE margin of the Sheeprock Mountains are even older, 53 ka BP. -from Authors

Fault Mitigation Schemes for Future Spaceflight Multicore Processors

NASA Technical Reports Server (NTRS)

Alexander, James W.; Clement, Bradley J.; Gostelow, Kim P.; Lai, John Y.

2012-01-01

Future planetary exploration missions demand significant advances in on-board computing capabilities over current avionics architectures based on a single-core processing element. The state-of-the-art multi-core processor provides much promise in meeting such challenges while introducing new fault tolerance problems when applied to space missions. Software-based schemes are being presented in this paper that can achieve system-level fault mitigation beyond that provided by radiation-hard-by-design (RHBD). For mission and time critical applications such as the Terrain Relative Navigation (TRN) for planetary or small body navigation, and landing, a range of fault tolerance methods can be adapted by the application. The software methods being investigated include Error Correction Code (ECC) for data packet routing between cores, virtual network routing, Triple Modular Redundancy (TMR), and Algorithm-Based Fault Tolerance (ABFT). A robust fault tolerance framework that provides fail-operational behavior under hard real-time constraints and graceful degradation will be demonstrated using TRN executing on a commercial Tilera(R) processor with simulated fault injections.

Holonomic surface codes for fault-tolerant quantum computation

NASA Astrophysics Data System (ADS)

Zhang, Jiang; Devitt, Simon J.; You, J. Q.; Nori, Franco

2018-02-01

Surface codes can protect quantum information stored in qubits from local errors as long as the per-operation error rate is below a certain threshold. Here we propose holonomic surface codes by harnessing the quantum holonomy of the system. In our scheme, the holonomic gates are built via auxiliary qubits rather than the auxiliary levels in multilevel systems used in conventional holonomic quantum computation. The key advantage of our approach is that the auxiliary qubits are in their ground state before and after each gate operation, so they are not involved in the operation cycles of surface codes. This provides an advantageous way to implement surface codes for fault-tolerant quantum computation.

Automated Classification of Phonological Errors in Aphasic Language

PubMed Central

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.

Superconducting quantum circuits at the surface code threshold for fault tolerance.

PubMed

Barends, R; Kelly, J; Megrant, A; Veitia, A; Sank, D; Jeffrey, E; White, T C; Mutus, J; Fowler, A G; Campbell, B; Chen, Y; Chen, Z; Chiaro, B; Dunsworth, A; Neill, C; O'Malley, P; Roushan, P; Vainsencher, A; Wenner, J; Korotkov, A N; Cleland, A N; Martinis, John M

2014-04-24

A quantum computer can solve hard problems, such as prime factoring, database searching and quantum simulation, at the cost of needing to protect fragile quantum states from error. Quantum error correction provides this protection by distributing a logical state among many physical quantum bits (qubits) by means of quantum entanglement. Superconductivity is a useful phenomenon in this regard, because it allows the construction of large quantum circuits and is compatible with microfabrication. For superconducting qubits, the surface code approach to quantum computing is a natural choice for error correction, because it uses only nearest-neighbour coupling and rapidly cycled entangling gates. The gate fidelity requirements are modest: the per-step fidelity threshold is only about 99 per cent. Here we demonstrate a universal set of logic gates in a superconducting multi-qubit processor, achieving an average single-qubit gate fidelity of 99.92 per cent and a two-qubit gate fidelity of up to 99.4 per cent. This places Josephson quantum computing at the fault-tolerance threshold for surface code error correction. Our quantum processor is a first step towards the surface code, using five qubits arranged in a linear array with nearest-neighbour coupling. As a further demonstration, we construct a five-qubit Greenberger-Horne-Zeilinger state using the complete circuit and full set of gates. The results demonstrate that Josephson quantum computing is a high-fidelity technology, with a clear path to scaling up to large-scale, fault-tolerant quantum circuits.

High resolution t-LiDAR scanning of an active bedrock fault scarp for palaeostress analysis

NASA Astrophysics Data System (ADS)

Reicherter, Klaus; Wiatr, Thomas; Papanikolaou, Ioannis; Fernández-Steeger, Tomas

2013-04-01

Palaeostress analysis of an active bedrock normal fault scarp based on kinematic indicators is carried applying terrestrial laser scanning (t-LiDAR or TLS). For this purpose three key elements are necessary for a defined region on the fault plane: (i) the orientation of the fault plane, (ii) the orientation of the slickenside lineation or other kinematic indicators and (iii) the sense of motion of the hanging wall. We present a workflow to obtain palaeostress data from point cloud data using terrestrial laser scanning. The entire case-study was performed on a continuous limestone bedrock normal fault scarp on the island of Crete, Greece, at four different locations along the WNW-ESE striking Spili fault. At each location we collected data with a mobile terrestrial light detection and ranging system and validated the calculated three-dimensional palaeostress results by comparison with the conventional palaeostress method with compass at three of the locations. Numerous kinematics indicators for normal faulting were discovered on the fault plane surface using t-LiDAR data and traditional methods, like Riedel shears, extensional break-outs, polished corrugations and many more. However, the kinematic indicators are more or less unidirectional and almost pure dip-slip. No oblique reactivations have been observed. But, towards the tips of the fault, inclination of the striation tends to point towards the centre of the fault. When comparing all reconstructed palaeostress data obtained from t-LiDAR to that obtained through manual compass measurements, the degree of fault plane orientation divergence is around ±005/03 for dip direction and dip. The degree of slickenside lineation variation is around ±003/03 for dip direction and dip. Therefore, the percentage threshold error of the individual vector angle at the different investigation site is lower than 3 % for the dip direction and dip for planes, and lower than 6 % for strike. The maximum mean variation of the complete calculated palaeostress tensors is ±005/03. So, technically t-LiDAR measurements are in the error range of conventional compass measurements. The advantages is that remote palaeostress analysis is possible. Further steps in our research will be studying reactivated faults planes with multiple kinematic indicators or striations with t-LiDAR.

Architecture Fault Modeling and Analysis with the Error Model Annex, Version 2

DTIC Science & Technology

2016-06-01

outgoing error propagation condition declara- tions (see Section 5.2.2). The declaration consists of a source error behavior state, possibly anno - tated...2012. [Feiler 2013] Feiler, P. H.; Goodenough, J . B.; Gurfinkel, A.; Weinstock, C. B.; & Wrage, L. Four Pillars for Improving the Quality of...May 2002. [Paige 2009] Paige, Richard F.; Rose, Louis M.; Ge, Xiaocheng; Kolovos, Dimitrios S.; & Brooke, Phillip J . FPTC: Automated Safety

Design of materials with prescribed nonlinear properties

NASA Astrophysics Data System (ADS)

Wang, F.; Sigmund, O.; Jensen, J. S.

2014-09-01

We systematically design materials using topology optimization to achieve prescribed nonlinear properties under finite deformation. Instead of a formal homogenization procedure, a numerical experiment is proposed to evaluate the material performance in longitudinal and transverse tensile tests under finite deformation, i.e. stress-strain relations and Poissons ratio. By minimizing errors between actual and prescribed properties, materials are tailored to achieve the target. Both two dimensional (2D) truss-based and continuum materials are designed with various prescribed nonlinear properties. The numerical examples illustrate optimized materials with rubber-like behavior and also optimized materials with extreme strain-independent Poissons ratio for axial strain intervals of εi∈[0.00, 0.30].

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

PubMed

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

2016-12-01

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

Distributed adaptive neural network control for a class of heterogeneous nonlinear multi-agent systems subject to actuation failures

NASA Astrophysics Data System (ADS)

Cui, Bing; Zhao, Chunhui; Ma, Tiedong; Feng, Chi

2017-02-01

In this paper, the cooperative adaptive consensus tracking problem for heterogeneous nonlinear multi-agent systems on directed graph is addressed. Each follower is modelled as a general nonlinear system with the unknown and nonidentical nonlinear dynamics, disturbances and actuator failures. Cooperative fault tolerant neural network tracking controllers with online adaptive learning features are proposed to guarantee that all agents synchronise to the trajectory of one leader with bounded adjustable synchronisation errors. With the help of linear quadratic regulator-based optimal design, a graph-dependent Lyapunov proof provides error bounds that depend on the graph topology, one virtual matrix and some design parameters. Of particular interest is that if the control gain is selected appropriately, the proposed control scheme can be implemented in a unified framework no matter whether there are faults or not. Furthermore, the fault detection and isolation are not needed to implement. Finally, a simulation is given to verify the effectiveness of the proposed method.

The use of automatic programming techniques for fault tolerant computing systems

NASA Technical Reports Server (NTRS)

Wild, C.

1985-01-01

It is conjectured that the production of software for ultra-reliable computing systems such as required by Space Station, aircraft, nuclear power plants and the like will require a high degree of automation as well as fault tolerance. In this paper, the relationship between automatic programming techniques and fault tolerant computing systems is explored. Initial efforts in the automatic synthesis of code from assertions to be used for error detection as well as the automatic generation of assertions and test cases from abstract data type specifications is outlined. Speculation on the ability to generate truly diverse designs capable of recovery from errors by exploring alternate paths in the program synthesis tree is discussed. Some initial thoughts on the use of knowledge based systems for the global detection of abnormal behavior using expectations and the goal-directed reconfiguration of resources to meet critical mission objectives are given. One of the sources of information for these systems would be the knowledge captured during the automatic programming process.

About problematic peculiarities of Fault Tolerance digital regulation organization

NASA Astrophysics Data System (ADS)

Rakov, V. I.; Zakharova, O. V.

2018-05-01

The solution of problems concerning estimation of working capacity of regulation chains and possibilities of preventing situations of its violation in three directions are offered. The first direction is working out (creating) the methods of representing the regulation loop (circuit) by means of uniting (combining) diffuse components and forming algorithmic tooling for building predicates of serviceability assessment separately for the components and the for regulation loops (circuits, contours) in general. The second direction is creating methods of Fault Tolerance redundancy in the process of complex assessment of current values of control actions, closure errors and their regulated parameters. The third direction is creating methods of comparing the processes of alteration (change) of control actions, errors of closure and regulating parameters with their standard models or their surroundings. This direction allows one to develop methods and algorithmic tool means, aimed at preventing loss of serviceability and effectiveness of not only a separate digital regulator, but also the whole complex of Fault Tolerance regulation.

Comparative analysis of neural network and regression based condition monitoring approaches for wind turbine fault detection

NASA Astrophysics Data System (ADS)

Schlechtingen, Meik; Ferreira Santos, Ilmar

2011-07-01

This paper presents the research results of a comparison of three different model based approaches for wind turbine fault detection in online SCADA data, by applying developed models to five real measured faults and anomalies. The regression based model as the simplest approach to build a normal behavior model is compared to two artificial neural network based approaches, which are a full signal reconstruction and an autoregressive normal behavior model. Based on a real time series containing two generator bearing damages the capabilities of identifying the incipient fault prior to the actual failure are investigated. The period after the first bearing damage is used to develop the three normal behavior models. The developed or trained models are used to investigate how the second damage manifests in the prediction error. Furthermore the full signal reconstruction and the autoregressive approach are applied to further real time series containing gearbox bearing damages and stator temperature anomalies. The comparison revealed all three models being capable of detecting incipient faults. However, they differ in the effort required for model development and the remaining operational time after first indication of damage. The general nonlinear neural network approaches outperform the regression model. The remaining seasonality in the regression model prediction error makes it difficult to detect abnormality and leads to increased alarm levels and thus a shorter remaining operational period. For the bearing damages and the stator anomalies under investigation the full signal reconstruction neural network gave the best fault visibility and thus led to the highest confidence level.

Development and evaluation of a Fault-Tolerant Multiprocessor (FTMP) computer. Volume 3: FTMP test and evaluation

NASA Technical Reports Server (NTRS)

Lala, J. H.; Smith, T. B., III

1983-01-01

The experimental test and evaluation of the Fault-Tolerant Multiprocessor (FTMP) is described. Major objectives of this exercise include expanding validation envelope, building confidence in the system, revealing any weaknesses in the architectural concepts and in their execution in hardware and software, and in general, stressing the hardware and software. To this end, pin-level faults were injected into one LRU of the FTMP and the FTMP response was measured in terms of fault detection, isolation, and recovery times. A total of 21,055 stuck-at-0, stuck-at-1 and invert-signal faults were injected in the CPU, memory, bus interface circuits, Bus Guardian Units, and voters and error latches. Of these, 17,418 were detected. At least 80 percent of undetected faults are estimated to be on unused pins. The multiprocessor identified all detected faults correctly and recovered successfully in each case. Total recovery time for all faults averaged a little over one second. This can be reduced to half a second by including appropriate self-tests.

Sensor fault diagnosis of singular delayed LPV systems with inexact parameters: an uncertain system approach

NASA Astrophysics Data System (ADS)

Hassanabadi, Amir Hossein; Shafiee, Masoud; Puig, Vicenc

2018-01-01

In this paper, sensor fault diagnosis of a singular delayed linear parameter varying (LPV) system is considered. In the considered system, the model matrices are dependent on some parameters which are real-time measurable. The case of inexact parameter measurements is considered which is close to real situations. Fault diagnosis in this system is achieved via fault estimation. For this purpose, an augmented system is created by including sensor faults as additional system states. Then, an unknown input observer (UIO) is designed which estimates both the system states and the faults in the presence of measurement noise, disturbances and uncertainty induced by inexact measured parameters. Error dynamics and the original system constitute an uncertain system due to inconsistencies between real and measured values of the parameters. Then, the robust estimation of the system states and the faults are achieved with H∞ performance and formulated with a set of linear matrix inequalities (LMIs). The designed UIO is also applicable for fault diagnosis of singular delayed LPV systems with unmeasurable scheduling variables. The efficiency of the proposed approach is illustrated with an example.

Prescription Errors in Older Individuals with an Intellectual Disability: Prevalence and Risk Factors in the Healthy Ageing and Intellectual Disability Study

ERIC Educational Resources Information Center

Zaal, Rianne J.; van der Kaaij, Annemieke D. M.; Evenhuis, Heleen M.; van den Bemt, Patricia M. L. A.

2013-01-01

Prescribing pharmacotherapy for older individuals with an intellectual disability (ID) is a complex process, possibly leading to an increased risk of prescription errors. The objectives of this study were (1) to determine the prevalence of older individuals with an intellectual disability with at least one prescription error and (2) to identify…

Automated error correction in IBM quantum computer and explicit generalization

NASA Astrophysics Data System (ADS)

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

2018-06-01

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

Research on bearing fault diagnosis of large machinery based on mathematical morphology

NASA Astrophysics Data System (ADS)

Wang, Yu

2018-04-01

To study the automatic diagnosis of large machinery fault based on support vector machine, combining the four common faults of the large machinery, the support vector machine is used to classify and identify the fault. The extracted feature vectors are entered. The feature vector is trained and identified by multi - classification method. The optimal parameters of the support vector machine are searched by trial and error method and cross validation method. Then, the support vector machine is compared with BP neural network. The results show that the support vector machines are short in time and high in classification accuracy. It is more suitable for the research of fault diagnosis in large machinery. Therefore, it can be concluded that the training speed of support vector machines (SVM) is fast and the performance is good.

Distributed asynchronous microprocessor architectures in fault tolerant integrated flight systems

NASA Technical Reports Server (NTRS)

Dunn, W. R.

1983-01-01

The paper discusses the implementation of fault tolerant digital flight control and navigation systems for rotorcraft application. It is shown that in implementing fault tolerance at the systems level using advanced LSI/VLSI technology, aircraft physical layout and flight systems requirements tend to define a system architecture of distributed, asynchronous microprocessors in which fault tolerance can be achieved locally through hardware redundancy and/or globally through application of analytical redundancy. The effects of asynchronism on the execution of dynamic flight software is discussed. It is shown that if the asynchronous microprocessors have knowledge of time, these errors can be significantly reduced through appropiate modifications of the flight software. Finally, the papear extends previous work to show that through the combined use of time referencing and stable flight algorithms, individual microprocessors can be configured to autonomously tolerate intermittent faults.

Towards fault tolerant adiabatic quantum computation.

PubMed

Lidar, Daniel A

2008-04-25

I show how to protect adiabatic quantum computation (AQC) against decoherence and certain control errors, using a hybrid methodology involving dynamical decoupling, subsystem and stabilizer codes, and energy gaps. Corresponding error bounds are derived. As an example, I show how to perform decoherence-protected AQC against local noise using at most two-body interactions.

Quantifying Carbon Flux Estimation Errors

NASA Astrophysics Data System (ADS)

Wesloh, D.

2017-12-01

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

Fault-tolerant linear optical quantum computing with small-amplitude coherent States.

PubMed

Lund, A P; Ralph, T C; Haselgrove, H L

2008-01-25

Quantum computing using two coherent states as a qubit basis is a proposed alternative architecture with lower overheads but has been questioned as a practical way of performing quantum computing due to the fragility of diagonal states with large coherent amplitudes. We show that using error correction only small amplitudes (alpha>1.2) are required for fault-tolerant quantum computing. We study fault tolerance under the effects of small amplitudes and loss using a Monte Carlo simulation. The first encoding level resources are orders of magnitude lower than the best single photon scheme.

Adjustable Parameter-Based Distributed Fault Estimation Observer Design for Multiagent Systems With Directed Graphs.

PubMed

Zhang, Ke; Jiang, Bin; Shi, Peng

2017-02-01

In this paper, a novel adjustable parameter (AP)-based distributed fault estimation observer (DFEO) is proposed for multiagent systems (MASs) with the directed communication topology. First, a relative output estimation error is defined based on the communication topology of MASs. Then a DFEO with AP is constructed with the purpose of improving the accuracy of fault estimation. Based on H ∞ and H 2 with pole placement, multiconstrained design is given to calculate the gain of DFEO. Finally, simulation results are presented to illustrate the feasibility and effectiveness of the proposed DFEO design with AP.

Fault Identification Based on Nlpca in Complex Electrical Engineering

NASA Astrophysics Data System (ADS)

Zhang, Yagang; Wang, Zengping; Zhang, Jinfang

2012-07-01

The fault is inevitable in any complex systems engineering. Electric power system is essentially a typically nonlinear system. It is also one of the most complex artificial systems in this world. In our researches, based on the real-time measurements of phasor measurement unit, under the influence of white Gaussian noise (suppose the standard deviation is 0.01, and the mean error is 0), we used mainly nonlinear principal component analysis theory (NLPCA) to resolve fault identification problem in complex electrical engineering. The simulation results show that the fault in complex electrical engineering is usually corresponding to the variable with the maximum absolute value coefficient in the first principal component. These researches will have significant theoretical value and engineering practical significance.

Coil motion effects in watt balances: a theoretical check

NASA Astrophysics Data System (ADS)

Li, Shisong; Schlamminger, Stephan; Haddad, Darine; Seifert, Frank; Chao, Leon; Pratt, Jon R.

2016-04-01

A watt balance is a precision apparatus for the measurement of the Planck constant that has been proposed as a primary method for realizing the unit of mass in a revised International System of Units. In contrast to an ampere balance, which was historically used to realize the unit of current in terms of the kilogram, the watt balance relates electrical and mechanical units through a virtual power measurement and has far greater precision. However, because the virtual power measurement requires the execution of a prescribed motion of a coil in a fixed magnetic field, systematic errors introduced by horizontal and rotational deviations of the coil from its prescribed path will compromise the accuracy. We model these potential errors using an analysis that accounts for the fringing field in the magnet, creating a framework for assessing the impact of this class of errors on the uncertainty of watt balance results.

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

PubMed

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

2015-01-01

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

Standardized Competencies for Parenteral Nutrition Prescribing: The American Society for Parenteral and Enteral Nutrition Model.

PubMed

Guenter, Peggi; Boullata, Joseph I; Ayers, Phil; Gervasio, Jane; Malone, Ainsley; Raymond, Erica; Holcombe, Beverly; Kraft, Michael; Sacks, Gordon; Seres, David

2015-08-01

Parenteral nutrition (PN) provision is complex, as it is a high-alert medication and prone to a variety of potential errors. With changes in clinical practice models and recent federal rulings, the number of PN prescribers may be increasing. Safe prescribing of this therapy requires that competency for prescribers from all disciplines be demonstrated using a standardized process. A standardized model for PN prescribing competency is proposed based on a competency framework, the American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.)-published interdisciplinary core competencies, safe practice recommendations, and clinical guidelines. This framework will guide institutions and agencies in developing and maintaining competency for safe PN prescription by their staff. © 2015 American Society for Parenteral and Enteral Nutrition.

Simultaneous Event-Triggered Fault Detection and Estimation for Stochastic Systems Subject to Deception Attacks.

PubMed

Li, Yunji; Wu, QingE; Peng, Li

2018-01-23

In this paper, a synthesized design of fault-detection filter and fault estimator is considered for a class of discrete-time stochastic systems in the framework of event-triggered transmission scheme subject to unknown disturbances and deception attacks. A random variable obeying the Bernoulli distribution is employed to characterize the phenomena of the randomly occurring deception attacks. To achieve a fault-detection residual is only sensitive to faults while robust to disturbances, a coordinate transformation approach is exploited. This approach can transform the considered system into two subsystems and the unknown disturbances are removed from one of the subsystems. The gain of fault-detection filter is derived by minimizing an upper bound of filter error covariance. Meanwhile, system faults can be reconstructed by the remote fault estimator. An recursive approach is developed to obtain fault estimator gains as well as guarantee the fault estimator performance. Furthermore, the corresponding event-triggered sensor data transmission scheme is also presented for improving working-life of the wireless sensor node when measurement information are aperiodically transmitted. Finally, a scaled version of an industrial system consisting of local PC, remote estimator and wireless sensor node is used to experimentally evaluate the proposed theoretical results. In particular, a novel fault-alarming strategy is proposed so that the real-time capacity of fault-detection is guaranteed when the event condition is triggered.

Examining Relay Ramp Evolution Through Paleo-shoreline Deformation Analysis, Warner Valley Fault, Oregon

NASA Astrophysics Data System (ADS)

Young, C. S.; Dawers, N. H.

2017-12-01

Fault growth is often accomplished by linking a series of en echelon faults through relay ramps. A relay ramp is the area between two overlapping fault segments that tilts and deforms as the faults accrue displacement. The structural evolution of breached normal fault relay ramps remains poorly understood because of the difficulty in defining how slip is partitioned between the most basinward fault (known as the outboard fault), the overlapping fault (inboard fault), and any ramp-breaching linking faults. Along the Warner Valley fault in south-central Oregon, two relay ramps displaying different fault linkage geometries are lined with a series of paleo-lacustrine shorelines that record a Pleistocene paleolake regression. The inner edges of these shorelines act as paleo-horizontal datums that have been deformed by fault activity, and are used to measure relative slip variations across the relay ramp bounding faults. By measuring the elevation changes using a 10m digital elevation model (DEM) of shoreline inner edges, we estimate the amount of slip partitioned between the inboard, outboard and ramp-breaching linking faults. In order to attribute shoreline deformation to fault activity we identify shoreline elevation anomalies, where deformation exceeds a ± 3.34 m window, which encompass our conservative estimates of natural variability in the shoreline geomorphology and the error associated with the data collection. Fault activity along the main length of the fault for each ramp-breaching style is concentrated near the intersection of the linking fault and the outboard portion of the main fault segment. However, fault activity along the outboard fault tip varies according to breaching style. At a footwall breach the entire outboard fault tip appears relatively inactive. At a mid-ramp breach the outboard fault tip remains relatively active because of the proximity of the linking fault to this fault tip.

An empirical study of flight control software reliability

NASA Technical Reports Server (NTRS)

Dunham, J. R.; Pierce, J. L.

1986-01-01

The results of a laboratory experiment in flight control software reliability are reported. The experiment tests a small sample of implementations of a pitch axis control law for a PA28 aircraft with over 14 million pitch commands with varying levels of additive input and feedback noise. The testing which uses the method of n-version programming for error detection surfaced four software faults in one implementation of the control law. The small number of detected faults precluded the conduct of the error burst analyses. The pitch axis problem provides data for use in constructing a model in the prediction of the reliability of software in systems with feedback. The study is undertaken to find means to perform reliability evaluations of flight control software.

Disjointness of Stabilizer Codes and Limitations on Fault-Tolerant Logical Gates

NASA Astrophysics Data System (ADS)

Jochym-O'Connor, Tomas; Kubica, Aleksander; Yoder, Theodore J.

2018-04-01

Stabilizer codes are among the most successful quantum error-correcting codes, yet they have important limitations on their ability to fault tolerantly compute. Here, we introduce a new quantity, the disjointness of the stabilizer code, which, roughly speaking, is the number of mostly nonoverlapping representations of any given nontrivial logical Pauli operator. The notion of disjointness proves useful in limiting transversal gates on any error-detecting stabilizer code to a finite level of the Clifford hierarchy. For code families, we can similarly restrict logical operators implemented by constant-depth circuits. For instance, we show that it is impossible, with a constant-depth but possibly geometrically nonlocal circuit, to implement a logical non-Clifford gate on the standard two-dimensional surface code.

Assessing pediatrics residents' mathematical skills for prescribing medication: a need for improved training.

PubMed

Glover, Mark L; Sussmane, Jeffrey B

2002-10-01

To evaluate residents' skills in performing basic mathematical calculations used for prescribing medications to pediatric patients. In 2001, a test of ten questions on basic calculations was given to first-, second-, and third-year residents at Miami Children's Hospital in Florida. Four additional questions were included to obtain the residents' levels of training, specific pediatrics intensive care unit (PICU) experience, and whether or not they routinely double-checked doses and adjusted them for each patient's weight. The test was anonymous and calculators were permitted. The overall score and the score for each resident class were calculated. Twenty-one residents participated. The overall average test score and the mean test score of each resident class was less than 70%. Second-year residents had the highest mean test scores, although there was no significant difference between the classes of residents (p =.745) or relationship between the residents' PICU experiences and their exam scores (p =.766). There was no significant difference between residents' levels of training and whether they double-checked their calculations (p =.633) or considered each patient's weight relative to the dose prescribed (p =.869). Seven residents committed tenfold dosing errors, and one resident committed a 1,000-fold dosing error. Pediatrics residents need to receive additional education in performing the calculations needed to prescribe medications. In addition, residents should be required to demonstrate these necessary mathematical skills before they are allowed to prescribe medications.

Response to "Improving Patient Safety With Error Identification in Chemotherapy Orders by Verification Nurses"
.

PubMed

Zhu, Ling-Ling; Lv, Na; Zhou, Quan

2016-12-01

We read, with great interest, the study by Baldwin and Rodriguez (2016), which described the role of the verification nurse and details the verification process in identifying errors related to chemotherapy orders. We strongly agree with their findings that a verification nurse, collaborating closely with the prescribing physician, pharmacist, and treating nurse, can better identify errors and maintain safety during chemotherapy administration.

Surrogate oracles, generalized dependency and simpler models

NASA Technical Reports Server (NTRS)

Wilson, Larry

1990-01-01

Software reliability models require the sequence of interfailure times from the debugging process as input. It was previously illustrated that using data from replicated debugging could greatly improve reliability predictions. However, inexpensive replication of the debugging process requires the existence of a cheap, fast error detector. Laboratory experiments can be designed around a gold version which is used as an oracle or around an n-version error detector. Unfortunately, software developers can not be expected to have an oracle or to bear the expense of n-versions. A generic technique is being investigated for approximating replicated data by using the partially debugged software as a difference detector. It is believed that the failure rate of each fault has significant dependence on the presence or absence of other faults. Thus, in order to discuss a failure rate for a known fault, the presence or absence of each of the other known faults needs to be specified. Also, in simpler models which use shorter input sequences without sacrificing accuracy are of interest. In fact, a possible gain in performance is conjectured. To investigate these propositions, NASA computers running LIC (RTI) versions are used to generate data. This data will be used to label the debugging graph associated with each version. These labeled graphs will be used to test the utility of a surrogate oracle, to analyze the dependent nature of fault failure rates and to explore the feasibility of reliability models which use the data of only the most recent failures.

Clinical Errors and Medical Negligence

PubMed Central

Oyebode, Femi

2013-01-01

This paper discusses the definition, nature and origins of clinical errors including their prevention. The relationship between clinical errors and medical negligence is examined as are the characteristics of litigants and events that are the source of litigation. The pattern of malpractice claims in different specialties and settings is examined. Among hospitalized patients worldwide, 3–16s% suffer injury as a result of medical intervention, the most common being the adverse effects of drugs. The frequency of adverse drug effects appears superficially to be higher in intensive care units and emergency departments but once rates have been corrected for volume of patients, comorbidity of conditions and number of drugs prescribed, the difference is not significant. It is concluded that probably no more than 1 in 7 adverse events in medicine result in a malpractice claim and the factors that predict that a patient will resort to litigation include a prior poor relationship with the clinician and the feeling that the patient is not being kept informed. Methods for preventing clinical errors are still in their infancy. The most promising include new technologies such as electronic prescribing systems, diagnostic and clinical decision-making aids and error-resistant systems. PMID:23343656

Clinical errors and medical negligence.

PubMed

Oyebode, Femi

2013-01-01

This paper discusses the definition, nature and origins of clinical errors including their prevention. The relationship between clinical errors and medical negligence is examined as are the characteristics of litigants and events that are the source of litigation. The pattern of malpractice claims in different specialties and settings is examined. Among hospitalized patients worldwide, 3-16% suffer injury as a result of medical intervention, the most common being the adverse effects of drugs. The frequency of adverse drug effects appears superficially to be higher in intensive care units and emergency departments but once rates have been corrected for volume of patients, comorbidity of conditions and number of drugs prescribed, the difference is not significant. It is concluded that probably no more than 1 in 7 adverse events in medicine result in a malpractice claim and the factors that predict that a patient will resort to litigation include a prior poor relationship with the clinician and the feeling that the patient is not being kept informed. Methods for preventing clinical errors are still in their infancy. The most promising include new technologies such as electronic prescribing systems, diagnostic and clinical decision-making aids and error-resistant systems. Copyright © 2013 S. Karger AG, Basel.

Implementation Of The Configurable Fault Tolerant System Experiment On NPSAT 1

DTIC Science & Technology

2016-03-01

REPORT TYPE AND DATES COVERED Master’s thesis 4. TITLE AND SUBTITLE IMPLEMENTATION OF THE CONFIGURABLE FAULT TOLERANT SYSTEM EXPERIMENT ON NPSAT...open-source microprocessor without interlocked pipeline stages (MIPS) based processor softcore, a cached memory structure capable of accessing double...data rate type three and secure digital card memories, an interface to the main satellite bus, and XILINX’s soft error mitigation softcore. The

U.S. Navy Fault-Tolerant Microcomputer.

DTIC Science & Technology

1982-07-01

105 8929 SEPULVEDA BLVD. LOS ANGELES, CALIFORNIA 90045 To: DEFENSE TECHNICAL INFORMATION CENTER Fal-ae Technoog Corporation MILITARY STANDARD FAULT...maintainability. Com- puter errors at any significant level can be disastrous in terms of human injury, aborted missions, loss of critical information and...employed to resolve the question "who checks the checker?" The IOC votes on information received from the bus and outputs the maiority decision. Thus no

SCADA-based Operator Support System for Power Plant Equipment Fault Forecasting

NASA Astrophysics Data System (ADS)

Mayadevi, N.; Ushakumari, S. S.; Vinodchandra, S. S.

2014-12-01

Power plant equipment must be monitored closely to prevent failures from disrupting plant availability. Online monitoring technology integrated with hybrid forecasting techniques can be used to prevent plant equipment faults. A self learning rule-based expert system is proposed in this paper for fault forecasting in power plants controlled by supervisory control and data acquisition (SCADA) system. Self-learning utilizes associative data mining algorithms on the SCADA history database to form new rules that can dynamically update the knowledge base of the rule-based expert system. In this study, a number of popular associative learning algorithms are considered for rule formation. Data mining results show that the Tertius algorithm is best suited for developing a learning engine for power plants. For real-time monitoring of the plant condition, graphical models are constructed by K-means clustering. To build a time-series forecasting model, a multi layer preceptron (MLP) is used. Once created, the models are updated in the model library to provide an adaptive environment for the proposed system. Graphical user interface (GUI) illustrates the variation of all sensor values affecting a particular alarm/fault, as well as the step-by-step procedure for avoiding critical situations and consequent plant shutdown. The forecasting performance is evaluated by computing the mean absolute error and root mean square error of the predictions.

Towards New Metrics for High-Performance Computing Resilience

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

Hukerikar, Saurabh; Ashraf, Rizwan A; Engelmann, Christian

Ensuring the reliability of applications is becoming an increasingly important challenge as high-performance computing (HPC) systems experience an ever-growing number of faults, errors and failures. While the HPC community has made substantial progress in developing various resilience solutions, it continues to rely on platform-based metrics to quantify application resiliency improvements. The resilience of an HPC application is concerned with the reliability of the application outcome as well as the fault handling efficiency. To understand the scope of impact, effective coverage and performance efficiency of existing and emerging resilience solutions, there is a need for new metrics. In this paper, wemore » develop new ways to quantify resilience that consider both the reliability and the performance characteristics of the solutions from the perspective of HPC applications. As HPC systems continue to evolve in terms of scale and complexity, it is expected that applications will experience various types of faults, errors and failures, which will require applications to apply multiple resilience solutions across the system stack. The proposed metrics are intended to be useful for understanding the combined impact of these solutions on an application's ability to produce correct results and to evaluate their overall impact on an application's performance in the presence of various modes of faults.« less

Fault detection of helicopter gearboxes using the multi-valued influence matrix method

NASA Technical Reports Server (NTRS)

Chin, Hsinyung; Danai, Kourosh; Lewicki, David G.

1993-01-01

In this paper we investigate the effectiveness of a pattern classifying fault detection system that is designed to cope with the variability of fault signatures inherent in helicopter gearboxes. For detection, the measurements are monitored on-line and flagged upon the detection of abnormalities, so that they can be attributed to a faulty or normal case. As such, the detection system is composed of two components, a quantization matrix to flag the measurements, and a multi-valued influence matrix (MVIM) that represents the behavior of measurements during normal operation and at fault instances. Both the quantization matrix and influence matrix are tuned during a training session so as to minimize the error in detection. To demonstrate the effectiveness of this detection system, it was applied to vibration measurements collected from a helicopter gearbox during normal operation and at various fault instances. The results indicate that the MVIM method provides excellent results when the full range of faults effects on the measurements are included in the training set.

Algorithm-Based Fault Tolerance for Numerical Subroutines

NASA Technical Reports Server (NTRS)

Tumon, Michael; Granat, Robert; Lou, John

2007-01-01

A software library implements a new methodology of detecting faults in numerical subroutines, thus enabling application programs that contain the subroutines to recover transparently from single-event upsets. The software library in question is fault-detecting middleware that is wrapped around the numericalsubroutines. Conventional serial versions (based on LAPACK and FFTW) and a parallel version (based on ScaLAPACK) exist. The source code of the application program that contains the numerical subroutines is not modified, and the middleware is transparent to the user. The methodology used is a type of algorithm- based fault tolerance (ABFT). In ABFT, a checksum is computed before a computation and compared with the checksum of the computational result; an error is declared if the difference between the checksums exceeds some threshold. Novel normalization methods are used in the checksum comparison to ensure correct fault detections independent of algorithm inputs. In tests of this software reported in the peer-reviewed literature, this library was shown to enable detection of 99.9 percent of significant faults while generating no false alarms.

Reliability of Measured Data for pH Sensor Arrays with Fault Diagnosis and Data Fusion Based on LabVIEW

PubMed Central

Liao, Yi-Hung; Chou, Jung-Chuan; Lin, Chin-Yi

2013-01-01

Fault diagnosis (FD) and data fusion (DF) technologies implemented in the LabVIEW program were used for a ruthenium dioxide pH sensor array. The purpose of the fault diagnosis and data fusion technologies is to increase the reliability of measured data. Data fusion is a very useful statistical method used for sensor arrays in many fields. Fault diagnosis is used to avoid sensor faults and to measure errors in the electrochemical measurement system, therefore, in this study, we use fault diagnosis to remove any faulty sensors in advance, and then proceed with data fusion in the sensor array. The average, self-adaptive and coefficient of variance data fusion methods are used in this study. The pH electrode is fabricated with ruthenium dioxide (RuO2) sensing membrane using a sputtering system to deposit it onto a silicon substrate, and eight RuO2 pH electrodes are fabricated to form a sensor array for this study. PMID:24351636

Reliability of measured data for pH sensor arrays with fault diagnosis and data fusion based on LabVIEW.

PubMed

Liao, Yi-Hung; Chou, Jung-Chuan; Lin, Chin-Yi

2013-12-13

Fault diagnosis (FD) and data fusion (DF) technologies implemented in the LabVIEW program were used for a ruthenium dioxide pH sensor array. The purpose of the fault diagnosis and data fusion technologies is to increase the reliability of measured data. Data fusion is a very useful statistical method used for sensor arrays in many fields. Fault diagnosis is used to avoid sensor faults and to measure errors in the electrochemical measurement system, therefore, in this study, we use fault diagnosis to remove any faulty sensors in advance, and then proceed with data fusion in the sensor array. The average, self-adaptive and coefficient of variance data fusion methods are used in this study. The pH electrode is fabricated with ruthenium dioxide (RuO2) sensing membrane using a sputtering system to deposit it onto a silicon substrate, and eight RuO2 pH electrodes are fabricated to form a sensor array for this study.

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

A study of the relationship between the performance and dependability of a fault-tolerant computer

NASA Technical Reports Server (NTRS)

Goswami, Kumar K.

1994-01-01

This thesis studies the relationship by creating a tool (FTAPE) that integrates a high stress workload generator with fault injection and by using the tool to evaluate system performance under error conditions. The workloads are comprised of processes which are formed from atomic components that represent CPU, memory, and I/O activity. The fault injector is software-implemented and is capable of injecting any memory addressable location, including special registers and caches. This tool has been used to study a Tandem Integrity S2 Computer. Workloads with varying numbers of processes and varying compositions of CPU, memory, and I/O activity are first characterized in terms of performance. Then faults are injected into these workloads. The results show that as the number of concurrent processes increases, the mean fault latency initially increases due to increased contention for the CPU. However, for even higher numbers of processes (less than 3 processes), the mean latency decreases because long latency faults are paged out before they can be activated.

Error threshold for color codes and random three-body Ising models.

PubMed

Katzgraber, Helmut G; Bombin, H; Martin-Delgado, M A

2009-08-28

We study the error threshold of color codes, a class of topological quantum codes that allow a direct implementation of quantum Clifford gates suitable for entanglement distillation, teleportation, and fault-tolerant quantum computation. We map the error-correction process onto a statistical mechanical random three-body Ising model and study its phase diagram via Monte Carlo simulations. The obtained error threshold of p(c) = 0.109(2) is very close to that of Kitaev's toric code, showing that enhanced computational capabilities do not necessarily imply lower resistance to noise.

Necessity of using heterogeneous ellipsoidal Earth model with terrain to calculate co-seismic effect

NASA Astrophysics Data System (ADS)

Cheng, Huihong; Zhang, Bei; Zhang, Huai; Huang, Luyuan; Qu, Wulin; Shi, Yaolin

2016-04-01

Co-seismic deformation and stress changes, which reflect the elasticity of the earth, are very important in the earthquake dynamics, and also to other issues, such as the evaluation of the seismic risk, fracture process and triggering of earthquake. Lots of scholars have researched the dislocation theory and co-seismic deformation and obtained the half-space homogeneous model, half-space stratified model, spherical stratified model, and so on. Especially, models of Okada (1992) and Wang (2003, 2006) are widely applied in the research of calculating co-seismic and post-seismic effects. However, since both semi-infinite space model and layered model do not take the role of the earth curvature or heterogeneity or topography into consideration, there are large errors in calculating the co-seismic displacement of a great earthquake in its impacted area. Meanwhile, the computational methods of calculating the co-seismic strain and stress are different between spherical model and plane model. Here, we adopted the finite element method which could well deal with the complex characteristics (such as anisotropy, discontinuities) of rock and different conditions. We use the mash adaptive technique to automatically encrypt the mesh at the fault and adopt the equivalent volume force replace the dislocation source, which can avoid the difficulty in handling discontinuity surface with conventional (Zhang et al., 2015). We constructed an earth model that included earth's layered structure and curvature, the upper boundary was set as a free surface and the core-mantle boundary was set under buoyancy forces. Firstly, based on the precision requirement, we take a testing model - - a strike-slip fault (the length of fault is 500km and the width is 50km, and the slippage is 10m) for example. Because of the curvature of the Earth, some errors certainly occur in plane coordinates just as previous studies (Dong et al., 2014; Sun et al., 2012). However, we also found that: 1) the co-seismic displacement and strain are no longer symmetric with different latitudes in plane model while always theoretically symmetrical in spherical model. 2) The errors of co-seismic strain will be increased when using corresponding formulas in plane coordinate. When we set the strike-slip fault along the equator, the maximum relative error can reach to several tens of thousand times in high latitude while 30 times near the fault. 3) The style of strain changes are eight petals while the errors are four petals, and apparent distortion at high latitudes. Furthermore, the influence of the earth's ellipticity and heterogeneity and terrain were calculated respectively. Especially the effect of terrain, which induced huge differences, should not be overlooked during the co-seismic calculations. Finally, taking all those affecting factors into account, we calculated the co-seismic effect of the 2008 Wenchuan earthquake and its adjacent area and faults using the heterogeneous ellipsoidal Earth model with terrain.

Pattern and Predictors of Medication Dosing Errors in Chronic Kidney Disease Patients in Pakistan: A Single Center Retrospective Analysis

PubMed Central

Saleem, Ahsan; Masood, Imran

2016-01-01

Background Chronic kidney disease (CKD) alters the pharmacokinetic and pharmacodynamic response of various drugs and increases the risk of toxicity. The data regarding the pattern and predictors of medication dosing errors is scare from the developing countries. Therefore, the present study was conducted to assess the pattern and predictors of medication dosing errors in CKD patients in a tertiary care setting in Pakistan. Methods A retrospective study design was employed and medical charts of all those CKD patients who had an eGFR ≤60ml/min/1.73m2, hospitalization ≥24 hours, and admitted in the nephrology unit during January 2013 to December 2014 were assessed. Descriptive statistics and the logistic regression analysis were done using IBM SPSS version 20. Results In total, 205 medical charts were assessed. The mean age of patients was 38.64 (±16.82) years. Overall, 1534 drugs were prescribed to CKD patients, of which, nearly 34.0% drugs required dose adjustment. Among those drugs, only 41.8% were properly adjusted, and the remaining 58.2% were unadjusted. The logistic regression analysis revealed that the medication dosing errors were significantly associated with the CKD stages, i.e. stage 4 (OR 0.054; 95% CI [0.017–0.177]; p <0.001) and stage 5 (OR 0.098; 95% CI [0.040–0.241]; p <0.001), the number of prescribed medicines ≥ 5 (OR 0.306; 95% CI [0.133–0.704]; p 0.005), and the presence of a comorbidity (OR 0.455; 95% CI [0.226–0.916]; p 0.027) such as the hypertension (OR 0.453; 95% CI [0.231–0.887]; p 0.021). Conclusions It is concluded that more than half drugs prescribed to CKD patients requiring dose adjustment were unadjusted. The predictors of medication dosing errors were the severe-to-end stages of chronic kidney disease, the presence of a comorbidity such as hypertension, and a higher number of prescribed medicines. Therefore, attention should be paid to these risk factors. PMID:27367594

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

PubMed

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

2016-03-01

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

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

Chen, S.; Peng, L.; Bronevetsky, G.

As HPC systems approach Exascale, their circuit feature will shrink, while their overall size will grow, all at a fixed power limit. These trends imply that soft faults in electronic circuits will become an increasingly significant problem for applications that run on these systems, causing them to occasionally crash or worse, silently return incorrect results. This is motivating extensive work on application resilience to such faults, ranging from generic techniques such as replication or checkpoint/restart to algorithm-specific error detection and resilience techniques. Effective use of such techniques requires a detailed understanding of (1) which vulnerable parts of the application aremore » most worth protecting (2) the performance and resilience impact of fault resilience mechanisms on the application. This paper presents FaultTelescope, a tool that combines these two and generates actionable insights by presenting in an intuitive way application vulnerabilities and impact of fault resilience mechanisms on applications.« less

Narrowing the scope of failure prediction using targeted fault load injection

NASA Astrophysics Data System (ADS)

Jordan, Paul L.; Peterson, Gilbert L.; Lin, Alan C.; Mendenhall, Michael J.; Sellers, Andrew J.

2018-05-01

As society becomes more dependent upon computer systems to perform increasingly critical tasks, ensuring that those systems do not fail becomes increasingly important. Many organizations depend heavily on desktop computers for day-to-day operations. Unfortunately, the software that runs on these computers is written by humans and, as such, is still subject to human error and consequent failure. A natural solution is to use statistical machine learning to predict failure. However, since failure is still a relatively rare event, obtaining labelled training data to train these models is not a trivial task. This work presents new simulated fault-inducing loads that extend the focus of traditional fault injection techniques to predict failure in the Microsoft enterprise authentication service and Apache web server. These new fault loads were successful in creating failure conditions that were identifiable using statistical learning methods, with fewer irrelevant faults being created.

Integral Sliding Mode Fault-Tolerant Control for Uncertain Linear Systems Over Networks With Signals Quantization.

PubMed

Hao, Li-Ying; Park, Ju H; Ye, Dan

2017-09-01

In this paper, a new robust fault-tolerant compensation control method for uncertain linear systems over networks is proposed, where only quantized signals are assumed to be available. This approach is based on the integral sliding mode (ISM) method where two kinds of integral sliding surfaces are constructed. One is the continuous-state-dependent surface with the aim of sliding mode stability analysis and the other is the quantization-state-dependent surface, which is used for ISM controller design. A scheme that combines the adaptive ISM controller and quantization parameter adjustment strategy is then proposed. Through utilizing H ∞ control analytical technique, once the system is in the sliding mode, the nature of performing disturbance attenuation and fault tolerance from the initial time can be found without requiring any fault information. Finally, the effectiveness of our proposed ISM control fault-tolerant schemes against quantization errors is demonstrated in the simulation.

Development and analysis of the Software Implemented Fault-Tolerance (SIFT) computer

NASA Technical Reports Server (NTRS)

Goldberg, J.; Kautz, W. H.; Melliar-Smith, P. M.; Green, M. W.; Levitt, K. N.; Schwartz, R. L.; Weinstock, C. B.

1984-01-01

SIFT (Software Implemented Fault Tolerance) is an experimental, fault-tolerant computer system designed to meet the extreme reliability requirements for safety-critical functions in advanced aircraft. Errors are masked by performing a majority voting operation over the results of identical computations, and faulty processors are removed from service by reassigning computations to the nonfaulty processors. This scheme has been implemented in a special architecture using a set of standard Bendix BDX930 processors, augmented by a special asynchronous-broadcast communication interface that provides direct, processor to processor communication among all processors. Fault isolation is accomplished in hardware; all other fault-tolerance functions, together with scheduling and synchronization are implemented exclusively by executive system software. The system reliability is predicted by a Markov model. Mathematical consistency of the system software with respect to the reliability model has been partially verified, using recently developed tools for machine-aided proof of program correctness.

Privacy-Assured Aggregation Protocol for Smart Metering: A Proactive Fault-Tolerant Approach [Proactive Fault-Tolerant Aggregation Protocol for Privacy-Assured Smart Metering

DOE PAGES

Won, Jongho; Ma, Chris Y. T.; Yau, David K. Y.; ...

2016-06-01

Smart meters are integral to demand response in emerging smart grids, by reporting the electricity consumption of users to serve application needs. But reporting real-time usage information for individual households raises privacy concerns. Existing techniques to guarantee differential privacy (DP) of smart meter users either are not fault tolerant or achieve (possibly partial) fault tolerance at high communication overheads. In this paper, we propose a fault-tolerant protocol for smart metering that can handle general communication failures while ensuring DP with significantly improved efficiency and lower errors compared with the state of the art. Our protocol handles fail-stop faults proactively bymore » using a novel design of future ciphertexts, and distributes trust among the smart meters by sharing secret keys among them. We prove the DP properties of our protocol and analyze its advantages in fault tolerance, accuracy, and communication efficiency relative to competing techniques. We illustrate our analysis by simulations driven by real-world traces of electricity consumption.« less

A no-fault compensation system for medical injury is long overdue.

PubMed

Weisbrot, David; Breen, Kerry J

2012-09-03

The 2011 report of the Productivity Commission (PC) recommended the establishment of a no-fault national injury insurance scheme limited to "catastrophic" injury, including medical injury. The report is welcome, but represents a missed opportunity to establish simultaneously a much-needed no-fault scheme for all medical injuries. The existing indemnity scheme based on negligence remains a slow, costly, inefficient, ill targeted and stress-creating system. A fault-based negligence scheme cannot deter non-intentional errors and does little to identify or prevent systems failures. In addition, it discourages reporting, and thus is antithetical to the modern focus on universal patient safety. A no-fault scheme has the potential to be fairer, quicker and no more costly, and to contribute to patient safety. No-fault schemes have been in place in at least six developed countries for many years. This extensive experience in comparable countries should be examined to assist Australia to design an effective, comprehensive system. Before implementing the recommendations of the PC, the federal government should ask the Commission to study and promptly report on an ancillary no-fault scheme that covers all medical injury.

Privacy-Assured Aggregation Protocol for Smart Metering: A Proactive Fault-Tolerant Approach [Proactive Fault-Tolerant Aggregation Protocol for Privacy-Assured Smart Metering

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

Won, Jongho; Ma, Chris Y. T.; Yau, David K. Y.

Smart meters are integral to demand response in emerging smart grids, by reporting the electricity consumption of users to serve application needs. But reporting real-time usage information for individual households raises privacy concerns. Existing techniques to guarantee differential privacy (DP) of smart meter users either are not fault tolerant or achieve (possibly partial) fault tolerance at high communication overheads. In this paper, we propose a fault-tolerant protocol for smart metering that can handle general communication failures while ensuring DP with significantly improved efficiency and lower errors compared with the state of the art. Our protocol handles fail-stop faults proactively bymore » using a novel design of future ciphertexts, and distributes trust among the smart meters by sharing secret keys among them. We prove the DP properties of our protocol and analyze its advantages in fault tolerance, accuracy, and communication efficiency relative to competing techniques. We illustrate our analysis by simulations driven by real-world traces of electricity consumption.« less

Prevalence of refractive error among preschool children in an urban population: the Baltimore Pediatric Eye Disease Study.

PubMed

Giordano, Lydia; Friedman, David S; Repka, Michael X; Katz, Joanne; Ibironke, Josephine; Hawes, Patricia; Tielsch, James M

2009-04-01

To determine the age-specific prevalence of refractive errors in white and African-American preschool children. The Baltimore Pediatric Eye Disease Study is a population-based evaluation of the prevalence of ocular disorders in children aged 6 to 71 months in Baltimore, Maryland. Among 4132 children identified, 3990 eligible children (97%) were enrolled and 2546 children (62%) were examined. Cycloplegic autorefraction was attempted in all children with the use of a Nikon Retinomax K-Plus 2 (Nikon Corporation, Tokyo, Japan). If a reliable autorefraction could not be obtained after 3 attempts, cycloplegic streak retinoscopy was performed. Mean spherical equivalent (SE) refractive error, astigmatism, and prevalence of higher refractive errors among African-American and white children. The mean SE of right eyes was +1.49 diopters (D) (standard deviation [SD] = 1.23) in white children and +0.71 D (SD = 1.35) in African-American children (mean difference of 0.78 D; 95% confidence interval [CI], 0.67-0.89). Mean SE refractive error did not decline with age in either group. The prevalence of myopia of 1.00 D or more in the eye with the lesser refractive error was 0.7% in white children and 5.5% in African-American children (relative risk [RR], 8.01; 95% CI, 3.70-17.35). The prevalence of hyperopia of +3 D or more in the eye with the lesser refractive error was 8.9% in white children and 4.4% in African-American children (RR, 0.49; 95% CI, 0.35-0.68). The prevalence of emmetropia (<-1.00 D to <+1.00 D) was 35.6% in white children and 58.0% in African-American children (RR, 1.64; 95% CI, 1.49-1.80). On the basis of published prescribing guidelines, 5.1% of the children would have benefited from spectacle correction. However, only 1.3% had been prescribed correction. Significant refractive errors are uncommon in this population of urban preschool children. There was no evidence for a myopic shift over this age range in this cross-sectional study. A small proportion of preschool children would likely benefit from refractive correction, but few have had this prescribed.

Robust approximation-free prescribed performance control for nonlinear systems and its application

NASA Astrophysics Data System (ADS)

Sun, Ruisheng; Na, Jing; Zhu, Bin

2018-02-01

This paper presents a robust prescribed performance control approach and its application to nonlinear tail-controlled missile systems with unknown dynamics and uncertainties. The idea of prescribed performance function (PPF) is incorporated into the control design, such that both the steady-state and transient control performance can be strictly guaranteed. Unlike conventional PPF-based control methods, we further tailor a recently proposed systematic control design procedure (i.e. approximation-free control) using the transformed tracking error dynamics, which provides a proportional-like control action. Hence, the function approximators (e.g. neural networks, fuzzy systems) that are widely used to address the unknown nonlinearities in the nonlinear control designs are not needed. The proposed control design leads to a robust yet simplified function approximation-free control for nonlinear systems. The closed-loop system stability and the control error convergence are all rigorously proved. Finally, comparative simulations are conducted based on nonlinear missile systems to validate the improved response and the robustness of the proposed control method.

Results of the Arizona Medicaid health information technology pharmacy focus groups.

PubMed

Warholak, Terri L; Murcko, Anita; McKee, Megan; Urbine, Terry

2011-12-01

In 2007, a federal Medicaid Transformation Grant was awarded to design, develop, and deploy a statewide Health Information Exchange and Electronic Health Record in Arizona, United States. To explore the health information technology needs, knowledge, and expectations of Arizona's health care professionals, moderated focus groups were conducted. This article describes the results of the pharmacist focus groups. Focus group activities included a brief presentation, completion of a paper-based survey, and group discussion. The methods included solicitation by invitation, participant selection, meeting content, collaterals, focus group execution, recording, analysis, and discerning comparability among groups. Pharmacy focus group discussions centered on electronic prescribing, including the anticipated advantages: reducing handwriting interpretation errors, improving formulary compliance, improving communication with prescribers, increasing efficiency, and ensuring data accuracy. Disadvantages included: medication errors, inadequate training and knowledge of software applications, and inflated patient expectations. Pharmacists ranked e-prescribing as the highest priority feature of an electronic health system. Copyright © 2011 Elsevier Inc. All rights reserved.

The impact of model prediction error in designing geodetic networks for crustal deformation applications

NASA Astrophysics Data System (ADS)

Murray, J. R.

2017-12-01

Earth surface displacements measured at Global Navigation Satellite System (GNSS) sites record crustal deformation due, for example, to slip on faults underground. A primary objective in designing geodetic networks to study crustal deformation is to maximize the ability to recover parameters of interest like fault slip. Given Green's functions (GFs) relating observed displacement to motion on buried dislocations representing a fault, one can use various methods to estimate spatially variable slip. However, assumptions embodied in the GFs, e.g., use of a simplified elastic structure, introduce spatially correlated model prediction errors (MPE) not reflected in measurement uncertainties (Duputel et al., 2014). In theory, selection algorithms should incorporate inter-site correlations to identify measurement locations that give unique information. I assess the impact of MPE on site selection by expanding existing methods (Klein et al., 2017; Reeves and Zhe, 1999) to incorporate this effect. Reeves and Zhe's algorithm sequentially adds or removes a predetermined number of data according to a criterion that minimizes the sum of squared errors (SSE) on parameter estimates. Adapting this method to GNSS network design, Klein et al. select new sites that maximize model resolution, using trade-off curves to determine when additional resolution gain is small. Their analysis uses uncorrelated data errors and GFs for a uniform elastic half space. I compare results using GFs for spatially variable strike slip on a discretized dislocation in a uniform elastic half space, a layered elastic half space, and a layered half space with inclusion of MPE. I define an objective criterion to terminate the algorithm once the next site removal would increase SSE more than the expected incremental SSE increase if all sites had equal impact. Using a grid of candidate sites with 8 km spacing, I find the relative value of the selected sites (defined by the percent increase in SSE that further removal of each site would cause) is more uniform when MPE is included. However, the number and distribution of selected sites depends primarily on site location relative to the fault. For this test case, inclusion of MPE has minimal practical impact; I will investigate whether these findings hold for more densely spaced candidate grids and dipping faults.

Loss Tolerance in One-Way Quantum Computation via Counterfactual Error Correction

NASA Astrophysics Data System (ADS)

Varnava, Michael; Browne, Daniel E.; Rudolph, Terry

2006-09-01

We introduce a scheme for fault tolerantly dealing with losses (or other “leakage” errors) in cluster state computation that can tolerate up to 50% qubit loss. This is achieved passively using an adaptive strategy of measurement—no coherent measurements or coherent correction is required. Since the scheme relies on inferring information about what would have been the outcome of a measurement had one been able to carry it out, we call this counterfactual error correction.

Delivery and application of precise timing for a traveling wave powerline fault locator system

NASA Technical Reports Server (NTRS)

Street, Michael A.

1990-01-01

The Bonneville Power Administration (BPA) has successfully operated an in-house developed powerline fault locator system since 1986. The BPA fault locator system consists of remotes installed at cardinal power transmission line system nodes and a central master which polls the remotes for traveling wave time-of-arrival data. A power line fault produces a fast rise-time traveling wave which emanates from the fault point and propagates throughout the power grid. The remotes time-tag the traveling wave leading edge as it passes through the power system cardinal substation nodes. A synchronizing pulse transmitted via the BPA analog microwave system on a wideband channel sychronizes the time-tagging counters in the remote units to a different accuracy of better than one microsecond. The remote units correct the raw time tags for synchronizing pulse propagation delay and return these corrected values to the fault locator master. The master then calculates the power system disturbance source using the collected time tags. The system design objective is a fault location accuracy of 300 meters. BPA's fault locator system operation, error producing phenomena, and method of distributing precise timing are described.

Fault detection, isolation, and diagnosis of self-validating multifunctional sensors.

PubMed

Yang, Jing-Li; Chen, Yin-Sheng; Zhang, Li-Li; Sun, Zhen

2016-06-01

A novel fault detection, isolation, and diagnosis (FDID) strategy for self-validating multifunctional sensors is presented in this paper. The sparse non-negative matrix factorization-based method can effectively detect faults by using the squared prediction error (SPE) statistic, and the variables contribution plots based on SPE statistic can help to locate and isolate the faulty sensitive units. The complete ensemble empirical mode decomposition is employed to decompose the fault signals to a series of intrinsic mode functions (IMFs) and a residual. The sample entropy (SampEn)-weighted energy values of each IMFs and the residual are estimated to represent the characteristics of the fault signals. Multi-class support vector machine is introduced to identify the fault mode with the purpose of diagnosing status of the faulty sensitive units. The performance of the proposed strategy is compared with other fault detection strategies such as principal component analysis, independent component analysis, and fault diagnosis strategies such as empirical mode decomposition coupled with support vector machine. The proposed strategy is fully evaluated in a real self-validating multifunctional sensors experimental system, and the experimental results demonstrate that the proposed strategy provides an excellent solution to the FDID research topic of self-validating multifunctional sensors.

A systematic review of clinical pharmacist interventions in paediatric hospital patients.

PubMed

Drovandi, Aaron; Robertson, Kelvin; Tucker, Matthew; Robinson, Niechole; Perks, Stephen; Kairuz, Therése

2018-06-19

Clinical pharmacists provide beneficial services to adult patients, though their benefits for paediatric hospital patients are less defined. Five databases were searched using the MeSH terms 'clinical pharmacist', 'paediatric/paediatric', 'hospital', and 'intervention' for studies with paediatric patients conducted in hospital settings, and described pharmacist-initiated interventions, published between January 2000 and October 2017. The search strategy after full-text review identified 12 articles matching the eligibility criteria. Quality appraisal checklists from the Joanna Briggs Institute were used to appraise the eligible articles. Clinical pharmacist services had a positive impact on paediatric patient care. Medication errors intercepted by pharmacists included over- and under-dosing, missed doses, medication history gaps, allergies, and near-misses. Interventions to address these errors were positively received, and implemented by physicians, with an average acceptance rate of over 95%. Clinical pharmacist-initiated education resulted in improved medication understanding and adherence, improved patient satisfaction, and control of chronic medical conditions. This review found that clinical pharmacists in paediatric wards may reduce drug-related problems and improve patient outcomes. The benefits of pharmacist involvement appear greatest when directly involved in ward rounds, due to being able to more rapidly identify medication errors during the prescribing phase, and provide real-time advice and recommendations to prescribers. What is Known: • Complex paediatric conditions can require multiple pharmaceutical treatments, utilised in a safe manner to ensure good patient outcomes • The benefits of pharmacist interventions when using these treatments are well-documented in adult patients, though less so in paediatric patients What is New: • Pharmacists are adept at identifying and managing medication errors for paediatric patients, including incorrect doses, missed doses, and gaps in medication history • Interventions recommended by pharmacists are generally well-accepted by prescribing physicians, especially when recommendations can be made during the prescribing phase of treatment.

Combining task analysis and fault tree analysis for accident and incident analysis: a case study from Bulgaria.

PubMed

Doytchev, Doytchin E; Szwillus, Gerd

2009-11-01

Understanding the reasons for incident and accident occurrence is important for an organization's safety. Different methods have been developed to achieve this goal. To better understand the human behaviour in incident occurrence we propose an analysis concept that combines Fault Tree Analysis (FTA) and Task Analysis (TA). The former method identifies the root causes of an accident/incident, while the latter analyses the way people perform the tasks in their work environment and how they interact with machines or colleagues. These methods were complemented with the use of the Human Error Identification in System Tools (HEIST) methodology and the concept of Performance Shaping Factors (PSF) to deepen the insight into the error modes of an operator's behaviour. HEIST shows the external error modes that caused the human error and the factors that prompted the human to err. To show the validity of the approach, a case study at a Bulgarian Hydro power plant was carried out. An incident - the flooding of the plant's basement - was analysed by combining the afore-mentioned methods. The case study shows that Task Analysis in combination with other methods can be applied successfully to human error analysis, revealing details about erroneous actions in a realistic situation.

Making classical ground-state spin computing fault-tolerant.

PubMed

Crosson, I J; Bacon, D; Brown, K R

2010-09-01

We examine a model of classical deterministic computing in which the ground state of the classical system is a spatial history of the computation. This model is relevant to quantum dot cellular automata as well as to recent universal adiabatic quantum computing constructions. In its most primitive form, systems constructed in this model cannot compute in an error-free manner when working at nonzero temperature. However, by exploiting a mapping between the partition function for this model and probabilistic classical circuits we are able to show that it is possible to make this model effectively error-free. We achieve this by using techniques in fault-tolerant classical computing and the result is that the system can compute effectively error-free if the temperature is below a critical temperature. We further link this model to computational complexity and show that a certain problem concerning finite temperature classical spin systems is complete for the complexity class Merlin-Arthur. This provides an interesting connection between the physical behavior of certain many-body spin systems and computational complexity.

Source analysis using regional empirical Green's functions: The 2008 Wells, Nevada, earthquake

USGS Publications Warehouse

Mendoza, C.; Hartzell, S.

2009-01-01

We invert three-component, regional broadband waveforms recorded for the 21 February 2008 Wells, Nevada, earthquake using a finite-fault methodology that prescribes subfault responses using eight MW∼4 aftershocks as empirical Green's functions (EGFs) distributed within a 20-km by 21.6-km fault area. The inversion identifies a seismic moment of 6.2 x 1024 dyne-cm (5.8 MW) with slip concentrated in a compact 6.5-km by 4-km region updip from the hypocenter. The peak slip within this localized area is 88 cm and the stress drop is 72 bars, which is higher than expected for Basin and Range normal faults in the western United States. The EGF approach yields excellent fits to the complex regional waveforms, accounting for strong variations in wave propagation and site effects. This suggests that the procedure is useful for studying moderate-size earthquakes with limited teleseismic or strong-motion data and for examining uncertainties in slip models obtained using theoretical Green's functions.

A novel Lagrangian approach for the stable numerical simulation of fault and fracture mechanics

NASA Astrophysics Data System (ADS)

Franceschini, Andrea; Ferronato, Massimiliano; Janna, Carlo; Teatini, Pietro

2016-06-01

The simulation of the mechanics of geological faults and fractures is of paramount importance in several applications, such as ensuring the safety of the underground storage of wastes and hydrocarbons or predicting the possible seismicity triggered by the production and injection of subsurface fluids. However, the stable numerical modeling of ground ruptures is still an open issue. The present work introduces a novel formulation based on the use of the Lagrange multipliers to prescribe the constraints on the contact surfaces. The variational formulation is modified in order to take into account the frictional work along the activated fault portion according to the principle of maximum plastic dissipation. The numerical model, developed in the framework of the Finite Element method, provides stable solutions with a fast convergence of the non-linear problem. The stabilizing properties of the proposed model are emphasized with the aid of a realistic numerical example dealing with the generation of ground fractures due to groundwater withdrawal in arid regions.

Improved characterisation of measurement errors in electrical resistivity tomography (ERT) surveys

NASA Astrophysics Data System (ADS)

Tso, C. H. M.; Binley, A. M.; Kuras, O.; Graham, J.

2016-12-01

Measurement errors can play a pivotal role in geophysical inversion. Most inverse models require users to prescribe a statistical model of data errors before inversion. Wrongly prescribed error levels can lead to over- or under-fitting of data, yet commonly used models of measurement error are relatively simplistic. With the heightening interests in uncertainty estimation across hydrogeophysics, better characterisation and treatment of measurement errors is needed to provide more reliable estimates of uncertainty. We have analysed two time-lapse electrical resistivity tomography (ERT) datasets; one contains 96 sets of direct and reciprocal data collected from a surface ERT line within a 24h timeframe, while the other is a year-long cross-borehole survey at a UK nuclear site with over 50,000 daily measurements. Our study included the characterisation of the spatial and temporal behaviour of measurement errors using autocorrelation and covariance analysis. We find that, in addition to well-known proportionality effects, ERT measurements can also be sensitive to the combination of electrodes used. This agrees with reported speculation in previous literature that ERT errors could be somewhat correlated. Based on these findings, we develop a new error model that allows grouping based on electrode number in additional to fitting a linear model to transfer resistance. The new model fits the observed measurement errors better and shows superior inversion and uncertainty estimates in synthetic examples. It is robust, because it groups errors together based on the number of the four electrodes used to make each measurement. The new model can be readily applied to the diagonal data weighting matrix commonly used in classical inversion methods, as well as to the data covariance matrix in the Bayesian inversion framework. We demonstrate its application using extensive ERT monitoring datasets from the two aforementioned sites.

Fault detection and bypass in a sequence information signal processor

NASA Technical Reports Server (NTRS)

Peterson, John C. (Inventor); Chow, Edward T. (Inventor)

1992-01-01

The invention comprises a plurality of scan registers, each such register respectively associated with a processor element; an on-chip comparator, encoder and fault bypass register. Each scan register generates a unitary signal the logic state of which depends on the correctness of the input from the previous processor in the systolic array. These unitary signals are input to a common comparator which generates an output indicating whether or not an error has occurred. These unitary signals are also input to an encoder which identifies the location of any fault detected so that an appropriate multiplexer can be switched to bypass the faulty processor element. Input scan data can be readily programmed to fully exercise all of the processor elements so that no fault can remain undetected.

Neural-Network-Based Adaptive Decentralized Fault-Tolerant Control for a Class of Interconnected Nonlinear Systems.

PubMed

Li, Xiao-Jian; Yang, Guang-Hong

2018-01-01

This paper is concerned with the adaptive decentralized fault-tolerant tracking control problem for a class of uncertain interconnected nonlinear systems with unknown strong interconnections. An algebraic graph theory result is introduced to address the considered interconnections. In addition, to achieve the desirable tracking performance, a neural-network-based robust adaptive decentralized fault-tolerant control (FTC) scheme is given to compensate the actuator faults and system uncertainties. Furthermore, via the Lyapunov analysis method, it is proven that all the signals of the resulting closed-loop system are semiglobally bounded, and the tracking errors of each subsystem exponentially converge to a compact set, whose radius is adjustable by choosing different controller design parameters. Finally, the effectiveness and advantages of the proposed FTC approach are illustrated with two simulated examples.

Paleomagnetism of the Oligocene Kalamazoo Tuff: implications for middle Tertiary extension in east central Nevada

USGS Publications Warehouse

Hagstrum, J.T.; Gans, P.B.

1989-01-01

The Oligocene Kalamazoo Tuff (???35 Ma) was sampled for paleomagnetic analysis across a 100-km-wide zone of highly extended crust in east central Nevada to estimate between-site vertical axis rotations and thus the relative importance of strike-slip faulting to the mechanism of extension. The tilt-corrected data, with sources of error reduced or eliminated, exhibit a 28?? ?? 12?? clockwise rotation of the Schell Creek Range relative to the Kern Mountains region. This rotation implies differential extension accommodated by strike-slip faulting or N-S shortening. The paleomagnetic results also suggest that large changes in strike of layered units near faults with presumed strike-slip movement need not be the result of oroclinal bending, but could result from superimposed sets of orthogonal normal faults. -from Authors

Intelligent classifier for dynamic fault patterns based on hidden Markov model

NASA Astrophysics Data System (ADS)

Xu, Bo; Feng, Yuguang; Yu, Jinsong

2006-11-01

It's difficult to build precise mathematical models for complex engineering systems because of the complexity of the structure and dynamics characteristics. Intelligent fault diagnosis introduces artificial intelligence and works in a different way without building the analytical mathematical model of a diagnostic object, so it's a practical approach to solve diagnostic problems of complex systems. This paper presents an intelligent fault diagnosis method, an integrated fault-pattern classifier based on Hidden Markov Model (HMM). This classifier consists of dynamic time warping (DTW) algorithm, self-organizing feature mapping (SOFM) network and Hidden Markov Model. First, after dynamic observation vector in measuring space is processed by DTW, the error vector including the fault feature of being tested system is obtained. Then a SOFM network is used as a feature extractor and vector quantization processor. Finally, fault diagnosis is realized by fault patterns classifying with the Hidden Markov Model classifier. The importing of dynamic time warping solves the problem of feature extracting from dynamic process vectors of complex system such as aeroengine, and makes it come true to diagnose complex system by utilizing dynamic process information. Simulating experiments show that the diagnosis model is easy to extend, and the fault pattern classifier is efficient and is convenient to the detecting and diagnosing of new faults.

Event-triggered fault detection for a class of discrete-time linear systems using interval observers.

PubMed

Zhang, Zhi-Hui; Yang, Guang-Hong

2017-05-01

This paper provides a novel event-triggered fault detection (FD) scheme for discrete-time linear systems. First, an event-triggered interval observer is proposed to generate the upper and lower residuals by taking into account the influence of the disturbances and the event error. Second, the robustness of the residual interval against the disturbances and the fault sensitivity are improved by introducing l 1 and H ∞ performances. Third, dilated linear matrix inequalities are used to decouple the Lyapunov matrices from the system matrices. The nonnegative conditions for the estimation error variables are presented with the aid of the slack matrix variables. This technique allows considering a more general Lyapunov function. Furthermore, the FD decision scheme is proposed by monitoring whether the zero value belongs to the residual interval. It is shown that the information communication burden is reduced by designing the event-triggering mechanism, while the FD performance can still be guaranteed. Finally, simulation results demonstrate the effectiveness of the proposed method. Copyright © 2016 ISA. Published by Elsevier Ltd. All rights reserved.

Verifiable fault tolerance in measurement-based quantum computation

NASA Astrophysics Data System (ADS)

Fujii, Keisuke; Hayashi, Masahito

2017-09-01

Quantum systems, in general, cannot be simulated efficiently by a classical computer, and hence are useful for solving certain mathematical problems and simulating quantum many-body systems. This also implies, unfortunately, that verification of the output of the quantum systems is not so trivial, since predicting the output is exponentially hard. As another problem, the quantum system is very delicate for noise and thus needs an error correction. Here, we propose a framework for verification of the output of fault-tolerant quantum computation in a measurement-based model. In contrast to existing analyses on fault tolerance, we do not assume any noise model on the resource state, but an arbitrary resource state is tested by using only single-qubit measurements to verify whether or not the output of measurement-based quantum computation on it is correct. Verifiability is equipped by a constant time repetition of the original measurement-based quantum computation in appropriate measurement bases. Since full characterization of quantum noise is exponentially hard for large-scale quantum computing systems, our framework provides an efficient way to practically verify the experimental quantum error correction.

Assessing the Progress of Trapped-Ion Processors Towards Fault-Tolerant Quantum Computation

NASA Astrophysics Data System (ADS)

Bermudez, A.; Xu, X.; Nigmatullin, R.; O'Gorman, J.; Negnevitsky, V.; Schindler, P.; Monz, T.; Poschinger, U. G.; Hempel, C.; Home, J.; Schmidt-Kaler, F.; Biercuk, M.; Blatt, R.; Benjamin, S.; Müller, M.

2017-10-01

A quantitative assessment of the progress of small prototype quantum processors towards fault-tolerant quantum computation is a problem of current interest in experimental and theoretical quantum information science. We introduce a necessary and fair criterion for quantum error correction (QEC), which must be achieved in the development of these quantum processors before their sizes are sufficiently big to consider the well-known QEC threshold. We apply this criterion to benchmark the ongoing effort in implementing QEC with topological color codes using trapped-ion quantum processors and, more importantly, to guide the future hardware developments that will be required in order to demonstrate beneficial QEC with small topological quantum codes. In doing so, we present a thorough description of a realistic trapped-ion toolbox for QEC and a physically motivated error model that goes beyond standard simplifications in the QEC literature. We focus on laser-based quantum gates realized in two-species trapped-ion crystals in high-optical aperture segmented traps. Our large-scale numerical analysis shows that, with the foreseen technological improvements described here, this platform is a very promising candidate for fault-tolerant quantum computation.

Quantum error-correction failure distributions: Comparison of coherent and stochastic error models

NASA Astrophysics Data System (ADS)

Barnes, Jeff P.; Trout, Colin J.; Lucarelli, Dennis; Clader, B. D.

2017-06-01

We compare failure distributions of quantum error correction circuits for stochastic errors and coherent errors. We utilize a fully coherent simulation of a fault-tolerant quantum error correcting circuit for a d =3 Steane and surface code. We find that the output distributions are markedly different for the two error models, showing that no simple mapping between the two error models exists. Coherent errors create very broad and heavy-tailed failure distributions. This suggests that they are susceptible to outlier events and that mean statistics, such as pseudothreshold estimates, may not provide the key figure of merit. This provides further statistical insight into why coherent errors can be so harmful for quantum error correction. These output probability distributions may also provide a useful metric that can be utilized when optimizing quantum error correcting codes and decoding procedures for purely coherent errors.

Analysis and design of algorithm-based fault-tolerant systems

NASA Technical Reports Server (NTRS)

Nair, V. S. Sukumaran

1990-01-01

An important consideration in the design of high performance multiprocessor systems is to ensure the correctness of the results computed in the presence of transient and intermittent failures. Concurrent error detection and correction have been applied to such systems in order to achieve reliability. Algorithm Based Fault Tolerance (ABFT) was suggested as a cost-effective concurrent error detection scheme. The research was motivated by the complexity involved in the analysis and design of ABFT systems. To that end, a matrix-based model was developed and, based on that, algorithms for both the design and analysis of ABFT systems are formulated. These algorithms are less complex than the existing ones. In order to reduce the complexity further, a hierarchical approach is developed for the analysis of large systems.

Estimation of reliable range of electron temperature measurements with sets of given optical bandpass filters for KSTAR Thomson scattering system based on synthetic Thomson data

NASA Astrophysics Data System (ADS)

Kim, K.-h.; Oh, T.-s.; Park, K.-r.; Lee, J. H.; Ghim, Y.-c.

2017-11-01

One factor determining the reliability of measurements of electron temperature using a Thomson scattering (TS) system is transmittance of the optical bandpass filters in polychromators. We investigate the system performance as a function of electron temperature to determine reliable range of measurements for a given set of the optical bandpass filters. We show that such a reliability, i.e., both bias and random errors, can be obtained by building a forward model of the KSTAR TS system to generate synthetic TS data with the prescribed electron temperature and density profiles. The prescribed profiles are compared with the estimated ones to quantify both bias and random errors.

Medication regimens of frail older adults after discharge from home health care

PubMed Central

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

Application of Ensemble Kalman Filter in Power System State Tracking and Sensitivity

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

Li, Yulan; Huang, Zhenyu; Zhou, Ning

2012-05-01

Ensemble Kalman Filter (EnKF) is proposed to track dynamic states of generators. The algorithm of EnKF and its application to generator state tracking are presented in detail. The accuracy and sensitivity of the method are analyzed with respect to initial state errors, measurement noise, unknown fault locations, time steps and parameter errors. It is demonstrated through simulation studies that even with some errors in the parameters, the developed EnKF can effectively track generator dynamic states using disturbance data.

Progressive retry for software error recovery in distributed systems

NASA Technical Reports Server (NTRS)

Wang, Yi-Min; Huang, Yennun; Fuchs, W. K.

1993-01-01

In this paper, we describe a method of execution retry for bypassing software errors based on checkpointing, rollback, message reordering and replaying. We demonstrate how rollback techniques, previously developed for transient hardware failure recovery, can also be used to recover from software faults by exploiting message reordering to bypass software errors. Our approach intentionally increases the degree of nondeterminism and the scope of rollback when a previous retry fails. Examples from our experience with telecommunications software systems illustrate the benefits of the scheme.

Resilience Design Patterns - A Structured Approach to Resilience at Extreme Scale (version 1.0)

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

Hukerikar, Saurabh; Engelmann, Christian

Reliability is a serious concern for future extreme-scale high-performance computing (HPC) systems. Projections based on the current generation of HPC systems and technology roadmaps suggest that very high fault rates in future systems. The errors resulting from these faults will propagate and generate various kinds of failures, which may result in outcomes ranging from result corruptions to catastrophic application crashes. Practical limits on power consumption in HPC systems will require future systems to embrace innovative architectures, increasing the levels of hardware and software complexities. The resilience challenge for extreme-scale HPC systems requires management of various hardware and software technologies thatmore » are capable of handling a broad set of fault models at accelerated fault rates. These techniques must seek to improve resilience at reasonable overheads to power consumption and performance. While the HPC community has developed various solutions, application-level as well as system-based solutions, the solution space of HPC resilience techniques remains fragmented. There are no formal methods and metrics to investigate and evaluate resilience holistically in HPC systems that consider impact scope, handling coverage, and performance & power eciency across the system stack. Additionally, few of the current approaches are portable to newer architectures and software ecosystems, which are expected to be deployed on future systems. In this document, we develop a structured approach to the management of HPC resilience based on the concept of resilience-based design patterns. A design pattern is a general repeatable solution to a commonly occurring problem. We identify the commonly occurring problems and solutions used to deal with faults, errors and failures in HPC systems. The catalog of resilience design patterns provides designers with reusable design elements. We define a design framework that enhances our understanding of the important constraints and opportunities for solutions deployed at various layers of the system stack. The framework may be used to establish mechanisms and interfaces to coordinate flexible fault management across hardware and software components. The framework also enables optimization of the cost-benefit trade-os among performance, resilience, and power consumption. The overall goal of this work is to enable a systematic methodology for the design and evaluation of resilience technologies in extreme-scale HPC systems that keep scientific applications running to a correct solution in a timely and cost-ecient manner in spite of frequent faults, errors, and failures of various types.« less

Bayesian estimation of source parameters and associated Coulomb failure stress changes for the 2005 Fukuoka (Japan) Earthquake

NASA Astrophysics Data System (ADS)

Dutta, Rishabh; Jónsson, Sigurjón; Wang, Teng; Vasyura-Bathke, Hannes

2018-04-01

Several researchers have studied the source parameters of the 2005 Fukuoka (northwestern Kyushu Island, Japan) earthquake (Mw 6.6) using teleseismic, strong motion and geodetic data. However, in all previous studies, errors of the estimated fault solutions have been neglected, making it impossible to assess the reliability of the reported solutions. We use Bayesian inference to estimate the location, geometry and slip parameters of the fault and their uncertainties using Interferometric Synthetic Aperture Radar and Global Positioning System data. The offshore location of the earthquake makes the fault parameter estimation challenging, with geodetic data coverage mostly to the southeast of the earthquake. To constrain the fault parameters, we use a priori constraints on the magnitude of the earthquake and the location of the fault with respect to the aftershock distribution and find that the estimated fault slip ranges from 1.5 to 2.5 m with decreasing probability. The marginal distributions of the source parameters show that the location of the western end of the fault is poorly constrained by the data whereas that of the eastern end, located closer to the shore, is better resolved. We propagate the uncertainties of the fault model and calculate the variability of Coulomb failure stress changes for the nearby Kego fault, located directly below Fukuoka city, showing that the main shock increased stress on the fault and brought it closer to failure.

Failed oceanic transform models: experience of shaking the tree

NASA Astrophysics Data System (ADS)

Gerya, Taras

2017-04-01

In geodynamics, numerical modeling is often used as a trial-and-error tool, which does not necessarily requires full understanding or even a correct concept for a modeled phenomenon. Paradoxically, in order to understand an enigmatic process one should simply try to model it based on some initial assumptions, which must not even be correct… The reason is that our intuition is not always well "calibrated" for understanding of geodynamic phenomena, which develop on space- and timescales that are very different from our everyday experience. We often have much better ideas about physical laws governing geodynamic processes than on how these laws should interact on geological space- and timescales. From this prospective, numerical models, in which these physical laws are self-consistently implemented, can gradually calibrate our intuition by exploring what scenarios are physically sensible and what are not. I personally went through this painful learning path many times and one noteworthy example was my 3D numerical modeling of oceanic transform faults. As I understand in retrospective, my initial literature-inspired concept of how and why transform faults form and evolve was thermomechanically inconsistent and based on two main assumptions (btw. both were incorrect!): (1) oceanic transforms are directly inherited from the continental rifting and breakup stages and (2) they represent plate fragmentation structures having peculiar extension-parallel orientation due to the stress rotation caused by thermal contraction of the oceanic lithosphere. During one year (!) of high-resolution thermomechanical numerical experiments exploring various physics (including very computationally demanding thermal contraction) I systematically observed how my initially prescribed extension-parallel weak transform faults connecting ridge segments rotated away from their original orientation and get converted into oblique ridge sections… This was really an epic failure! However, at the very same time, some pseudo-2D "side-models" with initial strait ridge and ad-hock strain weakened rheology, which were run for curiosity, suddenly showed spontaneous development of ridge curvature… Fraction of these models showed spontaneous development of orthogonal ridge-transform patterns by rotation of oblique ridge sections toward extension-parallel direction to accommodate asymmetric plate accretion. The later was controlled by detachment faults stabilized by strain weakening. Further exploration of these "side-models" resulted in complete changing of my concept for oceanic transforms: they are not plate fragmentation but rather plate growth structures stabilized by continuous plate accretion and rheological weakening of deforming rocks (Gerya, 2010, 2013). The conclusion is - keep shaking the tree and banana will fall… Gerya, T. (2010) Dynamical instability produces transform faults at mid-ocean ridges. Science, 329, 1047-1050. Gerya, T.V. (2013) Three-dimensional thermomechanical modeling of oceanic spreading initiation and evolution. Phys. Earth Planet. Interiors, 214, 35-52.

Computations of Aerodynamic Performance Databases Using Output-Based Refinement

NASA Technical Reports Server (NTRS)

Nemec, Marian; Aftosmis, Michael J.

2009-01-01

Objectives: Handle complex geometry problems; Control discretization errors via solution-adaptive mesh refinement; Focus on aerodynamic databases of parametric and optimization studies: 1. Accuracy: satisfy prescribed error bounds 2. Robustness and speed: may require over 105 mesh generations 3. Automation: avoid user supervision Obtain "expert meshes" independent of user skill; and Run every case adaptively in production settings.

Minimizing Experimental Error in Thinning Research

Treesearch

C. B. Briscoe

1964-01-01

Many diverse approaches have been made prescribing and evaluating thinnings on an objective basis. None of the techniques proposed hasbeen widely accepted. Indeed. none has been proven superior to the others nor even widely applicable. There are at least two possible reasons for this: none of the techniques suggested is of any general utility and/or experimental error...

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

PubMed

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

2005-10-05

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

The relationships among work stress, strain and self-reported errors in UK community pharmacy.

PubMed

Johnson, S J; O'Connor, E M; Jacobs, S; Hassell, K; Ashcroft, D M

2014-01-01

Changes in the UK community pharmacy profession including new contractual frameworks, expansion of services, and increasing levels of workload have prompted concerns about rising levels of workplace stress and overload. This has implications for pharmacist health and well-being and the occurrence of errors that pose a risk to patient safety. Despite these concerns being voiced in the profession, few studies have explored work stress in the community pharmacy context. To investigate work-related stress among UK community pharmacists and to explore its relationships with pharmacists' psychological and physical well-being, and the occurrence of self-reported dispensing errors and detection of prescribing errors. A cross-sectional postal survey of a random sample of practicing community pharmacists (n = 903) used ASSET (A Shortened Stress Evaluation Tool) and questions relating to self-reported involvement in errors. Stress data were compared to general working population norms, and regressed on well-being and self-reported errors. Analysis of the data revealed that pharmacists reported significantly higher levels of workplace stressors than the general working population, with concerns about work-life balance, the nature of the job, and work relationships being the most influential on health and well-being. Despite this, pharmacists were not found to report worse health than the general working population. Self-reported error involvement was linked to both high dispensing volume and being troubled by perceived overload (dispensing errors), and resources and communication (detection of prescribing errors). This study contributes to the literature by benchmarking community pharmacists' health and well-being, and investigating sources of stress using a quantitative approach. A further important contribution to the literature is the identification of a quantitative link between high workload and self-reported dispensing errors. Copyright © 2014 Elsevier Inc. All rights reserved.

Using certification trails to achieve software fault tolerance

NASA Technical Reports Server (NTRS)

Sullivan, Gregory F.; Masson, Gerald M.

1993-01-01

A conceptually novel and powerful technique to achieve fault tolerance in hardware and software systems is introduced. When used for software fault tolerance, this new technique uses time and software redundancy and can be outlined as follows. In the initial phase, a program is run to solve a problem and store the result. In addition, this program leaves behind a trail of data called a certification trail. In the second phase, another program is run which solves the original problem again. This program, however, has access to the certification trail left by the first program. Because of the availability of the certification trail, the second phase can be performed by a less complex program and can execute more quickly. In the final phase, the two results are accepted as correct; otherwise an error is indicated. An essential aspect of this approach is that the second program must always generate either an error indication or a correct output even when the certification trail it receives from the first program is incorrect. The certification trail approach to fault tolerance was formalized and it was illustrated by applying it to the fundamental problem of finding a minimum spanning tree. Cases in which the second phase can be run concorrectly with the first and act as a monitor are discussed. The certification trail approach was compared to other approaches to fault tolerance. Because of space limitations we have omitted examples of our technique applied to the Huffman tree, and convex hull problems. These can be found in the full version of this paper.

Barriers to electronic prescribing: Nebraska pharmacists' perspective.

PubMed

Lander, Lina; Klepser, Donald G; Cochran, Gary L; Lomelin, Daniel E; Morien, Marsha

2013-01-01

Electronic prescribing (e-prescribing) and its accompanying clinical decision support capabilities have been promoted as means for reducing medication errors and improving efficiency. The objectives of this study were to identify the barriers to adoption of e-prescribing among nonparticipating Nebraska pharmacies and to describe how the lack of pharmacy participation impacts the ability of physicians to meet meaningful use criteria. We interviewed pharmacists and/or managers from nonparticipating pharmacies to determine barriers to the adoption of e-prescribing. We used open-ended questions and a structured questionnaire to capture participants' responses. Of the 23 participants, 10 (43%) reported plans to implement e-prescribing sometime in the future but delayed participation due to transaction fees and maintenance costs, as well as lack of demand from customers and prescribers to implement e-prescribing. Nine participants (39%) reported no intention to e-prescribe in the future, citing start-up costs for implementing e-prescribing, transaction fees and maintenance costs, happiness with the current system, and lack of understanding about e-prescribing's benefits and how to implement e-prescribing. The barriers to e-prescribing identified by both late adopters and those not willing to accept e-prescriptions were similar and were mainly initial costs and transaction fees associated with each new prescription. For some rural pharmacies, not participating in e-prescribing may be a rational business decision. To increase participation, waiving or reimbursing transaction fees, based on demographic or financial characteristics of the pharmacy, may be warranted. © 2012 National Rural Health Association.

Fault Diagnosis for the Heat Exchanger of the Aircraft Environmental Control System Based on the Strong Tracking Filter

PubMed Central

Ma, Jian; Lu, Chen; Liu, Hongmei

2015-01-01

The aircraft environmental control system (ECS) is a critical aircraft system, which provides the appropriate environmental conditions to ensure the safe transport of air passengers and equipment. The functionality and reliability of ECS have received increasing attention in recent years. The heat exchanger is a particularly significant component of the ECS, because its failure decreases the system’s efficiency, which can lead to catastrophic consequences. Fault diagnosis of the heat exchanger is necessary to prevent risks. However, two problems hinder the implementation of the heat exchanger fault diagnosis in practice. First, the actual measured parameter of the heat exchanger cannot effectively reflect the fault occurrence, whereas the heat exchanger faults are usually depicted by utilizing the corresponding fault-related state parameters that cannot be measured directly. Second, both the traditional Extended Kalman Filter (EKF) and the EKF-based Double Model Filter have certain disadvantages, such as sensitivity to modeling errors and difficulties in selection of initialization values. To solve the aforementioned problems, this paper presents a fault-related parameter adaptive estimation method based on strong tracking filter (STF) and Modified Bayes classification algorithm for fault detection and failure mode classification of the heat exchanger, respectively. Heat exchanger fault simulation is conducted to generate fault data, through which the proposed methods are validated. The results demonstrate that the proposed methods are capable of providing accurate, stable, and rapid fault diagnosis of the heat exchanger. PMID:25823010

Fault diagnosis for the heat exchanger of the aircraft environmental control system based on the strong tracking filter.

PubMed

Ma, Jian; Lu, Chen; Liu, Hongmei

2015-01-01

The aircraft environmental control system (ECS) is a critical aircraft system, which provides the appropriate environmental conditions to ensure the safe transport of air passengers and equipment. The functionality and reliability of ECS have received increasing attention in recent years. The heat exchanger is a particularly significant component of the ECS, because its failure decreases the system's efficiency, which can lead to catastrophic consequences. Fault diagnosis of the heat exchanger is necessary to prevent risks. However, two problems hinder the implementation of the heat exchanger fault diagnosis in practice. First, the actual measured parameter of the heat exchanger cannot effectively reflect the fault occurrence, whereas the heat exchanger faults are usually depicted by utilizing the corresponding fault-related state parameters that cannot be measured directly. Second, both the traditional Extended Kalman Filter (EKF) and the EKF-based Double Model Filter have certain disadvantages, such as sensitivity to modeling errors and difficulties in selection of initialization values. To solve the aforementioned problems, this paper presents a fault-related parameter adaptive estimation method based on strong tracking filter (STF) and Modified Bayes classification algorithm for fault detection and failure mode classification of the heat exchanger, respectively. Heat exchanger fault simulation is conducted to generate fault data, through which the proposed methods are validated. The results demonstrate that the proposed methods are capable of providing accurate, stable, and rapid fault diagnosis of the heat exchanger.

Flight Investigation of Prescribed Simultaneous Independent Surface Excitations for Real-Time Parameter Identification

NASA Technical Reports Server (NTRS)

Moes, Timothy R.; Smith, Mark S.; Morelli, Eugene A.

2003-01-01

Near real-time stability and control derivative extraction is required to support flight demonstration of Intelligent Flight Control System (IFCS) concepts being developed by NASA, academia, and industry. Traditionally, flight maneuvers would be designed and flown to obtain stability and control derivative estimates using a postflight analysis technique. The goal of the IFCS concept is to be able to modify the control laws in real time for an aircraft that has been damaged in flight. In some IFCS implementations, real-time parameter identification (PID) of the stability and control derivatives of the damaged aircraft is necessary for successfully reconfiguring the control system. This report investigates the usefulness of Prescribed Simultaneous Independent Surface Excitations (PreSISE) to provide data for rapidly obtaining estimates of the stability and control derivatives. Flight test data were analyzed using both equation-error and output-error PID techniques. The equation-error PID technique is known as Fourier Transform Regression (FTR) and is a frequency-domain real-time implementation. Selected results were compared with a time-domain output-error technique. The real-time equation-error technique combined with the PreSISE maneuvers provided excellent derivative estimation in the longitudinal axis. However, the PreSISE maneuvers as presently defined were not adequate for accurate estimation of the lateral-directional derivatives.

Detection of Naturally Occurring Gear and Bearing Faults in a Helicopter Drivetrain

DTIC Science & Technology

2014-01-01

comply with a collection of information if it does not display a currently valid OMB control number. PLEASE DO NOT RETURN YOUR FORM TO THE ABOVE...resistance to gear tooth fracture under power levels exceeding the maximum continuous rating. During posttest inspection, it was found that a tooth...accessible, a trial and error approach was taken to find the band that best captured the bearing fault. Figure 11b shows the magnitude of the

Training the Recurrent neural network by the Fuzzy Min-Max algorithm for fault prediction

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

Zemouri, Ryad; Racoceanu, Daniel; Zerhouni, Noureddine

2009-03-05

In this paper, we present a training technique of a Recurrent Radial Basis Function neural network for fault prediction. We use the Fuzzy Min-Max technique to initialize the k-center of the RRBF neural network. The k-means algorithm is then applied to calculate the centers that minimize the mean square error of the prediction task. The performances of the k-means algorithm are then boosted by the Fuzzy Min-Max technique.

Design Trade-off Between Performance and Fault-Tolerance of Space Onboard Computers

NASA Astrophysics Data System (ADS)

Gorbunov, M. S.; Antonov, A. A.

2017-01-01

It is well known that there is a trade-off between performance and power consumption in onboard computers. The fault-tolerance is another important factor affecting performance, chip area and power consumption. Involving special SRAM cells and error-correcting codes is often too expensive with relation to the performance needed. We discuss the possibility of finding the optimal solutions for modern onboard computer for scientific apparatus focusing on multi-level cache memory design.

A Long-term Slip Model for the San Ramón Fault, Santiago de Chile, from Tectonically Reconcilable Boundary Conditions

NASA Astrophysics Data System (ADS)

Aron, F.; Estay, N.; Cembrano, J. M.; Yanez, G. A.

2016-12-01

We constructed a 3D Boundary Elements model simulating subduction of the Nazca plate underneath South America, from 29° to 38° S, to compute long-term surface deformation and slip rates on crustal faults imbedded in the upper-plate wedge of the Andean orogen. We tested our model on the San Ramón Fault (SRF), a major E-dipping, thrust structure limiting the western front of the Main Cordillera with surface expression along the entire, 40 km long, extension of the Santiago de Chile basin. Long-lived thrusting has produced more than 2 km of differential uplift of the mountains. Given its proximity to the country's largest city, this potentially seismogenic fault —dormant during historic times— has drawn increasing public attention. We used earthquake hypocenters captured over a one-year seismic deployment, 2D resistivity profiles, and published geologic cross-sections to determine the geometry of the SRF. The base of the lithosphere and plate interface surfaces were defined based on average Andean values and the Slab1.0 model. The simulation reproduces plate convergence and mechanic decoupling of the lithospheric plates across the subduction seismic cycle using mixed boundary conditions. Relative plate motion is achieved prescribing uniform, far-field horizontal displacement over the depth extension of both the oceanic and continental lithospheric plates. Long-term deformation is carried out in two steps. First, the modeled surfaces are allowed to slip freely emulating continuous slip on the subduction megathrust; subsequently, zero displacement is prescribed on the locking zone of the megathrust down to 40 km depth, while keeping the rest of the surfaces traction free, mimicking interseismic conditions. Long-term slip rate fields obtained for the SRF range between 0.1 and 1% the plate convergence rate, with maximum values near the surface. Interestingly, at an estimated 76-77 mm/yr relative plate motion velocity, those rates agree well with what has been reported on studies at one paleoseismic trench site across the fault. These results might contribute to determining possible seismic scenarios for Santiago but perhaps more importantly, our approach could be use in estimations of long-term slip rates and surface deformation due to other crustal structures with unknown displacement history.

Adaptive extended-state observer-based fault tolerant attitude control for spacecraft with reaction wheels

NASA Astrophysics Data System (ADS)

Ran, Dechao; Chen, Xiaoqian; de Ruiter, Anton; Xiao, Bing

2018-04-01

This study presents an adaptive second-order sliding control scheme to solve the attitude fault tolerant control problem of spacecraft subject to system uncertainties, external disturbances and reaction wheel faults. A novel fast terminal sliding mode is preliminarily designed to guarantee that finite-time convergence of the attitude errors can be achieved globally. Based on this novel sliding mode, an adaptive second-order observer is then designed to reconstruct the system uncertainties and the actuator faults. One feature of the proposed observer is that the design of the observer does not necessitate any priori information of the upper bounds of the system uncertainties and the actuator faults. In view of the reconstructed information supplied by the designed observer, a second-order sliding mode controller is developed to accomplish attitude maneuvers with great robustness and precise tracking accuracy. Theoretical stability analysis proves that the designed fault tolerant control scheme can achieve finite-time stability of the closed-loop system, even in the presence of reaction wheel faults and system uncertainties. Numerical simulations are also presented to demonstrate the effectiveness and superiority of the proposed control scheme over existing methodologies.

Pattern classifier for health monitoring of helicopter gearboxes

NASA Technical Reports Server (NTRS)

Chin, Hsinyung; Danai, Kourosh; Lewicki, David G.

1993-01-01

The application of a newly developed diagnostic method to a helicopter gearbox is demonstrated. This method is a pattern classifier which uses a multi-valued influence matrix (MVIM) as its diagnostic model. The method benefits from a fast learning algorithm, based on error feedback, that enables it to estimate gearbox health from a small set of measurement-fault data. The MVIM method can also assess the diagnosability of the system and variability of the fault signatures as the basis to improve fault signatures. This method was tested on vibration signals reflecting various faults in an OH-58A main rotor transmission gearbox. The vibration signals were then digitized and processed by a vibration signal analyzer to enhance and extract various features of the vibration data. The parameters obtained from this analyzer were utilized to train and test the performance of the MVIM method in both detection and diagnosis. The results indicate that the MVIM method provided excellent detection results when the full range of faults effects on the measurements were included in training, and it had a correct diagnostic rate of 95 percent when the faults were included in training.

VLSI Implementation of Fault Tolerance Multiplier based on Reversible Logic Gate

NASA Astrophysics Data System (ADS)

Ahmad, Nabihah; Hakimi Mokhtar, Ahmad; Othman, Nurmiza binti; Fhong Soon, Chin; Rahman, Ab Al Hadi Ab

2017-08-01

Multiplier is one of the essential component in the digital world such as in digital signal processing, microprocessor, quantum computing and widely used in arithmetic unit. Due to the complexity of the multiplier, tendency of errors are very high. This paper aimed to design a 2×2 bit Fault Tolerance Multiplier based on Reversible logic gate with low power consumption and high performance. This design have been implemented using 90nm Complemetary Metal Oxide Semiconductor (CMOS) technology in Synopsys Electronic Design Automation (EDA) Tools. Implementation of the multiplier architecture is by using the reversible logic gates. The fault tolerance multiplier used the combination of three reversible logic gate which are Double Feynman gate (F2G), New Fault Tolerance (NFT) gate and Islam Gate (IG) with the area of 160μm x 420.3μm (67.25 mm2). This design achieved a low power consumption of 122.85μW and propagation delay of 16.99ns. The fault tolerance multiplier proposed achieved a low power consumption and high performance which suitable for application of modern computing as it has a fault tolerance capabilities.

Fault detection and diagnosis for non-Gaussian stochastic distribution systems with time delays via RBF neural networks.

PubMed

Yi, Qu; Zhan-ming, Li; Er-chao, Li

2012-11-01

A new fault detection and diagnosis (FDD) problem via the output probability density functions (PDFs) for non-gausian stochastic distribution systems (SDSs) is investigated. The PDFs can be approximated by radial basis functions (RBFs) neural networks. Different from conventional FDD problems, the measured information for FDD is the output stochastic distributions and the stochastic variables involved are not confined to Gaussian ones. A (RBFs) neural network technique is proposed so that the output PDFs can be formulated in terms of the dynamic weighings of the RBFs neural network. In this work, a nonlinear adaptive observer-based fault detection and diagnosis algorithm is presented by introducing the tuning parameter so that the residual is as sensitive as possible to the fault. Stability and Convergency analysis is performed in fault detection and fault diagnosis analysis for the error dynamic system. At last, an illustrated example is given to demonstrate the efficiency of the proposed algorithm, and satisfactory results have been obtained. Copyright © 2012 ISA. Published by Elsevier Ltd. All rights reserved.

Care 3 phase 2 report, maintenance manual

NASA Technical Reports Server (NTRS)

Bryant, L. A.; Stiffler, J. J.

1982-01-01

CARE 3 (Computer-Aided Reliability Estimation, version three) is a computer program designed to help estimate the reliability of complex, redundant systems. Although the program can model a wide variety of redundant structures, it was developed specifically for fault-tolerant avionics systems--systems distinguished by the need for extremely reliable performance since a system failure could well result in the loss of human life. It substantially generalizes the class of redundant configurations that could be accommodated, and includes a coverage model to determine the various coverage probabilities as a function of the applicable fault recovery mechanisms (detection delay, diagnostic scheduling interval, isolation and recovery delay, etc.). CARE 3 further generalizes the class of system structures that can be modeled and greatly expands the coverage model to take into account such effects as intermittent and transient faults, latent faults, error propagation, etc.

A Regularizer Approach for RBF Networks Under the Concurrent Weight Failure Situation.

PubMed

Leung, Chi-Sing; Wan, Wai Yan; Feng, Ruibin

2017-06-01

Many existing results on fault-tolerant algorithms focus on the single fault source situation, where a trained network is affected by one kind of weight failure. In fact, a trained network may be affected by multiple kinds of weight failure. This paper first studies how the open weight fault and the multiplicative weight noise degrade the performance of radial basis function (RBF) networks. Afterward, we define the objective function for training fault-tolerant RBF networks. Based on the objective function, we then develop two learning algorithms, one batch mode and one online mode. Besides, the convergent conditions of our online algorithm are investigated. Finally, we develop a formula to estimate the test set error of faulty networks trained from our approach. This formula helps us to optimize some tuning parameters, such as RBF width.

How do Community Pharmacies Recover from E-prescription Errors?

PubMed Central

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

2014-01-01

Background The use of e-prescribing is increasing annually, with over 788 million e-prescriptions received in US pharmacies in 2012. Approximately 9% of e-prescriptions have medication errors. Objective To describe the process used by community pharmacy staff to detect, explain, and correct e-prescription errors. Methods The error recovery conceptual framework was employed for data collection and analysis. 13 pharmacists and 14 technicians from five community pharmacies in Wisconsin participated in the study. A combination of data collection methods were utilized, including direct observations, interviews, and focus groups. The transcription and content analysis of recordings were guided by the three-step error recovery model. Results Most of the e-prescription errors were detected during the entering of information into the pharmacy system. These errors were detected by both pharmacists and technicians using a variety of strategies which included: (1) performing double checks of e-prescription information; (2) printing the e-prescription to paper and confirming the information on the computer screen with information from the paper printout; and (3) using colored pens to highlight important information. Strategies used for explaining errors included: (1) careful review of patient’ medication history; (2) pharmacist consultation with patients; (3) consultation with another pharmacy team member; and (4) use of online resources. In order to correct e-prescription errors, participants made educated guesses of the prescriber’s intent or contacted the prescriber via telephone or fax. When e-prescription errors were encountered in the community pharmacies, the primary goal of participants was to get the order right for patients by verifying the prescriber’s intent. Conclusion Pharmacists and technicians play an important role in preventing e-prescription errors through the detection of errors and the verification of prescribers’ intent. Future studies are needed to examine factors that facilitate or hinder recovery from e-prescription errors. PMID:24373898

Prescription errors before and after introduction of electronic medication alert system in a pediatric emergency department.

PubMed

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.

Fault-tolerance thresholds for the surface code with fabrication errors

NASA Astrophysics Data System (ADS)

Auger, James M.; Anwar, Hussain; Gimeno-Segovia, Mercedes; Stace, Thomas M.; Browne, Dan E.

2017-10-01

The construction of topological error correction codes requires the ability to fabricate a lattice of physical qubits embedded on a manifold with a nontrivial topology such that the quantum information is encoded in the global degrees of freedom (i.e., the topology) of the manifold. However, the manufacturing of large-scale topological devices will undoubtedly suffer from fabrication errors—permanent faulty components such as missing physical qubits or failed entangling gates—introducing permanent defects into the topology of the lattice and hence significantly reducing the distance of the code and the quality of the encoded logical qubits. In this work we investigate how fabrication errors affect the performance of topological codes, using the surface code as the test bed. A known approach to mitigate defective lattices involves the use of primitive swap gates in a long sequence of syndrome extraction circuits. Instead, we show that in the presence of fabrication errors the syndrome can be determined using the supercheck operator approach and the outcome of the defective gauge stabilizer generators without any additional computational overhead or use of swap gates. We report numerical fault-tolerance thresholds in the presence of both qubit fabrication and gate fabrication errors using a circuit-based noise model and the minimum-weight perfect-matching decoder. Our numerical analysis is most applicable to two-dimensional chip-based technologies, but the techniques presented here can be readily extended to other topological architectures. We find that in the presence of 8 % qubit fabrication errors, the surface code can still tolerate a computational error rate of up to 0.1 % .

Probabilistic In Situ Stress Estimation and Forecasting using Sequential Data Assimilation

NASA Astrophysics Data System (ADS)

Fichtner, A.; van Dinther, Y.; Kuensch, H. R.

2017-12-01

Our physical understanding and forecasting ability of earthquakes, and other solid Earth dynamic processes, is significantly hampered by limited indications on the evolving state of stress and strength on faults. Integrating observations and physics-based numerical modeling to quantitatively estimate this evolution of a fault's state is crucial. However, systematic attempts are limited and tenuous, especially in light of the scarcity and uncertainty of natural data and the difficulty of modelling the physics governing earthquakes. We adopt the statistical framework of sequential data assimilation - extensively developed for weather forecasting - to efficiently integrate observations and prior knowledge in a forward model, while acknowledging errors in both. To prove this concept we perform a perfect model test in a simplified subduction zone setup, where we assimilate synthetic noised data on velocities and stresses from a single location. Using an Ensemble Kalman Filter, these data and their errors are assimilated to update 150 ensemble members from a Partial Differential Equation-driven seismic cycle model. Probabilistic estimates of fault stress and dynamic strength evolution capture the truth exceptionally well. This is possible, because the sampled error covariance matrix contains prior information from the physics that relates velocities, stresses and pressure at the surface to those at the fault. During the analysis step, stress and strength distributions are thus reconstructed such that fault coupling can be updated to either inhibit or trigger events. In the subsequent forecast step the physical equations are solved to propagate the updated states forward in time and thus provide probabilistic information on the occurrence of the next event. At subsequent assimilation steps, the system's forecasting ability turns out to be significantly better than that of a periodic recurrence model (requiring an alarm 17% vs. 68% of the time). This thus provides distinct added value with respect to using observations or numerical models separately. Although several challenges for applications to a natural setting remain, these first results indicate the large potential of data assimilation techniques for probabilistic seismic hazard assessment and other challenges in dynamic solid earth systems.

An intravenous medication safety system: preventing high-risk medication errors at the point of care.

PubMed

Hatcher, Irene; Sullivan, Mark; Hutchinson, James; Thurman, Susan; Gaffney, F Andrew

2004-10-01

Improving medication safety at the point of care--particularly for high-risk drugs--is a major concern of nursing administrators. The medication errors most likely to cause harm are administration errors related to infusion of high-risk medications. An intravenous medication safety system is designed to prevent high-risk infusion medication errors and to capture continuous quality improvement data for best practice improvement. Initial testing with 50 systems in 2 units at Vanderbilt University Medical Center revealed that, even in the presence of a fully mature computerized prescriber order-entry system, the new safety system averted 99 potential infusion errors in 8 months.

Fault-Tolerant Signal Processing Architectures with Distributed Error Control.

DTIC Science & Technology

1985-01-01

Zm, Revisited," Information and Control, Vol. 37, pp. 100-104, 1978. 13. J. Wakerly , Error Detecting Codes. SeIf-Checkino Circuits and Applications ...However, the newer results concerning applications of real codes are still in the publication process. Hence, two very detailed appendices are included to...significant entities to be protected. While the distributed finite field approach afforded adequate protection, its applicability was restricted and

Event-triggered decentralized adaptive fault-tolerant control of uncertain interconnected nonlinear systems with actuator failures.

PubMed

Choi, Yun Ho; Yoo, Sung Jin

2018-06-01

This paper investigates the event-triggered decentralized adaptive tracking problem of a class of uncertain interconnected nonlinear systems with unexpected actuator failures. It is assumed that local control signals are transmitted to local actuators with time-varying faults whenever predefined conditions for triggering events are satisfied. Compared with the existing control-input-based event-triggering strategy for adaptive control of uncertain nonlinear systems, the aim of this paper is to propose a tracking-error-based event-triggering strategy in the decentralized adaptive fault-tolerant tracking framework. The proposed approach can relax drastic changes in control inputs caused by actuator faults in the existing triggering strategy. The stability of the proposed event-triggering control system is analyzed in the Lyapunov sense. Finally, simulation comparisons of the proposed and existing approaches are provided to show the effectiveness of the proposed theoretical result in the presence of actuator faults. Copyright © 2018 ISA. Published by Elsevier Ltd. All rights reserved.

Observer-Based Adaptive Fault-Tolerant Tracking Control of Nonlinear Nonstrict-Feedback Systems.

PubMed

Wu, Chengwei; Liu, Jianxing; Xiong, Yongyang; Wu, Ligang

2017-06-28

This paper studies an output-based adaptive fault-tolerant control problem for nonlinear systems with nonstrict-feedback form. Neural networks are utilized to identify the unknown nonlinear characteristics in the system. An observer and a general fault model are constructed to estimate the unavailable states and describe the fault, respectively. Adaptive parameters are constructed to overcome the difficulties in the design process for nonstrict-feedback systems. Meanwhile, dynamic surface control technique is introduced to avoid the problem of ''explosion of complexity''. Furthermore, based on adaptive backstepping control method, an output-based adaptive neural tracking control strategy is developed for the considered system against actuator fault, which can ensure that all the signals in the resulting closed-loop system are bounded, and the system output signal can be regulated to follow the response of the given reference signal with a small error. Finally, the simulation results are provided to validate the effectiveness of the control strategy proposed in this paper.

Ciliates learn to diagnose and correct classical error syndromes in mating strategies

PubMed Central

Clark, Kevin B.

2013-01-01

Preconjugal ciliates learn classical repetition error-correction codes to safeguard mating messages and replies from corruption by “rivals” and local ambient noise. Because individual cells behave as memory channels with Szilárd engine attributes, these coding schemes also might be used to limit, diagnose, and correct mating-signal errors due to noisy intracellular information processing. The present study, therefore, assessed whether heterotrich ciliates effect fault-tolerant signal planning and execution by modifying engine performance, and consequently entropy content of codes, during mock cell–cell communication. Socially meaningful serial vibrations emitted from an ambiguous artificial source initiated ciliate behavioral signaling performances known to advertise mating fitness with varying courtship strategies. Microbes, employing calcium-dependent Hebbian-like decision making, learned to diagnose then correct error syndromes by recursively matching Boltzmann entropies between signal planning and execution stages via “power” or “refrigeration” cycles. All eight serial contraction and reversal strategies incurred errors in entropy magnitude by the execution stage of processing. Absolute errors, however, subtended expected threshold values for single bit-flip errors in three-bit replies, indicating coding schemes protected information content throughout signal production. Ciliate preparedness for vibrations selectively and significantly affected the magnitude and valence of Szilárd engine performance during modal and non-modal strategy corrective cycles. But entropy fidelity for all replies mainly improved across learning trials as refinements in engine efficiency. Fidelity neared maximum levels for only modal signals coded in resilient three-bit repetition error-correction sequences. Together, these findings demonstrate microbes can elevate survival/reproductive success by learning to implement classical fault-tolerant information processing in social contexts. PMID:23966987

Research Supporting Satellite Communications Technology

NASA Technical Reports Server (NTRS)

Horan Stephen; Lyman, Raphael

2005-01-01

This report describes the second year of research effort under the grant Research Supporting Satellite Communications Technology. The research program consists of two major projects: Fault Tolerant Link Establishment and the design of an Auto-Configurable Receiver. The Fault Tolerant Link Establishment protocol is being developed to assist the designers of satellite clusters to manage the inter-satellite communications. During this second year, the basic protocol design was validated with an extensive testing program. After this testing was completed, a channel error model was added to the protocol to permit the effects of channel errors to be measured. This error generation was used to test the effects of channel errors on Heartbeat and Token message passing. The C-language source code for the protocol modules was delivered to Goddard Space Flight Center for integration with the GSFC testbed. The need for a receiver autoconfiguration capability arises when a satellite-to-ground transmission is interrupted due to an unexpected event, the satellite transponder may reset to an unknown state and begin transmitting in a new mode. During Year 2, we completed testing of these algorithms when noise-induced bit errors were introduced. We also developed and tested an algorithm for estimating the data rate, assuming an NRZ-formatted signal corrupted with additive white Gaussian noise, and we took initial steps in integrating both algorithms into the SDR test bed at GSFC.

Liquid Medication Dosing Errors in Children: Role of Provider Counseling Strategies

PubMed Central

Yin, H. Shonna; Dreyer, Benard P.; Moreira, Hannah A.; van Schaick, Linda; Rodriguez, Luis; Boettger, Susanne; Mendelsohn, Alan L.

2014-01-01

Objective To examine the degree to which recommended provider counseling strategies, including advanced communication techniques and dosing instrument provision, are associated with reductions in parent liquid medication dosing errors. Methods Cross-sectional analysis of baseline data on provider communication and dosing instrument provision from a study of a health literacy intervention to reduce medication errors. Parents whose children (<9 years) were seen in two urban public hospital pediatric emergency departments (EDs) and were prescribed daily dose liquid medications self-reported whether they received counseling about their child’s medication, including advanced strategies (teachback, drawings/pictures, demonstration, showback) and receipt of a dosing instrument. Primary dependent variable: observed dosing error (>20% deviation from prescribed). Multivariate logistic regression analyses performed, controlling for: parent age, language, country, ethnicity, socioeconomic status, education, health literacy (Short Test of Functional Health Literacy in Adults); child age, chronic disease status; site. Results Of 287 parents, 41.1% made dosing errors. Advanced counseling and instrument provision in the ED were reported by 33.1% and 19.2%, respectively; 15.0% reported both. Advanced counseling and instrument provision in the ED were associated with decreased errors (30.5 vs. 46.4%, p=0.01; 21.8 vs. 45.7%, p=0.001). In adjusted analyses, ED advanced counseling in combination with instrument provision was associated with a decreased odds of error compared to receiving neither (AOR 0.3; 95% CI 0.1–0.7); advanced counseling alone and instrument alone were not significantly associated with odds of error. Conclusion Provider use of advanced counseling strategies and dosing instrument provision may be especially effective in reducing errors when used together. PMID:24767779

Liquid medication dosing errors in children: role of provider counseling strategies.

PubMed

Yin, H Shonna; Dreyer, Benard P; Moreira, Hannah A; van Schaick, Linda; Rodriguez, Luis; Boettger, Susanne; Mendelsohn, Alan L

2014-01-01

To examine the degree to which recommended provider counseling strategies, including advanced communication techniques and dosing instrument provision, are associated with reductions in parent liquid medication dosing errors. Cross-sectional analysis of baseline data on provider communication and dosing instrument provision from a study of a health literacy intervention to reduce medication errors. Parents whose children (<9 years) were seen in 2 urban public hospital pediatric emergency departments (EDs) and were prescribed daily dose liquid medications self-reported whether they received counseling about their child's medication, including advanced strategies (teachback, drawings/pictures, demonstration, showback) and receipt of a dosing instrument. The primary dependent variable was observed dosing error (>20% deviation from prescribed). Multivariate logistic regression analyses were performed, controlling for parent age, language, country, ethnicity, socioeconomic status, education, health literacy (Short Test of Functional Health Literacy in Adults); child age, chronic disease status; and site. Of 287 parents, 41.1% made dosing errors. Advanced counseling and instrument provision in the ED were reported by 33.1% and 19.2%, respectively; 15.0% reported both. Advanced counseling and instrument provision in the ED were associated with decreased errors (30.5 vs. 46.4%, P = .01; 21.8 vs. 45.7%, P = .001). In adjusted analyses, ED advanced counseling in combination with instrument provision was associated with a decreased odds of error compared to receiving neither (adjusted odds ratio 0.3; 95% confidence interval 0.1-0.7); advanced counseling alone and instrument alone were not significantly associated with odds of error. Provider use of advanced counseling strategies and dosing instrument provision may be especially effective in reducing errors when used together. Copyright © 2014 Academic Pediatric Association. Published by Elsevier Inc. All rights reserved.

Error detection and correction unit with built-in self-test capability for spacecraft applications

NASA Technical Reports Server (NTRS)

Timoc, Constantin

1990-01-01

The objective of this project was to research and develop a 32-bit single chip Error Detection and Correction unit capable of correcting all single bit errors and detecting all double bit errors in the memory systems of a spacecraft. We designed the 32-bit EDAC (Error Detection and Correction unit) based on a modified Hamming code and according to the design specifications and performance requirements. We constructed a laboratory prototype (breadboard) which was converted into a fault simulator. The correctness of the design was verified on the breadboard using an exhaustive set of test cases. A logic diagram of the EDAC was delivered to JPL Section 514 on 4 Oct. 1988.

Translating Patient Safety Research Into Clinical Practice

DTIC Science & Technology

2005-01-01

AIM approach is being used to evaluate a pharmacy alert intervention designed to detect and correct medication prescribing errors for all patients ...Standard Form 298 (Rev. 8-98) Prescribed by ANSI Std Z39-18 Advances in Patient Safety: Vol. 2 164 patients .6, 9 Medication use in the ambulatory care...subjects and patients with chronic illnesses) and settings (e.g., schools, worksites, and medical clinics).32 We illustrate each of the RE-AIM dimensions

Objectified quantification of uncertainties in Bayesian atmospheric inversions

NASA Astrophysics Data System (ADS)

Berchet, A.; Pison, I.; Chevallier, F.; Bousquet, P.; Bonne, J.-L.; Paris, J.-D.

2015-05-01

Classical Bayesian atmospheric inversions process atmospheric observations and prior emissions, the two being connected by an observation operator picturing mainly the atmospheric transport. These inversions rely on prescribed errors in the observations, the prior emissions and the observation operator. When data pieces are sparse, inversion results are very sensitive to the prescribed error distributions, which are not accurately known. The classical Bayesian framework experiences difficulties in quantifying the impact of mis-specified error distributions on the optimized fluxes. In order to cope with this issue, we rely on recent research results to enhance the classical Bayesian inversion framework through a marginalization on a large set of plausible errors that can be prescribed in the system. The marginalization consists in computing inversions for all possible error distributions weighted by the probability of occurrence of the error distributions. The posterior distribution of the fluxes calculated by the marginalization is not explicitly describable. As a consequence, we carry out a Monte Carlo sampling based on an approximation of the probability of occurrence of the error distributions. This approximation is deduced from the well-tested method of the maximum likelihood estimation. Thus, the marginalized inversion relies on an automatic objectified diagnosis of the error statistics, without any prior knowledge about the matrices. It robustly accounts for the uncertainties on the error distributions, contrary to what is classically done with frozen expert-knowledge error statistics. Some expert knowledge is still used in the method for the choice of an emission aggregation pattern and of a sampling protocol in order to reduce the computation cost. The relevance and the robustness of the method is tested on a case study: the inversion of methane surface fluxes at the mesoscale with virtual observations on a realistic network in Eurasia. Observing system simulation experiments are carried out with different transport patterns, flux distributions and total prior amounts of emitted methane. The method proves to consistently reproduce the known "truth" in most cases, with satisfactory tolerance intervals. Additionally, the method explicitly provides influence scores and posterior correlation matrices. An in-depth interpretation of the inversion results is then possible. The more objective quantification of the influence of the observations on the fluxes proposed here allows us to evaluate the impact of the observation network on the characterization of the surface fluxes. The explicit correlations between emission aggregates reveal the mis-separated regions, hence the typical temporal and spatial scales the inversion can analyse. These scales are consistent with the chosen aggregation patterns.

A pharmacist-led information technology intervention for medication errors (PINCER): a multicentre, cluster randomised, controlled trial and cost-effectiveness analysis

PubMed Central

Avery, Anthony J; Rodgers, Sarah; Cantrill, Judith A; Armstrong, Sarah; Cresswell, Kathrin; Eden, Martin; Elliott, Rachel A; Howard, Rachel; Kendrick, Denise; Morris, Caroline J; Prescott, Robin J; Swanwick, Glen; Franklin, Matthew; Putman, Koen; Boyd, Matthew; Sheikh, Aziz

2012-01-01

Summary Background Medication errors are common in primary care and are associated with considerable risk of patient harm. We tested whether a pharmacist-led, information technology-based intervention was more effective than simple feedback in reducing the number of patients at risk of measures related to hazardous prescribing and inadequate blood-test monitoring of medicines 6 months after the intervention. Methods In this pragmatic, cluster randomised trial general practices in the UK were stratified by research site and list size, and randomly assigned by a web-based randomisation service in block sizes of two or four to one of two groups. The practices were allocated to either computer-generated simple feedback for at-risk patients (control) or a pharmacist-led information technology intervention (PINCER), composed of feedback, educational outreach, and dedicated support. The allocation was masked to general practices, patients, pharmacists, researchers, and statisticians. Primary outcomes were the proportions of patients at 6 months after the intervention who had had any of three clinically important errors: non-selective non-steroidal anti-inflammatory drugs (NSAIDs) prescribed to those with a history of peptic ulcer without co-prescription of a proton-pump inhibitor; β blockers prescribed to those with a history of asthma; long-term prescription of angiotensin converting enzyme (ACE) inhibitor or loop diuretics to those 75 years or older without assessment of urea and electrolytes in the preceding 15 months. The cost per error avoided was estimated by incremental cost-effectiveness analysis. This study is registered with Controlled-Trials.com, number ISRCTN21785299. Findings 72 general practices with a combined list size of 480 942 patients were randomised. At 6 months' follow-up, patients in the PINCER group were significantly less likely to have been prescribed a non-selective NSAID if they had a history of peptic ulcer without gastroprotection (OR 0·58, 95% CI 0·38–0·89); a β blocker if they had asthma (0·73, 0·58–0·91); or an ACE inhibitor or loop diuretic without appropriate monitoring (0·51, 0·34–0·78). PINCER has a 95% probability of being cost effective if the decision-maker's ceiling willingness to pay reaches £75 per error avoided at 6 months. Interpretation The PINCER intervention is an effective method for reducing a range of medication errors in general practices with computerised clinical records. Funding Patient Safety Research Portfolio, Department of Health, England. PMID:22357106

14 CFR 171.315 - Azimuth monitor system requirements.

Code of Federal Regulations, 2012 CFR

2012-01-01

... an error in the time division multiplex synchronization of a particular azimuth function that the...). If the fault is not cleared within the time allowed, the ground equipment must be shut down. After...

14 CFR 171.315 - Azimuth monitor system requirements.

Code of Federal Regulations, 2013 CFR

2013-01-01

... an error in the time division multiplex synchronization of a particular azimuth function that the...). If the fault is not cleared within the time allowed, the ground equipment must be shut down. After...

14 CFR 171.315 - Azimuth monitor system requirements.

Code of Federal Regulations, 2011 CFR

2011-01-01

... an error in the time division multiplex synchronization of a particular azimuth function that the...). If the fault is not cleared within the time allowed, the ground equipment must be shut down. After...

Software Requirements Analysis as Fault Predictor

NASA Technical Reports Server (NTRS)

Wallace, Dolores

2003-01-01

Waiting until the integration and system test phase to discover errors leads to more costly rework than resolving those same errors earlier in the lifecycle. Costs increase even more significantly once a software system has become operational. WE can assess the quality of system requirements, but do little to correlate this information either to system assurance activities or long-term reliability projections - both of which remain unclear and anecdotal. Extending earlier work on requirements accomplished by the ARM tool, measuring requirements quality information against code complexity and test data for the same system may be used to predict specific software modules containing high impact or deeply embedded faults now escaping in operational systems. Such knowledge would lead to more effective and efficient test programs. It may enable insight into whether a program should be maintained or started over.

[Application of root cause analysis in healthcare].

PubMed

Hsu, Tsung-Fu

2007-12-01

The main purpose of this study was to explore various aspects of root cause analysis (RCA), including its definition, rationale concept, main objective, implementation procedures, most common analysis methodology (fault tree analysis, FTA), and advantages and methodologic limitations in regard to healthcare. Several adverse events that occurred at a certain hospital were also analyzed by the author using FTA as part of this study. RCA is a process employed to identify basic and contributing causal factors underlying performance variations associated with adverse events. The rationale concept of RCA offers a systemic approach to improving patient safety that does not assign blame or liability to individuals. The four-step process involved in conducting an RCA includes: RCA preparation, proximate cause identification, root cause identification, and recommendation generation and implementation. FTA is a logical, structured process that can help identify potential causes of system failure before actual failures occur. Some advantages and significant methodologic limitations of RCA were discussed. Finally, we emphasized that errors stem principally from faults attributable to system design, practice guidelines, work conditions, and other human factors, which induce health professionals to make negligence or mistakes with regard to healthcare. We must explore the root causes of medical errors to eliminate potential RCA system failure factors. Also, a systemic approach is needed to resolve medical errors and move beyond a current culture centered on assigning fault to individuals. In constructing a real environment of patient-centered safety healthcare, we can help encourage clients to accept state-of-the-art healthcare services.

Prevalence of Refractive Error among Preschool Children in an Urban Population: The Baltimore Pediatric Eye Disease Study

PubMed Central

Giordano, Lydia; Friedman, David S.; Repka, Michael X.; Katz, Joanne; Ibironke, Josephine; Hawes, Patricia; Tielsch, James M.

2009-01-01

Purpose To determine the age-specific prevalence of refractive errors in White and African-American preschool children. Design The Baltimore Pediatric Eye Disease Study is a population-based evaluation of the prevalence of ocular disorders in children aged six through 71 months in Baltimore, Maryland, United States. Participants Among 4,132 children identified, 3,990 eligible children (97%) were enrolled and 2,546 children (62%) were examined. Methods Cycloplegic autorefraction was attempted on all children using a Nikon Retinomax K-Plus 2. If a reliable autorefraction could not be obtained after three attempts, cycloplegic streak retinoscopy was performed. Main Outcome Measures Mean spherical equivalent (SE) refractive error, astigmatism, and prevalence of higher refractive errors among African American and White children. Results The mean spherical equivalent (SE) of right eyes was +1.49 diopter (D) (standard deviation (SD) =1.23) in White and +0.71D (SD=1.35) in African-American children (mean difference of 0.78D, 95% CI: 0.67, 0.89). Mean SE refractive error did not decline with age in either group. The prevalence of myopia of 1.00 D or more in the eye with the lesser refractive error was 0.7% in White and 5.5% in African-American children (RR: 8.01 95% confidence interval (CI): 3.70, 17.35). The prevalence of hyperopia of +3D or more in the eye with the lesser refractive error was 8.9% in White and 4.4% in African-American children (relative risk (RR): 0.49, 95% CI: 0.35, 0.68). The prevalence of emmetropia (less than −1.00 D to less than +1.00 D) was 35.6% in Whites and 58.0 % in African-Americans (RR: 1.64, 95% CI: 1.49, 1.80). Based on published prescribing guidelines 5.1% of the children would have benefited from spectacle correction. However, only 1.3% had been previously prescribed correction. Conclusions Significant refractive errors are uncommon in this population of urban preschool children. There was no evidence for a myopic shift over this age range in this cross-sectional study. A small proportion of preschool children would likely benefit from refractive correction, but few have had this prescribed. PMID:19243832

A novel Lagrangian approach for the stable numerical simulation of fault and fracture mechanics

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

Franceschini, Andrea; Ferronato, Massimiliano, E-mail: massimiliano.ferronato@unipd.it; Janna, Carlo

The simulation of the mechanics of geological faults and fractures is of paramount importance in several applications, such as ensuring the safety of the underground storage of wastes and hydrocarbons or predicting the possible seismicity triggered by the production and injection of subsurface fluids. However, the stable numerical modeling of ground ruptures is still an open issue. The present work introduces a novel formulation based on the use of the Lagrange multipliers to prescribe the constraints on the contact surfaces. The variational formulation is modified in order to take into account the frictional work along the activated fault portion accordingmore » to the principle of maximum plastic dissipation. The numerical model, developed in the framework of the Finite Element method, provides stable solutions with a fast convergence of the non-linear problem. The stabilizing properties of the proposed model are emphasized with the aid of a realistic numerical example dealing with the generation of ground fractures due to groundwater withdrawal in arid regions. - Highlights: • A numerical model is developed for the simulation of fault and fracture mechanics. • The model is implemented in the framework of the Finite Element method and with the aid of Lagrange multipliers. • The proposed formulation introduces a new contribution due to the frictional work on the portion of activated fault. • The resulting algorithm is highly non-linear as the portion of activated fault is itself unknown. • The numerical solution is validated against analytical results and proves to be stable also in realistic applications.« less

Improved characterisation and modelling of measurement errors in electrical resistivity tomography (ERT) surveys

NASA Astrophysics Data System (ADS)

Tso, Chak-Hau Michael; Kuras, Oliver; Wilkinson, Paul B.; Uhlemann, Sebastian; Chambers, Jonathan E.; Meldrum, Philip I.; Graham, James; Sherlock, Emma F.; Binley, Andrew

2017-11-01

Measurement errors can play a pivotal role in geophysical inversion. Most inverse models require users to prescribe or assume a statistical model of data errors before inversion. Wrongly prescribed errors can lead to over- or under-fitting of data; however, the derivation of models of data errors is often neglected. With the heightening interest in uncertainty estimation within hydrogeophysics, better characterisation and treatment of measurement errors is needed to provide improved image appraisal. Here we focus on the role of measurement errors in electrical resistivity tomography (ERT). We have analysed two time-lapse ERT datasets: one contains 96 sets of direct and reciprocal data collected from a surface ERT line within a 24 h timeframe; the other is a two-year-long cross-borehole survey at a UK nuclear site with 246 sets of over 50,000 measurements. Our study includes the characterisation of the spatial and temporal behaviour of measurement errors using autocorrelation and correlation coefficient analysis. We find that, in addition to well-known proportionality effects, ERT measurements can also be sensitive to the combination of electrodes used, i.e. errors may not be uncorrelated as often assumed. Based on these findings, we develop a new error model that allows grouping based on electrode number in addition to fitting a linear model to transfer resistance. The new model explains the observed measurement errors better and shows superior inversion results and uncertainty estimates in synthetic examples. It is robust, because it groups errors together based on the electrodes used to make the measurements. The new model can be readily applied to the diagonal data weighting matrix widely used in common inversion methods, as well as to the data covariance matrix in a Bayesian inversion framework. We demonstrate its application using extensive ERT monitoring datasets from the two aforementioned sites.

Combined methods of tolerance increasing for embedded SRAM

NASA Astrophysics Data System (ADS)

Shchigorev, L. A.; Shagurin, I. I.

2016-10-01

The abilities of combined use of different methods of fault tolerance increasing for SRAM such as error detection and correction codes, parity bits, and redundant elements are considered. Area penalties due to using combinations of these methods are investigated. Estimation is made for different configurations of 4K x 128 RAM memory block for 28 nm manufacturing process. Evaluation of the effectiveness of the proposed combinations is also reported. The results of these investigations can be useful for designing fault-tolerant “system on chips”.

An Analytic Training Effectiveness Analysis for a CTEA Update

DTIC Science & Technology

1977-11-01

minutes to insert a fault in the crtual harduare and an additional 5 minut(,s to remove the fault. This manual insertion of f,iults, therefore, will cut an...organizatioual mu Inten;4 nce m4n.for tle potrfo’ in.ý;e of hi 1 t ,ksx. Thus, feedlark would hatve to be piovil,,d by an Instrutor ohb.-erving ,v,.ry...use Information regarding problem parameters and student performance (time, errors). The problems in handling this such data manually are such that

Evaluation of a hybrid paper-electronic medication management system at a residential aged care facility.

PubMed

Elliott, Rohan A; Lee, Cik Yin; Hussainy, Safeera Y

2016-06-01

Objectives The aims of the study were to investigate discrepancies between general practitioners' paper medication orders and pharmacy-prepared electronic medication administration charts, back-up paper charts and dose-administration aids, as well as delays between prescribing, charting and administration, at a 90-bed residential aged care facility that used a hybrid paper-electronic medication management system. Methods A cross-sectional audit of medication orders, medication charts and dose-administration aids was performed to identify discrepancies. In addition, a retrospective audit was performed of delays between prescribing and availability of an updated electronic medication administration chart. Medication administration records were reviewed retrospectively to determine whether discrepancies and delays led to medication administration errors. Results Medication records for 88 residents (mean age 86 years) were audited. Residents were prescribed a median of eight regular medicines (interquartile range 5-12). One hundred and twenty-five discrepancies were identified. Forty-seven discrepancies, affecting 21 (24%) residents, led to a medication administration error. The most common discrepancies were medicine omission (44.0%) and extra medicine (19.2%). Delays from when medicines were prescribed to when they appeared on the electronic medication administration chart ranged from 18min to 98h. On nine occasions (for 10% of residents) the delay contributed to missed doses, usually antibiotics. Conclusion Medication discrepancies and delays were common. Improved systems for managing medication orders and charts are needed. What is known about the topic? Hybrid paper-electronic medication management systems, in which prescribers' orders are transcribed into an electronic system by pharmacy technicians and pharmacists to create medication administration charts, are increasingly replacing paper-based medication management systems in Australian residential aged care facilities. The accuracy and safety of these systems has not been studied. What does this paper add? The present study identified discrepancies between general practitioners' orders and pharmacy-prepared electronic medication administration charts, back-up paper medication charts and dose-administration aids, as well as delays between ordering, charting and administering medicines. Discrepancies and delays sometimes led to medication administration errors. What are the implications for practitioners? Facilities that use hybrid systems need to implement robust systems for communicating medication changes to their pharmacy and reconciling prescribers' orders against pharmacy-generated medication charts and dose-administration aids. Fully integrated, paperless medication management systems, in which prescribers' electronic medication orders directly populate an electronic medication administration chart and are automatically communicated to the facility's pharmacy, could improve patient safety.

Adiabatic gate teleportation.

PubMed

Bacon, Dave; Flammia, Steven T

2009-09-18

The difficulty in producing precisely timed and controlled quantum gates is a significant source of error in many physical implementations of quantum computers. Here we introduce a simple universal primitive, adiabatic gate teleportation, which is robust to timing errors and many control errors and maintains a constant energy gap throughout the computation above a degenerate ground state space. This construction allows for geometric robustness based upon the control of two independent qubit interactions. Further, our piecewise adiabatic evolution easily relates to the quantum circuit model, enabling the use of standard methods from fault-tolerance theory for establishing thresholds.

Pilot interaction with automated airborne decision making systems

NASA Technical Reports Server (NTRS)

Hammer, John M.; Wan, C. Yoon; Vasandani, Vijay

1987-01-01

The current research is focused on detection of human error and protection from its consequences. A program for monitoring pilot error by comparing pilot actions to a script was described. It dealt primarily with routine errors (slips) that occurred during checklist activity. The model to which operator actions were compared was a script. Current research is an extension along these two dimensions. The ORS fault detection aid uses a sophisticated device model rather than a script. The newer initiative, the model-based and constraint-based warning system, uses an even more sophisticated device model and is to prevent all types of error, not just slips or bad decision.

A Cooperative Approach to Virtual Machine Based Fault Injection

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

Naughton III, Thomas J; Engelmann, Christian; Vallee, Geoffroy R

Resilience investigations often employ fault injection (FI) tools to study the effects of simulated errors on a target system. It is important to keep the target system under test (SUT) isolated from the controlling environment in order to maintain control of the experiement. Virtual machines (VMs) have been used to aid these investigations due to the strong isolation properties of system-level virtualization. A key challenge in fault injection tools is to gain proper insight and context about the SUT. In VM-based FI tools, this challenge of target con- text is increased due to the separation between host and guest (VM).more » We discuss an approach to VM-based FI that leverages virtual machine introspection (VMI) methods to gain insight into the target s context running within the VM. The key to this environment is the ability to provide basic information to the FI system that can be used to create a map of the target environment. We describe a proof- of-concept implementation and a demonstration of its use to introduce simulated soft errors into an iterative solver benchmark running in user-space of a guest VM.« less

Near-Fault Strong Ground Motions during the 2016 Kumamoto, Japan, Earthquake

NASA Astrophysics Data System (ADS)

Iwata, T.; Asano, K.

2016-12-01

The 2016 Kumamoto mainshock (Mw7.0) produced a surface ruptured fault of about 20km long with maximum 2m offset, and identified as a surface ruptured event. Two strong motion records were observed near the surface ruptured fault at Mashiki town hall and Nishihara village hall. We investigated characteristics of those strong ground motions. As the acceleration records consisted of the baseline errors caused by nonzero initial acceleration and tilting of the accelerograph, we carefully removed the baseline errors (c.f. Chiu, 2001, Boore and Bommer, 2005) so as to obtain velocity and displacements. The observed permanent displacements were about 1.2m in horizontal direction and about 0.7m sinking in vertical direction at Mashiki town hall, and about 1.7m and 1.8m, respectively, at Nishihara village hall. Those permanent displacements almost coincide to results by GNSS and InSAR analysis (e.g., GSI, 2016). It takes about only 3 s to reach the permanent displacement. Somerville (2003) pointed out that ground motions from earthquakes producing large surface ruptures appeared to have systematically weaker ground motions than ground motions from earthquakes whose rupture were confined to the subsurface using the Ground Motion Prediction Equation (GMPE) for response spectra (Abrahamson and Silva, 1997). We calculated the response spectra of those records, compared them to the GMPE with the same manner and found two records were systematically larger than the expected from the GMPE in the period range of 0.3 s to 5 s. We need to re-consider the working hypothesis that the near-fault ground motions are weaker and to separate the near-fault and site effects on ground motions. Strong motions in the longer period range would be mainly caused by the near-fault (near-field term) effect.We used the acceleration data of the Kumamoto seismic intensity information network, provided by JMA.

Hypervitaminosis D associated with a vitamin D dispensing error.

PubMed

Jacobsen, Ryan B; Hronek, Brett W; Schmidt, Ginelle A; Schilling, Margo L

2011-10-01

To report a case of hypervitaminosis D resulting in hypercalcemia and acute kidney injury in a 70-year-old female who was prescribed a standard dose of vitamin D but given a toxic dose of vitamin D 50,000 IU (1.25 mg) daily resulting from a dispensing error. A 70-year-old female in her usual state of health was instructed to begin supplementation with vitamin D 1000 IU daily. Three months later she developed confusion, slurred speech, unstable gait, and increased fatigue. She was hospitalized for hypercalcemia and acute kidney injury secondary to hypervitaminosis D. All vitamin D supplementation was discontinued and 5 months after discharge, the patient's serum calcium and vitamin D concentrations, as well as renal function, had returned to baseline values. Upon review of the patient's records, it was discovered that she had been taking vitamin D 50,000 IU daily. There is an increased interest in vitamin D, resulting in more health care providers recommending--and patients taking--supplemental vitamin D. Hypervitaminosis D is rarely reported and generally only in the setting of gross excess of vitamin D. This report highlights a case of hypervitaminosis D in the setting of a prescribed standard dose of vitamin D that resulted in toxic ingestion of vitamin D 50,000 IU daily due to a dispensing error. As more and more people use vitamin D supplements, it is important to recognize that, while rare, hypervitaminosis D is a possibility and dosage conversion of vitamin D units can result in errors. Health care providers and patients should be educated on the advantages and risks associated with vitamin D supplementation and be informed of safety measures to avoid hypervitaminosis D. In addition, health care providers should understand dosage conversion regarding vitamin D and electronic prescribing and dispensing software should be designed to detect such errors.

Space geodetic observations of repeating slow slip events beneath the Bonin Islands

NASA Astrophysics Data System (ADS)

Arisa, Deasy; Heki, Kosuke

2017-09-01

The Pacific Plate subducts beneath the Philippine Sea Plate along the Izu-Bonin Trench. We investigated crustal movements at the Bonin Islands, using Global Navigation Satellite System and geodetic Very Long Baseline Interferometry data to reveal how the two plates converge in this subduction zone. These islands are located ∼100 km from the trench, just at the middle between the volcanic arc and the trench, making these islands suitable for detecting signatures of episodic deformation such as slow slip events (SSEs). During 2007-2016, we found five SSEs repeating quasi-periodically with similar displacement patterns. In estimating their fault parameters, we assumed that the fault lies on the prescribed plate boundary, and optimized the size, shape and position of the fault and dislocation vectors. Average fault slip was ∼5 cm, and the average moment magnitude was ∼6.9. We also found one SSE occurred in 2008 updip of the repeating SSE in response to an M6 class interplate earthquake. In spite of the frequent occurrence of SSEs, there is no evidence for long-term strain accumulation in the Bonin Islands that may lead to future megathrust earthquakes. Plate convergence in Mariana-type subduction zones may occur, to a large extent, episodically as repeating SSEs.

A novel fault location scheme for power distribution system based on injection method and transient line voltage

NASA Astrophysics Data System (ADS)

Huang, Yuehua; Li, Xiaomin; Cheng, Jiangzhou; Nie, Deyu; Wang, Zhuoyuan

2018-02-01

This paper presents a novel fault location method by injecting travelling wave current. The new methodology is based on Time Difference Of Arrival(TDOA)measurement which is available measurements the injection point and the end node of main radial. In other words, TDOA is the maximum correlation time when the signal reflected wave crest of the injected and fault appear simultaneously. Then distance calculation is equal to the wave velocity multiplied by TDOA. Furthermore, in case of some transformers connected to the end of the feeder, it’s necessary to combine with the transient voltage comparison of amplitude. Finally, in order to verify the effectiveness of this method, several simulations have been undertaken by using MATLAB/SIMULINK software packages. The proposed fault location is useful to short the positioning time in the premise of ensuring the accuracy, besides the error is 5.1% and 13.7%.

Reliability issues in active control of large flexible space structures

NASA Technical Reports Server (NTRS)

Vandervelde, W. E.

1986-01-01

Efforts in this reporting period were centered on four research tasks: design of failure detection filters for robust performance in the presence of modeling errors, design of generalized parity relations for robust performance in the presence of modeling errors, design of failure sensitive observers using the geometric system theory of Wonham, and computational techniques for evaluation of the performance of control systems with fault tolerance and redundancy management

Numerical simulations of earthquakes and the dynamics of fault systems using the Finite Element method.

NASA Astrophysics Data System (ADS)

Kettle, L. M.; Mora, P.; Weatherley, D.; Gross, L.; Xing, H.

2006-12-01

Simulations using the Finite Element method are widely used in many engineering applications and for the solution of partial differential equations (PDEs). Computational models based on the solution of PDEs play a key role in earth systems simulations. We present numerical modelling of crustal fault systems where the dynamic elastic wave equation is solved using the Finite Element method. This is achieved using a high level computational modelling language, escript, available as open source software from ACcESS (Australian Computational Earth Systems Simulator), the University of Queensland. Escript is an advanced geophysical simulation software package developed at ACcESS which includes parallel equation solvers, data visualisation and data analysis software. The escript library was implemented to develop a flexible Finite Element model which reliably simulates the mechanism of faulting and the physics of earthquakes. Both 2D and 3D elastodynamic models are being developed to study the dynamics of crustal fault systems. Our final goal is to build a flexible model which can be applied to any fault system with user-defined geometry and input parameters. To study the physics of earthquake processes, two different time scales must be modelled, firstly the quasi-static loading phase which gradually increases stress in the system (~100years), and secondly the dynamic rupture process which rapidly redistributes stress in the system (~100secs). We will discuss the solution of the time-dependent elastic wave equation for an arbitrary fault system using escript. This involves prescribing the correct initial stress distribution in the system to simulate the quasi-static loading of faults to failure; determining a suitable frictional constitutive law which accurately reproduces the dynamics of the stick/slip instability at the faults; and using a robust time integration scheme. These dynamic models generate data and information that can be used for earthquake forecasting.

Application of the Systematic Sensor Selection Strategy for Turbofan Engine Diagnostics

NASA Technical Reports Server (NTRS)

Sowers, T. Shane; Kopasakis, George; Simon, Donald L.

2008-01-01

The data acquired from available system sensors forms the foundation upon which any health management system is based, and the available sensor suite directly impacts the overall diagnostic performance that can be achieved. While additional sensors may provide improved fault diagnostic performance, there are other factors that also need to be considered such as instrumentation cost, weight, and reliability. A systematic sensor selection approach is desired to perform sensor selection from a holistic system-level perspective as opposed to performing decisions in an ad hoc or heuristic fashion. The Systematic Sensor Selection Strategy is a methodology that optimally selects a sensor suite from a pool of sensors based on the system fault diagnostic approach, with the ability of taking cost, weight, and reliability into consideration. This procedure was applied to a large commercial turbofan engine simulation. In this initial study, sensor suites tailored for improved diagnostic performance are constructed from a prescribed collection of candidate sensors. The diagnostic performance of the best performing sensor suites in terms of fault detection and identification are demonstrated, with a discussion of the results and implications for future research.

Application of the Systematic Sensor Selection Strategy for Turbofan Engine Diagnostics

NASA Technical Reports Server (NTRS)

Sowers, T. Shane; Kopasakis, George; Simon, Donald L.

2008-01-01

The data acquired from available system sensors forms the foundation upon which any health management system is based, and the available sensor suite directly impacts the overall diagnostic performance that can be achieved. While additional sensors may provide improved fault diagnostic performance there are other factors that also need to be considered such as instrumentation cost, weight, and reliability. A systematic sensor selection approach is desired to perform sensor selection from a holistic system-level perspective as opposed to performing decisions in an ad hoc or heuristic fashion. The Systematic Sensor Selection Strategy is a methodology that optimally selects a sensor suite from a pool of sensors based on the system fault diagnostic approach, with the ability of taking cost, weight and reliability into consideration. This procedure was applied to a large commercial turbofan engine simulation. In this initial study, sensor suites tailored for improved diagnostic performance are constructed from a prescribed collection of candidate sensors. The diagnostic performance of the best performing sensor suites in terms of fault detection and identification are demonstrated, with a discussion of the results and implications for future research.

Quantitative fault tolerant control design for a hydraulic actuator with a leaking piston seal

NASA Astrophysics Data System (ADS)

Karpenko, Mark

Hydraulic actuators are complex fluid power devices whose performance can be degraded in the presence of system faults. In this thesis a linear, fixed-gain, fault tolerant controller is designed that can maintain the positioning performance of an electrohydraulic actuator operating under load with a leaking piston seal and in the presence of parametric uncertainties. Developing a control system tolerant to this class of internal leakage fault is important since a leaking piston seal can be difficult to detect, unless the actuator is disassembled. The designed fault tolerant control law is of low-order, uses only the actuator position as feedback, and can: (i) accommodate nonlinearities in the hydraulic functions, (ii) maintain robustness against typical uncertainties in the hydraulic system parameters, and (iii) keep the positioning performance of the actuator within prescribed tolerances despite an internal leakage fault that can bypass up to 40% of the rated servovalve flow across the actuator piston. Experimental tests verify the functionality of the fault tolerant control under normal and faulty operating conditions. The fault tolerant controller is synthesized based on linear time-invariant equivalent (LTIE) models of the hydraulic actuator using the quantitative feedback theory (QFT) design technique. A numerical approach for identifying LTIE frequency response functions of hydraulic actuators from acceptable input-output responses is developed so that linearizing the hydraulic functions can be avoided. The proposed approach can properly identify the features of the hydraulic actuator frequency response that are important for control system design and requires no prior knowledge about the asymptotic behavior or structure of the LTIE transfer functions. A distributed hardware-in-the-loop (HIL) simulation architecture is constructed that enables the performance of the proposed fault tolerant control law to be further substantiated, under realistic operating conditions. Using the HIL framework, the fault tolerant hydraulic actuator is operated as a flight control actuator against the real-time numerical simulation of a high-performance jet aircraft. A robust electrohydraulic loading system is also designed using QFT so that the in-flight aerodynamic load can be experimentally replicated. The results of the HIL experiments show that using the fault tolerant controller to compensate the internal leakage fault at the actuator level can benefit the flight performance of the airplane.

Pharmacist independent prescribing in critical care: results of a national questionnaire to establish the 2014 UK position.

PubMed

Bourne, Richard S; Whiting, Paul; Brown, Lisa S; Borthwick, Mark

2016-04-01

Clinical pharmacist practice is well established in the safe and effective use of medicines in the critically ill patient. In the UK, independent pharmacist prescribers are generally recognised as a valuable and desirable resource. However, currently, there are only anecdotal reports of pharmacist-independent prescribing in critical care. The aim of this questionnaire was to determine the current and proposed future independent prescribing practice of UK clinical pharmacists working in adult critical care. The questionnaire was distributed electronically to UK Clinical Pharmacy Association members (closed August 2014). There were 134 responses to the questionnaire (response rate at least 33%). Over a third of critical care pharmacists were practising independent prescribers in the specialty, and 70% intended to be prescribers within the next 3 years. Pharmacists with ≥5 years critical care experience (P < 0.001) or worked in a team (P = 0.005) were more likely to be practising independent prescribers. Pharmacists reported significant positives to the use of independent prescribing in critical care both in patient care and job satisfaction. Independently, prescribing was routine in: dose adjustment for multi-organ failure, change in route or formulation, correction prescribing errors, therapeutic drug monitoring and chronic medication. The majority of pharmacist prescribers reported they spent ≤5% of their clinical time prescribing and accounted for ≤5% of new prescriptions in critical care patients. Most critical care pharmacists intend to be practising as independent prescribers within the next 3 years. The extent and scope of critical care pharmacist prescribing appear to be of relatively low volume and within niche prescribing areas. © 2015 Royal Pharmaceutical Society.

Using surface creep rate to infer fraction locked for sections of the San Andreas fault system in northern California from alignment array and GPS data

USGS Publications Warehouse

Lienkaemper, James J.; McFarland, Forrest S.; Simpson, Robert W.; Caskey, S. John

2014-01-01

Surface creep rate, observed along five branches of the dextral San Andreas fault system in northern California, varies considerably from one section to the next, indicating that so too may the depth at which the faults are locked. We model locking on 29 fault sections using each section’s mean long‐term creep rate and the consensus values of fault width and geologic slip rate. Surface creep rate observations from 111 short‐range alignment and trilateration arrays and 48 near‐fault, Global Positioning System station pairs are used to estimate depth of creep, assuming an elastic half‐space model and adjusting depth of creep iteratively by trial and error to match the creep observations along fault sections. Fault sections are delineated either by geometric discontinuities between them or by distinctly different creeping behaviors. We remove transient rate changes associated with five large (M≥5.5) regional earthquakes. Estimates of fraction locked, the ratio of moment accumulation rate to loading rate, on each section of the fault system provide a uniform means to inform source parameters relevant to seismic‐hazard assessment. From its mean creep rates, we infer the main branch (the San Andreas fault) ranges from only 20%±10% locked on its central creeping section to 99%–100% on the north coast. From mean accumulation rates, we infer that four urban faults appear to have accumulated enough seismic moment to produce major earthquakes: the northern Calaveras (M 6.8), Hayward (M 6.8), Rodgers Creek (M 7.1), and Green Valley (M 7.1). The latter three faults are nearing or past their mean recurrence interval.

ASCS online fault detection and isolation based on an improved MPCA

NASA Astrophysics Data System (ADS)

Peng, Jianxin; Liu, Haiou; Hu, Yuhui; Xi, Junqiang; Chen, Huiyan

2014-09-01

Multi-way principal component analysis (MPCA) has received considerable attention and been widely used in process monitoring. A traditional MPCA algorithm unfolds multiple batches of historical data into a two-dimensional matrix and cut the matrix along the time axis to form subspaces. However, low efficiency of subspaces and difficult fault isolation are the common disadvantages for the principal component model. This paper presents a new subspace construction method based on kernel density estimation function that can effectively reduce the storage amount of the subspace information. The MPCA model and the knowledge base are built based on the new subspace. Then, fault detection and isolation with the squared prediction error (SPE) statistic and the Hotelling ( T 2) statistic are also realized in process monitoring. When a fault occurs, fault isolation based on the SPE statistic is achieved by residual contribution analysis of different variables. For fault isolation of subspace based on the T 2 statistic, the relationship between the statistic indicator and state variables is constructed, and the constraint conditions are presented to check the validity of fault isolation. Then, to improve the robustness of fault isolation to unexpected disturbances, the statistic method is adopted to set the relation between single subspace and multiple subspaces to increase the corrective rate of fault isolation. Finally fault detection and isolation based on the improved MPCA is used to monitor the automatic shift control system (ASCS) to prove the correctness and effectiveness of the algorithm. The research proposes a new subspace construction method to reduce the required storage capacity and to prove the robustness of the principal component model, and sets the relationship between the state variables and fault detection indicators for fault isolation.

Resilience Design Patterns - A Structured Approach to Resilience at Extreme Scale (version 1.1)

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

Hukerikar, Saurabh; Engelmann, Christian

Reliability is a serious concern for future extreme-scale high-performance computing (HPC) systems. Projections based on the current generation of HPC systems and technology roadmaps suggest the prevalence of very high fault rates in future systems. The errors resulting from these faults will propagate and generate various kinds of failures, which may result in outcomes ranging from result corruptions to catastrophic application crashes. Therefore the resilience challenge for extreme-scale HPC systems requires management of various hardware and software technologies that are capable of handling a broad set of fault models at accelerated fault rates. Also, due to practical limits on powermore » consumption in HPC systems future systems are likely to embrace innovative architectures, increasing the levels of hardware and software complexities. As a result the techniques that seek to improve resilience must navigate the complex trade-off space between resilience and the overheads to power consumption and performance. While the HPC community has developed various resilience solutions, application-level techniques as well as system-based solutions, the solution space of HPC resilience techniques remains fragmented. There are no formal methods and metrics to investigate and evaluate resilience holistically in HPC systems that consider impact scope, handling coverage, and performance & power efficiency across the system stack. Additionally, few of the current approaches are portable to newer architectures and software environments that will be deployed on future systems. In this document, we develop a structured approach to the management of HPC resilience using the concept of resilience-based design patterns. A design pattern is a general repeatable solution to a commonly occurring problem. We identify the commonly occurring problems and solutions used to deal with faults, errors and failures in HPC systems. Each established solution is described in the form of a pattern that addresses concrete problems in the design of resilient systems. The complete catalog of resilience design patterns provides designers with reusable design elements. We also define a framework that enhances a designer's understanding of the important constraints and opportunities for the design patterns to be implemented and deployed at various layers of the system stack. This design framework may be used to establish mechanisms and interfaces to coordinate flexible fault management across hardware and software components. The framework also supports optimization of the cost-benefit trade-offs among performance, resilience, and power consumption. The overall goal of this work is to enable a systematic methodology for the design and evaluation of resilience technologies in extreme-scale HPC systems that keep scientific applications running to a correct solution in a timely and cost-efficient manner in spite of frequent faults, errors, and failures of various types.« less

Medication Errors in Pediatric Anesthesia: A Report From the Wake Up Safe Quality Improvement Initiative.

PubMed

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.

Modeling caprock fracture, CO2 migration and time dependent fault healing: A numerical study.

NASA Astrophysics Data System (ADS)

MacFarlane, J.; Mukerji, T.; Vanorio, T.

2017-12-01

The Campi Flegrei caldera, located near Naples, Italy, is one of the highest risk volcanoes on Earth due to its recent unrest and urban setting. A unique history of surface uplift within the caldera is characterized by long duration uplift and subsidence cycles which are periodically interrupted by rapid, short period uplift events. Several models have been proposed to explain this history; in this study we will present a hydro-mechanical model that takes into account the caprock that seismic studies show to exist at 1-2 km depth. Specifically, we develop a finite element model of the caldera and use a modified version of fault-valve theory to represent fracture within the caprock. The model accounts for fault healing using a simplified, time-dependent fault sealing model. Multiple fracture events are incorporated by using previous solutions to test prescribed conditions and determine changes in rock properties, such as porosity and permeability. Although fault-valve theory has been used to model single fractures and recharge, this model is unique in its ability to model multiple fracture events. By incorporating multiple fracture events we can assess changes in both long and short-term reservoir behavior at Campi Flegrei. By varying the model inputs, we model the poro-elastic response to CO2 injection at depth and the resulting surface deformation. The goal is to enable geophysicists to better interpret surface observations and predict outcomes from observed changes in reservoir conditions.

Nurse prescribing: reflections on safety in practice.

PubMed

Bradley, Eleanor; Hynam, Brian; Nolan, Peter

2007-08-01

This qualitative study explores how recently qualified nurse prescribers describe, and rate, the safety of their prescribing. Internationally, the costs of drug errors are enormous and they can have serious implications for staff and patients. Nurses are now undertaking extended prescribing practice throughout the UK. Nurse prescribers work across different work settings and although safe prescribing is a priority in all of them, it is essential to ascertain the conditions that foster the highest levels of safety and how nurses can be supported in practice. Thirty-one nurses form the West Midlands area of England agreed to participate in an in-depth interview which sought to elicit their responses to various aspects of their prescribing work. They came from a variety of specialities and from hospital, community and general practice backgrounds. On completion of their training nurses were acutely aware of the responsibility that prescribing imposed on them. Although this awareness was thought to encourage caution and safety, it may also account for the fact that 26% of the nurses (n=8) had not prescribed since qualifying. Nurses felt that the multidisciplinary team had a vital role to play in supporting their prescribing practice as did collaborative working. It is concluded that those working in specialty areas that are less well-defined in terms of scope of practice (e.g. older adult nursing and learning disability) would benefit in particular from ongoing mentoring relationships with experienced prescribers and the development of individual formularies.

Distributed fault detection over sensor networks with Markovian switching topologies

NASA Astrophysics Data System (ADS)

Ge, Xiaohua; Han, Qing-Long

2014-05-01

This paper deals with the distributed fault detection for discrete-time Markov jump linear systems over sensor networks with Markovian switching topologies. The sensors are scatteredly deployed in the sensor field and the fault detectors are physically distributed via a communication network. The system dynamics changes and sensing topology variations are modeled by a discrete-time Markov chain with incomplete mode transition probabilities. Each of these sensor nodes firstly collects measurement outputs from its all underlying neighboring nodes, processes these data in accordance with the Markovian switching topologies, and then transmits the processed data to the remote fault detector node. Network-induced delays and accumulated data packet dropouts are incorporated in the data transmission between the sensor nodes and the distributed fault detector nodes through the communication network. To generate localized residual signals, mode-independent distributed fault detection filters are proposed. By means of the stochastic Lyapunov functional approach, the residual system performance analysis is carried out such that the overall residual system is stochastically stable and the error between each residual signal and the fault signal is made as small as possible. Furthermore, a sufficient condition on the existence of the mode-independent distributed fault detection filters is derived in the simultaneous presence of incomplete mode transition probabilities, Markovian switching topologies, network-induced delays, and accumulated data packed dropouts. Finally, a stirred-tank reactor system is given to show the effectiveness of the developed theoretical results.

Early experiences with E-prescribing.

PubMed

Halamka, John

2006-01-01

Most physicians understand that e-prescribing will reduce medical errors and will be perceived by patients as making the prescription process easier. However, they are skeptical about a number of things. They worry whether their office processes will be improved or streamlined; e-prescribing will interface seamlessly with their existing practice management software; training and support will be available; e-prescribing data will be seamlessly transferable to an electronic health record when they implement a more advanced clinical record system for their practice; and if they will achieve a return on investment. Early adopting clinicians in Massachusetts can convince the majority of clinicians to adopt e-prescribing by sharing their motivations for adopting e-prescribing, the challenges that they needed to overcome, the hardware and software requirements, and integration into their office workflow. Finally, interaction with the physicians and practice managers in the audience makes the adoption of e-prescribing seem both reasonable and exciting. Resources such as vendor lists, questions to ask, and hardware and software requirements also need to be readily available and in a form that non-technical staff can read and understand. Physicians who know the "why" would also like to know

Electronic prescribing in ambulatory practice: promises, pitfalls, and potential solutions.

PubMed

Papshev, D; Peterson, A M

2001-07-01

To examine advantages of and obstacles to electronic prescribing in the ambulatory care environment. MEDLINE and International Pharmaceutical Abstract searches were conducted for the period from January 1980 to September 2000. Key words were electronic prescribing, computerized physician order entry, prior authorization, drug utilization review, and consumer satisfaction. In September 2000, a public search engine (www.google.com) was used to find additional technical information. In addition, pertinent articles were cross-referenced to identify other resources. Articles, symposia proceedings, and organizational position statements published in the United States on electronic prescribing and automation in healthcare are cited. Electronic prescribing can eliminate the time gap between point of care and point of service, reduce medication errors, improve quality of care, and increase patient satisfaction. Considerable funding requirements, segmentation of healthcare markets, lack of technology standardization, providers' resistance to change, and regulatory indecisiveness create boundaries to the widespread use of automated prescribing. The potential solutions include establishing a standardizing warehouse or a router and gaining stakeholder support in implementation of the technology. Electronic prescribing can provide immense benefits to healthcare providers, patients, and managed care. Resolution of several obstacles that limit feasibility of this technology will determine its future.

How should teaching of undergraduates in clinical pharmacology and therapeutics be delivered and assessed?

PubMed Central

Maxwell, Simon R J

2012-01-01

Clinical pharmacology and therapeutics is the academic discipline that informs rational prescribing of medicines. There is accumulating evidence that a significant minority of prescriptions in the UK National Health Service contain errors. This comes at a time when the approach to and success of undergraduate education in this area has been called into question. Various stakeholders are now in agreement that this challenging area of undergraduate education needs to be strengthened. The principles that should form the basis of future educational strategy include greater visibility of clinical pharmacology and therapeutics in the curriculum, clear learning outcomes that are consistent with national guidance, strong and enthusiastic leadership, a student formulary, opportunities to practice prescribing, a robust assessment of prescribing competencies and external quality control. Important new developments in the UK are Prescribe, a repository of e-learning materials to support education in clinical pharmacology and prescribing, and the Prescribing Skills Assessment, a national online assessment designed to allow medical students to demonstrate that they have achieved the core competencies required to begin postgraduate training. PMID:22360965

Finite-time fault tolerant attitude stabilization control for rigid spacecraft.

PubMed

Huo, Xing; Hu, Qinglei; Xiao, Bing

2014-03-01

A sliding mode based finite-time control scheme is presented to address the problem of attitude stabilization for rigid spacecraft in the presence of actuator fault and external disturbances. More specifically, a nonlinear observer is first proposed to reconstruct the amplitude of actuator faults and external disturbances. It is proved that precise reconstruction with zero observer error is achieved in finite time. Then, together with the system states, the reconstructed information is used to synthesize a nonsingular terminal sliding mode attitude controller. The attitude and the angular velocity are asymptotically governed to zero with finite-time convergence. A numerical example is presented to demonstrate the effectiveness of the proposed scheme. © 2013 Published by ISA on behalf of ISA.

A Unified Fault-Tolerance Protocol

NASA Technical Reports Server (NTRS)

Miner, Paul; Gedser, Alfons; Pike, Lee; Maddalon, Jeffrey

2004-01-01

Davies and Wakerly show that Byzantine fault tolerance can be achieved by a cascade of broadcasts and middle value select functions. We present an extension of the Davies and Wakerly protocol, the unified protocol, and its proof of correctness. We prove that it satisfies validity and agreement properties for communication of exact values. We then introduce bounded communication error into the model. Inexact communication is inherent for clock synchronization protocols. We prove that validity and agreement properties hold for inexact communication, and that exact communication is a special case. As a running example, we illustrate the unified protocol using the SPIDER family of fault-tolerant architectures. In particular we demonstrate that the SPIDER interactive consistency, distributed diagnosis, and clock synchronization protocols are instances of the unified protocol.

Interim reliability-evaluation program: analysis of the Browns Ferry, Unit 1, nuclear plant. Appendix B - system descriptions and fault trees

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

Mays, S.E.; Poloski, J.P.; Sullivan, W.H.

1982-07-01

This report describes a risk study of the Browns Ferry, Unit 1, nuclear plant. The study is one of four such studies sponsored by the NRC Office of Research, Division of Risk Assessment, as part of its Interim Reliability Evaluation Program (IREP), Phase II. This report is contained in four volumes: a main report and three appendixes. Appendix B provides a description of Browns Ferry, Unit 1, plant systems and the failure evaluation of those systems as they apply to accidents at Browns Ferry. Information is presented concerning front-line system fault analysis; support system fault analysis; human error models andmore » probabilities; and generic control circuit analyses.« less

Experimental analysis of computer system dependability

NASA Technical Reports Server (NTRS)

Iyer, Ravishankar, K.; Tang, Dong

1993-01-01

This paper reviews an area which has evolved over the past 15 years: experimental analysis of computer system dependability. Methodologies and advances are discussed for three basic approaches used in the area: simulated fault injection, physical fault injection, and measurement-based analysis. The three approaches are suited, respectively, to dependability evaluation in the three phases of a system's life: design phase, prototype phase, and operational phase. Before the discussion of these phases, several statistical techniques used in the area are introduced. For each phase, a classification of research methods or study topics is outlined, followed by discussion of these methods or topics as well as representative studies. The statistical techniques introduced include the estimation of parameters and confidence intervals, probability distribution characterization, and several multivariate analysis methods. Importance sampling, a statistical technique used to accelerate Monte Carlo simulation, is also introduced. The discussion of simulated fault injection covers electrical-level, logic-level, and function-level fault injection methods as well as representative simulation environments such as FOCUS and DEPEND. The discussion of physical fault injection covers hardware, software, and radiation fault injection methods as well as several software and hybrid tools including FIAT, FERARI, HYBRID, and FINE. The discussion of measurement-based analysis covers measurement and data processing techniques, basic error characterization, dependency analysis, Markov reward modeling, software-dependability, and fault diagnosis. The discussion involves several important issues studies in the area, including fault models, fast simulation techniques, workload/failure dependency, correlated failures, and software fault tolerance.

Adaptive artificial neural network for autonomous robot control

NASA Technical Reports Server (NTRS)

Arras, Michael K.; Protzel, Peter W.; Palumbo, Daniel L.

1992-01-01

The topics are presented in viewgraph form and include: neural network controller for robot arm positioning with visual feedback; initial training of the arm; automatic recovery from cumulative fault scenarios; and error reduction by iterative fine movements.

(Quickly) Testing the Tester via Path Coverage

NASA Technical Reports Server (NTRS)

Groce, Alex

2009-01-01

The configuration complexity and code size of an automated testing framework may grow to a point that the tester itself becomes a significant software artifact, prone to poor configuration and implementation errors. Unfortunately, testing the tester by using old versions of the software under test (SUT) may be impractical or impossible: test framework changes may have been motivated by interface changes in the tested system, or fault detection may become too expensive in terms of computing time to justify running until errors are detected on older versions of the software. We propose the use of path coverage measures as a "quick and dirty" method for detecting many faults in complex test frameworks. We also note the possibility of using techniques developed to diversify state-space searches in model checking to diversify test focus, and an associated classification of tester changes into focus-changing and non-focus-changing modifications.

Implementing a strand of a scalable fault-tolerant quantum computing fabric.

PubMed

Chow, Jerry M; Gambetta, Jay M; Magesan, Easwar; Abraham, David W; Cross, Andrew W; Johnson, B R; Masluk, Nicholas A; Ryan, Colm A; Smolin, John A; Srinivasan, Srikanth J; Steffen, M

2014-06-24

With favourable error thresholds and requiring only nearest-neighbour interactions on a lattice, the surface code is an error-correcting code that has garnered considerable attention. At the heart of this code is the ability to perform a low-weight parity measurement of local code qubits. Here we demonstrate high-fidelity parity detection of two code qubits via measurement of a third syndrome qubit. With high-fidelity gates, we generate entanglement distributed across three superconducting qubits in a lattice where each code qubit is coupled to two bus resonators. Via high-fidelity measurement of the syndrome qubit, we deterministically entangle the code qubits in either an even or odd parity Bell state, conditioned on the syndrome qubit state. Finally, to fully characterize this parity readout, we develop a measurement tomography protocol. The lattice presented naturally extends to larger networks of qubits, outlining a path towards fault-tolerant quantum computing.

Analyzing the effectiveness of a frame-level redundancy scrubbing technique for SRAM-based FPGAs

DOE PAGES

Tonfat, Jorge; Lima Kastensmidt, Fernanda; Rech, Paolo; ...

2015-12-17

Radiation effects such as soft errors are the major threat to the reliability of SRAM-based FPGAs. This work analyzes the effectiveness in correcting soft errors of a novel scrubbing technique using internal frame redundancy called Frame-level Redundancy Scrubbing (FLR-scrubbing). This correction technique can be implemented in a coarse grain TMR design. The FLR-scrubbing technique was implemented on a mid-size Xilinx Virtex-5 FPGA device used as a case study. The FLR-scrubbing technique was tested under neutron radiation and fault injection. Implementation results demonstrated minimum area and energy consumption overhead when compared to other techniques. The time to repair the fault ismore » also improved by using the Internal Configuration Access Port (ICAP). Lastly, neutron radiation test results demonstrated that the proposed technique is suitable for correcting accumulated SEUs and MBUs.« less

Analytical minimization of synchronicity errors in stochastic identification

NASA Astrophysics Data System (ADS)

Bernal, D.

2018-01-01

An approach to minimize error due to synchronicity faults in stochastic system identification is presented. The scheme is based on shifting the time domain signals so the phases of the fundamental eigenvector estimated from the spectral density are zero. A threshold on the mean of the amplitude-weighted absolute value of these phases, above which signal shifting is deemed justified, is derived and found to be proportional to the first mode damping ratio. It is shown that synchronicity faults do not map precisely to phasor multiplications in subspace identification and that the accuracy of spectral density estimated eigenvectors, for inputs with arbitrary spectral density, decrease with increasing mode number. Selection of a corrective strategy based on signal alignment, instead of eigenvector adjustment using phasors, is shown to be the product of the foregoing observations. Simulations that include noise and non-classical damping suggest that the scheme can provide sufficient accuracy to be of practical value.

A second generation experiment in fault-tolerant software

NASA Technical Reports Server (NTRS)

Knight, J. C.

1986-01-01

Information was collected on the efficacy of fault-tolerant software by conducting two large-scale controlled experiments. In the first, an empirical study of multi-version software (MVS) was conducted. The second experiment is an empirical evaluation of self testing as a method of error detection (STED). The purpose ot the MVS experiment was to obtain empirical measurement of the performance of multi-version systems. Twenty versions of a program were prepared at four different sites under reasonably realistic development conditions from the same specifications. The purpose of the STED experiment was to obtain empirical measurements of the performance of assertions in error detection. Eight versions of a program were modified to include assertions at two different sites under controlled conditions. The overall structure of the testing environment for the MVS experiment and its status are described. Work to date in the STED experiment is also presented.

Analyzing the effectiveness of a frame-level redundancy scrubbing technique for SRAM-based FPGAs

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

Tonfat, Jorge; Lima Kastensmidt, Fernanda; Rech, Paolo

Radiation effects such as soft errors are the major threat to the reliability of SRAM-based FPGAs. This work analyzes the effectiveness in correcting soft errors of a novel scrubbing technique using internal frame redundancy called Frame-level Redundancy Scrubbing (FLR-scrubbing). This correction technique can be implemented in a coarse grain TMR design. The FLR-scrubbing technique was implemented on a mid-size Xilinx Virtex-5 FPGA device used as a case study. The FLR-scrubbing technique was tested under neutron radiation and fault injection. Implementation results demonstrated minimum area and energy consumption overhead when compared to other techniques. The time to repair the fault ismore » also improved by using the Internal Configuration Access Port (ICAP). Lastly, neutron radiation test results demonstrated that the proposed technique is suitable for correcting accumulated SEUs and MBUs.« less

Using Medications Safely

MedlinePlus

... health systems play an important role in preventing medication errors. To make sure you use medicines safely and effectively, ASHP recommends that you: Keep a list of all medications that you take (prescribed drugs, nonprescription medicines, herbal ...

Junior doctor-led ‘near-peer’ prescribing education for medical students

PubMed Central

Gibson, Kyle R; Qureshi, Zeshan U; Ross, Michael T; Maxwell, Simon R

2014-01-01

Aims Prescribing errors are common and inadequate preparation of prescribers appears to contribute. A junior doctor-led prescribing tutorial programme has been developed for Edinburgh final year medical students to increase exposure to common prescribing tasks. The aim of this study was to assess the impact of these tutorials on students and tutors. Methods One hundred and ninety-six tutorials were delivered to 183 students during 2010–2011. Each student completed a questionnaire after tutorial attendance which explored their previous prescribing experiences and the perceived benefits of tutorial attendance. Tutors completed a questionnaire which evaluated their teaching experiences and the impact on their prescribing practice. Student tutorial attendance was compared with end-of-year examination performance using linear regression analysis. Results The students reported increased confidence in their prescribing knowledge and skills after attending tutorials. Students who attended more tutorials also tended to perform better in end-of-year examinations (Drug prescribing: r = 0.16, P = 0.015; Fluid prescribing: r = 0.18, P = 0.007). Tutors considered that participation enhanced their own prescribing knowledge and skills. Although they were occasionally unable to address student uncertainties, 80% of tutors reported frequently correcting misconceptions and deficits in student knowledge. Ninety-five percent of students expressed a preference for prescribing training delivered by junior doctors over more senior doctors. Conclusions A ‘near-peer’ junior doctor-led approach to delivering prescribing training to medical students was highly valued by both students and tutors. Although junior doctors have relatively less clinical experience of prescribing, we believe that this can be addressed by training and academic supervision and is outweighed by the benefits of these tutorials. PMID:23617320

Robust Fault Detection Using Robust Z1 Estimation and Fuzzy Logic

NASA Technical Reports Server (NTRS)

Curry, Tramone; Collins, Emmanuel G., Jr.; Selekwa, Majura; Guo, Ten-Huei (Technical Monitor)

2001-01-01

This research considers the application of robust Z(sub 1), estimation in conjunction with fuzzy logic to robust fault detection for an aircraft fight control system. It begins with the development of robust Z(sub 1) estimators based on multiplier theory and then develops a fixed threshold approach to fault detection (FD). It then considers the use of fuzzy logic for robust residual evaluation and FD. Due to modeling errors and unmeasurable disturbances, it is difficult to distinguish between the effects of an actual fault and those caused by uncertainty and disturbance. Hence, it is the aim of a robust FD system to be sensitive to faults while remaining insensitive to uncertainty and disturbances. While fixed thresholds only allow a decision on whether a fault has or has not occurred, it is more valuable to have the residual evaluation lead to a conclusion related to the degree of, or probability of, a fault. Fuzzy logic is a viable means of determining the degree of a fault and allows the introduction of human observations that may not be incorporated in the rigorous threshold theory. Hence, fuzzy logic can provide a more reliable and informative fault detection process. Using an aircraft flight control system, the results of FD using robust Z(sub 1) estimation with a fixed threshold are demonstrated. FD that combines robust Z(sub 1) estimation and fuzzy logic is also demonstrated. It is seen that combining the robust estimator with fuzzy logic proves to be advantageous in increasing the sensitivity to smaller faults while remaining insensitive to uncertainty and disturbances.

Aftershocks of the 2010 Mw 7.2 El Mayor-Cucapah earthquake revealcomplex faulting in the Yuha Desert, California

USGS Publications Warehouse

Kroll, K.; Cochran, Elizabeth S.; Richards-Dinger, K.; Sumy, Danielle

2013-01-01

We detect and precisely locate over 9500 aftershocks that occurred in the Yuha Desert region during a 2 month period following the 4 April 2010 Mw 7.2 El Mayor-Cucapah (EMC) earthquake. Events are relocated using a series of absolute and relative relocation procedures that include Hypoinverse, Velest, and hypoDD. Location errors are reduced to ~40 m horizontally and ~120 m vertically.Aftershock locations reveal a complex pattern of faulting with en echelon fault segments trending toward the northwest, approximately parallel to the North American-Pacific plate boundary and en echelon, conjugate features trending to the northeast. The relocated seismicity is highly correlated with published surface mapping of faults that experienced triggered surface slip in response to the EMC main shock. Aftershocks occurred between 2 km and 11 km depths, consistent with previous studies of seismogenic thickness in the region. Three-dimensional analysis reveals individual and intersecting fault planes that are limited in their along-strike length. These fault planes remain distinct structures at depth, indicative of conjugate faulting, and do not appear to coalesce onto a throughgoing fault segment. We observe a complex spatiotemporal migration of aftershocks, with seismicity that jumps between individual fault segments that are active for only a few days to weeks. Aftershock rates are roughly consistent with the expected earthquake production rates of Dieterich (1994). The conjugate pattern of faulting and nonuniform aftershock migration patterns suggest that strain in the Yuha Desert is being accommodated in a complex manner.

Generation of a crowned pinion tooth surface by a surface of revolution

NASA Technical Reports Server (NTRS)

Litvin, F. L.; Zhang, J.; Handschuh, R. F.

1988-01-01

A method of generating crowned pinion tooth surfaces using a surface of revolution is developed. The crowned pinion meshes with a regular involute gear and has a prescribed parabolic type of transmission errors when the gears operate in the aligned mode. When the gears are misaligned the transmission error remains parabolic with the maximum level still remaining very small (less than 0.34 arc sec for the numerical examples). Tooth contact analysis (TCA) is used to simulate the conditions of meshing, determine the transmission error, and determine the bearing contact.

Adaptive control of nonlinear uncertain active suspension systems with prescribed performance.

PubMed

Huang, Yingbo; Na, Jing; Wu, Xing; Liu, Xiaoqin; Guo, Yu

2015-01-01

This paper proposes adaptive control designs for vehicle active suspension systems with unknown nonlinear dynamics (e.g., nonlinear spring and piece-wise linear damper dynamics). An adaptive control is first proposed to stabilize the vertical vehicle displacement and thus to improve the ride comfort and to guarantee other suspension requirements (e.g., road holding and suspension space limitation) concerning the vehicle safety and mechanical constraints. An augmented neural network is developed to online compensate for the unknown nonlinearities, and a novel adaptive law is developed to estimate both NN weights and uncertain model parameters (e.g., sprung mass), where the parameter estimation error is used as a leakage term superimposed on the classical adaptations. To further improve the control performance and simplify the parameter tuning, a prescribed performance function (PPF) characterizing the error convergence rate, maximum overshoot and steady-state error is used to propose another adaptive control. The stability for the closed-loop system is proved and particular performance requirements are analyzed. Simulations are included to illustrate the effectiveness of the proposed control schemes. Copyright © 2014 ISA. Published by Elsevier Ltd. All rights reserved.

Dynamic assertion testing of flight control software

NASA Technical Reports Server (NTRS)

Andrews, D. M.; Mahmood, A.; Mccluskey, E. J.

1985-01-01

An experiment in using assertions to dynamically test fault tolerant flight software is described. The experiment showed that 87% of typical errors introduced into the program would be detected by assertions. Detailed analysis of the test data showed that the number of assertions needed to detect those errors could be reduced to a minimal set. The analysis also revealed that the most effective assertions tested program parameters that provided greater indirect (collateral) testing of other parameters.

Integrated Data and Control Level Fault Tolerance Techniques for Signal Processing Computer Design

DTIC Science & Technology

1990-09-01

TOLERANCE TECHNIQUES FOR SIGNAL PROCESSING COMPUTER DESIGN G. Robert Redinbo I. INTRODUCTION High-speed signal processing is an important application of...techniques and mathematical approaches will be expanded later to the situation where hardware errors and roundoff and quantization noise affect all...detect errors equal in number to the degree of g(X), the maximum permitted by the Singleton bound [13]. Real cyclic codes, primarily applicable to

ANALYZING NUMERICAL ERRORS IN DOMAIN HEAT TRANSPORT MODELS USING THE CVBEM.

USGS Publications Warehouse

Hromadka, T.V.

1987-01-01

Besides providing an exact solution for steady-state heat conduction processes (Laplace-Poisson equations), the CVBEM (complex variable boundary element method) can be used for the numerical error analysis of domain model solutions. For problems where soil-water phase change latent heat effects dominate the thermal regime, heat transport can be approximately modeled as a time-stepped steady-state condition in the thawed and frozen regions, respectively. The CVBEM provides an exact solution of the two-dimensional steady-state heat transport problem, and also provides the error in matching the prescribed boundary conditions by the development of a modeling error distribution or an approximate boundary generation.

Dynamic modeling of stress evolution and crustal deformation associated with the seismogenic process of the 2008 Mw7.9 Wenchuan, China earthquake

NASA Astrophysics Data System (ADS)

Tao, W.; Wan, Y.; Wang, K.; Zeng, Y.; Shen, Z.

2009-12-01

We model stress evolution and crustal deformation associated with the seismogenic process of the 2008 Mw7.9 Wenchuan, China earthquake. This earthquake ruptured a section of the Longmen Shan fault, which is a listric fault separating the eastern Tibetan plateau at northwest from the Sichuan basin at southeast, with a predominantly thrust component for the southwest section of the fault. Different driving mechanisms have been proposed for the fault system: either by channel flow in the lower crust, or lateral push from the eastern Tibetan plateau on the entire crust. A 2-D finite element model is devised to simulate the tectonic process and test validities of the models. A layered viscoelastic media is prescribed, and constrained from seismological and other geophysical investigation results, characterized with a weak lower crust in the western Tibetan plateau and a strong lower crust in the Sichuan basin. The interseismic, coseismic, and postseismic deformation processes are modeled, under constraints of GPS observed deformation fields during these time periods. Our preliminary result shows concentration of elastic strain energy accumulated mainly surrounding the lower part of the locking section of the seismogenic fault during the interseismic time period, implying larger stress drop at the lower part than at the upper part of the locking section of the fault, assuming a total release of the elastic stress accumulation during an earthquake. The coseismic stress change is the largest at the near field in the hanging-wall, offering explanation of extensive aftershock activities occurred in the region after the Wenchuan mainshock. A more complete picture of stress evolution and interaction between the upper and lower crust in the process during an earthquake cycle will be presented at the meeting.

Fault tolerance issues in nanoelectronics

NASA Astrophysics Data System (ADS)

Spagocci, S. M.

The astonishing success story of microelectronics cannot go on indefinitely. In fact, once devices reach the few-atom scale (nanoelectronics), transient quantum effects are expected to impair their behaviour. Fault tolerant techniques will then be required. The aim of this thesis is to investigate the problem of transient errors in nanoelectronic devices. Transient error rates for a selection of nanoelectronic gates, based upon quantum cellular automata and single electron devices, in which the electrostatic interaction between electrons is used to create Boolean circuits, are estimated. On the bases of such results, various fault tolerant solutions are proposed, for both logic and memory nanochips. As for logic chips, traditional techniques are found to be unsuitable. A new technique, in which the voting approach of triple modular redundancy (TMR) is extended by cascading TMR units composed of nanogate clusters, is proposed and generalised to other voting approaches. For memory chips, an error correcting code approach is found to be suitable. Various codes are considered and a lookup table approach is proposed for encoding and decoding. We are then able to give estimations for the redundancy level to be provided on nanochips, so as to make their mean time between failures acceptable. It is found that, for logic chips, space redundancies up to a few tens are required, if mean times between failures have to be of the order of a few years. Space redundancy can also be traded for time redundancy. As for memory chips, mean times between failures of the order of a few years are found to imply both space and time redundancies of the order of ten.

Study on Unified Chaotic System-Based Wind Turbine Blade Fault Diagnostic System

NASA Astrophysics Data System (ADS)

Kuo, Ying-Che; Hsieh, Chin-Tsung; Yau, Her-Terng; Li, Yu-Chung

At present, vibration signals are processed and analyzed mostly in the frequency domain. The spectrum clearly shows the signal structure and the specific characteristic frequency band is analyzed, but the number of calculations required is huge, resulting in delays. Therefore, this study uses the characteristics of a nonlinear system to load the complete vibration signal to the unified chaotic system, applying the dynamic error to analyze the wind turbine vibration signal, and adopting extenics theory for artificial intelligent fault diagnosis of the analysis signal. Hence, a fault diagnostor has been developed for wind turbine rotating blades. This study simulates three wind turbine blade states, namely stress rupture, screw loosening and blade loss, and validates the methods. The experimental results prove that the unified chaotic system used in this paper has a significant effect on vibration signal analysis. Thus, the operating conditions of wind turbines can be quickly known from this fault diagnostic system, and the maintenance schedule can be arranged before the faults worsen, making the management and implementation of wind turbines smoother, so as to reduce many unnecessary costs.

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

Sarrack, A.G.

The purpose of this report is to document fault tree analyses which have been completed for the Defense Waste Processing Facility (DWPF) safety analysis. Logic models for equipment failures and human error combinations that could lead to flammable gas explosions in various process tanks, or failure of critical support systems were developed for internal initiating events and for earthquakes. These fault trees provide frequency estimates for support systems failures and accidents that could lead to radioactive and hazardous chemical releases both on-site and off-site. Top event frequency results from these fault trees will be used in further APET analyses tomore » calculate accident risk associated with DWPF facility operations. This report lists and explains important underlying assumptions, provides references for failure data sources, and briefly describes the fault tree method used. Specific commitments from DWPF to provide new procedural/administrative controls or system design changes are listed in the ''Facility Commitments'' section. The purpose of the ''Assumptions'' section is to clarify the basis for fault tree modeling, and is not necessarily a list of items required to be protected by Technical Safety Requirements (TSRs).« less

An improved PCA method with application to boiler leak detection.

PubMed

Sun, Xi; Marquez, Horacio J; Chen, Tongwen; Riaz, Muhammad

2005-07-01

Principal component analysis (PCA) is a popular fault detection technique. It has been widely used in process industries, especially in the chemical industry. In industrial applications, achieving a sensitive system capable of detecting incipient faults, which maintains the false alarm rate to a minimum, is a crucial issue. Although a lot of research has been focused on these issues for PCA-based fault detection and diagnosis methods, sensitivity of the fault detection scheme versus false alarm rate continues to be an important issue. In this paper, an improved PCA method is proposed to address this problem. In this method, a new data preprocessing scheme and a new fault detection scheme designed for Hotelling's T2 as well as the squared prediction error are developed. A dynamic PCA model is also developed for boiler leak detection. This new method is applied to boiler water/steam leak detection with real data from Syncrude Canada's utility plant in Fort McMurray, Canada. Our results demonstrate that the proposed method can effectively reduce false alarm rate, provide effective and correct leak alarms, and give early warning to operators.

Observer-based distributed adaptive fault-tolerant containment control of multi-agent systems with general linear dynamics.

PubMed

Ye, Dan; Chen, Mengmeng; Li, Kui

2017-11-01

In this paper, we consider the distributed containment control problem of multi-agent systems with actuator bias faults based on observer method. The objective is to drive the followers into the convex hull spanned by the dynamic leaders, where the input is unknown but bounded. By constructing an observer to estimate the states and bias faults, an effective distributed adaptive fault-tolerant controller is developed. Different from the traditional method, an auxiliary controller gain is designed to deal with the unknown inputs and bias faults together. Moreover, the coupling gain can be adjusted online through the adaptive mechanism without using the global information. Furthermore, the proposed control protocol can guarantee that all the signals of the closed-loop systems are bounded and all the followers converge to the convex hull with bounded residual errors formed by the dynamic leaders. Finally, a decoupled linearized longitudinal motion model of the F-18 aircraft is used to demonstrate the effectiveness. Copyright © 2017 ISA. Published by Elsevier Ltd. All rights reserved.

Latent component-based gear tooth fault detection filter using advanced parametric modeling

NASA Astrophysics Data System (ADS)

Ettefagh, M. M.; Sadeghi, M. H.; Rezaee, M.; Chitsaz, S.

2009-10-01

In this paper, a new parametric model-based filter is proposed for gear tooth fault detection. The designing of the filter consists of identifying the most proper latent component (LC) of the undamaged gearbox signal by analyzing the instant modules (IMs) and instant frequencies (IFs) and then using the component with lowest IM as the proposed filter output for detecting fault of the gearbox. The filter parameters are estimated by using the LC theory in which an advanced parametric modeling method has been implemented. The proposed method is applied on the signals, extracted from simulated gearbox for detection of the simulated gear faults. In addition, the method is used for quality inspection of the produced Nissan-Junior vehicle gearbox by gear profile error detection in an industrial test bed. For evaluation purpose, the proposed method is compared with the previous parametric TAR/AR-based filters in which the parametric model residual is considered as the filter output and also Yule-Walker and Kalman filter are implemented for estimating the parameters. The results confirm the high performance of the new proposed fault detection method.

Using Performance Tools to Support Experiments in HPC Resilience

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

Naughton, III, Thomas J; Boehm, Swen; Engelmann, Christian

2014-01-01

The high performance computing (HPC) community is working to address fault tolerance and resilience concerns for current and future large scale computing platforms. This is driving enhancements in the programming environ- ments, specifically research on enhancing message passing libraries to support fault tolerant computing capabilities. The community has also recognized that tools for resilience experimentation are greatly lacking. However, we argue that there are several parallels between performance tools and resilience tools . As such, we believe the rich set of HPC performance-focused tools can be extended (repurposed) to benefit the resilience community. In this paper, we describe the initialmore » motivation to leverage standard HPC per- formance analysis techniques to aid in developing diagnostic tools to assist fault tolerance experiments for HPC applications. These diagnosis procedures help to provide context for the system when the errors (failures) occurred. We describe our initial work in leveraging an MPI performance trace tool to assist in provid- ing global context during fault injection experiments. Such tools will assist the HPC resilience community as they extend existing and new application codes to support fault tolerances.« less

Adaptive Fault-Tolerant Control of Uncertain Nonlinear Large-Scale Systems With Unknown Dead Zone.

PubMed

Chen, Mou; Tao, Gang

2016-08-01

In this paper, an adaptive neural fault-tolerant control scheme is proposed and analyzed for a class of uncertain nonlinear large-scale systems with unknown dead zone and external disturbances. To tackle the unknown nonlinear interaction functions in the large-scale system, the radial basis function neural network (RBFNN) is employed to approximate them. To further handle the unknown approximation errors and the effects of the unknown dead zone and external disturbances, integrated as the compounded disturbances, the corresponding disturbance observers are developed for their estimations. Based on the outputs of the RBFNN and the disturbance observer, the adaptive neural fault-tolerant control scheme is designed for uncertain nonlinear large-scale systems by using a decentralized backstepping technique. The closed-loop stability of the adaptive control system is rigorously proved via Lyapunov analysis and the satisfactory tracking performance is achieved under the integrated effects of unknown dead zone, actuator fault, and unknown external disturbances. Simulation results of a mass-spring-damper system are given to illustrate the effectiveness of the proposed adaptive neural fault-tolerant control scheme for uncertain nonlinear large-scale systems.

On the mechanisms governing dike arrest: Insight from the 2000 Miyakejima dike injection

NASA Astrophysics Data System (ADS)

Maccaferri, F.; Rivalta, E.; Passarelli, L.; Aoki, Y.

2016-01-01

Magma stored beneath volcanoes is sometimes transported out of the magma chambers by means of laterally propagating dikes, which can lead to fissure eruptions if they intersect the Earth's surface. The driving force for lateral dike propagation can be a lateral tectonic stress gradient, the stress gradient due to the topographic loads, the overpressure of the magma chamber, or a combination of those forces. The 2000 dike intrusion at Miyakejima volcano, Izu arc, Japan, propagated laterally for about 30 km and stopped in correspondence of a strike-slip system, sub-perpendicular to the dike plane. Then the dike continued to inflate, without further propagation. Abundant seismicity was produced, including five M > 6 earthquakes, one of which occurred on the pre-existing fault system close to the tip of the dike, at approximately the time of arrest. It has been proposed that the main cause for the dike arrest was the fault-induced stress. Here we use a boundary element numerical approach to study the interplay between a propagating dike and a pre-stressed strike-slip fault and check the relative role played by dike-fault interaction and topographic loading in arresting the Miyakejima dike. We calibrate the model parameters according to previous estimates of dike opening and fault displacement based on crustal deformation observations. By computing the energy released during the propagation, our model indicates whether the dike will stop at a given location. We find that the stress gradient induced by the topography is needed for an opening distribution along the dike consistent with the observed seismicity, but it cannot explain its arrest at the prescribed location. On the other hand, the interaction of dike with the fault explains the arrest but not the opening distribution. The joint effect of the topographic load and the stress interaction with strike-slip fault is consistent with the observations, provided the pre-existing fault system is pre-loaded with a significant stress, released gradually during the dike-fault interplay. Our results reveal how the mechanical interaction between dikes and faults may affect the propagation of magmatic intrusions in general. This has implications for our understanding of the geometrical arrangement of rift segments and transform faults in Mid Ocean Ridges, and for the interplay between dikes and dike-induced graben systems.

Methodological Challenges in Describing Medication Dosing Errors in Children

DTIC Science & Technology

2005-01-01

recommendations. As an example, amoxicillin is the most commonly used medication in children. This one drug accounts for approximately 10 percent of...and a team intervention on prevention of serious medication errors. JAMA 1998;280(15):1311–6. 13. Bates DW, Teich JM, Lee J, et al. The impact of...barriers include prescribing medication that is not labeled for use in children, discrepancies in published dosing recommendations for many

Software fault tolerance using data diversity

NASA Technical Reports Server (NTRS)

Knight, John C.

1991-01-01

Research on data diversity is discussed. Data diversity relies on a different form of redundancy from existing approaches to software fault tolerance and is substantially less expensive to implement. Data diversity can also be applied to software testing and greatly facilitates the automation of testing. Up to now it has been explored both theoretically and in a pilot study, and has been shown to be a promising technique. The effectiveness of data diversity as an error detection mechanism and the application of data diversity to differential equation solvers are discussed.

Incorporating medication indications into the prescribing process.

PubMed

Kron, Kevin; Myers, Sara; Volk, Lynn; Nathan, Aaron; Neri, Pamela; Salazar, Alejandra; Amato, Mary G; Wright, Adam; Karmiy, Sam; McCord, Sarah; Seoane-Vazquez, Enrique; Eguale, Tewodros; Rodriguez-Monguio, Rosa; Bates, David W; Schiff, Gordon

2018-04-19

The incorporation of medication indications into the prescribing process to improve patient safety is discussed. Currently, most prescriptions lack a key piece of information needed for safe medication use: the patient-specific drug indication. Integrating indications could pave the way for safer prescribing in multiple ways, including avoiding look-alike/sound-alike errors, facilitating selection of drugs of choice, aiding in communication among the healthcare team, bolstering patient understanding and adherence, and organizing medication lists to facilitate medication reconciliation. Although strongly supported by pharmacists, multiple prior attempts to encourage prescribers to include the indication on prescriptions have not been successful. We convened 6 expert panels to consult high-level stakeholders on system design considerations and requirements necessary for building and implementing an indications-based computerized prescriber order-entry (CPOE) system. We summarize our findings from the 6 expert stakeholder panels, including rationale, literature findings, potential benefits, and challenges of incorporating indications into the prescribing process. Based on this stakeholder input, design requirements for a new CPOE interface and workflow have been identified. The emergence of universal electronic prescribing and content knowledge vendors has laid the groundwork for incorporating indications into the CPOE prescribing process. As medication prescribing moves in the direction of inclusion of the indication, it is imperative to design CPOE systems to efficiently and effectively incorporate indications into prescriber workflows and optimize ways this can best be accomplished. Copyright © 2018 by the American Society of Health-System Pharmacists, Inc. All rights reserved.

Single-Event Upset Characterization of Common First- and Second-Order All-Digital Phase-Locked Loops

NASA Astrophysics Data System (ADS)

Chen, Y. P.; Massengill, L. W.; Kauppila, J. S.; Bhuva, B. L.; Holman, W. T.; Loveless, T. D.

2017-08-01

The single-event upset (SEU) vulnerability of common first- and second-order all-digital-phase-locked loops (ADPLLs) is investigated through field-programmable gate array-based fault injection experiments. SEUs in the highest order pole of the loop filter and fraction-based phase detectors (PDs) may result in the worst case error response, i.e., limit cycle errors, often requiring system restart. SEUs in integer-based linear PDs may result in loss-of-lock errors, while SEUs in bang-bang PDs only result in temporary-frequency errors. ADPLLs with the same frequency tuning range but fewer bits in the control word exhibit better overall SEU performance.

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

PubMed

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

2011-07-01

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

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

PubMed

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

2018-05-05

To investigate the epidemiology of medication errors and error-related adverse events in adults in primary care, ambulatory care and patients' homes. Systematic review. Six international databases were searched for publications between 1 January 2006 and 31 December 2015. Two researchers independently extracted data from eligible studies and assessed the quality of these using established instruments. Synthesis of data was informed by an appreciation of the medicines' management process and the conceptual framework from the International Classification for Patient Safety. 60 studies met the inclusion criteria, of which 53 studies focused on medication errors, 3 on error-related adverse events and 4 on risk factors only. The prevalence of prescribing errors was reported in 46 studies: prevalence estimates ranged widely from 2% to 94%. Inappropriate prescribing was the most common type of error reported. Only one study reported the prevalence of monitoring errors, finding that incomplete therapeutic/safety laboratory-test monitoring occurred in 73% of patients. The incidence of preventable adverse drug events (ADEs) was estimated as 15/1000 person-years, the prevalence of drug-drug interaction-related adverse drug reactions as 7% and the prevalence of preventable ADE as 0.4%. A number of patient, healthcare professional and medication-related risk factors were identified, including the number of medications used by the patient, increased patient age, the number of comorbidities, use of anticoagulants, cases where more than one physician was involved in patients' care and care being provided by family physicians/general practitioners. A very wide variation in the medication error and error-related adverse events rates is reported in the studies, this reflecting heterogeneity in the populations studied, study designs employed and outcomes evaluated. This review has identified important limitations and discrepancies in the methodologies used and gaps in the literature on the epidemiology and outcomes of medication errors in community settings. © Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.

Generic drug names and social welfare.

PubMed

Lobo, Félix; Feldman, Roger

2013-06-01

This article studies how well International Nonproprietary Names (INNs), the "generic" names for pharmaceuticals, address the problems of imperfect information. Left in private hands, the identification of medicines leads to confusion and errors. Developed in the 1950s by the World Health Organization, INNs are a common, global, scientific nomenclature designed to overcome this failure. Taking stock after sixty years, we argue that the contribution of INNs to social welfare is paramount. They enhance public health by reducing errors and improving patient safety. They also contribute to economic efficiency by creating transparency as the foundation of competitive generic drug markets, reducing transaction costs, and favoring trade. The law in most countries requires manufacturers to designate pharmaceuticals with INNs in labeling and advertising. Generic substitution is also permitted or mandatory in many countries. But not all the benefits of INNs are fully realized because prescribers may not use them. We advocate strong incentives or even legally binding provisions to extend the use of INNs by prescribing physicians and dispensing pharmacists, but we do not recommend replacing brand names entirely with INNs. Instead, we propose dual use of brand names and INNs in prescribing, as in drug labeling.