Sample records for human error decrease
-
Human Error: The Stakes Are Raised.
ERIC Educational Resources Information Center
Greenberg, Joel
1980-01-01
Mistakes related to the operation of nuclear power plants and other technologically complex systems are discussed. Recommendations are given for decreasing the chance of human error in the operation of nuclear plants. The causes of the Three Mile Island incident are presented in terms of the human error element. (SA)
-
Vavilov, A Iu; Viter, V I
2007-01-01
Mathematical questions of data errors of modern thermometrical models of postmortem cooling of the human body are considered. The main diagnostic areas used for thermometry are analyzed to minimize these data errors. The authors propose practical recommendations to decrease data errors of determination of prescription of death coming.
-
A Quality Improvement Project to Decrease Human Milk Errors in the NICU.
Oza-Frank, Reena; Kachoria, Rashmi; Dail, James; Green, Jasmine; Walls, Krista; McClead, Richard E
2017-02-01
Ensuring safe human milk in the NICU is a complex process with many potential points for error, of which one of the most serious is administration of the wrong milk to the wrong infant. Our objective was to describe a quality improvement initiative that was associated with a reduction in human milk administration errors identified over a 6-year period in a typical, large NICU setting. We employed a quasi-experimental time series quality improvement initiative by using tools from the model for improvement, Six Sigma methodology, and evidence-based interventions. Scanned errors were identified from the human milk barcode medication administration system. Scanned errors of interest were wrong-milk-to-wrong-infant, expired-milk, or preparation errors. The scanned error rate and the impact of additional improvement interventions from 2009 to 2015 were monitored by using statistical process control charts. From 2009 to 2015, the total number of errors scanned declined from 97.1 per 1000 bottles to 10.8. Specifically, the number of expired milk error scans declined from 84.0 per 1000 bottles to 8.9. The number of preparation errors (4.8 per 1000 bottles to 2.2) and wrong-milk-to-wrong-infant errors scanned (8.3 per 1000 bottles to 2.0) also declined. By reducing the number of errors scanned, the number of opportunities for errors also decreased. Interventions that likely had the greatest impact on reducing the number of scanned errors included installation of bedside (versus centralized) scanners and dedicated staff to handle milk. Copyright © 2017 by the American Academy of Pediatrics.
-
Prediction of human errors by maladaptive changes in event-related brain networks.
Eichele, Tom; Debener, Stefan; Calhoun, Vince D; Specht, Karsten; Engel, Andreas K; Hugdahl, Kenneth; von Cramon, D Yves; Ullsperger, Markus
2008-04-22
Humans engaged in monotonous tasks are susceptible to occasional errors that may lead to serious consequences, but little is known about brain activity patterns preceding errors. Using functional MRI and applying independent component analysis followed by deconvolution of hemodynamic responses, we studied error preceding brain activity on a trial-by-trial basis. We found a set of brain regions in which the temporal evolution of activation predicted performance errors. These maladaptive brain activity changes started to evolve approximately 30 sec before the error. In particular, a coincident decrease of deactivation in default mode regions of the brain, together with a decline of activation in regions associated with maintaining task effort, raised the probability of future errors. Our findings provide insights into the brain network dynamics preceding human performance errors and suggest that monitoring of the identified precursor states may help in avoiding human errors in critical real-world situations.
-
Prediction of human errors by maladaptive changes in event-related brain networks
Eichele, Tom; Debener, Stefan; Calhoun, Vince D.; Specht, Karsten; Engel, Andreas K.; Hugdahl, Kenneth; von Cramon, D. Yves; Ullsperger, Markus
2008-01-01
Humans engaged in monotonous tasks are susceptible to occasional errors that may lead to serious consequences, but little is known about brain activity patterns preceding errors. Using functional MRI and applying independent component analysis followed by deconvolution of hemodynamic responses, we studied error preceding brain activity on a trial-by-trial basis. We found a set of brain regions in which the temporal evolution of activation predicted performance errors. These maladaptive brain activity changes started to evolve ≈30 sec before the error. In particular, a coincident decrease of deactivation in default mode regions of the brain, together with a decline of activation in regions associated with maintaining task effort, raised the probability of future errors. Our findings provide insights into the brain network dynamics preceding human performance errors and suggest that monitoring of the identified precursor states may help in avoiding human errors in critical real-world situations. PMID:18427123
-
Structured methods for identifying and correcting potential human errors in aviation operations
DOE Office of Scientific and Technical Information (OSTI.GOV)
Nelson, W.R.
1997-10-01
Human errors have been identified as the source of approximately 60% of the incidents and accidents that occur in commercial aviation. It can be assumed that a very large number of human errors occur in aviation operations, even though in most cases the redundancies and diversities built into the design of aircraft systems prevent the errors from leading to serious consequences. In addition, when it is acknowledged that many system failures have their roots in human errors that occur in the design phase, it becomes apparent that the identification and elimination of potential human errors could significantly decrease the risksmore » of aviation operations. This will become even more critical during the design of advanced automation-based aircraft systems as well as next-generation systems for air traffic management. Structured methods to identify and correct potential human errors in aviation operations have been developed and are currently undergoing testing at the Idaho National Engineering and Environmental Laboratory (INEEL).« less
-
Ching, Joan M; Williams, Barbara L; Idemoto, Lori M; Blackmore, C Craig
2014-08-01
Virginia Mason Medical Center (Seattle) employed the Lean concept of Jidoka (automation with a human touch) to plan for and deploy bar code medication administration (BCMA) to hospitalized patients. Integrating BCMA technology into the nursing work flow with minimal disruption was accomplished using three steps ofJidoka: (1) assigning work to humans and machines on the basis of their differing abilities, (2) adapting machines to the human work flow, and (3) monitoring the human-machine interaction. Effectiveness of BCMA to both reinforce safe administration practices and reduce medication errors was measured using the Collaborative Alliance for Nursing Outcomes (CALNOC) Medication Administration Accuracy Quality Study methodology. Trained nurses observed a total of 16,149 medication doses for 3,617 patients in a three-year period. Following BCMA implementation, the number of safe practice violations decreased from 54.8 violations/100 doses (January 2010-September 2011) to 29.0 violations/100 doses (October 2011-December 2012), resulting in an absolute risk reduction of 25.8 violations/100 doses (95% confidence interval [CI]: 23.7, 27.9, p < .001). The number of medication errors decreased from 5.9 errors/100 doses at baseline to 3.0 errors/100 doses after BCMA implementation (absolute risk reduction: 2.9 errors/100 doses [95% CI: 2.2, 3.6,p < .001]). The number of unsafe administration practices (estimate, -5.481; standard error 1.133; p < .001; 95% CI: -7.702, -3.260) also decreased. As more hospitals respond to health information technology meaningful use incentives, thoughtful, methodical, and well-managed approaches to technology deployment are crucial. This work illustrates how Jidoka offers opportunities for a smooth transition to new technology.
-
Information systems and human error in the lab.
Bissell, Michael G
2004-01-01
Health system costs in clinical laboratories are incurred daily due to human error. Indeed, a major impetus for automating clinical laboratories has always been the opportunity it presents to simultaneously reduce cost and improve quality of operations by decreasing human error. But merely automating these processes is not enough. To the extent that introduction of these systems results in operators having less practice in dealing with unexpected events or becoming deskilled in problemsolving, however new kinds of error will likely appear. Clinical laboratories could potentially benefit by integrating findings on human error from modern behavioral science into their operations. Fully understanding human error requires a deep understanding of human information processing and cognition. Predicting and preventing negative consequences requires application of this understanding to laboratory operations. Although the occurrence of a particular error at a particular instant cannot be absolutely prevented, human error rates can be reduced. The following principles are key: an understanding of the process of learning in relation to error; understanding the origin of errors since this knowledge can be used to reduce their occurrence; optimal systems should be forgiving to the operator by absorbing errors, at least for a time; although much is known by industrial psychologists about how to write operating procedures and instructions in ways that reduce the probability of error, this expertise is hardly ever put to use in the laboratory; and a feedback mechanism must be designed into the system that enables the operator to recognize in real time that an error has occurred.
-
Safety coaches in radiology: decreasing human error and minimizing patient harm.
Dickerson, Julie M; Koch, Bernadette L; Adams, Janet M; Goodfriend, Martha A; Donnelly, Lane F
2010-09-01
Successful programs to improve patient safety require a component aimed at improving safety culture and environment, resulting in a reduced number of human errors that could lead to patient harm. Safety coaching provides peer accountability. It involves observing for safety behaviors and use of error prevention techniques and provides immediate feedback. For more than a decade, behavior-based safety coaching has been a successful strategy for reducing error within the context of occupational safety in industry. We describe the use of safety coaches in radiology. Safety coaches are an important component of our comprehensive patient safety program.
-
Development and implementation of a human accuracy program in patient foodservice.
Eden, S H; Wood, S M; Ptak, K M
1987-04-01
For many years, industry has utilized the concept of human error rates to monitor and minimize human errors in the production process. A consistent quality-controlled product increases consumer satisfaction and repeat purchase of product. Administrative dietitians have applied the concepts of using human error rates (the number of errors divided by the number of opportunities for error) at four hospitals, with a total bed capacity of 788, within a tertiary-care medical center. Human error rate was used to monitor and evaluate trayline employee performance and to evaluate layout and tasks of trayline stations, in addition to evaluating employees in patient service areas. Long-term employees initially opposed the error rate system with some hostility and resentment, while newer employees accepted the system. All employees now believe that the constant feedback given by supervisors enhances their self-esteem and productivity. Employee error rates are monitored daily and are used to counsel employees when necessary; they are also utilized during annual performance evaluation. Average daily error rates for a facility staffed by new employees decreased from 7% to an acceptable 3%. In a facility staffed by long-term employees, the error rate increased, reflecting improper error documentation. Patient satisfaction surveys reveal satisfaction, for tray accuracy increased from 88% to 92% in the facility staffed by long-term employees and has remained above the 90% standard in the facility staffed by new employees.
-
Henneman, Elizabeth A; Roche, Joan P; Fisher, Donald L; Cunningham, Helene; Reilly, Cheryl A; Nathanson, Brian H; Henneman, Philip L
2010-02-01
This study examined types of errors that occurred or were recovered in a simulated environment by student nurses. Errors occurred in all four rule-based error categories, and all students committed at least one error. The most frequent errors occurred in the verification category. Another common error was related to physician interactions. The least common errors were related to coordinating information with the patient and family. Our finding that 100% of student subjects committed rule-based errors is cause for concern. To decrease errors and improve safe clinical practice, nurse educators must identify effective strategies that students can use to improve patient surveillance. Copyright 2010 Elsevier Inc. All rights reserved.
-
NASA Technical Reports Server (NTRS)
Mattson, Marifran; Petrin, Donald A.; Young, John P.
2001-01-01
The study of human factors has had a decisive impact on the aviation industry. However, the entire aviation system often is not considered in researching, training, and evaluating human factors issues especially with regard to safety. In both conceptual and practical terms, we argue for the proactive management of human error from both an individual and organizational systems perspective. The results of a multidisciplinary research project incorporating survey data from professional pilots and maintenance technicians and an exploratory study integrating students from relevant disciplines are reported. Survey findings suggest that latent safety errors may occur during the maintenance discrepancy reporting process because pilots and maintenance technicians do not effectively interact with one another. The importance of interdepartmental or cross-disciplinary training for decreasing these errors and increasing safety is discussed as a primary implication.
-
NASA Technical Reports Server (NTRS)
Uhlemann, H.; Geiser, G.
1975-01-01
Multivariable manual compensatory tracking experiments were carried out in order to determine typical strategies of the human operator and conditions for improvement of his performance if one of the visual displays of the tracking errors is supplemented by an auditory feedback. Because the tracking error of the system which is only visually displayed is found to decrease, but not in general that of the auditorally supported system, it was concluded that the auditory feedback unloads the visual system of the operator who can then concentrate on the remaining exclusively visual displays.
-
A cognitive taxonomy of medical errors.
Zhang, Jiajie; Patel, Vimla L; Johnson, Todd R; Shortliffe, Edward H
2004-06-01
Propose a cognitive taxonomy of medical errors at the level of individuals and their interactions with technology. Use cognitive theories of human error and human action to develop the theoretical foundations of the taxonomy, develop the structure of the taxonomy, populate the taxonomy with examples of medical error cases, identify cognitive mechanisms for each category of medical error under the taxonomy, and apply the taxonomy to practical problems. Four criteria were used to evaluate the cognitive taxonomy. The taxonomy should be able (1) to categorize major types of errors at the individual level along cognitive dimensions, (2) to associate each type of error with a specific underlying cognitive mechanism, (3) to describe how and explain why a specific error occurs, and (4) to generate intervention strategies for each type of error. The proposed cognitive taxonomy largely satisfies the four criteria at a theoretical and conceptual level. Theoretically, the proposed cognitive taxonomy provides a method to systematically categorize medical errors at the individual level along cognitive dimensions, leads to a better understanding of the underlying cognitive mechanisms of medical errors, and provides a framework that can guide future studies on medical errors. Practically, it provides guidelines for the development of cognitive interventions to decrease medical errors and foundation for the development of medical error reporting system that not only categorizes errors but also identifies problems and helps to generate solutions. To validate this model empirically, we will next be performing systematic experimental studies.
-
The Effect of Age, Accommodation and Refractive Error on the Adult Human Eye
Richdale, Kathryn; Bullimore, Mark A.; Sinnott, Loraine T.; Zadnik, Karla
2015-01-01
Purpose To quantify changes in ocular dimensions associated with age, refractive error, and accommodative response, in vivo, in 30- to 50-year-old human subjects. Methods The right eyes of 91 adults were examined using ultrasonography, phakometry, keratometry, pachymetry, interferometry, anterior segment optical coherence tomography, and high resolution magnetic resonance imaging. Accommodation was measured subjectively with a push-up test and objectively using open-field autorefraction. Regression analyses were used to assess differences in ocular parameters with age, refractive error and accommodation. Results With age, crystalline lens thickness increased (0.03 mm/yr), anterior lens curvature steepened (0.11 mm/yr), anterior chamber depth decreased (0.02 mm/y) and lens equivalent refractive index decreased (0.001 /y) (all p < 0.01). With increasing myopia, there were significant increases in axial length (0.37 mm/D), vitreous chamber depth (0.34 mm/D), vitreous chamber height (0.09 mm/D) and ciliary muscle ring diameter (0.10 mm/D) (all p < 0.05). Increasing myopia was also associated with steepening of both the cornea (0.16 mm/D) and anterior lens surface (0.011 mm/D) (both p < 0.04). With accommodation, the ciliary muscle ring diameter decreased (0.08 mm/D), and the muscle thinned posteriorly (0.008 mm/D), allowing the lens to shorten equatorially (0.07 mm/D) and thicken axially (0.06 mm/D) (all p < 0.03). Conclusions Refractive error is significantly correlated with not only the axial dimensions, but the anterior equatorial dimension of the adult eye. Further testing and development of accommodating intraocular lenses should account for differences in patients’ preoperative refractive error. PMID:26703933
-
Suba, Eric J; Pfeifer, John D; Raab, Stephen S
2007-10-01
Patient identification errors in surgical pathology often involve switches of prostate or breast needle core biopsy specimens among patients. We assessed strategies for decreasing the occurrence of these uncommon and yet potentially catastrophic events. Root cause analyses were performed following 3 cases of patient identification error involving prostate needle core biopsy specimens. Patient identification errors in surgical pathology result from slips and lapses of automatic human action that may occur at numerous steps during pre-laboratory, laboratory and post-laboratory work flow processes. Patient identification errors among prostate needle biopsies may be difficult to entirely prevent through the optimization of work flow processes. A DNA time-out, whereby DNA polymorphic microsatellite analysis is used to confirm patient identification before radiation therapy or radical surgery, may eliminate patient identification errors among needle biopsies.
-
Krigolson, Olav E; Hassall, Cameron D; Handy, Todd C
2014-03-01
Our ability to make decisions is predicated upon our knowledge of the outcomes of the actions available to us. Reinforcement learning theory posits that actions followed by a reward or punishment acquire value through the computation of prediction errors-discrepancies between the predicted and the actual reward. A multitude of neuroimaging studies have demonstrated that rewards and punishments evoke neural responses that appear to reflect reinforcement learning prediction errors [e.g., Krigolson, O. E., Pierce, L. J., Holroyd, C. B., & Tanaka, J. W. Learning to become an expert: Reinforcement learning and the acquisition of perceptual expertise. Journal of Cognitive Neuroscience, 21, 1833-1840, 2009; Bayer, H. M., & Glimcher, P. W. Midbrain dopamine neurons encode a quantitative reward prediction error signal. Neuron, 47, 129-141, 2005; O'Doherty, J. P. Reward representations and reward-related learning in the human brain: Insights from neuroimaging. Current Opinion in Neurobiology, 14, 769-776, 2004; Holroyd, C. B., & Coles, M. G. H. The neural basis of human error processing: Reinforcement learning, dopamine, and the error-related negativity. Psychological Review, 109, 679-709, 2002]. Here, we used the brain ERP technique to demonstrate that not only do rewards elicit a neural response akin to a prediction error but also that this signal rapidly diminished and propagated to the time of choice presentation with learning. Specifically, in a simple, learnable gambling task, we show that novel rewards elicited a feedback error-related negativity that rapidly decreased in amplitude with learning. Furthermore, we demonstrate the existence of a reward positivity at choice presentation, a previously unreported ERP component that has a similar timing and topography as the feedback error-related negativity that increased in amplitude with learning. The pattern of results we observed mirrored the output of a computational model that we implemented to compute reward prediction errors and the changes in amplitude of these prediction errors at the time of choice presentation and reward delivery. Our results provide further support that the computations that underlie human learning and decision-making follow reinforcement learning principles.
-
CBP for Field Workers – Results and Insights from Three Usability and Interface Design Evaluations
DOE Office of Scientific and Technical Information (OSTI.GOV)
Oxstrand, Johanna Helene; Le Blanc, Katya Lee; Bly, Aaron Douglas
2015-09-01
Nearly all activities that involve human interaction with the systems in a nuclear power plant are guided by procedures. Even though the paper-based procedures (PBPs) currently used by industry have a demonstrated history of ensuring safety, improving procedure use could yield significant savings in increased efficiency as well as improved nuclear safety through human performance gains. The nuclear industry is constantly trying to find ways to decrease the human error rate, especially the human errors associated with procedure use. As a step toward the goal of improving procedure use and adherence, researchers in the Light-Water Reactor Sustainability (LWRS) Program, togethermore » with the nuclear industry, have been investigating the possibility and feasibility of replacing the current paper-based procedure process with a computer-based procedure (CBP) system. This report describes a field evaluation of new design concepts of a prototype computer-based procedure system.« less
-
Stern, Shani; Biron, David; Moses, Elisha
2016-07-11
Down syndrome incidence in humans increases dramatically with maternal age. This is mainly the result of increased meiotic errors, but factors such as differences in abortion rate may play a role as well. Since the meiotic error rate increases almost exponentially after a certain age, its contribution to the overall incidence aneuploidy may mask the contribution of other processes. To focus on such selection mechanisms we investigated transmission in trisomic females, using data from mouse models and from Down syndrome humans. In trisomic females the a-priori probability for trisomy is independent of meiotic errors and thus approximately constant in the early embryo. Despite this, the rate of transmission of the extra chromosome decreases with age in females of the Ts65Dn and, as we show, for the Tc1 mouse models for Down syndrome. Evaluating progeny of 73 Tc1 births and 112 Ts65Dn births from females aged 130 days to 250 days old showed that both models exhibit a 3-fold reduction of the probability to transmit the trisomy with increased maternal ageing. This is concurrent with a 2-fold reduction of litter size with maternal ageing. Furthermore, analysis of previously reported 30 births in Down syndrome women shows a similar tendency with an almost three fold reduction in the probability to have a Down syndrome child between a 20 and 30 years old Down syndrome woman. In the two types of mice models for Down syndrome that were used for this study, and in human Down syndrome, older females have significantly lower probability to transmit the trisomy to the offspring. Our findings, taken together with previous reports of decreased supportive environment of the older uterus, add support to the notion that an older uterus negatively selects the less fit trisomic embryos.
-
Neural dynamics of reward probability coding: a Magnetoencephalographic study in humans
Thomas, Julie; Vanni-Mercier, Giovanna; Dreher, Jean-Claude
2013-01-01
Prediction of future rewards and discrepancy between actual and expected outcomes (prediction error) are crucial signals for adaptive behavior. In humans, a number of fMRI studies demonstrated that reward probability modulates these two signals in a large brain network. Yet, the spatio-temporal dynamics underlying the neural coding of reward probability remains unknown. Here, using magnetoencephalography, we investigated the neural dynamics of prediction and reward prediction error computations while subjects learned to associate cues of slot machines with monetary rewards with different probabilities. We showed that event-related magnetic fields (ERFs) arising from the visual cortex coded the expected reward value 155 ms after the cue, demonstrating that reward value signals emerge early in the visual stream. Moreover, a prediction error was reflected in ERF peaking 300 ms after the rewarded outcome and showing decreasing amplitude with higher reward probability. This prediction error signal was generated in a network including the anterior and posterior cingulate cortex. These findings pinpoint the spatio-temporal characteristics underlying reward probability coding. Together, our results provide insights into the neural dynamics underlying the ability to learn probabilistic stimuli-reward contingencies. PMID:24302894
-
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.
-
Target Uncertainty Mediates Sensorimotor Error Correction
Vijayakumar, Sethu; Wolpert, Daniel M.
2017-01-01
Human movements are prone to errors that arise from inaccuracies in both our perceptual processing and execution of motor commands. We can reduce such errors by both improving our estimates of the state of the world and through online error correction of the ongoing action. Two prominent frameworks that explain how humans solve these problems are Bayesian estimation and stochastic optimal feedback control. Here we examine the interaction between estimation and control by asking if uncertainty in estimates affects how subjects correct for errors that may arise during the movement. Unbeknownst to participants, we randomly shifted the visual feedback of their finger position as they reached to indicate the center of mass of an object. Even though participants were given ample time to compensate for this perturbation, they only fully corrected for the induced error on trials with low uncertainty about center of mass, with correction only partial in trials involving more uncertainty. The analysis of subjects’ scores revealed that participants corrected for errors just enough to avoid significant decrease in their overall scores, in agreement with the minimal intervention principle of optimal feedback control. We explain this behavior with a term in the loss function that accounts for the additional effort of adjusting one’s response. By suggesting that subjects’ decision uncertainty, as reflected in their posterior distribution, is a major factor in determining how their sensorimotor system responds to error, our findings support theoretical models in which the decision making and control processes are fully integrated. PMID:28129323
-
Target Uncertainty Mediates Sensorimotor Error Correction.
Acerbi, Luigi; Vijayakumar, Sethu; Wolpert, Daniel M
2017-01-01
Human movements are prone to errors that arise from inaccuracies in both our perceptual processing and execution of motor commands. We can reduce such errors by both improving our estimates of the state of the world and through online error correction of the ongoing action. Two prominent frameworks that explain how humans solve these problems are Bayesian estimation and stochastic optimal feedback control. Here we examine the interaction between estimation and control by asking if uncertainty in estimates affects how subjects correct for errors that may arise during the movement. Unbeknownst to participants, we randomly shifted the visual feedback of their finger position as they reached to indicate the center of mass of an object. Even though participants were given ample time to compensate for this perturbation, they only fully corrected for the induced error on trials with low uncertainty about center of mass, with correction only partial in trials involving more uncertainty. The analysis of subjects' scores revealed that participants corrected for errors just enough to avoid significant decrease in their overall scores, in agreement with the minimal intervention principle of optimal feedback control. We explain this behavior with a term in the loss function that accounts for the additional effort of adjusting one's response. By suggesting that subjects' decision uncertainty, as reflected in their posterior distribution, is a major factor in determining how their sensorimotor system responds to error, our findings support theoretical models in which the decision making and control processes are fully integrated.
-
Two States Mapping Based Time Series Neural Network Model for Compensation Prediction Residual Error
NASA Astrophysics Data System (ADS)
Jung, Insung; Koo, Lockjo; Wang, Gi-Nam
2008-11-01
The objective of this paper was to design a model of human bio signal data prediction system for decreasing of prediction error using two states mapping based time series neural network BP (back-propagation) model. Normally, a lot of the industry has been applied neural network model by training them in a supervised manner with the error back-propagation algorithm for time series prediction systems. However, it still has got a residual error between real value and prediction result. Therefore, we designed two states of neural network model for compensation residual error which is possible to use in the prevention of sudden death and metabolic syndrome disease such as hypertension disease and obesity. We determined that most of the simulation cases were satisfied by the two states mapping based time series prediction model. In particular, small sample size of times series were more accurate than the standard MLP model.
-
Error propagation in eigenimage filtering.
Soltanian-Zadeh, H; Windham, J P; Jenkins, J M
1990-01-01
Mathematical derivation of error (noise) propagation in eigenimage filtering is presented. Based on the mathematical expressions, a method for decreasing the propagated noise given a sequence of images is suggested. The signal-to-noise ratio (SNR) and contrast-to-noise ratio (CNR) of the final composite image are compared to the SNRs and CNRs of the images in the sequence. The consistency of the assumptions and accuracy of the mathematical expressions are investigated using sequences of simulated and real magnetic resonance (MR) images of an agarose phantom and a human brain.
-
A Meta-Analysis Suggests Different Neural Correlates for Implicit and Explicit Learning.
Loonis, Roman F; Brincat, Scott L; Antzoulatos, Evan G; Miller, Earl K
2017-10-11
A meta-analysis of non-human primates performing three different tasks (Object-Match, Category-Match, and Category-Saccade associations) revealed signatures of explicit and implicit learning. Performance improved equally following correct and error trials in the Match (explicit) tasks, but it improved more after correct trials in the Saccade (implicit) task, a signature of explicit versus implicit learning. Likewise, error-related negativity, a marker for error processing, was greater in the Match (explicit) tasks. All tasks showed an increase in alpha/beta (10-30 Hz) synchrony after correct choices. However, only the implicit task showed an increase in theta (3-7 Hz) synchrony after correct choices that decreased with learning. In contrast, in the explicit tasks, alpha/beta synchrony increased with learning and decreased thereafter. Our results suggest that explicit versus implicit learning engages different neural mechanisms that rely on different patterns of oscillatory synchrony. Copyright © 2017 Elsevier Inc. All rights reserved.
-
Causes and Prevention of Laparoscopic Bile Duct Injuries
Way, Lawrence W.; Stewart, Lygia; Gantert, Walter; Liu, Kingsway; Lee, Crystine M.; Whang, Karen; Hunter, John G.
2003-01-01
Objective To apply human performance concepts in an attempt to understand the causes of and prevent laparoscopic bile duct injury. Summary Background Data Powerful conceptual advances have been made in understanding the nature and limits of human performance. Applying these findings in high-risk activities, such as commercial aviation, has allowed the work environment to be restructured to substantially reduce human error. Methods The authors analyzed 252 laparoscopic bile duct injuries according to the principles of the cognitive science of visual perception, judgment, and human error. The injury distribution was class I, 7%; class II, 22%; class III, 61%; and class IV, 10%. The data included operative radiographs, clinical records, and 22 videotapes of original operations. Results The primary cause of error in 97% of cases was a visual perceptual illusion. Faults in technical skill were present in only 3% of injuries. Knowledge and judgment errors were contributory but not primary. Sixty-four injuries (25%) were recognized at the index operation; the surgeon identified the problem early enough to limit the injury in only 15 (6%). In class III injuries the common duct, erroneously believed to be the cystic duct, was deliberately cut. This stemmed from an illusion of object form due to a specific uncommon configuration of the structures and the heuristic nature (unconscious assumptions) of human visual perception. The videotapes showed the persuasiveness of the illusion, and many operative reports described the operation as routine. Class II injuries resulted from a dissection too close to the common hepatic duct. Fundamentally an illusion, it was contributed to in some instances by working too deep in the triangle of Calot. Conclusions These data show that errors leading to laparoscopic bile duct injuries stem principally from misperception, not errors of skill, knowledge, or judgment. The misperception was so compelling that in most cases the surgeon did not recognize a problem. Even when irregularities were identified, corrective feedback did not occur, which is characteristic of human thinking under firmly held assumptions. These findings illustrate the complexity of human error in surgery while simultaneously providing insights. They demonstrate that automatically attributing technical complications to behavioral factors that rely on the assumption of control is likely to be wrong. Finally, this study shows that there are only a few points within laparoscopic cholecystectomy where the complication-causing errors occur, which suggests that focused training to heighten vigilance might be able to decrease the incidence of bile duct injury. PMID:12677139
-
Impact of Standardized Communication Techniques on Errors during Simulated Neonatal Resuscitation.
Yamada, Nicole K; Fuerch, Janene H; Halamek, Louis P
2016-03-01
Current patterns of communication in high-risk clinical situations, such as resuscitation, are imprecise and prone to error. We hypothesized that the use of standardized communication techniques would decrease the errors committed by resuscitation teams during neonatal resuscitation. In a prospective, single-blinded, matched pairs design with block randomization, 13 subjects performed as a lead resuscitator in two simulated complex neonatal resuscitations. Two nurses assisted each subject during the simulated resuscitation scenarios. In one scenario, the nurses used nonstandard communication; in the other, they used standardized communication techniques. The performance of the subjects was scored to determine errors committed (defined relative to the Neonatal Resuscitation Program algorithm), time to initiation of positive pressure ventilation (PPV), and time to initiation of chest compressions (CC). In scenarios in which subjects were exposed to standardized communication techniques, there was a trend toward decreased error rate, time to initiation of PPV, and time to initiation of CC. While not statistically significant, there was a 1.7-second improvement in time to initiation of PPV and a 7.9-second improvement in time to initiation of CC. Should these improvements in human performance be replicated in the care of real newborn infants, they could improve patient outcomes and enhance patient safety. Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.
-
Toward a human-centered aircraft automation philosophy
NASA Technical Reports Server (NTRS)
Billings, Charles E.
1989-01-01
The evolution of automation in civil aircraft is examined in order to discern trends in the respective roles and functions of automation technology and the humans who operate these aircraft. The effects of advances in automation technology on crew reaction is considered and it appears that, though automation may well have decreased the frequency of certain types of human errors in flight, it may also have enabled new categories of human errors, some perhaps less obvious and therefore more serious than those it has alleviated. It is suggested that automation could be designed to keep the pilot closer to the control of the vehicle, while providing an array of information management and aiding functions designed to provide the pilot with data regarding flight replanning, degraded system operation, and the operational status and limits of the aircraft, its systems, and the physical and operational environment. The automation would serve as the pilot's assistant, providing and calculating data, watching for the unexpected, and keeping track of resources and their rate of expenditure.
-
Wave aberrations in rhesus monkeys with vision-induced ametropias
Ramamirtham, Ramkumar; Kee, Chea-su; Hung, Li-Fang; Qiao-Grider, Ying; Huang, Juan; Roorda, Austin; Smith, Earl L.
2007-01-01
The purpose of this study was to investigate the relationship between refractive errors and high-order aberrations in infant rhesus monkeys. Specifically, we compared the monochromatic wave aberrations measured with a Shack-Hartman wavefront sensor between normal monkeys and monkeys with vision-induced refractive errors. Shortly after birth, both normal monkeys and treated monkeys reared with optically induced defocus or form deprivation showed a decrease in the magnitude of high-order aberrations with age. However, the decrease in aberrations was typically smaller in the treated animals. Thus, at the end of the lens-rearing period, higher than normal amounts of aberrations were observed in treated eyes, both hyperopic and myopic eyes and treated eyes that developed astigmatism, but not spherical ametropias. The total RMS wavefront error increased with the degree of spherical refractive error, but was not correlated with the degree of astigmatism. Both myopic and hyperopic treated eyes showed elevated amounts of coma and trefoil and the degree of trefoil increased with the degree of spherical ametropia. Myopic eyes also exhibited a much higher prevalence of positive spherical aberration than normal or treated hyperopic eyes. Following the onset of unrestricted vision, the amount of high-order aberrations decreased in the treated monkeys that also recovered from the experimentally induced refractive errors. Our results demonstrate that high-order aberrations are influenced by visual experience in young primates and that the increase in high-order aberrations in our treated monkeys appears to be an optical byproduct of the vision-induced alterations in ocular growth that underlie changes in refractive error. The results from our study suggest that the higher amounts of wave aberrations observed in ametropic humans are likely to be a consequence, rather than a cause, of abnormal refractive development. PMID:17825347
-
Human Error: A Concept Analysis
NASA Technical Reports Server (NTRS)
Hansen, Frederick D.
2007-01-01
Human error is the subject of research in almost every industry and profession of our times. This term is part of our daily language and intuitively understood by most people however, it would be premature to assume that everyone's understanding of human error s the same. For example, human error is used to describe the outcome or consequence of human action, the causal factor of an accident, deliberate violations,a nd the actual action taken by a human being. As a result, researchers rarely agree on the either a specific definition or how to prevent human error. The purpose of this article is to explore the specific concept of human error using Concept Analysis as described by Walker and Avant (1995). The concept of human error is examined as currently used in the literature of a variety of industries and professions. Defining attributes and examples of model, borderline, and contrary cases are described. The antecedents and consequences of human error are also discussed and a definition of human error is offered.
-
NASA Astrophysics Data System (ADS)
Landry, Guillaume; Parodi, Katia; Wildberger, Joachim E.; Verhaegen, Frank
2013-08-01
Dedicated methods of in-vivo verification of ion treatment based on the detection of secondary emitted radiation, such as positron-emission-tomography and prompt gamma detection require high accuracy in the assignment of the elemental composition. This especially concerns the content in carbon and oxygen, which are the most abundant elements of human tissue. The standard single-energy computed tomography (SECT) approach to carbon and oxygen concentration determination has been shown to introduce significant discrepancies in the carbon and oxygen content of tissues. We propose a dual-energy CT (DECT)-based approach for carbon and oxygen content assignment and investigate the accuracy gains of the method. SECT and DECT Hounsfield units (HU) were calculated using the stoichiometric calibration procedure for a comprehensive set of human tissues. Fit parameters for the stoichiometric calibration were obtained from phantom scans. Gaussian distributions with standard deviations equal to those derived from phantom scans were subsequently generated for each tissue for several values of the computed tomography dose index (CTDIvol). The assignment of %weight carbon and oxygen (%wC,%wO) was performed based on SECT and DECT. The SECT scheme employed a HU versus %wC,O approach while for DECT we explored a Zeff versus %wC,O approach and a (Zeff, ρe) space approach. The accuracy of each scheme was estimated by calculating the root mean square (RMS) error on %wC,O derived from the input Gaussian distribution of HU for each tissue and also for the noiseless case as a limiting case. The (Zeff, ρe) space approach was also compared to SECT by comparing RMS error for hydrogen and nitrogen (%wH,%wN). Systematic shifts were applied to the tissue HU distributions to assess the robustness of the method against systematic uncertainties in the stoichiometric calibration procedure. In the absence of noise the (Zeff, ρe) space approach showed more accurate %wC,O assignment (largest error of 2%) than the Zeff versus %wC,O and HU versus %wC,O approaches (largest errors of 15% and 30%, respectively). When noise was present, the accuracy of the (Zeff, ρe) space (DECT approach) was decreased but the RMS error over all tissues was lower than the HU versus %wC,O (SECT approach) (5.8%wC versus 7.5%wC at CTDIvol = 20 mGy). The DECT approach showed decreasing RMS error with decreasing image noise (or increasing CTDIvol). At CTDIvol = 80 mGy the RMS error over all tissues was 3.7% for DECT and 6.2% for SECT approaches. However, systematic shifts greater than ±5HU undermined the accuracy gains afforded by DECT at any dose level. DECT provides more accurate %wC,O assignment than SECT when imaging noise and systematic uncertainties in HU values are not considered. The presence of imaging noise degrades the DECT accuracy on %wC,O assignment but it remains superior to SECT. However, DECT was found to be sensitive to systematic shifts of human tissue HU.
-
Empirical evidence for resource-rational anchoring and adjustment.
Lieder, Falk; Griffiths, Thomas L; M Huys, Quentin J; Goodman, Noah D
2018-04-01
People's estimates of numerical quantities are systematically biased towards their initial guess. This anchoring bias is usually interpreted as sign of human irrationality, but it has recently been suggested that the anchoring bias instead results from people's rational use of their finite time and limited cognitive resources. If this were true, then adjustment should decrease with the relative cost of time. To test this hypothesis, we designed a new numerical estimation paradigm that controls people's knowledge and varies the cost of time and error independently while allowing people to invest as much or as little time and effort into refining their estimate as they wish. Two experiments confirmed the prediction that adjustment decreases with time cost but increases with error cost regardless of whether the anchor was self-generated or provided. These results support the hypothesis that people rationally adapt their number of adjustments to achieve a near-optimal speed-accuracy tradeoff. This suggests that the anchoring bias might be a signature of the rational use of finite time and limited cognitive resources rather than a sign of human irrationality.
-
Sensitivity to prediction error in reach adaptation
Haith, Adrian M.; Harran, Michelle D.; Shadmehr, Reza
2012-01-01
It has been proposed that the brain predicts the sensory consequences of a movement and compares it to the actual sensory feedback. When the two differ, an error signal is formed, driving adaptation. How does an error in one trial alter performance in the subsequent trial? Here we show that the sensitivity to error is not constant but declines as a function of error magnitude. That is, one learns relatively less from large errors compared with small errors. We performed an experiment in which humans made reaching movements and randomly experienced an error in both their visual and proprioceptive feedback. Proprioceptive errors were created with force fields, and visual errors were formed by perturbing the cursor trajectory to create a visual error that was smaller, the same size, or larger than the proprioceptive error. We measured single-trial adaptation and calculated sensitivity to error, i.e., the ratio of the trial-to-trial change in motor commands to error size. We found that for both sensory modalities sensitivity decreased with increasing error size. A reanalysis of a number of previously published psychophysical results also exhibited this feature. Finally, we asked how the brain might encode sensitivity to error. We reanalyzed previously published probabilities of cerebellar complex spikes (CSs) and found that this probability declined with increasing error size. From this we posit that a CS may be representative of the sensitivity to error, and not error itself, a hypothesis that may explain conflicting reports about CSs and their relationship to error. PMID:22773782
-
Dynamic Simulation of Human Gait Model With Predictive Capability.
Sun, Jinming; Wu, Shaoli; Voglewede, Philip A
2018-03-01
In this paper, it is proposed that the central nervous system (CNS) controls human gait using a predictive control approach in conjunction with classical feedback control instead of exclusive classical feedback control theory that controls based on past error. To validate this proposition, a dynamic model of human gait is developed using a novel predictive approach to investigate the principles of the CNS. The model developed includes two parts: a plant model that represents the dynamics of human gait and a controller that represents the CNS. The plant model is a seven-segment, six-joint model that has nine degrees-of-freedom (DOF). The plant model is validated using data collected from able-bodied human subjects. The proposed controller utilizes model predictive control (MPC). MPC uses an internal model to predict the output in advance, compare the predicted output to the reference, and optimize the control input so that the predicted error is minimal. To decrease the complexity of the model, two joints are controlled using a proportional-derivative (PD) controller. The developed predictive human gait model is validated by simulating able-bodied human gait. The simulation results show that the developed model is able to simulate the kinematic output close to experimental data.
-
Dopamine Modulates Adaptive Prediction Error Coding in the Human Midbrain and Striatum.
Diederen, Kelly M J; Ziauddeen, Hisham; Vestergaard, Martin D; Spencer, Tom; Schultz, Wolfram; Fletcher, Paul C
2017-02-15
Learning to optimally predict rewards requires agents to account for fluctuations in reward value. Recent work suggests that individuals can efficiently learn about variable rewards through adaptation of the learning rate, and coding of prediction errors relative to reward variability. Such adaptive coding has been linked to midbrain dopamine neurons in nonhuman primates, and evidence in support for a similar role of the dopaminergic system in humans is emerging from fMRI data. Here, we sought to investigate the effect of dopaminergic perturbations on adaptive prediction error coding in humans, using a between-subject, placebo-controlled pharmacological fMRI study with a dopaminergic agonist (bromocriptine) and antagonist (sulpiride). Participants performed a previously validated task in which they predicted the magnitude of upcoming rewards drawn from distributions with varying SDs. After each prediction, participants received a reward, yielding trial-by-trial prediction errors. Under placebo, we replicated previous observations of adaptive coding in the midbrain and ventral striatum. Treatment with sulpiride attenuated adaptive coding in both midbrain and ventral striatum, and was associated with a decrease in performance, whereas bromocriptine did not have a significant impact. Although we observed no differential effect of SD on performance between the groups, computational modeling suggested decreased behavioral adaptation in the sulpiride group. These results suggest that normal dopaminergic function is critical for adaptive prediction error coding, a key property of the brain thought to facilitate efficient learning in variable environments. Crucially, these results also offer potential insights for understanding the impact of disrupted dopamine function in mental illness. SIGNIFICANCE STATEMENT To choose optimally, we have to learn what to expect. Humans dampen learning when there is a great deal of variability in reward outcome, and two brain regions that are modulated by the brain chemical dopamine are sensitive to reward variability. Here, we aimed to directly relate dopamine to learning about variable rewards, and the neural encoding of associated teaching signals. We perturbed dopamine in healthy individuals using dopaminergic medication and asked them to predict variable rewards while we made brain scans. Dopamine perturbations impaired learning and the neural encoding of reward variability, thus establishing a direct link between dopamine and adaptation to reward variability. These results aid our understanding of clinical conditions associated with dopaminergic dysfunction, such as psychosis. Copyright © 2017 Diederen et al.
-
Emken, Jeremy L; Benitez, Raul; Reinkensmeyer, David J
2007-03-28
A prevailing paradigm of physical rehabilitation following neurologic injury is to "assist-as-needed" in completing desired movements. Several research groups are attempting to automate this principle with robotic movement training devices and patient cooperative algorithms that encourage voluntary participation. These attempts are currently not based on computational models of motor learning. Here we assume that motor recovery from a neurologic injury can be modelled as a process of learning a novel sensory motor transformation, which allows us to study a simplified experimental protocol amenable to mathematical description. Specifically, we use a robotic force field paradigm to impose a virtual impairment on the left leg of unimpaired subjects walking on a treadmill. We then derive an "assist-as-needed" robotic training algorithm to help subjects overcome the virtual impairment and walk normally. The problem is posed as an optimization of performance error and robotic assistance. The optimal robotic movement trainer becomes an error-based controller with a forgetting factor that bounds kinematic errors while systematically reducing its assistance when those errors are small. As humans have a natural range of movement variability, we introduce an error weighting function that causes the robotic trainer to disregard this variability. We experimentally validated the controller with ten unimpaired subjects by demonstrating how it helped the subjects learn the novel sensory motor transformation necessary to counteract the virtual impairment, while also preventing them from experiencing large kinematic errors. The addition of the error weighting function allowed the robot assistance to fade to zero even though the subjects' movements were variable. We also show that in order to assist-as-needed, the robot must relax its assistance at a rate faster than that of the learning human. The assist-as-needed algorithm proposed here can limit error during the learning of a dynamic motor task. The algorithm encourages learning by decreasing its assistance as a function of the ongoing progression of movement error. This type of algorithm is well suited for helping people learn dynamic tasks for which large kinematic errors are dangerous or discouraging, and thus may prove useful for robot-assisted movement training of walking or reaching following neurologic injury.
-
Using a Hybrid Model to Forecast the Prevalence of Schistosomiasis in Humans.
Zhou, Lingling; Xia, Jing; Yu, Lijing; Wang, Ying; Shi, Yun; Cai, Shunxiang; Nie, Shaofa
2016-03-23
We previously proposed a hybrid model combining both the autoregressive integrated moving average (ARIMA) and the nonlinear autoregressive neural network (NARNN) models in forecasting schistosomiasis. Our purpose in the current study was to forecast the annual prevalence of human schistosomiasis in Yangxin County, using our ARIMA-NARNN model, thereby further certifying the reliability of our hybrid model. We used the ARIMA, NARNN and ARIMA-NARNN models to fit and forecast the annual prevalence of schistosomiasis. The modeling time range included was the annual prevalence from 1956 to 2008 while the testing time range included was from 2009 to 2012. The mean square error (MSE), mean absolute error (MAE) and mean absolute percentage error (MAPE) were used to measure the model performance. We reconstructed the hybrid model to forecast the annual prevalence from 2013 to 2016. The modeling and testing errors generated by the ARIMA-NARNN model were lower than those obtained from either the single ARIMA or NARNN models. The predicted annual prevalence from 2013 to 2016 demonstrated an initial decreasing trend, followed by an increase. The ARIMA-NARNN model can be well applied to analyze surveillance data for early warning systems for the control and elimination of schistosomiasis.
-
Kasuga, Shoko; Kurata, Makiko; Liu, Meigen; Ushiba, Junichi
2015-05-01
Human's sophisticated motor learning system paradoxically interferes with motor performance when visual information is mirror-reversed (MR), because normal movement error correction further aggravates the error. This error-increasing mechanism makes performing even a simple reaching task difficult, but is overcome by alterations in the error correction rule during the trials. To isolate factors that trigger learners to change the error correction rule, we manipulated the gain of visual angular errors when participants made arm-reaching movements with mirror-reversed visual feedback, and compared the rule alteration timing between groups with normal or reduced gain. Trial-by-trial changes in the visual angular error was tracked to explain the timing of the change in the error correction rule. Under both gain conditions, visual angular errors increased under the MR transformation, and suddenly decreased after 3-5 trials with increase. The increase became degressive at different amplitude between the two groups, nearly proportional to the visual gain. The findings suggest that the alteration of the error-correction rule is not dependent on the amplitude of visual angular errors, and possibly determined by the number of trials over which the errors increased or statistical property of the environment. The current results encourage future intensive studies focusing on the exact rule-change mechanism. Copyright © 2014 Elsevier Ireland Ltd and the Japan Neuroscience Society. All rights reserved.
-
Bayesian Analysis of Silica Exposure and Lung Cancer Using Human and Animal Studies.
Bartell, Scott M; Hamra, Ghassan Badri; Steenland, Kyle
2017-03-01
Bayesian methods can be used to incorporate external information into epidemiologic exposure-response analyses of silica and lung cancer. We used data from a pooled mortality analysis of silica and lung cancer (n = 65,980), using untransformed and log-transformed cumulative exposure. Animal data came from chronic silica inhalation studies using rats. We conducted Bayesian analyses with informative priors based on the animal data and different cross-species extrapolation factors. We also conducted analyses with exposure measurement error corrections in the absence of a gold standard, assuming Berkson-type error that increased with increasing exposure. The pooled animal data exposure-response coefficient was markedly higher (log exposure) or lower (untransformed exposure) than the coefficient for the pooled human data. With 10-fold uncertainty, the animal prior had little effect on results for pooled analyses and only modest effects in some individual studies. One-fold uncertainty produced markedly different results for both pooled and individual studies. Measurement error correction had little effect in pooled analyses using log exposure. Using untransformed exposure, measurement error correction caused a 5% decrease in the exposure-response coefficient for the pooled analysis and marked changes in some individual studies. The animal prior had more impact for smaller human studies and for one-fold versus three- or 10-fold uncertainty. Adjustment for Berkson error using Bayesian methods had little effect on the exposure-response coefficient when exposure was log transformed or when the sample size was large. See video abstract at, http://links.lww.com/EDE/B160.
-
Human Error In Complex Systems
NASA Technical Reports Server (NTRS)
Morris, Nancy M.; Rouse, William B.
1991-01-01
Report presents results of research aimed at understanding causes of human error in such complex systems as aircraft, nuclear powerplants, and chemical processing plants. Research considered both slips (errors of action) and mistakes (errors of intention), and influence of workload on them. Results indicated that: humans respond to conditions in which errors expected by attempting to reduce incidence of errors; and adaptation to conditions potent influence on human behavior in discretionary situations.
-
Short-term adaptation of the VOR: non-retinal-slip error signals and saccade substitution
NASA Technical Reports Server (NTRS)
Eggers, Sscott D Z.; De Pennington, Nick; Walker, Mark F.; Shelhamer, Mark; Zee, David S.
2003-01-01
We studied short-term (30 min) adaptation of the vestibulo-ocular reflex (VOR) in five normal humans using a "position error" stimulus without retinal image motion. Both before and after adaptation a velocity gain (peak slow-phase eye velocity/peak head velocity) and a position gain (total eye movement during chair rotation/amplitude of chair motion) were measured in darkness using search coils. The vestibular stimulus was a brief ( approximately 700 ms), 15 degrees chair rotation in darkness (peak velocity 43 degrees /s). To elicit adaptation, a straight-ahead fixation target disappeared during chair movement and when the chair stopped the target reappeared at a new location in front of the subject for gain-decrease (x0) adaptation, or 10 degrees opposite to chair motion for gain-increase (x1.67) adaptation. This position-error stimulus was effective at inducing VOR adaptation, though for gain-increase adaptation the primary strategy was to substitute augmenting saccades during rotation while for gain-decrease adaptation both corrective saccades and a decrease in slow-phase velocity occurred. Finally, the presence of the position-error signal alone, at the end of head rotation, without any attempt to fix upon it, was not sufficient to induce adaptation. Adaptation did occur, however, if the subject did make a saccade to the target after head rotation, or even if the subject paid attention to the new location of the target without actually looking at it.
-
Package Design Affects Accuracy Recognition for Medications.
Endestad, Tor; Wortinger, Laura A; Madsen, Steinar; Hortemo, Sigurd
2016-12-01
Our aim was to test if highlighting and placement of substance name on medication package have the potential to reduce patient errors. An unintentional overdose of medication is a large health issue that might be linked to medication package design. In two experiments, placement, background color, and the active ingredient of generic medication packages were manipulated according to best human factors guidelines to reduce causes of labeling-related patient errors. In two experiments, we compared the original packaging with packages where we varied placement of the name, dose, and background of the active ingredient. Age-relevant differences and the effect of color on medication recognition error were tested. In Experiment 1, 59 volunteers (30 elderly and 29 young students), participated. In Experiment 2, 25 volunteers participated. The most common error was the inability to identify that two different packages contained the same active ingredient (young, 41%, and elderly, 68%). This kind of error decreased with the redesigned packages (young, 8%, and elderly, 16%). Confusion errors related to color design were reduced by two thirds in the redesigned packages compared with original generic medications. Prominent placement of substance name and dose with a band of high-contrast color support recognition of the active substance in medications. A simple modification including highlighting and placing the name of the active ingredient in the upper right-hand corner of the package helps users realize that two different packages can contain the same active substance, thus reducing the risk of inadvertent medication overdose. © 2016, Human Factors and Ergonomics Society.
-
NASA Technical Reports Server (NTRS)
Alexander, Tiffaney Miller
2017-01-01
Research results have shown that more than half of aviation, aerospace and aeronautics mishaps incidents are attributed to human error. As a part of Safety within space exploration ground processing operations, the identification and/or classification of underlying contributors and causes of human error must be identified, in order to manage human error. This research provides a framework and methodology using the Human Error Assessment and Reduction Technique (HEART) and Human Factor Analysis and Classification System (HFACS), as an analysis tool to identify contributing factors, their impact on human error events, and predict the Human Error probabilities (HEPs) of future occurrences. This research methodology was applied (retrospectively) to six (6) NASA ground processing operations scenarios and thirty (30) years of Launch Vehicle related mishap data. This modifiable framework can be used and followed by other space and similar complex operations.
-
NASA Technical Reports Server (NTRS)
Alexander, Tiffaney Miller
2017-01-01
Research results have shown that more than half of aviation, aerospace and aeronautics mishaps/incidents are attributed to human error. As a part of Safety within space exploration ground processing operations, the identification and/or classification of underlying contributors and causes of human error must be identified, in order to manage human error. This research provides a framework and methodology using the Human Error Assessment and Reduction Technique (HEART) and Human Factor Analysis and Classification System (HFACS), as an analysis tool to identify contributing factors, their impact on human error events, and predict the Human Error probabilities (HEPs) of future occurrences. This research methodology was applied (retrospectively) to six (6) NASA ground processing operations scenarios and thirty (30) years of Launch Vehicle related mishap data. This modifiable framework can be used and followed by other space and similar complex operations.
-
NASA Technical Reports Server (NTRS)
Alexander, Tiffaney Miller
2017-01-01
Research results have shown that more than half of aviation, aerospace and aeronautics mishaps incidents are attributed to human error. As a part of Quality within space exploration ground processing operations, the identification and or classification of underlying contributors and causes of human error must be identified, in order to manage human error.This presentation will provide a framework and methodology using the Human Error Assessment and Reduction Technique (HEART) and Human Factor Analysis and Classification System (HFACS), as an analysis tool to identify contributing factors, their impact on human error events, and predict the Human Error probabilities (HEPs) of future occurrences. This research methodology was applied (retrospectively) to six (6) NASA ground processing operations scenarios and thirty (30) years of Launch Vehicle related mishap data. This modifiable framework can be used and followed by other space and similar complex operations.
-
Obstetric Neuraxial Drug Administration Errors: A Quantitative and Qualitative Analytical Review.
Patel, Santosh; Loveridge, Robert
2015-12-01
Drug administration errors in obstetric neuraxial anesthesia can have devastating consequences. Although fully recognizing that they represent "only the tip of the iceberg," published case reports/series of these errors were reviewed in detail with the aim of estimating the frequency and the nature of these errors. We identified case reports and case series from MEDLINE and performed a quantitative analysis of the involved drugs, error setting, source of error, the observed complications, and any therapeutic interventions. We subsequently performed a qualitative analysis of the human factors involved and proposed modifications to practice. Twenty-nine cases were identified. Various drugs were given in error, but no direct effects on the course of labor, mode of delivery, or neonatal outcome were reported. Four maternal deaths from the accidental intrathecal administration of tranexamic acid were reported, all occurring after delivery of the fetus. A range of hemodynamic and neurologic signs and symptoms were noted, but the most commonly reported complication was the failure of the intended neuraxial anesthetic technique. Several human factors were present; most common factors were drug storage issues and similar drug appearance. Four practice recommendations were identified as being likely to have prevented the errors. The reported errors exposed latent conditions within health care systems. We suggest that the implementation of the following processes may decrease the risk of these types of drug errors: (1) Careful reading of the label on any drug ampule or syringe before the drug is drawn up or injected; (2) labeling all syringes; (3) checking labels with a second person or a device (such as a barcode reader linked to a computer) before the drug is drawn up or administered; and (4) use of non-Luer lock connectors on all epidural/spinal/combined spinal-epidural devices. Further study is required to determine whether routine use of these processes will reduce drug error.
-
Understanding human management of automation errors
McBride, Sara E.; Rogers, Wendy A.; Fisk, Arthur D.
2013-01-01
Automation has the potential to aid humans with a diverse set of tasks and support overall system performance. Automated systems are not always reliable, and when automation errs, humans must engage in error management, which is the process of detecting, understanding, and correcting errors. However, this process of error management in the context of human-automation interaction is not well understood. Therefore, we conducted a systematic review of the variables that contribute to error management. We examined relevant research in human-automation interaction and human error to identify critical automation, person, task, and emergent variables. We propose a framework for management of automation errors to incorporate and build upon previous models. Further, our analysis highlights variables that may be addressed through design and training to positively influence error management. Additional efforts to understand the error management process will contribute to automation designed and implemented to support safe and effective system performance. PMID:25383042
-
Understanding human management of automation errors.
McBride, Sara E; Rogers, Wendy A; Fisk, Arthur D
2014-01-01
Automation has the potential to aid humans with a diverse set of tasks and support overall system performance. Automated systems are not always reliable, and when automation errs, humans must engage in error management, which is the process of detecting, understanding, and correcting errors. However, this process of error management in the context of human-automation interaction is not well understood. Therefore, we conducted a systematic review of the variables that contribute to error management. We examined relevant research in human-automation interaction and human error to identify critical automation, person, task, and emergent variables. We propose a framework for management of automation errors to incorporate and build upon previous models. Further, our analysis highlights variables that may be addressed through design and training to positively influence error management. Additional efforts to understand the error management process will contribute to automation designed and implemented to support safe and effective system performance.
-
Zahurancik, Walter J.; Klein, Seth J.; Suo, Zucai
2014-01-01
Most eukaryotic DNA replication is performed by A- and B-family DNA polymerases which possess a faithful polymerase activity that preferentially incorporates correct over incorrect nucleotides. Additionally, many replicative polymerases have an efficient 3′→5′ exonuclease activity that excises misincorporated nucleotides. Together, these activities contribute to overall low polymerase error frequency (one error per 106–108 incorporations) and support faithful eukaryotic genome replication. Eukaryotic DNA polymerase ϵ (Polϵ) is one of three main replicative DNA polymerases for nuclear genomic replication and is responsible for leading strand synthesis. Here, we employed pre-steady-state kinetic methods and determined the overall fidelity of human Polϵ (hPolϵ) by measuring the individual contributions of its polymerase and 3′→5′ exonuclease activities. The polymerase activity of hPolϵ has a high base substitution fidelity (10−4–10−7) resulting from large decreases in both nucleotide incorporation rate constants and ground-state binding affinities for incorrect relative to correct nucleotides. The 3′→5′ exonuclease activity of hPolϵ further enhances polymerization fidelity by an unprecedented 3.5 × 102 to 1.2 × 104-fold. The resulting overall fidelity of hPolϵ (10−6–10−11) justifies hPolϵ to be a primary enzyme to replicate human nuclear genome (0.1–1.0 error per round). Consistently, somatic mutations in hPolϵ, which decrease its exonuclease activity, are connected with mutator phenotypes and cancer formation. PMID:25414327
-
Prospect theory does not describe the feedback-related negativity value function.
Sambrook, Thomas D; Roser, Matthew; Goslin, Jeremy
2012-12-01
Humans handle uncertainty poorly. Prospect theory accounts for this with a value function in which possible losses are overweighted compared to possible gains, and the marginal utility of rewards decreases with size. fMRI studies have explored the neural basis of this value function. A separate body of research claims that prediction errors are calculated by midbrain dopamine neurons. We investigated whether the prospect theoretic effects shown in behavioral and fMRI studies were present in midbrain prediction error coding by using the feedback-related negativity, an ERP component believed to reflect midbrain prediction errors. Participants' stated satisfaction with outcomes followed prospect theory but their feedback-related negativity did not, instead showing no effect of marginal utility and greater sensitivity to potential gains than losses. Copyright © 2012 Society for Psychophysiological Research.
-
Human operator response to error-likely situations in complex engineering systems
NASA Technical Reports Server (NTRS)
Morris, Nancy M.; Rouse, William B.
1988-01-01
The causes of human error in complex systems are examined. First, a conceptual framework is provided in which two broad categories of error are discussed: errors of action, or slips, and errors of intention, or mistakes. Conditions in which slips and mistakes might be expected to occur are identified, based on existing theories of human error. Regarding the role of workload, it is hypothesized that workload may act as a catalyst for error. Two experiments are presented in which humans' response to error-likely situations were examined. Subjects controlled PLANT under a variety of conditions and periodically provided subjective ratings of mental effort. A complex pattern of results was obtained, which was not consistent with predictions. Generally, the results of this research indicate that: (1) humans respond to conditions in which errors might be expected by attempting to reduce the possibility of error, and (2) adaptation to conditions is a potent influence on human behavior in discretionary situations. Subjects' explanations for changes in effort ratings are also explored.
-
Human error and human factors engineering in health care.
Welch, D L
1997-01-01
Human error is inevitable. It happens in health care systems as it does in all other complex systems, and no measure of attention, training, dedication, or punishment is going to stop it. The discipline of human factors engineering (HFE) has been dealing with the causes and effects of human error since the 1940's. Originally applied to the design of increasingly complex military aircraft cockpits, HFE has since been effectively applied to the problem of human error in such diverse systems as nuclear power plants, NASA spacecraft, the process control industry, and computer software. Today the health care industry is becoming aware of the costs of human error and is turning to HFE for answers. Just as early experimental psychologists went beyond the label of "pilot error" to explain how the design of cockpits led to air crashes, today's HFE specialists are assisting the health care industry in identifying the causes of significant human errors in medicine and developing ways to eliminate or ameliorate them. This series of articles will explore the nature of human error and how HFE can be applied to reduce the likelihood of errors and mitigate their effects.
-
Cheng, Ching-Min; Hwang, Sheue-Ling
2015-03-01
This paper outlines the human error identification (HEI) techniques that currently exist to assess latent human errors. Many formal error identification techniques have existed for years, but few have been validated to cover latent human error analysis in different domains. This study considers many possible error modes and influential factors, including external error modes, internal error modes, psychological error mechanisms, and performance shaping factors, and integrates several execution procedures and frameworks of HEI techniques. The case study in this research was the operational process of changing chemical cylinders in a factory. In addition, the integrated HEI method was used to assess the operational processes and the system's reliability. It was concluded that the integrated method is a valuable aid to develop much safer operational processes and can be used to predict human error rates on critical tasks in the plant. Copyright © 2014 Elsevier Ltd and The Ergonomics Society. All rights reserved.
-
Human error in airway facilities.
DOT National Transportation Integrated Search
2001-01-01
This report examines human errors in Airway Facilities (AF) with the intent of preventing these errors from being : passed on to the new Operations Control Centers. To effectively manage errors, they first have to be identified. : Human factors engin...
-
Using a Hybrid Model to Forecast the Prevalence of Schistosomiasis in Humans
Zhou, Lingling; Xia, Jing; Yu, Lijing; Wang, Ying; Shi, Yun; Cai, Shunxiang; Nie, Shaofa
2016-01-01
Background: We previously proposed a hybrid model combining both the autoregressive integrated moving average (ARIMA) and the nonlinear autoregressive neural network (NARNN) models in forecasting schistosomiasis. Our purpose in the current study was to forecast the annual prevalence of human schistosomiasis in Yangxin County, using our ARIMA-NARNN model, thereby further certifying the reliability of our hybrid model. Methods: We used the ARIMA, NARNN and ARIMA-NARNN models to fit and forecast the annual prevalence of schistosomiasis. The modeling time range included was the annual prevalence from 1956 to 2008 while the testing time range included was from 2009 to 2012. The mean square error (MSE), mean absolute error (MAE) and mean absolute percentage error (MAPE) were used to measure the model performance. We reconstructed the hybrid model to forecast the annual prevalence from 2013 to 2016. Results: The modeling and testing errors generated by the ARIMA-NARNN model were lower than those obtained from either the single ARIMA or NARNN models. The predicted annual prevalence from 2013 to 2016 demonstrated an initial decreasing trend, followed by an increase. Conclusions: The ARIMA-NARNN model can be well applied to analyze surveillance data for early warning systems for the control and elimination of schistosomiasis. PMID:27023573
-
Chiu, Ming-Chuan; Hsieh, Min-Chih
2016-05-01
The purposes of this study were to develop a latent human error analysis process, to explore the factors of latent human error in aviation maintenance tasks, and to provide an efficient improvement strategy for addressing those errors. First, we used HFACS and RCA to define the error factors related to aviation maintenance tasks. Fuzzy TOPSIS with four criteria was applied to evaluate the error factors. Results show that 1) adverse physiological states, 2) physical/mental limitations, and 3) coordination, communication, and planning are the factors related to airline maintenance tasks that could be addressed easily and efficiently. This research establishes a new analytic process for investigating latent human error and provides a strategy for analyzing human error using fuzzy TOPSIS. Our analysis process complements shortages in existing methodologies by incorporating improvement efficiency, and it enhances the depth and broadness of human error analysis methodology. Copyright © 2015 Elsevier Ltd and The Ergonomics Society. All rights reserved.
-
Abrams, Robert M
2015-09-01
Sleep deprivation occurs when inadequate sleep leads to decreased performance, inadequate alertness, and deterioration in health. It is incompletely understood why humans need sleep, although some theories include energy conservation, restoration, and information processing. Sleep deprivation has many deleterious health effects. Residency programs have enacted strict work restrictions because of medically related errors due to sleep deprivation. Because obstetrics is an unpredictable specialty with long irregular hours, enacting a hospitalist program enhances patient safety, decreases malpractice risk, and improves the physician's quality of life by allowing obstetricians to get sufficient rest. Copyright © 2015 Elsevier Inc. All rights reserved.
-
Emken, Jeremy L; Benitez, Raul; Reinkensmeyer, David J
2007-01-01
Background A prevailing paradigm of physical rehabilitation following neurologic injury is to "assist-as-needed" in completing desired movements. Several research groups are attempting to automate this principle with robotic movement training devices and patient cooperative algorithms that encourage voluntary participation. These attempts are currently not based on computational models of motor learning. Methods Here we assume that motor recovery from a neurologic injury can be modelled as a process of learning a novel sensory motor transformation, which allows us to study a simplified experimental protocol amenable to mathematical description. Specifically, we use a robotic force field paradigm to impose a virtual impairment on the left leg of unimpaired subjects walking on a treadmill. We then derive an "assist-as-needed" robotic training algorithm to help subjects overcome the virtual impairment and walk normally. The problem is posed as an optimization of performance error and robotic assistance. The optimal robotic movement trainer becomes an error-based controller with a forgetting factor that bounds kinematic errors while systematically reducing its assistance when those errors are small. As humans have a natural range of movement variability, we introduce an error weighting function that causes the robotic trainer to disregard this variability. Results We experimentally validated the controller with ten unimpaired subjects by demonstrating how it helped the subjects learn the novel sensory motor transformation necessary to counteract the virtual impairment, while also preventing them from experiencing large kinematic errors. The addition of the error weighting function allowed the robot assistance to fade to zero even though the subjects' movements were variable. We also show that in order to assist-as-needed, the robot must relax its assistance at a rate faster than that of the learning human. Conclusion The assist-as-needed algorithm proposed here can limit error during the learning of a dynamic motor task. The algorithm encourages learning by decreasing its assistance as a function of the ongoing progression of movement error. This type of algorithm is well suited for helping people learn dynamic tasks for which large kinematic errors are dangerous or discouraging, and thus may prove useful for robot-assisted movement training of walking or reaching following neurologic injury. PMID:17391527
-
NASA Technical Reports Server (NTRS)
Fields, J. M.
1980-01-01
The data from seven surveys of community response to environmental noise are reanalyzed to assess the relative influence of peak noise levels and the numbers of noise events on human response. The surveys do not agree on the value of the tradeoff between the effects of noise level and numbers of events. The value of the tradeoff cannot be confidently specified in any survey because the tradeoff estimate may have a large standard error of estimate and because the tradeoff estimate may be seriously biased by unknown noise measurement errors. Some evidence suggests a decrease in annoyance with very high numbers of noise events but this evidence is not strong enough to lead to the rejection of the conventionally accepted assumption that annoyance is related to a log transformation of the number of noise events.
-
Medication errors in anesthesia: unacceptable or unavoidable?
Dhawan, Ira; Tewari, Anurag; Sehgal, Sankalp; Sinha, Ashish Chandra
Medication errors are the common causes of patient morbidity and mortality. It adds financial burden to the institution as well. Though the impact varies from no harm to serious adverse effects including death, it needs attention on priority basis since medication errors' are preventable. In today's world where people are aware and medical claims are on the hike, it is of utmost priority that we curb this issue. Individual effort to decrease medication error alone might not be successful until a change in the existing protocols and system is incorporated. Often drug errors that occur cannot be reversed. The best way to 'treat' drug errors is to prevent them. Wrong medication (due to syringe swap), overdose (due to misunderstanding or preconception of the dose, pump misuse and dilution error), incorrect administration route, under dosing and omission are common causes of medication error that occur perioperatively. Drug omission and calculation mistakes occur commonly in ICU. Medication errors can occur perioperatively either during preparation, administration or record keeping. Numerous human and system errors can be blamed for occurrence of medication errors. The need of the hour is to stop the blame - game, accept mistakes and develop a safe and 'just' culture in order to prevent medication errors. The newly devised systems like VEINROM, a fluid delivery system is a novel approach in preventing drug errors due to most commonly used medications in anesthesia. Similar developments along with vigilant doctors, safe workplace culture and organizational support all together can help prevent these errors. Copyright © 2016. Published by Elsevier Editora Ltda.
-
Stochastic Models of Human Errors
NASA Technical Reports Server (NTRS)
Elshamy, Maged; Elliott, Dawn M. (Technical Monitor)
2002-01-01
Humans play an important role in the overall reliability of engineering systems. More often accidents and systems failure are traced to human errors. Therefore, in order to have meaningful system risk analysis, the reliability of the human element must be taken into consideration. Describing the human error process by mathematical models is a key to analyzing contributing factors. Therefore, the objective of this research effort is to establish stochastic models substantiated by sound theoretic foundation to address the occurrence of human errors in the processing of the space shuttle.
-
Operational Interventions to Maintenance Error
NASA Technical Reports Server (NTRS)
Kanki, Barbara G.; Walter, Diane; Dulchinos, VIcki
1997-01-01
A significant proportion of aviation accidents and incidents are known to be tied to human error. However, research of flight operational errors has shown that so-called pilot error often involves a variety of human factors issues and not a simple lack of individual technical skills. In aircraft maintenance operations, there is similar concern that maintenance errors which may lead to incidents and accidents are related to a large variety of human factors issues. Although maintenance error data and research are limited, industry initiatives involving human factors training in maintenance have become increasingly accepted as one type of maintenance error intervention. Conscientious efforts have been made in re-inventing the team7 concept for maintenance operations and in tailoring programs to fit the needs of technical opeRAtions. Nevertheless, there remains a dual challenge: 1) to develop human factors interventions which are directly supported by reliable human error data, and 2) to integrate human factors concepts into the procedures and practices of everyday technical tasks. In this paper, we describe several varieties of human factors interventions and focus on two specific alternatives which target problems related to procedures and practices; namely, 1) structured on-the-job training and 2) procedure re-design. We hope to demonstrate that the key to leveraging the impact of these solutions comes from focused interventions; that is, interventions which are derived from a clear understanding of specific maintenance errors, their operational context and human factors components.
-
Reduction of Maintenance Error Through Focused Interventions
NASA Technical Reports Server (NTRS)
Kanki, Barbara G.; Walter, Diane; Rosekind, Mark R. (Technical Monitor)
1997-01-01
It is well known that a significant proportion of aviation accidents and incidents are tied to human error. In flight operations, research of operational errors has shown that so-called "pilot error" often involves a variety of human factors issues and not a simple lack of individual technical skills. In aircraft maintenance operations, there is similar concern that maintenance errors which may lead to incidents and accidents are related to a large variety of human factors issues. Although maintenance error data and research are limited, industry initiatives involving human factors training in maintenance have become increasingly accepted as one type of maintenance error intervention. Conscientious efforts have been made in re-inventing the "team" concept for maintenance operations and in tailoring programs to fit the needs of technical operations. Nevertheless, there remains a dual challenge: to develop human factors interventions which are directly supported by reliable human error data, and to integrate human factors concepts into the procedures and practices of everyday technical tasks. In this paper, we describe several varieties of human factors interventions and focus on two specific alternatives which target problems related to procedures and practices; namely, 1) structured on-the-job training and 2) procedure re-design. We hope to demonstrate that the key to leveraging the impact of these solutions comes from focused interventions; that is, interventions which are derived from a clear understanding of specific maintenance errors, their operational context and human factors components.
-
NASA Technical Reports Server (NTRS)
Diorio, Kimberly A.; Voska, Ned (Technical Monitor)
2002-01-01
This viewgraph presentation provides information on Human Factors Process Failure Modes and Effects Analysis (HF PFMEA). HF PFMEA includes the following 10 steps: Describe mission; Define System; Identify human-machine; List human actions; Identify potential errors; Identify factors that effect error; Determine likelihood of error; Determine potential effects of errors; Evaluate risk; Generate solutions (manage error). The presentation also describes how this analysis was applied to a liquid oxygen pump acceptance test.
-
NASA Technical Reports Server (NTRS)
Mcruer, D. T.; Clement, W. F.; Allen, R. W.
1981-01-01
Human errors tend to be treated in terms of clinical and anecdotal descriptions, from which remedial measures are difficult to derive. Correction of the sources of human error requires an attempt to reconstruct underlying and contributing causes of error from the circumstantial causes cited in official investigative reports. A comprehensive analytical theory of the cause-effect relationships governing propagation of human error is indispensable to a reconstruction of the underlying and contributing causes. A validated analytical theory of the input-output behavior of human operators involving manual control, communication, supervisory, and monitoring tasks which are relevant to aviation, maritime, automotive, and process control operations is highlighted. This theory of behavior, both appropriate and inappropriate, provides an insightful basis for investigating, classifying, and quantifying the needed cause-effect relationships governing propagation of human error.
-
The contributions of human factors on human error in Malaysia aviation maintenance industries
NASA Astrophysics Data System (ADS)
Padil, H.; Said, M. N.; Azizan, A.
2018-05-01
Aviation maintenance is a multitasking activity in which individuals perform varied tasks under constant pressure to meet deadlines as well as challenging work conditions. These situational characteristics combined with human factors can lead to various types of human related errors. The primary objective of this research is to develop a structural relationship model that incorporates human factors, organizational factors, and their impact on human errors in aviation maintenance. Towards that end, a questionnaire was developed which was administered to Malaysian aviation maintenance professionals. Structural Equation Modelling (SEM) approach was used in this study utilizing AMOS software. Results showed that there were a significant relationship of human factors on human errors and were tested in the model. Human factors had a partial effect on organizational factors while organizational factors had a direct and positive impact on human errors. It was also revealed that organizational factors contributed to human errors when coupled with human factors construct. This study has contributed to the advancement of knowledge on human factors effecting safety and has provided guidelines for improving human factors performance relating to aviation maintenance activities and could be used as a reference for improving safety performance in the Malaysian aviation maintenance companies.
-
NASA Technical Reports Server (NTRS)
Mcruer, D. T.; Clement, W. F.; Allen, R. W.
1980-01-01
Human error, a significant contributing factor in a very high proportion of civil transport, general aviation, and rotorcraft accidents is investigated. Correction of the sources of human error requires that one attempt to reconstruct underlying and contributing causes of error from the circumstantial causes cited in official investigative reports. A validated analytical theory of the input-output behavior of human operators involving manual control, communication, supervisory, and monitoring tasks which are relevant to aviation operations is presented. This theory of behavior, both appropriate and inappropriate, provides an insightful basis for investigating, classifying, and quantifying the needed cause-effect relationships governing propagation of human error.
-
Human Reliability and the Cost of Doing Business
NASA Technical Reports Server (NTRS)
DeMott, Diana
2014-01-01
Most businesses recognize that people will make mistakes and assume errors are just part of the cost of doing business, but does it need to be? Companies with high risk, or major consequences, should consider the effect of human error. In a variety of industries, Human Errors have caused costly failures and workplace injuries. These have included: airline mishaps, medical malpractice, administration of medication and major oil spills have all been blamed on human error. A technique to mitigate or even eliminate some of these costly human errors is the use of Human Reliability Analysis (HRA). Various methodologies are available to perform Human Reliability Assessments that range from identifying the most likely areas for concern to detailed assessments with human error failure probabilities calculated. Which methodology to use would be based on a variety of factors that would include: 1) how people react and act in different industries, and differing expectations based on industries standards, 2) factors that influence how the human errors could occur such as tasks, tools, environment, workplace, support, training and procedure, 3) type and availability of data and 4) how the industry views risk & reliability influences ( types of emergencies, contingencies and routine tasks versus cost based concerns). The Human Reliability Assessments should be the first step to reduce, mitigate or eliminate the costly mistakes or catastrophic failures. Using Human Reliability techniques to identify and classify human error risks allows a company more opportunities to mitigate or eliminate these risks and prevent costly failures.
-
Human Reliability and the Cost of Doing Business
NASA Technical Reports Server (NTRS)
DeMott, D. L.
2014-01-01
Human error cannot be defined unambiguously in advance of it happening, it often becomes an error after the fact. The same action can result in a tragic accident for one situation or a heroic action given a more favorable outcome. People often forget that we employ humans in business and industry for the flexibility and capability to change when needed. In complex systems, operations are driven by their specifications of the system and the system structure. People provide the flexibility to make it work. Human error has been reported as being responsible for 60%-80% of failures, accidents and incidents in high-risk industries. We don't have to accept that all human errors are inevitable. Through the use of some basic techniques, many potential human error events can be addressed. There are actions that can be taken to reduce the risk of human error.
-
Human Error Analysis in a Permit to Work System: A Case Study in a Chemical Plant
Jahangiri, Mehdi; Hoboubi, Naser; Rostamabadi, Akbar; Keshavarzi, Sareh; Hosseini, Ali Akbar
2015-01-01
Background A permit to work (PTW) is a formal written system to control certain types of work which are identified as potentially hazardous. However, human error in PTW processes can lead to an accident. Methods This cross-sectional, descriptive study was conducted to estimate the probability of human errors in PTW processes in a chemical plant in Iran. In the first stage, through interviewing the personnel and studying the procedure in the plant, the PTW process was analyzed using the hierarchical task analysis technique. In doing so, PTW was considered as a goal and detailed tasks to achieve the goal were analyzed. In the next step, the standardized plant analysis risk-human (SPAR-H) reliability analysis method was applied for estimation of human error probability. Results The mean probability of human error in the PTW system was estimated to be 0.11. The highest probability of human error in the PTW process was related to flammable gas testing (50.7%). Conclusion The SPAR-H method applied in this study could analyze and quantify the potential human errors and extract the required measures for reducing the error probabilities in PTW system. Some suggestions to reduce the likelihood of errors, especially in the field of modifying the performance shaping factors and dependencies among tasks are provided. PMID:27014485
-
Managing human fallibility in critical aerospace situations
NASA Astrophysics Data System (ADS)
Tew, Larry
2014-11-01
Human fallibility is pervasive in the aerospace industry with over 50% of errors attributed to human error. Consider the benefits to any organization if those errors were significantly reduced. Aerospace manufacturing involves high value, high profile systems with significant complexity and often repetitive build, assembly, and test operations. In spite of extensive analysis, planning, training, and detailed procedures, human factors can cause unexpected errors. Handling such errors involves extensive cause and corrective action analysis and invariably schedule slips and cost growth. We will discuss success stories, including those associated with electro-optical systems, where very significant reductions in human fallibility errors were achieved after receiving adapted and specialized training. In the eyes of company and customer leadership, the steps used to achieve these results lead to in a major culture change in both the workforce and the supporting management organization. This approach has proven effective in other industries like medicine, firefighting, law enforcement, and aviation. The roadmap to success and the steps to minimize human error are known. They can be used by any organization willing to accept human fallibility and take a proactive approach to incorporate the steps needed to manage and minimize error.
-
Defining the Relationship Between Human Error Classes and Technology Intervention Strategies
NASA Technical Reports Server (NTRS)
Wiegmann, Douglas A.; Rantanen, Eas M.
2003-01-01
The modus operandi in addressing human error in aviation systems is predominantly that of technological interventions or fixes. Such interventions exhibit considerable variability both in terms of sophistication and application. Some technological interventions address human error directly while others do so only indirectly. Some attempt to eliminate the occurrence of errors altogether whereas others look to reduce the negative consequences of these errors. In any case, technological interventions add to the complexity of the systems and may interact with other system components in unforeseeable ways and often create opportunities for novel human errors. Consequently, there is a need to develop standards for evaluating the potential safety benefit of each of these intervention products so that resources can be effectively invested to produce the biggest benefit to flight safety as well as to mitigate any adverse ramifications. The purpose of this project was to help define the relationship between human error and technological interventions, with the ultimate goal of developing a set of standards for evaluating or measuring the potential benefits of new human error fixes.
-
Applying lessons learned to enhance human performance and reduce human error for ISS operations
DOE Office of Scientific and Technical Information (OSTI.GOV)
Nelson, W.R.
1999-01-01
A major component of reliability, safety, and mission success for space missions is ensuring that the humans involved (flight crew, ground crew, mission control, etc.) perform their tasks and functions as required. This includes compliance with training and procedures during normal conditions, and successful compensation when malfunctions or unexpected conditions occur. A very significant issue that affects human performance in space flight is human error. Human errors can invalidate carefully designed equipment and procedures. If certain errors combine with equipment failures or design flaws, mission failure or loss of life can occur. The control of human error during operation ofmore » the International Space Station (ISS) will be critical to the overall success of the program. As experience from Mir operations has shown, human performance plays a vital role in the success or failure of long duration space missions. The Department of Energy{close_quote}s Idaho National Engineering and Environmental Laboratory (INEEL) is developing a systematic approach to enhance human performance and reduce human errors for ISS operations. This approach is based on the systematic identification and evaluation of lessons learned from past space missions such as Mir to enhance the design and operation of ISS. This paper will describe previous INEEL research on human error sponsored by NASA and how it can be applied to enhance human reliability for ISS. {copyright} {ital 1999 American Institute of Physics.}« less
-
Applying lessons learned to enhance human performance and reduce human error for ISS operations
DOE Office of Scientific and Technical Information (OSTI.GOV)
Nelson, W.R.
1998-09-01
A major component of reliability, safety, and mission success for space missions is ensuring that the humans involved (flight crew, ground crew, mission control, etc.) perform their tasks and functions as required. This includes compliance with training and procedures during normal conditions, and successful compensation when malfunctions or unexpected conditions occur. A very significant issue that affects human performance in space flight is human error. Human errors can invalidate carefully designed equipment and procedures. If certain errors combine with equipment failures or design flaws, mission failure or loss of life can occur. The control of human error during operation ofmore » the International Space Station (ISS) will be critical to the overall success of the program. As experience from Mir operations has shown, human performance plays a vital role in the success or failure of long duration space missions. The Department of Energy`s Idaho National Engineering and Environmental Laboratory (INEEL) is developed a systematic approach to enhance human performance and reduce human errors for ISS operations. This approach is based on the systematic identification and evaluation of lessons learned from past space missions such as Mir to enhance the design and operation of ISS. This paper describes previous INEEL research on human error sponsored by NASA and how it can be applied to enhance human reliability for ISS.« less
-
Impact of an antiretroviral stewardship strategy on medication error rates.
Shea, Katherine M; Hobbs, Athena Lv; Shumake, Jason D; Templet, Derek J; Padilla-Tolentino, Eimeira; Mondy, Kristin E
2018-05-02
The impact of an antiretroviral stewardship strategy on medication error rates was evaluated. This single-center, retrospective, comparative cohort study included patients at least 18 years of age infected with human immunodeficiency virus (HIV) who were receiving antiretrovirals and admitted to the hospital. A multicomponent approach was developed and implemented and included modifications to the order-entry and verification system, pharmacist education, and a pharmacist-led antiretroviral therapy checklist. Pharmacists performed prospective audits using the checklist at the time of order verification. To assess the impact of the intervention, a retrospective review was performed before and after implementation to assess antiretroviral errors. Totals of 208 and 24 errors were identified before and after the intervention, respectively, resulting in a significant reduction in the overall error rate ( p < 0.001). In the postintervention group, significantly lower medication error rates were found in both patient admissions containing at least 1 medication error ( p < 0.001) and those with 2 or more errors ( p < 0.001). Significant reductions were also identified in each error type, including incorrect/incomplete medication regimen, incorrect dosing regimen, incorrect renal dose adjustment, incorrect administration, and the presence of a major drug-drug interaction. A regression tree selected ritonavir as the only specific medication that best predicted more errors preintervention ( p < 0.001); however, no antiretrovirals reliably predicted errors postintervention. An antiretroviral stewardship strategy for hospitalized HIV patients including prospective audit by staff pharmacists through use of an antiretroviral medication therapy checklist at the time of order verification decreased error rates. Copyright © 2018 by the American Society of Health-System Pharmacists, Inc. All rights reserved.
-
Norman, Geoffrey R; Monteiro, Sandra D; Sherbino, Jonathan; Ilgen, Jonathan S; Schmidt, Henk G; Mamede, Silvia
2017-01-01
Contemporary theories of clinical reasoning espouse a dual processing model, which consists of a rapid, intuitive component (Type 1) and a slower, logical and analytical component (Type 2). Although the general consensus is that this dual processing model is a valid representation of clinical reasoning, the causes of diagnostic errors remain unclear. Cognitive theories about human memory propose that such errors may arise from both Type 1 and Type 2 reasoning. Errors in Type 1 reasoning may be a consequence of the associative nature of memory, which can lead to cognitive biases. However, the literature indicates that, with increasing expertise (and knowledge), the likelihood of errors decreases. Errors in Type 2 reasoning may result from the limited capacity of working memory, which constrains computational processes. In this article, the authors review the medical literature to answer two substantial questions that arise from this work: (1) To what extent do diagnostic errors originate in Type 1 (intuitive) processes versus in Type 2 (analytical) processes? (2) To what extent are errors a consequence of cognitive biases versus a consequence of knowledge deficits?The literature suggests that both Type 1 and Type 2 processes contribute to errors. Although it is possible to experimentally induce cognitive biases, particularly availability bias, the extent to which these biases actually contribute to diagnostic errors is not well established. Educational strategies directed at the recognition of biases are ineffective in reducing errors; conversely, strategies focused on the reorganization of knowledge to reduce errors have small but consistent benefits.
-
Rational integration of noisy evidence and prior semantic expectations in sentence interpretation.
Gibson, Edward; Bergen, Leon; Piantadosi, Steven T
2013-05-14
Sentence processing theories typically assume that the input to our language processing mechanisms is an error-free sequence of words. However, this assumption is an oversimplification because noise is present in typical language use (for instance, due to a noisy environment, producer errors, or perceiver errors). A complete theory of human sentence comprehension therefore needs to explain how humans understand language given imperfect input. Indeed, like many cognitive systems, language processing mechanisms may even be "well designed"--in this case for the task of recovering intended meaning from noisy utterances. In particular, comprehension mechanisms may be sensitive to the types of information that an idealized statistical comprehender would be sensitive to. Here, we evaluate four predictions about such a rational (Bayesian) noisy-channel language comprehender in a sentence comprehension task: (i) semantic cues should pull sentence interpretation towards plausible meanings, especially if the wording of the more plausible meaning is close to the observed utterance in terms of the number of edits; (ii) this process should asymmetrically treat insertions and deletions due to the Bayesian "size principle"; such nonliteral interpretation of sentences should (iii) increase with the perceived noise rate of the communicative situation and (iv) decrease if semantically anomalous meanings are more likely to be communicated. These predictions are borne out, strongly suggesting that human language relies on rational statistical inference over a noisy channel.
-
Rational integration of noisy evidence and prior semantic expectations in sentence interpretation
Gibson, Edward; Bergen, Leon; Piantadosi, Steven T.
2013-01-01
Sentence processing theories typically assume that the input to our language processing mechanisms is an error-free sequence of words. However, this assumption is an oversimplification because noise is present in typical language use (for instance, due to a noisy environment, producer errors, or perceiver errors). A complete theory of human sentence comprehension therefore needs to explain how humans understand language given imperfect input. Indeed, like many cognitive systems, language processing mechanisms may even be “well designed”–in this case for the task of recovering intended meaning from noisy utterances. In particular, comprehension mechanisms may be sensitive to the types of information that an idealized statistical comprehender would be sensitive to. Here, we evaluate four predictions about such a rational (Bayesian) noisy-channel language comprehender in a sentence comprehension task: (i) semantic cues should pull sentence interpretation towards plausible meanings, especially if the wording of the more plausible meaning is close to the observed utterance in terms of the number of edits; (ii) this process should asymmetrically treat insertions and deletions due to the Bayesian “size principle”; such nonliteral interpretation of sentences should (iii) increase with the perceived noise rate of the communicative situation and (iv) decrease if semantically anomalous meanings are more likely to be communicated. These predictions are borne out, strongly suggesting that human language relies on rational statistical inference over a noisy channel. PMID:23637344
-
Kraemer, Sara; Carayon, Pascale
2007-03-01
This paper describes human errors and violations of end users and network administration in computer and information security. This information is summarized in a conceptual framework for examining the human and organizational factors contributing to computer and information security. This framework includes human error taxonomies to describe the work conditions that contribute adversely to computer and information security, i.e. to security vulnerabilities and breaches. The issue of human error and violation in computer and information security was explored through a series of 16 interviews with network administrators and security specialists. The interviews were audio taped, transcribed, and analyzed by coding specific themes in a node structure. The result is an expanded framework that classifies types of human error and identifies specific human and organizational factors that contribute to computer and information security. Network administrators tended to view errors created by end users as more intentional than unintentional, while errors created by network administrators as more unintentional than intentional. Organizational factors, such as communication, security culture, policy, and organizational structure, were the most frequently cited factors associated with computer and information security.
-
Intervention strategies for the management of human error
NASA Technical Reports Server (NTRS)
Wiener, Earl L.
1993-01-01
This report examines the management of human error in the cockpit. The principles probably apply as well to other applications in the aviation realm (e.g. air traffic control, dispatch, weather, etc.) as well as other high-risk systems outside of aviation (e.g. shipping, high-technology medical procedures, military operations, nuclear power production). Management of human error is distinguished from error prevention. It is a more encompassing term, which includes not only the prevention of error, but also a means of disallowing an error, once made, from adversely affecting system output. Such techniques include: traditional human factors engineering, improvement of feedback and feedforward of information from system to crew, 'error-evident' displays which make erroneous input more obvious to the crew, trapping of errors within a system, goal-sharing between humans and machines (also called 'intent-driven' systems), paperwork management, and behaviorally based approaches, including procedures, standardization, checklist design, training, cockpit resource management, etc. Fifteen guidelines for the design and implementation of intervention strategies are included.
-
Uy, Raymonde Charles Y; Kury, Fabricio P; Fontelo, Paul A
2015-01-01
The standard of safe medication practice requires strict observance of the five rights of medication administration: the right patient, drug, time, dose, and route. Despite adherence to these guidelines, medication errors remain a public health concern that has generated health policies and hospital processes that leverage automation and computerization to reduce these errors. Bar code, RFID, biometrics and pharmacy automation technologies have been demonstrated in literature to decrease the incidence of medication errors by minimizing human factors involved in the process. Despite evidence suggesting the effectivity of these technologies, adoption rates and trends vary across hospital systems. The objective of study is to examine the state and adoption trends of automatic identification and data capture (AIDC) methods and pharmacy automation technologies in U.S. hospitals. A retrospective descriptive analysis of survey data from the HIMSS Analytics® Database was done, demonstrating an optimistic growth in the adoption of these patient safety solutions.
-
ERIC Educational Resources Information Center
Boedigheimer, Dan
2010-01-01
Approximately 70% of aviation accidents are attributable to human error. The greatest opportunity for further improving aviation safety is found in reducing human errors in the cockpit. The purpose of this quasi-experimental, mixed-method research was to evaluate whether there was a difference in pilot attitudes toward reducing human error in the…
-
Evaluating a medical error taxonomy.
Brixey, Juliana; Johnson, Todd R; Zhang, Jiajie
2002-01-01
Healthcare has been slow in using human factors principles to reduce medical errors. The Center for Devices and Radiological Health (CDRH) recognizes that a lack of attention to human factors during product development may lead to errors that have the potential for patient injury, or even death. In response to the need for reducing medication errors, the National Coordinating Council for Medication Errors Reporting and Prevention (NCC MERP) released the NCC MERP taxonomy that provides a standard language for reporting medication errors. This project maps the NCC MERP taxonomy of medication error to MedWatch medical errors involving infusion pumps. Of particular interest are human factors associated with medical device errors. The NCC MERP taxonomy of medication errors is limited in mapping information from MEDWATCH because of the focus on the medical device and the format of reporting.
-
DOE Office of Scientific and Technical Information (OSTI.GOV)
Terezakis, Stephanie A., E-mail: stereza1@jhmi.edu; Harris, Kendra M.; Ford, Eric
Purpose: Systems to ensure patient safety are of critical importance. The electronic incident reporting systems (IRS) of 2 large academic radiation oncology departments were evaluated for events that may be suitable for submission to a national reporting system (NRS). Methods and Materials: All events recorded in the combined IRS were evaluated from 2007 through 2010. Incidents were graded for potential severity using the validated French Nuclear Safety Authority (ASN) 5-point scale. These incidents were categorized into 7 groups: (1) human error, (2) software error, (3) hardware error, (4) error in communication between 2 humans, (5) error at the human-software interface,more » (6) error at the software-hardware interface, and (7) error at the human-hardware interface. Results: Between the 2 systems, 4407 incidents were reported. Of these events, 1507 (34%) were considered to have the potential for clinical consequences. Of these 1507 events, 149 (10%) were rated as having a potential severity of ≥2. Of these 149 events, the committee determined that 79 (53%) of these events would be submittable to a NRS of which the majority was related to human error or to the human-software interface. Conclusions: A significant number of incidents were identified in this analysis. The majority of events in this study were related to human error and to the human-software interface, further supporting the need for a NRS to facilitate field-wide learning and system improvement.« less
-
Jeon, Hong Jin; Kim, Ji-Hae; Kim, Bin-Na; Park, Seung Jin; Fava, Maurizio; Mischoulon, David; Kang, Eun-Ho; Roh, Sungwon; Lee, Dongsoo
2014-12-01
Human error is defined as an unintended error that is attributable to humans rather than machines, and that is important to avoid to prevent accidents. We aimed to investigate the association between sleep quality and human errors among train drivers. Cross-sectional. Population-based. A sample of 5,480 subjects who were actively working as train drivers were recruited in South Korea. The participants were 4,634 drivers who completed all questionnaires (response rate 84.6%). None. The Pittsburgh Sleep Quality Index (PSQI), the Center for Epidemiologic Studies Depression Scale (CES-D), the Impact of Event Scale-Revised (IES-R), the State-Trait Anxiety Inventory (STAI), and the Korean Occupational Stress Scale (KOSS). Of 4,634 train drivers, 349 (7.5%) showed more than one human error per 5 y. Human errors were associated with poor sleep quality, higher PSQI total scores, short sleep duration at night, and longer sleep latency. Among train drivers with poor sleep quality, those who experienced severe posttraumatic stress showed a significantly higher number of human errors than those without. Multiple logistic regression analysis showed that human errors were significantly associated with poor sleep quality and posttraumatic stress, whereas there were no significant associations with depression, trait and state anxiety, and work stress after adjusting for age, sex, education years, marital status, and career duration. Poor sleep quality was found to be associated with more human errors in train drivers, especially in those who experienced severe posttraumatic stress. © 2014 Associated Professional Sleep Societies, LLC.
-
Learning mechanisms to limit medication administration errors.
Drach-Zahavy, Anat; Pud, Dorit
2010-04-01
This paper is a report of a study conducted to identify and test the effectiveness of learning mechanisms applied by the nursing staff of hospital wards as a means of limiting medication administration errors. Since the influential report ;To Err Is Human', research has emphasized the role of team learning in reducing medication administration errors. Nevertheless, little is known about the mechanisms underlying team learning. Thirty-two hospital wards were randomly recruited. Data were collected during 2006 in Israel by a multi-method (observations, interviews and administrative data), multi-source (head nurses, bedside nurses) approach. Medication administration error was defined as any deviation from procedures, policies and/or best practices for medication administration, and was identified using semi-structured observations of nurses administering medication. Organizational learning was measured using semi-structured interviews with head nurses, and the previous year's reported medication administration errors were assessed using administrative data. The interview data revealed four learning mechanism patterns employed in an attempt to learn from medication administration errors: integrated, non-integrated, supervisory and patchy learning. Regression analysis results demonstrated that whereas the integrated pattern of learning mechanisms was associated with decreased errors, the non-integrated pattern was associated with increased errors. Supervisory and patchy learning mechanisms were not associated with errors. Superior learning mechanisms are those that represent the whole cycle of team learning, are enacted by nurses who administer medications to patients, and emphasize a system approach to data analysis instead of analysis of individual cases.
-
Analyzing human errors in flight mission operations
NASA Technical Reports Server (NTRS)
Bruno, Kristin J.; Welz, Linda L.; Barnes, G. Michael; Sherif, Josef
1993-01-01
A long-term program is in progress at JPL to reduce cost and risk of flight mission operations through a defect prevention/error management program. The main thrust of this program is to create an environment in which the performance of the total system, both the human operator and the computer system, is optimized. To this end, 1580 Incident Surprise Anomaly reports (ISA's) from 1977-1991 were analyzed from the Voyager and Magellan projects. A Pareto analysis revealed that 38 percent of the errors were classified as human errors. A preliminary cluster analysis based on the Magellan human errors (204 ISA's) is presented here. The resulting clusters described the underlying relationships among the ISA's. Initial models of human error in flight mission operations are presented. Next, the Voyager ISA's will be scored and included in the analysis. Eventually, these relationships will be used to derive a theoretically motivated and empirically validated model of human error in flight mission operations. Ultimately, this analysis will be used to make continuous process improvements continuous process improvements to end-user applications and training requirements. This Total Quality Management approach will enable the management and prevention of errors in the future.
-
Wilharm, A.; Hurschler, Ch.; Dermitas, T.; Bohnsack, M.
2013-01-01
Pressure-sensitive K-Scan 4000 sensors (Tekscan, USA) provide new possibilities for the dynamic measurement of force and pressure in biomechanical investigations. We examined the sensors to determine in particular whether they are also suitable for reliable measurements of retropatellar forces and pressures. Insertion approaches were also investigated and a lateral parapatellar arthrotomy supplemented by parapatellar sutures proved to be the most reliable method. The ten human cadaver knees were tested in a knee-simulating machine at a torque of 30 and 40 Nm. Each test cycle involved a dynamic extension from 120° flexion. All recorded parameters showed a decrease of 1-2% per measurement cycle. Although we supplemented the sensors with a Teflon film, the decrease, which was likely caused by shear force, was significant. We evaluated 12 cycles and observed a linear decrease in parameters up to 17.2% (coefficient of regression 0.69–0.99). In our opinion, the linear decrease can be considered a systematic error and can therefore be quantified and accounted for in subsequent experiments. That will ensure reliable retropatellar usage of Tekscan sensors and distinguish the effects of knee joint surgeries from sensor wear-related effects. PMID:24369018
-
Human Error and the International Space Station: Challenges and Triumphs in Science Operations
NASA Technical Reports Server (NTRS)
Harris, Samantha S.; Simpson, Beau C.
2016-01-01
Any system with a human component is inherently risky. Studies in human factors and psychology have repeatedly shown that human operators will inevitably make errors, regardless of how well they are trained. Onboard the International Space Station (ISS) where crew time is arguably the most valuable resource, errors by the crew or ground operators can be costly to critical science objectives. Operations experts at the ISS Payload Operations Integration Center (POIC), located at NASA's Marshall Space Flight Center in Huntsville, Alabama, have learned that from payload concept development through execution, there are countless opportunities to introduce errors that can potentially result in costly losses of crew time and science. To effectively address this challenge, we must approach the design, testing, and operation processes with two specific goals in mind. First, a systematic approach to error and human centered design methodology should be implemented to minimize opportunities for user error. Second, we must assume that human errors will be made and enable rapid identification and recoverability when they occur. While a systematic approach and human centered development process can go a long way toward eliminating error, the complete exclusion of operator error is not a reasonable expectation. The ISS environment in particular poses challenging conditions, especially for flight controllers and astronauts. Operating a scientific laboratory 250 miles above the Earth is a complicated and dangerous task with high stakes and a steep learning curve. While human error is a reality that may never be fully eliminated, smart implementation of carefully chosen tools and techniques can go a long way toward minimizing risk and increasing the efficiency of NASA's space science operations.
-
Modeling human response errors in synthetic flight simulator domain
NASA Technical Reports Server (NTRS)
Ntuen, Celestine A.
1992-01-01
This paper presents a control theoretic approach to modeling human response errors (HRE) in the flight simulation domain. The human pilot is modeled as a supervisor of a highly automated system. The synthesis uses the theory of optimal control pilot modeling for integrating the pilot's observation error and the error due to the simulation model (experimental error). Methods for solving the HRE problem are suggested. Experimental verification of the models will be tested in a flight quality handling simulation.
-
Qi, Yulin; Geib, Timon; Schorr, Pascal; Meier, Florian; Volmer, Dietrich A
2015-01-15
Isobaric interferences in human serum can potentially influence the measured concentration levels of 25-hydroxyvitamin D [25(OH)D], when low resolving power liquid chromatography/tandem mass spectrometry (LC/MS/MS) instruments and non-specific MS/MS product ions are employed for analysis. In this study, we provide a detailed characterization of these interferences and a technical solution to reduce the associated systematic errors. Detailed electrospray ionization Fourier transform ion cyclotron resonance (FTICR) high-resolution mass spectrometry (HRMS) experiments were used to characterize co-extracted isobaric components of 25(OH)D from human serum. Differential ion mobility spectrometry (DMS), as a gas-phase ion filter, was implemented on a triple quadrupole mass spectrometer for separation of the isobars. HRMS revealed the presence of multiple isobaric compounds in extracts of human serum for different sample preparation methods. Several of these isobars had the potential to increase the peak areas measured for 25(OH)D on low-resolution MS instruments. A major isobaric component was identified as pentaerythritol oleate, a technical lubricant, which was probably an artifact from the analytical instrumentation. DMS was able to remove several of these isobars prior to MS/MS, when implemented on the low-resolution triple quadrupole mass spectrometer. It was shown in this proof-of-concept study that DMS-MS has the potential to significantly decrease systematic errors, and thus improve accuracy of vitamin D measurements using LC/MS/MS. Copyright © 2014 John Wiley & Sons, Ltd.
-
Zupanc, Christine M; Burgess-Limerick, Robin J; Wallis, Guy
2007-08-01
To investigate error and reaction time consequences of alternating compatible and incompatible steering arrangements during a simulated obstacle avoidance task. Underground coal mine shuttle cars provide an example of a vehicle in which operators are required to alternate between compatible and incompatible steering configurations. This experiment examines the performance of 48 novice participants in a virtual analogy of an underground coal mine shuttle car. Participants were randomly assigned to a compatible condition, an incompatible condition, an alternating condition in which compatibility alternated within and between hands, or an alternating condition in which compatibility alternated between hands. Participants made fewer steering direction errors and made correct steering responses more quickly in the compatible condition. Error rate decreased over time in the incompatible condition. A compatibility effect for both errors and reaction time was also found when the control-response relationship alternated; however, performance improvements over time were not consistent. Isolating compatibility to a hand resulted in reduced error rate and faster reaction time than when compatibility alternated within and between hands. The consequences of alternating control-response relationships are higher error rates and slower responses, at least in the early stages of learning. This research highlights the importance of ensuring consistently compatible human-machine directional control-response relationships.
-
On the development of voluntary and reflexive components in human saccade generation.
Fischer, B; Biscaldi, M; Gezeck, S
1997-04-18
The saccadic performance of a large number (n = 281) of subjects of different ages (8-70 years) was studied applying two saccade tasks: the prosaccade overlap (PO) task and the antisaccade gap (AG) task. From the PO task, the mean reaction times and the percentage of express saccades were determined for each subject. From the AG task, the mean reaction time of the correct antisaccades and of the erratic prosaccades were measured. In addition, we determined the error rate and the mean correction time, i.e. the time between the end of the first erratic prosaccade and the following corrective antisaccade. These variables were measured separately for stimuli presented (in random order) at the right or left side. While strong correlations were seen between variables for the right and left sides, considerable side asymmetries were obtained from many subjects. A factor analysis revealed that the seven variables (six eye movement variables plus age) were mainly determined by only two factors, V and F. The V factor was dominated by the variables from the AG task (reaction time, correction time, error rate) the F factor by variables from the PO task (reaction time, percentage express saccades) and the reaction time of the errors (prosaccades!) from the AG task. The relationship between the percentage number of express saccades and the percentage number of errors was completely asymmetric: high numbers of express saccades were accompanied by high numbers of errors but not vice versa. Only the variables in the V factor covaried with age. A fast decrease of the antisaccade reaction time (by 50 ms), of the correction times (by 70 ms) and of the error rate (from 60 to 22%) was observed between age 9 and 15 years, followed by a further period of slower decrease until age 25 years. The mean time a subject needed to reach the side opposite to the stimulus as required by the antisaccade task decreased from approximately 350 to 250 ms until age 15 years and decreased further by 20 ms before it increased again to approximately 280 ms. At higher ages, there was a slight indication for a return development. Subjects with high error rates had long antisaccade latencies and needed a long time to reach the opposite side on error trials. The variables obtained from the PO task varied also significantly with age but by smaller amounts. The results are discussed in relation to the subsystems controlling saccade generation: a voluntary and a reflex component the latter being suppressed by active fixation. Both systems seem to develop differentially. The data offer a detailed baseline for clinical studies using the pro- and antisaccade tasks as an indication of functional impairments, circumscribed brain lesions, neurological and psychiatric diseases and cognitive deficits.
-
Episodic Memory Encoding Interferes with Reward Learning and Decreases Striatal Prediction Errors
Braun, Erin Kendall; Daw, Nathaniel D.
2014-01-01
Learning is essential for adaptive decision making. The striatum and its dopaminergic inputs are known to support incremental reward-based learning, while the hippocampus is known to support encoding of single events (episodic memory). Although traditionally studied separately, in even simple experiences, these two types of learning are likely to co-occur and may interact. Here we sought to understand the nature of this interaction by examining how incremental reward learning is related to concurrent episodic memory encoding. During the experiment, human participants made choices between two options (colored squares), each associated with a drifting probability of reward, with the goal of earning as much money as possible. Incidental, trial-unique object pictures, unrelated to the choice, were overlaid on each option. The next day, participants were given a surprise memory test for these pictures. We found that better episodic memory was related to a decreased influence of recent reward experience on choice, both within and across participants. fMRI analyses further revealed that during learning the canonical striatal reward prediction error signal was significantly weaker when episodic memory was stronger. This decrease in reward prediction error signals in the striatum was associated with enhanced functional connectivity between the hippocampus and striatum at the time of choice. Our results suggest a mechanism by which memory encoding may compete for striatal processing and provide insight into how interactions between different forms of learning guide reward-based decision making. PMID:25378157
-
Defining the Relationship Between Human Error Classes and Technology Intervention Strategies
NASA Technical Reports Server (NTRS)
Wiegmann, Douglas A.; Rantanen, Esa; Crisp, Vicki K. (Technical Monitor)
2002-01-01
One of the main factors in all aviation accidents is human error. The NASA Aviation Safety Program (AvSP), therefore, has identified several human-factors safety technologies to address this issue. Some technologies directly address human error either by attempting to reduce the occurrence of errors or by mitigating the negative consequences of errors. However, new technologies and system changes may also introduce new error opportunities or even induce different types of errors. Consequently, a thorough understanding of the relationship between error classes and technology "fixes" is crucial for the evaluation of intervention strategies outlined in the AvSP, so that resources can be effectively directed to maximize the benefit to flight safety. The purpose of the present project, therefore, was to examine the repositories of human factors data to identify the possible relationship between different error class and technology intervention strategies. The first phase of the project, which is summarized here, involved the development of prototype data structures or matrices that map errors onto "fixes" (and vice versa), with the hope of facilitating the development of standards for evaluating safety products. Possible follow-on phases of this project are also discussed. These additional efforts include a thorough and detailed review of the literature to fill in the data matrix and the construction of a complete database and standards checklists.
-
An optomechanical model eye for ophthalmological refractive studies.
Arianpour, Ashkan; Tremblay, Eric J; Stamenov, Igor; Ford, Joseph E; Schanzlin, David J; Lo, Yuhwa
2013-02-01
To create an accurate, low-cost optomechanical model eye for investigation of refractive errors in clinical and basic research studies. An optomechanical fluid-filled eye model with dimensions consistent with the human eye was designed and fabricated. Optical simulations were performed on the optomechanical eye model, and the quantified resolution and refractive errors were compared with the widely used Navarro eye model using the ray-tracing software ZEMAX (Radiant Zemax, Redmond, WA). The resolution of the physical optomechanical eye model was then quantified with a complementary metal-oxide semiconductor imager using the image resolution software SFR Plus (Imatest, Boulder, CO). Refractive, manufacturing, and assembling errors were also assessed. A refractive intraocular lens (IOL) and a diffractive IOL were added to the optomechanical eye model for tests and analyses of a 1951 U.S. Air Force target chart. Resolution and aberrations of the optomechanical eye model and the Navarro eye model were qualitatively similar in ZEMAX simulations. Experimental testing found that the optomechanical eye model reproduced properties pertinent to human eyes, including resolution better than 20/20 visual acuity and a decrease in resolution as the field of view increased in size. The IOLs were also integrated into the optomechanical eye model to image objects at distances of 15, 10, and 3 feet, and they indicated a resolution of 22.8 cycles per degree at 15 feet. A life-sized optomechanical eye model with the flexibility to be patient-specific was designed and constructed. The model had the resolution of a healthy human eye and recreated normal refractive errors. This model may be useful in the evaluation of IOLs for cataract surgery. Copyright 2013, SLACK Incorporated.
-
Saidi, Maryam; Towhidkhah, Farzad; Gharibzadeh, Shahriar; Lari, Abdolaziz Azizi
2013-12-01
Humans perceive the surrounding world by integration of information through different sensory modalities. Earlier models of multisensory integration rely mainly on traditional Bayesian and causal Bayesian inferences for single causal (source) and two causal (for two senses such as visual and auditory systems), respectively. In this paper a new recurrent neural model is presented for integration of visual and proprioceptive information. This model is based on population coding which is able to mimic multisensory integration of neural centers in the human brain. The simulation results agree with those achieved by casual Bayesian inference. The model can also simulate the sensory training process of visual and proprioceptive information in human. Training process in multisensory integration is a point with less attention in the literature before. The effect of proprioceptive training on multisensory perception was investigated through a set of experiments in our previous study. The current study, evaluates the effect of both modalities, i.e., visual and proprioceptive training and compares them with each other through a set of new experiments. In these experiments, the subject was asked to move his/her hand in a circle and estimate its position. The experiments were performed on eight subjects with proprioception training and eight subjects with visual training. Results of the experiments show three important points: (1) visual learning rate is significantly more than that of proprioception; (2) means of visual and proprioceptive errors are decreased by training but statistical analysis shows that this decrement is significant for proprioceptive error and non-significant for visual error, and (3) visual errors in training phase even in the beginning of it, is much less than errors of the main test stage because in the main test, the subject has to focus on two senses. The results of the experiments in this paper is in agreement with the results of the neural model simulation.
-
Frequency-specific hippocampal-prefrontal interactions during associative learning
Brincat, Scott L.; Miller, Earl K.
2015-01-01
Much of our knowledge of the world depends on learning associations (e.g., face-name), for which the hippocampus (HPC) and prefrontal cortex (PFC) are critical. HPC-PFC interactions have rarely been studied in monkeys, whose cognitive/mnemonic abilities are akin to humans. Here, we show functional differences and frequency-specific interactions between HPC and PFC of monkeys learning object-pair associations, an animal model of human explicit memory. PFC spiking activity reflected learning in parallel with behavioral performance, while HPC neurons reflected feedback about whether trial-and-error guesses were correct or incorrect. Theta-band HPC-PFC synchrony was stronger after errors, was driven primarily by PFC to HPC directional influences, and decreased with learning. In contrast, alpha/beta-band synchrony was stronger after correct trials, was driven more by HPC, and increased with learning. Rapid object associative learning may occur in PFC, while HPC may guide neocortical plasticity by signaling success or failure via oscillatory synchrony in different frequency bands. PMID:25706471
-
Ananda, Guruprasad; Hile, Suzanne E.; Breski, Amanda; Wang, Yanli; Kelkar, Yogeshwar; Makova, Kateryna D.; Eckert, Kristin A.
2014-01-01
Interruptions of microsatellite sequences impact genome evolution and can alter disease manifestation. However, human polymorphism levels at interrupted microsatellites (iMSs) are not known at a genome-wide scale, and the pathways for gaining interruptions are poorly understood. Using the 1000 Genomes Phase-1 variant call set, we interrogated mono-, di-, tri-, and tetranucleotide repeats up to 10 units in length. We detected ∼26,000–40,000 iMSs within each of four human population groups (African, European, East Asian, and American). We identified population-specific iMSs within exonic regions, and discovered that known disease-associated iMSs contain alleles present at differing frequencies among the populations. By analyzing longer microsatellites in primate genomes, we demonstrate that single interruptions result in a genome-wide average two- to six-fold reduction in microsatellite mutability, as compared with perfect microsatellites. Centrally located interruptions lowered mutability dramatically, by two to three orders of magnitude. Using a biochemical approach, we tested directly whether the mutability of a specific iMS is lower because of decreased DNA polymerase strand slippage errors. Modeling the adenomatous polyposis coli tumor suppressor gene sequence, we observed that a single base substitution interruption reduced strand slippage error rates five- to 50-fold, relative to a perfect repeat, during synthesis by DNA polymerases α, β, or η. Computationally, we demonstrate that iMSs arise primarily by base substitution mutations within individual human genomes. Our biochemical survey of human DNA polymerase α, β, δ, κ, and η error rates within certain microsatellites suggests that interruptions are created most frequently by low fidelity polymerases. Our combined computational and biochemical results demonstrate that iMSs are abundant in human genomes and are sources of population-specific genetic variation that may affect genome stability. The genome-wide identification of iMSs in human populations presented here has important implications for current models describing the impact of microsatellite polymorphisms on gene expression. PMID:25033203
-
Westendorff, Stephanie; Kuang, Shenbing; Taghizadeh, Bahareh; Donchin, Opher; Gail, Alexander
2015-04-01
Different error signals can induce sensorimotor adaptation during visually guided reaching, possibly evoking different neural adaptation mechanisms. Here we investigate reach adaptation induced by visual target errors without perturbing the actual or sensed hand position. We analyzed the spatial generalization of adaptation to target error to compare it with other known generalization patterns and simulated our results with a neural network model trained to minimize target error independent of prediction errors. Subjects reached to different peripheral visual targets and had to adapt to a sudden fixed-amplitude displacement ("jump") consistently occurring for only one of the reach targets. Subjects simultaneously had to perform contralateral unperturbed saccades, which rendered the reach target jump unnoticeable. As a result, subjects adapted by gradually decreasing reach errors and showed negative aftereffects for the perturbed reach target. Reach errors generalized to unperturbed targets according to a translational rather than rotational generalization pattern, but locally, not globally. More importantly, reach errors generalized asymmetrically with a skewed generalization function in the direction of the target jump. Our neural network model reproduced the skewed generalization after adaptation to target jump without having been explicitly trained to produce a specific generalization pattern. Our combined psychophysical and simulation results suggest that target jump adaptation in reaching can be explained by gradual updating of spatial motor goal representations in sensorimotor association networks, independent of learning induced by a prediction-error about the hand position. The simulations make testable predictions about the underlying changes in the tuning of sensorimotor neurons during target jump adaptation. Copyright © 2015 the American Physiological Society.
-
Westendorff, Stephanie; Kuang, Shenbing; Taghizadeh, Bahareh; Donchin, Opher
2015-01-01
Different error signals can induce sensorimotor adaptation during visually guided reaching, possibly evoking different neural adaptation mechanisms. Here we investigate reach adaptation induced by visual target errors without perturbing the actual or sensed hand position. We analyzed the spatial generalization of adaptation to target error to compare it with other known generalization patterns and simulated our results with a neural network model trained to minimize target error independent of prediction errors. Subjects reached to different peripheral visual targets and had to adapt to a sudden fixed-amplitude displacement (“jump”) consistently occurring for only one of the reach targets. Subjects simultaneously had to perform contralateral unperturbed saccades, which rendered the reach target jump unnoticeable. As a result, subjects adapted by gradually decreasing reach errors and showed negative aftereffects for the perturbed reach target. Reach errors generalized to unperturbed targets according to a translational rather than rotational generalization pattern, but locally, not globally. More importantly, reach errors generalized asymmetrically with a skewed generalization function in the direction of the target jump. Our neural network model reproduced the skewed generalization after adaptation to target jump without having been explicitly trained to produce a specific generalization pattern. Our combined psychophysical and simulation results suggest that target jump adaptation in reaching can be explained by gradual updating of spatial motor goal representations in sensorimotor association networks, independent of learning induced by a prediction-error about the hand position. The simulations make testable predictions about the underlying changes in the tuning of sensorimotor neurons during target jump adaptation. PMID:25609106
-
DNA assembly with error correction on a droplet digital microfluidics platform.
Khilko, Yuliya; Weyman, Philip D; Glass, John I; Adams, Mark D; McNeil, Melanie A; Griffin, Peter B
2018-06-01
Custom synthesized DNA is in high demand for synthetic biology applications. However, current technologies to produce these sequences using assembly from DNA oligonucleotides are costly and labor-intensive. The automation and reduced sample volumes afforded by microfluidic technologies could significantly decrease materials and labor costs associated with DNA synthesis. The purpose of this study was to develop a gene assembly protocol utilizing a digital microfluidic device. Toward this goal, we adapted bench-scale oligonucleotide assembly methods followed by enzymatic error correction to the Mondrian™ digital microfluidic platform. We optimized Gibson assembly, polymerase chain reaction (PCR), and enzymatic error correction reactions in a single protocol to assemble 12 oligonucleotides into a 339-bp double- stranded DNA sequence encoding part of the human influenza virus hemagglutinin (HA) gene. The reactions were scaled down to 0.6-1.2 μL. Initial microfluidic assembly methods were successful and had an error frequency of approximately 4 errors/kb with errors originating from the original oligonucleotide synthesis. Relative to conventional benchtop procedures, PCR optimization required additional amounts of MgCl 2 , Phusion polymerase, and PEG 8000 to achieve amplification of the assembly and error correction products. After one round of error correction, error frequency was reduced to an average of 1.8 errors kb - 1 . We demonstrated that DNA assembly from oligonucleotides and error correction could be completely automated on a digital microfluidic (DMF) platform. The results demonstrate that enzymatic reactions in droplets show a strong dependence on surface interactions, and successful on-chip implementation required supplementation with surfactants, molecular crowding agents, and an excess of enzyme. Enzymatic error correction of assembled fragments improved sequence fidelity by 2-fold, which was a significant improvement but somewhat lower than expected compared to bench-top assays, suggesting an additional capacity for optimization.
-
Reflections on human error - Matters of life and death
NASA Technical Reports Server (NTRS)
Wiener, Earl L.
1989-01-01
The last two decades have witnessed a rapid growth in the introduction of automatic devices into aircraft cockpits, and eleswhere in human-machine systems. This was motivated in part by the assumption that when human functioning is replaced by machine functioning, human error is eliminated. Experience to date shows that this is far from true, and that automation does not replace humans, but changes their role in the system, as well as the types and severity of the errors they make. This altered role may lead to fewer, but more critical errors. Intervention strategies to prevent these errors, or ameliorate their consequences include basic human factors engineering of the interface, enhanced warning and alerting systems, and more intelligent interfaces that understand the strategic intent of the crew and can detect and trap inconsistent or erroneous input before it affects the system.
-
A stochastic dynamic model for human error analysis in nuclear power plants
NASA Astrophysics Data System (ADS)
Delgado-Loperena, Dharma
Nuclear disasters like Three Mile Island and Chernobyl indicate that human performance is a critical safety issue, sending a clear message about the need to include environmental press and competence aspects in research. This investigation was undertaken to serve as a roadmap for studying human behavior through the formulation of a general solution equation. The theoretical model integrates models from two heretofore-disassociated disciplines (behavior specialists and technical specialists), that historically have independently studied the nature of error and human behavior; including concepts derived from fractal and chaos theory; and suggests re-evaluation of base theory regarding human error. The results of this research were based on comprehensive analysis of patterns of error, with the omnipresent underlying structure of chaotic systems. The study of patterns lead to a dynamic formulation, serving for any other formula used to study human error consequences. The search for literature regarding error yielded insight for the need to include concepts rooted in chaos theory and strange attractors---heretofore unconsidered by mainstream researchers who investigated human error in nuclear power plants or those who employed the ecological model in their work. The study of patterns obtained from the rupture of a steam generator tube (SGTR) event simulation, provided a direct application to aspects of control room operations in nuclear power plant operations. In doing so, the conceptual foundation based in the understanding of the patterns of human error analysis can be gleaned, resulting in reduced and prevent undesirable events.
-
Human factors in aviation crashes involving older pilots.
Li, Guohua; Baker, Susan P; Lamb, Margaret W; Grabowski, Jurek G; Rebok, George W
2002-02-01
Pilot errors are recognized as a contributing factor in as many as 80% of aviation crashes. Experimental studies using flight simulators indicate that due to decreased working memory capacity, older pilots are outperformed by their younger counterparts in communication tasks and flight summary scores. This study examines age-related differences in crash circumstances and pilot errors in a sample of pilots who flew commuter aircraft or air taxis and who were involved in airplane or helicopter crashes. A historical cohort of 3306 pilots who in 1987 flew commuter aircraft or air taxis and were 45-54 yr of age was constructed using the Federal Aviation Administration's airmen information system. Crash records of the study subjects for the years 1983-1997 were obtained from the National Transportation Safety Board (NTSB) by matching name and date of birth. NTSB's investigation reports were reviewed to identify pilot errors and other contributing factors. Comparisons of crash circumstances and human factors were made between pilots aged 40-49 yr and pilots aged 50-63 yr. A total of 165 crash records were studied, with 52% of these crashes involving pilots aged 50-63 yr. Crash circumstances, such as time and location of crash, type and phase of flight, and weather conditions, were similar between the two age groups. Pilot error was a contributing factor in 73% of the crashes involving younger pilots and in 69% of the crashes involving older pilots (p = 0.50). Age-related differences in the pattern of pilot errors were statistically insignificant. Overall, 23% of pilot errors were attributable to inattentiveness, 20% to flawed decisions, 18% to mishandled aircraft kinetics, and 18% to mishandled wind/runway conditions. Neither crash circumstances nor the prevalence and patterns of pilot errors appear to change significantly as age increases from the 40s to the 50s and early 60s.
-
High definition video teaching module for learning neck dissection.
Mendez, Adrian; Seikaly, Hadi; Ansari, Kal; Murphy, Russell; Cote, David
2014-03-25
Video teaching modules are proven effective tools for enhancing student competencies and technical skills in the operating room. Integration into post-graduate surgical curricula, however, continues to pose a challenge in modern surgical education. To date, video teaching modules for neck dissection have yet to be described in the literature. To develop and validate an HD video-based teaching module (HDVM) to help instruct post-graduate otolaryngology trainees in performing neck dissection. This prospective study included 6 intermediate to senior otolaryngology residents. All consented subjects first performed a control selective neck dissection. Subjects were then exposed to the video teaching module. Following a washout period, a repeat procedure was performed. Recordings of the both sets of neck dissections were de-identified and reviewed by an independent evaluator and scored using the Observational Clinical Human Reliability Assessment (OCHRA) system. In total 91 surgical errors were made prior to the HDVM and 41 after exposure, representing a 55% decrease in error occurrence. The two groups were found to be significantly different. Similarly, 66 and 24 staff takeover events occurred pre and post HDVM exposure, respectively, representing a statistically significant 64% decrease. HDVM is a useful adjunct to classical surgical training. Residents performed significantly less errors following exposure to the HD-video module. Similarly, significantly less staff takeover events occurred following exposure to the HDVM.
-
Human factors process failure modes and effects analysis (HF PFMEA) software tool
NASA Technical Reports Server (NTRS)
Chandler, Faith T. (Inventor); Relvini, Kristine M. (Inventor); Shedd, Nathaneal P. (Inventor); Valentino, William D. (Inventor); Philippart, Monica F. (Inventor); Bessette, Colette I. (Inventor)
2011-01-01
Methods, computer-readable media, and systems for automatically performing Human Factors Process Failure Modes and Effects Analysis for a process are provided. At least one task involved in a process is identified, where the task includes at least one human activity. The human activity is described using at least one verb. A human error potentially resulting from the human activity is automatically identified, the human error is related to the verb used in describing the task. A likelihood of occurrence, detection, and correction of the human error is identified. The severity of the effect of the human error is identified. The likelihood of occurrence, and the severity of the risk of potential harm is identified. The risk of potential harm is compared with a risk threshold to identify the appropriateness of corrective measures.
-
Chaplain Corps Cadet Chapel Community Center Chapel Institutional Review Board Not Human Subjects Research Requirements 7 Not Human Subjects Research Form 8 Researcher Instructions - Activities Submitted to DoD IRB 9 Review 18 Not Human Subjects Errors 19 Exempt Research Most Frequent Errors 20 Most Frequent Errors for
-
Development of an FAA-EUROCONTROL technique for the analysis of human error in ATM : final report.
DOT National Transportation Integrated Search
2002-07-01
Human error has been identified as a dominant risk factor in safety-oriented industries such as air traffic control (ATC). However, little is known about the factors leading to human errors in current air traffic management (ATM) systems. The first s...
-
Goodyear, Kimberly; Parasuraman, Raja; Chernyak, Sergey; de Visser, Ewart; Madhavan, Poornima; Deshpande, Gopikrishna; Krueger, Frank
2017-10-01
As society becomes more reliant on machines and automation, understanding how people utilize advice is a necessary endeavor. Our objective was to reveal the underlying neural associations during advice utilization from expert human and machine agents with fMRI and multivariate Granger causality analysis. During an X-ray luggage-screening task, participants accepted or rejected good or bad advice from either the human or machine agent framed as experts with manipulated reliability (high miss rate). We showed that the machine-agent group decreased their advice utilization compared to the human-agent group and these differences in behaviors during advice utilization could be accounted for by high expectations of reliable advice and changes in attention allocation due to miss errors. Brain areas involved with the salience and mentalizing networks, as well as sensory processing involved with attention, were recruited during the task and the advice utilization network consisted of attentional modulation of sensory information with the lingual gyrus as the driver during the decision phase and the fusiform gyrus as the driver during the feedback phase. Our findings expand on the existing literature by showing that misses degrade advice utilization, which is represented in a neural network involving salience detection and self-processing with perceptual integration.
-
Avoiding Human Error in Mission Operations: Cassini Flight Experience
NASA Technical Reports Server (NTRS)
Burk, Thomas A.
2012-01-01
Operating spacecraft is a never-ending challenge and the risk of human error is ever- present. Many missions have been significantly affected by human error on the part of ground controllers. The Cassini mission at Saturn has not been immune to human error, but Cassini operations engineers use tools and follow processes that find and correct most human errors before they reach the spacecraft. What is needed are skilled engineers with good technical knowledge, good interpersonal communications, quality ground software, regular peer reviews, up-to-date procedures, as well as careful attention to detail and the discipline to test and verify all commands that will be sent to the spacecraft. Two areas of special concern are changes to flight software and response to in-flight anomalies. The Cassini team has a lot of practical experience in all these areas and they have found that well-trained engineers with good tools who follow clear procedures can catch most errors before they get into command sequences to be sent to the spacecraft. Finally, having a robust and fault-tolerant spacecraft that allows ground controllers excellent visibility of its condition is the most important way to ensure human error does not compromise the mission.
-
Brennan, Peter A; Mitchell, David A; Holmes, Simon; Plint, Simon; Parry, David
2016-01-01
Human error is as old as humanity itself and is an appreciable cause of mistakes by both organisations and people. Much of the work related to human factors in causing error has originated from aviation where mistakes can be catastrophic not only for those who contribute to the error, but for passengers as well. The role of human error in medical and surgical incidents, which are often multifactorial, is becoming better understood, and includes both organisational issues (by the employer) and potential human factors (at a personal level). Mistakes as a result of individual human factors and surgical teams should be better recognised and emphasised. Attitudes and acceptance of preoperative briefing has improved since the introduction of the World Health Organization (WHO) surgical checklist. However, this does not address limitations or other safety concerns that are related to performance, such as stress and fatigue, emotional state, hunger, awareness of what is going on situational awareness, and other factors that could potentially lead to error. Here we attempt to raise awareness of these human factors, and highlight how they can lead to error, and how they can be minimised in our day-to-day practice. Can hospitals move from being "high risk industries" to "high reliability organisations"? Copyright © 2015 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
-
Using a Delphi Method to Identify Human Factors Contributing to Nursing Errors.
Roth, Cheryl; Brewer, Melanie; Wieck, K Lynn
2017-07-01
The purpose of this study was to identify human factors associated with nursing errors. Using a Delphi technique, this study used feedback from a panel of nurse experts (n = 25) on an initial qualitative survey questionnaire followed by summarizing the results with feedback and confirmation. Synthesized factors regarding causes of errors were incorporated into a quantitative Likert-type scale, and the original expert panel participants were queried a second time to validate responses. The list identified 24 items as most common causes of nursing errors, including swamping and errors made by others that nurses are expected to recognize and fix. The responses provided a consensus top 10 errors list based on means with heavy workload and fatigue at the top of the list. The use of the Delphi survey established consensus and developed a platform upon which future study of nursing errors can evolve as a link to future solutions. This list of human factors in nursing errors should serve to stimulate dialogue among nurses about how to prevent errors and improve outcomes. Human and system failures have been the subject of an abundance of research, yet nursing errors continue to occur. © 2016 Wiley Periodicals, Inc.
-
DOE Office of Scientific and Technical Information (OSTI.GOV)
Lon N. Haney; David I. Gertman
2003-04-01
Beginning in the 1980s a primary focus of human reliability analysis was estimation of human error probabilities. However, detailed qualitative modeling with comprehensive representation of contextual variables often was lacking. This was likely due to the lack of comprehensive error and performance shaping factor taxonomies, and the limited data available on observed error rates and their relationship to specific contextual variables. In the mid 90s Boeing, America West Airlines, NASA Ames Research Center and INEEL partnered in a NASA sponsored Advanced Concepts grant to: assess the state of the art in human error analysis, identify future needs for human errormore » analysis, and develop an approach addressing these needs. Identified needs included the need for a method to identify and prioritize task and contextual characteristics affecting human reliability. Other needs identified included developing comprehensive taxonomies to support detailed qualitative modeling and to structure meaningful data collection efforts across domains. A result was the development of the FRamework Assessing Notorious Contributing Influences for Error (FRANCIE) with a taxonomy for airline maintenance tasks. The assignment of performance shaping factors to generic errors by experts proved to be valuable to qualitative modeling. Performance shaping factors and error types from such detailed approaches can be used to structure error reporting schemes. In a recent NASA Advanced Human Support Technology grant FRANCIE was refined, and two new taxonomies for use on space missions were developed. The development, sharing, and use of error taxonomies, and the refinement of approaches for increased fidelity of qualitative modeling is offered as a means to help direct useful data collection strategies.« less
-
Who Believes in the Storybook Image of the Scientist?
Veldkamp, Coosje L S; Hartgerink, Chris H J; van Assen, Marcel A L M; Wicherts, Jelte M
2017-01-01
Do lay people and scientists themselves recognize that scientists are human and therefore prone to human fallibilities such as error, bias, and even dishonesty? In a series of three experimental studies and one correlational study (total N = 3,278) we found that the "storybook image of the scientist" is pervasive: American lay people and scientists from over 60 countries attributed considerably more objectivity, rationality, open-mindedness, intelligence, integrity, and communality to scientists than to other highly-educated people. Moreover, scientists perceived even larger differences than lay people did. Some groups of scientists also differentiated between different categories of scientists: established scientists attributed higher levels of the scientific traits to established scientists than to early-career scientists and Ph.D. students, and higher levels to Ph.D. students than to early-career scientists. Female scientists attributed considerably higher levels of the scientific traits to female scientists than to male scientists. A strong belief in the storybook image and the (human) tendency to attribute higher levels of desirable traits to people in one's own group than to people in other groups may decrease scientists' willingness to adopt recently proposed practices to reduce error, bias and dishonesty in science.
-
Who Believes in the Storybook Image of the Scientist?
Veldkamp, Coosje L. S.; Hartgerink, Chris H. J.; van Assen, Marcel A. L. M.; Wicherts, Jelte M.
2017-01-01
ABSTRACT Do lay people and scientists themselves recognize that scientists are human and therefore prone to human fallibilities such as error, bias, and even dishonesty? In a series of three experimental studies and one correlational study (total N = 3,278) we found that the “storybook image of the scientist” is pervasive: American lay people and scientists from over 60 countries attributed considerably more objectivity, rationality, open-mindedness, intelligence, integrity, and communality to scientists than to other highly-educated people. Moreover, scientists perceived even larger differences than lay people did. Some groups of scientists also differentiated between different categories of scientists: established scientists attributed higher levels of the scientific traits to established scientists than to early-career scientists and Ph.D. students, and higher levels to Ph.D. students than to early-career scientists. Female scientists attributed considerably higher levels of the scientific traits to female scientists than to male scientists. A strong belief in the storybook image and the (human) tendency to attribute higher levels of desirable traits to people in one’s own group than to people in other groups may decrease scientists’ willingness to adopt recently proposed practices to reduce error, bias and dishonesty in science. PMID:28001440
-
Changes in medical errors after implementation of a handoff program.
Starmer, Amy J; Spector, Nancy D; Srivastava, Rajendu; West, Daniel C; Rosenbluth, Glenn; Allen, April D; Noble, Elizabeth L; Tse, Lisa L; Dalal, Anuj K; Keohane, Carol A; Lipsitz, Stuart R; Rothschild, Jeffrey M; Wien, Matthew F; Yoon, Catherine S; Zigmont, Katherine R; Wilson, Karen M; O'Toole, Jennifer K; Solan, Lauren G; Aylor, Megan; Bismilla, Zia; Coffey, Maitreya; Mahant, Sanjay; Blankenburg, Rebecca L; Destino, Lauren A; Everhart, Jennifer L; Patel, Shilpa J; Bale, James F; Spackman, Jaime B; Stevenson, Adam T; Calaman, Sharon; Cole, F Sessions; Balmer, Dorene F; Hepps, Jennifer H; Lopreiato, Joseph O; Yu, Clifton E; Sectish, Theodore C; Landrigan, Christopher P
2014-11-06
Miscommunications are a leading cause of serious medical errors. Data from multicenter studies assessing programs designed to improve handoff of information about patient care are lacking. We conducted a prospective intervention study of a resident handoff-improvement program in nine hospitals, measuring rates of medical errors, preventable adverse events, and miscommunications, as well as resident workflow. The intervention included a mnemonic to standardize oral and written handoffs, handoff and communication training, a faculty development and observation program, and a sustainability campaign. Error rates were measured through active surveillance. Handoffs were assessed by means of evaluation of printed handoff documents and audio recordings. Workflow was assessed through time-motion observations. The primary outcome had two components: medical errors and preventable adverse events. In 10,740 patient admissions, the medical-error rate decreased by 23% from the preintervention period to the postintervention period (24.5 vs. 18.8 per 100 admissions, P<0.001), and the rate of preventable adverse events decreased by 30% (4.7 vs. 3.3 events per 100 admissions, P<0.001). The rate of nonpreventable adverse events did not change significantly (3.0 and 2.8 events per 100 admissions, P=0.79). Site-level analyses showed significant error reductions at six of nine sites. Across sites, significant increases were observed in the inclusion of all prespecified key elements in written documents and oral communication during handoff (nine written and five oral elements; P<0.001 for all 14 comparisons). There were no significant changes from the preintervention period to the postintervention period in the duration of oral handoffs (2.4 and 2.5 minutes per patient, respectively; P=0.55) or in resident workflow, including patient-family contact and computer time. Implementation of the handoff program was associated with reductions in medical errors and in preventable adverse events and with improvements in communication, without a negative effect on workflow. (Funded by the Office of the Assistant Secretary for Planning and Evaluation, U.S. Department of Health and Human Services, and others.).
-
Remembering Places in Space: A Human Analog Study of the Morris Water Maze
NASA Astrophysics Data System (ADS)
Fitting, Sylvia; Allen, Gary L.; Wedell, Douglas H.
We conducted a human analog study of the Morris Water Maze, with individuals indicating a remembered location in a 3 m diameter arena over different intervals of time and with different memory loads. The primary focus of the study was to test a theory of how varying cue location and number of cues affects memory for spatial location. As expected, memory performance, as measured by proximity to the actual location, was negatively affected by increasing memory load, increasing delay interval, and decreasing the number of cues. As memory performance decremented, bias effects increased and were in accordance with the cue-based memory model described by Fitting, Wedell and Allen (2005). Specifically, remembered locations were biased toward the nearest cue and error decreased with more cues. These results demonstrate that localization processes that apply to small two-dimensional task fields may generalize to a larger traversable task field.
-
Analysis of measured data of human body based on error correcting frequency
NASA Astrophysics Data System (ADS)
Jin, Aiyan; Peipei, Gao; Shang, Xiaomei
2014-04-01
Anthropometry is to measure all parts of human body surface, and the measured data is the basis of analysis and study of the human body, establishment and modification of garment size and formulation and implementation of online clothing store. In this paper, several groups of the measured data are gained, and analysis of data error is gotten by analyzing the error frequency and using analysis of variance method in mathematical statistics method. Determination of the measured data accuracy and the difficulty of measured parts of human body, further studies of the causes of data errors, and summarization of the key points to minimize errors possibly are also mentioned in the paper. This paper analyses the measured data based on error frequency, and in a way , it provides certain reference elements to promote the garment industry development.
-
The effects of center of rotation errors on cardiac SPECT imaging
NASA Astrophysics Data System (ADS)
Bai, Chuanyong; Shao, Ling; Ye, Jinghan; Durbin, M.
2003-10-01
In SPECT imaging, center of rotation (COR) errors lead to the misalignment of projection data and can potentially degrade the quality of the reconstructed images. In this work, we study the effects of COR errors on cardiac SPECT imaging using simulation, point source, cardiac phantom, and patient studies. For simulation studies, we generate projection data using a uniform MCAT phantom first without modeling any physical effects (NPH), then with the modeling of detector response effect (DR) alone. We then corrupt the projection data with simulated sinusoid and step COR errors. For other studies, we introduce sinusoid COR errors to projection data acquired on SPECT systems. An OSEM algorithm is used for image reconstruction without detector response correction, but with nonuniform attenuation correction when needed. The simulation studies show that, when COR errors increase from 0 to 0.96 cm: 1) sinusoid COR errors in axial direction lead to intensity decrease in the inferoapical region; 2) step COR errors in axial direction lead to intensity decrease in the distal anterior region. The intensity decrease is more severe in images reconstructed from projection data with NPH than with DR; and 3) the effects of COR errors in transaxial direction seem to be insignificant. In other studies, COR errors slightly degrade point source resolution; COR errors of 0.64 cm or above introduce visible but insignificant nonuniformity in the images of uniform cardiac phantom; COR errors up to 0.96 cm in transaxial direction affect the lesion-to-background contrast (LBC) insignificantly in the images of cardiac phantom with defects, and COR errors up to 0.64 cm in axial direction only slightly decrease the LBC. For the patient studies with COR errors up to 0.96 cm, images have the same diagnostic/prognostic values as those without COR errors. This work suggests that COR errors of up to 0.64 cm are not likely to change the clinical applications of cardiac SPECT imaging when using iterative reconstruction algorithm without detector response correction.
-
Tailoring a Human Reliability Analysis to Your Industry Needs
NASA Technical Reports Server (NTRS)
DeMott, D. L.
2016-01-01
Companies at risk of accidents caused by human error that result in catastrophic consequences include: airline industry mishaps, medical malpractice, medication mistakes, aerospace failures, major oil spills, transportation mishaps, power production failures and manufacturing facility incidents. Human Reliability Assessment (HRA) is used to analyze the inherent risk of human behavior or actions introducing errors into the operation of a system or process. These assessments can be used to identify where errors are most likely to arise and the potential risks involved if they do occur. Using the basic concepts of HRA, an evolving group of methodologies are used to meet various industry needs. Determining which methodology or combination of techniques will provide a quality human reliability assessment is a key element to developing effective strategies for understanding and dealing with risks caused by human errors. There are a number of concerns and difficulties in "tailoring" a Human Reliability Assessment (HRA) for different industries. Although a variety of HRA methodologies are available to analyze human error events, determining the most appropriate tools to provide the most useful results can depend on industry specific cultures and requirements. Methodology selection may be based on a variety of factors that include: 1) how people act and react in different industries, 2) expectations based on industry standards, 3) factors that influence how the human errors could occur such as tasks, tools, environment, workplace, support, training and procedure, 4) type and availability of data, 5) how the industry views risk & reliability, and 6) types of emergencies, contingencies and routine tasks. Other considerations for methodology selection should be based on what information is needed from the assessment. If the principal concern is determination of the primary risk factors contributing to the potential human error, a more detailed analysis method may be employed versus a requirement to provide a numerical value as part of a probabilistic risk assessment. Industries involved with humans operating large equipment or transport systems (ex. railroads or airlines) would have more need to address the man machine interface than medical workers administering medications. Human error occurs in every industry; in most cases the consequences are relatively benign and occasionally beneficial. In cases where the results can have disastrous consequences, the use of Human Reliability techniques to identify and classify the risk of human errors allows a company more opportunities to mitigate or eliminate these types of risks and prevent costly tragedies.
-
Polμ tumor variants decrease the efficiency and accuracy of NHEJ
Sastre-Moreno, Guillermo; Pryor, John M.; Díaz-Talavera, Alberto; Ruiz, José F.; Ramsden, Dale A.
2017-01-01
Abstract The non homologous end-joining (NHEJ) pathway of double-strand break (DSB) repair often requires DNA synthesis to fill the gaps generated upon alignment of the broken ends, a complex task performed in human cells by two specialized DNA polymerases, Polλ and Polμ. It is now well established that Polμ is the one adapted to repair DSBs with non-complementary ends, the most challenging scenario, although the structural basis and physiological implications of this adaptation are not fully understood. Here, we demonstrate that two human Polμ point mutations, G174S and R175H, previously identified in two different tumor samples and affecting two adjacent residues, limit the efficiency of accurate NHEJ by Polμ in vitro and in vivo. Moreover, we show that this limitation is the consequence of a decreased template dependency during NHEJ, which renders the error-rate of the mutants higher due to the ability of Polμ to randomly incorporate nucleotides at DSBs. These results highlight the relevance of the 8 kDa domain of Polμ for accurate and efficient NHEJ, but also its contribution to the error-prone behavior of Polμ at 2-nt gaps. This work provides the first demonstration that mutations affecting Polμ identified in tumors can alter the efficiency and fidelity of NHEJ. PMID:28973441
-
Using APEX to Model Anticipated Human Error: Analysis of a GPS Navigational Aid
NASA Technical Reports Server (NTRS)
VanSelst, Mark; Freed, Michael; Shefto, Michael (Technical Monitor)
1997-01-01
The interface development process can be dramatically improved by predicting design facilitated human error at an early stage in the design process. The approach we advocate is to SIMULATE the behavior of a human agent carrying out tasks with a well-specified user interface, ANALYZE the simulation for instances of human error, and then REFINE the interface or protocol to minimize predicted error. This approach, incorporated into the APEX modeling architecture, differs from past approaches to human simulation in Its emphasis on error rather than e.g. learning rate or speed of response. The APEX model consists of two major components: (1) a powerful action selection component capable of simulating behavior in complex, multiple-task environments; and (2) a resource architecture which constrains cognitive, perceptual, and motor capabilities to within empirically demonstrated limits. The model mimics human errors arising from interactions between limited human resources and elements of the computer interface whose design falls to anticipate those limits. We analyze the design of a hand-held Global Positioning System (GPS) device used for radical and navigational decisions in small yacht recalls. The analysis demonstrates how human system modeling can be an effective design aid, helping to accelerate the process of refining a product (or procedure).
-
Hooper, Brionny J; O'Hare, David P A
2013-08-01
Human error classification systems theoretically allow researchers to analyze postaccident data in an objective and consistent manner. The Human Factors Analysis and Classification System (HFACS) framework is one such practical analysis tool that has been widely used to classify human error in aviation. The Cognitive Error Taxonomy (CET) is another. It has been postulated that the focus on interrelationships within HFACS can facilitate the identification of the underlying causes of pilot error. The CET provides increased granularity at the level of unsafe acts. The aim was to analyze the influence of factors at higher organizational levels on the unsafe acts of front-line operators and to compare the errors of fixed-wing and rotary-wing operations. This study analyzed 288 aircraft incidents involving human error from an Australasian military organization occurring between 2001 and 2008. Action errors accounted for almost twice (44%) the proportion of rotary wing compared to fixed wing (23%) incidents. Both classificatory systems showed significant relationships between precursor factors such as the physical environment, mental and physiological states, crew resource management, training and personal readiness, and skill-based, but not decision-based, acts. The CET analysis showed different predisposing factors for different aspects of skill-based behaviors. Skill-based errors in military operations are more prevalent in rotary wing incidents and are related to higher level supervisory processes in the organization. The Cognitive Error Taxonomy provides increased granularity to HFACS analyses of unsafe acts.
-
Uy, Raymonde Charles Y.; Kury, Fabricio P.; Fontelo, Paul A.
2015-01-01
The standard of safe medication practice requires strict observance of the five rights of medication administration: the right patient, drug, time, dose, and route. Despite adherence to these guidelines, medication errors remain a public health concern that has generated health policies and hospital processes that leverage automation and computerization to reduce these errors. Bar code, RFID, biometrics and pharmacy automation technologies have been demonstrated in literature to decrease the incidence of medication errors by minimizing human factors involved in the process. Despite evidence suggesting the effectivity of these technologies, adoption rates and trends vary across hospital systems. The objective of study is to examine the state and adoption trends of automatic identification and data capture (AIDC) methods and pharmacy automation technologies in U.S. hospitals. A retrospective descriptive analysis of survey data from the HIMSS Analytics® Database was done, demonstrating an optimistic growth in the adoption of these patient safety solutions. PMID:26958264
-
Flight-deck automation - Promises and problems
NASA Technical Reports Server (NTRS)
Wiener, E. L.; Curry, R. E.
1980-01-01
The paper analyzes the role of human factors in flight-deck automation, identifies problem areas, and suggests design guidelines. Flight-deck automation using microprocessor technology and display systems improves performance and safety while leading to a decrease in size, cost, and power consumption. On the other hand negative factors such as failure of automatic equipment, automation-induced error compounded by crew error, crew error in equipment set-up, failure to heed automatic alarms, and loss of proficiency must also be taken into account. Among the problem areas discussed are automation of control tasks, monitoring of complex systems, psychosocial aspects of automation, and alerting and warning systems. Guidelines are suggested for designing, utilising, and improving control and monitoring systems. Investigation into flight-deck automation systems is important as the knowledge gained can be applied to other systems such as air traffic control and nuclear power generation, but the many problems encountered with automated systems need to be analyzed and overcome in future research.
-
Liu, Hsiu-Chu; Li, Hsing; Chang, Hsin-Fei; Lu, Mei-Rou; Chen, Feng-Chuan
2015-01-01
Learning from the experience of another medical center in Taiwan, Kaohsiung Municipal Kai-Suan Psychiatric Hospital has changed the nursing informatics system step by step in the past year and a half . We considered ethics in the original idea of implementing barcodes on the test tube labels to process the identification of the psychiatric patients. The main aims of this project are to maintain the confidential information and to transport the sample effectively. The primary nurses had been using different work sheets for this project to ensure the acceptance of the new barcode system. In the past two years the errors in the blood testing process were as high as 11,000 in 14,000 events per year, resulting in wastage of resources. The actions taken by the nurses and the new barcode system implementation can improve the clinical nursing care quality, safety of the patients, and efficiency, while decreasing the cost due to the human error.
-
Image based Monte Carlo Modeling for Computational Phantom
NASA Astrophysics Data System (ADS)
Cheng, Mengyun; Wang, Wen; Zhao, Kai; Fan, Yanchang; Long, Pengcheng; Wu, Yican
2014-06-01
The evaluation on the effects of ionizing radiation and the risk of radiation exposure on human body has been becoming one of the most important issues for radiation protection and radiotherapy fields, which is helpful to avoid unnecessary radiation and decrease harm to human body. In order to accurately evaluate the dose on human body, it is necessary to construct more realistic computational phantom. However, manual description and verfication of the models for Monte carlo(MC)simulation are very tedious, error-prone and time-consuming. In addiation, it is difficult to locate and fix the geometry error, and difficult to describe material information and assign it to cells. MCAM (CAD/Image-based Automatic Modeling Program for Neutronics and Radiation Transport Simulation) was developed as an interface program to achieve both CAD- and image-based automatic modeling by FDS Team (Advanced Nuclear Energy Research Team, http://www.fds.org.cn). The advanced version (Version 6) of MCAM can achieve automatic conversion from CT/segmented sectioned images to computational phantoms such as MCNP models. Imaged-based automatic modeling program(MCAM6.0) has been tested by several medical images and sectioned images. And it has been applied in the construction of Rad-HUMAN. Following manual segmentation and 3D reconstruction, a whole-body computational phantom of Chinese adult female called Rad-HUMAN was created by using MCAM6.0 from sectioned images of a Chinese visible human dataset. Rad-HUMAN contains 46 organs/tissues, which faithfully represented the average anatomical characteristics of the Chinese female. The dose conversion coefficients(Dt/Ka) from kerma free-in-air to absorbed dose of Rad-HUMAN were calculated. Rad-HUMAN can be applied to predict and evaluate dose distributions in the Treatment Plan System (TPS), as well as radiation exposure for human body in radiation protection.
-
Hughes, Charmayne M L; Baber, Chris; Bienkiewicz, Marta; Worthington, Andrew; Hazell, Alexa; Hermsdörfer, Joachim
2015-01-01
Approximately 33% of stroke patients have difficulty performing activities of daily living, often committing errors during the planning and execution of such activities. The objective of this study was to evaluate the ability of the human error identification (HEI) technique SHERPA (Systematic Human Error Reduction and Prediction Approach) to predict errors during the performance of daily activities in stroke patients with left and right hemisphere lesions. Using SHERPA we successfully predicted 36 of the 38 observed errors, with analysis indicating that the proportion of predicted and observed errors was similar for all sub-tasks and severity levels. HEI results were used to develop compensatory cognitive strategies that clinicians could employ to reduce or prevent errors from occurring. This study provides evidence for the reliability and validity of SHERPA in the design of cognitive rehabilitation strategies in stroke populations.
-
Discriminative echolocation in a porpoise, 12
Turner, Ronald N.; Norris, Kenneth S.
1966-01-01
Operant conditioning techniques were used to establish a discriminative echolocation performance in a porpoise. Pairs of spheres of disparate diameters were presented in an under-water display, and the positions of the spheres were switched according to a scrambled sequence while the blindfolded porpoise responded on a pair of submerged response levers. Responses which identified the momentary state of the display were food-reinforced, while those which did not (errors) produced time out. Errors were then studied in relation to decreased disparity between the spheres. As disparity was decreased, errors which terminated runs of correct responses occurred more frequently and were followed by longer strings of consecutive errors. Increased errors and disruption of a stable pattern of collateral behavior were associated. Since some sources of error other than decreased disparity were present, the porpoise's final performance did not fully reflect the acuity of its echolocation channel. PMID:5964509
-
2010-03-15
Swiss cheese model of human error causation. ................................................................... 3 2. Results for the classification of...based on Reason’s “ Swiss cheese ” model of human error (1990). Figure 1 describes how an accident is likely to occur when all of the errors, or “holes...align. A detailed description of HFACS can be found in Wiegmann and Shappell (2003). Figure 1. The Swiss cheese model of human error
-
Impedance modulation and feedback corrections in tracking targets of variable size and frequency.
Selen, Luc P J; van Dieën, Jaap H; Beek, Peter J
2006-11-01
Humans are able to adjust the accuracy of their movements to the demands posed by the task at hand. The variability in task execution caused by the inherent noisiness of the neuromuscular system can be tuned to task demands by both feedforward (e.g., impedance modulation) and feedback mechanisms. In this experiment, we studied both mechanisms, using mechanical perturbations to estimate stiffness and damping as indices of impedance modulation and submovement scaling as an index of feedback driven corrections. Eight subjects tracked three differently sized targets (0.0135, 0.0270, and 0.0405 rad) moving at three different frequencies (0.20, 0.25, and 0.33 Hz). Movement variability decreased with both decreasing target size and movement frequency, whereas stiffness and damping increased with decreasing target size, independent of movement frequency. These results are consistent with the theory that mechanical impedance acts as a filter of noisy neuromuscular signals but challenge stochastic theories of motor control that do not account for impedance modulation and only partially for feedback control. Submovements during unperturbed cycles were quantified in terms of their gain, i.e., the slope between their duration and amplitude in the speed profile. Submovement gain decreased with decreasing movement frequency and increasing target size. The results were interpreted to imply that submovement gain is related to observed tracking errors and that those tracking errors are expressed in units of target size. We conclude that impedance and submovement gain modulation contribute additively to tracking accuracy.
-
Individual differences in conflict detection during reasoning.
Frey, Darren; Johnson, Eric D; De Neys, Wim
2018-05-01
Decades of reasoning and decision-making research have established that human judgment is often biased by intuitive heuristics. Recent "error" or bias detection studies have focused on reasoners' abilities to detect whether their heuristic answer conflicts with logical or probabilistic principles. A key open question is whether there are individual differences in this bias detection efficiency. Here we present three studies in which co-registration of different error detection measures (confidence, response time and confidence response time) allowed us to assess bias detection sensitivity at the individual participant level in a range of reasoning tasks. The results indicate that although most individuals show robust bias detection, as indexed by increased latencies and decreased confidence, there is a subgroup of reasoners who consistently fail to do so. We discuss theoretical and practical implications for the field.
-
Human errors and measurement uncertainty
NASA Astrophysics Data System (ADS)
Kuselman, Ilya; Pennecchi, Francesca
2015-04-01
Evaluating the residual risk of human errors in a measurement and testing laboratory, remaining after the error reduction by the laboratory quality system, and quantifying the consequences of this risk for the quality of the measurement/test results are discussed based on expert judgments and Monte Carlo simulations. A procedure for evaluation of the contribution of the residual risk to the measurement uncertainty budget is proposed. Examples are provided using earlier published sets of expert judgments on human errors in pH measurement of groundwater, elemental analysis of geological samples by inductively coupled plasma mass spectrometry, and multi-residue analysis of pesticides in fruits and vegetables. The human error contribution to the measurement uncertainty budget in the examples was not negligible, yet also not dominant. This was assessed as a good risk management result.
-
Longitudinal Growth Curves of Brain Function Underlying Inhibitory Control through Adolescence
Foran, William; Velanova, Katerina; Luna, Beatriz
2013-01-01
Neuroimaging studies suggest that developmental improvements in inhibitory control are primarily supported by changes in prefrontal executive function. However, studies are contradictory with respect to how activation in prefrontal regions changes with age, and they have yet to analyze longitudinal data using growth curve modeling, which allows characterization of dynamic processes of developmental change, individual differences in growth trajectories, and variables that predict any interindividual variability in trajectories. In this study, we present growth curves modeled from longitudinal fMRI data collected over 302 visits (across ages 9 to 26 years) from 123 human participants. Brain regions within circuits known to support motor response control, executive control, and error processing (i.e., aspects of inhibitory control) were investigated. Findings revealed distinct developmental trajectories for regions within each circuit and indicated that a hierarchical pattern of maturation of brain activation supports the gradual emergence of adult-like inhibitory control. Mean growth curves of activation in motor response control regions revealed no changes with age, although interindividual variability decreased with development, indicating equifinality with maturity. Activation in certain executive control regions decreased with age until adolescence, and variability was stable across development. Error-processing activation in the dorsal anterior cingulate cortex showed continued increases into adulthood and no significant interindividual variability across development, and was uniquely associated with task performance. These findings provide evidence that continued maturation of error-processing abilities supports the protracted development of inhibitory control over adolescence, while motor response control regions provide early-maturing foundational capacities and suggest that some executive control regions may buttress immature networks as error processing continues to mature. PMID:24227721
-
DOE Office of Scientific and Technical Information (OSTI.GOV)
Callan, J.R.; Kelly, R.T.; Quinn, M.L.
1995-05-01
Remote Afterloading Brachytherapy (RAB) is a medical process used in the treatment of cancer. RAB uses a computer-controlled device to remotely insert and remove radioactive sources close to a target (or tumor) in the body. Some RAB problems affecting the radiation dose to the patient have been reported and attributed to human error. To determine the root cause of human error in the RAB system, a human factors team visited 23 RAB treatment sites in the US The team observed RAB treatment planning and delivery, interviewed RAB personnel, and performed walk-throughs, during which staff demonstrated the procedures and practices usedmore » in performing RAB tasks. Factors leading to human error in the RAB system were identified. The impact of those factors on the performance of RAB was then evaluated and prioritized in terms of safety significance. Finally, the project identified and evaluated alternative approaches for resolving the safety significant problems related to human error.« less
-
DOT National Transportation Integrated Search
2001-02-01
The Human Factors Analysis and Classification System (HFACS) is a general human error framework : originally developed and tested within the U.S. military as a tool for investigating and analyzing the human : causes of aviation accidents. Based upon ...
-
Kim, Myoung-Soo; Kim, Jung-Soon; Jung, In Sook; Kim, Young Hae; Kim, Ho Jung
2007-03-01
The purpose of this study was to develop and evaluate an error reporting promoting program(ERPP) to systematically reduce the incidence rate of nursing errors in operating room. A non-equivalent control group non-synchronized design was used. Twenty-six operating room nurses who were in one university hospital in Busan participated in this study. They were stratified into four groups according to their operating room experience and were allocated to the experimental and control groups using a matching method. Mann-Whitney U Test was used to analyze the differences pre and post incidence rates of nursing errors between the two groups. The incidence rate of nursing errors decreased significantly in the experimental group compared to the pre-test score from 28.4% to 15.7%. The incidence rate by domains, it decreased significantly in the 3 domains-"compliance of aseptic technique", "management of document", "environmental management" in the experimental group while it decreased in the control group which was applied ordinary error-reporting method. Error-reporting system can make possible to hold the errors in common and to learn from them. ERPP was effective to reduce the errors of recognition-related nursing activities. For the wake of more effective error-prevention, we will be better to apply effort of risk management along the whole health care system with this program.
-
Diagnostic decision-making and strategies to improve diagnosis.
Thammasitboon, Satid; Cutrer, William B
2013-10-01
A significant portion of diagnostic errors arises through cognitive errors resulting from inadequate knowledge, faulty data gathering, and/or faulty verification. Experts estimate that 75% of diagnostic failures can be attributed to clinician diagnostic thinking failure. The cognitive processes that underlie diagnostic thinking of clinicians are complex and intriguing, and it is imperative that clinicians acquire explicit appreciation and application of different cognitive approaches to make decisions better. A dual-process model that unifies many theories of decision-making has emerged as a promising template for understanding how clinicians think and judge efficiently in a diagnostic reasoning process. The identification and implementation of strategies for decreasing or preventing such diagnostic errors has become a growing area of interest and research. Suggested strategies to decrease diagnostic error incidence include increasing clinician's clinical expertise and avoiding inherent cognitive errors to make decisions better. Implementing Interventions focused solely on avoiding errors may work effectively for patient safety issues such as medication errors. Addressing cognitive errors, however, requires equal effort on expanding the individual clinician's expertise. Providing cognitive support to clinicians for robust diagnostic decision-making serves as the final strategic target for decreasing diagnostic errors. Clinical guidelines and algorithms offer another method for streamlining decision-making and decreasing likelihood of cognitive diagnostic errors. Addressing cognitive processing errors is undeniably the most challenging task in reducing diagnostic errors. While many suggested approaches exist, they are mostly based on theories and sciences in cognitive psychology, decision-making, and education. The proposed interventions are primarily suggestions and very few of them have been tested in the actual practice settings. Collaborative research effort is required to effectively address cognitive processing errors. Researchers in various areas, including patient safety/quality improvement, decision-making, and problem solving, must work together to make medical diagnosis more reliable. © 2013 Mosby, Inc. All rights reserved.
-
Doerry, Armin W.; Heard, Freddie E.; Cordaro, J. Thomas
2010-07-20
Motion measurement errors that extend beyond the range resolution of a synthetic aperture radar (SAR) can be corrected by effectively decreasing the range resolution of the SAR in order to permit measurement of the error. Range profiles can be compared across the slow-time dimension of the input data in order to estimate the error. Once the error has been determined, appropriate frequency and phase correction can be applied to the uncompressed input data, after which range and azimuth compression can be performed to produce a desired SAR image.
-
Murtazina, E P
2015-01-01
Investigation of the processes of studying human instructions relevant follow-up in terms of systemic mechanisms of learning and memory processes, and moreover affects such a fundamental issue as psychophysiology focused attention, understanding the meaning of the information provided and the formation of social motivation in human activities. Analysis of heart rate variability in reading the instructions compared to the initial state of operational rest showed that this stage of the activity causes pronounced emotional stress, which is manifested in increased heart rate, decrease in variability and pronounced changes in the spectral characteristics of heart rate. Besides, it was revealed that heart rate variability in a state of operational rest before testing, and in the process of reading instructions positively correlated with the duration of the instruction reading and inversely correlated with effectiveness and the level of resistance of the subjects to the error after error when follow-up activities. Showing pronounced gender differences in the relationships between changes in the variability of heart rate when reading the instructions and the subsequent execution indicators of visual-motor test.
-
Dispensing error rate after implementation of an automated pharmacy carousel system.
Oswald, Scott; Caldwell, Richard
2007-07-01
A study was conducted to determine filling and dispensing error rates before and after the implementation of an automated pharmacy carousel system (APCS). The study was conducted in a 613-bed acute and tertiary care university hospital. Before the implementation of the APCS, filling and dispensing rates were recorded during October through November 2004 and January 2005. Postimplementation data were collected during May through June 2006. Errors were recorded in three areas of pharmacy operations: first-dose or missing medication fill, automated dispensing cabinet fill, and interdepartmental request fill. A filling error was defined as an error caught by a pharmacist during the verification step. A dispensing error was defined as an error caught by a pharmacist observer after verification by the pharmacist. Before implementation of the APCS, 422 first-dose or missing medication orders were observed between October 2004 and January 2005. Independent data collected in December 2005, approximately six weeks after the introduction of the APCS, found that filling and error rates had increased. The filling rate for automated dispensing cabinets was associated with the largest decrease in errors. Filling and dispensing error rates had decreased by December 2005. In terms of interdepartmental request fill, no dispensing errors were noted in 123 clinic orders dispensed before the implementation of the APCS. One dispensing error out of 85 clinic orders was identified after implementation of the APCS. The implementation of an APCS at a university hospital decreased medication filling errors related to automated cabinets only and did not affect other filling and dispensing errors.
-
Compound Stimulus Presentation Does Not Deepen Extinction in Human Causal Learning
Griffiths, Oren; Holmes, Nathan; Westbrook, R. Fred
2017-01-01
Models of associative learning have proposed that cue-outcome learning critically depends on the degree of prediction error encountered during training. Two experiments examined the role of error-driven extinction learning in a human causal learning task. Target cues underwent extinction in the presence of additional cues, which differed in the degree to which they predicted the outcome, thereby manipulating outcome expectancy and, in the absence of any change in reinforcement, prediction error. These prediction error manipulations have each been shown to modulate extinction learning in aversive conditioning studies. While both manipulations resulted in increased prediction error during training, neither enhanced extinction in the present human learning task (one manipulation resulted in less extinction at test). The results are discussed with reference to the types of associations that are regulated by prediction error, the types of error terms involved in their regulation, and how these interact with parameters involved in training. PMID:28232809
-
Mental rotation of primate hands: human-likeness and thumb saliency.
Bläsing, Bettina; de Castro Campos, Marcella; Schack, Thomas; Brugger, Peter
2012-08-01
Mental rotation of human hands has been found to differ essentially from mental rotation of objects in such a way that reaction times and error rates of handedness judgements are influenced by the comfort and familiarity of the presented hand postures. To investigate the role of the similarity of the presented hands to the participant's own hand, we used different primates' hands as stimuli in a mental rotation task. Five out of 24 primate hands were chosen for their ratings in human-likeness and saliency of the thumb according to a questionnaire study and presented in two mental rotation experiments; in the second experiment, they were modified in such a way that all hands appeared thumbless. Results of both experiments revealed effects of species and orientation on reaction times, and an interaction between species and hand side occurred in the second experiment. In the first experiment, the thumbless Colobus hand differed from all other hands, showing the highest reaction times and error rates and failing to show the expected medial-over-lateral advantage. In the second experiment, the eccentricity of the Colobus hand was decreased and the facilitating effect of human-likeness was slightly increased. We conclude that motor strategies were applied that relied less on the asymmetry of the stimuli but rather on their similarity to the human hand. We argue that motor simulation might facilitate the processing of incomplete stimuli by mentally completing them, especially if all stimuli can be processed in a consistent manner.
-
Kim, Jun Sik; Jeong, Byung Yong
2018-05-03
The study aimed to describe the characteristics of occupational injuries of female workers in the residential healthcare facilities for the elderly, and analyze human errors as causes of accidents. From the national industrial accident compensation data, 506 female injuries were analyzed by age and occupation. The results showed that medical service worker was the most prevalent (54.1%), followed by social welfare worker (20.4%). Among injuries, 55.7% were <1 year of work experience, and 37.9% were ≥60 years old. Slips/falls were the most common type of accident (42.7%), and proportion of injured by slips/falls increases with age. Among human errors, action errors were the primary reasons, followed by perception errors, and cognition errors. Besides, the ratios of injuries by perception errors and action errors increase with age, respectively. The findings of this study suggest that there is a need to design workplaces that accommodate the characteristics of older female workers.
-
2008-01-01
One way in which physicians can respond to a medical error is to apologize. Apologies—statements that acknowledge an error and its consequences, take responsibility, and communicate regret for having caused harm—can decrease blame, decrease anger, increase trust, and improve relationships. Importantly, apologies also have the potential to decrease the risk of a medical malpractice lawsuit and can help settle claims by patients. Patients indicate they want and expect explanations and apologies after medical errors and physicians indicate they want to apologize. However, in practice, physicians tend to provide minimal information to patients after medical errors and infrequently offer complete apologies. Although fears about potential litigation are the most commonly cited barrier to apologizing after medical error, the link between litigation risk and the practice of disclosure and apology is tenuous. Other barriers might include the culture of medicine and the inherent psychological difficulties in facing one’s mistakes and apologizing for them. Despite these barriers, incorporating apology into conversations between physicians and patients can address the needs of both parties and can play a role in the effective resolution of disputes related to medical error. PMID:18972177
-
Optimal interpolation schemes to constrain pmPM2.5 in regional modeling over the United States
NASA Astrophysics Data System (ADS)
Sousan, Sinan Dhia Jameel
This thesis presents the use of data assimilation with optimal interpolation (OI) to develop atmospheric aerosol concentration estimates for the United States at high spatial and temporal resolutions. Concentration estimates are highly desirable for a wide range of applications, including visibility, climate, and human health. OI is a viable data assimilation method that can be used to improve Community Multiscale Air Quality (CMAQ) model fine particulate matter (PM2.5) estimates. PM2.5 is the mass of solid and liquid particles with diameters less than or equal to 2.5 µm suspended in the gas phase. OI was employed by combining model estimates with satellite and surface measurements. The satellite data assimilation combined 36 x 36 km aerosol concentrations from CMAQ with aerosol optical depth (AOD) measured by MODIS and AERONET over the continental United States for 2002. Posterior model concentrations generated by the OI algorithm were compared with surface PM2.5 measurements to evaluate a number of possible data assimilation parameters, including model error, observation error, and temporal averaging assumptions. Evaluation was conducted separately for six geographic U.S. regions in 2002. Variability in model error and MODIS biases limited the effectiveness of a single data assimilation system for the entire continental domain. The best combinations of four settings and three averaging schemes led to a domain-averaged improvement in fractional error from 1.2 to 0.97 and from 0.99 to 0.89 at respective IMPROVE and STN monitoring sites. For 38% of OI results, MODIS OI degraded the forward model skill due to biases and outliers in MODIS AOD. Surface data assimilation combined 36 × 36 km aerosol concentrations from the CMAQ model with surface PM2.5 measurements over the continental United States for 2002. The model error covariance matrix was constructed by using the observational method. The observation error covariance matrix included site representation that scaled the observation error by land use (i.e. urban or rural locations). In theory, urban locations should have less effect on surrounding areas than rural sites, which can be controlled using site representation error. The annual evaluations showed substantial improvements in model performance with increases in the correlation coefficient from 0.36 (prior) to 0.76 (posterior), and decreases in the fractional error from 0.43 (prior) to 0.15 (posterior). In addition, the normalized mean error decreased from 0.36 (prior) to 0.13 (posterior), and the RMSE decreased from 5.39 µg m-3 (prior) to 2.32 µg m-3 (posterior). OI decreased model bias for both large spatial areas and point locations, and could be extended to more advanced data assimilation methods. The current work will be applied to a five year (2000-2004) CMAQ simulation aimed at improving aerosol model estimates. The posterior model concentrations will be used to inform exposure studies over the U.S. that relate aerosol exposure to mortality and morbidity rates. Future improvements for the OI techniques used in the current study will include combining both surface and satellite data to improve posterior model estimates. Satellite data have high spatial and temporal resolutions in comparison to surface measurements, which are scarce but more accurate than model estimates. The satellite data are subject to noise affected by location and season of retrieval. The implementation of OI to combine satellite and surface data sets has the potential to improve posterior model estimates for locations that have no direct measurements.
-
NASA Technical Reports Server (NTRS)
Page, J.
1981-01-01
The effects of an independent verification and integration (V and I) methodology on one class of application are described. Resource profiles are discussed. The development environment is reviewed. Seven measures are presented to test the hypothesis that V and I improve the development and product. The V and I methodology provided: (1) a decrease in requirements ambiguities and misinterpretation; (2) no decrease in design errors; (3) no decrease in the cost of correcting errors; (4) a decrease in the cost of system and acceptance testing; (5) an increase in early discovery of errors; (6) no improvement in the quality of software put into operation; and (7) a decrease in productivity and an increase in cost.
-
Gating of neural error signals during motor learning
Kimpo, Rhea R; Rinaldi, Jacob M; Kim, Christina K; Payne, Hannah L; Raymond, Jennifer L
2014-01-01
Cerebellar climbing fiber activity encodes performance errors during many motor learning tasks, but the role of these error signals in learning has been controversial. We compared two motor learning paradigms that elicited equally robust putative error signals in the same climbing fibers: learned increases and decreases in the gain of the vestibulo-ocular reflex (VOR). During VOR-increase training, climbing fiber activity on one trial predicted changes in cerebellar output on the next trial, and optogenetic activation of climbing fibers to mimic their encoding of performance errors was sufficient to implant a motor memory. In contrast, during VOR-decrease training, there was no trial-by-trial correlation between climbing fiber activity and changes in cerebellar output, and climbing fiber activation did not induce VOR-decrease learning. Our data suggest that the ability of climbing fibers to induce plasticity can be dynamically gated in vivo, even under conditions where climbing fibers are robustly activated by performance errors. DOI: http://dx.doi.org/10.7554/eLife.02076.001 PMID:24755290
-
[Risk and risk management in aviation].
Müller, Manfred
2004-10-01
RISK MANAGEMENT: The large proportion of human errors in aviation accidents suggested the solution--at first sight brilliant--to replace the fallible human being by an "infallible" digitally-operating computer. However, even after the introduction of the so-called HITEC-airplanes, the factor human error still accounts for 75% of all accidents. Thus, if the computer is ruled out as the ultimate safety system, how else can complex operations involving quick and difficult decisions be controlled? OPTIMIZED TEAM INTERACTION/PARALLEL CONNECTION OF THOUGHT MACHINES: Since a single person is always "highly error-prone", support and control have to be guaranteed by a second person. The independent work of mind results in a safety network that more efficiently cushions human errors. NON-PUNITIVE ERROR MANAGEMENT: To be able to tackle the actual problems, the open discussion of intervened errors must not be endangered by the threat of punishment. It has been shown in the past that progress is primarily achieved by investigating and following up mistakes, failures and catastrophes shortly after they happened. HUMAN FACTOR RESEARCH PROJECT: A comprehensive survey showed the following result: By far the most frequent safety-critical situation (37.8% of all events) consists of the following combination of risk factors: 1. A complication develops. 2. In this situation of increased stress a human error occurs. 3. The negative effects of the error cannot be corrected or eased because there are deficiencies in team interaction on the flight deck. This means, for example, that a negative social climate has the effect of a "turbocharger" when a human error occurs. It needs to be pointed out that a negative social climate is not identical with a dispute. In many cases the working climate is burdened without the responsible person even noticing it: A first negative impression, too much or too little respect, contempt, misunderstandings, not expressing unclear concern, etc. can considerably reduce the efficiency of a team.
-
NASA Astrophysics Data System (ADS)
Mundermann, Lars; Mundermann, Annegret; Chaudhari, Ajit M.; Andriacchi, Thomas P.
2005-01-01
Anthropometric parameters are fundamental for a wide variety of applications in biomechanics, anthropology, medicine and sports. Recent technological advancements provide methods for constructing 3D surfaces directly. Of these new technologies, visual hull construction may be the most cost-effective yet sufficiently accurate method. However, the conditions influencing the accuracy of anthropometric measurements based on visual hull reconstruction are unknown. The purpose of this study was to evaluate the conditions that influence the accuracy of 3D shape-from-silhouette reconstruction of body segments dependent on number of cameras, camera resolution and object contours. The results demonstrate that the visual hulls lacked accuracy in concave regions and narrow spaces, but setups with a high number of cameras reconstructed a human form with an average accuracy of 1.0 mm. In general, setups with less than 8 cameras yielded largely inaccurate visual hull constructions, while setups with 16 and more cameras provided good volume estimations. Body segment volumes were obtained with an average error of 10% at a 640x480 resolution using 8 cameras. Changes in resolution did not significantly affect the average error. However, substantial decreases in error were observed with increasing number of cameras (33.3% using 4 cameras; 10.5% using 8 cameras; 4.1% using 16 cameras; 1.2% using 64 cameras).
-
Competition between learned reward and error outcome predictions in anterior cingulate cortex.
Alexander, William H; Brown, Joshua W
2010-02-15
The anterior cingulate cortex (ACC) is implicated in performance monitoring and cognitive control. Non-human primate studies of ACC show prominent reward signals, but these are elusive in human studies, which instead show mainly conflict and error effects. Here we demonstrate distinct appetitive and aversive activity in human ACC. The error likelihood hypothesis suggests that ACC activity increases in proportion to the likelihood of an error, and ACC is also sensitive to the consequence magnitude of the predicted error. Previous work further showed that error likelihood effects reach a ceiling as the potential consequences of an error increase, possibly due to reductions in the average reward. We explored this issue by independently manipulating reward magnitude of task responses and error likelihood while controlling for potential error consequences in an Incentive Change Signal Task. The fMRI results ruled out a modulatory effect of expected reward on error likelihood effects in favor of a competition effect between expected reward and error likelihood. Dynamic causal modeling showed that error likelihood and expected reward signals are intrinsic to the ACC rather than received from elsewhere. These findings agree with interpretations of ACC activity as signaling both perceptions of risk and predicted reward. Copyright 2009 Elsevier Inc. All rights reserved.
-
Tarrasch, Ricardo; Berman, Zohar; Friedmann, Naama
2016-01-01
This study explored the effects of a Mindfulness-Based Stress Reduction (MBSR) intervention on reading, attention, and psychological well-being among people with developmental dyslexia and/or attention deficits. Various types of dyslexia exist, characterized by different error types. We examined a question that has not been tested so far: which types of errors (and dyslexias) are affected by MBSR training. To do so, we tested, using an extensive battery of reading tests, whether each participant had dyslexia, and which errors types s/he makes, and then compared the rate of each error type before and after the MBSR workshop. We used a similar approach to attention disorders: we evaluated the participants' sustained, selective, executive, and orienting of attention to assess whether they had attention-disorders, and if so, which functions were impaired. We then evaluated the effect of MBSR on each of the attention functions. Psychological measures including mindfulness, stress, reflection and rumination, lifesatisfaction, depression, anxiety, and sleep-disturbances were also evaluated. Nineteen Hebrew-readers completed a 2-month mindfulness workshop. The results showed that whereas reading errors of letter-migrations within and between words and vowelletter errors did not decrease following the workshop, most participants made fewer reading errors in general following the workshop, with a significant reduction of 19% from their original number of errors. This decrease mainly resulted from a decrease in errors that occur due to reading via the sublexical rather than the lexical route. It seems, therefore, that mindfulness helped reading by keeping the readers on the lexical route. This improvement in reading probably resulted from improved sustained attention: the reduction in sublexical reading was significant for the dyslexic participants who also had attention deficits, and there were significant correlations between reduced reading errors and decreases in impulsivity. Following the meditation workshop, the rate of commission errors decreased, indicating decreased impulsivity, and the variation in RTs in the CPT task decreased, indicating improved sustained attention. Significant improvements were obtained in participants' mindfulness, perceived-stress, rumination, depression, state-anxiety, and sleep-disturbances. Correlations were also obtained between reading improvement and increased mindfulness following the workshop. Thus, whereas mindfulness training did not affect specific types of errors and did not improve dyslexia, it did affect the reading of adults with developmental dyslexia and ADHD, by helping them to stay on the straight path of the lexical route while reading. Thus, the reading improvement induced by mindfulness sheds light on the intricate relation between attention and reading. Mindfulness reduced impulsivity and improved sustained attention, and this, in turn, improved reading of adults with developmental dyslexia and ADHD, by helping them to read via the straight path of the lexical route.
-
Tarrasch, Ricardo; Berman, Zohar; Friedmann, Naama
2016-01-01
This study explored the effects of a Mindfulness-Based Stress Reduction (MBSR) intervention on reading, attention, and psychological well-being among people with developmental dyslexia and/or attention deficits. Various types of dyslexia exist, characterized by different error types. We examined a question that has not been tested so far: which types of errors (and dyslexias) are affected by MBSR training. To do so, we tested, using an extensive battery of reading tests, whether each participant had dyslexia, and which errors types s/he makes, and then compared the rate of each error type before and after the MBSR workshop. We used a similar approach to attention disorders: we evaluated the participants’ sustained, selective, executive, and orienting of attention to assess whether they had attention-disorders, and if so, which functions were impaired. We then evaluated the effect of MBSR on each of the attention functions. Psychological measures including mindfulness, stress, reflection and rumination, lifesatisfaction, depression, anxiety, and sleep-disturbances were also evaluated. Nineteen Hebrew-readers completed a 2-month mindfulness workshop. The results showed that whereas reading errors of letter-migrations within and between words and vowelletter errors did not decrease following the workshop, most participants made fewer reading errors in general following the workshop, with a significant reduction of 19% from their original number of errors. This decrease mainly resulted from a decrease in errors that occur due to reading via the sublexical rather than the lexical route. It seems, therefore, that mindfulness helped reading by keeping the readers on the lexical route. This improvement in reading probably resulted from improved sustained attention: the reduction in sublexical reading was significant for the dyslexic participants who also had attention deficits, and there were significant correlations between reduced reading errors and decreases in impulsivity. Following the meditation workshop, the rate of commission errors decreased, indicating decreased impulsivity, and the variation in RTs in the CPT task decreased, indicating improved sustained attention. Significant improvements were obtained in participants’ mindfulness, perceived-stress, rumination, depression, state-anxiety, and sleep-disturbances. Correlations were also obtained between reading improvement and increased mindfulness following the workshop. Thus, whereas mindfulness training did not affect specific types of errors and did not improve dyslexia, it did affect the reading of adults with developmental dyslexia and ADHD, by helping them to stay on the straight path of the lexical route while reading. Thus, the reading improvement induced by mindfulness sheds light on the intricate relation between attention and reading. Mindfulness reduced impulsivity and improved sustained attention, and this, in turn, improved reading of adults with developmental dyslexia and ADHD, by helping them to read via the straight path of the lexical route. PMID:27242565
-
Rong, Hao; Tian, Jin; Zhao, Tingdi
2016-01-01
In traditional approaches of human reliability assessment (HRA), the definition of the error producing conditions (EPCs) and the supporting guidance are such that some of the conditions (especially organizational or managerial conditions) can hardly be included, and thus the analysis is burdened with incomprehensiveness without reflecting the temporal trend of human reliability. A method based on system dynamics (SD), which highlights interrelationships among technical and organizational aspects that may contribute to human errors, is presented to facilitate quantitatively estimating the human error probability (HEP) and its related variables changing over time in a long period. Taking the Minuteman III missile accident in 2008 as a case, the proposed HRA method is applied to assess HEP during missile operations over 50 years by analyzing the interactions among the variables involved in human-related risks; also the critical factors are determined in terms of impact that the variables have on risks in different time periods. It is indicated that both technical and organizational aspects should be focused on to minimize human errors in a long run. Copyright © 2015 Elsevier Ltd and The Ergonomics Society. All rights reserved.
-
Giuliani, Manuel; Mirnig, Nicole; Stollnberger, Gerald; Stadler, Susanne; Buchner, Roland; Tscheligi, Manfred
2015-01-01
Human-robot interactions are often affected by error situations that are caused by either the robot or the human. Therefore, robots would profit from the ability to recognize when error situations occur. We investigated the verbal and non-verbal social signals that humans show when error situations occur in human-robot interaction experiments. For that, we analyzed 201 videos of five human-robot interaction user studies with varying tasks from four independent projects. The analysis shows that there are two types of error situations: social norm violations and technical failures. Social norm violations are situations in which the robot does not adhere to the underlying social script of the interaction. Technical failures are caused by technical shortcomings of the robot. The results of the video analysis show that the study participants use many head movements and very few gestures, but they often smile, when in an error situation with the robot. Another result is that the participants sometimes stop moving at the beginning of error situations. We also found that the participants talked more in the case of social norm violations and less during technical failures. Finally, the participants use fewer non-verbal social signals (for example smiling, nodding, and head shaking), when they are interacting with the robot alone and no experimenter or other human is present. The results suggest that participants do not see the robot as a social interaction partner with comparable communication skills. Our findings have implications for builders and evaluators of human-robot interaction systems. The builders need to consider including modules for recognition and classification of head movements to the robot input channels. The evaluators need to make sure that the presence of an experimenter does not skew the results of their user studies.
-
de Cordova, Pamela B; Bradford, Michelle A; Stone, Patricia W
2016-02-15
Shift workers have worse health outcomes than employees who work standard business hours. However, it is unclear how this poorer health shift may be related to employee work productivity. The purpose of this systematic review is to assess the relationship between shift work and errors and performance. Searches of MEDLINE/PubMed, EBSCOhost, and CINAHL were conducted to identify articles that examined the relationship between shift work, errors, quality, productivity, and performance. All articles were assessed for study quality. A total of 435 abstracts were screened with 13 meeting inclusion criteria. Eight studies were rated to be of strong, methodological quality. Nine studies demonstrated a positive relationship that night shift workers committed more errors and had decreased performance. Night shift workers have worse health that may contribute to errors and decreased performance in the workplace.
-
Wiegmann, D A; Shappell, S A
2001-11-01
The Human Factors Analysis and Classification System (HFACS) is a general human error framework originally developed and tested within the U.S. military as a tool for investigating and analyzing the human causes of aviation accidents. Based on Reason's (1990) model of latent and active failures, HFACS addresses human error at all levels of the system, including the condition of aircrew and organizational factors. The purpose of the present study was to assess the utility of the HFACS framework as an error analysis and classification tool outside the military. The HFACS framework was used to analyze human error data associated with aircrew-related commercial aviation accidents that occurred between January 1990 and December 1996 using database records maintained by the NTSB and the FAA. Investigators were able to reliably accommodate all the human causal factors associated with the commercial aviation accidents examined in this study using the HFACS system. In addition, the classification of data using HFACS highlighted several critical safety issues in need of intervention research. These results demonstrate that the HFACS framework can be a viable tool for use within the civil aviation arena. However, additional research is needed to examine its applicability to areas outside the flight deck, such as aircraft maintenance and air traffic control domains.
-
To Err Is Human; To Structurally Prime from Errors Is Also Human
ERIC Educational Resources Information Center
Slevc, L. Robert; Ferreira, Victor S.
2013-01-01
Natural language contains disfluencies and errors. Do listeners simply discard information that was clearly produced in error, or can erroneous material persist to affect subsequent processing? Two experiments explored this question using a structural priming paradigm. Speakers described dative-eliciting pictures after hearing prime sentences that…
-
Human factors analysis and classification system-HFACS.
DOT National Transportation Integrated Search
2000-02-01
Human error has been implicated in 70 to 80% of all civil and military aviation accidents. Yet, most accident : reporting systems are not designed around any theoretical framework of human error. As a result, most : accident databases are not conduci...
-
Package Design Affects Accuracy Recognition for Medications
Endestad, Tor; Wortinger, Laura A.; Madsen, Steinar; Hortemo, Sigurd
2016-01-01
Objective: Our aim was to test if highlighting and placement of substance name on medication package have the potential to reduce patient errors. Background: An unintentional overdose of medication is a large health issue that might be linked to medication package design. In two experiments, placement, background color, and the active ingredient of generic medication packages were manipulated according to best human factors guidelines to reduce causes of labeling-related patient errors. Method: In two experiments, we compared the original packaging with packages where we varied placement of the name, dose, and background of the active ingredient. Age-relevant differences and the effect of color on medication recognition error were tested. In Experiment 1, 59 volunteers (30 elderly and 29 young students), participated. In Experiment 2, 25 volunteers participated. Results: The most common error was the inability to identify that two different packages contained the same active ingredient (young, 41%, and elderly, 68%). This kind of error decreased with the redesigned packages (young, 8%, and elderly, 16%). Confusion errors related to color design were reduced by two thirds in the redesigned packages compared with original generic medications. Conclusion: Prominent placement of substance name and dose with a band of high-contrast color support recognition of the active substance in medications. Application: A simple modification including highlighting and placing the name of the active ingredient in the upper right-hand corner of the package helps users realize that two different packages can contain the same active substance, thus reducing the risk of inadvertent medication overdose. PMID:27591209
-
Discretization vs. Rounding Error in Euler's Method
ERIC Educational Resources Information Center
Borges, Carlos F.
2011-01-01
Euler's method for solving initial value problems is an excellent vehicle for observing the relationship between discretization error and rounding error in numerical computation. Reductions in stepsize, in order to decrease discretization error, necessarily increase the number of steps and so introduce additional rounding error. The problem is…
-
Technical approaches for measurement of human errors
NASA Technical Reports Server (NTRS)
Clement, W. F.; Heffley, R. K.; Jewell, W. F.; Mcruer, D. T.
1980-01-01
Human error is a significant contributing factor in a very high proportion of civil transport, general aviation, and rotorcraft accidents. The technical details of a variety of proven approaches for the measurement of human errors in the context of the national airspace system are presented. Unobtrusive measurements suitable for cockpit operations and procedures in part of full mission simulation are emphasized. Procedure, system performance, and human operator centered measurements are discussed as they apply to the manual control, communication, supervisory, and monitoring tasks which are relevant to aviation operations.
-
Völker, Martin; Fiederer, Lukas D J; Berberich, Sofie; Hammer, Jiří; Behncke, Joos; Kršek, Pavel; Tomášek, Martin; Marusič, Petr; Reinacher, Peter C; Coenen, Volker A; Helias, Moritz; Schulze-Bonhage, Andreas; Burgard, Wolfram; Ball, Tonio
2018-06-01
Error detection in motor behavior is a fundamental cognitive function heavily relying on local cortical information processing. Neural activity in the high-gamma frequency band (HGB) closely reflects such local cortical processing, but little is known about its role in error processing, particularly in the healthy human brain. Here we characterize the error-related response of the human brain based on data obtained with noninvasive EEG optimized for HGB mapping in 31 healthy subjects (15 females, 16 males), and additional intracranial EEG data from 9 epilepsy patients (4 females, 5 males). Our findings reveal a multiscale picture of the global and local dynamics of error-related HGB activity in the human brain. On the global level as reflected in the noninvasive EEG, the error-related response started with an early component dominated by anterior brain regions, followed by a shift to parietal regions, and a subsequent phase characterized by sustained parietal HGB activity. This phase lasted for more than 1 s after the error onset. On the local level reflected in the intracranial EEG, a cascade of both transient and sustained error-related responses involved an even more extended network, spanning beyond frontal and parietal regions to the insula and the hippocampus. HGB mapping appeared especially well suited to investigate late, sustained components of the error response, possibly linked to downstream functional stages such as error-related learning and behavioral adaptation. Our findings establish the basic spatio-temporal properties of HGB activity as a neural correlate of error processing, complementing traditional error-related potential studies. Copyright © 2018 The Authors. Published by Elsevier Inc. All rights reserved.
-
NASA Astrophysics Data System (ADS)
Downs, Matthew E.; Buch, Amanda; Karakatsani, Maria Eleni; Konofagou, Elisa E.; Ferrera, Vincent P.
2015-10-01
Over the past fifteen years, focused ultrasound coupled with intravenously administered microbubbles (FUS) has been proven an effective, non-invasive technique to open the blood-brain barrier (BBB) in vivo. Here we show that FUS can safely and effectively open the BBB at the basal ganglia and thalamus in alert non-human primates (NHP) while they perform a behavioral task. The BBB was successfully opened in 89% of cases at the targeted brain regions of alert NHP with an average volume of opening 28% larger than prior anesthetized FUS procedures. Safety (lack of edema or microhemorrhage) of FUS was also improved during alert compared to anesthetized procedures. No physiological effects (change in heart rate, motor evoked potentials) were observed during any of the procedures. Furthermore, the application of FUS did not disrupt reaching behavior, but in fact improved performance by decreasing reaction times by 23 ms, and significantly decreasing touch error by 0.76 mm on average.
-
Niemann, Dorothee; Bertsche, Astrid; Meyrath, David; Koepf, Ellen D; Traiser, Carolin; Seebald, Katja; Schmitt, Claus P; Hoffmann, Georg F; Haefeli, Walter E; Bertsche, Thilo
2015-01-01
To prevent medication errors in drug handling in a paediatric ward. One in five preventable adverse drug events in hospitalised children is caused by medication errors. Errors in drug prescription have been studied frequently, but data regarding drug handling, including drug preparation and administration, are scarce. A three-step intervention study including monitoring procedure was used to detect and prevent medication errors in drug handling. After approval by the ethics committee, pharmacists monitored drug handling by nurses on an 18-bed paediatric ward in a university hospital prior to and following each intervention step. They also conducted a questionnaire survey aimed at identifying knowledge deficits. Each intervention step targeted different causes of errors. The handout mainly addressed knowledge deficits, the training course addressed errors caused by rule violations and slips, and the reference book addressed knowledge-, memory- and rule-based errors. The number of patients who were subjected to at least one medication error in drug handling decreased from 38/43 (88%) to 25/51 (49%) following the third intervention, and the overall frequency of errors decreased from 527 errors in 581 processes (91%) to 116/441 (26%). The issue of the handout reduced medication errors caused by knowledge deficits regarding, for instance, the correct 'volume of solvent for IV drugs' from 49-25%. Paediatric drug handling is prone to errors. A three-step intervention effectively decreased the high frequency of medication errors by addressing the diversity of their causes. Worldwide, nurses are in charge of drug handling, which constitutes an error-prone but often-neglected step in drug therapy. Detection and prevention of errors in daily routine is necessary for a safe and effective drug therapy. Our three-step intervention reduced errors and is suitable to be tested in other wards and settings. © 2014 John Wiley & Sons Ltd.
-
Palmero, David; Di Paolo, Ermindo R; Beauport, Lydie; Pannatier, André; Tolsa, Jean-François
2016-01-01
The objective of this study was to assess whether the introduction of a new preformatted medical order sheet coupled with an introductory course affected prescription quality and the frequency of errors during the prescription stage in a neonatal intensive care unit (NICU). Two-phase observational study consisting of two consecutive 4-month phases: pre-intervention (phase 0) and post-intervention (phase I) conducted in an 11-bed NICU in a Swiss university hospital. Interventions consisted of the introduction of a new preformatted medical order sheet with explicit information supplied, coupled with a staff introductory course on appropriate prescription and medication errors. The main outcomes measured were formal aspects of prescription and frequency and nature of prescription errors. Eighty-three and 81 patients were included in phase 0 and phase I, respectively. A total of 505 handwritten prescriptions in phase 0 and 525 in phase I were analysed. The rate of prescription errors decreased significantly from 28.9% in phase 0 to 13.5% in phase I (p < 0.05). Compared with phase 0, dose errors, name confusion and errors in frequency and rate of drug administration decreased in phase I, from 5.4 to 2.7% (p < 0.05), 5.9 to 0.2% (p < 0.05), 3.6 to 0.2% (p < 0.05), and 4.7 to 2.1% (p < 0.05), respectively. The rate of incomplete and ambiguous prescriptions decreased from 44.2 to 25.7 and 8.5 to 3.2% (p < 0.05), respectively. Inexpensive and simple interventions can improve the intelligibility of prescriptions and reduce medication errors. Medication errors are frequent in NICUs and prescription is one of the most critical steps. CPOE reduce prescription errors, but their implementation is not available everywhere. Preformatted medical order sheet coupled with an introductory course decrease medication errors in a NICU. Preformatted medical order sheet is an inexpensive and readily implemented alternative to CPOE.
-
The use of collaboration to implement evidence-based safe practices.
Clarke, John R
2013-12-01
The Pennsylvania Patient Safety Authority receives over 235,000 reports of medical error per year. Near miss and serious event reports of common and interesting problems are analysed to identify best practices for preventing harmful errors. Dissemination of this evidence-based information in the peer-reviewed Pennsylvania Patient Safety Advisory and presentations to medical staffs are not sufficient for adoption of best practices. Adoption of best practices has required working with institutions to identify local barriers to and incentives for adopting best practices and redesigning the delivery system to make desired behaviour easy and undesirable behaviour more difficult. Collaborations, where institutions can learn from the experiences of others, have show decreases in harmful events. The Pennsylvania Program to Prevent Wrong-Site Surgery is used as an example. Two collaborations to prevent wrong-site surgery have been completed, one with 30 institutions in eastern Pennsylvania and one with 19 in western Pennsylvania. The first collaboration achieved a 73% decrease in the rolling average of wrong-site events over 18 months. The second collaboration experienced no wrong-site operating room procedures over more than one year. Significance for public healthSince the Institute of Medicine's To Err is Human identified medical errors as a major cause of death, the public has been interested in the recommendations for reporting of medical errors and implementing safe systems for the delivery of healthcare. The Commonwealth of Pennsylvania has followed those recommendations and found that an essential intermediate step between analysing reports and implementing safe systems is collaborative learning among healthcare institutions. The experience in Pennsylvania should be useful to other public organizations wishing to improve safety.
-
Effects of Retinal Eccentricity on Human Manual Control
NASA Technical Reports Server (NTRS)
Popovici, Alexandru; Zaal, Peter M. T.
2017-01-01
This study investigated the effects of viewing a primary flight display at different retinal eccentricities on human manual control behavior and performance. Ten participants performed a pitch tracking task while looking at a simplified primary flight display at different horizontal and vertical retinal eccentricities, and with two different controlled dynamics. Tracking performance declined at higher eccentricity angles and participants behaved more nonlinearly. The visual error rate gain increased with eccentricity for single-integrator-like controlled dynamics, but decreased for double-integrator-like dynamics. Participants' visual time delay was up to 100 ms higher at the highest horizontal eccentricity compared to foveal viewing. Overall, vertical eccentricity had a larger impact than horizontal eccentricity on most of the human manual control parameters and performance. Results might be useful in the design of displays and procedures for critical flight conditions such as in an aerodynamic stall.
-
Development of an errorable car-following driver model
NASA Astrophysics Data System (ADS)
Yang, H.-H.; Peng, H.
2010-06-01
An errorable car-following driver model is presented in this paper. An errorable driver model is one that emulates human driver's functions and can generate both nominal (error-free), as well as devious (with error) behaviours. This model was developed for evaluation and design of active safety systems. The car-following data used for developing and validating the model were obtained from a large-scale naturalistic driving database. The stochastic car-following behaviour was first analysed and modelled as a random process. Three error-inducing behaviours were then introduced. First, human perceptual limitation was studied and implemented. Distraction due to non-driving tasks was then identified based on the statistical analysis of the driving data. Finally, time delay of human drivers was estimated through a recursive least-square identification process. By including these three error-inducing behaviours, rear-end collisions with the lead vehicle could occur. The simulated crash rate was found to be similar but somewhat higher than that reported in traffic statistics.
-
Time trend of injection drug errors before and after implementation of bar-code verification system.
Sakushima, Ken; Umeki, Reona; Endoh, Akira; Ito, Yoichi M; Nasuhara, Yasuyuki
2015-01-01
Bar-code technology, used for verification of patients and their medication, could prevent medication errors in clinical practice. Retrospective analysis of electronically stored medical error reports was conducted in a university hospital. The number of reported medication errors of injected drugs, including wrong drug administration and administration to the wrong patient, was compared before and after implementation of the bar-code verification system for inpatient care. A total of 2867 error reports associated with injection drugs were extracted. Wrong patient errors decreased significantly after implementation of the bar-code verification system (17.4/year vs. 4.5/year, p< 0.05), although wrong drug errors did not decrease sufficiently (24.2/year vs. 20.3/year). The source of medication errors due to wrong drugs was drug preparation in hospital wards. Bar-code medication administration is effective for prevention of wrong patient errors. However, ordinary bar-code verification systems are limited in their ability to prevent incorrect drug preparation in hospital wards.
-
Lost in Translation: the Case for Integrated Testing
NASA Technical Reports Server (NTRS)
Young, Aaron
2017-01-01
The building of a spacecraft is complex and often involves multiple suppliers and companies that have their own designs and processes. Standards have been developed across the industries to reduce the chances for critical flight errors at the system level, but the spacecraft is still vulnerable to the introduction of critical errors during integration of these systems. Critical errors can occur at any time during the process and in many cases, human reliability analysis (HRA) identifies human error as a risk driver. Most programs have a test plan in place that is intended to catch these errors, but it is not uncommon for schedule and cost stress to result in less testing than initially planned. Therefore, integrated testing, or "testing as you fly," is essential as a final check on the design and assembly to catch any errors prior to the mission. This presentation will outline the unique benefits of integrated testing by catching critical flight errors that can otherwise go undetected, discuss HRA methods that are used to identify opportunities for human error, lessons learned and challenges over ownership of testing will be discussed.
-
Human factors in aircraft incidents - Results of a 7-year study (Andre Allard Memorial Lecture)
NASA Technical Reports Server (NTRS)
Billings, C. E.; Reynard, W. D.
1984-01-01
It is pointed out that nearly all fatal aircraft accidents are preventable, and that most such accidents are due to human error. The present discussion is concerned with the results of a seven-year study of the data collected by the NASA Aviation Safety Reporting System (ASRS). The Aviation Safety Reporting System was designed to stimulate as large a flow as possible of information regarding errors and operational problems in the conduct of air operations. It was implemented in April, 1976. In the following 7.5 years, 35,000 reports have been received from pilots, controllers, and the armed forces. Human errors are found in more than 80 percent of these reports. Attention is given to the types of events reported, possible causal factors in incidents, the relationship of incidents and accidents, and sources of error in the data. ASRS reports include sufficient detail to permit authorities to institute changes in the national aviation system designed to minimize the likelihood of human error, and to insulate the system against the effects of errors.
-
Human factors in surgery: from Three Mile Island to the operating room.
D'Addessi, Alessandro; Bongiovanni, Luca; Volpe, Andrea; Pinto, Francesco; Bassi, PierFrancesco
2009-01-01
Human factors is a definition that includes the science of understanding the properties of human capability, the application of this understanding to the design and development of systems and services, the art of ensuring their successful applications to a program. The field of human factors traces its origins to the Second World War, but Three Mile Island has been the best example of how groups of people react and make decisions under stress: this nuclear accident was exacerbated by wrong decisions made because the operators were overwhelmed with irrelevant, misleading or incorrect information. Errors and their nature are the same in all human activities. The predisposition for error is so intrinsic to human nature that scientifically it is best considered as inherently biologic. The causes of error in medical care may not be easily generalized. Surgery differs in important ways: most errors occur in the operating room and are technical in nature. Commonly, surgical error has been thought of as the consequence of lack of skill or ability, and is the result of thoughtless actions. Moreover the 'operating theatre' has a unique set of team dynamics: professionals from multiple disciplines are required to work in a closely coordinated fashion. This complex environment provides multiple opportunities for unclear communication, clashing motivations, errors arising not from technical incompetence but from poor interpersonal skills. Surgeons have to work closely with human factors specialists in future studies. By improving processes already in place in many operating rooms, safety will be enhanced and quality increased.
-
Preoperative Safety Briefing Project
DeFontes, James; Surbida, Stephanie
2004-01-01
Context: Increased media attention on surgical procedures that were performed on the wrong anatomic site or wrong patient has prompted the health care industry to identify and address human factors that lead to medical errors. Objective: To increase patient safety in the perioperative setting, our objective was to create a climate of improved communication, collaboration, team-work, and situational awareness while the surgical team reviewed pertinent information about the patient and the pending procedure. Methods: A team of doctors, nurses, and technicians used human factors principles to develop the Preoperative Safety Briefing for use by surgical teams, a briefing similar to the preflight checklist used by the airline industry. A six-month pilot of the briefing began in the Kaiser Permanente (KP) Anaheim Medical Center in February 2002. Four indicators of safety culture were used to measure success of the pilot: occurrence of wrong-site/wrong procedures, attitudinal survey data, near-miss reports, and nursing personnel turnover data. Results: Wrong-site surgeries decreased from 3 to 0 (300%) per year; employee satisfaction increased 19%; nursing personnel turnover decreased 16%; and perception of the safety climate in the operating room improved from “good” to “outstanding.” Operating suite personnel perception of teamwork quality improved substantially. Operating suite personnel perception of patient safety as a priority, of personnel communication, of their taking responsibility for patient safety, of nurse input being well received, of overall morale, and of medical errors being handled appropriately also improved substantially. Conclusions: Team members who work together and communicate well can quickly detect and more easily avoid errors. The Preoperative Safety Briefing is now standard in many operating suites in the KP Orange County Service Area. The concepts and design of this project are transferable, and similar projects are underway in the Departments of Radiology and of Labor and Delivery at KP Anaheim Medical Center. PMID:26704913
-
The Human Factors Analysis and Classification System : HFACS : final report.
DOT National Transportation Integrated Search
2000-02-01
Human error has been implicated in 70 to 80% of all civil and military aviation accidents. Yet, most accident reporting systems are not designed around any theoretical framework of human error. As a result, most accident databases are not conducive t...
-
Kaneko, Takaaki; Tomonaga, Masaki
2014-06-01
Humans are often unaware of how they control their limb motor movements. People pay attention to their own motor movements only when their usual motor routines encounter errors. Yet little is known about the extent to which voluntary actions rely on automatic control and when automatic control shifts to deliberate control in nonhuman primates. In this study, we demonstrate that chimpanzees and humans showed similar limb motor adjustment in response to feedback error during reaching actions, whereas attentional allocation inferred from gaze behavior differed. We found that humans shifted attention to their own motor kinematics as errors were induced in motor trajectory feedback regardless of whether the errors actually disrupted their reaching their action goals. In contrast, chimpanzees shifted attention to motor execution only when errors actually interfered with their achieving a planned action goal. These results indicate that the species differed in their criteria for shifting from automatic to deliberate control of motor actions. It is widely accepted that sophisticated motor repertoires have evolved in humans. Our results suggest that the deliberate monitoring of one's own motor kinematics may have evolved in the human lineage. Copyright © 2014 Elsevier B.V. All rights reserved.
-
Preventable Medical Errors Driven Modeling of Medical Best Practice Guidance Systems.
Ou, Andrew Y-Z; Jiang, Yu; Wu, Po-Liang; Sha, Lui; Berlin, Richard B
2017-01-01
In a medical environment such as Intensive Care Unit, there are many possible reasons to cause errors, and one important reason is the effect of human intellectual tasks. When designing an interactive healthcare system such as medical Cyber-Physical-Human Systems (CPHSystems), it is important to consider whether the system design can mitigate the errors caused by these tasks or not. In this paper, we first introduce five categories of generic intellectual tasks of humans, where tasks among each category may lead to potential medical errors. Then, we present an integrated modeling framework to model a medical CPHSystem and use UPPAAL as the foundation to integrate and verify the whole medical CPHSystem design models. With a verified and comprehensive model capturing the human intellectual tasks effects, we can design a more accurate and acceptable system. We use a cardiac arrest resuscitation guidance and navigation system (CAR-GNSystem) for such medical CPHSystem modeling. Experimental results show that the CPHSystem models help determine system design flaws and can mitigate the potential medical errors caused by the human intellectual tasks.
-
Mullan, F; Bartlett, D; Austin, R S
2017-06-01
To investigate the measurement performance of a chromatic confocal profilometer for quantification of surface texture of natural human enamel in vitro. Contributions to the measurement uncertainty from all potential sources of measurement error using a chromatic confocal profilometer and surface metrology software were quantified using a series of surface metrology calibration artifacts and pre-worn enamel samples. The 3D surface texture analysis protocol was optimized across 0.04mm 2 of natural and unpolished enamel undergoing dietary acid erosion (pH 3.2, titratable acidity 41.3mmolOH/L). Flatness deviations due to the x, y stage mechanical movement were the major contribution to the measurement uncertainty; with maximum Sz flatness errors of 0.49μm. Whereas measurement noise; non-linearity's in x, y, z and enamel sample dimensional instability contributed minimal errors. The measurement errors were propagated into an uncertainty budget following a Type B uncertainty evaluation in order to calculate the Standard Combined Uncertainty (u c ), which was ±0.28μm. Statistically significant increases in the median (IQR) roughness (Sa) of the polished samples occurred after 15 (+0.17 (0.13)μm), 30 (+0.12 (0.09)μm) and 45 (+0.18 (0.15)μm) min of erosion (P<0.001 vs. baseline). In contrast, natural unpolished enamel samples revealed a statistically significant decrease in Sa roughness of -0.14 (0.34) μm only after 45min erosion (P<0.05s vs. baseline). The main contribution to measurement uncertainty using chromatic confocal profilometry was from flatness deviations however by optimizing measurement protocols the profilometer successfully characterized surface texture changes in enamel from erosive wear in vitro. Copyright © 2017 The Academy of Dental Materials. All rights reserved.
-
Hicks, Christopher M; Bandiera, Glen W; Denny, Christopher J
2008-11-01
Emergency department (ED) resuscitation requires the coordinated efforts of an interdisciplinary team. Human errors are common and have a negative impact on patient safety. Although crisis resource management (CRM) skills are utilized in other clinical domains, most emergency medicine (EM) caregivers currently receive no formal CRM training. The objectives were to compile and compare attitudes toward CRM training among EM staff physicians, nurses, and residents at two Canadian academic teaching hospitals. Emergency physicians (EPs), residents, and nurses were asked to complete a Web survey that included Likert scales and short answer questions. Focus groups and pilot testing were used to inform survey development. Thematic content analysis was performed on the qualitative data set and compared to quantitative results. The response rate was 75.7% (N = 84). There was strong consensus regarding the importance of core CRM principles (i.e., effective communication, team leadership, resource utilization, problem-solving, situational awareness) in ED resuscitation. Problems with coordinating team actions (58.8%), communication (69.6%), and establishing priorities (41.3%) were among factors implicated in adverse events. Interdisciplinary collaboration (95.1%), efficiency of patient care (83.9%), and decreased medical error (82.6%) were proposed benefits of CRM training. Communication between disciplines is a barrier to effective ED resuscitation for 94.4% of nurses and 59.7% of EPs (p = 0.008). Residents reported a lack of exposure to (64.3%), yet had interest in (96.4%) formal CRM education using human patient simulation. Nurses rate communication as a barrier to teamwork more frequently than physicians. EM residents are keen to learn CRM skills. An opportunity exists to create a novel interdisciplinary CRM curriculum to improve EM team performance and mitigate human error.
-
Philippoff, Joanna; Baumgartner, Erin
2016-03-01
The scientific value of citizen-science programs is limited when the data gathered are inconsistent, erroneous, or otherwise unusable. Long-term monitoring studies, such as Our Project In Hawai'i's Intertidal (OPIHI), have clear and consistent procedures and are thus a good model for evaluating the quality of participant data. The purpose of this study was to examine the kinds of errors made by student researchers during OPIHI data collection and factors that increase or decrease the likelihood of these errors. Twenty-four different types of errors were grouped into four broad error categories: missing data, sloppiness, methodological errors, and misidentification errors. "Sloppiness" was the most prevalent error type. Error rates decreased with field trip experience and student age. We suggest strategies to reduce data collection errors applicable to many types of citizen-science projects including emphasizing neat data collection, explicitly addressing and discussing the problems of falsifying data, emphasizing the importance of using standard scientific vocabulary, and giving participants multiple opportunities to practice to build their data collection techniques and skills.
-
Decreasing patient identification band errors by standardizing processes.
Walley, Susan Chu; Berger, Stephanie; Harris, Yolanda; Gallizzi, Gina; Hayes, Leslie
2013-04-01
Patient identification (ID) bands are an essential component in patient ID. Quality improvement methodology has been applied as a model to reduce ID band errors although previous studies have not addressed standardization of ID bands. Our specific aim was to decrease ID band errors by 50% in a 12-month period. The Six Sigma DMAIC (define, measure, analyze, improve, and control) quality improvement model was the framework for this study. ID bands at a tertiary care pediatric hospital were audited from January 2011 to January 2012 with continued audits to June 2012 to confirm the new process was in control. After analysis, the major improvement strategy implemented was standardization of styles of ID bands and labels. Additional interventions included educational initiatives regarding the new ID band processes and disseminating institutional and nursing unit data. A total of 4556 ID bands were audited with a preimprovement ID band error average rate of 9.2%. Significant variation in the ID band process was observed, including styles of ID bands. Interventions were focused on standardization of the ID band and labels. The ID band error rate improved to 5.2% in 9 months (95% confidence interval: 2.5-5.5; P < .001) and was maintained for 8 months. Standardization of ID bands and labels in conjunction with other interventions resulted in a statistical decrease in ID band error rates. This decrease in ID band error rates was maintained over the subsequent 8 months.
-
Building sector feedbacks lead to increased energy demands
NASA Astrophysics Data System (ADS)
Hartin, C.; Link, R. P.; Patel, P.; Horowitz, R.; Clarke, L.; Mundra, A.
2017-12-01
Typically in human-earth system modeling studies, feedbacks between the earth and human systems are analyzed by passing information between independent models, leading to data errors and poor reproducibility. In this study we explore the two-way feedbacks between the human and earth systems in the building sector of GCAM, an integrated assessment model and, its fully-integrated climate component, Hector. While there is a general agreement in the literature that increasing temperatures will increase cooling energy demands and decrease heating energy demands, there has been no fully-coupled analysis of this dynamic that would, for example, account for the feedbacks on hydrofluorocarbons from increased cooling demands. Using a statistical relationship between global mean temperature change and heating and cooling degree days, we find that the feedbacks on hydrofluorocarbons lead to an increase in global mean temperature of between 0.16 to 0.27 °C in 2100. Demands for electricity increase by about 10% in Africa, while demands decrease in Canada by about 3.0% when taking into account these feedbacks. While the feedbacks between building energy demand and global mean temperature are modest by themselves, this study prompts future research on coupled human-earth system feedbacks, in particular in regards to land, water, and other energy infrastructure.
-
Tirilazad mesylate protects stored erythrocytes against osmotic fragility.
Epps, D E; Knechtel, T J; Bacznskyj, O; Decker, D; Guido, D M; Buxser, S E; Mathews, W R; Buffenbarger, S L; Lutzke, B S; McCall, J M
1994-12-01
The hypoosmotic lysis curve of freshly collected human erythrocytes is consistent with a single Gaussian error function with a mean of 46.5 +/- 0.25 mM NaCl and a standard deviation of 5.0 +/- 0.4 mM NaCl. After extended storage of RBCs under standard blood bank conditions the lysis curve conforms to the sum of two error functions instead of a possible shift in the mean and a broadening of a single error function. Thus, two distinct sub-populations with different fragilities are present instead of a single, broadly distributed population. One population is identical to the freshly collected erythrocytes, whereas the other population consists of osmotically fragile cells. The rate of generation of the new, osmotically fragile, population of cells was used to probe the hypothesis that lipid peroxidation is responsible for the induction of membrane fragility. If it is so, then the antioxidant, tirilazad mesylate (U-74,006f), should protect against this degradation of stored erythrocytes. We found that tirilazad mesylate, at 17 microM (1.5 mol% with respect to membrane lecithin), retards significantly the formation of the osmotically fragile RBCs. Concomitantly, the concentration of free hemoglobin which accumulates during storage is markedly reduced by the drug. Since the presence of the drug also decreases the amount of F2-isoprostanes formed during the storage period, an antioxidant mechanism must be operative. These results demonstrate that tirilazad mesylate significantly decreases the number of fragile erythrocytes formed during storage in the blood bank.
-
Modeling human tracking error in several different anti-tank systems
NASA Technical Reports Server (NTRS)
Kleinman, D. L.
1981-01-01
An optimal control model for generating time histories of human tracking errors in antitank systems is outlined. Monte Carlo simulations of human operator responses for three Army antitank systems are compared. System/manipulator dependent data comparisons reflecting human operator limitations in perceiving displayed quantities and executing intended control motions are presented. Motor noise parameters are also discussed.
-
You, Jeong Soon; Ji, Hye-In; Chang, Kyung Ja; Yoo, Myung Chul; Yang, Hyung-In; Jeong, In-Kyung; Kim, Kyoung Soo
2013-08-01
To evaluate the extent to which fat mass contributes to serum osteopontin (OPN) concentration, we investigated whether serum OPN levels are decreased by exercise-induced fat mass loss and whether they are associated with body fat percentage in obese humans. Twenty‑three female college students were recruited to participate in an 8‑week body weight control program. Body composition [body weight, soft lean mass, body fat mass, body fat percentage, waist-hip ratio and body mass index (BMI)] were assessed prior to and following the program. Serum lipid profiles and serum adiponectin, leptin and osteopontin levels were measured from serum collected prior to and following the program. To understand the effect of fat mass loss on the serum levels of adipokine, which is mainly produced in adipose tissue, the leptin and adiponectin levels were also measured prior to and following the program. Serum leptin levels (mean ± standard error of the mean) decreased significantly following the program (from 9.82±0.98 to 7.23±0.67 ng/ml) and were closely correlated with body fat percentage. In addition, serum adiponectin levels were negatively correlated with body fat percentage, while serum adiponectin levels were not significantly altered. By contrast, serum OPN levels decreased significantly following the program (from 16.03±2.34 to 10.65±1.22 ng/ml). However, serum OPN levels were not correlated with body fat percentage, suggesting that serum OPN levels are controlled by several other factors in humans. In conclusion, a high expression of OPN in adipose tissues may not be correlated with serum OPN levels in obese humans. Thus, tissues or physiological factors other than fat mass may have a greater contribution to the serum OPN levels.
-
Smiley, A M
1990-10-01
In February of 1986 a head-on collision occurred between a freight train and a passenger train in western Canada killing 23 people and causing over $30 million of damage. A Commission of Inquiry appointed by the Canadian government concluded that human error was the major reason for the collision. This report discusses the factors contributing to the human error: mainly poor work-rest schedules, the monotonous nature of the train driving task, insufficient information about train movements, and the inadequate backup systems in case of human error.
-
A Conceptual Framework for Predicting Error in Complex Human-Machine Environments
NASA Technical Reports Server (NTRS)
Freed, Michael; Remington, Roger; Null, Cynthia H. (Technical Monitor)
1998-01-01
We present a Goals, Operators, Methods, and Selection Rules-Model Human Processor (GOMS-MHP) style model-based approach to the problem of predicting human habit capture errors. Habit captures occur when the model fails to allocate limited cognitive resources to retrieve task-relevant information from memory. Lacking the unretrieved information, decision mechanisms act in accordance with implicit default assumptions, resulting in error when relied upon assumptions prove incorrect. The model helps interface designers identify situations in which such failures are especially likely.
-
Alastruey, Jordi; Hunt, Anthony A E; Weinberg, Peter D
2014-01-01
We present a novel analysis of arterial pulse wave propagation that combines traditional wave intensity analysis with identification of Windkessel pressures to account for the effect on the pressure waveform of peripheral wave reflections. Using haemodynamic data measured in vivo in the rabbit or generated numerically in models of human compliant vessels, we show that traditional wave intensity analysis identifies the timing, direction and magnitude of the predominant waves that shape aortic pressure and flow waveforms in systole, but fails to identify the effect of peripheral reflections. These reflections persist for several cardiac cycles and make up most of the pressure waveform, especially in diastole and early systole. Ignoring peripheral reflections leads to an erroneous indication of a reflection-free period in early systole and additional error in the estimates of (i) pulse wave velocity at the ascending aorta given by the PU–loop method (9.5% error) and (ii) transit time to a dominant reflection site calculated from the wave intensity profile (27% error). These errors decreased to 1.3% and 10%, respectively, when accounting for peripheral reflections. Using our new analysis, we investigate the effect of vessel compliance and peripheral resistance on wave intensity, peripheral reflections and reflections originating in previous cardiac cycles. PMID:24132888
-
Design Guidance for Computer-Based Procedures for Field Workers
DOE Office of Scientific and Technical Information (OSTI.GOV)
Oxstrand, Johanna; Le Blanc, Katya; Bly, Aaron
Nearly all activities that involve human interaction with nuclear power plant systems are guided by procedures, instructions, or checklists. Paper-based procedures (PBPs) currently used by most utilities have a demonstrated history of ensuring safety; however, improving procedure use could yield significant savings in increased efficiency, as well as improved safety through human performance gains. The nuclear industry is constantly trying to find ways to decrease human error rates, especially human error rates associated with procedure use. As a step toward the goal of improving field workers’ procedure use and adherence and hence improve human performance and overall system reliability, themore » U.S. Department of Energy Light Water Reactor Sustainability (LWRS) Program researchers, together with the nuclear industry, have been investigating the possibility and feasibility of replacing current paper-based procedures with computer-based procedures (CBPs). PBPs have ensured safe operation of plants for decades, but limitations in paper-based systems do not allow them to reach the full potential for procedures to prevent human errors. The environment in a nuclear power plant is constantly changing, depending on current plant status and operating mode. PBPs, which are static by nature, are being applied to a constantly changing context. This constraint often results in PBPs that are written in a manner that is intended to cover many potential operating scenarios. Hence, the procedure layout forces the operator to search through a large amount of irrelevant information to locate the pieces of information relevant for the task and situation at hand, which has potential consequences of taking up valuable time when operators must be responding to the situation, and potentially leading operators down an incorrect response path. Other challenges related to use of PBPs are management of multiple procedures, place-keeping, finding the correct procedure for a task, and relying on other sources of additional information to ensure a functional and accurate understanding of the current plant status (Converse, 1995; Fink, Killian, Hanes, and Naser, 2009; Le Blanc, Oxstrand, and Waicosky, 2012). This report provides design guidance to be used when designing the human-system interaction and the design of the graphical user interface for a CBP system. The guidance is based on human factors research related to the design and usability of CBPs conducted by Idaho National Laboratory, 2012 - 2016.« less
-
Rong, Hao; Tian, Jin
2015-05-01
The study contributes to human reliability analysis (HRA) by proposing a method that focuses more on human error causality within a sociotechnical system, illustrating its rationality and feasibility by using a case of the Minuteman (MM) III missile accident. Due to the complexity and dynamics within a sociotechnical system, previous analyses of accidents involving human and organizational factors clearly demonstrated that the methods using a sequential accident model are inadequate to analyze human error within a sociotechnical system. System-theoretic accident model and processes (STAMP) was used to develop a universal framework of human error causal analysis. To elaborate the causal relationships and demonstrate the dynamics of human error, system dynamics (SD) modeling was conducted based on the framework. A total of 41 contributing factors, categorized into four types of human error, were identified through the STAMP-based analysis. All factors are related to a broad view of sociotechnical systems, and more comprehensive than the causation presented in the accident investigation report issued officially. Recommendations regarding both technical and managerial improvement for a lower risk of the accident are proposed. The interests of an interdisciplinary approach provide complementary support between system safety and human factors. The integrated method based on STAMP and SD model contributes to HRA effectively. The proposed method will be beneficial to HRA, risk assessment, and control of the MM III operating process, as well as other sociotechnical systems. © 2014, Human Factors and Ergonomics Society.
-
Addressing the unit of analysis in medical care studies: a systematic review.
Calhoun, Aaron W; Guyatt, Gordon H; Cabana, Michael D; Lu, Downing; Turner, David A; Valentine, Stacey; Randolph, Adrienne G
2008-06-01
We assessed the frequency that patients are incorrectly used as the unit of analysis among studies of physicians' patient care behavior in articles published in high impact journals. We surveyed 30 high-impact journals across 6 medical fields for articles susceptible to unit of analysis errors published from 1994 to 2005. Three reviewers independently abstracted articles using previously published criteria to determine the presence of analytic errors. One hundred fourteen susceptible articles were found published in 15 journals, 4 journals published the majority (71 of 114 or 62.3%) of studies, 40 were intervention studies, and 74 were noninterventional studies. The unit of analysis error was present in 19 (48%) of the intervention studies and 31 (42%) of the noninterventional studies (overall error rate 44%). The frequency of the error decreased between 1994-1999 (N = 38; 65% error) and 2000-2005 (N = 76; 33% error) (P = 0.001). Although the frequency of the error in published studies is decreasing, further improvement remains desirable.
-
[Pharmaceutical care strategies to prevent medication errors].
Ucha-Samartín, Marisol; Martínez-López de Castro, Noemí; Troncoso-Mariño, Amelia; Campelo-Sánchez, Eva; Vázquez-López, Cristina; Inaraja-Bobo, María Teresa
2009-08-01
To evaluate the impact of implementing new programs to improve the quality of the pharmaceutical care and unit-dose distribution system for in-patients. An observational and prospective study was carried out in a general hospital during two different six-monthly period. Transcription and dispensation errors were evaluated in twelve wards during the first six months. Then, two new measures were introduced: the first- reference ward-pharmacist and the second-a new protocol for checking medication on the ward. Results were evaluated by SPSS v. 14 program. In the transcription evaluation, units without a ward pharmacist did not improve. Transcription errors significantly decreased in three units: gynaecology-urology (3.24% vs. 0.52%), orthopaedic (2% vs. 1.69%) and neurology-pneumology (2.81% vs. 2.02%). In dispensing, only units with the new protocol decreased their medication errors (1.77% vs. 1.24%). The participation of pharmacists in multidisciplinary teams and exhaustive protocols for dispensing medication were effective in detecting and decreasing medication errors in patients.
-
Qiao-Grider, Ying; Hung, Li-Fang; Kee, Chea-Su; Ramamirtham, Ramkumar; Smith, Earl L
2010-08-23
We analyzed the contribution of individual ocular components to vision-induced ametropias in 210 rhesus monkeys. The primary contribution to refractive-error development came from vitreous chamber depth; a minor contribution from corneal power was also detected. However, there was no systematic relationship between refractive error and anterior chamber depth or between refractive error and any crystalline lens parameter. Our results are in good agreement with previous studies in humans, suggesting that the refractive errors commonly observed in humans are created by vision-dependent mechanisms that are similar to those operating in monkeys. This concordance emphasizes the applicability of rhesus monkeys in refractive-error studies. Copyright 2010 Elsevier Ltd. All rights reserved.
-
Qiao-Grider, Ying; Hung, Li-Fang; Kee, Chea-su; Ramamirtham, Ramkumar; Smith, Earl L.
2010-01-01
We analyzed the contribution of individual ocular components to vision-induced ametropias in 210 rhesus monkeys. The primary contribution to refractive-error development came from vitreous chamber depth; a minor contribution from corneal power was also detected. However, there was no systematic relationship between refractive error and anterior chamber depth or between refractive error and any crystalline lens parameter. Our results are in good agreement with previous studies in humans, suggesting that the refractive errors commonly observed in humans are created by vision-dependent mechanisms that are similar to those operating in monkeys. This concordance emphasizes the applicability of rhesus monkeys in refractive-error studies. PMID:20600237
-
Matus, Bethany A; Bridges, Kayla M; Logomarsino, John V
2018-06-21
Individualized feeding care plans and safe handling of milk (human or formula) are critical in promoting growth, immune function, and neurodevelopment in the preterm infant. Feeding errors and disruptions or limitations to feeding processes in the neonatal intensive care unit (NICU) are associated with negative safety events. Feeding errors include contamination of milk and delivery of incorrect or expired milk and may result in adverse gastrointestinal illnesses. The purpose of this review was to evaluate the effect(s) of centralized milk preparation, use of trained technicians, use of bar code-scanning software, and collaboration between registered dietitians and registered nurses on feeding safety in the NICU. A systematic review of the literature was completed, and 12 articles were selected as relevant to search criteria. Study quality was evaluated using the Downs and Black scoring tool. An evaluation of human studies indicated that the use of centralized milk preparation, trained technicians, bar code-scanning software, and possible registered dietitian involvement decreased feeding-associated error in the NICU. A state-of-the-art NICU includes a centralized milk preparation area staffed by trained technicians, care supported by bar code-scanning software, and utilization of a registered dietitian to improve patient safety. These resources will provide nurses more time to focus on nursing-specific neonatal care. Further research is needed to evaluate the impact of factors related to feeding safety in the NICU as well as potential financial benefits of these quality improvement opportunities.
-
Schleier, Jerome J.; Peterson, Robert K.D.; Irvine, Kathryn M.; Marshall, Lucy M.; Weaver, David K.; Preftakes, Collin J.
2012-01-01
One of the more effective ways of managing high densities of adult mosquitoes that vector human and animal pathogens is ultra-low-volume (ULV) aerosol applications of insecticides. The U.S. Environmental Protection Agency uses models that are not validated for ULV insecticide applications and exposure assumptions to perform their human and ecological risk assessments. Currently, there is no validated model that can accurately predict deposition of insecticides applied using ULV technology for adult mosquito management. In addition, little is known about the deposition and drift of small droplets like those used under conditions encountered during ULV applications. The objective of this study was to perform field studies to measure environmental concentrations of insecticides and to develop a validated model to predict the deposition of ULV insecticides. The final regression model was selected by minimizing the Bayesian Information Criterion and its prediction performance was evaluated using k-fold cross validation. Density of the formulation and the density and CMD interaction coefficients were the largest in the model. The results showed that as density of the formulation decreases, deposition increases. The interaction of density and CMD showed that higher density formulations and larger droplets resulted in greater deposition. These results are supported by the aerosol physics literature. A k-fold cross validation demonstrated that the mean square error of the selected regression model is not biased, and the mean square error and mean square prediction error indicated good predictive ability.
-
Outcomes of a Failure Mode and Effects Analysis for medication errors in pediatric anesthesia.
Martin, Lizabeth D; Grigg, Eliot B; Verma, Shilpa; Latham, Gregory J; Rampersad, Sally E; Martin, Lynn D
2017-06-01
The Institute of Medicine has called for development of strategies to prevent medication errors, which are one important cause of preventable harm. Although the field of anesthesiology is considered a leader in patient safety, recent data suggest high medication error rates in anesthesia practice. Unfortunately, few error prevention strategies for anesthesia providers have been implemented. Using Toyota Production System quality improvement methodology, a multidisciplinary team observed 133 h of medication practice in the operating room at a tertiary care freestanding children's hospital. A failure mode and effects analysis was conducted to systematically deconstruct and evaluate each medication handling process step and score possible failure modes to quantify areas of risk. A bundle of five targeted countermeasures were identified and implemented over 12 months. Improvements in syringe labeling (73 to 96%), standardization of medication organization in the anesthesia workspace (0 to 100%), and two-provider infusion checks (23 to 59%) were observed. Medication error reporting improved during the project and was subsequently maintained. After intervention, the median medication error rate decreased from 1.56 to 0.95 per 1000 anesthetics. The frequency of medication error harm events reaching the patient also decreased. Systematic evaluation and standardization of medication handling processes by anesthesia providers in the operating room can decrease medication errors and improve patient safety. © 2017 John Wiley & Sons Ltd.
-
Estimation of Full-Body Poses Using Only Five Inertial Sensors: An Eager or Lazy Learning Approach?
Wouda, Frank J.; Giuberti, Matteo; Bellusci, Giovanni; Veltink, Peter H.
2016-01-01
Human movement analysis has become easier with the wide availability of motion capture systems. Inertial sensing has made it possible to capture human motion without external infrastructure, therefore allowing measurements in any environment. As high-quality motion capture data is available in large quantities, this creates possibilities to further simplify hardware setups, by use of data-driven methods to decrease the number of body-worn sensors. In this work, we contribute to this field by analyzing the capabilities of using either artificial neural networks (eager learning) or nearest neighbor search (lazy learning) for such a problem. Sparse orientation features, resulting from sensor fusion of only five inertial measurement units with magnetometers, are mapped to full-body poses. Both eager and lazy learning algorithms are shown to be capable of constructing this mapping. The full-body output poses are visually plausible with an average joint position error of approximately 7 cm, and average joint angle error of 7∘. Additionally, the effects of magnetic disturbances typical in orientation tracking on the estimation of full-body poses was also investigated, where nearest neighbor search showed better performance for such disturbances. PMID:27983676
-
Estimation of Full-Body Poses Using Only Five Inertial Sensors: An Eager or Lazy Learning Approach?
Wouda, Frank J; Giuberti, Matteo; Bellusci, Giovanni; Veltink, Peter H
2016-12-15
Human movement analysis has become easier with the wide availability of motion capture systems. Inertial sensing has made it possible to capture human motion without external infrastructure, therefore allowing measurements in any environment. As high-quality motion capture data is available in large quantities, this creates possibilities to further simplify hardware setups, by use of data-driven methods to decrease the number of body-worn sensors. In this work, we contribute to this field by analyzing the capabilities of using either artificial neural networks (eager learning) or nearest neighbor search (lazy learning) for such a problem. Sparse orientation features, resulting from sensor fusion of only five inertial measurement units with magnetometers, are mapped to full-body poses. Both eager and lazy learning algorithms are shown to be capable of constructing this mapping. The full-body output poses are visually plausible with an average joint position error of approximately 7 cm, and average joint angle error of 7 ∘ . Additionally, the effects of magnetic disturbances typical in orientation tracking on the estimation of full-body poses was also investigated, where nearest neighbor search showed better performance for such disturbances.
-
Designing and Developing Web-Based Administrative Tools for Program Management
NASA Technical Reports Server (NTRS)
Gutensohn, Michael
2017-01-01
The task assigned for this internship was to develop a new tool for tracking projects, their subsystems, the leads, backups, and other employees assigned to them, as well as all the relevant information related to the employee (WBS (time charge) codes, time distribution, certifications, and assignments). Currently, this data is tracked manually using a number of different spreadsheets and other tools simultaneously by a number of different people; some of these documents are then merged into one large document. This often leads to inconsistencies and loss in data due to human error. By simplifying the process of tracking this data and aggregating it into a single tool, it is possible to significantly decrease the potential for human error and time spent collecting and checking this information. II. Objective The main objective of this internship is to develop a web-based tool using Ruby on Rails to serve as a method of easily tracking projects, subsystems, and points of contact, along with employees, their assignments, time distribution, certifications, and contact information. Additionally, this tool must be capable of generating a number of different reports based on the data collected. It was important that this tool deliver all of this information using a readable and intuitive interface.
-
Andriole, Katherine P; Morin, Richard L; Arenson, Ronald L; Carrino, John A; Erickson, Bradley J; Horii, Steven C; Piraino, David W; Reiner, Bruce I; Seibert, J Anthony; Siegel, Eliot
2004-12-01
The Society for Computer Applications in Radiology (SCAR) Transforming the Radiological Interpretation Process (TRIP) Initiative aims to spearhead research, education, and discovery of innovative solutions to address the problem of information and image data overload. The initiative will foster interdisciplinary research on technological, environmental and human factors to better manage and exploit the massive amounts of data. TRIP will focus on the following basic objectives: improving the efficiency of interpretation of large data sets, improving the timeliness and effectiveness of communication, and decreasing medical errors. The ultimate goal of the initiative is to improve the quality and safety of patient care. Interdisciplinary research into several broad areas will be necessary to make progress in managing the ever-increasing volume of data. The six concepts involved are human perception, image processing and computer-aided detection (CAD), visualization, navigation and usability, databases and integration, and evaluation and validation of methods and performance. The result of this transformation will affect several key processes in radiology, including image interpretation; communication of imaging results; workflow and efficiency within the health care enterprise; diagnostic accuracy and a reduction in medical errors; and, ultimately, the overall quality of care.
-
Huckels-Baumgart, Saskia; Baumgart, André; Buschmann, Ute; Schüpfer, Guido; Manser, Tanja
2016-12-21
Interruptions and errors during the medication process are common, but published literature shows no evidence supporting whether separate medication rooms are an effective single intervention in reducing interruptions and errors during medication preparation in hospitals. We tested the hypothesis that the rate of interruptions and reported medication errors would decrease as a result of the introduction of separate medication rooms. Our aim was to evaluate the effect of separate medication rooms on interruptions during medication preparation and on self-reported medication error rates. We performed a preintervention and postintervention study using direct structured observation of nurses during medication preparation and daily structured medication error self-reporting of nurses by questionnaires in 2 wards at a major teaching hospital in Switzerland. A volunteer sample of 42 nurses was observed preparing 1498 medications for 366 patients over 17 hours preintervention and postintervention on both wards. During 122 days, nurses completed 694 reporting sheets containing 208 medication errors. After the introduction of the separate medication room, the mean interruption rate decreased significantly from 51.8 to 30 interruptions per hour (P < 0.01), and the interruption-free preparation time increased significantly from 1.4 to 2.5 minutes (P < 0.05). Overall, the mean medication error rate per day was also significantly reduced after implementation of the separate medication room from 1.3 to 0.9 errors per day (P < 0.05). The present study showed the positive effect of a hospital-based intervention; after the introduction of the separate medication room, the interruption and medication error rates decreased significantly.
-
The fitness cost of mis-splicing is the main determinant of alternative splicing patterns.
Saudemont, Baptiste; Popa, Alexandra; Parmley, Joanna L; Rocher, Vincent; Blugeon, Corinne; Necsulea, Anamaria; Meyer, Eric; Duret, Laurent
2017-10-30
Most eukaryotic genes are subject to alternative splicing (AS), which may contribute to the production of protein variants or to the regulation of gene expression via nonsense-mediated messenger RNA (mRNA) decay (NMD). However, a fraction of splice variants might correspond to spurious transcripts and the question of the relative proportion of splicing errors to functional splice variants remains highly debated. We propose a test to quantify the fraction of AS events corresponding to errors. This test is based on the fact that the fitness cost of splicing errors increases with the number of introns in a gene and with expression level. We analyzed the transcriptome of the intron-rich eukaryote Paramecium tetraurelia. We show that in both normal and in NMD-deficient cells, AS rates strongly decrease with increasing expression level and with increasing number of introns. This relationship is observed for AS events that are detectable by NMD as well as for those that are not, which invalidates the hypothesis of a link with the regulation of gene expression. Our results show that in genes with a median expression level, 92-98% of observed splice variants correspond to errors. We observed the same patterns in human transcriptomes and we further show that AS rates correlate with the fitness cost of splicing errors. These observations indicate that genes under weaker selective pressure accumulate more maladaptive substitutions and are more prone to splicing errors. Thus, to a large extent, patterns of gene expression variants simply reflect the balance between selection, mutation, and drift.
-
Contributions of the cerebellum and the motor cortex to acquisition and retention of motor memories
Herzfeld, David J.; Pastor, Damien; Haith, Adrian M.; Rossetti, Yves; Shadmehr, Reza; O’Shea, Jacinta
2014-01-01
We investigated the contributions of the cerebellum and the motor cortex (M1) to acquisition and retention of human motor memories in a force field reaching task. We found that anodal transcranial direct current stimulation (tDCS) of the cerebellum, a technique that is thought to increase neuronal excitability, increased the ability to learn from error and form an internal model of the field, while cathodal cerebellar stimulation reduced this error-dependent learning. In addition, cathodal cerebellar stimulation disrupted the ability to respond to error within a reaching movement, reducing the gain of the sensory-motor feedback loop. By contrast, anodal M1 stimulation had no significant effects on these variables. During sham stimulation, early in training the acquired motor memory exhibited rapid decay in error-clamp trials. With further training the rate of decay decreased, suggesting that with training the motor memory was transformed from a labile to a more stable state. Surprisingly, neither cerebellar nor M1 stimulation altered these decay patterns. Participants returned 24 hours later and were re-tested in error-clamp trials without stimulation. The cerebellar group that had learned the task with cathodal stimulation exhibited significantly impaired retention, and retention was not improved by M1 anodal stimulation. In summary, non-invasive cerebellar stimulation resulted in polarity-dependent up- or down-regulation of error-dependent motor learning. In addition, cathodal cerebellar stimulation during acquisition impaired the ability to retain the motor memory overnight. Thus, in the force field task we found a critical role for the cerebellum in both formation of motor memory and its retention. PMID:24816533
-
Human Error as an Emergent Property of Action Selection and Task Place-Holding.
Tamborello, Franklin P; Trafton, J Gregory
2017-05-01
A computational process model could explain how the dynamic interaction of human cognitive mechanisms produces each of multiple error types. With increasing capability and complexity of technological systems, the potential severity of consequences of human error is magnified. Interruption greatly increases people's error rates, as does the presence of other information to maintain in an active state. The model executed as a software-instantiated Monte Carlo simulation. It drew on theoretical constructs such as associative spreading activation for prospective memory, explicit rehearsal strategies as a deliberate cognitive operation to aid retrospective memory, and decay. The model replicated the 30% effect of interruptions on postcompletion error in Ratwani and Trafton's Stock Trader task, the 45% interaction effect on postcompletion error of working memory capacity and working memory load from Byrne and Bovair's Phaser Task, as well as the 5% perseveration and 3% omission effects of interruption from the UNRAVEL Task. Error classes including perseveration, omission, and postcompletion error fall naturally out of the theory. The model explains post-interruption error in terms of task state representation and priming for recall of subsequent steps. Its performance suggests that task environments providing more cues to current task state will mitigate error caused by interruption. For example, interfaces could provide labeled progress indicators or facilities for operators to quickly write notes about their task states when interrupted.
-
NASA Astrophysics Data System (ADS)
Tian, F.; Lu, Y.
2017-12-01
Based on socioeconomic and hydrological data in three arid inland basins and error analysis, the dynamics of human water consumption (HWC) are analyzed to be asymmetric, i.e., HWC increase rapidly in wet periods while maintain or decrease slightly in dry periods. Besides the qualitative analysis that in wet periods great water availability inspires HWC to grow fast but the now expanded economy is managed to sustain by over-exploitation in dry periods, two quantitative models are established and tested, based on expected utility theory (EUT) and prospect theory (PT) respectively. EUT states that humans make decisions based on the total expected utility, namely the sum of utility function multiplied by probability of each result, while PT states that the utility function is defined over gains and losses separately, and probability should be replaced by probability weighting function.
-
How to minimize perceptual error and maximize expertise in medical imaging
NASA Astrophysics Data System (ADS)
Kundel, Harold L.
2007-03-01
Visual perception is such an intimate part of human experience that we assume that it is entirely accurate. Yet, perception accounts for about half of the errors made by radiologists using adequate imaging technology. The true incidence of errors that directly affect patient well being is not known but it is probably at the lower end of the reported values of 3 to 25%. Errors in screening for lung and breast cancer are somewhat better characterized than errors in routine diagnosis. About 25% of cancers actually recorded on the images are missed and cancer is falsely reported in about 5% of normal people. Radiologists must strive to decrease error not only because of the potential impact on patient care but also because substantial variation among observers undermines confidence in the reliability of imaging diagnosis. Observer variation also has a major impact on technology evaluation because the variation between observers is frequently greater than the difference in the technologies being evaluated. This has become particularly important in the evaluation of computer aided diagnosis (CAD). Understanding the basic principles that govern the perception of medical images can provide a rational basis for making recommendations for minimizing perceptual error. It is convenient to organize thinking about perceptual error into five steps. 1) The initial acquisition of the image by the eye-brain (contrast and detail perception). 2) The organization of the retinal image into logical components to produce a literal perception (bottom-up, global, holistic). 3) Conversion of the literal perception into a preferred perception by resolving ambiguities in the literal perception (top-down, simulation, synthesis). 4) Selective visual scanning to acquire details that update the preferred perception. 5) Apply decision criteria to the preferred perception. The five steps are illustrated with examples from radiology with suggestions for minimizing error. The role of perceptual learning in the development of expertise is also considered.
-
The Sustained Influence of an Error on Future Decision-Making.
Schiffler, Björn C; Bengtsson, Sara L; Lundqvist, Daniel
2017-01-01
Post-error slowing (PES) is consistently observed in decision-making tasks after negative feedback. Yet, findings are inconclusive as to whether PES supports performance accuracy. We addressed the role of PES by employing drift diffusion modeling which enabled us to investigate latent processes of reaction times and accuracy on a large-scale dataset (>5,800 participants) of a visual search experiment with emotional face stimuli. In our experiment, post-error trials were characterized by both adaptive and non-adaptive decision processes. An adaptive increase in participants' response threshold was sustained over several trials post-error. Contrarily, an initial decrease in evidence accumulation rate, followed by an increase on the subsequent trials, indicates a momentary distraction of task-relevant attention and resulted in an initial accuracy drop. Higher values of decision threshold and evidence accumulation on the post-error trial were associated with higher accuracy on subsequent trials which further gives credence to these parameters' role in post-error adaptation. Finally, the evidence accumulation rate post-error decreased when the error trial presented angry faces, a finding suggesting that the post-error decision can be influenced by the error context. In conclusion, we demonstrate that error-related response adaptations are multi-component processes that change dynamically over several trials post-error.
-
Factors associated with reporting of medication errors by Israeli nurses.
Kagan, Ilya; Barnoy, Sivia
2008-01-01
This study investigated medication error reporting among Israeli nurses, the relationship between nurses' personal views about error reporting, and the impact of the safety culture of the ward and hospital on this reporting. Nurses (n = 201) completed a questionnaire related to different aspects of error reporting (frequency, organizational norms of dealing with errors, and personal views on reporting). The higher the error frequency, the more errors went unreported. If the ward nurse manager corrected errors on the ward, error self-reporting decreased significantly. Ward nurse managers have to provide good role models.
-
Simultaneous Control of Error Rates in fMRI Data Analysis
Kang, Hakmook; Blume, Jeffrey; Ombao, Hernando; Badre, David
2015-01-01
The key idea of statistical hypothesis testing is to fix, and thereby control, the Type I error (false positive) rate across samples of any size. Multiple comparisons inflate the global (family-wise) Type I error rate and the traditional solution to maintaining control of the error rate is to increase the local (comparison-wise) Type II error (false negative) rates. However, in the analysis of human brain imaging data, the number of comparisons is so large that this solution breaks down: the local Type II error rate ends up being so large that scientifically meaningful analysis is precluded. Here we propose a novel solution to this problem: allow the Type I error rate to converge to zero along with the Type II error rate. It works because when the Type I error rate per comparison is very small, the accumulation (or global) Type I error rate is also small. This solution is achieved by employing the Likelihood paradigm, which uses likelihood ratios to measure the strength of evidence on a voxel-by-voxel basis. In this paper, we provide theoretical and empirical justification for a likelihood approach to the analysis of human brain imaging data. In addition, we present extensive simulations that show the likelihood approach is viable, leading to ‘cleaner’ looking brain maps and operationally superiority (lower average error rate). Finally, we include a case study on cognitive control related activation in the prefrontal cortex of the human brain. PMID:26272730
-
Human error and the search for blame
NASA Technical Reports Server (NTRS)
Denning, Peter J.
1989-01-01
Human error is a frequent topic in discussions about risks in using computer systems. A rational analysis of human error leads through the consideration of mistakes to standards that designers use to avoid mistakes that lead to known breakdowns. The irrational side, however, is more interesting. It conditions people to think that breakdowns are inherently wrong and that there is ultimately someone who is responsible. This leads to a search for someone to blame which diverts attention from: learning from the mistakes; seeing the limitations of current engineering methodology; and improving the discourse of design.
-
Errors Affect Hypothetical Intertemporal Food Choice in Women
Sellitto, Manuela; di Pellegrino, Giuseppe
2014-01-01
Growing evidence suggests that the ability to control behavior is enhanced in contexts in which errors are more frequent. Here we investigated whether pairing desirable food with errors could decrease impulsive choice during hypothetical temporal decisions about food. To this end, healthy women performed a Stop-signal task in which one food cue predicted high-error rate, and another food cue predicted low-error rate. Afterwards, we measured participants’ intertemporal preferences during decisions between smaller-immediate and larger-delayed amounts of food. We expected reduced sensitivity to smaller-immediate amounts of food associated with high-error rate. Moreover, taking into account that deprivational states affect sensitivity for food, we controlled for participants’ hunger. Results showed that pairing food with high-error likelihood decreased temporal discounting. This effect was modulated by hunger, indicating that, the lower the hunger level, the more participants showed reduced impulsive preference for the food previously associated with a high number of errors as compared with the other food. These findings reveal that errors, which are motivationally salient events that recruit cognitive control and drive avoidance learning against error-prone behavior, are effective in reducing impulsive choice for edible outcomes. PMID:25244534
-
NASA Astrophysics Data System (ADS)
Pokhrel, Samir; Saha, Subodh Kumar; Dhakate, Ashish; Rahman, Hasibur; Chaudhari, Hemantkumar S.; Salunke, Kiran; Hazra, Anupam; Sujith, K.; Sikka, D. R.
2016-04-01
A detailed analysis of sensitivity to the initial condition for the simulation of the Indian summer monsoon using retrospective forecast by the latest version of the Climate Forecast System version-2 (CFSv2) is carried out. This study primarily focuses on the tropical region of Indian and Pacific Ocean basin, with special emphasis on the Indian land region. The simulated seasonal mean and the inter-annual standard deviations of rainfall, upper and lower level atmospheric circulations and Sea Surface Temperature (SST) tend to be more skillful as the lead forecast time decreases (5 month lead to 0 month lead time i.e. L5-L0). In general spatial correlation (bias) increases (decreases) as forecast lead time decreases. This is further substantiated by their averaged value over the selected study regions over the Indian and Pacific Ocean basins. The tendency of increase (decrease) of model bias with increasing (decreasing) forecast lead time also indicates the dynamical drift of the model. Large scale lower level circulation (850 hPa) shows enhancement of anomalous westerlies (easterlies) over the tropical region of the Indian Ocean (Western Pacific Ocean), which indicates the enhancement of model error with the decrease in lead time. At the upper level circulation (200 hPa) biases in both tropical easterly jet and subtropical westerlies jet tend to decrease as the lead time decreases. Despite enhancement of the prediction skill, mean SST bias seems to be insensitive to the initialization. All these biases are significant and together they make CFSv2 vulnerable to seasonal uncertainties in all the lead times. Overall the zeroth lead (L0) seems to have the best skill, however, in case of Indian summer monsoon rainfall (ISMR), the 3 month lead forecast time (L3) has the maximum ISMR prediction skill. This is valid using different independent datasets, wherein these maximum skill scores are 0.64, 0.42 and 0.57 with respect to the Global Precipitation Climatology Project, CPC Merged Analysis of Precipitation and the India Meteorological Department precipitation dataset respectively for L3. Despite significant El-Niño Southern Oscillation (ENSO) spring predictability barrier at L3, the ISMR skill score is highest at L3. Further, large scale zonal wind shear (Webster-Yang index) and SST over Niño3.4 region is best at L1 and L0. This implies that predictability aspect of ISMR is controlled by factors other than ENSO and Indian Ocean Dipole. Also, the model error (forecast error) outruns the error acquired by the inadequacies in the initial conditions (predictability error). Thus model deficiency is having more serious consequences as compared to the initial condition error for the seasonal forecast. All the model parameters show the increase in the predictability error as the lead decreases over the equatorial eastern Pacific basin and peaks at L2, then it further decreases. The dynamical consistency of both the forecast and the predictability error among all the variables indicates that these biases are purely systematic in nature and improvement of the physical processes in the CFSv2 may enhance the overall predictability.
-
NASA Astrophysics Data System (ADS)
Li, Will X. Y.; Cui, Ke; Zhang, Wei
2017-04-01
Cognitive neural prosthesis is a manmade device which can be used to restore or compensate for lost human cognitive modalities. The generalized Laguerre-Volterra (GLV) network serves as a robust mathematical underpinning for the development of such prosthetic instrument. In this paper, a hardware implementation scheme of Gauss error function for the GLV network targeting reconfigurable platforms is reported. Numerical approximations are formulated which transform the computation of nonelementary function into combinational operations of elementary functions, and memory-intensive look-up table (LUT) based approaches can therefore be circumvented. The computational precision can be made adjustable with the utilization of an error compensation scheme, which is proposed based on the experimental observation of the mathematical characteristics of the error trajectory. The precision can be further customizable by exploiting the run-time characteristics of the reconfigurable system. Compared to the polynomial expansion based implementation scheme, the utilization of slice LUTs, occupied slices, and DSP48E1s on a Xilinx XC6VLX240T field-programmable gate array has decreased by 94.2%, 94.1%, and 90.0%, respectively. While compared to the look-up table based scheme, 1.0 ×1017 bits of storage can be spared under the maximum allowable error of 1.0 ×10-3 . The proposed implementation scheme can be employed in the study of large-scale neural ensemble activity and in the design and development of neural prosthetic device.
-
Peripheral refraction in normal infant rhesus monkeys
Hung, Li-Fang; Ramamirtham, Ramkumar; Huang, Juan; Qiao-Grider, Ying; Smith, Earl L.
2008-01-01
Purpose To characterize peripheral refractions in infant monkeys. Methods Cross-sectional data for horizontal refractions were obtained from 58 normal rhesus monkeys at 3 weeks of age. Longitudinal data were obtained for both the vertical and horizontal meridians from 17 monkeys. Refractive errors were measured by retinoscopy along the pupillary axis and at eccentricities of 15, 30, and 45 degrees. Axial dimensions and corneal power were measured by ultrasonography and keratometry, respectively. Results In infant monkeys, the degree of radial astigmatism increased symmetrically with eccentricity in all meridians. There were, however, initial nasal-temporal and superior-inferior asymmetries in the spherical-equivalent refractive errors. Specifically, the refractions in the temporal and superior fields were similar to the central ametropia, but the refractions in the nasal and inferior fields were more myopic than the central ametropia and the relative nasal field myopia increased with the degree of central hyperopia. With age, the degree of radial astigmatism decreased in all meridians and the refractions became more symmetrical along both the horizontal and vertical meridians; small degrees of relative myopia were evident in all fields. Conclusions As in adult humans, refractive error varied as a function of eccentricity in infant monkeys and the pattern of peripheral refraction varied with the central refractive error. With age, emmetropization occurred for both central and peripheral refractive errors resulting in similar refractions across the central 45 degrees of the visual field, which may reflect the actions of vision-dependent, growth-control mechanisms operating over a wide area of the posterior globe. PMID:18487366
-
Why do adult dogs (Canis familiaris) commit the A-not-B search error?
Sümegi, Zsófia; Kis, Anna; Miklósi, Ádám; Topál, József
2014-02-01
It has been recently reported that adult domestic dogs, like human infants, tend to commit perseverative search errors; that is, they select the previously rewarded empty location in Piagetian A-not-B search task because of the experimenter's ostensive communicative cues. There is, however, an ongoing debate over whether these findings reveal that dogs can use the human ostensive referential communication as a source of information or the phenomenon can be accounted for by "more simple" explanations like insufficient attention and learning based on local enhancement. In 2 experiments the authors systematically manipulated the type of human cueing (communicative or noncommunicative) adjacent to the A hiding place during both the A and B trials. Results highlight 3 important aspects of the dogs' A-not-B error: (a) search errors are influenced to a certain extent by dogs' motivation to retrieve the toy object; (b) human communicative and noncommunicative signals have different error-inducing effects; and (3) communicative signals presented at the A hiding place during the B trials but not during the A trials play a crucial role in inducing the A-not-B error and it can be induced even without demonstrating repeated hiding events at location A. These findings further confirm the notion that perseverative search error, at least partially, reflects a "ready-to-obey" attitude in the dog rather than insufficient attention and/or working memory.
-
The decline and fall of Type II error rates
Steve Verrill; Mark Durst
2005-01-01
For general linear models with normally distributed random errors, the probability of a Type II error decreases exponentially as a function of sample size. This potentially rapid decline reemphasizes the importance of performing power calculations.
-
Development of multiple-eye PIV using mirror array
NASA Astrophysics Data System (ADS)
Maekawa, Akiyoshi; Sakakibara, Jun
2018-06-01
In order to reduce particle image velocimetry measurement error, we manufactured an ellipsoidal polyhedral mirror and placed it between a camera and flow target to capture n images of identical particles from n (=80 maximum) different directions. The 3D particle positions were determined from the ensemble average of n C2 intersecting points of a pair of line-of-sight back-projected points from a particle found in any combination of two images in the n images. The method was then applied to a rigid-body rotating flow and a turbulent pipe flow. In the former measurement, bias error and random error fell in a range of ±0.02 pixels and 0.02–0.05 pixels, respectively; additionally, random error decreased in proportion to . In the latter measurement, in which the measured value was compared to direct numerical simulation, bias error was reduced and random error also decreased in proportion to .
-
Common medial frontal mechanisms of adaptive control in humans and rodents
Frank, Michael J.; Laubach, Mark
2013-01-01
In this report, we describe how common brain networks within the medial frontal cortex facilitate adaptive behavioral control in rodents and humans. We demonstrate that low frequency oscillations below 12 Hz are dramatically modulated after errors in humans over mid-frontal cortex and in rats within prelimbic and anterior cingulate regions of medial frontal cortex. These oscillations were phase-locked between medial frontal cortex and motor areas in both rats and humans. In rats, single neurons that encoded prior behavioral outcomes were phase-coherent with low-frequency field oscillations particularly after errors. Inactivating medial frontal regions in rats led to impaired behavioral adjustments after errors, eliminated the differential expression of low frequency oscillations after errors, and increased low-frequency spike-field coupling within motor cortex. Our results describe a novel mechanism for behavioral adaptation via low-frequency oscillations and elucidate how medial frontal networks synchronize brain activity to guide performance. PMID:24141310
-
#2 - An Empirical Assessment of Exposure Measurement Error ...
Background• Differing degrees of exposure error acrosspollutants• Previous focus on quantifying and accounting forexposure error in single-pollutant models• Examine exposure errors for multiple pollutantsand provide insights on the potential for bias andattenuation of effect estimates in single and bipollutantepidemiological models The National Exposure Research Laboratory (NERL) Human Exposure and Atmospheric Sciences Division (HEASD) conducts research in support of EPA mission to protect human health and the environment. HEASD research program supports Goal 1 (Clean Air) and Goal 4 (Healthy People) of EPA strategic plan. More specifically, our division conducts research to characterize the movement of pollutants from the source to contact with humans. Our multidisciplinary research program produces Methods, Measurements, and Models to identify relationships between and characterize processes that link source emissions, environmental concentrations, human exposures, and target-tissue dose. The impact of these tools is improved regulatory programs and policies for EPA.
-
Walter, Brittany S; Schultz, John J
2013-05-10
Scene mapping is an integral aspect of processing a scene with scattered human remains. By utilizing the appropriate mapping technique, investigators can accurately document the location of human remains and maintain a precise geospatial record of evidence. One option that has not received much attention for mapping forensic evidence is the differential global positioning (DGPS) unit, as this technology now provides decreased positional error suitable for mapping scenes. Because of the lack of knowledge concerning this utility in mapping a scene, controlled research is necessary to determine the practicality of using newer and enhanced DGPS units in mapping scattered human remains. The purpose of this research was to quantify the accuracy of a DGPS unit for mapping skeletal dispersals and to determine the applicability of this utility in mapping a scene with dispersed remains. First, the accuracy of the DGPS unit in open environments was determined using known survey markers in open areas. Secondly, three simulated scenes exhibiting different types of dispersals were constructed and mapped in an open environment using the DGPS. Variables considered during data collection included the extent of the dispersal, data collection time, data collected on different days, and different postprocessing techniques. Data were differentially postprocessed and compared in a geographic information system (GIS) to evaluate the most efficient recordation methods. Results of this study demonstrate that the DGPS is a viable option for mapping dispersed human remains in open areas. The accuracy of collected point data was 11.52 and 9.55 cm for 50- and 100-s collection times, respectfully, and the orientation and maximum length of long bones was maintained. Also, the use of error buffers for point data of bones in maps demonstrated the error of the DGPS unit, while showing that the context of the dispersed skeleton was accurately maintained. Furthermore, the application of a DGPS for accurate scene mapping is discussed and guidelines concerning the implementation of this technology for mapping human scattered skeletal remains in open environments are provided. Copyright © 2013 Elsevier Ireland Ltd. All rights reserved.
-
Decreased attention to object size information in scale errors performers.
Grzyb, Beata J; Cangelosi, Angelo; Cattani, Allegra; Floccia, Caroline
2017-05-01
Young children sometimes make serious attempts to perform impossible actions on miniature objects as if they were full-size objects. The existing explanations of these curious action errors assume (but never explicitly tested) children's decreased attention to object size information. This study investigated the attention to object size information in scale errors performers. Two groups of children aged 18-25 months (N=52) and 48-60 months (N=23) were tested in two consecutive tasks: an action task that replicated the original scale errors elicitation situation, and a looking task that involved watching on a computer screen actions performed with adequate to inadequate size object. Our key finding - that children performing scale errors in the action task subsequently pay less attention to size changes than non-scale errors performers in the looking task - suggests that the origins of scale errors in childhood operate already at the perceptual level, and not at the action level. Copyright © 2017 Elsevier Inc. All rights reserved.
-
Fore, Amanda M; Sculli, Gary L; Albee, Doreen; Neily, Julia
2013-01-01
To implement the sterile cockpit principle to decrease interruptions and distractions during high volume medication administration and reduce the number of medication errors. While some studies have described the importance of reducing interruptions as a tactic to reduce medication errors, work is needed to assess the impact on patient outcomes. Data regarding the type and frequency of distractions were collected during the first 11 weeks of implementation. Medication error rates were tracked 1 year before and after 1 year implementation. Simple regression analysis showed a decrease in the mean number of distractions, (β = -0.193, P = 0.02) over time. The medication error rate decreased by 42.78% (P = 0.04) after implementation of the sterile cockpit principle. The use of crew resource management techniques, including the sterile cockpit principle, applied to medication administration has a significant impact on patient safety. Applying the sterile cockpit principle to inpatient medical units is a feasible approach to reduce the number of distractions during the administration of medication, thus, reducing the likelihood of medication error. 'Do Not Disturb' signs and vests are inexpensive, simple interventions that can be used as reminders to decrease distractions. © 2012 Blackwell Publishing Ltd.
-
Moran, Lauren V; Stoeckel, Luke E; Wang, Kristina; Caine, Carolyn E; Villafuerte, Rosemond; Calderon, Vanessa; Baker, Justin T; Ongur, Dost; Janes, Amy C; Evins, A Eden; Pizzagalli, Diego A
2018-03-01
Nicotine improves attention and processing speed in individuals with schizophrenia. Few studies have investigated the effects of nicotine on cognitive control. Prior functional magnetic resonance imaging (fMRI) research demonstrates blunted activation of dorsal anterior cingulate cortex (dACC) and rostral anterior cingulate cortex (rACC) in response to error and decreased post-error slowing in schizophrenia. Participants with schizophrenia (n = 13) and healthy controls (n = 12) participated in a randomized, placebo-controlled, crossover study of the effects of transdermal nicotine on cognitive control. For each drug condition, participants underwent fMRI while performing the stop signal task where participants attempt to inhibit prepotent responses to "go (motor activation)" signals when an occasional "stop (motor inhibition)" signal appears. Error processing was evaluated by comparing "stop error" trials (failed response inhibition) to "go" trials. Resting-state fMRI data were collected prior to the task. Participants with schizophrenia had increased nicotine-induced activation of right caudate in response to errors compared to controls (DRUG × GROUP effect: p corrected < 0.05). Both groups had significant nicotine-induced activation of dACC and rACC in response to errors. Using right caudate activation to errors as a seed for resting-state functional connectivity analysis, relative to controls, participants with schizophrenia had significantly decreased connectivity between the right caudate and dACC/bilateral dorsolateral prefrontal cortices. In sum, we replicated prior findings of decreased post-error slowing in schizophrenia and found that nicotine was associated with more adaptive (i.e., increased) post-error reaction time (RT). This proof-of-concept pilot study suggests a role for nicotinic agents in targeting cognitive control deficits in schizophrenia.
-
Lexical Errors and Accuracy in Foreign Language Writing. Second Language Acquisition
ERIC Educational Resources Information Center
del Pilar Agustin Llach, Maria
2011-01-01
Lexical errors are a determinant in gaining insight into vocabulary acquisition, vocabulary use and writing quality assessment. Lexical errors are very frequent in the written production of young EFL learners, but they decrease as learners gain proficiency. Misspellings are the most common category, but formal errors give way to semantic-based…
-
Cutting the Cord: Discrimination and Command Responsibility in Autonomous Lethal Weapons
2014-02-13
machine responses to identical stimuli, and it was the job of a third party human “witness” to determine which participant was man and which was...machines may be error free, but there are potential benefits to be gained through autonomy if machines can meet or exceed human performance in...lieu of human operators and reap the benefits that autonomy provides. Human and Machine Error It would be foolish to assert that either humans
-
Human error identification for laparoscopic surgery: Development of a motion economy perspective.
Al-Hakim, Latif; Sevdalis, Nick; Maiping, Tanaphon; Watanachote, Damrongpan; Sengupta, Shomik; Dissaranan, Charuspong
2015-09-01
This study postulates that traditional human error identification techniques fail to consider motion economy principles and, accordingly, their applicability in operating theatres may be limited. This study addresses this gap in the literature with a dual aim. First, it identifies the principles of motion economy that suit the operative environment and second, it develops a new error mode taxonomy for human error identification techniques which recognises motion economy deficiencies affecting the performance of surgeons and predisposing them to errors. A total of 30 principles of motion economy were developed and categorised into five areas. A hierarchical task analysis was used to break down main tasks of a urological laparoscopic surgery (hand-assisted laparoscopic nephrectomy) to their elements and the new taxonomy was used to identify errors and their root causes resulting from violation of motion economy principles. The approach was prospectively tested in 12 observed laparoscopic surgeries performed by 5 experienced surgeons. A total of 86 errors were identified and linked to the motion economy deficiencies. Results indicate the developed methodology is promising. Our methodology allows error prevention in surgery and the developed set of motion economy principles could be useful for training surgeons on motion economy principles. Copyright © 2015 Elsevier Ltd and The Ergonomics Society. All rights reserved.
-
Managing human error in aviation.
Helmreich, R L
1997-05-01
Crew resource management (CRM) programs were developed to address team and leadership aspects of piloting modern airplanes. The goal is to reduce errors through team work. Human factors research and social, cognitive, and organizational psychology are used to develop programs tailored for individual airlines. Flight crews study accident case histories, group dynamics, and human error. Simulators provide pilots with the opportunity to solve complex flight problems. CRM in the simulator is called line-oriented flight training (LOFT). In automated cockpits CRM promotes the idea of automation as a crew member. Cultural aspects of aviation include professional, business, and national culture. The aviation CRM model has been adapted for training surgeons and operating room staff in human factors.
-
Empirical Analysis of Systematic Communication Errors.
1981-09-01
human o~ . .... 8 components in communication systems. (Systematic errors were defined to be those that occur regularly in human communication links...phase of the human communication process and focuses on the linkage between a specific piece of information (and the receiver) and the transmission...communication flow. (2) Exchange. Exchange is the next phase in human communication and entails a concerted effort on the part of the sender and receiver to share
-
NASA Technical Reports Server (NTRS)
DeMott, Diana
2013-01-01
Compared to equipment designed to perform the same function over and over, humans are just not as reliable. Computers and machines perform the same action in the same way repeatedly getting the same result, unless equipment fails or a human interferes. Humans who are supposed to perform the same actions repeatedly often perform them incorrectly due to a variety of issues including: stress, fatigue, illness, lack of training, distraction, acting at the wrong time, not acting when they should, not following procedures, misinterpreting information or inattention to detail. Why not use robots and automatic controls exclusively if human error is so common? In an emergency or off normal situation that the computer, robotic element, or automatic control system is not designed to respond to, the result is failure unless a human can intervene. The human in the loop may be more likely to cause an error, but is also more likely to catch the error and correct it. When it comes to unexpected situations, or performing multiple tasks outside the defined mission parameters, humans are the only viable alternative. Human Reliability Assessments (HRA) identifies ways to improve human performance and reliability and can lead to improvements in systems designed to interact with humans. Understanding the context of the situation that can lead to human errors, which include taking the wrong action, no action or making bad decisions provides additional information to mitigate risks. With improved human reliability comes reduced risk for the overall operation or project.
-
Identifying Human Factors Issues in Aircraft Maintenance Operations
NASA Technical Reports Server (NTRS)
Veinott, Elizabeth S.; Kanki, Barbara G.; Shafto, Michael G. (Technical Monitor)
1995-01-01
Maintenance operations incidents submitted to the Aviation Safety Reporting System (ASRS) between 1986-1992 were systematically analyzed in order to identify issues relevant to human factors and crew coordination. This exploratory analysis involved 95 ASRS reports which represented a wide range of maintenance incidents. The reports were coded and analyzed according to the type of error (e.g, wrong part, procedural error, non-procedural error), contributing factors (e.g., individual, within-team, cross-team, procedure, tools), result of the error (e.g., aircraft damage or not) as well as the operational impact (e.g., aircraft flown to destination, air return, delay at gate). The main findings indicate that procedural errors were most common (48.4%) and that individual and team actions contributed to the errors in more than 50% of the cases. As for operational results, most errors were either corrected after landing at the destination (51.6%) or required the flight crew to stop enroute (29.5%). Interactions among these variables are also discussed. This analysis is a first step toward developing a taxonomy of crew coordination problems in maintenance. By understanding what variables are important and how they are interrelated, we may develop intervention strategies that are better tailored to the human factor issues involved.
-
Managing Errors to Reduce Accidents in High Consequence Networked Information Systems
DOE Office of Scientific and Technical Information (OSTI.GOV)
Ganter, J.H.
1999-02-01
Computers have always helped to amplify and propagate errors made by people. The emergence of Networked Information Systems (NISs), which allow people and systems to quickly interact worldwide, has made understanding and minimizing human error more critical. This paper applies concepts from system safety to analyze how hazards (from hackers to power disruptions) penetrate NIS defenses (e.g., firewalls and operating systems) to cause accidents. Such events usually result from both active, easily identified failures and more subtle latent conditions that have resided in the system for long periods. Both active failures and latent conditions result from human errors. We classifymore » these into several types (slips, lapses, mistakes, etc.) and provide NIS examples of how they occur. Next we examine error minimization throughout the NIS lifecycle, from design through operation to reengineering. At each stage, steps can be taken to minimize the occurrence and effects of human errors. These include defensive design philosophies, architectural patterns to guide developers, and collaborative design that incorporates operational experiences and surprises into design efforts. We conclude by looking at three aspects of NISs that will cause continuing challenges in error and accident management: immaturity of the industry, limited risk perception, and resource tradeoffs.« less
-
Sarter, Nadine
2008-06-01
The goal of this article is to illustrate the problem-driven, cumulative, and highly interdisciplinary nature of human factors research by providing a brief overview of the work on mode errors on modern flight decks over the past two decades. Mode errors on modem flight decks were first reported in the late 1980s. Poor feedback, inadequate mental models of the automation, and the high degree of coupling and complexity of flight deck systems were identified as main contributors to these breakdowns in human-automation interaction. Various improvements of design, training, and procedures were proposed to address these issues. The author describes when and why the problem of mode errors surfaced, summarizes complementary research activities that helped identify and understand the contributing factors to mode errors, and describes some countermeasures that have been developed in recent years. This brief review illustrates how one particular human factors problem in the aviation domain enabled various disciplines and methodological approaches to contribute to a better understanding of, as well as provide better support for, effective human-automation coordination. Converging operations and interdisciplinary collaboration over an extended period of time are hallmarks of successful human factors research. The reported body of research can serve as a model for future research and as a teaching tool for students in this field of work.
-
The Swiss cheese model of adverse event occurrence--Closing the holes.
Stein, James E; Heiss, Kurt
2015-12-01
Traditional surgical attitude regarding error and complications has focused on individual failings. Human factors research has brought new and significant insights into the occurrence of error in healthcare, helping us identify systemic problems that injure patients while enhancing individual accountability and teamwork. This article introduces human factors science and its applicability to teamwork, surgical culture, medical error, and individual accountability. Copyright © 2015 Elsevier Inc. All rights reserved.
-
Behind Human Error: Cognitive Systems, Computers and Hindsight
1994-12-01
evaluations • Organize and/or conduct workshops and conferences CSERIAC is a Department of Defense Information Analysis Cen- ter sponsored by the Defense...Process 185 Neutral Observer Criteria 191 Error Analysis as Causal Judgment 193 Error as Information 195 A Fundamental Surprise 195 What is Human...Kahnemann, 1974), and in risk analysis (Dougherty and Fragola, 1990). The discussions have continued in a wide variety of forums, includ- ing the
-
Kuselman, Ilya; Pennecchi, Francesca; Epstein, Malka; Fajgelj, Ales; Ellison, Stephen L R
2014-12-01
Monte Carlo simulation of expert judgments on human errors in a chemical analysis was used for determination of distributions of the error quantification scores (scores of likelihood and severity, and scores of effectiveness of a laboratory quality system in prevention of the errors). The simulation was based on modeling of an expert behavior: confident, reasonably doubting and irresolute expert judgments were taken into account by means of different probability mass functions (pmfs). As a case study, 36 scenarios of human errors which may occur in elemental analysis of geological samples by ICP-MS were examined. Characteristics of the score distributions for three pmfs of an expert behavior were compared. Variability of the scores, as standard deviation of the simulated score values from the distribution mean, was used for assessment of the score robustness. A range of the score values, calculated directly from elicited data and simulated by a Monte Carlo method for different pmfs, was also discussed from the robustness point of view. It was shown that robustness of the scores, obtained in the case study, can be assessed as satisfactory for the quality risk management and improvement of a laboratory quality system against human errors. Copyright © 2014 Elsevier B.V. All rights reserved.
-
A GPU-based symmetric non-rigid image registration method in human lung.
Haghighi, Babak; D Ellingwood, Nathan; Yin, Youbing; Hoffman, Eric A; Lin, Ching-Long
2018-03-01
Quantitative computed tomography (QCT) of the lungs plays an increasing role in identifying sub-phenotypes of pathologies previously lumped into broad categories such as chronic obstructive pulmonary disease and asthma. Methods for image matching and linking multiple lung volumes have proven useful in linking structure to function and in the identification of regional longitudinal changes. Here, we seek to improve the accuracy of image matching via the use of a symmetric multi-level non-rigid registration employing an inverse consistent (IC) transformation whereby images are registered both in the forward and reverse directions. To develop the symmetric method, two similarity measures, the sum of squared intensity difference (SSD) and the sum of squared tissue volume difference (SSTVD), were used. The method is based on a novel generic mathematical framework to include forward and backward transformations, simultaneously, eliminating the need to compute the inverse transformation. Two implementations were used to assess the proposed method: a two-dimensional (2-D) implementation using synthetic examples with SSD, and a multi-core CPU and graphics processing unit (GPU) implementation with SSTVD for three-dimensional (3-D) human lung datasets (six normal adults studied at total lung capacity (TLC) and functional residual capacity (FRC)). Success was evaluated in terms of the IC transformation consistency serving to link TLC to FRC. 2-D registration on synthetic images, using both symmetric and non-symmetric SSD methods, and comparison of displacement fields showed that the symmetric method gave a symmetrical grid shape and reduced IC errors, with the mean values of IC errors decreased by 37%. Results for both symmetric and non-symmetric transformations of human datasets showed that the symmetric method gave better results for IC errors in all cases, with mean values of IC errors for the symmetric method lower than the non-symmetric methods using both SSD and SSTVD. The GPU version demonstrated an average of 43 times speedup and ~5.2 times speedup over the single-threaded and 12-threaded CPU versions, respectively. Run times with the GPU were as fast as 2 min. The symmetric method improved the inverse consistency, aiding the use of image registration in the QCT-based evaluation of the lung.
-
Continuous quantum error correction for non-Markovian decoherence
DOE Office of Scientific and Technical Information (OSTI.GOV)
Oreshkov, Ognyan; Brun, Todd A.; Communication Sciences Institute, University of Southern California, Los Angeles, California 90089
2007-08-15
We study the effect of continuous quantum error correction in the case where each qubit in a codeword is subject to a general Hamiltonian interaction with an independent bath. We first consider the scheme in the case of a trivial single-qubit code, which provides useful insights into the workings of continuous error correction and the difference between Markovian and non-Markovian decoherence. We then study the model of a bit-flip code with each qubit coupled to an independent bath qubit and subject to continuous correction, and find its solution. We show that for sufficiently large error-correction rates, the encoded state approximatelymore » follows an evolution of the type of a single decohering qubit, but with an effectively decreased coupling constant. The factor by which the coupling constant is decreased scales quadratically with the error-correction rate. This is compared to the case of Markovian noise, where the decoherence rate is effectively decreased by a factor which scales only linearly with the rate of error correction. The quadratic enhancement depends on the existence of a Zeno regime in the Hamiltonian evolution which is absent in purely Markovian dynamics. We analyze the range of validity of this result and identify two relevant time scales. Finally, we extend the result to more general codes and argue that the performance of continuous error correction will exhibit the same qualitative characteristics.« less
-
Human-computer interaction in multitask situations
NASA Technical Reports Server (NTRS)
Rouse, W. B.
1977-01-01
Human-computer interaction in multitask decisionmaking situations is considered, and it is proposed that humans and computers have overlapping responsibilities. Queueing theory is employed to model this dynamic approach to the allocation of responsibility between human and computer. Results of simulation experiments are used to illustrate the effects of several system variables including number of tasks, mean time between arrivals of action-evoking events, human-computer speed mismatch, probability of computer error, probability of human error, and the level of feedback between human and computer. Current experimental efforts are discussed and the practical issues involved in designing human-computer systems for multitask situations are considered.
-
Nguyen, Hung P.; Dingwell, Jonathan B.
2012-01-01
Determining how the human nervous system contends with neuro-motor noise is vital to understanding how humans achieve accurate goal-directed movements. Experimentally, people learning skilled tasks tend to reduce variability in distal joint movements more than in proximal joint movements. This suggests that they might be imposing greater control over distal joints than proximal joints. However, the reasons for this remain unclear, largely because it is not experimentally possible to directly manipulate either the noise or the control at each joint independently. Therefore, this study used a 2 degree-of-freedom torque driven arm model to determine how different combinations of noise and/or control independently applied at each joint affected the reaching accuracy and the total work required to make the movement. Signal-dependent noise was simultaneously and independently added to the shoulder and elbow torques to induce endpoint errors during planar reaching. Feedback control was then applied, independently and jointly, at each joint to reduce endpoint error due to the added neuromuscular noise. Movement direction and the inertia distribution along the arm were varied to quantify how these biomechanical variations affected the system performance. Endpoint error and total net work were computed as dependent measures. When each joint was independently subjected to noise in the absence of control, endpoint errors were more sensitive to distal (elbow) noise than to proximal (shoulder) noise for nearly all combinations of reaching direction and inertia ratio. The effects of distal noise on endpoint errors were more pronounced when inertia was distributed more toward the forearm. In contrast, the total net work decreased as mass was shifted to the upper arm for reaching movements in all directions. When noise was present at both joints and joint control was implemented, controlling the distal joint alone reduced endpoint errors more than controlling the proximal joint alone for nearly all combinations of reaching direction and inertia ratio. Applying control only at the distal joint was more effective at reducing endpoint errors when more of the mass was more proximally distributed. Likewise, controlling the distal joint alone required less total net work than controlling the proximal joint alone for nearly all combinations of reaching distance and inertia ratio. It is more efficient to reduce endpoint error and energetic cost by selectively applying control to reduce variability in the distal joint than the proximal joint. The reasons for this arise from the biomechanical configuration of the arm itself. PMID:22757504
-
Nguyen, Hung P; Dingwell, Jonathan B
2012-06-01
Determining how the human nervous system contends with neuro-motor noise is vital to understanding how humans achieve accurate goal-directed movements. Experimentally, people learning skilled tasks tend to reduce variability in distal joint movements more than in proximal joint movements. This suggests that they might be imposing greater control over distal joints than proximal joints. However, the reasons for this remain unclear, largely because it is not experimentally possible to directly manipulate either the noise or the control at each joint independently. Therefore, this study used a 2 degree-of-freedom torque driven arm model to determine how different combinations of noise and/or control independently applied at each joint affected the reaching accuracy and the total work required to make the movement. Signal-dependent noise was simultaneously and independently added to the shoulder and elbow torques to induce endpoint errors during planar reaching. Feedback control was then applied, independently and jointly, at each joint to reduce endpoint error due to the added neuromuscular noise. Movement direction and the inertia distribution along the arm were varied to quantify how these biomechanical variations affected the system performance. Endpoint error and total net work were computed as dependent measures. When each joint was independently subjected to noise in the absence of control, endpoint errors were more sensitive to distal (elbow) noise than to proximal (shoulder) noise for nearly all combinations of reaching direction and inertia ratio. The effects of distal noise on endpoint errors were more pronounced when inertia was distributed more toward the forearm. In contrast, the total net work decreased as mass was shifted to the upper arm for reaching movements in all directions. When noise was present at both joints and joint control was implemented, controlling the distal joint alone reduced endpoint errors more than controlling the proximal joint alone for nearly all combinations of reaching direction and inertia ratio. Applying control only at the distal joint was more effective at reducing endpoint errors when more of the mass was more proximally distributed. Likewise, controlling the distal joint alone required less total net work than controlling the proximal joint alone for nearly all combinations of reaching distance and inertia ratio. It is more efficient to reduce endpoint error and energetic cost by selectively applying control to reduce variability in the distal joint than the proximal joint. The reasons for this arise from the biomechanical configuration of the arm itself.
-
Pranata, Adrian; Perraton, Luke; El-Ansary, Doa; Clark, Ross; Fortin, Karine; Dettmann, Tim; Brandham, Robert; Bryant, Adam
2017-07-01
The ability to control lumbar extensor force output is necessary for daily activities. However, it is unknown whether this ability is impaired in chronic low back pain patients. Similarly, it is unknown whether lumbar extensor force control is related to the disability levels of chronic low back pain patients. Thirty-three chronic low back pain and 20 healthy people performed lumbar extension force-matching task where they increased and decreased their force output to match a variable target force within 20%-50% maximal voluntary isometric contraction. Force control was quantified as the root-mean-square-error between participants' force output and target force across the entire, during the increasing and decreasing portions of the force curve. Within- and between-group differences in force-matching error and the relationship between back pain group's force-matching results and their Oswestry Disability Index scores were assessed using ANCOVA and linear regression respectively. Back pain group demonstrated more overall force-matching error (mean difference=1.60 [0.78, 2.43], P<0.01) and more force-matching error while increasing force output (mean difference=2.19 [1.01, 3.37], P<0.01) than control group. The back pain group demonstrated more force-matching error while increasing than decreasing force output (mean difference=1.74, P<0.001, 95%CI [0.87, 2.61]). A unit increase in force-matching error while decreasing force output is associated with a 47% increase in Oswestry score in back pain group (R 2 =0.19, P=0.006). Lumbar extensor muscle force control is compromised in chronic low back pain patients. Force-matching error predicts disability, confirming the validity of our force control protocol for chronic low back pain patients. Copyright © 2017 Elsevier Ltd. All rights reserved.
-
Psychophysiological Approach To Support Of Cosmonauts Performance Reliability
NASA Astrophysics Data System (ADS)
Nechaev, A. P.
Space flight factors may effect negatively on psychophysiological state (PPS) and work capacity of crewmembers, lead to errors in tasks performance. Such errors cannot be entirely prevented during "crew-spacecraft" system designing and/or crewmembers training as they are consequence of a human "psychophysiological troubles". In the present investigation we paid special attention to work and rest schedule (WRS) intensity due to sleep-wake rhythm disturbances and crewmembers overload may cause PPS aggravation. By methods of the correlation analysis of the data collected during 9 "Mir" missions (18 Russian cosmonauts, 226 flight weeks) the significant (p<0.05) interrelations between WRS intensity and cosmonauts PPS as well as between cosmonauts PPS and crewmembers errors (CE) frequency have been established. It allows to consider WRS intensity as "the controlling factor" in relation to crewmember's PPS. Quantitative characteristics of these interrelations have been also determined. This findings have been used for development of algorithm of crewmember's PPS management with the purpose of decrease in CE frequency. The algorithm can be briefly described in the following kind. On the basis of the analysis of crew forthcoming work experts should assess WRS intensity, possible crewmembers PPS alterations, and expected CE frequency. If CE frequency is allowable the management may be limited to recommendations that operative vigilance increase. If CE frequency is higher allowable it is necessary to carry out the measures on crewmembers PPS normalization by means of decrease in WRS intensity. The algorithm is intended for use in the on-ground expert system of psychophysiological support of cosmonauts performance.
-
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.
-
He, Yin; Ming, Yue; Li, Wei; Li, Yafang; Wu, Maoqi; Song, Jinzhong; Li, Xiaojiu; Liu, Hao
2018-01-01
A facile method for preparing an easy processing, repeatable and flexible pressure sensor was presented via the synthesis of modified multi-walled carbon nanotubes (m-MWNTs) and polyurethane (PU) films. The surface modification of multi-walled carbon nanotubes (MWNTs) simultaneously used a silane coupling agent (KH550) and sodium dodecyl benzene sulfonate (SDBS) to improve the dispersibility and compatibility of the MWNTs in a polymer matrix. The electrical property and piezoresistive behavior of the m-MWNT/PU composites were compared with raw multi-walled carbon nanotube (raw MWNT)/PU composites. Under linear uniaxial pressure, the m-MWNT/PU composite exhibited 4.282%kPa−1 sensitivity within the pressure of 1 kPa. The nonlinear error, hysteresis error and repeatability error of the piezoresistivity of m-MWNT/PU decreased 9%, 16.72% and 54.95% relative to raw MWNT/PU respectively. Therefore, the piezoresistive response of m-MWNT/PU had better stability than that of raw MWNT/PU composites. The m-MWNT/PU sensors could be utilized in wearable devices for body movement detection, monitoring of respiration and pressure detection in garments. PMID:29701643
-
Factors associated with aberrant imprint methylation and oligozoospermia
Kobayashi, Norio; Miyauchi, Naoko; Tatsuta, Nozomi; Kitamura, Akane; Okae, Hiroaki; Hiura, Hitoshi; Sato, Akiko; Utsunomiya, Takafumi; Yaegashi, Nobuo; Nakai, Kunihiko; Arima, Takahiro
2017-01-01
Disturbingly, the number of patients with oligozoospermia (low sperm count) has been gradually increasing in industrialized countries. Epigenetic alterations are believed to be involved in this condition. Recent studies have clarified that intrinsic and extrinsic factors can induce epigenetic transgenerational phenotypes through apparent reprogramming of the male germ line. Here we examined DNA methylation levels of 22 human imprinted loci in a total of 221 purified sperm samples from infertile couples and found methylation alterations in 24.8% of the patients. Structural equation model suggested that the cause of imprint methylation errors in sperm might have been environmental factors. More specifically, aberrant methylation and a particular lifestyle (current smoking, excess consumption of carbonated drinks) were associated with severe oligozoospermia, while aging probably affected this pathology indirectly through the accumulation of PCB in the patients. Next we examined the pregnancy outcomes for patients when the sperm had abnormal imprint methylation. The live-birth rate decreased and the miscarriage rate increased with the methylation errors. Our research will be useful for the prevention of methylation errors in sperm from infertile men, and sperm with normal imprint methylation might increase the safety of assisted reproduction technology (ART) by reducing methylation-induced diseases of children conceived via ART. PMID:28186187
-
He, Yin; Ming, Yue; Li, Wei; Li, Yafang; Wu, Maoqi; Song, Jinzhong; Li, Xiaojiu; Liu, Hao
2018-04-26
A facile method for preparing an easy processing, repeatable and flexible pressure sensor was presented via the synthesis of modified multi-walled carbon nanotubes (m-MWNTs) and polyurethane (PU) films. The surface modification of multi-walled carbon nanotubes (MWNTs) simultaneously used a silane coupling agent (KH550) and sodium dodecyl benzene sulfonate (SDBS) to improve the dispersibility and compatibility of the MWNTs in a polymer matrix. The electrical property and piezoresistive behavior of the m-MWNT/PU composites were compared with raw multi-walled carbon nanotube (raw MWNT)/PU composites. Under linear uniaxial pressure, the m-MWNT/PU composite exhibited 4.282%kPa −1 sensitivity within the pressure of 1 kPa. The nonlinear error, hysteresis error and repeatability error of the piezoresistivity of m-MWNT/PU decreased 9%, 16.72% and 54.95% relative to raw MWNT/PU respectively. Therefore, the piezoresistive response of m-MWNT/PU had better stability than that of raw MWNT/PU composites. The m-MWNT/PU sensors could be utilized in wearable devices for body movement detection, monitoring of respiration and pressure detection in garments.
-
Kis, Anna; Gácsi, Márta; Range, Friederike; Virányi, Zsófia
2012-01-01
In this paper, we describe a behaviour pattern similar to the "A-not-B" error found in human infants and young apes in a monkey species, the common marmosets (Callithrix jacchus). In contrast to the classical explanation, recently it has been suggested that the "A-not-B" error committed by human infants is at least partially due to misinterpretation of the hider's ostensively communicated object hiding actions as potential 'teaching' demonstrations during the A trials. We tested whether this so-called Natural Pedagogy hypothesis would account for the A-not-B error that marmosets commit in a standard object permanence task, but found no support for the hypothesis in this species. Alternatively, we present evidence that lower level mechanisms, such as attention and motivation, play an important role in committing the "A-not-B" error in marmosets. We argue that these simple mechanisms might contribute to the effect of undeveloped object representational skills in other species including young non-human primates that commit the A-not-B error.
-
Updating expected action outcome in the medial frontal cortex involves an evaluation of error type.
Maier, Martin E; Steinhauser, Marco
2013-10-02
Forming expectations about the outcome of an action is an important prerequisite for action control and reinforcement learning in the human brain. The medial frontal cortex (MFC) has been shown to play an important role in the representation of outcome expectations, particularly when an update of expected outcome becomes necessary because an error is detected. However, error detection alone is not always sufficient to compute expected outcome because errors can occur in various ways and different types of errors may be associated with different outcomes. In the present study, we therefore investigate whether updating expected outcome in the human MFC is based on an evaluation of error type. Our approach was to consider an electrophysiological correlate of MFC activity on errors, the error-related negativity (Ne/ERN), in a task in which two types of errors could occur. Because the two error types were associated with different amounts of monetary loss, updating expected outcomes on error trials required an evaluation of error type. Our data revealed a pattern of Ne/ERN amplitudes that closely mirrored the amount of monetary loss associated with each error type, suggesting that outcome expectations are updated based on an evaluation of error type. We propose that this is achieved by a proactive evaluation process that anticipates error types by continuously monitoring error sources or by dynamically representing possible response-outcome relations.
-
Agosto-Arroyo, Emmanuel; Coshatt, Gina M; Winokur, Thomas S; Harada, Shuko; Park, Seung L
2017-01-01
The molecular diagnostics laboratory faces the challenge of improving test turnaround time (TAT). Low and consistent TATs are of great clinical and regulatory importance, especially for molecular virology tests. Laboratory information systems (LISs) contain all the data elements necessary to do accurate quality assurance (QA) reporting of TAT and other measures, but these reports are in most cases still performed manually: a time-consuming and error-prone task. The aim of this study was to develop a web-based real-time QA platform that would automate QA reporting in the molecular diagnostics laboratory at our institution, and minimize the time expended in preparing these reports. Using a standard Linux, Nginx, MariaDB, PHP stack virtual machine running atop a Dell Precision 5810, we designed and built a web-based QA platform, code-named Alchemy. Data files pulled periodically from the LIS in comma-separated value format were used to autogenerate QA reports for the human immunodeficiency virus (HIV) quantitation, hepatitis C virus (HCV) quantitation, and BK virus (BKV) quantitation. Alchemy allowed the user to select a specific timeframe to be analyzed and calculated key QA statistics in real-time, including the average TAT in days, tests falling outside the expected TAT ranges, and test result ranges. Before implementing Alchemy, reporting QA for the HIV, HCV, and BKV quantitation assays took 45-60 min of personnel time per test every month. With Alchemy, that time has decreased to 15 min total per month. Alchemy allowed the user to select specific periods of time and analyzed the TAT data in-depth without the need of extensive manual calculations. Alchemy has significantly decreased the time and the human error associated with QA report generation in our molecular diagnostics laboratory. Other tests will be added to this web-based platform in future updates. This effort shows the utility of informatician-supervised resident/fellow programming projects as learning opportunities and workflow improvements in the molecular laboratory.
-
Computerized clinical documentation system in the pediatric intensive care unit
2001-01-01
Background To determine whether a computerized clinical documentation system (CDS): 1) decreased time spent charting and increased time spent in patient care; 2) decreased medication errors; 3) improved clinical decision making; 4) improved quality of documentation; and/or 5) improved shift to shift nursing continuity. Methods Before and after implementation of CDS, a time study involving nursing care, medication delivery, and normalization of serum calcium and potassium values was performed. In addition, an evaluation of completeness of documentation and a clinician survey of shift to shift reporting were also completed. This was a modified one group, pretest-posttest design. Results With the CDS there was: improved legibility and completeness of documentation, data with better accessibility and accuracy, no change in time spent in direct patient care or charting by nursing staff. Incidental observations from the study included improved management functions of our nurse manager; improved JCAHO documentation compliance; timely access to clinical data (labs, vitals, etc); a decrease in time and resource use for audits; improved reimbursement because of the ability to reconstruct lost charts; limited human data entry by automatic data logging; eliminated costs of printing forms. CDS cost was reasonable. Conclusions When compared to a paper chart, the CDS provided a more legible, compete, and accessible patient record without affecting time spent in direct patient care. The availability of the CDS improved shift to shift reporting. Other observations showed that the CDS improved management capabilities; helped physicians deliver care; improved reimbursement; limited data entry errors; and reduced costs. PMID:11604105
-
Measuring Individual Differences in the Perfect Automation Schema.
Merritt, Stephanie M; Unnerstall, Jennifer L; Lee, Deborah; Huber, Kelli
2015-08-01
A self-report measure of the perfect automation schema (PAS) is developed and tested. Researchers have hypothesized that the extent to which users possess a PAS is associated with greater decreases in trust after users encounter automation errors. However, no measure of the PAS currently exists. We developed a self-report measure assessing two proposed PAS factors: high expectations and all-or-none thinking about automation performance. In two studies, participants responded to our PAS measure, interacted with imperfect automated aids, and reported trust. Each of the two PAS measure factors demonstrated fit to the hypothesized factor structure and convergent and discriminant validity when compared with propensity to trust machines and trust in a specific aid. However, the high expectations and all-or-none thinking scales showed low intercorrelations and differential relationships with outcomes, suggesting that they might best be considered two separate constructs rather than two subfactors of the PAS. All-or-none thinking had significant associations with decreases in trust following aid errors, whereas high expectations did not. Results therefore suggest that the all-or-none thinking scale may best represent the PAS construct. Our PAS measure (specifically, the all-or-none thinking scale) significantly predicted the severe trust decreases thought to be associated with high PAS. Further, it demonstrated acceptable psychometric properties across two samples. This measure may be used in future work to assess levels of PAS in users of automated systems in either research or applied settings. © 2015, Human Factors and Ergonomics Society.
-
Pedestrian dead reckoning employing simultaneous activity recognition cues
NASA Astrophysics Data System (ADS)
Altun, Kerem; Barshan, Billur
2012-02-01
We consider the human localization problem using body-worn inertial/magnetic sensor units. Inertial sensors are characterized by a drift error caused by the integration of their rate output to obtain position information. Because of this drift, the position and orientation data obtained from inertial sensors are reliable over only short periods of time. Therefore, position updates from externally referenced sensors are essential. However, if the map of the environment is known, the activity context of the user can provide information about his position. In particular, the switches in the activity context correspond to discrete locations on the map. By performing localization simultaneously with activity recognition, we detect the activity context switches and use the corresponding position information as position updates in a localization filter. The localization filter also involves a smoother that combines the two estimates obtained by running the zero-velocity update algorithm both forward and backward in time. We performed experiments with eight subjects in indoor and outdoor environments involving walking, turning and standing activities. Using a spatial error criterion, we show that the position errors can be decreased by about 85% on the average. We also present the results of two 3D experiments performed in realistic indoor environments and demonstrate that it is possible to achieve over 90% error reduction in position by performing localization simultaneously with activity recognition.
-
From feedback- to response-based performance monitoring in active and observational learning.
Bellebaum, Christian; Colosio, Marco
2014-09-01
Humans can adapt their behavior by learning from the consequences of their own actions or by observing others. Gradual active learning of action-outcome contingencies is accompanied by a shift from feedback- to response-based performance monitoring. This shift is reflected by complementary learning-related changes of two ACC-driven ERP components, the feedback-related negativity (FRN) and the error-related negativity (ERN), which have both been suggested to signal events "worse than expected," that is, a negative prediction error. Although recent research has identified comparable components for observed behavior and outcomes (observational ERN and FRN), it is as yet unknown, whether these components are similarly modulated by prediction errors and thus also reflect behavioral adaptation. In this study, two groups of 15 participants learned action-outcome contingencies either actively or by observation. In active learners, FRN amplitude for negative feedback decreased and ERN amplitude in response to erroneous actions increased with learning, whereas observational ERN and FRN in observational learners did not exhibit learning-related changes. Learning performance, assessed in test trials without feedback, was comparable between groups, as was the ERN following actively performed errors during test trials. In summary, the results show that action-outcome associations can be learned similarly well actively and by observation. The mechanisms involved appear to differ, with the FRN in active learning reflecting the integration of information about own actions and the accompanying outcomes.
-
Helle, Samuli
2018-03-01
Revealing causal effects from correlative data is very challenging and a contemporary problem in human life history research owing to the lack of experimental approach. Problems with causal inference arising from measurement error in independent variables, whether related either to inaccurate measurement technique or validity of measurements, seem not well-known in this field. The aim of this study is to show how structural equation modeling (SEM) with latent variables can be applied to account for measurement error in independent variables when the researcher has recorded several indicators of a hypothesized latent construct. As a simple example of this approach, measurement error in lifetime allocation of resources to reproduction in Finnish preindustrial women is modelled in the context of the survival cost of reproduction. In humans, lifetime energetic resources allocated in reproduction are almost impossible to quantify with precision and, thus, typically used measures of lifetime reproductive effort (e.g., lifetime reproductive success and parity) are likely to be plagued by measurement error. These results are contrasted with those obtained from a traditional regression approach where the single best proxy of lifetime reproductive effort available in the data is used for inference. As expected, the inability to account for measurement error in women's lifetime reproductive effort resulted in the underestimation of its underlying effect size on post-reproductive survival. This article emphasizes the advantages that the SEM framework can provide in handling measurement error via multiple-indicator latent variables in human life history studies. © 2017 Wiley Periodicals, Inc.
-
Reliability of drivers in urban intersections.
Gstalter, Herbert; Fastenmeier, Wolfgang
2010-01-01
The concept of human reliability has been widely used in industrial settings by human factors experts to optimise the person-task fit. Reliability is estimated by the probability that a task will successfully be completed by personnel in a given stage of system operation. Human Reliability Analysis (HRA) is a technique used to calculate human error probabilities as the ratio of errors committed to the number of opportunities for that error. To transfer this notion to the measurement of car driver reliability the following components are necessary: a taxonomy of driving tasks, a definition of correct behaviour in each of these tasks, a list of errors as deviations from the correct actions and an adequate observation method to register errors and opportunities for these errors. Use of the SAFE-task analysis procedure recently made it possible to derive driver errors directly from the normative analysis of behavioural requirements. Driver reliability estimates could be used to compare groups of tasks (e.g. different types of intersections with their respective regulations) as well as groups of drivers' or individual drivers' aptitudes. This approach was tested in a field study with 62 drivers of different age groups. The subjects drove an instrumented car and had to complete an urban test route, the main features of which were 18 intersections representing six different driving tasks. The subjects were accompanied by two trained observers who recorded driver errors using standardized observation sheets. Results indicate that error indices often vary between both the age group of drivers and the type of driving task. The highest error indices occurred in the non-signalised intersection tasks and the roundabout, which exactly equals the corresponding ratings of task complexity from the SAFE analysis. A comparison of age groups clearly shows the disadvantage of older drivers, whose error indices in nearly all tasks are significantly higher than those of the other groups. The vast majority of these errors could be explained by high task load in the intersections, as they represent difficult tasks. The discussion shows how reliability estimates can be used in a constructive way to propose changes in car design, intersection layout and regulation as well as driver training.
-
Error-associated behaviors and error rates for robotic geology
NASA Technical Reports Server (NTRS)
Anderson, Robert C.; Thomas, Geb; Wagner, Jacob; Glasgow, Justin
2004-01-01
This study explores human error as a function of the decision-making process. One of many models for human decision-making is Rasmussen's decision ladder [9]. The decision ladder identifies the multiple tasks and states of knowledge involved in decision-making. The tasks and states of knowledge can be classified by the level of cognitive effort required to make the decision, leading to the skill, rule, and knowledge taxonomy (Rasmussen, 1987). Skill based decisions require the least cognitive effort and knowledge based decisions require the greatest cognitive effort. Errors can occur at any of the cognitive levels.
-
Decreasing Errors in Reading-Related Matching to Sample Using a Delayed-Sample Procedure
ERIC Educational Resources Information Center
Doughty, Adam H.; Saunders, Kathryn J.
2009-01-01
Two men with intellectual disabilities initially demonstrated intermediate accuracy in two-choice matching-to-sample (MTS) procedures. A printed-letter identity MTS procedure was used with 1 participant, and a spoken-to-printed-word MTS procedure was used with the other participant. Errors decreased substantially under a delayed-sample procedure,…
-
Procedural error monitoring and smart checklists
NASA Technical Reports Server (NTRS)
Palmer, Everett
1990-01-01
Human beings make and usually detect errors routinely. The same mental processes that allow humans to cope with novel problems can also lead to error. Bill Rouse has argued that errors are not inherently bad but their consequences may be. He proposes the development of error-tolerant systems that detect errors and take steps to prevent the consequences of the error from occurring. Research should be done on self and automatic detection of random and unanticipated errors. For self detection, displays should be developed that make the consequences of errors immediately apparent. For example, electronic map displays graphically show the consequences of horizontal flight plan entry errors. Vertical profile displays should be developed to make apparent vertical flight planning errors. Other concepts such as energy circles could also help the crew detect gross flight planning errors. For automatic detection, systems should be developed that can track pilot activity, infer pilot intent and inform the crew of potential errors before their consequences are realized. Systems that perform a reasonableness check on flight plan modifications by checking route length and magnitude of course changes are simple examples. Another example would be a system that checked the aircraft's planned altitude against a data base of world terrain elevations. Information is given in viewgraph form.
-
Weinstock, Alona; Oron-Gilad, Tal; Parmet, Yisrael
2012-01-01
Lack of system reliability has been repeatedly identified as a factor that decreases trust. However, aesthetics has an important role in the development of trust. Most of the research concerning the connection between aesthetics and trust focused on mobile commerce and websites while very little has been done in examining aesthetics in automated systems. This study integrated aesthetics manipulations into an imperfect in-vehicle automation system and focused on the power of aesthetics to decrease the negative effects of errors on trust, satisfaction, annoyance, and human-automation cooperation perceptions. Participants used the navigation system in either 100% or 85% accuracy levels with an aesthetic or non aesthetic system (4 conditions). In both aesthetic and non aesthetic systems, perceptions of trust, satisfaction and human automation cooperation were decreased in the imperfect system compared to the perfect one. However, in the annoyance rating, this trend was found only in the aesthetic system while in the non-aesthetic system no difference was found between the two levels of accuracy. This single effect may indicate upon the possibility that in automated systems aesthetics affects trust and satisfaction more moderately compared to mobile commerce applications and websites. However, more research is needed to assess this assumption.
-
Flisiak, Robert; Horban, Andrzej; Gallay, Philippe; Bobardt, Michael; Selvarajah, Suganya; Wiercinska-Drapalo, Alicja; Siwak, Ewa; Cielniak, Iwona; Higersberger, Jozef; Kierkus, Jarek; Aeschlimann, Christian; Grosgurin, Pierre; Nicolas-Métral, Valérie; Dumont, Jean-Maurice; Porchet, Hervé; Crabbé, Raf; Scalfaro, Pietro
2008-03-01
Debio-025 is an oral cyclophilin (Cyp) inhibitor with potent anti-hepatitis C virus activity in vitro. Its effect on viral load as well as its influence on intracellular Cyp levels was investigated in a randomized, double-blind, placebo-controlled study. Mean hepatitis C viral load decreased significantly by 3.6 log(10) after a 14-day oral treatment with 1200 mg twice daily (P < 0.0001) with an effect against the 3 genotypes (1, 3, and 4) represented in the study. In addition, the absence of viral rebound during treatment indicates that Debio-025 has a high barrier for the selection of resistance. In Debio-025-treated patients, cyclophilin B (CypB) levels in peripheral blood mononuclear cells decreased from 67 +/- 6 (standard error) ng/mg protein (baseline) to 5 +/- 1 ng/mg protein at day 15 (P < 0.01). Debio-025 induced a strong drop in CypB levels, coinciding with the decrease in hepatitis C viral load. These are the first preliminary human data supporting the hypothesis that CypB may play an important role in hepatitis C virus replication and that Cyp inhibition is a valid target for the development of anti-hepatitis C drugs.
-
A circadian rhythm in skill-based errors in aviation maintenance.
Hobbs, Alan; Williamson, Ann; Van Dongen, Hans P A
2010-07-01
In workplaces where activity continues around the clock, human error has been observed to exhibit a circadian rhythm, with a characteristic peak in the early hours of the morning. Errors are commonly distinguished by the nature of the underlying cognitive failure, particularly the level of intentionality involved in the erroneous action. The Skill-Rule-Knowledge (SRK) framework of Rasmussen is used widely in the study of industrial errors and accidents. The SRK framework describes three fundamental types of error, according to whether behavior is under the control of practiced sensori-motor skill routines with minimal conscious awareness; is guided by implicit or explicit rules or expertise; or where the planning of actions requires the conscious application of domain knowledge. Up to now, examinations of circadian patterns of industrial errors have not distinguished between different types of error. Consequently, it is not clear whether all types of error exhibit the same circadian rhythm. A survey was distributed to aircraft maintenance personnel in Australia. Personnel were invited to anonymously report a safety incident and were prompted to describe, in detail, the human involvement (if any) that contributed to it. A total of 402 airline maintenance personnel reported an incident, providing 369 descriptions of human error in which the time of the incident was reported and sufficient detail was available to analyze the error. Errors were categorized using a modified version of the SRK framework, in which errors are categorized as skill-based, rule-based, or knowledge-based, or as procedure violations. An independent check confirmed that the SRK framework had been applied with sufficient consistency and reliability. Skill-based errors were the most common form of error, followed by procedure violations, rule-based errors, and knowledge-based errors. The frequency of errors was adjusted for the estimated proportion of workers present at work/each hour of the day, and the 24 h pattern of each error type was examined. Skill-based errors exhibited a significant circadian rhythm, being most prevalent in the early hours of the morning. Variation in the frequency of rule-based errors, knowledge-based errors, and procedure violations over the 24 h did not reach statistical significance. The results suggest that during the early hours of the morning, maintenance technicians are at heightened risk of "absent minded" errors involving failures to execute action plans as intended.
-
Spatial durbin error model for human development index in Province of Central Java.
NASA Astrophysics Data System (ADS)
Septiawan, A. R.; Handajani, S. S.; Martini, T. S.
2018-05-01
The Human Development Index (HDI) is an indicator used to measure success in building the quality of human life, explaining how people access development outcomes when earning income, health and education. Every year HDI in Central Java has improved to a better direction. In 2016, HDI in Central Java was 69.98 %, an increase of 0.49 % over the previous year. The objective of this study was to apply the spatial Durbin error model using angle weights queen contiguity to measure HDI in Central Java Province. Spatial Durbin error model is used because the model overcomes the spatial effect of errors and the effects of spatial depedency on the independent variable. Factors there use is life expectancy, mean years of schooling, expected years of schooling, and purchasing power parity. Based on the result of research, we get spatial Durbin error model for HDI in Central Java with influencing factors are life expectancy, mean years of schooling, expected years of schooling, and purchasing power parity.
-
Diuk, Carlos; Tsai, Karin; Wallis, Jonathan; Botvinick, Matthew; Niv, Yael
2013-03-27
Studies suggest that dopaminergic neurons report a unitary, global reward prediction error signal. However, learning in complex real-life tasks, in particular tasks that show hierarchical structure, requires multiple prediction errors that may coincide in time. We used functional neuroimaging to measure prediction error signals in humans performing such a hierarchical task involving simultaneous, uncorrelated prediction errors. Analysis of signals in a priori anatomical regions of interest in the ventral striatum and the ventral tegmental area indeed evidenced two simultaneous, but separable, prediction error signals corresponding to the two levels of hierarchy in the task. This result suggests that suitably designed tasks may reveal a more intricate pattern of firing in dopaminergic neurons. Moreover, the need for downstream separation of these signals implies possible limitations on the number of different task levels that we can learn about simultaneously.
-
Golonka, Krystyna; Mojsa-Kaja, Justyna; Gawlowska, Magda; Popiel, Katarzyna
2017-01-01
The presented study refers to cognitive aspects of burnout as the effects of long-term work-related stress. The purpose of the study was to investigate electrophysiological correlates of burnout to explain the mechanisms of the core burnout symptoms: exhaustion and depersonalization/cynicism. The analyzed error-related electrophysiological markers shed light on impaired cognitive mechanisms and the specific changes in information-processing in burnout. In the EEG study design (N = 80), two components of error-related potential (ERP), error-related negativity (ERN), and error positivity (Pe), were analyzed. In the non-clinical burnout group (N = 40), a significant increase in ERN amplitude and a decrease in Pe amplitude were observed compared to controls (N = 40). Enhanced error detection, indexed by increased ERN amplitude, and diminished response monitoring, indexed by decreased Pe amplitude, reveal emerging cognitive problems in the non-clinical burnout group. Cognitive impairments in burnout subjects relate to both reactive and unconscious (ERN) and proactive and conscious (Pe) aspects of error processing. The results indicate a stronger ‘reactive control mode’ that can deplete resources for proactive control and the ability to actively maintain goals. The analysis refers to error processing and specific task demands, thus should not be extended to cognitive processes in general. The characteristics of ERP patterns in burnout resemble psychophysiological indexes of anxiety (increased ERN) and depressive symptoms (decreased Pe), showing to some extent an overlapping effect of burnout and related symptoms and disorders. The results support the scarce existing data on the psychobiological nature of burnout, while extending and specifying its cognitive characteristics. PMID:28507528
-
Mental representation of symbols as revealed by vocabulary errors in two bonobos (Pan paniscus).
Lyn, Heidi
2007-10-01
Error analysis has been used in humans to detect implicit representations and categories in language use. The present study utilizes the same technique to report on mental representations and categories in symbol use from two bonobos (Pan paniscus). These bonobos have been shown in published reports to comprehend English at the level of a two-and-a-half year old child and to use a keyboard with over 200 visuographic symbols (lexigrams). In this study, vocabulary test errors from over 10 years of data revealed auditory, visual, and spatio-temporal generalizations (errors were more likely items that looked like sounded like, or were frequently associated with the sample item in space or in time), as well as hierarchical and conceptual categorizations. These error data, like those of humans, are a result of spontaneous responding rather than specific training and do not solely depend upon the sample mode (e.g. auditory similarity errors are not universally more frequent with an English sample, nor were visual similarity errors universally more frequent with a photograph sample). However, unlike humans, these bonobos do not make errors based on syntactical confusions (e.g. confusing semantically unrelated nouns), suggesting that they may not separate syntactical and semantic information. These data suggest that apes spontaneously create a complex, hierarchical, web of representations when exposed to a symbol system.
-
Federal Register 2010, 2011, 2012, 2013, 2014
2013-02-15
... management of human error in its operations and system safety programs, and the status of PTC implementation... UP's safety management policies and programs associated with human error, operational accident and... Chairman of the Board of Inquiry 2. Introduction of the Board of Inquiry and Technical Panel 3...
-
Xiao, Yi; Ma, Feng; Lv, Yixuan; Cai, Gui; Teng, Peng; Xu, FengGang; Chen, Shanguang
2015-01-01
Attention is important in error processing. Few studies have examined the link between sustained attention and error processing. In this study, we examined how error-related negativity (ERN) of a four-choice reaction time task was reduced in the mental fatigue condition and investigated the role of sustained attention in error processing. Forty-one recruited participants were divided into two groups. In the fatigue experiment group, 20 subjects performed a fatigue experiment and an additional continuous psychomotor vigilance test (PVT) for 1 h. In the normal experiment group, 21 subjects only performed the normal experimental procedures without the PVT test. Fatigue and sustained attention states were assessed with a questionnaire. Event-related potential results showed that ERN (p < 0.005) and peak (p < 0.05) mean amplitudes decreased in the fatigue experiment. ERN amplitudes were significantly associated with the attention and fatigue states in electrodes Fz, FC1, Cz, and FC2. These findings indicated that sustained attention was related to error processing and that decreased attention is likely the cause of error processing impairment. PMID:25756780
-
Smith, Kenneth J; Handler, Steven M; Kapoor, Wishwa N; Martich, G Daniel; Reddy, Vivek K; Clark, Sunday
2016-07-01
This study sought to determine the effects of automated primary care physician (PCP) communication and patient safety tools, including computerized discharge medication reconciliation, on discharge medication errors and posthospitalization patient outcomes, using a pre-post quasi-experimental study design, in hospitalized medical patients with ≥2 comorbidities and ≥5 chronic medications, at a single center. The primary outcome was discharge medication errors, compared before and after rollout of these tools. Secondary outcomes were 30-day rehospitalization, emergency department visit, and PCP follow-up visit rates. This study found that discharge medication errors were lower post intervention (odds ratio = 0.57; 95% confidence interval = 0.44-0.74; P < .001). Clinically important errors, with the potential for serious or life-threatening harm, and 30-day patient outcomes were not significantly different between study periods. Thus, automated health system-based communication and patient safety tools, including computerized discharge medication reconciliation, decreased hospital discharge medication errors in medically complex patients. © The Author(s) 2015.
-
Feys, Marjolein; Anseel, Frederik
2015-03-01
People's affective forecasts are often inaccurate because they tend to overestimate how they will feel after an event. As life decisions are often based on affective forecasts, it is crucial to find ways to manage forecasting errors. We examined the impact of a fair treatment on forecasting errors in candidates in a Belgian reality TV talent show. We found that perceptions of fair treatment increased the forecasting error for losers (a negative audition decision) but decreased it for winners (a positive audition decision). For winners, this effect was even more pronounced when candidates were highly invested in their self-view as a future pop idol whereas for losers, the effect was more pronounced when importance was low. The results in this study point to a potential paradox between maximizing happiness and decreasing forecasting errors. A fair treatment increased the forecasting error for losers, but actually made them happier. © 2014 The British Psychological Society.
-
Habibi, Ehsanollah; Dehghan, Habibollah; Dehkordy, Sina Eshraghy; Maracy, Mohammad Reza
2013-01-01
Background: Among the most important and effective factors affecting the efficiency of the human workforce are accuracy, promptness, and ability. In the context of promoting levels and quality of productivity, the aim of this study was to investigate the effects of exposure to noise on the rate of errors, speed of work, and capability in performing manual activities. Methods: This experimental study was conducted on 96 students (52 female and 44 male) of the Isfahan Medical Science University with the average and standard deviations of age, height, and weight of 22.81 (3.04) years, 171.67 (8.51) cm, and 65.05 (13.13) kg, respectively. Sampling was conducted with a randomized block design. Along with controlling for intervening factors, a combination of sound pressure levels [65 dB (A), 85 dB (A), and 95 dB (A)] and exposure times (0, 20, and 40) were used for evaluation of precision and speed of action of the participants, in the ergonomic test of two-hand coordination. Data was analyzed by SPSS18 software using a descriptive and analytical statistical method by analysis of covariance (ANCOVA) repeated measures. Results: The results of this study showed that increasing sound pressure level from 65 to 95 dB in network ‘A’ increased the speed of work (P < 0.05). Increase in the exposure time (0 to 40 min of exposure) and gender showed no significant differences statistically in speed of work (P > 0.05). Male participants got annoyed from the noise more than females. Also, increase in sound pressure level increased the rate of error (P < 0.05). Conclusions: According to the results of this research, increasing the sound pressure level decreased efficiency and increased the errors and in exposure to sounds less than 85 dB in the beginning, the efficiency decreased initially and then increased in a mild slope. PMID:23930164
-
Intravenous Chemotherapy Compounding Errors in a Follow-Up Pan-Canadian Observational Study.
Gilbert, Rachel E; Kozak, Melissa C; Dobish, Roxanne B; Bourrier, Venetia C; Koke, Paul M; Kukreti, Vishal; Logan, Heather A; Easty, Anthony C; Trbovich, Patricia L
2018-05-01
Intravenous (IV) compounding safety has garnered recent attention as a result of high-profile incidents, awareness efforts from the safety community, and increasingly stringent practice standards. New research with more-sensitive error detection techniques continues to reinforce that error rates with manual IV compounding are unacceptably high. In 2014, our team published an observational study that described three types of previously unrecognized and potentially catastrophic latent chemotherapy preparation errors in Canadian oncology pharmacies that would otherwise be undetectable. We expand on this research and explore whether additional potential human failures are yet to be addressed by practice standards. Field observations were conducted in four cancer center pharmacies in four Canadian provinces from January 2013 to February 2015. Human factors specialists observed and interviewed pharmacy managers, oncology pharmacists, pharmacy technicians, and pharmacy assistants as they carried out their work. Emphasis was on latent errors (potential human failures) that could lead to outcomes such as wrong drug, dose, or diluent. Given the relatively short observational period, no active failures or actual errors were observed. However, 11 latent errors in chemotherapy compounding were identified. In terms of severity, all 11 errors create the potential for a patient to receive the wrong drug or dose, which in the context of cancer care, could lead to death or permanent loss of function. Three of the 11 practices were observed in our previous study, but eight were new. Applicable Canadian and international standards and guidelines do not explicitly address many of the potentially error-prone practices observed. We observed a significant degree of risk for error in manual mixing practice. These latent errors may exist in other regions where manual compounding of IV chemotherapy takes place. Continued efforts to advance standards, guidelines, technological innovation, and chemical quality testing are needed.
-
Spacecraft and propulsion technician error
NASA Astrophysics Data System (ADS)
Schultz, Daniel Clyde
Commercial aviation and commercial space similarly launch, fly, and land passenger vehicles. Unlike aviation, the U.S. government has not established maintenance policies for commercial space. This study conducted a mixed methods review of 610 U.S. space launches from 1984 through 2011, which included 31 failures. An analysis of the failure causal factors showed that human error accounted for 76% of those failures, which included workmanship error accounting for 29% of the failures. With the imminent future of commercial space travel, the increased potential for the loss of human life demands that changes be made to the standardized procedures, training, and certification to reduce human error and failure rates. Several recommendations were made by this study to the FAA's Office of Commercial Space Transportation, space launch vehicle operators, and maintenance technician schools in an effort to increase the safety of the space transportation passengers.
-
42 CFR 1005.23 - Harmless error.
Code of Federal Regulations, 2012 CFR
2012-10-01
... 42 Public Health 5 2012-10-01 2012-10-01 false Harmless error. 1005.23 Section 1005.23 Public Health OFFICE OF INSPECTOR GENERAL-HEALTH CARE, DEPARTMENT OF HEALTH AND HUMAN SERVICES OIG AUTHORITIES APPEALS OF EXCLUSIONS, CIVIL MONEY PENALTIES AND ASSESSMENTS § 1005.23 Harmless error. No error in either...
-
42 CFR 1005.23 - Harmless error.
Code of Federal Regulations, 2014 CFR
2014-10-01
... 42 Public Health 5 2014-10-01 2014-10-01 false Harmless error. 1005.23 Section 1005.23 Public Health OFFICE OF INSPECTOR GENERAL-HEALTH CARE, DEPARTMENT OF HEALTH AND HUMAN SERVICES OIG AUTHORITIES APPEALS OF EXCLUSIONS, CIVIL MONEY PENALTIES AND ASSESSMENTS § 1005.23 Harmless error. No error in either...
-
42 CFR 1005.23 - Harmless error.
Code of Federal Regulations, 2010 CFR
2010-10-01
... 42 Public Health 5 2010-10-01 2010-10-01 false Harmless error. 1005.23 Section 1005.23 Public Health OFFICE OF INSPECTOR GENERAL-HEALTH CARE, DEPARTMENT OF HEALTH AND HUMAN SERVICES OIG AUTHORITIES APPEALS OF EXCLUSIONS, CIVIL MONEY PENALTIES AND ASSESSMENTS § 1005.23 Harmless error. No error in either...
-
42 CFR 1005.23 - Harmless error.
Code of Federal Regulations, 2013 CFR
2013-10-01
... 42 Public Health 5 2013-10-01 2013-10-01 false Harmless error. 1005.23 Section 1005.23 Public Health OFFICE OF INSPECTOR GENERAL-HEALTH CARE, DEPARTMENT OF HEALTH AND HUMAN SERVICES OIG AUTHORITIES APPEALS OF EXCLUSIONS, CIVIL MONEY PENALTIES AND ASSESSMENTS § 1005.23 Harmless error. No error in either...
-
42 CFR 1005.23 - Harmless error.
Code of Federal Regulations, 2011 CFR
2011-10-01
... 42 Public Health 5 2011-10-01 2011-10-01 false Harmless error. 1005.23 Section 1005.23 Public Health OFFICE OF INSPECTOR GENERAL-HEALTH CARE, DEPARTMENT OF HEALTH AND HUMAN SERVICES OIG AUTHORITIES APPEALS OF EXCLUSIONS, CIVIL MONEY PENALTIES AND ASSESSMENTS § 1005.23 Harmless error. No error in either...
-
42 CFR 3.552 - Harmless error.
Code of Federal Regulations, 2010 CFR
2010-10-01
... 42 Public Health 1 2010-10-01 2010-10-01 false Harmless error. 3.552 Section 3.552 Public Health PUBLIC HEALTH SERVICE, DEPARTMENT OF HEALTH AND HUMAN SERVICES GENERAL PROVISIONS PATIENT SAFETY ORGANIZATIONS AND PATIENT SAFETY WORK PRODUCT Enforcement Program § 3.552 Harmless error. No error in either the...
-
45 CFR 98.100 - Error Rate Report.
Code of Federal Regulations, 2013 CFR
2013-10-01
... 45 Public Welfare 1 2013-10-01 2013-10-01 false Error Rate Report. 98.100 Section 98.100 Public Welfare DEPARTMENT OF HEALTH AND HUMAN SERVICES GENERAL ADMINISTRATION CHILD CARE AND DEVELOPMENT FUND Error Rate Reporting § 98.100 Error Rate Report. (a) Applicability—The requirements of this subpart...
-
45 CFR 98.100 - Error Rate Report.
Code of Federal Regulations, 2014 CFR
2014-10-01
... 45 Public Welfare 1 2014-10-01 2014-10-01 false Error Rate Report. 98.100 Section 98.100 Public Welfare Department of Health and Human Services GENERAL ADMINISTRATION CHILD CARE AND DEVELOPMENT FUND Error Rate Reporting § 98.100 Error Rate Report. (a) Applicability—The requirements of this subpart...
-
45 CFR 98.100 - Error Rate Report.
Code of Federal Regulations, 2012 CFR
2012-10-01
... 45 Public Welfare 1 2012-10-01 2012-10-01 false Error Rate Report. 98.100 Section 98.100 Public Welfare DEPARTMENT OF HEALTH AND HUMAN SERVICES GENERAL ADMINISTRATION CHILD CARE AND DEVELOPMENT FUND Error Rate Reporting § 98.100 Error Rate Report. (a) Applicability—The requirements of this subpart...
-
45 CFR 98.100 - Error Rate Report.
Code of Federal Regulations, 2011 CFR
2011-10-01
... 45 Public Welfare 1 2011-10-01 2011-10-01 false Error Rate Report. 98.100 Section 98.100 Public Welfare DEPARTMENT OF HEALTH AND HUMAN SERVICES GENERAL ADMINISTRATION CHILD CARE AND DEVELOPMENT FUND Error Rate Reporting § 98.100 Error Rate Report. (a) Applicability—The requirements of this subpart...
-
Defense Mapping Agency (DMA) Raster-to-Vector Analysis
1984-11-30
model) to pinpoint critical deficiencies and understand trade-offs between alternative solutions. This may be exemplified by the allocation of human ...process, prone to errors (i.e., human operator eye/motor control limitations), and its time consuming nature (as a function of data density). It should...achieved through the facilities of coinputer interactive graphics. Each error or anomaly is individually identified by a human operator and corrected
-
Adenomatous Polyposis Coli Mutation Leads to Myopia Development in Mice
Li, Jing; Zhu, Zhenzhen; Yang, Wenzhao; Zhou, Xiangtian; An, Jianhong; Huang, Furong; Wang, Qiongsi; Reinach, Peter S.; Li, Wei; Chen, Wensheng; Liu, Zuguo
2015-01-01
Myopia incidence in China is rapidly becoming a very serious sight compromising problem in a large segment of the general population. Therefore, delineating the underlying mechanisms leading to myopia will markedly lessen the likelihood of other sight compromising complications. In this regard, there is some evidence that patients afflicted with familial adenomatous polyposis (FAP), havean adenomatous polyposis coli (APC) mutation and a higher incidence of myopia. To clarify this possible association, we determined whether the changes in pertinent biometric and biochemical parameters underlying postnatal refractive error development in APCMin mice are relevant for gaining insight into the pathogenesis of this disease in humans. The refraction and biometrics in APCMin mice and age-matched wild-type (WT) littermates between postnatal days P28 and P84 were examined with eccentric infrared photorefraction (EIR) and customized optical coherence tomography (OCT). Compared with WT littermates, the APCMin mutated mice developed myopia (average -4.64 D) on P84 which was associated with increased vitreous chamber depth (VCD). Furthermore, retinal and scleral changes appear in these mice along with: 1) axial length shortening; 2) increased retinal cell proliferation; 3) and decreased tyrosine hydroxylase (TH) expression, the rate-limiting enzyme of DA synthesis. Scleral collagen fibril diameters became heterogeneous and irregularly organized in the APCMin mice. Western blot analysis showed that scleral alpha-1 type I collagen (col1α1) expression also decreased whereas MMP2 and MMP9 mRNA expression was invariant. These results indicate that defective APC gene function promotes refractive error development. By characterizing in APCMin mice ocular developmental changes, this approach provides novel insight into underlying pathophysiological mechanisms contributing to human myopia development. PMID:26495845
-
Prepopulated radiology report templates: a prospective analysis of error rate and turnaround time.
Hawkins, C M; Hall, S; Hardin, J; Salisbury, S; Towbin, A J
2012-08-01
Current speech recognition software allows exam-specific standard reports to be prepopulated into the dictation field based on the radiology information system procedure code. While it is thought that prepopulating reports can decrease the time required to dictate a study and the overall number of errors in the final report, this hypothesis has not been studied in a clinical setting. A prospective study was performed. During the first week, radiologists dictated all studies using prepopulated standard reports. During the second week, all studies were dictated after prepopulated reports had been disabled. Final radiology reports were evaluated for 11 different types of errors. Each error within a report was classified individually. The median time required to dictate an exam was compared between the 2 weeks. There were 12,387 reports dictated during the study, of which, 1,173 randomly distributed reports were analyzed for errors. There was no difference in the number of errors per report between the 2 weeks; however, radiologists overwhelmingly preferred using a standard report both weeks. Grammatical errors were by far the most common error type, followed by missense errors and errors of omission. There was no significant difference in the median dictation time when comparing studies performed each week. The use of prepopulated reports does not alone affect the error rate or dictation time of radiology reports. While it is a useful feature for radiologists, it must be coupled with other strategies in order to decrease errors.
-
Causal Evidence from Humans for the Role of Mediodorsal Nucleus of the Thalamus in Working Memory.
Peräkylä, Jari; Sun, Lihua; Lehtimäki, Kai; Peltola, Jukka; Öhman, Juha; Möttönen, Timo; Ogawa, Keith H; Hartikainen, Kaisa M
2017-12-01
The mediodorsal nucleus of the thalamus (MD), with its extensive connections to the lateral pFC, has been implicated in human working memory and executive functions. However, this understanding is based solely on indirect evidence from human lesion and imaging studies and animal studies. Direct, causal evidence from humans is missing. To obtain direct evidence for MD's role in humans, we studied patients treated with deep brain stimulation (DBS) for refractory epilepsy. This treatment is thought to prevent the generalization of a seizure by disrupting the functioning of the patient's anterior nuclei of the thalamus (ANT) with high-frequency electric stimulation. This structure is located superior and anterior to MD, and when the DBS lead is implanted in ANT, tip contacts of the lead typically penetrate through ANT into the adjoining MD. To study the role of MD in human executive functions and working memory, we periodically disrupted and recovered MD's function with high-frequency electric stimulation using DBS contacts reaching MD while participants performed a cognitive task engaging several aspects of executive functions. We hypothesized that the efficacy of executive functions, specifically working memory, is impaired when the functioning of MD is perturbed by high-frequency stimulation. Eight participants treated with ANT-DBS for refractory epilepsy performed a computer-based test of executive functions while DBS was repeatedly switched ON and OFF at MD and at the control location (ANT). In comparison to stimulation of the control location, when MD was stimulated, participants committed 2.26 times more errors in general (total errors; OR = 2.26, 95% CI [1.69, 3.01]) and 2.86 times more working memory-related errors specifically (incorrect button presses; OR = 2.88, CI [1.95, 4.24]). Similarly, participants committed 1.81 more errors in general ( OR = 1.81, CI [1.45, 2.24]) and 2.08 times more working memory-related errors ( OR = 2.08, CI [1.57, 2.75]) in comparison to no stimulation condition. "Total errors" is a composite score consisting of basic error types and was mostly driven by working memory-related errors. The facts that MD and a control location, ANT, are only few millimeters away from each other and that their stimulation produces very different results highlight the location-specific effect of DBS rather than regionally unspecific general effect. In conclusion, disrupting and recovering MD's function with high-frequency electric stimulation modulated participants' online working memory performance providing causal, in vivo evidence from humans for the role of MD in human working memory.
-
A Method for the Study of Human Factors in Aircraft Operations
NASA Technical Reports Server (NTRS)
Barnhart, W.; Billings, C.; Cooper, G.; Gilstrap, R.; Lauber, J.; Orlady, H.; Puskas, B.; Stephens, W.
1975-01-01
A method for the study of human factors in the aviation environment is described. A conceptual framework is provided within which pilot and other human errors in aircraft operations may be studied with the intent of finding out how, and why, they occurred. An information processing model of human behavior serves as the basis for the acquisition and interpretation of information relating to occurrences which involve human error. A systematic method of collecting such data is presented and discussed. The classification of the data is outlined.
-
An interactive framework for acquiring vision models of 3-D objects from 2-D images.
Motai, Yuichi; Kak, Avinash
2004-02-01
This paper presents a human-computer interaction (HCI) framework for building vision models of three-dimensional (3-D) objects from their two-dimensional (2-D) images. Our framework is based on two guiding principles of HCI: 1) provide the human with as much visual assistance as possible to help the human make a correct input; and 2) verify each input provided by the human for its consistency with the inputs previously provided. For example, when stereo correspondence information is elicited from a human, his/her job is facilitated by superimposing epipolar lines on the images. Although that reduces the possibility of error in the human marked correspondences, such errors are not entirely eliminated because there can be multiple candidate points close together for complex objects. For another example, when pose-to-pose correspondence is sought from a human, his/her job is made easier by allowing the human to rotate the partial model constructed in the previous pose in relation to the partial model for the current pose. While this facility reduces the incidence of human-supplied pose-to-pose correspondence errors, such errors cannot be eliminated entirely because of confusion created when multiple candidate features exist close together. Each input provided by the human is therefore checked against the previous inputs by invoking situation-specific constraints. Different types of constraints (and different human-computer interaction protocols) are needed for the extraction of polygonal features and for the extraction of curved features. We will show results on both polygonal objects and object containing curved features.
-
New methodology to reconstruct in 2-D the cuspal enamel of modern human lower molars.
Modesto-Mata, Mario; García-Campos, Cecilia; Martín-Francés, Laura; Martínez de Pinillos, Marina; García-González, Rebeca; Quintino, Yuliet; Canals, Antoni; Lozano, Marina; Dean, M Christopher; Martinón-Torres, María; Bermúdez de Castro, José María
2017-08-01
In the last years different methodologies have been developed to reconstruct worn teeth. In this article, we propose a new 2-D methodology to reconstruct the worn enamel of lower molars. Our main goals are to reconstruct molars with a high level of accuracy when measuring relevant histological variables and to validate the methodology calculating the errors associated with the measurements. This methodology is based on polynomial regression equations, and has been validated using two different dental variables: cuspal enamel thickness and crown height of the protoconid. In order to perform the validation process, simulated worn modern human molars were employed. The associated errors of the measurements were also estimated applying methodologies previously proposed by other authors. The mean percentage error estimated in reconstructed molars for these two variables in comparison with their own real values is -2.17% for the cuspal enamel thickness of the protoconid and -3.18% for the crown height of the protoconid. This error significantly improves the results of other methodologies, both in the interobserver error and in the accuracy of the measurements. The new methodology based on polynomial regressions can be confidently applied to the reconstruction of cuspal enamel of lower molars, as it improves the accuracy of the measurements and reduces the interobserver error. The present study shows that it is important to validate all methodologies in order to know the associated errors. This new methodology can be easily exportable to other modern human populations, the human fossil record and forensic sciences. © 2017 Wiley Periodicals, Inc.
-
Safety and Performance Analysis of the Non-Radar Oceanic/Remote Airspace In-Trail Procedure
NASA Technical Reports Server (NTRS)
Carreno, Victor A.; Munoz, Cesar A.
2007-01-01
This document presents a safety and performance analysis of the nominal case for the In-Trail Procedure (ITP) in a non-radar oceanic/remote airspace. The analysis estimates the risk of collision between the aircraft performing the ITP and a reference aircraft. The risk of collision is only estimated for the ITP maneuver and it is based on nominal operating conditions. The analysis does not consider human error, communication error conditions, or the normal risk of flight present in current operations. The hazards associated with human error and communication errors are evaluated in an Operational Hazards Analysis presented elsewhere.
-
Correcting a fundamental error in greenhouse gas accounting related to bioenergy.
Haberl, Helmut; Sprinz, Detlef; Bonazountas, Marc; Cocco, Pierluigi; Desaubies, Yves; Henze, Mogens; Hertel, Ole; Johnson, Richard K; Kastrup, Ulrike; Laconte, Pierre; Lange, Eckart; Novak, Peter; Paavola, Jouni; Reenberg, Anette; van den Hove, Sybille; Vermeire, Theo; Wadhams, Peter; Searchinger, Timothy
2012-06-01
Many international policies encourage a switch from fossil fuels to bioenergy based on the premise that its use would not result in carbon accumulation in the atmosphere. Frequently cited bioenergy goals would at least double the present global human use of plant material, the production of which already requires the dedication of roughly 75% of vegetated lands and more than 70% of water withdrawals. However, burning biomass for energy provision increases the amount of carbon in the air just like burning coal, oil or gas if harvesting the biomass decreases the amount of carbon stored in plants and soils, or reduces carbon sequestration. Neglecting this fact results in an accounting error that could be corrected by considering that only the use of 'additional biomass' - biomass from additional plant growth or biomass that would decompose rapidly if not used for bioenergy - can reduce carbon emissions. Failure to correct this accounting flaw will likely have substantial adverse consequences. The article presents recommendations for correcting greenhouse gas accounts related to bioenergy.
-
Ringing Artefact Reduction By An Efficient Likelihood Improvement Method
NASA Astrophysics Data System (ADS)
Fuderer, Miha
1989-10-01
In MR imaging, the extent of the acquired spatial frequencies of the object is necessarily finite. The resulting image shows artefacts caused by "truncation" of its Fourier components. These are known as Gibbs artefacts or ringing artefacts. These artefacts are particularly. visible when the time-saving reduced acquisition method is used, say, when scanning only the lowest 70% of the 256 data lines. Filtering the data results in loss of resolution. A method is described that estimates the high frequency data from the low-frequency data lines, with the likelihood of the image as criterion. It is a computationally very efficient method, since it requires practically only two extra Fourier transforms, in addition to the normal. reconstruction. The results of this method on MR images of human subjects are promising. Evaluations on a 70% acquisition image show about 20% decrease of the error energy after processing. "Error energy" is defined as the total power of the difference to a 256-data-lines reference image. The elimination of ringing artefacts then appears almost complete..
-
Differential sensitivity to human communication in dogs, wolves, and human infants.
Topál, József; Gergely, György; Erdohegyi, Agnes; Csibra, Gergely; Miklósi, Adám
2009-09-04
Ten-month-old infants persistently search for a hidden object at its initial hiding place even after observing it being hidden at another location. Recent evidence suggests that communicative cues from the experimenter contribute to the emergence of this perseverative search error. We replicated these results with dogs (Canis familiaris), who also commit more search errors in ostensive-communicative (in 75% of the total trials) than in noncommunicative (39%) or nonsocial (17%) hiding contexts. However, comparative investigations suggest that communicative signals serve different functions for dogs and infants, whereas human-reared wolves (Canis lupus) do not show doglike context-dependent differences of search errors. We propose that shared sensitivity to human communicative signals stems from convergent social evolution of the Homo and the Canis genera.
-
Metrics for Business Process Models
NASA Astrophysics Data System (ADS)
Mendling, Jan
Up until now, there has been little research on why people introduce errors in real-world business process models. In a more general context, Simon [404] points to the limitations of cognitive capabilities and concludes that humans act rationally only to a certain extent. Concerning modeling errors, this argument would imply that human modelers lose track of the interrelations of large and complex models due to their limited cognitive capabilities and introduce errors that they would not insert in a small model. A recent study by Mendling et al. [275] explores in how far certain complexity metrics of business process models have the potential to serve as error determinants. The authors conclude that complexity indeed appears to have an impact on error probability. Before we can test such a hypothesis in a more general setting, we have to establish an understanding of how we can define determinants that drive error probability and how we can measure them.
-
Tsai, Karin; Wallis, Jonathan; Botvinick, Matthew
2013-01-01
Studies suggest that dopaminergic neurons report a unitary, global reward prediction error signal. However, learning in complex real-life tasks, in particular tasks that show hierarchical structure, requires multiple prediction errors that may coincide in time. We used functional neuroimaging to measure prediction error signals in humans performing such a hierarchical task involving simultaneous, uncorrelated prediction errors. Analysis of signals in a priori anatomical regions of interest in the ventral striatum and the ventral tegmental area indeed evidenced two simultaneous, but separable, prediction error signals corresponding to the two levels of hierarchy in the task. This result suggests that suitably designed tasks may reveal a more intricate pattern of firing in dopaminergic neurons. Moreover, the need for downstream separation of these signals implies possible limitations on the number of different task levels that we can learn about simultaneously. PMID:23536092
-
Associations between errors and contributing factors in aircraft maintenance
NASA Technical Reports Server (NTRS)
Hobbs, Alan; Williamson, Ann
2003-01-01
In recent years cognitive error models have provided insights into the unsafe acts that lead to many accidents in safety-critical environments. Most models of accident causation are based on the notion that human errors occur in the context of contributing factors. However, there is a lack of published information on possible links between specific errors and contributing factors. A total of 619 safety occurrences involving aircraft maintenance were reported using a self-completed questionnaire. Of these occurrences, 96% were related to the actions of maintenance personnel. The types of errors that were involved, and the contributing factors associated with those actions, were determined. Each type of error was associated with a particular set of contributing factors and with specific occurrence outcomes. Among the associations were links between memory lapses and fatigue and between rule violations and time pressure. Potential applications of this research include assisting with the design of accident prevention strategies, the estimation of human error probabilities, and the monitoring of organizational safety performance.
-
Neuroanatomical dissociation for taxonomic and thematic knowledge in the human brain
Schwartz, Myrna F.; Kimberg, Daniel Y.; Walker, Grant M.; Brecher, Adelyn; Faseyitan, Olufunsho K.; Dell, Gary S.; Mirman, Daniel; Coslett, H. Branch
2011-01-01
It is thought that semantic memory represents taxonomic information differently from thematic information. This study investigated the neural basis for the taxonomic-thematic distinction in a unique way. We gathered picture-naming errors from 86 individuals with poststroke language impairment (aphasia). Error rates were determined separately for taxonomic errors (“pear” in response to apple) and thematic errors (“worm” in response to apple), and their shared variance was regressed out of each measure. With the segmented lesions normalized to a common template, we carried out voxel-based lesion-symptom mapping on each error type separately. We found that taxonomic errors localized to the left anterior temporal lobe and thematic errors localized to the left temporoparietal junction. This is an indication that the contribution of these regions to semantic memory cleaves along taxonomic-thematic lines. Our findings show that a distinction long recognized in the psychological sciences is grounded in the structure and function of the human brain. PMID:21540329
-
Huh, Yeamin; Smith, David E.; Feng, Meihau Rose
2014-01-01
Human clearance prediction for small- and macro-molecule drugs was evaluated and compared using various scaling methods and statistical analysis.Human clearance is generally well predicted using single or multiple species simple allometry for macro- and small-molecule drugs excreted renally.The prediction error is higher for hepatically eliminated small-molecules using single or multiple species simple allometry scaling, and it appears that the prediction error is mainly associated with drugs with low hepatic extraction ratio (Eh). The error in human clearance prediction for hepatically eliminated small-molecules was reduced using scaling methods with a correction of maximum life span (MLP) or brain weight (BRW).Human clearance of both small- and macro-molecule drugs is well predicted using the monkey liver blood flow method. Predictions using liver blood flow from other species did not work as well, especially for the small-molecule drugs. PMID:21892879
-
The Observational Determination of the Primordial Helium Abundance: a Y2K Status Report
NASA Astrophysics Data System (ADS)
Skillman, Evan D.
I review observational progress and assess the current state of the determination of the primordial helium abundance, Yp. At present there are two determinations with non-overlapping errors. My impression is that the errors have been under-estimated in both studies. I review recent work on errors assessment and give suggestions for decreasing systematic errors in future studies.
-
Yousef, Nadin; Yousef, Farah
2017-09-04
Whereas one of the predominant causes of medication errors is a drug administration error, a previous study related to our investigations and reviews estimated that the incidences of medication errors constituted 6.7 out of 100 administrated medication doses. Therefore, we aimed by using six sigma approach to propose a way that reduces these errors to become less than 1 out of 100 administrated medication doses by improving healthcare professional education and clearer handwritten prescriptions. The study was held in a General Government Hospital. First, we systematically studied the current medication use process. Second, we used six sigma approach by utilizing the five-step DMAIC process (Define, Measure, Analyze, Implement, Control) to find out the real reasons behind such errors. This was to figure out a useful solution to avoid medication error incidences in daily healthcare professional practice. Data sheet was used in Data tool and Pareto diagrams were used in Analyzing tool. In our investigation, we reached out the real cause behind administrated medication errors. As Pareto diagrams used in our study showed that the fault percentage in administrated phase was 24.8%, while the percentage of errors related to prescribing phase was 42.8%, 1.7 folds. This means that the mistakes in prescribing phase, especially because of the poor handwritten prescriptions whose percentage in this phase was 17.6%, are responsible for the consequent) mistakes in this treatment process later on. Therefore, we proposed in this study an effective low cost strategy based on the behavior of healthcare workers as Guideline Recommendations to be followed by the physicians. This method can be a prior caution to decrease errors in prescribing phase which may lead to decrease the administrated medication error incidences to less than 1%. This improvement way of behavior can be efficient to improve hand written prescriptions and decrease the consequent errors related to administrated medication doses to less than the global standard; as a result, it enhances patient safety. However, we hope other studies will be made later in hospitals to practically evaluate how much effective our proposed systematic strategy really is in comparison with other suggested remedies in this field.
-
Wang, Hua-fen; Jin, Jing-fen; Feng, Xiu-qin; Huang, Xin; Zhu, Ling-ling; Zhao, Xiao-ying; Zhou, Quan
2015-01-01
Background Medication errors may occur during prescribing, transcribing, prescription auditing, preparing, dispensing, administration, and monitoring. Medication administration errors (MAEs) are those that actually reach patients and remain a threat to patient safety. The Joint Commission International (JCI) advocates medication error prevention, but experience in reducing MAEs during the period of before and after JCI accreditation has not been reported. Methods An intervention study, aimed at reducing MAEs in hospitalized patients, was performed in the Second Affiliated Hospital of Zhejiang University, Hangzhou, People’s Republic of China, during the journey to JCI accreditation and in the post-JCI accreditation era (first half-year of 2011 to first half-year of 2014). Comprehensive interventions included organizational, information technology, educational, and process optimization-based measures. Data mining was performed on MAEs derived from a compulsory electronic reporting system. Results The number of MAEs continuously decreased from 143 (first half-year of 2012) to 64 (first half-year of 2014), with a decrease in occurrence rate by 60.9% (0.338% versus 0.132%, P<0.05). The number of MAEs related to high-alert medications decreased from 32 (the second half-year of 2011) to 16 (the first half-year of 2014), with a decrease in occurrence rate by 57.9% (0.0787% versus 0.0331%, P<0.05). Omission was the top type of MAE during the first half-year of 2011 to the first half-year of 2014, with a decrease by 50% (40 cases versus 20 cases). Intravenous administration error was the top type of error regarding administration route, but it continuously decreased from 64 (first half-year of 2012) to 27 (first half-year of 2014). More experienced registered nurses made fewer medication errors. The number of MAEs in surgical wards was twice that in medicinal wards. Compared with non-intensive care units, the intensive care units exhibited higher occurrence rates of MAEs (1.81% versus 0.24%, P<0.001). Conclusion A 3-and-a-half-year intervention program on MAEs was confirmed to be effective. MAEs made by nursing staff can be reduced, but cannot be eliminated. The depth, breadth, and efficiency of multidiscipline collaboration among physicians, pharmacists, nurses, information engineers, and hospital administrators are pivotal to safety in medication administration. JCI accreditation may help health systems enhance the awareness and ability to prevent MAEs and achieve successful quality improvements. PMID:25767393
-
Wang, Hua-Fen; Jin, Jing-Fen; Feng, Xiu-Qin; Huang, Xin; Zhu, Ling-Ling; Zhao, Xiao-Ying; Zhou, Quan
2015-01-01
Medication errors may occur during prescribing, transcribing, prescription auditing, preparing, dispensing, administration, and monitoring. Medication administration errors (MAEs) are those that actually reach patients and remain a threat to patient safety. The Joint Commission International (JCI) advocates medication error prevention, but experience in reducing MAEs during the period of before and after JCI accreditation has not been reported. An intervention study, aimed at reducing MAEs in hospitalized patients, was performed in the Second Affiliated Hospital of Zhejiang University, Hangzhou, People's Republic of China, during the journey to JCI accreditation and in the post-JCI accreditation era (first half-year of 2011 to first half-year of 2014). Comprehensive interventions included organizational, information technology, educational, and process optimization-based measures. Data mining was performed on MAEs derived from a compulsory electronic reporting system. The number of MAEs continuously decreased from 143 (first half-year of 2012) to 64 (first half-year of 2014), with a decrease in occurrence rate by 60.9% (0.338% versus 0.132%, P<0.05). The number of MAEs related to high-alert medications decreased from 32 (the second half-year of 2011) to 16 (the first half-year of 2014), with a decrease in occurrence rate by 57.9% (0.0787% versus 0.0331%, P<0.05). Omission was the top type of MAE during the first half-year of 2011 to the first half-year of 2014, with a decrease by 50% (40 cases versus 20 cases). Intravenous administration error was the top type of error regarding administration route, but it continuously decreased from 64 (first half-year of 2012) to 27 (first half-year of 2014). More experienced registered nurses made fewer medication errors. The number of MAEs in surgical wards was twice that in medicinal wards. Compared with non-intensive care units, the intensive care units exhibited higher occurrence rates of MAEs (1.81% versus 0.24%, P<0.001). A 3-and-a-half-year intervention program on MAEs was confirmed to be effective. MAEs made by nursing staff can be reduced, but cannot be eliminated. The depth, breadth, and efficiency of multidiscipline collaboration among physicians, pharmacists, nurses, information engineers, and hospital administrators are pivotal to safety in medication administration. JCI accreditation may help health systems enhance the awareness and ability to prevent MAEs and achieve successful quality improvements.
-
DOE Office of Scientific and Technical Information (OSTI.GOV)
Takahashi, Y; National Cancer Center, Kashiwa, Chiba; Tachibana, H
Purpose: Total body irradiation (TBI) and total marrow irradiation (TMI) using Tomotherapy have been reported. A gantry-based linear accelerator uses one isocenter during one rotational irradiation. Thus, 3–5 isocenter points should be used for a whole plan of TBI-VMAT during smoothing out the junctional dose distribution. IGRT provides accurate and precise patient setup for the multiple junctions, however it is evident that some setup errors should occur and affect accuracy of dose distribution in the area. In this study, we evaluated the robustness for patient’s setup error in VMAT-TBI. Methods: VMAT-TBI Planning was performed in an adult whole-body human phantommore » using Eclipse. Eight full arcs with four isocenter points using 6MV-X were used to cover the entire whole body. Dose distribution was optimized using two structures of patient’s body as PTV and lung. The two arcs were shared with one isocenter and the two arcs were 5 cm-overlapped with the other two arcs. Point absolute dose using ionization-chamber and planer relative dose distribution using film in the junctional regions were performed using water-equivalent slab phantom. In the measurements, several setup errors of (+5∼−5mm) were added. Results: The result of the chamber measurement shows the deviations were within ±3% when the setup errors were within ±3 mm. In the planer evaluation, the pass ratio of gamma evaluation (3%/2mm) shows more than 90% if the errors within ±3 mm. However, there were hot/cold areas in the edge of the junction even with acceptable gamma pass ratio. 5 mm setup error caused larger hot and cold areas and the dosimetric acceptable areas were decreased in the overlapped areas. Conclusion: It can be clinically acceptable for VMAT-TBI when patient setup error is within ±3mm. Averaging effects from patient random error would be helpful to blur the hot/cold area in the junction.« less
-
Fifty Years of THERP and Human Reliability Analysis
DOE Office of Scientific and Technical Information (OSTI.GOV)
Ronald L. Boring
2012-06-01
In 1962 at a Human Factors Society symposium, Alan Swain presented a paper introducing a Technique for Human Error Rate Prediction (THERP). This was followed in 1963 by a Sandia Laboratories monograph outlining basic human error quantification using THERP and, in 1964, by a special journal edition of Human Factors on quantification of human performance. Throughout the 1960s, Swain and his colleagues focused on collecting human performance data for the Sandia Human Error Rate Bank (SHERB), primarily in connection with supporting the reliability of nuclear weapons assembly in the US. In 1969, Swain met with Jens Rasmussen of Risø Nationalmore » Laboratory and discussed the applicability of THERP to nuclear power applications. By 1975, in WASH-1400, Swain had articulated the use of THERP for nuclear power applications, and the approach was finalized in the watershed publication of the NUREG/CR-1278 in 1983. THERP is now 50 years old, and remains the most well known and most widely used HRA method. In this paper, the author discusses the history of THERP, based on published reports and personal communication and interviews with Swain. The author also outlines the significance of THERP. The foundations of human reliability analysis are found in THERP: human failure events, task analysis, performance shaping factors, human error probabilities, dependence, event trees, recovery, and pre- and post-initiating events were all introduced in THERP. While THERP is not without its detractors, and it is showing signs of its age in the face of newer technological applications, the longevity of THERP is a testament of its tremendous significance. THERP started the field of human reliability analysis. This paper concludes with a discussion of THERP in the context of newer methods, which can be seen as extensions of or departures from Swain’s pioneering work.« less
-
Error-free replicative bypass of (6–4) photoproducts by DNA polymerase ζ in mouse and human cells
Yoon, Jung-Hoon; Prakash, Louise; Prakash, Satya
2010-01-01
The ultraviolet (UV)-induced (6–4) pyrimidine–pyrimidone photoproduct [(6–4) PP] confers a large structural distortion in DNA. Here we examine in human cells the roles of translesion synthesis (TLS) DNA polymerases (Pols) in promoting replication through a (6–4) TT photoproduct carried on a duplex plasmid where bidirectional replication initiates from an origin of replication. We show that TLS contributes to a large fraction of lesion bypass and that it is mostly error-free. We find that, whereas Pol η and Pol ι provide alternate pathways for mutagenic TLS, surprisingly, Pol ζ functions independently of these Pols and in a predominantly error-free manner. We verify and extend these observations in mouse cells and conclude that, in human cells, TLS during replication can be markedly error-free even opposite a highly distorting DNA lesion. PMID:20080950
-
DOE Office of Scientific and Technical Information (OSTI.GOV)
Agarwal, Vivek; Oxstrand, Johanna H.; Le Blanc, Katya L.
The work management process in current fleets of national nuclear power plants is so highly dependent on large technical staffs and quality of work instruction, i.e., paper-based, that this puts nuclear energy at somewhat of a long-term economic disadvantage and increase the possibility of human errors. Technologies like mobile portable devices and computer-based procedures can play a key role in improving the plant work management process, thereby increasing productivity and decreasing cost. Automated work packages are a fundamentally an enabling technology for improving worker productivity and human performance in nuclear power plants work activities because virtually every plant work activitymore » is accomplished using some form of a work package. As part of this year’s research effort, automated work packages architecture is identified and an initial set of requirements identified, that are essential and necessary for implementation of automated work packages in nuclear power plants.« less
-
A Framework for Modeling Human-Machine Interactions
NASA Technical Reports Server (NTRS)
Shafto, Michael G.; Rosekind, Mark R. (Technical Monitor)
1996-01-01
Modern automated flight-control systems employ a variety of different behaviors, or modes, for managing the flight. While developments in cockpit automation have resulted in workload reduction and economical advantages, they have also given rise to an ill-defined class of human-machine problems, sometimes referred to as 'automation surprises'. Our interest in applying formal methods for describing human-computer interaction stems from our ongoing research on cockpit automation. In this area of aeronautical human factors, there is much concern about how flight crews interact with automated flight-control systems, so that the likelihood of making errors, in particular mode-errors, is minimized and the consequences of such errors are contained. The goal of the ongoing research on formal methods in this context is: (1) to develop a framework for describing human interaction with control systems; (2) to formally categorize such automation surprises; and (3) to develop tests for identification of these categories early in the specification phase of a new human-machine system.
-
Inborn Errors of Human JAKs and STATs
Casanova, Jean-Laurent; Holland, Steven M.; Notarangelo, Luigi D.
2012-01-01
Inborn errors of the genes encoding two of the four human JAKs (JAK3 and TYK2) and three of the six human STATs (STAT1, STAT3, and STAT5B) have been described. We review the disorders arising from mutations in these five genes, highlighting the way in which the molecular and cellular pathogenesis of these conditions has been clarified by the discovery of inborn errors of cytokines, hormones, and their receptors, including those interacting with JAKs and STATs. The phenotypic similarities between mice and humans lacking individual JAK-STAT components suggest that the functions of JAKs and STATs are largely conserved in mammals. However, a wide array of phenotypic differences has emerged between mice and humans carrying bi-allelic null alleles of JAK3, TYK2, STAT1, or STAT5B. Moreover, the high level of allelic heterogeneity at the human JAK3, STAT1, and STAT3 loci has revealed highly diverse immunological and clinical phenotypes, which had not been anticipated. PMID:22520845
-
Inborn errors of human JAKs and STATs.
Casanova, Jean-Laurent; Holland, Steven M; Notarangelo, Luigi D
2012-04-20
Inborn errors of the genes encoding two of the four human JAKs (JAK3 and TYK2) and three of the six human STATs (STAT1, STAT3, and STAT5B) have been described. We review the disorders arising from mutations in these five genes, highlighting the way in which the molecular and cellular pathogenesis of these conditions has been clarified by the discovery of inborn errors of cytokines, hormones, and their receptors, including those interacting with JAKs and STATs. The phenotypic similarities between mice and humans lacking individual JAK-STAT components suggest that the functions of JAKs and STATs are largely conserved in mammals. However, a wide array of phenotypic differences has emerged between mice and humans carrying biallelic null alleles of JAK3, TYK2, STAT1, or STAT5B. Moreover, the high degree of allelic heterogeneity at the human JAK3, TYK2, STAT1, and STAT3 loci has revealed highly diverse immunological and clinical phenotypes, which had not been anticipated. Copyright © 2012 Elsevier Inc. All rights reserved.
-
Use of modeling to identify vulnerabilities to human error in laparoscopy.
Funk, Kenneth H; Bauer, James D; Doolen, Toni L; Telasha, David; Nicolalde, R Javier; Reeber, Miriam; Yodpijit, Nantakrit; Long, Myra
2010-01-01
This article describes an exercise to investigate the utility of modeling and human factors analysis in understanding surgical processes and their vulnerabilities to medical error. A formal method to identify error vulnerabilities was developed and applied to a test case of Veress needle insertion during closed laparoscopy. A team of 2 surgeons, a medical assistant, and 3 engineers used hierarchical task analysis and Integrated DEFinition language 0 (IDEF0) modeling to create rich models of the processes used in initial port creation. Using terminology from a standardized human performance database, detailed task descriptions were written for 4 tasks executed in the process of inserting the Veress needle. Key terms from the descriptions were used to extract from the database generic errors that could occur. Task descriptions with potential errors were translated back into surgical terminology. Referring to the process models and task descriptions, the team used a modified failure modes and effects analysis (FMEA) to consider each potential error for its probability of occurrence, its consequences if it should occur and be undetected, and its probability of detection. The resulting likely and consequential errors were prioritized for intervention. A literature-based validation study confirmed the significance of the top error vulnerabilities identified using the method. Ongoing work includes design and evaluation of procedures to correct the identified vulnerabilities and improvements to the modeling and vulnerability identification methods. Copyright 2010 AAGL. Published by Elsevier Inc. All rights reserved.
-
Using mobile devices to improve the safety of medication administration processes.
Navas, H; Graffi Moltrasio, L; Ares, F; Strumia, G; Dourado, E; Alvarez, M
2015-01-01
Within preventable medical errors, those related to medications are frequent in every stage of the prescribing cycle. Nursing is responsible for maintaining each patients safety and care quality. Moreover, nurses are the last people who can detect an error in medication before its administration. Medication administration is one of the riskiest tasks in nursing. The use of information and communication technologies is related to a decrease in these errors. Including mobile devices related to 2D code reading of patients and medication will decrease the possibility of error when preparing and administering medication by nurses. A cross-platform software (iOS and Android) was developed to ensure the five Rights of the medication administration process (patient, medication, dose, route and schedule). Deployment in November showed 39% use.
-
NASA Astrophysics Data System (ADS)
Pinnington, Ewan; Casella, Eric; Dance, Sarah; Lawless, Amos; Morison, James; Nichols, Nancy; Wilkinson, Matthew; Quaife, Tristan
2016-04-01
Forest ecosystems play an important role in sequestering human emitted carbon-dioxide from the atmosphere and therefore greatly reduce the effect of anthropogenic induced climate change. For that reason understanding their response to climate change is of great importance. Efforts to implement variational data assimilation routines with functional ecology models and land surface models have been limited, with sequential and Markov chain Monte Carlo data assimilation methods being prevalent. When data assimilation has been used with models of carbon balance, background "prior" errors and observation errors have largely been treated as independent and uncorrelated. Correlations between background errors have long been known to be a key aspect of data assimilation in numerical weather prediction. More recently, it has been shown that accounting for correlated observation errors in the assimilation algorithm can considerably improve data assimilation results and forecasts. In this paper we implement a 4D-Var scheme with a simple model of forest carbon balance, for joint parameter and state estimation and assimilate daily observations of Net Ecosystem CO2 Exchange (NEE) taken at the Alice Holt forest CO2 flux site in Hampshire, UK. We then investigate the effect of specifying correlations between parameter and state variables in background error statistics and the effect of specifying correlations in time between observation error statistics. The idea of including these correlations in time is new and has not been previously explored in carbon balance model data assimilation. In data assimilation, background and observation error statistics are often described by the background error covariance matrix and the observation error covariance matrix. We outline novel methods for creating correlated versions of these matrices, using a set of previously postulated dynamical constraints to include correlations in the background error statistics and a Gaussian correlation function to include time correlations in the observation error statistics. The methods used in this paper will allow the inclusion of time correlations between many different observation types in the assimilation algorithm, meaning that previously neglected information can be accounted for. In our experiments we compared the results using our new correlated background and observation error covariance matrices and those using diagonal covariance matrices. We found that using the new correlated matrices reduced the root mean square error in the 14 year forecast of daily NEE by 44 % decreasing from 4.22 g C m-2 day-1 to 2.38 g C m-2 day-1.
-
Milekovic, Tomislav; Ball, Tonio; Schulze-Bonhage, Andreas; Aertsen, Ad; Mehring, Carsten
2013-01-01
Background Brain-machine interfaces (BMIs) can translate the neuronal activity underlying a user’s movement intention into movements of an artificial effector. In spite of continuous improvements, errors in movement decoding are still a major problem of current BMI systems. If the difference between the decoded and intended movements becomes noticeable, it may lead to an execution error. Outcome errors, where subjects fail to reach a certain movement goal, are also present during online BMI operation. Detecting such errors can be beneficial for BMI operation: (i) errors can be corrected online after being detected and (ii) adaptive BMI decoding algorithm can be updated to make fewer errors in the future. Methodology/Principal Findings Here, we show that error events can be detected from human electrocorticography (ECoG) during a continuous task with high precision, given a temporal tolerance of 300–400 milliseconds. We quantified the error detection accuracy and showed that, using only a small subset of 2×2 ECoG electrodes, 82% of detection information for outcome error and 74% of detection information for execution error available from all ECoG electrodes could be retained. Conclusions/Significance The error detection method presented here could be used to correct errors made during BMI operation or to adapt a BMI algorithm to make fewer errors in the future. Furthermore, our results indicate that smaller ECoG implant could be used for error detection. Reducing the size of an ECoG electrode implant used for BMI decoding and error detection could significantly reduce the medical risk of implantation. PMID:23383315
-
Composable Framework Support for Software-FMEA Through Model Execution
NASA Astrophysics Data System (ADS)
Kocsis, Imre; Patricia, Andras; Brancati, Francesco; Rossi, Francesco
2016-08-01
Performing Failure Modes and Effect Analysis (FMEA) during software architecture design is becoming a basic requirement in an increasing number of domains; however, due to the lack of standardized early design phase model execution, classic SW-FMEA approaches carry significant risks and are human effort-intensive even in processes that use Model-Driven Engineering.Recently, modelling languages with standardized executable semantics have emerged. Building on earlier results, this paper describes framework support for generating executable error propagation models from such models during software architecture design. The approach carries the promise of increased precision, decreased risk and more automated execution for SW-FMEA during dependability- critical system development.
-
On the importance of Task 1 and error performance measures in PRP dual-task studies.
Strobach, Tilo; Schütz, Anja; Schubert, Torsten
2015-01-01
The psychological refractory period (PRP) paradigm is a dominant research tool in the literature on dual-task performance. In this paradigm a first and second component task (i.e., Task 1 and Task 2) are presented with variable stimulus onset asynchronies (SOAs) and priority to perform Task 1. The main indicator of dual-task impairment in PRP situations is an increasing Task 2-RT with decreasing SOAs. This impairment is typically explained with some task components being processed strictly sequentially in the context of the prominent central bottleneck theory. This assumption could implicitly suggest that processes of Task 1 are unaffected by Task 2 and bottleneck processing, i.e., decreasing SOAs do not increase reaction times (RTs) and error rates of the first task. The aim of the present review is to assess whether PRP dual-task studies included both RT and error data presentations and statistical analyses and whether studies including both data types (i.e., RTs and error rates) show data consistent with this assumption (i.e., decreasing SOAs and unaffected RTs and/or error rates in Task 1). This review demonstrates that, in contrast to RT presentations and analyses, error data is underrepresented in a substantial number of studies. Furthermore, a substantial number of studies with RT and error data showed a statistically significant impairment of Task 1 performance with decreasing SOA. Thus, these studies produced data that is not primarily consistent with the strong assumption that processes of Task 1 are unaffected by Task 2 and bottleneck processing in the context of PRP dual-task situations; this calls for a more careful report and analysis of Task 1 performance in PRP studies and for a more careful consideration of theories proposing additions to the bottleneck assumption, which are sufficiently general to explain Task 1 and Task 2 effects.
-
On the importance of Task 1 and error performance measures in PRP dual-task studies
Strobach, Tilo; Schütz, Anja; Schubert, Torsten
2015-01-01
The psychological refractory period (PRP) paradigm is a dominant research tool in the literature on dual-task performance. In this paradigm a first and second component task (i.e., Task 1 and Task 2) are presented with variable stimulus onset asynchronies (SOAs) and priority to perform Task 1. The main indicator of dual-task impairment in PRP situations is an increasing Task 2-RT with decreasing SOAs. This impairment is typically explained with some task components being processed strictly sequentially in the context of the prominent central bottleneck theory. This assumption could implicitly suggest that processes of Task 1 are unaffected by Task 2 and bottleneck processing, i.e., decreasing SOAs do not increase reaction times (RTs) and error rates of the first task. The aim of the present review is to assess whether PRP dual-task studies included both RT and error data presentations and statistical analyses and whether studies including both data types (i.e., RTs and error rates) show data consistent with this assumption (i.e., decreasing SOAs and unaffected RTs and/or error rates in Task 1). This review demonstrates that, in contrast to RT presentations and analyses, error data is underrepresented in a substantial number of studies. Furthermore, a substantial number of studies with RT and error data showed a statistically significant impairment of Task 1 performance with decreasing SOA. Thus, these studies produced data that is not primarily consistent with the strong assumption that processes of Task 1 are unaffected by Task 2 and bottleneck processing in the context of PRP dual-task situations; this calls for a more careful report and analysis of Task 1 performance in PRP studies and for a more careful consideration of theories proposing additions to the bottleneck assumption, which are sufficiently general to explain Task 1 and Task 2 effects. PMID:25904890
-
Inborn Errors of Fructose Metabolism. What Can We Learn from Them?
Tran, Christel
2017-04-03
Fructose is one of the main sweetening agents in the human diet and its ingestion is increasing globally. Dietary sugar has particular effects on those whose capacity to metabolize fructose is limited. If intolerance to carbohydrates is a frequent finding in children, inborn errors of carbohydrate metabolism are rare conditions. Three inborn errors are known in the pathway of fructose metabolism; (1) essential or benign fructosuria due to fructokinase deficiency; (2) hereditary fructose intolerance; and (3) fructose-1,6-bisphosphatase deficiency. In this review the focus is set on the description of the clinical symptoms and biochemical anomalies in the three inborn errors of metabolism. The potential toxic effects of fructose in healthy humans also are discussed. Studies conducted in patients with inborn errors of fructose metabolism helped to understand fructose metabolism and its potential toxicity in healthy human. Influence of fructose on the glycolytic pathway and on purine catabolism is the cause of hypoglycemia, lactic acidosis and hyperuricemia. The discovery that fructose-mediated generation of uric acid may have a causal role in diabetes and obesity provided new understandings into pathogenesis for these frequent diseases.
-
Inborn Errors of Fructose Metabolism. What Can We Learn from Them?
Tran, Christel
2017-01-01
Fructose is one of the main sweetening agents in the human diet and its ingestion is increasing globally. Dietary sugar has particular effects on those whose capacity to metabolize fructose is limited. If intolerance to carbohydrates is a frequent finding in children, inborn errors of carbohydrate metabolism are rare conditions. Three inborn errors are known in the pathway of fructose metabolism; (1) essential or benign fructosuria due to fructokinase deficiency; (2) hereditary fructose intolerance; and (3) fructose-1,6-bisphosphatase deficiency. In this review the focus is set on the description of the clinical symptoms and biochemical anomalies in the three inborn errors of metabolism. The potential toxic effects of fructose in healthy humans also are discussed. Studies conducted in patients with inborn errors of fructose metabolism helped to understand fructose metabolism and its potential toxicity in healthy human. Influence of fructose on the glycolytic pathway and on purine catabolism is the cause of hypoglycemia, lactic acidosis and hyperuricemia. The discovery that fructose-mediated generation of uric acid may have a causal role in diabetes and obesity provided new understandings into pathogenesis for these frequent diseases. PMID:28368361
-
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
-
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.
-
ERIC Educational Resources Information Center
Bowe, Melissa; Sellers, Tyra P.
2018-01-01
The Performance Diagnostic Checklist-Human Services (PDC-HS) has been used to assess variables contributing to undesirable staff performance. In this study, three preschool teachers completed the PDC-HS to identify the factors contributing to four paraprofessionals' inaccurate implementation of error-correction procedures during discrete trial…
-
The Importance of HRA in Human Space Flight: Understanding the Risks
NASA Technical Reports Server (NTRS)
Hamlin, Teri
2010-01-01
Human performance is critical to crew safety during space missions. Humans interact with hardware and software during ground processing, normal flight, and in response to events. Human interactions with hardware and software can cause Loss of Crew and/or Vehicle (LOCV) through improper actions, or may prevent LOCV through recovery and control actions. Humans have the ability to deal with complex situations and system interactions beyond the capability of machines. Human Reliability Analysis (HRA) is a method used to qualitatively and quantitatively assess the occurrence of human failures that affect availability and reliability of complex systems. Modeling human actions with their corresponding failure probabilities in a Probabilistic Risk Assessment (PRA) provides a more complete picture of system risks and risk contributions. A high-quality HRA can provide valuable information on potential areas for improvement, including training, procedures, human interfaces design, and the need for automation. Modeling human error has always been a challenge in part because performance data is not always readily available. For spaceflight, the challenge is amplified not only because of the small number of participants and limited amount of performance data available, but also due to the lack of definition of the unique factors influencing human performance in space. These factors, called performance shaping factors in HRA terminology, are used in HRA techniques to modify basic human error probabilities in order to capture the context of an analyzed task. Many of the human error modeling techniques were developed within the context of nuclear power plants and therefore the methodologies do not address spaceflight factors such as the effects of microgravity and longer duration missions. This presentation will describe the types of human error risks which have shown up as risk drivers in the Shuttle PRA which may be applicable to commercial space flight. As with other large PRAs of complex machines, human error in the Shuttle PRA proved to be an important contributor (12 percent) to LOCV. An existing HRA technique was adapted for use in the Shuttle PRA, but additional guidance and improvements are needed to make the HRA task in space-related PRAs easier and more accurate. Therefore, this presentation will also outline plans for expanding current HRA methodology to more explicitly cover spaceflight performance shaping factors.
-
Comment on "Differential sensitivity to human communication in dogs, wolves, and human infants".
Fiset, Sylvain
2010-07-09
Topál et al. (Reports, 4 September 2009, p. 1269) reported that dogs' sensitivity to reading and using human signals contributes to the emergence of a spatial perseveration error (the A-not-B error) for locating objects. Here, I argue that the authors' conclusion was biased by two confounding factors: the use of an atypical A-not-B search task and an inadequate nonsocial condition as a control.
-
NASA: Model development for human factors interfacing
NASA Technical Reports Server (NTRS)
Smith, L. L.
1984-01-01
The results of an intensive literature review in the general topics of human error analysis, stress and job performance, and accident and safety analysis revealed no usable techniques or approaches for analyzing human error in ground or space operations tasks. A task review model is described and proposed to be developed in order to reduce the degree of labor intensiveness in ground and space operations tasks. An extensive number of annotated references are provided.
-
Syntactic and semantic errors in radiology reports associated with speech recognition software.
Ringler, Michael D; Goss, Brian C; Bartholmai, Brian J
2017-03-01
Speech recognition software can increase the frequency of errors in radiology reports, which may affect patient care. We retrieved 213,977 speech recognition software-generated reports from 147 different radiologists and proofread them for errors. Errors were classified as "material" if they were believed to alter interpretation of the report. "Immaterial" errors were subclassified as intrusion/omission or spelling errors. The proportion of errors and error type were compared among individual radiologists, imaging subspecialty, and time periods. In all, 20,759 reports (9.7%) contained errors, of which 3992 (1.9%) were material errors. Among immaterial errors, spelling errors were more common than intrusion/omission errors ( p < .001). Proportion of errors and fraction of material errors varied significantly among radiologists and between imaging subspecialties ( p < .001). Errors were more common in cross-sectional reports, reports reinterpreting results of outside examinations, and procedural studies (all p < .001). Error rate decreased over time ( p < .001), which suggests that a quality control program with regular feedback may reduce errors.
-
Designing to Control Flight Crew Errors
NASA Technical Reports Server (NTRS)
Schutte, Paul C.; Willshire, Kelli F.
1997-01-01
It is widely accepted that human error is a major contributing factor in aircraft accidents. There has been a significant amount of research in why these errors occurred, and many reports state that the design of flight deck can actually dispose humans to err. This research has led to the call for changes in design according to human factors and human-centered principles. The National Aeronautics and Space Administration's (NASA) Langley Research Center has initiated an effort to design a human-centered flight deck from a clean slate (i.e., without constraints of existing designs.) The effort will be based on recent research in human-centered design philosophy and mission management categories. This design will match the human's model of the mission and function of the aircraft to reduce unnatural or non-intuitive interfaces. The product of this effort will be a flight deck design description, including training and procedures, and a cross reference or paper trail back to design hypotheses, and an evaluation of the design. The present paper will discuss the philosophy, process, and status of this design effort.
-
Advancing Usability Evaluation through Human Reliability Analysis
DOE Office of Scientific and Technical Information (OSTI.GOV)
Ronald L. Boring; David I. Gertman
2005-07-01
This paper introduces a novel augmentation to the current heuristic usability evaluation methodology. The SPAR-H human reliability analysis method was developed for categorizing human performance in nuclear power plants. Despite the specialized use of SPAR-H for safety critical scenarios, the method also holds promise for use in commercial off-the-shelf software usability evaluations. The SPAR-H method shares task analysis underpinnings with human-computer interaction, and it can be easily adapted to incorporate usability heuristics as performance shaping factors. By assigning probabilistic modifiers to heuristics, it is possible to arrive at the usability error probability (UEP). This UEP is not a literal probabilitymore » of error but nonetheless provides a quantitative basis to heuristic evaluation. When combined with a consequence matrix for usability errors, this method affords ready prioritization of usability issues.« less
-
Yang, Minglei; Ding, Hui; Zhu, Lei; Wang, Guangzhi
2016-12-01
Ultrasound fusion imaging is an emerging tool and benefits a variety of clinical applications, such as image-guided diagnosis and treatment of hepatocellular carcinoma and unresectable liver metastases. However, respiratory liver motion-induced misalignment of multimodal images (i.e., fusion error) compromises the effectiveness and practicability of this method. The purpose of this paper is to develop a subject-specific liver motion model and automatic registration-based method to correct the fusion error. An online-built subject-specific motion model and automatic image registration method for 2D ultrasound-3D magnetic resonance (MR) images were combined to compensate for the respiratory liver motion. The key steps included: 1) Build a subject-specific liver motion model for current subject online and perform the initial registration of pre-acquired 3D MR and intra-operative ultrasound images; 2) During fusion imaging, compensate for liver motion first using the motion model, and then using an automatic registration method to further correct the respiratory fusion error. Evaluation experiments were conducted on liver phantom and five subjects. In the phantom study, the fusion error (superior-inferior axis) was reduced from 13.90±2.38mm to 4.26±0.78mm by using the motion model only. The fusion error further decreased to 0.63±0.53mm by using the registration method. The registration method also decreased the rotation error from 7.06±0.21° to 1.18±0.66°. In the clinical study, the fusion error was reduced from 12.90±9.58mm to 6.12±2.90mm by using the motion model alone. Moreover, the fusion error decreased to 1.96±0.33mm by using the registration method. The proposed method can effectively correct the respiration-induced fusion error to improve the fusion image quality. This method can also reduce the error correction dependency on the initial registration of ultrasound and MR images. Overall, the proposed method can improve the clinical practicability of ultrasound fusion imaging. Copyright © 2016 Elsevier Ltd. All rights reserved.
-
Improving Patient Safety in Anesthesia: A Success Story?
DOE Office of Scientific and Technical Information (OSTI.GOV)
Botney, Richard
2008-05-01
Anesthesia is necessary for surgery; however, it does not deliver any direct therapeutic benefit. The risks of anesthesia must therefore be as low as possible. Anesthesiology has been identified as a leader in improving patient safety. Anesthetic mortality has decreased, and in healthy patients can be as low as 1:250,000. Trends in anesthetic morbidity have not been as well defined, but it appears that the risk of injury is decreasing. Studies of error during anesthesia and Closed Claims studies have identified sources of risk and methods to reduce the risks associated with anesthesia. These include changes in technology, such asmore » anesthetic delivery systems and monitors, the application of human factors, the use of simulation, and the establishment of reporting systems. A review of the important events in the past 50 years illustrates the many steps that have contributed to the improvements in anesthesia safety.« less
-
Maikusa, Norihide; Yamashita, Fumio; Tanaka, Kenichiro; Abe, Osamu; Kawaguchi, Atsushi; Kabasawa, Hiroyuki; Chiba, Shoma; Kasahara, Akihiro; Kobayashi, Nobuhisa; Yuasa, Tetsuya; Sato, Noriko; Matsuda, Hiroshi; Iwatsubo, Takeshi
2013-06-01
Serial magnetic resonance imaging (MRI) images acquired from multisite and multivendor MRI scanners are widely used in measuring longitudinal structural changes in the brain. Precise and accurate measurements are important in understanding the natural progression of neurodegenerative disorders such as Alzheimer's disease. However, geometric distortions in MRI images decrease the accuracy and precision of volumetric or morphometric measurements. To solve this problem, the authors suggest a commercially available phantom-based distortion correction method that accommodates the variation in geometric distortion within MRI images obtained with multivendor MRI scanners. The authors' method is based on image warping using a polynomial function. The method detects fiducial points within a phantom image using phantom analysis software developed by the Mayo Clinic and calculates warping functions for distortion correction. To quantify the effectiveness of the authors' method, the authors corrected phantom images obtained from multivendor MRI scanners and calculated the root-mean-square (RMS) of fiducial errors and the circularity ratio as evaluation values. The authors also compared the performance of the authors' method with that of a distortion correction method based on a spherical harmonics description of the generic gradient design parameters. Moreover, the authors evaluated whether this correction improves the test-retest reproducibility of voxel-based morphometry in human studies. A Wilcoxon signed-rank test with uncorrected and corrected images was performed. The root-mean-square errors and circularity ratios for all slices significantly improved (p < 0.0001) after the authors' distortion correction. Additionally, the authors' method was significantly better than a distortion correction method based on a description of spherical harmonics in improving the distortion of root-mean-square errors (p < 0.001 and 0.0337, respectively). Moreover, the authors' method reduced the RMS error arising from gradient nonlinearity more than gradwarp methods. In human studies, the coefficient of variation of voxel-based morphometry analysis of the whole brain improved significantly from 3.46% to 2.70% after distortion correction of the whole gray matter using the authors' method (Wilcoxon signed-rank test, p < 0.05). The authors proposed a phantom-based distortion correction method to improve reproducibility in longitudinal structural brain analysis using multivendor MRI. The authors evaluated the authors' method for phantom images in terms of two geometrical values and for human images in terms of test-retest reproducibility. The results showed that distortion was corrected significantly using the authors' method. In human studies, the reproducibility of voxel-based morphometry analysis for the whole gray matter significantly improved after distortion correction using the authors' method.
-
Autonomous Control Modes and Optimized Path Guidance for Shipboard Landing in High Sea States
2015-11-16
a degraded visual environment, workload during the landing task begins to approach the limits of a human pilot’s capability. It is a similarly...Figure 2. Approach Trajectory ±4 ft landing error ±8 ft landing error ±12 ft landing error Flight Path -3000...heave and yaw axes. Figure 5. Open loop system generation ±4 ft landing error ±8 ft landing error ±12 ft landing error -10 -8 -6 -4 -2 0 2 4
-
Cirrus Cloud Retrieval Using Infrared Sounding Data: Multilevel Cloud Errors.
NASA Astrophysics Data System (ADS)
Baum, Bryan A.; Wielicki, Bruce A.
1994-01-01
In this study we perform an error analysis for cloud-top pressure retrieval using the High-Resolution Infrared Radiometric Sounder (HIRS/2) 15-µm CO2 channels for the two-layer case of transmissive cirrus overlying an overcast, opaque stratiform cloud. This analysis includes standard deviation and bias error due to instrument noise and the presence of two cloud layers, the lower of which is opaque. Instantaneous cloud pressure retrieval errors are determined for a range of cloud amounts (0.1 1.0) and cloud-top pressures (850250 mb). Large cloud-top pressure retrieval errors are found to occur when a lower opaque layer is present underneath an upper transmissive cloud layer in the satellite field of view (FOV). Errors tend to increase with decreasing upper-cloud elective cloud amount and with decreasing cloud height (increasing pressure). Errors in retrieved upper-cloud pressure result in corresponding errors in derived effective cloud amount. For the case in which a HIRS FOV has two distinct cloud layers, the difference between the retrieved and actual cloud-top pressure is positive in all casts, meaning that the retrieved upper-cloud height is lower than the actual upper-cloud height. In addition, errors in retrieved cloud pressure are found to depend upon the lapse rate between the low-level cloud top and the surface. We examined which sounder channel combinations would minimize the total errors in derived cirrus cloud height caused by instrument noise and by the presence of a lower-level cloud. We find that while the sounding channels that peak between 700 and 1000 mb minimize random errors, the sounding channels that peak at 300—500 mb minimize bias errors. For a cloud climatology, the bias errors are most critical.
-
Prediction-error in the context of real social relationships modulates reward system activity.
Poore, Joshua C; Pfeifer, Jennifer H; Berkman, Elliot T; Inagaki, Tristen K; Welborn, Benjamin L; Lieberman, Matthew D
2012-01-01
The human reward system is sensitive to both social (e.g., validation) and non-social rewards (e.g., money) and is likely integral for relationship development and reputation building. However, data is sparse on the question of whether implicit social reward processing meaningfully contributes to explicit social representations such as trust and attachment security in pre-existing relationships. This event-related fMRI experiment examined reward system prediction-error activity in response to a potent social reward-social validation-and this activity's relation to both attachment security and trust in the context of real romantic relationships. During the experiment, participants' expectations for their romantic partners' positive regard of them were confirmed (validated) or violated, in either positive or negative directions. Primary analyses were conducted using predefined regions of interest, the locations of which were taken from previously published research. Results indicate that activity for mid-brain and striatal reward system regions of interest was modulated by social reward expectation violation in ways consistent with prior research on reward prediction-error. Additionally, activity in the striatum during viewing of disconfirmatory information was associated with both increases in post-scan reports of attachment anxiety and decreases in post-scan trust, a finding that follows directly from representational models of attachment and trust.
-
The Accuracy of GBM GRB Localizations
NASA Astrophysics Data System (ADS)
Briggs, Michael Stephen; Connaughton, V.; Meegan, C.; Hurley, K.
2010-03-01
We report an study of the accuracy of GBM GRB localizations, analyzing three types of localizations: those produced automatically by the GBM Flight Software on board GBM, those produced automatically with ground software in near real time, and localizations produced with human guidance. The two types of automatic locations are distributed in near real-time via GCN Notices; the human-guided locations are distributed on timescale of many minutes or hours using GCN Circulars. This work uses a Bayesian analysis that models the distribution of the GBM total location error by comparing GBM locations to more accurate locations obtained with other instruments. Reference locations are obtained from Swift, Super-AGILE, the LAT, and with the IPN. We model the GBM total location errors as having systematic errors in addition to the statistical errors and use the Bayesian analysis to constrain the systematic errors.
-
Flynn, Fran; Evanish, Julie Q; Fernald, Josephine M; Hutchinson, Dawn E; Lefaiver, Cheryl
2016-08-01
Because of the high frequency of interruptions during medication administration, the effectiveness of strategies to limit interruptions during medication administration has been evaluated in numerous quality improvement initiatives in an effort to reduce medication administration errors. To evaluate the effectiveness of evidence-based strategies to limit interruptions during scheduled, peak medication administration times in 3 progressive cardiac care units (PCCUs). A secondary aim of the project was to evaluate the impact of limiting interruptions on medication errors. The percentages of interruptions and medication errors before and after implementation of evidence-based strategies to limit interruptions were measured by using direct observations of nurses on 2 PCCUs. Nurses in a third PCCU served as a comparison group. Interruptions (P < .001) and medication errors (P = .02) decreased significantly in 1 PCCU after implementation of evidence-based strategies to limit interruptions. Avoidable interruptions decreased 83% in PCCU1 and 53% in PCCU2 after implementation of the evidence-based strategies. Implementation of evidence-based strategies to limit interruptions in PCCUs decreases avoidable interruptions and promotes patient safety. ©2016 American Association of Critical-Care Nurses.
-
Effect of correlated observation error on parameters, predictions, and uncertainty
Tiedeman, Claire; Green, Christopher T.
2013-01-01
Correlations among observation errors are typically omitted when calculating observation weights for model calibration by inverse methods. We explore the effects of omitting these correlations on estimates of parameters, predictions, and uncertainties. First, we develop a new analytical expression for the difference in parameter variance estimated with and without error correlations for a simple one-parameter two-observation inverse model. Results indicate that omitting error correlations from both the weight matrix and the variance calculation can either increase or decrease the parameter variance, depending on the values of error correlation (ρ) and the ratio of dimensionless scaled sensitivities (rdss). For small ρ, the difference in variance is always small, but for large ρ, the difference varies widely depending on the sign and magnitude of rdss. Next, we consider a groundwater reactive transport model of denitrification with four parameters and correlated geochemical observation errors that are computed by an error-propagation approach that is new for hydrogeologic studies. We compare parameter estimates, predictions, and uncertainties obtained with and without the error correlations. Omitting the correlations modestly to substantially changes parameter estimates, and causes both increases and decreases of parameter variances, consistent with the analytical expression. Differences in predictions for the models calibrated with and without error correlations can be greater than parameter differences when both are considered relative to their respective confidence intervals. These results indicate that including observation error correlations in weighting for nonlinear regression can have important effects on parameter estimates, predictions, and their respective uncertainties.
-
A multifaceted program for improving quality of care in intensive care units: IATROREF study.
Garrouste-Orgeas, Maite; Soufir, Lilia; Tabah, Alexis; Schwebel, Carole; Vesin, Aurelien; Adrie, Christophe; Thuong, Marie; Timsit, Jean Francois
2012-02-01
To test the effects of three multifaceted safety programs designed to decrease insulin administration errors, anticoagulant prescription and administration errors, and errors leading to accidental removal of endotracheal tubes and central venous catheters, respectively. Medical errors and adverse events are associated with increased mortality in intensive care patients, indicating an urgent need for prevention programs. Multicenter cluster-randomized study. One medical intensive care unit in a university hospital and two medical-surgical intensive care units in community hospitals belonging to the Outcomerea Study Group. Consecutive patients >18 yrs admitted from January 2007 to January 2008 to the intensive care units. We tested three multifaceted safety programs vs. standard care in random order, each over 2.5 months, after a 1.5-month observation period. Incidence rates of medical errors/1000 patient-days in the multifaceted safety program and standard-care groups were compared using adjusted hierarchical models. In 2117 patients with 15,014 patient-days, 8520 medical errors (567.5/1000 patient-days) were reported, including 1438 adverse events (16.9%, 95.8/1000 patient-days). The insulin multifaceted safety program significantly decreased errors during implementation (risk ratio 0.65; 95% confidence interval [CI] 0.52-0.82; p = .0003) and after implementation (risk ratio 0.51; 95% CI 0.35-0.73; p = .0004). A significant Hawthorne effect was found. The accidental tube/catheter removal multifaceted safety program decreased errors significantly during implementation (odds ratio [OR] 0.34; 95% CI 0.15-0.81; p = .01]) and nonsignificantly after implementation (OR 1.65; 95% CI 0.78-3.48). The anticoagulation multifaceted safety program was not significantly effective (OR 0.64; 95% CI 0.26-1.59) but produced a significant Hawthorne effect. A multifaceted program was effective in preventing insulin errors and accidental tube/catheter removal. Significant Hawthorne effects occurred, emphasizing the need for appropriately designed studies before definitively implementing strategies. clinicaltrials.gov Identifier: NCT00461461.
-
THERP and HEART integrated methodology for human error assessment
NASA Astrophysics Data System (ADS)
Castiglia, Francesco; Giardina, Mariarosa; Tomarchio, Elio
2015-11-01
THERP and HEART integrated methodology is proposed to investigate accident scenarios that involve operator errors during high-dose-rate (HDR) treatments. The new approach has been modified on the basis of fuzzy set concept with the aim of prioritizing an exhaustive list of erroneous tasks that can lead to patient radiological overexposures. The results allow for the identification of human errors that are necessary to achieve a better understanding of health hazards in the radiotherapy treatment process, so that it can be properly monitored and appropriately managed.
-
Patient safety in otolaryngology: a descriptive review.
Danino, Julian; Muzaffar, Jameel; Metcalfe, Chris; Coulson, Chris
2017-03-01
Human evaluation and judgement may include errors that can have disastrous results. Within medicine and healthcare there has been slow progress towards major changes in safety. Healthcare lags behind other specialised industries, such as aviation and nuclear power, where there have been significant improvements in overall safety, especially in reducing risk of errors. Following several high profile cases in the USA during the 1990s, a report titled "To Err Is Human: Building a Safer Health System" was published. The report extrapolated that in the USA approximately 50,000 to 100,000 patients may die each year as a result of medical errors. Traditionally otolaryngology has always been regarded as a "safe specialty". A study in the USA in 2004 inferred that there may be 2600 cases of major morbidity and 165 deaths within the specialty. MEDLINE via PubMed interface was searched for English language articles published between 2000 and 2012. Each combined two or three of the keywords noted earlier. Limitations are related to several generic topics within patient safety in otolaryngology. Other areas covered have been current relevant topics due to recent interest or new advances in technology. There has been a heightened awareness within the healthcare community of patient safety; it has become a major priority. Focus has shifted from apportioning blame to prevention of the errors and implementation of patient safety mechanisms in healthcare delivery. Type of Errors can be divided into errors due to action and errors due to knowledge or planning. In healthcare there are several factors that may influence adverse events and patient safety. Although technology may improve patient safety, it also introduces new sources of error. The ability to work with people allows for the increase in safety netting. Team working has been shown to have a beneficial effect on patient safety. Any field of work involving human decision-making will always have a risk of error. Within Otolaryngology, although patient safety has evolved along similar themes as other surgical specialties; there are several specific high-risk areas. Medical error is a common problem and its human cost is of immense importance. Steps to reduce such errors require the identification of high-risk practice within a complex healthcare system. The commitment to patient safety and quality improvement in medicine depend on personal responsibility and professional accountability.
-
Advanced automated glass cockpit certification: Being wary of human factors
NASA Technical Reports Server (NTRS)
Amalberti, Rene; Wilbaux, Florence
1994-01-01
This paper presents some facets of the French experience with human factors in the process of certification of advanced automated cockpits. Three types of difficulties are described: first, the difficulties concerning the hotly debated concept of human error and its non-linear relationship to risk of accident; a typology of errors to be taken into account in the certification process is put forward to respond to this issue. Next, the difficulties connected to the basically gradual and evolving nature of pilot expertise on a given type of aircraft, which contrasts with the immediate and definitive style of certifying systems. The last difficulties to be considered are those related to the goals of certification itself on these new aircraft and the status of findings from human factor analyses (in particular, what should be done with disappointing results, how much can the changes induced by human factors investigation economically affect aircraft design, how many errors do we need to accumulate before we revise the system, what should be remedied when human factor problems are discovered at the certification stage: the machine? pilot training? the rules? or everything?). The growth of advanced-automated glass cockpits has forced the international aeronautical community to pay more attention to human factors during the design phase, the certification phase and pilot training. The recent creation of a human factor desk at the DGAC-SFACT (Official French services) is a direct consequence of this. The paper is divided into three parts. Part one debates human error and its relationship with system design and accident risk. Part two describes difficulties connected to the basically gradual and evolving nature of pilot expertise on a given type of aircraft, which contrasts with the immediate and definitive style of certifying systems. Part three focuses on concrete outcomes of human factors for certification purposes.
-
Normal accidents: human error and medical equipment design.
Dain, Steven
2002-01-01
High-risk systems, which are typical of our technologically complex era, include not just nuclear power plants but also hospitals, anesthesia systems, and the practice of medicine and perfusion. In high-risk systems, no matter how effective safety devices are, some types of accidents are inevitable because the system's complexity leads to multiple and unexpected interactions. It is important for healthcare providers to apply a risk assessment and management process to decisions involving new equipment and procedures or staffing matters in order to minimize the residual risks of latent errors, which are amenable to correction because of the large window of opportunity for their detection. This article provides an introduction to basic risk management and error theory principles and examines ways in which they can be applied to reduce and mitigate the inevitable human errors that accompany high-risk systems. The article also discusses "human factor engineering" (HFE), the process which is used to design equipment/ human interfaces in order to mitigate design errors. The HFE process involves interaction between designers and endusers to produce a series of continuous refinements that are incorporated into the final product. The article also examines common design problems encountered in the operating room that may predispose operators to commit errors resulting in harm to the patient. While recognizing that errors and accidents are unavoidable, organizations that function within a high-risk system must adopt a "safety culture" that anticipates problems and acts aggressively through an anonymous, "blameless" reporting mechanism to resolve them. We must continuously examine and improve the design of equipment and procedures, personnel, supplies and materials, and the environment in which we work to reduce error and minimize its effects. Healthcare providers must take a leading role in the day-to-day management of the "Perioperative System" and be a role model in promoting a culture of safety in their organizations.
-
Wagar, Elizabeth A; Tamashiro, Lorraine; Yasin, Bushra; Hilborne, Lee; Bruckner, David A
2006-11-01
Patient safety is an increasingly visible and important mission for clinical laboratories. Attention to improving processes related to patient identification and specimen labeling is being paid by accreditation and regulatory organizations because errors in these areas that jeopardize patient safety are common and avoidable through improvement in the total testing process. To assess patient identification and specimen labeling improvement after multiple implementation projects using longitudinal statistical tools. Specimen errors were categorized by a multidisciplinary health care team. Patient identification errors were grouped into 3 categories: (1) specimen/requisition mismatch, (2) unlabeled specimens, and (3) mislabeled specimens. Specimens with these types of identification errors were compared preimplementation and postimplementation for 3 patient safety projects: (1) reorganization of phlebotomy (4 months); (2) introduction of an electronic event reporting system (10 months); and (3) activation of an automated processing system (14 months) for a 24-month period, using trend analysis and Student t test statistics. Of 16,632 total specimen errors, mislabeled specimens, requisition mismatches, and unlabeled specimens represented 1.0%, 6.3%, and 4.6% of errors, respectively. Student t test showed a significant decrease in the most serious error, mislabeled specimens (P < .001) when compared to before implementation of the 3 patient safety projects. Trend analysis demonstrated decreases in all 3 error types for 26 months. Applying performance-improvement strategies that focus longitudinally on specimen labeling errors can significantly reduce errors, therefore improving patient safety. This is an important area in which laboratory professionals, working in interdisciplinary teams, can improve safety and outcomes of care.
-
Clarke, D L; Kong, V Y; Naidoo, L C; Furlong, H; Aldous, C
2013-01-01
Acute surgical patients are particularly vulnerable to human error. The Acute Physiological Support Team (APST) was created with the twin objectives of identifying high-risk acute surgical patients in the general wards and reducing both the incidence of error and impact of error on these patients. A number of error taxonomies were used to understand the causes of human error and a simple risk stratification system was adopted to identify patients who are particularly at risk of error. During the period November 2012-January 2013 a total of 101 surgical patients were cared for by the APST at Edendale Hospital. The average age was forty years. There were 36 females and 65 males. There were 66 general surgical patients and 35 trauma patients. Fifty-six patients were referred on the day of their admission. The average length of stay in the APST was four days. Eleven patients were haemo-dynamically unstable on presentation and twelve were clinically septic. The reasons for referral were sepsis,(4) respiratory distress,(3) acute kidney injury AKI (38), post-operative monitoring (39), pancreatitis,(3) ICU down-referral,(7) hypoxia,(5) low GCS,(1) coagulopathy.(1) The mortality rate was 13%. A total of thirty-six patients experienced 56 errors. A total of 143 interventions were initiated by the APST. These included institution or adjustment of intravenous fluids (101), blood transfusion,(12) antibiotics,(9) the management of neutropenic sepsis,(1) central line insertion,(3) optimization of oxygen therapy,(7) correction of electrolyte abnormality,(8) correction of coagulopathy.(2) CONCLUSION: Our intervention combined current taxonomies of error with a simple risk stratification system and is a variant of the defence in depth strategy of error reduction. We effectively identified and corrected a significant number of human errors in high-risk acute surgical patients. This audit has helped understand the common sources of error in the general surgical wards and will inform on-going error reduction initiatives. Copyright © 2013 Surgical Associates Ltd. Published by Elsevier Ltd. All rights reserved.
-
Sturgeon, Jared D; Cox, John A; Mayo, Lauren L; Gunn, G Brandon; Zhang, Lifei; Balter, Peter A; Dong, Lei; Awan, Musaddiq; Kocak-Uzel, Esengul; Mohamed, Abdallah Sherif Radwan; Rosenthal, David I; Fuller, Clifton David
2015-10-01
Digitally reconstructed radiographs (DRRs) are routinely used as an a priori reference for setup correction in radiotherapy. The spatial resolution of DRRs may be improved to reduce setup error in fractionated radiotherapy treatment protocols. The influence of finer CT slice thickness reconstruction (STR) and resultant increased resolution DRRs on physician setup accuracy was prospectively evaluated. Four head and neck patient CT-simulation images were acquired and used to create DRR cohorts by varying STRs at 0.5, 1, 2, 2.5, and 3 mm. DRRs were displaced relative to a fixed isocenter using 0-5 mm random shifts in the three cardinal axes. Physician observers reviewed DRRs of varying STRs and displacements and then aligned reference and test DRRs replicating daily KV imaging workflow. A total of 1,064 images were reviewed by four blinded physicians. Observer errors were analyzed using nonparametric statistics (Friedman's test) to determine whether STR cohorts had detectably different displacement profiles. Post hoc bootstrap resampling was applied to evaluate potential generalizability. The observer-based trial revealed a statistically significant difference between cohort means for observer displacement vector error ([Formula: see text]) and for [Formula: see text]-axis [Formula: see text]. Bootstrap analysis suggests a 15% gain in isocenter translational setup error with reduction of STR from 3 mm to [Formula: see text]2 mm, though interobserver variance was a larger feature than STR-associated measurement variance. Higher resolution DRRs generated using finer CT scan STR resulted in improved observer performance at shift detection and could decrease operator-dependent geometric error. Ideally, CT STRs [Formula: see text]2 mm should be utilized for DRR generation in the head and neck.
-
Markerless attenuation correction for carotid MRI surface receiver coils in combined PET/MR imaging
NASA Astrophysics Data System (ADS)
Eldib, Mootaz; Bini, Jason; Robson, Philip M.; Calcagno, Claudia; Faul, David D.; Tsoumpas, Charalampos; Fayad, Zahi A.
2015-06-01
The purpose of the study was to evaluate the effect of attenuation of MR coils on quantitative carotid PET/MR exams. Additionally, an automated attenuation correction method for flexible carotid MR coils was developed and evaluated. The attenuation of the carotid coil was measured by imaging a uniform water phantom injected with 37 MBq of 18F-FDG in a combined PET/MR scanner for 24 min with and without the coil. In the same session, an ultra-short echo time (UTE) image of the coil on top of the phantom was acquired. Using a combination of rigid and non-rigid registration, a CT-based attenuation map was registered to the UTE image of the coil for attenuation and scatter correction. After phantom validation, the effect of the carotid coil attenuation and the attenuation correction method were evaluated in five subjects. Phantom studies indicated that the overall loss of PET counts due to the coil was 6.3% with local region-of-interest (ROI) errors reaching up to 18.8%. Our registration method to correct for attenuation from the coil decreased the global error and local error (ROI) to 0.8% and 3.8%, respectively. The proposed registration method accurately captured the location and shape of the coil with a maximum spatial error of 2.6 mm. Quantitative analysis in human studies correlated with the phantom findings, but was dependent on the size of the ROI used in the analysis. MR coils result in significant error in PET quantification and thus attenuation correction is needed. The proposed strategy provides an operator-free method for attenuation and scatter correction for a flexible MRI carotid surface coil for routine clinical use.
-
NASA Astrophysics Data System (ADS)
Wi, S.; Freeman, S.; Brown, C.
2017-12-01
This study presents a general approach to developing computational models of human-hydrologic systems where human modification of hydrologic surface processes are significant or dominant. A river basin system is represented by a network of human-hydrologic response units (HHRUs) identified based on locations where river regulations happen (e.g., reservoir operation and diversions). Natural and human processes in HHRUs are simulated in a holistic framework that integrates component models representing rainfall-runoff, river routing, reservoir operation, flow diversion and water use processes. We illustrate the approach in a case study of the Cutzamala water system (CWS) in Mexico, a complex inter-basin water transfer system supplying the Mexico City Metropolitan Area (MCMA). The human-hydrologic system model for CWS (CUTZSIM) is evaluated in terms of streamflow and reservoir storages measured across the CWS and to water supplied for MCMA. The CUTZSIM improves the representation of hydrology and river-operation interaction and, in so doing, advances evaluation of system-wide water management consequences under altered climatic and demand regimes. The integrated modeling framework enables evaluation and simulation of model errors throughout the river basin, including errors in representation of the human component processes. Heretofore, model error evaluation, predictive error intervals and the resultant improved understanding have been limited to hydrologic processes. The general framework represents an initial step towards fuller understanding and prediction of the many and varied processes that determine the hydrologic fluxes and state variables in real river basins.
-
A Foundation for Systems Anthropometry: Lumbar/Pelvic Kinematics
1983-02-01
caused by human error in positioning the cursor of the digitizing board and inaccuracy of the digitizer. (Human error is approximately + .02 an and...Milne, J.S. and Lauder, I.J. 1974. "Age Effects in Kyphosis and Lordosis in Adults." Ann. Hum. Biol. 1(3):327-337. Mchr, G.C., Brinkley, J.W., Kazarian
-
Comment on "Differential sensitivity to human communication in dogs, wolves, and human infants".
Marshall-Pescini, S; Passalacqua, C; Valsecchi, P; Prato-Previde, E
2010-07-09
Topál et al. (Reports, 4 September 2009, p. 1269) showed that dogs, like infants but unlike wolves, make perseverative search errors that can be explained by the use of ostensive cues from the experimenter. We suggest that a simpler learning process, local enhancement, can account for errors made by dogs.
-
Review of U.S. Army Unmanned Aerial Systems Accident Reports: Analysis of Human Error Contributions
2018-03-20
USAARL Report No. 2018-08 Review of U.S. Army Unmanned Aerial Systems Accident Reports: Analysis of Human Error Contributions By Kathryn A...3 Statistical Analysis Approach ..............................................................................................3 Results...1 Introduction The success of unmanned aerial systems (UAS) operations relies upon a variety of factors, including, but not limited to
-
Impact of human error on lumber yield in rough mills
Urs Buehlmann; R. Edward Thomas; R. Edward Thomas
2002-01-01
Rough sawn, kiln-dried lumber contains characteristics such as knots and bark pockets that are considered by most people to be defects. When using boards to produce furniture components, these defects are removed to produce clear, defect-free parts. Currently, human operators identify and locate the unusable board areas containing defects. Errors in determining a...
-
Action errors, error management, and learning in organizations.
Frese, Michael; Keith, Nina
2015-01-03
Every organization is confronted with errors. Most errors are corrected easily, but some may lead to negative consequences. Organizations often focus on error prevention as a single strategy for dealing with errors. Our review suggests that error prevention needs to be supplemented by error management--an approach directed at effectively dealing with errors after they have occurred, with the goal of minimizing negative and maximizing positive error consequences (examples of the latter are learning and innovations). After defining errors and related concepts, we review research on error-related processes affected by error management (error detection, damage control). Empirical evidence on positive effects of error management in individuals and organizations is then discussed, along with emotional, motivational, cognitive, and behavioral pathways of these effects. Learning from errors is central, but like other positive consequences, learning occurs under certain circumstances--one being the development of a mind-set of acceptance of human error.
-
NASA Technical Reports Server (NTRS)
Silva-Martinez, Jackelynne; Ellenberger, Richard; Dory, Jonathan
2017-01-01
This project aims to identify poor human factors design decisions that led to error-prone systems, or did not facilitate the flight crew making the right choices; and to verify that NASA is effectively preventing similar incidents from occurring again. This analysis was performed by reviewing significant incidents and close calls in human spaceflight identified by the NASA Johnson Space Center Safety and Mission Assurance Flight Safety Office. The review of incidents shows whether the identified human errors were due to the operational phase (flight crew and ground control) or if they initiated at the design phase (includes manufacturing and test). This classification was performed with the aid of the NASA Human Systems Integration domains. This in-depth analysis resulted in a tool that helps with the human factors classification of significant incidents and close calls in human spaceflight, which can be used to identify human errors at the operational level, and how they were or should be minimized. Current governing documents on human systems integration for both government and commercial crew were reviewed to see if current requirements, processes, training, and standard operating procedures protect the crew and ground control against these issues occurring in the future. Based on the findings, recommendations to target those areas are provided.
-
Adapt-Mix: learning local genetic correlation structure improves summary statistics-based analyses
Park, Danny S.; Brown, Brielin; Eng, Celeste; Huntsman, Scott; Hu, Donglei; Torgerson, Dara G.; Burchard, Esteban G.; Zaitlen, Noah
2015-01-01
Motivation: Approaches to identifying new risk loci, training risk prediction models, imputing untyped variants and fine-mapping causal variants from summary statistics of genome-wide association studies are playing an increasingly important role in the human genetics community. Current summary statistics-based methods rely on global ‘best guess’ reference panels to model the genetic correlation structure of the dataset being studied. This approach, especially in admixed populations, has the potential to produce misleading results, ignores variation in local structure and is not feasible when appropriate reference panels are missing or small. Here, we develop a method, Adapt-Mix, that combines information across all available reference panels to produce estimates of local genetic correlation structure for summary statistics-based methods in arbitrary populations. Results: We applied Adapt-Mix to estimate the genetic correlation structure of both admixed and non-admixed individuals using simulated and real data. We evaluated our method by measuring the performance of two summary statistics-based methods: imputation and joint-testing. When using our method as opposed to the current standard of ‘best guess’ reference panels, we observed a 28% decrease in mean-squared error for imputation and a 73.7% decrease in mean-squared error for joint-testing. Availability and implementation: Our method is publicly available in a software package called ADAPT-Mix available at https://github.com/dpark27/adapt_mix. Contact: noah.zaitlen@ucsf.edu PMID:26072481
-
Uncorrected refractive errors.
Naidoo, Kovin S; Jaggernath, Jyoti
2012-01-01
Global estimates indicate that more than 2.3 billion people in the world suffer from poor vision due to refractive error; of which 670 million people are considered visually impaired because they do not have access to corrective treatment. Refractive errors, if uncorrected, results in an impaired quality of life for millions of people worldwide, irrespective of their age, sex and ethnicity. Over the past decade, a series of studies using a survey methodology, referred to as Refractive Error Study in Children (RESC), were performed in populations with different ethnic origins and cultural settings. These studies confirmed that the prevalence of uncorrected refractive errors is considerably high for children in low-and-middle-income countries. Furthermore, uncorrected refractive error has been noted to have extensive social and economic impacts, such as limiting educational and employment opportunities of economically active persons, healthy individuals and communities. The key public health challenges presented by uncorrected refractive errors, the leading cause of vision impairment across the world, require urgent attention. To address these issues, it is critical to focus on the development of human resources and sustainable methods of service delivery. This paper discusses three core pillars to addressing the challenges posed by uncorrected refractive errors: Human Resource (HR) Development, Service Development and Social Entrepreneurship.
-
ERIC Educational Resources Information Center
Sun, Wei; And Others
1992-01-01
Identifies types and distributions of errors in text produced by optical character recognition (OCR) and proposes a process using machine learning techniques to recognize and correct errors in OCR texts. Results of experiments indicating that this strategy can reduce human interaction required for error correction are reported. (25 references)…
-
Emodiversity and the emotional ecosystem.
Quoidbach, Jordi; Gruber, June; Mikolajczak, Moïra; Kogan, Alexsandr; Kotsou, Ilios; Norton, Michael I
2014-12-01
[Correction Notice: An Erratum for this article was reported in Vol 143(6) of Journal of Experimental Psychology: General (see record 2014-49316-001). There is a color coding error in Figure 2. The correct color coding is explained in the erratum.] Bridging psychological research exploring emotional complexity and research in the natural sciences on the measurement of biodiversity, we introduce--and demonstrate the benefits of--emodiversity: the variety and relative abundance of the emotions that humans experience. Two cross-sectional studies across more than 37,000 respondents demonstrate that emodiversity is an independent predictor of mental and physical health--such as decreased depression and doctor's visits--over and above mean levels of positive and negative emotion. These results remained robust after controlling for gender, age, and the 5 main dimensions of personality. Emodiversity is a practically important and previously unidentified metric for assessing the health of the human emotional ecosystem. PsycINFO Database Record (c) 2014 APA, all rights reserved.
-
Precision and repeatability of the Optotrak 3020 motion measurement system.
States, R A; Pappas, E
2006-01-01
Several motion analysis systems are used by researchers to quantify human motion and to perform accurate surgical procedures. The Optotrak 3020 is one of these systems and despite its widespread use there is not any published information on its precision and repeatability. We used a repeated measures design study to evaluate the precision and repeatability of the Optotrak 3020 by measuring distance and angle in three sessions, four distances and three conditions (motion, static vertical, and static tilted). Precision and repeatability were found to be excellent for both angle and distance although they decreased with increasing distance from the sensors and with tilt from the plane of the sensors. Motion did not have a significant effect on the precision of the measurements. In conclusion, the measurement error of the Optotrak is minimal. Further studies are needed to evaluate its precision and repeatability under human motion conditions.
-
Garbe, James C.; Vrba, Lukas; Sputova, Klara; ...
2014-10-29
Telomerase reactivation and immortalization are critical for human carcinoma progression. However, little is known about the mechanisms controlling this crucial step, due in part to the paucity of experimentally tractable model systems that can examine human epithelial cell immortalization as it might occur in vivo. We achieved efficient non-clonal immortalization of normal human mammary epithelial cells (HMEC) by directly targeting the 2 main senescence barriers encountered by cultured HMEC. The stress-associated stasis barrier was bypassed using shRNA to p16INK4; replicative senescence due to critically shortened telomeres was bypassed in post-stasis HMEC by c-MYC transduction. Thus, 2 pathologically relevant oncogenic agentsmore » are sufficient to immortally transform normal HMEC. The resultant non-clonal immortalized lines exhibited normal karyotypes. Most human carcinomas contain genomically unstable cells, with widespread instability first observed in vivo in pre-malignant stages; in vitro, instability is seen as finite cells with critically shortened telomeres approach replicative senescence. Our results support our hypotheses that: (1) telomere-dysfunction induced genomic instability in pre-malignant finite cells may generate the errors required for telomerase reactivation and immortalization, as well as many additional “passenger” errors carried forward into resulting carcinomas; (2) genomic instability during cancer progression is needed to generate errors that overcome tumor suppressive barriers, but not required per se; bypassing the senescence barriers by direct targeting eliminated a need for genomic errors to generate immortalization. Achieving efficient HMEC immortalization, in the absence of “passenger” genomic errors, should facilitate examination of telomerase regulation during human carcinoma progression, and exploration of agents that could prevent immortalization.« less
-
The Impact of Bar Code Medication Administration Technology on Reported Medication Errors
ERIC Educational Resources Information Center
Holecek, Andrea
2011-01-01
The use of bar-code medication administration technology is on the rise in acute care facilities in the United States. The technology is purported to decrease medication errors that occur at the point of administration. How significantly this technology affects actual rate and severity of error is unknown. This descriptive, longitudinal research…
-
Correction of motion measurement errors beyond the range resolution of a synthetic aperture radar
Doerry, Armin W [Albuquerque, NM; Heard, Freddie E [Albuquerque, NM; Cordaro, J Thomas [Albuquerque, NM
2008-06-24
Motion measurement errors that extend beyond the range resolution of a synthetic aperture radar (SAR) can be corrected by effectively decreasing the range resolution of the SAR in order to permit measurement of the error. Range profiles can be compared across the slow-time dimension of the input data in order to estimate the error. Once the error has been determined, appropriate frequency and phase correction can be applied to the uncompressed input data, after which range and azimuth compression can be performed to produce a desired SAR image.
-
Error in telemetry studies: Effects of animal movement on triangulation
Schmutz, Joel A.; White, Gary C.
1990-01-01
We used Monte Carlo simulations to investigate the effects of animal movement on error of estimated animal locations derived from radio-telemetry triangulation of sequentially obtained bearings. Simulated movements of 0-534 m resulted in up to 10-fold increases in average location error but <10% decreases in location precision when observer-to-animal distances were <1,000 m. Location error and precision were minimally affected by censorship of poor locations with Chi-square goodness-of-fit tests. Location error caused by animal movement can only be eliminated by taking simultaneous bearings.
-
Recognizing and managing errors of cognitive underspecification.
Duthie, Elizabeth A
2014-03-01
James Reason describes cognitive underspecification as incomplete communication that creates a knowledge gap. Errors occur when an information mismatch occurs in bridging that gap with a resulting lack of shared mental models during the communication process. There is a paucity of studies in health care examining this cognitive error and the role it plays in patient harm. The goal of the following case analyses is to facilitate accurate recognition, identify how it contributes to patient harm, and suggest appropriate management strategies. Reason's human error theory is applied in case analyses of errors of cognitive underspecification. Sidney Dekker's theory of human incident investigation is applied to event investigation to facilitate identification of this little recognized error. Contributory factors leading to errors of cognitive underspecification include workload demands, interruptions, inexperienced practitioners, and lack of a shared mental model. Detecting errors of cognitive underspecification relies on blame-free listening and timely incident investigation. Strategies for interception include two-way interactive communication, standardization of communication processes, and technological support to ensure timely access to documented clinical information. Although errors of cognitive underspecification arise at the sharp end with the care provider, effective management is dependent upon system redesign that mitigates the latent contributory factors. Cognitive underspecification is ubiquitous whenever communication occurs. Accurate identification is essential if effective system redesign is to occur.
-
Comprehensive analysis of a medication dosing error related to CPOE.
Horsky, Jan; Kuperman, Gilad J; Patel, Vimla L
2005-01-01
This case study of a serious medication error demonstrates the necessity of a comprehensive methodology for the analysis of failures in interaction between humans and information systems. The authors used a novel approach to analyze a dosing error related to computer-based ordering of potassium chloride (KCl). The method included a chronological reconstruction of events and their interdependencies from provider order entry usage logs, semistructured interviews with involved clinicians, and interface usability inspection of the ordering system. Information collected from all sources was compared and evaluated to understand how the error evolved and propagated through the system. In this case, the error was the product of faults in interaction among human and system agents that methods limited in scope to their distinct analytical domains would not identify. The authors characterized errors in several converging aspects of the drug ordering process: confusing on-screen laboratory results review, system usability difficulties, user training problems, and suboptimal clinical system safeguards that all contributed to a serious dosing error. The results of the authors' analysis were used to formulate specific recommendations for interface layout and functionality modifications, suggest new user alerts, propose changes to user training, and address error-prone steps of the KCl ordering process to reduce the risk of future medication dosing errors.
-
Full temperature single event upset characterization of two microprocessor technologies
NASA Technical Reports Server (NTRS)
Nichols, Donald K.; Coss, James R.; Smith, L. S.; Rax, Bernard; Huebner, Mark
1988-01-01
Data for the 9450 I3L bipolar microprocessor and the 80C86 CMOS/epi (vintage 1985) microprocessor are presented, showing single-event soft errors for the full MIL-SPEC temperature range of -55 to 125 C. These data show for the first time that the soft-error cross sections continue to decrease with decreasing temperature at subzero temperatures. The temperature dependence of the two parts, however, is very different.
-
Federal Register 2010, 2011, 2012, 2013, 2014
2013-03-20
...The Food and Drug Administration (FDA or we) is correcting the preamble to a proposed rule that published in the Federal Register of January 16, 2013. That proposed rule would establish science-based minimum standards for the safe growing, harvesting, packing, and holding of produce, meaning fruits and vegetables grown for human consumption. FDA proposed these standards as part of our implementation of the FDA Food Safety Modernization Act. The document published with several technical errors, including some errors in cross references, as well as several errors in reference numbers cited throughout the document. This document corrects those errors. We are also placing a corrected copy of the proposed rule in the docket.
-
Patient identification using a near-infrared laser scanner
NASA Astrophysics Data System (ADS)
Manit, Jirapong; Bremer, Christina; Schweikard, Achim; Ernst, Floris
2017-03-01
We propose a new biometric approach where the tissue thickness of a person's forehead is used as a biometric feature. Given that the spatial registration of two 3D laser scans of the same human face usually produces a low error value, the principle of point cloud registration and its error metric can be applied to human classification techniques. However, by only considering the spatial error, it is not possible to reliably verify a person's identity. We propose to use a novel near-infrared laser-based head tracking system to determine an additional feature, the tissue thickness, and include this in the error metric. Using MRI as a ground truth, data from the foreheads of 30 subjects was collected from which a 4D reference point cloud was created for each subject. The measurements from the near-infrared system were registered with all reference point clouds using the ICP algorithm. Afterwards, the spatial and tissue thickness errors were extracted, forming a 2D feature space. For all subjects, the lowest feature distance resulted from the registration of a measurement and the reference point cloud of the same person. The combined registration error features yielded two clusters in the feature space, one from the same subject and another from the other subjects. When only the tissue thickness error was considered, these clusters were less distinct but still present. These findings could help to raise safety standards for head and neck cancer patients and lays the foundation for a future human identification technique.
-
Human factors evaluation of remote afterloading brachytherapy. Volume 2, Function and task analysis
DOE Office of Scientific and Technical Information (OSTI.GOV)
Callan, J.R.; Gwynne, J.W. III; Kelly, T.T.
1995-05-01
A human factors project on the use of nuclear by-product material to treat cancer using remotely operated afterloaders was undertaken by the Nuclear Regulatory Commission. The purpose of the project was to identify factors that contribute to human error in the system for remote afterloading brachytherapy (RAB). This report documents the findings from the first phase of the project, which involved an extensive function and task analysis of RAB. This analysis identified the functions and tasks in RAB, made preliminary estimates of the likelihood of human error in each task, and determined the skills needed to perform each RAB task.more » The findings of the function and task analysis served as the foundation for the remainder of the project, which evaluated four major aspects of the RAB system linked to human error: human-system interfaces; procedures and practices; training and qualifications of RAB staff; and organizational practices and policies. At its completion, the project identified and prioritized areas for recommended NRC and industry attention based on all of the evaluations and analyses.« less
-
Prediction error induced motor contagions in human behaviors.
Ikegami, Tsuyoshi; Ganesh, Gowrishankar; Takeuchi, Tatsuya; Nakamoto, Hiroki
2018-05-29
Motor contagions refer to implicit effects on one's actions induced by observed actions. Motor contagions are believed to be induced simply by action observation and cause an observer's action to become similar to the action observed. In contrast, here we report a new motor contagion that is induced only when the observation is accompanied by prediction errors - differences between actions one observes and those he/she predicts or expects. In two experiments, one on whole-body baseball pitching and another on simple arm reaching, we show that the observation of the same action induces distinct motor contagions, depending on whether prediction errors are present or not. In the absence of prediction errors, as in previous reports, participants' actions changed to become similar to the observed action, while in the presence of prediction errors, their actions changed to diverge away from it, suggesting distinct effects of action observation and action prediction on human actions. © 2018, Ikegami et al.
-
Neuromotor Noise Is Malleable by Amplifying Perceived Errors
Zhang, Zhaoran; Abe, Masaki O.; Sternad, Dagmar
2016-01-01
Variability in motor performance results from the interplay of error correction and neuromotor noise. This study examined whether visual amplification of error, previously shown to improve performance, affects not only error correction, but also neuromotor noise, typically regarded as inaccessible to intervention. Seven groups of healthy individuals, with six participants in each group, practiced a virtual throwing task for three days until reaching a performance plateau. Over three more days of practice, six of the groups received different magnitudes of visual error amplification; three of these groups also had noise added. An additional control group was not subjected to any manipulations for all six practice days. The results showed that the control group did not improve further after the first three practice days, but the error amplification groups continued to decrease their error under the manipulations. Analysis of the temporal structure of participants’ corrective actions based on stochastic learning models revealed that these performance gains were attained by reducing neuromotor noise and, to a considerably lesser degree, by increasing the size of corrective actions. Based on these results, error amplification presents a promising intervention to improve motor function by decreasing neuromotor noise after performance has reached an asymptote. These results are relevant for patients with neurological disorders and the elderly. More fundamentally, these results suggest that neuromotor noise may be accessible to practice interventions. PMID:27490197
-
Schwantes-An, Tae-Hwi; Sung, Heejong; Sabourin, Jeremy A; Justice, Cristina M; Sorant, Alexa J M; Wilson, Alexander F
2016-01-01
In this study, the effects of (a) the minor allele frequency of the single nucleotide variant (SNV), (b) the degree of departure from normality of the trait, and (c) the position of the SNVs on type I error rates were investigated in the Genetic Analysis Workshop (GAW) 19 whole exome sequence data. To test the distribution of the type I error rate, 5 simulated traits were considered: standard normal and gamma distributed traits; 2 transformed versions of the gamma trait (log 10 and rank-based inverse normal transformations); and trait Q1 provided by GAW 19. Each trait was tested with 313,340 SNVs. Tests of association were performed with simple linear regression and average type I error rates were determined for minor allele frequency classes. Rare SNVs (minor allele frequency < 0.05) showed inflated type I error rates for non-normally distributed traits that increased as the minor allele frequency decreased. The inflation of average type I error rates increased as the significance threshold decreased. Normally distributed traits did not show inflated type I error rates with respect to the minor allele frequency for rare SNVs. There was no consistent effect of transformation on the uniformity of the distribution of the location of SNVs with a type I error.
-
Synchronizing movements with the metronome: nonlinear error correction and unstable periodic orbits.
Engbert, Ralf; Krampe, Ralf Th; Kurths, Jürgen; Kliegl, Reinhold
2002-02-01
The control of human hand movements is investigated in a simple synchronization task. We propose and analyze a stochastic model based on nonlinear error correction; a mechanism which implies the existence of unstable periodic orbits. This prediction is tested in an experiment with human subjects. We find that our experimental data are in good agreement with numerical simulations of our theoretical model. These results suggest that feedback control of the human motor systems shows nonlinear behavior. Copyright 2001 Elsevier Science (USA).
-
Human error in aviation operations
NASA Technical Reports Server (NTRS)
Billings, C. E.; Lanber, J. K.; Cooper, G. E.
1974-01-01
This report is a brief description of research being undertaken by the National Aeronautics and Space Administration. The project is designed to seek out factors in the aviation system which contribute to human error, and to search for ways of minimizing the potential threat posed by these factors. The philosophy and assumptions underlying the study are discussed, together with an outline of the research plan.
-
Tarczy-Hornoch, Kristina; Cotter, Susan A; Borchert, Mark; McKean-Cowdin, Roberta; Lin, Jesse; Wen, Ge; Kim, Jeniffer; Varma, Rohit
2013-06-01
To determine the prevalence and causes of decreased visual acuity (VA). Population-based cross-sectional study. Multi-ethnic sample of children 30 to 72 months of age identified in Los Angeles. All eligible children underwent a comprehensive ophthalmic evaluation including monocular VA testing, cover testing, cycloplegic autorefraction, fundus evaluation, and VA retesting with refractive correction. Decreased VA was defined as presenting or best-measured VA worse than 20/50 in children 30 to 47 months of age and worse than 20/40 for children 48 months of age and older. The prevalence and causes of decreased VA were determined, for both presenting and best-measured VA, in the better-seeing and the worse-seeing eyes. Prevalence and causes of decreased vision. Presenting VA was assessed in 1840 children and best-measured VA was assessed in 1886 children. Presenting VA was decreased in the worse eye of 4.2% of Asian children and of 3.6% of non-Hispanic white (NHW) children. Close to one-fourth of these cases had no identifiable cause, and 81% of these resolved on retesting. Decreased presenting VA in the worse eye with an identifiable ophthalmic cause was present in 3.4% of Asian children and in 2.6% of NHW children. Decreased presenting VA attributable to simple refractive error (myopia ≥ 0.5 diopters [D]; hyperopia ≥ 3.0 D; astigmatism ≥ 2.0 D or ≥ 1.5 D for children older than 36 months) was present in the worse eye of 2.3% of Asian children and of 1.4% of NHW children and in the better eye of 0.5% of Asian children and of 0.3% of NHW children. Decreased best-measured VA attributable to a cause was present in the worse eye of 1.2% of both Asian children and NHW children and in the better eye of 0.2% of Asian and of 0.3% of NHW children. Amblyopia related to refractive error was the most common cause, and was 10 times as common as ocular disease. Severe visual impairment was rare. Seventy percent of all decreased VA in Asian and NHW preschool children and more than 90% of decreased VA with an identifiable cause is related to refractive error--either uncorrected refractive error or amblyopia resulting from refractive error. The author(s) have no proprietary or commercial interest in any materials discussed in this article. Copyright © 2013 American Academy of Ophthalmology. Published by Elsevier Inc. All rights reserved.
-
Human Factors Directions for Civil Aviation
NASA Technical Reports Server (NTRS)
Hart, Sandra G.
2002-01-01
Despite considerable progress in understanding human capabilities and limitations, incorporating human factors into aircraft design, operation, and certification, and the emergence of new technologies designed to reduce workload and enhance human performance in the system, most aviation accidents still involve human errors. Such errors occur as a direct or indirect result of untimely, inappropriate, or erroneous actions (or inactions) by apparently well-trained and experienced pilots, controllers, and maintainers. The field of human factors has solved many of the more tractable problems related to simple ergonomics, cockpit layout, symbology, and so on. We have learned much about the relationships between people and machines, but know less about how to form successful partnerships between humans and the information technologies that are beginning to play a central role in aviation. Significant changes envisioned in the structure of the airspace, pilots and controllers' roles and responsibilities, and air/ground technologies will require a similarly significant investment in human factors during the next few decades to ensure the effective integration of pilots, controllers, dispatchers, and maintainers into the new system. Many of the topics that will be addressed are not new because progress in crucial areas, such as eliminating human error, has been slow. A multidisciplinary approach that capitalizes upon human studies and new classes of information, computational models, intelligent analytical tools, and close collaborations with organizations that build, operate, and regulate aviation technology will ensure that the field of human factors meets the challenge.
-
45 CFR 98.102 - Content of Error Rate Reports.
Code of Federal Regulations, 2013 CFR
2013-10-01
....102 Public Welfare DEPARTMENT OF HEALTH AND HUMAN SERVICES GENERAL ADMINISTRATION CHILD CARE AND DEVELOPMENT FUND Error Rate Reporting § 98.102 Content of Error Rate Reports. (a) Baseline Submission Report... payments by the total dollar amount of child care payments that the State, the District of Columbia or...
-
45 CFR 98.102 - Content of Error Rate Reports.
Code of Federal Regulations, 2014 CFR
2014-10-01
....102 Public Welfare Department of Health and Human Services GENERAL ADMINISTRATION CHILD CARE AND DEVELOPMENT FUND Error Rate Reporting § 98.102 Content of Error Rate Reports. (a) Baseline Submission Report... payments by the total dollar amount of child care payments that the State, the District of Columbia or...
-
45 CFR 98.102 - Content of Error Rate Reports.
Code of Federal Regulations, 2012 CFR
2012-10-01
....102 Public Welfare DEPARTMENT OF HEALTH AND HUMAN SERVICES GENERAL ADMINISTRATION CHILD CARE AND DEVELOPMENT FUND Error Rate Reporting § 98.102 Content of Error Rate Reports. (a) Baseline Submission Report... payments by the total dollar amount of child care payments that the State, the District of Columbia or...
-
45 CFR 98.102 - Content of Error Rate Reports.
Code of Federal Regulations, 2011 CFR
2011-10-01
....102 Public Welfare DEPARTMENT OF HEALTH AND HUMAN SERVICES GENERAL ADMINISTRATION CHILD CARE AND DEVELOPMENT FUND Error Rate Reporting § 98.102 Content of Error Rate Reports. (a) Baseline Submission Report... payments by the total dollar amount of child care payments that the State, the District of Columbia or...
-
45 CFR 98.100 - Error Rate Report.
Code of Federal Regulations, 2010 CFR
2010-10-01
... Welfare DEPARTMENT OF HEALTH AND HUMAN SERVICES GENERAL ADMINISTRATION CHILD CARE AND DEVELOPMENT FUND... rates, which is defined as the percentage of cases with an error (expressed as the total number of cases with an error compared to the total number of cases); the percentage of cases with an improper payment...
-
Code of Federal Regulations, 2010 CFR
2010-10-01
... Government misrepresentation, inaction, or error. 407.32 Section 407.32 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES MEDICARE PROGRAM SUPPLEMENTARY MEDICAL INSURANCE... enrollment rights because of Federal Government misrepresentation, inaction, or error. If an individual's...
-
Code of Federal Regulations, 2011 CFR
2011-10-01
... Government misrepresentation, inaction, or error. 407.32 Section 407.32 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES MEDICARE PROGRAM SUPPLEMENTARY MEDICAL INSURANCE... enrollment rights because of Federal Government misrepresentation, inaction, or error. If an individual's...
-
Can eye-tracking technology improve situational awareness in paramedic clinical education?
Williams, Brett; Quested, Andrew; Cooper, Simon
2013-01-01
Human factors play a significant part in clinical error. Situational awareness (SA) means being aware of one's surroundings, comprehending the present situation, and being able to predict outcomes. It is a key human skill that, when properly applied, is associated with reducing medical error: eye-tracking technology can be used to provide an objective and qualitative measure of the initial perception component of SA. Feedback from eye-tracking technology can be used to improve the understanding and teaching of SA in clinical contexts, and consequently, has potential for reducing clinician error and the concomitant adverse events.
-
Agosto-Arroyo, Emmanuel; Coshatt, Gina M.; Winokur, Thomas S.; Harada, Shuko; Park, Seung L.
2017-01-01
Background: The molecular diagnostics laboratory faces the challenge of improving test turnaround time (TAT). Low and consistent TATs are of great clinical and regulatory importance, especially for molecular virology tests. Laboratory information systems (LISs) contain all the data elements necessary to do accurate quality assurance (QA) reporting of TAT and other measures, but these reports are in most cases still performed manually: a time-consuming and error-prone task. The aim of this study was to develop a web-based real-time QA platform that would automate QA reporting in the molecular diagnostics laboratory at our institution, and minimize the time expended in preparing these reports. Methods: Using a standard Linux, Nginx, MariaDB, PHP stack virtual machine running atop a Dell Precision 5810, we designed and built a web-based QA platform, code-named Alchemy. Data files pulled periodically from the LIS in comma-separated value format were used to autogenerate QA reports for the human immunodeficiency virus (HIV) quantitation, hepatitis C virus (HCV) quantitation, and BK virus (BKV) quantitation. Alchemy allowed the user to select a specific timeframe to be analyzed and calculated key QA statistics in real-time, including the average TAT in days, tests falling outside the expected TAT ranges, and test result ranges. Results: Before implementing Alchemy, reporting QA for the HIV, HCV, and BKV quantitation assays took 45–60 min of personnel time per test every month. With Alchemy, that time has decreased to 15 min total per month. Alchemy allowed the user to select specific periods of time and analyzed the TAT data in-depth without the need of extensive manual calculations. Conclusions: Alchemy has significantly decreased the time and the human error associated with QA report generation in our molecular diagnostics laboratory. Other tests will be added to this web-based platform in future updates. This effort shows the utility of informatician-supervised resident/fellow programming projects as learning opportunities and workflow improvements in the molecular laboratory. PMID:28480121
-
Natung, Tanie; Taye, Trishna; Lyngdoh, Laura Amanda; Dkhar, Begonia; Hajong, Ranendra
2017-01-01
Purpose: To determine the magnitude and pattern of refractive errors among patients attending the ophthalmology department of a new medical college in North-East India. Materials and Methods: A prospective study of the new patients (age ≥5 years), who were phakic and whose unaided visual acuities were worse than 20/20 but improved with pinhole, was done. Complete ophthalmic examination and refraction with appropriate cycloplegia for age were done for the 4582 eligible patients. Spherical equivalents (SE) of refractive errors of the right eyes were used for analysis. Results: Of the 4582 eligible patients, 2546 patients had refractive errors (55.56%). The proportion of emmetropia (SE − 0.50–+0.50 diopter sphere [DS]), myopia (SE <−0.50 DS), high myopia (SE >−5.0 DS), and hypermetropia (>+0.50 DS for adults and >+2.0 DS for children) were 53.1%, 27.4%, 2.6%, and 16.9%, respectively. The proportion of hyperopia increased till 59 years and then decreased with age (P = 0.000). The proportion of myopia and high myopia decreased significantly with age after 39 years (P = 0.000 and P = 0.004, respectively). Of the 1510 patients with astigmatism, 17% had with-the-rule (WTR), 23.4% had against-the-rule (ATR), and 19% had oblique astigmatisms. The proportion of WTR and ATR astigmatisms significantly decreased (P = 0.000) and increased (P = 0.000) with age, respectively. Conclusions: This study has provided the magnitude and pattern of refractive errors in the study population. It will serve as the initial step for conducting community-based studies on the prevalence of refractive errors in this part of the country since such data are lacking from this region. Moreover, this study will help the primary care physicians to have an overview of the magnitude and pattern of refractive errors presenting to a health-care center as refractive error is an established and significant public health problem worldwide. PMID:29417005
-
Natung, Tanie; Taye, Trishna; Lyngdoh, Laura Amanda; Dkhar, Begonia; Hajong, Ranendra
2017-01-01
To determine the magnitude and pattern of refractive errors among patients attending the ophthalmology department of a new medical college in North-East India. A prospective study of the new patients (age ≥5 years), who were phakic and whose unaided visual acuities were worse than 20/20 but improved with pinhole, was done. Complete ophthalmic examination and refraction with appropriate cycloplegia for age were done for the 4582 eligible patients. Spherical equivalents (SE) of refractive errors of the right eyes were used for analysis. Of the 4582 eligible patients, 2546 patients had refractive errors (55.56%). The proportion of emmetropia (SE - 0.50-+0.50 diopter sphere [DS]), myopia (SE <-0.50 DS), high myopia (SE >-5.0 DS), and hypermetropia (>+0.50 DS for adults and >+2.0 DS for children) were 53.1%, 27.4%, 2.6%, and 16.9%, respectively. The proportion of hyperopia increased till 59 years and then decreased with age ( P = 0.000). The proportion of myopia and high myopia decreased significantly with age after 39 years ( P = 0.000 and P = 0.004, respectively). Of the 1510 patients with astigmatism, 17% had with-the-rule (WTR), 23.4% had against-the-rule (ATR), and 19% had oblique astigmatisms. The proportion of WTR and ATR astigmatisms significantly decreased ( P = 0.000) and increased ( P = 0.000) with age, respectively. This study has provided the magnitude and pattern of refractive errors in the study population. It will serve as the initial step for conducting community-based studies on the prevalence of refractive errors in this part of the country since such data are lacking from this region. Moreover, this study will help the primary care physicians to have an overview of the magnitude and pattern of refractive errors presenting to a health-care center as refractive error is an established and significant public health problem worldwide.
-
Henneman, Elizabeth A
2017-07-01
The Institute of Medicine (now National Academy of Medicine) reports "To Err is Human" and "Crossing the Chasm" made explicit 3 previously unappreciated realities: (1) Medical errors are common and result in serious, preventable adverse events; (2) The majority of medical errors are the result of system versus human failures; and (3) It would be impossible for any system to prevent all errors. With these realities, the role of the nurse in the "near miss" process and as the final safety net for the patient is of paramount importance. The nurse's role in patient safety is described from both a systems perspective and a human factors perspective. Critical care nurses use specific strategies to identify, interrupt, and correct medical errors. Strategies to identify errors include knowing the patient, knowing the plan of care, double-checking, and surveillance. Nursing strategies to interrupt errors include offering assistance, clarifying, and verbally interrupting. Nurses correct errors by persevering, being physically present, reviewing/confirming the plan of care, or involving another nurse or physician. Each of these strategies has implications for education, practice, and research. Surveillance is a key nursing strategy for identifying medical errors and reducing adverse events. Eye-tracking technology is a novel approach for evaluating the surveillance process during common, high-risk processes such as blood transfusion and medication administration. Eye tracking has also been used to examine the impact of interruptions to care caused by bedside alarms as well as by other health care personnel. Findings from this safety-related eye-tracking research provide new insight into effective bedside surveillance and interruption management strategies. ©2017 American Association of Critical-Care Nurses.
-
Preventing medical errors by designing benign failures.
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 lean to improve medication administration safety: in search of the "perfect dose".
Ching, Joan M; Long, Christina; Williams, Barbara L; Blackmore, C Craig
2013-05-01
At Virginia Mason Medical Center (Seattle), the Collaborative Alliance for Nursing Outcomes (CALNOC) Medication Administration Accuracy Quality Study was used in combination with Lean quality improvement efforts to address medication administration safety. Lean interventions were targeted at improving the medication room layout, applying visual controls, and implementing nursing standard work. The interventions were designed to prevent medication administration errors through improving six safe practices: (1) comparing medication with medication administration record, (2) labeling medication, (3) checking two forms of patient identification, (4) explaining medication to patient, (5) charting medication immediately, and (6) protecting the process from distractions/interruptions. Trained nurse auditors observed 9,244 doses for 2,139 patients. Following the intervention, the number of safe-practice violations decreased from 83 violations/100 doses at baseline (January 2010-March 2010) to 42 violations/100 doses at final follow-up (July 2011-September 2011), resulting in an absolute risk reduction of 42 violations/100 doses (95% confidence interval [CI]: 35-48), p < .001). The number of medication administration errors decreased from 10.3 errors/100 doses at baseline to 2.8 errors/100 doses at final follow-up (absolute risk reduction: 7 violations/100 doses [95% CI: 5-10, p < .001]). The "perfect dose" score, reflecting compliance with all six safe practices and absence of any of the eight medication administration errors, improved from 37 in compliance/100 doses at baseline to 68 in compliance/100 doses at the final follow-up. Lean process improvements coupled with direct observation can contribute to substantial decreases in errors in nursing medication administration.
-
Trivedi, Hari; Mesterhazy, Joseph; Laguna, Benjamin; Vu, Thienkhai; Sohn, Jae Ho
2018-04-01
Magnetic resonance imaging (MRI) protocoling can be time- and resource-intensive, and protocols can often be suboptimal dependent upon the expertise or preferences of the protocoling radiologist. Providing a best-practice recommendation for an MRI protocol has the potential to improve efficiency and decrease the likelihood of a suboptimal or erroneous study. The goal of this study was to develop and validate a machine learning-based natural language classifier that can automatically assign the use of intravenous contrast for musculoskeletal MRI protocols based upon the free-text clinical indication of the study, thereby improving efficiency of the protocoling radiologist and potentially decreasing errors. We utilized a deep learning-based natural language classification system from IBM Watson, a question-answering supercomputer that gained fame after challenging the best human players on Jeopardy! in 2011. We compared this solution to a series of traditional machine learning-based natural language processing techniques that utilize a term-document frequency matrix. Each classifier was trained with 1240 MRI protocols plus their respective clinical indications and validated with a test set of 280. Ground truth of contrast assignment was obtained from the clinical record. For evaluation of inter-reader agreement, a blinded second reader radiologist analyzed all cases and determined contrast assignment based on only the free-text clinical indication. In the test set, Watson demonstrated overall accuracy of 83.2% when compared to the original protocol. This was similar to the overall accuracy of 80.2% achieved by an ensemble of eight traditional machine learning algorithms based on a term-document matrix. When compared to the second reader's contrast assignment, Watson achieved 88.6% agreement. When evaluating only the subset of cases where the original protocol and second reader were concordant (n = 251), agreement climbed further to 90.0%. The classifier was relatively robust to spelling and grammatical errors, which were frequent. Implementation of this automated MR contrast determination system as a clinical decision support tool may save considerable time and effort of the radiologist while potentially decreasing error rates, and require no change in order entry or workflow.
-
NASA Astrophysics Data System (ADS)
Young, Kenneth C.; Cook, James J. H.; Oduko, Jennifer M.; Bosmans, Hilde
2006-03-01
European Guidelines for quality control in digital mammography specify minimum and achievable standards of image quality in terms of threshold contrast, based on readings of images of the CDMAM test object by human observers. However this is time-consuming and has large inter-observer error. To overcome these problems a software program (CDCOM) is available to automatically read CDMAM images, but the optimal method of interpreting the output is not defined. This study evaluates methods of determining threshold contrast from the program, and compares these to human readings for a variety of mammography systems. The methods considered are (A) simple thresholding (B) psychometric curve fitting (C) smoothing and interpolation and (D) smoothing and psychometric curve fitting. Each method leads to similar threshold contrasts but with different reproducibility. Method (A) had relatively poor reproducibility with a standard error in threshold contrast of 18.1 +/- 0.7%. This was reduced to 8.4% by using a contrast-detail curve fitting procedure. Method (D) had the best reproducibility with an error of 6.7%, reducing to 5.1% with curve fitting. A panel of 3 human observers had an error of 4.4% reduced to 2.9 % by curve fitting. All automatic methods led to threshold contrasts that were lower than for humans. The ratio of human to program threshold contrasts varied with detail diameter and was 1.50 +/- .04 (sem) at 0.1mm and 1.82 +/- .06 at 0.25mm for method (D). There were good correlations between the threshold contrast determined by humans and the automated methods.
-
Fast temporal neural learning using teacher forcing
NASA Technical Reports Server (NTRS)
Toomarian, Nikzad (Inventor); Bahren, Jacob (Inventor)
1992-01-01
A neural network is trained to output a time dependent target vector defined over a predetermined time interval in response to a time dependent input vector defined over the same time interval by applying corresponding elements of the error vector, or difference between the target vector and the actual neuron output vector, to the inputs of corresponding output neurons of the network as corrective feedback. This feedback decreases the error and quickens the learning process, so that a much smaller number of training cycles are required to complete the learning process. A conventional gradient descent algorithm is employed to update the neural network parameters at the end of the predetermined time interval. The foregoing process is repeated in repetitive cycles until the actual output vector corresponds to the target vector. In the preferred embodiment, as the overall error of the neural network output decreasing during successive training cycles, the portion of the error fed back to the output neurons is decreased accordingly, allowing the network to learn with greater freedom from teacher forcing as the network parameters converge to their optimum values. The invention may also be used to train a neural network with stationary training and target vectors.
-
Fast temporal neural learning using teacher forcing
NASA Technical Reports Server (NTRS)
Toomarian, Nikzad (Inventor); Bahren, Jacob (Inventor)
1995-01-01
A neural network is trained to output a time dependent target vector defined over a predetermined time interval in response to a time dependent input vector defined over the same time interval by applying corresponding elements of the error vector, or difference between the target vector and the actual neuron output vector, to the inputs of corresponding output neurons of the network as corrective feedback. This feedback decreases the error and quickens the learning process, so that a much smaller number of training cycles are required to complete the learning process. A conventional gradient descent algorithm is employed to update the neural network parameters at the end of the predetermined time interval. The foregoing process is repeated in repetitive cycles until the actual output vector corresponds to the target vector. In the preferred embodiment, as the overall error of the neural network output decreasing during successive training cycles, the portion of the error fed back to the output neurons is decreased accordingly, allowing the network to learn with greater freedom from teacher forcing as the network parameters converge to their optimum values. The invention may also be used to train a neural network with stationary training and target vectors.
-
An Algebraic Approach to Guarantee Harmonic Balance Method Using Gröbner Base
NASA Astrophysics Data System (ADS)
Yagi, Masakazu; Hisakado, Takashi; Okumura, Kohshi
Harmonic balance (HB) method is well known principle for analyzing periodic oscillations on nonlinear networks and systems. Because the HB method has a truncation error, approximated solutions have been guaranteed by error bounds. However, its numerical computation is very time-consuming compared with solving the HB equation. This paper proposes an algebraic representation of the error bound using Gröbner base. The algebraic representation enables to decrease the computational cost of the error bound considerably. Moreover, using singular points of the algebraic representation, we can obtain accurate break points of the error bound by collisions.
-
Doerry, Armin W.; Heard, Freddie E.; Cordaro, J. Thomas
2010-08-17
Motion measurement errors that extend beyond the range resolution of a synthetic aperture radar (SAR) can be corrected by effectively decreasing the range resolution of the SAR in order to permit measurement of the error. Range profiles can be compared across the slow-time dimension of the input data in order to estimate the error. Once the error has been determined, appropriate frequency and phase correction can be applied to the uncompressed input data, after which range and azimuth compression can be performed to produce a desired SAR image.
-
Naidoo, Kovin S; Jaggernath, Jyoti
2012-01-01
Global estimates indicate that more than 2.3 billion people in the world suffer from poor vision due to refractive error; of which 670 million people are considered visually impaired because they do not have access to corrective treatment. Refractive errors, if uncorrected, results in an impaired quality of life for millions of people worldwide, irrespective of their age, sex and ethnicity. Over the past decade, a series of studies using a survey methodology, referred to as Refractive Error Study in Children (RESC), were performed in populations with different ethnic origins and cultural settings. These studies confirmed that the prevalence of uncorrected refractive errors is considerably high for children in low-and-middle-income countries. Furthermore, uncorrected refractive error has been noted to have extensive social and economic impacts, such as limiting educational and employment opportunities of economically active persons, healthy individuals and communities. The key public health challenges presented by uncorrected refractive errors, the leading cause of vision impairment across the world, require urgent attention. To address these issues, it is critical to focus on the development of human resources and sustainable methods of service delivery. This paper discusses three core pillars to addressing the challenges posed by uncorrected refractive errors: Human Resource (HR) Development, Service Development and Social Entrepreneurship. PMID:22944755
-
Competence in Streptococcus pneumoniae is regulated by the rate of ribosomal decoding errors.
Stevens, Kathleen E; Chang, Diana; Zwack, Erin E; Sebert, Michael E
2011-01-01
Competence for genetic transformation in Streptococcus pneumoniae develops in response to accumulation of a secreted peptide pheromone and was one of the initial examples of bacterial quorum sensing. Activation of this signaling system induces not only expression of the proteins required for transformation but also the production of cellular chaperones and proteases. We have shown here that activity of this pathway is sensitively responsive to changes in the accuracy of protein synthesis that are triggered by either mutations in ribosomal proteins or exposure to antibiotics. Increasing the error rate during ribosomal decoding promoted competence, while reducing the error rate below the baseline level repressed the development of both spontaneous and antibiotic-induced competence. This pattern of regulation was promoted by the bacterial HtrA serine protease. Analysis of strains with the htrA (S234A) catalytic site mutation showed that the proteolytic activity of HtrA selectively repressed competence when translational fidelity was high but not when accuracy was low. These findings redefine the pneumococcal competence pathway as a response to errors during protein synthesis. This response has the capacity to address the immediate challenge of misfolded proteins through production of chaperones and proteases and may also be able to address, through genetic exchange, upstream coding errors that cause intrinsic protein folding defects. The competence pathway may thereby represent a strategy for dealing with lesions that impair proper protein coding and for maintaining the coding integrity of the genome. The signaling pathway that governs competence in the human respiratory tract pathogen Streptococcus pneumoniae regulates both genetic transformation and the production of cellular chaperones and proteases. The current study shows that this pathway is sensitively controlled in response to changes in the accuracy of protein synthesis. Increasing the error rate during ribosomal decoding induced competence, while decreasing the error rate repressed competence. This pattern of regulation was promoted by the HtrA protease, which selectively repressed competence when translational fidelity was high but not when accuracy was low. Our findings demonstrate that this organism is able to monitor the accuracy of information used for protein biosynthesis and suggest that errors trigger a response addressing both the immediate challenge of misfolded proteins and, through genetic exchange, upstream coding errors that may underlie protein folding defects. This pathway may represent an evolutionary strategy for maintaining the coding integrity of the genome.
-
Pearce, Matthew G; Pearce, Nicole
2012-11-01
Eye care professionals have been making short visits to developing countries for decades in an effort to reduce visual impairment caused by refractive error. A 2006 survey revealed that volunteer organisations were not working within the Vision 2020 framework. Recommendations were made for volunteer organisations that would better align their work with accepted Vision 2020 and public health principles. This study re-evaluates the alignment of volunteer organisations with Vision 2020 and public health principles. To determine their philosophies and methods, a web-based survey was sent to 89 volunteer organisations identified from an internet search. The response rate was 48 per cent. Many (70.7 per cent) organisations exclusively mention direct service provision in their statement of purpose, often provided by student volunteers (75.6 per cent). A few (19.5 per cent) provide short training in refraction, not necessarily following best principles. The majority (82.1 per cent) dispenses recycled spectacles and many use medications not on national essential drug lists. Few attempt to follow aid effectiveness principles with only 26.8 per cent stating they follow Vision 2020 country plans. Overall, as in 2006, the work of these organisations is largely not in alignment with Vision 2020 and public health principles. Organisations interested in decreasing visual impairment due to refractive error in the developing world are encouraged to transition to organisations that not only recognise but also implement public health principles. This should include reprioritisation of their work to developing human resources and infrastructure, determining the burden and causes of disease, assisting in the training of mid-level personnel and providing professional and community education, collaborating via partnerships, discontinuing the use of recycled spectacles and inappropriate medications, and evaluating their outcomes. Following these recommendations as well as creating a better alignment with public health principles in general will increase the likelihood that their programs will be effective in decreasing visual impairment due to refractive error in the developing world. © 2012 The Authors. Clinical and Experimental Optometry © 2012 Optometrists Association Australia.
-
Chen, David D; Pei, Laura; Chan, John S Y; Yan, Jin H
2012-10-01
Recent research using deliberate amplification of spatial errors to increase motor learning leads to the question of whether amplifying temporal errors may also facilitate learning. We investigated transfer effects caused by manipulating temporal constraints on learning a two-choice reaction time (CRT) task with varying degrees of stimulus-response compatibility. Thirty-four participants were randomly assigned to one of the three groups and completed 120 trials during acquisition. For every fourth trial, one group was instructed to decrease CRT by 50 msec. relative to the previous trial and a second group was instructed to increase CRT by 50 msec. The third group (the control) was told not to change their responses. After a 5-min. break, participants completed a 40-trial no-feedback transfer test. A 40-trial delayed transfer test was administered 24 hours later. During acquisition, the Decreased Reaction Time group responded faster than the two other groups, but this group also made more errors than the other two groups. In the 5-min. delayed test (immediate transfer), the Decreased Reaction Time group had faster reaction times than the other two groups, while for the 24-hr. delayed test (delayed transfer), both the Decreased Reaction Time group and Increased Reaction Time group had significantly faster reaction times than the control. For delayed transfer, both Decreased and Increased Reaction Time groups reacted significantly faster than the control group. Analyses of error scores in the transfer tests indicated revealed no significant group differences. Results were discussed with regard to the notion of practice variability and goal-setting benefits.
-
Colas, Jaron T; Pauli, Wolfgang M; Larsen, Tobias; Tyszka, J Michael; O'Doherty, John P
2017-10-01
Prediction-error signals consistent with formal models of "reinforcement learning" (RL) have repeatedly been found within dopaminergic nuclei of the midbrain and dopaminoceptive areas of the striatum. However, the precise form of the RL algorithms implemented in the human brain is not yet well determined. Here, we created a novel paradigm optimized to dissociate the subtypes of reward-prediction errors that function as the key computational signatures of two distinct classes of RL models-namely, "actor/critic" models and action-value-learning models (e.g., the Q-learning model). The state-value-prediction error (SVPE), which is independent of actions, is a hallmark of the actor/critic architecture, whereas the action-value-prediction error (AVPE) is the distinguishing feature of action-value-learning algorithms. To test for the presence of these prediction-error signals in the brain, we scanned human participants with a high-resolution functional magnetic-resonance imaging (fMRI) protocol optimized to enable measurement of neural activity in the dopaminergic midbrain as well as the striatal areas to which it projects. In keeping with the actor/critic model, the SVPE signal was detected in the substantia nigra. The SVPE was also clearly present in both the ventral striatum and the dorsal striatum. However, alongside these purely state-value-based computations we also found evidence for AVPE signals throughout the striatum. These high-resolution fMRI findings suggest that model-free aspects of reward learning in humans can be explained algorithmically with RL in terms of an actor/critic mechanism operating in parallel with a system for more direct action-value learning.
-
Pauli, Wolfgang M.; Larsen, Tobias; Tyszka, J. Michael; O’Doherty, John P.
2017-01-01
Prediction-error signals consistent with formal models of “reinforcement learning” (RL) have repeatedly been found within dopaminergic nuclei of the midbrain and dopaminoceptive areas of the striatum. However, the precise form of the RL algorithms implemented in the human brain is not yet well determined. Here, we created a novel paradigm optimized to dissociate the subtypes of reward-prediction errors that function as the key computational signatures of two distinct classes of RL models—namely, “actor/critic” models and action-value-learning models (e.g., the Q-learning model). The state-value-prediction error (SVPE), which is independent of actions, is a hallmark of the actor/critic architecture, whereas the action-value-prediction error (AVPE) is the distinguishing feature of action-value-learning algorithms. To test for the presence of these prediction-error signals in the brain, we scanned human participants with a high-resolution functional magnetic-resonance imaging (fMRI) protocol optimized to enable measurement of neural activity in the dopaminergic midbrain as well as the striatal areas to which it projects. In keeping with the actor/critic model, the SVPE signal was detected in the substantia nigra. The SVPE was also clearly present in both the ventral striatum and the dorsal striatum. However, alongside these purely state-value-based computations we also found evidence for AVPE signals throughout the striatum. These high-resolution fMRI findings suggest that model-free aspects of reward learning in humans can be explained algorithmically with RL in terms of an actor/critic mechanism operating in parallel with a system for more direct action-value learning. PMID:29049406
-
Hakala, John L; Hung, Joseph C; Mosman, Elton A
2012-09-01
The objective of this project was to ensure correct radiopharmaceutical administration through the use of a bar code system that links patient and drug profiles with on-site information management systems. This new combined system would minimize the amount of manual human manipulation, which has proven to be a primary source of error. The most common reason for dosing errors is improper patient identification when a dose is obtained from the nuclear pharmacy or when a dose is administered. A standardized electronic transfer of information from radiopharmaceutical preparation to injection will further reduce the risk of misadministration. Value stream maps showing the flow of the patient dose information, as well as potential points of human error, were developed. Next, a future-state map was created that included proposed corrections for the most common critical sites of error. Transitioning the current process to the future state will require solutions that address these sites. To optimize the future-state process, a bar code system that links the on-site radiology management system with the nuclear pharmacy management system was proposed. A bar-coded wristband connects the patient directly to the electronic information systems. The bar code-enhanced process linking the patient dose with the electronic information reduces the number of crucial points for human error and provides a framework to ensure that the prepared dose reaches the correct patient. Although the proposed flowchart is designed for a site with an in-house central nuclear pharmacy, much of the framework could be applied by nuclear medicine facilities using unit doses. An electronic connection between information management systems to allow the tracking of a radiopharmaceutical from preparation to administration can be a useful tool in preventing the mistakes that are an unfortunate reality for any facility.
-
Correcting a fundamental error in greenhouse gas accounting related to bioenergy
Haberl, Helmut; Sprinz, Detlef; Bonazountas, Marc; Cocco, Pierluigi; Desaubies, Yves; Henze, Mogens; Hertel, Ole; Johnson, Richard K.; Kastrup, Ulrike; Laconte, Pierre; Lange, Eckart; Novak, Peter; Paavola, Jouni; Reenberg, Anette; van den Hove, Sybille; Vermeire, Theo; Wadhams, Peter; Searchinger, Timothy
2012-01-01
Many international policies encourage a switch from fossil fuels to bioenergy based on the premise that its use would not result in carbon accumulation in the atmosphere. Frequently cited bioenergy goals would at least double the present global human use of plant material, the production of which already requires the dedication of roughly 75% of vegetated lands and more than 70% of water withdrawals. However, burning biomass for energy provision increases the amount of carbon in the air just like burning coal, oil or gas if harvesting the biomass decreases the amount of carbon stored in plants and soils, or reduces carbon sequestration. Neglecting this fact results in an accounting error that could be corrected by considering that only the use of ‘additional biomass’ – biomass from additional plant growth or biomass that would decompose rapidly if not used for bioenergy – can reduce carbon emissions. Failure to correct this accounting flaw will likely have substantial adverse consequences. The article presents recommendations for correcting greenhouse gas accounts related to bioenergy. PMID:23576835
-
Non-intrusive practitioner pupil detection for unmodified microscope oculars.
Fuhl, Wolfgang; Santini, Thiago; Reichert, Carsten; Claus, Daniel; Herkommer, Alois; Bahmani, Hamed; Rifai, Katharina; Wahl, Siegfried; Kasneci, Enkelejda
2016-12-01
Modern microsurgery is a long and complex task requiring the surgeon to handle multiple microscope controls while performing the surgery. Eye tracking provides an additional means of interaction for the surgeon that could be used to alleviate this situation, diminishing surgeon fatigue and surgery time, thus decreasing risks of infection and human error. In this paper, we introduce a novel algorithm for pupil detection tailored for eye images acquired through an unmodified microscope ocular. The proposed approach, the Hough transform, and six state-of-the-art pupil detection algorithms were evaluated on over 4000 hand-labeled images acquired from a digital operating microscope with a non-intrusive monitoring system for the surgeon eyes integrated. Our results show that the proposed method reaches detection rates up to 71% for an error of ≈3% w.r.t the input image diagonal; none of the state-of-the-art pupil detection algorithms performed satisfactorily. The algorithm and hand-labeled data set can be downloaded at:: www.ti.uni-tuebingen.de/perception. Copyright © 2016 Elsevier Ltd. All rights reserved.
-
2009-12-01
SWISS CHEESE ” MODEL........................................... 16 1. Errors and Violations...16 Figure 5. Reason’s Swiss Cheese Model (After: Reason, 1990, p. 208) ........... 20 Figure 6. The HFACS Swiss Cheese Model of...become more complex. E. REASON’S “ SWISS CHEESE ” MODEL Reason’s (1990) book, Human Error, is generally regarded as the seminal work on the subject
-
Assisting Movement Training and Execution With Visual and Haptic Feedback.
Ewerton, Marco; Rother, David; Weimar, Jakob; Kollegger, Gerrit; Wiemeyer, Josef; Peters, Jan; Maeda, Guilherme
2018-01-01
In the practice of motor skills in general, errors in the execution of movements may go unnoticed when a human instructor is not available. In this case, a computer system or robotic device able to detect movement errors and propose corrections would be of great help. This paper addresses the problem of how to detect such execution errors and how to provide feedback to the human to correct his/her motor skill using a general, principled methodology based on imitation learning. The core idea is to compare the observed skill with a probabilistic model learned from expert demonstrations. The intensity of the feedback is regulated by the likelihood of the model given the observed skill. Based on demonstrations, our system can, for example, detect errors in the writing of characters with multiple strokes. Moreover, by using a haptic device, the Haption Virtuose 6D, we demonstrate a method to generate haptic feedback based on a distribution over trajectories, which could be used as an auxiliary means of communication between an instructor and an apprentice. Additionally, given a performance measurement, the haptic device can help the human discover and perform better movements to solve a given task. In this case, the human first tries a few times to solve the task without assistance. Our framework, in turn, uses a reinforcement learning algorithm to compute haptic feedback, which guides the human toward better solutions.
-
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.
-
The Error in Total Error Reduction
Witnauer, James E.; Urcelay, Gonzalo P.; Miller, Ralph R.
2013-01-01
Most models of human and animal learning assume that learning is proportional to the discrepancy between a delivered outcome and the outcome predicted by all cues present during that trial (i.e., total error across a stimulus compound). This total error reduction (TER) view has been implemented in connectionist and artificial neural network models to describe the conditions under which weights between units change. Electrophysiological work has revealed that the activity of dopamine neurons is correlated with the total error signal in models of reward learning. Similar neural mechanisms presumably support fear conditioning, human contingency learning, and other types of learning. Using a computational modelling approach, we compared several TER models of associative learning to an alternative model that rejects the TER assumption in favor of local error reduction (LER), which assumes that learning about each cue is proportional to the discrepancy between the delivered outcome and the outcome predicted by that specific cue on that trial. The LER model provided a better fit to the reviewed data than the TER models. Given the superiority of the LER model with the present data sets, acceptance of TER should be tempered. PMID:23891930
-
Nature and Nurture: the complex genetics of myopia and refractive error
Wojciechowski, Robert
2010-01-01
The refractive errors, myopia and hyperopia, are optical defects of the visual system that can cause blurred vision. Uncorrected refractive errors are the most common causes of visual impairment worldwide. It is estimated that 2.5 billion people will be affected by myopia alone with in the next decade. Experimental, epidemiological and clinical research has shown that refractive development is influenced by both environmental and genetic factors. Animal models have demonstrated that eye growth and refractive maturation during infancy are tightly regulated by visually-guided mechanisms. Observational data in human populations provide compelling evidence that environmental influences and individual behavioral factors play crucial roles in myopia susceptibility. Nevertheless, the majority of the variance of refractive error within populations is thought to be due to hereditary factors. Genetic linkage studies have mapped two dozen loci, while association studies have implicated more than 25 different genes in refractive variation. Many of these genes are involved in common biological pathways known to mediate extracellular matrix composition and regulate connective tissue remodeling. Other associated genomic regions suggest novel mechanisms in the etiology of human myopia, such as mitochondrial-mediated cell death or photoreceptor-mediated visual signal transmission. Taken together, observational and experimental studies have revealed the complex nature of human refractive variation, which likely involves variants in several genes and functional pathways. Multiway interactions between genes and/or environmental factors may also be important in determining individual risks of myopia, and may help explain the complex pattern of refractive error in human populations. PMID:21155761
-
Optical Oversampled Analog-to-Digital Conversion
1992-06-29
hologram weights and interconnects in the digital image halftoning configuration. First, no temporal error diffusion occurs in the digital image... halftoning error diffusion ar- chitecture as demonstrated by Equation (6.1). Equation (6.2) ensures that the hologram weights sum to one so that the exact...optimum halftone image should be faster. Similarly, decreased convergence time suggests that an error diffusion filter with larger spatial dimensions
-
Decrease in medical command errors with use of a "standing orders" protocol system.
Holliman, C J; Wuerz, R C; Meador, S A
1994-05-01
The purpose of this study was to determine the physician medical command error rates and paramedic error rates after implementation of a "standing orders" protocol system for medical command. These patient-care error rates were compared with the previously reported rates for a "required call-in" medical command system (Ann Emerg Med 1992; 21(4):347-350). A secondary aim of the study was to determine if the on-scene time interval was increased by the standing orders system. Prospectively conducted audit of prehospital advanced life support (ALS) trip sheets was made at an urban ALS paramedic service with on-line physician medical command from three local hospitals. All ALS run sheets from the start time of the standing orders system (April 1, 1991) for a 1-year period ending on March 30, 1992 were reviewed as part of an ongoing quality assurance program. Cases were identified as nonjustifiably deviating from regional emergency medical services (EMS) protocols as judged by agreement of three physician reviewers (the same methodology as a previously reported command error study in the same ALS system). Medical command and paramedic errors were identified from the prehospital ALS run sheets and categorized. Two thousand one ALS runs were reviewed; 24 physician errors (1.2% of the 1,928 "command" runs) and eight paramedic errors (0.4% of runs) were identified. The physician error rate was decreased from the 2.6% rate in the previous study (P < .0001 by chi 2 analysis). The on-scene time interval did not increase with the "standing orders" system.(ABSTRACT TRUNCATED AT 250 WORDS)
-
Effects of a direct refill program for automated dispensing cabinets on medication-refill errors.
Helmons, Pieter J; Dalton, Ashley J; Daniels, Charles E
2012-10-01
The effects of a direct refill program for automated dispensing cabinets (ADCs) on medication-refill errors were studied. This study was conducted in designated acute care areas of a 386-bed academic medical center. A wholesaler-to-ADC direct refill program, consisting of prepackaged delivery of medications and bar-code-assisted ADC refilling, was implemented in the inpatient pharmacy of the medical center in September 2009. Medication-refill errors in 26 ADCs from the general medicine units, the infant special care unit, the surgical and burn intensive care units, and intermediate units were assessed before and after the implementation of this program. Medication-refill errors were defined as an ADC pocket containing the wrong drug, wrong strength, or wrong dosage form. ADC refill errors decreased by 77%, from 62 errors per 6829 refilled pockets (0.91%) to 8 errors per 3855 refilled pockets (0.21%) (p < 0.0001). The predominant error type detected before the intervention was the incorrect medication (wrong drug, wrong strength, or wrong dosage form) in the ADC pocket. Of the 54 incorrect medications found before the intervention, 38 (70%) were loaded in a multiple-drug drawer. After the implementation of the new refill process, 3 of the 5 incorrect medications were loaded in a multiple-drug drawer. There were 3 instances of expired medications before and only 1 expired medication after implementation of the program. A redesign of the ADC refill process using a wholesaler-to-ADC direct refill program that included delivery of prepackaged medication and bar-code-assisted refill significantly decreased the occurrence of ADC refill errors.
-
Bell, Sigall K; White, Andrew A; Yi, Jean C; Yi-Frazier, Joyce P; Gallagher, Thomas H
2017-12-01
Transparent communication after medical error includes disclosing the mistake to the patient, discussing the event with colleagues, and reporting to the institution. Little is known about whether attitudes about these transparency practices are related. Understanding these relationships could inform educational and organizational strategies to promote transparency. We analyzed responses of 3038 US and Canadian physicians to a medical error communication survey. We used bivariate correlations, principal components analysis, and linear regression to determine whether and how physician attitudes about transparent communication with patients, peers, and the institution after error were related. Physician attitudes about disclosing errors to patients, peers, and institutions were correlated (all P's < 0.001) and represented 2 principal components analysis factors, namely, communication with patients and communication with peers/institution. Predictors of attitudes supporting transparent communication with patients and peers/institution included female sex, US (vs Canadian) doctors, academic (vs private) practice, the belief that disclosure decreased likelihood of litigation, and the belief that system changes occur after error reporting. In addition, younger physicians, surgeons, and those with previous experience disclosing a serious error were more likely to agree with disclosure to patients. In comparison, doctors who believed that disclosure would decrease patient trust were less likely to agree with error disclosure to patients. Previous disclosure education was associated with attitudes supporting greater transparency with peers/institution. Physician attitudes about discussing errors with patients, colleagues, and institutions are related. Several predictors of transparency affect all 3 practices and are potentially modifiable by educational and institutional strategies.
-
Stannard, David L.; Rosenberry, Donald O.; Winter, Thomas C.; Parkhurst, Renee S.
2004-01-01
Micrometeorological measurements of evapotranspiration (ET) often are affected to some degree by errors arising from limited fetch. A recently developed model was used to estimate fetch-induced errors in Bowen-ratio energy-budget measurements of ET made at a small wetland with fetch-to-height ratios ranging from 34 to 49. Estimated errors were small, averaging −1.90%±0.59%. The small errors are attributed primarily to the near-zero lower sensor height, and the negative bias reflects the greater Bowen ratios of the drier surrounding upland. Some of the variables and parameters affecting the error were not measured, but instead are estimated. A sensitivity analysis indicates that the uncertainty arising from these estimates is small. In general, fetch-induced error in measured wetland ET increases with decreasing fetch-to-height ratio, with increasing aridity and with increasing atmospheric stability over the wetland. Occurrence of standing water at a site is likely to increase the appropriate time step of data integration, for a given level of accuracy. Occurrence of extensive open water can increase accuracy or decrease the required fetch by allowing the lower sensor to be placed at the water surface. If fetch is highly variable and fetch-induced errors are significant, the variables affecting fetch (e.g., wind direction, water level) need to be measured. Fetch-induced error during the non-growing season may be greater or smaller than during the growing season, depending on how seasonal changes affect both the wetland and upland at a site.
-
Huynh, Chi; Wong, Ian C K; Correa-West, Jo; Terry, David; McCarthy, Suzanne
2017-04-01
Since the publication of To Err Is Human: Building a Safer Health System in 1999, there has been much research conducted into the epidemiology, nature and causes of medication errors in children, from prescribing and supply to administration. It is reassuring to see growing evidence of improving medication safety in children; however, based on media reports, it can be seen that serious and fatal medication errors still occur. This critical opinion article examines the problem of medication errors in children and provides recommendations for research, training of healthcare professionals and a culture shift towards dealing with medication errors. There are three factors that we need to consider to unravel what is missing and why fatal medication errors still occur. (1) Who is involved and affected by the medication error? (2) What factors hinder staff and organisations from learning from mistakes? Does the fear of litigation and criminal charges deter healthcare professionals from voluntarily reporting medication errors? (3) What are the educational needs required to prevent medication errors? It is important to educate future healthcare professionals about medication errors and human factors to prevent these from happening. Further research is required to apply aviation's 'black box' principles in healthcare to record and learn from near misses and errors to prevent future events. There is an urgent need for the black box investigations to be published and made public for the benefit of other organisations that may have similar potential risks for adverse events. International sharing of investigations and learning is also needed.
-
DOE Office of Scientific and Technical Information (OSTI.GOV)
Barbee, D; McCarthy, A; Galavis, P
Purpose: Errors found during initial physics plan checks frequently require replanning and reprinting, resulting decreased departmental efficiency. Additionally, errors may be missed during physics checks, resulting in potential treatment errors or interruption. This work presents a process control created using the Eclipse Scripting API (ESAPI) enabling dosimetrists and physicists to detect potential errors in the Eclipse treatment planning system prior to performing any plan approvals or printing. Methods: Potential failure modes for five categories were generated based on available ESAPI (v11) patient object properties: Images, Contours, Plans, Beams, and Dose. An Eclipse script plugin (PlanCheck) was written in C# tomore » check errors most frequently observed clinically in each of the categories. The PlanCheck algorithms were devised to check technical aspects of plans, such as deliverability (e.g. minimum EDW MUs), in addition to ensuring that policy and procedures relating to planning were being followed. The effect on clinical workflow efficiency was measured by tracking the plan document error rate and plan revision/retirement rates in the Aria database over monthly intervals. Results: The number of potential failure modes the PlanCheck script is currently capable of checking for in the following categories: Images (6), Contours (7), Plans (8), Beams (17), and Dose (4). Prior to implementation of the PlanCheck plugin, the observed error rates in errored plan documents and revised/retired plans in the Aria database was 20% and 22%, respectively. Error rates were seen to decrease gradually over time as adoption of the script improved. Conclusion: A process control created using the Eclipse scripting API enabled plan checks to occur within the planning system, resulting in reduction in error rates and improved efficiency. Future work includes: initiating full FMEA for planning workflow, extending categories to include additional checks outside of ESAPI via Aria database queries, and eventual automated plan checks.« less
-
Gildersleeve-Neumann, Christina E; Kester, Ellen S; Davis, Barbara L; Peña, Elizabeth D
2008-07-01
English speech acquisition by typically developing 3- to 4-year-old children with monolingual English was compared to English speech acquisition by typically developing 3- to 4-year-old children with bilingual English-Spanish backgrounds. We predicted that exposure to Spanish would not affect the English phonetic inventory but would increase error frequency and type in bilingual children. Single-word speech samples were collected from 33 children. Phonetically transcribed samples for the 3 groups (monolingual English children, English-Spanish bilingual children who were predominantly exposed to English, and English-Spanish bilingual children with relatively equal exposure to English and Spanish) were compared at 2 time points and for change over time for phonetic inventory, phoneme accuracy, and error pattern frequencies. Children demonstrated similar phonetic inventories. Some bilingual children produced Spanish phonemes in their English and produced few consonant cluster sequences. Bilingual children with relatively equal exposure to English and Spanish averaged more errors than did bilingual children who were predominantly exposed to English. Both bilingual groups showed higher error rates than English-only children overall, particularly for syllable-level error patterns. All language groups decreased in some error patterns, although the ones that decreased were not always the same across language groups. Some group differences of error patterns and accuracy were significant. Vowel error rates did not differ by language group. Exposure to English and Spanish may result in a higher English error rate in typically developing bilinguals, including the application of Spanish phonological properties to English. Slightly higher error rates are likely typical for bilingual preschool-aged children. Change over time at these time points for all 3 groups was similar, suggesting that all will reach an adult-like system in English with exposure and practice.
-
de Azevedo Neto, Raymundo Machado; Teixeira, Luis Augusto
2011-05-01
This investigation aimed at assessing the extent to which memory from practice in a specific condition of target displacement modulates temporal errors and movement timing of interceptive movements. We compared two groups practicing with certainty of future target velocity either in unchanged target velocity or in target velocity decrease. Following practice, both experimental groups were probed in the situations of unchanged target velocity and target velocity decrease either under the context of certainty or uncertainty about target velocity. Results from practice showed similar improvement of temporal accuracy between groups, revealing that target velocity decrease did not disturb temporal movement organization when fully predictable. Analysis of temporal errors in the probing trials indicated that both groups had higher timing accuracy in velocity decrease in comparison with unchanged velocity. Effect of practice was detected by increased temporal accuracy of the velocity decrease group in situations of decreased velocity; a trend consistent with the expected effect of practice was observed for temporal errors in the unchanged velocity group and in movement initiation at a descriptive level. An additional point of theoretical interest was the fast adaptation in both groups to a target velocity pattern different from that practiced. These points are discussed under the perspective of integration of vision and motor control by means of an internal forward model of external motion.
-
The effects of training on errors of perceived direction in perspective displays
NASA Technical Reports Server (NTRS)
Tharp, Gregory K.; Ellis, Stephen R.
1990-01-01
An experiment was conducted to determine the effects of training on the characteristic direction errors that are observed when subjects estimate exocentric directions on perspective displays. Changes in five subjects' perceptual errors were measured during a training procedure designed to eliminate the error. The training was provided by displaying to each subject both the sign and the direction of his judgment error. The feedback provided by the error display was found to decrease but not eliminate the error. A lookup table model of the source of the error was developed in which the judgement errors were attributed to overestimates of both the pitch and the yaw of the viewing direction used to produce the perspective projection. The model predicts the quantitative characteristics of the data somewhat better than previous models did. A mechanism is proposed for the observed learning, and further tests of the model are suggested.
-
Evaluation of an Airborne Spacing Concept, On-Board Spacing Tool, and Pilot Interface
NASA Technical Reports Server (NTRS)
Swieringa, Kurt; Murdoch, Jennifer L.; Baxley, Brian; Hubbs, Clay
2011-01-01
The number of commercial aircraft operations is predicted to increase in the next ten years, creating a need for improved operational efficiency. Two areas believed to offer significant increases in efficiency are optimized profile descents and dependent parallel runway operations. It is envisioned that during both of these types of operations, flight crews will precisely space their aircraft behind preceding aircraft at air traffic control assigned intervals to increase runway throughput and maximize the use of existing infrastructure. This paper describes a human-in-the-loop experiment designed to study the performance of an onboard spacing algorithm and pilots ratings of the usability and acceptability of an airborne spacing concept that supports dependent parallel arrivals. Pilot participants flew arrivals into the Dallas Fort-Worth terminal environment using one of three different simulators located at the National Aeronautics and Space Administration s (NASA) Langley Research Center. Scenarios were flown using Interval Management with Spacing (IM-S) and Required Time of Arrival (RTA) control methods during conditions of no error, error in the forecast wind, and offset (disturbance) to the arrival flow. Results indicate that pilots delivered their aircraft to the runway threshold within +/- 3.5 seconds of their assigned arrival time and reported that both the IM-S and RTA procedures were associated with low workload levels. In general, pilots found the IM-S concept, procedures, speeds, and interface acceptable; with 92% of pilots rating the procedures as complete and logical, 218 out of 240 responses agreeing that the IM-S speeds were acceptable, and 63% of pilots reporting that the displays were easy to understand and displayed in appropriate locations. The 22 (out of 240) responses, indicating that the commanded speeds were not acceptable and appropriate occurred during scenarios containing wind error and offset error. Concerns cited included the occurrence of multiple speed changes within a short time period, speed changes required within twenty miles of the runway, and an increase in airspeed followed shortly by a decrease in airspeed. Within this paper, appropriate design recommendations are provided, and the need for continued, iterative human-centered design is discussed.
-
Human Error and Commercial Aviation Accidents: A Comprehensive, Fine-Grained Analysis Using HFACS
2006-07-01
Factors Figure 2. The HFACS framework. 3 practiced and seemingly automatic behaviors is that they are particularly susceptible to attention and/or memory...been included in most error frameworks, the third and final error form, perceptual errors, has received comparatively less attention . No less...operate safely. After all, just as not everyone can play linebacker for their favorite professional football team or be a concert pianist , not
-
Aoki, Hirofumi; Ohno, Ryuzo; Yamaguchi, Takao
2005-01-01
In a virtual weightless environment, subjects' orientation skills were studied to examine what kind of cognitive errors people make when they moved through the interior space of virtual space stations and what kind of visual information effectively decreases those errors. Subjects wearing a head-mounted display moved from one end to the other end in space station-like routes constructed of rectangular and cubical modules, and did Pointing and Modeling tasks. In Experiment 1, configurations of the routes were changed with such variables as the number of bends, the number of embedding planes, and the number of planes with respect to the body posture. The results indicated that spatial orientation ability was relevant to the variables and that orientational errors were explained by two causes. One of these was that the place, the direction, and the sequence of turns were incorrect. The other was that subjects did not recognize the rotation of the frame of reference, especially when they turned in pitch direction rather than in yaw. In Experiment 2, the effect of the interior design was examined by testing three design settings. Wall colors that showed the allocentric frame of reference and the different interior design of vertical and horizontal modules were effective; however, there was a limit to the effectiveness in complicated configurations. c2005 Published by Elsevier Ltd.
-
Lakhin, A V; Efremova, A S; Makarova, I V; Grishina, E E; Shram, S I; Tarantul, V Z; Gening, L V
2013-01-01
The DNA polymerase iota (Pol iota), which has some peculiar features and is characterized by an extremely error-prone DNA synthesis, belongs to the group of enzymes preferentially activated by Mn2+ instead of Mg2+. In this work, the effect of Mn2+ on DNA synthesis in cell extracts from a) normal human and murine tissues, b) human tumor (uveal melanoma), and c) cultured human tumor cell lines SKOV-3 and HL-60 was tested. Each group displayed characteristic features of Mn-dependent DNA synthesis. The changes in the Mn-dependent DNA synthesis caused by malignant transformation of normal tissues are described. It was also shown that the error-prone DNA synthesis catalyzed by Pol iota in extracts of all cell types was efficiently suppressed by an RNA aptamer (IKL5) against Pol iota obtained in our work earlier. The obtained results suggest that IKL5 might be used to suppress the enhanced activity of Pol iota in tumor cells.
-
DOE Office of Scientific and Technical Information (OSTI.GOV)
Weston, Louise Marie
2007-09-01
A recent report on criticality accidents in nuclear facilities indicates that human error played a major role in a significant number of incidents with serious consequences and that some of these human errors may be related to the emotional state of the individual. A pre-shift test to detect a deleterious emotional state could reduce the occurrence of such errors in critical operations. The effectiveness of pre-shift testing is a challenge because of the need to gather predictive data in a relatively short test period and the potential occurrence of learning effects due to a requirement for frequent testing. This reportmore » reviews the different types of reliability and validity methods and testing and statistical analysis procedures to validate measures of emotional state. The ultimate value of a validation study depends upon the percentage of human errors in critical operations that are due to the emotional state of the individual. A review of the literature to identify the most promising predictors of emotional state for this application is highly recommended.« less
-
Multi-muscle FES force control of the human arm for arbitrary goals.
Schearer, Eric M; Liao, Yu-Wei; Perreault, Eric J; Tresch, Matthew C; Memberg, William D; Kirsch, Robert F; Lynch, Kevin M
2014-05-01
We present a method for controlling a neuroprosthesis for a paralyzed human arm using functional electrical stimulation (FES) and characterize the errors of the controller. The subject has surgically implanted electrodes for stimulating muscles in her shoulder and arm. Using input/output data, a model mapping muscle stimulations to isometric endpoint forces measured at the subject's hand was identified. We inverted the model of this redundant and coupled multiple-input multiple-output system by minimizing muscle activations and used this inverse for feedforward control. The magnitude of the total root mean square error over a grid in the volume of achievable isometric endpoint force targets was 11% of the total range of achievable forces. Major sources of error were random error due to trial-to-trial variability and model bias due to nonstationary system properties. Because the muscles working collectively are the actuators of the skeletal system, the quantification of errors in force control guides designs of motion controllers for multi-joint, multi-muscle FES systems that can achieve arbitrary goals.
-
The current approach to human error and blame in the NHS.
Ottewill, Melanie
There is a large body of research to suggest that serious errors are widespread throughout medicine. The traditional response to these adverse events has been to adopt a 'person approach' - blaming the individual seen as 'responsible'. The culture of medicine is highly complicit in this response. Such an approach results in enormous personal costs to the individuals concerned and does little to address the root causes of errors and thus prevent their recurrence. Other industries, such as aviation, where safety is a paramount concern and which have similar structures to the medical profession, have, over the past decade or so, adopted a 'systems' approach to error, recognizing that human error is ubiquitous and inevitable and that systems need to be developed with this in mind. This approach has been highly successful, but has necessitated, first and foremost, a cultural shift. It is in the best interests of patients, and medical professionals alike, that such a shift is embraced in the NHS.
-
Cognitive errors: thinking clearly when it could be child maltreatment.
Laskey, Antoinette L
2014-10-01
Cognitive errors have been studied in a broad array of fields, including medicine. The more that is understood about how the human mind processes complex information, the more it becomes clear that certain situations are particularly susceptible to less than optimal outcomes because of these errors. This article explores how some of the known cognitive errors may influence the diagnosis of child abuse, resulting in both false-negative and false-positive diagnoses. Suggested remedies for these errors are offered. Copyright © 2014 Elsevier Inc. All rights reserved.
-
Raab, Stephen S; Andrew-Jaja, Carey; Condel, Jennifer L; Dabbs, David J
2006-01-01
The objective of the study was to determine whether the Toyota production system process improves Papanicolaou test quality and patient safety. An 8-month nonconcurrent cohort study that included 464 case and 639 control women who had a Papanicolaou test was performed. Office workflow was redesigned using Toyota production system methods by introducing a 1-by-1 continuous flow process. We measured the frequency of Papanicolaou tests without a transformation zone component, follow-up and Bethesda System diagnostic frequency of atypical squamous cells of undetermined significance, and diagnostic error frequency. After the intervention, the percentage of Papanicolaou tests lacking a transformation zone component decreased from 9.9% to 4.7% (P = .001). The percentage of Papanicolaou tests with a diagnosis of atypical squamous cells of undetermined significance decreased from 7.8% to 3.9% (P = .007). The frequency of error per correlating cytologic-histologic specimen pair decreased from 9.52% to 7.84%. The introduction of the Toyota production system process resulted in improved Papanicolaou test quality.
-
Does the A-not-B error in adult pet dogs indicate sensitivity to human communication?
Kis, Anna; Topál, József; Gácsi, Márta; Range, Friederike; Huber, Ludwig; Miklósi, Adám; Virányi, Zsófia
2012-07-01
Recent dog-infant comparisons have indicated that the experimenter's communicative signals in object hide-and-search tasks increase the probability of perseverative (A-not-B) errors in both species (Topál et al. 2009). These behaviourally similar results, however, might reflect different mechanisms in dogs and in children. Similar errors may occur if the motor response of retrieving the object during the A trials cannot be inhibited in the B trials or if the experimenter's movements and signals toward the A hiding place in the B trials ('sham-baiting') distract the dogs' attention. In order to test these hypotheses, we tested dogs similarly to Topál et al. (2009) but eliminated the motor search in the A trials and 'sham-baiting' in the B trials. We found that neither an inability to inhibit previously rewarded motor response nor insufficiencies in their working memory and/or attention skills can explain dogs' erroneous choices. Further, we replicated the finding that dogs have a strong tendency to commit the A-not-B error after ostensive-communicative hiding and demonstrated the crucial effect of socio-communicative cues as the A-not-B error diminishes when location B is ostensively enhanced. These findings further support the hypothesis that the dogs' A-not-B error may reflect a special sensitivity to human communicative cues. Such object-hiding and search tasks provide a typical case for how susceptibility to human social signals could (mis)lead domestic dogs.
-
Lombardo, Franco; Berellini, Giuliano; Labonte, Laura R; Liang, Guiqing; Kim, Sean
2016-03-01
We present a systematic evaluation of the Wajima superpositioning method to estimate the human intravenous (i.v.) pharmacokinetic (PK) profile based on a set of 54 marketed drugs with diverse structure and range of physicochemical properties. We illustrate the use of average of "best methods" for the prediction of clearance (CL) and volume of distribution at steady state (VDss) as described in our earlier work (Lombardo F, Waters NJ, Argikar UA, et al. J Clin Pharmacol. 2013;53(2):178-191; Lombardo F, Waters NJ, Argikar UA, et al. J Clin Pharmacol. 2013;53(2):167-177). These methods provided much more accurate prediction of human PK parameters, yielding 88% and 70% of the prediction within 2-fold error for VDss and CL, respectively. The prediction of human i.v. profile using Wajima superpositioning of rat, dog, and monkey time-concentration profiles was tested against the observed human i.v. PK using fold error statistics. The results showed that 63% of the compounds yielded a geometric mean of fold error below 2-fold, and an additional 19% yielded a geometric mean of fold error between 2- and 3-fold, leaving only 18% of the compounds with a relatively poor prediction. Our results showed that good superposition was observed in any case, demonstrating the predictive value of the Wajima approach, and that the cause of poor prediction of human i.v. profile was mainly due to the poorly predicted CL value, while VDss prediction had a minor impact on the accuracy of human i.v. profile prediction. Copyright © 2016. Published by Elsevier Inc.
-
Automatic learning rate adjustment for self-supervising autonomous robot control
NASA Technical Reports Server (NTRS)
Arras, Michael K.; Protzel, Peter W.; Palumbo, Daniel L.
1992-01-01
Described is an application in which an Artificial Neural Network (ANN) controls the positioning of a robot arm with five degrees of freedom by using visual feedback provided by two cameras. This application and the specific ANN model, local liner maps, are based on the work of Ritter, Martinetz, and Schulten. We extended their approach by generating a filtered, average positioning error from the continuous camera feedback and by coupling the learning rate to this error. When the network learns to position the arm, the positioning error decreases and so does the learning rate until the system stabilizes at a minimum error and learning rate. This abolishes the need for a predetermined cooling schedule. The automatic cooling procedure results in a closed loop control with no distinction between a learning phase and a production phase. If the positioning error suddenly starts to increase due to an internal failure such as a broken joint, or an environmental change such as a camera moving, the learning rate increases accordingly. Thus, learning is automatically activated and the network adapts to the new condition after which the error decreases again and learning is 'shut off'. The automatic cooling is therefore a prerequisite for the autonomy and the fault tolerance of the system.
-
EEG Frequency Changes Prior to Making Errors in an Easy Stroop Task
Atchley, Rachel; Klee, Daniel; Oken, Barry
2017-01-01
Background: Mind-wandering is a form of off-task attention that has been associated with negative affect and rumination. The goal of this study was to assess potential electroencephalographic markers of task-unrelated thought, or mind-wandering state, as related to error rates during a specialized cognitive task. We used EEG to record frontal frequency band activity while participants completed a Stroop task that was modified to induce boredom, task-unrelated thought, and therefore mind-wandering. Methods: A convenience sample of 27 older adults (50–80 years) completed a computerized Stroop matching task. Half of the Stroop trials were congruent (word/color match), and the other half were incongruent (mismatched). Behavioral data and EEG recordings were assessed. EEG analysis focused on the 1-s epochs prior to stimulus presentation in order to compare trials followed by correct versus incorrect responses. Results: Participants made errors on 9% of incongruent trials. There were no errors on congruent trials. There was a decrease in alpha and theta band activity during the epochs followed by error responses. Conclusion: Although replication of these results is necessary, these findings suggest that potential mind-wandering, as evidenced by errors, can be characterized by a decrease in alpha and theta activity compared to on-task, accurate performance periods. PMID:29163101
-
Error rates in forensic DNA analysis: definition, numbers, impact and communication.
Kloosterman, Ate; Sjerps, Marjan; Quak, Astrid
2014-09-01
Forensic DNA casework is currently regarded as one of the most important types of forensic evidence, and important decisions in intelligence and justice are based on it. However, errors occasionally occur and may have very serious consequences. In other domains, error rates have been defined and published. The forensic domain is lagging behind concerning this transparency for various reasons. In this paper we provide definitions and observed frequencies for different types of errors at the Human Biological Traces Department of the Netherlands Forensic Institute (NFI) over the years 2008-2012. Furthermore, we assess their actual and potential impact and describe how the NFI deals with the communication of these numbers to the legal justice system. We conclude that the observed relative frequency of quality failures is comparable to studies from clinical laboratories and genetic testing centres. Furthermore, this frequency is constant over the five-year study period. The most common causes of failures related to the laboratory process were contamination and human error. Most human errors could be corrected, whereas gross contamination in crime samples often resulted in irreversible consequences. Hence this type of contamination is identified as the most significant source of error. Of the known contamination incidents, most were detected by the NFI quality control system before the report was issued to the authorities, and thus did not lead to flawed decisions like false convictions. However in a very limited number of cases crucial errors were detected after the report was issued, sometimes with severe consequences. Many of these errors were made in the post-analytical phase. The error rates reported in this paper are useful for quality improvement and benchmarking, and contribute to an open research culture that promotes public trust. However, they are irrelevant in the context of a particular case. Here case-specific probabilities of undetected errors are needed. These should be reported, separately from the match probability, when requested by the court or when there are internal or external indications for error. It should also be made clear that there are various other issues to consider, like DNA transfer. Forensic statistical models, in particular Bayesian networks, may be useful to take the various uncertainties into account and demonstrate their effects on the evidential value of the forensic DNA results. Copyright © 2014 Elsevier Ireland Ltd. All rights reserved.
-
Fast maximum likelihood estimation using continuous-time neural point process models.
Lepage, Kyle Q; MacDonald, Christopher J
2015-06-01
A recent report estimates that the number of simultaneously recorded neurons is growing exponentially. A commonly employed statistical paradigm using discrete-time point process models of neural activity involves the computation of a maximum-likelihood estimate. The time to computate this estimate, per neuron, is proportional to the number of bins in a finely spaced discretization of time. By using continuous-time models of neural activity and the optimally efficient Gaussian quadrature, memory requirements and computation times are dramatically decreased in the commonly encountered situation where the number of parameters p is much less than the number of time-bins n. In this regime, with q equal to the quadrature order, memory requirements are decreased from O(np) to O(qp), and the number of floating-point operations are decreased from O(np(2)) to O(qp(2)). Accuracy of the proposed estimates is assessed based upon physiological consideration, error bounds, and mathematical results describing the relation between numerical integration error and numerical error affecting both parameter estimates and the observed Fisher information. A check is provided which is used to adapt the order of numerical integration. The procedure is verified in simulation and for hippocampal recordings. It is found that in 95 % of hippocampal recordings a q of 60 yields numerical error negligible with respect to parameter estimate standard error. Statistical inference using the proposed methodology is a fast and convenient alternative to statistical inference performed using a discrete-time point process model of neural activity. It enables the employment of the statistical methodology available with discrete-time inference, but is faster, uses less memory, and avoids any error due to discretization.
-
Bastos, Francisco I; Bongertz, Vera; Teixeira, Sylvia Lopes; Morgado, Mariza G; Hacker, Mariana A
2005-02-01
We briefly review findings from Brazilian settings where the human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) epidemic among injection drug users (IDUs) seems to be decreasing, highlighting recent findings from Rio de Janeiro and discussing methodological alternatives. Former analyses using serologic testing algorithm for recent HIV seroconversion have shown that HIV incidence has been low in IDUs recruited by two different surveys carried out in Rio, where low injection frequencies and infection rates have been found among new injectors. The proportion of AIDS cases among IDUs in Rio has been fairly modest, compared to São Paulo and especially to the southernmost states. Notwithstanding, the interpretation of findings from serial surveys constitutes a challenge, magnified in the assessment of HIV spread among IDUs due to the dynamic nature of the drug scenes and limitations of sampling strategies targeting hard-to-reach populations. Assessment of epidemic trends may profit from the triangulation of data, but cannot avert biases associated with sampling errors. Efforts should be made to triangulate data from different sources, besides exploring specific studies from different perspectives. In an attempt to further assess the observed trends, we carried out original analyses using data from Brazilian AIDS databank.
-
Alastruey, Jordi; Khir, Ashraf W; Matthys, Koen S; Segers, Patrick; Sherwin, Spencer J; Verdonck, Pascal R; Parker, Kim H; Peiró, Joaquim
2011-08-11
The accuracy of the nonlinear one-dimensional (1-D) equations of pressure and flow wave propagation in Voigt-type visco-elastic arteries was tested against measurements in a well-defined experimental 1:1 replica of the 37 largest conduit arteries in the human systemic circulation. The parameters required by the numerical algorithm were directly measured in the in vitro setup and no data fitting was involved. The inclusion of wall visco-elasticity in the numerical model reduced the underdamped high-frequency oscillations obtained using a purely elastic tube law, especially in peripheral vessels, which was previously reported in this paper [Matthys et al., 2007. Pulse wave propagation in a model human arterial network: Assessment of 1-D numerical simulations against in vitro measurements. J. Biomech. 40, 3476-3486]. In comparison to the purely elastic model, visco-elasticity significantly reduced the average relative root-mean-square errors between numerical and experimental waveforms over the 70 locations measured in the in vitro model: from 3.0% to 2.5% (p<0.012) for pressure and from 15.7% to 10.8% (p<0.002) for the flow rate. In the frequency domain, average relative errors between numerical and experimental amplitudes from the 5th to the 20th harmonic decreased from 0.7% to 0.5% (p<0.107) for pressure and from 7.0% to 3.3% (p<10(-6)) for the flow rate. These results provide additional support for the use of 1-D reduced modelling to accurately simulate clinically relevant problems at a reasonable computational cost. Copyright © 2011 Elsevier Ltd. All rights reserved.
-
The Effect of Varying Jaw-elevator Muscle Forces on a Finite Element Model of a Human Cranium.
Toro-Ibacache, Viviana; O'Higgins, Paul
2016-07-01
Finite element analyses simulating masticatory system loading are increasingly undertaken in primates, hominin fossils and modern humans. Simplifications of models and loadcases are often required given the limits of data and technology. One such area of uncertainty concerns the forces applied to cranial models and their sensitivity to variations in these forces. We assessed the effect of varying force magnitudes among jaw-elevator muscles applied to a finite element model of a human cranium. The model was loaded to simulate incisor and molar bites using different combinations of muscle forces. Symmetric, asymmetric, homogeneous, and heterogeneous muscle activations were simulated by scaling maximal forces. The effects were compared with respect to strain distribution (i.e., modes of deformation) and magnitudes; bite forces and temporomandibular joint (TMJ) reaction forces. Predicted modes of deformation, strain magnitudes and bite forces were directly proportional to total applied muscle force and relatively insensitive to the degree of heterogeneity of muscle activation. However, TMJ reaction forces and mandibular fossa strains decrease and increase on the balancing and working sides according to the degree of asymmetry of loading. These results indicate that when modes, rather than magnitudes, of facial deformation are of interest, errors in applied muscle forces have limited effects. However the degree of asymmetric loading does impact on TMJ reaction forces and mandibular fossa strains. These findings are of particular interest in relation to studies of skeletal and fossil material, where muscle data are not available and estimation of muscle forces from skeletal proxies is prone to error. Anat Rec, 299:828-839, 2016. © 2016 Wiley Periodicals, Inc. © 2016 Wiley Periodicals, Inc.
-
Context cue-dependent saccadic adaptation in rhesus macaques cannot be elicited using color
Smalianchuk, Ivan; Khanna, Sanjeev B.; Smith, Matthew A.; Gandhi, Neeraj J.
2015-01-01
When the head does not move, rapid movements of the eyes called saccades are used to redirect the line of sight. Saccades are defined by a series of metrical and kinematic (evolution of a movement as a function of time) relationships. For example, the amplitude of a saccade made from one visual target to another is roughly 90% of the distance between the initial fixation point (T0) and the peripheral target (T1). However, this stereotypical relationship between saccade amplitude and initial retinal error (T1-T0) may be altered, either increased or decreased, by surreptitiously displacing a visual target during an ongoing saccade. This form of motor learning (called saccadic adaptation) has been described in both humans and monkeys. Recent experiments in humans and monkeys have suggested that internal (proprioceptive) and external (target shape, color, and/or motion) cues may be used to produce context-dependent adaptation. We tested the hypothesis that an external contextual cue (target color) could be used to evoke differential gain (actual saccade/initial retinal error) states in rhesus monkeys. We did not observe differential gain states correlated with target color regardless of whether targets were displaced along the same vector as the primary saccade or perpendicular to it. Furthermore, this observation held true regardless of whether adaptation trials using various colors and intrasaccade target displacements were randomly intermixed or presented in short or long blocks of trials. These results are consistent with hypotheses that state that color cannot be used as a contextual cue and are interpreted in light of previous studies of saccadic adaptation in both humans and monkeys. PMID:25995353
-
Wonnapinij, Passorn; Chinnery, Patrick F.; Samuels, David C.
2010-01-01
In cases of inherited pathogenic mitochondrial DNA (mtDNA) mutations, a mother and her offspring generally have large and seemingly random differences in the amount of mutated mtDNA that they carry. Comparisons of measured mtDNA mutation level variance values have become an important issue in determining the mechanisms that cause these large random shifts in mutation level. These variance measurements have been made with samples of quite modest size, which should be a source of concern because higher-order statistics, such as variance, are poorly estimated from small sample sizes. We have developed an analysis of the standard error of variance from a sample of size n, and we have defined error bars for variance measurements based on this standard error. We calculate variance error bars for several published sets of measurements of mtDNA mutation level variance and show how the addition of the error bars alters the interpretation of these experimental results. We compare variance measurements from human clinical data and from mouse models and show that the mutation level variance is clearly higher in the human data than it is in the mouse models at both the primary oocyte and offspring stages of inheritance. We discuss how the standard error of variance can be used in the design of experiments measuring mtDNA mutation level variance. Our results show that variance measurements based on fewer than 20 measurements are generally unreliable and ideally more than 50 measurements are required to reliably compare variances with less than a 2-fold difference. PMID:20362273
-
Souvestre, P A; Landrock, C K; Blaber, A P
2008-08-01
Human factors centered aviation accident analyses report that skill based errors are known to be cause of 80% of all accidents, decision making related errors 30% and perceptual errors 6%1. In-flight decision making error is a long time recognized major avenue leading to incidents and accidents. Through the past three decades, tremendous and costly efforts have been developed to attempt to clarify causation, roles and responsibility as well as to elaborate various preventative and curative countermeasures blending state of the art biomedical, technological advances and psychophysiological training strategies. In-flight related statistics have not been shown significantly changed and a significant number of issues remain not yet resolved. Fine Postural System and its corollary, Postural Deficiency Syndrome (PDS), both defined in the 1980's, are respectively neurophysiological and medical diagnostic models that reflect central neural sensory-motor and cognitive controls regulatory status. They are successfully used in complex neurotraumatology and related rehabilitation for over two decades. Analysis of clinical data taken over a ten-year period from acute and chronic post-traumatic PDS patients shows a strong correlation between symptoms commonly exhibited before, along side, or even after error, and sensory-motor or PDS related symptoms. Examples are given on how PDS related central sensory-motor control dysfunction can be correctly identified and monitored via a neurophysiological ocular-vestibular-postural monitoring system. The data presented provides strong evidence that a specific biomedical assessment methodology can lead to a better understanding of in-flight adaptive neurophysiological, cognitive and perceptual dysfunctional status that could induce in flight-errors. How relevant human factors can be identified and leveraged to maintain optimal performance will be addressed.
-
Development and validation of Aviation Causal Contributors for Error Reporting Systems (ACCERS).
Baker, David P; Krokos, Kelley J
2007-04-01
This investigation sought to develop a reliable and valid classification system for identifying and classifying the underlying causes of pilot errors reported under the Aviation Safety Action Program (ASAP). ASAP is a voluntary safety program that air carriers may establish to study pilot and crew performance on the line. In ASAP programs, similar to the Aviation Safety Reporting System, pilots self-report incidents by filing a short text description of the event. The identification of contributors to errors is critical if organizations are to improve human performance, yet it is difficult for analysts to extract this information from text narratives. A taxonomy was needed that could be used by pilots to classify the causes of errors. After completing a thorough literature review, pilot interviews and a card-sorting task were conducted in Studies 1 and 2 to develop the initial structure of the Aviation Causal Contributors for Event Reporting Systems (ACCERS) taxonomy. The reliability and utility of ACCERS was then tested in studies 3a and 3b by having pilots independently classify the primary and secondary causes of ASAP reports. The results provided initial evidence for the internal and external validity of ACCERS. Pilots were found to demonstrate adequate levels of agreement with respect to their category classifications. ACCERS appears to be a useful system for studying human error captured under pilot ASAP reports. Future work should focus on how ACCERS is organized and whether it can be used or modified to classify human error in ASAP programs for other aviation-related job categories such as dispatchers. Potential applications of this research include systems in which individuals self-report errors and that attempt to extract and classify the causes of those events.
-
Giuliani, Manuel; Mirnig, Nicole; Stollnberger, Gerald; Stadler, Susanne; Buchner, Roland; Tscheligi, Manfred
2015-01-01
Human–robot interactions are often affected by error situations that are caused by either the robot or the human. Therefore, robots would profit from the ability to recognize when error situations occur. We investigated the verbal and non-verbal social signals that humans show when error situations occur in human–robot interaction experiments. For that, we analyzed 201 videos of five human–robot interaction user studies with varying tasks from four independent projects. The analysis shows that there are two types of error situations: social norm violations and technical failures. Social norm violations are situations in which the robot does not adhere to the underlying social script of the interaction. Technical failures are caused by technical shortcomings of the robot. The results of the video analysis show that the study participants use many head movements and very few gestures, but they often smile, when in an error situation with the robot. Another result is that the participants sometimes stop moving at the beginning of error situations. We also found that the participants talked more in the case of social norm violations and less during technical failures. Finally, the participants use fewer non-verbal social signals (for example smiling, nodding, and head shaking), when they are interacting with the robot alone and no experimenter or other human is present. The results suggest that participants do not see the robot as a social interaction partner with comparable communication skills. Our findings have implications for builders and evaluators of human–robot interaction systems. The builders need to consider including modules for recognition and classification of head movements to the robot input channels. The evaluators need to make sure that the presence of an experimenter does not skew the results of their user studies. PMID:26217266
-
NASA Astrophysics Data System (ADS)
Lee, Minho; Cho, Nahm-Gyoo
2013-09-01
A new probing and compensation method is proposed to improve the three-dimensional (3D) measuring accuracy of 3D shapes, including irregular surfaces. A new tactile coordinate measuring machine (CMM) probe with a five-degree of freedom (5-DOF) force/moment sensor using carbon fiber plates was developed. The proposed method efficiently removes the anisotropic sensitivity error and decreases the stylus deformation and the actual contact point estimation errors that are major error components of shape measurement using touch probes. The relationship between the measuring force and estimation accuracy of the actual contact point error and stylus deformation error are examined for practical use of the proposed method. The appropriate measuring force condition is presented for the precision measurement.
-
Yazmir, Boris; Reiner, Miriam
2018-05-15
Any motor action is, by nature, potentially accompanied by human errors. In order to facilitate development of error-tailored Brain-Computer Interface (BCI) correction systems, we focused on internal, human-initiated errors, and investigated EEG correlates of user outcome successes and errors during a continuous 3D virtual tennis game against a computer player. We used a multisensory, 3D, highly immersive environment. Missing and repelling the tennis ball were considered, as 'error' (miss) and 'success' (repel). Unlike most previous studies, where the environment "encouraged" the participant to perform a mistake, here errors happened naturally, resulting from motor-perceptual-cognitive processes of incorrect estimation of the ball kinematics, and can be regarded as user internal, self-initiated errors. Results show distinct and well-defined Event-Related Potentials (ERPs), embedded in the ongoing EEG, that differ across conditions by waveforms, scalp signal distribution maps, source estimation results (sLORETA) and time-frequency patterns, establishing a series of typical features that allow valid discrimination between user internal outcome success and error. The significant delay in latency between positive peaks of error- and success-related ERPs, suggests a cross-talk between top-down and bottom-up processing, represented by an outcome recognition process, in the context of the game world. Success-related ERPs had a central scalp distribution, while error-related ERPs were centro-parietal. The unique characteristics and sharp differences between EEG correlates of error/success provide the crucial components for an improved BCI system. The features of the EEG waveform can be used to detect user action outcome, to be fed into the BCI correction system. Copyright © 2016 IBRO. Published by Elsevier Ltd. All rights reserved.
-
Injection Molding Parameters Calculations by Using Visual Basic (VB) Programming
NASA Astrophysics Data System (ADS)
Tony, B. Jain A. R.; Karthikeyen, S.; Alex, B. Jeslin A. R.; Hasan, Z. Jahid Ali
2018-03-01
Now a day’s manufacturing industry plays a vital role in production sectors. To fabricate a component lot of design calculation has to be done. There is a chance of human errors occurs during design calculations. The aim of this project is to create a special module using visual basic (VB) programming to calculate injection molding parameters to avoid human errors. To create an injection mold for a spur gear component the following parameters have to be calculated such as Cooling Capacity, Cooling Channel Diameter, and Cooling Channel Length, Runner Length and Runner Diameter, Gate Diameter and Gate Pressure. To calculate the above injection molding parameters a separate module has been created using Visual Basic (VB) Programming to reduce the human errors. The outcome of the module dimensions is the injection molding components such as mold cavity and core design, ejector plate design.
-
Human error mitigation initiative (HEMI) : summary report.
DOE Office of Scientific and Technical Information (OSTI.GOV)
Stevens, Susan M.; Ramos, M. Victoria; Wenner, Caren A.
2004-11-01
Despite continuing efforts to apply existing hazard analysis methods and comply with requirements, human errors persist across the nuclear weapons complex. Due to a number of factors, current retroactive and proactive methods to understand and minimize human error are highly subjective, inconsistent in numerous dimensions, and are cumbersome to characterize as thorough. An alternative and proposed method begins with leveraging historical data to understand what the systemic issues are and where resources need to be brought to bear proactively to minimize the risk of future occurrences. An illustrative analysis was performed using existing incident databases specific to Pantex weapons operationsmore » indicating systemic issues associated with operating procedures that undergo notably less development rigor relative to other task elements such as tooling and process flow. Future recommended steps to improve the objectivity, consistency, and thoroughness of hazard analysis and mitigation were delineated.« less
-
Giardina, M; Castiglia, F; Tomarchio, E
2014-12-01
Failure mode, effects and criticality analysis (FMECA) is a safety technique extensively used in many different industrial fields to identify and prevent potential failures. In the application of traditional FMECA, the risk priority number (RPN) is determined to rank the failure modes; however, the method has been criticised for having several weaknesses. Moreover, it is unable to adequately deal with human errors or negligence. In this paper, a new versatile fuzzy rule-based assessment model is proposed to evaluate the RPN index to rank both component failure and human error. The proposed methodology is applied to potential radiological over-exposure of patients during high-dose-rate brachytherapy treatments. The critical analysis of the results can provide recommendations and suggestions regarding safety provisions for the equipment and procedures required to reduce the occurrence of accidental events.
-
Liquid Medication Dosing Errors in Children: Role of Provider Counseling Strategies
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.
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.
-
NASA Astrophysics Data System (ADS)
Zhou, Yongbo; Sun, Xuejin; Mielonen, Tero; Li, Haoran; Zhang, Riwei; Li, Yan; Zhang, Chuanliang
2018-01-01
For inhomogeneous cirrus clouds, cloud optical thickness (COT) and effective diameter (De) provided by the Moderate Resolution Imaging Spectrometer (MODIS) Collection 6 cloud products are associated with errors due to the single habit assumption (SHA), independent pixel assumption (IPA), photon absorption effect (PAE), and plane-parallel assumption (PPA). SHA means that every cirrus cloud is assumed to have the same shape habit of ice crystals. IPA errors are caused by three-dimensional (3D) radiative effects. PPA and PAE errors are caused by cloud inhomogeneity. We proposed a method to single out these different errors. These errors were examined using the Spherical Harmonics Discrete Ordinate Method simulations done for the MODIS 0.86 μm and 2.13 μm bands. Four midlatitude and tropical cirrus cases were studied. For the COT retrieval, the impacts of SHA and IPA were especially large for optically thick cirrus cases. SHA errors in COT varied distinctly with scattering angles. For the De retrieval, SHA decreased De under most circumstances. PAE decreased De for optically thick cirrus cases. For the COT and De retrievals, the dominant error source was SHA for overhead sun whereas for oblique sun, it could be any of SHA, IPA, and PAE, varying with cirrus cases and sun-satellite viewing geometries. On the domain average, the SHA errors in COT (De) were within -16.1%-42.6% (-38.7%-2.0%), whereas the 3-D radiative effects- and cloud inhomogeneity-induced errors in COT (De) were within -5.6%-19.6% (-2.9%-8.0%) and -2.6%-0% (-3.7%-9.8%), respectively.
-
DOT National Transportation Integrated Search
1999-11-01
The program implements DOT Human Factors Coordinating Committee (HFCC) recommendations for a coordinated Departmental Human Factors Research Program to advance the human-centered systems approach for enhancing transportation safety. Human error is a ...
-
Johnstone, Megan-Jane; Kanitsaki, Olga
2006-03-01
Nurses globally are required and expected to report nursing errors. As is clearly demonstrated in the international literature, fulfilling this requirement is not, however, without risks. In this discussion paper, the notion of 'nursing error', the practical and moral importance of defining, distinguishing and disclosing nursing errors and how a distinct definition of 'nursing error' fits with the new 'system approach' to human-error management in health care are critiqued. Drawing on international literature and two key case exemplars from the USA and Australia, arguments are advanced to support the view that although it is 'right' for nurses to report nursing errors, it will be very difficult for them to do so unless a non-punitive approach to nursing-error management is adopted.
-
Is adult gait less susceptible than paediatric gait to hip joint centre regression equation error?
Kiernan, D; Hosking, J; O'Brien, T
2016-03-01
Hip joint centre (HJC) regression equation error during paediatric gait has recently been shown to have clinical significance. In relation to adult gait, it has been inferred that comparable errors with children in absolute HJC position may in fact result in less significant kinematic and kinetic error. This study investigated the clinical agreement of three commonly used regression equation sets (Bell et al., Davis et al. and Orthotrak) for adult subjects against the equations of Harrington et al. The relationship between HJC position error and subject size was also investigated for the Davis et al. set. Full 3-dimensional gait analysis was performed on 12 healthy adult subjects with data for each set compared to Harrington et al. The Gait Profile Score, Gait Variable Score and GDI-kinetic were used to assess clinical significance while differences in HJC position between the Davis and Harrington sets were compared to leg length and subject height using regression analysis. A number of statistically significant differences were present in absolute HJC position. However, all sets fell below the clinically significant thresholds (GPS <1.6°, GDI-Kinetic <3.6 points). Linear regression revealed a statistically significant relationship for both increasing leg length and increasing subject height with decreasing error in anterior/posterior and superior/inferior directions. Results confirm a negligible clinical error for adult subjects suggesting that any of the examined sets could be used interchangeably. Decreasing error with both increasing leg length and increasing subject height suggests that the Davis set should be used cautiously on smaller subjects. Copyright © 2016 Elsevier B.V. All rights reserved.
-
DOE Office of Scientific and Technical Information (OSTI.GOV)
Audren, Benjamin; Lesgourgues, Julien; Bird, Simeon
2013-01-01
We present forecasts for the accuracy of determining the parameters of a minimal cosmological model and the total neutrino mass based on combined mock data for a future Euclid-like galaxy survey and Planck. We consider two different galaxy surveys: a spectroscopic redshift survey and a cosmic shear survey. We make use of the Monte Carlo Markov Chains (MCMC) technique and assume two sets of theoretical errors. The first error is meant to account for uncertainties in the modelling of the effect of neutrinos on the non-linear galaxy power spectrum and we assume this error to be fully correlated in Fouriermore » space. The second error is meant to parametrize the overall residual uncertainties in modelling the non-linear galaxy power spectrum at small scales, and is conservatively assumed to be uncorrelated and to increase with the ratio of a given scale to the scale of non-linearity. It hence increases with wavenumber and decreases with redshift. With these two assumptions for the errors and assuming further conservatively that the uncorrelated error rises above 2% at k = 0.4 h/Mpc and z = 0.5, we find that a future Euclid-like cosmic shear/galaxy survey achieves a 1-σ error on M{sub ν} close to 32 meV/25 meV, sufficient for detecting the total neutrino mass with good significance. If the residual uncorrelated errors indeed rises rapidly towards smaller scales in the non-linear regime as we have assumed here then the data on non-linear scales does not increase the sensitivity to the total neutrino mass. Assuming instead a ten times smaller theoretical error with the same scale dependence, the error on the total neutrino mass decreases moderately from σ(M{sub ν}) = 18 meV to 14 meV when mildly non-linear scales with 0.1 h/Mpc < k < 0.6 h/Mpc are included in the analysis of the galaxy survey data.« less
-
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.
-
Cheng, Christopher P; Parker, David; Taylor, Charles A
2002-09-01
Arterial wall shear stress is hypothesized to be an important factor in the localization of atherosclerosis. Current methods to compute wall shear stress from magnetic resonance imaging (MRI) data do not account for flow profiles characteristic of pulsatile flow in noncircular vessel lumens. We describe a method to quantify wall shear stress in large blood vessels by differentiating velocity interpolation functions defined using cine phase-contrast MRI data on a band of elements in the neighborhood of the vessel wall. Validation was performed with software phantoms and an in vitro flow phantom. At an image resolution corresponding to in vivo imaging data of the human abdominal aorta, time-averaged, spatially averaged wall shear stress for steady and pulsatile flow were determined to be within 16% and 23% of the analytic solution, respectively. These errors were reduced to 5% and 8% with doubling in image resolution. For the pulsatile software phantom, the oscillation in shear stress was predicted to within 5%. The mean absolute error of circumferentially resolved shear stress for the nonaxisymmetric phantom decreased from 28% to 15% with a doubling in image resolution. The irregularly shaped phantom and in vitro investigation demonstrated convergence of the calculated values with increased image resolution. We quantified the shear stress at the supraceliac and infrarenal regions of a human abdominal aorta to be 3.4 and 2.3 dyn/cm2, respectively.
-
Motamedzadeh, Majid; Golmohammadi, Rostam; Kazemi, Reza; Heidarimoghadam, Rashid
2017-08-01
Night-shift works are basically accompanied by reduced cognitive performance, sleepiness, and higher possibility for human error and related incidents. It is therefore crucial to improve individuals' performance and alertness in sensitive places like industries' control room with the ultimate goal of increasing efficiency and reducing the number of possible incidents. Previous research has indicated that blue light is a critical cue for entraining circadian rhythm. As a result, the present study was an attempt to investigate whether blue-enriched white light illumination was a practical strategy to decrease sleepiness and improve cognitive performance during night shifts. The study, which adopted a before-after interventional design, was conducted among 30 control room staff members of petrochemical industry. After baseline assessments under existing lighting conditions, every participant was exposed to two new lighting conditions (namely, 17,000K and 6500K blue-enriched white light), each lasting for a week. Assessments were conducted again at the end of these treatments. In order to measure the subjective sleepiness, Karolinska Sleepiness Scale (KSS) was utilized. Subjects also performed the Conners' Continuous Performance Test II (CPT-II) and 1-back test in order to gauge their cognitive performance, and melatonin assessment was carried out using salivary and Eliza technique. The data was analyzed using two-way repeated measure ANOVA. The results indicated that, compared to normal lighting conditions, participants' sleepiness and melatonin rhythm significantly declined when they were exposed to blue-enriched white light. Furthermore, the experimental condition had a significant effect on the reduction of working memory errors. It also decreased omission errors and the reaction time during the sustained attention task. Thus, using blue-enriched white light may be a proper ergonomic strategy for improving performance and alertness, especially during night, in sensitive environments like control rooms. Copyright © 2017 Elsevier Inc. All rights reserved.
-
The error in total error reduction.
Witnauer, James E; Urcelay, Gonzalo P; Miller, Ralph R
2014-02-01
Most models of human and animal learning assume that learning is proportional to the discrepancy between a delivered outcome and the outcome predicted by all cues present during that trial (i.e., total error across a stimulus compound). This total error reduction (TER) view has been implemented in connectionist and artificial neural network models to describe the conditions under which weights between units change. Electrophysiological work has revealed that the activity of dopamine neurons is correlated with the total error signal in models of reward learning. Similar neural mechanisms presumably support fear conditioning, human contingency learning, and other types of learning. Using a computational modeling approach, we compared several TER models of associative learning to an alternative model that rejects the TER assumption in favor of local error reduction (LER), which assumes that learning about each cue is proportional to the discrepancy between the delivered outcome and the outcome predicted by that specific cue on that trial. The LER model provided a better fit to the reviewed data than the TER models. Given the superiority of the LER model with the present data sets, acceptance of TER should be tempered. Copyright © 2013 Elsevier Inc. All rights reserved.
-
Clinical decision-making: heuristics and cognitive biases for the ophthalmologist.
Hussain, Ahsen; Oestreicher, James
Diagnostic errors have a significant impact on health care outcomes and patient care. The underlying causes and development of diagnostic error are complex with flaws in health care systems, as well as human error, playing a role. Cognitive biases and a failure of decision-making shortcuts (heuristics) are human factors that can compromise the diagnostic process. We describe these mechanisms, their role with the clinician, and provide clinical scenarios to highlight the various points at which biases may emerge. We discuss strategies to modify the development and influence of these processes and the vulnerability of heuristics to provide insight and improve clinical outcomes. Copyright © 2017 Elsevier Inc. All rights reserved.
-
NASA Astrophysics Data System (ADS)
Pan, X.; Yang, Y.; Liu, Y.; Fan, X.; Shan, L.; Zhang, X.
2018-04-01
Error source analyses are critical for the satellite-retrieved surface net radiation (Rn) products. In this study, we evaluate the Rn error sources in the Clouds and the Earth's Radiant Energy System (CERES) project at 43 sites from July in 2007 to December in 2007 in China. The results show that cloud fraction (CF), land surface temperature (LST), atmospheric temperature (AT) and algorithm error dominate the Rn error, with error contributions of -20, 15, 10 and 10 W/m2 (net shortwave (NSW)/longwave (NLW) radiation), respectively. For NSW, the dominant error source is algorithm error (more than 10 W/m2), particularly in spring and summer with abundant cloud. For NLW, due to the high sensitivity of algorithm and large LST/CF error, LST and CF are the largest error sources, especially in northern China. The AT influences the NLW error large in southern China because of the large AT error in there. The total precipitable water has weak influence on Rn error even with the high sensitivity of algorithm. In order to improve Rn quality, CF and LST (AT) error in northern (southern) China should be decreased.
-
NASA Technical Reports Server (NTRS)
Warner, Thomas T.; Key, Lawrence E.; Lario, Annette M.
1989-01-01
The effects of horizontal and vertical data resolution, data density, data location, different objective analysis algorithms, and measurement error on mesoscale-forecast accuracy are studied with observing-system simulation experiments. Domain-averaged errors are shown to generally decrease with time. It is found that the vertical distribution of error growth depends on the initial vertical distribution of the error itself. Larger gravity-inertia wave noise is produced in forecasts with coarser vertical data resolution. The use of a low vertical resolution observing system with three data levels leads to more forecast errors than moderate and high vertical resolution observing systems with 8 and 14 data levels. Also, with poor vertical resolution in soundings, the initial and forecast errors are not affected by the horizontal data resolution.
-
46 CFR 520.14 - Special permission.
Code of Federal Regulations, 2010 CFR
2010-10-01
... the Commission, in its discretion and for good cause shown, to permit increases or decreases in rates... its discretion and for good cause shown, permit departures from the requirements of this part. (b) Clerical errors. Typographical and/or clerical errors constitute good cause for the exercise of special...
-
46 CFR 520.14 - Special permission.
Code of Federal Regulations, 2011 CFR
2011-10-01
... the Commission, in its discretion and for good cause shown, to permit increases or decreases in rates... its discretion and for good cause shown, permit departures from the requirements of this part. (b) Clerical errors. Typographical and/or clerical errors constitute good cause for the exercise of special...
-
Meiotic Divisions: No Place for Gender Equality.
El Yakoubi, Warif; Wassmann, Katja
2017-01-01
In multicellular organisms the fusion of two gametes with a haploid set of chromosomes leads to the formation of the zygote, the first cell of the embryo. Accurate execution of the meiotic cell division to generate a female and a male gamete is required for the generation of healthy offspring harboring the correct number of chromosomes. Unfortunately, meiosis is error prone. This has severe consequences for fertility and under certain circumstances, health of the offspring. In humans, female meiosis is extremely error prone. In this chapter we will compare male and female meiosis in humans to illustrate why and at which frequency errors occur, and describe how this affects pregnancy outcome and health of the individual. We will first introduce key notions of cell division in meiosis and how they differ from mitosis, followed by a detailed description of the events that are prone to errors during the meiotic divisions.
-
[Relations between health information systems and patient safety].
Nøhr, Christian
2012-11-05
Health information systems have the potential to reduce medical errors, and indeed many studies have shown a significant reduction. However, if the systems are not designed and implemented properly, there is evidence that suggest that new types of errors will arise--i.e., technology-induced errors. Health information systems will need to undergo a more rigorous evaluation. Usability evaluation and simulation test with humans in the loop can help to detect and prevent technology-induced errors before they are deployed in real health-care settings.
-
Comparison of students from private and public schools on the spelling performance.
Silva, Nathane Sanches Marques; Crenitte, Patrícia Abreu Pinheiro
2015-01-01
To compare the spelling ability of schoolchildren from the fourth to sixth grades of the elementary schools in the private and public schools of Bauru, São Paulo, and to verify whether errors are overcome as studies progress and the hierarchy of errors as to how often they occur. A dictation was applied to 384 schoolchildren: 206 from the private schools: 74 were at the fourth grade, 65 at the fifth grade, and 67 at the sixth grade; and 178 from the public schools; 56 at the fourth grade, 63 at the fifth grade, and 59 at the sixth grade of elementary school. Student's t test was used. In comparison of total spelling errors score, difference was found among the fourth and sixth grades of the private and public schools. Spelling errors decreased as education progressed, and those related to language irregularities were more common. Spelling ability and performance of students from the private and public schools are not similar in the fourth and sixth grades, but it is in the fifth grade. Spelling errors are gradually overcome as education progresses; however, this overcome rate was considerable between the fourth and fifth grades in the public schools. Decrease in the types of spelling errors follows a hierarchy of categories: phoneme/grapheme conversion, simple contextual rules, complex contextual rules, and language irregularities. Finally, the most common type of spelling error found was that related to language irregularities.
-
Effect of tumor amplitude and frequency on 4D modeling of Vero4DRT system.
Miura, Hideharu; Ozawa, Shuichi; Hayata, Masahiro; Tsuda, Shintaro; Yamada, Kiyoshi; Nagata, Yasushi
2017-01-01
An important issue in indirect dynamic tumor tracking with the Vero4DRT system is the accuracy of the model predictions of the internal target position based on surrogate infrared (IR) marker measurement. We investigated the predictive uncertainty of 4D modeling using an external IR marker, focusing on the effect of the target and surrogate amplitudes and periods. A programmable respiratory motion table was used to simulate breathing induced organ motion. Sinusoidal motion sequences were produced by a dynamic phantom with different amplitudes and periods. To investigate the 4D modeling error, the following amplitudes (peak-to-peak: 10-40 mm) and periods (2-8 s) were considered. The 95th percentile 4D modeling error (4D- E 95% ) between the detected and predicted target position ( μ + 2SD) was calculated to investigate the 4D modeling error. 4D- E 95% was linearly related to the target motion amplitude with a coefficient of determination R 2 = 0.99 and ranged from 0.21 to 0.88 mm. The 4D modeling error ranged from 1.49 to 0.14 mm and gradually decreased with increasing target motion period. We analyzed the predictive error in 4D modeling and the error due to the amplitude and period of target. 4D modeling error substantially increased with increasing amplitude and decreasing period of the target motion.
-
Diagnostic Error in Stroke-Reasons and Proposed Solutions.
Bakradze, Ekaterina; Liberman, Ava L
2018-02-13
We discuss the frequency of stroke misdiagnosis and identify subgroups of stroke at high risk for specific diagnostic errors. In addition, we review common reasons for misdiagnosis and propose solutions to decrease error. According to a recent report by the National Academy of Medicine, most people in the USA are likely to experience a diagnostic error during their lifetimes. Nearly half of such errors result in serious disability and death. Stroke misdiagnosis is a major health care concern, with initial misdiagnosis estimated to occur in 9% of all stroke patients in the emergency setting. Under- or missed diagnosis (false negative) of stroke can result in adverse patient outcomes due to the preclusion of acute treatments and failure to initiate secondary prevention strategies. On the other hand, the overdiagnosis of stroke can result in inappropriate treatment, delayed identification of actual underlying disease, and increased health care costs. Young patients, women, minorities, and patients presenting with non-specific, transient, or posterior circulation stroke symptoms are at increased risk of misdiagnosis. Strategies to decrease diagnostic error in stroke have largely focused on early stroke detection via bedside examination strategies and a clinical decision rules. Targeted interventions to improve the diagnostic accuracy of stroke diagnosis among high-risk groups as well as symptom-specific clinical decision supports are needed. There are a number of open questions in the study of stroke misdiagnosis. To improve patient outcomes, existing strategies to improve stroke diagnostic accuracy should be more broadly adopted and novel interventions devised and tested to reduce diagnostic errors.
-
DOE Office of Scientific and Technical Information (OSTI.GOV)
Cournoyer, Michael E.; Trujillo, Stanley; Lawton, Cindy M.
A traditional view of incidents is that they are caused by shortcomings in human competence, attention, or attitude. It may be under the label of “loss of situational awareness,” procedure “violation,” or “poor” management. A different view is that human error is not the cause of failure, but a symptom of failure – trouble deeper inside the system. In this perspective, human error is not the conclusion, but rather the starting point of investigations. During an investigation, three types of information are gathered: physical, documentary, and human (recall/experience). Through the causal analysis process, apparent cause or apparent causes are identifiedmore » as the most probable cause or causes of an incident or condition that management has the control to fix and for which effective recommendations for corrective actions can be generated. A causal analysis identifies relevant human performance factors. In the following presentation, the anatomy of a radiological incident is discussed, and one case study is presented. We analyzed the contributing factors that caused a radiological incident. When underlying conditions, decisions, actions, and inactions that contribute to the incident are identified. This includes weaknesses that may warrant improvements that tolerate error. Measures that reduce consequences or likelihood of recurrence are discussed.« less
-
Cournoyer, Michael E.; Trujillo, Stanley; Lawton, Cindy M.; ...
2016-03-23
A traditional view of incidents is that they are caused by shortcomings in human competence, attention, or attitude. It may be under the label of “loss of situational awareness,” procedure “violation,” or “poor” management. A different view is that human error is not the cause of failure, but a symptom of failure – trouble deeper inside the system. In this perspective, human error is not the conclusion, but rather the starting point of investigations. During an investigation, three types of information are gathered: physical, documentary, and human (recall/experience). Through the causal analysis process, apparent cause or apparent causes are identifiedmore » as the most probable cause or causes of an incident or condition that management has the control to fix and for which effective recommendations for corrective actions can be generated. A causal analysis identifies relevant human performance factors. In the following presentation, the anatomy of a radiological incident is discussed, and one case study is presented. We analyzed the contributing factors that caused a radiological incident. When underlying conditions, decisions, actions, and inactions that contribute to the incident are identified. This includes weaknesses that may warrant improvements that tolerate error. Measures that reduce consequences or likelihood of recurrence are discussed.« less
-
Acoustothermometric study of the human hand under hyperthrmia and hypothermia
NASA Astrophysics Data System (ADS)
Anosov, A. A.; Belyaev, R. V.; Vilkov, V. A.; Dvornikova, M. V.; Dvornikova, V. V.; Kazanskii, A. S.; Kuryatnikova, N. A.; Mansfel'd, A. D.
2013-01-01
The results of an acoustothermometric study of the human hand under local hyperthermia and hypothermia are presented. Individuals under testing plunged their hands in hot or cold water for several minutes. Thermal acoustic radiation was detected by two sensors placed near the palm and near the backside of the tested hand. The internal temperature profiles of the hand were reconstructed. The indirect estimate of the reconstruction error was 0.6°C, which is acceptable for medical applications. Hyperthermia was achieved by placing the hand in water with a maximal temperature of 44°C for 2 min. In this case, the internal temperature was 35.4 ± 0.6°C. Hypothermia was achieved by placing the hand in water with a temperature of 17.8°C for 15 min. In this case, the internal temperature decreased from 26 to 24°C. The use of a four-sensor planar receiving array allowed dynamic mapping of the acoustic brightness temperature of the hand.
-
NASA Astrophysics Data System (ADS)
Watanabe, Y.; Abe, S.
2014-06-01
Terrestrial neutron-induced soft errors in MOSFETs from a 65 nm down to a 25 nm design rule are analyzed by means of multi-scale Monte Carlo simulation using the PHITS-HyENEXSS code system. Nuclear reaction models implemented in PHITS code are validated by comparisons with experimental data. From the analysis of calculated soft error rates, it is clarified that secondary He and H ions provide a major impact on soft errors with decreasing critical charge. It is also found that the high energy component from 10 MeV up to several hundreds of MeV in secondary cosmic-ray neutrons has the most significant source of soft errors regardless of design rule.
-
Effects of Tropospheric Spatio-Temporal Correlated Noise on the Analysis of Space Geodetic Data
NASA Technical Reports Server (NTRS)
Romero-Wolf, A. F.; Jacobs, C. S.
2011-01-01
The standard VLBI analysis models measurement noise as purely thermal errors modeled according to uncorrelated Gaussian distributions. As the price of recording bits steadily decreases, thermal errors will soon no longer dominate. It is therefore expected that troposphere and instrumentation/clock errors will increasingly become more dominant. Given that both of these errors have correlated spectra, properly modeling the error distributions will become more relevant for optimal analysis. This paper will discuss the advantages of including the correlations between tropospheric delays using a Kolmogorov spectrum and the frozen ow model pioneered by Treuhaft and Lanyi. We will show examples of applying these correlated noise spectra to the weighting of VLBI data analysis.
-
An educational and audit tool to reduce prescribing error in intensive care.
Thomas, A N; Boxall, E M; Laha, S K; Day, A J; Grundy, D
2008-10-01
To reduce prescribing errors in an intensive care unit by providing prescriber education in tutorials, ward-based teaching and feedback in 3-monthly cycles with each new group of trainee medical staff. Prescribing audits were conducted three times in each 3-month cycle, once pretraining, once post-training and a final audit after 6 weeks. The audit information was fed back to prescribers with their correct prescribing rates, rates for individual error types and total error rates together with anonymised information about other prescribers' error rates. The percentage of prescriptions with errors decreased over each 3-month cycle (pretraining 25%, 19%, (one missing data point), post-training 23%, 6%, 11%, final audit 7%, 3%, 5% (p<0.0005)). The total number of prescriptions and error rates varied widely between trainees (data collection one; cycle two: range of prescriptions written: 1-61, median 18; error rate: 0-100%; median: 15%). Prescriber education and feedback reduce manual prescribing errors in intensive care.
-
Rathert, Cheryl; May, Douglas R
2007-01-01
Experts continue to decry the lack of progress made in decreasing the alarming frequency of medical errors in health care organizations (Leape, L. L., & Berwick, D. M. (2005). Five years after to err is human: What have we learned?. Journal of the American Medical Association, 293(19), 2384-2390). At the same time, other experts are concerned about the lack of job satisfaction and turnover among nurses (. Keeping patients safe: Transforming the work environment of nurses. Washington, DC: National Academy Press). Research and theory suggest that a work environment that facilitates patient-centered care should increase patient safety and nurse satisfaction. The present study began with a conceptual model that specifies how work environment variables should be related to both nurse and patient outcomes. Specifically, we proposed that health care work units with climates for patient-centered care should have nurses who are more satisfied with their jobs. Such units should also have higher levels of patient safety, with fewer medication errors. We examined perceptions of nurses from three acute care hospitals in the eastern United States. Nurses who perceived their work units as more patient centered were significantly more satisfied with their jobs than were those whose units were perceived as less patient centered. Those whose work units were more patient centered reported that medication errors occurred less frequently in their units and said that they felt more comfortable reporting errors and near-misses than those in less patient-centered units. Patients and quality leaders continue to call for delivery of patient-centered care. If climates that facilitate such care are also related to improved patient safety and nurse satisfaction, proactive, patient-centered management of the work environment could result in improved patient, employee, and organizational outcomes.
-
Automated brainstem co-registration (ABC) for MRI.
Napadow, Vitaly; Dhond, Rupali; Kennedy, David; Hui, Kathleen K S; Makris, Nikos
2006-09-01
Group data analysis in brainstem neuroimaging is predicated on accurate co-registration of anatomy. As the brainstem is comprised of many functionally heterogeneous nuclei densely situated adjacent to one another, relatively small errors in co-registration can manifest in increased variance or decreased sensitivity (or significance) in detecting activations. We have devised a 2-stage automated, reference mask guided registration technique (Automated Brainstem Co-registration, or ABC) for improved brainstem co-registration. Our approach utilized a brainstem mask dataset to weight an automated co-registration cost function. Our method was validated through measurement of RMS error at 12 manually defined landmarks. These landmarks were also used as guides for a secondary manual co-registration option, intended for outlier individuals that may not adequately co-register with our automated method. Our methodology was tested on 10 healthy human subjects and compared to traditional co-registration techniques (Talairach transform and automated affine transform to the MNI-152 template). We found that ABC had a significantly lower mean RMS error (1.22 +/- 0.39 mm) than Talairach transform (2.88 +/- 1.22 mm, mu +/- sigma) and the global affine (3.26 +/- 0.81 mm) method. Improved accuracy was also found for our manual-landmark-guided option (1.51 +/- 0.43 mm). Visualizing individual brainstem borders demonstrated more consistent and uniform overlap for ABC compared to traditional global co-registration techniques. Improved robustness (lower susceptibility to outliers) was demonstrated with ABC through lower inter-subject RMS error variance compared with traditional co-registration methods. The use of easily available and validated tools (AFNI and FSL) for this method should ease adoption by other investigators interested in brainstem data group analysis.
-
Vanderhoof, Melanie; Distler, Hayley; Mendiola, Di Ana; Lang, Megan
2017-01-01
Natural variability in surface-water extent and associated characteristics presents a challenge to gathering timely, accurate information, particularly in environments that are dominated by small and/or forested wetlands. This study mapped inundation extent across the Upper Choptank River Watershed on the Delmarva Peninsula, occurring within both Maryland and Delaware. We integrated six quad-polarized Radarsat-2 images, Worldview-3 imagery, and an enhanced topographic wetness index in a random forest model. Output maps were filtered using light detection and ranging (lidar)-derived depressions to maximize the accuracy of forested inundation extent. Overall accuracy within the integrated and filtered model was 94.3%, with 5.5% and 6.0% errors of omission and commission for inundation, respectively. Accuracy of inundation maps obtained using Radarsat-2 alone were likely detrimentally affected by less than ideal angles of incidence and recent precipitation, but were likely improved by targeting the period between snowmelt and leaf-out for imagery collection. Across the six Radarsat-2 dates, filtering inundation outputs by lidar-derived depressions slightly elevated errors of omission for water (+1.0%), but decreased errors of commission (−7.8%), resulting in an average increase of 5.4% in overall accuracy. Depressions were derived from lidar datasets collected under both dry and average wetness conditions. Although antecedent wetness conditions influenced the abundance and total area mapped as depression, the two versions of the depression datasets showed a similar ability to reduce error in the inundation maps. Accurate mapping of surface water is critical to predicting and monitoring the effect of human-induced change and interannual variability on water quantity and quality.
-
Ardekani, Siamak; Selva, Luis; Sayre, James; Sinha, Usha
2006-11-01
Single-shot echo-planar based diffusion tensor imaging is prone to geometric and intensity distortions. Parallel imaging is a means of reducing these distortions while preserving spatial resolution. A quantitative comparison at 3 T of parallel imaging for diffusion tensor images (DTI) using k-space (generalized auto-calibrating partially parallel acquisitions; GRAPPA) and image domain (sensitivity encoding; SENSE) reconstructions at different acceleration factors, R, is reported here. Images were evaluated using 8 human subjects with repeated scans for 2 subjects to estimate reproducibility. Mutual information (MI) was used to assess the global changes in geometric distortions. The effects of parallel imaging techniques on random noise and reconstruction artifacts were evaluated by placing 26 regions of interest and computing the standard deviation of apparent diffusion coefficient and fractional anisotropy along with the error of fitting the data to the diffusion model (residual error). The larger positive values in mutual information index with increasing R values confirmed the anticipated decrease in distortions. Further, the MI index of GRAPPA sequences for a given R factor was larger than the corresponding mSENSE images. The residual error was lowest in the images acquired without parallel imaging and among the parallel reconstruction methods, the R = 2 acquisitions had the least error. The standard deviation, accuracy, and reproducibility of the apparent diffusion coefficient and fractional anisotropy in homogenous tissue regions showed that GRAPPA acquired with R = 2 had the least amount of systematic and random noise and of these, significant differences with mSENSE, R = 2 were found only for the fractional anisotropy index. Evaluation of the current implementation of parallel reconstruction algorithms identified GRAPPA acquired with R = 2 as optimal for diffusion tensor imaging.
-
A Simple Model Predicting Individual Weight Change in Humans
Thomas, Diana M.; Martin, Corby K.; Heymsfield, Steven; Redman, Leanne M.; Schoeller, Dale A.; Levine, James A.
2010-01-01
Excessive weight in adults is a national concern with over 2/3 of the US population deemed overweight. Because being overweight has been correlated to numerous diseases such as heart disease and type 2 diabetes, there is a need to understand mechanisms and predict outcomes of weight change and weight maintenance. A simple mathematical model that accurately predicts individual weight change offers opportunities to understand how individuals lose and gain weight and can be used to foster patient adherence to diets in clinical settings. For this purpose, we developed a one dimensional differential equation model of weight change based on the energy balance equation is paired to an algebraic relationship between fat free mass and fat mass derived from a large nationally representative sample of recently released data collected by the Centers for Disease Control. We validate the model's ability to predict individual participants’ weight change by comparing model estimates of final weight data from two recent underfeeding studies and one overfeeding study. Mean absolute error and standard deviation between model predictions and observed measurements of final weights are less than 1.8 ± 1.3 kg for the underfeeding studies and 2.5 ± 1.6 kg for the overfeeding study. Comparison of the model predictions to other one dimensional models of weight change shows improvement in mean absolute error, standard deviation of mean absolute error, and group mean predictions. The maximum absolute individual error decreased by approximately 60% substantiating reliability in individual weight change predictions. The model provides a viable method for estimating individual weight change as a result of changes in intake and determining individual dietary adherence during weight change studies. PMID:24707319
-
NASA Astrophysics Data System (ADS)
Raju, P. V. S.; Potty, Jayaraman; Mohanty, U. C.
2011-09-01
Comprehensive sensitivity analyses on physical parameterization schemes of Weather Research Forecast (WRF-ARW core) model have been carried out for the prediction of track and intensity of tropical cyclones by taking the example of cyclone Nargis, which formed over the Bay of Bengal and hit Myanmar on 02 May 2008, causing widespread damages in terms of human and economic losses. The model performances are also evaluated with different initial conditions of 12 h intervals starting from the cyclogenesis to the near landfall time. The initial and boundary conditions for all the model simulations are drawn from the global operational analysis and forecast products of National Center for Environmental Prediction (NCEP-GFS) available for the public at 1° lon/lat resolution. The results of the sensitivity analyses indicate that a combination of non-local parabolic type exchange coefficient PBL scheme of Yonsei University (YSU), deep and shallow convection scheme with mass flux approach for cumulus parameterization (Kain-Fritsch), and NCEP operational cloud microphysics scheme with diagnostic mixed phase processes (Ferrier), predicts better track and intensity as compared against the Joint Typhoon Warning Center (JTWC) estimates. Further, the final choice of the physical parameterization schemes selected from the above sensitivity experiments is used for model integration with different initial conditions. The results reveal that the cyclone track, intensity and time of landfall are well simulated by the model with an average intensity error of about 8 hPa, maximum wind error of 12 m s-1and track error of 77 km. The simulations also show that the landfall time error and intensity error are decreasing with delayed initial condition, suggesting that the model forecast is more dependable when the cyclone approaches the coast. The distribution and intensity of rainfall are also well simulated by the model and comparable with the TRMM estimates.
-
Application of manual control theory to the study of biological stress
NASA Technical Reports Server (NTRS)
Replogle, C. R.; Holden, F. M.; Iay, C. N.
1972-01-01
A study was run using both a stable, third-order task and an adaptive first-order unstable task singly and in combination to test the effects of 2 min hypoxia (22000 ft) on human operator. The results indicate that the RMS error in the stable task does not change as a function of hypoxic stress whereas the error in an unstable task changes significantly. Models involving human operator parameter changes and noise injection are discussed.
-
Effects of an Environmental Education Course on Consensus Estimates for Proenvironmental Intentions
ERIC Educational Resources Information Center
Hovardas, Tasos; Korfiatis, Konstantinos
2012-01-01
An environmental education intervention in a university conservation-related course was designed to decrease students' errors in consensus estimates for proenvironmental intentions, that is, their errors in guessing their classmates' proenvironmental intentions. Before and after the course, the authors measured two intentions regarding willingness…
-
Proposed Interventions to Decrease the Frequency of Missed Test Results
ERIC Educational Resources Information Center
Wahls, Terry L.; Cram, Peter
2009-01-01
Numerous studies have identified that delays in diagnosis related to the mishandling of abnormal test results are an import contributor to diagnostic errors. Factors contributing to missed results included organizational factors, provider factors and patient-related factors. At the diagnosis error conference continuing medical education conference…
-
21st Century Human Performance.
ERIC Educational Resources Information Center
Clark, Ruth Colvin
1995-01-01
Technology can extend human memory and improve performance, but bypassing human intelligence has its dangers. Cognitive apprenticeships that compress learning experiences, provide coaching, and allow trial and error can build complex problem-solving skills and develop expertise. (SK)
-
NASA Astrophysics Data System (ADS)
Zhou, Yanru; Zhao, Yuxiang; Tian, Hui; Zhang, Dengwei; Huang, Tengchao; Miao, Lijun; Shu, Xiaowu; Che, Shuangliang; Liu, Cheng
2016-12-01
In an axial magnetic field (AMF), which is vertical to the plane of the fiber coil, a polarization-maintaining fiber optic gyro (PM-FOG) appears as an axial magnetic error. This error is linearly related to the intensity of an AMF, the radius of the fiber coil, and the light wavelength, and also influenced by the distribution of fiber twist. When a PM-FOG is manufactured completely, this error only appears a linear correlation with the AMF. A real-time compensation model is established to eliminate the error, and the experimental results show that the axial magnetic error of the PM-FOG is decreased from 5.83 to 0.09 deg/h in 12G AMF with 18-dB suppression.
-
Steer-PROP: a GRASE-PROPELLER sequence with interecho steering gradient pulses.
Srinivasan, Girish; Rangwala, Novena; Zhou, Xiaohong Joe
2018-05-01
This study demonstrates a novel PROPELLER (periodically rotated overlapping parallel lines with enhanced reconstruction) pulse sequence, termed Steer-PROP, based on gradient and spin echo (GRASE), to reduce the imaging times and address phase errors inherent to GRASE. The study also illustrates the feasibility of using Steer-PROP as an alternative to single-shot echo planar imaging (SS-EPI) to produce distortion-free diffusion images in all imaging planes. Steer-PROP uses a series of blip gradient pulses to produce N (N = 3-5) adjacent k-space blades in each repetition time, where N is the number of gradient echoes in a GRASE sequence. This sampling strategy enables a phase correction algorithm to systematically address the GRASE phase errors as well as the motion-induced phase inconsistency. Steer-PROP was evaluated on phantoms and healthy human subjects at both 1.5T and 3.0T for T 2 - and diffusion-weighted imaging. Steer-PROP produced similar image quality as conventional PROPELLER based on fast spin echo (FSE), while taking only a fraction (e.g., 1/3) of the scan time. The robustness against motion in Steer-PROP was comparable to that of FSE-based PROPELLER. Using Steer-PROP, high quality and distortion-free diffusion images were obtained from human subjects in all imaging planes, demonstrating a considerable advantage over SS-EPI. The proposed Steer-PROP sequence can substantially reduce the scan times compared with FSE-based PROPELLER while achieving adequate image quality. The novel k-space sampling strategy in Steer-PROP not only enables an integrated phase correction method that addresses various sources of phase errors, but also minimizes the echo spacing compared with alternative sampling strategies. Steer-PROP can also be a viable alternative to SS-EPI to decrease image distortion in all imaging planes. Magn Reson Med 79:2533-2541, 2018. © 2017 International Society for Magnetic Resonance in Medicine. © 2017 International Society for Magnetic Resonance in Medicine.
-
Graf, Heiko; Metzger, Coraline D; Walter, Martin; Abler, Birgit
2016-01-06
Investigating the effects of serotonergic antidepressants on neural correlates of visual erotic stimulation revealed decreased reactivity within the dopaminergic reward network along with decreased subjective sexual functioning compared with placebo. However, a global dampening of the reward system under serotonergic drugs is not intuitive considering clinical observations of their beneficial effects in the treatment of depression. Particularly, learning signals as coded in prediction error processing within the dopaminergic reward system can be assumed to be rather enhanced as antidepressant drugs have been demonstrated to facilitate the efficacy of psychotherapeutic interventions relying on learning processes. Within the same study sample, we now explored the effects of serotonergic and dopaminergic/noradrenergic antidepressants on prediction error signals compared with placebo by functional MRI. A total of 17 healthy male participants (mean age: 25.4 years) were investigated under the administration of paroxetine, bupropion and placebo for 7 days each within a randomized, double-blind, within-subject cross-over design. During functional MRI, we used an established monetary incentive task to explore neural prediction error signals within the bilateral nucleus accumbens as region of interest within the dopaminergic reward system. In contrast to diminished neural activations and subjective sexual functioning under the serotonergic agent paroxetine under visual erotic stimulation, we revealed unaffected or even enhanced neural prediction error processing within the nucleus accumbens under this antidepressant along with unaffected behavioural processing. Our study provides evidence that serotonergic antidepressants facilitate prediction error signalling and may support suggestions of beneficial effects of these agents on reinforced learning as an essential element in behavioural psychotherapy.
-
Blood specimen labelling errors: Implications for nephrology nursing practice.
Duteau, Jennifer
2014-01-01
Patient safety is the foundation of high-quality health care, as recognized both nationally and worldwide. Patient blood specimen identification is critical in ensuring the delivery of safe and appropriate care. The practice of nephrology nursing involves frequent patient blood specimen withdrawals to treat and monitor kidney disease. A critical review of the literature reveals that incorrect patient identification is one of the major causes of blood specimen labelling errors. Misidentified samples create a serious risk to patient safety leading to multiple specimen withdrawals, delay in diagnosis, misdiagnosis, incorrect treatment, transfusion reactions, increased length of stay and other negative patient outcomes. Barcode technology has been identified as a preferred method for positive patient identification leading to a definitive decrease in blood specimen labelling errors by as much as 83% (Askeland, et al., 2008). The use of a root cause analysis followed by an action plan is one approach to decreasing the occurrence of blood specimen labelling errors. This article will present a review of the evidence-based literature surrounding blood specimen labelling errors, followed by author recommendations for completing a root cause analysis and action plan. A failure modes and effects analysis (FMEA) will be presented as one method to determine root cause, followed by the Ottawa Model of Research Use (OMRU) as a framework for implementation of strategies to reduce blood specimen labelling errors.
-
McComas, Jeffery; Riingen, Michelle; Chae Kim, Son
2014-12-01
The study aims were to evaluate the impact of electronic medication administration record implementation on medication administration efficiency and occurrence of medication errors as well as to identify the predictors of medication administration efficiency in an acute care setting. A prospective, observational study utilizing time-and-motion technique was conducted before and after electronic medication administration record implementation in November 2011. A total of 156 cases of medication administration activities (78 pre- and 78 post-electronic medication administration record) involving 38 nurses were observed at the point of care. A separate retrospective review of the hospital Midas+ medication error database was also performed to collect the rates and origin of medication errors for 6 months before and after electronic medication administration record implementation. The mean medication administration time actually increased from 11.3 to 14.4 minutes post-electronic medication administration record (P = .039). In a multivariate analysis, electronic medication administration record was not a predictor of medication administration time, but the distractions/interruptions during medication administration process were significant predictors. The mean hospital-wide medication errors significantly decreased from 11.0 to 5.3 events per month post-electronic medication administration record (P = .034). Although no improvement in medication administration efficiency was observed, electronic medication administration record improved the quality of care with a significant decrease in medication errors.
-
Safety margins in older adults increase with improved control of a dynamic object
Hasson, Christopher J.; Sternad, Dagmar
2014-01-01
Older adults face decreasing motor capabilities due to pervasive neuromuscular degradations. As a consequence, errors in movement control increase. Thus, older individuals should maintain larger safety margins than younger adults. While this has been shown for object manipulation tasks, several reports on whole-body activities, such as posture and locomotion, demonstrate age-related reductions in safety margins. This is despite increased costs for control errors, such as a fall. We posit that this paradox could be explained by the dynamic challenge presented by the body or also an external object, and that age-related reductions in safety margins are in part due to a decreased ability to control dynamics. To test this conjecture we used a virtual ball-in-cup task that had challenging dynamics, yet afforded an explicit rendering of the physics and safety margin. The hypotheses were: (1) When manipulating an object with challenging dynamics, older adults have smaller safety margins than younger adults. (2) Older adults increase their safety margins with practice. Nine young and 10 healthy older adults practiced moving the virtual ball-in-cup to a target location in exactly 2 s. The accuracy and precision of the timing error quantified skill, and the ball energy relative to an escape threshold quantified the safety margin. Compared to the young adults, older adults had increased timing errors, greater variability, and decreased safety margins. With practice, both young and older adults improved their ability to control the object with decreased timing errors and variability, and increased their safety margins. These results suggest that safety margins are related to the ability to control dynamics, and may explain why in tasks with simple dynamics older adults use adequate safety margins, but in more complex tasks, safety margins may be inadequate. Further, the results indicate that task-specific training may improve safety margins in older adults. PMID:25071566
-
Mental fatigue and impaired response processes: event-related brain potentials in a Go/NoGo task.
Kato, Yuichiro; Endo, Hiroshi; Kizuka, Tomohiro
2009-05-01
The effects of mental fatigue on the availability of cognitive resources and associated response-related processes were examined using event-related brain potentials. Subjects performed a Go/NoGo task for 60 min. Reaction time, number of errors, and mental fatigue scores all significantly increased with time spent on the task. The NoGo-P3 amplitude significantly decreased with time on task, but the Go-P3 amplitude was not modulated. The amplitude of error-related negativity (Ne/ERN) also decreased with time on task. These results indicate that mental fatigue attenuates resource allocation and error monitoring for NoGo stimuli. The Go- and NoGo-P3 latencies both increased with time on task, indicative of a delay in stimulus evaluation time due to mental fatigue. NoGo-N2 latency increased with time on task, but NoGo-N2 amplitude was not modulated. The amplitude of response-locked lateralized readiness potential (LRP) significantly decreased with time on task. Mental fatigue appears to slows down the time course of response inhibition, and impairs the intensity of response execution.
-
Addressing Medical Errors in Hand Surgery
Johnson, Shepard P.; Adkinson, Joshua M.; Chung, Kevin C.
2014-01-01
Influential think-tank such as the Institute of Medicine has raised awareness about the implications of medical errors. In response, organizations, medical societies, and institutions have initiated programs to decrease the incidence and effects of these errors. Surgeons deal with the direct implications of adverse events involving patients. In addition to managing the physical consequences, they are confronted with ethical and social issues when caring for a harmed patient. Although there is considerable effort to implement system-wide changes, there is little guidance for hand surgeons on how to address medical errors. Admitting an error is difficult, but a transparent environment where patients are notified of errors and offered consolation and compensation is essential to maintain trust. Further, equipping hand surgeons with a guide for addressing medical errors will promote compassionate patient interaction, help identify system failures, provide learning points for safety improvement, and demonstrate a commitment to ethically responsible medical care. PMID:25154576
-
Human error in hospitals and industrial accidents: current concepts.
Spencer, F C
2000-10-01
Most data concerning errors and accidents are from industrial accidents and airline injuries. General Electric, Alcoa, and Motorola, among others, all have reported complex programs that resulted in a marked reduction in frequency of worker injuries. In the field of medicine, however, with the outstanding exception of anesthesiology, there is a paucity of information, most reports referring to the 1984 Harvard-New York State Study, more than 16 years ago. This scarcity of information indicates the complexity of the problem. It seems very unlikely that simple exhortation or additional regulations will help because the problem lies principally in the multiple human-machine interfaces that constitute modern medical care. The absence of success stories also indicates that the best methods have to be learned by experience. A liaison with industry should be helpful, although the varieties of human illness are far different from a standardized manufacturing process. Concurrent with the studies of industrial and nuclear accidents, cognitive psychologists have intensively studied how the brain stores and retrieves information. Several concepts have emerged. First, errors are not character defects to be treated by the classic approach of discipline and education, but are byproducts of normal thinking that occur frequently. Second, major accidents are rarely causedby a single error; instead, they are often a combination of chronic system errors, termed latent errors. Identifying and correcting these latent errors should be the principal focus for corrective planning rather than searching for an individual culprit. This nonpunitive concept of errors is a key basis for an effective reporting system, brilliantly demonstrated in aviation with the ASRS system developed more than 25 years ago. The ASRS currently receives more than 30,000 reports annually and is credited with the remarkable increase in safety of airplane travel. Adverse drug events constitute about 25% of hospital errors. In the future, the combination of new drugs and a vast amount of new information will additionally increase the possibilities for error. Two major advances in recent years have been computerization and active participation of the pharmacist with dispensing medications. Further investigation of hospital errors should concentrate primarily on latent system errors. Significant system changes will require broad staff participation throughout the hospital. This, in turn, should foster development of an institutional safety culture, rather than the popular attitude that patient safety responsibility is concentrated in the Quality Assurance-Risk Management division. Quality of service and patient safety are closely intertwined.
-
NASA Technical Reports Server (NTRS)
Landon, Lauren Blackwell; Vessey, William B.; Barrett, Jamie D.
2015-01-01
A team is defined as: "two or more individuals who interact socially and adaptively, have shared or common goals, and hold meaningful task interdependences; it is hierarchically structured and has a limited life span; in it expertise and roles are distributed; and it is embedded within an organization/environmental context that influences and is influenced by ongoing processes and performance outcomes" (Salas, Stagl, Burke, & Goodwin, 2007, p. 189). From the NASA perspective, a team is commonly understood to be a collection of individuals that is assigned to support and achieve a particular mission. Thus, depending on context, this definition can encompass both the spaceflight crew and the individuals and teams in the larger multi-team system who are assigned to support that crew during a mission. The Team Risk outcomes of interest are predominantly performance related, with a secondary emphasis on long-term health; this is somewhat unique in the NASA HRP in that most Risk areas are medically related and primarily focused on long-term health consequences. In many operational environments (e.g., aviation), performance is assessed as the avoidance of errors. However, the research on performance errors is ambiguous. It implies that actions may be dichotomized into "correct" or "incorrect" responses, where incorrect responses or errors are always undesirable. Researchers have argued that this dichotomy is a harmful oversimplification, and it would be more productive to focus on the variability of human performance and how organizations can manage that variability (Hollnagel, Woods, & Leveson, 2006) (Category III1). Two problems occur when focusing on performance errors: 1) the errors are infrequent and, therefore, difficult to observe and record; and 2) the errors do not directly correspond to failure. Research reveals that humans are fairly adept at correcting or compensating for performance errors before such errors result in recognizable or recordable failures. Astronauts are notably adept high performers. Most failures are recorded only when multiple, small errors occur and humans are unable to recognize and correct or compensate for these errors in time to prevent a failure (Dismukes, Berman, Loukopoulos, 2007) (Category III). More commonly, observers record variability in levels of performance. Some teams commit no observable errors but fail to achieve performance objectives or perform only adequately, while other teams commit some errors but perform spectacularly. Successful performance, therefore, cannot be viewed as simply the absence of errors or the avoidance of failure Johnson Space Center (JSC) Joint Leadership Team, 2008). While failure is commonly attributed to making a major error, focusing solely on the elimination of error(s) does not significantly reduce the risk of failure. Failure may also occur when performance is simply insufficient or an effort is incapable of adjusting sufficiently to a contextual change (e.g., changing levels of autonomy).
-
Human factors and the FDA's goals: improved medical device design.
Burlington, D B
1996-01-01
The Food and Drug Administration's new human factors design requirements for medical devices were previewed by the director of the FDA's Center for Devices and Radiological Health (CDRH) at AAMI/FDA's Human Factors in Medical Devices Conference held in September 1995. Director Bruce Burlington, MD, said the FDA plans to take a closer look at how new medical devices are designed to ensure proper attention has been paid to human error prevention. As a medical practitioner who has witnessed use-related deaths and injuries, Burlington stressed the importance of the medical community's reporting use errors as they occur and manufacturers' creating easy-to-use labeling and packaging. He also called for simplicity and quality of design in medical products, and asked for a consolidated effort of all professionals involved in human factors issues to help implement and further the FDA's new human factors program. An edited version of his presentation appears here.
-
Schultze, A E; Irizarry, A R
2017-02-01
Veterinary clinical pathologists are well positioned via education and training to assist in investigations of unexpected results or increased variation in clinical pathology data. Errors in testing and unexpected variability in clinical pathology data are sometimes referred to as "laboratory errors." These alterations may occur in the preanalytical, analytical, or postanalytical phases of studies. Most of the errors or variability in clinical pathology data occur in the preanalytical or postanalytical phases. True analytical errors occur within the laboratory and are usually the result of operator or instrument error. Analytical errors are often ≤10% of all errors in diagnostic testing, and the frequency of these types of errors has decreased in the last decade. Analytical errors and increased data variability may result from instrument malfunctions, inability to follow proper procedures, undetected failures in quality control, sample misidentification, and/or test interference. This article (1) illustrates several different types of analytical errors and situations within laboratories that may result in increased variability in data, (2) provides recommendations regarding prevention of testing errors and techniques to control variation, and (3) provides a list of references that describe and advise how to deal with increased data variability.
-
IRBs, conflict and liability: will we see IRBs in court? Or is it when?
Icenogle, Daniel L
2003-01-01
The entire human research infrastructure is under intense and increasing financial pressure. These pressures may have been responsible for several errors in judgment by those responsible for managing human research and protecting human subjects. The result of these errors has been some terrible accidents, some of which have cost the lives of human research volunteers. This, in turn, is producing both increased liability risk for those who manage the various aspects of human research and increasing scrutiny as to the capability of the human research protection structure as currently constituted. It is the author's contention that the current structure is fully capable of offering sufficient protection for participants in human research-if Institutional Review Board (IRB) staff and members are given sufficient resources and perform their tasks with sufficient responsibility. The status quo alternative is that IRBs and their members will find themselves at great risk of becoming defendants in lawsuits seeking compensation for damages resulting from human experimentation gone awry.
-
Farag, Amany; Blegen, Mary; Gedney-Lose, Amalia; Lose, Daniel; Perkhounkova, Yelena
2017-05-01
Medication errors are one of the most frequently occurring errors in health care settings. The complexity of the ED work environment places patients at risk for medication errors. Most hospitals rely on nurses' voluntary medication error reporting, but these errors are under-reported. The purpose of this study was to examine the relationship among work environment (nurse manager leadership style and safety climate), social capital (warmth and belonging relationships and organizational trust), and nurses' willingness to report medication errors. A cross-sectional descriptive design using a questionnaire with a convenience sample of emergency nurses was used. Data were analyzed using descriptive, correlation, Mann-Whitney U, and Kruskal-Wallis statistics. A total of 71 emergency nurses were included in the study. Emergency nurses' willingness to report errors decreased as the nurses' years of experience increased (r = -0.25, P = .03). Their willingness to report errors increased when they received more feedback about errors (r = 0.25, P = .03) and when their managers used a transactional leadership style (r = 0.28, P = .01). ED nurse managers can modify their leadership style to encourage error reporting. Timely feedback after an error report is particularly important. Engaging experienced nurses to understand error root causes could increase voluntary error reporting. Published by Elsevier Inc.