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

PubMed

Stultz, Jeremy S; Nahata, Milap C

2015-07-01

Information technology (IT) has the potential to prevent medication errors. While many studies have analyzed specific IT technologies and preventable adverse drug events, no studies have identified risk factors for errors still occurring that are not preventable by IT. The objective of this study was to categorize reported or trigger tool-identified errors and adverse events (AEs) at a pediatric tertiary care institution. Also, we sought to identify medication errors preventable by IT, determine why IT-preventable errors occurred, and to identify risk factors for errors that were not preventable by IT. This was a retrospective analysis of voluntarily reported or trigger tool-identified errors and AEs occurring from 1 July 2011 to 30 June 2012. Medication errors reaching the patients were categorized based on the origin, severity, and location of the error, the month in which they occurred, and the age of the patient involved. Error characteristics were included in a multivariable logistic regression model to determine independent risk factors for errors occurring that were not preventable by IT. A medication error was defined as a medication-related failure of a planned action to be completed as intended or the use of a wrong plan to achieve an aim. An IT-preventable error was defined as having an IT system in place to aid in prevention of the error at the phase and location of its origin. There were 936 medication errors (identified by voluntarily reporting or a trigger tool system) included and analyzed. Drug administration errors were identified most frequently (53.4% ), but prescribing errors most frequently caused harm (47.2 % of harmful errors). There were 470 (50.2 %) errors that were IT preventable at their origin, including 155 due to IT system bypasses, 103 due to insensitivity of IT alerting systems, and 47 with IT alert overrides. Dispensing, administration, and documentation errors had higher odds than prescribing errors for being not preventable by IT

Two statistics for evaluating parameter identifiability and error reduction

USGS Publications Warehouse

Doherty, John; Hunt, Randall J.

2009-01-01

Two statistics are presented that can be used to rank input parameters utilized by a model in terms of their relative identifiability based on a given or possible future calibration dataset. Identifiability is defined here as the capability of model calibration to constrain parameters used by a model. Both statistics require that the sensitivity of each model parameter be calculated for each model output for which there are actual or presumed field measurements. Singular value decomposition (SVD) of the weighted sensitivity matrix is then undertaken to quantify the relation between the parameters and observations that, in turn, allows selection of calibration solution and null spaces spanned by unit orthogonal vectors. The first statistic presented, "parameter identifiability", is quantitatively defined as the direction cosine between a parameter and its projection onto the calibration solution space. This varies between zero and one, with zero indicating complete non-identifiability and one indicating complete identifiability. The second statistic, "relative error reduction", indicates the extent to which the calibration process reduces error in estimation of a parameter from its pre-calibration level where its value must be assigned purely on the basis of prior expert knowledge. This is more sophisticated than identifiability, in that it takes greater account of the noise associated with the calibration dataset. Like identifiability, it has a maximum value of one (which can only be achieved if there is no measurement noise). Conceptually it can fall to zero; and even below zero if a calibration problem is poorly posed. An example, based on a coupled groundwater/surface-water model, is included that demonstrates the utility of the statistics. ?? 2009 Elsevier B.V.

MO-FG-202-05: Identifying Treatment Planning System Errors in IROC-H Phantom Irradiations

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

Kerns, J; Followill, D; Howell, R

Purpose: Treatment Planning System (TPS) errors can affect large numbers of cancer patients receiving radiation therapy. Using an independent recalculation system, the Imaging and Radiation Oncology Core-Houston (IROC-H) can identify institutions that have not sufficiently modelled their linear accelerators in their TPS model. Methods: Linear accelerator point measurement data from IROC-H’s site visits was aggregated and analyzed from over 30 linear accelerator models. Dosimetrically similar models were combined to create “classes”. The class data was used to construct customized beam models in an independent treatment dose verification system (TVS). Approximately 200 head and neck phantom plans from 2012 to 2015more » were recalculated using this TVS. Comparison of plan accuracy was evaluated by comparing the measured dose to the institution’s TPS dose as well as the TVS dose. In cases where the TVS was more accurate than the institution by an average of >2%, the institution was identified as having a non-negligible TPS error. Results: Of the ∼200 recalculated plans, the average improvement using the TVS was ∼0.1%; i.e. the recalculation, on average, slightly outperformed the institution’s TPS. Of all the recalculated phantoms, 20% were identified as having a non-negligible TPS error. Fourteen plans failed current IROC-H criteria; the average TVS improvement of the failing plans was ∼3% and 57% were found to have non-negligible TPS errors. Conclusion: IROC-H has developed an independent recalculation system to identify institutions that have considerable TPS errors. A large number of institutions were found to have non-negligible TPS errors. Even institutions that passed IROC-H criteria could be identified as having a TPS error. Resolution of such errors would improve dose delivery for a large number of IROC-H phantoms and ultimately, patients.« less

Identifying the latent failures underpinning medication administration errors: an exploratory study.

PubMed

Lawton, Rebecca; Carruthers, Sam; Gardner, Peter; Wright, John; McEachan, Rosie R C

2012-08-01

The primary aim of this article was to identify the latent failures that are perceived to underpin medication errors. The study was conducted within three medical wards in a hospital in the United Kingdom. The study employed a cross-sectional qualitative design. Interviews were conducted with 12 nurses and eight managers. Interviews were transcribed and subject to thematic content analysis. A two-step inter-rater comparison tested the reliability of the themes. Ten latent failures were identified based on the analysis of the interviews. These were ward climate, local working environment, workload, human resources, team communication, routine procedures, bed management, written policies and procedures, supervision and leadership, and training. The discussion focuses on ward climate, the most prevalent theme, which is conceptualized here as interacting with failures in the nine other organizational structures and processes. This study is the first of its kind to identify the latent failures perceived to underpin medication errors in a systematic way. The findings can be used as a platform for researchers to test the impact of organization-level patient safety interventions and to design proactive error management tools and incident reporting systems in hospitals. © Health Research and Educational Trust.

Theoretical and experimental errors for in situ measurements of plant water potential.

PubMed

Shackel, K A

1984-07-01

Errors in psychrometrically determined values of leaf water potential caused by tissue resistance to water vapor exchange and by lack of thermal equilibrium were evaluated using commercial in situ psychrometers (Wescor Inc., Logan, UT) on leaves of Tradescantia virginiana (L.). Theoretical errors in the dewpoint method of operation for these sensors were demonstrated. After correction for these errors, in situ measurements of leaf water potential indicated substantial errors caused by tissue resistance to water vapor exchange (4 to 6% reduction in apparent water potential per second of cooling time used) resulting from humidity depletions in the psychrometer chamber during the Peltier condensation process. These errors were avoided by use of a modified procedure for dewpoint measurement. Large changes in apparent water potential were caused by leaf and psychrometer exposure to moderate levels of irradiance. These changes were correlated with relatively small shifts in psychrometer zero offsets (-0.6 to -1.0 megapascals per microvolt), indicating substantial errors caused by nonisothermal conditions between the leaf and the psychrometer. Explicit correction for these errors is not possible with the current psychrometer design.

An automated technique to identify potential inappropriate traditional Chinese medicine (TCM) prescriptions.

PubMed

Yang, Hsuan-Chia; Iqbal, Usman; Nguyen, Phung Anh; Lin, Shen-Hsien; Huang, Chih-Wei; Jian, Wen-Shan; Li, Yu-Chuan

2016-04-01

Medication errors such as potential inappropriate prescriptions would induce serious adverse drug events to patients. Information technology has the ability to prevent medication errors; however, the pharmacology of traditional Chinese medicine (TCM) is not as clear as in western medicine. The aim of this study was to apply the appropriateness of prescription (AOP) model to identify potential inappropriate TCM prescriptions. We used the association rule of mining techniques to analyze 14.5 million prescriptions from the Taiwan National Health Insurance Research Database. The disease and TCM (DTCM) and traditional Chinese medicine-traditional Chinese medicine (TCMM) associations are computed by their co-occurrence, and the associations' strength was measured as Q-values, which often referred to as interestingness or life values. By considering the number of Q-values, the AOP model was applied to identify the inappropriate prescriptions. Afterwards, three traditional Chinese physicians evaluated 1920 prescriptions and validated the detected outcomes from the AOP model. Out of 1920 prescriptions, 97.1% of positive predictive value and 19.5% of negative predictive value were shown by the system as compared with those by experts. The sensitivity analysis indicated that the negative predictive value could improve up to 27.5% when the model's threshold changed to 0.4. We successfully applied the AOP model to automatically identify potential inappropriate TCM prescriptions. This model could be a potential TCM clinical decision support system in order to improve drug safety and quality of care. Copyright © 2016 John Wiley & Sons, Ltd.

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

PubMed

Huckels-Baumgart, Saskia; Manser, Tanja

2014-10-01

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

Use of graph theory measures to identify errors in record linkage.

PubMed

Randall, Sean M; Boyd, James H; Ferrante, Anna M; Bauer, Jacqueline K; Semmens, James B

2014-07-01

Ensuring high linkage quality is important in many record linkage applications. Current methods for ensuring quality are manual and resource intensive. This paper seeks to determine the effectiveness of graph theory techniques in identifying record linkage errors. A range of graph theory techniques was applied to two linked datasets, with known truth sets. The ability of graph theory techniques to identify groups containing errors was compared to a widely used threshold setting technique. This methodology shows promise; however, further investigations into graph theory techniques are required. The development of more efficient and effective methods of improving linkage quality will result in higher quality datasets that can be delivered to researchers in shorter timeframes. Copyright © 2014 Elsevier Ireland Ltd. All rights reserved.

Limitations of Surface Mapping Technology in Accurately Identifying Critical Errors in Dental Students' Crown Preparations.

PubMed

Furness, Alan R; Callan, Richard S; Mackert, J Rodway; Mollica, Anthony G

2018-01-01

The aim of this study was to evaluate the effectiveness of the Planmeca Compare software in identifying and quantifying a common critical error in dental students' crown preparations. In 2014-17, a study was conducted at one U.S. dental school that evaluated an ideal crown prep made by a faculty member on a dentoform to modified preps. Two types of preparation errors were created by the addition of flowable composite to the occlusal surface of identical dies of the preparations to represent the underreduction of the distolingual cusp. The error was divided into two classes: the minor class allowed for 1 mm of occlusal clearance, and the major class allowed for no occlusal clearance. The preparations were then digitally evaluated against the ideal preparation using Planmeca Compare. Percent comparison values were obtained from each trial and averaged together. False positives and false negatives were also identified and used to determine the accuracy of the evaluation. Critical errors that did not involve a substantial change in the surface area of the preparation were inconsistently identified. Within the limitations of this study, the authors concluded that the Compare software was unable to consistently identify common critical errors within an acceptable degree of error.

Masked and unmasked error-related potentials during continuous control and feedback

NASA Astrophysics Data System (ADS)

Lopes Dias, Catarina; Sburlea, Andreea I.; Müller-Putz, Gernot R.

2018-06-01

The detection of error-related potentials (ErrPs) in tasks with discrete feedback is well established in the brain–computer interface (BCI) field. However, the decoding of ErrPs in tasks with continuous feedback is still in its early stages. Objective. We developed a task in which subjects have continuous control of a cursor’s position by means of a joystick. The cursor’s position was shown to the participants in two different modalities of continuous feedback: normal and jittered. The jittered feedback was created to mimic the instability that could exist if participants controlled the trajectory directly with brain signals. Approach. This paper studies the electroencephalographic (EEG)—measurable signatures caused by a loss of control over the cursor’s trajectory, causing a target miss. Main results. In both feedback modalities, time-locked potentials revealed the typical frontal-central components of error-related potentials. Errors occurring during the jittered feedback (masked errors) were delayed in comparison to errors occurring during normal feedback (unmasked errors). Masked errors displayed lower peak amplitudes than unmasked errors. Time-locked classification analysis allowed a good distinction between correct and error classes (average Cohen-, average TPR  =  81.8% and average TNR  =  96.4%). Time-locked classification analysis between masked error and unmasked error classes revealed results at chance level (average Cohen-, average TPR  =  60.9% and average TNR  =  58.3%). Afterwards, we performed asynchronous detection of ErrPs, combining both masked and unmasked trials. The asynchronous detection of ErrPs in a simulated online scenario resulted in an average TNR of 84.0% and in an average TPR of 64.9%. Significance. The time-locked classification results suggest that the masked and unmasked errors were indistinguishable in terms of classification. The asynchronous classification results suggest that the

UMI-tools: modeling sequencing errors in Unique Molecular Identifiers to improve quantification accuracy

PubMed Central

2017-01-01

Unique Molecular Identifiers (UMIs) are random oligonucleotide barcodes that are increasingly used in high-throughput sequencing experiments. Through a UMI, identical copies arising from distinct molecules can be distinguished from those arising through PCR amplification of the same molecule. However, bioinformatic methods to leverage the information from UMIs have yet to be formalized. In particular, sequencing errors in the UMI sequence are often ignored or else resolved in an ad hoc manner. We show that errors in the UMI sequence are common and introduce network-based methods to account for these errors when identifying PCR duplicates. Using these methods, we demonstrate improved quantification accuracy both under simulated conditions and real iCLIP and single-cell RNA-seq data sets. Reproducibility between iCLIP replicates and single-cell RNA-seq clustering are both improved using our proposed network-based method, demonstrating the value of properly accounting for errors in UMIs. These methods are implemented in the open source UMI-tools software package. PMID:28100584

Identifying model error in metabolic flux analysis - a generalized least squares approach.

PubMed

Sokolenko, Stanislav; Quattrociocchi, Marco; Aucoin, Marc G

2016-09-13

The estimation of intracellular flux through traditional metabolic flux analysis (MFA) using an overdetermined system of equations is a well established practice in metabolic engineering. Despite the continued evolution of the methodology since its introduction, there has been little focus on validation and identification of poor model fit outside of identifying "gross measurement error". The growing complexity of metabolic models, which are increasingly generated from genome-level data, has necessitated robust validation that can directly assess model fit. In this work, MFA calculation is framed as a generalized least squares (GLS) problem, highlighting the applicability of the common t-test for model validation. To differentiate between measurement and model error, we simulate ideal flux profiles directly from the model, perturb them with estimated measurement error, and compare their validation to real data. Application of this strategy to an established Chinese Hamster Ovary (CHO) cell model shows how fluxes validated by traditional means may be largely non-significant due to a lack of model fit. With further simulation, we explore how t-test significance relates to calculation error and show that fluxes found to be non-significant have 2-4 fold larger error (if measurement uncertainty is in the 5-10 % range). The proposed validation method goes beyond traditional detection of "gross measurement error" to identify lack of fit between model and data. Although the focus of this work is on t-test validation and traditional MFA, the presented framework is readily applicable to other regression analysis methods and MFA formulations.

Identifiability Of Systems With Modeling Errors

NASA Technical Reports Server (NTRS)

Hadaegh, Yadolah " fred" ; Bekey, George A.

1988-01-01

Advances in theory of modeling errors reported. Recent paper on errors in mathematical models of deterministic linear or weakly nonlinear systems. Extends theoretical work described in NPO-16661 and NPO-16785. Presents concrete way of accounting for difference in structure between mathematical model and physical process or system that it represents.

Theoretical and Experimental Errors for In Situ Measurements of Plant Water Potential 1

PubMed Central

Shackel, Kenneth A.

1984-01-01

Errors in psychrometrically determined values of leaf water potential caused by tissue resistance to water vapor exchange and by lack of thermal equilibrium were evaluated using commercial in situ psychrometers (Wescor Inc., Logan, UT) on leaves of Tradescantia virginiana (L.). Theoretical errors in the dewpoint method of operation for these sensors were demonstrated. After correction for these errors, in situ measurements of leaf water potential indicated substantial errors caused by tissue resistance to water vapor exchange (4 to 6% reduction in apparent water potential per second of cooling time used) resulting from humidity depletions in the psychrometer chamber during the Peltier condensation process. These errors were avoided by use of a modified procedure for dewpoint measurement. Large changes in apparent water potential were caused by leaf and psychrometer exposure to moderate levels of irradiance. These changes were correlated with relatively small shifts in psychrometer zero offsets (−0.6 to −1.0 megapascals per microvolt), indicating substantial errors caused by nonisothermal conditions between the leaf and the psychrometer. Explicit correction for these errors is not possible with the current psychrometer design. PMID:16663701

Psychrometric Measurement of Leaf Water Potential: Lack of Error Attributable to Leaf Permeability.

PubMed

Barrs, H D

1965-07-02

A report that low permeability could cause gross errors in psychrometric determinations of water potential in leaves has not been confirmed. No measurable error from this source could be detected for either of two types of thermocouple psychrometer tested on four species, each at four levels of water potential. No source of error other than tissue respiration could be demonstrated.

Developmental Changes in Error Monitoring: An Event-Related Potential Study

ERIC Educational Resources Information Center

Wiersema, Jan R.; van der Meere, Jacob J.; Roeyers, Herbert

2007-01-01

The aim of the study was to investigate the developmental trajectory of error monitoring. For this purpose, children (age 7-8), young adolescents (age 13-14) and adults (age 23-24) performed a Go/No-Go task and were compared on overt reaction time (RT) performance and on event-related potentials (ERPs), thought to reflect error detection…

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

PubMed

Tully, Mary P; Buchan, Iain E

2009-12-01

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

Event-related potentials for post-error and post-conflict slowing.

PubMed

Chang, Andrew; Chen, Chien-Chung; Li, Hsin-Hung; Li, Chiang-Shan R

2014-01-01

In a reaction time task, people typically slow down following an error or conflict, each called post-error slowing (PES) and post-conflict slowing (PCS). Despite many studies of the cognitive mechanisms, the neural responses of PES and PCS continue to be debated. In this study, we combined high-density array EEG and a stop-signal task to examine event-related potentials of PES and PCS in sixteen young adult participants. The results showed that the amplitude of N2 is greater during PES but not PCS. In contrast, the peak latency of N2 is longer for PCS but not PES. Furthermore, error-positivity (Pe) but not error-related negativity (ERN) was greater in the stop error trials preceding PES than non-PES trials, suggesting that PES is related to participants' awareness of the error. Together, these findings extend earlier work of cognitive control by specifying the neural correlates of PES and PCS in the stop signal task.

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

PubMed Central

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

2015-01-01

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

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

PubMed

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

2015-02-01

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

Errors in retarding potential analyzers caused by nonuniformity of the grid-plane potential.

NASA Technical Reports Server (NTRS)

Hanson, W. B.; Frame, D. R.; Midgley, J. E.

1972-01-01

One aspect of the degradation in performance of retarding potential analyzers caused by potential depressions in the retarding grid is quantitatively estimated from laboratory measurements and theoretical calculations. A simple expression is obtained that permits the use of laboratory measurements of grid properties to make first-order corrections to flight data. Systematic positive errors in ion temperature of approximately 16% for the Ogo 4 instrument and 3% for the Ogo 6 instrument are deduced. The effects of the transverse electric fields arising from the grid potential depressions are not treated.

Blood transfusion sampling and a greater role for error recovery.

PubMed

Oldham, Jane

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

Errare machinale est: the use of error-related potentials in brain-machine interfaces

PubMed Central

Chavarriaga, Ricardo; Sobolewski, Aleksander; Millán, José del R.

2014-01-01

The ability to recognize errors is crucial for efficient behavior. Numerous studies have identified electrophysiological correlates of error recognition in the human brain (error-related potentials, ErrPs). Consequently, it has been proposed to use these signals to improve human-computer interaction (HCI) or brain-machine interfacing (BMI). Here, we present a review of over a decade of developments toward this goal. This body of work provides consistent evidence that ErrPs can be successfully detected on a single-trial basis, and that they can be effectively used in both HCI and BMI applications. We first describe the ErrP phenomenon and follow up with an analysis of different strategies to increase the robustness of a system by incorporating single-trial ErrP recognition, either by correcting the machine's actions or by providing means for its error-based adaptation. These approaches can be applied both when the user employs traditional HCI input devices or in combination with another BMI channel. Finally, we discuss the current challenges that have to be overcome in order to fully integrate ErrPs into practical applications. This includes, in particular, the characterization of such signals during real(istic) applications, as well as the possibility of extracting richer information from them, going beyond the time-locked decoding that dominates current approaches. PMID:25100937

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

PubMed

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

2018-01-01

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

Acute Respiratory Distress Syndrome Measurement Error. Potential Effect on Clinical Study Results

PubMed Central

Cooke, Colin R.; Iwashyna, Theodore J.; Hofer, Timothy P.

2016-01-01

Rationale: Identifying patients with acute respiratory distress syndrome (ARDS) is a recognized challenge. Experts often have only moderate agreement when applying the clinical definition of ARDS to patients. However, no study has fully examined the implications of low reliability measurement of ARDS on clinical studies. Objectives: To investigate how the degree of variability in ARDS measurement commonly reported in clinical studies affects study power, the accuracy of treatment effect estimates, and the measured strength of risk factor associations. Methods: We examined the effect of ARDS measurement error in randomized clinical trials (RCTs) of ARDS-specific treatments and cohort studies using simulations. We varied the reliability of ARDS diagnosis, quantified as the interobserver reliability (κ-statistic) between two reviewers. In RCT simulations, patients identified as having ARDS were enrolled, and when measurement error was present, patients without ARDS could be enrolled. In cohort studies, risk factors as potential predictors were analyzed using reviewer-identified ARDS as the outcome variable. Measurements and Main Results: Lower reliability measurement of ARDS during patient enrollment in RCTs seriously degraded study power. Holding effect size constant, the sample size necessary to attain adequate statistical power increased by more than 50% as reliability declined, although the result was sensitive to ARDS prevalence. In a 1,400-patient clinical trial, the sample size necessary to maintain similar statistical power increased to over 1,900 when reliability declined from perfect to substantial (κ = 0.72). Lower reliability measurement diminished the apparent effectiveness of an ARDS-specific treatment from a 15.2% (95% confidence interval, 9.4–20.9%) absolute risk reduction in mortality to 10.9% (95% confidence interval, 4.7–16.2%) when reliability declined to moderate (κ = 0.51). In cohort studies, the effect on risk factor associations

Identifying and Correcting Timing Errors at Seismic Stations in and around Iran

DOE PAGES

Syracuse, Ellen Marie; Phillips, William Scott; Maceira, Monica; ...

2017-09-06

A fundamental component of seismic research is the use of phase arrival times, which are central to event location, Earth model development, and phase identification, as well as derived products. Hence, the accuracy of arrival times is crucial. However, errors in the timing of seismic waveforms and the arrival times based on them may go unidentified by the end user, particularly when seismic data are shared between different organizations. Here, we present a method used to analyze travel-time residuals for stations in and around Iran to identify time periods that are likely to contain station timing problems. For the 14more » stations with the strongest evidence of timing errors lasting one month or longer, timing corrections are proposed to address the problematic time periods. Finally, two additional stations are identified with incorrect locations in the International Registry of Seismograph Stations, and one is found to have erroneously reported arrival times in 2011.« less

Real-time recognition of feedback error-related potentials during a time-estimation task.

PubMed

Lopez-Larraz, Eduardo; Iturrate, Iñaki; Montesano, Luis; Minguez, Javier

2010-01-01

Feedback error-related potentials are a promising brain process in the field of rehabilitation since they are related to human learning. Due to the fact that many therapeutic strategies rely on the presentation of feedback stimuli, potentials generated by these stimuli could be used to ameliorate the patient's progress. In this paper we propose a method that can identify, in real-time, feedback evoked potentials in a time-estimation task. We have tested our system with five participants in two different days with a separation of three weeks between them, achieving a mean single-trial detection performance of 71.62% for real-time recognition, and 78.08% in offline classification. Additionally, an analysis of the stability of the signal between the two days is performed, suggesting that the feedback responses are stable enough to be used without the needing of training again the user.

Refractive errors and schizophrenia.

PubMed

Caspi, Asaf; Vishne, Tali; Reichenberg, Abraham; Weiser, Mark; Dishon, Ayelet; Lubin, Gadi; Shmushkevitz, Motti; Mandel, Yossi; Noy, Shlomo; Davidson, Michael

2009-02-01

Refractive errors (myopia, hyperopia and amblyopia), like schizophrenia, have a strong genetic cause, and dopamine has been proposed as a potential mediator in their pathophysiology. The present study explored the association between refractive errors in adolescence and schizophrenia, and the potential familiality of this association. The Israeli Draft Board carries a mandatory standardized visual accuracy assessment. 678,674 males consecutively assessed by the Draft Board and found to be psychiatrically healthy at age 17 were followed for psychiatric hospitalization with schizophrenia using the Israeli National Psychiatric Hospitalization Case Registry. Sib-ships were also identified within the cohort. There was a negative association between refractive errors and later hospitalization for schizophrenia. Future male schizophrenia patients were two times less likely to have refractive errors compared with never-hospitalized individuals, controlling for intelligence, years of education and socioeconomic status [adjusted Hazard Ratio=.55; 95% confidence interval .35-.85]. The non-schizophrenic male siblings of schizophrenia patients also had lower prevalence of refractive errors compared to never-hospitalized individuals. Presence of refractive errors in adolescence is related to lower risk for schizophrenia. The familiality of this association suggests that refractive errors may be associated with the genetic liability to schizophrenia.

Identifying presence of correlated errors in GRACE monthly harmonic coefficients using machine learning algorithms

NASA Astrophysics Data System (ADS)

Piretzidis, Dimitrios; Sra, Gurveer; Karantaidis, George; Sideris, Michael G.

2017-04-01

A new method for identifying correlated errors in Gravity Recovery and Climate Experiment (GRACE) monthly harmonic coefficients has been developed and tested. Correlated errors are present in the differences between monthly GRACE solutions, and can be suppressed using a de-correlation filter. In principle, the de-correlation filter should be implemented only on coefficient series with correlated errors to avoid losing useful geophysical information. In previous studies, two main methods of implementing the de-correlation filter have been utilized. In the first one, the de-correlation filter is implemented starting from a specific minimum order until the maximum order of the monthly solution examined. In the second one, the de-correlation filter is implemented only on specific coefficient series, the selection of which is based on statistical testing. The method proposed in the present study exploits the capabilities of supervised machine learning algorithms such as neural networks and support vector machines (SVMs). The pattern of correlated errors can be described by several numerical and geometric features of the harmonic coefficient series. The features of extreme cases of both correlated and uncorrelated coefficients are extracted and used for the training of the machine learning algorithms. The trained machine learning algorithms are later used to identify correlated errors and provide the probability of a coefficient series to be correlated. Regarding SVMs algorithms, an extensive study is performed with various kernel functions in order to find the optimal training model for prediction. The selection of the optimal training model is based on the classification accuracy of the trained SVM algorithm on the same samples used for training. Results show excellent performance of all algorithms with a classification accuracy of 97% - 100% on a pre-selected set of training samples, both in the validation stage of the training procedure and in the subsequent use of

Clinical review: Medication errors in critical care

PubMed Central

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

2008-01-01

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

Medication errors room: a simulation to assess the medical, nursing and pharmacy staffs' ability to identify errors related to the medication-use system.

PubMed

Daupin, Johanne; Atkinson, Suzanne; Bédard, Pascal; Pelchat, Véronique; Lebel, Denis; Bussières, Jean-François

2016-12-01

The medication-use system in hospitals is very complex. To improve the health professionals' awareness of the risks of errors related to the medication-use system, a simulation of medication errors was created. The main objective was to assess the medical, nursing and pharmacy staffs' ability to identify errors related to the medication-use system using a simulation. The secondary objective was to assess their level of satisfaction. This descriptive cross-sectional study was conducted in a 500-bed mother-and-child university hospital. A multidisciplinary group set up 30 situations and replicated a patient room and a care unit pharmacy. All hospital staff, including nurses, physicians, pharmacists and pharmacy technicians, was invited. Participants had to detect if a situation contained an error and fill out a response grid. They also answered a satisfaction survey. The simulation was held during 100 hours. A total of 230 professionals visited the simulation, 207 handed in a response grid and 136 answered the satisfaction survey. The participants' overall rate of correct answers was 67.5% ± 13.3% (4073/6036). Among the least detected errors were situations involving a Y-site infusion incompatibility, an oral syringe preparation and the patient's identification. Participants mainly considered the simulation as effective in identifying incorrect practices (132/136, 97.8%) and relevant to their practice (129/136, 95.6%). Most of them (114/136; 84.4%) intended to change their practices in view of their exposure to the simulation. We implemented a realistic medication-use system errors simulation in a mother-child hospital, with a wide audience. This simulation was an effective, relevant and innovative tool to raise the health care professionals' awareness of critical processes. © 2016 John Wiley & Sons, Ltd.

Analyzing Software Requirements Errors in Safety-Critical, Embedded Systems

NASA Technical Reports Server (NTRS)

Lutz, Robyn R.

1993-01-01

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

The Use of Neural Networks in Identifying Error Sources in Satellite-Derived Tropical SST Estimates

PubMed Central

Lee, Yung-Hsiang; Ho, Chung-Ru; Su, Feng-Chun; Kuo, Nan-Jung; Cheng, Yu-Hsin

2011-01-01

An neural network model of data mining is used to identify error sources in satellite-derived tropical sea surface temperature (SST) estimates from thermal infrared sensors onboard the Geostationary Operational Environmental Satellite (GOES). By using the Back Propagation Network (BPN) algorithm, it is found that air temperature, relative humidity, and wind speed variation are the major factors causing the errors of GOES SST products in the tropical Pacific. The accuracy of SST estimates is also improved by the model. The root mean square error (RMSE) for the daily SST estimate is reduced from 0.58 K to 0.38 K and mean absolute percentage error (MAPE) is 1.03%. For the hourly mean SST estimate, its RMSE is also reduced from 0.66 K to 0.44 K and the MAPE is 1.3%. PMID:22164030

Identifying Engineering Students' English Sentence Reading Comprehension Errors: Applying a Data Mining Technique

ERIC Educational Resources Information Center

Tsai, Yea-Ru; Ouyang, Chen-Sen; Chang, Yukon

2016-01-01

The purpose of this study is to propose a diagnostic approach to identify engineering students' English reading comprehension errors. Student data were collected during the process of reading texts of English for science and technology on a web-based cumulative sentence analysis system. For the analysis, the association-rule, data mining technique…

Systematic Error in Leaf Water Potential Measurements with a Thermocouple Psychrometer.

PubMed

Rawlins, S L

1964-10-30

To allow for the error in measurement of water potentials in leaves, introduced by the presence of a water droplet in the chamber of the psychrometer, a correction must be made for the permeability of the leaf.

EEG error potentials detection and classification using time-frequency features for robot reinforcement learning.

PubMed

Boubchir, Larbi; Touati, Youcef; Daachi, Boubaker; Chérif, Arab Ali

2015-08-01

In thought-based steering of robots, error potentials (ErrP) can appear when the action resulting from the brain-machine interface (BMI) classifier/controller does not correspond to the user's thought. Using the Steady State Visual Evoked Potentials (SSVEP) techniques, ErrP, which appear when a classification error occurs, are not easily recognizable by only examining the temporal or frequency characteristics of EEG signals. A supplementary classification process is therefore needed to identify them in order to stop the course of the action and back up to a recovery state. This paper presents a set of time-frequency (t-f) features for the detection and classification of EEG ErrP in extra-brain activities due to misclassification observed by a user exploiting non-invasive BMI and robot control in the task space. The proposed features are able to characterize and detect ErrP activities in the t-f domain. These features are derived from the information embedded in the t-f representation of EEG signals, and include the Instantaneous Frequency (IF), t-f information complexity, SVD information, energy concentration and sub-bands' energies. The experiment results on real EEG data show that the use of the proposed t-f features for detecting and classifying EEG ErrP achieved an overall classification accuracy up to 97% for 50 EEG segments using 2-class SVM classifier.

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

PubMed

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

2017-06-01

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

Outpatient Prescribing Errors and the Impact of Computerized Prescribing

PubMed Central

Gandhi, Tejal K; Weingart, Saul N; Seger, Andrew C; Borus, Joshua; Burdick, Elisabeth; Poon, Eric G; Leape, Lucian L; Bates, David W

2005-01-01

Background Medication errors are common among inpatients and many are preventable with computerized prescribing. Relatively little is known about outpatient prescribing errors or the impact of computerized prescribing in this setting. Objective To assess the rates, types, and severity of outpatient prescribing errors and understand the potential impact of computerized prescribing. Design Prospective cohort study in 4 adult primary care practices in Boston using prescription review, patient survey, and chart review to identify medication errors, potential adverse drug events (ADEs) and preventable ADEs. Participants Outpatients over age 18 who received a prescription from 24 participating physicians. Results We screened 1879 prescriptions from 1202 patients, and completed 661 surveys (response rate 55%). Of the prescriptions, 143 (7.6%; 95% confidence interval (CI) 6.4% to 8.8%) contained a prescribing error. Three errors led to preventable ADEs and 62 (43%; 3% of all prescriptions) had potential for patient injury (potential ADEs); 1 was potentially life-threatening (2%) and 15 were serious (24%). Errors in frequency (n=77, 54%) and dose (n=26, 18%) were common. The rates of medication errors and potential ADEs were not significantly different at basic computerized prescribing sites (4.3% vs 11.0%, P=.31; 2.6% vs 4.0%, P=.16) compared to handwritten sites. Advanced checks (including dose and frequency checking) could have prevented 95% of potential ADEs. Conclusions Prescribing errors occurred in 7.6% of outpatient prescriptions and many could have harmed patients. Basic computerized prescribing systems may not be adequate to reduce errors. More advanced systems with dose and frequency checking are likely needed to prevent potentially harmful errors. PMID:16117752

Error processing and response inhibition in excessive computer game players: an event-related potential study.

PubMed

Littel, Marianne; van den Berg, Ivo; Luijten, Maartje; van Rooij, Antonius J; Keemink, Lianne; Franken, Ingmar H A

2012-09-01

Excessive computer gaming has recently been proposed as a possible pathological illness. However, research on this topic is still in its infancy and underlying neurobiological mechanisms have not yet been identified. The determination of underlying mechanisms of excessive gaming might be useful for the identification of those at risk, a better understanding of the behavior and the development of interventions. Excessive gaming has been often compared with pathological gambling and substance use disorder. Both disorders are characterized by high levels of impulsivity, which incorporates deficits in error processing and response inhibition. The present study aimed to investigate error processing and response inhibition in excessive gamers and controls using a Go/NoGo paradigm combined with event-related potential recordings. Results indicated that excessive gamers show reduced error-related negativity amplitudes in response to incorrect trials relative to correct trials, implying poor error processing in this population. Furthermore, excessive gamers display higher levels of self-reported impulsivity as well as more impulsive responding as reflected by less behavioral inhibition on the Go/NoGo task. The present study indicates that excessive gaming partly parallels impulse control and substance use disorders regarding impulsivity measured on the self-reported, behavioral and electrophysiological level. Although the present study does not allow drawing firm conclusions on causality, it might be that trait impulsivity, poor error processing and diminished behavioral response inhibition underlie the excessive gaming patterns observed in certain individuals. They might be less sensitive to negative consequences of gaming and therefore continue their behavior despite adverse consequences. © 2012 The Authors, Addiction Biology © 2012 Society for the Study of Addiction.

Errors in measuring water potentials of small samples resulting from water adsorption by thermocouple psychrometer chambers.

PubMed

Bennett, J M; Cortes, P M

1985-09-01

The adsorption of water by thermocouple psychrometer assemblies is known to cause errors in the determination of water potential. Experiments were conducted to evaluate the effect of sample size and psychrometer chamber volume on measured water potentials of leaf discs, leaf segments, and sodium chloride solutions. Reasonable agreement was found between soybean (Glycine max L. Merr.) leaf water potentials measured on 5-millimeter radius leaf discs and large leaf segments. Results indicated that while errors due to adsorption may be significant when using small volumes of tissue, if sufficient tissue is used the errors are negligible. Because of the relationship between water potential and volume in plant tissue, the errors due to adsorption were larger with turgid tissue. Large psychrometers which were sealed into the sample chamber with latex tubing appeared to adsorb more water than those sealed with flexible plastic tubing. Estimates are provided of the amounts of water adsorbed by two different psychrometer assemblies and the amount of tissue sufficient for accurate measurements of leaf water potential with these assemblies. It is also demonstrated that water adsorption problems may have generated low water potential values which in prior studies have been attributed to large cut surface area to volume ratios.

Understanding the nature of errors in nursing: using a model to analyse critical incident reports of errors which had resulted in an adverse or potentially adverse event.

PubMed

Meurier, C E

2000-07-01

Human errors are common in clinical practice, but they are under-reported. As a result, very little is known of the types, antecedents and consequences of errors in nursing practice. This limits the potential to learn from errors and to make improvement in the quality and safety of nursing care. The aim of this study was to use an Organizational Accident Model to analyse critical incidents of errors in nursing. Twenty registered nurses were invited to produce a critical incident report of an error (which had led to an adverse event or potentially could have led to an adverse event) they had made in their professional practice and to write down their responses to the error using a structured format. Using Reason's Organizational Accident Model, supplemental information was then collected from five of the participants by means of an individual in-depth interview to explore further issues relating to the incidents they had reported. The detailed analysis of one of the incidents is discussed in this paper, demonstrating the effectiveness of this approach in providing insight into the chain of events which may lead to an adverse event. The case study approach using critical incidents of clinical errors was shown to provide relevant information regarding the interaction of organizational factors, local circumstances and active failures (errors) in producing an adverse or potentially adverse event. It is suggested that more use should be made of this approach to understand how errors are made in practice and to take appropriate preventative measures.

Understanding human management of automation errors.

PubMed

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

2014-01-01

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

On the use of interaction error potentials for adaptive brain computer interfaces.

PubMed

Llera, A; van Gerven, M A J; Gómez, V; Jensen, O; Kappen, H J

2011-12-01

We propose an adaptive classification method for the Brain Computer Interfaces (BCI) which uses Interaction Error Potentials (IErrPs) as a reinforcement signal and adapts the classifier parameters when an error is detected. We analyze the quality of the proposed approach in relation to the misclassification of the IErrPs. In addition we compare static versus adaptive classification performance using artificial and MEG data. We show that the proposed adaptive framework significantly improves the static classification methods. Copyright © 2011 Elsevier Ltd. All rights reserved.

Functional requirements for the man-vehicle systems research facility. [identifying and correcting human errors during flight simulation

NASA Technical Reports Server (NTRS)

Clement, W. F.; Allen, R. W.; Heffley, R. K.; Jewell, W. F.; Jex, H. R.; Mcruer, D. T.; Schulman, T. M.; Stapleford, R. L.

1980-01-01

The NASA Ames Research Center proposed a man-vehicle systems research facility to support flight simulation studies which are needed for identifying and correcting the sources of human error associated with current and future air carrier operations. The organization of research facility is reviewed and functional requirements and related priorities for the facility are recommended based on a review of potentially critical operational scenarios. Requirements are included for the experimenter's simulation control and data acquisition functions, as well as for the visual field, motion, sound, computation, crew station, and intercommunications subsystems. The related issues of functional fidelity and level of simulation are addressed, and specific criteria for quantitative assessment of various aspects of fidelity are offered. Recommendations for facility integration, checkout, and staffing are included.

The District Nursing Clinical Error Reduction Programme.

PubMed

McGraw, Caroline; Topping, Claire

2011-01-01

The District Nursing Clinical Error Reduction (DANCER) Programme was initiated in NHS Islington following an increase in the number of reported medication errors. The objectives were to reduce the actual degree of harm and the potential risk of harm associated with medication errors and to maintain the existing positive reporting culture, while robustly addressing performance issues. One hundred medication errors reported in 2007/08 were analysed using a framework that specifies the factors that predispose to adverse medication events in domiciliary care. Various contributory factors were identified and interventions were subsequently developed to address poor drug calculation and medication problem-solving skills and incorrectly transcribed medication administration record charts. Follow up data were obtained at 12 months and two years. The evaluation has shown that although medication errors do still occur, the programme has resulted in a marked shift towards a reduction in the associated actual degree of harm and the potential risk of harm.

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

PubMed

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

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

Understanding human management of automation errors

PubMed Central

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

2013-01-01

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

CPTAC Investigators Identify Rogue Breast Tumor Proteins That Point To Potential Drug Therapies | Office of Cancer Clinical Proteomics Research

Cancer.gov

For patients with difficult-to-treat cancers, doctors increasingly rely on genomic testing of tumors to identify errors in the DNA that indicate a tumor can be targeted by existing therapies. But this approach overlooks another potential marker — rogue proteins — that may be driving cancer cells and also could be targeted with existing treatments.

Errors in Measuring Water Potentials of Small Samples Resulting from Water Adsorption by Thermocouple Psychrometer Chambers 1

PubMed Central

Bennett, Jerry M.; Cortes, Peter M.

1985-01-01

The adsorption of water by thermocouple psychrometer assemblies is known to cause errors in the determination of water potential. Experiments were conducted to evaluate the effect of sample size and psychrometer chamber volume on measured water potentials of leaf discs, leaf segments, and sodium chloride solutions. Reasonable agreement was found between soybean (Glycine max L. Merr.) leaf water potentials measured on 5-millimeter radius leaf discs and large leaf segments. Results indicated that while errors due to adsorption may be significant when using small volumes of tissue, if sufficient tissue is used the errors are negligible. Because of the relationship between water potential and volume in plant tissue, the errors due to adsorption were larger with turgid tissue. Large psychrometers which were sealed into the sample chamber with latex tubing appeared to adsorb more water than those sealed with flexible plastic tubing. Estimates are provided of the amounts of water adsorbed by two different psychrometer assemblies and the amount of tissue sufficient for accurate measurements of leaf water potential with these assemblies. It is also demonstrated that water adsorption problems may have generated low water potential values which in prior studies have been attributed to large cut surface area to volume ratios. PMID:16664367

Genome-wide meta-analyses of multiancestry cohorts identify multiple new susceptibility loci for refractive error and myopia.

PubMed

Verhoeven, Virginie J M; Hysi, Pirro G; Wojciechowski, Robert; Fan, Qiao; Guggenheim, Jeremy A; Höhn, René; MacGregor, Stuart; Hewitt, Alex W; Nag, Abhishek; Cheng, Ching-Yu; Yonova-Doing, Ekaterina; Zhou, Xin; Ikram, M Kamran; Buitendijk, Gabriëlle H S; McMahon, George; Kemp, John P; Pourcain, Beate St; Simpson, Claire L; Mäkelä, Kari-Matti; Lehtimäki, Terho; Kähönen, Mika; Paterson, Andrew D; Hosseini, S Mohsen; Wong, Hoi Suen; Xu, Liang; Jonas, Jost B; Pärssinen, Olavi; Wedenoja, Juho; Yip, Shea Ping; Ho, Daniel W H; Pang, Chi Pui; Chen, Li Jia; Burdon, Kathryn P; Craig, Jamie E; Klein, Barbara E K; Klein, Ronald; Haller, Toomas; Metspalu, Andres; Khor, Chiea-Chuen; Tai, E-Shyong; Aung, Tin; Vithana, Eranga; Tay, Wan-Ting; Barathi, Veluchamy A; Chen, Peng; Li, Ruoying; Liao, Jiemin; Zheng, Yingfeng; Ong, Rick T; Döring, Angela; Evans, David M; Timpson, Nicholas J; Verkerk, Annemieke J M H; Meitinger, Thomas; Raitakari, Olli; Hawthorne, Felicia; Spector, Tim D; Karssen, Lennart C; Pirastu, Mario; Murgia, Federico; Ang, Wei; Mishra, Aniket; Montgomery, Grant W; Pennell, Craig E; Cumberland, Phillippa M; Cotlarciuc, Ioana; Mitchell, Paul; Wang, Jie Jin; Schache, Maria; Janmahasatian, Sarayut; Janmahasathian, Sarayut; Igo, Robert P; Lass, Jonathan H; Chew, Emily; Iyengar, Sudha K; Gorgels, Theo G M F; Rudan, Igor; Hayward, Caroline; Wright, Alan F; Polasek, Ozren; Vatavuk, Zoran; Wilson, James F; Fleck, Brian; Zeller, Tanja; Mirshahi, Alireza; Müller, Christian; Uitterlinden, André G; Rivadeneira, Fernando; Vingerling, Johannes R; Hofman, Albert; Oostra, Ben A; Amin, Najaf; Bergen, Arthur A B; Teo, Yik-Ying; Rahi, Jugnoo S; Vitart, Veronique; Williams, Cathy; Baird, Paul N; Wong, Tien-Yin; Oexle, Konrad; Pfeiffer, Norbert; Mackey, David A; Young, Terri L; van Duijn, Cornelia M; Saw, Seang-Mei; Bailey-Wilson, Joan E; Stambolian, Dwight; Klaver, Caroline C; Hammond, Christopher J

2013-03-01

Refractive error is the most common eye disorder worldwide and is a prominent cause of blindness. Myopia affects over 30% of Western populations and up to 80% of Asians. The CREAM consortium conducted genome-wide meta-analyses, including 37,382 individuals from 27 studies of European ancestry and 8,376 from 5 Asian cohorts. We identified 16 new loci for refractive error in individuals of European ancestry, of which 8 were shared with Asians. Combined analysis identified 8 additional associated loci. The new loci include candidate genes with functions in neurotransmission (GRIA4), ion transport (KCNQ5), retinoic acid metabolism (RDH5), extracellular matrix remodeling (LAMA2 and BMP2) and eye development (SIX6 and PRSS56). We also confirmed previously reported associations with GJD2 and RASGRF1. Risk score analysis using associated SNPs showed a tenfold increased risk of myopia for individuals carrying the highest genetic load. Our results, based on a large meta-analysis across independent multiancestry studies, considerably advance understanding of the mechanisms involved in refractive error and myopia.

[Improving blood safety: errors management in transfusion medicine].

PubMed

Bujandrić, Nevenka; Grujić, Jasmina; Krga-Milanović, Mirjana

2014-01-01

The concept of blood safety includes the entire transfusion chain starting with the collection of blood from the blood donor, and ending with blood transfusion to the patient. The concept involves quality management system as the systematic monitoring of adverse reactions and incidents regarding the blood donor or patient. Monitoring of near-miss errors show the critical points in the working process and increase transfusion safety. The aim of the study was to present the analysis results of adverse and unexpected events in transfusion practice with a potential risk to the health of blood donors and patients. One-year retrospective study was based on the collection, analysis and interpretation of written reports on medical errors in the Blood Transfusion Institute of Vojvodina. Errors were distributed according to the type, frequency and part of the working process where they occurred. Possible causes and corrective actions were described for each error. The study showed that there were not errors with potential health consequences for the blood donor/patient. Errors with potentially damaging consequences for patients were detected throughout the entire transfusion chain. Most of the errors were identified in the preanalytical phase. The human factor was responsible for the largest number of errors. Error reporting system has an important role in the error management and the reduction of transfusion-related risk of adverse events and incidents. The ongoing analysis reveals the strengths and weaknesses of the entire process and indicates the necessary changes. Errors in transfusion medicine can be avoided in a large percentage and prevention is cost-effective, systematic and applicable.

Sources of medical error in refractive surgery.

PubMed

Moshirfar, Majid; Simpson, Rachel G; Dave, Sonal B; Christiansen, Steven M; Edmonds, Jason N; Culbertson, William W; Pascucci, Stephen E; Sher, Neal A; Cano, David B; Trattler, William B

2013-05-01

To evaluate the causes of laser programming errors in refractive surgery and outcomes in these cases. In this multicenter, retrospective chart review, 22 eyes of 18 patients who had incorrect data entered into the refractive laser computer system at the time of treatment were evaluated. Cases were analyzed to uncover the etiology of these errors, patient follow-up treatments, and final outcomes. The results were used to identify potential methods to avoid similar errors in the future. Every patient experienced compromised uncorrected visual acuity requiring additional intervention, and 7 of 22 eyes (32%) lost corrected distance visual acuity (CDVA) of at least one line. Sixteen patients were suitable candidates for additional surgical correction to address these residual visual symptoms and six were not. Thirteen of 22 eyes (59%) received surgical follow-up treatment; nine eyes were treated with contact lenses. After follow-up treatment, six patients (27%) still had a loss of one line or more of CDVA. Three significant sources of error were identified: errors of cylinder conversion, data entry, and patient identification error. Twenty-seven percent of eyes with laser programming errors ultimately lost one or more lines of CDVA. Patients who underwent surgical revision had better outcomes than those who did not. Many of the mistakes identified were likely avoidable had preventive measures been taken, such as strict adherence to patient verification protocol or rigorous rechecking of treatment parameters. Copyright 2013, SLACK Incorporated.

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

PubMed

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

2012-09-01

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

Online adaptation of a c-VEP Brain-computer Interface(BCI) based on error-related potentials and unsupervised learning.

PubMed

Spüler, Martin; Rosenstiel, Wolfgang; Bogdan, Martin

2012-01-01

The goal of a Brain-Computer Interface (BCI) is to control a computer by pure brain activity. Recently, BCIs based on code-modulated visual evoked potentials (c-VEPs) have shown great potential to establish high-performance communication. In this paper we present a c-VEP BCI that uses online adaptation of the classifier to reduce calibration time and increase performance. We compare two different approaches for online adaptation of the system: an unsupervised method and a method that uses the detection of error-related potentials. Both approaches were tested in an online study, in which an average accuracy of 96% was achieved with adaptation based on error-related potentials. This accuracy corresponds to an average information transfer rate of 144 bit/min, which is the highest bitrate reported so far for a non-invasive BCI. In a free-spelling mode, the subjects were able to write with an average of 21.3 error-free letters per minute, which shows the feasibility of the BCI system in a normal-use scenario. In addition we show that a calibration of the BCI system solely based on the detection of error-related potentials is possible, without knowing the true class labels.

Experiences with Lean Six Sigma as improvement strategy to reduce parenteral medication administration errors and associated potential risk of harm.

PubMed

van de Plas, Afke; Slikkerveer, Mariëlle; Hoen, Saskia; Schrijnemakers, Rick; Driessen, Johanna; de Vries, Frank; van den Bemt, Patricia

2017-01-01

In this controlled before-after study the effect of improvements, derived from Lean Six Sigma strategy, on parenteral medication administration errors and the potential risk of harm was determined. During baseline measurement, on control versus intervention ward, at least one administration error occurred in 14 (74%) and 6 (46%) administrations with potential risk of harm in 6 (32%) and 1 (8%) administrations. Most administration errors with high potential risk of harm occurred in bolus injections: 8 (57%) versus 2 (67%) bolus injections were injected too fast with a potential risk of harm in 6 (43%) and 1 (33%) bolus injections on control and intervention ward. Implemented improvement strategies, based on major causes of too fast administration of bolus injections, were: Substitution of bolus injections by infusions, education, availability of administration information and drug round tabards. Post intervention, on the control ward in 76 (76%) administrations at least one error was made (RR 1.03; CI95:0.77-1.38), with a potential risk of harm in 14 (14%) administrations (RR 0.45; CI95:0.20-1.02). In 40 (68%) administrations on the intervention ward at least one error occurred (RR 1.47; CI95:0.80-2.71) but no administrations were associated with a potential risk of harm. A shift in wrong duration administration errors from bolus injections to infusions, with a reduction of potential risk of harm, seems to have occurred on the intervention ward. Although data are insufficient to prove an effect, Lean Six Sigma was experienced as a suitable strategy to select tailored improvements. Further studies are required to prove the effect of the strategy on parenteral medication administration errors.

Experiences with Lean Six Sigma as improvement strategy to reduce parenteral medication administration errors and associated potential risk of harm

PubMed Central

van de Plas, Afke; Slikkerveer, Mariëlle; Hoen, Saskia; Schrijnemakers, Rick; Driessen, Johanna; de Vries, Frank; van den Bemt, Patricia

2017-01-01

In this controlled before-after study the effect of improvements, derived from Lean Six Sigma strategy, on parenteral medication administration errors and the potential risk of harm was determined. During baseline measurement, on control versus intervention ward, at least one administration error occurred in 14 (74%) and 6 (46%) administrations with potential risk of harm in 6 (32%) and 1 (8%) administrations. Most administration errors with high potential risk of harm occurred in bolus injections: 8 (57%) versus 2 (67%) bolus injections were injected too fast with a potential risk of harm in 6 (43%) and 1 (33%) bolus injections on control and intervention ward. Implemented improvement strategies, based on major causes of too fast administration of bolus injections, were: Substitution of bolus injections by infusions, education, availability of administration information and drug round tabards. Post intervention, on the control ward in 76 (76%) administrations at least one error was made (RR 1.03; CI95:0.77-1.38), with a potential risk of harm in 14 (14%) administrations (RR 0.45; CI95:0.20-1.02). In 40 (68%) administrations on the intervention ward at least one error occurred (RR 1.47; CI95:0.80-2.71) but no administrations were associated with a potential risk of harm. A shift in wrong duration administration errors from bolus injections to infusions, with a reduction of potential risk of harm, seems to have occurred on the intervention ward. Although data are insufficient to prove an effect, Lean Six Sigma was experienced as a suitable strategy to select tailored improvements. Further studies are required to prove the effect of the strategy on parenteral medication administration errors. PMID:28674608

Software platform for managing the classification of error- related potentials of observers

NASA Astrophysics Data System (ADS)

Asvestas, P.; Ventouras, E.-C.; Kostopoulos, S.; Sidiropoulos, K.; Korfiatis, V.; Korda, A.; Uzunolglu, A.; Karanasiou, I.; Kalatzis, I.; Matsopoulos, G.

2015-09-01

Human learning is partly based on observation. Electroencephalographic recordings of subjects who perform acts (actors) or observe actors (observers), contain a negative waveform in the Evoked Potentials (EPs) of the actors that commit errors and of observers who observe the error-committing actors. This waveform is called the Error-Related Negativity (ERN). Its detection has applications in the context of Brain-Computer Interfaces. The present work describes a software system developed for managing EPs of observers, with the aim of classifying them into observations of either correct or incorrect actions. It consists of an integrated platform for the storage, management, processing and classification of EPs recorded during error-observation experiments. The system was developed using C# and the following development tools and frameworks: MySQL, .NET Framework, Entity Framework and Emgu CV, for interfacing with the machine learning library of OpenCV. Up to six features can be computed per EP recording per electrode. The user can select among various feature selection algorithms and then proceed to train one of three types of classifiers: Artificial Neural Networks, Support Vector Machines, k-nearest neighbour. Next the classifier can be used for classifying any EP curve that has been inputted to the database.

Analyzing Software Errors in Safety-Critical Embedded Systems

NASA Technical Reports Server (NTRS)

Lutz, Robyn R.

1994-01-01

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

Legal consequences of the moral duty to report errors.

PubMed

Hall, Jacqulyn Kay

2003-09-01

Increasingly, clinicians are under a moral duty to report errors to the patients who are injured by such errors. The sources of this duty are identified, and its probable impact on malpractice litigation and criminal law is discussed. The potential consequences of enforcing this new moral duty as a minimum in law are noted. One predicted consequence is that the trend will be accelerated toward government payment of compensation for errors. The effect of truth-telling on individuals is discussed.

Medication errors: definitions and classification

PubMed Central

Aronson, Jeffrey K

2009-01-01

To understand medication errors and to identify preventive strategies, we need to classify them and define the terms that describe them. The four main approaches to defining technical terms consider etymology, usage, previous definitions, and the Ramsey–Lewis method (based on an understanding of theory and practice). A medication error is ‘a failure in the treatment process that leads to, or has the potential to lead to, harm to the patient’. Prescribing faults, a subset of medication errors, should be distinguished from prescription errors. A prescribing fault is ‘a failure in the prescribing [decision-making] process that leads to, or has the potential to lead to, harm to the patient’. The converse of this, ‘balanced prescribing’ is ‘the use of a medicine that is appropriate to the patient's condition and, within the limits created by the uncertainty that attends therapeutic decisions, in a dosage regimen that optimizes the balance of benefit to harm’. This excludes all forms of prescribing faults, such as irrational, inappropriate, and ineffective prescribing, underprescribing and overprescribing. A prescription error is ‘a failure in the prescription writing process that results in a wrong instruction about one or more of the normal features of a prescription’. The ‘normal features’ include the identity of the recipient, the identity of the drug, the formulation, dose, route, timing, frequency, and duration of administration. Medication errors can be classified, invoking psychological theory, as knowledge-based mistakes, rule-based mistakes, action-based slips, and memory-based lapses. This classification informs preventive strategies. PMID:19594526

PREST-plus identifies pedigree errors and cryptic relatedness in the GAW18 sample using genome-wide SNP data.

PubMed

Sun, Lei; Dimitromanolakis, Apostolos

2014-01-01

Pedigree errors and cryptic relatedness often appear in families or population samples collected for genetic studies. If not identified, these issues can lead to either increased false negatives or false positives in both linkage and association analyses. To identify pedigree errors and cryptic relatedness among individuals from the 20 San Antonio Family Studies (SAFS) families and cryptic relatedness among the 157 putatively unrelated individuals, we apply PREST-plus to the genome-wide single-nucleotide polymorphism (SNP) data and analyze estimated identity-by-descent (IBD) distributions for all pairs of genotyped individuals. Based on the given pedigrees alone, PREST-plus identifies the following putative pairs: 1091 full-sib, 162 half-sib, 360 grandparent-grandchild, 2269 avuncular, 2717 first cousin, 402 half-avuncular, 559 half-first cousin, 2 half-sib+first cousin, 957 parent-offspring and 440,546 unrelated. Using the genotype data, PREST-plus detects 7 mis-specified relative pairs, with their IBD estimates clearly deviating from the null expectations, and it identifies 4 cryptic related pairs involving 7 individuals from 6 families.

Noise-induced errors in geophysical parameter estimation from retarding potential analyzers in low Earth orbit

NASA Astrophysics Data System (ADS)

Debchoudhury, Shantanab; Earle, Gregory

2017-04-01

Retarding Potential Analyzers (RPA) have a rich flight heritage. Standard curve-fitting analysis techniques exist that can infer state variables in the ionospheric plasma environment from RPA data, but the estimation process is prone to errors arising from a number of sources. Previous work has focused on the effects of grid geometry on uncertainties in estimation; however, no prior study has quantified the estimation errors due to additive noise. In this study, we characterize the errors in estimation of thermal plasma parameters by adding noise to the simulated data derived from the existing ionospheric models. We concentrate on low-altitude, mid-inclination orbits since a number of nano-satellite missions are focused on this region of the ionosphere. The errors are quantified and cross-correlated for varying geomagnetic conditions.

Risk Factors for Increased Severity of Paediatric Medication Administration Errors

PubMed Central

Sears, Kim; Goodman, William M.

2012-01-01

Patients' risks from medication errors are widely acknowledged. Yet not all errors, if they occur, have the same risks for severe consequences. Facing resource constraints, policy makers could prioritize factors having the greatest severe–outcome risks. This study assists such prioritization by identifying work-related risk factors most clearly associated with more severe consequences. Data from three Canadian paediatric centres were collected, without identifiers, on actual or potential errors that occurred. Three hundred seventy-two errors were reported, with outcome severities ranging from time delays up to fatalities. Four factors correlated significantly with increased risk for more severe outcomes: insufficient training; overtime; precepting a student; and off-service patient. Factors' impacts on severity also vary with error class: for wrong-time errors, the factors precepting a student or working overtime significantly increase severe-outcomes risk. For other types, caring for an off-service patient has greatest severity risk. To expand such research, better standardization is needed for categorizing outcome severities. PMID:23968607

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

PubMed

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

2018-06-01

Opioids are a high-risk medicine frequently used to manage palliative patients' cancer-related pain and other symptoms. Despite the high volume of opioid use in inpatient palliative care services, and the potential for patient harm, few studies have focused on opioid errors in this population. To (i) identify the number of opioid errors reported by inpatient palliative care services, (ii) identify reported opioid error characteristics and (iii) determine the impact of opioid errors on palliative patient outcomes. A 24-month retrospective review of opioid errors reported in three inpatient palliative care services in one Australian state. Of the 55 opioid errors identified, 84% reached the patient. Most errors involved morphine (35%) or hydromorphone (29%). Opioid administration errors accounted for 76% of reported opioid errors, largely due to omitted dose (33%) or wrong dose (24%) errors. Patients were more likely to receive a lower dose of opioid than ordered as a direct result of an opioid error (57%), with errors adversely impacting pain and/or symptom management in 42% of patients. Half (53%) of the affected patients required additional treatment and/or care as a direct consequence of the opioid error. This retrospective review has provided valuable insights into the patterns and impact of opioid errors in inpatient palliative care services. Iatrogenic harm related to opioid underdosing errors contributed to palliative patients' unrelieved pain. Better understanding the factors that contribute to opioid errors and the role of safety culture in the palliative care service context warrants further investigation. © Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.

Error-related brain activity and error awareness in an error classification paradigm.

PubMed

Di Gregorio, Francesco; Steinhauser, Marco; Maier, Martin E

2016-10-01

Error-related brain activity has been linked to error detection enabling adaptive behavioral adjustments. However, it is still unclear which role error awareness plays in this process. Here, we show that the error-related negativity (Ne/ERN), an event-related potential reflecting early error monitoring, is dissociable from the degree of error awareness. Participants responded to a target while ignoring two different incongruent distractors. After responding, they indicated whether they had committed an error, and if so, whether they had responded to one or to the other distractor. This error classification paradigm allowed distinguishing partially aware errors, (i.e., errors that were noticed but misclassified) and fully aware errors (i.e., errors that were correctly classified). The Ne/ERN was larger for partially aware errors than for fully aware errors. Whereas this speaks against the idea that the Ne/ERN foreshadows the degree of error awareness, it confirms the prediction of a computational model, which relates the Ne/ERN to post-response conflict. This model predicts that stronger distractor processing - a prerequisite of error classification in our paradigm - leads to lower post-response conflict and thus a smaller Ne/ERN. This implies that the relationship between Ne/ERN and error awareness depends on how error awareness is related to response conflict in a specific task. Our results further indicate that the Ne/ERN but not the degree of error awareness determines adaptive performance adjustments. Taken together, we conclude that the Ne/ERN is dissociable from error awareness and foreshadows adaptive performance adjustments. Our results suggest that the relationship between the Ne/ERN and error awareness is correlative and mediated by response conflict. Copyright © 2016 Elsevier Inc. All rights reserved.

Task-dependent signal variations in EEG error-related potentials for brain-computer interfaces.

PubMed

Iturrate, I; Montesano, L; Minguez, J

2013-04-01

A major difficulty of brain-computer interface (BCI) technology is dealing with the noise of EEG and its signal variations. Previous works studied time-dependent non-stationarities for BCIs in which the user's mental task was independent of the device operation (e.g., the mental task was motor imagery and the operational task was a speller). However, there are some BCIs, such as those based on error-related potentials, where the mental and operational tasks are dependent (e.g., the mental task is to assess the device action and the operational task is the device action itself). The dependence between the mental task and the device operation could introduce a new source of signal variations when the operational task changes, which has not been studied yet. The aim of this study is to analyse task-dependent signal variations and their effect on EEG error-related potentials. The work analyses the EEG variations on the three design steps of BCIs: an electrophysiology study to characterize the existence of these variations, a feature distribution analysis and a single-trial classification analysis to measure the impact on the final BCI performance. The results demonstrate that a change in the operational task produces variations in the potentials, even when EEG activity exclusively originated in brain areas related to error processing is considered. Consequently, the extracted features from the signals vary, and a classifier trained with one operational task presents a significant loss of performance for other tasks, requiring calibration or adaptation for each new task. In addition, a new calibration for each of the studied tasks rapidly outperforms adaptive techniques designed in the literature to mitigate the EEG time-dependent non-stationarities.

Medication administration errors in nursing homes using an automated medication dispensing system.

PubMed

van den Bemt, Patricia M L A; Idzinga, Jetske C; Robertz, Hans; Kormelink, Dennis Groot; Pels, Neske

2009-01-01

OBJECTIVE To identify the frequency of medication administration errors as well as their potential risk factors in nursing homes using a distribution robot. DESIGN The study was a prospective, observational study conducted within three nursing homes in the Netherlands caring for 180 individuals. MEASUREMENTS Medication errors were measured using the disguised observation technique. Types of medication errors were described. The correlation between several potential risk factors and the occurrence of medication errors was studied to identify potential causes for the errors. RESULTS In total 2,025 medication administrations to 127 clients were observed. In these administrations 428 errors were observed (21.2%). The most frequently occurring types of errors were use of wrong administration techniques (especially incorrect crushing of medication and not supervising the intake of medication) and wrong time errors (administering the medication at least 1 h early or late).The potential risk factors female gender (odds ratio (OR) 1.39; 95% confidence interval (CI) 1.05-1.83), ATC medication class antibiotics (OR 11.11; 95% CI 2.66-46.50), medication crushed (OR 7.83; 95% CI 5.40-11.36), number of dosages/day/client (OR 1.03; 95% CI 1.01-1.05), nursing home 2 (OR 3.97; 95% CI 2.86-5.50), medication not supplied by distribution robot (OR 2.92; 95% CI 2.04-4.18), time classes "7-10 am" (OR 2.28; 95% CI 1.50-3.47) and "10 am-2 pm" (OR 1.96; 1.18-3.27) and day of the week "Wednesday" (OR 1.46; 95% CI 1.03-2.07) are associated with a higher risk of administration errors. CONCLUSIONS Medication administration in nursing homes is prone to many errors. This study indicates that the handling of the medication after removing it from the robot packaging may contribute to this high error frequency, which may be reduced by training of nurse attendants, by automated clinical decision support and by measures to reduce workload.

Errors in Aviation Decision Making: Bad Decisions or Bad Luck?

NASA Technical Reports Server (NTRS)

Orasanu, Judith; Martin, Lynne; Davison, Jeannie; Null, Cynthia H. (Technical Monitor)

1998-01-01

Despite efforts to design systems and procedures to support 'correct' and safe operations in aviation, errors in human judgment still occur and contribute to accidents. In this paper we examine how an NDM (naturalistic decision making) approach might help us to understand the role of decision processes in negative outcomes. Our strategy was to examine a collection of identified decision errors through the lens of an aviation decision process model and to search for common patterns. The second, and more difficult, task was to determine what might account for those patterns. The corpus we analyzed consisted of tactical decision errors identified by the NTSB (National Transportation Safety Board) from a set of accidents in which crew behavior contributed to the accident. A common pattern emerged: about three quarters of the errors represented plan-continuation errors, that is, a decision to continue with the original plan despite cues that suggested changing the course of action. Features in the context that might contribute to these errors were identified: (a) ambiguous dynamic conditions and (b) organizational and socially-induced goal conflicts. We hypothesize that 'errors' are mediated by underestimation of risk and failure to analyze the potential consequences of continuing with the initial plan. Stressors may further contribute to these effects. Suggestions for improving performance in these error-inducing contexts are discussed.

Effect of Bar-code Technology on the Incidence of Medication Dispensing Errors and Potential Adverse Drug Events in a Hospital Pharmacy

PubMed Central

Poon, Eric G; Cina, Jennifer L; Churchill, William W; Mitton, Patricia; McCrea, Michelle L; Featherstone, Erica; Keohane, Carol A; Rothschild, Jeffrey M; Bates, David W; Gandhi, Tejal K

2005-01-01

We performed a direct observation pre-post study to evaluate the impact of barcode technology on medication dispensing errors and potential adverse drug events in the pharmacy of a tertiary-academic medical center. We found that barcode technology significantly reduced the rate of target dispensing errors leaving the pharmacy by 85%, from 0.37% to 0.06%. The rate of potential adverse drug events (ADEs) due to dispensing errors was also significantly reduced by 63%, from 0.19% to 0.069%. In a 735-bed hospital where 6 million doses of medications are dispensed per year, this technology is expected to prevent about 13,000 dispensing errors and 6,000 potential ADEs per year. PMID:16779372

Evaluation of drug administration errors in a teaching hospital

PubMed Central

2012-01-01

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

Evaluation of drug administration errors in a teaching hospital.

PubMed

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

2012-03-12

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

Methods of identifying potential vanpool riders.

DOT National Transportation Integrated Search

1977-01-01

Identifying potential vanpool riders and matching them to form pools are fundamental tasks in the initiation of a vanpool program. The manner in which these tasks are done will determine the costs and benefits of the program. This report presents the...

Task-dependent signal variations in EEG error-related potentials for brain-computer interfaces

NASA Astrophysics Data System (ADS)

Iturrate, I.; Montesano, L.; Minguez, J.

2013-04-01

Objective. A major difficulty of brain-computer interface (BCI) technology is dealing with the noise of EEG and its signal variations. Previous works studied time-dependent non-stationarities for BCIs in which the user’s mental task was independent of the device operation (e.g., the mental task was motor imagery and the operational task was a speller). However, there are some BCIs, such as those based on error-related potentials, where the mental and operational tasks are dependent (e.g., the mental task is to assess the device action and the operational task is the device action itself). The dependence between the mental task and the device operation could introduce a new source of signal variations when the operational task changes, which has not been studied yet. The aim of this study is to analyse task-dependent signal variations and their effect on EEG error-related potentials.Approach. The work analyses the EEG variations on the three design steps of BCIs: an electrophysiology study to characterize the existence of these variations, a feature distribution analysis and a single-trial classification analysis to measure the impact on the final BCI performance.Results and significance. The results demonstrate that a change in the operational task produces variations in the potentials, even when EEG activity exclusively originated in brain areas related to error processing is considered. Consequently, the extracted features from the signals vary, and a classifier trained with one operational task presents a significant loss of performance for other tasks, requiring calibration or adaptation for each new task. In addition, a new calibration for each of the studied tasks rapidly outperforms adaptive techniques designed in the literature to mitigate the EEG time-dependent non-stationarities.

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

PubMed

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

2016-12-01

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

Reducing Diagnostic Errors through Effective Communication: Harnessing the Power of Information Technology

PubMed Central

Naik, Aanand Dinkar; Rao, Raghuram; Petersen, Laura Ann

2008-01-01

Diagnostic errors are poorly understood despite being a frequent cause of medical errors. Recent efforts have aimed to advance the "basic science" of diagnostic error prevention by tracing errors to their most basic origins. Although a refined theory of diagnostic error prevention will take years to formulate, we focus on communication breakdown, a major contributor to diagnostic errors and an increasingly recognized preventable factor in medical mishaps. We describe a comprehensive framework that integrates the potential sources of communication breakdowns within the diagnostic process and identifies vulnerable steps in the diagnostic process where various types of communication breakdowns can precipitate error. We then discuss potential information technology-based interventions that may have efficacy in preventing one or more forms of these breakdowns. These possible intervention strategies include using new technologies to enhance communication between health providers and health systems, improve patient involvement, and facilitate management of information in the medical record. PMID:18373151

A day in the life of a volunteer incident commander: errors, pressures and mitigating strategies.

PubMed

Bearman, Christopher; Bremner, Peter A

2013-05-01

To meet an identified gap in the literature this paper investigates the tasks that a volunteer incident commander needs to carry out during an incident, the errors that can be made and the way that errors are managed. In addition, pressure from goal seduction and situation aversion were also examined. Volunteer incident commanders participated in a two-part interview consisting of a critical decision method interview and discussions about a hierarchical task analysis constructed by the authors. A SHERPA analysis was conducted to further identify potential errors. The results identified the key tasks, errors with extreme risk, pressures from strong situations and mitigating strategies for errors and pressures. The errors and pressures provide a basic set of issues that need to be managed by both volunteer incident commanders and fire agencies. The mitigating strategies identified here suggest some ways that this can be done. Copyright © 2012 Elsevier Ltd and The Ergonomics Society. All rights reserved.

Bootstrap Estimates of Standard Errors in Generalizability Theory

ERIC Educational Resources Information Center

Tong, Ye; Brennan, Robert L.

2007-01-01

Estimating standard errors of estimated variance components has long been a challenging task in generalizability theory. Researchers have speculated about the potential applicability of the bootstrap for obtaining such estimates, but they have identified problems (especially bias) in using the bootstrap. Using Brennan's bias-correcting procedures…

Uses of tuberculosis mortality surveillance to identify programme errors and improve database reporting.

PubMed

Selig, L; Guedes, R; Kritski, A; Spector, N; Lapa E Silva, J R; Braga, J U; Trajman, A

2009-08-01

In 2006, 848 persons died from tuberculosis (TB) in Rio de Janeiro, Brazil, corresponding to a mortality rate of 5.4 per 100 000 population. No specific TB death surveillance actions are currently in place in Brazil. Two public general hospitals with large open emergency rooms in Rio de Janeiro City. To evaluate the contribution of TB death surveillance in detecting gaps in TB control. We conducted a survey of TB deaths from September 2005 to August 2006. Records of TB-related deaths and deaths due to undefined causes were investigated. Complementary data were gathered from the mortality and TB notification databases. Seventy-three TB-related deaths were investigated. Transmission hazards were identified among firefighters, health care workers and in-patients. Management errors included failure to isolate suspected cases, to confirm TB, to correct drug doses in underweight patients and to trace contacts. Following the survey, 36 cases that had not previously been notified were included in the national TB notification database and the outcome of 29 notified cases was corrected. TB mortality surveillance can contribute to TB monitoring and evaluation by detecting correctable and specific programme- and hospital-based care errors, and by improving the accuracy of TB database reporting. Specific local and programmatic interventions can be proposed as a result.

Medication Administration Errors in Nursing Homes Using an Automated Medication Dispensing System

PubMed Central

van den Bemt, Patricia M.L.A.; Idzinga, Jetske C.; Robertz, Hans; Kormelink, Dennis Groot; Pels, Neske

2009-01-01

Objective To identify the frequency of medication administration errors as well as their potential risk factors in nursing homes using a distribution robot. Design The study was a prospective, observational study conducted within three nursing homes in the Netherlands caring for 180 individuals. Measurements Medication errors were measured using the disguised observation technique. Types of medication errors were described. The correlation between several potential risk factors and the occurrence of medication errors was studied to identify potential causes for the errors. Results In total 2,025 medication administrations to 127 clients were observed. In these administrations 428 errors were observed (21.2%). The most frequently occurring types of errors were use of wrong administration techniques (especially incorrect crushing of medication and not supervising the intake of medication) and wrong time errors (administering the medication at least 1 h early or late).The potential risk factors female gender (odds ratio (OR) 1.39; 95% confidence interval (CI) 1.05–1.83), ATC medication class antibiotics (OR 11.11; 95% CI 2.66–46.50), medication crushed (OR 7.83; 95% CI 5.40–11.36), number of dosages/day/client (OR 1.03; 95% CI 1.01–1.05), nursing home 2 (OR 3.97; 95% CI 2.86–5.50), medication not supplied by distribution robot (OR 2.92; 95% CI 2.04–4.18), time classes “7–10 am” (OR 2.28; 95% CI 1.50–3.47) and “10 am-2 pm” (OR 1.96; 1.18–3.27) and day of the week “Wednesday” (OR 1.46; 95% CI 1.03–2.07) are associated with a higher risk of administration errors. Conclusions Medication administration in nursing homes is prone to many errors. This study indicates that the handling of the medication after removing it from the robot packaging may contribute to this high error frequency, which may be reduced by training of nurse attendants, by automated clinical decision support and by measures to reduce workload. PMID:19390109

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

PubMed Central

Allison, David B.

2018-01-01

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

A continuous quality improvement project to reduce medication error in the emergency department.

PubMed

Lee, Sara Bc; Lee, Larry Ly; Yeung, Richard Sd; Chan, Jimmy Ts

2013-01-01

Medication errors are a common source of adverse healthcare incidents particularly in the emergency department (ED) that has a number of factors that make it prone to medication errors. This project aims to reduce medication errors and improve the health and economic outcomes of clinical care in Hong Kong ED. In 2009, a task group was formed to identify problems that potentially endanger medication safety and developed strategies to eliminate these problems. Responsible officers were assigned to look after seven error-prone areas. Strategies were proposed, discussed, endorsed and promulgated to eliminate the problems identified. A reduction of medication incidents (MI) from 16 to 6 was achieved before and after the improvement work. This project successfully established a concrete organizational structure to safeguard error-prone areas of medication safety in a sustainable manner.

Incidence of speech recognition errors in the emergency department.

PubMed

Goss, Foster R; Zhou, Li; Weiner, Scott G

2016-09-01

Physician use of computerized speech recognition (SR) technology has risen in recent years due to its ease of use and efficiency at the point of care. However, error rates between 10 and 23% have been observed, raising concern about the number of errors being entered into the permanent medical record, their impact on quality of care and medical liability that may arise. Our aim was to determine the incidence and types of SR errors introduced by this technology in the emergency department (ED). Level 1 emergency department with 42,000 visits/year in a tertiary academic teaching hospital. A random sample of 100 notes dictated by attending emergency physicians (EPs) using SR software was collected from the ED electronic health record between January and June 2012. Two board-certified EPs annotated the notes and conducted error analysis independently. An existing classification schema was adopted to classify errors into eight errors types. Critical errors deemed to potentially impact patient care were identified. There were 128 errors in total or 1.3 errors per note, and 14.8% (n=19) errors were judged to be critical. 71% of notes contained errors, and 15% contained one or more critical errors. Annunciation errors were the highest at 53.9% (n=69), followed by deletions at 18.0% (n=23) and added words at 11.7% (n=15). Nonsense errors, homonyms and spelling errors were present in 10.9% (n=14), 4.7% (n=6), and 0.8% (n=1) of notes, respectively. There were no suffix or dictionary errors. Inter-annotator agreement was 97.8%. This is the first estimate at classifying speech recognition errors in dictated emergency department notes. Speech recognition errors occur commonly with annunciation errors being the most frequent. Error rates were comparable if not lower than previous studies. 15% of errors were deemed critical, potentially leading to miscommunication that could affect patient care. Copyright © 2016 Elsevier Ireland Ltd. All rights reserved.

Intravenous Chemotherapy Compounding Errors in a Follow-Up Pan-Canadian Observational Study.

PubMed

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

Potential lost productivity resulting from the global burden of uncorrected refractive error.

PubMed

Smith, T S T; Frick, K D; Holden, B A; Fricke, T R; Naidoo, K S

2009-06-01

To estimate the potential global economic productivity loss associated with the existing burden of visual impairment from uncorrected refractive error (URE). Conservative assumptions and national population, epidemiological and economic data were used to estimate the purchasing power parity-adjusted gross domestic product (PPP-adjusted GDP) loss for all individuals with impaired vision and blindness, and for individuals with normal sight who provide them with informal care. An estimated 158.1 million cases of visual impairment resulted from uncorrected or undercorrected refractive error in 2007; of these, 8.7 million were blind. We estimated the global economic productivity loss in international dollars (I$) associated with this burden at I$ 427.7 billion before, and I$ 268.8 billion after, adjustment for country-specific labour force participation and employment rates. With the same adjustment, but assuming no economic productivity for individuals aged > 50 years, we estimated the potential productivity loss at I$ 121.4 billion. Even under the most conservative assumptions, the total estimated productivity loss, in $I, associated with visual impairment from URE is approximately a thousand times greater than the global number of cases. The cost of scaling up existing refractive services to meet this burden is unknown, but if each affected individual were to be provided with appropriate eyeglasses for less than I$ 1000, a net economic gain may be attainable.

Potential lost productivity resulting from the global burden of uncorrected refractive error

PubMed Central

Frick, KD; Holden, BA; Fricke, TR; Naidoo, KS

2009-01-01

Abstract Objective To estimate the potential global economic productivity loss associated with the existing burden of visual impairment from uncorrected refractive error (URE). Methods Conservative assumptions and national population, epidemiological and economic data were used to estimate the purchasing power parity-adjusted gross domestic product (PPP-adjusted GDP) loss for all individuals with impaired vision and blindness, and for individuals with normal sight who provide them with informal care. Findings An estimated 158.1 million cases of visual impairment resulted from uncorrected or undercorrected refractive error in 2007; of these, 8.7 million were blind. We estimated the global economic productivity loss in international dollars (I$) associated with this burden at I$ 427.7 billion before, and I$ 268.8 billion after, adjustment for country-specific labour force participation and employment rates. With the same adjustment, but assuming no economic productivity for individuals aged ≥ 50 years, we estimated the potential productivity loss at I$ 121.4 billion. Conclusion Even under the most conservative assumptions, the total estimated productivity loss, in $I, associated with visual impairment from URE is approximately a thousand times greater than the global number of cases. The cost of scaling up existing refractive services to meet this burden is unknown, but if each affected individual were to be provided with appropriate eyeglasses for less than I$ 1000, a net economic gain may be attainable. PMID:19565121

Identifying the causes of road crashes in Europe

PubMed Central

Thomas, Pete; Morris, Andrew; Talbot, Rachel; Fagerlind, Helen

2013-01-01

This research applies a recently developed model of accident causation, developed to investigate industrial accidents, to a specially gathered sample of 997 crashes investigated in-depth in 6 countries. Based on the work of Hollnagel the model considers a collision to be a consequence of a breakdown in the interaction between road users, vehicles and the organisation of the traffic environment. 54% of road users experienced interpretation errors while 44% made observation errors and 37% planning errors. In contrast to other studies only 11% of drivers were identified as distracted and 8% inattentive. There was remarkably little variation in these errors between the main road user types. The application of the model to future in-depth crash studies offers the opportunity to identify new measures to improve safety and to mitigate the social impact of collisions. Examples given include the potential value of co-driver advisory technologies to reduce observation errors and predictive technologies to avoid conflicting interactions between road users. PMID:24406942

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

PubMed

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

2016-04-01

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

Workshops Increase Students' Proficiency at Identifying General and APA-Style Writing Errors

ERIC Educational Resources Information Center

Jorgensen, Terrence D.; Marek, Pam

2013-01-01

To determine the effectiveness of 20- to 30-min workshops on recognition of errors in American Psychological Association-style writing, 58 introductory psychology students attended one of the three workshops (on grammar, mechanics, or references) and completed error recognition tests (pretest, initial posttest, and three follow-up tests). As a…

Latent error detection: A golden two hours for detection.

PubMed

Saward, Justin R E; Stanton, Neville A

2017-03-01

Undetected error in safety critical contexts generates a latent condition that can contribute to a future safety failure. The detection of latent errors post-task completion is observed in naval air engineers using a diary to record work-related latent error detection (LED) events. A systems view is combined with multi-process theories to explore sociotechnical factors associated with LED. Perception of cues in different environments facilitates successful LED, for which the deliberate review of past tasks within two hours of the error occurring and whilst remaining in the same or similar sociotechnical environment to that which the error occurred appears most effective. Identified ergonomic interventions offer potential mitigation for latent errors; particularly in simple everyday habitual tasks. It is thought safety critical organisations should look to engineer further resilience through the application of LED techniques that engage with system cues across the entire sociotechnical environment, rather than relying on consistent human performance. Crown Copyright © 2016. Published by Elsevier Ltd. All rights reserved.

Errors in veterinary practice: preliminary lessons for building better veterinary teams.

PubMed

Kinnison, T; Guile, D; May, S A

2015-11-14

Case studies in two typical UK veterinary practices were undertaken to explore teamwork, including interprofessional working. Each study involved one week of whole team observation based on practice locations (reception, operating theatre), one week of shadowing six focus individuals (veterinary surgeons, veterinary nurses and administrators) and a final week consisting of semistructured interviews regarding teamwork. Errors emerged as a finding of the study. The definition of errors was inclusive, pertaining to inputs or omitted actions with potential adverse outcomes for patients, clients or the practice. The 40 identified instances could be grouped into clinical errors (dosing/drugs, surgical preparation, lack of follow-up), lost item errors, and most frequently, communication errors (records, procedures, missing face-to-face communication, mistakes within face-to-face communication). The qualitative nature of the study allowed the underlying cause of the errors to be explored. In addition to some individual mistakes, system faults were identified as a major cause of errors. Observed examples and interviews demonstrated several challenges to interprofessional teamworking which may cause errors, including: lack of time, part-time staff leading to frequent handovers, branch differences and individual veterinary surgeon work preferences. Lessons are drawn for building better veterinary teams and implications for Disciplinary Proceedings considered. British Veterinary Association.

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

ERIC Educational Resources Information Center

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

2012-01-01

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

Improving specialist drug prescribing in primary care using task and error analysis: an observational study.

PubMed

Chana, Narinder; Porat, Talya; Whittlesea, Cate; Delaney, Brendan

2017-03-01

Electronic prescribing has benefited from computerised clinical decision support systems (CDSSs); however, no published studies have evaluated the potential for a CDSS to support GPs in prescribing specialist drugs. To identify potential weaknesses and errors in the existing process of prescribing specialist drugs that could be addressed in the development of a CDSS. Semi-structured interviews with key informants followed by an observational study involving GPs in the UK. Twelve key informants were interviewed to investigate the use of CDSSs in the UK. Nine GPs were observed while performing case scenarios depicting requests from hospitals or patients to prescribe a specialist drug. Activity diagrams, hierarchical task analysis, and systematic human error reduction and prediction approach analyses were performed. The current process of prescribing specialist drugs by GPs is prone to error. Errors of omission due to lack of information were the most common errors, which could potentially result in a GP prescribing a specialist drug that should only be prescribed in hospitals, or prescribing a specialist drug without reference to a shared care protocol. Half of all possible errors in the prescribing process had a high probability of occurrence. A CDSS supporting GPs during the process of prescribing specialist drugs is needed. This could, first, support the decision making of whether or not to undertake prescribing, and, second, provide drug-specific parameters linked to shared care protocols, which could reduce the errors identified and increase patient safety. © British Journal of General Practice 2017.

A numerical study of some potential sources of error in side-by-side seismometer evaluations

USGS Publications Warehouse

Holcomb, L. Gary

1990-01-01

This report presents the results of a series of computer simulations of potential errors in test data, which might be obtained when conducting side-by-side comparisons of seismometers. These results can be used as guides in estimating potential sources and magnitudes of errors one might expect when analyzing real test data. First, the derivation of a direct method for calculating the noise levels of two sensors in a side-by-side evaluation is repeated and extended slightly herein. This bulk of this derivation was presented previously (see Holcomb 1989); it is repeated here for easy reference.This method is applied to the analysis of a simulated test of two sensors in a side-by-side test in which the outputs of both sensors consist of white noise spectra with known signal-tonoise ratios (SNR's). This report extends this analysis to high SNR's to determine the limitations of the direct method for calculating the noise levels at signal-to-noise levels which are much higher than presented previously (see Holcomb 1989). Next, the method is used to analyze a simulated test of two sensors in a side-by-side test in which the outputs of both sensors consist of bandshaped noise spectra with known signal-tonoise ratios. This is a much more realistic representation of real world data because the earth's background spectrum is certainly not flat.Finally, the results of the analysis of simulated white and bandshaped side-by-side test data are used to assist in interpreting the analysis of the effects of simulated azimuthal misalignment in side-by-side sensor evaluations. A thorough understanding of azimuthal misalignment errors is important because of the physical impossibility of perfectly aligning two sensors in a real world situation. The analysis herein indicates that alignment errors place lower limits on the levels of system noise which can be resolved in a side-by-side measurement It also indicates that alignment errors are the source of the fact that real data noise

Error and Error Mitigation in Low-Coverage Genome Assemblies

PubMed Central

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

2011-01-01

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

Processor register error correction management

DOEpatents

Bose, Pradip; Cher, Chen-Yong; Gupta, Meeta S.

2016-12-27

Processor register protection management is disclosed. In embodiments, a method of processor register protection management can include determining a sensitive logical register for executable code generated by a compiler, generating an error-correction table identifying the sensitive logical register, and storing the error-correction table in a memory accessible by a processor. The processor can be configured to generate a duplicate register of the sensitive logical register identified by the error-correction table.

The incidence and severity of errors in pharmacist-written discharge medication orders.

PubMed

Onatade, Raliat; Sawieres, Sara; Veck, Alexandra; Smith, Lindsay; Gore, Shivani; Al-Azeib, Sumiah

2017-08-01

Background Errors in discharge prescriptions are problematic. When hospital pharmacists write discharge prescriptions improvements are seen in the quality and efficiency of discharge. There is limited information on the incidence of errors in pharmacists' medication orders. Objective To investigate the extent and clinical significance of errors in pharmacist-written discharge medication orders. Setting 1000-bed teaching hospital in London, UK. Method Pharmacists in this London hospital routinely write discharge medication orders as part of the clinical pharmacy service. Convenient days, based on researcher availability, between October 2013 and January 2014 were selected. Pre-registration pharmacists reviewed all discharge medication orders written by pharmacists on these days and identified discrepancies between the medication history, inpatient chart, patient records and discharge summary. A senior clinical pharmacist confirmed the presence of an error. Each error was assigned a potential clinical significance rating (based on the NCCMERP scale) by a physician and an independent senior clinical pharmacist, working separately. Main outcome measure Incidence of errors in pharmacist-written discharge medication orders. Results 509 prescriptions, written by 51 pharmacists, containing 4258 discharge medication orders were assessed (8.4 orders per prescription). Ten prescriptions (2%), contained a total of ten erroneous orders (order error rate-0.2%). The pharmacist considered that one error had the potential to cause temporary harm (0.02% of all orders). The physician did not rate any of the errors with the potential to cause harm. Conclusion The incidence of errors in pharmacists' discharge medication orders was low. The quality, safety and policy implications of pharmacists routinely writing discharge medication orders should be further explored.

A new simplex chemometric approach to identify olive oil blends with potentially high traceability.

PubMed

Semmar, N; Laroussi-Mezghani, S; Grati-Kamoun, N; Hammami, M; Artaud, J

2016-10-01

Olive oil blends (OOBs) are complex matrices combining different cultivars at variable proportions. Although qualitative determinations of OOBs have been subjected to several chemometric works, quantitative evaluations of their contents remain poorly developed because of traceability difficulties concerning co-occurring cultivars. Around this question, we recently published an original simplex approach helping to develop predictive models of the proportions of co-occurring cultivars from chemical profiles of resulting blends (Semmar & Artaud, 2015). Beyond predictive model construction and validation, this paper presents an extension based on prediction errors' analysis to statistically define the blends with the highest predictability among all the possible ones that can be made by mixing cultivars at different proportions. This provides an interesting way to identify a priori labeled commercial products with potentially high traceability taking into account the natural chemical variability of different constitutive cultivars. Copyright © 2016 Elsevier Ltd. All rights reserved.

Threat and error management for anesthesiologists: a predictive risk taxonomy

PubMed Central

Ruskin, Keith J.; Stiegler, Marjorie P.; Park, Kellie; Guffey, Patrick; Kurup, Viji; Chidester, Thomas

2015-01-01

Purpose of review Patient care in the operating room is a dynamic interaction that requires cooperation among team members and reliance upon sophisticated technology. Most human factors research in medicine has been focused on analyzing errors and implementing system-wide changes to prevent them from recurring. We describe a set of techniques that has been used successfully by the aviation industry to analyze errors and adverse events and explain how these techniques can be applied to patient care. Recent findings Threat and error management (TEM) describes adverse events in terms of risks or challenges that are present in an operational environment (threats) and the actions of specific personnel that potentiate or exacerbate those threats (errors). TEM is a technique widely used in aviation, and can be adapted for the use in a medical setting to predict high-risk situations and prevent errors in the perioperative period. A threat taxonomy is a novel way of classifying and predicting the hazards that can occur in the operating room. TEM can be used to identify error-producing situations, analyze adverse events, and design training scenarios. Summary TEM offers a multifaceted strategy for identifying hazards, reducing errors, and training physicians. A threat taxonomy may improve analysis of critical events with subsequent development of specific interventions, and may also serve as a framework for training programs in risk mitigation. PMID:24113268

Prescribing Errors Involving Medication Dosage Forms

PubMed Central

Lesar, Timothy S

2002-01-01

CONTEXT Prescribing errors involving medication dose formulations have been reported to occur frequently in hospitals. No systematic evaluations of the characteristics of errors related to medication dosage formulation have been performed. OBJECTIVE To quantify the characteristics, frequency, and potential adverse patient effects of prescribing errors involving medication dosage forms . DESIGN Evaluation of all detected medication prescribing errors involving or related to medication dosage forms in a 631-bed tertiary care teaching hospital. MAIN OUTCOME MEASURES Type, frequency, and potential for adverse effects of prescribing errors involving or related to medication dosage forms. RESULTS A total of 1,115 clinically significant prescribing errors involving medication dosage forms were detected during the 60-month study period. The annual number of detected errors increased throughout the study period. Detailed analysis of the 402 errors detected during the last 16 months of the study demonstrated the most common errors to be: failure to specify controlled release formulation (total of 280 cases; 69.7%) both when prescribing using the brand name (148 cases; 36.8%) and when prescribing using the generic name (132 cases; 32.8%); and prescribing controlled delivery formulations to be administered per tube (48 cases; 11.9%). The potential for adverse patient outcome was rated as potentially “fatal or severe” in 3 cases (0.7%), and “serious” in 49 cases (12.2%). Errors most commonly involved cardiovascular agents (208 cases; 51.7%). CONCLUSIONS Hospitalized patients are at risk for adverse outcomes due to prescribing errors related to inappropriate use of medication dosage forms. This information should be considered in the development of strategies to prevent adverse patient outcomes resulting from such errors. PMID:12213138

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...

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

PubMed Central

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

2011-01-01

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

Double ErrP Detection for Automatic Error Correction in an ERP-Based BCI Speller.

PubMed

Cruz, Aniana; Pires, Gabriel; Nunes, Urbano J

2018-01-01

Brain-computer interface (BCI) is a useful device for people with severe motor disabilities. However, due to its low speed and low reliability, BCI still has a very limited application in daily real-world tasks. This paper proposes a P300-based BCI speller combined with a double error-related potential (ErrP) detection to automatically correct erroneous decisions. This novel approach introduces a second error detection to infer whether wrong automatic correction also elicits a second ErrP. Thus, two single-trial responses, instead of one, contribute to the final selection, improving the reliability of error detection. Moreover, to increase error detection, the evoked potential detected as target by the P300 classifier is combined with the evoked error potential at a feature-level. Discriminable error and positive potentials (response to correct feedback) were clearly identified. The proposed approach was tested on nine healthy participants and one tetraplegic participant. The online average accuracy for the first and second ErrPs were 88.4% and 84.8%, respectively. With automatic correction, we achieved an improvement around 5% achieving 89.9% in spelling accuracy for an effective 2.92 symbols/min. The proposed approach revealed that double ErrP detection can improve the reliability and speed of BCI systems.

Minimizing treatment planning errors in proton therapy using failure mode and effects analysis.

PubMed

Zheng, Yuanshui; Johnson, Randall; Larson, Gary

2016-06-01

Failure mode and effects analysis (FMEA) is a widely used tool to evaluate safety or reliability in conventional photon radiation therapy. However, reports about FMEA application in proton therapy are scarce. The purpose of this study is to apply FMEA in safety improvement of proton treatment planning at their center. The authors performed an FMEA analysis of their proton therapy treatment planning process using uniform scanning proton beams. The authors identified possible failure modes in various planning processes, including image fusion, contouring, beam arrangement, dose calculation, plan export, documents, billing, and so on. For each error, the authors estimated the frequency of occurrence, the likelihood of being undetected, and the severity of the error if it went undetected and calculated the risk priority number (RPN). The FMEA results were used to design their quality management program. In addition, the authors created a database to track the identified dosimetric errors. Periodically, the authors reevaluated the risk of errors by reviewing the internal error database and improved their quality assurance program as needed. In total, the authors identified over 36 possible treatment planning related failure modes and estimated the associated occurrence, detectability, and severity to calculate the overall risk priority number. Based on the FMEA, the authors implemented various safety improvement procedures into their practice, such as education, peer review, and automatic check tools. The ongoing error tracking database provided realistic data on the frequency of occurrence with which to reevaluate the RPNs for various failure modes. The FMEA technique provides a systematic method for identifying and evaluating potential errors in proton treatment planning before they result in an error in patient dose delivery. The application of FMEA framework and the implementation of an ongoing error tracking system at their clinic have proven to be useful in error

Insar Unwrapping Error Correction Based on Quasi-Accurate Detection of Gross Errors (quad)

NASA Astrophysics Data System (ADS)

Kang, Y.; Zhao, C. Y.; Zhang, Q.; Yang, C. S.

2018-04-01

Unwrapping error is a common error in the InSAR processing, which will seriously degrade the accuracy of the monitoring results. Based on a gross error correction method, Quasi-accurate detection (QUAD), the method for unwrapping errors automatic correction is established in this paper. This method identifies and corrects the unwrapping errors by establishing a functional model between the true errors and interferograms. The basic principle and processing steps are presented. Then this method is compared with the L1-norm method with simulated data. Results show that both methods can effectively suppress the unwrapping error when the ratio of the unwrapping errors is low, and the two methods can complement each other when the ratio of the unwrapping errors is relatively high. At last the real SAR data is tested for the phase unwrapping error correction. Results show that this new method can correct the phase unwrapping errors successfully in the practical application.

Impact and quantification of the sources of error in DNA pooling designs.

PubMed

Jawaid, A; Sham, P

2009-01-01

The analysis of genome wide variation offers the possibility of unravelling the genes involved in the pathogenesis of disease. Genome wide association studies are also particularly useful for identifying and validating targets for therapeutic intervention as well as for detecting markers for drug efficacy and side effects. The cost of such large-scale genetic association studies may be reduced substantially by the analysis of pooled DNA from multiple individuals. However, experimental errors inherent in pooling studies lead to a potential increase in the false positive rate and a loss in power compared to individual genotyping. Here we quantify various sources of experimental error using empirical data from typical pooling experiments and corresponding individual genotyping counts using two statistical methods. We provide analytical formulas for calculating these different errors in the absence of complete information, such as replicate pool formation, and for adjusting for the errors in the statistical analysis. We demonstrate that DNA pooling has the potential of estimating allele frequencies accurately, and adjusting the pooled allele frequency estimates for differential allelic amplification considerably improves accuracy. Estimates of the components of error show that differential allelic amplification is the most important contributor to the error variance in absolute allele frequency estimation, followed by allele frequency measurement and pool formation errors. Our results emphasise the importance of minimising experimental errors and obtaining correct error estimates in genetic association studies.

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

PubMed

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

2017-02-01

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

Identifying and mitigating errors in satellite telemetry of polar bears

USGS Publications Warehouse

Arthur, Stephen M.; Garner, Gerald W.; Olson, Tamara L.

1998-01-01

Satellite radiotelemetry is a useful method of tracking movements of animals that travel long distances or inhabit remote areas. However, the logistical constraints that encourage the use of satellite telemetry also inhibit efforts to assess accuracy of the resulting data. To investigate effectiveness of methods that might be used to improve the reliability of these data, we compared 3 sets of criteria designed to select the most plausible locations of polar bears (Ursus maritimus) that were tracked using satellite radiotelemetry in the Bering, Chukchi, East Siberian, Laptev, and Kara seas during 1988-93. We also evaluated several indices of location accuracy. Our results suggested that, although indices could provide information useful in evaluating location accuracy, no index or set of criteria was sufficient to identify all the implausible locations. Thus, it was necessary to examine the data and make subjective decisions about which locations to accept or reject. However, by using a formal set of selection criteria, we simplified the task of evaluating locations and ensured that decisions were made consistently. This approach also enabled us to evaluate biases that may be introduced by the criteria used to identify location errors. For our study, the best set of selection criteria comprised: (1) rejecting locations for which the distance to the nearest other point from the same day was >50 km; (2) determining the highest accuracy code (NLOC) for a particular day and rejecting locations from that day with lesser values; and (3) from the remaining locations for each day, selecting the location closest to the location chosen for the previous transmission period. Although our selection criteria seemed unlikely to bias studies of habitat use or geographic distribution, basing selection decisions on distances between points might bias studies of movement rates or distances. It is unlikely that any set of criteria will be best for all situations; to make efficient use

Apologies and Medical Error

PubMed Central

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

Perceptual Bias in Speech Error Data Collection: Insights from Spanish Speech Errors

ERIC Educational Resources Information Center

Perez, Elvira; Santiago, Julio; Palma, Alfonso; O'Seaghdha, Padraig G.

2007-01-01

This paper studies the reliability and validity of naturalistic speech errors as a tool for language production research. Possible biases when collecting naturalistic speech errors are identified and specific predictions derived. These patterns are then contrasted with published reports from Germanic languages (English, German and Dutch) and one…

Applying Intelligent Algorithms to Automate the Identification of Error Factors.

PubMed

Jin, Haizhe; Qu, Qingxing; Munechika, Masahiko; Sano, Masataka; Kajihara, Chisato; Duffy, Vincent G; Chen, Han

2018-05-03

Medical errors are the manifestation of the defects occurring in medical processes. Extracting and identifying defects as medical error factors from these processes are an effective approach to prevent medical errors. However, it is a difficult and time-consuming task and requires an analyst with a professional medical background. The issues of identifying a method to extract medical error factors and reduce the extraction difficulty need to be resolved. In this research, a systematic methodology to extract and identify error factors in the medical administration process was proposed. The design of the error report, extraction of the error factors, and identification of the error factors were analyzed. Based on 624 medical error cases across four medical institutes in both Japan and China, 19 error-related items and their levels were extracted. After which, they were closely related to 12 error factors. The relational model between the error-related items and error factors was established based on a genetic algorithm (GA)-back-propagation neural network (BPNN) model. Additionally, compared to GA-BPNN, BPNN, partial least squares regression and support vector regression, GA-BPNN exhibited a higher overall prediction accuracy, being able to promptly identify the error factors from the error-related items. The combination of "error-related items, their different levels, and the GA-BPNN model" was proposed as an error-factor identification technology, which could automatically identify medical error factors.

Robust global identifiability theory using potentials--Application to compartmental models.

PubMed

Wongvanich, N; Hann, C E; Sirisena, H R

2015-04-01

This paper presents a global practical identifiability theory for analyzing and identifying linear and nonlinear compartmental models. The compartmental system is prolonged onto the potential jet space to formulate a set of input-output equations that are integrals in terms of the measured data, which allows for robust identification of parameters without requiring any simulation of the model differential equations. Two classes of linear and non-linear compartmental models are considered. The theory is first applied to analyze the linear nitrous oxide (N2O) uptake model. The fitting accuracy of the identified models from differential jet space and potential jet space identifiability theories is compared with a realistic noise level of 3% which is derived from sensor noise data in the literature. The potential jet space approach gave a match that was well within the coefficient of variation. The differential jet space formulation was unstable and not suitable for parameter identification. The proposed theory is then applied to a nonlinear immunological model for mastitis in cows. In addition, the model formulation is extended to include an iterative method which allows initial conditions to be accurately identified. With up to 10% noise, the potential jet space theory predicts the normalized population concentration infected with pathogens, to within 9% of the true curve. Copyright © 2015 Elsevier Inc. All rights reserved.

Classification and reduction of pilot error

NASA Technical Reports Server (NTRS)

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

1989-01-01

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

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

PubMed

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

2016-06-01

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

Reducing error and improving efficiency during vascular interventional radiology: implementation of a preprocedural team rehearsal.

PubMed

Morbi, Abigail H M; Hamady, Mohamad S; Riga, Celia V; Kashef, Elika; Pearch, Ben J; Vincent, Charles; Moorthy, Krishna; Vats, Amit; Cheshire, Nicholas J W; Bicknell, Colin D

2012-08-01

To determine the type and frequency of errors during vascular interventional radiology (VIR) and design and implement an intervention to reduce error and improve efficiency in this setting. Ethical guidance was sought from the Research Services Department at Imperial College London. Informed consent was not obtained. Field notes were recorded during 55 VIR procedures by a single observer. Two blinded assessors identified failures from field notes and categorized them into one or more errors by using a 22-part classification system. The potential to cause harm, disruption to procedural flow, and preventability of each failure was determined. A preprocedural team rehearsal (PPTR) was then designed and implemented to target frequent preventable potential failures. Thirty-three procedures were observed subsequently to determine the efficacy of the PPTR. Nonparametric statistical analysis was used to determine the effect of intervention on potential failure rates, potential to cause harm and procedural flow disruption scores (Mann-Whitney U test), and number of preventable failures (Fisher exact test). Before intervention, 1197 potential failures were recorded, of which 54.6% were preventable. A total of 2040 errors were deemed to have occurred to produce these failures. Planning error (19.7%), staff absence (16.2%), equipment unavailability (12.2%), communication error (11.2%), and lack of safety consciousness (6.1%) were the most frequent errors, accounting for 65.4% of the total. After intervention, 352 potential failures were recorded. Classification resulted in 477 errors. Preventable failures decreased from 54.6% to 27.3% (P < .001) with implementation of PPTR. Potential failure rates per hour decreased from 18.8 to 9.2 (P < .001), with no increase in potential to cause harm or procedural flow disruption per failure. Failures during VIR procedures are largely because of ineffective planning, communication error, and equipment difficulties, rather than a result of

Missed opportunities for diagnosis: lessons learned from diagnostic errors in primary care.

PubMed

Goyder, Clare R; Jones, Caroline H D; Heneghan, Carl J; Thompson, Matthew J

2015-12-01

Because of the difficulties inherent in diagnosis in primary care, it is inevitable that diagnostic errors will occur. However, despite the important consequences associated with diagnostic errors and their estimated high prevalence, teaching and research on diagnostic error is a neglected area. To ascertain the key learning points from GPs' experiences of diagnostic errors and approaches to clinical decision making associated with these. Secondary analysis of 36 qualitative interviews with GPs in Oxfordshire, UK. Two datasets of semi-structured interviews were combined. Questions focused on GPs' experiences of diagnosis and diagnostic errors (or near misses) in routine primary care and out of hours. Interviews were audiorecorded, transcribed verbatim, and analysed thematically. Learning points include GPs' reliance on 'pattern recognition' and the failure of this strategy to identify atypical presentations; the importance of considering all potentially serious conditions using a 'restricted rule out' approach; and identifying and acting on a sense of unease. Strategies to help manage uncertainty in primary care were also discussed. Learning from previous examples of diagnostic errors is essential if these events are to be reduced in the future and this should be incorporated into GP training. At a practice level, learning points from experiences of diagnostic errors should be discussed more frequently; and more should be done to integrate these lessons nationally to understand and characterise diagnostic errors. © British Journal of General Practice 2015.

Evaluating mixed samples as a source of error in non-invasive genetic studies using microsatellites

USGS Publications Warehouse

Roon, David A.; Thomas, M.E.; Kendall, K.C.; Waits, L.P.

2005-01-01

The use of noninvasive genetic sampling (NGS) for surveying wild populations is increasing rapidly. Currently, only a limited number of studies have evaluated potential biases associated with NGS. This paper evaluates the potential errors associated with analysing mixed samples drawn from multiple animals. Most NGS studies assume that mixed samples will be identified and removed during the genotyping process. We evaluated this assumption by creating 128 mixed samples of extracted DNA from brown bear (Ursus arctos) hair samples. These mixed samples were genotyped and screened for errors at six microsatellite loci according to protocols consistent with those used in other NGS studies. Five mixed samples produced acceptable genotypes after the first screening. However, all mixed samples produced multiple alleles at one or more loci, amplified as only one of the source samples, or yielded inconsistent electropherograms by the final stage of the error-checking process. These processes could potentially reduce the number of individuals observed in NGS studies, but errors should be conservative within demographic estimates. Researchers should be aware of the potential for mixed samples and carefully design gel analysis criteria and error checking protocols to detect mixed samples.

Identifying potential academic leaders

PubMed Central

White, David; Krueger, Paul; Meaney, Christopher; Antao, Viola; Kim, Florence; Kwong, Jeffrey C.

2016-01-01

Objective To identify variables associated with willingness to undertake leadership roles among academic family medicine faculty. Design Web-based survey. Bivariate and multivariable analyses (logistic regression) were used to identify variables associated with willingness to undertake leadership roles. Setting Department of Family and Community Medicine at the University of Toronto in Ontario. Participants A total of 687 faculty members. Main outcome measures Variables related to respondents’ willingness to take on various academic leadership roles. Results Of all 1029 faculty members invited to participate in the survey, 687 (66.8%) members responded. Of the respondents, 596 (86.8%) indicated their level of willingness to take on various academic leadership roles. Multivariable analysis revealed that the predictors associated with willingness to take on leadership roles were as follows: pursuit of professional development opportunities (odds ratio [OR] 3.79, 95% CI 2.29 to 6.27); currently holding at least 1 leadership role (OR 5.37, 95% CI 3.38 to 8.53); a history of leadership training (OR 1.86, 95% CI 1.25 to 2.78); the perception that mentorship is important for one’s current role (OR 2.25, 95% CI 1.40 to 3.60); and younger age (OR 0.97, 95% CI 0.95 to 0.99). Conclusion Willingness to undertake new or additional leadership roles was associated with 2 variables related to leadership experiences, 2 variables related to perceptions of mentorship and professional development, and 1 demographic variable (younger age). Interventions that support opportunities in these areas might expand the pool and strengthen the academic leadership potential of faculty members. PMID:27331226

Size-dependent error of the density functional theory ionization potential in vacuum and solution

DOE PAGES

Sosa Vazquez, Xochitl A.; Isborn, Christine M.

2015-12-22

Density functional theory is often the method of choice for modeling the energetics of large molecules and including explicit solvation effects. It is preferable to use a method that treats systems of different sizes and with different amounts of explicit solvent on equal footing. However, recent work suggests that approximate density functional theory has a size-dependent error in the computation of the ionization potential. We here investigate the lack of size-intensivity of the ionization potential computed with approximate density functionals in vacuum and solution. We show that local and semi-local approximations to exchange do not yield a constant ionization potentialmore » for an increasing number of identical isolated molecules in vacuum. Instead, as the number of molecules increases, the total energy required to ionize the system decreases. Rather surprisingly, we find that this is still the case in solution, whether using a polarizable continuum model or with explicit solvent that breaks the degeneracy of each solute, and we find that explicit solvent in the calculation can exacerbate the size-dependent delocalization error. We demonstrate that increasing the amount of exact exchange changes the character of the polarization of the solvent molecules; for small amounts of exact exchange the solvent molecules contribute a fraction of their electron density to the ionized electron, but for larger amounts of exact exchange they properly polarize in response to the cationic solute. As a result, in vacuum and explicit solvent, the ionization potential can be made size-intensive by optimally tuning a long-range corrected hybrid functional.« less

Size-dependent error of the density functional theory ionization potential in vacuum and solution

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

Sosa Vazquez, Xochitl A.; Isborn, Christine M., E-mail: cisborn@ucmerced.edu

2015-12-28

Density functional theory is often the method of choice for modeling the energetics of large molecules and including explicit solvation effects. It is preferable to use a method that treats systems of different sizes and with different amounts of explicit solvent on equal footing. However, recent work suggests that approximate density functional theory has a size-dependent error in the computation of the ionization potential. We here investigate the lack of size-intensivity of the ionization potential computed with approximate density functionals in vacuum and solution. We show that local and semi-local approximations to exchange do not yield a constant ionization potentialmore » for an increasing number of identical isolated molecules in vacuum. Instead, as the number of molecules increases, the total energy required to ionize the system decreases. Rather surprisingly, we find that this is still the case in solution, whether using a polarizable continuum model or with explicit solvent that breaks the degeneracy of each solute, and we find that explicit solvent in the calculation can exacerbate the size-dependent delocalization error. We demonstrate that increasing the amount of exact exchange changes the character of the polarization of the solvent molecules; for small amounts of exact exchange the solvent molecules contribute a fraction of their electron density to the ionized electron, but for larger amounts of exact exchange they properly polarize in response to the cationic solute. In vacuum and explicit solvent, the ionization potential can be made size-intensive by optimally tuning a long-range corrected hybrid functional.« less

Predictors of Errors of Novice Java Programmers

ERIC Educational Resources Information Center

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

2012-01-01

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

#2 - An Empirical Assessment of Exposure Measurement Error ...

EPA Pesticide Factsheets

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.

Radar error statistics for the space shuttle

NASA Technical Reports Server (NTRS)

Lear, W. M.

1979-01-01

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

A cognitive taxonomy of medical errors.

PubMed

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

2004-06-01

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

Laboratory errors and patient safety.

PubMed

Miligy, Dawlat A

2015-01-01

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

Detecting medication errors in the New Zealand pharmacovigilance database: a retrospective analysis.

PubMed

Kunac, Desireé L; Tatley, Michael V

2011-01-01

Despite the traditional focus being adverse drug reactions (ADRs), pharmacovigilance centres have recently been identified as a potentially rich and important source of medication error data. To identify medication errors in the New Zealand Pharmacovigilance database (Centre for Adverse Reactions Monitoring [CARM]), and to describe the frequency and characteristics of these events. A retrospective analysis of the CARM pharmacovigilance database operated by the New Zealand Pharmacovigilance Centre was undertaken for the year 1 January-31 December 2007. All reports, excluding those relating to vaccines, clinical trials and pharmaceutical company reports, underwent a preventability assessment using predetermined criteria. Those events deemed preventable were subsequently classified to identify the degree of patient harm, type of error, stage of medication use process where the error occurred and origin of the error. A total of 1412 reports met the inclusion criteria and were reviewed, of which 4.3% (61/1412) were deemed preventable. Not all errors resulted in patient harm: 29.5% (18/61) were 'no harm' errors but 65.5% (40/61) of errors were deemed to have been associated with some degree of patient harm (preventable adverse drug events [ADEs]). For 5.0% (3/61) of events, the degree of patient harm was unable to be determined as the patient outcome was unknown. The majority of preventable ADEs (62.5% [25/40]) occurred in adults aged 65 years and older. The medication classes most involved in preventable ADEs were antibacterials for systemic use and anti-inflammatory agents, with gastrointestinal and respiratory system disorders the most common adverse events reported. For both preventable ADEs and 'no harm' events, most errors were incorrect dose and drug therapy monitoring problems consisting of failures in detection of significant drug interactions, past allergies or lack of necessary clinical monitoring. Preventable events were mostly related to the prescribing and

FRamework Assessing Notorious Contributing Influences for Error (FRANCIE): Perspective on Taxonomy Development to Support Error Reporting and Analysis

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

Pediatric crisis resource management training improves emergency medicine trainees' perceived ability to manage emergencies and ability to identify teamwork errors.

PubMed

Bank, Ilana; Snell, Linda; Bhanji, Farhan

2014-12-01

Improved pediatric crisis resource management (CRM) training is needed in emergency medicine residencies because of the variable nature of exposure to critically ill pediatric patients during training. We created a short, needs-based pediatric CRM simulation workshop with postactivity follow-up to determine retention of CRM knowledge. Our aims were to provide a realistic learning experience for residents and to help the learners recognize common errors in teamwork and improve their perceived abilities to manage ill pediatric patients. Residents participated in a 4-hour objectives-based workshop derived from a formal needs assessment. To quantify their subjective abilities to manage pediatric cases, the residents completed a postworkshop survey (with a retrospective precomponent to assess perceived change). Ability to identify CRM errors was determined via a written assessment of scripted errors in a prerecorded video observed before and 1 month after completion of the workshop. Fifteen of the 16 eligible emergency medicine residents (postgraduate year 1-5) attended the workshop and completed the surveys. There were significant differences in 15 of 16 retrospective pre to post survey items using the Wilcoxon rank sum test for non-parametric data. These included ability to be an effective team leader in general (P < 0.008), delegating tasks appropriately (P < 0.009), and ability to ensure closed-loop communication (P < 0.008). There was a significant improvement in identification of CRM errors through the use of the video assessment from 3 of the 12 CRM errors to 7 of the 12 CRM errors (P < 0.006). The pediatric CRM simulation-based workshop improved the residents' self-perceptions of their pediatric CRM abilities and improved their performance on a video assessment task.

Adverse Drug Events caused by Serious Medication Administration Errors

PubMed Central

Sawarkar, Abhivyakti; Keohane, Carol A.; Maviglia, Saverio; Gandhi, Tejal K; Poon, Eric G

2013-01-01

OBJECTIVE To determine how often serious or life-threatening medication administration errors with the potential to cause patient harm (or potential adverse drug events) result in actual patient harm (or adverse drug events (ADEs)) in the hospital setting. DESIGN Retrospective chart review of clinical events that transpired following observed medication administration errors. BACKGROUND Medication errors are common at the medication administration stage for hospitalized patients. While many of these errors are considered capable of causing patient harm, it is not clear how often patients are actually harmed by these errors. METHODS In a previous study where 14,041 medication administrations in an acute-care hospital were directly observed, investigators discovered 1271 medication administration errors, of which 133 had the potential to cause serious or life-threatening harm to patients and were considered serious or life-threatening potential ADEs. In the current study, clinical reviewers conducted detailed chart reviews of cases where a serious or life-threatening potential ADE occurred to determine if an actual ADE developed following the potential ADE. Reviewers further assessed the severity of the ADE and attribution to the administration error. RESULTS Ten (7.5% [95% C.I. 6.98, 8.01]) actual adverse drug events or ADEs resulted from the 133 serious and life-threatening potential ADEs, of which 6 resulted in significant, three in serious, and one life threatening injury. Therefore 4 (3% [95% C.I. 2.12, 3.6]) serious and life threatening potential ADEs led to serious or life threatening ADEs. Half of the ten actual ADEs were caused by dosage or monitoring errors for anti-hypertensives. The life threatening ADE was caused by an error that was both a transcription and a timing error. CONCLUSION Potential ADEs at the medication administration stage can cause serious patient harm. Given previous estimates of serious or life-threatening potential ADE of 1.33 per 100

Single Versus Multiple Events Error Potential Detection in a BCI-Controlled Car Game With Continuous and Discrete Feedback.

PubMed

Kreilinger, Alex; Hiebel, Hannah; Müller-Putz, Gernot R

2016-03-01

This work aimed to find and evaluate a new method for detecting errors in continuous brain-computer interface (BCI) applications. Instead of classifying errors on a single-trial basis, the new method was based on multiple events (MEs) analysis to increase the accuracy of error detection. In a BCI-driven car game, based on motor imagery (MI), discrete events were triggered whenever subjects collided with coins and/or barriers. Coins counted as correct events, whereas barriers were errors. This new method, termed ME method, combined and averaged the classification results of single events (SEs) and determined the correctness of MI trials, which consisted of event sequences instead of SEs. The benefit of this method was evaluated in an offline simulation. In an online experiment, the new method was used to detect erroneous MI trials. Such MI trials were discarded and could be repeated by the users. We found that, even with low SE error potential (ErrP) detection rates, feasible accuracies can be achieved when combining MEs to distinguish erroneous from correct MI trials. Online, all subjects reached higher scores with error detection than without, at the cost of longer times needed for completing the game. Findings suggest that ErrP detection may become a reliable tool for monitoring continuous states in BCI applications when combining MEs. This paper demonstrates a novel technique for detecting errors in online continuous BCI applications, which yields promising results even with low single-trial detection rates.

Towards eliminating systematic errors caused by the experimental conditions in Biochemical Methane Potential (BMP) tests

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

Strömberg, Sten, E-mail: sten.stromberg@biotek.lu.se; Nistor, Mihaela, E-mail: mn@bioprocesscontrol.com; Liu, Jing, E-mail: jing.liu@biotek.lu.se

Highlights: • The evaluated factors introduce significant systematic errors (10–38%) in BMP tests. • Ambient temperature (T) has the most substantial impact (∼10%) at low altitude. • Ambient pressure (p) has the most substantial impact (∼68%) at high altitude. • Continuous monitoring of T and p is not necessary for kinetic calculations. - Abstract: The Biochemical Methane Potential (BMP) test is increasingly recognised as a tool for selecting and pricing biomass material for production of biogas. However, the results for the same substrate often differ between laboratories and much work to standardise such tests is still needed. In the currentmore » study, the effects from four environmental factors (i.e. ambient temperature and pressure, water vapour content and initial gas composition of the reactor headspace) on the degradation kinetics and the determined methane potential were evaluated with a 2{sup 4} full factorial design. Four substrates, with different biodegradation profiles, were investigated and the ambient temperature was found to be the most significant contributor to errors in the methane potential. Concerning the kinetics of the process, the environmental factors’ impact on the calculated rate constants was negligible. The impact of the environmental factors on the kinetic parameters and methane potential from performing a BMP test at different geographical locations around the world was simulated by adjusting the data according to the ambient temperature and pressure of some chosen model sites. The largest effect on the methane potential was registered from tests performed at high altitudes due to a low ambient pressure. The results from this study illustrate the importance of considering the environmental factors’ influence on volumetric gas measurement in BMP tests. This is essential to achieve trustworthy and standardised results that can be used by researchers and end users from all over the world.« less

Minimizing treatment planning errors in proton therapy using failure mode and effects analysis

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

Zheng, Yuanshui, E-mail: yuanshui.zheng@okc.procure.com; Johnson, Randall; Larson, Gary

Purpose: Failure mode and effects analysis (FMEA) is a widely used tool to evaluate safety or reliability in conventional photon radiation therapy. However, reports about FMEA application in proton therapy are scarce. The purpose of this study is to apply FMEA in safety improvement of proton treatment planning at their center. Methods: The authors performed an FMEA analysis of their proton therapy treatment planning process using uniform scanning proton beams. The authors identified possible failure modes in various planning processes, including image fusion, contouring, beam arrangement, dose calculation, plan export, documents, billing, and so on. For each error, the authorsmore » estimated the frequency of occurrence, the likelihood of being undetected, and the severity of the error if it went undetected and calculated the risk priority number (RPN). The FMEA results were used to design their quality management program. In addition, the authors created a database to track the identified dosimetric errors. Periodically, the authors reevaluated the risk of errors by reviewing the internal error database and improved their quality assurance program as needed. Results: In total, the authors identified over 36 possible treatment planning related failure modes and estimated the associated occurrence, detectability, and severity to calculate the overall risk priority number. Based on the FMEA, the authors implemented various safety improvement procedures into their practice, such as education, peer review, and automatic check tools. The ongoing error tracking database provided realistic data on the frequency of occurrence with which to reevaluate the RPNs for various failure modes. Conclusions: The FMEA technique provides a systematic method for identifying and evaluating potential errors in proton treatment planning before they result in an error in patient dose delivery. The application of FMEA framework and the implementation of an ongoing error tracking system at

The Neural Basis of Error Detection: Conflict Monitoring and the Error-Related Negativity

ERIC Educational Resources Information Center

Yeung, Nick; Botvinick, Matthew M.; Cohen, Jonathan D.

2004-01-01

According to a recent theory, anterior cingulate cortex is sensitive to response conflict, the coactivation of mutually incompatible responses. The present research develops this theory to provide a new account of the error-related negativity (ERN), a scalp potential observed following errors. Connectionist simulations of response conflict in an…

Economic impact of medication error: a systematic review.

PubMed

Walsh, Elaine K; Hansen, Christina Raae; Sahm, Laura J; Kearney, Patricia M; Doherty, Edel; Bradley, Colin P

2017-05-01

Medication error is a significant source of morbidity and mortality among patients. Clinical and cost-effectiveness evidence are required for the implementation of quality of care interventions. Reduction of error-related cost is a key potential benefit of interventions addressing medication error. The aim of this review was to describe and quantify the economic burden associated with medication error. PubMed, Cochrane, Embase, CINAHL, EconLit, ABI/INFORM, Business Source Complete were searched. Studies published 2004-2016 assessing the economic impact of medication error were included. Cost values were expressed in Euro 2015. A narrative synthesis was performed. A total of 4572 articles were identified from database searching, and 16 were included in the review. One study met all applicable quality criteria. Fifteen studies expressed economic impact in monetary terms. Mean cost per error per study ranged from €2.58 to €111 727.08. Healthcare costs were used to measure economic impact in 15 of the included studies with one study measuring litigation costs. Four studies included costs incurred in primary care with the remaining 12 measuring hospital costs. Five studies looked at general medication error in a general population with 11 studies reporting the economic impact of an individual type of medication error or error within a specific patient population. Considerable variability existed between studies in terms of financial cost, patients, settings and errors included. Many were of poor quality. Assessment of economic impact was conducted predominantly in the hospital setting with little assessment of primary care impact. Limited parameters were used to establish economic impact. Copyright © 2017 John Wiley & Sons, Ltd. Copyright © 2017 John Wiley & Sons, Ltd.

Passive quantum error correction of linear optics networks through error averaging

NASA Astrophysics Data System (ADS)

Marshman, Ryan J.; Lund, Austin P.; Rohde, Peter P.; Ralph, Timothy C.

2018-02-01

We propose and investigate a method of error detection and noise correction for bosonic linear networks using a method of unitary averaging. The proposed error averaging does not rely on ancillary photons or control and feedforward correction circuits, remaining entirely passive in its operation. We construct a general mathematical framework for this technique and then give a series of proof of principle examples including numerical analysis. Two methods for the construction of averaging are then compared to determine the most effective manner of implementation and probe the related error thresholds. Finally we discuss some of the potential uses of this scheme.

Coping with medical error: a systematic review of papers to assess the effects of involvement in medical errors on healthcare professionals' psychological well-being.

PubMed

Sirriyeh, Reema; Lawton, Rebecca; Gardner, Peter; Armitage, Gerry

2010-12-01

Previous research has established health professionals as secondary victims of medical error, with the identification of a range of emotional and psychological repercussions that may occur as a result of involvement in error.2 3 Due to the vast range of emotional and psychological outcomes, research to date has been inconsistent in the variables measured and tools used. Therefore, differing conclusions have been drawn as to the nature of the impact of error on professionals and the subsequent repercussions for their team, patients and healthcare institution. A systematic review was conducted. Data sources were identified using database searches, with additional reference and hand searching. Eligibility criteria were applied to all studies identified, resulting in a total of 24 included studies. Quality assessment was conducted with the included studies using a tool that was developed as part of this research, but due to the limited number and diverse nature of studies, no exclusions were made on this basis. Review findings suggest that there is consistent evidence for the widespread impact of medical error on health professionals. Psychological repercussions may include negative states such as shame, self-doubt, anxiety and guilt. Despite much attention devoted to the assessment of negative outcomes, the potential for positive outcomes resulting from error also became apparent, with increased assertiveness, confidence and improved colleague relationships reported. It is evident that involvement in a medical error can elicit a significant psychological response from the health professional involved. However, a lack of literature around coping and support, coupled with inconsistencies and weaknesses in methodology, may need be addressed in future work.

Evaluating a medical error taxonomy.

PubMed

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

2002-01-01

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

Invariance and variability in interaction error-related potentials and their consequences for classification

NASA Astrophysics Data System (ADS)

Abu-Alqumsan, Mohammad; Kapeller, Christoph; Hintermüller, Christoph; Guger, Christoph; Peer, Angelika

2017-12-01

Objective. This paper discusses the invariance and variability in interaction error-related potentials (ErrPs), where a special focus is laid upon the factors of (1) the human mental processing required to assess interface actions (2) time (3) subjects. Approach. Three different experiments were designed as to vary primarily with respect to the mental processes that are necessary to assess whether an interface error has occurred or not. The three experiments were carried out with 11 subjects in a repeated-measures experimental design. To study the effect of time, a subset of the recruited subjects additionally performed the same experiments on different days. Main results. The ErrP variability across the different experiments for the same subjects was found largely attributable to the different mental processing required to assess interface actions. Nonetheless, we found that interaction ErrPs are empirically invariant over time (for the same subject and same interface) and to a lesser extent across subjects (for the same interface). Significance. The obtained results may be used to explain across-study variability of ErrPs, as well as to define guidelines for approaches to the ErrP classifier transferability problem.

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

PubMed Central

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

2015-01-01

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

Identifying Potential Kidney Donors Using Social Networking Websites

PubMed Central

Chang, Alexander; Anderson, Emily E.; Turner, Hang T.; Shoham, David; Hou, Susan H.; Grams, Morgan

2013-01-01

Social networking sites like Facebook may be a powerful tool for increasing rates of live kidney donation. They allow for wide dissemination of information and discussion, and could lessen anxiety associated with a face-to-face request for donation. However, sparse data exist on the use of social media for this purpose. We searched Facebook, the most popular social networking site, for publicly available English-language pages seeking kidney donors for a specific individual, abstracting information on the potential recipient, characteristics of the page itself, and whether potential donors were tested. In the 91 pages meeting inclusion criteria, the mean age of potential recipients was 37 (range: 2–69); 88% were U.S. residents. Other posted information included the individual’s photograph (76%), blood type (64%), cause of kidney disease (43%), and location (71%). Thirty-two percent of pages reported having potential donors tested, and 10% reported receiving a live donor kidney transplant. Those reporting donor testing shared more potential recipient characteristics, provided more information about transplantation, and had higher page traffic. Facebook is already being used to identify potential kidney donors. Future studies should focus on how to safely, ethically, and effectively use social networking sites to inform potential donors and potentially expand live kidney donation. PMID:23600791

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

PubMed

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

2007-07-01

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

Heuristic errors in clinical reasoning.

PubMed

Rylander, Melanie; Guerrasio, Jeannette

2016-08-01

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

Apoplastic water fraction and rehydration techniques introduce significant errors in measurements of relative water content and osmotic potential in plant leaves.

PubMed

Arndt, Stefan K; Irawan, Andi; Sanders, Gregor J

2015-12-01

Relative water content (RWC) and the osmotic potential (π) of plant leaves are important plant traits that can be used to assess drought tolerance or adaptation of plants. We estimated the magnitude of errors that are introduced by dilution of π from apoplastic water in osmometry methods and the errors that occur during rehydration of leaves for RWC and π in 14 different plant species from trees, grasses and herbs. Our data indicate that rehydration technique and length of rehydration can introduce significant errors in both RWC and π. Leaves from all species were fully turgid after 1-3 h of rehydration and increasing the rehydration time resulted in a significant underprediction of RWC. Standing rehydration via the petiole introduced the least errors while rehydration via floating disks and submerging leaves for rehydration led to a greater underprediction of RWC. The same effect was also observed for π. The π values following standing rehydration could be corrected by applying a dilution factor from apoplastic water dilution using an osmometric method but not by using apoplastic water fraction (AWF) from pressure volume (PV) curves. The apoplastic water dilution error was between 5 and 18%, while the two other rehydration methods introduced much greater errors. We recommend the use of the standing rehydration method because (1) the correct rehydration time can be evaluated by measuring water potential, (2) overhydration effects were smallest, and (3) π can be accurately corrected by using osmometric methods to estimate apoplastic water dilution. © 2015 Scandinavian Plant Physiology Society.

Nurses' behaviors and visual scanning patterns may reduce patient identification errors.

PubMed

Marquard, Jenna L; Henneman, Philip L; He, Ze; Jo, Junghee; Fisher, Donald L; Henneman, Elizabeth A

2011-09-01

Patient identification (ID) errors occurring during the medication administration process can be fatal. The aim of this study is to determine whether differences in nurses' behaviors and visual scanning patterns during the medication administration process influence their capacities to identify patient ID errors. Nurse participants (n = 20) administered medications to 3 patients in a simulated clinical setting, with 1 patient having an embedded ID error. Error-identifying nurses tended to complete more process steps in a similar amount of time than non-error-identifying nurses and tended to scan information across artifacts (e.g., ID band, patient chart, medication label) rather than fixating on several pieces of information on a single artifact before fixating on another artifact. Non-error-indentifying nurses tended to increase their durations of off-topic conversations-a type of process interruption-over the course of the trials; the difference between groups was significant in the trial with the embedded ID error. Error-identifying nurses tended to have their most fixations in a row on the patient's chart, whereas non-error-identifying nurses did not tend to have a single artifact on which they consistently fixated. Finally, error-identifying nurses tended to have predictable eye fixation sequences across artifacts, whereas non-error-identifying nurses tended to have seemingly random eye fixation sequences. This finding has implications for nurse training and the design of tools and technologies that support nurses as they complete the medication administration process. (c) 2011 APA, all rights reserved.

Error Detection/Correction in Collaborative Writing

ERIC Educational Resources Information Center

Pilotti, Maura; Chodorow, Martin

2009-01-01

In the present study, we examined error detection/correction during collaborative writing. Subjects were asked to identify and correct errors in two contexts: a passage written by the subject (familiar text) and a passage written by a person other than the subject (unfamiliar text). A computer program inserted errors in function words prior to the…

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

PubMed

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

2012-01-01

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

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.

Avoiding and identifying errors and other threats to the credibility of health economic models.

PubMed

Tappenden, Paul; Chilcott, James B

2014-10-01

Health economic models have become the primary vehicle for undertaking economic evaluation and are used in various healthcare jurisdictions across the world to inform decisions about the use of new and existing health technologies. Models are required because a single source of evidence, such as a randomised controlled trial, is rarely sufficient to provide all relevant information about the expected costs and health consequences of all competing decision alternatives. Whilst models are used to synthesise all relevant evidence, they also contain assumptions, abstractions and simplifications. By their very nature, all models are therefore 'wrong'. As such, the interpretation of estimates of the cost effectiveness of health technologies requires careful judgements about the degree of confidence that can be placed in the models from which they are drawn. The presence of a single error or inappropriate judgement within a model may lead to inappropriate decisions, an inefficient allocation of healthcare resources and ultimately suboptimal outcomes for patients. This paper sets out a taxonomy of threats to the credibility of health economic models. The taxonomy segregates threats to model credibility into three broad categories: (i) unequivocal errors, (ii) violations, and (iii) matters of judgement; and maps these across the main elements of the model development process. These three categories are defined according to the existence of criteria for judging correctness, the degree of force with which such criteria can be applied, and the means by which these credibility threats can be handled. A range of suggested processes and techniques for avoiding and identifying these threats is put forward with the intention of prospectively improving the credibility of models.

The next organizational challenge: finding and addressing diagnostic error.

PubMed

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

2014-03-01

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

Release of genetically engineered insects: a framework to identify potential ecological effects

PubMed Central

David, Aaron S; Kaser, Joe M; Morey, Amy C; Roth, Alexander M; Andow, David A

2013-01-01

Genetically engineered (GE) insects have the potential to radically change pest management worldwide. With recent approvals of GE insect releases, there is a need for a synthesized framework to evaluate their potential ecological and evolutionary effects. The effects may occur in two phases: a transitory phase when the focal population changes in density, and a steady state phase when it reaches a new, constant density. We review potential effects of a rapid change in insect density related to population outbreaks, biological control, invasive species, and other GE organisms to identify a comprehensive list of potential ecological and evolutionary effects of GE insect releases. We apply this framework to the Anopheles gambiae mosquito – a malaria vector being engineered to suppress the wild mosquito population – to identify effects that may occur during the transitory and steady state phases after release. Our methodology reveals many potential effects in each phase, perhaps most notably those dealing with immunity in the transitory phase, and with pathogen and vector evolution in the steady state phase. Importantly, this framework identifies knowledge gaps in mosquito ecology. Identifying effects in the transitory and steady state phases allows more rigorous identification of the potential ecological effects of GE insect release. PMID:24198955

Using SMAP to identify structural errors in hydrologic models

NASA Astrophysics Data System (ADS)

Crow, W. T.; Reichle, R. H.; Chen, F.; Xia, Y.; Liu, Q.

2017-12-01

Despite decades of effort, and the development of progressively more complex models, there continues to be underlying uncertainty regarding the representation of basic water and energy balance processes in land surface models. Soil moisture occupies a central conceptual position between atmosphere forcing of the land surface and resulting surface water fluxes. As such, direct observations of soil moisture are potentially of great value for identifying and correcting fundamental structural problems affecting these models. However, to date, this potential has not yet been realized using satellite-based retrieval products. Using soil moisture data sets produced by the NASA Soil Moisture Active/Passive mission, this presentation will explore the use of the remotely-sensed soil moisture data products as a constraint to reject certain types of surface runoff parameterizations within a land surface model. Results will demonstrate that the precision of the SMAP Level 4 Surface and Root-Zone soil moisture product allows for the robust sampling of correlation statistics describing the true strength of the relationship between pre-storm soil moisture and subsequent storm-scale runoff efficiency (i.e., total storm flow divided by total rainfall both in units of depth). For a set of 16 basins located in the South-Central United States, we will use these sampled correlations to demonstrate that so-called "infiltration-excess" runoff parameterizations under predict the importance of pre-storm soil moisture for determining storm-scale runoff efficiency. To conclude, we will discuss prospects for leveraging this insight to improve short-term hydrologic forecasting and additional avenues for SMAP soil moisture products to provide process-level insight for hydrologic modelers.

Positive Beliefs about Errors as an Important Element of Adaptive Individual Dealing with Errors during Academic Learning

ERIC Educational Resources Information Center

Tulis, Maria; Steuer, Gabriele; Dresel, Markus

2018-01-01

Research on learning from errors gives reason to assume that errors provide a high potential to facilitate deep learning if students are willing and able to take these learning opportunities. The first aim of this study was to analyse whether beliefs about errors as learning opportunities can be theoretically and empirically distinguished from…

Bayesian network models for error detection in radiotherapy plans

NASA Astrophysics Data System (ADS)

Kalet, Alan M.; Gennari, John H.; Ford, Eric C.; Phillips, Mark H.

2015-04-01

The purpose of this study is to design and develop a probabilistic network for detecting errors in radiotherapy plans for use at the time of initial plan verification. Our group has initiated a multi-pronged approach to reduce these errors. We report on our development of Bayesian models of radiotherapy plans. Bayesian networks consist of joint probability distributions that define the probability of one event, given some set of other known information. Using the networks, we find the probability of obtaining certain radiotherapy parameters, given a set of initial clinical information. A low probability in a propagated network then corresponds to potential errors to be flagged for investigation. To build our networks we first interviewed medical physicists and other domain experts to identify the relevant radiotherapy concepts and their associated interdependencies and to construct a network topology. Next, to populate the network’s conditional probability tables, we used the Hugin Expert software to learn parameter distributions from a subset of de-identified data derived from a radiation oncology based clinical information database system. These data represent 4990 unique prescription cases over a 5 year period. Under test case scenarios with approximately 1.5% introduced error rates, network performance produced areas under the ROC curve of 0.88, 0.98, and 0.89 for the lung, brain and female breast cancer error detection networks, respectively. Comparison of the brain network to human experts performance (AUC of 0.90 ± 0.01) shows the Bayes network model performs better than domain experts under the same test conditions. Our results demonstrate the feasibility and effectiveness of comprehensive probabilistic models as part of decision support systems for improved detection of errors in initial radiotherapy plan verification procedures.

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

PubMed Central

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

2005-01-01

angle or wedge orientation. For parallel‐opposed 60° wedge fields, this error could be as high as 80% to a point off‐axis. Other examples of dosimetric impact included the following: SSD, ~2%/cm for photons or electrons; photon energy (6 MV vs. 18 MV), on average 16% depending on depth, electron energy, ~0.5cm of depth coverage per MeV (mega‐electron volt). Of these examples, incorrect distances were most likely but rapidly detected by in vivo dosimetry. Errors were categorized by occurrence rate, methods and timing of detection, longevity, and dosimetric impact. Solutions were devised according to these criteria. To date, no one has studied the dosimetric impact of global errors in radiation oncology. Although there is heightened awareness that with increased use of ancillary devices and automation, there must be a parallel increase in quality check systems and processes, errors do and will continue to occur. This study has helped us identify and prioritize potential errors in our clinic according to frequency and dosimetric impact. For example, to reduce the use of an incorrect wedge direction, our clinic employs off‐axis in vivo dosimetry. To avoid a treatment distance setup error, we use both vertical table settings and optical distance indicator (ODI) values to properly set up fields. As R&V systems become more automated, more accurate and efficient data transfer will occur. This will require further analysis. Finally, we have begun examining potential intensity‐modulated radiation therapy (IMRT) errors according to the same criteria. PACS numbers: 87.53.Xd, 87.53.St PMID:16143793

Development of sensitivity to orthographic errors in children: An event-related potential study.

PubMed

Heldmann, Marcus; Puppe, Svetlana; Effenberg, Alfred O; Münte, Thomas F

2017-09-01

To study the development of orthographic sensitivity during elementary school, we recorded event-related brain potentials (ERPs) from 2nd and 4th grade children who were exposed to line drawing of object or animals upon which the correctly or incorrectly spelled name was superimposed. Stimulus-locked ERPs showed a modulation of a frontocentral negativity between 200 and 500ms which was larger for the 4th grade children but did not show an effect of correctness of spelling. This effect was followed by a pronounced positive shift which was only seen in the 4th grade children and which showed a modulation of spelling correctness. This effect can be seen as an electrophysiological correlate of orthographic sensitivity and replicates earlier findings in adults. Moreover, response-locked ERPs triggered to the children's button presses indicating orthographic (in)-correctness showed a succession of waves including the frontocentral error-related negativity and a subsequent negativity with a more posterior distribution. This latter negativity was generally larger for the 4th grade children. Only for the 4th grade children, this negativity was smaller for the false alarm trials suggesting a conscious registration of the error in these children. Copyright © 2017 IBRO. Published by Elsevier Ltd. All rights reserved.

Error reduction in EMG signal decomposition

PubMed Central

Kline, Joshua C.

2014-01-01

Decomposition of the electromyographic (EMG) signal into constituent action potentials and the identification of individual firing instances of each motor unit in the presence of ambient noise are inherently probabilistic processes, whether performed manually or with automated algorithms. Consequently, they are subject to errors. We set out to classify and reduce these errors by analyzing 1,061 motor-unit action-potential trains (MUAPTs), obtained by decomposing surface EMG (sEMG) signals recorded during human voluntary contractions. Decomposition errors were classified into two general categories: location errors representing variability in the temporal localization of each motor-unit firing instance and identification errors consisting of falsely detected or missed firing instances. To mitigate these errors, we developed an error-reduction algorithm that combines multiple decomposition estimates to determine a more probable estimate of motor-unit firing instances with fewer errors. The performance of the algorithm is governed by a trade-off between the yield of MUAPTs obtained above a given accuracy level and the time required to perform the decomposition. When applied to a set of sEMG signals synthesized from real MUAPTs, the identification error was reduced by an average of 1.78%, improving the accuracy to 97.0%, and the location error was reduced by an average of 1.66 ms. The error-reduction algorithm in this study is not limited to any specific decomposition strategy. Rather, we propose it be used for other decomposition methods, especially when analyzing precise motor-unit firing instances, as occurs when measuring synchronization. PMID:25210159

Analysis of naturalistic driving videos of fleet services drivers to estimate driver error and potentially distracting behaviors as risk factors for rear-end versus angle crashes.

PubMed

Harland, Karisa K; Carney, Cher; McGehee, Daniel

2016-07-03

The objective of this study was to estimate the prevalence and odds of fleet driver errors and potentially distracting behaviors just prior to rear-end versus angle crashes. Analysis of naturalistic driving videos among fleet services drivers for errors and potentially distracting behaviors occurring in the 6 s before crash impact. Categorical variables were examined using the Pearson's chi-square test, and continuous variables, such as eyes-off-road time, were compared using the Student's t-test. Multivariable logistic regression was used to estimate the odds of a driver error or potentially distracting behavior being present in the seconds before rear-end versus angle crashes. Of the 229 crashes analyzed, 101 (44%) were rear-end and 128 (56%) were angle crashes. Driver age, gender, and presence of passengers did not differ significantly by crash type. Over 95% of rear-end crashes involved inadequate surveillance compared to only 52% of angle crashes (P < .0001). Almost 65% of rear-end crashes involved a potentially distracting driver behavior, whereas less than 40% of angle crashes involved these behaviors (P < .01). On average, drivers spent 4.4 s with their eyes off the road while operating or manipulating their cell phone. Drivers in rear-end crashes were at 3.06 (95% confidence interval [CI], 1.73-5.44) times adjusted higher odds of being potentially distracted than those in angle crashes. Fleet driver driving errors and potentially distracting behaviors are frequent. This analysis provides data to inform safe driving interventions for fleet services drivers. Further research is needed in effective interventions to reduce the likelihood of drivers' distracting behaviors and errors that may potentially reducing crashes.

Meta-analysis of gene-environment-wide association scans accounting for education level identifies additional loci for refractive error.

PubMed

Fan, Qiao; Verhoeven, Virginie J M; Wojciechowski, Robert; Barathi, Veluchamy A; Hysi, Pirro G; Guggenheim, Jeremy A; Höhn, René; Vitart, Veronique; Khawaja, Anthony P; Yamashiro, Kenji; Hosseini, S Mohsen; Lehtimäki, Terho; Lu, Yi; Haller, Toomas; Xie, Jing; Delcourt, Cécile; Pirastu, Mario; Wedenoja, Juho; Gharahkhani, Puya; Venturini, Cristina; Miyake, Masahiro; Hewitt, Alex W; Guo, Xiaobo; Mazur, Johanna; Huffman, Jenifer E; Williams, Katie M; Polasek, Ozren; Campbell, Harry; Rudan, Igor; Vatavuk, Zoran; Wilson, James F; Joshi, Peter K; McMahon, George; St Pourcain, Beate; Evans, David M; Simpson, Claire L; Schwantes-An, Tae-Hwi; Igo, Robert P; Mirshahi, Alireza; Cougnard-Gregoire, Audrey; Bellenguez, Céline; Blettner, Maria; Raitakari, Olli; Kähönen, Mika; Seppala, Ilkka; Zeller, Tanja; Meitinger, Thomas; Ried, Janina S; Gieger, Christian; Portas, Laura; van Leeuwen, Elisabeth M; Amin, Najaf; Uitterlinden, André G; Rivadeneira, Fernando; Hofman, Albert; Vingerling, Johannes R; Wang, Ya Xing; Wang, Xu; Tai-Hui Boh, Eileen; Ikram, M Kamran; Sabanayagam, Charumathi; Gupta, Preeti; Tan, Vincent; Zhou, Lei; Ho, Candice E H; Lim, Wan'e; Beuerman, Roger W; Siantar, Rosalynn; Tai, E-Shyong; Vithana, Eranga; Mihailov, Evelin; Khor, Chiea-Chuen; Hayward, Caroline; Luben, Robert N; Foster, Paul J; Klein, Barbara E K; Klein, Ronald; Wong, Hoi-Suen; Mitchell, Paul; Metspalu, Andres; Aung, Tin; Young, Terri L; He, Mingguang; Pärssinen, Olavi; van Duijn, Cornelia M; Jin Wang, Jie; Williams, Cathy; Jonas, Jost B; Teo, Yik-Ying; Mackey, David A; Oexle, Konrad; Yoshimura, Nagahisa; Paterson, Andrew D; Pfeiffer, Norbert; Wong, Tien-Yin; Baird, Paul N; Stambolian, Dwight; Wilson, Joan E Bailey; Cheng, Ching-Yu; Hammond, Christopher J; Klaver, Caroline C W; Saw, Seang-Mei; Rahi, Jugnoo S; Korobelnik, Jean-François; Kemp, John P; Timpson, Nicholas J; Smith, George Davey; Craig, Jamie E; Burdon, Kathryn P; Fogarty, Rhys D; Iyengar, Sudha K; Chew, Emily; Janmahasatian, Sarayut; Martin, Nicholas G; MacGregor, Stuart; Xu, Liang; Schache, Maria; Nangia, Vinay; Panda-Jonas, Songhomitra; Wright, Alan F; Fondran, Jeremy R; Lass, Jonathan H; Feng, Sheng; Zhao, Jing Hua; Khaw, Kay-Tee; Wareham, Nick J; Rantanen, Taina; Kaprio, Jaakko; Pang, Chi Pui; Chen, Li Jia; Tam, Pancy O; Jhanji, Vishal; Young, Alvin L; Döring, Angela; Raffel, Leslie J; Cotch, Mary-Frances; Li, Xiaohui; Yip, Shea Ping; Yap, Maurice K H; Biino, Ginevra; Vaccargiu, Simona; Fossarello, Maurizio; Fleck, Brian; Yazar, Seyhan; Tideman, Jan Willem L; Tedja, Milly; Deangelis, Margaret M; Morrison, Margaux; Farrer, Lindsay; Zhou, Xiangtian; Chen, Wei; Mizuki, Nobuhisa; Meguro, Akira; Mäkelä, Kari Matti

2016-03-29

Myopia is the most common human eye disorder and it results from complex genetic and environmental causes. The rapidly increasing prevalence of myopia poses a major public health challenge. Here, the CREAM consortium performs a joint meta-analysis to test single-nucleotide polymorphism (SNP) main effects and SNP × education interaction effects on refractive error in 40,036 adults from 25 studies of European ancestry and 10,315 adults from 9 studies of Asian ancestry. In European ancestry individuals, we identify six novel loci (FAM150B-ACP1, LINC00340, FBN1, DIS3L-MAP2K1, ARID2-SNAT1 and SLC14A2) associated with refractive error. In Asian populations, three genome-wide significant loci AREG, GABRR1 and PDE10A also exhibit strong interactions with education (P<8.5 × 10(-5)), whereas the interactions are less evident in Europeans. The discovery of these loci represents an important advance in understanding how gene and environment interactions contribute to the heterogeneity of myopia.

Meta-analysis of gene–environment-wide association scans accounting for education level identifies additional loci for refractive error

PubMed Central

Fan, Qiao; Verhoeven, Virginie J. M.; Wojciechowski, Robert; Barathi, Veluchamy A.; Hysi, Pirro G.; Guggenheim, Jeremy A.; Höhn, René; Vitart, Veronique; Khawaja, Anthony P.; Yamashiro, Kenji; Hosseini, S Mohsen; Lehtimäki, Terho; Lu, Yi; Haller, Toomas; Xie, Jing; Delcourt, Cécile; Pirastu, Mario; Wedenoja, Juho; Gharahkhani, Puya; Venturini, Cristina; Miyake, Masahiro; Hewitt, Alex W.; Guo, Xiaobo; Mazur, Johanna; Huffman, Jenifer E.; Williams, Katie M.; Polasek, Ozren; Campbell, Harry; Rudan, Igor; Vatavuk, Zoran; Wilson, James F.; Joshi, Peter K.; McMahon, George; St Pourcain, Beate; Evans, David M.; Simpson, Claire L.; Schwantes-An, Tae-Hwi; Igo, Robert P.; Mirshahi, Alireza; Cougnard-Gregoire, Audrey; Bellenguez, Céline; Blettner, Maria; Raitakari, Olli; Kähönen, Mika; Seppala, Ilkka; Zeller, Tanja; Meitinger, Thomas; Ried, Janina S.; Gieger, Christian; Portas, Laura; van Leeuwen, Elisabeth M.; Amin, Najaf; Uitterlinden, André G.; Rivadeneira, Fernando; Hofman, Albert; Vingerling, Johannes R.; Wang, Ya Xing; Wang, Xu; Tai-Hui Boh, Eileen; Ikram, M. Kamran; Sabanayagam, Charumathi; Gupta, Preeti; Tan, Vincent; Zhou, Lei; Ho, Candice E. H.; Lim, Wan'e; Beuerman, Roger W.; Siantar, Rosalynn; Tai, E-Shyong; Vithana, Eranga; Mihailov, Evelin; Khor, Chiea-Chuen; Hayward, Caroline; Luben, Robert N.; Foster, Paul J.; Klein, Barbara E. K.; Klein, Ronald; Wong, Hoi-Suen; Mitchell, Paul; Metspalu, Andres; Aung, Tin; Young, Terri L.; He, Mingguang; Pärssinen, Olavi; van Duijn, Cornelia M.; Jin Wang, Jie; Williams, Cathy; Jonas, Jost B.; Teo, Yik-Ying; Mackey, David A.; Oexle, Konrad; Yoshimura, Nagahisa; Paterson, Andrew D.; Pfeiffer, Norbert; Wong, Tien-Yin; Baird, Paul N.; Stambolian, Dwight; Wilson, Joan E. Bailey; Cheng, Ching-Yu; Hammond, Christopher J.; Klaver, Caroline C. W.; Saw, Seang-Mei; Rahi, Jugnoo S.; Korobelnik, Jean-François; Kemp, John P.; Timpson, Nicholas J.; Smith, George Davey; Craig, Jamie E.; Burdon, Kathryn P.; Fogarty, Rhys D.; Iyengar, Sudha K.; Chew, Emily; Janmahasatian, Sarayut; Martin, Nicholas G.; MacGregor, Stuart; Xu, Liang; Schache, Maria; Nangia, Vinay; Panda-Jonas, Songhomitra; Wright, Alan F.; Fondran, Jeremy R.; Lass, Jonathan H.; Feng, Sheng; Zhao, Jing Hua; Khaw, Kay-Tee; Wareham, Nick J.; Rantanen, Taina; Kaprio, Jaakko; Pang, Chi Pui; Chen, Li Jia; Tam, Pancy O.; Jhanji, Vishal; Young, Alvin L.; Döring, Angela; Raffel, Leslie J.; Cotch, Mary-Frances; Li, Xiaohui; Yip, Shea Ping; Yap, Maurice K.H.; Biino, Ginevra; Vaccargiu, Simona; Fossarello, Maurizio; Fleck, Brian; Yazar, Seyhan; Tideman, Jan Willem L.; Tedja, Milly; Deangelis, Margaret M.; Morrison, Margaux; Farrer, Lindsay; Zhou, Xiangtian; Chen, Wei; Mizuki, Nobuhisa; Meguro, Akira; Mäkelä, Kari Matti

2016-01-01

Myopia is the most common human eye disorder and it results from complex genetic and environmental causes. The rapidly increasing prevalence of myopia poses a major public health challenge. Here, the CREAM consortium performs a joint meta-analysis to test single-nucleotide polymorphism (SNP) main effects and SNP × education interaction effects on refractive error in 40,036 adults from 25 studies of European ancestry and 10,315 adults from 9 studies of Asian ancestry. In European ancestry individuals, we identify six novel loci (FAM150B-ACP1, LINC00340, FBN1, DIS3L-MAP2K1, ARID2-SNAT1 and SLC14A2) associated with refractive error. In Asian populations, three genome-wide significant loci AREG, GABRR1 and PDE10A also exhibit strong interactions with education (P<8.5 × 10−5), whereas the interactions are less evident in Europeans. The discovery of these loci represents an important advance in understanding how gene and environment interactions contribute to the heterogeneity of myopia. PMID:27020472

Voice Onset Time in Consonant Cluster Errors: Can Phonetic Accommodation Differentiate Cognitive from Motor Errors?

ERIC Educational Resources Information Center

Pouplier, Marianne; Marin, Stefania; Waltl, Susanne

2014-01-01

Purpose: Phonetic accommodation in speech errors has traditionally been used to identify the processing level at which an error has occurred. Recent studies have challenged the view that noncanonical productions may solely be due to phonetic, not phonological, processing irregularities, as previously assumed. The authors of the present study…

Analyzing communication errors in an air medical transport service.

PubMed

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

2013-01-01

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

Learning from Error

DTIC Science & Technology

1988-01-01

AD-A 199 117 . fNOooN - 6 -JS/_~ Learning from Error Colleen M. Seifert . . i’ UCSDand NPRDC L" , Edwin L. Hutchins UCSD -,- -" Introduction Most...always rely on learning on the job, and where there is the need for learning , there is potential for error. A naturally situated system of cooperative work...reorganized, change the things they do, and change the technology they utilize to do the job. Even if tasks and tools could be somehow frozen, changes in

Genome-wide association meta-analysis highlights light-induced signaling as a driver for refractive error.

PubMed

Tedja, Milly S; Wojciechowski, Robert; Hysi, Pirro G; Eriksson, Nicholas; Furlotte, Nicholas A; Verhoeven, Virginie J M; Iglesias, Adriana I; Meester-Smoor, Magda A; Tompson, Stuart W; Fan, Qiao; Khawaja, Anthony P; Cheng, Ching-Yu; Höhn, René; Yamashiro, Kenji; Wenocur, Adam; Grazal, Clare; Haller, Toomas; Metspalu, Andres; Wedenoja, Juho; Jonas, Jost B; Wang, Ya Xing; Xie, Jing; Mitchell, Paul; Foster, Paul J; Klein, Barbara E K; Klein, Ronald; Paterson, Andrew D; Hosseini, S Mohsen; Shah, Rupal L; Williams, Cathy; Teo, Yik Ying; Tham, Yih Chung; Gupta, Preeti; Zhao, Wanting; Shi, Yuan; Saw, Woei-Yuh; Tai, E-Shyong; Sim, Xue Ling; Huffman, Jennifer E; Polašek, Ozren; Hayward, Caroline; Bencic, Goran; Rudan, Igor; Wilson, James F; Joshi, Peter K; Tsujikawa, Akitaka; Matsuda, Fumihiko; Whisenhunt, Kristina N; Zeller, Tanja; van der Spek, Peter J; Haak, Roxanna; Meijers-Heijboer, Hanne; van Leeuwen, Elisabeth M; Iyengar, Sudha K; Lass, Jonathan H; Hofman, Albert; Rivadeneira, Fernando; Uitterlinden, André G; Vingerling, Johannes R; Lehtimäki, Terho; Raitakari, Olli T; Biino, Ginevra; Concas, Maria Pina; Schwantes-An, Tae-Hwi; Igo, Robert P; Cuellar-Partida, Gabriel; Martin, Nicholas G; Craig, Jamie E; Gharahkhani, Puya; Williams, Katie M; Nag, Abhishek; Rahi, Jugnoo S; Cumberland, Phillippa M; Delcourt, Cécile; Bellenguez, Céline; Ried, Janina S; Bergen, Arthur A; Meitinger, Thomas; Gieger, Christian; Wong, Tien Yin; Hewitt, Alex W; Mackey, David A; Simpson, Claire L; Pfeiffer, Norbert; Pärssinen, Olavi; Baird, Paul N; Vitart, Veronique; Amin, Najaf; van Duijn, Cornelia M; Bailey-Wilson, Joan E; Young, Terri L; Saw, Seang-Mei; Stambolian, Dwight; MacGregor, Stuart; Guggenheim, Jeremy A; Tung, Joyce Y; Hammond, Christopher J; Klaver, Caroline C W

2018-06-01

Refractive errors, including myopia, are the most frequent eye disorders worldwide and an increasingly common cause of blindness. This genome-wide association meta-analysis in 160,420 participants and replication in 95,505 participants increased the number of established independent signals from 37 to 161 and showed high genetic correlation between Europeans and Asians (>0.78). Expression experiments and comprehensive in silico analyses identified retinal cell physiology and light processing as prominent mechanisms, and also identified functional contributions to refractive-error development in all cell types of the neurosensory retina, retinal pigment epithelium, vascular endothelium and extracellular matrix. Newly identified genes implicate novel mechanisms such as rod-and-cone bipolar synaptic neurotransmission, anterior-segment morphology and angiogenesis. Thirty-one loci resided in or near regions transcribing small RNAs, thus suggesting a role for post-transcriptional regulation. Our results support the notion that refractive errors are caused by a light-dependent retina-to-sclera signaling cascade and delineate potential pathobiological molecular drivers.

Water displacement leg volumetry in clinical studies - A discussion of error sources

PubMed Central

2010-01-01

Background Water displacement leg volumetry is a highly reproducible method, allowing the confirmation of efficacy of vasoactive substances. Nevertheless errors of its execution and the selection of unsuitable patients are likely to negatively affect the outcome of clinical studies in chronic venous insufficiency (CVI). Discussion Placebo controlled double-blind drug studies in CVI were searched (Cochrane Review 2005, MedLine Search until December 2007) and assessed with regard to efficacy (volume reduction of the leg), patient characteristics, and potential methodological error sources. Almost every second study reported only small drug effects (≤ 30 mL volume reduction). As the most relevant error source the conduct of volumetry was identified. Because the practical use of available equipment varies, volume differences of more than 300 mL - which is a multifold of a potential treatment effect - have been reported between consecutive measurements. Other potential error sources were insufficient patient guidance or difficulties with the transition from the Widmer CVI classification to the CEAP (Clinical Etiological Anatomical Pathophysiological) grading. Summary Patients should be properly diagnosed with CVI and selected for stable oedema and further clinical symptoms relevant for the specific study. Centres require a thorough training on the use of the volumeter and on patient guidance. Volumetry should be performed under constant conditions. The reproducibility of short term repeat measurements has to be ensured. PMID:20070899

Evaluation of truncation error and adaptive grid generation for the transonic full potential flow calculations

NASA Technical Reports Server (NTRS)

Nakamura, S.

1983-01-01

The effects of truncation error on the numerical solution of transonic flows using the full potential equation are studied. The effects of adapting grid point distributions to various solution aspects including shock waves is also discussed. A conclusion is that a rapid change of grid spacing is damaging to the accuracy of the flow solution. Therefore, in a solution adaptive grid application an optimal grid is obtained as a tradeoff between the amount of grid refinement and the rate of grid stretching.

On the isobaric space of 25-hydroxyvitamin D in human serum: potential for interferences in liquid chromatography/tandem mass spectrometry, systematic errors and accuracy issues.

PubMed

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.

Uncharted territory: measuring costs of diagnostic errors outside the medical record.

PubMed

Schwartz, Alan; Weiner, Saul J; Weaver, Frances; Yudkowsky, Rachel; Sharma, Gunjan; Binns-Calvey, Amy; Preyss, Ben; Jordan, Neil

2012-11-01

In a past study using unannounced standardised patients (USPs), substantial rates of diagnostic and treatment errors were documented among internists. Because the authors know the correct disposition of these encounters and obtained the physicians' notes, they can identify necessary treatment that was not provided and unnecessary treatment. They can also discern which errors can be identified exclusively from a review of the medical records. To estimate the avoidable direct costs incurred by physicians making errors in our previous study. In the study, USPs visited 111 internal medicine attending physicians. They presented variants of four previously validated cases that jointly manipulate the presence or absence of contextual and biomedical factors that could lead to errors in management if overlooked. For example, in a patient with worsening asthma symptoms, a complicating biomedical factor was the presence of reflux disease and a complicating contextual factor was inability to afford the currently prescribed inhaler. Costs of missed or unnecessary services were computed using Medicare cost-based reimbursement data. Fourteen practice locations, including two academic clinics, two community-based primary care networks with multiple sites, a core safety net provider, and three Veteran Administration government facilities. Contribution of errors to costs of care. Overall, errors in care resulted in predicted costs of approximately $174,000 across 399 visits, of which only $8745 was discernible from a review of the medical records alone (without knowledge of the correct diagnoses). The median cost of error per visit with an incorrect care plan differed by case and by presentation variant within case. Chart reviews alone underestimate costs of care because they typically reflect appropriate treatment decisions conditional on (potentially erroneous) diagnoses. Important information about patient context is often entirely missing from medical records. Experimental

Error Estimates for Approximate Solutions of the Riccati Equation with Real or Complex Potentials

NASA Astrophysics Data System (ADS)

Finster, Felix; Smoller, Joel

2010-09-01

A method is presented for obtaining rigorous error estimates for approximate solutions of the Riccati equation, with real or complex potentials. Our main tool is to derive invariant region estimates for complex solutions of the Riccati equation. We explain the general strategy for applying these estimates and illustrate the method in typical examples, where the approximate solutions are obtained by gluing together WKB and Airy solutions of corresponding one-dimensional Schrödinger equations. Our method is motivated by, and has applications to, the analysis of linear wave equations in the geometry of a rotating black hole.

Overview of medical errors and adverse events

PubMed Central

2012-01-01

Safety is a global concept that encompasses efficiency, security of care, reactivity of caregivers, and satisfaction of patients and relatives. Patient safety has emerged as a major target for healthcare improvement. Quality assurance is a complex task, and patients in the intensive care unit (ICU) are more likely than other hospitalized patients to experience medical errors, due to the complexity of their conditions, need for urgent interventions, and considerable workload fluctuation. Medication errors are the most common medical errors and can induce adverse events. Two approaches are available for evaluating and improving quality-of-care: the room-for-improvement model, in which problems are identified, plans are made to resolve them, and the results of the plans are measured; and the monitoring model, in which quality indicators are defined as relevant to potential problems and then monitored periodically. Indicators that reflect structures, processes, or outcomes have been developed by medical societies. Surveillance of these indicators is organized at the hospital or national level. Using a combination of methods improves the results. Errors are caused by combinations of human factors and system factors, and information must be obtained on how people make errors in the ICU environment. Preventive strategies are more likely to be effective if they rely on a system-based approach, in which organizational flaws are remedied, rather than a human-based approach of encouraging people not to make errors. The development of a safety culture in the ICU is crucial to effective prevention and should occur before the evaluation of safety programs, which are more likely to be effective when they involve bundles of measures. PMID:22339769

A Swiss cheese error detection method for real-time EPID-based quality assurance and error prevention.

PubMed

Passarge, Michelle; Fix, Michael K; Manser, Peter; Stampanoni, Marco F M; Siebers, Jeffrey V

2017-04-01

). Including cases that led to slightly modified but clinically equivalent plans, 89.1% were detected by the SCED method within 2°. Based on the type of check that detected the error, determination of error sources was achieved. With noise ranging from no random noise to four times the established noise value, the averaged relevant dose error detection rate of the SCED method was between 94.0% and 95.8% and that of gamma between 82.8% and 89.8%. An EPID-frame-based error detection process for VMAT deliveries was successfully designed and tested via simulations. The SCED method was inspected for robustness with realistic noise variations, demonstrating that it has the potential to detect a large majority of relevant dose errors. Compared to a typical (3%, 3 mm) gamma analysis, the SCED method produced a higher detection rate for all introduced dose errors, identified errors in an earlier stage, displayed a higher robustness to noise variations, and indicated the error source. © 2017 American Association of Physicists in Medicine.

Identifying and acting on potentially inappropriate care? Inadequacy of current hospital coding for this task.

PubMed

Cooper, P David; Smart, David R

2017-06-01

Recent Australian attempts to facilitate disinvestment in healthcare, by identifying instances of 'inappropriate' care from large Government datasets, are subject to significant methodological flaws. Amongst other criticisms has been the fact that the Government datasets utilized for this purpose correlate poorly with datasets collected by relevant professional bodies. Government data derive from official hospital coding, collected retrospectively by clerical personnel, whilst professional body data derive from unit-specific databases, collected contemporaneously with care by clinical personnel. Assessment of accuracy of official hospital coding data for hyperbaric services in a tertiary referral hospital. All official hyperbaric-relevant coding data submitted to the relevant Australian Government agencies by the Royal Hobart Hospital, Tasmania, Australia for financial year 2010-2011 were reviewed and compared against actual hyperbaric unit activity as determined by reference to original source documents. Hospital coding data contained one or more errors in diagnoses and/or procedures in 70% of patients treated with hyperbaric oxygen that year. Multiple discrete error types were identified, including (but not limited to): missing patients; missing treatments; 'additional' treatments; 'additional' patients; incorrect procedure codes and incorrect diagnostic codes. Incidental observations of errors in surgical, anaesthetic and intensive care coding within this cohort suggest that the problems are not restricted to the specialty of hyperbaric medicine alone. Publications from other centres indicate that these problems are not unique to this institution or State. Current Government datasets are irretrievably compromised and not fit for purpose. Attempting to inform the healthcare policy debate by reference to these datasets is inappropriate. Urgent clinical engagement with hospital coding departments is warranted.

Use of Event-Related Potentials to Identify Language and Reading Skills

ERIC Educational Resources Information Center

Molfese, Victoria J.; Molfese, Dennis L.; Beswick, Jennifer L.; Jacobi-Vessels, Jill; Molfese, Peter J.; Molnar, Andrew E.; Wagner, Mary C.; Haines, Brittany L.

2008-01-01

The extent to which oral language and emergent literacy skills are influenced by event-related potential measures of phonological processing was examined. Results revealed that event-related potential responses identify differences in letter naming but not receptive language skills.

Sources of error in the retracted scientific literature.

PubMed

Casadevall, Arturo; Steen, R Grant; Fang, Ferric C

2014-09-01

Retraction of flawed articles is an important mechanism for correction of the scientific literature. We recently reported that the majority of retractions are associated with scientific misconduct. In the current study, we focused on the subset of retractions for which no misconduct was identified, in order to identify the major causes of error. Analysis of the retraction notices for 423 articles indexed in PubMed revealed that the most common causes of error-related retraction are laboratory errors, analytical errors, and irreproducible results. The most common laboratory errors are contamination and problems relating to molecular biology procedures (e.g., sequencing, cloning). Retractions due to contamination were more common in the past, whereas analytical errors are now increasing in frequency. A number of publications that have not been retracted despite being shown to contain significant errors suggest that barriers to retraction may impede correction of the literature. In particular, few cases of retraction due to cell line contamination were found despite recognition that this problem has affected numerous publications. An understanding of the errors leading to retraction can guide practices to improve laboratory research and the integrity of the scientific literature. Perhaps most important, our analysis has identified major problems in the mechanisms used to rectify the scientific literature and suggests a need for action by the scientific community to adopt protocols that ensure the integrity of the publication process. © FASEB.

When is an error not a prediction error? An electrophysiological investigation.

PubMed

Holroyd, Clay B; Krigolson, Olave E; Baker, Robert; Lee, Seung; Gibson, Jessica

2009-03-01

A recent theory holds that the anterior cingulate cortex (ACC) uses reinforcement learning signals conveyed by the midbrain dopamine system to facilitate flexible action selection. According to this position, the impact of reward prediction error signals on ACC modulates the amplitude of a component of the event-related brain potential called the error-related negativity (ERN). The theory predicts that ERN amplitude is monotonically related to the expectedness of the event: It is larger for unexpected outcomes than for expected outcomes. However, a recent failure to confirm this prediction has called the theory into question. In the present article, we investigated this discrepancy in three trial-and-error learning experiments. All three experiments provided support for the theory, but the effect sizes were largest when an optimal response strategy could actually be learned. This observation suggests that ACC utilizes dopamine reward prediction error signals for adaptive decision making when the optimal behavior is, in fact, learnable.

Cognitive tests predict real-world errors: the relationship between drug name confusion rates in laboratory-based memory and perception tests and corresponding error rates in large pharmacy chains

PubMed Central

Schroeder, Scott R; Salomon, Meghan M; Galanter, William L; Schiff, Gordon D; Vaida, Allen J; Gaunt, Michael J; Bryson, Michelle L; Rash, Christine; Falck, Suzanne; Lambert, Bruce L

2017-01-01

Background Drug name confusion is a common type of medication error and a persistent threat to patient safety. In the USA, roughly one per thousand prescriptions results in the wrong drug being filled, and most of these errors involve drug names that look or sound alike. Prior to approval, drug names undergo a variety of tests to assess their potential for confusability, but none of these preapproval tests has been shown to predict real-world error rates. Objectives We conducted a study to assess the association between error rates in laboratory-based tests of drug name memory and perception and real-world drug name confusion error rates. Methods Eighty participants, comprising doctors, nurses, pharmacists, technicians and lay people, completed a battery of laboratory tests assessing visual perception, auditory perception and short-term memory of look-alike and sound-alike drug name pairs (eg, hydroxyzine/hydralazine). Results Laboratory test error rates (and other metrics) significantly predicted real-world error rates obtained from a large, outpatient pharmacy chain, with the best-fitting model accounting for 37% of the variance in real-world error rates. Cross-validation analyses confirmed these results, showing that the laboratory tests also predicted errors from a second pharmacy chain, with 45% of the variance being explained by the laboratory test data. Conclusions Across two distinct pharmacy chains, there is a strong and significant association between drug name confusion error rates observed in the real world and those observed in laboratory-based tests of memory and perception. Regulators and drug companies seeking a validated preapproval method for identifying confusing drug names ought to consider using these simple tests. By using a standard battery of memory and perception tests, it should be possible to reduce the number of confusing look-alike and sound-alike drug name pairs that reach the market, which will help protect patients from potentially

Cognitive tests predict real-world errors: the relationship between drug name confusion rates in laboratory-based memory and perception tests and corresponding error rates in large pharmacy chains.

PubMed

Schroeder, Scott R; Salomon, Meghan M; Galanter, William L; Schiff, Gordon D; Vaida, Allen J; Gaunt, Michael J; Bryson, Michelle L; Rash, Christine; Falck, Suzanne; Lambert, Bruce L

2017-05-01

Drug name confusion is a common type of medication error and a persistent threat to patient safety. In the USA, roughly one per thousand prescriptions results in the wrong drug being filled, and most of these errors involve drug names that look or sound alike. Prior to approval, drug names undergo a variety of tests to assess their potential for confusability, but none of these preapproval tests has been shown to predict real-world error rates. We conducted a study to assess the association between error rates in laboratory-based tests of drug name memory and perception and real-world drug name confusion error rates. Eighty participants, comprising doctors, nurses, pharmacists, technicians and lay people, completed a battery of laboratory tests assessing visual perception, auditory perception and short-term memory of look-alike and sound-alike drug name pairs (eg, hydroxyzine/hydralazine). Laboratory test error rates (and other metrics) significantly predicted real-world error rates obtained from a large, outpatient pharmacy chain, with the best-fitting model accounting for 37% of the variance in real-world error rates. Cross-validation analyses confirmed these results, showing that the laboratory tests also predicted errors from a second pharmacy chain, with 45% of the variance being explained by the laboratory test data. Across two distinct pharmacy chains, there is a strong and significant association between drug name confusion error rates observed in the real world and those observed in laboratory-based tests of memory and perception. Regulators and drug companies seeking a validated preapproval method for identifying confusing drug names ought to consider using these simple tests. By using a standard battery of memory and perception tests, it should be possible to reduce the number of confusing look-alike and sound-alike drug name pairs that reach the market, which will help protect patients from potentially harmful medication errors. Published by the BMJ

Magnetic Nanoparticle Thermometer: An Investigation of Minimum Error Transmission Path and AC Bias Error

PubMed Central

Du, Zhongzhou; Su, Rijian; Liu, Wenzhong; Huang, Zhixing

2015-01-01

The signal transmission module of a magnetic nanoparticle thermometer (MNPT) was established in this study to analyze the error sources introduced during the signal flow in the hardware system. The underlying error sources that significantly affected the precision of the MNPT were determined through mathematical modeling and simulation. A transfer module path with the minimum error in the hardware system was then proposed through the analysis of the variations of the system error caused by the significant error sources when the signal flew through the signal transmission module. In addition, a system parameter, named the signal-to-AC bias ratio (i.e., the ratio between the signal and AC bias), was identified as a direct determinant of the precision of the measured temperature. The temperature error was below 0.1 K when the signal-to-AC bias ratio was higher than 80 dB, and other system errors were not considered. The temperature error was below 0.1 K in the experiments with a commercial magnetic fluid (Sample SOR-10, Ocean Nanotechnology, Springdale, AR, USA) when the hardware system of the MNPT was designed with the aforementioned method. PMID:25875188

Error and its meaning in forensic science.

PubMed

Christensen, Angi M; Crowder, Christian M; Ousley, Stephen D; Houck, Max M

2014-01-01

The discussion of "error" has gained momentum in forensic science in the wake of the Daubert guidelines and has intensified with the National Academy of Sciences' Report. Error has many different meanings, and too often, forensic practitioners themselves as well as the courts misunderstand scientific error and statistical error rates, often confusing them with practitioner error (or mistakes). Here, we present an overview of these concepts as they pertain to forensic science applications, discussing the difference between practitioner error (including mistakes), instrument error, statistical error, and method error. We urge forensic practitioners to ensure that potential sources of error and method limitations are understood and clearly communicated and advocate that the legal community be informed regarding the differences between interobserver errors, uncertainty, variation, and mistakes. © 2013 American Academy of Forensic Sciences.

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

PubMed Central

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

2016-01-01

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

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

PubMed

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

2016-01-01

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

WE-H-BRC-05: Catastrophic Error Metrics for Radiation Therapy

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

Murphy, S; Molloy, J

Purpose: Intuitive evaluation of complex radiotherapy treatments is impractical, while data transfer anomalies create the potential for catastrophic treatment delivery errors. Contrary to prevailing wisdom, logical scrutiny can be applied to patient-specific machine settings. Such tests can be automated, applied at the point of treatment delivery and can be dissociated from prior states of the treatment plan, potentially revealing errors introduced early in the process. Methods: Analytical metrics were formulated for conventional and intensity modulated RT (IMRT) treatments. These were designed to assess consistency between monitor unit settings, wedge values, prescription dose and leaf positioning (IMRT). Institutional metric averages formore » 218 clinical plans were stratified over multiple anatomical sites. Treatment delivery errors were simulated using a commercial treatment planning system and metric behavior assessed via receiver-operator-characteristic (ROC) analysis. A positive result was returned if the erred plan metric value exceeded a given number of standard deviations, e.g. 2. The finding was declared true positive if the dosimetric impact exceeded 25%. ROC curves were generated over a range of metric standard deviations. Results: Data for the conventional treatment metric indicated standard deviations of 3%, 12%, 11%, 8%, and 5 % for brain, pelvis, abdomen, lung and breast sites, respectively. Optimum error declaration thresholds yielded true positive rates (TPR) between 0.7 and 1, and false positive rates (FPR) between 0 and 0.2. Two proposed IMRT metrics possessed standard deviations of 23% and 37%. The superior metric returned TPR and FPR of 0.7 and 0.2, respectively, when both leaf position and MUs were modelled. Isolation to only leaf position errors yielded TPR and FPR values of 0.9 and 0.1. Conclusion: Logical tests can reveal treatment delivery errors and prevent large, catastrophic errors. Analytical metrics are able to identify errors in

Financial errors in dementia: Testing a neuroeconomic conceptual framework

PubMed Central

Chiong, Winston; Hsu, Ming; Wudka, Danny; Miller, Bruce L.; Rosen, Howard J.

2013-01-01

Financial errors by patients with dementia can have devastating personal and family consequences. We developed and evaluated a neuroeconomic conceptual framework for understanding financial errors across different dementia syndromes, using a systematic, retrospective, blinded chart review of demographically-balanced cohorts of patients with Alzheimer’s disease (AD, n=100) and behavioral variant frontotemporal dementia (bvFTD, n=50). Reviewers recorded specific reports of financial errors according to a conceptual framework identifying patient cognitive and affective characteristics, and contextual influences, conferring susceptibility to each error. Specific financial errors were reported for 49% of AD and 70% of bvFTD patients (p = 0.012). AD patients were more likely than bvFTD patients to make amnestic errors (p< 0.001), while bvFTD patients were more likely to spend excessively (p = 0.004) and to exhibit other behaviors consistent with diminished sensitivity to losses and other negative outcomes (p< 0.001). Exploratory factor analysis identified a social/affective vulnerability factor associated with errors in bvFTD, and a cognitive vulnerability factor associated with errors in AD. Our findings highlight the frequency and functional importance of financial errors as symptoms of AD and bvFTD. A conceptual model derived from neuroeconomic literature identifies factors that influence vulnerability to different types of financial error in different dementia syndromes, with implications for early diagnosis and subsequent risk prevention. PMID:23550884

Method and apparatus for analyzing error conditions in a massively parallel computer system by identifying anomalous nodes within a communicator set

DOEpatents

Gooding, Thomas Michael [Rochester, MN

2011-04-19

An analytical mechanism for a massively parallel computer system automatically analyzes data retrieved from the system, and identifies nodes which exhibit anomalous behavior in comparison to their immediate neighbors. Preferably, anomalous behavior is determined by comparing call-return stack tracebacks for each node, grouping like nodes together, and identifying neighboring nodes which do not themselves belong to the group. A node, not itself in the group, having a large number of neighbors in the group, is a likely locality of error. The analyzer preferably presents this information to the user by sorting the neighbors according to number of adjoining members of the group.

Error-Eliciting Problems: Fostering Understanding and Thinking

ERIC Educational Resources Information Center

Lim, Kien H.

2014-01-01

Student errors are springboards for analyzing, reasoning, and justifying. The mathematics education community recognizes the value of student errors, noting that "mistakes are seen not as dead ends but rather as potential avenues for learning." To induce specific errors and help students learn, choose tasks that might produce mistakes.…

Potential errors in optical density measurements due to scanning side in EBT and EBT2 Gafchromic film dosimetry.

PubMed

Desroches, Joannie; Bouchard, Hugo; Lacroix, Frédéric

2010-04-01

The purpose of this study is to determine the effect on the measured optical density of scanning on either side of a Gafchromic EBT and EBT2 film using an Epson (Epson Canada Ltd., Toronto, Ontario) 10000XL flat bed scanner. Calibration curves were constructed using EBT2 film scanned in landscape orientation in both reflection and transmission mode on an Epson 10000XL scanner. Calibration curves were also constructed using EBT film. Potential errors due to an optical density difference from scanning the film on either side ("face up" or "face down") were simulated. Scanning the film face up or face down on the scanner bed while keeping the film angular orientation constant affects the measured optical density when scanning in reflection mode. In contrast, no statistically significant effect was seen when scanning in transmission mode. This effect can significantly affect relative and absolute dose measurements. As an application example, the authors demonstrate potential errors of 17.8% by inverting the film scanning side on the gamma index for 3%-3 mm criteria on a head and neck intensity modulated radiotherapy plan, and errors in absolute dose measurements ranging from 10% to 35% between 2 and 5 Gy. Process consistency is the key to obtaining accurate and precise results in Gafchromic film dosimetry. When scanning in reflection mode, care must be taken to place the film consistently on the same side on the scanner bed.

Punishing an error improves learning: the influence of punishment magnitude on error-related neural activity and subsequent learning.

PubMed

Hester, Robert; Murphy, Kevin; Brown, Felicity L; Skilleter, Ashley J

2010-11-17

Punishing an error to shape subsequent performance is a major tenet of individual and societal level behavioral interventions. Recent work examining error-related neural activity has identified that the magnitude of activity in the posterior medial frontal cortex (pMFC) is predictive of learning from an error, whereby greater activity in this region predicts adaptive changes in future cognitive performance. It remains unclear how punishment influences error-related neural mechanisms to effect behavior change, particularly in key regions such as pMFC, which previous work has demonstrated to be insensitive to punishment. Using an associative learning task that provided monetary reward and punishment for recall performance, we observed that when recall errors were categorized by subsequent performance--whether the failure to accurately recall a number-location association was corrected at the next presentation of the same trial--the magnitude of error-related pMFC activity predicted future correction. However, the pMFC region was insensitive to the magnitude of punishment an error received and it was the left insula cortex that predicted learning from the most aversive outcomes. These findings add further evidence to the hypothesis that error-related pMFC activity may reflect more than a prediction error in representing the value of an outcome. The novel role identified here for the insular cortex in learning from punishment appears particularly compelling for our understanding of psychiatric and neurologic conditions that feature both insular cortex dysfunction and a diminished capacity for learning from negative feedback or punishment.

Error Analysis in Mathematics. Technical Report #1012

ERIC Educational Resources Information Center

Lai, Cheng-Fei

2012-01-01

Error analysis is a method commonly used to identify the cause of student errors when they make consistent mistakes. It is a process of reviewing a student's work and then looking for patterns of misunderstanding. Errors in mathematics can be factual, procedural, or conceptual, and may occur for a number of reasons. Reasons why students make…

Identifying potential kidney donors using social networking web sites.

PubMed

Chang, Alexander; Anderson, Emily E; Turner, Hang T; Shoham, David; Hou, Susan H; Grams, Morgan

2013-01-01

Social networking sites like Facebook may be a powerful tool for increasing rates of live kidney donation. They allow for wide dissemination of information and discussion and could lessen anxiety associated with a face-to-face request for donation. However, sparse data exist on the use of social media for this purpose. We searched Facebook, the most popular social networking site, for publicly available English-language pages seeking kidney donors for a specific individual, abstracting information on the potential recipient, characteristics of the page itself, and whether potential donors were tested. In the 91 pages meeting inclusion criteria, the mean age of potential recipients was 37 (range: 2-69); 88% were US residents. Other posted information included the individual's photograph (76%), blood type (64%), cause of kidney disease (43%), and location (71%). Thirty-two percent of pages reported having potential donors tested, and 10% reported receiving a live-donor kidney transplant. Those reporting donor testing shared more potential recipient characteristics, provided more information about transplantation, and had higher page traffic. Facebook is already being used to identify potential kidney donors. Future studies should focus on how to safely, ethically, and effectively use social networking sites to inform potential donors and potentially expand live kidney donation. © 2013 John Wiley & Sons A/S.

Human Error Analysis in a Permit to Work System: A Case Study in a Chemical Plant

PubMed Central

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

A Methodology for Validating Safety Heuristics Using Clinical Simulations: Identifying and Preventing Possible Technology-Induced Errors Related to Using Health Information Systems

PubMed Central

Borycki, Elizabeth; Kushniruk, Andre; Carvalho, Christopher

2013-01-01

Internationally, health information systems (HIS) safety has emerged as a significant concern for governments. Recently, research has emerged that has documented the ability of HIS to be implicated in the harm and death of patients. Researchers have attempted to develop methods that can be used to prevent or reduce technology-induced errors. Some researchers are developing methods that can be employed prior to systems release. These methods include the development of safety heuristics and clinical simulations. In this paper, we outline our methodology for developing safety heuristics specific to identifying the features or functions of a HIS user interface design that may lead to technology-induced errors. We follow this with a description of a methodological approach to validate these heuristics using clinical simulations. PMID:23606902

Clarification of terminology in medication errors: definitions and classification.

PubMed

Ferner, Robin E; Aronson, Jeffrey K

2006-01-01

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

Electronic inventory systems and barcode technology: impact on pharmacy technical accuracy and error liability.

PubMed

Oldland, Alan R; Golightly, Larry K; May, Sondra K; Barber, Gerard R; Stolpman, Nancy M

2015-01-01

To measure the effects associated with sequential implementation of electronic medication storage and inventory systems and product verification devices on pharmacy technical accuracy and rates of potential medication dispensing errors in an academic medical center. During four 28-day periods of observation, pharmacists recorded all technical errors identified at the final visual check of pharmaceuticals prior to dispensing. Technical filling errors involving deviations from order-specific selection of product, dosage form, strength, or quantity were documented when dispensing medications using (a) a conventional unit dose (UD) drug distribution system, (b) an electronic storage and inventory system utilizing automated dispensing cabinets (ADCs) within the pharmacy, (c) ADCs combined with barcode (BC) verification, and (d) ADCs and BC verification utilized with changes in product labeling and individualized personnel training in systems application. Using a conventional UD system, the overall incidence of technical error was 0.157% (24/15,271). Following implementation of ADCs, the comparative overall incidence of technical error was 0.135% (10/7,379; P = .841). Following implementation of BC scanning, the comparative overall incidence of technical error was 0.137% (27/19,708; P = .729). Subsequent changes in product labeling and intensified staff training in the use of BC systems was associated with a decrease in the rate of technical error to 0.050% (13/26,200; P = .002). Pharmacy ADCs and BC systems provide complementary effects that improve technical accuracy and reduce the incidence of potential medication dispensing errors if this technology is used with comprehensive personnel training.

Electronic Inventory Systems and Barcode Technology: Impact on Pharmacy Technical Accuracy and Error Liability

PubMed Central

Oldland, Alan R.; May, Sondra K.; Barber, Gerard R.; Stolpman, Nancy M.

2015-01-01

Purpose: To measure the effects associated with sequential implementation of electronic medication storage and inventory systems and product verification devices on pharmacy technical accuracy and rates of potential medication dispensing errors in an academic medical center. Methods: During four 28-day periods of observation, pharmacists recorded all technical errors identified at the final visual check of pharmaceuticals prior to dispensing. Technical filling errors involving deviations from order-specific selection of product, dosage form, strength, or quantity were documented when dispensing medications using (a) a conventional unit dose (UD) drug distribution system, (b) an electronic storage and inventory system utilizing automated dispensing cabinets (ADCs) within the pharmacy, (c) ADCs combined with barcode (BC) verification, and (d) ADCs and BC verification utilized with changes in product labeling and individualized personnel training in systems application. Results: Using a conventional UD system, the overall incidence of technical error was 0.157% (24/15,271). Following implementation of ADCs, the comparative overall incidence of technical error was 0.135% (10/7,379; P = .841). Following implementation of BC scanning, the comparative overall incidence of technical error was 0.137% (27/19,708; P = .729). Subsequent changes in product labeling and intensified staff training in the use of BC systems was associated with a decrease in the rate of technical error to 0.050% (13/26,200; P = .002). Conclusions: Pharmacy ADCs and BC systems provide complementary effects that improve technical accuracy and reduce the incidence of potential medication dispensing errors if this technology is used with comprehensive personnel training. PMID:25684799

[Responsibility due to medication errors in France: a study based on SHAM insurance data].

PubMed

Theissen, A; Orban, J-C; Fuz, F; Guerin, J-P; Flavin, P; Albertini, S; Maricic, S; Saquet, D; Niccolai, P

2015-03-01

The safe medication practices at the hospital constitute a major public health problem. Drug supply chain is a complex process, potentially source of errors and damages for the patient. SHAM insurances are the biggest French provider of medical liability insurances and a relevant source of data on the health care complications. The main objective of the study was to analyze the type and cause of medication errors declared to SHAM and having led to a conviction by a court. We did a retrospective study on insurance claims provided by SHAM insurances with a medication error and leading to a condemnation over a 6-year period (between 2005 and 2010). Thirty-one cases were analysed, 21 for scheduled activity and 10 for emergency activity. Consequences of claims were mostly serious (12 deaths, 14 serious complications, 5 simple complications). The types of medication errors were a drug monitoring error (11 cases), an administration error (5 cases), an overdose (6 cases), an allergy (4 cases), a contraindication (3 cases) and an omission (2 cases). Intravenous route of administration was involved in 19 of 31 cases (61%). The causes identified by the court expert were an error related to service organization (11), an error related to medical practice (11) or nursing practice (13). Only one claim was due to the hospital pharmacy. The claim related to drug supply chain is infrequent but potentially serious. These data should help strengthen quality approach in risk management. Copyright © 2014 Elsevier Masson SAS. All rights reserved.

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

NASA Technical Reports Server (NTRS)

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

2010-01-01

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

Coherent errors in quantum error correction

NASA Astrophysics Data System (ADS)

Greenbaum, Daniel; Dutton, Zachary

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

Exome Sequencing Identifies Potentially Druggable Mutations in Nasopharyngeal Carcinoma.

PubMed

Chow, Yock Ping; Tan, Lu Ping; Chai, San Jiun; Abdul Aziz, Norazlin; Choo, Siew Woh; Lim, Paul Vey Hong; Pathmanathan, Rajadurai; Mohd Kornain, Noor Kaslina; Lum, Chee Lun; Pua, Kin Choo; Yap, Yoke Yeow; Tan, Tee Yong; Teo, Soo Hwang; Khoo, Alan Soo-Beng; Patel, Vyomesh

2017-03-03

In this study, we first performed whole exome sequencing of DNA from 10 untreated and clinically annotated fresh frozen nasopharyngeal carcinoma (NPC) biopsies and matched bloods to identify somatically mutated genes that may be amenable to targeted therapeutic strategies. We identified a total of 323 mutations which were either non-synonymous (n = 238) or synonymous (n = 85). Furthermore, our analysis revealed genes in key cancer pathways (DNA repair, cell cycle regulation, apoptosis, immune response, lipid signaling) were mutated, of which those in the lipid-signaling pathway were the most enriched. We next extended our analysis on a prioritized sub-set of 37 mutated genes plus top 5 mutated cancer genes listed in COSMIC using a custom designed HaloPlex target enrichment panel with an additional 88 NPC samples. Our analysis identified 160 additional non-synonymous mutations in 37/42 genes in 66/88 samples. Of these, 99/160 mutations within potentially druggable pathways were further selected for validation. Sanger sequencing revealed that 77/99 variants were true positives, giving an accuracy of 78%. Taken together, our study indicated that ~72% (n = 71/98) of NPC samples harbored mutations in one of the four cancer pathways (EGFR-PI3K-Akt-mTOR, NOTCH, NF-κB, DNA repair) which may be potentially useful as predictive biomarkers of response to matched targeted therapies.

Exome Sequencing Identifies Potentially Druggable Mutations in Nasopharyngeal Carcinoma

PubMed Central

Chow, Yock Ping; Tan, Lu Ping; Chai, San Jiun; Abdul Aziz, Norazlin; Choo, Siew Woh; Lim, Paul Vey Hong; Pathmanathan, Rajadurai; Mohd Kornain, Noor Kaslina; Lum, Chee Lun; Pua, Kin Choo; Yap, Yoke Yeow; Tan, Tee Yong; Teo, Soo Hwang; Khoo, Alan Soo-Beng; Patel, Vyomesh

2017-01-01

In this study, we first performed whole exome sequencing of DNA from 10 untreated and clinically annotated fresh frozen nasopharyngeal carcinoma (NPC) biopsies and matched bloods to identify somatically mutated genes that may be amenable to targeted therapeutic strategies. We identified a total of 323 mutations which were either non-synonymous (n = 238) or synonymous (n = 85). Furthermore, our analysis revealed genes in key cancer pathways (DNA repair, cell cycle regulation, apoptosis, immune response, lipid signaling) were mutated, of which those in the lipid-signaling pathway were the most enriched. We next extended our analysis on a prioritized sub-set of 37 mutated genes plus top 5 mutated cancer genes listed in COSMIC using a custom designed HaloPlex target enrichment panel with an additional 88 NPC samples. Our analysis identified 160 additional non-synonymous mutations in 37/42 genes in 66/88 samples. Of these, 99/160 mutations within potentially druggable pathways were further selected for validation. Sanger sequencing revealed that 77/99 variants were true positives, giving an accuracy of 78%. Taken together, our study indicated that ~72% (n = 71/98) of NPC samples harbored mutations in one of the four cancer pathways (EGFR-PI3K-Akt-mTOR, NOTCH, NF-κB, DNA repair) which may be potentially useful as predictive biomarkers of response to matched targeted therapies. PMID:28256603

Addressing Systematic Errors in Correlation Tracking on HMI Magnetograms

NASA Astrophysics Data System (ADS)

Mahajan, Sushant S.; Hathaway, David H.; Munoz-Jaramillo, Andres; Martens, Petrus C.

2017-08-01

Correlation tracking in solar magnetograms is an effective method to measure the differential rotation and meridional flow on the solar surface. However, since the tracking accuracy required to successfully measure meridional flow is very high, small systematic errors have a noticeable impact on measured meridional flow profiles. Additionally, the uncertainties of this kind of measurements have been historically underestimated, leading to controversy regarding flow profiles at high latitudes extracted from measurements which are unreliable near the solar limb.Here we present a set of systematic errors we have identified (and potential solutions), including bias caused by physical pixel sizes, center-to-limb systematics, and discrepancies between measurements performed using different time intervals. We have developed numerical techniques to get rid of these systematic errors and in the process improve the accuracy of the measurements by an order of magnitude.We also present a detailed analysis of uncertainties in these measurements using synthetic magnetograms and the quantification of an upper limit below which meridional flow measurements cannot be trusted as a function of latitude.

Error simulation of paired-comparison-based scaling methods

NASA Astrophysics Data System (ADS)

Cui, Chengwu

2000-12-01

Subjective image quality measurement usually resorts to psycho physical scaling. However, it is difficult to evaluate the inherent precision of these scaling methods. Without knowing the potential errors of the measurement, subsequent use of the data can be misleading. In this paper, the errors on scaled values derived form paired comparison based scaling methods are simulated with randomly introduced proportion of choice errors that follow the binomial distribution. Simulation results are given for various combinations of the number of stimuli and the sampling size. The errors are presented in the form of average standard deviation of the scaled values and can be fitted reasonably well with an empirical equation that can be sued for scaling error estimation and measurement design. The simulation proves paired comparison based scaling methods can have large errors on the derived scaled values when the sampling size and the number of stimuli are small. Examples are also given to show the potential errors on actually scaled values of color image prints as measured by the method of paired comparison.

Perceived barriers to medical-error reporting: an exploratory investigation.

PubMed

Uribe, Claudia L; Schweikhart, Sharon B; Pathak, Dev S; Dow, Merrell; Marsh, Gail B

2002-01-01

Medical-error reporting is an essential component for patient safety enhancement. Unfortunately, medical errors are largely underreported across healthcare institutions. This problem can be attributed to different factors and barriers present at organizational and individual levels that ultimately prevent individuals from generating the report. This study explored the factors that affect medical-error reporting among physicians and nurses at a large academic medical center located in the midwest United States. A nominal group session was conducted to identify the most relevant factors that act as barriers for error reporting. These factors were then used to design a questionnaire that explored the likelihood of the factors to act as barriers and their likelihood to be modified. Using these two parameters, the results were analyzed and combined into a Factor Relevance Matrix. The matrix identifies the factors for which immediate actions should be undertaken to improve medical-error reporting (immediate action factors). It also identifies factors that require long-term strategies (long-term strategy factors) as well as factors that the organization should be aware of but that are of lower priority (awareness factors). The strategies outlined in this study may assist healthcare organizations in improving medical-error reporting, as part of the efforts toward patient-safety enhancement. Although factors affecting medical-error reporting may vary between different organizations, the process used in identifying the factors and the Factor Relevance Matrix developed in this study are easily adaptable to any organizational setting.

Dysfunctional error-related processing in female psychopathy

PubMed Central

Steele, Vaughn R.; Edwards, Bethany G.; Bernat, Edward M.; Calhoun, Vince D.; Kiehl, Kent A.

2016-01-01

Neurocognitive studies of psychopathy have predominantly focused on male samples. Studies have shown that female psychopaths exhibit similar affective deficits as their male counterparts, but results are less consistent across cognitive domains including response modulation. As such, there may be potential gender differences in error-related processing in psychopathic personality. Here we investigate response-locked event-related potential (ERP) components [the error-related negativity (ERN/Ne) related to early error-detection processes and the error-related positivity (Pe) involved in later post-error processing] in a sample of incarcerated adult female offenders (n = 121) who performed a response inhibition Go/NoGo task. Psychopathy was assessed using the Hare Psychopathy Checklist-Revised (PCL-R). The ERN/Ne and Pe were analyzed with classic windowed ERP components and principal component analysis (PCA). Consistent with previous research performed in psychopathic males, female psychopaths exhibited specific deficiencies in the neural correlates of post-error processing (as indexed by reduced Pe amplitude) but not in error monitoring (as indexed by intact ERN/Ne amplitude). Specifically, psychopathic traits reflecting interpersonal and affective dysfunction remained significant predictors of both time-domain and PCA measures reflecting reduced Pe mean amplitude. This is the first evidence to suggest that incarcerated female psychopaths exhibit similar dysfunctional post-error processing as male psychopaths. PMID:26060326

[Errors in Peruvian medical journals references].

PubMed

Huamaní, Charles; Pacheco-Romero, José

2009-01-01

References are fundamental in our studies; an adequate selection is asimportant as an adequate description. To determine the number of errors in a sample of references found in Peruvian medical journals. We reviewed 515 scientific papers references selected by systematic randomized sampling and corroborated reference information with the original document or its citation in Pubmed, LILACS or SciELO-Peru. We found errors in 47,6% (245) of the references, identifying 372 types of errors; the most frequent were errors in presentation style (120), authorship (100) and title (100), mainly due to spelling mistakes (91). References error percentage was high, varied and multiple. We suggest systematic revision of references in the editorial process as well as to extend the discussion on this theme. references, periodicals, research, bibliometrics.

42 CFR 431.960 - Types of payment errors.

Code of Federal Regulations, 2013 CFR

2013-10-01

... Estimating Improper Payments in Medicaid and CHIP § 431.960 Types of payment errors. (a) General rule. State or provider errors identified for the Medicaid and CHIP improper payments measurement under the... been paid by a third party but were inappropriately paid by Medicaid or CHIP. (v) Pricing errors. (vi...

42 CFR 431.960 - Types of payment errors.

Code of Federal Regulations, 2012 CFR

2012-10-01

... Estimating Improper Payments in Medicaid and CHIP § 431.960 Types of payment errors. (a) General rule. State or provider errors identified for the Medicaid and CHIP improper payments measurement under the... been paid by a third party but were inappropriately paid by Medicaid or CHIP. (v) Pricing errors. (vi...

42 CFR 431.960 - Types of payment errors.

Code of Federal Regulations, 2014 CFR

2014-10-01

... Estimating Improper Payments in Medicaid and CHIP § 431.960 Types of payment errors. (a) General rule. State or provider errors identified for the Medicaid and CHIP improper payments measurement under the... been paid by a third party but were inappropriately paid by Medicaid or CHIP. (v) Pricing errors. (vi...

42 CFR 431.960 - Types of payment errors.

Code of Federal Regulations, 2011 CFR

2011-10-01

... Estimating Improper Payments in Medicaid and CHIP § 431.960 Types of payment errors. (a) General rule. State or provider errors identified for the Medicaid and CHIP improper payments measurement under the... been paid by a third party but were inappropriately paid by Medicaid or CHIP. (v) Pricing errors. (vi...

Annotation of Korean Learner Corpora for Particle Error Detection

ERIC Educational Resources Information Center

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

2009-01-01

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

Diagnostic Errors in Ambulatory Care: Dimensions and Preventive Strategies

ERIC Educational Resources Information Center

Singh, Hardeep; Weingart, Saul N.

2009-01-01

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

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

PubMed

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

2016-06-25

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

Using a watershed-centric approach to identify potentially impacted beaches

EPA Science Inventory

Beaches can be affected by a variety of contaminants. Of particular concern are beaches impacted by human fecal contamination and urban runoff. This poster demonstrates a methodology to identify potentially impacted beaches using Geographic Information Systems (GIS). Since h...

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.

Improving probabilistic prediction of daily streamflow by identifying Pareto optimal approaches for modelling heteroscedastic residual errors

NASA Astrophysics Data System (ADS)

David, McInerney; Mark, Thyer; Dmitri, Kavetski; George, Kuczera

2017-04-01

This study provides guidance to hydrological researchers which enables them to provide probabilistic predictions of daily streamflow with the best reliability and precision for different catchment types (e.g. high/low degree of ephemerality). Reliable and precise probabilistic prediction of daily catchment-scale streamflow requires statistical characterization of residual errors of hydrological models. It is commonly known that hydrological model residual errors are heteroscedastic, i.e. there is a pattern of larger errors in higher streamflow predictions. Although multiple approaches exist for representing this heteroscedasticity, few studies have undertaken a comprehensive evaluation and comparison of these approaches. This study fills this research gap by evaluating 8 common residual error schemes, including standard and weighted least squares, the Box-Cox transformation (with fixed and calibrated power parameter, lambda) and the log-sinh transformation. Case studies include 17 perennial and 6 ephemeral catchments in Australia and USA, and two lumped hydrological models. We find the choice of heteroscedastic error modelling approach significantly impacts on predictive performance, though no single scheme simultaneously optimizes all performance metrics. The set of Pareto optimal schemes, reflecting performance trade-offs, comprises Box-Cox schemes with lambda of 0.2 and 0.5, and the log scheme (lambda=0, perennial catchments only). These schemes significantly outperform even the average-performing remaining schemes (e.g., across ephemeral catchments, median precision tightens from 105% to 40% of observed streamflow, and median biases decrease from 25% to 4%). Theoretical interpretations of empirical results highlight the importance of capturing the skew/kurtosis of raw residuals and reproducing zero flows. Recommendations for researchers and practitioners seeking robust residual error schemes for practical work are provided.

Improving probabilistic prediction of daily streamflow by identifying Pareto optimal approaches for modeling heteroscedastic residual errors

NASA Astrophysics Data System (ADS)

McInerney, David; Thyer, Mark; Kavetski, Dmitri; Lerat, Julien; Kuczera, George

2017-03-01

Reliable and precise probabilistic prediction of daily catchment-scale streamflow requires statistical characterization of residual errors of hydrological models. This study focuses on approaches for representing error heteroscedasticity with respect to simulated streamflow, i.e., the pattern of larger errors in higher streamflow predictions. We evaluate eight common residual error schemes, including standard and weighted least squares, the Box-Cox transformation (with fixed and calibrated power parameter λ) and the log-sinh transformation. Case studies include 17 perennial and 6 ephemeral catchments in Australia and the United States, and two lumped hydrological models. Performance is quantified using predictive reliability, precision, and volumetric bias metrics. We find the choice of heteroscedastic error modeling approach significantly impacts on predictive performance, though no single scheme simultaneously optimizes all performance metrics. The set of Pareto optimal schemes, reflecting performance trade-offs, comprises Box-Cox schemes with λ of 0.2 and 0.5, and the log scheme (λ = 0, perennial catchments only). These schemes significantly outperform even the average-performing remaining schemes (e.g., across ephemeral catchments, median precision tightens from 105% to 40% of observed streamflow, and median biases decrease from 25% to 4%). Theoretical interpretations of empirical results highlight the importance of capturing the skew/kurtosis of raw residuals and reproducing zero flows. Paradoxically, calibration of λ is often counterproductive: in perennial catchments, it tends to overfit low flows at the expense of abysmal precision in high flows. The log-sinh transformation is dominated by the simpler Pareto optimal schemes listed above. Recommendations for researchers and practitioners seeking robust residual error schemes for practical work are provided.

Controller and pilot error in airport operations : a review of previous research and analysis of safety data

DOT National Transportation Integrated Search

2001-01-01

The purpose of this study was to examine controller and pilot errors in airport operations to identify potential tower remedies. The : first part of the report contains a review of the literature of studies conducted of tower operationsand of efforts...

Exploratory Factor Analysis of Reading, Spelling, and Math Errors

ERIC Educational Resources Information Center

O'Brien, Rebecca; Pan, Xingyu; Courville, Troy; Bray, Melissa A.; Breaux, Kristina; Avitia, Maria; Choi, Dowon

2017-01-01

Norm-referenced error analysis is useful for understanding individual differences in students' academic skill development and for identifying areas of skill strength and weakness. The purpose of the present study was to identify underlying connections between error categories across five language and math subtests of the Kaufman Test of…

Learning mechanisms to limit medication administration errors.

PubMed

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.

Using voluntary reports from physicians to learn from diagnostic errors in emergency medicine.

PubMed

Okafor, Nnaemeka; Payne, Velma L; Chathampally, Yashwant; Miller, Sara; Doshi, Pratik; Singh, Hardeep

2016-04-01

Diagnostic errors are common in the emergency department (ED), but few studies have comprehensively evaluated their types and origins. We analysed incidents reported by ED physicians to determine disease conditions, contributory factors and patient harm associated with ED-related diagnostic errors. Between 1 March 2009 and 31 December 2013, ED physicians reported 509 incidents using a department-specific voluntary incident-reporting system that we implemented at two large academic hospital-affiliated EDs. For this study, we analysed 209 incidents related to diagnosis. A quality assurance team led by an ED physician champion reviewed each incident and interviewed physicians when necessary to confirm the presence/absence of diagnostic error and to determine the contributory factors. We generated descriptive statistics quantifying disease conditions involved, contributory factors and patient harm from errors. Among the 209 incidents, we identified 214 diagnostic errors associated with 65 unique diseases/conditions, including sepsis (9.6%), acute coronary syndrome (9.1%), fractures (8.6%) and vascular injuries (8.6%). Contributory factors included cognitive (n=317), system related (n=192) and non-remedial (n=106). Cognitive factors included faulty information verification (41.3%) and faulty information processing (30.6%) whereas system factors included high workload (34.4%) and inefficient ED processes (40.1%). Non-remediable factors included atypical presentation (31.3%) and the patients' inability to provide a history (31.3%). Most errors (75%) involved multiple factors. Major harm was associated with 34/209 (16.3%) of reported incidents. Most diagnostic errors in ED appeared to relate to common disease conditions. While sustaining diagnostic error reporting programmes might be challenging, our analysis reveals the potential value of such systems in identifying targets for improving patient safety in the ED. Published by the BMJ Publishing Group Limited. For

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

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

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

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

ERP correlates of error processing during performance on the Halstead Category Test.

PubMed

Santos, I M; Teixeira, A R; Tomé, A M; Pereira, A T; Rodrigues, P; Vagos, P; Costa, J; Carrito, M L; Oliveira, B; DeFilippis, N A; Silva, C F

2016-08-01

The Halstead Category Test (HCT) is a neuropsychological test that measures a person's ability to formulate and apply abstract principles. Performance must be adjusted based on feedback after each trial and errors are common until the underlying rules are discovered. Event-related potential (ERP) studies associated with the HCT are lacking. This paper demonstrates the use of a methodology inspired on Singular Spectrum Analysis (SSA) applied to EEG signals, to remove high amplitude ocular and movement artifacts during performance on the test. This filtering technique introduces no phase or latency distortions, with minimum loss of relevant EEG information. Importantly, the test was applied in its original clinical format, without introducing adaptations to ERP recordings. After signal treatment, the feedback-related negativity (FRN) wave, which is related to error-processing, was identified. This component peaked around 250ms, after feedback, in fronto-central electrodes. As expected, errors elicited more negative amplitudes than correct responses. Results are discussed in terms of the increased clinical potential that coupling ERP information with behavioral performance data can bring to the specificity of the HCT in diagnosing different types of impairment in frontal brain function. Copyright © 2016. Published by Elsevier B.V.

Reducing medication errors in critical care: a multimodal approach

PubMed Central

Kruer, Rachel M; Jarrell, Andrew S; Latif, Asad

2014-01-01

The Institute of Medicine has reported that medication errors are the single most common type of error in health care, representing 19% of all adverse events, while accounting for over 7,000 deaths annually. The frequency of medication errors in adult intensive care units can be as high as 947 per 1,000 patient-days, with a median of 105.9 per 1,000 patient-days. The formulation of drugs is a potential contributor to medication errors. Challenges related to drug formulation are specific to the various routes of medication administration, though errors associated with medication appearance and labeling occur among all drug formulations and routes of administration. Addressing these multifaceted challenges requires a multimodal approach. Changes in technology, training, systems, and safety culture are all strategies to potentially reduce medication errors related to drug formulation in the intensive care unit. PMID:25210478

Clover: Compiler directed lightweight soft error resilience

DOE PAGES

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

2015-05-01

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

A cerebellar thalamic cortical circuit for error-related cognitive control.

PubMed

Ide, Jaime S; Li, Chiang-shan R

2011-01-01

Error detection and behavioral adjustment are core components of cognitive control. Numerous studies have focused on the anterior cingulate cortex (ACC) as a critical locus of this executive function. Our previous work showed greater activation in the dorsal ACC and subcortical structures during error detection, and activation in the ventrolateral prefrontal cortex (VLPFC) during post-error slowing (PES) in a stop signal task (SST). However, the extent of error-related cortical or subcortical activation across subjects was not correlated with VLPFC activity during PES. So then, what causes VLPFC activation during PES? To address this question, we employed Granger causality mapping (GCM) and identified regions that Granger caused VLPFC activation in 54 adults performing the SST during fMRI. These brain regions, including the supplementary motor area (SMA), cerebellum, a pontine region, and medial thalamus, represent potential targets responding to errors in a way that could influence VLPFC activation. In confirmation of this hypothesis, the error-related activity of these regions correlated with VLPFC activation during PES, with the cerebellum showing the strongest association. The finding that cerebellar activation Granger causes prefrontal activity during behavioral adjustment supports a cerebellar function in cognitive control. Furthermore, multivariate GCA described the "flow of information" across these brain regions. Through connectivity with the thalamus and SMA, the cerebellum mediates error and post-error processing in accord with known anatomical projections. Taken together, these new findings highlight the role of the cerebello-thalamo-cortical pathway in an executive function that has heretofore largely been ascribed to the anterior cingulate-prefrontal cortical circuit. Copyright © 2010 Elsevier Inc. All rights reserved.

Modeling Inborn Errors of Hepatic Metabolism Using Induced Pluripotent Stem Cells.

PubMed

Pournasr, Behshad; Duncan, Stephen A

2017-11-01

Inborn errors of hepatic metabolism are because of deficiencies commonly within a single enzyme as a consequence of heritable mutations in the genome. Individually such diseases are rare, but collectively they are common. Advances in genome-wide association studies and DNA sequencing have helped researchers identify the underlying genetic basis of such diseases. Unfortunately, cellular and animal models that accurately recapitulate these inborn errors of hepatic metabolism in the laboratory have been lacking. Recently, investigators have exploited molecular techniques to generate induced pluripotent stem cells from patients' somatic cells. Induced pluripotent stem cells can differentiate into a wide variety of cell types, including hepatocytes, thereby offering an innovative approach to unravel the mechanisms underlying inborn errors of hepatic metabolism. Moreover, such cell models could potentially provide a platform for the discovery of therapeutics. In this mini-review, we present a brief overview of the state-of-the-art in using pluripotent stem cells for such studies. © 2017 American Heart Association, Inc.

Detection and correction of prescription errors by an emergency department pharmacy service.

PubMed

Stasiak, Philip; Afilalo, Marc; Castelino, Tanya; Xue, Xiaoqing; Colacone, Antoinette; Soucy, Nathalie; Dankoff, Jerrald

2014-05-01

Emergency departments (EDs) are recognized as a high-risk setting for prescription errors. Pharmacist involvement may be important in reviewing prescriptions to identify and correct errors. The objectives of this study were to describe the frequency and type of prescription errors detected by pharmacists in EDs, determine the proportion of errors that could be corrected, and identify factors associated with prescription errors. This prospective observational study was conducted in a tertiary care teaching ED on 25 consecutive weekdays. Pharmacists reviewed all documented prescriptions and flagged and corrected errors for patients in the ED. We collected information on patient demographics, details on prescription errors, and the pharmacists' recommendations. A total of 3,136 ED prescriptions were reviewed. The proportion of prescriptions in which a pharmacist identified an error was 3.2% (99 of 3,136; 95% confidence interval [CI] 2.5-3.8). The types of identified errors were wrong dose (28 of 99, 28.3%), incomplete prescription (27 of 99, 27.3%), wrong frequency (15 of 99, 15.2%), wrong drug (11 of 99, 11.1%), wrong route (1 of 99, 1.0%), and other (17 of 99, 17.2%). The pharmacy service intervened and corrected 78 (78 of 99, 78.8%) errors. Factors associated with prescription errors were patient age over 65 (odds ratio [OR] 2.34; 95% CI 1.32-4.13), prescriptions with more than one medication (OR 5.03; 95% CI 2.54-9.96), and those written by emergency medicine residents compared to attending emergency physicians (OR 2.21, 95% CI 1.18-4.14). Pharmacists in a tertiary ED are able to correct the majority of prescriptions in which they find errors. Errors are more likely to be identified in prescriptions written for older patients, those containing multiple medication orders, and those prescribed by emergency residents.

Dissociable Genetic Contributions to Error Processing: A Multimodal Neuroimaging Study

PubMed Central

Agam, Yigal; Vangel, Mark; Roffman, Joshua L.; Gallagher, Patience J.; Chaponis, Jonathan; Haddad, Stephen; Goff, Donald C.; Greenberg, Jennifer L.; Wilhelm, Sabine; Smoller, Jordan W.; Manoach, Dara S.

2014-01-01

Background Neuroimaging studies reliably identify two markers of error commission: the error-related negativity (ERN), an event-related potential, and functional MRI activation of the dorsal anterior cingulate cortex (dACC). While theorized to reflect the same neural process, recent evidence suggests that the ERN arises from the posterior cingulate cortex not the dACC. Here, we tested the hypothesis that these two error markers also have different genetic mediation. Methods We measured both error markers in a sample of 92 comprised of healthy individuals and those with diagnoses of schizophrenia, obsessive-compulsive disorder or autism spectrum disorder. Participants performed the same task during functional MRI and simultaneously acquired magnetoencephalography and electroencephalography. We examined the mediation of the error markers by two single nucleotide polymorphisms: dopamine D4 receptor (DRD4) C-521T (rs1800955), which has been associated with the ERN and methylenetetrahydrofolate reductase (MTHFR) C677T (rs1801133), which has been associated with error-related dACC activation. We then compared the effects of each polymorphism on the two error markers modeled as a bivariate response. Results We replicated our previous report of a posterior cingulate source of the ERN in healthy participants in the schizophrenia and obsessive-compulsive disorder groups. The effect of genotype on error markers did not differ significantly by diagnostic group. DRD4 C-521T allele load had a significant linear effect on ERN amplitude, but not on dACC activation, and this difference was significant. MTHFR C677T allele load had a significant linear effect on dACC activation but not ERN amplitude, but the difference in effects on the two error markers was not significant. Conclusions DRD4 C-521T, but not MTHFR C677T, had a significant differential effect on two canonical error markers. Together with the anatomical dissociation between the ERN and error-related dACC activation

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

PubMed

Chua, S S; Tea, M H; Rahman, M H A

2009-04-01

Drug administration errors were the second most frequent type of medication errors, after prescribing errors but the latter were often intercepted hence, administration errors were more probably to reach the patients. Therefore, this study was conducted to determine the frequency and types of drug administration errors in a Malaysian hospital ward. This is a prospective study that involved direct, undisguised observations of drug administrations in a hospital ward. A researcher was stationed in the ward under study for 15 days to observe all drug administrations which were recorded in a data collection form and then compared with the drugs prescribed for the patient. A total of 1118 opportunities for errors were observed and 127 administrations had errors. This gave an error rate of 11.4 % [95% confidence interval (CI) 9.5-13.3]. If incorrect time errors were excluded, the error rate reduced to 8.7% (95% CI 7.1-10.4). The most common types of drug administration errors were incorrect time (25.2%), followed by incorrect technique of administration (16.3%) and unauthorized drug errors (14.1%). In terms of clinical significance, 10.4% of the administration errors were considered as potentially life-threatening. Intravenous routes were more likely to be associated with an administration error than oral routes (21.3% vs. 7.9%, P < 0.001). The study indicates that the frequency of drug administration errors in developing countries such as Malaysia is similar to that in the developed countries. Incorrect time errors were also the most common type of drug administration errors. A non-punitive system of reporting medication errors should be established to encourage more information to be documented so that risk management protocol could be developed and implemented.

Identifying subassemblies by ultrasound to prevent fuel handling error in sodium fast reactors: First test performed in water

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

Paumel, Kevin; Lhuillier, Christian

2015-07-01

Identifying subassemblies by ultrasound is a method that is being considered to prevent handling errors in sodium fast reactors. It is based on the reading of a code (aligned notches) engraved on the subassembly head by an emitting/receiving ultrasonic sensor. This reading is carried out in sodium with high temperature transducers. The resulting one-dimensional C-scan can be likened to a binary code expressing the subassembly type and number. The first test performed in water investigated two parameters: width and depth of the notches. The code remained legible for notches as thin as 1.6 mm wide. The impact of the depthmore » seems minor in the range under investigation. (authors)« less

Applying lessons from social psychology to transform the culture of error disclosure.

PubMed

Han, Jason; LaMarra, Denise; Vapiwala, Neha

2017-10-01

The ability to carry out prompt and effective error disclosure has been described in the literature as an essential skill among physicians that can lead to improved patient satisfaction, staff well-being and hospital outcomes. However, few studies have addressed the social psychology principles that may influence physician behaviour. The authors provide an overview of recent administrative measures designed to encourage physicians to disclose error, but note that deliberate practice, buttressed with lessons from social psychology, is needed to implement further productive behavioural changes. Two main cognitive biases that may hinder error disclosure are identified, namely: fundamental attribution error, and forecasting error. Strategies to overcome these maladaptive cognitive patterns are discussed. The authors note that interactions with standardised patients (SPs) can be used to simulate hospital encounters and help teach important behavioural considerations. Virtual reality is introduced as an immersive, realistic and easily scalable technology that can supplement traditional curricula. Lastly, the authors highlight the importance of establishing a professional standard of competence, potentially by incorporating difficult patient encounters, including disclosure of error, into medical licensing examinations that assess clinical skills. Existing curricula that cover physician error disclosure may benefit from reviewing the social psychology literature. These lessons, incorporated into SP programmes and emerging technological platforms, may improve training and evaluative methods for all medical trainees. © 2017 John Wiley & Sons Ltd and The Association for the Study of Medical Education.

Development of an Efficient Identifier for Nuclear Power Plant Transients Based on Latest Advances of Error Back-Propagation Learning Algorithm

NASA Astrophysics Data System (ADS)

Moshkbar-Bakhshayesh, Khalil; Ghofrani, Mohammad B.

2014-02-01

This study aims to improve the performance of nuclear power plants (NPPs) transients training and identification using the latest advances of error back-propagation (EBP) learning algorithm. To this end, elements of EBP, including input data, initial weights, learning rate, cost function, activation function, and weights updating procedure are investigated and an efficient neural network is developed. Usefulness of modular networks is also examined and appropriate identifiers, one for each transient, are employed. Furthermore, the effect of transient type on transient identifier performance is illustrated. Subsequently, the developed transient identifier is applied to Bushehr nuclear power plant (BNPP). Seven types of the plant events are probed to analyze the ability of the proposed identifier. The results reveal that identification occurs very early with only five plant variables, whilst in the previous studies a larger number of variables (typically 15 to 20) were required. Modular networks facilitated identification due to its sole dependency on the sign of each network output signal. Fast training of input patterns, extendibility for identification of more transients and reduction of false identification are other advantageous of the proposed identifier. Finally, the balance between the correct answer to the trained transients (memorization) and reasonable response to the test transients (generalization) is improved, meeting one of the primary design criteria of identifiers.

Utilizing measure-based feedback in control-mastery theory: A clinical error.

PubMed

Snyder, John; Aafjes-van Doorn, Katie

2016-09-01

Clinical errors and ruptures are an inevitable part of clinical practice. Often times, therapists are unaware that a clinical error or rupture has occurred, leaving no space for repair, and potentially leading to patient dropout and/or less effective treatment. One way to overcome our blind spots is by frequently and systematically collecting measure-based feedback from the patient. Patient feedback measures that focus on the process of psychotherapy such as the Patient's Experience of Attunement and Responsiveness scale (PEAR) can be used in conjunction with treatment outcome measures such as the Outcome Questionnaire 45.2 (OQ-45.2) to monitor the patient's therapeutic experience and progress. The regular use of these types of measures can aid clinicians in the identification of clinical errors and the associated patient deterioration that might otherwise go unnoticed and unaddressed. The current case study describes an instance of clinical error that occurred during the 2-year treatment of a highly traumatized young woman. The clinical error was identified using measure-based feedback and subsequently understood and addressed from the theoretical standpoint of the control-mastery theory of psychotherapy. An alternative hypothetical response is also presented and explained using control-mastery theory. (PsycINFO Database Record (c) 2016 APA, all rights reserved).

The interacting correlated fragments model for weak interactions, basis set superposition error, and the helium dimer potential

NASA Astrophysics Data System (ADS)

Liu, B.; McLean, A. D.

1989-08-01

We report the LM-2 helium dimer interaction potential, from helium separations of 1.6 Å to dissociation, obtained by careful convergence studies with respect to configuration space, through a sequence of interacting correlated fragment (ICF) wave functions, and with respect to the primitive Slater-type basis used for orbital expansion. Parameters of the LM-2 potential are re=2.969 Å, rm=2.642 Å, and De=10.94 K, in near complete agreement with those of the best experimental potential of Aziz, McCourt, and Wong [Mol. Phys. 61, 1487 (1987)], which are re=2.963 Å, rm=2.637 Å, and De=10.95 K. The computationally estimated accuracy of each point on the potential is given; at re it is 0.03 K. Extrapolation procedures used to produce the LM-2 potential make use of the orbital basis inconsistency (OBI) and configuration base inconsistency (CBI) adjustments to separated fragment energies when computing the interaction energy. These components of basis set superposition error (BSSE) are given a full discussion.

Electron Beam Propagation Through a Magnetic Wiggler with Random Field Errors

DTIC Science & Technology

1989-08-21

Another quantity of interest is the vector potential 6.A,.(:) associated with the field error 6B,,,(:). Defining the normalized vector potentials ba = ebA...then follows that the correlation of the normalized vector potential errors is given by 1 . 12 (-a.(zj)a.,(z2)) = a,k,, dz’ , dz" (bBE(z’)bB , (z")) a2...Throughout the following, terms of order O(z:/z) will be neglected. Similarly, for the y-component of the normalized vector potential errors, one

Surprise beyond prediction error

PubMed Central

Chumbley, Justin R; Burke, Christopher J; Stephan, Klaas E; Friston, Karl J; Tobler, Philippe N; Fehr, Ernst

2014-01-01

Surprise drives learning. Various neural “prediction error” signals are believed to underpin surprise-based reinforcement learning. Here, we report a surprise signal that reflects reinforcement learning but is neither un/signed reward prediction error (RPE) nor un/signed state prediction error (SPE). To exclude these alternatives, we measured surprise responses in the absence of RPE and accounted for a host of potential SPE confounds. This new surprise signal was evident in ventral striatum, primary sensory cortex, frontal poles, and amygdala. We interpret these findings via a normative model of surprise. PMID:24700400

A system dynamics approach to analyze laboratory test errors.

PubMed

Guo, Shijing; Roudsari, Abdul; Garcez, Artur d'Avila

2015-01-01

Although many researches have been carried out to analyze laboratory test errors during the last decade, it still lacks a systemic view of study, especially to trace errors during test process and evaluate potential interventions. This study implements system dynamics modeling into laboratory errors to trace the laboratory error flows and to simulate the system behaviors while changing internal variable values. The change of the variables may reflect a change in demand or a proposed intervention. A review of literature on laboratory test errors was given and provided as the main data source for the system dynamics model. Three "what if" scenarios were selected for testing the model. System behaviors were observed and compared under different scenarios over a period of time. The results suggest system dynamics modeling has potential effectiveness of helping to understand laboratory errors, observe model behaviours, and provide a risk-free simulation experiments for possible strategies.

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

PubMed

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

2014-01-01

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

Addressing Medical Errors in Hand Surgery

PubMed Central

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

tPA Prescription and Administration Errors within a Regional Stroke System

PubMed Central

Chung, Lee S; Tkach, Aleksander; Lingenfelter, Erin M; Dehoney, Sarah; Rollo, Jeannie; de Havenon, Adam; DeWitt, Lucy Dana; Grantz, Matthew Ryan; Wang, Haimei; Wold, Jana J; Hannon, Peter M; Weathered, Natalie R; Majersik, Jennifer J

2015-01-01

Background IV tPA utilization in acute ischemic stroke (AIS) requires weight-based dosing and a standardized infusion rate. In our regional network, we have tried to minimize tPA dosing errors. We describe the frequency and types of tPA administration errors made in our comprehensive stroke center (CSC) and at community hospitals (CHs) prior to transfer. Methods Using our stroke quality database, we extracted clinical and pharmacy information on all patients who received IV tPA from 2010–11 at the CSC or CH prior to transfer. All records were analyzed for the presence of inclusion/exclusion criteria deviations or tPA errors in prescription, reconstitution, dispensing, or administration, and analyzed for association with outcomes. Results We identified 131 AIS cases treated with IV tPA: 51% female; mean age 68; 32% treated at CSC, 68% at CH (including 26% by telestroke) from 22 CHs. tPA prescription and administration errors were present in 64% of all patients (41% CSC, 75% CH, p<0.001), the most common being incorrect dosage for body weight (19% CSC, 55% CH, p<0.001). Of the 27 overdoses, there were 3 deaths due to systemic hemorrhage or ICH. Nonetheless, outcomes (parenchymal hematoma, mortality, mRS) did not differ between CSC and CH patients nor between those with and without errors. Conclusion Despite focus on minimization of tPA administration errors in AIS patients, such errors were very common in our regional stroke system. Although an association between tPA errors and stroke outcomes was not demonstrated, quality assurance mechanisms are still necessary to reduce potentially dangerous, avoidable errors. PMID:26698642

Action errors, error management, and learning in organizations.

PubMed

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.

Modeling coherent errors in quantum error correction

NASA Astrophysics Data System (ADS)

Greenbaum, Daniel; Dutton, Zachary

2018-01-01

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

Action Research of an Error Self-Correction Intervention: Examining the Effects on the Spelling Accuracy Behaviors of Fifth-Grade Students Identified as At-Risk

ERIC Educational Resources Information Center

Turner, Jill; Rafferty, Lisa A.; Sullivan, Ray; Blake, Amy

2017-01-01

In this action research case study, the researchers used a multiple baseline across two student pairs design to investigate the effects of the error self-correction method on the spelling accuracy behaviors for four fifth-grade students who were identified as being at risk for learning disabilities. The dependent variable was the participants'…

Dysfunctional error-related processing in incarcerated youth with elevated psychopathic traits

PubMed Central

Maurer, J. Michael; Steele, Vaughn R.; Cope, Lora M.; Vincent, Gina M.; Stephen, Julia M.; Calhoun, Vince D.; Kiehl, Kent A.

2016-01-01

Adult psychopathic offenders show an increased propensity towards violence, impulsivity, and recidivism. A subsample of youth with elevated psychopathic traits represent a particularly severe subgroup characterized by extreme behavioral problems and comparable neurocognitive deficits as their adult counterparts, including perseveration deficits. Here, we investigate response-locked event-related potential (ERP) components (the error-related negativity [ERN/Ne] related to early error-monitoring processing and the error-related positivity [Pe] involved in later error-related processing) in a sample of incarcerated juvenile male offenders (n = 100) who performed a response inhibition Go/NoGo task. Psychopathic traits were assessed using the Hare Psychopathy Checklist: Youth Version (PCL:YV). The ERN/Ne and Pe were analyzed with classic windowed ERP components and principal component analysis (PCA). Using linear regression analyses, PCL:YV scores were unrelated to the ERN/Ne, but were negatively related to Pe mean amplitude. Specifically, the PCL:YV Facet 4 subscale reflecting antisocial traits emerged as a significant predictor of reduced amplitude of a subcomponent underlying the Pe identified with PCA. This is the first evidence to suggest a negative relationship between adolescent psychopathy scores and Pe mean amplitude. PMID:26930170

Use of FMEA analysis to reduce risk of errors in prescribing and administering drugs in paediatric wards: a quality improvement report.

PubMed

Lago, Paola; Bizzarri, Giancarlo; Scalzotto, Francesca; Parpaiola, Antonella; Amigoni, Angela; Putoto, Giovanni; Perilongo, Giorgio

2012-01-01

Administering medication to hospitalised infants and children is a complex process at high risk of error. Failure mode and effect analysis (FMEA) is a proactive tool used to analyse risks, identify failures before they happen and prioritise remedial measures. To examine the hazards associated with the process of drug delivery to children, we performed a proactive risk-assessment analysis. Five multidisciplinary teams, representing different divisions of the paediatric department at Padua University Hospital, were trained to analyse the drug-delivery process, to identify possible causes of failures and their potential effects, to calculate a risk priority number (RPN) for each failure and plan changes in practices. To identify higher-priority potential failure modes as defined by RPNs and planning changes in clinical practice to reduce the risk of patients harm and improve safety in the process of medication use in children. In all, 37 higher-priority potential failure modes and 71 associated causes and effects were identified. The highest RPNs related (>48) mainly to errors in calculating drug doses and concentrations. Many of these failure modes were found in all the five units, suggesting the presence of common targets for improvement, particularly in enhancing the safety of prescription and preparation of endovenous drugs. The introductions of new activities in the revised process of administering drugs allowed reducing the high-risk failure modes of 60%. FMEA is an effective proactive risk-assessment tool useful to aid multidisciplinary groups in understanding a process care and identifying errors that may occur, prioritising remedial interventions and possibly enhancing the safety of drug delivery in children.

Technology utilization to prevent medication errors.

PubMed

Forni, Allison; Chu, Hanh T; Fanikos, John

2010-01-01

Medication errors have been increasingly recognized as a major cause of iatrogenic illness and system-wide improvements have been the focus of prevention efforts. Critically ill patients are particularly vulnerable to injury resulting from medication errors because of the severity of illness, need for high risk medications with a narrow therapeutic index and frequent use of intravenous infusions. Health information technology has been identified as method to reduce medication errors as well as improve the efficiency and quality of care; however, few studies regarding the impact of health information technology have focused on patients in the intensive care unit. Computerized physician order entry and clinical decision support systems can play a crucial role in decreasing errors in the ordering stage of the medication use process through improving the completeness and legibility of orders, alerting physicians to medication allergies and drug interactions and providing a means for standardization of practice. Electronic surveillance, reminders and alerts identify patients susceptible to an adverse event, communicate critical changes in a patient's condition, and facilitate timely and appropriate treatment. Bar code technology, intravenous infusion safety systems, and electronic medication administration records can target prevention of errors in medication dispensing and administration where other technologies would not be able to intercept a preventable adverse event. Systems integration and compliance are vital components in the implementation of health information technology and achievement of a safe medication use process.

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

PubMed

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

2016-11-01

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

Identifying and preventing medical errors in patients with limited English proficiency: key findings and tools for the field.

PubMed

Wasserman, Melanie; Renfrew, Megan R; Green, Alexander R; Lopez, Lenny; Tan-McGrory, Aswita; Brach, Cindy; Betancourt, Joseph R

2014-01-01

Since the 1999 Institute of Medicine (IOM) report To Err is Human, progress has been made in patient safety, but few efforts have focused on safety in patients with limited English proficiency (LEP). This article describes the development, content, and testing of two new evidence-based Agency for Healthcare Research and Quality (AHRQ) tools for LEP patient safety. In the content development phase, a comprehensive mixed-methods approach was used to identify common causes of errors for LEP patients, high-risk scenarios, and evidence-based strategies to address them. Based on our findings, Improving Patient Safety Systems for Limited English Proficient Patients: A Guide for Hospitals contains recommendations to improve detection and prevention of medical errors across diverse populations, and TeamSTEPPS Enhancing Safety for Patients with Limited English Proficiency Module trains staff to improve safety through team communication and incorporating interpreters in the care process. The Hospital Guide was validated with leaders in quality and safety at diverse hospitals, and the TeamSTEPPS LEP module was field-tested in varied settings within three hospitals. Both tools were found to be implementable, acceptable to their audiences, and conducive to learning. Further research on the impact of the combined use of the guide and module would shed light on their value as a multifaceted intervention. © 2014 National Association for Healthcare Quality.

Identifying and reducing error in cluster-expansion approximations of protein energies.

PubMed

Hahn, Seungsoo; Ashenberg, Orr; Grigoryan, Gevorg; Keating, Amy E

2010-12-01

Protein design involves searching a vast space for sequences that are compatible with a defined structure. This can pose significant computational challenges. Cluster expansion is a technique that can accelerate the evaluation of protein energies by generating a simple functional relationship between sequence and energy. The method consists of several steps. First, for a given protein structure, a training set of sequences with known energies is generated. Next, this training set is used to expand energy as a function of clusters consisting of single residues, residue pairs, and higher order terms, if required. The accuracy of the sequence-based expansion is monitored and improved using cross-validation testing and iterative inclusion of additional clusters. As a trade-off for evaluation speed, the cluster-expansion approximation causes prediction errors, which can be reduced by including more training sequences, including higher order terms in the expansion, and/or reducing the sequence space described by the cluster expansion. This article analyzes the sources of error and introduces a method whereby accuracy can be improved by judiciously reducing the described sequence space. The method is applied to describe the sequence-stability relationship for several protein structures: coiled-coil dimers and trimers, a PDZ domain, and T4 lysozyme as examples with computationally derived energies, and SH3 domains in amphiphysin-1 and endophilin-1 as examples where the expanded pseudo-energies are obtained from experiments. Our open-source software package Cluster Expansion Version 1.0 allows users to expand their own energy function of interest and thereby apply cluster expansion to custom problems in protein design. © 2010 Wiley Periodicals, Inc.

Interventions to reduce medication errors in neonatal care: a systematic review

PubMed Central

Nguyen, Minh-Nha Rhylie; Mosel, Cassandra

2017-01-01

Background: Medication errors represent a significant but often preventable cause of morbidity and mortality in neonates. The objective of this systematic review was to determine the effectiveness of interventions to reduce neonatal medication errors. Methods: A systematic review was undertaken of all comparative and noncomparative studies published in any language, identified from searches of PubMed and EMBASE and reference-list checking. Eligible studies were those investigating the impact of any medication safety interventions aimed at reducing medication errors in neonates in the hospital setting. Results: A total of 102 studies were identified that met the inclusion criteria, including 86 comparative and 16 noncomparative studies. Medication safety interventions were classified into six themes: technology (n = 38; e.g. electronic prescribing), organizational (n = 16; e.g. guidelines, policies, and procedures), personnel (n = 13; e.g. staff education), pharmacy (n = 9; e.g. clinical pharmacy service), hazard and risk analysis (n = 8; e.g. error detection tools), and multifactorial (n = 18; e.g. any combination of previous interventions). Significant variability was evident across all included studies, with differences in intervention strategies, trial methods, types of medication errors evaluated, and how medication errors were identified and evaluated. Most studies demonstrated an appreciable risk of bias. The vast majority of studies (>90%) demonstrated a reduction in medication errors. A similar median reduction of 50–70% in medication errors was evident across studies included within each of the identified themes, but findings varied considerably from a 16% increase in medication errors to a 100% reduction in medication errors. Conclusion: While neonatal medication errors can be reduced through multiple interventions aimed at improving the medication use process, no single intervention appeared clearly superior. Further research is required to evaluate

Towards eliminating systematic errors caused by the experimental conditions in Biochemical Methane Potential (BMP) tests.

PubMed

Strömberg, Sten; Nistor, Mihaela; Liu, Jing

2014-11-01

The Biochemical Methane Potential (BMP) test is increasingly recognised as a tool for selecting and pricing biomass material for production of biogas. However, the results for the same substrate often differ between laboratories and much work to standardise such tests is still needed. In the current study, the effects from four environmental factors (i.e. ambient temperature and pressure, water vapour content and initial gas composition of the reactor headspace) on the degradation kinetics and the determined methane potential were evaluated with a 2(4) full factorial design. Four substrates, with different biodegradation profiles, were investigated and the ambient temperature was found to be the most significant contributor to errors in the methane potential. Concerning the kinetics of the process, the environmental factors' impact on the calculated rate constants was negligible. The impact of the environmental factors on the kinetic parameters and methane potential from performing a BMP test at different geographical locations around the world was simulated by adjusting the data according to the ambient temperature and pressure of some chosen model sites. The largest effect on the methane potential was registered from tests performed at high altitudes due to a low ambient pressure. The results from this study illustrate the importance of considering the environmental factors' influence on volumetric gas measurement in BMP tests. This is essential to achieve trustworthy and standardised results that can be used by researchers and end users from all over the world. Copyright © 2014 Elsevier Ltd. All rights reserved.

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

PubMed Central

2011-01-01

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

Model misspecification detection by means of multiple generator errors, using the observed potential map.

PubMed

Zhang, Z; Jewett, D L

1994-01-01

Due to model misspecification, currently-used Dipole Source Localization (DSL) methods may contain Multiple-Generator Errors (MulGenErrs) when fitting simultaneously-active dipoles. The size of the MulGenErr is a function of both the model used, and the dipole parameters, including the dipoles' waveforms (time-varying magnitudes). For a given fitting model, by examining the variation of the MulGenErrs (or the fit parameters) under different waveforms for the same generating-dipoles, the accuracy of the fitting model for this set of dipoles can be determined. This method of testing model misspecification can be applied to evoked potential maps even when the parameters of the generating-dipoles are unknown. The dipole parameters fitted in a model should only be accepted if the model can be shown to be sufficiently accurate.

Measurement error in environmental epidemiology and the shape of exposure-response curves.

PubMed

Rhomberg, Lorenz R; Chandalia, Juhi K; Long, Christopher M; Goodman, Julie E

2011-09-01

Both classical and Berkson exposure measurement errors as encountered in environmental epidemiology data can result in biases in fitted exposure-response relationships that are large enough to affect the interpretation and use of the apparent exposure-response shapes in risk assessment applications. A variety of sources of potential measurement error exist in the process of estimating individual exposures to environmental contaminants, and the authors review the evaluation in the literature of the magnitudes and patterns of exposure measurement errors that prevail in actual practice. It is well known among statisticians that random errors in the values of independent variables (such as exposure in exposure-response curves) may tend to bias regression results. For increasing curves, this effect tends to flatten and apparently linearize what is in truth a steeper and perhaps more curvilinear or even threshold-bearing relationship. The degree of bias is tied to the magnitude of the measurement error in the independent variables. It has been shown that the degree of bias known to apply to actual studies is sufficient to produce a false linear result, and that although nonparametric smoothing and other error-mitigating techniques may assist in identifying a threshold, they do not guarantee detection of a threshold. The consequences of this could be great, as it could lead to a misallocation of resources towards regulations that do not offer any benefit to public health.

Errors Made by Elementary Fourth Grade Students When Modelling Word Problems and the Elimination of Those Errors through Scaffolding

ERIC Educational Resources Information Center

Ulu, Mustafa

2017-01-01

This study aims to identify errors made by primary school students when modelling word problems and to eliminate those errors through scaffolding. A 10-question problem-solving achievement test was used in the research. The qualitative and quantitative designs were utilized together. The study group of the quantitative design comprises 248…

Pilot age and error in air taxi crashes.

PubMed

Rebok, George W; Qiang, Yandong; Baker, Susan P; Li, Guohua

2009-07-01

The associations of pilot error with the type of flight operations and basic weather conditions are well documented. The correlation between pilot characteristics and error is less clear. This study aims to examine whether pilot age is associated with the prevalence and patterns of pilot error in air taxi crashes. Investigation reports from the National Transportation Safety Board for crashes involving non-scheduled Part 135 operations (i.e., air taxis) in the United States between 1983 and 2002 were reviewed to identify pilot error and other contributing factors. Crash circumstances and the presence and type of pilot error were analyzed in relation to pilot age using Chi-square tests. Of the 1751 air taxi crashes studied, 28% resulted from mechanical failure, 25% from loss of control at landing or takeoff, 7% from visual flight rule conditions into instrument meteorological conditions, 7% from fuel starvation, 5% from taxiing, and 28% from other causes. Crashes among older pilots were more likely to occur during the daytime rather than at night and off airport than on airport. The patterns of pilot error in air taxi crashes were similar across age groups. Of the errors identified, 27% were flawed decisions, 26% were inattentiveness, 23% mishandled aircraft kinetics, 15% mishandled wind and/or runway conditions, and 11% were others. Pilot age is associated with crash circumstances but not with the prevalence and patterns of pilot error in air taxi crashes. Lack of age-related differences in pilot error may be attributable to the "safe worker effect."

Pilot Age and Error in Air-Taxi Crashes

PubMed Central

Rebok, George W.; Qiang, Yandong; Baker, Susan P.; Li, Guohua

2010-01-01

Introduction The associations of pilot error with the type of flight operations and basic weather conditions are well documented. The correlation between pilot characteristics and error is less clear. This study aims to examine whether pilot age is associated with the prevalence and patterns of pilot error in air-taxi crashes. Methods Investigation reports from the National Transportation Safety Board for crashes involving non-scheduled Part 135 operations (i.e., air taxis) in the United States between 1983 and 2002 were reviewed to identify pilot error and other contributing factors. Crash circumstances and the presence and type of pilot error were analyzed in relation to pilot age using Chi-square tests. Results Of the 1751 air-taxi crashes studied, 28% resulted from mechanical failure, 25% from loss of control at landing or takeoff, 7% from visual flight rule conditions into instrument meteorological conditions, 7% from fuel starvation, 5% from taxiing, and 28% from other causes. Crashes among older pilots were more likely to occur during the daytime rather than at night and off airport than on airport. The patterns of pilot error in air-taxi crashes were similar across age groups. Of the errors identified, 27% were flawed decisions, 26% were inattentiveness, 23% mishandled aircraft kinetics, 15% mishandled wind and/or runway conditions, and 11% were others. Conclusions Pilot age is associated with crash circumstances but not with the prevalence and patterns of pilot error in air-taxi crashes. Lack of age-related differences in pilot error may be attributable to the “safe worker effect.” PMID:19601508

What is the epidemiology of medication errors, error-related adverse events and risk factors for errors in adults managed in community care contexts? A systematic review of the international literature.

PubMed

Assiri, Ghadah Asaad; Shebl, Nada Atef; Mahmoud, Mansour Adam; Aloudah, Nouf; Grant, Elizabeth; Aljadhey, Hisham; Sheikh, Aziz

2018-05-05

To investigate the epidemiology of medication errors and error-related adverse events in adults in primary care, ambulatory care and patients' homes. Systematic review. Six international databases were searched for publications between 1 January 2006 and 31 December 2015. Two researchers independently extracted data from eligible studies and assessed the quality of these using established instruments. Synthesis of data was informed by an appreciation of the medicines' management process and the conceptual framework from the International Classification for Patient Safety. 60 studies met the inclusion criteria, of which 53 studies focused on medication errors, 3 on error-related adverse events and 4 on risk factors only. The prevalence of prescribing errors was reported in 46 studies: prevalence estimates ranged widely from 2% to 94%. Inappropriate prescribing was the most common type of error reported. Only one study reported the prevalence of monitoring errors, finding that incomplete therapeutic/safety laboratory-test monitoring occurred in 73% of patients. The incidence of preventable adverse drug events (ADEs) was estimated as 15/1000 person-years, the prevalence of drug-drug interaction-related adverse drug reactions as 7% and the prevalence of preventable ADE as 0.4%. A number of patient, healthcare professional and medication-related risk factors were identified, including the number of medications used by the patient, increased patient age, the number of comorbidities, use of anticoagulants, cases where more than one physician was involved in patients' care and care being provided by family physicians/general practitioners. A very wide variation in the medication error and error-related adverse events rates is reported in the studies, this reflecting heterogeneity in the populations studied, study designs employed and outcomes evaluated. This review has identified important limitations and discrepancies in the methodologies used and gaps in the literature

Predicting and interpreting identification errors in military vehicle training using multidimensional scaling.

PubMed

Bohil, Corey J; Higgins, Nicholas A; Keebler, Joseph R

2014-01-01

We compared methods for predicting and understanding the source of confusion errors during military vehicle identification training. Participants completed training to identify main battle tanks. They also completed card-sorting and similarity-rating tasks to express their mental representation of resemblance across the set of training items. We expected participants to selectively attend to a subset of vehicle features during these tasks, and we hypothesised that we could predict identification confusion errors based on the outcomes of the card-sort and similarity-rating tasks. Based on card-sorting results, we were able to predict about 45% of observed identification confusions. Based on multidimensional scaling of the similarity-rating data, we could predict more than 80% of identification confusions. These methods also enabled us to infer the dimensions receiving significant attention from each participant. This understanding of mental representation may be crucial in creating personalised training that directs attention to features that are critical for accurate identification. Participants completed military vehicle identification training and testing, along with card-sorting and similarity-rating tasks. The data enabled us to predict up to 84% of identification confusion errors and to understand the mental representation underlying these errors. These methods have potential to improve training and reduce identification errors leading to fratricide.

Stop! Look & Lesson: A Guide to Identifying and Correcting Common Mathematical Errors Strategies.

ERIC Educational Resources Information Center

Palmer, Don; And Others

This book provides a comprehensive collection of 66 teaching strategies and ideas to help overcome problems with number, each linked to a specific kind of error described in the related manual. Most of these strategies are classroom-ready and easily implemented. Some are notes for the teacher to read and then plan activities accordingly, and many…

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

PubMed

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

2015-02-01

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

Discovering Potential Pathogens among Fungi Identified as Nonsporulating Molds▿

PubMed Central

Pounder, June I.; Simmon, Keith E.; Barton, Claudia A.; Hohmann, Sheri L.; Brandt, Mary E.; Petti, Cathy A.

2007-01-01

Fungal infections are increasing, particularly among immunocompromised hosts, and a rapid diagnosis is essential to initiate antifungal therapy. Often fungi cannot be identified by conventional methods and are classified as nonsporulating molds (NSM).We sequenced internal transcribed spacer regions from 50 cultures of NSM and found 16 potential pathogens that can be associated with clinical disease. In selected clinical settings, identification of NSM could prove valuable and have an immediate impact on patient management. PMID:17135442

Proteomics-based approach identified differentially expressed proteins with potential roles in endometrial carcinoma.

PubMed

Li, Zhengyu; Min, Wenjiao; Huang, Canhua; Bai, Shujun; Tang, Minghai; Zhao, Xia

2010-01-01

We used proteomic approaches to identify altered expressed proteins in endometrial carcinoma, with the aim of discovering potential biomarkers or therapeutic targets for endometrial carcinoma. The global proteins extracted from endometrial carcinoma and normal endometrial tissues were separated by 2-dimensional electrophoresis and analyzed with PDQuest (Bio-Rad, Hercules, Calif) software. The differentially expressed spots were identified by mass spectrometry and searched against NCBInr protein database. Those proteins with potential roles were confirmed by Western blotting and immunohistochemical assays. Ninety-nine proteins were identified by mass spectrometry, and a cluster diagram analysis indicated that these proteins were involved in metabolism, cell transformation, protein folding, translation and modification, proliferation and apoptosis, signal transduction, cytoskeleton, and so on. In confirmatory immunoblotting and immunohistochemical analyses, overexpressions of epidermal fatty acid-binding protein, calcyphosine, and cyclophilin A were also observed in endometrial carcinoma tissues, which were consistent with the proteomic results. Our results suggested that these identified proteins, including epidermal fatty acid-binding protein, calcyphosine, and cyclophilin A, might be of potential values in the studies of endometrial carcinogenesis or investigations of diagnostic biomarkers or treatment targets for endometrial carcinoma.

Novel Myopia Genes and Pathways Identified From Syndromic Forms of Myopia

PubMed Central

Loughman, James; Wildsoet, Christine F.; Williams, Cathy; Guggenheim, Jeremy A.

2018-01-01

Purpose To test the hypothesis that genes known to cause clinical syndromes featuring myopia also harbor polymorphisms contributing to nonsyndromic refractive errors. Methods Clinical phenotypes and syndromes that have refractive errors as a recognized feature were identified using the Online Mendelian Inheritance in Man (OMIM) database. One hundred fifty-four unique causative genes were identified, of which 119 were specifically linked with myopia and 114 represented syndromic myopia (i.e., myopia and at least one other clinical feature). Myopia was the only refractive error listed for 98 genes and hyperopia and the only refractive error noted for 28 genes, with the remaining 28 genes linked to phenotypes with multiple forms of refractive error. Pathway analysis was carried out to find biological processes overrepresented within these sets of genes. Genetic variants located within 50 kb of the 119 myopia-related genes were evaluated for involvement in refractive error by analysis of summary statistics from genome-wide association studies (GWAS) conducted by the CREAM Consortium and 23andMe, using both single-marker and gene-based tests. Results Pathway analysis identified several biological processes already implicated in refractive error development through prior GWAS analyses and animal studies, including extracellular matrix remodeling, focal adhesion, and axon guidance, supporting the research hypothesis. Novel pathways also implicated in myopia development included mannosylation, glycosylation, lens development, gliogenesis, and Schwann cell differentiation. Hyperopia was found to be linked to a different pattern of biological processes, mostly related to organogenesis. Comparison with GWAS findings further confirmed that syndromic myopia genes were enriched for genetic variants that influence refractive errors in the general population. Gene-based analyses implicated 21 novel candidate myopia genes (ADAMTS18, ADAMTS2, ADAMTSL4, AGK, ALDH18A1, ASXL1, COL4A1

Error Analysis in Composition of Iranian Lower Intermediate Students

ERIC Educational Resources Information Center

Taghavi, Mehdi

2012-01-01

Learners make errors during the process of learning languages. This study examines errors in writing task of twenty Iranian lower intermediate male students aged between 13 and 15. A subject was given to the participants was a composition about the seasons of a year. All of the errors were identified and classified. Corder's classification (1967)…

Unavoidable Errors: A Spatio-Temporal Analysis of Time-Course and Neural Sources of Evoked Potentials Associated with Error Processing in a Speeded Task

ERIC Educational Resources Information Center

Vocat, Roland; Pourtois, Gilles; Vuilleumier, Patrik

2008-01-01

The detection of errors is known to be associated with two successive neurophysiological components in EEG, with an early time-course following motor execution: the error-related negativity (ERN/Ne) and late positivity (Pe). The exact cognitive and physiological processes contributing to these two EEG components, as well as their functional…

Exome sequencing of a large family identifies potential candidate genes contributing risk to bipolar disorder.

PubMed

Zhang, Tianxiao; Hou, Liping; Chen, David T; McMahon, Francis J; Wang, Jen-Chyong; Rice, John P

2018-03-01

Bipolar disorder is a mental illness with lifetime prevalence of about 1%. Previous genetic studies have identified multiple chromosomal linkage regions and candidate genes that might be associated with bipolar disorder. The present study aimed to identify potential susceptibility variants for bipolar disorder using 6 related case samples from a four-generation family. A combination of exome sequencing and linkage analysis was performed to identify potential susceptibility variants for bipolar disorder. Our study identified a list of five potential candidate genes for bipolar disorder. Among these five genes, GRID1(Glutamate Receptor Delta-1 Subunit), which was previously reported to be associated with several psychiatric disorders and brain related traits, is particularly interesting. Variants with functional significance in this gene were identified from two cousins in our bipolar disorder pedigree. Our findings suggest a potential role for these genes and the related rare variants in the onset and development of bipolar disorder in this one family. Additional research is needed to replicate these findings and evaluate their patho-biological significance. Copyright © 2017 Elsevier B.V. All rights reserved.

Use of FMEA analysis to reduce risk of errors in prescribing and administering drugs in paediatric wards: a quality improvement report

PubMed Central

Lago, Paola; Bizzarri, Giancarlo; Scalzotto, Francesca; Parpaiola, Antonella; Amigoni, Angela; Putoto, Giovanni; Perilongo, Giorgio

2012-01-01

Objective Administering medication to hospitalised infants and children is a complex process at high risk of error. Failure mode and effect analysis (FMEA) is a proactive tool used to analyse risks, identify failures before they happen and prioritise remedial measures. To examine the hazards associated with the process of drug delivery to children, we performed a proactive risk-assessment analysis. Design and setting Five multidisciplinary teams, representing different divisions of the paediatric department at Padua University Hospital, were trained to analyse the drug-delivery process, to identify possible causes of failures and their potential effects, to calculate a risk priority number (RPN) for each failure and plan changes in practices. Primary outcome To identify higher-priority potential failure modes as defined by RPNs and planning changes in clinical practice to reduce the risk of patients harm and improve safety in the process of medication use in children. Results In all, 37 higher-priority potential failure modes and 71 associated causes and effects were identified. The highest RPNs related (>48) mainly to errors in calculating drug doses and concentrations. Many of these failure modes were found in all the five units, suggesting the presence of common targets for improvement, particularly in enhancing the safety of prescription and preparation of endovenous drugs. The introductions of new activities in the revised process of administering drugs allowed reducing the high-risk failure modes of 60%. Conclusions FMEA is an effective proactive risk-assessment tool useful to aid multidisciplinary groups in understanding a process care and identifying errors that may occur, prioritising remedial interventions and possibly enhancing the safety of drug delivery in children. PMID:23253870

Hot spot analysis applied to identify ecosystem services potential in Lithuania

NASA Astrophysics Data System (ADS)

Pereira, Paulo; Depellegrin, Daniel; Misiune, Ieva

2016-04-01

Hot spot analysis are very useful to identify areas with similar characteristics. This is important for a sustainable use of the territory, since we can identify areas that need to be protected, or restored. This is a great advantage in terms of land use planning and management, since we can allocate resources, reduce the economical costs and do a better intervention in the landscape. Ecosystem services (ES) are different according land use. Since landscape is very heterogeneous, it is of major importance understand their spatial pattern and where are located the areas that provide better ES and the others that provide less services. The objective of this work is to use hot-spot analysis to identify areas with the most valuable ES in Lithuania. CORINE land-cover (CLC) of 2006 was used as the main spatial information. This classification uses a grid of 100 m resolution and extracted a total of 31 land use types. ES ranking was carried out based on expert knowledge. They were asked to evaluate the ES potential of each different CLC from 0 (no potential) to 5 (very high potential). Hot spot analysis were evaluated using the Getis-ord test, which identifies cluster analysis available in ArcGIS toolbox. This tool identifies areas with significantly high low values and significant high values at a p level of 0.05. In this work we used hot spot analysis to assess the distribution of providing, regulating cultural and total (sum of the previous 3) ES. The Z value calculated from Getis-ord was used to statistical analysis to access the clusters of providing, regulating cultural and total ES. ES with high Z value show that they have a high number of cluster areas with high potential of ES. The results showed that the Z-score was significantly different among services (Kruskal Wallis ANOVA =834. 607, p<0.001). The Z score of providing services (0.096±2.239) were significantly higher than the total (0.093±2.045), cultural (0.080±1.979) and regulating (0.076±1.961). These

System review: a method for investigating medical errors in healthcare settings.

PubMed

Alexander, G L; Stone, T T

2000-01-01

System analysis is a process of evaluating objectives, resources, structure, and design of businesses. System analysis can be used by leaders to collaboratively identify breakthrough opportunities to improve system processes. In healthcare systems, system analysis can be used to review medical errors (system occurrences) that may place patients at risk for injury, disability, and/or death. This study utilizes a case management approach to identify medical errors. Utilizing an interdisciplinary approach, a System Review Team was developed to identify trends in system occurrences, facilitate communication, and enhance the quality of patient care by reducing medical errors.

Assessing the connection between health and education: identifying potential leverage points for public health to improve school attendance.

PubMed

Gase, Lauren N; Kuo, Tony; Coller, Karen; Guerrero, Lourdes R; Wong, Mitchell D

2014-09-01

We examined multiple variables influencing school truancy to identify potential leverage points to improve school attendance. A cross-sectional observational design was used to analyze inner-city data collected in Los Angeles County, California, during 2010 to 2011. We constructed an ordinal logistic regression model with cluster robust standard errors to examine the association between truancy and various covariates. The sample was predominantly Hispanic (84.3%). Multivariable analysis revealed greater truancy among students (1) with mild (adjusted odds ratio [AOR] = 1.57; 95% confidence interval [CI] = 1.22, 2.01) and severe (AOR = 1.80; 95% CI = 1.04, 3.13) depression (referent: no depression), (2) whose parents were neglectful (AOR = 2.21; 95% CI = 1.21, 4.03) or indulgent (AOR = 1.71; 95% CI = 1.04, 2.82; referent: authoritative parents), (3) who perceived less support from classes, teachers, and other students regarding college preparation (AOR = 0.87; 95% CI = 0.81, 0.95), (4) who had low grade point averages (AOR = 2.34; 95% CI = 1.49, 4.38), and (5) who reported using alcohol (AOR = 3.47; 95% CI = 2.34, 5.14) or marijuana (AOR = 1.59; 95% CI = 1.06, 2.38) during the past month. Study findings suggest depression, substance use, and parental engagement as potential leverage points for public health to intervene to improve school attendance.

A national physician survey of diagnostic error in paediatrics.

PubMed

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

2016-10-01

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

Experimental Errors in QSAR Modeling Sets: What We Can Do and What We Cannot Do.

PubMed

Zhao, Linlin; Wang, Wenyi; Sedykh, Alexander; Zhu, Hao

2017-06-30

Numerous chemical data sets have become available for quantitative structure-activity relationship (QSAR) modeling studies. However, the quality of different data sources may be different based on the nature of experimental protocols. Therefore, potential experimental errors in the modeling sets may lead to the development of poor QSAR models and further affect the predictions of new compounds. In this study, we explored the relationship between the ratio of questionable data in the modeling sets, which was obtained by simulating experimental errors, and the QSAR modeling performance. To this end, we used eight data sets (four continuous endpoints and four categorical endpoints) that have been extensively curated both in-house and by our collaborators to create over 1800 various QSAR models. Each data set was duplicated to create several new modeling sets with different ratios of simulated experimental errors (i.e., randomizing the activities of part of the compounds) in the modeling process. A fivefold cross-validation process was used to evaluate the modeling performance, which deteriorates when the ratio of experimental errors increases. All of the resulting models were also used to predict external sets of new compounds, which were excluded at the beginning of the modeling process. The modeling results showed that the compounds with relatively large prediction errors in cross-validation processes are likely to be those with simulated experimental errors. However, after removing a certain number of compounds with large prediction errors in the cross-validation process, the external predictions of new compounds did not show improvement. Our conclusion is that the QSAR predictions, especially consensus predictions, can identify compounds with potential experimental errors. But removing those compounds by the cross-validation procedure is not a reasonable means to improve model predictivity due to overfitting.

Experimental Errors in QSAR Modeling Sets: What We Can Do and What We Cannot Do

PubMed Central

2017-01-01

Numerous chemical data sets have become available for quantitative structure–activity relationship (QSAR) modeling studies. However, the quality of different data sources may be different based on the nature of experimental protocols. Therefore, potential experimental errors in the modeling sets may lead to the development of poor QSAR models and further affect the predictions of new compounds. In this study, we explored the relationship between the ratio of questionable data in the modeling sets, which was obtained by simulating experimental errors, and the QSAR modeling performance. To this end, we used eight data sets (four continuous endpoints and four categorical endpoints) that have been extensively curated both in-house and by our collaborators to create over 1800 various QSAR models. Each data set was duplicated to create several new modeling sets with different ratios of simulated experimental errors (i.e., randomizing the activities of part of the compounds) in the modeling process. A fivefold cross-validation process was used to evaluate the modeling performance, which deteriorates when the ratio of experimental errors increases. All of the resulting models were also used to predict external sets of new compounds, which were excluded at the beginning of the modeling process. The modeling results showed that the compounds with relatively large prediction errors in cross-validation processes are likely to be those with simulated experimental errors. However, after removing a certain number of compounds with large prediction errors in the cross-validation process, the external predictions of new compounds did not show improvement. Our conclusion is that the QSAR predictions, especially consensus predictions, can identify compounds with potential experimental errors. But removing those compounds by the cross-validation procedure is not a reasonable means to improve model predictivity due to overfitting. PMID:28691113

Error-related processing following severe traumatic brain injury: An event-related functional magnetic resonance imaging (fMRI) study

PubMed Central

Sozda, Christopher N.; Larson, Michael J.; Kaufman, David A.S.; Schmalfuss, Ilona M.; Perlstein, William M.

2011-01-01

Continuous monitoring of one’s performance is invaluable for guiding behavior towards successful goal attainment by identifying deficits and strategically adjusting responses when performance is inadequate. In the present study, we exploited the advantages of event-related functional magnetic resonance imaging (fMRI) to examine brain activity associated with error-related processing after severe traumatic brain injury (sTBI). fMRI and behavioral data were acquired while 10 sTBI participants and 12 neurologically-healthy controls performed a task-switching cued-Stroop task. fMRI data were analyzed using a random-effects whole-brain voxel-wise general linear model and planned linear contrasts. Behaviorally, sTBI patients showed greater error-rate interference than neurologically-normal controls. fMRI data revealed that, compared to controls, sTBI patients showed greater magnitude error-related activation in the anterior cingulate cortex (ACC) and an increase in the overall spatial extent of error-related activation across cortical and subcortical regions. Implications for future research and potential limitations in conducting fMRI research in neurologically-impaired populations are discussed, as well as some potential benefits of employing multimodal imaging (e.g., fMRI and event-related potentials) of cognitive control processes in TBI. PMID:21756946

Error-related processing following severe traumatic brain injury: an event-related functional magnetic resonance imaging (fMRI) study.

PubMed

Sozda, Christopher N; Larson, Michael J; Kaufman, David A S; Schmalfuss, Ilona M; Perlstein, William M

2011-10-01

Continuous monitoring of one's performance is invaluable for guiding behavior towards successful goal attainment by identifying deficits and strategically adjusting responses when performance is inadequate. In the present study, we exploited the advantages of event-related functional magnetic resonance imaging (fMRI) to examine brain activity associated with error-related processing after severe traumatic brain injury (sTBI). fMRI and behavioral data were acquired while 10 sTBI participants and 12 neurologically-healthy controls performed a task-switching cued-Stroop task. fMRI data were analyzed using a random-effects whole-brain voxel-wise general linear model and planned linear contrasts. Behaviorally, sTBI patients showed greater error-rate interference than neurologically-normal controls. fMRI data revealed that, compared to controls, sTBI patients showed greater magnitude error-related activation in the anterior cingulate cortex (ACC) and an increase in the overall spatial extent of error-related activation across cortical and subcortical regions. Implications for future research and potential limitations in conducting fMRI research in neurologically-impaired populations are discussed, as well as some potential benefits of employing multimodal imaging (e.g., fMRI and event-related potentials) of cognitive control processes in TBI. Copyright © 2011 Elsevier B.V. All rights reserved.

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

PubMed

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

2018-03-05

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

Exploiting Task Constraints for Self-Calibrated Brain-Machine Interface Control Using Error-Related Potentials

PubMed Central

Iturrate, Iñaki; Grizou, Jonathan; Omedes, Jason; Oudeyer, Pierre-Yves; Lopes, Manuel; Montesano, Luis

2015-01-01

This paper presents a new approach for self-calibration BCI for reaching tasks using error-related potentials. The proposed method exploits task constraints to simultaneously calibrate the decoder and control the device, by using a robust likelihood function and an ad-hoc planner to cope with the large uncertainty resulting from the unknown task and decoder. The method has been evaluated in closed-loop online experiments with 8 users using a previously proposed BCI protocol for reaching tasks over a grid. The results show that it is possible to have a usable BCI control from the beginning of the experiment without any prior calibration. Furthermore, comparisons with simulations and previous results obtained using standard calibration hint that both the quality of recorded signals and the performance of the system were comparable to those obtained with a standard calibration approach. PMID:26131890

Designing and evaluating an automated system for real-time medication administration error detection in a neonatal intensive care unit.

PubMed

Ni, Yizhao; Lingren, Todd; Hall, Eric S; Leonard, Matthew; Melton, Kristin; Kirkendall, Eric S

2018-05-01

Timely identification of medication administration errors (MAEs) promises great benefits for mitigating medication errors and associated harm. Despite previous efforts utilizing computerized methods to monitor medication errors, sustaining effective and accurate detection of MAEs remains challenging. In this study, we developed a real-time MAE detection system and evaluated its performance prior to system integration into institutional workflows. Our prospective observational study included automated MAE detection of 10 high-risk medications and fluids for patients admitted to the neonatal intensive care unit at Cincinnati Children's Hospital Medical Center during a 4-month period. The automated system extracted real-time medication use information from the institutional electronic health records and identified MAEs using logic-based rules and natural language processing techniques. The MAE summary was delivered via a real-time messaging platform to promote reduction of patient exposure to potential harm. System performance was validated using a physician-generated gold standard of MAE events, and results were compared with those of current practice (incident reporting and trigger tools). Physicians identified 116 MAEs from 10 104 medication administrations during the study period. Compared to current practice, the sensitivity with automated MAE detection was improved significantly from 4.3% to 85.3% (P = .009), with a positive predictive value of 78.0%. Furthermore, the system showed potential to reduce patient exposure to harm, from 256 min to 35 min (P < .001). The automated system demonstrated improved capacity for identifying MAEs while guarding against alert fatigue. It also showed promise for reducing patient exposure to potential harm following MAE events.

Identifying potential impact of lead contamination using a geographic information system

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

Bocco, G.; Sanchez, R.

1997-01-01

The main objective of this research was to identify the potential hazards associated with lead contamination from fixed sources in the city of Tijuana. An exploratory model is presented that describes the potential polluting sources as well as the exposed universe. The results of the analysis provide a clear picture of the geographic distribution of hazards areas for potential lead pollution in Tijuana. The findings are indicative of the dramatic consequences of rapid industrialization and urbanization in a city where there have not been significant planning efforts to mitigate the negative effects of this growth. The approach followed helps tomore » narrow the universe of potential pollution sources, which can help to direct attention, research priorities, and resources to the most critical areas. 16 refs.« less

Modeling resident error-making patterns in detection of mammographic masses using computer-extracted image features: preliminary experiments

NASA Astrophysics Data System (ADS)

Mazurowski, Maciej A.; Zhang, Jing; Lo, Joseph Y.; Kuzmiak, Cherie M.; Ghate, Sujata V.; Yoon, Sora

2014-03-01

Providing high quality mammography education to radiology trainees is essential, as good interpretation skills potentially ensure the highest benefit of screening mammography for patients. We have previously proposed a computer-aided education system that utilizes trainee models, which relate human-assessed image characteristics to interpretation error. We proposed that these models be used to identify the most difficult and therefore the most educationally useful cases for each trainee. In this study, as a next step in our research, we propose to build trainee models that utilize features that are automatically extracted from images using computer vision algorithms. To predict error, we used a logistic regression which accepts imaging features as input and returns error as output. Reader data from 3 experts and 3 trainees were used. Receiver operating characteristic analysis was applied to evaluate the proposed trainee models. Our experiments showed that, for three trainees, our models were able to predict error better than chance. This is an important step in the development of adaptive computer-aided education systems since computer-extracted features will allow for faster and more extensive search of imaging databases in order to identify the most educationally beneficial cases.

Error-related negativities elicited by monetary loss and cues that predict loss.

PubMed

Dunning, Jonathan P; Hajcak, Greg

2007-11-19

Event-related potential studies have reported error-related negativity following both error commission and feedback indicating errors or monetary loss. The present study examined whether error-related negativities could be elicited by a predictive cue presented prior to both the decision and subsequent feedback in a gambling task. Participants were presented with a cue that indicated the probability of reward on the upcoming trial (0, 50, and 100%). Results showed a negative deflection in the event-related potential in response to loss cues compared with win cues; this waveform shared a similar latency and morphology with the traditional feedback error-related negativity.

The decline and fall of Type II error rates

Treesearch

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.

Quantum Error Correction for Metrology

NASA Astrophysics Data System (ADS)

Sushkov, Alex; Kessler, Eric; Lovchinsky, Igor; Lukin, Mikhail

2014-05-01

The question of the best achievable sensitivity in a quantum measurement is of great experimental relevance, and has seen a lot of attention in recent years. Recent studies [e.g., Nat. Phys. 7, 406 (2011), Nat. Comms. 3, 1063 (2012)] suggest that in most generic scenarios any potential quantum gain (e.g. through the use of entangled states) vanishes in the presence of environmental noise. To overcome these limitations, we propose and analyze a new approach to improve quantum metrology based on quantum error correction (QEC). We identify the conditions under which QEC allows one to improve the signal-to-noise ratio in quantum-limited measurements, and we demonstrate that it enables, in certain situations, Heisenberg-limited sensitivity. We discuss specific applications to nanoscale sensing using nitrogen-vacancy centers in diamond in which QEC can significantly improve the measurement sensitivity and bandwidth under realistic experimental conditions.

Comment on “Two statistics for evaluating parameter identifiability and error reduction” by John Doherty and Randall J. Hunt

USGS Publications Warehouse

Hill, Mary C.

2010-01-01

Doherty and Hunt (2009) present important ideas for first-order-second moment sensitivity analysis, but five issues are discussed in this comment. First, considering the composite-scaled sensitivity (CSS) jointly with parameter correlation coefficients (PCC) in a CSS/PCC analysis addresses the difficulties with CSS mentioned in the introduction. Second, their new parameter identifiability statistic actually is likely to do a poor job of parameter identifiability in common situations. The statistic instead performs the very useful role of showing how model parameters are included in the estimated singular value decomposition (SVD) parameters. Its close relation to CSS is shown. Third, the idea from p. 125 that a suitable truncation point for SVD parameters can be identified using the prediction variance is challenged using results from Moore and Doherty (2005). Fourth, the relative error reduction statistic of Doherty and Hunt is shown to belong to an emerging set of statistics here named perturbed calculated variance statistics. Finally, the perturbed calculated variance statistics OPR and PPR mentioned on p. 121 are shown to explicitly include the parameter null-space component of uncertainty. Indeed, OPR and PPR results that account for null-space uncertainty have appeared in the literature since 2000.

Neural response to errors in combat-exposed returning veterans with and without post-traumatic stress disorder: a preliminary event-related potential study.

PubMed

Rabinak, Christine A; Holman, Alexis; Angstadt, Mike; Kennedy, Amy E; Hajcak, Greg; Phan, Kinh Luan

2013-07-30

Post-traumatic stress disorder (PTSD) is characterized by sustained anxiety, hypervigilance for potential threat, and hyperarousal. These symptoms may enhance self-perception of one's actions, particularly the detection of errors, which may threaten safety. The error-related negativity (ERN) is an electrocortical response to the commission of errors, and previous studies have shown that other anxiety disorders associated with exaggerated anxiety and enhanced action monitoring exhibit an enhanced ERN. However, little is known about how traumatic experience and PTSD would affect the ERN. To address this gap, we measured the ERN in returning Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) veterans with combat-related PTSD (PTSD group), combat-exposed OEF/OIF veterans without PTSD [combat-exposed control (CEC) group], and non-traumatized healthy participants [healthy control (HC) group]. Event-related potential and behavioral measures were recorded while 16 PTSD patients, 18 CEC, and 16 HC participants completed an arrow version of the flanker task. No difference in the magnitude of the ERN was observed between the PTSD and HC groups; however, in comparison with the PTSD and HC groups, the CEC group displayed a blunted ERN response. These findings suggest that (1) combat trauma itself does not affect the ERN response; (2) PTSD is not associated with an abnormal ERN response; and (3) an attenuated ERN in those previously exposed to combat trauma but who have not developed PTSD may reflect resilience to the disorder, less motivation to do the task, or a decrease in the significance or meaningfulness of 'errors,' which could be related to combat experience. Copyright © 2013 Elsevier Ireland Ltd. All rights reserved.

Understanding error generation in fused deposition modeling

NASA Astrophysics Data System (ADS)

Bochmann, Lennart; Bayley, Cindy; Helu, Moneer; Transchel, Robert; Wegener, Konrad; Dornfeld, David

2015-03-01

Additive manufacturing offers completely new possibilities for the manufacturing of parts. The advantages of flexibility and convenience of additive manufacturing have had a significant impact on many industries, and optimizing part quality is crucial for expanding its utilization. This research aims to determine the sources of imprecision in fused deposition modeling (FDM). Process errors in terms of surface quality, accuracy and precision are identified and quantified, and an error-budget approach is used to characterize errors of the machine tool. It was determined that accuracy and precision in the y direction (0.08-0.30 mm) are generally greater than in the x direction (0.12-0.62 mm) and the z direction (0.21-0.57 mm). Furthermore, accuracy and precision tend to decrease at increasing axis positions. The results of this work can be used to identify possible process improvements in the design and control of FDM technology.

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

PubMed

Cao, Hui; Stetson, Peter; Hripcsak, George

2003-01-01

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

Review of medication errors that are new or likely to occur more frequently with electronic medication management systems.

PubMed

Van de Vreede, Melita; McGrath, Anne; de Clifford, Jan

2018-05-14

Objective. The aim of the present study was to identify and quantify medication errors reportedly related to electronic medication management systems (eMMS) and those considered likely to occur more frequently with eMMS. This included developing a new classification system relevant to eMMS errors. Methods. Eight Victorian hospitals with eMMS participated in a retrospective audit of reported medication incidents from their incident reporting databases between May and July 2014. Site-appointed project officers submitted deidentified incidents they deemed new or likely to occur more frequently due to eMMS, together with the Incident Severity Rating (ISR). The authors reviewed and classified incidents. Results. There were 5826 medication-related incidents reported. In total, 93 (47 prescribing errors, 46 administration errors) were identified as new or potentially related to eMMS. Only one ISR2 (moderate) and no ISR1 (severe or death) errors were reported, so harm to patients in this 3-month period was minimal. The most commonly reported error types were 'human factors' and 'unfamiliarity or training' (70%) and 'cross-encounter or hybrid system errors' (22%). Conclusions. Although the results suggest that the errors reported were of low severity, organisations must remain vigilant to the risk of new errors and avoid the assumption that eMMS is the panacea to all medication error issues. What is known about the topic? eMMS have been shown to reduce some types of medication errors, but it has been reported that some new medication errors have been identified and some are likely to occur more frequently with eMMS. There are few published Australian studies that have reported on medication error types that are likely to occur more frequently with eMMS in more than one organisation and that include administration and prescribing errors. What does this paper add? This paper includes a new simple classification system for eMMS that is useful and outlines the most commonly

Neurophysiological correlates of error monitoring and inhibitory processing in juvenile violent offenders.

PubMed

Vilà-Balló, Adrià; Hdez-Lafuente, Prado; Rostan, Carles; Cunillera, Toni; Rodriguez-Fornells, Antoni

2014-10-01

Performance monitoring is crucial for well-adapted behavior. Offenders typically have a pervasive repetition of harmful-impulsive behaviors, despite an awareness of the negative consequences of their actions. However, the link between performance monitoring and aggressive behavior in juvenile offenders has not been closely investigated. Event-related brain potentials (ERPs) were used to investigate performance monitoring in juvenile non-psychopathic violent offenders compared with a well-matched control group. Two ERP components associated with error monitoring, error-related negativity (ERN) and error-positivity (Pe), and two components related to inhibitory processing, the stop-N2 and stop-P3 components, were evaluated using a combined flanker-stop-signal task. The results showed that the amplitudes of the ERN, the stop-N2, the stop-P3, and the standard P3 components were clearly reduced in the offenders group. Remarkably, no differences were observed for the Pe. At the behavioral level, slower stop-signal reaction times were identified for offenders, which indicated diminished inhibitory processing. The present results suggest that the monitoring of one's own behavior is affected in juvenile violent offenders. Specifically, we determined that different aspects of executive function were affected in the studied offenders, including error processing (reduced ERN) and response inhibition (reduced N2 and P3). However, error awareness and compensatory post-error adjustment processes (error correction) were unaffected. The current pattern of results highlights the role of performance monitoring in the acquisition and maintenance of externalizing harmful behavior that is frequently observed in juvenile offenders. Copyright © 2014 Elsevier B.V. All rights reserved.

Spontaneous swallowing frequency has potential to identify dysphagia in acute stroke.

PubMed

Crary, Michael A; Carnaby, Giselle D; Sia, Isaac; Khanna, Anna; Waters, Michael F

2013-12-01

Spontaneous swallowing frequency has been described as an index of dysphagia in various health conditions. This study evaluated the potential of spontaneous swallow frequency analysis as a screening protocol for dysphagia in acute stroke. In a cohort of 63 acute stroke cases, swallow frequency rates (swallows per minute [SPM]) were compared with stroke and swallow severity indices, age, time from stroke to assessment, and consciousness level. Mean differences in SPM were compared between patients with versus without clinically significant dysphagia. Receiver operating characteristic curve analysis was used to identify the optimal threshold in SPM, which was compared with a validated clinical dysphagia examination for identification of dysphagia cases. Time series analysis was used to identify the minimally adequate time period to complete spontaneous swallow frequency analysis. SPM correlated significantly with stroke and swallow severity indices but not with age, time from stroke onset, or consciousness level. Patients with dysphagia demonstrated significantly lower SPM rates. SPM differed by dysphagia severity. Receiver operating characteristic curve analysis yielded a threshold of SPM≤0.40 that identified dysphagia (per the criterion referent) with 0.96 sensitivity, 0.68 specificity, and 0.96 negative predictive value. Time series analysis indicated that a 5- to 10-minute sampling window was sufficient to calculate spontaneous swallow frequency to identify dysphagia cases in acute stroke. Spontaneous swallowing frequency presents high potential to screen for dysphagia in acute stroke without the need for trained, available personnel.

Spontaneous Swallowing Frequency [Has Potential to] Identify Dysphagia in Acute Stroke

PubMed Central

Carnaby, Giselle D; Sia, Isaac; Khanna, Anna; Waters, Michael

2014-01-01

Background and Purpose Spontaneous swallowing frequency has been described as an index of dysphagia in various health conditions. This study evaluated the potential of spontaneous swallow frequency analysis as a screening protocol for dysphagia in acute stroke. Methods In a cohort of 63 acute stroke cases swallow frequency rates (swallows per minute: SPM) were compared to stroke and swallow severity indices, age, time from stroke to assessment, and consciousness level. Mean differences in SPM were compared between patients with vs. without clinically significant dysphagia. ROC analysis was used to identify the optimal threshold in SPM which was compared to a validated clinical dysphagia examination for identification of dysphagia cases. Time series analysis was employed to identify the minimally adequate time period to complete spontaneous swallow frequency analysis. Results SPM correlated significantly with stroke and swallow severity indices but not with age, time from stroke onset, or consciousness level. Patients with dysphagia demonstrated significantly lower SPM rates. SPM differed by dysphagia severity. ROC analysis yielded a threshold of SPM ≤ 0.40 which identified dysphagia (per the criterion referent) with 0.96 sensitivity, 0.68 specificity, and 0.96 negative predictive value. Time series analysis indicated that a 5 to 10 minute sampling window was sufficient to calculate spontaneous swallow frequency to identify dysphagia cases in acute stroke. Conclusions Spontaneous swallowing frequency presents high potential to screen for dysphagia in acute stroke without the need for trained, available personnel. PMID:24149008

Identifying Potential Norovirus Epidemics in China via Internet Surveillance

PubMed Central

Chen, Bin; Jiang, Tao; Cai, Gaofeng; Jiang, Zhenggang; Chen, Yongdi; Wang, Zhengting; Gu, Hua; Chai, Chengliang

2017-01-01

Background Norovirus is a common virus that causes acute gastroenteritis worldwide, but a monitoring system for norovirus is unavailable in China. Objective We aimed to identify norovirus epidemics through Internet surveillance and construct an appropriate model to predict potential norovirus infections. Methods The norovirus-related data of a selected outbreak in Jiaxing Municipality, Zhejiang Province of China, in 2014 were collected from immediate epidemiological investigation, and the Internet search volume, as indicated by the Baidu Index, was acquired from the Baidu search engine. All correlated search keywords in relation to norovirus were captured, screened, and composited to establish the composite Baidu Index at different time lags by Spearman rank correlation. The optimal model was chosen and possibly predicted maps in Zhejiang Province were presented by ArcGIS software. Results The combination of two vital keywords at a time lag of 1 day was ultimately identified as optimal (ρ=.924, P<.001). The exponential curve model was constructed to fit the trend of this epidemic, suggesting that a one-unit increase in the mean composite Baidu Index contributed to an increase of norovirus infections by 2.15 times during the outbreak. In addition to Jiaxing Municipality, Hangzhou Municipality might have had some potential epidemics in the study time from the predicted model. Conclusions Although there are limitations with early warning and unavoidable biases, Internet surveillance may be still useful for the monitoring of norovirus epidemics when a monitoring system is unavailable. PMID:28790023

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

PubMed Central

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

2007-01-01

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

Flight instrumentation specification for parameter identification: Program user's guide. [instrument errors/error analysis

NASA Technical Reports Server (NTRS)

Mohr, R. L.

1975-01-01

A set of four digital computer programs is presented which can be used to investigate the effects of instrumentation errors on the accuracy of aircraft and helicopter stability-and-control derivatives identified from flight test data. The programs assume that the differential equations of motion are linear and consist of small perturbations about a quasi-steady flight condition. It is also assumed that a Newton-Raphson optimization technique is used for identifying the estimates of the parameters. Flow charts and printouts are included.

Errors, error detection, error correction and hippocampal-region damage: data and theories.

PubMed

MacKay, Donald G; Johnson, Laura W

2013-11-01

This review and perspective article outlines 15 observational constraints on theories of errors, error detection, and error correction, and their relation to hippocampal-region (HR) damage. The core observations come from 10 studies with H.M., an amnesic with cerebellar and HR damage but virtually no neocortical damage. Three studies examined the detection of errors planted in visual scenes (e.g., a bird flying in a fish bowl in a school classroom) and sentences (e.g., I helped themselves to the birthday cake). In all three experiments, H.M. detected reliably fewer errors than carefully matched memory-normal controls. Other studies examined the detection and correction of self-produced errors, with controls for comprehension of the instructions, impaired visual acuity, temporal factors, motoric slowing, forgetting, excessive memory load, lack of motivation, and deficits in visual scanning or attention. In these studies, H.M. corrected reliably fewer errors than memory-normal and cerebellar controls, and his uncorrected errors in speech, object naming, and reading aloud exhibited two consistent features: omission and anomaly. For example, in sentence production tasks, H.M. omitted one or more words in uncorrected encoding errors that rendered his sentences anomalous (incoherent, incomplete, or ungrammatical) reliably more often than controls. Besides explaining these core findings, the theoretical principles discussed here explain H.M.'s retrograde amnesia for once familiar episodic and semantic information; his anterograde amnesia for novel information; his deficits in visual cognition, sentence comprehension, sentence production, sentence reading, and object naming; and effects of aging on his ability to read isolated low frequency words aloud. These theoretical principles also explain a wide range of other data on error detection and correction and generate new predictions for future test. Copyright © 2013 Elsevier Ltd. All rights reserved.

Differences in Error Detection Skills by Band and Choral Preservice Teachers

ERIC Educational Resources Information Center

Stambaugh, Laura A.

2016-01-01

Band and choral preservice teachers (N = 44) studied band and choral scores, listened to recordings of school ensembles, and identified errors in the recordings. Results indicated that preservice teachers identified significantly more errors when listening to recordings of their primary area (band majors listening to band, p = 0.045; choral majors…

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

PubMed

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

2009-01-01

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

Error detection and reduction in blood banking.

PubMed

Motschman, T L; Moore, S B

1996-12-01

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

Medication errors in residential aged care facilities: a distributed cognition analysis of the information exchange process.

PubMed

Tariq, Amina; Georgiou, Andrew; Westbrook, Johanna

2013-05-01

Medication safety is a pressing concern for residential aged care facilities (RACFs). Retrospective studies in RACF settings identify inadequate communication between RACFs, doctors, hospitals and community pharmacies as the major cause of medication errors. Existing literature offers limited insight about the gaps in the existing information exchange process that may lead to medication errors. The aim of this research was to explicate the cognitive distribution that underlies RACF medication ordering and delivery to identify gaps in medication-related information exchange which lead to medication errors in RACFs. The study was undertaken in three RACFs in Sydney, Australia. Data were generated through ethnographic field work over a period of five months (May-September 2011). Triangulated analysis of data primarily focused on examining the transformation and exchange of information between different media across the process. The findings of this study highlight the extensive scope and intense nature of information exchange in RACF medication ordering and delivery. Rather than attributing error to individual care providers, the explication of distributed cognition processes enabled the identification of gaps in three information exchange dimensions which potentially contribute to the occurrence of medication errors namely: (1) design of medication charts which complicates order processing and record keeping (2) lack of coordination mechanisms between participants which results in misalignment of local practices (3) reliance on restricted communication bandwidth channels mainly telephone and fax which complicates the information processing requirements. The study demonstrates how the identification of these gaps enhances understanding of medication errors in RACFs. Application of the theoretical lens of distributed cognition can assist in enhancing our understanding of medication errors in RACFs through identification of gaps in information exchange. Understanding

Low-dimensional Representation of Error Covariance

NASA Technical Reports Server (NTRS)

Tippett, Michael K.; Cohn, Stephen E.; Todling, Ricardo; Marchesin, Dan

2000-01-01

Ensemble and reduced-rank approaches to prediction and assimilation rely on low-dimensional approximations of the estimation error covariances. Here stability properties of the forecast/analysis cycle for linear, time-independent systems are used to identify factors that cause the steady-state analysis error covariance to admit a low-dimensional representation. A useful measure of forecast/analysis cycle stability is the bound matrix, a function of the dynamics, observation operator and assimilation method. Upper and lower estimates for the steady-state analysis error covariance matrix eigenvalues are derived from the bound matrix. The estimates generalize to time-dependent systems. If much of the steady-state analysis error variance is due to a few dominant modes, the leading eigenvectors of the bound matrix approximate those of the steady-state analysis error covariance matrix. The analytical results are illustrated in two numerical examples where the Kalman filter is carried to steady state. The first example uses the dynamics of a generalized advection equation exhibiting nonmodal transient growth. Failure to observe growing modes leads to increased steady-state analysis error variances. Leading eigenvectors of the steady-state analysis error covariance matrix are well approximated by leading eigenvectors of the bound matrix. The second example uses the dynamics of a damped baroclinic wave model. The leading eigenvectors of a lowest-order approximation of the bound matrix are shown to approximate well the leading eigenvectors of the steady-state analysis error covariance matrix.

Error management training and simulation education.

PubMed

Gardner, Aimee; Rich, Michelle

2014-12-01

The integration of simulation into the training of health care professionals provides context for decision making and procedural skills in a high-fidelity environment, without risk to actual patients. It was hypothesised that a novel approach to simulation-based education - error management training - would produce higher performance ratings compared with traditional step-by-step instruction. Radiology technology students were randomly assigned to participate in traditional procedural-based instruction (n = 11) or vicarious error management training (n = 11). All watched an instructional video and discussed how well each incident was handled (traditional instruction group) or identified where the errors were made (vicarious error management training). Students then participated in a 30-minute case-based simulation. Simulations were videotaped for performance analysis. Blinded experts evaluated performance using a predefined evaluation tool created specifically for the scenario. Blinded experts evaluated performance using a predefined evaluation tool created specifically for the scenario The vicarious error management group scored higher on observer-rated performance (Mean = 9.49) than students in the traditional instruction group (Mean = 9.02; p < 0.01). These findings suggest that incorporating the discussion of errors and how to handle errors during the learning session will better equip students when performing hands-on procedures and skills. This pilot study provides preliminary evidence for integrating error management skills into medical curricula and for the design of learning goals in simulation-based education. © 2014 John Wiley & Sons Ltd.

Sources of Error in Substance Use Prevalence Surveys

PubMed Central

Johnson, Timothy P.

2014-01-01

Population-based estimates of substance use patterns have been regularly reported now for several decades. Concerns with the quality of the survey methodologies employed to produce those estimates date back almost as far. Those concerns have led to a considerable body of research specifically focused on understanding the nature and consequences of survey-based errors in substance use epidemiology. This paper reviews and summarizes that empirical research by organizing it within a total survey error model framework that considers multiple types of representation and measurement errors. Gaps in our knowledge of error sources in substance use surveys and areas needing future research are also identified. PMID:27437511

Preventing Unintended Disclosure of Personally Identifiable Data Following Anonymisation.

PubMed

Smith, Chris

2017-01-01

Errors and anomalies during the capture and processing of health data have the potential to place personally identifiable values into attributes of a dataset that are expected to contain non-identifiable values. Anonymisation focuses on those attributes that have been judged to enable identification of individuals. Attributes that are judged to contain non-identifiable values are not considered, but may be included in datasets that are shared by organisations. Consequently, organisations are at risk of sharing datasets that unintendedly disclose personally identifiable values through these attributes. This would have ethical and legal implications for organisations and privacy implications for individuals whose personally identifiable values are disclosed. In this paper, we formulate the problem of unintended disclosure following anonymisation, describe the necessary steps to address this problem, and discuss some key challenges to applying these steps in practice.

Quantitative evaluation for accumulative calibration error and video-CT registration errors in electromagnetic-tracked endoscopy.

PubMed

Liu, Sheena Xin; Gutiérrez, Luis F; Stanton, Doug

2011-05-01

Electromagnetic (EM)-guided endoscopy has demonstrated its value in minimally invasive interventions. Accuracy evaluation of the system is of paramount importance to clinical applications. Previously, a number of researchers have reported the results of calibrating the EM-guided endoscope; however, the accumulated errors of an integrated system, which ultimately reflect intra-operative performance, have not been characterized. To fill this vacancy, we propose a novel system to perform this evaluation and use a 3D metric to reflect the intra-operative procedural accuracy. This paper first presents a portable design and a method for calibration of an electromagnetic (EM)-tracked endoscopy system. An evaluation scheme is then described that uses the calibration results and EM-CT registration to enable real-time data fusion between CT and endoscopic video images. We present quantitative evaluation results for estimating the accuracy of this system using eight internal fiducials as the targets on an anatomical phantom: the error is obtained by comparing the positions of these targets in the CT space, EM space and endoscopy image space. To obtain 3D error estimation, the 3D locations of the targets in the endoscopy image space are reconstructed from stereo views of the EM-tracked monocular endoscope. Thus, the accumulated errors are evaluated in a controlled environment, where the ground truth information is present and systematic performance (including the calibration error) can be assessed. We obtain the mean in-plane error to be on the order of 2 pixels. To evaluate the data integration performance for virtual navigation, target video-CT registration error (TRE) is measured as the 3D Euclidean distance between the 3D-reconstructed targets of endoscopy video images and the targets identified in CT. The 3D error (TRE) encapsulates EM-CT registration error, EM-tracking error, fiducial localization error, and optical-EM calibration error. We present in this paper our

Modeling misidentification errors in capture-recapture studies using photographic identification of evolving marks

USGS Publications Warehouse

Yoshizaki, J.; Pollock, K.H.; Brownie, C.; Webster, R.A.

2009-01-01

Misidentification of animals is potentially important when naturally existing features (natural tags) are used to identify individual animals in a capture-recapture study. Photographic identification (photoID) typically uses photographic images of animals' naturally existing features as tags (photographic tags) and is subject to two main causes of identification errors: those related to quality of photographs (non-evolving natural tags) and those related to changes in natural marks (evolving natural tags). The conventional methods for analysis of capture-recapture data do not account for identification errors, and to do so requires a detailed understanding of the misidentification mechanism. Focusing on the situation where errors are due to evolving natural tags, we propose a misidentification mechanism and outline a framework for modeling the effect of misidentification in closed population studies. We introduce methods for estimating population size based on this model. Using a simulation study, we show that conventional estimators can seriously overestimate population size when errors due to misidentification are ignored, and that, in comparison, our new estimators have better properties except in cases with low capture probabilities (<0.2) or low misidentification rates (<2.5%). ?? 2009 by the Ecological Society of America.

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

PubMed

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

2018-01-01

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

A Systematic Approach for Identifying Level-1 Error Covariance Structures in Latent Growth Modeling

ERIC Educational Resources Information Center

Ding, Cherng G.; Jane, Ten-Der; Wu, Chiu-Hui; Lin, Hang-Rung; Shen, Chih-Kang

2017-01-01

It has been pointed out in the literature that misspecification of the level-1 error covariance structure in latent growth modeling (LGM) has detrimental impacts on the inferences about growth parameters. Since correct covariance structure is difficult to specify by theory, the identification needs to rely on a specification search, which,…

Barriers to Medical Error Reporting for Physicians and Nurses.

PubMed

Soydemir, Dilek; Seren Intepeler, Seyda; Mert, Hatice

2017-10-01

The purpose of the study was to determine what barriers to error reporting exist for physicians and nurses. The study, of descriptive qualitative design, was conducted with physicians and nurses working at a training and research hospital. In-depth interviews were held with eight physicians and 15 nurses, a total of 23 participants. Physicians and nurses do not choose to report medical errors that they experience or witness. When barriers to error reporting were examined, it was seen that there were four main themes involved: fear, the attitude of administration, barriers related to the system, and the employees' perceptions of error. It is important in terms of preventing medical errors to identify the barriers that keep physicians and nurses from reporting errors.

Eliminating US hospital medical errors.

PubMed

Kumar, Sameer; Steinebach, Marc

2008-01-01

Healthcare costs in the USA have continued to rise steadily since the 1980s. Medical errors are one of the major causes of deaths and injuries of thousands of patients every year, contributing to soaring healthcare costs. The purpose of this study is to examine what has been done to deal with the medical-error problem in the last two decades and present a closed-loop mistake-proof operation system for surgery processes that would likely eliminate preventable medical errors. The design method used is a combination of creating a service blueprint, implementing the six sigma DMAIC cycle, developing cause-and-effect diagrams as well as devising poka-yokes in order to develop a robust surgery operation process for a typical US hospital. In the improve phase of the six sigma DMAIC cycle, a number of poka-yoke techniques are introduced to prevent typical medical errors (identified through cause-and-effect diagrams) that may occur in surgery operation processes in US hospitals. It is the authors' assertion that implementing the new service blueprint along with the poka-yokes, will likely result in the current medical error rate to significantly improve to the six-sigma level. Additionally, designing as many redundancies as possible in the delivery of care will help reduce medical errors. Primary healthcare providers should strongly consider investing in adequate doctor and nurse staffing, and improving their education related to the quality of service delivery to minimize clinical errors. This will lead to an increase in higher fixed costs, especially in the shorter time frame. This paper focuses additional attention needed to make a sound technical and business case for implementing six sigma tools to eliminate medical errors that will enable hospital managers to increase their hospital's profitability in the long run and also ensure patient safety.

Learning time-dependent noise to reduce logical errors: real time error rate estimation in quantum error correction

NASA Astrophysics Data System (ADS)

Huo, Ming-Xia; Li, Ying

2017-12-01

Quantum error correction is important to quantum information processing, which allows us to reliably process information encoded in quantum error correction codes. Efficient quantum error correction benefits from the knowledge of error rates. We propose a protocol for monitoring error rates in real time without interrupting the quantum error correction. Any adaptation of the quantum error correction code or its implementation circuit is not required. The protocol can be directly applied to the most advanced quantum error correction techniques, e.g. surface code. A Gaussian processes algorithm is used to estimate and predict error rates based on error correction data in the past. We find that using these estimated error rates, the probability of error correction failures can be significantly reduced by a factor increasing with the code distance.

Using Social Media Data to Identify Potential Candidates for Drug Repurposing: A Feasibility Study.

PubMed

Rastegar-Mojarad, Majid; Liu, Hongfang; Nambisan, Priya

2016-06-16

Drug repurposing (defined as discovering new indications for existing drugs) could play a significant role in drug development, especially considering the declining success rates of developing novel drugs. Typically, new indications for existing medications are identified by accident. However, new technologies and a large number of available resources enable the development of systematic approaches to identify and validate drug-repurposing candidates. Patients today report their experiences with medications on social media and reveal side effects as well as beneficial effects of those medications. Our aim was to assess the feasibility of using patient reviews from social media to identify potential candidates for drug repurposing. We retrieved patient reviews of 180 medications from an online forum, WebMD. Using dictionary-based and machine learning approaches, we identified disease names in the reviews. Several publicly available resources were used to exclude comments containing known indications and adverse drug effects. After manually reviewing some of the remaining comments, we implemented a rule-based system to identify beneficial effects. The dictionary-based system and machine learning system identified 2178 and 6171 disease names respectively in 64,616 patient comments. We provided a list of 10 common patterns that patients used to report any beneficial effects or uses of medication. After manually reviewing the comments tagged by our rule-based system, we identified five potential drug repurposing candidates. To our knowledge, this is the first study to consider using social media data to identify drug-repurposing candidates. We found that even a rule-based system, with a limited number of rules, could identify beneficial effect mentions in patient comments. Our preliminary study shows that social media has the potential to be used in drug repurposing.

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

PubMed

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

2009-02-01

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

Learning from Errors: A Model of Individual Processes

ERIC Educational Resources Information Center

Tulis, Maria; Steuer, Gabriele; Dresel, Markus

2016-01-01

Errors bear the potential to improve knowledge acquisition, provided that learners are able to deal with them in an adaptive and reflexive manner. However, learners experience a host of different--often impeding or maladaptive--emotional and motivational states in the face of academic errors. Research has made few attempts to develop a theory that…

Obstetric Neuraxial Drug Administration Errors: A Quantitative and Qualitative Analytical Review.

PubMed

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

Identifying High Academic Potential in Australian Aboriginal Children Using Dynamic Testing

ERIC Educational Resources Information Center

Chaffey, Graham W.; Bailey, Stan B.; Vine, Ken W.

2015-01-01

The primary purpose of this study was to determine the effectiveness of dynamic testing as a method for identifying high academic potential in Australian Aboriginal children. The 79 participating Aboriginal children were drawn from Years 3-5 in rural schools in northern New South Wales. The dynamic testing method used in this study involved a…

Human error identification for laparoscopic surgery: Development of a motion economy perspective.

PubMed

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.

Medical errors in primary care clinics – a cross sectional study

PubMed Central

2012-01-01

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

Unforced errors and error reduction in tennis

PubMed Central

Brody, H

2006-01-01

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

Your Health Care May Kill You: Medical Errors.

PubMed

Anderson, James G; Abrahamson, Kathleen

2017-01-01

Recent studies of medical errors have estimated errors may account for as many as 251,000 deaths annually in the United States (U.S)., making medical errors the third leading cause of death. Error rates are significantly higher in the U.S. than in other developed countries such as Canada, Australia, New Zealand, Germany and the United Kingdom (U.K). At the same time less than 10 percent of medical errors are reported. This study describes the results of an investigation of the effectiveness of the implementation of the MEDMARX Medication Error Reporting system in 25 hospitals in Pennsylvania. Data were collected on 17,000 errors reported by participating hospitals over a 12-month period. Latent growth curve analysis revealed that reporting of errors by health care providers increased significantly over the four quarters. At the same time, the proportion of corrective actions taken by the hospitals remained relatively constant over the 12 months. A simulation model was constructed to examine the effect of potential organizational changes resulting from error reporting. Four interventions were simulated. The results suggest that improving patient safety requires more than voluntary reporting. Organizational changes need to be implemented and institutionalized as well.

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.

Errors in imaging patients in the emergency setting

PubMed Central

Reginelli, Alfonso; Lo Re, Giuseppe; Midiri, Federico; Muzj, Carlo; Romano, Luigia; Brunese, Luca

2016-01-01

Emergency and trauma care produces a “perfect storm” for radiological errors: uncooperative patients, inadequate histories, time-critical decisions, concurrent tasks and often junior personnel working after hours in busy emergency departments. The main cause of diagnostic errors in the emergency department is the failure to correctly interpret radiographs, and the majority of diagnoses missed on radiographs are fractures. Missed diagnoses potentially have important consequences for patients, clinicians and radiologists. Radiologists play a pivotal role in the diagnostic assessment of polytrauma patients and of patients with non-traumatic craniothoracoabdominal emergencies, and key elements to reduce errors in the emergency setting are knowledge, experience and the correct application of imaging protocols. This article aims to highlight the definition and classification of errors in radiology, the causes of errors in emergency radiology and the spectrum of diagnostic errors in radiography, ultrasonography and CT in the emergency setting. PMID:26838955

Errors in imaging patients in the emergency setting.

PubMed

Pinto, Antonio; Reginelli, Alfonso; Pinto, Fabio; Lo Re, Giuseppe; Midiri, Federico; Muzj, Carlo; Romano, Luigia; Brunese, Luca

2016-01-01

Emergency and trauma care produces a "perfect storm" for radiological errors: uncooperative patients, inadequate histories, time-critical decisions, concurrent tasks and often junior personnel working after hours in busy emergency departments. The main cause of diagnostic errors in the emergency department is the failure to correctly interpret radiographs, and the majority of diagnoses missed on radiographs are fractures. Missed diagnoses potentially have important consequences for patients, clinicians and radiologists. Radiologists play a pivotal role in the diagnostic assessment of polytrauma patients and of patients with non-traumatic craniothoracoabdominal emergencies, and key elements to reduce errors in the emergency setting are knowledge, experience and the correct application of imaging protocols. This article aims to highlight the definition and classification of errors in radiology, the causes of errors in emergency radiology and the spectrum of diagnostic errors in radiography, ultrasonography and CT in the emergency setting.

Acetaminophen attenuates error evaluation in cortex

PubMed Central

Kam, Julia W.Y.; Heine, Steven J.; Inzlicht, Michael; Handy, Todd C.

2016-01-01

Acetaminophen has recently been recognized as having impacts that extend into the affective domain. In particular, double blind placebo controlled trials have revealed that acetaminophen reduces the magnitude of reactivity to social rejection, frustration, dissonance and to both negatively and positively valenced attitude objects. Given this diversity of consequences, it has been proposed that the psychological effects of acetaminophen may reflect a widespread blunting of evaluative processing. We tested this hypothesis using event-related potentials (ERPs). Sixty-two participants received acetaminophen or a placebo in a double-blind protocol and completed the Go/NoGo task. Participants’ ERPs were observed following errors on the Go/NoGo task, in particular the error-related negativity (ERN; measured at FCz) and error-related positivity (Pe; measured at Pz and CPz). Results show that acetaminophen inhibits the Pe, but not the ERN, and the magnitude of an individual’s Pe correlates positively with omission errors, partially mediating the effects of acetaminophen on the error rate. These results suggest that recently documented affective blunting caused by acetaminophen may best be described as an inhibition of evaluative processing. They also contribute to the growing work suggesting that the Pe is more strongly associated with conscious awareness of errors relative to the ERN. PMID:26892161

A Model of Self-Monitoring Blood Glucose Measurement Error.

PubMed

Vettoretti, Martina; Facchinetti, Andrea; Sparacino, Giovanni; Cobelli, Claudio

2017-07-01

A reliable model of the probability density function (PDF) of self-monitoring of blood glucose (SMBG) measurement error would be important for several applications in diabetes, like testing in silico insulin therapies. In the literature, the PDF of SMBG error is usually described by a Gaussian function, whose symmetry and simplicity are unable to properly describe the variability of experimental data. Here, we propose a new methodology to derive more realistic models of SMBG error PDF. The blood glucose range is divided into zones where error (absolute or relative) presents a constant standard deviation (SD). In each zone, a suitable PDF model is fitted by maximum-likelihood to experimental data. Model validation is performed by goodness-of-fit tests. The method is tested on two databases collected by the One Touch Ultra 2 (OTU2; Lifescan Inc, Milpitas, CA) and the Bayer Contour Next USB (BCN; Bayer HealthCare LLC, Diabetes Care, Whippany, NJ). In both cases, skew-normal and exponential models are used to describe the distribution of errors and outliers, respectively. Two zones were identified: zone 1 with constant SD absolute error; zone 2 with constant SD relative error. Goodness-of-fit tests confirmed that identified PDF models are valid and superior to Gaussian models used so far in the literature. The proposed methodology allows to derive realistic models of SMBG error PDF. These models can be used in several investigations of present interest in the scientific community, for example, to perform in silico clinical trials to compare SMBG-based with nonadjunctive CGM-based insulin treatments.

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

PubMed

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

2016-12-01

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

Impact of an antiretroviral stewardship strategy on medication error rates.

PubMed

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.

Using Click Chemistry to Identify Potential Drug Targets in Plasmodium

DTIC Science & Technology

2015-04-01

step of the Plasmodium mammalian cycle . Inhibiting this step can block malaria at an early step. However, few anti-malarials target liver infection...points in the life cycle of malaria parasites. PLoS Biol 12: e1001806. 2. Falae A, Combe A, Amaladoss A, Carvalho T, Menard R, et al. (2010) Role of...AWARD NUMBER: W81XWH-13-1-0429 TITLE: Using "Click Chemistry" to Identify Potential Drug Targets in Plasmodium PRINCIPAL INVESTIGATOR: Dr. Purnima

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

PubMed

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

2016-12-01

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

Methods for Addressing Technology-induced Errors: The Current State.

PubMed

Borycki, E; Dexheimer, J W; Hullin Lucay Cossio, C; Gong, Y; Jensen, S; Kaipio, J; Kennebeck, S; Kirkendall, E; Kushniruk, A W; Kuziemsky, C; Marcilly, R; Röhrig, R; Saranto, K; Senathirajah, Y; Weber, J; Takeda, H

2016-11-10

The objectives of this paper are to review and discuss the methods that are being used internationally to report on, mitigate, and eliminate technology-induced errors. The IMIA Working Group for Health Informatics for Patient Safety worked together to review and synthesize some of the main methods and approaches associated with technology- induced error reporting, reduction, and mitigation. The work involved a review of the evidence-based literature as well as guideline publications specific to health informatics. The paper presents a rich overview of current approaches, issues, and methods associated with: (1) safe HIT design, (2) safe HIT implementation, (3) reporting on technology-induced errors, (4) technology-induced error analysis, and (5) health information technology (HIT) risk management. The work is based on research from around the world. Internationally, researchers have been developing methods that can be used to identify, report on, mitigate, and eliminate technology-induced errors. Although there remain issues and challenges associated with the methodologies, they have been shown to improve the quality and safety of HIT. Since the first publications documenting technology-induced errors in healthcare in 2005, we have seen in a short 10 years researchers develop ways of identifying and addressing these types of errors. We have also seen organizations begin to use these approaches. Knowledge has been translated into practice in a short ten years whereas the norm for other research areas is of 20 years.

Methods for Addressing Technology-Induced Errors: The Current State

PubMed Central

Dexheimer, J. W.; Hullin Lucay Cossio, C.; Gong, Y.; Jensen, S.; Kaipio, J.; Kennebeck, S.; Kirkendall, E.; Kushniruk, A. W.; Kuziemsky, C.; Marcilly, R.; Röhrig, R.; Saranto, K.; Senathirajah, Y.; Weber, J.; Takeda, H.

2016-01-01

Summary Objectives The objectives of this paper are to review and discuss the methods that are being used internationally to report on, mitigate, and eliminate technology-induced errors. Methods The IMIA Working Group for Health Informatics for Patient Safety worked together to review and synthesize some of the main methods and approaches associated with technology-induced error reporting, reduction, and mitigation. The work involved a review of the evidence-based literature as well as guideline publications specific to health informatics. Results The paper presents a rich overview of current approaches, issues, and methods associated with: (1) safe HIT design, (2) safe HIT implementation, (3) reporting on technology-induced errors, (4) technology-induced error analysis, and (5) health information technology (HIT) risk management. The work is based on research from around the world. Conclusions Internationally, researchers have been developing methods that can be used to identify, report on, mitigate, and eliminate technology-induced errors. Although there remain issues and challenges associated with the methodologies, they have been shown to improve the quality and safety of HIT. Since the first publications documenting technology-induced errors in healthcare in 2005, we have seen in a short 10 years researchers develop ways of identifying and addressing these types of errors. We have also seen organizations begin to use these approaches. Knowledge has been translated into practice in a short ten years whereas the norm for other research areas is of 20 years. PMID:27830228

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.

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.

The science of medical decision making: neurosurgery, errors, and personal cognitive strategies for improving quality of care.

PubMed

Fargen, Kyle M; Friedman, William A

2014-01-01

During the last 2 decades, there has been a shift in the U.S. health care system towards improving the quality of health care provided by enhancing patient safety and reducing medical errors. Unfortunately, surgical complications, patient harm events, and malpractice claims remain common in the field of neurosurgery. Many of these events are potentially avoidable. There are an increasing number of publications in the medical literature in which authors address cognitive errors in diagnosis and treatment and strategies for reducing such errors, but these are for the most part absent in the neurosurgical literature. The purpose of this article is to highlight the complexities of medical decision making to a neurosurgical audience, with the hope of providing insight into the biases that lead us towards error and strategies to overcome our innate cognitive deficiencies. To accomplish this goal, we review the current literature on medical errors and just culture, explain the dual process theory of cognition, identify common cognitive errors affecting neurosurgeons in practice, review cognitive debiasing strategies, and finally provide simple methods that can be easily assimilated into neurosurgical practice to improve clinical decision making. Copyright © 2014 Elsevier Inc. All rights reserved.

Removing systematic errors in interionic potentials of mean force computed in molecular simulations using reaction-field-based electrostatics

PubMed Central

Baumketner, Andrij

2009-01-01

The performance of reaction-field methods to treat electrostatic interactions is tested in simulations of ions solvated in water. The potential of mean force between sodium chloride pair of ions and between side chains of lysine and aspartate are computed using umbrella sampling and molecular dynamics simulations. It is found that in comparison with lattice sum calculations, the charge-group-based approaches to reaction-field treatments produce a large error in the association energy of the ions that exhibits strong systematic dependence on the size of the simulation box. The atom-based implementation of the reaction field is seen to (i) improve the overall quality of the potential of mean force and (ii) remove the dependence on the size of the simulation box. It is suggested that the atom-based truncation be used in reaction-field simulations of mixed media. PMID:19292522

Recognizing and managing errors of cognitive underspecification.

PubMed

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.

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

PubMed

Alexander, William H; Brown, Joshua W

2010-02-15

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

Error-correction coding

NASA Technical Reports Server (NTRS)

Hinds, Erold W. (Principal Investigator)

1996-01-01

This report describes the progress made towards the completion of a specific task on error-correcting coding. The proposed research consisted of investigating the use of modulation block codes as the inner code of a concatenated coding system in order to improve the overall space link communications performance. The study proposed to identify and analyze candidate codes that will complement the performance of the overall coding system which uses the interleaved RS (255,223) code as the outer code.

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

PubMed Central

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

2018-01-01

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

Impact of Communication Errors in Radiology on Patient Care, Customer Satisfaction, and Work-Flow Efficiency.

PubMed

Siewert, Bettina; Brook, Olga R; Hochman, Mary; Eisenberg, Ronald L

2016-03-01

The purpose of this study is to analyze the impact of communication errors on patient care, customer satisfaction, and work-flow efficiency and to identify opportunities for quality improvement. We performed a search of our quality assurance database for communication errors submitted from August 1, 2004, through December 31, 2014. Cases were analyzed regarding the step in the imaging process at which the error occurred (i.e., ordering, scheduling, performance of examination, study interpretation, or result communication). The impact on patient care was graded on a 5-point scale from none (0) to catastrophic (4). The severity of impact between errors in result communication and those that occurred at all other steps was compared. Error evaluation was performed independently by two board-certified radiologists. Statistical analysis was performed using the chi-square test and kappa statistics. Three hundred eighty of 422 cases were included in the study. One hundred ninety-nine of the 380 communication errors (52.4%) occurred at steps other than result communication, including ordering (13.9%; n = 53), scheduling (4.7%; n = 18), performance of examination (30.0%; n = 114), and study interpretation (3.7%; n = 14). Result communication was the single most common step, accounting for 47.6% (181/380) of errors. There was no statistically significant difference in impact severity between errors that occurred during result communication and those that occurred at other times (p = 0.29). In 37.9% of cases (144/380), there was an impact on patient care, including 21 minor impacts (5.5%; result communication, n = 13; all other steps, n = 8), 34 moderate impacts (8.9%; result communication, n = 12; all other steps, n = 22), and 89 major impacts (23.4%; result communication, n = 45; all other steps, n = 44). In 62.1% (236/380) of cases, no impact was noted, but 52.6% (200/380) of cases had the potential for an impact. Among 380 communication errors in a radiology department, 37

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

PubMed Central

Gagnon, Bernadine; Miozzo, Michele

2017-01-01

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

Trauma center maturity measured by an analysis of preventable and potentially preventable deaths: there is always something to be learned….

PubMed

Matsumoto, Shokei; Jung, Kyoungwon; Smith, Alan; Coimbra, Raul

2018-06-23

To establish the preventable and potentially preventable death rates in a mature trauma center and to identify the causes of death and highlight the lessons learned from these cases. We analyzed data from a Level-1 Trauma Center Registry, collected over a 15-year period. Data on demographics, timing of death, and potential errors were collected. Deaths were judged as preventable (PD), potentially preventable (PPD), or non-preventable (NPD), following a strict external peer-review process. During the 15-year period, there were 874 deaths, 15 (1.7%) and 6 (0.7%) of which were considered PPDs and PDs, respectively. Patients in the PD and PPD groups were not sicker and had less severe head injury than those in the NPD group. The time-death distribution differed according to preventability. We identified 21 errors in the PD and PPD groups, but only 61 (7.3%) errors in the NPD group (n = 853). Errors in judgement accounted for the majority and for 90.5% of the PD and PPD group errors. Although the numbers of PDs and PPDs were low, denoting maturity of our trauma center, there are important lessons to be learned about how errors in judgment led to deaths that could have been prevented.

E-Prescribing Errors in Community Pharmacies: Exploring Consequences and Contributing Factors

PubMed Central

Stone, Jamie A.; Chui, Michelle A.

2014-01-01

Objective To explore types of e-prescribing errors in community pharmacies and their potential consequences, as well as the factors that contribute to e-prescribing errors. Methods Data collection involved performing 45 total hours of direct observations in five pharmacies. Follow-up interviews were conducted with 20 study participants. Transcripts from observations and interviews were subjected to content analysis using NVivo 10. Results Pharmacy staff detected 75 e-prescription errors during the 45 hour observation in pharmacies. The most common e-prescribing errors were wrong drug quantity, wrong dosing directions, wrong duration of therapy, and wrong dosage formulation. Participants estimated that 5 in 100 e-prescriptions have errors. Drug classes that were implicated in e-prescribing errors were antiinfectives, inhalers, ophthalmic, and topical agents. The potential consequences of e-prescribing errors included increased likelihood of the patient receiving incorrect drug therapy, poor disease management for patients, additional work for pharmacy personnel, increased cost for pharmacies and patients, and frustrations for patients and pharmacy staff. Factors that contribute to errors included: technology incompatibility between pharmacy and clinic systems, technology design issues such as use of auto-populate features and dropdown menus, and inadvertently entering incorrect information. Conclusion Study findings suggest that a wide range of e-prescribing errors are encountered in community pharmacies. Pharmacists and technicians perceive that causes of e-prescribing errors are multidisciplinary and multifactorial, that is to say e-prescribing errors can originate from technology used in prescriber offices and pharmacies. PMID:24657055

Error and uncertainty in Raman thermal conductivity measurements

DOE PAGES

Thomas Edwin Beechem; Yates, Luke; Graham, Samuel

2015-04-22

We investigated error and uncertainty in Raman thermal conductivity measurements via finite element based numerical simulation of two geometries often employed -- Joule-heating of a wire and laser-heating of a suspended wafer. Using this methodology, the accuracy and precision of the Raman-derived thermal conductivity are shown to depend on (1) assumptions within the analytical model used in the deduction of thermal conductivity, (2) uncertainty in the quantification of heat flux and temperature, and (3) the evolution of thermomechanical stress during testing. Apart from the influence of stress, errors of 5% coupled with uncertainties of ±15% are achievable for most materialsmore » under conditions typical of Raman thermometry experiments. Error can increase to >20%, however, for materials having highly temperature dependent thermal conductivities or, in some materials, when thermomechanical stress develops concurrent with the heating. A dimensionless parameter -- termed the Raman stress factor -- is derived to identify when stress effects will induce large levels of error. Together, the results compare the utility of Raman based conductivity measurements relative to more established techniques while at the same time identifying situations where its use is most efficacious.« less

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.

[Errors in laboratory daily practice].

PubMed

Larrose, C; Le Carrer, D

2007-01-01

Legislation set by GBEA (Guide de bonne exécution des analyses) requires that, before performing analysis, the laboratory directors have to check both the nature of the samples and the patients identity. The data processing of requisition forms, which identifies key errors, was established in 2000 and in 2002 by the specialized biochemistry laboratory, also with the contribution of the reception centre for biological samples. The laboratories follow a strict criteria of defining acceptability as a starting point for the reception to then check requisition forms and biological samples. All errors are logged into the laboratory database and analysis report are sent to the care unit specifying the problems and the consequences they have on the analysis. The data is then assessed by the laboratory directors to produce monthly or annual statistical reports. This indicates the number of errors, which are then indexed to patient files to reveal the specific problem areas, therefore allowing the laboratory directors to teach the nurses and enable corrective action.

Headaches associated with refractive errors: myth or reality?

PubMed

Gil-Gouveia, R; Martins, I P

2002-04-01

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

Exponential error reduction in pretransfusion testing with automation.

PubMed

South, Susan F; Casina, Tony S; Li, Lily

2012-08-01

Protecting the safety of blood transfusion is the top priority of transfusion service laboratories. Pretransfusion testing is a critical element of the entire transfusion process to enhance vein-to-vein safety. Human error associated with manual pretransfusion testing is a cause of transfusion-related mortality and morbidity and most human errors can be eliminated by automated systems. However, the uptake of automation in transfusion services has been slow and many transfusion service laboratories around the world still use manual blood group and antibody screen (G&S) methods. The goal of this study was to compare error potentials of commonly used manual (e.g., tiles and tubes) versus automated (e.g., ID-GelStation and AutoVue Innova) G&S methods. Routine G&S processes in seven transfusion service laboratories (four with manual and three with automated G&S methods) were analyzed using failure modes and effects analysis to evaluate the corresponding error potentials of each method. Manual methods contained a higher number of process steps ranging from 22 to 39, while automated G&S methods only contained six to eight steps. Corresponding to the number of the process steps that required human interactions, the risk priority number (RPN) of the manual methods ranged from 5304 to 10,976. In contrast, the RPN of the automated methods was between 129 and 436 and also demonstrated a 90% to 98% reduction of the defect opportunities in routine G&S testing. This study provided quantitative evidence on how automation could transform pretransfusion testing processes by dramatically reducing error potentials and thus would improve the safety of blood transfusion. © 2012 American Association of Blood Banks.

Prevalence and reporting of recruitment, randomisation and treatment errors in clinical trials: A systematic review.

PubMed

Yelland, Lisa N; Kahan, Brennan C; Dent, Elsa; Lee, Katherine J; Voysey, Merryn; Forbes, Andrew B; Cook, Jonathan A

2018-06-01

Background/aims In clinical trials, it is not unusual for errors to occur during the process of recruiting, randomising and providing treatment to participants. For example, an ineligible participant may inadvertently be randomised, a participant may be randomised in the incorrect stratum, a participant may be randomised multiple times when only a single randomisation is permitted or the incorrect treatment may inadvertently be issued to a participant at randomisation. Such errors have the potential to introduce bias into treatment effect estimates and affect the validity of the trial, yet there is little motivation for researchers to report these errors and it is unclear how often they occur. The aim of this study is to assess the prevalence of recruitment, randomisation and treatment errors and review current approaches for reporting these errors in trials published in leading medical journals. Methods We conducted a systematic review of individually randomised, phase III, randomised controlled trials published in New England Journal of Medicine, Lancet, Journal of the American Medical Association, Annals of Internal Medicine and British Medical Journal from January to March 2015. The number and type of recruitment, randomisation and treatment errors that were reported and how they were handled were recorded. The corresponding authors were contacted for a random sample of trials included in the review and asked to provide details on unreported errors that occurred during their trial. Results We identified 241 potentially eligible articles, of which 82 met the inclusion criteria and were included in the review. These trials involved a median of 24 centres and 650 participants, and 87% involved two treatment arms. Recruitment, randomisation or treatment errors were reported in 32 in 82 trials (39%) that had a median of eight errors. The most commonly reported error was ineligible participants inadvertently being randomised. No mention of recruitment, randomisation

Medical error and systems of signaling: conceptual and linguistic definition.

PubMed

Smorti, Andrea; Cappelli, Francesco; Zarantonello, Roberta; Tani, Franca; Gensini, Gian Franco

2014-09-01

In recent years the issue of patient safety has been the subject of detailed investigations, particularly as a result of the increasing attention from the patients and the public on the problem of medical error. The purpose of this work is firstly to define the classification of medical errors, which are distinguished between two perspectives: those that are personal, and those that are caused by the system. Furthermore we will briefly review some of the main methods used by healthcare organizations to identify and analyze errors. During this discussion it has been determined that, in order to constitute a practical, coordinated and shared action to counteract the error, it is necessary to promote an analysis that considers all elements (human, technological and organizational) that contribute to the occurrence of a critical event. Therefore, it is essential to create a culture of constructive confrontation that encourages an open and non-punitive debate about the causes that led to error. In conclusion we have thus underlined that in health it is essential to affirm a system discussion that considers the error as a learning source, and as a result of the interaction between the individual and the organization. In this way, one should encourage a non-guilt bearing discussion on evident errors and on those which are not immediately identifiable, in order to create the conditions that recognize and corrects the error even before it produces negative consequences.

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

PubMed Central

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

2014-01-01

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

Pilot error in air carrier accidents: does age matter?

PubMed

Li, Guohua; Grabowski, Jurek G; Baker, Susan P; Rebok, George W

2006-07-01

The relationship between pilot age and safety performance has been the subject of research and controversy since the "Age 60 Rule" became effective in 1960. This study aimed to examine age-related differences in the prevalence and patterns of pilot error in air carrier accidents. Investigation reports from the National Transportation Safety Board for accidents involving Part 121 operations in the United States between 1983 and 2002 were reviewed to identify pilot error and other contributing factors. Accident circumstances and the presence and type of pilot error were analyzed in relation to pilot age using Chi-square tests. Of the 558 air carrier accidents studied, 25% resulted from turbulence, 21% from mechanical failure, 16% from taxiing events, 13% from loss of control at landing or takeoff, and 25% from other causes. Accidents involving older pilots were more likely to be caused by turbulence, whereas accidents involving younger pilots were more likely to be taxiing events. Pilot error was a contributing factor in 34%, 38%, 35%, and 34% of the accidents involving pilots ages 25-34 yr, 35-44 yr, 45-54 yr, and 55-59 yr, respectively (p = 0.87). The patterns of pilot error were similar across age groups. Overall, 26% of the pilot errors identified were inattentiveness, 22% flawed decisions, 22% mishandled aircraft kinetics, and 11% poor crew interactions. The prevalence and patterns of pilot error in air carrier accidents do not seem to change with pilot age. The lack of association between pilot age and error may be due to the "safe worker effect" resulting from the rigorous selection processes and certification standards for professional pilots.

Superdense coding interleaved with forward error correction

DOE PAGES

Humble, Travis S.; Sadlier, Ronald J.

2016-05-12

Superdense coding promises increased classical capacity and communication security but this advantage may be undermined by noise in the quantum channel. We present a numerical study of how forward error correction (FEC) applied to the encoded classical message can be used to mitigate against quantum channel noise. By studying the bit error rate under different FEC codes, we identify the unique role that burst errors play in superdense coding, and we show how these can be mitigated against by interleaving the FEC codewords prior to transmission. As a result, we conclude that classical FEC with interleaving is a useful methodmore » to improve the performance in near-term demonstrations of superdense coding.« less

Counting OCR errors in typeset text

NASA Astrophysics Data System (ADS)